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Socio-demographic and Clinical Characteristics of Early vs. Late Readmissions in the VA: A Study
Loveland S, O'Brien W, Shwartz M, Borzecki A, Shin M, Cevasco M, Hanchate AD, Rosen AK. Socio-demographic and Clinical Characteristics of Early vs. Late Readmissions in the VA: A Study. Presented at: AcademyHealth Annual Research Meeting; 2011 Jun 13; Seattle, WA.
CMS uses a 30-day window to measure readmissions after hospitalization for pneumonia (PN), acute myocardial infarction (AMI), and heart failure (HF). However, a 15-day window may be more appropriate because readmissions within that period may be more strongly associated with the quality of inpatient care. This study compares characteristics of readmissions within 15 days of initial discharge ("early readmissions") with those between 16-30 days ("late readmissions") for patients initially hospitalized with PN, AMI, or HF. We hypothesize that: 1) early readmissions have greater disease burden than late readmissions; and 2) diagnoses at early readmission are more likely to be related to the index diagnosis.
We conducted a retrospective cross-sectional study of acute-care discharges from VA hospitals in a five-year period (2003-2007). Descriptive statistics explored patients' socio-demographic and clinical characteristics, including: number of readmissions, age, index and readmission lengths of stay (LOS), readmission to same hospital, and number of comorbidities. These were grouped by the three index conditions (PN, AMI, and HF) and by early vs. late readmissions. We aggregated individual principal diagnoses at readmission into AHRQ Clinical Classification Software categories, and calculated the most frequent reasons for readmission for each index condition.
VA patients discharged from acute care who subsequently had a 30-day "all-cause" readmission to a VA hospital, and whose initial principal diagnosis was PN (n = 9,921), AMI (n = 5,915), or HF (n = 16,175).
With respect to socio-demographic characteristics, patients readmitted early were slightly older (70.9 vs. 70.2 [p = 0.003] for PN, 70.4 vs. 69.9 [p = 0.003] for HF, 68.8 vs. 68.3 [p = 0.117] for AMI). However, there were no significant differences in mean number of comorbidities. Index discharges with PN or HF that resulted in early readmission were more likely to have longer index LOS compared with late readmissions (8.55 vs. 7.85 [p = 0.009] for PN, 6.78 vs. 6.26 [p = 0.018] for HF, 8.12 vs. 8.01 [p = 0.727] for AMI), while discharges with AMI were more likely to have longer readmission LOS (8.36 vs. 7.92 [p = 0.119] for PN, 7.10 vs. 7.09 [p = 0.969] for HF, 6.73 vs. 6.02 [p = 0.002] for AMI). Early readmission after initial diagnosis of HF or AMI was associated with a small but significant increased likelihood of readmission to the same hospital vs. different hospital (95.7% vs. 95.2% [p = 0.181] for PN, 94.9% vs. 94.0% [p = 0.011] for HF, 90.8% vs. 88.3% [p = 0.003] for AMI). There were few clinical differences in the reasons for early vs. late readmissions in any condition cohort.
Higher age and longer LOS for patients readmitted early suggests initial evidence of greater disease burden and less preventability of readmission. Readmission diagnoses do not appear to indicate that early readmissions necessarily reflect inpatient activities more so than late readmissions. Further research is needed to determine the relative impact of quality of care vs. disease burden as determinants of early readmissions.
Implications for Policy, Delivery or Practice
Although preliminary efforts detected only minor differences in early vs. late readmissions, the use of a 15-day window may allow for more targeted quality improvement efforts if future research can establish a causal link between quality of care and early readmissions.