Among our subjects, we found that men have a higher rate of hospital utilisation within 30 days of hospital discharge than women. ED visits accounted for most of this difference. Among both men and women, prior hospital utilisation is predictive of future utilisation; however, risk factors including being retired, unmarried and having a positive depression screen were identified as risk factors exclusively in men. Additionally, men fared more poorly at understanding and attending their follow-up appointments, which also appeared to be an independent risk factor for returning to the hospital for men in this study.
Identifying and addressing risk factors associated with early post-discharge hospital utilisation is useful so that resources can be efficiently tailored to each individual patient's risk profile. Ideally, methods to ameliorate important risk factors are available. Some risk factors, like gender, however, may seem inherently immutable. Yet, as we demonstrated in this study, male gender is associated with other parameters that could potentially be effectively targeted.
Our findings raise the possibility that social isolation—as illustrated by the positive association with being retired, unmarried and symptoms of depression—may be important factors to target for intervention. Supporting these findings are studies examining the impact of social support and social networks. These studies have found that, in general, men are more socially isolated than women and that this contributes to worse health outcomes among men.13
Men who were socially isolated were found to be less likely to undergo screening for blood pressure, cholesterol and cancer.16
Other studies suggest that men report less help-seeking behaviours, use primary care less10
and are less likely to have a primary care physician when compared with women.13
Overall, women use more health services than men due to pregnancy and cervical and breast cancer screening programmes.6
However, lower rate of connectedness to primary care among men may also contribute to their excess use of hospital services and the finding that they may delay accessing care when it is needed.17
Perhaps paradoxically, one study showed that increased access to primary care actually increased subsequent hospital utilisation; however, this study was conducted in the VA with almost exclusively male subjects and may have reflected appropriate use of hospital services among those who had been previously underserved.18
Evidence suggests other factors that may impact a man's health-seeking behaviour including (1) men may have an overly optimistic perception of their health status, (2) the role women play in care-seeking decisions of men, (3) the influence of social networks and mood disorders and (4) the relatively lower value men appear to place on preventive care.13
Mood disorders can exacerbate the impact of social isolation on health. Men are far less likely than women to seek help for depression or anxiety.19
Even when they do present for care, depression is often misdiagnosed or overlooked by providers.20
These differences may be due to the differences in perceptions of distress experienced by men and women but may contribute to the low help-seeking behaviours exhibited by men. Still, given the effective treatment available for depression and anxiety disorders, depression represents a targetable risk for reducing unwarranted hospital utilisation by men.
This analysis suggests that approaches to mitigate the risk of post-discharge rehospitalisations or ED visits among men may be to develop interventions that promote a connection to primary care, address social isolation and diagnose and treat depressive symptoms. Addressing these risks will require a creative and innovative approach including methods like routine screening for depressive symptoms, more aggressive empowerment of patients to engage the healthcare system proactively rather than reactively and establishing group visits within primary care to foster a social environment paired with the provision of primary care services and health education, as has been used in diabetes care and other chronic illnesses.21
This study has several limitations. Data on hospital utilisation outside Boston Medical Center were determined using patient self-report and not confirmed by EMR review at other hospitals. We were, however, able to confirm 91% of all events by consulting our own EMR. Second, our results may not be generalisable to populations other than those served by urban safety-net hospitals or other populations excluded from the RED trial (eg, non-English-speaking patients and patients admitted from nursing homes). Third, not all patients were reached at 30 days for the follow-up phone call, which is how the information regarding PCP follow-up was gathered. Finally, having done our project in Massachusetts, our population may have had an uncommonly high level of access to primary care.
In summary, our findings suggest that male gender is an important risk factor for early unplanned hospital utilisation within 30 days of discharge. This association may be linked to social behavioural patterns commonly associated with male gender, such as delayed help-seeking behaviours, often resulting in sporadic and episodic use of health services by men. Interventions targeting factors at the root of this phenomenon—such as social isolation, low rates of primary and preventive healthcare use and treatment of depressive symptoms—may help mitigate this gender effect. As health insurance reform and workforce development in primary care evolve, special efforts may be needed to acculturate men to the use of outpatient services.