Chronically ill patients in frequent contact with the health care system are at high risk of readmission

A team of researchers from The North Denmark Region has been investigating factors characterizing senior citizens who are at particular risk of being re-hospitalized.

Pre-hospital factors rather than hospital factors account for the greatest risk of hospital readmission. This is the result of a new study of people over the age of 65 who have been admitted to a Danish hospital:

Not surprisingly, patients at risk of readmission often suffers from chronic illnesses and are already in contact with a number of different healthcare professionals. Apparently, they tend to experience a downward spiral, where repeated acute admissions and interactions between the various institutions become part of their everyday life, explains Mona Kyndi Pedersen, who is a researcher at the Department of Internal Medicine, Aalborg University Hospital.

The survey provides a contribution to understanding how organizational, medical, and not least, civil-law relationships are playing together. 

In principle, you can already assess whether a patient is likely to be readmitted based on pre-hospital information obtainable at the time of the admission. For example, if the patient is using a lot of medicine, is in frequent contact with general practitioner or a doctor on call, pays regular visits to the emergency unit or has recently been admitted to a hospital. These are all markers indicating that the patient is at high risk of being readmitted, says Mona Kyndi Pedersen.

The research team has developed a database that links information from different registries. Thereby, they have been able to describe patients' contacts with the healthcare system over time and identify cross-sector contact patterns. The information is then linked with a series of information about the individual's living conditions and social conditions.

This enabled us to describe the course of care for each individual in the year prior to the hospitalization, during the hospitalization and after the discharge, and to connect it with information about what happened in the patient's life prior to the hospitalization.

The database includes 1,275,000 hospitalisations and includes almost 500,000 people who have been admitted to a hospital once or several times in the period 2007-2010. 

According to Mona Kyndi Pedersen, the results of the study contribute to the ability of future identification of the specific groups of citizens who are at risk of readmission. 

This means that we will be able to target efforts that focus on defined issues and needs. The results can also help us clarify some of the ongoing health policy discussions, for instance the prevention of readmissions. It is time for a more integrated approach to deal with risk of excess readmissions across sectors, ends Mona Kyndi Pedersen. 

Articles

Risk assessment of acute, all-cause 30-day readmission in patients aged 65+: a nationwide, register-based cohort study

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

 

Support

This work was supported by the A.P. Moeller Foundation for the Advancement of Medical Science, Speciallaege Heinrich Kopps Legat, Novo Nordisk Foundation, and The Danish Nursing Research Foundation. They had no role in the design or conduct of this study. 

Contact

Mona Kyndi Pedersen, postdoc in clinical nursing
Department of Internal Medicine,  Aalborg University Hospital, Denmark
E-mail: mokyp@rn.dk / Tel: +45 24348870