Readmission of elderly patients to hospital: still ill-defined and poorly understood--a response.

In the accompanying article, Dr Hasan has highlighted a setting. In contrast to the institutional setting, where professional care is often readily on hand should an individual range of issues surrounding the use of ‘readmission rates’ among elderly patients as both a measure of performance become ill, the threshold for short-term institutional care (i.e. hospital care) is considerably lower for the communityquality of a health care service and as an indicator of possible dysfunction within modern health care systems. The resident sick and frail elderly. Periods of ill-health demand continuous surveillance by a carer, quite apart from the attractiveness of the measure rests with the relative ease of monitoring such categorical events. However, the lack of professional input required to deliver care, making the older person living alone particularly susceptible to the need for conformity around definition of patient groups, time periods from the index admission and so-called ‘unplanned’ events inpatient care. Much has been made of the impact of Prospective Payment severely compromise its utility. Does this mean that the measure is without value? Before Systems (PPS) based on clinical Diagnosis Related Groups (DRG) on reduction in length of stay. Such systems promote drawing such a conclusion, one must consider the lack of robust alternatives that might provide insight into the shorter lengths of hospital stay [3]. It is speculated that this may result in hasty and poorly executed discharge planning, phenomena that the indicator seeks to capture. These include, at the patient level, premature discharge, poor discharge resulting in higher readmission rates. The evidence to support this proposition is inconclusive. The introduction of PPSpreparation and inadequate follow-up care; and at the health system level, changing patterns of health service populations based payment systems in the USA may have improved some patient outcomes in the first few years of implementation. and hospital utilization. Examples of such measures might include assessment of unmet needs after discharge, patient However, the impact of such systems may vary as the duration of their use increases. In the short-term, reductions in length satisfaction through interview or survey and mortality rates in the post discharge period. These measures are either of stay may have only marginal effects, whereas, over the longer term, repeated payment reductions for each care expensive to obtain or suffer similar, but more serious, limitations than are associated with the readmission measure. episode may result in declining standards of care as safe thresholds of hospital length of stay are transgressed. These considerations demand a careful examination of the capacity to refine the readmission measure. Potential If it is accepted that such funding approaches do result in higher rates of readmission, a further level of scrutiny is improvements might be gained through standardization of the definition of unplanned readmission, reporting of readmission required. If there is indeed a trade-off between reduced length of stay and readmission, what is the appropriate balance? It rates at a series of time periods after discharge (7, 28, 90 days) and adjustment of the indicator in relation to confounding can be argued that unnecessarily long lengths of hospital stay may have detrimental effects on elderly patients, and be variables including diagnosis. While there is no obvious mechanism to secure consensus associated with higher hospital and perhaps health care system costs. On the other hand, readmission is also associated with on these matters at an international level, within the context of a national or local health care system such agreements can additional cost, and might have negative effects on patients’ morale. Unfortunately, there is little published information be secured. The measure then becomes available as one of a range of tools to monitor performance of the system over that enables clear elucidation of this balance. Intervention studies provide some insight into the balance. time and to compare similar services within the system. There does seem to be mounting evidence that readmission However, they were designed in order to understand the impact of a preventive intervention in a known health care rates are increasing [1–2]. This would appear to reflect changing characteristics of either the population being served system environment. They do not directly explore the relationship between length of stay and readmission rates. This or the system that is delivering the care. A variety of factors might be contributing to the demand aspects of this pheis an area that requires further analysis. Hasan has considered whether readmissions can be nomenon. Population aging, in the setting of widespread policy development that reduces availability and access to avoided. Once again, the evidence is weak. Avoidance might be secured through interventions designed to improve health, permanent institutional care, may result in a significantly larger proportion of sick elderly people living in a community enhance discharge planning or ensure appropriate follow up.