An area of suspected poor medical care receiving a great deal of attention is readmission to the hospital shortly after discharge. For Medicare the numbers are somewhat shocking–twenty percent of recently discharged patients are readmitted within 30 days and more than thirty percent within 90 days. Almost all of these readmissions are unplanned and many believed to be preventable. Medicare might save over ten billion dollars annually if it could reduce these readmissions. A few conditions account for many of the rehospitalizations and one of the primary ones is heart failure. The Journal of the American Medical Association published a recent study looking at might be done to create better outcomes. (JAMA Article)
An obvious cause of readmission is be failure to plan for the care needed to keep the patient stable, or even in improving health once he or she leaves the hospital. The DRG payment system has resulted in hospitals not wanting to keep patients any longer than absolutely necessary, but that means that follow-up care becomes even more important. The researchers looked at variation in time to a follow-up visit with a physician among discharged Medicare heart failure patients and that variation’s relationship to readmission. A visit within seven days of discharge was defined as early follow-up.
Most patients had a physician visit scheduled before discharge, but less than a third of the time that visit occurred within seven days. Rarely was the visit with a cardiologist and often it was not with the physician who attended the patient in the hospital. An early physician visit after discharge was strongly associated with not being readmitted within 30 days. The authors observed very substantial differences in hospital’s post-discharge care practices. Many hospitals probably don’t feel any specific responsibility for ensuring follow-up with a physician, viewing that as the doctor’s responsibility. The impending readmission penalties will likely change that, but CMS could also incorporate into certain DRGs an additional payment conditioned on a mandated set of physician visits shortly after discharge. One encouraging aspect of this area of poor care is that it appears to be relatively easily addressable and improvements would result both in better outcomes and lower costs.