Predictors of 30-day readmission following hospitalisation with community-acquired pneumonia

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Abstract

Background

There is a paucity of UK data to aid healthcare professionals in predicting which patients hospitalised with community-acquired pneumonia (CAP) are at greatest risk of 30-day readmission and to determine which readmissions may occur soonest.

Methods

An analysis of CAP cases admitted to nine UK hospitals participating in the Advancing Quality Pneumonia Programme.

Results

An analysis was performed of 12 157 subjects hospitalised with CAP in the Advancing Quality Programme Database. 26% of those discharged were readmitted within 30 days with readmission predicted by comorbidity including non-metastatic cancer, diabetes with complications and chronic kidney disease. 41% and 66% of readmissions occurred within 7 and 14 days of discharge, respectively. Patients readmitted within 14 days were more likely to have metastatic cancer (6.6% vs 4.5%; p=0.03) compared with those readmitted at 15–30 days.

Conclusions

A quarter of patients hospitalised for CAP are readmitted within 30 days; of those, two-thirds are readmitted within 2 weeks. Further research is required to determine whether such readmissions might be preventable through imple menting measures including in-hospital cross-specialty comorbidity management, convalescence in intermediate care, targeted rehabilitation and advanced care planning.

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Most cited references 28

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A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation

Mary Charlson, Peter Pompei, Kathy Ales … (1987)

The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.

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Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.

Kumar Dharmarajan, Angela F. Hsieh, Zhenqiu Lin … (2013)

To better guide strategies intended to reduce high rates of 30-day readmission after hospitalization for heart failure (HF), acute myocardial infarction (MI), or pneumonia, further information is needed about readmission diagnoses, readmission timing, and the relationship of both to patient age, sex, and race. To examine readmission diagnoses and timing among Medicare beneficiaries readmitted within 30 days after hospitalization for HF, acute MI, or pneumonia. We analyzed 2007-2009 Medicare fee-for-service claims data to identify patterns of 30-day readmission by patient demographic characteristics and time after hospitalization for HF, acute MI, or pneumonia. Readmission diagnoses were categorized using an aggregated version of the Centers for Medicare & Medicaid Services' Condition Categories. Readmission timing was determined by day after discharge. We examined the percentage of 30-day readmissions occurring on each day (0-30) after discharge; the most common readmission diagnoses occurring during cumulative periods (days 0-3, 0-7, 0-15, and 0-30) and consecutive periods (days 0-3, 4-7, 8-15, and 16-30) after hospitalization; median time to readmission for common readmission diagnoses; and the relationship between patient demographic characteristics and readmission diagnoses and timing. From 2007 through 2009, we identified 329,308 30-day readmissions after 1,330,157 HF hospitalizations (24.8% readmitted), 108,992 30-day readmissions after 548,834 acute MI hospitalizations (19.9% readmitted), and 214,239 30-day readmissions after 1,168,624 pneumonia hospitalizations (18.3% readmitted). The proportion of patients readmitted for the same condition was 35.2% after the index HF hospitalization, 10.0% after the index acute MI hospitalization, and 22.4% after the index pneumonia hospitalization. Of all readmissions within 30 days of hospitalization, the majority occurred within 15 days of hospitalization: 61.0%, HF cohort; 67.6%, acute MI cohort; and 62.6%, pneumonia cohort. The diverse spectrum of readmission diagnoses was largely similar in both cumulative and consecutive periods after discharge. Median time to 30-day readmission was 12 days for patients initially hospitalized for HF, 10 days for patients initially hospitalized for acute MI, and 12 days for patients initially hospitalized for pneumonia and was comparable across common readmission diagnoses. Neither readmission diagnoses nor timing substantively varied by age, sex, or race. Among Medicare fee-for-service beneficiaries hospitalized for HF, acute MI, or pneumonia, 30-day readmissions were frequent throughout the month after hospitalization and resulted from a similar spectrum of readmission diagnoses regardless of age, sex, race, or time after discharge.

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Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines.

E. Halm, M J Fine, T Marrie … (1998)

Many groups have developed guidelines to shorten hospital length of stay in pneumonia in order to decrease costs, but the length of time until a patient hospitalized with pneumonia becomes clinically stable has not been established. To describe the time to resolution of abnormalities in vital signs, ability to eat, and mental status in patients with community-acquired pneumonia and assess clinical outcomes after achieving stability. Prospective, multicenter, observational cohort study. Three university and 1 community teaching hospital in Boston, Mass, Pittsburgh, Pa, and Halifax, Nova Scotia. Six hundred eighty-six adults hospitalized with community-acquired pneumonia. Time to resolution of vital signs, ability to eat, mental status, hospital length of stay, and admission to an intensive care, coronary care, or telemetry unit. The median time to stability was 2 days for heart rate ( or =90 mm Hg), and 3 days for respiratory rate ( or =90%), and temperature (< or =37.2 degrees C [99 degrees F]). The median time to overall clinical stability was 3 days for the most lenient definition of stability and 7 days for the most conservative definition. Patients with more severe cases of pneumonia at presentation took longer to reach stability. Once stability was achieved, clinical deterioration requiring intensive care, coronary care, or telemetry monitoring occurred in 1% of cases or fewer. Between 65% to 86% of patients stayed in the hospital more than 1 day after reaching stability, and fewer than 29% to 46% were converted to oral antibiotics within 1 day of stability, depending on the definition of stability. Our estimates of time to stability in pneumonia and explicit criteria for defining stability can provide an evidence-based estimate of optimal length of stay, and outline a clinically sensible approach to improving the efficiency of inpatient management.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open Respir Res

Journal ID (iso-abbrev): BMJ Open Respir Res

Journal ID (hwp): bmjresp

Journal ID (publisher-id): bmjopenrespres

Title: BMJ Open Respiratory Research

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2052-4439

Publication date Collection: 2021

Publication date (Electronic): 26 March 2021

Volume: 8

Issue: 1

Electronic Location Identifier: e000883

Affiliations

[1 ]Liverpool University Hospitals NHS Foundation Trust , Liverpool, UK

[2 ]departmentBiostatistics , University of Liverpool , Liverpool, UK

[3 ]Advancing Quality Alliance , Salford, UK

[4 ]University Hospitals of North Midlands , Stoke, UK

[5 ]departmentInstitute of Infection, Veterinary and Ecological Sciences , University of Liverpool , Liverpool, UK

Author notes

[Correspondence to ] Dr Biswajit Chakrabarti; biz@ 123456doctors.org.uk

Article

Publisher ID: bmjresp-2021-000883

DOI: 10.1136/bmjresp-2021-000883

PMC ID: 8006847

PubMed ID: 33771814

SO-VID: d2a891e0-65de-4d14-b87d-18a30ac27809

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 26 January 2021

Date revision received : 01 March 2021

Date accepted : 02 March 2021

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Keywords: pneumonia,respiratory infection

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Keywords: pneumonia, respiratory infection

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Predictors of 30-day readmission following hospitalisation with community-acquired pneumonia

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Novel Coronavirus Disease COVID-19

Most cited references 28

A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation

Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.

Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines.

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Cited by 2

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