Development of a prediction model for 30-day acute readmissions among older medical patients: the influence of social factors along with other patient-specific and organisational factors.

Background: Readmission rate is one way to measure quality of care for older patients. Knowledge is sparse on how different social factors can contribute to predict readmission. We aimed to develop and internally validate a comprehensive model for prediction of acute 30-day readmission among older medical patients using various social factors along with demographic, organisational and health-related factors. Methods: We performed an observational prospective study based on a group of 770 medical patients aged 65 years or older, who were consecutively screened for readmission risk factors at an acute care university hospital during the period from February to September 2012. Data on outcome and candidate predictors were obtained from clinical screening and administrative registers. We used multiple logistic regression analyses with backward selection of predictors. Measures of model performance and performed internal validation were calculated. Results: Twenty percent of patients were readmitted within 30 days from index discharge. The final model showed that low educational level, along with male gender, contact with emergency doctor, specific diagnosis, higher Charlson Comorbidity Index score, longer hospital stay, cognitive problems, and medical treatment for thyroid disease, acid-related disorders, and glaucoma, predicted acute 30-day readmission. Area under the receiver operating characteristic curve (0.70) indicated acceptable discriminative ability of the model. Calibration slope was 0.98 and calibration intercept was 0.01. In internal validation analysis, both discrimination and calibration measures were stable. Conclusions: We developed a model for prediction of readmission among older medical patients. The model showed that social factors in the form of educational level along with demographic, organisational and health-related factors contributed to prediction of acute 30-day readmissions among older medical patients.

Patient-specific versus Organisational Barriers to Program Adherence: A Multivariate Analysis.

INTRODUCTION: This article explores the influence of patient-specific and organisational factors on adherence to program guidelines in an integrated care program targeting older patients. METHODS: The integrated care program aimed to offer post-discharge follow-up visits by a municipality nurse and the general practitioner to frail older patients after discharge from hospital. Adherence was measured as step 1) successful referral from the hospital and step 2) completed post-discharge follow-up visit. We followed a cohort of 1,659 patients who were selected to receive a post-discharge follow-up visit in 2014. We obtained unique data from hospitals, municipalities and from administrative registers. RESULTS: We found substantial lack of adherence in both steps of the program: 69% adherence in step 1 and 54% adherence in step 2. In step 1, adherence was related to hospital, and receiving municipal home care prior to admission. In step 2, level of adherence varied according to municipality, the type of general practitioner and the patient's gender. CONCLUSION: We found that adherence was strongly related to organisational factors. Adherence differed significantly at all organisational levels (hospital, municipality, general practice), thus indicating challenges in the vertical integration of care. Gender influenced adherence as the only patient-related factor.

Can municipality-based post-discharge follow-up visits including a general practitioner reduce early readmission among the fragile elderly (65+ years old)? A randomized controlled trial.

OBJECTIVE: To evaluate how municipality-based post-discharge follow-up visits including a general practitioner and municipal nurse affect early readmission among high-risk older people discharged from a hospital department of internal medicine. DESIGN AND SETTING: Centrally randomized single-centre pragmatic controlled trial comparing intervention and usual care with investigator-blinded outcome assessment. INTERVENTION: The intervention was home visits with a general practitioner and municipal nurse within seven days of discharge focusing on medication, rehabilitation plan, functional level, and need for further health care initiatives. The visit was concluded by planning one or two further visits. Controls received standard health care services. PATIENTS: People aged 65 + years discharged from Holbæk University Hospital, Denmark, in 2012 considered at high risk of readmission. MAIN OUTCOME MEASURES: The primary outcome was readmission within 30 days. Secondary outcomes at 30 and 180 days included readmission, primary health care, and municipal services. Outcomes were register-based and analysis used the intention-to-treat principle. RESULTS: A total of 270 and 261 patients were randomized to intervention and control groups, respectively. The groups were similar in baseline characteristics. In all 149 planned discharge follow-up visits were carried out (55%). Within 30 days, 24% of the intervention group and 23% of the control group were readmitted (p = 0.93). No significant differences were found for any other secondary outcomes except that the intervention group received more municipal nursing services. CONCLUSION: This municipality-based follow-up intervention was only feasible in half the planned visits. The intervention as delivered had no effect on readmission or subsequent use of primary or secondary health care services.

Repeated measurements of generic indicators: a Danish national program to benchmark and improve quality of care.

OBJECTIVE: To measure performance on the basis of generic (non-diagnoses related) standards of care developed in a national Danish quality improvement programme in departments of internal medicine, and to determine the power of repetitive national audits to increase levels of performance. DESIGN: Multifaceted intervention: national audits in 2001 and 2002 based on the standards of the program, combined with direct contact with heads of departments and a national conference to discuss audit results. SETTING: Seventy-nine and 82 wards in 2001 and 2002, respectively, covering 71% of Danish hospitals receiving medical emergencies. The wards participated on a voluntary basis. PARTICIPANTS: In the first audit round, 3950 patients were admitted as emergencies, while 4068 patients were admitted as emergencies in the second audit. Patients were included without reference to diagnoses. MAIN OUTCOME MEASURES: Correct initial diagnostic assessment, early interdisciplinary action plans, correct drug prescriptions, waiting times for examinations, documented patient information, readmissions, and content and processing time for discharge letters. RESULTS: For the 70 wards participating in both rounds, the general level of performance improved significantly between the two audits: the proportion of patients with correct initial diagnostic assessment increased from 75.9% to 79.4%, the proportion of patients with correct drug prescriptions increased from 83.8% to 85.9%, and the proportion of sufficiently informed patients increased from 32.4% to 36.2% (P < 0.05). The proportion of medical records containing action plans for selected clinical problems (nutritional and functional problems, fever, and treatment of pain) increased from 72.8% to 75.9% (P < 0.05). Length of stay in hospital was significantly related to a correct initial assessment and to waiting time for examinations. Wards with a common medication chart for physicians and nurses had significantly more correct drug prescriptions than wards that did not use a medication chart. Fifty-four (75%) of the participating departments indicated that the result of the first audit round had led to organizational changes in the department. CONCLUSION: Professional self-regulation guided by a multidisciplinary audit tool developed in cooperation with professionals can improve quality of care. It is possible to conduct and repeat a national audit on a voluntary basis.

[The Good Medical Department. Results from a national survey of quality in 1998]. / Den gode medicinske afdeling. Resultater fra en national undersøgelse af kvalitet i 1998.

INTRODUCTION: This cross-sectional study describes quality related data from 39 medical wards in Denmark. MATERIAL AND METHODS: The study is based on a review of 1517 medical records and a short patient interview. The medical departments took part voluntarily in the study, which was initiated by the Danish Society for Internal Medicine. RESULTS: A total of 23 quality-related indicators related to the planning of the treatment, documentation in patient records, and care were registered. The day before the data collection was an inactive inpatient day for 22.8 +/- 1.1% of patients. Allergy was insufficiently documented in the medical record for 18.8 +/- 1.0% of patients. Weight was not documented in 48.8 +/- 1.3% of patients. Considerations about anticoagulation treatment of atrial fibrillation were not documented in 50.1 +/- 3.6% of patients with atrial fibrillation. DISCUSSION: This study indicates that it is possible on a voluntary basis to collect and distribute quality-related data. The survey has recently been repeated with a modified data registration sheet.