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Hospital Readmission Rate in HIV Group 44% Higher Than in US Population
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XIX International AIDS Conference, July 22-27, 2012, Washington, DC
Mark Mascolini
Nearly 20% of HIV-positive HIV Research Network (HRN) members admitted to the hospital got readmitted within 30 days, a rate 44% higher than in the general US population [1]. Cancer, AIDS-defining illnesses, renal/genitourinary disease, gastrointestinal/liver disease, and endocrine/metabolic disease accounted for the highest proportions of readmissions in these people.
HRN investigators noted that readmission rates within 30 days of a first admission are becoming a benchmark for hospital quality of care and reimbursement. But little is known about how often or why HIV-positive people get readmitted.
To address those questions, the HRN team analyzed records of people receiving HIV care from 2005 through 2010 at 9 US sites--4 in the Northeast, 2 in the South, 2 in the West, and 1 in the Midwest. The researchers considered everyone discharged from an initial admission that was not itself a readmission.
Of 12,048 people with an initial hospital admission, 9729 (81%) did not got readmitted within 30 days and 2319 (19%) did. Median time from initial admission to readmission was 11 days (interquartile range 5 to 19 days).
Compared with admitted people with no readmission within 30 days, the readmitted group had higher proportions with a CD4 count at or below 50 (25% versus 17%) or 51 to 200 (27% versus 24%) and lower proportions with a CD4 count of 201 to 350 (20% versus 22%) or above 350 (28% versus 37%). Compared with the no-readmission group, the readmitted group had a lower proportion with a viral load below 400 (36% versus 40%), a similar proportion with 400 to 49,999 copies (31% versus 33%), and a higher proportion with a viral load above 49,999 (30% versus 25%).
Higher proportions of readmitted people had an initial hospital stay of 5 to 8 days (22% versus 19%) or longer (25% versus 17%). Non-AIDS infections accounted for the most initial admissions (3192), followed by cardiovascular disease (1203), an AIDS illness (1150), gastrointestinal/liver disease (914), renal/genitourinary disease (652), and pulmonary disease (629). Cancer accounted for 434 initial admissions.
The initial admission diagnosis with the highest proportion of readmissions was cancer (about 28%), followed by an AIDS-defining illness (about 26%), renal or genitourinary disease, gastrointestinal or liver disease, and endocrinologic or metabolic disease (all about 21% to 22%). Readmission rates were about 20% for pulmonary disease, about 18% for cardiovascular disease, and about 17% for non-AIDS infections.
The 19% readmission rate in this HIV group compares with a 13.2% estimated 30-day readmission rate in the general US population of 18- to 64-year-olds in 2008 [2], so the HIV readmission rate was 44% higher.
Statistical analysis that accounted for gender, race, calendar year, injection drug use, and viral load determined that older age independently raised the risk of readmission. Compared with 18-to-34-year-olds, 35-to-44-year-olds had an 19% higher readmission risk (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.02 to 1.39), 45-to-54-year-olds had a 17% higher readmission risk (HR 1.17, 95% CI 1.00 to 1.36), and 55-to-64-year-olds had a 23% higher risk (HR 1.23, 95% CI 1.03 to 1.47).
Compared with a CD4 count above 350, lower counts independently made readmission more likely:
-- 50 CD4s or under: HR 1.78, 95% CI 1.54 to 2.04
-- 51 to 200 CD4s: HR 1.44, 95% CI 1.29 to 1.63
-- 201 to 350 CD4s: HR 1.20, 95% CI 1.06 to 1.36
Compared with people who stayed in the hospital for 1 to 3 days on their initial admission, those who stayed 6 to 8 days had a 47% higher chance of readmission (HR 1.47, 95% CI 1.22 to 1.55) and those who stayed 9 days or longer had a 71% higher chance (HR 1.71, 95% CI 1.52 to 1.93).
In two additional models, diagnoses that independently raised the readmission risk were cancer, an AIDS-defining infection, gastrointestinal/liver disease, renal/genitourinary disease, and endocrine/metabolic disease (compared with a non-AIDS infection). Cardiovascular disease independently raised the readmission risk in one model but not the other.
"Readmissions are cost-drivers as well as markers of quality of care for people living with HIV," the researchers observed. They recommended that these high rates "should be addressed by providers, hospitals, and policymakers."
The HRN investigators called for further study to see whether better discharge planning, "especially when focused on highest risk hospitalizations," can cut the readmission rate. They also recommended further analysis of readmission of HIV-positive people compared with an HIV-negative population matched for age, gender, and socioeconomic status.
References
1. Berry, SA Fleishman JA, Yehia BR, et al. Unexpected complications: high 30 day readmission rates among persons living with HIV. XIX International AIDS Conference. July 22-27, 2012. Abstract MOPE110.
2. Wier LM, Barrett M, Steiner C, Jiang HJ. All-cause readmissions by payer and age, 2008. June 2011. Healthcare Cost and Utilization Project Statistical Brief #115. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb115.pdf.
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