Robert Chang writes…
Stephen Jencks, Mark Williams and Eric Coleman recently published what some rightfully consider a landmark article in NEJM 2009 that discusses the readmission rates in the Medicare population. Most of us have some awareness that the readmission rate is high although I doubt most would have empirically said 1 in 5.
Some significant proportion of these readmissions is preventable. The Society of Hospital Medicine has collected a large number of resources in Project BOOST and hospitalists in our institution are eagerly participating. We all can recollect patients that “if only”…perhaps they wouldn’t have had to return to the hospital. Medication reconciliation, patient literacy and a host of other factors that fill our daily work lives…the story of preventable readmissions syncs with our experience in daily care.
But there are portions of the readmission story that do not sync with a lump categorization of “one readmission is like another”. We sometimes walk away from a day of work knowing that someone is coming back, no matter what we do, for medical, social, and logistical reasons that are sometimes (even often) beyond our control.
Here are some patients I worry about falling into the lump categorization:
1. “We can’t fix you” – We are far too enamored with our ability to cure. The reason COPD, CHF and psychosis have the highest readmission rates of identical cause as the index admission is that we cannot yet fix some of these medical problems or the fix is to control their environment in a way that they cannot or will not. Even an expertly managed failing heart still leads to a basal readmission rate. By definition, hospitalization cannot eliminate readmission. It was never intended to.
2. “Don’t fix me” – corollary to “we can’t fix you” is this is a miniscule but demoralizing group of people that come in who have no desire to be fixed. The attention, the medications and the environment are too good. “Good care” isn’t the problem for these patients – that’s what attracts them. We have no societal answer for this group of patients. Medicare fraud applies to physicians (top 20 Google hits all speak of physician fraud), not patients.
3. The “good catch” – we want people to come back if they are sick. The very reason we schedule a follow-up visit in this “less than 100% follow-up visit for all discharged patient” state is that we are worried about someone. To be readmitted is a good thing in this case.
4. The “sojourner” – we all know patients that move hospital to hospital (but we probably just don’t know that they do) for mental disability, illicit or abused substances like alcohol, or secondary gain. An article on habitually wandering patients conduced in 1994 in the VA system is a good example, found here. They find a mix of the people we can’t fix and people who don’t want to be fixed.
I’m sure you can come up with more. The point I bring to the table is not that the cause of reducing readmissions is hopeless or unworthy of our attention. We must participate in this venture and we must find ways to address reversible issues. My point is that our local leadership is incredibly important and one of the key measures we need to promote as leaders is appropriate expectations. Jencks et al does not state that the readmission rate should be zero but the quoted sum of $17.6 billion dollars spent on readmissions is derived from the elimination of all unplanned readmissions. In the “we can’t fix you” patients, that is an impossible expectation to meet and in the “good catch”, it is not an expectation that we would want to meet.
As our hospitals and hospitalists start viewing this issue with a keener and keener eye, we have to balance the splintering of an issue into fragments that no longer mean anything and lumping things together into an undifferentiated blob that doesn’t actually inform. But then again, that’s what hospitalists do best.