Preventable Hospital Readmissions—Opportunities for Anesthesiologists

In 2011, 12.3 percent of Medicare hospital admissions were followed by a potentially preventable readmission, according to the Medicare Payment Advisory Commission (MedPAC), which has just released its latest Report to Congress on Medicare and the Health Care Delivery System.

To be clear from the outset, not all potentially preventable admissions can be avoided. A classification system developed by 3M Health Information Systems and discussed in the MedPAC report defines a potentially preventable readmission “as a readmission that is clinically related to the initial hospitalization in that the underlying reason for the readmission may be plausibly related to the care during and immediately after a prior hospital stay.  A clinically related readmission may have resulted from a process of care or treatment during the prior admission or from a lack of postdischarge follow-up rather than from unrelated events that occurred after the prior admission.”

Preventing readmissions typically depends more on primary care physicians and on hospital and home health care personnel than on anesthesiologists, although anesthesiologists’ role in reducing the rate of surgical infections, some of which can lead to readmission, is well understood.  Nevertheless, this is an area with which anesthesiologists should become familiar for several related reasons:  (1) the financial and quality implications are important in their own right; (2) healthcare transition and coordination strategies currently being implemented may suggest opportunities for anesthesiologists and nurse anesthetists, and (3) reducing preventable readmissions may be a factor in bundled payments, gainsharing arrangements and other post-fee for service payment models.

Frequency and Cost of Potentially Preventable Readmissions

Jencks’s seminal research into the rate of Rehospitalizations among Patients in the Medicare Fee-for-Service Program (N Engl J Med 2009; 360:1418-1428; April 2, 2009) revealed that 19.6 percent of Medicare patients were rehospitalized within 30 days and 34 percent within 90 days.  (Across all ages, 14 to 19 percent of patients were rehospitalized within 30 days.)  For surgical patients, those with vascular surgery had the highest 30-day readmission rate (23.9 percent), followed by those with hip or femur surgery (17.9 percent).

Examining more recent data, MedPAC found that both overall rates of readmission from all causes and potentially preventable readmissions had decreased each year from 2006 through 2011.  By 2011, the rate of potentially preventable Medicare readmissions, adjusted for age, sex and diagnosis related group (DRG), had declined from 13.4 to 12.3 percent.  The Centers for Medicare and Medicaid Services (CMS) has reported a comparable decrease since 2011.

Jencks estimated that the annual cost of having one in five Medicare patients return to the hospital within 30 days was between $12 billion and $15 billion.  Looked at another way, as MedPAC did, the numbers suggest that reducing avoidable readmissions by 10 percent would achieve savings of at least $1 billion per year. 

The Medicare Hospital Readmissions Reduction Program

The Patient Protection and Affordable Care Act of 2010 enacted into law a penalty that reduces Medicare payments, beginning in 2013, to hospitals that have had above-average readmission rates.  Hospitals with above-average Medicare readmissions for specific conditions will receive reduced DRG payments based on readmission rates for the most recent three years of available data.

The aggregate amount of penalties will be equal to 0.3 percent of aggregate inpatient base operating payments.  An individual hospital’s penalty is computed according to a complex formula that basically multiplies the product of the payment rate for the initial DRG and the adjusted number of excess readmissions by the reciprocal of the national readmission rate for the condition.   The penalty is capped as shown in the table below:

 

The formula is designed to produce penalties that are much higher than the Medicare payments for the excess readmissions, thus avoiding perverse incentives to keep the number of readmissions high.

In its Report to Congress, Medicare recommends adopting legislation to address design issues in the Hospital Readmissions Reduction Program including the inverse relationship of heart failure readmission rates and heart failure mortality rates and the positive correlation of readmission rates with low-income patient population.

Methods to Reduce the Rate of Potentially Preventable Readmissions

Numerous health systems have already found ways to reduce the volume of readmissions.  Most of these strategies relate to the challenges of coordinating care between the acute and post-acute phases.  The following is a partial list:

1. Improving processes so as to reduce medical errors and the incidence of hospital-acquired infections;
2. Making a follow-up plan and scheduling follow-up visits for “frequent flyer” patients before discharge;
3. Reconciling medications before discharge and managing patients’ medications during transitions to home or nursing facility; sending patient home with 30-day supply, wrapped in packaging that explains timing, dosage and frequency where appropriate and feasible;
4. Better transition planning and implementation through better communication among providers; teams must talk to each other at every handoff, and standardize these transitions;
5. Encouraging patient education and self-management;
6. Having discharge summaries prepared by the time the patient is discharged and creating easy-to-understand postdischarge plans;
7. Offering guidance of a health coach.  One hospital sends a nurse to the patient's home at no charge 24 to 48 hours after discharge, and follows up later with a phone call as part of a program that has cut the hospital's 30-day readmission rate for congestive heart failure patients in half, from 12 to 6 percent; and
8. Supporting interventions by pharmacists, home health nurses and other post-acute care providers and facilitators to prevent rehospitalizations.  “Just like Meals-on-Wheels can be scheduled in advance, so can case management, housekeeping services, transportation to the pharmacy and physician's office.”  (C. Clark, 12 Ways to Reduce Hospital Readmissions, Health Leaders Media, December 27, 2010).

Except for improving processes to reduce certain complications of surgery, including pain, most anesthesiologists have little training or experience in coordinating patients’ care after discharge from the PACU.  The specialty is catching up, however. 

Anesthesiologists on the whole are comfortable with checklists.  Nathan Smischney, MD and colleagues in the Department of Anesthesiology at the Mayo Clinic presented an abstract at the 2013 annual congress of the Society for Critical Care Medicine described a project in which the use of an ICU checklist avoided unplanned readmissions by reducing the communication gap between the surgical ICU and the wards.   The checklist contained seven items addressing the clinical plans for pain, delirium, arrhythmias, respiratory support, antibiotics, diuretics, blood products, anticoagulation, antihypertensive management and nursing concerns. Completed copies were placed in charts accompanying patients to their new units. Over a five-week period in 2012, the tool was used for 42 of the 141 transitions (apparently the length of the checklist discouraged some of the residents from using it).  Seventeen unplanned readmissions to ICU occurred; in none of these had the checklist been used.  The study was too small to reach conclusions about causality, but it had generated enough enthusiasm at the Mayo that fellows were reportedly at work shortening the checklist and planning to increase its use.

At Johns Hopkins, the Department of Surgery implemented a “Comprehensive Unit-Based Safety Program” (CUSP) that reduced by one-third surgical site infections (SSIs) following colorectal surgery.  The CUSP involved both using a checklist and officially encouraging all caregivers to speak up if they saw potentially unsafe practices.  Six key interventions identified by the CUSP team included warming of patients in the pre-anesthesia holding area and addressing lapses in administering prophylactic antibiotics.  The researchers estimated “that, if applied to all types of surgical procedures, locally developed checklists and similar culture change programs could reduce the total number of SSIs by 170,000 and result in a nationwide cost savings of $102 million to $170 million annually”  according a Johns Hopkins Medicine news release dated July 30, 2012.

Anesthesiology has a well-known history of leading patient safety enhancements.  There are doubtless many other examples of anesthesiologists designing and/or participating in programs to reduce perioperative complication and unplanned readmission rates.   We would very much like to hear from readers who are involved in such programs.