Easily Identifiable Clinical and Demographic Factors Associated with Hospital Readmission
Clinical question: Which clinical, operational, or demographic factors are associated with 30-day readmission for general medicine patients?
Background: While a few clinical risk factors for hospital readmission have been well defined in subgroups of inpatients, there are still limited data regarding readmission risk that might be associated with a broad range of operational, demographic, and clinical factors in a heterogeneous population of general medicine patients.
Study design: Retrospective observational study.
Setting: Single academic medical center.
Synopsis: The study examined more than 10,300 consecutive admissions (6,805 patients) discharged over a two-year period from 2006 to 2008 from the general medicine service of an urban academic medical center. The 30-day readmission rate was 17.0%.
In multivariate analysis, factors associated with readmission included black race (OR 1.43, 95% CI, 1.24-1.65), inpatient use of narcotics (OR 1.33, 95% CI, 1.16-1.53) and corticosteroids (OR 1.24, 95% CI, 1.09-1.42), and the disease states of cancer (with metastasis 1.61, 95% CI, 1.33-1.95; without metastasis 1.95, 95% CI 1.54-2.47), renal failure (OR 1.19, 95% CI 1.05-1.36), congestive heart failure (OR 1.30, 95% CI, 1.09-1.56), and weight loss (OR 1.26, 95% CI, 1.09-1.47). Medicaid payor status (OR 1.15, 95% CI, 0.97-1.36) had a trend toward readmission. None of the operational factors were significantly associated with readmission, including discharge to skilled nursing facility or weekend discharge.
A major limitation of the study was its inability to capture readmissions to hospitals other than the study hospital, which, based on prior studies, could have accounted for nearly a quarter of readmissions.
Bottom line: Readmission of general medicine patients within 30 days is common and associated with several easily identifiable clinical and nonclinical factors.
Citation: Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011;6(2):54-60.
Unplanned Medical ICU Transfers Tied to Preventable Errors
Clinical question: What fraction of unplanned medical ICU (MICU) transfers result from errors in care and why do they occur?
Background: Prior studies have suggested that 14% to 28% of patients admitted to the MICU are unplanned transfers. It is not known what fraction of these transfers result from errors in care, and whether these transfers could be prevented.
Study design: Retrospective cohort study.
Setting: University-affiliated academic medical center.
Synopsis: All unplanned transfers to the MICU from June 1, 2005, to May 30, 2006, were included in the study. Three independent observers, all hospitalists for more than three years, reviewed patient records to determine the cause of unplanned transfers according to a taxonomy the researchers developed for classifying the transfers. They also determined whether the transfer could have been prevented.
Of the 4,468 general medicine admissions during the study period, 152 met inclusion criteria for an unplanned MICU transfer. Errors in care were judged to account for 19% (n=29) of unplanned transfers, 15 of which were due to incorrect triage at admission and 14 to iatrogenic errors, such as opiate overdose during pain treatment or delayed treatment. All 15 triage errors were considered preventable. Of the iatrogenic errors, eight were considered preventable through an earlier intervention. Overall, 23 errors (15%) were thought to be preventable. Observer agreement was moderate to almost perfect (κ0.55-0.90).
Bottom line: Nearly 1 in 7 unplanned transfers to the medical ICU are associated with preventable errors in care, with the most common error being inappropriate admission triage.
Citation: Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. J Hosp Med. 2011;6(2):68-72. TH