BLOGS Voices Follow

24 Jan 2013

Hospital Readmissions May Be Just the Tip of the Iceberg

The period after hospital discharge is full of challenges and, often, dangers. Well-intended efforts to improve the transition from hospital to home often rely on hospital readmission rates to measure success — but that measure may miss the point.

As an emergency medicine physician, I see an alarming number of patients return to the ED soon after hospital discharge. Of course, some come back for acute, unforeseen complications, but many others return because of a breakdown in social support or difficulty accessing and communicating with providers. Quite a few merely require clarification of their expected course of recovery or symptom management and are safely discharged home. Return ED visits that arise from an unmet need or gap in care contribute to an overall fragmentation of care, to ED overcrowding, and to higher costs.

My colleagues and I conducted a study, just published in JAMA, to determine to what extent treat-and-release ED encounters contribute to overall use of acute-care services after hospital discharge. Analyzing data from 5 million hospitalizations during 2008 and 2009 in three states (California, Nebraska, and Florida), we found that for every 1000 discharges, there were 97.5 ED treat-and-release visits and 147.6 hospital readmissions in the 30 days after discharge. Visits to the ED represented nearly 40% of all post-discharge acute-care encounters. Moreover, patients often returned to the ED for reasons related to their initial hospitalization.

I am concerned that hospital quality measures do not fully capture the many patients who seek acute care after hospital discharge and do not reflect the substantial post-discharge care that EDs provide. I fear that looming crackdowns on hospital readmissions may have unintended consequences. When patients return to the ED, will I be encouraged, even pressured, to avoid readmitting them? If so, how safe is it to discharge patients for whom outpatient care has already failed once?

I have become convinced that ED utilization can be a useful, patient-centered metric to track, along with rehospitalization rates. Even if readmission rates drop, high or increasing rates of ED use may uncover care deficiencies during the precarious transition from hospital to home. To improve the transition, physicians will need to think less about measures and incentives — and more about individual patients’ needs. Why are patients returning to the ED and the hospital in droves? Are we not educating them well enough about home transition? Do we lack capacity in the system for care teams to coordinate follow-up care when patients have a complication? We clearly must do a better job of anticipating and meeting patients’ needs — before they return to the ED.

It is no surprise that patients recovering from a recent hospitalization have difficulty navigating our complex health care system. Indeed, they shouldn’t leave the hospital without a realistic care plan. “See your doctor in 2 weeks and return to the ED if feeling worse” doesn’t cut it. An ideal plan would monitor a patient’s post-discharge recovery process. That might require providing patients with innovative venues and opportunities for asking questions. We must also think creatively about ways to deliver care and guidance effectively outside of EDs and hospitals.

My questions to you:

1. Do you know when your patients end up back in the ED but are not rehospitalized?

2. How do you help your patients avoid post-discharge acute ED visits and hospital readmissions?