D Healthcare Daily

Nearly one of five Dallas-Fort Worth patients who are readmitted to the hospital within 30 days do not return to the facility that discharged them, according to a Dallas-Fort Worth Hospital Council Foundation (DFWHCF) report.

The foundation’s study included data from more than 70 DFW hospitals and is one of the few databases that can track patient admissions to different hospitals.

Twenty-six hospitals in the four-county Dallas-Fort Worth metropolitan area are among the more than 2,000 hospitals across the country that will be penalized by the federal government, because too many of their patients are readmitted soon after discharge, according to Centers for Medicare and Medicaid Services (CMS).

The current penalties, which began Oct. 1, are capped at 1 percent of Medicare hospital payments. Hospitals are being measured for three medical conditions: heart attacks, heart failure and pneumonia. The penalties gradually will rise to 3 percent and four additional conditions will be measured: joint replacements, stenting, heart bypass and stroke treatment.

The study also found:

• About 1 out of 7 hospitalized patients 18 years or older were readmitted within 30 days of discharged
• Septicemia was among the top 50 percent of reasons that patients are readmitted within 30 days. The blood infection is preventable and has a high mortality rate. Septicemia patients often are readmitted because of early discharge, improper antibiotic treatment, lack of medication adherence or bacterial infection that is resistant to prescribed antibiotics. Pam Doughty, the foundation’s director of health services research and the report’s lead author, pointed out that returning patients with septicemia  have a higher mortality rate and longer length of stay.
• Medicare patients accounted for the largest percentage readmissions for any reason at about 45 percent. However, commercially insured patients were more likely to return for complications or infections.
• Patients discharged to skilled nursing facilities, home health, rehabilitation facilities and short-term care are far more likely to be readmitted than those who are discharged to other settings.

Doughty said the local rate of hospital readmissions has been steadily decreasing. According to MedPAC, the national Medicare readmission rate has fallen slightly from 15.6 percent to 15.3 percent in the past three years while potentially preventable readmissions have fallen from 13 percent to 12.3 percent.

Donald Kennerly, MD, vice president of patient safety and chief patient safety officer for Baylor Health Care System, said the fact that 1 out of 5 readmitted patients go to a different hospital did not surprise him. He said Baylor’s data shows that 10-15 percent of its readmissions are to a different facility.

Kennerly said, “How you measure and manage readmissions is very complicated. The goal is not to get to zero. You have to have as few preventable admissions as possible. For example, a cancer patient could be readmitted for another round of chemotherapy. That is not suboptimal care. Or women who have complex pregnancies are admitted, sent home and then return to have their babies. This is not something we should be avoiding.”

Kennerly attributed the higher readmission rate for infection and complications for younger patients to a number of factors. He said patients age 50-64 are more likely to be surgical patients, and procedures create post-operative complications. He also said younger patients are a smaller fraction of admissions and more likely to survive a hospitalization to return for more treatment.

Kennerly noted that there may be quality-of-care issues in skilled nursing facilities, but more seriously ill patients than those who are discharged to their homes.

Mark Lester, MD, executive vice president and clinical leader Texas Health Resources (THR) southeast zone, noted post-acute care is a key aspect of readmissions.

“We are looking at exactly that problem right now.  It’s enormous. It’s hundreds and hundreds (of healthcare organizations THR deals with). There is not a good way to frame all that.”

Lester pointed out it is up to Medicare beneficiaries to decide where they want to pursue care, and that hospitals have no way of knowing whether their patients are going elsewhere for readmissions.

“(Readmissions) is a rapidly evolving topic. We’re all learning. There is a robust literature that is reporting on what people are doing and what impact they’re having. We are seeing that what works great at one hospital didn’t work at all at another. We’ll all get better at this,” he said.

Steve Love, president and chief executive officer of the hospital council, praised North Texas hospitals for “having the foresight” to share data to work collaboratively on hospital readmissions.

He said lawmakers need to revisit the readmission penalties, so that hospitals are not penalized for planned readmissions, which he called “ludicrous.”

“You could leave the hospital and have an accident and come back. It’s clearly not related to the previous treatment,” he said.

Steve Jacob is editor of D Healthcare Daily and author of the new book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at steve.jacob@dmagazine.com.