Patient Discharge Disposition Research Articles

307 The Hospital Frailty Risk Score Independently Predicts Increased Complication Rates and Healthcare Resource Utilization After Endovascular Treatment of Ruptured Aneurysms

INTRODUCTION: Frailty has emerged as an important indicator of patients who are at greater risk of adverse healthcare outcomes. The Hospital Frailty Risk Score (HFRS) was recently developed utilizing ICD-10 diagnostic codes to identify frailty using routine administrative hospital data but has not been applied to the evaluation of patients with ruptured intracranial aneurysms (IAs). METHODS: A retrospective cohort study was performed using the 2016-2017 National Inpatient Sample (NIS) database. All adult patients (=18 years) undergoing endovascular treatment for IAs after subarachnoid hemorrhage were identified using ICD-10-CM diagnostic and procedural codes. Patients were categorized into three HFRS-based frailty cohorts: Low (HFRS<5), Intermediate (HFRS=5 and <15), and High (HFRS=15). Patient demographics, comorbidities, treatment modality, perioperative complications, LOS, discharge disposition, and total cost of hospital admission were assessed. A multivariate logistic regression analyses were used to identify independent predictors of prolonged LOS, increased cost and non-routine discharge. RESULTS: Of the 16,290 patients identified, 4,200 (25.8%) were found to be Low frailty, 9,505 (58.3%) were Intermediate, and 2,585 (15.9%) were High by HFRS criteria. A greater proportion of patients in the Intermediate and High frailty cohorts experienced greater than one perioperative complication than Low frailty (Low: 16.4% vs Intermediate: 61.7% vs High: 87.6%, p < 0.001). There is a step-wise increase in mean LOS (Low: 12.2 ± 9.4 days vs Intermediate: 19.0 ± 14.8 days vs High: 26.9 ± 19.3 days, p < 0.001), mean total hospital cost (Low: $62,642 ± 39,552 vs Intermediate:$98,415 ± 63,042 vs High: $132,087 ± 75,263, p < 0.001), and non-routine discharge (Low: 20.0% vs Intermediate: 46.5% vs High: 73.9%, p < 0.001) with increasing frailty. On multivariate regression analysis, similar step-wise impact was found with increasing frailty in prolonged LOS [Intermediate: OR 1.56 (p = 0.02) and High: OR 2.82 (p < 0.001)], hospital cost [High: OR 2.01 (p = 0.001)], and non-routine discharge [Intermediate:OR 1.59 (p < 0.001) and High: OR 3.12 (p < 0.001)]. CONCLUSION: Our study is the first to use the HFRS to assess the impact of frailty on patients undergoing endovascular treatment of ruptured IAs. We found that greater frailty was associated with increased complications, prolonged LOS, higher costs, and non-routine discharge.

Discharge Disposition and Clinical Outcomes After Spine Surgery.

Spinal decompression with or without fusion is one of the most commonly performed procedures in spine surgery. However, there is limited evidence on the effect of discharge environment on outcomes after surgery. The purpose of this study is to identify the effects of discharge disposition setting on clinical outcomes after spine surgery. Patients who underwent lumbar decompression, lumbar decompression and fusion, or posterior cervical decompression and fusion surgery were retrospectively identified. All clinical and demographic data were obtained from electronic health records. Surgical outcomes included wound complications, revision surgery, "30-day" readmission (0-30 d), and "90-day" readmission (31-90 d). Discharge disposition was stratified into home/self-care, acute inpatient rehabilitation, and subacute rehabilitation. Patient-reported outcome measures including VAS Back, VAS Leg, VAS Neck, VAS Arm, PCS-12 and MCS-12, ODI, and NDI were compared between patient discharge disposition settings using the Mann-Whitney U test. Pearson's chi-square analysis was used to assess for differences in wound complications, revision surgery, 30-day readmission, or 90-day readmission rates. Multivariate logistic regression incorporating age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), and discharge disposition was used to determine independent predictors of wound complications. A total of 637 patients were included in the study. A significant difference (P = 0.03) was found in wound complication based on discharge disposition, with subacute disposition having the highest proportion of wound complications (6.1%) and home disposition having the lowest (1.5%). There were no significant differences in the rates of revision surgery, 30-day readmission, or 90-day readmission between groups. Subacute rehabilitation (odds ratio: 3.67, P = 0.047) and CCI (odds ratio 1.49, P = 0.01) were independent predictors of wound complications. Significant improvement in PROMs was seen across all postacute discharge dispositions. Baseline (P = 0.02) and postoperative (P = 0.02) ODI were significantly higher among patients discharged to an acute facility (49.4 and 32.0, respectively) compared to home (42.2 and 20.0) or subacute (47.4 and 28.4) environments. Subacute rehabilitation disposition and CCI are independent predictors of wound complications after spinal decompression surgery. Patients undergoing spine surgery have similar readmission and revision rates and experience similar clinical improvement across all postacute discharge dispositions.

Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program

BackgroundConcerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution’s exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A). MethodsWe reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions.Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions. ResultsPost-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224). ConclusionsSince leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.

Atrial Fibrillation and Acute Ischemic Stroke: Evaluation of the Contemporary 2018 National Inpatient Sample Database

BackgroundAtrial fibrillation (AF) in acute ischemic stroke (AIS) is considered a binary entity regardless of AF type. We aim to investigate in-hospital morbidity and mortality among patients with nonparoxysmal AF–related AIS. MethodsPatients hospitalized for AIS with associated paroxysmal or persistent AF were identified from the 2018 national inpatient sample database. We compared in-hospital mortality, stroke-related morbidity, hospital cost, length of stay, and discharge disposition in patients hospitalized with paroxysmal or persistent AF. ResultsA total of 26,470 patients were hospitalized for AIS with paroxysmal or persistent AF. Patient with AIS with persistent AF had a longer hospital length of stay (paroxysmal AF, mean [M] 5.7 days, standard deviation [SD] ±6.8 days; persistent AF, M 7.4 days, SD ±11.9 days, P < 0.001) and in-hospital costs (paroxysmal AF, M $15,449, SD ±$18,320; persistent AF, M $19,834 SD ±$23,312, P < 0.001). Patients with AIS with permanent AF had higher in-hospital mortality (paroxysmal AF, 4.6%, vs permanent AF, 6.2%, P < 0.001). Indirect markers of stroke-related disability, like intracranial hemorrhage (odds ratio [OR]: 1.9, 95% confidence interval (CI): 1.6-2.2), need for gastrostomy (OR: 2.1, 95% CI: 1.8-2.4), and tracheostomy (OR: 3.1, 95% CI: 2.1-4.4) were more associated with AIS from persistent AF. ConclusionsPersistent AF is associated with poor in-hospital stroke-related outcome, possibly due to a worse thrombo-embolic phenomenon. AF pattern may be a harbinger of worse stroke-related morbidity.

Abstract TP121: Examination Of Initial NIHSS And Discharge Disposition In Patients Hospitalized With Acute Ischemic Stroke

Introduction: Acute ischemic stroke (AIS) patients require post-acute care (PAC) rehabilitation that is consistent with degree of stroke deficit. Appropriate PAC disposition for AIS patients varies widely. We examine the relationship between initial National Institutes of Health Stroke Scale (NIHSS) and discharge disposition to determine if stroke severity is associated with disposition. Methods: In our IRB-approved database, consecutive Emergency Department stroke code activations with confirmed diagnosis of AIS were retrospectively analyzed from January 2004-May 2021 at UC San Diego. Patients were grouped into mild (NIHSS 0-5), moderate (NIHSS 6-14), and severe (NIHSS &gt;14) stroke. Outcome variables were PAC disposition: Home, Inpatient Rehab Facility (IRF), Skilled Nursing Facility (SNF), Expired, and Other. Chi-squared and Kruskal-Wallis followed by pairwise proportion tests were used for analysis. Analyses were adjusted for age, sex, baseline modified Rankin score (mRS), and acute stroke treatment. Results: Total 2316 patients were included for analysis. There was a difference between initial stroke severity and discharge disposition overall (p&lt;0.001). (Table 1). Mild stroke patients had less discharges to IRF, SNF, Expired, or Other compared to moderate (p&lt;0.001) and severe (p&lt;0.001) strokes. There was no difference between moderate and severe stroke patients discharged to IRF (p=0.44) or SNF (p=0.48). Age, baseline mRS, and receiving acute stroke treatment were independent predictors for discharge to home, IRF, and SNF. Baseline mRS was an independent predictor for Expired patients. Conclusion: Patients with mild strokes are discharged home more than moderate and severe strokes, but there was no difference between moderate and severe stroke patients discharged to either IRF or SNF. This suggests PAC disposition is not consistent with stroke severity and further studies are needed to investigate other factors related to final disposition.

Abstract TMP51: Predictors Of Severe Disease In Posterior Reversible Encephalopathy Syndrome

Background: Despite its name, posterior reversible encephalopathy syndrome (PRES) is not always fully reversible and there might be residual neurologic sequelae or even mortality in a significant minority of patients. Factors predisposing to severe disease course in PRES are largely unclear. The aim of this study was to evaluate the predictors of in-hospital mortality and adverse discharge disposition in patients hospitalized due to PRES. Methods: Hospitalizations due to the primary diagnosis of PRES with known discharge disposition were identified from the Nationwide Readmissions Database 2016-2018. Survey statistics were used to compute national estimates. Univariate and multivariable logistic regression analyses were used to identify factors associated with the study outcomes. P-value &lt;0.01 was considered significant. Results: There were 9,298 patients with PRES (mean±SD age: 56.2±17.6 years; female: 71.2%). Of these, 207 (2.2%) had in-hospital mortality and 4,002 (43.0%) had adverse discharge disposition, defined as discharge to a short-term hospital, a rehabilitation facility, home with in-home healthcare or hospice. Figure 1 shows the independent predictors of the study outcomes. Advanced age, history of cancer, concurrent sepsis, coma, ischemic stroke, and mechanical ventilation were associated with higher in-hospital mortality. Whereas advanced age, female sex, higher Charlson comorbidity index score, mechanical ventilation, and longer length of hospital stay were associated with a higher likelihood of adverse discharge disposition. Conclusion: Nearly half of the hospitalized patients with PRES have severe disease. This study identifies several clinical predictors of severe disease course in PRES.

Abstract TP3: Seizures As Stroke Mimics In Ultra-early Treatment On A Mobile Stroke Unit: A Pilot Study

Background: Stroke mimics are often difficult to distinguish from true ischemic and hemorrhagic cerebrovascular accidents, and present a challenge for appropriate delivery of rapid stroke treatment. This is particularly true in ultra-early stroke care with Mobile Stroke Units (MSU), which administer tPA in the field, within minutes of symptom onset. We sought to evaluate and characterize stroke mimics during prehospital care with an MSU at a Comprehensive Stroke Center. Methods: The study compared patient and stroke characteristics, neurologic evaluation, and treatment between confirmed strokes and stroke mimics treated during a one-year pilot period on the MSU at a large urban medical center. Variables included patient demographics, NIHSS score, tPA administration, final diagnosis, and discharge disposition. Results: Between Jan. 15, 2016 and Jan. 9, 2017, 47 patients received prehospital management on the MSU, and 44 were admitted to UC hospital and had an available final diagnosis. Of these, 12 (27%) were stroke mimics. Mimics were younger [median age 60 (IQR 54-71) years, mimics vs. 68 (IQR 60-77) years, strokes], and were more often female (58%, mimics vs. 47%, strokes). Initial NIHSS score was lower for confirmed strokes [median 3 (IQR 2-10) strokes, vs. 6 (IQR 4-12) mimics], but severe strokes with a NIHSS score &gt;17, were more common in strokes (16%, strokes vs. 0%, mimics). Of mimics, 6 (50%) were seizures, 2 (17%) migraine, 2 (17%) conversion, 1 (8%) encephalopathy, and 1 (8%) delirium. Thirteen (30%) of all patients were treated with IV tPA on the MSU, of whom 4 (31%) were mimics. Of mimics given tPA, 2 were seizures, 1 migraine and 1 conversion. Mimics were more likely to be discharged to home (64%, mimics vs. 46%, strokes) while strokes more likely received rehabilitation (23%, strokes vs. 9%, mimics). Conclusions: One third of patients treated on the MSU were stroke mimics, and among these the most common diagnosis was seizures. These results suggest vigilance is warranted for seizure, as well as further study of rapid EEG technologies to guide appropriate treatment for presentations that appear to be stroke, including antiepileptic drugs, in ultra-early MSU care of suspected CVA.

Endovascular thrombectomy with and without preceding intravenous thrombolysis for treatment of large vessel anterior circulation stroke: A cross-sectional analysis of 50,000 patients

IntroductionThe safety and efficacy of intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) for large vessel occlusion stroke remains a highly contested and unanswered clinical question. We aim to characterize the clinical profile, complications, and discharge disposition of EVT patients treated with and without preceding IVT using a large, nationally-representative sample. MethodsThe National Inpatient Sample was queried from 2015 to 2018 to identify adult patients with anterior circulation stroke treated with EVT with and without preceding IVT. Multivariable logistic regression analysis and propensity-score matching were employed to assess adjusted associations with clinical endpoints and to address confounding by indication for IVT, respectively. ResultsAmong 48,525 patients identified, 40.7% (n = 19,735) received IVT prior to EVT. On unadjusted analysis, patients treated with IVT bridging therapy experienced higher rates of intracranial hemorrhage (26% vs. 24%, p = 0.003) and routine discharge to home with or without services (33% vs. 27%, p < 0.001), a lower frequency of thromboembolic complications (3% vs. 5%, p < 0.001), and lower rates of extended hospital stays (eLOS) (20% vs. 24%, p < 0.001). Multivariable logistic regression analysis adjusting for demographic and baseline clinical characteristics demonstrated independent associations of IVT bridging therapy with intracranial hemorrhage (aOR 1.28, 95% CI 1.15, 1.43; p < 0.001), thromboembolic complications (aOR 0.66, 95% CI 0.53, 0.83; p < 0.001), routine discharge (aOR 1.27, 95% CI 1.15, 1.40; p < 0.001), and eLOS (aOR 0.76, 95% CI 0.68, 0.85; p < 0.001). Sensitivity testing confirmed these findings. ConclusionPreceding IVT was associated with favorable functional outcomes following endovascular therapy. Prospective randomized clinical trials are warranted for further evaluation.

The Predictive Accuracy of the CareMOSAIC Risk Assessment for Discharge Disposition in Medicare Bundle Patients After Total Joint Arthroplasty.

BackgroundThis article evaluates the predictive accuracy of the CareMOSAIC Risk Assessment for discharge disposition in Medicare patients undergoing total joint arthroplasty.MethodsRetrospectively collected data from a single institution on 499 consecutive Medicare patients who underwent primary total hip arthroplasty or total knee arthroplasty were reviewed. The CareMOSAIC Risk Assessment was completed by each patient during the preoperative period. The CareMOSAIC Risk Assessment scores were calculated via the CareMOSAIC software, and the scores indicate a risk category for each patient as it relates to post–acute care discharge needs.ResultsThe CareMOSAIC Risk Assessment with a binary logistic regression area under the receiver operating characteristic curve of 0.798 appears to be a reliable tool for predicting discharge disposition. The assessment had a positive predictive value of 90.0% and negative predictive value of 76.3% for discharge disposition.ConclusionsThe CareMOSAIC Risk Assessment effectively predicts the discharge disposition for Medicare patients undergoing total hip or total knee arthroplasty.

Hospital Frailty Risk Score and Healthcare Resource Utilization After Surgery for Primary Spinal Intradural/Cord Tumors.

The Hospital Frailty Risk Score (HFRS) is a metric that measures frailty among patients in large national datasets using ICD-10 codes. While other metrics have been utilized to demonstrate the association between frailty and poor outcomes in spine oncology, none have examined the HFRS. The aim of this study was to investigate the impact of frailty using the HFRS on complications, length of stay, cost of admission, and discharge disposition in patients undergoing surgery for primary tumors of the spinal cord and meninges. A retrospective cohort study was performed using the Nationwide Inpatient Sample database from 2016 to 2018. Adult patients undergoing surgery for primary tumors of the spinal cord and meninges were identified using ICD-10-CM codes. Patients were categorized into 2 cohorts based on HFRS score: Non-Frail (HFRS<5) and Frail (HFRS≥5). Patient characteristics, treatment, perioperative complications, LOS, discharge disposition, and cost of admission were assessed. Of the 5955 patients identified, 1260 (21.2%) were Frail. On average, the Frail cohort was nearly 8 years older (P < .001) and experienced more postoperative complications (P = .001). The Frail cohort experienced longer LOS (P < .001), a higher rate of non-routine discharge (P = .001), and a greater mean cost of admission (P < .001). Frailty was found to be an independent predictor of extended LOS (P < .001) and non-routine discharge (P < .001). Our study is the first to use the HFRS to assess the impact of frailty on patients with primary spinal tumors. We found that frailty was associated with prolonged LOS, non-routine discharge, and increased hospital costs.

Impact of Diabetes, Hypertension and Heart Failure on Stroke Rehabilitation Care

Background: Stroke patients who have multiple comorbidities at inpatient rehabilitation admission might experience poorer outcomes than those without comorbidities. Some differences in outcomes between these two groups may be based on age and type of comorbidity. Materials and Methods: Retrospective administrative data from an inpatient stroke rehabilitation unit in a Southwestern Ontario hospital were examined to determine the independent associations between diabetes, hypertension, and heart failure in stroke patients and rehabilitation length of stay (LOS), functional gains in rehabilitation, and discharge destination. We also examined the associations between CHADS2 score and rehabilitation LOS, functional gains in rehabilitation, and discharge destination. Results: Seven hundred and seven cases of stroke subcategorized as experiencing mild (n = 193), moderate (n = 454), and severe (n = 60) stroke were included in the study. Of these patients, 16.4% (n = 116) had type 2 diabetes, 58.7% (n = 415) had hypertension, and 5.8% (n = 41) had congestive heart failure (CHF) prior to stroke. CHF patients were significantly (p = 0.02) older, had significantly (p = 0.014) lower mean FIM gains and were discharged to residential care facilities compared to non-CHF cases. A higher CHADS2 score was significantly associated with Lower FIM gains and discharge to longer term settings. Conclusion: Significant differences exist in the functional gains and discharge disposition of stroke patients based on age of patient, type of comorbidity in stroke, and CHADS2 score.

Impact of early mobilization on discharge disposition and functional status in patients with subarachnoid hemorrhage: A retrospective cohort study.

Whereas early rehabilitation improves the patients’ physical function in patients with cerebral infarction and hemorrhage, complications in the early stage are the main barriers in patients with subarachnoid hemorrhage (SAH). Therefore, the clinical impact of early rehabilitation in patients with SAH is not well documented. We sought to investigate whether early mobilization is associated with favorable discharge disposition and functional status in patients with SAH.Hospitalization data of 35 patients (65.7 ± 13.7 years, 37.1% men) were retrospectively reviewed. The early and delayed mobilization groups were defined as those who had and had not participated in walking rehabilitation on day 14, respectively. We investigated whether patients were discharged or transferred to another hospital and assessed their functional status using the Functional Ambulation Categories, Ambulation Index, Glasgow Outcome Scale, and modified Rankin Scale scores.Nine patients (69.2%) in the early mobilization group and one patient (4.5%) in the delayed mobilization group were discharged home directly (P < .001). In multivariate logistic regression analysis, early mobilization was independently associated with home discharge after adjustment using the World Federation of Neurosurgical Societies grade (adjusted odds ratio = 30.20, 95% CI = 2.77–329.00, P < .01). Early mobilization was associated with favorable functional status at discharge through multivariate linear regression analysis (standardized beta = 0.64 with P < .001 for the Functional Ambulation Category and beta = -0.62 with P < .001 for the modified Rankin Scale, respectively).Early mobilization was associated with home discharge and favorable functional status at discharge. Larger prospective studies are warranted.

Predicting Community Discharge for Occupational Therapy Recipients in the Neurological Critical Care Unit.

Occupational therapy in the neurological critical care unit (NCCU) may enable safe community discharge by restoring functional ability. However, the influence of patient characteristics and NCCU occupational therapy on discharge disposition is largely unknown. To examine how patient factors and receipt of occupational therapy predict discharge disposition for NCCU patients. Retrospective cross-sectional cohort study of electronic health records data from adults admitted to the NCCU between May 2013 and September 30, 2015. NCCU in a large urban academic hospital. Adults age 18 yr or older (N = 1,134) admitted to the NCCU. Outcomes and Measures: Using logistic regression with discharge disposition as the dependent variable, we entered sex, age, length of stay (LOS), baseline Glasgow Coma Scale score, Elixhauser Comorbidity Index, and receipt of occupational therapy services as predictor variables. Of NCCU patients, 39% received occupational therapy. Younger age, shorter LOS, lower comorbidity burden, and not receiving occupational therapy services increased the likelihood of discharge to the community. Men who received occupational therapy were less likely to be discharged to the community than men who did not receive occupational therapy. As age increased, differences in the probability of community discharge decreased between recipients and nonrecipients of occupational therapy services. Our results suggest that patients receiving occupational therapy services in the NCCU may have a lower likelihood of community discharge. However, these findings may result from therapist's consideration of the safest discharge location to ensure the greatest balance between independence and support. What This Article Adds: This study's findings suggest that receipt of occupational therapy in the NCCU is associated with higher likelihood for noncommunity discharge (i.e., to inpatient rehabilitation, skilled nursing, or long-term care). However, activity limitations and comorbidity burden may be greater for recipients of occupational therapy, and these NCCU patients are presumably less prepared for community discharge.

Influence of socioeconomic status on the incidence of aneurysmal subarachnoid haemorrhage and clinical recovery

BackgroundThe relevance of socioeconomic status (SES) on the incidence of aneurysmal subarachnoid haemorrhage (aSAH) and discharge functional outcomes following treatment is not clear. MethodsA retrospective cross-sectional study was performed on data retrieved from the Nationwide Hospital Morbidity Database for all aSAH cases in Australia between 2012 and 2018. Information on patient characteristics, procedures performed, discharge disposition and SES were extracted. SES data was derived from classifications by the Australian Bureau of Statistics. Putative risk factors were evaluated with univariate and multivariate logistic regression analysis to identify independent predictor of unfavourable discharge outcomes (defined as death or dependency). ResultsA total of 3,591 low SES patients (49.8%) were identified in our study cohort. Average crude incidence of aSAH was persistently higher among the SES disadvantaged (6.6 cases per 100,000 person-years, 95% CI 6.3 – 6.8), compared to the SES advantaged group (4.1 cases per 100,000 person-years, 95% CI 4.0–4.2) (p < 0.0001). Patients in the Low SES group were more likely to be active smokers, have type 2 diabetes mellitus, or live in non-metropolitan residence, and have overall worse discharge functional outcomes (27.7% versus 24.5%, p = 0.0015). Adjusting for well-established risk factors such as older age, and intracranial bleed (ICH and/or IVH), disadvantaged SES remained a significant predictor of poor discharge outcome following aSAH (p = 0.0003). ConclusionaSAH occurs more frequently among low SES communities, and once ruptured, there is a greater risk of poor recovery..

Visualizing Frailty: Exploring Radiographical Measures of Frailty in Trauma Patients

Purpose: This study assessed the relationship of core muscle sarcopenia, myosteatosis, and L1 attenuation to the 5-factor modified frailty index (mFI-5), discharge disposition, and post-admission complications in orthopedic and general trauma patients. It was hypothesized that reduced sarcopenia, L1 attenuation, and increased myosteatosis is associated with higher mFI-5 scores (≥ 0.3), discharge into care, and increased post-admission complications.Methods: This prospective cohort study was performed at a Level 1 trauma center. Patients were surveyed and metrics of the mFI-5 were used. Frail was categorized as a mFI-5 score ≥ 0.3. Recent abdominal computed tomography (CT) scans were used to extract radiographical information of total psoas cross-sectional area, psoas myosteatosis, and L1 vertebrae attenuation.Results: There were 140 patients who consented to the study, of which 83 had available abdomen and pelvis CT scans. The mean age was 43.19 (± 17.36), and 65% were male (&lt;i&gt;n&lt;/i&gt; = 52). When comparing the frail (16%, &lt;i&gt;n&lt;/i&gt; = 13) and not frail (84%, &lt;i&gt;n&lt;/i&gt; = 70) patients, there was a significant difference in mean psoas myosteatosis (&lt;i&gt;p&lt;/i&gt; &lt; 0.0001) and the attenuation of the L1 vertebrae (&lt;i&gt;p&lt;/i&gt; &lt; 0.001). On multivariate analysis when accounting for age, myosteatosis of the psoas muscles was predictive of an mFI-5 score ≥ 0.3.Conclusion: The findings suggest that myosteatosis and L1 attenuation are associated with frailty indices (mFI-5) after traumatic injury. Future studies are needed to prospectively assess the validity of both radiographical and index-based markers of frailty in predicting post-traumatic complications, mortality, and hospital utilization.

Reoperation, Readmission, and Discharge Disposition for Patients With Degenerative Lumbar Pathology Treated With Either Open or Minimally Invasive Techniques: A Single-Center Retrospective Review of 1435 Cases

Altshuler, Marcelle MD; Mueller, Kyle B MD; MacConnell, Ashley MD; Wirth, Peter MD; Sandhu, Faheem A MD, PhD; Voyadzis, Jean-Marc MD

The Impact of NC Statewide Telepsychiatry Program (NC-STeP) on Cost Savings by Reducing Unnecessary Psychiatric Hospitalizations During a 6½ Year Period.

To study the impact of the North Carolina Statewide Telepsychiatry Program in reducing unnecessary psychiatric hospitalizations and cost savings during a 6½ year period. Patient encounter data was extracted from the NC-STeP database that captured records of 19,383 patients who received services over a 6½ -years' period. We analyzed the data to calculate the total number of patient encounters, the number of encounters with an IVC, and the number of encounters with an IVC that was overturned. For encounters with an overturned IVC, we also determined the patient discharge disposition. We estimated the cost of a typical mental health hospitalization to measure the savings generated by the overturned IVCs in the NC-STeP program. Over the 6½ year period there were 19,383 NC-STeP patient encounters at partner hospital emergency departments. There were 13,537 encounters where the patient had an IVC in place during the ED stay, and 4,627 where the IVC was overturned (34 %). For patients where there was an IVC that was overturned, 85.9 % of those patients were ultimately discharged home. Using the "three-way bed" cost estimate of $ 4,500 for each overturned IVC, the cost savings generated by the NC-STeP program from November 2013 to June 2020 were $ 20,821,500. Telepsychiatry consultation services in the emergency departments can decrease unnecessary psychiatric hospitalizations and contribute to significant cost savings to the healthcare system and society and improve the outcomes for patients and families by decreasing financial burden and stress associated with a hospital stay.

Abstract 14234: Stroke Center Volume, Not Accreditation Status, is Associated With Outcomes of Stroke Patients Treated by Mechanical Thrombectomy

Introduction: In the USA, endovascular capable stroke centers (ECC) that perform mechanical thrombectomy (MT) for large vessel stroke can be accredited by a number of agencies. However, there remains little evidence on recommendations for minimum case volume required for centers to maintain competency. Hypothesis: Clinical outcomes (namely hospital mortality and home discharge disposition) of stroke patients treated by MT are associated with center volume but not accreditation status. Methods: We obtained nationwide MedPAR data from the Center for Medicare and Medicaid Services (CMS) for 2017 and 2018. Endovascular MT cases were identified using ICD 10 codes. A list of ECCs was obtained from the Joint Commission, HFAP, DNV, and State Health Departments and was cross-referenced with a list of accredited centers. Independent t-tests were used to compare the mean rates of mortality and home discharge between accredited and non-accredited centers. Pearson’s correlation was used to test the association of annual case volume (in 10 groups in logarithmic increments from minimum to maximum) with the rates of mortality and home discharge. Results: In 2017 and 2018, we identified 29,536 cases of MT that were performed at 847 centers (of which 354 were accredited) across the USA. There was no significant difference between accredited and non-accredited centers with regard to hospital mortality (14.8% vs. 14.5%, p-value=0.34) and home discharge disposition (12.1% vs. 12.0%, p-value=0.78). Hospital mortality was significantly negatively correlated with center volume (r=-0.83, 95%CI=-0.96 to -0.44, p-value=0.003), whereas home discharge disposition was significantly positively correlated with center volume (r=0.68, 95%CI=0.09 to 0.92, p-value=0.030). Conclusions: Accreditation showed no correlation to clinical outcomes. However, increasing volume of MT cases in ECCs correlated to increasing mortality and decreasing rate of home discharge.

National Trends in Post-Acute Care Costs Following Total Hip Arthroplasty from 2010 through 2018.

Post-acute care remains a target for episode-of-care cost reduction following total hip arthroplasty (THA). The introduction of bundled payment models in the United States in 2013 aligned incentives among providers to reduce post-acute care resource utilization. Institution-level studies have shown increased rates of home discharge with substantial cost savings after adoption of bundled payment models; however, national data have yet to be reported. The purpose of this study was to evaluate national trends in post-acute care utilization and costs following primary THA over the last decade. We reviewed the cases of 189,847 patients undergoing primary THA during 2010 through 2018 from the PearlDiver database. Annual trends in patient demographics, discharge disposition, and post-acute care resource utilization were evaluated. Post-acute care reimbursements were standardized to 2020 dollars and included outpatient visits, prescriptions, physical therapy, home health, inpatient rehabilitation, skilled nursing facilities, and any rehospitalizations or emergency department (ED) visits within 90 days of surgery. From 2010 to 2018, the mean episode-of-care costs ($31,562 versus $24,188; p < 0.001) and overall post-acute care costs ($5,903 versus $3,485; p < 0.001) both declined. Post-acute care savings were primarily driven by reduced costs of skilled nursing facilities ($1,533 versus $627; p < 0.001), home health ($1,041 versus $763; p = 0.002), inpatient rehabilitation ($949 versus $552; p < 0.001), ED visits ($508 versus $102; p < 0.001), and rehospitalizations ($367 versus $179; p < 0.001). Post-acute care costs declined by $578 (p = 0.025) during 2010 to 2012, $768 (p = 0.038) during 2013 to 2015, and $884 (p = 0.020) during 2016 to 2018. Over the last decade, the rate of home discharge after THA increased while rehospitalization and ED visit rates declined, resulting in a substantial decrease in total and post-acute care costs. Post-acute care costs declined most rapidly after the introduction of the new Medicare bundled payment programs in 2013 and 2016.

Early Physical and Occupational Therapy and Discharge Disposition in Patients with Sepsis

<h3>Research Objectives</h3> To explore whether implementing an early mobility protocol conducted by professionals from PT and or occupational therapy (OT) is associated with discharge location for a group of patients with sepsis, septic shock, or severe sepsis. <h3>Design</h3> A quasi-experimental study design was used with a non-equivalent post-test design. The data were collected for 3 months. <h3>Setting</h3> Mid-sized Midwestern hospital. <h3>Participants</h3> The population of the usual care group were 117 adult patients admitted to any unit with a diagnosis of sepsis, septic shock, or severe sepsis from February 1, 2019, through April 30, 2019. The early rehabilitation group were 96 patients admitted May 6, 2019 through July 31, 2019. <h3>Interventions</h3> The usual care group received PT and OT when an order was received from the hospital medicine provider. The experimental group were treated with PT and OT per an early rehabilitation protocol. <h3>Main Outcome Measures</h3> The dependent variables were number of PT and OT visits and discharge disposition. <h3>Results</h3> There was no statistically significant (p < 0.05) difference found between the groups for PT treatments (t(131) = -0.307, p = 0.760) nor for the OT treatments (t (104) = 0.925, p = 0.357). The mean number of PT and OT visits in each group were approximately the same as well (PT visits 3.86, SD = 3.83 vs. 4.05 visits, SD = 3.302; OT visits, 3.85, SD = 3.764 vs. 3.25, SD = 2.855; Table 2). The data demonstrated that the patients who received PT and OT were significantly more likely to be discharged to home/home health care (p = 0.029 for PT, p = 0.047 for OT) rather than to inpatient healthcare services (See Table 3). <h3>Conclusions</h3> This study demonstrates that the inclusion of PT and OT treatment in the care of patients with sepsis-related illness admitted to the hospital may influence their discharge disposition. The majority of the patients in this study were able to discharge to home. <h3>Author(s) Disclosures</h3> The author, Karen Clark, does not have any conflicts of interest in regards to this study.