All-cause Readmission Research Articles

Impact of Elevated Gradients After Transcatheter Aortic Valve Implantation for Degenerated Surgical Aortic Valve Bioprostheses.

Elevated aortic valve gradients are common after transcatheter aortic valve implantation for degenerated surgical aortic valve replacement bioprostheses, but their clinical impact is uncertain. A total of 12 122 patients who underwent transcatheter aortic valve implantation-in-surgical aortic valve replacement from November 2011 to December 2019 in the Society of Thoracic Surgery/American College of Cardiology Transvalvular Therapeutics Registry were included. The primary outcome was a composite of 1-year all-cause mortality, stroke, myocardial infarction, or valve reintervention. Secondary outcomes included 1-year all-cause mortality, readmission, and change from baseline 12-question self-administered Kansas City Cardiomyopathy Questionnaire-Overall Summary Score. Due to nonlinearity observed with restricted cubic splines analysis, a Cox regression analysis with aortic valve mean gradient modeled as a spline-continuous variable (with 20 mm Hg as a cutoff) was used to study the 1-year composite outcome and mortality. The composite outcome occurred most frequently in patients with aortic valve mean gradient ≥30 and <10 mm Hg, as compared with those with 10 to 20 and 20 to 30 mm Hg ranges (unadjusted rates, 13.9%, 12.1%, 7.5%, and 6.5%, respectively; P=0.002). When the mean aortic valve gradient was ≥20 mm Hg, higher gradients were associated with greater risk of the 1-year composite outcome (adjusted hazard ratio, 1.02 [1.02-1.03] per mm Hg; P<0.001) and 1-year mortality (adjusted hazard ratio, 1.02 [1.00-1.03] per mm Hg; P=0.007). Whereas when the mean aortic valve gradient was <20 mm Hg, higher gradients were not significantly associated with the composite outcome (adjusted hazard ratio, 0.99 [0.98-1.003] per mm Hg; P=0.12) but were associated with lower 1-year mortality (adjusted hazard ratio, 0.98 [0.97-0.99] per mm Hg; P=0.007). The relationship between postprocedural aortic valve mean gradient after transcatheter aortic valve implantation-in-surgical aortic valve replacement and clinical outcomes is complex and nonlinear, with relatively greater adverse events occurring at low and high gradient extremes. Further study of factors mediating the relationship between postprocedural gradients and clinical outcomes, including low-flow states, is necessary.

#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.

#1994 Analysis of dynamics of parameters of safety and effectiveness of rivaroxaban in patients with stage IV chronic kidney disease and atrial fibrillation

Abstract Background and Aims Research in the field of comorbidity of chronic kidney disease (CKD) and atrial fibrillation (AF) is becoming increasingly relevant, especially given the continuously increasing prevalence of this arrhythmia and its contribution to the risk of adverse events, the unity of factors in the development and progression of these diseases. This comorbidity is accompanied by an increased risk of thromboembolic complications (TEC) and atherothrombotic events, as well as the incidence of bleeding during anticoagulant therapy (ACT), which undoubtedly underlies the higher rates of cardiovascular and overall mortality in this cohort of patients. In this regard, we set the following goal: analysis of the dynamics and assessment of the safety parameters and effectiveness of the use of rivaroxaban in patients with a glomerular filtration rate (GFR) of 15–29 ml/min/1.73 m2 with non-valvular atrial fibrillation. Method The medical records of 12,026 patients were analyzed; non-valvular AF was diagnosed in 3,715 cases. 502 (15%) patients had stage IV CKD or a sustained decrease in GFR to 15–29 l/min/1.73 m2 during hospitalization. Of these, 109 (3%) patients met the inclusion criteria and were randomized 2:1 to rivaroxaban 15 mg (n = 73) or warfarin (n = 36). The average follow-up period was 18 months. Of the 109 included patients, 2 refused to participate in the study, contact with 9 was lost, 8 patients started taking another direct oral anticoagulant, CKD progressed to stage V in 4 patients, and antiplatelet agents were added in 6 cases. Results To assess the dynamics of changes in creatinine levels and GFR, mixed linear models were constructed, where the individual dynamics of each patient's indicators were selected as random effects, and time and drug intake were selected as fixed effects. A graphical interpretation of the dynamics and differences is presented in Figs 1 and 2. There was a significant improvement in the dynamics of creatinine and GFR in the rivaroxaban group compared to the warfarin group: while patients receiving rivaroxaban had an increase in GFR and a decrease in creatinine levels, patients taking warfarin, on the contrary, showed inverse dynamics in renal function indicators. It should be noted that during the study, a transition from stage IV CKD to stage III was recorded in 43% of patients in the rivaroxaban group and in 34% in the warfarin group (p = 0.26). There were no significant differences in the incidence of any acute cerebrovascular accident, myocardial infarction and all-cause mortality (warfarin—1.4%; 6.9%; 6.8% versus rivaroxaban—5.6%; 2.85; 8.3% (p = 0.25; 0.66; 0.78). Patients taking warfarin were significantly more likely to develop minor bleeding compared to rivaroxaban (36.9% versus 61.1% (p = 0. 01)) and all clinically significant bleeding (10.9% vs. 27.7% (p = 0.03)) according to the ISTH scale. In the warfarin group, TTR&amp;gt;70% was achieved in 94% of patients. All-cause readmission rates were 43% in the rivaroxaban group and 48% in the warfarin group (p = 0.57). Among these patients, 36.9% and 40.7% (respectively) were hospitalized for emergency reasons (p = 0.96). Conclusion In patients with atrial fibrillation and a low glomerular filtration rate (eGFR &amp;lt;30 ml/min/1.73 m2), it is reasonable to consider the use of rivaroxaban based on the current study showing a slower rate of decline in renal function, as well as favorable efficacy and safety profiles of rivaroxaban compared with warfarin in this group of patients.

Clinical Implications of Remote Dielectric Sensing-Guided Management.

Background: Remote dielectric sensing (ReDS) systems can quantify the degree of pulmonary congestion rapidly and non-invasively. However, the clinical implications of ReDS-guided medication adjustment remain uncertain. Methods: Patients hospitalized to treat cardiovascular diseases, including heart failure, valvular disease, and coronary artery disease, and underwent ReDS measurement before index discharge between 2021 and 2022 were included. According to our institutional protocol, ReDS values were blinded to the attending clinicians until February 2022 (blind period). After the period, ReDS values were timely opened to the attending clinicians, and medications such as diuretics were adjusted according to the ReDS values (target value between 20% and 35%) before index discharge (open period). A composite primary outcome of all-cause death and heart failure readmissions was compared between the two groups. Results: A total of 183 patients were included (median 79 years old, 101 men), consisting of 138 patients in the blind period and 45 patients in the open period. During a median of 646 (401, 818) days after the index discharge, 33 patients experienced the primary outcome of interest. Management during the open period, where medications were adjusted according to ReDS values, was independently associated with a lower incidence of the primary outcome with an adjusted hazard ratio of 0.22 (95% confidence interval 0.05-0.94, p = 0.041), as compared with those of the blind period. Conclusions: According to the findings of the present retrospective study, ReDS-guided management may have the potential to reduce the risk of mortality and heart failure admission in individuals hospitalized for cardiovascular diagnoses. Further prospective randomized control trials involving those with a variety of background etiologies and clinical scenarios are warranted to validate our findings and establish optimal ReDS-guided management.

The Impact of Acute Heart Failure on Frailty Degree and Outcomes in Elderly Patients with Severe Aortic Stenosis and Chronic Heart Failure with Preserved Ejection Fraction.

Frailty degree plays a critical role in the decision-making and outcomes of elderly patients with severe aortic stenosis (AS). Acute heart failure (AHF) results in a severely worse clinical hemodynamic status in this population. This study aimed to evaluate the impact of AHF on frailty degree and outcomes in older patients referred for tailored interventional treatment due to AS. A total of 109 patients (68% female; mean age 83.3 ± 5.4), evaluated by a multidisciplinary path for "frailty-based management" of valve disease, were divided into two groups, one with (AHF+) and one without AHF (AHF-) and preserved ejection fraction (mean value EF: 57.4 ± 8.6). AHF occurred a mean value of 55 days before geriatric, clinical, and surgical assessment. A follow-up for all-cause mortality and readmission was conducted at 20 months. AHF+ patients showed a higher frequency of advanced frailty (53.3% vs. 46.7%, respectively), rehospitalization (35.5% vs. 12.8; p = 0.007), and death (41.9% vs. 12.8%; p < 0.001). In stepwise logistic regression analysis, AHF emerged as an independent risk factor for advanced frailty (OR: 3.8 CI 1.3-10.7; p = 0.01) and hospital readmission (OR: 3.6 CI 1.1-11.6; p = 0.03). In addition, preceding AHF was an independent determinant associated with a higher risk of mortality (HR 2.65; CI 95% 1.04-6.74; p-value 0.04). AHF is independently associated with advanced frailty and poor outcomes in elderly patients with severe AS. So, this population needs careful clinical and geriatric monitoring and the implementation of interventional therapy for AS in the early stages of frailty to avoid the occurrence of AHF and poor outcomes.

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.

Titration of Medications After Acute Heart Failure Is Safe, Tolerated, and Effective Regardless of Risk

BackgroundGuideline-directed medical therapy (GDMT) decisions may be less affected by single patient variables such as blood pressure or kidney function and more by overall risk profile. In STRONG-HF (Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure), high-intensity care (HIC) in the form of rapid uptitration of heart failure (HF) GDMT was effective overall, but the safety, tolerability and efficacy of HIC across the spectrum of HF severity is unknown. Evaluating this with a simple risk-based framework offers an alternative and more clinically translatable approach than traditional subgroup analyses. ObjectivesThe authors sought to assess safety, tolerability, and efficacy of HIC according to the simple, powerful, and clinically translatable MAGGIC (Meta-Analysis Global Group in Chronic) HF risk score. MethodsIn STRONG-HF, 1,078 patients with acute HF were randomized to HIC (uptitration of treatments to 100% of recommended doses within 2 weeks of discharge and 4 scheduled outpatient visits over the 2 months after discharge) vs usual care (UC). The primary endpoint was the composite of all-cause death or first HF rehospitalization at day 180. Baseline HF risk profile was determined by the previously validated MAGGIC risk score. Treatment effect was stratified according to MAGGIC risk score both as a categorical and continuous variable. ResultsAmong 1,062 patients (98.5%) with complete data for whom a MAGGIC score could be calculated at baseline, GDMT use at baseline was similar across MAGGIC tertiles. Overall GDMT prescriptions achieved for individual medication classes were higher in the HIC vs UC group and did not differ by MAGGIC risk score tertiles (interaction nonsignificant). The incidence of all-cause death or HF readmission at day 180 was, respectively, 16.3%, 18.9%, and 23.2% for MAGGIC risk score tertiles 1, 2, and 3. The HIC arm was at lower risk of all-cause death or HF readmission at day 180 (HR: 0.66; 95% CI: 0.50-0.86) and this finding was robust across MAGGIC risk score modeled as a categorical (HR: 0.51; 95% CI: 0.62-0.68 in tertiles 1, 2, and 3; interaction nonsignificant) for all comparisons and continuous (interaction nonsignificant) variable. The rate of adverse events was higher in the HIC group, but this observation did not differ based on MAGGIC risk score tertile (interaction nonsignificant). ConclusionsHIC led to better use of GDMT and lower HF-related morbidity and mortality compared with UC, regardless of the underlying HF risk profile. (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP testinG, of Heart Failure Therapies [STRONG-HF]; NCT03412201)

Improving patient education in hospitalized patients with chronic obstructive pulmonary disease: A quality improvement initiative using LEAN methodology.

Chronic obstructive pulmonary disease (COPD) is a costly chronic disease affecting more than 15 million Americans. The prevalence among US veterans is 3 times higher than the general population. The Veteran Health Administration developed a standardized, evidence-based COPD educational tool called Green Light to Go (GLTG) designed to educate patients on managing their COPD symptoms at home. Despite the availability of this resource, inpatient education on COPD self-management practices is highly variable across different medical teams. This quality improvement (QI) initiative sought to standardize inpatient COPD patient education using the GLTG tool. This initiative also assessed whether patients receiving standardized patient education during their index hospitalization had lower COPD 30-day readmission rates. The QI initiative followed the LEAN methodology and the A3 framework. The team performed rapid tests of change (plan-do-study-act cycles) to increase the percentage of veterans receiving COPD education. The interventions implemented for this QI initiative focused on clinical, patient, and system improvements. This initiative standardized COPD patient education and increased the percentage of veterans receiving (a) daily COPD education from 0% to 66%, (b) verbal COPD education on discharge from a baseline of 20% to 100%, (c) receipt of written educational material on discharge from 20% to 100%, and (d) the cohort all-cause 30-day readmission rate declined from 19.3% to 14.3%. Given the substantial economic burden of COPD readmissions on the health care system and patients, evidence-based educational interventions may potentially improve outcomes and reduce hospital readmissions in this veteran population.

Stroke Transition of Care Intervention with Stroke Nurse Navigators and Early Stroke Clinic Follow-up Reduces Readmissions for Stroke at 12 Months

Background One in four strokes occur in stroke victims, with hospital readmissions contributing to high-cost care. Transition of care programs have been successful in reducing hospital readmissions in other diseases, but the data on such programs for stroke are mixed. A transition of care program was implemented with the goal of reducing recurrent strokes and hospital readmissions. Methods We implemented a transition of care program using nurse navigators and early outpatient follow-up with a vascular neurologist. Data were obtained on: Rate of recurrent stroke admissions within one-year, all-cause readmission within one-year, all-cause readmission within 30 days, initial follow-up scheduled within 7-10 days, compliance with follow up, and compliance rates with provision of two-day post-hospital discharge phone calls. Results An improvement was seen in process measures reflecting adherence to the intervention across all 3 years. The rate of readmission for stroke at 12 months was 8.5%, 9.0%, 6.6%, and 4.2% for year 0, 1, 2, and 3, respectively, representing a 50% reduction from baseline year 0. All-cause readmission remained unchanged, at 38.9%, 42.6%, 36.6%, and 37.4% for year 0, 1, 2, and 3 respectively. Conclusions Our nurse navigator led stroke transition intervention was associated with significant reduction in readmissions for stroke but did not impact all cause readmission at one year or 30 days. Our focus on Centers for Medicare/Medicaid intervention compliance has produced a sustainable program capable of now expanding to support other important patient needs.

Interpretable (not just posthoc-explainable) medical claims modeling for discharge placement to reduce preventable all-cause readmissions or death

We developed an inherently interpretable multilevel Bayesian framework for representing variation in regression coefficients that mimics the piecewise linearity of ReLU-activated deep neural networks. We used the framework to formulate a survival model for using medical claims to predict hospital readmission and death that focuses on discharge placement, adjusting for confounding in estimating causal local average treatment effects. We trained the model on a 5% sample of Medicare beneficiaries from 2008 and 2011, based on their 2009–2011 inpatient episodes (approximately 1.2 million), and then tested the model on 2012 episodes (approximately 400 thousand). The model scored an out-of-sample AUROC of approximately 0.75 on predicting all-cause readmissions—defined using official Centers for Medicare and Medicaid Services (CMS) methodology—or death within 30-days of discharge, being competitive against XGBoost and a Bayesian deep neural network, demonstrating that one need-not sacrifice interpretability for accuracy. Crucially, as a regression model, it provides what blackboxes cannot—its exact gold-standard global interpretation, explicitly defining how the model performs its internal “reasoning” for mapping the input data features to predictions. In doing so, we identify relative risk factors and quantify the effect of discharge placement. We also show that the posthoc explainer SHAP provides explanations that are inconsistent with the ground truth model reasoning that our model readily admits.

Clinical characteristics and prognosis of patients with infective endocarditis admitted to a coronary unit in a hospital with cardiac surgery

Abstract Funding Acknowledgements None. Introduction Cardiac critical care units are essential for the management of complicated infective endocarditis (IE). Objective We set out to analyze the baseline characteristics, clinical complications and prognosis of patients with IE admitted to a Coronary Care Unit (CCU), as well as to compare them with patients admitted to hospital wards. Material and Methods Prospective, single-centre, observational study including patients who were diagnosed of IE from 2016-2022 and admitted in a hospital with cardiac surgery. They were classified into two groups according to whether or not they were admitted to the CCU. We collected data on microbiological isolation, cardiac and systemic complications as well as in-hospital mortality. Patients were followed long-term for cardiovascular (CV) and all-cause mortality, readmission and IE recurrence. All variables (qualitative) were compared by Chi-square test and overall mortality was compared in both groups by the LogRank test. We established a significance level of p&amp;lt;0.05. Results From a total of 162 patients with a median age of 68 years (IQR 68), 28.4% (46) were admitted to the CCU. These patients were similar in age to those not admitted (mean 65 vs 66 years, NS), but had a higher percentage of diabetics (47.8 vs 27.6%, p=0.01). The most frequent previous heart disease in both groups was valvular heart disease. The most frequently isolated microorganisms in CCU patients were Staphylococcus aureus (46.4%) and Streptococcus epidermidis (37.9%) which, in our series, produced the highest percentage of shock (35.7% and 23.3% respectively) in a statistically significant way (p&amp;lt;0.01), with the need for noradrenaline (60.9%) and dobutamine (28.3%); no ventricular assist devices were used. Critically ill patients had a higher incidence of atrioventricular block requiring a permanent pacemaker (32.6% vs 4.3%, p&amp;lt;0.01), valve dysfunction (76.1% vs 55.2%, p=0.014) and were more frequently operated than those admitted to the ward (56.%% vs 38%, p=0.04). Among all IE patients, 24.6% died during admission, most of them (15.7% of the total) were admitted to the coronary unit (p&amp;lt;0.01). In our 36-month mean follow-up, we found significantly higher readmission rates in the CCU group (36.6% vs. 15%, p&amp;lt;0.01), unrelated to IE recurrences. The critically ill group exhibited a higher mortality rate due to cardiovascular disease and all-cause causes (43.5% vs 15.9%, p0.01; 63% vs 23.9%, p0.01). In the CCU group there is significantly lower survival (mean 65 vs 37 months, LogRank p&amp;lt;0.01) with respect to the hospital ward group. Conclusion Our CCU is responsible for treating patients with IE that is highly complex and that progresses poorly, with a higher frequency of shock and in-hospital mortality, which leads to a decreased prognosis during follow-up. Anticipating complications and collaborating with cardiac surgery is essential to improve clinical outcomes.

Feasibility of a Telemedicine-Based Principal Illness Navigation (PIN) Service for Complex Populations Following Hospital Discharge After Acute Stroke

Background Principal Illness Navigation (PIN) services may play an important role in helping patients through important transitions in care following acute hospitalization. We evaluated a novel PIN telemedicine approach to understand the feasibility of providing these services to diverse patient cohorts. Methods A single-arm, retrospective observational study of Kandu Health’s post-acute PIN service was conducted in patients experiencing ischemic or hemorrhagic stroke in California and New Jersey. The technology-enabled program offered remote healthcare support led by occupational therapists and licensed clinical social workers that was tailored to individual patient needs to facilitate transition to community settings post-discharge. Barriers to recovery were addressed through patient education, one-on-one guidance, and specialized referrals. Patient outcomes were assessed through in-app assessments and clinician-assessed modified Rankin Scores conducted via video consultation. Readmissions were monitored through both patient reporting and admission/discharge/transfer feeds from health information exchanges. Results A total of 111 patients were enrolled between June 22, 2022 and January 11, 2024. Patients were onboarded an average of 29 ± 40 days (median 18, IQR 8-32) after acute care hospital discharge and spent an average of 81 ± 21 days (median 90, IQR 75-90) in the program. During that time, the average enrollee spent 333 ± 156 minutes (median 350, IQR 205-435) of 1:1 time interacting with their dedicated navigator, and navigators spent an additional 113 ± 87 minutes (median 95, IQR 61-140) per patient on care coordination and curriculum curation. Patients with 5 or more social determinants of health (SDOH) needs required over 50% more navigator time than those without any SDOH needs. Within 6 weeks of hospital discharge, 8.5% experienced an inpatient hospital all-cause readmission that was not associated with race, ethnicity, or SDOH. Conclusions High rates of enrollment and extensive patient engagement in both navigator-facilitated and self-directed program elements can be achieved using the Kandu program. Our findings indicate that telemedicine facilitated, app-supported PIN is feasible to deliver following acute stroke discharge across diverse ages, races, ethnicities, functional status (mRS), and social needs.

The significance of metabolic alkalosis on acute decompensated heart failure: the ALCALOTIC study.

To determine the prevalence and the impact on prognosis of metabolic alkalosis (MA) in patients admitted for acute heart failure (AHF). The ALCALOTIC is a multicenter, observational cohort study that prospectively included patients admitted for AHF. Patients were classified into four groups according to their acid-base status on admission: acidosis, MA, respiratory alkalosis, and normal pH (reference group for comparison). Primary endpoint was all-cause in-hospital mortality, and secondary endpoints included 30/90-day all-cause mortality, all-cause readmission, and readmission for HF. Associations between endpoints and acid-base alterations were estimated in a multivariate Cox regression model including sex, age, comorbidities, and Barthel index and expressed as hazard ratio (HR) with 95% confidence interval (95% CI). Six hundred sixty-five patients were included (84years and 57% women), and 40% had acid-base alterations on admission: 188 (28%) acidosis and 78 (12%) alkalosis. The prevalence (95% CI) of MA was 9% (6.8-11.2%). Patients with MA were more women; had fewer comorbidities, better renal function, and higher left ventricle ejection fraction values; and received more treatment with oral acetazolamide during hospitalization and at discharge. MA was not associated with a higher risk of in-hospital mortality and 30/90-day all-cause mortality or readmissions but was associated with a significant increase in readmissions for HF at 30 and 90days (adjusted HR [95% CI] 3.294 [1.397-7.767], p = 0.006 and 2.314 [1.075-4.978], p = 0.032). The prevalence of MA in patients admitted for AHF was 9%, and its presence was associated with more readmissions for HF but not with all-cause mortality.

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.

Long-Term Clinical Outcomes of Acute Kidney Disease in Patients Receiving Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is widely used; however, studies on the long-term outcomes of ECMO are scarce. We investigated the long-term clinical outcomes of acute kidney disease (AKD) in patients receiving ECMO. Electronic data (2009-2018) were retrospectively collected from a multicenter database. Patients were divided into two groups (AKD and non-AKD) according to their AKD status 8-90 days after the initiation of ECMO. Inverse probability of treatment weighting was used to balance baseline covariates between the two groups. The primary outcomes were major adverse kidney events (MAKEs) and major adverse cardiovascular events (MACEs), and the secondary outcomes were all-cause readmission, sepsis-related readmission, infection-related readmission, and dementia. Totally, 395 patients were eligible for analysis; of them, 160 patients (40.5%) developed AKD. The AKD group had a higher risk of MAKEs (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.68-2.53) than did the non-AKD group. Subgroup analysis revealed that the observed unfavorable effect of AKD on the risk of MAKEs was more pronounced in patients receiving venovenous ECMO than in those receiving venoarterial ECMO (HR: 5.69 vs. 1.85, respectively; p for interaction = 0.004). AKD group had a higher risk of MACE during the initial 3-year post-ECMO in comparison to those without (HR: 1.68; 95% CI: 1.22-2.30). Moreover, the risks of all-cause, sepsis-related, and infection-related readmissions were high in AKD survivors. AKD is associated with an increased risk of long-term MAKEs and initial 3-year MACE in ECMO recipients. In addition, AKD is associated with increased risks of all-cause, infection-related, and sepsis-related readmissions.

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.

3-Year Outcomes for Degenerative Mitral Regurgitation Repair in a Medicare Population.

Mitral valve repair (MVr) has become the standard therapy for degenerative mitral regurgitation (DMR), but real-world late mortality, reintervention, and readmission data are lacking. This study estimates MVr outcomes for DMR to 3 years in the Medicare fee-for-service population. There were 4,219 DMR patients older than 65 years undergoing MVr within the Medicare 100% standard analytic file from October 2015 to December 2018 who were evaluated. Outcomes were analyzed for isolated MVr patients (n = 2,433) and patients undergoing MVr with certain concomitant procedures: MVr + tricuspid valve surgery (TVS; n = 619), MVr + cardiac ablation (CA; n = 540), and MVr + left atrial appendage closure (n = 627). Outcomes over a 3-year period included all-cause mortality, reintervention, rehospitalization, and common complications. All outcomes were modeled with adjustments for patient demographics and comorbid conditions. The average age for all patients was 71.9 ± 5.2 years. Adjusted all-cause mortality and MV reintervention (surgery or transcatheter) at 3 years for the primary cohort of isolated MVr was 3.5% and 1.6%, respectively. Directionally higher mortality at 3 years was observed in patients with concomitant TVS or CA. All-cause readmission and cardiac readmission for isolated MVr was 37.0% and 14.1%, with the highest rates for those with concomitant TVS or CA. Acute kidney injury and stroke/transient ischemic attack were the most common adverse events over 3 years for all patients. The 3-year mortality and reintervention rates in Medicare patients undergoing degenerative MVr are low. Those undergoing concomitant TVS or CA had directionally higher mortality and cardiac readmission rates. These results help refine outcome benchmarks as new transcatheter MVr procedures continue to emerge.

Impact of Pharmacist Transitions of Care on 30-Day Readmissions Within a Primary Care-Based Accountable Care Organization.

Previous studies in the ambulatory care setting have shown inconsistent results in regard to, or with respect to pharmacist telephonic transitions of care (TOC) encounters and reduction in 30-day readmission rates. No studies that have been completed within an accountable care organization (ACO) evaluating the impact of telephonic TOC encounters performed by a pharmacist have been identified. The objective of this study was to analyze the impact of clinical pharmacy telephonic TOC encounters on readmission rates within a primary care-based ACO. In this retrospective chart review, data for those who had a pharmacist telephonic TOC encounter and those who had an attempt were collected. The primary outcome of this study was all-cause 30-day readmission rate. Secondary outcomes included 30-day readmission rate for targeted disease states, time to readmission, and readmission reason the same as previous discharge reason. For subjects who received a telephonic TOC encounter, pharmacist intervention type and provider acceptance of intervention(s) were described. For the final analysis, 154 encounters were included, 83 encounters in the telephonic TOC encounter group, and 71 did not receive a telephonic TOC encounter. The 30-day readmission rates were similar among those who received a telephonic TOC encounter and those who did not: the difference was not significant (15.7% vs. 28.2%; P = 0.059). There was also no statistical difference in the secondary outcomes. Even so, the results of this study suggest that performing a pharmacist telephonic TOC encounter in a primary care-based ACO setting has the potential to reduce 30-day readmission rates and further research appears to be warranted in this important area of practice.

Impact of infection on healthcare costs and clinical outcomes in elderly hospitalized patients with multimorbidity

BackgroundElderly patients with multimorbidity are at higher risk of greater healthcare costs and poor outcomes due to decreased physical function. The aim of this study was to investigate the impact of infection on healthcare costs and poor outcomes in elderly hospitalized patients with multimorbidity. MethodsWe retrospectively enrolled 264 patients who met the inclusion criteria from the department of geriatrics of a large public hospital in Shanghai, China between January 2020 and December 2020. Patients were divided into two groups based on whether they had infection [infection present on admission (IPOA) or healthcare-associated infection(HAI)]. We recorded the basic information and follow-up information of all patients. The follow-up information included 30-day and 1-year all-cause readmission and mortality. Then we analyzed the association between infection and healthcare costs and clinical outcomes. ResultsAmong 264 subjects, 47.73 % of them achieved IPOA or HAI. The 30-day poor outcomes rate was 45.45 %, and the 1-year poor outcomes rate was 78.41 %. Compared with subjects without infection, the number of drugs and the disease burden were greater in subjects with infection(P < 0.001). Subjects with infection had longer length of hospital stay(P < 0.001) and had greater healthcare cost(P < 0.001). Moreover, subjects with infection had higher poor outcomes rates of 30-day and 1-year(P < 0.001). Infection could predict greater total cost [odds ratio (OR): 1.32, 95 % CI: 1.18,1.49,P < 0.001], nursing cost(OR: 11.45, 95 % CI: 3.49,37.63,P < 0.001), and medicine cost (OR: 2.37, 95 % CI: 1.70,3.31,P < 0.001). In addition, infection was also independently associated with the 30-day poor outcomes rate(OR:3.07, 95%CI: 1.80,5.24,P < 0.001), but we found no association between infection and 1-year poor outcomes rate(OR:1.43, 95 % CI:0.73,2.79,P = 0.300) after adjustment. ConclusionsInfection was a risk factor for higher healthcare cost and 30-day poor outcome rate in elderly hospitalized patients with multimorbidity.

AB046. SOH24AB_122. Key risk factors and reasons for all-cause readmission following bariatric surgery: a systematic review and meta-analysis

AB046. SOH24AB_122. Key risk factors and reasons for all-cause readmission following bariatric surgery: a systematic review and meta-analysis