What a learning experience it's been, writing this blog -- what an interesting dialogue with so many readers. 

Sadly, it's time for it to come to an end.

Recently, I was assigned to the reporting team responsible for investigations and consumer watchdog stories and my responsibilities at the Tribune have changed.  

People may have wanted more details when they read my Sunday story on a Batavia mom who lost a baby girl to MRSA and then discovered that another newborn infant was colonized with bacteria.

Here's a sample of what I found in the literature:

From the journal Obstetrics & Gynecology, May 2009:  A study by researchers at the University of Pittsburgh Medical Center estimated that 14,924 pregnant or postparturm woman experience invasive MRSA infections in the U.S. each year. 

Most are infections of the breast, known as mastitis.  Another large subset consists of wound infections.

The authors conclude that MRSA represents a "modest burden" of infection in pregnant women and those who've just given birth.  "It does not seem from this investigation that a universal screening of the entire pregnant population for MRSA colonization with subsequent attempts to de-colonize women is a cost-effective strategy," they write.

Colonization refers to people who carry bacteria in their nose or on other parts of their body.  Most people colonized with MRSA don't have any symptoms, though they are at higher risk of becoming infected.

From Obstetrics & Gynecology, September 2006: Reseachers at Columbia University in New York City examined the extent to which pregnant women were colonized with methicillin-sensitive or methicilllin-resistant staph bacteria. 

Cultures were taken from women tested between 35 and 37 weeks into their pregnancy for Group B Streptococcus. Almost 3,000 specimens were analyzed. Of these, 507 tests positive for Staphyloccocus aureus. Of this sub-group, 14 were MRSA and all but one were the variety that circulates in the community (community-associated MRSA).

Authors note that other research from the 1990s showed that 7.5 percent of pregnant women in Japan and 8.2 percent of pregnant women in Britain tested positive for staph bacteria.

The risk that moms who carry MRSA in their vaginas or rectums could transmit MRSA to infants "is not known," the authors note. But case reports suggest the potential for transmission of the bacteria from mother to infant, they say.

From Obstetrics & Gynecology, January 2008: This is a later report that looks at the risk of mother-to-infant transmission of MRSA from pregnant women colonized with the bacteria in their genital tract. The authors are from the department of obstetrics and gynecology at the University of Alabama at Birmingham.

Like the study above, moms tested for group B Streptococcus also had cultures done for staph.  Of 5,732 moms in the study, 14.5 percent were colonized with staph bacteria.  Of those, 24.3 percent were MRSA, for a total MRSA colonization rate of 3.5 percent. 

"The fact that gential tract MRSA colonization in our study was much higher than that reported [in the study described above] probably indicates that such colonization is variable geographically," the authors conclude.  MRSA colonization in pregnant women's genital tracts may also vary based on "socioeconomic status or ethnic composition," they suggest.

As for transmission, only two infants born to MRSA-positive moms were diagnosed with MRSA infections.  One infant likely picked up the infection from a hospital, the authors note.  In the other case, the infant had the same type of MRA as its mom, supporting "the potential for colonization of the newborn by MRSA residing in the maternal genital tract," they write.

From the journal Pediatrics, April 2009: This study looked at a neonatal intensive care unit that implemented screening of all infants for MRSA with weekly nasal or rectal swabs.  When babies tested positive, they were isolated and measures were taken to limit the spread of infections.  The NICU was at Beth Israel Deaconess Medical Center in Boston.

While MRSA cases decreased over the first five years, they increased during the final two years of the period studied.  In other words, despite early signs of success, "the surveillance program did not eradicate MRSA permanently from the NICU," the authors write. 

Very few infants were colonized by MRSA within the first three days of life, suggesting that "vertical transmission [from mother to infant] was an uncommon source of colonization," they said.  Even treatment with top-of-the-line antibiotic vancomycin didn't eliminate the bacteria altogether and "many infants were discharged from the hospital with persistent MRSA colonization," they observed. 

Over time, MRSA in the NICU appears to have come from various sources.  "We speculate that a greater community burden of MRSA contributed to the increase seen in 2006-2007," they authors suggest.  "If this is the case, then elimination of MRSA from the NICU setting may not be a realistic goal."

MRSA was first noted in a hospital NICU in 1981 and multiple outbreaks in NICUs have occured over the past decade, the authors write.

From the journal Infection Control and Hospital Epidemiology, September 2004:  This report is from researchers at the University of Chicago.   It notes that an outbreak of MRSA occurred at the U of C NICU in June 2001 and ended in April 2002. Thirty three of 498 infants in the NICU during this period were found to have MRSA.

The report centers on triplets who were delivered prematurely at 26 weeks.  The three babies had swabs of their nose, throat and umbilical areas that were negative for MRSA initially.  But later, Baby A baby tested positive for MRSA on the 10th day of life and Baby B tested positive on the 18th day of life.  (Baby C died of lung disease unrelated to MRSA.)

Researchers tested samples of the mother's breast milk and found MRSA.  The mother's breast milk had been given to Baby A and B before they wre found to be colonized with the bacteria.  Further molecular tests indicated the germ from the mom was the same as that found on the babies and different from other MRSA strains found in the NICU.

It appears the babies contracted the bacteria from their mom's breast milk, the authors concluded.  "In the setting of an outbreak of MRSA in the NICU, breast milk should be considered as a source of colonization and infection of infants when no other obvious risk factors are identified," they write.

Patricia Merryweather, senior vice president at the hospital association, said the organization's Web site would be "complementary to" the new Web site being created by the state.

The goal is to present additional data about hospitals in a consumer-friendly format, Merryweather said. 

The site will include administrative data -- for instance, what procedures hospitals perform and in what volume -- information about the quality of care drawn from Medicare's Hospital Compare database,  hospitals' community benefits (the services they provide that help justify their tax-exempt status ) and more data about the ratio of nurses to patients at various institutions, Merryweather said. 

The state site will also contain data about nursing staffing ratios;  the hospital association's site will provide an opportunity for hospitals to explain "what their numbers represent," Merrryweather said.  Each hospital will provide a contact for consumers who have additional questions.

The hospital association thinks the site will be up in October, which is also when state officials said they plan to publish the long-delayed Hospital Report Card and Consumer Guide.

That means Illinois consumers will have a wealth of information about hospitals that wasn't previously available.  Whether the multiple sites will confuse consumers remains to be seen.

For more information about the state's efforts, see my story published Sunday and reprinted below:

This fall Illinois will start publishing data about hospitals' performance on a public Web site, according to officials from the Illinois Department of Public Health.

The data will include rates of hospital-acquired infections such as MRSA, the ratio of nurses to patients, and information about the cost and volume of 30 leading procedures performed by hospitals and ambulatory surgery centers.

Laws calling for the reports, passed in 2004, were groundbreaking at the time. But several states moved far faster to put information about hospitals in the public domain, while the process in Illinois dragged on.

Health officials blamed the need to amend legislation, a burdensome rulemaking process and, more recently, a "somewhat chaotic" state of affairs in the governor's office, as one official put it.

Outside experts faulted the department for being inefficient and suffering from bureaucratic inertia.

Now things seem to be on track. The department has the data in hand and has hired IPRO of Lake Success, N.Y., to analyze it and set up a Web site to debut in October. Illinois' site will be similar to one in New York, said Mary Driscoll, chief of the Illinois health department's division of patient safety and quality.

Illinois' site will report about MRSA and Clostridium difficile infections acquired in hospitals.

It's not clear yet whether the October reports will present aggregate data or data for individual medical centers, said David Carvalho, deputy director of the health department's office of policy and planning.

But the ultimate intent is to report the infection data for each hospital across the state, he said.

Inouye had been doing research for years on seniors who become disoriented and confused in the hospital. She knew what was happening to her dad, even though she wasn’t able to prevent it.

“My feeling of helplessness impressed on me how much our health care system has to change before we do a better job of taking care of older people,” said Inouye, a professor of medicine at Harvard Medical School and director of the Institute for Aging Research at Hebrew SeniorLife in Boston.

Delirium in seniors admitted to hospitals is a case in point.

This often overlooked medical condition is defined as an abrupt change in a patient’s mental status. Typically, symptoms are intermittent and include inattention, forgetfulness, an inability to concentrate and sometimes paranoia, agitation or hallucinations.

“People will say my loved one was doing OK but she looks different, her thinking is disorganized, she’s a lot more confused. She’s just not herself,” said Dr. Malaz Boustani, associate professor of medicine at Indiana University School of Medicine.

Delirium affects 2.5 million seniors admitted to medical institutions every year. Elderly people at higher-than-average risk include those 75 or older and those with cognitive impairments or severe underlying illnesses. Estimated Medicare expenses associated with delirium run to about $7 billion each year.

The condition is important because it increases the chance that an older person will lose his or her independence, become more disabled and die.

“If you develop delirium, you have two times the risk of death within 30 days of hospitalization and twice the odds of being discharged into a nursing home or another institutional setting,” Boustani said.

Yet, research indicates that two-thirds of the time, the medical staff doesn’t recognize delirium in hospitalized elderly patients, Inouye said. Also, they don’t realize how hospital practices can foster delirium or changing practices can help prevent this distressing condition.

Inouye’s research has clarified what needs to be done. Look for factors that may be contributing to the older patient’s disorientation and agitation. Does he have his eyeglasses and hearing aids to see and hear what is going on? (Often those are left at home.) Is the patient being restrained unnecessarily in bed?

Is there a clock in the room so a senior can tell what time it is? Is the room dark and quiet at night so sleep is undisturbed? Is the staff getting the patient up and about quickly, so he or she doesn’t lose mobility? Is someone talking to the patient several times a day, making eye contact and explaining what to expect? And, most important, have all medications been reviewed and assessed?

Tactics like these have reduced instances of delirium in hospitalized seniors by up to 40 percent, according to research published in the New England Journal of Medicine.

Sometimes, very agitated patients with delirium will require medication. Boustani recently published a review of pharmacologic strategies for this condition in the Journal of General Internal Medicine. The conclusion: Anti-psychotics are probably the best first-line treatment, Boustani said.

“Most physicians are prescribing overly high doses. Our study found you can use a much lower dose and potentially improve the management of these patients,” he said.

The Food and Drug Administration hasn’t approved any drug for treatment of delirium in hospitalized patients.

For more information about what family members can do to help prevent delirium in a loved one, click here.

COBRA is a program that allows people to keep their employer-sponsored health insurance after losing a job.  Typically, someone can maintain coverage for up to 18 months -- so long as he or she pays the full cost of the premium.

The 65 percent subsidy makes it possible for more people to elect this option during this economic downturn. But some folks are having a hard time getting it or are being told they don't qualify. 

If you're among them, the government has set up a new Web site -- www.ContinuationCoverage.net -- and a new toll-free phone number, 1-866-400-6689.  Check them if you've been told you can't get the COBRA subsidy and you want to request an expedited review.

Here's more background information from the U.S. Department of Health and Human Services about the subsidy and the appeals process:

The Recovery Act's premium assistance applies to periods of continuation
coverage beginning on or after February 17, 2009 (when ARRA became law),
and lasts for up to nine months. 

To qualify for premium assistance, a worker must be involuntarily
terminated between September 1, 2008, and December 31, 2009, and elect
continuation coverage. The subsidy ends when the worker is offered any
new employer-sponsored health care coverage or becomes eligible for
Medicare.  Workers who were involuntarily terminated between September
1, 2008, and February 16, 2009, but who failed to elect COBRA coverage
at that time, most likely because it was unaffordable, or who elected
COBRA after September 1, 2008, but let it drop because it was
unaffordable, would be given an additional 60 days after employer
notifications are released to elect COBRA and receive the subsidy.
Depending on actions taken by their states, individuals with state
continuation coverage may also be eligible for this additional election
period.  To ensure that the premium assistance is targeted at workers
who are most in need, the subsidy generally will be available only to
people whose income does not exceed $125,000 for individuals ($250,000
for families).

When an individual's former group health plan denies access to ARRA's
premium assistance, he or she may request an expedited review of the
denial.  Under the law, CMS handles requests for review for all Federal
government employees, employees of state and local governments, and
those individuals covered by certain state continuation coverage laws
(sometimes called "mini-COBRA" programs) that apply to employers with
fewer than 20 employees.  Decisions on appeals will be made within 15
business days after receipt.

In 2000, Thomas -- who hails from Chicago -- contracted a virulent form of MRSA after slipping on the ice and having ankle surgery.  Six painful surgeries were needed to correct the damage the bacteria wreaked on her body.

Three years later, Thomas founded the MRSA Survivors Network, hoping to raise public awareness and create a forum for people who'd been infected by the germ. (For more information, click here.)

Then, Thomas set her attention on Springfield, promoting legislation that would require all Illinois hospitals to screen at-risk patients for MRSA and take measures to prevent its spread.  The legislation passed two summers ago and became effective at that time.

Now, Thomas has established World MRSA Day, which will be launched in Chicago Oct. 1 at Loyola University's downtown campus.  She hopes it will inspire grassroots activism to fight MRSA and become an annual event.  (For more information, click here.)

Thomas told me "There's never been any event recognizing all the people who have died from MRSA."  A memorial ceremony is part of the gathering.  Elsewhere, World MRSA Day will be held Oct. 2;  Thomas scheduled the events in Chicago a day early to get the effort off the ground. 

Drug-resistant bacteria were eating holes in the lungs of 7-week-old Madeline Reimer of Batavia. The most powerful antibiotics available could not stop them.

The baby died four years ago this week, succumbing to an infection that flared at home after birth. Angry and grieving, Beth Reimer called publicly for better efforts to control the bacterium that killed her daughter: methicillin-resistant Staphylococcus aureus, or MRSA.

It was a threat the 37-year-old woman would meet again, with horror and disbelief.

Longing for another child, Reimer eventually set aside her anxiety and gave birth to a girl in April. But days after Emma was born, hospital staff discovered the infant carried MRSA on her body, putting her at a much higher risk of infection.

"What are the odds of this happening twice, in the same family?" Reimer said recently in her kitchen as a healthy Emma napped quietly in her lap.

"We had the whole fear we were going to bury another child," said her husband, Ken Reimer.

The Reimers' story is highly unusual; MRSA doesn't strike newborns very often. But it underscores the continuing spread of this potentially dangerous bacterium in hospitals and the community -- and the difficulty of keeping it at bay.

The methicillin-resistant form of the bacterium commonly known as staph was identified in the 1970s, in hospitals. By the 1980s, it had surfaced across the world. A decade later, University of Chicago researchers identified a community form of the germ that is now circulating widely in day-care centers, gyms and schools.

Up to 1.2 million MRSA infections occur in hospitals each year in the U.S., and invasive MRSA infections kill more than 19,000 people each year, according to estimates. Reliable data about trends aren't available because MRSA isn't tracked nationally, unlike mumps or HIV/AIDS.

The bacterium sometimes causes life-threatening infections, but people often are "colonized" without becoming ill and carry it for years in or on their body. To avoid transmission in the community, experts urge people not to share towels or clothing in gyms, to clean wounds and keep them covered, and to wash hands frequently. Active infections can be treated with vancomycin, a top-of-the-line antibiotic.

In the past several years, hospitals across the country have mounted aggressive campaigns against MRSA, stressing hand-washing by staff and thorough cleaning of rooms and equipment with disinfectants. Yet many U.S. hospitals are cutting infection control budgets amid the current economic downturn, according to a survey released last month by the Association for Professionals in Infection Control and Epidemiology.

Two years ago, Illinois became the first state to mandate that hospitals screen all at-risk patients for MRSA and take measures to stop the bacterium's spread. People considered at risk include frail seniors transferred from nursing homes and all patients in intensive care. This fall, Illinois will begin reporting data about MRSA infections in hospitals.

Nationally, legislation introduced last month in Congress would require hospitals to screen patients for MRSA and report the number of infections publicly.

Where the bacteria that entered Emma's body came from remains a mystery that haunts the Reimers.

"The hospital had Emma in isolation. How does a newborn get something like this?" Ken Reimer asked.

Not from her mother, apparently: Beth Reimer also had a MRSA test after giving birth in April and the results were negative.

Dr. Jeffrey Loughead, director of neonatal intensive care at Central DuPage Hospital in Winfield, where Emma was born, said, "It's highly unlikely" she contracted the germ from a health-care worker.

"We don't have MRSA in labor and delivery, the [neonatal intensive care], the [pediatric intensive care] or the nursery," Loughead said.

Some neonatal intensive care units and nurseries at area hospitals have persistent problems with MRSA, but Central DuPage is not among them, he said.

Among pregnant women, 2.1 percent to 3.5 percent are colonized with MRSA, according to several small research studies cited by Dr. Laura Riley, an expert on the subject and director of labor and delivery at Massachusetts General Hospital in Boston. Transmission from mother to baby during childbirth is not common, she said, but MRSA can be passed through breast milk. Riley and other physicians report increasing numbers of mothers with breast infections involving the bacterium.

When MRSA was discovered on Emma, prompt diagnosis and treatment eliminated it from her body. Today, at 3 months old, she is fine, but her mother lives with anxiety and dread.

Every time Emma coughs, Reimer remembers the dry cough that was the first symptom Madeline was ill. Every person who comes into the house represents another opportunity for MRSA to be carried in on Reimer's hands or clothes.

At home, she sterilizes toys regularly for Emma and Luke, Madeline's twin brother, age 4. Hand-washing is mandatory, several times a day. When anyone in the family becomes sick, everyone uses paper towels. The couple also have an 18-year-old son from Ken Reimer's first marriage.

Beth Reimer's persistent fear is that her baby will become infected and she will learn too late. That is what happened with Madeline.

At 4 pounds 10 ounces, Madeline was the smaller of the twins born at 32 weeks in June 2005 after Reimer had an emergency Caesarean section at Edward Hospital in Naperville.

"She seemed to be healthier; she never needed oxygen," Reimer said. In all, Madeline spent 2½ weeks in the neonatal intensive care unit.

Edward Hospital spokesman Keith Hartenberger said the medical center investigated the case in 2005 and determined the baby's MRSA was acquired outside the hospital.

Madeline was a sweet baby with petite features and big blue eyes that seemed to look right through whoever was holding her, her mother remembers. Two days after Madeline started coughing and a doctor diagnosed a likely viral infection, Reimer found her limp and blue in the middle of the night when she went to pick her up for a feeding.

An ambulance rushed Madeline to Rush-Copley Medical Center in Aurora with suspected meningitis. After several tests, she was airlifted to Loyola University Medical Center in Maywood in critical condition. Doctors there put Madeline on a ventilator and diagnosed sepsis and a virulent pneumonia that was destroying her lungs. Cultures showed the culprit was MRSA.

Dr. Kathleen Webster, a pediatric critical care physician at Loyola, cared for Madeline for 11 days before the baby died. She described a roller coaster course of illness: a touch-and-go situation in the first 24 hours, growing optimism as the infant's condition appeared to stabilize, then acute crisis as her lungs collapsed.

Often, Madeline's grandfather sat beside her, urging her not to give up, the doctor remembered. Every night, Beth Reimer slept at her daughter's side -- except once, the night before Madeline died, when Reimer went to the Ronald McDonald House near Loyola. The next morning, Webster recalled, Reimer walked into the hospital and said: "She's not going to get better."

"She knew before we did," Webster said.

All day, nothing the doctors tried prevented the baby's oxygen from dropping. Madeline died that night, surrounded by family and the physicians who had cared for her, including Webster, who had come in on her day off, Ken Reimer said.

"You spend the next weeks and months thinking, 'Is there something I could have done?' " Webster said.

After the funeral, the Reimers learned the entire family had some form of MRSA. Beth Reimer was colonized with the bacterium and was crushed by guilt, thinking she might have passed MRSA to Madeline. Luke, who was admitted to neonatal intensive care the day after Madeline died, also was carrying MRSA. A boil on Ken Reimer's hip was lanced and tested positive for the bacterium. The family was treated until the bacterium disappeared.

The Reimers' experience highlights the unpredictability of MRSA.

"Why do some people exposed to MRSA get severe infections -- like Madeline -- and others have no or mild infections, like Luke?" Webster asked. "That's the million-dollar question and we don't have an answer."

Delirium is a medical problem in its own right.  When an elderly patient develops this condition, he or she is much more likely to be placed in a nursing home after a hospitalization.  Also, patients with delirium are more likely to deteriorate physically or mentally and to die.

It's a surprisingly common problem:  as many as one out of every five seniors who are hospitalized become delirious, research shows.  Depending on the circumstances – whether the patient has underlying dementia, whether they end up in intensive care – the numbers can be much higher.

Hospital procedures can foster delirium in frail older people by disrupting their routines, exposing them to new medications, interfering with their their sleep and making them feel out of control.   Studies have shown that several interventions can make a difference, such as putting clocks in rooms so someone can tell what time it is, minimizing the use of restraints, keeping rooms quiet and dark at night, and carefully managing medication.

There's also a role for families.  Dr. Malaz Boustani, an associate professor of medicine at Indiana University School of Medicine, suggests the first step is awareness:  recognize that your older parent or uncle is at higher risk of delirium if he has cognitive impairments or is over 75 years old or has multiple chronic illnesses.

If your loved-one is vulnerable, "work with their doctor," Boustani says.  "Tell them that my mom or dad is scheduled for a hip replacement and I hear they could develop dementia after surgery.  Can you tell me how you would assess their risk?  Are they taking any medications that could increase that vulnerability?  Could we hold off on that medication until after the surgery?"

In the hospital, stay tuned to abrupt mental changes in a loved-one.   "If they're more confused, if their attention is really bad, they might have delirium," Boustani says.  "Tell the nurse you're worried and ask for an assessment.  Also, ask for a consultation with a geriatrician."

Don't let hospital staff minimize your concerns.  "Family members are usually the first ones to pick up that something is wrong.  If you know that mom or dad is just not right, not themselves, don't let the doctors or nurses pooh pooh it," said Dr. Sharon Inouye, a professor at Harvard Medical School and director of the Institute for Aging Research at Hebrew SeniorLife in Boston.

Make sure you monitor your loved-one's condition in the hospital and are there as much as possible.  "Are they eating and maintaining hydration?," Inouye says.  "Are they sleeping much more?  Are there personality or behavior changes?"  It's very important for family members to be around as much as possible to provide comfort and a sense of connection and orientation to an older patient, Inouye says. 

Economic pressures on hospitals make it hard for even the best-intentioned staff to do everything they should, so help out when you can, Inouye says.  Make sure the call button is where your loved-one can reach it (often it's not) and that a water jug is within reach.  If side rails are up, take them down and help your relative get out of bed and walk around the floor.  Have an intelligent conversation with your older parent or spouse several times a day;  human interaction is crucial, Inouye says.

Useful materials on this topic are available from the Hospital Elder Life Program, which promotes the delirium prevention programs across the country.   Inouye founded the organization and is closely involved in its work.  I reprint a section from their Web site below: 

Avoid Confusion in the Hospital – Ten Tips

By taking these ten steps, you may be able to reduce the risk of delirium:

1. Bring to the hospital a complete list of all medications (with their dosages), as well as over-the-counter medicines. It may help to bring the medication bottles as well.

2. Prepare a "medical information sheet" listing all allergies, names and phone numbers of physicians, the name of the patient's usual pharmacy and all known medical conditions. Also, be sure all pertinent medical records have been forwarded to the doctors who will be caring for the patient.

3. Bring glasses, hearing aids (with fresh batteries), and dentures to the hospital. Older persons do better if they can see, hear and eat.

4. Bring in a few familiar objects from home. Things such as family photos, a favorite comforter or blanket for the bed, rosary beads, a beloved book and relaxation tapes can be quite comforting.

5. Help orient the patient throughout the day. Speak in a calm, reassuring tone of voice and tell the patient where he is and why he is there.

6. When giving instructions, state one fact or simple task at a time. Do not overwhelm or over stimulate the patient.

7. Massage can be soothing for some patients.

8. Stay with the hospitalized patient as much as possible. During an acute episode of delirium, relatives should try to arrange shifts so someone can be present around the clock.

9. If you detect new signs that could indicate delirium -- confusion, memory problems, personality changes -- it is important to discuss these with the nurses or physicians as soon as you can. Family members are often the first to notice subtle changes.

10. Find out more about delirium. The American Psychiatric Association's "Patient and Family Guide to Understanding an Identifying Delirium" is available on line. For a copy, click here.

Why should medical centers be held accountable for what happens to patients who walk out through their doors, several hospital executives ask. What if these patients decide not to take their medication or schedule a follow up visit with the doctor?  Why should this reflect poorly on a medical center?

"This is a new frontier," acknowledged Dr. Mark Williams, co-author of a recent study on hospital readmissions published by the New England Journal of Medicine and chief of the division of hospital medicine at Northwestern's Feinberg School of Medicine.

On the one hand, it's important to educate patients about what to expect and connect them with useful resources before they leave the hospital, Williams said.  Hospitals have devoted insufficient resources to careful discharge planning, leaving too many patients to their own devices, he noted. 

On the other hand, it's important to ensure that patients who need to return to hospitals have the opportunity to do so, without facing new hurdles. "You have to ask, if we push readmissions down, will mortality go up?," William said.  "We don't have an answer."

In many ways, he believes new Medicare data on hospital readmissions will be more useful to hospitals than it will be to patients.  Hospitals haven't had this information before, especially information about which of their patients are admitted to other medical centers. 

At Northwestern Memorial Hospital, for instance, a number of patients who are referred for specialized services -- for instance, treatments for heart failure -- go home to their communities where they are managed by their personal doctors.

"It's fair to ask, is it Northwestern's responsibility" if these patients receive less than optimal care in their communities?," Williams said.  "This is a community care issue, not just a hospital issue."

Yet still, Williams believes it's important to focus on readmissions.  "What this will do is drive us to improve the continuum of care" and that will be of wide-ranging benefit, he said.  Hospitals need to do a better of job of helping patients making the transition back home and certainly the financial incentives that drive hospitals need to be changed, he explained.

"Currently, our health care system is paid to do things for patients but not to prevent bad things from happening," Williams said.  Whatever new incentives are put in place should support care management across health care settings and shouldn't penalize hospitals that care for sickest, most complex, and poorest patients, he added.

Here are some comments from other hospitals who I contacted for my Sunday article on hospital readmissions and new data published by Medicare on its Hospital Compare Web site:

The Carle Foundation Hospital sent a statement from Mike Billimack, vice president of marketing and strategic planning.  The Urbana hospital had a higher-than-average readmission rate for seniors with heart attacks.

"We continually look into the data for patients discharged from our hospital after AMI [acute myocardial infarction) and subsequently readmitted.  Unfortunately, the (Hospital Compare) performance report includes patients discharged from Carle Foundation Hospital and readmitted to any other hospital for any reason (except stent placements and [coronary artery bypass] procedures).   We do not have access to data for those patients admitted elsewhere.  Therefore, the data is somewhat misleading."

It's true that the Medicare data includes readmissions to any hospital -- not just the hospital where the patient was originally treated.  But hospitals like Carle have the opportunity to learn from Medicare where their patients are being readmitted and to initiate conversations with those institutions about how care for patient can be improved, said Dr. Stephen Jencks, a former top official with Medicare responsible for quality improvement.

Billimack also said that Carle ranked highly on other measures of performance for heart attack patients. It's important to acknowledge this and note that readmissions data doesn't tell the whole story. 

Arnie Kimmel, chief executive officer of MetroSouth Medical Center in Blue Island, noted that the hospital, formerly known as St. Francis, is under new ownership.  The 36 months of Medicare data only reflect eight months of the hospital's operation under new management, he said.

"Not all of the responsibility is the hospital's," he said, referring to why patients are readmitted within 30 days of discharge.  "A significant part of the reason we have to attribute to [patients] lack of compliance" with medical recommendations.  While the hospital is analyzing its criteria for admission through the emergency room,  Kimmel said, he doesn't think it needs to make any other changes.

Kimmel observed that death rates for MetroSouth patients were well below the national average in the most recent period reported;  a check of the Hospital Compare Web site confirmed this.   Overall, he appeared to dismiss the signifiance of the readmissions data.

Ingalls Hospital in Harvey made available Linda Ambrosecchia, director of quality assurance, infection control and patient safety to discuss its higher-than-average readmissions rate for seniors with pneumonia.  "We find a disconnect in the (Medicare measurements)," she said.   The death rate for Medicare patients at the hospital is lower than the national average yet its readmission rate for pneumonia patients is higher, she observed.

Ingalls has been reviewing its readmissions for pneumonia and the trend line is moving downward.  "In the last year, our rate was at the national average," Ambrosecchia said. She noted that the senior population Ingalls serves tends to be lower income and have multiple chronic conditions.  "Some patients may not have basic resources to support their care at home," she said.

Medicare's data using sophisticated techniques to adjust for how ill patients are, a spokesman said. Therefore, patients' chronic illnesses shouldn't skew a hospital's results.

Advocate Health Care played up the good news -- lower-than-expected death rates for seniors at six of its hospitals -- in a statement.   Regarding lower than-average readmissions rates for seven hospitals, the system down-played the significance of the data on the second page of a press release:

"Advocate continues to address opportunities to reduce readmission rates.  The newly released data includes cases from up to four years ago, so the numbers do not capture improvements that are being made on an ongoing basis," said Dr. Lee Sacks, chief medical officer. "Also, the [Medicare] readmission rate is calculated without taking into consideration why the patient is being readmitted, if the patient followed the post-acute care plan and other factors not related to the quality of hospital care during an intial admission."

 

First, the federal agency started releasing information about so-called "processes" of care -- what hospital staff were doing to treat patients' illnesses.

Whether hospital are delivering recommended care is only one dimension of quality.  Another is what happens to patients who are treated, or so-called "outcomes" of care. 

Of course, the ultimate outcome is mortality -- whether a patient lives or dies.  Last August, Medicare began publishing mortality rates for seniors with heart attacks, heart failure and pneumonia.  That data is being updated regularly;  the newest information was published last Thursday.

Yet another aspect of quality care is how patients feel about their experiences at hospitals -- whether their pain was well controlled or their rooms quiet at night, for instance.  Medicare began publishing this kind of data in April 2008 and it's being updated regularly as well.

Now comes yet another dimension on which hospitals are being evaluated:  how often they readmit elderly patients with heart attacks, heart failure and pneumonia.  A readmission is defined as unexpected re-entry of a patient to a hospital within 30 days. 

The patient doesn't have to return to the hospital where he or she was originally treated, nor does the reason for the hospitalization have to be the same.  In other words, if someone was originally hospitalized with pneumonia but comes back two weeks later with heart failure and is admitted again, that counts.  The data is adjusted for how severely ill patients are and for some socioeconomic factors, such as the degree of poverty in neighborhoods surrounding a medical center.

Readmissions are of concern because they can signal poor plans were made to help a hospital patient transition back home.  In some cases, that care during the original hospitalization may not have been adequate. Patients can contribute by not following medical recommendations when they go back home.  A patient's social circumstances -- the lack of anyone at home to help -- can contribute as well.

Whaever the reason, it's expensive to stabilize someone and then have them deteriorate upon discharge to the point they need a second hospital stay.

"The President and Congress have both identified the reduction of readmissions as a target area for health reform," said Health and Human Services Secretary Kathleen Sebelius in a prepared statement. "When we reduce readmissions, we improve the quality of care patients receive and cut health care costs." 

Today, I look at issues surrounding hospital readmissions in a story in the Chicago Tribune.   Not included in that story are the data for Chicago hospitals with higher- or lower-than-average readmissions rates.  It took me hours to compile that data, which I include below.  Separately, in another blog post, I'll go into more depth about hospitals' reactions to the data.