All-cause Hospital Readmission Research Articles

Survival models and longitudinal medical events for hospital readmission forecasting.

The rate of 30-day all-cause hospital readmissions can affect the funding a hospital receives. An accurate and reliable readmission prediction model could save money and increase quality-of-care. Few projects have explored formulating this task as a survival prediction problem, where models can exploit a real-valued time-to-readmission target. This paper demonstrates the effectiveness of a survival-inspired readmission model, especially when paired with a longitudinal patient representation that is agnostic to disease-cohort and predictive task. We forecast readmissions for a population-level cohort of 421,088 patients discharged in 2015 and 2016 from hospitals in Alberta, Canada. Clinical features and sequences of historical medical codes (calculated from at least four full years prior to discharge) from linked administrative sources serve as model inputs. We trained binary 30-day readmission models (XGBoost and a Deep Neural Network) and time-to-event readmission models (CoxPH and N-MTLR) with and without machine-learned medical knowledge at initialization, then compared against the popular LACE-based model using the AUROC score at 30 days (AUROC@30). Survival models are additionally evaluated using concordance, Integrated Brier, and L1-loss scores. All models that utilize sequence features markedly out-perform even the best models trained on only clinical features. Further, a time-to-event target improves predictive performance at 30 days, given the same model inputs and architecture. N-MTLR, using solely sequence inputs and initialized with pre-learned medical knowledge, achieves an average AUROC@30 of 0.8460 over five folds with a standard deviation of 0.003. All trained models match or out-perform the LACE baseline of 0.6587±0.003. Sequences of administrative medical codes contain rich predictive information for forecasting readmissions, and embedding medical knowledge a priori using machine learning provides readmission models an advantageous foundation for training. When combined with a model that can leverage a time-to-event target, excellent performance is possible on the 30-day all-cause readmission task using only administrative data.

TRanscatheter Aortic-Valve Implantation with or without on-site Cardiac Surgery: the TRACS trial: TAVI in centers without on-site cardiac surgery

Transcatheter aortic valve implantation (TAVI) has emerged as an effective and safe treatment for patients with symptomatic aortic stenosis. The indication to TAVI should be agreed upon by a Heart Team, and the procedure should be performed in centers with on-site cardiac surgery. However, TAVI complications requiring emergent cardiac surgery (ECS) have become very rare. Concurrently, access disparities and prolonged waiting times are pressing issues due to increasing clinical demand of TAVI. Many solutions have been proposed and one of them is the possibility of performing TAVI in centers without on-site cardiac surgery. The TRanscatheter Aortic-Valve Implantation with or without on-site Cardiac Surgery (TRACS) trial is a prospective, randomized, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients with symptomatic severe aortic stenosis and deemed inoperable, at high surgical risk, or presenting with at least one clinical factor compromising the benefit/risk ratio for ECS, will be randomized to undergo TAVI either in centers with or without on-site cardiac surgery. The primary endpoint will be the composite occurrence of all-cause death, stroke, and hospital readmission for cardiovascular causes at one year. The safety endpoint will include death attributable to periprocedural complications actionable by ECS. The study aims to enroll 566 patients. The TRACS trial aims to address critical gaps in knowledge regarding the safety and efficacy of TAVI procedures performed in centers without on-site cardiac surgery, potentially improving access and outcomes for high-risk patients. ClinicalTrials.gov NCT05751577.

Prognostic impact of myocarditis as aetiology compared with dilated cardiomyopathy and ischaemic heart disease in heart failure

Abstract Background A subgroup of myocarditis can lead to heart failure. However, whether prognosis of myocarditis-induced heart failure differs from other heart failure remains largely unknown. Aim This study aimed to investigate the prognostic impact of myocarditis induced heart failure compared with heart failure with dilated cardiomyopathy and ischaemic heart disease as causes respectively in the overall population and a propensity score-matched cohort, based on patient-level data from the Swedish Heart Failure Registry (SwedeHF). Methods Patients with heart failure (HF) were enrolled from the SwedeHF (2003-2020) linked with the National Patient Register, and the Swedish Cause of Death Register. Endpoints were all-cause mortality, cardiovascular death, and hospital re-admissions, followed up from the index date until censoring or event. Results Of 54416 patients identified through the SwedeHF with HF, 418 hade myocarditis as aetiology (MC-HF), 6,871 with dilated cardiomyopathy (DCM-HF) and 47127 with ischemic heart diseases (IHD-HF). In general patients with MC-HF have shorter disease duration and less comorbidities compared with DCM-HF and IHD-HF, but older than DCM-HF and younger than IHD-HF. Compared with DCM-HF, MC-HF are associated with 29% higher risk for all cause mortality [(1.29 (1.07 - 1.55), p=0.0079] and 40% higher risk for cardiovascular death [ 1.40 (1.09 - 1.80), p=0.0088], and 19 % higher risk for heart failure rehospitalization [1.19 (1.03 - 1.37), p=0.018] and even higher risk by censoring within one-year . However, compared with IHD-HF, patients with MC-HF have similar risk for all cause mortality [0.95 (0.80 - 1.13), p=0.54], cardiovascular death [0.95 (0.75 - 1.20), p=0.65], and heart failure rehospitalization [0.93 (0.81 - 1.06), p=0.29]. Similar results were obtained from a propensity 1:2 matched cohort. No significant interactions were found regardless of age (< and < 70 years) , sex, LVEF (≥50%, 40-49%, 30-39% and < 30%) for all cause mortality comparing MC-HF vs DCM-HF, and MC-HF vs IHD-HF. Conclusion Patients with myocarditis-induced heart failure have worse outcome than heart failure due to dilated cardiomyopathy, with even higher risk during one year. This finding highlights the importance of early and more effective customized management of patients with myocarditis in particular those with high risk to develope heart failure.

Fluticasone Furoate/Umeclidinium/Vilanterol Initiation Following a COPD Exacerbation: Benefits of Prompt Initiation on COPD Outcomes.

Previous real-world evidence suggests that prompt versus delayed initiation of single-inhaler triple therapy (SITT) with fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) following an exacerbation results in improved clinical outcomes for patients with chronic obstructive pulmonary disease (COPD). This prior study was conducted in the first 2years following FF/UMEC/VI approval, representing early trends. The current updated analysis aims to further elucidate the real-world evidence for FF/UMEC/VI. This was a retrospective cohort study using the IQVIA PharMetrics® Plus database. Patients with COPD initiating SITT with FF/UMEC/VI within 6months of an exacerbation (index date) were classified as prompt (≤ 30days following exacerbation) or delayed (31-180days) initiators. The baseline period comprised the 12months prior to index. Inverse probability of treatment weighting was used to balance differences in baseline characteristics between cohorts. COPD exacerbations, hospital readmission rates, and healthcare costs were compared between cohorts post-index. Overall, 5421 patients (prompt, 2057; delayed, 3364) were included. After weighting, baseline characteristics were well balanced between cohorts. For up to 12months post-index, prompt initiators of FF/UMEC/VI had significantly lower rates of exacerbations per person-year versus delayed initiators (0.74 vs. 1.06; rate ratio 0.70, 95% confidence interval [CI] 0.64-0.77; P < 0.001). A 1-day delay in FF/UMEC/VI initiation was associated with a 0.31% increase in the rate of exacerbations. At 90days post-index, Kaplan-Meier rates of all-cause (hazard ratio [HR] 0.62, 95%CI 0.45-0.86; P = 0.004) and COPD-related (HR 0.58, 95%CI 0.35-0.98; P = 0.042) hospital readmissions were significantly lower in the prompt versus delayed cohort. Total COPD-related healthcare costs per person per year were significantly lower for patients in the prompt versus delayed cohort. Healthcare providers should consider the positive impact of prompt FF/UMEC/VI initiation on exacerbation rate, hospital readmission rate, and costs when treating patients with COPD at risk of exacerbations.

Leaving Against Medical Advice From Children's Hospitals.

Leaving the hospital against medical advice (AMA) reflects a breakdown in the family-clinician relationship and creates ethical dilemmas in inpatient pediatric care. There are no national data on frequency or characteristics of leaving AMA from US children's hospitals. We performed a retrospective cohort study of hospital discharges for children under 18 years old from January 1, 2018 to December 31, 2022 in 43 children's hospitals in the Pediatric Health Information System (PHIS) database. The primary outcome was leaving AMA. Exposures were demographic, geographic, and clinical characteristics. We used multivariable mixed effects logistic regression models to assess independent factors associated with leaving AMA and all-cause 14-day hospital readmission. Among 3 672 243 included inpatient encounters, 2972 (0.08%) ended in leaving AMA. Compared with non-Hispanic white patients, non-Hispanic Black patients had higher odds of leaving AMA (adjusted odds ratio [aOR] 1.31 [95% confidence interval (CI) 1.19-1.44]), whereas Hispanic patients (aOR 0.66 [95% CI 0.59-0.75]) had lower odds of leaving AMA. Hospitalizations for patients with noncommercial insurance were more likely to end in leaving AMA. Leaving AMA was associated with increased odds of 14-day inpatient readmission (aOR 1.41 [95% CI 1.24-1.61]) compared with patients who did not leave AMA. There was substantial interhospital variability in standardized rates of leaving AMA (range 0.18-2.14 discharges per 1000 inpatient encounters). Approximately 1 in 1235 inpatient encounters ended in leaving AMA. Non-Hispanic Black patients had increased odds of leaving AMA. Leaving AMA was associated with increased odds of 14-day readmission.

Homeward Stroke Recovery: Results of a Home Rehabilitation Program

Evaluate the feasibility of a homeward stroke recovery (HSR) program by measuring functional outcomes, intervention fidelity, and Profit &amp; Loss. A retrospective observational analysis of 23 stroke survivors discharged to a home healthcare (HHC) program offering early and intensive rehabilitative therapy within 24 hours of index hospitalization. Functional outcomes include timed up-and-go, transfer functional independent measures, and Barthel Index. Clinical outcomes are mortality, all-cause 30-day hospital readmission, and fall rates. Process measures consist of time-to-first HHC visit, number of physical therapy (PT) and occupational therapy (OT) visits from initial evaluation, and total number of visits by clinician type. Financial outcomes include average daily gross HSR revenue compared with an inpatient rehabilitation facility (IRF) stay and average daily net HSR profit. Functional outcomes significantly improved across all measures ( p &lt; .001) without reported falls, deaths, and only one unrelated readmission. On average, HSR began within 1.6 days from hospital discharge including 4.2 PT and 3.7 OT visits within 5 days of respective initial evaluation. Patients received an average of 9.4 nursing, 9.2 PT, 6.4 OT, and 2.2 speech therapy visits. Exploratory analyses demonstrated similar functional recovery despite longer hospitalization (rs = 0.43; p = .039). Revenue per day was lower for HSR than IRF services but costs exceeded the reimbursement rates for this program. The HSR program is feasible given that patients realized significant functional improvement with negligible consequences. Reimbursement reform is necessary to sustain and scale the program. Further studies with larger sample sizes are warranted.

Hospital Readmissions Among Infants With Neonatal Opioid Withdrawal Syndrome

Although cases of neonatal opioid withdrawal syndrome (NOWS) increased 5-fold in recent years, no study has examined national hospital readmission rates for these infants. To examine hospital readmissions for infants with and without NOWS. This retrospective cohort study analyzed serial cross-sectional samples of US hospital discharge records from the Nationwide Readmissions Database for calendar years 2016 to 2020. Infants with NOWS were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. The data analysis was performed between January 5, 2023, and May 6, 2024. Neonatal opioid withdrawal syndrome. Survey-weighted logistic regression was used to examine 90-day all-cause and cause-specific hospital readmissions. Multivariable models adjusted for sex, low birth weight, gestational age, multiple gestation, type of insurance, and year of birth. Of the 13 855 246 newborns identified in this weighted analysis, 89 018 (0.6%) were diagnosed with NOWS, of whom 53.8% were male and 81.1% born full-term (>36 weeks gestation). The 90-day all-cause readmission rate was 4.2% for infants with NOWS compared with 3.0% for those without NOWS (P < .001). After risk adjustment, the odds of all-cause readmission were higher among infants with NOWS (adjusted odds ratio [AOR], 1.18; 95% CI, 1.08-1.29). Infants with NOWS had significantly higher odds of readmissions for seizures (AOR, 1.58; 95% CI, 1.01-2.46), failure to thrive (AOR, 1.99; 95% CI, 1.36-2.93), traumatic brain injury (AOR, 2.95; 95% CI, 1.76-4.93), and skull fractures (AOR 3.72; 95% CI, 2.33-5.93). Infants with NOWS had higher odds of receiving a diagnosis of confirmed maltreatment (AOR, 4.26; 95% CI, 2.19-8.27), including for neglect (AOR, 14.18; 95% CI, 5.55-36.22) and physical abuse (AOR, 2.42; 95% CI, 0.93-6.29); however, the latter finding was not statistically significant. In this nationally representative cohort study, infants with NOWS were at increased risk of readmission for any cause as well as for trauma and confirmed maltreatment. These findings may in part reflect the dual stressors that mothers with opioid use disorder face in caring for a newborn with NOWS in the context of a substance use disorder and underscore the need for family-based, in-home services that focus concurrently on substance use treatment and parenting support.

Rapid-recovery protocol for minimally invasive mitral valve repair

BackgroundMinimally invasive mitral valve repair (MIMVR), often performed within specialized care pathways, has been shown to reduce hospital length of stay and improve patient recovery. The relative value of rapid-recovery protocols as a component of care pathways, including enhanced recovery programs (ERPs), has not been well described. This study compared clinical outcomes following implementation of a new, comprehensive rapid-recovery protocol within a previously established, mature ERP for patients undergoing MIMVR. MethodsThe rapid-recovery protocol was developed and implemented by a multidisciplinary team to further optimize patient recovery within an existing ERP. The protocol was applied to 75 consecutive patients undergoing MIMVR between September 2022 and December 2023. Outcomes were compared retrospectively to 75 ERP control patients who did not receive the rapid-recovery protocol but experienced the ERP. The primary outcome was a composite of discharge from the intensive care unit (ICU) by postoperative day (POD) 1, discharge to home by POD 4, and no all-cause hospital readmission by 30 days. ResultsBaseline characteristics were similar in the 2 groups. Patients in the rapid-recovery group achieved the primary composite outcome significantly more often compared to the control group (60% vs 40%, respectively). There was no between-group difference in postoperative complications. Multivariable logistic regression showed that age ≤60 years was significantly associated with rapid-recovery protocol success. Clinical barriers to achieving individual components of the primary outcome were described. ConclusionsA rapid-recovery protocol for MIMVR was associated with early ICU and hospital discharge. These benefits were safely achieved without any increase in hospital readmission, morbidity, or mortality up to 30 days postoperatively.

Effects of Social Isolation and Loneliness on Heart Failure Self-care: A Cross-sectional Analysis.

Patients with heart failure (HF) who engage in effective HF self-care have better quality of life, and lower risks of all-cause and HF-related hospital readmission and mortality. It is unclear whether social isolation and loneliness, which are prevalent among patients with HF and known to affect other self-care behaviors, can predict HF self-care. The aim was to explore the relationship between social isolation, loneliness, and HF self-care. This was a cross-sectional secondary analysis (n = 49) of the GEtting iNTo Light Exercise for HF randomized controlled trial, a 6-month home-based live group gentle exercise intervention for patients with HF. Measures included the following: 6-item Lubben Social Network Scale for social isolation, Patient-Reported Outcomes Measurement Information System Social Isolation survey for loneliness, Self-Care of Heart Failure Index, and Patient-Reported Outcomes Measurement Information System Depression survey. Multiple linear regression modeling was used to examine the relationships of 4 HF self-care processes to social isolation and loneliness, adjusting for depression and grouping (control group or intervention group). Scores indicating less social isolation predicted higher self-care maintenance (B = 0.937, P = .015), monitoring (B = 0.799, P = .041), and management (B = 1.812, P < .001). Loneliness did not predict HF self-care. To our knowledge, this is the first study to predict HF self-care using distinct measures for social isolation and loneliness. Patients who were less socially isolated engaged in better HF self-care; loneliness had no relationship with HF self-care. Prospective studies are needed to investigate causal relationships between social isolation and HF-self-care engagement to determine the effect on outcomes such as hospital readmission and mortality.

Home based cardiac rehabilitation: A retrospective cohort analysis on all-cause mortality and hospital readmission rates across sexes and races

ObjectiveStudies have shown that both home-based cardiac rehabilitation (HBCR) and center-based cardiac rehabilitation (CBCR) exhibit comparable efficacy in reducing mortality during short-term follow-up periods of up to 12 months. However, research on sex- and race-specific outcomes associated with HBCR is limited. This study examines all-cause mortality and hospital readmission among patients referred to HBCR, with stratification by sex and race. MethodsThis Kaiser Permanente Southern California (KPSC) retrospective cohort study followed 6,868 patients from HBCR referral until death, disenrollment, or December 31, 2021. There were 3,835 HBCR graduates, 722 non-graduates, and 2,311 non-enrolled patients. Cox models were used to estimate hazard ratios (HR) and 95 % confidence intervals (CI) comparing 1) HBCR graduates vs. non-enrolled, and 2) HBCR graduates vs. non-graduates, stratified by sex and race. Differential outcomes among strata were analyzed using Kaplan-Meier curves. ResultsAmong the 6,868 patients referred to HBCR, 4693 (68.3 %) were male, 2,175 (31.7 %) female, 870 (12.7 %) Asian/Pacific Islander, 731 (10.6 %) African American, 1,612 (23.6 %) Hispanic/Latino, and 3,646 non-Hispanic White (53.1 %). Over a mean follow-up period of 2.28 years, HBCR graduates, compared to patients who did not enroll in HBCR, had overall significantly lower risks of all-cause mortality and hospitalization. These results remained significant with stratification by sex and race. Compared to HBCR non-graduates, HBCR graduates overall had significantly lower risks of all-cause mortality and hospitalization. In the same comparison, mortality risk was significantly reduced for male and White patients; risk of hospital readmission was significantly reduced in both sexes, African American, and White patients. Among HBCR graduates, no significant differences in all-cause mortality or hospital readmission were observed across sexes and races. ConclusionHBCR participation is associated with reduction of all-cause mortality and hospital readmission rates across sexes and races. Notably, we observed benefits at varying levels of engagement, which suggests that even partial completion of HBCR is associated with risk reduction. Among HBCR graduates, we found similar outcomes across sexes and races, which suggests that the program can be effective among diverse patient groups.

A multicenter randomized trial to compare automatic versus as-needed follow-up for children hospitalized with common infections: The FAAN-C trial protocol.

Physicians commonly recommend automatic primary care follow-up visits to children being discharged from the hospital. While automatic follow-up provides an opportunity to address postdischarge needs, the alternative is as-needed follow-up. With this strategy, families monitor their child's symptoms and decide if they need a follow-up visit in the days after discharge. In addition to being family centered, as-needed follow-up has the potential to reduce time and financial burdens on both families and the healthcare system. As-needed follow-up has been shown to be safe and effective for children hospitalized with bronchiolitis, but the extent to which hospitalized children with other common conditions might benefit from as-needed follow-up is unclear. The Follow-up Automatically versus As-Needed Comparison (FAAN-C, or "fancy") trial is a multicenter randomized controlled trial. Children who are hospitalized for pneumonia, urinary tract infection, skin and soft tissue infection, or acute gastroenteritis are eligible to participate. Participants are randomized to an as-needed versus automatic posthospitalization follow-up recommendation. The sample size estimate is 2674 participants and the primary outcome is all-cause hospital readmission within 14 days of discharge. Secondary outcomes are medical interventions and child health-related quality of life. Analyses will be conducted in an intention-to-treat manner, testing noninferiority of as-needed follow-up compared with automatic follow-up. FAAN-C will elucidate the relative benefits of an as-needed versus automatic follow-up recommendation, informing one of the most common decisions faced by families of hospitalized children and their medical providers. Findings from FAAN-C will also have implications for national quality metrics and guidelines.

A Preoperative Risk Assessment Tool for Predicting Adverse Outcomes among Total Shoulder Arthroplasty Patients

With the increased utilization of Total Shoulder Arthroplasty (TSA) in the outpatient setting, understanding the risk factors associated with complications and hospital readmissions becomes a more significant consideration. Prior developed assessment metrics in the literature either consisted of hard-to-implement tools or relied on postoperative data to guide decision-making. This study aimed to develop a preoperative risk assessment tool to help predict the risk of hospital readmission and other postoperative adverse outcomes. We retrospectively evaluated the 2019-2022(Q2) Medicare fee-for-service inpatient and outpatient claims data to identify primary anatomic or reserve TSAs and to predict postoperative adverse outcomes within 90days postdischarge, including all-cause hospital readmissions, postoperative complications, emergency room visits, and mortality. We screened 108 candidate predictors, including demographics, social determinants of health, TSA indications, prior 12-month hospital, and skilled nursing home admissions, comorbidities measured by hierarchical conditional categories, and prior orthopedic device-related complications. We used two approaches to reduce the number of predictors based on 80% of the data: 1) the Least Absolute Shrinkage and Selection Operator logistic regression and 2) the machine-learning-based cross-validation approach, with the resulting predictor sets being assessed in the remaining 20% of the data. A scoring system was created based on the final regression models' coefficients, and score cutoff points were determined for low, medium, and high-risk patients. A total of 208,634 TSA cases were included. There was a 6.8% hospital readmission rate with 11.2% of cases having at least one postoperative adverse outcome. Fifteen covariates were identified for predicting hospital readmission with the area under the curve of 0.70, and 16 were selected to predict any adverse postoperative outcome (area under the curve =0.75). The Least Absolute Shrinkage and Selection Operator and machine learning approaches had similar performance. Advanced age and a history of fracture due to orthopedic devices are among the top predictors of hospital readmissions and other adverse outcomes. The score range for hospital readmission and an adverse postoperative outcome was 0 to 48 and 0 to 79, respectively. The cutoff points for the low, medium, and high-risk categories are 0-9, 10-14, ≥15 for hospital readmissions, and 0-11, 12-16, ≥17 for the composite outcome. Based on Medicare fee-for-service claims data, this study presents a preoperative risk stratification tool to assess hospital readmission or adverse surgical outcomes following TSA. Further investigation is warranted to validate these tools in a variety of diverse demographic settings and improve their predictive performance.

#87 Hospital readmissions among individuals with severe kidney disease hospitalized for fluid overload

Abstract Background and Aims Fluid overload is a common presentation and a leading cause for hospitalizations in severe kidney disease, but interventions can help reduce readmissions. To identify at-risk individuals, we evaluated the incidence and risk factors associated with fluid overload and all-cause hospital readmission among individuals with severe kidney disease. Method Single-center retrospective cohort study of patients hospitalized in Singapore General Hospital for fluid overload between 2015 and 2017. Fluid overload was identified from discharge codes for fluid overload, heart failure, pulmonary edema, and generalized edema. Patients were included if their estimated glomerular filtration rate (eGFR) was between 11 and 30 ml/min/1.73 m2, but excluded if they had urgent indications for dialysis or were lost to follow-up (Fig. 1). Baseline data on demographics, comorbidities, biochemistry and medication use during admission were retrieved from electronic medical records up till 30th December 2018. The outcomes were fluid overload-related and all-cause readmissions within 30 days of discharge of the index hospitalization. Multivariable logistic regression analysis (stepwise method) was performed with inclusion of covariates with P ≤ .10 on univariate analysis. Results Among 783 patients, the median age was 75 (IQR 67, 83) years and the admission eGFR was 20.9 (IQR 16.1, 25.4) ml/min/1.73 m2 at index hospitalization. 30-day readmission for fluid overload and all-causes occurred in 10.6% and 26.8% of the cohort, respectively (Table 1). Individuals with fluid overload readmissions were more likely to have atherosclerotic cardiovascular disease (ASCVD), atrial fibrillation (AF), prior hospitalization for fluid overload within 6 months, lower serum sodium and bicarbonate, but higher serum potassium at admission (Table 1). They were less likely to have hypertension, prior nephrology consult within 3 months and renin-angiotensin system (RAS) blocker prescription at discharge. In multivariable analysis, 30-day readmission for fluid overload was independently associated with ASCVD (adjusted odds ratio (aOR) 1.81, 95% CI 1.08-3.03, P = .02), AF (aOR 1.93, 95% CI 1.13-3.29, p = 0.02), higher serum potassium (aOR 1.61, 95% CI 1.14-2.26, P = .007), high-dose intravenous furosemide (aOR 1.66, 95% CI 1.02-2.67, P = .04), and inversely associated with prior nephrology consult (aOR, 0.51, 95% CI 0.29-0.89, P = .02) and RAS blocker prescription at discharge (aOR 0.61, 95% CI 0.38-0.99, P = .04). Individuals with all-cause readmissions were more likely to have AF, more frequent emergency department visits within 6 months, lower eGFR and serum sodium, but higher serum potassium on admission, longer length of stay and higher LACE index (Table 1). They were less likely to have hypertension, RAS blocker and statin prescription at discharge. 30-day readmission for all-causes was independently associated with higher number of emergency department visits (aOR 1.21, 95% CI 1.04-1.40, P = .02), higher LACE index (aOR 1.08, 95% CI 0.001-1.17, P = .048), and inversely associated with mineralocorticoid receptor blocker (aOR 0.55, 95% CI 0.31-0.97, P = .04) and statin prescription at discharge (aOR 0.51, 95% CI 0.33-0.78, P = .002) in multivariable analysis. Conclusion Risk stratification of patients with severe kidney disease who are at-risk of fluid overload and all-cause readmissions may allow for targeted interventions to reduce hospital readmissions.

Blood Pressure, Readmission, and Mortality Among Patients Hospitalized With Acute Kidney Injury

Acute kidney injury (AKI) complicates 20% to 25% of hospital admissions and is associated with long-term mortality, especially from cardiovascular disease. Lower systolic blood pressure (SBP) following AKI may be associated with lower mortality, but potentially at the cost of higher short-term complications. To determine associations of SBP with mortality and hospital readmissions following AKI, and to determine whether time from discharge affects these associations. This retrospective cohort study of adults with AKI during a hospitalization in Veteran Healthcare Association (VHA) hospitals was conducted between January 2013 and December 2018. Patients with 1 year or less of data within the VA system prior to admission, severe or end-stage liver disease, stage 4 or 5 chronic kidney disease, end-stage kidney disease, metastatic cancer, and no blood pressure values within 30 days of discharge were excluded. Data analysis was conducted from May 2022 to February 2024. SBP was treated as time-dependent (categorized as <120 mm Hg, 120-129 mm Hg, 130-139 mm Hg, 140-149 mm Hg, 150-159 mm Hg, and ≥160 mm Hg [comparator]). Time spent in each SBP category was accumulated over time and represented in 30-day increments. Primary outcomes were time to mortality and time to all-cause hospital readmission. Cox proportional hazards regression was adjusted for demographics, comorbidities, and laboratory values. To evaluate associations over time, hazard ratios (HRs) were calculated at 60 days, 90 days, 120 days, 180 days, 270 days, and 365 days from discharge. Of 237 409 admissions with AKI, 80 960 (57 242 aged 65 years or older [70.7%]; 77 965 male [96.3%] and 2995 female [3.7%]) were included. The cohort had high rates of diabetes (16 060 patients [20.0%]), congestive heart failure (22 516 patients [28.1%]), and chronic lung disease (27 682 patients [34.2%]), and 1-year mortality was 15.9% (12 876 patients). Overall, patients with SBP between 130 and 139 mm Hg had the most favorable risk level for mortality and readmission. There were clear, time-dependent mediations on associations in all groups. Compared with patients with SBP of 160 mm Hg or greater, the risk of mortality for patients with SBP between 130 and 139 mm Hg decreased between 60 days (adjusted HR, 1.20; 99% CI, 1.00-1.44) and 365 days (adjusted HR, 0.58; 99% CI, 0.45-0.76). SBP less than 120 mm Hg was associated with increased risk of mortality at all time points. In this retrospective cohort study of post-AKI patients, there were important time-dependent mediations of the association of blood pressure with mortality and readmission. These findings may inform timing of post-AKI blood pressure treatment.

Clinical outcomes in patients with piperacillin/tazobactam-non-susceptible but ceftriaxone-susceptible E. coli or K. pneumoniae bloodstream infection.

A small proportion of Escherichia coli and Klebsiella pneumoniae demonstrate in vitro non-susceptibility to piperacillin/tazobactam but retain susceptibility to ceftriaxone. Uncertainty remains regarding how best to treat these isolates. We sought to compare clinical outcomes between patients with piperacillin/tazobactam-non-susceptible but ceftriaxone-susceptible E. coli or K. pneumoniae bloodstream infection receiving definitive therapy with ceftriaxone versus an alternative effective antibiotic. We retrospectively identified patients with a positive blood culture for piperacillin/tazobactam-non-susceptible but ceftriaxone-susceptible E. coli or K. pneumoniae between 1 January 2013 and 31 December 2022. Patients were divided into one of two definitive treatment groups: ceftriaxone or alternative effective antibiotic. Our primary outcome was a composite of 90 day all-cause mortality, hospital readmission, or recurrence of infection. We used Cox proportional hazards models to compare time with the composite outcome between groups. Sixty-two patients were included in our analysis. Overall, median age was 63 years (IQR 49.5-71.0), the most common source of infection was intra-abdominal (25/62; 40.3%) and the median total duration of therapy was 12.0 days (IQR 9.0-16.8). A total of 9/22 (40.9%) patients in the ceftriaxone treatment group and 18/40 (45.0%) patients in the alternative effective antibiotic group met the composite endpoint. In an adjusted time-to-event analysis, there was no difference in the composite endpoint between groups (HR 0.67, 95% CI 0.30-1.50). The adjusted Bayesian posterior probability that the HR was less than or equal to 1 (i.e. ceftriaxone is as good or better than alternative therapy) was 85%. These findings suggest that ceftriaxone can be used to effectively treat bloodstream infections with E. coli or K. pneumoniae that are non-susceptible to piperacillin/tazobactam but susceptible to ceftriaxone.

PEERLESS II: A Randomized Controlled Trial of Large-Bore Thrombectomy Versus Anticoagulation in Intermediate-Risk Pulmonary Embolism

BackgroundAnticoagulation (AC) is the guideline-recommended treatment for intermediate-risk pulmonary embolism (PE); however, it remains unclear whether mechanical thrombectomy provides benefit over AC alone. The PEERLESS II study aims to evaluate outcomes in intermediate-risk PE patients randomized to treatment with large-bore mechanical thrombectomy and AC vs AC alone. MethodsPEERLESS II is an international randomized controlled trial enrolling up to 1200 patients with intermediate-risk PE and additional clinical risk factors from up to 100 sites. Treatment is randomized 1:1 to large-bore mechanical thrombectomy with the FlowTriever System (Inari Medical) and AC or AC alone. Outcomes will be evaluated for up to 3 months, with safety events independently adjudicated. The primary end point is a hierarchical composite win ratio of (1) all-cause mortality by 30 days, (2) clinical deterioration (earlier of discharge or 30 days), (3) all-cause hospital readmission by 30 days, (4) bailout therapy (earlier of discharge or 30 days), and (5) Modified Medical Research Council (mMRC) dyspnea score of ≥1 at the 48-hour visit. Secondary end points include all-cause and PE-related mortality (30-day and 90-day), all-cause and PE-related readmission (30-day and 90-day), major bleeding (30-day and 90-day), clinical deterioration (earlier of discharge or 30 days), bailout (earlier of discharge or 30 days), right ventricle-to-left ventricle diameter ratio (48-hour visit), mMRC dyspnea score (48-hour, 1-month, and 3-month visits), quality of life using Pulmonary Embolism Quality of Life and EuroQol-5 Dimensions-5 Levels (1-month and 3-month visits), 6-minute walk distance (1-month visit), and post-PE impairment diagnosis (3-month visit). ConclusionsPEERLESS II will inform the understanding of mechanical thrombectomy treatment for intermediate-risk PE and provide evidence for consideration in future treatment guidelines.

Prognostic impact of insomnia in patients receiving trans-catheter aortic valve replacement

BackgroundThe presence of insomnia exhibits a profound association with diverse cardiovascular pathologies. However, its prognostic implications in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis remain ambiguous. MethodsThis retrospective study enrolled patients who underwent TAVR for severe aortic stenosis at a prominent academic center from 2015 to 2022. The impact of insomnia, operationally defined as the prescription of soporific agents, on the two-year composite primary outcome comprising all-cause mortality and hospital readmissions was scrutinized. ResultsA cohort of 345 patients (median age 85 years, 99 males) was encompassed in the analysis. All subjects underwent successful TAVR and subsequent discharge. The presence of insomnia (N = 91) emerged as an independent predictor of the two-year composite endpoint, with an adjusted hazard ratio of 1.66 (95 % confidence interval 1.08–2.57, p = 0.022), significantly delineating the two-year cumulative incidence of the primary endpoint (40 % versus 30 %, p = 0.035). ConclusionApproximately one-fourth of TAVR candidates manifested symptoms of insomnia, a condition autonomously correlated with heightened mortality and morbidity following the TAVR procedure. The optimal strategy for addressing insomnia in TAVR candidates constitutes a paramount consideration for future interventions.

Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data.

Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty. Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes. A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time ( P < 0.001). TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued. Level III, therapeutic retrospective cohort study.

Analysis of 30-day hospital readmissions and related risk factors for COVID-19 patients with myocarditis hospitalized in the United States during 2020

Background Despite extensive research on COVID-19 and its association with myocarditis, limited data are available on readmission rates for this subset of patients. Thirty-day hospital readmission rate is an established quality metric that is associated with increased mortality and cost. Methods This retrospective analysis utilized the Nationwide Readmission Database for the year 2020 to evaluate 30-day hospital readmission rates, risk factors, and clinical outcomes among COVID-19 patients who presented with myocarditis at their index hospitalization. Results Our analysis revealed that 1) the 30-day all-cause hospital readmission rate for patients initially hospitalized with COVID-19 and myocarditis was 11.7%; 2) after multivariate adjustment, the primary predictor of readmission for COVID-19 patients with myocarditis was discharge against medical advice; 3) COVID-19 patients with myocarditis who required readmission had a higher proportion of older patients and Medicare beneficiaries; 4) the most common diagnoses at readmission were COVID-19, sepsis, congestive heart failure, acute myocardial infarction, and pneumonia; and 5) readmitted patients were more likely to require renal replacement therapy during their index hospitalization. Conclusion This study underscores the importance of optimizing discharge plans, preventing irregular discharges through shared decision-making, and ensuring robust post-hospital follow-up for patients with COVID-19 and myocarditis at index admission.

Impact of Frailty on Heart Failure Prognosis: Is Sex Relevant?

Heart failure (HF) is one of the most frequent causes of hospital admission in elderly patients, especially in women, who present a high prevalence of geriatric syndromes like frailty. Studies have suggested that frailty and its impact may also differ between males and females. Understanding how frailty may differently affect HF patients depending on sex is therefore imperative for providing personalized care. The aim of this review is to summarize the role of sex in the prognostic impact of frailty in HF patients. Numerous studies have identified frailty as a significant predictor of all-cause mortality and hospital readmissions. A recent study of elderly HF out-patients demonstrated that while women had a higher prevalence of frailty, it was an independent predictor of mortality and readmission only in men. Moreover, another study revealed that physical frailty was associated with time to first clinical event among men but not among women. These results raise the question about why frailty affects differently HF prognosis in men and women. Women with HF present a higher prevalence of frailty, especially when it is considered as physical decline. Nevertheless, frailty affects differently HF prognosis in men and women. Women with HF present lower mortality than men and frailty is related with prognosis only in men. The different severity of HF between men and women and other hormonal, psychosocial, and clinical factors might be involved in this fact.