Hospital readmissions are one of the expressions of the complex relationship between the different levels of care, as well as an important indicator of quality. Many of these readmissions are unavoidable and justified, but many of them are inadequate and could be prevented by changes in the care protocol of the registered patient. Even so, an intervention to reduce readmissions has not been found yet.
In an issue of JAMA magazine, Dr. Dhalla, an internist at St. Michael Hospital and professor at the University of Toronto, evaluates and compares the results of a virtual unit with those obtained by providing routine care to reduce readmissions and deaths after hospital discharge. The virtual units were created in 2004 in the United Kingdom for their alleged potential to reduce hospital readmissions, but had not yet been rigorously evaluated. The basic idea is simple: it’s about using already proven care systems from the hospital setting (equipment, coverage, access, etc.) and applying them to complex and high-risk patients in their own homes.
The model operates with some key elements such as coverage for 24 hours a day 7 days a week, a circuit for quick access to patients and a care model based on a multidisciplinary team that includes a doctor, two care coordinators, a pharmacist and a part-time nurse, as well as administrative support. Based on the application of a mathematical model (LACE Index) that predicts the risk of readmission or death within 30 days after hospital discharge, patients who can benefit from this intervention are identified. The team designs a customized care plan for each patient, including phone calls, visits and exchange of views with the primary care physician, while the patient and the rest of the team are involved in the care process.
The results obtained by comparing 2,000 patients randomly assigned (half of them to a virtual unit and the other half to usual care) are not as expected. A combination of readmission or death at 30 days in 24% of patients assigned to usual care, and in about 21% of patients assigned to the virtual unit, although the difference was not statistically significant. The results at 90 days, six months and one year, show no noticeable difference.
Dhalla points out some of the possible reasons for the lack of positive results:
- A fragmented health system makes it difficult to provide a truly integrated care. Seamless collaboration among virtual team members and the primary care team is necessary.
- Different electronic health records systems at each site makes it difficult to know what kind of care the patient has received or is receiving.
- The interventions to prevent readmissions should have been initiated during the acute hospitalization and not when the patient is discharged.
Improving the care at discharge of chronic patients remains a challenge for which there are no simple solutions and against which we must continue to seek creative alternatives, such as when Dick Fosbury dared to break the rules and used a new technique for his jump. It seemed crazy, but today is used by all jumpers. He jumped backwards facing the sky, thus achieving a different perspective and a much higher jump.