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Postop bouncebacks? Blame the surgeons
Early discharges may be the problem

Keywords: Hospital readmissions: Surgeons may be to blame for early discharges


by Paula S. Katz



Published in the September 2012 issue of Today's Hospitalist

SHOULD HOSPITALISTS REPLACE SURGEONS when it comes to deciding when to discharge postop patients? According to two recent studies, that may be the best way to prevent more readmissions of patients discharged when hospital utilization is running high.

One study, published in the March 2012 issue of Health Care Management Science, looked at the impact of surgical utilization on readmissions. The data, which covered 7,800 surgeries performed at one hospital in 2007, considered hospital occupancy rates, days of the week, staffing levels and patient age.

While an earlier study by some
"Have diagnosis and treatment done by different people."

–David Anderson
University of Maryland

of the same authors found that patients' discharge rate is much higher on days when there is an abnormally high surgical demand or high utilization, the March analysis went one step further. It found that patients discharged when the postop unit was close to capacity were not only more likely to be readmitted within 72 hours, but within 30 days as well.

When capacity of the postop unit topped 94%, for instance, 15.4% of patients discharged were readmitted within 72 hours vs. 10% when utilization fell below that level. And 30-day all-cause readmission rates were 55% for high-risk patients discharged when postop-unit utilization was over 94%. When postop-unit utilization was lower, the discharge rate for these patients was 50%.

Why? One of the studies' co-authors offers this explanation: Because surgeons are financially motivated to keep a full schedule, they're much more likely to let patients go a day or two earlier than normal to free up beds.

"If surgeons send a person home and that patient comes back, he is likely to be admitted to a general medical floor," says co-author David Anderson, a fourth-year PhD candidate at the R. H. Smith School of Business at the University of Maryland in College Park, Md. "Now, he's someone else's problem."

Some solutions the authors suggested—modifying how elective surgeries are scheduled, finding more postop beds, using discharge checklists to make sure patients are really ready to go home—are already receiving a positive reaction. And Mr. Anderson says that a solution not mentioned in the March article is the one that nonetheless stands the best chance of actually reducing readmission rates: putting hospitalists in charge of postop discharges.

Today's Hospitalist talked to Mr. Anderson about the study's findings.

Why did your focus on utilization break new ground?
Studies looking at the effects of length of stay on readmission and outcomes say that LOS doesn't matter as long as you stay in the hospital the right amount of time.

LOS is a problem when it's artificially shortened because of insurance, or because the patient can't pay or wants to go home, or because there are resource shortages. These people have significantly worse outcomes.

Our study finds artificial shortenings, and it isolates and identifies shortened LOS. It's really a mismatch of resource utilization. On any given day, there's a balance between a patient who needs surgery now and a patient who needs a bed so he's not readmitted in a week.

Why are surgeons taking the heat on this?
Surgeons are the people making decisions; they're the schedulers. But they're surgeons, so if they can do surgery today, they want to operate. We suggest that surgeons may discharge patients early to free beds.

Surgeons also can play games with beds and do bed blocking. Say there's high utilization and I'm worried because I have a surgery tomorrow and I can't operate because there's no bed. I may have a patient ready to go home today but I hold onto him until tomorrow, then discharge him and slip my patient into that bed.

One solution you proposed was to tie surgeons' compensation plans to readmission rates. Is this realistic?
There's only so much money, and it has to get distributed somehow. It doesn't matter if you call it a punishment or a bonus. It's a great idea, but politically we don't think it's going to happen.

What were other suggestions?
One was to find other beds for patients to recover in instead of postop units. But hospitals can be provincial. One section may say, "These are my beds and I don't want to share with you." That may be good for each slice, but bad for the hospital as a whole.

If sections can talk to each other, they can match supply and demand. There are some costs, but it's important to invest in additional training for nurses so there's more flexibility. Another idea was to use transition coaches. They're expensive, but it's cheaper to pay $20 an hour than for an extra hospital bed.

Which idea has had the most positive response?
People like the idea of discharge checklists. They are the easiest to implement even though they might yield the smallest benefit. These checklists would include how well patients are doing with activities of daily living and pain, and if they have somewhere stable to go home to. Using checklists would quantify that the patient is ready to go home rather than leaving it up to the subjective view of a surgeon.

Where do hospitalists fit in?
It's a big change to take decision-making out of surgeons' hands and give it to hospitalists, but our study would tend to support that. Surgeons' best interest is not always best for the hospital, and hospitalists make decisions based on what's best for the patient. Surgeons don't like giving up control, but it would free them up to do more surgery. This could be a win-win for both the surgeons and the hospital, but we may need to convince surgeons.

We mention using hospitalists (or a similar system) in our first study. We talk about how one typical answer to these problems is to have diagnosis and treatment done by different people. By decoupling the discharge decision from the people doing the surgery, we can help mitigate the misalignment of incentives.

Your findings were from a large academic center. Would you expect the same results in a smaller hospital?
The results might even be more pronounced in a smaller facility where there's a smaller margin for error. If you have 300 beds, you may have more wiggle room, resources and the ability to handle overflow than a smaller hospital. A big hospital also is more likely to have more marginal people closer to the borderline of being OK enough to discharge.

Are there other ways to better manage beds?
The key is to plan ahead. Hospitals run out of beds on Thursday and Friday because they do surgeries Monday through Wednesday and are empty over the weekend. Instead, schedule surgeries taking this cyclic variation in utilization in mind: short surgeries at the beginning of the week, longer ones at the end to flatten out the variation.

How do you get any of these changes made?
You need to get the CEO interested, or someone else who has a hammer and can use it.

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.

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