Preventing Re-admissions

CLAHRC WM is working with Sandwell and Birmingham Hospitals group to improve care of patients on discharge from hospital. This is a worthwhile exercise since handover from hospital to community is a ‘fault-line’ for safe care. Some think that improving care over this transition may reduce re-admission rates, and indeed differences in re-admission rates across hospital sites within the group prompted the above initiative in the first place.

However, the CLAHRC WM Director is circumspect regarding the prospects for reduced re-admissions. His argument is simple: most re-admissions result from inter-current or progressive disease, while the proportion of re-admissions that are preventable is small, especially beyond the first four weeks after discharge. It follows that re-admissions are a small signal easily buried in noise.[1] This does not, of course, mean that improving care at discharge is not a worthwhile objective.

A recent RCT of an expensive intervention based on one-to-one self-management education from a discharge nurse, backed up by telephone calls after discharge, did not lead to reduced re-admissions and may have actually increased hospital contact overall.[2] Is this yet a further example of an intervention motivated by the need to reduce healthcare utilisation that results instead in improved care but no reduction, or even an increase, in healthcare costs?

— Richard Lilford, CLAHRC WM Director

References:

  1. Girling AJ, Hofer TP, Wu J, Chilton PJ, Nicholl JP, Mohammed MA, Lilford RJ. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modelling study. BMJ Quality & Safety. 2012; 21: 1052-6.
  2. Goldman LE, Sarkar U, Kessell E, et al. Support From Hospital to Home for Elders: A Randomized Trial. Ann Intern Med. 2014; 161(7): 472-81.
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4 thoughts on “Preventing Re-admissions”

  1. Readmissions Thank you Richard. I speak from a carer perspective. First, discharge from hospital: this can take a great deal of time eg if Consultant ‘releases’ a patient on a Friday it may be Monday before the patient can leave – senior staff not working over weekends; on weekdays discharge can take several hours with little feedback on progress. This affects patients and their carers; and the availability of hospital beds. Another factor in discharge is the availability of community support – often meaning family
    Post discharge: after a lot of caring I conclude that the role aof Carers may be an untapped resource – I wrote an article for the Times about this ‘Carers need a charter’ saying that carers often do the job of health care professionals but with little guidance on best practice. This can be expanded to Carer as Facilitator for patient support – using the experience of the carer to support the technical work of health care professionals; and I thought this might reduce readmissions – but no longer sure about this after your article. I raised the issue pf Carer as Facilitator at a recent Research meeting of Cov and Warks FT and was asked to expand. But I don’t want to spend time on this if my premise – better care for patients after discharge hence reduced readmissions – is weak.

  2. The argument is too simple. Lack of evidence on impact suggests that the current interventions are poorly designed resulting in little or no effect. Evidence from healthcare professionals and patients experiencing multimorbidity and hospital discharge from North Midlands suggests that we need to consider pathway management of discharge that takes account of pre-admission factors (primary care, planned hospital activity and OPD interaction), intra-hospital planning, and actual clinical co-ordination of the discharge planning through to continuity and follow up. This does require a rather more sophisticated development of a ‘flow pathway’ that incorporates particularly an unplanned hospital admission, than presented by in this argument. Perhaps then we might get better co-ordinated activity with more cost effectiveness of when where delivery of care should occur and resulting in impacts that we might hypothesise could occur.

  3. Interested in Chris Roseveare’s comment – in our national analysis of 5,804,472 emergency 30-day
    readmissions over a 6-year period, (http://emj.bmj.com/content/early/2014/03/25/emermed-2013-202531) we grouped readmissions into exclusive categories:

    1. potentially preventable – 1 739 519 (30.0%);
    2. broadly related (same body system) – 1 751 368 (30.2%);
    3. anticipated but unpredictable (patients with
    chronic disease or likely to need long-term care) – 1 141 987 (19.7%);
    4. a result of accident, coincidence or related to a different body system – 1 101 818 (19.0%);
    5. preference-related – 53,718 (0.9%);
    6. artefact of data collection – 16 062 (0.3%);

    In the end we considered that about a fifth of readmissions might be unpredictable (accident, coincidence or related to a different body system) with an additional tiny proportion related to data artefacts or patient preference. This leaves 80%. We considered that 30% overall were potentially preventable – leaving a whopping 50% in categories where changes in care patterns inside and outside hospital might well reduce readmission rates. This study was necessarily broad brush of course and would benefit from validation. What do others think?
    Aileen Clarke
    aileen.clarke@warwick.ac.uk

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