30-day All-cause Research Articles

Home Health Care Utilization Trend, Predictors, and Association With Early Rehospitalization Following Endovascular Transcatheter Aortic Valve Replacement

Background/purposeHome healthcare (HHC) utilization is associated with higher rates of rehospitalization in patients with heart failure and transcatheter mitral valve repair. This study sought to assess the utilization, predictors, and the association of HHC with 30-day readmission in patients undergoing transcatheter aortic valve replacement (TAVR). Methods/materialsWe queried the Nationwide Readmission Database from January 2012 to December 2017 for TAVR discharges with and without HHC referral. Using multivariate analysis, we identified predictors of HHC utilization, and its association with outcomes. ResultsOf 60,950 TAVR discharges, 21,724 (35.7%) had HHC referral. On multivariable analysis, female sex (OR, 1.34; 95% CI, 1.29–1.40), non-elective admission (OR, 1.49; 95% CI, 1.42–1.56), diabetes mellitus (OR, 1.09; 95% CI, 1.05–1.13), prior stroke (OR, 1.06; 95% CI, 1.01–1.12), anemia (OR, 1.16; 95% CI, 1.11–1.21), and in-hospital complications including cardiogenic shock (OR, 1.37; 95% CI, 1.16–1.50), cardiac arrest (OR, 1.22; 95% CI, 1.00–1.50), stroke (OR, 2.62; 95% CI, 2.20–3.18), and new Permanent pacemaker (OR, 1.49; 95% CI, 1.41–1.58) were identified as independent predictors of HHC referral. HHC utilization was associated with longer median length of stay (4 days vs. 2 days, P < 0.001), higher rate of 30-day all-cause (15.5% vs. 10.6%, P < 0.001) and heart failure (2.1%vs. 1.1%, P < 0.001) readmission rates compared to those without HHC. ConclusionsOur study identified a vulnerable group of TAVR patients that are at higher risk of 30-day readmission. Evidence-based interventions proven effective in reducing the burden of readmissions should be pursed in these patients to improve outcomes and quality of life.

Effects, trends, costs associated with readmission in early-aged patients with suicidal ideation

ABSTRACT Objective To examine determinants, trends, and costs associated with 30-day all-cause readmission (R) for suicidal ideation (SI) in early–aged patients. Methods This was a retrospective cohort study using the 2010–2014 Nationwide Readmissions Database. Discharge records for those aged 5–24 with an SI diagnosis were analyzed. Hierarchical models (HMs) were used to assess factors of R, length of stay (LOS), and total costs of Rs. Results There were 197,603 SI index admissions (IAs). Of these, 2% had a R. The annualized trend of R rates for all age groups remained constant. Those aged 13–18 had the highest rate of Rs, while IA and R mean total costs were highest for those aged 5–12 (IA, $4,546–$5,822; R, $5,361–$7,113). The strongest risk factors for increasing R included nonelective admission and private hospital ownership. The strongest risk factors for increasing LOS and cost were major/extreme severity of illness and 30-day all–cause R. The intracluster correlation coefficient for the HMs were 0.06, 0.33, and 0.55 for the R, LOS, and cost model, respectively. Conclusions The R rate was highest for those in the 13–18 age group, while the costs were highest for those aged 5–12.

Association of Dual Eligibility for Medicare and Medicaid With Heart Failure Quality and Outcomes Among Get With The Guidelines–Heart Failure Hospitals

The Centers for Medicare & Medicaid Services uses a new peer group-based payment system to compare hospital performance as part of its Hospital Readmissions Reduction Program, which classifies hospitals into quintiles based on their share of dual-eligible beneficiaries for Medicare and Medicaid. However, little is known about the association of a hospital's share of dual-eligible beneficiaries with the quality of care and outcomes for patients with heart failure (HF). To evaluate the association between a hospital's proportion of patients with dual eligibility for Medicare and Medicaid and HF quality of care and outcomes. This retrospective cohort study evaluated 436 196 patients hospitalized for HF using the Get With The Guidelines-Heart Failure registry from January 1, 2010, to December 31, 2017. The analysis included patients 65 years or older with available data on dual-eligibility status. Hospitals were divided into quintiles based on their share of dual-eligible patients. Quality and outcomes were analyzed using unadjusted and adjusted multivariable logistic regression models. Data analysis was performed from April 1, 2020, to January 1, 2021. The primary outcome was 30-day all-cause readmission. The secondary outcomes included in-hospital mortality, 30-day HF readmissions, 30-day all-cause mortality, and HF process of care measures. A total of 436 196 hospitalized HF patients 65 years or older from 535 hospital sites were identified, with 258 995 hospitalized patients (median age, 81 years; interquartile range, 74-87 years) at 455 sites meeting the study criteria and included in the primary analysis. A total of 258 995 HF hospitalizations from 455 sites were included in the primary analysis of the study. Hospitals in the highest dual-eligibility quintile (quintile 5) tended to care for patients who were younger, were more likely to be female, belonged to racial minority groups, or were located in rural areas compared with quintile 1 sites. After multivariable adjustment, hospitals with the highest quintile of dual eligibility were associated with lower rates of key process measures, including evidence-based β-blocker prescription, measure of left ventricular function, and anticoagulation for atrial fibrillation or atrial flutter. Differences in clinical outcomes were seen with higher 30-day all-cause (adjusted odds ratio, 1.24; 95% CI, 1.14-1.35) and HF (adjusted odds ratio, 1.14; 95% CI, 1.03-1.27) readmissions in higher dual-eligible quintile 5 sites compared with quintile 1 sites. Risk-adjusted in-hospital and 30-day mortality did not significantly differ in quintile 1 vs quintile 5 hospitals. In this cohort study, hospitals with a higher share of dual-eligible patients provided care with lower rates of some of the key HF quality of care process measures and with higher 30-day all-cause or HF readmissions compared with lower dual-eligibility quintile hospitals.

Dieulafoy’s lesion of the upper GI tract: a comprehensive nationwide database analysis

We sought to determine the incidence, risk factors, and treatment outcomes of Dieulafoy's lesion of the upper GI tract (UDL) hemorrhage among adult patients in the United States. UDL and non-Dieulafoy upper GI bleeding (UGIB) were identified from the Nationwide Inpatient Sample and Nationwide Readmission Database using International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding System codes. Multivariate logistic (binary) and linear (continuous) regressions were used to model dependent variables. The incidence of UDL hemorrhage was 1.6 of 100,000 persons. Patients with UDL and UGIB who required endoscopic therapeutic intervention had similar in-hospital (adjusted odds ratio [aOR], .77; 95% confidence interval [CI], .42-1.43; P= .41) mortality rates. UDL was associated with more severe systemic illness, including higher rates of mechanical ventilation (aOR, 1.52; 95% CI, 1.07-2.15; P< .05), hypovolemic shock (aOR, 1.50; 95% CI, 1.08-2.08; P< .05), acute kidney injury (aOR, 1.25; 95% CI, 1.02-1.54; P< .05), and multiple endoscopies (aOR, 1.57; 95% CI, 1.28-1.93; P< .05) compared with other UGIB patients who required endoscopic therapeutic intervention. UDL was also associated with higher 30-day all-cause (aOR, 1.23; 95% CI, 1.12-1.35; P< .05) and recurrent bleeding-related (aOR, 1.73; 95% CI, 1.45-2.06; P< .05) readmissions. The rate of successful endoscopic treatment was 96.81%. UDL hemorrhage is an uncommon but highly morbid condition. Current UDL treatment modalities are effective in reducing mortality. Further investigations are warranted to lower recurrent bleeding rates.

Patient Characteristics and Clinical Outcomes of Type 1 Versus Type 2 Myocardial Infarction

BackgroundType 2 myocardial infarction (MI) patients may have different characteristics and outcomes when compared with type 1 MI. ObjectivesThe purpose of this study was to compare patients with type 1 MI to those with type 2 MI in the United States. MethodsUsing the Nationwide Readmissions Database, MI patients were categorized over the 3 months following the introduction of an International Classification of Diseases-10th Revision code specific for type 2 MI. Baseline characteristics and inpatient and post-discharge outcomes among both cohorts were compared. ResultsThere were 216,657 patients with type 1 MI, 37,765 patients with type 2 MI, and 1,525 patients with both type 1 and 2 MI. Patients with type 2 MI were older (71 years vs. 69 years; p < 0.001), were more likely to be women (47.3% vs. 40%; p < 0.001), and had higher prevalence of heart failure (27.9% vs. 10.9%; p < 0.001), kidney disease (35.7% vs. 25.7%; p < 0.001), and atrial fibrillation (31% vs. 21%; p < 0.001). Rates of coronary angiography (10.9% vs. 57.3%; p < 0.001), percutaneous coronary intervention (1.7% vs. 38.5%; p < 0.001), and coronary artery bypass grafting (0.4% vs. 7.8%; p < 0.001) were lower among type 2 MI patients. Patients with type 2 MI had lower risk of in-hospital mortality (adjusted odds ratio: 0.57 [95% confidence interval: 0.54 to 0.60]) and 30-day MI readmission (adjusted odds ratio: 0.46 [95% confidence interval: 0.35 to 0.59]). There was no difference in risk of 30-day all-cause or heart failure readmission. ConclusionsPatients with type 2 MI have a unique cardiovascular phenotype when compared with type 1 MI, and are managed in a heterogenous manner. Validated management strategies for type 2 MI are needed.

Reducing Readmissions for Chronic Obstructive Pulmonary Disease in Response to the Hospital Readmissions Reduction Program.

Rationale: In August 2013, the Hospital Readmission Reduction Program announced financial penalties on hospitals with higher than expected risk-adjusted 30-day readmission rates for Medicare beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD) exacerbation. In October 2014, penalties were imposed. We hypothesized that penalties would be associated with decreased readmissions after COPD hospitalizations. Objectives: To determine whether the announcement and enactment of financial penalties for COPD were associated with decreases in hospital readmissions for COPD. Methods: We used data from California's Office of Statewide Health Planning and Development to examine unplanned 30-day all-cause and COPD-related readmissions after COPD hospitalization. The preannouncement period was January 2010 to July 2013. The postannouncement period was August 2013 to September 2014. The postenactment period was October 2014 to December 2017. Using interrupted time series, we investigated the immediate change after the intervention (level change) and differences in the preintervention and postintervention trends (slope change). Results: We identified 333,429 index hospitalizations for COPD from 449 California hospitals. Overall, 69% of patients had Medicare insurance. For all-cause readmissions, the level change at announcement was 0.16% (95% confidence interval [CI], -1.07 to 1.38; P = 0.80); the change in slope between preannouncement and postannouncement periods was -0.01% (95% CI, -0.15 to 0.13; P = 0.92). The level change at enactment was 0.29% (95% CI, -1.11 to 1.69; P = 0.68); the change in slope between postannouncement and postenactment was 0.04% (95% CI, -0.10 to 0.18; P = 0.57). For patients with COPD-related readmissions, the level change at the time of the announcement was 0.09% (95% CI, -0.68 to 0.85; P = 0.83); the change in slope was 0.003% (95% CI, -0.08 to 0.09; P = 0.94). The level change at the time of the enactment was 0.22% (95% CI, -0.69 to 1.12; P = 0.64); the change in slope was -0.02% (95% CI, -0.10 to 0.07; P = 0.72). Conclusions: We did not detect decreases in either all-cause or COPD-related readmission rates at either time point. Although this would suggest that the Hospital Readmission Reduction Program penalty was ineffective for COPD, COPD readmissions had decreased at an earlier time point (October 2012) when penalties were announced for conditions other than COPD. Based on this, we believe early, broad interventions decreased readmissions, such that no difference was seen at this later time points despite institution of COPD-specific penalties.

Risk Factors Associated With All-Cause 30-Day Mortality in Nursing Home Residents With COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has severely affected nursing homes. Vulnerable nursing home residents are at high risk for adverse outcomes, but improved understanding is needed to identify risk factors for mortality among nursing home residents. To identify risk factors for 30-day all-cause mortality among US nursing home residents with COVID-19. This cohort study was conducted at 351 US nursing homes among 5256 nursing home residents with COVID-19-related symptoms who had severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection confirmed by polymerase chain reaction testing between March 16 and September 15, 2020. Resident-level characteristics, including age, sex, race/ethnicity, symptoms, chronic conditions, and physical and cognitive function. Death due to any cause within 30 days of the first positive SARS-CoV-2 test result. The study included 5256 nursing home residents (3185 women [61%]; median age, 79 years [interquartile range, 69-88 years]; and 3741 White residents [71%], 909 Black residents [17%], and 586 individuals of other races/ethnicities [11%]) with COVID-19. Compared with residents aged 75 to 79 years, the odds of death were 1.46 (95% CI, 1.14-1.86) times higher for residents aged 80 to 84 years, 1.59 (95% CI, 1.25-2.03) times higher for residents aged 85 to 89 years, and 2.14 (95% CI, 1.70-2.69) times higher for residents aged 90 years or older. Women had lower risk for 30-day mortality than men (odds ratio [OR], 0.69 [95% CI, 0.60-0.80]). Two comorbidities were associated with mortality: diabetes (OR, 1.21 [95% CI, 1.05-1.40]) and chronic kidney disease (OR, 1.33 [95%, 1.11-1.61]). Fever (OR, 1.66 [95% CI, 1.41-1.96]), shortness of breath (OR, 2.52 [95% CI, 2.00-3.16]), tachycardia (OR, 1.31 [95% CI, 1.04-1.64]), and hypoxia (OR, 2.05 [95% CI, 1.68-2.50]) were also associated with increased risk of 30-day mortality. Compared with cognitively intact residents, the odds of death among residents with moderate cognitive impairment were 2.09 (95% CI, 1.68-2.59) times higher, and the odds of death among residents with severe cognitive impairment were 2.79 (95% CI, 2.14-3.66) times higher. Compared with residents with no or limited impairment in physical function, the odds of death among residents with moderate impairment were 1.49 (95% CI, 1.18-1.88) times higher, and the odds of death among residents with severe impairment were 1.64 (95% CI, 1.30-2.08) times higher. In this cohort study of US nursing home residents with COVID-19, increased age, male sex, and impaired cognitive and physical function were independently associated with mortality. Understanding these risk factors can aid in the development of clinical prediction models of mortality in this population.

Urgent transcatheter aortic valve replacement may be performed with acceptable long-term outcomes.

The wide availability of transcatheter aortic valve replacement (TAVR) and broadening of its indications to most patients with aortic stenosis may increase its utilization in the urgent setting. However, a comparison of long-term outcomes of patients undergoing urgent TAVR when compared to elective TAVR have not been well studied. All patients that underwent TAVR from 2011 to 2018 were included. Primary outcomes included operative (30-day), 1-, and 5-year survival and readmissions. The total patient population undergoing TAVR was divided into urgent (n = 247) and elective (n = 946) cohorts. Thirty days mortality (6.5% vs. 2.3%; p = .001), acute kidney injury (2.8% vs. 0.6%; p = .003), and length of stay (12 vs. 3 days; p < .001) were higher for the urgent cohort. There was no significant difference between cohorts for 30-day all-cause (14.6% vs. 10.8%; p = .097) readmissions. Freedom from readmission for heart failure at 1-year (73.6% vs. 83.4%; p < .001) was lower for the urgent cohort. One- (79.0% vs. 87.1%; p < .001) and five-year (39.6% vs. 43.5%; p = .005) survival was lower for the urgent cohort. This difference was eliminated after risk adjustment (hazard ratio [HR]: 1.3; p = .158 and HR: 1.1; p = .639, respectively). Unadjusted survival was significantly worse for the urgent cohort up to 1 year. This trend continued for 5-year survival, however, after risk adjustment there was no significant difference in survival between cohorts. Although urgent TAVR is associated with increased periprocedural risk due to more comorbid disease, outcomes and long-term survival are encouraging and support the consideration of urgent TAVR as a viable alternative for this patient population.

Abstract 15007: Association Of Dual Eligibility For Medicare And Medicaid With Heart Failure Quality And Outcomes Among Gwtg-hf Hospitals

Introduction: The Centers for Medicare &amp; Medicaid Services (CMS) is using a new peer group-based payment system to compare hospital performance which classifies hospitals into quintiles based on their share of dual eligible beneficiaries for Medicare and Medicaid. This study evaluated the association of percent dual eligibility for Medicare Medicaid with HF quality of care and outcomes. Methods: This is a retrospective analysis of patients hospitalized for HF using the Get With The Guidelines-HF (GWTG-HF) registry between July, 1 2010 - December 31, 2017. Study endpoints included HF process of care measures, in-hospital mortality, 30-day all-cause or HF readmissions, 30-day all-cause mortality. We included patients aged ≥65 years old with available data on dual eligibility status. Hospitals were divided into quintiles based on their share dual eligible patients. Quality and outcomes were analyzed using unadjusted and adjusted multivariable logistic regression models. Results: A total of 258,995 HF hospitalizations from 455 sites were included in the primary analysis of the study. Hospitals in the highest dual eligibility quintile (Q5) tended to care for patients who were younger, more likely female, belong to racial minority groups, or located in rural areas compared with Q1 sites. After multivariable adjustment, hospitals with the highest quintile of dual eligibility (Q5 sites) were associated with lower rates of key process measures including evidence-based beta blocker prescription (aOR: 0.70, 95% CI [0.52,0.94]), measure of left ventricular function (aOR: 0.39, 95% CI [0.21,0.72]), anticoagulation for atrial fibrillation or atrial flutter (aOR: 0.68, 95% CI [0.51,0.91]). Differences in clinical outcomes were seen with higher 30-day all-cause (aOR: 1.24, 95% CI [1.14,1.35]) and HF (aOR: 1.14, 95% CI [1.03,1.27]) readmissions in higher dual eligible Q5 sites compared to Q1 sites. Risk-adjusted in-hospital and 30-day mortality did not significantly differ in Q1 vs Q5 hospitals. Conclusions: Higher dual eligibility quintile sites were associated with lower rates of key HF quality of care process measures and higher 30-day all-cause or HF readmissions compared to lower dual eligibility quintile sites.

Measures of Care Coordination at Inpatient Psychiatric Facilities and the Medicare 30-Day All-Cause Readmission Rate.

Since late 2012, the Medicare Inpatient Psychiatric Facility Quality Reporting (IPFQR) program of the Centers for Medicare and Medicaid Services (CMS) has required inpatient psychiatric facilities to collect and publicly report a suite of quality measures. This study explored the association between facility-level 30-day risk-adjusted all-cause readmission (medical or psychiatric) after psychiatric hospitalization (READM-30-IPF) and care coordination process measures in the IPFQR program. The study used publicly reported IPFQR facility-level performance data of the Hospital Compare Web site for 1,343 inpatient psychiatric facilities, reflecting performance from July 2015 to June 2017. The authors used a cross-sectional design and linear regression models controlling for hospital and community characteristics and using state as fixed effect. The mean±SD facility-level READM-30-IPF was 20%±3%, with substantial variation by facility type, ownership status, rurality, and percentage of racial-ethnic minority residents in the county. Regression results showed that facilities with performance in the top tercile on the measure of 7-day mental health follow-up after discharge had readmission rates significantly lower than facilities in the bottom tercile (coefficient=-0.58, p<0.01), although the magnitude of this difference was small. READM-30-IPF, however, did not vary by facilities' performance on measures of discharge plan creation and transmission. Results suggest that facilities have substantial opportunities to reduce readmissions after psychiatric hospitalization. The association between hospital performance on care coordination process measures and the all-cause readmission measure currently included in the IPFQR program was minimal. The CMS should evaluate whether the IPFQR measures adequately capture compliance with evidence-based processes and desired outcomes.

Reducing 30-Day All-Cause Rehospitalizations: A Pharmacist-Led Telehealth Service

BACKGROUND: Use of skilled nursing facilities (SNFs) has grown as an intermediary step for patients unready to discharge to lower acuity care settings. Discharge planning from SNFs has become a critical component of the care continuum and may impact patient outcomes and facility payment status. Currently, the discharge process does not include a pharmacist-led comprehensive medication review.<br/> OBJECTIVES: To determine the impact of a pharmacistdriven discharge consultation service on 30-day allcause rehospitalization. Secondary outcomes included hospital readmission diagnosis, discharge consultation times, number of pharmacist interventions, and patient satisfaction.<br/> METHODS: The institutional review board approved this prospective cohort with a historical control pilot study to evaluate patients discharging from SNFs. Patients who provided informed consent were enrolled to participate in a video consultation service at the time of discharge. The primary outcome measured was 30-day hospital readmission rate postdischarge compared with one year prior.<br/> RESULTS: One hundred ninety-six counseling sessions were performed at three facilities. The average time per discharge was 15.4 ± 3.3 minutes, average number of medications was 15.5 ± 6.2, and average Charlson Comorbidity Index was 5.6 ± 2.2. Patient readmission data were tracked by diagnosis and reported by facility.<br/> CONCLUSION: A positive correlation between reduced readmission rates and participation in consultation service were observed. Second, positive patient satisfaction surveys indicated patients value medication education. The use of a pharmacist-led telehealth service like the one described in this study may lead to a reduction in facility readmission penalties and improve patient access to pharmacist services in remote locations.

Reducing 30-Day All-Cause Rehospitalizations: A Pharmacist-Led Telehealth Service.

BACKGROUND: Use of skilled nursing facilities (SNFs) has grown as an intermediary step for patients unready to discharge to lower acuity care settings. Discharge planning from SNFs has become a critical component of the care continuum and may impact patient outcomes and facility payment status. Currently, the discharge process does not include a pharmacist-led comprehensive medication review.<br/> OBJECTIVES: To determine the impact of a pharmacistdriven discharge consultation service on 30-day allcause rehospitalization. Secondary outcomes included hospital readmission diagnosis, discharge consultation times, number of pharmacist interventions, and patient satisfaction.<br/> METHODS: The institutional review board approved this prospective cohort with a historical control pilot study to evaluate patients discharging from SNFs. Patients who provided informed consent were enrolled to participate in a video consultation service at the time of discharge. The primary outcome measured was 30-day hospital readmission rate postdischarge compared with one year prior.<br/> RESULTS: One hundred ninety-six counseling sessions were performed at three facilities. The average time per discharge was 15.4 ± 3.3 minutes, average number of medications was 15.5 ± 6.2, and average Charlson Comorbidity Index was 5.6 ± 2.2. Patient readmission data were tracked by diagnosis and reported by facility.<br/> CONCLUSION: A positive correlation between reduced readmission rates and participation in consultation service were observed. Second, positive patient satisfaction surveys indicated patients value medication education. The use of a pharmacist-led telehealth service like the one described in this study may lead to a reduction in facility readmission penalties and improve patient access to pharmacist services in remote locations.

Etiologies, trends, and predictors of 30-day pediatric readmissions after hospitalizations for diabetic ketoacidosis in the United States.

To determine the causes, predictors, and trends of 30-day readmissions following hospitalizations for pediatric diabetic ketoacidosis (DKA) in the United States (US) from 2010 to 2014. We used International Classification of Diseases, ninth revision, Clinical Modification codes to identify children with DKA aged 2 to 18 years from the National Readmission Database in the US. Patients who had readmission within 30 days after an index admission for DKA were included in the study. We combined similar diagnoses into clinically important categories to determine the cause of readmission. The primary outcome was all-cause 30-day (AC30) readmissions. Categorical and continuous variables were analyzed using chi-square or student's t-test or Wilcoxon rank sum tests respectively. We performed multivariable logistic regression to identify predictors of 30-day readmission. From 2010 through 2014, a weighted total of 87 815 index DKA-related pediatric hospitalizations were identified of which, 4055 patients (4.6%) had AC30 readmissions and this remained unchanged during the study period. Of all the readmissions, 69% were attributed to DKA. In multivariable regression analysis, the odds of AC30 readmission and 30-day readmission attributed to DKA alone were increased for females, adolescents, patients with depression and psychosis, and discharge against medical advice, while private insurance, the highest income quartile, and admission at teaching hospitals were associated with lower odds of AC30 readmission and 30-day readmission attributed to DKA only. We identified several factors associated with readmission after hospitalization for DKA. Addressing these factors such as depression may help lower readmissions after an admission for DKA.

Weight change in heart failure inpatients not associated with 30-day readmission.

Background: The association of weight change and short-term readmission in patients hospitalized for heart failure (HF) has not been well studied. Methods: We collected clinical and weight data from patients admitted with decompensated HF to a single center (2012-2013). We performed logistic regression to determine the association between weight change and two outcomes: a total of30-day HF-specific readmission and 30-day all-cause readmission. Results: Admission and discharge weights were documented in 479/658 patients (73%). Weight loss >2kg was not associated with 30-day all-cause or HF-specific readmission when compared with more modest inpatient weight change (-2kg to+2kg;all-cause readmission odds ratio: 0.86; CI: 0.56-1.37; HF-specific readmission odds ratio: 1.15; CI: 0.61-2.16). Conclusion: Among HF inpatients, in-hospital weight loss was not associated with 30-day all-cause or HF-specific readmission.

The impact of changing reflexive to clinician-ordered Clostridioides difficile polymerase chain reaction (PCR) testing for indeterminate cases: Cost savings without associated adverse events.

To evaluate changing Clostridioides difficile infection (CDI) testing among inpatients with indeterminate enzyme immunoassay (EIA) results (antigen+/toxin-) from reflexive polymerase chain reaction (PCR) testing to clinician-ordered PCR testing. Multicenter, before-and-after, quasi-experimental study. Four large urban tertiary-care hospitals. We evaluated two 6-month periods before and after an intervention. The primary study outcome was the change in the number of CDI diagnoses between periods. Secondary outcomes included the number of PCR tests performed, adverse events, and healthcare cost savings. In total, 500 EIA-indeterminate C. difficile test results were evaluated: 281 before the intervention and 219 thereafter. CDI was diagnosed by PCR among EIA-indeterminate cases in 182 in the preintervention period versus 94 patients in the postintervention period (48% reduction; P < .01). PCR testing was performed in 99.6% of indeterminate cases (280 of 281; 1 not performed due to an inhibitor) in the preintervention period versus 66% (144 of 219) in the postintervention period (34% reduction; P < .01). We observed no differences between study periods in 30-day all-cause (P = .96), GI-related (P = .93), or C. difficile (P = .47) readmissions, nor in 30-day C. difficile infections (P > .99). No patient without a PCR test in the postintervention period and not treated was later diagnosed with CDI. Each reflexive PCR test not performed led to a cost savings of $4,498 per patient. Applying diagnostic stewardship to C. difficile PCR testing in the inpatient setting led to significant reductions in both testing and cases. Changing the C. difficile PCR testing algorithm for EIA-indeterminate cases from reflexive to clinician-required ordering resulted in valuable cost savings without associated adverse events.

Heart Failure Nurse Navigator Program Interventions Based on LACE Scores Reduces Inpatient Heart Failure Readmission Rates

Objective This presentation will identify top causes for Heart Failure (HF) patient readmissions and strategies for HF readmission prevention. The HF Nurse Navigator's role in preventing readmissions will be described. The implementation of the HF standard work discharge tool with seven interventions based on LACE scores used in the HF Nurse Navigator program will also be defined. Background Heart Failure continues to be one of the leading causes for hospitalization (national 30-day All-Cause HF readmission rates average: 22%). The goal of this community hospital is to decrease their average 30-day All-Cause HF patients' readmission rates from 21% to Problem Statement Increasing Heart Failure readmission rates due to avoidable readmission causes are unfavorable for our cardiac patients' quality of life and contribute to payment penalties. Methods The Heart Failure Nurse Navigator (HF NN) role was created at this hospital with the goal of decreasing readmissions and improving patient outcomes for the HF patient across the continuum of care. The HF NN is an expert clinician leader and a resource to the healthcare team in Progressive Care and other inpatient units through one-on-one HF education with the patient or significant other and assists in identification of services unique to each patient's needs for a smooth transition from hospital to home. New Nurse Leader roles such as an Advanced Practice Nurse Navigator equipped with Evidence Based knowledge and training is vital to oversee a specialized patient population in Acute Care; to design and implement interventions that can improve patient outcomes and decrease the patient's risk for readmission within 30 days. The HF NN in collaboration with the HF Team designed a Quality Improvement project implementing a HF Standard Work Discharge Checklist with seven patient interventions for the Acute Heart Failure patient. These interventions include: HF Teach-Back education; HF clinic referral; Outpatient pharmacy prescription delivery to bedside; Discharge Medication list education by the Pharmacist; Follow-up appointments made prior to discharge; Transitional Medical Clinic appointment within 5 days of discharge; and Home Health RN HF Medical Management. LACE (Length of-Stay, Acuity, Co-Morbidities and ED visits) scoring developed by Van Walvaren et al. (2010) was used to assess for readmission risk and to implement interventions specific for each HF patient based on their LACE score. Results This hospital's average 6-month All-Cause HF readmission rate decreased to 12.94% after the pilot of the HF Nurse Navigator program, vs. 21.1% pre-intervention. After the HF NN role was implemented, the average 6-month HF 30-day All-Cause readmission rate decreased by 39% postintervention over the 6-month pilot period. Conclusions The team-based HF Nurse Navigator interventions described when implemented for every Acute HF patient admission decreased HF readmission rates. There is a need to have 7-day a week coverage by a HF NN in an institution to ensure identification of services unique to each HF patient's complex needs. The HF NN can ensure that the HF patient has a smooth transition from hospital to home with these interventions, resulting in a decreased readmission risk.

PREDICTORS OF MORTALITY IN ACUTE CORONARY SYNDROME-RELATED CARDIOGENIC SHOCK REQUIRING SHORT-TERM MECHANICAL CIRCULATORY SUPPORT

Short-term mechanical circulatory support (MCS) is becoming increasingly utilized in acute coronary syndrome (ACS)-related refractory cardiogenic shock (rCS). Identifying patients at risk of short-term mortality can impact clinical management. We sought to identify predictors of 30-day all-cause

Admission Leukocyte Count is Associated with Late Cardiogenic Shock Development and All-Cause 30-Day Mortality in Patients with St-Elevation Myocardial Infarction.

Thirty-day mortality in ST-elevation myocardial infarction (STEMI) patients is primarily driven by cardiogenic shock (CS). High neutrophil counts and high neutrophil/lymphocyte ratios (NLR) have previously been associated with mortality in STEMI patients; however, there is only sparse knowledge regarding their association with CS. We sought to assess the associations between neutrophil count and NLR with the development of CS as well as 30-day mortality in STEMI patients. Patients admitted with STEMI at two tertiary Heart Centres throughout 1 year were included in the study and stratified into quartiles according to the level of leukocyte count upon admission. The primary endpoint was development of CS both before (early CS) and after leaving the catheterization laboratory (late CS). The secondary endpoint was all-cause 30-day mortality. A total of 1,892 STEMI patients were included, whereof 194 (10%) developed CS while 122 (6.4%) died within 30 days. Patients in the highest quartile of neutrophils (OR: 2.54; 95% CI: 1.40-4.60; P = 0.002) and NLR (OR: 3.64; 95% CI: 2.02-6.54; P<0.0001) were at increased risk of developing late CS compared with patients in the lower quartiles, whereas there was no risk difference across quartiles regarding development of early CS. Both biomarkers correlated strongly to an increased 30-day mortality (plogrank<0.0001) and, moreover, a high level of neutrophils was independently associated with 30-day mortality (HR: 1.95; 95% CI: 1.25-3.03; P = 0.003). High levels of neutrophils and a high NLR upon admission for STEMI were independently associated with an increased risk of developing late CS and, additionally, both biomarkers showed association to 30-day mortality.

The subclinical hypothyroid state might predict 30-day readmission in patients admitted with acute heart failure syndrome and reduced left ventricular ejection fraction.

Introduction:Thyroid hormone (TH) has an essential role on the functional capability of cardiac muscle with its gene modulation and induction of vasodilatory effects. There is considerable evidence to suggest the role of TH in patients with acute coronary syndrome, but less is known about its prognostic role in heart failure (HF) patients. We aim to evaluate the association between subclinical hypothyroid state (SCHS) and event rates including 30-day all-cause and HF readmission in patients with an index hospitalization for acute HF syndrome (AHFS).Methodology:A retrospective chart review analysis of 2335 patients admitted with the diagnosis of AHFS between 1 January 2007 and 31 December 2017 was conducted. SCHS was defined as thyroid-stimulating hormone (TSH) level >4.50 mIU/L with a normal thyroxine (T4) level. Patients with pre-existing thyroid disease or receiving thyroid replacement therapy were excluded. HF with preserved ejection fraction (HFpEF) was defined as left ventricular ejection fraction (LVEF) >40% and HF with reduced ejection fraction (HFrEF) was defined as having LVEF ⩽40%. Percentage of 30-day, 3-month and 6-month all-cause readmission and mortality rates were calculated in both cohorts of AHFS (HFpEF and HFrEF) with and without SCHS.Results:The mean age of the 2335 AHFS population was 65 (±14.8) years. Of the 2335 patients admitted with AHFS, 1228 (52.6%) patients were found to have HFrEF and 1107 (47.4%) with HFpEF. There were 170 (7.3%) patients with AHFS found to have SCHS. There were more males than females (54% versus 46%). The percentage of hospital readmission within 30 days was higher for patients with SCHS compared with those without SCHS in the HFrEF group (42% versus 30%, p = 0.001). Hospital readmission within 30 days for patients with SCHS compared with those without SCHS in the HFpEF group did not differ (36.5% versus 31%, p = 0.47). Additionally, all-cause mortality was higher among patients with SCHS compared with patients without SCHS in the HFrEF group (18.7% versus 7.0%, p < 0.001). All-cause mortality was found similar in both arms of the HFpEF group (9.5% versus 7.7%, p = 0.73).Conclusion:During an index hospital admission for AHFS, SCHS was an independent predictor of readmission in 30 days in patients with HFrEF but not in patients with HFpEF. Additionally, it was related to adverse outcome such as all-cause mortality in HFrEF patients but not in HFpEF patients. Further studies regarding the concept of tissue thyroid and the potential for a therapeutic target are warranted.

RACIAL DISPARITIES IN 30-DAY READMISSION RATES AMONG MEDICARE PATIENTS DISCHARGED TO SKILLED NURSING FACILITIES

The 30-Day All-Cause Readmission Measure is part of the Skilled Nursing Facility Value-Based Purchasing (SNFVBP) beginning 2019. The objective of the study was to characterize racial and ethnic disparities in 30-day rehospitalization rates from SNF among fee-for-service (FFS) and Medicare Advantage (MA) patients using the Minimum Data Set. The American Health Care Association risk-adjusted model was used. The primary independent variables were race/ethnicity and enrollment in FFS and MA. The sample included 1,813,963 patients from 15,412 SNFs across the US in 2015. Readmission rates were lower for whites. However, MA patients had readmission rates that were ~1 to 2 percentage points lower. In addition, we also found that African-Americans had higher readmission rates than whites, even when they received care within the same SNF. The inclusion of MA patients could change SNF penalties. Successful efforts to reduce rehospitalizations in SNF settings often require improving care coordination and care planning.