30-day Postdischarge Readmission Research Articles

Analysis of 30-day postdischarge morbidity and readmission after radical gastrectomy for gastric carcinoma: a single-center study of 2107 patients with prospective data.

PD morbidity and readmission pose a substantial clinical and economic burden to the healthcare system. Comprehensive PD complications and readmission data are essential for developing initiatives to improve patient care. No previous studies have extensively investigated PD complications after gastric cancer surgery.We investigated the incidence, types, treatment, and risk factors of 30-day postdischarge (PD) complications after gastric cancer surgery.Between 2010 and 2013, data concerning complications and readmission within 30 days of hospital discharge were prospectively collected in 2107 patients undergoing gastric cancer surgery.In total, 1642 patients (77.9%) underwent distal gastrectomy, 418 (19.8%) total gastrectomy, and 47 (2.3%) other procedures. Postoperative morbidity and mortality were 17.4% and 0.6%, respectively, with a mean 8.8-day hospital stay. Sixty-one patients (2.9%) developed 30-day PD morbidity (58 local and 3 systemic complications), accounting for 16.6% of overall morbidity; 47 (2.2%) were readmitted; and 7 (0.3%) underwent a reoperation. The mean time to PD complications was 9.5 days after index hospital discharge. The most common complication was intra-abdominal abscess (n = 14), followed by wound, ascites, and anastomosis leakage. No mortality occurred resulting from PD complications. In the univariate and multivariate analyses, underlying comorbidity (hypertension and liver cirrhosis) and obesity were independent risk factors for developing PD complications.The early PD period is a vulnerable time for surgical patients with substantial risk of complication and readmission. Tailored discharge plans along with appropriate PD patient support are essential for improving the quality of patient care.

The association of acute kidney injury in the critically ill and postdischarge outcomes: a cohort study*.

Hospital readmissions contribute significantly to the cost of inpatient care and are targeted as a marker for quality of care. Little is known about risk factors associated with hospital readmission in survivors of critical illness. We hypothesized that acute kidney injury in patients who survived critical care would be associated with increased risk of 30-day postdischarge hospital readmission, postdischarge mortality, and progression to end-stage renal disease. Two center observational cohort study. Medical and surgical ICUs at the Brigham and Women's Hospital and the Massachusetts General Hospital in Boston, Massachusetts. We studied 62,096 patients, 18 years old and older, who received critical care between 1997 and 2012 and survived hospitalization. None : All data was obtained from the Research Patient Data Registry at Partners HealthCare. The exposure of interest was acute kidney injury defined as meeting Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease Risk, Injury or Failure criteria occurring 3 days prior to 7 days after critical care initiation. The primary outcome was hospital readmission in the 30 days following hospital discharge. The secondary outcome was mortality in the 30 days following hospital discharge. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both acute kidney injury and readmission status. Adjustment included age, race (white vs nonwhite), gender, Deyo-Charlson Index, patient type (medical vs surgical) and sepsis. Additionally, long-term progression to End Stage Renal Disease in patients with acute kidney injury was analyzed with a risk-adjusted Cox proportional hazards regression model. The absolute risk of 30-day readmission was 12.3%, 19.0%, 21.2%, and 21.1% in patients with No Acute Kidney Injury, Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Injury, and Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Failure, respectively. In patients who received critical care and survived hospitalization, acute kidney injury was a robust predictor of hospital readmission and post-discharge mortality and remained so following multivariable adjustment. The odds of 30-day post-discharge hospital readmission in patients with Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Injury, or Failure fully adjusted were 1.44 (95% CI, 1.25-1.66), 1.98 (95% CI, 1.66-2.36), and 1.55 (95% CI, 1.26-1.91) respectively, relative to patients without acute kidney injury. Further, the odds of 30-day post-discharge mortality in patients with Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Injury, or Failure fully adjusted per our primary analysis were 1.39 (95% CI, 1.28-1.51), 1.46 (95% CI, 1.30-1.64), and 1.42 (95% CI, 1.26-1.61) respectively, relative to patients without acute kidney injury. The addition of the propensity score to the multivariable model did not change the point estimates significantly. Finally, taking into account age, gender, race, Deyo-Charlson Index, and patient type, we observed a relationship between acute kidney injury and development of end-stage renal disease. Patients with Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Injury, Failure experienced a significantly higher risk of end-stage renal disease during follow-up than patients without acute kidney injury (hazard ratio, 2.03; 95% CI, 1.56-2.65; hazard ratio, 3.99; 95% CI, 3.04-5.23; hazard ratio, 10.40; 95% CI, 8.54-12.69, respectively). Patients who suffer acute kidney injury are among a high-risk group of ICU survivors for adverse outcomes. In patients treated with critical care who survive hospitalization, acute kidney injury is a robust predictor of subsequent unplanned hospital readmission. In critical illness survivors, acute kidney injury is also associated with the odds of 30-day postdischarge mortality and the risk of subsequent end-stage renal disease.

Contemporary predictors of extended postoperative hospital length of stay after carotid endarterectomy

Hospital length of stay (LOS) contributes to costs. Carotid endarterectomy (CEA) is performed frequently by vascular surgeons, making contemporary CEA LOS rates and predictors vital knowledge for quality evaluation and cost containment initiatives. Using a prospective single-institution database, we retrospectively identified consecutive patients undergoing CEA from 2001 to 2011. Demographic and perioperative factors were prospectively collected. The primary end point was extended postoperative LOS (ELOS), defined as postoperative LOS ≥2 days. Factors associated with ELOS were analyzed in a multivariable logistic regression model. Rates of 1-year readmission and death were compared with the Kaplan-Meier method (log-rank test). Eight hundred forty patients underwent 897 CEAs with 39% of procedures among females and 35% for symptomatic disease. One hundred two (11.4%) patients were inpatients prior to the day of CEA ("preadmitted"); their preoperative days by definition are not included in ELOS. Median postoperative LOS was 1 day (interquartile range, 1-2). Four hundred fourteen patients (46.2%) had ELOS. Preadmission was associated with ELOS (72% vs 41%; P < .01) and ELOS patients were less likely to be discharged home (11.9% vs 1.5%; P < .01). There was no association between ELOS and unplanned 30-day postdischarge readmission (6.0% vs 7.0%; P = .59). On multivariable analysis, preoperative factors significantly associated with ELOS included preadmission (adjusted odds ratio [OR], 3.3; 95% confidence interval [CI], 1.9-5.7; P < .001), history of congestive heart failure (OR, 2.1; 95% CI, 1.1-4.2; P = .03), female gender (OR, 1.9; 95% CI, 1.4-2.6; P < .001), and history of chronic obstructive pulmonary disease (OR, 1.7; 95% CI, 1.0-2.9; P = .04). Operative factors included electroencephalography change (OR, 1.9; 95% CI, 1.2-3.2; P = .01), operating room start time after 12:00 pm (OR, 1.7; 95% CI, 1.2-2.4; P < .01), and total operating room time (OR, 1.5 per hour; 95% CI, 1.2-2.9; P < .01). Postoperative factors included transfer to intensive care unit (OR, 5.4; 95% CI, 3.1-9.4; P < .01), number of in-hospital postoperative complications (OR, 3.7; 95% CI, 2.2-6.5; P < .01), and Foley catheter placement (OR, 2.1; 95% CI, 1.3-3.4; P < .01). Over 1 year, ELOS was associated with increased hospital readmission (93.6% vs 84.7%; log-rank test, P < .01) and decreased survival (95.1% vs 98.3%; log-rank test, P < .01). Nearly half of CEA patients were discharged on or after postoperative day 2. Interventions on modifiable risk factors, such as early Foley catheter placement to prevent urinary retention and morning CEA scheduling, may decrease LOS. ELOS may identify a subset of patients at increased risk for long-term readmission and mortality.

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Introduction: Hospital readmissions contribute significantly to the cost of inpatient care and are targeted as a marker for quality of care. Little is known about risk factors associated with hospital readmission in survivors of critical illness. Methods: We studied 62,587 patients, age ≥ 18 years, who received critical care between 1997 and 2012 and survived hospitalization. The exposure of interest was acute kidney injury (AKI) defined as meeting RIFLE Risk, Injury or Failure criteria occurring 3 days prior to 7 days after critical care initiation. Patients with end stage renal disease prior to critical care initiation were identified by submitting the administrative data to the United States Renal Data System and excluded. In patients whom developed end stage renal disease following an AKI episode, the date chronic dialysis began was recorded. The primary outcome was unplanned hospital readmission in the 30 days following hospital discharge. The first hospitalization associated with critical care is identified as the index critical care exposure, and a 30-day unplanned readmission was defined as a subsequent unplanned admission to the hospitals under study within 30 days of discharge following the hospitalization associated with the index critical care exposure. Readmissions with DRG codes commonly associated with planned readmissions were excluded. The secondary outcome was mortality in the 30 days following hospital discharge. Information on vital status for the study cohort was obtained from the Social Security Administration Death Master File. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both AKI and readmission status. Adjustment included age, race (white versus non-white), gender, Deyo-Charlson Index, patient type (medical versus surgical) and sepsis. Additionally, long-term progression to End Stage Renal Disease in patients with AKI was analyzed with a risk-adjusted Cox proportional hazards regression model. Results: Most cohort patients were men (60%) and white (78%). 48% had medically related DRGs. The mean age at hospital admission was 57 (SD 18) years. 30-day post-discharge hospital readmission rate was 13% and the 30-day post-discharge mortality rate was 3%. In patients who received critical care and survived hospitalization, AKI was a robust predictor of unplanned hospital readmission and post-discharge mortality and remained so following multivariable adjustment. The odds of 30-day post-discharge hospital readmission in patients with RIFLE class Risk, Injury or Failure fully adjusted were 1.44 (95%CI, 1.25, 1.66), 1.98 (95%CI, 1.66, 2.36), and 1.55 (95%CI, 1.26, 1.91) respectively, relative to patients without AKI. Further, the odds of 30-day post-discharge mortality in patients with RIFLE class Risk, Injury or Failure fully adjusted per our primary analysis were 1.39 (95%CI, 1.28, 1.51), 1.46 (95%CI, 1.30, 1.64), and 1.42 (95%CI, 1.26, 1.61) respectively, relative to patients without AKI. Finally, taking into account age, gender, race, Deyo-Charlson Index, and patient type (medical versus surgical), we observed a relationship between AKI and development of End Stage Renal Disease. Patients with RIFLE class Risk, Injury, Failure experienced a significantly higher risk of End Stage Renal Disease during follow-up than patients without acute kidney injury (HR 2.03, 95% CI, 1.56, 2.65; HR 3.99, 95%CI, 3.04, 5.23; HR 10.40, 95%CI, 8.54, 12.69 respectively). Conclusions: Patients who suffer acute kidney injury during critical illness are among a high-risk group of ICU survivors for adverse outcomes. In patients treated with critical care who survive hospitalization, acute kidney injury is a robust predictor of subsequent unplanned hospital readmission. In critical illness survivors, acute kidney injury is also associated with the odds of 30-day post-discharge mortality and the risk of subsequent End Stage Renal Disease.

Changes in Heart Failure Outcomes After a Province-Wide Change in Health Service Provision A Natural Experiment in Alberta, Canada

The Alberta Cardiac Access (ACA) initiative was implemented in the spring of 2008 to increase access to specialized heart failure (HF) clinics after hospital discharge. We identified all adults hospitalized with a most responsible diagnosis of HF between April 1999 and December 2009. We randomly selected 1 episode of care per patient and evaluated outcomes using interrupted time series: the a priori specified primary outcome was all-cause readmission or death in the first 30 days postdischarge. Between 1999 and 2009, median length of stay increased from 8 days to 10 days (P<0.001), and 30-day mortality increased from 9.1% to 11.5% (P<0.001) in the 37891 HF hospitalizations we examined. However, these temporal changes were attributable to the increasing comorbidity burden over time: the adjusted Risk Ratio for 30-day mortality in 2009 versus 1999 was 0.99, 95% confidence interval, 0.86 to 1.15. After adjusting for secular trends, the ACA initiative was associated with changes in 30-day postdischarge mortality or readmission rates (which were increasing 0.3% per month [0.2%-0.3%] pre-ACA and decreased 1.4% per month [0.3%-2.5%] in the 18 months post-ACA; P=0.008). After roll out of the ACA initiative, patients discharged from vanguard regions (those that had specialized HF clinics) exhibited lower 30-day postdischarge death/readmission rates than those discharged from other areas of the province (18.6% versus 22.2%, adjusted odds ratio 0.83, 95% confidence interval, 0.75-0.93). An initiative which increased specialized HF clinic access was associated with a statistically significant improvement in 30-day postdischarge mortality/readmission rates.

The effect of pharmacotherapeutic counseling on readmissions and emergency department visits

To evaluate the impact of pharmacotherapeutic counseling on the rates and causes of 30-day post-discharge hospital readmissions and emergency department visits. The study was conducted at the Medical Clinic of University Hospital Dubrava, Zagreb, Croatia. The study included elderly patients prescribed with two or more medications for the treatment of chronic diseases. The patients randomized into the intervention group received pre-discharge counseling by the clinical pharmacologist about each prescribed medication. The control group received no counseling. The rates and causes of 30-day postdischarge hospital readmissions and emergency department visits. Medication compliance was also evaluated, using the pill count method. A total of 160 patients were randomly selected for the study. No significant difference was found in the readmission and emergency department visit rates between the intervention and control groups (p = 0.224). There were 34.9 % more compliant patients in the intervention group. Significantly more non-compliant patients in the control group were readmitted or visited emergency department because of the disease progression (p = 0.031). In the intervention group, significantly more patients were readmitted or visited emergency department because of an adverse drug reaction (p = 0.022). Pharmacotherapeutic counseling can reduce readmission and emergency department visit rates for disease progression. Improved patient knowledge about adverse drug reactions could be the reason for increased rates of readmissions and emergency department visits due to adverse drug reactions in the intervention group.

Hospitalizations for Heart Failure in the United States—A Sign of Hope

HEART FAILURE (HF) IS THE MOST COMMON CAUSE OF hospitalization in patients older than 65 years in the United States. In the early 1990s, data from clinical trials and registries demonstrated that in patients hospitalized with HF, mortality and rehospitalization rates could be as high as 15% and 30%, respectively, at 60 to 90 days after discharge. During this period, major efforts were directed toward reducing the length of stay in patients hospitalized with HF. Performance measures were developed and later adopted by the Centers for Medicare & Medicaid Services (CMS) with the intent to improve postdischarge outcomes. Although these measures were implemented across the country, the rehospitalization rate for patients with HF did not appear to decrease. Recently, because of changes in CMS reimbursement patterns, the focus has shifted toward 30-day postdischarge readmission rates as a measure of care. In this issue of JAMA, Chen et al reviewed administrative data of more than 55 million Medicare fee-for-service beneficiaries,withameanageof79years,whowerehospitalizedwith a discharge diagnosis of HF. Black patients represented 11% of the total studypopulation.Theoverall ratesof risk-adjusted hospitalizationforHFdeclined30%over thestudyperiodfrom 2845 per 100 000 person-years in 1998 to 2007 per 100 000 person-years in2008.Theauthorsattribute thisdecline inhospitalizations to reductions in the incidence of coronary artery disease, improved control of blood pressure, increased use of evidence-based therapies, and possibly changes in admission thresholds. In contrast to this significant reduction in hospitalizations forHF,1-year risk-adjustedall-causemortality rate declined minimally but remained high at approximately 30%. This report is a substantial contribution to existing HF epidemiological literature because it is the first to document an improvementinhospitalizationrates inHFintheUnitedStates. These improvementsappear tobemoreevident inrecentyears during which major progress has been made in promoting evidence-basedtherapies forcoronaryarterydisease.However, thissubstantialdecline inhospitalizationrateswassignificantly less in black men than in white men. Another important observation was that the decreases in hospitalization rates across states were not uniform. The authors also noted that comorbidities such as hypertension and renal dysfunction increased over time. Approximately 40% of these patients had diabetes and 30% had chronic obstructive pulmonary disease. The general reduction in admission rates may reflect improvements in overall management of HF risk factors, as suggested by Chen et al, but the persistently high 1-year mortality rates suggest that postdischarge practices for patients with HF have not been as effective. Although the admission rates for HF have decreased based on Medicare data reported by Chen et al, the available data suggest that rehospitalization rates after an index admission for HF have remained unchanged or have even increased over a similar time frame. It is important to recognize that among patients discharged following hospital admission for HF, a significant number of rehospitalizations are not related to HF. In the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome StudywithTolvaptan) trial conducted inpatientsadmitted for worsening HF with reduced ejection fraction, the total rehospitalizationrateexceeded50%at9.9months,andless thanhalf of rehospitalizations were due to HF. This occurred despite the studypopulationbeing relativelyyoung forHF(meanage, 62years),withfewmajorcomorbidconditions.IntheDIG(Digitalis Investigation Group) ancillary trial that studied outpatients with HF and preserved ejection fraction, the total hospitalization rate exceeded 65% during a mean follow-up of 37 months.Ofthesehospitalizations,only35%wererelatedtoHF. Inbothstudies,totalcardiovascularhospitalizationsrepresented a large proportion of the hospitalizations. Targeting total rehospitalization rather than rehospitalization for HF rates may be especially important given the aging population and their associated cardiac and noncardiac comorbid conditions. Chen et al suggested that the reduction in HF admissions may be related to changes in the threshold for admission in emergency departments. Lee et al reported that patients with HF who were discharged home directly from the emergency department, representing 30% of total HF presentations in their cohort, had a high risk-adjusted early death compared with patients who were admitted. If the reduction in number of hospitalizations noted by Chen et al is

Elective Surgery for Diverticulitis is Associated with High Risk of Intestinal Diversion and Hospital Readmission in Older Adults

PurposeThis study seeks to compare outcomes (in-hospital mortality, colostomy rates, and 30-day readmission rates) in older adult patients undergoing emergency/urgent versus elective surgery for diverticulitis. MethodsData were derived from the 100% Medicare Provider Analysis and Review (MEDPAR) inpatient file from 2004–2007. All patients 65 years of age and above with a primary diagnosis of diverticulitis that underwent left colon resection, colostomy, or ileostomy were included. The primary outcome variable was in-hospital mortality. Secondary outcome variables included intestinal diversion, 30-day post-discharge readmission rates, discharge destination, length of stay, and total charges. Patients were grouped in two categories for comparison: emergent/urgent (EU) versus elective surgery, as defined by admission type. Multivariate analysis was performed adjusting for age (categorized by five groups), gender, race, and medical comorbidity as measured by Charlson Index. ResultsFifty-three thousand three hundred sixteen individuals were eligible for inclusion, with 23,764 (44.6%) in the elective group. On average, EU patients were older (76.8 vs. 73.9 years of age, p < 0.001) and less likely to be female (65.4% vs. 71.1%, p < 0.001). EU patients had higher in-hospital mortality (8.0% vs. 1.4%, p < 0.001), higher intestinal diversion rates (64.2% vs. 12.7%, p < 0.001), and higher 30-day readmission rates (21.4% vs. 11.9%, p < 0.001) and the worse outcomes persisted even after adjustment for risk factors. Unadjusted and adjusted mortality rates dramatically increased by age, although the affect of age on mortality was more pronounced in the elective group where mortality rates ranged from 0.56% in patients 65–69 years old to 6.5% in patients 85+ years old. The rates of ostomy and 30-day readmission generally increased with age, with worse outcomes noted particularly in the elective group. ConclusionsAs expected, older adults undergoing emergent/urgent surgical treatment for diverticulitis have significantly increased risks of poor outcomes compared with elective patients. While advancing age is associated with a substantial increase in mortality, intestinal diversion and 30-day readmission after surgery for diverticulitis, this affect is especially evident among patients undergoing elective colectomy. Our data suggest that given the considerable risk of prophylactic colon resection in elderly patients with sigmoid diverticulitis, a reappraisal of the proper role of elective colectomy in this population may be warranted.

Higher age predicts adverse outcome and readmission after coronary artery bypass grafting.

The present prospective clinical study was carried out to investigate the effect of age on mortality, morbidity, and readmission rates after coronary artery bypass grafting (CABG). Data on 1131 consecutive CABG patients were collected in a surgical center and in all 18 secondary referral hospitals up to 3 months after discharge. Analysis was based on three age groups: 64 years or less (510 patients), 65 to 74 years (448 patients), and 75 years or more (173 patients). Thirty-day mortality rates were 1.6% for the youngest, 5.4% for the middle age group, and 6.9% for the oldest. Major complications occurred in 10.8%, 21.2%, and 24.9% of these patients, respectively. Higher age was associated with more readmissions to health care facilities: The oldest patients had a rate twice as high as those in the youngest group (34.5% vs. 18.6%). Atrial fibrillation (15.4%), chest pain (10.6%), and congestive heart failure (8.5%) were the most common reasons for readmission. In conclusion, elderly patients, who are often suboptimal candidates for CABG, have higher 30-day mortality, higher morbidity, longer length of stay in health care facilities, and an increased risk of readmission within 3 months after CABG; age was an independent predictor of 30-day mortality and postdischarge readmission. Despite the higher risk of adverse events after surgery, three out of four elderly patients recover uneventfully.