The Most Cost-Effective Way to Reduce Rehospitalizations
Journal of the American Medical Association
Teryl Nuckols, MD (Cedars-Sinai Medical Center) and colleagues recently released the first-ever systematic review of the cost-effectiveness of various rehospitalization quality improvement programs. Their results are published in the Journal of the American Medical Association.
Since the Hospital Readmission Reduction Program of 2012, 30-day hospital readmissions have been on the decline among Medicare beneficiaries. These advancements suggest greater protection of patient health during the high-risk periods following transition from institution to home. Research suggests that readmissions within one week of discharge most often relate to the stress of acute illness, intensified self-care needs, impaired function, and/or new medications. Later readmissions, on the other hand, tend to reflect chronic illness. Over the past decade, probably every hospital in the U.S. has implemented quality improvement programs to better protect patients after discharge and thereby reduce unplanned rehospitalizations. The good news is that Nuckols et al. find that, by and large, quality improvement programs work. They reduce rehospitalizations. In that case, which rehospitalization reduction programs work better, and which ones prove the most cost-effective?
To help answer this question, Nuckols and colleagues analyzed the results of 50 studies encompassing more than 16,000 patients. The rehospitalization reduction programs tended to include multiple interventions. Researchers categorized each intervention into one of five categories: risk assessment and stratification models, engagement of the patient and caregiver, medication reconciliation, facilitating connection of patients to their usual clinicians, and supplementing the care of the usual clinicians. The research team found all interventions to be effective at reducing rehospitalization. All-cause rehospitalization risk declined by 28% on average. Among the interventions studied, the shortest lasted 14 days post-discharge. Those lasting greater than 30 days proved more cost-effective.Patient/caregiver engagement proved to be the most cost-effective intervention. Interventions that included patient/caregiver engagement created a net savings in healthcare spending that was $8,282 larger than the savings achieved by other interventions. Patient/caregiver engagements were those interventions focused on improving patient capacity for self-care and reducing reliance on healthcare. This might include home exercise training post-myocardial infarction, diet training for diabetics, recognizing signs and symptoms of worsening wound status, medication adherence training, etc.
Why would post-discharge patient/caregiver engagement be so effective considering that most of what is taught in the home has already been taught during the inpatient stay or an outpatient visit? The answer is that people learn with time, repetition, verification (aka testing), and reteaching based on deficits revealed by testing. Community-based healthcare models are ideal for this sort of engagement. Repeated, convenient visits to the patient’s home help ensure thorough teaching, while the home environment often makes the ideal classroom for teaching home-based self-care. When you have homebound patients who could use repetition, testing, and re-teaching to ensure implementation of important self-care instructions, please remember the attentive and personalized home nursing services of My Home Nurses.
Please tell your patients about My Home Nurses.
- Nuckols TK, Keeler E, Morton S, Anderson L, Doyle BJ, Pevnick J, Booth M, Shanman R, Arifkhanova A, Shekelle P. Economic evaluation of quality improvement interventions designed to prevent hospital readmission: a systematic review and meta-analysis. JAMA Internal Medicine. 2017 Jul 1;177(7):975-85.
- Zuckerman RB, Sheingold SH, Orav EJ, Ruhter J, Epstein AM. Readmissions, observation, and the hospital readmissions reduction program. New England Journal of Medicine. 2016 Apr 21;374(16):1543-51.
- Graham KL, Marcantonio ER. Differences between early and late readmissions among patients. Annals of Internal Medicine. 2015 Oct 20;163(8):650.