Implementing Posthospital Interprofessional Care Team Visits to Improve Care Transitions and Decrease Hospital Readmission Rates.

The incidence of spinal epidural abscesses is increasing. What is more, they are associated with high rates of morbidity and mortality. Advances in diagnostic imaging and antibiotic therapies have made earlier diagnosis and nonoperative management feasible in appropriately selected patients. Nonoperative treatment also has the advantage of lower immediate healthcare charges; however, it is unknown whether initial nonoperative care leads to higher healthcare charges long term. (1) Does operative intervention generate higher charges than nonoperative treatment over the course of 1 year after the initial treatment of spinal epidural abscesses? (2) Does the treatment of spinal epidural abscesses in people who actively use intravenous drugs generate higher charges than management in people who do not? This retrospective comparative study at two tertiary academic centers compared adult patients with spinal epidural abscesses treated operatively and nonoperatively from January 2016 through December 2017. Ninety-five patients were identified, with four excluded for lack of billing data and one excluded for concomitant intracranial abscess. Indications for operative management included new or progressive motor deficit, lack of response to nonoperative treatment including persistent or progressive systemic illness, or initial sepsis requiring urgent source control. Of the included patients, 52% (47 of 90) received operative treatment with no differences in age, gender, BMI, and Charlson comorbidity index between groups, nor any difference in 30-day all-cause readmission rate, 1-year reoperation rate, or 2-year mortality. Furthermore, 29% (26 of 90) of patients actively used intravenous drugs and were younger, with a lower BMI and lower Charlson comorbidity index, with no differences in 30-day all-cause readmission rate, 1-year reoperation rate, or 2-year mortality. Cumulative charges at the index hospital discharge and 90 days and 1 year after discharge were compared based on operative or nonoperative management and secondarily by intravenous drug use status. Medical records, laboratory results, and hospital billing data were reviewed for data extraction. Demographic factors including age, gender, region of abscess, intravenous drug use, and comorbidities were extracted, along with clinical factors such as symptoms and ambulatory function at presentation, spinal instability, intensive care unit admission, and complications. The primary outcome was charges associated with care at the index hospital discharge and 90 days and 1 year after discharge. All covariates extracted were included in this analysis using negative binomial regression that accounted for confounders and the nonparametric nature of charge data. Results are presented as an incidence rate ratio with 95% confidence intervals. After adjusting for demographic and clinical variables such as age, gender, BMI, ambulatory status, presence of mechanical instability, and intensive care unit admission among others, we found higher charges for the group treated with surgery compared with those treated nonoperatively at the index admission (incidence rate ratio [IRR] 1.62 [95% CI 1.35 to 1.94]; p < 0.001) and at 1 year (IRR 1.36 [95% CI 1.10 to 1.68]; p = 0.004). Adjusted analysis also showed that active intravenous drug use was also associated with higher charges at the index admission (IRR 1.57 [95% CI 1.16 to 2.14]; p = 0.004) but no difference at 1 year (IRR 1.11 [95% CI 0.79 to 1.57]; p = 0.55). Multidisciplinary teams caring for patients with spinal epidural abscesses should understand that the decreased charges associated with selecting nonoperative management during the index admission persist at 1 year with no difference in 30-day readmission rates, 1-year reoperation rates, or 2-year mortality. On the other hand, patients with active intravenous drug use have higher index admission charges that do not persist at 1 year, with no difference in 30-day readmission rates, 1-year reoperation rates, or 2-year mortality. These results suggest possible economic benefit to nonoperative management of epidural abscesses without increases in readmission or mortality rates, further tipping the scale in an evolving framework of clinical decision-making. Future studies should investigate if these economic implications are mirrored on the patient-facing side to determine whether any financial burden is shifted onto patients and their families in nonoperative management. Level III, therapeutic study.

Nationwide US data on readmission rates for patients with cirrhosis admitted with hepatorenal syndrome (HRS) is lacking. We reviewed 30-day readmission rates after HRS-related hospitalizations, the associated predictors of readmissions, and their impact on resource utilization and mortality in the United States. We identified all adults admitted with HRS between 2016 and 2019 using the Nationwide Readmission database of the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. The primary outcome was all-cause 30-day readmission rate. Secondary outcomes were inpatient mortality rate, predictors of readmission, and resource utilization. We identified 245 850 hospitalizations of patients admitted for HRS in the United States from 2016 to 2019. Of these, 214 890 met the inclusion criteria. Mean age was 59.16 years, and 61.31% were males. Medicare was the most common primary payer (44.82%) followed by Medicaid (25.58%). The readmission rate was 24.6% within 30 days of discharge from index hospitalization. The most common cause of readmission was alcoholic cirrhosis with ascites (14.87%), followed by sepsis (9.32%) and unspecified hepatic failure (9%). The in-hospital mortality rate for index hospitalization was 29.52% and 14.35% among those readmitted within 30 days. The mean length of stay (12.33 days vs. 7.15 days, p < 0.01) and hospitalization costs ($44 903 vs. $22 353, p < 0.01) were higher for index hospitalizations than readmissions. Our study demonstrated that all-cause 30-day readmission and in-hospital mortality rates after the development of HRS were strikingly high. This warrants health policies and interventions at the institutional level, including close post-hospital discharge follow-up, to decrease readmission rates, improve patient outcomes, and reduce cost burden.

Reduction of 30-day all-cause readmissions for heart failure (HF) has become an important quality-of-care metric for health care systems. Many hospitals have implemented quality improvement programs designed to reduce 30-day all-cause readmissions for HF. Electronic medical record (EMR)-based measures have been employed to aid in these efforts, but their use has been largely adjunctive to, rather than integrated with, the overall effort. We hypothesized that a comprehensive EMR-based approach utilizing an HF dashboard in addition to an established HF readmission reduction program would further reduce 30-day all-cause index hospital readmission rates for HF. After establishing a quality improvement program to reduce 30-day HF readmission rates, we instituted EMR-based measures designed to improve cohort identification, intervention tracking, and readmission analysis, the latter 2 supported by an electronic HF dashboard. Our primary outcome measure was the 30-day index hospital readmission rate for HF, with secondary measures including the accuracy of identification of patients with HF and the percentage of patients receiving interventions designed to reduce all-cause readmissions for HF. The HF dashboard facilitated improved penetration of our interventions and reduced readmission rates by allowing the clinical team to easily identify cohorts with high readmission rates and/or low intervention rates. We significantly reduced 30-day index hospital all-cause HF readmission rates from 18.2% at baseline to 14% after implementation of our quality improvement program ( P = .045). Implementation of our EMR-based approach further significantly reduced 30-day index hospital readmission rates for HF to 10.1% ( P for trend = .0001). Daily time to screen patients decreased from 1 hour to 15 minutes, accuracy of cohort identification improved from 83% to 94.6% ( P = .0001), and the percentage of patients receiving our interventions, such as patient education, also improved significantly from 22% to 100% over time ( P < .0001). In an institution with a quality improvement program already in place to reduce 30-day readmission rates for HF, an EMR-based approach further significantly reduced 30-day index hospital readmission rates.

Transitions in Care From Acute Care Telemetry Unit to Home: An Evidence-Based Quality Improvement Project.

The utilization outcomes of nurse practitioners (NPs) in the acute care setting have not been widely studied. The purpose of this study was to determine the impact on utilization outcomes of NPs on medical teams who take care of patients admitted to a cardiovascular intensive care unit. A retrospective 2-group comparative design was used to evaluate the outcomes of 185 patients with ST- or non ST-segment elevation myocardial infarction or heart failure who were admitted to a cardiovascular intensive care unit in an urban medical center. Patients received care from a medical team that included a cardiac acute care NP (n = 109) or medical team alone (n = 76). Patient history, cardiac assessment, medical interventions, discharge disposition, discharge time, and 3 utilization outcomes (ie, length of stay, 30-day readmission, and time of discharge) were compared between the 2 treatment groups. Logistic regression was used to identify predictors of 30-day readmission. Patients receiving care from a medical team that included an NP were rehospitalized approximately 50% less often compared with those receiving care from a medical team without an NP. Thirty-day hospital readmission (P = .011) and 30-day return rates to the emergency department (P = .021) were significantly lower in the intervention group. Significant predictors for rehospitalization included diagnosis of heart failure versus myocardial infarction (odds ratio [OR], 3.153, P = 0.005), treatment by a medical team without NP involvement (OR, 2.905, P = 0.008), and history of diabetes (OR, 2.310, P = 0.032). The addition of a cardiac acute care NP to medical teams caring for myocardial infarction and heart failure patients had a positive impact on 30-day emergency department return and hospital readmission rates.

BackgroundCommunity-acquired pneumonia (CAP) is one of the most common communicable diseases worldwide associated with significant levels of morbidity and mortality causing a substantial economic burden. 30-day hospital readmission rate is...

Surgical treatment for proximal humerus fractures has increased exponentially. Recent health care policies incentivize centers to reduce hospital readmission rates. Better understanding of risk factors for readmission and early mortality in this population will assist in identifying favorable risk-benefit patient profiles. To identify incidence and risk factors of 30-day hospital readmission rate and 1-year mortality rate after open surgery of proximal humerus fractures. Retrospective cohort analysis from Kaiser Permanente Southern California Region database. Using International Classification of Diseases, Ninth Revision, diagnosis and procedure codes, all operative proximal humerus fractures were validated. Hospital readmission, one-year mortality, and demographic and medical data were collected. A logistic regression test was performed to assess potential risk factors for outcomes. From 1387 surgical patients, the 30-day all-cause readmission rate was 5.6%. Forty percent of hospital read-missions were due to surgery-related reasons. Severe liver disease (odds ratio [OR], 3.48, 95% confidence interval [CI] = 1.42-8.55) and LACE (length of stay, acuity of admission, comorbidities, and number of Emergency Department visits in the previous 6 months) index score ≥ 10 (OR, 4.47, 95% CI = 2.54-7.86) were independent risk factors of readmission on multivariate analysis. The 1-year mortality rate was 4.86%. Multivariate analysis showed length of hospital stay (OR 1.11, 95% CI = 1.05-1.19), cancer (OR 3.38, 95% CI = 1.61-7.10), 30-day readmission (OR 3.31, 95% CI = 1.34-8.21), and Charlson comorbidity index greater than or equal to 4 (OR 13.94, 95% CI = 4.40-44.17) predicted higher mortality risk. After open treatment of proximal humerus fractures, there was a 5.6% all-cause 30-day hospital readmission rate. Surgical complications accounted for 40% of read-missions. Severe liver disease and LACE score correlated best with postoperative 30-day readmission risk. Length of hospital stay, preexisting cancer, 30-day readmission, and Charlson comorbidity index were predictive of 1-year mortality.

BackgroundThe number of lumbar spine surgeries has been increasing during the last 20 years, which also leads to an increase in hospital costs and complications related to surgery. Therefore, there is a greater concern about the costs and safety of the techniques and implants used.MethodsPatients (aged from 18 to 50 years) presenting with lumbago /sciatica (ICD-10-CM M54.3, M54.4) due to lumbar disc herniation lasting more than 12 weeks, were included. Patients with disc herniation larger than size-2 or size-3 according to the MSU Classification were eligible for participation. Intervention was divided in two groups. In Group 1, patients underwent microdiscectomy and Interspinous Dynamic Stabilization System (IDSS). Meanwhile, in Group 2, patients received discectomy and posterior lumbar interbody fusion (PLIF). The primary outcome measure was the length of stay and costs during hospital admission. We also evaluated several other outcome parameters, including 90- day readmission rate, 90-day complication rate, and re-operations rate. The study was an observational prospective cohort study carried out from January 2015 to August 2016 in which two surgical techniques were compared. Our hypothesis was that a less aggressive procedure, such as discectomy and DSS, will decrease the length of stay and costs, and that it will also reduce the rate of complications with respect to PLIF.ResultsA total of 67 patients (mean age 39.8 ± 8.4 years) were included. Patients in the PLIF group had a length of stay increase of 109% (4.52 ± 1.76 days vs 2.16 ± 1.18 days p < 0.001) and an in-hospital cost increase of 71% (1821.97 ± 460.41€ vs. 1066.20 ± 284.34€ p < 0.001). The reduction of one day of stay is equivalent to a reduction of total in-hospital costs of 12.5%. Patients in the IDSS cohort had no significant differences regarding PLIF cohort in the 90-day readmission rate (12.9% vs 11.1% € p > 0.999, respectively), 90-day re-operation rate (12.9% vs 11.1% € p > 0.999) and 90-day complication rates (35.5% vs 52.8% € p > 0.156). Dural tear and urinary tract infection rates were higher in the PLIF cohort (13.9% vs 3.2%. p = 0.205 and 11.1% vs 0% p = 0.118, respectively). Implant related complications were the most frequent in both IDSS and PLIF groups (32.3% vs 38.9% p = 0.572).ConclusionsPatients who underwent IDSS had a significant decrease of the length of stay and costs in relation to PLIF group. No significant differences were found in 90-day readmission and reintervention rates for both groups. Although differences were not significant, dural tear and urinary tract infection rates were lower in the interspinous group. IDSS or PLIF after discectomy, did not protect against subsequent 90-day re-operation or readmission compared to discectomy alone.

Malnutrition Is Associated With Greater Lengths Of Stay And Rates Of Readmission Following Cardiac Transplant Or Left Ventricular Assist Device Placement

Sex differences in 30-day readmission rates, etiology, and predictors after transcatheter aortic valve replacement

Hospital readmissions in the United States, especially in patients at high-risk, cost more than $17 billion annually. Although care transitions is an important area of research, data are limited regarding its efficacy, especially among rural patients. In this study, we describe a novel transitions-of-care clinic (TOCC) to reduce 30-day readmissions in a Veterans Health Administration setting that serves a high proportion of rural veterans. In this quality improvement initiative we conducted a pre-post study evaluating clinical outcomes in adult patients at high risk for 30-day readmission (Care Assessment Needs score > 85) discharged from the Iowa City Veterans Affairs (ICVA) Health Care System from 2017 to 2020. The ICVA serves 184,000 veterans across 50 counties in eastern Iowa, western Illinois, and northern Missouri, with more than 60% of these patients residing in rural areas. We implemented a multidisciplinary TOCC to provide in-person or virtual follow-up to high-risk veterans after hospital discharge. The main purpose of this study was to assess how TOCC follow-up impacted the monthly 30-day patient readmission rate. The TOCC resulted in a 19.2% relative reduction in 30-day readmission rates in the 12-month postimplementation period compared to the preimplementation period (9.2% vs 11.4%, P = .04). Virtual visits were more popular than in-person visits among both urban and rural veterans. There was no difference in outcomes between these two follow-up options, and both groups had reduced readmission rates compared to non-TOCC follow-up. A multidisciplinary TOCC within the ICVA featuring both virtual and in-person visits reduced the 30-day readmission rate. This reduction was particularly notable among patients with congestive heart failure.

The 30-day readmission rate is a common quality metric used by Medicare for adult patients. However, studies in pediatrics have shown lower readmission rates and potentially less preventability. Therefore, some question the utility of the 30-day readmission time frame in pediatrics. Our objective was to describe the characteristics of patients readmitted within 30 days of discharge over a 1-year period and determine the preventability of readmissions occurring 0 to 7 vs 8 to 30 days after discharge from a pediatric hospitalist service at an academic children's hospital. Retrospective chart review and hospital administrative data were used to gather medical characteristics, demographics, and process-level metrics for readmitted patients between July 1, 2015, and June 30, 2016. All readmissions were reviewed by 2 senior authors and assigned a preventability category. Subgroup analysis comparing preventability in 0-to-7- and 8-to-30-day readmissions groups was performed. Qualitative thematic analysis was performed on readmissions deemed preventable. Of 1523 discharges that occurred during the study period, 49 patients, with 65 distinct readmission encounters, were readmitted for an overall 30-day readmission rate of 4.3% (65 of 1523). Twenty-eight percent (9 of 32) of readmissions within 7 days of discharge and 12.1% (4 of 33) occurring 8 to 30 days after discharge were deemed potentially preventable (P = .13). Combined, the 30-day preventable readmission rate was 20% (13 of 65). We identified a possible association between preventability and time to readmission. If confirmed by larger studies, the 7-day, rather than 30-day, time frame may represent a better quality metric for readmitted pediatric patients.

Background Heart failure (HF) is a main health problem in western countries, and a major cause of hospitalizations and death, particularly in older people. Few data are available about clinical features and prognosis of very old patients, those aged 90 or more years. Purpose To analyse the clinical features and short-term prognosis (in-hospital mortality and 30-day readmission rate) of patients aged 90 or more years hospitalized with HF in Spain in the last years. Methods We conducted a retrospective analysis of patients discharged with an ICD-10 main diagnosis of HF from the Spanish National Health System (SNHS) public hospitals between 2016 and 2019, using as source of data the Minimum Basic Data Set of the SNHS. A comparison of clinical profile, in-hospital mortality and 30-day cardiovascular readmission rate between patients aged 75 to 89 years and those with 90 or more years was performed. Results From 2016 to 2019, 354,792 episodes of people older than 74-year and principal diagnosis of HF were included, being 59.2% female. Mean age of the whole population was 85.2±5.5 years, crude in-hospital mortality rate was 12.7% and crude cardiovascular 30-day readmission rate, 11.8%. The very older patients' subgroup (90 or more year-old) comprised 78.777 patients (22.2%). Table 1 shows the differences in clinical features between these patients and those aged 75 to 89 (77.8%). Patients aged 90 or more years were female in a higher proportion and showed a higher prevalence of cognitive impairment and renal failure, but a lower prevalence of most comorbidities (coronary artery revascularization, valve heart disease, cancer, diabetes mellitus, chronic liver disease). The diagnosis of previous myocardial infarction, stroke and systemic hypertension was similar in both groups (Table 1). Crude 30-day cardiovascular readmission rate was slightly but significantly lower in the oldest subgroup (10.9% vs 12%, p&amp;lt;0.001), while crude in-hospital mortality was higher (18.5% vs 11%, p&amp;lt;0.001). Conclusions Patients aged 90 or more years represents almost a fourth part of elderly patients hospitalized with HF in Spain within the last years. In general, prevalence of comorbidities and associated heart disease was similar or lower, but in-hospital mortality was twice higher, as compared with less older patients. Funding Acknowledgement Type of funding sources: None.

Additional therapies for hepatic encephalopathy (HE) treatment are warranted. There are data evaluating the use of zinc for HE; however, clinical outcomes, specifically in the United States, are unknown. To compare 30-day and 1-year all-cause readmission rates in patients with cirrhosis complicated by HE on lactulose and rifaximin to those on lactulose, rifaximin, and zinc. This retrospective study included patients admitted with documented cirrhosis and home medications of lactulose and rifaximin, with or without zinc. Patients were stratified into 2 groups: those receiving lactulose and rifaximin for HE (control) and those receiving lactulose, rifaximin, and zinc for HE (treatment). The primary outcomes were 30-day and 1-year all-cause readmission rates. One-hundred fifty-seven patients were included (102 in control group, 55 in treatment group). Regarding 30-day and 1-year all-cause readmission rates, there was no difference between the control and treatment groups. This is the first study conducted in the United States evaluating zinc for HE treatment. Zinc did not impact 30-day or 1-year all-cause readmission rates. Further studies are warranted to evaluate the potential benefit of zinc for HE, possibly in correlation with Model for End-stage Liver Disease-Sodium (MELD-Na) scores.

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a high risk for morbidity, mortality, and hospital readmission. Data regarding those risks in the United States is scarce. We assessed post-ERCP 30-day readmission rates, their etiologies, and impact on the health care system using national data. Using the National Readmission Database 2016, we identified patients who underwent inpatient ERCP from January 2016 to December 2016 using ICD-10-CM procedure codes. The primary endpoint was all-cause 30-day readmission rate. Etiologies of readmission were identified by tallying primary diagnosis. Multivariable logistic regression with complex survey design was used to identify independent risk factors associated with readmission. A total of 130,145 patients underwent ERCP, 16,278 (12.5%) were readmitted within 30 days, with an associated cost of 268 million dollars. Nearly 40% of readmissions occurred within 7 days, and 47.9% were related to gastrointestinal etiologies. Male gender, increased comorbidities, cirrhosis, Medicare insurance, and pancreatitis or pancreatitis-related indications for ERCP were readmission risk factors. Performance of cholecystectomy on index hospitalization decreased odds of readmission by 50% (adjusted odds ratio: 0.48, 95% confidence interval: 0.45-0.52, P <0.0001). While academic and nonacademic centers had similar readmission rates, high ERCP volume centers had higher rates compared with low-volume centers (adjusted odds ratio:1.10, P =0.008). All-cause 30-day readmission rates after inpatient ERCPs are high, mostly occur shortly postdischarge, and impose a heavy health care system burden. Large, multicenter prospective studies assessing the impact of center procedure volume on complications and readmission rates are needed.