Authors
- Pedersen, Mona Kyndi RN, MScN, MA(ed)
- Meyer, Gabriele PhD
- Uhrenfeldt, Lisbeth RN MScN, PhD
Abstract
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.
Article Content
Inclusion criteria
Types of participants
This systematic review will consider studies that include participants of both sexes, aged 60 years or older from western countries, who have been admitted to hospital as an in-patient, discharged to their homes or to residential care facilities and readmitted to an acute care hospital within one month. One month is defined as a period ranking between immediate after discharge until 28-31 days after discharge.. The age limit of 60+ has been chosen as the criterion for a person being considered as old and only studies where it is possible to identify participants were aged 60 or more will be included. Western countries cover the following areas: North America (USA and Canada), Australia, New Zealand and Europe. Studies on persons who are readmitted to hospital for palliative or psychiatric care and/or discharged from psychiatric of palliative wards will be excluded, as well as studies on persons readmitted for elective treatment.
Phenomena of interest
The phenomenon of interest in this review is the risk factors for hospital readmission within one month of discharge in western countries. Risk factors in this review consider non-modifiable risk markers such as demographics (age, sex, ethnicity) and modifiable risk factors, such as socioeconomics (income, education, civic status, social support), health/illness (medication, diagnosis, comorbidity, functional and cognitive capability), health care utilization (emergency room visits, out-patient department visits, GP visits) and pathway-related factors (length of stay, medical specialties involved, need for intensive care treatment).26 Studies focusing on specific treatments or diagnoses will be excluded.
Types of outcomes
The primary outcome of interest is readmission of older persons to an acute care hospital within one month of discharge from a former hospital admission. Studies that do not report on the outcome of interest as a primary or secondary outcome and at a time interval within one month will be excluded. Subgroup analyses will be conducted for studies investigating hospital readmission within shorter time intervals than one month.
Types of studies
This review will consider analytical and descriptive epidemiological study designs including prospective and retrospective cohort studies, case control studies, case series, individual case reports and cross sectional studies that evaluate risk factors for hospital readmission for inclusion. Cohort studies nested in experimental studies and studies that identify, describe and evaluate the explanatory or predictive value of risk factors for hospital readmission within one month will be included. Studies will only be included if they present results based on measures of risk such as frequencies, rates, medians, percentiles or relative measures such as relative risk (RR), odds ratios (OR) or area under ROC curve (AUC). Results from experimental studies (randomized and non-randomized controlled trials, quasi-experimental studies) or validation of screening tools and diagnostic studies are outside the scope of this review and will be excluded.
Search strategy
The search strategy aims to find both published and unpublished studies.
A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL will be undertaken, followed by analysis of the text words contained in the title and abstract and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in the English, German, French, Swedish, Norwegian and Danish languages will be considered for inclusion in this systematic review. Databases will be searched from January 1, 2004 to December 31, 2013.
The search terms and the PICOS (Population, Intervention, Comparator, Outcome, Study types)22 have been discussed and specified in collaboration between the primary and secondary reviewers and in discussion with a research librarian, aiming to identify the maximum of articles possible.
The databases to be searched for published studies will include:
PubMed, Embase, CINAHL, TRIP Database and PsycINFO.
Additional searching for published literature will include:
Hand searching reference lists and databases for studies identified in the Joanna Briggs Institute Library of Systematic Reviews, PROSPERO and the Cochrane Database of Systematic Reviews.
The search for unpublished studies will include:
Conducting an online search of unpublished studies in MedNar, Google Scholar and relevant homepages.
Initial keywords/search terms to be used will be:
Aged (Mesh) OR aged (tiab) OR elder* (tiab) OR old*(tiab)
AND
Risk (Mesh) OR risk (tiab) OR predict*(tiab) OR characteristic*(tiab)
AND
Patient Readmission (Mesh) OR readmission*(tiab) OR rehosp*(tiab) OR re hosp* OR readmit*(tiab)
AND
Epidemiologic Studies (Mesh) OR Registries (Mesh) OR epidemiology (Subheading) OR Epidemiology (Mesh) OR epidemiolog*(tiab) OR cohort*(tiab) OR registries (tiab) OR registry*(tiab) OR observati*(tiab) OR descriptiv*(tiab)
The Mesh terms are PubMed-terms and synonyms will be used when searching the other databases.
To manage the references Ref Works will be used. Records will be retrieved and added to the library by the primary reviewer. All decisions about rejecting or obtaining documents will be recorded by the same person. The primary reviewer will be responsible for the library of references. To be able to replicate the search process all searches, all decisions and steps will be documented based on PRISMA statement guidelines.27
Assessment of methodological quality
Papers selected for retrieval will be assessed independently by the primary and secondary reviewer for methodological validity prior to inclusion in the review using the following standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI); the JBI Critical Appraisal Checklist for Descriptive/Case Series and the JBI Critical Appraisal Checklist for Comparable Cohort/Case Control studies (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data collection
Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II) in combination with a self-developed data extraction tool which has been recently validated in a review by the authors of the present review and was adapted to the needs of the present review.28 The data extracted will cover specific details about the study design, such as the exposures/risk factors, settings, populations, study methods and outcomes of significance to the review objective and question. The data extraction process will be done independently by two reviewers and any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. In the case of missing information or unclear data, the author of primary studies will be contacted.
Data synthesis
Results will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. For categorical measures, results will be analyzed and reported as relative risk (RR), odds ratios (OR) or area under the ROC curve (AUC) and cut offs. For continuous measures, results will be analyzed and reported as weighted differences in frequencies/rates/means/percentiles. 95% confidence intervals will be calculated. A Random effects model will be used and heterogeneity will be assessed statistically using the standard chi-square. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest
None identified.
Acknowledgements
The authors want to thank Chief Librarian Conni Skrubbeltrang, M.L.I.Si. Medical Library Aalborg University Hospital for the advice on the systematic search strategy.
The study is partly financed by Clinic for Internal Medicine, Aalborg University Hospital and Aalborg University Hospital Science and Innovation Center. External funding is received from The A.P.Moeller Foundation for the Advancement of Medical Science, Speciallaege Heinrich Kopps Legate, Novo Nordisk Foundation and The Danish Nursing Research Foundation.
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Appendix I: Appraisal instruments
MAStARI appraisal instrument[Context Link]
Appendix II: Data extraction instruments
MAStARI data extraction instrument[Context Link]
Keywords: Hospital readmission; Risk factor; Older person