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Get out, and stay out, of the hospital

Too many people wind up back at the hospital after being discharged, Consumer Reports investigation finds

Published: April 2014

If you or someone you care for has ever spent time in a hospital, you know that you count the days, hours even, until you can go home. But for too many patients, the return is only temporary. For some of the most common conditions treated in hospitals, as many as one in five patients is readmitted within 30 days of his or her discharge, reports the federal Agency for Healthcare Research and Quality. And nearly one in seven patients undergoing certain major surgeries have to be readmitted within 30 days, according to a study in the New England Journal of Medicine in 2013.

Why do so many patients have to head back to the hospital so soon after their discharge? Sometimes it’s unavoidable, because of a new health problem that emerges after you return home, for example. But often it’s because of a complication that only emerges when you get home, such as an infection, or because you were discharged before you were healed, and have to return for additional treatment.

Our most recent hospital Ratings, which include readmission rates for 4,460 hospitals in all 50 states plus Washington, D.C. and Puerto Rico, show that some hospitals do a much better job than others in avoiding readmissions. For example, Sarasota Memorial Hospital, in Sarasota, Fla., had a readmission rate of 13.3 percent, the lowest among the hospitals in our Ratings with at least 500 beds. By comparison, Nassau University Medical Center, in East Meadow, N.Y., had a readmission rate of 20.2 percent, the highest among hospitals with at least 500 beds. Overall, 28 percent of hospitals earned a high Rating in readmissions; but just about as many—27 percent—got a low Rating in the measure. The data, which come from the Centers for Medicare and Medicaid Services, is for patients 65 and older and covers July 2011 to June 2012, the most recent dates that are publically available.

The high toll of readmission

Being readmitted has consequences. For one, readmissions cost Medicare an estimated $17.5 billion a year, as hospitals bill the government for the care.  

But the toll readmission takes on patients and their families is incalculable. “The most important problem of readmission is not the cost but the fact that patients are ending up back in the hospital,” David C. Goodman, M.D., co-principal investigator of the Dartmouth Atlas of Healthcare, said. “That means they have gotten sicker or that there is a failure to care for them in the community.”

Readmission carries health risks as well. “Every readmission is a traumatic event for the patient,” Kumar Dharmarajan, M.D., a visiting scholar in cardiology at the Yale School of Medicine, who has researched the issue, said. “Every time a person enters a hospital, he is at risk for multiple complications.” Those include infections from drug-resistant organisms, side-effects from medicines and invasive procedures, and outright medical errors. “Specific problems that older patients face include accelerated loss of muscle mass from bed rest, sleep disruption, and worsened cognition,” he said.

Readmission red flags

The older and sicker a patient is, the more likely he or she will develop a problem. “Many patients have a constellation of illnesses that are interconnected,” Goodman said. “They receive care for the most acute illness in the hospital and sometimes the interrelated problems are ignored. But these problems may become more severe when the patient goes home.”

Researchers refer to the fragile period following discharge as “post-hospital syndrome.” Because the newly discharged patient is often weak, she may be at higher risk for health issues, she may experience medication changes during her hospital stay that affect an existing condition, or the patient and her health care provider may be so focused on the diagnosis that caused her hospitalization that other underlying problems are overlooked and may worsen.

That doesn’t have to be the case. “It is good for patients not to have to come into a hospital, but when they do, it is an opportunity to address the broad set of medical problems,”  Goodman said.  

A hospital’s culture matters, too, especially if it’s a culture in which nurses, who are at the bedsides of hospitalized patients 24/7, are valued and empowered. “Good patient education during the hospitalization and good discharge planning are the bread and butter of nursing,” Matthew D. McHugh, Ph.D., J.D., R.N., associate director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia, said. “In an environment where there is not a focus on nurses or enough of them, those things tend to suffer.”

In a study published in the journal Medical Care, McHugh found that being cared for in a hospital with a good versus a poor work environment lowers the odds of being readmitted for heart failure by seven percent, for heart attack by six percent, and for pneumonia by 10 percent.

The nurse-patient ratio is also crucial. In that same study, McHugh found that each additional patient per nurse above and beyond the average workload increased the likelihood of readmission by seven percent for patients with heart failure, by six percent for pneumonia patients, and by nine percent for heart attack patients.  

One other factor that could influence readmission rates is how the government reimburses hospitals for patients who are readmitted. Since 2012, Medicare has penalized hospitals with high readmission rates by cutting payments. The hope was that that would motivate hospitals to get better, and some research suggests it has. But the financial penalties hit large teaching hospitals and hospitals that care for the poor harder than other hospitals, since they tend to have higher readmission rates. And some experts worry that those penalties have actually made it harder for hospitals to improve the care they provide, making readmission rates even higher.

Discharge planning is key

Experts emphasize that good discharge planning is crucial and should begin the day a patient is admitted. The data in our our Ratings support that idea. It shows that hospitals that do a good job communicating with patients about discharge instructions tend to have lower readmission rates.

Ideally, the hospital should schedule a follow-up appointment before the patient is discharged, and provide a phone number to call if he or she feels ill, Dharmarajan said. If a patient is elderly or in poor health, his or her caregiver and the receiving rehab center should be looped in. Hospitals “need to create a safety net for patients so that if they were to feel worse, it is there to catch them,” Dharmarajan said.

That safety net is in place at Margaret R. Pardee Memorial Hospital in Hendersonville, N.C. The 138-bed facility received our highest Rating for readmissions. “One of the most important factors in reducing readmissions is to make sure the patient gets rapid and appropriate follow-up care,” Robert Kiskaddon, M.D., chief medical officer and vice president of medical affairs at Pardee UNC Health Care, said. Pardee’s focus, he said, is on managing “the transition and the continuity of care for patients.” That, he said, is accomplished with “aggressive case management.” For one, the patient’s doctor is notified via email about the admission and her medical records are sent to the physician upon discharge.

“We schedule follow-up appointments for patients (often before they are discharged) and if a patient doesn’t have a primary care provider, we make sure she is assigned one,” Dr. Kiskaddon said. “We also make sure a patient understands her medications and how to take them and that she has someone to care for her at home.”

Patients are called within 24 to 48 hours of discharge to learn if they need anything, have questions, or have had a change in their condition, for example. That way, potential problems can be addressed immediately.

Sanford USD Medical Center in Sioux Falls, S.D., which received our highest Safety Score among teaching hospitals, also earned our top Rating for readmissions. An interdisciplinary transition team along with a case manager works with the patient at admission and discharge, ensuring that she understands her medication regimen, has an appointment with her primary care provider within one week of discharge, and receives a follow-up call within 48 hours of leaving the 511-bed hospital.

“We make sure communication with the patient’s primary provider is seamless so he or she knows exactly what happened during the hospitalization,” Mike Wilde, M.D., chief medical offer at Sanford, said. And if a patient is readmitted, the transition team wants to know why. “We look at whether we need to change systems to prevent this going forward,” Dr. Wilde said. “We want to know what we can do to minimize this as much as possible.”

What to do

To reduce your chance of having to be readmitted, take these steps.

1. See a discharge planner. You or someone who is caring for you should try to do this at least a day before you leave so your family, your doctor, or the hospital can arrange for monitoring or services you'll need at home.

2. Decide if you're ready to go home. Hospitals and insurance companies have strong financial incentives to discharge you as soon as possible. And for most patients, the sooner you get home the better. But if you don't feel ready, say so. You shouldn't go home if you feel disoriented, faint, or unsteady, have pain that's not controlled by oral medication, can't go to the bathroom unassisted, can't urinate or move your bowels, or can't keep food or drink down. If your doctor isn't able to extend your stay, appeal to the discharge planner, the hospital's patient advocate or, if available, a state appeals board.

3. Get a discharge summary. Ask for a clear written statement of what you should do when you get home—for example, how to care for surgical wounds or a broken bone covered by a cast, how active you should be, and when you can shower, drive a car, return to work, and resume your normal diet.

4. Get a discharge list of medication. Ask about drugs you started in the hospital that you should continue when you get home, including their purpose and side effects, and if you should resume or eliminate drugs you were on before your admission. If you had anesthesia, ask what lingering side effects you might expect.

5. Get late test results. Make sure your doctor has test results that were done while you were in the hospital, especially those in the 24 hours before you left. Consider asking for copies of the results so you can give them to your doctor. Also find out what follow-up blood or imaging tests you'll need after you leave.

6. Schedule an appointment with your doctor. It should be about a week or two after your hospital stay, though in some cases, such as to check the healing of surgical wounds, it might be sooner. If you don't have a primary-care doctor, ask the physician who oversaw your care in the hospital whom you should see.

7. Check our hospital Ratings. We have information on readmission rates for more than 4,400 hospitals across the country. Shown below are the 12 teaching hospitals in the country that got our highest Rating in this measure, and the 39 teaching hospitals that got our lowest Rating. Use our hospital Ratings to see how hospitals in your area compare on readmissions and other measures. Our Ratings show the chance that a patient will have to be readmitted to a hospital within 30 days of his or her initial discharge. The information is collected by the Centers for Medicare and Medicaid Services. Patients can be readmitted to the same or different hospital, and for the same or different condition. The data are for patients 65 and older and cover July 2011 to June 2012, the most recent that's publically available. Read more about how we rate hospitals.

Teaching hospitals that earned our highest Rating in readmissions (listed alphabetically)

Teaching hospitals that earned our lowest Rating in  readmissions (listed alphabetically)

 

 

Get hospital safety Ratings

 

Click on the map at right to find Ratings of hospitals nationwide (available to subscribers). The Ratings include information on readmissions, as well as other measures of hospital safety and quality.  

 

   

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