Background: Hospital readmission became an important metric for measuring quality of patient care. Although transitions of care interventions prevented readmission in various settings, they have not been evaluated in kidney transplant (KT). We provide discharge planning, medication teaching by pharmacists, discharge medication reconciliation, and follow-up within 48 hours of discharge via phone or office visit. This study was to evaluate the effectiveness of the transitions of care and identify factors that are associated with early readmission after KT.

Methods: This is a retrospective review of medical records for adult KT patients at a large university hospital between July 2010 and June 2012. Patients who had multi-organ transplants, died or lost their graft prior to discharge, or were discharged to another facility were excluded. Baseline characteristics and the transitions of care interventions were compared between patients with and without readmission within 30 days from KT. A multivariate regression model was tested.

Results: Of the 314 patients included in the study, 113 patients (36.0%) had at least one readmission within 30 days of KT. Two groups were similar with respect to age, race distribution, gender, history of diabetes, and receipt of induction therapy.

In the univariate analyses, readmitted patients were likely to have longer hospital stay following transplant (4.3 ± 2.3 vs. 3.6 ± 1.7 days; p = 0.001), deceased donor transplant (63.7 vs. 52.2%; p = 0.05), previous transplant (17.7 vs. 10.5%; p = 0.02), and delayed graft function (23.9 vs. 12.9%; p = 0.01). After controlling for other factors, only length of stay ≥ 4 days remained statistically significant (OR 1.83; 95% CI 1.01-3.33).

Conclusion: More than one third of KT patients are readmitted within 30 days after transplant. The current transitions of care did not appear to affect the overall 30-day readmission rate in our KT patients. Targeted interventions need to be developed for a specific population such as patients with prolonged hospitalization after KT.

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