Hospital readmissions.

Mar 2012
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New Hampshire
#12
That's a surprise. I'd like to dig into that.
Great article.

I talked to a public health official and asked him what's the best way to anticipate where there might be higher than normal rates of vaccine noncompliance, and he said take a map and put a pin wherever there's a Whole Foods. I sort of laughed, and he said, "No, really, I'm not joking." It's those communities with the Prius driving, composting, organic food-eating people.

https://www.sciencemag.org/news/2011/01/why-prius-driving-composting-set-fears-vaccines
 
Feb 2015
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#13
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.
Being in a hospital and being in a long term care or rehab are two very different things. One is for the sick or injured, the other is for caring for them once stable. Sadly all carry the possibility for nosocomial infections.
 
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Feb 2015
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#14
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.
Yes, what you describe can be hard on a patient...but that is the norm. How far or annoying coming back to have some procedure done it is not part of the discharge equation. Make no mistake, money is the bottom line. It is very expensive keeping someone in a bed and room just for the convince of the patienter. Coming back to have stitches removed or a having a small test or procedure done is not considered "readmission" but more as follow up.

Have you seen the nosocomial commercials? After some cheom treatments you had to come back for just a single shot.... now they make a patch that will give the shot without coming back.

I personality have been well known for asking for a suture removal kit to take home and remove stitches myself. Granted, not many other people would be willing to do something like that to themselves... but it is very easy.
 
Feb 2015
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#15
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.
*eye pop*.... gads the horror!!! prednisome!!! For me that is an automatic hospital stay as long as i am on the drug. It can have some very nasty side effects. If you have never had that drug it is possible they wanted to watch you for any adverse symptoms of the drug.
 
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Feb 2015
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#16
Great article.

I talked to a public health official and asked him what's the best way to anticipate where there might be higher than normal rates of vaccine noncompliance, and he said take a map and put a pin wherever there's a Whole Foods. I sort of laughed, and he said, "No, really, I'm not joking." It's those communities with the Prius driving, composting, organic food-eating people.

https://www.sciencemag.org/news/2011/01/why-prius-driving-composting-set-fears-vaccines

omg... LMAO

the sad thing is the is absolutely right!!!
 
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HCProf

Moderator
Sep 2014
26,300
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USA
#17
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.
It is not really the hospital but the insurance companies. Hospitals are paid by DRG. They are paid a set fee for any condition or group of conditions. Part of that is length of stay. The insurance companies determine the LOS. It also depends on the condition. It would be interesting to see the break down per diagnosis for the readmissions. There is always the surgery patient who thinks it is a good idea to mow the lawn and create a complication. I

Medicare is very strict regarding readmissions. If a Medicare patient is re-admitted within 24 hours they will not pay the claim. The hospital usually eats the cost . Boston and MA, from the articles I have read, has a excellent health care systems. This is problem that they can fix. Hospitals do not like issues like this...it is reported to their accreditors as well.
 
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Feb 2015
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#18
It is not really the hospital but the insurance companies. Hospitals are paid by DRG. They are paid a set fee for any condition or group of conditions. Part of that is length of stay. The insurance companies determine the LOS. It also depends on the condition. It would be interesting to see the break down per diagnosis for the readmissions. There is always the surgery patient who thinks it is a good idea to mow the lawn and create a complication. I

Medicare is very strict regarding readmissions. If a Medicare patient is re-admitted within 24 hours they will not pay the claim. The hospital usually eats the cost . Boston and MA, from the articles I have read, has a excellent health care systems. This is problem that they can fix. Hospitals do not like issues like this...it is reported to their accreditors as well.
lol..i was hoping you were going to jump in here without my @ing you :)
 
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HCProf

Moderator
Sep 2014
26,300
15,103
USA
#19
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.
If your airway was closing it is completely reasonable to keep you over night for airway management. Just because you feel better does not mean you will remain better. It also depends on what time you checked in the ER. If it were late, it could be a good idea to stick around. If hospitals were just filling beds they would be filling beds with patients who have non life threatening symptoms. There is a recommended triage chart physicians use that was published by the AMA.
 

HCProf

Moderator
Sep 2014
26,300
15,103
USA
#20
Yes, what you describe can be hard on a patient...but that is the norm. How far or annoying coming back to have some procedure done it is not part of the discharge equation. Make no mistake, money is the bottom line. It is very expensive keeping someone in a bed and room just for the convince of the patienter. Coming back to have stitches removed or a having a small test or procedure done is not considered "readmission" but more as follow up.

Have you seen the nosocomial commercials? After some cheom treatments you had to come back for just a single shot.... now they make a patch that will give the shot without coming back.

I personality have been well known for asking for a suture removal kit to take home and remove stitches myself. Granted, not many other people would be willing to do something like that to themselves... but it is very easy.
I have my own suture removal kit along with many other items in my kit. LOL I always removed my own sutures after my surgeries. By the time I go back for my follow up, my suture sites are perfect and very well healed. It was like a obsession with wound care. :)
 
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