Signing up isn't enough


When it comes to preventing readmissions, even the hardest-working hospitals have a lot more work to do, a recent study found.

Researchers surveyed 599 hospitals that were participating in a couple of the best-known readmission initiatives around: the State Action on Avoidable Rehospitalization (STAAR) and the Hospital-to-Home Campaign (H2H). The answers they received from participants in both improvement projects showed a lot of room for additional improvement.

Photo courtesy of Elizabeth H Bradley, PhD
Photo courtesy of Elizabeth H. Bradley, PhD.

Only half of the hospitals reported monitoring whether they provide discharge summaries to primary care physicians or schedule follow-up appointments. Most hospitals also failed to have anyone follow up on test results returned after discharge. The initial objective of the study was to compare use of recommended strategies between the 2 initiatives, but the researchers concluded that there were significant gaps in both.

In results published in the November 2013 Journal of Hospital Medicine, the authors identified a potential leadership role for hospitalists in improving this situation. ACP Hospitalist spoke to lead study author Elizabeth H. Bradley, PhD, a professor of public health at Yale University in New Haven, Conn.

Q: What was the motivation for this study?

A: Across the country, the readmission rates by hospital are very different. Some are doing really well and some really are not doing very well. If we adjust for everything a patient brings, like their clinical profile, why is it that one hospital does better than another hospital, and can we influence it? Both H2H and STAAR are collaborations and campaigns that make an effort to try to impart the best practices to reduce readmission rates and try to excite hospitals to do this. Our study was trying to understand, are these hospitals that are participating in these collaborations and campaigns taking up the strategies that are recommended?

Q: Were you surprised by the results?

A: Some of the results were exactly as we expected them. STAAR was an intervention that worked holistically in selected U.S. states, trying to get the hospital association to incentivize hospitals and trying to get the state government to enable hospitals to work together better. If you look at the strategies hospitals in STAAR took up, they tended to be strategies that reflect that state-wide approach. They are really working closely and partnering with local hospitals, community agencies, community physicians. They are doing that far more than the H2H hospitals and that is quite consistent with what STARR recommended, and it's actually pretty consistent with what we know works.

Q: What are the lessons of your work for hospitalists?

A: The hospitalists are so fundamental to this because they really set the tone in the hospital of the connection between inpatient care and primary care. Hospitalists are critical to shifting the hospital culture from one where we say, “Hey, the patient is discharged. They're gone” to one of really making the connection with the primary care setting. Hospitalists have a huge opportunity to set the right tone, the right culture.

Q: What lessons can designers of quality improvement programs take from your findings?

A: They can look at the strategies that very few but successful [hospitals] are doing and really try to do a more focused effort on a few of those strategies. The data tell you how much can really be done from the outside and how much really is up to that individual hospital working with its physicians. These national collaborations maybe set the stage for movement, but at the hospital level, there has to be greater leadership.

Q: Your study found significant geographic variation in the use of the strategies. What are the implications of that?

A: The geographic variation speaks to the notion that you've got to work in concert in a community to make the readmissions come down. That's exactly how STAAR was designed. You see that's successful in how it's worked in those states. They were more able to implement, particularly, the partnerships between hospitals.