Who Has the Highest Rate of Readmission After Hospital Discharge?

MedicalResearch.com Interview with:
"patient in hospital bed with nursing staff gathered around" by Penn State is licensed under CC BY-NC-ND 2.0Andrea Gruneir, PhD
Department of Family Medicine
University of Alberta
Edmonton, AB Canada

MedicalResearch.com: What is the background for this study?

Response: Hospital readmissions – when a patient is discharged from hospital but then returns to hospital in a short period of time – are known to be a problem, both for the patients and for the larger health system. Hospital readmissions have received considerable attention and there have been a number of initiatives to try to reduce them, but with mixed success. Older adults are among the most vulnerable group for hospital readmission. Older adults are also the largest users of continuing care services, such as home care and long-term care homes (also known as nursing homes). Yet, few large studies have really considered how older adults with different pathways through hospital compare on the risk of hospital readmission.

In our study, we take a population-level approach and use health administrative data to create a large cohort of older adults who were hospitalized in Ontario between 2008 and 2015. For each of the 701,527 patients in our study, we identified where they received care before the hospitalization (in the community or in long-term care) and where they received care after discharge (in the community, in the community with home care, or in long-term care).  Continue reading

Coordination Program Reduced ER Visits and Readmissions in Medicaid Population

MedicalResearch.com Interview with:

Roberta Capp MD Assistant Professor Director for Care Transitions in the Department of Emergency Medicine University of Colorado School of Medicine Medical Director of Colorado Access Medicaid Aurora Colorado

Dr. Capp

Roberta Capp MD
Assistant Professor
Director for Care Transitions in the Department of Emergency Medicine
University of Colorado School of Medicine
Medical Director of Colorado Access Medicaid
Aurora Colorado

 

 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Medicaid clients are at highest risk for utilizing the hospital system due to barriers in accessing outpatient services and social determinants.

We have found that providing care management services improves primary care utilization, which leads to better chronic disease management and reductions in emergency department use and hospital admissions.

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Patients Treated By Female Doctors Have Better Outcomes and Fewer Readmissions

MedicalResearch.com Interview with:

Yusuke Tsugawa, MD, MPH, PhD Department of Health Policy and Management Harvard T. H. Chan School of Public Health, Department of Medicine Brigham and Women’s Hospital and Harvard Medical School Boston, Massachusetts

Dr. Yusuke Tsugawa

Yusuke Tsugawa, MD, MPH, PhD
Department of Health Policy and Management
Harvard T. H. Chan School of Public Health,
Department of Medicine
Brigham and Women’s Hospital and Harvard Medical School
Boston, Massachusetts 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We analyzed a 20% sample of Medicare beneficiaries hospitalized with a medical condition in 2011-2014, and found that patients treated by female doctors have lower mortality and readmission rates than those cared for by male doctors.

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Better Patient Safety Linked to Lower Hospital Readmission Rates

MedicalResearch.com Interview with:
Sheila Eckenrode, RN, CPHQ
Project Manager
Medicare Patient Safety Monitoring System (MPSMS)
Qualidigm

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We sought to investigate the association at the hospital-level between 21 in-hospital adverse event rates and both mortality and readmission rates for Medicare Fee-For-Service patients with AMI. We used data from the Medicare Patient Safety Monitoring System (MPSMS), the nation’s largest randomly selected hospital medical record-abstracted patient safety database, and data from the Centers for Medicare & Medicaid Services, which includes hospital performance on mortality and readmissions for over 4,000 Medicare-certified hospitals, to assess the association between hospital performance on patient safety and hospital performance on 30-day all-cause mortality and readmissions for Medicare fee-for-service patients discharged with AMI.

We found that hospital performance on patient safety is associated with hospital performance on mortality and readmission rates for AMI. Hospitals with poorer patient safety performance are likely to have higher 30-day all-cause mortality and readmission rates for these patients.

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Statewide Collaboration Reduced Preventable Hospital Readmissions by 20%

MedicalResearch.com Interview with:

Thomas P. Meehan, MD, MPH Associate Medical Director Harvard Pilgrim Health Care Qualidigm, Wethersfield Quinnipiac University, North Haven CT

Dr. Thomas Meehan

Thomas P. Meehan, MD, MPH
Associate Medical Director
Harvard Pilgrim Health Care
Qualidigm, Wethersfield
Quinnipiac University, North Haven
CT

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: There is a national effort to decrease preventable hospital readmissions in order to improve both the quality and cost of healthcare. Part of this national effort includes local quality improvement projects which are organized and conducted by a variety of organizations working by themselves or with others. We describe one statewide quality improvement project which was led by a Medicare-funded Quality Improvement Organization and conducted with a hospital association and many other collaborators. We document our activities and a relative decrease in the statewide 30-day aggregate readmission rate among fee-for service Medicare beneficiaries of 20.3% over four and a half years. While we are extremely proud of our work and this outcome, we recognize that there are many factors that impacted the outcome and that we can’t claim sole credit.

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Declining Admission Rates and 30-Day Readmissions Linked

MedicalResearch.com Interview with:

Kumar Dharmarajan, MD, MBA Assistant Professor of Medicine (Cardiology) Cardiovascular Medicine: Center for Outcomes Research & Evaluation (CORE) Yale School of Medicine

Dr. Kumar Dharmarajan

Kumar Dharmarajan, MD, MBA
Assistant Professor of Medicine (Cardiology)
Cardiovascular Medicine: Center for Outcomes Research & Evaluation (CORE)
Yale School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Programs from the Centers for Medicare and Medicaid Services simultaneously promote strategies to lower hospital admissions and readmissions. However, there is concern that hospitals in communities that successfully reduce admissions may be penalized, as patients that are ultimately hospitalized may be sicker and at higher risk of readmission. We therefore examined the relationship between changes from 2010 to 2013 in admission rates and thirty-day readmission rates for elderly Medicare beneficiaries.

We found that communities with the greatest decline in admission rates also had the greatest decline in thirty-day readmission rates, even though hospitalized patients did grow sicker as admission rates declined. The relationship between changing admission and readmission rates persisted in models that measured observed readmission rates, risk-standardized readmission rates, and the combined rate of readmission and death.

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Non-Medical Workers and Mobile Technology Can Help Predict Hospital Readmissions

MedicalResearch.com Interview with:

Andrey Ostrovsky, MD CEO | Co-Founder Care at Hand

Dr. Andrey Ostrovsky

Andrey Ostrovsky, MD
CEO | Co-Founder
Care at Hand 

Medical Research: What is the background for this study?

Dr. Ostrovsky: Hospital readmissions are a large source of wasteful healthcare spending, and current care transition models are too expensive to be sustainable. One way to circumvent cost-prohibitive care transition programs is complement nurse-staffed care transition programs with those staffed by less expensive nonmedical workers. A major barrier to utilizing nonmedical workers is determining the appropriate time to escalate care to a clinician with a wider scope of practice. The objective of this study is to show how mobile technology can use the observations of nonmedical workers to stratify patients on the basis of their hospital readmission risk.

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Late Hospital Readmissions Linked To Chronic Health and Social Problems

MedicalResearch.com Interview with:
Kelly L. Graham, MD, MPH

Instructor in Medicine
Harvard Medical School Division of General Medicine and Primary Care
Beth Israel Deaconess Medical Center

Medical Research: What is the background for this study? What are the main findings?

Dr. Graham: 30-day readmissions have become a standard quality metric used to represent inpatient quality of care and unnecessary healthcare utilization.  Effective 10/1/2009, hospitals with excess 30-day readmissions have been faced with financial penalties.  Experts have questioned the validity of this metric, and have raised concerns about the potential unintended consequence of creating health disparities, as critical access hospitals caring for the most socioeconomically burdened patients have faced the highest penalties. We were interested to see if factors associated with readmissions in the early part of the 30 day window (0-7 days post-discharge) differed from those associated with the later window (8-30 days post-discharge), ultimately attempting to better understand the “pathophysiology” of a readmission.

Our findings suggest that early readmissions are associated with many factors, including those related to the index admission (acute illness burden and suboptimal discharge timing), and factors that are not related to the index hospitalization, such as chronic illness burden and social determinants of health.  In contrast, late readmissions were only associated with chronic illness burden and social determinants of health.
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Most Patients Go Back To Same Hospital For 30-Day Readmissions

MedicalResearch.com Interview with:
Rachel Mosher Henke, Ph.D.
Truven Health Analytics
Director of Research
Cambridge, MA

Medical Research: What is the background for this study? What are the main findings?

Dr. Henke: We wanted to see what percentage of patients return to the same hospital for their readmission.  Hospitals are increasingly at risk for the cost of readmissions through new initiatives, such as bundled payment programs.  If a patient goes to another hospital for their readmission, the original hospital has little control over the decision to admit and the intensity of care provided.

We found about three quarters of patients do go back to the same hospital for 30-day readmissions, with some variation in rates by condition.  Patients admitted through the emergency department and patients who live in the same county as the hospital were more likely to return to the same hospital for their readmission. Continue reading

Quality of Discharge Summaries Linked to Hospital Readmission Rate

Leora Horwitz, MD, MHS Director, Center for Healthcare Innovation and Delivery Science New York University Langone Medical Center Director, Division of Healthcare Delivery Science Department of Population Health, NYU School of Medicine New York, NY 10016MedicalResearch.com Interview with:
Leora Horwitz, MD, MHS

Director, Center for Healthcare Innovation and Delivery Science
New York University Langone Medical Center
Director, Division of Healthcare Delivery Science
Department of Population Health, NYU School of Medicine
New York, NY 10016

Medical Research: What is the background for this study? What are the main findings?

Dr. Horwitz: We reviewed over 1500 discharge summaries from 46 hospitals around the nation that had been collected as part of a large randomized controlled trial (Telemonitoring to Improve Heart Failure Outcomes). All summaries were of patients who were admitted with heart failure and survived to discharge. We found that not one of them met all three criteria of being timely, transmitted to the right physician and fully comprehensive in content. We also found that hospitals varied very widely in their average quality. For instance, in some hospitals, 98% of summaries were completed on the day of discharge; in others, none were. In the accompanying Data Report, we show that summaries transmitted to outside clinicians and including more key content elements are associated with lower risk of rehospitalization within 30 days of discharge. This is the first study to demonstrate an association of discharge summary quality with readmission.

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Hospital Readmissions May Not Be A Good Quality Indicator

MedicalResearch.com Interview with:
Ralitza P. Parina, MPH,
Senior medical student
John Rose, MD MPH
Department of Surgery at University of California San Diego

Medical Research: What is the background for this study? What are the main findings?

Response: This study looked at the association between hospital 30-day readmission rates and 30-day mortality rates. While readmission rates are coming into increasing focus with CMS reimbursement cuts for hospitals with higher than expected rates, they remain a poorly studied metric of quality. High readmission rates have been unequivocally tied to increased costs, but it remains unclear whether they actually represent poor quality of care and worse outcomes for patients. We chose to compare readmission rates as a quality metric to the well-established “gold standard” of mortality.

We found that 85% of hospitals did not show a correlation between readmission and mortality, i.e. their rates were not both high or both low. Furthermore, among hospitals that were outliers in at least one of the measures, almost a third were in the category of low or normal readmission rates with higher than expected mortality.

The implications are twofold: first, readmission and mortality rates are not strongly correlated.
Second, focusing on readmission rates as an outcome will miss a large number of poorly performing hospitals with higher than expected mortality rates but low or expected readmissions.

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Epilepsy: Readmissions Increased By Refractory Seizures and Psychiatric Comorbidities

MedicalResearch.com Interview with:
Tracie A. Caller, MD , MPH
Neurophysiology Fellow
Dartmouth-Hitchcock Medical Center
1 Medical Center Dr., Lebanon NH 03756, USA

MedicalResearch: What are the main findings of the study?

Dr. Caller: We identified factors that appeared to increase the risk for a 30 day readmissions in the epilepsy population, which included refractory seizures but also coexistence of nonepileptic seizures and psychiatric comorbidities.
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Multifaceted Approach Required to Improve Self-Care, Reduce Hospital Readmissions

Aaron L. Leppin, MD Knowledge and Evaluation Research Unit Mayo Clinic, Rochester, MinnesotaMedicalResearch.com Interview with:
Aaron L. Leppin, MD
Knowledge and Evaluation Research Unit
Mayo Clinic, Rochester, Minnesota

MedicalResearch.com: What are the main findings of the study?

Dr. Leppin: We conducted a systematic review and meta-analysis of randomized trials assessing the effectiveness of hospital discharge interventions on reducing 30-day readmission rates. We identified 47 trials, 42 of which contributed to the primary meta-analysis.

Overall, the interventions that have been tested to reduce early hospital readmissions reduce them by about 20%.

The ones that are most effective, though, reduce them by almost 40% and use a consistent but complex approach. These interventions make a robust effort to fully understand the patient’s post-discharge context, often by visiting the patient’s home. They focus on identifying all the things the patient needs to do to be well—whether that’s organizing medications, getting a ride to the clinic, or paying the electric bill—and they determine whether the patient has the necessary resources and capacity to pull it all off. When limitations are found, these interventions have a strategy in place to support the patient through the post-discharge period.

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Follow Your Heart Program Reduced Hospital Readmissions Following Heart Surgery

Michael H. Hall, MD North Shore-LIJ Health SystemMedicalResearch.com Interview with:
Michael H. Hall, MD
North Shore-LIJ Health System

MedicalResearch: What are the key points of your research?

Dr. Hall: Our study was designed to improve care transition from the hospital to home after coronary bypass surgery. The innovative program (Follow Your Heart), implemented at one of our system hospitals, involves sending cardiac surgery nurse practitioners (NPs) who cared for the patients in the hospital to the homes of discharged patients for at least two visits in the first two weeks after discharge. Their goal is to provide continuity of care for patients that they know from the hospital setting and to provide robust medication management, coordinate community services, and be a communications hub for hospital and community providers (primary care, cardiology, and community nurse home visit services). The  nurse practitioners interact with community resources to ensure understanding and satisfaction of the patients’ needs prior to hand-off to those resources after two weeks. Our  nurse practitioners utilize encrypted smart phones to provide reports to all appropriate providers and can even send pictures of incisions to the surgeon when necessary.

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Hospital Readmissions: Many Caused by Co-Morbid Diseases, Infections

Dr. Jacques Donzé MD PhD Research Associate Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital Harvard Medical School, Boston, MA 02115, USADivision of General Internal Medicine, Bern University Hospital, 3010 Bern, SwitzerlandMedicalResearch.com Interview with:
Dr. Jacques Donzé MD PhD
Research Associate
Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital
Harvard Medical School, Boston, MA 02115,

MedicalResearch.com: What are the main findings of the study?

Dr. Donzé: In a large retrospective cohort study, we identified the primary diagnoses of 30-day potentially avoidable readmissions in medical patients according to the most common comorbidities. Interestingly, almost all of the top five diagnoses of potentially avoidable readmissions for each comorbidity were possible direct or indirect complications of that comorbidity. Patients with cancer, heart failure, and chronic kidney disease had a significantly higher risk of potentially avoidable readmission than those without those comorbidities. Also, when readmitted, patients with chronic kidney disease had a 20% higher risk of having the readmission be potentially avoidable.

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Electronic Medical Records: Tool to Identify Readmission Risk

Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice Medical Director, Clinical Decision Support Chair, Department of Medicine Quality Committee Senior Associate Director, ECRI-Penn AHRQ Evidence-based Practice Center University of Pennsylvania Philadelphia, PA 19104MedicalResearch.com Interview with:
Craig A Umscheid, MD, MSCE, FACP
Assistant Professor of Medicine and Epidemiology
Director, Center for Evidence-based Practice
Medical Director, Clinical Decision Support
Chair, Department of Medicine Quality Committee
Senior Associate Director, ECRI-Penn AHRQ Evidence-based Practice Center
University of Pennsylvania Philadelphia, PA 19104

MedicalResearch.com: What are the main findings of the study?

Dr. Umscheid: We developed and successfully deployed into the electronic health record of the University of Pennsylvania Health System an automated prediction tool which identifies newly admitted patients who are at risk for readmission within 30 days of discharge.  Using local data, we found that having been admitted to the hospital two or more times in the 12 months prior to admission was the best way to predict which patients are at risk for being readmitted in the 30 days after discharge. Using this finding, our automated tool identifies patients who are “high risk” for readmission and creates a “flag” in their electronic health record (EHR). The flag appears next to the patient’s name in a column titled “readmission risk.” The flag can be double-clicked to display detailed information relevant to discharge planning.  In a one year prospective validation of the tool, we found that patients who triggered the readmission alert were subsequently readmitted 31 percent of the time. When an alert was not triggered, patients were readmitted only 11 percent of the time.  There was no evidence for an effect of the intervention on 30-day all-cause readmission rates in the 12-month period after implementation.
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Hospital Readmissions: Best US Hospitals Reduce Globally

Kumar Dharmarajan MD MBA Fellow in Cardiovascular Medicine Columbia University Medical CenterMedicalResearch.com Interview with:
Kumar Dharmarajan MD MBA
Fellow in Cardiovascular Medicine
Columbia University Medical Center

MedicalResearch.com: What were the main findings of the study

Dr. Dharmarajan: In the United States, 1 in 5 older patients is readmitted to the
hospital within 30 days of hospital discharge. However, there is great
variation in rates of 30-day readmission across hospitals, and we do
not know why some hospitals are able to achieve much lower readmission
rates than others.

We therefore wondered whether top performing hospitals with low 30-day
readmission rates are systematically better at preventing readmissions
from particular conditions or time periods after discharge. For
example, are hospitals with low 30-day readmission rates after
hospitalization for heart failure especially good at preventing
readmissions due to recurrent heart failure or possible complications
of treatment? Similarly, are top performing hospitals especially good
at preventing readmissions that occur very soon after discharge, which
may signify poor transitional care as the patient moves form the
hospital back home?
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Cognitive Impairment and Hospital Readmissions

Mark W. Ketterer, PhD, ABPP Senior Bioscientific Staff Henry Ford Hospital/A2 Detroit, MI 48202 Clinical Professor of Psychiatry & Behavioral Neurosciences Department of Psychiatry Wayne State UniversityMedicalResearch.com Interview with:
Mark W. Ketterer, PhD, ABPP
Senior Bioscientific Staff
Henry Ford Hospital/A2
Detroit, MI 48202
Clinical Professor of Psychiatry & Behavioral Neurosciences
Department of Psychiatry Wayne State University

MedicalResearch.com: What are the main findings of the study:

Dr. Ketterer:  A survey of 84 patients admitted to Henry Ford Hospital found 54% to have Moderate-Severe Cognitive Impairment (CI).
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