Hospital stressors may be catalyst for readmissions

Hospital readmissions appear to be an intractable problem, despite efforts to curb rates using interventions, penalties and other strategies. Perhaps providers and public policy leaders are focusing on the wrong target, Harlan M. Krumholz, MD, told Cardiovascular Business. His hypothesis was published Jan. 10 in the New England Journal of Medicine.

Krumholz, director of Yale-New Haven Hospital Center for Outcomes Research and Evaluation and a professor in the Yale School of Medicine in New Haven, Conn., wrote in a Perspectives article that nearly 20 percent of Medicare patients who are discharged from a hospital are readmitted within 30 days. Medicare is now penalizing hospitals that have higher than expected preventable readmission rates for three conditions—heart failure, acute MI and pneumonia.

But the cause of the readmission often is not the same as to the index admission. For instance, one study found that less than half of rehospitalizations were related to the index MI or its treatment. The percentage of readmissions that were for the same reason as the index admission were even lower for  heart failure and pneumonia, at 37 percent and 29 percent, respectively.

While many researchers suggested patients’ multiple morbidities might be the underlying reason for readmissions, Krumholz offered another possibility. “Maybe it is the cumulative effect of stressors that occur to people in a hospital in addition to their acute illness,” Krumholz said. “[Patients] come in sick, depleted and with no reserve, and then they end up being sleep deprived, their schedule is disrupted, they are malnourished, deconditioned and given medications that throw off their cognition. … Their hematologic, immunologic and metabolic systems are not working right.”

In the article, Krumholz listed the numerous stressors that may contribute to what he termed the post-hospital syndrome: interrupted and disrupted sleep that affects metabolism, cognitive performance, physical functions and coordination; poor nutrition, whether because they don’t or can’t eat or medical orders to withhold food and fluids for certain tests; a parade of healthcare professionals; pain and other discomfort; medications; and deconditioning due to limited mobility.

Providers must continue to find ways to improve transitional care and successfully treat the index condition, Krumholz said, but they should also look for opportunities to reduce or eliminate stressors during hospitalization and early recovery that may contribute to the post-hospital syndrome. “We’re focused in the life-threatening aspect, but while we are doing that can we make the hospital less toxic, more healing and prepare people better for safe passage after they go home?” he said.

He recommended interventions to reduce sleep disruption, minimize pain and stress, maximize nutrition, optimize medications and incorporating other practices to improve patients’ cognition and physical condition. He added that shorter stays, with a truncated opportunity for recovery, make this even more critical.       

“We have not historically taken this approach, but the key to improving patient outcomes after leaving the hospital and to reducing this readmissions problem might lie on paying attention to this,” he said. He emphasized the need for research to ensure that such interventions make patients less susceptible to the factors that lead to post-hospital syndrome.