In 2012, Burke et al. published an article describing an
ideal process to transition patients from hospital care and avoid readmission.
About a year later, two of the four authors of that paper, Dr. Sunil Kripalani and Dr. Eduard E. Vasilevskis, together with Dr. Cecelia N. Theobald and Beth Anctil, published a follow-up in the Annual Review of Medicine. The available data states that their original model was correct.
The best way to reduce hospital readmissions appears to be a process, and not an event.
Interest in reducing readmissions is growing, and more and more data is becoming available. Although, Kripalani et al. state, better studies are needed. A review of 43 interventions found only 16 were randomized control trials.1
The available data seems to confirm the 10-domain “bridge” transition model. There is
no consistent evidence from RCTs that any one intervention by itself significantly reduced the likelihood of hospital readmission.
In fact, only 5 of the 16 trials did reduce readmissions, and 4 of those were
multicomponent intervention bundles:
Consistent with prior reviews, no one intervention component significantly reduced readmissions, although a trend was present for patient education and engaging social and community supports (p = 0.06 for each). The only significant predictor of success in reducing readmissions was the number of domains included in the intervention (p = 0.002).
The authors go on to compare three different programs which were shown to reduce readmission rates. Each involves a nurse as a “key element”, who quarterbacks at least the initial stages and plan of the discharge.
The authors also note that
successful interventions have included caregivers longitudinally throughout the discharge process,2 particularly as it relates to education, medication counseling, and planning outpatient follow-up.
The word “longitudinally” always makes my ears prick. Medical care can be extremely compartmentalized. A longitudinal view helps put all of the medical events and interventions into a context and flow. This can aid patients and providers to keep the long-term goals of health and healing in mind.
Stories were made for this. The patient’s health, the patient’s desires for care, and the expressed goal of keeping the patient out of the hospital are the impetus for action. A dedicated healthcare professional can help keep those elements in the other providers’ and patient’s mind as care progresses. Those problems to solve become the beginning of a story stretching into the future. That story involves obstacles and other characters, like Burke et al. detailed in their 10 domains.
Kripalani et al. mention technology, and how remote monitoring seems promising, although its implementation hasn’t been shown so far to actually reduce readmission.3 This isn’t to say that technology isn’t important, but it has to be understood like everything else in the process of reducing readmissions. A single event or intervention is unlikely to help. When providers and patients start understanding the narrative of what it’s going to take to keep them out of the hospital, though, all of those tools can come together to drive towards that single goal.
The article reviewed: Kripalani, Sunil, Cecelia N. Theobald, Beth Anctil, and Eduard E. Vasilevskis. “Reducing Hospital Readmission Rates: Current Strategies and Future Directions.” Annual Review of Medicine 65, no. 1 (January 14, 2014): 471–85. https://doi.org/10.1146/annurev-med-022613-090415.
1 Hansen, Luke O., Robert S. Young, Keiki Hinami, Alicia Leung, and Mark V. Williams. “Interventions to Reduce 30-Day Rehospitalization: A Systematic Review.” Annals of Internal Medicine 155, no. 8 (October 18, 2011): 520–28. https://doi.org/10.7326/0003-4819-155-8-201110180-00008. ↑
2 Coleman, Eric A., Carla Parry, Sandra Chalmers, and Sung-joon Min. “The Care Transitions Intervention.” Archives of Internal Medicine 166, no. 17 (September 25, 2006): 1822–28. https://doi.org/10.1001/archinte.166.17.1822. ↑
3 Chaudhry, Sarwat I., Jennifer A. Mattera, Jeptha P. Curtis, John A. Spertus, Jeph Herrin, Zhenqiu Lin, Christopher O. Phillips, Beth V. Hodshon, Lawton S. Cooper, and Harlan M. Krumholz. “Telemonitoring in Patients with Heart Failure.” New England Journal of Medicine 363, no. 24 (December 9, 2010): 2301–9. https://doi.org/10.1056/NEJMoa1010029. ↑
Featured Image: cropped from Stepping Stones, by Flickr user Catherine Singleton, used under a CC BY-SA 2.0 license