Following surgery, as their condition improve, patients are frequently referred by hospitals to inpatient facilities such as skilled nursing homes, inpatient rehabilitation centers, home healthcare and other outpatient services. A new UCLA study, published in the February 2016 edition of the journal Medical Care, has found that frequent use of post-acute care associated with higher hospital readmission rates; thus, increasing the healthcare costs.
The researchers found that spending on post-acute care varies widely across different parts of the U.S., suggesting that medical centers in some areas may be using these services too infrequently and others may be using them more often than necessary. A recent report by the Institute of Medicine found that the primary driver of regional variations in Medicare spending is the differences in the costs of post-acute care. However, little is known about why those variations occur.
The new study revealed that some hospitals refer less than 3% of their patients to inpatient facilities, while others refer up to 40%. In addition, some hospitals prescribe home healthcare for only 3% of patients, while others refer up to 58% of patients; this variance in policy prompted the researchers to investigate whether the wide variation correlated with differences in the overall quality of care delivered by the hospitals.
For the study, the authors reviewed data for 112,620 patients treated at 217 hospitals in 39 states. They extracted information from a national surgery registry and Medicare claims, as well as from American Hospital Association annual surveys from 2005 through 2008. They calculated the correlation between post-acute care usage rates and hospital quality measures such as mortality rates, complications, readmissions and lengths of stay.
The investigators found no association between how often hospitals used post-acute care and the number of recorded postoperative deaths or complications. However, the study did discover a relationship between “indirect” measures of hospital quality, metrics such as length of stay and readmission rates, and use of post-acute care. Specifically, hospitals that tend to refer patients to inpatient facilities more often also tend to have shorter lengths of stay and higher readmission rates. “These findings suggest that some hospitals may be using post-acute care as a substitute for inpatient care,” noted lead investigator Greg Sacks, MD, a resident in general surgery at UCLA and a Robert Wood Johnson/Veterans Affairs Clinical Scholar. He added, “This might lead to patients being discharged from the hospital prematurely, which then results in higher readmission rates.”
Dr. Sacks noted that surgeons and hospitals have virtually no guidelines to help them determine the best post-acute care services for their patients, and that better recommendations could help reduce some of the variation in how the services are used and the costs associated with them. The study revealed that hospitals that referred patients to inpatient facilities most often were more likely to readmit patients within 30 days (24.1%) versus those who referred patients to inpatient facilities least often (21.2%). The study did not find a similar correlation between referrals to home healthcare and hospital readmission.
Other findings were that teaching hospitals referred patients to home healthcare 21.4% of the time, versus 18.0% for non-teaching hospitals, and hospitals with the shortest average length of stay used inpatient facilities more frequently (24% versus 19.5%). The authors also suggested that healthcare payment policies that create financial incentives for hospitals to discharge patients prematurely could be driving hospitals’ post-acute care decisions.
The authors wrote: “Our findings suggest that there is an urgent need to study the appropriate use of post-acute care to develop guidelines to assist postoperative discharge planning. The new evidence and guidelines based on that evidence would help ensure that patients receive the post-discharge care they need, while avoiding additional care they do not need.”