By Harlan Krumholz, MD
The July issue of CardioSource WorldNews featured an article focused on readmissions, giving voice to those cardiologists who bemoan the national focus on this topic. They argue about who is responsible and whether readmissions are preventable. They discuss the possible dangers of such a focus and even suggest that a high readmission rate might indicate a successful hospital.
About one in five hospitalized patients will experience an event in the 30 days post-discharge that will necessitate a rehospitalization. Despite having survived the throes of an acute illness, these patients remain part of an exceptionally high-risk group—one whose members might prefer that we devote our energies to considering their perspective rather than to squabbling over who is responsible.
It would be difficult to identify another non-hospitalized group of individuals that has such a pronounced risk of catastrophic health events within a 30-day period. And yet, until the recent advent of national measures, the issue was rarely discussed and hardly visible. No mainstream textbook devoted pages to it. No medical school curriculum taught future physicians about it. Only a small number of individuals and institutions paid attention to the precarious position in which many patients find themselves after leaving the hospital.
Readmissions are the ultimate systems challenge. The transition from inpatient to outpatient status involves assessments, preparations, hand-offs, and coordination. These seemingly mundane tasks are essential components of a system that should promote safe passage for a patient who no longer needs the acute care setting, but who is still recovering from an acute illness.
Why Focus on Readmissions?
Naysayers cite three principal objections to the focus on readmissions. Let’s examine those concerns:
It is those darn patients. I frequently hear and read that patients are to blame. They do not follow directions or they lack family support. They cannot afford their medications or they lead unhealthy lifestyles. Surely, patients can play a role in promoting a successful recovery, but can any of us closely examine the discharge process and feel satisfied that we are doing our best? Hospitals are rife with errors, miscommunications, and poor coordination of care at the time of discharge. Patient education is ineffective and our medical reconciliation efforts are too often inaccurate. Patients commonly do not have appointments within a week of discharge, and information about their hospitalization is frequently unavailable or inadequate. Clinicians in the community, including nursing agencies, often lack clear instructions or critical information that could help them understand and address the specific needs of each patient or the care plan intended by hospital clinicians. Miscommunications are particularly prone to occur between physicians and their patients who have multiple comorbidities. And the list goes on. Is it really those darn patients—or can we accept responsibility too?
You cannot do well on readmission and mortality. There is a belief by some, fostered by a letter to the editor of the New England Journal of Medicine, that performance on mortality and readmission is inversely related. That is, if you have a low mortality rate then you are discharging more ill patients who will inevitably have a higher readmission rate. This leads some to view a high readmission rate as a badge of honor. In truth, many hospitals have both low mortality and low readmission rates. The association is weak for heart failure and not present at all for acute MI (AMI). A hospital’s performance on mortality does not dictate its readmission rate.
It is only about preventable readmissions, which represent a small number of patients. There are those who wish to narrow the problem by focusing on readmissions that clearly resulted from poor quality of care. As the preventability of any single admission is often hard to determine, it might be wiser to characterize the situation in terms of risk. A hospital and community environment characterized by poor coordination and quality of care will increase its patients’ risk of adverse health events and readmission. There will be more readmissions in that high-risk environment, even as the extra readmissions may be difficult to identify. In an analogy to cardiovascular risk, a community with more risk factors might have more AMIs, but it may be hard to determine which of the events would not have occurred had the risk been lower. The issue involves finding ways to lower the risk, which in the case of readmissions could be accomplished through better systems.
The cardiology community has tremendous potential to take a leadership role in instituting changes in practice that will reduce readmission risk. The Hospital to Home (H2H) initiative, sponsored by the ACC and the Institute for Healthcare Improvement, provides a community for the exchange of ideas, the sharing of best practices, and the communication of innovative approaches. Check out the website (www.h2hquality.org) for information about webinars, tools, and the listserv. An easy calculator, based on models developed for Medicare (www.readmissionscore.org) to estimate readmission risk for individual patients, is also posted at the site and available on iTunes as a free iPhone app.
The solutions to the challenges presented by hospital readmission may not be simple or obvious, and rates will not yield easily to interventions. The path forward lies in learning from each other and improving the systems that support patients. Efforts to correct only selected problems may be for naught if other unaddressed issues create interference. Improvements in the timeliness of dictating discharge summaries must, for example, be accompanied by the inclusion of complete and relevant information that is delivered to the right clinicians.
Readmissions are a problem, in part, because no one in the health system has taken responsibility to address the issues that promote adverse health outcomes early after hospital discharge. Progress is possible. Together, we can improve the transition out of the hospital, avoid health setbacks that result in readmissions, and achieve successful recoveries for our patients.
Harlan M. Krumholz, MD, is a cardiologist and the Harold H. Hines, Jr. Professor of Medicine and Epidemiology and Public Health at Yale University School of Medicine.