Chapter 20 Preventing Rehospitalization

of the readmissions for SNF and LTC residents are avoidable. A 2010 study by Ouslander et al showed that 67% of hospitalizations among LTC residents were rated by clinicians as potentially avoidable (13). In addition, one study found that in 2004, 23% of the $972 million spent on hospitalizations of LTC residents in the state of New York were for ambulatory care-sen- sitive diagnoses (ACSDs), a proxy measure for poten- tially unnecessary hospitalizations (14). These readmissions can be costly to the health care system and disruptive to the resident and his or her care and can increase the resident’s risk for hospital-acquired infections and comorbidities (15).

NUTRITIONAL RISK FACTORS FOR

HOSPITAL READMISSIONS The American population is aging, and older adults often suffer from more acute and chronic health condi- tions and utilize more health care than younger adults. In addition, older adults are at higher risk for nutri- tional deficits, weight loss, and malnutrition. Malnutrition impacts older adults across the health care continuum, from community-dwelling older adults to those in the hospital, affecting up to 60% of hospital- ized older adults (16). The cause of malnutrition is often multifactorial, including aging itself, inadequate food intake, and acute and chronic medical conditions (16,17). Often, older adults do not just suffer from mal- nutrition alone; it is frequently accompanied by loss of lean body mass (LBM), loss of strength or functional- ity, or sarcopenia. Moreover, older adults are more likely to be hospitalized for illness, injuries, and sur- geries, further accelerating the loss of LBM. This loss of LBM and functionality results in weakness, decreased mobility, reduced functionality, and decreased ability to perform activities of daily living (ADLs), thereby adding to caregiver burden (18-21). Older adults with nutritional risk factors, weight loss, or malnutrition are more likely to experience hos- pital readmission than well-nourished individuals (22- 26). One study found that those hospitalized who had lost weight or exhibited no improvement in serum albumin within one month of discharge had a greater risk for readmission when compared to well-nourished individuals (24). Additionally, two studies in 2011 showed that weight loss (adjusted odds ratio [OR] 1.26) and being underweight (adjusted OR 12.7) were significant predictors of readmission (22,27). Research by Thomas et al found that 25% of malnourished older adults required hospital readmission compared to 11% of well-nourished individuals (24). A 2012 study of hospitalized individuals showed that malnourished individuals were more likely to be readmitted within 15 days than well-nourished individuals (adjusted

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relative risk = 1.9, 95% CI 1.1–3.2, p = 0.025) (28). Additionally, hospitalized individuals with sarcopenia have a significantly higher risk of nonelective hospital readmissions in the six months after hospital discharge than individuals without sarcopenia (adjusted hazard ratio 0.53, 95% CI: 0.32–0.87, p = 0.013) (29). A 2007 study by Lanièce et al of over 1,000 adult inpatients showed that markers of frailty and severe disability for self-feeding were the most important predictors of early readmission to the hospital. Specifically, individ- uals with a recent loss of the ability to self-feed had an almost two times increased risk for readmission (OR 1.9) (23). These data highlight that nutritional risk is associated with increased risk of readmission and that early identification of these factors in key populations could help reduce potentially avoidable readmissions. See Box 20.1 for key nutritional risk factors associated with hospital readmission.

BOX 20.1 Key Nutritional Risk Factors and Patient Conditions Associated with Hospital Readmission

●

Markers of frailty, such as poor overall condition, pressure ulcers, and prior hospitalization

●

Severe disability, including inability to self-feed

● Weight loss ● Body mass index (BMI)

● Underweight and overweight ●

● Surgery Source: Data are from references 22–26, 28–32.

Chronic diseases, many of which have a nutri- tional component, are also associated with increased readmission risk. A 2010 study of hospitalized individ- uals aged 50 and older found that chronic conditions, such as CHF, diabetes, cancer, and renal disease, were associated with unplanned readmissions (22). Research has also shown that inpatients with PNA, malnutrition is an independent predictor of readmission (30). Addit- ionally, in individuals with COPD, those readmitted within three months of hospital discharge had less lean body mass than those who were not readmitted (31). Surgery patients with malnutrition have also been shown to be at higher risk for hospital readmission. A study by Kassin et al demonstrated that in a sample of 1,442 general surgery individuals, the most common

Chronic conditions or diseases such as cancer, renal failure, COPD, pneumonia, CHF, and diabetes