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.