Friday, January 6, 2012

Not news: Shorter hospital lengths of stay = higher readmission rates

A study in the Journal of the American Medical Association from researchers at Duke University reveals that 14.5% of American patients who were admitted for acute myocardial infarction were readmitted within 30 days. Patients in other countries were readmitted only 9.9% of the time, a significant difference. (p = 0.001)

Patients in the US had significantly shorter initial hospitalization lengths of stay [LOS], 3 days vs. 6 days. The authors concluded that the short initial hospitalization LOS is highly likely to be the cause of the increased rate of readmission.

Why are patients being readmitted in such high numbers? In a press release the senior author of the MI study, Dr. Manesh R. Patel said, “In the United States, care is episodic, not always coordinated, and it's not clear in many cases whether the patient is seen again by the same doctor or care team within the first seven days after discharge.” Can you say “hospitalist”? The same doctor may not even see the patient every day in the hospital. That’s how the hospitalist model works.

Here’s an interesting fact. The 30-day readmission rate of 14.5% for US MI patients is actually less than that of all medical discharges (21.0%) found in a large study of Medicare patients published in the New England Journal of Medicine in 2009. That study also showed that readmissions are very costly.

I’m a mere surgeon, not a statistician or epidemiologist, but I can tell you that it is not surprising that the shorter an initial hospital stay is, the higher the readmission rate will be.

Here’s my theory on this subject. In case you haven’t heard, we are under tremendous pressure to discharge patients quickly. In every hospital, utilization review [UR] is conducted by squads of clipboard-wielding nurses, who are trained to prod doctors into sending patients home as soon as possible. Third party payers demand short LOSs. Digression: Lengths of stay are often based on the Milliman care guidelines. But remember, guidelines are just that. They aren’t meant to apply to 100% of patients.

I used to be intimidated by the pressure to send patients home. It was very uncomfortable to go into a patient’s room and explain to him that he had to be discharged because the some arbitrary authority had mandated it. No matter how I spun it, the patient felt that I was the villain for “kicking him out” before he was ready.

I have reached an age where I really don’t care what the UR nurse says. I refuse to jeopardize my relationship with a patient to please the bureaucrats. When I feel a patient is medically ready, I discharge him, but I do listen to the patient. If he has a valid reason for not wanting to go home, I will usually acquiesce.

I advise my medical colleagues to keep their MI patients in the hospital for what they believe is a reasonable time, UR be damned. Show them the JAMA article if they give you a hard time.


Anonymous said...

Surest way to toss all your skill in the garbage in the minds of your patients. Bad postop. That's all it takes.


Anonymous said...

Don't beat up the messenger. UR nurses don't determine when patients need to be discharged. The Milliman guidelines are developed by physicians and state that patients are ready for discharge when certain milestones are met. The ultimate decision to admit or discharge is the physician's call, but keep in mind, a longer LOS does not prevent readmissions or improve quality of care either. On the contrary, the longer a patient is hospitalized, the more likely chance they have for picking up infections, falling, etc.

Skeptical Scalpel said...

Thanks to bth anonymouses for your comments.

Are there any studies that support your statement that a longer LOS does not prevent or is not associated with fewer readmissions? I agree that the longer a patient stays the more chance he has of falling, infection or med error. I'm not sure everyone understands that keeping a patient in hospital is not advantageous for surgeons either monetarily or from the standpoint of time consumption. We get paid the same for an operation regardless of the LOS. There is no incentive for us to keep patients in the hospital.

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