Reducing preventable hospital readmissions: a way forward

Unplanned hospital readmission figures are used in many healthcare systems as a quality indicator. They have been linked with poor inpatient care, badly organised support or a lack of suitable rehabilitation after discharge. The UK Department of Health defines emergency readmissions as unplanned hospital admissions occurring within 30 days of the last hospital discharge, excluding admissions for malignant cancer, cancer chemotherapy, or specialist obstetric or mental health services. It is estimated that readmissions cost the NHS £2.4bn in 2012–2013^[1]
. As an incentive to improve inpatient care and the quality of the discharge process, NHS acute care hospital trusts face financial penalties for emergency readmissions^[2]
.

Older people have a significantly higher readmission rate than younger people. This is thought to be the result of a combination of complex medical conditions and social vulnerability, both of which require collaborative working and careful planning by health and social care professionals arranging the hospital discharge and after care^[1]
. The charity Age UK reports that, more often than not, readmission to hospital has a negative impact on the health and well-being of an older person^[3]
.

Clinicians and managers working to reduce readmissions in the UK face a number of challenges. First, hospital episode statistics (HES) data are flawed because pseudo-anonymisation and international classification of diseases (ICD) coding processes are complex and therefore prone to human error^[4]
. Second, most published evidence concerning hospital readmissions comes from health settings in the United States or Canada and may not be directly transferable to the UK^[5],[6]
. Third, identifying patients at risk of readmission is difficult. Health and social care professionals are unable to predict accurately which individual patients will be readmitted^[7]
and prediction tools for hospital readmission within 30 days are based on epidemiological data and are moderately sensitive at best
^[5],[8]
. Fourth, multiple factors contribute to readmissions and the Health Belief Model — which includes reference to self-efficacy of the patient — suggests that behaviour change interventions may be needed to tackle inappropriate beliefs or behaviours^[9]
. Finally, staffing resources are increasingly under pressure across the NHS because of ongoing cost-saving programmes, and effective interventions may be resource intensive, particularly if conducted in the patient’s home
^[5]
.

Weak to moderate correlations can be found in the literature between certain medicines, polypharmacy, transfer of care regarding medicines and likelihood of admission or readmission. However, causality is not proven and our understanding of medication-related readmissions is still poor, not least because adverse drug reactions are often a diagnosis of exclusion at hospital admission, under-recognised and under-reported^[10]
.

Rigorous studies specifically addressing the prevention of medication-related readmissions are lacking. However, there are four themes relating to medication that are emerging from the literature as important in readmissions.

• Medicine reconciliation at admission and discharge: this needs to occur soon after admission (ideally within 24 hours) and should be followed up with timely discharge communication with the primary care physician and community pharmacist, including information about any medication changes, in order to facilitate safe transfer of care. Engagement with other key individuals who facilitate safe transfer (e.g. community matron, intermediate care, patients and carers) is important at this stage. Guidance on optimising medicines-related transfer of care^[11]
  and best practice for medicines reconciliation^[12]
  is available.
• Person-centred patient education: this ensures that the time, place and format of education are acceptable to patients, and the conversation is led by them, focusing on what is important to them about their medicines in the context of their lives. Patient-centred conversations can address the modifiable barriers to medicines adherence through exploration of information requirements, discussion of beliefs about medicines and increasing patient responsibility for managing their own health through medicines use.
• Shared decision making: patients and their carers are central when making decisions about their treatment and the planning of their care. If patient involvement is considered as a continuum, then patients who are experts in their condition are at one end and patients who prefer health and social care professionals to take all responsibility for decisions are at the other end. Patients can be at different points on the continuum at different times in their lives and for different decisions. The role of the health and social care professional is to empower patients to take an increased responsibility for their health management because most of the time they manage it without a professional present.
• Follow up through community pharmacy: provision of both the new medicine service at any time and a medicines use review after hospital discharge can reduce the incidence of harm and increase the medicines adherence rate. Hospital pharmacy staff are well placed to identify and refer patients into this service, joining up pharmaceutical care across primary and secondary care and ensuring patients are followed up after discharge.

It is unfortunate but there is no ‘one-size-fits-all’ option for support. Individual patients need an integrated assessment of requirements for medication support during their hospital stay and after discharge, with care planning to include follow up and monitoring.

Encouragingly, two recent studies suggest that prevention of medication-related readmissions can be cost-effective. London North West Healthcare NHS Trust provides an integrated medicines management service to identify patients at risk of preventable medicines-related problems and reduce the risk of readmission after discharge. In a case-control study of 836 patients, a statistically significant reduction in preventable medicines-related readmissions was found in a group of patients who received the service (P<0.002). This service used a health-coaching approach to consultations and provided a saving of £3 for every £1 spent on an integrated medicines management pharmacist^[13]
.

Newcastle upon Tyne Hospitals NHS Foundation Trust found that the risk of hospital readmission was reduced by 40% when pharmacy staff provided care for older people in a person-centred way. In this study, 90% of post-discharge follow-up by hospital or community pharmacy was possible by telephone rather than by home visit^[14]
.

Pharmacy teams looking for practice resources in this area have a number to choose from (see ‘Practice resources for pharmacy teams working in this field’). The theme that links these resources is that understanding and addressing what is important to the patient, as well as the factors that place the patient at risk of medicines-related problems, is at least as important as identifying and managing a high risk medicine.

Investment in resources to adjust and evaluate existing readmission risk prediction models is unlikely to solve the issue. We suggest that investment in person-centred pharmaceutical care during and after a hospital admission (i.e. meeting each individual’s need for information, risk management or support in taking their medicines, and increasing their responsibility for self-care) will contribute to reducing the rate of emergency readmissions caused by non-adherence or troublesome side effects. This requires us to view patients as partners in their care and necessitates joining up pharmacy services across sectors. Several good practice models already exist^[19]
and opportunities are arising from community pharmacy access to the summary care record and the Royal Pharmaceutical Society (RPS) workstream on person-centred care. Meaningful progress in this field will require these efforts alongside a greater understanding of the problem (qualitative and quantitative understanding and consistent ICD coding), increased incident reporting, integration, and real-time feedback for health and social care professionals.