Brian Doyle

Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission: A Systematic Review and Meta-analysis

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 Medicines 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

Challenges in Assessing the Process–Outcome Link in Practice

972 among patients with HF (95% CI, −

Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: a randomised controlled trial

642 to

Economic Evaluation of Quality Improvement Interventions for Bloodstream Infections Related to Central Catheters: A Systematic Review

2586; P = .23; 24 studies), and the mean net loss was

Economic Evaluation of Quality Improvement Interventions Designed to Improve Glycemic Control in Diabetes: A Systematic Review and Weighted Regression Analysis

169 among general populations (95% CI, −

Supplemental insurance reduces out-of-pocket costs in medicare observation services.

2610 to

In reference to “Patient financial responsibility for observation care” and “observation versus inpatient hospitalization: What do medicare beneficiaries pay?”

2949; P = .90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings (

Opioid Prescribing: A Systematic Review and Critical Appraisal of Guidelines for Chronic Pain

1714 vs −

Minimizing Medication Histories Errors for Patients Admitted to the Hospital Through the Emergency Department: A Three-Arm Pragmatic Randomized Controlled Trial of Adding Admission Medication History Interviews by Pharmacists or Pharmacist-Supervised Pharmacy Technicians to Usual Care

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.

Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission

The expanded use of clinical process-of-care measures to assess the quality of health care in the context of public reporting and pay-for-performance applications has led to a desire to demonstrate the value of such efforts in terms of improved patient outcomes. The inability to observe associations between improved delivery of clinical processes and improved clinical outcomes in practice has raised concerns about the value of holding providers accountable for delivery of clinical processes of care. Analyses that attempt to investigate this relationship are fraught with many challenges, including selection of an appropriate outcome, the proximity of the outcome to the receipt of the clinical process, limited power to detect an effect, small expected effect sizes in practice, potential bias due to unmeasured confounding factors, and difficulties due to changes in measure specification over time. To avoid potentially misleading conclusions about an observed or lack of observed association between a clinical process of care and an outcome in the context of observational studies, individuals conducting and interpreting such studies should carefully consider, evaluate, and acknowledge these types of challenges.