Published in the January 2011 issue of Today’s Hospitalist
CUTTING READMISSION RATES is at the top of everyone’s to-do list. That’s particularly true for readmission rates for heart attack, heart failure and pneumonia that are being publicly reported “and may eventually be tied to financial incentives.
To get a handle on what was going on within its own wards, the 28-physician hospitalist group at Gaston Memorial Hospital in Gastonia, N.C., looked at readmission rates for its patients in 2008. Of more than 5,200 patients admitted to the hospitalist service that year, only 1.6% (85 patients) were readmitted within 30 days for the same diagnosis.
That figure is in stark contrast to other high-profile studies, which have found that almost 20% of Medicare patients bounce back. That may be explained by the fact that most studies track all-cause readmissions, while the hospitalists at Gaston Memorial tracked only same-cause readmissions. (The study was published in the November issue of the Southern Medical Journal.)
While that difference raises questions about the results, the data taught the hospitalist group a great deal, explains lead author and hospitalist Beril Cakir, MD, who chairs Gaston Memorial’s research committee. The hospitalists handle 90% of the hospital’s medical admissions.
The good news was that 90% of readmitted patients received an accurate medication list at discharge. The bad news was that at discharge, follow-up appointments had been made for only 27% of patients who bounced back.
Those findings led the group to launch a quality improvement project targeting congestive heart failure patients and focusing on all-cause readmissions. Dr. Cakir encourages other community-based hospitalist groups to analyze readmission rates and create quality improvement projects based on the data they produce.
“Hospitalists in community hospitals need to be involved in quality improvement,” she says. “Readmission rate-related studies lead to simple interventions that definitely improve our quality of care.”
Dr. Cakir spoke with Today’s Hospitalist about the study and her group’s current quality improvement efforts.
You looked at same-diagnosis readmissions, which makes your study unique. What did you learn about patients being readmitted for the same diagnosis?
We now realize that all-cause readmissions are more important in suggesting interventions that can improve care. But this was our first study on readmissions, and we wanted to see where to start.
The results told us that patients being readmitted for the same condition may not really be the population to focus on because, whatever you do, you may not be able to prevent these readmissions.
Among readmitted patients, 84% had been hospitalized in the previous year, and 76% were admitted again within three months of the readmission covered in the study. On average, they each had more than seven comorbidities and had a 15% mortality rate within three months of the readmission, so that’s how sick this patient population was. There will always be frail patients for whom you can’t do much, but there are patients for whom interventions can change their outcome.
You mention in the study that this type of research helps hospitalists identify weaknesses. What problems did you uncover?
The biggest problem was not spending enough time on discharge planning. That should start on the first day of hospitalization, and it requires a multidisciplinary approach because physicians can’t do everything.
Discharge planning has to include patient education on symptoms that patients should look for to prevent a readmission, and families need to be involved. Our patients are old, they lack social support, they need assistance with everyday activities, and health illiteracy is a problem.
Another weakness was not making early appointments. In our study, 90% of the readmitted patients had a primary care physician and 80% had insurance, so those weren’t the problems. Today, the hospitalists write an order to make an outpatient appointment for patients, and clerks on each unit have been trained to make those appointments. For congestive heart failure patients, a transitional care manager now checks to see that these appointments are made.
Your study was also unusual in terms of the top 10 diagnoses requiring readmission: Pneumonia was No. 1, and sepsis was No. 2.
I was surprised about the sepsis, and it may have to do with how we code and document. Are we entering more sepsis diagnoses than before? Most patients with UTI and pneumonia do present with early clinical sepsis, so we may need to study that further.
As for pneumonia, it is the No. 2 readmission diagnosis among Medicare patients. We now have case managers working specifically with those patients, and I think we’re doing a good job choosing the appropriate antibiotics and starting those on time. With pneumonia being our No. 1 readmission diagnosis, we may want to do further studies looking at their length of stay and type of antibiotics prescribed at discharge to identify the reasons behind the readmissions.
We certainly haven’t moved to create any new rules, but if it looks like patients need a lot of assistance, we may push harder for a stay in a nursing home to prevent a rehospitalization. And we definitely now get home health on board. We’re paying more attention to that than in the past.
Among your readmissions, why did almost one-third have some level of noncompliance?
When we checked those patients’ readmission charts, we saw that their medication lists didn’t always include the drugs we prescribed at discharge. This told us that some patients don’t fill their prescriptions after discharge. With our CHF patients, we now make follow-up phone calls to make sure they fill their prescriptions and keep their appointments.
That raises the question of whether we should be doing that for all discharged patients. That would require a lot of manpower, so that’s why patient education is important. We need to teach patients how to take greater control of their illness.
Are you planning other interventions to reduce readmissions?
We certainly know about Project BOOST and the Society of Hospital Medicine’s mentoring program on discharge planning interventions. But our group didn’t think we were ready for that time-wise or labor-wise, so we decided to take some simple steps on our own and go from there.
For community hospitalists thinking about getting involved in this kind of effort, I’d suggest they pick a diagnosis and start a quality improvement project. You could also focus on an age group such as patients older than 75 or other high-risk groups taking certain medications, but you have to start somewhere.
Edward Doyle is Editor of Today’s Hospitalist.