Initial research on outcomes following Project BOOST (Better Outcomes for Older Adults through Safe Transitions) implementation shows modest improvement in rehospitalization rates. Moreover, some experts suggest the real problem might lie in using 30-day hospital readmissions, now a target for Medicare reimbursement penalties, as the quality metric for care transitions out of the hospital.
Study data showed a 2% absolute reduction in all-patient, 30-day readmission rates at 11 of the original 30 BOOST sites (to 12.7% from 14.7%), according to an article in the August issue of the Journal of Hospital Medicine.1
“Everybody has talked about readmissions as the quality target, but really it should be about improving transitions of care for the patient going home,” says Ashish Jha, MD, MPH, of the Harvard School of Public Health, Health Policy and Management. “If we’re going to use readmissions as our quality measure, maybe we’re set up to fail. Can we do care transitions better? Yes, we can. Can we do better quality measures? Yes. My take-home message is that we should get clearer on what we are trying to achieve.”
Project BOOST (www.hospitalmedicine.org/boost) has been a major quality initiative for SHM since 2008 and one of several national programs aimed at helping hospitals improve care-transitions processes and patient outcomes. BOOST offers participating sites an online toolkit of strategies and interventions, along with the support of an expert mentor.
“Participation in Project BOOST appeared to be associated with a decrease in readmission rates,” the authors conclude. But two accompanying editorials in the journal expressed disappointment with a lack of “robustness” to these results and lack of participation by BOOST sites.2,3 The editorials also acknowledge the challenges of multisite, voluntary research on a topic that, so far, has largely resisted validated, generalizable research outcomes demonstrating what really works in preventing readmissions.
“I think people want a silver bullet on this issue,” says lead author Luke Hansen, MD, MHS, of the division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago. “They want to be able to define an intervention to take care of all of the avoidable fraction of rehospitalizations. But I don’t think that’s possible. The disappointment may come from the fact that this is a more complicated issue than we thought.”
Dr. Hansen says data reporting was voluntary and uncompensated, and the BOOST research team is trying to facilitate better reporting from subsequent cohorts. He says one of BOOST’s unique aspects—tailoring interventions to local circumstances—could be a drawback to outcomes research. “We have to incorporate the diversity of experience into our research methods and our expectations,” he says.
Hospitalist Bradley Flansbaum, DO, MPH, FACP, SFHM, of Lenox Hill Hospital in New York City says BOOST reinforces many of things hospitalists should be doing to provide optimal discharges and transitions
—Ashish Jha, MD, MPH, Harvard School of Public Health, Health Policy, and Management, Boston
“Like appropriate teaching and patient education, medication reconciliation, and setting up follow-up appointments,” says Dr. Flansbaum, a member of SHM’s Public Policy Committee and regular contributor to SHM’s Practice Management blog. “But if there was one thing I’d like hospitalists to take home from this research, it’s the cognitive dissonance—the challenge of matching the evidence with what the regulatory bodies expect from us and knowing that the evidence is falling short.
“As much as we might be held accountable for outcomes like readmissions, the reality is that we can’t control them. What we’re learning is that this is really hard to do.”
Amy Boutwell, MD, MPP, a hospitalist in Newton, Mass., and founder of Collaborative Healthcare Strategies, agrees transitions of care are difficult. However, she also thinks hospitals and hospitalists cannot wait for conclusive research that proves what works in preventing readmissions.
“The BOOST results reflect my own experience working with more than a hundred STAAR [State Action on Avoidable Readmissions] hospitals. We haven’t yet been able to sufficiently extract the data about readmissions from the field—and we need to figure out how to do that,” she says. “But when you look at the issue from a patient’s perspective and their desire for a safe transition, why would you not do the things recommended by Project BOOST and similar initiatives?”
Primary-care physicians (PCPs) need to know about major changes in a discharged patient’s plan of care in a timely manner, along with any results from pending lab tests, Dr. Boutwell explains. She emphasizes that patients and their caregivers need to be given clear discharge instructions when they leave the hospital.
“We have an obligation to do what we know to be best practices and standards of care. The BOOST toolkit of recommendations is very comprehensive and gives hospitals a lot of options to improve their internal processes,” Dr. Boutwell says. “It’s hard to argue against any of them, even if it’s hard to draw clear links between them and readmissions rates. These are the self-evident, basic tasks that I would want done for myself or my child or my parent, if we were in the hospital.”
Larry Beresford is a freelance writer in San Francisco.
- Hansen L, Greenwald J, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. doi: 10.1002/jhm.2054. Epub 2013 Jul 22.
- Auerbach A, Fang M, Glasheen J, Brotman D, O’Leary KJ, Horwitz LJ. BOOST: Evidence needing a lift. J Hosp Med. 2013;8(8):468-469. doi: 10.1002/jhm.2065. Epub 2013 Jul 22.
- Jha A. BOOST and readmissions: Thinking beyond the walls of the hospital. J Hosp Med. 2013;8(8):470-471. doi: 10.1002/jhm.2069. Epub 2013 Jul 22.