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Making the Case to Include EDs in Readmission Rates

Making the Case to Include EDs in Readmission Rates

In recent years, CMS has invested heavily in policies, incentives, and other interventions to encourage healthcare providers to improve transitions in care and reduce avoidable readmissions. Studies have shown that many patients return to the hospital via the ED within 30 days of discharge, but specifications for measuring rehospitalization vary. “Unless patients are readmitted to the hospital through the ED, they aren’t being counted in measurements of readmissions,” says Kristin L. Rising, MD. “By limiting the focus to inpatient-to-inpatient events and omitting ED visits, we’re missing a substantial source of healthcare utilization that is managed solely in the ED.” Patients may be effectively stabilized and discharged from the ED shortly after hospital discharge, but few data are available on the frequency and cost of ED visits after such discharges. Previous analyses have found that 40% of patients who sought acute medical care had multiple visits for inpatient or ED stays. About one-quarter of these patients had multiple inpatient stays, whereas one-third had multiple ED treat-and-release visits. Taking a Comprehensive Approach to Readmission Factors According to Dr. Rising, a comprehensive approach to understanding the factors that contribute to subsequent healthcare use in the post-hospital discharge period should include a closer look at ED use within 30 days of hospital discharge. In a retrospective study published in Annals of Emergency Medicine, Dr. Rising and colleagues examined 15,519 patient discharge records over a 5-month period. Nearly one-quarter (23.8%) of these discharges resulted in at least one ED visit within the subsequent 30 days, and more than half (54.0%) of these visits resulted in discharge back home. The median number of ED visits per patient...
Identifying Post-Op Complications for Readmission in General Surgery

Identifying Post-Op Complications for Readmission in General Surgery

In June 2009, CMS began publishing 30-day readmission data for select medical diseases, resulting in hospital readmissions becoming an important metric for measuring the quality of patient care. The changing regulations issued by CMS means that hospital reimbursements can be reduced based on an adjustment factor determined by a hospital’s expected and observed 30-day readmission rates. These changes have also raised the bar for decreasing unnecessary surgical readmissions. In addition to the financial implications, unplanned hospital readmissions further limit hospital resources. For each patient readmitted, there is an opportunity lost to treat another patient who needs care (see also, Strategies for Reducing Hospital Readmissions). “Reducing the number of 30-day readmissions after surgery is important for institutions as well as patients,” says John F. Sweeney, MD, FACS. “Developing a better understanding of the predictors of readmission for general surgery patients will allow hospitals to develop programs to decrease readmission rates. Surgical patients are different from medical patients because surgery, in and of itself, places them at risk for readmission, above and beyond their medical problems. There is an opportunity to intervene preoperatively to decrease the risk of readmission postoperatively.” Important New Data on Hospital Readmission In the Journal of the American College of Surgeons, Dr. Sweeney and colleagues had a study published that analyzed patient records of 1,442 general surgery patients operated on between 2009 and 2011. Of them, 163 patients (11.3%) were readmitted to the hospital within 30 days of discharge. There is a paucity of information focusing on readmission rates among surgical patients, says Dr. Sweeney. “Although factors associated with 30-day readmission after general surgery procedures are multifactorial,...
67% of Hospitals Face Readmission Penalties

67% of Hospitals Face Readmission Penalties

The Centers for Medicare & Medicaid Services’ new policy that penalizes hospitals for excessive readmissions will have an unexpected consequence: Two-thirds of U.S. hospitals will receive penalties averaging $125,000, according to the Medicare Payment Advisory Commission (MedPAC). The commission has been discussing refining the hospital readmissions reduction program. Hospitals now face up to a 1% penalty for readmissions related to acute myocardial infarction, heart failure, and pneumonia starting last October. In 2014, the penalty will rise to 2% and to 3% in 2015, with four conditions added to the list. Two Harvard research physicians, Karen E. Joynt, MD, MPH, and Ashish K. Jha, MD, MPH, published a commentary this month in the New England Journal of Medicine, which includes several suggestions to avoid punishing hospitals for factors outside of their control, including: Adjusting readmission rates for socioeconomic status (eg, adding patients’ eligibility for Supplemental Security Income to risk-adjustment models). Such adjustments would ensure whether safety-net hospitals are achieving readmission rates for poor patients comparable to those that are not safety-net facilities. Penalties should be weighted according to the timing of readmissions, counting readmissions within a few days more heavily than those occurring 4 weeks later. Later admissions are more likely to be attributable to disease severity than to lack of care coordination. Give hospitals credit for low mortality rates, since they often have higher readmission rates despite being high-performing facilities. Hospitals with high mortality rates but low readmission rates do better under the CMS payment scheme than do low-mortality hospitals with high admission rates, the authors note. They suggest CMS could combine the two outcomes by assessing patients’ 30-day...

Exploring Variances in Dual-Chamber ICD Use

Each year in the United States, approximately 140,000 implantable cardioverter-defibrillators (ICDs) are implanted in cardiac patients. Physicians often face challenges when working with patients to decide whether it’s best to use a single- or dual-chamber device. Some patients have a clear indication for a dual-chamber device because they have an indication for a pacemaker. For patients without an indication for a pacemaker, the decision is much less clear. The potential benefits of dual-chamber devices remain to be proven, and they may have more complications. Clinical trial data to guide physicians on which option to choose have been lacking. Currently, nearly two-thirds of patients undergoing ICD implantation for primary prevention receive dual-chamber devices. Variations in Dual-Chamber ICD Use In a study published in the April 23, 2012 Archives of Internal Medicine, my colleagues and I set out to explore hospital-level variation in the use of dual-chamber ICDs across the U.S. Using the Medicare-mandated National Cardiovascular Data Registry (NCDR) ICD registry, we looked at 87,115 patients from 2006 to 2009 receiving an ICD as primary prevention without a documented indication for a pacemaker. We only wanted to analyze patients for whom it wasn’t clear whether a single- or dual-chamber ICD was the appropriate choice. Of these patients, about 58% received a dual-chamber ICD. More importantly, use of each ICD type varied significantly by hospital and by physician. In some hospitals and with some physicians, 100% of patients without a clear indication for a dual-chamber ICD received such a device. At other hospitals and with other physicians, 0% of these patients received a dual-chamber ICD. “Differences in the local culture and practice...

10 Ways to Make EMR Meaningful and Useful

OK, I am an EMR geek who isn’t so thrilled with the direction of EMR.  So what, I have been asked, would make EMR something that is really meaningful?  What would be the things that would truly help, and not just make more hoops for me to jump through?  A lot of this is not in the hands of the gods of MU, but in the realm of the demons of reimbursement, but I will give it a try anyhow. Here’s my list: 1. Require all visits to have a simple summary. One of the biggest problems I have with EMR is the “data diarrhea” it creates, throwing piles of words into notes that are not useful for anything but assuring compliance with billing codes. I waste a huge amount of time trying to figure out the specialists, colleagues, and even what my own assessment and plan was for any given visit. Each note should have an easily accessible visit summary (but not at the bottom of 5 pages of droll historical data I already know because I sent them the patient in the first place!). 2. Allow coding gibberish to be hidden. Related to #1 would be the ability to hide as much “fluff” in notes as possible.  I only care about the review of systems and a repetition of past histories 1 out of 100 times. Most of the time I am only interested in the history of the present illness, pertinent physical findings, and the plan generated from any given encounter. The rest of the note (which is about 75% of the words used) should be hidden,...
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