Differential risk factors for early and later hospital readmission of older patients

Frequency and Risk Factors of Re-hospitalization in Geriatric Inpatient Wards: A Multicenter Retrospective Analysis

PURPOSE

We aimed to evaluate frequency and risk factors of re-hospitalization which are not stated in comorbidity indexes in geriatric wards.

METHODS

A total of 585 patients who were admitted to tertiary care geriatric inpatient clinics at least once between 1 September 2017 and 1 September 2018 and who survived to discharge during initial hospitalization were included in this cross-sectional retrospective multicenter study.

RESULTS

Overall, 507(86.7%) patients were hospitalized once for treatment during the study period, while re-hospitalization occurred in 78(13.3%) patients. Rates of previous surgery (10.3 vs. 3.0%, p = .006), urinary incontinence (UI) (50.0 vs. 36.3%, p = .021), controlled hypertension (64.1 vs. 46.4%, p = .024), malnutrition (55.1 vs. 29.6%, p = .014) were significantly higher in re-hospitalized patients. Re-hospitalized patients were younger (mean ± SD 76.4 ± 8.3 vs. 79.6 ± 7.9 years, p = .002) than once-hospitalized patients. Multivariate logistic regression analysis revealed the younger patient age (OR, 0.942, 95% CI 0.910 to 0.976, p = .001), higher Modified Charlson Comorbidity Index (MCCI) score (OR, 1.368, 95% CI 1.170 to 1.600, p < .001) to significantly predict the increased risk of re-hospitalization.

CONCLUSIONS

Our findings showed that previous history of surgery and geriatric syndromes such as UI, malnutrition were determined to significantly predict the increased risk of re-hospitalization. We suggest that these risk factors be added to prognostic tools designed for elderly patients.

The Geriatric Nutritional Risk Index as a predictor of complications in geriatric trauma patients

BACKGROUND

Malnutrition is associated with increased morbidity and mortality after trauma. The Geriatric Nutritional Risk Index (GNRI) is a validated scoring system used to predict the risk of complications related to malnutrition in nontrauma patients. We hypothesized that GNRI is predictive of worse outcomes in geriatric trauma patients.

METHODS

This was a single-center retrospective study of trauma patients 65 years or older admitted in 2019. Geriatric Nutritional Risk Index was calculated based on admission albumin level and ratio of actual body weight to ideal body weight. Groups were defined as major risk (GNRI <82), moderate risk (GNRI 82-91), low risk (GNRI 92-98), and no risk (GNRI >98). The primary outcome was mortality. Secondary outcomes included ventilator days, intensive care unit length of stay (LOS), hospital LOS, discharge home, sepsis, pneumonia, and acute respiratory distress syndrome. Bivariate and multivariable logistic regression analyses were performed to determine the association between GNRI risk category and outcomes.

RESULTS

A total of 513 patients were identified for analysis. Median age was 78 years (71-86 years); 24 patients (4.7%) were identified as major risk, 66 (12.9%) as moderate risk, 72 (14%) as low risk, and 351 (68.4%) as no risk. Injury Severity Scores and Charlson Comorbidity Indexes were similar between all groups. Patients in the no risk group had decreased rates of death, and after adjusting for Injury Severity Score, age, and Charlson Comorbidity Index, the no risk group had decreased odds of death (odds ratio, 0.13; 95% confidence interval, 0.04-0.41) compared with the major risk group. The no risk group also had fewer infectious complications including sepsis and pneumonia, and shorter hospital LOS and were more likely to be discharged home.

CONCLUSIONS

Major GNRI risk is associated with increased mortality and infectious complications in geriatric trauma patients. Further studies should target interventional strategies for those at highest risk based on GNRI.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Total elbow arthroplasty in elderly trauma patients: adding a new perspective for functional evaluation

PURPOSE

Total elbow arthroplasty (TEA) has evolved over the last years, with satisfactory early results, mainly not only in degenerative arthritis, but also increasingly after trauma. Outcome studies in recently published papers are mainly based on the range of motion (ROM), complication rate as well as patient-reported outcome scales and questionnaires. The purpose of this study was to add a new perspective with the "Purdue Pegboard" skill tests in a homogenous set of elderly trauma patients to contribute to a more precise objective outcome measurement in this specific population.

METHODS

A retrospective review was performed on a consecutive cohort of all patients with age above 60 years that received TEA after trauma. Data from follow-up examinations over a standardized time-schedule within 2 years after TEA were included. Mayo Elbow Performance Score (MEPS), "Disability of Arm, Shoulder and Hand" (DASH) Questionnaire, ROM as well as test-scores using the Pegboard test were evaluated.

RESULTS

Mean age was 76.0 years ± 10.3. Indications for TEA were posttraumatic arthrosis in 68.8% (n = 11) and extensive fractures that could not be reconstructed surgically in 31.3% (n = 5). The mean score of MEPS was 82.81 ± 16.63 and 29.18 ± 12.01 in the DASH. ROM presented with a mean of 109.7° ± 15.4. Patients demonstrated good, but marginally reduced test scores in the Pegboard skill tests in comparison with the healthy reference population. No relevant differences between the arm with and the arm without TEA (0.3 ± 3.6; p = 0.715) were noted after 2 years.

CONCLUSION

In the elderly trauma patient with complex fractures of the elbow, TEA is a good alternative to joint reconstruction using various osteosynthesis techniques. TEA is able to avoid revision surgery after open reduction and internal fixation of complex fractures. In cases of failed reconstruction, it is also a viable secondary procedure in posttraumatic arthrosis. Good outcomes in functionality and dexterity can be achieved. Skill tests like the Purdue Pegboard could add a valuable perspective in assessing functional outcomes after TEA.

Importance of telephone follow-up and combined home visit and telephone follow-up interventions in reducing acute healthcare utilization

Purpose

Transitional care is increasingly important in reducing readmission rates and length of stay (LOS). Singapore is focusing on transitional care to address the evolving care needs of a multi-morbid ageing population. This study aims to investigate the impact of transitional care programs (TCPs) on acute healthcare utilization.

Design/methodology/approach

A retrospective, longitudinal, interventional study was conducted. High-risk patients were enrolled into a transitional care program of local tertiary hospital. Patients received either telephone follow-up (TFU) or home-based intervention (HBI) with TFU. Readmission rates and LOS were assessed for both groups.

Findings

There was no statistically significant difference in readmissions or LOS between TFU and HBI. After excluding demised patients, TFU had statistically significant lower LOS than HBI. Both interventions demonstrated statistically significant reductions in readmissions and LOS in pre–post analyses.

Research limitations/implications

TFU may be more effective than HBI in patients with lower clinical severity, despite both interventions showing statistically significant reductions in acute healthcare utilization. Study findings may be used to inform transitional care practices. Future studies should continue to examine the comparative effectiveness of transitional care interventions and the patient populations most likely to benefit.

Originality/value

Previous studies demonstrated promising outcomes for TFU and HBIs, but few have evaluated their comparative effectiveness on acute healthcare utilization and specific patient populations most likely to benefit. This study evaluated interventional effectiveness of both, which might be useful for informing allocation of resources based on clinical complexity and care needs.

Cost-analysis of opportunistic influenza vaccination in general medical inpatients

Influenza vaccination is an important preventative health measure in the elderly and those with medical comorbidities. It has been shown to reduce hospitalisations, cardiovascular and respiratory complications. A significant proportion of patients admitted to general medicine are eligible for opportunistic inpatient influenza vaccination. This study explores the cost-effectiveness of such a strategy in reducing subsequent healthcare utilisation costs.

Investigating the characteristics and needs of frequently admitting hospital patients: a cross-sectional study in the UK

OBJECTIVES

This study forms the user requirements phase of the OPTIMAL project, which, through a predictive model and supportive intervention, aims to decrease early hospital readmissions. This phase aims to investigate the needs and characteristics of patients who had been admitted to hospital ≥2 times in the past 12 months.

SETTING

This was a cross-sectional study involving patients from Croydon University Hospital (CUH), London, UK.

PARTICIPANTS

A total of 347 patients responded to a postal questionnaire, a response rate of 12.7%. To meet the inclusion criteria, participants needed to be aged ≥18 and have been admitted ≥2 times in the previous 12 months (August 2014-July 2015) to CUH.

PRIMARY AND SECONDARY OUTCOMES

To profile patients identified as frequent admitters to assess gaps in care at discharge or post-discharge. Additionally, to understand the patients' experience of admission, discharge and post-discharge care.

RESULTS

The range of admissions in the past 12 months was 2-30, with a mean of 2.8. At discharge 72.4% (n=231/347) were not given a contact for out-of-hours help. Regression analysis identified patient factors that were significantly associated with frequent admissions (>2 in 12 months), which included age (p=0.008), being in receipt of care (p=0.005) and admission due to a fall (p=0.01), but not receiving polypharmacy. Post-discharge, 41.8% (n=145/347) were concerned about being readmitted to the hospital. In the first 30 days after discharge, over half of patients (54.5% n=189/347) had no contact from a healthcare professional.

CONCLUSION

Considering that social care needs were more of a determinant of admission risk than medical needs, rectifying the lack of integration, communication and the under-utilisation of existing patient services could prevent avoidable problems during the transition of care and help decrease the likelihood of hospital readmission.

Identifying elderly patients at risk of readmission after discharge from a short-stay unit in the emergency department using performance-based tests of daily activities

Background

Readmission is a serious and adverse event for elderly patients. Despite efforts, predicting the risk of readmission remains imprecise. The objective of this study is to examine if performance-based tests of daily activities can identify elderly patients at risk of readmission within 26 weeks after discharge from a short-stay unit in the emergency department.

Methods

The current study is an observational study based on data from 144 elderly patients included in a previous non-randomised controlled trial. Before discharge, patients were assessed for limitations in performing daily activities using three performance-based tests with predetermined cut-off values: the Assessment of Motor and Process Skills, Timed Up and Go and the 30s-Chair Stand Test. Outcome was risk of readmission within 26 weeks after discharge.

Results

Limitations in performing daily activities were associated with risk of readmission as measured by the Assessment of Motor and Process Skills motor scale (Crude OR = 4.38 [1.36; 14.12]), (Adjusted OR = 4.17 [1.18; 14.75]) and the 30s-Chair Stand Test (Adjusted OR = 3.36 [1.42; 7.93]). No significant associations were found in regards to other measures.

Conclusion

The Assessment of Motor and Process Skills motor scale and the age, gender and comorbidity adjusted 30s-Chair Stand Test can identify elderly patients at increased risk of readmission after discharge from the emergency department. The results were limited by one-third of the patients did not perform the Assessment of Motor and Process Skills and the association between 30s-Chair Stand Test and risk of readmission were only positive when adjusted for age, gender and comorbidity.

Perioperative Stroke and Readmissions Rates in Noncardiac Non-Neurologic Surgery

BACKGROUND AND AIM

Perioperative stroke is a feared and potentially disastrous complication of surgery. Postdischarge care, specifically hospital readmissions, can significantly impact postsurgical recovery and provides a useful metric for quality care. Our primary aim was examining 30-day readmissions for patients who had a perioperative stroke undergoing noncardiac non-neurosurgery.

METHODS

We analyzed data from the State Inpatient Database, a database of community hospital discharges, in California between 2008 and2011. Surgical patients undergoing one of the 10 highest-volume procedures were included; patients less than 18 years old, undergoing pregnancy-related procedures, or who died in-hospital were excluded. Our dataset covariates included demographic and clinical variables, comorbidities, and discharge location. After running an initial bivariate analysis using Chi-square and t-tests and testing for multicollinearity, logistical models were run to calculate adjusted odds ratios and confidence intervals for readmission predictors.

RESULTS

30-day readmissions for patients with perioperative stroke (n = 1613) occurred at a rate of 21.08% (340 patients), compared to 6.29% (63,856 patients) for patients without perioperative stroke (adjusted OR = 1.40, 95% CI 1.23-1.59, P < .0001). Demographic predictors of 30-day readmissions included male sex and African-American race. Clinical predictors of 30-day readmissions included several comorbidities (i.e. liver disease, hypertension), and discharge to a postacute care facility. Key 30-day readmission diagnoses for perioperative stroke patients included septicemia, stroke, aspiration pneumonitis, and urinary tract infections.

CONCLUSIONS

Patients with perioperative stroke have high 30-day readmissions rates. A number of demographic and clinical factors increase readmission risk in this population. Further research is warranted to better support patients with perioperative stroke undergoing care transitions.

Risk Factors and Outcomes Associated With Treatment of Asymptomatic Bacteriuria in Hospitalized Patients

IMPORTANCE

Treatment of asymptomatic bacteriuria (ASB) with antibiotics is a common factor in inappropriate antibiotic use, but risk factors and outcomes associated with treatment of ASB in hospitalized patients are not well defined.

OBJECTIVE

To evaluate factors associated with treatment of ASB among hospitalized patients and the possible association between treatment and clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted from January 1, 2016, through February 1, 2018, at 46 hospitals participating in the Michigan Hospital Medicine Safety Consortium. A total of 2733 hospitalized medical patients with ASB, defined as a positive urine culture without any documented signs or symptoms attributable to urinary tract infection, were included in the analysis.

EXPOSURES

One or more antibiotic dose for treatment of ASB.

MAIN OUTCOMES AND MEASURES

Estimators of antibiotic treatment of ASB. Secondary outcomes included 30-day mortality, 30-day hospital readmission, 30-day emergency department visit, discharge to post-acute care settings, Clostridioides difficile infection (formerly known as Clostridium difficile) at 30 days, and duration of hospitalization after urine testing.

RESULTS

Of 2733 patients with ASB, 2138 were women (78.2%); median age was 77 years (interquartile range [IQR], 66-86 years). A total of 2259 patients (82.7%) were treated with antibiotics for a median of 7 days (IQR, 4-9 days). Factors associated with ASB treatment included older age (odds ratio [OR], 1.10 per 10-year increase; 95% CI, 1.02-1.18), dementia (OR, 1.57; 95% CI, 1.15-2.13), acutely altered mental status (OR, 1.93; 95% CI, 1.23-3.04), urinary incontinence (OR, 1.81; 95% CI, 1.36-2.41), leukocytosis (white blood cell count >10 000/μL) (OR, 1.55; 95% CI, 1.21-2.00), positive urinalysis (presence of leukocyte esterase or nitrite, or >5 white blood cells per high-power field) (OR, 2.83; 95% CI, 2.05-3.93), and urine culture with a bacterial colony count greater than 100 000 colony-forming units per high-power field (OR, 2.30; 95% CI, 1.83-2.91). Treatment of ASB was associated with longer duration of hospitalization after urine testing (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47). No other differences in secondary outcomes were identified after propensity weighting.

CONCLUSIONS AND RELEVANCE

Hospitalized patients with ASB commonly receive inappropriate antibiotic therapy. Antibiotic treatment did not appear to be associated with improved outcomes; rather, treatment may be associated with longer duration of hospitalization after urine testing. To possibly reduce inappropriate antibiotic use, stewardship efforts should focus on improving urine testing practices and management strategies for elderly patients with altered mental status.

The association between patient engagement HIT functionalities and quality of care: Does more mean better?

OBJECTIVE

To explore the relationship between the number (breadth) of patient engagement functionalities offered through health information technology (HIT) by hospitals and the hospitals' quality of care.

METHODS

Data on hospital adoption of patient engagement functionalities were combined with quality data obtained from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare. Fixed effects regression models were used to analyze a panel data consisting 1,463 hospitals from 2012 to 2014.

RESULTS

This study revealed a significant positive relationship between the breadth of patient engagement functionalities and patient satisfaction (β = 0.126, p < 0.05). The number of functionalities was also found to be negatively associated with 30-day readmission rates for myocardial infarction (β= -0.085, p < 0.05), heart failure (β= -0.109, p < 0.05), and pneumonia (β= -0.048, p < 0.05).

DISCUSSION

The breadth of functionalities offered by hospitals to engage patients was a significant factor in decreasing hospital 30-day readmission rates for pneumonia, acute myocardial infarction, and heart failure, and also influenced patients' perception of the hospital.

CONCLUSIONS

The findings suggest that hospitals with more patient engagement HIT functionalities are likely to have higher patient satisfaction and lower readmission rates for infarction, heart failure, and pneumonia. This study will potentially assist hospital administrators to justify their strategic deployment of HIT resources to improve both perceived and actual care quality.

Association between the level of municipality healthcare services and outcome among acutely older patients in the emergency department: a Danish population-based cohort study

OBJECTIVES

This study aims to describe the association between use of municipality healthcare services before an emergency department (ED) contact and mortality, hospital reattendance and institutionalisation.

DESIGN

Population-based prospective cohort study.

SETTING

ED of a large university hospital.

PARTICIPANTS

All medical patients ≥65 years of age from a single municipality with a first attendance to the ED during a 1-year period (November 2013 to November 2014).

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients were categorised as independent of home care, dependent of home care or in residential care depending on municipality healthcare before ED contact. Patients were followed 360 days after discharge. Outcomes were postdischarge mortality, hospital reattendance and institutionalisation.

RESULTS

A total of 3775 patients were included (55% women), aged (median (IQR) 78 years (71-85)). At baseline, 48.9% were independent, 34.9% received home care and 16.2% were in residential care. Receiving home care or being in residential care was a strong predictor of mortality, hospital reattendance and institutionalisation. Among patients who were independent, 64.3% continued being independent up to 360 days after discharge. Even among patients ≥85 years, 35.4% lived independently in their own house 1 year after ED contact.

CONCLUSION

Prehospital information on municipality healthcare is closely related to patient outcome in older ED patients. It might have the potential to be used in risk stratification and planning of needs of older acute medical patients attending the ED.

Risk Assessment of Acute, All-Cause 30-Day Readmission in Patients Aged 65+: a Nationwide, Register-Based Cohort Study

BACKGROUND

Hospital readmission is considered an adverse health outcome in older people, adding additional pressure on clinical resources within health care services. Despite numerous studies on risk factors for readmissions, studies find different strengths of respective determinants and there is a need to explore and identify patterns of risk factors in larger cohorts.

OBJECTIVE

Exploring and identifying patterns of risk factors for acute, all-cause 30-day readmission in a Danish cohort of patients aged 65+.

DESIGN

Register-based cohort study using individual-level linkable information on demographics, social determinants, clinical conditions, health care utilization, and provider determinants obtained from primary and secondary health care.

PARTICIPANTS

Historic cohort of 1,267,752 admissions in 479,854 patients, aged 65+, discharged from Danish public hospitals from January 2007 to September 2010.

MAIN MEASURES

We included patient-level variables and admission-level variables. Outcome was acute, all-cause 30-day readmission. Data was analyzed by univariable and multivariable logistic regression. Strength of associations was analyzed using Wald test statistics. Receiver operating characteristic (ROC) analysis was used for quantification of predictive ability. For validation, we used split-sample design.

KEY RESULTS

Acute admission and number of days since previous hospital discharge were factors strongly associated with readmission. Patients at risk of future readmission suffered from comorbidity, consumed more drugs, and were frequent users of in- and outpatient health care services in the year prior to the index admission. Factors related to index admission were only weakly associated with readmission. The predictive ability was 0.709 (0.707-0.711) for acute readmission.

CONCLUSIONS

In a general population of older people, we found that pre-hospital factors rather than hospital factors account for increased risk of readmission and are dominant contributors to predict acute all-cause 30-day readmission. Therefore, risk for excess readmission should be shared across sectors and focus the care trajectory over time rather than distinct care episodes.

A Call for Interfacing Measures of Instrumental Activities of Daily Living Across the Transition of Care

The ability to maintain functional status is an essential aspect of self-care for older adults. Instrumental activities of daily living (IADLs) decline within hours of hospitalization and are often overlooked, underassessed, and underreported. The aim of this integrative review was to examine and compare methods used to assess IADLs to determine the best measure for use across the care continuum, especially during transitions of care. A literature search without date restrictions was conducted using PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Embase databases. Twelve studies of moderate quality were included in this review. More than half (58%) of the studies utilized the Lawton and Brody Scale to measure IADL among home-based and hospitalized patients. Implementation of this scale as standard practice and sharing the results with healthcare providers would encourage continuity of care with the goal of supporting older adults aging in place and preventing rehospitalization. In turn, this communication process may improve the transition from the inpatient to home setting, where, since 1999, the Outcome and Assessment Information Set has been mandated.

[Domiciliary intervention by occupational therapy after hospital discharge in order to prevent re-admission in the elderly: Study protocol for a randomised clinical trial]

BACKGROUND AND OBJECTIVE

Re-admission to hospital by the elderly is a frequent event that is associated with complications. The aim of this article is to describe a randomised clinical trial protocol which has the aim of describing and comparing the impact of a home-based intervention by Occupational Therapists (OT) in the likelihood of re-admission at 6 months.

MATERIAL AND METHOD

Randomised controlled trial conducted in medical units of the "Hospital Clínico de la Universidad de Chile" and "Hospital de la Fuerza Aérea de Chile", with 217 patients aged 60 years or older admitted for acute or decompensated chronic disease, provided that they have a person of reference after hospital discharge. The control group consists of the usual care regarding post-discharge patients. This will be compared to the experimental group that includes a home visit from OT on two occasions over a six-month period, who will apply a multicomponent intervention. Informed consent will be requested with the sociodemographic and hospital admission information, functional (Barthel index; Lawton & Brody Scale) and cognitive performance (Short Portable Mental Status Questionnaire; Functional Activities Questionnaire; Confusion Assessment Method), and comorbidity (Cumulative Illness Rating Scale for Geriatrics). Both groups will receive a telephone follow-up at 4, 12 and 24 weeks after hospital discharge.

RESULTS

The intervention will reduce the rate of hospital re-admissions by at least 40% at 6 months compared with usual care.

CONCLUSION

It will be useful to know the components that reduce the risk of hospital re-admissions and improve hospital discharge healthcare for elderly.

Impact of potentially inappropriate medications and polypharmacy on 3-month readmission among older patients discharged from acute care hospital: a prospective study

BACKGROUND

Polypharmacy and potentially inappropriate medications (PIMs) are known to affect several negative outcomes in older patients. However, studies comparatively assessing polypharmacy and PIMs in relation to readmission are distinctively lacking.

AIMS

To compare the impact of polypharmacy and PIMs on 3-month readmission among older patients discharged from acute care hospital.

METHODS

Our series consisted of 647 patients consecutively enrolled in a multicenter observational study. The outcome of the study was the occurrence of any admission during the 3-month follow-up after discharge. Polypharmacy was defined as use of more than eight medications. PIMs were identified using 2015 version of Beers and Screening Tool of Older Persons Prescriptions (STOPP) criteria. Statistical analysis was performed using logistic regression models.

RESULTS

After adjusting for potential confounders, polypharmacy (OR 2.72, 95% CI 1.48-4.99) was found associated with the outcome, while Beers (OR 0.85, 95% CI 0.46-1.56), STOPP (OR 1.60, 95% CI 0.85-3.01), or combined Beers and STOPP violations (OR 0.99, 95% CI 0.57-1.74) were not. The association between polypharmacy and 3-month readmission was confirmed in logistic regression models including Beers (OR 2.88, 95% CI 1.55-5.34), STOPP (OR 2.64, 95% CI 1.43-4.87), or combined Beers and STOPP violations (OR 2.80, 95% CI 1.51-5.21).

DISCUSSION

Besides confirming that polypharmacy should be considered as a marker for readmission risk among older patients discharged from acute care hospital, our findings suggest that the association between polypharmacy and 3-month readmission is substantially independent of use of PIMs.

CONCLUSIONS

Polypharmacy, but not PIMs was significantly associated with readmission. Hospitalization should always be considered as a clue to individuate unnecessary polypharmacy and to reduce the burden of medications whenever possible.

Development of a complex intervention aimed at reducing the risk of readmission of elderly patients discharged from the emergency department using the intervention mapping protocol

Background

Limitations in performing daily activities and a incoherent discharge are risk factors for readmission of elderly patients after discharge from the emergency department. This paper describes the development and design of a complex intervention whose aim was to reduce the risk of readmission of elderly patients discharged from the emergency department.

Methods

The intervention was described using the Intervention Mapping approach. In step 1, a needs assessment was conducted to analyse causes of readmission. In steps 2 and 3, expected improvements in terms of intervention outcomes, performance objectives and change objectives were specified and linked to selected theory- and evidence-based methods. In step 4, the specific intervention components were developed; and in step 5, an implementation plan was described. Finally, in step 6, a plan for evaluating the effectiveness of the intervention was described. The intervention was informed by input from a literature search, informal interviews and an expert steering group.

Results

A three-phased theory- and evidence-based intervention was developed. The intervention consisted of 1) assessment of performance of daily activities, 2) defining a rehabilitation plan and 3) a follow-up home visit the day after discharge with focus on enhancing the patients’ performance of daily activities.

Conclusion

The intervention mapping protocol was found to be a useful method to describe and systemize this theory- and evidence-based intervention.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3391-4) contains supplementary material, which is available to authorized users.

Thirty-day rehospitalizations among elderly patients with acute myocardial infarction: Impact of postdischarge ambulatory care

Rehospitalization after acute myocardial infarction (AMI) is common in elderly patients. It increases morbimortality and health care expenditures. The association between ambulatory care after discharge for AMI and rehospitalization has never been studied in France. We analyzed the impact of ambulatory care on rehospitalization of elderly patients (≥65 years) within 30 days after hospital discharge.We conducted a nationwide population-based study of elderly patients hospitalized with a main diagnosis of AMI in France between 2011 and 2013. We excluded patients hospitalized for AMI in the previous year and those who died during the index hospitalization or within 30 days after discharge. The primary outcome was the first all-cause 30-day rehospitalization in an acute care hospital. Individual and neighborhood-level variables were compared among rehospitalized and nonrehospitalized patients. Determinants of 30-day rehospitalization were identified using logistic regression models.Among the 624 eligible patients, 137 (22.0%) were rehospitalized within 30 days after discharge. In multivariate analyses, chronic kidney failure (odds ratio [OR] 1.88; 95% confidence interval [CI], 1.01-3.53) was an independent predictor of 30-day rehospitalization. We found no association among deprivation and spatial accessibility measures and 30-day rehospitalization. The purchase of lipid-lowering drugs prescription within 7 days after discharge was associated with a reduced risk of 30-day rehospitalization (OR 0.53; 95% CI, 0.36-0.79).This study highlights the role of coordination among hospital and primary care physicians in post-AMI discharge and follow-up among elderly patients. Specifically, targeted interventions to reduce 30-day rehospitalizations should focus on patients with comorbidities and use of prescription drugs after hospital discharge.

Risk factors for acute care hospital readmission in older persons in Western countries: a systematic review

BACKGROUND

Hospital readmission in older persons is common and reported as a post-discharge adverse outcome from hospitalization. Readmission relates to a mix of factors associated with increasing age, living conditions, progression of disease as well as factors related to the processes of care. To allow health professionals to focus more intensively on patients at risk of readmission, there is a need to identify the characteristics of those patients.

OBJECTIVES

To identify and synthesize the best available evidence on risk factors for acute care hospital readmission within one month of discharge in older persons in Western countries.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Participants were older persons from Western countries, hospitalized and discharged home or to residential care facilities.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

The factors of interest considered generic factors related to socio-demographics, health characteristics and clinical and organizational factors related to the care pathway.

TYPES OF STUDIES

The current review considered analytical and descriptive epidemiological study designs that evaluated risk factors for acute care hospital readmission.

OUTCOMES

The outcome was readmission to an acute care hospital within one month of discharge.

SEARCH STRATEGY

A three-step search was utilized to find published and unpublished studies in English, French, German, Norwegian, Swedish or Danish. Five electronic databases were searched from 2004 to 2013, followed by a manual search for additional studies.

METHODOLOGICAL QUALITY

Methodological quality was assessed independently by two reviewers, using the standardized Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) critical appraisal tool.

DATA EXTRACTION

Data were extracted verbatim using a data extraction form, which identified the components from the standardized JBI data extraction tool from JBI-MAStARI and was adapted to the needs of the present review.

DATA SYNTHESIS

Due to the clinical and methodological heterogeneity of the studies included, a narrative summary and metasynthesis of the quantitative findings was conducted.

RESULTS

Based on a review of nine studies from ten Western countries, we found several significant risk factors pertaining to readmission to an acute care hospital within one month of discharge in persons aged 65 years and over. Factors associated with higher risk of hospital readmission covered socio-demographics such as higher age, male gender, ethnicity, living conditions, health characteristics such as poor overall condition and functional disability as well as prior admissions. Organizational factors including length of hospital stay, method of referral and discharge destination were associated with increased risk of acute care hospital readmission.

CONCLUSION

We found several significant, but inconsistent, associations between readmission to an acute care hospital within one month of discharge in persons aged 65 years and over. These associations involved a mix of socio-demographic factors, factors related to health and illness, previous hospitalizations, length of stay as well as clinical and organizational determinants related to the index admission. Although more studies concluded that certain diagnoses or comorbid conditions affected the risk of readmission, they did not agree on any disease in particular.Due to the breadth and diversity of variables examined and the lack of comparability of findings, the impact of these varying factors and their value as risk adjusters and application in different settings and populations are limited.

Comparison of self-reported and performance-based measures of functional ability in elderly patients in an emergency department: implications for selection of clinical outcome measures

Background

Assessment of functional ability in elderly patients is often based on self-reported rather than performance-based measures. This study aims to compare self-reported and performance-based measures of functional ability in a population of elderly patients at an emergency department (ED).

Methods

Participants were 61 patients aged 65 years and above admitted to an ED. The self-reported measure used was the Barthel-20; the performance-based measures were Timed Up and Go (TUG); 30s-Chair Stand Test (30s-CST) and Assessment of Motor and Process Skills (AMPS) with the two scales; motor and process. Correlation analyses were conducted to examine the relationships between the self-reported and performance-based measures of functional ability.

Results

The correlation between the Barthel-20 and the TUG was moderate (r = −0.64). The correlation between the Barthel-20 and the AMPS motor was also moderate (r = 0.53). The correlation between the Barthel-20 and the 30s-CST was fair (r = 0.45). The correlation between Barthel-20 and the AMPS process was non-significant. The results were affected by high ceiling effect (Barthel-20).

Conclusion

Self-reported and performance-based measures seem to assess different aspects of functional ability. Thus, the two methods provide different information, and this highlight the importance of supplementing self-reported measures with performance-based measures when assessing functional ability in elderly patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0376-1) contains supplementary material, which is available to authorized users.

Predicting Inpatient Readmission and Outpatient Admission in Elderly: A Population-Based Cohort Study

Recognizing potentially avoidable hospital readmission and admissions are important health care quality issues. We develop prediction models for inpatient readmission and outpatient admission to hospitals for older adults In the retrospective cohort study with 2 million sampling file of the National Health Insurance Research Database in Taiwan, older adults (aged ≥65 y/o) with a first admission in 2008 were enrolled in the inpatient cohort (N = 39,156). The outpatient cohort included subjects who had ≥1 outpatient visit in 2008 (N = 178,286). Each cohort was split into derivation (3/4) and validation (1/4) data set. Primary outcome of the inpatient cohort: 30-day readmission from the date of discharge. The outpatient cohort included hospital admissions within the 1-year follow-up period. Candidate risk factors include demographics, comorbidities, and previous health care utilizations. Series of logistic regression models were applied with area under the receiver operating curves (AUCs) to identify the best model. Roughly 1 of 7 (14.6%) of the inpatients was readmitted within 30 days, and 1 of 5 (19.1%) of the outpatient cohort was admitted within 1 year. Age, education, use of home health care, and selected comorbidities (e.g., cancer with metastasis) were included in the final model. The AUC of the inpatient readmission model was 0.655 (95% confidence interval [CI] 0.646-0.664) and outpatient admission model was 0.642 (95% CI 0.639-0.646). Predictive performance was maintained in both validation data sets. The goodness-to-fit model demonstrated good calibration in both groups. We developed and validated practical clinical prediction models for inpatient readmission and outpatient admissions for general older adults with indicators easily obtained from an administrative data set.

Predicting 30-day readmissions with preadmission electronic health record data

BACKGROUND

Readmission prevention should begin as early as possible during the index admission. Early identification may help target patients for within-hospital readmission prevention interventions.

OBJECTIVES

To develop and validate a 30-day readmission prediction model using data from electronic health records available before the index admission.

RESEARCH DESIGN

Retrospective cohort study of admissions between January 1 and March 31, 2010.

SUBJECTS

Adult enrollees of Clalit Health Services, an integrated delivery system, admitted to an internal medicine ward in any hospital in Israel.

MEASURES

All-cause 30-day emergency readmissions. A prediction score based on before admission electronic health record and administrative data (the Preadmission Readmission Detection Model-PREADM) was developed using a preprocessing variable selection step with decision trees and neural network algorithms. Admissions with a recent prior hospitalization were excluded and automatically flagged as "high-risk." Selected variables were entered into multivariable logistic regression, with a derivation (two-thirds) and a validation cohort (one-third).

RESULTS

The derivation dataset comprised 17,334 admissions, of which 2913 (16.8%) resulted in a 30-day readmission. The PREADM includes 11 variables: chronic conditions, prior health services use, body mass index, and geographical location. The c-statistic was 0.70 in the derivation set and of 0.69 in the validation set. Adding length of stay did not change the discriminatory power of the model.

CONCLUSIONS

The PREADM is designed for use by health plans for early high-risk case identification, presenting discriminatory power better than or similar to that of previously reported models, most of which include data available only upon discharge.

Identifying risk of readmission in hospitalized elderly adults through inpatient medication exposure

OBJECTIVE

To use electronic health record (EHR) data to examine the association between inpatient medication exposure and risk of hospital readmission.

DESIGN

Retrospective, observational study.

SETTING

Tertiary and quaternary care academic health system in Durham, North Carolina.

PARTICIPANTS

All individuals aged 60 and older who were residents of Durham County, North Carolina and were hospitalized and discharged alive from Duke University Hospital between 2007 and 2009 (N = 4,627).

MEASUREMENTS

Independent variables were inpatient exposure to individual medication classes. Primary outcome was readmission to a Duke Health System hospital within 30 days.

RESULTS

Readmission rate was 21% (n = 955). In adjusted models, exposure to anticonvulsants (odds ratio OR 1.26, 95% confidence interval (CI) = 1.08-1.48), benzodiazepines (OR = 1.23, 95% CI = 1.04-1.44), corticosteroids (OR = 1.26, 95% CI = 1.07-1.50), and opioids (OR = 1.25, 95% CI = 1.06-1.47) was associated with greater likelihood of readmission. Exposure to antidepressants (OR = 1.85, 95% CI = 1.16-2.96) and opioids on the cardiology service (OR = 1.76, 95% CI = 1.01-3.07) and exposure to opioids on the medicine service (OR = 1.94, 95% CI = 1.17-3.22) were associated with greater odds of readmission than for individuals on the surgery service.

CONCLUSION

Exposure of hospitalized elderly adults to certain medication classes was associated with greater likelihood of readmission. Incorporating medication data from EHRs may improve the performance of hospital readmission prediction models.

Assessing functional ability in older patients

Aim:

This study aimed to develop an understanding of how primary and secondary care health professionals perceive current practice and challenges in assessing older patients' functional abilities. A secondary aim was to gain insight into how these professionals perceive the need for generic tools for assessing functional ability among older patients.

Method:

A qualitative design was used to explore health professionals' perspectives on the assessment of older patients' functional ability. Two groups of health professionals participated in focus group interviews, with one group for each of the two different settings: the local hospital and the municipality.

Results:

Focus group interviews showed that health professionals in the hospital and the municipality expressed the need for an observation-based tool to predict and guide decisions about the rehabilitation needs of older patients. Participants from the hospital expressed a need for a fast and simple screening tool to identify those in need of further rehabilitation and care after discharge. Participants from the municipality expressed a need for a more detailed assessment tool to capture information about patients' ability to perform daily activities, any need for food delivery, and information about social relationships and home environment.

Conclusion:

The health professionals at the hospital and in the municipality had different expectations when it comes to assessment tools. All participants would like a simple tool that is quick to administer, to assess the quality of functional ability and predict the need for rehabilitation. The different context (hospital or primary care) seems to influence the way health professionals perceive the need for assessment of functional ability in older patients.

Are physically frail older persons more at risk of adverse outcomes if they also suffer from cognitive, social, and psychological frailty?

Frailty is considered a predictor for negative outcomes such as disability, decreased quality of life, and hospital admission. Frailty measures have been developed that include different dimensions. We examined whether people who are physically frail are more at risk for negative outcomes of frailty if they also suffer from psychological, cognitive, or social frailty. Frailty was measured at baseline by means of the Groningen Frailty Indicator (GFI), which comprises a physical, cognitive, social, and psychological dimension. Only frail persons were included in the study (GFI ≥ 5) that, in addition, had to be frail in the physical dimension (i.e., ≥1 on this dimension). IADL disability and quality of life were measured at baseline and at 12 months. Hospital admission was assessed during this period. In this, physically frail sample effects of the other three frailty dimensions were studied in regression models. The sample (n = 334, mean age 78.1, and range 70-92) included 40.1 % frail men and 59.9 % frail women. Overall, no additional effects for the cognitive, social, or psychosocial dimensions were found: other frailty dimensions did not have an additional impact on disability, quality of life, or hospital admission in people who already suffered from physical frailty. Higher scores of physical frailty were significantly related to IADL disability (p < 0.05) and hospital admission (p < 0.05). Additional analysis showed that the physical frailty score predicted IADL disability and hospital admission better than the GFI overall score. Results of this study suggest that persons, who are physically frail, according to the GFI, are not more at risk for negative outcomes of frailty (i.e., IADL disability, decreased quality of life, and hospital admission) if they in addition suffer from cognitive, social, or psychological frailty. In addition, for the prediction of IADL disability or hospital admission, the focus for screening should be on the physical frailty score instead of the GFI overall score including different dimensions.

Impacto de multimorbidade sobre mortalidade em idosos: estudo de coorte pós-hospitalização

OBJETIVOS: Avaliar a associação entre comorbidades e risco de morte e reinternação em idosos após alta de enfermarias de clínica médica de um hospital universitário. MÉTODOS: Estudo de coorte de idosos que receberam alta do Hospital Universitário Lauro Wanderley. Foram utilizados o Índice de Comorbidade de Charlson (ICC) e o ICC associado à idade (ICIC). O desfecho primário foi mortalidade pós-hospitalização e o secundário, ocorrência de reinternações. RESULTADOS: Foram acompanhados 104 pacientes por 40,9±27,6 semanas; 31 (29,8%) morreram e 38 (36,5%) foram reinternados. A curva de sobrevida foi descendente com proporção acumulada de 50%. Óbito relacionou-se com idade (p=0,04), número de prescrições hospitalares (p=0,01), ICC (p=0,001) e ICIC (p=0,001). Não houve associação de ICC com reinternação. CONCLUSÕES: A gravidade das comorbidades em idosos relacionou-se com maior risco de morte pós-hospitalização. Salienta-se a necessidade de se disporem de dados de comorbidade para avaliar cuidados a essa clientela.

Predicting clinical instability of older patients in post-acute care units: a nationwide cohort study

AIM

Although patients admitted to post-acute care (PAC) units are usually clinically stable, unexpected medical conditions requiring acute ward readmissions still occur and can jeopardize the clinical effectiveness of PAC services. The main purpose of the present study was to evaluate predictive factors for clinical instability of patients in PAC units to improve the quality of PAC services.

METHODS

This was a nationwide multicenter cohort study that recruited patients from five PAC units in Taiwan between July 2007 and June 2009. All patients received the comprehensive geriatric assessment (CGA) within 72 h of PAC unit admissions. Conditions requiring acute ward re-admissions from PAC units were defined as clinical instability. Causes of clinical instability for all patients and data of CGA were collected for analysis.

RESULTS

Of 918 enrolled participants, 119 (12.9%) experienced acute ward readmissions, including 106 (89.1%) admissions related to medical conditions and 13 (10.9%) for surgical causes. Common conditions included diseases of the respiratory system (n = 32, 26.9%), genitourinary system (n = 24, 20.2%) and digestive system (n = 14, 11.8%). Surgical conditions, mainly fractures and dislocation of upper limbs, were significantly more likely to occur later (P = 0.05) in the PAC unit admissions than medical conditions. Compared with the non-readmission group, the readmission group was leaner (mean body mass index 21.1 ± 2.8 vs 22.0 ± 3.8 kg/m(2) , P = 0.007), having poorer functional status (mean Barthel Index 41.0 ± 19.4 vs 45.4 ± 20.3, P = 0.02; mean IADL: 1.3 ± 1.6 vs 1.7 ± 1.8, P = 0.016), poorer cognitive function (mean Mini-Mental State Examination: 16.8 ± 6.4 vs 18.3 ± 6.4, P = 0.022), poorer ambulation (mean Timed Up & Go test 32.7 ± 18.7 vs 26.6 ± 11.7 s, P = 0.039) and poorer nutritional status (mean Mini-Nutrition Assessment 13.3 ± 5.7 vs 15.4 ± 5.8, P < 0.001), but similar in depression status (mean Geriatric Depression Score 3.7 ± 3.3 vs 3.4 ± 2.8, P = 0.247). In multivariate logistical regression model, lower Mini-Mental State Examination score was the only independent predictor for clinical instability (odds ratio 3.8, 95% confidence interval 1.348-10.870, P = 0.012).

CONCLUSION

Approximately 13% of PAC patients might experience acute ward readmissions, and nearly 90% of them are caused by medical conditions. Poor cognitive function is a significant predictive factor for clinical instability in PAC, which deserves more clinical attention for all PAC patients.

Risk factors for hospital readmission of elderly patients

BACKGROUND

The aim of this study was to identify which factors were associated with a risk of hospital readmission within 3 months after discharge of a sample of elderly patients admitted to internal medicine and geriatric wards.

METHODS

Of the 1178 patients aged 65 years or more and discharged from one of the 66 wards of the 'Registry Politerapie SIMI (REPOSI)' during 2010, 766 were followed up by phone interview 3 months after discharge and were included in this analysis. Univariate and multivariate logistic regression models were used to evaluate the association of several variables with rehospitalization within 3 months from discharge.

RESULTS

Nineteen percent of patients were readmitted at least once within 3 months after discharge. By univariate analysis in-hospital clinical adverse events (AEs), a previous hospital admission, number of diagnoses and drugs, comorbidity and severity index (according to Cumulative Illness Rating Scale-CIRS), vascular and liver diseases with a level of impairment at discharge of 3 or more at CIRS were significantly associated with risk of readmission. Multivariate logistic regression analysis showed that only AEs during hospitalization, previous hospital admission, and vascular and liver diseases were significantly associated with the likelihood of readmission.

CONCLUSIONS

The results demonstrate the need for increased medical attention towards elderly patients discharged from hospital with characteristics such as AEs during the hospitalization, previous admission, vascular and liver diseases.

Hospital readmission prevalence and analysis of those potentially avoidable in southern Italy

Background

One quality indicator of hospital care, which can be used to judge the process of care, is the prevalence of hospital readmission because it reflects the impact of hospital care on the patient’s condition after discharge. The purposes of the study were to measure the prevalence of hospital readmissions, to identify possible factors that influence such readmission and to measure the prevalence of readmissions potentially avoidable in Italy.

Methods

A sample of 2289 medical records of patients aged 18 and over admitted for medical or surgical illness at one 502-bed community non-teaching hospital were randomly selected.

Results

A total of 2252 patients were included in the final analysis, equaling a response rate of 98.4%. The overall hospital readmission prevalence within 30 days of discharge was 10.2%. Multivariate logistic regression analysis revealed that the proportion of patients readmitted within 30 days of discharge significantly increased regardless of Charlson et al. comorbidity score, among unemployed or retired patients, and in patients in general surgery. A total of 43.7% hospital readmissions were judged to be potentially avoidable. Multivariate logistic regression analysis showed that potentially avoidable readmissions were significantly higher in general surgery, in patients referred to hospital by an emergency department physician, and in those with a shortened time between discharge and readmission.

Conclusion

Additional research on intervention or bundle of interventions applicable to acute inpatient populations that aim to reduce potentially avoidable readmissions is strongly needed, and health care providers are urged to implement evidence-based programs for more cost-effective delivery of health care.

Readmissions to medical wards: analysis of demographic and socio-medical factors

BACKGROUND

Unplanned readmissions affect occupancy rates in medical wards and these have been constantly increasing in Israel. We examined the frequency and risk factors affecting the likelihood of 30-day emergency medical readmissions.

METHODS

We compared the clinical, epidemiological, and socioeconomic characteristics of readmitted patients during 2009 to a control group matched by age, sex, and primary medical diagnosis.

RESULTS

Rate of unplanned readmissions within 30 days was 12.2%. The mean time to readmission was 12.8 days. The mean length of hospital stay at index admission was 4.4 and 3.8 days for the study and control groups, respectively, and 4.99 days in the second admission (study group only). By simple univariate logistic regression, living in a nursing home, chronic kidney disease, ischemic heart disease, previous cerebrovascular accident, number of chronic medications, length of hospital stay at index admission, and hospitalization in the previous year prior to index admission were significantly associated with risk of readmission. In multivariate logistic regression model, only living in a nursing home (OR=2.94, 95%CI=1.15-7.48), presence of chronic kidney disease (OR=1.62, 95%CI=1.06-2.46), length of index admission ≥ 3 days (OR=1.53, 95%CI=1.07-2.2), and hospitalization in the previous year (OR=3.33, 95%CI=2.34-4.74) were found to be significantly associated with likelihood of readmission.

CONCLUSION

Risk factors affecting 30-days readmission at our medical centre are similar to previous observations, and yet, some are perhaps unique to our region.

Activity in GEriatric acute CARe (AGECAR): rationale, design and methods

Background

The Activity in GEriatric acute CARe (AGECAR) is a randomised control trial to assess the effectiveness of an intrahospital strength and walk program during short hospital stays for improving functional capacity of patients aged 75 years or older.

Methods/Design

Patients aged 75 years or older admitted for a short hospital stay (≤14 days) will be randomly assigned to either a usual care (control) group or an intervention (training) group. Participants allocated in the usual care group will receive normal hospital care and participants allocated in the intervention group will perform multiple sessions per day of lower limb strength training (standing from a seated position) and walking (10 min bouts) while hospitalized. The primary outcome to be assessed pre and post of the hospital stay will be functional capacity, using the Short Physical Performance Battery (SPPB), and time to walk 10 meters. Besides length of hospitalization, the secondary outcomes that will also be assessed at hospital admission and discharge will be pulmonary ventilation (forced expiratory volume in one second, FEV₁) and peripheral oxygen saturation. The secondary outcomes that will be assessed by telephone interview three months after discharge will be mortality, number of falls since discharge, and ability to cope with activities of daily living (ADLs, using the Katz ADL score and Barthel ADL index).

Discussion

Results will help to better understand the potential of regular physical activity during a short hospital stay for improving functional capacity in old patients. The increase in life expectancy has resulted in a large segment of the population being over 75 years of age and an increase in hospitalization of this same age group. This calls attention to health care systems and public health policymakers to focus on promoting methods to improve the functional capacity of this population.

Trial registration

ClinicalTrials.gov ID: NCT01374893.

Evidence-based risk factors for adverse health outcomes in older patients after discharge home and assessment tools: a systematic review

The current health care system is discharging elderly patients "quicker" and "sicker" from acute care facilities. Consequently, hospital readmission is common; however, readmission may be only one aspect of adverse outcomes of importance to social work discharge planners. The early recognition of risk factors might ensure a successful transition from the hospital to the home. A systematic review was conducted to identify factors associated with adverse outcomes in older patients discharged from hospital to home. Using a content analysis, factors were characterized in five domains: demographic factors, patient characteristics, medical and biological factors, social factors, and discharge factors. The most frequently reported risks were depression, poor cognition, comorbidities, length of hospital stay, prior hospital admission, functional status, patient age, multiple medications, and lack of social support. A systematic search identified four discharge assessment tools for use with the general population of elderly patients. Practice and research implications are offered.

Risk factors for hospital readmissions in elderly patients: a systematic review

Population ageing is associated with an increase in hospital admissions. Defining the factors that affect the risk of hospital readmission could identify individuals at high risk and enable targeted interventions to be designed. This aim of this study was to identify the risk factors for hospital readmission in elderly people. A systematic review of the literature published in English or Spanish was performed by electronically searching EMBASE, MEDLINE, CINAHL, SCI and SSCI. Some keywords were aged, elder, readmission, risk, etc. Selection criteria were: prospective cohort studies with suitable statistical analysis such as logistic regression, that explored the relationship between the risk of readmission with clinical, socio-demographic or other factors in elderly patients (aged at least 75 years) admitted to hospital. Studies that fulfilled these criteria were reviewed and data were extracted by two reviewers. We assessed the methodological quality of the studies and prepared a narrative synthesis. We included 12 studies: 11 were selected from 1392 articles identified from the electronic search and one additional reference was selected by manual review. Socio-demographic factors were only explanatory in a few models, while prior admissions and duration of hospital stay were frequently relevant factors in others. Morbidity and functional disability were the most common risk factors. The results demonstrate the need for increased vigilance of elderly patients who are admitted to hospital with specific characteristics that include previous hospital admissions, duration of hospital stay, morbidity and functional disability.

The short mean length of stay of post-emergency geriatric units is associated with the rate of early readmission in frail elderly

BACKGROUND AND AIMS

Specific postemergency short-stay geriatric units may decrease length of hospital stay, functional decline, and early readmission rates. The aim of this study was to evaluate risk factors of early rehospitalization in a shortstay geriatric unit.

METHODS

This study was a prospective observational study comprising over one year patients aged over 75 years, admitted to the post-emergency short-stay geriatric unit (Hôpital Saint André, Bordeaux, France) and discharged home. Socio-demographic data, length of hospital stay, and a standardized geriatric assessment were collected for all patients. One month after home discharge, patients were followed-up by phone, and the hospital readmission rate was calculated.

STATISTICAL ANALYSES

descriptive, unvaried and multivariate analyses were carried out.

RESULTS

A total of 476 patients were included in this study (mean age 86.5±6 yrs; 154 men, 322 women). Mean length of stay in the post-emergency short-stay geriatric unit was 6.3±2.7 days, and a total of 68 (14.3%) patients were readmitted within one month after home discharge. The readmission rate was associated with a diagnosis of delirium (Odds Ratio (OR) 1.9; 95% CI 1.1-3.3; p=0.02), mean length of stay exceeding 6 days (OR 1.9, 95% CI 1.1-3.5; p=0.02), and decision of home discharge (OR 2.4; 95% CI 1.4-4.1; p=0.002).

CONCLUSION

Short mean lengths of stay were not considered as a risk factor for readmissions within one month, even in frail, dependent, hospitalized elderly persons.

A scoring system to predict readmission of patients with acute pancreatitis to the hospital within thirty days of discharge

BACKGROUND & AIMS

Reducing rapid readmission of patients after discharge could improve quality of treatment and reduce costs. Little is known about clinical predictors of early readmission for acute pancreatitis (AP). We developed a strategy to identify and stratify patients with AP at risk for readmission within 30 days of discharge.

METHODS

We derived and validated a model in a cohort of patients hospitalized with AP from June 2005-October 2009. Early readmission was defined as admission to the hospital or reevaluation in the emergency department within 30 days of discharge. The cohort was divided into a derivation cohort (admitted June 2005-December 2007, n = 248) and a validation cohort (admitted January 2008-October 2009, n = 198). A weighted scoring system was developed using logistic regression for the prediction of early readmission. Accuracy was assessed by area under the receiver-operator characteristic (ROC) curve analysis.

RESULTS

Of the total patients, 21% (92/446) had early readmission. Multivariable analysis identified the following discharge characteristics as independent risk factors for early readmission: gastrointestinal symptoms, eating less than a solid diet, pancreatic necrosis, treatment with antibiotics, and pain (P < .05). Weighted risk scores stratified patients into groups of low, moderate, and high risk for early readmission: 4%, 15%, and 87%, respectively, in the derivation cohort and 5%, 18%, and 68%, respectively, in the validation cohort. Area under the ROC curve demonstrated an accurate prediction (c-statistic = 0.83).

CONCLUSIONS

We created a scoring system that accurately predicts which patients with AP have high and low risk of readmission within 30 days of discharge.

Early readmission in acute pancreatitis: incidence and risk factors

OBJECTIVES

Early unplanned readmission is a potential target for quality improvement and cost reduction. The aims of this study were to (i) determine the frequency of early readmission following hospitalization for acute pancreatitis (AP) and (ii) identify risk factors for early readmission in patients hospitalized for AP.

METHODS

A retrospective, observational cohort study was performed including all inpatients with AP at a tertiary-care hospital between June 2005 and December 2007. Early readmission was defined as admission to the hospital or reevaluation in the emergency department within 30 days of discharge. We analyzed demographics, etiology, markers of severity (according to Atlanta symposium), comorbidities, complications, therapeutic interventions, and discharge symptoms as potential risk factors for readmission.

RESULTS

There were a total of 248 patients discharged with AP during the study period, of whom 19% (47/248) had an early readmission. Median time to readmission was 9 days (interquartile range, 5-15). Median rehospitalization length of stay was 4 days (2.5-8). In multivariate analysis, the strongest risk factors for early readmission included (i) gastrointestinal symptoms (nausea, vomiting, or diarrhea) at discharge (odds ratio (OR) 44.2; 95% confidence interval (CI) 4.1-472.1); (ii) discharge on less than a solid diet (OR 23.8; 95% CI 4.8-118.2); and (iii) moderate to heavy alcohol use (OR 10.1; 95% CI 1.2-82.6).

CONCLUSIONS

(i) Early readmission is a common occurrence in AP. (ii) Risk factors for early readmission included moderate to heavy alcohol use, persistent symptoms, and diet at the time of discharge.

Preventing the preventable: reducing rehospitalizations through coordinated, patient-centered discharge processes

OBJECTIVES

Growing literature suggests that a significant proportion of rehospitalizations could be prevented if systems were put in place aimed at identifying and addressing some of the underlying issues that cause them. This article highlights key risk factors for unplanned rehospitalizations and illustrates a project that has successfully addressed many of the underlying issues that contribute to them.

PRIMARY PRACTICE SETTING(S)

The study illustrated herein took place at an inner-city academic teaching hospital.

FINDINGS/CONCLUSIONS

Proactively identifying patient-, clinician-, and system-associated barriers to successful discharge transitions is critical for effective transitions of care for patients leaving the hospital setting. This process represents a culture change, requires a multidisciplinary approach to care, and mandates clear delineation of roles and responsibilities in the process, with ultimate and clear process ownership being defined. With such steps in place in a system of care, it is reasonable to expect a reduction in preventable rehospitalizations.

Decreased length of stay and cumulative hospitalized days despite increased patient admissions and readmissions in an area of urban poverty

BACKGROUND

Length of stay at US acute care hospitals has been steadily decreasing since 1960, and there is ongoing concern that increasing financial pressures on hospitals with high proportions of Medicaid patients may be causing unduly short lengths of stay.

OBJECTIVE

To study temporal trends in hospital utilization on internal medicine services at Temple University Hospital, which has the highest percentage of Medicaid and uninsured patients in the state of Pennsylvania.

DESIGN

Examination of temporal changes in hospital practice over three time periods spanning 13 years.

MEASUREMENTS

Numbers of discharges, 1- and 12-month re-admission rates, and lengths of stay. US census data from 1990 to 2000 were examined for the eight major zip codes in which hospitalized patients live.

MAIN RESULTS

The number of internal medicine admissions increased from 1991 (117/month) to 2004 (455/month); p < 0.0001. Mean length of stay for the index admission decreased from 8.7 to 4.9 days; p < 0.001. The percentage of patients readmitted within 12 months of the discharge date of the index admission increased from 42.3% to 49.5%; p = 0.045. Mean cumulative length of stay over 12 months, including readmissions, decreased significantly (15.8 to 12.5 days; p = 0.031). Compared to all US hospitals, our hospital had a greater increase in admissions and a greater decrease in length of stay. During this time period, in surrounding zip codes, there were decreases in total population and total number of persons living in poverty, but also multiple closures of area hospitals that served poor patients.

CONCLUSION

During the 13-year study period, despite increased readmission rates, the overall number of hospitalized days per year on the internal medicine inpatient service decreased. As local hospitals serving this inner city low income area have closed, our hospital had atypically high increases in numbers of admissions and decreases in length of stay. This raises questions about current adequacy of hospital care in inner city areas of poverty.

Screening for risk of unplanned readmission in older patients admitted to hospital: predictive accuracy of three instruments

BACKGROUND AND AIMS

Hospital readmission after discharge is an important clinical and health policy issue. We compared the predictive accuracy of the Identification of Seniors at Risk (ISAR), the Flemish version of the Triage Risk Screening Tool (TRST) and Variable Indicative of Placement risk (VIP) in assessing unplanned readmissions.

METHODS

We included 213 patients (≥65 years), hospitalized following admission to the emergency department. The ISAR, TRST and VIP were administered at admission. Unplanned readmissions were registered by telephone follow-up 14, 30 and 90 days post-discharge.

RESULTS

Unplanned readmission rates were 6.8%, 14.7% and 23.5% after 14, 30, and 90 days, respectively. The ISAR showed low to moderate sensitivity (54%-69%) and a high negative predictive value (≥78%) at all measurement points. Specificity and positive predictive value were low (≤33% and ≤24%, respectively). The TRST had low to moderate sensitivity (42%-67%) and a high negative predictive value (≥82%). Specificity and positive predictive value were low (≤45% and ≤27%, respectively). The VIP had very low sensitivity (≤26%) and high specificity (≥80%). Its negative predictive value was high (≥79%) and its positive predictive value was low (≤22%).

CONCLUSIONS

Due to their moderate to low sensitivity, and low specificity and positive predictive value, none of the instruments was capable of accurately predicting unplanned readmission in older, hospitalized patients. Overall, reducing or increasing the original cut-off value by one point did not result in improved performance. Our findings suggest that these instruments lack the necessary sophistication to capture the complexity of (unplanned) readmissions.

[Factors associated with hospital readmissions in the elderly]

OBJECTIVE

To identify factors associated with hospital readmissions in the elderly.

DESIGN

Observational descriptive study.

SETTING

Health area 3 of Madrid.

PARTICIPANTS

Patients 74 years-old and over with a hospital admission to Hospital Universitario Príncipe de Asturias in 2006. Those with a hospital admission in the previous 6 months were excluded. A total of 1051 patients were identified.

MAIN MEASURES

Hospital Discharge Minimum Basic Data Set and primary care information system were used to develop logistical regression models. The dependent variable was the hospital readmission in a 6 month period. Independent variables were socio-demographics, health status and health care activity.

RESULTS

There were 22.6% readmissions in the first 6 months. Variables associated with higher risk of readmission were, hospital stay (hospital stay greater than 15 days had an OR: 1.73 (95% CI:1.17-2.54), the total number of medicines prescribed to the patient (OR: 1.05; 95% CI:1.01-1.09), having hypertension (OR:1.56; 95% CI:1.11-2.18), heart failure (OR: 1.56; 95% CI:1.00-2.44) or ischemic heart disease (OR: 1.51; 95% CI:1.00-2.26), and the primary care nursing mean attendance pressure (OR: 0.93; 95% CI:0.87-0.98). The model that integrates information from both systems explains a higher number of factors associated with readmission.

CONCLUSIONS

Hospital readmissions have been associated to patient medical condition and to factors related to the health care received. Integrating information from hospital and primary care administrative data bases improves the capacity to identify factors associated with a higher readmission risk.

Factors identified by experts to support decision making for post acute referral

BACKGROUND

Each year, more than 13 million post acute referral decisions are made for Medicare recipients, yet there are no national, empirically derived decision support tools to assist in making these important decisions.

OBJECTIVES

The aim of this study was to elicit expert knowledge about factors important to referral decision making and identify the characteristics of hospitalized patients who need a post acute referral.

METHODS

This was a retrospective and prospective mixed-methods study of the referral decisions made by discharge planning experts for 355 hospitalized older adults. Variables included sociodemographics, living arrangement, insurance, diagnosis, comorbid conditions, adverse events, medications, home care use, hospitalization in last 30 days or 6 months, patients' perception of need for and use of assistive devices or post acute services, length of stay, cognition, self-rated health, depression, functional status, and post acute referral decision.

RESULTS

The final model identified six factors associated with the need for a post acute referral. A cutpoint was derived with a sensitivity and specificity of 87.6% and 63.2%, respectively. Experts were more likely to refer patients who had no or intermittent help available (odds ratio [OR] = 3.0), major walking restrictions (OR = 6.5), less than excellent self-rated health (3.1 and 4.0 times more likely with good and fair-poor health, respectively), remained in the hospital longer (OR = 1.2), and had higher depression scores (OR = 1.1) or number of comorbidities (OR = 1.2).

DISCUSSION

This study begins to identify information useful to clinicians caring for hospitalized older adults who may benefit from post acute services. By assuring the systematic, valid, and reliable collection of these items, the multidisciplinary team is alerted to patients who may benefit from post acute services. Further work is needed to increase the specificity and generalizability of the model and to test its effects on patient and clinician outcomes.

Incidence and main factors associated with early unplanned hospital readmission among French medical inpatients aged 75 and over admitted through emergency units

BACKGROUND

among elderly patients, readmission in the month following hospital discharge is a frequent occurrence which involves a risk of functional decline, particularly among frail subjects. While previous studies have identified risk factors of early readmission, geriatric syndromes, as markers of frailty have not been assessed as potential predictors.

OBJECTIVE

to evaluate the risk of early unplanned readmission, and to identify predictors in inpatients aged 75 and over, admitted to medical wards through emergency departments.

DESIGN

prospective multi-centre study.

SETTING

nine French hospitals.

SUBJECTS

one thousand three hundred and six medical inpatients, aged 75 and older admitted through emergency departments (SAFES cohort).

METHODS

using logistic regressions, factors associated with early unplanned re-hospitalisation (defined as first unplanned readmission in the thirty days after discharge) were identified using data from the first week of hospital index stay obtained by comprehensive geriatric assessment.

RESULTS

data from a thousand out of 1,306 inpatients were analysed. Early unplanned readmission occurred in 14.2% of inpatients and was not related with sociodemographic characteristics, comorbidity burden or cognitive impairment. Pressure sores (OR = 2.05, 95% CI = 1.0-3.9), poor overall condition (OR = 2.01, 95% CI = 1.3-3.0), recent loss of ability for self-feeding (OR = 1.9, 95% CI = 1.2-2.9), prior hospitalisation during the last 3 months (OR = 1.6, 95% CI = 1.1-2.5) were found to be risk factors, while sight disorders appeared as negatively associated (OR = 0.5, 95% CI = 0.3--0.8).

CONCLUSIONS

markers of frailty (poor overall condition, pressure sores, prior hospitalisation) or severe disability (for self-feeding) were the most important predictors of early readmission among elderly medical inpatients. Early identification could facilitate preventive strategies in risk group.

Outcomes at 12 months in a population of elderly patients discharged from a rehabilitation unit

OBJECTIVES

This study investigates the cognitive, functional, and clinical variables associated with the risk of institutionalization, rehospitalization, and death at 12 months among a population of elderly discharged from a Rehabilitation and Aged Care Unit (RACU) within a 1-year period (May 1, 2004 to April 30, 2005). The RACU is a relatively new setting of care providing intensive rehabilitation and clinical support to elderly with highly heterogeneous reasons for admission.

METHODS

There were 1303 patients (> or =65 years old) contacted 12 months after discharge from the RACU. We obtained information about institutionalization, rehospitalization, and death. Predictors were all the demographic and clinical variables potentially related to these outcomes. The relationship among predictors and outcomes was tested with multiple stepwise logistic regression models.

RESULTS

Among the 1072 patients alive at the 12-month follow-up, 90 (8.4%) were institutionalized (3.4% early at discharge and 4.9% within the next period). The logistic regression analysis showed that 2 ranges of age (78 to 83 years and 84 years or more), living alone, occurrence of delirium, cognitive impairment (Mini Mental State Examination lower or equal to 20/30), and poor functional status at discharge (Barthel Index scores ranging from 69 to 85 and Barthel Index scores lower than 68/100) were independently and significantly associated with the risk of institutionalization during the 12 months following discharge from the RACU. Three hundred and twenty-three (30.1%) patients had been rehospitalized once and 86 (8.0%) patients twice at the 12-month follow-up. In the multivariate analysis, comorbidity (Charlson Index scores ranging from 2 to 3 and Charlson Index scores higher than 4) and delirium were significantly and independently associated with this outcome. One hundred and thirty-six (11.3%) patients had died by the 12-month follow-up. The stepwise logistic regression analysis showed that age greater than 83 years, poor functional status (Barthel Index lower than 60/100 at discharge), high comorbidity (Charlson Index scores ranging from 3 to 4 and Charlson Index scores higher than 4, respectively), and albumin serum levels ranging from 3.2 to 2.9 mg/dL and lower than 2.9 mg/dL independently and significantly predicted the 12-month risk of death. Absence of depressive symptoms (Geriatric Depression Scale <2/15) had instead a protective effect.

CONCLUSION

Variables related to the sociodemographic, cognitive, functional, and health status predicted, with different degree of association, the 12-month risk of institutionalization, rehospitalization, and death among a population of elderly patients discharged from a RACU. Accordingly, various clinical and organizational approaches may be planned for prevention.

Survival in the community of the very old depressed, discharged from medical inpatient care

OBJECTIVES

To examine the prevalence and associated risk factors of depression in older patients discharged home from acute medical care and their influence on duration of survival in the community.

DESIGN

A cross-sectional, prevalence study of depression in recently discharged patients and a prospective, case-controlled study of depressed and psychiatrically asymptomatic sub groups, exploring the relationship between depression, associated risk factors, and duration of survival in the community.

SETTING

A community study of patients aged 75 and older discharged from the Countess of Chester Hospital and Wirral Hospitals Trust serving Wirral and West Cheshire, England.

PARTICIPANTS

Three hundred and eleven patients were entered into the prevalence study. One hundred and fifty-eight patients (54 depressed and 104 asymptomatic) were entered into the prospective case controlled study and followed up for up to two years.

MEASUREMENTS

Depression was defined by GMS/AGECAT criteria. Demographic details, handicap, pain, forced expiratory volume and social network were measured as dependent variables in the prevalence study and included in the analysis of risk factors potentially associated with duration of survival in the community.

RESULTS

A depression prevalence rate of 17.4% was found. Age (p = 0.049, CI; 0.813, 0.999), forced expiratory volume (p = 0.034, CI; 0.991, 1.000) and handicap (p = 0.000, CI; 1.268, 1.723) were associated with depression but depression (p = 0.040, CI; 1.039, 4.915) was the only base-line variable associated with reduced survival in the community as defined by mortality and re-admission.

CONCLUSIONS

Depression is common in older people discharged from acute medical care and is a major risk factor for reduced duration of community survival.