Sex inequality for hospital readmissions due to pulmonary diseases: a sex perspective in management is warrant

Background Pulmonary diseases are a common and costly cause of 30-day readmissions. Few studies have focused on the difference in risk for rehospitalization between men and women in older patients. In this study we analyzed the association between sex and the risk of readmission in a cohort of patients admitted to the hospital for chronic obstructive pulmonary disease (COPD) exacerbation and other major pulmonary diseases. Methods This was a retrospective cohort study based on administrative data collected in the Veneto Region in 2016. We included 14,869 hospital admissions among residents aged ≥ 65 years for diagnosis related groups (DRGs) of the most common disorders of the respiratory system: bronchitis and asthma, pneumonia, pulmonary edema, respiratory failure, and COPD. Multilevel logistic regressions were performed to test the association between 30-day hospital readmission and sex, adjusting for confounding factors. Results For bronchitis and asthma, male patients had significantly higher odds of 30-day readmission than female patients (aOR, 2.07; 95% CI, 1.11-3.87). The odds of readmission for men were also significantly higher for pneumonia (aOR, 1.40; 95% CI, 1.13-1.72), for pulmonary edema and respiratory failure (aOR, 1.28; 95% CI, 1.05-1.55), and for COPD (aOR, 1.34; 95% CI, 1.00-1.81). Conclusions This study found that male sex is a major risk factors for readmission in patients aged more than 65 years with a primary pulmonary diagnosis. More studies are needed to understand the underlying determinants of this phenomena and to provide targets for future interventions


Abstract
Background Pulmonary diseases are a common and costly cause of 30-day readmissions.
Few studies have focused on the difference in risk for rehospitalization between men and women in older patients. In this study we analyzed the association between sex and the risk of readmission in a cohort of patients admitted to the hospital for chronic obstructive pulmonary disease (COPD) exacerbation and other major pulmonary diseases. Methods This was a retrospective cohort study based on administrative data collected in the Veneto Region in 2016. We included 14,869 hospital admissions among residents aged ≥ 65 years for diagnosis related groups (DRGs) of the most common disorders of the respiratory system: bronchitis and asthma, pneumonia, pulmonary edema, respiratory failure, and COPD. Multilevel logistic regressions were performed to test the association between 30-day hospital readmission and sex, adjusting for confounding factors. Results For bronchitis and asthma, male patients had significantly higher odds of 30-day readmission than female patients (aOR, 2.07; 95% CI, 1.11-3.87). The odds of readmission for men were also significantly higher for pneumonia (aOR, 1.40; 95% CI, 1.13-1.72), for pulmonary edema and respiratory failure (aOR, 1.28; 95% CI, 1.05-1.55), and for COPD (aOR, 1.34; 95% CI, 1.00-1.81).
Conclusions This study found that male sex is a major risk factors for readmission in patients aged more than 65 years with a primary pulmonary diagnosis. More studies are needed to understand the underlying determinants of this phenomena and to provide targets for future interventions Background Countries with developed healthcare systems are working to reduce unnecessary hospital readmissions to reach the triple aim of reducing costs, improving patient satisfaction, and improving health. Readmissions impact both health and satisfaction of patients, as multiple hospitalizations of subjects with chronic comorbidities are associated with emotional distress, loss of function, nosocomial infections, and increased mortality (1).
Moreover, hospital readmissions are also considered an index of low-quality care and in some health systems incur financial penalties for hospitals (2). It is therefore important to analyze which factors lead to readmissions and to develop efficient strategies to reduce unnecessary readmissions, both at the hospital and health system levels.
Among the top 20 causes of readmission within 30 days are several respiratory diagnoses, including respiratory insufficiency and respiratory arrest (3 rd place), COPD and bronchiectasis (9 th place), and aspiration pneumonia (11 th place) (3). While several studies have analyzed the risk factors for rehospitalization in patients with pulmonary disease, few have focused on the difference in risk between men and women. In this study we analyzed data from a cohort of patients from the Veneto Region to determine the association between sex of the patient and readmission to the hospital. The ultimate goal is to use this information to help tailor a discharge program to prevent readmission and waste in resource use.

Methods
In the Veneto Region, regional authorities coordinate and control local health units (LHU), each of which is a separate unit in the Italian National Health System (NHS). The NHS plans and delivers health services, primary care, and hospital care to its local community, based on a regional health plan. This was a retrospective cohort study conducted in any facility operating under the NHS in the Veneto Region in 2016 (population 4,907,529).
In order to select the "Index Admissions" (IA), we included diagnosis-related groups (DRGs) of common respiratory diagnoses involving residents aged ≥ 65 years: bronchitis and asthma (DRG 96 and 97); pneumonia (DRG 89 or 90); pulmonary edema and respiratory failure (DRG 87); and COPD (DRG 88). We excluded patients meeting the following criteria: admission with ICD-9-CM principal diagnostic codes cancer (140._-239._), admission with psychiatric DRG (425-433 and 523), admission with DRG of chemotherapy and radiotherapy (409, 410, 492), admissions for day hospital care or rehabilitation, and those concerning patients residing outside the region. We also excluded patients whose discharge was due to voluntary discharge, transfer to another public or private care institution for acute cases, transfer to another ward of the same structure, or transfer to a rehabilitation institute. If the same patient was admitted to hospital for the same condition several times, all the admissions were considered as IA.
"Hospital readmission" was defined as the same patient readmitted for the same disease within 30 days of the IA.
Multilevel logistic regression models were created with hospital readmissions within 30days for each pulmonary condition above as the dependent variable (attributing a value of 1 for each indicator associated with a readmission, as defined earlier) and considering the sex as the independent variable. Potential confounders included at first admission level: age as a continuous variable, formal education (university, high school, middle school and no education/primary school), citizenship (Italian/Not Italian), length of stay as continuous variable, type of discharge (at home, at home with domiciliary care, residential care), and The sample's characteristics are shown in Table 1. Table 2 shows the number of Index Admissions and the percentage of readmissions overall and by sex for selected respiratory conditions.

Discussion
This population-based study found that male sex is a risk factor for readmission in patients aged more than 65 years admitted to hospital with the diagnosis of several common respiratory diseases: bronchitis and asthma, pneumonia, pulmonary edema and respiratory failure and COPD.
This sex gap has been reported previously in other studies conducted in various settings, where male sex is indicated as an independent risk factor for readmission for COPD (5,6).
Dal Negro (7), analyzing Italian patients diagnosed with COPD, chronic bronchitis and emphysema, concludes that direct costs for management are higher in male than in female patients. Moreover, this study draws attention to the fact that the major part of direct costs for the management of this diseases is yielded by the inpatient hospitalization. As regards pneumonia, our findings are concordant with literature data, which shows that women have less risk to be readmitted for pneumonia than men (8).
This relevant phenomenon is difficult to explain clinically but could be due to management of disease after discharge. In fact, men report less help-seeking behavior, which may delay accessing care when it is needed (9). Moreover, men use primary care health services less frequently than women, are less involved in preventive initiatives and are less health literate (10). For instance, it has been seen that fewer men understand and attend their follow-up appointments after acute hospitalization compared with women (11).
Help-seeking behavior is a complex phenomenon in which gender plays a fundamental role.
Masculine attitudes, behavior and values in general could lead to men ignoring symptoms of ill-health and failing to seek help from the health services because they see it as a sign of weakness (12). Risk-taking behaviors are also more strongly associated with male role models (13): in many cultures, the use of tobacco (a major risk factor for several lung diseases and associated with their severity) is closely linked with the perception of being a "real man" (14). Some biological factors may also influence the higher risk of rehospitalization for pneumonia in men. For instance, men have a weaker immune response and have also been shown to have more chronic mucus hypersecretion, which may worsen their prognosis and increase the likelihood of death (8). The association of sex with post-hospitalization risk is complex, and likely to be influenced by multiple factors. However, whatever the causes of the phenomenon, it is important to think about how to prevent readmissions.
Indeed, it could be useful to talk about gender-based medicine and prevention strategies, in order to address the resources in the most efficient way to reduce readmission rate and, consequently, costs for the health system.
To achieve this goal, it is important to give male patients adequate access to providers and personnel of intermediate and long-term care plans (15).
In particular, currently, there are few studies that evaluate the effectiveness of interventions that promote the access of men to primary care. A recent review found that physical activity, education, peer support-based interventions improve quality of life in men with long-term conditions (16). More studies are needed to understand what is successful in improving elderly men's health and reducing the risk of readmission.
This study relied on routinely-collected administrative data, which unfortunately provides no information on the severity of a patient's disease -a variable strongly associated with the probability of readmission. That said, in order to be considered as a confounder in a multivariate analysis, a variable should be associated with both the outcome and the exposure. For instance, in the present case, to explain the greater risk of readmissions in male by means of confounder effect of severity of the disease, we have to admit that the severity of disease would be greater in male than in female patients admitted to hospital, but the same protocols are used for both sexes when it comes to admitting a patient for hospital care. submitted.
M Sperotto carried out the statistical analyses, and approved the final manuscript as submitted.
M Saia coordinated and supervised data collection, and approved the final manuscript as submitted.
PF obtained funding and designed the data collection tools, and approved the final manuscript as submitted.
AD, CB, TB drafted the manuscript, and approved the final manuscript as submitted.
interventions for men with long-term conditions: a systematic review and metaanalysis. BMJ Open. 2015;5:e006620 Tables   Table 1 Table 2. Number of index admissions and % of readmissions overall and by sex for selected pulmonary diseases in adults age 65 years and older