A hospital readmission is a TACT that occurs when an Other Guy who has already gotten in-patient treatment in a hospital then has to return for more treatment, usually counted within 30 days, for problems related to the original treatment. Stated another way, the original problem did not get solved. If you take some time to search this literature you will find that in the US anywhere from 10-20% of Other Guys will get readmitted within 30 days. You can understand why everyone in this Local is motivated to understand readmissions. They cost more resource (time, money, space), put more pressure on crucial care facilities, and imply that the original treatment was done poorly. The interesting question with readmission is this: Can it be prevented? And, if it can, how?
Today we’ll look at an in-depth case analysis. This is not an experiment (Good grief, you cannot randomize Other Guys to good treatment and bad treatment and count readmission rates). The nature of the problem traps the kind of science you can do on it. But, keep in mind the method limitations anyway. Always look at method limitations. Always.
That noted, let’s begin.
An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors.
Blessedly, the researchers drew these 1000 readmissions within that academic network with random selection. Of course, we’re only looking at 12 academic med centers which are different from for-profit operations. And, it’s only 12 centers, not all academic centers. These 1000 Other Guys are different from people in other Locals. But, we’ve got a random sample from a well organized network that will provide reliable and valid data about these Other Guys. It’s a good starting point for a more detailed look at the factors that drive readmissions.
The case analysis is extremely detailed and I highly recommend that you read the paper if only to admire the intelligence and effort. Very briefly, data on each of the 1000 was generated through interviews, surveys, and medical records. This information was then analyzed by teams of physicians to classify each case, the factors behind the readmission, and resolving “close calls” through discussion. Again, please get the paper and read the method. This is extremely effective and sophisticated data collection. After all this, 2 physicians then read each case and made the final scoring on all elements related to the readmission. Their scores became the final database for statistical analysis.
[Survey Sidebar:] Look at this example of the survey that patients completed as part of the data collection.
Now. Think about each item, but applied to a different area like teaching or auto repair or home remodeling contractors. You could easily reword each item but directed toward students, car owners, or home owners. For me the items have a general validity of measuring key TACTs Other Guys should be hitting whether working with physicians, surgeons, coaches, mechanics, or carpenters. I like this survey for the generalizability. Anyone providing a service or product to Other Guys should be asking these questions and getting the correct answers.
[End of Survey Sidebar.]
Let’s count some change. Begin with the big count.
Of these, 269 (26.9%) were considered potentially preventable.
About 1 in 4 readmissions could have been avoided. The good news is that the large majority of readmissions just had to happen. The Other Guys were really sick, known complications did arise, life happened. This suggests that academic hospitals which often use less experienced and trained personnel are still doing a pretty good job. However. They are still letting 25% fail. Put that number in context.
Go back to my Survey Sidebar as we considered how the items for the hospital Local could be easily and validly reworded for the education Local or the repair Local. Imagine that you could prevent 25% of your “readmissions” if you had done the job right the first time. We have already seen that from 10-20% of cases will be readmitted and with this evidence we see that 25% could be prevented. That would bring the readmission rate down to 7-15% and that would be approaching the state of the art, the best we can do with what we know. While these numbers are smaller, we are dealing with a life and death Local where even a little means a lot.
So, we know that 25% of readmissions may be preventable. How could that happen?
In multivariable models, 4 factors were most strongly associated with potentially preventable readmissions. These included premature discharge from the index hospitalization (adjusted odds ratio [aOR], 3.88; 95% CI, 2.44-6.17), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17-8.09), lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39-10.64), and emergency department decision making to admit a patient who may not have required an inpatient stay (aOR, 9.13; 95% CI, 5.23-15.95).
First, look at the size of the Windowpanes as I’ve highlighted. A Large ratio is 4.25, Medium is 2.50, and Small is 1.50. These four factors just shout out their obviousness. Second, realize that these are adjusted ratios meaning that the researchers tried to find other variables that would (most likely) reduce the Windowpane. For example, older and sicker Other Guys are at much higher risk of readmission simply because their problem is likely to be more difficult. Even accounting for such obvious issues as age and severity of conditions, those Windowpane still open from Medium to Large. Third, realize communication and persuasion can make a difference: Failure to relay information between health care workers, lack of discussion with patient Other Guys, and premature release by hospital protocol.
Assuming these data generalize, we know at least four factors that are extremely obvious and controllable. And three of them are prime candidates for persuasion: Failure to relay information between health care workers and lack of discussion with patient Other Guys, and premature release by hospital protocol. And even that factor related to incorrect hospitalization from the ER strikes the researchers as persuasion and communication-related.
One key observation in our cohort related to improving decision making for patients arriving in the emergency department, a factor that represents not a shortcoming of emergency medicine or emergency departments, but a limitation of the health system itself. Overcoming gaps in care in the attempt to avoid potentially unnecessary admissions from the emergency department may need to involve improved communication among primary care health care professionals, hospital-based physicians, and emergency medicine physicians about criteria for admission and resources available in the community, in addition to providing greater access to urgent care for patients who would otherwise seek care in an emergency department and improving patients’ understanding of how and when to seek emergency care.
As we consider this paper, you see the persuasion possibilities in this Local. While the word, Communication, gets used or implied in the four factors, realize the issue is not simply the exchange of information. We’re talking about experienced professionals operating in their Local. These docs know what they are doing, what standards and practices apply, and they are not hitting that professional standard. Merely telling them in a basic sense of communication will make no difference. You need to persuade them.
Work from our continuing look at another common medical failure: Hand washing. We know that hospital infections would be a Top 10 killer if the CDC counted it as a category and we know that the infection rate drops to near zero if health care workers just wash their hands. They all know this, but the problem persists. When you put persuasion, rather than communication, on this TACT, you get more change.
I’d argue the same applies with the four factors in preventable readmissions. You don’t need a checklist or an email reminder. You need tactics like Skinner Boxes or Implementation Intentions. You need small scale campaigns. Think about each factor.
1. Failure to relay information between health care workers.
2. Lack of discussion with patient Other Guys.
3. Premature release by hospital protocol.
4. Incorrect routing from ER.
Now think about making TACTs out of these factors. Take the first one about Inter-Agency Coordination.
Who? You’ve got to identify all the workers who have contact with the patient Other Guy. You need to know their schedules, their protocols, their organization. You need to know how they are linked or not linked with each other.
What? Okay, you know Who, now What should each one be doing with each other? Share a checklist? Meet as a group and discuss? Ring a bell to signal a handoff? You need to identify for each Who the behavior needed to fulfill the task.
When and Where? Some of the Who’s and some of the What’s must vary in time and place. You’ve got to be flexible on some of the When and Where. But, sometimes you need all of the Who’s talking about all of the What’s in the same place and same time – a daily meeting one hour before a shift change, for example.
Just this sketch lets you know that the persuasion is more complicated than team members need better communication or somebody needs to talk with the patient before he leaves the hospital. This research describes the solutions in a general way. You must specify everything in TACTs.
Then you figure out the persuasion plays. Feedback. Comparison. Skinner Boxes with pleasure and pain. Implementation Intentions.
Last. If you do this, you must panther it. Park the Sincerity in garage. You are making the Other Guys change. Remember the Three Campaigns. Get the idiots out of the room or at least give them toys to play with. Think beyond the perimeter of good and evil and get creative. Then get ethical or legal or safe or whatever constrains you. Finally. Count the change.
Hey, the readmission you save could be your own!
Auerbach AD, Kripalani S, Vasilevskis EE, et al. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med. Published online March 07, 2016.
P.S. Come on. Please, please me like I please you! (YouTube)