At the recent Crittenden Medical Conference which took place from March 30-April 1, 2014, essential factors for reducing hospital readmissions for the prevention and management of venous thromboembolism (“VTE” or commonly referred to as blood clots) were presented.
In a February 2013 report, the Robert Wood Johnson Foundation identified that discharged patients are being readmitted in what is termed as “a revolving door” of readmissions. The report found that two critical rates of occurrence that were virtually unchanged from 2008. These rates are:
- 1 in 8 Medicare patients were readmitted within 30 days after surgery in 2010.
- 1 in 6 Medicare non-surgical patients were readmitted within 30 days of being discharged.
As cited in the report, both of these rates increase the health care costs and additional expense of the readmission hospital stay. There is direct impact of what Medicare wants to save and hospitals will pay as a result of fiscal penalties for not preventing the readmission. There are identified challenges in clinical specialties, but most noted is in the stroke specialty in terms of volume:approximately one in every four of the nearly 800,000 strokes that occur each year is recurrent and as a result of mortality and disability related to stroke. One key source of preventable readmissions is VTE.
During his hospital readmission presentation, Gregory Maynard, MD, MCS, SFHM (Health Sciences Professor of Medicine; Director, UC San Diego Center for Innovation and Improvement Science) emphasized the effectiveness of the use of performance improvement tools such as BOOST. BOOST is the acronym for “Better Outcomes by Optimizing Safe Transitions”. It is a quality improvement toolkit and program whose goals are to help hospitals optimize the discharge process and improve outcomes by reducing adverse events that might have occurred during the transition of care process.
Central messages pointed out by Dr. Maynard at the conference were:
- Prevention is better than management
- Core Measures for VTE – better than no measures, but not good enough to propel QI and reduce VTE or readmissions.
- VTE – an under-recognized risk factor for re-admission
- Attempts to reduce VTE complications/readmissions should be integrated into larger transitions of care efforts
- BOOST example and power of collaboration
Patients with VTE are high risk for readmission for the following reasons:
- Risk factors for VTE are also risk factors for readmission (i.e. age, cancer, prolonged ICU stay, central lines, etc.)
- Anticoagulant management that is difficult during care transition.
- Social/fiscal/access/psychiatric issues and challenges
The above slide presented by Dr. Maynard reflects a dramatic reduction in 30 day all cause readmission rates for patients with VTE at UC San Diego. Reducing readmissions entails a comprehensive approach in which a key aspect is to truly help to extend care beyond the walls of the hospital. “At UC San Diego,” says Dr. Maynard,” we have transition care nurses who are tasked with bridging patients from the inpatient hospital setting to after discharge”
Dr. Maynard also discussed patient adherence and its importance in an overall strategy to reducing readmissions and preventing VTE:
- Physician-prescribed medications (in particular anticoagulants) to prevent hospital readmission
- Use of sequential compression devices (SCDs) to improve DVT prevention which would prevent a potential VTE related readmission
A cited example Dr. Maynard used was ”a sequential compression device is useless if it is under the patient’s bed or hung over a bedrail. We have to make sure SCDs are prescribed and then used appropriately by the patient.” This requires patient and clinician adherence as well as a level of “real time“ monitoring to ensure the SCD use is being worn properly as prescribed.
Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health and Safety) emphasized that hospital readmissions is a lose–lose–lose scenario. Said Mr. Wong:
“Hospital and caregivers lose because they are exposed to possible readmission fiscal penalties, increased public transparency, and law suits. Patients lose because they not only suffer the inconvenience of readmission but endure adverse event that develops and possible death.”
The PPAHS presentation included discussion of three patient stories to put those affected faces as the challenge and ensuing problems associated with hospital readmissions. For a complete copy of this presentation made at the Crittenden Medical Conference April 2014, please click here.