病院の再入院率の高さは「ますます粉々にされた医療システムの結果の1つ」であるとDr. Stephen F. Jencksは言う。非計画的な入退院のコストが2004年だけで170億ドルであったと概算している。
また、現在のシステムでは再入院患者を減らすことでベッドを満たす必要のある病院の不利益に働く可能性がある。約1/4の病院では25%が再入院患者である。「現在の環境では入院数を減らすことは刑罰を与えるようなものである」と医療改良研究所の政策専門家Dr. Amy E. Boutwellは言う。研究所は、不必要な入退院を防止するために病院が医師などとともにより密接に働くことを促進するためにどのように決済システムを変更するかを決定するためにマサチューセッツ、ワシントン、およびミシガンを含む州とともに働いている。
Study Finds Many on Medicare Return to Hospital
By REED ABELSON
Published: April 1, 2009
The nation spends billions of dollars a year on patients’ return visits to the hospital ― many of which are readmissions that could be prevented with better follow-up care, according to a study published Wednesday in the New England Journal of Medicine.
As many as a fifth of all Medicare patients are readmitted within a month of being discharged, according to the study, and a third are rehospitalized within 90 days.
Half the patients who returned to the hospital within 30 days of undergoing treatment other than surgery apparently did not see a doctor before they went back.
The high rate of hospital readmissions is “one of the fruits of an increasingly fragmented health care system,” said Dr. Stephen F. Jencks, a former Medicare official who is an author of the study, which analyzed Medicare claims information for 2003 and 2004. He estimated that the cost of the unplanned return trips was $17 billion in 2004 alone.
Policy analysts say that while high return rates have long been a problem, controlling those costs is increasingly urgent.
“Given the current financial situation, this is no longer something we can ignore,” said Dr. Anne-Marie J. Audet, a policy specialist for the nonprofit Commonwealth Fund, a health research foundation that helped pay for the recent study.
The Obama administration, as it seeks money to provide health care for more Americans, has already identified hospital readmissions as a source of potential cost-cutting. The president’s budget calls for $26 billion in savings from readmissions over 10 years, which includes lowering payments to hospitals with high numbers of patients who are readmitted.
Many elderly patients who leave the hospital with a chronic illness like heart failure or diabetes are left to cope largely on their own. They often do not receive clear instructions on what medications they should be taking, and they frequently have difficulties making doctor appointments to continue their treatment outside the hospital.
“When you get out of the hospital, you need to have an active interaction with the health system,” said Dr. Audet of the Commonwealth Fund, which also provided a grant to the nonprofit Institute for Healthcare Improvement to work with states to try to reduce the number of times patients go back to the hospital. “The patient has to be seen.”
Some hospitals have already shown they can reduce readmissions by taking seemingly simple steps to make sure patients get necessary follow-up care when they go home or to a nursing facility.
At Geisinger Health System, a network in Pennsylvania that has been a leader in improving the quality of hospital care, doctors say they are taking varied approaches to reducing readmissions rates, depending on why the patient was initially hospitalized.
With surgery patients, for example, Geisinger has focused on educating people before they come to the hospital about what they are likely to experience and what they should expect when they leave. The effort could reduce readmission rates by as much as 20 percent, said Dr. Ronald A. Paulus, a senior executive at the health system. Geisinger’s early findings, he said, indicate that if patients “are not ready by the time they come in, it’s too late.”
Geisinger has also found it effective to alert the patients’ doctor about the hospital visit, including a brief summary of the patient’s discharge plan that is sent the doctor within 72 hours of the patient’s departure. That kind of simple step, Dr. Paulus noted, does not require an overhaul of the current system.
Successful measures elsewhere have included working more closely with patients or their caregivers to better manage conditions like diabetes, said Dr. Eric A. Coleman, one of the study’s authors and a policy specialist at the University of Colorado at Denver. Coaching patients to be more diligent about taking their medicine and recognizing when their condition is deteriorating helps people stay out of the hospital, he said.
But Dr. Coleman also said doctors needed to take more responsibility for their patients’ continuing care. “Physicians haven’t really been stepping up to the plate and taking on this accountability,” he said, although he said several professional societies were expected this spring to clarify the doctors’ roles.
Many policy analysts say that insurers like Medicare must change the way they pay hospitals and doctors ― rewarding medical providers that help patients get and stay better. Under the current system, reducing the number of returning patients can work against the financial interests of a hospital needing to fill empty beds. About one in four of the nation’s hospitals derive 25 percent of their admissions from return visits by patients, according to the study.
“Reducing admissions in a hospital is quite punitive in today’s environment,” said Dr. Amy E. Boutwell, a policy specialist at the Institute for Healthcare Improvement. The institute is working with states including Massachusetts, Washington and Michigan to determine how to change the payment system to encourage hospitals to work more closely with doctors and others to prevent needless round trips.
NEJM Volume 360:1418-1428 April 2, 2009 Number 14
Rehospitalizations among Patients in the Medicare Fee-for-Service Program
Stephen F. Jencks, M.D., M.P.H., Mark V. Williams, M.D., and Eric A. Coleman, M.D., M.P.H.
Background Reducing rates of rehospitalization has attracted attention from policymakers as a way to improve quality of care and reduce costs. However, we have limited information on the frequency and patterns of rehospitalization in the United States to aid in planning the necessary changes.
Methods We analyzed Medicare claims data from 2003–2004 to describe the patterns of rehospitalization and the relation of rehospitalization to demographic characteristics of the patients and to characteristics of the hospitals.
Results Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. In the case of 50.2% of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician's office between the time of discharge and rehospitalization. Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition. We estimate that about 10% of rehospitalizations were likely to have been planned. The average stay of rehospitalized patients was 0.6 day longer than that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously. We estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion.
Conclusions Rehospitalizations among Medicare beneficiaries are prevalent and costly.
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