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Back in the hospital again

If you get admitted to a hospital, chances are way too good that you’ll be back before long — maybe more than once

By Karen Weintraub
June 21, 2010

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Lucille Jeffries has had a pretty rotten six weeks. Since a May 4 car accident, the 84-year-old has been in Carney Hospital briefly, and admitted to Tufts Medical Center three times, Marian Manor for rehab twice, and Brigham and Women’s Hospital once.

Now, the Dorchester resident is in the Hebrew Rehabilitation Center for three weeks, while her collarbone heals enough for her to head back to the Brigham for surgery on her aorta.

“I never rode in so many ambulances in my life,’’ said the great-grandmother, who would much rather be playing bingo with her friends.

In Massachusetts, more than 10 percent of patients are back in the hospital for the same or unrelated complaints within a month, according to the Institute for Healthcare Improvement, a Cambridge-based nonprofit think tank. Over two years, more than a quarter of all patients end up paying a repeat visit to the hospital, a new 12-state study by the US Agency for Healthcare Research and Quality found.

Three-quarters of readmissions could likely be avoided with better care, according to a 2007 congressional report by the Medicare Payment Advisory Commission that got the attention of hospitals, insurance companies, doctors’ groups, patient advocates, and the US Congress.

Cutting back on readmissions offers an opportunity to cut costs while improving care. “There’s now enough interest to make the status quo untenable,’’ said Dr. Harlan M. Krumholz, a Yale cardiologist who published a study in the June 2 issue of the Journal of the American Medical Association showing that 20 percent of heart failure patients were back in the hospital within a month.

Medicare alone spends more than $15 billion a year on rehospitalizations, and the Obama administration estimates that $26 billion could be saved over 10 years from an overall reduction in the hospital-return rate — a good chunk of which could be used to help pay for its other health care priorities.

Complicating the discussion, there is no standard definition for the terms “readmission’’ and “rehospitalization.’’ Depending on the agency or institution applying the labels, the timeframe for a hospital patient’s return varies from seven days to more than a year. Under the new federal health care law, the Centers for Medicare & Medicaid Services will use a 30-day cutoff to start penalizing hospitals with higher than expected rates of readmissions, starting in 2012.

The causes of readmissions vary widely. Patients may return because of the same health issue — their heart failure is getting worse, say; or because of a new one — disoriented by new medications, patients are more likely to fall and break a hip.

In recent years, a number of hospitals have been making an effort to keep track of returning patients and ask why they ended up hospitalized again, said Dr. Amy E. Boutwell, who heads up IHI’s national effort to improve such transitions. So far, said Boutwell, also a general internist at Newton-Wellesley Hospital, 90 hospitals have joined IHI’s initiative. Among them are 22 Massachusetts hospitals, including Tufts Medical Center and Brigham and Women’s Hospital.

Sometimes a patient is readmitted because of a complication caused by a medical error — a patient is prescribed too much of a drug, for instance. Other times, patients are not adequately instructed how to care for themselves at home.

Often, Boutwell and others said, there’s a lack of coordination between hospitals and caregivers in the community. Or between the hospitals themselves — as Jeffries found out the hard way.

For weeks after Jeffries’s accident, doctors and nurses assumed her shortness of breath was related to the ribs and collarbone she broke when she drove her 1991 Honda Civic into a pole to avoid hitting a pedestrian. No one knew or thought to ask her about the tests her Brigham cardiologist conducted the day before the accident. When she was finally transferred to the Brigham — at the insistence of a granddaughter who is a nurse practitioner — it became clear that a flawed aortic valve was causing her shortness of breath.

Jeffries says the lack of coordination doesn’t upset her. “I have too much to live for,’’ she said, citing her three children, eight grandchildren, and great-grandchildren — the ninth of whom is due “any day now.’’

But her daughter-in-law Marian says the whole experience has been frustrating and upsetting for the family. And it didn’t have to happen.

Her caregivers “should have looked at her more comprehensively,’’ said Marian, acknowledging that most other hospitals and nursing homes would probably have done the same thing.

“It’s nothing against those individual places, it’s just medicine today,’’ said Marian, a nurse practitioner at Massachusetts General Hospital. “It’s a tough call to see the whole patient.’’

Such fragmentation has gone on so long in part because hospitals are rewarded every time a patient is readmitted, said Dr. Stephen Jencks, a former official with the federal Centers for Medicare & Medicaid Services, who is generally credited with helping to put the issue on the government’s radar.

“If you tried to design a system to fragment care, you probably couldn’t have come up with a much better one,’’ said Jencks, an independent consultant and senior fellow at IHI.

But it is starting to change, he and others said, with the Obama administration’s attention, and with pilot projects around the country that have proven that return rates can be brought down. Among the most successful ones:

■ At Boston Medical Center, Dr. Brian Jack’s Project RED (for ReEngineered Discharge) teaches recently released patients to identify potential problems early, connects them to resources in their communities, and ensures that they get to see a primary care doctor shortly after they leave the hospital.

■ At the University of Colorado, Dr. Eric A. Coleman has developed the Care Transitions Program, whose coaches teach patients self-management skills, and assist them in their first month out of the hospital.

■ At the University of Pennsylvania School of Nursing, Mary D. Naylor has organized a program to get nurses working with severely chronically ill patients while they’re still hospitalized, to prevent infections, coordinate care, and develop a plan for care after they go home. The same nurse visits the patient at home for several months and goes with him or her on visits to the primary care doctor, building a relationship that can pay off if the patient starts to have problems.

Dr. Ashish K. Jha, an associate professor of health policy at the Harvard School of Public Health and a staff physician with the Boston Veterans Health Administration, said he supports any effort that’s proven effective. It’s overly optimistic, though, to assume that millions of dollars can be saved by reducing hospital readmissions — the problem is just too entrenched, he said.

“To me, if you do it for the financial savings you might very well be disappointed,’’ he said. “But doing it for better care is reason enough.’’

Karen Weintraub can be reached at karen@karenweintraub.com.

Reducing readmissions

To avoid ending up back in the hospital, researchers suggest asking the following questions before being discharged:

■ Are you familiar with and capable of following your medication plan, and do you have access to the proper drugs?

■ Do you have a follow-up visit scheduled within a week of discharge, and are you able to get there?

■ Do you fully understand the signs and symptoms that require medical attention, and whom to contact if they occur?

SOURCE: Institute for Healthcare Improvement

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