Hospital administrators charged with reducing patient readmissions have an even tougher job than they thought. While the industry has kept its readmission-reduction efforts largely focused on direct care improvements, such as in transitions and care coordination, a new study indicates other, broader factors may influence hospital readmission rates.

Researchers with the Dartmouth Institute for Health Policy & Clinical Practice examined outcomes for Medicare patients hospitalized for heart attacks and found an unsurprising association between readmission rates and quality of care at discharge. But they also found an association between readmissions and both the supply of primary care physicians and intensity of care in the last six months of life.

Those findings mean hospital executives may have to alter their approach to reducing readmissions. “There might be added benefit toward targeting and looking at overall population health management,” says Jeremiah Brown, assistant professor at the Dartmouth Institute and lead author of the study, published online by the Journal of the American Heart Association.

“You can do the best you can with transitional care planning — and we’re dropping the readmissions rate very slowly, about 2 percent overall in the last couple of years — but the overall system and how patients are being managed also needs to be looked at,” Brown says.

Nancy Foster, vice president of quality and patient safety policy for the American Hospital Association, says the results indicate that if hospital officials can identify strategies to reduce the propensity by medical staff to admit patients, they could possibly reduce admissions and readmissions. Foster notes that doing so, like other changes taking place in health care, hurts a hospital’s revenue in its still sizable fee-for-service covered care.

Nonetheless, hospitals are addressing population health management with new programs. “Many hospitals are now doing really innovative things in working with their communities, particularly around patients who have a chronic disease or disorder that may result in hospitalization,” Foster says.

One example: hospitals that partner with schools to ensure that asthma patients have needed medicine. Another: hospice care that allows patients near the end of life to choose how they want to be managed. “Rarely does that come across as a patient saying, ‘Yes, I would like to be in the hospital,’ ” Foster says.

Strategies like those can reduce the need to admit or readmit patients to the hospital.

Additional data on how effective different strategies are in reducing readmissions are expected. Dartmouth’s Brown says the institute will continue its research with a broader population, perhaps among all medical or all surgical patients.