Readmission of patients to hospital: still ill defined and poorly understood.

The need to improve our understanding of readmission of Overall, the readmission rates in the adult population vary patients to hospitals after discharge is becoming increasingly from 5% to 29% [1,17–19]. Although the evidence to explain recognised. Hospital admission and readmission rates have this variation is limited, these discrepancies appear to be due increased over the last few decades [1–5]. It is reported that to a lack of uniformity in defining readmission and the absence readmissions may be responsible for up to half of all hospital of precision in the measurements used. The definitions of admissions [6]. The rise in readmission rates is not unique a readmission varied from readmission within 2 weeks, 1 to western countries, as studies from the developing world month, 3 months, 6 months or 1 year from the time of the indicate a similar trend [7]. While the increases in readmission index admission [8]. rates are not directly related to age, older individuals make a A number of other factors account for these disparities major contribution [8]. including variation in the types of readmissions (whether The cost of readmissions to a nation’s health service is high. planned or unplanned) investigated, in the settings used and It is estimated that repeated admissions may be responsible for in the specialities involved in different studies [1]. Also, the up to 60% of hospital expenditure [6]. The cost of multiple age of the population studied differed from study to study. admissions to the patients and their relatives, in terms of While no association of readmission with age has been found distress, morbidity and mortality, is immeasurable. It has [13], the elderly were the focus of study in many papers been reported that hospital admission, particularly of elderly published on readmission. patients is associated with an increase in both morbidity and mortality [8,9]. It has also been suggested that repeated hospital admissions may promote dependency and lead to a Readmissions – the causes self-perpetuating cycle often described as the ‘revolving door syndrome’ of readmissions [8]. A review of the literature on readmission of adults reveals a Readmission rates have received considerable attention in considerable variation in the probable causes for the increase the literature for a number of reasons. Economic concerns in readmission rates. Previous studies have identified factors resulted in publications designed to monitor the impact of which might lead to repeated admissions such as hospital changes in health care systems, including the effect of various admission during the most recent year, premature discharge, payment/reimbursement schemes on readmission rates [3, poor patient compliance, age of the patient, male sex, chronic 10,11], while several studies examined the use of readmission disability, patient living alone, unavoidable relapse, inadequate as a measure of outcome of the quality of care delivered in medical management, poor self-rated general health, inhospital [12–14]. adequate rehabilitation and poor discharge planning [1,17,18, It is claimed that a significant number of readmissions are 20]. In addition, patients with specific diagnostic categories avoidable and potentially preventable [5,15]. The interest in such as chronic heart failure and chronic obstructive pulreadmission is driven by the assumption that improvement monary disease are said to be at greater risk of readmission [8]. in hospital care can result in a reduction in readmissions and However, there is no general agreement about the underlying medical care costs [16]. This editorial aims to provide an causes of readmission. Although some conditions occur overview of the major issues raised by the literature on repeatedly, in many cases diagnostic subgroups may be a readmission, to stimulate further debate and to identify areas marker for other factors associated with readmission including for future research. the organisation and quality of care [8]. Attention has also focused on the association between the rates of readmission and the length of the initial hospital Readmission rates – how big is the stay. It has been proposed that the increased readmission rates are perhaps the inevitable price of early discharge [21]. problem? Although premature discharge has been recognised as an important factor responsible for unplanned readmission [18], The published data on readmission of patients to hospitals report a wide variation in the rates and patterns of readmission. a positive relationship between the two has not yet been