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Readmission after intensive care: frequent, hazardous, and possibly preventable*.

In this issue of Critical Care Medicine, Hua et al (1) aim to present data describing the frequency of readmission among intensive care patients who survive to discharge and to identify risk factors associated with readmission. The decision to discharge a patient is a daily dilemma to physicians across all specialties. The current evidence to support the decision is sparse and often limited to specific patient populations (2). Early readmissions carry substantial negative impact on the life of patients and their families and remain a burden on resources of healthcare systems (3, 4). This is especially true in the setting of post–intensive care, since readmission is in its essence, an indicator of unsuccessful treatment in these vulnerable patients. It is clearly not satisfactory that our current practice involves readmitting patients within days or weeks. In recognition of this, low readmission rates have been associated with and adopted as marker of good quality in healthcare systems (5, 6). However, little systematic evidence has been available to estimate the magnitude of the problem and to support a specific discharge practice to avoid early readmission. Hua et al (1) present data on nearly half a million of patients admitted to ICUs in the state of New York, United States. Using state-of-the-art statistical analysis, they substantiate that one of six intensive care patients get readmitted to hospital within the first month after discharge and this number rises even more within the next 5 months. Notably, nearly a quarter of these early readmissions require intensive care again during readmission and a substantial part of the readmitted patients die during the readmission. The strongest predictors of readmission are surprisingly found to be the length of the index hospitalization, discharge to a skilled nursing facility, and having metastatic cancer. The main message from the study is that readmission after intensive care is a frequent and hazardous event, which we should be more concerned about preventing. Even though the authors are not able to identify a single well-defined patient population to aim interventions against, they do find other interesting associations. Two of the independent predictors of readmissions observed, long index hospitalization and discharge to skilled nursing facility, can be seen simply as markers of severity and thus confounders of other real causes of a less favorable prognosis. However, they do also leave open a possibility for a more controversial hypothesis: that at least some patients are substantially harmed by (too) long intensive care courses. Critical illness, hospitalization, and intensive care admission in particular is associated with well-known side effect such as muscle wasting, loss of daily living activity, and psychological deprivation (7–9). Perhaps, even though this may seem counterintuitive, we may actually be harming a group of patients by keeping them too long time in the ICU? Additionally, patients discharged to nursing facilities may sometimes be readmitted without a valid indication? Could some of these readmissions be prevented by sufficient and timely follow-up on the cause of admission and specialist evaluation of chronic diseases by consultants, that is, in the patients’ home, reduce the readmission rate in this fragile high-risk population? The data from this study cannot lead to any conclusions on this, and thus, we do need more data to guide us in the design of future intensive care strategies. In conclusion, we are faced with a challenge with regard to reducing the frequency of readmission. The study by Hua et al (1) has substantiated this and draws attention to interesting and new potentially causal relationships between admission and readmission. We encourage further investigations into this largely unchartered territory to find innovative ways of improving in-patient care to increase duration and quality of out-of-hospital life.