Article Title Hospital Readmissions Published By Pramit Sengupta, Georgia Institute of Technology Hospital Readmissions Overview of Hospital Readmission A readmission is defined as a hospitalization that occurs shortly after a discharge; which is most often measured as within 30 days but it could be shorter or longer. Such readmissions are often but not always related to a problem inadequately resolved in the prior hospitalization, such as a hospitalacquired infection or unstable heart functioning. They also can be caused by deterioration in a patient s health after discharge due to inadequate management of their condition, misunderstanding of how to manage it, or lack of access to appropriate services or medications. Therefore, interventions to reduce readmissions target both inpatient care, through efforts to improve the quality and safety of care, and the transition to outpatient care, through efforts to ensure continuity and coordination between providers and timely access to needed follow-up services. At a time when health care leaders are driven to reduce waste and inefficiency, eliminating unnecessary readmissions has been identified as a desirable and achievable goal by both practitioners and policymakers. For most patients who leave the hospital, the last thing they want is to return anytime soon. Yet, many Medicare patients discharged from an inpatient stay find themselves back in the hospital within 30 days. Some of these readmissions are planned, and others may be part of the natural course of treatment for specific conditions; but, increasingly, some hospital readmissions are being thought of as avoidable and as indicators of poor care or missed opportunities to better coordinate care. Multiple factors contribute to avoidable hospital readmissions: they may result from poor quality care or from poor transitions between different providers and care settings. Likewise, such readmissions may occur if patients are discharged from hospitals or other health care settings prematurely, are discharged to inappropriate settings, or do not receive adequate information or resources to ensure continued progression. A lack of system factors, such as coordinated care and seamless communication and information exchange between inpatient and community-based providers, may also lead to unplanned readmissions. Hospital readmissions are massively expensive. A recent study of Medicare patients found that one in five admissions results in a bounce back within 30 days of discharge, costing the federal government an estimated $17.4 billion per year.
Significant variability in 30-day readmission rates across U.S. hospitals suggests that some are more successful than others at providing safe, high-quality inpatient care and promoting smooth transitions to follow-up care. The hospitals with low readmission rates also seek to ensure smooth care transitions as their patients are discharged helping to avoid the deterioration in health status that often brings patients back to the hospital. The hospitals identify and target patients at the highest risk for readmissions, particularly heart failure patients, the very elderly, patients with complex medical and social needs, and those without the financial resources to obtain post-hospital care. Causes for Hospital Readmission The causes of readmissions may be inferred from differences in their rates among various patient populations. Of all discharges from general acute care hospitals, the proportion of readmissions has been reported to be 5% to 14% after 1 month and 32% to 49% after 1 year. Somewhat higher rates have been reported for geriatric patients, i.e., 12% to 16% after 1 month, 60% to 64% after 6 months, and 34% to 67% after 1 year. The highest readmission rates have been observed in high-risk or severely ill geriatric patients, mostly with heart failure and chronic obstructive pulmonary disease, i.e., 35 % after 1 month, 26% to 44% after 4 to 6 and 70% after 1 year.
The 20 most frequently diagnosed diseases or conditions at initial hospitalization for the readmission and comparison groups are presented in Table1. Diabetes mellitus (17.0%), fluid/electrolyte disorder (16.4%), essential hypertension (14.4%), nondependent drug abuse (10.2%), and heart failure (10.1%) were the most frequent diagnoses for patients who were subsequently readmitted within 90 days; whereas single live birth (25.9%), fluid/electrolyte disorder (12.8%), essential hypertension (12.6%), and diabetes mellitus (11.0%) were the most frequent diagnoses for non-readmitted patients. While patients readmitted within 30 days and those readmitted within 31-60 days were similar in their diagnostic characteristics at the initial hospitalization, patients readmitted within 61-90 days were more likely than patients admitted within 60 days to have had diabetes mellitus, hypertension, heart failure, and chronic airway obstruction diagnoses (Table 2). Measures to Reduce Hospital Readmission A review of studies published from 1998 to 2008 revealed that a variety of quality improvement and process redesign approaches have lowered readmission rates, including: close coordination of care in the post-acute period, early post-discharge follow-up care, enhanced patient education and selfmanagement training, proactive end-of-life counseling, and extending the resources and clinical expertise available to patients over time via multidisciplinary team management. The California HealthCare Foundation profiled nine efforts in the state that sought to coordinate post-hospital care across settings, reconcile patients medications, schedule follow-up appointments, and engage patients and families in managing health needs. Now it is working with a set of hospitals to implement changes that may reduce readmissions.
A case study done of hospitals with low readmission rates offer the following lessons for hospitals seeking to reduce avoidable readmissions: Invest in quality first: care for patients correctly and readmission rates fall, performance on quality measures improves, and savings are realized as byproducts. Use of health information technology (e.g., electronic health records, patient registries, and risk stratification software) to improve quality and integrate care across settings. Begin care management and discharge planning early, target high-risk patients, and ensure frequent communication across the care team. Educate patients and their families in managing conditions. Teach at a level appropriate to patients and ensure they understand and can teach back key instructions. Maintain a lifeline with high-risk patients after discharge through telephone calls, tele monitoring, or other practices. Align hospitals efforts with those of community providers to provide a range of care. While this may be best achieved in integrated systems, such cooperation can be facilitated through collaborative relationships among hospital and community providers. Solutions to Reduce Hospital Readmission The measures that can be taken by a hospital to reduce re-hospitalization can be as follows: 1. Educate the patient about his or her diagnosis throughout the hospital stay 2. Make appointments for clinician follow-up, test result follow up, and post-discharge testing 3. Organizes post-discharge services 4. Confirm the medication plan 5. Reconciles the discharge plan with national guidelines and clinical pathways 6. Gives the patient a written discharge plan and assess the patient s understanding of the plan 7. Tell the patient what to do if a problem arises 8. Expedites transmission of the Discharge Résumé (summary) to outpatient providers
References 1. Centers for Medicare and Medicaid Services 2. Centers for Medicare and Medicaid Services Research, Statistics and Data Systems 3. Reducing Hospital Readmissions by Jenny Minott 4. Reducing Hospital Readmissions: Lessons from Top-Performing Hospitals The Commonwealth Fund. Authors: Sharon Silow-Carroll, M.B.A., M.S.W., Jennifer N. Edwards, Dr.P.H., M.H.S., and Aimee Lashbrook, J.D., M.H.S.A. 5. Classifying Reasons for hospital readmissions PubMed.gov US National Library of Medicine. Hughes MR, Johnson NJ, Nemeth LS. Division of Outcomes Management, Research, and Development, Medical University of South Carolina, Charleston, USA 6. Anatomy of Hospital bounce back by Paul D. Abramson, MD, MS 7. Mayo Clinic Readmission Rates 8. Health Reform Takes Aim at Hospital Readmission Rates 9. Characteristics and Risk Factors for Hospital Readmission in the Ohio Medicaid Population 10. Effective Interventions to Reduce Re-hospitalizations: A Compendium of 15 Promising Interventions