National Estimates of 30-Day Unplanned Readmissions of Patients on Maintenance Hemodialysis

Abstract

Background and objectives: Patients on hemodialysis have high 30-day unplanned readmission rates. Using a national all-payer administrative database, we describe the epidemiology of 30-day unplanned readmissions in patients on hemodialysis, determine concordance of reasons for initial admission and readmission, and identify predictors for readmission.

Design, setting, participants, & measurements: This is a retrospective cohort study using the Nationwide Readmission Database from the year 2013 to identify index admissions and readmission in patients with ESRD on hemodialysis. The Clinical Classification Software was used to categorize admission diagnosis into mutually exclusive clinically meaningful categories and determine concordance of reasons for admission on index hospitalizations and readmissions. Survey logistic regression was used to identify predictors of at least one readmission.

Results: During 2013, there were 87,302 (22%) index admissions with at least one 30-day unplanned readmission. Although patient and hospital characteristics were statistically different between those with and without readmissions, there were small absolute differences. The highest readmission rate was for acute myocardial infarction (25%), whereas the lowest readmission rate was for hypertension (20%). The primary reasons for initial hospitalization and subsequent 30-day readmission were discordant in 80% of admissions. Comorbidities that were associated with readmissions included depression (odds ratio, 1.10; 95% confidence interval [95% CI], 1.05 to 1.15; P<0.001), drug abuse (odds ratio, 1.41; 95% CI, 1.31 to 1.51; P<0.001), and discharge against medical advice (odds ratio, 1.57; 95% CI, 1.45 to 1.70; P<0.001). A group of high utilizers, which constituted 2% of the population, was responsible for 20% of all readmissions.

Conclusions: In patients with ESRD on hemodialysis, nearly one quarter of admissions were followed by a 30-day unplanned readmission. Most readmissions were for primary diagnoses that were different from initial hospitalization. A small proportion of patients accounted for a disproportionate number of readmissions.

Keywords: Comorbidity; Depressive Disorder; Humans; Kidney Failure, Chronic; Logistic Models; Myocardial Infarction; Odds Ratio; Patient Discharge; Patient Readmission; Readmission; Retrospective Studies; Software; Substance-Related Disorders; Surveys and Questionnaires; depression; dialysis; end stage kidney disease; hospitalization; hypertension; mortality; renal dialysis.

Figure 1.

High readmission rate among the top ten reasons for index admission. Black bars represent the percentage of index admissions for each primary diagnosis compared with all index admissions for patients with ESRD on hemodialysis. Gray bars represent the percentage of index admissions with any readmission for each primary diagnosis. AMI, acute myocardial infarction; CHF, congestive heart failure.

Figure 2.

Low concordance between index admission diagnosis and readmission diagnosis. Black bars represent the percentage of readmissions diagnoses that were different from index admission diagnoses. Gray bars represent the percentage of readmission diagnoses that were the same as index admission diagnosis. AMI, acute myocardial infarction; CCS, Clinical Classification Software; CHF, congestive heart failure; Dx, diagnosis.