Many Medicare patients return soon after hospital discharge

Readmissions within days of discharge cost program billions

One in five Medicare patients are readmitted to the hospital within 30 days of being discharged—and one in three are back within 90 days—in large part because they lacked a primary care provider, according to a new national study released Wednesday.

More than half of the nonsurgical patients in the study had not seen a doctor prior to being re-hospitalized.

The study, published in this week's New England Journal of Medicine, put the cost of the readmissions at $17.4 billion, a significant amount of the $103 billion paid by Medicare to hospitals in 2004, the most recent year for which figures were available.

The five most common medical conditions requiring readmission were heart failure, pneumonia, chronic obstructive pulmonary disease, psychosis and gastrointestinal problems. The five most common surgical procedures were cardiac stent placement, major hip or knee surgery, vascular surgery, major bowel surgery and other hip or femur surgery.

The study analyzed hospital data for almost 12 million patients enrolled in the Medicare program between Oct. 1, 2003 and Dec. 31, 2004.

Readmission rates rose over time; 19.6 percent of patients had to be hospitalized within 30 days of discharge, 34 percent within 90 days and 56.1 percent within a year. Rates varied by state, ranging from 13 percent in Idaho to 23 percent in the District of Columbia. Illinois was almost 22 percent.

Having to be readmitted to a hospital so soon after being discharged can be emotionally devastating for elderly patients, especially when it could have been prevented, a study co-author said.

"A lot of these patients come into the hospital extremely sick, sometimes near death, and when they recuperate and leave the hospital they don't want to return," said Dr. Mark Williams, chief of hospital medicine at Northwestern University Feinberg School of Medicine. "It's very frustrating and scary, especially for elderly patients with multiple medical problems."

Seventy percent of the patients admitted after surgery suffered from a medical problem such as urinary tract infection or pneumonia.

A number of factors might be contributing to the high readmissions rate. Many patients do not have a primary care provider or can't get an appointment right away, Williams said. Some may not be able to afford their medications or are not taking them as prescribed.

"Additionally, there is significant pressure in a lot of hospitals that are filled to capacity to move patients to the outpatient setting as quickly as possible," Williams said. Ten years ago, patients were hospitalized about seven to 10 days on average. Today it's more like four days, he said.

"These high rates may result, in part, from inadequate coordination of care and poor discharge planning, since half of the patients who were readmitted within 30 days had no ambulatory visit before the rehospitalization," wrote Harvard's Dr. Arnold Epstein in an editorial that accompanied the study.

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