1. 30 Day Readmissions Cause for Concern? S Finney, S Nandhra, G Urwin, KC Chan, V Hanchanale, MJ Stower, JR Wilson

2. Aims of Presentation The 30 day rule; its dreams and aspirations The audit and Methods Results Implications and conclusions Response

3. Set out in the ‘White Paper’ -Equity and excellence: Liberating the NHS’ (Dept of Health) Implemented in the: ‘NHS Operating Framework for 2011/12’ as incentives ‘hospitals will not be reimbursed for emergency readmissions within 30 days of an elective admission, all other readmissions within 30 days of discharge locally agreed penalties’ What is the 30 Day Rule? Hospitals to face financial penalties for readmissions By Michelle Roberts Health reporter, BBC News Health Secretary Andrew Lansley: "This promises to be a much better system” Hospitals will face financial penalties if patients are readmitted as an emergency within 30 days of being discharged, under government plans. The scheme was unveiled on Tuesday by Andrew Lansley, in his first major speech as the new health secretary. Hospitals in England will be paid for initial treatment but not paid again if a patient is brought back in with a related problem, he said. It has been argued that patients are being discharged early to free up beds.

4. The ‘30 day rule’ Stimulus for efficiency savings ◦ Readmissions to hospital grown over the last decade (50% between 1998/9 and 2007/8) – particularly for older people Presumption – emergency re-admissions occur due to incomplete initial treatments. ◦ £1.6 Billion per annum Implementing the 30 day rule: ◦ Incentivise providers to discharge patients appropriately with adequate community support. ◦ Encourage collaboration between the hospital and community care services to avoid readmission.

5. Methods York Urologists hold a morbidity and mortality meeting every two weeks which focuses on: ◦ Deaths ◦ Returns to theatre ◦ LOS>7days ◦ Re-admission within 30 days Data for each admission was taken from the online patient database and discharge summaries.

6. Stratification of Readmissions Each Re-admission was stratified into one of 10 categories: ◦ Unrelated ◦ Planned elective ◦ Terminal malignancy ◦ Standard conservative mx, ◦ Self discharges, ◦ Investigation/ treatment of a chronic condition, ◦ Accepted common complications, ◦ Ongoing issue, ◦ Ongoing non-urological issue ◦ Serious or uncommon complication.

7. Results Analysis of readmissions within 30 days for period August 2010 to February 2011 194 patients identified Male = 150 Female = 44 Mean age = 63yrs, range (3 – 92)

8. Demographics

9. Results (194 patients)

10. Financial implications (£319,010)

11. Interpretation of results Assume strict adherence to 30 Day Rule: ◦ 194 patients readmitted ◦ £319010 in lost revenue ◦ Equates to £638,020 per annum ◦ Minimum as upscale costs not taken into account Assume only accountable for serious complications and ongoing issues  Ie: potentially avoidable or preventable readmissions. ◦ 49 (25%) out 194 patients ◦ £61,152 (19%) of original total of £319,010 ◦ Equates to £122,304 per annum Urology services at York generate and estimated £4.6m/annum ◦ Potential loss of 14% revenue (-£638,020)

12. Conclusions and Implications As demonstrated the cost implications are HUGE. CHKS estimates all hospital readmissions within 30 days costing NHS around £1.6 billion 30 day rule ignores conditions where there is a high likelihood of readmission – eg: late stage cancer (acceptable readmissions) Readmissions not always down to specific failings at hospital level – depends on community support available

13. Conclusions and Implications Current Pitfalls in the 30 day rule ◦ Data collation and analysis need to be improved ◦ Hospital data needs to define reasons for readmission more accurately ◦ Close scrutiny via M and M meetings and internal review of readmissions Improvements ◦ Discharge information needs to improve ◦ Negotiations at a local commissioning level to determine acceptable exemptions ◦ Tariffs should be costed to include an element for predictable and recognised complications of the procedure

14. Closing thoughts Are the trusts’ aware of the significant cost implications or rather financial penalties 30 Day readmission rule applied across the board is not entirely accurate Readmissions could be divided and coded into acceptable and inacceptable admissions Harder to break down for other specialties (particularly medical).