Most Early Readmissions Followed by More Readmissions

SAN DIEGO – Nearly 70% of patients readmitted within 30 days of discharge from a hospital were patients who had "serial readmissions" during a 6-month period, a study of 82 readmissions among 75 patients found.

Interviews with the patients and medical staff suggest that a portion of both "isolated readmissions" and "serial readmissions" were due to events that might be amenable to simple interventions, but the patients who have serial readmissions tend to have serious medical or social problems that may need complex interventions to reduce readmission rates, Dr. Romsai T. Boonyasai and his associates reported at the annual meeting of the Society of Hospital Medicine.

His study was honored by the society as one of the best three presented at the meeting.

The investigators identified patients who were readmitted within 30 days of discharge from a hospitalist service at a 365-bed teaching hospital in the first 3 months of 2011. They interviewed the patients within 24 hours of readmission, shared the patients’ responses with the hospitalists, and surveyed the hospitalists on whether the readmissions were preventable. The researchers then followed the patients for 6 months to differentiate isolated readmissions from serial readmissions, defined as two or more readmissions during those 6 months.

Among the 52 patients with serial readmissions (69%), 17 were rehospitalized twice (33%), 14 were readmitted three times (27%), 10 returned four times (19%), 3 had five readmissions (6%), 4 had six readmissions (8%), and 4 others were readmitted 10 or more times (8%), said Dr. Boonyasai of Johns Hopkins University, Baltimore.

Forty patients in the entire cohort were female (53%), and patients had a mean age of 60 years. A median of 14 days elapsed between discharge and readmission. Forty-three patients said they had felt "ready to leave" the hospital at the time of the initial discharge (57%), and 51 patients (68%) rated the initial admission as "patient-centered."

After the hospitalists had a chance to reflect on these cases and patients’ responses, the investigators identified several themes among the readmissions, Dr. Boonyasai said.

Some rehospitalizations were planned in both the "isolated" and "serial" readmission groups, such as the readmission of a 32-year-old woman who needed to have ureteral stents removed. Patients in both groups also experienced unexpected or adverse events after discharge, such as a 79-year-old man who slipped on a curb as he was getting into a taxi while leaving a rehabilitation facility.

Among patients with serial readmissions, however, rehospitalizations seemed to be caused by the patients’ nonadherence to the plan for care, advanced or chronic diseases, or a need for postdischarge care, Dr. Boonyasai said.

One 61-year-old woman who had a pattern of ignoring physicians’ recommendations continued to smoke despite nonsmoking policies at nursing homes and occasionally abused alcohol or other substances against recommendations. She was readmitted twice in 6 months.

Among patients with advanced or chronic disease, a steroid-dependent 68-year-old woman was readmitted six times in 6 months (and 12 times over a 12-month period) for frequent exacerbations of chronic obstructive pulmonary disease. A 67-year-old man with recurrent cancer had two readmissions in 6 months and was likely to have more. A 38-year-old man whose substance abuse problems were not under control was readmitted 12 times in 6 months, and rehospitalizations were likely to continue until the core problem was under control.

A 68-year-old woman who was readmitted six times in 6 months provided an example of the need for postdischarge care. The hospitalists felt that her readmissions were preventable if she had a good discharge plan that involved responsive outpatient health care providers. The patient was considered to have very low self-efficacy, and she felt isolated from her care providers. If her primary physician, insurer, and home-care resources could be brought together, a care plan could be crafted for her "to seek help when things start to go south (typically after 3 or 4 days)," one hospitalist wrote.

Dr. Boonyasai said that his personal conclusion from the study is that "really sick patients keep coming back a lot." His next step will be to investigate what it means to have complex interventions for these patients.

Dr. Boonyasai’s hospitalist colleagues suggested several interventions to reduce readmissions, he added, including "shadowing" patients at home, visiting the nursing homes from which patients get rehospitalized, teaching techniques for motivational interviewing to hospitalists, and creating a better process for having early discussions with patients about palliative care.

In general, about 25% of physicians learn that patients they discharged have been rehospitalized, which means opportunities to learn from these cases are being missed, Dr. Boonyasai said. The researchers tried to shed some light on patient subpopulations among early readmissions, a topic that has not been well understood.

The findings were limited by the small size of the study; drawing data from a single institution, with possible recall bias in interview responses; and the possibility that responses were modified to meet socially desirable expectations.

Dr. Boonyasai reported having no financial disclosures.

SAN DIEGO – Nearly 70% of patients readmitted within 30 days of discharge from a hospital were patients who had "serial readmissions" during a 6-month period, a study of 82 readmissions among 75 patients found.

Interviews with the patients and medical staff suggest that a portion of both "isolated readmissions" and "serial readmissions" were due to events that might be amenable to simple interventions, but the patients who have serial readmissions tend to have serious medical or social problems that may need complex interventions to reduce readmission rates, Dr. Romsai T. Boonyasai and his associates reported at the annual meeting of the Society of Hospital Medicine.

His study was honored by the society as one of the best three presented at the meeting.

The investigators identified patients who were readmitted within 30 days of discharge from a hospitalist service at a 365-bed teaching hospital in the first 3 months of 2011. They interviewed the patients within 24 hours of readmission, shared the patients’ responses with the hospitalists, and surveyed the hospitalists on whether the readmissions were preventable. The researchers then followed the patients for 6 months to differentiate isolated readmissions from serial readmissions, defined as two or more readmissions during those 6 months.

Among the 52 patients with serial readmissions (69%), 17 were rehospitalized twice (33%), 14 were readmitted three times (27%), 10 returned four times (19%), 3 had five readmissions (6%), 4 had six readmissions (8%), and 4 others were readmitted 10 or more times (8%), said Dr. Boonyasai of Johns Hopkins University, Baltimore.

Forty patients in the entire cohort were female (53%), and patients had a mean age of 60 years. A median of 14 days elapsed between discharge and readmission. Forty-three patients said they had felt "ready to leave" the hospital at the time of the initial discharge (57%), and 51 patients (68%) rated the initial admission as "patient-centered."

After the hospitalists had a chance to reflect on these cases and patients’ responses, the investigators identified several themes among the readmissions, Dr. Boonyasai said.

Some rehospitalizations were planned in both the "isolated" and "serial" readmission groups, such as the readmission of a 32-year-old woman who needed to have ureteral stents removed. Patients in both groups also experienced unexpected or adverse events after discharge, such as a 79-year-old man who slipped on a curb as he was getting into a taxi while leaving a rehabilitation facility.

Among patients with serial readmissions, however, rehospitalizations seemed to be caused by the patients’ nonadherence to the plan for care, advanced or chronic diseases, or a need for postdischarge care, Dr. Boonyasai said.

One 61-year-old woman who had a pattern of ignoring physicians’ recommendations continued to smoke despite nonsmoking policies at nursing homes and occasionally abused alcohol or other substances against recommendations. She was readmitted twice in 6 months.

Among patients with advanced or chronic disease, a steroid-dependent 68-year-old woman was readmitted six times in 6 months (and 12 times over a 12-month period) for frequent exacerbations of chronic obstructive pulmonary disease. A 67-year-old man with recurrent cancer had two readmissions in 6 months and was likely to have more. A 38-year-old man whose substance abuse problems were not under control was readmitted 12 times in 6 months, and rehospitalizations were likely to continue until the core problem was under control.

A 68-year-old woman who was readmitted six times in 6 months provided an example of the need for postdischarge care. The hospitalists felt that her readmissions were preventable if she had a good discharge plan that involved responsive outpatient health care providers. The patient was considered to have very low self-efficacy, and she felt isolated from her care providers. If her primary physician, insurer, and home-care resources could be brought together, a care plan could be crafted for her "to seek help when things start to go south (typically after 3 or 4 days)," one hospitalist wrote.

Dr. Boonyasai said that his personal conclusion from the study is that "really sick patients keep coming back a lot." His next step will be to investigate what it means to have complex interventions for these patients.

Dr. Boonyasai’s hospitalist colleagues suggested several interventions to reduce readmissions, he added, including "shadowing" patients at home, visiting the nursing homes from which patients get rehospitalized, teaching techniques for motivational interviewing to hospitalists, and creating a better process for having early discussions with patients about palliative care.

In general, about 25% of physicians learn that patients they discharged have been rehospitalized, which means opportunities to learn from these cases are being missed, Dr. Boonyasai said. The researchers tried to shed some light on patient subpopulations among early readmissions, a topic that has not been well understood.

The findings were limited by the small size of the study; drawing data from a single institution, with possible recall bias in interview responses; and the possibility that responses were modified to meet socially desirable expectations.

Dr. Boonyasai reported having no financial disclosures.

SAN DIEGO – Nearly 70% of patients readmitted within 30 days of discharge from a hospital were patients who had "serial readmissions" during a 6-month period, a study of 82 readmissions among 75 patients found.

Interviews with the patients and medical staff suggest that a portion of both "isolated readmissions" and "serial readmissions" were due to events that might be amenable to simple interventions, but the patients who have serial readmissions tend to have serious medical or social problems that may need complex interventions to reduce readmission rates, Dr. Romsai T. Boonyasai and his associates reported at the annual meeting of the Society of Hospital Medicine.

His study was honored by the society as one of the best three presented at the meeting.

The investigators identified patients who were readmitted within 30 days of discharge from a hospitalist service at a 365-bed teaching hospital in the first 3 months of 2011. They interviewed the patients within 24 hours of readmission, shared the patients’ responses with the hospitalists, and surveyed the hospitalists on whether the readmissions were preventable. The researchers then followed the patients for 6 months to differentiate isolated readmissions from serial readmissions, defined as two or more readmissions during those 6 months.

Among the 52 patients with serial readmissions (69%), 17 were rehospitalized twice (33%), 14 were readmitted three times (27%), 10 returned four times (19%), 3 had five readmissions (6%), 4 had six readmissions (8%), and 4 others were readmitted 10 or more times (8%), said Dr. Boonyasai of Johns Hopkins University, Baltimore.

Forty patients in the entire cohort were female (53%), and patients had a mean age of 60 years. A median of 14 days elapsed between discharge and readmission. Forty-three patients said they had felt "ready to leave" the hospital at the time of the initial discharge (57%), and 51 patients (68%) rated the initial admission as "patient-centered."

After the hospitalists had a chance to reflect on these cases and patients’ responses, the investigators identified several themes among the readmissions, Dr. Boonyasai said.

Some rehospitalizations were planned in both the "isolated" and "serial" readmission groups, such as the readmission of a 32-year-old woman who needed to have ureteral stents removed. Patients in both groups also experienced unexpected or adverse events after discharge, such as a 79-year-old man who slipped on a curb as he was getting into a taxi while leaving a rehabilitation facility.

Among patients with serial readmissions, however, rehospitalizations seemed to be caused by the patients’ nonadherence to the plan for care, advanced or chronic diseases, or a need for postdischarge care, Dr. Boonyasai said.

One 61-year-old woman who had a pattern of ignoring physicians’ recommendations continued to smoke despite nonsmoking policies at nursing homes and occasionally abused alcohol or other substances against recommendations. She was readmitted twice in 6 months.

Among patients with advanced or chronic disease, a steroid-dependent 68-year-old woman was readmitted six times in 6 months (and 12 times over a 12-month period) for frequent exacerbations of chronic obstructive pulmonary disease. A 67-year-old man with recurrent cancer had two readmissions in 6 months and was likely to have more. A 38-year-old man whose substance abuse problems were not under control was readmitted 12 times in 6 months, and rehospitalizations were likely to continue until the core problem was under control.

A 68-year-old woman who was readmitted six times in 6 months provided an example of the need for postdischarge care. The hospitalists felt that her readmissions were preventable if she had a good discharge plan that involved responsive outpatient health care providers. The patient was considered to have very low self-efficacy, and she felt isolated from her care providers. If her primary physician, insurer, and home-care resources could be brought together, a care plan could be crafted for her "to seek help when things start to go south (typically after 3 or 4 days)," one hospitalist wrote.

Dr. Boonyasai said that his personal conclusion from the study is that "really sick patients keep coming back a lot." His next step will be to investigate what it means to have complex interventions for these patients.

Dr. Boonyasai’s hospitalist colleagues suggested several interventions to reduce readmissions, he added, including "shadowing" patients at home, visiting the nursing homes from which patients get rehospitalized, teaching techniques for motivational interviewing to hospitalists, and creating a better process for having early discussions with patients about palliative care.

In general, about 25% of physicians learn that patients they discharged have been rehospitalized, which means opportunities to learn from these cases are being missed, Dr. Boonyasai said. The researchers tried to shed some light on patient subpopulations among early readmissions, a topic that has not been well understood.

The findings were limited by the small size of the study; drawing data from a single institution, with possible recall bias in interview responses; and the possibility that responses were modified to meet socially desirable expectations.

Dr. Boonyasai reported having no financial disclosures.