Journal of General Internal Medicine

, Volume 28, Issue 2, pp 269–282

Impact of Social Factors on Risk of Readmission or Mortality in Pneumonia and Heart Failure: Systematic Review

  • Linda Calvillo–King
  • Danielle Arnold
  • Kathryn J. Eubank
  • Matthew Lo
  • Pete Yunyongying
  • Heather Stieglitz
  • Ethan A. Halm
Reviews

ABSTRACT

BACKGROUND

Readmission and mortality after hospitalization for community-acquired pneumonia (CAP) and heart failure (HF) are publically reported. This systematic review assessed the impact of social factors on risk of readmission or mortality after hospitalization for CAP and HF—variables outside a hospital’s control.

METHODS

We searched OVID, PubMed and PSYCHINFO for studies from 1980 to 2012. Eligible articles examined the association between social factors and readmission or mortality in patients hospitalized with CAP or HF. We abstracted data on study characteristics, domains of social factors examined, and presence and magnitude of associations.

RESULTS

Seventy-two articles met inclusion criteria (20 CAP, 52 HF). Most CAP studies evaluated age, gender, and race and found older age and non-White race were associated with worse outcomes. The results for gender were mixed. Few studies assessed higher level social factors, but those examined were often, but inconsistently, significantly associated with readmissions after CAP, including lower education, low income, and unemployment, and with mortality after CAP, including low income. For HF, older age was associated with worse outcomes and results for gender were mixed. Non-Whites had more readmissions after HF but decreased mortality. Again, higher level social factors were less frequently studied, but those examined were often, but inconsistently, significantly associated with readmissions, including low socioeconomic status (Medicaid insurance, low income), living situation (home stability rural address), lack of social support, being unmarried and risk behaviors (smoking, cocaine use and medical/visit non-adherence). Similar findings were observed for factors associated with mortality after HF, along with psychiatric comorbidities, lack of home resources and greater distance to hospital.

CONCLUSIONS

A broad range of social factors affect the risk of post-discharge readmission and mortality in CAP and HF. Future research on adverse events after discharge should study social determinants of health.

KEY WORDS

readmission mortality systematic review heart failure community acquired pneumonia 

REFERENCES

  1. 1.
    Medicaid CfMa. Publicly reporting risk-standardized, 30-day readmission measures for AMI, HF and PN. http://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1219069855273. September 7, 2012.
  2. 2.
    Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA. 2011;306(15):1688–1698.PubMedCrossRefGoogle Scholar
  3. 3.
    Krumholz HM, Wang Y, Mattera JA, et al. An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2006;113(13):1693–1701.Google Scholar
  4. 4.
    Bratzler DW, Normand S-LT, Wang Y, et al. An administrative claims model for profiling hospital 30-day mortality rates for pneumonia patients. PLoS One. 2011;6(4):e17401.PubMedCrossRefGoogle Scholar
  5. 5.
    Keenan PS, Normand S-LT, Lin Z, et al. An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2008;1(1):29–37.PubMedCrossRefGoogle Scholar
  6. 6.
    Lindenauer PK, Normand S-LT, Drye EE, et al. Development, validation, and results of a measure of 30-day readmission following hospitalization for pneumonia. J Hosp Med (Online). 2011;6(3):142–150.CrossRefGoogle Scholar
  7. 7.
    Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Heal Soc Behav. 1995;36(1):1–10.CrossRefGoogle Scholar
  8. 8.
    Vrbova L, Mamdani M, Moineddin R, Jaakimainen L, Upshur R. Does socioeconomic status affect mortality subsequent to hospital admission for community acquired pneumonia among older persons? J Negat Results Biomed. 2005;4:4.PubMedCrossRefGoogle Scholar
  9. 9.
    Philbin E, DiSalvo T. Influence of race and gender on care process, resource use, and hospital-based outcomes in congestive heart failure. Am J Cardiol. 1998;82(1):76–81.PubMedCrossRefGoogle Scholar
  10. 10.
    Philbin E, DiSalvo T. Prediction of hospital readmission for heart failure: development of a simple risk score based on administrative data. J Am Coll Cardiol. 1999;33(6):1560–1566.PubMedCrossRefGoogle Scholar
  11. 11.
    Philbin E, DiSalvo T. Managed care for congestive heart failure: influence of payer status on process of care, resource utilization, and short-term outcomes. Am Heart J. 1998;136(3):553–561.PubMedCrossRefGoogle Scholar
  12. 12.
    Amarasingham R, Moore BJ, Tabak YP, et al. An automated model to identify heart failure patients at risk for 30-day readmission or death using electronic medical record data. Med Care. 2010;48(11):981–988.PubMedCrossRefGoogle Scholar
  13. 13.
    Schwarz K, Elman C. Identification of factors predictive of hospital readmissions for patients with heart failure. Heart Lung. 2003;32(2):88–99.PubMedCrossRefGoogle Scholar
  14. 14.
    Watson AJ, O’Rourke J, Jethwani K, et al. Linking electronic health record-extracted psychosocial data in real-time to risk of readmission for heart failure. Psychosomatics. 2011;52(4):319–327.PubMedCrossRefGoogle Scholar
  15. 15.
    Anderson MA, Levsen J, Dusio ME, et al. Evidenced-based factors in readmission of patients with heart failure. J Nurs Care Qual. 2006;21(2):160–167.PubMedCrossRefGoogle Scholar
  16. 16.
    Ross JS, Maynard C, Krumholz HM, et al. Use of administrative claims models to assess 30-day mortality among Veterans Health Administration hospitals. Med Care. 2010;48(7):652–658.PubMedCrossRefGoogle Scholar
  17. 17.
    Ross JS, Mulvey GK, Stauffer B, et al. Statistical models and patient predictors of readmission for heart failure: a systematic review. Arch Intern Med. 2008;168(13):1371–1386.PubMedCrossRefGoogle Scholar
  18. 18.
    Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the chronic care model in the New Millennium. Heal Aff. 2009;28(1):75–85.CrossRefGoogle Scholar
  19. 19.
    Herzog N, Bratzler D, Houck P, et al. Effects of previous influenza vaccination on subsequent readmission and mortality in elderly patients hospitalized with pneumonia. Am J Med. 2003;115(6):454–461.PubMedCrossRefGoogle Scholar
  20. 20.
    Whittle J, Lin C, Lave J, et al. Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia. Med Care. 1998;36(7):977–987.PubMedCrossRefGoogle Scholar
  21. 21.
    Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675–681.PubMedCrossRefGoogle Scholar
  22. 22.
    Jasti H, Mortensen E, Obrosky D, Kapoor W, Fine M. Causes and risk factors for rehospitalization of patients hospitalized with community-acquired pneumonia. Clin Infect Dis. 2008;46(4):550–556.PubMedCrossRefGoogle Scholar
  23. 23.
    McGregor M, Reid R, Schulzer M, Fitzgerald J, Levy A, Cox M. Socioeconomic status and hospital utilization among younger adult pneumonia admissions at a Canadian hospital. BMC Health Serv Res. 2006;6:152.PubMedCrossRefGoogle Scholar
  24. 24.
    Kaplan V, Angus D, Griffin M, Clermont G, Scott Watson R, Linde-Zwirble W. Hospitalized community-acquired pneumonia in the elderly: age- and sex-related patterns of care and outcome in the United States.[see comment]. Am J Respir Crit Care Med. 2002;165(6):766–772.PubMedGoogle Scholar
  25. 25.
    Oliver M, Stukenborg G, Wagner D, et al. Comorbid disease and the effect of race and ethnicity on in-hospital mortality from aspiration pneumonia. J Natl Med Assoc. 2004;96(11):1462–1469.PubMedGoogle Scholar
  26. 26.
    Tabak Y, Johannes R, Silber J. Using automated clinical data for risk adjustment: development and validation of six disease-specific mortality predictive models for pay-for-performance. Med Care. 2007;45(8):789–805.PubMedCrossRefGoogle Scholar
  27. 27.
    Polsky D, Jha A, Lave J, et al. Short- and long-term mortality after an acute illness for elderly whites and blacks. Health Serv Res. 2008;43(4):1388–1402.PubMedCrossRefGoogle Scholar
  28. 28.
    Mortensen E, Cornell J, Whittle J. Racial variations in processes of care for patients with community-acquired pneumonia. BMC Health Serv Res. 2004;4(1):20.PubMedCrossRefGoogle Scholar
  29. 29.
    Abrams T, Vaughan-Sarrazin M, Rosenthal G. Variations in the associations between psychiatric comorbidity and hospital mortality according to the method of identifying psychiatric diagnoses. J Gen Intern Med. 2008;23(3):317–322.PubMedCrossRefGoogle Scholar
  30. 30.
    Saitz R, Ghali W, Moskowitz M. The impact of alcohol-related diagnoses on pneumonia outcomes. Arch Intern Med. 1997;157(13):1446–1452.PubMedCrossRefGoogle Scholar
  31. 31.
    de Roux A, Cavalcanti M, Marcos M, et al. Impact of alcohol abuse in the etiology and severity of community-acquired pneumonia. Chest. 2006;129(5):1219–1225.PubMedCrossRefGoogle Scholar
  32. 32.
    Vaughan-Sarrazin M, Wakefield B, Rosenthal G. Mortality of Department of Veterans Affairs patients admitted to private sector hospitals for 5 common medical conditions. Am J Med Qual. 2007;22(3):186–197.PubMedCrossRefGoogle Scholar
  33. 33.
    Jiang W, Alexander J, Christopher E, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure.[see comment]. Arch Intern Med. 2001;161(15):1849–1856.PubMedCrossRefGoogle Scholar
  34. 34.
    Kossovsky M, Sarasin F, Perneger T, Chopard P, Sigaud P, Gaspoz J. Unplanned readmissions of patients with congestive heart failure: do they reflect in-hospital quality of care or patient characteristics? Am J Med. 2000;109(5):386–390.PubMedCrossRefGoogle Scholar
  35. 35.
    Opasich C, Cafiero M, Scherillo M, et al. Impact of diabetes on the current in-hospital management of heart failure. From the TEMISTOCLE study. Ital Heart J. 2003;4(10):685–694.PubMedGoogle Scholar
  36. 36.
    Roe-Prior P. Sociodemographic variables predicting poor post-discharge outcomes for hospitalized elders with heart failure. Medsurg Nurs. 2007;16(5):317–321.PubMedGoogle Scholar
  37. 37.
    Rathore S, Foody J, Wang Y, et al. Race, quality of care, and outcomes of elderly patients hospitalized with heart failure.[see comment]. JAMA. 2003;289(19):2517–2524.PubMedCrossRefGoogle Scholar
  38. 38.
    Kociol RD, Greiner MA, Hammill BG, et al. Long-term outcomes of medicare beneficiaries with worsening renal function during hospitalization for heart failure. Am J Cardiol. 2010;105(12):1786–1793.PubMedCrossRefGoogle Scholar
  39. 39.
    Rodriguez F, Joynt KE, Lopez L, Saldana F, Jha AK. Readmission rates for Hispanic Medicare beneficiaries with heart failure and acute myocardial infarction. Am Heart J. 2011;162(2):254–261.e253.PubMedCrossRefGoogle Scholar
  40. 40.
    Aranda JM Jr, Johnson JW, Conti JB. Current trends in heart failure readmission rates: analysis of Medicare data. Clin Cardiol. 2009;32(1):47–52.PubMedCrossRefGoogle Scholar
  41. 41.
    Luthi J, Lund M, Sampietro-Colom L, Kleinbaum D, Ballard D, McClellan W. Readmissions and the quality of care in patients hospitalized with heart failure. Int J Qual Health Care. 2003;15(5):413–421.PubMedCrossRefGoogle Scholar
  42. 42.
    Krumholz H, Parent E, Tu N, et al. Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. [see comment]. Arch Intern Med. 1997;157(1):99–104.PubMedCrossRefGoogle Scholar
  43. 43.
    Howie-Esquivel J, Dracup K. Does oxygen saturation or distance walked predict rehospitalization in heart failure? J Cardiovasc Nurs. 2008;23(4):349–356.PubMedGoogle Scholar
  44. 44.
    Philbin E, Dec G, Jenkins P, DiSalvo T. Socioeconomic status as an independent risk factor for hospital readmission for heart failure. Am J Cardiol. 2001;87(12):1367–1371.PubMedCrossRefGoogle Scholar
  45. 45.
    Rathore S, Masoudi F, Wang Y, et al. Socioeconomic status, treatment, and outcomes among elderly patients hospitalized with heart failure: findings from the National Heart Failure Project. Am Heart J. 2006;152(2):371–378.PubMedCrossRefGoogle Scholar
  46. 46.
    Tsuchihashi M, Tsutsui H, Kodama K, et al. Medical and socioenvironmental predictors of hospital readmission in patients with congestive heart failure. Am Heart J. 2001;142(4):E7.PubMedCrossRefGoogle Scholar
  47. 47.
    Albert NM, Fonarow GC, Abraham WT, et al. Depression and clinical outcomes in heart failure: an OPTIMIZE-HF analysis. Am J Med. 2009;122(4):366–373.PubMedCrossRefGoogle Scholar
  48. 48.
    Struthers A, Anderson G, Donnan P, MacDonald T. Social deprivation increases cardiac hospitalisations in chronic heart failure independent of disease severity and diuretic non-adherence. Heart. 2000;83(1):12–16.PubMedCrossRefGoogle Scholar
  49. 49.
    Chioncel O, Vinereanu D, Datcu M, et al. The Romanian Acute Heart Failure Syndromes (RO-AHFS) registry. Am Heart J. 2011;162(1):142–153.e141.PubMedCrossRefGoogle Scholar
  50. 50.
    Saczynski JS, Darling CE, Spencer FA, Lessard D, Gore JM, Goldberg RJ. Clinical features, treatment practices, and hospital and long-term outcomes of older patients hospitalized with decompensated heart failure: The Worcester Heart Failure Study. J Am Geriatr Soc. 2009;57(9):1587–1594.PubMedCrossRefGoogle Scholar
  51. 51.
    Feinglass J, Martin G, Lin E, Johnson M, Gheorghiade M. Is heart failure survival improving? Evidence from 2323 elderly patients hospitalized between 1989–2000. Am Heart J. 2003;146(1):111–114.PubMedCrossRefGoogle Scholar
  52. 52.
    Garty M, Shotan A, Gottlieb S, et al. The management, early and one year outcome in hospitalized patients with heart failure: a national Heart Failure Survey in Israel–HFSIS 2003. Isr Med Assoc J. 2007;9(4):227–233.PubMedGoogle Scholar
  53. 53.
    Lee DS, Austin PC, Rouleau JL, Liu PP, Naimark D, Tu JV. Predicting Mortality Among Patients Hospitalized for Heart Failure: Derivation and Validation of a Clinical Model. JAMA. 2003;290(19):2581–2587.PubMedCrossRefGoogle Scholar
  54. 54.
    Goldberg R, Spencer F, Farmer C, Meyer T, Pezzella S. Incidence and hospital death rates associated with heart failure: a community-wide perspective. Am J Med. 2005;118(7):728–734.PubMedCrossRefGoogle Scholar
  55. 55.
    Zuccala G, Pedone C, Cesari M, et al. The effects of cognitive impairment on mortality among hospitalized patients with heart failure.[see comment]. Am J Med. 2003;115(2):97–103.PubMedCrossRefGoogle Scholar
  56. 56.
    Pearson M, Kahn K, Harrison E, et al. Differences in quality of care for hospitalized elderly men and women. JAMA. 1992;268(14):1883–1889.PubMedCrossRefGoogle Scholar
  57. 57.
    Ni H, Nauman D, Hershberger R. Managed care and outcomes of hospitalization among elderly patients with congestive heart failure. Arch Intern Med. 1998;158(11):1231–1236.PubMedCrossRefGoogle Scholar
  58. 58.
    Fonarow G, Abraham W, Albert N, et al. Factors identified as precipitating hospital admissions for heart failure and clinical outcomes: findings from OPTIMIZE-HF. Arch Intern Med. 2008;168(8):847–854.PubMedCrossRefGoogle Scholar
  59. 59.
    Ambardekar AV, Fonarow GC, Hernandez AF, et al. Characteristics and in-hospital outcomes for nonadherent patients with heart failure: findings from Get With The Guidelines-Heart Failure (GWTG-HF). Am Heart J. 2009;158(4):644–652.PubMedCrossRefGoogle Scholar
  60. 60.
    Zuluaga MC, Guallar-Castillon P, Conthe P, et al. Housing conditions and mortality in older patients hospitalized for heart failure. Am Heart J. 2011;161(5):950–955.PubMedCrossRefGoogle Scholar
  61. 61.
    Torres J, Cardenas O, Vasquez A, Schlossberg D. Streptococcus pneumoniae bacteremia in a community hospital.[see comment]. Chest. 1998;113(2):387–390.PubMedCrossRefGoogle Scholar
  62. 62.
    Bohannon R, Maljanian R. Hospital readmissions of elderly patients hospitalized with pneumonia. Conn Med. 2003;67(10):599–603.PubMedGoogle Scholar
  63. 63.
    El Solh A, Pineda L, Bouquin P, Mankowski C. Determinants of short and long term functional recovery after hospitalization for community-acquired pneumonia in the elderly: role of inflammatory markers. BMC Geriatr. 2006;6:12.PubMedCrossRefGoogle Scholar
  64. 64.
    Vinson J, Rich M, Sperry J, Shah A, McNamara T. Early readmission of elderly patients with congestive heart failure.[see comment]. J Am Geriatr Soc. 1990;38(12):1290–1295.PubMedGoogle Scholar
  65. 65.
    Afzal A, Ananthasubramaniam K, Sharma N, et al. Racial differences in patients with heart failure. Clin Cardiol. 1999;22(12):791–794.PubMedCrossRefGoogle Scholar
  66. 66.
    Krumholz H, Chen Y, Wang Y, Vaccarino V, Radford M, Horwitz R. Predictors of readmission among elderly survivors of admission with heart failure. Am Heart J. 2000;139(1 Pt 1):72–77.PubMedCrossRefGoogle Scholar
  67. 67.
    Chen M, Chang H, Cheng C, Chen Y, Chai H. Risk stratification of in-hospital mortality in patients hospitalized for chronic congestive heart failure secondary to non-ischemic cardiomyopathy. Cardiology. 2003;100(3):136–142.PubMedCrossRefGoogle Scholar
  68. 68.
    Formiga F, Chivite D, Sole A, Manito N, Ramon J, Pujol R. Functional outcomes of elderly patients after the first hospital admission for decompensated heart failure (HF). A prospective study. Arch Gerontol Geriatr. 2006;43(2):175–185.PubMedCrossRefGoogle Scholar
  69. 69.
    Luttik M, Jaarsma T, Veeger N, van Veldhuisen D. Marital status, quality of life, and clinical outcome in patients with heart failure. Heart Lung. 2006;35(1):3–8.PubMedCrossRefGoogle Scholar
  70. 70.
    Howie-Esquivel J, Dracup K. Effect of gender, ethnicity, pulmonary disease, and symptom stability on rehospitalization in patients with heart failure. Am J Cardiol. 2007;100(7):1139–1144.PubMedCrossRefGoogle Scholar
  71. 71.
    Najafi F, Dobson A, Jamrozik K. Recent changes in heart failure hospitalisations in Australia. Eur J Heart Fail. 2007;9(3):228–233.PubMedCrossRefGoogle Scholar
  72. 72.
    Mullens W, Abrahams Z, Sokos G, et al. Gender differences in patients admitted with advanced decompensated heart failure. Am J Cardiol. 2008;102(4):454–458.PubMedCrossRefGoogle Scholar
  73. 73.
    Lofvenmark C, Mattiasson A-C, Billing E, Edner M. Perceived loneliness and social support in patients with chronic heart failure. Eur J Cardiovasc Nurs. 2009;8(4):251–258.PubMedCrossRefGoogle Scholar
  74. 74.
    Moser DK, Yamokoski L, Sun JL, et al. Improvement in health-related quality of life after hospitalization predicts event-free survival in patients with advanced heart failure. J Card Fail. 2009;15(9):763–769.PubMedCrossRefGoogle Scholar
  75. 75.
    Muus KJ, Knudson A, Klug MG, Gokun J, Sarrazin M, Kaboli P. Effect of post-discharge follow-up care on re-admissions among US veterans with congestive heart failure: a rural–urban comparison. Rural Remote Heal. 2010;10(2):1447.Google Scholar
  76. 76.
    Akosah K, Schaper A, Haus L, Mathiason M, Barnhart S, McHugh V. Improving outcomes in heart failure in the community: long-term survival benefit of a disease-management program. Chest. 2005;127(6):2042–2048.PubMedCrossRefGoogle Scholar
  77. 77.
    Alberts MJ, Bhatt DL, Mas J-L, et al. Three-year follow-up and event rates in the international Reduction of Atherothrombosis for Continued Health Registry. Eur Heart J. 2009;30(19):2318–2326.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Linda Calvillo–King
    • 1
  • Danielle Arnold
    • 1
  • Kathryn J. Eubank
    • 1
  • Matthew Lo
    • 1
  • Pete Yunyongying
    • 1
  • Heather Stieglitz
    • 1
  • Ethan A. Halm
    • 1
    • 2
  1. 1.Division of General Internal MedicineUniversity of Texas Southwestern Medical CenterDallasUSA
  2. 2.Department of Clinical SciencesUniversity of Texas Southwestern Medical Center at DallasDallasUSA

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