complicated transition; hospital readmission; bounce back

Introduction

Movement of a patient from a less intensive care setting to a more intensive care setting (30 day window).

Examples:

• readmission after hospital discharge
• emergency department visit after hospital discharge

also see transition of care & hospitalization

Etiology

• common causes of recurrent hospitalization
  • medication non-adherence*
  • non-adherence to sodium restriction or fluid restriction*
  • poor social support
  • inadequate follow-up
  • acquired new geriatric syndrome (gait instability fatigue, frailty) during hospital stay
• risk factors for suboptimal care transitions
  • low health literacy; limited education (not high school graduate)
  • unmet need for assistance with at least 1 ADL
  • limited self-management ability
  • worse self-rating of health
  • living alone
  • transition to home with home-care services
  • prior hospitalization
  • excess days in acute care
  • low income or Medicaid eligible
  • older age
  • 5 or more comorbidities
  • specific diagnoses:
    • depression
    • heart disease
      • acute coronary syndrome, myocardial infarction
      • heart failure
      • recurrent atrial fibrillation
    • pneumonia
    • diabetes mellitus
    • cancer
  • treatment at a teaching hospital does not increase 30-day readmissions or mortality
• risk factors for multiple complicated transitions
  • older age
  • black race (strongest predictor)
  • male gender
  • multiple hospitalizations
  • fluid imbalance & electrolyte disorders
  • discharge to nursing home or long-term care facility
• ~78% of all 30-day readmissions from SNFs to hospital are due to 5 conditions
  • heart failure
  • urinary tract infection
  • respiratory infection
  • sepsis
  • electrolyte imbalance
• risk factors after ischemic stroke*
  • older age
  • black race
  • longer length of hospitalization
  • discharge to nursing home or long-term care facility
  • larger number of comorbities
  • enrollment in Medicaid
• comorbidities affect risk for 30-day hospital readmission
  • major comorbidities affecting readmission
    • cancer, chronic heart failure, chronic kidney disease
  • most common readmission diagnoses
    • neoplasm, infection, heart failure, liver disease, gastrointestinal disease
  • comorbidities including heart failure, lung cancer, anxiety, depression & osteoporosis increase early hospital readmission in patients with COPD & COPD exacerbation
• risk factors for rehospitalization after hospital discharge with intravenous antibiotic therapy
  • drug-resistant bacteria
  • previous hospital admission
  • aminoglycoside use
  • skilled nursing facility performance measures not consistently associated with hospital readmission or death
  • no particular criteria identify risk factors for earlier (within 7 days) versus later (8-30 days) readmission during the 30 day window
  • 1% increase in 30-day readmissions for every 3-day delay in hospital discharge summary
    • 43% of hospital readmissions occur before hospital discharge summary available

* most common

Epidemiology

• among Medicare beneficiaries, hospital readmissions occur within 1 year after
  • 67% of hospitalizations for heart failure*
    • 36% of patients die within 1 year
  • 50% of hospitalizations for MI*
    • 25% of patients die within 1 year
  • 56% of hospitalizations for pneumonia*
    • 31% of patients die within 1 year
  • COPD* (4th condition) tracked by CMS utilizing readmission as quality marker
  • 30-day hospital readmission for sepsis more common than readmission for any of the 4 CMS index conditions*, associated with longer length of stay after readmission, & is associated with higher cost
• risk of readmission highest within the 1st few weeks of hospital discharge
• hospital readmissions > 1 week after discharge less likely to be preventable than early readmissions
• among Medicare fee-for-service beneficiaries, 30-day mortality less likely as readmission rates decrease*
• 30-day unplanned hospital readmission rate following first-time admissions was 12% for patients >= 65 years
• comorbidities better predictor of hospital readmission than age itself
• among children, young adults, & middle-aged adults, a mental health diagnosis most commonly associated with hospital readmission
• among patients >= 65 years, sepsis & urinary tract infections most commonly associated with hospital readmission
• female patients have slightly fewere readmissions & lower in-hospital mortality when their physicians are women

* readmission used by CMS as quality markers for index conditions (heart failure, MI, pneumonia, COPD)

Complications

• poorly managed transitions can diminish health & increase costs
  • an estimated $25-$45 billion was wasted in 2011 through avoidable complications & unnecessary hospital readmissions
• end-of-rotation intern transitions associated with excess inpatient mortality
• anesthesia transition of care mid-surgery associated with poor outcomes (combined mortality, hospital readmission, & major complications within 30 days) 44% vs 29% with continuity of care - poor communication may play a role
• sleep, mobility, nutrition, & mood disturbances dubbed "trauma of hospitalization" may contribute to higher risk for readmissions or emergency department visits

Management

• successful hospital-to-home transitional care programs all center around interprofessional coordination teams
  • a transition care provider (hospitalist transitions coach) is a component of an interprofessional coordination team
• home-visits reduce all-cause hospital readmissions & mortality over 3-6 months for patients hospitalized with heart failure
• comprehensive discharge planning with home follow-up
• 3 measures prevent hospital readmission
  • medication reconciliation & teaching at hospital discharge
  • partnering with primary care (hospital discharge sent to primary care)
  • scheduling follow-upappointments prior to discharge
• medication reconciliation & deprescribing in older hospitalized patients can reduce hospital readmissions by reducing inappropriate medications
• physician follow-up within 1 week after discharge for patients hospitalized with heart failure reduces risk of future hospitalizations for heart failure
• a post-hospital discharge appointment increases likelihood of primary care physician followup within 7 days (60% vs 29%) with fewer hospital readmissions within 30 days (14.7% vs 16.7%) or emergency department visits within 30 days (22.3% vs 23.1%)
• primary care follow-up within 7 days of hospital discharge has not consistently been associated with a decrease in 30-day readmissions (GRS11)
• a healthcare team at a skilled nursing facility connected to the discharging hospital modestly reduces hospital readmissions
• multi-hospital initiative to prevent rehospitalization in Medicare beneficiaries with only modest success
• a reengineered hospital discharge program incorporating personal health record maintenance by the patient & a series of visits & telephone calls with a transition coach
• comprehensive discharge planning with an after-hospital plan document, & telephone contact with a pharmacist to review medications 2-4 days after discharge
• telehealth intervention without proven benefit
• Interventions to Reduce Acute Care Transfers program (INTERACT II) for reducing hospitalization of nursing home residents
  • includes early identification of conditions that may be managed in the nursing home & effective communication between providers
  • nurse practitioners & physician assistants work in concert with physicians in the nursing home to prevent avoidable hospitalization
  • preventing unnecessary hospitalizations & ED visits in nursing home patients involves more than just staff education & care planning
• oral nutritional supplements may reduce hospital readmission in the elderly
• patient satisfaction & good provider communication associated with lower 30 day hospital readmission
• 'hotspotting' offers home visits, phone calls, & other resources to recently discharged 'superutilizers' of no benefit (62% readmission within 180 days)

* editorial comment:

• comprehensive discharge planning, medication reconciliation, physician & home follow-up, & patient participation in their healthcare are likely the key components of preventing hospital readmission

Notes

• as of Oct 1, 2012 Medicare will fine hospitals with high 30-day readmission rates for myocardial infarction (MI), heart failure, pneumonia + COPD
• 30-day mortality does not correlate with 30-day readmission rate for myocardial infarction, heart failure, or pneumonia
• lowering 30 day hospital readmissions may shift care to emergency departments & observation units
• hospital quality contributes in part to readmission rates independent of factors involving patients
• lower-volume hospitals generally have lower readmission rates than higher-volume hospitals
• hospital-wide readmission measure (reflecting all readmissions, not just readmissions for patients with 5 specific conditions: heart failure, myocardial infarction, pneumonia, hip replacement or knee replacement, & COPD) disproportionately penalize large-volume safety-net hospitals
• CMS readmission measures for Medicare patients rehospitalized for MI, heart failure, or pneumonia do not reflect readmissions for non-Medicare patients hospitalized for the same 3 conditions or for Medicare patients hospitalized for other conditions
• after implementation of CMS hospital readmissions reduction program, 30-day postdischarge mortality rose for patients with heart failure or pneumonia
• implementation of a patient-centered transitional care model did not improve clinical outcomes vs usual care after hospitalization for heart failure
• Medicare Advantage patients with slightly higher hospital readmission rates than traditional Medicare patients for: myocardial infarction (17.2% vs 16.9%), heart failure (21.7% vs 21.4%), & pneumonia (16.5% vs 16.0%)

More general terms

• complication
• transition of care; health care transition

Additional terms

• hospitalization
• Interventions to Reduce Acute Care Transfers (INTERACT)