Age, plasma exchange may predict hospital readmission in 30 days

About 1 in 10 hospitalized NMOSD patients return within a month: US study

Margarida Maia, PhD avatar

by Margarida Maia, PhD |

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About 1 in 10 people who are hospitalized for neuromyelitis optica spectrum disorder (NMOSD) are readmitted to the hospital within 30 days, or about one month after discharge, a U.S. study found.

Older patients — specifically those in the age range of 65 to 74 — and individuals who had received treatment with plasma exchange, a blood-cleaning procedure, were significantly more likely to be readmitted to the hospital, the data also showed.

The most frequent causes behind readmission were neurologic, followed by infections and respiratory complications.

These findings suggest that “treatment targeted toward these [causes] may result in reduced overall readmission, thereby decreasing overall disease burden,” the researchers wrote.

The study, “Hospital Readmission Rates in Patients With Neuromyelitis Optica Spectrum Disorder,” was published in the International Journal of MS Care.

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Invesigating the factors behind hospital readmission for NMOSD patients

NMOSD occurs when self-reactive antibodies mistakenly turn against healthy nervous system cells, causing damaging inflammation in the spinal cord and the nerves of the eyes. The resulting damage leads to symptoms of the disease.

Many people with NMOSD experience flares, or periods when symptoms become worse.

“Treatment of flares usually requires hospitalization and subsequent immunomodulatory therapy with corticosteroids, intravenous immunoglobulin (IVIG), or plasma exchange,” the researchers wrote.

Immunomodulatory treatments work by modifying the response of a person’s immune system. Typically, this is done by decreasing — by using immunosuppressants — or increasing the production of antibodies in the blood.

In IVIG, healthy antibodies are given to a patient to neutralize the harmful self-reactive antibodies in the blood. Plasma exchange, meanwhile, is a procedure that uses a machine to separate and remove such abnormal antibodies from a patient’s blood.

Patients with aggressive disease may require more frequent hospital readmissions for continued immunomodulatory therapy.

Some patients also may receive other intravenous or into-the-vein treatment with rituximab, an immunosuppressive therapy used off-label in NMOSD, and Soliris (eculizumab), which is approved for the majority of patients with the disorder.

“The range of recovery after a flare is variable: some patients have no improvement, and a minority have full recovery,” the researchers wrote, adding that “patients with aggressive disease may require more frequent hospital readmissions for continued immunomodulatory therapy.”

Black race, older age, and male sex have been shown to be risk factors of aggressive NMOSD disease.

Here, scientists questioned whether analyses of hospital readmissions among patients might help to identify additional factors associated with high-risk NMOSD.

To that end, a trio of researchers at the University of South Alabama College of Medicine searched the U.S. Nationwide Readmissions Database for hospital stays due to NMOSD in 2017. The team focused on patients who were readmitted to the hospital within 30 days of the first recorded hospitalization.

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Half of all hospital readmissions came less than 2 weeks after discharge

In 2017, a total of 2,447 patients, with ages between 18 and older than 75 years, were admitted to the hospital due to NMOSD.

Of them, 292 (11.9%) were readmitted within 30 days of discharge. Most readmissions occurred in the first few days after the patient left the hospital, “with half of all readmissions occurring within 13 days of discharge,” the team wrote.

Those readmitted within 30 days were significantly older — 52 versus 45 years — than those who did not return for a second hospital stay. Individuals who were readmitted also had a first hospitalization that was significantly longer (eight vs. five days) and more expensive ($16,377 vs. $11,200) in comparison to the second stay.

Patients with private insurance, those discharged home to self care, individuals with milder loss of function, and those less likely to die were significantly less likely to be readmitted.

The presence of other health conditions, including cardiovascular, respiratory, kidney, and neurocognitive disorders, also was linked to a significantly greater chance of being readmitted to the hospital.

The most frequent causes of readmission were neurologic problems, affecting 50.2%. This was followed by infections (15.3%) and respiratory complications (6%). The most frequent diagnosis for readmission was NMOSD (25.6%).

Statistical analyses adjusted for potential influencing factors showed that patients ages 65 to 74 were nearly twice as likely as patients of other ages to return for a second hospital stay.

“This finding may suggest that disease activity in NMOSD peaks in the sixth or seventh decade of life and then begins to decrease,” the researchers wrote.

When accounting for simultaneous health conditions, “sex had no effect on readmission odds,” the team noted.

Having other simultaneous conditions, including respiratory failure, reduced blood flow to a body part, cognitive problems, or neurologic damage-related vision loss also significantly increased the odds for readmission, between two to nearly four times.

Receiving treatment with IVIG or intravenous immunosuppressive medications were not predictive factors, but plasma exchange significantly increased the odds for readmission by about 48%.

Some protective factors also were identified, including coverage by private insurance relative to Medicaid. Receiving treatment at teaching metropolitan hospitals and nonmetropolitan hospitals, as compared with metropolitan, nonteaching hospitals, also was a protective factor.

“Improved understanding and predictors of patients at high risk for disease activity will allow for better stratification,” the researchers wrote, adding that their study “identified several characteristics that increased patient risk of hospital readmission.”

“Future efforts could include the development of higher-efficacy immunomodulatory therapies for high-risk patients to decrease hospital readmissions and overall disease burden,” the team concluded.