Difference In Readmission Rates Research Articles

Evaluation of Corticosteroid Dose in Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

Background: Several recent studies have shown that both lower doses and shorter durations of systemic corticosteroids have similar efficacy for treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, each trial has limitations that constrain direct applicability to a US hospital population. Objective: The aim of this study was to determine whether, in a US community hospital, low doses of corticosteroids provide the lowest risk of adverse effects without increasing length of stay or readmission rate. Methods: A single-center retrospective cohort was performed using patients meeting criteria for AECOPD. Primary endpoints included length of hospitalization, proportion of patients with >30% increase in blood glucose from baseline, and rate of 30-day readmission; multivariable regression analysis was used for comparison. The 3 inpatient cumulative dose range groups were low: ≤250-mg prednisone equivalents, medium: 251 to 500 mg, and high: ≥501 mg. Results: A total of 665 records were evaluated, with 369 records included. As the corticosteroid dose ranges increased, there were more patients with increased blood glucose (33.3%, 54.4%, 59.9%). When holding all other factors constant, there was a statistically significant increase in patients with elevated blood glucose with the medium- and high-dose groups as compared with the low-dose group (P < .009, P < .001), the average length of stay was 21.3 hours higher in the high-dose group as compared with the low-dose group (P < .001), and there were no significant differences in readmission rates between the dose groups. Conclusions: The lowest dose range of corticosteroids was associated with the lowest rate of impaired blood glucose without a statistically significant increase in length of stay or readmission rate.

Outcomes and mortality in parturient and non-parturient patients with peripartum cardiomyopathy: A national readmission database study.

Peripartum cardiomyopathy (PPCM) affects young females and mortality occurs after the peripartum period. Hospital readmissions for patients discharged with PPCM are poorly understood. The aim of this study was to evaluate differences in readmission rates, risk factors, and mortality in women with PPCM. We conducted a retrospective cohort analysis using the Healthcare Cost and Utilization Project 2013 National Readmissions Database. From the database, we selected patients with PPCM to include patients discharged between January and November 2013. Readmission rate, mortality rate and risk factors were analyzed. In our cohort of 3800 patients, we found a readmission rate of 15.1% and a mortality rate of 1.6%. Comorbidities associated with readmission were pulmonary hypertension, obesity, renal failure, and drug abuse. Mortality on initial admission was associated with coagulation disorders and respiratory failure. Women who delivered on initial admission had a statistically lower rate of readmission than women who did not deliver on initial admission. In a large retrospective nationwide analysis of PPCM patients, we found associated conditions that may help predict which patients will have a higher risk for readmission and mortality.

Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission

Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value. To systematically review economic evaluations of QI interventions designed to reduce readmissions. Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016). Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs. Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs. Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10 445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P < .001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P < .001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, -$642 to $2586; P = .23; 24 studies), and the mean net loss was $169 among general populations (95% CI, -$2610 to $2949; P = .90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs -$6568; P = .006). Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.

IMPROVING OUTPATIENT FOLLOW-UP AFTER DISCHARGE FROM HOSPITAL FOR PATIENTS WITH SICKLE CELL DISEASE AT HIGH RISK FOR READMISSION

Abstract BACKGROUND: Recent evidence has shown that outpatient follow-up after hospitalization plays an important role in reducing readmission rates for patients with Sickle Cell Disease (SCD). Reducing 28-day readmission rates in patients with SCD has become an established part of our hospitals quality improvement (QI) plan. OBJECTIVES: To increase the proportion of SCD patients at high risk for readmission who receive outpatient Hematology follow-up within 14 days of discharge from 28% to 90%. DESIGN/METHODS: SCD patients at high risk for readmission were defined (based on literature) as those with 3 hospital admissions for vaso-occlusive episodes (VOE) or 1 admission for acute chest syndrome (ACS) within 12 months of the index admission. An interdisciplinary team created a process map to identify barriers and opportunities for improvement. In July 2015, multimodal process steps were introduced using posters, emails, and presentations to direct medical trainees, registered nurses and ward clerks to identify high risk patients, inform the SCD team of admissions, ensure follow-up is booked within 14 days, and confirm with families prior to discharge. A pre- and post-intervention chart review (quarterly, July 2014 through December 2015) was performed on all SCD hospital admissions identified as crisis by ICD10 code 57.0, which includes VOE, ACS and splenic sequestration. RESULTS: During the 18-month period, there were 223 hospital admissions for 131 patients. Forty-seven percent of admissions were for high-risk patients. Fifty-five percent of patients were taking hydroxyurea at the time of index admission. The 28-day readmission rate was 12.6%, and did not change significantly over the time period. There was no difference in readmission rates between high-risk and standard-risk patients. The mean number of days from discharge to follow-up for patients prior to initiation of the intervention (July 2015) was 40 days, and only 28% of high-risk patients were seen in Hematology clinic within 14 days of discharge. In the first quarter after the introduction of the process steps, this improved to 16 days and 73%, respectively. The improvement, however, was not sustained into the final quarter. CONCLUSION: Our multimodal strategy resulted in improved time to follow-up for SCD patients at high risk for readmission. The lack of maintenance into the final quarter suggests the need for ongoing education to sustain positive changes. Further data collection is required to determine the impact of improved time to follow-up on readmission rates.

Do 30-Day Postpartum Readmissions Rates Vary by Site of Care for Vulnerable Patients? [9OP

INTRODUCTION: To determine 30-day readmission rates following delivery in the United States, assess for access-based differences in readmission rates, and determine if differences vary by site of care. METHODS: We used Nationwide Readmissions Database to identify deliveries between January-October 2013. We categorized Medicaid, uninsured, and low-income patients as “vulnerable” and ranked hospitals by the proportion of vulnerable patients that they served. Differences in 30-day readmissions among higher (more than 74th percentile) versus lower (1-74th) vulnerable patient-serving hospitals were compared using multivariable logistic regression. Models adjusted for differences in patient demographics, comorbidities, pregnancy risk-status, type of deliveries, and hospital characteristics. RESULTS: A total of 1,392,622 deliveries were included, weighted to represent 3,932,181 deliveries nationwide. In 2013, 136 women/10,000 deliveries (1.4%) were readmitted within 30 post-discharge days. The most common reasons for readmissions were wound infection(n=1733, 9.1%), endometritis (n=1454, 7.7%), and hypertension(n=1181, 6.2%). A total of 732,441 (52.6%) deliveries were to vulnerable patients; 505,807 (36.3%) received care at hospitals managing a higher proportion of such patients. 30-day readmissions were higher among vulnerable patients (1.5% vs. 1.1%, OR [95% CI]: 1.39 [1.33-1.45]). CONCLUSION: Vulnerable patients experienced higher 30-day readmission rates, regardless of site of care. While differences were marginally pronounced at hospitals managing a lower proportion of vulnerable patients, the ubiquitousness of the finding across institutions speaks to the pervasive need to address disparities in perinatal care.

The Association Between Surgical Route and Perioperative Outcomes for Women Undergoing Myomectomy [25H

INTRODUCTION: Fibroids are the most common solid pelvic tumor. Most symptomatic fibroids are managed surgically. The abdominal approach to myomectomy is more commonly performed than the laparoscopic approach. Primary objectives include examining the association between the route chosen for myomectomy and the 30-day perioperative outcomes for women undergoing the procedure. METHODS: Data for this retrospective review was obtained from the American College of Surgeons-National Surgical Quality Improvement Project database. Using Current Procedural Terminology. All women over the age of 18 years who underwent a myomectomy from 2005-2014 were included. A mixed-effects logistic regression analyses were performed to analyze the association between the route of myomectomy and 30-day perioperative outcomes, and to control for confounding factors including age, race, and fibroid weight. RESULTS: 2,862 women underwent myomectomy; 1,207 were laparoscopic (42%) and 1,655 were open (58%). Laparoscopic myomectomy was less likely to be utilized for fibroids larger than 250 gm (45.9%) versus less than 250 gm (54.1%) [ORadj (95%CI)] [0.737 (0.575, 0.946)]. Laparoscopic myomectomy was associated with decreased length of hospital stay 0 d versus 2 d [ORadj (95%CI)] [0.143 (0.123, 0.167)], and longer operating times 157 m versus 116 m [ORadj (95%CI)] [1.014 (1.012, 1016)] compared to open myomectomy. There was no significant difference in readmission rate, postoperative urinary tract infection and pneumonia, and occurrence of deep vein thrombosis. CONCLUSION: Laparoscopic myomectomy was utilized less frequently for fibroids larger than 250 gm. Laparoscopic myomectomy was associated with a shorter hospital stay but a longer operative time.

Team-based versus traditional primary care models and short-term outcomes after hospital discharge.

Strategies to reduce hospital readmission have been studied mainly at the local level. We assessed associations between population-wide policies supporting team-based primary care delivery models and short-term outcomes after hospital discharge. We extracted claims data on hospital admissions for any cause from 2002 to 2009 in the province of Quebec. We included older or chronically ill patients enrolled in team-based or traditional primary care practices. Outcomes were rates of readmission, emergency department visits and mortality in the 90 days following hospital discharge. We used inverse probability weighting to balance exposure groups on covariates and used marginal structural survival models to estimate rate differences and hazard ratios. We included 620 656 index admissions involving 312 377 patients. Readmission rates at any point in the 90-day post-discharge period were similar between primary care models. Patients enrolled in team-based primary care practices had lower 30-day rates of emergency department visits not associated with readmission (adjusted difference 7.5 per 1000 discharges, 95% confidence interval [CI] 4.2 to 10.8) and lower 30-day mortality (adjusted difference 3.8 deaths per 1000 discharges, 95% CI 1.7 to 5.9). The 30-day difference for mortality differed according to morbidity level (moderate morbidity: 1.0 fewer deaths per 1000 discharges in team-based practices, 95% CI 0.3 more to 2.3 fewer deaths; very high morbidity: 4.2 fewer deaths per 1000 discharges, 95% CI 3.0 to 5.3; p < 0.001). Our study showed that enrolment in the newer team-based primary care practices was associated with lower rates of postdischarge emergency department visits and death. We did not observe differences in readmission rates, which suggests that more targeted or intensive efforts may be needed to affect this outcome.

Short-term complications associated with the use of transvaginal mesh in pelvic floor reconstructive surgery: Results from a multi-institutional prospectively maintained dataset.

Vaginal reconstructive surgery can be performed with or without mesh. We sought to determine comparative rates of perioperative complications of native tissue versus vaginal mesh repairs for pelvic organ prolapse. Using the National Surgical Quality Improvement Program (NSQIP) database, we concatenated surgical data from vaginal procedures for prolapse repair, including anterior and posterior colporrhaphy, paravaginal defect repair, enterocele repair, and vaginal colpopexy using Current Procedural Terminology (CPT) coding. We stratified this data by the modifier associated with mesh usage at the time of the procedure. We then compared 30-day perioperative outcomes, postoperative complications (bleeding, infection, etc), and readmission rates between women with and without mesh-based repairs. We identified 10 657 vaginal reconstructive procedures without mesh and 959 mesh-based repairs from 2009 through 2013. Patients undergoing mesh repair were more likely to experience at least one complication than native tissue repair (9.28% vs 6.15%, P < 0.001), with the overall complication rate also being higher in the mesh group (11.37% vs 9.39%, P = 0.03). Procedures with mesh had a higher rate of perioperative bleeding requiring transfusion than native tissue repair (2.3% vs 0.49%, P < 0.001), and organ surgical site infection (SSI) (0.52% vs 0.17%, P = 0.02). There were no significant differences in rates of readmission, superficial, or deep SSIs, pneumonia, urinary tract infection, sepsis, or renal failure. The use of vaginal mesh for pelvic organ prolapse repair appears to result in a higher rate of perioperative complications than native tissue repair. Patients undergoing these procedures should be counselled preoperatively concerning these risks.

The Efficacy of Telemedicine-Supported Discharge Within an In Home Model of Care.

To determine if mobile videoconferencing technology can facilitate the discharge of low-acuity patients receiving in-home care without compromising short-term health outcomes. A 6-month trial commenced in July 2015 with 345 patients considered unsuited to Criteria Led Discharge (CLD) receiving in-home care included as participants. Nurses providing clinical support to patients in their homes were supplied with a tablet computer (Apple iPad) with Internet connectivity (Telstra 4G Network) and videoconferencing software (Cisco Jabber for Telepresence). Device usage data combined with hospital admission records were collected to determine (a) instances where a telemedicine-facilitated discharge occurred and (b) if the accepted measure of short-term health outcomes (readmission within 28 days) was adversely affected by this alternative method. Telemedicine technology facilitated the discharge of 10.1% (n = 35) of patients considered unsuitable for CLD from the Hospital in the Home model during the trial period. Statistically insignificant differences in rates of readmission between patients discharged in person versus those participating in the telemedicine-supported model suggest that the clinical standards of the service have been maintained. The results of evaluating telemedicine support for nurses providing low-acuity in-home care indicate that patients may be discharged remotely while maintaining the existing clinical standards of the service.

Abstract 90: Cost-Benefit Comparison of Inpatient versus Clinical Decision Unit Management of TIA

Introduction: Because TIA increases the risk of subsequent stroke, rapid TIA management is key to stroke prevention. Controversy remains regarding the appropriate site of care for TIA patients. Recent literature shows high variability in care processes, admission rates, timeliness of interventions, cost of care, and outcomes, regardless of site of care. We developed a rapid TIA management process in our Clinical Decision Unit (CDU) to reduce cost and adverse outcomes. TIA patients that present to our ED are admitted to the CDU, but transfer patients with TIA are admitted to the inpatient unit (IPU). Methods: Retrospectively, we identified TIA cases by ICD coding, and reviewed records from 4/1/2012 to 3/31/2016 for patients in the CDU and in the IPU. We compared length of stay (LOS), cost of care, readmission rates, and TIA/stroke recurrence between the two groups. Statistical analysis included Chi-square and Wilcoxon two-sample test for recurrence and readmission rates, and generalized linear modeling and Poisson analysis for LOS and cost analysis. Results: A total of 731 patients presented for TIA management in the study period; 393 in CDU, and 338 in IPU. There was no statistical difference in age or sex between the two groups. Mean LOS (hours) in CDU vs IPU was 15 vs 108 (p&lt;0.001), respectively. Total cost of care in CDU vs IPU was $3,835 vs $11,904 (p&lt;0.001), respectively. Univariate analysis showed no appreciable difference in recurrent TIA or stroke rates; multivariate analysis of stroke recurrence for CDU (1.0%) vs IPU (3.6%) did show a small difference (p=0.024). When factoring in reduction of stroke recurrence, the final cost savings of the CDU program equaled $8,258 per patient. There was no difference in readmission rates between the two groups. Conclusion: Using a rapid TIA management protocol yielded a significantly lower LOS and cost per patient. This may justify an avoidance of inpatient admission for TIA patients.

Pediatric peritonsillar abscess: Outcomes and cost savings from using transcervical ultrasound.

1) To analyze clinical outcomes of children stratified by ultrasound into three diagnoses: acute tonsillitis, peritonsillar phlegmon, and abscess; and 2) To compare clinical outcomes and financial impact between children who underwent ultrasound protocol to those who did not. Retrospective analysis between two cohorts: ultrasound protocol group and control group. Children with peritonsillar abscess (PTA) diagnosed in the emergency department (ED) were enrolled during a 2-year period for transcervical ultrasound evaluation of bilateral tonsillar fossae. Data from a cohort of patients with PTA prior to ultrasound screening were also collected from retrospective chart review. Outcome variables were analyzed using multivariate logistic regression. Seventy-eight children (mean 12.3 years) were enrolled in the ultrasound protocol, compared to 101 children (mean 13.6 years) evaluated using traditional methods of examination and/or computed tomography (CT) imaging. Demographics between the two groups were not significantly different. Only one-third of patients presumed to have PTA by ED staff had ultrasound findings consistent with abscess. Overall treatment failure rate was 8%, requiring readmission or surgical intervention for abscess. Length of stay, surgical drainage, and radiation exposure from CT scans were reduced significantly in the ultrasound group (P < 0.006). Differences in readmission rates and mean charges between the two groups did not reach significance. Peritonsillar abscess is a common infection in the pediatric population, but diagnosis can be challenging. Transcervical ultrasound is a safe, cost-effective, and accurate modality to help stratify patients into medical and surgical treatment arms. 3b. Laryngoscope, 127:1924-1929, 2017.

Risk Factors for Unplanned Readmission and Stump Complications following Major Lower Extremity Amputation

Unplanned 30-day readmission rates (a marker of quality of patient care) after major lower extremity amputation are limited. We evaluated predictors of readmission at our institution. We conducted a retrospective review of all patients undergoing above-knee (AKA) or below-knee amputation (BKA) with closure between November 2007 and November 2014. Patient demographics were collected. Predictors of unplanned 30-day readmission and stump complications were determined by multivariable logistic regression. We identified 811 patients (AKA 325; BKA 486). The overall 30-day readmission rate was 26.3% (AKA 24.3%; BKA 27.6%). The cohort consisted of 54% men and had a mean age of 68.7 ± 14.9 years. Stump complications accounted for 25.8% of readmissions (AKA 20.0%; BKA 80.0%). Other common diagnoses included sepsis (27.7%), infection without the diagnosis of sepsis (9.9%), congestive heart failure exacerbation (7.0%), and diabetes-related complications (6.6%). Surgical intervention was performed on 61.8% of stump complications (AKA 11.8%; BKA 88.2%). BKA stump complications were converted to AKAs in 34.1% of cases. None of the AKA stump complications required a higher level of amputation (ie, hip disarticulation). Independent predictors of 30-day readmission included previous contralateral or ipsilateral major amputation, American Society of Anesthesiologists class 4, end-stage renal disease, and gangrene as the indication for the index procedure. Independent predictors of 30-day readmission for stump complications included previous major amputation, BKA, Hispanic ethnicity, and chronic kidney disease (stages II-V). Multivariate odds ratios (95% confidence interval) and P values are listed below (Table). The 30-day readmission rate following major lower extremity amputation is high, with wound infections accounting for a significant proportion of these readmissions. There was no difference in readmission rates based on level of amputation. However, those undergoing a BKA were more likely to present with stump complications, require a surgical intervention, and often a higher level of amputation. Identification of high-risk patients may play a role in reducing postoperative readmissions, and stump complications.TableMultivariate odds ratios (95% confidence interval) and P valuesIndependent predictors of 30-day readmissionMultivariate odds ratio (95% confidence interval)Multivariate P valuePrevious major amputation2.91 (1.77-4.78)<.01ASA 41.71 (1.15-2.51).01ESRD1.65 (1.10-2.43).01Gangrene1.51 (1.08-2.11).02Independent predictors of 30-day readmission for stump complicationsMultivariate odds ratio (95% confidence interval)Multivariate P valuePrevious major amputation12.75 (6.34-26.0)<.01BKA5.27 (2.55-11.95)<.01Hispanic ethnicity1.99 (1.08-3.66).03Chronic kidney disease2.40 (1.07-6.21).05Noninsulin-dependent diabetes0.45 (0.24-0.83).01Independent predictors of 30-day readmission for stump complications requiring surgical interventionMultivariate odds ratio (95% confidence interval)Multivariate P valuePrevious major amputation27.89 (11.91-68.43)<.01BKA13.93 (4.73-53.00)<.01Rest pain3.81 (1.30-10.24).01Hispanic Ethnicity2.57 (1.16-5.83).02AKA, Above-knee amputation; ASA, American Society of Anesthesiologists; BKA, below-knee amputation; ESRD, end-stage renal disease. Open table in a new tab

Abstract 13933: A Comparative Analysis of 30-day Readmission Rates, Etiologies and Resource Utilization Following Transcatheter and Surgical Aortic Valve Replacement From the Nationwide Readmission Database

Background: There is sparse comparative data on short-term readmissions following Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). Methods: The study cohort was derived from the National Readmission Data (NRD) 2013, a subset of the Healthcare Cost and Utilization Project (HCUP) sponsored by AHRQ. TAVR and SAVR were identified using appropriate ICD-9-CM codes (TAVR - 35.05, 35.06 &amp; SAVR - 35.21, 35.22) as either primary or secondary procedural codes. Variables which could affect treatment assignment, were adjusted with propensity score match analysis and Match (1:1) cohort was generated. Readmission causes were identified by ICD 9 code in primary diagnosis. Results: Our analysis included 3,886 TAVR and SAVR procedures each in the propensity matched cohorts. There was no significant difference in terms of readmission rates amongst patients who underwent TAVR vs. SAVR [21.41% vs. 21.07% (OR: 1.02, 95% CI: 0.92 - 1.14) p = 0.702]. Cardiac etiologies were more likely to be responsible for readmissions following SAVR (42.66% vs. 35.91%, p = 0.006). Atrial fibrillation (AF) was a much more common cause of readmission following SAVR (7.81% vs. 3.37%, p &lt;0.001). Overall vascular (3.24% vs. 1.32%, p = 0.006) and bleeding complications (9% vs. 6.2%, p = 0.025) were more likely to result in readmission in patients undergoing TAVR. Cost of care of index admission and readmission was similar in both groups. Readmission mortality was higher amongst patient with TAVR vs. SAVR (6.49 vs. 3.91, p = 0.02). 50% of TAVR and SAVR readmission occur within 11 days post discharge. Conclusion: In our study from a large nationwide database, there was no significant difference in readmission rate, median readmission rate and resource utilization between TAVR and SAVR. Arrhythmias especially AF accounted for more SAVR readmission and Bleeding/vascular complications were more commonly responsible for readmissions following TAVR.

Pre- and postoperative stoma education and guidance within an enhanced recovery after surgery (ERAS) programme reduces length of hospital stay in colorectal surgery

IntroductionStoma formation delays discharge after colorectal surgery. Stoma education is widely recommended, but little data are available regarding whether educational interventions are effective. The aim of this prospective study was to investigate whether an enhanced recovery after surgery (ERAS) programme with dedicated ERAS and stoma nurse specialists focusing on counselling and stoma education can reduce the length of hospital stay, re-admission, and stoma-related complications and improve health-related quality of life (HRQoL) compared to current stoma education in a traditional standard care pathway. MethodsIn a single-center study 122 adult patients eligible for laparoscopic or open colorectal resection who received a planned stoma were treated in either the ERAS program with extended stoma education (n = 61) or standard care with current stoma education (n = 61). The primary endpoint was total postoperative hospital stay. Secondary endpoints were postoperative hospital stay, major or minor morbidity, early stoma-related complications, health-related quality of life, re-admission rate, and mortality. HRQoL was measured by the generic 15D instrument. ResultsTotal hospital stay was significantly shorter in the ERAS group with education than the standard care group (median [range], 6 days [2–21 days] vs. 9 days [5–45 days]; p < 0.001). Regarding overall major and minor morbidity, re-admission rate, HRQoL, stoma-related complications and 30-day mortality, the two treatment groups exhibited similar outcomes. ConclusionPatients receiving a planned stoma can be included in an ERAS program. Pre-operative and postoperative stoma education in an enhanced recovery programme is associated with a significantly shorter hospital stay without any difference in re-admission rate or early stoma-related complications.

Incidence and Predictors of 30-day Readmission among Patients Hospitalized for Clostridium difficile Infection

Introduction:Clostridium difficile infection is associated with high costs and health-care utilization. Patient characteristics and risk for hospital readmission within 30 days for CDI have not been well elucidated. In this study, we evaluated patient, hospital and clinical predictors of readmission after CDI hospitalizations. Methods: We performed a retrospective analysis using the National Readmission Database (NRD) from January 2013-December 2013 in adult patients (Age>18 years) discharged with a primary diagnosis of CDI. Index stays were identified from January to November to allow for a 30-day readmission window for all index stays. Index stays required “live” discharge status and available length of stay. Clinical variables were based on secondary diagnoses at the time of first admission and selected based on the frequency of occurrence and potential clinical value for risk stratification. Statistical analyses were performed using SAS (Version 9.4, The SAS institute, Cary, NC). Results: Overall 99,162 admissions for CDI met the criteria for index admissions, with 24,002 patients readmitted within 30 days (24%). On multivariate analysis, females were less likely to be readmitted compared to males {OR 0.91 (0.86 - 0.96)}. There were no differences in readmission rates with respect to size or ownership (government vs. private) of hospitals. Patients on Medicaid had higher rates of readmission compared to patients on Medicare {OR 1.12 (1.00 - 1.25)}, while patients with private insurance had lower rates {OR 0.68 (0.61-0.74)}. Patients who were discharged to long-term care (LTC) had a higher likelihood of readmission {OR 1.17 (1.09 -1.26)}. Higher Charlson co-morbidity index (CCI) scores (>1) were associated with readmission {OR 1.71 (1.60 - 1.83)}. Markers of increased severity of illness such as anemia {OR 1.08 (1.02 - 1.15)} and blood transfusion during admission {OR 1.33 (1.22 - 1.47)} were associated with higher odds of readmission.Figure 1Conclusion: In this exploratory study, 24% of discharges for primary CDI are readmitted within 30 days. Increasing comorbid disease, as indicated by the CCI, and increased severity of disease, as indicated by anemia and the need for blood transfusions, were associated with higher odds of readmission. Medicaid patients and those discharged to LTC also had a higher likelihood of readmission. This study identifies important potential risk factors for readmission after CDI that could be addressed in future studies and quality improvement initiatives.

Risk Factors for Unplanned Readmission and Stump Complications After Major Lower Extremity Amputation

Unplanned 30-day readmission rates—a marker of quality of patient care—after major lower extremity amputation are limited. We evaluated predictors of readmission at our institution. We conducted a retrospective review of all patients undergoing above-knee amputation (AKA) or below-knee amputation (BKA) with closure between November 2007 and November 2014. Patient demographics were collected. Predictors of unplanned 30-day readmission and stump complications were determined by multivariable logistic regression. We identified 811 patients (AKA, 325; BKA, 486). The overall 30-day readmission rate was 26.3% (AKA, 24.3%; BKA, 27.6%). The cohort consisted of 54% men and had a mean age of 68.7 ± 14.9 years. Stump complications accounted for 25.8% of readmissions (AKA, 20.0%; BKA, 80.0%). Other common diagnoses included sepsis (27.7%), infection without the diagnosis of sepsis (9.9%), congestive heart failure exacerbation (7.0%), and diabetes-related complications (6.6%). Surgical intervention was performed on 61.8% of stump complications (AKA, 11.8%; BKA, 88.2%). BKA stump complications were converted to AKAs in 34.1% of cases. None of the AKA stump complications required a higher level of amputation (ie, hip disarticulation). Independent predictors of 30-day readmission included previous contralateral or ipsilateral major amputation, American Society of Anesthesiologists class 4, end-stage renal disease, and gangrene as the indication for the index procedure. Independent predictors of 30-day readmission for stump complications included previous major amputation, BKA, Hispanic ethnicity, and chronic kidney disease (stages 2-5). Multivariate odds ratios and P values are listed (Table). The 30-day readmission rate after major lower extremity amputation is high, with wound infections accounting for a significant proportion of these readmissions. There was no difference in readmission rates based on level of amputation. However, those undergoing a BKA were more likely to present with stump complications, to require a surgical intervention, and often to require a higher level of amputation. Identification of high-risk patients may play a role in reducing postoperative readmissions and stump complications.TableMultivariate odds ratios (95% confidence interval) and P valuesMultivariate odds ratio (95% confidence interval)Multivariate P valueIndependent predictors of 30-day readmission Previous major amputation2.91 (1.77-4.78)<.01 ASA class 41.71 (1.15-2.51).01 ESRD1.65 (1.10-2.43).01 Gangrene1.51 (1.08-2.11).02Independent predictors of 30-day readmission for stump complications Previous major amputation12.75 (6.34-26.0)<.01 BKA5.27 (2.55-11.95)<.01 Hispanic ethnicity1.99 (1.08-3.66).03 Chronic kidney disease2.40 (1.07-6.21).05 Non-insulin-dependent diabetes0.45 (0.24-0.83).01Independent predictors of 30-day readmission for stump complications requiring surgical intervention Previous major amputation27.89 (11.91-68.43)<.01 BKA13.93 (4.73-53.00)<.01 Rest pain3.81 (1.30-10.24).01 Hispanic ethnicity2.57 (1.16-5.83).02ASA, American Society of Anesthesiologists; BKA, below-knee amputation; ESRD, end-stage renal disease. Open table in a new tab

Indication for Lower Extremity Revascularization and Hospital Profiling of Readmissions

Surgical readmissions are common, costly, and the focus of national quality improvement efforts. Given the relatively high readmission rates among vascular patients, pay-for-performance initiatives such as Medicare's Hospital Readmissions Reduction Program (HRRP) have targeted vascular surgery for increased scrutiny in the near future. Yet, the extent to which institutional case mix influences hospital profiling remains unexplored. We sought to evaluate whether higher readmission rates in vascular surgery are a reflection of worse performance or of treating sicker patients. This retrospective observational cohort study of the national Medicare population includes 479,047 beneficiaries undergoing lower extremity revascularization (LER) in 1,701 hospitals from 2005 to 2009. We employed hierarchical logistic regression to mimic Center for Medicare and Medicaid Services methodology accounting for age, gender, preexisting comorbidities, and differences in hospital operative volume. We estimated 30-day risk-standardized readmission rates (RSRR) for each hospital when including (1) all LER patients; (2) claudicants; or (3) high-risk patients (rest pain, ulceration, or tissue loss). We stratified hospitals into quintiles based on overall RSRR for all LERs and examined differences in RSRR for claudicants and high-risk patients between and within quintiles. Next, we evaluated differences in case mix (the proportion of claudicants and high-risk patients treated) across quintiles. Finally, we simulated differences in the receipt of penalties before and after adjusting for hospital case mix. Readmission rates varied widely by indication: 7.3% (claudicants) vs. 19.5% (high risk). Even after adjusting for patient demographics, length of stay, and discharge destination, high-risk patients were significantly more likely to be readmitted (odds ratio 1.76, 95% confidence interval 1.71-1.81). The Best hospitals (top quintile) under the HRRP treated a much lower proportion of high-risk patients compared with the Worst hospitals (bottom quintile) (20% vs. 56%, P<0.001). In the absence of case-mix adjustment, we observed a stepwise increase in the proportion of hospitals penalized as the proportion of high-risk patients treated increased (35-60%, P<0.001). However, after case-mix adjustment, there were no differences between quintiles in the proportion of hospitalized penalized (50-46%, P=0.30). Our findings suggest that the differences in readmission rates following LER are largely driven by hospital case mix rather than true differences in quality.

Is Outpatient Arthroplasty as Safe as Fast-Track Inpatient Arthroplasty? A Propensity Score Matched Analysis

BackgroundIn the emerging fiscal climate of value-based decision-making and shared risk and remuneration, outpatient total joint arthroplasty is attractive provided the incidence of costly complications is comparable to contemporary “fast-track” inpatient pathways. MethodsAll patients undergoing total hip arthroplasty or total knee arthroplasty between 2011 and 2013 were selected from the American College of Surgeons–National Surgical Quality Improvement Program database. A propensity score was used to match 1476 fast-track (≤2 day length of stay) inpatients with 492 outpatients (3:1 ratio). Thirty-day complication, reoperation, and readmission rates were compared, both during and after hospitalization. Logistic regression was used to calculate propensity score adjusted odds ratios. ResultsAfter matching, outpatients had higher rates of medical complication (anytime, 10.0% vs 6.7%, P = .018; post discharge, 6.3% vs 1.1%, P < .001). Most complications were bleeding requiring transfusion, which occurred at similar rates after surgery but at higher rates post discharge in outpatients (anytime, 7.5% outpatients vs 5.6% inpatients, P = .113; post discharge, 4.1% outpatients vs 0.1% inpatients, P < .001). There was no difference in readmission rate (2.4% outpatient vs 2.0% inpatient, P = .589). ConclusionOutpatients experience higher rates of post-discharge complications, which may countermand cost savings. Surgeons wishing to implement outpatient total joint arthroplasty clinical pathways must focus on preventing post-discharge medical complications to include blood management strategies.

Impact of Risk Adjustment for Socioeconomic Status on Risk-adjusted Surgical Readmission Rates.

To assess whether differences in readmission rates between safety-net hospitals (SNH) and non-SNHs are due to differences in hospital quality, and to compare the results of hospital profiling with and without SES adjustment. In response to concerns that quality measures unfairly penalizes SNH, NQF recently recommended that performance measures adjust for socioeconomic status (SES) when SES is a risk factor for poor patient outcomes. Multivariate regression was used to examine the association between SNH status and 30-day readmission after major surgery. The results of hospital profiling with and without SES adjustment were compared using the CMS Hospital Compare and the Hospital Readmissions Reduction Program (HRRP) methodologies. Adjusting for patient risk and SES, patients admitted to SNHs were not more likely to be readmitted compared with patients in in non-SNHs (AOR 1.08; 95% CI:0.95-1.23; P = 0.23). The results of hospital profiling based on Hospital Compare were nearly identical with and without SES adjustment (ICC 0.99, κ 0.96). Using the HRRP threshold approach, 61% of SNHs were assigned to the penalty group versus 50% of non-SNHs. After adjusting for SES, 51% of SNHs were assigned to the penalty group. Differences in surgery readmissions between SNHs and non-SNHs are due to differences in the patient case mix of low-SES patients, and not due to differences in quality. Adjusting readmission measures for SES leads to changes in hospital ranking using the HRRP threshold approach, but not using the CMS Hospital Compare methodology. CMS should consider either adjusting for the effects of SES when calculating readmission thresholds for HRRP, or replace it with the approach used in Hospital Compare.

MP82-13 POST PCNL SIRS IS NOT A PREDICTOR OF UNPLANNED READMISSION

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation I1 Apr 2016MP82-13 POST PCNL SIRS IS NOT A PREDICTOR OF UNPLANNED READMISSION Rachel Moses, Vidit Sharma, Eric Raffin, Boyd Viers, Deepak Agarwal, Amy Krambeck, and Vernon Pais Rachel MosesRachel Moses More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Eric RaffinEric Raffin More articles by this author , Boyd ViersBoyd Viers More articles by this author , Deepak AgarwalDeepak Agarwal More articles by this author , Amy KrambeckAmy Krambeck More articles by this author , and Vernon PaisVernon Pais More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2154AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Postoperative Systemic Inflammatory Response Syndrome (SIRS) may be considered an ominous predictor of unplanned infectious complications and readmissions. Anecdotally, otherwise well patients following percutaneous nephrolithotomy (PCNL) will meet criteria for SIRS. We sought to evaluate whether SIRS following PCNL is predictive of unplanned 90 day readmission. METHODS We retrospectively reviewed consecutive patients undergoing PCNL in two dedicated endourologic practices. Patient characteristics including demographics, perioperative urine cultures, stone composition, and operative characteristics were collected. SIRS was defined as having two or more of the following: maximum white blood cell count < 4,000 or >12,000, temperature< 34°C or >38°C, heart rate >90bmp, and respiratory rate >20bpm within 24hrs following PCNL. Univariate and multivariate analyses were used to identify significant associations. RESULTS We identified 389 patients undergoing PCNL, 43% (167/382) that met criteria for SIRS within 24hrs of PCNL. No patient with a temperature >38.4°C was discharged within 48 hours post operatively. On bivariate analysis, length of stay >48hrs (32% vs 13%, p=<0.01), preoperative oral antibiotics (71% vs. 61%, p=0.03), positive intraoperative stone culture (22% vs. 13%, p=0.01), multiple PCNL accesses (17% vs. 6%, p<0.01), and struvite stones (10% vs. 5%, p=0.03) were more likely to develop postoperative SIRS. When excluding febrile patients, LOS>48hrs was no longer associated. On multivariate analysis, multiple PCNL accesses (OR 2.3; 1.1-4.8, p=0.02) was the only significant factor associated with SIRS. Overall, readmission within 90 days was required in 8% (31/389). The most common reason for readmission was infection 68% (21/31). Possession of a struvite stone was the only characteristic associated with unplanned 90day readmission (16% vs. 4%, p<0.01). There were no differences in readmission rates between patients with perioperative SIRS (26% vs. 44% p=0.14) and patients with afebrile SIRS discharged within 48hours (26% vs. 29%, p=0.84). CONCLUSIONS More than 43% of patients met criteria for SIRS following PCNL. Although perhaps an ominous prognosticator in other settings, there was no significant correlation between SIRS and any cause or infection related 90 day readmission in this postoperative PCNL cohort. In the absence of fever, patients undergoing PCNL that meet SIRS criteria may in fact be safely discharged on postoperative day one without increased risk of unplanned readmission. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1077 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Rachel Moses More articles by this author Vidit Sharma More articles by this author Eric Raffin More articles by this author Boyd Viers More articles by this author Deepak Agarwal More articles by this author Amy Krambeck More articles by this author Vernon Pais More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...