Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission

A Systematic Review and Meta-analysis

Published in: JAMA Internal Medicine, 2017;177(7):975-985. doi: 10.1001/jamainternmed.2017.1136

Posted on RAND.org on July 12, 2017

by Teryl K. Nuckols, Emmett B. Keeler, Sally C. Morton, Laura Anderson, Brian Doyle, Joshua M. Pevnick, Marika Booth, Roberta M. Shanman, Aziza Arifkhanova, Paul G. Shekelle

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Importance

Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value.

Objective

To systematically review economic evaluations of QI interventions designed to reduce readmissions.

Data Sources

Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016).

Study Selection

Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs.

Data Extraction and Synthesis

Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs.

Main Outcomes and Measures

Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Results

Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10,445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P<.001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P<.001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, -$642 to $2586; P=.23; 24 studies), and the mean net loss was $169 among general populations (95% CI, -$2610 to $2949; P=.90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs -$6568; P=.006).

Conclusions and Relevance

Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.

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