Cause Of Readmission Research Articles

RF01 | PMON158 Does Early Moderate Fluid Restriction Decrease Incidence of Delayed Hyponatremia Following Transsphenoidal Surgery? A Randomized Prospective Trial

Abstract Background Delayed hyponatremia is the most common cause for readmission after transsphenoidal surgery (TSS), occurring in up to 35% of patients. Due to lack of reliable predictive risk factors for the development of delayed hyponatremia, some institutions have implemented a post-operative fluid restriction for all patients undergoing TSS. Retrospective studies have demonstrated a reduction in the incidence of hyponatremia and readmission for hyponatremia after implementation of post-operative fluid restriction of varying volumes and duration. To our knowledge, a randomized prospective study on fluid restriction post-TSS has not been published previously. We present an interim analysis of a prospective randomized controlled study comparing two approaches to post-TSS fluid management. Methods Participants scheduled for TSS were randomly assigned to the control (CON, n=79) or fluid restriction group (FR1, n=38; FR2, n=37). Participants with chronic kidney disease stage III or greater, NYHA class III or IV heart failure, diabetes insipidus on postoperative day (POD) 3, chronic hyponatremia, or untreated adrenal insufficiency or hypothyroidism were excluded. All participants were started on postoperative weight-based intravenous fluids until POD 1 and allowed to drink freely. Participants in the initial fluid restriction group (FR1) were fluid restricted to 1.8 liters/day (2 liters/day if weight > 100 kg) from POD 3 through POD 14. The fluid restriction was changed to 1 liter/day (1.2 liters/day if weight > 100 kg) (FR2) during the study due to an interim analysis suggesting a trend toward a reduction in the incidence of hyponatremia with fluid restriction and new publications advocating for a tighter fluid restriction. Participants in the CON group were instructed to drink ad lib. Serum sodium (Na) levels were checked every 8 hours in the hospital and on POD 3, 7, 10, and 14. Incidence of hyponatremia (Na < 135 mmol/L), severe hyponatremia (Na < 125 mmol/L), and readmissions for hyponatremia were evaluated. Results There was no significant difference in baseline characteristics between the three groups. 25 participants (31.6%) in CON, 11 (28.9%) in FR1, and 9 (24.3%) in FR2 developed hyponatremia (FR2 vs CON, p=0.556). The incidence of severe hyponatremia was 0% in the FR2 group compared to 7.6% in the CON group (p=0.175). The rate of readmission for hyponatremia was 2.7% in the FR2 group compared to 6.3% in the CON group (p=0.71). There was no difference in the incidence of acute kidney injury or hypernatremia. Conclusion Preliminary results suggest a trend towards decreased rates of severe hyponatremia with 1L/day post-operative fluid restriction. A higher overall incidence of hyponatremia was noted in this interim analysis compared to previously published retrospective studies and may be related to increased screening in the current study. Further analysis with more participants is needed. Presentation: Saturday, June 11, 2022 1:06 p.m. - 1:11 p.m., Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

PMON47 Fluid restriction reduces hyponatremia and hospital readmission rates following pituitary surgery

Abstract Rationale: Hyponatremia occurs in approximately 20% of patients after transsphenoidal pituitary surgery (TSS). Symptomatic delayed hyponatremia from SIADH is a major cause of morbidity and hospital readmission. Prophylactic fluid restriction (FR) protocols starting 2-5 days after surgery may potentially reduce rates of symptomatic hyponatremia and readmissions. Methods Patients who underwent TSS for sellar and parasellar masses at a tertiary referral center were discharged with a one-liter fluid restriction protocol. Serum sodium levels were measured on post-operative day (POD) 7 with telephone follow-up care. Rates of hyponatremia and readmissions were compared to a cohort of 316 post-operative patients treated prior to the protocol. Numerical variables were summarized as mean ± SD and significance testing calculated by Chi-square and t-test. Results 105 patients were enrolled on the FR protocol upon discharge. Twelve patients were excluded as they had diabetes insipidus or prolonged hospitalization beyond POD 7. Ninety-three patients were included in the analysis, of whom 74.3% had pituitary adenomas, 5.4% Rathke's Cleft cysts, 8.6% meningiomas, 5.4% apoplexy, 2.2% craniopharyngiomas, and 4.3% other masses. Hyponatremia occurred in 13/93 (14%) patients. Mean POD 7 sodium was 137.9 mmol/L across the entire cohort. Two patients (2.1%) were readmitted for hyponatremia, while 3 were re-admitted for other causes. 88/93 (94.6%) of patients complied with the FR protocol. Of the 5 non-compliant patients, 2 developed hyponatremias (40%) compared to 3/88 (3.4%) in those who complied (p=0.008). Mean POD7 sodium was 138 (+/-4.5) mmol/L in those that complied and 135 (+/- 4.7) mmol/L in those who did not. Overall readmission rate for those with postoperative hyponatremia was 23% compared to 2.5% for those with normal sodium levels (p=0.0023). 15.4% of patients with hyponatremia were re-admitted for hyponatremia treatment, compared to 0/80 (0%) of those who did not develop post-operative hyponatremia (p=0.0004). Age and BMI did not impact hyponatremia rates. In 316 patients treated in 2012-2018 prior to the FR protocol, 78 (24.7%) developed delayed hyponatremia with 6% readmitted for hyponatremia. Thirty nine percent of patients with delayed hyponatremia were re-admitted, compared to 7.6% for those without hyponatremia. Compared to patients not on FR, patients on the FR protocol had 50% reduced risk of hyponatremia (OR=0.49 (95% CI 0.26-0.94, p=0.03), and a 3-fold reduced risk of overall readmissions (OR=0.31; 95% CI 0.12-0.81, p=0.0157) and readmission for hyponatremia (OR= 0.34;95% CI 0.08-1.5, p=0.16). A post-operative CSF leak or use of a lumbar drain were associated with an increased readmission rate in the historical cohort. Conclusion Instituting a one-liter daily FR protocol in patients after TSS results in significantly reduced rates of hyponatremia, overall readmissions, and readmission for symptomatic hyponatremia. A FR protocol should become routine practice in the post-operative care of patients undergoing pituitary surgery. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

30-Days Same-Cause Congestive Heart Failure Readmission Rate at JHAH

Congestive heart failure attracts quality initiatives to address its high prevalence and massive impacts. It is a major global public health problem and burden on healthcare systems, especially in developing countries, and the most common cause of hospitalization and readmission among older patients, especially 30-day readmission. This article will share achievement in reducing CHF readmission rate and address and discuss interventions to improve patient quality of life and reduce re-hospitalization.

Neighborhood disadvantage and the racial disparity in postpartum hypertension

Postpartum hypertension is the leading cause of postpartum readmission and has long-lasting cardiovascular effects. Black patients have higher incidence rates of hypertensive disorders after delivery and subsequent severe maternal morbidity. Neighborhood advantage, a marker of social determinants of health, has not been studied concerning postpartum hypertension. Moreover, the interplay between race and neighborhood advantage and their effect on postpartum hypertension have not been previously explored. This study aimed to evaluate the association between neighborhood-level social determinants of health and postpartum hypertension and explore whether these factors explain previously documented racial disparities. This study included a retrospective cohort of people enrolled in a remote monitoring program of postpartum hypertension at the time of delivery within 1 health network from March 2019 to September 2021. Patients were eligible for enrollment after a diagnosis of hypertensive disorder during pregnancy or delivery. We further limited the cohort to self-reported Black and White patients with blood pressures recorded at 3 weeks and 6 weeks postpartum. The neighborhood advantage for each person at the time of delivery was classified using the area deprivation index, an accepted surrogate of social determinants of health and our primary exposure. The secondary exposure was self-reported race. Study outcomes of interest were hypertensive status (stage 1 hypertension: ≥130 to 139/80 to 89 mm Hg; stage 2 hypertension: ≥140/90 mm Hg) at 3 and 6 weeks after delivery. In addition, hypertensive status by neighborhood area deprivation index using logistic regression was molded. In secondary analyses, a case-control cohort matched on the area deprivation index was created, and conditional logistic regression was used to evaluate race. Finally, mixed-effects models modeling hypertension by race and clustering within the area deprivation index were used. Of 4193 people enrolled, 2722 were Black or White and had blood pressure data recorded at 3 weeks after delivery, and 1126 had blood pressure data recorded at 6 weeks after delivery. After accounting for prenatal body mass index, smoking status, type of hypertension, and antihypertensives prescribed at discharge, persons living in the most disadvantaged neighborhoods were twice as likely (adjusted odds ratio, 2.03; 95% confidence interval, 1.53-2.69) to develop stage 2 hypertension at 21 days after delivery and 1.67 times more likely (95% confidence interval, 1.06-2.64) to develop stage 2 hypertension at 6 weeks after delivery than persons living in the most advantaged neighborhoods. Both associations were attenuated after adjusting for race. When people with stage 2 hypertension were matched on area deprivation index with normotensive counterparts, Black patients were still 3 to 4 times more likely to develop stage 2 hypertension at 3 (adjusted odds ratio, 3.00; 95% confidence interval, 1.95-4.63) and 6 (adjusted odds ratio, 4.61; 95% confidence interval, 2.05-10.36) weeks after delivery. This association remained after clustering within a neighborhood at 3 (adjusted odds ratio, 3.12; 95% confidence interval, 2.41-4.06) and 6 (adjusted odds ratio, 2.99; 95% confidence interval, 1.96-4.54) weeks after delivery. There was no significant difference in stage 1 hypertension. Neighborhood advantage was associated with the development of persistent hypertension at 3 and 6 weeks after delivery. This association did not explain the racial disparity in sustained high blood pressure.

Asthma Hospital Admission and Readmission Spikes, Advancing Accurate Classification to Advance Understanding of Causes.

Background: An important component of asthma care is understanding potential causes of high asthma admissions (HAADs) or readmissions (HARDs) with potential of risk mitigation. Crucial to this research is accurately distinguishing these events from background seasonal changes and time trends. To date, classification methods have been based on ad hoc and untested definitions which may hamper understanding causes of HAADs and HARDs due to misclassification. The aim of this article is to introduce an easily applied robust statistical approach, with high classification accuracy in other settings—the Seasonal Hybrid Extreme Studentized Deviate (S-H-ESD) method. Methods: We demonstrate S-H-ESD on a time series between 1996 and 2009 of all daily paediatric asthma hospital admissions in Victoria, Australia. Results: S-H-ESD clearly identified HAADs and HARDs without applying ad hoc classification definitions, while appropriately accounting for seasonality and time trend. Importantly, it was done with statistical testing, providing evidence in support of their identification. Conclusion: S-H-ESD is useful and statistically appropriate for accurate classification of HAADs and HARDS. It obviates ad hoc approaches and presents as a means of systemizing their accurate classification and detection. This will strengthen synthesis and efficacy of research toward understanding causes of HAADs and HARDs for their risk mitigation.

One-year unplanned readmission after percutaneous coronary intervention in ST-elevation myocardial infarction: rates, causes and predictors

Abstract Introduction and aim Unplanned readmission after percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) has a significant impact on the healthcare system. Nevertheless, most of the previous literature evaluated readmission within one month only post PCI without assessing the long-term readmission rates and predictors post-PCI. Therefore, we conducted a retrospective observational study to determine the rates, causes, and predictors of readmission post PCI among patients with STEMI over 1-year follow-up. Methods We conducted a single-center retrospective observation cohort study. Study population included all patients who were admitted to the hospital with diagnosis of STEMI and underwent PCI during the same admission (index admission) and discharged alive in the period between Jan 1st, 2016 and Sep 30th, 2018. Patients were divided into two groups: those who had one or more unplanned readmission within one year after PCI and those who were not readmitted. Rates and causes of readmission within one year following PCI were reported. Predictors of readmission post-PCI were assessed using multivariate logistic regression and reported as odds ratio (OR) with p<0.05 indicating statistical significance. Results A total of 1257 patients were included in our retrospective analysis. Most of the patients were male (95.9%). The mean age of the study population was 51±10. The most frequent culprit vessel was left anterior descending artery (LAD) in 56.3%. The median troponin T upon presentation was 47 ng/L [interquartile range: 171], with 25th percentile of 17 ng/L and 75th percentile of 2197 ng/L. Although around 70% of patients had reduced ejection fraction during the index admission, only 13.4% of the study population had clinical heart failure (HF). The unplanned readmission rate within one year post PCI was 11.5%, with 8.2% due to cardiac readmission while the remaining 3.3% due to non-cardiac causes. The most common cardiac causes for readmission were acute coronary syndrome and HF as shown in Table 1. As demonstrated in Table 2, positive predictors for all-cause readmission within one year after PCI among patients with STEMI were female gender (aOR= 4.14, 95% CI 2.10–8.18; p-value<0.001), chronic kidney disease (aOR= 2.76, 95% CI 1.07–7.08; p-value= 0.035), PCI using more than one stent (aOR= 1.66, 95% CI 1.09–2.55; p-value= 0.019) and clinical HF during index admission (aOR= 2.36, 95% CI 1.49–3.74; p-value<0.001). Conclusion The rate of one-year unplanned readmissions after PCI among patients with STEMI was 11.5%, with acute coronary syndrome and HF as most common causes of cardiac readmission. We found that female gender, chronic kidney disease, PCI with more than one stent and clinical HF were associated with a significantly increased likelihood of readmission after PCI among patients with STEMI which may warrant close and frequent follow-up for these populations. Funding Acknowledgement Type of funding sources: None.

Outcomes in hypertrophic obstructive cardiomyopathy patients undergoing non-cardiac surgery-a nationwide analysis

Abstract Introduction Patients with hypertrophic obstructive cardiomyopathy (HOCM) have a unique pathophysiological profile that increases their chances of having adverse events in the postoperative period following surgical procedures. Owing to the rarity of the disease, few studies are available for assessing readmission risk in HOCM patients undergoing noncardiac surgical procedures. Purpose Our study aimed to assess 30-day readmission rates and causes for readmissions among HOCM patients who had undergone noncardiac surgeries in hospitals across the United States (US). Methods We used appropriate International Classification of Diseases Code, 10th Revision Clinical Modification (ICD-10-CM) codes to identify patients who had been admitted for non-cardiac surgeries between January 2016 and December 2019 based on data from the National Readmissions Database (NRD). The NRD is a publicly available all-payer in-patient database sponsored by the Agency for Healthcare Research and Quality, containing discharge data from approximately 18 million discharges each year, accounting for 61.8% of the total US resident population. Patients were subdivided into two sub-groups based on the presence or absence of HOCM. 30-day readmission rates and causes of readmissions were compared between both groups. STATA version 17 (College Station,TX: StataCorp LLC) was used for statistical analyses. Results A total of 5,497,134 patients out of whom 2,089 had HOCM were identified and included for analysis. Patients with HOCM had statistically significant higher rates of readmissions for central nervous system related complications such as stroke or transient ischemic attack (TIA), cardiogenic shock, acute heart failure, unspecified iatrogenic cardiac complications, acute kidney injury, sepsis in addition to higher rates of post op respiratory failure, acute myocardial infarction and major adverse cardiovascular and cerebrovascular events (MACCE) during the index admission when compared to the other subgroup. Conclusion Our study, despite being retrospective in nature, is one of the largest to date assessing readmission risk in HOCM patients undergoing noncardiac surgeries. Similar to previous studies, HOCM patients have higher rates of readmissions and MACCE in the 30-day period following noncardiac surgical procedures. In light of these findings, shared medical decision making and appropriate counseling regarding complications in the postoperative period will be necessary for HOCM patients who undergo noncardiac surgical procedures. Funding Acknowledgement Type of funding sources: None.

Using Machine Learning to Predict Likelihood and Cause of Readmission After Hospitalization for Chronic Obstructive Pulmonary Disease Exacerbation.

BackgroundChronic obstructive pulmonary disease (COPD) is a leading cause of hospital readmissions. Few existing tools use electronic health record (EHR) data to forecast patients’ readmission risk during index hospitalizations.ObjectiveWe used machine learning and in-hospital data to model 90-day risk for and cause of readmission among inpatients with acute exacerbations of COPD (AE-COPD).DesignRetrospective cohort study.ParticipantsAdult patients admitted for AE-COPD at the University of Chicago Medicine between November 7, 2008 and December 31, 2018 meeting International Classification of Diseases (ICD)-9 or −10 criteria consistent with AE-COPD were included.MethodsRandom forest models were fit to predict readmission risk and respiratory-related readmission cause. Predictor variables included demographics, comorbidities, and EHR data from patients’ index hospital stays. Models were derived on 70% of observations and validated on a 30% holdout set. Performance of the readmission risk model was compared to that of the HOSPITAL score.ResultsAmong 3238 patients admitted for AE-COPD, 1103 patients were readmitted within 90 days. Of the readmission causes, 61% (n = 672) were respiratory-related and COPD (n = 452) was the most common. Our readmission risk model had a significantly higher area under the receiver operating characteristic curve (AUROC) (0.69 [0.66, 0.73]) compared to the HOSPITAL score (0.63 [0.59, 0.67]; p = 0.002). The respiratory-related readmission cause model had an AUROC of 0.73 [0.68, 0.79].ConclusionOur models improve on current tools by predicting 90-day readmission risk and cause at the time of discharge from index admissions for AE-COPD. These models could be used to identify patients at higher risk of readmission and direct tailored post-discharge transition of care interventions that lower readmission risk.

S998 Predictors and Outcomes of 90-Day Readmission in Inflammatory Bowel Disease Patients Admitted for Percutaneous Coronary Intervention

Introduction: The outcome of patients with Inflammatory bowel disease (IBD) presenting with coronary artery disease (CAD) requiring percutaneous coronary intervention (PCI) has limited evidence in the literature. The aim of this study is to examine the predictors and outcomes of 90-day readmissions in IBD patients requiring PCI. Methods: The International Classification of Diseases Code,10th Revision Clinical Modification (ICD-10) was used to identify patients who were hospitalized for PCI. Patients were identified from the Healthcare Cost and Utilization Project databases (HCUP) using the National readmission database (NRD) between 2016 and 2019. Patients were classified into 2 groups depending on whether they have IBD or not. Outcomes were all-cause and cause-specific 90-day readmissions and mortality rate during readmission. Multiple logistic regression model was used to identify the factors associated with readmission Results: 1,851,473 patients underwent PCI between 2016 and 2019. 9295 (0.5%) patients had IBD. The mean age was 65.3 in patients with no IBD and 67.7 in patients with IBD. Total of 239105 readmissions were identified, 1522 (0.6%) were patients with IBD. The rate of admission for patients with IBD was 16.3% as compared to 12.9 % for patient without IBD (p< 0.001). Multivariate logistic regression was performed and showed OR of 1.31 (95% CI 1.18,1.455) (P< 0.001) for 90 days readmission for patients with IBD who underwent PCI as compared to those without IBD. Gastrointestinal bleed occurred in 7 % in patients readmitted who had IBD as compared to 3 % in patients without IBD, OR 1.89 (95% CI 1.57,2.27) (P< 0.001). Most important predictors of readmission were history of coronary artery disease (CAD), Congestive heart failure (CHF) and renal failure. Conclusion: It appears that IBD is an independent risk factor for re-admission in patients undergoing PCI. Bleeding is a major cause of readmission which might be related to use of anticoagulation and antiplatelet agents in patients undergoing PCI. Further studies are needed to identify other possible causes of readmission and optimal means to control them.

S866 Malnutrition and Opioid Use Disorder Are Associated With Higher 30-Day Readmission Rates in Patients Initially Admitted for Ulcerative Colitis

Introduction: Ulcerative colitis (UC) is a chronic disorder that predisposes patients to multiple complications. Readmissions to the hospital pose a burden to patients and health-care systems. Preventing readmissions is important for quality of care and quality of life of patients with UC. We aim to identify the incidence of 30-day readmissions and its predictors. Methods: Retrospective review of the 2018 National Readmission Database (NRD) of adult patients readmitted after an index admission of UC. ICD-10CM/PCS codes were used to identify UC, other comorbidities and procedures. We identified the most common causes for readmission and independent risk factors for readmission were identified using Cox regression analysis. Results: A total of 68,889 index admission (IA) patients were identified, out of which 16.5% (n=11,411) were readmitted within 30-days of discharge. 8.3% of readmissions were secondary to sepsis. Readmitted patients had higher rates of in-hospital mortality (3.4% vs. 2.1%; P< 0.01). Readmitted patients were less likely to be female (50.5% vs 52.8%; P< 0.01), to have private insurance (34.4% vs 40.3%; P< 0.01), to undergo colonoscopy (10.8% vs 17.7%; P< 0.01) and to be from the highest quartile of income (21.9% vs 23.3%; P=0.01). They were more likely to be older (54.0 vs 53.2 years; P< 0.01), to have a Charlson Comorbidity Index (CCI) score of ≥3 (34.1 vs 24.1; P< 0.01), to be from large metropolitan areas with at least 1 million residents (61.1 vs 59.9; P< 0.01), to require parenteral nutrition (3.2% vs 1.5%; P< 0.01), to be malnourished (20.3% vs 11.8%; P< 0.01), to have concomitant Clostridium difficile (6.9% vs. 5.7%; P< 0.01), primary sclerosing cholangitis (0.5% vs 0.2%; P< 0.01) and opioid use disorder (OUD) (3.5% vs 2.4%; P< 0.01). Independent predictors of readmission were CCI of ≥ 3 (aHR 1.95; 95% CI [1.78- 2.13]), undergoing ileostomy during IA (aHR 1.39; 95% CI [1.06-1.82]), increasing LOS (aHR 1.00; 95% CI [1.00-1.01), malnutrition (aHR 1.29; 95% CI [1.17-1.43]) and OUD (aHR 1.45; 95% CI [1.26-1.68]). Private insurance (aHR 0.78; 95% CI [0.72-0.85]), female gender (aHR 0.92; 95% CI [0.87-0.98]) and younger age (aHR 0.99; 95% CI [0.99-0.99]) were associated with less odds of early readmission. (Figure) (Table) Conclusion: The 30-day readmission rate for UC in 2018 was 16.5%. Readmission is associated with higher mortality and are associated with risk factors such as malnutrition and OUD. Early readmissions in UC continues to pose a high burden to patients and our health-care system.Figure 1.: Kaplan Meier graph of 30-day readmission Table 1. - Independent Predictors of 30-day readmission Variable Adjusted odds ratio (95% confidence interval) P value Female 0.92 (0.87-0.98) < 0.01 Age 0.99 (0.99-0.99) < 0.01 Length of stay 1.00 (1.00-1.01) < 0.01 Insurance Provider Medicare Reference Reference Medicaid 0.96 (0.87-1.06) 0.48 Private 0.78 (0.72-0.85) < 0.01 Uninsured 0.81 (0.69-0.96) 0.01 Charlson Comorbidity Index Score 0 1 Reference Reference 2 1.12 (1.03-1.22) < 0.01 ≥3 1.37 (1.24-1.51) < 0.01 Patient residence Large metropolitan area with at least 1 million residents Reference Reference Small metropolitan areas with less than 1 million residents 0.98 (0.92-1.05) 0.75 Micropolitan areas 0.94 (0.79-1.12) 0.53 Not metropolitan or micropolitan (nonurban residual) 0.75 (0.55-1.04) 0.08 In-Hospital Procedures Partial Colectomy 0.91 (0.62-1.32) 0.63 Total colectomy 0.92 (0.70-1.22) 0.58 Ileostomy 1.39 (1.06- 1.82) 0.01 Colonoscopy 1.04 (0.89-1.23) 0.57 Parenteral nutrition 1.19 (0.97-1.46) 0.09 Other Comorbidities Malnutrition 1.29 (1.17-1.43) < 0.01 Obesity 1.00 (0.92-1.08) 0.95 PSC 1.44 (0.98-2.11) 0.06 Alcohol use disorder 1.05 (0.92-1.19) 0.42 Opioid use disorder 1.45 (1.26-1.68) < 0.01 Cannabis use disorder 0.87 (0.72-1.06) 0.18 Diabetes type 1 1.49 (0.98-2.26) 0.06 Diabetes type 2 1.01 (0.93-1.09) 0.74 Shock 1.09 (0.87-1.38) 0.41 Teaching bed size Small Reference Medium 0.96 (0.87-1.06) 0.45 Large 1.06 (0.97-1.15) 0.16

Outcomes of patients with heart failure with preserved ejection fraction undergoing catheter ablation of atrial fibrillation

Limited real-world data exist on early outcomes in patients with heart failure with preserved ejection fraction (HFpEF) undergoing atrial fibrillation (AF) ablation. The purpose of this study was to examine and compare rates of index procedural complications and 30-day readmissions after AF ablation in patients with HFpEF, with heart failure with reduced ejection fraction (HFrEF), and without heart failure. Using the Nationwide Readmissions Database (NRD), we examined 50,299 admissions of adults with heart failure undergoing AF catheter ablation between 2010 and 2014. Using ICD-9-CM codes, we identified procedural complications and causes of readmission after AF ablation. From 2010 to 2014, the prevalence of HFpEF among patients undergoing AF ablation increased from 3.05% to 7.35% (P for trend <.001). Compared to patients without heart failure, patients with HFpEF had significantly increased procedural complications and index mortality (8.4% vs 6.2% and 0.30% vs 0.08%, respectively; P = .016 and P = .010, respectively). Index complication rates between patients with HFpEF and HFrEF were similar. All-cause 30-day readmissions occurred in 18.3% of patients with HFpEF compared to 9.5% of patients without heart failure (P <.001). Compared to no heart failure, the presence of HFpEF was independently associated with all-cause readmissions (adjusted odds ratio 1.52; 95% confidence interval 1.15-1.96; P = .002), but not with procedural complications, cardiac readmissions, or early mortality. Rates of 30-day readmissions after AF ablation are high in patients with HFpEF. However, after adjustment for age and comorbidities, complications and early mortality after AF ablation between patients with HFpEF and those without heart failure are comparable.

S1624 Differences in Gastroparesis Hospitalizations Between Rural and Urban Settings

Introduction: Although gastroparesis is debilitating disease with high comorbidity burden, the data on the epidemiology of this disease is limited. We aim to determine rural vs urban differences in outcomes of hospitalized gastroparesis patients. Methods: We utilized the National Readmission Database (2010-2017) to study the outcomes of rural and urban populations in patients with history of gastroparesis. Associations of rural population with readmission and hospital resource utilization were computed in multivariable models adjusted for age, sex, presence of hypertension, diabetes, congestive heart failure, obesity, chronic kidney disease, pneumonia, HIV, alcohol use, smoking, disposition, teaching hospital status and insurance type. Results: During 2010 – 2017, 2,053,840 patients (mean age 52.8 ± 17.2, 65.3% females) with history of gastroparesis had indexed hospital admissions (Table). In all, 214,711 (10.5%) patients were residing in rural area. The diabetes mellitus was highly prevalent (69.7%) in gastroparesis population. Hypertension, chronic kidney disease, end stage renal disease, diabetic complications, HIV and history of malignancy were more common in urban population whereas coronary artery disease, chronic obstructive pulmonary disease were more prevalent in rural population. The 30-day readmission rates (HR: 0.89, 95% CI: 0.86-0.92), median cost ($22,634 IQR: 12,850,42,658 vs 31,394 17,443-59,734) (β: -13316, 95% CI -15264 to-11367) and median length of stay (4 days IQR: 2,6 vs 4 days IQR: 2,7 β: -0.97, 95% CI: -1.1 to -0.83) were lower in rural vs urban hospitalizations (Figure). The in-hospital mortality was similar in both groups. Diabetic ketoacidosis was the most common reason for 30-day readmission in rural population whereas diabetic neuropathy was the most common cause of readmission in urban group. The trends of 30-day readmission were improving in urban populations from 2010 to 2017. Conclusion: The hospitalized rural gastroparesis population has lower comorbidity burden as compared to urban population. The 30-day readmission rates, hospital cost and length of stay were much lower in the rural population.Figure 1.: A) Kaplan Meier curve showing 30 days readmission of hospitalized rural vs urban gastroparesis population. B) Trends of 30-day readmission of gastroparesis hospitalized patient from 2010 to 2017. Table 1. - Baseline characteristics of gastroparesis indexed admissions from 2010- 2017 Variables n=number of patients Total gastroparesis patients (n=2,384,095) Rural population (n =330,292) Urban population (n=2,053,840) P-value Age 53.0 ± 16.7 53.5 ± 16.5 52.9 ± 16.7 < 0.001 Female 1,556,551 (65.3) 214,711 (65.0) 1,341,840 (65.3) 0.27 Smoker 511,931 (21.5) 73,127 (22.1) 438,805 (21.4) 0.02 Alcohol 47,458 (2.0) 5,884 (1.8) 41,575 (2.0) < 0.001 Obesity 405,670 (17.0) 56,092 (17.0) 349,578 (17.0) 0.86 Hypertension 1,039,488 (62.4) 134,978 (60.9) 904,510 (62.6) < 0.001 Type 1 DM 411,749 (17.3) 59,162 (17.9) 352,587 (17.2) 0.005 Type 2 DM 1,248,767 (52.4) 175,134 (53) 1,073,634 (52.3) 0.03 Diabetic retinopathy 198,473 (8.3) 22,905 (6.9) 175,568 (8.6) < 0.001 Diabetic neuropathy 627,526 (26.3) 88,362 (26.8) 539,164 (26.3) 0.18 Diabetic nephropathy 259,042 (10.9) 32,852 (10.0) 226,190 (11.0) < 0.001 COPD 174,409 (7.3) 30,971 (9.4) 143,438 (7.0) < 0.001 Coronary artery disease 565,482 (23.7) 82,628 (25.0) 482,854 (23.5) < 0.001 Congestive heart failure 728,433 (30.6) 100,306 (30.4) 628,127 (30.6) 0.5 Chronic kidney disease 552,153 (23.2) 71,564 (21.7) 480,589 (23.4) < 0.001 ESRD 334,265 (14.0) 35,575 (10.8) 298,690 (14.5) < 0.001 Malnutrition 217,134 (9.1) 30,010 (9.1) 187,124 (9.1) 0.89 Pneumonia 163,785 (6.9) 26,115 (7.9) 137,670 (6.7) < 0.001 HIV 15,842 (0.7) 1,086 (0.3) 14,757 (0.7) < 0.001 History of malignancy 126,355 (5.3) 15,813 (4.8) 110,542 (5.4) < 0.001 Peptic ulcer disease 200,478 (8.4) 26,184 (7.9) 174,294 (8.5) 0.005 Nonvariceal upper GI bleeding 87,294 (3.7) 10.969 (3.3) 76,325 (3.7) < 0.001 Lower GI bleeding 86,666 (3.6) 11,792 (3.6) 74,873 (3.7) 0.34 Septic shock 36,783 (1.5) 4,540 (1.4) 32,244 (1.6) < 0.001 ICU admission 89,768 (3.8) 10,958 (3.3) 78,810 (3.8) < 0.001 Teaching hospital 1,366,346 (57.3) 79,730 (24.1) 1,286,616 (62.6) < 0.001 Insurance Medicare 1,270,059 (53.4) 187,504 (57) 1,082,555 (52.8) < 0.001 Medicaid 473,251 (19.9) 61,691 (18.7) 411,561 (20.1) Private 468,711 (19.7) 55,655 (16.9) 413,056 (20.1) Self-pay 94,936 (4.0) 14,816 (4.5) 80,120 (3.9) High Charlson comorbidity score 1,758,091 (73.7) 240,094 (72.7) 1,517,998 (73.9) < 0.001 Disposition Home 1,563,076 (65.6) 222,497 (67.4) 1,340,579 (65.3) < 0.001 Short term inpatient 18,135 (0.8) 4,402 (1.3) 13,732 (0.7) Transfer to SNF, ICF 317,217 (13.3) 43,663 (13.2) 273,554 (13.3) Home care 389,479 (16.3) 47,970 (14.5) 341,508 (16.6)

Rates, Reasons, and Independent Predictors of Readmissions in Portal Venous Thrombosis Hospitalizations in the USA.

Portal vein thrombosis (PVT), generally considered rare, is becoming increasingly recognized with advanced imaging. Limited data exist regarding readmissions in PVT and its burden on the overall healthcare cost. This study aimed to outline the burden of PVT readmissions and identify the modifiable predictors of readmissions. The National Readmission Database (NRD) was used to identify PVT admissions from 2016 to 2019. Using the patient demographic and hospital-specific variables within the NRD, we grouped patient encounters into two cohorts, 30- and 90-day readmission cohorts. We assessed comorbidities using the validated Elixhauser comorbidity index. We obtained inpatient mortality rates, mean length of hospital stay (LOS), total hospital cost (THC), and causes of readmissions in both 30- and 90-day readmission cohorts. Using a multivariate Cox regression analysis, we identified the independent predictors of 30-day readmissions. We identified 17,971 unique index hospitalizations, of which 2,971 (16.5%) were readmitted within 30 days. The top five causes of readmissions in both 30-day and 90-day readmission cohorts were PVT, sepsis, hepatocellular cancer, liver failure, and alcoholic liver cirrhosis. The following independent predictors of 30-day readmission were identified: discharge against medical advice (AMA) (adjusted hazard ratio (aHR) 1.86; P = 0.002); renal failure (aHR 1.44, P = 0.014), metastatic cancer (aHR 1.31, P = 0.016), fluid and electrolyte disorders (aHR 1.20, P = 0.004), diabetes mellitus (aHR 1.31, P = 0.001) and alcohol abuse (aHR 1.31, P ≤ 0.001). The readmission rate identified in this study was higher than the national average and targeted interventions addressing these factors may help reduce the overall health care costs.

Readmission in acute pancreatitis: Etiology, risk factors, and opportunities for improvement

Acute pancreatitis is associated with a readmission rate ranging from 7 to 34%. Readmission rates are highest among biliary (4–37%) and alcohol-induced (2–60%) acute pancreatitis. Severe acute pancreatitis and necrotizing pancreatitis have readmission rates ranging from 20 to 75%. The most common causes of readmission include recurrent acute pancreatitis (17–45% of readmissions) and smoldering symptoms/local complications (17–38%). A number of risk scores reliably estimate risk of readmission in acute pancreatitis. Decreased rates of readmission were reported in patients that underwent same-admission cholecystectomy in biliary pancreatitis and alcohol cessation interventions in alcohol-induced pancreatitis. This review article discusses readmission in acute pancreatitis, including etiology, risk factors, and opportunities for improved patient care.

In-hospital mortality rate and predictors of 30-day readmission in patients with iron deficiency anemia and diastolic heart failure: A cross-sectional study

Introduction: There is currently strong evidence of the adverse effects of anemia on the prognosis of heart failure with reduced ejection fraction. Unfortunately, the data on the effects of anemia on a large sample of patients with diastolic heart failure (DHF) is lacking. In this study, we aimed to evaluate the effect of iron deficiency anemia on DHF readmission rates and its corresponding causes and burdens on the healthcare system. Methods: We utilized 2018 Nationwide readmission data and included patients aged ≥18 years with ICD-10 CM code indicating acute or acute chronic diastolic heart failure and iron deficiency anemia was included in the study. The primary outcome is 30-day readmission rates. Secondary outcomes were mortality rates, common causes of readmission, and healthcare utilization. Independent predictors for readmission were identified using cox regression analysis. Results: The total number of admissions in our study was 795,777. The mean age was 74.4 years (SD=13.7), and 63.54% were females. The 30-day readmission rate in patients with diastolic heart failure and iron deficiency anemia was 18.32 % vs. 16.01% in patients without anemia. The mortality rate at index admission and readmission was 3.62 % (2601) and 5.82 % (737), respectively. The most common cause of readmission was hypertensive heart and kidney disease with heart failure (17.74%). The independent predictors of readmission were age&lt;85 years, household income &lt;59000$/per year, Medicare and Medicaid insurance, higher Elixhauser comorbidities score, longer Length of stay during the index admission, discharge to a nursing home, hospital located in a large metropolitan area. The financial burden on healthcare for all the readmission was $837 million for 2018. Conclusion: The 30-day readmission rate in patients with diastolic heart failure and iron deficiency anemia is 18.32% in the year 2018. The mortality rate increased from 3.62 % to 5.82 % with readmission. The financial burden for readmission during that year was $837 million. Future studies are warranted to treat iron deficiency anemia to prevent readmissions in diastolic heart failure.

Thirty-day readmission in patients with heart failure with preserved ejection fraction: Insights from the nationwide readmission database.

BACKGROUNDThere are rising numbers of patients who have heart failure with preserved ejection fraction (HFpEF). Poorly understood pathophysiology of heart failure with preserved and reduced ejection fraction and due to a sparsity of studies, the management of HFpEF is challenging.AIMTo determine the hospital readmission rate within 30 d of acute or acute on chronic heart failure with preserved ejection fraction and its effect on mortality and burden on health care in the United States.METHODSWe performed a retrospective study using the Agency for Health-care Research and Quality Health-care Cost and Utilization Project, Nationwide Readmissions Database for the year 2017. We collected data on hospital readmissions of 60514 adults hospitalized for acute or acute on chronic HFpEF. The primary outcome was the rate of all-cause readmission within 30 d of discharge. Secondary outcomes were cause of readmission, mortality rate in readmitted and index patients, length of stay, total hospitalization costs and charges. Independent risk factors for readmission were identified using Cox regression analysis. RESULTSThe thirty day readmission rate was 21%. Approximately 9.17% of readmissions were in the setting of acute on chronic diastolic heart failure. Hypertensive chronic kidney disease with heart failure (1245; 9.7%) was the most common readmission diagnosis. Readmitted patients had higher in-hospital mortality (7.9% vs 2.9%, P = 0.000). Our study showed that Medicaid insurance, higher Charlson co-morbidity score, patient admitted to a teaching hospital and longer hospital stay were significant variables associated with higher readmission rates. Lower readmission rate was found in residents of small metropolitan or micropolitan areas, older age, female gender, and private insurance or no insurance were associated with lower risk of readmission.CONCLUSIONWe found that patients hospitalized for acute or acute on chronic HFpEF, the thirty day readmission rate was 21%. Readmission cases had a higher mortality rate and increased healthcare resource utilization. The most common cause of readmission was cardio-renal syndrome.

Postpartum readmissions for hypertensive disorders in pregnancy during the COVID-19 pandemic

BACKGROUNDHypertensive disorders in pregnancy are one of the most common causes of readmission in the postpartum period. Because of the COVID-19 pandemic, early hospital discharge was encouraged for patients who were medically stable, because hospitalization rates among SARS-CoV-2–infected patients steadily increased in 2020. The impact of an early discharge policy on postpartum readmission rates among patients with hypertensive disorders in pregnancy is unknown.OBJECTIVEThis study aimed to compare the postpartum readmission rates of patients with hypertensive disorders in pregnancy before and after implementation of an early discharge policy owing to the COVID-19 pandemic.STUDY DESIGNThis was a quality improvement, retrospective cohort study of postpartum patients with antenatal hypertensive disorders in pregnancy who delivered and were readmitted because of hypertensive disorders in pregnancy at the New York University Langone Health medical center from March 1, 2019 to February 29, 2020 (control cohort) and from April 1, 2020 to March 31, 2021 (COVID-19 cohort). During the pandemic, our institution introduced an early discharge policy for all postpartum patients to be discharged no later than 2 days postpartum during the delivery admission if deemed medically appropriate. The reduction in postpartum length of stay was accompanied by the continuation of patient education, home blood pressure monitoring, and outpatient follow-up. The primary outcome was the comparison of the readmission rates for patients with postpartum hypertensive disorders in pregnancy. Data were analyzed using Fisher's Exact tests, chi-square tests, and Wilcoxon rank-sum tests with significance defined as P<.05.RESULTSThere was no statistical difference in the readmission rates for patients with postpartum hypertensive disorders in pregnancy before vs after implementation of an early discharge policy (1.08% for the control cohort vs 0.59% for the COVID-19 cohort). The demographics in each group were similar, as were the median times to readmission (5.0 days; interquartile range, 4.0–6.0 days vs 6.0 days; interquartile range, 5.0–6.0 days; P=.13) and the median readmission length of stay (3.0 days; interquartile range, 2.0–4.0 days vs 3.0 days; interquartile range, 2.0–4.0 days; P=.45). There was 1 intensive care unit readmission in the COVID-19 cohort and none in the control cohort (P=.35). There were no severe maternal morbidities or maternal deaths.CONCLUSIONThese findings suggest that policies calling for a reduced postpartum length of stay, which includes patients with hypertensive disorders in pregnancy, can be implemented without impacting the hospital readmission rate for patients with hypertensive disorders in pregnancy. Continuation of patient education and outpatient surveillance during the pandemic was instrumental for the outpatient postpartum management of the study cohort. Further investigation into best practices to support early discharges is warranted.

Readmissions and deaths from complications associated with alcohol abuse

Objective: to analyze readmissions and deaths of hospitalized patients due to the effects of alcohol abuse. Methods: documentary, longitudinal and retrospective study, by analysis of hospital records, carried out in a teaching hospital, by descriptive analysis, univariate association, using Pearson's chi-square test. Results: 399 readmissions of 278 patients were analyzed. Two hospitalizations predominated (69.6%). Most were male (85.2%), and the mean age was 47.15 years (± 13.91); 91.2% were readmissions due to the use of alcoholic beverages, with 45.3% of complications associated with injuries, poisoning and external causes of morbidity and mortality. Twenty-seven (9.7%) patients died. The readmissions of retirees/housewives had an odds ratio of 3.0 of progressing to death. Conclusion: the analysis showed prevalent readmissions and mortality in males, productive age group, with a significant association of risk in intensive care patients and cause of death associated with complications of chronic alcohol use. Contributions to practice: the identification of the causes of readmissions helps nursing professionals in the early recognition of signs of severity and serves as a subsidy for the development of prevention strategies and actions to improve the care network.

Drug-related risk of hospital readmission in children with chronic diseases, a systematic review

Drug-related problems (DRPs) are one of the leading causes of hospital readmissions. Children with chronic diseases are more likely to experience DRPs than adults. The burden and characteristics of drug-related readmissions at and after hospital discharge in children remain unclear. We aimed to summarize the impact of DRPs at and after hospital discharge on the risk of readmissions in children with chronic diseases. We conducted a systematic review searching PubMed from inception until January 2022. Study selection criteria were studies assessing the impact of different factors at discharge and after discharge on the risk of hospital readmissions in children with chronic diseases, reporting an assessment of DRPs. DRP could be the only risk factor assessed or one among others. Included studies were assessed with the Risk of Bias in Non-Randomized Studies - of Exposure (ROBINS-E) tool. We summarized the qualitative impact of the reported DRPs on hospital readmission as conclusive (significant association) or inconclusive. Of the 4734 studies initially identified, 13 met inclusion criteria. Eleven studies were retrospective, using electronic health records. The studies assessed the impact of DRPs at or after discharge according to the type of medication (in 6 studies), number of medication (in 5 studies) and medication nonadherence (in 2 studies). From the 44 reported associations between DRPs and the risk of readmission 26 (59% [95% CI, 43%-73%]) were conclusive, of which 81% increased the risk and 19% decreased the risk, and 17 (39% [95% CI, 24%-55%]) were inconclusive. The impact of DRPs on hospital readmissions in children with chronic diseases displayed conflicting results, estimated associations having potentially a serious risk of bias. We need more evidence with a lower risk of bias.

Hospital Readmissions After Total Joint Arthroplasty: An Updated Analysis and Implications for Value-Based Care

BackgroundWhile risk factors have been published for readmissions following primary total joint arthroplasty, little is known about the etiology of those costly adverse events. In this study, we sought to identify the reasons for 30-day readmission following primary total joint arthroplasty in a contemporary national patient sample. MethodsThe American College of Surgeons National Surgical Quality Improvement Program was queried to identify 367,199 patients who underwent primary total knee (TKA) or hip arthroplasty (THA) between 2011 and 2018. The primary outcomes were the annual rates of 30-day readmissions and the causes of those readmissions. ResultsThe 30-day readmission rate trended downward from 4.5% in 2011 to 3.3% in 2018. Medical complications accounted for 52.6% and 38.5% of readmissions following TKA and THA, respectively. Diseases of the circulatory system, abnormal laboratory values, and diseases of the digestive system were the leading causes of medical readmissions. Surgical complications accounted for 37.7% and 50.7% of readmissions following TKA and THA, respectively. Surgical site infections/wound disruption and venous thromboembolism were the leading two causes of surgical readmissions for THA and TKA. Prosthetic complications—namely dislocations and periprosthetic fractures—were the third leading cause of surgical readmissions for THA. For TKA, musculoskeletal conditions—namely pain and hematoma—were the third leading cause of surgical readmissions. ConclusionMedical complications accounted for half of all TKA readmissions and more than a third of THA readmissions. This could penalize institutions participating in value-based payment programs or dissuade others who are considering participation in such programs.