LETTER
Thirty-day readmission rates and hospital quality To the Editor: Unplanned hospital readmissions result from interplay of hospital, patient and communitylevel factors (1). No single intervention was regularly associated with reduced risk of readmission (2) and using readmissions as a marker of compromised hospital efficiency has been frequently debated. Two recent studies by Goodwin et al. (3) and Stefan et al. (4) examine different issues of hospital performance by a different methodology, but reach a common conclusion. Both found substantial 30-day readmission rates of 15.6% of > 131,000 admissions (3) or 19.1–25.3% for three medical conditions examined (4). Goodwin et al. demonstrate small variance in readmissions among 1099 hospitalists. Stefan et al. show that readmissions do not significantly vary among hospitals in the first or fourth quartile of adherence to recommended process of care quality measures. The inference is that readmissions have little to do with the quality of care at the hospital. In fact, abandoning the impact of hospitalrelated quality factors may be premature. Our own prospective study, based on individual chart analysis of a mix of consecutive readmitted and non-readmitted patients, yielded a different conclusion. Two experienced clinicians examined potential quality of care (QOC) problems in
the index admission to a teaching hospital according to a predetermined protocol, blindly comparing prospectively readmitted patients and non-readmitted matched controls. Studying 271 urgent readmissions over 3 months using both patient interviews and chart review, we found significant QOC problems in 33% vs. 6% of 140 controls (p < 0.001) (5). All were judged preventable. Inpatient mortality of readmitted patients with and without QOC problems was 6.7% vs. 1.7% (OR 4.1, CI 1.0–16.7). Other studies identified fewer avoidable readmissions – overall, 848 of 3669 (23.1%) readmissions in 16 studies (6), but studies were heterogeneous and few shared our carefully controlled individual patient review. Thus, hospital quality cannot be regarded as an innocent bystander in considering readmissions. Rather than use it to penalise out of line hospitals, we suggest that a regular analysis of all readmissions for preventable QOC factors in the index admission should be used as a window of opportunity for the hospital to identify and address correctable weaknesses in the provision of care. Ami Schattner1,2 Department of Medicine, Kaplan Medical Centre, Rehovot, Israel
2
The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel Email: [email protected]
References 1 Joynt KE, Jha AK. Thirty-day readmissions – truth and consequences. N Engl J Med 2012; 366: 1366–9. 2 Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med 2011; 155: 520–8. 3 Goodwin JS, Lin YL, Singh S, Kuo YF. Variation in length of stay and outcomes among hospitalized patients attributable to hospitals and hospitalists. J Gen Intern Med 2013; 28: 370–6. 4 Stefan MS, Pekow PS, Nsa W et al. Hospital performance measures and 30-day readmission rates. J Gen Intern Med 2013; 28: 377–85. 5 Balla U, Malnick S, Schattner A. Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems. Medicine (Baltimore) 2008; 87: 294–300. 6 van Walraven C, Jennings A, Forster AJ. A meta-analysis of hospital 30-day avoidable readmission rates. J Eval Clin Pract 2012; 18: 1211–8.
Disclosure None.
1
doi: 10.1111/ijcp.12244
LETTER
Predictors of exacerbations in COPD patients: the role of anaemia Linked Comment: Ozyilmaz and Kokturk. Int J Clin Pract 2014; 68: 140.
To the Editor: We read with great interest the study regarding risk factors for severe exacerbations among COPD patients (1). Anaemia is, indeed, an extrapulmonary factor of great significance, which is associated with both exercise limitation and survival in COPD (2,3). Although the aetiology of anaemia is multifactorial, systemic inflammation seems to be important for its establishment (4). As correctly stated by the authors, haemoglobin levels can be further decreased during COPD exacerbations, indicating that the burst of circulating inflammatory mediators may further inhibit erythropoiesis (5). In the current study, multivariate regression analysis indicated that a lower hematocrit independently predicted both frequent exacerª 2013 John Wiley & Sons Ltd Int J Clin Pract, January 2014, 68, 1, 139–140
bations and readmissions because of severe exacerbations in COPD patients. Of course, there is no optimal statistical technique which can identify a true causal relationship between hematocrit levels and readmission rate. However, this strong independent association between the two variables could be explained in both directions: anaemia is a true surrogate of morbidity and mortality in COPD so low hematocrit levels could identify the more severe ill patients who tend to be frequently hospitalised. Nevertheless, low hematocrit levels could also be a consequence rather than a predictor of repeated severe exacerbations, driven by the increased inflammatory responses during the latter. Although the term ‘predictor’ is merely a statistical one, giving no
information regarding the nature of the association between the two variables, a further description of these two potential explanations could better clarify this dual relationship. A. K. Boutou, N. S. Hopkinson M. I. Polkey, NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefiled NHS Foundation Trust and Imperial College, London, UK Email: [email protected]
References 1 Ozyilmaz E, Kokturk N, Teksut G, Tatlicioglu T. Unsuspected risk factors of frequent exacerbations requiring hospital admission in chronic obstructive pulmonary disease. Int J Clin Pract 2013; 67: 691–7.
139
Thirty-day readmission rates and hospital quality To the Editor: Unplanned hospital readmissions result from interplay of hospital, patient and communitylevel factors (1). No single intervention was regularly associated with reduced risk of readmission (2) and using readmissions as a marker of compromised hospital efficiency has been frequently debated. Two recent studies by Goodwin et al. (3) and Stefan et al. (4) examine different issues of hospital performance by a different methodology, but reach a common conclusion. Both found substantial 30-day readmission rates of 15.6% of > 131,000 admissions (3) or 19.1–25.3% for three medical conditions examined (4). Goodwin et al. demonstrate small variance in readmissions among 1099 hospitalists. Stefan et al. show that readmissions do not significantly vary among hospitals in the first or fourth quartile of adherence to recommended process of care quality measures. The inference is that readmissions have little to do with the quality of care at the hospital. In fact, abandoning the impact of hospitalrelated quality factors may be premature. Our own prospective study, based on individual chart analysis of a mix of consecutive readmitted and non-readmitted patients, yielded a different conclusion. Two experienced clinicians examined potential quality of care (QOC) problems in
the index admission to a teaching hospital according to a predetermined protocol, blindly comparing prospectively readmitted patients and non-readmitted matched controls. Studying 271 urgent readmissions over 3 months using both patient interviews and chart review, we found significant QOC problems in 33% vs. 6% of 140 controls (p < 0.001) (5). All were judged preventable. Inpatient mortality of readmitted patients with and without QOC problems was 6.7% vs. 1.7% (OR 4.1, CI 1.0–16.7). Other studies identified fewer avoidable readmissions – overall, 848 of 3669 (23.1%) readmissions in 16 studies (6), but studies were heterogeneous and few shared our carefully controlled individual patient review. Thus, hospital quality cannot be regarded as an innocent bystander in considering readmissions. Rather than use it to penalise out of line hospitals, we suggest that a regular analysis of all readmissions for preventable QOC factors in the index admission should be used as a window of opportunity for the hospital to identify and address correctable weaknesses in the provision of care. Ami Schattner1,2 Department of Medicine, Kaplan Medical Centre, Rehovot, Israel
2
The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel Email: [email protected]
References 1 Joynt KE, Jha AK. Thirty-day readmissions – truth and consequences. N Engl J Med 2012; 366: 1366–9. 2 Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med 2011; 155: 520–8. 3 Goodwin JS, Lin YL, Singh S, Kuo YF. Variation in length of stay and outcomes among hospitalized patients attributable to hospitals and hospitalists. J Gen Intern Med 2013; 28: 370–6. 4 Stefan MS, Pekow PS, Nsa W et al. Hospital performance measures and 30-day readmission rates. J Gen Intern Med 2013; 28: 377–85. 5 Balla U, Malnick S, Schattner A. Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems. Medicine (Baltimore) 2008; 87: 294–300. 6 van Walraven C, Jennings A, Forster AJ. A meta-analysis of hospital 30-day avoidable readmission rates. J Eval Clin Pract 2012; 18: 1211–8.
Disclosure None.
1
doi: 10.1111/ijcp.12244
LETTER
Predictors of exacerbations in COPD patients: the role of anaemia Linked Comment: Ozyilmaz and Kokturk. Int J Clin Pract 2014; 68: 140.
To the Editor: We read with great interest the study regarding risk factors for severe exacerbations among COPD patients (1). Anaemia is, indeed, an extrapulmonary factor of great significance, which is associated with both exercise limitation and survival in COPD (2,3). Although the aetiology of anaemia is multifactorial, systemic inflammation seems to be important for its establishment (4). As correctly stated by the authors, haemoglobin levels can be further decreased during COPD exacerbations, indicating that the burst of circulating inflammatory mediators may further inhibit erythropoiesis (5). In the current study, multivariate regression analysis indicated that a lower hematocrit independently predicted both frequent exacerª 2013 John Wiley & Sons Ltd Int J Clin Pract, January 2014, 68, 1, 139–140
bations and readmissions because of severe exacerbations in COPD patients. Of course, there is no optimal statistical technique which can identify a true causal relationship between hematocrit levels and readmission rate. However, this strong independent association between the two variables could be explained in both directions: anaemia is a true surrogate of morbidity and mortality in COPD so low hematocrit levels could identify the more severe ill patients who tend to be frequently hospitalised. Nevertheless, low hematocrit levels could also be a consequence rather than a predictor of repeated severe exacerbations, driven by the increased inflammatory responses during the latter. Although the term ‘predictor’ is merely a statistical one, giving no
information regarding the nature of the association between the two variables, a further description of these two potential explanations could better clarify this dual relationship. A. K. Boutou, N. S. Hopkinson M. I. Polkey, NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefiled NHS Foundation Trust and Imperial College, London, UK Email: [email protected]
References 1 Ozyilmaz E, Kokturk N, Teksut G, Tatlicioglu T. Unsuspected risk factors of frequent exacerbations requiring hospital admission in chronic obstructive pulmonary disease. Int J Clin Pract 2013; 67: 691–7.
139
