Postdischarge period poses perils

map

After receiving hospital treatment, many elderly patients have to return for acute care only a few weeks following their release, risking more severe medical problems and adding unnecessary stress to the national health care system.

A Yale study published in the Jan. 23 Journal of the American Medical Association, or JAMA, found that seniors who are hospitalized for one disease are often readmitted soon after for another, suggesting that the hospitalization experience may leave patients vulnerable to other illnesses shortly after discharge. By improving the hospital environment and focusing on a patient’s general health beyond the acute disease for which the patient was admitted, hospitals may be able to reduce readmission rates, which are currently at around 20 percent for Medicare beneficiaries, said lead author Kumar Dharmarajan, a visiting scholar at the Yale School of Medicine.

“Many of these rehospitalizations are preventable and are exposing older patients to infections and medical errors,” Dharmarajan said. “We need to think more holistically about the patients and the things that they are at risk for.”

Senior author Harlan Krumholz, Yale professor of medicine and public health, said the disruptive hospital setting may render patients more vulnerable to developing other health problems, a condition he called “posthospital syndrome.” Hospitals need to pay attention to how much sleep patients get, as nurses disrupt their sleep to check vital signs and conduct tests. Nurses also need to ensure patients are properly nourished, and should be “judicious” in their use of medication that may impair brain function, he added.

Hospital treatment and follow-up sessions in the post-discharge period tend to focus exclusively on treating the initial diagnosis and preventing its recurrence, leaving patients vulnerable to other health problems. Dharmarajan attributed this phenomenon to the specialized training that physicians currently receive in medical schools, adding that doctors need to think more broadly about the patient as being at a “generalized health risk.”

In an effort to curb readmissions, the Centers for Medicare & Medicaid Services began penalizing hospitals last October for high readmission rates within 30 days of discharge following heart failure, heart attacks or pneumonia, three common acute-care conditions. But another Yale study in the Jan. 23 JAMA issue added that there are around two-thirds as many emergency room visits after discharge as there are readmissions, though these visits are unaccounted for by CMS’s current penalty.

Lead author Anita Vashi, a Medical School postdoctoral fellow, and senior author Cary Gross, associate professor of internal medicine, said that primary care providers and hospitals also need to improve communication with each other and with the patient so that patients can continue to be monitored for health problems in the weeks following discharge.

“If you’re a patient who’s been discharged from the hospital and feel unwell for any reason, even if it’s unrelated to the initial illness, talk to your doctor,” Dharmarajan said.

Although preventable rehospitalizations have been a constant burden on the health care system, Krumholz said the phenomenon has only recently come under scrutiny by researchers and policymakers due to rising health care costs and attempts to bridge the silos of outpatient care and hospital care.

“Hospitals were rewarded for high readmissions rates. There was no incentive to look at this aspect of health care,” Krumholz added. “We’re also starting to believe this is an area in health care where we can do better.”

Hospital readmissions cost the government more than $17 billion annually.

Comments