By Kenneth P. Steinberg, MD, FACP, Editor
Professor of Medicine, University of Washington School of Medicine Seattle, WA
Dr. Steinberg reports no financial relationships in this field of study.
SOURCE: Cloyd JM, e al. Is weekend discharge associated with hospital readmission? J Hosp Med 2015; 10:731-737.
This study was designed to investigate whether or not there was an association between weekend discharge and 30- and 90-day readmission rates. The population of interest was patients hospitalized for medical diagnoses included in the Centers for Medicare and Medicaid Services’ Hospital Readmission Reduction Program (HRRP): acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia (PNA). The authors hypothesized that patients with these primary diagnoses discharged on a weekend would have higher hospital readmission rates compared to patients discharged on a weekday. After obtaining IRB approval, the authors used a large database for this study: the California Office of State Health Planning and Development (OSHPD) Patient Discharge Data (PDD) from 2012. This inclusive database contained records for all patients admitted and discharged from every general, acute, nonfederal hospital in the state of California. In this database, patients could be tracked even if they were discharged from one hospital and readmitted to another facility. Demographic and clinical data were captured including discharge disposition (home, acute rehabilitation, skilled nursing facility, residential facility, or other). Demographic data, hospital variables, and readmission rates were directly compared for patients discharged on a weekend compared to a weekday after an admission for AMI, CHF, or PNA. Hospital readmission for any reason was tracked for 30 and 90 days after the index admission. Univariate and multivariate logistic regression models were built to study the effect on readmission of age, gender, race, Charlson Comorbidity Index, discharge disposition, and admission type.
There were 266,519 patients admitted with a principle diagnosis of AMI, CHF, or PNA in California during 2012 who met the criteria for inclusion (patients were excluded if they died during the index hospitalization, were transferred to another acute care facility, and if they had invalid tracking numbers). The majority of patients were discharged on a weekday instead of a weekend (77.5% versus 22.5%). Patients discharged on the weekend had a shorter length of stay for all 3 diagnosis groups, and a higher proportion was discharged to home and a smaller proportion was discharged to a SNF.
Among all patients, there were no significant differences between unadjusted readmission rates for patients discharged on the weekend versus weekday at either 30 days (16.7% vs. 17.0%) or 90 days (26.9% vs. 27.5%). In the subsets, unadjusted readmission rates were the same for patients with AMI and PNA at both 30 and 90 days; the unadjusted readmission rates were higher for weekday discharges in CHF at 30 days (15.4% vs. 16.0%, P= 0.04). The same difference was seen at 90 days.
In multivariate logistic regression, weekend discharge was not associated with increased rate of readmission for any diagnosis. Increasing age, male gender, black race, greater Charlson Comorbidity Index, occurrence of a complication, and increased LOS were all associated with readmission. Interestingly, lack of insurance was associated with decreased odds of readmission for all diagnoses.
COMMENTARY
Studies have shown an association between weekend admission and increased mortality but very few studies have focused on the effect of weekend discharge on hospital readmission rate. Hospital readmission is associated with increased short-term morbidity, mortality, and medical costs. Hospitals are now incentivized to reduce readmissions for AMI, CHF, and PNA as part of the Patient Protection and Affordable Care Act of 2013 as penalties are being assessed against hospitals that have high rates of readmission for these diagnoses. Hospitalists are at the forefront of working to reduce readmissions through coordination of safe discharges. Discharge from the hospital is a complex task involving good coordination and communication among team members, and patients and their families. There are many reasons why weekend discharges might be higher risk including decreased staffing, lack of continuity of care, inability to make follow-up appointments, less robust medication reconciliation, and less access to outpatient pharmacies on the weekend.
Importantly, this study demonstrated that it might be safe to discharge patients on the weekend as there was not an increased readmission rate for that group of patients compared to patients discharged on a weekday. This is a robust study with a very large number of patients across many institutions in a large state with a very complete database. Although there are always inherent limitations to studies using administrative databases, the observation that weekend discharge is not a predictor of readmission in patients with AMI, CHF, or PNA in California is likely valid. However, one important caveat for the lack of correlation between weekend discharge and readmission could be that sicker and higher risk patients were selected for discharge on a weekday, a possibility that could make it difficult to see an increased risk of readmission for weekend discharges. The authors correctly point out, though, that the despite fears that access to staffing and supplies are reduced during the weekend, it might be that weekend discharge resources are in fact not the limiting factor in efforts to reduce readmissions.
In summary, this study challenges the preconceptions that weekend discharges are less safe and are a predictor for readmission. Routinely delaying a discharge until Monday likely only increases costs and may not reduce the risk for readmission. Efforts to reduce readmission rates should focus on reducing risk factors other than day of discharge. Hospitalists need to be aware of these observations to reduce healthcare costs and help their hospitals reduce readmission rates.
