COMMENTARY

No Return Trips: Hospitals Under Pressure to Lower Readmissions

Shmuel Shoham, MD

Disclosures

April 23, 2015

In This Article

Targeting Surgical-Site Infection

As in everything else in medicine, one size will not fit all. Specific interventions will need to be tailored on the basis of the propensity for developing an infection that requires rehospitalization. Patients who are older and have multiple comorbid conditions and complex medical regimens are more likely to require rehospitalization. Likewise, patients requiring certain surgical procedures are at higher risk.

Although the most common reason for unplanned readmission after an operation is a surgical-site infection, the risk for rehospitalization differs widely depending on the type of operation. A recent study[14] evaluating nearly 500,000 operations in the United States found the readmission rate to be 3.8% for hysterectomy and 14.9% for lower-extremity vascular bypass.

A solution that is increasingly used for keeping patients with serious infections out of the hospital is outpatient parenteral antibiotic therapy (OPAT). The need for such therapy will only increase in the coming years, as pressure to limit length of hospital stay and mandates to reduce rehospitalization dovetail with the trend toward increasing antimicrobial resistance. Infections that could previously be treated with oral antibiotics are now increasingly requiring intravenous therapy that is often delivered at home after, or instead of, a hospitalization.

However, OPAT is not without concerns. Provision of intravenous therapy at home is fraught with potential complications, including failure of therapy and problems related to placement and management of a central venous catheter in the outpatient setting. In a recent study,[15] the unplanned 30-day readmission rate for patients managed with OPAT was 26%, which is more than four times higher than the typical rates. Not surprisingly, most of those readmissions were related to worsening or new infections.

Teams Plus Support Equals Success

My experience is that clinicians can only do so much when working alone. To provide the best care, which includes eliminating preventable readmissions, an effective team supported by a solid infrastructure is required. Care for patients who are sick enough to be in the hospital can no longer be done solo or with antiquated modes of communication.

Consider, for example, a woman with diabetes, CHF, and a urinary tract infection who is discharged from the hospital. Her chances of being readmitted are substantially lower if she understands her postdischarge medical plan, has access to the right medications, and is "plugged back in" to outpatient care. A nearly indecipherable discharge summary that leaves her confused about medications and her next medical appointments will not help to keep her out of the hospital. Nor will prescriptions for medications that she already has at home (but with different names or dosages) and other drugs that her insurance plan won't pay for.

When this same patient contacts her primary care provider with symptoms of burning on urination 2 weeks after hospital discharge, that clinician needs to know what transpired during the most recent hospitalization and whether a standard course of antibiotics for urinary tract infection is likely to resolve her infection. A discharge summary that arrives 21 days after she has left the hospital (and 1 week after it was needed) is of little use.

Are 30-day rehospitalization rates an accurate measure of the quality of care? Are the financial penalties to hospitals fair? These are legitimate points for debate. It is clear that these measures and the incurred penalties are the current reality, and the healthcare industry is responding. Research spurred by the changing landscape is already shedding light on the problem. Characterization of a new entity—the posthospital syndrome—has given a name to the transient period of vulnerability to a range of adverse health events that occurs after hospitalization.

In the next few years, we will find out more about the risks, causes, and therapies for this entity and for the need for early readmission to the hospital. Although some of the work will be done using traditional research methodologies, much of it will also result from trial and error as hospitals try to meet the new mandates. Clinicians, including those with expertise in infectious diseases, should be at the center of these initiatives.

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