Christopher Moriates, MD, SFHM

There is at least one aspect of “Obamacare” that my mother-in-law and I can firmly agree on: Hospitals should not get paid for frequent readmissions.

The Hospital Readmission Reduction Program (HRRP), enacted by the Centers for Medicare & Medicaid Services in 2012 with the goal of penalizing hospitals for excessive readmissions, has great face validity – and noble intentions. Does it also have a potentially disastrous downside?

On one side of the coin, the HRRP has been a remarkable success. It moved the national needle significantly on readmission rates. Yes, there are some caveats about increases in observation status patients and other shifts that could account for some of the difference, but it is fairly uncontroversial that overall, there are fewer 30-day readmissions across the country following initiation of HRRP. That is perhaps encouraging evidence of the potential positive impact that policy can make to drive changes for specific targets.

However, there is also a murkier – and more controversial – side. There have been a number of studies that have suggested reductions in readmission rates may have been associated with an increase in mortality in some patient groups. You discharge a patient and hope they won’t return to the hospital, but perhaps you should be more careful what you actually wish for.

Overall, the evidence of an association between readmissions and mortality has been complicated and conflicting. Headlines have alternately raised alarm about increased deaths and then reassured that there has been no change or perhaps even some concordant improvements in mortality. Not necessarily surprising, considering that these studies are all unavoidably of observational design and use different criteria, datasets and analytic models, which then drive their seemingly conflicting results.

An article published recently in the Journal of Hospital Medicine enters into this fray. The researchers examined the potential association between changes in rates of chronic obstructive pulmonary disease (COPD) readmissions and 30-day mortality following HRRP introduction. While the initial HRRP program and subsequent analyses included patients with heart failure, acute MI, and pneumonia, the program was extended in 2014 to include patients with COPD. So, what happened in this patient group?

Through a number of statistical gymnastics, which as a nonstatistician I am having difficulty truly wrapping my head around, the researchers seem to have found a number of important insights:

• The all-cause 30-day risk-standardized readmission rate declined from 2010 to 2017.
• The all-cause 30-day risk-standardized mortality rate increased from 2010 to 2017, and the rate of increase in mortality appears to be accelerating.
• Hospitals with higher readmission rates prior to COPD readmission penalties had a lower rate of increase in mortalities.
• Hospitals that had a larger decrease in readmission rates had a larger rate of increase in mortality.

These researchers could not evaluate data at the patient level and could not adjust for changes in disease severity. However, taken together, these findings suggest that something bad may be truly happening here.

The authors of this study also point out that the associations with increased mortality have largely been seen in patients with heart failure – and now in patients with COPD – which are both chronic diseases characterized by exacerbations, as opposed to acute MI and pneumonia, which are episodic and treatable. Perhaps in those types of disease, efforts to avoid readmissions may be more universally helpful. Maybe.

Even if it is challenging for me to adjudicate the complicated methods and results of this study, I find it concerning that there is “biological plausibility” for this association. Hospitalists know exactly how this might have happened. Have you heard of the pop-up alerts that fire in the emergency department to let the physicians know that this patient was discharged within the past 30 days? You know that alert is not meant to tell you what to do, but you just might want to consider trying to discharge them or at least place them in observation – use your clinical judgment, if you know what I mean.

Within the past decade, observation units quickly cropped up all over the country, often not staffed by hospitalists nor cardiologists, where patients with decompensated heart failure, chest pain, and/or COPD, can be given Lasix and/or nebulizer treatments – at least just enough to let them walk on back out that door without a hospital admission.

At the end of the day, whether mortality rates have truly increased in the real world, this well-intentioned program seems to have serious issues. As Ashish Jha, MD, wrote in 2018, “Right now, a high-readmission, low-mortality hospital will be penalized at 6-10 times the rate of a low-readmission, high-mortality hospital. The signal from policy makers is clear – readmissions matter a lot more than mortality – and this signal needs to stop.”

Dr. Moriates is a hospitalist, the assistant dean for health care value, and an associate professor of internal medicine at Dell Medical School at University of Texas, Austin. He is also director of implementation initiatives at Costs of Care. This article first appeared on the Hospital Leader, SHM’s official blog, at hospitalleader.org.

There is at least one aspect of “Obamacare” that my mother-in-law and I can firmly agree on: Hospitals should not get paid for frequent readmissions.

The Hospital Readmission Reduction Program (HRRP), enacted by the Centers for Medicare & Medicaid Services in 2012 with the goal of penalizing hospitals for excessive readmissions, has great face validity – and noble intentions. Does it also have a potentially disastrous downside?

On one side of the coin, the HRRP has been a remarkable success. It moved the national needle significantly on readmission rates. Yes, there are some caveats about increases in observation status patients and other shifts that could account for some of the difference, but it is fairly uncontroversial that overall, there are fewer 30-day readmissions across the country following initiation of HRRP. That is perhaps encouraging evidence of the potential positive impact that policy can make to drive changes for specific targets.

However, there is also a murkier – and more controversial – side. There have been a number of studies that have suggested reductions in readmission rates may have been associated with an increase in mortality in some patient groups. You discharge a patient and hope they won’t return to the hospital, but perhaps you should be more careful what you actually wish for.

Overall, the evidence of an association between readmissions and mortality has been complicated and conflicting. Headlines have alternately raised alarm about increased deaths and then reassured that there has been no change or perhaps even some concordant improvements in mortality. Not necessarily surprising, considering that these studies are all unavoidably of observational design and use different criteria, datasets and analytic models, which then drive their seemingly conflicting results.

An article published recently in the Journal of Hospital Medicine enters into this fray. The researchers examined the potential association between changes in rates of chronic obstructive pulmonary disease (COPD) readmissions and 30-day mortality following HRRP introduction. While the initial HRRP program and subsequent analyses included patients with heart failure, acute MI, and pneumonia, the program was extended in 2014 to include patients with COPD. So, what happened in this patient group?

Through a number of statistical gymnastics, which as a nonstatistician I am having difficulty truly wrapping my head around, the researchers seem to have found a number of important insights:

• The all-cause 30-day risk-standardized readmission rate declined from 2010 to 2017.
• The all-cause 30-day risk-standardized mortality rate increased from 2010 to 2017, and the rate of increase in mortality appears to be accelerating.
• Hospitals with higher readmission rates prior to COPD readmission penalties had a lower rate of increase in mortalities.
• Hospitals that had a larger decrease in readmission rates had a larger rate of increase in mortality.

These researchers could not evaluate data at the patient level and could not adjust for changes in disease severity. However, taken together, these findings suggest that something bad may be truly happening here.

The authors of this study also point out that the associations with increased mortality have largely been seen in patients with heart failure – and now in patients with COPD – which are both chronic diseases characterized by exacerbations, as opposed to acute MI and pneumonia, which are episodic and treatable. Perhaps in those types of disease, efforts to avoid readmissions may be more universally helpful. Maybe.

Even if it is challenging for me to adjudicate the complicated methods and results of this study, I find it concerning that there is “biological plausibility” for this association. Hospitalists know exactly how this might have happened. Have you heard of the pop-up alerts that fire in the emergency department to let the physicians know that this patient was discharged within the past 30 days? You know that alert is not meant to tell you what to do, but you just might want to consider trying to discharge them or at least place them in observation – use your clinical judgment, if you know what I mean.

Within the past decade, observation units quickly cropped up all over the country, often not staffed by hospitalists nor cardiologists, where patients with decompensated heart failure, chest pain, and/or COPD, can be given Lasix and/or nebulizer treatments – at least just enough to let them walk on back out that door without a hospital admission.

At the end of the day, whether mortality rates have truly increased in the real world, this well-intentioned program seems to have serious issues. As Ashish Jha, MD, wrote in 2018, “Right now, a high-readmission, low-mortality hospital will be penalized at 6-10 times the rate of a low-readmission, high-mortality hospital. The signal from policy makers is clear – readmissions matter a lot more than mortality – and this signal needs to stop.”

Dr. Moriates is a hospitalist, the assistant dean for health care value, and an associate professor of internal medicine at Dell Medical School at University of Texas, Austin. He is also director of implementation initiatives at Costs of Care. This article first appeared on the Hospital Leader, SHM’s official blog, at hospitalleader.org.

There is at least one aspect of “Obamacare” that my mother-in-law and I can firmly agree on: Hospitals should not get paid for frequent readmissions.

The Hospital Readmission Reduction Program (HRRP), enacted by the Centers for Medicare & Medicaid Services in 2012 with the goal of penalizing hospitals for excessive readmissions, has great face validity – and noble intentions. Does it also have a potentially disastrous downside?

On one side of the coin, the HRRP has been a remarkable success. It moved the national needle significantly on readmission rates. Yes, there are some caveats about increases in observation status patients and other shifts that could account for some of the difference, but it is fairly uncontroversial that overall, there are fewer 30-day readmissions across the country following initiation of HRRP. That is perhaps encouraging evidence of the potential positive impact that policy can make to drive changes for specific targets.

However, there is also a murkier – and more controversial – side. There have been a number of studies that have suggested reductions in readmission rates may have been associated with an increase in mortality in some patient groups. You discharge a patient and hope they won’t return to the hospital, but perhaps you should be more careful what you actually wish for.

Overall, the evidence of an association between readmissions and mortality has been complicated and conflicting. Headlines have alternately raised alarm about increased deaths and then reassured that there has been no change or perhaps even some concordant improvements in mortality. Not necessarily surprising, considering that these studies are all unavoidably of observational design and use different criteria, datasets and analytic models, which then drive their seemingly conflicting results.

An article published recently in the Journal of Hospital Medicine enters into this fray. The researchers examined the potential association between changes in rates of chronic obstructive pulmonary disease (COPD) readmissions and 30-day mortality following HRRP introduction. While the initial HRRP program and subsequent analyses included patients with heart failure, acute MI, and pneumonia, the program was extended in 2014 to include patients with COPD. So, what happened in this patient group?

Through a number of statistical gymnastics, which as a nonstatistician I am having difficulty truly wrapping my head around, the researchers seem to have found a number of important insights:

• The all-cause 30-day risk-standardized readmission rate declined from 2010 to 2017.
• The all-cause 30-day risk-standardized mortality rate increased from 2010 to 2017, and the rate of increase in mortality appears to be accelerating.
• Hospitals with higher readmission rates prior to COPD readmission penalties had a lower rate of increase in mortalities.
• Hospitals that had a larger decrease in readmission rates had a larger rate of increase in mortality.

These researchers could not evaluate data at the patient level and could not adjust for changes in disease severity. However, taken together, these findings suggest that something bad may be truly happening here.

The authors of this study also point out that the associations with increased mortality have largely been seen in patients with heart failure – and now in patients with COPD – which are both chronic diseases characterized by exacerbations, as opposed to acute MI and pneumonia, which are episodic and treatable. Perhaps in those types of disease, efforts to avoid readmissions may be more universally helpful. Maybe.

Even if it is challenging for me to adjudicate the complicated methods and results of this study, I find it concerning that there is “biological plausibility” for this association. Hospitalists know exactly how this might have happened. Have you heard of the pop-up alerts that fire in the emergency department to let the physicians know that this patient was discharged within the past 30 days? You know that alert is not meant to tell you what to do, but you just might want to consider trying to discharge them or at least place them in observation – use your clinical judgment, if you know what I mean.

Within the past decade, observation units quickly cropped up all over the country, often not staffed by hospitalists nor cardiologists, where patients with decompensated heart failure, chest pain, and/or COPD, can be given Lasix and/or nebulizer treatments – at least just enough to let them walk on back out that door without a hospital admission.

At the end of the day, whether mortality rates have truly increased in the real world, this well-intentioned program seems to have serious issues. As Ashish Jha, MD, wrote in 2018, “Right now, a high-readmission, low-mortality hospital will be penalized at 6-10 times the rate of a low-readmission, high-mortality hospital. The signal from policy makers is clear – readmissions matter a lot more than mortality – and this signal needs to stop.”

Dr. Moriates is a hospitalist, the assistant dean for health care value, and an associate professor of internal medicine at Dell Medical School at University of Texas, Austin. He is also director of implementation initiatives at Costs of Care. This article first appeared on the Hospital Leader, SHM’s official blog, at hospitalleader.org.

“You can teach a canary in a coal mine to meditate, but it is still going to die.”

I have seen the canary sentiment above – used as a metaphor for health care and burnout – pop up a few times on Twitter, attributed to a few different thoughtful doctors, including Jenny Ramsey, MD, of the Cleveland Clinic (at Hospital Medicine 2018); Lucy Kalanithi, MD, a clinical assistant professor of medicine at Stanford (Calif.) University and widow of Paul Kalanithi, MD, of “When Breath Becomes Air” fame; and Stuart Slavin, MD, associate dean for curriculum and a professor of pediatrics at Saint Louis University.

To be honest, I am rather burned out on reading about physician burnout at this point. Nevertheless, I love the canary idea; it is such a perfect visual of the current problem facing physicians.

I was thinking about the meditating canary when I read the new “Charter on Physician Well-Being,” published in JAMA and already endorsed by most major medical organizations/acronyms, including SHM, ACP, SGIM, AMA, AAMC, AAIM, ABIM, ACCME, APA, and the IHI. This physician well-being charter was created by the Collaborative for Healing and Renewal in Medicine, a group that includes leading medical centers and organizations.

What makes this different from previous attempts at addressing burnout? The charter takes a systems-based approach to physician well-being. Aha, of course! As the patient safety movement realized more than 2 decades ago, real progress would only be made when we stopped focusing our attention, blame, and interventions on individuals and instead looked at systems; now, the physician well-being movement has officially made the same bold proclamation.

It is not the fault of the burned-out physician who apparently just needs to be hammered over the head with better coping skills – just as the majority of medical errors would not be fixed by continuing to tell physicians that they screwed up and should figure out how not to do that again!

We need to make real changes to the system. For example, one of the charter’s authors, Colin P. West, MD, PhD, highlighted why it is important that organizations commit to optimizing highly functioning interprofessional teams: “Can you imagine @KingJames [LeBron James] or @Oprah applying their unique skills AND personally seating the crowd, collecting stats, assessing satisfaction, etc.? So why do we?”

The authors also call for organizations to commit to reducing time spent on documentation and administration. Hallelujah!

Now the question is whether this charter will actually have any teeth or whether it will have the same fate as our canary, slowly fading away, never to be heard from again?

Read the full post at hospitalleader.org.

Dr. Moriates is the assistant dean for health care value and an associate professor of internal medicine at the University of Texas, Austin.
 

Also in The Hospital Leader

“What’s a Cost, Charge, and Price?” by Brad Flansbaum, DO, MPH, MHM

“There Is a ‘You’ in Team,” by Tracy Cardin, ACNP-BC, SFHM

“‘Harper’s Index’ of Hospital Medicine 2018,” by Jordan Messler, MD, SFHM

“You can teach a canary in a coal mine to meditate, but it is still going to die.”

I have seen the canary sentiment above – used as a metaphor for health care and burnout – pop up a few times on Twitter, attributed to a few different thoughtful doctors, including Jenny Ramsey, MD, of the Cleveland Clinic (at Hospital Medicine 2018); Lucy Kalanithi, MD, a clinical assistant professor of medicine at Stanford (Calif.) University and widow of Paul Kalanithi, MD, of “When Breath Becomes Air” fame; and Stuart Slavin, MD, associate dean for curriculum and a professor of pediatrics at Saint Louis University.

To be honest, I am rather burned out on reading about physician burnout at this point. Nevertheless, I love the canary idea; it is such a perfect visual of the current problem facing physicians.

I was thinking about the meditating canary when I read the new “Charter on Physician Well-Being,” published in JAMA and already endorsed by most major medical organizations/acronyms, including SHM, ACP, SGIM, AMA, AAMC, AAIM, ABIM, ACCME, APA, and the IHI. This physician well-being charter was created by the Collaborative for Healing and Renewal in Medicine, a group that includes leading medical centers and organizations.

What makes this different from previous attempts at addressing burnout? The charter takes a systems-based approach to physician well-being. Aha, of course! As the patient safety movement realized more than 2 decades ago, real progress would only be made when we stopped focusing our attention, blame, and interventions on individuals and instead looked at systems; now, the physician well-being movement has officially made the same bold proclamation.

It is not the fault of the burned-out physician who apparently just needs to be hammered over the head with better coping skills – just as the majority of medical errors would not be fixed by continuing to tell physicians that they screwed up and should figure out how not to do that again!

We need to make real changes to the system. For example, one of the charter’s authors, Colin P. West, MD, PhD, highlighted why it is important that organizations commit to optimizing highly functioning interprofessional teams: “Can you imagine @KingJames [LeBron James] or @Oprah applying their unique skills AND personally seating the crowd, collecting stats, assessing satisfaction, etc.? So why do we?”

The authors also call for organizations to commit to reducing time spent on documentation and administration. Hallelujah!

Now the question is whether this charter will actually have any teeth or whether it will have the same fate as our canary, slowly fading away, never to be heard from again?

Read the full post at hospitalleader.org.

Dr. Moriates is the assistant dean for health care value and an associate professor of internal medicine at the University of Texas, Austin.
 

Also in The Hospital Leader

“What’s a Cost, Charge, and Price?” by Brad Flansbaum, DO, MPH, MHM

“There Is a ‘You’ in Team,” by Tracy Cardin, ACNP-BC, SFHM

“‘Harper’s Index’ of Hospital Medicine 2018,” by Jordan Messler, MD, SFHM

“You can teach a canary in a coal mine to meditate, but it is still going to die.”

I have seen the canary sentiment above – used as a metaphor for health care and burnout – pop up a few times on Twitter, attributed to a few different thoughtful doctors, including Jenny Ramsey, MD, of the Cleveland Clinic (at Hospital Medicine 2018); Lucy Kalanithi, MD, a clinical assistant professor of medicine at Stanford (Calif.) University and widow of Paul Kalanithi, MD, of “When Breath Becomes Air” fame; and Stuart Slavin, MD, associate dean for curriculum and a professor of pediatrics at Saint Louis University.

To be honest, I am rather burned out on reading about physician burnout at this point. Nevertheless, I love the canary idea; it is such a perfect visual of the current problem facing physicians.

I was thinking about the meditating canary when I read the new “Charter on Physician Well-Being,” published in JAMA and already endorsed by most major medical organizations/acronyms, including SHM, ACP, SGIM, AMA, AAMC, AAIM, ABIM, ACCME, APA, and the IHI. This physician well-being charter was created by the Collaborative for Healing and Renewal in Medicine, a group that includes leading medical centers and organizations.

What makes this different from previous attempts at addressing burnout? The charter takes a systems-based approach to physician well-being. Aha, of course! As the patient safety movement realized more than 2 decades ago, real progress would only be made when we stopped focusing our attention, blame, and interventions on individuals and instead looked at systems; now, the physician well-being movement has officially made the same bold proclamation.

It is not the fault of the burned-out physician who apparently just needs to be hammered over the head with better coping skills – just as the majority of medical errors would not be fixed by continuing to tell physicians that they screwed up and should figure out how not to do that again!

We need to make real changes to the system. For example, one of the charter’s authors, Colin P. West, MD, PhD, highlighted why it is important that organizations commit to optimizing highly functioning interprofessional teams: “Can you imagine @KingJames [LeBron James] or @Oprah applying their unique skills AND personally seating the crowd, collecting stats, assessing satisfaction, etc.? So why do we?”

The authors also call for organizations to commit to reducing time spent on documentation and administration. Hallelujah!

Now the question is whether this charter will actually have any teeth or whether it will have the same fate as our canary, slowly fading away, never to be heard from again?

Read the full post at hospitalleader.org.

Dr. Moriates is the assistant dean for health care value and an associate professor of internal medicine at the University of Texas, Austin.
 

Also in The Hospital Leader

“What’s a Cost, Charge, and Price?” by Brad Flansbaum, DO, MPH, MHM

“There Is a ‘You’ in Team,” by Tracy Cardin, ACNP-BC, SFHM

“‘Harper’s Index’ of Hospital Medicine 2018,” by Jordan Messler, MD, SFHM

“We are playing the same sport, but a different game,” the wise, thoughtful emergency medicine attending physician once told me. “I am playing speed chess – I need to make a move quickly, or I lose – no matter what. My moves have to be right, but they don’t always necessarily need to be the optimal one. I am not always thinking five moves ahead. You guys [in internal medicine] are playing master chess. You have more time, but that means you are trying to always think about the whole game and make the best move possible.”

Also on The Hospital Leader …

• How Hospitalists See the Forgotten Victims of Gun Violence by Vineet Arora, MD, MAPP, MHM
• Hospitals, Hospice and SNFs: The Big Deceit by Brad Flansbaum, DO, MPH, MHM
• But He’s a Good Doctor by Leslie Flores, MHA, SFHM

“We are playing the same sport, but a different game,” the wise, thoughtful emergency medicine attending physician once told me. “I am playing speed chess – I need to make a move quickly, or I lose – no matter what. My moves have to be right, but they don’t always necessarily need to be the optimal one. I am not always thinking five moves ahead. You guys [in internal medicine] are playing master chess. You have more time, but that means you are trying to always think about the whole game and make the best move possible.”

Also on The Hospital Leader …

• How Hospitalists See the Forgotten Victims of Gun Violence by Vineet Arora, MD, MAPP, MHM
• Hospitals, Hospice and SNFs: The Big Deceit by Brad Flansbaum, DO, MPH, MHM
• But He’s a Good Doctor by Leslie Flores, MHA, SFHM

“We are playing the same sport, but a different game,” the wise, thoughtful emergency medicine attending physician once told me. “I am playing speed chess – I need to make a move quickly, or I lose – no matter what. My moves have to be right, but they don’t always necessarily need to be the optimal one. I am not always thinking five moves ahead. You guys [in internal medicine] are playing master chess. You have more time, but that means you are trying to always think about the whole game and make the best move possible.”

Also on The Hospital Leader …

• How Hospitalists See the Forgotten Victims of Gun Violence by Vineet Arora, MD, MAPP, MHM
• Hospitals, Hospice and SNFs: The Big Deceit by Brad Flansbaum, DO, MPH, MHM
• But He’s a Good Doctor by Leslie Flores, MHA, SFHM