Hospital readmissions.

Sep 2017
4,884
5,805
Massachusetts
#1
US News is known for their clickbait rankings (e.g,. best colleges, best cities, etc.) It can be fun to dig into those rankings to see what games they play with their numbers to get the list they're trying to achieve. For example, consider their recent list of the ten best states in America:

https://www.usnews.com/news/best-states/slideshows/10-best-states-in-america

Being a fan of my own state of Massachusetts, I was curious how we did (we came out eighth). One thing that surprised me, though, is that we were only fifth for healthcare. The top overall state, Iowa --not exactly known for its healthcare system-- came out third. I was curious how that could be. If you dig down into the magazine's methods, you'll see the healthcare ranking is composed of several pieces. Massachusetts did well on access (the state has good subsidies to ensure access to healthcare for the poor, the nation's lowest rate of non-insurance, etc.) But, oddly, they didn't do well for "healthcare quality" -- 31st in the nation, versus ninth for Iowa. If you dig still further, you find that's driven pretty much entirely by hospital readmissions, where Massachusetts comes in dead last, due to a high rate of readmissions.

There are at least two possible reasons for high readmissions. One is if people are getting thrown out of hospitals prematurely (e.g., they're uninsured and the hospital tosses them out as soon as possible), only to have their condition worsen resulting in readmission. The other is if doctors are cautious and quick to admit someone to a hospital if recovery isn't going quite as well as hoped. No attempt is made to distinguish between them. If you check the rankings, many of the more liberal, wealthier, and healthier states are among those with high readmission rates, including Massachusetts, Connecticut, New York, and New Jersey, suggesting maybe it's not the negative indicator it's being treated as.

I think, ultimately, the proof is in the hard numbers. Compare US News' shining star, Iowa, to Massachusetts across actual public health outcomes. Massachusetts is fifth in the nation for life expectancy, versus 14th for Iowa. Massachusetts has the third-lowest infant morality, Iowa is 27th. Massachusetts has the very lowest child death rate of any state, while Iowa is 23rd, etc. Looking at outcomes, it seems like maybe it isn't a good idea to focus too much on driving down hospital readmissions. A focus on that stat might be resulting in some hospitals being reluctant to readmit patients with complications, leading to death.

Maybe it would be better, instead, to focus on something like hospitalization survival rate (e.g., what percentage of people admitted to a hospital are still alive a year later). That would discourage prematurely throwing someone out of a hospital, without also discouraging readmitted someone who needs care.
 
Mar 2012
52,745
34,903
New Hampshire
#2
I have a friend thats a nurse and she had told me years ago when NH had high readmission rates that its mostly antibiotics. Those hospitals that load up every patient with antibiotics have lesser rates of readmission. But the AMA had warned about superbugs and over prescribing right afterwards. But she told me her hospital then began pumping up the drugs. Especially with senior citizens who have the highest chances of being readmitted. Break a leg? Get antibiotics just in case. She said as long as they go back to their doctors if they have a problem, as long as its not the hospital thats considered a "win." Long term however? MA and other states have better longevity because they have better immune systems.
 
Sep 2017
4,884
5,805
Massachusetts
#3
I have a friend thats a nurse and she had told me years ago when NH had high readmission rates that its mostly antibiotics. Those hospitals that load up every patient with antibiotics have lesser rates of readmission. But the AMA had warned about superbugs and over prescribing right afterwards. But she told me her hospital then began pumping up the drugs. Especially with senior citizens who have the highest chances of being readmitted. Break a leg? Get antibiotics just in case. She said as long as they go back to their doctors if they have a problem, as long as its not the hospital thats considered a "win." Long term however? MA and other states have better longevity because they have better immune systems.
Interesting perspective. Assuming it's right, it makes it even harder to track results, because the negative impact of over-prescribing antibiotics can hit third parties. For example, maybe if you over-prescribe, those actually leaving the hospitals end up better off, or at least no worse off, on average, but maybe others around them end up worse off, due to a heightened chance of them serving as a breeding ground for super-bugs.

It seems that re-admission data also could reflect a difference in attitudes about warehousing people in hospitals long term. For example, picture two systems. System A keeps elderly patients for a month after a bad fall, while System B releases them after a week, but with help from home nursing and other state social spending. System A is likely to have a lower readmission rate. But it's not clear that System A's patients will be better off. They'll likely get less exercise and social contact and may be more likely to become depressed or to contract one of the infections that are common in a hospital. They may also be dumped, at the end of that month, without good ways to cope, whereas System B's patients may have been transitioned more smoothly. It's quite possible that if you checked back in a year, System B's patients would have a higher survival rate from their serious falls than System A. There's also the morbid observation that if a hospital kills a patient then, by definition, he won't be readmitted.
 
Mar 2012
52,745
34,903
New Hampshire
#4
Interesting perspective. Assuming it's right, it makes it even harder to track results, because the negative impact of over-prescribing antibiotics can hit third parties. For example, maybe if you over-prescribe, those actually leaving the hospitals end up better off, or at least no worse off, on average, but maybe others around them end up worse off, due to a heightened chance of them serving as a breeding ground for super-bugs.

It seems that re-admission data also could reflect a difference in attitudes about warehousing people in hospitals long term. For example, picture two systems. System A keeps elderly patients for a month after a bad fall, while System B releases them after a week, but with help from home nursing and other state social spending. System A is likely to have a lower readmission rate. But it's not clear that System A's patients will be better off. They'll likely get less exercise and social contact and may be more likely to become depressed or to contract one of the infections that are common in a hospital. They may also be dumped, at the end of that month, without good ways to cope, whereas System B's patients may have been transitioned more smoothly. It's quite possible that if you checked back in a year, System B's patients would have a higher survival rate from their serious falls than System A. There's also the morbid observation that if a hospital kills a patient then, by definition, he won't be readmitted.
Its not something overly straightforward. Insurance does play a role too. Big insurers tend to allow longer hospital stays so I would wonder if readmission rates then are less? A state like MA has a myriad of all sorts of insurers from the big ones to small local ones. So they would be all over the place. MA also has tons of places that offer day surgeries and outcare. A state like Iowa doesnt. They have mostly hospitals. So people stay there longer which might aid them more. Also I wonder if they took overall demographics and social issues into consideration? MA has a lot of holistic practitioners which are popular with a younger demographic, and people from foreign countries who seek Eastern medicine where Iowa doesnt. Many variables make the difference.
 
Likes: HCProf
Mar 2012
52,745
34,903
New Hampshire
#5
I just did a search and found that MA has led the nation for over a decade with hospital readmissions. Its actually gotten better over the last two years or so. Found this interesting as well.

Dr. Amy Boutwell, who practices at Newton-Wellesley Hospital, believes an over-supply of hospital beds in the state has made readmitting patients an easier choice for physicians. “Readmissions in Massachusetts have always been high and relatively speaking they have remained high,’’ said Boutwell, who is president of Collaborative Healthcare Strategies, a Lexington-based consulting company. “If you have the supply, you use it and practice patterns develop. You say to the patient ‘Let me bring you in and we’ll check you out.’ We need to teach ourselves not to do that.’’

As part of the Affordable Care Act, Medicare penalizes hospitals with high readmission rates for patients with heart failure, pneumonia, chronic obstructive pulmonary disease, or who have had a heart attack, hip or knee replacement, or cardiac bypass surgery. More than three-quarters of Massachusetts hospitals were penalized in the fiscal year that ended Sept. 30, losing an average of 0.7 percent of their total Medicare payments.

Patients with mental illness or substance abuse problems, on top of their underlying medical conditions, are at much higher than average risk of returning to the hospital and account for 60 percent of all readmissions in Massachusetts, according to an August report from the Center for Health Information and Analysis.

A revolving door at Mass. hospitals - The Boston Globe
 
Sep 2017
4,884
5,805
Massachusetts
#6
Its not something overly straightforward. Insurance does play a role too. Big insurers tend to allow longer hospital stays so I would wonder if readmission rates then are less? A state like MA has a myriad of all sorts of insurers from the big ones to small local ones. So they would be all over the place. MA also has tons of places that offer day surgeries and outcare. A state like Iowa doesnt. They have mostly hospitals. So people stay there longer which might aid them more. Also I wonder if they took overall demographics and social issues into consideration? MA has a lot of holistic practitioners which are popular with a younger demographic, and people from foreign countries who seek Eastern medicine where Iowa doesnt. Many variables make the difference.
Yes --- other things being equal, I'd expect longer hospital stays in rural states than urban ones. If you're a four-hour drive from your hospital, you're not going to want to, say, get surgery, stay a day, then go home, then come back in a couple days for a follow-up procedure, stay another day, then go home again, then come back to get your stitches out, etc. If you can just stay an extra few days in the hospital, that's going to strike everyone as a better option. If, however, you live five miles down the road, such that transportation isn't going to be an issue and you can be to the hospital in minutes if complications arise, it'll make more sense to have you go home, even if that gets recorded as more "readmissions."

The people who do such stats tend to be pretty smart people, so I assume there has been a lot of thought into such matters, and the stats don't get misused too badly by the professionals. But when they trickle down to listicle makers like US News, that nuance gets lost.

Sort of a side point here, but I've also detected a desire by US News to create lists with certain geographic diversity, and I think it causes them to play games with which numbers they pick and how they use them. For example, when they do their "best places to live" rankings, they include education quality as a factor. But, they don't use a standard measure across the country (e.g., NAEP scores), which would allow meaningful rankings between different places in different states. Instead, they show where a given town is ranked relative to its state. So, for example, a 25th percentile place in Mississippi might look like it has better schools than a 30th percentile place in Massachusetts, even if the latter outscores it by an enormous margin. But they aren't consistent about it, because when it comes to other stats, like real estate prices or weather, they do absolute rankings, rather than rankings only relative to one's own state.

So, it's clear their method isn't dictated by principle, but rather by a desire to create a list with geographic diversity, so that the "Best Places" list isn't dominated almost exclusively by towns in a handful of states. If your ultimate goal is to sell magazines, you want the lists to be interesting to people in every state, by making sure every state has some offerings in the list. So, you end up gaming the numbers until the list looks the way you want it to look. If you want places like Mississippi, Alabama, and West Virginia to have any offerings, you effectively have to grade them on a curve.
 
Mar 2012
52,745
34,903
New Hampshire
#7
Yes --- other things being equal, I'd expect longer hospital stays in rural states than urban ones. If you're a four-hour drive from your hospital, you're not going to want to, say, get surgery, stay a day, then go home, then come back in a couple days for a follow-up procedure, stay another day, then go home again, then come back to get your stitches out, etc. If you can just stay an extra few days in the hospital, that's going to strike everyone as a better option. If, however, you live five miles down the road, such that transportation isn't going to be an issue and you can be to the hospital in minutes if complications arise, it'll make more sense to have you go home, even if that gets recorded as more "readmissions."

The people who do such stats tend to be pretty smart people, so I assume there has been a lot of thought into such matters, and the stats don't get misused too badly by the professionals. But when they trickle down to listicle makers like US News, that nuance gets lost.

Sort of a side point here, but I've also detected a desire by US News to create lists with certain geographic diversity, and I think it causes them to play games with which numbers they pick and how they use them. For example, when they do their "best places to live" rankings, they include education quality as a factor. But, they don't use a standard measure across the country (e.g., NAEP scores), which would allow meaningful rankings between different places in different states. Instead, they show where a given town is ranked relative to its state. So, for example, a 25th percentile place in Mississippi might look like it has better schools than a 30th percentile place in Massachusetts, even if the latter outscores it by an enormous margin. But they aren't consistent about it, because when it comes to other stats, like real estate prices or weather, they do absolute rankings, rather than rankings only relative to one's own state.

So, it's clear their method isn't dictated by principle, but rather by a desire to create a list with geographic diversity, so that the "Best Places" list isn't dominated almost exclusively by towns in a handful of states. If your ultimate goal is to sell magazines, you want the lists to be interesting to people in every state, by making sure every state has some offerings in the list. So, you end up gaming the numbers until the list looks the way you want it to look. If you want places like Mississippi, Alabama, and West Virginia to have any offerings, you effectively have to grade them on a curve.
A few years ago there was a study that showed Mississippi had the highest vaccination rates in the US while states like MA, OR, WA and VT had some of the worst. If you dug deeper it came down to money. Poor people didnt want to risk a child getting sick even if it was chicken pox because it meant time lost from work and a trip to the doctors. In wealthier states they could afford that and more often read blogs and such written by anti vaxxers. Or they bought into "big pharma is pushing them so I am not interested" mentality. It basically came down to money.
 
Likes: HCProf
Sep 2017
4,884
5,805
Massachusetts
#8
I just did a search and found that MA has led the nation for over a decade with hospital readmissions. Its actually gotten better over the last two years or so. Found this interesting as well.

Dr. Amy Boutwell, who practices at Newton-Wellesley Hospital, believes an over-supply of hospital beds in the state has made readmitting patients an easier choice for physicians. “Readmissions in Massachusetts have always been high and relatively speaking they have remained high,’’ said Boutwell, who is president of Collaborative Healthcare Strategies, a Lexington-based consulting company. “If you have the supply, you use it and practice patterns develop. You say to the patient ‘Let me bring you in and we’ll check you out.’ We need to teach ourselves not to do that.’’

As part of the Affordable Care Act, Medicare penalizes hospitals with high readmission rates for patients with heart failure, pneumonia, chronic obstructive pulmonary disease, or who have had a heart attack, hip or knee replacement, or cardiac bypass surgery. More than three-quarters of Massachusetts hospitals were penalized in the fiscal year that ended Sept. 30, losing an average of 0.7 percent of their total Medicare payments.

Patients with mental illness or substance abuse problems, on top of their underlying medical conditions, are at much higher than average risk of returning to the hospital and account for 60 percent of all readmissions in Massachusetts, according to an August report from the Center for Health Information and Analysis.

A revolving door at Mass. hospitals - The Boston Globe
Interesting. That's definitely the issue I was talking about -- where readmissions could reflect not a practice of releasing at-risk patients prematurely, but instead a practice of readmitting borderline patients easily.

I've never actually stayed at a hospital, myself, but I almost did, once, with a bad allergic reaction. I was already feeling all better, after a couple hours in the ER (my throat had been closing up, but once they IVed some Prednisone and anithistamines, that got better almost immediately). The doctor recommended that I check in overnight for observation, in case the symptoms came back. My house was just a few miles down the road, so I declined, and everything was fine. But it surprised me how quick they were to book someone into the hospital that way. Maybe, as your article says, that's about an oversupply of beds.
 
Mar 2012
52,745
34,903
New Hampshire
#9
Interesting. That's definitely the issue I was talking about -- where readmissions could reflect not a practice of releasing at-risk patients prematurely, but instead a practice of readmitting borderline patients easily.

I've never actually stayed at a hospital, myself, but I almost did, once, with a bad allergic reaction. I was already feeling all better, after a couple hours in the ER (my throat had been closing up, but once they IVed some Prednisone and anithistamines, that got better almost immediately). The doctor recommended that I check in overnight for observation, in case the symptoms came back. My house was just a few miles down the road, so I declined, and everything was fine. But it surprised me how quick they were to book someone into the hospital that way. Maybe, as your article says, that's about an oversupply of beds.
I think its a big combination of things. If you are on Medicare you are covered and its affordable. If you have a 12K deductible its not. I know my kids refuse medical treatment all the time even for minor things like sore throats and such due to their deductibles. They would rather stick it out but if they ever did get terribly sick they would be more likely to be admitted than just see a doctor at urgent care.
 
Sep 2017
4,884
5,805
Massachusetts
#10
A few years ago there was a study that showed Mississippi had the highest vaccination rates in the US while states like MA, OR, WA and VT had some of the worst. If you dug deeper it came down to money. Poor people didnt want to risk a child getting sick even if it was chicken pox because it meant time lost from work and a trip to the doctors. In wealthier states they could afford that and more often read blogs and such written by anti vaxxers. Or they bought into "big pharma is pushing them so I am not interested" mentality. It basically came down to money.
That's a surprise. I'd like to dig into that.