Alcohol and hospital readmission (2)
Editor – We read with interest the paper by Shalchi et al looking at readmission rates after acute medical treatment (Clin Med October 2009 pp 426–30). As the authors state, there are concerns that the pressure to diagnose, treat and discharge patients from acute medical units (AMU) is leading to increased readmission rates. These rates may be an important indicator of the quality of medical care delivered, especially in vulnerable, frail older people.
We have been examining outcomes for frail older patients attending AMUs in the East Midlands. In one centre, readmission rates following attendance at an AMU with a multidisciplinary team (MDT)-facilitated discharge were as high as 53% over one year, with associated high mortality rates (28%).1 In another centre, frail older people comprised 20% of all attendees aged ⋛70 years. This group were the least likely to be discharged from AMUs (4% ν 19% for non-frail older people) and once admitted had longer mean length of stay (9 ν 5 days, p<0.001). Once discharged, frail older people were more likely to be readmitted within 30 days (30% ν 22% for non-complex older people, p<0.001), hazard ratio for readmission over time 2.2.
Based on these worrying process outcomes for frail older people, and drawing on the extensive evidence base which supports comprehensive geriatric assessment for frail older people in acute and community settings, we established an ‘acute frailty unit’ (AFU) within one AMU.2–5
Patients in the AFU have access to all usual care (including the MDT), but have an increased nursing ratio, and some specialist geriatric input. Despite limited resources, we have been able to show some clinically important trends toward improved process outcomes compared to historical controls (also frail older people):
increased discharge rates (AFU 9% ν 5% AMU) odds ratio 1.4 (0.8–2.3), p=0.17
mean difference in length of stay for AFU patients 0.5 days, p=0.6
equivalent 90-day readmission rates (historical control 36% (32–47%), AFU 36% (29–56%)).
While these data lack sufficient precision, or indeed the robustness of a controlled trial, they do point to potentially useful new ways of addressing acute care of frail older people.
Footnotes
Please submit letters for the Editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2010 Royal College of Physicians
References
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- Day P,
- Rasmussen P
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