30 Day Readmissions30 Day Readmissions

Cause for Concern?Cause for Concern?

S Finney, S Nandhra, G Urwin, KC Chan, V Hanchanale, MJ Stower, JR Wilson

Aims of PresentationAims of Presentation

The 30 day rule; its dreams and aspirations

The audit and MethodsResultsImplications and conclusions Response

Set out in the ‘White Paper’ -Equity and excellence: Liberating the NHS’ (Dept of Health)

Implemented in the: ‘NHS Operating

Framework for 2011/12’ as incentives

‘hospitals will not be reimbursed for

emergency readmissions within 30 days

of an elective admission, all other

readmissions within 30 days of discharge

locally agreed penalties’

What is the 30 Day Rule?What is the 30 Day Rule?

Hospitals to face financial penalties for readmissionsBy Michelle Roberts Health reporter, BBC News

Health Secretary Andrew Lansley:

"This promises to be a much better system”

Hospitals will face financial penalties if patients are readmitted as an emergency within 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.

The ‘30 day rule’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.

MethodsMethods 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 Stratification of ReadmissionsReadmissions 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.

ResultsResultsAnalysis of readmissions within

30 days for period August 2010 to February 2011

194 patients identifiedMale = 150Female = 44Mean age = 63yrs, range (3 – 92)

DemographicsDemographics

Results (194 patients)Results (194 patients)

Financial implications Financial implications (£319,010)(£319,010)

Interpretation of resultsInterpretation of resultsAssume 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 Conclusions and ImplicationsImplicationsAs 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 Conclusions and ImplicationsImplications 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 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).