Peeling Yet Another Layer of the Onion: Polypharmacy and Readmissions Reduction Efforts

Oct. 4, 2016
It turns out that the number of medications prescribed to the discharging patient is a significant indicator of readmissions risk—a factor that clinician leaders and clinical informaticists need to consider, as they pursue readmissions reduction work

It was bracing to read about a study described in the American Journal of Managed Care online last week, and which had initially been published in BMC Health Services Research.

Basically, the study found a strong link between the number of medications prescribed to a patient at the time of discharge and the risk of a 30-day readmission.

As the AJMC article, published online July 27 noted, “Researchers studied 5507 patients, 1147 of which were readmitted within 30 days of discharge, at the Barnes-Jewish Hospital. They found that patients who received a greater number of discharge medications were more likely to be readmitted within 30 days.” And it quoted the authors of the study as saying that “Polypharmacy has been identified as a risk factor for readmission for patients discharged from internal medicine services. However, the overall impact of the number of discharge medications on hospital readmission is still undefined.”
As the AJMC article noted, “Patients readmitted within 30 days were younger and more likely to be African American, and readmitted patients had significantly more comorbidities, such as coronary artery disease, congestive heart disease, peripheral vascular disease, chronic obstructive pulmonary disease, cirrhosis, diabetes mellitus, and metastatic cancer. In addition,” it stated, “patients with a 30-day readmission had longer durations of hospitalization, more emergency department visits in the 6 months prior to their hospitalization, and were more likely to have Medicaid insurance compared with patients without a 30-day readmission.”

The study’s authors found two reasons explaining why a larger number of discharge medications is linked to readmission. First, increasing medication use is likely related to disease severity, which is a good marker for readmission risk; and second, the more medications a patient is prescribed, the less likely the patient will be compliant due to either cost issues, side effects, or inability to keep track of medication use.

In the original BMC Health Services Research article, the authors stated that “Patients requiring hospital readmission within thirty days were younger and more likely to be African-American compared to patients not readmitted within thirty days. Readmitted patients had significantly more comorbidities as manifested by significantly larger Charlson scores and individual comorbidities including coronary artery disease, congestive heart disease, peripheral vascular disease, chronic obstructive pulmonary disease, connective tissue disease, peptic ulcer disease, cirrhosis, diabetes mellitus, paralysis, renal failure, underlying malignancy, lymphoma, and metastatic cancer. Patients with a thirty-day readmission were more likely to be transferred to the intensive care unit during their hospital stay, had longer durations of hospitalization, more emergency department visits in the six month period prior to their hospitalization, significantly lower minimum hemoglobin measurements during hospitalization, significantly higher maximum serum creatinine values, and were more likely to have Medicaid insurance compared to patients without a thirty-day readmission.”

They also note that “Our study further highlights the nature and extent of medication-related hospitalizations in several ways. First, increasing medication use is likely a surrogate marker of disease severity and complexity, making it a good marker for readmission risk. Secondly, as the number of medications increases, it is more likely that patients will not be compliant with al prescribed medications, due to either cost issues, side effects, or inability to keep accurate tracking of all their medication consumption.”

They also note that “Quality improvement programs have been implemented to reduce the number and complexity of discharge medications in order to minimize adverse events and to improve compliance. A pharmacist-directed discharge medication management program,” they note, “has been shown to be successful in decreasing both number and type of discharge medications. Overall,” they summarize, “patient system readmission rates were also significantly decreased in association with implementation of the discharge medication management program.”

I think that there are some major implications here for both clinician leaders and clinical informaticists. To begin with, as hospital leaders begin to drill down into the layers of elements connected to readmissions, they will need to look carefully at how they are facilitating their medication reconciliation and discharge processes, and especially, at how they are making connections as they create processes for post-discharge follow-up with case management/care management nurses, particularly under care management, patient-centered medical home, and population health management, patient management models.

In addition, hospital leaders need to get assertive in leveraging data analytics solutions in order to find out exactly where their medication-related readmissions issues actually are. That will require drilling down a few layers, something that hospital leaders are only beginning to do right now.

And doing this will require the intensive participation of clinical informaticists—physician informaticists, nurse informaticists, pharmacist informaticists (still that rarest group of clinical informaticists)—in order to be successful at readmissions reduction. Indeed, what we are finding in healthcare is that readmissions reduction work is turning out to be far more complex and challenging than many might have anticipated at first blush. Readmissions reduction work is turning out to be very much like the proverbial peeling of the onion—peel away one layer and you find another layer of onion.

It also is turning out to be a massively multidisciplinary kind of initiative to engage in. To be successful, we will need all the types of clinical informaticists I’ve mentioned, but also every type of clinician leader, lots of departmental and service chairs and managers, and of course, core IT leaders and managers. In short, we’re now beginning to get to the heart of readmissions issues—and, as with peeling onions, we’re finding layers upon layers.

So this study is yet one more piece of evidence in a broadening arsenal of evidence—and it certainly helps further point to where this whole ship needs to go.

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