Published in the April 2013 issue of Today’s Hospitalist
IF SOMEONE CRASHES HIS CAR less than a month after being discharged from the hospital with pneumonia, many might say the readmission resulting from the accident had nothing to do with the initial hospitalization. Hence, the reasoning would go, the new hospitalization shouldn’t count against the hospital as a preventable readmission.
But “what if people are at elevated risk of accidents” because they were recently hospitalized, asks Harlan M. Krumholz, MD, professor of cardiology and health policy at Yale University and Yale-New Haven Hospital. Dr. Krumholz is one of the chief architects of the government’s new, punitive hospital readmission measures. “Then it is related.”
In an essay in the Jan. 10 issue of the New England Journal of Medicine (NEJM), Dr. Krumholz suggests that the immediate post-hospitalization period may need to be re-imagined as “phase 2” of an illness, a period marked by heightened “generalized risk” for many conditions. After all, the first few weeks post-discharge “and arguably longer “are particularly dangerous for patients, with 20% being readmitted within a month.
“I call it ‘post-hospital syndrome’ because a label gets the attention of doctors,” Dr. Krumholz explains. “It gets you thinking that this could actually be a coherent syndrome that is acquired, transient and something patients didn’t have before they came to the hospital.”
True, Dr. Krumholz admits, these individuals “were probably really sick with something else before, which is why they were hospitalized in the first place. But they weren’t sick with these generalized susceptibilities.”
If research proves that hypothesis, it could drive dramatic changes in what hospitalizations look like and how convalescence afterwards is managed. Moreover, hospitalists would be perfectly positioned to figure out how to make sure that patients leave the hospital in better shape than many do now. In other words, preventing readmissions may not just be about building a better discharge, but about building a better hospital stay.
Right now, Dr. Krumholz points out, more research is needed to find out “how well people are functioning when they go home from the hospital.” If it turns out that patients who lose less functionality while hospitalized have a lower risk of readmission, then re-engineering what happens at a hospital could become job No. 1 for hospitalists.
Deprivation and stress
Consider the example of an 85-year-old man hospitalized with a heart attack. After that patient is discharged, according to a study in the Jan. 23/30 issue of the Journal of the American Medical Association (JAMA) by Dr. Krumholz and his colleagues at Yale, he has a one-in-five chance of being readmitted within 30 days.
But the study found that only 10% of those readmissions would be for a second acute myocardial infarction. The research, which tracked half a million Medicare readmissions from 2007 through 2009, reported that most readmissions were for some completely different condition. For heart attack patients, half of 30-day readmissions were due to “cardiovascular disease” “but the other half were chalked up to a host of other reasons, ranging from renal disorders and pneumonia to gastrointestinal hemorrhage and “complications of care.”
“We are taught to think in medical school that the issue that led to the initial hospitalization is the one you are going to look at first,” explains Kumar Dharmarajan, MD, a cardiology fellow at Columbia University and the lead author of the JAMA article. “But if I am just thinking about a second heart attack, I am going to miss nine out of 10 reasons a patient ends up back in the hospital.”
Everyone knows that hospitalization may “unnecessarily be exposing patients to things like infection and medical errors,” Dr. Dharmarajan adds. But it also may subject them “to things the public may be less aware of, like immobility, sleep deprivation, pain, multiple medication changes and long periods of time when they are not eating anything.”
Certainly, that 85-year-old man was not in top shape to start with. But while being treated in the hospital, he may have become malnourished, groggy and weak. He may have become disoriented or even delirious, lonely, depressed or scared of dying.
His pain medication undoubtedly fogged his thinking. And the roommate in his shared room may have coded and passed away. No one ever acknowledges that kind of emotional strain, let alone offers counseling.
Do patients “need to be as stressed as much as they are?” asks Dr. Krumholz, describing this familiar scenario. “They have no reserve and have just been through a major illness.” And when they are discharged, he adds, “it’s not like they are all better.” Instead of “better,” physicians need to think in terms of patient fragility and resilience post-discharge. “I think patients might be entering a second hazardous phase where we have to be thinking about what interventions are going to make it safer.”
Impairments, not inconveniences
At Yale-New Haven Hospital, Sarwat I. Chaudhry, MD, a colleague of Dr. Krumholz’s who directs the academic hospitalist group, is now enrolling patients in a national study to more accurately define the vulnerabilities that increase when older patients are hospitalized. Her research, known as the SILVER-AMI study, is looking at patients older than 75 who are hospitalized with acute myocardial infarction.
The results are some years off. But Dr. Chaudhry hopes the study will “quantify the sum impact of geriatric vulnerabilities” exacerbated by hospital stays, as well as the effect of that impact on outcomes like readmissions.
Meanwhile, Dr. Chaudhry and her hospitalist and geriatrics colleagues aren’t waiting for study results to start thinking about changes to make. They are looking seriously, for example, at how to make sure that patients are not forced awake in the middle of the night to have vital signs taken.
Researchers have long known that sleep deprivation has “debilitating behavioral and physiological effects” on everything from metabolism, cognitive performance, physical and immune function, and cardiac risk, Dr. Krumholz points out. He suggests that all the disruptions of a person’s sleep-wake cycle in the hospital may confer “jet-lag-type disabilities” that contribute to this second phase of illness when people have a “susceptibility to almost everything.”
“We have tended to think of all these things as inconveniences,” Dr. Krumholz says. “Sorry for waking you up. Sorry you didn’t eat because we held your breakfast and lunch for procedures. Sorry you are worried because your finances are all screwed up.”
“I think people go home impaired cognitively, emotionally and physically,” he adds. “They have substantial impairments during the early recovery period, with an inability to fend off disease and susceptibility to mental error.”
Revising discharge instructions
Nutrition is another area that receives less attention than it should, Dr. Krumholz notes.
One study found that one-fifth of hospitalized seniors had an “average nutrient intake of less than 50% of their calculated maintenance energy requirements,” he notes. It’s also well known that “malnutrition can affect every system in the body.” That includes impaired wound healing, increased risk of infections and pressure ulcers, and decreased respiratory and cardiac function, let alone poorer physical function overall.
Given what’s happening with patients in hospitals, Dr. Krumholz says that discharge instructions probably should stress that people “shouldn’t drive for a while.” Doctors at discharge should also emphasize that patients are more susceptible to infections (not just hospital-acquired ones), so they “don’t want to go to the movies or be around people who are sick.”
“We don’t want to scare patients,” Dr. Dharmarajan points out, “but they need to understand that just because they were discharged, that doesn’t mean everything is back to normal. They need to be vigilant.”
That might also mean advising patients to call their doctors about a range of concerns, not just if their heart symptoms are back or a drug gave them a rash. And physicians need to learn to encourage patients to make these general complaints, even something as non-specific as they don’t feel the same as before they were admitted.
“If physicians, when contacted, don’t take those complaints as seriously as they should,” says Dr. Dharmarajan, “patients may end up back in the hospital for conditions that aren’t clearly related to their initial admission but are serious.”
Timing of readmissions
As Dr. Krumholz postulates in his NEJM article, many of the interventions that may help in the hospital are those that have been developed for reducing delirium. Little research, however, has explored whether delirium-prevention programs reduce readmission risk.
To that end, Dr. Chaudhry has another study under way on the real-world effectiveness of an acute care of the elderly (ACE) unit. She and her colleagues are looking specifically at whether care on such a unit results in fewer readmissions than among elderly patients cared for on regular floors.
And Dr. Krumholz and his colleagues are taking a close look at the timing of post-discharge readmissions. For instance, Dr. Chaudhry explains, “if you get readmitted within seven days, that might say something about the transition of care. It would say something different than a readmission within six months.”
Dr. Dharmarajan says his study has already shed some light on this. Although about 60% of readmissions seemed to occur within the first two weeks, “that still means 40% are happening in the latter half of the month.” (His study also found that readmission diagnoses didn’t vary based on time after discharge.)
What that means, Dr. Dharmarajan says, is that physicians have to start to “think longitudinally. There isn’t a safe period that occurs after a week or two. Patients are at elevated risk throughout this whole period.”
For health systems that have a policy of seeing all patients within 72 hours post-discharge, “that’s great,” he adds. “But if you think that means everything is going OK, you are going to miss a big percentage of events that happen after that.”
For Dr. Krumholz, the new findings open up an entirely new way of thinking about patient care.
“We have never focused on the period between discharge from the hospital and when you might become a stable outpatient,” he says. Patients are traditionally viewed as either inpatients or outpatients; if you aren’t in the hospital, you must be well enough. “That’s been our conceptualization of it, but physicians and patients have to think more broadly.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.