All-Cause Readmission to Acute Care and Return to the Emergency Department June 2012

Overview Readmissions a focus in Canada and internationally Implications for improving quality and potentially reducing costs Study objectives: To quantify all-cause unplanned readmission rates in Canada, as well as post-discharge unplanned visits to emergency departments (EDs) To identify factors associated with higher rates of readmissions Are common, costly and in some cases potentially avoidable. May impact a patients’ quality of life or create anxiety for their families. Are a result of many complex health system interactions.

Approach Three perspectives are examined throughout the report: Patient effects Age, gender, reason for initial hospitalization Hospital effects Hospital size, length-of-stay patterns Community effects Neighbourhood income quintile, rural/urban location

30-Day All-Cause Unplanned Readmission Rates Overall Readmission Rate: 8.5% Sources Discharge Abstract Database, 2010–2011, Canadian Institute for Health Information; Fichier des hospitalisations MED-ÉCHO, 2009–2010, ministère de la Santé et des Services sociaux du Québec; All-Cause Readmission to Acute Care and Return to the Emergency Department, CIHI, 2012.

Patient Effects Medical patients Surgical patients Patients with chronic obstructive pulmonary disease (COPD) and heart failure are among the highest volume of readmissions The primary reason for readmission is the same condition as primary discharge Surgical patients Colostomy, unilateral knee replacement and hysterectomy patients are among the highest volume of readmissions The primary reason for readmission is post-operative complication

95% Confidence Intervals Hospital Effects Patients discharged from the hospitals that on average have longer lengths of stay (than expected) have lower readmission rates Odds Ratios for Acute Care Readmission, by Hospital Length-of-Stay Variance Hospital LOS Variance Odds Ratios 95% Confidence Intervals <-1.00 Day 1.40 (1.31–1.50) -1.00 to -0.49 Days 1.03 (1.01–1.06) -0.50 to -0.01 Days 1.04 (1.03–1.05) 0 to 0.49 Days Reference 0.50 to 0.99 Days 0.96 (0.94–0.97) ≥1 Day 0.95 (0.92–0.97) Patients discharged from hospitals that had average lengths of stay that were shorter than the expected length of stay (ELOS) had higher readmission rates. The risk of readmission increased by around 40% in patients discharged from hospitals with an average length of stay that was more than one day shorter than the national average ELOS Notes Odds ratios were adjusted for patient group, age, sex, neighbourhood income quintiles, rural/urban residence, admission via emergency department and number of acute care visits six months prior to index discharge. Sources Discharge Abstract Database, 2010–2011, Canadian Institute for Health Information; Fichier des hospitalisations MED-ÉCHO, 2009–2010, ministère de la Santé et des Services sociaux du Québec; All-Cause Readmission to Acute Care and Return to the Emergency Department, CIHI, 2012.

Community Effects: Risk-Adjusted 30-Day Unplanned Readmission Rates, by Province/Territory B.C. Y.T. N.W.T. Nun. Alta. Sask. Man. Ont. Que. N.L. P.E.I. N.B. N.S. Canada 8.2 (8.0–8.4) 8.4 (8.2–8.6) 8.6 (8.4–8.9) 8.9 (8.4–9.4) 8.3 (8.2–8.4) (8.4–8.5) 8.8 (8.6–9.0) 9.8 (8.6–9.9) (8.1–8.3) 9.0 (8.9–9.1) 8.5 (8.49–8.56) (7.2–9.6) 9.5 (8.6–10.6) 11.2 (9.6–12.9) Sources Discharge Abstract Database, 2010–2011, Canadian Institute for Health Information; Fichier des hospitalisations MED-ÉCHO, 2009–2010, ministère de la Santé et des Services sociaux du Québec; All-Cause Readmission to Acute Care and Return to the Emergency Department, CIHI, 2012.

Community Effects Rate of Inpatient Readmissions by Urban/Rural Residence, Overall and by Patient Group Patients living in rural communities readmitted more often than those in urban communities Neighbourhood income quintile an important factor in readmissions only for the lowest quintile Sources Discharge Abstract Database, 2010–2011, Canadian Institute for Health Information; Fichier des hospitalisations MED-ÉCHO, 2009–2010, ministère de la Santé et des Services sociaux du Québec; All-Cause Readmission to Acute Care and Return to the Emergency Department, CIHI, 2012.

Unplanned Return to the ED Within One Week, Ontario, Alberta and Yukon Overall Rate: 9.0% Sources Discharge Abstract Database and National Ambulatory Care Reporting System, 2010–2011, Canadian Institute for Health Information; All-Cause Readmission to Acute Care and Return to the Emergency Department, CIHI, 2012.

Return to Emergency Department Rate of Return to the Emergency Department, by Urban/Rural Residence, Overall and by Patient Group Patients living in rural areas returned to the ED at a higher rate than patients living in urban areas 56% of all patients residing in rural areas returned for non-urgent care compared with 20% of patients residing in urban areas Many factors contribute to readmission and returns to the emergency department. Readmissions cannot be eliminated from the system. However, understanding the factors may contribute to the development of programs targeted to reduce the number of patients being readmitted on an annual basis. Patient group Sources Discharge Abstract Database and National Ambulatory Care Reporting System, 2010–2011, Canadian Institute for Health Information; All-Cause Readmission to Acute Care and Return to the Emergency Department, CIHI, 2012.