30-d Readmission Rates Research Articles

The Optimal Length of Stay Associated With the Lowest Readmission Risk Following Surgery

BackgroundIndex length of stay (LOS) and readmissions are viewed as important quality measures. However, these metrics represent competing demands as an inordinate reduction in LOS may lead to unplanned readmissions. We sought to assess the optimal LOS associated with the lowest 90-d readmission rate following discharge after common surgical procedures. Materials and methodsThis was a retrospective study relying on Tricare claims. We identified all eligible adult patients (18-64 y) receiving a series of common surgical procedures between 2006 and 2014. We used a generalized additive model with spline regression to determine the optimal LOS associated with the lowest 90-d risk of readmission. ResultsNinety-day readmission rates varied from 6.03% to 34.69%. Most procedures exhibited a logit linear relationship, with the lowest risk of readmission evident on postoperative day-1 and increasing thereafter. Among the more invasive procedures (e.g., esophagectomy and radical cystectomy), a U-shaped relationship was realized, indicating that expedited discharge would increase the potential for readmission as would any extended hospital LOS. For these procedures, the ideal index LOS appeared to be 6-7 d for radical cystectomy and 12-13 d for esophagectomy. ConclusionsOur results support the practice of discharging patients as soon as clinically feasible after hip and knee arthroplasty, lumbar spine surgery, hernia repair, appendectomy, nephrectomy, and colectomy. Among esophagectomy or radical cystectomy, there is a well-defined optimal index admission period and discharge outside this window appears to be detrimental. Our results suggest that invasive procedures appear to possess a unique “signature” when it comes to optimal LOS.

Comparison of implant related complications amongst patients with opioid use disorder and non-users following total knee arthroplasty.

BACKGROUNDThe influence of opioid use disorder on implant related complications, infection and readmission rates, and total global episode-of-care costs following primary total knee arthroplasty (TKA) is limited.AIMTo examine whether opioid abuse in patients undergoing primary TKA.METHODSA retrospective analysis of the Medicare dataset, using the PearlDiver database, from 2005-2014 comparing outcomes in patients with opioid abusers (OUD) to non-opioid abusers (NOU) undergoing primary TKA was performed. Patient outcomes were analyzed including implant complications, readmission rates, and day-of-surgery and 90-d cost. Statistical analysis was performed with R (University of Auckland, New Zealand) calculating odds-ratio (OR) along with their respective 95% confidence interval (95%CI) and P-values.RESULTSThe OUD group was at greater odds of having implant related complications overall (20.84% vs 11.25%; OR: 2.07; 95%CI: 1.93-2.23; P < 0.001). Revision (OR: 2.07; 95%CI: 1.11-3.84; P < 0.001), infection (OR: 1.92; 95%CI: 1.72–2.18; P < 0.001), periprosthetic fractures (OR: 1.83; 95%CI: 1.16-4.79; P < 0.001), and 90-d readmission rates (OR: 1.47, 95%CI: 1.35-1.61, P < 0.001) were also significantly increased. OUD patients also incurred in higher day-of-surgery and total global 90-d episode-of-care costs compared to NOU.CONCLUSIONPatients with OUD show an increased risk of complications compared to the non-opioid users group. Appropriate recognition, pre-surgical optimization, and patient education are essential to mitigate these complications and improve patient outcome.

Increased Hospital Surgical Volume Reduces Rate of 30- and 90-Day Readmission After Acoustic Neuroma Surgery

Hospital readmissions are commonly linked to elevated health care costs, with significant financial incentive introduced by the Affordable Care Act to reduce readmissions. To study the association between patient, hospital, and payer factors with national rate of readmission in acoustic neuroma surgery. All adult inpatients undergoing surgery for acoustic neuroma in the newly introduced Nationwide Readmissions Database from 2013 to 2014 were included. We identified readmissions for any cause with a primary diagnosis of neurological, surgical, or systemic complication within 30- and 90-d after undergoing acoustic neuroma surgery. Multivariable models were employed to identify patient, hospital, and administrative factors associated with readmission. Hospital volume was measured as the number of cases per year. We included patients representing a weighted estimate of 4890 admissions for acoustic neuroma surgery in 2013 and 2014, with 355 30-d (7.7%) and 341 90-d (9.1%) readmissions. After controlling for patient, hospital, and payer factors, procedural volume was significantly associated with 30-d readmission rate (OR [odds ratio] 0.992, p = 0.03), and 90-d readmission rate (OR 0.994, p = 0.047). The most common diagnoses during readmission in both 30- and 90-d cohorts included general central nervous system complications/deficits, hydrocephalus, infection, and leakage of cerebrospinal fluid (rhinorrhea/otorrhea). After controlling for patient, hospital, and payer factors, increased procedural volume is associated with decreased 30- and 90-d readmission rate for acoustic neuroma surgery. Future studies seeking to improve outcomes and reduce cost in acoustic neuroma surgery may seek to further evaluate the role of hospital procedural volume and experience.

Readmission Following Surgical Resection for Intractable Epilepsy: Nationwide Rates, Causes, Predictors, and Outcomes.

Hospital readmissions can be detrimental to patients and may interfere with the potential benefits of the therapeutic procedure. Government agencies have begun to focus on reducing readmissions; however, the etiology of readmissions is lacking. To report the national rates, risk factors, and outcomes associated with 30- and 90-d readmissions following surgery for intractable epilepsy. We queried the Nationwide Readmissions Database from January to September 2013 using International Classification of Diseases, Ninth Edition, Clinical Modification codes to identify all patients with intractable epilepsy, who underwent hemispherectomy (01.52), brain lobectomy (01.53), amydalohippocampectomy, or partial lobectomy (01.59). Predictor variables included epilepsy type, presurgical diagnostic testing, surgery type, medical complications, surgical complications, and discharge disposition. In 1587 patients, the 30- and 90-d readmission rates were 11.5% and 16.8%, respectively. The most common reasons for readmission were persistent epilepsy, video electroencephalography monitoring, postoperative infection, and postoperative central nervous system complication. In multivariable analysis, risk factors associated with both 30- and 90-d readmission were Medicare payer status, lowest quartile of median income, depression, hemispherectomy, and postoperative complications (P<.05). The only unique predictor of 30-d readmission was small bedsize hospital (P=.001). Readmissions within 30 d were associated with longer length of stay (6.8 vs 5.8 d), greater costs ($18 660 vs $15 515), and increased adverse discharges (26.4% vs 21.8%). Following epilepsy surgery, most readmissions that occurred within 30 d can be attributed to management of persistent epilepsy and predicted by Medicare payer status, depression, and complications. These data can assist the clinician in preventing readmissions and assist policy makers determine which admissions are potentially avoidable.

Abstract TP374: Implementation of Stroke Pathways to Reduce Length of Stay, Cost, Readmissions, and Mortality

Introduction: Acute stroke is a major contributor to healthcare costs. In 2012, estimated direct costs associated with stroke was $71B, which is projected to double to $184B by 2030. As healthcare evolves and reimbursements decrease, cost control in disease specific populations is critical. In January 2017, length of stay (LOS) peaked at 5.25 days, as did variable and total cost/case (Table). In fiscal year 2017 the 30-d readmission rate was 9% and the mortality rate was 12%. Compliance with stroke admission order sets was at 55%. Methods: A multidisciplinary committee was formed in February 2017 to develop standardized, evidence-based clinical pathways for three populations: Ischemic stroke (IS) treated with IV tPA, TIA/IS without IV tPA, and intracerebral hemorrhage. The team met biweekly to standardize clinical pathways, decrease time to follow-up imaging, focus on physician order set utilization, and control costs. A comprehensive education program for all clinical staff was completed; official implementation of the pathways was in November 2017. Pathways are discussed in stroke multidisciplinary rounds and rapid discharge rounds daily to ensure compliance and identify opportunities for improvement. We reviewed a retrospective financial report of all in-hospital cases coded as MS-DRG 61-69 from 12/2017 through 6/2018 and compared it the 1/2017 report. Results: A total of 83 cases where available for 1/2017 and of 456 for 12/2017 through 6/2018. There was a reduced LOS by 10% (4.74 days), reduced variable cost/case by 24% ($5,958), reduced total cost/case by 23% ($13,790), reduced the 30-d readmission rate to 6%, and reduced the mortality rate to 9%. Case mix index was 6% higher at 1.2753 (vs. 1.2055 previously). Order set compliance improved to 91% (Table). Discussion: Standardization of stroke clinical pathways led to improved order set compliance, almost ¼ reduction in variable and total costs per case, shortened LOS, and reduced mortality and readmission rates.

Interhospital Variability in Quality Outcomes of Pancreatic Surgery

BackgroundAssessment of optimal patient outcomes from health care delivery is critical for success amidst current reform. We developed a composite index of quality for pancreaticoduodenectomy (PD) and compared high and low performers nationwide. MethodsWe performed a retrospective analysis of 17,220 patients undergoing elective PD between October 2010 and June 2014 using the Vizient database. A quality index score (QIS) was developed from five variables associated with optimal outcomes: postoperative complication rate, length of stay, 30-d readmission rate, mortality rate, and hospital volume. Value was defined as hospital-based QIS divided by mean hospital charges. High-value centers (top quintile) were compared to low-value centers (bottom quintile). ResultsThe majority of high-value centers (79%) achieved top performer status in 1-2 of five quality categories though only 11% were low performer in at least one category. Conversely, 41% of low-value centers were top performers in at least one category, although rarely more than one (8%); 63% of low-value centers were low performers in two or more categories. There was no significant association between QIS and hospital charges (−570, 95% CI −1308 to 168, P = 0.13). ConclusionsHigh-value centers infrequently provided high quality surgical care across all five metrics but instead excelled in a few quality metrics while avoiding low performance in any quality metric. Although low-value centers could achieve excellence in one quality metric, they were frequently low performers in two or more outcomes. Improvements in value of PD can be achieved by a consistent effort across all quality metrics rather than efforts at constraining financial expenditures of health care delivery.

Variability in Partial Nephrectomy Outcomes: Does Your Surgeon Matter?

BackgroundUnderstanding physician-level discrepancies is increasingly a target of US healthcare reform for the delivery of quality-focused patient care. ObjectiveTo estimate the relative contributions of patient and surgeon characteristics to the variability in key outcomes after partial nephrectomy (PN). Design, setting, and participantsRetrospective review of 1461 patients undergoing PN performed by 19 surgeons between 2011 and 2016 at a tertiary care referral center. InterventionPN for a renal mass. Outcomes measurements and statistical analysisHierarchical linear and logistic regression models were built to determine the percentage variability contributed by fixed patient and surgeon factors on peri- and postoperative outcomes. Residual between- and within-surgeon variability was calculated while adjusting for fixed factors. Results and limitationsOn null hierarchical models, there was significant between-surgeon variability in operative time, estimated blood loss (EBL), ischemia time, excisional volume loss, length of stay, positive margins, Clavien complications, and 30-d readmission rate (all p<0.001), but not chronic kidney disease upstaging (p=0.47) or percentage preservation of glomerular filtration rate (p=0.49). Patient factors explained 82% of the variability in excisional volume loss and 0–32% of the variability in the remainder of outcomes. Quantifiable surgeon factors explained modest amounts (10–40%) of variability in intraoperative outcomes, and noteworthy amounts of variability (90–100%) in margin rates and patient morbidity outcomes. Immeasurable surgeon factors explained the residual variability in operative time (27%), EBL (6%), and ischemia time (31%). ConclusionsThere is significant between-surgeon variability in outcomes after PN, even after adjusting for patient characteristics. While renal functional outcomes are consistent across surgeons, measured and unmeasured surgeon factors account for 18–100% of variability of the remaining peri- and postoperative variables. With the increasing utilization of value-based medicine, this has important implications for the goal of optimizing patient care. Patient summaryWe reviewed our institutional database on partial nephrectomy performed for renal cancer. We found significant variability between surgeons for key outcomes after the intervention, even after adjusting for patient characteristics.

Thirty-day Readmission Rates for Carotid Endarterectomy Versus Carotid Artery Stenting

BackgroundBecause of the emergence of readmission-related Medicare penalties, efforts are being made to identify and reduce patient readmissions. The purpose of this study was to compare rates and risk factors for 30-d readmission and hospital length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) among patients treated for carotid artery stenosis in Pennsylvania. Materials and methodsData were from the Pennsylvania Health Care Cost Containment Council (PHC4). We identified 15,966 patients who underwent CEA (n = 13,557) or CAS (n = 2409) in Pennsylvania between 2011 and 2014. Logistic regression was used to determine risk factors for 30-d readmission, whereas linear regression was used to model factors influencing LOS. Propensity score analysis was used to control for imbalanced covariates between procedures. ResultsThirty-day readmission rates in Pennsylvania after CEA and CAS for carotid artery stenosis were similar (9.8% and 9.6%, respectively; P = 0.794). Not home discharge destination, Charlson comorbidity index ≥2, and LOS >1 d were all significantly associated with readmission risk. Procedure type (CEA or CAS) did not significantly influence risk. A significant difference in LOS was found between CEA and CAS, but the magnitude of the difference was small (2.38 for CAS versus 2.59 for CEA; P = 0.007). Black race, urgent and emergent cases, and not home discharges significantly increased LOS by notable amounts (1, 1.5, 3.9, and 1.9 d, respectively). ConclusionsCarotid artery stenosis patients in Pennsylvania undergoing CEA or CAS had similar 30-d readmission rates. Although LOS was significantly different, the magnitude of the difference was not large.

Pilot Prehabilitation Program for Patients With Esophageal Cancer During Neoadjuvant Therapy and Surgery

BackgroundLocally advanced esophageal cancer is often treated with neoadjuvant therapy followed by surgery. Many patients present with or experience clinical deconditioning during neoadjuvant therapy. Prehabilitation programs in other areas of surgery have demonstrated improved postoperative outcomes. The aims of this study were to evaluate the feasibility of a pilot prehabilitation program and determine preliminary effects on surgical and cancer-related outcomes. MethodsA retrospective review of patients treated at a single institution with resectable esophageal cancer was performed (n = 22). Patients in the prehabilitation group received protocol-structured intervention in several clinical domains including nutrition, psychosocial support, and physical exercise. ResultsClinical stage and comorbidities were well matched between groups. The structured prehabilitation program was feasible and well received by participants. Fewer patients required admission during neoadjuvant therapy in the prehabilitation group (27.3% versus 54.5%). Percentage weight loss during treatment was 3.0% in the prehabilitation group versus 4.3% in the control group. Compared with the control group, the prehabilitation group demonstrated 0.0% versus 18.2% 30-d postoperative readmission rate and 18.2% versus 27.3% 90-d postoperative readmission rate. There were no statistically significant differences between groups in regard to complications or mortality. ConclusionsThe pilot prehabilitation program demonstrated feasibility of implementing a structured program for patients receiving neoadjuvant therapy for esophageal cancer. Although the small population limits evaluation of statistical significance, trends in the data suggest a potential benefit of the prehabilitation program on neoadjuvant hospital admission rates, postsurgical readmission rates, and nutritional status.

Multilevel Analysis of Readmissions After Radical Cystectomy for Bladder Cancer in the USA: Does the Hospital Make a Difference?

BackgroundHospitals are increasingly being held responsible for their readmissions rates. The contribution of hospital versus patient factors (eg, case mix) to hospital readmissions is unknown. ObjectiveTo estimate the relative contribution of hospital and patient factors to readmissions after radical cystectomy (RC) for bladder cancer. Design, setting, and participantsWe identified individuals who underwent RC in 2014 in the Nationwide Readmissions Database (NRD). The NRD is a nationally representative (USA), all-payer database that includes readmissions at index and nonindex hospitals. Survey weights were used to generate national estimates. Outcome measurements and statistical analysisThe main outcome was readmission within 30 d after RC. Using a multilevel mixed-effects model, we estimated the statistical association between patient and hospital characteristics and readmission. A hospital-level random-effects term was used to estimate hospital-level readmission rates while holding patient characteristics constant. Results and limitationsWe identified a weighted sample of 7095 individuals who underwent RC at 341 hospitals in the USA. The 30-d readmission rate was 29.5% (95% confidence interval [CI] 27.8–31.2%), ranging from 1.4% (95% CI 0.6–2.2%) in the bottom quartile to 73.6% (95% CI 68.4–78.7) in the top. In our multilevel model, female sex and comorbidity score were associated with a higher likelihood of readmission. The hospital random-effects term, encompassing both measured and unmeasured hospital characteristics, contributed minimally to the model for readmission when patient characteristics were held constant at population mean values (pseudo-R2<0.01% for hospital effects). Surgical volume, bed size, hospital ownership, and academic status were not significantly associated with readmission rates when these terms were added to the model. ConclusionsAfter adjusting for patient characteristics, hospital-level effects explained little of the large between-hospital variability in readmission rates. These findings underscore the limitations of using 30-d post-discharge readmissions as a hospital quality metric. Patient summaryThe chance of being readmitted after radical cystectomy varies substantially between hospitals. Little of this variability can be explained by hospital-level characteristics, while far more can be explained by patient characteristics and random variability.

Frequency of hospital readmission and care fragmentation in gastroparesis: A nationwide analysis.

AIMTo evaluate rates and predictors of hospital readmission and care fragmentation in patients hospitalized with gastroparesis.METHODSWe identified all adult hospitalizations with a primary diagnosis of gastroparesis in the 2010-2014 National Readmissions Database, which captures statewide readmissions. We excluded patients who died during the hospitalization, and calculated 30 and 90-d unplanned readmission and care fragmentation rates. Readmission to a non-index hospital (i.e., different from the hospital of the index admission) was considered as care fragmentation. A multivariate Cox regression model was used to analyze predictors of 30-d readmissions. Logistic regression was used to determine hospital and patient factors independently associated with 30-d care fragmentation. Patients readmitted within 30 d were followed for 60 d post discharge from the first readmission. Mortality during the first readmission, hospitalization cost, length of stay, and rates of 60-d readmission were compared between those with and without care fragmentation.RESULTSThere were 30064 admissions with a primary diagnosis of gastroparesis. The rates of 30 and 90-d readmissions were 26.8% and 45.6%, respectively. Younger age, male patient, diabetes, parenteral nutrition, ≥ 4 Elixhauser comorbidities, longer hospital stay (> 5 d), large and metropolitan hospital, and Medicaid insurance were associated with increased hazards of 30-d readmissions. Gastric surgery, routine discharge and private insurance were associated with lower 30-d readmissions. The rates of 30 and 90-d care fragmentation were 28.1% and 33.8%, respectively. Younger age, longer hospital stay (> 5 d), self-pay or Medicaid insurance were associated with increased risk of 30-d care fragmentation. Diabetes, enteral tube placement, parenteral nutrition, large metropolitan hospital, and routine discharge were associated with decreased risk of 30-d fragmentation. Patients who were readmitted to a non-index hospital had longer length of stay (6.5 vs 5.8 d, P = 0.03), and higher mean hospitalization cost ($15645 vs $12311, P < 0.0001), compared to those readmitted to the index hospital. There were no differences in mortality (1.0% vs 1.3%, P = 0.84), and 60-d readmission rate (55.3% vs 54.6%, P = 0.99) between the two groups.CONCLUSIONSeveral factors are associated with the high 30-d readmission and care fragmentation in gastroparesis. Knowledge of these predictors can play a role in implementing effective preventive interventions to high-risk patients.

Outcomes of Elderly Patients Undergoing Curative Resection for Retroperitoneal Sarcomas: Analysis From the US Sarcoma Collaborative

BackgroundThe postoperative outcomes of elderly patients undergoing resection of retroperitoneal sarcomas (RPS) have not been widely studied. MethodsPatients undergoing surgical resection for primary or recurrent RPS between 2000 and 2015 at participating US Sarcoma Collaborative institutions were identified. Patient demographics, perioperative morbidity, mortality, length of stay, discharge to home, disease-specific survival, and disease-free survival were compared between elderly (≥70 y, n = 171) and nonelderly (<70 y, n = 494) patients. ResultsThere was no difference in perioperative morbidity (total and major complications elderly versus nonelderly: 39% versus 35%; P = 0.401 and 18% versus 17%; P = 0.646, respectively) or mortality between elderly and nonelderly patients with each group experiencing a 1% 30-d mortality rate. Length of stay and 30-d readmission rates were similar (elderly versus nonelderly; 7 d interquartile range [IQR: 5-9] versus 6 d [IQR: 4-9], P = 0.528 and 11% versus 12%, P = 0.667). Elderly patients were more likely to be discharged to a skilled nursing or rehabilitation facility (elderly versus nonelderly; 19% versus 7%, P < 0.001). There was no difference in 3-y disease-free survival between the elderly and nonelderly patients (41% versus 43%, P = 0.65); however, elderly patients had a lower 3-y disease-specific survival (60% versus 76%, P < 0.001). In elderly patients, the presence of multiple comorbidities and high-grade tumors were most predictive of outcomes. ConclusionsAdvanced age was not associated with an increased risk of perioperative morbidity and mortality following resection of RPS in this multi-institutional review. Although short-term oncologic outcomes were similar in both groups, the risk of death after sarcoma recurrence was higher in elderly patients and may be related to comorbidity burden and tumor histology.

Impact of New-Onset Postoperative Depression on Readmission Outcomes After Surgical Coronary Revascularization

BackgroundDepression affects between 10% and 40% of cardiac surgery patients and is associated with significantly worse outcomes. The incidence and impact of new-onset depression beyond acute follow-up remain ill-defined. The present study aimed to evaluate the incidence, risk factors, and prognostic implication of depression on 90-d readmission rates after coronary artery bypass grafting (CABG) surgery. MethodsA retrospective cohort study was performed identifying adult patients without prior depression who underwent CABG surgery using the 2010-2014 National Readmissions Database. CABG patients who were readmitted more than 2 wk but within 90 d of discharge were categorized based on the presence of new-onset depression. Association between the development of new-onset depression and rehospitalization were morbidity, mortality, costs, and length of stay (LOS) and were examined using multivariable regression. ResultsDuring the study period, 1,001,945 patients underwent CABG. Of these, 11.7% of patients were readmitted after 14 d but within 90 d of discharge with 5.1% of these patients having a diagnosis of new-onset depression. Postoperative new-onset depression was not associated with increased readmission morbidity, costs, or LOS. Mortality in new-onset depression readmissions was 1.2%, compared with 2.3% in all readmitted patients (P = 0.014). Depression was associated with lower odds of mortality (OR = 0.56, P = 0.02). ConclusionsNew-onset depression following CABG discharge was not associated with increased odds of mortality, morbidity, costs, or increased LOS on readmission. Rather, new-onset depression is associated with decreased odds of readmission mortality. Overall, CABG readmissions are decreasing, whereas the rate of new-onset depression is slightly increasing. Implementation of routine depression screening tools in postoperative CABG care may aid in early detection and management of depression to enhance postoperative recovery and quality of life.

Different Sampling and Modeling Strategies Affect Analyses of Readmission Risk among Diabetes Patients

Readmissions are an undesirable outcome for which hospitals are being held accountable. Despite a growing literature, there is little consensus on the optimal method of sampling hospitalizations for calculating readmission rate and modeling methods for analyzing risk factors. We compared 2 sampling and 3 multivariable predictive modeling strategies in a retrospective cohort of adult patients with diabetes discharged from an academic medical center between 2004 and 2012. Diabetes was defined by ICD-9-CM code 250 or documentation of taking a diabetes-specific medication. The outcome for all models was all-cause readmission within 30 days of discharge (30d readmission). Models were built on 46 sociodemographic, clinical and administrative variables. With sampling only the first discharge per patient (N=17,284), the 30d readmission rate was 10.2% vs. 20.3% for all discharges per patient (N=44,203). Model performance varied by sampling and modeling strategy. Logistic regression (LR) without generalized estimating equations (GEE) using all discharges had the highest overall performance. Sampling only the first discharge per patient underestimates the readmission rate and is associated with misleading measures of model performance. LR without GEE may yield overly optimistic measures of model performance. Because commonly used approaches may produce misleading results, consensus is needed. Performance of logistic regression models to predict all-cause 30d readmission.Model and Sampling StrategyPerformance Measurement(95% CI)First Discharges without GEEAll Discharges without GEEAll Discharges with GEEAll Discharges with weighted GEEArea Under ROC Curve (C-statistic)0.821 (0.806, 0.835)0.811 (0.803, 0.818)0.803 (0.796, 0.811)0.791 (0.783, 0.798)Correlation Coefficient0.366 (0.345, 0.386)0.450 (0.438, 0.462)0.437 (0.425, 0.449)0.415 (0.403, 0.427)Coefficient of Determination, %14.96 (14.06, 15.86)21.00 (20.39, 21.61)18.40 (17.85, 18.96)15.83 (15.32, 16.34)Brier Score0.080 (0.075, 0.084)0.129 (0.126, 0.132)0.132 (0.128, 0.135)0.135 (0.132, 0.139)GEE=generalized estimating equations with an exchangeable correlation structure Disclosure H. Zhao: None. S. Tanner: None. S. Golden: None. S.G. Fisher: None. D.J. Rubin: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc..

Cervical Total Disc Replacement and Anterior Cervical Discectomy and Fusion: Reoperation Rates, Complications, and Hospital Resource Utilization in 72 688 Patients in the United States.

Healthcare readmissions are important causes of increased cost and have profound clinical impact. Thirty-day readmissions in spine surgery have been well documented. However, rates, causes, and outcomes are not well understood outside 30 d. To analyze 30- and 90-d readmissions for a retrospective cohort of anterior cervical discectomy and fusions (ACDF) and total disc replacement (TDR) for degenerative cervical conditions. The Nationwide Readmissions Database approximates 50% of all US hospitalizations with patient identifiers to track patients longitudinally. Patients greater than 18 yr old were identified. Rates of readmission for 30 and 90 d were calculated. Predictor variables, complications, outcomes, and costs were analyzed via univariate and multivariable analyses. Between January and September 2013, 72 688 patients were identified. The 30- and 90-d readmission rates were 2.67% and 5.97%, respectively. The most prevalent reason for 30-d readmission was complication of medical/surgical care (20.3%), whereas for 90-d readmission it was degenerative spine etiology (19.2%). Common risk factors for 30- and 90-d readmission included older age, male gender, Medicare/Medicaid, prolonged initial length of stay, and various comorbidities. Unique risk factors for 30- and 90-d readmissions included adverse discharge disposition and mechanical implant-related complications, respectively. When comparing ACDF and TDR, ACDFs were associated with increased 90-d readmissions (6.0% vs 4.3%). The TDR cohort had a shorter length of stay, lower complication rate, and fewer adverse discharge dispositions. Identification of readmission causes and predictors is important to potentially allow for changes in periperative management. Decreasing readmissions would improve patient outcomes and reduce healthcare costs.

Predicting 30-Day All-Cause Readmission Risk for Subjects Admitted With Pneumonia at the Point of Care.

The pneumonia 30-d readmission rate has been endorsed by the National Quality Forum as a quality metric. Hospital readmissions can potentially be lowered by improving in-hospital care, transitions of care, and post-discharge disease management programs. The purpose of this study was to create an accurate prediction model for determining the risk of 30-d readmission at the point of discharge. The model was created using a data set of 1,295 hospitalizations at the Cleveland Clinic Main Campus with pneumonia over 3 y. Candidate variables were limited to structured variables available in the electronic health record. The final model was compared with the Centers for Medicare and Medicaid Services (CMS) model among subjects 65 y of age and older (n = 628) and was externally validated. Three hundred thirty subjects (25%) were readmitted within 30 d. The final model contained 13 variables and had a bias-corrected C statistic of 0.74 (95% CI 0.71-0.77). Number of admissions in the prior 6 months, opioid prescription, serum albumin during the first 24 h, international normalized ratio and blood urea nitrogen during the last 24 h were the predictor variables with the greatest weight in the model. In terms of discriminative performance, the Cleveland Clinic model outperformed the CMS model on the validation cohort (C statistic 0.69 vs 0.60, P = .042). The proposed risk prediction model performed better than the CMS model. Accurate readmission risk prediction at the point of discharge is feasible and can potentially be used to focus post-acute care interventions in a high-risk group of patients.

Hospital readmissions in decompensated cirrhotics: Factors pointing toward a prevention strategy.

AIMTo reduce readmissions and improve patient outcomes in cirrhotic patients through better understanding of readmission predictors.METHODSWe performed a single-center retrospective study of patients admitted with decompensated cirrhosis from January 1, 2011 to December 31, 2013 (n = 222). Primary outcomes were time to first readmission and 30-d readmission rate due to complications of cirrhosis. Clinical and demographic data were collected to help describe predictors of readmission, along with care coordination measures such as post-discharge status and outpatient follow-up. Univariate and multivariate analyses were performed to describe variables associated with readmission.RESULTSOne hundred thirty-two patients (59.4%) were readmitted at least once during the study period. Median time to first and second readmissions were 54 and 93 d, respectively. Thirty and 90-d readmission rates were 20.7 and 30.1 percent, respectively. Predictors of 30-d readmission included education level, hepatic encephalopathy at index, ALT more than upper normal limit and Medicare coverage. There were no statistically significant differences in readmission rates when stratified by discharge disposition, outpatient follow-up provider or time to first outpatient visit.CONCLUSIONReadmissions are challenging aspect of care for cirrhotic patients and risk continues beyond 30 d. More initiatives are needed to develop enhanced, longitudinal post-discharge systems.

Myocardial functional changes in transfemoral versus transapical aortic valve replacement

BackgroundTranscatheter aortic valve replacement (TAVR) has greatly expanded the treatment options available for patients with severe aortic stenosis at high surgical risk. Materials and methodsWe compared changes in myocardial function in TAVR with a transfemoral (TF) versus a transapical (TA) approach at a major tertiary hospital from 2012-2016. Traditional echocardiographic measures of cardiac structure and function were tracked, alongside the use of two-dimensional speckle tracking echocardiography to measure myocardial strain and strain rates. ResultsFor the entire cohort with complete data at all time points (n = 42), between the pre-TAVR baseline (mean: 20.1 d) and the post-TAVR 1-mo follow-up (mean: 32.7 d), global longitudinal strain significantly increased (from −15.6% to −18.2%, P < 0.001). When comparing the TF (n = 31) and TA (n = 11) groups, TA patients showed persistently impaired apical longitudinal strain at the 1-mo follow-up (−15.9% versus −22.3%, P < 0.05). In terms of clinical outcomes, both groups (n = 131 for TF, n = 53 for TA) were similar in terms of 30-d mortality, readmission rate, and risk of post-TAVR acute kidney injury. However, TA patients experienced significantly longer length of hospitalization (7.58 versus 3.92 d, P = 0.02), intensive care unit hours (105.4 versus 47.1 h, P = 0.02), and were at a greater risk of long-term (>72 h) intensive care unit stay (45% versus 25%, P = 0.01). ConclusionsPatients undergoing TA-TAVR exhibit impaired apical longitudinal strain, although global myocardial function is similar to TF-TAVR otherwise. Myocardial strain measured by two-dimensional speckle tracking echocardiography appears to be a sensitive method to detect subtle cardiac remodeling after TAVR.

The impact of the robotic platform on assistant variability in complex gastrointestinal surgery

BackgroundNissen fundoplication is considered an advanced minimally invasive procedure whether performed laparoscopically or robotically. In laparoscopic surgery, it is evident that assistant skill level impacts operative times. However, the robotic platform allows improved surgeon autonomy. We aimed to determine the impact of assistant training level on operative times in robotic Nissen fundoplication (RNF) and laparoscopic Nissen fundoplication (LNF). MethodsA prospectively maintained Nissen database (2011-2016) from a single academic institution was utilized to collect patient characteristics, operative times, length of stay, intraoperative complications, postoperative complications, readmission rate, and assistant training level. Assistants were either postgraduate year-3 surgery residents defined as junior-level assistants or a minimally invasive surgery (MIS) fellow defined as senior-level assistants. ResultsThere were 105 patients included in our analyses. When comparing postgraduate year-3 residents to MIS fellows performing LNF, the median operative time was significantly decreased when senior-level assistants were present in the LNF group, 85 (75-103) versus 129 (74-269) min, P = 0.02. In comparison, median operative times in the RNF group were independent of the assistant's level of training, 154 (71-300) versus 158 (101-215) min, P = 0.34. There were no significant differences in outcomes between the junior- and senior-level assistant cohorts for estimated blood loss, length of stay, postoperative complications, and 30-d readmission rates in either the LNF or RNF group. ConclusionsAssistant training level impacted operative time for LNF but not RNF. These differences are most likely attributed to increased autonomy of the operating surgeon afforded by the robotic platform reducing assistant variability.

Variation in readmission expenditures after high-risk surgery

BackgroundThe Hospital Readmissions Reduction Program reduces payments to hospitals with excess readmissions for three common medical conditions and recently extended its readmission program to surgical patients. We sought to investigate readmission intensity as measured by readmission cost for high-risk surgeries and examine predictors of higher readmission costs. Materials and methodsWe used the Healthcare Cost and Utilization Project's State Inpatient Database to perform a retrospective cohort study of patients undergoing major chest (aortic valve replacement, coronary artery bypass grafting, lung resection) and major abdominal (abdominal aortic aneurysm repair [open approach], cystectomy, esophagectomy, pancreatectomy) surgery in 2009 and 2010. We fit a multivariable logistic regression model with generalized estimation equations to examine patient and index admission factors associated with readmission costs. ResultsThe 30-d readmission rate was 16% for major chest and 22% for major abdominal surgery (P < 0.001). Discharge to a skilled nursing facility was associated with higher readmission costs for both chest (odds ratio [OR]: 1.99; 95% confidence interval [CI]: 1.60-2.48) and abdominal surgeries (OR: 1.86; 95% CI: 1.24-2.78). Comorbidities, length of stay, and receipt of blood or imaging was associated with higher readmission costs for chest surgery patients. Readmission >3 wk after discharge was associated with lower costs among abdominal surgery patients. ConclusionsReadmissions after high-risk surgery are common, affecting about one in six patients. Predictors of higher readmission costs differ among major chest and abdominal surgeries. Better identifying patients susceptible to higher readmission costs may inform future interventions to either reduce the intensity of these readmissions or eliminate them altogether.