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Could a new diagnosis help fix readmissions?
By Stacey Butterfield
Even hospitalists practicing under a rock for the past few years have likely been tasked with reducing 30-day readmissions. Yet the leaders of the field have still not found a definitive method to keep their patients from returning to the hospital.
“We made a little bit of headway on the readmissions problem but with a lot of effort and a lot of programs,” said Robert M. Wachter, MD, FACP, chief of the medical service and the division of hospital medicine at the University of California, San Francisco. “No one's found the magic bullet. No one's found a way to have a major impact on readmissions.”
Photo by Thinkstock.
Perhaps it's time to look at the problem in a new way. That's the proposal of a recent, attention-grabbing article by Harlan M. Krumholz, MD, titled “Post-Hospital Syndrome—An Acquired, Transient Condition of Generalized Risk,” which was published in the Jan. 10 New England Journal of Medicine.
“Traditionally we focus on the reason that the patient came in the hospital in the first place, and we look intently at every opportunity to address that problem,” said Dr. Krumholz who is a professor of cardiology at Yale University in New Haven, Conn. “But sometimes we're not paying attention to the fact that patients, when they go home, may not be only at risk from that [illness], but from many other things.”
According to his new theory, those other things may include problems that are actually caused by hospitalization itself. “In the course of all the great things that happen to help save people in their acute illness, patients incur a tremendous amount of stress—physical, mental, social stress,” he said.
That stress may be a significant cause of readmissions, he posited. In support of this argument, Dr. Krumholz and colleagues recently published an analysis of the causes of 30-day readmissions. They reviewed Medicare claims for heart failure, acute myocardial infarction and pneumonia hospitalizations between 2007 and 2009 and found that the vast majority of patients who were readmitted were not coming to the hospital with the same problem.
Instead, more than 60% of the heart failure patients, 75% of the pneumonia patients and 90% of the myocardial infarction patients had a different diagnosis at readmission than at their initial hospitalization. The study was published in the Jan. 23/30 Journal of the American Medical Association.
The theory and the data have drawn the attention of hospitalist leaders around the country. In recent conversations with ACP Hospitalist, they debated the merits of creating a new clinical entity of “post-hospital syndrome” and considered how Dr. Krumholz's ideas could impact current and future efforts to reduce 30-day readmissions and generally improve care and outcomes for hospitalized patients.
Support and dissent
Some hospitalist leaders are excited about the new concept. “The fact that [Dr. Krumholz] named it is brilliant, because it's real,” said Brian Jack, MD, professor and chair of family medicine at Boston University School of Medicine and Boston Medical Center in Massachusetts. “It happens enough that we ought to call it something.”
Naming the problem will allow it to be more easily researched and treated, he added. “It will help us all to think about it a little more,” Dr. Jack said.
Other experts agree that the syndrome can provide a useful new perspective on an issue that hospitalists have been aware of, but have perhaps not really focused on, for a while.
“Periodically, it's important to have a conceptual reframing of a topic in order to get people to think about it differently,” said Dr. Wachter, who is also the chair of the American Board of Internal Medicine this year. “We've come to recognize that readmissions are a common problem….We pretty rapidly went from that recognition to a set of policy initiatives around payment and a set of improvement activities that were all well-meaning but may have been a little simplistic.”
Physicians naturally tend to focus on patients' predominant problems, Dr. Wachter said. “One's instinct when one sees that a Medicare patient has a 30% chance of being readmitted within a month if they were hospitalized for heart failure…is to focus on that disease,” he said. “Are we focusing on too limited a target, or even the wrong targets?”
But calling the problem post-hospital syndrome inappropriately puts the target on the hospital, other experts countered. “Any time an elderly patient becomes ill, they commonly have a post-illness syndrome, and that's actually a more appropriate description for this than post-hospitalization,” said Mark V. Williams, MD, FACP, professor and chief of hospital medicine at Northwestern University in Chicago.
“I don't think blaming the hospital is necessarily the right way to go….Patients will interpret it as ‘Oh, if I go into the hospital, I will get sick’ when they actually need the hospital to get better,” Dr. Williams said.
Other hospitalists are concerned that the syndrome doesn't describe enough of the problems caused by hospitals. Dr. Krumholz's NEJM article included a list of factors that contribute to patients' post-discharge difficulties.
“During hospitalization, patients are commonly deprived of sleep, experience disruption of normal circadian rhythms, are nourished poorly, have pain and discomfort, confront a baffling array of mentally challenging situations, receive medications that can alter cognition and physical function, and become deconditioned by bed rest or inactivity,” he wrote.
“Those are all in the physical category,” said Amy E. Boutwell, MD, MPP, president of Collaborative Healthcare Strategies, co-founder of the Institute for Healthcare Improvement's STAAR (State Action on Avoidable Readmissions) Initiative, and a hospitalist at Newton-Wellesley and Massachusetts General Hospitals in Massachusetts. “It's important to go a little bit further to say explicitly that the financial and social support structures of the individual also need to be attended to….When we ask them to buy a whole new regimen of medications and follow up with their doctor in ten days, we actually hear people saying, ‘I don't have the money to pay for the transportation, the parking, the co-pay.’”
In addition to being too narrow, post-hospital syndrome might also be too broad a concept, Dr. Boutwell added. “The risks vary by type of person and circumstance, so when we think about creating a new clinical entity or labeling something in medicine, I think that the label would need to be slightly more specific,” she said. “Really, what we're saying is, ‘Please recognize that hospitalization has not only dealt with the chief complaint or primary diagnosis, but it has impacted the physiology and even the social, economic and support structure of this person.’”
Her statement is a little more unwieldy to enter in a patient's chart (“I won't be shocked if physicians begin listing ‘post-hospital syndrome,’ on their problem lists,” said Dr. Wachter), but it fairly accurately describes the response of hospitalist experts to the concept of post-hospital syndrome, regardless of whether they endorse the new name.
There's less consensus and certainty about what to do to fix the problem once it's been collectively acknowledged. Not surprisingly, researchers call for more study. “I hate saying [this], but it is clear we do need research in this area to identify best approaches,” said Dr. Williams.
“We can now study this,” agreed Dr. Jack. “We can make a research definition and then identify people who have it and study its complications and adverse events, its relation to other comorbidities and rehospitalization.”
But while the research is ongoing, hospitalists shouldn't hesitate to take action, said Dr. Boutwell. “The field is still very early in being able to tell providers with any sort of certainty what should be done, but that can't be an excuse for doing nothing,” she said.
Research and improvement can take place at the same time, agreed Dr. Krumholz. “What if we really did start to monitor how much sleep people got and how good their nutrition was and got them ambulating as soon as possible and we tried not to disturb their circadian rhythm? Could we do all that and still treat their acute illness and would they be doing better at the end?” he asked. “I would love to have places say, ‘We'll try this and see what happens.’”
Some of these ideas aren't new at all, noted Christine K. Cassel, MD, MACP, a geriatrician and president and CEO of the American Board of Internal Medicine. She described a scene she used to routinely witness on geriatric units. “The doctors would not see a patient in bed if they could possibly get the patient out of bed. Just say, ‘OK, Mrs. Smith, let's see you walk across the room.’ The doctor can see whether the patient is strong enough to walk across the room and secondly, even that little bit of ambulation creates some stress on the muscles, gets the circulation going, helps prevent deconditioning.”
Many geriatricians have already focused on these component causes of post-hospital syndrome, she noted. “Geriatric medicine has a deep and very substantial literature on this topic of hospital-acquired vulnerability and actually some ways of reducing those consequences,” Dr. Cassel said.
One potential solution, which she favors, is more acute care for the elderly, or ACE, units. “The literature on ACE units shows they have very good results at reducing some of these risks,” Dr. Cassel said. “One approach would be to identify a risk score so that patients who are particularly high risk for these complications might be admitted to a special unit.” The disadvantage of such a plan is that some patients would miss out on the extra interventions. “A lot of this is stuff that probably would benefit everyone,” Dr. Cassel said.
Other experts also supported early assessment of patients' risk for the problems of post-hospital syndrome. “As we emphasize in Project BOOST [Better Outcomes by Optimizing Safe Transitions, the Society of Hospital Medicine's care transitions project], you begin planning discharge at the time of admission,” said Dr. Williams.
“As you're doing your history and physical, incorporate into that finding out who will be helping the patient after discharge. Who is their caregiver? What's their home environment like?” said Devan Kansagara, MD, FACP, assistant professor of medicine at Oregon Health & Science University and a staff physician at the Portland Veterans Administration Hospital.
Starting patient education earlier could also be a help, experts said. “Build in patient-centered education, including caregivers, beginning shortly after admission, so you're not presenting them with a whole bolus of information, just as they're sick and tired from a week-long hospital stay and ready to leave,” said Dr. Kansagara.
“People are clearly not on top of their cognitive game when they're being discharged,” agreed Dr. Jack. “Implement organized programs that help people to understand what they're supposed to do when they go home.” Components of Project RED (Re-Engineered Discharge), the discharge improvement program he developed at Boston University School of Medicine and Boston Medical Center, include writing down patient education (in graphic or large-print form when needed) and using teachback to ensure patients understand.
As the existence of these projects shows, discharge planning and education have already attracted hospitalists' notice, but the hospital stay itself might need additional attention as well. “I'm seeing much more attention, in the meetings I go to and in the literature, to the transition part and the coordination part, all of which is important, but less to what actually happens during those four or five days in the hospital,” said Dr. Cassel.
Interventions during hospitalization to avert post-hospital syndrome could include greater use of physical therapy. “We probably ought to be thinking about intensive physical therapy for elderly patients right when they're hospitalized,” said Dr. Williams. However, trials of intense therapy have shown mixed results, so it's still hard to know which patients would benefit from it, he added.
But perhaps more communication between physicians and physical therapists could make that clearer. “Hospitalists and the members of the health care team should encourage and participate in multi-disciplinary rounds—physical therapy, nursing, nutrition, pharmacy. That's one way to address some of the points Dr. Krumholz brings up,” said Dr. Kansagara.
Dr. Krumholz also had some suggestions. “The health care system right now is often configured for the convenience of the providers,” he said. “The patient may be told there's a cardiologist that's going to come see you today. They don't know when they can take a nap, when they can go for a walk….We schedule a procedure [that requires the patient to] miss breakfast and lunch, then reschedule it.”
Physicians could inform patients when they're going to be rounding on them and pay attention to whether their schedules are placing undue burdens on patients by depriving them of food or sleep, Dr. Krumholz recommended.
Dr. Kansagara had more ideas along those lines. “We can try to minimize unnecessary interventions and testings when appropriate, especially those things that impact the patient's quality of life while they're in the hospital, like frequent fingerstick checks…or three-times-a-day heparin orders or early morning lab draws,” he said.
But more medical care could also be a solution rather than the problem. “Probably the best preventives are going to be careful attention to the many comorbid illnesses that are often occurring in the patient in addition to what was attributed as the single cause for initial admission,” said Seth Landefeld, MD, FACP, chair of the department of medicine at the University of Alabama at Birmingham.
“If somebody was initially hospitalized for heart failure and then they're readmitted for a COPD exacerbation or pneumonia, that's not totally unrelated to what was going on with their cardiac function,” he added. “This phenomenon that when one thing goes awry then other things often go awry is well worth looking at.”
It may also be worth talking to patients about. “People are getting the message, ‘You're well enough to go home and make an appointment when you can, and good luck’ as opposed to saying, ‘You're through phase 1—this life-threatening part that required all the tools of a modern hospital—but you're entering phase 2, which is very dangerous and could land you back in the hospital if we're not careful,’” said Dr. Krumholz.
“You might tell people, ‘It's typical for people to be susceptible to infections when they leave the hospital…and it wouldn't be good for you to be around sick people or go to a movie theater where people are coughing,’” he added. Not driving or making big decisions might be other reasonable recommendations, he suggested.
Hospitalists could also help patients think more about how they're going to get along during this period of lower functioning, said Dr. Kansagara. “It gets into really practical things. If they have a spouse who is their caregiver, will they need to take time off work? Could they have a cousin come up and help out for the next few weeks? Do we need to get home health nursing involved?” he said.
The last of those ideas is an area of major potential improvement, said Dr. Boutwell. She described trials in which all discharged heart failure patients were referred for at least one home health visit, regardless of apparent need. “A large percentage of those automatic home health referrals convert into qualifying Medicare home health episodes,” she said. “When the inpatient team assesses a patient in their hospital bed, we greatly overestimate that person's ability to make a smooth transition to home.”
All of the experts reaffirmed the primary importance of hospitalists connecting with outpatient physicians to further smooth that transition. Dr. Krumholz's JAMA study also looked at when heart failure, heart attack and pneumonia patients were readmitted, and found that more than 60% of readmissions occurred within 15 days.
That finding could hold significance for the timing of the crucial post-discharge follow-up visit. “In my view, that follow-up should be in the order of two, three, four days, not two or three weeks,” said Dr. Landefeld.
Also in those days after discharge, a phone call from the hospital could be helpful to assess the patient's post-hospital problems and, in some cases, correct them. “When we make a phone call two days later, we find that half the people are doing something wrong with their medications,” said Dr. Jack.
Taking the lead
Completing all these recommended steps and changes to prevent and treat post-hospital syndrome would be an overwhelming task for a lone hospitalist, which is why experts want the profession as a whole to focus on leading the efforts.
“Hospitalists have a real opportunity for leadership here,” said Dr. Cassel. “I would urge them to add these kinds of considerations to the way they think about patient safety, the way they think about quality-of-care measures, the way they think about staffing and teamwork in the hospitals.”
Dr. Krumholz agreed. “Hospitalists have a real opportunity to be the innovators here and…try some innovative approaches that might lead to making the hospital a more restful, helpful environment,” he said.
The establishment and expansion of 30-day readmission penalties might mean that there's more funding for those innovations, whether they're large or small. “If I propose to my hospital a new set of interventions designed to address some of the issues, and it's a half-a-million-dollar program, there is some possibility that people will look at that as a reasonable investment given that the potential Medicare penalties may be substantially higher than that,” said Dr. Wachter.
Although no one's found the magic bullet for post-hospital syndrome, administrators may also be reassured that many of the interventions suggested by the experts already have strong evidence support, whether through Medicare demonstrations or efforts like Project BOOST and Project RED.
“We need to really take the lessons from the pilot efforts of 2011 and 2012 and expand those efforts to serve all high-risk patients in 2013 and beyond,” concluded Dr. Boutwell.
Preempting post-intensive care syndrome
Experts discuss strategies at critical care meeting
By Jessica Berthold
The overarching effects of the hospital experience on patients were also on the minds of speakers and attendees at the Society of Critical Care Medicine's (SCCM) 42nd Congress, held in San Juan, Puerto Rico, in January.
Critical care experts spoke specifically about reducing the negative physical, cognitive and psychological impact of time spent in an intensive care unit (ICU). These effects, called post-intensive care syndrome or PICS by researchers, occur in a sizable number of ICU and other seriously ill patients, noted Theodore Iwashyna, MD, PhD, a critical care physician and health services researcher at the University of Michigan in Ann Arbor.
“A patient has triple the odds of cognitive impairment after severe sepsis,” Dr. Iwashyna said. “In general, 59% of older patients have worse disability or cognitive impairment after severe sepsis. This has practical effects, even in younger patients: Forty-eight percent of [acute respiratory distress syndrome] patients had not gone back to work one year after discharge, for example.”
SCCM has a PICS task force currently working on a portfolio of interventions aimed at reducing these problems, noted Dr. Iwashyna. This task force includes broad participation from a variety of groups, including hospitalists, physical therapists and regulators.
The first element of the package to reduce the burdens of PICS, he said, will be to minimize the level and duration of critical illness through measures such as the updated 2012 Surviving Sepsis Guidelines and use of the ABCDE bundle (Awakening the patient daily, Breathing via interruption of mechanical ventilation, Coordination of awakening and breathing, Delirium monitoring, Exercise and early mobility).
Second, physicians must protect patients from developing new problems by vaccinating them against diseases for which they haven't been immunized, Dr. Iwashyna said. Doctors must also help patients return to strength as soon as possible by advocating prompt rehabilitation and physical therapy, with use of compensatory devices like walkers, if needed.
The final step is to enhance life for those who have survived the ICU, whatever their level of lingering disability. To that end, the PICS task force is working on a “survivors supporting survivors” initiative, he said.
“There are few proven therapies for PICS, but we know excellent hospital care is a linchpin, and novel solutions will be key,” said Dr. Iwashyna.
Family members, as well as patients, can suffer enormous stress from the ICU experience, said Judy Davidson, RN, DNP, director of research integration and management at Scripps Clinical Research Center in La Jolla, Calif.
“Many family members have a strong need for presence and safeguarding. It causes them more anxiety during their time of crisis if we make them leave when they feel the need to stay. A patient's mother once told me that she resorted to hiding under the bed at night to stay with her daughter after the doctors told her she would very likely die during the hospitalization. She further disclosed that she needed to have therapy because of being sent away—not from the trauma or from nearly losing her daughter, but because of the ICU experience,” Dr. Davidson said.
Getting family members involved in care can help reduce their anxiety and depression at having a loved one in the ICU.
For example, giving families flexible visiting hours so they can be present during bedside rounds and take part in decision making can reduce feelings of helplessness, Dr. Davidson said. It can also help improve care.
“When it comes to keeping sedation light, waking patients up, and getting them mobile…family members can help occupy the patient's mind, assist in improving their range of motion, and monitor for any potential problems,” she said.
Dr. Davidson and her task force colleagues would like to add an “FGH” to the ABCDE bundle of care, she added: “F” for family inclusion and follow-up referrals, “G” for good communication that includes family input and “H” for handing the family written information about what will happen with the patient once he or she leaves the hospital.
Encouraging families to keep diaries during the ICU stay also has been shown to reduce anxiety in both family members and patients after discharge, because it helps them make sense of the experience, noted Ramona O. Hopkins, PhD, a professor of psychology and neuroscience at Brigham Young University in Provo, Utah and a researcher at Intermountain Medical Center in Murray, Utah.
“We no longer measure success by mortality,” Dr. Hopkins said. “[ICU] survival is not the end point—returning to the highest quality of life is.”
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From the April 16, 2014 edition
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