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Posted by Ishani Ganguli April 3, 2012 11:35 AM
To my internist eyes, the Emergency Department (ED) is a wondrous and bewildering zoo of activity: muckety-mucks neighbor detox-ing alcoholics and surgeons comingle with psychiatrists in this microcosm of the hospital ecosystem. It is also a fork in the road for our regulatory target du jour, one that has come under recent scrutiny: The Hospital Readmission.
For the past decade or so, hospital readmission rates - the percentages of patients admitted to the hospital who return within 30 (or 7, or 15) days of ending their previous stay - have been used to judge hospital quality. Under the Affordable Care Act, hospitals that have higher than “expected” 30-day readmission rates get a financial slap on the wrist from the Centers for Medicare and Medicaid Services. This metric is intended to address a few important gaps in health care quality by countering other financial incentives to reduce the time patients spend in the hospital and to encourage better planning for their departure and follow-up.
"The reason [this quality measure has] gotten so much traction is that it does seem on the surface to have such face validity. How could a readmission be good?,” asks Ashish Jha, Associate Professor of Health Policy and Management at Harvard and co-author of a recent commentary in the New England Journal of Medicine that argues that the answer is not so simple.
Nearly two weeks into my brief stint as an ED doctor, I’ve come to appreciate this sometimes frustrating reality.
Readmissions are a poor gauge of quality, Jha tells me, in part because the majority of them are not preventable. Like the older gentleman I met last week who spoke little English. He came to the ED after three hospital stays in the past two months for complications of his surgery. This visit, however, was not the result of any problems during his hospital stays: he was swollen with retained fluid because he had trouble refilling his diuretic prescription. I put him in queue for an inpatient bed with a twinge of compunction. Sorry, MGH, I had no choice.
A patient’s socioeconomic background and his community's resources often play a bigger role in whether or not he is readmitted than the hospital itself, Jha tells me. Asking institutions to compete on this basis unfairly penalizes those who care for the underserved.
And higher readmission rates aren’t always a bad thing, he argues: they might reflect successful efforts to keep the sickest patients alive; to help patients access more, appropriate care; or to keep other (healthier) community members out of the hospital altogether so that they never enter into the denominator.
In a Medicare–funded study, MGH assigned case managers to coordinate the care of some of its sickest, highest cost patients. The intervention slowed their growing rate of ED visits and hospitalizations, reduced mortality, and cut costs compared to a control group. But tellingly, it had no impact on 90-day readmissions.
Chasing lower admission rates can come at the expense of patient-centered care. And zooming in from a bird’s eye view, I’ve found that most doctors disregard this quality metric as irrelevant in the course of a clinical decision. At MGH, ED residents usually decide if a patient will be (re)admitted, so I asked some of them if they factor a previous admission into their decision. If anything, one of them told me, it might make her more likely to readmit the patient (if it worked once...).
With all of these holes in the readmission metric, it’s no wonder that U.S. rates have hardly budged. Our national discussion of readmission rates may have helped us to think about better continuity of care (how can I help my patient get his diuretic prescription refilled?), but we’d be better served by measures that make more clinical sense. We should “focus on discharge planning, focus on effective handoff to the primary care provider. Put really strong incentives around those,” Jha says.
Later on in the same shift, another patient came in for an episode of body aches and stiffness - apparently, a consequence of her rare condition. To my fresh eyes, she looked incredibly ill, and in the hectic setting of the ED, admitting her seemed the safest next step. Another resident and I sifted through her records, discovering that she was admitted recently. But when we called her outpatient doctor, we learned that for her, hospital admissions have had little benefit. Buff up her electrolytes, give her the right meds, and she'll be well enough to go home suggested. So we did. She got better. And we sent her home. You’re welcome, MGH (though we did it for the patient).
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