Hospitalists have been paying close attention to 30-day readmission figures since public reporting and payment programs embraced that number as an indicator of the quality of hospital care. But there is limited evidence to demonstrate 30-day readmission is really a meaningful interval of time, according to a recent study, “Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators of Quality of Care.”
“I began to dig through the literature to find some sort of evidence to support this figure – I couldn’t find anything. In talking with quality experts, they all, more or less, believe that things that happen outside of 7 or 10 days are really out of the control of the clinician,” says lead author David L. Chin, PhD, of the Center for Healthcare Policy and Research at the University of California, Davis.
Dr. Chin and his team examined the 30-day risk of unplanned inpatient readmission at the hospital level for Medicare patients aged 65 and older in four states and for three conditions: acute myocardial infarction, heart failure, and pneumonia. Across states and diagnoses, the hospital-level quality signal captured in readmission risk was highest on the first day after discharge, and it declined quickly to its lowest level at day 7.
“The rapid decay in the quality signal suggests that most readmissions after the seventh-day postdischarge were explained by community- and household-level factors beyond hospitals’ control,” the authors concluded.
Dr. Chin said the study results show the 30-day measure is “a blunt instrument.”
“It isn’t really measuring anything that we’re supposed to be measuring,” he explains. “Essentially, 97% of the reasons a person comes back to the hospital is due to some other, non-hospital thing.”
He does not advocate for 7 days as the new standard, however.
“This is more intended to be a message that this is really not the right way of approaching [readmissions] to begin with,” he says. “I think we convincingly showed that it shouldn’t be 30 days, but we don’t really have a very good picture of what is driving readmission. Hospitals are getting dinged on these things that have happened that, really, they don’t have direct influence on.”
1. Chin DL, Bang H, Manickam RN, Romano PS. Rethinking thirty-day hospital readmissions: shorter intervals might be better indicators of quality of care. Health Aff (Millwood)..
Quality Improvement: Overuse as medical error
Hospitalists may recognize a culture of overuse at their hospitals, but how can they address it? That’s the question behind an HM16 abstract, “Occam’s Conference: Overuse as a Medical Error.”
“We wanted to change the culture of overuse here among the hospitalists and the house staff,” said lead author Hyung Cho, MD, director of quality and patient safety at the Icahn School of Medicine at Mount Sinai in New York City. “We wanted to frame it in a way that people can recognize and feel free to talk about and also give it the weight that it deserves. It’s a common thing that we all do: the chest x-ray or the EKG before a surgery, things like that.”
Seeing overuse as a medical error is a place to start.
“A framework in which overuse is considered a medical error would facilitate understanding of the drivers of overuse and systems factors that lead to it,” the authors wrote.
Dr. Cho and colleagues chose a monthly inpatient conference format, with all the relevant players gathered together.
“We also wanted to use the formula that Brandon Combs had with the ‘Do No Harm’ project, which is taking cases of overuse that actually lead to harm or a near miss. I think people respond to that as opposed to just talking about the cost, which people have a hard time actually figuring out,” Dr. Cho said.
The resulting Occam’s Conference provides a process to identify and discuss overuse as a medical error. It uses a fish-bone diagram to help analyze each case.
“That conversation needs to happen,” Dr. Cho said. “You realize that people are all on the same page, and if they’re not, they need to get on the same page and have an open dialogue.”
1. Cho HJ, Lutz C, Truong TTN, et al. Occam’s Conference: overuse as a medical error [abstract]..
Practice Management: There’s an app for … end-of-life communications
Hospitalists wanting to help patients navigate end-of-life decisions or assist bereaved families in dealing with the death of a loved one have some new tools, according to The New York Times article, “Start-Ups for the End of Life.”
A start-up called Grace is intended to help its users deal with the myriad issues family members face after a death; it connects users with estate lawyers, financial planners, funeral homes, and caterers. Grace customers receive a list of tasks to complete before and after a death, and it includes relevant paperwork. The app also has staff ready to assist customers.
Currently, there’s little guidance available in this area, Alex Kruger, Grace’s cofounder and chief executive, and a licensed funeral director, told the New York Times: “At Grace we say, ‘Here are the 17 things you need to do this week’ and you can check them off as you do them. Here’s what you do the week before someone dies, when they die and then two weeks later.”
Another start-up mentioned in the article that could be relevant to hospitalists and their patients is called Parting. It provides an online directory of funeral homes searchable by ZIP code so users can quickly compare prices, services, and locations.
1. Zimmerman E. “New York Times, Nov. 22, 2016.
Quality Improvement: How to create a high-value culture
Hospitalists today are overseeing the health system’s movement toward an emphasis on value over volume.
“As leaders begin to strategize the best ways to spur transformation, our team realized that checklists and algorithms alone would likely not be enough to create sustained change in divisions and practices across the country,” said Reshma Gupta, MD, MSHPM, of the Robert Wood Johnson Clinical Scholars Program in the department of medicine at the University of California, Los Angeles. She’s the lead author of the recent study, “Development of a High-Value Care Culture Survey: A Modified Delphi Process and Psychometric Evaluation.”“Patient safety culture surveys have previously been used to drive care improvements, but no comparable survey of high-value care culture currently exists,” the authors wrote. “We aimed to develop a High-Value Care Culture Survey (HVCCS) for use by health care leaders and training programs to target future improvements in value-based care.”
Researchers conducted a two-phase, national modified Delphi process among 28 physicians and nurse experts with diverse backgrounds. They then administered a cross-sectional survey at two large academic medical centers among 162 internal medicine residents and 91 hospitalists for psychometric evaluation.
Four factors emerged with strong reliability:
• Leadership and health system messaging.
• Data transparency and access.
• Comfort with cost conversations.
• Blame-free environment.
The HVCCS can assist hospitalists and administrators in identifying tangible areas to target, Dr. Gupta said. The instrument was found to have good reliability and appears to correlate with an important patient outcome metric: the Centers for Medicare & Medicaid Services value-based purchasing score that has determined hospital reimbursement in recent years.
Now that this instrument has been created, the next step is for hospitals to begin using it. Dr. Gupta recognizes hospital medicine already has been a national leader in efforts to promote value-based care.
“With hospitalists leading many operational or research efforts in this area,” she says, “it will be vital to measure and address culture change. We believe this tool can aid them in their efforts to shape the story of value promotion at their institutions.”
Gupta R, Moriates C, Harrison JD, et al. Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation [published online ahead of print Oct. 26, 2016]. BMJ Qual Saf. doi:.
Quick Byte: Cleaning robotic surgical instruments
Robotic surgical instruments can retain some contamination even after cleaning, a new study suggests. Over 21 months, the researchers assessed protein residue on robotic and standard surgical instruments that were cleaned according to manufacturers’ instructions. The cleanings were 99.1% effective on the standard instruments but 97.6% effective on the robotic instruments, suggesting complete eradication of surface contaminants from robotic surgical instruments may not be possible with the current cleaning procedures.
1. Preidt R. “,” HealthDay News, Nov. 1, 2016.
Suzanne Bopp is a freelance writer in New Jersey.