A Review of Studies Looking at Hospital Readmissions and ER Visits After Discharge Finds No Clear Path Out of the Woods

The Takeaway

1. Stephanie Rennke, MD at UCSF Medical Center led a team funded by the U.S. Department of Health and Human Services that reviewed studies on hospital-based interventions to reduce adverse events after discharge for medical patients. The results were published in the Annals of Internal Medicine on March 5.

2.  Of  20, 248 studies published between 1990 and 2012, they were able to find 47 that looked solely at  the general adult medical population to determine the effect of transitional care strategies on postdischarge emergency department use, hospital readmission or a combination of both.

3.  The complexity of the intervention process and the variety of settings in which it has to be applied has meant that no clear single strategy has yet emerged that hospitals can be sure will reduce 30-day readmissions.

4. A number of institutions have had promising results using a "dedicated transition provider," (generally a nurse or a clinical pharmacist) who had primary responsibility for managing the discharge and follow-up process.

5. Project Red, which used a nurse discharge advocate in an urban "safety net hospital," and Care Transitions Intervention (CTI), which used a transition coach, were among the programs that did show significant reductions in adverse events 30 days post discharge.  CTI was the only intervention that has already been scaled up to different types of hospitals and health care systems, and found effective.

6.  The overall body of evidence is too weak so far to know how different interventions will perform in different organizations, each with their own safety and quality improvement cultures.  Nor do we yet know which interventions will best scale-up for wider implementation across the country.

7.  The financial onus is already on hospitals to reduce hospital readmission rates but in terms of evidence-based research, we are still in the stage of identifying best practices.

The One Minute Summary

With 20 percent of medical patients returning to the hospital or emergency department within 30 days after being released, reducing adverse events after discharge has become a priority for policy makers. The Partnership for Patients, a government/industry joint effort to increase patient safety and improve care, has identified hospital readmissions as one of its key focus areas. They are using a carrot and stick approach.  The carrot is that under the Affordable Care Act, the Dept of Health and Human Services has been provided with $218 million to create Hospital Engagement Networks to identify best practices and help spread them across the health care industry.  The stick is that the Centers for Medicare and Medicaid will now begin to reduce payments to hospitals that don't reach their targets.

In this context we should expect to see a lot of attention being paid to the problem of reducing readmissions, and a lot of fresh studies being published.  Much of what has been done so far has focused on patients with specific diseases such as diabetes, asthma and heart disease.  It is only logical that complex systems like hospitals should focus first on more easily defined groups.  The results of those studies were excluded from this review because they wanted to see what has been applied to general medical population. The authors were not able to find much, nor would one expect them to. We are still in early days yet.

The good news is that interventions that begin in the hospital with patient education and review of medication changes, and are then "bridged" afterwards with follow-up phone calls, home visits or both, did reduce ED visits and readmissions by a significant amount.  The bad news is that the effect was weak because the studies were too difficult to compare with one another.  No standard way to measure results has yet been agreed on that can allow researchers in different health care settings, delivery systems, and communities to compare data.  When this is developed policy makers will be able to ask the most pressing question: have these interventions been able to lower costs?

TL:DR "Bridging strategies" using nurse coaches, pharmacists or some other type of dedicated transition providers did reduce 30-day hospital readmissions in some cases.  It's too soon to tell if this will be scalable or if it will save money.

Read the Study: Hospital-Initiated Care Interventions as a Patient Safety Strategy
By Stephanie Rennke, MD; Oanh Nguyen, MD; Marwa Shoeb, MD; Yimdriuska Magan, BS; Robert Wachter, MD and Sumant Ranji, MD.