Doctor Remodel


How often are patients in your program readmitted in 30 days to any hospital? I know many of you monitor readmission rates back to your own program or facility. But if you examine the patient perspective, how often are patients you discharge being readmitted to any acute care hospital within 30 days?

Given the increasing frequency that the Centers for Medicare and Medicaid Services (CMS) is reporting about readmission rates, I asked my quality director to research our hospital’s data.

As would any reasonable chief medical officer (CMO), I figured we probably had some opportunities for improvement, but overall I felt the numbers were probably fine. Like any hospital I have worked in, we have a core group of patients who return to the hospital frequently. But from a working hospitalist perspective, it didn’t seem to be a problem in our hospital.

So, when the data returned, our initial impressions about the rates were reaffirmed. The overall hospital 30-day readmit rate to our hospital was about 6%. We looked across different payers, socioeconomic groups, discharging services, and diagnosis for areas of opportunity. We found that two populations had slightly higher rates of readmission—congestive heart failure (CHF) and sickle-cell pain crisis—but in general, there were no particular outliers.

I admit from personal experience that the readmission number CMS touts has always boggled my mind to a degree. This means that almost one in five patients returns to a hospital within 30 days. Having worked in a variety of hospitals and communities, I couldn’t imagine a rate this high. I had never seen patients bouncing back that often.

I commissioned two quality improvement groups to begin looking at these areas, though I felt pretty good about our data. Although this was not a true all-facility, 30-day readmission rate, we felt it had to be a reasonable proxy for the true rate, which we could not obtain.

We looked to benchmark ourselves because we had no reference for comparison. CMS refers frequently to an approximate 20% readmission rate across the nation; we felt good because our rates were significantly lower. We did some like-facility comparisons, and our rate was still a little better than those facilities, so we continued to feel good.

For those of you who prefer more exact numbers, MedPac reported in June 2007 that 17.6% of admissions resulted in a readmission within 30 days, accounting for about $15 billion in Medicare spending. Further, 6% of admissions resulted in a seven-day readmission rate.

I admit from personal experience that the number CMS touts has always boggled my mind to a degree. This means that almost one in five patients returns to a hospital within 30 days. Having worked in a variety of hospitals and communities, I couldn’t imagine a rate this high. I had never seen patients bouncing back that often.

To me, this simply reaffirmed the hypothesis that healthcare has a serious problem with continuity of care and communication. But this was not my hospital’s problem—we were better than 20%! This was a problem for communities with a poor primary care base or perhaps a community without hospitalists to efficiently take care of inpatients.

But it turns out I fell into a classic leadership trap: thinking we are better than we really are.

Several months ago, I was sitting in a meeting with the quality and patient safety staff, when one of the outcomes managers passed a report to me from CMS. It was the “Pepper Report,” which CMS had begun sending to all hospitals in the past year. One of the key bits of data in this report is the hospital’s 30-day readmit rate. Because CMS is able to gather data from all facilities, this is the true readmit rate—at least for the Medicare population. Ours was approximately 17%. I was immediately deflated.

But like the optimistic person I am, I immediately saw a burning platform for change and began to plan our attack on this problem.

What is our chief tactic? A good discharge. I am convinced more than ever that we simply need to focus on a better discharge.

I am not alone in this thinking. Almost from the beginning of the hospitalist movement, we have focused on the “black hole,” that period of time from discharge to first followup appointment. Many of you who have come to SHM meetings have attended discharge planning and transitions of care sessions. We have worked closely with the Hartford Foundation in developing a good discharge for elderly patients. Part of this effort resulted in discharge checklist you will find on the SHM Web site ( The next version of this is Project BOOST (Better Outcomes for Older Adults through Safe Transitions), led by Mark V. Williams, MD, principal investigator on the project and professor and chief of the Division of Hospital Medicine at the Feinberg School of Medicine at Northwestern University in Chicago.

In early June, a group of SHM leaders visited with MedPac, which advises Congress on Medicare policy. MedPac is interested in recommendations to improve the readmission rates in the U.S. If the plea to simply provide good medical care doesn’t move you, I hope the CMS “incentives” will.

What You Can Do

Focus on the good discharge. Many tactics are intuitive. Ensure that a succinct yet complete discharge summary is sent to the next physician in a timely manner. Clearly articulate a treatment plan not only immediately after discharge but for the next several months in general. Be sure to list all test results, their interpretation, and any pending at the time of discharge. Reconcile all medications from the admission list. Teach patients and families about the illness and what to do in certain circumstances.

These are just a few of the things to do. I am sure we will discover more or refine those we know. But by simply focusing on a good discharge, your program and hospital will be in good shape for the coming scrutiny. TH

Dr. Cawley is president of SHM.

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