Mona Kyndi Pedersen

Description of OPRA: A Danish database designed for the analyses of risk factors associated with 30-day hospital readmission of people aged 65+ years

Aims: To describe the construction of the Older Person at Risk Assessment (OPRA) database, the ability to link this database with existing data sources obtained from Danish nationwide population-based registries and to discuss its research potential for the analyses of risk factors associated with 30-day hospital readmission. Methods: We reviewed Danish nationwide registries to obtain information on demographic and social determinants as well as information on health and health care use in a population of hospitalised older people. The sample included all people aged 65+ years discharged from Danish public hospitals in the period from 1 January 2007 to 30 September 2010. We used personal identifiers to link and integrate the data from all events of interest with the outcome measures in the OPRA database. The database contained records of the patients, admissions and variables of interest. Results: The cohort included 1,267,752 admissions for 479,854 unique people. The rate of 30-day all-cause acute readmission was 18.9% (n=239,077) and the overall 30-day mortality was 5.0% (n=63,116). Conclusions: The OPRA database provides the possibility of linking data on health and life events in a population of people moving into retirement and ageing. Construction of the database makes it possible to outline individual life and health trajectories over time, transcending organisational boundaries within health care systems. The OPRA database is multi-component and multi-disciplinary in orientation and has been prepared to be used in a wide range of subgroup analyses, including different outcome measures and statistical methods.

Risk factors for acute care hospital readmission in older persons in Western countries: a systematic review

Background Hospital readmission in older persons is common and reported as a post-discharge adverse outcome from hospitalization. Readmission relates to a mix of factors associated with increasing age, living conditions, progression of disease as well as factors related to the processes of care. To allow health professionals to focus more intensively on patients at risk of readmission, there is a need to identify the characteristics of those patients. Objectives To identify and synthesize the best available evidence on risk factors for acute care hospital readmission within one month of discharge in older persons in Western countries. Inclusion criteria Types of participants Participants were older persons from Western countries, hospitalized and discharged home or to residential care facilities. Types of intervention(s)/phenomena of interest The factors of interest considered generic factors related to socio-demographics, health characteristics and clinical and organizational factors related to the care pathway. Types of studies The current review considered analytical and descriptive epidemiological study designs that evaluated risk factors for acute care hospital readmission. Outcomes The outcome was readmission to an acute care hospital within one month of discharge. Search strategy A three-step search was utilized to find published and unpublished studies in English, French, German, Norwegian, Swedish or Danish. Five electronic databases were searched from 2004 to 2013, followed by a manual search for additional studies. Methodological quality Methodological quality was assessed independently by two reviewers, using the standardized Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) critical appraisal tool. Data extraction Data were extracted verbatim using a data extraction form, which identified the components from the standardized JBI data extraction tool from JBI-MAStARI and was adapted to the needs of the present review. Data synthesis Due to the clinical and methodological heterogeneity of the studies included, a narrative summary and metasynthesis of the quantitative findings was conducted. Results Based on a review of nine studies from ten Western countries, we found several significant risk factors pertaining to readmission to an acute care hospital within one month of discharge in persons aged 65 years and over. Factors associated with higher risk of hospital readmission covered socio-demographics such as higher age, male gender, ethnicity, living conditions, health characteristics such as poor overall condition and functional disability as well as prior admissions. Organizational factors including length of hospital stay, method of referral and discharge destination were associated with increased risk of acute care hospital readmission. Conclusion We found several significant, but inconsistent, associations between readmission to an acute care hospital within one month of discharge in persons aged 65 years and over. These associations involved a mix of socio-demographic factors, factors related to health and illness, previous hospitalizations, length of stay as well as clinical and organizational determinants related to the index admission. Although more studies concluded that certain diagnoses or comorbid conditions affected the risk of readmission, they did not agree on any disease in particular. Due to the breadth and diversity of variables examined and the lack of comparability of findings, the impact of these varying factors and their value as risk adjusters and application in different settings and populations are limited.

risk factors for acute care hospital readmission in persons aged 60 and over from western countries: a systematic review protocol

Review question/objective The objective of this systematic review is to identify and synthesize the best available evidence on risk factors for acute care hospital readmission in older people. More specifically, the review question is: What are the main risk factors for acute care hospital readmission within one month of discharge in people aged 60 years or older from western countries? Background In most western countries the population is aging. Both the number of older persons is increasing as well as the complexity of their health needs. In addition, advances in medical science have enabled more active treatment for people with multiple co‐morbidities and patients in health care, on average, need more intensive management.1 This is placing additional pressure on clinical time and resources within health care services and support.2 Limiting rising costs and increasing ‘efficiency’ is a leading policy goal in all health care systems and health units, including hospitals. Different initiatives have been undertaken to limit costs, including reducing the average length of hospital stay and decreasing the number of beds in hospitals.1 Hospital readmission, defined as a return to hospital shortly after discharge from a recent hospital stay,3, 4 has been reported over a considerable period of time,5, 6 as a common negative health outcome from hospitalization of older persons.3, 4, 7, 8, 9, 10 Readmission rates are used as indicators of quality of hospital care.14 The reported rates of readmission vary across populations, countries, hospitals and medical specialities.4,10 A report from the Danish Health and Medicines Authority has found for example, that one out of five persons aged 67 and over was readmitted within 30 days of discharge.15 A French prospective multi‐center study found the hospital readmission rate to be 14%, varying between hospitals and ranging from 9.8 to 17%.9 A retrospective cohort study from the USA found the incidence of hospital readmission to be 17%.3 Hospital readmission is emotionally upsetting for many older persons and an unnecessary burden of illness, leading to anxiety and distress.11,12 Being transferred from one setting to another may be experienced as a critical event; unpredictable, scary and stressful for the person being transferred.12 Unplanned readmissions of recently discharged patients also impose a significant burden on hospitals with limited bed capacity and ressources.13 The literature relating to hospital readmissions identifies a subset of patients who may be categorized as ‘risk‐patients’.3,14 The term older person varies across countries, across diverse populations and cultures within countries. Cheek refers to different categories of being old;1 ‘young‐old’, ‘old‐old’ or ‘oldest‐old’, in the range of people known as older. According to the WHO, in most developed countries the chronological age of 65 years is accepted as a definition of becoming an ‘older person’ ‐ equivalent to retirement age.17 An agreed United Nations (UN) decision defines the age 60+ as the cut off for a person being old.17 The category of older persons ‘at risk’, understood as clinically, complex and frail persons,18 is characterized by co‐morbid conditions,16 polypharmacy19 and at increased risk of negative outcomes and future readmission.18,20 Not meeting the specific needs of these patients can make them become ‘frequent flyers’; patients who keep bouncing back to hospital.21 Identifying the characteristics of this group of patients may distinguish patients most likely to benefit from interventions and thereby lead to substantial reductions in the rate of hospital readmissions among older persons.8,21 In this systematic review the term ‘risk’ refers to the probability of a deleterious or adverse outcome during everyday life, or an exposure to a risk factor.22 An initial literature review was undertaken for the development of this protocol. This suggests that a varying range of hospital readmissions in different settings13 and populations21 may have been avoidable and could have been prevented.11,14 Second, it clarified that a number of studies have been undertaken to identify risk factors for hospital readmission in older persons and that these suggest that hospital readmissions among older persons are related to unmet complex care needs23 and a mix of health‐related and social factors.4,5,10,24,25 The literature identifies not only demographic variables (age, gender, diagnosis, co morbidities) as risk factors, but also conditions related to functional status and cognitive function. Other risk factors that have been highlighted are discharge and health care system related factors such as length of stay and the number of previous hospitalizations.3 A recent systematic review summarizing prospective cohort studies found that risk factors as well as protective factors for hospital readmission, such as being a woman and life satisfaction, differed according to the follow up period.10 The evidence base identified by the initial literature review comprised a range of study designs, data sources, patient populations, settings and age groups. It also showed a lack of consistency of study objectives, definitions and outcome measures. The evidence base identified by the initial literature review revealed no systematic review dealing with the same topic. The proposed systematic review is motivated firstly by the absence of a systematic review on the topic within the last three years. Secondly, by the importance of hospital administrators and policy having access to the best available evidence on risk factors for hospital readmissions in older persons, in order to design effective strategies to reduce readmissions.