Risk Factors for Potentially Avoidable Readmissions Due to End‐of‐Life Care Issues

Background:

Repeated hospitalizations are frequent toward the end of life, and each admission may be an opportunity to initiate advanced care planning to ensure that care continues to be consistent with patient/caregiver wishes, to address issues such as pain, and to reduce future unnecessary readmissions. Because resources are limited, there is a need to prioritize palliative care services for those most likely to benefit, for example, those likely to have readmissions because of unresolved end‐of‐life issues. We aimed to identify risk factors for having a 30‐day potentially avoidable readmission due to end‐of‐life care issues.

Methods:

We included all consecutive discharges from any medical service of an academic tertiary medical center in Boston between July 1, 2009, and June 30, 2010. Potentially avoidable 30‐day readmissions to the index hospital or 2 other hospitals within its network were then identified using a validated computerized algorithm based on administrative data (SQLape®). Finally, a random sample of the 30‐day potentially avoidable readmissions was reviewed by 1 of 9 trained physicians to identify the ones due to end‐of‐life issues, defined by the following 2 criteria: (1) patient has a terminal clinical condition with a life expectancy of 6 months or less; and (2) the readmission is part of the terminal disease process that was not adequately addressed during the index hospitalization. A nested case–control study was designed in which potentially avoidable end‐of‐life readmission cases were compared with nonreadmitted controls. We performed multivariable logistic regression in which the final model included variables that were found to be significantly associated with the outcome in bivariable testing; age and Elixhauser comorbidity index were forced into the model as important potential confounders.

Results:

Our study included 80 cases with potentially avoidable end‐of‐life readmission and 7974 controls without any 30‐day readmission. In a multivariable analysis, the following risk factors were significantly associated (Table): number of admissions in the previous 12 months, malignant neoplasm, opiate medication use, and Elixhauser comorbidity index. The C statistic for the final model was 0.85, indicating excellent discrimination.

Conclusions:

In a medical population, the main risk factors associated with 30‐day potentially avoidable readmission because of end‐of‐life care issues are a higher number of prior admissions, a diagnosis of cancer, the use of opiates, and higher comorbidity score. Palliative care prior to discharge could be prioritized to the patients with these risk factors in order to improve end‐of‐life care and possibly reduce unnecessary hospitalizations.