Patient readmission

Purpose. -Evaluate heart failure management in a Military Hospital in 2005. Methods. -Retrospective audit of 46 case records of patients hospitalised with heart failure within the framework of an accreditation procedure. Results. -The left ventricular ejection fraction was evaluated in 85% of cases during the reference hospital stay. Systolic heart failure was detected in 63% of cases. At least one NT-proBNP assay was performed for each patient. A global assessment was systematically performed, except for the mini mental state examination in patients aged over 75 years who represented 80% of patients. Initial therapeutic education was provided for 50% of systolic heart failure patients. Prescription rates in systolic heart failure were 76% for angiotensinconverting enzyme inhibitors, 7 % for angiotensin receptor antagonists; 84% for at least one medicinal product in the above 2 classes; 68 % for beta-blockers and 32 % for spironolactone. A hospital discharge report was available for 93% of the patients. Elective re-admissions to hospital for uptitration of treatment concerned 10% of systolic heart failure patients. Emergency hospital re-admissions after a cardiovascular event (usually decompensation), concerned 35% of patients, after an average duration of one year of follow-up. These latter readmissions, often repeated, led to 4% of additional hospital deaths. The initial hospital mortality rate was 13%. Conclusion. -Therapeutic patient education is under development. Medication may still be optimised, both qualitatively and quantitatively. Surveillance is planned with a yearly audit.

To assess the frequency of, causes for, and factors associated with acute rehospitalization during 9 months after discharge from inpatient rehabilitation for traumatic brain injury (TBI). Multicenter observational cohort. Community. Individuals with TBI (N=1850) admitted for inpatient rehabilitation. Not applicable. Occurrences of proxy or self-report of postrehabilitation acute care rehospitalization, as well as length of and causes for rehospitalizations. A total of 510 participants (28%) had experienced 775 acute rehospitalizations. All experienced 1 admission (510 participants [66%]), whereas 154 (20%) had 2 admissions, 60 (8%) had 3, 23 (3%) had 4, 27 had between 5 and 11, and 1 had 12. The most common rehospitalization causes were infection (15%), neurological (13%), neurosurgical (11%), injury (7%), psychiatric (7%), and orthopedic (7%). The mean time from rehabilitation discharge to first rehospitalization was 113 days. The mean rehospitalization duration was 6.5 days. Logis...

Background High readmission rates are viewed by the Centers for Medicare & Medicaid Services as a quality of care determinant but it is unclear whether readmission rates per se reflect quality and the drivers of readmissions after hip arthroplasty remain unclear. Question/purposes We therefore describe the effects of (1) insurance, discharge disposition, and mental health status as they relate to rates; (2) rehospitalization charges; and (3) reasons for readmissions. Methods We studied a cohort of all 27,019 patients who initially underwent hip arthroplasty in Florida (April 2009 to March 2010). Participants were identified using the All Patient-Refined Diagnosis-Related Group 301. Data were provided by the Agency for Health Care Administration and the Florida Hospital Association who with the Florida Orthopedic Society studied readmissions within 15 days. We extracted readmission rates and their reasons; original payers, discharge disposition, mental health status; and readmission charges. The readmission rate in the first 15 days was 5%. Rates varied by type of insurance: self-pay/underinsured, Medicaid, and Medicare patients (6%) had higher rates than individuals with commercial insurance, HMO, or PPO (3%). Patients discharged to skilled nursing facilities (SNFs) had higher rates (7%) than patients discharged home with/without health care (both 3%). Patients with a mental health issue (10%) were readmitted more frequently than patients without it (5%). Medicare readmissions comprised 81% (USD 59,222,829) of the total readmission charges in this cohort. The most common reasons were infections (all 27%), hip arthroplasty (11%), and cardiovascular problems (9%). Conclusions Patients were more frequently readmitted if their payer was the government, they were discharged to a SNF, or they had a mental health disorder. Infections were the most common reasons for readmission. Our data suggest readmission rates alone do not necessarily reflect quality of care.

Race-associated disparities often occur in patients who undergo lower extremity total joint arthroplasty (TJA). Although it is imperative to elucidate and describe the disparities in race and ethnicity that may influence patient perception, satisfaction, and surgical outcomes, there is a paucity of reports detailing the nature of potential racial disparities in TJA. Therefore, the purpose of this review was to examine racial and ethnic disparities in the (1) physician-patient relationship; (2) use of TJA; (3) intraoperative and 30-day postoperative complications; and (4) patient-reported outcomes. Although there are limited studies that evaluated this topic, it has been shown that there are race-specific differences in physician-patient relationships. Specifically, African American patients report lower satisfaction rates in communication with their physician than their Caucasian counterparts and physicians were more apt to describe African Americans as less "medically cooperat...

Health care use of children with medical complexity (CMC), such as those with neurologic impairment or other complex chronic conditions (CCCs) and those with technology assistance (TA), is not well understood. The objective of the study was to evaluate health care utilization and costs in a population-based sample of CMC in Ontario, Canada. Hospital discharge data from 2005 through 2007 identified CMC. Complete health system use and costs were analyzed over the subsequent 2-year period. The study identified 15 771 hospitalized CMC (0.67% of children in Ontario); 10 340 (65.6%) had single-organ CCC, 1063 (6.7%) multiorgan CCC, 4368 (27.6%) neurologic impairment, and 1863 (11.8%) had TA. CMC saw a median of 13 outpatient physicians and 6 distinct subspecialists. Thirty-six percent received home care services. Thirty-day readmission varied from 12.6% (single CCC without TA) to 23.7% (multiple CCC with TA). CMC accounted for almost one-third of child health spending. Rehospitalization a...

BACKGROUND AND OBJECTIVES: To improve hospital to home transitions, a 4-element pediatric patient-centered transition bundle was developed, including: a transition readiness checklist; predischarge teach-back education; timely and complete written handoff to the primary care provider; and a postdischarge phone call. The objective of this study was to demonstrate the feasibility of bundle implementation and report initial outcomes at 4 pilot sites. Outcome measures included postdischarge caregiver ability to teach-back key home management information and 30-day reuse rates. METHODS: A multisite, observational time series using multiple planned sequential interventions to implement bundle components with non–technology-supported and technology-supported patients. Data were collected via electronic health record reviews and during postdischarge phone calls. Statistical process control charts were used to assess outcomes. RESULTS: Four pilot sites implemented the bundle between January ...

Background: In contrast to colorectal surgery, enhanced recovery pathways (ERPs) have not yet become standard practice after major upper abdominal surgery. The aim of this study was to assess the feasibility and outcomes after implementation of an ERP after liver a resection. Methods: Patients who underwent a liver resection in two consecutive 6-month periods before (July-December 2013) and after (January-June 2014) implementation of an ERP were included in a prospective study. Patients who underwent live donation, ALPPS (associating liver partition with portal vein ligation for staged hepatectomy) or concomitant procedures were excluded. Peri-operative outcomes were compared between groups, and multivariate analysis of factors influencing the length of hospital stay (LOS) was performed. Results: Two hundred and eleven patients (93 pre-ERP and 91 post-ERP patients) underwent a liver resection during the study period. There was no significant difference in the median LOS (P = 0.907) and 30-day readmission rates (P = 0.645) between the groups. Severe (Clavien grade III-V) complications were reduced in ERP patients (13.9% versus 4.3%; P = 0.039). On multivariate analysis, an increased age (< 0.001), open resection (< 0.001) and complications (< 0.001) were associated with an increased LOS. Enhanced recovery after a liver resection appears to be safe, feasible and may reduce severe complications. However, the LOS was significantly influenced by patient age, open surgery and post-operative complications, but not by an ERP.

Introduction: Managing people with diabetes is a health priority worldwide. Cost benefit attempts at avoiding non elective admissions (NEA) have had some success. To develop an NEA avoidance service, we audited multiple NEA in those with diabetes. Method: All people with diabetes who had ≥3 NEA to our hospital over 12 months were identified (n = 418); 104 (1 in 4) patients were randomly selected and retrospective data collected in 98 subjects on their index (latest, 3rd) admission. Results: Of 98 subjects (50 males, 60 Caucasians, 86 type 2 diabetes, aged 69 ± 16 years).Conditions contributing to admission included: Significant co-morbidities in 95 patients (≥2 in 57, ≥4 in 24). Only 14 admission were directly due to diabetes: hypoglycaemia (5); hyperglycaemia (6); DKA (2), Infected foot ulcer (1).97 admissions were justified at the time of presentation. However whilst 78 were unavoidable, 19 were deemed avoidable amongst whom 10 were diabetes related. The majority of re-admissions were due to multi-morbidity and were often nondiabetes related. The concept of avoidability must be distinguished from point justification at the time of acute need. This would allow the prospective identification of high risk patients and requires an integrated working process to avoid NEA.

Previous studies have documented use of health care services by oncology patients in the Emergency Department (ED), but little is known about the utilization of health services of patients with acute leukemia after induction therapy. The aim of this study was to examine chief reasons for ED and hospital use by patients newly diagnosed with acute leukemia patients after induction therapy up to one year after discharge. A retrospective, longitudinal study of all visits to the ED or unplanned hospital admissions at a single institution for patients with acute leukemia was conducted. Inclusion criteria were patients ≥18 years of age at time of diagnosis, a confirmed diagnosis of AML or ALL, and received and discharged from induction treatment between 2007-2010. Donabedian's structure-process-outcome framework guided this study examining health

Background: Hospital readmission is a significant health burden. More than 20% of heart failure (HF) patients are readmitted within 30 days of discharge leading to billions of dollars in health care expenditures. However, the role of prior hospital admissions to predict 30-day readmission for HF patients is not fully understood. Methods: We retrospectively analyzed HF hospitalization data for 4 years at a single medical center. Association between prior admission and 30-day readmission after HF hospitalization was assessed using a multivariate logistic regression model. Results: A total of 1,999 patients with index HF hospitalizations were identified, and 366 of them (18%) were readmitted within 30 days. The rate of readmission was 14%, 20%, and 33% in patients with 0, 1, ≥ 2 prior admissions. Patients with one prior admission had a 50% higher risk (confidence interval [CI] 1.10-2.05, p = 0.011) for readmission, while those with ≥ 2 prior admissions had a more than 3-fold increase in readmission p < 0.001), after adjustments for relevant clinical covariates. Prior hospital admission provided incremental value in predicting readmissions, shown by the significant improvement in the readmission predictive model (C-statistics increased from 0.57 to 0.63). However, neither the length of stay nor recency of prior admission was a significant factor in predicting readmissions. Conclusions: Hospital admission prior to an index HF hospitalization is associated with a significantly increased risk for 30-day hospital readmission and could be used to identify patients at high-risk for readmission and potentially target interventions to reduce the risk of readmission for these patients.

Background: Our aim was to determine if hyponatremia, defined as serum sodium level < 135 mmol/L, is a predictor of worse outcome in a cohort of real-world patients with heart failure (HF). Methods: We used data of the National registry of HF (RICA) from Spain, an ongoing multicenter, prospective cohort study. The patients were assigned to two groups regarding sodium levels. Primary end-point was first all-cause readmission, or death by any cause. Secondary end-points were the number of days hospitalized, and the presence of complications. Results: We identified 973 patients, 147 (15.11%) with hyponatremia. The median age of patients enrolled was 77.25 ± 8.79 years-old, the global comorbidity measured by Charlson comorbidity index (CCI) was upper 3 points and preserved ejection fraction was present in 67.1% of them. Clinical complications during admission were significantly higher in the patients with hyponatremia (35.41%, p < 0.001) and this remained as significant predictor after logistic regression adjustment (OR 1.08, p < 0.01). Also mortality and readmissions were more frequent in patients with hyponatremia (20.69% and 22.41%, respectively) but after Cox regression adjustment hyponatremia in our cohort was not associated with increase in 90-day all-cause mortality and readmissions, and only CCI remained significant for primary end-point (HR 1.08, p < 0.001). Conclusions: Hyponatremia is an independent predictor of complications during hospitalization in our real-world cohort, but was not associated with 90 days mortality or readmissions. Global comorbidity, however, played an important role, and could influence the mortality and readmissions of our patients.

Background: Surgical readmissions will be targeted for reimbursement cuts in the near future. We sought to understand differences between hospitals with high and low readmission rates in a statewide surgical collaborative to identify potential quality improvement targets. We studied 5,181 patients undergoing laparoscopic or open colectomy at 24 hospitals participating in the Michigan Surgical Quality Collaborative between May 2007 and Jan 2011. We first calculated hospital risk-adjusted 30-day readmission rates. We then compared reasons for readmission, risk-adjusted complication rates, risk-adjusted inpatient length of stay and composite process compliance across readmission rate quartiles. Results: Hospitals with the lowest 30-day readmission rates averaged 5.1%, compared to 10.3% in hospitals with the highest rates (p<0.01). Despite wide variability in readmission rates, reasons for readmission were similar between hospitals. Compared to hospitals with low readmission rates, hospitals with high readmission rates had higher risk-adjusted complication rates (29% vs. 22%, p=0.03), but similar median length of stay (5.5 days vs. 5.6, p=0.61). While measures to reduce complications were associated with lower surgical site infection rates, they were not associated with reduced overall complication or readmission rates. There was wide variation in complication rates among hospitals with similar readmission rates. There is wide variation in hospital readmission rates after colectomy that correlates with overall complication rates. However, the wide variation in complication rates among hospitals with similar readmission rates suggests that hospital complication rates explain little of their readmission rates. Preventing readmissions after colectomy in hospitals with high readmission rates will require more attention to different care processes currently unmeasured in many clinical registries as well as complication prevention.

Person-centred care (PCC) emphasizes a partnership in care between patients and healthcare professionals and is advocated by WHO as a key component of quality health care. We evaluated outcomes of PCC in hospitalized patients with chronic heart failure (CHF) with respect to the length of hospital stay (LOS), activities of daily living (ADL), health-related quality of life (HRQL) and 6-month readmission rate. During 2008-2010, 248 consecutive patients hospitalized for symptoms of worsening CHF were enrolled in a controlled before and after designed study. A Usual care group (n ¼ 123) was recruited according to pre-defined criteria to map usual CHF care and assess outcomes at five designated hospital wards. Based on the mapping, a panel of in-house clinicians and researchers developed measures aimed at aligning usual care with basic PCC principles. These measures were incorporated into a study protocol to guide care procedures at the same five wards. Person-centred care was then implemented at these wards and evaluated in 125 patients. Both length of hospital stay and 6-month readmission were extracted from patient records. Activities of daily living were evaluated at baseline and discharge and HRQL was evaluated at baseline and after 3 months. In the analysis of all patients, the LOS was reduced by 1 day (P ¼ 0.16) while retaining ADL (P ¼ 0.07). When PCC was fully implemented (per protocol analysis), LOS was reduced by 2.5 days (P ¼ 0.01) and the ADL-level better preserved (P ¼ 0.04). Health-related quality of life and time-to-first readmission did not differ. In this proof-of-concept study, our findings suggest that a fully implemented PCC approach shortens hospital stay and maintains functional performance in patients hospitalized for worsening CHF, without increasing risk for readmission or jeopardizing patients' HRQL.

This study evaluated the impact of a Virtual Intensivist Support (VIS)
Model on Intensive Care Unit (ICU) clinical outcomes at a rural Canadian
hospital, Erie Shores HealthCare, where intensivist resources were previously
limited. The model involved daily virtual rounds by off-site intensivists on all
ICU patients and any other patients with critical care needs. A retrospectiveprospective comparison of the ICU data, focusing on ICU admissions,
antibiotic use, venous thromboembolism prophylaxis, patient transfers, and
physiotherapy orders indicated a significant decrease in antibiotic-free days
(OR = 0.56; p < 0.001), while challenges in patient transfers were mitigated as
intensivists provided real-time updates and advocated for proper escalation.
We also noticed higher transfer rates and physiotherapy orders and lower
venous thromboembolism prophylaxis orders. The findings suggest that the
VIS Model may influence clinical practice patterns, highlighting its potential
to enhance ICU workflows in rural settings.

Background: Regional disparities in medical care and outcomes with patients suffering from an acute coronary syndrome (ACS) have been reported and raise the need to a better understanding of links between treatment, care and outcomes. Little is known about the relationship and its spatial variability between invasive cardiac procedure (ICP), hospital death (HD), length of stay (LoS) and early hospital readmission (EHR). The objectives were to describe and compare the regional rates of ICP, HD, EHR, and the average LoS after an ACS in 2000 in the province of Quebec. We also assessed whether there was a relationship between ICP and HD, LoS, and EHR, and if the relationships varied spatially. Methods: Using secondary data from a provincial hospital register, a population-based retrospective cohort of 24,544 patients hospitalized in Quebec (Canada) for an ACS in 2000 was built. ACS was defined as myocardial infarction (ICD-9: 410) or unstable angina (ICD-9: 411). ICP was defined as the presence of angiography, angioplasty or aortocoronary bypass (CCA: 480-483, 489), HD as all death cause at index hospitalization, LoS as the number of days between admission and discharge from the index hospitalization, and EHR as hospital readmission for a coronary heart disease ≤30 days after discharge from hospital. The EHR was evaluated on survivors at discharge. Results: ICP rate was 43.7% varying from 29.4% to 51.6% according to regions. HD rate was 6.9% (range: 3.3-8.2%), average LoS was 11.5 days (range: 7.5-14.4; median LoS: 8 days) and EHR rate was 8.3% (range: 4.7-14.2%). ICP was positively associated with LoS and negatively with HD and EHR; the relationship between ICP and LoS varied spatially. An increased distance to a specialized cardiology center was associated with a decreased likelihood of ICP, a decrease in LoS, but an increased likelihood of EHR. The main results of this study are the regional variability of the outcomes even after accounting for age, gender, ICP and distance to a cardiology center; the significant relationships between ICP and HD, LoS and EHR, and the spatial variability in the relationships between ICP and LoS.

Objectives: Posttraumatic stress disorder (PTSD) prospectively increases the risk of incident cardiovascular disease (CVD) independent of other risk factors in otherwise healthy individuals. Between 10% and 20% of patients develop PTSD related to the traumatic experience of myocardial infarction (MI). We investigated the hypothesis that PTSD symptoms caused by MI predict adverse cardiovascular outcome. Methods: We studied 297 patients (61 ± 10 years, 83% men) who self-rated PTSD symptoms attributable to a previous index MI. Non-fatal CVD-related hospital readmissions (i.e. recurrent MI, elective and non-elective intracoronary stenting, bypass surgery, pacemaker implantation, cardiac arrhythmia, cerebrovascular event) were assessed at follow-up. Cox proportional hazard models controlled for demographic factors, coronary heart disease severity, major CVD risk factors, cardiac medication, and mental health treatment. Results: Forty-three patients (14.5%) experienced an adverse event during a mean follow-up of 2.8 years (range 1.3-3.8). A 10 point higher level in the PTSD symptom score (mean 8.8 ± 9.0, range 0-47) revealed a hazard ratio (HR) of 1.42 (95% CI 1.07-1.88) for a CVD-related hospital readmission in the fully adjusted model. A similarly increased risk (HR 1.45, 95% CI 1.07-1.97) emerged for patients with a major or unscheduled CVD-related readmission (i.e. when excluding patients with elective stenting).

Background: During acute coronary syndromes patients perceive intense distress. We hypothesized that retrospective ratings of patients' MI-related fear of dying, helplessness, or pain, all assessed within the first year post-MI, are associated with poor cardiovascular outcome. Methods: We studied 304 patients (61 ± 11 years, 85% men) who after a median of 52 days (range 12-365 days) after index MI retrospectively rated the level of distress in the form of fear of dying, helplessness, or pain they had perceived at the time of MI on a numeric scale ranging from 0 ("no distress") to 10 ("extreme distress"). Non-fatal hospital readmissions due to cardiovascular disease (CVD) related events (i.e., recurrent MI, elective and non-elective stent implantation, bypass surgery, pacemaker implantation, cerebrovascular incidents) were assessed at follow-up. The relative CVD event risk was computed for a (clinically meaningful) 2-point increase of distress using Cox proportional hazard models. Results: During a median follow-up of 32 months (range 16-45), 45 patients (14.8%) experienced a CVD-related event requiring hospital readmission. Greater fear of dying (HR 1.21, 95% CI 1.03-1.43), helplessness (HR 1.22, 95% CI 1.04-1.44), or pain (HR 1.27, 95% CI 1.02-1.58) were significantly associated with an increased CVD risk without adjustment for covariates. A similarly increased relative risk emerged in patients with an unscheduled CVD-related hospital readmission, i.e., when excluding patients with elective stenting (fear of dying: HR 1.26, 95% CI 1.05-1.51; helplessness: 1.26, 95% CI 1.05-1.52; pain: HR 1.30, 95% CI 1.01-1.66). In the fully-adjusted models controlling for age, the number of diseased coronary vessels, hypertension, and smoking, HRs were 1.24 (95% CI 1.04-1.46) for fear of dying, 1.26 (95% CI 1.06-1.50) for helplessness, and 1.26 (95% CI 1.01-1.57) for pain. Conclusions: Retrospectively perceived MI-related distress in the form of fear of dying, helplessness, or pain was associated with non-fatal cardiovascular outcome independent of other important prognostic factors.

Clinical pathways are promoted for standardizing patient care and decreasing resource use without compromising outcome. Once established, we hypothesized that clinical pathways can then be used to modify patient care to achieve specific goals. Our aim was to evaluate a clinical pathway for the bariatric surgical patient that was initially designed to standardize care and later altered to modify the postoperative course. We retrospectively reviewed 150 consecutive patients undergoing open gastric bypass by a single surgeon. The first 50 patients were managed without a formal pathway, (group I). The next 50 were managed with a pathway that standardized care in order to reduce length of stay (LOS), (group II). For the final 50 patients, the pathway was modified to shorten nasogastric decompression time (group III). Patient information, blood loss (EBL), operative time, length of stay (LOS), nasogastric decompression, 30-day complication rates, and early readmissions were reviewed. The ...

S evere hyperbilirubinemia continues to be the most common cause of neonatal readmission to hospitals in North America. This pattern continues despite attempts to identify newborns at risk of clinically important hyperbilirubinemia before they are discharged from hospital. Long-term results of severe hyperbilirubinemia, including bilirubin encephalopathy and kernicterus, were thought to be rare since the advent of exchange transfusion, maternal rhesus immunoglobulin prophylaxis and phototherapy. 10-12 However, cases of kernicterus have been reported recently in healthy near-term and term infants with no evidence of hemolytic disease or other risk factors. As a result, a sentinel event alert was issued by the US Centers for Disease Control and Prevention to identify cases of kernicterus in healthy term infants. The resurgence of severe neonatal hyperbilirubinemia and kernicterus (a largely preventable disease) is of grave concern. Risk factors recognized to be associated with severe hyperbilirubinemia in newborns have included jaundice in the first 24 hours of life, jaundice noted before discharge from hospital, a sibling who had jaundice treated with phototherapy, near-term gestational age of 35-36 weeks, Asian race and the presence of infant bruising or cephalhematoma. Causes identified by laboratory investigations include rhesus and ABO incompatibility, as well as glucose-6-phosphate dehydrogenase (G6PD) deficiency. We conducted this study to estimate the incidence of severe hyperbilirubinemia in Canada and to determine the underlying causes, which would be of value in identifying and implementing strategies to prevent morbidity from this condition. The Canadian Paediatric Surveillance Program (CPSP) was used to study severe neonatal hyperbilirubinemia in Canada. This program surveys more than 2400 Canadian pediatricians and pediatric subspecialists to obtain national surveillance and research data on uncommon pediatric diseases and conditions. Pediatricians and pediatric subspecialists were targeted for this study since it would be expected that infants meeting the case definition would be seen by a pediatrician at

Total knee arthroplasty (TKA) is a well-established procedure for managing advanced knee osteoarthritis, providing significant pain relief and functional improvement [1]. However, despite its success, postoperative complications and hospital readmissions remain a concern [2,3]. This mini review focuses on the causes and risk factors associated with readmission after TKA, highlighting findings from recent literature, including our retrospective study. The primary reasons for readmission include surgical site infections, wound complications, thromboembolic events, and medical comorbidities [4,5]. Understanding these factors is crucial for developing strategies to minimize readmission rates and improve patient outcomes.

Introduction In 2010 the National Institute for Health and Clinical Excellence (NICE) released guidelines on venous thromboembolism. Strategy focused on risk assessment, antiembolic stockings, sequential compression devices, subcutaneous high dose enoxaparin (40mg), early mobilisation and hydration. The 40mg enoxaparin dose over the previous 20mg regimen was worrisome, and its effect on pericardial effusion rates and mortality in proximal aortic surgery was investigated. Methods Proximal aortic reconstructions performed between December 2008 and April 2011 were identified from prospectively collected data in a tertiary centre database. Retrospective analysis of patient notes was performed. Proximal aortic surgery patients were categorised as low dose (20mg) enoxaparin and high dose (40mg) enoxaparin, and compared for confounding variables. In-hospital, early and one-year readmission rates for pericardial effusion were ascertained from echocardiography reports. The primary outcome wa...

Background: Heart failure with preserved ejection fraction (HFpEF) is more frequent in the elderly and is associated with important economic implications because of repetitive and prolonged hospitalizations, due to both cardiovascular and noncardiovascular causes. Purpose: To identify the causes, as well as the clinical and biological markers, that could be used as predictors of hospital readmissions in HFpEF patients aged 65 years. Patients and methods: Consecutive eligible patients hospitalized for a first heart failure (HF) episode were prospectively included and divided into one of two age groups (elderly: 65 years; and nonelderly: 65 years). The clinical features, therapeutic approaches, and clinical outcomes during the 1-year follow-up period were analyzed. Results: A total of 178 patients were included, with a mean age of 64.6±8.6 years; 80 (45%) were women. A total of 98 patients (55%) were aged 65 years, and 80 (45%) were aged 65 years. In the group aged 65 years, 58 patients (59%) were women, while in the group aged 65 years, 22 patients (28%) were women (P=0.0001). During the 1-year follow-up, no patients died or were lost to follow-up. Moreover, 116 (65%) of the HFpEF patients experienced hospital readmissions. The elderly patients had a significantly higher readmission rate (73% vs 55%, respectively; P0.02); readmissions due to aggravated HF were significantly more frequent in this age group (41% vs 18%, respectively; P0.002). Multivariate logistic regression analysis indicated that the independent predictors of readmission due to HF aggravation included plasma levels of brain natriuretic peptide 450 pg/mL (P0.01) and N-terminal-pro-brain natriuretic peptide 477 pg/mL (P0.02) in the elderly group, while in the nonelderly group, the independent predictors of this outcome were a New York Heart Association functional class of IV at initial hospitalization (P0.04), as well as plasma levels of brain natriuretic peptide 390 pg/mL (P=0.03) and tumor necrosis factor (TNF)-α 7.1 pg/mL (P0.001). Readmissions due to noncardiovascular causes were independently predicted by plasma levels of TNF-α 10 pg/mL in the elderly (P=0.003) and of interleukin (IL)-6 1.9 pg/mL in the nonelderly (P0.04). We conclude that in HFpEF patients aged 65 years, the main cause of rehospitalization during the 1-year follow-up was HF aggravation. The risk of this outcome was independently predicted by increased levels of cardiac peptides, while the risk of noncardiovascular readmissions was predicted by increased levels of inflammatory biomarkers. Increased TNF-α levels predicted both cardiovascular and noncardiovascular readmissions, while increased levels of high-sensitivity C-reactive protein did not predict any of these outcomes in our study.

Background: Accelerated recovery from surgery has been achieved when patients are managed within a multimodal Enhanced Recovery After Surgery (ERAS) protocol. This study evaluated the benefit of an ERAS programme for patients undergoing liver resection. The ERAS protocol of epidural analgesia, early oral intake and early mobilization was studied prospectively in a consecutive series of 61 patients. Outcomes were compared with those in a consecutive series of 100 patients who underwent liver resection before the start of the study. Endpoints were postoperative length of hospital stay, postoperative resumption of oral intake, readmissions, morbidity and mortality. Results: Fifty-six patients (92 per cent) in the ERAS group tolerated fluids within 4 h of surgery and a normal diet on day 1 after surgery. Median hospital stay, including readmissions, was 6•0 days compared with 8•0 days in the control group (P < 0•001). There were no significant differences in rates of readmission (13 and 10•0 per cent respectively), morbidity (41 and 31•0 per cent) and mortality (0 and 2•0 per cent) between ERAS and control groups. The ERAS fast-track protocol is safe and effective for patients undergoing liver resection. It allows early oral intake, promotes faster postoperative recovery and reduces hospital stay.

Background: Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers. Methods: This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from longstay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed-and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described. Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable. Conclusions: Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.

During the COVID-19 pandemic Missouri Quality Initiative APRNs worked in 16 nursing homes (NHs) providing clinical expertise and support. To understand their influence on the NH COVID-19 response, we conducted four group interviews with APRNs from 13 of the 16 NHs. Using thematic analysis, we identified similarities and differences between NH groups and then compared groups by COVID-19 infection rates. Leaders from NHs with high COVID-19 rates were unwilling to report infections and were resistant to resident/staff testing. In contrast, leaders from NHs with low COVID-19 rates were strategic about acquiring supplies, held daily huddles, and initiated CDC recommendations almost immediately. All reported residents lost weight, and experienced mood and physical decline resulting from quarantine/isolation. APRNs worked with providers to identify potentially ill residents/staff, improve isolation/quarantine procedures, manage ill residents, and supported efforts to mitigate viral spread....

The future of cognitive assessments and brain-training programs is very likely to involve mobile applications for phones and tablets. However, adherence to these programs over the long haul is notoriously low. In an effort to countervail this trend, we ran online focus groups with both older and younger adults to understand from a user-centered perspective how to better design apps to increase adherence. Using thematic content analysis (Braun & Clarke, 2006) with an inductive bottom-up approach (Frith & Gleeson, 2004), we found a surprising number of common themes across older and younger adults that superseded many of their superficial differences. For instance, both younger and older adults were reluctant to engage in the program unless it had some obvious perceived benefit; both wanted the program personalized to their individual preferences; both wanted the ability to customize features and reminders; and both generally agreed that the tasks had to be fun.

Background--Although models exist for predicting hospital readmission after coronary artery bypass surgery, no such models exist for predicting readmission after heart valve surgery (HVS). Methods and Results--Using a geographically and structurally diverse sample of US hospitals (Premier Inpatient Database, January 2007-June 2011), we examined patient, hospital, and clinical factors predictive of short-and medium-term hospital readmission post-HVS. We set aside 20% of hospitals for model validation. A generalized estimating equation model accounted for clustering within hospitals. At 219 hospitals, we identified 38 532 patients (67 years, 56% male, 62% aortic valve surgery) who underwent HVS. A total of 3125 (7.8%) and 4943 (12.8%) patients were readmitted to the index hospital within 1 and 3 months, respectively. Our 3-month model predicted readmission rates between 3% and 61% with fair discrimination (C-statistic, 0.67) and good calibration (predicted vs observed differences in validation cohort averaged 1.9% across all deciles of predicted readmission risk). Results were similar for our 1-month model and our simplified 3-month model (suitable for clinical use), which used the 5 strongest predictors of readmission: transfused units of packed Red blood cells, presence of End-stage renal disease, type of Valve surgery, Emergency hospital admission, and hospital Length of stay (REVEaL). Conclusions--We described and validated key factors that predict short-and medium-term hospital readmission post-HVS. These models should enable clinicians to identify individuals with HVS who are at increased risk for hospital readmission and are most likely to benefit from improved postdischarge care and follow-up.

Thirty-day readmission rates, a widely utilized quality metric, are high among HIV-infected individuals. However, it is unknown how many 30-day readmissions are preventable, especially in HIV patients, who have been excluded from prior potentially preventable readmission analyses. We used electronic medical records to identify all readmissions within 30 days of discharge among HIV patients hospitalized at a large urban safety net hospital in 2011. Two independent reviewers assessed whether readmissions were potentially preventable using both published criteria and detailed chart review, how readmissions might have been prevented, and the phase of care deemed suboptimal (inpatient care, discharge planning, post-discharge). Of 1137 index admissions, 213 (19%) resulted in 30-day readmissions. These admissions occurred among 930 unique HIV patients, with 130 individuals (14%) experiencing 30-day readmissions. Of these 130, about half were determined to be potentially preventable using published criteria (53%) or implicit chart review (48%). Not taking antiretroviral therapy (ART) greatly increased the odds of a preventable readmission (OR 5.9, CI:2.4-14.8). Most of the preventable causes of readmission were attributed to suboptimal care during the index hospitalization. Half of 30-day readmission in HIV patients are potentially preventable. Increased focus on early ART initiation, adherence counseling, management of chronic conditions, and appropriate timing of discharge may help reduce readmissions in this vulnerable population.

Background: Hospital at home schemes are a recently adopted method of service delivery for the management of acute exacerbations of chronic obstructive pulmonary disease aimed at reducing demand for acute hospital in-patient beds and promoting a patient centered approach through admission avoidance. However, evidence in support of such a service is contradictory. Objectives: To evaluate the efficacy of "hospital at home" compared to hospital inpatient care in acute exacerbations of chronic obstructive pulmonary disease. Search strategy: The Cochrane Central Register of Controlled Trials; electronically available databases e.g. MEDLINE (1966-current), EMBASE (1980-current), PubMed, ClincalTrials, Science Citation Index and on-line individual respiratory journals; bibliographies of included trials were all searched and contact with authors was made to obtain studies. The most recent searches were carried out in August 2003. Selection criteria: Only randomised controlled trials were considered where patients presented to the emergency department with an exacerbation of their chronic obstructive pulmonary disease. Studies must not have recruited patients that are usually deemed obligatory admissions. Data collection and analysis: Two reviewers independently selected articles for inclusion, evaluated methodological quality of the studies and abstracted data. Main results: Seven studies with 754 patients were included in the review. Studies provided data on hospital readmission and mortality both of which were not significantly different when the two study groups were compared (RR 0.89; 95%CI 0.72 to 1.12 & RR 0.61; 95%CI 0.36 to 1.05, respectively). Both the patients and the carers preferred hospital at home schemes to inpatient care (RR 1.53; 95%CI 1.23 to 1.90). Other reported outcomes included few studies. Página 2 de 36 Ovid: Ram: The Cochrane Library, Volume (4).2004. 10/01/2005 Conclusions: This review has shown that one in four carefully selected patients presenting to hospital emergency departments with acute exacerbations of chronic obstructive pulmonary disease can be safely and successfully treated at home with support from respiratory nurses. This review found no evidence of significant differences between "hospital at home" patients and hospital inpatients for readmission rates and mortality at two to three months after the initial exacerbation. Both the patients and carers preferred "hospital at home" schemes to inpatient care.

Severe anemia (hemoglobin level, <6 g per deciliter) is a leading cause of hospital admission and death in children in sub-Saharan Africa. The World Health Organization recommends transfusion of 20 ml of whole-blood equivalent per kilogram of body weight for anemia, regardless of hemoglobin level. In this factorial, open-label trial, we randomly assigned Ugandan and Malawian children 2 months to 12 years of age with a hemoglobin level of less than 6 g per deciliter and severity features (e.g., respiratory distress or reduced consciousness) to receive immediate blood transfusion with 20 ml per kilogram or 30 ml per kilogram. Three other randomized analyses investigated immediate as compared with no immediate transfusion, the administration of postdischarge micronutrients, and postdischarge prophylaxis with trimethoprim-sulfamethoxazole. The primary outcome was 28-day mortality. A total of 3196 eligible children (median age, 37 months; 2050 [64.1%] with malaria) were assigned to receive a transfusion of 30 ml per kilogram (1598 children) or 20 ml per kilogram (1598 children) and were followed for 180 days. A total of 1592 children (99.6%) in the higher-volume group and 1596 (99.9%) in the lower-volume group started transfusion (median, 1.2 hours after randomization). The mean (±SD) volume of total blood transfused per child was 475±385 ml and 353±348 ml, respectively; 197 children (12.3%) and 300 children (18.8%) in the respective groups received additional transfusions. Overall, 55 children (3.4%) in the higher-volume group and 72 (4.5%) in the lower-volume group died before 28 days (hazard ratio, 0.76; 95% confidence interval [CI], 0.54 to 1.08; P = 0.12 by log-rank test). This finding masked significant heterogeneity in 28-day mortality according to the presence or absence of fever (>37.5°C) at screening (P=0.001 after Sidak correction). Among the 1943 children (60.8%) without fever, mortality was lower with a transfusion volume of 30 ml per kilogram than with a volume of 20 ml per kilogram (hazard ratio, 0.43; 95% CI, 0.27 to 0.69). Among the 1253 children (39.2%) with fever, mortality was higher with 30 ml per kilogram than with 20 ml per kilogram (hazard ratio, 1.91; 95% CI, 1.04 to 3.49). There was no evidence of differences between the randomized groups in readmissions, serious adverse events, or hemoglobin recovery at 180 days. Overall mortality did not differ between the two transfusion strategies. (Funded by the

The World Health Organization recommends not performing transfusions in African children hospitalized for uncomplicated severe anemia (hemoglobin level of 4 to 6 g per deciliter and no signs of clinical severity). However, high mortality and readmission rates suggest that less restrictive transfusion strategies might improve outcomes.

Background--Approximately one third of patients with ST-segment elevation myocardial infarction (STEMI) have left ventricular hypertrophy (LVH), which is associated with impaired outcome. However, the causal association between LVH and outcome in STEMI is unknown. We evaluated the association between LVH and: myocardial infarct size, area at risk, myocardial salvage, microvascular obstruction, left ventricular (LV) function (all determined by cardiac magnetic resonance [CMR]), and all-cause mortality and readmission for heart failure in STEMI patients treated with primary percutaneous coronary intervention. Methods and Results--In this substudy of the DANAMI-3 trial, 764 patients underwent CMR. LVH was defined by CMR and considered present if LV mass exceeded 77 (men) and 67 g/m 2 (women). One hundred seventy-eight patients (24%) had LVH. LVH was associated with a larger final infarct size (15% [interquartile range {IQR}, 10-21] vs 9% [IQR, 3-17]; P<0.001) and smaller final myocardial salvage index (0.6 [IQR, 0.5-0.7] vs 0.7 [IQR, 0.5-0.9]; P<0.001). The LVH group had a higher incidence of microvascular obstruction (66% vs 45%; P<0.001) and lower final LV ejection fraction (LVEF; 53% [IQR, 47-60] vs 61% [IQR, 55-65]; P<0.001). In a Cox regression analysis, LVH was associated with a higher risk of all-cause mortality and readmission for heart failure (hazard ratio 2.59 [95% CI, 1.38-4.90], P=0.003). The results remained statistically significant in multivariable models. Conclusions--LVH is independently associated with larger infarct size, less myocardial salvage, higher incidence of microvascular obstruction, lower LVEF, and a higher risk of all-cause mortality and incidence of heart failure in STEMI patients treated with primary percutaneous coronary intervention.

OBJECTIVE Extended hospital length of stay (LOS), unplanned hospital readmission, and need for inpatient rehabilitation after elective spine surgery contribute significantly to the variation in surgical health care costs. As novel payment models shift the risk of cost overruns from payers to providers, understanding patient-level risk of LOS, readmission, and inpatient rehabilitation is critical. The authors set out to develop a grading scale that effectively stratifies risk of these costly events after elective surgery for degenerative lumbar pathologies. METHODS The Quality and Outcomes Database (QOD) registry prospectively enrolls patients undergoing surgery for degenerative lumbar spine disease. This registry was queried for patients who had undergone elective 1- to 3-level lumbar surgery for degenerative spine pathology. The association between preoperative patient variables and extended postoperative hospital LOS (LOS ≥ 7 days), discharge status (inpatient facility vs home), a...

Purpose. To assess the effectiveness of acute medical units (AMUs) in hospitals. Data sources. (i) Controlled and observational studies in peer-reviewed journals retrieved from PubMed, EPOC, CINAHL and ERIC databases published between January 1990 and July 2008; and (ii) reports from non-peer-reviewed websites combined with Google search. Study selection. Articles reporting effects of the introduction of an AMU on mortality, length of stay, discharge disposition, readmissions, resource use and patient and/or staff satisfaction. Data extraction. Data on unit operations and outcome measures were extracted by a single author and confirmed by a second author, with disagreement settled by consensus. Results of data synthesis. Nine peer-reviewed reports of before -after analyses of seven units introduced into the UK and Ireland were analysed. Two studies, one prospective, reported significant reductions in in-patient mortality between 0.6 and 5.6% points following commencement of AMU. Four studies reported significant reductions in the length of stay between 1.5 and 2.5 days. Waiting times for patient transfer from emergency departments to medical beds decreased by 30% in one study. In three studies, the proportion of medical patients discharged directly home from the AMU increased by 8-25% points. Three studies noted no increase in 30-day readmission rates following unit commencement. Two studies described significant improvements in patient and staff satisfaction with care. Eight non-peer-reviewed reports relating to 48 units confirmed reductions in the length of stay. Limited observational data suggest AMUs reduce in-patient mortality, length of stay and emergency department access block without increasing readmission rates, and improve patient and staff satisfaction.

Background.Unplanned readmissions of recently discharged patients impose a significant burden on hospitals with limited bed capacity. Deficiencies in discharge processes contribute to such readmissions, which have prompted experimentation with multiple types of peridischarge interventions. Objective.To determine the relative efficacy of peridischarge interventions categorised into two groups: (1) single component interventions (sole or predominant) implemented either before or after discharge; and (2) integrated multicomponent interventions which have pre- and postdischarge elements. Design.Systematic metareview of controlled trials. Data collection.Search of four electronic databases for controlled trials or systematic reviews of trials published between January 1990 and April 2009 that reported effects on readmissions. Data synthesis.Among single-component interventions, only four (intense self-management and transition coaching of high-risk patients and nurse home visits and tele...

To examine 30-day readmission rates after vaginal and cesarean delivery by race-ethnicity and insurance status. We analyzed hospital discharge data contained in a statewide database maintained by the Connecticut Department of Public Health. Discharge data for patients admitted for vaginal delivery without complication (n5167,857) and cesarean delivery without complication (n575,552) from 2005 to 2012 were analyzed using marginal logistic models for clustered data with generalized estimating equations. Results from logistic models indicated that 30-day readmission rates per 1,000 patients were significantly higher among black (28.9/1,000; confidence interval [CI] 25.5-32.7) and Hispanic women (21.4/1,000; CI 18.9-24.2) than among white women (12.9/1,000; CI 11.9-14.0) after cesarean delivery. Similarly higher rates of readmission were observed for black (14.6/1,000; CI 13.0-16.5) and Hispanic women (10.7/1,000; CI 9.6-12.0) relative to white women (7.5/1,000; CI 7.0-8.1) after vaginal delivery. Rates of 30-day readmission were significantly higher (odds ratio 1.27-1.30) among those covered by Medicaid. Controlling for patient socioeconomic status, comorbidities, and payer did not substantially reduce race and ethic differences in the odds of readmission. CONCLUSION: Significant racial and ethnic disparities in readmissions were observed for procedures related to childbirth using a statewide database capturing all payers across all acute care hospital settings. Compared with white women, black women were twice as likely and Hispanic women 40-50% more likely to be readmitted within 30 days of vaginal or cesarean delivery.

To examine 30-day readmission rates after vaginal and cesarean delivery by race-ethnicity and insurance status. We analyzed hospital discharge data contained in a statewide database maintained by the Connecticut Department of Public Health. Discharge data for patients admitted for vaginal delivery without complication (n5167,857) and cesarean delivery without complication (n575,552) from 2005 to 2012 were analyzed using marginal logistic models for clustered data with generalized estimating equations. Results from logistic models indicated that 30-day readmission rates per 1,000 patients were significantly higher among black (28.9/1,000; confidence interval [CI] 25.5-32.7) and Hispanic women (21.4/1,000; CI 18.9-24.2) than among white women (12.9/1,000; CI 11.9-14.0) after cesarean delivery. Similarly higher rates of readmission were observed for black (14.6/1,000; CI 13.0-16.5) and Hispanic women (10.7/1,000; CI 9.6-12.0) relative to white women (7.5/1,000; CI 7.0-8.1) after vaginal delivery. Rates of 30-day readmission were significantly higher (odds ratio 1.27-1.30) among those covered by Medicaid. Controlling for patient socioeconomic status, comorbidities, and payer did not substantially reduce race and ethic differences in the odds of readmission. CONCLUSION: Significant racial and ethnic disparities in readmissions were observed for procedures related to childbirth using a statewide database capturing all payers across all acute care hospital settings. Compared with white women, black women were twice as likely and Hispanic women 40-50% more likely to be readmitted within 30 days of vaginal or cesarean delivery.

Objectives The present database contains information on sociodemographic and clinical data as well as data from the Care Transition Measure (CTM 15-Brazil) of cancer patients undergoing clinical or surgical treatment. Data collection was carried out 7 to 30 days after patients’ hospital discharge from June to August 2019. Understanding these data can contribute to improving quality of care transitions and avoiding hospital readmissions. Data description This data set encompasses 213 cancer patients characterized by the follow variables: gender, age range, place of residence, race, marital status, schooling, paid work activity, type of treatment, cancer staging, metastasis, comorbidities, main complaint, main complaint grouped as, continuing medication, diagnosis, diagnosis grouped as, cancer type, year of diagnosis, oncology treatment, first hospitalization, readmission in the last 30 days, number of hospitalizations in the last 30 days, readmission in the last 6 months, number of h...

Introduccio´n: En pancreatitis biliar leve, la colecistectomı ´a disminuye el riesgo de recurrencia. Esta debe realizarse durante la hospitalizacio ´n inicial, pero incluso en esta puede prolongarse la estancia hospitalaria, con aumento de costos y morbilidad. El objetivo de este estudio es comparar las complicaciones entre los pacientes a los que se les realizo ´colecistectomı ´a temprana (<48 h) vs. tardı ´a (>48 h). Materiales y me´todos: Se realizo ´una bu ´ squeda sistema ´tica en las bases de datos: PubMed, EMBASE, LILACS y Scielo. Se incluyeron artı ´culos de pacientes con pancreatitis aguda biliar leve que fueron llevados a colecistectomı ´a durante la hospitalizacio ´n inicial de manera temprana comparados con colecistectomı ´a tardı ´a, para evaluar las complicaciones, dı ´as de estancia hospitalaria y readmisio ´n. Se evaluaron la calidad de los estudios y el riesgo de sesgos. Resultados: Se identificaron 580 tı ´tulos y resu ´ menes de los cuales se incluyeron 3 estudios observacionales y un experimento clı ´nico aleatorizado. Un total de 636 pacientes fueron incluidos, a los que se les realizo ´colecistectomı ´a durante la hospitalizacio ´n inicial. En 10 de 207 (4,83%) se presento ´algu ´ n tipo de complicacio ´n en el grupo de colecistectomı ´a temprana y 19 de 429 (4,42%) en el de colecistectomı ´a tardı ´a, con diferencia de riesgo de -0,0016 IC 95% ([-0.04]-0.04). De los estudios incluidos 3 fueron de baja calidad y uno de alta calidad. No se evidencio śesgo de publicacio ´n. Conclusio´n: No se encontro ´diferencia entre los que son llevados a colecistectomı ´a temprana en comparacio ´n con colecistectomı ´a tardı ´a en cuanto a complicaciones, sin embargo se deben realizar ma ´s estudios para confirmar o refutar estos hallazgos.

Cardiac rehabilitation (CR) following myocardial infarction is vastly underused. As such the aim of this study was to test a digital health intervention (DHI) as an adjunct to CR. Patients undergoing standard Mayo Clinic CR were recruited prior to CR (n=25) or after three months CR (n=17). Changes in risk factors and rehospitalizations plus emergency department (ED) visits were assessed after three months. Patients assigned to DHI during CR had significant reductions in weight (-4.0+5.2 kg, P=.001), blood pressure (-10.8±13.5 mmHg, P=.0009), and the group using DHI after three months of CR had significant reductions in weight (-2.5±3.8 kg, P=.04) and systolic BP (-12.6±12.4 mmHg, P=.001) compared to the control groups. Both DHI groups also displayed significant reductions in rehospitalizations/ED visits (-37.9%, P=0.01 and -28%, P=.04, respectively). This study suggests that a guideline-driven, DHI CR program can augment secondary prevention strategies during usual CR by improving risk factors for repeat events.

Cardiac rehabilitation (CR) following myocardial infarction is vastly underused. As such the aim of this study was to test a digital health intervention (DHI) as an adjunct to CR. Patients undergoing standard Mayo Clinic CR were recruited prior to CR (n=25) or after three months CR (n=17). Changes in risk factors and rehospitalizations plus emergency department (ED) visits were assessed after three months. Patients assigned to DHI during CR had significant reductions in weight (-4.0+5.2 kg, P=.001), blood pressure (-10.8±13.5 mmHg, P=.0009), and the group using DHI after three months of CR had significant reductions in weight (-2.5±3.8 kg, P=.04) and systolic BP (-12.6±12.4 mmHg, P=.001) compared to the control groups. Both DHI groups also displayed significant reductions in rehospitalizations/ED visits (-37.9%, P=0.01 and -28%, P=.04, respectively). This study suggests that a guideline-driven, DHI CR program can augment secondary prevention strategies during usual CR by improving risk factors for repeat events.

BackgroundTranssphenoidal pituitary surgery has evolved into a safe procedure with shorter hospitalizations, yet unplanned readmissions remain a quality measure for which there is a paucity of data. We sought to examine rates, timing, etiologic factors, and costs surrounding readmission after transsphenoidal pituitary surgery.MethodsThe Nationwide Readmissions Database (NRD) was queried for patients who underwent transsphenoidal pituitary between January 2013 and November 2013. Patient, procedure, admission, and hospital‐level characteristics were compared for patients with and without unplanned 30‐day readmission. Multivariate logistic regression was used to identify readmission predictors. A total of 8546 patients were included in this retrospective study.ResultsA total of 8546 patients with a median age of 54 years and female predominance were identified, with 742 patients experiencing at least 1 unplanned readmission within 30 days of index admission. Hypertension, hypothyroidis...

Areca nut is widely consumed in many parts of the world, especially in South and Southeast Asia, where cardiovascular disease (CVD) is also a huge burden. Among the forms of CVD, acute coronary syndrome (ACS) is a major cause of mortality and morbidity. Research has shown areca nut chewing to be associated with diabetes, hypertension, oropharyngeal and esophageal cancers, and CVD, but little is known about mortality and re-hospitalization secondary to ACS among areca nut users and non-users. A prospective cohort was studied to quantify the effect of areca nut chewing on patients with newly diagnosed ACS by categorizing the study population into exposed and non-exposed groups according to baseline chewing status. Cox proportional hazards models were used to examine the associations of areca nut chewing with the risk of re-hospitalization and 30-day mortality secondary to ACS. Of the 384 ACS patients, 49.5% (n=190) were areca users. During 1-month of follow-up, 20.3% (n=78) deaths and...

Background: Surgical management is currently the most common treatment offered for ruptured Achilles tendon; however, the length of hospital stay varies among hospitals. The objective of our study was to compare the costs associated with hospital stay and safety in 2 groups of patients undergoing surgical treatment of Achilles tendon ruptures. The first group of patients represented the surgical arm of a randomized clinical trial, the Multicentre Achilles Tendon Treatment Study (MATTS), and the second group comprised surgically treated patients not included in that trial (non-MATTS). Methods: We performed an observational analytical retrospective chart review of all patients surgically treated for acute Achilles tendon ruptures at all Calgary-area hospitals over a 3-year period (October 2002-September 2005) who met our inclusion criteria. We determined the costs associated with hospital stay, complications and readmissions for all patients. Results: A total of 282 patients met our inclusion criteria. Hospital admission costs of patients enrolled in the MATTS trial were less than those of non-MATTS patients treated at each of the 3 Calgary adult hospitals. Non-MATTS patients remained in hospital for 1-4 days in contrast to MATTS patients, who were typically admitted and discharged the day of surgery. The complication rate was similar in both groups (MATTS 9% v. non-MATTS 8%). There were no readmissions in the MATTS group and 2 in the non-MATTS group. Between October 2002 and September 2005, an additional $236,436 was spent on non-MATTS patients who underwent surgery for Achilles tendon rupture. Conclusion: Acute achilles tendon repair surgery is safe and less costly as an out-patient procedure.

Patients who leave hospital against medical advice (AMA) may be at risk of adverse health outcomes and readmission. In this study we examined rates of readmission and predictors of readmission among patients leaving hospital AMA. We prospectively studied 97 consecutive patients who left the general medicine service of an urban teaching hospital AMA. Each patient was matched according to age, sex and primary diagnosis with a control patient who was discharged routinely. Readmission rates were examined using Kaplan-Meier analysis. Regression models were used to test the hypothesis that readmissions among patients discharged AMA followed a biphasic curve. Patients who left AMA were much more likely than the control patients to be readmitted within 15 days (21% v. 3%, p &lt; 0.001). Readmissions occurred at an accelerated pace during the first 15 days, followed by a 75-day period during which readmissions occurred at a rate comparable to that among the control patients. Among the patien...

Background: Several studies have focused on stratifying patients according to their level of readmission risk, fueled in part by incentive programs in the U.S. that link readmission rates to the annual payment update by Medicare. Patient-specific predictions about readmission have not seen widespread use because of their limited accuracy and questions about the efficacy of using measures of risk to guide clinical decisions. We construct a predictive model for readmissions for congestive heart failure (CHF) and study how its predictions can be used to perform patient-specific interventions. We assess the cost-effectiveness of a methodology that combines prediction and decision making to allocate interventions. The results highlight the importance of combining predictions with decision analysis. We construct a statistical classifier from a retrospective database of 793 hospital visits for heart failure that predicts the likelihood that patients will be rehospitalized within 30 days of discharge. We introduce a decision analysis that uses the predictions to guide decisions about post-discharge interventions. We perform a cost-effectiveness analysis of 379 additional hospital visits that were not included in either the formulation of the classifiers or the decision analysis. We report the performance of the methodology and show the overall expected value of employing a real-time decision system. Findings: For the cohort studied, readmissions are associated with a mean cost of 13,679 with a standard error of 1,214. Given a post-discharge plan that costs 1,300 and that reduces 30-day rehospitalizations by 35%, use of the proposed methods would provide an 18.2% reduction in rehospitalizations and save 3.8% of costs. Conclusions: Classifiers learned automatically from patient data can be joined with decision analysis to guide the allocation of post-discharge support to CHF patients. Such analyses are especially valuable in the common situation where it is not economically feasible to provide programs to all patients.