Hospitalizations and the Patient Discharge: Has Society Overlooked Quality in Favor of Efficiency? (and what if anything can we, as individuals do about.

Hospitalizations and the Patient Discharge: Has Society Overlooked Quality in Favor of

Efficiency?(and what if anything can we, as individuals do

about it?)

Eric E. Howell, M.D.Associate Professor of Medicine

Johns Hopkins University, School of MedicineJohns Hopkins Bayview Medical Center

Disclosures

Co-Investigator of BOOST (better outcomes for older adults through safe transitions) an SHM/Hartford foundation funded projectLecture on transitions of care No off label medication discussionsNo device discussions

Objectives

Review national LOS and readmissions dataReview data on the hospital discharge processProvide an overview of studies that

Improved DC efficiencyImproved DC quality

Provide examples of resources available

Background: It was 1983

The DRG payment system institutedGoals:

Reduced LOSIncrease efficiencyReduce cost

Some concern about quality (readmissions)

Little done to monitorUntil recently, not studied

Background: 2009

Health care reform front & centerGoals:

Increase efficiencyReduce costImprove quality

DeFrances et al, Adv data, 2007 Jul 12;(385):1-19

Average LOS: US Hospitals 1970-2005

>65 yo: 12.6 to 5.5 days

Lower LOS Value

The Commonwealth Fund, 2006

Hospitalists $50 more per DCMuch of cost due to readmissionAlso more NH dischargesAnd more ED visits

Jencks S, Williams MV, Coleman EA. N Engl J Med 2009;360:1418-1428

Rates of Rehospitalization within 30 Days after Hospital Discharge

20% rehospitalization rate @ 30 days$17Billion in costsWide variability in rehospitalization by state (13-23%)

What is the relationship between LOS and hospital readmissions?

90 Day Readmission Rate (%)Elderly Pts with CHF

Rich, et al. Am J Public Health. 1988 June; 78(6): 680–682.

CONCLUSION in 1988: “shorter hospitalstays under the DRG system are not necessarily associated

with a rebound increase in readmission frequency”

90 Day Readmission Rate (%)20th vs 21st Century

Medicare 60 Day Readmission Rates

Jencks et al, N Engl J Med 2009

Discussion: “…difference is more likely to indicate an actual increase in rehospitalization rates over time, perhaps owing to a shorter

duration of index hospitalization…”

LOS & Readmission

59 hospitals, >100,000 ptsHospitals with shorter LOS found to be at risk for increased readmissionsBetter staffing ratios mitigated risk somewhatNorwegian study

Health Serv Res. 2002;37:647-665

LOS & Readmission

1913 patients, single Academic Medical Center31% of readmitted pts had “too short hospital stay”Sicker patients had same LOS as all pts50% of reahospitalized patients had LOS < 2 daysDone in Israel

Medicine. 2008 Sep;87(5):294-300.

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Re-engineer the “J-curve”

Appropriately focus on LOS & keep short!Follow rehospitalization rate“engineer” systems to improve quality of DC processAlign reimbursement to focus on quality & efficiency

Efficiency Quality

Current reward systemIdeal Reward system

Hospital Discharge

“Random events connected to highly variable actions with only a remote possibility of meeting implied expectations.”

© 2006 Institute for Healthcare Improvement“Steal shamelessly, share senselessly”

A lot of Evidence Emerging that DC Process is Broken

Discharge Communication Poor

Hospitalist-PCP communication documented 3-20% of time

Phone notification of D/C 31% of time

Less than 1/3 of PCPs do not receive D/C summary by f/u appointment!

Hruby, how do patients view the role of the primary care physician in inpatient care?Pantilat, primary care physician attitudes regarding communication with hospitalistsVan Walraven, dissemination of discharge summaries. Not reaching follow-up physicians (Can Fam Physician. 2002 Apr;48:737-42.)Kripalani, Deficits in communication and information transfer between hospital-based and primary care physicians, JAMA 2007 Feb 28;297(8):831-41

Discharge Summary Quality Poor

No diagnostic test results (33-63%)No hospital course/treatment (7-22%)No discharge meds (2-40%)Pending tests not listed (65%)Lack of follow-up plan listed (2-43%)

Kripalani, JAMA 2007 Feb 28;297(8):831-41

The Dangers of DC41% of patients discharged with pending test results

9.4% could require actionOf the 9.4%

37.1% “actionable”- change in plan of car needed12.6% “urgent” - action requiredMDs unaware 61% of time

Roy, 2005;143(2):121-128

The Dangers of DC¼ of discharged patients require outpatient workupMore than one third not done (35.9%)Discharge summaries improved work up rateIncreased time from D/C to F/U appointment decrease work up rate

Moore, arch int med, 2007;167:1305-1311

The Dangers of DC1 in 5 (23%) discharges with adverse event72% of adverse events due to medications16% due to “therapeutic errors”Half of events for preventable or ameliorable

Forster, (CMAJ 2004;170(3):345-9

Better Efficiency Does not Always = Reduced Quality

TuftsHospitalist managed pts for 6 weeksLOS Reduced from 3.45 to 2.19266 increased admissions annuallyCost reduced from $2,332 to $1,775No change in readmission

Health Serv Res. 2003 Jun;38(3):905-18

Better Efficiency Does not Always = Reduced Quality

Urban community teaching hospital5308 patients cared for by hospitalistsLOS shorter by 0.61 daysCost lower ($822)Lower mortality rate in hospital & at 30 & 60 daysReadmission rate similar at 10 days

Ann Intern Med. 2002 Dec 3;137(11):859-65

Better Efficiency Does not Always = Reduced Quality

• Review of hospitalist studies 1996-2001

JAMA. 2002;287(4):487-94

…hospitalists improve inpatient effic

iency without

harmful effects on quality…

Multiple Studies Show Discharge Quality can be Improved

30,000 Patients

2003-2006

Readmission rate

23.3% for “low follow up” (<~33%)

20.5% for “higher follow up” rate

(>~33%)

May 2010

RCT of 749 hospitalized adultsNurse Discharge Advocate

F/U appt, Medication ReconciliationPatient education

Individualized instruction bookletPharmacist call 2-4 days post-discharge

Review medications

Jack, B. W. et. al. Ann Intern Med 2009;150:178-187

Project RED Outcomes

Intervention(n = 370)

Control(n = 368)

ER Visits* 16.5% 24.5%

Rehospitalization** 15% 21%

PCP f/u in 30 days* 62% 44%

Prepared for Discharge* 65% 55%

*p < 0.05

**p = 0.09

Coleman’s Transition Coach

Eric Coleman and others (n=750):“Transition coach”

HospitalHomePhone

EmpowermentSelf managementPatient owned health recordTimely follow-upA list of “red flags” and what to do

Coleman, Arch Int Med. 2006;166:1822-1828

Coleman’s Transition Coach

Eric Coleman and others (n=750):Reduced readmissions

30 days90 days

Reduced readmission for same dx90 days 180 days

Reduced Cost ~ $300k a yearAdopted by over 135 leading health care organizations nationwide

Coleman, Arch Int Med. 2006;166:1822-1828

237 elderly patients at 3 hospitalsAcademic, community

5 component interventionAdmission form with geriatric cuesFax to PCPInterdisciplinary worksheetPharmacist-Physician Med RecPre-Discharge Planning Appointments

J Am Geriatr Soc. 2009 Aug 18

Safe STEP Data

Pre-Intervention InterventionColman CTM > 72 68% 89%

ED Visit 3 days 10% 3%ED Visit 30 days 21% 14%

Readmission 22% 14%Feel Better 71% 84%

Post discharge - follow-up by RN or MD

Naylor et al: RN visit post d/c for geriatric medical patients

decreased rehospitalizations10% vs. 23% (p = 0.04) @ 6 wksN/S by 12 weeks

Anderson et al: MD visit post d/c for stroke decreased rehospitalizations

26% vs. 44% @ 6 months

Ann Intern Med 1994;120(12):999-1006.

Stroke 2000;31:1038-48.

Pharmacists & Transitions of Care

Pharmacist medication reconciliationCounseling at DC and 3 day f/u

Helpful with adverse drug events (ADEs)Decreased preventable medication ED visitsNo difference in total ADEs, health care utilization, pt satisfaction, med compliance

Schnipper, Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006 Mar 13;166(5):565-71

Pharmacists & Transitions of Care

Pharmacist post discharge phone callHigher patient satisfaction19% pts had medication problems resolved15% of pts had new problems identifiedLower 30 day ED visitsTrend towards lower re-admission rate

Dudas, The impact of follow-up telephone calls to patients after hospitalization.Am J Med. 2001 Dec 21;111(9B):26S-30S

Pharmacists & Transitions of Care

HOMER trial- home visits by pharmacists 2 & 8 weeks post DC

Higher hospital readmission rateNo improvement in QOL or death

Holland, Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial. BMJ. 2005 Feb 5;330(7486):293

Your participation can transform…

…This… …into This!!

Tools for Improving the Discharge Process

NQF Safe Discharge Practice (project RED)

National Transitions of Care Coalition (NTOCC)

Initial BOOST

Hartford Foundation-SHM Collaborative30 hospitals Web resources

Resource guideInterdisciplinary Teaches QILeadership infoSample letters to hospital leaders

http://www.hospitalmedicine.org/BOOST

BOOST

Hartford Foundation-SHM CollaborativeDedicated mentors

Meet with hospitalCall at min 1, 3, 6, 9 monthsSite visit

Implementation toolkit Risk assessment (TARGET)Patient friendly DC (PASS, GAP)

http://www.hospitalmedicine.org/BOOST

http://www.hospitalmedicine.org/BOOST

Web Resources

http://www.hospitalmedicine.org/BOOST

Summary

The discharge process is brokenCurrent system outdatedReadmission rates high: 1 in 5 patients returnIncentives focus only on LOS (for now)There is associated cost ($17B)

Summary

Possible to improve the DC processProject RedSafe STEPColeman’s Care Transition Coach

Improvement projects (BOOST) availableReadmission reduction by 1/3 could save billions and is feasible

Eric E. Howell M.D.ehowell@jhmi.edu