hospital readmissions in portugal over the last decade introdução à medicina ii class 1 fmup...

Hospital readmissions in Portugal over the last decade

Introdução à medicina IIClass 1

FMUP 2010/2011

Ana Rita GomesAndreia OliveiraBernardo PintoCarlos IvoGustavo Costa

João RamosJoel SilvaMaria Carolina CarneiroMaria João CunhaMaria João Domingues

Advisor: Professor Alberto Freitas

Summary

1. Introduction-Background-Justification

2. Aims3. Type of Study4. Articles’ search 5. Statistical analysis6. Results7. Discussion8. References

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Hospital management should concern on:• patient needs• hospital inside organization• security• economical sustainability

In the U.S.A., readmissions’ number is increasing due to:• Economical pressure• Reduction of hospitalization endurance - earlier discharges• Deficient/inadequate health careAnderson, 1999, Nursing Research.

1. Introduction - Background

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Hospital readmission:

• “Hospitalization within 1, 2, 4, or 12 months of discharge”

• Often used as an indicator of health care qualityBenbassat, 2000, Archives of Internal Medicine

Readmissions are related with:

• Patients’ profile (age, sex, medical history,...)Benbassat, 2000, Archives of Internal Medicine

• Hospital characteristics (technology, organization,...)Heggestad, 2002, Hospital Services Research


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“According to different pathologies, readmission rates in adults vary between 5-29%”Hasan, 2001, Int J Qual Health Care

“(…) 12% to 75% of all readmissions can be prevented by patient education, pre-discharge assessment, and domiciliary aftercare” Benbassat, 2000, Archives of Internal Medicine


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Studying Hospital Readmissions allows to:

•Learn about the Portuguese hospital situation •Understand which factors increase them•Show how hospital costs can be reduced and treatment quality may be improved, by reducing hospital readmissions Ashish , 2009, The New England Journal Of Medicine

1. Introduction - Justification

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However, there are very few studies in Portugal, characterizing hospital readmissions, in spite of their importance.

1. Introduction - Justification

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Summary

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1. Introduction2. Aims3. Type of Study4. Articles’ search5. Statistical analysis6. Results7. Discussion8. References

2. Aims

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∙ To characterize the evolution of hospital readmissions in the past decade;

∙ To study hospital readmissions in relation to hospital mortality rates.

∙ To define an average profile for the “readmitted citizen”, according to:

- Gender;

- Age;

- Major Diagnostic Category;

∙ To study the rate of hospital readmissions according to the region and complexity of the hospital;

∙ To compare Portuguese hospital readmissions’ rates with readmissions’ rates in Europe and North America.

Summary

1. Introduction2. Aims3. Type of Study4. Articles’ search5. Statistical analysis6. Results7. Discussion8. References

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3. Type of Study

In order to study Portuguese hospital readmissions, we did an analytical observational study

Observational study:

This study requires the observation and analysis of data and no direct intervention on the populations

Analytical study:

This study requires the analysis of data from a National Health System`s database, in order to study different variables

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Summary

1. Introduction2. Aims3. Type of Study4. Articles’ search

-Databases used-Query Strategies-Queries Used-Inclusion and Exclusion Criteria

5. Statistical analysis6. Results7. Discussion8. References

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4. Articles’ search

In order to gather information about readmissions rates in Europe and North America, we searched for several articles.

This also allowed us (in an early stage of this study) to learn more about hospital readmissions and to speculate about the expected results.

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4. Articles’ search - Databases used

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Usage of MeSH terms: “Patient Readmission” “Quality of Health Care” “Mortality”

Usage of Keywords: “30-days” “Unplanned” “Portuguese” “Portugal” “Greece” “Spain” “Italy”

Usage of Boolean Operators (AND, OR, NOT)

4. Articles’ search - Query Strategies

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Searching for articles in general:

"Patient Readmission"[Mesh] AND ("Quality of Health Care"[Mesh] OR "Mortality"[Mesh] OR hospital type OR patient profile)

Searching for articles related to Portugal, Spain, Italy or Greece:

"Patient Readmission"[Mesh] AND ("Portugal" OR "Spain" OR "Italy" OR "Greece")*

* We are focusing on those countries, since they share several social, economical, geographical and historical characteristics with Portugal.

4. Articles’ search - Queries Used

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Inclusion

Articles relating hospital readmissions with:

-Mortality rates-Type of Hospital-Particular patient’s

profile

Exclusion

-Low quality rate*-Language other than English, Portuguese, Spanish or Italian

4. Articles’ search - Inclusion and Exclusion Criteria

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* Articles were rated according to criteria expressed in an article published by Sindhu et al., 1997

4. Articles’ search - Inclusion and Exclusion Criteria

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Summary

1. Introduction2. Aims3. Type of Study4. Articles’ search5. Statistical analysis

-Database and software used-Tests used-Strategy adopted-Syntax

6. Results7. Discussion8. References

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5. Statistical analysis – Database and software used

We analysed a National Health’s System database;

This database includes hospitalizations in Portuguese public hospitals, in a period of 9 years (2000-2008);

This database was edited, using SPSS (version 18) and was given by our advisor*.

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* Database provided by ACSS (Central Autority for Health’s Systems).

5. Statistical Analysis – Strategy adopted

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Select hospital readmissions within 30 days by Major Diagnosis Group

Select only unplanned readmissions

Analyse hospital readmissions according to the variables defined and apply the appropriate statistical test

5. Statistical Analysis – Variables used

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Percentage of hospital readmissions per year

Variable Type of Variable Database’s variables used

Occurence of Readmissions Discrete RINT30; MDC; ADM_TIP

Year Discrete ENT1

Hospital mortality Discrete DSP

Gender Discrete SEX

Age Group Discrete CL_IDADAN

Major Diagnosis Group Discrete MDC

Nuts II regions Discrete HOSP_RESIDE

Complexity of the hospital Discrete TIPOC

This allowed us to study only unplanned 30-days readmissions by the same Major Diagnosis Group

5. Statistical Analysis – Tests used

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Since the variables studied are discrete and since we have a large number of episodes, we applied chi-square test, in order to compare variables statistically.

We considered statistically significant, p values smaller then 0.05.

5. Statistical Analysis – Syntax

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Summary

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1. Introduction2. Aims3. Type of Study4. Articles’ search5. Statistical analysis6. Results

- Presentation of results according to aims7. Discussion8. References

6. Results – Presentation of results according to aims

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From 2000 to 2008, we found a rate of unplanned readmissions within 30-days )by the same Major Diagnois Group) of 2.4%.

First Aim: To characterize the evolution of hospital readmissions in the past decade.

Results:

Percentage of hospital readmissions per year

YearReadmissions Hospitalizations

FrequencyFrequency Rate (%)

2000 20,374 2.3 903,025

2001 23,294 2.5 916,551

2002 27,264 2.9 938,840

2003 27,536 2.8 974,440

2004 29,003 3.0 980,339

2005 31,910 3.2 989,355

2006 29,696 2.9 1,020,028

2007 30,549 1.8 1,657,796

2008 30,015 1.7 1,801,405

Total 262,407 2.4 11,060,523

Although the number of unplanned readmissions is increasing, its rate has actually decreased (although the rates increased in the first five years).


p-value for chi-square test <0.001

Readmissions rates by hospital mortality

Hospital Mortality

Frequency Rate (%)

Readmissions episodes 25,716 9.8

Non-readmissions episodes

356,338 3.3

Total 382,054 3.5

Higher levels of readmissions are associated with higher hospital mortality rates.

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Second Aim: To study hospital readmissions in relation to hospital mortality rates.

Results:



Readmissions rates by gender

GenderReadmissions

HospitalizationsFrequency

Frequency Rate (%)

Male 126,092 2.5 4,946,762

Female 137,928 2.2 6,139,538

Total 262,407 2.4 11,060,523

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Males have a higher rate of readmissions than females.

Third aim: To define an average profile for the “readmitted citizen”, according to

gender, age and major diagnosis category:



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Rates of Hospital readmissions by age group

Age Group(years)

ReadmissionsHospitalizations


0-14 38,023 2.2 1,721,477

15-24 16,825 2.8 610,555

25-44 48,899 2.2 2,218,394

45-64 45,427 1.7 2,700,881

+65 114,846 3.0 3,835,171Total 262,407 2.4 11,060,523

We divided age into five age groups, since this division is widely used by the Health Ministery.

Individuals with more than 65 years have a higher rate of readmissions.



Readmissions rates (%)

Readmissions rates per Major Diagnostic Category

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p<0.001

• In order to study hospital readmissions by region, we adopted NUTS II division

• NUTS II divides Mainland Portugal into five regions – Northern Portugal, Central Portugal, Lisbon, Alentejo and Algarve

• We found out that Algarve and Alentejo have higher readmissions’ rates.

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6. Results - Presentation of results according to aims

Fourth Aim: To study the rate of hospital readmissions according to the region and complexity of the hospital.

Results:

Rates of readmissions by NUTS II regions

RegionReadmissions Hospitalizations

frequencyFrequency Rate (%)

Northern Portugal 109,060 2.7 4,026,880

Central Portugal 71,638 2.7 2,621,398Lisbon 48,463 1.4 3,435,054

Alentejo 19,258 3.3 578,230

Algarve 13,988 3.5 398,961

Total 262,407 2.4 11,060,523

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Rates of readmissions by complexity of the hospital

ReadmissionsHospitalizations


Central Hospitals 68,249 1.3 5,157,991

District Hospitals 175,272 3.2 5,419,403

District Hospitals Level 1 18,903 3.9 483,554

Total 262,407 2.4 11,060,523

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Central hospitals have significantly a smaller rate of hospital readmissions than District Hospitals and District Hospitals Level 1.

6. Results - Presentation of results according to aims


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Fifth aim: To compare Portuguese hospital readmissions’ rates with readmissions’

rates in Europe and North America.

Results:

• We found no nation-wide studies concerning 30-days unplanned hospital

readmissions’ rates.

•However, there were some articles, studying 30-days unplanned

readmissions’ rates in specific hospitals.

• We compared our results with the ones presented in those articles.


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Readmission rates in Europe and North America


González , 2010, Revista Clínica Española

Abenhaim, 2000, Canadian Medical Association Journal

Boulding, 2011, The American Journal of Managed Care

Allaudeen , 2011, Journal of Hospital Medicine

Summary

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1. Introduction2. Aims3. Type of study4. Articles’ search5. Statistical analysis6. Results7. Discussion8. References

7. Discussion – Conclusions

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• Readmissions’ rates increased (and stabilized) between 2000 and 2006 and decreased since 2007. Perhaps this happened because, since 2007, more ambulatory care episodes were included in the database.

• Readmitted individuals have higher rates of hospital mortality. This conclusion was also found in the articles we read. This might be associated with diseases that are not well treated in the hospital or might be due to the fact that readmissions are more common in patients with more severe cases.

• Older people have higher rates of readmissions, probably, because their health is more fragile. Morbidity and functional disability are risk factors for hospital readmissions in elderly patients.

• Alentejo and Algarve were the regions with higher readmissions’ rates. This may be due to the fact that there is a higher proportion of older people in these regions. In Portuguese Census, 2001

García-Pérez , 2011, QJM

7. Discussion - Limitations

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• This database only contained episodes from Public Hospitals in Mainland Portugal.

•The patient’s code changes every year and it is different in each hospital. This means that the “true” readmissions’ rate value is bigger than the one, we found.

• We couldn’t exclude ambulatory care episodes from the database (this probably led to lower readmissions rates in 2007 and 2008).

• We used administrative data in a health study. These data might not be completely accurate or complete. However, administrative data is commonly used in such studies, since is accessible and inexpensive.

• There are no articles concerning 30-days unplanned hospital readmissions in Portugal, with which we could compare results.

Torchiana, 2005, J Thorac Cardiovasc Surg

7. Discussion – Strong Points

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• This is the first study of this kind in Portugal.

• We analyzed all hospitalizations in public hospitals from Mainland Portugal from 2000 to 2008, and not just a sample of them.

• The fact that we analyzed hospital readmissions from 2000 to 2008 allowed us to see the evolution of hospital readmissions in Portugal.

• We compared several variables and the data we found, can be used as a starting point to reduce hospital readmissions.

Summary

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1. Introduction2. Aims3. Type of study4. Articles’ search5. Statistical analysis6. Results7. Discussion8. References

• Benbassat J., Taragin M., MD. “Hospital Readmissions as a Measure of Quality of Health Care”. Archives of Internal Medicine 2000; 160:1074-1081.

• Ashish K. Jha, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D., Public Reporting of Discharge Planning and Rates of Readmissions, The New England Journal Of Medicine, 361;27, 2009

• Utzolino S, Kaffarnik M, Keck T, Berlet M, Hopt UT. Unplanned discharges from a surgical intensive care unit: readmissions and mortality. J Crit Care 2010 Sep

• Hasan et al, Readmission of patients to hospital: still ill defined and poorly understood, Int J Qual Health Care, 2001; 13(3):177-9.

• Heggestad, T. Do hospital length of stay and staffing ratio affect elderly patients' risk of readmission? A nation-wide study of Norwegian hospitals. Hospital Services Research, 2002; 37(3):647-65.

• Anderson, Mary Ann; Helms, Lelia B.; Hanson, Kathleen S.; DeVilder, Nancy W., Unplanned Hospital Readmissions: A Home Care Perspective. Nursing Reserach. 1999;48(6):299-307.

• Sindhu F, Carpenter L, Seers K., Development of a tool to rate the quality assessment of randomized controlled trials using a Delphi technique. Journal of Advanced Nursing. 1997 Jun;25(6):1262-8.

• García-Pérez L, Linertová R, Lorenzo-Riera A, Vázquez-Díaz JR, Duque-González B, Sarría-Santamera A. QJM. 2011 May 10.

• http://paginas.ispgaya.pt/~vmca/Documentos_links/censo2001.pdf• Abenhaim H.A., Kahn S.R., Raffoul J., Becker R. Program description: A hospitalistrun, medical short-stay

unit in a teaching hospital. CMAJ. 2000; 163:1477-83.• Seoane González B, Nicolás Miguel R, Ramos Polledo V, Pellicer Vázquez C, de la Iglesia Martínez F.

Short stay medical unit. Causes of readmissions. Rev Clin Esp. 2010 Mar;210(3):118-23.

8. References

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• Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining readmission risk factors for general medicine patients. Journal of Hospital Medicine. 2011 Feb;6(2):54-60.

• Maurer PP, Ballmer PE. Hospital readmissions--are they predictable and avoidable? Swiss Med Wkly. 2004 Oct 16;134(41-42):606-11.

• Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011 Jan;17(1):41-8.

• Torchiana DF, Meyer GS. Use of administrative data for clinical quality measurement. J Thorac Cardiovasc Surg. 2005 Jun;129(6):1223-5.

8. References

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hospital readmissions in portugal over the last decade introdução à medicina ii class 1 fmup...

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