Hospital readmissions

# Overview
Hospital readmission is the unplanned readmission for any cause to any acute care hospital within a certain period of time following the discharge from a hospitalization.  Centers for Medicare and Medicaid Services (CMS) choose to measure unplanned readmission within 30 days instead of over longer time periods (such as 90 days), because readmissions over longer periods may be impacted by factors outside hospitals control such as other complicating illnesses, patients own behavior, or care provided to patients after discharge.
Reporting readmissons that occur within 2 days may be more important than 30 days.

# Epidemiology
Among Medicare patients in the United States receiving care in a fee-for-service setting during 2003-2004, 19.6% were rehospitalized within 30 days following their discharge from the hospital.
Shown below is an image depicting the hospital readmission rate in 2013 according to Centers for Medicare and Medicaid Services (CMS). Current rates are available at / .

# Causes
In a study of Medicare patients in the United States, most of the variation in rates of readmission are due to characteristics of patients. A much smaller degree of variation is due to characteristics of hospitals or health care providers.
A systematic review found that approximately 25% of readmissions are avoidable; however, rates varied widely among individual studies included within the review.

# Costs

# Prediction
Physicians are specific in their predictors, but not sensitive.
A number of methods have been developed to predict which patients will be readmitted.  Two or more italizations within a year is a simple predictor of readmission. A study of adult patients in the University of Pennsylvania Health System found that  2 inpatient admissions in the past 12 months had a sensitivity and specificity of 39% and 84%, respectively, for predicting readmission. In populations similar to those in this study which had a prevalence of ital readmission of 15%, the probabilities of ital readmission among patients with and without  2 inpatient admissions in the past 12 months were 30.0% and 11.0%, respectively.

# Prevention
Approximately a third of hospitalizations are preventable. Likely locations to intervene are:
- The hospital:
Early readmissions: 47%
Late readmissions: 25%
- Early readmissions: 47%
- Late readmissions: 25%
- The home
- Early readmissions: 14%
Late readmissions: 19%
- Early readmissions: 14%
- Late readmissions: 19%
- The primary care clinic
Early readmissions: 7%
Late readmissions: 15%
- Early readmissions: 7%
- Late readmissions: 15%

## Adults
A meta-analysis of 42 randomized clinical trials found interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care.
This review also reported that more recent trials showed less impact. Accordingly, more recent trials were negative, but had strong interventions in the control group.
- In one of the trials, a virtual ward reduced admissions by 4%, but this was not statistically significant.  A more recent review found uncertain benefit from virtual wards
- Another subsequent trial reports an insignificant increase in readmissions or emergency department visits in the intervention group.
- A more recent trial of an interprofessional intervention found benefit (about 50% had a transition of care visit within 7 days).
- The Complex High Admission Management Program (CHAMP) trial in 2021 found no benefit, but both the intervention and control group had benefits Part of the CHAMP intervention included 'After discharge, patients were scheduled to follow up with the CHAMP team in an outpatient clinic embedded in existing transitional care clinic space.' Of the intervention patients, '48% (27/56) attended CHAMP clinic at least once'. The role of coordination with primary care was not mentioned in the trial's publication.
Regarding prioritized rounds by the inpatient physicians on the day of discharge, this did not affect the length of stay or time of discharge; however, readmissions were not studied.
Regarding telephone calls to patients after discharge, detailed, scripted phone calls may be effective

### Discharge planning =
Discharge planning with coordination of services following discharge may help.

### Medication review
A medication review, if combined with other interventions, may reduce hospital readmissions according to a systematic review WHen the medication review is done by the hospital team, there may be no benefit.
Previously, regarding medication reconciliations, a meta-analysis by the Cochrane Collaboration found no clear benefit.

### The role of primary care
Notifying the primary care physician at the time of admission, using the hospital's HL7 Admission, discharge, and transfer system (ADT) message or feed may reduce readmissions.
.Regarding seeing a primary care provider within one week of discharge, a cohort of Medicaid patients found benefit. However, among a cohort of patients who all have a primary care physician, the impact of the primary care physician is not certain.
The Beth Israel Deaconess Medical Center found that interventions have been able to increase outpatient follow-up visits (after 60% of hospitalizations), but the impact of this on preventing readmission is not certain. interpretation of the results may have been limited by sample size as the readmission rate dropped by 2% but this was not statistically significant.
Phone calls from primary care sites to patients after discharge may help.
Follow-up visits after emergency department visits may also be important and may reduce disparities in readmissions.
Regarding telephone calls to primary care providers by hospital providers, readmissions may not be reduced..
Team-based care may reduce hospitalizations among veterans, although readmissions was not specifically studied.

### Unsuccessful efforts
The Hospital Readmissions Reduction Program (HRRP) has not clearly shown benefit.
The Camden Coalition of Healthcare Providers using the Camden Core Model and "hotspotting" was not able to reduce readmissions among superusers in a randomized controlled trial. Limitations of the study included "a home visit within 5 days after hospital discharge and a visit to a providers office within 7 days after discharge  were achieved less than 30% of the time." Visit with a physician within 7 days occurred after 36% of hospitalizations.
The TARGET-READ project was also unsuccessful, perhaps because it did not result in increase visits to primary care practices.

## Pediatrics
A systematic review of observational studies regarding the prevention of readmissions observed patients receiving home visits, care coordination, chronic care-management, and continuity across settings had fewer preventable hospitalizations. In addition, a proactive and coordinated effort of the pharmacy team during discharge planning may have a positive impact on patients obtaining medications according to a trial not included in the systematic review  (intervention 84%, control 69%). With regards to written patient information, those receiving both verbal and written information showed increased health-care related knowledge at follow-up visits compared with verbal discharge instructions alone  (intervention 79%, control 73%).
Hospital consultation from outpatient clinicians for medically complex children may reduce readmissions and hospital length of stay.