Thursday, March 20, 2014

Hospital readmissions: not necessarily the fault of poor care transition

CMS has penalties for hospital readmissions. These are based on the premise that inadequate hospital care, poor discharge planning and poor transitions care are to blame. That premise, for a large number of today's hospitalized patients, is false according to a recent NEJM Perspective piece. These patients, referred to in the article as hospital-dependent, belong in a separate category. We don't have data from systematic studies but in clinical experience hospital-dependent patients account for a large portion of readmissions. So we have two categories of readmission (these overlap somewhat but it is useful to think of it in this way): (a) preventable and (b) inevitable due to inherent patient attributes. The hospital-dependent patient is category (b).

An example from category (a) might be the heart failure patient who is otherwise healthy (translate: doesn't have a problem list a mile long) discharged with inadequate education or without timely clinic access.

Category (b) patients have these characteristics:


Multiple complex problems each of which, despite optimal management, is precariously close to decompensation at any moment.

Little physiologic reserve.

Not terminal and desiring to live.

Live from one exacerbation to another, discharged from inpatient care each time they are, however tenuously, patched together. Again.

We like to think patients are ultimately better off at home because the hospital can be an unsafe place in many ways. But it's different, say the authors, for hospital-dependent patients. The hospital may be the safest environment for them. They are in continual need, even in the post-acute phase, of rapidly accessible technology and high level care teams. Despite all of today's systems improvements that environment doesn't exist outside the hospital.

The first principle of evidence based medicine is respect for patient preferences and values. Hospital-dependent patients, despite being made aware of the availability of hospice care, want to live even if much of that life is spent in the confines of a hospital. Our health care system does not have good options for them. The authors might not admit it but in my reading of the article they come just short of saying that what these patients really need is to spend the rest of their lives in acute care hospitals.

Early in my career frail patients with multiple complex problems were kept in hospitals for extended periods of time. The Prospective Payment System came along in 1984 and no longer allowed that. The “bounce-back” became the norm as a result.

If there is a systems approach to accommodate this large population of patients it will be very expensive, say the authors. Maybe darn near as expensive as life long acute care hospitalization.

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