Patients with a primary UC index hospitalization who subsequently had a 30-day unplanned readmission were more likely to be younger, men, less likely to have had a colonoscopy on index admission, had significantly higher rates of depression and PSC, lower median household income, and more severe loss of function on the APR-DRG scale. Thirty-day readmissions were also significantly associated with longer LOS (≥7 days), Medicaid or private insurance, and index hospitalization at a metropolitan teaching hospital. The most common primary diagnoses for readmissions were UC (58.2%), complications of surgical/medical care (5.5%), Clostridium difficile infection (4.8%), septicemia (4.3%), and intestinal obstruction (2.3%).
Among 48,189 index admissions that had UC as a secondary diagnosis, there were 3419 unplanned 30-day readmissions (7.0%). The most common reasons for the index admission were septicemia (7.6%), intestinal infection (6.2%), intestinal obstruction (4.1%), other gastrointestinal disorders (3.9%), complications related to surgical/medical care (3.2%), and pneumonia (2.4%). The most common primary diagnoses for 30-day readmissions among patients with index admission with UC as secondary diagnosis included UC (13.2%), septicemia (7.3%), complications of surgical/medical care (5.9%), complications of device (4.7%), and C. difficile infection (3.8%).
Lastly, we conducted multivariable analyses to assess which covariates are associated with increased risk of 30-day unplanned readmission after index hospitalization with UC as primary diagnosis (Table 2). After adjusting for patient, hospital, comorbidity, and admission confounders, not having a colonoscopy on index hospitalization was associated with 20% higher odds for readmissions (adjusted odds ratio 1.20, 95% confidence interval [CI], 1.04–1.38) and depression was associated with 40% higher odds (adjusted odds ratio 1.40, 95% CI, 1.16–1.66). A length of stay of LOS ≥7 days on index hospitalization was associated with 54% higher odds of readmission (OR 1.54, 95% CI, 1.24–1.90). 58.2% of readmissions had at least one of these predictors during the index hospitalization. In addition, patients were less likely to be readmitted if they were women or if the hospitalization was covered by self-pay (Table 2). Colectomy during index admission did not significantly increase 30-day readmission risk (adjusted odds ratio 1.14, 95% CI, 0.86–1.52).
In a nationally representative U.S. database, patients admitted for UC had a 10.6% 30-day unplanned readmission rate. Over half of the readmissions had UC as the primary diagnosis. On multivariable analysis, patients were significantly more likely to be readmitted if they had depression, did not have an endoscopy on the index admission, and LOS ≥7 days. Most readmissions had at least one of these predictors. To the best of our knowledge, this is one of the first studies to examine UC readmissions in the United States on a national level.
One prior study presented in abstract form used the state inpatient databases and found that 19% of patients with IBD-related hospitalizations were readmitted within 30 days.21 This rate is higher than what we observed in our study, but subgroup data on UC patients were not available, and predictors of readmission were not reported. Other studies that have examined readmission rates in UC have been primarily single center experiences. A study from Cleveland Clinic found that IBD patients admitted to a gastroenterology service had a 30-day all-cause readmission rate of 18%, although the rate for UC alone was not reported.22 This is also higher than the 10.6% 30-day readmission rate found in our study. The difference in findings may reflect the higher severity of patients at a tertiary care center compared with the general hospitalized population which is captured by the NRD. Alternatively, the higher readmission rate may have been driven by Crohn's disease patients who made up nearly three-fourth of the study population. Factors associated with readmission in this study included narcotics prescription on discharge, benzodiazepines during hospitalization, abscess drainage, and discharge to an assisted-care facility. The 30-day readmission rate in the NRD was similar to the findings from a retrospective study of severe UC patients admitted to the Mount Sinai Medical Center between 2007 and 2011 which reported a 30-day all-cause readmission rate of 11.7%.12 In this study, the only significant independent predictors of 30-day readmission were extensive colitis, albumin on admission, and admission to a housestaff service.
The only national-level studies on IBD readmissions are from Canada. A large study from the pre-biologic era used a national database to examine hospitalizations from 1994 to 2001.16 16.7% of UC patients were readmitted within 2 years with a median time to readmission of 11 months. Thirty-day readmissions were not specifically reported. A more recent study from Canada analyzed over 26,000 patients who were hospitalized for IBD between 2004 and 2010 and found a 1 month readmission rate of 2.4% among UC patients, which is substantially lower than our cohort.14 Predictors of readmission for all IBD patients included younger age, lower IBD volume hospital, and surgery. We were unable to determine IBD volume by hospital based on the NRD data and did not see a significant impact of surgery on readmission risk. There was a trend toward increased readmission risk for the youngest age group (18–34 years), but this was statistically significant only when compared with the 50 to 64 years old age group.
Regarding patient demographics, prior studies on the general Medicare population found that male sex was a risk factor for 30-day readmission.1 Male UC patients were at higher risk of readmissions than female patients in our study. The reasons for this are unclear and warrant further investigation in future studies. In addition, we found that patients who were self-pay and did not have insurance coverage for their index hospitalization were less likely to be readmitted. This likely highlights a socioeconomic group that is less likely to use health services given the cost burden.
Our observed 30-day unplanned readmission rate for UC is similar or somewhat lower than rates seen in other common inpatient gastrointestinal conditions. The unplanned 30-day readmission rate for upper and lower gastrointestinal bleeding in recent studies varies from 5% to 21% with the range likely attributable to differences in study populations and methods.23–26 Thirty-day readmission rates after hospitalizations for acute pancreatitis are higher at around 20%.27,28 Additionally, 30-day readmission rate among patients admitted for cirrhosis and related complications was 12.9% in a recent population-based study.29
We found that depression significantly increased the odds of readmission by 40%. Depression is a major comorbidity for many UC patients and can have a major impact on IBD in a number of ways including increased symptoms, medication nonadherence, illicit drug use, and negative illness perception30,31 Around 22% of UC patients have depression and rates increase in active disease.32 In a prospective observational study, clinically inactive IBD patients with depression were more likely to have a relapse over an 18 month follow-up period.33 Major depressive disorder increases the chance of treatment failure with infliximab in Crohn's disease.34 Depression has been associated with readmissions in non-IBD patients. According to a meta-analysis, patients admitted to medical services were more likely to be readmitted within 30 days if they had a history of depressive symptoms (RR 1.73, 95% CI, 1.16–2.58).35 Depression also increased the readmission risk in chronic obstructive pulmonary disease.36 Our results highlight the importance of addressing depression in UC, particularly during and after hospitalization.30–32
Patients in our study were more likely to have a 30-day readmission if they did not have an endoscopy during the index hospitalization. It is generally recommended that patients with severe UC admitted to the hospital undergo a flexible sigmoidoscopy.37 For example, the Toronto consensus statements on hospitalized UC recommend flexible sigmoidoscopy early in the course of hospitalization to assess disease severity and identify superinfections such as cytomegalovirus.38 Endoscopic disease severity can help clinicians risk stratify patients by identifying those more likely to need rescue therapies (biologics or cyclosporine) and those at highest risk of colectomy.37,39 Our data suggest the importance of performing an endoscopic evaluation for patients admitted with UC as it may decrease subsequent readmissions.
Lastly, LOS ≥7 days was a significant predictor of 30-day readmission. Longer LOS has previously been associated with readmissions in other diseases. For example, data on heart failure hospitalizations suggest that patients with longer LOS are significantly more likely to have a 30-day readmission.40 In a study on colorectal resections, patients who required an emergency readmission had longer LOS during their index admissions.41 In contrast to these findings, a large study of Veterans Affairs hospitals found no significant relationship between LOS and overall risk of 30-day readmission although hospitals with a mean risk-adjusted LOS that was lower than expected had a higher readmission rate suggesting a potential inverse relationship.42 For patients admitted primarily for UC, it is likely that a longer LOS may be a surrogate marker for higher disease severity. Although fewer than 10% of the patients in our cohort underwent colectomy during index hospitalization, a national study of UC patients who underwent colectomy more than 6 days after admission had significantly increased morbidity and mortality.43 We were unfortunately unable to assess disease severity with the NRD data. However, it is likely that UC patients who are in the hospital longer are sicker and not responding to first line treatments such as steroids, and are then undergoing rescue therapy with infliximab or cyclosporine which would lead to a longer LOS.
Based on our findings and prior studies, a number of potentially modifiable risk factors for readmission have been identified that hospitals and clinicians can potentially address. First, comorbid mental health issues, in particular depression, can be helped by linking patients with appropriate psychological or psychiatric care. Performing a flexible sigmoidoscopy during an admission for UC should be strongly considered for a number of reasons including getting a more accurate assessment of disease severity which may lead to a better informed treatment plan and decreased risk of readmission. Decreasing LOS, if feasible, may decrease readmission rates but LOS may not be modifiable as it is potentially a marker of disease severity. Readmission rates also may be lower at centers with higher IBD volume. Lastly, admission to a house staff service has been associated with a higher risk of readmission. Careful oversight in these cases will ensure appropriate care and disposition; however, this may be a marker of disease severity as more acute patients are typically admitted to house staff services.
Our study had several limitations. First, the NRD does not provide data on race or ethnicity, and we were therefore unable to account for these potentially confounding variables in our analysis. Second, these data rely on administrative health claims so we could not directly verify the coded diagnoses nor were we able to specifically assess UC disease severity for these admissions. However, we were able to control for general disease severity using the APR-DRG scale and adjusting for the comorbidity index. Because the NRD only contains data from hospitalizations, we were not able to study what occurred in between the index hospitalization and readmission. For example, seeing a physician soon after discharge may potentially decrease the risk of readmission. Although there are inherent limitations to using administrative health claims codes (i.e., verification of diagnoses, accuracy of coding), the NRD allows for careful tracking of readmissions across hospitals and similar administrative data have previously been used to study readmissions among Medicare patients and Veterans.44,45 Lastly, only the primary payer for hospitalization was available so the effect of secondary insurances could not be studied.
In summary, patients in a national database who were admitted for a primary diagnosis of UC had a 10.6% rate of 30-day readmission and were more likely to be readmitted if they had an LOS ≥7 days, did not have an endoscopy on the index hospitalization, or had depression. These factors may be used to identify higher risk UC patients who should be targeted for interventions to decrease risk of readmission such as closely coordinated outpatient follow up, better assessment and treatment of psychosocial factors, or enrollment in a medical home.46 The rate of 30-day readmission in the U.S. NRD is higher than comparable data from Canada and can be used as a baseline to measure the impact of interventions. Future studies are needed to further understand approaches to decreasing unplanned hospitalizations in UC.
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Keywords:© Crohn's & Colitis Foundation of America, Inc.
hospitalization; depression; length of stay; inflammatory bowel disease