New research highlights problem of substance use and rehospitalizations

Utilization is high among users

Researchers have found that patients who are diagnosed with a substance use disorder are about twice as likely to be readmitted to the hospital as patients without this diagnosis. These findings suggest that hospitals could intervene with substance use screening and programs designed to reduce subsequent hospital utilization.1

"This paper shows that those who have substance use disorders are more likely to be readmitted to the hospital within 30 days," says Brian Jack, MD, professor and vice chair in the department of family medicine at Boston University School of Medicine/Boston Medical Center in Boston. Jack is the principal investigator for the Project RED – Re-Engineered Discharge program.

"Reducing readmissions is a very high priority across the country," Jack says. "The amount of money that can be saved by reducing readmissions from Medicare is in the tens of billions of dollars, and there’s a lot of interest in finding ways to do that."

The study finding a connection between substance use and readmissions is a secondary analysis, conducted on top of a Project RED study, says Alexander Walley, MD, MSc, assistant professor of medicine at the Boston University School of Medicine.

The original study, published two years ago, showed that a Project RED package of services reduced rehospitalization at 30 days, he notes.

"What we did was take the sample of general medical service patients from that study and reanalyzed data to see what the rehospitalization rates were for patients who had a substance use disorder diagnosis at discharge," Walley says. "What we saw was that patients who did have a substance use disorder diagnosis were rehospitalized more often and were more likely to be rehospitalized."

The study controlled for other factors that can make someone at high risk of rehospitalization, including depressive symptoms, age, lack of insurance, and comorbidities, Walley says.

Their acute care utilization, which also included emergency department visits, was higher than the acute care utilization of patients who did not have the substance use disorder diagnosis, he adds.

The new study also found that 17% of the patients had a substance use disorder diagnosis.

Substance use disorder diagnoses were based on discharge codes, and it’s likely a portion of potential diagnoses were missed, he adds.

The 17% finding would suggest that close to one out of five patients likely have a substance use problem, says Steven M. Vincent, PhD, LP, Care Center director, behavioral health services at St. Cloud Hospital of St. Cloud, MN. The hospital is part of the CentraCare Health System.

"Anytime we’re dealing with a health care concern that might impact one out of five inpatients deserves attention," Vincent says. "What we’ve done in our own hospital on this topic is use a set of protocols to observe for signs of alcohol or drug abuse and the potential for withdrawal [symptoms]."

Substance use is the latest in a series of identified risk factors for hospital readmission, Jack notes.

It joins the more commonly known risk factors of low health literacy, long lengths of stay (LOS), having comorbidities, and being older.

"Other papers we’ve published show that people who have depressive symptoms are more likely to be readmitted within 30 days," Jack says. "Also, patients who have a low score on the patient activation measure, which is a measure of their motivation and ability to influence their care, are more likely to be readmitted."

Screening tools

Patients at very high risk of readmission need some kind of intervention designed to follow them in the days after hospitalization to help them stay on track with their health, he says.

"It would be very helpful to have risk prediction scores to identify who those people are," Jack says.

High risk screening tools can help identify substance use problems, as well as other issues that could lead to hospital readmissions, says Tom Sedgwick, LCSW, CCM, director of social work at New York University Langone Medical Center in New York City.

"We screen patients within the first 24 hours to see whether or not they need further social work services," Sedgwick says. "We do a full psychosocial assessment, and the social worker could pick up on substance use problems during the assessment."

Patients’ medical histories also can provide clues about substance use and readmission risk.

"We look at previous medical records to see what the patient was here for and whether there are any patterns," Sedgwick says.

At St. Cloud Hospital, a patient’s medical history of substance use would suggest a need for an intervention to prevent readmissions, Vincent says.

"If they don’t have known history of substance use, then we inquire about the volume and frequency of alcohol use or use of other drugs," he adds.

Patients’ answers might trigger a request for a consultation with a mental health and substance use case manager.

"We have a specific case manager in our hospital whose area of expertise and scope of responsibility are patients with psychiatric and substance use disorders," Vincent says. "The real emphasis is on substance use and potential for withdrawal."

Substance use can affect patients’ overall health, undoing any medical stabilization the patient gained while hospitalized, Sedgwick says.

"They’ll come back to us if they go home and are drinking and fall or are not compliant with their treatment regiment," he says.

Integration of care is very important for these patients, says Mirean Coleman, MSW, LICSW, CT, senior practice associate with the National Association of Social Workers in Washington, DC.

"If a patient has a substance use problem upon discharge then they should be integrated into the community," Coleman says. "Make sure the patient receives a referral before leaving the hospital, and, if possible, have them make an appointment to see a doctor so there is some continuity of care."

When patients with substance use problems are repeatedly admitted to the hospital, it also might be a worthwhile investment to place them on a case management program in which they could be followed by a case manager, Walley suggests.

"It would be worth the investment of resources to have a case manager who can get to know the patient and work specifically on preventing future hospitalizations," he adds. "A lot of times the person’s substance use interrupts the normal process of people getting their basic needs met, such as housing, food, and going to medical care appointments."

This interruption leads to patients who fail to address their chronic health problems, and it leads to acute episodes that send the patient back to the hospital, he explains.
"Not everyone who comes in one time with a drug or alcohol problem needs to have a case manager, but for those who are readmitted, it might be worth the cost," Walley says.

More hospitals will reach this conclusion once the Medicare financial disincentive for 30-day readmissions is fully implemented, he adds.

Reference

1. Walley AY, Paasche-Orlow M, Lee EC, et al. Acute care hospitalization utilization among medical inpatients discharged with a substance use disorder diagnosis. J Addict Med. 2011. Oct. 4[Epub ahead of print].