Managing Healthcare Costs: readmission

Today’s Managing Health Care Cost Indicator is 19.6%

Source

There’s been a lot of talk about preventing hospital readmissions -- and the Affordable Care Act has some early incentives for hospitals that can lower readmission rates, and some painful later penalties for those which continue to have higher readmission rates.

One in five Medicare beneficiaries discharged from a hospital is readmitted within 30 days. (It’s 24% among the disabled under 65, and 19% among those over 65). MedPAC suggested that the cost of preventable Medicare hospitalizations could be $12 billion per year. There are innumerable demonstration projects to lower hospital readmission rates. They often include better discharge planning and patient education, medication reconciliation, post-discharge phone calls and appointments, and home visits. Some of the more innovative include home visits by pharmacists, since improper use of medication is a frequent cause of readmissions.

There’s a disappointing review of the published literature in the late October Annals of Internal Medicine. The authors examined over 4000 articles, and did in depth review of about a tenth of them. 43 articles met inclusion criteria because they and compared outcomes between an intervention group and a control group. Even so, most of the studies met less than half of the Cochrane Collaborative criteria regarding unbiased clinical trial reports.

Of the 43 trials reported, only 7 were randomized, and most were quite small.

The authors’ conclusion:

We did not identify a discrete intervention or bundle of interventions that appears to reliably reduce re-hospitalization.

Hospital readmissions are the largest opportunity in Medicare and in disabled populations, and those with chronic disease. In employer-insured populations under age 65, many of the readmissions are either related to mental health, or are planned (scheduled chemotherapy) or desirable (organs becoming available for those requiring transplants).

The special sauce to substantially reduce hospitalizations still hasn’t been identified.

A JAMA article last week showed that shorter lengths of stays for congestive heart failure over the last decade and a half have been associated with higher levels of readmissions.

The study is impressive. In each time period there are close to a million fee for service Medicare members admitted, and data is presented both with risk adjustment and in raw form. (The numbers are so large that the risk adjustment doesn't matter so much). The study was based on claims data only, and the press accounts I've read have emphasized that this data represents a failure of the health care delivery system

We can do better. Studies have shown that a simple intervention like a post-discharge phone call can prevent many readmissions The good news is there is a real spotlight on hospital readmissions, since Medicare will start paying hospitals with high readmission less in 2014.

There is good news in this study that has been largely overlooked. Mortality rates have tumbled dramatically.

What does this mean for readmissions? Those surviving initial hospitalization are dramatically sicker. (Indeed, 53% more are being discharged to nursing facilities). These patients with more serious underlying disease might in fact be more likely to be readmitted to the hospital regardless of length of stay. It's also possible that the increase in discharge to nursing homes with vigilant professionals picks up more patient decompensation - so some who might have died at home are transferred for yet another hospitalization.

Society is getting a higher survival rate because health care for those with late-stage congestive heart failure has improved dramatically since the 1990s. The additional quality adjusted life years we are gaining are not coming without cost.