The Unique Needs of Older Adults Readmitted to the Hospital

To the Editor: Approximately 20% of Medicare beneficiaries are readmitted within 30 days of discharge from the hospital, costing $17.4 billion per year.1 A number of studies have examined the factors associated with risk of hospital readmissions.1 To the best of the knowledge of the authors of the current study, no studies have examined the characteristics of individuals who are on their second hospital stay. Identification of these characteristics is important for quality care, better interventions, and economic reasons.2 This study was performed to examine the characteristics and vulnerabilities of individuals aged 65 and older who had a second hospital stay within 30 days of discharge. Acute Care for Elders (ACE) Tracker is a checklist unique to Aurora's healthcare system created from the electronic health record (EHR) that may be used at the bedside.3, 4 It pulls data already present in the EHR, and no additional resources are required to create the checklist. Inclusion criteria were admission to the hospital and aged 65 and older. To provide a convenience sample, the ACE Tracker checklist was printed every Wednesday for a month. Data were collected on demographic characteristics, number of medications, cognitive status, presence of delirium, high-risk medications using the Beers criteria,5 Morse fall score, history of falls, bed rest, urinary catheter use, wound care, pressure ulcers, Braden score, and pain score. Functional status was defined according to Katz activity of daily living (ADL) score or Morse fall score. Delirium was defined according to symptoms of delirium as noted by a nurse, use of physical restraints, and use of haloperidol on the ACE Tracker. Cognitive impairment was defined as history of dementia or use of common medications for memory loss. Use of therapies was defined according to physician orders placed for physical, speech, or occupational therapies. Readmission was defined as a hospital stay in the healthcare system preceding the current hospital stay within the prior 30 days. One thousand three hundred six ACE Tracker encounters were included for 966 individuals. Statistical analysis was performed for the 966 individuals. The chi-square test was used for categorical variables and the t-test for continuous variables. Logistic regression was used to identify risk factors for 30-day readmission. An alpha level of .05 was used for all statistical tests. All statistical analysis was done using SAS 9.2 software (SAS Institute, Inc., Cary, NC). The study was approved by the Aurora institutional review board. One hundred fifty (15.5%) of the 966 individuals (average age 77.7 ± 7.8, range 65–98) were rehospitalized (Table 1). The average length of the original hospital stay was 6.5 ± 7.7 days for those who were readmitted and 6.0 ± 10.4 days for those who were not (P = .50). The overall mean Katz ADL score was 9 out of 12, and 70% had a Morse fall score greater than 40; the high-risk Morse fall score is 45 or greater. The overall use of Beers potentially inappropriate medications was 37%, and the mean number of medications was 13.0 ± 5.1. Participants who were rehospitalized were prescribed more medications than those who had only one admission (13.0 vs 11.6, P = .002) and more likely to be taking Beers potentially inappropriate medications (44% vs 32.5%, P = .03) and have a urinary catheter (28.7% vs 18.8%, P = .02), a pressure ulcer (14.7% vs 9.9%, P = .004); a wound care consultation (16.8% vs 9.9%, P = 0.048), and an albumin level less than 3.5 g/dL (95% vs 81%, P < .001). There was no difference in the presence of delirium, decline in functional status, Braden score, use of therapies, prescription of haloperidol, or presence of dementia. Logistic regression analysis demonstrated that those who were readmitted were 2.7 times as likely to receive haloperidol and 1.6 times more likely to receive Beers potentially inappropriate medications. Several limitations to this study should be noted. Readmission rate might have been underestimated because participants who were readmitted outside of the Aurora healthcare system were not captured. Data collected were limited to those available on the ACE Tracker. Data were collected over 1 month and might not have taken into account seasonal variations. Older adults who are readmitted may have additional vulnerabilities than those admitted to a hospital for the first time. Healthcare professionals can use these findings to critically review the cognitive assessment and medications of people who are rehospitalized. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to this paper. Sponsor's Role: None.