Do Pay-for-Performance Incentives Lead to Higher Patient Readmission Rates?

Pay for performance (P4P) incentive programs, which have been implemented in various hospitals worldwide, can lead to patient discharges associated with return visits and readmissions (RA), according to a study published in Academic Emergency Medicine.

To conduct this study, researchers analyzed 813,491 patient visits to the four major EDs in the metro Vancouver area. The visit data they analyzed were all recorded in the National Ambulatory Care Reporting System from April 2013 to March 2016. The study period was divided into two phases: the pretermination phase took place between study inception to March 2014, during a period when the P4P program was in effect in all four of the study EDs, and the posttermination period which occurred between April 2014 and March 2016, when the P4P program was discontinued.

Each patient visit comprised demographic information, arrival mode (walk in or ambulance), chief complain system and description, triage acuity code, disposition decision (discharged or admitted), time or arrival, time to see a doctor, as well as the LOS in the ED. Each patient was classified into discharged or admitted by the disposition decision. The study’s primary endpoint was the LOS distribution directly monitored by P4P.

Evaluating Target Length of Stay Times

According to the results of the study, before the P4P program was discontinued, in all four EDs, the LOS density of admitted patients suffered a significant drop at the P4P 10‐hours admission LOS target. The study observed similar findings among discharged patients at the 4‐hours discharge LOS target, but only in the two lower‐volume EDs.

Moreover, in a lower‐volume ED, the results showed that patients who were discharged right before the 4‐hours P4P LOS target had a higher 7‐day RA rate than patients discharged subsequent to the LOS target. Furthermore, following the termination of the discharge incentive, the discontinuity at the discharge LOS target became less evident, however patients were still more frequently admitted just before 10 hours in three of the four EDs as the local health authority continued to support the admission incentive scheme after the government terminated the P4P program.

“Our findings suggest that the pay‐for‐performance program implemented in British Columbia affected the timing of patient disposition in the participating EDs. Such influence includes reduction in the ED length of stay for admitted patients, but possibly higher return‐and‐admission rate for patients who were discharged right before the target time in certain Eds,” the study authors wrote in their conclusion.

“These observations suggest that we may only include the admission time target in a length of stay–based pay‐for‐performance program for now. While implementing the discharge target calls for further justification, one may consider combining it with other measurements preventing the potential risk of discharging patients prematurely.”