Why Hospitals Need to Look Beyond 30-Day Readmissions

The Patient Protection and Affordable Care Act has hospitals watching their 30-day readmission rates closely. In fiscal year 2014, U.S. hospitals face up to a 2 percent loss in Medicare and Medicaid reimbursements as a penalty for excessive readmissions.

However, focusing solely on 30-day readmissions may overlook risks faced by patients both within the 30-day window and far beyond.

A discharged patient's risk for both readmission and mortality is "never going to reach the same risk as a person who hasn't been hospitalized," says Kumar Dharmarajan, MD, lead author of the study "Trajectories of Risk After Hospitalization for Heart Failure and Acute Myocardial Infarction" presented at the American Heart Association's Quality of
Care and Outcomes Research meeting in Baltimore on May 16, and who continues to study the issue.  

Recently, Dr. Dharmarajan has been studying Medicare patients' risk of readmission and mortality for the year after hospitalization for heart attacks and heart failure, conditions he selected not only for their high prevalence among patients aged 65 and over, but also because of their current role in determining Medicare readmission reimbursement penalties.

For all these conditions, "we have good reason to believe that risk is elevated well beyond the first month," he says. "Many patients who leave the hospital have a significant decline in their everyday function," explains Dr. Dharmarajan, compared to how they were before the hospitalization. Patients who were living independently before hospitalization often come home with reduced capabilities, ranging from struggles with transportation and cooking to even feeding themselves or using the restroom. These compromised abilities may extend risk for both hospitalization and death long after they are discharged from the hospital.   

"From a patient's perspective, there is nothing magical about 30 days," says Dr. Dharmarajan. "Not much changes for a patient between days 29 and 31," he says, or even one month to the next. "Many are going to be below their normal level of health for longer than a month."  

Dr. Dharmarajan and colleagues studied more than 1.5 million Medicare patients who had been discharged from the hospital after having had an admission for a heart attack or heart failure, and his results show that risk does not disappear after day 30.

"It is very common for a patient to die or be readmitted within a year" following discharge for one of these conditions, says Dr. Dharmarajan. He found that about three in four heart failure patients are readmitted at least once, and two in five will die within the year following the initial discharge. For heart attack patients, he found that half will be readmitted and a fourth will be dead within a year.

Moreover, the risk of death and readmission does not drop off drastically within the commonly-measured 30-day readmission window. Dr. Dharmarajan found that it's not until the 43rd day that a heart failure patient's risk of re-hospitalization is half what it was directly following discharge. After the first 90 days, a heart failure patient is still 10 times more likely to be admitted to the hospital as compared to the general Medicare population.

A patient's risk of death also remains elevated past the first month. Dr. Dharmarajan found that a heart attack patient's likelihood of death is 40 times that of the general population in the week following discharge. During the first three months, a heart attack patient still has a risk of mortality 12 times higher than the general population.  

This is important to hospitals, says Dr. Dharmarajan, because of its impact on patient care. He designed his research to answer questions patients have at discharge: "How long will my risk of death or re-hospitalization be elevated? How will it change with time? How does my risk compare to someone else my age?"  

When a hospital can help a patient understand the answers to these questions, says Dr. Dharmarajan, the patient will have a better understanding of his or her condition and may be more motivated to take steps to reduce his or her risk. "Patients may be motivated to maintain closer ties with their doctor, or be vigilant about detecting evidence that their health is deteriorating," he says. This can help the patient with long-term thinking, and long-term planning for his or her medical care.

Focusing on risk beyond the initial month after discharge can help a hospital achieve truly patient-centered care. "We know that risk is elevated for months" following discharge, says Dr. Dharmarajan. Therefore hospitals should design follow-up care that looks beyond the first 30 days to help patients manage the long-term risk they face, and connect with the patient beyond the initial follow-up appointment immediately after discharge. "We can't automatically say, 'we saw them early after discharge and things looked okay, therefore their risk for readmission or death is low,'" he says.

Dr. Dharmarajan notes that healthcare reform and bundled payments are quickly moving the industry toward a higher level of accountability for hospitals in their patients' long-term outcomes.

"The days when hospitals could only be concerned with the outcomes that happened within their walls are gone," he says. "Hospitals need to start thinking about the long-term healthcare needs of their patients."

More Articles on Patient-Centered Care:

Developing a Workforce Strategy for Patient-Centered Care: 6 Key Steps
Patient Care Coordination: Strategies and Leading Practices
The Secret to a High Reliability Healthcare Organization

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