Evaluating Hospital Readmission Rates After Discharge From Inpatient Rehabilitation

The Effect of Teach-Back on Readmission Rates in Rehabilitation Patients

PURPOSE

Thirty-day readmissions often occur in rehabilitation patients and can happen for many reasons. One of those reasons is when patients do not fully understand how to effectively manage their health after discharge. The purpose of this evidence-based quality improvement project was to determine if implementing the teach-back intervention from the Agency for Healthcare Research and Quality's (AHRQ) Health Literacy Universal Precautions Toolkit would impact 30-day readmission rates among adult rehabilitation patients.

METHODS

Data were collected from the electronic health record of rehabilitation patients. The comparative group included all rehabilitation admissions for 8 weeks prior to the intervention. The implementation group was composed of the rehabilitation admissions for 8 weeks post-implementation. All patients were then followed for 30 days postdischarge to capture readmissions.

RESULTS

The total sample size was 79 ( n = 43 in the comparative group, n = 36 in the implementation group). There was a 45% decrease in the mean percentage of the 30-day readmission rate in the implementation group as compared with the comparative group.

CONCLUSION

Based on the results, using the teach-back intervention from AHRQ's Health Literacy Universal Precautions Toolkit may impact 30-day readmission rates.

Risk factors for readmission of patients with amputation to acute care from inpatient rehabilitation: A retrospective cohort study

INTRODUCTION

Amputation is a major condition that requires inpatient rehabilitation. Some research has been conducted to explore the risk factors for readmission of patients from inpatient rehabilitation facilities to acute care hospitals. However, few studies have included patients with amputation in the study population.

OBJECTIVE

To identify the risk factors for readmission of patients with amputation to acute care hospitals from an inpatient rehabilitation facility.

DESIGN

Retrospective cohort study.

SETTING

An acute rehabilitation hospital associated with a community-based tertiary medical center.

PATIENTS

A retrospective review of 156 independent admissions of 145 patients from June 2019 to July 2022.

MAIN OUTCOME MEASURE

The study outcome measure was readmission to acute care from an acute rehabilitation unit.

RESULTS

Of the 156 independent admissions, the readmission rate was 19% (29/156). The most common cause of transfer was incision-site complications (9/29, 31%), including wound infection and wound dehiscence. Patients with amputation readmitted to acute care are more likely to be receiving dialysis (p < .001), have a longer length of stay in acute care before admission to the rehabilitation facility (p = .039), and have a lower Section GG score on admission (p < .001). Age, sex, ethnicity, amputation level, and history of diabetes mellitus were not associated with acute care hospital readmission. The logistic regression model revealed that patients being on dialysis was the only significant risk factor predictive of readmission to acute care (odds ratio [OR] 4.82, p = .006).

CONCLUSIONS

This study showed that incision-site complications were the most common cause of disruption in inpatient rehabilitation via acute hospital readmission in patients with amputation. Being on dialysis was associated with a higher risk of readmission to acute care hospitals. Based on the results of this study, specific rehabilitation plans might be required for patients with amputation who carry certain risk factors to reduce rehospitalization to the acute care unit.

Care patterns and predictors of community residence among older patients after hospital discharge for traumatic brain injury

BACKGROUND

An increasing number of older adults with traumatic brain injury (TBI) require hospitalization, but it is unknown whether they return to their community following discharge. We examined community residence following acute hospital discharge for TBI in Texas and identified factors associated with 90-day community residence and readmission.

METHODS

We conducted a retrospective cohort study using 100% Texas Medicare claims data of patients older than 65 years hospitalized for a TBI from January 1, 2014, through December 31, 2017, and followed for 20 weeks after discharge. Discharges to short-term and long-term acute hospital, inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term nursing home (NH), and hospice were identified. The primary outcome was 90-day community residence. Our secondary outcome was 90-day, all-cause readmission.

RESULTS

In Texas, 26,985 Medicare fee-for-service patients were hospitalized for TBI (Racial and ethnic minorities: 21.1%; Females 57.3%). At 90 days and 20 weeks following discharge, 80% and 84% were living in the community respectively. Female sex (OR = 1.16 [1.08-1.25]), Hispanic ethnicity (OR = 2.01 [1.80-2.25]), "other" race (OR = 2.19 [1.73-2.77]), and prior primary care provider (PCP; OR = 1.51 [1.40-1.62]) were associated with increased likelihood of 90-day community residence. Patients aged 75+, prior NH residence, dual eligibility, prior TBI diagnosis, and moderate-to-severe injury severity were associated with decreased likelihood of 90-day community residence. Being non-Hispanic Black (HR = 1.33 [1.20-1.46]), discharge to SNF (HR = 1.56 [1.48-1.65]) or IRF (HR = 1.49 [1.40-1.59]), having prior PCP (HR = 1.23 [1.17-1.30]), dual eligibility (HR = 1.11 [1.04-1.18]), and prior TBI diagnosis (HR = 1.05 [1.01-1.10]) were associated with increased risk of 90-day readmission. Female sex and "other" race were associated with decreased risk of 90-day readmission.

CONCLUSIONS

Most older adults with TBI return to the community following hospital discharge. Disparities exist in returning to the community and in risk of 90-day readmission following hospital discharge. Future studies should explore how having a PCP influences post-hospital outcomes in chronic care management of older patients with TBI.

Data-Driven Smart Living Lab to Promote Participation in Rehabilitation Exercises and Sports Programs for People with Disabilities in Local Communities

Patients discharged from hospitals after an inpatient course of medical treatment for any ailment or traumatic injury that results in disabling conditions and are rendered mobility impaired require ongoing systematic sports and exercise programs to maintain healthy lifestyles. Under such circumstances, a rehabilitation exercise and sports center, accessible throughout local communities, is critical for promoting beneficial living and community participation for these individuals with disabilities. An innovative data-driven system equipped with state-of-the-art smart and digital equipment, set up in architecturally barrier-free infrastructures, is essential for these individuals to promote health maintenance and overcome secondary medical complications following an acute inpatient hospitalization or suboptimal rehabilitation. A federally funded collaborative research and development (R&D) program proposes to build a multi-ministerial data-driven system of exercise programs using a smart digital living lab as a platform to provide pilot services in physical education and counseling with exercise and sports programs for this patient population. We describe the social and critical aspects of rehabilitating such a population of patients by presenting a full study protocol. A modified sub-dataset of the previously generated 280-item full dataset is applied using a data-collecting system-"The Elephant"-as an example of how data acquisition will be achieved to assess the effects of lifestyle rehabilitative exercise programs for people with disabilities.

Data-Driven Smart Living Lab to Promote Participation in Rehabilitation Exercises and Sports Programs for People with Disabilities in Local Communities

Patients discharged from hospitals after an inpatient course of medical treatment for any ailment or traumatic injury that results in disabling conditions and are rendered mobility impaired require ongoing systematic sports and exercise programs to maintain healthy lifestyles. Under such circumstances, a rehabilitation exercise and sports center, accessible throughout local communities, is critical for promoting beneficial living and community participation for these individuals with disabilities. An innovative data-driven system equipped with state-of-the-art smart and digital equipment, set up in architecturally barrier-free infrastructures, is essential for these individuals to promote health maintenance and overcome secondary medical complications following an acute inpatient hospitalization or suboptimal rehabilitation. A federally funded collaborative research and development (R&D) program proposes to build a multi-ministerial data-driven system of exercise programs using a smart digital living lab as a platform to provide pilot services in physical education and counseling with exercise and sports programs for this patient population. We describe the social and critical aspects of rehabilitating such a population of patients by presenting a full study protocol. A modified sub-dataset of the previously generated 280-item full dataset is applied using a data-collecting system—“The Elephant”—as an example of how data acquisition will be achieved to assess the effects of lifestyle rehabilitative exercise programs for people with disabilities.

Graft-Versus-Host Disease: an Update on Functional Implications and Rehabilitation Interventions

PURPOSE OF REVIEW

Despite advances in treatment, chronic graft-versus-host disease (cGVHD) remains a highly morbid complication of allogeneic hematopoietic stem cell transplantation. Due to direct effects of the disease on specific body sites, and its treatment, patients lose function. This review summarizes the latest evidence surrounding how cGVHD affects function, and restorative interventions.

RECENT FINDINGS

Different body sites of cGVHD carry a higher risk of functional decline, including pulmonary and sclerotic/fascial. Support should be comprehensive and individualized, with precautions taken to avoid worsening fibrosis, offloading painful joints and fractures, and utilizing function-directed skilled therapies. Inpatient rehabilitation improves function in hospitalized people with cGVHD. For people with cGVHD, rehabilitation addresses different aspects of impaired function across the spectrum of disease. Given the dynamic nature of the disease process, routine assessment may be warranted. Rehabilitation may also improve deleterious effects of anti-cGVHD medication including glucocorticoids and tyrosine kinase inhibitors.

Bounce-Back: Predicting Acute Readmission From Inpatient Rehabilitation for Patients With Stroke

OBJECTIVE

The aim of the study was to identify demographic, medical, and functional risk factors for discharge to an acute hospital before completion of an inpatient rehabilitation program and 7- and 30-day readmissions after completion of an inpatient rehabilitation program.

DESIGN

This cohort study included 138,063 fee-for-service Medicare beneficiaries with a primary diagnosis of new onset stroke discharged from an inpatient rehabilitation facility from June 2009 to December 2011. Multivariate models examined readmission outcomes and included data from 6 mos before onset of the stroke to 30 days after discharge from the inpatient rehabilitation facility.

RESULTS

In the acute discharge model (n = 9870), comorbidities and complications added risk, and the longer the stroke onset to admission to inpatient rehabilitation facility, the more likely discharge to the acute hospital. In the 7-day (n = 4755) and 30-day (n = 9861) readmission models, patients who were more complex with comorbidities, were black, or had managed care Medicare were more likely to have a readmission. Functional status played a role in all three models.

CONCLUSIONS

Results suggest that certain demographic, medical, and functional characteristics are associated differentially with rehospitalization after completion inpatient rehabilitation. The strongest model was the discharge to the acute hospital model with concordance statistic (c-statistic) of 0.87.

Data-Driven Smart Medical Rehabilitation Exercise and Sports Program Using a Living Lab Platform to Promote Community Participation of Individuals with a Disability: A Research and Development Pilot Program

Patients discharged from hospitals following the onset of an acute illness or injury rendered with disabling conditions require systematic medical-based and rehabilitation-focused sports and exercise programs accessible in their communities. This proposal aims to build a data-driven smart health system that allows people with disabilities to continuously improve their health by alleviating modifiable factors, including architectural barriers and related challenges following discharge from an inpatient hospital or rehabilitation course. Our goal is to promote a multi-ministerial data-driven innovative medical exercise system using a digital living lab platform as a testbed program to provide lifestyle exercise and physical education for community-dwelling individuals with disabilities. The pilot program of services will be rendered at the living lab center of the National Rehabilitation Center, equipped with data servers for storing accumulated pertinent information and continuous data acquisition. We envision an encrypted data collection and acquisition system, whereby newly acquired data will be merged with data information from original records of individuals generated during the inpatient hospital course.

Thirty-day hospital readmission rate, reasons, and risk factors after acute inpatient cancer rehabilitation

Objectives

To evaluate the 30‐day hospital readmission rate, reasons, and risk factors for patients with cancer who were discharged to home setting after acute inpatient rehabilitation.

Design, Setting, and Participants

This was a secondary retrospective analysis of participants in a completed prospective survey study that assessed the continuity of care and functional safety concerns upon discharge and 30 days after discharge in adults. Patients were enrolled from September 5, 2018, to February 7, 2020, at a large academic quaternary cancer center with National Cancer Institute Comprehensive Cancer Center designation.

Main Outcomes and Measures

Thirty‐day hospital readmission rate, descriptive summary of reasons for readmissions, and statistical analyses of risk factors related to readmission.

Results

Fifty‐five (21%) of the 257 patients were readmitted to hospital within 30 days of discharge from acute inpatient rehabilitation. The reasons for readmissions were infection (20, 7.8%), neoplasm (9, 3.5%), neurological (7, 2.7%), gastrointestinal disorder (6, 2.3%), renal failure (3, 1.1%), acute coronary syndrome (3, 1.1%), heart failure (1, 0.4%), fracture (1, 0.4%), hematuria (1, 0.4%), wound (1, 0.4%), nephrolithiasis (1, 0.4%), hypervolemia (1, 0.4%), and pain (1, 0.4%). Multivariate logistic regression modeling indicated that having a lower locomotion score (OR = 1.29; 95% CI, 1.07–1.56; p = 0.007) at discharge, having an increased number of medications (OR = 1.12; 95% CI, 1.01–1.25; p = 0.028) at discharge, and having a lower hemoglobin at discharge (OR = 1.31; 95% CI, 1.03–1.66; p = 0.031) were independently associated with 30‐day readmission.

Conclusion and Relevance

Among adult patients with cancer discharged to home setting after acute inpatient rehabilitation, the 30‐day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation.

Research is needed to determine the rates of and risk factors for 30‐day hospital readmission after acute inpatient cancer rehabilitation to understand the nature of this problem and to decrease costs associated with readmissions. Among adult patients with cancer discharged to a home setting after acute inpatient rehabilitation, the 30‐day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation. Cancer rehabilitation patients may have unique risk factors for readmission.

A Machine Learning Approach to Predicting Readmission or Mortality in Patients Hospitalized for Stroke or Transient Ischemic Attack

Readmissions after stroke are not only associated with greater levels of disability and a higher risk of mortality but also increase overall medical costs. Predicting readmission risk and understanding its causes are thus essential for healthcare resource allocation and quality improvement planning. By using machine learning techniques on initial admission data, this study aimed to develop prediction models for readmission or mortality after stroke. During model development, resampling methods were implemented to balance the class distribution. Two-layer nested cross-validation was used to build and evaluate the prediction models. A total of 3422 patients were included for analysis. The 90-day rate of readmission or mortality was 17.6%. This study identified several important predictive factors, including age, prior emergency department visits, pre-stroke functional status, stroke severity, body mass index, consciousness level, and use of a nasogastric tube. The Naïve Bayes model with class weighting to compensate for class imbalance achieved the highest discriminatory capacity in terms of the area under the receiver operating characteristic curve (0.661). Despite having room for improvement, the prediction models could be used for early risk assessment of patients with stroke. Identification of patients at high risk for readmission or mortality immediately after admission has the potential of enabling early discharge planning and transitional care interventions.

Inpatient rehabilitation facilities' hospital readmission rates for medicare beneficiaries treated following a stroke

BACKGROUND

Stroke is the leading cause for admission to the nearly 1,200 Inpatient Rehabilitation Facilities (IRFs) nationally in the US. For many patients, post-acute care is an important component of their rehabilitation. Several quality measures have been publicly reported for post-acute care providers, including hospital readmissions. However, to date none have focused on specific medical conditions, limiting the usability for patients and quality improvement.

OBJECTIVE

To assess hospital readmission rates for Medicare patients receiving inpatient rehabilitation following stroke and to identify risk factors in order to evaluate the feasibility of a stroke-specific hospital readmission measure.

METHODS

Observational study analyzing national Medicare inpatient claims and administrative data to assess hospital readmissions. Using logistic regression, we calculated unadjusted and risk-standardized readmission rates, which adjusted for patient characteristics, including type of stroke and admission function, to capture stroke severity.

RESULTS

Our national study included 116,073 fee-for-service Medicare beneficiary discharged from IRFs in 2013-2014 following stroke from 1,162 IRFs nationally. The observed hospital readmission rate among IRF patients following stroke was 11.6% and varied by patients' admission motor function. Patients with greater functional dependence had higher readmission rates on average. Lower admission function, hemorrhagic and other stroke types (relative to ischemic) were significantly associated with higher odds of hospital readmission.

CONCLUSION

Results suggest it is feasible to assess hospital readmission rates among a stroke-cohort treated in IRFs. Stroke-focused quality measures would be useful to patients in selecting a provider and for providers in evaluating their stroke rehabilitation program outcomes. Secondary results suggest that admission function (FIM) capture stroke severity, a limitation with other claims-based stroke measures.

Associations of Hospital Discharge Services With Potentially Avoidable Readmissions Within 30 Days Among Older Adults After Rehabilitation in Acute Care Hospitals in Tokyo, Japan

OBJECTIVE

To examine the associations of 3 major hospital discharge services covered under health insurance (discharge planning, rehabilitation discharge instruction, and coordination with community care) with potentially avoidable readmissions (PARs) within 30 days in older adults after rehabilitation in acute care hospitals in Tokyo, Japan.

DESIGN

Retrospective cohort study using a large-scale medical claims database of all Tokyo residents aged ≥75 years.

SETTING

Acute care hospitals.

PARTICIPANTS

Patients who underwent rehabilitation and were discharged to home (N=31,247; mean age in years ± SD, 84.1±5.7) between October 2013 and July 2014.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

30-day PAR.

RESULTS

Among the patients, 883 (2.9%) experienced 30-day PAR. A multivariable logistic generalized estimating equation model (with a logit link function and binominal sampling distribution) that adjusted for patient characteristics and clustering within hospitals showed that the discharge services were not significantly associated with 30-day PAR. The odds ratios were 0.962 (95% confidence interval [CI], 0.805-1.151) for discharge planning, 1.060 (95% CI, 0.916-1.227) for rehabilitation discharge instruction, and 1.118 (95% CI, 0.817-1.529) for coordination with community care. In contrast, the odds of 30-day PAR among patients with home medical care services were 1.431 times higher than those of patients without these services (P<.001), and the odds of 30-day PAR among patients with a higher number (median or higher) of rehabilitation units were 2.031 times higher than those of patients with a lower number (below median) (P<.001). Also, the odds of 30-day PAR among patients with a higher Hospital Frailty Risk Score (median or higher) were 1.252 times higher than those of patients with a lower score (below median) (P=.001).

CONCLUSIONS

The insurance-covered discharge services were not associated with 30-day PAR, and the development of comprehensive transitional care programs through the integration of existing discharge services may help to reduce such readmissions.

Frailty Is Associated With Early Hospital Readmission in Older Medical Patients

Given the pervasiveness of frailty and its negative effects on health care–related outcomes, we evaluated patient frailty and comorbidity and determined the relationship between these measures and the probability of early readmission and length of hospital stay. Our retrospective analysis includes 435 patients evaluated using the Reported Edmonton Frailty Scale and the Age-Adjusted Charlson Comorbidity Index. We found that frailty as measured by the Reported Edmonton Frailty Scale was a significant predictor of hospital readmission and length of stay, and frailty outperformed the explanatory power of our comorbidity metric. One unit of increase in the Reported Edmonton Frailty Scale increased the odds of readmission by a factor of 1.12 (95% confidence interval [CI]: [1.04, 1.20]), and an increase of 10 units tripled the odds of readmission (odds ratio = 3.02, 95% CI: [1.48, 6.24]). These findings underscore the importance of prompt identification and management of frailty by bedside clinicians.

Causes and correlates of 30 day and 180 day readmission following discharge from a Medicine for the Elderly Rehabilitation unit

Background

Recently hospitalized patients experience a period of generalized risk of adverse health events. This study examined reasons for, and predictors of, readmission to acute care facilities within 30 and 180 days of discharge from an inpatient rehabilitation unit for older people.

Methods

Routinely collected, linked clinical data on admissions to a single inpatient rehabilitation facility over a 13-year period were analysed. Data were available regarding demographics, comorbid disease, admission and discharge Barthel scores, length of hospital stay, and number of medications on discharge. Discharge diagnoses for the index admission and readmissions were available from hospital episode statistics. Univariate and multivariate Cox regression analyses were performed to identify baseline factors that predicted 30 and 180-day readmission.

Results

A total of 3984 patients were included in the analysis. The cohort had a mean age of 84.1 years (SD 7.4), and 39.7% were male. Overall, 5.6% (n = 222) and 23.2% (n = 926) of the patients were readmitted within 30 days and 180 days of discharge respectively. For patients readmitted to hospital, 26.6% and 21.1% of patients were readmitted with the same condition as their initial admission at 30 days and 180 respectively. For patients readmitted within 30 days, 13.5% (n = 30) were readmitted with the same condition with the most common diagnoses associated with readmission being chest infection, falls/immobility and stroke. For patients readmitted within 180 days, 12.4% (n = 115) of patients were readmitted with the same condition as the index condition with the most common diagnoses associated with readmission being falls/immobility, cancer and chest infections. In multivariable Cox regression analyses, older age, male sex, length of stay and heart failure predicted 30 or 180-day readmission. In addition, discharge from hospital to patients own home predicted 30-day readmission, whereas diagnoses of cancer, previous myocardial infarction or chronic obstructive pulmonary disease predicted 180-day readmission.

Conclusion

Most readmissions of older people after discharge from inpatient rehabilitation occurred for different reasons to the original hospital admission. Patterns of predictors for early and late readmission differed, suggesting the need for different mitigation strategies.

Geographic Region and Profit Status Drive Variation in Hospital Readmission Outcomes Among Inpatient Rehabilitation Facilities in the United States

OBJECTIVE

To examine whether there are differences in inpatient rehabilitation facilities' (IRFs') all-cause 30-day postdischarge hospital readmission rates vary by organizational characteristics and geographic regions.

DESIGN

Observational study.

SETTING

IRFs.

PARTICIPANTS

Medicare fee-for-service beneficiaries discharged from all IRFs nationally in 2013 and 2014 (N = 1166 IRFs).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We applied specifications for an existing quality measure adopted by Centers for Medicare & Medicaid Services for public reporting that assesses all-cause unplanned hospital readmission measure for 30 days postdischarge from inpatient rehabilitation. We estimated facility-level observed and risk-standardized readmission rates and then examined variation by several organizational characteristics (facility type, profit status, teaching status, proportion of low-income patients, size) and geographic factors (rural/urban, census division, state).

RESULTS

IRFs' mean risk-standardized hospital readmission rate was 13.00%±0.77%. After controlling for organizational characteristics and practice patterns, we found substantial variation in IRFs' readmission rates: for-profit IRFs had significantly higher readmission rates than did not-for-profit IRFs (P<.001). We also found geographic variation: IRFs in the South Atlantic and South Central census regions had the highest hospital readmission rates than did IRFs in New England that had the lowest rates.

CONCLUSIONS

Our findings point to variation in quality of care as measured by risk-standardized hospital readmission rates after IRF discharge. Thus, monitoring of readmission outcomes is important to encourage quality improvement in discharge care planning, care transitions, and follow-up.