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The Buck Stops with Discharge Planning
Abstract & commentary
By Barbara A. Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington. Dr. Phillips is a retained consultant for Cephalon and Ventus, and serves on the speakers bureau for Cephalon and Boehringer Ingelheim.
Synopsis: Almost one-fifth of Medicare patients who were discharged from a hospital were rehospitalized within 30 days, and about a third were rehospitalized within 90 days. Most of these readmissions were not planned.
Source: Jencks SF, et al. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360:1418-1428.
This study is the result of a collaboration from the Division of Hospital Medicine at Northwestern University, the Division of Health Care Policy at the University of Colorado, and an independent consulting practice. The first author worked for the Centers for Medicare and Medicaid Services (CMS) until recently. The purposes of the study were to determine the current rate of rehospitalization for Medicare patients, how long the risk for rehospitalization is elevated after a hospital discharge, and the frequency of outpatient visits for recently discharged patients. The authors used data from the Medicare Provider Analysis and Review (MEDPAR) file for a 15-month period in 2003-2004. Inpatient claims for individual patients were linked by the Health Insurance Claim Number-Beneficiary Identification Code. To investigate outpatient visits after discharge, the authors used a national sample of linked physician and hospital claims for 2003. Rehospitalization was defined as discharge from an acute care hospital with subsequent readmission to any acute care hospital within 30 days. Transfers to other health care facilities (e.g., rehabilitation) were excluded from analysis.
The investigators identified the 5 medical and 5 surgical diagnosis related groups (DRGs) that accounted for the largest number of rehospitalizations within 30 days after discharge and evaluated the 10 most frequent reasons for rehospitalization for each DRG. They estimated the fraction of rehospitalizations that might have been planned by considering whether planning was clinically likely for each DRG (e.g., decompensated heart failure vs elective hip surgery).
Each hospital's expected rehospitalization rate was calculated as the rehospitalization rate expected if each of its Medicare patients who were discharged had the same rehospitalization risk as the national average for Medicare discharges in the same DRG. Hospitals were then stratified into quartiles of rehospitalization risk. The investigators then assessed whether the patient was readmitted to the same hospital from which he or she had been discharged. They also tabulated length of stay and Medicare payment weights for DRGs for rehospitalized patients and for those who had not been hospitalized in the previous 6 months.
Over the course of the study period, 13,062,937 patients were discharged from 4926 hospitals; 516,959 of these patients died and 690,276 were transferred, so there were 11,855,702 patients at risk for rehospitalization. One in 5 (19.6%) of these patients was rehospitalized within 30 days, a third (34.0%) within 90 days, and more than half (56.1%) within a year. Of note to readers of this publication, the rate of readmission or death for medical patients was higher (62.9%) than for surgical patients (51.5%).
The most common medical reasons for readmission were heart failure (26.9%), pneumonia (20.1%), COPD (22.6%), psychoses (24.6%), and "GI problems" (19.2%). The most common surgical reasons for readmission were cardiac stent replacement (14.5%), major hip or knee surgery (9.9%), other vascular surgery (23.9%), major bowel surgery (16.6%), and other hip or femur surgery (17.9%). The authors estimated that about 90% of rehospitalizations were unplanned (e.g., for pneumonia) rather than planned (e.g., for cardiac stenting).
There were definite geographic variations in the rates of hospitalization, with Western, less-populated states tending to have slightly lower rates. The rehospitalization rate was 45% higher in the 5 states with the highest rates than in the 5 states with the lowest rates. The correlation between the number of patients discharged from a given hospital and the rate of rehospitalization was low. But those hospitals with fewer discharges tended to be more likely to have readmissions of patients to different facilities than those with more discharges.
The average hospital stay for rehospitalized patients was slightly longer than the stay for patients with the same diagnosis who had not been hospitalized within the previous 6 months. Predictors of rehospitalization included the hospital's performance (the ratio of observed to expected hospitalizations), the patient's diagnosis, the number of previous hospitalizations of that patient, length of stay for the original hospitalization, black race, disability, end-stage renal disease, receipt of supplemental security income, male gender, and increasing age. The reason for the index (original) hospitalization (i.e., the DRG), the number of previous hospitalizations, and the length of stay had more influence on the risk of rehospitalization than demographic factors such as age, sex, black race, SSI status, and presence or absence of disability.
Having an outpatient visit soon after discharge appeared to protect somewhat against rehospitalization. There was no associated bill for an outpatient visit for 50.1% of the patients who were rehospitalized within 30 days after discharge and for 52.0% of those who were rehospitalized for heart failure within 30 days after discharge.
Like many articles on health care patterns and policy, this one was picked up by the lay press. The focus in my local paper1 was that our current Medicare reimbursement policy actually encourages readmission, by paying for each hospitalization separately. Medicare payments for unplanned rehospitalizations in 2004 accounted for about $17.4 billion of the $102.6 billion in hospital payments from Medicare,2 making them a large target for cost reduction. Some policymakers have suggested that Medicare cut payments to hospitals with high readmission rates as an attempt to address this trend. Certainly, something needs to be done.
In their well-written discussion, the authors discuss ways to reduce rates of rehospitalization. These include interventions at the time of discharge, supportive palliative care, and appropriate use of home health care.3-7 In addition, the results of this study indicate that prompt outpatient follow-up after discharge is associated with a reduced risk of rehospitalization. This is likely to be true both for surgical and for medical patients, since this study demonstrated that a substantial majority of postsurgical rehospitalizations are for medical conditions.
You can bet that we will be hearing more about this ... .
1. Lexington Herald-Leader. April 1, 2009.
2. Medicare & Medicaid statistical supplement. Baltimore, MD: Centers for Medicare & Medicaid Services; 2007. Available at: www.cms.hhs.gov/MedicareMedicaidStatSupp/downloads/2007Table5.1b.pdf. Accessed March 9, 2009.
3. Coleman EA, et al. The care transitions intervention: Results of a randomized controlled trial. Arch Intern Med 2006;166:1822-1828.
4. Naylor MD, et al. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. J Am Geriatr Soc 2004;52:675-684.
5. Jack BW, et al. A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Ann Intern Med 2009;150:178-187.
6. Brumley R, et al. Increased satisfaction with care and lower costs: Results of a randomized trial of in-home palliative care. J Am Geriatr Soc 2007;55:993-1000.
7. Rollow W, et al. Assessment of the Medicare quality improvement organization program. Ann Intern Med 2006;145:342-353.