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Correspondence |

30-Day Readmissions in Hospitalized Adults With Asthma Exacerbations: Insights From the Nationwide Readmission Database FREE TO VIEW

Sreenivas P. Veeranki, MBBS, MPH, DrPH; Kanika Sharma, MBBS; Michael U. Ohabughiro, BS; Hemalkumar B. Mehta, PhD; Deepak Adhikari, MS; Yong-Fang Kuo, PhD; William J. Calhoun, MD
Author and Funding Information

Editor’s Note: Authors are invited to respond to Correspondence that cites their previously published work. Those responses appear after the related letter. In cases where there is no response, the author of the original article declined to respond or did not reply to our invitation.

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

aDepartment of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX

bDepartment of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA

cSchool of Medicine, University of Texas Medical Branch, Galveston, TX

dDepartment of Surgery, University of Texas Medical Branch, Galveston, TX

eDivision of Pulmonary Critical Care & Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX

CORRESPONDENCE TO: Sreenivas P. Veeranki, MBBS, MPH, DrPH, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, 301 University Blvd, Ewing Hall Ste 1.128, Galveston, TX 77555


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(5):1162-1165. doi:10.1016/j.chest.2016.07.043
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Published online

Using the state inpatient databases for California, Florida, and Nebraska, Hasegawa et al (April 2016) investigated 30-day any-cause readmissions in adults across stratified age groups. Although we commend the authors for their meticulous efforts, the analysis based on limited states for several years (2005-2011) may contribute to potential bias relating to generalizability. In addition, the data used for the analysis are not current. To address these issues, we conducted a similar analysis based on the authors’ work using the 2013 National Readmission Database, a unique cohort that offers data cumulative from 21 state inpatient databases that include 14 million discharges accounting for 49.1% of hospitalizations in the United States.

Of the 153,892 adult patients registered with an index hospitalization for asthma exacerbation, 14.2% were noted to have 30-day any-cause readmission. Compared with those without readmissions, these patients were relatively older (mean age: 64.5 vs 60.6 years; P > .001), largely funded via public insurance (Medicare: 65% vs 53% [P < .001]; Medicaid: 17% vs 16% [P = .002]), had a higher number of comorbidities (mean, 7.0 vs 4.4; P < .001), and longer length of stay (mean, 6.6 vs 5.0 days; P < .001) (Table 1). A multivariable regression model fitted with a generalized estimating equation to limit clustering of similar outcomes within hospitals showed that elderly (OR, 1.30 [95% CI, 1.22-1.40]; P < .001) and middle-aged (OR, 1.45 [95% CI, 1.36-1.54]; P < .001) patients had a higher likelihood of readmission than younger age groups; these findings were similar to those reported by Hasegawa et al, albeit with lower point estimates (Fig 1A). Sensitivity analysis with a model-based multiple imputation approach for missing values for several covariates yielded similar results. However, unlike their study, we found no differences in daily percentages of readmissions between the three defined age groups. The highest rate of readmissions for all adults was between 2 and 3 days’ postdischarge (Fig 1B). Overall, our findings were consistent for the most part with those reported by Hasegawa et al.

Table Graphic Jump Location
Table 1 Characteristics of Patients Registered in the National Readmission Database 2013 With an Index Hospitalization for Asthma Exacerbation Based on 30-Day Any-Cause Readmission
a Frequencies and proportions reported after excluding patients with missing values for income (1.58%), payer (0.12%), discharge disposition (0.10%), and LOS (0.02%).
b Reported P values derived from the nonparametric Mann-Whitney U test after graphic (ie, histograms, Q-Q plots, stem-and-leaf plots) and numeric (ie, Shapiro-Wilk test) assessments confirming non-Gaussian distribution for covariates.
c Computed based on the median cutoff value of 50 index admissions at each facility for 2013 for asthma exacerbation.

Values in boldface are statistically significant, determined at α ≤ 0.05. LOS = length of stay.

Figure Jump LinkFigure 1 A, Association of age-stratified groups with 30-day any-cause readmission for patients having an index hospitalization for asthma exacerbation. The corresponding forests plots are displayed on the right. Reference values are younger patients (aged 18-39 years) with an index hospitalization for asthma exacerbation. B, Proportions of 30-day any-cause readmissions stratified on the basis of age groups.Grahic Jump Location

Beginning October 1, 2012, Section 3025 of the Patient Protection and Affordable Care Act [1886(q)] established the Readmissions Reduction Program, which required Centers for Medicare & Medicaid Services to reduce payments to hospitals with excess readmissions. Therefore, 30-day readmissions have been the focus of national improvement efforts. Advancing age has been identified as an independent predictor of readmission in hospitalized patients with asthma, possibly due to higher comorbid conditions,,, reduced lung elastic recoil,,, poor response to medications, and reduced compliance with asthma management guidelines.,, Our study findings substantiate those identified by Hasegawa et al and propose development of strategies aimed at reducing readmissions among hospitalized patients with asthma.

References

Hasegawa K. .Gibo K. .Tsugawa Y. .et al Age-related differences in the rate, timing, and diagnosis of 30-day readmissions in hospitalized adults with asthma exacerbation. Chest. 2016;149:1021-1029 [PubMed]journal. [CrossRef] [PubMed]
 
HCUP Nationwide Readmission Database (NRD). Healthcare Cost and Utilization Project (HCUP). 2013. Agency for Healthcare Research and Quality, Rockville, MD.https://www.hcup-us.ahrq.gov/nrdoverview.jsp. Accessed September 22, 2016.
 
Panageas K.S. .Schrag D. .Riedel E. .et al The effect of clustering of outcomes on the association of procedure volume and surgical outcomes. Ann Intern Med. 2003;139:658-665 [PubMed]journal. [CrossRef] [PubMed]
 
Center for Medicare & Medicaid Services. Readmissions Reduction Program. 2016.https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed September 16, 2016.
 
Gibson P.G. .McDonald V.M. .Marks G.B. . Asthma in older adults. Lancet. 2010;376:803-813 [PubMed]journal. [CrossRef] [PubMed]
 
Marks G.B. .Poulos L.M. .Jenkins C.R. .et al Asthma in older adults: a holistic, person-centred and problem-oriented approach. Med J Aust. 2009;191:197-199 [PubMed]journal. [PubMed]
 
Tsai C.L. .Lee W.Y. .Hanania N.A. .et al Age-related differences in clinical outcomes for acute asthma in the United States, 2006-2008. J Allergy Clin Immunol. 2012;129:1252-1258.e1 [PubMed]journal. [CrossRef] [PubMed]
 
Sharma G. .Goodwin J. . Effect of aging on respiratory system physiology and immunology. Clin Interv Aging. 2006;1:253-260 [PubMed]journal. [CrossRef] [PubMed]
 
Lalley P.M. . The aging respiratory system—pulmonary structure, function and neural control. Respir Physiol Neurobiol. 2013;187:199-210 [PubMed]journal. [CrossRef] [PubMed]
 
Zeleznik J. . Normative aging of the respiratory system. Clin Geriatr Med. 2003;19:1-18 [PubMed]journal. [CrossRef] [PubMed]
 
Connolly M.J. .Crowley J.J. .Charan N.B. .et al Impaired bronchodilator response to albuterol in healthy elderly men and women. Chest. 1995;108:401-406 [PubMed]journal. [CrossRef] [PubMed]
 
Goodman E.R. .Federman A.D. .Martynenko M. .et al Adherence to Multiple Medications in Older Adults with Asthma. J Am Geriatr Soc. 2016;64:1133-1135 [PubMed]journal. [CrossRef] [PubMed]
 
Hartert T.V. .Togias A. .Mellen B.G. .et al Underutilization of controller and rescue medications among older adults with asthma requiring hospital care. J Am Geriatr Soc. 2000;48:651-657 [PubMed]journal. [CrossRef] [PubMed]
 
O'Conor R. .Wolf M.S. .Smith S.G. .et al Health literacy, cognitive function, proper use, and adherence to inhaled asthma controller medications among older adults with asthma. Chest. 2015;147:1307-1315 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 A, Association of age-stratified groups with 30-day any-cause readmission for patients having an index hospitalization for asthma exacerbation. The corresponding forests plots are displayed on the right. Reference values are younger patients (aged 18-39 years) with an index hospitalization for asthma exacerbation. B, Proportions of 30-day any-cause readmissions stratified on the basis of age groups.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 Characteristics of Patients Registered in the National Readmission Database 2013 With an Index Hospitalization for Asthma Exacerbation Based on 30-Day Any-Cause Readmission
a Frequencies and proportions reported after excluding patients with missing values for income (1.58%), payer (0.12%), discharge disposition (0.10%), and LOS (0.02%).
b Reported P values derived from the nonparametric Mann-Whitney U test after graphic (ie, histograms, Q-Q plots, stem-and-leaf plots) and numeric (ie, Shapiro-Wilk test) assessments confirming non-Gaussian distribution for covariates.
c Computed based on the median cutoff value of 50 index admissions at each facility for 2013 for asthma exacerbation.

Values in boldface are statistically significant, determined at α ≤ 0.05. LOS = length of stay.

References

Hasegawa K. .Gibo K. .Tsugawa Y. .et al Age-related differences in the rate, timing, and diagnosis of 30-day readmissions in hospitalized adults with asthma exacerbation. Chest. 2016;149:1021-1029 [PubMed]journal. [CrossRef] [PubMed]
 
HCUP Nationwide Readmission Database (NRD). Healthcare Cost and Utilization Project (HCUP). 2013. Agency for Healthcare Research and Quality, Rockville, MD.https://www.hcup-us.ahrq.gov/nrdoverview.jsp. Accessed September 22, 2016.
 
Panageas K.S. .Schrag D. .Riedel E. .et al The effect of clustering of outcomes on the association of procedure volume and surgical outcomes. Ann Intern Med. 2003;139:658-665 [PubMed]journal. [CrossRef] [PubMed]
 
Center for Medicare & Medicaid Services. Readmissions Reduction Program. 2016.https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed September 16, 2016.
 
Gibson P.G. .McDonald V.M. .Marks G.B. . Asthma in older adults. Lancet. 2010;376:803-813 [PubMed]journal. [CrossRef] [PubMed]
 
Marks G.B. .Poulos L.M. .Jenkins C.R. .et al Asthma in older adults: a holistic, person-centred and problem-oriented approach. Med J Aust. 2009;191:197-199 [PubMed]journal. [PubMed]
 
Tsai C.L. .Lee W.Y. .Hanania N.A. .et al Age-related differences in clinical outcomes for acute asthma in the United States, 2006-2008. J Allergy Clin Immunol. 2012;129:1252-1258.e1 [PubMed]journal. [CrossRef] [PubMed]
 
Sharma G. .Goodwin J. . Effect of aging on respiratory system physiology and immunology. Clin Interv Aging. 2006;1:253-260 [PubMed]journal. [CrossRef] [PubMed]
 
Lalley P.M. . The aging respiratory system—pulmonary structure, function and neural control. Respir Physiol Neurobiol. 2013;187:199-210 [PubMed]journal. [CrossRef] [PubMed]
 
Zeleznik J. . Normative aging of the respiratory system. Clin Geriatr Med. 2003;19:1-18 [PubMed]journal. [CrossRef] [PubMed]
 
Connolly M.J. .Crowley J.J. .Charan N.B. .et al Impaired bronchodilator response to albuterol in healthy elderly men and women. Chest. 1995;108:401-406 [PubMed]journal. [CrossRef] [PubMed]
 
Goodman E.R. .Federman A.D. .Martynenko M. .et al Adherence to Multiple Medications in Older Adults with Asthma. J Am Geriatr Soc. 2016;64:1133-1135 [PubMed]journal. [CrossRef] [PubMed]
 
Hartert T.V. .Togias A. .Mellen B.G. .et al Underutilization of controller and rescue medications among older adults with asthma requiring hospital care. J Am Geriatr Soc. 2000;48:651-657 [PubMed]journal. [CrossRef] [PubMed]
 
O'Conor R. .Wolf M.S. .Smith S.G. .et al Health literacy, cognitive function, proper use, and adherence to inhaled asthma controller medications among older adults with asthma. Chest. 2015;147:1307-1315 [PubMed]journal. [CrossRef] [PubMed]
 
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