Nutrition Can Help Reduce Hospital Readmissions
Friday, November 15, 2013
by: Abby C. Sauer, MPH, RD, Section Manager, Abbott Nutrition, Scientific and Medical Affairs

Section: Corporate Partners




Sponsored by

www.abbottnutrition.com

Hospital readmissions are a growing problem for the US healthcare system, which drain costs and resources for healthcare systems and negatively impact quality of life and outcomes for patients.  Hospitals have become “revolving doors” for many patients who are readmitted quickly after discharge, particularly older adult patients and those with certain chronic diseases.  Almost one fifth (19.6%) of Medicare beneficiaries who had been discharged from a hospital were readmitted within 30 days 1. For older adults, three conditions account for almost 15% of hospitalizations – heart failure, acute myocardial infarction (AMI), and pneumonia 2.  Among Medicare fee-for-service beneficiaries hospitalized for heart failure, AMI or pneumonia, 30-day readmission rates are 24.8%, 19.9%, and 18.3% respectively 3.  They also found that the majority of readmissions occurred within 15 days of the initial hospitalization 3.  Not only are hospital readmissions common, they are also costly to our healthcare system.  Estimates show that hospital readmissions cost approximately $26 billion annually, including $17 billion for inpatient hospital costs 1.   Estimates also show that the majority, or up to 76%, of these readmissions are potentially avoidable 4.  These figures highlight significant gaps in our current healthcare delivery system during hospitalization and during transition of care after hospital discharge.
 
In addition to certain diagnoses, many patient and clinical factors are associated with increased readmission rates, including nutrition related factors 5-7. Various research studies have demonstrated that nutritional risk increases a patient’s risk of readmission to the hospital 5-7. A 2007 study by Laniece et al. of over 1,000 adult inpatients showed that markers of frailty (including poor overall condition, pressure ulcers, previous hospitalization) or severe disability (for self-feeding) were the most important predictors of early readmission to the hospital 5. Specifically, patients with a recent loss of the ability to self-feed had an almost 2 times increased risk for readmission (OR 1.9) 5. Additionally, two studies in 2011 showed that weight loss (OR 1.26) and being underweight (adjusted OR 12.7) were significant predictors of readmission in adult inpatients  6-7. These data highlight that nutritional risk is associated with increased risk of readmission, and that early identification of these factors in key patient populations could help reduce potentially avoidable readmissions.
 
Moreover, research has consistently shown that nutrition intervention can help decrease readmission rates, therefore helping to decrease costs and improve quality of care. Several studies have examined the impact of nutrition intervention via oral nutritional supplementation during and/or after hospitalization on readmission rates in various patient populations 8-10. A 2008 study by Norman et al. examined the effect of a three-month post-hospital nutrition intervention with high protein oral nutritional supplements in malnourished gastrointestinal (GI) patients 8. Patients were randomized to receive either oral nutritional supplements in addition to dietary counseling or only dietary counseling for three months 8. The study results showed that patients receiving only dietary counseling experienced significantly more readmissions (n=20) than patients receiving oral nutritional supplements in addition to dietary counseling (n=10) (p=0.041) 8

The significant decrease in readmission rates seen in clinical trials with nutrition intervention has also been shown in recent systematic reviews and meta-analyses.  A 2012 review by Cawood et al. showed that intervention with high protein oral nutritional supplements compared to standard care reduced overall readmissions by 30% 9. Similar findings were shown most recently in a 2013 review by Stratton et al that showed that oral nutritional supplements significantly reduce hospital readmissions, particularly in older patient populations, with economic implications for health care 10.    This review examined 6 randomized controlled trials involving 852 patients and showed a 41% reduction in readmission risk with oral nutritional supplementation compared with routine care (OR 0.59, 95% CI 0.43-0.80, P=0.001) 10
 
In addressing the issue of hospital readmissions, it is important to consider the care patients receive both during hospitalization and after hospitalization.  A recent commentary in The New England Journal of Medicine by Dr. Harlan Krumholz states that to promote a successful recovery after hospitalization, health care professionals need to focus on not only the admitting diagnosis but also the effects of that hospitalization on the patient’s body function 11.  Dr Krumholz calls this state “post-hospital syndrome” which is an acquired, transient period of vulnerability after hospitalization 11.  At discharge, often patients’ physiological systems are impaired, reserves are depleted, and the body cannot effectively defend itself 11.  This post-hospital syndrome occurs as a result of the acute illness along with other factors including sleep deprivation, decreased cognition function, pain and discomfort, and poor nutrition 11.  As we often see in the hospital, patients commonly have an inadequate intake during hospitalization and are at high risk for malnutrition 11.  Dr. Krumholz suggests that the healthcare team implement interventions to improve the health status of these patients after hospital discharge, including promoting good nutrition and addressing nutritional deficiencies .

Older adults and those with chronic disease are at high risk for hospital readmissions.  These readmissions result in high costs to the healthcare system and to the patient, in regards to quality of care and quality of life.  Key patient populations, including those with heart failure, AMI and pneumonia, are the focus of current CMS strategies to reduce payment for excessive readmission rates to help contain costs.  In addition to these diagnoses, nutrition risk factors, including weight loss and inability to self-feed are associated with higher readmission rates. Fortunately, nutrition intervention, particularly through oral nutritional supplementation, has been shown to significantly reduce readmission rates in various patient populations. Dietitians can play a key role in helping their institutions efforts to decrease readmission rates through effective nutrition screening, assessment and intervention.  Ultimately, hospitals and healthcare systems need to determine best practices to help care for these patients during their inpatient stay and after they are discharged to help stop the “revolving door” of hospital readmissions.
 
References:
  1. Jencks SF, Willians MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360: 1418-1428.
  2. Kocher RP, Adashi EY. Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. 2011;306:1794-1795.
  3. Dharmarajan K, Hsieh AF, Lin Z et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA 2013; 309: 355-363.
  4. Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC, 2007.
  5. Laniece I, Couturier P, Drame M, et al. Incidence and main factors associated with early unplanned hospital readmission among French medical inpatients aged 75 and over admitted through emergency units. Age Ageing 2008; 37: 416-422.
  6. Allaudeen N, Vidyarthi A, Maselli J et al. Redefining Readmission Risk Factors for General Medicine Patients. J Hosp Med 2011; 6: 54-60.
  7. Mudge AM, Kasper K, Clair A et al. Recurrent Readmissions in Medical Patients: a Prospective Study. J Hosp Med 2011; 6: 61-67.
  8. Norman K, Kirchner H, Freudenreich M et al. Three month intervention with protein and energy rich supplements improve muscle function and quality of life in malnourished patients with non-neoplastic gastrointestinal disease—A randomized controlled trial. Clin Nutr 2008; 27: 48-56.
  9. Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Research Reviews 2012; 11: 278-296.
  10. Stratton RJ, Hebuterne X, Elia M. A systematic review and meta-analysis of the impact of oral nutritional supplements on hospital readmissions. Ageing Research Reviews 2013, in press. Doi: 101016/j.arr.2013.07.002.
  11.  Krumholz  HM. Post-hospital syndrome-an acquired, transient condition of generalized risk. N Engl J Med 2013;368(2): 121-128. 

©2013 Abbott Laboratories
89328/October 2013
 

 

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