As a way to contain health care costs and improve patient care, the Centers for Medicare and Medicaid Services (CMS) is proposing that patients receive specific follow-up appointments when discharged from hospitals, which should, in theory, prevent costly readmissions. Some studies have shown that this strategy reduces hospital readmission rates in patients with heart failure and in psychiatric patients. In a new study conducted at the Mayo Clinic hospitals, however, follow-up appointments for general internal medicine patients didn't improve readmission rates, ED visits, or survival.

The researchers analyzed hospital dismissal instructions for 4,989 general medicine patients released in 2006, and 3,037 (61%) contained instructions for follow-up appointments. Thirty days after discharge, hospital-readmission, ED-visit, and mortality rates in patients with documented follow-up appointments didn't differ from rates in patients not given appointments. At 180 days after discharge, those with documented follow-up appointments were more likely to have been readmitted to the hospital or have visited an ED. And only 39% of readmissions and 35% of ED visits were related to the previous hospital stay, a surprise finding that throws into question the idea of using readmissions as a quality indicator.

The Mayo Clinic researchers had hypothesized that general internal medicine patients would benefit from receiving specific instructions about hospital follow-up appointments. Instead, they found that follow-up instructions slightly raised the likelihood of readmission or an ED visit, suggesting that some initiatives aimed at reducing hospital readmissions may not achieve desired outcomes.

Those hospital readmissions that are purportedly avoidable cost Medicare an estimated $12 billion annually, and the CMS is considering lowering payments to hospitals for readmissions. "Before health care payers consider reducing payments for hospital readmissions, more research is needed to identify avoidable readmissions," the Mayo team writes. They also urge health care payers to "exercise caution when implementing financial incentives for initiatives that have not been clearly shown to improve outcomes."

"This study shows that there is no one-size-fits-all solution when it comes to preventing poor outcomes," said Mary Naylor, a nursing professor at the University of Pennsylvania. More research is needed to understand what interventions benefit different patient types. "Patients with complex chronic health conditions need more than timely physician follow-up," she said. Her research over the past decade has shown that nurse-led, in-home team interventions, often within 24 hours of discharge, reduce hospital readmissions in patients with chronic conditions.-Carol Potera