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Making Sure Minnie Doesn't Bounceback


James Cooper, MDToo often, ' people like Minnie L. are readmitted to a hospital after being discharged a few days before.'  So I was pleased this morning when I got the fax.'  It was a hospital discharge summary for Minnie, our 84 year old friend and patient with heart failure, who had been discharged yesterday. ' I was even more pleased when I got the email making sure I had received the summary.'  Ah, the system is working, I thought, smugly.'  The summary provides information we need for primary care follow-up. ' It will increase her odds of staying home longer, of not being readmitted soon,'  of not being what is popularly called a bounceback.

I wanted to brag about how good we were as a medical center.'  To bolster my position, I looked up our statistics in the 'Outcomes of Care' section of the Hospital Compare site.'  But it turns out that for ' hospital readmission, we'  were, 'Worse Than (the) U.S. National Rate,' at least for heart failure patients.

These statistics come from CMS, the Medicaid and Medicare agency.'  CMS recognizes the devastating impacts of hospital readmission, both the feelings of despair, depression and emotional exhaustion for the patient and family, and also the extra cost of the second admission. ' CMS has made readmission rates a quality indicator for hospital care, and expects to save $8.2 billion by reducing bouncebacks.

I was working this morning in clinic with one of our young doctors.'  ' I asked her opinion about why we were worse than the national rate.

I expected her to say, 'Because our patients are different, less healthy.''  There is some merit to that.'  CMS statistics account for gender, other diseases, and age, so they are supposed to adjust for illness severity.'  But they don't take into account all physiologic characteristics.'  Nor do they include culture and education.'  Some of our patients are in households that eat a lot of salt, which can be as deadly as poison to heart failure patients.'  And education may influence how well a person and her family understand and are motivated to provide the best ' home aftercare.

But she didn't say that.

I expected her to say, 'Because we keep people out of the hospital until they are very sick.''  There is some merit to that, too.'  We often treat heart failure in the emergency room and only admit very complicated patients.'  When we do admit, it is likely something terribly wrong has happened to the heart.'  We believe we have a higher threshold for admission than many community hospitals because we try to keep people in their homes, which is good.

But she didn't say that, either.

She said 'Possibly because we follow standard treatment guidelines for heart failure too strictly. ' Sometimes following standard one-size-fits-all guidelines intended for the average patient may produce an unintended outcome, she explained.

We need more research on these ideas.'  Hospitals that serve extremely ill people probably have higher readmission rates, and should not be punished for that.'  Guidelines need to adapt better to different situations to minimize readmission rates .'  The very concept of simple readmission rates as a quality indicator needs to be considered.'  One study showed that hospitals with higher 30-day readmission rates actually had lower (better) patient mortality rates.

Still, advocating for simple improvements such as better information flow from hospital to office just makes a lot of sense.'  The fax I got this morning, sadly, is not yet the universal pattern at my medical center. That should be fixed.'  At the same time, 'someone' should address other barriers to excellent aftercare.'  Someone should find a way for all our Minnie's to be sure they have the information they need, and to get their new medications, to have and get to their early post-hospital doctor's appointments, and to live in a home environment most conducive to healing. ' This will require someone's attention to patient and family motivation and behavior as well as improving the infrastructure to facilitate the best hospital aftercare. ' ' I'm not sure who that someone is.

Questions for you:

(1)' Is bounceback (bb) rate among the best hospital care quality indicators (QI)?

(2)' ' If bb is a reasonable QI,' then where are the critical and most cost-effective points to produce improvement? (vote for your favorite)

a.' '  in the hospital (guidelines, transition, logistics)

b.' '  in the primary care provider' office

c.' '  with the patient's knowledge and motivation for self care

d.' '  with barriers to getting new meds, getting and keeping a follow-up appointment

e.' ' ' with family knowledge, resources and motivation

More Blog Posts by James Cooper, MD

author bio

James Cooper, MD, FACPM, is a Clinical Professor of Medicine, Division of Geriatrics and Palliative Care at George Washington University. His practice is associated with George Washington University Medical Center, in Washington, DC.

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