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Hospitals Financially Penalized for Readmissions Outside Their Control

CHICAGO – Penalizing hospitals for patient readmissions following surgery appears to be ineffective, and possibly even counterproductive, for improving the quality of hospital care in America.

The reason? Most surgical readmissions are not due to poor care coordination or mismanagement of known issues, according to a new study. Researchers instead found that more than 97% of the time readmissions were due to expected surgical complications, such as wound infections, that occurred after discharge and were not present during a patient's hospital stay.

The report from the American College of Surgeons and Northwestern University was published recently in the Journal of the American Medical Association.

"There has been a growing focus on reducing hospital readmissions from policymakers in recent years, including readmissions after surgery," said co-author Karl Y. Bilimoria, MD, MS, a surgical oncologist and vice chair for quality at Northwestern Memorial Hospital. “But before this study, we didn't really understand the underlying reasons why patients were being readmitted to hospitals following surgery."

Not only does CMS publicly report a hospital's rate of unplanned readmissions, including surgical patients, it also reduces reimbursements if a hospital has too many readmissions within 30 days post-discharge for certain types of care, such as total hip and knee replacement surgery.

The Readmissions Reduction Program, put into effect in 2012 as part of the Affordable Care Act, initially only focused on readmissions for heart attack, heart failure and pneumonia but more recently added surgical categories. The study authors note that other surgery types will be incorporated into the program in the near future.

To gain a better understanding of postoperative readmissions, researchers collected data from the American College of Surgeons' National Surgical Quality Improvement Program from 346 U.S. hospitals for 2012. Data on 498,975 separate patient cases included the underlying reason for why the readmission occurred based on the medical record, discussions with treating doctors, and the patients themselves – information not available elsewhere.

The six procedures reviewed were:

  • Bariatric surgery,
  • Colectomy or proctectomy,
  • Hysterectomy,
  • Total hip or knee replacement,
  • Ventral hernia repair, and
  • Lower extremity vascular bypass.

Results indicate that 5.7% of the patient cases had unplanned readmissions, but only 2.3% were readmitted due to a complication that occurred during their initial stay in the hospital.

"These results clearly demonstrate that the vast majority of complications that cause readmissions are not due to a lack of coordination or complications that occurred during the initial hospitalizations," Bilimoria said. "These complications were new and occurred after the patients were discharged and were recovering at home."

The most common cause for unplanned readmissions was surgical-site infections at 19.5%, followed by delayed return of bowel function with an overall rate of 10.3%.

"Our results also highlighted that many of the complications involved in readmissions, such as surgical-site infections, are already well-know and part of other CMS pay-for-performance programs, which means hospitals are effectively being penalized twice for the same complications," Bilimoria noted.

Just focusing on complication rates after discharge is counter-productive, the authors write, adding, “Readmissions after surgery may not be an appropriate measure for pay-for-performance programs but rather better suited as measure for hospitals to track internally.”



Study Questions Practice of Giving IV Fluids to Heart Failure Patients

NEW HAVEN, CT – More than one in 10 patients with severe heart failure were given intravenous fluids in combination to diuretics during their first two days of hospitalization, according to a new study that linked the practice with adverse outcomes.

The observational study, published in the Journal of the American College of Cardiology: Heart Failure, says it is the first to examine use of common IV fluids in hospitalized heart failure patients.

Diuretics are commonly used in heart failure to avoid excess fluid buildup and to improve symptoms. Noting that many inpatients also receive IV fluids during early care in hospitals, Yale University researchers sought to determine the effect of the practice.

The study involved data from more than 130,000 hospitalizations of patients with decompensated heart failure who received IV fluids during the first two days. Results indicate that 11% of the patients were treated with IV fluids in addition to diuretics.

"It was given to over 10% of heart failure patients, which to us is a big number," said first author Behnood Bikdeli, MD, internal medicine resident at Yale School of Medicine and a research scholar at Yale Center for Outcomes Research and Evaluation. The percentage represents a lot of patients, Bikdeli points out, because about 5 million people in the United States have a diagnosis of heart failure.

After receiving both therapies, patients were more likely to suffer adverse consequences, such as higher rates of critical care admission (5.7% vs. 3.8%), intubation (1.4% vs. 1.0%), renal replacement therapy (0.6% vs. 0.3%), and hospital death (3.3% vs. 1.8%) compared with those who received only diuretics.

The study was unable to clearly link the negative outcomes to the use of IV fluids but suggests that further investigation is warranted.

"It's counterintuitive. Although we have several potential explanations in mind, use of fluids may have led to worse outcomes," Bikdeli said.

The retrospective review also found widespread differences in the type and amount of IV fluids given to hospitalized heart failure patients. The median volume of administered fluid was 1,000 ml, and the most commonly used fluids were normal saline (80%) and half-normal saline (12%).

"Our findings are surprising and provocative," Bikdeli added. "We need to better understand who these patients are, why they received intravenous fluids, and whether use of intravenous fluids was the cause of their worse outcomes. In the interim, it would be helpful for hospital administrators to promote policies that help reduce inadvertent use of intravenous fluids for patients with heart failure."


Older Americans with Flu Have Highest Hospitalization Rate in a Decade

EDM for ED pushATLANTA – If your hospital is deluged with influenza patients, here’s why: At the beginning of February, the flu-associated hospitalization rate among Americans 65 and older was the highest rate recorded since the CDC began tracking the data a decade ago.

Overall, flu remains widespread across most of the country and severity indicators are still high, according to a recent FluView report from the CDC.

With flu activity elevated for 11 consecutive weeks nationally, it is expected to continue for several more weeks, especially in parts of the country where flu cases showed up later. An average flu season lasts about 13 weeks – with a range of one week to 19 weeks for the past 13 seasons – but this season started relatively early and is expected to last longer than average.

The good news is that influenza-like-illness levels are declining slowly nationally. At a regional level, some parts of the country are enjoying declines in activity while others report increases.

One of the reasons for the high hospitalization rate is that older Americans have been hit hard by H3N2 flu viruses that continue to predominate across the country. Because of a shift after the vaccine components were chosen, those viruses are a mismatch to this season’s flu shot.

Nearly 60% of flu-associated hospitalizations are among people 65 years and older, representing more than 92,000 patients. The vast majority of patients hospitalized for the flu, nearly 94%, have had at least one reported underlying medical condition. Most common have been heart disease, metabolic disorders including diabetes, and obesity.

The second-highest hospitalization rates have been in children 4 years old and younger. Children, like older people, often are hardest hit during H3N2-predominant seasons but their hospitalization rate is in line with 2012-13, the last H3N2-predominant season.

This season's vaccine reduces the risk of having to seek medical help from flu infection in vaccinated people by 23%, which is about half of what is usually seen when vaccine viruses and circulating flu viruses are well-matched.


Non-pharmaceutical Techniques Can Decrease Delirium, Associated Problems

BOSTON – As complicated as hospital care for an older patient can be, delirium multiples the difficulties many times over.

A sudden onset of confusion, which frequently is seen in older patients, increases the risk of falls, often leads to lengthy hospital stays and can contribute to more than over $164 billion in healthcare costs, according to a study published recently in JAMA Internal Medicine.

A study team from Brigham and Women’s Hospital and Hebrew SeniorLife’s Institute for Aging Research, suggest that delirium is preventable and that non-medication strategies can reduce risk and improve outcomes.

To reach those results, researchers conducted a meta-analysis of 14 studies involving multi-component non-pharmacologic interventions for delirium.

"Delirium is a major problem at many hospitals and preventing its downstream consequences, including falls, is a priority,” said lead author Tammy Hshieh, MD. “Delirium can be the source of anxiety for many patients and their families and often they wish that there was a pill that would make the patient’s symptoms go away. Our study demonstrates that there are effective strategies for preventing delirium and treating patients that don’t rely on medications.”

Six interventions that targeted delirium risk factors, guided by principles derived from the original delirium prevention study, the Hospital Elder Life Program, were reviewed.

Interventions included strategies:

  • To improve patients’ nutrition and hydration;
  • To ensure uninterrupted sleep;
  • To make available daily exercise and therapeutic activities to improve cognition; and
  • To introduce “re-orientation” techniques such as telling patients where they are and the date and time every day.

The studies were conducted at 12 hospital sites from all over the world.

“These preventive approaches provide evidence-based models to improve processes of care for older hospitalized persons,” explained senior author Sharon K. Inouye, MD, MPH. “The fact that these approaches are so effective for prevention of delirium, falls and institutionalization provides strong support for their importance in the setting of accountable, cost-effective care. We hope this study will bring to attention these important models for hospital administrators and policymakers.”

Older patients who received non-medication based interventions were at decreased risk of both delirium and falls, according to study results. The authors also say they found trends toward decreased length of hospital stay and institutionalization. Based on their results, they estimate that, each year, about 1 million cases of delirium could be prevented using non-medication based interventions, resulting in a Medicare cost savings of $10 billion per year.

The report notes that 29-64% of hospitalized elderly patients suffer from delirium, with the wide range and under-diagnosis explained by its confusing presentation. Patients can exhibit anything from agitation to confusion or just be non-responsive.

“Multicomponent non-pharmacological delirium prevention interventions are effective in reducing delirium incidence and preventing falls, with a trend toward decreasing length of stay and avoiding institutionalization,” the authors conclude. “Given the current focus on prevention of hospital-based complications and improved cost-effectiveness of care, this meta-analysis supports the use of these interventions to advance acute care for older persons.”