COMMENTARY

No Return Trips: Hospitals Under Pressure to Lower Readmissions

Shmuel Shoham, MD

Disclosures

April 23, 2015

In This Article

The Well-Traveled Patient

Hospitalizations are a lot like air travel. Being an inpatient, like flying coach, is somewhere between staying at a hotel and serving a prison sentence. The patients get to choose their meals and TV channels (to a point), the fellow passengers are usually well-behaved, and there is a lot riding on having someone competent at the controls.

The healthcare industry's safety movement borrows heavily from the tools and terminology pioneered by the airlines. But although commercial airlines celebrate return customers, no one wants to be a "frequent flyer" at a hospital.

Reducing rehospitalizations is a big issue in US medicine. Rehospitalization is increasingly viewed as a failure of medical care. The Robert Wood Johnson Foundation's report The Revolving Door: A Report on US Hospital Readmissions claimed that rehospitalizations within 30 days of discharge (also known as "bounce-backs") occur in 1 of 6 medical and 1 of 8 surgical Medicare patients. This confirmed what clinicians, patients, and their families had long suspected: Discharge from the hospital is not necessarily a one-way trip home.

Such terms as "index admission diagnosis," "30-day unplanned readmission," and "risk adjustment" have become part of the lexicon. These key terms are defined in Table 1.

Table 1. Key Terms and Definitions[1]

Term Definition
Index admission diagnosis The diagnosis at the time of the initial hospitalization.
Unplanned 30-day readmission Admission to any acute care hospital within 30 days of discharge from the index hospitalization, except when the patient was discharged with specific intent to readmit soon afterwards for a planned procedure (eg, revascularization) Special attention is paid to readmission rates for the following index diagnoses: AMI, CHF, COPD exacerbation, elective total hip or knee arthroplasty, and pneumonia.
Risk adjustment A means of trying to "level the playing field" by adjusting 30-day readmission rates for type and complexity of patients (eg, in terms of age, comorbid conditions, and discharge diagnosis).

AMI = acute myocardial infarction; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease.

The index admission diagnosis is the reason that the patient was in the hospital in the first place. This is used as the denominator in determining the rate of rehospitalization. Specific attention is paid to patients whose index admissions are for acute myocardial infarction (AMI), congestive heart failure (CHF), acute exacerbation of chronic obstructive pulmonary disease (COPD), elective total hip or knee arthroplasty, and pneumonia.

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