Pneumonia Readmissions in Nursing Home Residents 65 and Older

Background and Scope of the Problem

Pneumonia remains a serious health condition in the United States. It accounts for roughly one million hospital admissions and over 50,000 deaths annually. Approximately ten to twenty percent of pneumonia cases require admission to the Intensive Care Unit (ICU). Moreover, pneumonia accounts for nearly 140,000 hospital readmissions each year, costing in excess of ten billion dollars in medical expenses. In the current era of quality and cost accountability, pneumonia readmission rates for older adults over the age of 65 have become a subject of increasing attention and quality improvement efforts. With the enactment of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) holds hospitals accountable for excess readmissions by linking readmission rates to reimbursement. In 2013, CMS penalized 2,225 hospitals with reduced payments based on their readmission rates (De Alba & Amin, 2014).

Numerous prior efforts to understand the epidemiology of readmission after hospitalization for pneumonia have relied on large analyses of CMS datasets, primarily addressing the population aged 65 and older. Approximately 20% to 25% of these patients are readmitted within just thirty days. However, such analyses have been limited because they have typically lacked individual-level information on severity of illness and treatment factors, such as the appropriateness of initial antibiotic therapy (Shorr et al., 2013).

Given the central problem of healthcare costs, there is an emphasis on quality improvement efforts to prevent and reduce pneumonia readmissions. Third-party payers like CMS have issued several guidelines that attempt to tie payments and obligations to treatment quality processes. One initiative addresses readmission rates following an inpatient stay for pneumonia. CMS proposes that by offering a single payment to cover an "episode of care," it can restructure incentives so that hospitals and physicians alter their practices. It is hoped that, as a result, care will be better coordinated and transitions from the hospital to the home will be improved, thereby preventing subsequent readmissions (Shorr et al., 2013).

Importantly, no prior study had attempted to examine the difference between community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP) with respect to readmissions. This is a critical consideration for the nursing home population. HCAP describes a group of individuals who present to a hospital with pneumonia, similar to those with CAP, but who are distinct because of their ongoing contact with the healthcare system. As a result, patients with HCAP are at risk for infection with a broader range of pathogens than those typically seen in CAP. Patients with HCAP also tend to have more comorbidities and are generally more seriously ill than those with CAP (Calvillo et al., 2013). Consequently, HCAP produces different outcomes compared with CAP. Understanding the differential effect of HCAP and CAP on readmission is essential for determining whether case-mix variability between the two may alter a hospital's average readmission rate. Understanding the contribution of HCAP is also important for identifying potentially modifiable risk factors that institutions can target to reduce readmission rates (Shorr et al., 2013).

The Population at Risk

Elderly individuals discharged from acute-care hospitals are vulnerable to thirty-day readmission and even death. In 2012, nearly one in five hospital stays among Medicare fee-for-service (FFS) beneficiaries discharged alive resulted in a subsequent rehospitalization within thirty days. Although more than 80% of Medicare beneficiaries aged 65 and older prefer to die at home, in 2013, one-third of the 1,904,640 deaths among individuals aged 65 and older in the United States occurred in a hospital — approximately the same proportion as in the previous twelve years. Among patients admitted to the hospital for pneumonia, 12.1% died within thirty days of admission; of these, nearly half died after hospital discharge (Yelena et al., 2015).

A number of studies have assessed hospital readmission rates for pneumonia, and these vary widely depending on the population studied, geographic region, and other factors. The literature indicates that readmission following an episode of pneumonia is a fairly common occurrence, particularly among those aged 65 and older and those with multiple comorbidities. Many researchers have focused on the Medicare population, reporting all-cause thirty-day readmission rates of 17% to 25%. For example, in a 2011 report based on national Medicare data, pneumonia rehospitalization rates hovered around 20% but ranged from as low as 8% to as high as 27%. This variability was explained by overall admission rates, individual case mix, quality of discharge preparation, and bed availability.

In a comparable study of nearly twelve million subjects, the thirty-day readmission rate for patients discharged following a pneumonia-related hospitalization was 20.1%, consistent with rates reported in other studies. Notably, approximately one-third (29.1%) of readmissions were attributed to pneumonia-related causes; the remainder were due to other active comorbidities. These included heart failure (7.4%), COPD (6.1%), and septicemia (3.6%), followed by nutritional or metabolic complications, gastrointestinal issues, and urinary tract infections. In another study based on hospital and outpatient Medicare records from 2006 to 2009, the thirty-day pneumonia rehospitalization rate was consistent at 18.3% (De Alba & Amin, 2014).

Root Causes of Pneumonia Readmissions

The Root Cause Analysis (RCA) focuses on the rehospitalization of patients. Primarily, due to an aging population, antibiotic resistance patterns, and an increasing prevalence of comorbidities, the number of pneumonia-related admissions has risen considerably in recent years. Pneumonia disproportionately affects already frail populations, including older adults and those with underlying chronic conditions such as diabetes, chronic obstructive pulmonary disease (COPD), and congestive heart failure. Rehospitalization imposes a further burden on these vulnerable groups.

The RCA establishes the basis for prospective prevention programs specifically related to hospital pneumonia readmissions in patients over the age of 65. Although many pneumonia readmissions — whether due to pneumonia-related causes, decompensated comorbidities, or unrelated factors — are not preventable, evidence suggests room for improvement. Several factors support the idea that pneumonia readmission rates can be reduced. A decline in all-cause rehospitalization rates has occurred in the United States: from 2007 to 2011, the national thirty-day all-cause hospital readmission rate was 19%; in 2012, this rate fell to 18.4%. In addition, controlled studies indicate that certain interventions can reduce the rate of rehospitalization for some conditions. The literature has identified a number of potentially modifiable factors that may be targeted for intervention. These factors may be patient-, physician-, or system-related (De Alba & Amin, 2014).

Conclusion

Pneumonia remains a serious health condition in the United States, responsible for approximately one million hospitalizations and nearly 140,000 rehospitalizations each year. The literature on this subject indicates that roughly one in five pneumonia patients is rehospitalized within thirty days of discharge and that the majority of rehospitalizations are not due to pneumonia-related causes. A number of studies have assessed rehospitalization rates for pneumonia; these vary widely depending on the population studied, geographic region, and other factors. The literature consistently shows that rehospitalization following a pneumonia episode is a fairly common occurrence, particularly among individuals aged 65 and older and those with multiple comorbidities.

Although many pneumonia rehospitalizations may not be preventable, reducing rehospitalization rates is achievable, as demonstrated by recent trends in CMS data. Modifiable patient-, physician-, and system-level factors can be targeted for intervention. Numerous interventions focused on care transitions, care coordination, and post-discharge follow-up have demonstrated the potential to reduce rehospitalization rates (De Alba & Amin, 2014).

References

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