Yale GHLI Study Examines Hospital Readmissions Rates

View inside of an operating room
Doug Desjardins

Hospitals are doing a better job implementing best practices to reduce 30-day readmission rates for cardiac patients, but even “the best-of-the-best” are still falling short in other key areas, Yale researchers find.

A study from researchers at Yale University found that hospitals taking part in a national program to reduce preventable 30-day readmissions for cardiac patients are taking a more pro-active approach to following protocols designed to reduce readmissions.

And though the results of the follow-up study showed “statistically significant changes of substantial magnitude in several specific strategies,” it also showed there was “no significant change” in a number of key areas including collaboration with a patient’s primary care physician after they’ve been discharged.

The study, titled “Contemporary Data about Hospital Strategies for Reducing Unplanned Readmissions: What has Changed?” and published in the October issue of JAMA Internal Medicine, revisited a 2012 Yale University survey of 537 U.S. hospitals taking part in the national Hospital to Home (H2H) Quality Improvement Program to reduce 30-day readmissions for patients with heart failure and acute myocardial infraction (AMI).

The H2H initiative establishes 10 best practices hospitals should follow to reduce readmissions. The 2012 study found that, on average, hospitals surveyed were using only 4.8 of the best practices at all times and that only 3% were using all 10 practices.

Shortfalls Among Best-of-the-Best
“It was surprising because many of these hospitals are part of large health systems, considered to be among the best-of-the-best, who signed up for this program,” said Leslie Curry, a senior research scientist with Yale University and one of the authors of both studies.

The 10 recommended practices in the H2H program are

  1. Having a quality improvement team dedicated to reducing readmissions for heart failure and AMI patients
  2. Monitoring the percentage of patients with follow-up appointments within seven days of discharge
  3. Monitoring 30-day readmission rates
  4. Providing patients with medication management instructions
  5. Having a pharmacist available to patients for medication management questions upon discharge
  6. Having a pharmacy technician compile a patient’s medication history
  7. Providing patients and caregivers with an emergency care plan
  8. Arranging a follow-up appointment for patients before they are discharged
  9. Alerting a patient’s primary care physician within 48 hours of their discharge
  10. Contacting patients after discharge to answer any follow-up questions

Most of the shortfalls identified in the 2012 study were in the post-discharge area of care. The study found that only 22.9% of hospitals had partnered with local hospitals to manage patients at a high risk of readmission.

It also found that patient discharge summaries were sent to the patient’s primary care physician only 23.5% of the time and that only 32.1% of hospitals reported conducting follow-up reviews to ensure that patients saw their primary care physicians within seven days of being discharged.

Better Followup Seen
In the follow-up study, 437 hospitals who responded showed marked improvement in several areas. It showed that 30.7% of hospitals were partnering with other hospitals to reduce readmissions compared to 22.9% in 2012 and that 61.1% of hospitals scheduled follow-up appointments for patients before they were discharged compared to 52.4% in 2012. 

The new study also found that more hospitals had adopted a formal procedure for assessing a patient’s risk of being readmitted (34.6% vs. 22.5%) and that more hospitals were providing post-care action plans for patients upon discharge (60% vs. 52.2%) and calling patients after discharge to follow-up on their care plans (71.4% vs. 62.9%).

Curry said the improvements show that hospitals are getting better at following patients once they leave the hospital.

“The care transition process is extremely complex because there are so many inherent vulnerabilities,” said Curry. “Even if you conduct a thorough review when a patient is discharged and do everything correctly, you can never fully anticipate the problems patients can encounter once they leave the four walls of the hospital.”

Little Improvement in Collaboration
The study also showed that hospitals made little or no improvement in several key areas. For example, it found that only 77.4% of hospitals provided patients with a full review of their medications and how to take them upon discharge compared to 78% in 2012 and that only 36.6% of hospitals had a process in place to ensure that a patient’s primary care physician was notified within 48 hours of their discharge compared to 38% in 2012.

“Collaboration between hospitals and caregivers in the local community is critically important because, often times, people don’t have the support outside the hospital to ensure they take their medications as prescribed or make it to a follow-up appointment,” said Curry. She added that “with the emergence of ACOs, we may start seeing new models of care that create a more comprehensive approach.”

On average, the study estimates that 25% of heart failure patients are readmitted to the hospital within 30 days of discharge and nearly 20% of AMI patients return within 30 days, readmissions that cost Medicare an estimated $17 billion in additional healthcare costs each year.

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