Understandings Predictors Can Decrease Unplanned Hospital Readmissions

Patients with blood cancers are at an increased risk for multiple hospital readmissions. However, multidisciplinary teams and patients can work together to identify predictors and avoid these occurrences.

Newly diagnosed, hospitalized patients with hematologic malignancies tend to have high symptom burdens from the diagnosis itself. This patient population also needs prolonged courses of chemotherapy and consequent transfusion support. Because of this, they are predisposed to unplanned readmissions to the hospital.

Researchers from the Taussig Cancer Institute at the Cleveland Clinic evaluated 30-day unplanned readmissions, defined as hospitalization within 30 days of original admission for any reason other than planned chemotherapy, that occurred at their institution from January 2011 to February 2016.

“We specifically looked at how we can predict a readmission after the first readmission,” Girish Kunapareddy, M.D., from the Leukemia Program at the Taussig Cancer Institute at Cleveland Clinic, said in an interview with CURE. Kunapareddy presented results from their study at the American Society of Hematology Annual Meeting and Exposition.

Hematologic malignancies included acute leukemias, myelodysplastic syndromes and aggressive lymphomas. To evaluate associated predictors, the researchers collected information regarding demographics, clinical characteristics, disease status, body mass index at discharge, absolute neutrophil count at discharge/readmission, reason for readmission, length of stay at original admission/readmission and discharge characteristics.

The researchers observed 259 30-day unplanned readmissions in 157 patients, including 107 patients who had a single occurrence, and 50 with more than two.

The majority of patients were male (59 percent), a median age of 66 years, and had acute myeloid leukemia (44 percent), including half with relapsed or refractory disease. Median income was approximately $51,000, and 86 percent of patients had more than a high school education, according to census tract-based data. In addition, 49 percent of patients were covered by Medicare, 21 percent by Medicaid and 36 percent by private insurance.

Following unplanned readmission discharges, patients were either sent home (50 percent), sent home with home health (32 percent), sent to a nursing facility (15 percent) or hospice (3 percent). Among these readmission discharges, 10 percent of patients were sent on intravenous antibiotics, 44 percent on opioids and 48 percent on psychotropic drugs.

Neutropenic fever appeared to be the primary diagnosis (61 percent) at readmission, with 59 percent demonstrating symptoms at presentation of readmission.

At discharge from unplanned readmissions, median absolute neutrophil count was 870 mL and increased to 940 mL at the time of readmission. Patients stayed for a median of five days, and were readmitted approximately 11 days later. Unplanned readmissions originated from visits to outpatient clinics, emergency departments or patients’ homes (46 percent), as well as non-health care facilities (27 percent) or outside hospital transfers (22 percent).

The researchers found 30-day readmissions were associated with absolute neutrophil counts of more than 2,000 mL at last discharge; constitutional symptoms — such as fevers, chills, sweats and severe fatigue – at admission presentation; gastrointestinal symptoms; if patients were transferred from an outside facility; febrile neutropenia as the reason for admission; relapsed or refractory disease; and higher education.

Of note, Kunapareddy and colleagues were most surprised by higher education having an association with increased 30-day unplanned readmissions. “Maybe having higher education means these patients are more likely to follow instructions or know what symptoms to look for to come in to the hospital,” he said. “Or it may be other reasons for socioeconomic status, like having good transportation, having good access to care, being able to miss work, or having family who can take off to bring you to the hospital, or if you are more financially stable.”

To address high hospital readmissions rates, Kunapareddy recommends for physicians to create individualized care plans and closer patient follow-up. “It is better to create individualized plans for each patient. The only way you can do that is if you have a multidisciplinary team — social work, case management, care coordinators, physician assistants, palliative medicine oncology – that sits around as a round table and discusses this particular patient’s issues and figure out things we can do to help.”

Patients should also be their own advocates, utilize additional resources at institutions, and most importantly, not wait to see their physicians at the onset of symptoms, Kunapareddy added. “Reporting these findings earlier to the doctor, even if patients think it seems minor, help with better symptom control early on.”