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High Rate of Rehospitalizations Costing Billions
Date:4/1/2009

More than half of discharged Medicare patients are readmitted within a year, study finds

WEDNESDAY, April 1 (HealthDay News) -- One in five Medicare patients discharged from the hospital is readmitted within 30 days, while half end up back in the hospital within a year, a new study finds.

The groundbreaking research exposes a "frequent, costly and sometimes life-threatening" problem that researchers believe could be prevented through better care coordination. The study appears in the April 2 issue of the New England Journal of Medicine.

The message here for Medicare patients and their families: Be your own advocate to avoid landing back in the hospital.

"The things that may not feel right to you about the discharge process may not be right, and you should be prepared to stand up for what you need," said study author Dr. Stephen F. Jencks, former director of the Quality Improvement Group at the Centers for Medicare and Medicaid Services in Baltimore.

Not only do Medicare patients need to know how to care for themselves at home and who to call if they have a problem, they also need to make sure a follow-up appointment is scheduled with a physician before leaving the hospital, Jencks said.

In 2004, unplanned rehospitalizations cost Medicare an estimated $17.4 billion, the study authors noted.

President Barack Obama's 2009 budget proposal targets the problem through a combination of financial incentives and penalties. He would pay hospitals a "bundled" rate that includes inpatient care as well as certain post-acute care services provided 30 days after hospitalization. Hospitals with high readmission rates would be paid less if patients are readmitted to the hospital within the same 30-day period.

To date, most studies examining rehospitalization have focused on specific diseases, such as heart failure or chronic obstructive pulmonary disease.

"I think one of the strengths of the Jencks analysis is that he looks at all-cause rehospitalizations, and that's a unique and a new view," said Dr. Amy Boutwell, a general internist at Newton-Wellesley Hospital in Newton, Mass., and director of the Institute for Healthcare Improvement's reducing rehospitalizations initiative.

For the study, researchers analyzed Medicare claims data from October 2003 through December 2004. The study included information on almost 12 million patients discharged from a hospital during that time.

Overall, the data showed that the risk of rehospitalization persists over time. About two in every three Medicare beneficiaries (62.9 percent) discharged from the hospital were readmitted or died within a year.

The study also revealed wide geographic disparities in rates of rehospitalization within 30 days of discharge -- from a low of 13.3 percent in Idaho to a high of 23.2 percent in Washington, D.C.

Often, the people who cycle in and out of the hospital suffer from multiple medical conditions or psychiatric or social problems, Boutwell said. Someone who relies on an intricate caregiving network -- say, their daughter-in-law, their neighbor and a church member -- can get into trouble when that social safety net breaks down, she explained.

"We have a short-hand nickname for them. We call them 'bounce-backs' or frequent fliers," Boutwell said. "And although that's not a very sensitive term, I think it reflects the fact that throughout the medical profession we implicitly recognize that there is this group of patients who are in and out of the hospital with quite high frequency."

But it's not just about being sick and ending up back in the hospital. "It's about traversing from one setting of care to the next setting of care successfully and stably," said Boutwell, who is leading a multi-state initiative to reduce avoidable rehospitalizations.

The fundamental barrier to better care, said Jencks, is a health system built around what he called "silos" -- the hospital, the doctor's office, the nursing home -- resulting in poor transitions from one care setting to another.

In an accompanying editorial, Dr. Arnold M. Epstein of the Harvard School of Public Health in Boston, said that "providing appropriate incentives for hospitals and community providers to share accountability and provide efficient care will be no easy task."

But Jencks suggested that immediate action is imperative. "The evidence is that the system is not working right and it's costing us billions of dollars a year and it's causing a great deal of patient and family misery," he said, "and we need to get cracking on it."

More information

Medicare has a checklist of questions that patients and caregivers should ask before leaving the hospital.



SOURCES: Stephen F. Jencks, M.D., M.P.H., independent consultant, Baltimore; Amy Boutwell, M.D., M.P.P., general internist, Newton-Wellesley Hospital, Newton, Mass., content director, Institute for Healthcare Improvement, and director, IHI's reducing rehospitalizations initiative, Cambridge, Mass.; Budget of the United States Government, Fiscal Year 2010, Office of Management and Budget, Washington, D.C.; April 2, 2009, New England Journal of Medicine


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