Wednesday, September 27, 2023
HomeHospital MedicineHigh number of older adults re-admitted to hospital with pre-existing infections

High number of older adults re-admitted to hospital with pre-existing infections

Too many older adults readmitted to hospitals with same infections they took home. However, a University of Michigan study found that a disproportionately high number of adults return for pre-existing, or linked infections – infections presumably treated during the first hospital stay. Further, patients discharged home or to home care were more likely to return with a linked infection than those discharged to skilled nursing homes.

"We found that as many as 5% of patients leaving the hospital with an infection have a re-admission for that pre-existing infection – that's bad," said study lead author Geoffrey Hoffman, assistant professor in the U-M School of Nursing. Hoffman and Lona Mody, professor of internal medicine and epidemiology, and colleagues examined Medicare records for more than 318,000 hospital discharges for patients 65 and older. They found that, overall, 2.5% of hospitalised older adults return because of linked infections.

The most common infection was Clostridioides difficile (roughly 5% readmission), a potentially deadly germ that causes diarrhea and colitis, followed by urinary tract infections (2.4% readmission).

Hoffman said the overall 2.5% re-admission rate looks small, but context is important. First, it's critical to remember that hospitals know how to treat these infections, and knew the patient had the infection upon discharge. "Presumably they've been treated for the infection since the hospital has already billed Medicare," Hoffman said. "Re-admissions shouldn't be zero, but they should be much closer to zero."

Also, the population of patients with the same diagnosis at re-admission and discharge is very narrow, Hoffman said, so the number will by default be much smaller than overall hospital readmissions or readmissions for complex conditions.

For instance, heart failure and chronic obstructive pulmonary disease, or COPD, have about 10% and 8% linked readmission rates, respectively. However, unlike infections, those complex conditions aren't entirely curable, so complications are more frequent, Hoffman said.

Surprisingly, patients discharged home or to home care were 38% more likely to return with a linked infection than those discharged to skilled nursing facilities, Hoffman said. "I was very surprised," he said. "This is somewhat conflated with the conventional wisdom, which is that skilled nursing facilities are warehouses for infection transmission.

"The fact that patients discharged to skilled nursing had lower readmission rates for Clostridioides difficile infections than people discharged home is pretty amazing, given that those patients by definition are sicker and would more likely to be re-admitted than those discharged home."

This suggests that while it's true that infections spread at high rates in skilled nursing homes, these facilities are also adept at treating them. Fifty percent of the patients were discharged to skilled nursing, 26% to home health care and 24% to home.

"There are probably some gaps in self-care for patients going home with an infection from the hospital," he said. "This suggests home health care agencies aren't up to snuff with infection control and patients going home without home health care probably need better training, as do their caregivers."

So, how can patients and family members protect against readmission? Be their own best advocate, Hoffman said. Ask questions until discharge instructions are clear.

The research was funded by the Agency for Healthcare Research and Quality, U-M Older Americans Independence Centre Research Education Core and the U-M Pepper Centre pilot.

Objectives: Although preventable, healthcare‐associated infections (HAIs) are commonly observed in post‐acute care settings for at‐risk older adults and are a leading cause of hospital readmissions. However, whether HAIs resulting in avoidable readmissions for preexisting HAIs (the same HAI as at the index admission) are more common for patients discharged to post‐acute care as opposed to home is unknown. We examined the risk of preexisting HAI readmissions according to patient discharge disposition and comorbidity level.

Design: We used 2013‐2014 national hospital discharge data to estimate the likelihood of readmissions for preexisting HAIs according to patients' discharge disposition and whether the likelihood varies according to patient comorbidity level, across four common types of HAIs (not including respiratory infections).
Participants: A total of 702 304 hospital discharges for Medicare beneficiaries 65 years or older.

Measurements: Our outcome was a 30‐day preexisting, or “linked,” HAI readmission (readmission involving the same HAI diagnosis as at the index admission). Patient discharge disposition was skilled nursing facility (SNF), home health care, and home care without home health care (“home”).
Results: Of 702 304 index admissions involving HAI treatment, 353 073 (50%) were discharged to a SNF, 179 490 (26%) to home health care, and 169 872 (24%) to home. Overall, 17 523 (2.5%) of preexisting HAIs resulted in linked HAI readmissions, which were more common for Clostridioides difficile infections (4.0%) and urinary tract infections (2.4%) than surgical site infections (1.1%; P < .001). Being discharged to a SNF compared to home or to home health care was associated with a 1.15 percentage point (95% confidence interval = −1.29 to −1.00), or 38%, lower risk of a linked HAI readmission. This risk difference was observed to increase with greater patient comorbidity.
Conclusions: SNF discharges were associated with fewer avoidable readmissions for preexisting HAIs compared with home discharges. Further research to identify modifiable mechanisms that improve posthospital infection care at home is needed.

Geoffrey J Hoffman, Lillian C Min, Haiyin Liu, Dan J Marciniak, Lona Mody

[link url=""]University of Michigan material[/link]

[link url=""]Journal of the American Geriatrics Society abstract[/link]

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