The neurologic revolving door: Time to pay attention to readmissions

Last October, the Centers for Medicare and Medicaid Services (CMS) began a program aimed at reducing hospital 30-day readmissions, based primarily on the notion that a higher readmission rate is a marker of poor quality care during the index admission. Under this initiative, CMS penalizes hospitals with excessive readmission rates, which are currently calculated by examining hospitalizations for myocardial infarction (MI), pneumonia, and congestive heart failure (CHF). Common neurological problems such as stroke could certainly be next. Initial results indicate that nearly two-thirds of all hospitals in the United States will be penalized this year totaling around $300 million. This penalty is scheduled to increase in the coming years. Like it or not, readmissions have become very important to the bottom line, and neurologists will increasingly be called upon to be attentive to their rates and processes that can improve them. On detailed inspection, readmission rates as currently defined are a curious marker for quality care. While some readmissions may be generated by sloppy care or cognitive errors during the initial hospitalization, others may be perfectly acceptable and even planned. Take the patient with a staged endovascular procedure over multiple admissions or one with a disabling demyelinating attack that did not resolve following corticosteroid treatment who returns for plasmapheresis; neither should trigger a financial penalty, but each would be counted just the same as any other readmission once these rules are applied to neurologic diagnoses. The 30-day mark also seems quite arbitrary–should a patient who returns to the hospital 24 hours after discharge be considered the same “error” as one who returns at 24 days? Academic hospitals, institutions that care for socioeconomically disadvantaged populations, and those that have medically complex patients are more likely to be penalized under this new system. Patients who are sicker tend naturally to be readmitted more frequently. The traditional mission of most tertiary care hospitals to accept in transfer patients who are too complex to be managed in the community may indeed lead to higher readmission rates. Will there be new pressure to limit aid to our community-based colleagues? In addition, readmissions may have little to do with the actual index hospitalization and rather depend more on the quality of follow-up care after discharge. Socioeconomically disadvantaged patients often do not have easy access to outpatient health care and therefore are more prone to return to inpatient care. While some could argue that this CMS initiative will therefore encourage hospitals to work to improve outpatient care in their communities, this assumes a type of closed network that encompasses a broad swath of payors and patients that most academic hospitals simply do not have in place. Perhaps most concerning of all is the multiple ways by which hospitals can, and likely will, “game the system” to reduce readmission rates and avoid penalties. A readmission is obviously only counted if a patient is actually admitted, tempting institutions to hold patients in the emergency department or in observation wards for extended periods of time, contributing to overcrowding in these already challenging and often resource-strapped settings. While much work has been done over the years to reduce length of stay in the hospital to reduce costs, unnecessary tests, and the risk of hospital-acquired complications, these new penalties encourage additional days in the hospital to make sure the patient will not become the dreaded “bounce back” after discharge. Very few stroke patients would likely be readmitted if they all were kept in the hospital for a month (but at much greater cost to the health care system). So what should we do as a field to address this new challenge? It is likely that stroke or other neurologic conditions will soon be included in the list of disorders that are tracked by CMS (and probably other insurers), but as it stands, there is very little data available as to the expected frequency of these neurologic readmissions to use as a benchmark. Research is needed not only to define these expected rates but to determine which conditions and patient profiles in neurology are most likely to lead to readmissions, setting the stage for targeted interventions for specific populations. Many neurologists for years have ignored non-neurologic complications in our outpatients, but here emerges