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Reader Remarks on:

Medicare Bounce-Back Hospital Admissions

• bounce backs
• DRG impacts - ''Discharge quicker and sicker''
• what do you expect?
• oh wow, now it's my fault that they don't follow-up
• Fall related readmissions
• Homecare
• Readmission rates related to underdiagnosed geriatric syndromes
• hospital to nursing home
• Remark from Journal Watch editor Allan Brett

bounce backs

Thomas D. Franklin, retired orthopedist, Palo Alto, 1 Apr 2009 11:28 PM EST

Competing interests: None declared

Another factor in the bounce backs is probably too early discharges. There is a tremendous amount of pressure to get the patients out the door. A more comploete predischarge mandatory checklist is a good idea.

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DRG impacts - ''Discharge quicker and sicker''

R.D. Bartucci, 2 Apr 2009 2:07 AM EST

Competing interests: None declared

Like any other physician familiar with the impact of the diagnosis- related groups (DRG) reimbursement paradigm upon hospital care for Medicare clients, I'm very interested in learning to what extent these high rates of unplanned readmission - and the costs associated therewith - are due to pressure upon attending physicians to get these patients discharged "quicker and sicker."

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what do you expect?

emanuel goldberg, 2 Apr 2009 10:51 AM EST

Competing interests: None declared

the hospitals are now rewarded for earlier discharge. although failure of followup may be a problem it is also clear that premiums for early discharged based on arbitrary guidelines for what is a reasonable time to keep a person in the hospital will inevitably lead to early readmission. I was offerred a premium as were all attending physicians as part of a medicare program to facilitate early discharge by sharing in the "savings"i refused having seen several of my patients prematurely discharged and requiring re-admission.

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oh wow, now it's my fault that they don't follow-up

C. A. Evans, outpatient office, 3 Apr 2009 6:36 AM EST

Competing interests: None declared

I know that they patients here are advised to see me, and even have appts. made for them with me, by the hospitalists. I am NOT capable of FORCING them to show up. The hospitalist is not capable of that either. When is someone going to take notice that the patient and/or their family has some large part in the ongoing problem?????

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Fall related readmissions

Colleen M Campbell, Public Health, 3 Apr 2009 10:20 AM EST

Competing interests: None declared

I'm curious to know if anyone has data on readmissions of older adult patients who were originally seen in and discharged from the ED after a fall.

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Homecare

Anita M Brown, 7 Apr 2009 1:41 PM EST

Competing interests: None declared

It would seem that providing more patients with after care in the home could prevent some of these readmissions. Unfortunately, some insurance companies are cutting home care benefits. The cost savings should be apparent. It has been demonstrated that end-of-the-week discharges from acute care feel abandoned and have a higher incidence of readmission.

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Readmission rates related to underdiagnosed geriatric syndromes

Kayla I Brodkin, 7 Apr 2009 3:38 PM EST

Competing interests: None declared

Often geriatric syndromes including falls, delirium and adverse drug effects remain undetected during hospitalizations. It is not until a patient is discharged home to the demands of resuming pre-hospital self- care that the inadequacy of disposition planning is identified. In addition to potential unidentified acquired functional deficits predisposing an elderly or chroncally ill individual to falling, I suspect the high rate (24.6%) of 'psychosis' responsible for <30 d readmission rate may reflect undiagnosed/untreated delirium from the index hospital stay. More involvement of geriatricians and multidisciplinary care teams to the care and disposition of elderly may impact readmission rates for this cohort of vulnerable individuals.

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hospital to nursing home

Julie E. Yoon, Geriatrics, St John's Home, 11 Apr 2009 4:14 PM EST

Competing interests: None declared

Even with close MD follow-up as with hospital-to-rehab or hospital-to -nursing home transfers, there are still a fair number of bounce-backs. I share others' feelings that it has a lot to do with pressure to discharge and poor transmission of pertinant data. Upon arrival of patients to our facility, I am indundated with xeroxed chart notes of little relevance and a very shoddy d/c summary. Medication errors are very common.

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Remark from Journal Watch editor Allan Brett

Allan S Brett, University of South Carolina, 22 Apr 2009 12:17 AM EST

Competing interests: None declared

Many readers commented on the possibility that too-early discharge from the hospital is a major cause of bounce-back admissions. I went to the original article to see whether it included any data on this matter. Table 3 shows that people whose index hospitalization was short (less than half the DRG expected length-of-stay [LOS]) actually had a lower rate of bounce-back hospitalization, and those whose index hospitalization was long (more than twice the DRG expected LOS) actually had higher rehospitalization rates. At first glance, these figures seem diametrically opposed to the idea that too-early discharges are a major cause of readmission. But on further thought, I’ll bet these figures aren’t very helpful, for the following reason: An extremely short LOS -- less than half the DRG expectation -- is probably a marker for a less-sick patient. And a very long LOS -- more than twice the DRG expectation -- is probably a marker for sicker patients. What we really need to know is individual patient-level data on whether patients are clinically stable on the day they’re discharged. The Medicare database that was the source of the New England Journal study doesn’t provide this information.

I just saw another study that sheds some light on this topic (see Palacio C, et al. A comparative study of unscheduled hospital readmissions in a resident-staffed teaching service and a hospitalist-based service. Southern Medical Journal 2009;102:145-149). In this study from a large urban teaching hospital, the probability of readmission decreased significantly as LOS increased. This observation doesn’t prove cause-and- effect, but it supports readers who believe that too-early discharge is one cause of bounce-back admissions.

Allan Brett, MD, Editor-in-Chief, Journal Watch General Medicine

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