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Hospital Readmissions

By October 6, 2014Commentary

The Centers for Medicare Services has just penalized hospitals a record amount in the latest year of its poorly constructed hospital readmission reduction initiative, notwithstanding that such readmissions have continued to fall.  No wonder people keep trying to identify effective methods to prevent patients from returning to the hospital.  The latest issue of the Journal of the American Medical Association has both a study on a specific intervention and a brief summary of research to date.  (JAMA Review)  (JAMA Article)   The specific intervention is a virtual ward, which involves intensive team management of a patient’s care at home beginning immediately after discharge.  The team included a physician, nurse practitioners, care coordinators and pharmacists.  Round the clock phone intervention was available and home visits were conducted.  A detailed care plan was created and the patient’s primary care physician was involved.  In this trial about 1900 patients were randomized to the virtual ward or to usual care after discharge.  The primary outcome was readmission to the hospital within 30 days after discharge or death.  Within 30 days after discharge, 24.6% of the patients in usual care and 21.2% of the patients in the virtual ward had been readmitted or died.  With 90 days from leaving the hospital, 38% of the usual care and 37.1% of the virtual ward patients had been readmitted or died.  Despite the intensity of care received by the virtual ward patients there was no significant difference in the outcomes of their care, at least by the readmission or death measure.  While the authors hypothesize reasons for the lack of difference, the most likely explanation is that these are very sick patients and it doesn’t matter what you do, they are likely to need to be re-hospitalized.

In regard to the brief review, it also suggests the difficulty of preventing readmissions, particularly in a manner that doesn’t cost as much money as it is saving.  The article was basically a comment on a meta-review in JAMA Internal Medicine which found that it was hard to identify specific interventions that worked to reduce readmissions, but that more complex ones appeared to be most effective, along with features that increased the patient’s ability to do self-care and self-management of health.  Those complex interventions are also the most expensive.     One lesson we should learn from all the absurdity around preventing readmissions is that maybe there is nothing wrong with patients going back to the hospital if it is the best thing for their overall health and care.  As we have repeatedly noted, the only rational way to implement an appropriateness of readmission program is to have a case-by-case review to determine whether the readmission could have been avoided and then don’t pay for ones that clearly could have been.

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