Inadequate Patient Discharge Instructions and Intervention Resulting in Rehospitalization: Prevalent, Costly and Sometimes Malpractice
Studies have found that when patients leave the hospital without clear understanding of their diagnoses, medication instructions, or need for primary care follow-up, chances are that they will wind up back in the emergency department, and many will be readmitted. Questions are being asked within the medical community whether the standards of care relating to hospitals discharge instructions and follow-up are in fact inadequate and costly to the system by resulting in unnecessary rehospitalizations. A study published in the New England Journal of Medicine (April 2, 2009) found that Medicare patients discharged from a hospital are frequently readmitted within a few months, a situation sometimes referred to as bounce-back admissions. In the study, the cost of unplanned rehospitalizations in 2004 was estimated to account for US$17.4 billion of the $102.6 billion in hospital payments from Medicare. The researchers analyzed data on some 11.9 million fee-for-service beneficiaries whose Medicare records showed a hospital discharge in 2003 and 2004. The analysis revealed that 20% of older hospitalized patients were readmitted within 30 days, 34% returned within 90 days, 45% returned within 180 days, and 56% returned within 1 year. Two-thirds of those hospitalized with medical conditions, as well as 51.5% of patients undergoing surgery, were rehospitalized or died within a year of discharge, the researchers also found. The top five common medical conditions that required readmission were: Heart failure; Pneumonia; Chronic obstructive pulmonary disease; Psychoses; and Gastrointestinal problems. The top five common surgical procedures requiring readmission were: Cardiac stent placement; Major hip or knee surgery; Vascular surgery; Major bowel surgery, and Other hip or femur surgery. A major finding of the study was that the problem is not only due to discharge instructions that could be clearer, but also due to inadequate follow-up after discharge. More particularly, half all patients rehospitalized within 30 days had no record of outpatient care following the initial discharge. And as late as three months after discharge, some 20% still had not been seen by a physician. Patients need to have an active interaction with the health system after they are discharged. Significant predictors of 30-day rehospitalization in the period from Oct. 1, 2003 through Dec. 31, 2004 included: Two rehospitalizations: HR 1.75 (95% CI 1.75 to 1.76) Three rehospitalizations: HR 2.50 (95% CI 2.50 to 2.51) Length of stay more than twice the DRG expectation: HR 1.27 (95% CI 1.26 to 1.27) End-stage renal disease: HR 1.42 (95% CI 1.41 to 1.43). Age was a relatively weak, though statistically significant, predictor of rehospitalization, with hazard ratios of 1.02, 1.07, and 1.10 for individuals in the 70 to 74, 75 to 79, and 80 to 84 age groups, respectively. In the opinion of Neil H. Winawer, MD, FHM, a large percentage of bounce-back admissions appear to be related directly to poorly coordinated transitions of care. He asserts that tremendous improvement might be possible if patients were seen by their primary care physicians within a few weeks after discharge. Dr. Winawer states that hospitals and primary care providers need shared incentives and accountability for solving this problem, perhaps with the Centers for Medicare and Medicaid Services (CMS) informing hospitals of their risk-adjusted readmission rates and providing lower payments for hospitals that have high rates of readmissions for certain conditions. 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 presidents 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. This idea is similar to Medicare's fairly recent policy of not paying hospital's when so-called "never events" have necessitated the hospital's cost in caring for a patient. In a randomized controlled trial (Jack BW et al. A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Ann Intern Med 2009 Feb 3; 150:178), investigators at Boston Medical Center compared a standardized discharge intervention with usual care for 749 patients who were admitted to the medical teaching service. The intervention had three main components: Nurse discharge advocates who coordinated discharge plans with the hospital team and educated and prepared patients for discharge After-hospital care plans (also coordinated by the discharge advocate), which contained reasons for hospitalization, discharge medication lists with instructions, contact information for discharge advocates and primary care providers, appointment calendars, and lists of pending tests Follow-up phone contact by clinical pharmacists at 2 to 4 days after discharge to reinforce discharge plans and to address any medication-related problems. At 30 days after discharge, 90 patients in the usual-care group versus 61 in the intervention group had visited an ED; 76 readmissions had occurred in the usual-care group versus 55 in the intervention group. The intervention patients were significantly more likely to know their discharge diagnoses (79% vs. 70%), to be able to identify their primary care providers (95% vs. 89%), and to report that they were prepared adequately for discharge (65% vs. 55%). Estimated total direct cost savings for the intervention was US$149,995 an average of $412 per person who received it. Not every case of a hospital readmission would involve medical malpractice. Key issues could involve the sufficiency of the discharge instructions, whether the hospital sufficiently undertook to be certain that the patient understood the instructions, and whether the hospital had reason to know that in the absence of its following-up, such as to make appointments for the patient with the patients doctors, the patient would not receive necessary care and be exposed to great risk of harm. A medical expert would have to review medical records to evaluate the circumstances to determine whether there was a deviation from the standard of care. The existence of studies such as the ones referenced in this blog could assist in making the case that the hospital (or doctors or nurses) had reason to know that its discharge instructions and procedures were inadequate. The lawyers at Levine & Slavit have decades of experience handling personal injury claims including those involving medical malpractice. For 50 years spanning 3 generations, we have obtained results for satisfied clients. We have offices in Manhattan and Long Island, handling cases in New York City, the Bronx, Brooklyn, Queens and surrounding areas. To learn more, watch our videos.
