CHICAGO—When a patient is discharged from the hospital, just about the last thing he or she wants is to be back in again within the next month. But a new national study has found that's exactly what happens to one out of five Medicare patients, costing billions in health care and suffering for patients.
The study, coauthored by a researcher from the Northwestern University Feinberg School of Medicine, also found that more than half the patients rehospitalized within 30 days appear not to have seen a physician as an outpatient since they were released from the hospital.
"We were surprised that more than half of these patients weren't being seen by their primary care doctors before they went back into the hospital," said study co-author Mark Williams, M.D., chief of hospital medicine for Northwestern's Feinberg School and for Northwestern Memorial Hospital. "This represents a major disconnect between care in the hospital and outside it. We've got to do better."
The study will be published in the New England Journal of Medicine April 2.
The unplanned readmissions cost more than $17 billion in 2004, a sizeable chuck of the $102.6 billion Medicare paid to hospitals. "There is also the emotional toll on patients," Williams said. "They suffer when they must be rehospitalized after the initial difficult experience of hospitalization."
The readmission rates rise with time; 19.6 percent of patients were readmitted within 30 days of discharge, 34 percent within 90 days and 56.1 percent within a year.
When patients are readmitted after surgery, 70 percent of them suffer from a medical problem such as a urinary tract infection or pneumonia.
Medicare and other insurers pay for readmissions except for those within 24 hours of discharge, Williams explained. This probably contributes to lack of effort to decrease them.
"They pay for quantity of service, not quality," Williams said. "While insurers will pay thousands of dollars for a hospitalization, they do not target payments to improve patient understanding of their care and the need for follow up. Hospitals and doctors are rewarded for 'doing things' instead of preventing them."
For example, he said, Medicare does not pay pharmacists to spend time with patients to ensure they understand their medication instructions and compare their medication list before hospitalization to their new list at discharge. Yet, strong research evidence shows this would ultimately prevent bad events and reduce visits to the emergency room and rehospitalizations.
To help prevent rehospitalizations, the health care team needs to focus throughout the hospital visit on preparing the patient and caregivers for the transition to home, Williams said. This should not occur just moments before discharge. The hospital also needs to coordinate follow-up care with primary care physicians.
"We strongly encourage our residents and hospitalists to communicate directly with the primary care doctor on admission and at discharge," Williams said.
Supportive palliative care can also reduce rehospitalizations and increase patient satisfaction. "When patients and their caregivers understand the goals of their care, they commonly get better relief from their symptoms and use less health care services at their request," Williams said.
Prior to this study, there has been little research on the causes and other issues connected to hospital readmissions. The study was conducted to learn more about the frequency of rehospitalization, the risk of readmission and the frequency of follow-up outpatient physician visits prior to discharge. In an attempt to reduce costs and improve the quality of health care, legislators and government agencies have recommended reducing payments for readmission services and making value-based hospital payments based on readmission rates.
The study examined Medicare fee-for-service claims data for nearly 12 million Medicare beneficiaries discharged from a hospital in 2003 and 2004.
Journal
New England Journal of Medicine