Why some patients become "hospital-dependent"

"Hospital-dependent" patients are a distinct group from patients with chronic illnesses and hospitals must properly understand them in order to reduce readmission rates, two physicians write in an opinion piece for the New England Journal of Medicine.

Hospital-dependent patients are usually elderly with multiple chronic conditions and are physiologically ill-equipped to handle stressful or harmful situations, write David B. Reuben, M.D. and Mary E. Tinetti, M.D. They are particularly susceptible to pulmonary edema, myocardial ischemia, acute kidney injury, fever, delirium and falls.

These patients "may be precariously and transiently compensated while hospitalized," and usually have an acceptable quality of life in the hospital, the authors explain. However, they cannot function once they leave the hospital and necessary treatments are not available or quickly accessible. 

Complicating matters, these patients are rarely identifiable upon first admission, the authors write. At that point, family and clinicians alike are usually confident the patient will make a speedy recovery. When they are readmitted, it has nothing to do with the quality of their care and everything to do with the fact that they can't manage their condition outside a hospital setting.

"It is tempting to conclude that these patients are discharged to the wrong location and that they should be sent to skilled nursing facilities (SNFs)," Reuben and Tinetti write, "but most SNFs cannot or do not provide the needed level of treatment and support for them, and the readmission rates from SNFs are similar to those from home."

Hospital-dependent patients often feel more secure in the hospital than at home or in SNFs, according to the piece, and have friendly relationships with staff. Their condition usually worsens with each readmission, with treatment increasingly less effective, and hospital-dependent patients often either switch to hospice care or die in the hospital.

Although hospitals have always had these types of patients,  the authors say it is important to analyze them in an era of readmission penalties. The presence of hospital-dependent patients in readmission statistics creates a false impression that they receive inadequate care.

"Medicine has yet to acknowledge the ethical and practical predicament of having created a population of incurable, fragile, but not yet terminally ill patients without concurrently developing a healthcare system that can meet their needs," they write. "By default, frequent, unplanned readmissions to the acute care hospital have become the fail-safe backup."

To learn more:
- read the piece