When should patients be discharged following major surgeries, and what's the best option for follow-up care? The answers to these questions vary dramatically from hospital to hospital, according to a recent UCLA study.
Post-acute care — provided by home health services, skilled nursing homes or rehabilitation centers — accounts for $62 billion in annual Medicare spending. According to a recent report by the Institute of Medicine, the frequency in which hospitals use these services also contributes to wide variations in healthcare spending across different regions of the U.S.
To better understand why these variations occur and how they affect patient outcomes, UCLA researchers analyzed data for 112,620 patients treated at 217 hospitals in 39 states.
"We wanted to get more of a granular look," says Greg Sacks, MD, PhD, the study's lead investigator and a general surgery resident at the David Geffen School of Medicine at UCLA. "So we looked at the hospital level, rather than the regional level."
Findings and implications
Dr. Mayank Mehta
According to the UCLA study, published in February in the peer-reviewed journal Medical Care, some hospitals refer fewer than 3 percent of post-surgical patients to inpatient facilities, while others refer up to 40 percent. Meanwhile, some hospitals prescribe home healthcare for just 3 percent of patients; others refer up to 58 percent.
"This was after controlling for patient characteristics, such as age, how sick patients were and whether they had complications," says Dr. Sacks. "Such dramatic variations typically suggest there's either overuse of services on the high end or underuse on the low end."
The researchers dug deeper to determine how these variations affect quality of care. Their findings: Hospitals that most frequently used inpatient post-acute care facilities tended to have shorter lengths of stay and were likelier to readmit patients within 30 days (24.1 percent versus 21.2 percent for those that referred patients least often). The study found similar, but not as statistically relevant, associations between home healthcare referrals and hospital readmissions.
"Either of these findings alone — shorter lengths of stay and higher readmission rates — would make us scratch our heads," says Dr. Sacks. "But together, they suggest that some hospitals might be using post-acute care as a substitute for keeping patients in the hospital longer. Hospitals are under some pressure to reduce lengths of stay, both for medical and monetary reasons. The longer patients stay in the hospital, the more exposed they are to hospital-acquired infections. But since many are being readmitted, they might not have been ready for discharge in the first place."
Traditionally, hospitals have also had a financial incentive for discharging patients as soon as possible. "These data were from 2005 to 2008, so they don't reflect the changes made under the Affordable Care Act (ACA). Back then, hospitals would get a set amount of money for Medicare/Medicaid patients, per hospitalization," Dr. Sacks explains. "With ACA payment reforms, reimbursements are increasingly bundled payments for an entire episode of care, and hospitals are penalized for excessive readmissions. These policy changes are addressing some potentially perverse financial incentives and already seem to be reducing hospital readmission rates."
Recommendations
Dr. Sacks says their findings highlight the need for standardized guidelines on the effective usage of post-acute care.
"Medical providers don't know exactly which patients will benefit most from these services and how frequently they should be used. Currently, there are no definitive guidelines, so when to discharge patients and when to offer post-acute care are at the hospital's or physician's discretion. Having better knowledge about that would enable us to see which hospitals are over or underutilizing these services, and try to work towards hitting the sweet spot."
By Taylor Mallory Holland
