Hospital readmission for older patients often for different illness

(Press-News.org) CHICAGO – Among approximately 3 million Medicare patients hospitalized for heart failure, heart attack, or pneumonia, readmissions were frequent throughout the 30 days following the hospitalization, and resulted from a wide variety of diagnoses that often differed from the cause of the index hospitalization, according to a study appearing in the January 23/30 issue of JAMA.

"Hospital readmissions are common and can be a marker of poor health care quality and efficiency. To lower readmission rates, the Centers for Medicare & Medicaid Services (CMS) began publicly reporting 30-day risk-standardized readmission rates for heart failure (HF), acute myocardial infarction [MI; heart attack], and pneumonia after these measures were endorsed by the National Quality Forum. These measures are part of a federal strategy to provide incentives to improve quality of care by reducing preventable readmissions. Critical to the development of effective programs to reduce readmission is an understanding of the diagnoses and timing associated with these events," according to background information in the article. "Insights into the diversity and variation of readmission diagnoses can illustrate the potential benefits of general vs. disease-specific interventions in reducing the overall number of readmissions."

Kumar Dharmarajan, M.D., M.B.A., of Columbia University Medical Center, New York, and colleagues analyzed 2007-2009 Medicare fee-for-service claims data to examine readmission diagnoses and timing among Medicare beneficiaries readmitted within 30 days after hospitalization for HF, heart attack, or pneumonia, conditions that are primarily responsible for almost 15 percent of hospitalizations in older persons, and are the focus of current public reporting efforts.

During the time period analyzed, the researchers identified 329,308 30-day readmissions after 1,330,157 hospitalizations for HF (24.8 percent readmitted), 108,992 30-day readmissions after 548,834 hospitalizations for acute MI (19.9 percent readmitted), and 214,239 30-day readmissions after 1,168,624 hospitalizations for pneumonia (18.3 percent readmitted). Following hospitalization for HF and acute MI, readmission was most often due to HF (35.2 percent and 19.3 percent of readmissions, respectively). Following hospitalizations for pneumonia, readmission was most likely for recurrent pneumonia (22.4 percent).

"Of all 30-day readmissions, we found that 61.0 percent of the HF, 67.6 percent of the acute MI, and 62.6 percent of the pneumonia cohorts occurred during days 0 through 15 following discharge. More than 30 percent of 30-day readmissions occurred during days 16 through 30 for all 3 cohorts," the authors write.

Median (midpoint) times to readmission were 12 days for patients initially hospitalized with HF, 10 days for patients initially hospitalized with acute MI, and 12 days for patients initially hospitalized with pneumonia. Neither readmission diagnoses nor timing substantively varied by age, sex, or race.

"The diagnoses associated with 30-day readmission are diverse and are not associated with patient demographic characteristics or time after discharge for older patients initially hospitalized with HF, acute MI, or pneumonia. Although a high percentage of 30-day readmissions occurred relatively soon after hospitalization, readmissions remained frequent during days 16 through 30 after discharge regardless of patient age, sex, or race. This heightened vulnerability of recently hospitalized patients to a broad spectrum of conditions throughout the postdischarge period favors a generalized approach to preventing readmissions that is broadly applicable across potential readmission diagnoses and effective for at least the full month after hospitalization. Strategies that are specific to particular diseases or periods may only address a fraction of patients at risk for rehospitalization," the authors write.

(JAMA. 2013;309(4):355-363; Available pre-embargo to the media at http://media.jamanetwork.com)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

There will also be a digital news release available for this study, including the JAMA Report video, embedded and downloadable video, audio files, text, documents, and related links. This content will be available at 3 p.m. CT Tuesday, January 22 at this link.

### To contact corresponding author Harlan M. Krumholz, M.D., S.M., call Karen Peart at 203-432-1326 or email karen.peart@yale.edu.