SYMPTOM TRACKING TOOLS

Building a Quantitative Case for the Medical

and Economic Potential of Symptom Tracking

Tools

Imran A. Khan

Abstract--Since 2007, the Centers for Medicare

and Medicaid Services (CMS) have devised

outcome measures that focus on high quality

patient care. A hospital readmission rate over a

30-day period is one such measure that allows

medical professionals and patients to critically

appraise health care providers and provides a

framework for hospitals to meet quality control

standards. Hospital readmission rates, especially

for elderly patients, are a significant concern in

U.S. Healthcare since 1 in 5 patients on

Medicare & Medicaid is re-admitted to hospitals

within 30 days of their treatment. This is

currently costing the U.S. government over $17

billion per year and is projected to increase. On

October 2012, the U. S. government started

implementing penalties, which could reach as

high as 40 million, to hospitals with high rates of

readmission over a 30-day period. The objective

of this paper is to analyze the efficacy of the use

of symptom tracking tools and to build a

quantitative case for the medical and economic

potential of symptom tracking tools using the

30-day readmission rate metric.

Keywords - Symptom Tracking Tools, Center for

Medicare and Medicaid Services, Electronic Health

Records, 30-day Readmission, Excess Readmission

Ratio.

I. INTRODUCTION

One of the most important and controversial

issues affecting todays American healthcare system is how to cost-effectively improve on

hospital readmission. Patients readmission shortly after they are discharged from the hospital is

widely cited as a significant contributor to the

decreasing poor quality of care and rising

healthcare costs [1] [2] [3]. It is reported that 1 in 5

Medicare patients discharged from hospital are re-

admitted within 30 days of their treatment [4].

Patients are therefore, forced to incur additional

costs to cater for such bills. In 2004, the total cost

spend on re-hospitalization was estimated at $17.5

billion [5]. Currently, it is estimated that Medicare

alone spends close to $15 billion annually on re-

hospitalizations [6]. These figures only accounts

for the cost incurred due to readmission.

Dissatisfaction and distress experienced by patients

who find themselves readmitted in hospitals and

the high intangible readmissions strain put on

hospitals is not taken into account in these tallies.

However, as noted by Optum [7], three-quarters of

these hospital readmissions could easily be avoided

with better care and the US Congress, insurance

companies as well as hospitals have taken notice of

this.

Although it is still not clear whether these

readmissions can be preventable, there is evidence

that their causes vary widely. While in certain cases

conditions of patients can unavoidably worsen,

studies have shown that more than 50% of the

patients are often readmitted quickly because of

errors that may have occurred in their first hospital

visit. As revealed by the Agency for Healthcare

Research and Quality's (AHRQ), 1 in 5 patients has

an adverse event or a complication after they are

drastically discharged from hospitals, increasing

their likelihood of readmission [2].

Measures have been put in place to ensure the

rate of hospital readmission decreases. The two key

measures were: the introduction of Electronic

Health Records (EHRs) and the Center for

Medicare and Medicaid (CMS) by the US

Congress. In 2012, the US Congress enacted a

federal healthcare law under which the Center for

Medicare and Medicaid (CMS) services were

mandated to start using the 30-day cutoff to

penalize hospitals whose readmission rates were

found to be higher than the required readmission

rates. The law also allowed the CMS to refuse

paying for selected diagnoses that may have

occurred during the 30-day cutoff. CMS was also

mandated to closely monitor global payment

systems and to start pilot projects aimed at looking

at reimbursement per diagnosis. The US Congress

also enacted the HITECCH Act, which is part of

the 2009 American Recovery and Reinvestment

Act, to ensure hospitals make meaningful use of

symptom tracking tools to help improve patient

care. By implementing the use of symptom

tracking tools, hospitals can store, as well as

retrieve patients detailed information to be used by patients and health care providers across settings

and during patient hospitalizations. Since these two

laws came into practice, there has been increased

adoption of programs aimed at reducing

readmission rate. More than before, hospitals are

SYMPTOM TRACKING TOOLS 2

focusing on organizing their approaches in the way

they assess risk for readmission. They are

increasingly prioritizing areas that need

intervention and developing and applying

appropriate strategies for prevention. This move

has ensured a significant increase in the number of

Americans using electronics applications to track

their health. One of these electronic applications is

the symptom tracking tool. What remains unclear,

however, is whether electronic applications can

effectively serve the purpose. The objective of this

paper is to analyze the efficacy of the use of

symptom tracking tools and to build a quantitative

case for the medical and economic potential of

symptom tracking tools using the 30-day

readmission rate metric.

II. THE MAIN CAUSES OF READMISSION

Understanding the root causes of readmission is

the starting point to formulating policies to help

keep readmissions to a minimum. However,

findings the root causes of patient rebounds can be

one of the most complex undertakings. There exist

many factors that can contribute to readmissions. In

a root cause analysis, such factors must be

accounted for. As noted by Hunter, Nelson, &

Birmingham [6] to ascertain the main causes of

readmission, there are multiple questions to be

asked: How was the patients way of managing his or her condition prior to his or her hospitalization?

What happened during the patients period of hospitalization? Was the patient following proper

orders from their physician when taking prescribed

medication? Was the patient regularly visiting the

physician or primary care?

With a view to validate the hypothesis around the

main causes of readmission, researchers (e.g., Hill

physicians) used a specific population from

Accountable Care Organizations (ACO) hospital partners to carry out a root-cause analysis [8]. The

sample population included discharge planners,

doctors, hospital nurses, and other team members

working in these health care centers. After

discussing individual readmissions, the hospital

system and Hill Physicians were able to decrease

its 30-day commercial readmission percentage by

20% in one year - from 5.4% to 4.3% - by

modifying inpatient and outpatient system and

clinical processes. They also sought patients perspective over the root cause of readmission.

Readmitted patients were interviewed in order to

gain insight on their thoughts concerning what led

them to be readmitted to the hospital, what they did

not understand about instructions of their

discharge, and what they would have done

differently in order to achieve ideal outcomes. This

study found clinical and non-clinical factors as two

important factors that determine whether a patient

is readmitted to the hospital or not. According to

this studys findings, clinical factors leading to patient rebounds fall under three categories of

patients: ones that do not follow up with their

physicians after leaving the hospital, ones that

either adhere to harmful regimen or do not follow

the prescribed medication regimen, and ones that

are often in worse condition with more healthcare

needs. Other studies (e.g., Coffey [9] and

continuity-care-programs) support this finding

suggesting that patients seen by a physician shortly

after the inpatient discharge have a less likelihood

of rebounding. Coffey [9] further asserts that many

patients, in particular those taking multiple

medications, often get confused about what to take

and when to take it. He indicates that such patients

follow medications regimens based on faulty and

misleading medication reconciliation. With regard

to the issue of patients becoming sicker with other

care demands, Optum [7] noted that as patients stays in the hospital get shorter, they are transferred

to lower levels of care, causing them to experience

multiple transitions between nursing homes, their

home, SNFs, and rehabilitation hospitals. This

leads to limited continuity of care, and fragmented

provider communication.

The study revealed that non-clinical causes of

readmission offer significant challenges and that

these types of factors are the most difficult to

address. Optum [7] noted that non-clinical

readmission causes require a level of patient

support and engagement. These non-clinical

readmission causes are categorized as follows: (1)

medical literacy in patients is substandard, (2)

patients lack adequate support structure, and (3)

information is not relayed to care providers early

enough. The study found that when discharge

instructions are shared among patients in a

standardized procedure, those who convey the

information do not ensure that the patients have a

background that can help them understand what is

being told to them. According to this study, this

problem is caused by cultural beliefs, medical

context issues and language barriers. It also

emerged that some patients rebound to emergency

or hospital departments because they do not have

the necessary support from close friends or family

members who can help them follow the proper

post-discharge program. It was also revealed that

lack of interoperability standards have continued to

impede information from being shared across

outpatient and inpatient settings.

Minott [10] categorized factors contributing to

patient rebound into four criteria: poor transitions

between different care settings and providers, or

poor quality care, the discharging of patients to

inappropriate settings, the failure to provide

patients with adequate resources of information to

SYMPTOM TRACKING TOOLS 3

ensure continuous progression, and the lack of

seamless communication, coordinated care, and

information exchange between community-based

providers and inpatient.

III. COST OF READMISSION

Medicare data on patient rebounds and

readmissions shows both the size of opportunity

and the scale of the problem that is facing multiple

efforts underway and the Medicare program. Data

from the Centers for Medicare and Medicaid

Services (CMS) [11] reveals that in 2010, Medicare

payment from readmission rate was 19.2%. It

shows that just under 10 million admissions, there

were about 1.91 million readmissions. This report

indicates that $17.5 billion was spent on

readmission costs with 99% of this cash being

spent on inpatient. It also reveals that out of more

than 30 million beneficiaries of Medicare, less than

4% had a readmission. As indicated in Table 1,

from 2007 to 2008, the national readmission rate

remained relatively unchanged (Table 1). Between

2007 and 2010, the actual numbers of readmissions

reduced by approximately 75,000. However, there

was a proportional reduction in the total index

admissions. This caused the readmission rate to

remain relatively constant (Table 1). Data on the

2011 readmission rate shows that there was no

significant change in the readmission rate from the

2010 figures [12]. Just as in 2010, both index

readmissions and admissions appear to maintain

the downward trend in 2011 (Table 02). Since

2012, the average national hospital readmission

rate of Medicare has remained relatively constant

over time (Centers for Medicare and Medicaid

Services, 2012). In 2012, Centers for Medicare and

Medicaid Services (CMS) [12] indicated that the

average national hospital readmissions rate was

19%, with almost 4% of the beneficiaries of

Medicare reported to have two or more

readmissions in a period of 30 days. Findings of

Lauren, Wier, et al [13] indicate that commercial

payers 30-day readmission rate ranged from 10.1% to 11.9%. In regards to age-bound

grouping, the study found that adults age ranging

between 18 and 44 had a readmission rate of

10.1%, while adults whose age ranged between 45

and 64, had average readmission rate of 11.9%.

Optimum [14] indicated that of 6.3 million

commercially insured patients, the average

commercial readmission costs was 37% higher than

the average hospital admission. These high costs of

readmission informed payers such as Aetna, United

Healthcare and WellPoint to introduce initiatives

that helped reduce readmission rates among their

insured populations [15][16][17]. Other studies

(e.g., [18][19]) have indicated that in Medicare,

expenditure on inpatient care accounts for 38% of

total spending, with readmission contributing

significantly to this cost. Medicare Payment

Advisory Commission [20] indicates that 18% of

patients discharged from hospitals are readmitted

within 30 days of their discharge. This study

indicates that this accounts for $15 billion in

spending.

TABLE 1: NATIONAL READMISSION RATE FROM

2007 TO 2010 (DATA OBTAINED FROM CMS)

YEAR 2007 2008 2009 2010 07-10

CHANGE

READMISSION

RATE (%)

19.2 19.3 19.4 19.2 0.1

INDEX

ADMITS PER

1,000

BENEFITS

329 327 320 316 -3.9

READMITS

PER, 1000

BENEFITS

63 63 62 61 -3.8

TABLE 2: NATIONAL READMISSION RATE FROM

2007 TO 2010 (DATA OBTAINED FROM CMS)

YEAR 2010 2011

INDEX ADMITS

PER 1000 BENES

316 308

READMISSION

RATE (%)

19.2 19.0

It is evident that readmissions increase the

costs of health care and negatively impact the

quality outcome of health care.

IV. HOW PREVENTABLE READMISSIONS ARE

Readmissions are generally costly yet they can

be prevented. It is indicated that in 2003 and 2004,

over 2.4 million patients were readmitted within 30

days of their discharge [21]. Jencks [4] indicates

that currently, Medicare alone spends close to $15

billion annually on re-hospitalizations.

Commonwealth Fund [22] indicates that if national

rates of hospital readmission were reduced to a

level where top-performing regions could achieve,

Medicare could save about $ 1.9 billion annually

[22]. This is supported by the Medicare Payment

Advisory Commission (MedPAC) [20], which

shows that in 2005, 17.7% of patients were re-

hospitalized within a period of 30 days of their

SYMPTOM TRACKING TOOLS 4

discharge and that 77% of these reported

readmissions were potentially preventable. The

estimated average payment for a potentially preventable readmissions was $7,200 per person [20]. Other studies e.g., [32] have estimated the

rate of preventable readmissions to be as high as 76

percent and as low as 12 percent. This study [32]

shows that readmissions resulting from inadequate

transitional care or poor quality of care may be

preventable, but those readmissions that result from

the worsening of chronic diseases or progression of

diseases are unavoidable. In view of randomized

controlled studies, readmissions rates could be

reduced if improvements were made in the

following key areas: communication between

patients, clinicians, and the patients caregivers, pre-discharge assessment, coordination of care

after the patients have been discharged from

hospitals, and patient education. There is also

evidence that readmission rates can be reduced by

putting in place quality-of care initiatives. This

illustrates the impact that hospital practices can

have on the readmission rates. Randomized trials

have successfully reduced rates of 30-day

readmissions by 20% - 40% [10] [23].

Other studies have argued that whether

readmissions can be prevented or not depends on

whether those readmissions are planned or

unplanned. The Medicare Payment Advisory

Commission (MedPAC) (2) categorizes

readmissions into three categories: planned

readmissions; unplanned readmissions, and

readmissions that are unrelated to the cause of

initial hospitalization. Some planned readmissions

are unavoidable since they may be due to patients preferences, natural progression of a disease, or

accepted treatment protocol. On the contrary the

unplanned readmissions, especially those that are

related to patients initial admission, can potentially

be avoided. The unplanned readmission may occur

as a result of a hospital having lapsed in providing

patients with the right treatment or care at the right

time. The majority (90%) of hospital readmissions

are due to unplanned complications while the

remaining 10% of the readmissions are planned. It

is indicated that missed hand-offs from outpatient

to inpatient care or lack of adequate primary

infrastructure can lead to increased unplanned

readmission.

In other studies, it has been suggested that

readmissions can be prevented by putting in place

certain measures. These measures vary from one

hospital to another. However, the widely suggested

prevention methods include: (1) tracking patients

symptoms using symptom tracking tools, (2)

reviewing cases of readmission to check if some of

the readmissions could have been prevented, (3)

checking the risk of readmission for each patient,

(4) using consistent processes for discharging

patients from hospitals that include ensuring that

patients understand instructions and medication

they are given, (5) arranging ongoing

appointments, prompt follow-ups, and

physiotherapy with the general practitioner , and

(6) monitoring hospital data on patient discharge to

ensure the rate of unplanned readmissions does not

increase. Furthermore, effective discharge plans

can help prevent unplanned readmissions. This can

be achieved by giving patients the care instructions

they need after a hospital stay and by helping

patients recognize symptoms that may require

immediate medical attention. In fact, as recent

CMS data shows, since measures aimed at reducing

30-day readmissions rates were put in place, many

states have witnessed a remarkable reduction in the

number of patient rebounds with about 50% of

states now recording excess readmission ratio of

one or less than 1.0 (Figure 01).

Figure 01: Excess readmission rates by State (Data obtained from CMS)

SYMPTOM TRACKING TOOLS

As evidenced from studies, readmissions are

related to the quality of care. It is also evident that

interventions such as tracking patients symptoms using symptom tracking tools can reduce the rates

of 30-day readmissions. It is therefore, prudent to

consider using an all-condition rate of admission as

a measure of quality of care.

V. WHAT CAN BE DONE TO PREVENT READMISSIONS AND THEIR ASSOCIATED

COSTS?

It is now clear that reducing avoidable

readmissions is a challenge to health care

organizations and the U.S government. Even after

implementing EHRs and other measures aimed at

reducing the rate of readmissions, the number of

complications resulting from hospital readmissions

is still worrying. Recent CMS data [11] on the

number of hospitals at which complications occur

reveals that the number of hospitals with the same

or worse complications far exceed the number of

hospitals with better and fewer complications.

This represents a unique opportunity for payers,

providers, and policy makers. They have to come

up with strategies to help reduce the increasing

costs of readmissions while increasing the safety of

patients and the quality of health care. Identifying

policy levers and ideal practices to help reduce

avoidable hospital readmissions would most likely

decrease unnecessary health care costs and

utilizations. It would promote patient-centered care,

improve quality of care, and increase value of the

health care systems.

There is, therefore, the need to consider other

measures to help reduce these hospital

readmissions. Studies have suggested that hospitals

should adopt symptom tracking tools to help

prevent the readmissions and their associated costs.

Tracking symptoms of diseases that contribute to

high hospital readmission can help prevent and

reduce these readmissions. Most recent data from

the Center of Medicare and Medicaid Services

(CMS) reveals that among the key contributors of

increased hospital readmissions include accidental

cuts and tears from medical treatment, Acute

Myocardiac Infraction (AMI), Heart Failure (HF),

Pneumonia (PN), and hip-knee surgery (Figure 02).

The deaths occurring among patients with serious

yet treatable complications after surgery (Figure

02) can also be reduced by use of symptom

tracking tools to track symptoms that are likely to

increase the occurrence of such complications.

Figure 02: Readmission complications (Data

obtained from CMS)

Furthermore, the most recent data from the

Centers for Medicare and Medicaid Services

(CMS) reveal that the use of symptom tracking

tools can potentially help reduce the Excess

readmission ratio from more than 1.0 to less than

0.8 (Figure 03).

Figure 03: Hospital Reduction Readmissions (Data

obtained from CMS)

SYMPTOM TRACKING TOOLS 6

The effective use of symptoms tracking tools to

track symptoms or illness-related issues have been

demonstrated in several studies. Rockwood et al

[25] sought to find out whether symptom tracking

tools could effectively be used to track dementia

stage. They used clinical data obtained from a

known stage of dementia to come up with a model

that classifies a persons stage of dementia basing on the symptoms profile. Their results revealed that

symptoms targeted by care partners for online

tracking can be effectively used to stage dementia.

Weiss [24] used a computer-administered interview

to identify and track symptoms and assess

treatment outcomes. The objective was to

determine the efficacy, reliability, and validity of

the Symptoms of Schizophrenia (SOS) inventory.

Weiss designed the Symptoms of Schizophrenia

(SOS) Inventory self-report instrument to be used

by schizophrenia and schizoaffective disorders

patients. The researcher used the VA Medical

Center inpatient wards and Louis Stokes Cleveland

outpatient psychiatric clinics with a sample

population of 138 veterans with diagnosis of

schizoaffective or schizophrenia disorder. The

study measurements were based on the scores of

the Symptoms of Schizophrenia Inventory and the

Colorado Symptom Index (CSI). Weiss found

reliable differences between outpatients and

inpatients (t=3.56, p

SYMPTOM TRACKING TOOLS 7

focused, (2) defining the objectives of the app, (3)

evaluating the potential needs of the users, (4)

brainstorming the use-case modeling and app

features, (5) reviewing existing prototypes and app

features, (6) refining functionalities (7) writing the

user narratives, (8) visualizing feature and

navigation design, and (9) identifying the content.

The project outcome included selecting the

following app features: medication reminders and

appointment reminders, a medical summary, a

social media component, easy navigation, symptom

tracking, personalization, gamification, and

informal content. Hermansen-Kobulnisky and

Purtzer [30] showed that patients need to keep

track of their illness-related issues. The author

intended to create awareness of potential

shortcomings and opportunities of patient self-

monitoring for clinical practice. Schaefer et al [31]

sought to determine whether experimentally

increasing the interceptive accuracy can increase

the severity of symptom in somatoform disorder.

The study found that improving heartbeat

perception among patients who have medically

unexplained symptoms can reduce symptom

distress. The findings of this study suggest an

association between perception of symptoms in

somatoform disorders and lower interceptive

accuracy.

VI. CONCLUSION

When the relevant information is put into a

dashboard, care and leadership management teams

can quickly review the outcomes. Organizations

can use this to take immediate actions. The

dashboard illustrates the performance at the

aggregate level from which information can be

segmented based on key factors including: payer,

facility, diagnosis segment, and market. For

providers who work under the fee-for-value

arrangements and other accountable care

organizations, costs associated with emergency and

inpatient department readmissions are too high to

leave unmanaged. Reducing and managing

readmissions starts with having the right tool to

track relevant data and patient symptoms.

Adopting Symptom Tracking tools is a novel idea

for healthcare providers. Symptom tracking tools

can help further prevent and reduce hospital

readmissions. As clearly demonstrated, the

potential use of Symptom Tracking Tools to track

symptoms or illness-related issues can boost the

countrys effort to reduce expenditure on health. Policy makers, providers, and healthcare centers

should encourage the use of Symptom Tracking

Tools as a new strategy to prevent and reduce

hospital readmissions.

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