Hospital readmissions represent a constant problem in hospitals, as if their causes are not identified, measured and controlled, they can increase risks for patients and financial losses for institutions.
Hospital readmission is the term used by Anvisa (Brazil), Medicare (USA) and other health agencies worldwide to refer to the calculation of the patient’s return within 30 days of receiving discharge.
Studies in the literature calculate readmissions in 28 to 30 days, identifying rates that vary from 5 to 25%, using the following formula: (number of readmissions in the period / number of total discharges in the period) × 100.
Studies show that rates vary from 18 to 25% for cardiovascular and respiratory diseases, especially in patients over 60 years of age, where comorbidities are present, representing an additional cost to the healthcare system.
The readmission rate after hospital discharge fell from 21.9% in 2019 to 17.1% in 2020 and 16% in 2021, according to data from Fundação Getúlio Vargas.
The costs of readmissions are so significant that the package of measures known as Obamacare, in the USA since 2012, determines that readmissions are burdened by the hospital, which “must treat the patient well from the first time”.
The literature demonstrates several factors responsible for hospital readmissions.
Hospital readmission by teenage mothers
Refers to the phenomenon of teenage mothers returning to the hospital after giving birth or postpartum care.
It can occur due to complications during childbirth, lack of family support, lack of education about baby care and socioeconomic factors.
The goal is to reduce readmissions through education programs, social support and access to family planning services.
Hospital readmission due to social determinants
It involves patients who return to the hospital due to health problems related to social determinants, such as poverty, homelessness, alcoholism, limited access to healthy foods, difficulty accessing medicines and poor education.
Social determinants have a significant impact on health, and frequent readmission may be a reflection of these underlying issues.
Interdisciplinary approaches are needed to address this issue, including cooperation between health and social care services.
Early hospital readmission
Refers to patients who return to the hospital within a short period of time after initial medical discharge.
It may occur due to premature hospital discharge, lack of continuity of care, lack of adherence to treatment or previously unidentified complications. It can also occur in situations where in-hospital care was not of adequate quality.
It is important to improve care coordination, patient education, and post-discharge follow-up to prevent early readmissions.
Hospital readmission for chronic diseases
It involves patients with chronic diseases, such as heart failure, chronic obstructive pulmonary disease (COPD) and diabetes, who return to the hospital due to complications or exacerbations of these conditions. It usually happens when patients do not follow the necessary recommendations or do not adhere to pharmacological treatment and do not pharmacological.
Proper management of chronic diseases involves patient education, treatment adherence, regular monitoring and preventive interventions.
Coordinated care programs and effective transitions of care can reduce readmissions for chronic illnesses.
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In all of these scenarios, preventing hospital readmission involves a holistic approach that takes into account medical, social and lifestyle factors. Care coordination and health promotion are essential to minimize readmissions and improve patients’ quality of life.
Given this scenario, the importance of quality certifications in hospital institutions is fundamental to contributing to the reduction in hospital readmission rates, and also for the greater good, to improve the quality, safety, effectiveness of health services and especially for patients, where, in these certification processes, health professionals are instructed to involve them in their respective care, that is, they carry out structured and appropriate discharge planning for each type of patient, according to their social and environmental conditions, where they are informed regarding knowledge of their pathology, treatments, care, recommendations, among other information, both during the in-hospital period and information regarding self-care at home. Of course, we have situations, as previously mentioned, that can worsen the condition of patients, such as social and environmental factors, hence the importance of public authorities investing in these situations, with monitoring and visits by health professionals to these most vulnerable patients, offering a patient-centered care, checking access to and adherence to medications, as well as following recommendations.
Some studies demonstrate some data regarding hospital readmission:
- Hollaway, Thomas and Shapiro (1998). Approximately a quarter of MEDICARE hospitalization costs are due to readmissions that occur within 60 days of hospital discharge. High readmission rates may be due to poor quality of care. The main diseases in this study were Heart Failure (HF), Diabetes Melitus and Chronic Obstructive Pulmonary Disease (COPD).
- Ashton et al, stated in a study that readmission within 31 days of discharge is linked to the in-hospital treatment process, which increases the risk of readmission by 55% if this treatment was of relatively low quality.
- Kossovsky et al (2000), for patients with heart failure, readmitted after 31 days after discharge, demonstrated a rate of 7.1%. In this case, the determining factor was suboptimal preparation for hospital discharge and had no relationship with the quality of in-hospital care and the clinical and demographic characteristics of the patients were determining factors for this fact.
- In a large study carried out by Westert et al (2002), data were presented from three European countries (Finland, Scotland and the Netherlands) and three American states (New York, Washington and California), and aimed to analyze whether readmission rates vary between causes of hospitalization and populations and whether length of stay is inversely related to readmission rates. The diseases selected were: Heart Failure, Diabetes, Chronic Obstructive Pulmonary Disease (COPD), Asthma, Heart Attack and some surgical procedures. The results of this study demonstrated that Heart Failure and COPD were responsible for the higher readmission rate in Europe (10.9%) than in the USA (8.1%).
- Halfon et al (2002) reported in a study that the readmission rate in Swiss hospitals is around 5%.
- Data from Heggestad (2002), in hospitals in Norway for patients aged 65 years or older, the rate was 8.57%.
- Lagoe et al (2001) obtained a rate of 9% in a New York hospital.
A Brazilian study carried out by Rocha, Simões and Guedes (1997), focused on comparing patients from the SUS (the brazilian public health system), group medicine and private patients, in relation to readmission rates. The results of this study demonstrated that patients with more than one hospitalization in the year were higher in the group medicine category, 16.4%, SUS patients with a rate of 16.3% and in patients in the private category the rate was 11.1%. In this study, all repeat readmissions throughout the year were counted.
In a study published in the Revista Brasileira de Enfermagem, making a relationship between self-care and readmission of patients with heart failure, it was demonstrated that the less knowledge the patient has regarding their underlying disease, the greater the number of hospitalizations due to HF. decompensated, and that this disease is responsible for 21.6% of total hospital readmissions, with the majority in this study being male and over 61 years of age. This demonstrates the importance of guidance, education, knowledge, and patient involvement in their underlying disease and treatment.
Below are some recommendations for mitigating and reducing hospital readmissions:
- Health Data Integration: Integrating electronic medical record systems and sharing data between hospitals and clinics can improve continuity of care by reducing errors and unnecessary readmissions.
- Telemedicine and Remote Monitoring: Telemedicine and remote monitoring are being used to monitor patients after discharge, identify complications early and adjust treatments, thus reducing the need for readmissions, mainly related to patients’ adherence to medications and following medical recommendations.
- Alert Systems: Automated alert systems can help identify patients at risk of readmission, allowing for early intervention and adjustment of treatments.
- Care Transition Management Programs: Focus specifically on ensuring a smooth transition of care from the hospital to the home environment, with follow-up visits and care coordination.
- Use of Apps and Mobile Technology: Apps and mobile devices ( smartphones , smartwatches ) are being used to educate patients, remind them to take medications, and monitor their health after hospital discharge.
- Psychosocial Support: Psychological and social support can play an important role in preventing readmissions, especially in patients facing emotional stress, anxiety, or social isolation.
- Preventive Medicine Programs: Focus on disease prevention. Vaccination, screening and regular screening can reduce the need for readmissions related to preventable complications.
- Personalized Medicine: Personalized medicine approaches, which take into account patients’ individual genetic and physiological characteristics, can result in more effective treatments and a lower risk of readmission.
- Rehabilitation Programs: Physical and occupational rehabilitation programs can help patients recover completely after surgical procedures or medical events, thus reducing the likelihood of readmission, especially in patients with cardiovascular diseases.
- Partnerships with Pharmacies and Community Health Professionals: Partnerships with local pharmacies and community health professionals can ensure that patients have access to medicines and appropriate follow-up care, involving public authorities and facilitating access to medicines for patients with the greatest need.
- Healthcare Professional Training: The importance of ongoing training of healthcare professionals to ensure they are up to date with best practices and can prevent medical errors that lead to readmissions, and carry out effective discharge planning.
- Involvement of the patient’s family during discharge: The involvement of both the patient and family is important in post-discharge care, as following recommendations and adhering to treatment will reduce the rate of readmissions.
In short, hospital readmission is a significant challenge that burdens the healthcare system and negatively impacts patients’ quality of life. To mitigate this problem, it is crucial to adopt preventive approaches, such as continued care, post-discharge monitoring and patient and family education, use of quality tools, apply new methodologies, such as Lean Healthcare, in addition to improving coordination between healthcare professionals. and promote awareness about the importance of self-care. Readmitting patients is Muda (waste in Lean terminology) and must be eliminated, which is why they must be treated well the first time, with higher quality care.
These measures, when implemented effectively, have the potential to reduce readmission rates, improve clinical outcomes, and provide a more efficient, patient-centered healthcare system.
Bibliographic references
- Teston EF, Silva JP, Garanhani ML, Marcon SS, Early Hospital Readmission from the Perspective of Chronic Patients, 2016, Universidade Federal do Ceará.
- Merli, Ana Paula Delgado, 2007, Readmissions at Hospital De Bauru.
- AC Linn, K Azzolin, Souza MN,2016, Association between Self-care and hospital readmission of Patients with Heart Failure.
- LM Hayakawa, Schmidt KT, Rosseto EG, Souza SNDH, Bengozi TM, 2010 Incidence of readmission of very low birth weight premature infants born in a university hospital.