Abstract
BackgroundWhen older adult patients with hip fracture (HFx) have unplanned hospital readmissions within 30 days of discharge, it doubles their 1-year mortality, resulting in substantial personal and financial burdens. Although such unplanned readmissions are predominantly caused by reasons not related to HFx surgery, few studies have focused on how pre-existing high-risk comorbidities co-occur within and across subgroups of patients with HFx.ObjectiveThis study aims to use a combination of supervised and unsupervised visual analytical methods to (1) obtain an integrated understanding of comorbidity risk, comorbidity co-occurrence, and patient subgroups, and (2) enable a team of clinical and methodological stakeholders to infer the processes that precipitate unplanned hospital readmission, with the goal of designing targeted interventions.MethodsWe extracted a training data set consisting of 16,886 patients (8443 readmitted patients with HFx and 8443 matched controls) and a replication data set consisting of 16,222 patients (8111 readmitted patients with HFx and 8111 matched controls) from the 2010 and 2009 Medicare database, respectively. The analyses consisted of a supervised combinatorial analysis to identify and replicate combinations of comorbidities that conferred significant risk for readmission, an unsupervised bipartite network analysis to identify and replicate how high-risk comorbidity combinations co-occur across readmitted patients with HFx, and an integrated visualization and analysis of comorbidity risk, comorbidity co-occurrence, and patient subgroups to enable clinician stakeholders to infer the processes that precipitate readmission in patient subgroups and to propose targeted interventions.ResultsThe analyses helped to identify (1) 11 comorbidity combinations that conferred significantly higher risk (ranging from P<.001 to P=.01) for a 30-day readmission, (2) 7 biclusters of patients and comorbidities with a significant bicluster modularity (P<.001; Medicare=0.440; random mean 0.383 [0.002]), indicating strong heterogeneity in the comorbidity profiles of readmitted patients, and (3) inter- and intracluster risk associations, which enabled clinician stakeholders to infer the processes involved in the exacerbation of specific combinations of comorbidities leading to readmission in patient subgroups.ConclusionsThe integrated analysis of risk, co-occurrence, and patient subgroups enabled the inference of processes that precipitate readmission, leading to a comorbidity exacerbation risk model for readmission after HFx. These results have direct implications for (1) the management of comorbidities targeted at high-risk subgroups of patients with the goal of pre-emptively reducing their risk of readmission and (2) the development of more accurate risk prediction models that incorporate information about patient subgroups.
Highlights
Background it is well known that hip fractures (HFx) in older adults are a leading cause of morbidity, long-term functional impairment, and mortality [1], these outcomes are exacerbated when such patients are readmitted to the hospital within 30 days of hospital discharge after surgery, in addition to doubling their risk of 1-year mortality [2].While many readmissions are unavoidable, unplanned hospital readmissions can negate the functional gains painstakingly achieved through weeks of post–acute rehabilitation and can increase the risk of infections acquired during hospital stays [3]
The integrated analysis of risk, co-occurrence, and patient subgroups enabled the inference of processes that precipitate readmission, leading to a comorbidity exacerbation risk model for readmission after hip fracture Hospital Readmissions Reduction Program (HRRP) (HFx)
It is well known that hip fractures (HFx) in older adults are a leading cause of morbidity, long-term functional impairment, and mortality [1], these outcomes are exacerbated when such patients are readmitted to the hospital within 30 days of hospital discharge after surgery, in addition to doubling their risk of 1-year mortality [2]
Summary
While many readmissions are unavoidable, unplanned hospital readmissions can negate the functional gains painstakingly achieved through weeks of post–acute rehabilitation and can increase the risk of infections acquired during hospital stays [3] This loss is over and above the costs to caregivers and relatives who have to relive the stress of the original HFx episode, reorganize their work schedules to care for the patient, resulting in loss of productivity, and restart rehabilitation after discharge [3]. The CMS instituted the Hospital Readmissions Reduction Program (HRRP) [6], which has imparted penalties on hospitals if their 30-day readmission rates exceeded the national average Such incentives initially appeared to improve the readmission rates in US hospitals [7], recent reports argue that the start of the HRRP coincided with an increase in mortality among older adults [6,8]. Such unplanned readmissions are predominantly caused by reasons not related to HFx surgery, few studies have focused on how pre-existing high-risk comorbidities co-occur within and across subgroups of patients with HFx
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