The Penetrating Point

Since the introduction of defibrillation and closed chest cardiopulmonary resuscitation (CPR) in the 1950s, the ability to revive an arrested heart has been a realized possibility. Around the same time, endotracheal intubation with mechanical ventilation (MV) came into wide practice, allowing doctors to augment or even replace their patients' breathing. But just as the 1950s and 1960s saw the rise of these enhanced medical techniques, they also saw the increased importance of medical ethicsin particular, patient autonomy. A natural reaction to medicine's use of CPR and MV was the advent of advance directives and more specific do‐not‐resuscitate (DNR) and do‐not‐intubate (DNI) orders meant to protect a patient's ability to remain autonomous with their end of life decisions.[1]

Unfortunately, the code status discussions that lead to these orders often collapse cardiac arrest with prearrest respiratory failure and CPR with MV.[2, 3] This is a problem for a number of reasons. First, cardiac arrest and prearrest respiratory failure are unique end points, and though their respective treatments (CPR and MV) are often required simultaneously for an individual patient, they are distinct medical interventions with different goals, indications, and associated disease states. Although MV is typically a part of the cadre of interventions meant to ensure continued tissue oxygenation in the setting of a cardiac arrest, this accounts for <2% of indications for MV.[4] The vast majority of MV is used to treat prearrest causes of respiratory failure, such as pneumonia, congestive heart failure, acute exacerbations of chronic obstructive pulmonary disease, and following surgery.[4]

We do not believe these differences are adequately reflected in typical code status discussions.[2, 3] One study using audio‐recorded admission encounters included transcripts of hospitalist‐led code status discussions that all resembled the following: Physician: [I]f an emergency were to happenand your heart would (stop) or your breathing became so difficult that you needed to be attached to machines, would you want the nurses and doctors to attempt heroic measures to try to restart your heart and attach you to a breathing machine?[2] It would come as little surprise if a patient hearing this assumed that just 1 question were being asked and that decisions relating to any cause of respiratory failure (including prearrest causes) were being made. In practice, many physicians then extrapolate DNR orders to other treatment decision (including MV) and interpret them as precluding intubation, even for prearrest states.[5, 6, 7]

A second issue is that the mortality associated with cardiopulmonary arrest requiring CPR and prearrest respiratory failure requiring MV are not equal. Though the mortality after in‐hospital cardiac arrest has decreased over the last decade, it remains >75%.[8] The outcomes for MV for isolated respiratory failure, on the other hand, are not as grim; studies of the general population typically report mortality rates <40%. Despite this, descriptions of outcomes are often left out of goals of care discussions.[9, 10] For example, Sharma et al. recently reported that only one‐third of residents, including those who had undergone training on goals of care discussions, discussed outcomes.[9] And when outcomes are included, they are typically for CPR but not MV as an independent intervention for prearrest respiratory failure.[10] Given that many of the conditions that lead to respiratory failure are among the most common reasons for hospitalization,[11] distinguishing between decisions regarding CPR and prearrest MV with discussion of their associated outcomes is of particular importance to hospitalists. Failing to do so impedes patients from making informed autonomous decisions that incorporate an accurate understanding of the treatments being discussed.

Imagine you are caring for a 75‐year‐old man with a history of coronary artery disease and congestive heart failure now admitted with pneumonia. Given his age, admitting diagnosis, and comorbidities, you feel it would be appropriate to engage him in a discussion of goals of care. His chances of survival with near return to baseline after a cardiac arrest requiring CPR are not the same as his chances of surviving an episode of worsening pneumonia requiring MV. To discuss cardiac arrest and prearrest respiratory failure in the same breath, without acknowledging the differences, is misleading. Based on his goals and values, this patient may see a trial of MV as acceptable. One recent study supports this hypothesis, as 28% of hospitalized patients with a combined DNR/DNI order would accept a trial of MV for pneumonia.[12] If the genesis of these orders was our desire to ensure that patients' autonomous preferences are respected, we must actually know those preferences, and those preferences should be based on adequate information about the expected outcomes, highlighting the differences outlined above.

Some may consider separating CPR from MVtherefore allowing for more clearly separate DNR and DNI ordersproblematic, as it may result in a menu of choices for patients. However, although CPR and MV may be performed at the same time for the same patient, they do not overlap in 100% of their occurrences. This is conceptually different from discussing whether to use epinephrine versus vasopressin, for example, or offering options such as chest compressions alone. More clearly separating CPR from MV would not be dissimilar to what is done with renal dialysis; a patient may wish to be DNR while still electing to undergo dialysis for failing kidneys. Though the discussions surrounding renal dialysis are less urgent, this alone does not adequately explain why the topic is not routinely collapsed into the discussion of CPR. Instead, renal dialysis is an intervention with unique indications, goals, and outcomes; this is what prompts the separation. The same is true of MV.

No matter the situation, code status discussions should focus on determining an individual patient's values and goals of care and should guide physicians in provision (or omission) of certain interventions. For the patient with pneumonia described above, his goal may be to promote quality of life over extension of life. Although this may prompt a recommendation to forego CPR, (if it were felt that his quality of life, even after successful return of spontaneous circulation, would be low), it may not be inconsistent for him to accept a trial of MV were his pneumonia to get worse (if it were felt that he could quickly improve and return to a quality of life close to what he experienced before the episode of pneumonia). We recommend that when discussing options with patients, the indications for and outcomes of CPR and MV be more clearly separated. It may be as simple as saying, there are 2 different situations I would like to discuss with you, followed by a discussion of the associated scenarios and likely outcomes in the best judgment of the care team. For a hospitalist, framing the discussion of MV around anticipated causes of pre‐arrest respiratory failure (eg, pneumonia, acute pulmonary edema) is essential.

In conclusion, if DNR and DNI orders are going to meet their promise of ensuring patients make informed decisions congruent with their goals, then the discussions from which they follow will need to more clearly acknowledge the important differences in indications and outcomes. Although a patient's goals should still be the framework upon which decisions regarding interventions are made, an important distinction should be made between cardiopulmonary arrest and prearrest respiratory failure, with a more explicit accompanying discussion of how the corresponding interventions fit within the patient's overall goals of care.

Since the introduction of defibrillation and closed chest cardiopulmonary resuscitation (CPR) in the 1950s, the ability to revive an arrested heart has been a realized possibility. Around the same time, endotracheal intubation with mechanical ventilation (MV) came into wide practice, allowing doctors to augment or even replace their patients' breathing. But just as the 1950s and 1960s saw the rise of these enhanced medical techniques, they also saw the increased importance of medical ethicsin particular, patient autonomy. A natural reaction to medicine's use of CPR and MV was the advent of advance directives and more specific do‐not‐resuscitate (DNR) and do‐not‐intubate (DNI) orders meant to protect a patient's ability to remain autonomous with their end of life decisions.[1]

Unfortunately, the code status discussions that lead to these orders often collapse cardiac arrest with prearrest respiratory failure and CPR with MV.[2, 3] This is a problem for a number of reasons. First, cardiac arrest and prearrest respiratory failure are unique end points, and though their respective treatments (CPR and MV) are often required simultaneously for an individual patient, they are distinct medical interventions with different goals, indications, and associated disease states. Although MV is typically a part of the cadre of interventions meant to ensure continued tissue oxygenation in the setting of a cardiac arrest, this accounts for <2% of indications for MV.[4] The vast majority of MV is used to treat prearrest causes of respiratory failure, such as pneumonia, congestive heart failure, acute exacerbations of chronic obstructive pulmonary disease, and following surgery.[4]

We do not believe these differences are adequately reflected in typical code status discussions.[2, 3] One study using audio‐recorded admission encounters included transcripts of hospitalist‐led code status discussions that all resembled the following: Physician: [I]f an emergency were to happenand your heart would (stop) or your breathing became so difficult that you needed to be attached to machines, would you want the nurses and doctors to attempt heroic measures to try to restart your heart and attach you to a breathing machine?[2] It would come as little surprise if a patient hearing this assumed that just 1 question were being asked and that decisions relating to any cause of respiratory failure (including prearrest causes) were being made. In practice, many physicians then extrapolate DNR orders to other treatment decision (including MV) and interpret them as precluding intubation, even for prearrest states.[5, 6, 7]

A second issue is that the mortality associated with cardiopulmonary arrest requiring CPR and prearrest respiratory failure requiring MV are not equal. Though the mortality after in‐hospital cardiac arrest has decreased over the last decade, it remains >75%.[8] The outcomes for MV for isolated respiratory failure, on the other hand, are not as grim; studies of the general population typically report mortality rates <40%. Despite this, descriptions of outcomes are often left out of goals of care discussions.[9, 10] For example, Sharma et al. recently reported that only one‐third of residents, including those who had undergone training on goals of care discussions, discussed outcomes.[9] And when outcomes are included, they are typically for CPR but not MV as an independent intervention for prearrest respiratory failure.[10] Given that many of the conditions that lead to respiratory failure are among the most common reasons for hospitalization,[11] distinguishing between decisions regarding CPR and prearrest MV with discussion of their associated outcomes is of particular importance to hospitalists. Failing to do so impedes patients from making informed autonomous decisions that incorporate an accurate understanding of the treatments being discussed.

Imagine you are caring for a 75‐year‐old man with a history of coronary artery disease and congestive heart failure now admitted with pneumonia. Given his age, admitting diagnosis, and comorbidities, you feel it would be appropriate to engage him in a discussion of goals of care. His chances of survival with near return to baseline after a cardiac arrest requiring CPR are not the same as his chances of surviving an episode of worsening pneumonia requiring MV. To discuss cardiac arrest and prearrest respiratory failure in the same breath, without acknowledging the differences, is misleading. Based on his goals and values, this patient may see a trial of MV as acceptable. One recent study supports this hypothesis, as 28% of hospitalized patients with a combined DNR/DNI order would accept a trial of MV for pneumonia.[12] If the genesis of these orders was our desire to ensure that patients' autonomous preferences are respected, we must actually know those preferences, and those preferences should be based on adequate information about the expected outcomes, highlighting the differences outlined above.

Some may consider separating CPR from MVtherefore allowing for more clearly separate DNR and DNI ordersproblematic, as it may result in a menu of choices for patients. However, although CPR and MV may be performed at the same time for the same patient, they do not overlap in 100% of their occurrences. This is conceptually different from discussing whether to use epinephrine versus vasopressin, for example, or offering options such as chest compressions alone. More clearly separating CPR from MV would not be dissimilar to what is done with renal dialysis; a patient may wish to be DNR while still electing to undergo dialysis for failing kidneys. Though the discussions surrounding renal dialysis are less urgent, this alone does not adequately explain why the topic is not routinely collapsed into the discussion of CPR. Instead, renal dialysis is an intervention with unique indications, goals, and outcomes; this is what prompts the separation. The same is true of MV.

No matter the situation, code status discussions should focus on determining an individual patient's values and goals of care and should guide physicians in provision (or omission) of certain interventions. For the patient with pneumonia described above, his goal may be to promote quality of life over extension of life. Although this may prompt a recommendation to forego CPR, (if it were felt that his quality of life, even after successful return of spontaneous circulation, would be low), it may not be inconsistent for him to accept a trial of MV were his pneumonia to get worse (if it were felt that he could quickly improve and return to a quality of life close to what he experienced before the episode of pneumonia). We recommend that when discussing options with patients, the indications for and outcomes of CPR and MV be more clearly separated. It may be as simple as saying, there are 2 different situations I would like to discuss with you, followed by a discussion of the associated scenarios and likely outcomes in the best judgment of the care team. For a hospitalist, framing the discussion of MV around anticipated causes of pre‐arrest respiratory failure (eg, pneumonia, acute pulmonary edema) is essential.

In conclusion, if DNR and DNI orders are going to meet their promise of ensuring patients make informed decisions congruent with their goals, then the discussions from which they follow will need to more clearly acknowledge the important differences in indications and outcomes. Although a patient's goals should still be the framework upon which decisions regarding interventions are made, an important distinction should be made between cardiopulmonary arrest and prearrest respiratory failure, with a more explicit accompanying discussion of how the corresponding interventions fit within the patient's overall goals of care.

Since the introduction of defibrillation and closed chest cardiopulmonary resuscitation (CPR) in the 1950s, the ability to revive an arrested heart has been a realized possibility. Around the same time, endotracheal intubation with mechanical ventilation (MV) came into wide practice, allowing doctors to augment or even replace their patients' breathing. But just as the 1950s and 1960s saw the rise of these enhanced medical techniques, they also saw the increased importance of medical ethicsin particular, patient autonomy. A natural reaction to medicine's use of CPR and MV was the advent of advance directives and more specific do‐not‐resuscitate (DNR) and do‐not‐intubate (DNI) orders meant to protect a patient's ability to remain autonomous with their end of life decisions.[1]

Unfortunately, the code status discussions that lead to these orders often collapse cardiac arrest with prearrest respiratory failure and CPR with MV.[2, 3] This is a problem for a number of reasons. First, cardiac arrest and prearrest respiratory failure are unique end points, and though their respective treatments (CPR and MV) are often required simultaneously for an individual patient, they are distinct medical interventions with different goals, indications, and associated disease states. Although MV is typically a part of the cadre of interventions meant to ensure continued tissue oxygenation in the setting of a cardiac arrest, this accounts for <2% of indications for MV.[4] The vast majority of MV is used to treat prearrest causes of respiratory failure, such as pneumonia, congestive heart failure, acute exacerbations of chronic obstructive pulmonary disease, and following surgery.[4]

We do not believe these differences are adequately reflected in typical code status discussions.[2, 3] One study using audio‐recorded admission encounters included transcripts of hospitalist‐led code status discussions that all resembled the following: Physician: [I]f an emergency were to happenand your heart would (stop) or your breathing became so difficult that you needed to be attached to machines, would you want the nurses and doctors to attempt heroic measures to try to restart your heart and attach you to a breathing machine?[2] It would come as little surprise if a patient hearing this assumed that just 1 question were being asked and that decisions relating to any cause of respiratory failure (including prearrest causes) were being made. In practice, many physicians then extrapolate DNR orders to other treatment decision (including MV) and interpret them as precluding intubation, even for prearrest states.[5, 6, 7]

A second issue is that the mortality associated with cardiopulmonary arrest requiring CPR and prearrest respiratory failure requiring MV are not equal. Though the mortality after in‐hospital cardiac arrest has decreased over the last decade, it remains >75%.[8] The outcomes for MV for isolated respiratory failure, on the other hand, are not as grim; studies of the general population typically report mortality rates <40%. Despite this, descriptions of outcomes are often left out of goals of care discussions.[9, 10] For example, Sharma et al. recently reported that only one‐third of residents, including those who had undergone training on goals of care discussions, discussed outcomes.[9] And when outcomes are included, they are typically for CPR but not MV as an independent intervention for prearrest respiratory failure.[10] Given that many of the conditions that lead to respiratory failure are among the most common reasons for hospitalization,[11] distinguishing between decisions regarding CPR and prearrest MV with discussion of their associated outcomes is of particular importance to hospitalists. Failing to do so impedes patients from making informed autonomous decisions that incorporate an accurate understanding of the treatments being discussed.

Imagine you are caring for a 75‐year‐old man with a history of coronary artery disease and congestive heart failure now admitted with pneumonia. Given his age, admitting diagnosis, and comorbidities, you feel it would be appropriate to engage him in a discussion of goals of care. His chances of survival with near return to baseline after a cardiac arrest requiring CPR are not the same as his chances of surviving an episode of worsening pneumonia requiring MV. To discuss cardiac arrest and prearrest respiratory failure in the same breath, without acknowledging the differences, is misleading. Based on his goals and values, this patient may see a trial of MV as acceptable. One recent study supports this hypothesis, as 28% of hospitalized patients with a combined DNR/DNI order would accept a trial of MV for pneumonia.[12] If the genesis of these orders was our desire to ensure that patients' autonomous preferences are respected, we must actually know those preferences, and those preferences should be based on adequate information about the expected outcomes, highlighting the differences outlined above.

Some may consider separating CPR from MVtherefore allowing for more clearly separate DNR and DNI ordersproblematic, as it may result in a menu of choices for patients. However, although CPR and MV may be performed at the same time for the same patient, they do not overlap in 100% of their occurrences. This is conceptually different from discussing whether to use epinephrine versus vasopressin, for example, or offering options such as chest compressions alone. More clearly separating CPR from MV would not be dissimilar to what is done with renal dialysis; a patient may wish to be DNR while still electing to undergo dialysis for failing kidneys. Though the discussions surrounding renal dialysis are less urgent, this alone does not adequately explain why the topic is not routinely collapsed into the discussion of CPR. Instead, renal dialysis is an intervention with unique indications, goals, and outcomes; this is what prompts the separation. The same is true of MV.

No matter the situation, code status discussions should focus on determining an individual patient's values and goals of care and should guide physicians in provision (or omission) of certain interventions. For the patient with pneumonia described above, his goal may be to promote quality of life over extension of life. Although this may prompt a recommendation to forego CPR, (if it were felt that his quality of life, even after successful return of spontaneous circulation, would be low), it may not be inconsistent for him to accept a trial of MV were his pneumonia to get worse (if it were felt that he could quickly improve and return to a quality of life close to what he experienced before the episode of pneumonia). We recommend that when discussing options with patients, the indications for and outcomes of CPR and MV be more clearly separated. It may be as simple as saying, there are 2 different situations I would like to discuss with you, followed by a discussion of the associated scenarios and likely outcomes in the best judgment of the care team. For a hospitalist, framing the discussion of MV around anticipated causes of pre‐arrest respiratory failure (eg, pneumonia, acute pulmonary edema) is essential.

In conclusion, if DNR and DNI orders are going to meet their promise of ensuring patients make informed decisions congruent with their goals, then the discussions from which they follow will need to more clearly acknowledge the important differences in indications and outcomes. Although a patient's goals should still be the framework upon which decisions regarding interventions are made, an important distinction should be made between cardiopulmonary arrest and prearrest respiratory failure, with a more explicit accompanying discussion of how the corresponding interventions fit within the patient's overall goals of care.

Hospital readmissions cost Medicare $15 to $17 billion per year.[1, 2] In 2010, the Hospital Readmission Reduction Program (HRRP), created by the Patient Protection and Affordable Care Act, authorized the Centers for Medicare and Medicaid Services (CMS) to penalize hospitals with higher‐than‐expected readmission rates for certain index conditions.[3] Other payers may follow suit, so hospitals and health systems nationwide are devoting significant resources to reducing readmissions.[4, 5, 6]

Implicit in these efforts are the assumptions that a significant proportion of readmissions are preventable, and that preventable readmissions can be identified. Unfortunately, estimates of preventability vary widely.[7, 8] In this article, we examine how preventable readmissions have been defined, measured, and calculated, and explore the associated implications for readmission reduction efforts.

THE MEDICARE READMISSION METRIC

The medical literature reveals substantial heterogeneity in how readmissions are assessed. Time periods range from 14 days to 4 years, and readmissions may be counted differently depending on whether they are to the same hospital or to any hospital, whether they are for the same (or a related) condition or for any condition, whether a patient is allowed to count only once during the follow‐up period, how mortality is treated, and whether observation stays are considered.[9]

Despite a lack of consensus in the literature, the approach adopted by CMS is endorsed by the National Quality Forum (NQF)[10] and has become the de facto standard for calculating readmission rates. CMS derives risk‐standardized readmission rates for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN), using administrative claims data for each Medicare fee‐for‐service beneficiary 65 years or older.[11, 12, 13, 14] CMS counts the first readmission (but not subsequent ones) for any cause within 30 days of the index discharge, including readmissions to other facilities. Certain planned readmissions for revascularization are excluded, as are patients who left against medical advice, transferred to another acute‐care hospital, or died during the index admission. Admissions to psychiatric, rehabilitation, cancer specialty, and children's hospitals[12] are also excluded, as well as patients classified as observation status for either hospital stay.[15] Only administrative data are used in readmission calculations (ie, there are no chart reviews or interviews with healthcare personnel or patients). Details are published online and updated at least annually.[15]

EFFECTS AND LIMITATIONS OF THE HRRP AND THE CMS READMISSION METRIC

Penalizing hospitals for higher‐than‐expected readmission rates based on the CMS metric has been successful in the sense that hospitals now feel more accountable for patient outcomes after discharge; they are implementing transitional care programs, improving communication, and building relationships with community programs.[4, 5, 16] Early data suggest a small decline in readmission rates of Medicare beneficiaries nationally.[17] Previously, such readmission rates were constant.[18]

Nevertheless, significant concerns with the current approach have surfaced.[19, 20, 21] First, why choose 30 days? This time horizon was believed to be long enough to identify readmissions attributable to an index admission and short enough to reflect hospital‐delivered care and transitions to the outpatient setting, and it allows for collaboration between hospitals and their communities to reduce readmissions.[3] However, some have argued that this time horizon has little scientific basis,[22] and that hospitals are unfairly held accountable for a timeframe when outcomes may largely be influenced by the quality of outpatient care or the development of new problems.[23, 24] Approximately one‐third of 30‐day readmissions occur within the first 7 days, and more than half (55.7%) occur within the first 14 days[22, 25]; such time frames may be more appropriate for hospital accountability.[26]

Second, spurred by the focus of CMS penalties, efforts to reduce readmissions have largely concerned patients admitted for HF, AMI, or PN, although these 3 medical conditions account for only 10% of Medicare hospitalizations.[18] Programs focused on a narrow patient population may not benefit other patients with high readmission rates, such as those with gastrointestinal or psychiatric problems,[2] or lead to improvements in the underlying processes of care that could benefit patients in additional ways. Indeed, research suggests that low readmission rates may not be related to other measures of hospital quality.[27, 28]

Third, public reporting and hospital penalties are based on 3‐year historical performance, in part to accumulate a large enough sample size for each diagnosis. Hospitals that seek real‐time performance monitoring are limited to tracking surrogate outcomes, such as readmissions back to their own facility.[29, 30] Moreover, because of the long performance time frame, hospitals that achieve rapid improvement may endure penalties precisely when they are attempting to sustain their achievements.

Fourth, the CMS approach utilizes a complex risk‐standardization methodology, which has only modest ability to predict readmissions and allow hospital comparisons.[9] There is no adjustment for community characteristics, even though practice patterns are significantly associated with readmission rates,[9, 31] and more than half of the variation in readmission rates across hospitals can be explained by characteristics of the community such as access to care.[32] Moreover, patient factors, such as race and socioeconomic status, are currently not included in an attempt to hold hospitals to similar standards regardless of their patient population. This is hotly contested, however, and critics note this policy penalizes hospitals for factors outside of their control, such as patients' ability to afford medications.[33] Indeed, the June 2013 Medicare Payment Advisory Committee (MedPAC) report to Congress recommended evaluating hospital performance against facilities with a like percentage of low‐income patients as a way to take into account socioeconomic status.[34]

Fifth, observation stays are excluded, so patients who remain in observation status during their index or subsequent hospitalization cannot be counted as a readmission. Prevalence of observation care has increased, raising concerns that inpatient admissions are being shifted to observation status, producing an artificial decline in readmissions.[35] Fortunately, recent population‐level data provide some reassuring evidence to the contrary.[36]

Finally, and perhaps most significantly, the current readmission metric does not consider preventability. Recent reviews have demonstrated that estimates of preventability vary widely in individual studies, ranging from 5% to 79%, depending on study methodology and setting.[7, 8] Across these studies, on average, only 23% of 30‐day readmissions appear to be avoidable.[8] Another way to consider the preventability of hospital readmissions is by noting that the most effective multimodal care‐transition interventions reduce readmission rates by only about 30%, and most interventions are much less effective.[26] The likely fact that only 23% to 30% of readmissions are preventable has profound implications for the anticipated results of hospital readmission reduction efforts. Interventions that are 75% effective in reducing preventable readmissions should be expected to produce only an 18% to 22% reduction in overall readmission rates.[37]

FOCUSING ON PREVENTABLE READMISSIONS

A greater focus on identifying and targeting preventable readmissions would offer a number of advantages over the present approach. First, it is more meaningful to compare hospitals based on their percentage of discharges resulting in a preventable readmission, than on the basis of highly complex risk standardization procedures for selected conditions. Second, a focus on preventable readmissions more clearly identifies and permits hospitals to target opportunities for improvement. Third, if the focus were on preventable readmissions for a large number of conditions, the necessary sample size could be obtained over a shorter period of time. Overall, such a preventable readmissions metric could serve as a more agile and undiluted performance indicator, as opposed to the present 3‐year rolling average rate of all‐cause readmissions for certain conditions, the majority of which are probably not preventable.

DEFINING PREVENTABILITY

Defining a preventable readmission is critically important. However, neither a consensus definition nor a validated standard for assessing preventable hospital readmissions exists. Different conceptual frameworks and terms (eg, avoidable, potentially preventable, or urgent readmission) complicate the issue.[38, 39, 40]

Although the CMS measure does not address preventability, it is helpful to consider whether other readmission metrics incorporate this concept. The United Health Group's (UHG, formerly Pacificare) All‐Cause Readmission Index, University HealthSystem Consortium's 30‐Day Readmission Rate (all cause), and 3M Health Information Systems' (3M) Potentially Preventable Readmissions (PPR) are 3 commonly used measures.

Of these, only the 3M PPR metric includes the concept of preventability. 3M created a proprietary matrix of 98,000 readmission‐index admission All Patient Refined Diagnosis Related Group pairs based on the review of several physicians and the logical assumption that a readmission for a clinically related diagnosis is potentially preventable.[24, 41] Readmission and index admissions are considered clinically related if any of the following occur: (1) medical readmission for continuation or recurrence of an initial, or closely related, condition; (2) medical readmission for acute decompensation of a chronic condition that was not the reason for the index admission but was plausibly related to care during or immediately afterward (eg, readmission for diabetes in a patient whose index admission was AMI); (3) medical readmission for acute complication plausibly related to care during index admission; (4) readmission for surgical procedure for continuation or recurrence of initial problem (eg, readmission for appendectomy following admission for abdominal pain and fever); or (5) readmission for surgical procedure to address complication resulting from care during index admission.[24, 41] The readmission time frame is not standardized and may be set by the user. Though conceptually appealing in some ways, CMS and the NQF have expressed concern about this specific approach because of the uncertain reliability of the relatedness of the admission‐readmission diagnosis dyads.[3]

In the research literature, only a few studies have examined the 3M PPR or other preventability assessments that rely on the relatedness of diagnostic codes.[8] Using the 3M PPR, a study showed that 78% of readmissions were classified as potentially preventable,[42] which explains why the 3M PPR and all‐cause readmission metric may correlate highly.[43] Others have demonstrated that ratings of hospital performance on readmission rates vary by a moderate to large amount, depending on whether the 3M PPR, CMS, or UHG methodology is used.[43, 44] An algorithm called SQLape[45, 46] is used in Switzerland to benchmark hospitals and defines potentially avoidable readmissions as being related to index diagnoses or complications of those conditions. It has recently been tested in the United States in a single‐center study,[47] and a multihospital study is underway.

Aside from these algorithms using related diagnosis codes, most ratings of preventability have relied on subjective assessments made primarily through a review of hospital records, and approximately one‐third also included data from clinic visits or interviews with the treating medical team or patients/families.[8] Unfortunately, these reports provide insufficient detail on how to apply their preventability criteria to subsequent readmission reviews. Studies did, however, provide categories of preventability into which readmissions could be organized (see Supporting Information, Appendix Table 1, in the online version of this article for details from a subset of studies cited in van Walraven's reviews that illustrate this point).

Assessment of preventability by clinician review can be challenging. In general, such assessments have considered readmissions resulting from factors within the hospital's control to be avoidable (eg, providing appropriate discharge instructions, reconciling medications, arranging timely postdischarge follow‐up appointments), whereas readmissions resulting from factors not within the hospital's control are unavoidable (eg, patient socioeconomic status, social support, disease progression). However, readmissions resulting from patient behaviors or social reasons could potentially be classified as avoidable or unavoidable depending on the circumstances. For example, if a patient decides not to take a prescribed antibiotic and is readmitted with worsening infection, this could be classified as an unavoidable readmission from the hospital's perspective. Alternatively, if the physician prescribing the antibiotic was inattentive to the cost of the medication and the patient would have taken a less expensive medication had it been prescribed, this could be classified as an avoidable readmission. Differing interpretations of contextual factors may partially account for the variability in clinical assessments of preventability.

Indeed, despite the lack of consensus around a standard method of defining preventability, hospitals and health systems are moving forward to address the issue and reduce readmissions. A recent survey by America's Essential Hospitals (previously the National Association of Public Hospitals and Health Systems), indicated that: (1) reducing readmissions was a high priority for the majority (86%) of members, (2) most had established interdisciplinary teams to address the issue, and (3) over half had a formal process for determining which readmissions were potentially preventable. Of the survey respondents, just over one‐third rely on staff review of individual patient charts or patient and family interviews, and slightly less than one‐third rely on other mechanisms such as external consultants, criteria developed by other entities, or the Institute for Clinical Systems Improvement methodology.[48] Approximately one‐fifth make use of 3M's PPR product, and slightly fewer use the list of the Agency for Healthcare Research and Quality's ambulatory care sensitive conditions (ACSCs). These are medical conditions for which it is believed that good outpatient care could prevent the need for hospitalization (eg, asthma, congestive heart failure, diabetes) or for which early intervention minimizes complications.[49] Hospitalization rates for ACSCs may represent a good measure of excess hospitalization, with a focus on the quality of outpatient care.

RECOMMENDATIONS

We recommend that reporting of hospital readmission rates be based on preventable or potentially preventable readmissions. Although we acknowledge the challenges in doing so, the advantages are notable. At minimum, a preventable readmission rate would more accurately reflect the true gap in care and therefore hospitals' real opportunity for improvement, without being obscured by readmissions that are not preventable.

Because readmission rates are used for public reporting and financial penalties for hospitals, we favor a measure of preventability that reflects the readmissions that the hospital or hospital system has the ability to prevent. This would not penalize hospitals for factors that are under the control of others, namely patients and caregivers, community supports, or society at large. We further recommend that this measure apply to a broader composite of unplanned care, inclusive of both inpatient and observation stays, which have little distinction in patients' eyes, and both represent potentially unnecessary utilization of acute‐care resources.[50] Such a measure would require development, validation, and appropriate vetting before it is implemented.

The first step is for researchers and policy makers to agree on how a measure of preventable or potentially preventable readmissions could be defined. A common element of preventability assessment is to identify the degree to which the reasons for readmission are related to the diagnoses of the index hospitalization. To be reliable and scalable, this measure will need to be based on algorithms that relate the index and readmission diagnoses, most likely using claims data. Choosing common medical and surgical conditions and developing a consensus‐based list of related readmission diagnoses is an important first step. It would also be important to include some less common conditions, because they may reflect very different aspects of hospital care.

An approach based on a list of related diagnoses would represent potentially preventable rehospitalizations. Generally, clinical review is required to determine actual preventability, taking into account patient factors such as a high level of illness or functional impairment that leads to clinical decompensation in spite of excellent management.[51, 52] Clinical review, like a root cause analysis, also provides greater insight into hospital processes that may warrant improvement. Therefore, even if an administrative measure of potentially preventable readmissions is implemented, hospitals may wish to continue performing detailed clinical review of some readmissions for quality improvement purposes. When clinical review becomes more standardized,[53] a combined approach that uses administrative data plus clinical verification and arbitration may be feasible, as with hospital‐acquired infections.

Similar work to develop related sets of admission and readmission diagnoses has already been undertaken in development of the 3M PPR and SQLape measures.[41, 46] However, the 3M PPR is a proprietary system that has low specificity and a high false‐positive rate for identifying preventable readmissions when compared to clinical review.[42] Moreover, neither measure has yet achieved the consensus required for widespread adoption in the United States. What is needed is a nonproprietary listing of related admission and readmission diagnoses, developed with the engagement of relevant stakeholders, that goes through a period of public comment and vetting by a body such as the NQF.

Until a validated measure of potentially preventable readmission can be developed, how could the current approach evolve toward preventability? The most feasible, rapidly implementable change would be to alter the readmission time horizon from 30 days to 7 or 15 days. A 30‐day period holds hospitals accountable for complications of outpatient care or new problems that may develop weeks after discharge. Even though this may foster shared accountability and collaboration among hospitals and outpatient or community settings, research has demonstrated that early readmissions (eg, within 715 days of discharge) are more likely preventable.[54] Second, consideration of the socioeconomic status of hospital patients, as recommended by MedPAC,[34] would improve on the current model by comparing hospitals to like facilities when determining penalties for excess readmission rates. Finally, adjustment for community factors, such as practice patterns and access to care, would enable readmission metrics to better reflect factors under the hospital's control.[32]

CONCLUSION

Holding hospitals accountable for the quality of acute and transitional care is an important policy initiative that has accelerated many improvements in discharge planning and care coordination. Optimally, the policies, public reporting, and penalties should target preventable readmissions, which may represent as little as one‐quarter of all readmissions. By summarizing some of the issues in defining preventability, we hope to foster continued refinement of quality metrics used in this arena.

Hospital readmissions cost Medicare $15 to $17 billion per year.[1, 2] In 2010, the Hospital Readmission Reduction Program (HRRP), created by the Patient Protection and Affordable Care Act, authorized the Centers for Medicare and Medicaid Services (CMS) to penalize hospitals with higher‐than‐expected readmission rates for certain index conditions.[3] Other payers may follow suit, so hospitals and health systems nationwide are devoting significant resources to reducing readmissions.[4, 5, 6]

Implicit in these efforts are the assumptions that a significant proportion of readmissions are preventable, and that preventable readmissions can be identified. Unfortunately, estimates of preventability vary widely.[7, 8] In this article, we examine how preventable readmissions have been defined, measured, and calculated, and explore the associated implications for readmission reduction efforts.

THE MEDICARE READMISSION METRIC

The medical literature reveals substantial heterogeneity in how readmissions are assessed. Time periods range from 14 days to 4 years, and readmissions may be counted differently depending on whether they are to the same hospital or to any hospital, whether they are for the same (or a related) condition or for any condition, whether a patient is allowed to count only once during the follow‐up period, how mortality is treated, and whether observation stays are considered.[9]

Despite a lack of consensus in the literature, the approach adopted by CMS is endorsed by the National Quality Forum (NQF)[10] and has become the de facto standard for calculating readmission rates. CMS derives risk‐standardized readmission rates for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN), using administrative claims data for each Medicare fee‐for‐service beneficiary 65 years or older.[11, 12, 13, 14] CMS counts the first readmission (but not subsequent ones) for any cause within 30 days of the index discharge, including readmissions to other facilities. Certain planned readmissions for revascularization are excluded, as are patients who left against medical advice, transferred to another acute‐care hospital, or died during the index admission. Admissions to psychiatric, rehabilitation, cancer specialty, and children's hospitals[12] are also excluded, as well as patients classified as observation status for either hospital stay.[15] Only administrative data are used in readmission calculations (ie, there are no chart reviews or interviews with healthcare personnel or patients). Details are published online and updated at least annually.[15]

EFFECTS AND LIMITATIONS OF THE HRRP AND THE CMS READMISSION METRIC

Penalizing hospitals for higher‐than‐expected readmission rates based on the CMS metric has been successful in the sense that hospitals now feel more accountable for patient outcomes after discharge; they are implementing transitional care programs, improving communication, and building relationships with community programs.[4, 5, 16] Early data suggest a small decline in readmission rates of Medicare beneficiaries nationally.[17] Previously, such readmission rates were constant.[18]

Nevertheless, significant concerns with the current approach have surfaced.[19, 20, 21] First, why choose 30 days? This time horizon was believed to be long enough to identify readmissions attributable to an index admission and short enough to reflect hospital‐delivered care and transitions to the outpatient setting, and it allows for collaboration between hospitals and their communities to reduce readmissions.[3] However, some have argued that this time horizon has little scientific basis,[22] and that hospitals are unfairly held accountable for a timeframe when outcomes may largely be influenced by the quality of outpatient care or the development of new problems.[23, 24] Approximately one‐third of 30‐day readmissions occur within the first 7 days, and more than half (55.7%) occur within the first 14 days[22, 25]; such time frames may be more appropriate for hospital accountability.[26]

Second, spurred by the focus of CMS penalties, efforts to reduce readmissions have largely concerned patients admitted for HF, AMI, or PN, although these 3 medical conditions account for only 10% of Medicare hospitalizations.[18] Programs focused on a narrow patient population may not benefit other patients with high readmission rates, such as those with gastrointestinal or psychiatric problems,[2] or lead to improvements in the underlying processes of care that could benefit patients in additional ways. Indeed, research suggests that low readmission rates may not be related to other measures of hospital quality.[27, 28]

Third, public reporting and hospital penalties are based on 3‐year historical performance, in part to accumulate a large enough sample size for each diagnosis. Hospitals that seek real‐time performance monitoring are limited to tracking surrogate outcomes, such as readmissions back to their own facility.[29, 30] Moreover, because of the long performance time frame, hospitals that achieve rapid improvement may endure penalties precisely when they are attempting to sustain their achievements.

Fourth, the CMS approach utilizes a complex risk‐standardization methodology, which has only modest ability to predict readmissions and allow hospital comparisons.[9] There is no adjustment for community characteristics, even though practice patterns are significantly associated with readmission rates,[9, 31] and more than half of the variation in readmission rates across hospitals can be explained by characteristics of the community such as access to care.[32] Moreover, patient factors, such as race and socioeconomic status, are currently not included in an attempt to hold hospitals to similar standards regardless of their patient population. This is hotly contested, however, and critics note this policy penalizes hospitals for factors outside of their control, such as patients' ability to afford medications.[33] Indeed, the June 2013 Medicare Payment Advisory Committee (MedPAC) report to Congress recommended evaluating hospital performance against facilities with a like percentage of low‐income patients as a way to take into account socioeconomic status.[34]

Fifth, observation stays are excluded, so patients who remain in observation status during their index or subsequent hospitalization cannot be counted as a readmission. Prevalence of observation care has increased, raising concerns that inpatient admissions are being shifted to observation status, producing an artificial decline in readmissions.[35] Fortunately, recent population‐level data provide some reassuring evidence to the contrary.[36]

Finally, and perhaps most significantly, the current readmission metric does not consider preventability. Recent reviews have demonstrated that estimates of preventability vary widely in individual studies, ranging from 5% to 79%, depending on study methodology and setting.[7, 8] Across these studies, on average, only 23% of 30‐day readmissions appear to be avoidable.[8] Another way to consider the preventability of hospital readmissions is by noting that the most effective multimodal care‐transition interventions reduce readmission rates by only about 30%, and most interventions are much less effective.[26] The likely fact that only 23% to 30% of readmissions are preventable has profound implications for the anticipated results of hospital readmission reduction efforts. Interventions that are 75% effective in reducing preventable readmissions should be expected to produce only an 18% to 22% reduction in overall readmission rates.[37]

FOCUSING ON PREVENTABLE READMISSIONS

A greater focus on identifying and targeting preventable readmissions would offer a number of advantages over the present approach. First, it is more meaningful to compare hospitals based on their percentage of discharges resulting in a preventable readmission, than on the basis of highly complex risk standardization procedures for selected conditions. Second, a focus on preventable readmissions more clearly identifies and permits hospitals to target opportunities for improvement. Third, if the focus were on preventable readmissions for a large number of conditions, the necessary sample size could be obtained over a shorter period of time. Overall, such a preventable readmissions metric could serve as a more agile and undiluted performance indicator, as opposed to the present 3‐year rolling average rate of all‐cause readmissions for certain conditions, the majority of which are probably not preventable.

DEFINING PREVENTABILITY

Defining a preventable readmission is critically important. However, neither a consensus definition nor a validated standard for assessing preventable hospital readmissions exists. Different conceptual frameworks and terms (eg, avoidable, potentially preventable, or urgent readmission) complicate the issue.[38, 39, 40]

Although the CMS measure does not address preventability, it is helpful to consider whether other readmission metrics incorporate this concept. The United Health Group's (UHG, formerly Pacificare) All‐Cause Readmission Index, University HealthSystem Consortium's 30‐Day Readmission Rate (all cause), and 3M Health Information Systems' (3M) Potentially Preventable Readmissions (PPR) are 3 commonly used measures.

Of these, only the 3M PPR metric includes the concept of preventability. 3M created a proprietary matrix of 98,000 readmission‐index admission All Patient Refined Diagnosis Related Group pairs based on the review of several physicians and the logical assumption that a readmission for a clinically related diagnosis is potentially preventable.[24, 41] Readmission and index admissions are considered clinically related if any of the following occur: (1) medical readmission for continuation or recurrence of an initial, or closely related, condition; (2) medical readmission for acute decompensation of a chronic condition that was not the reason for the index admission but was plausibly related to care during or immediately afterward (eg, readmission for diabetes in a patient whose index admission was AMI); (3) medical readmission for acute complication plausibly related to care during index admission; (4) readmission for surgical procedure for continuation or recurrence of initial problem (eg, readmission for appendectomy following admission for abdominal pain and fever); or (5) readmission for surgical procedure to address complication resulting from care during index admission.[24, 41] The readmission time frame is not standardized and may be set by the user. Though conceptually appealing in some ways, CMS and the NQF have expressed concern about this specific approach because of the uncertain reliability of the relatedness of the admission‐readmission diagnosis dyads.[3]

In the research literature, only a few studies have examined the 3M PPR or other preventability assessments that rely on the relatedness of diagnostic codes.[8] Using the 3M PPR, a study showed that 78% of readmissions were classified as potentially preventable,[42] which explains why the 3M PPR and all‐cause readmission metric may correlate highly.[43] Others have demonstrated that ratings of hospital performance on readmission rates vary by a moderate to large amount, depending on whether the 3M PPR, CMS, or UHG methodology is used.[43, 44] An algorithm called SQLape[45, 46] is used in Switzerland to benchmark hospitals and defines potentially avoidable readmissions as being related to index diagnoses or complications of those conditions. It has recently been tested in the United States in a single‐center study,[47] and a multihospital study is underway.

Aside from these algorithms using related diagnosis codes, most ratings of preventability have relied on subjective assessments made primarily through a review of hospital records, and approximately one‐third also included data from clinic visits or interviews with the treating medical team or patients/families.[8] Unfortunately, these reports provide insufficient detail on how to apply their preventability criteria to subsequent readmission reviews. Studies did, however, provide categories of preventability into which readmissions could be organized (see Supporting Information, Appendix Table 1, in the online version of this article for details from a subset of studies cited in van Walraven's reviews that illustrate this point).

Assessment of preventability by clinician review can be challenging. In general, such assessments have considered readmissions resulting from factors within the hospital's control to be avoidable (eg, providing appropriate discharge instructions, reconciling medications, arranging timely postdischarge follow‐up appointments), whereas readmissions resulting from factors not within the hospital's control are unavoidable (eg, patient socioeconomic status, social support, disease progression). However, readmissions resulting from patient behaviors or social reasons could potentially be classified as avoidable or unavoidable depending on the circumstances. For example, if a patient decides not to take a prescribed antibiotic and is readmitted with worsening infection, this could be classified as an unavoidable readmission from the hospital's perspective. Alternatively, if the physician prescribing the antibiotic was inattentive to the cost of the medication and the patient would have taken a less expensive medication had it been prescribed, this could be classified as an avoidable readmission. Differing interpretations of contextual factors may partially account for the variability in clinical assessments of preventability.

Indeed, despite the lack of consensus around a standard method of defining preventability, hospitals and health systems are moving forward to address the issue and reduce readmissions. A recent survey by America's Essential Hospitals (previously the National Association of Public Hospitals and Health Systems), indicated that: (1) reducing readmissions was a high priority for the majority (86%) of members, (2) most had established interdisciplinary teams to address the issue, and (3) over half had a formal process for determining which readmissions were potentially preventable. Of the survey respondents, just over one‐third rely on staff review of individual patient charts or patient and family interviews, and slightly less than one‐third rely on other mechanisms such as external consultants, criteria developed by other entities, or the Institute for Clinical Systems Improvement methodology.[48] Approximately one‐fifth make use of 3M's PPR product, and slightly fewer use the list of the Agency for Healthcare Research and Quality's ambulatory care sensitive conditions (ACSCs). These are medical conditions for which it is believed that good outpatient care could prevent the need for hospitalization (eg, asthma, congestive heart failure, diabetes) or for which early intervention minimizes complications.[49] Hospitalization rates for ACSCs may represent a good measure of excess hospitalization, with a focus on the quality of outpatient care.

RECOMMENDATIONS

We recommend that reporting of hospital readmission rates be based on preventable or potentially preventable readmissions. Although we acknowledge the challenges in doing so, the advantages are notable. At minimum, a preventable readmission rate would more accurately reflect the true gap in care and therefore hospitals' real opportunity for improvement, without being obscured by readmissions that are not preventable.

Because readmission rates are used for public reporting and financial penalties for hospitals, we favor a measure of preventability that reflects the readmissions that the hospital or hospital system has the ability to prevent. This would not penalize hospitals for factors that are under the control of others, namely patients and caregivers, community supports, or society at large. We further recommend that this measure apply to a broader composite of unplanned care, inclusive of both inpatient and observation stays, which have little distinction in patients' eyes, and both represent potentially unnecessary utilization of acute‐care resources.[50] Such a measure would require development, validation, and appropriate vetting before it is implemented.

The first step is for researchers and policy makers to agree on how a measure of preventable or potentially preventable readmissions could be defined. A common element of preventability assessment is to identify the degree to which the reasons for readmission are related to the diagnoses of the index hospitalization. To be reliable and scalable, this measure will need to be based on algorithms that relate the index and readmission diagnoses, most likely using claims data. Choosing common medical and surgical conditions and developing a consensus‐based list of related readmission diagnoses is an important first step. It would also be important to include some less common conditions, because they may reflect very different aspects of hospital care.

An approach based on a list of related diagnoses would represent potentially preventable rehospitalizations. Generally, clinical review is required to determine actual preventability, taking into account patient factors such as a high level of illness or functional impairment that leads to clinical decompensation in spite of excellent management.[51, 52] Clinical review, like a root cause analysis, also provides greater insight into hospital processes that may warrant improvement. Therefore, even if an administrative measure of potentially preventable readmissions is implemented, hospitals may wish to continue performing detailed clinical review of some readmissions for quality improvement purposes. When clinical review becomes more standardized,[53] a combined approach that uses administrative data plus clinical verification and arbitration may be feasible, as with hospital‐acquired infections.

Similar work to develop related sets of admission and readmission diagnoses has already been undertaken in development of the 3M PPR and SQLape measures.[41, 46] However, the 3M PPR is a proprietary system that has low specificity and a high false‐positive rate for identifying preventable readmissions when compared to clinical review.[42] Moreover, neither measure has yet achieved the consensus required for widespread adoption in the United States. What is needed is a nonproprietary listing of related admission and readmission diagnoses, developed with the engagement of relevant stakeholders, that goes through a period of public comment and vetting by a body such as the NQF.

Until a validated measure of potentially preventable readmission can be developed, how could the current approach evolve toward preventability? The most feasible, rapidly implementable change would be to alter the readmission time horizon from 30 days to 7 or 15 days. A 30‐day period holds hospitals accountable for complications of outpatient care or new problems that may develop weeks after discharge. Even though this may foster shared accountability and collaboration among hospitals and outpatient or community settings, research has demonstrated that early readmissions (eg, within 715 days of discharge) are more likely preventable.[54] Second, consideration of the socioeconomic status of hospital patients, as recommended by MedPAC,[34] would improve on the current model by comparing hospitals to like facilities when determining penalties for excess readmission rates. Finally, adjustment for community factors, such as practice patterns and access to care, would enable readmission metrics to better reflect factors under the hospital's control.[32]

CONCLUSION

Holding hospitals accountable for the quality of acute and transitional care is an important policy initiative that has accelerated many improvements in discharge planning and care coordination. Optimally, the policies, public reporting, and penalties should target preventable readmissions, which may represent as little as one‐quarter of all readmissions. By summarizing some of the issues in defining preventability, we hope to foster continued refinement of quality metrics used in this arena.

Hospital readmissions cost Medicare $15 to $17 billion per year.[1, 2] In 2010, the Hospital Readmission Reduction Program (HRRP), created by the Patient Protection and Affordable Care Act, authorized the Centers for Medicare and Medicaid Services (CMS) to penalize hospitals with higher‐than‐expected readmission rates for certain index conditions.[3] Other payers may follow suit, so hospitals and health systems nationwide are devoting significant resources to reducing readmissions.[4, 5, 6]

Implicit in these efforts are the assumptions that a significant proportion of readmissions are preventable, and that preventable readmissions can be identified. Unfortunately, estimates of preventability vary widely.[7, 8] In this article, we examine how preventable readmissions have been defined, measured, and calculated, and explore the associated implications for readmission reduction efforts.

THE MEDICARE READMISSION METRIC

The medical literature reveals substantial heterogeneity in how readmissions are assessed. Time periods range from 14 days to 4 years, and readmissions may be counted differently depending on whether they are to the same hospital or to any hospital, whether they are for the same (or a related) condition or for any condition, whether a patient is allowed to count only once during the follow‐up period, how mortality is treated, and whether observation stays are considered.[9]

Despite a lack of consensus in the literature, the approach adopted by CMS is endorsed by the National Quality Forum (NQF)[10] and has become the de facto standard for calculating readmission rates. CMS derives risk‐standardized readmission rates for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN), using administrative claims data for each Medicare fee‐for‐service beneficiary 65 years or older.[11, 12, 13, 14] CMS counts the first readmission (but not subsequent ones) for any cause within 30 days of the index discharge, including readmissions to other facilities. Certain planned readmissions for revascularization are excluded, as are patients who left against medical advice, transferred to another acute‐care hospital, or died during the index admission. Admissions to psychiatric, rehabilitation, cancer specialty, and children's hospitals[12] are also excluded, as well as patients classified as observation status for either hospital stay.[15] Only administrative data are used in readmission calculations (ie, there are no chart reviews or interviews with healthcare personnel or patients). Details are published online and updated at least annually.[15]

EFFECTS AND LIMITATIONS OF THE HRRP AND THE CMS READMISSION METRIC

Penalizing hospitals for higher‐than‐expected readmission rates based on the CMS metric has been successful in the sense that hospitals now feel more accountable for patient outcomes after discharge; they are implementing transitional care programs, improving communication, and building relationships with community programs.[4, 5, 16] Early data suggest a small decline in readmission rates of Medicare beneficiaries nationally.[17] Previously, such readmission rates were constant.[18]

Nevertheless, significant concerns with the current approach have surfaced.[19, 20, 21] First, why choose 30 days? This time horizon was believed to be long enough to identify readmissions attributable to an index admission and short enough to reflect hospital‐delivered care and transitions to the outpatient setting, and it allows for collaboration between hospitals and their communities to reduce readmissions.[3] However, some have argued that this time horizon has little scientific basis,[22] and that hospitals are unfairly held accountable for a timeframe when outcomes may largely be influenced by the quality of outpatient care or the development of new problems.[23, 24] Approximately one‐third of 30‐day readmissions occur within the first 7 days, and more than half (55.7%) occur within the first 14 days[22, 25]; such time frames may be more appropriate for hospital accountability.[26]

Second, spurred by the focus of CMS penalties, efforts to reduce readmissions have largely concerned patients admitted for HF, AMI, or PN, although these 3 medical conditions account for only 10% of Medicare hospitalizations.[18] Programs focused on a narrow patient population may not benefit other patients with high readmission rates, such as those with gastrointestinal or psychiatric problems,[2] or lead to improvements in the underlying processes of care that could benefit patients in additional ways. Indeed, research suggests that low readmission rates may not be related to other measures of hospital quality.[27, 28]

Third, public reporting and hospital penalties are based on 3‐year historical performance, in part to accumulate a large enough sample size for each diagnosis. Hospitals that seek real‐time performance monitoring are limited to tracking surrogate outcomes, such as readmissions back to their own facility.[29, 30] Moreover, because of the long performance time frame, hospitals that achieve rapid improvement may endure penalties precisely when they are attempting to sustain their achievements.

Fourth, the CMS approach utilizes a complex risk‐standardization methodology, which has only modest ability to predict readmissions and allow hospital comparisons.[9] There is no adjustment for community characteristics, even though practice patterns are significantly associated with readmission rates,[9, 31] and more than half of the variation in readmission rates across hospitals can be explained by characteristics of the community such as access to care.[32] Moreover, patient factors, such as race and socioeconomic status, are currently not included in an attempt to hold hospitals to similar standards regardless of their patient population. This is hotly contested, however, and critics note this policy penalizes hospitals for factors outside of their control, such as patients' ability to afford medications.[33] Indeed, the June 2013 Medicare Payment Advisory Committee (MedPAC) report to Congress recommended evaluating hospital performance against facilities with a like percentage of low‐income patients as a way to take into account socioeconomic status.[34]

Fifth, observation stays are excluded, so patients who remain in observation status during their index or subsequent hospitalization cannot be counted as a readmission. Prevalence of observation care has increased, raising concerns that inpatient admissions are being shifted to observation status, producing an artificial decline in readmissions.[35] Fortunately, recent population‐level data provide some reassuring evidence to the contrary.[36]

Finally, and perhaps most significantly, the current readmission metric does not consider preventability. Recent reviews have demonstrated that estimates of preventability vary widely in individual studies, ranging from 5% to 79%, depending on study methodology and setting.[7, 8] Across these studies, on average, only 23% of 30‐day readmissions appear to be avoidable.[8] Another way to consider the preventability of hospital readmissions is by noting that the most effective multimodal care‐transition interventions reduce readmission rates by only about 30%, and most interventions are much less effective.[26] The likely fact that only 23% to 30% of readmissions are preventable has profound implications for the anticipated results of hospital readmission reduction efforts. Interventions that are 75% effective in reducing preventable readmissions should be expected to produce only an 18% to 22% reduction in overall readmission rates.[37]

FOCUSING ON PREVENTABLE READMISSIONS

A greater focus on identifying and targeting preventable readmissions would offer a number of advantages over the present approach. First, it is more meaningful to compare hospitals based on their percentage of discharges resulting in a preventable readmission, than on the basis of highly complex risk standardization procedures for selected conditions. Second, a focus on preventable readmissions more clearly identifies and permits hospitals to target opportunities for improvement. Third, if the focus were on preventable readmissions for a large number of conditions, the necessary sample size could be obtained over a shorter period of time. Overall, such a preventable readmissions metric could serve as a more agile and undiluted performance indicator, as opposed to the present 3‐year rolling average rate of all‐cause readmissions for certain conditions, the majority of which are probably not preventable.

DEFINING PREVENTABILITY

Defining a preventable readmission is critically important. However, neither a consensus definition nor a validated standard for assessing preventable hospital readmissions exists. Different conceptual frameworks and terms (eg, avoidable, potentially preventable, or urgent readmission) complicate the issue.[38, 39, 40]

Although the CMS measure does not address preventability, it is helpful to consider whether other readmission metrics incorporate this concept. The United Health Group's (UHG, formerly Pacificare) All‐Cause Readmission Index, University HealthSystem Consortium's 30‐Day Readmission Rate (all cause), and 3M Health Information Systems' (3M) Potentially Preventable Readmissions (PPR) are 3 commonly used measures.

Of these, only the 3M PPR metric includes the concept of preventability. 3M created a proprietary matrix of 98,000 readmission‐index admission All Patient Refined Diagnosis Related Group pairs based on the review of several physicians and the logical assumption that a readmission for a clinically related diagnosis is potentially preventable.[24, 41] Readmission and index admissions are considered clinically related if any of the following occur: (1) medical readmission for continuation or recurrence of an initial, or closely related, condition; (2) medical readmission for acute decompensation of a chronic condition that was not the reason for the index admission but was plausibly related to care during or immediately afterward (eg, readmission for diabetes in a patient whose index admission was AMI); (3) medical readmission for acute complication plausibly related to care during index admission; (4) readmission for surgical procedure for continuation or recurrence of initial problem (eg, readmission for appendectomy following admission for abdominal pain and fever); or (5) readmission for surgical procedure to address complication resulting from care during index admission.[24, 41] The readmission time frame is not standardized and may be set by the user. Though conceptually appealing in some ways, CMS and the NQF have expressed concern about this specific approach because of the uncertain reliability of the relatedness of the admission‐readmission diagnosis dyads.[3]

In the research literature, only a few studies have examined the 3M PPR or other preventability assessments that rely on the relatedness of diagnostic codes.[8] Using the 3M PPR, a study showed that 78% of readmissions were classified as potentially preventable,[42] which explains why the 3M PPR and all‐cause readmission metric may correlate highly.[43] Others have demonstrated that ratings of hospital performance on readmission rates vary by a moderate to large amount, depending on whether the 3M PPR, CMS, or UHG methodology is used.[43, 44] An algorithm called SQLape[45, 46] is used in Switzerland to benchmark hospitals and defines potentially avoidable readmissions as being related to index diagnoses or complications of those conditions. It has recently been tested in the United States in a single‐center study,[47] and a multihospital study is underway.

Aside from these algorithms using related diagnosis codes, most ratings of preventability have relied on subjective assessments made primarily through a review of hospital records, and approximately one‐third also included data from clinic visits or interviews with the treating medical team or patients/families.[8] Unfortunately, these reports provide insufficient detail on how to apply their preventability criteria to subsequent readmission reviews. Studies did, however, provide categories of preventability into which readmissions could be organized (see Supporting Information, Appendix Table 1, in the online version of this article for details from a subset of studies cited in van Walraven's reviews that illustrate this point).

Assessment of preventability by clinician review can be challenging. In general, such assessments have considered readmissions resulting from factors within the hospital's control to be avoidable (eg, providing appropriate discharge instructions, reconciling medications, arranging timely postdischarge follow‐up appointments), whereas readmissions resulting from factors not within the hospital's control are unavoidable (eg, patient socioeconomic status, social support, disease progression). However, readmissions resulting from patient behaviors or social reasons could potentially be classified as avoidable or unavoidable depending on the circumstances. For example, if a patient decides not to take a prescribed antibiotic and is readmitted with worsening infection, this could be classified as an unavoidable readmission from the hospital's perspective. Alternatively, if the physician prescribing the antibiotic was inattentive to the cost of the medication and the patient would have taken a less expensive medication had it been prescribed, this could be classified as an avoidable readmission. Differing interpretations of contextual factors may partially account for the variability in clinical assessments of preventability.

Indeed, despite the lack of consensus around a standard method of defining preventability, hospitals and health systems are moving forward to address the issue and reduce readmissions. A recent survey by America's Essential Hospitals (previously the National Association of Public Hospitals and Health Systems), indicated that: (1) reducing readmissions was a high priority for the majority (86%) of members, (2) most had established interdisciplinary teams to address the issue, and (3) over half had a formal process for determining which readmissions were potentially preventable. Of the survey respondents, just over one‐third rely on staff review of individual patient charts or patient and family interviews, and slightly less than one‐third rely on other mechanisms such as external consultants, criteria developed by other entities, or the Institute for Clinical Systems Improvement methodology.[48] Approximately one‐fifth make use of 3M's PPR product, and slightly fewer use the list of the Agency for Healthcare Research and Quality's ambulatory care sensitive conditions (ACSCs). These are medical conditions for which it is believed that good outpatient care could prevent the need for hospitalization (eg, asthma, congestive heart failure, diabetes) or for which early intervention minimizes complications.[49] Hospitalization rates for ACSCs may represent a good measure of excess hospitalization, with a focus on the quality of outpatient care.

RECOMMENDATIONS

We recommend that reporting of hospital readmission rates be based on preventable or potentially preventable readmissions. Although we acknowledge the challenges in doing so, the advantages are notable. At minimum, a preventable readmission rate would more accurately reflect the true gap in care and therefore hospitals' real opportunity for improvement, without being obscured by readmissions that are not preventable.

Because readmission rates are used for public reporting and financial penalties for hospitals, we favor a measure of preventability that reflects the readmissions that the hospital or hospital system has the ability to prevent. This would not penalize hospitals for factors that are under the control of others, namely patients and caregivers, community supports, or society at large. We further recommend that this measure apply to a broader composite of unplanned care, inclusive of both inpatient and observation stays, which have little distinction in patients' eyes, and both represent potentially unnecessary utilization of acute‐care resources.[50] Such a measure would require development, validation, and appropriate vetting before it is implemented.

The first step is for researchers and policy makers to agree on how a measure of preventable or potentially preventable readmissions could be defined. A common element of preventability assessment is to identify the degree to which the reasons for readmission are related to the diagnoses of the index hospitalization. To be reliable and scalable, this measure will need to be based on algorithms that relate the index and readmission diagnoses, most likely using claims data. Choosing common medical and surgical conditions and developing a consensus‐based list of related readmission diagnoses is an important first step. It would also be important to include some less common conditions, because they may reflect very different aspects of hospital care.

An approach based on a list of related diagnoses would represent potentially preventable rehospitalizations. Generally, clinical review is required to determine actual preventability, taking into account patient factors such as a high level of illness or functional impairment that leads to clinical decompensation in spite of excellent management.[51, 52] Clinical review, like a root cause analysis, also provides greater insight into hospital processes that may warrant improvement. Therefore, even if an administrative measure of potentially preventable readmissions is implemented, hospitals may wish to continue performing detailed clinical review of some readmissions for quality improvement purposes. When clinical review becomes more standardized,[53] a combined approach that uses administrative data plus clinical verification and arbitration may be feasible, as with hospital‐acquired infections.

Similar work to develop related sets of admission and readmission diagnoses has already been undertaken in development of the 3M PPR and SQLape measures.[41, 46] However, the 3M PPR is a proprietary system that has low specificity and a high false‐positive rate for identifying preventable readmissions when compared to clinical review.[42] Moreover, neither measure has yet achieved the consensus required for widespread adoption in the United States. What is needed is a nonproprietary listing of related admission and readmission diagnoses, developed with the engagement of relevant stakeholders, that goes through a period of public comment and vetting by a body such as the NQF.

Until a validated measure of potentially preventable readmission can be developed, how could the current approach evolve toward preventability? The most feasible, rapidly implementable change would be to alter the readmission time horizon from 30 days to 7 or 15 days. A 30‐day period holds hospitals accountable for complications of outpatient care or new problems that may develop weeks after discharge. Even though this may foster shared accountability and collaboration among hospitals and outpatient or community settings, research has demonstrated that early readmissions (eg, within 715 days of discharge) are more likely preventable.[54] Second, consideration of the socioeconomic status of hospital patients, as recommended by MedPAC,[34] would improve on the current model by comparing hospitals to like facilities when determining penalties for excess readmission rates. Finally, adjustment for community factors, such as practice patterns and access to care, would enable readmission metrics to better reflect factors under the hospital's control.[32]

CONCLUSION

Holding hospitals accountable for the quality of acute and transitional care is an important policy initiative that has accelerated many improvements in discharge planning and care coordination. Optimally, the policies, public reporting, and penalties should target preventable readmissions, which may represent as little as one‐quarter of all readmissions. By summarizing some of the issues in defining preventability, we hope to foster continued refinement of quality metrics used in this arena.

Hospital‐based care has become more complex over time. Patients are sicker, with more chronic comorbid conditions requiring greater collaboration to provide coordinated patient care.[1, 2] Care coordination requires an interdisciplinary approach during hospitalization and especially during transitions of care.[3, 4] In addition, hospitals are tasked with managing and improving clinical workflow efficiencies, and implementing electronic health records (EHR)[5] that require healthcare professionals to learn new systems of care and technology. Payment models have also started to shift toward an incentive and penalty‐based structure in the form of value‐based purchasing, readmission penalties, hospital‐acquired conditions, and meaningful use.[4, 6]

In response to these pressures, hospitals are searching for ways to reliably deliver quality care that is safe, effective, patient centered, timely, efficient, and equitable.[7] Previous efforts to improve quality in the general medical inpatient setting have included redesign of the clinical work environment and new workflows through the use of checklists and whiteboards to enhance communication, patient‐centered bedside rounds, standardized protocols and handovers, and integrated clinical decision support using health information technology.[8, 9, 10, 11, 12, 13] Although each of these care coordination activities has potential value, integrating them at the unit level often remains a challenge. Some hospitals have addressed this challenge by establishing and supporting a unit‐based leadership model, where a medical director and nurse manager work together to assess and improve the quality, safety, efficiency, and patient experience‐based mission of the organization.[14, 15] However, there are few descriptions of this leadership model in the current literature. Herein, we present the unit‐based leadership model that has been developed and implemented at 6 hospitals.

MODELS OF UNIT‐BASED LEADERSHIP

The unit‐based leadership model is grounded on the idea that culture and clinical care are products of frontline structure, process, and relationships, and that leaders at the site of care can have the greatest influence on the local work environment.[16, 17] The objective is to influence care and culture at the bedside and the unit, where care is delivered and where alignment with organizational vision and mission must occur. The concept of the inpatient unit medical director is not new, and hospitals in the past have recruited physician leaders to become clinical champions for quality improvement and help establish a collaborative work environment for physicians and unit‐based staff.[18, 19, 20, 21, 22] These studies report on the challenges and benefits of incorporating a medical director to inpatient psychiatry or general care units, but do not provide specific details about the recruitment and responsibilities for unit‐based dyad partnerships, which are critical factors for success on multidisciplinary inpatient care units.

There are several logistical matters to consider when instituting a unit‐based leadership model. These include the composition of the leadership team, selection process of the leaders, the presence of trainees and permanent faculty, and whether the units are able to geographically cohort patients. Other considerations include a clear role description with established shared goals and expectations, and a compensation model that includes effort and incentives. In addition, there should be a clearly established reporting structure to senior leadership, and the unit leaders should be given opportunities for professional growth and development. Table 1 provides a summary overview of 6 hospitals' experiences to date.

DISCUSSION

In reviewing our 6 organization's collective experiences, we identified several common themes and some notable differences across sites. The core of the leadership team was primarily composed of the medical director and nurse manager on the unit. Across all 6 organizations, medical directors had a portion of their effort supported for their leadership work on the unit. Leadership development training was provided at all of our sites, with particular emphasis on quality improvement (QI) methods such as Six‐Sigma, Lean, or Plan, Do, Study, Act (PDSA). Additional leadership development sessions were provided through the organization's human resources or affiliated university. Common outcome measures of interest include patient satisfaction, interdisciplinary practice, and collaboration on the unit, and some hospital‐acquired condition measures. Last, there is a direct reporting relationship to a chief or senior nurse or physician leader within each organization. These commonalities and variances are further detailed below.

OTHER CONSIDERATIONS

Other infrastructure variables that may increase the effectiveness of the unit leadership dyad include unit‐based clinical services (geographic localization), engaging the frontline team members in the design and implementation of change innovations, a commitment to patient and family centered practices on the unit, and enhancing clinical workflow through the support of EHR functions such as concurrent documentation and provider order entry. Geographic localization, placing the fewest possible clinical service providers on the unit to work alongside unit‐based staff, allows for a cohesive interdisciplinary unit‐based team to develop under the dyad leadership, and has been shown to improve communication practices.[9, 31] Beyond geographic localization of patients, it is critical to ensure team members are committed to the changes in workflow by directly involving them through the design and implementation of new models of care taking place on the unit. This commitment starts from the top senior nurse and physician leaders in the organization, and extends to the unit‐based dyad partners, and down to each individual interdisciplinary team member on the unit.[1] Thus, it is critical to clarify roles and responsibilities and how team members on the unit will interact with each other. For some situations, conflict management training will be helpful to the unit‐based leaders to resolve issues. To appreciate potential barriers to successful rollout of this unit leadership model, a phased implementation of pilot units, followed by successive waves, should be considered. Many of the units that instituted unit‐based interdisciplinary team rounds solicited and implemented direct feedback from frontline team members in efforts to improve communication and be more patient centered. Conversely, there are also likely to be situations where the unit‐based leaders will be confronted with hindrances to their unit‐based collaborative improvement efforts. To help prepare the dyad leaders, many of our unit‐based leaders have received specific training on how to coach and conduct difficult conversations with individuals who have performance gaps or are perceived to be hindering the progress of the unit's work. These crucial negotiation skills are not innate among most managers and should be explicitly provided to new leaders across organizations.

The goals and merits of patient‐ and family‐centered care (PFCC) have been well described.[32, 33, 34] Organizational support to teach and disseminate PFCC practices throughout all settings of care may help the leadership dyads implement rounding strategies that engage all staff, patients, and family members throughout the hospital course and during the transitions out of the hospital.

Clinical workflow has become heavily dependent on the EHR systems. For those organizations that have yet to adopt a particular EHR system, the leadership dyads should be involved throughout the EHR design process to help ensure that the technological solutions will be built to assist the clinical workflow, and once the system has been built, the leadership dyad should monitor and enhance the interface between workflow and EHR system so that it can support the creation and advancement of interdisciplinary plans of care on the unit.

CONCLUSION

The care of the hospitalized patient has become more complex over time. Interdisciplinary teamwork needs to be improved at the unit level to achieve the strategic goals of the hospital. Although quality improvement is an organizational goal, change takes place locally. Physician leaders, in partnership with nurse managers, are needed now more than ever to take on this task to improve the hospital‐care experience for patients by functioning as the primary effector arms for changing the landscape of hospital‐based care. We have described characteristics of unit‐based leadership programs adopted across 6 organizations. Hospitalists with clinical experience as the principal providers of inpatient‐based care and quality improvement experience and training, have been key participants in the development and implementation of the local leadership models in each of these hospital systems. We hope the comparison of the various models featured in this article serves as a valuable reference to hospitals and healthcare organizations who are contemplating the incorporation of this model into their strategic plan.

Hospital‐based care has become more complex over time. Patients are sicker, with more chronic comorbid conditions requiring greater collaboration to provide coordinated patient care.[1, 2] Care coordination requires an interdisciplinary approach during hospitalization and especially during transitions of care.[3, 4] In addition, hospitals are tasked with managing and improving clinical workflow efficiencies, and implementing electronic health records (EHR)[5] that require healthcare professionals to learn new systems of care and technology. Payment models have also started to shift toward an incentive and penalty‐based structure in the form of value‐based purchasing, readmission penalties, hospital‐acquired conditions, and meaningful use.[4, 6]

In response to these pressures, hospitals are searching for ways to reliably deliver quality care that is safe, effective, patient centered, timely, efficient, and equitable.[7] Previous efforts to improve quality in the general medical inpatient setting have included redesign of the clinical work environment and new workflows through the use of checklists and whiteboards to enhance communication, patient‐centered bedside rounds, standardized protocols and handovers, and integrated clinical decision support using health information technology.[8, 9, 10, 11, 12, 13] Although each of these care coordination activities has potential value, integrating them at the unit level often remains a challenge. Some hospitals have addressed this challenge by establishing and supporting a unit‐based leadership model, where a medical director and nurse manager work together to assess and improve the quality, safety, efficiency, and patient experience‐based mission of the organization.[14, 15] However, there are few descriptions of this leadership model in the current literature. Herein, we present the unit‐based leadership model that has been developed and implemented at 6 hospitals.

MODELS OF UNIT‐BASED LEADERSHIP

The unit‐based leadership model is grounded on the idea that culture and clinical care are products of frontline structure, process, and relationships, and that leaders at the site of care can have the greatest influence on the local work environment.[16, 17] The objective is to influence care and culture at the bedside and the unit, where care is delivered and where alignment with organizational vision and mission must occur. The concept of the inpatient unit medical director is not new, and hospitals in the past have recruited physician leaders to become clinical champions for quality improvement and help establish a collaborative work environment for physicians and unit‐based staff.[18, 19, 20, 21, 22] These studies report on the challenges and benefits of incorporating a medical director to inpatient psychiatry or general care units, but do not provide specific details about the recruitment and responsibilities for unit‐based dyad partnerships, which are critical factors for success on multidisciplinary inpatient care units.

There are several logistical matters to consider when instituting a unit‐based leadership model. These include the composition of the leadership team, selection process of the leaders, the presence of trainees and permanent faculty, and whether the units are able to geographically cohort patients. Other considerations include a clear role description with established shared goals and expectations, and a compensation model that includes effort and incentives. In addition, there should be a clearly established reporting structure to senior leadership, and the unit leaders should be given opportunities for professional growth and development. Table 1 provides a summary overview of 6 hospitals' experiences to date.

DISCUSSION

In reviewing our 6 organization's collective experiences, we identified several common themes and some notable differences across sites. The core of the leadership team was primarily composed of the medical director and nurse manager on the unit. Across all 6 organizations, medical directors had a portion of their effort supported for their leadership work on the unit. Leadership development training was provided at all of our sites, with particular emphasis on quality improvement (QI) methods such as Six‐Sigma, Lean, or Plan, Do, Study, Act (PDSA). Additional leadership development sessions were provided through the organization's human resources or affiliated university. Common outcome measures of interest include patient satisfaction, interdisciplinary practice, and collaboration on the unit, and some hospital‐acquired condition measures. Last, there is a direct reporting relationship to a chief or senior nurse or physician leader within each organization. These commonalities and variances are further detailed below.

OTHER CONSIDERATIONS

Other infrastructure variables that may increase the effectiveness of the unit leadership dyad include unit‐based clinical services (geographic localization), engaging the frontline team members in the design and implementation of change innovations, a commitment to patient and family centered practices on the unit, and enhancing clinical workflow through the support of EHR functions such as concurrent documentation and provider order entry. Geographic localization, placing the fewest possible clinical service providers on the unit to work alongside unit‐based staff, allows for a cohesive interdisciplinary unit‐based team to develop under the dyad leadership, and has been shown to improve communication practices.[9, 31] Beyond geographic localization of patients, it is critical to ensure team members are committed to the changes in workflow by directly involving them through the design and implementation of new models of care taking place on the unit. This commitment starts from the top senior nurse and physician leaders in the organization, and extends to the unit‐based dyad partners, and down to each individual interdisciplinary team member on the unit.[1] Thus, it is critical to clarify roles and responsibilities and how team members on the unit will interact with each other. For some situations, conflict management training will be helpful to the unit‐based leaders to resolve issues. To appreciate potential barriers to successful rollout of this unit leadership model, a phased implementation of pilot units, followed by successive waves, should be considered. Many of the units that instituted unit‐based interdisciplinary team rounds solicited and implemented direct feedback from frontline team members in efforts to improve communication and be more patient centered. Conversely, there are also likely to be situations where the unit‐based leaders will be confronted with hindrances to their unit‐based collaborative improvement efforts. To help prepare the dyad leaders, many of our unit‐based leaders have received specific training on how to coach and conduct difficult conversations with individuals who have performance gaps or are perceived to be hindering the progress of the unit's work. These crucial negotiation skills are not innate among most managers and should be explicitly provided to new leaders across organizations.

The goals and merits of patient‐ and family‐centered care (PFCC) have been well described.[32, 33, 34] Organizational support to teach and disseminate PFCC practices throughout all settings of care may help the leadership dyads implement rounding strategies that engage all staff, patients, and family members throughout the hospital course and during the transitions out of the hospital.

Clinical workflow has become heavily dependent on the EHR systems. For those organizations that have yet to adopt a particular EHR system, the leadership dyads should be involved throughout the EHR design process to help ensure that the technological solutions will be built to assist the clinical workflow, and once the system has been built, the leadership dyad should monitor and enhance the interface between workflow and EHR system so that it can support the creation and advancement of interdisciplinary plans of care on the unit.

CONCLUSION

The care of the hospitalized patient has become more complex over time. Interdisciplinary teamwork needs to be improved at the unit level to achieve the strategic goals of the hospital. Although quality improvement is an organizational goal, change takes place locally. Physician leaders, in partnership with nurse managers, are needed now more than ever to take on this task to improve the hospital‐care experience for patients by functioning as the primary effector arms for changing the landscape of hospital‐based care. We have described characteristics of unit‐based leadership programs adopted across 6 organizations. Hospitalists with clinical experience as the principal providers of inpatient‐based care and quality improvement experience and training, have been key participants in the development and implementation of the local leadership models in each of these hospital systems. We hope the comparison of the various models featured in this article serves as a valuable reference to hospitals and healthcare organizations who are contemplating the incorporation of this model into their strategic plan.

Hospital‐based care has become more complex over time. Patients are sicker, with more chronic comorbid conditions requiring greater collaboration to provide coordinated patient care.[1, 2] Care coordination requires an interdisciplinary approach during hospitalization and especially during transitions of care.[3, 4] In addition, hospitals are tasked with managing and improving clinical workflow efficiencies, and implementing electronic health records (EHR)[5] that require healthcare professionals to learn new systems of care and technology. Payment models have also started to shift toward an incentive and penalty‐based structure in the form of value‐based purchasing, readmission penalties, hospital‐acquired conditions, and meaningful use.[4, 6]

In response to these pressures, hospitals are searching for ways to reliably deliver quality care that is safe, effective, patient centered, timely, efficient, and equitable.[7] Previous efforts to improve quality in the general medical inpatient setting have included redesign of the clinical work environment and new workflows through the use of checklists and whiteboards to enhance communication, patient‐centered bedside rounds, standardized protocols and handovers, and integrated clinical decision support using health information technology.[8, 9, 10, 11, 12, 13] Although each of these care coordination activities has potential value, integrating them at the unit level often remains a challenge. Some hospitals have addressed this challenge by establishing and supporting a unit‐based leadership model, where a medical director and nurse manager work together to assess and improve the quality, safety, efficiency, and patient experience‐based mission of the organization.[14, 15] However, there are few descriptions of this leadership model in the current literature. Herein, we present the unit‐based leadership model that has been developed and implemented at 6 hospitals.

MODELS OF UNIT‐BASED LEADERSHIP

The unit‐based leadership model is grounded on the idea that culture and clinical care are products of frontline structure, process, and relationships, and that leaders at the site of care can have the greatest influence on the local work environment.[16, 17] The objective is to influence care and culture at the bedside and the unit, where care is delivered and where alignment with organizational vision and mission must occur. The concept of the inpatient unit medical director is not new, and hospitals in the past have recruited physician leaders to become clinical champions for quality improvement and help establish a collaborative work environment for physicians and unit‐based staff.[18, 19, 20, 21, 22] These studies report on the challenges and benefits of incorporating a medical director to inpatient psychiatry or general care units, but do not provide specific details about the recruitment and responsibilities for unit‐based dyad partnerships, which are critical factors for success on multidisciplinary inpatient care units.

There are several logistical matters to consider when instituting a unit‐based leadership model. These include the composition of the leadership team, selection process of the leaders, the presence of trainees and permanent faculty, and whether the units are able to geographically cohort patients. Other considerations include a clear role description with established shared goals and expectations, and a compensation model that includes effort and incentives. In addition, there should be a clearly established reporting structure to senior leadership, and the unit leaders should be given opportunities for professional growth and development. Table 1 provides a summary overview of 6 hospitals' experiences to date.

DISCUSSION

In reviewing our 6 organization's collective experiences, we identified several common themes and some notable differences across sites. The core of the leadership team was primarily composed of the medical director and nurse manager on the unit. Across all 6 organizations, medical directors had a portion of their effort supported for their leadership work on the unit. Leadership development training was provided at all of our sites, with particular emphasis on quality improvement (QI) methods such as Six‐Sigma, Lean, or Plan, Do, Study, Act (PDSA). Additional leadership development sessions were provided through the organization's human resources or affiliated university. Common outcome measures of interest include patient satisfaction, interdisciplinary practice, and collaboration on the unit, and some hospital‐acquired condition measures. Last, there is a direct reporting relationship to a chief or senior nurse or physician leader within each organization. These commonalities and variances are further detailed below.

OTHER CONSIDERATIONS

Other infrastructure variables that may increase the effectiveness of the unit leadership dyad include unit‐based clinical services (geographic localization), engaging the frontline team members in the design and implementation of change innovations, a commitment to patient and family centered practices on the unit, and enhancing clinical workflow through the support of EHR functions such as concurrent documentation and provider order entry. Geographic localization, placing the fewest possible clinical service providers on the unit to work alongside unit‐based staff, allows for a cohesive interdisciplinary unit‐based team to develop under the dyad leadership, and has been shown to improve communication practices.[9, 31] Beyond geographic localization of patients, it is critical to ensure team members are committed to the changes in workflow by directly involving them through the design and implementation of new models of care taking place on the unit. This commitment starts from the top senior nurse and physician leaders in the organization, and extends to the unit‐based dyad partners, and down to each individual interdisciplinary team member on the unit.[1] Thus, it is critical to clarify roles and responsibilities and how team members on the unit will interact with each other. For some situations, conflict management training will be helpful to the unit‐based leaders to resolve issues. To appreciate potential barriers to successful rollout of this unit leadership model, a phased implementation of pilot units, followed by successive waves, should be considered. Many of the units that instituted unit‐based interdisciplinary team rounds solicited and implemented direct feedback from frontline team members in efforts to improve communication and be more patient centered. Conversely, there are also likely to be situations where the unit‐based leaders will be confronted with hindrances to their unit‐based collaborative improvement efforts. To help prepare the dyad leaders, many of our unit‐based leaders have received specific training on how to coach and conduct difficult conversations with individuals who have performance gaps or are perceived to be hindering the progress of the unit's work. These crucial negotiation skills are not innate among most managers and should be explicitly provided to new leaders across organizations.

The goals and merits of patient‐ and family‐centered care (PFCC) have been well described.[32, 33, 34] Organizational support to teach and disseminate PFCC practices throughout all settings of care may help the leadership dyads implement rounding strategies that engage all staff, patients, and family members throughout the hospital course and during the transitions out of the hospital.

Clinical workflow has become heavily dependent on the EHR systems. For those organizations that have yet to adopt a particular EHR system, the leadership dyads should be involved throughout the EHR design process to help ensure that the technological solutions will be built to assist the clinical workflow, and once the system has been built, the leadership dyad should monitor and enhance the interface between workflow and EHR system so that it can support the creation and advancement of interdisciplinary plans of care on the unit.

CONCLUSION

The care of the hospitalized patient has become more complex over time. Interdisciplinary teamwork needs to be improved at the unit level to achieve the strategic goals of the hospital. Although quality improvement is an organizational goal, change takes place locally. Physician leaders, in partnership with nurse managers, are needed now more than ever to take on this task to improve the hospital‐care experience for patients by functioning as the primary effector arms for changing the landscape of hospital‐based care. We have described characteristics of unit‐based leadership programs adopted across 6 organizations. Hospitalists with clinical experience as the principal providers of inpatient‐based care and quality improvement experience and training, have been key participants in the development and implementation of the local leadership models in each of these hospital systems. We hope the comparison of the various models featured in this article serves as a valuable reference to hospitals and healthcare organizations who are contemplating the incorporation of this model into their strategic plan.

As hospitalists now care for expanding numbers of America's aging patients, many of whom have chronic, debilitating illnesses or are near the end of life, there is a burgeoning need for innovative approaches to optimize quality of care and control costs, especially in the last year of life.[1, 2] In the inaugural issue of the Journal of Hospital Medicine, an overview of how hospitalists and palliative care specialists can work hand‐in‐hand to care for these seriously ill, hospitalized patients was presented.[3, 4] This perspective highlighted a symbiotic and mutually beneficial relationship between the 2 specialties based on their shared values, missions, and complementary strengths.[3, 4] Since then, a number of collaborative ventures offering palliative care for seriously ill, hospitalized patients have been developed and examined in a variety of settings.[4, 5, 6]

A key collaborative undertaking for hospitalists and palliative care specialists is the appreciation of the unique trajectory of each chronic illness toward the end of life. For example, patients with cancer or neurodegenerative disease tend to have relatively stable functional status until the final months of rapid deterioration. On the other hand, the courses of patients with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), end‐stage renal disease, and human immunodeficiency virus/acquired immunodeficiency syndrome tend to be punctuated by episodes of acute exacerbation with often nearly complete return to previous status. Finally, dementia usually follows a slow course of gradual decline leading to death.[7] Ideally, active management of symptoms and discussion of prognosis and goals of care should happen in the early stages of these chronic illnesses, yet most often they are left until an acute hospitalization late in the disease course. The following case illustrates the point.

CASE 1

Mrs. M is an 89‐year‐old woman with Alzheimer's dementia diagnosed 7 years ago who has been cared for at home by family members. She is admitted to the hospital for urinary tract infection and volume depletion. She is bedbound, cachectic, and has a stage III decubitus ulcer. Her daughter describes a 6‐month history of feeding problems, 20‐lb weight loss, and 2 recent hospitalizations for aspiration pneumonia. She improves somewhat with hydration and intravenous antibiotics, and the physical therapist recommends rehabilitation. Mrs. M does not have decision‐making capacity, and her long‐time family physician has not inquired about care preferences or goals. The hospitalist team meets with family members to discuss the trajectory and prognosis of advanced dementia, and recommends against artificial nutrition and hydration, and for initiation of palliative care service at a skilled nursing facility.

In this example, the hospitalist team recognizes the advent of frequent infections and diminished oral intake in advanced dementia as signals of increased morbidity and mortality warranting palliative care intervention.[8] This, we suggest, represents a sentinel hospitalization, a hospitalization in the disease course that heralds a need to reassess prognosis, treatment options and intensity, and goals of care. Hospitalists are well positioned to recognize such transition points in the disease course by considering the patient's recent history of illness, to offer an impartial overview of illness progression, and to optimize patient care using principles of palliative care. Additionally, hospitalists have advantages of geographic convenience, readily available consultants, systemic support, and a detachment from the longitudinal patient‐physician relationship, which may enable more accurate medical prognostication.[9]

There are many ways to identify a sentinel hospitalization. For example, hospitalists can use the surprise question, Would you be surprised if the patient died within 12 months? on admission for the majority of cancer and dialysis patients. The answer No predicts a 3.5‐ to 7‐fold increase in 1‐year mortality.[10, 11] In a powerful predictive model for 1‐year mortality using readily available clinical, laboratory, and functional characteristics, medical inpatients in the highest quartiles have 1‐year mortality exceeding 60%.[12] Recently, several more complicated prognostic models have been derived and validated in large cohorts of medical inpatients, which predict short‐term (30‐day) and long‐term (0.5‐1 year) mortality with great accuracy.[13, 14] There are also many disease‐specific prognostic features (eg, diagnosis of metastatic disease with poor performance status or high symptom burden, progression of chronic kidney disease with consideration of hemodialysis, additional stroke in multi‐infarct dementia, and frequent exacerbation of severe COPD or severe CHF).[15, 16, 17, 18, 19, 20, 21] Finally, frequent readmissions and prolonged hospital or intensive care unit stay can also be used.[17, 19] These criteria are summarized in Table 1 with time frames.

Once a sentinel hospitalization is identified, hospitalists, with input from the patient's primary care physician and subspecialists, can then develop a comprehensive strategy to evaluate current disease management, to educate patient and family accordingly, and to actively integrate palliative care services as appropriate. The next challenge facing the care team is how to deliver the necessary palliative care since it is unnecessary and improper to ask for palliative care specialist consultation for every sentinel hospitalization. We believe that the best approach is for hospitalists to be the primary deliverers of basic palliative care in the hospital while consulting palliative care specialists for refractory symptoms and complex scenarios.[22] According to this generalist‐specialist palliative care model, physicians of all specialties should define and master a basic palliative care skill set for their patients. For hospitalists, the relevant skill set includes assessing and treating pain and other symptoms such as dyspnea, nausea and vomiting, and constipation, estimating prognosis, and initiating goals of care discussions.[22] The following case illustrates this point.

CASE 2

Ms S, a 21‐year‐old Hispanic woman with advanced, recurrent head and neck cancer, status post multiple surgeries, chemotherapy, and radiation therapy, is admitted to the hospitalist service for aspiration pneumonia, which responds to antibiotics rapidly. However, her cancer‐related somatic and neuropathic pain soon becomes refractory to opioids prescribed by the hospitalist team. She also develops significant dyspnea, xerostomia, depression, anxiety, and existential suffering. With the help of the interdisciplinary palliative care team, her pain is relieved by a patient‐controlled analgesia pump and methadone. A palliative care social worker and chaplain visit her and her family daily to address their distress. Eventually, the care team is able to provide a stable medical regimen for symptom control and to use it across the entire care continuum.

In this example, the hospitalist team, with the support of palliative care specialists, provided basic palliative care and longitudinal integration of palliative practices into the patient's overall treatment scheme. Hospitalists, given their scope of practice and sheer volume of patients, are well positioned to rapidly gain competencies in symptom management, empathic communication, and interdisciplinary teamwork.[23, 24] Hospitalists may benefit from innovative and collaborative palliative care education using interactive online modules, case simulation, communication workshops, and observed evaluation and feedback.[25] Several modes of collaboration between hospital medicine and palliative care have been developed including implementation of palliative care consult triggers on admission, palliative care participation in hospitalist interdisciplinary rounds, and disease specific, integrated management programs.[17, 26] These collaborations are particularly important, as the quality of inpatient care at the end of life is still suboptimal and more appropriate use of palliative care will be beneficial.[27] Recently, some hospitals have developed specialized inpatient palliative care units, combining intensive palliation with inpatient medical surgical level of care, as well as providing hospice care. Staffed by palliative care specialists or hospitalists, they provide efficient, cost‐saving care to patients with advanced chronic illness or terminal disease in need of intensive symptom management.[28] Finally, there is mounting evidence supporting the clinical effectiveness of palliative care in diverse specialties such as oncology, pulmonary and critical care, and nephrology.[29] For example, in the setting of metastatic non‐small cell lung cancer, early initiation of palliative care has been shown to improve symptom control and quality of life, reduce chemotherapy use at the end of life, and interestingly, prolong median survival by almost 3 months.[30] This has led to a position statement from American Society of Clinical Oncology encouraging early integration of palliative care into standard oncologic care for advanced disease.[31]

Recognizing a sentinel hospitalization allows palliative care to be integrated at transitions of care and carried forward. For patients with chronic debilitating illnesses who are approaching the end of life, appropriate care transitions will ensure that their short‐ and long‐term care matches their goals of care, assure timely clinical follow‐ups, and help reduce hospital readmission and healthcare resource utilization.[32] Importantly, timely and compassionate communication is a key to the success of both hospital medicine and palliative care. Many patients with life‐limiting diseases prefer to receive prognostic information and to discuss goals of care.[33] How this information is integrated and communicated through the care continuum is crucial, especially in the era of duty hour limits and frequent handoffs. The information exchange needs to facilitate active participation of primary care physicians who may not be involved in hospital care. Some of the innovative strategies for communication and transfer of palliative care information, such as prognosis, goals of care, family meeting consensus, and symptom control interventions, include a palliative care checklist in the electronic health record, incorporation of prognostic and family meeting information in the discharge summary, and links to the national Physician Orders for Life‐Sustaining Treatment advanced care planning program.[34] Of note, a pilot program in the United Kingdom adopting an electronic palliative care summary has reduced after‐hour emergency room visits and hospital readmissions.[35] The following case illustrates this point.

CASE 3

Mrs. K, an 82‐year‐old Russian‐speaking woman with newly diagnosed metastatic pancreatic cancer, is admitted for worsening obstructive jaundice and a second opinion about treatment. A biliary stent is placed and her jaundice slowly improves. The patient and family have requested chemotherapy. However, the oncologist determines that she would only qualify for a phase I trial given her poor performance status. The hospitalist team requests the help of the palliative care consult team to manage her severe pain, depression, and to provide support to the family. After several family meetings, the patient and family choose not to pursue chemotherapy. Given the lack of adequate support at home, she is discharged to a skilled nursing facility for short‐term rehabilitation with plans to transition to the in‐house hospice program. The hospitalist, palliative care attending physician, and the medical director of the rehabilitation facility have a 3‐way phone conference to confirm the plans of care and to ensure a smooth care transition.

In this case, the hospitalist team recognizes that this is a sentinel hospitalization for Mrs. K that requires extensive palliative care intervention. Often, transitioning to skilled nursing facilities (SNF) is the default pathway for patients needing hospice/palliative care, especially when patients and families are not yet ready to discuss prognosis realistically or to accept hospice, or there is not enough support available at home. A recent large cohort study showed that 30% of patients in their last 6‐month of life had used, and nearly 10% of such patients had died, under Medicare's posthospitalization SNF benefit.[36] Although the worsening disease trajectory may not be apparent at hospital discharge, it is more likely that the financial and practical limitation of the Medicare Hospice Benefit accounts for this observation, which includes limited home health aid hours, lack of coverage for room and board, and lower payments to SNFs.[36] Hospitalists can help address the issue of discharge location for patients needing palliative care. Sometimes this requires extensive communication before and after discharge to help enhance the transition from a rehabilitation facility to hospice/palliative care. Appropriately integrated palliative care at the time of care transitions, in the form of hospice or longitudinal home‐based palliative care rather than just routine clinic follow‐up, has the potential to reduce 30‐day readmission for chronically ill, elderly patients and for patients near the end of life.[37, 38] It is critical that national policy, suitable reimbursement, and financial incentives support this practice. A demonstration project, Better Outcomes by Optimizing Safe Transitions (BOOST), organized by the Society of Hospital Medicine, integrates palliative care evaluation into a comprehensive discharge assessment tool. This intervention has been shown to reduce readmissions to acute care hospitals.[39]

In this article, we define a sentinel hospitalization and suggest that its recognition provides an important opportunity for hospitalists to actively integrate palliative care into patients' chronic disease management programs, with inputs from patients, their families, their primary physicians and subspecialists, as well as palliative care specialists. We also recognize that within nonsentinel hospitalizations, there are important opportunities to discuss prognosis, goals of care, and advanced care planning. This approach allows the fresh eyes of hospitalists to assess the patient's current health status and prognosis, to communicate these relevant clinical issues with the patient and family, and to encourage discussions about goals of care and advanced care planning during the sentinel hospitalization. It also provides a structured vehicle for soliciting the patient's (and family's) perspectives and documenting them in the medical record. A compilation of sample items to guide discussion can be found in Table 2. Hospitalists, equipped with basic palliative care skills and supported by hospital‐ and community‐based palliative care teams, can thrive in this unique position of optimizing the quality of care for these patients.[40] Almost 20 years ago, the field of palliative care rose to national prominence on the findings of the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) study, which investigated the suboptimal end‐of‐life experiences of hospitalized adult patients.[41] Since then, the fields of both hospital medicine and palliative care have grown, yet the best is still to come for their collaborative excellence, mutual education, and shared care innovation at the forefront of medicine.

As hospitalists now care for expanding numbers of America's aging patients, many of whom have chronic, debilitating illnesses or are near the end of life, there is a burgeoning need for innovative approaches to optimize quality of care and control costs, especially in the last year of life.[1, 2] In the inaugural issue of the Journal of Hospital Medicine, an overview of how hospitalists and palliative care specialists can work hand‐in‐hand to care for these seriously ill, hospitalized patients was presented.[3, 4] This perspective highlighted a symbiotic and mutually beneficial relationship between the 2 specialties based on their shared values, missions, and complementary strengths.[3, 4] Since then, a number of collaborative ventures offering palliative care for seriously ill, hospitalized patients have been developed and examined in a variety of settings.[4, 5, 6]

A key collaborative undertaking for hospitalists and palliative care specialists is the appreciation of the unique trajectory of each chronic illness toward the end of life. For example, patients with cancer or neurodegenerative disease tend to have relatively stable functional status until the final months of rapid deterioration. On the other hand, the courses of patients with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), end‐stage renal disease, and human immunodeficiency virus/acquired immunodeficiency syndrome tend to be punctuated by episodes of acute exacerbation with often nearly complete return to previous status. Finally, dementia usually follows a slow course of gradual decline leading to death.[7] Ideally, active management of symptoms and discussion of prognosis and goals of care should happen in the early stages of these chronic illnesses, yet most often they are left until an acute hospitalization late in the disease course. The following case illustrates the point.

CASE 1

Mrs. M is an 89‐year‐old woman with Alzheimer's dementia diagnosed 7 years ago who has been cared for at home by family members. She is admitted to the hospital for urinary tract infection and volume depletion. She is bedbound, cachectic, and has a stage III decubitus ulcer. Her daughter describes a 6‐month history of feeding problems, 20‐lb weight loss, and 2 recent hospitalizations for aspiration pneumonia. She improves somewhat with hydration and intravenous antibiotics, and the physical therapist recommends rehabilitation. Mrs. M does not have decision‐making capacity, and her long‐time family physician has not inquired about care preferences or goals. The hospitalist team meets with family members to discuss the trajectory and prognosis of advanced dementia, and recommends against artificial nutrition and hydration, and for initiation of palliative care service at a skilled nursing facility.

In this example, the hospitalist team recognizes the advent of frequent infections and diminished oral intake in advanced dementia as signals of increased morbidity and mortality warranting palliative care intervention.[8] This, we suggest, represents a sentinel hospitalization, a hospitalization in the disease course that heralds a need to reassess prognosis, treatment options and intensity, and goals of care. Hospitalists are well positioned to recognize such transition points in the disease course by considering the patient's recent history of illness, to offer an impartial overview of illness progression, and to optimize patient care using principles of palliative care. Additionally, hospitalists have advantages of geographic convenience, readily available consultants, systemic support, and a detachment from the longitudinal patient‐physician relationship, which may enable more accurate medical prognostication.[9]

There are many ways to identify a sentinel hospitalization. For example, hospitalists can use the surprise question, Would you be surprised if the patient died within 12 months? on admission for the majority of cancer and dialysis patients. The answer No predicts a 3.5‐ to 7‐fold increase in 1‐year mortality.[10, 11] In a powerful predictive model for 1‐year mortality using readily available clinical, laboratory, and functional characteristics, medical inpatients in the highest quartiles have 1‐year mortality exceeding 60%.[12] Recently, several more complicated prognostic models have been derived and validated in large cohorts of medical inpatients, which predict short‐term (30‐day) and long‐term (0.5‐1 year) mortality with great accuracy.[13, 14] There are also many disease‐specific prognostic features (eg, diagnosis of metastatic disease with poor performance status or high symptom burden, progression of chronic kidney disease with consideration of hemodialysis, additional stroke in multi‐infarct dementia, and frequent exacerbation of severe COPD or severe CHF).[15, 16, 17, 18, 19, 20, 21] Finally, frequent readmissions and prolonged hospital or intensive care unit stay can also be used.[17, 19] These criteria are summarized in Table 1 with time frames.

Once a sentinel hospitalization is identified, hospitalists, with input from the patient's primary care physician and subspecialists, can then develop a comprehensive strategy to evaluate current disease management, to educate patient and family accordingly, and to actively integrate palliative care services as appropriate. The next challenge facing the care team is how to deliver the necessary palliative care since it is unnecessary and improper to ask for palliative care specialist consultation for every sentinel hospitalization. We believe that the best approach is for hospitalists to be the primary deliverers of basic palliative care in the hospital while consulting palliative care specialists for refractory symptoms and complex scenarios.[22] According to this generalist‐specialist palliative care model, physicians of all specialties should define and master a basic palliative care skill set for their patients. For hospitalists, the relevant skill set includes assessing and treating pain and other symptoms such as dyspnea, nausea and vomiting, and constipation, estimating prognosis, and initiating goals of care discussions.[22] The following case illustrates this point.

CASE 2

Ms S, a 21‐year‐old Hispanic woman with advanced, recurrent head and neck cancer, status post multiple surgeries, chemotherapy, and radiation therapy, is admitted to the hospitalist service for aspiration pneumonia, which responds to antibiotics rapidly. However, her cancer‐related somatic and neuropathic pain soon becomes refractory to opioids prescribed by the hospitalist team. She also develops significant dyspnea, xerostomia, depression, anxiety, and existential suffering. With the help of the interdisciplinary palliative care team, her pain is relieved by a patient‐controlled analgesia pump and methadone. A palliative care social worker and chaplain visit her and her family daily to address their distress. Eventually, the care team is able to provide a stable medical regimen for symptom control and to use it across the entire care continuum.

In this example, the hospitalist team, with the support of palliative care specialists, provided basic palliative care and longitudinal integration of palliative practices into the patient's overall treatment scheme. Hospitalists, given their scope of practice and sheer volume of patients, are well positioned to rapidly gain competencies in symptom management, empathic communication, and interdisciplinary teamwork.[23, 24] Hospitalists may benefit from innovative and collaborative palliative care education using interactive online modules, case simulation, communication workshops, and observed evaluation and feedback.[25] Several modes of collaboration between hospital medicine and palliative care have been developed including implementation of palliative care consult triggers on admission, palliative care participation in hospitalist interdisciplinary rounds, and disease specific, integrated management programs.[17, 26] These collaborations are particularly important, as the quality of inpatient care at the end of life is still suboptimal and more appropriate use of palliative care will be beneficial.[27] Recently, some hospitals have developed specialized inpatient palliative care units, combining intensive palliation with inpatient medical surgical level of care, as well as providing hospice care. Staffed by palliative care specialists or hospitalists, they provide efficient, cost‐saving care to patients with advanced chronic illness or terminal disease in need of intensive symptom management.[28] Finally, there is mounting evidence supporting the clinical effectiveness of palliative care in diverse specialties such as oncology, pulmonary and critical care, and nephrology.[29] For example, in the setting of metastatic non‐small cell lung cancer, early initiation of palliative care has been shown to improve symptom control and quality of life, reduce chemotherapy use at the end of life, and interestingly, prolong median survival by almost 3 months.[30] This has led to a position statement from American Society of Clinical Oncology encouraging early integration of palliative care into standard oncologic care for advanced disease.[31]

Recognizing a sentinel hospitalization allows palliative care to be integrated at transitions of care and carried forward. For patients with chronic debilitating illnesses who are approaching the end of life, appropriate care transitions will ensure that their short‐ and long‐term care matches their goals of care, assure timely clinical follow‐ups, and help reduce hospital readmission and healthcare resource utilization.[32] Importantly, timely and compassionate communication is a key to the success of both hospital medicine and palliative care. Many patients with life‐limiting diseases prefer to receive prognostic information and to discuss goals of care.[33] How this information is integrated and communicated through the care continuum is crucial, especially in the era of duty hour limits and frequent handoffs. The information exchange needs to facilitate active participation of primary care physicians who may not be involved in hospital care. Some of the innovative strategies for communication and transfer of palliative care information, such as prognosis, goals of care, family meeting consensus, and symptom control interventions, include a palliative care checklist in the electronic health record, incorporation of prognostic and family meeting information in the discharge summary, and links to the national Physician Orders for Life‐Sustaining Treatment advanced care planning program.[34] Of note, a pilot program in the United Kingdom adopting an electronic palliative care summary has reduced after‐hour emergency room visits and hospital readmissions.[35] The following case illustrates this point.

CASE 3

Mrs. K, an 82‐year‐old Russian‐speaking woman with newly diagnosed metastatic pancreatic cancer, is admitted for worsening obstructive jaundice and a second opinion about treatment. A biliary stent is placed and her jaundice slowly improves. The patient and family have requested chemotherapy. However, the oncologist determines that she would only qualify for a phase I trial given her poor performance status. The hospitalist team requests the help of the palliative care consult team to manage her severe pain, depression, and to provide support to the family. After several family meetings, the patient and family choose not to pursue chemotherapy. Given the lack of adequate support at home, she is discharged to a skilled nursing facility for short‐term rehabilitation with plans to transition to the in‐house hospice program. The hospitalist, palliative care attending physician, and the medical director of the rehabilitation facility have a 3‐way phone conference to confirm the plans of care and to ensure a smooth care transition.

In this case, the hospitalist team recognizes that this is a sentinel hospitalization for Mrs. K that requires extensive palliative care intervention. Often, transitioning to skilled nursing facilities (SNF) is the default pathway for patients needing hospice/palliative care, especially when patients and families are not yet ready to discuss prognosis realistically or to accept hospice, or there is not enough support available at home. A recent large cohort study showed that 30% of patients in their last 6‐month of life had used, and nearly 10% of such patients had died, under Medicare's posthospitalization SNF benefit.[36] Although the worsening disease trajectory may not be apparent at hospital discharge, it is more likely that the financial and practical limitation of the Medicare Hospice Benefit accounts for this observation, which includes limited home health aid hours, lack of coverage for room and board, and lower payments to SNFs.[36] Hospitalists can help address the issue of discharge location for patients needing palliative care. Sometimes this requires extensive communication before and after discharge to help enhance the transition from a rehabilitation facility to hospice/palliative care. Appropriately integrated palliative care at the time of care transitions, in the form of hospice or longitudinal home‐based palliative care rather than just routine clinic follow‐up, has the potential to reduce 30‐day readmission for chronically ill, elderly patients and for patients near the end of life.[37, 38] It is critical that national policy, suitable reimbursement, and financial incentives support this practice. A demonstration project, Better Outcomes by Optimizing Safe Transitions (BOOST), organized by the Society of Hospital Medicine, integrates palliative care evaluation into a comprehensive discharge assessment tool. This intervention has been shown to reduce readmissions to acute care hospitals.[39]

In this article, we define a sentinel hospitalization and suggest that its recognition provides an important opportunity for hospitalists to actively integrate palliative care into patients' chronic disease management programs, with inputs from patients, their families, their primary physicians and subspecialists, as well as palliative care specialists. We also recognize that within nonsentinel hospitalizations, there are important opportunities to discuss prognosis, goals of care, and advanced care planning. This approach allows the fresh eyes of hospitalists to assess the patient's current health status and prognosis, to communicate these relevant clinical issues with the patient and family, and to encourage discussions about goals of care and advanced care planning during the sentinel hospitalization. It also provides a structured vehicle for soliciting the patient's (and family's) perspectives and documenting them in the medical record. A compilation of sample items to guide discussion can be found in Table 2. Hospitalists, equipped with basic palliative care skills and supported by hospital‐ and community‐based palliative care teams, can thrive in this unique position of optimizing the quality of care for these patients.[40] Almost 20 years ago, the field of palliative care rose to national prominence on the findings of the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) study, which investigated the suboptimal end‐of‐life experiences of hospitalized adult patients.[41] Since then, the fields of both hospital medicine and palliative care have grown, yet the best is still to come for their collaborative excellence, mutual education, and shared care innovation at the forefront of medicine.

As hospitalists now care for expanding numbers of America's aging patients, many of whom have chronic, debilitating illnesses or are near the end of life, there is a burgeoning need for innovative approaches to optimize quality of care and control costs, especially in the last year of life.[1, 2] In the inaugural issue of the Journal of Hospital Medicine, an overview of how hospitalists and palliative care specialists can work hand‐in‐hand to care for these seriously ill, hospitalized patients was presented.[3, 4] This perspective highlighted a symbiotic and mutually beneficial relationship between the 2 specialties based on their shared values, missions, and complementary strengths.[3, 4] Since then, a number of collaborative ventures offering palliative care for seriously ill, hospitalized patients have been developed and examined in a variety of settings.[4, 5, 6]

A key collaborative undertaking for hospitalists and palliative care specialists is the appreciation of the unique trajectory of each chronic illness toward the end of life. For example, patients with cancer or neurodegenerative disease tend to have relatively stable functional status until the final months of rapid deterioration. On the other hand, the courses of patients with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), end‐stage renal disease, and human immunodeficiency virus/acquired immunodeficiency syndrome tend to be punctuated by episodes of acute exacerbation with often nearly complete return to previous status. Finally, dementia usually follows a slow course of gradual decline leading to death.[7] Ideally, active management of symptoms and discussion of prognosis and goals of care should happen in the early stages of these chronic illnesses, yet most often they are left until an acute hospitalization late in the disease course. The following case illustrates the point.

CASE 1

Mrs. M is an 89‐year‐old woman with Alzheimer's dementia diagnosed 7 years ago who has been cared for at home by family members. She is admitted to the hospital for urinary tract infection and volume depletion. She is bedbound, cachectic, and has a stage III decubitus ulcer. Her daughter describes a 6‐month history of feeding problems, 20‐lb weight loss, and 2 recent hospitalizations for aspiration pneumonia. She improves somewhat with hydration and intravenous antibiotics, and the physical therapist recommends rehabilitation. Mrs. M does not have decision‐making capacity, and her long‐time family physician has not inquired about care preferences or goals. The hospitalist team meets with family members to discuss the trajectory and prognosis of advanced dementia, and recommends against artificial nutrition and hydration, and for initiation of palliative care service at a skilled nursing facility.

In this example, the hospitalist team recognizes the advent of frequent infections and diminished oral intake in advanced dementia as signals of increased morbidity and mortality warranting palliative care intervention.[8] This, we suggest, represents a sentinel hospitalization, a hospitalization in the disease course that heralds a need to reassess prognosis, treatment options and intensity, and goals of care. Hospitalists are well positioned to recognize such transition points in the disease course by considering the patient's recent history of illness, to offer an impartial overview of illness progression, and to optimize patient care using principles of palliative care. Additionally, hospitalists have advantages of geographic convenience, readily available consultants, systemic support, and a detachment from the longitudinal patient‐physician relationship, which may enable more accurate medical prognostication.[9]

There are many ways to identify a sentinel hospitalization. For example, hospitalists can use the surprise question, Would you be surprised if the patient died within 12 months? on admission for the majority of cancer and dialysis patients. The answer No predicts a 3.5‐ to 7‐fold increase in 1‐year mortality.[10, 11] In a powerful predictive model for 1‐year mortality using readily available clinical, laboratory, and functional characteristics, medical inpatients in the highest quartiles have 1‐year mortality exceeding 60%.[12] Recently, several more complicated prognostic models have been derived and validated in large cohorts of medical inpatients, which predict short‐term (30‐day) and long‐term (0.5‐1 year) mortality with great accuracy.[13, 14] There are also many disease‐specific prognostic features (eg, diagnosis of metastatic disease with poor performance status or high symptom burden, progression of chronic kidney disease with consideration of hemodialysis, additional stroke in multi‐infarct dementia, and frequent exacerbation of severe COPD or severe CHF).[15, 16, 17, 18, 19, 20, 21] Finally, frequent readmissions and prolonged hospital or intensive care unit stay can also be used.[17, 19] These criteria are summarized in Table 1 with time frames.

Once a sentinel hospitalization is identified, hospitalists, with input from the patient's primary care physician and subspecialists, can then develop a comprehensive strategy to evaluate current disease management, to educate patient and family accordingly, and to actively integrate palliative care services as appropriate. The next challenge facing the care team is how to deliver the necessary palliative care since it is unnecessary and improper to ask for palliative care specialist consultation for every sentinel hospitalization. We believe that the best approach is for hospitalists to be the primary deliverers of basic palliative care in the hospital while consulting palliative care specialists for refractory symptoms and complex scenarios.[22] According to this generalist‐specialist palliative care model, physicians of all specialties should define and master a basic palliative care skill set for their patients. For hospitalists, the relevant skill set includes assessing and treating pain and other symptoms such as dyspnea, nausea and vomiting, and constipation, estimating prognosis, and initiating goals of care discussions.[22] The following case illustrates this point.

CASE 2

Ms S, a 21‐year‐old Hispanic woman with advanced, recurrent head and neck cancer, status post multiple surgeries, chemotherapy, and radiation therapy, is admitted to the hospitalist service for aspiration pneumonia, which responds to antibiotics rapidly. However, her cancer‐related somatic and neuropathic pain soon becomes refractory to opioids prescribed by the hospitalist team. She also develops significant dyspnea, xerostomia, depression, anxiety, and existential suffering. With the help of the interdisciplinary palliative care team, her pain is relieved by a patient‐controlled analgesia pump and methadone. A palliative care social worker and chaplain visit her and her family daily to address their distress. Eventually, the care team is able to provide a stable medical regimen for symptom control and to use it across the entire care continuum.

In this example, the hospitalist team, with the support of palliative care specialists, provided basic palliative care and longitudinal integration of palliative practices into the patient's overall treatment scheme. Hospitalists, given their scope of practice and sheer volume of patients, are well positioned to rapidly gain competencies in symptom management, empathic communication, and interdisciplinary teamwork.[23, 24] Hospitalists may benefit from innovative and collaborative palliative care education using interactive online modules, case simulation, communication workshops, and observed evaluation and feedback.[25] Several modes of collaboration between hospital medicine and palliative care have been developed including implementation of palliative care consult triggers on admission, palliative care participation in hospitalist interdisciplinary rounds, and disease specific, integrated management programs.[17, 26] These collaborations are particularly important, as the quality of inpatient care at the end of life is still suboptimal and more appropriate use of palliative care will be beneficial.[27] Recently, some hospitals have developed specialized inpatient palliative care units, combining intensive palliation with inpatient medical surgical level of care, as well as providing hospice care. Staffed by palliative care specialists or hospitalists, they provide efficient, cost‐saving care to patients with advanced chronic illness or terminal disease in need of intensive symptom management.[28] Finally, there is mounting evidence supporting the clinical effectiveness of palliative care in diverse specialties such as oncology, pulmonary and critical care, and nephrology.[29] For example, in the setting of metastatic non‐small cell lung cancer, early initiation of palliative care has been shown to improve symptom control and quality of life, reduce chemotherapy use at the end of life, and interestingly, prolong median survival by almost 3 months.[30] This has led to a position statement from American Society of Clinical Oncology encouraging early integration of palliative care into standard oncologic care for advanced disease.[31]

Recognizing a sentinel hospitalization allows palliative care to be integrated at transitions of care and carried forward. For patients with chronic debilitating illnesses who are approaching the end of life, appropriate care transitions will ensure that their short‐ and long‐term care matches their goals of care, assure timely clinical follow‐ups, and help reduce hospital readmission and healthcare resource utilization.[32] Importantly, timely and compassionate communication is a key to the success of both hospital medicine and palliative care. Many patients with life‐limiting diseases prefer to receive prognostic information and to discuss goals of care.[33] How this information is integrated and communicated through the care continuum is crucial, especially in the era of duty hour limits and frequent handoffs. The information exchange needs to facilitate active participation of primary care physicians who may not be involved in hospital care. Some of the innovative strategies for communication and transfer of palliative care information, such as prognosis, goals of care, family meeting consensus, and symptom control interventions, include a palliative care checklist in the electronic health record, incorporation of prognostic and family meeting information in the discharge summary, and links to the national Physician Orders for Life‐Sustaining Treatment advanced care planning program.[34] Of note, a pilot program in the United Kingdom adopting an electronic palliative care summary has reduced after‐hour emergency room visits and hospital readmissions.[35] The following case illustrates this point.

CASE 3

Mrs. K, an 82‐year‐old Russian‐speaking woman with newly diagnosed metastatic pancreatic cancer, is admitted for worsening obstructive jaundice and a second opinion about treatment. A biliary stent is placed and her jaundice slowly improves. The patient and family have requested chemotherapy. However, the oncologist determines that she would only qualify for a phase I trial given her poor performance status. The hospitalist team requests the help of the palliative care consult team to manage her severe pain, depression, and to provide support to the family. After several family meetings, the patient and family choose not to pursue chemotherapy. Given the lack of adequate support at home, she is discharged to a skilled nursing facility for short‐term rehabilitation with plans to transition to the in‐house hospice program. The hospitalist, palliative care attending physician, and the medical director of the rehabilitation facility have a 3‐way phone conference to confirm the plans of care and to ensure a smooth care transition.

In this case, the hospitalist team recognizes that this is a sentinel hospitalization for Mrs. K that requires extensive palliative care intervention. Often, transitioning to skilled nursing facilities (SNF) is the default pathway for patients needing hospice/palliative care, especially when patients and families are not yet ready to discuss prognosis realistically or to accept hospice, or there is not enough support available at home. A recent large cohort study showed that 30% of patients in their last 6‐month of life had used, and nearly 10% of such patients had died, under Medicare's posthospitalization SNF benefit.[36] Although the worsening disease trajectory may not be apparent at hospital discharge, it is more likely that the financial and practical limitation of the Medicare Hospice Benefit accounts for this observation, which includes limited home health aid hours, lack of coverage for room and board, and lower payments to SNFs.[36] Hospitalists can help address the issue of discharge location for patients needing palliative care. Sometimes this requires extensive communication before and after discharge to help enhance the transition from a rehabilitation facility to hospice/palliative care. Appropriately integrated palliative care at the time of care transitions, in the form of hospice or longitudinal home‐based palliative care rather than just routine clinic follow‐up, has the potential to reduce 30‐day readmission for chronically ill, elderly patients and for patients near the end of life.[37, 38] It is critical that national policy, suitable reimbursement, and financial incentives support this practice. A demonstration project, Better Outcomes by Optimizing Safe Transitions (BOOST), organized by the Society of Hospital Medicine, integrates palliative care evaluation into a comprehensive discharge assessment tool. This intervention has been shown to reduce readmissions to acute care hospitals.[39]

In this article, we define a sentinel hospitalization and suggest that its recognition provides an important opportunity for hospitalists to actively integrate palliative care into patients' chronic disease management programs, with inputs from patients, their families, their primary physicians and subspecialists, as well as palliative care specialists. We also recognize that within nonsentinel hospitalizations, there are important opportunities to discuss prognosis, goals of care, and advanced care planning. This approach allows the fresh eyes of hospitalists to assess the patient's current health status and prognosis, to communicate these relevant clinical issues with the patient and family, and to encourage discussions about goals of care and advanced care planning during the sentinel hospitalization. It also provides a structured vehicle for soliciting the patient's (and family's) perspectives and documenting them in the medical record. A compilation of sample items to guide discussion can be found in Table 2. Hospitalists, equipped with basic palliative care skills and supported by hospital‐ and community‐based palliative care teams, can thrive in this unique position of optimizing the quality of care for these patients.[40] Almost 20 years ago, the field of palliative care rose to national prominence on the findings of the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) study, which investigated the suboptimal end‐of‐life experiences of hospitalized adult patients.[41] Since then, the fields of both hospital medicine and palliative care have grown, yet the best is still to come for their collaborative excellence, mutual education, and shared care innovation at the forefront of medicine.

Today you may be surprised by such an inquiry during morning rounds, but such questions are likely coming to your wards. At a time of societal fascination both with transparency and the explosion of health information technologies, a growing number of hospitals are offering, or will soon offer, patients and their family instantaneous access to their doctors' and nurses' notes. What will this new opportunity for patient engagement mean for the hospitalist?

BACKGROUND

Helping patients through highly complicated care processes is no easy feat, and enabling patients and their families to deal successfully with a constantly changing scenario is a particular challenge for hospitalists. Multiple studies show how poorly patients recall information offered them in office visits,[1, 2] and such settings are far less stressful than the rapid fire mixture of procedures, multiple medications, and morbid disease processes that take center stage in so many hospitalizations. And now something new: What is in store for patients and their doctors when patients in a hospital room gain access in real time not only to test results, but also to notes written by their hospitalists, nurses, and consultants?

ENGAGING PATIENTS

With the principal goal of promoting more active patient engagement in care, patient portals designed primarily for ambulatory practice are proliferating rapidly. Not only do they offer patients windows into their records and secure ways to communicate with their providers, their goal is also to automate chores such as reporting results or other administrative tasks that take away from valuable face‐to‐face time between providers and patients. First appearing shortly after the dawn of the Internet, secure electronic portals began to offer patients access to much of their chart.[3] Rapidly evolving beyond limited data feeds over very simple connections, portals today share far more data, are spreading rapidly, and in some cases offer patients access to their entire records. Whether or not 1 record can serve all the traditional users and also the patient and family is a fascinating question,[4] but the fact is that patients can now access their records from their computers, and via smartphones and tablets on the go. While lying in hospital beds, they can gain access to their laboratory and test data as the data evolve, and sometimes the patients see the findings well before their busy clinicians. Moreover, family members, other informal caregivers, or a formally designated health care proxy, will access the patient's record as well, whether through documented proxy functions or by informally peering at the patient's tablet.

MEANINGFUL USE INCENTIVES

Today, state and federal government regulations either encourage or require healthcare providers to grant patients access to their clinical information. But despite the rules embedded in the federal Health Insurance Portability and Accountability Act, patients often face time‐consuming obstacles in their quest for access, and many providers view compliance as a burden. We suggest an alternative view. Over time, we anticipate that inviting patients to review their medical record will reduce risk, increase knowledge, foster active engagement, and help them take more control of their care.

With the goal also of reducing medical errors and improving outcomes, the expansion of portals is accompanied by a combination of incentives, and in the future, sanctions, as the Center for Medicare and Medicaid Services (CMS) refines efforts to promote certified electronic health record technologies that focus on meaningful use (MU), which often include patient engagement tools such as portals. In the fall of 2012, CMS announced stage 2 MU objectives, with several having substantial implications for hospitalists and their patients. One calls for providing patients the ability to view online, download and transmit their health information within 4 business days of the information being available to the provider. Rather than an outpatient‐only requirement, it is a practice‐based requirement, and we can soon expect hospitalist data to appear on portals.

INSIGHTS FROM TRANSPARENCY IN PRIMARY CARE

The OpenNotes trial provides clues as to how such practice will affect both patients and providers.[5, 6] The trial included patients and primary care physicians (PCPs) from 3 diverse settings: Beth Israel Deaconess Medical Center (BIDMC), an urban academic health center in Boston, Massachusetts, and affiliated community practices near Boston; Geisinger Health System, a primarily rural integrated health system in Pennsylvania; and adult medicine and human immunodeficiency virus clinics at Harborview Medical Center, a safety net hospital in Seattle, Washington. More than 100 volunteering PCPs invited 20,000 of their patients enrolled in their institution's portals to read their office visit notes over a 1‐year period. Physicianpatient messaging was tracked to examine impact on physician workloads, and patients and physicians were surveyed before and after the intervention.

The experience generated considerable enthusiasm and potential clinical benefits among the patients, with little adverse impact on patients and providers. Of particular relevance for hospitalists, more than 4 in 5 patients read their notes, with more than 70% reporting they understood their medical conditions better and felt more in control of their care, and two‐thirds reported increased adherence to their medicines, a finding both unanticipated and striking. More than 1 in 5 shared their notes with others. And in spite of doctors' worries, few found their notes confusing (2%8% of patients at the 3 sites), worried more (5%8%), or felt offended by their notes (1%2%). At the end of the year‐long intervention, 99% of patients returning surveys recommended that the practice continue.

PCPs reported virtually no impact on their workflow, although about 1 in 3 reported changing their documentation, given the knowledge that their patients might read their notes. Fewer than 5% of physicians reported visits taking more time, whereas 15% to 20% of physicians reported taking longer to write their notes. Approximately 30% of physicians reported changing the content of their notes to address obesity, substance abuse, mental health, or issues concerning malignancies. Of note, physicians were given an opt out function for any note, but they called on this very rarely during the study. And at the end of the year, not 1 PCP chose to discontinue offering patients his or her notes.

The 3 participating institutions felt that the trial was so successful that they decided to expand this practice aggressively. At BIDMC, OpenNotes will soon extend to all clinical departments and include all notes signed in the online record by doctors (including housestaff and fellows), nurses, social workers, physician assistants, clinical pharmacists, nutritionists, and occupational and physical therapists. The only exceptions will be those notes authored primarily by students, and those the clinician chooses to monitor, thereby blinding access to patients.

With stage 2 MU incentives in place, and the patient engagement movement accelerating, such practice will likely spread rapidly nationwide. We expect that more and more patients will be soon able to read all signed notes by hospitalists in real time. But differences abound among outpatients and inpatients, and PCPs and hospitalists, and inpatient notes are vastly different from those describing office visits. How may this change in practice affect hospitalized patients and their clinicians?

IMPLICATIONS FOR HOSPITALISTS

Most inpatients meet their hospitalists for the first time at admission. During their stay, they may encounter many hospitalists, along with multiple specialty consultants, house officers, nurses, and ancillary providers. Moreover, inpatient notes vary widely in their content and context. They may describe the patient tersely, while spelling out both a broad (and frightening) differential diagnosis, along with options for addressing a range of contingencies. Such notes, written during the acute diagnostic and treatment phase of an admission, tend to focus primarily on acute and discrete issues at hand, in contrast to outpatient notes that may take a more comprehensive approach. Moreover, given the enormous burden and acuity of illness today among many hospitalized patients, a large volume of data is generated in a very short period of time. Due both to time constraints and complexity, decisions are made quickly, often without the patient's input. When did you last ask a hospitalized patient if you could order specific blood tests? Unless a major therapeutic change is anticipated, how often are your patients told their results as a matter of course?

As acutely ill patients suddenly experience a life out of their control, how will they and their families respond to new access to a large volume of information? Should hospitalists expect an avalanche of questions, or might the prime impact be a change in the nature of those questions, as patients and their families move from What was the result? to What is the meaning of this result, given my condition? When the patient sees test results and reads consultant notes before the hospitalist has had a chance to review them, how will this impact the process of care and shape the patient's view of the hospitalist? When questions arise, will they discuss them immediately with their hospitalists, might they try to contact the doctor with whom they have an ongoing relationship, or will they wait until discharge to contact their PCPs? One hopes that offering patients ready access to their hospital record will foster trust and facilitate a positive relationship with hospitalists. But notes could also foster confusion and distrust, particularly if patients feel out of the loop and perceive differing opinions among those caring for them.

We anticipate that transparent records will stimulate hospitalists, PCPs, and other caregivers to improve communication throughout the patient's hospital stay. We know that medical errors occur with alarming frequency in all care settings, and unfortunately electronic medical records make it easier to spread erroneous information widely. As providers we are both morally and legally responsible for eliminating such errors, inviting the patient (and family) to review the chart may help prevent mistakes well before an adverse outcome ensues.

OPPORTUNITIES FOR IMPROVED CARE

Open notes will be viewed by many as a disruptive change, and the best strategy for adapting will be to move proactively to create policies that establish clear guidelines. Consider the following strategies:

• Draw on complex provider notes that may include potentially alarming differential diagnoses as an opportunity for engaging and educating the patient and caregiver.
• Try to avoid jargon and wording that patients may find objectionable, such as patient denies, poor historian, or even obese. Instead, use more situational wording, such as the patient was unclear on his history.
• Avoid abbreviations when possible. They are a frequent source of confusion among clinicians, let alone patients.
• When it is likely that a treatment may not succeed or a diagnosis may prove wrong, address contingency plans in your notes. Where possible, express likelihoods in terms consistent with the patient's level of comfort with numbers.
• Teach trainees to review notes with supervisors before signing.
• Explain to patients and families when they may expect to see your notes.
• Try rephrasing some of the technical content of notes. Move from incr. Cr FeNa=Prerenal, 1L IVF, to Due to dehydration (creatinine rising to 1.8, and fena 0.8), will give 1L IV fluids. Although at first blush this seems like more work, short circuiting need for explanation may save the hospitalist or nurse time later on. And clarity may lead to important additional history from the patient, furnishing perhaps insight into how he or she became dehydrated.
• Expect patients to download, copy, paste, and forward your note. Document with this in mind.
• Discuss with providers concerns about potential medicallegal risks and how to address them.