Readmission After Intracerebral Hemorrhage: Can We Really Predict the Future?* Mohammed F. Rehman, DO Department of Neurology/Neurosurgery Henry Ford Hospital Detroit, Ml Mohammed S. Siddiqui, DO Department of Internal Medicine Beaumont Hospital Royal Oak, Ml
H
istorically, Medicare paid for majority of hospital readmissions until the advent of patient protection and Affordable Care Act (ACA) of 2010. Prior to 2008, most major hospitalizations for Medicare patients were reimbursed by Medicare subsidiaries except for readmissions within 24 hours for the same condition untu the Medicare Payment Advisory Commission recommended to Congress in June 2008 that hospitals receive from the Centers for Medicare and Medicaid Services (CMS) a confidential report of their risk-adjusted rehospitalization rates and recommended complementary changes in payment rates, so that hospitals with high risk-adjusted rates of rehospitalizations receive lower average case payments (1). This was further enhanced by the Patient Protection and ACA of 2010 which mandated that beginning October 1, 2012, acute care hospitals with high readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia had 1% of their Medicare payments cut forfiscalyear (FY) 2013, up to 2% for FY 2014, and up to 3% for FY 2015 (2, 3). According to the 2014 Medicare mandate, in FY 2015, four additional conditions will be included under the Readmissions Reductions Program: chronic obstructive pulmonary disease (COPD), coronary artery bypass graft, percutaneous transluminal coronary angioplasty, and "other vascular" surgical procedures v\dth possible addition of stroke. Beginning October 1, 2012, the CMS began reducing hospitals' Medicare payments based on 30-day hospital readmission rates for the above-named three conditions. The reductions were based on hospitals' 30-day risk-adjusted readmission rates relative to national averages. Penalties were imposed for each hospital's percentage of potentially preventable Medicare readmissions for those conditions. In FY 2013, two thirds of all applicable hospitals nationally were penalized as a result of this "See also p. 2762. Key Words: critical care; intracerebral hemorrhage; Medicare; readmission; stroke The authors have disclosed that they do not have any potential conflicts of interest. Gopyright © 2013 by the Society of Gritical Gare Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCIVI.ObOI 3e31829cb21 f
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provision with total penalties estimated at approximately $280 million nationally (2). With this backdrop in mind, a timely article by Liotta et al (4) in this issue of Critical Care Medicine attempted to provide much needed insight into 30-day readmission after intracerebral hemorrhage (ICH) for potentially identifying modifiable factors associated with readmissions in a single-center ICH cohort. Limited data exist regarding readmission rates in ICH compared with readmissions after ischémie stroke where the data are abundant. Readmission rates of ICHs have ranged from 14% to 17% (5,6, 7). Study by Litchman et al (6) in 2011 on Medicare patients taken care in Joint Commission-certified hospitals (JC-PSC) versus non-Joint Commission-certified hospitals analyzed 8,708 ICH discharges from JC-PSC and 22,564 ICH discharges from noncertified hospitals and found 30-day readmission rates to be similar (16.0% vs 15.5%). Liotta et al (4) in their study looked at Medicare patients presenting to their institution with ICH between December 2006 and July 2012. Patients were enrolled in a prospective observational cohort registry with objective of the study being to develop a method for identifying and interpreting associations between hospital course features specifically hospital réadmissions within 30 days to provide clinically meaningful data for their institution. Cohorts were divided into readmitted and not readmitted groups with data recorded on all patients, including demographic information, medical history, standardized clinical scales (Glasgow Coma Scale, National Institute of Health Stroke Scale, ICH score, and premorbid modified Rankin scale), imaging data, surgical interventions, and medical complications. In the study group of 193 patients, 22 patients (11%) were readmitted at a median of 9 days (interquartile range, 4-15 d). The two most common diagnosis for réadmissions included infections after discharge (n = 10) and vascular events (n = 6). Age, history of stroke and hypertension, severity of neurologic deficit at admission. Acute Physiology and Chronic Health Evaluation score, ICU and hospital length of stay, ventilator-free days, days febrile, and surgical procedures were noted not to be predictors of readmission. Despite the obvious limitation of this being a single-center cohort study with limited number of patients (not an administrative database) and selected Medicare population of advance age rather than a heterogeneous population, the study was useful in corroborating known data from the ischémie stroke trials regarding that infections and aspiration pneumonitis along with complications of immobility were the most common reasons for readmissions (8-11). Kind et al (9) in 2007 looked at more than 5,000 Medicare beneficiaries with stroke who were readmitted and noted a 15% to 43% rehospitalization rate due to infections and aspiration pneumonitis with skilled nursing facilities accounting for most of the rehospitalizations. But the question still remains: Are these readmissions December 2013'Volume 41 «Number 12
Editorial
preventable? The answer to this question is not simple as first thought to be. Despite the stipulation by CMS that payment changes will decrease readmission rates of patients diagnosed with pneumonia (approximately readmission rate of 20%), AMI (approximately readmission rate of 27%), and COPD (approximately readmission rate of 20%), the jury is still out. In conditions as complex as ICH and ischémie stroke, the current medical delivery systems provide high-technology interventions without routinely identifying the basic necessary care that is most appropriate for each patient after discharge from the acute care setting. It also fails to place value on the management of chronic disease or on a system of coordinated care. Correcting these problems could reduce rehospitalizations and the need for index hospitalizations. Some people feel that payment changes are a magic bullet that will solve the problem, but I think that the rapidity and magnitude of change will also depend on standardization of practices, transparent measurement of performance, technical assistance for providers, involvement of families as well as patients, coordinated community efforts, and modifications to the regulatory environment. The future still remains unpredictable.
REFERENCES 1. Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare fee-for-service program. N Engi J Med 2009; 360:1418-1428
2. Centers for Medicare and Medicaid Services, Readmissions Reduction Program. Available at: http://cms.gov/Medicare/MedicareFee-for-Service-Payment/AcutelnpatientPPS/ReadmissionsReduction-Program.html/. Accessed May 4, 2013 3. The Patient Protection and Affordable Care Act, HR 3590, 111th Congress Session (2009-2010) 4. Liotta EM, Singh M, Kosteva AR, et al: Predictors of 30-Day Readmission After Intracerebral Hemorrhage: A Single-Center Approach for Identifying Potentially Modifiable Associations With Readmission. Crit Care Med 2013; 41:2762-2769 5. Kind AJ, Smith MA, Liou Jl, et al: The price of bouncing back: Oneyear mortality and payments for acute stroke patients with 30-day bounce-backs. J Am Geriatr Soc 2008; 56:999-1005 6. Litchman JH, Jones SM, Leifheit-Limson EC, et al: 30-day mortality and readmission after hemorrhagic stroke among Medicare beneficiaries in joint commission primary stroke center-certified and noncertified hospitals. Stroke 2011 ; 42:3387-3391 7. Morgerstern LB, Hemphill JC, Anderson C, et al: Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Sirote 2010; 41:2108-2129 8. Bravata DM, Ho SY, Meehan TP, et al: Readmission and death after hospitalization for acute ischémie stroke: 5-year follow-up in the Medicare population. Stroke 2007; 36:1899-1904 9. Kind AJ, Smith MA, Frytak JR, et al: Bouncing back: Patterns and predictors of complicated transitions 30 days after hospitalization for acute ischémie stroke. J Am Geriatr Soc 2007; 55:365-373 10. Litchman JH, Leifheit-Limson EC, Jones SB, et al: Predictors of hospital readmission after stroke: A systemic review. Stroke 2010; 41:2525-2533 11. Lakshminarayn K, Schissel C, Anderson DC, et al: Five year rehospitalization outcomes in a cohort of acute ischémie stroke patients; Medicare linkage study. Stroke 2011 ; 42:1556-1562
Back to the PICU: Who Is at Risk and Outcome of Unplanned Readmissions* Francisco Cunha, MD, PhD Center of the Child and Adolescent Hospital Cuf Porto; and Departamento das Ciencias da Informaçâo e Decisâo em Saude CINTESIS, Faculdade de Medicina Universidade do Porto Porto, Portugal Armando Teixeira-Pinto, PhD Screening and Test Evaluation Program School of Public Health University of Sydney Sydney, NSW, Australia "See also p. 2773. Key Words: child; outcome assessment; patient readmission; pédiatrie intensive care units; quality of care Dr. Teixeira-Pinto received grant support from the National Health and Medical Research Council. Dr. Cunha has disclosed that he does not have any potential conflicts of interest. Copyright ® 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e3182a26S05
Critical Care Medicine
D
ischarging a patient from the PICU is the result of a delicate balance of pros and cons for the patient's wellbeing, greatly based on subjective factors. The need for a readmission is a concern for every intensive care physician when making this decision. Several studies, mostly in adult populations, have shown an increase in mortality, morbidity, and length of stay, for patients who had an unplanned readmission. This led institutions like the Society of Critical Care Medicine (SCCM) (1) and the National Quality Forum (2) to endorse measures of unplanned readmissions to ICUs, as part of the continuous evaluation of quality of care provided by the ICUs. More recently, most likely motivated by health budget constraints, governments and other payers are calling for actions to decrease the frequency of readmissions to hospitals (and PICUs) as a measure to reduce costs, while simultaneously improving care, and are suggesting reducing the payments for the readmissions of patients, putting extra pressure on the decision to discharge patients. To respond to these challenges, there is a clear need of more objective data about frequency, risk factors, and outcomes of patients with readmissions to the PICU. In this issue of Critical Care Medicine, Edwards et al (3) report data from a large www.ccmjournal.org
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Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
H
istorically, Medicare paid for majority of hospital readmissions until the advent of patient protection and Affordable Care Act (ACA) of 2010. Prior to 2008, most major hospitalizations for Medicare patients were reimbursed by Medicare subsidiaries except for readmissions within 24 hours for the same condition untu the Medicare Payment Advisory Commission recommended to Congress in June 2008 that hospitals receive from the Centers for Medicare and Medicaid Services (CMS) a confidential report of their risk-adjusted rehospitalization rates and recommended complementary changes in payment rates, so that hospitals with high risk-adjusted rates of rehospitalizations receive lower average case payments (1). This was further enhanced by the Patient Protection and ACA of 2010 which mandated that beginning October 1, 2012, acute care hospitals with high readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia had 1% of their Medicare payments cut forfiscalyear (FY) 2013, up to 2% for FY 2014, and up to 3% for FY 2015 (2, 3). According to the 2014 Medicare mandate, in FY 2015, four additional conditions will be included under the Readmissions Reductions Program: chronic obstructive pulmonary disease (COPD), coronary artery bypass graft, percutaneous transluminal coronary angioplasty, and "other vascular" surgical procedures v\dth possible addition of stroke. Beginning October 1, 2012, the CMS began reducing hospitals' Medicare payments based on 30-day hospital readmission rates for the above-named three conditions. The reductions were based on hospitals' 30-day risk-adjusted readmission rates relative to national averages. Penalties were imposed for each hospital's percentage of potentially preventable Medicare readmissions for those conditions. In FY 2013, two thirds of all applicable hospitals nationally were penalized as a result of this "See also p. 2762. Key Words: critical care; intracerebral hemorrhage; Medicare; readmission; stroke The authors have disclosed that they do not have any potential conflicts of interest. Gopyright © 2013 by the Society of Gritical Gare Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCIVI.ObOI 3e31829cb21 f
2830
www.ccmjournal.org
provision with total penalties estimated at approximately $280 million nationally (2). With this backdrop in mind, a timely article by Liotta et al (4) in this issue of Critical Care Medicine attempted to provide much needed insight into 30-day readmission after intracerebral hemorrhage (ICH) for potentially identifying modifiable factors associated with readmissions in a single-center ICH cohort. Limited data exist regarding readmission rates in ICH compared with readmissions after ischémie stroke where the data are abundant. Readmission rates of ICHs have ranged from 14% to 17% (5,6, 7). Study by Litchman et al (6) in 2011 on Medicare patients taken care in Joint Commission-certified hospitals (JC-PSC) versus non-Joint Commission-certified hospitals analyzed 8,708 ICH discharges from JC-PSC and 22,564 ICH discharges from noncertified hospitals and found 30-day readmission rates to be similar (16.0% vs 15.5%). Liotta et al (4) in their study looked at Medicare patients presenting to their institution with ICH between December 2006 and July 2012. Patients were enrolled in a prospective observational cohort registry with objective of the study being to develop a method for identifying and interpreting associations between hospital course features specifically hospital réadmissions within 30 days to provide clinically meaningful data for their institution. Cohorts were divided into readmitted and not readmitted groups with data recorded on all patients, including demographic information, medical history, standardized clinical scales (Glasgow Coma Scale, National Institute of Health Stroke Scale, ICH score, and premorbid modified Rankin scale), imaging data, surgical interventions, and medical complications. In the study group of 193 patients, 22 patients (11%) were readmitted at a median of 9 days (interquartile range, 4-15 d). The two most common diagnosis for réadmissions included infections after discharge (n = 10) and vascular events (n = 6). Age, history of stroke and hypertension, severity of neurologic deficit at admission. Acute Physiology and Chronic Health Evaluation score, ICU and hospital length of stay, ventilator-free days, days febrile, and surgical procedures were noted not to be predictors of readmission. Despite the obvious limitation of this being a single-center cohort study with limited number of patients (not an administrative database) and selected Medicare population of advance age rather than a heterogeneous population, the study was useful in corroborating known data from the ischémie stroke trials regarding that infections and aspiration pneumonitis along with complications of immobility were the most common reasons for readmissions (8-11). Kind et al (9) in 2007 looked at more than 5,000 Medicare beneficiaries with stroke who were readmitted and noted a 15% to 43% rehospitalization rate due to infections and aspiration pneumonitis with skilled nursing facilities accounting for most of the rehospitalizations. But the question still remains: Are these readmissions December 2013'Volume 41 «Number 12
Editorial
preventable? The answer to this question is not simple as first thought to be. Despite the stipulation by CMS that payment changes will decrease readmission rates of patients diagnosed with pneumonia (approximately readmission rate of 20%), AMI (approximately readmission rate of 27%), and COPD (approximately readmission rate of 20%), the jury is still out. In conditions as complex as ICH and ischémie stroke, the current medical delivery systems provide high-technology interventions without routinely identifying the basic necessary care that is most appropriate for each patient after discharge from the acute care setting. It also fails to place value on the management of chronic disease or on a system of coordinated care. Correcting these problems could reduce rehospitalizations and the need for index hospitalizations. Some people feel that payment changes are a magic bullet that will solve the problem, but I think that the rapidity and magnitude of change will also depend on standardization of practices, transparent measurement of performance, technical assistance for providers, involvement of families as well as patients, coordinated community efforts, and modifications to the regulatory environment. The future still remains unpredictable.
REFERENCES 1. Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare fee-for-service program. N Engi J Med 2009; 360:1418-1428
2. Centers for Medicare and Medicaid Services, Readmissions Reduction Program. Available at: http://cms.gov/Medicare/MedicareFee-for-Service-Payment/AcutelnpatientPPS/ReadmissionsReduction-Program.html/. Accessed May 4, 2013 3. The Patient Protection and Affordable Care Act, HR 3590, 111th Congress Session (2009-2010) 4. Liotta EM, Singh M, Kosteva AR, et al: Predictors of 30-Day Readmission After Intracerebral Hemorrhage: A Single-Center Approach for Identifying Potentially Modifiable Associations With Readmission. Crit Care Med 2013; 41:2762-2769 5. Kind AJ, Smith MA, Liou Jl, et al: The price of bouncing back: Oneyear mortality and payments for acute stroke patients with 30-day bounce-backs. J Am Geriatr Soc 2008; 56:999-1005 6. Litchman JH, Jones SM, Leifheit-Limson EC, et al: 30-day mortality and readmission after hemorrhagic stroke among Medicare beneficiaries in joint commission primary stroke center-certified and noncertified hospitals. Stroke 2011 ; 42:3387-3391 7. Morgerstern LB, Hemphill JC, Anderson C, et al: Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Sirote 2010; 41:2108-2129 8. Bravata DM, Ho SY, Meehan TP, et al: Readmission and death after hospitalization for acute ischémie stroke: 5-year follow-up in the Medicare population. Stroke 2007; 36:1899-1904 9. Kind AJ, Smith MA, Frytak JR, et al: Bouncing back: Patterns and predictors of complicated transitions 30 days after hospitalization for acute ischémie stroke. J Am Geriatr Soc 2007; 55:365-373 10. Litchman JH, Leifheit-Limson EC, Jones SB, et al: Predictors of hospital readmission after stroke: A systemic review. Stroke 2010; 41:2525-2533 11. Lakshminarayn K, Schissel C, Anderson DC, et al: Five year rehospitalization outcomes in a cohort of acute ischémie stroke patients; Medicare linkage study. Stroke 2011 ; 42:1556-1562
Back to the PICU: Who Is at Risk and Outcome of Unplanned Readmissions* Francisco Cunha, MD, PhD Center of the Child and Adolescent Hospital Cuf Porto; and Departamento das Ciencias da Informaçâo e Decisâo em Saude CINTESIS, Faculdade de Medicina Universidade do Porto Porto, Portugal Armando Teixeira-Pinto, PhD Screening and Test Evaluation Program School of Public Health University of Sydney Sydney, NSW, Australia "See also p. 2773. Key Words: child; outcome assessment; patient readmission; pédiatrie intensive care units; quality of care Dr. Teixeira-Pinto received grant support from the National Health and Medical Research Council. Dr. Cunha has disclosed that he does not have any potential conflicts of interest. Copyright ® 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e3182a26S05
Critical Care Medicine
D
ischarging a patient from the PICU is the result of a delicate balance of pros and cons for the patient's wellbeing, greatly based on subjective factors. The need for a readmission is a concern for every intensive care physician when making this decision. Several studies, mostly in adult populations, have shown an increase in mortality, morbidity, and length of stay, for patients who had an unplanned readmission. This led institutions like the Society of Critical Care Medicine (SCCM) (1) and the National Quality Forum (2) to endorse measures of unplanned readmissions to ICUs, as part of the continuous evaluation of quality of care provided by the ICUs. More recently, most likely motivated by health budget constraints, governments and other payers are calling for actions to decrease the frequency of readmissions to hospitals (and PICUs) as a measure to reduce costs, while simultaneously improving care, and are suggesting reducing the payments for the readmissions of patients, putting extra pressure on the decision to discharge patients. To respond to these challenges, there is a clear need of more objective data about frequency, risk factors, and outcomes of patients with readmissions to the PICU. In this issue of Critical Care Medicine, Edwards et al (3) report data from a large www.ccmjournal.org
2831
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
