Hospital Readmission In Older Adults Research Articles

Neighborhood matters for transitional care and heart failure hospital readmission in older adults

A retrospective correlational design with existing data was utilized to examine the relationship between early provider follow-up, nursing care coordination intensity, and 30-day hospital readmission in older adults with heart failure and determine if an interaction exists with neighborhood disadvantage. Forward logistic regression was conducted to determine which variables predicted early provider follow-up and readmission. Ordinary least squares regression, logistic regression, and bootstrap confidence intervals were used to test for mediation and moderation. A direct relationship between early provider follow-up and decreased readmission was identified, but no indirect relationship through care coordination intensity. Neighborhood disadvantage did not moderate the effect of provider follow-up on readmission. Early provider follow-up and care coordination intensity were related and moderated by neighborhood disadvantage, but not for those living in highly disadvantaged neighborhoods. Neighborhood disadvantage is a key factor that may negatively influence participation in transitional care interventions in the elderly heart failure population.

0780 Continuous Positive Airway Pressure Adherence and the Risk of 30-day Hospital Readmission in Older Adults with Obstructive Sleep Apnea and Cardiovascular Disease

Abstract Introduction Obstructive sleep apnea (OSA) negatively impacts outcomes among patients with pre-existing cardiovascular disease (CVD). Evidence suggests treating OSA can prevent additional cardiovascular events and health care utilization, but the benefits of continuous positive airway pressure (CPAP) are strongly related to adherence. We evaluated the effect of adherence to CPAP on 30-day hospital readmissions among Medicare beneficiaries with OSA and pre-existing CVD. Methods We conducted a retrospective study of a 5% sample of Medicare beneficiaries aged ≥ 65 years with pre-existing CVD who were newly diagnosed with OSA, initiated CPAP 2009-2013, maintained continuous Medicare coverage for 24 months post-CPAP initiation, and had at least one hospitalization. Monthly indicators of CPAP adherence (charges for machines, masks, or supplies) were summed over 25 months to create a CPAP adherence variable and then beneficiaries categorized as low, partial, or high adherers (i.e., <4, 4-12 and >12 CPAP charges, respectively).The primary outcome was the risk of 30-day readmission. Bivariate associations were assessed between CPAP adherence status, covariates, and potential confounders. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using logistic regression models, controlling for demographic factors, and pre-existing comorbidities. Statistical significance was assessed at p < 0.05. Results We identified 1,301 beneficiaries meeting study criteria. The mean age was 73±6 years, 87% were White (n=1,137), and 53% were male (n=684). In the 2-year period following CPAP initiation, the overall 30-day readmission rate was 10.2%. Beneficiaries who were readmitted were more likely to be male and with a higher comorbidity burden. In adjusted models and compared to patients with low CPAP use (<4 charges), those with partial use (4-12 charges) and high use (>12 charges) had a lower odds of 30-day readmission (OR = 0.82, 95% CI 0.53-1.23 and OR = 0.41, 95% CI 0.24-0.70). Conclusion In this nationally representative sample of older adults with CVD and comorbid OSA, higher CPAP use was associated with decreased odds of 30-day readmission, highlighting the importance of adherence in mitigating negative outcomes. Support (If Any) This work is supported by an investigator-initiated grant and a diversity supplement from the American Association of Sleep Medicine Foundation (Albrecht, PI).

Examining trajectories of hospital readmission in older adults hospitalised with hip fracture from residential aged care and the community.

To examine hospital service use trajectories of older adults who were hospitalised for hip fracture and living in a residential aged care facility (RACF) or the community, and to identify factors predictive of trajectory group membership. These findings may inform future programmes aimed at reducing unexpected hospitalisations and subsequently reduce health care costs. A group-based trajectory analysis of hospitalisations was conducted for adults aged ≥ 65years hospitalised for hip fracture during 2008-2009 in New South Wales, Australia. Linked hospitalisation and RACF data were examined for a 5-year period. Group-based trajectory models were derived for RACF and community-dwelling older adults based on the number of subsequent hospital admissions following the index hip fracture. Multinomial logistic regression examined predictors of trajectory group membership for subsequent hospital admissions. There were 5752 hip fracture hospitalisations, with two-thirds of hip fractures occurring in community-dwellers. Key predictors of trajectory group membership for both RACF residents and community-dwellers were age group, sex, hospital length of stay and cognitive impairment. Assistance with activities of daily living and complex health care needs were also predictive of group membership in RACF residents. Location of residence and time to move to a RACF were additional predictors of group membership for community-dwellers. Health service use trajectories differed for RACF residents and community-dwellers; however, there were similar patient characteristics that defined trajectory group membership. Low users of hospital services living in RACFs or the community included older adults with generally unfavourable health conditions, potentially indicating that palliative care or advanced care directives and community-care initiatives, respectively, have played a part in the lowered frequency of rehospitalisation.

Risk factors for hospital readmission in older adults within 30\u2009days of discharge \u2013 a comparative retrospective study

BackgroundThe area of hospital readmission in older adults within 30 days of discharge is extensively researched but few studies look at the whole process. In this study we investigated risk factors related, not only to patient characteristics prior to and events during initial hospitalisation, but also to the processes of discharge, transition of care and follow-up. We aimed to identify patients at most risk of being readmitted as well as processes in greatest need of improvement, the goal being to find tools to help reduce early readmissions in this population.MethodsThis comparative retrospective study included 720 patients in total. Medical records were reviewed and variables concerning patient characteristics prior to and events during initial hospital stay, as well as those related to the processes of discharge, transition of care and follow-up, were collected in a standardised manner. Either a Student’s t-test, χ2-test or Fishers’ exact test was used for comparisons between groups. A multiple logistic regression analysis was conducted to identify variables associated with readmission.ResultsThe final model showed increased odds of readmission in patients with a higher Charlson Co-morbidity Index (OR 1.12, p-value 0.002), excessive polypharmacy (OR 1.66, p-value 0.007) and living in the community with home care (OR 1.61, p-value 0.025). The odds of being readmitted within 30 days increased if the length of stay was 5 days or longer (OR 1.72, p-value 0.005) as well as if being discharged on a Friday (OR 1.88, p-value 0.003) or from a surgical unit (OR 2.09, p-value 0.001).ConclusionPatients of poor health, using 10 medications or more regularly and living in the community with home care, are at greater risk of being readmitted to hospital within 30 days of discharge. Readmissions occur more often after being discharged on a Friday or from a surgical unit. Our findings indicate patients at most risk of being readmitted as well as discharging routines in most need of improvement thus laying the ground for further studies as well as targeted actions to take in order to reduce hospital readmissions within 30 days in this population.

Importance of previous hospital stays on the risk of hospital re-admission in older adults: a real-life analysis of the PAERPA study population

consideration of the first hospital re-admission only and failure to take account of previous hospital stays, which are the two significant limitations when studying risk factors for hospital re-admission. The objective of the study was to use appropriate statistical models to analyse the impact of previous hospital stays on the risk of hospital re-admission among older patients. an exhaustive analysis of hospital discharge and health insurance data for a cohort of patients participating in the PAERPA ('Care Pathways for Elderly People at Risk of Loss of Personal Independence') project in the Hauts de France region of France. All patients aged 75 or over were included. All data on hospital re-admissions via the emergency department were extracted. The risk of unplanned hospital re-admission was estimated by applying a semiparametric frailty model, the risk of death by applying a time-dependent semiparametric Cox regression model. a total of 24,500 patients (median [interquartile range] age: 81 [77-85]) were included between 1 January 2015 and 31 December 2017. In a multivariate analysis, the relative risk (95% confidence interval [CI]) of hospital re-admission rose progressively from 1.8 (1.7-1.9) after one previous hospital stay to 3.0 (2.6-3.5) after five previous hospital stays. The relative risk [95%CI] of death rose slowly from 1.1 (1.07-1.11) after one previous hospital stay to 1.3 (1.1-1.5) after five previous hospital stays. analyses of the risk of hospital re-admission in older adults must take account of the number of previous hospital stays. The risk of death should also be analysed.

Association of Mineralocorticoid Receptor Antagonist Use With All-Cause Mortality and Hospital Readmission in Older Adults With Acute Decompensated Heart Failure

Scarce data are available on the association of mineralocorticoid receptor antagonist (MRA) use with outcomes in acute decompensated heart failure (ADHF). To investigate the association of MRA use with all-cause mortality and hospital readmission in patients with ADHF. This cohort study examines participants enrolled in the Kyoto Congestive Heart Failure (KCHF) registry, a physician-initiated, prospective, multicenter cohort study of consecutive patients admitted for ADHF, between October 1, 2014, and March 31, 2016, into 1 of 19 secondary and tertiary hospitals throughout Japan. To balance the baseline characteristics associated with the selection of MRA use, a propensity score-matched cohort design was used, yielding 2068 patients. Data analysis was conducted from April to August 2018. Prescription of MRA at discharge from the index hospitalization. Composite of all-cause death or heart failure hospitalization after discharge. Among 3717 patients hospitalized for ADHF, 1678 patients (45.1%) had received MRA at discharge and 2039 (54.9%) did not. After propensity score matching, 2068 patients (with a median [interquartile range] age of 80 [72-86] years, and of whom 937 [45.3%] were women) were included. In the matched cohort (n = 1034 in each group), the cumulative 1-year incidence of the primary outcome was statistically significantly lower in the MRA use group than in the no MRA use group (28.4% vs 33.9%; hazard ratio [HR], 0.81; 95% CI, 0.70-0.93; P = .003). Of the components of the primary outcome, the cumulative 1-year incidence of heart failure hospitalization was significantly lower in the MRA use group than in the no MRA use group (18.7% vs 24.8%; HR, 0.70; 95% CI, 0.60-0.86; P < .001), whereas no difference in mortality was found between the 2 groups (15.6% vs 15.8%; HR, 0.98; 95% CI, 0.82-1.18; P = .85). No difference in all-cause hospitalization was observed between the 2 groups (35.3% vs 38.2%; HR, 0.88; 95% CI, 0.77-1.01; P = .07). In additional analyses that stratified by left ventricular ejection fraction, the association of MRA use with the primary outcome was statistically significant in patients with left ventricular ejection fraction of 40% or greater. Use of MRA at discharge from ADHF hospitalization did not appear to be associated with lower mortality but was associated with a lower risk of heart failure readmission. This finding suggests that MRA treatment at discharge may have minimal, if any, clinical advantages.

Medication-Related Factors and Hospital Readmission in Older Adults with Chronic Kidney Disease.

This study aimed to examine the association between medication-related factors and risk of hospital readmission in older patients with chronic kidney disease (CKD). A retrospective analysis was conducted targeting older CKD (n = 204) patients admitted to an Australian hospital. Medication appropriateness (Medication Appropriateness Index; MAI), medication regimen complexity (number of medications and Medication Regimen Complexity Index; MRCI) and use of selected medication classes were exposure variables. Outcomes were occurrence of readmission within 30 and 90 days, and time to readmission within 90 days. Logistic and Cox hazards regression were used to identify factors associated with readmission. Overall, 50 patients (24%) were readmitted within 30 days, while 81 (40%) were readmitted within 90 days. Mean time to readmission within 90 days was 66 (SD 34) days. Medication appropriateness and regimen complexity were not independently associated with 30- or 90-day hospital readmissions in older adults with CKD, whereas use of renin-angiotensin blockers was associated with reduced occurrence of 30-day (adjusted OR 0.39; 95% CI 0.19–0.79) and 90-day readmissions (adjusted OR 0.45; 95% CI 0.24–0.84) and longer time to readmission within 90 days (adjusted HR 0.52; 95% CI 0.33–0.83). This finding highlights the importance of considering the potential benefits of individual medications during medication review in older CKD patients.

Medication Regimen Complexity and Hospital Readmission in Older Adults With Chronic Kidney Disease

Chronic kidney disease (CKD) is characterized by high rates of hospital admissions and readmissions. However, there is a scarcity of research into medication-related factors predicting such outcomes in this patient group. To evaluate the effect of medication regimen complexity at hospital discharge on subsequent readmissions and their timing in older adults with CKD. This was a 12-month retrospective cohort study of 204 older (⩾65 years) CKD patients in an Australian tertiary care hospital. Medication regimen complexity was quantified using the 65-item medication regimen complexity index (MRCI). The outcomes were the occurrence of readmission in 30 days and time to readmission within 12 months. Logistic regression was used to identify factors predicting 30-day readmission, and a competing risks proportional subdistribution hazard model, accounting for deaths, was used for factors predicting time to readmission. Overall, 50 (24%) patients, predominantly men (72%), were readmitted within 30 days of follow-up. MRCI was not significantly associated with 30-day readmission (odds ratio [OR] = 1.27; 95% CI = 0.94-1.73). The median (interquartile range) time to readmission within 12 months was 145 (31-365) days. On a multivariate analysis, a 10-unit increase in MRCI was associated with a shorter time to readmission within 12 months (subdistribution HR = 1.18; 95% CI = 1.01-1.36). Conclusion and Relevance: Medication regimen complexity was not significantly associated with 30-day readmission; however, it was associated with a significantly shorter time to 12-month readmission in older CKD patients. This finding highlights the importance of medication regimen complexity as a potential target for medical interventions to reduce readmission risks.

A comparative study of social capital and hospital readmission in older adults

Numerous factors contribute to hospital readmissions of older adults. The role social capital may play in preventing hospital readmissions is unknown. The aim of this descriptive, cross-sectional study was to determine if levels of personal social capital differ in two groups of patients aged 65 and older, those readmitted to the hospital within 30 days of discharge and those not readmitted. Participants in this study (N = 106) were community-dwelling older adults discharged from 11 hospitals in the Midwestern United States. The Personal Social Capital Scale and a demographic questionnaire were mailed to eligible participants for completion. Multivariate Analysis of Variance (MANOVA) was computed to examine the differences in the dependent variables of bonding and bridging social capital between those patients readmitted within 30 days and those not readmitted within 30 days. No significant differences between the two groups' mean levels of bonding or bridging social capital were identified.

Patient and health system factors associated with hospital readmission in older adults without cognitive impairment.

To study the factors associated with hospital readmission. Data used in this study came from a population-based survey of older adults without cognitive impairment. Cox regression was used to assess the factors associated with readmission within a 2-year follow-up period. According to Andersen's model of healthcare seeking behavior, study variables considered included predisposing, enabling and need factors at the individual and health system levels. Of the 433 participants with an index hospitalization, 97% were discharged with a physical and 3% with a psychiatric disorder. During follow-up, 29% (128/433) were readmitted with a median time to readmission reaching 83 days. The risk of readmission was associated with the following: age, marital status, attraction index of the region of residence for psychiatric services, the presence of an anxio-depressive and other mental disorder, as well as a disorder of the musculoskeletal system. The presence of a physical and psychiatric comorbidity was also associated with readmission. Post-discharge follow-up of vulnerable populations with a history of mental disorders and improved availability of psychiatric services in the community are associated with a reduced risk of readmission.

Identifying Cognitive Impairment in Hospitalized Older Adults to Prevent Readmission: Two Case Studies

ABSTRACTObjective: To describe two patient outcomes post-discharge from an acute hospital admission. Both patients underwent cognitive testing during hospitalization.Methods: A battery of cognitive tests was administered to two hospitalized older adult patients. Both patients were evaluated in their homes within 72 hours of discharge and again at 14- and 30-days by a nurse practitioner.Results: One of the patients was readmitted within 30 days of hospital discharge due to complications from an amputation. This patient did not perform well on cognitive measures which may have been related to his pain levels and/or his medication regimen.Conclusions: Not all readmissions are avoidable; however, if readmissions are related to cognitive impairment, implementing strategies tailored to this population may reduce readmission rates.Clinical Implications: Risk factors for readmission should be identified so the discharge team can develop a tailored plan of care. Including both the patient and an informal caregiver may reduce the chance of a hospital readmission in older adults with cognitive impairment regardless of the etiology.

Geriatric assessment as predictors of hospital readmission in older adults with cancer.

Hospital readmission is a common, costly problem. Little is known regarding risk factors for readmission in older adults with cancer. This study aims to identify factors associated with 30-day readmission in a cohort of older medical oncology patients. Adults age 65 and over hospitalized to an Oncology Acute Care for Elders Unit at Barnes-Jewish Hospital. Standard geriatric screening tests were administered in routine clinical care. Clinical data and 30-day readmission status were obtained through medical record review. 677 patients met the inclusion criteria. 77% were white and 53% were male. Thoracic (32%), hematologic (20%), and gastrointestinal (18%) malignancies were most common. The 30-day unplanned readmission rate was 35.2%. Multivariable analyses identified complete dependence in feeding (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.29-10.65), and some dependence (1.58, 1.04-2.41) and complete dependence (2.64, 1.70-4.12) in housekeeping, prior to admission, as associated with higher odds of readmission. Age<75 (1.49, 1.04-2.14), African-American race (1.59, 1.06-2.39), potentially inappropriate medications (1.36, 0.94-1.99), and higher-risk reasons for index admission (1.93, 1.34-2.78) also increased odds of readmission. These factors were organized into a prognostic index. Hospital readmission was common and higher than previously reported rates in general medical populations. We identified several previously unrecognized factors associated with increased risk for readmission, including some geriatric assessment parameters, and developed a practical tool that can be used by clinicians to assess risk of 30-day readmission.

Depressive Symptoms and Hospital Readmission in Older Adults

To quantify the risk of 30-day unplanned hospital readmission in adults aged 65 and older with depressive symptoms. Prospective cohort study. University of Maryland Medical Center. Individuals aged 65 and older admitted between July 1, 2011, and August 9, 2012, to the general medical and surgical units and followed for 31 days after hospital discharge (N = 750). Primary exposure was depressive symptoms at admission, defined as a score of 6 or more on the 15-item Geriatric Depression Scale. Primary outcome was unplanned 30-day hospital readmission, defined as an unscheduled overnight stay at any inpatient facility not occurring in the emergency department. Prevalence of depressive symptoms was 19% and incidence of 30-day unplanned hospital readmission was 19%. Depressive symptoms were not significantly associated with hospital readmission (relative risk (RR) = 1.20, 95% confidence interval (CI) = 0.83-1.72). Age, Charlson Comorbidity Index score, and number of hospitalizations within the past 6 months were significant predictors of unplanned 30-day hospital readmission. Although not associated with hospital readmission, depressive symptoms were associated with other poor outcomes and may be underdiagnosed in hospitalized older adults. Hospitals interested in reducing readmission should focus on older adults with more comorbid illness and recent hospitalizations.

Comparison of three screening tools to predict hospital readmission in older adults

Comparison of three screening tools to predict hospital readmission in older adults

Elective Surgery for Diverticulitis is Associated with High Risk of Intestinal Diversion and Hospital Readmission in Older Adults

PurposeThis study seeks to compare outcomes (in-hospital mortality, colostomy rates, and 30-day readmission rates) in older adult patients undergoing emergency/urgent versus elective surgery for diverticulitis. MethodsData were derived from the 100% Medicare Provider Analysis and Review (MEDPAR) inpatient file from 2004–2007. All patients 65 years of age and above with a primary diagnosis of diverticulitis that underwent left colon resection, colostomy, or ileostomy were included. The primary outcome variable was in-hospital mortality. Secondary outcome variables included intestinal diversion, 30-day post-discharge readmission rates, discharge destination, length of stay, and total charges. Patients were grouped in two categories for comparison: emergent/urgent (EU) versus elective surgery, as defined by admission type. Multivariate analysis was performed adjusting for age (categorized by five groups), gender, race, and medical comorbidity as measured by Charlson Index. ResultsFifty-three thousand three hundred sixteen individuals were eligible for inclusion, with 23,764 (44.6%) in the elective group. On average, EU patients were older (76.8 vs. 73.9 years of age, p < 0.001) and less likely to be female (65.4% vs. 71.1%, p < 0.001). EU patients had higher in-hospital mortality (8.0% vs. 1.4%, p < 0.001), higher intestinal diversion rates (64.2% vs. 12.7%, p < 0.001), and higher 30-day readmission rates (21.4% vs. 11.9%, p < 0.001) and the worse outcomes persisted even after adjustment for risk factors. Unadjusted and adjusted mortality rates dramatically increased by age, although the affect of age on mortality was more pronounced in the elective group where mortality rates ranged from 0.56% in patients 65–69 years old to 6.5% in patients 85+ years old. The rates of ostomy and 30-day readmission generally increased with age, with worse outcomes noted particularly in the elective group. ConclusionsAs expected, older adults undergoing emergent/urgent surgical treatment for diverticulitis have significantly increased risks of poor outcomes compared with elective patients. While advancing age is associated with a substantial increase in mortality, intestinal diversion and 30-day readmission after surgery for diverticulitis, this affect is especially evident among patients undergoing elective colectomy. Our data suggest that given the considerable risk of prophylactic colon resection in elderly patients with sigmoid diverticulitis, a reappraisal of the proper role of elective colectomy in this population may be warranted.

424 Elective Surgery for Diverticulitis is Associated With High Risk of Intestinal Diversion and Hospital Readmission in Older Adults

424 Elective Surgery for Diverticulitis is Associated With High Risk of Intestinal Diversion and Hospital Readmission in Older Adults