Risk of 30-Day Hospital Readmission Among Patients Discharged to Skilled Nursing Facilities: Development and Validation of a Risk-Prediction Model.

The study was retrospective and came from one health care system in the upper Midwest, with a largely white population, so the model may not apply elsewhere. It could not capture hospitalizations or emergency department visits that occurred outside that health care system. It could not reliably determine discharge medications or socioeconomic status, both of which may affect readmission risk. It could not clearly distinguish short-term skilled nursing facility residents from long-term residents. The model did not include skilled nursing facility provider care processes or facility factors. The model was checked by splitting the same dataset, not tested in a separate group of patients from other facilities. The model predicted all-cause readmission, not readmissions classified as avoidable. The study did not test whether interventions based on the model improve outcomes.

The supplied metadata lists NIH extramural and non-U.S. government research support. The article text provided does not include an author conflict of interest declaration.

Do not conclude that using this model will reduce hospital readmissions. The study developed and checked the model within the same dataset but did not test whether risk-stratified interventions improved outcomes.