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 Medicine Johns Hopkins Bayview Medical Center
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Hospitalizations and the Patient Discharge: Has Society Overlooked Quality in Favor of Efficiency? (and what if anything can we, as individuals do about.
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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
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.”
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
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
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
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