Reducing Rehospitalization: Policy, Ecology and Culture

Luke Hansen, MD MHSAssistant Professor, Northwestern University

Feinberg School of Medicine, SSOM ‘03

National Health Expenditures per Capita, 1960-2010

Notes: According to CMS, population is the U.S. Bureau of the Census resident-based population, less armed forces overseas.

Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2010; file nhegdp10.zip).

5.2% 7.2% 9.2% 12.5% 13.8% 14.5% 15.4% 15.9% 16.0% 16.1% 16.2% 16.4% 16.8% 17.9% 17.9%

NHE as a Share of GDP

Cumulative Percent Change in National Health Expenditures, by Selected Sources of Funds, 2000-2010

Notes: This figure omits national health spending that belongs in the categories of Other Public Insurance Programs, Other Third Party Payers and Programs, Public Health Activity, and Investment, which together represent about 20% of total national health spending in 2010. Medicare and Medicaid were enacted in 1965; by January 1970, all states but two were participating in Medicaid.

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2010; file nhe2010.zip).

Distribution of National Health Expenditures, by Type of Service (in Billions), 2010

Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc.

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2010; file nhe2010.zip).

NHE Total Expenditures: $2,593.6 billion

Nursing Care Facilities & Continuing Care Retirement

Communities, $143.1 (5.5%)

•19% rehospitalized in 30 days•$17.4 billion annually

MedPAC and the federal response to high rates of readmission

• MedPAC estimates annual cost of all avoidable readmission $12 Billion

• June 2007: Recommends public reporting of risk‐adjusted readmission

• Summer 2009: Public reporting of readmission outcomes goes live

• www.hospitalcompare.hhs.gov

“Beginning 2013, [Affordable Care Act(ACA)] imposes penalties on hospitals for so‐called ‘excess’ readmissions based on ‘expected’ 30‐day readmission rates for heart attack, heart failure, and pneumonia”

Starts in FY ’13 based on FY ’12 (starts Oct ’11). Payments for all Medicare patients will be reduced by up to 1% and increase to 3% by 2015, at which time COPD, CABG, PCI and others will be added.  

PPACA, 2010, Section 3025

What can be done to reduce readmission rates?

• Why do readmissions occur?• What are patient risk factors for readmission?• What has been tested to reduce readmission?

Why do readmissions occur?

Healthcare Quality

Medical Co-morbidity

Incidence of post‐discharge adverse events

• 19% of patients had a post discharge AE• ⅓ preventable and ⅓ ameliorable

Ann Intern Med 2003; Vol. 138

• ¼ of discharged patients require additional outpatient work‐ups

• > ⅓ of these are not completed• Increased time to post‐discharge f/u associated with lack of work‐up completion

• Availability of discharge summary increased likelihood of work‐up being done

Arch Intern Med. 2007;167:1305‐1311

Loose ends at discharge

“quicker and sicker”?

• 6,955,461 Medicare FFS hospitalizations for HF between 1993 and 2006, with 30‐day f/u.

• LOS 8.8 days down to 6.3 days• In‐hospital mortality from 8.5% to 4.3%• 30‐day mortality from 12.8% to 10.7%• Discharges to SNF increased from 13% to 20%• 30 day readmission increased from 17.2% to 20.1%

What can be done to reduce readmission rates?

• Why do readmissions occur?• What are patient risk factors for readmission?

• What has been tested to reduce readmission?

Home

Recovery

Rehospitalization

Risks of Readmission

Repeated admitsMedical co‐morbidityDepressionMaleInsuranceAge

RaceSelf perceived QOLMarriedRegular physicianPolypharmacy

Three approaches to risk assessment:• Calculated, Externally developed • Calculated, Internally developed• Not Calculated

Two approaches to targeting:• Proactive• Reactive

A statistical prelude:Discriminative Strength

The ROC curve and the C Statistic

Kansagara, D., H. Englander, et al. (2011). "Risk Prediction Models for Hospital Readmission." JAMA: The Journal of the American Medical Association 306(15): 1688-1698.

• 7843 articles reviewed• 30 studies included in the review

• 7 models could be used to risk stratify on admission

• C statistic 0.56-0.72

“Variables independently associated with [readmission and death] (from which we derived the mnemonic “LACE”) included length of stay (“L”); acuity of the admission (“A”); comorbidity of the patient (measured with the Charlson comorbidity index score) (“C”); and emergency department use (measured as the number of visits in the six months before admission) (“E”).

“The LACE index was discriminative (C statistic 0.684)”

Three approaches to risk assessment:• Calculated, Externally developed • Calculated, Internally developed• Not Calculated

Two approaches to targeting:• Proactive• Reactive

Development of a single hospital empiric readmission risk prediction model

ID Risks Develop scores Measure characteristics

Variable OR# admissions in previous year 1.32Male Sex 1.11Subjective weight loss 1.04# Chronic Conditions 1.03Age 0.93African American Race 0.92

• Initial model also considered marital status, insurance status• C statistic 0.68

ID Risks Develop scores Measure characteristics

Risk Factor Categories PointsAge

<20 -320-29 030-39 040-49 050-59 060-69 -170-79 -180-89 -1≥90 -1

SexMale 0Female 1

Non Black RaceBlack 0Non Black 1

Risk Factor Categories PointsAdmissions, past year

0 01 32 53 84 11≥5 19

Subjective Wt LossNo 0Yes 3

Comorbidity Count0 to 2 03 to 6 27 to 9 4>9 6

Development of a single hospital empiric readmission risk prediction model

ID Risks Develop scores Clinical Application

Readmitted? Risk Score<4 5-9 10-14 15-18 >19 Total

No 86.01% 78.44% 71.07% 64.56% 52.94% 76.32%

Yes 13.99% 21.56% 28.93% 35.44% 47.06% 23.68%

Development of a single hospital empiric readmission risk prediction model

Three approaches to risk assessment:• Calculated, Externally developed • Calculated, Internally developed• Not Calculated

Two approaches to targeting:• Proactive• Reactive

• Methods– aged ≥65, 550-bed tertiary care

academic medical center. – Staff estimated the chance of

unscheduled readmission within 30 days

• Results (as AUC) – 0.50 for case managers– 0.55 for RNs– 0.59 for interns– 0.58 for attendings– 0.56 for calculated index

JGIM 2011

The “8P” Risk Assessment

• Problem medications (insulin, warfarin, narcotics [see Budnitz NEJM 2011])

• Psychological Comorbidity

• Principal dx (CA, DM, COPD, CHF, CVA)

• Polypharmacy

• Poor health literacy

• Patient support lacking

• Prior hospitalizations

• Palliative care

Assumption 1: All Measurable Risk is Meaningful

“On logistic regression, a decreasing temperature was significantly associated with rehospitalization within 180 days (odds ratio, 4.01; 95% confidence interval, 1.63‐10.02; P < .003).”

Assumption 2:The ecology of rehospitalization

Community

Hospital

Family

patient

Assumption 2:The ecology of rehospitalization

Healthcare Quality

Medical Co-morbidity

Assumption 2:The ecology of rehospitalization

Hospital Quality

Physician Quality

Medical Co-morbidity

Assumption 2:The ecology of rehospitalization

Hospital Quality

Physician Quality

Medical Co-morbiditySocial Support

NeighborhoodEnvironment

Assumption 2:The ecology of rehospitalization

Arbaje, A., Wolff, J., Yu, Q., Powe, N., Anderson, G., & Boult, C. (2008). Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling Medicare beneficiaries. The Gerontologist, 48(4), 495.

Model 1 includes age aloneModel 2 includes model 1 plus patient comorbiditiesModel 3 includes model 2 plus discharge dispositionModel 4 includes model 3 plus hospital characteristics (size,

membership in a system, teaching status, ownership, location, region)

Model 5 includes model 4 plus percent Medicaid at each hospital and each hospital’s Disproportionate Share Index

Joynt, K. et al, JAMA, 2011

Assumption 2:The ecology of rehospitalization

What is the effect of “risk-adjustment” that does not account for all determinants of readmission?

The DC PROMIS Study

Prospective survey of hospitalized, non‐demented elders being discharged to home regarding self‐reported function in diverse domains:

– Physical function– Cognitive function– Emotional function– Social function

Not Readmitted (n=50)

Readmitted (n=18)

P value*

LACE Score 6.96 (±2.94) 8.00 (±2.32) 0.2901Social and functional variables, prior to discharge, mean T score (SD)

Physical function 39.99 (±10.10)

31.75 (±8.17) 0.0028

Applied cognitive ability 48.06 (±7.14)

45.91 (±6.17) 0.2622

Depressive symptoms 51.10 (±8.49)

52.03 (±4.75) 0.5765

Ability to access social support 49.44 (±10.12)

40.25 (±8.53) 0.0014

Social isolation 44.04 (±8.59)

49.05 (±5.97) 0.0301

*significance calculated using t-test for continuous variables and Fisher’s exact test for categorical variables

Assumption 3: Reduced Rehospitalization is improved health

Feng et al, Health Affairs 2012

Assumption 3: Reduced Rehospitalization is improved health

Krumholz, H. M., et al (2013). Relationship Between Hospital Readmission and Mortality Rates for Patients Hospitalized With Acute Myocardial Infarction, Heart Failure, or Pneumonia Hospital Performance and Readmission/Mortality Rates. JAMA, 309(6), 587‐593. 

Quality

Assumption 3: Reduced Rehospitalization is improved health

Cost

(Quality)(Access)↑Value =

Assumption 3: Reduced Rehospitalization is improved value?

What can be done to reduce readmission rates?

• Why do readmissions occur?• What are the risk factors for readmission?• What has been tested to reduce readmission?

• Literature between 1970 and January 2011• 4013 articles identified• Full text of 386 studies or reviews examined by

four physician team• 43 studies were included in final review which

reported a 30 day readmission outcome and interventions were not disease specific

Effectiveness Characteristic #1: Multifaceted intervention

Pre-Discharge Intervention

Post-DischargeIntervention

Patient educationPCP communicationDischarge planning

Medication reconciliation

Home visitFollow-up phone call

Patient hotlineEarly follow-up

Intervention Bridging the TransitionTransition coach

Patient-centered discharge instructionsIntegration of inpatient and outpatient care

Effectiveness Characteristic #2:Bridging Interventions

Facets PopulationSetting (nation)

Study design Control n

Intervention N

Absolute risk reduction (%)

Jack BW, et al. Project RED 6 wards USA RCT 368 370 6.0 (S)

Naylor M, et al. Transitional Care Intervention

5

≥65 yocardiac

medical and surgical DRG

USA RCT 70 72 12 (NS at 2 weeks)

Coleman EA et al.Care Transitions Intervention

4 ≥65 yo USA RCT 371 379 3.6 (S)

Interventions including a “bridging” component were significantly associated with a finding of statistically significant benefit.

The PASS: A Patient-centered discharge instruction

• Simple• Problem focused• Appropriate literacy• Robust Medication

Reconciliation– New meds– Stopped meds– Changed meds

NEW CONCEPT: Health information, advice, 

instructions, or change in management

Explain new concept / Demonstrate new skill

Patient recalls and comprehends / Demonstrates 

skill mastery

Assess patient comprehension / Ask patient to demonstrate

Clarify and tailor explanation

Re‐assess recall and comprehension /Ask 

patient to demonstrate

The Teach Back Method

Modified from Schillinger, D. et al. Arch Intern Med 2003;163:83‐90

Effectiveness analysis of sites participating in Project BOOST

• Readmission outcomes presented from 11 of 30 pilot sites

• Average rate of 30-day rehospitalization in BOOST units was 14.7% prior to implementation and 12.7% 12 months later (P=0.010)

• Absolute reduction of 2% • Relative reduction of 13.6%

Implementation Caveat 1: Will it play in Peoria?

Boston Medical Center

Proctor Medical Center

Location Boston, MA (pop 645,169)

Peoria, IL (pop 115,007)

Licensed beds 639 299

Medicare FFS HF admissions (7/1/06 to 6/30/09)

488 379

Teaching Hospital Yes No

Active NIH-funding FY 2010

$46,187,521 $0

Implementation Caveat 2: Context is critical

Ideas and products and messages and behaviors spread just like viruses do.

--Malcolm Gladwell, The Tipping Point

Project BOOST units in Pilot Cohort

5%

10%

15%

20%

Pre‐Implementation 1y Post‐Implementation

Readmission Ra

te

Project BOOST units in Pilot Cohort

5%

10%

15%

20%

Pre‐Implementation 1y Post‐Implementation

Readmission Ra

te

Contextual elements of the organization

Strategic environment• What are the organization’s strategic goals?• What is the organization’s financial status?• What is the competition doing?• How is the hospital perceived locally?

Organizational culture• Senior leadership engagement• How has change occurred previously in the organization?• What is the organization’s safety culture?

What is culture?

• An academic definition:“The integrated pattern of human knowledge, belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations.” 

• An easy definition: “It’s how we do things here.”

What is Safety Culture?“The accident can be said to have 

flowed from deficient safety culture, not only at the Chernobyl plant, but throughout the Soviet design, operating and regulatory organizations for nuclear power that existed at the time.”

‐‐International Atomic Energy Agency (IAEA)

What is Safety Culture?“BP has harnessed impressive scientific and technological experience…and you have to wonder why they hadn't harnessed similar science and technology to anticipate failure, to install redundancy to prevent failure…[they] cast doubt on whether the company has the commitment to the practice and the culture of safety necessary to protect the public.”Rep. James L. Oberstar (D‐Minn.), chairman of the House Transportation and Infrastructure Committee

0

5

10

15

20

25

% Problem

atic Respo

nse

(mean of 16 ite

ms)

VA hospitals (shaded) US hospitals (unshaded) and Naval aviation average (line)

Room for Improvement?

One US hospital from a sample of 97 performed better than the naval aviation average

Singer, et al. Health Mgmt Review 2010

Association between readmission and safety climate

AMI HF

Org

.

Senior Management Engagement 0.0804* 0.0744Organizational Resources 0.0642 0.0705Overall Emphasis on Safety 0.0968** 0.1130**Problem Responsiveness 0.0853* 0.0903

Clin

. uni

t

Unit Safety Norms 0.1860** 0.2590**Unit Recognition and Support 0.0345 0.0599Unit Manager Support 0.0506 0.0344Collective Learning 0.1160* 0.1600**Psychological Safety 0.0644 0.0602

Indi

v. Fear of Shame 0.0126 -0.0827Fear of Blame 0.0510 0.1060**Provision of Safe Care -0.0138 0.0067Summary Measure 0.1230* 0.1600*

**p<0.01, *p<.05, Regression models include region, hospital tax status, nurse staffing ratios

Take home points

• Communication at discharge, particularly regarding medications, is important

• Effectiveness is not efficacy• Frontline safety culture is a necessary although insufficient component of a high performing healthcare system

James Cassidy SSOM ‘48