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A new twist on readmissions

January 2012

Published in the January 2012 issue of Today’s Hospitalist

A new twist on readmissions

RESEARCHERS CRUNCHING MEDICARE DATA have identified a new culprit in high readmission rates: a hospital’s number of initial admissions for heart failure and pneumonia, which authors say varies by regional referral areas.

Writing in the Dec. 15 New England Journal of Medicine, the authors pointed out that poor discharge planning and comorbidity severity are factors in 30-, 60- and 90-day readmission rates. But in their analysis of Medicare admissions and readmissions from January 2008 through June 2008, researchers found stronger correlations between readmissions and hospitals’ number of initial admissions for patients with either of those two conditions.

They noted, for instance, that regions with more cardiovascular specialists have more heart failure admissions “and, subsequently, more heart failure readmissions. Regional readmission rates for heart failure ranged from 11% to 32%, while readmission rates for pneumonia patients ranged from 8% to 27%.

Payment incentives may need to change to reduce the number of initial hospitalizations, the authors concluded. They noted that reimbursement methods such as capitation, which rely on shared savings across an episode of care, may provide an incentive to curb initial hospitalization rates.

The drugs behind emergency adverse events

A REVIEW OF 2007-09 DATA finds that adverse drug events account for 1.5% of all emergency room visits and emergency hospital admissions among patients age 65 or older, with four drug classes causing two-thirds of those events. Almost half of those adverse events occurred in patients over age 80.

The analysis, which appeared in the Nov. 24 New England Journal of Medicine, looked at data from nearly 60 hospitals. It found that 33% of adverse events were related to warfarin while 14% involved insulins, 13% involved oral antiplatelets and 11% were caused by oral hypoglycemics.

Based on their sample, study authors estimated that more than 99,600 emergency hospitalizations took place in the U.S. per year for adverse drug events in the years covered by the research. Two-thirds of those hospitalizations, authors wrote, were due to unintentional overdoses.

The authors cautioned that drugs in those classes should be targeted for medical reconciliation efforts and should be more aggressively monitored post-discharge.

Low marks for door-in-door-out times

AN ANALYSIS OF DATA from more than 1,000 hospitals found that very few hospitals can transfer STEMI patients to other facilities for PCI in 30 minutes or less, the time recommended by national guidelines.

Researchers looking at records for nearly 14,000 transferred patients in 2009 learned that only 9% of those transfers occurred within that 30-minute time frame. (Transfers for 31% of patients took more than 90 minutes.) The study also indicated that transfer times for women were nearly nine minutes longer than for men, and more than nine minutes longer for African Americans than for whites. The study appeared in the Nov. 28 Archives of Internal Medicine.

Less than one-quarter of U.S. hospitals have PCI capability. An accompanying editorial noted that because EDs aren’t capable of hitting door-in-door-out benchmarks, other strategies need to be considered.

Chief among those alternatives, editorialists wrote, is not transferring STEMI patients with low or intermediate risk and instead ensuring that those patients get timely thrombolytic reperfusion at their original hospital.

Expanded use of tPA?

A NEW REVIEW BY SCOTTISH RESEARCHERS finds that ischemic stroke patients with diabetes, a previous stroke or both have better outcomes with tPA than patients who have those conditions but don’t receive thrombolysis.

The study, which was published online in November by Neurology, reported that in the U.S., diabetes or previous stroke are considered to be contraindications for tPA within the expanded administration time frame of between three and four and a half hours. In Europe, the authors wrote, diabetes and prior stroke are considered contraindications for the therapy at any time.

However, according to data on 29,500 patients, those who were diabetic, had had a previous stroke or both did significantly better than patients with those conditions who did not receive tPA. In addition, patients with diabetes, a prior stroke or both who received tPA had similar outcomes, as measured by 90-day modified Rankin scoring, as patients who received tPA and had no diabetes or previous stroke.

The authors concluded that these patient populations shouldn’t be excluded from receiving thrombolytic therapy.

The age of “distracted doctoring”

AS HOSPITALS FIND NEW WAYS for physicians to use tablets and smartphones to improve safety, there is growing concern that doctors and hospital staff are surfing the Web and staying connected “to the detriment of patient care.

An article in the Dec. 15 New York Times looking at “distracted doctoring” found that some hospitals are banning the use of personal devices in critical areas such as operating rooms. Some hospitals are also limiting medical students’ use of portable electronics.

The article states that a neurosurgeon has been sued for making personal phone calls during an operation in which the patient was left partially paralyzed.

Even doctors who use technology only for patient care are running the risk of spending more time on “the iPatient,” according to one source in the article, than relating to the actual patient in the bed.

A report released last month by a consulting firm that develops mobile learning apps claimed that 80% of U.S. physicians are already using smartphones and medical apps. In addition, the report said, 30% of practicing physicians have already purchased an iPad, with 28% more planning to buy one within the next six months.

Ready for room service?

IN ONE OF THE LATEST BIDS to boost patient satisfaction levels, some hospitals are now switching from traditional food service to patient room service, allowing patients to order from a restaurant-style menu and delivering food to their rooms within 45 minutes.

Emory University Hospital Midtown is now employing the room service model, according to an Emory press release. The payoff is expected to come not only in higher levels of patient satisfaction, but in allowing patients to schedule meals around tests and procedures and helping them maintain the same eating schedule they have at home with their medications.

The same approach has been in place for several years at two hospitals in Illinois: Advocate BroMenn Medical Center and OSF St. Joseph Medical Center. In news coverage of those hospitals, the food service director of OSF St. Joseph Medical Center noted that moving away from the traditional approach of serving all patients at the same time has cut down on wasted food and led to a 32% reduction in food costs in the service’s first year.