Where's the beef? Progress on reducing readmissions

The Hospital Readmission Reduction Program (HRRP) contained within the Affordable Care Act focused national and local attention on hospital resources and efforts to reduce hospital readmissions. Driven by the Centers for Medicare and Medicaid Services’ (CMS) desire to pay for value instead of volume, the response of hospitals and health systems appears to be yielding change across the United States. A number of recent publications in the Journal of Hospital Medicine (JHM) exemplify the keen interest in reducing readmissions, while providing guidance regarding interventions and where we might target future research. Evidence from an exemplary systematic review of the pediatric literature confirms some experience in adults regarding effective interventions—all studies were multifaceted— and highlights the importance of identifying a single healthcare provider or centrally coordinated hub to assume responsibility for extended care transition and follow-up. Notably, studies of pediatric patients and their families document the effectiveness of “enhanced inpatient education and engagement” while in the hospital. Unfortunately, a study among adults at a topranked academic institution indicates poor communication among nurses and physicians regarding patient discharge education. Efforts to improve nurse–physician communication by redesigning the hospitalist model of care delivery at a Veterans Affairs (VA) institution appeared to enhance perceptions of communication among the care team members and reduced length of stay, but disappointingly there was no reduction in readmission rates. Studies such as this are essential in identifying which specific interventions may actually change outcomes such as readmission rates. In 1984, a diminutive elderly woman provocatively squawked “Where’s the beef?”, launching a highly successful advertising campaign for Wendy’s hamburger chain. This catchphrase may aptly describe Bradley and colleague’s survey study of the State Action on Avoidable Rehospitalization (STAAR) and Hospital-to-Home (H2H) campaigns. Auerbach and colleagues eloquently stated in a 2007 New England Journal of Medicine perspective how they had “witnessed recent initiatives that emphasize dissemination of innovative but unproven strategies, an approach that runs counter to the principle of following the evidence in selecting interventions that meet quality and safety goals. . ..” I firmly agree with this assessment, and 6 years later believe we should be more thoughtful about potentially repeating implementation of unproven strategies. Do we know if the interventions recommended by H2H and STAAR are what hospital care teams should be attempting? Even the authors mention that “definitive evidence on their effectiveness is lacking.” The H2H and STAAR programs certainly encourage some theoretically laudable activities—medication reconciliation by nurses, alerting outpatient physicians within 48 hours of patient discharge, and providing skilled nursing facilities the direct contact number of the inpatient treating physician for patients transferred. However, do these efforts actually improve patient outcomes? Before embarking on state or national campaigns to improve care, we should consider carefully what are the best evidence-based interventions. Remarkably, some prior evidence indicates that direct communication between the hospital-based physician and primary care provider (PCP) may not actually impact patient outcomes. Newer research published in JHM confirms my belief that the PCP needs to be engaged by hospitalists during a hospitalization. Lindquist’s research group at Northwestern nicely demonstrated how communication between a patient’s PCP and the admitting hospitalist, complemented by contact between the PCP and patient within 24 hours postdischarge, reduced the probability of a medication discrepancy by 70%. Although no evaluation of the effect on readmissions was reported, this study may provide information on causality related to the importance of PCP involvement in the care of hospitalized patients. Numerous publications now document research on successfully implemented programs that lowered hospital readmissions, and are cited by CMS as evidencebased interventions. Projects Re-Engineered Discharge (RED) and Better Outcomes by Optimizing Safe Transitions target the hospital discharge process, and both appear to lower hospital readmission rates. The Care Transitions Intervention (CTI), Transitional Care Model (TCM), and the Guided Care model all leverage nurse practitioners or nurses to protect elderly patients during what can be a perilous care transition from hospital to home. CTI and *Address for correspondence and reprint requests: Mark V. Williams, MD, Center for Health Services Research, University of Kentucky, Lexington, KY 40506; E-mail: mark.will@uky.edu