January 24th, 2013

Hospital Readmissions May Be Just the Tip of the Iceberg

The period after hospital discharge is full of challenges and, often, dangers. Well-intended efforts to improve the transition from hospital to home often rely on hospital readmission rates to measure success — but that measure may miss the point.

As an emergency medicine physician, I see an alarming number of patients return to the ED soon after hospital discharge. Of course, some come back for acute, unforeseen complications, but many others return because of a breakdown in social support or difficulty accessing and communicating with providers. Quite a few merely require clarification of their expected course of recovery or symptom management and are safely discharged home. Return ED visits that arise from an unmet need or gap in care contribute to an overall fragmentation of care, to ED overcrowding, and to higher costs.

My colleagues and I conducted a study, just published in JAMA, to determine to what extent treat-and-release ED encounters contribute to overall use of acute-care services after hospital discharge. Analyzing data from 5 million hospitalizations during 2008 and 2009 in three states (California, Nebraska, and Florida), we found that for every 1000 discharges, there were 97.5 ED treat-and-release visits and 147.6 hospital readmissions in the 30 days after discharge. Visits to the ED represented nearly 40% of all post-discharge acute-care encounters. Moreover, patients often returned to the ED for reasons related to their initial hospitalization.

I am concerned that hospital quality measures do not fully capture the many patients who seek acute care after hospital discharge and do not reflect the substantial post-discharge care that EDs provide. I fear that looming crackdowns on hospital readmissions may have unintended consequences. When patients return to the ED, will I be encouraged, even pressured, to avoid readmitting them? If so, how safe is it to discharge patients for whom outpatient care has already failed once?

I have become convinced that ED utilization can be a useful, patient-centered metric to track, along with rehospitalization rates. Even if readmission rates drop, high or increasing rates of ED use may uncover care deficiencies during the precarious transition from hospital to home. To improve the transition, physicians will need to think less about measures and incentives — and more about individual patients’ needs. Why are patients returning to the ED and the hospital in droves? Are we not educating them well enough about home transition? Do we lack capacity in the system for care teams to coordinate follow-up care when patients have a complication? We clearly must do a better job of anticipating and meeting patients’ needs — before they return to the ED.

It is no surprise that patients recovering from a recent hospitalization have difficulty navigating our complex health care system. Indeed, they shouldn’t leave the hospital without a realistic care plan. “See your doctor in 2 weeks and return to the ED if feeling worse” doesn’t cut it. An ideal plan would monitor a patient’s post-discharge recovery process. That might require providing patients with innovative venues and opportunities for asking questions. We must also think creatively about ways to deliver care and guidance effectively outside of EDs and hospitals.

My questions to you:

1. Do you know when your patients end up back in the ED but are not rehospitalized?

2. How do you help your patients avoid post-discharge acute ED visits and hospital readmissions?

4 Responses to “Hospital Readmissions May Be Just the Tip of the Iceberg”

  1. Jean-Pierre Usdin, MD says:

    Lost in translation!
    Thank you so much dr Vashi for your very clear summary.

    You are perfectly right: hospital readmission or patient returning to ER few days after hospital discharge is a difficult and underestimated problem. I think “shame on me” when it happens to one of my patients!

    Can some improvements be done?
    One solution may be “medication conciliation”. This was very well explained in a paper from PT Chiabra and al. Res Social Adm Pharm. 2012 Jan;8(1):60-75. Epub 2011 Apr 21. ..And the comment by CG Huang: Medication Reconciliation: Just Because It’s Done Doesn’t Mean It’s Done Right October 29, 2012 in the columns of JWatch Hospital Medicine.

    Briefly: Not rarely changes in the patient’s usual treatment are done during the hospitalization: sometimes it is necessary but sometimes a product in the same class, without real improvement, is given and the most important changes are not explained. The patient finds on the discharge prescription, unknown products, leading to impair observance.
    In-hospital physicians have to be aware of this problem and comparing the patient’s own prescription with the discharge one may help; furthermore explaining to the patient and his GP why the changes were done is an alternative and prevents mistakes.

    Probably you had a look to this paper from Engel KG and al.: Patient Understanding of Emergency Department Discharge Instructions: Where Are Knowledge Deficits Greatest? Acad Emerg Med. 2012; 19: e1035-44. Concerning the comprehensiveness of the instructions done in ER: few hours after their discharge, interviewed by phone, 15% of the patients did not remember the discharge diagnosis, 22% did not know about the medications given and 80% forgot the care they should have at home!

    Explanation at every level is necessary but not always easy to give specially in urgent situations.
    As you say “Hospital readmission may be just the tip of the iceberg!”

    Answering to your first question is not so easy:
    When the patient is readmitted with the same discharge diagnostic I surely know it (unfortunately not so infrequent) but when readmitted for another reason, the patient himself or his family inform me; more frequently than me ER colleague…

  2. Edgar Abovich, MD says:

    This is a complex problem requiring a multitude of improvements and, unfortunately, I don’t see it happening. To answer your questions, Dr.Vashi, I usually know when my patient comes back to the ER for any reason, but especially cardiac issues. The second question is much more difficult. I try my best. Two types of common errors I try to prevent is the admission list of medications and discharge list. Both are notoriously incorrect. On admission, I correct it in the hospital since I take care of my patients both in the hospital and in the office post discharge. The discharge list is trickier. Too many people are involved. I usually ask my office nurse to call the patient home post discharge to verify the list and I also see them in the office within few days post discharge and ask them to bring their meds in the original packaging.
    There is also a lack of continuity of care as far as primary care physicians are concerned since they usually don’t admit their patients, like the old days, to the hospitals. Hospitalists do not communicate with them properly and they have to rely on discharge summaries of poor quality, many times dictated by physician assistants. Unfortunately, I don’t see any of it getting better any time soon.

  3. Anita Vashi, MD, MPH says:

    Thank you Drs. Abovich and Usdin for your comments. It seems from both your personal reflections and evidence in the literature, that medication reconciliation is a an important, but difficult issue to address. I recently read a report about a new effort at Barnes-Jewish Hospital in St. Louis that plans to provide an option to fill prescriptions at the patient’s bedside through investment in personnel and technology; nine additional pharmacists have been hired and technology has been added that allows patients to swipe their credit cards right at their bedsides. Efforts like this, and other innovative, practical solutions will hopefully lead to real improvements – especially from the way I often see med rec happening – a cursory, list checking method rarely involving patients.

    I also wholeheartedly agree that we must do a better job making sure patients understand their discharge instructions. Study after study has shown patients often leave the ED and hospital without even understanding their diagnosis, expected course of illness and followup instructions. My own work, reviewing audiotapes of providers giving discharge instructions to patients, was an eye-opening experience of the often lousy job we do of engaging patients in this process. At the very least, paying attention to how and what we relay to patients as they leave our clinic, OR, ED or hospital unit, and providing them with opportunities to ask questions, is a first step every provider can take to improve transitions in care.

  4. I discovered long ago that the best way to prevent readmissions for CHF is to constantly reiterate to the patient not to eat the following four food groups. 1. Canned foods (especially soups); 2. Restaurant foods; 3. Luncheon meats; 4. Cheese. Even Nanette Cass Wenger published in her monograph on heart failure 20 years ago that fully 38% of admissions for heart failure were due to dietary sodioum indescretion. It may seem difficult for patients to follow this advise, but it worked very well for me. My heart failure patients were rarely readmitted within 30 days of discharge. I just had to take the time to educate my patients myself.

    Patients hate going into pulomonary edema (I guess it might feel similar to “waterboarding”). They will be very careful with their diet if the cardiologist himself explains how eating salty foods can precipitate acute congestive heart failure in those with chronic heart failure. This must be done during the hospitalization and at each subsequent office visit. It is not just the job of the nurses or dieticians. It is the job of the cardiologist. Patients will naturally pay more attention to the cardiolgist.