Annual Readmission Rates Research Articles

Nationwide Readmission Rates and Hospital Charges for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 1-Craniotomy.

Despite patients experiencing high recurrence and readmission rates after surgical management of nontraumatic subdural hematomas (SDHs), few studies have examined the causes and predictors of unplanned readmissions in this population on a national scale. To analyze independent factors predicting 30-day hospital readmissions after surgical treatment of nontraumatic SDH in patients who survived their index surgery and evaluate hospital readmission rates and charges. Using the Nationwide Readmissions Database, we identified patients who underwent craniotomy for nontraumatic SDH evacuation (2010-2015) using a retrospective cohort observational study design. National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables. Among 49 013 patients, 10 643 (21.7%) had at least 1 readmission within 30 days of their index treatment and 38 370 (78.3%) were not readmitted. Annual readmission rates did not change during the study period ( P = .74). The most common primary causes of 30-day readmissions were recurrent SDH (n = 3949, 37.1%), venous thromboembolism (n = 1373, 12.9%), and delayed hyponatremia and syndrome of inappropriate antidiuretic hormone secretion (n = 1363, 12.8%). Comorbidities that independently predicted readmission included congestive heart failure, chronic obstructive pulmonary disease, coagulopathy, diabetes mellitus, liver disease, lymphoma, fluid and electrolyte disorders, metastatic cancer, peripheral vascular disease, psychosis, and renal failure ( P ≤ .03). Household income in the 51st to 75th percentile was associated with a decreased risk of readmission. National trends in 30-day readmission rates after nontraumatic SDH treatment by craniotomy provide quality benchmarks that can be used to drive quality improvement efforts on a national level.

306 Nationwide Readmission Rates and Costs for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 1—Craniotomy

INTRODUCTION: Despite patients experiencing high recurrence and readmission rates after surgical management of nontraumatic subdural hematomas (SDHs), few studies have examined the causes and predictors of unplanned readmissions in this population on a national scale. METHODS: Using the Nationwide Readmissions Database, we identified patients who underwent craniotomy for nontraumatic SDH evacuation (2010-2015) using a retrospective cohort observational study design. National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables. RESULTS: Among 49,013 patients, 10,643 (21.7%) had at least 1 readmission within 30 days of their index treatment and 38,370 (78.3%) were not readmitted. Annual readmission rates did not change during the study period (P = 0.74). The most common primary causes of 30-day readmissions were recurrent SDH (37.1%), venous thromboembolism (12.9%), and delayed hyponatremia and SIADH (syndrome of inappropriate antidiuretic hormone secretion) (12.8%). Comorbidities that independently predicted readmission included congestive heart failure, chronic obstructive pulmonary disease, coagulopathy, diabetes mellitus, liver disease, lymphoma, fluid and electrolyte disorders, metastatic cancer, peripheral vascular disease, psychosis, and renal failure (P = 0.03). Household income in the 51st-75th percentile was associated with a decreased risk of readmission. CONCLUSION: National trends in 30-day readmission rates after nontraumatic SDH treatment via craniotomy provide quality benchmarks that can be used to drive quality improvement efforts on a national level.

65 & Thrive: Improving Patient Length of Stay, Readmission, and Quality of Care by Becoming an Age-Friendly Hospital

Data indicates that older persons will increase in numbers along with having an increase of life expectancy in the United States. Kaiser Permanente Los Angeles Medical Center’s Utilization Department developed “65 & Thrive”—an age-specialized initiative to provide holistic care that preserves independence, quality of life, prevents functional and cognitive decline, and promotes both patients and their families to continue thriving. The initiative’s focus is guided by the 5 M’s model on mobility, medication, mentation, multi-morbidity, and what matters. Case management staff were given age-sensitivity trainings, improved workflows and made assessments that identified, addressed, and secured resources for patients throughout their hospitalization. Silver Angel volunteers were specially trained to prevent physical and mental decline and focused on activities to prevent delirium, depression and falls. The volunteers visited with patients daily for these interactions. The initiative was piloted in April 2020 on a stroke telemetry unit and since then the hospital has seen a significant decrease in the overall annual readmission rates by 3.1% when compared to 2019. The average length of stay for older adult patients; however, increased from 4.05 to 4.83 days unfortunately due to COVID-19. This initiative demonstrates the necessity to expand “65 & Thrive” throughout the hospital and ultimately to other Kaiser Permanente medical centers to best provide holistic care to older adults.

65 & Thrive: Improving Patient Length of Stay, Readmission, and Quality of Care by Becoming an Age-Friendly Hospital

Despite its importance for health and wellbeing, oral health quality of life (OHQoL) has received little attention in lower-income countries, such as Colombia. This study describes the prevalence of older adults’ OHQoL and variability by socioeconomic status. We use data from the 2015 SABE-Colombia (N=18,700), a nationally representative survey of community-dwelling Colombians ages 60 and older. We used the Simple Count Geriatric Oral Health Assessment Index (SC-GOHAI), a self-reported measure of frequent oral health problems such as chewing, swallowing, and speaking designed to assess OHQoL. The scale ranges from 0-12; higher scores indicate worse OHQoL. About 69% of older Colombians reported at least one OHQoL problem. The most common issues were difficulty chewing hard food and speaking. High education and income were associated with better OHQoL and smoking were associated with worse OHQoL. Oral health may therefore reflect another dimension of social and health inequality for older Colombians.

P004. 30-Day Hospital Readmission Rates, Frequencies, and Heart Failure Classification for Patients with Heart Failure

<h3>Background</h3> Congestive heart failure (CHF) is the leading cause of mortality, morbidity, and disability worldwide among patients. Both the incidence and the prevalence of heart failure are age dependent and are relatively common in individuals 40 years of age and older. CHF is one of the leading causes of inpatient hospitalization readmission in the United States, with readmission rates remaining above the 20% goal within 30 days. The Center for Medicare and Medicaid Services imposes a 3% reimbursement penalty for excessive readmissions including those who are readmitted within 30 days from prior hospitalization for heart failure. Hospitals risk losing millions of dollars due to poor performance. A reduction in CHF readmission rates not only improves healthcare system expenditures, but also patients' mortality, morbidity, and quality of life. <h3>Objectives</h3> The purpose of this DNP project is to determine 30-day hospital readmission rates, frequencies, and heart failure classification for patients with heart failure. Specific aims include comparing computed annual readmission rates with national average, determine the number of multiple 30-day readmissions, provide descriptive data for demographic variables, and correlate age and heart failure classification with the number of multiple readmissions. <h3>Methods</h3> A retrospective chart review was conducted to collect hospital admission and study data. The setting occurred in an urban hospital in Memphis, TN. The study was reviewed by the University of Tennessee Internal Review Board and deemed exempt. The electronic medical records were queried from July 1, 2019 through December 31, 2019 for heart failure ICD-10 codes beginning with the prefix 150 and a report was generated. Data was cleaned such that each patient admitted had only one heart failure ICD-10 code. The total number of heart failure admissions was computed and compared to national average. Using age ranges 40-80, the number of patients readmitted within 30 days was computed and descriptive and inferential statistics were computed using Microsoft Excel and R. <h3>Results</h3> A total of 3524 patients were admitted for heart failure within the six-month time frame. Of those, 297 were re-admitted within 30 days for heart failure exacerbation (8.39%). An annual estimate was computed (16.86%), well below the national average (21%). Of those re-admitted within 30 days, 50 were readmitted sequentially, on multiple occasions, ranging from two to eight readmissions. The median age was 60 and 60% were male. Due to the skewed distribution (most readmitted twice), nonparametric statistics were used for correlation. While graphic display of charts suggested a trend for most multiple readmissions due to diastolic dysfunction and least number due to systolic heart failure, there was no statistically significant correlation between age and number or multiple re-admissions (Spearman rank, p = 0.6208) or number of multiple re-admissions and heart failure classification (Kruskal Wallis, p=0.2553).

Real-world effectiveness of long-acting injectable antipsychotics to reduce 90-day and annual readmission in psychotic disorders: insights from a state psychiatric hospital.

To evaluate the effectiveness of long-acting injectable antipsychotics (LAI-a) in reducing the 90-day and annual readmission rates in schizophrenia inpatients. We conducted a cross-sectional study and included 180 adult patients with psychotic disorders discharged from 2018 to 2019 at a state psychiatric hospital. Descriptive statistics were used to measure the differences between the readmit and nonreadmit cohorts. Logistic regression model was used to measure the odds ratio (OR) for 90-day and annual readmission and was controlled for potential readmission risk factors. A lower proportion of patients receiving LAI-a were readmitted within 90-day (28.6%) and 1-year (32.4%) periods. Patients receiving LAI-a had lower odds of association for 90-day (OR 0.36, 95% confidence intervals [CI] 0.139-0.921) and annual (OR 0.35, 95% CI 0.131-0.954) readmissions compared to those discharged on oral antipsychotics. A higher proportion of inpatients who received fluphenazine LAI had 90-day (25%) and annual (18.2%) readmissions compared to other LAI-a. Utilization of LAI-a in patients with psychotic disorders can decrease both 90-day and annual psychiatric readmissions by 64% to 65%. Physicians should prefer LAI-a to reduce the readmission rate and improve the quality of life, and decrease the healthcare-related financial burden.

The July Effect for Total Joint Arthroplasty Procedures.

The "July effect" refers to the assumed increased risk of complications during the months when medical school graduates transition to residency programs. The actual existence of a July effect is controversial. With this study, the authors sought to determine whether evidence exists for the presence of a July effect among total joint arthroplasty (TJA) procedures. The 2013 and 2014 Nationwide Readmission Databases were combined and all index primary and revision arthroplasty procedures were identified, and then patients from December were excluded. Thirty-day readmission rates, time to readmission, and readmission costs were analyzed by index procedure month and index procedure type. A total of 1,193,034 procedures (index primary: n=1,107,657; revision arthroplasty: n=85,377) were identified. Among all procedure types, 46,674 (3.9%) 30-day readmissions were observed. Among all procedures, an index procedure with a discharge in July resulted in the highest monthly readmission rate of the year (4.2%), which was significantly higher than the mean annual readmission rate (P<.0001). This effect was most pronounced for primary total knee arthroplasty (3.9% vs 3.6%, P<.0001). When stratifying results into teaching vs nonteaching hospitals, the highest readmission rate occurred if the index procedure occurred at a nonteaching hospital in July (4.5%, P<.0001). These data provide evidence that a July effect appears to exist for TJA procedures and is most pronounced at nonteaching institutions. Based on published mean readmission costs, the total annualized cost variation attributable to the higher readmission rate for primary TJA procedures in July is approximately $18.6 million. [Orthopedics. 2020;43(6):e543-e548.].

Changes in coding of pneumonia and impact on the Hospital Readmission Reduction Program.

To evaluate whether changes in diagnosis assignment explain reductions in 30-day readmission for patients with pneumonia following the Hospital Readmission Reduction Program (HRRP). 100 percent MedPAR, 2008-2015. Retrospective cohort study of Medicare discharges in HRRP-eligible hospitals. Outcomes were 30-day readmission rates for pneumonia under a "narrow" definition (used for the HRRP until October 2015; n=2288644) and a "broad" definition that included certain diagnoses of sepsis and aspiration pneumonia (used since October 2015; n=3618215). We estimated changes in 30-day readmissions in the pre-HRRP period (January 2008-March 2010), the HRRP implementation period (April 2010-September 2012), and the HRRP penalty period (October 2012-June 2015). Under the narrow definition, adjusted annual readmission rates changed by +0.07 percentage points (pp) during the pre-HRRP period (95% CI: -0.03pp, +0.18pp), -1.07pp during HRRP implementation (95% CI: -1.15pp, -0.99pp), and -0.09pp during the penalty period (95% CI: -0.18pp, -0.00pp). Under the broad definition, 30-day readmissions changed by +0.21pp during the pre-HRRP period (95% CI: +0.12pp, +0.30pp), -1.28pp during HRRP implementation (95% CI: -1.35pp, -1.21pp), and -0.09pp during the penalty period (95% CI: -0.16pp, -0.02pp). Changes in the coding of inpatient pneumonia admissions do not explain readmission reduction following the HRRP.

Suboptimal Use of Inpatient Palliative Care Consultation May Lead to Higher Readmissions and Costs in End-Stage Liver Disease.

Background/Aims: Patients with end-stage liver disease (ESLD) have a high risk for readmission. We studied the role of palliative care consultation (PCC) in ESLD-related readmissions with a focus on health care resource utilization in the United States. Methods: We performed a retrospective longitudinal analysis on patients surviving hospitalizations with ESLD from January 2010 to September 2014 utilizing the Nationwide Readmissions Database with a 90-day follow-up after discharge. We analyzed annual trends in PCC among patients with ESLD. We matched PCC to no-PCC (1:1) using propensity scores to create a pseudorandomized clinical study. We estimated the impact of PCC on readmission rates (30- and 90-day), and length of stay (LOS) and cost during subsequent readmissions. Results: Of the 67,480 hospitalizations with ESLD, 3485 (5.3%) received PCC, with an annual increase from 3.6% to 6.7% (p for trend <0.01). The average 30- and 90-day annual readmission rates were 36.2% and 54.6%, respectively. PCC resulted in a lower risk for 30- and 90-day readmissions (hazard ratio: 0.42, 95% confidence interval [CI]: 0.38-0.47 and 0.38, 95% CI: 0.34-0.42, respectively). On subsequent 30- and 90-day readmissions, PCC was associated with decreased LOS (5.6- vs. 7.4 days and 5.7- vs. 6.9 days, p < 0.01) and cost (US $48,752 vs. US $75,810 and US $48,582 vs. US $69,035, p < 0.01). Conclusion: Inpatient utilization of PCC for ESLD is increasing annually, yet still remains low in the United States. More importantly, PCC was associated with a decline in readmission rates resulting in a lower burden on health care resource utilization and improvement in cost savings during subsequent readmissions.

A Nationwide Analysis of 30-Day and 90-Day Readmissions After Elective Cerebral Aneurysm Clipping in the United States: Causes, Predictors, and Trends

Thirty-day readmissions (30dRAs) and 90-day readmissions (90dRAs) are being increasingly scrutinized as quality metrics for hospital and provider performances. Little information regarding risk factors for 30dRA and 90dRA after elective cerebral aneurysm clipping (CAC) of unruptured cerebral aneurysms is available. We sought to characterize risk factors with a nationally representative administrative database. The Nationwide Readmissions Database was used to identify patients who underwent elective CAC between 2010 and 2014. The outcomes of interest were unplanned readmissions occurring within 30 or 90 days of discharge. Binary logistic regression was used to identify variables related to patients' demographics, comorbidities, and index hospital admission that were associated with readmission. A Cochran-Mantel-Haenszel test was used to evaluate for changes in annual readmission rates. A total of 1123 patients met the inclusion criteria for 30dRA analysis and 946 patients were eligible for 90dRA analysis. The 5-year 30dRA and 90dRA readmission rates were 9.1% and 14.9%, respectively. The annual rate of readmission between 2010 and 2014 did not change. Greater Charlson Comorbidity Index (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.14-6.28) and nonroutine discharge after the index admission (OR, 1.81; 95% CI, 1.04-3.14) were associated with greater odds of 30dRA. Charlson Comorbidity Index (OR, 3.45; 95% CI,1.57-7.56) and treatment at a metropolitan teaching hospital (OR, 2.21; 95% CI, 1.06-4.60) were associated with increased odds of 90dRA. Wound infection was the most common reason for readmission. Readmission rates after elective CAC remained unchanged between 2010 and 2014, suggesting that improved methods for reducing unplanned readmissions after CAC are needed.

Trajectory Modelling to Assess Trends in Long-Term Readmission Rate among Abdominal Aortic Aneurysm Patients.

Introduction The aim of the study was to use trajectory analysis to categorise high-impact users based on their long-term readmission rate and identify their predictors following AAA (abdominal aortic aneurysm) repair. Methods. In this retrospective cohort study, group-based trajectory modelling (GBTM) was performed on the patient cohort (2006-2009) identified through national administrative data from all NHS English hospitals. Proc Traj software was used in SAS program to conduct GBTM, which classified patient population into groups based on their annual readmission rates during a 5-year period following primary AAA repair. Based on the trends of readmission rates, patients were classified into low- and high-impact users. The high-impact group had a higher annual readmission rate throughout 5-year follow-up. Short-term high-impact users had initial high readmission rate followed by rapid decline, whereas chronic high-impact users continued to have high readmission rate. Results Based on the trends in readmission rates, GBTM classified elective AAA repair (n=16,973) patients into 2 groups: low impact (82.0%) and high impact (18.0%). High-impact users were significantly associated with female sex (P=0.001) undergoing other vascular procedures (P=0.003), poor socioeconomic status index (P < 0.001), older age (P < 0.001), and higher comorbidity score (P < 0.001). The AUC for c-statistics was 0.84. Patients with ruptured AAA repair (n=4144) had 3 groups: low impact (82.7%), short-term high impact (7.2%), and chronic high impact (10.1%). Chronic high impact users were significantly associated with renal failure (P < 0.001), heart failure (P = 0.01), peripheral vascular disease (P < 0.001), female sex (P = 0.02), open repair (P < 0.001), and undergoing other related procedures (P=0.05). The AUC for c-statistics was 0.71. Conclusion Patients with persistent high readmission rates exist among AAA population; however, their readmissions and mortality are not related to AAA repair. They may benefit from optimization of their medical management of comorbidities perioperatively and during their follow-up.

Long-term trends of use of health service among heart failure patients.

We aimed to identify subgroups in the patient population with different trajectories of long-term readmission rates. The study also aimed to assess common causes and their sequences of readmissions for each subgroup. Patients with a primary diagnosis of heart failure (HF) in the period 2008-09 were identified using nationally representative primary care data linked to national hospital data, which contain information on 10.5 million patients. Heart failure patients were followed up for 5 years. Group-based trajectory models and sequence analysis were applied. The model categorised the HF population (n = 9466) into five subgroups: low-impact (66.9%); two intermediate ones (27.4%); chronic high-impact (2.3%) with steady high annual readmission rates; and short-term high-impact (3.4%) with rapid decline in readmission rates. The groups were defined by their trends of yearly number of readmissions. The all-cause 5-year mortality was highest in the short-term high-impact group (n = 185, 72.8%), followed by Group 2 (intermediate users) (n = 744, 58.8%), low-impact (n = 4244, 56.9%), chronic high-impact (n = 88, 37.6%), and Group 1 (intermediate users) (n = 401, 30.3%) (P < 0.01). Compared with low-impact users, high-impact users were associated with higher mortality, bereavement episodes, and more out-of-hours general practitioner visits. The chronic high-impact users had distinct sequences of causes of emergency admissions most often consisting of chest infection, ischaemic heart disease, and cardio-pulmonary signs and/or symptoms. Chronic high-impact users constitute a small proportion of total patients, but they have increasingly high use of healthcare services. Short-term high-impact users represent largely end of life patients. They require prompt involvement of the palliative care team to reduce unnecessary readmissions to hospital.

Abstract T P341: Transitions of Care: Increasing Follow-up and Decreasing Readmission Rates After Hospitalization for Acute Ischemic Stroke

Background: Acute ischemic stroke accounts for nearly 800,000 inpatient hospitalizations annually in the United States. Post-discharge disposition varies greatly among stroke survivors. The transition to home or nursing facilities post-hospitalization provides an opportunity to improve quality of life; but also increases the potential for miscommunication between patients, care givers, and health care providers. This may result in the need for hospital readmission, which further complicates patient care. A timely post-discharge neurology clinic visit would be the ideal forum to address miscommunication and reduce readmission. Without dedicated infrastructure, it is difficult to see patients quickly, resulting in a poor follow-up rate. Our Stroke Center sought to improve transitions for stroke survivors with the addition of a neurology nurse case manager, creation of a targeted post-discharge plan, and implementation of the Bayview Stroke Intervention Clinic (BaSIC). Methods: Beginning in September 2013, all patients admitted with acute ischemic stroke were assessed by our case manager prior to discharge and a specific post-discharge plan was developed including a plan for follow-up within 4-6 weeks. This was achieved with the implementation of a weekly neurology clinic dedicated to post-stroke care, staffed by two cerebrovascular neurologists. To gauge the effectiveness of our intervention to improve follow-up rates and decrease hospital readmissions, we retrospectively compared stroke patients discharged in fiscal year 2013 (prior to implementation) to those discharged in 2014. Annual readmission rates as well as follow-up rates in neurology clinic at 30, 60 and 90 day post-discharge intervals were assessed. Results: With implementation of targeted post-discharge planning and BaSIC clinic, the 30 day follow-up rate (2.6% pre versus 8.4% post; p=0.01), 60 day follow-up rate (8.3% pre versus 16% post; p=0.01), and 90 day follow-up rate (14.4% pre versus 20.6% post; p=0.10) all improved. Hospital readmissions fell from 10.5% to 8.7% (p=0.63). Conclusion: Implementation of a targeted post-discharge plan and specialized stroke follow-up clinic decreases readmissions and increases follow-up visits with neurology.

Quality of care for elderly patients hospitalized for pneumonia in the United States, 2006 to 2010.

Nearly every US acute care hospital reports publicly on adherence to recommended processes of care for patients hospitalized with pneumonia. However, it remains uncertain how much performance of these process measures has improved over time or whether performance is associated with superior patient outcomes. To describe trends in processes of care, mortality, and readmission for elderly patients hospitalized for pneumonia and to assess the independent associations between processes and outcomes of care. Retrospective cohort study conducted from January 1, 2006, to December 31, 2010, at 4740 US acute care hospitals. The cohort included 1 818 979 cases of pneumonia in elderly (≥65 years), Medicare fee-for-service patients who were eligible for at least 1 of 7 pneumonia inpatient processes of care tracked by the Centers for Medicare & Medicaid Services (CMS). Annual performance rates for 7 pneumonia processes of care and an all-or-none composite of these measures; and 30-day, all-cause mortality and hospital readmission, adjusted for patient and hospital characteristics. Adjusted annual performance rates for all 7 CMS processes of care (expressed in percentage points per year) increased significantly from 2006 to 2010, ranging from 1.02 for antibiotic initiation within 6 hours to 5.30 for influenza vaccination (P < .001). All 7 measures were performed in more than 92% of eligible cases in 2010. The all-or-none composite demonstrated the largest adjusted relative increase over time (6.87 percentage points per year; P < .001) and was achieved in 87.4% of cases in 2010. Adjusted annual mortality decreased by 0.09 percentage points per year (P < .001), driven primarily by decreasing mortality in the subgroup not treated in the intensive care unit (ICU) (-0.18 percentage points per year; P < .001). Adjusted annual readmission rates decreased significantly by 0.25 percentage points per year (P < .001). All 7 processes of care were independently associated with reduced 30-day mortality, and 5 were associated with reduced 30-day readmission. Performance of processes of care for elderly patients hospitalized for pneumonia improved substantially from 2006 to 2010. Adjusted 30-day mortality declined slightly over time primarily owing to improved survival among non-ICU patients, and all individual processes of care were independently associated with reduced mortality.

Decreasing length of maternal hospital stay is not associated with increased readmission rates

To investigate changes in maternal length of postnatal stay by mode of birth and hospital type, and examine concurrent maternal readmission rates and reasons for readmission. Linked birth and hospital separation data were used to investigated mothers' birth admissions (n=597,475) and readmissions (n=19,094) in the six weeks post-birth in New South Wales, 2001-2007. Outcomes were postnatal length of stay (mean days) and rate of readmission per 100 deliveries. Poisson regression was used to investigate annual readmission rates and Wilcoxon-Mann-Whitney test was used to compare length of readmission stays. The overall mean postnatal length of stay declined from 3.7 days in 2001 to 3.4 days in 2007. Private hospitals had longer stays after Caesarean and vaginal deliveries, but mean length of stay fell for both private and public hospitals, and both modes of birth. The maternal readmission rate fell from 3.4% in 2001 to 3.0% in 2007. Leading primary diagnoses at readmission following vaginal birth were postpartum haemorrhage and breast/ lactation complications and following Caesarean section were wound complications and breast/ lactation complications. Despite the decrease in mean length of stay for birth admissions, there was no increase, and in fact a decrease, in the rate of postnatal readmissions. Current practices in hospital length of stay and care for women giving birth do not appear to be having serious adverse health effects as measured by readmissions.

Readmission and Death After Hospitalization for Acute Ischemic Stroke

Stroke is a leading cause of hospital admission among the elderly. Although studies have examined subsequent vascular outcomes, limited data are available regarding the full burden of hospital readmission after stroke. We sought to determine the rates of hospital readmissions and mortality and the reasons for readmission over a 5-year period after stroke. This retrospective observational cohort study included Medicare beneficiaries aged >65 years who survived hospitalization for an acute ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification codes 434 and 436) and who were discharged from Connecticut acute care hospitals in 1995. This population was followed from discharge in 1995 through 2000 using part A Medicare claims and Social Security Administration mortality data. The primary outcome was hospital readmission and mortality and readmission diagnosis. Among 2603 patients discharged alive, more than half had died or been readmitted at least once during the first year after discharge (1388/2603, 53.3%), and <15% survived admission-free for 5 years (372/2603, 14.3%). The reasons for hospital readmission varied over time, with stroke remaining a leading cause for readmission (3.9 to 6.1% of patients annually). Acute myocardial infarction accounted for a comparable number of readmissions (4.2 to 6.0% of patients annually). The most common diagnostic category associated with readmission, however, was pneumonia or respiratory illnesses, with an annual readmission rate between 8.2% and 9.0% throughout the first 5 years after stroke. Few stroke patients survive for 5 years without a hospital readmission. Between the acute care setting and readmission to the hospital, a window of opportunity may exist for interventions, beyond prevention of recurrent vascular events alone, to reduce the huge public health burden of poststroke morbidity.

Specialist Nurse-Led Intervention in Outpatients with Congestive Heart Failure

Congestive heart failure (CHF) encompasses a spectrum of clinical syndromes and presentations. It affects 1–2% of the population in the UK and is associated with significant mortality which is comparable to most cancers. It accounts for more than 5% of adult medical admissions in the UK, with significant annual re-admission rates. Improved understanding of the pathophysiology of CHF has resulted in significant advancements in CHF management. Current pharmacologic agents, such as ACE inhibitors, β-adrenoceptor antagonists and spironolactone, influence symptoms and improve mortality. Despite this, many patients still require hospitalization. Multiple, potentially reversible factors are involved which, if addressed effectively, may result in significant reductions in re-admission rates. Patients with CHF often have other conditions, such as respiratory disease, resulting in prolonged lengths of stay. Suboptimal care and failure to adhere to management guidelines is also a preventable cause for re-admission. There has been an increasing need to develop adjunctive, non-pharmacologic strategies for managing CHF, which are designed to improve the patient’s functional status and quality of life. Key elements include systematic follow-up care and patient education. The concept of intensive outpatient or home-based CHF intervention has been developed and extensively evaluated in several randomized controlled trials. Early studies were inconclusive but provided an indication that discharge planning and home-based education are valuable strategies. Recently, an increasing number of studies utilizing the CHF nurse practitioner have provided positive results for non-pharmacologic intervention and demonstrate the potential of these interventions to reduce admissions to hospital by up to 50%. These studies had specific inclusion criteria and could not be generalized to the CHF population as a whole. The Study to Evaluate the effectiveness of Nurse-led Intervention in the management of outpatients with heart Failure (SENIF) explored whether a similar approach to CHF management was beneficial in a typical outpatient population of patients with CHF. Over 12 months, fewer intervention group patients required admission, resulting in 69% fewer hospital days. Cost effectiveness of nurse-led intervention has been suggested in several studies including SENIF, resulting from reduced hospitalizations and re-admissions, which vastly outweighed the modest increase in expenditure required to run the programs. Hospitalizations because of CHF impact greatly on limited healthcare resources. Specialist nurse-led intervention in CHF is a cost-effective, non-pharmacological strategy to help optimize CHF management.

Effectiveness of an assertive outreach community treatment program

The purpose of this paper is to describe an Adult Community Treatment (ACT) program in Dandenong, Victoria, and its effect upon admission rates and time in hospital for 50 of the serviceapos;s most disturbed patients. The implementation of the program was associated with a reduction in the annual re-admission rate from 38% (1989–90) to 21% (1990–91); the total length of hospital stay was also significantly reduced. The results support the value of community support programs in the management of the seriously mentally ill.

Effectiveness of an Assertive Outreach Community Treatment Program

The purpose of this paper is to describe an Adult Community Treatment (ACT) program in Dandenong, Victoria, and its effect upon admission rates and time in hospital for 50 of the service's most disturbed patients. The implementation of the program was associated with a reduction in the annual re-admission rate from 38% (1989-90) to 21% (1990-91); the total length of hospital stay was also significantly reduced. The results support the value of community support programs in the management of the seriously mentally ill.