Annals of Internal Medicine
E ditorial
Opportunities and Challenges for Reducing Hospital Revisits ospital revisits are com m on and consequential events fo r patients. Data from the M edicare p o p u lation show th a t alm ost 1 in 5 o ld e r adults is rehospital ized w ithin 30 days o f discharge (1). Younger patients are also freq ue n tly readm itted at rates that may exceed those o f o ld e r patients fo r specific conditions, such as heart failure, diabetes, and selected psychiatric disor ders (2). Even in the absence o f readm ission, an a d d i tional 1 in 10 recently discharged patients receives care in an em ergency d ep artm en t (ED) as part o f a treatand-release visit (3). Two articles in this issue exam ine the clinical e p id e m io log y and p redictors o f 2 types o f hospital revisits. First, Duseja and colleagues (4) used statewide data to show th a t 8% o f patients return w ithin 3 days o f an in dex ED visit and 20% return w ithin 30 days. O f note, they fo un d that 1 in 3 revisits to an ED occurs at a d if fe re nt location than the initial site o f care; fo r perspec tive, 1 in 5 hospital readmissions occurs at a different institution (5). Finally, the authors showed that 9 o f 10 ED revisits w ithin 3 days o f discharge occur fo r the same c o nd itio n as the initial hospitalization. This fin d ing is in stark contrast with data on hospital readm is sions, m ost o f which occur fo r a d ifferen t condition (6). These findings h ig h lig h t an underappreciated p roblem , the central question o f which concerns the potential preventability o f revisits. To what extent do ED revisits represent gaps in quality as opposed to rea sonable strategies th a t prevent admissions at the cost o f additional revisits fo r acute care? Flow often do re visits represent failures o f transitional care, such as p o o r integration o f ED and prim ary care, suboptim al education o f patients and caregivers, or lack o f tim ely follow -up? Are certain strategies, such as clinical path ways fo r conditions that m ost often result in revisits to the ED (7), associated w ith low er risk? Studies are also needed to understand m ore a bo ut patients who have revisits. W hy do patients often seek care at d ifferent institutions? It may be th a t many are dissatisfied with th e ir initial encounter or are exercising greater discre tion in th e ir choice o f facility. The frequency at which ED revisits occur suggests that revisit measures m ight serve as the foundation fo r future perform ance m ea sures. Interpretation o f the second study, by Graham and colleagues (8), presents some challenges. A lth ou g h the authors posit th a t markers o f acute illness severity and inp atie nt care processes are associated with readm is sions w ithin 7 days o f hospital discharge, but not th e re after, th e ir results do not strongly su pp ort this conten tion (8). It is far from clear th a t the length o f tim e after discharge m odifies the effect o f the authors' set o f pre d ic to r variables. A lth ou g h some variables are signifi cant in one period or the other, the CIs fo r these vari ables have substantial overlap. M oreover, many illness and care process indicators, such as use o f the inten sive care unit during hospitalization, discontinuity in nursing care, and evidence o f clinical instability on dis
H
charge, are not associated with readmission during the first 7 days or days 8 to 30 after hospitalization. In con trast, a higher level o f illness acuity on a laboratorybased measure is associated with elevated risk fo r re admission during both tim e periods. Some findings are also counterintuitive. Patients with prim ary care physi cians w ho had access to the hospital's electronic m ed ical record were m ore likely to be readm itted in the week after discharge, and continuity in physician care was found to be associated with few er readmissions only after day 7. It is also d ifficult to determ ine w hether the results are generalizable or m aterially im portant. The study is lim ited to discharges from a single academ ic center, and only readmissions returning to the study hospital are available fo r analysis. Previous w ork has found that although 80% o f readm itted patients return to th e ir ini tial hospital, there is considerable variation (0% to 100%) by institution (5). As a result, we do not know if the exam ined hospital discharges and readm issions ac curately reflect national patterns or even those o f the academ ic center. In the absence o f summary data that w ould describe the perform ance o f the p rediction m odels, it is d ifficult to assess the degree to which markers o f acute illness severity and inpatient care p ro cesses differentiate patients who will and will not be rehospitalized w ithin the first 7 days after discharge. To be useful, any markers that differentiate patients should have the potential to im prove outcom es th rough higher quality care. Ultimately, a truly patient-centered approach to re ducing hospital revisits should incorporate know ledge o f patients' underlying vulnerabilities after discharge. Previous research has shown no specific day during the posthospitalization m onth after which risk fo r readm is sion drops precipitously (9). Rather, risk declines slowly over days and remains elevated beyond the 30-day pe riod th a t has been the focus o f federal readmission penalties (9). Previous work has also shown th a t pa tients are vulnerable to readmission due to a broad range o f conditions th ro u g h o u t the first m onth after discharge, regardless o f th e ir age, sex, or race (6). Tai loring interventions to patients' underlying vu ln era bili ties is a reasonable strategy to reduce hospital readm is sions or ED revisits and is preferable to one based on sim ple tem poral subdivisions w ithin the initial m onth or any period after discharge. These vulnerabilities m ight vary by patients' hospital experience because o f stres sors that are not yet w ell-defined or m easured (10). To im prove outcom es fo r patients, we must think broadly about th e ir experiences in m ultiple health care settings. The ED, with respect to revisits, represents a new venue fo r such inquiry. W hether factors associated with risk fo r readmission change over tim e and w hether this inform ation has im plications fo r interventions d e signed to reduce adverse events remains w orthy o f fu r th e r investigation. © 2015 American College of Physicians 793
E ditorial Kumar Dharmarajan, MD, MBA Harlan M. Krumholz, MD, SM Yale School o f M edicine New Haven, C onnecticut Disclaimer: The con tent is solely the responsibility o f the au thors and does not represent the official views o f the National Institutes o f Health. Grant Support: By the National Institute on A g in g and the Am erican Federation fo r A g in g Research th ro u g h the Paul B. Beeson Career D e velo pm e nt Awards in A g in g Research Pro gram (grant K23AG 048331-01; Dr. Dharm arajan) and the Na tional Heart, Lung, and Blood Institute (gra nt 1 U01 HL105270OS; Center fo r Cardiovascular O utcom es Research at Yale University [Dr. Krumholz]). Disclosures: Disclosures can be view ed at ww w.acponline.org /a u th o rs /ic m je /C o n flic tO fln te re s tF o rm s .d o ? m s N u m = M1 5 -0878. Requests for Single Reprints: Harlan Krumholz, MD, SM, Center fo r O utcom es Research and Evaluation, 1 Church Street, Suite 200, New Haven, CT 06510; e-mail, harlan .krum holz@ yale.edu. C urrent au thor addresses are available at w w w .annals.org.
A nn Intern Med. 20 1 5;162:793-794. d o i:1 0 .7 3 2 6 /M 1 5-0878
R eferences 1. Blum J. Statement of Johnathan Blum on delivery system reform: progress report from CMS before the U.S. Senate Finance Commit tee. 28 February 2013. Accessed at www.finance.senate.gov/imo
794 Annals of Internal Medicine • Vol. 162 No. 11 • 2 June 2015
Opportunities and Challenges for Reducing Hospital Revisits
/media/doc/CMS%20Delivery%20System%20Reform%20Testimony %202.28.13%20%28J.%20Blum%29.pdf on 16 April 2015. 2. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagno sis, 2010. Healthcare Cost and Utilization Project statistical brief no. 153. Rockville, MD: Agency for Healthcare Research and Quality; 2013. Accessed at www.hcup-us.ahrq.gov/reports/statbriefs/sb153 ,jsp on 16 April 2015. 3. Vashi AA, Fox JP, Carr BG, D'Onofrio G, Pines JM, Ross JS, et al. Use of hospital-based acute care among patients recently dis charged from the hospital. JAMA. 2013;309:364-71. [PMID: 23340638] doi:10.1001/jama.2012.216219 4. Duseja R, Bardach NS, Lin GA, Yazdany J, Dean ML, Clay TH, et al. Revisit rates and associated costs after an emergency department encounter. A multistate analysis. Ann Intern Med. 2015;162:750-56. doi: 10.7326/M14-1616 5. Nasir K, Lin Z, Bueno H, Normand SL, Drye EE, Keenan PS, et al. Is same-hospital readmission rate a good surrogate for all-hospital re admission rate? Med Care. 2010;48:477-81. [PMID: 20393366] doi: 10.1097/MLR.0b013e3181 d5fb24 6. Dharmarajan K, Hsieh AF, Lin Z, Bueno H, Ross JS, Horwitz LI, et al. Diagnoses and tim in g of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309:355-63. [PMID: 23340637] doi:10 ,1001/jam a.2012.216476 7. Schuur JD, Baugh CW, Hess EP, Hilton JA, Pines JM, Asplin BR. Critical pathways for post-emergency outpatient diagnosis and treat ment: tools to improve the value of emergency care. Acad Emerg Med. 2011;18:e52-63. [PMID: 21676050] doi:10.1111/j.1553-2712 ,2011.01096.x 8. Graham KL, Wilker EH, Howell MD, Davis RB, Marcantonio ER. Differences beween early and late readmissions among patients. A cohort study. Ann Intern Med. 2015;162:741-9. doi:10.7326/M14 -2159 9. Dharmarajan K, Hsieh AF, Kulkarni VT, Lin Z, Ross JS, Horwitz LI, et al. Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort study. BMJ. 2015;350:h411. [PMID: 25656852] doi:10.1136/bmj.h411 10. Detsky AS, Krumholz HM. Reducing the trauma of hospitaliza tion. JAMA. 2014;311:2169-70. [PMID: 24788549] doi:10.1001/jama .2014.3695
www.annals.org
Copyright © American College of Physicians 2015.
E ditorial
Opportunities and Challenges for Reducing Hospital Revisits ospital revisits are com m on and consequential events fo r patients. Data from the M edicare p o p u lation show th a t alm ost 1 in 5 o ld e r adults is rehospital ized w ithin 30 days o f discharge (1). Younger patients are also freq ue n tly readm itted at rates that may exceed those o f o ld e r patients fo r specific conditions, such as heart failure, diabetes, and selected psychiatric disor ders (2). Even in the absence o f readm ission, an a d d i tional 1 in 10 recently discharged patients receives care in an em ergency d ep artm en t (ED) as part o f a treatand-release visit (3). Two articles in this issue exam ine the clinical e p id e m io log y and p redictors o f 2 types o f hospital revisits. First, Duseja and colleagues (4) used statewide data to show th a t 8% o f patients return w ithin 3 days o f an in dex ED visit and 20% return w ithin 30 days. O f note, they fo un d that 1 in 3 revisits to an ED occurs at a d if fe re nt location than the initial site o f care; fo r perspec tive, 1 in 5 hospital readmissions occurs at a different institution (5). Finally, the authors showed that 9 o f 10 ED revisits w ithin 3 days o f discharge occur fo r the same c o nd itio n as the initial hospitalization. This fin d ing is in stark contrast with data on hospital readm is sions, m ost o f which occur fo r a d ifferen t condition (6). These findings h ig h lig h t an underappreciated p roblem , the central question o f which concerns the potential preventability o f revisits. To what extent do ED revisits represent gaps in quality as opposed to rea sonable strategies th a t prevent admissions at the cost o f additional revisits fo r acute care? Flow often do re visits represent failures o f transitional care, such as p o o r integration o f ED and prim ary care, suboptim al education o f patients and caregivers, or lack o f tim ely follow -up? Are certain strategies, such as clinical path ways fo r conditions that m ost often result in revisits to the ED (7), associated w ith low er risk? Studies are also needed to understand m ore a bo ut patients who have revisits. W hy do patients often seek care at d ifferent institutions? It may be th a t many are dissatisfied with th e ir initial encounter or are exercising greater discre tion in th e ir choice o f facility. The frequency at which ED revisits occur suggests that revisit measures m ight serve as the foundation fo r future perform ance m ea sures. Interpretation o f the second study, by Graham and colleagues (8), presents some challenges. A lth ou g h the authors posit th a t markers o f acute illness severity and inp atie nt care processes are associated with readm is sions w ithin 7 days o f hospital discharge, but not th e re after, th e ir results do not strongly su pp ort this conten tion (8). It is far from clear th a t the length o f tim e after discharge m odifies the effect o f the authors' set o f pre d ic to r variables. A lth ou g h some variables are signifi cant in one period or the other, the CIs fo r these vari ables have substantial overlap. M oreover, many illness and care process indicators, such as use o f the inten sive care unit during hospitalization, discontinuity in nursing care, and evidence o f clinical instability on dis
H
charge, are not associated with readmission during the first 7 days or days 8 to 30 after hospitalization. In con trast, a higher level o f illness acuity on a laboratorybased measure is associated with elevated risk fo r re admission during both tim e periods. Some findings are also counterintuitive. Patients with prim ary care physi cians w ho had access to the hospital's electronic m ed ical record were m ore likely to be readm itted in the week after discharge, and continuity in physician care was found to be associated with few er readmissions only after day 7. It is also d ifficult to determ ine w hether the results are generalizable or m aterially im portant. The study is lim ited to discharges from a single academ ic center, and only readmissions returning to the study hospital are available fo r analysis. Previous w ork has found that although 80% o f readm itted patients return to th e ir ini tial hospital, there is considerable variation (0% to 100%) by institution (5). As a result, we do not know if the exam ined hospital discharges and readm issions ac curately reflect national patterns or even those o f the academ ic center. In the absence o f summary data that w ould describe the perform ance o f the p rediction m odels, it is d ifficult to assess the degree to which markers o f acute illness severity and inpatient care p ro cesses differentiate patients who will and will not be rehospitalized w ithin the first 7 days after discharge. To be useful, any markers that differentiate patients should have the potential to im prove outcom es th rough higher quality care. Ultimately, a truly patient-centered approach to re ducing hospital revisits should incorporate know ledge o f patients' underlying vulnerabilities after discharge. Previous research has shown no specific day during the posthospitalization m onth after which risk fo r readm is sion drops precipitously (9). Rather, risk declines slowly over days and remains elevated beyond the 30-day pe riod th a t has been the focus o f federal readmission penalties (9). Previous work has also shown th a t pa tients are vulnerable to readmission due to a broad range o f conditions th ro u g h o u t the first m onth after discharge, regardless o f th e ir age, sex, or race (6). Tai loring interventions to patients' underlying vu ln era bili ties is a reasonable strategy to reduce hospital readm is sions or ED revisits and is preferable to one based on sim ple tem poral subdivisions w ithin the initial m onth or any period after discharge. These vulnerabilities m ight vary by patients' hospital experience because o f stres sors that are not yet w ell-defined or m easured (10). To im prove outcom es fo r patients, we must think broadly about th e ir experiences in m ultiple health care settings. The ED, with respect to revisits, represents a new venue fo r such inquiry. W hether factors associated with risk fo r readmission change over tim e and w hether this inform ation has im plications fo r interventions d e signed to reduce adverse events remains w orthy o f fu r th e r investigation. © 2015 American College of Physicians 793
E ditorial Kumar Dharmarajan, MD, MBA Harlan M. Krumholz, MD, SM Yale School o f M edicine New Haven, C onnecticut Disclaimer: The con tent is solely the responsibility o f the au thors and does not represent the official views o f the National Institutes o f Health. Grant Support: By the National Institute on A g in g and the Am erican Federation fo r A g in g Research th ro u g h the Paul B. Beeson Career D e velo pm e nt Awards in A g in g Research Pro gram (grant K23AG 048331-01; Dr. Dharm arajan) and the Na tional Heart, Lung, and Blood Institute (gra nt 1 U01 HL105270OS; Center fo r Cardiovascular O utcom es Research at Yale University [Dr. Krumholz]). Disclosures: Disclosures can be view ed at ww w.acponline.org /a u th o rs /ic m je /C o n flic tO fln te re s tF o rm s .d o ? m s N u m = M1 5 -0878. Requests for Single Reprints: Harlan Krumholz, MD, SM, Center fo r O utcom es Research and Evaluation, 1 Church Street, Suite 200, New Haven, CT 06510; e-mail, harlan .krum holz@ yale.edu. C urrent au thor addresses are available at w w w .annals.org.
A nn Intern Med. 20 1 5;162:793-794. d o i:1 0 .7 3 2 6 /M 1 5-0878
R eferences 1. Blum J. Statement of Johnathan Blum on delivery system reform: progress report from CMS before the U.S. Senate Finance Commit tee. 28 February 2013. Accessed at www.finance.senate.gov/imo
794 Annals of Internal Medicine • Vol. 162 No. 11 • 2 June 2015
Opportunities and Challenges for Reducing Hospital Revisits
/media/doc/CMS%20Delivery%20System%20Reform%20Testimony %202.28.13%20%28J.%20Blum%29.pdf on 16 April 2015. 2. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagno sis, 2010. Healthcare Cost and Utilization Project statistical brief no. 153. Rockville, MD: Agency for Healthcare Research and Quality; 2013. Accessed at www.hcup-us.ahrq.gov/reports/statbriefs/sb153 ,jsp on 16 April 2015. 3. Vashi AA, Fox JP, Carr BG, D'Onofrio G, Pines JM, Ross JS, et al. Use of hospital-based acute care among patients recently dis charged from the hospital. JAMA. 2013;309:364-71. [PMID: 23340638] doi:10.1001/jama.2012.216219 4. Duseja R, Bardach NS, Lin GA, Yazdany J, Dean ML, Clay TH, et al. Revisit rates and associated costs after an emergency department encounter. A multistate analysis. Ann Intern Med. 2015;162:750-56. doi: 10.7326/M14-1616 5. Nasir K, Lin Z, Bueno H, Normand SL, Drye EE, Keenan PS, et al. Is same-hospital readmission rate a good surrogate for all-hospital re admission rate? Med Care. 2010;48:477-81. [PMID: 20393366] doi: 10.1097/MLR.0b013e3181 d5fb24 6. Dharmarajan K, Hsieh AF, Lin Z, Bueno H, Ross JS, Horwitz LI, et al. Diagnoses and tim in g of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309:355-63. [PMID: 23340637] doi:10 ,1001/jam a.2012.216476 7. Schuur JD, Baugh CW, Hess EP, Hilton JA, Pines JM, Asplin BR. Critical pathways for post-emergency outpatient diagnosis and treat ment: tools to improve the value of emergency care. Acad Emerg Med. 2011;18:e52-63. [PMID: 21676050] doi:10.1111/j.1553-2712 ,2011.01096.x 8. Graham KL, Wilker EH, Howell MD, Davis RB, Marcantonio ER. Differences beween early and late readmissions among patients. A cohort study. Ann Intern Med. 2015;162:741-9. doi:10.7326/M14 -2159 9. Dharmarajan K, Hsieh AF, Kulkarni VT, Lin Z, Ross JS, Horwitz LI, et al. Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort study. BMJ. 2015;350:h411. [PMID: 25656852] doi:10.1136/bmj.h411 10. Detsky AS, Krumholz HM. Reducing the trauma of hospitaliza tion. JAMA. 2014;311:2169-70. [PMID: 24788549] doi:10.1001/jama .2014.3695
www.annals.org
Copyright © American College of Physicians 2015.
