Study authors note several possible reasons that LOS improved at the VA without adversely impacting the 30-day hospital readmission rate.

One possible explanation is inefficiencies in care at VA facilities, according to the report, which cited a 1982 General Accounting Office report suggesting that 43% of days in VA hospitals were “medically avoidable.”

The authors also noted internal studies finding that reduction in LOS in VA hospitals had not kept up with private-sector hospitals, although it was improving.

In a more positive take, the study cited VA’s Flow Improvement Inpatient Initiative, begun in 2006 to improve hospital flow.

“Although the focus was on inpatient flow, these efforts may have resulted in

changes in transitions of care that also improved readmission rates,” according to the study, which also made note of VA’s “extensive medication reconciliation efforts at the time of hospital transitions of care, an initiative shown to reduce readmissions.”

The use of a hospitalist model of care at the VA also could have contributed to the better outcomes, according to the authors. The study pointed out that, while only 10% of VA hospitals employed hospitalists in 1997, more than 65% did so by 2007.

“The use of hospitalists for inpatient care has been shown to reduce LOS by up to 15% and improve other measures of quality, although no studies have reported reduced readmissions,” according to the study.

While hospital readmission rates can be a valuable metric in some ways, according to an accompanying editorial written by two researchers from the Center for Health Services Research in Primary Care at the Durham, NC, VAMC, “hospital readmission rates may be a poor measure of quality of care because of the complexity of factors that cause them and the poor correlation among those factors.

“It’s not only the quality of care during the index hospitalization or the quality of the handoff to post-discharge care that influences readmission rates,” writes Eugene Z. Oddone, MD, MHSc, of the Duke University School of Medicine and Morris Weinberger, PhDm, of the Gillings School of Global at the Public Health, University of North Carolina at Chapel Hill, NC. “Rather, many important factors affect when and how often patients are hospitalized, including access to post-discharge care, ability to purchase evidence-based medications or services prescribed at discharge, disease and disease severity, socioeconomic status, community resources, and social support.”

Study authors agreed that LOS and readmission rates alone do not provide a complete picture.

“Recent discussions about proposed modifications to the Medicare prospective payment system, such as payments by acute care episode (that is, bundled payments), raise important questions about identification of appropriate rates of hospital readmission,” they write. “For chronic illnesses, such as COPD and cancer, repeated hospital admissions may represent appropriate care. Even patients with terminal conditions who are enrolled in hospice care are readmitted for symptom management to improve quality of life.

“Thus, it is neither possible nor desirable to expect complete elimination of 30-day readmissions, and efforts to reduce readmissions may have unintended consequences. Reporting hospital readmission rates should be coupled with rates of return to the emergency department, use of home care services and outpatient clinic care to identify shifting of resource use.”