One-third of patients don't follow up in month after hospital discharge

A new study underscores the increasingly collaborative role physicians can play in helping to reduce hospital readmissions.

The December analysis by the Center for Studying Health System Change found that one-third of adult patients discharged from a hospital do not see a physician within 30 days of release, putting them at risk of readmission. About 8% of discharged adults were rehospitalized during that time, while 33% were readmitted within a year.

Those figures included patients covered by public and private insurance, with private payers shouldering a greater share of readmission costs than Medicare.

Although health system reform efforts largely target hospitals and Medicare payments to curb unnecessary rehospitalizations, "this really suggests a systemic breakdown once patients leave the hospital," said lead study author and HSC senior researcher Anna Sommers, PhD. "No single payer or plan or hospital can resolve this problem. It's going to take a system of providers working together and pooling resources to help reduce the costly care resulting from our fragmented system."

That includes increased collaboration by hospitals and health plans to better support physicians and other practitioners with the tools they need to intervene, Sommers said. Shared information technology, for example, that notifies physicians and care managers of patients' hospitalization history could help doctors better identify and track high-risk patients.

The research brief revealed that most rehospitalizations involved patients with multiple chronic conditions or disabilities associated with preventable events. The analysis relied on 2000-08 data from the national Medical Expenditure Panel Survey on hospital readmissions for all causes, other than obstetrical care, for adults 21 and older (link).

Although 90% of patients reported having a regular source of primary care, researchers found that a majority had trouble accessing that care. The finding highlights a need for better care coordination at the community level through such models as medical homes and accountable care organizations.

The study also looked at long-term hospital readmission rates. Ninety days after discharge, 18% of patients had not seen a physician. Within a year, 37% of all rehospitalizations were unrelated to the initial admission.

"This really is an area of opportunity for primary care doctors, who can step back and determine [post-discharge] if there are other things going on with a patient that might put them at a higher risk for rehospitalization for something else," Sommers said.