Concomitancia entre desarrollo rural y turismo

Hospital readmissions and their associated costs have become an increasing concern over the last several years (Boutwell, 2011), with provisions of the 2010 Patient Protection and Affordable Care Act establishing penalties for hospitals with higher than average avoidable readmission rates (Santamour, 2011). These penalties are an attempt to curb the rising number of readmissions and their associated costs, which are significant. The Agency for Healthcare Research and Quality reported that in 2011 there were approximately 3.3 million adults, all- cause, 30-day readmissions in the United States at an estimated cost of $41.3 billion (Hines, Barrett, Jiang, & Steiner, 2014). The cost of readmissions for Medicare patients alone stands at an estimated $26 billion annually, out of which $17 billion are potentially preventable (Goodman, Fisher, Chang, Raymond, & Bronner, 2013; Robert Wood Johnson Foundation, 2013).

While the problem is compelling, its underlying causes are difficult to analyze. Readmission studies are often hampered by a lack of information on follow-up data among different care sites and the cohort of hospitals used in the studies (public vs. private hospitals, Medicare vs. Non- Medicare patients). For example, Chen et al. (2010) estimated a hospital cost model per medical condition, and used the observed mean cost of care per case for Medicare patients and a predicted mean cost of care to compare hospitals in a certain location and with specific characteristics. This study is limited by the current inability of tracking patients going to different hospitals.

Examples of common initial (“index”) diagnoses for hospitalizations and subsequent readmissions include congestive heart failure (CHF), renal failure, urinary tract infection (UTI), pneumonia, and chronic obstructive pulmonary disease (COPD) (Ouslander, Diaz, Hain, & Tappen, 2011; Press et al., 2010), with common causes including incomplete care during a hospital stay (Benbassat & Taragin, 2000; Ornstein, Smith, Foer, Lopez-Cantor, & Soriano, 2011), exacerbation of the initial condition or complication of the initial treatment (Marcantonio et al., 1999), substandard care during the transition out of the hospital (Boutwell, 2011), adverse

drug events post discharge (Allaudeen, Vidyarthi, Maselli, & Auerbach, 2010), and poor compliance to medication, exercise, and diet instructions after patients are discharged (Krumholz et al., 2002).

Estimates of the percent of discharged adult patients readmitted within a month of their original hospitalization range from 5% to 29% (Thomas & Holloway, 1991), with 90% of these readmissions estimated as unplanned (Jencks, Williams, & Coleman, 2009). For Medicare fee- for-service beneficiaries discharged between July 2005 and June 2008, the median 30-day readmission rates were 19.9% for acute myocardial infarction (AMI) and 24.4% for heart failure (HF) (Krumholz, Merrill, & Schone, 2009), with the overall annual cost of unplanned re-

hospitalizations estimated at $17.4 billion in 2004 (Jencks et al., 2009). According to hospital discharge data for residents of New York, Pennsylvania, Tennessee, and Wisconsin, from January to July in 1999, hospital costs for preventable readmissions were roughly $730 million (Friedman & Basu, 2004). Readmitted patients also tend to have significantly poorer outcomes and longer lengths of stay. More broadly, readmissions often are proposed as a general marker for the quality of care received during an index admission (Weissman et al., 1999). For example, early unplanned readmissions of patients with heart failure, diabetes, and obstructive lung disease have been linked to the quality of care during their previous hospital stay (Ashton, Kuykendall, Johnson, Wray, & Wu, 1995).

Despite this evidence and ensuing efforts to reduce readmissions, Karen E. Joynt and Jha (2012) found that risk-adjusted 30-day readmission rates for congestive heart failure,

pneumonia and acute myocardial infarction between 2002 and 2009 showed little improvement, arguing that overall 30-day readmission rates for these conditions may not appropriately reflect the quality of care because causes for most of those readmissions may not be under the hospital’s control. The Dartmouth Atlas Project in collaboration with the Robert Wood Johnson Foundation (2013) reported that overall improvement in 30-day readmission rates between 2008 and 2010 has been “slow and inconsistent” throughout academic hospitals in the United States.

The report points out that focusing on 30-day readmission rates may not improve the health of patients because it may lead to neglecting other important aspects of care, such as the prevention of longer term readmissions for patients with chronic diseases and the increase in hospital mortality (Goodman et al., 2013; Robert Wood Johnson Foundation, 2013). Still, 30-day readmission rates continue to be the metric used to evaluate the performance of hospitals.

The Centers for Medicare and Medicaid Services (CMS) began reporting 30-day risk- standardized readmission rates as a measure of hospital quality in 2009. In 2012, they

introduced a reimbursement system that penalizes hospitals with a high rate of readmissions for pneumonia, congestive heart failure, or acute myocardial infarction (AMI) patients. The penalty is assessed across all Medicare reimbursements for services rendered in a given hospital.

Given the magnitude of the readmission problem, financial pressures, and considerable national focus within healthcare, this manuscript summarizes recent literature describing the general problem, analytical studies, and intervention approaches. The intent is to provide sufficient background to enable systems engineers and related researchers to contribute meaningfully applied and theoretical work to this important area. Where useful, representative studies are cited to provide context and additional insight, although the intent is not to

exhaustively review all papers.

A total of 112 papers from 1987 through 2011 were generated by a keyword search within PubMED and reviewed for their key contributions. As summarized in Figure 1, the number of papers in eachcategory increased significantly in the past few years, somewhat coinciding with the 2009 introduction of Medicare’s new reimbursement policy. Partly driven by these reporting and financial motivations, institutions and researchers have developed a variety of strategies to identify and reduce preventable readmissions. Some studies have focused on describing the readmissions landscape at the national level while others have focused on the local and hospital levels. There have been a number of predictive studies exploring risk factors for different patient groups to better understand the dynamics of readmissions. These studies have shown a

pervasive lack of standard systems or processes to ensure post-discharge compliance to exercise treatment instructions (e.g. medication, diet, and follow-up care) (Krumholz et al., 2002), so a number of the studies have focused on developing interventions to improve information transfer and other aspects of the discharge process. We grouped the papers into three categories: descriptive analysis (43), intervention studies (34), and statistical or predictive models (35).

Figure 1. Publications categorized as descriptive, intervention, or predictive. The remainder of this paper is organized as follows: Section 2 discusses definitions, measurements, and descriptive analyses reported in the literature; Section 3 summarizes common preventive approaches proposed, evaluated or practiced by healthcare institutions; and Section 4 reviews statistical and predictive models discussed in the literature. A discussion

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