title: Site of hospital readmission and mortality: a population-based retrospective cohort study.
abstract: BACKGROUND
  Unplanned hospital readmission is a complex process, particularly if the patient is readmitted to an acute care institution other than the original hospital. This study tested the hypothesis that readmission to an alternative hospital is associated with increased mortality compared with readmission to the original hospital.
  
  
  METHODS
  We performed a population-based retrospective cohort analysis set between 1995 and 2010 for all 21 acute care adult general hospitals in the Greater Toronto and Hamilton Area. Participants were consecutive adults (age ≥ 18 yr) readmitted through the emergency department within 30 days after hospital discharge. The primary outcome measure was all-cause mortality within 30 days after readmission.
  
  
  RESULTS
  Of the 198 149 patients included in the study, 38 134 (19.2%) died within 30 days after readmission. Patients readmitted to an alternative hospital were more likely than those readmitted to the original hospital to be older, reside in a chronic-care facility and arrive by ambulance. Alternative-hospital readmission was associated with a higher risk of death within 30 days (22.3% v. 18.6%, p < 0.001; odds ratio [OR] 1.26, 95% confidence interval [CI] 1.23-1.30). The increased risk was substantially less after adjustment for patient- and hospital-level covariables (adjusted OR 1.06, 95% CI 1.02-1.10). Unadjusted Kaplan-Meier survival curves separated early and the absolute difference in mortality continued throughout the entire 1-year follow-up period, but no difference between groups was observed based on adjusted survival analyses.
  
  
  CONCLUSIONS
  Among patients readmitted within 30 days after discharge, readmission to an alternative hospital was associated with a higher risk of death than readmission to the original hospital. Whether this adverse prognosis reflects a true causal relation or residual confounding is unknown.
authors: Institute for Clinical Evaluative Sciences, Toronto, Ont. ; Division of General Internal Medicine, University of Washington, Seattle, Wash.
authors: John A
authors: JA
authors: Staples
authors: Institute for Clinical Evaluative Sciences, Toronto, Ont.
authors: Deva
authors: D
authors: Thiruchelvam
authors: Department of Medicine, University of Toronto, Toronto, Ont. ; Evaluative Clinical Sciences Platform, Sunnybrook Health Sciences Centre, Toronto, Ont.
authors: Donald A
authors: DA
authors: Redelmeier