IN this current issue of the journal, Health Care For All describes a 16-point attack on healthcare costs from a consumer's perspective, which has been put forward as proposed legislation in the Commonwealth of Massachusetts. Rather than comment on all the 16 points, I will focus on 2 areas: potentially preventable readmissions to hospitals and potentially preventable complications in hospitals.
Offering incentives to reduce these 2 types of events will likely benefit consumers and hospitals. I will discuss these areas and the likely benefits from a point of view that comes not from a review of the literature but from our actual experiences in working on these areas, among the many ways that we have worked to improve quality and promote patient safety at our hospitals. The punch line: Reducing readmissions and complications is not only multiply beneficial but also very doable.
A number of years ago, we began specifically tracking readmissions to the hospital because of the work we initiated to reduce hospital length of stay (LOS). There were concerns expressed that if we "pushed" patients out of the hospital too soon, they would be too ill to remain at home and would end up in the emergency department (ED), having clinically decompensated and requiring readmission. Over the ensuing years we have seen the readmission rate at our hospitals decline in parallel with reductions in our average LOS (ALOS). This has been a consistent pattern over a long period of time and in fact, when we have had upward trends in our ALOS, the readmission rate trended upward as well.
The cause of this observed effect is not entirely clear. We have speculated that perhaps the comprehensive and painstaking discharge planning and arrangements for care after discharge of patients who are being discharged at an earlier point in their episode of illness results in a more complete discharge plan. Perhaps the resulting, more complete plan reduces the likelihood of readmission.
Several years ago, we conducted a pilot study wherein we placed a trained RN case manager in the ED, whose role was to intervene and become involved in a patient's care while the patient was in the ED. The involvement of the case manager was to help determine and implement the appropriate level of care for the patient in a collaborative process with patient, family, caregiver, ED and hospital staff, and community resources. Such an approach is designed to reduce inappropriate admissions to the hospital. We feel the case manager in the ED can be most effective with populations of patients that include the chronically ill, the underinsured or uninsured, and the homeless.
The goals for this pilot program were to provide the right patient with the right care at the right time; reduce ED revisits; reduce inpatient LOS by using this early intervention; return nursing home patients to their facility directly from the ED whenever possible; improve patient satisfaction; and set expectations for appropriate LOS if the patient is admitted to the hospital.
The ED case manager focused efforts on ensuring the appropriate level of care for the patient, reducing 72-hour revisits to the ED, reducing the length of stay in the ED and of admitted patients, and sorting through eligibility criteria for patients to access care/service/resources outside the hospital setting. In addition, there was a focus on improving patient and family satisfaction.
The ED patient is a patient in transition, who is neither an inpatient nor a community-based patient. In the fast-paced environment of the ED, decisions about utilization of medical resources are made in a narrow timeframe, within the context of quality, safety, cost, and patient-specific resource needs.
Over the ensuing 6 to 12 months, in the 2 hospitals we piloted the program, we had the following findings when comparing the age-matched patients who experienced the case manager intervention with the patients who did not:
* Revisits to the ED within 72 hours were eliminated in the intervention group compared to a 3.5% revisit rate in the other group of patients (therefore, a reduction in readmissions to the hospital).
* Among the patients admitted to the hospital, the ALOS for the intervention group was one full-day shorter than that for the other group.
* The percentage of patients discharged at or less than the CMS-prescribed LOS ranged from 48% to 89% in the intervention group and 39% to 42% in the other group.
* Patient and staff satisfaction was higher in the intervention group.
In short, this program reduced readmissions, reduced ED revisits, reduced LOS, improved patient satisfaction, and more than paid for itself with the cost savings realized.
Perhaps the most important preventable complication (other than death) in hospitalized patients is hospital-acquired infections. In addition to the obvious benefits of the patient not acquiring an infection while in the hospital (eg, reductions in discomfort, prolonged recovery, and risk of premature death), there is also a potentially huge cost saving.
Our experience with reducing ventilator-associated pneumonia (VAP) is a good example. We know that a VAP costs us on average $33,000. This number is actual cost, not billed charges. We also know that third-party payers do not pay us anywhere near enough to cover that additional cost of care.
Using the Institute for Healthcare Improvement's promoted ventilator bundle with enhancements, we have been able to reduce the incidence of VAPs. In fact, at this writing, one of our hospitals has been free of VAP for 15 months and another of our hospitals has for 3 months.
We realize that there is some controversy over how to define a VAP for measurement purposes, but we have stayed with the definition from the National Nosocomial Infection Survey.
In summary, we feel that the attack points in the proposed legislation concerning preventing readmissions and in-hospital complications are important, multiply beneficial, and doable by most hospitals.