The costs and penalties associated with hospital readmissions have led to a laser-beam focus in research, yet the literature is still mostly at a loss when it comes to what causes these health care U-turns and whether they are preventable.
Now some researchers are taking a new approach to the question. “Because of the nature of the way we get data for research, surprisingly, very few people had actually really gone directly to patients to ask why they thought they were getting readmitted,” said cardiologist Larry Allen, MD, MHS, medical director for advanced heart failure at the University of Colorado Anschutz Medical Campus in Aurora.
To gain insight from patients, Dr. Allen and his research team systematically interviewed those who had been rehospitalized for heart failure, spending up to an hour with each patient to explore the possible causes of his or her return. “I think that was relatively novel,” he said. “Even though in hindsight it doesn't seem to me that novel to ask patients why they came back to the hospital.”
Preventable or not?
One question researchers hoped patient data might help answer was whether their readmissions were preventable. Dr. Allen's research, published in the March 2013 Circulation: Cardiovascular Quality and Outcomes, showed the answer to be complex. “I think it's hard to say in a dichotomous fashion whether readmission was either yes, preventable, or no[t] preventable,” Dr. Allen said.
A similar study, published in the November 2014 JAMA Internal Medicine, focused on the patient's perspective on readmissions. “There's a big discrepancy from what we get on chart reviews and what is really the patient's reason for coming in,” said lead author Nasim Afsar-manesh, MD, FACP, associate clinical professor in medicine and neurosurgery and chief quality officer for medicine at the University of California Los Angeles.
For example, based on chart review, it appeared that a recently discharged surgical patient came back with intractable pain, she noted. “She said, ‘I have pretty severe pain, and I called the office, and no one got back to me, and I called them the second day and no one got back to me, and the third day, I just came in,’” Dr. Afsar said. “Based on the interview, we realized this was really an access issue, not a pain management issue, as we were led to believe based on chart review.”
Dr. Afsar and her team also asked patients to self-classify their readmissions as preventable or not preventable. Of 98 interviewed patients, 68 (69%) reported that their readmission was not preventable, 26 (27%) reported that it was preventable, and 4 (4%) were undecided. Physician reviewers agreed 54% of the time with patients who said their readmissions were unpreventable and 30% of the time with those reporting preventable readmissions or those who were undecided.
One challenge, according to Dr. Afsar, is that common themes around readmissions were hard to find. “A lot of the literature focuses on how medication reconciliation or more consistent follow-up discharge appointments would change the results,” she said. “The problem is that, when we looked at our patient population, patients weren't coming back because of adverse events from erroneous medications or lack of follow-up appointments. They were on the right medications and had great follow-up, but they were still coming back in. It was critical for us to understand the underlying failures that lead to the rehospitalizations—and there's no one better to tell you than the patient.”
For Dr. Allen, the motivation to reach out to patients stemmed from his inkling that readmissions are complicated and that patients have fairly challenging and complex stories. He found that patient perspectives fell into the following 5 themes: distressing symptoms, unavoidable progression of chronic disease, influence of psychological and socioeconomic factors, self-care and adherence with medical recommendations, and health system factors.
“I think their personal stories about the difficulty of dealing with a complex, siloed health system were certainly powerful for me, because we're working as a health system to do a good job with transitions of care,” he said. “And actually hearing some of the frustrations they have with trying to deal with the system and the transitions between the hospital setting and the outpatient setting . . . made those challenges more personal to me.”
Another study, published in the May Journal of Hospital Medicine (JHM), tested several measures of patient-reported outcomes (PROs) after discharge to see whether any might predict readmission risk. “In some ways, it makes complete sense that patients should be able to tell us something about their experiences making them vulnerable to readmission,” said lead author Keiki Hinami, MD, MS, ACP Member.
The researchers found that physical symptom burden and physical health perceptions, on average, recovered measurably within 30 days of discharge before stabilizing, said Dr. Hinami, an internist and hospitalist at the John H. Stroger Hospital for Cook County in Chicago.
Patients who reported worse symptoms while in the hospital were no more likely to be readmitted than the other studied patients, the study showed. “When people get sick, they all get sick, and the degree to which they decline is not predictive of 30-day rehospitalization,” Dr. Hinami said.
However, patients' symptom burden and physical health perceptions once they recovered were associated with subsequent utilization. Mental health perception remained fairly stable on average across the hospital-to-home transition and was associated with utilization within 14 days of discharge, said Dr. Hinami, who also works in the Cook County Health and Hospitals System's collaborative research unit.
The results could be used to improve discharge planning and potentially reduce readmissions. In their study, Dr. Hinami and his coauthors proposed “a discharge plan that acknowledges physical symptoms that sometimes persist or recur beyond the hospitalization . . . by ensuring that acute symptoms are resolving, giving clear instructions for symptom management at home, as now the standard of care for conditions like asthma, and explicitly communicating the presence of residual symptoms to providers entrusted with continuity care.”
Despite the insight patient perspectives can provide, there are many barriers to routinely collecting them in clinical care, including the cost and time to clinicians and the effort- and literacy-related barriers facing patients, Dr. Hinami said. “And I think many organizations are unsure whether or not they should invest upfront costs of routinely collecting PROs when the utility of such data remains unproven,” he said. “I think our JHM paper is just one of the many pieces of evidence that may help build momentum.”
Readmission risk stratification is only 1 of the many potential uses of PROs, which haven't all been delineated in existing studies, Dr. Hinami said. “As such, I feel like this is an area where innovative scholars and clinicians can explore,” he said.
Focus on the patient—or else
Health care reform and the consumerization of medicine might provide additional incentives for that exploration. Hospitals may want to gather patients' perspectives not only to reduce readmissions, but to make their facilities more appealing, experts said.
“The balance of power has shifted quite a bit in the information age. . . . There's just more access to information, there's more access to health care services, the Affordable Care Act has certainly directed the health care industry to be more patient-centered, so I think that shift has been happening,” said Wendy Nickel, director of ACP's Center for Patient Partnership in Healthcare.
In fact, hospitals that haven't started thinking about patient input will fall behind, said Dr. Allen. “People have complained about the 30-day outcomes measures, but if anything, with bundled payments and other policy changes, outcomes measures are, I think, only going to become a bigger part of the financial incentives for what we do—not less so,” he said. “So these lessons we're learning now are going to become even more valuable as we move forward.”
Research funding is also moving toward this topic. “There is now a national focus through the establishment of federal institutions like PCORI (Patient-Centered Outcomes Research Institute),” said Dr. Hinami. “The explicit focus around patient-centered concern, I hope, continues to emerge as a counterweight to health care organizations' other priorities.”