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Abstract and Introduction
Abstract
Early rehospitalization after kidney transplantation (KT) is common and may predict future adverse outcomes. Previous studies using claims data have been limited in identifying preventable rehospitalizations. We assembled a cohort of 753 adults at our institution undergoing KT from January 1, 2003 to December 31, 2007. Two physicians independently reviewed medical records of 237 patients (32%) with early rehospitalization and identified (1) primary reason for and (2) preventability of rehospitalization. Mortality and graft failure were ascertained through linkage to the Scientific Registry of Transplant Recipients. Leading reasons for rehospitalization included surgical complications (15%), rejection (14%), volume shifts (11%) and systemic and surgical wound infections (11% and 2.5%). Reviewer agreement on primary reason (85% of cases) was strong (kappa = 0.78). Only 19 rehospitalizations (8%) met preventability criteria. Using logistic regression, weekend discharge (odds ratio [OR] 1.59, p = 0.01), waitlist time (OR 1.10, p = 0.04) and longer initial length of stay (OR 1.42, p = 0.03) were associated with early rehospitalization. Using Cox regression, early rehospitalization was associated with mortality (hazard ratio [HR] 1.55; p = 0.03) but not graft loss (HR 1.33; p = 0.09). Early rehospitalization has diverse causes and presents challenges as a quality metric after KT. These results should be validated prospectively at multiple centers to identify vulnerable patients and modifiable processes-of-care.
Introduction
Early rehospitalization following kidney transplantation (KT) is common, conferring high costs to the US healthcare system. An analysis of Medicare data from 2003 to 2006 found that 28.5% of KT recipients had Medicare claims for a readmission within 30 days, a considerably higher rate than for patients undergoing other intra-abdominal surgeries (10–16%) or patients in the general population (19.6%). The mean cost of each transplant rehospitalization was nearly $10 000. Recent changes in Medicare reimbursement penalize hospitals for early rehospitalization after certain admissions, and excess rehospitalization rates are scrutinized as a quality-of-care indicator. However, high rehospitalization rates may also reflect a patient population of greater medical complexity and acuity, characteristics that may be incompletely captured by risk-adjustment methods available to Medicare. Despite the relatively high frequency and cost associated with early rehospitalization following KT, little remains known about the reasons for these events and which rehospitalizations are unplanned or potentially preventable.
KT recipients are uniquely vulnerable to adverse events following discharge from transplantation, especially given the large burden of comorbidities in this population (including diabetes, hypertension and vascular disease) and more elderly patients being transplanted than ever before. Therefore, some early rehospitalizations following KT may be seen as part of the acceptable risk of a major surgical procedure in patients with significant comorbidities and the prospect of long-term clinical benefit, while others may be preventable, such as those due to failures in the process of transitioning care. In 2012, McAdams-Demarco et al examined early rehospitalization rates for Medicare-covered KT recipients. This important study revealed variation in early rehospitalization rates between centers, which may be explained not only by differences in patient populations but also by varying quality in transitions-of-care between transplant centers. However, with the exception of initial hospitalization length of stay (LOS), the study lacked detailed data about process-of-care measures that might lead to early rehospitalization.
To our knowledge, only one prior study has examined preventability of rehospitalizations after KT. In an analysis of over 400 000 rehospitalizations using Florida Medicare claims data, Goldfield et al estimated a potentially preventable rehospitalization (PPR) rate of 20.6% following KT, compared to an average surgical PPR rate of 7.9%. However, the PPR rates provided limited clinical insight, given they were calculated with a complex algorithm utilizing diagnosis-related group codes to determine whether readmissions were unplanned and/or related to the previous admission. Closer scrutiny of these events is needed to achieve a better understanding of the preventability of KT rehospitalizations.
In light of the limitations of previous studies, the goals of this study were to: (1) identify reasons for early rehospitalization following KT by chart review, (2) adjudicate potential preventability of these rehospitalizations, (3) examine associations of recipient, donor, allograft and process-of-care variables with early rehospitalization and (4) examine the associations of early rehospitalization with mortality and all-cause graft loss.
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