Patient and program level correlates of 30-day readmissions: a retrospective analysis of a transitional care program

Abstract

Background

Hospital readmissions present a substantial burden to patients and healthcare systems in terms of outcomes and financial penalties. The primary purpose of this study was to identify patient and program-specific factors linked to 30-day readmissions in patients with congestive health failure (CHF) enrolled in a hospital-based transitional care program.

Methods

We performed a retrospective analysis of electronic health record (EHR) data and program records from 343 community-dwelling adults (median age 81, 50.4% female, 67.9% White, 21% Black) with congestive heart failure (CHF) who were discharged from a community hospital in Westchester County, NY between January 1, 2023 and December 31, 2023. Our outcome of interest was 30-day hospital readmission. Logistic regression models were used to examine patient and program-specific predictors of 30-day readmission.

Results

Of 343 individuals, 19.8% were readmitted within 30 days. Each point increase in comorbidities was associated with 52% greater odds of readmission (p < 0.001, CI 1.24, 1.85). Those with ambulatory follow-up within 7 days had 63% lower odds of 30-day readmission compared to those without 7-day follow-up (p = 0.002, CI 0.2, 0.69). Those who interacted with the Transitional Care Management (TCM) team had an 84% lower risk of readmission compared to those who were not reached by the team.

Conclusion

Comprehensive transitional care programs have potential to reduce the risk of unnecessary hospital readmissions in patients with CHF. Touch points are key for patients discharged from the hospital following a CHF admission, whether via a transitional care program, ambulatory providers, or (ideally) both regardless of how soon after discharge this occurs.

Clinical trial number

Not applicable