Early Post-discharge Follow-up Research Articles

Primary care follow-up improves outcomes in older adults following emergency general surgery admission

BACKGROUND While preoperative optimization improves outcomes for older adults undergoing major elective surgery, no such optimization is possible in the emergent setting. Surgeons must identify postoperative interventions to improve outcomes among older emergency general surgery (EGS) patients. The objective of this cohort study was to examine the association between early follow-up with a primary care physician (PCP) and the risk of nursing home acceptance or death in the year following EGS admission among older adults. METHODS Using population-based administrative health data in Ontario, Canada (2006–2016), we followed all older adults (65 years or older) for 1 year after hospital admission for EGS conditions. A multivariable Cox model was used to identify the association between early postdischarge follow-up with a patient's PCP and the time to nursing home acceptance or death while adjusting for confounders. RESULTS Among 76,568 older EGS patients, 32,087 (41.9%) were seen by their usual PCP within 14 days of discharge, and 9,571 (12.5%) were accepted to a nursing home or died within 1 year. Primary care physician follow-up was associated with a 13% reduced risk of nursing home acceptance or death compared with no follow-up (hazard ratio 0.87; 95% confidence interval 0.84–0.91). This effect was consistent across age and frailty strata, patients managed operatively and nonoperatively, and patients who had both high and low baseline continuity of care with their PCP. CONCLUSION Early follow-up with a familiar PCP was associated with a reduced risk of nursing home acceptance or death among older adults following EGS admission. Structures and processes of care are needed to ensure that such follow-up is routinely arranged at discharge. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.

ARDS with septic shock managed successfully using a multidisciplinary approach: A case report

Acute respiratory distress syndrome (ARDS) is an inflammatory process in the lungs that results in hypoxemia and decreased lung compliance. Invasive mechanical ventilation and prone positioning have proven benefits in the management of patients with severe ARDS. Post-extubation rehabilitation programs are equally important for the recovery of these patients. We are reporting the case of a 30-year-old male with severe ARDS where lung protective ventilation, timely intubation, early prone positioning, multidisciplinary communication, and post-discharge follow-up with teleconsultation were used under expert supervision in the successful management of the case.

Postdischarge telephone follow-up among chronic disease patients discharged from a vascular surgery service: a best practice implementation project.

To improve postdischarge telephone follow-up in the context of chronic disease management (peripheral artery disease), in a vascular surgery service. Patients with chronic diseases, such as peripheral artery disease, present a higher risk of complications and greater constraints regarding their adherence to treatment, leading to an increasing mortality rate and decreased functional capacity. Comprehensive discharge planning plus postdischarge telephone follow-up may reduce 30-day re-hospitalization rates. The project used the JBI audit and feedback methodological approach to implement the best available evidence into practice. Two audit criteria were used: existence of comprehensive discharge planning and timely telephone follow-up. A baseline audit was conducted, followed by analysis of barriers, which led to the implementation of several strategies, namely, a targeted training program, the development of educational resources and standardized procedures for the discharge process, and postdischarge telephone follow-up. Results from the baseline and first follow-up audits showed improvement for both criteria. Compliance for criterion 1 (comprehensive discharge planning, including postdischarge telephone follow-up) increased from 0% to 40.7%, and for criterion 2 (patient is followed up by telephone within 2 weeks of discharge) increased from 0% to 44.4%. These two criteria sustained improvements in the second follow-up audit: compliance increased to 45% (criterion 1) and 60% (criterion 2). This implementation project contributed to the optimization of the chronic disease management, including improved compliance with discharge planning and early postdischarge telephone follow-up.

How to interpret a negative high-resolution pulse oximetry in hospitalized patients screened for obstructive sleep apnea: an exploratory analysis.

Obstructive sleep apnea (OSA) is a highly prevalent disorder that often is unrecognized. Recently, a novel protocol for screening hospitalized patients for OSA resulted in early initiation of positive airway pressure (PAP) therapy and early post-discharge follow-up. The protocol utilizes a combination of high-resolution pulse oximetry (HRPO) and home sleep apnea tests (HSATs); the former has been well-validated in previous studies against HSAT and polysomnography. While a definitive treatment plan can be generated for patients with a positive HRPO for OSA, it is less clear how best to manage patients with a negative HRPO. A retrospective analysis of a registry of patients screened for OSA was conducted. Consecutive patients with HRPO-derived ODI (oxygen desaturation index) < 5/h who underwent same-night HRPO and HSAT were identified. The demographic and clinical characteristics of patients with ODI < 5/h and AHI (apnea hypopnea index) < 5/h were compared with patients with ODI < 5/h and AHI ≥ 5/h. The analysis revealed 190 patients with ODI < 5/h. Only 23 (12%) of these patients had AHI ≥ 5/h. When compared with patients who had ODI < 5/h and AHI < 5/h, there was no difference in most testing and patient characteristics. However, antiplatelet use and total time in minutes with saturation < 88% greater than 100min were associated with a higher likelihood of discordant ODI and AHI. HRPO-derived ODI has a low rate of false negativity. Clinicians should be aware of the possibility of a false negative ODI for patients with antiplatelet use and time with saturation < 88% greater than 100min and antiplatelet therapy.

A multidisciplinary program based on early care in a day hospital after heart failure hospitalizations. Reduction of 30-day readmissions in patients discharged from cardiology departments

Abstract Introduction and objectives Readmission rates at 30 days after admission for heart failure (HF) are high. Patients admitted in Cardiology are usually younger and with lower comorbidity than the total population with HF. Our department leads a multidisciplinary program for the management of HF (MHFP), based on early post-discharge follow-up in a day hospital, for clinical-analytical assessment, optimization and titration of pharmacological treatment, structured education, promotion of self-care and intravenous treatment if appropriate. The objective of this study is to assess the impact of the MHFP on all cause 30-day readmission rate in our patients (MHFP group), compared with the rest of the Cardiology units in our region (control group). Methods All discharges with HF main diagnosis in our region were analyzed through anonymized consultation of the Minimum Basic Data Set (a public administrative data base) in the period 2009–2015. The first admission of each patient in the period was identified as index admission, excluding patients who died at that admission and selecting only discharges by Cardiology. Epidemiological characteristics, comorbidities and hospital length of stay were compared in the two groups. The outcome variable was the time to first readmission for any cause in the first 30 days after discharge from index admission. Quantitative variables were compared using Student's t and categorical variables with χ2. For the multivariate analysis, Cox method was used. Results We included 15,440 patients, 474 in the MHFP group and 14,966 in the control group. The epidemiological characteristics and main comorbidities were compared, and the results are shown in the table. Readmission rate was significantly lower in the MHFP group (9.9 vs 14.2%, HR 0.72, 95% CI: 0.54–0.96 in multivariate analysis). The variables independently associated with an increase in 30-day readmissions were the age-adjusted Charlson index and chronic kidney disease. Conclusions Over a period of 6 years, in patients with HF, discharged by Cardiology, a MHFP significantly reduced all cause 30-day readmissions. Funding Acknowledgement Type of funding sources: None.

A multidisciplinary program based on early follow-up in a day hospital after heart failure hospitalizations. Reduction of 30-day readmissions in a population analysis over a 6-year period

Abstract Introduction and objectives Readmission rates at 30 days after heart failure (HF) hospitalizations are high. Disease management programs have shown to reduce them; however, the results of clinical trials are difficult to extrapolate to the entire population with HF. Our hospital has a multidisciplinary program for HF management (MHFP) led by the Cardiology Department, based on early post-discharge follow-up in a day hospital, for clinical-analytical assessment, optimization and titration of pharmacological treatment, structured education, promotion of self-care and intravenous treatment if appropriate. The objective of this study is to assess the impact of the MHFP on our patients all cause 30-day readmission rate (MHFP group), compared with the rest of our region (control group). Methods All discharges with HF as main diagnosis in our region were analysed through anonymized consultation of the Minimum Basic Data Set (an administrative public data base) in the period 2009–2015. The first admission of each patient in the period was identified as index admission. Patients who died in the index admission were excluded. Epidemiological characteristics, comorbidities and hospital stay were compared in the two groups. The outcome variable was the time to first readmission in the first 30 days after discharge. Quantitative variables were compared using Student's t and categorical variables with χ2. Cox method was used for multivariate analysis. Results We included 62,162 patients, 1,447 in the MHFP group and 60,715 in the control group. Epidemiological characteristics and main comorbidities were compared, and the results are shown in the table. Readmission rate was significantly lower in the MHFP group (13.5 vs 16%, HR 0.85, 95% CI 0.74–0.98 in multivariate analysis). The variables independently associated with an increase in readmissions at 30 days were age adjusted Charlson index, hospital length of stay in index admission and several comorbidities (obstructive pulmonary disease, myocardial infarction, and renal failure) Conclusions Over a period of 6 years, a MHFP significantly reduced 30-day readmissions after admission for HF, in its reference area. The generalization of these programs could have a relevant impact on costs reduction. Funding Acknowledgement Type of funding sources: None.

Coordination of Oral Anticoagulant Care at Hospital Discharge (COACHeD): protocol for a pilot randomised controlled trial

BackgroundOral anticoagulants (OACs) are commonly prescribed, have well-documented benefits for important clinical outcomes but have serious harms as well. Rates of OAC-related adverse events including thromboembolic and hemorrhagic events are especially high shortly after hospital discharge. Expert OAC management involving virtual care is a research priority given its potential to reach remote communities in a more feasible, timely, and less costly way than in-person care. Our objective is to test whether a focused, expert medication management intervention using a mix of in-person consultation and virtual care follow-up, is feasible and effective in preventing anticoagulation-related adverse events, for patients transitioning from hospital to home.Methods and analysisA randomized, parallel, multicenter design enrolling consenting adult patients or the caregivers of cognitively impaired patients about to be discharged from medical wards with a discharge prescription for an OAC. The interdisciplinary multimodal intervention is led by a clinical pharmacologist and includes a detailed discharge medication reconciliation and management plan focused on oral anticoagulants at hospital discharge; a circle of care handover and coordination with patient, hospital team and community providers; and early post-discharge follow-up virtual medication check-up visits at 24 h, 1 week, and 1 month. The control group will receive usual care plus encouragement to use the Thrombosis Canada website.The primary feasibility outcomes include recruitment rate, participant retention rates, trial resources management, and the secondary clinical outcomes include adverse anticoagulant safety events composite (AASE), coordination and continuity of care, medication-related problems, quality of life, and healthcare resource utilization. Follow-up is 3 months.DiscussionThis pilot RCT tests whether there is sufficient feasibility and merit in coordinating oral anticoagulant care early post-hospital discharge to warrant a full sized RCT.Trial registrationNCT02777047.

606. Implementation of a Telehealth-based OPAT Early Post-Discharge Clinic May Reduce Hospital Readmission

BackgroundRecent studies suggest that early post-discharge follow-up for patients receiving outpatient parenteral antimicrobial therapy (OPAT) reduces readmission rates. We report our experience implementing a telehealth-based clinic to facilitate early (1-2 week) follow-up for selected OPAT patients perceived to be at high risk for readmission.MethodsWe identified patients who met criteria for and completed a supplemental OPAT telehealth visit following the initial seven months after implementation of this clinic (11/1/20 – 5/31/21). Clinical criteria triggering intake of patients for these visits included: endovascular or cardiac device-related infection; treatment with vancomycin, oxacillin/nafcillin, or aminoglycosides; ≥2 prior hospitalizations within past 1 year; treating Infectious Disease or OPAT team’s subjective assessment of high readmission risk. Patients planned for < 14 days of OPAT therapy were excluded. Categorical variables were compared using a Chi-square test at the α=0.05 level of significance.ResultsA total of 49 patients completed a telehealth visit; mean time from discharge to telehealth visit was 12.1 days (SD +/- 3.9). An intervention was made in 27% of these visits (13 of 49 patients), most commonly involving attempted mitigation of an adverse event or line-related complication (7 cases). The all-cause, 30-day readmission rate for this cohort was 6.1% (3 of 49 patients), while the rate for OPAT patients who did not receive an early telehealth visit during the same period was 22.7% (52 of 229 patients) which was statistically significant (p=0.008). This association of benefit was also found when comparing infection-related, 30-day readmission rates (0% vs 7.4%, p=0.049).ConclusionImplementation of OPAT telehealth encounters for high-risk patients resulted in a high rate of intervention to mitigate adverse events of OPAT therapy. Readmission occurred less than one-third as frequently in the telehealth group compared to patients with no early follow-up visit. Telehealth-based encounters appear comparable in effectiveness to those previously reported utilizing in-person visits, introducing efficiencies that may allow for broader implementation of this intervention.Disclosures Nicolas W. Cortes-Penfield, MD, Nothing to disclose Bryan Alexander, PharmD, Astellas Pharma (Advisor or Review Panel member)

Early Risk of Readmission Following Hospitalization for Reversible Cerebral Vasoconstriction Syndrome.

For evaluation of 90-day readmissions after an inpatient admission for reversible cerebral vasoconstriction syndrome (RCVS), hospitalizations due to RCVS were identified from the Nationwide Readmissions Database from 2016 to 2017. The primary outcome of interest was nonelective readmission within 90 days of index hospitalization discharge. Survival analysis was performed, and multivariable Cox proportional hazards regression was used to determine the factors associated with readmission. Among the 1,157 hospitalizations due to RCVS during the study period (mean ± SD age 48.6 ± 16.1 years, women 76.4%), 164 (14.2%) patients had nonelective readmission within 90 days of discharge. The most common reasons for readmissions included acute cerebrovascular events (18.9%), continued or recurrent symptoms of RCVS (13.4%), infections (11.6%), and headache (9.8%). Diabetes, history of tobacco use, opioid use, and longer length of index hospitalization were independent predictors of 90-day readmission. For readmissions, the mean (SD) length of stay was 5.2 (6.1) days, and the mean (SD) cost per hospitalization was $14,214 ($15,140). There was no in-hospital mortality; however, 37.2% of patients were not discharged to home. Nearly 14% of patients with RCVS are readmitted within 90 days of discharge, and a significant proportion of these readmissions are due to the ongoing/recurrent symptoms or neurologic sequelae of RCVS. Given that these patients are at a risk of early recurrence/worsening of their symptoms, an early postdischarge follow-up plan may need to be integrated into their care.

Abstract 15017: Early Post-discharge Follow-up Delay After Hospitalization for Heart Failure With Preserved Ejection Fraction Reduces Readmission for Heart Failure in the Following Year

Introduction: Early physician follow-up after hospital discharge for acute decompensated heart failure (ADHF) is recommended by the AHA to prevent early hospital readmission. This recommendation has not been specifically evaluated for heart failure with preserved ejection fraction (HFpEF). Hypothesis: Earlier follow-up should lead to decrease in readmissions for ADHF in the HFpEF population even when adjusting for confounding factors. Methods: Consecutive ADHF hospitalisation that occurred inclusively between 2015 and 2018 were reviewed. Main inclusion criterion was left ventricular ejection fraction ≥45%. The major exclusion criteria were: severe valvulopathy, hypertrophic cardiomyopathy, acute coronary syndrome 3 months before hospitalisation, chronic kidney failure (eGFR &lt;30 ml/min), severe chronic respiratory disease and death before discharge. Follow-up delay after discharge was dichotomized (early vs late/no follow up) by using the median delay. Main outcome was hospital readmission in the year following discharge. Multivariate logistic regression was performed for main outcome according to follow-up delay and adjusted for age, sex, medication at discharge and major comorbid conditions. Results: A total of 163 heart failure readmission (37% of patients) occurred in 438 patients in the year following the first hospitalisation. Median readmission delay was of 62 days. Median dedicated follow-up delay was 30 days and was arranged in 68% of cases. After adjusting for confounding variables, early follow-up was significantly associated with fewer readmission (adjusted odds ratio 0.57, 95% CI; 0.34-0.97). Conclusions: Early dedicated follow-up after discharge for HFpEF was associated with fewer readmission over the year following discharge even when adjusting for major confounding variables.

The Effect of Transitional Care on 30-Day Outcomes in Patients Hospitalised With Acute Heart Failure

Patients admitted to hospital with acute heart failure (AHF) are at increased risk of readmission and mortality post-discharge. The aim of the study was to examine health service utilisation within 30 days post-discharge from an AHF hospitalisation. This was a prospective, observational, non-randomised study of consecutive patients hospitalised with acute HF to one of 16 Victorian hospitals over a 30-day period each year and followed up for 30 days post-discharge. The project was conducted annually over three consecutive years from 2015 to2017. Of the 1,197 patients, 56.3% were male with an average age of 77±13.23 years. Over half of the patients (711, 62.5%) were referred to an outpatient clinic and a third (391, 34.4%) to a HF disease management program. In-hospital mortality was 5.1% with 30 day-mortality of 9% and readmission rate of 24.4%. Patients who experienced a subsequent readmission less than 10 days post-discharge and between 11 and 20 days post-discharge had a five- to six-fold increase in risk of mortality (adjusted OR 5.02, 95% CI 2.11-11.97; OR 6.45, 95% CI 2.69-15.42; respectively) compared to patients who were not readmitted to hospital. An outpatient appointment within 30 days post-discharge significantly reduced the risk of 30-day mortality by 81% (95% CI 0.09-0.43). Patients admitted to hospital with AHF who experience a subsequent readmission within 20 days post-discharge are at increased risk of dying. However, early follow-up post-discharge may reduce this risk. Early post-discharge follow-up is vital to address this vulnerable period after a HF admission.

ESTABLISHMENT OF A RAPID ACCESS HEART FAILURE CLINIC TO REDUCE HOSPITAL READMISSIONS

Heart failure (HF) is the most common cause of hospitalization in patients over the age of 65, and hospitalization due to HF represents the single most costly aspect of HF management. Therefore, reducing heart failure admissions has become a critical goal in the management of HF from both a patient and societal perspective. Despite major advances in HF management, the recently published PACT-HF trial still demonstrated a 20% 30-day all cause re-admission rate. This study examined whether patients evaluated by a HF cardiologist in a very early post-discharge HF follow-up clinic, called the quick Heart Failure (qHF) clinic, had a lower than predicted 30-day readmission rate.

Early Pulmonary Vascular Disease in Preterm Infants Is Associated with Late Respiratory Outcomes in Childhood.

Early pulmonary vascular disease (PVD) after preterm birth is associated with a high risk for developing bronchopulmonary dysplasia (BPD), but its relationship with late respiratory outcomes during early childhood remains uncertain. To determine whether PVD at 7 days after preterm birth is associated with late respiratory disease (LRD) during early childhood. This was a prospective study of preterm infants born before 34 weeks postmenstrual age (PMA). Echocardiograms were performed at 7 days and 36 weeks PMA. Prenatal and early postnatal factors and postdischarge follow-up survey data obtained at 6, 12, 18, and 24 months of age were analyzed in logistic regression models to identify early risk factors for LRD, defined as a physician diagnosis of asthma, reactive airways disease, BPD exacerbation, bronchiolitis, or pneumonia, or a respiratory-related hospitalization during follow-up. Of the 221 subjects (median, 27 wk PMA; interquartile range, 25-28 and 920 g; interquartile range, 770-1090 g) completing follow-up, 61% met LRD criteria. Gestational diabetes and both mechanical ventilator support and PVD at 7 days were associated with LRD. The combination of PVD and mechanical ventilator support at 7 days was among the strongest prognosticators of LRD (odds ratio, 8.1; confidence interval, 3.1-21.9; P < 0.001). Modeled prenatal and early postnatal factors accurately informed LRD (area under the curve, 0.764). Adding BPD status at 36 weeks PMA to the model did not change the accuracy (area under the curve, 0.771). Early echocardiographic evidence of PVD after preterm birth in combination with other perinatal factors is a strong risk factor for LRD, suggesting that early PVD may contribute to the pathobiology of BPD.

Abstract 118: Impact of an Early HF Discharge Follow-up Intervention on 30-Day Outcomes in a Veterans Hospital

Objective: Rehospitalizations occur in 25% of HF patients. We implemented an intervention to improve HF outcomes by focusing on early post-discharge follow-up. We conducted a pre- and post-intervention analysis to determine if the intervention was associated with improved 30-day HF composite outcome, defined as 30-day all-cause ED visit, all-cause rehospitalization, or death. Methods: In 2011, we created an intervention in which the discharge team was asked to refer all HF patients to HF clinic follow-up within 14 days. Patients were given an appointment prior to hospital discharge and received contact information for a HF nurse. In the post-intervention period, patients were seen by a NP or HF cardiologist, whereas in the pre-intervention period patients were seen by any cardiology provider. The study sample consisted of patients with a discharge diagnosis of HF hospitalized within 6 months before (‘pre-intervention’) or within 6 months after the intervention (‘post-intervention’) began. Clinical variables were collected including demographics, vital signs, lab values, and LVEF. We censored hospice patients. Descriptive statistics and incidence of individual and composite outcomes were calculated. Hospital utilization at outside hospitals was not available. We created a Cox proportional hazards model to evaluate the effect of the intervention on the 30-day composite outcome, adjusted for clinical predictors associated with the outcome (p&lt;0.1). Findings: 261 patients were studied (pre-intervention, n=142; post-intervention, n=119). Patients were male (99%), white (71%), with a mean age of 70 years. 65% of patients had LVEF ≤ 40%. Only BNP was different between the pre- and post-groups, respectively ((median 1212 [IQR, (613-2752)] vs. 990 [IQR, (426-1726]), p=.04)). 40% of intervention group was referred for cardiology follow-up within 7 days versus 12% of the pre-intervention group (p&lt;.001), with medians of 6 days (IQR [5,9)] and14 days (IQR [8,20] p&lt;.001), respectively. There was a trend towards lower unadjusted 30-day composite outcome incidence in the intervention group (p=.15). After adjustment for clinical predictors, the post-intervention period was associated with a reduced hazard of the 30-day composite endpoint (HR 0.56, 95%CI [0.33,0.94], p=.03). Discussion: The transitional HF care intervention was associated with a reduced risk of all-cause ED visit, all-cause rehospitalization, or death. This analysis confirms the importance of establishing a systematic follow-up program for all HF patients that bridges the transition from hospital to home.

Impact of Hospital Readmissions on Subsequent Mortality: a Temporal Trend Analysis of Hospital Admissions for Acute Heart Failure

Background: Patients admitted to hospital with acute heart failure (AHF) are at increased risk of readmission and mortality post-discharge. This study assessed the impact of hospital readmissions on subsequent mortality rates in patients discharged from hospital with AHF. Methods: Sixteen Victorian hospitals participated in a prospective statewide HF snapshot of patients admitted to hospital with AHF over one month and followed up for 30 days post-discharge. The project was conducted annually over three consecutive years from 2015–2017. Results: Of the 1197 patients, 56.3% were male with an average age of 77 years (SD 13.17 years). Hypertension, chronic renal disease and atrial fibrillation were the most common comorbidities (75.2%, 64% and 54.7%, respectively). Overall 50.4% of patients were admitted to General Medicine and 33.9% to Cardiology. In-hospital mortality rate was 5.1% with 30 day-mortality of 4.2% and readmission rate of 24.4%. Patients who experienced a subsequent readmission within 10 days of discharge from index hospitalisation had a 4.6-fold increase in risk of mortality (adjusted HR 4.6, 95% CI 2.16–9.81) compared to patients who were not readmitted and patients readmitted within 11–20 days post-discharge had a 4.3-fold increase in risk of mortality (adjusted HR 4.36, 95% CI 2.04–9.27). Conclusion: Patients admitted to hospital with AHF who experience a subsequent readmission within 20 days post-discharge are at increased risk of dying. It is vital that early post-discharge follow-up within 20 days is implemented to address this vulnerable period after an HF admission.

Outcomes of a Transitional Care Clinic to Reduce Heart Failure Readmissions at an Urban Academic Medical Center.

Heart Failure (HF) is one of the leading hospital readmission diagnoses in the United States. It is a major challenge in today’s healthcare environment to reduce hospital readmissions for HF and much of the expenditure on HF is on in-hospital treatment. In the USA, risk factors for readmission with HF include being African American, low-socioeconomic status, Medicare, Medicaid, self-pay/no insurance and drug abuse. The Transitional Care Clinic (TCC) model established at our institution integrated multiple facets of chronic HF management, including early post-discharge follow-up, phone call reminders as well as clinical pharmacists and nurse practitioner’s integration into the treatment team.Of 488 HF admissions to our institution from March 2015 until May 2017, mean age = 65 years (SD 13.03), 262 patients were males (53.6%) and 463 patients (94%) were Blacks. There was a total of 121 readmissions within 30 days after discharge (24.8%) and 43 readmissions 7 days after discharge (8.81%) during our study period. 159 patients (32.58%) followed up in our TCC, while 329 patients (67.41%) did not at TCC. Within 7 days post discharge, there was 3 (1.9%) Vs 40 (12.2%) readmissions for TCC and non-TCC groups respectively, P<0.01. There was 18 (11.32%) Vs 103(31.31%) readmissions within 30 days post discharge for TCC and non-TCC groups respectively P<0.01.Among high readmission risk and predominantly black population with HF, TCC resulted in significantly lower hospital readmission rate within 7 days and within 30 days of initial discharge. These data help inform policy makers regarding the effectiveness of TCC model for resource allocation and broader implementation, particularly among high risk population with the potential of cost saving and better patient outcomes.

Readmission and complications within 30days after intrathecal baclofen pump placement.

To describe 30-day outcomes after intrathecal baclofen (ITB) pump placement in children and identify risk factors for readmission, reoperation, and perioperative complication using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database. Patients aged 0 to 18years who underwent ITB pump placement (2012-2014) comprised the study cohort defined in the database. Multivariate regression analysis was performed using preoperative and perioperative data from the American College of Surgeons' NSQIP-P database. Outcomes of interest within 30 days of surgery were (1) unplanned reoperation; (2) unplanned readmission; and (3) composite postoperative event, including complication, reoperation, and/or readmission. We identified 423 surgeries; 246 (58.2%) patients were male, 177 (41.8%) patients were female. Median age was 12years and 11months. Median operative time was 70minutes (interquartile range 56-97min). Mean length of stay was 3.8days. The patient population had a high number of medical comorbidities. The overall readmission rate was 7.3%; mean postoperative admission date was 14.1days after surgery. Of readmitted patients, 64.5% underwent reoperation. The most common indication for reoperation was surgical site infection. Female sex was associated with decreased risk of readmission (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.09-0.65; p=0.01); American Society of Anesthesiologists Classification of greater than or equal to 3 was associated with decreased risk of unplanned return to surgery (OR 0.26, 95% CI 0.11-0.66; p=0.04); length of stay greater than or equal to 3days at index surgery was associated with increased risk of composite 30-day perioperative event (OR 2.33, 95% CI 1.29-4.20; p=0.01). Our data provide national perspectives on 30-day perioperative outcomes for ITB pump placement in children. Results illustrate NSQIP-P database collection methodology and highlight opportunities for quality improvement in clinical practice. Seven percent of patients who underwent intrathecal baclofen pump placementrequired readmission within 30days. The most common indication for reoperation was surgical site infection.

ANMCO/SIC Consensus Document: cardiology networks for outpatient heart failure care

Changing demographics and an increasing burden of multiple chronic comorbidities in Western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of- hospital phases of HF. In Italy, as well as in other countries, needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for acute hospitalized HF and those followed-up at HF clinics.The Italian Working Group on Heart Failure has drafted a guidance document for the organisation of a national HF care network. Aims of the document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among health-care professionals.The document classifies HF outpatient clinics in three groups: (i) community HF clinics, devoted to management of stable patients in strict liaison with primary care, periodic re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, (ii) hospital HF clinics, that target both new onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for general internal medicine units and community clinics, and (iii) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. Those different types of HF clinics are integrated in a dedicated network for management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multi-professional providers to ensure continuity of care and patient empowerment.In conclusion, This guidance document details roles and interactions of cardiology specialists, so as to best exploit the added value of their input in the care of HF patients and is intended to promote a more efficient and effective organization of HF services.

Impact of a Pharmacist-Managed Heart Failure Postdischarge (Bridge) Clinic for Veterans.

Hospitals that provide early postdischarge follow-up after heart failure (HF) hospitalization tend to have lower rates of readmission. However, HF postdischarge (bridge) clinics have not been extensively evaluated. To assess the impact of a pharmacist-managed HF bridge clinic in a veteran population. HF patients hospitalized from November 2010 to August 2013 were identified. Retrospective chart review was conducted of 122 HF patients seen at bridge clinic compared with 122 randomly selected HF patients not seen at this clinic (usual care). Primary end point was 90-day all-cause readmission and death. Secondary outcomes were 30-day all-cause readmission and death, time to first postdischarge follow-up, first all-cause readmission. Bridge clinic patients were at higher baseline risk of readmission and death; other characteristics were similar. 90-day death and all-cause readmission trended lower in bridge clinic patients (adjusted hazard ratio [HR] = 0.64; 95% CI = 0.40-1.02; P = 0.06). Time to first follow-up was shorter in bridge clinic patients (11 ± 6 vs 20 ± 23 days; P < 0.001); time to first all-cause readmission trended longer (40 ± 20 vs 33 ± 25days; P = 0.11). 30-day death and all-cause readmission was significantly lower in bridge clinic patients (adjusted HR = 0.44; 95% CI = 0.22-0.88; P = 0.02). In veteran patients hospitalized for HF, pharmacist-managed HF bridge clinic significantly reduced the time to initial follow-up compared with usual care. Improved short-term outcomes and trend toward improvement of longer-term outcomes in bridge clinic patients was shown.

Relationship between Early Physician Follow-Up and 30-Day Readmission after Acute Myocardial Infarction and Heart Failure.

BackgroundThirty-day readmission rates after acute myocardial infarction (AMI) and heart failure are important patient outcome metrics. Early post-discharge physician follow-up has been promoted as a method of reducing 30-day readmission rates. However, the relationships between early post-discharge follow-up and 30-day readmission for AMI and heart failure are inconclusive. We used nationwide population-based data to examine associations between 7-day physician follow-up and 30-day readmission, and further associations of 7-day same physician (during the index hospitalization and at follow-up) and cardiologist follow-up with 30-day readmission for non-ST-segment-elevation myocardial infarction (NSTEMI) or heart failure.MethodsWe analyzed all patients 18 years or older with NSTEMI and heart failure and discharged from hospitals in 2010 in Taiwan through Taiwan’s National Health Insurance Research Database. Cox proportional hazard models with robust sandwich variance estimates and propensity score weighting were performed after adjustment for patient and hospital characteristics to test associations between 7-day physician follow-up and 30-day readmission.ResultsThe study population for NSTEMI and heart failure included 5,008 and 13,577 patients, respectively. Early physician follow-up was associated with a lower hazard ratio of readmission compared with no early physician follow-up for patients with NSTEMI (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.39–0.57), and for patients with heart failure (HR, 0.54; 95% CI, 0.48–0.60). Same physician follow-up was associated with a reduced hazard ratio of readmission compared with different physician follow-up for patients with NSTEMI (HR, 0.56; 95% CI, 0.48–0.65), and for patients with heart failure (HR, 0.69; 95% CI, 0.62–0.76).ConclusionsFor each condition, patients who have an outpatient visit with a physician within 7 days of discharge have a lower risk of 30-day readmission. Moreover, patients who have an outpatient visit with the same physician within 7 days of discharge have a much lower risk of 30-day readmission.