Predictors of 30-Day Hospital Readmission among Maintenance Hemodialysis Patients: A Hospital’s Perspective

Abstract

Background and objectives Over 35% of patients on maintenance dialysis are readmitted to the hospital within 30 days of hospital discharge. Outpatient dialysis facilities often assume responsibility for readmission prevention. Hospital care and discharge practices may increase readmission risk. We undertook this study to elucidate risk factors identifiable from hospital-derived data for 30-day readmission among patients on hemodialysis.Design, setting, participants, & measurements Data were taken from patients on maintenance hemodialysis discharged from University of North Carolina Hospitals between May of 2008 and June of 2013 who received inpatient hemodialysis during their index hospitalizations. Multivariable logistic regression models with 30-day readmission as the dependent outcome were used to identify readmission risk factors. Models considered variables available at hospital admission and discharge separately.Results Among 349 patients, 112 (32.1%) had a 30-day hospital readmission. The discharge (versus admission) model was more predictive of 30-day readmission. In the discharge model, malignancy comorbid condition (odds ratio [OR], 2.08; 95% confidence interval [95% CI], 1.04 to 3.11), three or more hospitalizations in the prior year (OR, 1.97; 95% CI, 1.06 to 3.64), $10 outpatient medications at hospital admission (OR, 1.69; 95% CI, 1.00 to 2.88), catheter vascular access (OR, 1.82; 95% CI, 1.01 to 3.65), outpatient dialysis at a nonuniversity-affiliated dialysis facility (OR, 3.59; 95% CI, 2.03 to 6.36), intradialytic hypotension (OR, 3.10; 95% CI, 1.45 to 6.61), weekend discharge day (OR, 1.82; 95% CI, 1.01 to 3.31), and serum albumin ,3.3 g/dl (OR, 4.28; 95% CI, 2.37 to 7.73) were associated with higher readmission odds. A decrease in prescribed medications from admission to discharge (OR, 0.20; 95% CI, 0.08 to 0.51) was associated with lower readmission odds. Findings were robust across different model-building approaches.Conclusions Models containing discharge day data had greater predictive capacity of 30-day readmission than admission models. Identified modifiable readmission risk factors suggest that improved medication education and improved transitions from hospital to community may potentially reduce readmissions. Studies evaluating targeted transition programs among patients on dialysis are needed.

Psychosocial Factors and 30-Day Hospital Readmission among Individuals Receiving Maintenance Dialysis: A Prospective Study

“…[3] Objective patient characteristics such as older age, greater illness burden and poor nutritional status are associated with higher readmission odds in this population. [2,4,5] However, other characteristics such as poor social support and emotional challenges are plausible readmission risk factors that are often not adequately assessed in retrospective (registry) analyses.…”

Right TraC™ Post-Hospitalization Care Transitions Program to Reduce Readmissions for Hemodialysis Patients

“…The RCA was based on input from several of the authors and WV staff who participated in a full day of multidisciplinary brainstorming held in WV, during which local inpatient and outpatient experience, baseline WV causes of readmissions, and literature review findings were shared. Subsequently, interventions were designed to address the 3 RCA categories that were frequently cited in the literature [7,8,9,10,11,12,13,14] and were also common in WV: hospital-outpatient communication, post-hospital follow-up, and patient activation. These categories were determined to be within significant control of this nurse and operations-driven program, and would also impact other areas of the RCA.…”

“…Activity to reduce readmissions has been spurred by the Centers for Medicare & Medicaid Services (CMS) and the Hospital Readmission Reduction Program created by the Affordable Care Act [5]. Published studies offer strategies to reduce readmissions, but few are ESRD specific [6], and others have called for studies to evaluate care-transition programs in dialysis patients [7]. …”

Can Emergency Department Visits for Adverse Drug Reactions in Dialysis Patients be Reduced?

“…Furthermore, a reduction in the number of outpatient medications resulted in about 70–80% decrease in the likelihood of readmission within 30 days [2]. Medication-related problems (MRP) are a major contributor to the increase in in-patient care and emergency department (ED) visits in ESRD patients.…”

“…The alternative agent warfarin did not fare any better in an analysis showing 2.28 higher odds of 30-day readmission if the drug was part of the patient’s outpatient regimen. The impact of warfarin use on increased readmission risk surpassed the risk from having a catheter as vascular access and taking ≥10 medications [2]. This raises the question as to whether the use of anticoagulants should be reevaluated in ESRD patients.…”