Tuesday, October 2, 2012

How to lower hospital readmission rates: Let 'em die

As new Medicare rules kick in, some 2200 hospitals nationwide are facing financial penalties for high 30-day readmission rates for myocardial infarction, congestive heart failure and pneumonia. Medicare payments will be lowered by as much as 1%.

Investigators at the Skeptical Scalpel Institute for Evidence-Based Outcomes and Advanced Research (SSIEBOAR, catchy acronym, don’t you think?) have come up with a plan that is certain to lower readmission rates across the board. Some have said the idea should be patented but the institute is not-for-profit and thus is willing to share.

The solution is quite simple—let the patients die. Yes, death reduces readmission rates for all diseases, not just MI, CHF and pneumonia.

Oh, there may be some resistance and relatives of the patients may complain, but at least Medicare will be satisfied and after all, isn’t that why we became doctors?

Another outcome measure, hospital length of stay is also positively impacted by death. For example, if the average length of stay for a patient with a heart attack is 4 days, a patient who dies on hospital day #2 would lower the hospital’s average. Death also results in fewer resources being utilized, which saves the hospital money for those patients whose reimbursement is based on the DRG.

I confess. I’m not serious, and the idea is not original.

There are many issues. In most cases, as length of stay is ratcheted down, readmission rates will rise. One way to reduce readmissions is to keep patients in the hospital longer. And what about the things the hospitals and doctors can’t control? A recent study found that only 63% of Medicaid patients with diabetes, hypertension and hypercholesterolemia actually took their medications regularly.

So what is the solution?

Assessing quality of care in hospitals is a difficult task. People like me have complained about focusing on processes such as the Surgical Care Improvement Project because adherence to process measures does not always correlate with good outcomes. [See previous blog here.] However, processes are much easier to track than outcomes.

The problem with outcome measures is that experts can’t agree on which ones to measure. Even something as seemingly straightforward as death can actually be complex. A 2010 paper in the British Medical Journal on this subject was reviewed in a blog, which pointed out the difficulties with death as a benchmark. This holds true even when death is adjusted for risk.

Readmission rates are also controlled by physicians, not hospitals. Even concurrent review of readmissions by hospital utilization staffs has not been effective in reducing these numbers.

There is another factor. Here’s an anecdote that might help you understand the problem. An elderly woman was admitted for congestive heart failure. After a few days of intense medical care, she was discharged. She was readmitted for CHF three days later. When interviewed during her history and physical exam, she admitted that she 1) did not take any of her prescribed medications at home, 2) continued to smoke cigarettes and 3) did not follow her cardiac diet.

Is it really fair to penalize hospitals for readmissions, many of which cannot be prevented?


Anonymous said...

Your "plan" might be a viable,humane solution in some cases, for example; a 95 year old man admitted last evening (from a nursing facility) with a heart rate in the 20's(his last admission was <30 days ago for bradycardia, so this is a re-admission). In the ED he was given medication to counter this "problem" and his heart rate went back to the 50-60 range. He has dementia, and has no idea why, how or where. The record shows he is a DNR--Yet, he is in the hospital, having labs drawn, x-rays done and multiple disciplines consulted...When I saw him today, he struggled unsuccessfully to understand what was going on. The thought crossed my mind that he had been robbed of a peaceful death (heart rate slows, and he dies in his sleep). Now he will be at risk of developing some nosocomial infection or a hospital-acquired pressure ulcer. And he will suffer. And the healthcare system will spend thousands. There is no question in this case that the patient is non-compliant--he is just old and his body is trying to die, but "we" are not letting him. Who decides where to draw that line?

Skeptical Scalpel said...

Great comment. We've all been there. I wrote about this type of situation last year. Here is the link: http://skepticalscalpel.blogspot.com/2011/10/surgery-at-end-of-life-reality-check.html.

Anonymous said...

I cared for a man with COPD as a resident: readmission after readmission, housestaff and attendings confused. I tried reassessing his med profile, and since his insight was "I takes a red pill and a blue pill" I asked him to bring all his meds in for an expedited clinic visit. He did, all 4 shopping bags full of them. 4 Shopping bags. With handles. His explanation? He filled the prescriptions he was given at discharge like he was told, but nobody told him to take them, forget about inhaler use instructions.
Now then, who is responsible for this sort of stuff? I am sure mine is not an isolated case. Point is, where do the physician's responsibilities for common sense end? Why should WE be penalized for...whatever you'd like to call it.

Skeptical Scalpel said...

According to comments I received when I posted this on Physicians Weekly, it's your fault for not explaining things better. To many people, it's never the patient's fault. Blame the doctors.

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