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Consider four psychiatric patients, all discharged from an inpatient unit on the same day following stabilization of an acute psychotic episode. A week later, the following events takes place:
Arnold’s symptoms return and in despair he commits suicide.
Barbara’s symptoms return and she goes on a cocaine binge, fueling her aggressive tendencies to the point where she punches a cop, landing herself in jail.
Carlos’s symptoms return and he becomes convinced that his apartment is full of listening devices. He moves to living under a bridge far from town.
Derrick’s symptoms return, and, having learned about his illness in the hospital, he recognizes the problem and returns to his site of care. He is admitted for 24 hours, re-stabilizes, and is then maintained as an outpatient in the community.
So, why would some powerful players in our health care system consider Derrick to have had the worst outcome? Because he and not the others was re-admitted to care within 30 days of discharge.
This situation is not unique to psychiatry. Last week, I went to a meeting of cardiologists who are grappling with the same reality. Medicare ratings, consumer groups and an increasing number of insurers are pressuring cardiologists to have shorter lengths of stay and fewer rapid (i.e., within 30 days) readmissions. The desired outcome has become a measure of health care utilization rather than health. As this tail increasingly wags the dog, hospitals face some perverse incentives. If you aggressively monitor your patients after discharge, you are more likely to catch a symptom that warrants re-admission (Presuming you have this funny idea in your head that the health care system should try to save people’s lives). Likewise, if the hospital is in a location that provides easy access and its admission procedure poses minimal burearaucratic barriers — normally things we would cherish — re-admission is more likely and the hospital’s rating and level of reimbursement may go down.
If you follow the logic of the anti-readmission crowd out, you arrive at the conclusion that the best hospitals are those that close and those that kill every patient on the surgical table, because both types of facilities have a re-admission rate of zero.
[Cross-posted at Same Facts]
Ella on May 07, 2011 4:41 AM:
A country's treatment of its mentally ill citizens might be one of the best measures of the state of its soul. We're deeply lacking in this regard. If you've ever had a friend or family member with serious mental illness, you know this first hand.
ceildith on May 07, 2011 7:40 AM:
I'd consider readmissions a measure of failure only if we currently didn't kick people out of hospitals ridiculously early and without adequate inhome care. If you aren't a medical professional, a lot of what patients and families are now expected to provide in the way of aftercare is way beyond their expertise.
Sam on May 07, 2011 1:03 PM:
I am a practicing hospitalist and what I find is that readmission rates (particularly for heart failure patients) are often caused by poor outpatient follow-up and after-care after discharge. I often check the records of the patients I have discharged and see that patients get very little additional support after their one week follow-up appointment. That is where the incentives to prevent readmissions should be.
John Broughton on May 07, 2011 5:07 PM:
For certain hospital operations (putting in a pacemaker; removing an appendix, for example), we expect the problems to be fixed, at least for a while. For other treatments (mental health admissions, severe asthma attacks), we don't have such expectations. It's ridiculous to use examples of the second type to justify readmissions for treatments of the first type. Medicare may need to adjust its approach, but the basic concept is correct for many, if not most, hospital admissions.
Rich on May 08, 2011 11:27 AM:
The quicky inpatient tune-up can be a good thing, but a better outcome would be adequate community follow-up and more creative ways of dealing with crises, which often need more than a day to resolve. In some ways, this is a strawman example--more often someone else notices the problem and cajoles the patient (often with a threat of commitment) and the stay is for more than a day. Things like community commitment and intensive visiting nurse services for the mentally ill (which exist, but aren't widespread) would be better alternatives.
FGS on May 08, 2011 5:31 PM:
There has to be a balance between two bad extremes. Many hospitals are operating at or over capacity and many insurances pay a flat rate based on the diagnosis. Without a penalty for readmissions, the case-manager's incentive to turnover beds as fast as possible will dominate/
Brent Aleshire on May 16, 2011 1:58 PM:
Patients benefit when hospital staff assist them in planning for care at home upon discharge. Unfortunately, patients do not always receive the care and attention they need to have a successful discharge plan. Many readmissions could be prevented if the necessary education, planning and follow up care takes place. This is very labor intensive but good medicine for all concerned.