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:

• The patient and/or family may not completely understand discharge instructions.
• The home situation may not support what is outlined in the discharge instructions.
• Follow-up with a primary care doctor may be delayed.
• The patient or family may not know whom to call with questions after discharge. This often means the patient goes to the emergency room instead.
• Transition of care may be faulty. This refers to the timely communication from the hospital doctor to the primary care doctor about what happened in the hospital and what needs to be done after discharge.

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.

• Always have at least one family member present when the nurse reviews your discharge instructions. Read through all the instructions. Ask your family member to do this also. If anything is not clear, ask the nurse to explain. If it still doesn't make sense, feel free to ask if the doctor can stop by or at least speak on the telephone.
• Make sure you know the most important problems you need to look out for after discharge.
• Carefully review all your medicines. Are they different from what you were taking at home before you went into the hospital? Also check the dosages. They might have changed. If a medicine has been added or deleted, ask why the change was made.
• Be sure you have follow-up appointments. This will almost always include an appointment with your primary care doctor. You might also need to see one or two specialists. Ask the nurse why you are seeing these specialists and what will need to be accomplished during those office visits.
• If a nurse will visit you at home, ask what specifically the nurse will be checking. Do you need to do anything to prepare for the visits?
• Ask whom you should call if you have a question or concern before your first follow-up appointment. Get a specific telephone number to call.
• Write all this down so you can read it again later.

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.