Hospital readmissions among adults living with and without HIV in the US: findings from the Nationwide Readmissions Database

Abstract

Background: Thirty-day hospital readmission measures quality of care, but there are limited data among people with HIV (PWH) and people without HIV (PWoH) in the era of universal recommendation for antiretroviral therapy. We descriptively compared 30-day all-cause, unplanned readmission risk between PWH and PWoH.

Methods: A retrospective cohort study was conducted using the 2019 Nationwide Readmissions Database (2019/01/01-2019/12/31), an all-payer database that represents all US hospitalizations. Index (initial) admissions and readmissions were determined using US Centers for Medicare & Medicaid Services definitions. Crude and age-adjusted risk ratios (aRR) comparing the 30-day all-cause, unplanned readmission risk between PWH to PWoH were estimated using random effect logistic regressions and predicted marginal estimates. Survey weights were applied to all analyses.

Findings: We included 24,338,782 index admissions from 18,240,176 individuals. The median age was 52(IQR = 40-60) years for PWH and 61(IQR = 38-74) years for PWoH. The readmission risk was 20.9% for PWH and 12.2% for PWoH (age-adjusted-RR:1.88 [95%CI = 1.84-1.92]). Stratified by age and sex, young female (age 18-29 and 30-39 years) PWH had a higher readmission risk than young female PWoH (aRR = 3.50 [95%CI = 3.11-3.88] and aRR = 4.00 [95%CI = 3.67-4.32], respectively). While the readmission risk increased with age among PWoH, the readmission risk was persistently high across all age groups among PWH. The readmission risk exceeded 30% for PWH admitted for hypertensive heart disease, heart failure, and chronic kidney disease.

Interpretation: PWH have a disproportionately higher risk of readmission than PWoH, which is concerning given the aging profile of PWH. More efforts are needed to address readmissions among PWH.

Funding: US National Institutes of Health.

Keywords: Comorbidities; Nationwide; People with HIV; People without HIV; Readmissions.

Fig. 1

Flowchart of the index admissions and readmissions with (A) unweighted sample sizes and (B) weighted population sizes. Note: One person may contribute to one or more index hospitalizations in the study population. Among the index admissions excluded, the subcategories may overlap so the excluded numbers exceed the total.

Fig. 2

Comparison of the 30-day all-cause unplanned readmission risk between people with and without HIV overall and stratified by index admission characteristics. Abbreviations: PWH: people with HIV; PWoH: people without HIV; RR: risk ratio; aRR: age adjusted risk ratio; APRDRG: all patient refined diagnosis related groups. Note: number of readmissions and readmission risk (%) among index admissions were presented and all numbers were weighted estimates. RR and aRR were estimated using predicted marginal estimates (margins command in Stata) after random effect logistic regressions, and PWoH was the reference group. Pregnancy state was identified using primary diagnosis of Clinical Classifications Software Refined (CCSR) category of Pregnancy, Childbirth and the Puerperium. Other primary payer includes Worker’s Compensation, CHAMPUS, CHAMPVA, Title V, and other government programs. The All Patient Refined Diagnosis Related Groups (APRDRG) severity provided by HCUP were used to classify clinical severity of illness as defined by 3M. https://hcup-us.ahrq.gov/db/nation/nis/APR-DRGsV20MethodologyOverviewandBibliography.pdf. Different states may have different definitions of hospital bed size. A detailed definition is provided by HCUP. https://hcup-us.ahrq.gov/db/vars/hosp_bedsize/nrdnote.jsp. A person may contribute to one or more index admissions.

Fig. 3

Comparison of 30-day all-cause unplanned readmission risk between people with and without HIV stratified by age and sex. Abbreviations: PWoH: people without HIV; PWH: people with HIV. Note: All numbers were weighted estimates. Proportions were tabulated without accounting for repeated measures. Pregnancy state was identified using primary diagnosis of Clinical Classifications Software Refined (CCSR) category of Pregnancy, Childbirth and the Puerperium. A person may contribute to one or more index admissions.

Fig. 4

Comparison of the 30-day all-cause unplanned readmission risk between people with and without HIV by primary reasons for index admission. Abbreviations: PWoH: people without HIV; PWH: people with HIV; RR: risk ratio; aRR: age adjusted risk ratio. Note: number of readmissions and readmission risk (%) among each index admission diagnostic subgroup were presented and all numbers were weighted estimates. RR and aRR were estimated using predicted marginal estimates (margins command in Stata) after random effect logistic regressions, and PWoH was the reference group. AIDS defining illness and non-AIDS defining infection were exclusive to other Clinical Classifications Software Refined (CCSR) categories. Since cancers were excluded from index admissions per CMS guidelines, the category of neoplasms only included benign neoplasms and symptoms. Factors influencing health status and contact with health services includes administrative, prophylactic, aftercare and other management encounters. ∗Tabulated data ≤10 were suppressed per HCUP guidelines. †Model failed to converge. A person may contribute to one or more index admissions.