June 29, 2017 / 6:28 PM / 3 years ago

More follow-up needed for elderly 'observed' in hospitals

(Reuters Health) - When elderly patients stay in U.S. hospitals for “observation” but aren’t officially admitted, there’s a high likelihood they’ll soon be back for more hospital care, a new study shows.

One in five patients covered by Medicare, the federal insurance program for people over age 65, who were observed in a hospital but not admitted returned for a repeat visit within a month, researchers found.

Financial incentives and disincentives have led to an increase in the number of Medicare patients who spend up to 48 hours being observed in the hospital without being admitted. Today, 1.5 million Medicare beneficiaries are observed in hospitals each year, according to Dr. Kumar Dharmarajan, who led the study.

The new findings suggest that clinicians might need to focus more attention on caring for patients once they return home after being observed in the hospital, said Dharmarajan, a geriatrician and cardiologist at Yale School of Medicine in New Haven, Connecticut.

“These people are quite vulnerable after discharge,” he said in a phone interview. “We need to think hard about helping improve transitions as people leave observation services.”

As reported in The BMJ, Dharmarajan and his team analyzed Medicare data from 2006-2011 on hundreds of thousands of emergency department visits, observation stays and inpatient stays (that is, when patients were admitted to the hospital). The number of emergency department and inpatient stays remained the same, while the number of observation stays increased during the period.

More than 20 percent of patients discharged from observation stays returned to the hospital within 30 days. In nearly half of those revisits, the patients ended up being officially admitted to the hospital, the study found.

“If one in five are coming back, there probably are opportunities to improve care for these patients,” Dharmarajan said.

For example, he said, protocols should be in place to ensure that patients discharged from observation stays have follow-up appointments with their physicians.

“This is a group that’s been relatively neglected from an outcomes perspective, and a group that’s not going away,” he said. “Could something different have been done in the hospital the first time, and could something different have been done after they left?”

Dr. Michael Ross, an emergency physician who oversees six observation units in Atlanta, Georgia, agreed that care coordination and, when possible, clinic visits within a week of observations stays can help reduce the number of patients who need to revisit hospitals after observation stays.

“They’re sick patients, and anything that could be done to prevent return visits would be a step forward,” he said in a phone interview. “I can’t conclude from the paper that more could be done, but in principle, I could say there’s always more that can be done with follow-up clinic visits and home care.”

Ross, a professor at Emory University School of Medicine in Atlanta who was not involved in the new study, believes it suggests the need for separate observation units with clear protocols for patients who are watched by physicians for up to two days to determine if they should be admitted.

About one-third of U.S. hospitals have dedicated observation units, which Ross said have better outcomes than observation stays in other parts of hospitals.

“A big gap in American healthcare is that observation patients need to be placed in dedicated observation units. In a bed anywhere, it’s the Wild West. There are no protocols,” he said.

“A protocol-driven observation unit is more prone to facilitating outpatient care and making sure all patients receive complete testing before discharge,” he said. If patients don’t complete their testing in the hospital, they’re more likely to need hospital care soon again, he added.

SOURCE: bit.ly/2t0NIxk The BMJ, online June 20, 2017.

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