Alan McStravick for redOrbit.com – Your Universe Online
A perfect storm of research studies has come together to show, if not a broken, at least a failing system of healthcare in the US. Researchers looked at the rate of acute emergency care and hospital readmission for patients who had been discharged no more than 30 days prior to their seeking additional care. The studies, published in this week´s issue of JAMA, were compiled by researchers at the Columbia University Medical Center, the Yale School of Medicine and Boston Children´s Hospital. Each of the studies looked not only at readmission to the hospital but also explored the wide variety of diagnoses, upon readmission, finding that they often differed from the original cause for hospitalization in the first place.
Hospital readmission has garnered significant interest from patient advocates, payers such as insurance companies, and policymakers, but neither the timing nor causes of readmissions have been, until now, well described.
The Columbia University Medical Center study, led by Kumar Dharmarajan, MD, MBA, focused on readmission rates among elderly patients who were originally admitted to the hospital due to heart failure, heart attack or pneumonia. These conditions are responsible for 15 percent of hospitalizations for older people. Dharmarajan and his team analyzed Medicare data collected between 2007 and 2009, comparing initial hospitalization with a readmission among this group within 30 days of the patients discharge from the hospital.
Contained in their findings, the researchers claimed, “Hospital readmissions are common and can be a marker of poor health care quality and efficiency. To lower readmission rates, the Centers for Medicare & Medicaid Services (CMS) began publicly reporting 30-day risk-standardized readmission rates for heart failure, acute myocardial infarction, and pneumonia after these measures were endorsed by the National Quality Forum. These measures are part of a federal strategy to provide incentives to improve quality of care by reducing preventable readmissions. Critical to the development of effective programs to reduce readmission is an understanding of the diagnoses and timing associated with these events. Insights into the diversity and variation of readmission diagnoses can illustrate the potential benefits of general vs. disease-specific interventions in reducing the overall number of readmissions.”
Over the two year period for which they collected data, the team was able to identify 329,308 30-day readmissions after 1,330,157 hospitalizations for the three specific diagnoses. Individually, the diagnosis of heart failure accounted for 24.8 percent of readmissions, heart attack accounted for 19.9 percent of readmissions, and pneumonia accounted for 18.3 percent of readmissions. With the exception of those patients originally hospitalized for pneumonia, most patients who returned to the emergency room were readmitted with a diagnosis different than for what they originally sought care for.
“Of all 30-day readmissions, we found that 61.0 percent of the [heart failure], 67.6 percent of the [heart attack], and 62.6 percent of the pneumonia cohorts occurred during days 0 through 15 following discharge. More than 30 percent of 30-day readmissions occurred during days 16 through 30 for all 3 cohorts,” the authors write.
“To reduce readmissions, doctors and hospitals should design interventions that apply broadly across multiple potential medical conditions and time periods associated with rehospitalization,” said lead author Dharmarajan. “Interventions that are specific to particular diseases or time periods may only address a fraction of patients at risk for rehospitalization. We need to be more holistic in our approach.”
“We are just now recognizing that upon leaving the hospital patients may have entered a transient period of generalized risk,” said senior author Harlan Krumholz, M.D., the Harold H. Hines, Jr. Professor of Medicine (cardiology) and professor of investigative medicine and of public health (health policy); director of the Clinical Scholars Program; and director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. “Patients need to know that they are at risk for rehospitalization from a wide variety of medical conditions.”
Lead author of the Yale School of Medicine research team´s findings, Anita Vashi, MD, a Robert Wood Johnson clinical scholar said, “It´s frustrating to see people ending up back in the emergency room so soon after leaving the hospital. It makes me wonder about the cause. Are we not educating them well enough about how to safely transition home? Or do we not have the capacity in the system for their care team to coordinate follow-up care if they have a complication? Either way, care that is fragmented in this manner can lead to conflicting recommendations, medication errors, distress, and higher costs.”
While Dharmarajan´s team maintained a strict focus on the impact of readmission on elder care, Vashi and her team took a broader approach to the issue. She and her researchers studied more than five million patients who were discharged from acute care hospitals across the three states of California, Florida and Nebraska, over the years 2008 and 2009. What they were able to determine from data they collected and analyzed showed that nearly 18 percent of hospitalized patients returned to the hospital within 30 days of their discharge. Vashi´s conclusions also supported Dharmarajan´s conclusions that the percentage of return patients was higher among elderly patients.
“The big question is how many of these emergency room visits could have been avoided by tightening up our healthcare system, and ensuring close collaboration and communication between patients and their health providers inside and outside the hospital,” said senior author Cary Gross, M.D., associate professor of internal medicine at Yale School of Medicine and director of the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) center at Yale. “Future work should focus on identifying how to decrease the need for patients to seek emergency room care right after they leave the hospital.”
Among Vashi´s findings was the fact that the highest emergency room rates were related to mental health, drug and alcohol abuse, and prostate issues. “High and varying rates of emergency room utilization suggest there is potential to improve care coordination and acute care delivery,” she said. “If we don´t expand our view of post-acute care from readmissions to include emergency room visits, we will severely underestimate patient needs and system resources required to care for them.”
In a partner study, conducted by Jay G. Berry, MD, MPH, and his colleagues at Boston Children´s Hospital, a national sampling of 72 children´s hospitals showed that while the readmission rate among discharged patients was lower than the other two groups, a full 6.5 percent of hospitalized children were unexpectedly readmitted within 30 days.
“Although readmissions for adults have been the subject of substantial research, readmissions for children have received less attention. “¦ To understand potential opportunities to improve pediatric practice and reduce readmissions, information is needed on which diseases have the highest number of readmissions and whether there are differences in readmission rates across hospitals.”
Berry and his team looked not only at unplanned readmissions, but also reviewed which diagnoses had the highest rate of readmission, and also if there were varying rates of readmission among the sample hospitals.
“Adjusted rates were 28.6 percent greater in hospitals with high vs. low readmission rates (7.2 percent vs. 5.6 percent). For the 10 admission diagnoses with the highest readmission prevalence, the adjusted rates were 17.0 percent to 66.0 percent greater in hospitals with high vs. low readmission rates. For example, sickle cell rates were 20.1 percent vs. 12.7 percent in high vs. low hospitals, respectively,” the authors write.
Additionally, the authors continued, ““¦ we found substantial readmission rate variation across children’s hospitals that remained after controlling for patient age and chronic conditions. If hospitals with the highest readmission rates in this study were able to achieve the rates of the best performing hospitals, then the overall count of readmissions would be much smaller. It is possible that the distribution of pediatric readmission rates in this study could help hospitals interpret their own performance, identify target conditions for quality improvement, and determine whether an examination of the causes of their readmissions would be useful.”
Viewing each component of the studies, the researchers from each workgroup found there was substantial variability affecting patients utilization of emergency acute care facilities across the 470 different index discharge conditions.
“Although patients returned to the [emergency department] for a variety of reasons, for the highest volume conditions, [emergency department] treat-and-release visits were always related to the index hospitalization,” the authors write.
“In conclusion, hospital-based acute care encounters are frequent among patients recently discharged from an inpatient setting. An improved understanding of how the [emergency department] setting is best used in the management of acute care needs–particularly for patients recently discharged from the hospital–is an important component of the effort to improve care transitions. The use of hospital readmissions as a lone metric for post-discharge health care quality may be incomplete without considering the role of the [emergency department]. Just as the Patient Protection and Affordable Care Act requires the development of programs to reduce readmissions, further initiatives are necessary to understand the drivers of post-discharge [emergency department] use and the clinical and financial efficiency associated with providing such acute care in the [emergency department].”