Decrease In 30-day Readmission Rates Research Articles

Results of a postoperative telemedicine trial after cardiac surgery and incorporation into practice

ObjectiveThe study objective was to describe the implementation and results of a postoperative telemedicine program for adult cardiac surgery, including a clinical study and an organic postoperative telemedicine program aimed at reducing readmission rates and barriers to care. MethodsPatients undergoing coronary artery bypass grafting consented to enrollment in our Perfect Care study funded by The Duke Endowment including advanced practice provider–led postdischarge telemedicine services with data collection. There were 2 telemedicine visits at days 3 and 10 postdischarge using a live face-to-face video platform. Patients were provided with home wearables for heart rate monitoring, blood pressure cuffs, and scales. The success of the Perfect Care study led to the formation of our organic program, the Tele Heart Care, which was adapted to include a larger patient population while remaining structurally similar. ResultsFifty patients were enrolled prospectively between January and October 2021 in Perfect Care. The 30-day readmission rates for those enrolled was 4% compared with a 16% readmission rate for nonenrolled patients during this period. Furthermore, 36% of enrolled patients received medication modifications to optimize blood pressure, heart rate and rhythm, and fluid-volume status, or to treat infectious symptoms. Tele Heart Care enrolled 203 patients and was associated with a decrease in 30-day readmission rates in all cardiac surgery patients at our institution from 24% to 4% over a 6-month period. ConclusionsAn advanced practice provider–led postdischarge telemedicine program after cardiac surgery can reduce hospital readmission and barriers to care, and improve patient satisfaction. With involvement of multiple stakeholders, a successful program can be launched despite the present state of national health system finances with limited human capital and constrained access to monitoring equipment.

Impact of Podiatric Surgery Consultation for Foot and Ankle Wounds on Patient Outcomes in a Community Hospital

Previous studies have demonstrated that timely podiatric surgery consultation results in positive patient outcomes. However, there are limited studies focused on readmission rates in teaching community hospitals. The primary aim of this study is to determine if consulting podiatric services was associated with lower 30-day readmission rates and impact on length of stay in patients with lower extremity wounds. The secondary aim was to investigate medical and socio-economic factors associated with better outcomes. This study was a cross-sectional descriptive study. A retrospective chart review utilizing the hospital's electronic medical record system identified patients with lower extremity wounds (based on ICD-10 codes) admitted between July 2018 and December 2020. The results showed a 3-fold decrease in 30-day readmission rates in patients with podiatric surgery consultation compared to patients without consultation with lower extremity wounds (4.2% vs 11.3%, p=.03). Multivariate regression models showed patients with gangrene (AOR=7.61; p=.04) or osteomyelitis (AOR=9.07; p=.013) had a higher likelihood of readmission than patients with venous ulcer (reference category) after controlling for podiatric consultation. Among the group of patients with podiatric consultation, earlier podiatric consultations resulted in decreased length of stay. This study identifies prior amputation history and lack of podiatric consultation increased 30-day readmission rates.

Abstract 13291: Virtual Pharmacist Approach to Comprehensive Medication Management in Post-Discharge Heart Failure Patients: A Randomized Quality Improvement Initiative

Introduction: Successful management of Heart Failure (HF) patients post-discharge requires a multi-faceted approach including close medication management to decrease preventable readmissions. Methods: We conducted a one-year single center, single-blinded randomized trial of HF patients post-discharge comparing standard of care vs. intensive virtual care on HF readmission rates. The intensive virtual care included comprehensive medication management by a Virtual Clinical Pharmacist (VCP). Results: Among the 591 participants, the median age was 73.2 years, 52.5% male, and 56.2% white. There were 308 patients randomized into the intervention group of which 165 (53.5%) enrolled. During VCP visits, 155 patient concerns were identified including active symptoms (45.2%), lack of clarity of medication regimen (40.6%), concurrent uncontrolled hyperglycemia or hypertension (9%) and non-adherence with provider follow up appointments (5.2%). There were 625 VCP interventions in 165 HF patients. Of these patients, VCPs increased access to medical care (33.9%), optimized guideline directed medical therapy (17.6%), addressed symptoms of HF exacerbations (7.9%), and other impactful interventions (Table). VCP recommendations had a 59% acceptance rate into the patient’s treatment plan when clinicians were contacted directly. A 6.9% decrease in 30-day readmission rates was demonstrated (p=0.03) in the intervention group, in addition to a decrease from 24.4% to 19.2% in emergency department visits (p=0.15). For patients readmitted, the intervention arm had a shorter length of stay, 5.6 days, when compared to control, 6.8 days (p=0.14). Conclusion: This single center randomized trial demonstrated that Virtual Clinical Pharmacist-led comprehensive medication management identified key interventions with high-level clinician engagement for post-discharge HF patients that resulted in a 6.9% reduction in HF readmissions.

A Quality Improvement Project to Decrease Length of Stay after Total Hip and Total Knee Arthroplasty Surgery at a Veteran Affairs Academic Medical Center

Background: The purpose of this Quality Improvement Project (QIP) was to design and implement a multidisciplinary and multimodal pathway aimed at improving the length of stay (LOS) for total hip (THA) and total knee arthroplasty (TKA) patients at the Clement J Zablocki Veteran Affairs Medical Center. Methods: We performed a retrospective data analysis to establish a pre-pathway baseline for comparison and a prospective observational cohort analysis after implementation of the new protocol. We collected data on patients that underwent anterior THA (aTHA), posterior THA (pTHA), and TKA who were admitted before and after implementation of the multidisciplinary total joint pathway. Within the pre-pathway group, we collected data on 165 patients (102 TKA, 30 pTHA, and 33 aTHA) from May 1st, 2017 to January 31st, 2018. For the post-pathway group, we collected data on 208 patients (132 TKA, 36 pTHA, 40 aTHA) from February 1st, 2018 to December 31st, 2018. Demographic information (gender, race, BMI, ASA status, medical comorbidities) was also collected. One-way ANOVA and Chi-Squared tests were performed to determine significance between the groups. Results: Overall, there was no significant change in demographics between our pre and post-pathway groups. The TKA pre-pathway group average LOS was 3.06±1.32 days vs. 2.23±1.06 days in the TKA post-pathway LOS group (p<0.0001). The posterior THA pre-pathway group average LOS was 3.67±1.47 days vs. 2.81±1.83 days in posterior THA post-pathway group (p=0.0420). The anterior THA pre-pathway group LOS was 2.73±2.07 days vs. 2.10±1.78 days in anterior THA post-pathway group (p=0.1678). In addition, there was a decrease in 30-day readmission rates for both THA (6.7% to 2.3%) and TKA (5.0% to 3.3%) within our study period. Conclusions: We found that by focusing on pre-operative education, utilization of pre-operative physical therapy sessions, and post-operative mobilization within our new total joint pathway, the average LOS for our THA and TKA patients either met or fell below the VA LOS national averages. In addition, LOS within our institution was significantly decreased for posterior THA patients and TKA patients after implementation of the multidisciplinary clinical care pathway. The benefits of the new pathway were not seen in the anterior THA group.

Pharmacist Transition-of-Care Services Improve Patient Satisfaction and Decrease Hospital Readmissions

Background: Pharmacists ability to directly impact patient satisfaction through increases in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys utilizing transitions-of-care (TOC) services is unclear. Methods: Retrospective analysis of TOC patients from 07/01/2018 to 03/31/2019 was conducted. Intervention (INV) patients received pharmacist medication reconciliation and education prior to discharge and post-discharge telephone follow-up. All other patients served as control group (CON). Primary outcome: Evaluate impact of TOC services on HCAHPS scores for “Communication about Medicines” and “Care Transitions.” Secondary outcomes: 30-day readmissions, quantification of prevented potential safety events, assessment of discharge prescriptions sent to the academic medical center outpatient pharmacy (MOP) for TOC patients. Results: Of 1,728 patients screened, 414 patients met inclusion criteria (INV = 414, CON = 1314). A significant improvement (14.7%; p = <0.0001) in overall medication-related HCAHPS results was seen when comparing pre- vs post-implementation of the TOC service. Statistically significant increases for individual questions “staff told you what the medicine was for” (14.2%; p = 0.018), “staff describe possible effects” (21.2%; p = 0.004), and “understood the purpose of taking medications” (11.4%; p = 0.035) were observed. A non-significant decrease in 30-day readmission rates for the groups was observed (CON 16.4%, INV 13.3%; p = 0.133); however, an unplanned subgroup analysis evaluating impact of discharge phone calls on 30-day readmission rates revealed a significant reduction of 17.3% to 12.4% (p = 0.007). One hundred forty-three medication safety event(s) were potentially prevented by the TOC pharmacist. Lastly, 562 prescriptions were captured at the MOP as a result of the TOC initiative. Conclusions: Pharmacy-based TOC models can improve patient satisfaction, prevent hospital readmissions, and generate revenue.

30-day readmission prevention program in heart failure patients (RAP-HF) in a community hospital: creating a task force to improve performance in achieving CMS target goals

ABSTRACT In 2012, Centers for Medicare and Medicaid Services (CMS) announced it would penalize any hospitals that had 30-day readmission rates for heart failure (HF) patients above 20%. Mather Hospital Northwell Health, a community teaching hospital, organized a proactive task force to meet these goals. We describe our hospital-wide Readmission Prevention in Heart Failure (RAP-HF) project. We focused on the following interventions: early identification of patients at risk for readmission, discipline-specific mitigation planning by the interdisciplinary rounding team, enhanced medication education for heart failure patients, education of family/caregivers on medication and heart failure symptoms, facilitation in scheduling of post-discharge follow up visits and hard-wired communication between hospital and post-discharge care providers. We saw a 25.53% decrease in 30-day readmission rates.

1309. Effects of a Pharmacist-Driven Antiretroviral Stewardship and Transitions of Care Service in Persons Living with HIV/AIDS

BackgroundHistorical data demonstrate that PLWHA experience higher rates of medication-related errors when admitted to the inpatient setting. Prior to initiation of this program, rapid-start initiation of antiretroviral therapy (ART) was not implemented prior to discharge. The purpose of this study was to evaluate the impact of a pharmacist-driven antiretroviral stewardship and transitions of care service in persons living with HIV/AIDS (PLWHA).MethodsThis was a retrospective pre- and post-analysis of PLWHA hospitalized at University of Illinois Hospital (UIH). Patients included were adults following at UIH outpatient clinics for HIV care admitted to UIH for acute care. Data were collected between April 19, 2017 and October 19, 2017 for the pre-implementation phase, and between July 1, 2018 and December 31, 2018 for the post-implementation phase. The post-implementation phase included an HIV-trained clinical pharmacist (Figure 1). Primary and secondary endpoints included follow-up rates at UIH outpatient HIV clinics, 30-day readmission rates, and access to medications at hospital discharge. Statistical analysis included descriptive statistics and Fisher’s Exact test.ResultsA total of 119 patients were included in the analysis, 66 in the pre-implementation phase and 53 in the post-implementation phase. Patients included were mostly black males with median age of 48. In the pre-implementation phase 50 out of 65 (77%) patients attended follow-up visits for HIV care at UIH outpatient clinics, vs. 42 out of 47 (89%) patients in the post-implementation phase (P = 0.1329). Thirty-day readmission occurred in 17 of 62 (27%) patients in the pre-implementation phase vs. 5 of 52 (10%) of patients in the post-implementation phase (P = 0.0183). During the post-implementation phase, the HIV pharmacist secured access of ART and opportunistic infection medications prior to discharge for 22 patients (42%), 2 of which were new diagnoses.ConclusionA pharmacist-led antiretroviral stewardship and TOC program led to a decrease in 30-day readmission rates in PLWHA. Although not significant, the HIV-pharmacist led to higher rates of clinic follow-up. Finally, the HIV-pharmacist helped secure access to ART and initiate rapid-start therapy in newly diagnosed patients prior to leaving the hospital. Disclosures All authors: No reported disclosures.

Appointment Reminders to Decrease 30-Day Readmission Rates to Inpatient Psychiatric Hospitals.

The purpose of this quality improvement project was to reduce 30-day readmission rates to inpatient psychiatric hospitals by standardizing discharge processes by including scheduling outpatient psychiatric appointments for all patients at discharge and also to include the mailing postal reminders to prompt patients to attend their first outpatient mental health appointment following treatment. Inpatient psychiatric hospital. The project design was an analysis of readmission data obtained both 3 months before and after implementation of the postal reminder letters. This project took place at a 50-bed inpatient psychiatric hospital in the southeastern United States that accepts male and female adult patients with mental health and substance abuse disorders. The implementation of an appointment reminder letter resulted in a slight decrease in 30-day readmission rates. The average readmission rate 3 months prior to implementation was 10%. The average readmission rate 3 months postdischarge was 9%. December 2015 was included in the postimplementation data. December historically has higher rates of 30-day readmissions at this facility. If this month had been excluded, more dramatic decrease in 30-day readmission rates could be observed. Future implications for case management practice could include the usage of reminder prompts via telephone communication or text messaging in conjunction with postal reminders. The psychiatric population can be particularly challenging when considering increased risk for readmission within 30 days and also the impending pay-for-performance quality measures, which are soon to be implemented. Measures should be taken now to ensure that readmission rates decrease, not only to promote better patient outcomes, but also as a cost-saving measure. Although many variables may contribute to the risk for 30-day readmission rates including medication noncompliance, lack of proper follow-up, as well as seasonal trends, the postal appointment reminder letters may further decrease 30-day readmission rates. Other care management strategies combined with reminder letters may further address barriers that may exist to not only improve patient outcomes, but also to further reduce readmission rates. It is also important to mention that there are further implications that could be directly contributed to specific social determinants of health specific to the psychiatric population. For example, access to prescribed medications and transportation to appointments should be addressed to further reduce readmission rates for this vulnerable population.

Impact of a hospital bounceback policy to reduce readmissions

BackgroundBounceback policies for readmitted patients are commonly used by hospitals in the U.S., but to date there have been no studies of their impact on patient care or outcomes. In July 2011, a large, tertiary-care, academic medical center introduced a stronger bounceback policy for readmitted patients cared for by the resident service. The primary objective of this study was to determine the impact of the policy on readmission rates, length of stay (LOS), and LOS index. The secondary objective was to assess the effect of time within clinical rotations on the same outcomes. MethodsThis retrospective cohort study included patients admitted to the resident and hospitalist medicine services from 6/15/09 to 6/16/13. Total number of hospitalizations analyzed was 66,118. Measures included 30-day readmission rates, LOS, and adjusted LOS index. Covariates included time within clinical rotation and patient-level characteristics. The hospitalist service was used as a control group. ResultsAfter the policy was implemented, the resident service had an 8% lower relative risk ratio of 30-day readmission compared to the hospitalist service (p =.05). There was no significant different in LOS or LOS index. LOS for patients on the resident service exhibited a weekly pattern, with LOS lowest on Mondays and increasing throughout the week. ConclusionsA stronger bounceback policy resulted in a small decrease in 30-day readmission rates without increasing LOS. ImplicationsBounceback policies may be an effective and low-cost tool to reduce readmissions by leveraging non-financial incentives to change physicians’ behavior.

Improving coronary artery bypass grafting readmission outcomes from 2000 to 2012 in the Medicare population

ObjectiveThe study objective was to examine trends in 30-day readmission after coronary artery bypass grafting in the Medicare population over 13 years. MethodsThe study included isolated coronary artery bypass grafting procedures in the Medicare population from January 2000 to November 2012. Comorbidities and causes of readmission were determined using Internal Classification of Diseases, 9th Revision, Clinical Modification diagnostic codes. ResultsThe cohort included 1,116,991 patients. Readmission rates decreased from 19.5% in 2000 to 16.6% in 2012 (P = .0001). There was significant improvement across all categories of admission status, age, race, gender, and hospital annual coronary artery bypass grafting volume that were analyzed. Adjusted odds of readmission in 2000 compared with 2012 was 1.28 (95% confidence interval, 1.24-1.32). Median length of stay for the readmission episode was 5 days, which improved to 4 days by 2012. Hospital mortality during the readmission episode was 2.8% overall and declined to 2.4% in 2012 (P = .0001). The most common primary readmission diagnoses were heart failure (12.6%), postoperative wound infection/nonhealing wound (8.9%), arrhythmias (6.4%), and pleural effusions (3.7%). Readmission for wound infections/nonhealing wounds decreased significantly over time, from 9.8% to 6.5% (P = .0001). ConclusionsIn a large cohort of Medicare patients undergoing coronary artery bypass grafting over 13 years, there was a significant decrease in 30-day readmission rates, a reduction in readmission for wound infections, and reduced mortality during the readmission episode, despite an increase in patient comorbidities. The improvement in readmission rates was seen regardless of patient variables examined.

The Effect of a Randomized Trial of Home Telemonitoring on Medical Costs, 30-Day Readmissions, Mortality, and Health-Related Quality of Life in a Cohort of Community-Dwelling Heart Failure Patients

BackgroundTelemonitoring has been advocated as a way of decreasing costs and improving outcomes, but no study has looked at true Medicare payments and 30-day readmission rates in a randomized group of well treated patients. ObjectiveThe aim of this work was to analyze Medicare claims data to identify effects of home telemonitoring on medical costs, 30-day rehospitalization, mortality, and health-related quality of life. MethodsA total of 204 subjects were randomized to usual-care and monitored groups and evaluated with the SF-36 and Minnesota Living With Heart Failure Questionnaire (MLHF). Hospitalizations, Medicare payments, and mortality were also assessed. Monitored subjects transmitted weight, blood pressure, and heart rate, which were monitored by an experienced heart failure nurse practitioner. ResultsSubjects were followed for 802 ± 430 days; 75 subjects in the usual-care group (316 hospitalizations) and 81 in the monitored group (327 hospitalizations) were hospitalized at least once (P = .51). There were no differences in Medicare payments for inpatient or emergency department visits, and length of stay was not different between groups. There was no difference in 30-day readmissions (P = .627) or mortality (P = .575). Scores for SF-36 and MLHF improved (P < .001) over time, but there were no differences between groups. The percentage of patients readmitted within 30 days was lower with telemonitoring for the 1st year, but this did not persist. ConclusionsTelemonitoring did not result in lower total costs, decreased hospitalizations, improved symptoms, or improved mortality. A decrease in 30-day readmission rates for the 1st year did not result in decreased total cost or better outcomes.

Impact of a Guidelines-Based Educational Program on Heart Failure Readmissions to a Medical Teaching Service

Introduction: The literature supports successful reductions in readmissions and improved outcomes with nurse practitioner (NP)-led outpatient HF programs, however readmission rates in the U.S. have remained at 25% for the past decade. Little is known, however, about the impact of an inpatient NP-dedicated program facilitating the management of HF patients directed at advanced HF (NYHA class IIIIV). This study assesses the initiation of an inpatient NP-led HF program and the resulting readmission, mortality, and hospice referral rates Hypothesis/Aim: To review the impact of a comprehensive inpatient NP led HF program that included a rapid patient referral service to a heart transplant/ left ventricular assist device (LVAD) center. Methods: A retrospective cohort record review of HF patients admitted to a regional hospital within a large hospital system in north Texas. An inpatient NP-led HF program was initiated that included clinical management, patient/staff education, discharge programming, hospice and tertiary center referrals. All-cause readmission, mortality, and hospice referral rates for patients admitted with a primary diagnosis of HF from December 2011-January 2013 were assessed via the hospital’s electronic medical record system. Readmission rates and outcomes for advanced HF patients referred to a tertiary HF transplant/LVAD program within the same hospital system were also assessed. Results: From December 2011-January 2013, there were 651 patients with a primary diagnosis of HF admitted. The 30 -day readmission rates from December 2011-February 2012 ranged from 19-22%. The HF program was implemented in February 2012. Readmission rates began to trend downward and remained at or below 15% starting in March 2012-January 2013. Mortality rates remained unchanged at 3.5%, Hospice referrals however increased from 3% in 2011 to 7.9% in 2012. Eleven (NYHA class III-IV) HF patients deemed appropriate for advanced HF treatments were referred to the tertiary transplant/LVAD center starting in March 2012. Three patients were successfully transplanted within an average of 5 months of transfer date. Additionally, 1 patient was successfully implanted with an Heartmate II LVAD within 1 month of transfer. The 30-day readmission rate for this patient subset was 20% prior to referral and there were no 30day readmissions post referral. The mortality rate was 27%. Conclusions: After the implementation of this NP HF program there was a O4-7% decrease in 30-day readmission rates. These programs should continue to be evaluated in their ability to reduce HF readmissions.