If you heat water sufficiently, you get steam. When you cool the steam, you get water again. Using the same process for chocolate—more “busy” than water and composed of multiple ingredients—will take you from solid to liquid and back again. So why won’t this technique also apply to the egg?
Eggs, or egg whites to be specific, are made up almost exclusively of the protein albumin. The chains of amino acids in proteins are normally configured in elaborate and precise folds, spirals, and sheets. Upon heating, the albumin becomes denatured and alters its molecular structure in such a way that it unfolds and adheres to itself in a dysfunctional manner known as aggregates. In the end, albumin permanently changes from clear to white and retains a rigid form.
No intervention has been successful in returning albumin to its original viscosity and color—not cooling, not anything. The caveat is that there is exciting research being done with naturally existing heat shock proteins called chaperones that have the potential to return proteins to their native state. This research has enormous implications for treating diseases such as cystic fibrosis and Alzheimer’s.
It may seem idiosyncratic that while we can manipulate water and chocolate, we can’t unfry an egg. The answer is, simply, that proteins are too complex for simple logic or techniques.
In its June report, the Medicare Payment Advisory Commission (MedPAC), the group that advises Congress on issues affecting the Medicare program, formulated recommendations for amending the construct for payments to hospitals based on their readmission rates. The rationale for targeting readmission rates, according to MedPAC, is to create favorable financial incentives for hospitals that achieve lower readmissions. Sounds simple enough. The MedPAC report identified potential savings of $12 billion given a 13.3% rate of “potentially preventable readmissions” within 30 days. Not only does it sound simple, it sounds compelling for quality and financial imperatives.
SHM has long identified transitions of care as one of the most vulnerable events for patients. Some of the earliest presentations at SHM meetings vividly described the “voltage drop” of information that can occur when a patient enters or leaves the hospital—not to mention during intra-hospital transitions. SHM has embraced transitions of care as a core competency in hospital medicine, has built a quality improvement resource room online for care transitions of older adults, and in July year co-sponsored a summit on transitions of care.
Readmission rates are commonly considered a proxy outcome measure to reflect the broader issue of quality of care transitions at the time of hospital discharge; however, we must be clear that these two entities are not nearly synonymous. A hospital readmission does not necessarily reflect a poorly executed hospital discharge, and high-quality discharges do not absolutely prevent hospital readmissions. The challenge with improving transitions of care and reducing preventable readmissions lies in the systems, processes, facilities, and people involved.
To drive lower readmission rates, MedPAC is suggesting a bifurcated strategy: public reporting and altering payment schedules to hospitals. I believe the former, combined with appropriate public education on the multifactorial nature of readmissions and how to interpret the data, can be a positive step toward improving care transitions. The more transparent the healthcare system becomes, the more frank conversations we can have in the pursuit of higher quality care. Those conversations open the door to understanding the complexity of care processes and the dependency of various resources and stakeholders on one another. They also help to confront the brutal truth of care transitions: that there must be shared accountability for ensuring our patients receive the support they need, where and when they need it.