January 23, 2013
Two new studies suggest that about 1 patient out of 5 returns within 30 days after a hospital stay. One study examined 4 million hospital stays. About 18% of patients came back within a month after their hospital stay. About 40% of them went to the emergency room only. The others were admitted again. A second study looked at 3 million hospital stays by Medicare patients. Among those who were admitted for heart failure, nearly 25% were admitted again within 30 days. Almost 20% of those with heart attacks came back. So did 18% of those with pneumonia. Most people were admitted the second time for a different problem. The author of this second study said a long hospital stay can increase people's risk of illness or injury soon afterward. Some reasons include poor sleep in the hospitals or weaker muscles from bed rest. Medicare will soon penalize hospitals where patients are more likely to be admitted again within 30 days. But a commentary says there's no proof this is a useful measurement. Another commentary says emergency room visits also should be considered. The articles were published January 23 in the Journal of the American Medical Association. HealthDay News and USA Today wrote about them.
By Howard LeWine, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
The Patient Protection and Affordable Care Act is designed with the dual goals of providing more Americans with health insurance and reducing the rise in health care costs. This 2010 law is often referred to as "Obamacare."
One section of the act outlines cost reductions through decreased Medicare payments to hospitals for "excess readmissions." Hospitals with such an excess will receive less money for care during the readmissions.
Excess readmissions will be measured based on new hospital admissions within 30 days of discharge. This is an arbitrary definition. There is no evidence that it's a valid measure of hospital performance of care during the first hospital stay.
This week's issue of the Journal of the American Medical Association focuses on hospital readmissions.
People are admitted to the hospital again for many reasons. Several major ones may have nothing to do with what may have been ideal care during the prior hospital stay. For example:
In my opinion, none of the articles addressed one of the main reasons for repeat hospital admissions. It is actually a success story. We have improved our ability to keep people with chronic diseases alive for much longer.
People with long-term diseases such as heart failure are likely to get worse suddenly even when they do just what the doctor ordered. They are also much more likely to develop other problems such as stroke, blood clots and pneumonia. In fact, when people are admitted to the hospital again, it's most often for a different reason than their admission the first time.
In the articles, the authors list other reasons that penalizing hospitals for a new admission within 30 days does not make sense. Most importantly, what happens once the person leaves the hospital is out of the hospital's control.
What Changes Can I Make Now?
Despite the flaws in using 30-day readmission as a measure of performance, it has already had some benefit. Hospitals are improving discharge processes. The hope is that this will decrease readmissions.
If you have been in the hospital, you can help to prevent the need for a visit to the emergency room or a new hospital stay.
What Can I Expect Looking to the Future?
Hospital readmissions are only one problem in our very fragmented health care system.
We must have a very different model of payment for health services. Payment must be based on how well all of those involved in health care promote health and wellness and how closely they follow standard guidelines.
This will drive a new model of total team-based care. It's the only way a health care organization that is responsible for the health of patients enrolled there can survive financially.