Health for life

Years ago, the Disease Management Care Blog had a pediatrician colleague who was widely admired for his diagnostic acumen, attention to treatment detail and personalized attention. As further testimony to his reputation, every physician wanted him to be their childrens doctor. The DMCB was one of those lucky docs. The luck ran out, however, when the DMCBs spouse quickly realized that she couldnt get any appointments and even if she did, the physicians clinic routinely ran two hours late.

Persons who read this New England Journal Perspective testimonial on the joy and frustrations of a primary care career should keep that physician in mind.   That reality contrasts with Dr. Finegolds fantasy world of dedicated physicians with limitless time where 1) the personal physician individually guides complex patients through a complex health care system and 2) the doctor patient relationship is fountainhead of professional satisfaction and patient well being. Thats why insurers should pay anything and policymakers should do everything they can to support this vision.

The DMCB sadly disagrees.

Primary care physicians are a precious resource. Theyre not only expensive, they are becoming more rare over time. As a result, use of their time and effort has to be restricted to circumstances when there is no one else who can deal with the paper work, make medication adjustments, work to increase treatment compliance, maximize the insurance benefit, deal with the social issues and provide psychological support. The DMCB thinks there are non-physician professionals who are better at these activities and do can do it far more cheaply. The solution is not more primary care physicians but more primary care physician support.

The DMCB physician colleagues may argue that the doctor-patient relationship is truly Holy Ground. Unfortunately, it is becoming increasingly apparent that there at too many patients and too few physicians to allow Dr. Finegolds indulgence of being so immersed in their patients lives. The degree of personalized involvement described in this article may be a luxury - like open access to brand drugs, the latest technologies, the priciest specialists or a few extra days in the hospital - that society can no longer afford.

Well talk diabetes in a sec Mrs Smith, but first, hows those darling kids?

Just being back from a whirlwind tour, the Disease Management Care Blog is happy to report that it became newly acquanted with some colleagues who are furiously at work building care management programs for newly minted integrated health systems and ACO wannabes.

They provided two big insights for the DMCB:

1) While the DMCB guesstimated that the typical ratio of care management nurses to enrollees amongthe mainstream care management service companies was in the range of 1:1500, at least two new programs are using a 1:750 ratio.  By the way, 1:800 is what was quoted in this peer reviewed article.  Thats a lot of nurses for an "accountable" population and a lot of budget for a CFO to approve. 

2) There is less of an emphasis on care manager "productivity,"  thanks to a recognition that nurse-client conversations outside hard nosed chronic illness management "engagement," "barrier identification" and "shared decision making" contribute to relationship building.  The DMCB thinks of this as "magic nursing dust" that adds to the likelihood of patient behavior change.  There are no hard data on the topic, but its important in other parts of the health care universe, so why not here?

Im baaaaack!

When persons are admitted to a hospital, insurers payment rates are based on the diagnosis, not the number of days in the hospital (known as a "length of stay").  As a result, once the admission is triggered, the hospital has important economic incentive to discharge the patient as quickly as possible.  The Disease Management Care Blogs physician colleagues used to refer to this as "treat, then street."

Unfortunately, discharging patients too soon can result in readmissions.  Thats why the DMCB has agreed with others that diagnosis-based payment systems and a policy of "no pay" for readmissions were working at cross purposes.  Unified bundled payment approaches like this seem to be a good start.

But thats all theoretical.  Whats the science have to say?

Peter Kaboli and colleagues looked at the push-pull relationship between diagnosis-based payment incentives  and the likelihood of readmissions in a scientific paper just published in the Annals of Internal Medicine. 

The authors used the U.S. Veterans Administration (VA) Hospitals "Patient Treatment Files" to examine length of stay versus readmissions in 129 VA hospitals.  The sample consisted of over 4 million admissions and readmissions (defined as within 30 days and not involving another institution) from 1997 to 2010. The mean age started out at 63.8 years and increased to 65.5 years, while the proportion of persons aged 85 years or older increased from 2.5% to 8.8%. Over the years, admissions also grew more complicated with a higher rate of co-morbid conditions, such as diseases of the kidney (from 5% to 16%).

As length of stay went down, readmissions should have gone up, right?

The answer was yes and no.

Yes, if the data were trended over time: Over the 14 year period of observation, the number of days in the hospital (length of stay or LOS) decreased from 6.0 days to 4.3 days.  Yet, as LOS decreased, readmissions also decreased from 16.6% to 15.2%. 

The decreases held up when the LOS was risk-adjusted for hospital and patient characteristics.  There was also no increase in mortality rates

No, if hospitals were compared to each other:  Hospitals with risk-adjusted low lengths of stay had higher readmission rates compared to their average peers.  In that group, each day of saved LOS was associated with a 6% increased rate of 30-day readmissions.

It gets even more complicated.  As the LOS increased beyond the average, each additional day in the hospital was associated with a 3% increased rate of 30-day readmissions.

What should the DMCB learn from these data?  Keeping in mind that the VA is not necessarily generalizable to the typical community medical center,

1. Over 14 years of worth of VA data for 129 hospitals suggest it is possible to have your cake (a lower LOS) and eat it too (lower readmissions).  Thats the good news.

2. While overall performance improved over the years, between hospital comparisons showed there is a "U" shaped relationship between days in the hospital and the likelihood of readmission.  The DMCB agrees with the authors: premature discharge before the patient is ready is associated with an 6% per day readmission rate, while patients who are very sick and have to stay a few extra days in the hospital are also at risk to the tune of 3% per day.  Thats the sobering news.

What are the implications?

Overzealous efforts to discharge patients can backfire with readmissions.  It appears theres an optimum length of stay that minimizes, but will never eliminate, readmissions.

Patients who do go home "too soon" or need extra days in the hospital appear to be at special risk.  Accountable care organizations and population health management service providers should use this information to target patients at special risk of "treat, street and... repeat."