Hospital making you ill?

The stress, lost sleep, missed meals and anxiety associated with a hospital stay take their toll on patients' health.

But hospitals rarely deal with the cumulative impact of those personal stressors, which increase the risk of patients winding up back in the hospital, said Dr. Harlan Krumholz of the Yale University School of Medicine, New Haven, Conn. He coined the phrase “post-hospital syndrome” in a recent New England Journal of Medicine article to describe the dangerous period of cognitive impairment, reduced physical function and emotional stress that often follows a hospital stay.

“We tend to think of these things—fear, sleep deprivation, not getting around as much as we should—as just inconveniences that are part of being in the hospital. But in the aggregate, they can have a very powerful impact,” he said in an interview.

Post-hospital syndrome illustrates the folly of looking too closely at one condition and myopically trying to prevent future related complications, Krumholz said. The federal government's readmissions reduction program, however, relies on that framework.

Launched in October 2012, the CMS' readmission incentives program penalizes hospitals with higher-than-expected rates of readmissions for heart failure, heart attack and pneumonia. A better way, Krumholz wrote in the article, is to move away from “disproportionate attention to the hospitalization's cause” and move toward a general approach of heightened awareness and attention to patients' overall health and wellness after discharge.

Yale researchers crafted the measures that currently make up the CMS' readmissions program, and Krumholz said he felt a particular responsibility to make sure the initiative is successful. “One thing that really might be impeding our progress is our failure to take the whole patient into account,” he said.

Krumholz and his colleagues have followed up the original measures with an all-cause readmissions measure, which was endorsed by the National Quality Forum. He said it could more accurately capture the many causes that land people back in the hospital.

Hospital administrators need to recognize the implications of the syndrome and advise patients of them, Krumholz said. “They should be told, 'You are being discharged but you are not well yet,' ” he said. “ 'Your judgment might be off, you may not want to drive, you may need help getting around.' ”

Dr. Eric Coleman, a geriatrician and head of the division of healthcare policy and research at the University of Colorado, Aurora, and a well-known expert on transitions of care, endorsed the approach and praised Krumholz for calling attention to the wide-ranging effects that hospitalization can have on patients. The phenomenon has been well-established in the field of geriatrics for decades, he pointed out.

Despite the limitations of the CMS' program, hospitals can still move the needle on readmissions, Coleman said, by emphasizing health literacy, patient activation and the involvement of family caregivers. “Hospitals that have begun to look beyond the narrow three or four diagnoses are the ones making real progress,” he said.