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In the News

From the July ACP Hospitalist, copyright © 2009 by the American College of Physicians

Behavior changes triggered drop in MRSA rates, CDC study reports

A CDC program that encouraged positive behavioral changes to prevent the spread of infection resulted in from 26% to 62% reductions in rates of methicillin-resistant Staphylococcus aureus (MRSA) at participating hospitals.

Three hospitals participated in the program, which encouraged front-line hospital staff members to come up with novel approaches to infection control. For example, a staff member at one hospital stuffed his hospital gown into a medical glove before disposing of it in order to reduce the risk of transmission. The hospitals also undertook such measures as screening patients admitted to a MRSA pilot unit, isolating patients who tested positive for MRSA, and strictly adhering to hand hygiene and contact precautions, according to a news release from the Robert Wood Johnson Foundation, which co-sponsored the study along with the CDC and the nonprofit Plexus Institute.

In addition to falling MRSA rates, the participating hospitals also saw declines in the proportion of S. aureus infections caused by methicillin-resistant bacteria. The analysis was presented during the Society for Healthcare Epidemiology of America’s recent annual meeting.

High rate of readmissions tied to poor transitions at discharge

Poor transitions between hospital and ambulatory care contribute to high rates of rehospitalization among Medicare patients, a recent analysis found.

Researchers analyzed Medicare claims data for almost 12 million beneficiaries who were hospitalized from 2003-04. They found that almost 20% of those patients were readmitted within 30 days and 34% were rehospitalized within 90 days. In addition, more than half of patients discharged with medical conditions or after surgery were rehospitalized or died within the first year following discharge. The results appeared in the April 2 New England Journal of Medicine.

Based on billing records, half of the patients who were rehospitalized within 30 days following a medical discharge had not followed up with a physician between hospitalizations, the study found. Researchers estimated that only 10% of rehospitalizations were planned, and that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion. Heart failure and pneumonia were the most common reasons for readmission for both medical and surgical patients. Primary predictors for rehospitalization included the index DRG and length of stay, the previous number of rehospitalizations, and the need for dialysis. Researchers also noted geographic differences in readmission rates.

The study’s findings on readmission rates, lack of follow-up, and inadequate communication between doctors and patients and among doctors at the time of discharge suggest that there is a “lack of shared incentives for hospitals and physicians to use hospital care efficiently,” said an accompanying editorial. The Medicare Payment Advisory Commission has recommended that Medicare reduce payments to hospitals with relatively high readmission rates for certain conditions, such as heart failure. However, noted the editorial, readmission rates are a “crude outcome” since higher rates may represent more efficient care by reducing the complications and costs associated with longer hospital stays. Also, hospitals are likely to argue that many factors that affect readmission are out of their control.

Addressing the problem will require greater integration of the delivery system, the editorialist said. For example, hospitals could receive financial incentives for managing the initial transition and follow-up care. The study’s authors added that “from a system perspective, a safe transition from a hospital to the community or a nursing home requires care that centers on the patient and transcends organizational boundaries.” Because risk of rehospitalization persists over time, the authors suggest that future studies are needed to determine the relative contributions of failure in discharge planning, insufficient outpatient follow-up, and severe progressive illness. The study was limited by its reliance on Medicare billing and DRG data. Also, billing data did not capture most visits to nonphysician providers, and some patients may have had telephone follow-up that was not billed.

ACP, others release consensus standards on transitions of care

Six professional medical societies, including ACP, have developed a set of consensus standards for improving transitions of care.

The American College of Physicians, the Society of Hospital Medicine, the Society of General Internal Medicine, the American Geriatric Society, the American College of Emergency Physicians and the Society for Academic Emergency Medicine established 10 principles to address the quality gaps in transitions between inpatient and outpatient care

• Accountability;
• Communication;
• Timely interchange of information;
• Involvement of the patient and family member;
• Respect the hub of coordination of care;
• All patients and their family/caregivers should have a medical home or coordinating clinician;
• At every point of transitions the patient and/or their family/caregivers need to know who is responsible for their care at that point;
• National standards; and
• Standardized metrics related to these standards in order to lead to quality improvement and accountability.

The group then developed standards to help implement these principles and identified challenges that will need to be addressed in the future, such as use of electronic health records. The consensus statement was published online April 3 by the Journal of General Internal Medicine.

In the News is a product of ACP HospitalistWeekly, an e-newsletter provided every Wednesday by ACP Hospitalist. If you’re not already receiving ACP HospitalistWeekly, contact Customer Service at 800-523-1546, ext. 2600, or directly at 215-351-2600 (M-F, 9 a.m. to 5 p.m. EST) or send an e-mail.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated