北京市某三甲医院31天内非计划性再入院研究

目的 了解北京市某三甲综合性医院住院患者出院31天内非计划再入院的现状及其影响因素。方法 对北京市某三甲综合性医院2008年1月1日—12月31日之间出院后31天内非计划性再入院的患者进行描述性分析，通过t 检验和χ2检验进行单因素分析，选择有统计学意义的危险因素用向后逐步回归法进行非条件Logistic分析。结果 患者性别、患者年龄、出院—再入院的间隔天数、前次入院时入院状况和前次入院疾病是否治愈是31天内非计划性再入院的主要影响因素。结论 患者特征和医院相关因素均与患者出院31天内非计划性再入院相关。     

Incidence,risk factors and adequation of early readmission among the elderly

BACKGROUND: The objectives of the study were to estimate the incidence of readmission one month after discharge, to determine the proportion of planned readmissions and of those avoidable, and to identify risk factors associated with early readmissions in elderly admitted to an acute geriatric unit. METHODS: A prospective study was conducted on a sample of 322 patients, 75 years of age or older, discharged from an acute geriatric service. A phone follow-up was realized one month after discharge. A multivariate logistic regression model was used to identify risk factors for readmission. RESULTS: Global incidence of early readmission was 16.2% (that is 50 rehospitalizations), 18.0% of which were planned. Among the 21 readmissions to the same service, five were avoidable according to the Appropriateness Evaluation Protocol. Logistic regression analysis identified three patient characteristics that were independent predictors of early readmission, which were: a need of help for locomotion (OR=4.38, p=0.002), a negative answer to the question "do you feel that your life is empty?" (OR=2.22, p=0.02) and a short length of stay (p<0.02). CONCLUSION: A better knowledge of risk factors should allow targeting patients at high risk of early hospital readmission, which should profit by preventive interventions during the first hospitalization. Two domains of possible action were identified in this study: a sufficient length of stay and a better attention to patients with reduced autonomy, especially for those who go back home after discharge.     

Impact of physician training level on emergency readmission within internal medicine

OBJECTIVES: The research question was whether training level of admitting physicians and referrals from practitioners in primary health care (PHC) are risk factors for emergency readmission within 30 days to internal medicine. METHODS: This report is a prospective multicenter study carried out during 1 month in 1997 in seven departments of internal medicine in the County of Stockholm, Sweden. Two of the units were at university hospitals, three at county hospitals and two in district hospitals. The study area is metropolitan-suburban with 1,762,924 residents. Data were analyzed by multiple logistic regression. RESULTS: A total of 5,131 admissions, thereby 408 unplanned readmissions (8 percent) were registered (69.8 percent of 7348 true inpatient episodes). The risk of emergency readmission increased with patient's age and independently 1.40 times (95 percent confidence interval [CI], 1.13-1.74) when residents decided on hospitalization. Congestive heart failure as primary or comorbid condition was the main reason for unplanned readmission. Referrals from PHC were associated with risk decrease (odds ratio, 0.53; 95 percent CI, 0.38-0.73). CONCLUSION: The causes of unplanned hospital readmissions are mixed. Patient contact with primary health care appears to reduce the recurrence. In addition to the diagnoses of cardiac failure, training level of admitting physicians in emergency departments was an independent risk factor for early readmission. Our conclusion is that it is cost-effective to have all decisions on admission to hospital care confirmed by senior doctors. Inappropriate selection of patients to inpatient care contributes to poor patient outcomes and reduces cost-effectiveness and quality of care.     

Thirty‐Day Readmission Rate Is High for Hospitalized Patients Discharged With Home Parenteral Nutrition or Intravenous Fluids

Background: Reducing hospital readmissions decreases healthcare costs and improves quality of care. There are no published studies examining the rate of, and risk factors for, 30‐day readmissions for patients discharged with home parenteral support (HPS). Objective: Determine the rate of 30‐day readmissions for patients discharged with HPS and whether malnutrition and other demographic or clinical factors increase the risk. Materials and Methods: Retrospective review of patients discharged with HPS from the Cleveland Clinic between July 1, 2013, and June 30, 2014, and followed by the Cleveland Clinic Home Nutrition Support Service. Results: Of the 224 patients studied, 31.6% (n = 71) had unplanned readmissions within 30 days of hospital discharge. Of these, 21.1% (n = 15) were HPS related, with catheter‐related bloodstream infection (n = 5) and dehydration (n = 5) the most common. The majority of patients (84.4%) were diagnosed with malnutrition, but the presence or degree did not influence the readmission rate (P = .41). According to univariable analysis, patients with an ostomy (P = .037), a small bowel resection (P = .002), a higher HPS volume at discharge (P < .001), and a shorter period between HPS consult and hospital discharge (P < .026) had a lower risk of 30‐day readmission than their counterparts. On multivariable analysis, patients had a higher risk of 30‐day readmission if they had a history of heart disease (P = .048) and for every 1‐unit increase in white blood cells (P = .026). Conclusions: Patients discharged with HPS have a high 30‐day readmission rate, although most readmissions were not related to the HPS itself. The presence and degree of malnutrition were not associated with 30‐day readmissions.     

Factors associated with inpatient readmission among managed care enrollees with COPD

Objective. To assess factors associated with inpatient readmission among a US managed care population with chronic obstructive pulmonary disease (COPD). Background. COPD is often accompanied by intermittent acute exacerbations, which may result in hospitalizations. These exacerbations are often associated with an increased frequency of subsequent exacerbations, which may lead to inpatient readmissions. Methods. We assessed US managed care claims data for enrollees ≥ 40 years old with an inpatient admission with a primary diagnosis of COPD (ICD-9-CM codes 491.xx, 492.xx or 496.xx) between 1 January 2010 and 31 December 2013 (discharge date of first observed inpatient admission defined the “index date”). Patients were required to be continuously enrolled for ≥ 12 months before the index date. Two non-mutually exclusive cohorts were analyzed: (1) patients with ≥ 30 days of post-index date continuous enrollment (to evaluate 30-day readmission) and (2) patients with ≥ 90 days of post-index date continuous enrollment (to evaluate 90-day readmission). Logistic regression evaluated the association between patient characteristics and risk of 30- and 90-day COPD-related and all-cause readmission. Results. After applying selection criteria, 140,981 patients had ≥ 30 days of enrollment post-index date, and 123,545 patients had ≥ 90 days of enrollment post-index date. Within 30 days, nearly 20% of patients had an all-cause readmission and 7% had a COPD-related readmission. Within 90 days, 28% had an all-cause readmission and 12% had a COPD-related readmission. Logistic regression indicated that longer length of stay, older age, greater comorbidity burden, specific comorbidities and COPD complexity were associated with significantly greater odds of COPD-related 30- and 90-day readmission. Results for all-cause readmission were generally similar. Conclusions. Many of the factors associated with inpatient readmission documented here can be ascertained at discharge and may be used to inform discharge plans, with the end goal of improving patient outcomes, including reducing the risk of readmission.     

Measuring readmissions: focus on the time factor.

OBJECTIVE: To assess the effects of choosing different time-intervals of observation when using unplanned readmissions as an outcome indicator. DESIGN: A conceptual model was developed based on the risk curve. The model assigned readmissions above a background level as 'related' to the earlier episode of illness. The characteristics of the hazard curve were used to estimate how the rates of related and unrelated readmissions varied with time. SETTING: Patients living in a region of Middle Norway served by eight acute-care hospitals and discharged in the year 1996. MAIN OUTCOME MEASURE: The conditional risk (hazard rate) of having an unplanned readmission. The information gathered allowed inclusion of readmissions to all hospitals in the area, and to make risk corrections for deaths. RESULTS: The identified proportion of readmissions judged as related to the earlier episode of illness was found to be very sensitive to changes in the time interval. With the commonly used interval of 30 days, 0.5 of all related readmissions were identified, while 0.7 of the readmissions included at this time were estimated as related ones ('true positives'). The hazard curve was different for medical and surgical patients, but the corresponding proportions of related and unrelated readmissions were relatively similar. Adjusting for deaths in the observation period did not result in significantly different risk curves. CONCLUSION: When unplanned readmissions are used as an outcome indicator, the measure is susceptible to the choice of time interval. The operative characteristics must be interpreted in the context of where it is intended that the indicator should be used.     

Training in Readmission Reduction in an Indonesian Hospital

The authors implemented a new discharge protocol to reduce readmission rates in a hospital in West Java, Indonesia. Forty nurses were trained in the use of the protocol. Results indicate that posttest group readmission rates were significantly lower after the implementation of protocol, from 6.11% to 4.21%. The protocol was effective in reducing readmissions for patients discharged from internal medicine, pulmonology, and women. Differences were also found by type of insurance or payment method, generally suggesting that the lower the socioeconomic status of the patients was, the more effective the discharge protocol was.     

Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions

OBJECTIVE: To determine clinical and patient-centered factors predicting non-elective hospital readmissions. DESIGN: Secondary analysis from a randomized clinical trial. CLINICAL SETTING: Nine VA medical centers. PARTICIPANTS: Patients discharged from the medical service with diabetes mellitus, congestive heart failure, and/or chronic obstructive pulmonary disease (COPD). MAIN OUTCOME MEASUREMENT: Non-elective readmission within 90 days. RESULTS: Of 1378 patients discharged, 23.3% were readmitted. After controlling for hospital and intervention status, risk of readmission was increased if the patient had more hospitalizations and emergency room visits in the prior 6 months, higher blood urea nitrogen, lower mental health function, a diagnosis of COPD, and increased satisfaction with access to emergency care assessed on the index hospitalization. CONCLUSIONS: Both clinical and patient-centered factors identifiable at discharge are related to non-elective readmission. These factors identify high-risk patients and provide guidance for future interventions. The relationship of patient satisfaction measures to readmission deserves further study.     

Do Hospital Length of Stay and Staffing Ratio Affect Elderly Patients' Risk of Readmission? A Nation‐wide Study of Norwegian Hospitals

OBJECTIVE: To test whether there is an association between hospital operating conditions such as average length of stays (LOS) and staffing ratio, and elderly patients' risk of readmission. DATA SOURCES: The main data source was a national patient database of admissions to all acute-care Norwegian hospitals during the year of 1996. STUDY DESIGN: It is a cross-sectional study, where Cox' regression analysis was used to test the factors acting on the probability of early unplanned readmission (within 30 days), and later occuring ones. The principal hospital variables included average hospital LOS and staffing ratio (discharges per man-years of personnel). Adjusting patient variables in the model included age, gender, and cost-weights of the Diagnosis Related Groups (DRGs). DATA EXTRACTION METHODS: The selected material included discharges from 59 hospitals, and 113,055 elderly patients (> or = 67 years). Multiple admissions to the same hospital were linked together chronologically, and additional hospital data were matched on. To maximize the association between the index stay and the defined outcome (unplanned readmission), no intervening planned admission was accepted. PRINCIPAL FINDINGS: Being admitted to a hospital with relatively short average LOS increased the patient's risk of early readmission significantly. In addition it was found that more intensive care (more staff) could have a compensatory effect. Furthermore, the predictive factors were shown to be time dependent, as hospital variables had much less impact on readmissions occurring late (within 90-180 days). CONCLUSIONS: The results give support to the assumption of a link between hospital operating conditions and patient outcome.     

Effects of Postacute Settings on Readmission Rates and Reasons for Readmission Following Total Knee Arthroplasty

Objectives

Examine the effects of postacute discharge setting on unplanned hospital readmissions following total knee arthroplasty (TKA) in older adults.

某院出院患者31天内再住院分析与讨论

目的 分析某三级医院出院患者31天内再住院情况,为医院管理提供依据.方法 对某三级医院2013年第一季度31内天再住院患者进行描述性分析.结果 出院患者31天内非预期再住院率为3.32％,24小时内非预期再住院率为0.75％.因病情变化再住院占77.96％,出院24小时内再住院占22.69％,平均再住院时间为12.89天.结论 医院应关注31天内非预期再住院等重返类指标,重视此类患者诊疗,规范科间会诊与转科等医疗行为,加强医保患者管理等.     

Development of claims‐based measures of unplanned acute care with superior power for assessing the effectiveness of interventions following acute care

ObjectiveTo develop outcome measures that are more sensitive than current measures for evaluating primary or transitional care after hospitalizations, emergency department (ED) visits, or observation stays.Data SourcesMedicare claims data from January 1, 2015, to October 31, 2017, for 1 261 707 Medicare fee‐for‐service beneficiaries served by (a) primary care practices participating in Track 1 of the Comprehensive Primary Care Plus (CPC+) initiative, and (b) their matched comparison practices.Study DesignGiven the poor statistical power in many studies to detect effects on readmissions, we developed two novel claims‐based measures of unplanned acute care (UAC) following an index acute care event. The first measure assesses the proportion of hospitalizations followed by an unplanned readmission, ED visit, or observation stay within 30 days of discharge; the second assesses the proportion of ED visits and observation stays followed by a hospitalization, ED visit, or observation stay within 30 days. We calculate minimum detectable effects (MDEs) for both measures and for a conventional measure of 30‐day unplanned readmissions, using CPC+ data.Principal FindingsRepeat UAC events are common among Medicare beneficiaries served by the CPC+ practices. In 2017, 22% of discharges and 21% of ED visits and observation stays had a UAC event within 30 days. Readmissions were the most common UAC event following discharge, whereas ED visits were most common following index ED visits or observation stays. MDEs are 25%‐40% lower for the new measures than for the standard 30‐day readmissions measure, indicating better statistical power to detect impacts of primary or transitional care interventions.ConclusionsThis study introduces two new claims‐based measures to assess quality of care during a patient''s vulnerable period following acute care. The new measures complement existing measures, covering a broader range of UAC events than the standard 30‐day readmissions measure, and yielding greater statistical power.     

Risk of unplanned emergency department readmission after an acute-care hospital discharge among geriatric inpatients: Results from the geriatric EDEN cohort study

Objectives

The study aims 1) to examine whether items of the brief geriatric assessment (BGA) or their combinations predicted the risk of unplanned emergency department readmission after an acute care hospital discharge among geriatric inpatients, and 2) to determine whether BGA could be used as a prognostic tool for unplanned emergency department readmission.

Methods

A total of 312 older patients (mean age, 84.6 ± 5.4 years; 64.1% female) hospitalized in acute care wards after an emergency department visit were recruited in this observational prospective cohort study and separated into 2 groups based on the occurrence or not of an unplanned emergency department readmission during a 12-month follow-up period after their hospital discharge. A 6-item BGA was performed at emergency department admission before the discharge to acute care wards. Information on incident unplanned emergency department readmission was prospectively collected by phone call and by consulting the hospital registry. Several combinations of items of BGA identifying three levels of risk of unplanned emergency department readmission (i.e., low risk, intermediate risk and high risk) were examined.

Results

The unplanned emergency department readmission was more frequently associated with a temporal disorientation (P=0.004). Area under receiver operating characteristic curves of unplanned emergency department readmission based on BGA items and their combinations ranged from 0.53 to 0.61. The best predictor of unplanned emergency department readmission was the temporal disorientation (hazard ratio>1.65, P<0.035), which defined the high-risk group. Inpatients classified in high-risk group of unplanned emergency department readmission were more frequently readmitted to emergency department than those in intermediate- and low-risk groups (P log Rank <0.004). Prognostic values for unplanned emergency department readmission of items and their combinations were poor with sensitivity below 67%, specificity ranging from 36.4 to 53.7, and positive likelihood ratio below 1.4.

Conclusions

The items of BGA and their combinations were significant risk factors for unplanned emergency department readmission, but their prognostic value was poor.

     

Derivation and Validation of a Model to Predict 30-Day Readmission in Surgical Patients Discharged to Skilled Nursing Facility

ObjectivesTo identify factors associated with 30-day all-cause readmission rates in surgical patients discharged to skilled nursing facilities (SNFs), and derive and validate a risk score.DesignRetrospective cohort.Setting and participantsPatients admitted to 1 tertiary hospital's surgical services between January 1, 2011, and December 31, 2014 and subsequently discharged to 110 SNFs within a 25-mile radius of the hospital. The first 2 years were used for the derivation set and the last 2 for validation.MethodsData were collected on 30-day all cause readmissions, patient demographics, procedure and surgical service, comorbidities, laboratory tests, and prior health care utilization. Multivariate regression was used to identify risk factors for readmission.ResultsDuring the study period, 2405 surgical patients were discharged to 110 SNFs, and 519 (21.6%) of these patients experienced readmission within 30 days. In a multivariable regression model, hospital length of stay [odds ratio (OR) per day: 1.03, 95% confidence interval (CI) 1.02-1.04], number of hospitalizations in past year (OR 1.24 per hospitalization, 95% CI 1.18-1.31), nonelective surgery (OR 1.33, 95% CI 1.18-1.65), low-risk service (orthopedic/spine service) (OR 0.32, 95% CI 0.25-0.42), and intermediate-risk service (cardiothoracic surgery/urology/gynecology/ear, nose, throat) (OR 0.69, 95% CI 0.53-0.88) were associated with all-cause readmissions. The model had a C index of 0.71 in the validation set. Using the following risk score [0.8 × (hospital length of stay) + 7 × (number of hospitalizations in past year) +10 for nonelective surgery, +36 for high-risk surgery, and +20 for intermediate-risk surgery], a score of >40 identified patients at high risk of 30-day readmission (35.8% vs 12.6%, P < .001).Conclusions/ImplicationsAmong surgical patients discharged to an SNF, a simple risk score with 4 parameters can accurately predict the risk of 30-day readmission.     

The impact of postdischarge telephonic follow-up on hospital readmissions

Abstract Recurrent hospitalizations are responsible for considerable health care spending, although prior studies have shown that a substantial proportion of readmissions are preventable through effective discharge planning and patient follow-up after the initial hospital visit. This retrospective cohort study was undertaken to determine whether telephonic outreach to ensure patient understanding of and adherence to discharge orders following a hospitalization is effective at reducing hospital readmissions within 30 days after discharge. Claims data were analyzed from 30,272 members of a commercial health plan who were discharged from a hospital in 2008 to determine the impact of telephonic intervention on the reduction of 30-day readmissions. Members who received a telephone call within 14 days of discharge and were not readmitted prior to that call comprised the intervention group; all other members formed the comparison group. Multiple logistic regression was used to determine the impact of the intervention on 30-day readmissions, after adjusting for covariates. Results demonstrated that older age, male sex, and increased initial hospitalization length of stay were associated with an increased likelihood of readmission (P < 0.001). Receipt of a discharge call was associated with reduced rates of readmission; intervention group members were 23.1% less likely than the comparison group to be readmitted within 30 days of hospital discharge (P = 0.043). These findings indicate that timely discharge follow-up by telephone to supplement standard care is effective at reducing near-term hospital readmissions and, thus, provides a means of reducing costs for health plans and their members.     

Risk of Readmission After Discharge From Skilled Nursing Facilities Following Heart Failure Hospitalization: A Retrospective Cohort Study

Objective

Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less.

Readmissions to hospital: the contribution of morbidity data to the evaluation of asthma management

Abstract: We evaluated hospital readmission as an indicator of the quality of management of asthma patients, between July 1989 and June 1990. Using hospital separation data, we constructed a matched data set to identify early (within two weeks of discharge) readmissions. Of over 14 000 admissions for asthma in the 1-to-44-year age group, 2.8 per cent were classified as early readmissions. Admissions and readmissions were more common in rural than metropolitan areas. Admissions were most common during autumn, but early readmissions occurred most often during spring. Patients staving more than one day were 0.5 times (95 per cent confidence interval (CI) 0.37 to 0.68) as likely to have an early readmission than patients staving less than one day. Using the same data set, we identified patients who had the potential for readmission within a six-month period. Of the 5052 patients, 17.8 per cent were readmitted at least once during the period; 3.7 per cent had at least one early readmission, and 15.8 per cent had at least one late readmission (more than two weeks following discharge). A length of stay of more than one day was associated with 0.41 times (CI 0.24 to 0.70) the risk of early readmission in this cohort A length of stay of more than one day was associated with a higher risk of late readmission (1.52, CI 1.09 to 2.12), which was less likely to occur in rural than metropolitan areas (0.45, CI 0.37 to 0.55). This study showed that hospital data can identify factors associated with readmission for asthma; such readmission may be an indicator of asthma morbidity and/or management in the population.     

Appropriateness of admissions and discharges among readmitted patients.

This study examined the relationships between appropriateness of readmission within two weeks of discharge and appropriateness of previous admission and discharge, bed section, type of readmission, and patient demographic, medical condition, and hospital stay characteristics. Using the Department of Veterans Affairs (VA) Patient Treatment File and medical records, 445 readmissions to a highly affiliated midwestern VA Medical Center in fiscal year 1984 were examined. Appropriateness was determined by four trained medical record abstractors using InterQual admission and discharge standards. Type of readmission was based on a pilot-tested flowchart. Appropriateness of readmission was significantly associated with that of the previous admission and discharge, with the relationship varying by admission, discharge, and readmission bed sections. Reasons for inappropriate admissions, discharges, and readmissions also varied by bed section. For the majority of inappropriate readmissions, there was clear written evidence in the medical record during the previous hospital stay that the patient was directed to return for readmission. Inappropriate readmissions were more likely than appropriate readmissions to have a primary diagnosis of neoplasm or digestive disorder. These results indicate the importance of examining both the operational efficiencies during the previous admission and the clinical criteria for admitting, discharging, and readmitting patients in assessing the appropriateness of readmissions.     

Early discharge of Alberta mothers post-delivery and the relationship to potentially preventable newborn readmissions

OBJECTIVE: To determine whether early maternal discharge increases newborn readmission rates. METHODS: Singleton vaginal deliveries weighing at least 2500 grams were extracted from April 1, 1997 to March 31, 2000 Alberta hospital abstracts and linked to records of birth. Potentially preventable readmissions were for dehydration, jaundice, feeding problems, inadequate weight gain, and social reasons. RESULTS: The most common reason for readmission is jaundice (74%). In order of importance, influencing factors were: length of gestation, Aboriginal treaty status, first live birth, delivering in region of residence, number of deliveries done in the hospital, newborn sex, maternal smoking, birthweight, previous abortions, and delivering in nearest hospital. Post-delivery length of stay was associated with readmissions in the first 6 days post discharge (25% greater in those < 27 hours compared to those > 48 hours) but not in the first 28 days post discharge. CONCLUSION: Early maternal discharge is a minor determinant of potentially preventable newborn readmissions.