HIE Boosts Care Coordination, Home Discharge Among Older Adults

Health information exchange (HIE) may mitigate information discontinuity present in fragmented readmissions, according to a cohort study published in JAMA Network Open.

Fragmented readmissions, defined as readmissions to a different hospital than a patient was previously discharged from, may increase the risk of a non-home discharge for older adults.

Researchers retrospectively examined data from Medicare beneficiaries hospitalized for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues in 2018 and their 30-day readmission.

Fragmented readmissions made up more than 30 percent of all readmissions. For older adults with and without Alzheimer disease, fragmented readmission was associated with higher odds of discharge to a skilled nursing facility (SNF). Fragmented readmission was also associated with lower odds of discharge home with home health and higher odds of leaving against medical advice.

Notably, more than 85 percent of patients with fragmented readmission were readmitted to hospitals that did not share an HIE with the admission hospital.

While data sharing via HIE in fragmented readmissions was associated with discharge destination, the study authors noted that it was not enough to mitigate the association between fragmentation and discharge destination in most instances.

One exception to this trend was home health. In fragmented readmissions with shared HIE, beneficiaries with and without Alzheimer disease had 9 to 15 percent higher odds of discharge home with home health than fragmented readmissions in which HIE was unavailable.

The researchers noted that this association may be due to the electronically available health data. For example, accessing notes from previous hospitalization or outpatient visits may provide context about a patient’s goals of care or baseline functional status.

Fragmented readmissions were associated with 24 percent higher odds of dying during the readmission in beneficiaries without Alzheimer disease. Still, there was no statistically significant difference in the odds of dying during the readmission in beneficiaries with Alzheimer disease.

When those fragmented readmissions occurred at hospitals that shared an HIE, beneficiaries with Alzheimer disease had 23 percent lower odds of dying during the readmission compared with fragmented readmissions to hospitals that did not share an HIE.

“Older adults with Alzheimer disease may be particularly sensitive to poor care coordination, so the observation of a positive association with in-hospital mortality when information exchange is present is encouraging,” the researchers emphasized.

“While our data set does not define HIE pairs beyond hospitals, one potential reason for this observation may be that information exchange is not limited to hospitals; HIEs and other electronic information exchange systems also exist between the inpatient and outpatient settings and between hospitals and long-term-care facilities, which could further facilitate care coordination,” they added.

The study authors noted that their findings have implications beyond an individual patient and discharge destination, as certain discharge destinations add stressors to patients and the healthcare system.

For instance, discharges to SNFs are associated with higher costs and an increased risk of subsequent readmission.

“Discharges to home with home health support are increasing, and patients and payers may prefer these to inpatient post-acute care facilities,” the researchers said. “To provide each patient with the best possible care, including preventing unnecessarily intense care, clinicians should be encouraged to consider the effect of fragmentation and to seek additional information about care delivered elsewhere.”