Reduce Hospital Readmission Rates Research Articles

Management of Heart Failure in a Rural Community.

In rural Western New York, hospitalizations of patients over 65 years of age with heart failure (HF) exceed state and national levels, demonstrating a need for improved management of older adult HF patients in rural communities. The aim of this project was to implement an evidence-based practice (EBP) guideline for HF management at a certified home health agency (CHHA). The objective was to increase CHHA interdisciplinary staff knowledge and to implement an EBP HF guideline to improve care and reduce hospital readmission rates. This quality improvement project used a quantitative descriptive study design, with a convenience sample of 60 CHHA interdisciplinary staff. A series of four 30-minute educational sessions were provided to the staff regarding the EBP HF guideline. Data were collected using pre- and posteducation testing to assess knowledge. A 3-month evaluation was completed to assess implementation along with readmission data pre- and postimplementation. Of the 60 interdisciplinary staff who received the EBP HF guideline education, 17 participants completed both the pretest and posttest. Results demonstrated a statistically significant increase in knowledge from the pretest (Md = 60.00%) to the posttest (Md = 80.00%) (p = .001). In the 3-month follow-up survey, 66% of the staff reported using the EBP HF guideline on "most" or "all" older adult HF patients. The organization had a 4.32% reduction in all-cause 30-day rehospitalizations from 11.39% to 7.07% following the implementation of the EBP HF guideline.

Right TraC™ Post-Hospitalization Care Transitions Program to Reduce Readmissions for Hemodialysis Patients

Background: Hemodialysis (HD) patients have high hospitalization rates. This nonrandomized trial tested the effect of a bundle of renal-specific “Right TraC™” strategies on 30-day all-cause readmission rates and, secondarily, 90-day readmissions and overall admissions among HD patients. Methods: Twenty-six Fresenius clinics in West Virginia, Ohio, and Kentucky participated in the interventions. Eighteen matched clinics served as controls; intervention clinics also served as their own controls. We deployed the intervention in 3 incremental phases focused on patient information exchange, post-hospital follow-up, and telephonic case management. Thirty-day hospital readmissions per patient year (ppy) were calculated by dividing the total number of readmissions within 30 days of index admission by the total number of patient-years in baseline (2012) and remeasurement (2014) periods. We also compared readmission rates from 2010 to 2015. We used repeated measures Poisson regression to compare outcomes between groups and time periods. Results: From 2012 to 2014, 30-day all-cause readmissions ppy declined for Right TraC clinics (from 0.88 to 0.66 [p < 0.001]; for controls, from 0.73 to 0.61 [p = 0.16]). Difference in change between groups was nonsignificant (p = 0.26). Overall admissions ppy declined: for Right TraC clinics from 2.51 to 1.97 (p < 0.001); for controls from 2.14 to1.92 (p = 0.21); difference in change between groups was significant (p = 0.01). For 2010, 2011, and 2012, Right TraC clinic 30-day readmissions ppy were unchanged: 0.89, 1.00, 0.88 (p = 0.61 and p = 0.49); they declined to 0.66 (p < 0.001) in 2014 (intervention year); rose to 0.70 (p = 0.06) in 2015 (interventions discontinued). Conclusion: We conclude that Right TraC interventions may have been helpful in reducing hospital readmission rates.

Necessity is the mother of invention: an innovative hospitalist-resident initiative for improving quality and reducing readmissions from skilled nursing facilities

ABSTRACTBackground: Hospital readmissions have been a major challenge to the US health system. Medicare data shows that approximately 25% of Medicare skilled nursing facility (SNF) residents are readmitted back to the hospital within 30 days. Some of the major reasons for high readmission rates include fragmented information exchange during transitions of care and limited access to physicians round-the-clock in SNFs. These represent safety, quality, and health outcome concerns.Aim: The goal of the project was to reduce hospital readmission rates from SNFs by improving transition of care and increasing physician availability in SNFs (five to seven days a week physical presence with 24/7 accessibility by phone).Methods: We proposed a model whereby a hospitalist-led team, including the resident on the geriatrics rotation, followed patients discharged from the hospital to one SNF. Readmission rates pre- and post-implementation were compared.Study results: The period between January 2014 and June 2014 served as the baseline and showed readmission rate of 32.32% from the SNF back to the hospital. After we implemented the new hospitalist SNF model in June 2014, readmission rates decreased to 23.96% between July 2014 and December 2014. From January 2015 to June 2015, the overall readmission rate from the SNF reduced further to 16.06%. Statistical analysis revealed a post-intervention odds ratio of 0.403 (p < 0.001).Conclusion: The government is piloting several care models that incentivize value- based behavior. Our study strongly suggests that the hospitalist-resident continuity model of following patients to the SNFs can significantly decrease 30-days hospital readmission rates.

Effect of a Pediatric Prescription Medication Discharge Program on Reducing Hospital Readmission Rates.

To evaluate the pediatric prescription medication discharge delivery and counseling program, implemented at an 186-bed children's hospital integrated within a larger academic medical center, and its effectiveness on reducing hospital readmissions. This study was a retrospective chart review of existing data in the electronic medical record from patients <21 years of age who were discharged from our institution between September 1, 2014, and November 30, 2014. Patients who participated in the pediatric discharge program were compared to non-participants. The primary objective was to determine if the patient was readmitted within 30 days. Secondary objectives included time until readmission, diagnosis at discharge, and hospital unit at discharge. In total, 1804 patients were assessed. After exclusions, 932 subjects were included in the analysis. In total, 393 (42.2%) patients participated in the pediatric medication discharge and counseling program, and 539 did not participate. Of the patients who participated in the program, 52 were readmitted within 30 days (13.2%), compared with 67 patients (12.4%) who did not participate in the discharge program, p = 0.717. Patients with the diagnoses of malignancy and kidney injury were more likely to be readmitted within this time frame, and those with the diagnoses of heart defects or cardiology disorders and malignancy were more likely to participate in the pediatric prescription medication discharge program. Participation in the pediatric discharge medication delivery and counseling program did not reduce hospital readmission rate within 30 days.

Abstract 136: The Relationship of Changing Hospital Readmission Rates and Mortality Rates After Hospitalization for Heart Failure, Acute Myocardial Infarction, and Pneumonia

Background: It is unknown if financial pressures to reduce hospital readmission rates following passage of the Affordable Care Act (ACA) have had the unintended effect of increasing mortality rates after hospitalization. We therefore examined correlations between paired changes in hospital 30-day readmission rates and 30-day mortality rates among Medicare fee-for-service beneficiaries hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia from 2008 to 2014. Methods: We used linear regression to calculate monthly changes in hospitals’ 30-day risk-adjusted readmission rates (RARRs) and 30-day risk-adjusted mortality rates (RAMRs) after discharge for HF, AMI, and pneumonia from 2008 to 2014. Adjustment was made for patient age, sex, comorbidities, hospital length of stay, and season. We then examined the correlation of hospitals’ paired monthly changes in 30-day RARRs and monthly changes in 30-day RAMRs after discharge. Results: From 2008 to 2014, we identified 2,962,554, 1,229,939, and 2,544,530 hospitalizations for HF, AMI, and pneumonia at 5,016, 4,772, and 5,057 hospitals, respectively. Hospital 30-day RARRs declined for all three conditions from 2008 to 2014; the monthly change in RARRs was -0.053 (95% CI -0.055, -0.051) for HF, -0.044 (95% CI -0.047, -0.041) for AMI, and -0.033 (95% CI -0.035, -0.031) for pneumonia. In contrast, the monthly change in hospital 30-day RAMRs after discharge varied by admitting condition and was 0.008 (95% CI 0.007, 0.010) for HF, -0.003 (95% CI -0.006, -0.001) for AMI, and 0.001 (95% CI -0.001, 0.003) for pneumonia. The correlation between monthly changes in hospitals’ 30-day RARRs and 30-day RAMRs after discharge was 0.060 for HF (p&lt;0.001), 0.059 for AMI (p=0.003), and 0.106 for pneumonia (p&lt;0.001). Representative data showing the poor correlation in hospitals’ paired monthly changes in 30-day RARRs and 30-day RAMRs for AMI is shown in the Figure. Conclusion: Changes in hospital readmission rates for HF, AMI, and pneumonia were poorly correlated with changes in mortality rates after hospitalization between 2008 and 2014. These findings suggest that financial incentives to improve hospitals’ readmission performance have not increased mortality after hospitalization.

The effectiveness of cardiac rehabilitation on reducing hospital readmission rates among adult patients

The effectiveness of cardiac rehabilitation on reducing hospital readmission rates among adult patients

Effectiveness of nursing discharge planning interventions on health-related outcomes in discharged elderly inpatients: a systematic review.

Inadequate discharge planning for the growing elderly population poses significant challenges for health services. Effective discharge planning interventions have been examined in several studies, but little information is available on nursing's role or the specific components of these interventions. Despite the research published on the importance of discharge planning, the impact on patient's health outcomes still needs to be proven in practice. To determine the best available evidence on the effectiveness of discharge planning interventions involving at least one nurse on health-related outcomes for elderly inpatients discharged home and to assess the relative impact of individual components of discharge planning interventions. Elderly inpatients aged 65 years or older, discharged from acute care and post-acute care rehabilitation hospitals to home. The review focused on the six keys components of Naylor's Transitional Care Model: early geriatric assessment, discharge preparation, patient or caregiver's participation, continuity of care, day of discharge assessment and post-discharge follow-up. This review considered randomized and non-randomized controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies. The outcomes for this review were functional ability, symptoms management, adverse outcomes, unmet needs after discharge, coping with disease, health-related quality of life (QoL), satisfaction with care, readmission rate and healthcare utilization. A systematic search was undertaken across 13 databases to retrieve published and unpublished studies in English between 2000 and 2015. Critical appraisal was undertaken by two independent reviewers using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Quantitative data were extracted from included studies independently by the two reviewers using the standardized data extraction tool from JBI-MAStARI. Due to the wide range of outcome measures, a comprehensive meta-analysis for all studies was not possible. However, meta-analysis was conducted for specific outcome measures, such as readmission, length of stay and QoL. Thirteen studies met the inclusion criteria and were included in the review. Two out of the 13 studies were pilot studies and one had a pre-post design. Included studies involved a total of 3964 participants with a median age of 77 years. Nurse discharge planning did not significantly reduce hospital readmission rate (odds ratio [OR] = 0.73, 95% confidence intervals [CIs] = 0.53-1.01, P = 0.06). The overall effect score for length of stay was significant (weighted mean difference = 0.29, P < 0.01), suggesting that discharge planning increased the length of hospitalization. The effectiveness of discharge planning did not significantly impact QoL (mental OR = 0.37, P = 0.19 and physical OR = 0.47, P = 0.15). Findings of this review suggest that nursing discharge planning for elderly inpatients discharged home increases length of stay, yet neither reduces readmission rates nor improves QoL.

Interventions for Reducing Hospital Readmission Rates: The Role of Hospice and Palliative Care.

Despite evidence that enrollment with hospice services has the potential to reduce hospital readmission rates, previous research has not examined exactly how hospitals may promote the appropriate use of hospice and palliative care for their discharged patients. Therefore, we sought to explore the strategies used by hospitals to increase the use of hospice and palliative care for patients at risk of readmission. We conducted a secondary analysis of qualitative data from a study of hospitals that were participating in the State Action on Avoidable Readmissions (STAAR) initiative, a quality improvement collaborative. We used data attained from 46 in-depth interviews conducted during 10 hospital site visits using a standard discussion guide and protocol. We used a grounded theory approach using the constant comparative method to generate recurrent and unifying themes. We found that a positive effect for hospitals participating in the STAAR initiative was enhanced engagement in efforts to promote greater use of hospice and palliative care as a possible method of reducing unplanned readmissions, the central goal of the STAAR initiative. Hospital staff described strategies to increase the use of hospice and palliative care that included (1) designing and implementing tracking systems to identify patients most at risk of being readmitted, (2) providing education about hospice and palliative care to family, internal and external clinical groups, and (3) establishing closer links to posthospital settings. National efforts to reduce rehospitalizations may result in improved integration of hospice and palliative care for patients who are at risk of readmission.

Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community.

Hospital readmissions in older adult populations are an emerging quality indicator for acute care hospitals. Recent evidence has linked functional decline during and after hospitalization with an elevated risk of hospital readmission. However, models of care that have been developed to reduce hospital readmission rates do not adequately address functional deficits. Physical therapists, as experts in optimizing physical function, have a strong opportunity to contribute meaningfully to care transition models and demonstrate the value of physical therapy interventions in reducing readmissions. Thus, the purposes of this perspective article are: (1) to describe the need for physical therapist input during care transitions for older adults and (2) to outline strategies for expanding physical therapy participation in care transitions for older adults, with an overall goal of reducing avoidable 30-day hospital readmissions.

Early Hospital Readmission and Mortality Risk after Surgical Treatment of Proximal Humerus Fractures in a Community-Based Health Care Organization.

Surgical treatment for proximal humerus fractures has increased exponentially. Recent health care policies incentivize centers to reduce hospital readmission rates. Better understanding of risk factors for readmission and early mortality in this population will assist in identifying favorable risk-benefit patient profiles. To identify incidence and risk factors of 30-day hospital readmission rate and 1-year mortality rate after open surgery of proximal humerus fractures. Retrospective cohort analysis from Kaiser Permanente Southern California Region database. Using International Classification of Diseases, Ninth Revision, diagnosis and procedure codes, all operative proximal humerus fractures were validated. Hospital readmission, one-year mortality, and demographic and medical data were collected. A logistic regression test was performed to assess potential risk factors for outcomes. From 1387 surgical patients, the 30-day all-cause readmission rate was 5.6%. Forty percent of hospital read-missions were due to surgery-related reasons. Severe liver disease (odds ratio [OR], 3.48, 95% confidence interval [CI] = 1.42-8.55) and LACE (length of stay, acuity of admission, comorbidities, and number of Emergency Department visits in the previous 6 months) index score ≥ 10 (OR, 4.47, 95% CI = 2.54-7.86) were independent risk factors of readmission on multivariate analysis. The 1-year mortality rate was 4.86%. Multivariate analysis showed length of hospital stay (OR 1.11, 95% CI = 1.05-1.19), cancer (OR 3.38, 95% CI = 1.61-7.10), 30-day readmission (OR 3.31, 95% CI = 1.34-8.21), and Charlson comorbidity index greater than or equal to 4 (OR 13.94, 95% CI = 4.40-44.17) predicted higher mortality risk. After open treatment of proximal humerus fractures, there was a 5.6% all-cause 30-day hospital readmission rate. Surgical complications accounted for 40% of read-missions. Severe liver disease and LACE score correlated best with postoperative 30-day readmission risk. Length of hospital stay, preexisting cancer, 30-day readmission, and Charlson comorbidity index were predictive of 1-year mortality.

Remote monitoring in heart failure.

In the developed world, there has been a substantial increase over several decades in the prevalence of congestive heart failure (CHF), partly as a result of demographic changes. Overall, 1–2% of the adult population has CHF and this increases to ≥10% in the over 70s age group.1 However, hospitalization rates due to CHF are falling,2 and length of hospital stay and in-hospital mortality have also fallen.3 It could be argued that effective outpatient management of CHF through dedicated heart failure clinics, specialist nurses, and general practitioners has played a key role in these positive trends. However, given the significant patient morbidity and the inpatient costs associated with CHF, methods to reduce hospital readmission rates are imperative to alleviate an already overstretched system. Rahimi and colleagues4 present the development and assessment of an easy-to-use, android-based monitoring system to empower patients and reduce readmission rates in a cohort from the Seamless User-centred Proactive Provision Of Risk-stratified Treatment for Heart Failure (SUPPORT-HF) study. Patients were provided with internet-enabled tablets that were connected to commercially available sensors to record blood pressure, heart rate, and weight, and provide alerts to patients to see their doctor or healthcare provider when physiological parameters were perturbed. Although this particular self-management study focused primarily on patient uptake of monitoring … [↵][1]*Corresponding author. Tel: +44 1603 592376, Fax: +44 1603 593752, Email: m.frenneaux{at}uea.ac.uk [1]: #xref-corresp-1-1

Nurse-practitioner-run, Sub-acute Rehabilitation Program for Heart Failure Reduces Hospital Readmission Rates by Half

Nurse-practitioner-run, Sub-acute Rehabilitation Program for Heart Failure Reduces Hospital Readmission Rates by Half

Mobile Nurse Practitioner: A Pilot Program to Address Service Gaps Experienced by Homeless Individuals

An estimated 2.3 to 3.5 million individuals are homeless in the United States, many of whom have chronic medical and mental illnesses. Underserved individuals who are homeless experience gaps in services, resulting in poor health care outcomes and readmission to the hospital setting, often presenting in crisis through the emergency department. The financial state of hospitals is negatively impacted by the burden of patients returning to the hospital due to unresolved issues. The current article presents the role of a psychiatric-mental health nurse practitioner as part of a pilot program, Opportunity Village Mobile Health, that provides a comprehensive approach to meet the physical and mental health challenges of homeless individuals who are discharged from inpatient to outpatient services. Continuity of health care services are made available to this unique patient population to reduce hospital readmission rates and provide much needed transitional care.

Home Telemedicine in Heart Failure: A Pilot Study of Integrated Telemonitoring and Virtual Provider Appointments.

Congestive heart failure is a significant cause of hospitalization, rehospitalization, and death. Reducing hospital readmission rates is a national priority. Various telemonitoring devices and programs have been developed to help meet this goal. The Health Connect system incorporates monitoring of physiologic data with regular virtual provider appointments. The Health Connect system integrates traditional telemedicine with virtual provider appointments. Virtual appointments empower patients to advocate for their own health by providing numerous opportunities for education and feedback. In addition to early identification of impending decompensation, virtual appointments allow providers to address noncompliance, which is a major factor driving poor outcomes. Further research is required to confirm the benefit of the Health Connect system.

Effectiveness of nurse-led early discharge planning programmes for hospital inpatients with chronic disease or rehabilitation needs: a systematic review and meta-analysis.

To compare the effectiveness of nurse-led early discharge planning programmes to standard care for inpatients with chronic disease or rehabilitation needs. Nurse-directed early discharge planning could shorten inpatient stays and reduce medical costs; however, it is not known whether the development of discharge planning programmes is effective for inpatients with chronic disease nor how such programmes might be optimally organised. Systematic review and meta-analysis. The PubMed, MEDLINE, EMBASE, CINAHL and Cochrane Library were searched for randomized controlled trials assessing nurse-directed discharge planning for inpatients with chronic disease or rehabilitation needs. Two reviewers independently extracted data and assessed risk of bias. Meta-analyses were conducted for the eligible studies by RevMan 5.2.6. Data were pooled using a fixed-effect or random effects model. Where meta-analysis was not possible, narrative analysis was reported. Ten randomized controlled trials and 3438 participants were included. Meta-analysis demonstrated that, compared to standard care, early discharge planning programmes are effective in reducing hospital readmission rates, duration of inpatient readmissions and all-cause mortality. However, no reduction in the length of stay of the index admission was demonstrated. Narrative analysis suggested that discharge planning may reduce total and readmission costs, as well as improving patients' satisfaction and overall quality of life. Compared to standard care, nurse-led early discharge planning programmes have a positive impact on several aspects of care for inpatients with chronic disease and rehabilitation requirements, including reducing readmission, readmission length of stay and mortality and improving quality of life. These findings should be taken into account in future health service policy development. These findings are relevant to clinical and managerial staff in formulating and implementing discharge planning programmes for inpatients with chronic disease or rehabilitation needs.

Incentivizing cost-effective reductions in hospital readmission rates

The recent regulatory changes enacted by the Centers for Medicare and Medicaid Services (CMS) have identified hospital readmission rates as a critical healthcare quality metric. This research focuses on the utilization of pay-for-performance (P4P) mechanisms to cost effectively reduce hospital readmission rates and meet the regulatory standards set by CMS. Using the experimental economics laboratory we find that both of the P4P mechanisms researched, bonus and bundled payments, cost-effectively meet the performance criteria set forth by CMS. The bundled payment mechanism generates the largest reduction in patient length of stay (LOS) without altering the probability of readmission. Combined these results indicate that utilizing P4P mechanisms incentivizes cost effective reductions in hospital readmission rates.

Clinical practice of case management model in nursing care of patients with chronic kidney disease

Objective To explore the methods and effects of case management model in nursing care of patients with chronic kidney disease (CKD), so as to provide effective evidence for the model′s promotion in the clinic and provide the reference for specialist nursing development. Methods Base on consummated health education materials and fully preparation work, we chose experienced nurses, who were selected according to competence and trained as case managers, to take care of forty patients with CKD during January to June 2013 as experimental group. A total of forty CKD patients accepted routine nursing carein the January to June 2012 as control group. We compared the treatment compliance and renal function, other indicators measurement at discharge and 6 months after discharge, and hospital readmission rate between two groups within 6 months were measured and compared. Results After 6 months discharge, patients′ treatment compliance in the experimental group (46.5±3.8) was better than that of the control group (39.2±4.8) (t=-8.912; P 0.05). The readmission rate was 12.5% in the experimental group compared with 37.5% in the control group (Z=6.667, P<0.05). Conclusions Case management model can improve the patients′ treatment compliance, improve disease control, reduce hospital readmission rate, and is an effective nursing model to adapt development of the new period. Key words: Nursing care; Case management model; Chronic kidney disease

Impact of an integrated transition management program in primary care on hospital readmissions.

Poorly executed transitions in care from hospital to home are associated with increased vulnerability to adverse medication events and hospital readmissions, and also excess healthcare costs. Efforts to improve care coordination on hospital discharge have been shown to reduce hospital readmission rates but often rely on interventions that are not fully integrated within the primary care setting. The Patient Centered Medical Home (PCMH) model, whose core principles include care coordination in the posthospital setting, is an approach that addresses transitions in care in a more integrated fashion. We examined the impact of multicomponent transition management (TM) services on hospital readmission rates and time to hospital readmission among 118 patients enrolled in a TM program that is part of Care By Design, the University of Utah Community Clinics' version of the PCMH. We conducted a retrospective analysis comparing outcomes for patients before receiving TM services with outcomes for the same patients after receiving TM services. The all-cause 30-day hospital readmission rate decreased from 17.9% to 8.0%, and the mean time to hospital readmission within 180 days was delayed from 95 to 115 days. These findings support the effectiveness of TM activities integrated within the primary care setting.

Heart failure assessment at the community pharmacy level: A feasibility pilot study

A key element missing in disease-management programs for heart failure (HF) is participation of the community pharmacist. The purpose of this study is to determine if a simple and efficient clinical tool will allow community pharmacists to identify patients at risk for worsening HF. The One Minute Clinic for Heart Failure (TOM-C HF) was developed as a simple six-item symptom screening tool to be used during routine patient/customer interactions. Ten community pharmacies located in the upper Midwest. Self-identified HF patients. 121 unique patients were evaluated over a 12-month period. The application of this clinical tool took between 1 and 5 minutes in over 80% of the interactions. Seventy-five patients (62%) had one or more signs or symptoms of worsening HF. The most common symptoms detected included edema (39%) and increased shortness of breath (17%). Self-reported weight gain of more than 5 pounds was seen in 19% of patients. The TOM-C HF tool was used to identify patients in a time-efficient manner in the community pharmacy setting who appear to be developing worsening HF. Inclusion of the community pharmacists as an early screen for HF decompensation may be an important link in disease-management programs to help reduce hospital readmission rates.

Patterns and Predictors of Hospital Readmission in Taiwan.

PHP118 Patterns and Predictors of HosPital readmission in taiwan Cheng J.S.1, Ku H.P.1, Chang C.J.2 1Chang Gung University, Tao-Yuan, Taiwan, 2Chang Gung University, Kwei Shan, Tao Yuan, Taiwan Objectives: Hospital readmissions have been an important issue, as they reflect suboptimal quality of medical care and incur high health care expenditures. However, limited information is available on the patterns of hospital readmission in the entire population to support a thorough planning to prevent hospital readmissions. Therefore, this study aimed to examine the patterns and economic burden of hospital readmission in Taiwan, and identify predictors of hospital readmissions. MethOds: This study used the National Health Insurance Research Database of enrollees randomly selected from those enrolled in the National Health Insurance program in 2005. Individuals who were admitted to acute hospitals in 2005 were selected and their readmission patterns one-year after discharge were examined. Cox proportional hazards regression model was adopted to identify predictors of hospital readmission. Results: The 30-day, 6-month and one-year readmission rates were 11%, 25%, and 34%, respectively. During the one-year follow-up, 52% of total health care expenditures were due to hospital readmissions. Of those who were readmitted to hospitals, 56% were readmitted once and took up 29% of the cost of rehospitalization. However, those readmitted for more than three times (5%) accounted for 30% of the cost. The major disease category of the highest 30-day and one-year readmission rates was neoplasms. The disease of the highest 30-day and one-year readmission rates were cancer of bronchus and lung (36%) and cancer of liver and intrahepatic bile duct (74%), respectively, and the most frequent reason for readmission was the disease itself. Age, gender, place of residence, previous hospitalization history, comorbidities, and length of stay of the index hospitalization were risk factors of hospital readmissions. cOnclusiOns: This study identified diseases of higher short-term and long-term readmission rates, causes of shortterm and long-term hospital readmissions, and predictors of hospital readmission. The information is of importance for planning interventions to reduce hospital readmission rate.