1-year Readmission Rates Research Articles

National and Regional Trends in Deep Vein Thrombosis Hospitalization Rates, Discharge Disposition, and Outcomes for Medicare Beneficiaries

IntroductionOlder adults are at increased risk of developing deep vein thrombosis. Little is known about national trends of deep vein thrombosis hospitalizations in the context of primary and secondary prevention efforts. MethodsMedicare standard analytic files were analyzed from 2015-2017 to identify Fee-For-Service patients aged ≥65 years who had a principal discharge diagnosis for deep vein thrombosis from 1999 to 2010. We reported the deep vein thrombosis hospitalization rates per 100,000 person-years as well as 30-day and 1-year mortality rates. We used mixed-effects models to calculate adjusted outcomes. ResultsOverall, there were 726,423 deep vein thrombosis hospitalizations in Medicare Fee-for-Service from 1999 to 2010. Deep vein thrombosis hospitalization rate adjusted for age, sex, and race decreased from 264 per 100,000 person-years in 1999 to 167 per 100,000 person-years in 2010, a relative decline of 36.7% (P < .0001). Hospitalizations decreased for all subgroups by age, sex, and race with the exception of black patients (316 to 382 per 100,000 person-years, a relative increase of 20.8%) (P < .0001). Hospital length of stay decreased from 6.1 days in 1999 to 5.0 days in 2010, and the proportion of patients discharged to home decreased from 57.2% to 44.1%. Risk-adjusted 30-day, 6-month, and 1-year mortality and 30-day readmission rates remained relatively stable across the study period, but were highest among women in recent years. ConclusionsThe overall deep vein thrombosis hospitalization rate decreased from 1999 to 2010, except for black patients. Decreases in hospitalizations may reflect changes in clinical practice with increased outpatient rather than inpatient management, and faster transitions to outpatient care for management of deep vein thrombosis.

Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer

IntroductionThe need for routine diverting ileostomy following restorative total mesorectal excision (TME) is increasingly debated as the benefits might not outweigh the disadvantages. This study evaluated an institutional shift from routine (RD) to highly selective diversion (HSD) after TME surgery for rectal cancer. Materials and methodsPatients having TME with primary anastomosis and HSD for low or mid rectal cancer between December 2014 and March 2017 were compared with a historical control group with RD in the preceding period since January 2011. HSD was introduced in conjunction with uptake of transanal TME. ResultsIn the RD group, 45/50 patients (90%) had a primary diverting stoma, and 3/40 patients (8%) in the HSD group. Anastomotic leakage occurred in 10 (20%) and three (8%) cases after a median follow-up of 36 and 19 months after RD and HSD, respectively. There was no postoperative mortality. An unintentional stoma beyond 1 year postoperative was present in six and two patients, respectively. One-year stoma-related readmission and reoperation rate (including reversal) after RD were 84% and 86%, respectively. Corresponding percentages were significantly lower after HSD (17% and 17%; P < 0.001). Total hospital stay within one year was median 11 days (IQR 8–19) versus 5 days (IQR 4–11), respectively (P < 0.001). ConclusionThis single institutional comparative cohort study shows that highly selective defunctioning of a low anastomosis in rectal cancer patients did not adversely affect incidence or consequences of anastomotic leakage with a substantial decrease in 1-year readmission and reintervention rate, leading to an overall significantly reduced hospital stay.

Abstract 150: Care for Heart Failure Patients at the End of Life: Hospital Readmission and Mortality Amongst Heart Failure Patients Discharged to Hospice

Background: While 1 in 10 patients hospitalized with heart failure (HF) die within 30 days, end-of-life care for this high-risk population is not well described. Methods: We analyzed patients discharged alive from the Get With The Guidelines-HF registry between 2005-2014, linked to Medicare claims. We compared patients discharged to hospice to non-hospice “advanced HF” patients (ejection fraction ≤25% and either on inotropes, sodium ≤130, blood urea nitrogen ≥45 mg/dL, systolic blood pressure ≤90 mmHg or comfort measures) and to other GWTG-HF patients. Results: Of 121,990 US patients, hospice patients (n=4588, 2164 facility-based, 2424 home hospice) compared with advanced HF (n=4357) and others (113,045) were older (median age 86 years vs 78 years vs 81 years), more likely white race (88% vs 80% vs 82%), have intravenous loop diuretics used (74% vs 57% vs 63%), have an advanced care plan/surrogate decision maker discussed or documented (76% vs 62% vs 66%), had more dyspnea at rest (55% vs 46% vs 48%) and worse/unchanged symptoms at discharge (35% vs 2% vs 1%) (all p&lt;0.01). Discharge to hospice increased from 2% (n=109) in 2005 to 5% (n=968) in 2014. Median survival in hospice was 11 days (25 th , 75 th percentile: 3, 65 days) compared with advanced HF (318 days) and others (754 days); 34% of patients discharged to a hospice facility and 12% to home hospice died in &lt;3 days. (Figure) Median survival in hospice did not change significantly from 2005 to 2014. Hospital readmission at 30 days was 4% among hospice, 27% for advanced HF, and 22% for others. Median per-hospital hospice discharge rate over the study perior was 3% (1%, 6%). Hospice discharges had lower adjusted hazards of all-cause readmission (hospice compared with others: advanced HF odd ratio (OR) 0.15 (95% confidence interval (CI) 0.13-0.18), others OR 0.15 (95% CI 0.13-0.18). Hospice patients also had lower 6-month and 1-year readmission rate. Non-white race (OR 1.59 [95% CI 1.18-2.17]) and younger age (OR per 5 years 1.18 [95% CI 1.10-1.27)] were the strongest predictors of readmission from hospice. Conclusion: Hospice use in patients hospitalized with HF is limited but increasing. Few hospice patients are rehospitalized and almost a quarter die within 3 days of discharge. These findings may inform interventions to improve hospice care for HF patients.

Abstract 149: Care for Heart Failure Patients at the End of Life: Hospital Readmission and Mortality Amongst Heart Failure Patients Discharged to Hospice

Background: While 1 in 10 patients hospitalized with heart failure (HF) die within 30 days, end-of-life care for this high-risk population is not well described. Methods: We analyzed patients discharged alive from the Get With The Guidelines-HF registry between 2005-2014, linked to Medicare claims. We compared patients discharged to hospice to non-hospice “advanced HF” patients (ejection fraction ≤25% and either on inotropes, sodium ≤130, blood urea nitrogen ≥45 mg/dL, systolic blood pressure ≤90 mmHg or comfort measures) and to other GWTG-HF patients. Results: Of 121,990 US patients, hospice patients (n=4588, 2164 facility-based, 2424 home hospice) compared with advanced HF (n=4357) and others (113,045) were older (median age 86 years vs 78 years vs 81 years), more likely white race (88% vs 80% vs 82%), have intravenous loop diuretics used (74% vs 57% vs 63%), have an advanced care plan/surrogate decision maker discussed or documented (76% vs 62% vs 66%), had more dyspnea at rest (55% vs 46% vs 48%) and worse/unchanged symptoms at discharge (35% vs 2% vs 1%) (all p&lt;0.01). Discharge to hospice increased from 2% (n=109) in 2005 to 5% (n=968) in 2014. Median survival in hospice was 11 days (25 th , 75 th percentile: 3, 65 days) compared with advanced HF (318 days) and others (754 days); 34% of patients discharged to a hospice facility and 12% to home hospice died in &lt;3 days. (Figure) Median survival in hospice did not change significantly from 2005 to 2014. Hospital readmission at 30 days was 4% among hospice, 27% for advanced HF, and 22% for others. Median hospice discharge rate was 3.0 (0.7, 5.5). Hospice discharges had lower adjusted hazards of all-cause readmission (hospice compared with others: advanced HF odd ratio (OR) 0.15 (95% confidence interval (CI) 0.13-0.18), others OR 0.15 (95% CI 0.13-0.18). Hospice patients also had lower 6-month and 1-year readmission rate. Non-white race (OR 1.59 [95% CI 1.18-2.17]) and younger age (OR per 5 years 1.18 [95% CI 1.10-1.27)] were the strongest predictors of readmission from hospice. Conclusion: Hospice use in patients hospitalized with HF is limited but increasing. Few hospice patients are rehospitalized and almost a quarter die within 3 days of discharge. These findings may inform interventions to improve hospice care for HF patients.

Effect of Optimizing Guideline-Directed Medical Therapy Before Discharge on Mortality and Heart Failure Readmission in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

Guideline-directed medical therapy (GDMT) is recommended for patients with heart failure with reduced ejection fraction (HFrEF). However, the prognostic impact of medication optimization at the time of discharge in patients hospitalized with heart failure (HF) is unclear. We analyzed 534 patients (73 ± 13 years old) with HFrEF. The status of GDMT at the time of discharge (prescription of angiotensin converting enzyme inhibitor [ACE-I]/angiotensin receptor blocker [ARB] and β blocker [BB]) and its association with 1-year all-cause mortality and HF readmission were investigated. Patients were divided into 3 groups: those treated with both ACE-I/ARB and BB (Both group: n = 332, 62%), either ACE-I/ARB or BB (Either group: n = 169, 32%), and neither ACE-I/ARB nor BB (None group: n = 33, 6%), respectively. One-year mortality, but not 1-year HF readmission rate, was significantly different in the 3 groups, in favor of the Either and Both groups. A favorable impact of being on GDMT at the time of discharge on 1-year mortality was retained even after adjustment for covariates (Either group: hazard ratio [HR] 0.44, 95% confidence interval [CI] 0.21 to 0.90, p = 0.025 and Both group: HR 0.29, 95% CI 0.13-0.65, p = 0.002, vs None group). For 1-year HF readmission, no such association was found. In conclusion, optimization of GDMT before the time of discharge was associated with a lower 1-year mortality, but not with HF readmission rate, in patients hospitalized with HFrEF.

Heart failure with mid-range ejection fraction in patients admitted to internal medicine departments: Findings from the RICA Registry

AimTo improve the knowledge on characteristics, treatment and prognosis in patients with heart failure (HF) and mid-range ejection fraction discharged after an acute HF episode. MethodsWe prospectively included and followed 2753 patients admitted with HF to Internal Medicine units. Patients were classified according to ejection fraction (EF) into three strata: reduced, EF <40% (HFrEF); mid-range EF 40–49% (HFmrEF); and preserved EF ≥50% (HFpEF). Clinical, echocardiographic, laboratory data and treatment at discharge were recorded and the groups were compared. A multivariable analysis was performed to evaluate the association of EF with outcomes in these three groups. ResultsA total of 10.2% of patients had HFmrEF. They were more likely to be men and to have a history of chronic kidney disease and higher levels of NT-proBNP than those with HFpEF. Compared to patients with HFrEF, these patients had less frequently ischaemic aetiology and chronic obstructive pulmonary disease, and a higher proportion of atrial fibrillation and hypertension. In HFmrEF, the use of beta-blockers, aldosterone antagonists and antiplatelet drugs was lower than in HFrEF, but the use of calcium channel blockers and anticoagulants was higher. There were no differences between groups in 30-day and 1-year readmission rates. However, patients with HFrEF had significantly higher 1-year mortality (28%) than patients with HFmrEF and HFpEF (20% and 22%, p<0.001). ConclusionsClinical characteristics and treatment among patients with HF differ depending on EF strata. Prognosis of patients with HFmrEF is closer to that of HFpEF, being medium term survival better than in HFrEF.

Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure

Public reporting of hospitals' 30-day risk-standardized readmission rates following heart failure hospitalization and the financial penalization of hospitals with higher rates have been associated with a reduction in 30-day readmissions but have raised concerns regarding the potential for unintended consequences. To examine the association of the Hospital Readmissions Reduction Program (HRRP) with readmission and mortality outcomes among patients hospitalized with heart failure within a prospective clinical registry that allows for detailed risk adjustment. Interrupted time-series and survival analyses of index heart failure hospitalizations were conducted from January 1, 2006, to December 31, 2014. This study included 115 245 fee-for-service Medicare beneficiaries across 416 US hospital sites participating in the American Heart Association Get With The Guidelines-Heart Failure registry. Data analysis took place from January 1, 2017, to June 8, 2017. Time intervals related to the HRRP were before the HRRP implementation (January 1, 2006, to March 31, 2010), during the HRRP implementation (April 1, 2010, to September 30, 2012), and after the HRRP penalties went into effect (October 1, 2012, to December 31, 2014). Risk-adjusted 30-day and 1-year all-cause readmission and mortality rates. The mean (SD) age of the study population (n = 115 245) was 80.5 (8.4) years, 62 927 (54.6%) were women, and 91 996 (81.3%) were white and 11 037 (9.7%) were black. The 30-day risk-adjusted readmission rate declined from 20.0% before the HRRP implementation to 18.4% in the HRRP penalties phase (hazard ratio (HR) after vs before the HRRP implementation, 0.91; 95% CI, 0.87-0.95; P < .001). In contrast, the 30-day risk-adjusted mortality rate increased from 7.2% before the HRRP implementation to 8.6% in the HRRP penalties phase (HR after vs before the HRRP implementation, 1.18; 95% CI, 1.10-1.27; P < .001). The 1-year risk-adjusted readmission and mortality rates followed a similar pattern as the 30-day outcomes. The 1-year risk-adjusted readmission rate declined from 57.2% to 56.3% (HR, 0.92; 95% CI, 0.89-0.96; P < .001), and the 1-year risk-adjusted mortality rate increased from 31.3% to 36.3% (HR, 1.10; 95% CI, 1.06-1.14; P < .001) after vs before the HRRP implementation. Among fee-for-service Medicare beneficiaries discharged after heart failure hospitalizations, implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but an increase in 30-day and 1-year mortality. If confirmed, this finding may require reconsideration of the HRRP in heart failure.

Sleeve Gastrectomy: the first 3Years: evaluation of emergency department visits, readmissions, and reoperations for 14,080 patients in New York State.

The purpose of our study was to evaluate the indications for and incidence of both emergency department (ED) visits and hospital readmissions within the first postoperative year. We also sought to identify the rate of reoperation within the first 3years following a SG operation in New York State (NYS). The SPARCS database was examined for all SGs performed between 2011 and 2013. Using a unique identifier, patients were followed for at least 1year. Patients were followed for reoperation and/or conversion to Roux-en-Y Gastric Bypass (RYGB), as well as for any other hospital-based encounter. Using primary diagnosis codes, the top five reasons for ED visits and readmission were identified. There were 14,080 SG between 2011 and 2013. Among all patients, just over one-third of patients visited the ED (33.9%). One in every ten of these visits resulted in readmission (9.5%), with 12.5% of the total postoperative patient population undergoing readmission within their first year after SG surgery. ED visits were unrelated to surgery in just over half of the patients (n=4977; 53.88%). However, ED visits for abdominal pain (n=1029; 11.14%), vomiting (n=237; 2.57%), dehydration (n=224; 2.43%), and syncope (n=206; 2.23%) were attributed to surgery. The top five causes for readmission within the first year after SG were unrelated to surgery (n=1101; 41.74%), complication related to bariatric surgery (n=211; 8%), dehydration (n=171; 6.48%), postoperative wound complication (n=89; 3.37%), abdominal pain (n=78; 2.96%). Overall, there was a low reoperation rate (0.32%); specifically, rates of sleeve revision and conversion to RYBG were 0.11 and 0.21%, respectively. SG has increasing popularity in NYS. Although postoperative ED visits are high, SG has a low overall reoperation rate (0.32%), and of these patients, most undergo conversion to RYGB compared to sleeve revision. Overall 1-year readmission rates after SG are 12.5%.

Comparative Outcomes After Percutaneous Coronary Intervention Among Black and White Patients Treated at US Veterans Affairs Hospitals

Current comparative outcomes among black and white patients treated with percutaneous coronary intervention (PCI) in the Veterans Affairs (VA) health system are not known. To compare outcomes between black and white patients undergoing PCI in the VA health system. This study compared black and white patients who underwent PCI between October 1, 2007, and September 30, 2013, at 63 VA hospitals using data recorded in the VA Clinical Assessment, Reporting, and Tracking System for Cardiac Catheterization Laboratories (CART-CL) program. A generalized linear mixed model with a random intercept for site assessed the relative difference in odds of outcomes between black and white patients. The setting was integrated institutionalized hospital care. Excluded were all patients of other races or those with multiple listed races and those with missing data regarding race or the diagnostic cardiac catheterization. The dates of analysis were January 7, 2016, to April 17, 2017. Percutaneous coronary intervention at a VA hospital. The primary outcome was 1-year mortality. Secondary outcomes were 30-day all-cause readmission rates, 30-day acute kidney injury, 30-day blood transfusion, and 1-year readmission rates for myocardial infarction. In addition, variations in procedural and postprocedural care were examined, including the use of intravascular ultrasound, optical coherence tomography, fractional flow reserve measurements, bare-metal stents, postprocedural medications, and radial access. A total of 42 391 patients (13.3% black and 98.4% male; mean [SD] age, 65.2 [9.1] years) satisfied the inclusion and exclusion criteria. In unadjusted analyses, black patients had higher rates of 1-year mortality (7.1% vs 5.9%, P < .001) as well as secondary outcomes of 30-day acute kidney injury (20.8% vs 13.8%, P < .001), 30-day blood transfusion (3.4% vs 2.7%, P < .01), and 1-year readmission rates for myocardial infarction (3.3% vs 2.7%, P = .01) compared with white patients. After adjustment for demographics, comorbidities, and procedural characteristics, odds for 1-year mortality (odds ratio, 1.04; 95% CI, 0.90-1.19) were not different between black and white patients. There were also no differences in secondary outcomes with the exception of a higher rate of adjusted 30-day acute kidney injury (odds ratio, 1.22; 95% CI, 1.10-1.36). While black patients had a higher rate of mortality than white patients in unadjusted analyses, race was not independently associated with 1-year mortality among patients undergoing PCI in VA hospitals.

Race/Ethnic Differences in Outcomes Among Hospitalized Medicare Patients With Heart Failure and Preserved Ejection Fraction

ObjectivesThis study analyzed HFpEF patient characteristics and clinical outcomes according to race/ethnicity and adjusted for patient and hospital characteristics along with socioeconomic status (SES). BackgroundThe proportion of hospitalizations for heart failure with preserved ejection fraction (HFpEF) has increased over the last decade. Whether the short- and long-term outcomes differ between racial/ethnic groups is not well described. MethodsThe Get With The Guidelines–Heart Failure registry was linked to Medicare administrative data to identify hospitalized patients with HFpEF ≥65 years of age with left ventricular ejection fraction ≥50% between 2006 and 2014. Cox proportional hazards models were used to report hazard ratios (HRs) for 30-day and 1-year readmission and mortality rates with sequential adjustments for patient characteristics, hospital characteristics, and SES. ResultsThe final cohort included 53,065 patients with HFpEF. Overall 30-day mortality was 5.87%; at 1 year, it was 33.1%. The 30-day all-cause readmission rate was 22.2%, and it was 67.0% at 1 year. After adjusting for patient characteristics, hospital characteristics, and SES, 30-day mortality was lower for black patients (HR: 0.84; 95% confidence interval [CI]: 0.71 to 0.98; p = 0.031) and Hispanic patients (HR: 0.78; 95% CI: 0.64 to 0.96; p = 0.017) compared with white patients. One-year mortality was lower for black patients (HR: 0.93; 95% CI: 0.87 to 0.99; p = 0.031), Hispanic patients (HR: 0.83; 95% CI: 0.75 to 0.91; p < 0.001), and Asian patients (HR: 0.76; 95% CI: 0.66 to 0.88; p < 0.001) compared with white patients. Black patients had a higher risk of readmission at 30 days (HR: 1.09; 95% CI: 1.02 to 1.16; p = 0.012) and 1 year (HR: 1.14; 95% CI: 1.09 to 1.20; p < 0.001) compared with white patients. ConclusionsBlack, Hispanic, and Asian patients had a lower mortality risk after a hospitalization for HFpEF compared with white patients; black patients had higher readmission rates. These differences in mortality and readmission risk according to race/ethnicity persisted after adjusting for patient characteristics, SES, and hospital factors.

Racial and Ethnic Differences in Pediatric Readmissions for Common Chronic Conditions

To compare the timing and magnitude of variation of pediatric readmission rates across race/ethnicity for selected chronic conditions: asthma, diabetes, seizures, migraines, and depression. Retrospective analysis of hospitalizations at 48 children's hospitals in the 2013 Pediatric Health Information System database for children (ages 0-18 years) admitted for asthma (n = 36 910), seizure (n = 35 361), diabetes (n = 12 468), migraine (n = 5882), and depression (n = 5132). Generalized linear models with a random effect for hospital were used to compare the likelihood of readmission by patients' race/ethnicity, adjusting for severity of illness, age, payer, and medical complexity. Adjusted readmission rates were calculated by week over 1 year. Significant variation in adjusted readmission rates by race/ethnicity existed for conditions aside from depression. Disparities for diabetes and asthma emerged at 3 and 4 weeks, respectively; they remained divergent up to 1 year with the highest 1-year readmission rates in non-Hispanic blacks vs other race/ethnicities (diabetes: 21.7% vs 13.4%, P < .001; asthma: 21.4% vs 14.6%, P < .001). Disparities for migraines and seizure emerged at 6 and 7 weeks, respectively; they remained up to 1 year, with the highest 1-year readmission rates in non-Hispanic whites vs other race/ethnicities (migraine: 17.3% vs 13.6%, P < .001; seizure: 23.9% vs 21.9%, P < .001). Readmission disparities behave differently across chronic conditions. They emerge more quickly after discharge for children hospitalized with asthma or diabetes than for seizures or migraines. The highest readmission rates were not consistently observed for 1 particular race/ethnicity. Study findings can impact pediatric chronic disease management to improve care for children with these conditions.

Probabilistic Linkage of Two National Databases to Study Emergency Care and Hospital Readmission in Children who Survive Traumatic Injury

ABSTRACT&#x0D; ObjectivesTrauma and, in particular, traumatic brain injury (TBI) cause enormous morbidity and mortality worldwide. Children who survive trauma have many health burdens, but how often those burdens lead to emergency care or hospital readmission is unknown. Readmissions occur frequently in adult TBI survivors: approximately 21-28% within one year. No single existing U.S. database contains the necessary variables to study readmissions of children hospitalized after trauma. We previously demonstrated that probabilistic linkage with Markov chain Monte Carlo parameter refinement could accurately link records of children with severe TBI without using protected health information. That work was presented at the IHDLN Conference in 2014. The objectives of this study are to 1) expand the previous linkage to include children with any type of trauma and 2) to determine the 1-year rates of Emergency Department (ED) visit and hospital readmission in children with TBI versus other trauma.&#x0D; ApproachUsing the algorithm we reported previously, we linked the records of children hospitalized after trauma during 2007-2012 in the U.S. National Trauma Data Bank (NTDB) with the Pediatric Health Information System (PHIS) database. &#x0D; The NTDB contains the Glasgow Coma Scale (GCS), necessary to categorize TBI. The PHIS database contains a unique identifier for each patient at each hospital, making longitudinal studies possible. Probabilistic linkage was performed using LinkSolv (Strategic Matching, Inc., Morrisonville, NY). We identified ED visits and hospital readmissions of the index cohort in the PHIS database through March 31, 2015.&#x0D; ResultsAmong children hospitalized after acute trauma for &gt;= 2 days, we found that 83% of NTDB records linked accurately. Of the children hospitalized at 28 U.S. hospitals in 19 states, 49,477 were discharged alive; 15,438 had TBI. This represents approximately 10% of U.S. pediatric TBI hospitalizations during that period. The median age was 8 years and 64% were male. The 1-year hospital readmission rate was higher (12.2%, 283/2,306) in those with both TBI and other injuries than&#x0D; those with isolated TBI (8.5%, 1,120/13,132) or non-TBI injuries (8.1%, 2,790/34,039, p &lt; 0.01 across groups). The 1-year ED visit rate differed only modestly between those three groups (14.1% versus 15.4% versus 14.2%, p &lt; 0.01).&#x0D; ConclusionsThis study leverages two linked national datasets to investigate emergency care and hospital readmission in children who survive trauma. Multivariable analyses are ongoing and will be completed by August 2016. We will generate hypotheses about potentially modifiable causes of emergency care and readmission.

Specialist intervention is associated with improved patient outcomes in patients with decompensated heart failure: evaluation of the impact of a multidisciplinary inpatient heart failure team

ObjectiveThe study aimed to evaluate the impact of a multidisciplinary inpatient heart failure team (HFT) on treatment, hospital readmissions and mortality of patients with decompensated heart failure (HF).MethodsA retrospective service...

Readmissions After Surgical Resection of Metastatic Tumors of the Spine at a Single Institution

Surgical management of spinal metastasis is complex and can be associated with significant postoperative morbidity. Analyzing readmission rates may serve as a proxy for postoperative morbidity and functional decline, allowing patients and physicians to make informed decisions about treatment. Retrospective analysis was performed of patients with metastatic spine disease surgically treated at a tertiary center from 2003 to 2012. Patients with primary lung cancer, breast cancer, kidney cancer, bone marrow cancer, prostate cancer, gynecologic cancer, and melanoma were analyzed. Primary and secondary outcome variables were readmissions and overall survival. Multivariate Cox proportional hazards model was used to identify independent factors associated with readmissions. There were 159 patients analyzed. Lung, breast, and kidney represented the most common primary cancer sites, accounting for 22%, 19.5%, and 16.4%. Of patients, 56.6% had at least 1 readmission, with a 30-day readmission rate of 13.8% and 1-year readmission rate of 47.2%. Readmissions were for surgical complications (26.7%), oncologic disease progression (33.7%), and other medical reasons (36.7%). Patients with colorectal cancer had the highest number of readmissions. Patients with melanoma had more readmissions over the course of their limited postoperative survival. Overall mortality was 59.1%, with a median survival of 15.1 months. Multivariate analysis revealed age >60 years and previous radiation of the spine increased the likelihood of readmission. Readmissions provide an important window into understanding postoperative morbidity among patients with metastatic disease of the spine. This study offers an important starting point for understanding the nuances of patients' postoperative outcomes.

Relationship Between Severity Classification of Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Clinical Outcomes in Hospitalized Patients.

BackgroundLimited data are available regarding the impact of the potential validation of the Canadian Thoracic Society (CTS) guidelines recommendations in classifying patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in simple and complex. The aim of the present study was to assess the CTS recommendations regarding risk stratification on clinical outcomes among patients hospitalized with an AECOPD.MethodsWe developed a retrospective cohort study of patients admitted to one tertiary hospital with a diagnosis of AECOPD. The main clinical outcome was the percentage of treatment failure. Secondary outcomes were 30-day, 90-day, and 1-year readmission and mortality rate, length of stay in hospital, intensive care unit (ICU) admission rate, time to readmission, and time to death. Multivariate analyses were performed using 1-year mortality rate as the dependent measures.ResultsOne hundred forty-three patients composed the final study population, most of them (106 [74.1%)] classified as complex acute exacerbation (C-AE) of COPD. C-AE patients had similar rate of treatment failure compared with simple acute exacerbation (S-AE) of COPD (31.1% vs. 27%; p = 0.63). There were no differences regarding the length of stay in hospital, ICU admission rate, and 30-day, 90-day, and 1-year readmission rate. C-AE patients had faster declined measures on time to death (691.6 ± 430 days vs. 998.1 ± 355 days; p = 0.02). In the multivariate analysis, after adjusting for comorbidity, lung function and previous treatment, C-AE patients had a significant higher mortality at one year (Odds Ratio [OR] = 4.9 (Confidence Interval [CI] 95%: 1.16-21); p = 0.031).ConclusionsIn hospitalized patients with an AECOPD, CTS classification, according to the presence of risk factors, was not associated with worse short-term clinical outcomes although it is related with long-term mortality.

Presentation, Precipitants and Outcomes of Heart Failure and Preserved Ejection Fraction

Background: Although heart failure with preserved ejection fraction (HFpEF) is increasingly important, it has not been as well characterised as has heart failure with reduced ejection fraction (HFrEF). The aim of this study was to compare the precipitants, presenting symptoms, and outcomes of HFpEF versus HFrEF. We also investigated the long-term outcomes in response to medical therapy. Methods: We classified 5236 patients enrolled in the Management of Cardiac Failure (MACARF) program in Northern Sydney, into HFpEF (n = 1956, 37.3%) and HFrEF (n = 3280, 62.6%) patients using a cut-off left ventricular ejection fraction of 50%. Cox proportional hazards models were used for analysis of discharge medications. Results: Compared to HFrEF, the precipitant of hospitalisation for patients with HFpEF was more commonly infection (31.3% vs. 26.3%), and less likely to be ischaemia (18.7% vs. 23.3%). Although the predominant presenting symptom for all patients was dyspnoea, HFpEF patients were more likely to present with peripheral oedema (52.6% vs. 43.4%), whilst HFrEF patients were more likely to present with paroxysmal nocturnal dyspnoea, fatigue, weight gain, nausea and angina. Mortality rates at 30-days and 1-year were similar however HFpEF patients had higher 1-year readmission rates (45.4% vs. 40.7%) due to increased non-HF readmissions (34.7% vs. 29.8%). Adjusted hazard ratios showed improved survival for HFpEF patients discharged with beta blockers (HR 0.74; 95% CI: 0.60-0.88) and statins (HR 0.68; 95% CI: 0.53-0.88). Conclusion: Our study provides insight into differences between heart failure patients with preserved and reduced ejection fraction, and provides clues for prevention of hospitalisation and improved outcome.

Patterns of inpatient care for acute myocardial infarction and 30-day, 3-month and 1-year cardiac diseases readmission rates in Spain

BackgroundAcute myocardial infarction (AMI) is a common cause of hospital discharges and readmissions. Readmissions may indicate poor patient care and avoidable health expenditure, being key in quality improvement strategies. Our aim was to analyse cardiac diseases (CDs) readmissions in patients with AMI in Spain. MethodsA retrospective analysis of 33,538 hospital discharges with AMI being the “principal diagnosis” at hospitals of the Spanish National Health System in 2012 was performed using administrative data. We developed a logistic regression model and calculated 30-day, 3-month and 1-year CDs risk-standardized readmission rates (RSRRs) using a multivariate mixed model. ResultsVariables of the model (AMI location, age, previous angina pectoris/myocardial infarction or acute coronary syndrome, chronic kidney disease, rheumatic valvular disease, diabetes mellitus, vascular disease, female sex, chronic pulmonary disease, and anemia) were able to predict 30-day, 3-month and 1-year readmission rates and RSRRs after AMI (5.4%, 9.3% and 20.2%, respectively). For RSRRs the area under the ROC curve was 0.74 (p=0.0037), 0.77 (p=0.0041), and 0.73 (p=0.0025) for 1, 3months and 1-year readmission rate, respectively. Angioplasty, cardiology as the medical unit responsible for the discharge and a higher volume of activity (>204 AMI) were all significantly (p<0.001) associated with lower mortality, risk of development of heart failure and RSRRs. ConclusionsAngioplasty, cardiology as the medical unit responsible for the discharge and a higher volume of activity explain variability in CDs readmission rates after AMI, which can have implications for strategies to reduce readmissions rates.

Readmission Rates, Reasons, and Risk Factors in Elderly Patients Treated With Lumbar Fusion for Degenerative Pathology.

Retrospective database review. To determine readmission rates after 1 to 2 level, primary, elective lumbar spinal fusion surgery for degenerative pathology and elucidate risk factors that predict increased risk of 30-day readmission SUMMARY OF BACKGROUND DATA.: Early postoperative readmissions after spine surgery represent a significant source of increased cost and morbidity. As the elderly population represents a demographic with a growing need for spine surgery, readmissions within this population are of significant interest. Medicare data (2005-2012) from an insurance database was queried for patients who underwent primary 1 to 2 level posterolateral lumbar spine fusion surgeries for degenerative lumbar pathology. After applying specific exclusion criteria to select for elderly patients (65-84 yr) undergoing mostly elective procedures, 52,567 patients formed the final study population. Readmission rates for medical, surgical, and all reasons were calculated within 30 days, 90 days, and 1 year postoperatively. Risk factors for medical, surgical, and all 30-day readmissions were also determined. Within 30 days, 90 days, and 1 year, 1510 (2.9%), 2776 (5.3%), and 6574 (12.5%) patients were readmitted, respectively. At 30 days, surgical diagnoses constituted 50.1% of all readmissions. Wound infection was the reason for readmission in 25.8% of all readmissions within 30 days. Diagnoses of chronic pulmonary disease (OR 1.41 95% CI 1.22-1.63), obesity (OR 2.20 95% CI 1.90-2.54), and positive smoking history (OR 1.33 95% CI 1.15-1.54) were associated with increased risk of surgical readmission. Elderly patients undergoing lumbar spine fusion experience 30-day, 90-day, and 1-year readmission rates of 2.9, 5.3, and 12.5% for both medical and surgical reasons. Surgical site infection and wound complications are the most common surgery-related reasons for readmission. Medical diagnoses are more predominant during later readmissions, highlighting the comorbidity burden present in elderly patients. 4.

Association of 30-Day Readmission Metric for Heart Failure Under the Hospital Readmissions Reduction Program With Quality of Care and Outcomes

ObjectivesThis study sought to determine whether processes of care and long-term clinical outcomes for heart failure (HF) admissions across Get With The Guidelines-Heart Failure (GWTG-HF) program participating centers differ according to HF-specific risk-adjusted 30-day readmission rates (excess readmission ratio [ERR]) as determined by the Hospital Readmission Reduction Program (HRRP). BackgroundHRRP penalizes hospitals with higher than expected risk-adjusted 30-day readmission rates (ERR >1) for common conditions including HF. However, it is unclear whether the differences in this metric of hospital performance used by HRRP and related penalties are associated with measured quality of care and long-term outcomes. MethodsWe analyzed data from the GWTG-HF registry linked to Medicare claims from July 2008 to June 2011. Using publically available data on HF-ERR in 2013, we stratified the participating centers into groups with low (HF-ERR ≤1) versus high (HF-ERR >1) risk-adjusted readmission rates. We compared the care quality, in-hospital, and 1-year clinical outcomes across the 2 groups in unadjusted and multivariable adjusted analysis. ResultsThe analysis included 171 centers with 43,143 participants; 49% of centers had high risk-adjusted 30-day readmission rates (HF-ERR >1). There were no differences between the low and high risk-adjusted 30-day readmission groups in median adherence rate to all performance measures (95.7% vs. 96.5%; p = 0.37) or median percentage of defect-free care (90.0% vs. 91.1%; p = 0.47). The composite 1-year outcome of death or all-cause readmission rates was also not different between the 2 groups (median 62.9% vs. 65.3%; p = 0.10). The high HF-ERR group had higher 1-year all-cause readmission rates (median 59.1% vs. 54.7%; p = 0.01). However, the 1-year mortality rates were lower among high versus low HF-ERR group with a trend toward statistical significance (median 28.2% vs. 31.7%; p = 0.07). ConclusionsQuality of care and clinical outcomes were comparable among hospitals with high versus low risk-adjusted 30-day HF readmission rates. These findings raise questions about the validity of the HRRP performance metric in identifying and penalizing low-performance centers.

Sex-related Outcome Inequalities in Endovascular Aneurysm Repair

Women are known to have a higher rate of postoperative complications and mortality following open abdominal aortic aneurysm (AAA) repair. It is less clear whether this remains true of endovascular aneurysm repair (EVAR). This study examines the association between sex and hospital length of stay (LoS), readmission rates, and mortality following elective EVAR in the population of England between April 2006 and March 2015. Retrospective analysis of Hospital Episode Statistics (HES) was performed, including regression analysis of potential factors that may affect the primary outcomes (age, sex, deprivation, comorbidities and Trust volume). In total, 20,780 EVARs were performed in the time period, 11.2% (n=2,304) on women. The women were older (78 years [interquartile range {IQR} 74-82 years] vs. 76 years [IQR 70-80 years]; p<.001) and had a longer LoS (5 days [IQR 3-8 days] vs. 4 days [IQR 3-6 days]; p<.001). Women also had a higher readmission rate and mortality rate at both 30 days and 1 year. Following multivariate logistic regression, being female remained significantly related to poor outcome on all outcomes: LoS (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.69-2.05), 30-day readmission (OR 1.23, 95% CI 1.09-1.40), 1-year readmission (OR 1.16, 95% CI 1.06-1.28); 30-day mortality (OR 1.54, 95% CI 1.15-2.07), 1-year mortality (OR 1.24, 95% CI 1.06-1.45). Advancing age and increased comorbidity score were significantly related to longer LoS, higher readmission rates, and higher mortality. Deprivation score was associated with LoS and 1-year readmission rate but not with 30-day readmission and with increased mortality. Higher-volume Trusts (>50 EVARs per year) had higher readmission rates and 1-year mortality. These population-based data show that, following EVAR, women have a longer LoS and higher readmission and mortality than men. This reflects the same disparity in outcomes that is found in open AAA repair. Further work to clarify the cause of this is needed.