nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Tuesday, July 13, 2010

Re-Admission To The Hospital May Be A Poor Health Quality Measure

When you judge the quality of a hospital, there are a number of indicators:  wound infection rates, mortality, C-section rates, and re-admission within 30 days.  But the last of these may not be bad.

If you get admitted to the hospital for heart failure, undergo treatment to treat the condition, get sent home improved, and on treatment...that's a pretty good deal.  Heart failure is something that is almost never "cured," unless you get a new one (heart, that is).  But treatment can extend life for years.

You're now at home, doing well at first, but for some reason your condition worsens and you need to be re-admitted to the hospital.

Medicare views "readmission for any reason after an index hospitalization for heart failure as a sign of poor quality of care."  Comparisons by government agencies such as this one from Medicare will be the foundation for judging the health care we receive in this country under HCR.

Medicare reasons anything that could go wrong in the first 30 days should have been foreseen or addressed in the first admission.

At first glance, that sounds reasonable.  BUT, a closer look at Medicare's database shows that  lower readmission rates (good) are associated with higher death rates (bad).

Perversely, Medicare's quality measure could reward hospitals for more patients dying of heart failure.  Take a look at the graph:

The y-axis is 30 day mortality rate.  The x-axis is the 30 day readmission rate.  Put simply, the choices here are "how many die" on the left and "how many go home for a while, but have to come back", on the right.  Note that the chance of dying is higher when the re-admission rate is lower.  [Sorry for the poor quality graph, it's so hot-off-the-press, the online version isn't up yet]

So which would you choose?  The hospital that has a higher death rate, or the one that has a higher re-admission rate?

Clearly one way to have a low re-admission rate--which Medicare thinks is an indicator of high quality care--is to have more patients die.  Then they don't come back.  Voila!

The authors of this letter to the editor of the New England Journal, July 15 ("Are All Readmissions Bad Readmissions?") diplomatically suggest that a "nuanced" interpretation of Medicare quality data is needed.

I suggest we stop implementing crappy assessments of medical care quality.  In my experience, health care quality is always complex and "nuanced."

Doc D

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