Sunday, January 6, 2019

Re-admission rates should be a part of informed consent

Percutaneous coronary intervention (PCI) or stenting is a very frequently performed procedure now. But, complications do occur, both during the hospital stay and also after discharge, for which the patient may need to be hospitalized again.

Readmission rates at 30 days after PCI have been reported to be as high as 15% (J Am Coll Cardiol. 2009;54(10):903-7) In a single center study of over 15,000 patients who underwent (both urgent and non-urgent) PCI between 1998 and 2008, the 30-day rate was 9.4%. Patients who were readmitted were at significantly higher risk of one-year mortality (Arch Intern Med. 2012 Jan 23;172(2):112-7).

In this study, the following factors were found to be associated with an increased risk of readmission:

·         Female sex
·         Medicare insurance
·         Having less than a high school education
·         Unstable angina
·         Cerebrovascular accident or transient ischemic attack
·         Moderate to severe renal disease
·         Chronic obstructive pulmonary disease
·         Peptic ulcer disease
·         Metastatic cancer
·         Length of stay of more than 3 days 

These studies show that while readmission rates may vary among different hospitals, at least 10% of patients will be re-hospitalized post-PCI and the factors that increase the risk of re-hospitalization are all non-modifiable.

There are medicolegal implications to this.

Readmission rates for all diseases are used as a quality benchmark for health systems and indicate the quality of treatment. PCI is only one such example.

This is also a requirement of NABH (National Accreditation Board for Hospitals and Healthcare Providers) Standards for Hospitals. As per the NABH Guide to Accreditation Standards of Hospitals (2015), “The organisation shall ensure that the programme is in consonance with good clinical practices. Good clinical practices include monitoring infection rates, re-admission rates, re-intubation rates, etc.”

The re-admission rate should be mentioned in the contract or informed consent signed between the doctor and the patient at the time of admission and the discharge advice.

Readmission is a reality and should be anticipated. Re-hospitalization also means increased cost of treatment, which many patients can ill-afford. If insured, then most of them could have utilized their Mediclaim or at least a major part of it, for the procedure in the initial admission.

So, the treating doctor must explain the chances of death and unexpected complications and resultant financial implication at the time of admission.

Perhaps, the cost of treatment of complications can be included as part of initial payment as “insurance”, as a fixed charge. For instance, if the entire cost amounts to Rs 2 lakh, then the patient can be asked to pay a sum of Rs. 2.5 lakh. The extra amount would take care of 0-30 day readmission of the patient for complications related to the initial procedure performed.

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

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