Introduction: Thirty-day readmission is an important quality metric used to influence hospital compensation in the United States. However, there is currently insufficient evidence identifying which patients are at highest risk for readmission after aneurysmal subarachnoid hemorrhage (SAH). The objective of this study was to identify predictors of 30-day readmission after SAH, in order to focus preventative efforts and provide guidance to funding agencies that risk-adjust comparisons among hospitals.
Methods: We performed a case-control study of 30-day readmission among aneurysmal SAH patients treated at a single center from 2003-2013. To control for geographic distance from the hospital and year of treatment, we randomly matched each case (30-day readmission) with approximately two controls (no readmission) based on home zip code and treatment year. We evaluated variables related to patient demographics, socioeconomic characteristics, comorbidities, presentation severity (e.g. Hunt-Hess grade), and clinical course (e.g. gastrostomy or tracheostomy placement). Multilevel multivariable logistic regression was used to identify significant predictors.
Results: Among 80 SAH patients with unplanned readmission, we matched 76 patients with 150 non-readmitted controls. Age, demographics, and socioeconomic factors were not associated with readmission. In univariate analysis, Hunt-Hess grade (odds ratio [OR] for Hunt-Hess 4/5 vs. 1/2 =3.4), ventriculostomy (OR=1.9) or gastrostomy (OR=2.0) placement, length of hospital stay (OR=1.02), disposition (OR=4.5 for skilled nursing vs. home), and chronic pulmonary disease (OR=2.6) were significantly associated with readmission. However, the only significant predictors in multivariate analysis were admission Hunt-Hess grade (OR=3.4 for 4/5 vs. 1/2) and history of chronic pulmonary disease (OR=2.6).
Conclusions: Higher clinical severity and a history of chronic pulmonary disease were independent risk factors for 30-day readmission after aneurysmal SAH. These high-risk patients should be the focus of preventative efforts, including early scheduled follow-up, as well targeted post-discharge phone calls by transition care coaches. Funding agencies should also consider these factors when risk-adjusting readmission rates across hospitals.
Patient Care: Thirty-day readmission is an increasingly important topic both because of the economic burden it creates and also because of the potentially detrimental impact on patients and families. The results presented herein help identify which patients are at increased risk for readmission. Furthermore, based on a careful review of the readmission literature, we propose concrete steps that hospitals may take to reduce readmission, including the use of transition care “coaches” to perform post-discharge phone calls targeted at high-risk patients. Finally, these results will also serve as a guide for funding agencies that seek to risk-adjust readmission rates across hospitals. For these reasons, this study will help improve quality of life for SAH patients while also reducing the economic costs associated with treating this disease.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of 30-day hospital readmission in aneurysmal SAH patients; 2) Identify which SAH patients are at increased risk for readmission; and 3) Discuss concrete proposals to reduce avoidable readmissions after SAH.