Improve outpatient management to cut readmissions

Now that high readmission rates hurt hospitals' reimbursements, providers should consider targeting kidney transplant patients, given that one-third of them bounce back to the hospital within 30 days of discharge, according to research published online in the American Journal of Transplantation.

After examining six years of national data, Johns Hopkins researchers found that readmitted patients did not return only for problems related to their new organs but rather for complications related to other illnesses they had before transplant surgery.

The researchers cited several factors, including age, race, body mass index, diabetes and heart disease, with sending kidney transplant patients back to the hospital. For example, African-Americans had an 11 percent greater risk of readmission, obese patients had a 15 percent increased risk and diabetic women had a 29 percent greater risk.

Healthcare organizations with lower readmission rates likely schedule outpatient visits frequently, as well as allow patients to easily communicate with clinicians through email or the telephone, the study noted.

"We need to be aware that kidney transplant recipients have an extremely high risk of returning to the hospital in the first 30 days after discharge and that readmissions may very well be prevented by putting in place better systems for outpatient management," study leader Dorry L. Segev, an associate professor of surgery at the Johns Hopkins University School of Medicine, said today in a statement. "Some patients just need more intense monitoring."

With better outpatient management in mind, transitional care models are taking hold at hospitals across the country to curb readmissions. Best practices at discharge and during follow-up care involve not only phone calls to discharged patients but also figuring out which patients need those calls, which caregiver is responsible for making them and what to include in the phone call script, Greg Maynard, clinical professor of medicine at the University of California, San Diego, and director of UCSD's Center for Innovation and Improvement Science, recently told FierceHealthcare.

For more:
- here's the study abstract
- read the research announcement