30 day re-admissions: cause for concern?

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30 Day Readmissions
Cause for Concern?
S Finney, S Nandhra, G Urwin, KC
Chan,V Hanchanale, MJ Stower, JR
Wilson
Aims of Presentation
The 30 day rule; its dreams and
aspirations
 The audit and Methods
 Results
 Implications and conclusions
 Response

What is the 30 Day Rule?
 Set out in the ‘White Paper’ -Equity and excellence:
Hospitals
to
face
financial
penalties
Liberating the NHS’ (Dept of Health)
for readmissions
 Michelle
Implemented
in the:
‘NHS
By
Roberts Health
reporter,
BBCOperating
News
Framework for
2011/12’ as incentives
Health Secretary Andrew Lansley:
"This promises to be a much better system”
‘hospitals will not be reimbursed for emergency
 will face financial penalties if patients are readmitted as an emergency within
Hospitals
30 days of being discharged, under government plans. The scheme was unveiled on
Tuesday by Andrew Lansley, in his first major speech as the new health secretary.
Hospitals in England will be paid for initial treatment but not paid again if a patient is
brought back in with a related problem, he said. It has been argued that patients are
being discharged early to free up beds.
readmissions within 30 days of an elective admission,
all other readmissions within 30 days of discharge
locally agreed penalties’
The ‘30 day rule’

Stimulus for efficiency savings
◦ Readmissions to hospital grown over the last decade (50%
between 1998/9 and 2007/8) – particularly for older people

Presumption – emergency re-admissions occur due to
incomplete initial treatments.
◦ £1.6 Billion per annum

Implementing the 30 day rule:
◦ Incentivise providers to discharge patients appropriately with
adequate community support.
◦ Encourage collaboration between the hospital and community
care services to avoid readmission.
Methods
 York
Urologists hold a morbidity and mortality
meeting every two weeks which focuses on:
◦ Deaths
◦ Returns to theatre
◦ LOS>7days
◦ Re-admission within 30 days
Data for each admission was taken from the
online patient database and discharge summaries.

Stratification of Readmissions
 Each Re-admission was stratified into one of 10
categories:
◦ Unrelated
◦ Planned elective
◦ Terminal malignancy
◦ Standard conservative mx,
◦ Self discharges,
◦ Investigation/ treatment of a chronic condition,
◦ Accepted common complications,
◦ Ongoing issue,
◦ Ongoing non-urological issue
◦ Serious or uncommon complication.
Results
Analysis of readmissions within 30 days
for period August 2010 to February 2011
 194 patients identified
 Male = 150
 Female = 44
 Mean age = 63yrs, range (3 – 92)

Demographics
Female
Male
50
12
45
10
40
35
8
30
25
6
20
4
15
10
2
5
0
010
10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 20 30 40 50 60 70 80 90 100
0
010
10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 20 30 40 50 60 70 80 90 100
Results (194 patients)
Unrelated
17
3
Planned re-admission
Terminal Malignancy
29
82
Standard conservative
management
Self discharge
Investigations for a
chronic condition
Accepted common
comps
Ongoing issue
34
41
9
8
7
Ongoing non-urological
issue issue
Serious complication
Financial implications (£319,010)
Unrelated
4817
17702
Planned re-admission
Terminal Malignancy
38633
Standard conservative
management
Self discharge
40203
163447
Investigations for a
chronic condition
Accepted common comps
6826
1544
12891
Ongoing issue
Ongoing non-urological
issue issue
22300
10727
Serious complication
Interpretation of results

Assume strict adherence to 30 Day Rule:
◦
◦
◦
◦

194 patients readmitted
£319010 in lost revenue
Equates to £638,020 per annum
Minimum as upscale costs not taken into account
Assume only accountable for serious
complications and ongoing issues
 Ie: potentially avoidable or preventable readmissions.
◦ 49 (25%) out 194 patients
◦ £61,152 (19%) of original total of £319,010
◦ Equates to £122,304 per annum

Urology services at York generate and estimated
£4.6m/annum
◦ Potential loss of 14% revenue (-£638,020)
Conclusions and Implications

As demonstrated the cost implications are HUGE.

CHKS estimates all hospital readmissions within 30
days costing NHS around £1.6 billion

30 day rule ignores conditions where there is a high
likelihood of readmission – eg: late stage cancer
(acceptable readmissions)

Readmissions not always down to specific failings at
hospital level – depends on community support
available
Conclusions and Implications

Current Pitfalls in the 30 day rule
◦ Data collation and analysis need to be improved
◦ Hospital data needs to define reasons for readmission more
accurately
◦ Close scrutiny via M and M meetings and internal review of
readmissions

Improvements
◦ Discharge information needs to improve
◦ Negotiations at a local commissioning level to determine
acceptable exemptions
◦ Tariffs should be costed to include an element for predictable
and recognised complications of the procedure
Closing thoughts

Are the trusts’ aware of the significant cost
implications or rather financial penalties

30 Day readmission rule applied across the
board is not entirely accurate

Readmissions could be divided and coded
into acceptable and inacceptable admissions

Harder to break down for other specialties
(particularly medical).
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