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Hospital readmissions in Portugal over the last decade Introdução à medicina II Class 1 FMUP 2010/2011 Ana Rita Gomes Andreia Oliveira Bernardo Pinto Carlos.

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Presentation on theme: "Hospital readmissions in Portugal over the last decade Introdução à medicina II Class 1 FMUP 2010/2011 Ana Rita Gomes Andreia Oliveira Bernardo Pinto Carlos."— Presentation transcript:

1 Hospital readmissions in Portugal over the last decade Introdução à medicina II Class 1 FMUP 2010/2011 Ana Rita Gomes Andreia Oliveira Bernardo Pinto Carlos Ivo Gustavo Costa João Ramos Joel Silva Maria Carolina Carneiro Maria João Cunha Maria João Domingues Advisor: Professor Alberto Freitas

2 Summary 1. Introduction -Background -Justification 2. Aims 3. Type of Study 4. Articles’ search 5. Statistical analysis 6. Results 7. Discussion 8. References 2

3 Hospital management should concern on: patient needs hospital inside organization security economical sustainability In the U.S.A., readmissions’ number is increasing due to: Economical pressure Reduction of hospitalization endurance - earlier discharges Deficient/inadequate health care Anderson, 1999, Nursing Research. 1. Introduction - Background 3

4 Hospital readmission: “Hospitalization within 1, 2, 4, or 12 months of discharge” Often used as an indicator of health care quality Benbassat, 2000, Archives of Internal Medicine Readmissions are related with: Patients’ profile (age, sex, medical history,...) Benbassat, 2000, Archives of Internal Medicine Hospital characteristics (technology, organization,...) Heggestad, 2002, Hospital Services Research 1. Introduction - Background 4

5 “According to different pathologies, readmission rates in adults vary between 5-29%” Hasan, 2001, Int J Qual Health Care “(…) 12% to 75% of all readmissions can be prevented by patient education, pre-discharge assessment, and domiciliary aftercare” Benbassat, 2000, Archives of Internal Medicine 1. Introduction - Background 5

6 Studying Hospital Readmissions allows to: Learn about the Portuguese hospital situation Understand which factors increase them Show how hospital costs can be reduced and treatment quality may be improved, by reducing hospital readmissions Ashish, 2009, The New England Journal Of Medicine 1. Introduction - Justification 6

7 However, there are very few studies in Portugal, characterizing hospital readmissions, in spite of their importance. 1. Introduction - Justification 7

8 Summary 8 1. Introduction 2. Aims 3. Type of Study 4. Articles’ search 5. Statistical analysis 6. Results 7. Discussion 8. References

9 2. Aims 9 ∙ To characterize the evolution of hospital readmissions in the past decade; ∙ To study hospital readmissions in relation to hospital mortality rates. ∙ To define an average profile for the “readmitted citizen”, according to: - Gender; - Age; - Major Diagnostic Category; ∙ To study the rate of hospital readmissions according to the region and complexity of the hospital; ∙ To compare Portuguese hospital readmissions’ rates with readmissions’ rates in Europe and North America.

10 Summary 1. Introduction 2. Aims 3. Type of Study 4. Articles’ search 5. Statistical analysis 6. Results 7. Discussion 8. References 10

11 3. Type of Study In order to study Portuguese hospital readmissions, we did an analytical observational study Observational study: This study requires the observation and analysis of data and no direct intervention on the populations Analytical study: This study requires the analysis of data from a National Health System`s database, in order to study different variables 11

12 Summary 1. Introduction 2. Aims 3. Type of Study 4. Articles’ search -Databases used -Query Strategies -Queries Used -Inclusion and Exclusion Criteria 5. Statistical analysis 6. Results 7. Discussion 8. References 12

13 4. Articles’ search In order to gather information about readmissions rates in Europe and North America, we searched for several articles. This also allowed us (in an early stage of this study) to learn more about hospital readmissions and to speculate about the expected results. 13

14 4. Articles’ search - Databases used 14

15 Usage of MeSH terms: “Patient Readmission” “Quality of Health Care” “Mortality” Usage of Keywords: “30-days” “Unplanned” “Portuguese” “Portugal” “Greece” “Spain” “Italy” Usage of Boolean Operators (AND, OR, NOT) 4. Articles’ search - Query Strategies 15

16 Searching for articles in general: "Patient Readmission"[Mesh] AND ("Quality of Health Care"[Mesh] OR "Mortality"[Mesh] OR hospital type OR patient profile) Searching for articles related to Portugal, Spain, Italy or Greece: "Patient Readmission"[Mesh] AND ("Portugal" OR "Spain" OR "Italy" OR "Greece")* * We are focusing on those countries, since they share several social, economical, geographical and historical characteristics with Portugal. 4. Articles’ search - Queries Used 16

17 Inclusion Articles relating hospital readmissions with: -Mortality rates -Type of Hospital -Particular patient’s profile Exclusion - Low quality rate* -Language other than English, Portuguese, Spanish or Italian 4. Articles’ search - Inclusion and Exclusion Criteria 17

18 * Articles were rated according to criteria expressed in an article published by Sindhu et al., 1997 Best qualified articles *Full textAbstractsTitles 4. Articles’ search - Inclusion and Exclusion Criteria 18

19 Summary 1. Introduction 2. Aims 3. Type of Study 4. Articles’ search 5.Statistical analysis -Database and software used -Tests used -Strategy adopted -Syntax 6. Results 7. Discussion 8. References 19

20 5. Statistical analysis – Database and software used We analysed a National Health’s System database; This database includes hospitalizations in Portuguese public hospitals, in a period of 9 years ( ); This database was edited, using SPSS (version 18) and was given by our advisor*. 20 * Database provided by ACSS (Central Autority for Health’s Systems).

21 5. Statistical Analysis – Strategy adopted 21 Select hospital readmissions within 30 days by Major Diagnosis Group Select only unplanned readmissions Analyse hospital readmissions according to the variables defined and apply the appropriate statistical test

22 5. Statistical Analysis – Variables used 22 Percentage of hospital readmissions per year VariableType of VariableDatabase’s variables used Occurence of ReadmissionsDiscreteRINT30; MDC; ADM_TIP YearDiscreteENT1 Hospital mortalityDiscreteDSP GenderDiscreteSEX Age GroupDiscreteCL_IDADAN Major Diagnosis GroupDiscreteMDC Nuts II regionsDiscreteHOSP_RESIDE Complexity of the hospitalDiscreteTIPOC This allowed us to study only unplanned 30-days readmissions by the same Major Diagnosis Group

23 5. Statistical Analysis – Tests used 23 Since the variables studied are discrete and since we have a large number of episodes, we applied chi-square test, in order to compare variables statistically. We considered statistically significant, p values smaller then 

24 5. Statistical Analysis – Syntax 24

25 Summary Introduction 2. Aims 3. Type of Study 4. Articles’ search 5. Statistical analysis 6.Results - Presentation of results according to aims 7. Discussion 8. References

26 6. Results – Presentation of results according to aims 26 From 2000 to 2008, we found a rate of unplanned readmissions within 30-days )by the same Major Diagnois Group) of 2.4%. First Aim: To characterize the evolution of hospital readmissions in the past decade. Results:

27 Percentage of hospital readmissions per year Year Readmissions Hospitalizations Frequency Rate (%) , , , , , , , , , , , , , ,020, , ,657, , ,801,405 Total 262, ,060,523 Although the number of unplanned readmissions is increasing, its rate has actually decreased (although the rates increased in the first five years). 6. Results – Presentation of results according to aims p-value for chi-square test <0.001

28 Readmissions rates by hospital mortality Hospital Mortality FrequencyRate (%) Readmissions episodes 25, Non-readmissions episodes 356, Total 382, Higher levels of readmissions are associated with higher hospital mortality rates. 28 Second Aim: To study hospital readmissions in relation to hospital mortality rates. Results: 6. Results – Presentation of results according to aims p-value for chi-square test <0.001

29 Readmissions rates by gender Gender Readmissions Hospitalizations Frequency Rate (%) Male126, ,946,762 Female137, ,139,538 Total262, ,060, Males have a higher rate of readmissions than females. Third aim: To define an average profile for the “readmitted citizen”, according to gender, age and major diagnosis category: 6. Results – Presentation of results according to aims p-value for chi-square test <0.001

30 30 Rates of Hospital readmissions by age group Age Group (years) Readmissions Hospitalizations Frequency Rate (%) , ,721, , , , ,218, , ,700, , ,835,171 Total262, ,060,523 We divided age into five age groups, since this division is widely used by the Health Ministery. Individuals with more than 65 years have a higher rate of readmissions. 6. Results – Presentation of results according to aims p-value for chi-square test <0.001

31 Readmissions rates (%) Readmissions rates per Major Diagnostic Category Results – Presentation of results according to aims p<0.001

32 In order to study hospital readmissions by region, we adopted NUTS II division NUTS II divides Mainland Portugal into five regions – Northern Portugal, Central Portugal, Lisbon, Alentejo and Algarve We found out that Algarve and Alentejo have higher readmissions’ rates Results - Presentation of results according to aims Fourth Aim: To study the rate of hospital readmissions according to the region and complexity of the hospital. Results:

33 Rates of readmissions by NUTS II regions Region Readmissions Hospitalizations frequency FrequencyRate (%) Northern Portugal109, ,026,880 Central Portugal71, ,621,398 Lisbon48, ,435,054 Alentejo19, ,230 Algarve13, ,961 Total262, ,060, Results – Presentation of results according to aims p-value for chi-square test <0.001

34 Rates of readmissions by complexity of the hospital Readmissions Hospitalizations Frequency Rate (%) Central Hospitals68, ,157,991 District Hospitals175, ,419,403 District Hospitals Level 1 18, ,554 Total262, ,060, Central hospitals have significantly a smaller rate of hospital readmissions than District Hospitals and District Hospitals Level Results - Presentation of results according to aims p-value for chi-square test <0.001

35 35 Fifth aim: To compare Portuguese hospital readmissions’ rates with readmissions’ rates in Europe and North America. Results: We found no nation-wide studies concerning 30-days unplanned hospital readmissions’ rates. However, there were some articles, studying 30-days unplanned readmissions’ rates in specific hospitals. We compared our results with the ones presented in those articles. 6. Results – Presentation of results according to aims

36 36 Readmission rates in Europe and North America 6. Results – Presentation of results according to aims González, 2010, Revista Clínica Española Abenhaim, 2000, Canadian Medical Association Journal Boulding, 2011, The American Journal of Managed Care Allaudeen, 2011, Journal of Hospital Medicine

37 Summary Introduction 2. Aims 3. Type of study 4. Articles’ search 5. Statistical analysis 6. Results 7. Discussion 8. References

38 7. Discussion – Conclusions 38 Readmissions’ rates increased (and stabilized) between 2000 and 2006 and decreased since Perhaps this happened because, since 2007, more ambulatory care episodes were included in the database. Readmitted individuals have higher rates of hospital mortality. This conclusion was also found in the articles we read. This might be associated with diseases that are not well treated in the hospital or might be due to the fact that readmissions are more common in patients with more severe cases. Older people have higher rates of readmissions, probably, because their health is more fragile. Morbidity and functional disability are risk factors for hospital readmissions in elderly patients. Alentejo and Algarve were the regions with higher readmissions’ rates. This may be due to the fact that there is a higher proportion of older people in these regions. In Portuguese Census, 2001 García-Pérez, 2011, QJM

39 7. Discussion - Limitations 39 This database only contained episodes from Public Hospitals in Mainland Portugal. The patient’s code changes every year and it is different in each hospital. This means that the “true” readmissions’ rate value is bigger than the one, we found. We couldn’t exclude ambulatory care episodes from the database (this probably led to lower readmissions rates in 2007 and 2008). We used administrative data in a health study. These data might not be completely accurate or complete. However, administrative data is commonly used in such studies, since is accessible and inexpensive. There are no articles concerning 30-days unplanned hospital readmissions in Portugal, with which we could compare results. Torchiana, 2005, J Thorac Cardiovasc Surg

40 7. Discussion – Strong Points 40 This is the first study of this kind in Portugal. We analyzed all hospitalizations in public hospitals from Mainland Portugal from 2000 to 2008, and not just a sample of them. The fact that we analyzed hospital readmissions from 2000 to 2008 allowed us to see the evolution of hospital readmissions in Portugal. We compared several variables and the data we found, can be used as a starting point to reduce hospital readmissions.

41 Summary Introduction 2. Aims 3. Type of study 4. Articles’ search 5. Statistical analysis 6. Results 7. Discussion 8.References

42 Benbassat J., Taragin M., MD. “Hospital Readmissions as a Measure of Quality of Health Care”. Archives of Internal Medicine 2000; 160: Ashish K. Jha, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D., Public Reporting of Discharge Planning and Rates of Readmissions, The New England Journal Of Medicine, 361;27, 2009 Utzolino S, Kaffarnik M, Keck T, Berlet M, Hopt UT. Unplanned discharges from a surgical intensive care unit: readmissions and mortality. J Crit Care 2010 Sep Hasan et al, Readmission of patients to hospital: still ill defined and poorly understood, Int J Qual Health Care, 2001; 13(3): Heggestad, T. Do hospital length of stay and staffing ratio affect elderly patients' risk of readmission? A nation-wide study of Norwegian hospitals. Hospital Services Research, 2002; 37(3): Anderson, Mary Ann; Helms, Lelia B.; Hanson, Kathleen S.; DeVilder, Nancy W., Unplanned Hospital Readmissions: A Home Care Perspective. Nursing Reserach. 1999;48(6): Sindhu F, Carpenter L, Seers K., Development of a tool to rate the quality assessment of randomized controlled trials using a Delphi technique. Journal of Advanced Nursing Jun;25(6): García-Pérez L, Linertová R, Lorenzo-Riera A, Vázquez-Díaz JR, Duque-González B, Sarría-Santamera A. QJM May 10. Abenhaim H.A., Kahn S.R., Raffoul J., Becker R. Program description: A hospitalistrun, medical short-stay unit in a teaching hospital. CMAJ. 2000; 163: Seoane González B, Nicolás Miguel R, Ramos Polledo V, Pellicer Vázquez C, de la Iglesia Martínez F. Short stay medical unit. Causes of readmissions. Rev Clin Esp Mar;210(3): References 42

43 Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining readmission risk factors for general medicine patients. Journal of Hospital Medicine Feb;6(2): Maurer PP, Ballmer PE. Hospital readmissions--are they predictable and avoidable? Swiss Med Wkly Oct 16;134(41-42): Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care Jan;17(1):41-8. Torchiana DF, Meyer GS. Use of administrative data for clinical quality measurement. J Thorac Cardiovasc Surg Jun;129(6): References 43


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