Posts Tagged hospital re-admission
What are the causes of hospital readmission? A previous post details the most significant factor: fragmentation of health care. This post focuses on disease and the condition of the patient at discharge.
Until the past 5 years the prevailing view of re-hospitalization was it is unavoidable due to the nature of the chronic disease. The view changed when studies showed strong outpatient social and medical management vastly reduce re-admissions.
And yet, disease does catch up with those afflicted causing eventual death. Sometimes patients are discharged from a hospital and much to the surprise of clinicians the patient is back in the hospital before outpatient care can engage to deal with a potentially unstable situation. Even before the outpatient check 4 weeks after discharge the person decompensates and is hospitalized again.
Frustration born out of rapid re-hospitalization lead Michael Rothman to develop a statistical method to alert clinicians before hospital discharge to the presence of high risk. Whether the outpatient care network is sufficiently robust to act on the information is possibly the bigger issue. But, consideration of the “Rothman Index” is worth a few comments.
Mr. Rothman published the statistical findings “Development and validation of a continuous measure of patient condition using the Electronic Medical Record” (Journal of Biomedical Informatics 46 (2013) 837–848).
Rothman found he could predict bad outcome (and hospital re-admission) based on routine measurements done in every hospital, just combined in a statistical way. He divided the measurements into 3 equally weighted groups of (1) lab tests, (2) nursing observations and (3) vital signs. Overall there were 26 items such as potassium level, nursing charting by exception (like normal or abnormal respiration), and blood pressure. The index started at 100 and if all items were normal the index stayed at 100. But, if items were abnormal an amount was subtracted. The lower the score the worse the situation. In fact, he showed his index correlated with the 1-year mortality of the patient. The lower the index at discharge the more likely was re-hospitalization and even death. Mr Rothman started a company to calculate the index for interested hospitals.
The idea is great: identify high risk patients and focus more outpatient resources quickly.
Doctors always try to normalize abnormal findings. If the heart rate is too high find out why and correct it. If the potassium is too low find out why and correct it. If the blood pressure is too low find out why and correct it. When the end of the hospitalization comes hopefully everything is in the normal range. The Rothman Index basically says that if a concerted effort by doctors fails to normalize findings it means the patient will do poorly (an abnormality caused by a stroke just can’t be normalized). The very definition of chronic illness is that it can not be resolved by modern medicine.
Rothman’s research shows some interesting findings. The 1-year predicted mortality is increased by 10% if any the following findings are present at discharge:
|Clinical item||absent or below||present or above|
|Blood Urea Nitrogen||–||25|
|White Blood Count||4,000||14.000|
|Heart Rhythm|| anything other than
|Braden Scale (link)||19|
| Nursing Assessment
| any body system
The Rothman Index is important and either that index or other similar index should be calculated at discharge. If the index indicates an increase in mortality then questions need to be asked and answered:
- Have the abnormal findings been investigated and treatment started — if an available treatment has not been started it should be.
- Has enough time passed for the abnormal finding to normalize — if not the patient should either stay in the hospital or be seen as an outpatient in just a few days.
- The estimate of a poor prognosis should be discussed with the patient and family to make sure they understand why follow up is important.
- If the estimate of poor prognosis is very high (over 50% 1-year mortality) and not expected to improve then planning for death should be started.
The cause of hospital readmissions is not a secret. Patients are readmitted to the hospital because the patient, physician or both are too optimistic about the patient’s situation: too optimistic about the patient’s social problems, too optimistic about the strength of primary care, or too optimistic about the possibility of surgical complications.
It feels better to be Optimistic than the alternative. It feels better to the patient to be going home. It feels better to the doctor to believe all is well. But, the data about readmissions suggest the feelings are not always accurate. Perhaps we should be optimistic there are ways to find and correct the reasons for readmission. Providers need to focus on solving more problems before discharge, not just the problem of sending the patient out the door. Providers need to follow a discharge check list, just like a pilot getting ready for takeoff – not just be optimistic the plane will do just fine.
Rehospitalization is often attributed to fragmentation of health care. So, what constitutes a non-fragmented (smooth) transition from hospital to home? The following is the basis of that preflight checklist:
- The hospitalization is long enough to make sure the patient is stable.
- Providers anticipate the day of discharge:
- the likely date of discharge is discussed at least twice
- on the day of admission
- when the patient is feeling better, at least 48 hours before actual discharge
- patient questions are answered
- minimize medication complexity
- absolute minimum number of meds
- simplify dose schedule (don’t mix intervals)
- educate about new medications
- explain and write down
- the reason the patient was hospitalized
- the final diagnoses
- the name of surgery performed
- the complete list of medications including
- home meds discontinued
- home meds continued at same or different doses
- new meds (make sure they are generic or on the insurance formulary)
- why each medication is needed
- financial problems addressed (can medications be purchased?)
- home social situation reviewed
- obtain home monitoring equipment (glucose meters, scales, blood pressure checkers)
- send needed prescriptions to the patient’s pharmacy electronically
- the likely date of discharge is discussed at least twice
- family engaged, discharge plans discussed with family
- visiting nurses called if needed
- primary care providers called and discharge summary faxed same day
- discharge instructions reviewed verbally and in writing with patient
- follow up appointments made
- specialty care as needed
- primary care within one week
- transportation arranged
- phone follow-up next day by discharging provider
What indicates high risk for rehospitalization?
- Intensive care stay
- Living alone
- Previous readmissions
- Lack of insurance
- No primary care provider
- Smoking or other substance abuse
- Congestive heart failure
- COPD or asthma
- Insulin dependent diabetes
- Surgical wound drainage
- Weakness or falling
- Over 15 lb wt loss
- No phone at home
- No transportation (except ambulance)
Rehospitalization may be foreshadowed during a hospitalization. Health care providers sometimes fail to notice wound drainage, night time confusion, low grade fever, shortness of breath, leg swelling, anxiety, or comments about the cost of medications. The errors of omission can be reduced by minimizing provider changes and hand-offs — so patients do not “fall through the cracks”. Providers should take a second look at labs, vital signs and nursing notes before giving the green light for discharge.
Sarah Needleman of the Wall Street Journal was the author of “Rx to Avoid Health-Law Fines” which appeared August 8, 2013. She reported on new companies that help hospitals reduce hospital readmissions by printing sensible discharge instructions and also by predicting the chance of readmission to help focus resources on high risk patients.
Discharge software is expensive and probably not more effective than a good checklist of risks. Most importantly, hospitals must have action plans for each high readmission risk factor (like no transportation or no phone).
The Robert Wood Johnson Foundation published “The Revolving Door: A Report on U.S. Hospital Readmissions” in February 2013. The report puts a strong focus on fragmentation of care, being a root cause of rehospitalization. The fragmentation can be significantly reduced by strong primary care, doing close follow-up after discharge, engaging additional social services if needed, extensively using the phone to communicate with patients who have chronic illness.
A good idea: phone follow up. Many primary care providers complain that post hospital phone calls are an unreimbursed expenses (so they don’t make the calls) — hospitals should consider paying a fee to primary care for phone calls during the month after discharge.
Another good idea: the hospitalist outpatient check. Some hospitalist groups actually have a discharge follow-up clinic for patients who had a long hospitalization or who have rehospitalization risks. The visit is usually a couple of days after discharge and is focused on solving problems before they become big problems and also to make the transition to a new or existing primary care provider.
Hospitals have ignored the obvious problem of patients returning to the hospital soon after discharge. Decades of re-admissions have enriched hospitals — same charges over and over. Now re-admissions for heart attacks, heart failure and pneumonia lead to Medicare penalties. The problem is widespread and as always worse in some parts of the country.
The above graph comes from a an excellent Medicare study. It show a high rate of re-admission after pneumonia in some areas (dark blue). It should come as no surprise that some hospitals have been able to quickly drop the re-admission rate by 20% (because they were not trying very hard before).
Why did hospitals not care?
- Re-admissions were profitable
- Avoiding re-admission was considered an outpatient problem
- It was the patient’s fault for not taking the medications they were prescribed at discharge (no matter what the cost).
- Hospitals have no control over outpatient doctors.
- Dr. Donald Berwick cared. He was the administrator of Medicare who initiated the penalties.
- Hospitals purchased doctor practices — so now they really do control the outpatient doctors and thus assume a greater responsibility.
- Over 75% of cardiologists work for hospital systems
- Over 50% of primary care work for hospital systems
- Many health systems operate visiting nurse services.
- Hospitals have no excuse for failing connecting discharged patients with primary care (they own primary care)
- Hospitals have no excuse for failing to engage patients in heart failure clinics (they own cardiology).
- Hospitals must take an interest in what medications are prescribed at discharge — the right medications and generic medications if possible.
What can patients do to cut the odds of re-admission? According to a report by Jason Kane of PBS there are 7 things a patient can do:
- Work with the hospital to plan ahead (days before discharge)
- Understand your illness and ask questions about your health care
- Have a written discharge plan
- Understand your medications
- Don’t go it alone
- Follow through with follow-up care
- Find out how good the care is in your community for patients leaving the hospital.
A word of caution: just because you have been re-admitted, it does not mean you need to be on hospice care — indeed that will stop re-admissions but perhaps not the way you want (dead patients don’t return).
Your ace in the hole: strong primary care. The hospital team MUST communicate with primary care — make sure they do. A quick follow-up appointment and several short interval appointments will help to get back on track with the management of chronic illnesses. If you were just in the hospital for a heart attack, congestive heart failure or pneumonia (or other chronic conditions) an appointment in 6 months is totally inappropriate.