Difference In 30-day Readmission Rates Research Articles

Risk Factors for Bleeding in Hospitalized Patients with Elevated INR: No Vitamin K Therapy Received Versus Vitamin K Received.

Supratherapeutic international normalized ratio (INR) in patients on warfarin is a common side effect. Updated guidelines recommend against using vitamin K to correct INRs 4.5 to 10 in the absence of bleeding. The impact of compliance with updated guidelines during hospitalization has not been fully explored. A retrospective, observational study was performed utilizing electronic medical records. The goal was to evaluate management of supratherapeutic INR values for medicine inpatients and identify differences in clinical outcomes among inpatients treated and not treated with vitamin K. Records from adult inpatients with at least one INR value between 4.5 and 9 were reviewed. A total of 51 records were evaluated. Thirty-four patients did not receive vitamin K compared to 17 who did. Bleeding events, readmissions rates, length of stay, and familiarity with new guidelines were studied. Mean age of patients was 73 years, and 71% were female. No statistically significant differences were observed in bleeding events between patients who received vitamin K and those who did not: 2/17 (12%) and 1/34 (3%), respectively (P = .30). No differences in 30-day readmission rates (24% vs 18%; P = .71) or in length of stay (7 vs 4 days; P = .11) were found. All pharmacists (13 of 13) were familiar with CHEST 2012 guidelines on the management of supratherapeutic INR compared to 10 of 21 (48%) hospitalists (P = .001). With the national focus on reduction of health care costs, health systems are looking at innovative ways to reduce readmission rates and length of stay. This study, which evaluated the use of vitamin K administration, showed no statistical difference between bleeding events, readmission rates, and length of stay in patients who received vitamin K. Education on the updates of guidelines may be beneficial, as many providers were not familiar with the changes in recommendations.

Different setups of laparoscopic cholecystectomy: Conversion and complication rates: A retrospective cohort study

Background: Laparoscopic cholecystectomy (LC) is the gold standard treatment for gall bladder disease. Methods: We retrospectively reviewed charts of patients who underwent LC. Four LC groups were defined: elective LC – Group I; interval LC – Group II; LC during acute cholecystitis – Group III; and LC following percutaneous cholecystostomy (PCC) – Group IV. Results: The study comprised 1658 patients [mean age: 51.0 years (range 17–94)]: Group I: 1221 patients (73.6%); Group II: 271 patients (16.3%); Group III: 125 patients (7.6%); Group IV: 41 patients (2.5%). The operative time was significantly different between the groups (p < 0.05). The conversion rate was highest in Group III (24.8%) and was significantly higher than all the other groups. Group II had a higher conversion rate than Group I (p < 0.05). The length of hospital stay was not significantly different between Groups I and II (1.5 and 1.96 days, respectively), and between Groups III and IV (4.46 and 4.78 days, respectively). The differences between Groups I and II, and between Groups III and IV were significant. Complication rates were significantly different between Groups I (2.2%), II (5.6%), and III (13.6%) (p < 0.05.) There were no differences between Groups III and IV and there were no significant differences in 30-day readmission rates between the groups. Conclusions: The highest conversion and complication rates were encountered in patients undergoing LC during acute cholecystitis. A gradual increase of conversion and complication rates was noted between the groups of elective LC, interval LC and LC post PCC.

Transjugular Intrahepatic Portosystemic Shunts (TIPS) in Elderly Patients: To TIPS or Not to TIPS?

Introduction: Due to the continued debate on whether older patients (≥60 years old) would benefit from transjugular intrahepatic portosystemic shunt procedure (TIPS), we aimed to determine the efficacy and compare outcomes and mortality of individuals ≥60 years and <60 years undergoing TIPS. Methods: This single-center retrospective study reviewed the medical charts of 206 patients who consecutively underwent TIPS between 2004 and 2010. Sixty-one patients ≥60 years old who underwent TIPS were evaluated against a cohort of younger patients (<60 years). Procedure complications, rates of clinical improvement, readmission rates, and 30-day mortality rates in these patients were compared to a cohort of patients less than 60 years of age who underwent TIPS within the same time frame. Results: Two hundred six patients were included in this retrospective chart review. The average age at the time of TIPS was 54.8+11.5 years with 30% of subjects being over 60 years of age. Non-alcoholic steatohepatitis as an underlying cause of cirrhosis was significantly more common in patients ≥60 years old (p<0.001). Alcoholic liver disease and hepatitis C virus were found to be significantly less common in older patients. Patients ≥60 years, who were readmitted within 30 days of TIPS procedure, were also found to have a significantly shorter time to readmission than patients < 60 years of age (11 vs. 16.5 days p=0.046), however, there were no significant differences in 30-day readmission rates (42.6% vs. 44.1%; p=0.84). When 30-day post-TIPS mortality was evaluated, 8.3% of patients <60 years died within 30 days of TIPS, compared to 14.8% of patients ≥60 years who expired within 30 days. Only 4 deaths of these deaths could be attributed to immediate post-TIPS complications, which included hepatic infarct, air emboli, and sepsis immediately after the procedure. Conclusion: Our data suggests that there were no significant differences in mortality and post-TIPS complications between patients above the age of 60 and those below this age. Thus, proceeding with TIPS procedure in a patient above the age of 60, remains an individualized decision between the treating clinician and the patient.Table 1: Age Is Not Associated With Poor Outcomes at 30 Days in Patients With TIPS: Multivariable Cox Regression Analysis

Capsule commentary on Tang et al., Evaluation of a primary care-based post-discharge phone call program: keeping the primary care practice at the center of post-hospitalization care transition.

Post-hospital care transitions are potentially complex clinical events. A significant number of patients experience confusion or discontinuity of their care, which has important implications for patient safety and cost containment. In this issue, Tang and colleagues report a study of post-discharge phone calls from a primary care office.1 Among 486 full-scripted calls, nurses uncovered at least one problem in 371 discharges, of which 25 % included new symptoms and 47 % included medication issues. Discharges with full-scripted and message-scripted encounters were associated with higher rates of follow-up appointment attendance, but there was no significant difference in 30-day readmission rates. Post-discharge telephone follow-up plays a valuable role in many situations, including post-discharge emergency department visits and hospital admissions.2 Many discharge transitions are inadequately orchestrated, as unanticipated medical problems occur on nights or weekends and involve clinicians who may not have an ongoing relationship with the patient. The phone call becomes an opportunity for the patient to engage their chronic care team and inform them of current issues in what may be an evolving situation. Although primary care-based calls achieve some clinical goals, it has not been proven that this model is superior to calls from other comprehensive practices such as dialysis, transplant, or cancer centers. With the new CMS reimbursement for transitional care services, such calls should become an important self-sustaining component of the patient-centered medical home or neighborhood. Despite the growing use of primary care-based telephone follow-up in the post-discharge period, there are few high-quality studies demonstrating its full potential benefit.2,3 Recurrent hospitalizations are responsible for significant health care expenses, and a substantial proportion of readmissions are preventable through effective discharge planning and patient follow-up. Patients at high risk for readmission can be identified using data available at the time of hospital discharge, and all patients may benefit from a call. High-risk patients who receive a discharge call seem most likely to benefit from lower rates of readmission and reduced costs.4

Evaluation of a primary care-based post-discharge phone call program: keeping the primary care practice at the center of post-hospitalization care transition.

The post-hospitalization period is a precarious time for patients. Post-discharge nurse telephone call programs aiming to prevent unnecessary readmissions have had mixed results. Describe a primary-care based program to identify and address problems arising after hospital discharge. A quality improvement program embedding registered nurses in a primary care practice to call patients within 72 h of hospital discharge and route problems within the practice for real-time resolution. Adult patients with a primary care provider in the general internal medicine practice at the University of California San Francisco who were discharged home from the Medicine service. Patients reached directly by phone had a 'full-scripted encounter;' those reached only by voice-mail had a 'message-scripted encounter;' those not reached despite multiple attempts had a 'missed encounter.' Among patients with full-scripted encounters, we identified and cataloged problems arising after hospital discharge and measured the proportion of calls in which a problem was uncovered. For the different encounter types, we compared follow-up appointment attendance and 30-day readmission rates. Of 790 eligible discharges, 486 had a full-scripted, 229 a message-scripted and 75 a missed encounter. Among the 486 full-scripted encounters, nurses uncovered at least one problem in 371 (76 %) discharges, 25 % of which (n = 94) included new symptoms, and 47 % (n = 173) included medication issues. Discharges with full-scripted and message-scripted encounters were associated with higher follow-up appointment attendance rates compared with those with missed encounters (60.1 %, 58.5 %, 38.5 % respectively p = 0.004). There was no significant difference in 30-day readmission rates (12.8 %, 14.8 %, 14.7 %; p = 0.72). Our results suggest that centering a post-discharge phone call program within the primary care practice improves post-hospital care by identifying clinical and care-coordination problems early. With the new Medicare transitional care payment, such programs could become an important, self-sustaining part of the patient-centered medical home.

Abstract 28: Readmissions after Carotid Artery Revascularization in the Medicare Population

Introduction: In appropriately selected patients with severe carotid stenosis, carotid revascularization reduces risk of ischemic stroke. Prior clinical research has focused on the efficacy and safety of carotid revascularization, but few investigators have considered readmission as a clinically important outcome. We examined frequency and timing of 30-day readmission following carotid revascularization and assessed differences in 30-day readmission rates between patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS). We also examined whether hospital variation in procedural choice (CEA vs CAS) was associated with differences in hospitals’ risk standardized readmission rates (RSRR). Methods: Medicare administrative claims data were used to identify acute care hospitalizations of CEA and CAS from 2009 to 2011. The outcome of interest was time to first hospital readmission within 30-days of carotid revascularization. Hospitals performing more than 25 carotid interventions were stratified into tertiles by the proportion of CAS cases. RSRRs were derived from hierarchical generalized linear models adjusting for hospital clustering and standardized by unadjusted national readmission rate. Results: Of 180,059 revascularizations from 2,287 hospitals, CEA and CAS were performed in 81.5% and 18.5% of cases, respectively. The unadjusted 30-day readmission rate following carotid revascularization was 9.7% with half of these readmissions occurring by day 9. Crude 30-day readmission rates following CEA and CAS were 9.5% and 10.6%, respectively. In multivariable analysis, risk of readmission after CAS was higher than after CEA (Adjusted OR: 1.13, 95% CI: 1.08 - 1.18, P &lt;0.01). When stratified by tertiles of proportional use of CAS, median 30-day RSRR for hospitals using CAS more frequently were comparable to those of hospitals that used CAS less frequently (Figure 1). Conclusions: Almost 10% of Medicare patients undergoing carotid revascularization were readmitted within 30 days of discharge. Compared with CEA, CAS was associated with higher 30-day readmission rates. However, hospitals’ RSRR did not differ by their proportional use of CAS volume. Efforts to identify readmission risk factors are needed to reduce rates of readmissions following carotid revascularization.

Patient Outcomes in Teaching Versus Nonteaching General Internal Medicine Services

Patient care quality appears to be similar when delivered by trainee and attending physicians. The authors conducted a systematic review and meta-analysis to examine whether outcomes differ for general internal medicine (GIM) patients admitted to teaching versus nonteaching services. The authors searched Medline, EMBASE, and Cochrane Library databases in May 2012 to identify peer-reviewed, English-language studies with contemporaneous controls comparing inpatient mortality, 30-day readmission rate, and/or length of stay (LOS) for inpatients admitted to teaching or nonteaching GIM services. The 15 included studies (1 randomized controlled trial, 14 observational) included 108,570 patients admitted to U.S. hospitals during 1987-2011. Inpatient mortality did not differ between teaching and nonteaching services (13 studies, 108,015 patients; 2.5% versus 2.8%; OR, 1.07; 95% CI, 0.87-1.32; I = 82%); results were consistent in risk-adjusted studies (adjusted OR, 0.91; 95% CI, 0.76-1.08) and higher-quality studies (OR, 0.94; 95% CI, 0.73-1.21). There were no differences in 30-day readmission rates (11 studies, 106,021 patients; 15.1% versus 13.1%; OR, 1.05; 95% CI, 0.93-1.18). Patients on teaching services appeared to have longer LOS (11 studies, 82,352 patients; unadjusted mean difference, 0.40 days; 95% CI, 0.04-0.77 days), but there was substantial heterogeneity (I = 95%). Differences disappeared in risk-adjusted studies (mean difference: -0.09 days; 95% CI, -0.24 to 0.06 days) and in higher-quality studies (mean difference: -0.05 days; 95% CI, -0.37 to 0.28 days). There was no convincing evidence that outcomes differed substantively for patients admitted to teaching or nonteaching GIM services.

Complications after laparoscopic and open subtotal colectomy for inflammatory colitis: a case‐matched comparison

The aim of this study was to compare the early postoperative outcome of patients undergoing laparoscopic subtotal colectomy with those undergoing open subtotal colectomy for colitis refractory to medical treatment. A retrospective observational study was carried out of patients who underwent subtotal colectomy for refractory colitis, at a single centre, between 2006 and 2012. Patients were matched for age, gender, American Society of Anesthesiology (ASA) grade, urgency of operation and immunosuppressant/modulator treatment. The primary outcome measure was the number of postoperative complications, classified using the Clavien-Dindo scale. Secondary end-points included procedure duration, laparoscopic conversion rates, blood loss, 30-day readmission rates and length of hospital stay. Ninety-six patients were included, 39 of whom had laparoscopic surgery. Thirty-two of these were matched to similar patients who underwent an open procedure. The overall duration of the procedure was longer for laparoscopic surgery than for open surgery (median: 240 vs 150 min, P < 0.005) but estimated blood loss was less (median: 75 vs 400 ml, P < 0.005). In the laparoscopic group, 23 patients experienced 27 complications, and in the open surgery group, 23 patients experienced 30 complications. Most complications were minor (Grade I/II), and the distribution of complications, by grade, was similar between the two groups. There was no statistically significant difference in 30-day readmission rates between the laparoscopic and open groups (five readmissions vs eight readmissions, P = 0.536). Length of hospital stay was 4 days shorter for laparoscopic surgery, but this difference was not statistically significant (median: 7 vs 11 days, P = 0.159). In patients requiring colectomy for acute severe colitis, laparoscopic surgery reduced blood loss but increased operating time and was not associated with a reduction in early postoperative complications, length of hospital stay or readmission rates.

A clinical pathway for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for advanced ovarian and primary peritoneal cancers

Objectives. To evaluate the safety, feasibility, and economic impact of a clinical pathway, including rapid diet advancement, for patients undergoing rectosigmoid colectomy as part of cytoreductive surgery for advanced ovarian and primary peritoneal cancers. Methods. Between 8/1/98 and 6/30/06, 64 consecutive patients met study inclusion criteria. Using case–control methodology, post-operative management was dictated by a prescribed clinical pathway in 19 patients (Group A) and directed by individual surgeon preference in 45 patients (Group B). Critical elements of the clinical pathway included: rapid diet advancement, early discontinuance of nasogastric suction, criteria-based utilization of parenteral nutrition, selective laboratory testing, and deferring initiation of chemotherapy until after discharge. Results. Stage IIIC/IV disease was present in 94% of all patients. The median time to flatus was 6 days for both groups ( p = 0.95); however, the median time to tolerance of diet was 3 days for Group A and 6 days for Group B ( p = 0.013). Compared to Group B, patients in Group A had a significantly shorter median length of hospital stay (7 days vs 10 days, p = 0.014) and lower median 30-day post-operative hospital cost ($19,700 vs $25,110, p = 0.028), with no significant difference in 30-day readmission rate (21% vs 33%, p = 0.379). Clinical pathway-directed management was associated with a median reduction in hospital cost of $5410 per patient. Conclusions. A critical pathway incorporating rapid diet advancement for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for ovarian and primary peritoneal cancers is feasible, safe, and associated with a significant reduction in length of hospital stay and hospital-related costs.

Decreased hospital length of stay associated with presentation of cases at morning report with librarian support

The research sought to determine whether case discussion at residents' morning report (MR), accompanied by a computerized literature search and librarian support, affects hospital charges, length of stay (LOS), and thirty-day readmission rate. This case-control study, conducted from August 2004 to March 2005, compared outcomes for 105 cases presented at MR within 24 hours of admission to 19,210 potential matches, including cases presented at MR and cases not presented at MR. With matching criteria of patient age (+/- 5 years), identical primary diagnosis, and secondary diagnoses (within 3 additional diagnoses) using International Classification of Diseases (ICD-9) codes, 55 cases were matched to 136 controls. Statistical analyses included Student's t tests, chi-squared tests, and nonparametric methods. LOS differed significantly between matched MR cases and controls (3 days vs. 5 days, P < 0.024). Median total hospital charges were $7,045 for the MR group and $10,663 for the control group. There was no difference in 30-day readmission rate between the 2 groups. Presentation of a case at MR, followed by the timely dissemination of the results of an online literature review, resulted in a shortened LOS and lower hospital charges compared with controls. MR, in association with a computerized literature search guided by the librarians, was an effective means for introducing evidence-based medicine into patient care practices.

Is bigger better? Re-exploring the relationship between hospital volume and surgical outcomes

Is bigger better? Re-exploring the relationship between hospital volume and surgical outcomes