Year: 2016
Type: article
Abstract: See Article on Page 765 Potential conflict of interest: Nothing to report. Why Early Posttransplant Readmissions Matter Readmissions after transplant are associated with a marked increase in cost.1 Furthermore, they are frequently not reimbursed by accountable care or managed care payors. Although it is unclear whether readmissions are markers of illness severity (correlation) or independently contribute to morbidity and mortality (causation), they are definitely associated with decreased patient and graft survival.1 An intervention to safely reduce the risk of readmissions after transplant would therefore offer significant value to payers, clinicians, and patients. What We Do Not Know About Posttransplant Readmissions Data are limited on 2 critical aspects of posttransplant readmissions. First, it is unclear how to translate the known patient‐related factors into actionable items. Readmission risk factors include recipient age, pretransplant disease severity (Model for End‐Stage Liver Disease score, diabetes, dialysis dependence, or sarcopenia), and high‐risk allografts.2 These data may allow for risk adjustment; they do not provide obvious opportunities for intervention. Second, hospital‐related factors associated with readmission have not been identified. After adjusting for recipient characteristics, there is a substantial variation (26%‐50%) in readmission rates among transplant centers.3 Although penalties for readmission imply that variable rehospitalization rates reflect variable quality, this is likely an incomplete explanation. Wilson et al.3 recently described the typical reasons for readmission after transplant in the United States. These include fever, abdominal pain, abnormal blood tests, and renal injury. It is unclear what proportion of these presentations is preventable. Rather, as Russo et al.4 suggest in this issue of Liver Transplantation, perhaps a more important question is whether there are available alternatives to hospitalization to address common complications. Reducing Readmissions by Putting Quality Improvement (QI) Methods to Work In this important article, Russo et al.4 present the results of a novel QI program that significantly reduced posttransplant readmissions. The 30‐day readmissions declined from 40% over a 2‐year “pre” period to 20% over a 1‐year “post” period (P = 0.02) without affecting patient or graft survival. The authors achieved this by expanding clinic access with coordinated multispecialty care, using coordinated “observation” stays in place of longer admissions, addressing biliary complications with outpatient endoscopy, and promoting local hospital lodging after discharge. After adjusting for illness severity, intervention was associated with a significantly reduced readmission risk (odds ratio, 0.39; 95% confidence interval, 0.16‐0.92). These data demonstrate 2 highly generalizable insights. First, transplant programs wishing to reduce readmissions must do so by providing workable alternatives to readmission. Numerous interventions have been previously assessed for the purpose of preventing readmissions.5 These interventions can be broadly characterized as focusing on either enhanced monitoring (eg, telemonitoring, home visits, or early clinic follow‐up) or care coordination (eg, systematic communication with outpatient providers or linkage of inpatient and outpatient pharmacy records). Unfortunately, these interventions typically fail.5 Conversely, adding intensified outpatient resources for the management of postdischarge complications (eg, infusion centers, readily available procedure suites) to a comprehensive intervention, including monitoring and care coordination, is a winning strategy.5 Second, effective alternatives to readmission after transplant can be identified through a deliberate, multidisciplinary approach to their root causes. The authors’ approach reflects QI methods at their best. It can be summarized in 6 steps: Hold monthly or quarterly meetings to connect the transplant program's stakeholders with local experts. Formats could include small workgroups or divisional conferences.8 This setting is used to define and explore the program's problems. Prompted by a recently published article on posttransplant readmissions,9 the authors identified what they felt was a relative shortcoming of their program. Prospectively develop a “dashboard” to systematically track outcomes, maintain awareness, and standardize data collection (Fig. 1 of Russo et al.4). Review dashboard data. In this case, the authors validated findings from prior reports.1 Namely, their patients experienced a 40% 30‐day readmission rate predicted by pretransplant hemodialysis and diabetes. As elsewhere, reasons for readmission included biliary complications, infections, liver injury, and gastrointestinal symptoms. Perform a root cause analysis. From the QI perspective, the presenting complaint is less important than the process of presentation. Map out the path patients must take to address posttransplant complications. Focus on how patients engage with the clinical systems available to help them and then categorize the various threats to optimal outcomes. For example, the authors identified several modifiable “access” issues, such as the inability to take same‐day clinic visits or provide urgent outpatient infusions. “Patient factors” included health literacy and remote residence. The authors discovered, for example, that the patients were not provided pictures of their pills, making medication reconciliation challenging. Additionally, distance from the center led to readmission by making urgent outpatient evaluation difficult. As previously demonstrated by Perkins et al.,10 root cause analysis effectively addressed lower‐than‐expected transplant patient outcomes. Implement modifications for the current systems’ inadequacies (Table 1 of Russo et al.4). To name a few: slots for outpatient infusions, coordinated management of suspected biliary strictures, use of the hospital hotel for discharged patients, and picture books for pills. Additionally, in order to use “observation admissions” (discharged within 2 midnights or fewer) in place of full admission, the authors began coordinating care with consultants prior to the admission. Evaluate results using a pre‐post study design. Publish. The importance of the encouraging findings from Russo et al.,4 however, must be interpreted in the context of the study design. First, the postprotocol period was assessed in the short‐term, after 1 year and 46 transplants. Given the desired effect size (a reduction from 40% to 30% 30‐day readmissions), this study is somewhat underpowered. Accordingly, the observed significant reduction in readmission risk may be attenuated over time. Second, the beneficial effects of QI interventions are often lost when scaled up. Positive results can, for example, be the result of 1 particularly dedicated nurse or investigator.11 Furthermore, adherence to care protocols, such as the one reported in this article, often wanes over time.5 The most durable interventions, instead, are hard‐wired in formal clinical structures or electronic ordering systems.12 Third, a substantial portion of the effect was obtained through the use of observation status, and the definition of observation shifted from ≥1 night to >2 nights during the study. A >2 night stay is, admittedly, like a “mini‐admission.” Although the authors implemented care coordination strategies to facilitate effective short stays, a shift from 1 to 2 nights likely alters one's willingness to use observation status. Where Do We Go From Here? Prior reports have defined the rates of, the reasons for, and the clinical features associated with rapid readmissions after transplant.2 This first report of a QI intervention to reduce readmissions after liver transplant illuminates the path ahead. We need additional data on optimal transitions of care following transplant. Though QI is often viewed as a local activity, the goals addressed—patient well‐being, graft survival, and resource utilization—are shared by all transplant centers. These data are likely to be generalizable across transplant settings throughout the United States and beyond.
Source: Liver Transplantation
DOI: 10.1002/lt.24430
Author: Elliot B. Tapper
Institutions: Beth Israel Deaconess Medical Center, Harvard University
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2296674350