Monday, August 29, 2011

Readmission After Hospital Discharge is Not an Indication of Poor Care

Hospitals across the country are working on quality initiatives to reduce re-admissions to hospitals.  There are consultants, conferences, forums, meetings, physicians, nurses and administrators who are spending hours upon hours (and lots of $$$) to find ways to keep patients who have been discharged from being readmitted within 30 days.  Why all of this activity?  It is one of the quality measures that is being tracked by Medicare and Medical (CMS) and decreased reimbursement will be next if a patient is readmitted to any hospital within 30 days of a discharge. The diagnosis doesn't matter.

A new study shows all of this focus and cost may not be worth it.  Readmission after a hospital discharge may not be an indication of poor care.

The study, published in the Canadian Medical Association Journal looked at 4,812 patients and had medical experts review the cases of the 649 who needed urgent readmission within 6 months. (Not one month as we are measuring).  They found that avoidable readmissions were relatively uncommon.  Only 16% could have been prevented by better care, oversight or management of their condition.  And a tiny number of readmissions within 30 days, as we are tracking, were potentially avoidable.

This makes sense to me.  They found patients who were readmitted had more previous hospital admissions and more extensive health issues.  And the patients in this study were even younger than the typical Medicare patient.  No one wants to be in the hospital.  Doctors do not want to admit patients unless they are very very ill.   Patients who have many medical problems like heart failure, strokes, liver failure, cancer etc tend to decline in health as time goes on.  All of the out-patient care and case management cannot always prevent declines.  The study points out that we might be measuring the wrong thing if we think it is a measure of medical quality. 

They did find some urgent readmissions were avoidable.  But it didn't vary by hospital ranking so either all hospitals are performing the same or it isn't really a measure of quality. 

Message to CMS:  Judgments about readmission cannot be determined on the basis of administrative data alone and it requires subjective judgement, detailed patient data, multiple reviewers and an analysis that accounts for differing reviewer accuracy when collating judgments.  This is a big waste of money.  Readmission within 30 days (or 6 months) of discharge is not a marker of quality care.




9 comments:

Solitary Diner said...

Great post. Another downside to creating any sort of penalty for readmissions is the inevitable side effect of hospitals keeping patients longer than is required, thus leading to higher total costs per admission and higher rates of hospital-associated complications.

Nikko Marasigan said...

I agree, readmission is not an indication of Poor hospital care, it depends on some situation. History of patients etc etc...

btw nice read.

Michael Kirsch, M.D. said...

Yes, there is a new definition of medical quality. If you can measure it, then it must be quality. I think all these 'quality' and pay-for-performance initiative is moving the profession toward mechanical mediocrity. We need to push back on this.

Jennifer Giusti said...

Good blog on readmissions. I basically agree regarding any administrative data measures. But, I will say that when I worked on the Telemetry unit I was continually frustrated by the frequent flyer heart failure patients. I knew darn well that if they had proper monitoring and care after discharge they wouldn't be in our unit again so soon. I actually hatched a plan to partner with one of our cardiologists and start a heart failure clinic where we would do telemonitoring, patient teaching, and bring patients in for a little IV lasix in the infusion center when needed. So much of what we did in the hospital could have been managed outpatient, especially if we caught them before they couldn't breath. All that said, I don't know that 30 day readmit rates will get us where we need to go.

Anonymous said...

Great idea: planned, organized outpatient care to prevent inpatient care. We need more of that !

Anonymous said...

Well, readmission after abdominal surgery for abdominal leakage seems to be preventable with appropriate guidelines, yes?

www.sevilla-3d.com said...

Wow, there is a lot of helpful data above!

Anonymous said...

Yes, some patients DO want to be in the hospital. I've seen it time and time again when I worked in the ER at the local hospital. No real need to be hospitalized but they felt "safe" there. My Mom is a classic case - hospitalized 6 times within 6 months - for hip pain. Numerous CT scans, xrays, etc., every time. Each hospitalization lasted 3-5 days. She immediately felt better once she was admitted.

Toni Brayer, MD said...

Anon: I can't help but wonder if your mom had some skin in the game (ie: a hefty copay) if she would still like being admitted.

Did her pain keep her from walking? Did she have a primary care doctor or an orthopedic doctor to work with her as an out-patient on chronic pain? If being hospitalized was the only way she could get anxiety and pain relief that is too bad but understandable. Repeating the same tests over and over just shows poor communication from Emergency departments, caregivers and hospital doctors.

The primary care physician who knows the patient is the best preventive for unneeded hospitalizations. Thanks for commenting