Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2020;101:832-40

ORIGINAL RESEARCH

Associations of Hospital Discharge Services With

Potentially Avoidable Readmissions Within 30 Days
Among Older Adults After Rehabilitation in Acute
Care Hospitals in Tokyo, Japan
Seigo Mitsutake, PT, PhD,a Tatsuro Ishizaki, MD, PhD, MPH,a
Rumiko Tsuchiya-Ito, PT, PhD, MPH,a,b Kazuaki Uda, PT, MPH,a,c
Chie Teramoto, RN, PHN, PhD,d Sayuri Shimizu, PhD,e Hideki Ito, MD, PhDf
From the aHuman Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo; bDia Foundation for Research on Aging Societies,
Tokyo; cDepartment of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of
Tokyo, Tokyo; dDivision of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo; eInstitute for Health
Economics and Policy, Tokyo; and the fTokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan.

Abstract
Objective: To examine the associations of 3 major hospital discharge services covered under health insurance (discharge planning, rehabilitation
discharge instruction, and coordination with community care) with potentially avoidable readmissions (PARs) within 30 days in older adults after
rehabilitation in acute care hospitals in Tokyo, Japan.
Design: Retrospective cohort study using a large-scale medical claims database of all Tokyo residents aged
75 years.
Setting: Acute care hospitals.
Participants: Patients who underwent rehabilitation and were discharged to home (NZ31,247; mean age in years  SD, 84.15.7) between
October 2013 and July 2014.
Interventions: None.
Main Outcome Measure: 30-day PAR.
Results: Among the patients, 883 (2.9%) experienced 30-day PAR. A multivariable logistic generalized estimating equation model (with a logit
link function and binominal sampling distribution) that adjusted for patient characteristics and clustering within hospitals showed that the
discharge services were not significantly associated with 30-day PAR. The odds ratios were 0.962 (95% confidence interval [CI], 0.805-1.151) for
discharge planning, 1.060 (95% CI, 0.916-1.227) for rehabilitation discharge instruction, and 1.118 (95% CI, 0.817-1.529) for coordination with
community care. In contrast, the odds of 30-day PAR among patients with home medical care services were 1.431 times higher than those of
patients without these services (P<.001), and the odds of 30-day PAR among patients with a higher number (median or higher) of rehabilitation
units were 2.031 times higher than those of patients with a lower number (below median) (P<.001). Also, the odds of 30-day PAR among patients
with a higher Hospital Frailty Risk Score (median or higher) were 1.252 times higher than those of patients with a lower score (below median)
(PZ.001).
Conclusions: The insurance-covered discharge services were not associated with 30-day PAR, and the development of comprehensive transitional
care programs through the integration of existing discharge services may help to reduce such readmissions.
Archives of Physical Medicine and Rehabilitation 2020;101:832-40
ª 2020 by the American Congress of Rehabilitation Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Supported in part by the Japan Society for the Promotion of Science (KAKENHI Grant-in-Aid for Scientific Research; grant no. 18K17344).
Disclosures: none.
0003-9993/20/ª 2020 by the American Congress of Rehabilitation Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.apmr.2019.11.019
Discharge services and readmissions 833

Short-term unplanned readmissions can exert heavy clinical and to 11.2% in 2014.20,21 In this way, patients in DPC hospitals may
economic burdens on patients, providers, and payers. A United be more susceptible to PAR in Japan. To facilitate the develop-
States study reported that almost one-fifth of Medicare benefi- ment and improvement of interventions for reducing short-term
ciaries were rehospitalized within 30 days after being discharged readmissions after rehabilitation in DPC hospitals, it is impor-
and estimated that unplanned readmissions cost Medicare a total tant to first understand if current discharge services at these hos-
of $17.4 billion in 2004.1 Accordingly, the reduction of such pitals are associated with such readmissions.22 To the best of our
readmissions has become a major quality improvement goal for knowledge, no previous studies have been conducted on this topic.
the Medicare Fee-for-Service Program and hospitals.2 Functional This study aimed to examine the associations of major
impairment in patients is an important and potentially modifiable discharge services covered under health insurance with 30-day
risk factor for 30-day readmissions.3-7 Patients may require hos- PAR among older adults who received rehabilitation while
pital rehabilitation services for functional impairment after a admitted at acute care hospitals in Tokyo, Japan. Based on prior
major illness or injury, and studies have identified such patients to studies on discharge services and transitional care services,15-17
be at a higher risk of short-term readmissions.4,8 It is, therefore, we tested the hypothesis that major discharge services covered
important to implement interventions that reduce avoidable under health insurance are associated with reduced
readmissions after rehabilitation in acute care hospitals. 30-day PAR.
Although there is currently no consensus on what proportion of
readmissions are truly avoidable, some readmissions do indeed
appear to be preventable.9 In the United States, potentially
avoidable readmissions (PARs) to acute care hospitals represent an
Methods
important quality indicator, and financial incentives have been
introduced to reduce readmission rates.3,10-13 Prior studies have Database and study sample
examined readmissions following discharge from inpatient reha-
This retrospective cohort study was conducted using a large-scale,
bilitation facilities, but these have generally focused on all-cause
anonymized medical claims database obtained from the Tokyo
and unplanned readmissions.8,14 As a result, little is known
Extended Association of Medical Care for Latter-Stage Older
about PAR within 30 days of discharge (30-day PAR) in these
People, which manages the health insurance program for Tokyo
patients. Middleton et al6 examined the factors associated with 30-
residents aged 75 years or older.23 In Japan, citizens are mandated
day PAR after discharge from inpatient rehabilitation facilities, but
to enroll in this type of insurance program on their 75th birthday.23
few studies have analyzed the efficacy of existing interventions in
Accordingly, this database comprised data from all citizens aged
preventing readmissions. The assessment of such interventions
75 years or older living in Tokyo, Japan. The data included
may help to identify areas of improvement and enable the
patient-level sociodemographic characteristics, treatments, medi-
formulation of more effective preventive strategies.
cal facilities used, drugs prescribed, and diagnoses made during
Transitional care services, including discharge planning and
clinical encounters for the purpose of insurance claims. Diagnoses
follow-up, are increasingly used to prevent unnecessary read-
were recorded as International Classification of Diseasese10th
missions.15-17 While Japanese hospitals do not offer comprehen-
Revision (ICD-10) codes. We obtained data from approximately
sive transitional care programs under the health insurance system,
1.35 million patients aged 75 years or older who had received
some individual services (such as discharge planning) are covered
outpatient care, inpatient care, or home medical care from a
by insurance.18 The current health care payment system used by
medical institution between September 1, 2013 and
the majority of acute care hospitals in Japan is based on the
August 31, 2014.
diagnosis procedure combination (DPC) system, which enables
For this study, we focused on patients who had been admitted
case-mix adjustments for reimbursements. Because Japanese acute
to a DPC hospital between October 1, 2013 and July 28, 2014, and
care hospitals, including DPC hospitals, generally provide patients
had been discharged between October 4, 2013 and July 31, 2014.
with both acute care and postacute care (such as rehabilitation
Patients who underwent rehabilitation during this index admission
services) during the same hospitalization episode, the length of
were identified and included in analysis. If patients were admitted
stay (LOS) in these hospitals tends to be longer than in acute care
to a DPC hospital twice or more during the study period, we
hospitals in the United States.19 The DPC system was launched in
defined the index admission as the first hospitalization episode
2003, and was designed to encourage shorter LOS durations
with rehabilitation at a DPC hospital. As patients discharged from
through financial incentives.20 Although empirical analyses have
DPC hospitals to long-term care facilities would have more stable
indicated that mean LOS did decrease from 20.4 days in 2002 to
conditions and are unlikely to be readmitted, we excluded these
13.7 days in 2014, the 6-week readmission rates (including
patients from analysis. Patients younger than 75 years were also
planned readmissions) increased substantially from 4.7% in 2002
excluded from analysis. Moreover, patients with a short LOS
(3d) were also excluded because they are unlikely to use
discharge planning services due to lower barriers to discharge.
List of abbreviations:
CI confidence interval
DPC diagnosis procedure combination Outcome: 30-day PAR
GEE generalized estimating equation
HFRS Hospital Frailty Risk Score The outcome was the occurrence of 30-day PAR following reha-
ICD-10 International Classification of Diseasese10th bilitation in DPC hospitals. The causes of readmissions were
Revision identified using the reported ICD-10 codes.24,25 We defined
LOS length of stay 30-day PAR as the first unplanned readmission within 30 days
OR odds ratio
after discharge to a DPC hospital due to any of the following 15
PAR potentially avoidable readmission
medical conditions: respiratory infection; congestive heart failure;

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834 S. Mitsutake et al

urinary tract infection; fracture; electrolyte imbalance; con-

Table 1 ICD-10 codes of medical conditions in PARs
stipation, fecal impaction, and obstipation; skin ulcers and cellu-
litis; chronic obstructive pulmonary disease and asthma; seizures; Medical Condition
weight loss and malnutrition; anemia; diabetes; hypertension; Groups Diagnoses (ICD-10 Codes)
acute renal failure; and gastroenteritis. These medical conditions Respiratory infection Acute bronchitis: J20, J21
were selected based on a prior study on potentially avoidable Pneumonia (bacterial): J11, J12, J13,
hospitalizations among residents of long-term care facilities in J14, J15, J16, J17, J18
Japan.26 Diarrhea, Clostridium difficile infections, sepsis, and Pneumonia: J69
altered mental status were excluded as reasons for PAR because Congestive heart I50
we determined that these conditions are neither preventable nor failure
manageable in the home care setting, as indicated in previous Urinary tract Infections of kidney: N11, N15, N28, N12,
studies.27,28 The list of ICD-10 codes for these conditions is infection N16
provided in table 1. Cystitis: N30
Urethral abscess: N34
Urethral stricture due to infection: N35,
Independent variables of interest: discharge
N37
services Urinary tract infection: N39, N10
We identified the following 3 types of hospital services that are Inflammation of prostate: N41, N51, N42,
provided at discharge and covered under Japan’s health insurance N43, N45
system from fiscal year 2013 to fiscal year 2014: (1) discharge Fracture W01, W05eW08, W10, W18, W19, S02,
planning; (2) rehabilitation discharge instruction; and (3) coordi- S12, S22, S32, S42, S52, S62, S72, S82,
nation with community care. S92
Discharge planning aims to reduce barriers to discharge to Electrolyte E86, E87
home, institutions, or other hospitals. Nurses and medical social imbalance
workers in discharge planning departments promptly identify pa- (dehydration,
tients with potential barriers to discharge due to medical, physical, volume depletion,
or environmental problems; formulate an optimized discharge hyponatremia)
plan for each patient; and provide the necessary support for safe Constipation/fecal K56, K59
discharge. Moreover, discharge planning involves arrangements impaction/
with home care agencies, institutions, or other hospitals to ensure obstipation
that the patients’ and their families’ postdischarge needs Skin ulcers and Skin ulcers: L03, L97, M60, M86, R02, S91,
are met.18 cellulitis T13, T81, T87
Rehabilitation discharge instruction is designed to educate Cellulitis: L03, K12, L04, L08
patients and their families on self-management to prevent func- Chronic obstructive J40, J41, J42, J43, J44, J45, J46, J47,
tional impairment and improve independence in activities of daily pulmonary disease J60, J61, J62, J63, J64, J65, J66, J67
living. Physical therapists, occupational therapists, and speech and asthma
therapists coordinate with doctors, nurses, and medical social Seizures G40, R56
workers to provide this service before discharge. For example, Weight loss and Anorexia, abnormal weight loss,
physical therapists provide instruction on safe exercise methods malnutrition underweight, feeding difficulties: R63
and activities of daily living to patients and their families. Dysphagia: R13
Coordination with community care can be subcategorized into Nutritional marasmus: E41
2 types of services: “instructions for community care at discharge” Unspecified protein-calorie malnutrition:
and “coordination with long-term care.” Instructions for commu- E46
nity care at discharge promote coordination between hospital staff Other nutritional deficiencies: E63
and community care staff to provide postdischarge instructions Anemia Iron deficiency anemia: D50
(such as instructions for medication safety at home) to patients Other deficiency anemias: D51, D52, D53
and their families. Hospital doctors and nurses consult with Acute post-hemorrhagic anemia: D62
community care doctors and nurses to share information on pa- Anemia of chronic illness: D63
tient medications and activities of daily living, and hospital staff Diabetes E10, E11
provide summaries of these consultations to community Hypertension I10, I11, I12, I13, I15
care workers. Acute renal failure N17, N25
Coordination with long-term care aims to promote coordina- Gastroenteritis K52
tion between hospital workers and community care managers to
assess the need for formal long-term care services and formulate a
long-term care plan for each patient according to their medical,
physical, or environmental problems. Hospital staff (such as discharge, and provide this assessment to a care manager. In
nurses and community care managers) may provide this service addition, staff may also assess the care needs of patients just
once or twice before discharge. When long-term care is deter- before discharge and provide this assessment to a care manager.
mined to be necessary, staff assess the appropriate care settings The care manager then formulates a postdischarge long-term care
that can meet both patients’ and their families’ needs after plan based on this care needs assessment.

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Discharge services and readmissions 835

The provision or nonprovision of each discharge service was

identified using the medical claims data for the index admission.
Each discharge service can be provided alone or in combination
with the other services to a single patient.

Covariates
We selected other variables available in medical claims data that
were previously identified to be associated with providing
discharge services or 30-day PAR or had been used in similar risk-
adjustment models in other studies.5-8,22 We also collected infor-
mation from the database on other variables, such as patient sex,
age groups (75-79, 80-84, 85-89, and
90y), and insurance
copayment rate (10% for residents with a taxable
income<$14,078/y and 30% for residents with a taxable
income
$14,078/y).29 Using a previously described method,30 we
counted the number of 22 chronic diseases that are common in
older adults using ICD-10 codes and prescriptions of relevant
therapeutic agents. The number of chronic comorbidities was
divided into 4 categories (0-1, 2-3, 4-5, and
6 diseases) for
analysis. Also, the use or nonuse of home medical care services
before the index admission to a DPC hospital was identified
through relevant records in the claims data. We calculated the
LOS and the mean number of rehabilitation service units used per
day for each patient during the index admission. A rehabilitation
service unit consisted of 20 minutes of rehabilitation by a physical
therapist, occupational therapist, or speech therapist. LOS and
rehabilitation service units were each divided into 2 categories
(LOS: <20 and
20d; rehabilitation service units: <0.66 and

0.66 units per day of hospital stay) based on their median values.
Patient frailty was measured with the Hospital Frailty Risk Score
(HFRS), which was developed to screen for frail patients in the
United Kingdom using ICD-10 codes in claims databases.31 The
HFRS is an aggregate of 109 conditions that are known to be
associated with frail patients, and the score ranges from 0-99.
Patients with higher scores (ie, frail patients) were found to be
associated with higher mortality, longer hospitalizations, and
higher emergency readmission rates.31 Although the cut-off points
used in the original UK study were selected to create categories
that discriminated most strongly between individuals with differ-
ences in these outcomes,31 these cut-off points have yet to be
validated in the Japanese health care system. We therefore used
the median score to dichotomize the cohort for this analysis (<1.8
and
1.8). We also identified 8 categories of primary diagnoses in
the index admission using the corresponding ICD-10 codes for the
main causes of hospitalization, and included these as covariates in
the analyses. In addition to 6 diagnostic categories of hospitali-
zation causes identified in a previous report,25 we also included
diagnoses of fractures and musculoskeletal diseases that require
rehabilitation services.
Statistical analysis
First, the chi-square test was used to compare the characteristics
between patients with and without 30-day PAR. We then exam-
ined the association of each discharge service with 30-day PAR
using a logistic regression model fitted with a generalized esti-
mating equation (GEE) that adjusted for the covariates, other
discharge services, and clustering of patients within hospitals.32
The multivariable logistic GEE model used a logit link function
and binomial sampling distribution. P values (2-tailed) below .05
were considered statistically significant. The odds ratios (ORs)
Fig 1 Flow chart of patient selection.
and their 95% confidence intervals (CIs) were adjusted for the
covariates, other discharge services, and clustering of patients
within hospitals. All analyses were conducted using SPSS
version 23.0.a
Ethical considerations
The study protocol was approved by the Ethics Committee of the
Tokyo Metropolitan Geriatric Hospital and Institute of Geron-
tology. We performed all procedures in accordance with the
Ethical Guidelines for Medical and Health Research Involving
Human Subjects established by the Japanese government.
Results
Figure 1 shows the flow chart of patient selection. We first iden-
tified 33,221 candidate subjects who had received rehabilitation at
a DPC hospital during the study period. We excluded 1513 pa-
tients who were discharged to long-term care facilities, 230 pa-
tients aged below 75 years, and 231 patients with short LOS
(3d). The final sample for analysis comprised 31,247 patients.
The characteristics of the patients are summarized in table 2.
The overall mean age in years  SD was 84.15.7, and 12,363 of
the patients (39.6%) were men. A total of 883 patients (2.9%)
were identified as having 30-day PAR according to our identifi-
cation criteria.
Table 2 also shows the comparison of characteristics between
patients with and without 30-day PAR. Significantly more patients
with 30-day PAR received coordination with community care than
patients without 30-day PAR (PZ.008). In contrast, there were no
significant differences in the use of discharge planning (PZ.228)
and rehabilitation discharge instruction (PZ.325) between the
groups. Moreover, patients with 30-day PAR had significantly
higher use of home medical care before the index admission
(P<.001), longer LOS (PZ.775), higher mean number of reha-
bilitation service units (P<.001), and higher HFRS (P<.001) than
patients without 30-day PAR. Table 3 presents the causes of
30-day PAR. The most common causes were respiratory infection
(259 patients; 29.3%).

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836 S. Mitsutake et al

Table 2 Comparison of characteristics (percentages) between patients with and without PARs within 30 days (NZ31,247)
With PAR Within Without PAR Within
Characteristics Total NZ31,247 30 Days nZ883 30 Days nZ30,364 P Value*
Sex
Men 39.6 43.0 39.5 .032
Age groups (y)
75-79 25.9 15.6 26.2 <.001
80-84 30.5 29.8 30.5
85-89 25.3 29.3 25.2

90 18.3 25.3 18.1
Copayment rate (%)
10 86.1 86.7 86.0 .548
30 13.9 13.3 14.0
No. of concomitant chronic diseases
0-1 10.0 7.7 10.1 .001
2-3 21.6 19.5 21.7
4-5 31.4 29.8 31.4

6 36.9 43.0 36.8
Home medical care use before index admission
Yes 12.4 21.0 12.1 <.001
LOS (d)
<20 48.4 47.9 48.4 .775

20 51.6 52.1 51.6
Mean no. of rehabilitation units (units/d of hospital stay)
<0.66 49.7 38.5 50.0 <.001

0.66 50.3 61.5 50.0
HFRS
<1.8 49.6 42.5 49.8 <.001

1.8 50.4 57.5 50.2
Diagnosis at index admissiony
Fractures 17.8 10.9 18.0 <.001
Neurologic diseases 17.8 9.4 18.0
Cardiac diseases 10.3 21.6 9.9
Respiratory diseases 12.7 24.6 12.3
Musculoskeletal diseases 11.8 3.3 12.1
Gastrointestinal diseases 6.2 6.5 6.2
Malignancies 4.4 3.3 4.4
Metabolic and renal diseases 7.7 10.5 7.6
Others 11.4 10.0 11.4
Discharge services
Discharge planning
Yes 18.5 20.0 18.4 .228
Rehabilitation discharge instruction
Yes 41.8 43.4 41.7 .325
Coordination with community care
Yes 4.3 6.1 4.3 .008
* Indicates c2 test.
y
The causes of hospitalization in the index admission based on the corresponding ICD-10 codes.

Table 4 shows the associations of the 3 discharge services with
30-day PAR after adjusting for the covariates and patient clus-
tering within hospitals. None of the discharge services were
significantly associated with 30-day PAR: The ORs were 0.962
(95% CI, 0.805-1.151) for discharge planning, 1.060 (95% CI,
0.916-1.227) for rehabilitation discharge instruction, and 1.118
(95% CI, 0.817-1.529) for coordination with community care. In
contrast, the odds of 30-day PAR among patients with home
medical care services were 1.431 times higher than the odds
among patients without home medical care services (P<.001), and
the odds of 30-day PAR among patients with a higher number
(median or higher) of rehabilitation units were 2.031 times higher
than the odds among patients with a lower number (below median)
(P<.001). In addition, the odds of 30-day PAR among patients

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Discharge services and readmissions 837

Table 3 Breakdown of potentially avoidable readmission within Table 4 Associations of discharge services with PARs within 30
30 days (nZ883) days (NZ31,247)
Medical Condition Groups No. % Characteristics ORs 95% CIs P Value*
Respiratory infection 259 29.3 Sex
Congestive heart failure 200 22.7 Men 1.094 (0.963-1.244) .167
Urinary tract infection 113 12.8 Age groups (y)
Fracture 92 10.4 75-79 Reference
Electrolyte imbalance 84 9.5 80-84 1.454 (1.185-1.784) <.001
Constipation 41 4.6 85-89 1.506 (1.180-1.922) .001
Skin ulcers and cellulitis 29 3.3
90 1.646 (1.249-2.168) <.001
Chronic obstructive pulmonary 14 1.6 Copayment rate (%)
disease and asthma 10 Reference
Seizures 13 1.5 30 0.921 (0.749-1.133) .437
Acute renal failure 11 1.2 No. of concomitant chronic
Weight loss and malnutrition 9 1.0 diseases
Diabetes 7 0.8 0-1 Reference
Hypertension 6 0.7 2-3 1.213 (0.931-1.582) .153
Anemia 5 0.6 4-5 1.276 (0.965-1.687) .087
Gastroenteritis 0 0.0
6 1.511 (1.174-1.946) .001
Home medical care use
before index admission
with a higher HFRS (median or higher) were 1.252 times higher Yes 1.431 (1.206-1.699) <.001
than the odds among patients with a lower score (below LOS (d)
median) (PZ.001). <20 Reference

20 1.113 (0.967-1.281) .135
Mean no. of rehabilitation
Discussion units (units/d of
hospital stay)
This retrospective cohort study examined the associations between <0.66 Reference
3 major discharge services covered under Japanese health insur-
0.66 2.031 (1.729-2.386) <.001
ance and 30-day PAR among older adults after rehabilitation in an HFRS
acute care setting using a large-scale claims database that included <1.8 Reference
all Tokyo residents aged 75 years or older. The 30-day PAR rate
1.8 1.252 (1.094-1.432) .001
was 2.9% in DPC hospitals. Discharge planning, rehabilitation Diagnosis at index
discharge instruction, and coordination with community care were admissiony
not associated with 30-day PAR after adjusting for variations in Fractures Reference
patient characteristics. This indicates that these services may have Neurologic diseases 0.941 (0.715-1.240) .667
little or no effect on preventing PAR in DPC hospitals. Cardiac diseases 4.366 (3.202-5.954) <.001
In contrast to our findings, a previous meta-analysis of ran- Respiratory diseases 3.487 (2.683-4.533) <.001
domized controlled trials reported that discharge planning can Musculoskeletal diseases 0.576 (0.388-0.854) .006
reduce readmission rates and LOS.33 Another study found that a Gastrointestinal diseases 2.131 (1.566-2.900) <.001
higher ratio of ward nurses to beds may contribute to reducing Malignancies 1.794 (1.199-2.683) .004
readmission rates by improving transitional care in frail older Metabolic and renal 2.530 (1.916-3.341) <.001
adults.34 In Japan, discharge planning is performed by nurses or diseases
medical social workers belonging to a specialized discharge Others 1.628 (1.215-2.180) .001
planning department. Therefore, the lack of association between Discharge services
discharge planning and PAR in our analysis may be influenced by Discharge planning
staff-related factors. It may be important to determine if these staff Yes 0.962 (0.805-1.151) .674
have the necessary time, training, and resources to formulate Rehabilitation discharge
discharge plans that can effectively prevent 30-day PAR. More- instruction
over, discharge planning is provided to patients with potential Yes 1.060 (0.916-1.227) .435
barriers to discharge in order to decrease LOS, which is incen- Coordination with
tivized by the health insurance system. Therefore, insurance- community care
covered discharge planning may be more focused on reducing Yes 1.118 (0.817-1.529) .486
LOS than preventing short-term readmissions.
Rehabilitation discharge instruction and coordination with * Indicates multivariable logistic regression models were fitted with
generalized estimating equations.
community care were also not associated with 30-day PAR in our y
The causes of hospitalization in the index admission based on the
subjects. Although previous studies have indicated that improving corresponding ICD-10 codes.
patient self-care and coordination with other providers can reduce

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838
30-day readmission rates in heart failure patients,35,36 few studies
have examined the effects of these services on readmissions
among older patients using rehabilitation in acute care hospitals. It
has also been reported that multicomponent interventions are more
effective than single-component interventions in reducing short-
term readmissions.17,37 Le Berre et al38 conducted a systematic
evidence review to examine if transitional care interventions
reduced readmission rates among older adults with chronic dis-
eases after being discharged to home. Their review indicated that
transitional care (including discharge planning, education on self-
management, follow-up, and coordination among health care
providers) can reduce readmission, mortality, and acute care
resource utilization.38
Although Japanese hospitals do not provide insurance-covered
transitional care programs with multicomponent interventions,
such programs may be developed by integrating current services
and including a follow-up system. Postdischarge follow-up ac-
tivities under US transitional care programs include home visits
and telephone calls from nurses,15,16 but resource and workforce
limitations may make it difficult for nurses in Japan to conduct
these activities. Older adults with functional impairment can
receive medical care (eg, nursing care and rehabilitation) at low
cost under the medical insurance system or long-term care
insurance system in Japan.39 Because many older adults who use
rehabilitation services during hospitalization also use medical care
after discharge, it is important to promote continuity between
hospital care and community-based care to prevent read-
missions.36 However, the insurance-covered coordination with
community care services were not associated with 30-day PAR in
this study. As these services are currently provided only during
hospitalization and not after discharge, there may be inadequate
communication and information sharing between hospital staff
and community care staff or long-term care staff to ensure post-
discharge continuity of care. Japan’s medical and long-term care
insurance systems should be modified to promote communication
and information sharing between hospital staff and community
care staff or long-term care staff after discharge.
The finding that a higher frailty score is associated with 30-day
PAR is consistent with previous studies on the association between
frailty and all-cause emergency readmission.31,40 Because the
HFRS can be calculated using routinely collected claims data,31
this risk score may be applied to Japanese medical claims data
to efficiently screen for patients at higher risk of 30-day read-
mission. Also, patients who received home medical care services
before admission and underwent more intensive rehabilitation
were more likely to have 30-day PAR. Under Japan’s health in-
surance system, patients must be physically unable to travel to
receive nonemergency outpatient care in order to be eligible for
the use of home medical care services. Accordingly, these patients
have a higher risk of severe functional impairment. Similarly,
patients with severe functional impairment may have a greater
need for intensive rehabilitation than other patients. Functional
impairment in older patients is associated with an elevated risk of
readmissions after rehabilitation during hospitalization,3-8 and it is
therefore important to consider functional status when developing
PAR prediction models.
Highly sensitive prediction models that are easy to use may
provide an efficient method for identifying patients at high risk of
30-day PAR. Comprehensive geriatric assessments involve the
S. Mitsutake et al
systematic evaluation of frail older adults by teams of health
professionals and typically include assessments of medical, psy-
chiatric, functional, and social domains in order to increase a
patient’s likelihood of survival and living in their own homes after
an emergency hospitalization.41 The Japan Geriatrics Society
recommends the use of a shorter version of this tool in clinical
assessments of older patients.42 Therefore, data from easy-to-use,
comprehensive, geriatric assessments may be linked with medical
claims data to develop more accurate prediction models for short-
term PAR.
A strength of this study is the use of claims data from all
patients aged 75 years or older who received rehabilitation ser-
vices in DPC hospitals in Tokyo, Japan. These findings are
therefore representative of the population in this age group
residing in Tokyo. Another strength is the quantification of 30-
day PAR among older adults who received rehabilitation in acute
care hospitals using a large-scale database. Furthermore, this
study is the first in Japan to assess the risk of 30-day PAR to DPC
hospitals among patients discharged from DPC hospitals. In
contrast, previous studies using DPC databases have only
assessed unplanned readmissions to the same hospital as the
index admission.25,43
Study limitations
This study has several limitations. First, our database did not
include information on patients who were readmitted to non-DPC
hospitals. DPC hospitals accounted for approximately 63% of all
acute care beds in Japan in 2014, which may have led to an un-
derestimation of 30-day PAR.44 Second, this study was unable to
exclude patients who died after discharge as claims data lack this
information. This may have led to an underestimation of 30-day
PAR. Third, we could not account for variations in disease
burden due to the lack of disease severity information in our
database. Because disease severity can directly affect treatment
approaches and readmission rates, this variable should be
considered in future analyses. Fourth, our findings may not be
directly generalizable to other countries due to inherent differ-
ences in health care systems, although some predictors (such as
longer index admissions) may have similar effects on PAR.25
Fifth, the optimal cut-off points for the HFRS have yet to be
identified in the Japanese health care system, and further analyses
are required to understand the implications of this factor. Finally,
we could not ascertain the quality of discharge services in each
DPC hospital. However, we attempted to account for these vari-
ations by adjusting for the clustering of patients within hospitals
using GEEs.
Conclusions
The major insurance-covered discharge services were not associ-
ated with 30-day PAR in older adults after rehabilitation in acute
care hospitals in Tokyo, Japan. The development of comprehen-
sive transitional care programs (involving components of
discharge planning, education on self-management, follow-up,
and coordination among health care providers) through the inte-
gration of existing insurance-covered discharge services may help
to reduce 30-day PAR.
www.archives-pmr.org
Discharge services and readmissions
Supplier
a. SPSS version 23; IBM Corp.
Keywords
Big data; Health services for the aged; Patient readmission;
Rehabilitation; Transitional care
Corresponding author
Tatsuro Ishizaki, MD, PhD, MPH, Human Care Research Team,
Tokyo Metropolitan Institute of Gerontology, 35-2 Sakae-cho,
Itabashi-ku, Tokyo 173-0015, Japan. E-mail address: tatsuro@
tmig.or.jp.
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