Abstract
Background:
Early and late readmissions may have different causal factors, requiring different prevention strategies.
Objective:
To determine whether predictors of readmission change within 30 days after discharge.
Design:
Retrospective cohort study.
Setting:
Academic medical center.
Participants:
Patients admitted between 1 January 2009 and 31 December 2010.
Measurements:
Factors related to the index hospitalization (acute illness burden, inpatient care process factors, and clinical indicators of instability at discharge) and unrelated factors (chronic illness burden and social determinants of health) and how they affect early readmissions (0 to 7 days after discharge) and late readmissions (8 to 30 days after discharge).
Results:
13 334 admissions, representing 8078 patients, were included in the analysis. Early readmissions were associated with markers of acute illness burden, including length of hospital stay (odds ratio [OR], 1.02 [95% CI, 1.00 to 1.03]) and whether a rapid response team was called for assessment (OR, 1.48 [CI, 1.15 to 1.89]); markers of chronic illness burden, including receiving a medication indicating organ failure (OR, 1.19 [CI, 1.02 to 1.40]); and social determinants of health, including barriers to learning (OR, 1.18 [CI, 1.01 to 1.38]). Early readmissions were less likely if a patient was discharged between 8:00 a.m. and 12:59 p.m. (OR, 0.76 [CI, 0.58 to 0.99]). Late readmissions were associated with markers of chronic illness burden, including receiving a medication indicating organ failure (OR, 1.24 [CI, 1.08 to 1.41]) or hemodialysis (OR, 1.61 [CI, 1.12 to 2.17]), and social determinants of health, including barriers to learning (OR, 1.24 [CI, 1.09 to 1.42]) and having unsupplemented Medicare or Medicaid (OR, 1.16 [CI, 1.01 to 1.33]).
Limitation:
Readmissions were ascertained at 1 institution.
Conclusion:
The time frame of 30 days after hospital discharge may not be homogeneous. Causal factors and readmission prevention strategies may differ for the early versus late periods.
Primary Funding Source:
Health Resources and Services Administration, National Institute on Aging, National Institutes of Health, Harvard Catalyst, and Harvard University.
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Author, Article, and Disclosure Information
From Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, and Center for Quality and Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois.
Note: Dr. Graham had full access to all of the data and takes responsibility for its integrity and the accuracy of the data analysis. Dr. Wilker did the data analysis.
Acknowledgment: The authors thank George Silva (Data Analyst, Beth Israel Deaconess Medical Center) and the Insight Core at Beth Israel Deaconess Medical Center for their invaluable assistance in helping to create the data set and Kenneth Mukamal, MD, MPH (Associate Professor of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School), and Long Ngo, PhD (Associate Professor of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School) for insight and assistance with the statistical analysis. They received no compensation for their contributions.
Grant Support: Dr. Graham was supported by the Health Resources and Services Administration (training grant T32 HP12706). Dr. Marcantonio was supported by the National Institute on Aging (Midcareer Investigator Award in Patient-Oriented Research K24 AG035075). Dr. Wilker was supported by the National Institutes of Health (award K99 ES022243). This work was also conducted with support from the Harvard Catalyst (National Institutes of Health award 1UL1 TR001102-01) and financial contributions from Harvard University and its affiliated academic health care centers.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2159.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Graham (e-mail,[email protected]
Corresponding Author: Kelly L. Graham, MD, MPH, Instructor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, E/Shapiro 607D, Boston, MA 02215; e-mail, [email protected]
Current Author Addresses: Dr. Graham: Beth Israel Deaconess Medical Center, 330 Brookline Avenue, E/Shapiro 607D, Boston, MA 02215.
Dr. Wilker: Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, 375 Longwood Avenue, Boston, MA 02215.
Dr. Howell: 5841 South Maryland Avenue, MC 1135, Chicago, IL 60637.
Dr. Davis: Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CO-217, Boston, MA 02215.
Dr. Marcantonio: Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CO-218, Boston, MA 02215.
Author Contributions: Conception and design: K.L. Graham, E.R. Marcantonio.
Analysis and interpretation of the data: K.L. Graham, E.H. Wilker, M.D. Howell, R.B. Davis.
Drafting of the article: K.L. Graham.
Critical revision of the article for important intellectual content: K.L. Graham, E.H. Wilker, M.D. Howell, R.B. Davis, E.R. Marcantonio.
Final approval of the article: K.L. Graham, E.H. Wilker, M.D. Howell, R.B. Davis, E.R. Marcantonio.
Provision of study materials or patients: K.L. Graham.
Statistical expertise: R.B. Davis.
Obtaining of funding: E.R. Marcantonio.
Administrative, technical, or logistic support: K.L. Graham, M.D. Howell.
Collection and assembly of data: K.L. Graham, M.D. Howell.
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