The evaluation of quality for hospitals is complex. One of the routine and key measures of quality is the re-admission rate. This is how often does a population with a certain condition who gets discharged from a hospital return for another inpatient stay within 30 days. The idea is that at least some re-admissions are preventable through better post-discharge planning, support and interventions. From this idea, preventing the preventable re-admissions leads to better care and quality while also plausibly saving money. Facially this makes sense.
There are a lot of issues with this measure for this construct of quality, but I want to probe at something that has been bugging me for a year or more now.
There is an assumption that the marginal admission is mostly constant. The model assumes that there is always a bed available. The model also assumes that some patients should always be admitted/re-admitted to the hospital and some patients have a health status that dictates that they should never be re-admitted to the hospital. However there are some patients who could benefit from a hospitalization but who could also be just fine so the decision to send someone upstairs to an inpatient bed is a coin flip. These are the marginal patients.
In non-COVID times, the marginal patient might be pretty damn close to a constant over time and space once we take into account hospital and physician fixed effects and any regional trends. If that is the case, then there are other issues with readmission rates but a basic measurement problem can be waived away. However I don’t think the assumption that the marginal patient is a constant is a good assumption in COVID times. We know that the marginal patient admitted to a New York City hospital in April 2020 is very different than the marginal patient admitted to a New York City hospital in August 2020 much less April 2022. We know that entire regions were down to a handful of staffed beds available at different times. We know, in discussions with clinicians, that patients in pre-COVID times that would have been NO DOUBT ABOUT IT, ADMIT THEM, were being sent home with instructions to call if things got really bad.
More simply, someone who normatively should be re-admitted won’t be re-admitted if there is no staffed bed available for them to be readmitted to. Pulling this speculation a step further back, we could plausibly expect to see readmission rates decrease in regions/hospitals with COVID surges more than regions where COVID was not as severe at a given time just because the marginal patient who was discharged does not have a bed available to be re-admitted.
There are other factors at play here. We could plausibly believe that the severity of people who get initially admitted in high COVID region/times may be higher than those who would have been admitted to that same hospital in a no-COVID counterfactual or admitted to hospitals in low COVID regions/times. This higher hypothetical severity could lead to more re-admissions balancing or swamping the marginal patient problem. It is also conceivable that patients admitted to a hospital in high COVID region/time get less intensive care or less bed days due to a need of the hospital to clear a bed faster and thus leading to more re-admissions.
I think all of those stories are plausible right now. As a reviewer, I’m having a hard time figuring out what I should learn when a manuscript shows differences in re-admission rates across regions and time when the time period includes 2020-2022, and especially 2020-2021.
J R in WV
Wife has been to our local teaching hospital ER twice since February, stroke like symptoms in Feb, admitted, but only after spending 2 days in a tiny treatment room in the ER. Once a bed opened up she was visited by a neurosurgeon who shared her diagnosis of Spinal Stennosis causing the stroke like symptoms.
All the hospital rooms built for two patients had only a single bed, which cuts the number of available beds nearly in half. Plus many of their excellent staff were lured away by sensationally high salaries for RNs willing to travel to areas with staff shortages but plenty of money.
Her second visit was because of a very low blood oxygen level. The ER was pretty much a barely controlled madhouse, they were treating patients out in the waiting room.We listened helplessly while a woman seated very near us was told they had found a large mass involving her abdominal organs. I’m glad Wife doesn’t remember anything of those ER visits, but they did save her life.
Wife was quickly diagnosed with pneumonia and spent 6 days on IV antibiotics, also kept in an ER exam room for a couple of days until a room and staff could be found for her
Our medical infrastructure needs a big dose of rehab ASAP, based upon my first hand experiences~!!~ We are typically and deliberately totally unprepared for any nation-wide medical emergency!
doG prevent we have two plagues at once!Ā Refrigerated Trailers will be everywhere, full of bodies of people who could have been saved with a medical infrastructure designed with enough slack to deal with just such emergencies.
BradF
Why would you want to?
For the same reason, CMS suspended measures related to ACO/MSSP performance during the bulk of the pandemic because (they are not valid), no study should include (nor should you have much of interest) examining readmits during the same period.
Why would you want to study this mess for the reasons you cite? I do this for a living, and I am not interested in future papers including 2020-21. FUBAR data.
Brad
Justinb
//lurk
I’m not sure who else to ask, but if anyone knows the answer, I figure Jackals might.
In May, I was blue sheeted to the ER by my wife (who is an RN and has my medical POA, so I trust her), as AMS. So far, so good (well, aside from the trauma :). I was moved from there to Neuropsychiatry, where I was monitored and tested in a variety of ways for about 10 days. The hospital is now billing me for > $1200, which I understand, and insurance isn’t covering any except the ER charges (the hospital isn’t in network). Obviously, the testing and admission were not optional, and TBH, I was not capable enough to understand the transfer at that time anyway. In my view, the whole thing was an outgrowth of the original ER admission and should be covered (or so I’d like to believe) that way. This is Utah, the hospital is University of Utah, and insurance is Anthem Blue Cross/Blue Shield. I don’t want to call anybody before I understand what’s really going on – anybody?
//lurk
Justinb
Comment/question went poof? Weird.
David Anderson
@Justinb: Our spam filter on the back end has been a bit titchy lately.
David Anderson
@Justinb: From what you are saying, I understand the following sequence:
Is that correct?
I think the insurer is covering most of the inpatient admission if you are only get hit for $1200 as an inpatient day is usually $2000 to $3000 so this could be a coinsurance or a deductible.
I would recommend talking to an insurance navigator or an agent and show them both the bill and any explanation of benefits that you get to get more information.
I don’t think, on first glance, that you’re getting unfairly screwed.
David Anderson
@BradF: That is where my gut is telling me to go, but I’ve seen a few papers with re-admissions as a metric and I’ve not had a good reason beyond gut
justinb
@David Anderson: Thank you. The $1200 does seem low for that much time. I do understand the need for pretty much 24/7 EEG monitoring, and in retrospect, it doesn’t seem like a bad deal. I don’t remember much of it, until the transfer to neurology, but reading the notes I was totally off my rocker, and nobody could see why. No drugs, booze, nada. Since then, I’ve been having seizures periodically, though, so my wiring is perhaps a bit off