30-day All-cause Readmission Rate Research Articles

The impact of COVID 19 on heart failure hospitalization and management from an Asian perspective

Abstract Introduction COVID 19 is a global pandemic that has stretched healthcare resources. We explored the shift in patient demographics and clinical management of systolic heart failure (HF) patients during the COVID 19 outbreak. Purpose To examine the impact of COVID 19 on the hospitalization rates of decompensated systolic HF patients in a tertiary hospital in Asia and delineate differences in the clinical characteristics and management of these patients. Methods Data was extracted from the admission registry for systolic HF patients admitted to the tertiary hospital from January to June 2019 (pre-COVID) and the corresponding time period in 2020 during the COVID outbreak. We compared the demographics, clinical management and outcomes of these patients. Results There was a significant reduction in patients admitted for systolic HF during the COVID period, 174 (6.3%) compared to 240 (8.5%) pre-COVID (p=0.001). The baseline demographics were similar except for the age of patients admitted during the COVID 19 period, which were younger at 66.1±13.5 compared to 69.9±13.9 pre-COVID (p=0.007). The mean left ventricular ejection fraction (LVEF) was lower during the COVID period (22.9±10.1% vs 24.9±10.1%; p=0.032). More patients during the COVID period were placed on mineralocorticoid receptor antagonists (p=0.001) and SGLT2 inhibitors (p<0.001). For those with recurrent admission for systolic HF, the number for HF admissions in the preceding one year was lower during COVID period compared to pre-COVID (0.2±0.5 vs 0.5±1.0 readmissions, p<0.001). There was no COVID 19 infection among those admitted for systolic HF. The 30-day all-cause mortality and readmission rates were comparable between both groups. Cardiac related mortalities were higher during the COVID 19 period compared to the pre-COVID period (77.8% vs 100.0%, p=1.000). No difference was observed in the length of stay nor proportion of patients who required a higher level of care in high dependency or intensive care unit during the COVID outbreak. Those who were admitted during the COVID period were more likely first presentation of decompensated systolic HF, 119 (68.4%) compared to 135 (56.3%) pre-COVID (p=0.014). Conclusion Similar to the existing publications, there was a reduction in patients admitted for HF during the COVID period. However, for those who were admitted, these patients were younger and had lower LVEF. Most of them were first diagnosed with systolic HF during the hospitalizations. For those who had previous history of systolic HF, they had a lower number of HF admissions in the preceding one year compared to those who were admitted during the pre-COVID period. There was no difference in the 30-day mortality and utilization of high dependency or intensive care unit during the COVID outbreak. Funding Acknowledgement Type of funding sources: None.

Congestive Heart Failure 30-Day Readmission: Descriptive Study of Demographics, Co-morbidities, Heart Failure Knowledge, and Self-Care.

BackgroundCongestive heart failure (CHF) readmissions are associated with substantial financial and medical implications. We performed a descriptive study to determine demographic, clinical, and behavioral factors associated with 30-day readmission.Materials and methodsPatients hospitalized with CHF at William Beaumont Hospital in Royal Oak, MI, from March 2019-May 2019 were studied. Response to heart failure knowledge and self-care questionnaires along with the patients’ demographic and clinical factors were collected. Thirty-day readmission to any of the eight hospitals in the Beaumont Health System was documented.ResultsOne-hundred ninety-six (196) patients were included. The all-cause 30-day readmission rate was 23%. A numerical higher rate of readmissions was observed among males (23.7% vs 22.2%), current smokers (27.3% vs 22.9%), and patients with peripheral vascular disease (PVD; 28.9% vs 21.2%), diabetes mellitus (DM; 26.4% vs 18.9%), hypertension (HTN; 26.4% vs 10%), coronary artery disease (CAD; 24.6% vs 19%), and prior history of cerebrovascular accident (CVA; 28.9% vs 21.2%) (p>0.05). Reduced left ventricular ejection fraction (LVEF) was associated with higher readmissions (24.4% vs 20.5%, p=0.801). Patients with the highest reported questionnaire scores corresponding to better heart failure knowledge and self-care behaviors at home were readmitted at a similar rate compared to those scoring in the lowest interval (25%, p=0.681).ConclusionThough statistically insignificant due to the limitations of sample size, a higher percentage of readmissions was observed in male patients, current smokers, reduced LVEF, and higher comorbidity burden. Better reported patient self-care behavior, medication compliance, and heart failure knowledge did not correlate with reduced readmission rates. While the impact of medical comorbidities on 30-day readmissions is better established, the role of socioeconomic factors remains unclear and might suggest a focus for future work.

Targeted Clinical Interventions for Reducing Pediatric Readmissions.

In this interventional study, we addressed the selection and application of clinical interventions on pediatric patients identified as at risk by a predictive model for readmissions. A predictive model for readmissions was implemented, and a team of providers expanded corresponding clinical interventions for at-risk patients at a freestanding children's hospital. Interventions encompassed social determinants of health, outpatient care, medication reconciliation, inpatient and discharge planning, and postdischarge calls and/or follow-up. Statistical process control charts were used to compare readmission rates for the 3-year period preceding adoption of the model and clinical interventions with those for the 2-year period after adoption of the model and clinical interventions. Potential financial savings were estimated by using national estimates of the cost of pediatric inpatient readmissions. The 30-day all-cause readmission rates during the periods before and after predictive modeling (and corresponding 95% confidence intervals [CI]) were 12.5% (95% CI: 12.2%-12.8%) and 11.1% (95% CI: 10.8%-11.5%), respectively. More modest but similar improvements were observed for 7-day readmissions. Statistical process control charts indicated nonrandom reductions in readmissions after predictive model adoption. The national estimate of the cost of pediatric readmissions indicates an associated health care savings due to reduced 30-day readmission during the 2-year predictive modeling period at $2 673 264 (95% CI: $2 612 431-$2 735 364). A combination of predictive modeling and targeted clinical interventions to improve the management of pediatric patients at high risk for readmission was successful in reducing the rate of readmission and reducing overall health care costs. The continued prioritization of patients with potentially modifiable outcomes is key to improving patient outcomes.

Outcomes and predictors of readmission after implantation of a percutaneous left atrial appendage occlusion device in the United States: A propensity score-matched analysis from The National Readmission Database.

Left atrial appendage occlusion (LAAO) devices have become a favorable alternative option among nonvalvular atrial fibrillation (AF) patients with long-term contraindication to anticoagulation. Real-world experience with postprocedural readmission rates and predictors of readmission in LAAO patients is limited. To assess all-cause 30-day readmission rate and predictors of readmission after LAAOprocedure in the United States. This retrospective observational study included all AF patients undergoing percutaneous LAAO procedures in the United States from January 1, 2016, and December 31, 2017, in the National Readmission Database. The primary outcome measure was all-cause 30-day readmission. A propensity score-matched analysis compared outcomes with a non-LAAO AF cohort. Among 14 024 LAAO procedures (age: 76 ± 8 years; 60.5% males), 9.4% were readmitted within 30-days and,0.2% died during their index hospitalization. The most frequent primary diagnosis during readmission among LAAO was gastrointestinal bleeding (12%). The incidence of LAAO procedures increased by 102%. In the multivariate model, gender and CHA2 DS2 -VASc failed to predict readmission. Age 55-64 years had lower odds (adjusted odds ratios [aOR]: 0.41; 95% confidence interval [CI]: 0.18-0.94), while drug abuse (aOR: 4.1; 95% CI: 1.34-12.54), and deficiency anemia (aOR: 1.88; 95% CI: 1.12-3.18) had higher odds of readmission. In propensity-matched cohort, compared to non-LAAO AF, LAAO patients had lower 30-day readmission (9.4% vs. 10.98%, p = .002) and all-cause in-hospital mortality (0.19% vs. 0.57%, p < .001). The readmission rate following the LAAO procedure is substantial (approximately 10%), and largely attributable to gastrointestinal bleeding. Factors such as drug abuse and anemia must be explored further to minimize readmission risk.

Abstract 01: Thirty-day Readmission Rate For Hypertensive Crisis: A Nationwide Analysis

Objective: Hypertensive crisis is a life-threatening condition that leads to poor patient outcomes if not treated urgently. We evaluate the all-cause 30-day readmission rate, resource utilization, predictors of readmission, and the most common causes for readmission in patients admitted with hypertensive crisis. Methods: Using the National Readmission Database 2018, patients ≥18 years of age admitted with the principal diagnosis of the hypertensive crisis were included in the study. The primary outcome was the all-cause 30-day readmission rate in these patients. Results: We identified 129,239 patients as index admissions. The mean age of index patients was 61±0.14 years, and females were 56.6%. The 30-day readmission rate was 10.6 % (13,768± 355). The in-hospital mortality rate was 0.2 % for index admissions and 1.5 % for readmissions. The cumulative length of stay (LOS) for all readmitted patients was 62,046± 1,802 days. The cumulative total cost of hospital services in readmitted patients was 155 ± 4.6 million USD. Age&lt;65, lower-income, increased LOS, increased comorbidity burden, primary payer, and disposition were important predictors of readmission (Table). The most common causes of readmission were hypertensive crisis (19 %), CHF (12.4%), acute renal failure (4.4%), sepsis (2.6%), ESRD (2%), NSTEMI (2%), and stroke (1.7%) Conclusion: In conclusion, the 30-day readmission rate in patients with hypertensive crisis is high (10.6%), with hypertensive crisis and CHF as the most common causes. Resource utilization is also high, with many potential avoidable days and costs. Future strategies should address underlying factors, especially socioeconomic factors.

30-day readmission following urgent and elective transcatheter aortic valve replacement: A Nationwide Readmission Database analysis.

Transcatheter aortic valve replacement (TAVR) is being increasingly used for decompensated severe symptomatic aortic stenosis. Data on urgent and elective TAVR readmission is scarce in the literature. Here, we have performed a retrospective cohort study with the Nationwide Readmission Database of 2016 to identify the rate of 30-day all-cause readmission, common causes of readmission, and distribution of morbidity in index admission and readmission after urgent and elective TAVR. We used International Classification of Diseases, Tenth Revision codes (02R.F38H, 02R.F38Z, 02R.F48Z) for identification of all TAVR procedures done in 2016 in patients >18 years old. We found 8379 patients who underwent urgent TAVR and 32,006 patients who underwent elective TAVR in 2016. The mean age of patients undergoing urgent TAVR was 79 ± 9.97 years with 44.6% women. The mean age of patients undergoing elective TAVR was 80.7 ± 8.25 years with 46.2% women. We found the 30-day all-cause readmission rate of 15.5% and 9.5% in patients undergoing urgent and elective TAVR, respectively (p< 0.001). The cardiac cause was the predominant cause of readmission in both groups (43.77% vs. 42.11%, p =0.57), followed by pulmonary cause, gastrointestinal (GI) cause, and renal cause. Among cardiac causes, congestive heart failure (CHF) was predominant cause of readmission and was similar in both groups (18.73 in urgent TAVR vs. 15.73 in elective TAVR, p =0.12). We found that the all-cause 30-day readmission rate was higher in patients who had undergone urgent TAVR. Further studies are needed to better understand this difference.

Association between post-hospital clinic and telephone follow-up provider visits with 30-day readmission risk in an integrated health system

BackgroundFollow-up visits with clinic providers after hospital discharge may not be feasible for some patients due to functional limitations, transportation challenges, need for physical distancing, or fear of exposure especially during the current COVID-19 pandemic.MethodsThe aim of the study was to determine the effects of post-hospital clinic (POSH) and telephone (TPOSH) follow-up provider visits versus no visit on 30-day readmission. We used a retrospective cohort design based on data from 1/1/2017 to 12/31/2019 on adult patients (n = 213,513) discharged home from 15 Kaiser Permanente Southern California hospitals. Completion of POSH or TPOSH provider visits within 7 days of discharge was the exposure and all-cause 30-day inpatient and observation stay readmission was the primary outcome. We used matching weights to balance the groups and Fine-Gray subdistribution hazard model to assess for readmission risk.ResultsUnweighted all-cause 30-day readmission rate was highest for patients who completed a TPOSH (17.3%) followed by no visit (14.2%), non-POSH (evaluation and management visits that were not focused on the hospitalization: 13.6%) and POSH (12.6%) visits. The matching weighted models showed that the effects of POSH and TPOSH visits varied across patient subgroups. For high risk (LACE 11+) medicine patients, both POSH (HR: 0.77, 95% CI: 0.71, 0.85, P < .001) and TPOSH (HR: 0.91, 95% CI: 0.83, 0.99, P = .03) were associated with 23 and 9% lower risk of 30-day readmission, respectively, compared to no visit. For medium to low risk medicine patients (LACE< 11) and all surgical patients regardless of LACE score or age, there were no significant associations for either visit type with risk of 30-day readmission.ConclusionsPost-hospital telephone follow-up provider visits had only modest effects on 30-day readmission in high-risk medicine patients compared to clinic visits. It remains to be determined if greater use and comfort with virtual visits by providers and patients as a result of the pandemic might improve the effectiveness of these encounters.

Opioid dependence and treatment outcomes among patients with burn injury

BackgroundPatients with burn injuries cause significant healthcare economic burden, often utilising extra-hospital resources, caregiving, and specialized care. MethodsWe present a retrospective cohort analysis of the hospitalized patients in the USA with a primary diagnosis of burn injury. Opioid dependence was identified using ICD-10 CM codes. The 30-day all-cause readmission rate was the main outcome while secondary outcomes were inhospital mortality rate, resource utilization which included hospital length of stay, total hospitalization costs and charges and surgical procedures for burn injury treatment as well as the most important five principal diagnoses for admission and readmission. ResultsOut of 22,348 patients included in the study, 597 had opioid dependence. Older patients (43 years, range: 38.6–47.2 years) as well as males (70.8%) were more likely to be opioid dependent. Opioid dependence was associated with higher 30-day readmission rates (aOR: 1.83, 95% confidence interval (CI): 1.30–2.57, p-value: <0.01), higher total hospitalization costs (aMD: $14,981, CI: $3820–$26,142, p-value: 0.01), total hospitalization charges (aMD: $47,078, CI: −$5093 to $89,063, p-value: 0.03), and a shorter mean length of stay (aMD: 5.13 days, CI: 2.60–7.66, p-value: <0.01). However, patients with and without opioid dependence had similar in-hospital mortality rates (aOR: 0.27, CI: 0.06–1.28, p-value: 0.10). ConclusionWe are the first to our knowledge to report the association of treatment outcomes and opioid dependence in patients hospitalized at the national level with a burn injury. We show that there were higher 30-day all-cause readmission rates and in-hospital resource utilization among patients with opioid-dependence.

A Multi-Component Transition of Care Improvement Project to Reduce Hospital Readmissions Following Ischemic Stroke.

Ischemic stroke (IS) is a common cause of hospitalization which carries a significant economic burden and leads to high rates of death and disability. Readmission in the first 30 days after hospitalization is associated with increased healthcare costs and higher risk of death and disability. Efforts to decrease the number of patients returning to the hospital after IS may improve quality and cost of care. Improving care transitions to reduce readmissions is amenable to quality improvement (QI) initiatives. A multi-component QI intervention directed at IS patients being discharged to home from a stroke unit at an academic comprehensive stroke center using IS diagnosis-driven home care referrals, improved post-discharge telephone calls, and timely completion of discharge summaries was developed. The improvement project was implemented on July 1, 2019, and evaluated for the 6 months following initiation in comparison to the same 6-month period pre-intervention in 2018. Following implementation, a statistically significant decrease in 30-day all-cause same-hospital readmission rates from 7.4% to 2.8% (p = .031, d = 1.61) in the project population and from 6.6% to 3% (p = .010, d = 1.43) in the overall IS population was observed. Improvement was seen in all process measures as well as in patient satisfaction scores. An evidence-based bundled process improvement intervention for IS patients discharged to home was associated with decreased hospital readmission rates following IS.

Expert consensus on the use of human serum albumin in critically ill patients.

Expert consensus on the use of human serum albumin in critically ill patients.

OR6. Heart Failure Hospitalist Program: Innovation Drives Best Practice and Exceptional Outcomes

Purpose This presentation will describe a creative, integrated care-model for heart failure (HF) management. Two key areas of focus will be consistent, patient-centered care across the continuum and innovative inpatient strategies. Objectives HF Hospitalist Program objectives have three focuses: • Patient care delivered by a consistent provider resulting in ongoing development of goals of care, resolution of barriers to care and improved patient satisfaction. • Team engagement to coordinate care of high-risk patients, develop plans for transition of care/advanced HF management and consult other interdisciplinary teams. • System opportunities include reduction of 7-day and 30-day readmissions, reduction in length of stay, adherence to HF metrics, and early introduction of Palliative/Hospice. Methods After analysis of HF data by Cardiology and Hospitalist leadership, all parties recognized that consistent inpatient provider care was lacking in the current care-model. The concept of a dedicated Heart Failure Hospitalist service line emerged. Key strategies included: 1) Optimizing care by patient rounds at least twice daily 2) Documentation template to highlight guideline directed therapy, response to treatment and a transition plan (attachment 1) 3) Leading morning huddle and afternoon interdisciplinary rounds 4) Overseeing all non-critical care heart failure admissions in the emergency room and direct admissions 5) Coordinating care with the HF Program manager/Clinical Nurse Specialist and outpatient HF Center to improve metrics such as 5-7 day appointments and 72-hour re-evaluation to assure action plans for yellow day 6) Reducing emergency room utilization by: • Community Paramedicine program referrals for in-home evaluation and administration of IV diuretics • Flagging chronic/high utilizer records • Delivering care in observation units, avoiding costly admissions. Results HF Hospitalist Program and all provider outcomes were compared from 2018-2020. Critical organizational objectives were met. Length of stay for HF hospitalist program was lower by .5 to 1.3 days (see table #1). Guideline directed medical therapy was consistently supported by HF team. Adherence with order set usage, averaged 96.2% for hospitalist team as compared to 81.1% for all providers (see Table #2). Consistent with program objectives to provide compassionate management of end-of-life care and support goals of care discussions, the HF Hospitalist program facilitated more hospice discharges than all providers over 3 years. (see Table #3). All-cause 30-day HF readmission rates were at a system low for all providers in 2018 at 17.22% and currently average 21%. HF Hospitalist team impressively lowered this metric to 9% (2018), 8.34% (2019) and 5.34% (2020). Readmission with HF at 30-days for all providers averaged 7.6%, while the HF Hospitalist team averaged 3.41%. (see Tables #4&5) Conclusions Heart failure is a major health care issue, challenging all medical centers to develop a plan to tackle high prevalence, mortality, and cost of care. This organization's strategy of partnering a HF hospitalist service line with a successful Heart Failure Center, which maintains continuity of care, has shown to be a unique method to not only develop trusting relationships with our patients but also attain impressive results. Attachment #1 Documentation Template Acute on chronic diastolic heart failure (HCC) – (present on admission) Echocardiogram: Chief Complaint: NYHA admission: NYHA current: Device: Etiology for HF exacerbation: Compliance with medications: Compliance with diet: HF order set: BNP on admission: BNP at discharge: Admission Weight: Current Weight: Diuretic (home medication): Diuretic (inpatient): CKD Stage: Cr trend: Urine Output in last 24hrs: NET Output: Current HF medications: -Beta-blocker: -ACEI/ARB/ARNI: -Aldosterone Antagonist: # of Admissions last 6 months: Social Support: Hospice Discussion: TOC Appointment: Heart Failure Hospitalist Outcomes Compared to All Providers 2018-2020 YTD

Predictors of 30-day readmissions for adrenal insufficiency: A retrospective national database study.

The aim of this study was to describe rates and characteristics of non-elective 30-day readmission among patients hospitalized for adrenal insufficiency and to assess predictors of readmission. We analysed the 2018 National Readmission Database. Adrenal insufficiency hospitalizations were identified using the International Classification of Diseases, Tenth Revisions, Clinical Modification diagnosis codes for principal diagnostic codes of primary adrenal insufficiency, Addisonian crisis, drug-induced adrenocortical insufficiency, and other and unspecified adrenocortical insufficiency. During the study period, 7738 index hospitalizations were identified as patients with AI who met the inclusion criteria. Of these, 7691 were discharged alive. We utilized chi-squared tests to compare baseline characteristics between readmissions and index hospitalizations. Multivariate Cox regression was used to identify independent predictors of readmission. The 30-day all-cause readmission rate for AI was 17.3%. About 1 in 5 readmissions was for AI. Other reasons for readmission included sepsis (10.8%), unspecified pneumonia (3.1%) and acute renal failure unspecified (1.6%). Readmission was associated with significantly higher odds of inpatient mortality. Independent predictors of 30-day all-cause readmissions included index hospitalizations with the Charlson Comorbidity Index (CCI) ≥3 (adjusted hazards ratio (aHR): 2.53, 95% CI: 1.85-3.46, p<.001), protein-energy malnutrition (aHR: 1.28, 95% CI: 1.02-1.60, p=.035) and obesity (aHR: 1.26, 95% CI: 1.02-1.56, p=.035). The 30-day all-cause readmission rate was 17.3%. AI was the most common reason for readmission among other causes. Readmissions were associated with increased mortality. CCIs of 3 or more, protein-energy malnutrition and obesity were significant predictors of readmission.

Sex-based differences in clinical outcomes and resource utilization of type 2 myocardial infarction

BackgroundSex-based differences in clinical outcomes have been previously well described in type 1 myocardial infarction (T1MI). However, type 2 myocardial infarction (T2MI) is more common in contemporary practice, with scarce data regarding sex-based differences of outcomes. MethodsThe Nationwide Readmission Database 2018 was queried for hospitalizations with T2MI as a primary or secondary diagnosis. Complex samples multivariable logistic and linear regression models were used to determine the association between T2MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions) in females compared to males with T2MI. ResultsA total of 252,641 hospitalizations [119,783 (47.4%) females and 132,858 (52.6%) males] were included in this analysis. Females with T2MI was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.92; 95% confidence interval [CI] 0.88–0.96; P < 0.001), shorter LOS (adjusted parameter estimate [aPE] −0.28; 95% CI −0.38–0.17; P < 0.001), less hospital costs (aPE -1510.70; 95% CI −1916.04–1105.37; P < 0.001), and increased nursing home discharges (aOR 1.08; 95% CI 1.05–1.12; P < 0.001) compared to males with T2MI. Females and males with T2MI had similar rates of 30-day all-cause readmission (aOR 1.00; 95% CI 0.97–1.04; P = 0.841). ConclusionAmong T2MI hospitalizations, females have lower in-hospital mortality, hospitalization costs, shorter LOS, and increased rates of nursing home discharge compared to males. Although statistically significant, the clinical significance of these small differences are unknown and require future studies.

Rate and Predictors of 30-day Readmission Following Diabetic Ketoacidosis in Type 1 Diabetes Mellitus: A US Analysis.

Diabetic ketoacidosis (DKA) is a serious endocrine emergency, associated with morbidity and mortality. Readmissions play a significant but sometimes preventable role in healthcare cost burden on the US. This study aimed to describe rates and characteristics of nonelective 30-day readmission among adult patients with diabetes mellitus type 1 (T1DM) hospitalized for DKA and also identify predictors of readmission. The study analyzed the 2018 Nationwide Readmission Database. DKA hospitalizations in patients with T1DM were classified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We utilized chi-squared tests to compare baseline characteristics between readmissions and index hospitalizations. Multivariable Cox regression was employed to identify independent predictors of readmission. Following this, we developed a 30-day readmission risk scoring system based on independent predictors. The 30-day all-cause readmission rate for DKA was 19.4%. A majority of patients (64.8%) had DKA as the principal diagnosis on readmission. Readmitted patients had a significantly higher mean age (35.3 vs 34.9 years, P = .018) and a higher proportion of females (52.8 vs 49.6%, P < .001) than the index admission. Readmission following DKA was associated with higher odds of inpatient mortality (0.69 vs 0.24%, OR 2.84, 95% CI 1.99-4.06, P < .001). Independent predictors of 30-day all-cause readmission included female sex, index hospitalizations with Charlson Comorbidity Index (CCI) score of 3 or greater, and being discharged against medical advice (AMA). The readmission rate for DKA in T1DM patients is high, and most patients have DKA as the principal diagnosis on readmission. A CCI equal to or greater than 3, hypertension, female sex, and being discharged AMA were significant predictors of readmission.

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.

Development of Acute Myocardial Infarction Mortality and Readmission Models for Public Reporting on Hospital Performance in Canada

BackgroundGiven changes in the care and outcomes of acute myocardial infarction (AMI) patients over the past several decades, we sought to develop prediction models that could be used to generate accurate risk-adjusted mortality and readmission outcomes for hospitals in current practice across Canada.MethodsA Canadian national expert panel was convened to define appropriate AMI patients for reporting and develop prediction models. Preliminary candidate variable evaluation was conducted using Ontario patients hospitalized with a most responsible diagnosis of AMI from April 1, 2015 to March 31, 2018. National data from the Canadian Institute for Health Information was used to develop AMI prediction models. The main outcomes were 30-day all-cause in-hospital mortality and 30-day urgent all-cause readmission. Discrimination of these models (measured by c-statistics) was compared with that of existing Canadian Institute for Health Information models in the same study cohort.ResultsThe AMI mortality model was assessed in 54,240 Ontario AMI patients and 153,523 AMI patients across Canada. We observed a 30-day in-hospital mortality rate of 6.3%, and a 30-day all-cause urgent readmission rate of 10.7% in Canada. The final Canadian AMI mortality model included 12 variables and had a c-statistic of 0.834. For readmission, the model had 13 variables and a c-statistic of 0.679. Discrimination of the new AMI models had higher c-statistics compared with existing models (c-statistic 0.814 for mortality; 0.673 for readmission).ConclusionsIn this national collaboration, we developed mortality and readmission models that are suitable for profiling performance of hospitals treating AMI patients in Canada.

Inappropriateness of Proton Pump Inhibitors After Hospital Discharge Is Associated with Thirty-Day Hospital Readmission.

Concerns have been raised about the adverse effects of proton pump inhibitors (PPIs). Rather than PPIs themselves causing harm, we hypothesized that PPIs prescribed without appropriate indications would be associated with adverse outcomes compared to appropriately indicated PPIs. Adult patients initiated on a new PPI during a hospitalization at our institution from 2014 to 2018 were analyzed. The primary outcome was all-cause 30-day readmission rate. The primary exposure was long-term appropriateness of PPI determined by the presence of prespecified diagnostic codes and discharge medications. Logistic regression modeling was used to estimate the odds of 30-day readmission in patients discharged on inappropriate compared to appropriate new PPIs. Of 84,236 patients admitted to our institution, 7745 (9.2%) were discharged on a new PPI, of which 5136 (66.3%) lacked an appropriately documented indication. Inappropriate PPIs were associated with 30-day hospital readmission after adjusting for other factors (adjusted odds ratio 1.30, 95% confidence interval 1.10-1.53). The excess risk associated with lack of appropriate documentation for PPIs in these patients was 44 readmissions per 1000 hospitalizations (95% confidence interval 21-67). Discharge on inappropriate PPIs was associated with 30-day hospital readmission compared to appropriate PPIs. The harm associated with inappropriate PPIs is not likely due to direct effects of PPIs because all patients in the study received PPIs. Rather, patients who receive inappropriate PPIs may have additional patient-specific factors that place them at increased risk for hospital readmission.

Utilizing the care coordination Atlas as a framework: An integrative review of transitional care models

Introduction Care coordination reduces care fragmentation and costs while improving health care quality. Transitional care programs, guided by tested models are an important component of effective care coordination, and have been found to reduce adverse events and prevent hospital readmissions. Using the Care Coordination Atlas as a framework, this article reports an integrative review of two transitional care models including analysis of model components, implementation factors, and associated 30-day all-cause hospital readmission rates. Methods Integrative review methodology. PubMed and Scopus databases were searched from January 2015 to July 2020. Fourteen studies set in 18 skilled nursing facilities and 50 hospitals were selected for data extraction and analysis. Results The ReEngineered Discharge model had five components and the Better Outcomes by Optimizing Safe Transitions model had eight components in the nine Care Coordination Atlas domains. Communication dominated activities in both models while neither addressed accountability/responsibility. Implementation was influenced by leadership commitment to understanding complexity of the models, culture change, integration of models into workflows, and associated labor costs. Model implementation studies consistently reported improvements in facilities’ 30-day all-cause hospital readmission rates. Discussion The Care Coordination Atlas was a useful framework to guide analysis of transitional care models. Leadership commitment to and participation in model implementation is vital. The models do not focus beyond the immediate post-discharge period limiting the impact on chronic disease management. Frameworks such as the Care Coordination Atlas are useful to help guide development of care coordination activities and associations with readmission rates.

A90 A PROPENSITY SCORE-MATCHED, STATE-LEVEL COMPARISON OF INPATIENT CIRRHOSIS OUTCOMES IN ENGLISH VS NON-ENGLISH SPEAKING PATIENTS

Abstract Background United States (US) citizens speaking a foreign language at home has increased by 192% from 1980 to 2018. Aims With the increase in multiculturalism and ongoing concerns for health disparities in the US, we sought to compare inpatient outcomes between non-English speaking and English-speaking patients with cirrhosis. Methods The 2013–14 Maryland State inpatient databases were used to compare inpatient outcomes in adult patients with cirrhosis. The analysis cohort was identified using a validated algorithm of ICD-9 codes. Cirrhosis patients were stratified based on primary language into non-English-speaking patients [NESP] vs English-speaking patients [ESP]. A 1:3 propensity score matching analysis based on possible confounders was used to finalize the analysis cohort. The primary outcome (all-cause in-hospital mortality) and secondary outcomes including 30-day all-cause readmission rates, length of stay, total hospitalization charges were then compared between groups. Results In the study period, 3,035 NESP vs 21,212 ESP discharges were identified. We matched 1,659 NESP with 4,928 ESP using a 1:3 algorithm. Table 1 highlights demographic data. In the unmatched analysis, all-cause mortality was higher in the ESP cohort compared to NESP (6.71% vs 5.73%, p=0.046). However, after propensity-matching, inpatient mortality rate became comparable between both groups (6.45% vs 6.51%, p=0.9). Thirty day all-cause readmission rates were also similar between ESP vs NESP (4.87% vs 4.28%, p=0.18). Median length of stay in the ESP group was 4 days (IQR 3–8) vs 5 days (IQR 3–7) in the NESP group, while median total charges in ESP were $55,984 (IQR $33,897-$98,679) compared to $61,262 (IQR $36,228-$$108,369) in NESP. Conclusions While significant differences in socioeconomic status and payer type exist between non-English and English speaking cirrhosis patients, these do not appear to negatively impact inpatient outcomes including all-cause inpatient mortality, 30-day readmission rates, length of stay, total hospital charges. Funding Agencies None

Abstract P546: Emergent Carotid Artery Stenting and Intracranial Thrombectomy for Acute Stroke With Tandem Occlusion

Introduction: Safety of emergent carotid artery stenting (CAS) during endovascular thrombectomy (EVT) for acute strokes with intracranial large vessel and cervical internal carotid artery tandem occlusion is still unclear. Given the potential risk of symptomatic intracranial hemorrhage (ICH) with anti-thrombotic medications required in the setting of CAS, the decision between CAS versus carotid artery angioplasty (CAA) alone remains controversial. In this study, we aimed to identify the optimal endovascular carotid revascularization approach in this patient population, using a large, nationally representative dataset. Methods: We utilized the Nationwide Readmissions Database 2016-2017 to identify patients admitted due to acute ischemic stroke who underwent anterior circulation EVT as well as CAS or CAA on the same day. Survey design methods were used to generate national estimates. Logistic regression analysis was used to compare the in-hospital outcomes between patients who underwent CAS versus CAA. Survival analysis was used to estimate the 30-day readmissions. Results: We identified 2,042 hospitalizations meeting the study inclusion criteria (mean±SD age: 66.0±12.5 years, female 31.3%). Of these, 1,391 (68.1%) had undergone CAS and 651 (31.9%) CAA alone. Baseline characteristics between the two groups were similar except patients with CAS were more likely to be on anti-thrombotics and were less likely to have received intravenous thrombolysis (tPA) as compared to those with CAA. There was no significant difference in the clinical outcomes including ICH, in-hospital mortality, gastrostomy tube placement, prolonged mechanical ventilation, length of stay, and hospital charges between the two groups in unadjusted analysis and after adjustment for the demographics and tPA use. All-cause 30-day readmission rate was similar between the two groups [hazards ratio (HR) 0.98, 95% confidence interval (CI) 0.64-1.51, p-value 0.924]. Patients with CAS had more readmissions due to ICH (HR 2.72, 95% CI 0.30-24.74) and less readmissions due to ischemic events (HR 0.78, 95% CI 0.12-5.08), although the difference was not statistically significant. Conclusion: Emergent CAS-EVT approach appears to be safe with no adverse outcomes compared to CAA alone.