Frequent Readmissions Research Articles

OC-105 PARASTOMAL HERNIA REPAIRS: A RETROSPECTIVE NATIONAL COHORT STUDY IN THE REPUBLIC OF IRELAND

Abstract Aim In the context of improving colorectal cancer outcomes, post-survivorship quality of life has become an important outcome measure. Parastomal hernias and their associated morbidity remain largely under-reported and under-appreciated. Despite their burden, conservative management is common. This study aims to provide a national overview on the current trends in parastomal hernia repairs (PHRs). Material and Methods All PHRs performed in the country between 1/2017 to 7/2022 were identified retrospectively from the National Quality Assurance and Improvement System (NQAIS) database. Anonymised patient characteristics and quality indices were extracted for statistical analysis. Results A total of 565 PHRs, 64.1% elective and the remainder emergent, were identified across 27 hospitals. The 8 national colorectal units performed 67.3% of all repairs. While 42.3% of PHRs were standalone procedures, reversal of Hartmann's procedure was the commonest simultaneous procedure in the remainder. The median age, ASA and Charlson Co-Morbidity Index were 64 years (24–97), 3(1–5) and 3(0–48) respectively. Mean length of stay (LOS) was 16.2 days (SD=29.8). 29.0% of patients had at least 1 emergency readmission in 12 months, with a corresponding 12% 30-day readmission rate. Linear regression analysis associated ASA (95% CI 0.58–16.1, p<0.035) and emergency admissions (95% CI 5.9–25.5, P<0.002) with a significantly longer LOS, with the latter also associated with more frequent emergency re-admissions (95% CI 0.18–0.82, p<0.002). Conclusion Patients undergoing emergency PHR are subjected to longer stays and more frequent readmissions. A dedicated parastomal hernia registry will facilitate timely elective intervention, negating the undue morbidity and costs associated with emergency

Measured vs estimated renal function on cardiovascular outcomes in an acute heart failure population

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Complejo Hospitalario Universitario de Canarias, Tenerife -Spain. Background/Introduction HF syndrome is a highly prevalent disease which courses with frequent readmissions, mainly by Acute Heart Failure (AHF). Worsening renal function is associated with increased mortality in patients with HF. Therefore, an accurate and precise evaluation of renal function in patients with HF is crucial. The error of estimated GFR (eGFR) is wide and common, showing ±30% of variability compared to measured GFR (mGFR). However, there is no evidence on the error of the available formulas in reflecting real renal function and particularly the consequences of this error in patients with AHF. Methods This is a prospective pilot study comparing measured versus estimated renal function and its relationship with long-term cardiovascular (CV) outcomes in patients with AHF. A group of patients with AHF who required admission in the CICU were included. Plasma clearance of iohexol, a gold-standard method to mGFR was assessed at the same time as eGFR by five different creatinine- and cystatin c–based equations. The association between estimated or measured GFR and major CV outcomes was evaluated with univariate and multivariate logistic analysis and cox-survival analysis. The main outcome was the first onset of fatal and nonfatal major cardiovascular events during follow-up. Results A total of 90 patients were included. Average age was 66 (± 12 years) and 52 (57,8%) were male. A total of 53 patients (59%) had a cardiovascular event during follow-up, being fatal in 22 cases (41,5%). Other variables are shown in Table 1. None of eGFR was significantly associated with the primary outcome in the unadjusted analyses. In the adjusted regression models, mGFR was significantly associated (p 0,037) with major cardiovascular events when it was correlated with NTproBNP, BMI, LVEF and previous coronary artery disease. mGFR on admission predicts future CV events compared with eGFR based on creatinine or cystatin equations. eGFR overestimates renal function showing around ±20% variability of mGFR in our AHF population (Figure 1). Conclusions Frequently used eGFR formulas in our daily practice in AHF patients do not predict well long-term cardiovascular outcomes. Measured GFR in AHF admission predicts CV events, while eGFR reflects an important variability of the real renal function. Specific subpopulations of AHF may require better evaluation of renal function because it may have prognosis consequences.

Emergency Department Readmission for Early Pregnancy Concerns Among Patients Who Speak Spanish [ID: 1366721

INTRODUCTION: The purpose of this study was to compare readmission rates for early pregnancy concerns in the emergency department (ED) among patients that speak English versus Spanish as their primary language. METHODS: From January 1, 2020 to June 1, 2021, we conducted a chart review to identify pregnant patients presenting to the ED using ICD-10 codes for pregnancy and first-trimester diagnoses (n=383). Charts were excluded if pregnancy was beyond 13 weeks or an ultrasound-confirmed ectopic pregnancy. Readmission was a separate ED encounter during the first trimester of that same pregnancy. Preventable readmission was one that could have been prevented if the patient had received correct counseling, diagnosis, or management at the index admission. Our primary outcome was frequency of ED readmission among English versus Spanish speakers. This protocol was approved for IRB exemption by the University of Texas. RESULTS: Threatened abortion was the most common diagnosis among both groups. Readmissions were more frequent among Spanish speakers (40% versus 26% [P=.01]). Preventable readmissions were more common among Spanish speakers (31% versus 25%). The majority of preventable readmissions (81%) among Spanish speakers could have been prevented if correct management was offered, compared to 25% in English speakers (P=.03). CONCLUSION: Spanish and English speakers present with similar types of early pregnancy concerns, but Spanish speakers are not offered management of early pregnancy concerns at the same frequency. Standardization of care for early pregnancy concerns in the ED may help reduce language-based disparities in quality and equity of care.

Effects of Opioid-Limiting Legislation and Increased Provider Awareness on Postoperative Opioid Use and Complications After Hip Arthroscopy.

On August 31, 2017, Ohio passed legislation that regulates how opioids can be prescribed postoperatively. Studies have shown that such legislation is successful in reducing the morphine milligram equivalents (MMEs) prescribed after certain orthopaedic procedures. (1) To determine if the opioid prescription-limiting legislation in Ohio reduced the cumulative MMEs prescribed after hip arthroscopy without significantly affecting the rates of emergency department (ED) visits, hospital readmissions, and reoperations within 90 days postoperatively, and (2) to assess risk factors associated with increased postoperative opioid dosing. Cohort study; Level of evidence, 3. This study included patients who underwent primary and revision hip arthroscopy at a single institution over a 4-year period. The prelegislation (PRE) and postlegislation (POST) groups were defined as patients who underwent surgery before August 31, 2017, and on/after this date, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively, and patient medical records were reviewed to collect demographic, medical, surgical, and readmission data. Inverse probability weighting-adjusted mean treatment effect regression models were used to measure the difference in mean outcomes between the PRE and POST cohorts. A total of 546 patients (228 PRE, 318 POST) were identified. There was a 25% reduction in the cumulative MMEs prescribed to the POST group as compared with the PRE group during the first 90 days postoperatively (840 vs 1125 MME, respectively; P < .01). The legislation was associated with a significant decrease in the cumulative MMEs prescribed in the first 90 postoperative days (mean treatment effect = -280.6; P < .01), and there were no significant between-group differences in the frequency of ED encounters (8.8% PRE, 11.6% POST; P = .32), hospital readmissions (1.3% PRE, 0.9% POST; P = .70), or reoperations (0.9% PRE, 0.6% POST; P ≥ .99) during this period. Preoperative opioid use was a significant independent risk factor for increased cumulative MMEs in the first 90 days postoperatively (β = 275; P < .01). Opioid prescription-limiting legislation in Ohio was associated with significant reductions in opioid MMEs dosing in the 90-day period following hip arthroscopy. This legislation had no significant effect on ED utilization, hospital readmissions, or reoperations within the same period. Preoperative opioid use was a significant risk factor for increased MME dosing after hip arthroscopy.

Identifying predictors of frequency of 1-year readmission in adult patients with diabetes using count data regression models

Identifying predictors of frequency of 1-year readmission in adult patients with diabetes using count data regression models

A comparison of outcomes between laparoscopic and robotic appendectomy among ACS-NSQIP hospitals

ObjectiveRobotic general surgery remains controversial, with some employing the technology for common laparoscopic procedures such as appendectomies. Very few studies have compared robotic appendectomy (RA) to existing techniques, partly due to the relative scarcity of data. The purpose of this study was to compare outcomes for RA versus laparoscopic appendectomy (LA). MethodsThis retrospective cohort study evaluated procedural specific databases of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) for appendectomy between January 2016 and December 2019 and included all available cases at the time of analysis (June 2021). Demographic and surgical outcomes including composite 30-day complications, specific complications, and length of operation were analyzed using a univariate analysis. ResultsIn total, there were 52,559 appendectomies in the NSQIP database between 2016 and 2019. Analysis was restricted to those who underwent minimally invasive approaches. In total, 49,850 patients were included in the analysis. Of those, 49,800 patients underwent LA, and 50 patients underwent RA. Participants who underwent RA were older (35.8 ± 4.5 y vs. 23.0 ± 0.2 y, p < 0.01). There was no difference in the total number of comorbidities (92.0% vs. 73.4%, p = 0.32) or the severity of appendicitis (p > 0.90) between RA and LA cases. RA had a longer median operation time (71.0 min vs. 46.0 min, p < 0.01) but a shorter postoperative stay (0.7 d vs. 1.3 d, p < 0.01). There was no difference in the frequency of readmission likely related to procedure (4.0% vs. 3.0%, p = 0.88) or complications (18.0% vs. 23.8%, p = 0.88); however, RA was associated with increased 30-day mortality (2.0% vs. <0.1%, p < 0.01) compared to LA. ConclusionOur results demonstrated that LA and RA had a similar frequency and profile of complications. Robotic procedures took longer but resulted in shorter postoperative stays. Our study revealed that RA constituted a mere 0.1% of all cases, with only 50% showing pathology consistent with appendicitis, despite 92.2% of LA cases presenting with the condition. Despite our findings of RA offering some benefit, more research is necessary, particularly regarding outcomes and value delivery.

Association of Home Monitoring and Unanticipated Interstage Readmissions in Infants With Hypoplastic Left Heart Syndrome.

Background The impact of home monitoring on unanticipated interstage readmissions in infants with hypoplastic left heart syndrome has not been previously studied. We sought to examine the association of our institution's Infant Single Ventricle Management and Monitoring Program (ISVMP) with readmission frequency, cumulative readmission days, and readmission illness severity and to identify patient-level risk factors for readmission. Methods and Results We performed a retrospective single-center cohort study comparing infants with hypoplastic left heart syndrome enrolled in ISVMP (December 2010-December 2019) to historical controls (January 2007-November 2010). The primary outcome was number of readmissions per interstage days. Secondary outcomes were cumulative interstage readmission days and occurrence of severe readmissions. Inverse probability weighted and multivariable generalized linear models were used to examine the association between ISVMP and the outcomes. We compared 198 infants in the ISVMP to 128 historical controls. Infants in the ISVMP had more than double the risk of interstage readmission compared with controls (adjusted incidence rate ratio, 2.38 [95% CI, 1.50-3.78]; P=0.0003). There was no difference in cumulative interstage readmission days (adjusted incidence rate ratio, 1.02 [95% CI, 0.69-1.50]; P=0.90); however, infants in the ISVMP were less likely to have severe readmissions (adjusted odds ratio, 0.28 [95% CI, 0.11-0.68]; P=0.005). Other factors independently associated with number of readmissions included residing closer to our center, younger gestational age, genetic syndrome, and discharge on exclusive enteral feeds. Conclusions Infants in the ISVMP had more frequent readmissions but comparable readmission days and fewer severe unanticipated readmissions. These findings suggest that home monitoring can reduce interstage morbidity without increasing readmission days.

Identifying the origin of socioeconomic disparities in outcomes of major elective operations

BackgroundWhile the impact of socioeconomic status (SES) on surgical outcomes has been examined in limited series, it remains a significant determinant of healthcare outcomes at the national level. Therefore, the current study aims to determine SES disparities at three time-points: hospital accessibility, in-hospital outcomes, and post-discharge consequences. MethodsThe Nationwide Readmissions Database 2010–2018 was used to isolate major elective operations. SES was assigned using previously coded median income quartiles as defined by patient zip-code, with low SES defined as the lowest quartile and high SES as the highest. ResultsOf an estimated 4,816,837 patients undergoing major elective operations, 1,037,689 (21.3 %) were categorized as low SES and 1,288,618 (26.5 %) as high. On univariate analysis and compared to those of low SES, high SES patients were more frequently treated at high-volume centers (70.9 vs 55.6 %, p < 0.001), had lower rates of in-hospital complications (24.0 vs 29.0 %, p < 0.001) and mortality (0.4 vs 0.9 %, p < 0.001) as well as less frequent urgent readmissions at 30- (5.7 vs 7.1 %, p < 0.001) and 90-day timepoints (9.4 vs 10.7 %, p < 0.001). On multivariable analysis, high SES patients had higher odds of treatment at high-volume centers (Odds: 1.87, 95 % CI: 1.71–2.06), and lower odds of perioperative complications (Odds: 0.98, 95 % CI: 0.96–0.99), mortality (Odds: 0.70, 95 % CI: 0.65–0.75), and urgent readmissions at 90-days (Odds: 0.95, 95 % CI: 0.92–0.98). ConclusionThis study fills a much-needed gap in the current literature by establishing that all of the aforementioned timepoints include significant disadvantages for those of low socioeconomic status. Therefore, a multidisciplinary approach may be required for intervention to improve equity for surgical patients.

MP50-13 OPEN VERSUS MINIMAL INVASIVE RETROPERITONEAL LYMPH NODE DISSECTION: A NATIONAL CANCER DATABASE ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP50-13 OPEN VERSUS MINIMAL INVASIVE RETROPERITONEAL LYMPH NODE DISSECTION: A NATIONAL CANCER DATABASE ANALYSIS Harshit Garg, Mukund Bhandari, Gilda Digman, Onika Noel, Furkan Dursun, Dharam Kaushik, Deepak Pruthi, Michael Liss, Chethan Ramamurthy, and Ahmed Mansour Harshit GargHarshit Garg More articles by this author , Mukund BhandariMukund Bhandari More articles by this author , Gilda DigmanGilda Digman More articles by this author , Onika NoelOnika Noel More articles by this author , Furkan DursunFurkan Dursun More articles by this author , Dharam KaushikDharam Kaushik More articles by this author , Deepak PruthiDeepak Pruthi More articles by this author , Michael LissMichael Liss More articles by this author , Chethan RamamurthyChethan Ramamurthy More articles by this author , and Ahmed MansourAhmed Mansour More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003298.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Minimal invasive retroperitoneal lymph node dissection (RPLND), either by laparoscopic or robotic approach, has increasingly become popular. However, data comparative data on perioperative outcomes and survival outcomes is limited. In this study, we aim to compare minimal invasive -RPLND (MI-RPLND) with open (O-RPLND) using National Cancer Database. METHODS: Using the 2010-2019 National Cancer Database, patients with primary testicular germ cell tumors undergoing RPLND were identified and classified as Group A: O-RPLND and Group B: MI-RPLND. The primary outcome was overall survival (OS). Secondary outcomes included lymph nodal yield, death within 30 and 90 days of surgery, length of stay after surgery, and frequency of unplanned readmission within 30 days of surgical discharge. Inverse probability weighting (IPW) was utilized to balance the two groups. RESULTS: Overall, 3,184 patients were identified; 2971 (93.3%) patients were included in Group A and 213(6.7%) patients were included in Group B. Amongst them, 2419 (76%) had NSGCT. Factors associated with increased likelihood of MI-RPLND were treatment at academic research programs (p=0.003) and the treatment period between 2015-2019 (p<0.001). The median lymph nodal yield in O-RPLND and MI-RPLND group were similar [19 vs 22, p=0.623]. The 5-year OS was similar between the two groups [94.3% in O-RPLND vs 94.7%, in MI-RPLND p=0.77) (Figure 1a). The length of stay after surgery (p=0.623), frequency of unplanned readmission within 30 days of discharge (p=0.728), death within 30-days of surgery (p=0.74) and death within 90-days of surgery (p=0.06) were similar between the two groups. After IPW matched cohort analysis, the 5y-OS remained similar between the open and minimally invasive approach. [93.9% in O-RPLND vs 93.7% in MI-RPLND, p=0.94] (Figure 1b). CONCLUSIONS: Both O-RPLND and MI-RPLND are associated with similar OS. In terms of perioperative outcomes, both surgical approaches have similar length of hospital stay, similar rates of mortality within 30-day and 90-day of surgery, and similar rates of unplanned readmission rate within 30 days of surgical discharge. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e689 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Harshit Garg More articles by this author Mukund Bhandari More articles by this author Gilda Digman More articles by this author Onika Noel More articles by this author Furkan Dursun More articles by this author Dharam Kaushik More articles by this author Deepak Pruthi More articles by this author Michael Liss More articles by this author Chethan Ramamurthy More articles by this author Ahmed Mansour More articles by this author Expand All Advertisement PDF downloadLoading ...

5572697 TRIALS IN PROGRESS: THE THRIVE STUDIES EVALUATING THE EFFICACY, SAFETY, AND LONG-TERM TREATMENT WITH INCLACUMAB, A P-SELECTIN INHIBITOR, IN PATIENTS WITH SICKLE CELL DISEASE

Background: Sickle cell disease (SCD) is an autosomal recessive red blood cell (RBC) disorder caused by a single point mutation in the β-globin gene, resulting in the production of hemoglobin S. Hemoglobin S polymerization within deoxygenated RBCs contributes to hemolysis, anemia, vaso-occlusion, and end-organ damage. Additionally, abnormal heterocellular adhesive interactions between RBCs and endothelial cells, leukocytes, and platelets play a central role in triggering painful vaso-occlusive crises (VOCs) in patients with SCD. Inclacumab is a recombinant, fully human monoclonal antibody directed against human P-selectin, a cell adhesion molecule produced by endothelial cells and platelets. Inclacumab interferes with the adhesion of sickle RBCs, platelets, and leukocytes to endothelium by binding P-selectin and preventing P-selectin binding to its ligands. This is the putative mechanism by which inclacumab may potentially reduce the incidence of VOCs. Aims: We aim to conduct two global, multicenter, phase 3 studies and an open-label extension (OLE) study to evaluate the safety and efficacy of inclacumab in individuals with SCD. Methods: THRIVE-131 (NCT04935879) is a randomized, double-blind, placebo-controlled, multicenter trial in which ~240 participants aged ≥12 years experiencing 2 to 10 VOCs in the previous 12 months will be randomized 1:1 to receive intravenous (IV) inclacumab or placebo every 12 weeks for 48 weeks (Figure). The primary endpoint is the rate of VOCs during the 48-week treatment period. THRIVE-132 (NCT04927247) is a randomized, double-blind, placebo-controlled, multicenter trial in which ~280 participants aged ≥12 years experiencing 2 to 10 VOCs in the previous 12 months will be randomized 1:1 to receive a single dose of IV inclacumab or placebo within 5 days of resolution of an index VOC that required admission to a healthcare facility and treatment with parenteral pain medication. The primary endpoint is the proportion of participants with readmission for a VOC within 90 days of randomization. After completion of their participation in THRIVE-131 or THRIVE-132, participants may enroll in THRIVE-133 OLE, in which the long-term safety of inclacumab will be investigated. In THRIVE-133 OLE, participants will receive IV inclacumab every 12 weeks as long as the clinical benefit of treatment outweighs the risk and until access to inclacumab from an alternative source (eg, through commercialization or a managed-access program) becomes available. Results: Recruiting for both THRIVE-131 and THRIVE-132 began in October 2021 and is ongoing. Summary – Conclusion: The THRIVE-131 and THRIVE-132 phase 3 studies will examine the efficacy of inclacumab in reducing the frequency of VOCs and readmissions due to VOCs, and the THRIVE-133 OLE study will examine the long-term safety of inclacumab in individuals with SCD. Funding: These studies are supported by Global Blood Therapeutics. Figure: Designs of the THRIVE Studies

Hospital readmissions in children with new-onset infantile epileptic spasms syndrome.

To describe inpatient resource use in the 2 years following infantile epileptic spasms syndrome (IESS) diagnosis, examine the association between clinical/demographic variables and incidence of readmission, and identify risk factors/reasons for frequent readmissions. Retrospective cohort analysis of readmissions (scheduled/unscheduled) within the first 2 years following IESS diagnosis, details of readmissions (number/time between rehospitalizations, and length of stay), demographic/clinical variables, and reasons for readmissions were collected. Negative binomial regression analysis evaluated associations between incidence of readmissions (both scheduled/unscheduled and unscheduled alone) and demographic/clinical factors. Logistic regression assessed the risk of having recurrent readmissions (≥5 readmissions). Among 93 (60% males) new-onset IESS patients, there were 394 readmissions (56% scheduled and 44% unscheduled) within 2-years following IESS diagnosis. Mean length of stay was 3.5 days (SD: 5.9). Readmissions occurred in 82 patients (88%) and 37 (40%) experienced ≥5 readmissions. On multivariate regression analysis, readmissions were increased with use of multiple first-line treatments for IESS (P= 0.006), technology assistance (P≤ 0.001), and multispecialty care (P= 0.01); seizure freedom (P= 0.015) and known etiology (P= 0.011) lowered the incidence of readmissions. Examining unscheduled readmissions separately, increased readmissions occurred with public insurance (P= 0.013), technology use (P≤ 0.0.001), and multispecialty care (P= 0.013); seizure freedom decreased unscheduled readmissions (P= 0.006). Technology assistance (G-tube, NG tube, VP shunt, and tracheostomy use) increased the odds (P= 0.007) for recurrent readmissions. Reasons for readmissions included EEG monitoring (protocol driven for verification of IESS remission/characterization of events/EEG surveillance/presurgical monitoring) (51%), acute medical issues (21%), and seizure exacerbation (15%). Protocol-driven readmissions declined an estimated 52% following protocol modification during the study. In the 2 years following IESS diagnosis, there is substantial inpatient resource use with nearly 40% experiencing ≥5 readmissions (mostly epilepsy related). Since readmissions are increased by intrinsic patient characteristics such as medical complexity (technology use and multispecialty care) or epilepsy-related issues, the preventability of readmissions is uncertain, except for protocol-driven ones.

Caregivers’ experience with Tele-Savvy Caregiver Program post-hospitalization

Despite the frequent hospitalizations and readmissions of persons living with dementia (PLWD), no telehealth transitional care interventions focus on PLWDs’ unpaid caregivers. Tele-Savvy Caregiver Program is a 43-day evidence-based online psychoeducational intervention for PLWDs’ caregivers. The aim of this formative evaluation was to explore caregivers’ acceptability of and experience with their participation in Tele-Savvy after their PLWDs’ hospital discharge. Additionally, we gathered caregivers’ feedback on the recommended features of a transitional care intervention, suitable for caregivers’ schedule and needs post-discharge. Fifteen caregivers completed the interviews. Data were analyzed via conventional content analysis. Four categories were identified: (1) Tele-Savvy improved participants’ understanding of dementia and caregiving; (2) hospitalization started a “new level of normal”; (3) PLWDs’ health concerns; and (4) transitional care intervention development. Participation in Tele-Savvy was acceptable for most caregivers. Participants’ feedback provides content and structural guidance for the development of a new transitional care intervention for PLWDs’ caregivers.

Hospital length of stay and 30-day readmissions in older people: their association in a 20-year cohort study in Italy

BackgroundThere are conflicting data on whether hospital length of stay (LOS) reduction affects readmission rates in older adults. We explored 20-year trends of hospital LOS and 30-day rehospitalizations in a cohort of Italian older people, and investigated their association.MethodsParticipants in the Pro.V.A. project (n = 3099) were followed-up from 1996 to 2018. LOS and 30-day rehospitalizations, i.e. new hospitalizations within 30 days from a previous discharge, were obtained from personal interviews and regional registers. Rehospitalizations in the 6 months before death were also assessed. Linear regressions evaluated the associations between LOS and the frequency of 30-day rehospitalizations, adjusting for the mean age of the cohort within each year.ResultsOver 20 years, 2320 (74.9%) participants were hospitalized. Mean LOS gradually decreased from 17.3 days in 1996 to 11.3 days in 2018, while 30-day rehospitalization rates increased from 6.6% in 1996 to 13.6% in 2018. LOS was inversely associated with 30-day rehospitalizations frequency over time (β = -2.33, p = 0.01), similarly in men and women. A total of 1506 individuals was hospitalized within 6 months before death. The frequency of 30-day readmissions at the end of life increased from 1.4% in 1997 to 8.3% in 2017 and was associated with mean LOS (β = -1.17, p = 0.03).ConclusionsThe gradual LOS reduction observed in the latter decades is associated with higher 30-day readmission rates in older patients in Italy. This suggests that a careful pre-discharge assessment is warranted in older people, and that community healthcare services should be improved to reduce the risk of readmission.

Diabetes-Related Gastroparesis in the Acute Care Setting: A Case Report.

Diabetes-related gastroparesis is a challenging complication of diabetes that often results in flares of intractable vomiting and recurrent hospitalizations. Currently, there is no standard of care or guidelines for the management of diabetes-related gastroparesis in the acute care setting, leading to inconsistent and suboptimal care for these patients. Consequently, patients with diabetes-related gastroparesis may have prolonged inpatient lengths of stay and frequent readmissions affecting their overall health and well-being. Successful management of diabetes-related gastroparesis requires a coordinated multimodal approach to address the different components of an acute flare, including nausea and vomiting, pain, constipation, nutrition, and dysglycemia. This case report demonstrates how the development and implementation of an acute care diabetes-related gastroparesis treatment protocol demonstrates efficacy and promise for better quality of care for this population.

The prognostic value of kidney failure based on glomerular filtration rate in predicting long in-hospital outcomes in patients with unstable angina

Objectives: Numerous recent studies have emphasized the role of kidney failure in developing ischemic heart disease (IHD) and the resulting adverse consequences. The purpose of the present study was to quantitatively assess the effect of kidney failure based on glomerular filtration rate (GFR) in predicting clinical outcomes in patients with unstable angina (U/A).&#x0D; Methods: This retrospective cohort study included 129 patients with unstable angina with preserved left ventricular function. Serum creatinine levels were specified at the beginning of their admission. The GFR at admission time was determined based on the MDRD index. Based on the GFR value, patients were classified into two groups, i.e., normal GFR (&gt;60) and decreased GFR (&lt;60).&#x0D; Results: The frequency of one-month mortality in &lt;60 GFR and &gt;60 GFR was 3.2% and 0.0%, respectively. Furthermore, the prevalence of 6-month mortality in &lt;60 GFR and &gt;60 GFR was 8.1% and 0.0%, respectively. The frequency of readmission in &lt;60 GFR and &gt;60 GFR was 29% and 11%, respectively. Likewise, the frequency of revascularization through coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) in &lt;60 GFR and &gt;60 GFR was 25.8% and 8.9%, respectively. According to the multivariate logistic regression model, &lt;60 GFR increased the risk of 6-month mortality up to 0.2 times (probability ratio of 2.081, P-value of 0.023). Regarding readmission, &lt;60 GFR increased the need for readmission up to 2.4 times (probability ratio of 2.433, P-value of 0.049). On the other hand, the risk of CABG or PCI recurrence following initial intervention was 2.8 times higher in patients with &lt;60 GFR than in the &gt;60 GFR group (probability ratio 2.882, p-value .03.&#x0D; Conclusions: The study revealed that &lt;60 GFR compared to higher values ​​of GFR is associated with an increased risk of 6-month mortality, increased readmission, and increased revascularization in patients with unstable angina.

Pattern of care of brain tumor patients in the last months of life: analysis of a cohort of 3045 patients in the last 10years.

End-of-life in patients with brain cancer presents special challenges, and palliative care approach is underutilized. Patients with brain cancer, in the last months of life, receive frequent hospital readmissions, highlighting bad end-of-life care quality. Early integration of palliative care improves quality of care in advanced stage of disease and patient's quality of death. We retrospectively analyzed a consecutive series of patients with brain cancer discharged after diagnosis to evaluate pattern of treatment and rate of hospital readmission in the last months of life. Data were collected from the Lazio Region Healthcare database. Adult patients discharged with diagnosis ICD-9 191.* between January 1, 2010, and December 31, 2019 were included. A total of 6672 patients were identified, and 3045 deaths were included. In the last 30days 33% were readmitted to the hospital and 24.2% to the emergency room. 11.7% were treated with chemotherapy and 6% with radiotherapy. Most indicators of end-of-life care showed wide variability by hospital of discharge. Strategies to improve quality of care at the end of life and to decrease re-hospitalization and futile treatments are becoming increasingly important to improve quality of death and reduce healthcare costs. Variability observed by hospital of discharge indicates the lack of a standard approach to end-of-life care.

Supporting older people following out of hours discharge from the Emergency Department: An integrative review of the literature.

For many older people the emergency department (ED) is an important but sometimes difficult step in their healthcare journey. They often attend the ED with co and multi morbidities. Discharge home at evenings and weekends when post-discharge support services are limited can result in a delay or failure to follow through on their discharge plan leading to adverse health outcomes and in some cases, readmission to ED. The aim of this integrative review was to identify and appraise the support available to older people following discharge from the ED out of hours (OOH). For this review, out of hours referred to those times after 17.30 until 08.00 a.m. on Mondays to Fridays, all hours on weekends and public holidays. Whittemore and Knafl's (Journal of Advanced Nursing, 2005;52:546), framework was used to guide all stages of the review process. Articles were retrieved following a rigorous search of published works using various databases, the grey literature and hand search of the reference lists of the studies included. In total 31 articles were included in the review. These comprised systematic reviews, randomised control studies, cohort studies and surveys. Main themes identified included processes that enable support, support provision by health and social care professionals and telephone follow-up. Results identified a significant dearth of out of hours discharge research and a strong recommendation for more concise and thorough research in this important area of care transition. Older person discharge home from the ED presents an associated risk as previous research has identified frequent readmission and periods of ill health and dependency. Out of hours discharge can be even more problematic when it may be difficult to arrange support services and ensure continuity of care. Further work in this area is required, taking cognisance of the findings and recommendations identified in this review.

Breaking the Readmission Cycle

Breaking the Readmission Cycle Brian Hatten I want to share the story of my difficult patient Ms. L. She has twenty-seven current medical issues. Thirty-five active prescriptions. Limited mobility requiring the use of a motorized scooter. Non-medical care gaps. And over twenty hospital admissions since 2020. I met Ms. L approximately five years ago as her hospital attending and have continued to care for her during her frequent hospitalizations. I could recite this 77-year-old female's litany of medical problems. But sufficed to say, her history is complex, with her admitting diagnoses running the gambit from cellulitis to gastrointestinal bleeding to altered mental status. But, her diagnosis and frequent exacerbations of congestive heart failure (CHF) are particularly frustrating for us both and will be my focus today. CHF makes her susceptible to fluid overload leading to feelings of shortness of breath, which progresses to respiratory distress. Like other individuals with CHF, she uses diuretics to prevent herself from becoming fluid overloaded. And, like many individuals who take diuretics, she hates them. She (un)affectionately calls her water pills "the bomb" because the effect is sudden, profound, and explosive when they begin working. The combination of the diuretic effect and her limited mobility causes significant emotional stress for Ms. L, a woman who values presenting herself outwardly as in control, well-dressed, and put together. Her dislike of the medical effect of her diuretics has led to her either taking them less often or outright discontinuing them. So, while discontinuation avoids those frustrating effects, it leads to fluid accumulation, subsequent respiratory distress, and readmission to the hospital. Her medical records mention she has memory issues. It is unclear how much her mild cognitive impairment affects her frequent readmissions. We have had many conversations where I would never suspect something was amiss. But sometimes, she can be forgetful and does not recall our recent discussions. That being said, she knows the names and uses of her medications. She can report to me her home weights when she checks them and knows what her "dry" weight should be. Yet, she does not act when her scales begin reading heavier or when she develops leg swelling. Instead, she presents to the emergency department in extremis. When directly questioned about why she lets her situation deteriorate to such a state that she requires hospitalization, she demurs. She comments that she can often be stubborn, that the diuretic effect of "the bomb" is burdensome, but always reminds me she is honest in admitting she wasn't taking her water pills. During several admissions, I worried for her survival after she had self-discontinued her medications and showed up at the emergency department in respiratory failure. For any patient with recurrent admissions, I discuss their overall goals of care to ensure we are working together toward achievable medical ends. But this conversation was essential to have with Ms. L. The possibility existed that she would present to the hospital too late in her disease process, and we would not be able to correct her respiratory failure. I wanted to ensure that the hospital staff and I respected her wishes regarding her care. Despite raising my concerns, she would [End Page 22] decline to discuss her wishes. Even worse, attempting to have her complete advance care planning documents like advance directives or a Physician Orders for Life-Sustaining Treatment (POLST) form was a futile endeavor. Ms. L was always vague and non-committal. She simply did not want to engage in those types of conversations. When asked why she declined to discuss these issues, Ms. L would reply that she was doing okay, the discussion was unnecessary, and she had family members to make those decisions for her. Caring for her during her hospital stays was a source of professional frustration for me. Her recurrent admissions made me feel like I was failing her. During each hospital stay, we would go over her medications. We repeatedly discussed how she should check her weights daily and monitor for lower extremity edema. We created multiple action plans for when to call her physicians so we could head off another hospital visit. We completed all the...

Abstract P6-05-58: Comparing Patient-Reported Outcomes for Same-day Discharge and Inpatient Admission After Mastectomy

Abstract Background: Same-day discharge after mastectomy has been demonstrated to be safe in appropriately selected candidates. However, the association between same-day discharge after mastectomy and quality of life (QOL) is unclear. Patient-reported outcome (PRO) measures represent important indicators of QOL among patients undergoing treatment for breast cancer. In this study, we aimed to evaluate the effect of same-day discharge after mastectomy on PROs. Methods: We performed a retrospective review of a prospectively collected, longitudinal PRO registry of female breast cancer patients treated at an academic breast center between June 2019 and June 2022. Patients were invited to complete the BREAST-Q module, a validated PRO questionnaire measuring QOL domains such as psychosocial wellbeing, physical wellbeing, satisfaction with their surgeon, and satisfaction with their medical team. Preoperative and 2-week postoperative questionnaire responses were analyzed in this study. Patients who had a mastectomy with or without reconstruction were included in this analysis. Those who underwent immediate reconstruction with autologous tissue were excluded as these operations are not conducive to same-day discharge. Patients were divided into two groups: the first was discharged on the date of surgery while the second was admitted to the hospital for a minimum of one night. Clinical and demographic factors were collected from a review of the electronic medical record. The primary endpoints were mean satisfaction scores as well as differences between postoperative and preoperative scores for the psychosocial and physical wellbeing domains. T-tests were used to evaluate differences between groups. A multiple regression model was fit to adjust for the effects of relevant clinical and demographic factors. Results: A total of 104 patients within the registry underwent mastectomy during the study period and were offered questionnaires. Of these, 58 completed both the preoperative and 2-week postoperative questionnaire (56% response rate); 20 (34%) in the same-day discharge group and 38 (66%) in the inpatient admission group. The groups were similar in age, stage, American Society of Anesthesiologists’ classification group, body mass index, frequency of unplanned readmission or reoperation, and receipt of bilateral mastectomy, axillary lymph node dissection, post-mastectomy reconstruction, and neoadjuvant chemotherapy. Mean patient satisfaction scores and mean changes in psychosocial and physical wellbeing scores were similar between the groups 2 weeks after surgery (Table 1). After controlling for age, type of reconstructive operation, receipt of unplanned reoperation, and preoperative score, same-day discharge did not have a significant effect on satisfaction with the surgeon (Beta=-4.3, p=0.37), satisfaction with the medical team (Beta=0.2, p=0.97), physical wellbeing score (Beta=-0.1, p=0.99), or psychosocial wellbeing score (Beta=8.0, p=0.15). Conclusions: Patients who are discharged from the hospital on the same day of a mastectomy display similar levels of satisfaction with their care team and similar short-term trends in physical and psychosocial wellbeing compared to those who are admitted to the hospital. While further data are being accrued, these early results suggest patients tolerate same-day discharge after mastectomy well. Table 1 Patient-reported outcomes at 2 weeks after mastectomy for patients discharged on the date of surgery compared to those admitted inpatient Citation Format: Sudheer Vemuru, Kathryn Colborn, Laura Leonard, Victoria Huynh, Christodoulos Kaoutzanis, Justin Cohen, David Mathes, Nicole Christian, Gretchen M. Ahrendt, Christine M. Fisher, Simon Kim, Sarah Tevis. Comparing Patient-Reported Outcomes for Same-day Discharge and Inpatient Admission After Mastectomy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-58.

Malnutrition associated with readmission in elderly patients with chronic obstructive pulmonary disease.

Malnutrition associated with readmission in elderly patients with chronic obstructive pulmonary disease.