A number of studies have shown that people with learning disabilities have poorer health than people without learning disabilities. People with learning disabilities have also been shown to receive poorer quality healthcare than others.
One way of assessing the quality of healthcare that a person receives in hospital is to look at emergency readmission rates – unplanned or emergency readmissions to hospital that occur within a short period (typically 7 or 30 days) of being discharged. These readmissions are considered to be an indicator of poor quality care, particularly if they are related to the initial admission. The current article describes a study by Kelly and colleagues (2015).
The study aimed to compare one hospital’s readmission rates for people with learning disabilities with rates for people without learning disabilities, and to assess whether the readmissions of people with learning disabilities could possibly have been preventable.
The study team looked at hospital admission data over a one-year period from 2010-2011. All of the admissions were to a regional teaching hospital trust in the East of England. Data for people identified as having learning disabilities was compared to that from the rest of the patients.
In addition, a doctor and a specialist learning disability nurse reviewed the records of people with learning disabilities who had been readmitted, and decided whether each readmission was potentially preventable or not using detailed criteria.
The authors first looked at the proportion of people with and without learning disabilities who were readmitted following discharge from hospital.
Overall, on average, 5% of people were readmitted within 7 days of hospital discharge, and 11% were readmitted within 30 days of hospital discharge.
The authors found no significant difference between the proportion of people with learning disabilities and those without learning disabilities readmitted to hospital within 7 days or within 30 days.
The authors then looked at whether the readmissions of the 32 people with learning disabilities were potentially preventable or not.
They found that 60% of readmissions within 7 days, and over two thirds (69%) of the readmissions within 30 days could have possibly been prevented.
The most common reason for these potentially preventable readmissions was a recurrence of the medical condition that caused the original hospitalisation.
The authors conclude that although there was no significant difference in readmission rates between people with and without learning disabilities, there was a difference when considering potentially preventable readmissions.
They proposed that complex discharge planning for people with learning disabilities may be lacking, resulting in them being readmitted to hospital for the same issue when this could potentially have been avoided.
Strengths and limitations
The study is based in a single hospital trust and reliant on hospital data and recording systems, including the recording of whether a person has learning disabilities or not.
A significant limitation is that only readmissions of people with learning disabilities were examined to assess whether they were potentially preventable. Comparative data was drawn from a meta-analysis of 16 studies that used a diverse range of methods to classify readmissions as avoidable and hence would not be directly comparable to the definition of potentially preventable readmissions used in this study.
The small number of readmissions of people with learning disabilities (n=32) also makes interpretation of some of the findings problematic, particularly where the data is disaggregated, such as by level of learning disability, place of residence or hospital speciality.
The authors, for example, reported no statistically significant difference in the level of learning disability for those readmitted to hospital, but the small numbers involved means that caution is required in interpreting this.
The study is based on the premise that readmission rates are an informative way of assessing the quality of healthcare for people with learning disabilities. NHS England defines quality healthcare as comprising three elements: clinical effectiveness, safety, and care that is as positive an experience for patients as possible (See: https://www.england.nhs.uk/about/imp-our-mission/high-quality-care/)
High quality care is achieved when all three dimensions are present- not just one or two of them. In this respect readmission rates may be a useful measure as they can indicate an unsafe or premature discharge and readmission to hospital is unlikely to be a positive experience for a patient.
However, they may also indicate inadequate support at home to help the person recover, and as funding cuts to social care services take hold across the country, we need to be alert to the role that deficiencies in social care play in relation to hospital readmission rates for people with learning disabilities.
The authors suggest that people with profound learning disabilities are at increased risk of the provision of poor quality care because of the complexity of their conditions that pose challenges for healthcare practitioners.
However we should not overlook the risks faced by people with milder learning disabilities who fail to meet the threshold for access to social care services and who are left to negotiate their own health needs vis a vis complex healthcare systems, relatively unsupported.
The authors are correct that comprehensive discharge planning can be important in reducing readmission rates. Such planning should take a person-centred approach, should be coordinated effectively and should involve relevant members of the multidisciplinary team.
Just as clinicians must ensure that the person is fit to be discharged from hospital, so too must the discharge planning process ensure that those supporting the person with learning disabilities post-discharge are aware of, and can meet, all of the person’s needs.
Kelly, C. L., Thomson, K., Wagner, A. P., Waters, J. P., Thompson, A., Jones, S., Holland, A. J., and Redley, M. (2015) Investigating the widely held belief that men and women with learning disabilities receive poor quality healthcare when admitted to hospital: a single-site study of 30-day readmission rates. J Intellect Disabil Res, 59: 835–844 [abstract]