Percentage of emergency readmission to any hospital in England occurring within 28 days of discharge from hospitalIndirectly age, sex, method of admission of discharge spell, diagnosis (ICD 10 chapter/selected sub-chapters within medical specialties) and procedure (OPCS 4 chapter/selected sub-chapters within surgical specialties) standardised rates. Standardised to persons 2002-03Age group2005-062004-052003-042002-032001-022000-011999-20001998-990-158.888.578.248.288.158.007.947.8016-748.628.267.847.507.447.337.217.0475+13.5512.9712.1311.5411.0810.9110.6410.31 Notes:1. Numerator data The number of finished and unfinished continuous inpatient (CIP) spells that are emergency admissions within 0-27 days (inclusive) of the last, previous discharge from hospital (see denominator), including those where the patient dies, but excluding the following: those with a main specialty upon readmission coded under mental health specialties; and those where the readmitting spell has a diagnosis of cancer (other than benign or in situ) or chemotherapy for cancer coded anywhere in the spell. The date of the last, previous discharge from hospital, and the date and method of admission from the following CIP spell, are used to determine the interval between discharge and emergency readmission. The numerator is based on a pair of spells, the discharge spell and the next subsequent readmission spell (this spell must meet the numerator criteria). The selection process thus carries over the characteristics of the denominator for the discharge spell and applies additional ones to the readmission spell. The following fields and values are used for the numerator. The numerator is the number of denominator CIP spells where: Diagnosis of cancer is not coded in any position in the readmission spell; AND the first episode in readmission CIP spell ADMIDATE minus last episode in admission CIP spell DISDATE < 27 days inclusive (discharge date and admission date, includes negatives); AND the first episode in the readmission CIP spell has: ADMIMETH = 21, 22, 23, 24 or 28 (admission method); AND DIAG_01 does not begin with 'O' (primary diagnosis) AND MAINSPEF not 700-715, 501, 560, 610 (main specialty). Fields used from the first episode in a spell where there is a valid organisation of residence code include: SPELLRESPCTC, SPELLRESLADSTC, SPELLRESSTHAC. Other organisational levels (E, GOR, ONS Areas, Counties) are aggregates of the SPELLRESLADST field. Fields used from the last episode in a spell include: PROCODETC (provider code, unmapped). Provider clusters are aggregates of the PROCODETC field. Counts are by: age/sex/method of admission of discharge spell/diagnosis (ICD 10 chapter/selected sub-chapters within medical specialties) and procedure (OPCS 4 chapter/selected sub-chapters within surgical specialties)/organisation of residence in CIP spell (values for England are aggregates of these) where: age bands for the respective age specific indicators are : <1, 1-4, 5-9,10-15,16-64, 65-74, 75-84, 85+; 16-64, 65-74, 75-84, 85+; sex is 1, 2 (male and female); admission method is elective or non-elective; diagnosis (within medical specialties); procedure (within surgical specialties). HES for CIP spells intersecting the respective financial year, plus those up to 28 days in the next financial year, England, The Information Centre for health and social care. Individual finished consultant episodes are linked to other episodes where all are part of one continuous spell of care for a patient (see CIP spell construction sections in Annex 4 (Methods section of the Clinical and Health Outcomes Knowledge Base www.nchod.nhs.uk) for details). A spell may contain HES data from another year only when one of its episodes spans years. For example, a spell which finished during April may contain admission information from an episode which started during the previous March. The numerator (readmissions) consists of CIP spells (see denominator) that include both finished and unfinished (i.e. finished episodes from following years) episodes i.e. readmissions can be finished and unfinished CIP spells. Where there is more than one readmission within 28 days, each readmission is counted once, in relation to the previous discharge. Readmissions that end in death are included in the numerator. Patients within the mental health and maternity specialties as well as those with a diagnosis of cancer have been excluded because emergency readmission is often considered a necessary part of care. Spells are attributed to the organisation of residence, based on the numerator. The indicator includes discharges occurring after transfer to another Trust. Discharges are counted to the first valid organisation coded in the spell for residence based aggregates, and to the discharging trust for trust based aggregates. There is variation in the completeness of hospital records and quality of coding. 2. Denominator data The number of finished CIP spells within selected medical and surgical specialties, with a discharge date up to 31 March within the year of analysis. Day cases, spells with a discharge coded as death, maternity spells (based on specialty, episode type, diagnosis), and those with mention of a diagnosis of cancer or chemotherapy for cancer anywhere in the spell are excluded. Patients with mention of a diagnosis of cancer or chemotherapy for cancer anywhere in the financial year, or the last quarter of the previous financial year are excluded. Mental health specialties are also excluded. The following fields and values are used for the denominator. The first episode in the CIP spell has: ADMIMETH = 11, 12, 13, 21, 22, 23, 24, 28, 31, 32, 81, 82, 83, 84 or 89 (admission method); AND EPITYPE = 1 (episode type); AND CLASSPAT = 1 (patient classification); AND AGE = 0-15 or 7001-7007 (lnd. 4D), 16-74 (lnd.4A), 75+ (lnd. 4D); AND DOB not 01/01/1900 or 01/01/1901 (date of birth); AND SEX = 1 or 2 (sex); AND EPIORDER = 1 (episode order); AND EPISTART is valid (episode start date); AND DIAG_01 does not begin with 'O’ (primary diagnosis). AND the last episode in the CIP spell has: DISDATE is valid and < 04/03/YYYY+1 (discharge date); AND EPITYPE = 1 (episode type); AND MAINSPEF not 700-715, 501, 560, 610 (main specialty); AND DISMETH = 1, 2 or 3 (discharge method). Spells with any mention of a diagnosis of cancer (ICD10 codes C00-C97, D37-D48) or chemotherapy for cancer (ICD10 code Z51.1) are also excluded from the denominator, as are patients with mention of a diagnosis of cancer or chemotherapy for cancer anywhere in the financial year, or the last quarter of the previous financial year. Additionally, the following exclusions are applied (main specialty, first valid procedure and primary diagnosis): AND (episode where the first valid procedure took place MAINSPEF = 100, 101, 110, 120, 130, 140, 141, 142, 143, 150, 160, 170, 180 or 502 AND first valid procedure is not NULL) OR (first episode in CIP spell MAINSPEF 100, 101, 110, 120, 130, 140, 141, 142, 143, 150, 160, 170, 180 or 502 OR (first episode in CIP spell MAINSPEF = 190, 191, 300, 301, 302, 303, 304, 305, 310, 311, 312, 313, 314, 315, 320, 330, 340, 350, 360, 361, 370, 371, 400, 401, 410, 420, 421, 430, 450, 460, 800, 810 or 823 and first episode in CIP spell DIAG_01 is not NULL)). There is an additional 3 step piece of logic which is designed to ensure that the spells are allocated to the most appropriate group for standardisation: Step A) Look for spells where there is a valid procedure and surgical specialty (taken from the episode where the procedure was found). Step B) Excluding spells selected in step A, select spells where main specialty in the first episode is surgical, these spells are standardised under the 'no procedures' basket. Step C) Excluding those spells selected in step A and step B, select spells where main specialty of the first episode is medical. Those spells selected in A) are standardised by procedure subgroup. Note that procedures beginning with ‘Y’ or ‘Z’ are standardised in the 'no procedure' basket. Those spells selected in C) are standardised by diagnosis subgroup. Lists of specialties and sub-groups used for filtering/standardisation: Medical Specialties: ‘190’, ‘191’, ‘300’, ‘301’, ‘302’, ‘303’, ‘304’, ‘305’, ‘310’, ‘311’, ‘312’, ‘313’, ‘314’, ‘315’, ‘320’, ‘330’, ‘340’, ‘350’, ‘360’, ‘361’, ‘370’, ‘371’, ‘400’, ‘401’, ‘410’, ‘420’, ‘421’, ‘430’, ‘450’, ‘460’, ‘800’, ‘810’ ‘823’. Surgical Specialties: ‘100’, ‘101’, ‘110’, ‘120’, ‘130’, ‘140’, ‘141’, ‘142’, ‘143’, ‘150’, ‘160’, ‘170’, ‘180’, ‘502’Fields used from the first episode in a spell where there is a valid organisation of residence code include: SPELLRESPCTC, SPELLRESLADSTC., SPELLRESSTHAC. Other organisational levels (E, GOR, ONS Areas, Counties) are aggregates of the SPELLRESLADSTC field. Fields used from the last episode in a spell include: PROCODETC (provider code, unmapped). Provider clusters are aggregates of the PROCODETC field. Counts are by: age/sex/method of admission of discharge spell/diagnosis (ICD 10 chapter/selected sub-chapters within medical specialties) and procedure (OPCS 4 chapter/selected sub-chapters within surgical specialties)/organisation of residence in CIP spell (values for England are aggregates of these).Where age bands for the respective age specific indicators are: <1, 1-4, 5-9, 10-15, 16-64, 65-74, 75-84, 85+; 16-64, 65-74, 75-84, 85+ ; sex is 1, 2 (male and female); admission method is elective or non-elective; diagnosis (within medical specialties). HES for CIP spells intersecting the respective financial year, England, The Information Centre for health and social care. There is variation in the completeness of hospital records and quality of coding (see Data Quality sections in Annex 4 (Methods section of the Clinical and Health Outcomes Knowledge Base www.nchod.nhs.uk) for details). Quality of coding shows the proportion of diagnoses not coded. There may also be variation between hospitals in the way that they code diagnoses to the fourteen diagnosis fields in each episode, particularly primary diagnosis. For instance, they may code in the order in which the diagnoses were made, or according to their perceived importance or complexity. This may affect the group/subgroup within which a particular spell is selected for standardisation in this indicator. Similarly, there may be variation in which procedure is coded to the first position. The denominator consists of CIP spells that cover all continuous, consultant episodes for the same patient, including those following a transfer to another hospital. Denominator CIP spells must start with an admission episode and finish with a (live) discharge episode in the year of analysis. CIP spells with a discharge code of death are excluded from the denominator because readmission is not possible.3. Statistical Methods: The indicator is indirectly standardised by age, sex, method of admission and diagnosis/procedure. The person-based rate is standardised by using England age, sex, method of admission and diagnosis/procedure rates as standards. We defined the diagnosis and procedure groups for standardisation at ICD10/OPCS 4 coding chapter, sub-chapter or 3 digit level where the readmission rate was significantly different from that of the next higher level in two consecutive financial years and there were at least 50 discharges in each year. 4. Interpretation of indicator: Type of indicator—This is a generic, cross-sectional annual comparative indicator of outcome. In the absence of an absolute standard, comparative data are useful for monitoring in relation to rates achieved in comparable organisations. Effect of case-mix/severity—A number of factors outside the control of hospitals, such as the socio-economic mix of local populations and events prior to hospitalisation, may contribute to the variation shown by the indicators. Differences in case-mix, severity of illness, comorbidities and other potential risk factors also contribute to the variation. The data available do not allow adjustment for any of these factors. This may pose less of a constraint at geographical organisation level than at hospital level. We have tried to deal with this constraint by presenting the data in clusters that are similar with respect to institution or organisation type. An attempt has also been made to take into account differences between organisations in the mix of diagnoses within medical specialties and procedures within surgical specialties. No attempt has been made to assess whether the readmission was linked to the discharge in terms of diagnosis. A patient discharged after an operation may be readmitted into a community hospital with a wound or chest infection. There are many different possibilities and over-specifying may lead to readmissions being missed. Gender-specific data standardised to person rates are available. Analyses at England level by the Index of Multiple Deprivation are presented. Other potential confounding factors—A continuous inpatient spell may include transfers to other hospitals, e.g. for rehabilitation. The patterns of providing care may vary between NHS hospital trusts in terms of whether patients are transferred elsewhere before final discharge. Planned transfers, for example for rehabilitation, may affect discharge destination figures and readmission rates. Variation between hospitals in average length of stay may lead to variation between hospitals in the proportion of complications occurring in hospital, as opposed to in the community after discharge from hospital. Readmissions may reflect self-discharge against medical advice, and levels of primary care and community resources available to manage care outside hospital. Readmissions may not be linked clinically to the previous spell and may be appropriate for the clinical care of the patient. There may be variation between Trusts in the way emergency admissions are coded. Routine data do not allow for all of these aspects to be identified and removed from the indicator, however, this may be done through local audit.Sources: HES and National Statistics The Information Centre for health and social care. Compendium of Clinical and Health Indicators/Clinical and Health Outcomes Knowledge Base www.nchod.nhs.uk or nww.nchod.nhs.uk, released May 2007