Causes Of Unplanned Readmissions Research Articles

299 Predictors of Unplanned Readmission in Patients Undergoing Intracranial Tumor Resection: A Multi-center Analysis of 31,776 Patients

INTRODUCTION: Although unplanned readmission is a postoperative outcome metric associated with significant morbidity and financial burden, precise assessment tools for its prediction are yet to be developed. The Revised Risk Analysis Index (RAI) has been recently endorsed as a robust frailty index for predicting surgical outcomes. Hence, the RAI could potentially be utilized to help improve prediction unplanned readmission in patients undergoing intracranial tumor resection (ITR). METHODS: Data of patients undergoing ITR were obtained from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from the years 2012-2019 using the ICD-9 and ICD-10 codes, indicating ITR. Baseline characteristics, preoperative clinical status, and outcomes were compared between patients with and without unplanned readmission. Frailty, as a measure of baseline physiological reserve, was calculated using the RAI. Univariate and multivariate logistic regression analyses were performed to identify independent associations between unplanned readmissions and patient characteristics. RESULTS: The unplanned readmission rate of this cohort (N = 31,776) was 10.8% (N = 3,420). Among the readmitted patients, 958 required unplanned reoperation. Multiple characteristics were significantly different between the readmitted and non-readmitted patients, including age, BMI, comorbidities, and RAI groups (p < 0.05). The most common causes of unplanned readmission were infection (9.4%), seizures (6%), and pulmonary embolism (4%). Patient characteristics identified as reliable predictors of unplanned readmission, included age, body mass index (BMI), functional status, diabetes, hypertension, hyponatremia, and their RAI score (p < 0.05). In multivariate analysis, RAI “frail” patients had an unplanned readmission odds ratio (OR) of 1.3(95%CI; 1.2-1.4), and RAI “severely frail” patients had an OR of 1.6 (95%CI; 1.3-2.1) (p < 0.001). CONCLUSIONS: The RAI is a reliable pre-operative frailty index for predicting unplanned readmission following ITR. Utilizing the RAI to identify high risk patients may decrease unplanned readmission through implementation of appropriate management guidelines.

Vulnerability to functional decline is associated with noncardiovascular cause of 90-day readmission in hospitalized patients with heart failure.

Hospital readmission is common among patients with heart failure. Vulnerability to decline in physical function may increase the risk of noncardiovascular readmission for these patients, but the association between vulnerability and the cause of unplanned readmission is poorly understood, inhibiting the development of effective interventions. We examined the association of vulnerability with the cause of readmission (cardiovascular vs. noncardiovascular) among hospitalized patients with acute decompensated heart failure. This prospective longitudinal study is part of the Vanderbilt Inpatient Cohort Study. The primary outcome was the cause of unplanned readmission (cardiovascular vs. noncardiovascular). The primary independent variable was vulnerability, measured using the Vulnerable Elders Survey (VES-13). Among 804 hospitalized patients with acute decompensated heart failure, 315 (39.2%) experienced an unplanned readmission within 90 days of discharge. In a multinomial logistic model with no readmission as the reference category, higher vulnerability was associated with readmission for noncardiovascular causes (relative risk ratio [RRR] = 1.36, 95% confidence interval [CI]: 1.06-1.75) in the first 90 days after discharge. The VES-13 score was not associated with readmission for cardiovascular causes (RRR = 0.94, 95% CI: 0.75-1.17). Vulnerability to functional decline predicted noncardiovascular readmission risk among hospitalized patients with heart failure. The VES-13 is a brief, validated, and freely available tool that should be considered in planning care transitions. Additional work is needed to examine the efficacy of interventions to monitor and mitigate noncardiovascular concerns among vulnerable patients with heart failure being discharged from the hospital.

Causes and Predictors of Unplanned Readmission in Patients Undergoing Intracranial Tumor Resection: A Multicenter Analysis of 31,776 Patients

Although unplanned readmission is a postoperative outcome metric associated with significant morbidity and financial burden, precise assessment tools for its prediction are yet to be developed. The Risk Analysis Index (RAI) could potentially be utilized to help improve prediction unplanned readmission in patients undergoing intracranial tumor resection (ITR). Here we evaluate the predictive accuracy of frailty on 30-day unplanned readmission following ITR using the RAI. Data were obtained from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Baseline characteristics, preoperative clinical status, and outcomes were compared between patients with and without unplanned readmission. Frailty was calculated using the RAI. Univariate and multivariate logistic regression analyses were performed to identify independent associations between unplanned readmissions and patient characteristics. The unplanned readmission rate of this cohort (N=31,776) was 10.8% (N= 3,420). Among the readmitted patients, 958 required unplanned reoperation. Multiple characteristics were significantly different between the readmitted and non-readmitted patients, including age, BMI, comorbidities, and RAI groups (p<0.05). Common causes of unplanned readmission included infection (9.4%), seizures (6%), and pulmonary embolism (4%). Patient characteristics identified as reliable predictors of unplanned readmission, included age, body mass index (BMI), functional status, diabetes, hypertension, hyponatremia, and their RAI score (p<0.05). Frail status, hyponatremia, leukocytosis, hypertension, and thrombocytosis were significant predictors of unplanned readmission. The RAI is a reliable pre-operative frailty index for predicting unplanned readmission following ITR. Utilizing the RAI may decrease unplanned readmission thorough identifying high risk patients, and enabling future implementation of appropriate management guidelines.

READMISSÃO NÃO PLANEJADA EM 30 DIAS APÓS CIRURGIAS DA COLUNA: ANÁLISE DE 650 CASOS

ABSTRACT Objective: Postoperative readmission rates can be used to assess hospital care quality. The rates of unplanned readmission within 30 days after spine surgery are variable in the literature, and no studies have evaluated such rates in a single Latin American center. This study aimed to assess the rate of unplanned hospital readmission within 30 days after a spine surgery at a single Brazilian institution and to identify possible risk factors. Methods: Patients who underwent spine surgery at a single private hospital between January 2018 and December 2020 were retrospectively analyzed, and those with unplanned readmissions within 30 days of discharge were identified. Risk factors were determined, and the reoperation rate was assessed. Results: 650 patients were included in the analysis, and 74 (11.28%) were readmitted within 30 days after surgery. Higher readmission rates were observed after vertebroplasty and surgeries involving spinal or bone tumors. The risk factors found in the series were older age, longer hospital stays, higher ASA scores, instrumented surgeries, diabetes mellitus, and surgeries involving primary or secondary spinal tumors. The most common causes of unplanned readmission were infection and pain. Of the readmissions, 28.37% required a return to the operating room. Conclusions: This study suggests infection and pain management were the most common causes of unplanned readmission after spine surgery. Strategies to improve perioperative and postoperative care are required to reduce unplanned readmissions. Level of Evidence III; Retrospective Comparative Study.

Incidence and Factors Associated with Postoperative Delayed Hyponatremia after Transsphenoidal Pituitary Surgery: A Meta-Analysis and Systematic Review.

Introduction Postoperative delayed hyponatremia is a complication associated with transsphenoidal pituitary surgery. Due to a wide spectrum of symptoms, the reported incidence and predictors of postoperative delayed hyponatremia vary among studies, and this deserves to be reviewed systematically. Methods PubMed, EMBASE, and CENTRAL databases were searched until September 1, 2020. Studies were included when (1) the event number of delayed hyponatremia after transsphenoidal pituitary surgery was reported, or (2) the associated factors of such complication were evaluated. Results A total of 27 studies were included for meta-analysis. The pooled incidence of overall and symptomatic delayed hyponatremia was 10.5% (95% confidence interval (CI) = 7.4–14.7%) and 5.0% (95% CI = 3.6–6.9%), respectively. No overt variations of the pooled estimates were observed upon subgroups stratified by endoscopic and microscopic procedure, publication year, and patients' age. In addition, 44.3% (95% CI = 29.6–60.2%) of unplanned hospital readmissions within 30 days were caused by delayed hyponatremia. Among the predictors evaluated, older age was the only significant factor associated with increased delayed hyponatremia (odds ratio = 1.16, 95% CI = 1.04–1.29, P = 0.006). Conclusion This meta-analysis and systematic review evaluated the incidence of postoperative delayed hyponatremia and found it as a major cause of unplanned readmissions after transsphenoidal pituitary surgery. Older patients are more prone to such complications and should be carefully followed. The retrospective nature and heterogeneity among the included studies and the small number of studies used for risk factor evaluation might weaken the corresponding results. Future prospective clinical studies are required to compensate for these limitations.

Predictors of 30-Day Unplanned Readmission After Carotid Artery Stenting Using Artificial Intelligence.

IntroductionThis study aimed to describe the rates and causes of unplanned readmissions within 30 days following carotid artery stenting (CAS) and to use artificial intelligence machine learning analysis for creating a prediction model for short-term readmissions. The prediction of unplanned readmissions after index CAS remains challenging. There is a need to leverage deep machine learning algorithms in order to develop robust prediction tools for early readmissions.MethodsPatients undergoing inpatient CAS during the year 2017 in the US Nationwide Readmission Database (NRD) were evaluated for the rates, predictors, and costs of unplanned 30-day readmission. Logistic regression, support vector machine (SVM), deep neural network (DNN), random forest, and decision tree models were evaluated to generate a robust prediction model.ResultsWe identified 16,745 patients who underwent CAS, of whom 7.4% were readmitted within 30 days. Depression [p < 0.001, OR 1.461 (95% CI 1.231–1.735)], heart failure [p < 0.001, OR 1.619 (95% CI 1.363–1.922)], cancer [p < 0.001, OR 1.631 (95% CI 1.286–2.068)], in-hospital bleeding [p = 0.039, OR 1.641 (95% CI 1.026–2.626)], and coagulation disorders [p = 0.007, OR 1.412 (95% CI 1.100–1.813)] were the strongest predictors of readmission. The artificial intelligence machine learning DNN prediction model has a C-statistic value of 0.79 (validation 0.73) in predicting the patients who might have all-cause unplanned readmission within 30 days of the index CAS discharge.ConclusionsMachine learning derived models may effectively identify high-risk patients for intervention strategies that may reduce unplanned readmissions post carotid artery stenting.Central IllustrationFigure 2: ROC and AUPRC analysis of DNN prediction model with other classification models on 30-day readmission data for CAS subjectsSupplementary InformationThe online version contains supplementary material available at 10.1007/s12325-021-01709-7.

Thirty-Day Unplanned Readmission After Ambulatory Laparoscopic Cholecystectomy in Western China: A Retrospective Study.

BackgroundDay surgery has been gradually accepted by health professions globally, which can shorten the hospital stay and reduce medical costs. The ambulatory laparoscopic cholecystectomy (LC) has been performed in China since over 10 years. However, few studies focus on its 30-day unplanned readmission rate of ambulatory LC and no standard of unplanned readmission rate for that now.PurposeThis study aimed to evaluate the unplanned readmission rate and the reasons readmission after ambulatory LC in a tertiary hospital, which is the earliest ambulatory surgery implementation place in western China.MethodsA retrospective analysis was conducted. The patients who underwent ambulatory LC from September 2015 to September 2019 in West China Hospital were screened. The 30-day unplanned readmission rate was calculated as the first outcome. The reasons for unplanned readmission were analyzed and classified as the second outcome.ResultsThe study included 3,014 patients, and the unplanned readmission rate was 1.53%. The rate of patients diagnosed with cholecystolithiasis with cholecystitis was significantly higher in the unplanned readmission group (73.9% vs. 48.9%, p=0.003), and medical cost of unplanned readmission patients was significantly more than that of non-readmission patients (8,102.4±1,375.7 Yuan vs. 7,574.61±10,14.0 Yuan; p=0.008). It was observed that 71.7% readmission happened in the first seven days. Wound problems (60.9%) and abdominal pain (26.1%) went the two main reasons for unplanned readmission.ConclusionsThe analysis revealed that the unplanned readmission rate of 1.53% was low for ambulatory LC. Some causes of unplanned readmission, such as abdominal pain and wound site pain, wound exudate could be reduced by some simple interventions of the clinical professions.

Improved Outpatient Communication Decreases Unplanned Readmission in Necrotizing Pancreatitis

BackgroundUnplanned readmission rates in necrotizing pancreatitis (NP) are among the highest of any medical disease (72%). Recent work has identified several potentially preventable causes of unplanned readmission in NP. We hypothesized that intensive outpatient communication would identify developing problems and decrease unplanned hospital readmission. Materials and methodsA review of NP patients treated at a single institution between 2016 and 2019 compared patients 2 y before (NP-pre, 2016-2018) and 1 y after (NP-post, 2018-2019) the establishment of a dedicated pancreatitis nurse coordinator. Unplanned hospital readmission and emergency room visits were compared between groups. ResultsA total of 178 NP patients were treated—112 patients in the NP-pre group and 66 patients in the NP-post group. No differences between groups were observed in age, sex, comorbidities, pancreatitis etiology, NP severity, or mortality. A mean of 5.4 ± 0.2 outpatient communications per patient with the pancreatitis nurse coordinator was documented in the NP-post group. Unplanned readmission rates decreased significantly from 64% (NP-pre) to 45% (NP-post; P = 0.02). The frequency of readmission decreased from 1.6 readmissions per patient (NP-pre) to 0.8 readmissions per patient (NP-post; P = 0.001). Readmissions because of symptomatic necrosis, failure to thrive, nonnecrosis infection, and drain dysfunction decreased (P < 0.05). Overall disease duration was similar (NP-pre, 4.6 ± 0.3 mo; NP-post, 5.0 ± 0.3 mo; P = 0.4); however, the mean number of unplanned inpatient days decreased from 15.4 ± 2.2 d (NP-pre) to 7.8 ± 1.6 d (NP-post; P = 0.02). ConclusionsImproved outpatient communication identifies treatable problems and significantly decreases unplanned readmission in NP patients.

Possible preventable causes of unplanned readmission after elective liver resection, results from a non-academic referral HPB center.

Unplanned readmission is a common event after liver resection, and it is a burden for both patients and healthcare policy makers. This study evaluates the incidence of and reasons for unplanned readmission after liver resection, in order to identify possible preventable causes. In this single-center cohort study, data from patients who underwent liver resection for both malignant and benign indications from 2001 to 2016 at our institute were collected from a database with prospective data. Readmissions were analyzed for their reasons and risk factors. Patients with general complaints with no specific complications were categorized as failure to thrive. In 406 patients, the readmission rate was 11.6%. Most patients were readmitted because of failure to thrive (35%), deep and superficial surgical site infection (28%), or cardiopulmonary complications (15%). A multivariate analysis revealed that unplanned readmission was associated with the occurrence of complications during index admission—with an odds ratio of 4.69 (CI 2.41–9.12, p < 0.001). Readmission occurs in more than 1 in 10 patients after liver resection, and it is associated with a complicated course during index admission. One-third of readmissions occur because of failure to thrive and might be preventable. Future research in strategies to reduce readmission rates should focus on both the prevention of complications during index admission and programs at the interface between primary and secondary care.

Towards a patient journey perspective on causes of unplanned readmissions using a classification framework: results of a systematic review with narrative synthesis

BackgroundSeveral literature reviews have been published focusing on the prevalence and/or preventability of hospital readmissions. To our knowledge, none focused on the different causes which have been used to evaluate the preventability of readmissions. Insight into the range of causes is crucial to understand the complex nature of readmissions.With this review we aim to: 1) evaluate the range of causes of unplanned readmissions in a patient journey, and 2) present a cause classification framework that can support future readmission studies.MethodsA literature search was conducted in PUBMED and EMBASE using “readmission” and “avoidability” or “preventability” as key terms. Studies that specified causes of unplanned readmissions were included. The causes were classified into eight preliminary root causes: Technical, Organization (integrated care), Organization (hospital department level), Human (care provider), Human (informal caregiver), Patient (self-management), Patient (disease), and Other. The root causes were based on expert opinions and the root cause analysis tool of PRISMA (Prevention and Recovery Information System for Monitoring and Analysis). The range of different causes were analyzed using Microsoft Excel.ResultsForty-five studies that reported 381 causes of readmissions were included. All studies reported causes related to organization of care at the hospital department level. These causes were often reported as preventable. Twenty-two studies included causes related to patient’s self-management and 19 studies reported causes related to patient’s disease. Studies differed in which causes were seen as preventable or unpreventable. None reported causes related to technical failures and causes due to integrated care issues were reported in 18 studies.ConclusionsThis review showed that causes for readmissions were mainly evaluated from a hospital perspective. However, causes beyond the scope of the hospital can also play a major role in unplanned readmissions. Opinions regarding preventability seem to depend on contextual factors of the readmission. This study presents a cause classification framework that could help future readmission studies to gain insight into a broad range of causes for readmissions in a patient journey.In conclusion, we aimed to: 1) evaluate the range of causes for unplanned readmissions, and 2) present a cause classification framework for causes related to readmissions.

Causes of Hospital Readmissions Within 7 Days From the Neurosurgical Service of a Quaternary Referral Hospital

Abstract INTRODUCTION Unplanned hospital readmission after discharge is an important quality metric. Such readmissions are associated with greater healthcare costs, decreased patient satisfaction, decreased clinical outcomes, and sometimes financial penalties. A large amount of data has been documented regarding 30-d readmissions for neurosurgical populations. However, a focus on 7-d readmissions may provide an insight into the causes of unplanned readmissions, perhaps translate into decreases in 30-d readmissions. This study was performed in order to determine the causes of 7-d readmissions and to define risk factors that, if addressed, would allow for a reduction of such readmissions. METHODS All patients readmitted after discharge within 7 d from the neurosurgical service from the University of Pittsburgh Medical Center, Presbyterian Hospital, during 2018 were evaluated. There were 18 different providers. Demographic data were collected for all patients. The primary reason for readmission was organized using a 5-category system: surgical site infection, pain, altered mental status/seizures, other postoperative complications [eg, venous thromboembolism (VTE), urinary tract infection, pneumonia, CSF leak, hematoma, shunt failure] and “unrelated.” RESULTS Of 5184 discharges, 169 patients (3.3%) were readmitted within 7 d (55% men; mean age 62 yr). A total of 65% had undergone care for cranial pathology and 35% for spine (versus 55% and 45%, respectively, in the total discharge population). Other postoperative complications were the leading cause of readmission (40%), followed by altered mental status/seizure and unrelated (20% each). Surgical site infection and postoperative pain exhibited the lowest rates of 10% each. CONCLUSION The overall 7-d readmission rate was 3.3%. There was nearly a 2:1 ratio for cranial versus spinal patients for 7-d readmissions. The majority of readmissions were related to postoperative complications, whether directly related to surgical intervention or perioperative complications. Focal efforts to decrease specific postoperative complications should translate into a reduction in both 7- and 30-d unplanned readmissions.

Timing and Causes of Unplanned Readmissions After Percutaneous Coronary Intervention: Insights From the Nationwide Readmission Database

ObjectivesThe aim of this study was to describe the rates and causes of unplanned readmissions at different time periods following percutaneous coronary intervention (PCI). BackgroundThe rates and causes of readmission at different time periods after PCI remain incompletely elucidated. MethodsPatients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were evaluated for the rates, causes, predictors, and costs of unplanned readmission between 0 and 7 days, 8 and 30 days, 31 and 90 days, and 91 and 180 days after index discharge. ResultsThis analysis included 2,412,000 patients; 2.5% were readmitted between 0 and 7 days, 7.6% between 8 and 30 days, 8.9% between 31 and 90 days, and 8.0% between 91 and 180 days (cumulative rates 2.5%, 9.9%, 18.0%, and 24.8%, respectively). The majority of readmissions during each time period were due to noncardiac causes (53.1% to 59.6%). Nonspecific chest pain was the most common identifiable noncardiac cause for readmission during each time period (14.2% to 22.7% of noncardiac readmissions). Coronary artery disease including angina was the most common cardiac cause for readmission during each time period (37.4% to 39.3% of cardiac readmissions). The second most common cardiac cause for readmission was acute myocardial infarction between 0 and 7 days (27.6% of cardiac readmissions) and heart failure during all subsequent time periods (22.2% to 23.7% of cardiac readmissions). ConclusionsApproximately 25% of patients following PCI have unplanned readmissions within 6 months. Causes of readmission depend on the timing at which they are assessed, with noncardiovascular causes becoming more important at longer time points.

Unplanned readmission after ocular trauma ambulatory surgery: A retrospective study of the Zhongshan Ophthalmic Center.

Ambulatory surgery (AS) has become common in recent years. This study explored the causes of unplanned readmission after AS and the trends in the rate of unplanned readmission in the Ocular Trauma Department of Zhongshan Ophthalmic Center. We collected information on patients who underwent AS from 1 January 2015 to 31 December 2017, summarized the causes of ambulatory hospitalization, and analysed the type of initial surgical procedure and the reasons for 31-day unplanned readmission. The Ocular Trauma Department started to perform AS in around mid-2015, and we collected information on patients who underwent ambulatory pars plana vitrectomy (APPV) from 1 January 2016 to 31 December 2017 to explore the predictive factors for the 31-day unplanned readmission of APPV patients. In 2015, 2016, and 2017, a total of 3443 patients underwent AS, among whom the three most common causes of ambulatory hospitalization were eye wall and appendages injury, aphakia, and silicone oil-filled eye. Of the 3443 patients, 32 returned for 31-day unplanned readmission, a readmission rate of 0.93%. The most common surgery (34.4%, 11/32) that resulted in unplanned readmission was pars plana vitrectomy (PPV). The major reasons for unplanned readmission were retinal detachment (RD) (34.4%, 11/32) and high intraocular pressure (HIP) (18.8%, 6/32). There were 860 patients who underwent APPV from 1 January 2016 to 31 December 2017, among whom 10 needed 31-day unplanned readmission, and the readmission rate of APPV for ocular trauma in 2016 and 2017 was 1.16%. Length of procedure (P<0.05) and use of silicone oil filling (P<0.05) were significantly related to the risk of unplanned readmission for APPV surgery. It is generally safe to perform AS on patients with ocular trauma. However, longer operative times and silicone oil filling increase the risk of unplanned readmission for APPV surgery.

Effect of Comorbidity On Unplanned Readmissions After Percutaneous Coronary Intervention (From The Nationwide Readmission Database)

It is unclear how comorbidity influences rates and causes of unplanned readmissions following percutaneous coronary intervention (PCI). We analyzed patients in the Nationwide Readmission Database who were admitted to hospital between 2010 and 2014. The comorbidity burden as defined by the Charlson Comorbidity Index (CCI). Primary outcomes were 30-day readmission rates and causes of readmission according to comorbidity burden. A total of 2,294,346 PCI procedures were included the analysis. The patients in CCI = 0, 1, 2 and ≥3 were 842,272(36.7%), 701,476(30.6%), 347,537(15.1%) and 403,061(17.6%), respectively. 219,227(9.6%) had an unplanned readmission within 30 days and rates by CCI group were 6.6%, 8.6%, 11.4% and 15.9% for CCI groups 0, 1, 2 and ≥3, respectively. The CCI score was also associated with greater cost (cost of index PCI for not readmitted vs readmitted was CCI = 0 $21,257 vs $19,764 and CCI ≥ 3 $26,736 vs $27,723). Compared to patients with CCI = 0, greater CCI score was associated with greater independent odds of readmission (CCI = 1 OR 1.25(1.22–1.28), p < 0.001, CCI ≥ 3 OR 2.08(2.03–2.14), p < 0.001). Rates of non-cardiac causes for readmissions increased with increasing CCI group from 49.4% in CCI = 0 to 57.1% in CCI ≥ 3. Rates of early unplanned readmission increase with greater comorbidity burden and non-cardiac readmissions are higher among more comorbid patients.

Relation Between Age and Unplanned Readmissions After Percutaneous Coronary Intervention (Findings from the Nationwide Readmission Database)

It is unclear how age affects rates and causes of unplanned early readmissions after percutaneous coronary intervention (PCI). We analyzed patients in the Nationwide Readmission Database in the United States from 2010 to 2014 and examined the impact of age on readmissions after PCI. The primary outcomes were age-specific 30-day rates and causes of unplanned readmissions. A total of 2,294,345 procedures were analyzed with a 9.6% unplanned readmission rate within 30 days. Unplanned readmissions were 8.1%, 8.1%, 9.5%, and 12.6% for age groups <55, 55.0 to 64.9, 65.0-74.9, and ≥75 years, respectively. With increasing age, there was an increase in the rate of noncardiac causes for readmissions (for ages <55, 55.0 to 64.9, and ≥75 years, the rates were 54.1%, 54.8%, 56.6%, and 57.1%, respectively; p <0.001). Older age was associated with an increased prevalence of infections (13.9% ≥75 years vs 7.7% <55 years), gastrointestinal disease (11.5% ≥75 years vs 9.5% <55 years), and bleeding (7.4% ≥75 years vs 2.9% <55 years) as causes for noncardiac readmissions and a reduced prevalence of nonspecific chest pain (9.9% ≥75 years vs 31.4% <55 years). For cardiac causes, older age was associated with increased prevalence for readmissions due to heart failure (34.6% ≥75 years vs 11.9% <55 years) but a reduced prevalence of coronary artery disease, including angina (25.7% ≥75 years vs 51.3% <55 years). In conclusion, older patients have the highest rates of unplanned 30-day readmissions after PCI, with different causes for readmission compared with younger patients. Interventions designed to reduce readmissions after PCI should be age specific.

Abstract WP29: The Causes of 30-Day Unplanned Readmission in Acute Ischemic Stroke Patients Treated With MT, IV-tPA and Combined Group: A National Analysis

Background: Acute ischemic stroke (AIS) patients undergoing complex treatments are highly vulnerable to readmission. Limited studies have been performed to compare the 30-day readmission rates and causes in AIS patients treated with Intravenous tissue plasminogen activator (IV-tPA), mechanical thrombectomy (MT), and both. Methods: We obtained national readmission dataset (NRD 2014), a subset of Healthcare Cost and Utilization Project (HCUP) to analyze the 30-day readmission estimates from January to November 2014 after excluding elective readmission. The AIS patients undergoing IV-tPA and MT were identified by using ICD-9 diagnosis codes 99.10, V45.88 and 39.74 respectively. We used SAS 9.4 version for data analysis and SURVEYMEANS procedure was used to measure readmission rate. Discharge weights were provided by HCUP applied to produce national estimates. Results: The NRD contained 341621 admissions (weighted N =741129) of AIS patients in 2014. After excluding elective readmissions, all cause 30-day readmission rate was 10.64%, 13.07%, and 10.66% for IV-tPA, MT and combined treatment group. The top causes of unplanned readmission in all 3 groups were infections and acute cerebrovascular disease. The next common causes for readmission were congestive heart failure, acute renal failure in MT group, transient cerebral ischemia and congestive heart failure in IV- tPA group whereas, cardiac dysrhythmia and complications of medical and surgical care in combined group. Other causes are shown in Table 1 . Conclusions: Infections and acute CVD were the most common culprits of readmissions in all 3 groups. Amidst the ongoing debate over advantage of adding IV-tPA in stroke patients undergoing MT, the insights into 30-day readmission rates and causes comparison will help to strategize post-AIS preventive care to lower down the readmission rates and health care burden.

Unplanned readmission within 90 days after pediatric neurosurgery.

OBJECTIVE Readmission and return to operating room after surgery are increasingly being used as a proxy for quality of care. Nearly 60% of these readmissions are unplanned, which translates into billions of dollars in health care costs. The authors set out to analyze the incidence of readmission at their center, to define causes of unplanned readmission, and to determine the preoperative and surgical variables associated with readmissions following pediatric neurosurgery. METHODS A total of 536 children who underwent operations for neurosurgical diagnoses between 2012 and 2015 and who were later readmitted were included in the final analysis. Unplanned readmissions were defined to have occurred as a result of complications within 90 days after index surgery. Patient records were retrospectively reviewed to determine the primary diagnosis, surgery indication, and cause of readmission and return to operating room. The cost for index hospitalization, readmission episode, and total cost were derived based on the charges obtained from administrative data. Bivariate and multivariable analyses were conducted. RESULTS Of 536 patients readmitted in total, 17.9% (n = 96) were readmitted within 90 days. Of the overall readmissions, 11.9% (n = 64) were readmitted within 30 days, and 5.97% (n = 32) were readmitted between 31 and 90 days. The median duration between discharge and readmission was 20 days (first quartile [Q1]: 9 days, third quartile [Q3]: 36 days). The most common reason for readmission was shunt related (8.2%, n = 44), followed by wound infection (4.7%, n = 25). In the risk-adjusted multivariable logistic regression model for total 90-day readmission, patients with the following characteristics: younger age (p = 0.001, OR 0.886, 95% CI 0.824-0.952); "other" (nonwhite, nonblack) race (p = 0.024, OR 5.49, 95% CI 1.246-24.2); and those born preterm (p = 0.032, OR 2.1, 95% CI 1.1-4.12) had higher odds of being readmitted within 90 days after discharge. The total median cost for patients undergoing surgery in this study cohort was $11,520 (Q1: $7103, Q3: $19,264). For the patients who were readmitted, the median cost for a readmission episode was $8981 (Q1: $5051, Q3: $18,713). CONCLUSIONS Unplanned 90-day readmissions in pediatric neurosurgery are primarily due to CSF-related complications. Patients with the following characteristics: young age at presentation; "other" race; and children born preterm have a higher likelihood of being readmitted within 90 days after surgery. The median cost was > $8000, which suggests that the readmission episode can be as expensive as the index hospitalization. Clearly, readmission reduction has the potential for significant cost savings in pediatric neurosurgery. Future efforts, such as targeted education related to complication signs, should be considered in the attempt to reduce unplanned events. Given the single-center, retrospective study design, the results of this study are primarily applicable to this population and cannot necessarily be generalized to other institutions without further study.

Optimizing the Management of Abnormal Liver Function Tests after Orthotopic Liver Transplant: A Systems-Based Analysis of Health Care Utilization

Elevated liver function tests (eLFTs) are a major cause of unplanned readmissions (UR) after orthotopic liver transplantation. Diagnostic workup for eLFTs requires multiple invasive and noninvasive procedures, often done in the inpatient setting to expedite diagnosis, yet consequently resulting in increased costs. In this study, we evaluated eLFT readmissions at a single institution with respect to resource utilization. From 3/2013 to 12/2015, 388 patients underwent orthotopic liver transplantation, resulting in 463 UR totaling 5833 bed days; 87 (18.8%) UR and 929 (15.9%) bed days were for eLFTs. During eLFT-UR all patients underwent repeat laboratory testing, 75 (86.2%) liver ultrasound, 66 (75.8%) liver biopsy, and 17 (19.5%) endoscopic retrograde cholangiopancreatography. Discharge diagnoses were acute cellular rejection (40.2%), transaminitis not otherwise specified (17.2%), biliary complications (16.1%), recurrent hepatitis (11.5%), vascular complications (5.8%), viral hepatitis (5.8%), and steatohepatitis (3.5%). The greatest bed-day utilization was secondary to acute cellular rejection (60.8%) and biliary complications (13.7%). More than 35 per cent of eLFT-UR were due to transaminitis not otherwise specified, steatohepatitis, recurrent or viral hepatitis, none of which necessitate inpatient treatment. In addition, >25 per cent of eLFT-UR bed days were attributed to diagnostic workup. Identifying patients who can undergo expedited outpatient workup and require only outpatient management will result in significantly decreased readmissions, bed days, and hospital costs.

Temporal Relations of Unplanned Readmissions Following Total Knee Arthroplasty: A Study of Large State Inpatient Databases

BackgroundCenters for Medicare & Medicaid Services stipulate a 90-day global period for hospitals for unplanned readmissions after primary total knee arthroplasty (TKA). However, not all readmissions are directly attributable to index surgery, and reasons for readmissions vary during this time period. This study identifies causes and temporal relations of readmissions using large state inpatient databases. MethodsState inpatient databases of New York and California were queried for all primary TKAs performed from 2005 to 2011 and frequencies of all causes of unplanned readmission were identified from 0 to 90 days after index surgery using the International Classification of Diseases, Ninth Revision, codes. Temporal differences in proportions of readmission diagnoses were tested using the Pearson chi-square test. ResultsThe query identified 419,805 cases of primary TKA from 2005 to 2011. There were 26,924 readmissions during the 90-day recovery period, with 15,547 (57.7%) at 0-30 days, 6593 (24.5%) at 31-60 days, and 4784 (17.8%) at 61-90 days. Primary diagnoses at readmission that were identified to be directly attributable to surgery comprised 38.3% readmissions at 0-30 days, 24.0% at 31-60 days, and 16.3% at 60-90 days. Proportion of readmissions directly attributable to surgery decreased over the 90-day period after index surgery. ConclusionFrom this analysis of 2 large state inpatient databases, primary diagnoses at readmission vary with time, and majority of these may not be directly attributable to index surgery or postoperative state up to 90 days. These findings suggest that the current 90-day global period policy for this procedure should be reformed to better reflect the profile of unplanned readmissions after TKA.

Unplanned readmissions after primary total knee arthroplasty in Korean patients: Rate, causes, and risk factors

BackgroundUnplanned hospital readmissions are indicators of the quality and performance of a health care system, but data on early readmission after primary total knee arthroplasty (TKA) in the Asian population are limited. The purpose of this study was to determine the causes, risk factors, and rate of unplanned readmission after primary TKA at a single institution in Korea. MethodsWe analyzed all primary TKAs from 2004 to 2013 using the data from our institutional electronic database. A total of 4596 TKAs were performed on 3049 patients. All unplanned readmissions within 30 and 90days of discharge were identified, categorized into arthroplasty-related, medical, and other orthopedic causes. ResultsThe overall unplanned readmission rate was 1.9% (n=59) within 30days and 3.3% (n=101) within 90days, and both the 30 and 90day readmission rates remained stable over the entire study period. The majority of readmissions involved arthroplasty-related causes; the most common cause being wound problems, accounting for 22% (13/59) within 30days and 24% (24/101) within 90days. Age (P=0.029) and hypertension (P=0.021) were identified as risk factors for unplanned readmissions after TKA. ConclusionThis study demonstrates that unplanned readmissions after TKA are not infrequent in Korean patients and has identified wound complication as the most frequent cause of unplanned readmissions. Optimized care systems should be established to minimize unplanned readmissions, particularly for patients with high risk factors.