Thirty-day rehospitalization readmissions of elderly patients from nursing homes

30-Day Hospital Readmission

day Readmission to the Hospital for Elderly Nursing Home Residents

The Centers for Medicare and Medicaid Services uses calculation of 30-day readmission to the hospital for patients with certain severe conditions. Readmission occurs when a patient who has been discharged from the hospital with a serious illness such as acute heart attack, heart failure, or pneumonia and are readmitted from a non-hospital setting. These rates are evaluated by comparison to other facilities. They are used as a measure of quality of care and other quality metrics. The following will use root cause analysis to examine readmission rates and the factors behind them in an attempt to find ways to reduce 30-day readmission rates.

Statement of the Problem

Hospitals must compete in terms of the quality of care that they deliver. This is a matter of trust between the hospitals, patients, insurance underwriters, and others in the community. Hospitals exist for the purpose of providing the best quality of care for their patients. The 30-day readmission rate is used as a metric that is compared to local, state and national averages. In a sense, this creates a sense of competition among hospitals. They must lower their 30-day readmission rates in order to gain the trust of their stakeholders. They can only do this by examining the root cause of readmission and addressing these areas. The problem being studied in this research determining the reasons for 30-day readmission rates among elderly patients who have been released into long-term care facilities and nursing homes.

Significance of the Problem

Hospitals have the greatest stake in reducing 30-day readmission rates. Their reputation, ability to get insurance reimbursement, and ability to avoid malpractice suits depends on it. The patient represents perhaps a stakeholder with even greater concerns than the hospital. Their lives depend selecting a hospital that can treat their condition and provide the best quality of care. Improvements in the 30-day readmission rate have a significant impact on the lives of patients and their families. Insurance companies and legal professionals represent the next sphere of stakeholders. They have a financial interest in improving the 30-day readmission rate. The final tier of stakeholders in the community, which can benefit from having a high quality hospital in their neighborhood.

Statement of the Purpose

The purpose of this research is to examine the root causes of 30-day readmissions at a local general hospital among elderly patients who have been released into long-term care facilities and nursing homes.

Research Question

The following research questions will be the key guidelines for conduct of this study.

1. What is the current readmission rate for this hospital?

2. What are the problems for which patients were admitted the first time?

3. What was the severity of the patient's problem during the first admission?

4. How long was their stay the first time, in comparison to other patients with similar conditions and severity?

5. What was the overall condition of the patient upon release?

6. What was the reason for readmission?

7. Was the reason for readmission, a relapse of the same condition, or a different condition?

8. What was the final outcome of the patient after the second admission?

Conceptual Framework

The conceptual framework for this study will be based on current literature regarding how to reduce hospital readmission rates. Ludke and Booth (1993) presented the concept that hospitals could reduce their readmission rates by improving a number of quality of care indicators. This concept forms the key rationale for the current research study. Subsequent studies by Ludke and Booth supported their initial premise. These quality of care indicators include premature discharges, abnormal diagnosis, readmission status and other factors that will be discussed in the literature review.

This research is based on the premise that quality of care indicators can be used to develop a mean system of metrics that can be used by individual hospitals to pinpoint problems in their system that can be improved, having the net result of improving their 30-day readmission rate. It will examine the quality of care indicators developed by Ludke and Booth, as well as those developed by other authors. The work of many other authors supports the basic conceptual model presented by Ludke and Booth (Goldfield, McCullough, & Hughes et al., 2008; Guo, Chung, & Casey et al., 2007; Palicio, Alexandraki, & House, et al., 2009). It will use these indicators to develop and study a method that applies these indicators to real-world cases using a comparative study of elderly hospital patients.

Operational Definitions

The following operational definitions will apply to the proposed research study. They will also be used to describe the sample population and parameters of the study.

Elderly. Person's aged 65 or older.

Hospital -- For the purposes of applicability, this will refer to institution public of private that functions as a hospital. They may be general or specialized. They must qualify as an institution that is required to calculate 30- day readmission rates as an indicator of quality of care. In this proposal and the final study, when "the hospital" is used, it will refer to the local hospital at which the study was conducted.

Nursing Home. A facility designed for long-term care of patients, but not acute care.

Quality of Care. For the purpose of this study, quality of care will be limited only to the conditions measured by the study. There are many different forms and levels measurement for quality of care. However, these must be limited to those defined in the parameters of the study in order to eliminate sources of bias.

30-day Readmission. In general, this refers to the number of patients that must be readmitted to the hospital within thirty days of release for heart attack, heart disease, or pneumonia. For the purposes of this study, these will be limited to the parameters of measure used at the local study used in the study.

Assumptions

A several assumptions will be used in the study. The first will that the records will be accurate and that they will represent accurate data sets. The second will be that the researcher understands the implications of introducing bias into the study and will not select only studies that support the hypothesis. All qualified data will be included, and none will be intentionally or unintentionally excluded.

Limitations

Has several limitations that may affect the ability of the researcher to draw conclusions. The first is that not all hospitals will have similar patient populations, procedures and record keeping methods. This might limit the applicability of the study to only those that are similar to the chosen hospital in respect to these variables. However, the purpose of the study is not to produce a system that is applicable in a number of clinical settings. The purpose is to determine if and how discovering the root causes of 30-day readmissions can be used to develop such as system. It is not intended to provide solutions for every healthcare system, but rather to provide an example that can be used to devise their own system.

Summary

The proposed study will address a serious problem in the healthcare industry. In a highly competitive marketplace and increasing pressure from the public and government to improve quality of care, hospitals face increasing pressure to improve the quality of care that they provide. 30-day readmissions are a standard metric that is used to measure quality of care. Hospitals can use this metric to help spot problem area so that they can be addressed and resolved, resulting in a higher standard of care for patients. This study will examine how this can be accomplished.

Section II: Review of Literature

Many academic studies have addressed issues of quality of care in the hospital setting. Since the works Ludke and Booth, 30-day readmissions became a standard measure for quality metrics. The focus of this study is on defining quality of care using the 30-day readmission paradigm. It will also explore some of the known root causes of 30-day readmissions in hospital settings. The literature review will explore recent academic literature on topics that are related to the study at hand.

Current Body of Research

In a similar comparative study to the one being proposed, Silverstein, Qin, & Mercer et al. (2008) found that several attributes increased the likelihood that patients would be readmitted to the hospital within 30 days of release. Major comorbid factors were found to be predictive of the potential for 30-day readmission. This study found that patients with systemic conditions, fluid disorders, and electrolyte disorders were more likely to be readmitted. Demographic models were not found to be predictive.

Studies that focused on specific conditions or that generated complex prediction models were found to be unreliable in reducing hospital readmission rates. Point scales based on certain factors are the most common of these methods, resulting in a cumulative risk factor. Hasan,

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Meltzer%20DO%22%5BAuthor%5D Meltzer & Shaykevich et al., (2010) found that these models had little predictive value. This study and others that are similar form the basis for the proposed research study.

One of the key reasons that was found to be a factor in readmissions is that insurance companies continue to push for shorter hospital stays. They have reduced the number of days that they will pay for certain conditions. This was found to be a key factor in releasing patients early, when they might have benefited from a longer hospital stay (Bueno, Ross, & Wang et al., 2010; Capelastegui, A,, Espana, P., & Quintana, J. et al., 2008), This factor will have to be considered as a potential barrier to the study. It may be that insurance companies and Medicaid/Medicare reimbursements are a factor in early release of patients rather than hospital practices.

Factors that were identified in other studies of hospital 30-day readmissions included the presence of deep vein thrombosis and pulmonary embolism (Spencer, Gore, & Lessard et al., 2008). Severity scores such as those for community-acquired pneumonia were found to be predictive of clinical outcomes. These initial scores were found to be predictive of the initial length of stay for those patients (Yandola, Capelastegui, & Quintana et al., 2009). Numerous studies were found that examine a number of risk factors that might influence early release and the potential for 30-day readmission. These will be explored at greater length as part of the final research project.

Theoretical Summary

Sufficient evidence was found in a preliminary literature review to support the primary theoretical and conceptual model used for the study. Other researchers were found to have used this conceptual model as the basis for their research into the same area. Many of the studies were based on the model introduced by Ludke and Booth that 30-day readmissions could be used to determine quality of care. Since that time, this theory has been expanded to include the concept that 30-day readmissions can be used as a tool to uncover weaknesses in the system so that they can be addressed. This results in the ability to use the 30-day risk factor as a means to improve the quality of care at hospitals.

Empirical Summary

A majority of the studies used statistical methods to arrive at their results. The most common types of studies were longitudinal and comparative. Some of them used a start point and measured data from that point to a predetermined point in the future. However, using historical data was another common study method. For this type of study, historical data was found to be appropriate, as that is the same type of data used to measure 30-day readmissions by the hospitals themselves.