Part 2 – Readmissions & Health Care Reform

Robert Chang writes…

As a continuation from my previous post, readmissions has caused continued chatter on health-care blogs and the downstream discussion on health care reform.  Some comments from blogs are supportive like The Commonwealth Fund, whereas others are not.  The comments section on the latter blog is both inflammatory and informative, with the comment from John Fembup summing up one of the key issues at hand (you can just read his comment in a shared Google document here) – where is physician leadership on this issue?

If you think the issue is irrelevant, the Hospital Compare website may change your mind, with support from many national physician organizations.  Hmm. Lots of support for looking closely at readmission reductions (re-aductions) already.  I turned to a quick Google search on the ACP and AMA websites – reasonable proxies for physician leadership – which have brief statements here and here.  Not a lot we can tell.

Here is a proposed view on the situation.  A highly informative publication tells us about discharges and readmissions with a reasonable perspective that we might be able to do something about it.  Known data on CHF readmissions suggests that we have perhaps a 25% reduction rate with fairly intensive interventions in a narrow field with reasonable detection rates and reasonable success of acute management with good symptom control (i.e. diuretics, weight monitoring, food and fluid rationing).  The other major causes of readmissions include psychosis, COPD, and pneumonia, none of which have terribly effective outpatient management, may progress/worsen despite best treatment, and require good monitoring.  The reported readmission rate of 67% for psychosis hospitalizations portends that we are actually quite ineffective at medically managing these patients and yet not all psychotic patients have a readmission rate that high.  Some are not admitted at all.  This would suggest that non-medical issues such as patient response to treatment, social support, access to medications, compliance and other factors that are not controllable by hospitals determine this readmission rate and that hospitalization is not as pertinent a factor as other contributors.

And yet, we’re on board with readmission reduction as a source of significant financial savings?  We believe that the hospital is the best agent to both effect change and hold the financial responsibility (read: burden) of managing these patients?  We believe the available manpower, infrastructure, administrative support and guaranteed financial return for upfront high overhead costs is available and will bear fruit?  Based on the tumult surrounding readmissions, is there any position we can take in this political and financial climate except a save-face yes?

It is our responsibility as leaders in the field, particularly in hospital medicine, to pay attention to this issue and lead thoughtfully, according to the best data available.  The politics say we can do this and effect financial savings.  I’m not sure that is possible or should be the goal.  Some back-of-the-envelope estimates from President Obama’s plan in “Jumpstarting the economy” (starts on page 10) indicates $26 billion in savings in 10 years for readmission reductions.  Assuming we implement immediately, the target would be to $2.6 billion per year, with Jencks’s article suggesting $17 billion is wasted per year.  If that savings is all derived from readmission reduction, we would need to achieve a 15% reduction within the first year and sustain it over the next 10 years.  The upfront cost to create a 15% reduction in admissions is likely to be substantial and given the financal climate, unavailable without further federal spending.  Likelihood of success…?

Just as you would not hire someone that you do not think will fit the job even if there is an urgent need to fill that spot, urgency should not define how we respond to the financial  and the call to health care reform.  We should not blindly accept that readmission reduction is reasonable, despite high political pressure to support it.  I’m all for advocating for patient safety and improving the process by which a patient gets home.  I’m against accountability without the clear means of accomplishing the task at hand.

2 Comments

  1. Bob on September 10, 2009 at 10:55 am

    We must be sure that, in the zeal to reduce the LOS, we do not contribute to the cause of readmissions. Also, the lack of communication with the PCPs is contributing to unnecessary duplication of labs and radiologic studies. Reducing LOS is a great metric to prove our worth/value but, let us not forget the big picture of quality healthcare. This is despite the current popularity of equating lower cost with quality.

  2. Robert Chang on September 10, 2009 at 12:53 pm

    Bob,

    Thanks for your thoughts, they are definite critiques of the LOS analyses. The 1984 readmissions study by Anderson et al. was performed in an era where LOS was comparatively quite long. The Jencks study that their reported difference in readmissions “more likely…indicate[s] an actual increase in rehospitalization rates over time, perhaps owing to a shorter duration of index hospitalization or to the increase in ambulatory surgery over the past 30 years”. There is likely a loose inverse relationship between LOS and readmission rate. Another difference is also likely complexity of patients. Hemodialysis and transplantation alone have catapulted our ability to keep patients alive who had previously died…very complicated and sick patients.

    Consider:
    Kidney failure and the Federal Government, Institute of Medicine, 1991 suggests the total number of patients on dialysis in 1980 was in the 26000 range. The United States Renal Data system, found here (http://www.usrds.org/qtr/qrt_report_table_new.html) indicates we have ~ 26000 new dialysis patients per quarter. We currently have approximately 500,000 patients on dialysis.

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