Higher Rates Of Unplanned Readmission Research Articles

Role of systematic lymphadenectomy at the time of interval debulking surgery for patients with advanced-stage epithelial ovarian carcinoma who achieved complete gross resection

ObjectiveTo evaluate the role of systematic lymphadenectomy at the time of interval cytoreductive surgery for patients with advanced-stage epithelial ovarian carcinoma who achieved complete gross resection.MethodsThe National Cancer DataBase was...

547 ADHD and Burn Injuries: The Hidden Readmission Risk in Pediatric Patients

Abstract Introduction Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with the hallmark characteristics of poor impulse control, inattention, hyperactivity, and other cognitive dysfunction; as a consequence, children with ADHD are at an increased risk of burn injury. We hypothesized that pediatric burn patients with ADHD have a higher rate of unplanned readmission compared to patients without a diagnosis of ADHD. Methods We analyzed the Nationwide Readmission Database (01/2018 - 10/2018) to compare 60-days readmission rates in children (< 18 yo) with and without a diagnosis of ADHD who were treated for burn injuries on their index admission. Weighted multiple logistic regression was performed to obtain population estimates of odds ratios (OR), adjusting for patients’ demographics, burn severity and location, comorbidities, socioeconomic status, other psychiatric illnesses, and burn treatment on index admission. Results Our cohort included 1,879 children with burn injury. Of these, 79 (4.2%) had a diagnosis of ADHD. ADHD patients were more likely to be male (86.1% vs 59.8%, p=0.0002 ) and older (11.6 ± 3.7 vs 5.4 ± 5.3 years, p=0.0001). Children with ADHD were more likely to have other psychiatric diagnoses (26.6% vs 3.8%), specifically obsessive compulsive disorder (2.5% vs 0%, p=0.004), and other developmental disorders (15.2% vs 1.6%, p=0.0002). Patients with ADHD were more likely to be readmitted within 60 days of their index admission (15.2% vs. 4.8%, p=0.002). On weighted multiple regression analysis, ADHD had a higher adjusted odds ratio of readmission (OR: 2.66, 95%CI: 1.13-6.29). Conclusions Children with ADHD have a higher adjusted risk of readmission following thermal injury. This is potentially due to higher barriers to compliance with wound care, physical therapy, and scar management. Targeted discharge planning for patients with ADHD, including scheduled short-term follow-up appointments, home nursing assistance, and post-discharge phone calls, may potentially lower readmission risks in this vulnerable population. Applicability of Research to Practice Pediatric patients with ADHD are at higher than average risk for unplanned readmission within 60 days of discharge. Pediatric burn centers have the opportunity to adjust their post-discharge practice with these high-risk patients to decrease this risk. Interventions could include: more frequent clinic follow-up, longer duration with outpatient therapy, and additional coaching for caretakers on how to improve patient compliance.

Role of colectomy in the management of appendiceal tumors: a retrospective cohort study

BackgroundAppendiceal tumors represent a range of histologies that vary in behavior. Recommendations for treatment with appendectomy versus right hemicolectomy (RHC) for different tumor types are evolving and sometimes conflicting. This study sought to characterize variation in the United States around surgical treatment of major appendiceal tumor types over time and describe differences in outcomes based on procedure.MethodsPatients diagnosed with appendiceal goblet cell adenocarcinoma (GCA), mucinous adenocarcinoma, neuroendocrine neoplasm (NEN), or non-mucinous adenocarcinoma from 2004–2017 were identified in the National Cancer Database. Trends in RHC over time and predictors of RHC were identified. Surgical outcomes for each histologic type and stage were compared.ResultsOf 18,216 patients, 11% had GCAs, 34% mucinous adenocarcinoma, 31% NENs, and 24% non-mucinous adenocarcinoma. Rate of RHC for NEN decreased from 68% in 2004 to 40% in 2017 (p = 0.008) but remained constant around 60–75% for other tumor types. Higher stage was associated with increased odds of RHC for all tumor types. RHC was associated with higher rate of unplanned readmission (5% vs. 3%, p < 0.001) and longer postoperative hospital stay (median 5 days vs. 3 days, p < 0.001). On risk-adjusted analysis, RHC was significantly associated with increased survival versus appendectomy for stage 2 disease of all tumor types (HRs 0.43 to 0.63) and for stage 1 non-mucinous adenocarcinoma (HR = 0.56).ConclusionsMost patients with appendiceal tumors undergo RHC, which is associated with increased readmission, longer length of stay, and improved survival for stage 2 disease of all types. RHC should be offered selectively for appendiceal tumors.

Readmission after early thoracic endovascular aortic repair versus medical management of acute type B aortic dissection

BackgroundThe use of thoracic endovascular aortic repair (TEVAR) for the management of acute uncomplicated type B aortic dissection (TBAD) has increased. Although the results from early studies were promising, larger randomized trials evaluating TEVAR are lacking. It is also unclear where sufficient equipoise exists for such trials. In the present study, we evaluated the number of readmissions and unplanned operations after TEVAR vs those after medical management as the initial treatment of acute uncomplicated TBAD and the frequency of each treatment in this population. MethodsWe performed a multi-institutional retrospective review of patients with acute TBAD from 2015 to 2020 with the 1-year outcomes available, excluding patients with prior aortic intervention or chronic, iatrogenic or traumatic etiologies. The primary exposure was TEVAR vs medical management at the index admission. The patient demographics, clinical presentation, and imaging findings were analyzed using bivariate and multivariate logistic regression for the primary outcomes of unplanned readmission and/or operation after the initial admission. The secondary outcomes were mortality, myocardial infarction, stroke, renal failure requiring dialysis, retrograde type A dissection, and length of stay. We hypothesized that the readmissions would be higher with medical management. ResultsA total of 216 patients with TBAD (47 with complicated and 169 with uncomplicated) from two large academic centers were identified. Of the 169 patients with uncomplicated TBAD, 83 (49%) had been treated medically and 86 (51%) had undergone TEVAR at the initial admission. No differences were found in the demographics or high-risk imaging features at presentation. The medically managed patients had had higher rates of unplanned readmission (34% vs 9%; P = .0001) and operation (28% vs 8%; P = .0007) but shorter lengths of stay (6.3 vs 13.1 days; P < .0001). No differences were found in mortality, although the rate of myocardial infarction was higher in the medically managed group (10.8% vs 2.3%; P = .02). Although 28% of the medically managed patients had later required operation, they had had morbidity and mortality similar to those of patients who had undergone initial TEVAR. Initial medical management was associated with unplanned readmission (odds ratio, 8.3; P = .02) and the need for operation (odds ratio, 4.56; P = .006). No differences were found in the outcomes according to the involved aortic zones. ConclusionsIn the present study, medical management of acute uncomplicated TBAD was associated with higher rates of readmission and the need for unplanned operation compared with TEVAR. However, no differences were found in the 1-year mortality for the patients for whom medical management had failed. Because one half of the patients had undergone medical management and one half had undergone early TEVAR, this finding suggests clinical equipoise for the treatment of acute uncomplicated TBAD. Therefore, a larger randomized trial appears warranted to determine whether a clear benefit exists for early TEVAR.

Outcomes of colorectal cancer resection in patients with inflammatory bowel disease: a national population-based analysis in England and Wales.

The aim was to compare early postoperative outcomes and 2-year cancer-specific mortality following colorectal cancer (CRC) resection in patients with and without inflammatory bowel disease (IBD) in England and Wales. Records for patients in the National Bowel Cancer Audit who had major CRC resection between April 2014 and December 2017 were linked to routinely collected hospital level administrative datasets and chemotherapy and radiotherapy datasets. Multivariable regression models were used to compare outcomes with adjustment for patient and tumour characteristics. In all, 63 365 patients were included. 1285 (2.0%) had an IBD diagnosis: 839 (65.3%) ulcerative colitis, 435 (33.9%) Crohn's disease and 11 (0.9%) were indeterminate. IBD patients were younger, had more advanced cancer staging and a higher proportion of right-sided tumours. They also had a higher proportion of emergency resection, total/subtotal colectomy, open surgery and stoma formation at resection, with longer hospital admissions and higher rates of unplanned readmission and reoperation. Fewer rectal cancer patients with IBD received neoadjuvant radiotherapy (24.8% vs. 36.0%, P= 0.005) whilst similar proportions of Stage III colon cancer patients received adjuvant chemotherapy. Ninety-day postoperative mortality was similar, but unadjusted 2-year cancer-specific mortality was significantly higher in patients with IBD (subdistribution hazard ratio 1.35, 95% CI 1.18-1.55). Risk adjustment for patient and tumour factors reduced this association (adjusted subdistribution hazard ratio 1.22, 95% CI 1.05-1.43). Patients with IBD and CRC are a distinct patient group who develop CRC at a younger age and undergo more radical surgery. They have worse cancer survival, with the difference in prognosis appearing after the early postoperative period.

Impact of systematic lymphadenectomy at the time of interval debulking surgery on the survival of patients with advanced-stage epithelial ovarian carcinoma following neoadjuvant chemotherapy

<h3>Objectives:</h3> In light of evidence from the LION trial, we aimed to evaluate the impact of systematic lymphadenectomy (LN) at the time of interval debulking surgery (IDS) for patients with advanced stage epithelial ovarian carcinoma. <h3>Methods:</h3> Patients with stage III-IV epithelial ovarian carcinoma without a history of another tumor who underwent neoadjuvant chemotherapy and underwent interval debulking with complete gross resection (CGR) were identified in the National Cancer Database (2010-2015). Based on pathology report patients who did not undergo any lymphadenectomy and those who underwent systematic lymphadenectomy (defined as at least 20 lymph nodes removed) were selected for further analysis. Median overall survival was compared with the log-rank test and a Cox multivariate model was constructed to control for confounders. <h3>Results:</h3> A total of 1060 patients who met the inclusion criteria were identified. Median patient age was 64 years while the majority had serous tumors (95.8%) and did not have co-morbidities (79.2%). Systematic LND was performed for 125 (11.8%) patients with a median of 29 LNs (range 20-72) removed. Rate of positive LNs was 62.4%, while median number of positive LN was 5 (range 1-28). Patients who underwent systematic LND had higher rate of unplanned readmission (8.9% vs 1.6%, p<0.001), and median hospital stay (6 vs 4 days, p<0.001). Median OS for patients who did not undergo LND was 40.38 months compared to 44.19 for those who underwent systematic LND, p=0.40. After controlling for patient age, insurance status, race, presence of comorbidities, tumor histology, and disease stage, performance of systematic LND was not associated with better survival (HR: 0.98, 95% CI: 0.80, 1.19). Lastly, median overall survival of patients with positive LNs (n=78) was 40.05 months. <h3>Conclusions:</h3> Systematic lymphadenectomy is rarely performed at the time of interval debulking surgery and was not associated with a survival benefit.

Sequencing of Renal Mass Biopsy and Ablation: Results from the National Cancer Database.

We assessed current utilization and sequencing of renal mass biopsy (RMB) and thermal ablation for renal cell carcinoma (RCC) patients in the United States. The 2004-2014 National Cancer Database was queried for adult patients with histopathologically diagnosed American Joint Committee on Cancer stage I RCC ≤5 cm undergoing RMB and thermal ablation. RMB sequencing was stratified into "staged RMB" (separate sessions for RMB/ablation) or "concomitant RMB" (same date RMB/ablation). Demographics, cancer variables and time trends were compared. Univariate and multivariable logistic regression identified predictors of concomitant RMB, and evaluated their impact on inpatient hospital stay and 30-day unplanned readmissions. A total of 6,323 patients were included, of whom 2,913 (46.1%) underwent staged RMB and 3,410 (53.9%) underwent concomitant RMB. Concomitant RMB was more frequently performed until 2012, and staged RMB thereafter (trend p <0.001). In multivariable logistic regression models, private insurance, clear cell RCC, right-sided disease and smaller tumor diameter demonstrated higher probability of concomitant RMB. Furthermore, geographical differences across the United States were evident (concomitant RMB West/South Central region 64.6% versus New England 29.3%, multivariable p <0.05). Concomitant RMB was associated with greater odds of inpatient hospital stay (multivariable OR=1.42, 95% CI=1. 27-1. 60; p <0.001) and 30-day unplanned hospital readmissions (OR=1.55, 95% CI=1.07-2.27; p=0.022). Staged RMB is more frequently performed in more recent years and is associated with lower odds of inpatient hospital stay and unplanned readmissions within 30 days. These potential benefits, combined with the potential to limit ablation of benign tumors, need to be weighed against additional health care costs and inconvenience associated with 2 interventions.

604. Factors Associated with Adverse Drug Reactions Leading to Discontinuation of Vancomycin in Outpatient Parenteral Antimicrobial Therapy

BackgroundOver 250,000 patients receive outpatient parenteral antimicrobial therapy (OPAT) in the United States each year. Vancomycin is commonly used in OPAT but has a high rate of discontinuations due to adverse drug reactions (ADRs). Being able to predict the occurrence of these ADRs and assess their impact could improve the overall quality of OPAT services when utilizing vancomycin.MethodsThis was a retrospective chart review of all adult University of Utah Health (UUH) patients who received vancomycin OPAT and had planned follow-up with UUH infectious disease (ID) providers between October 25, 2018 and July 31, 2019. Patients were excluded if they were less than 18 years of age, pregnant, did not have planned follow up with UUH ID physicians, or were on any form of renal replacement therapy. The primary outcome assessed was discontinuation of vancomycin due to ADR, as documented by the ID provider. Type of ADR leading to discontinuation and 30-day unplanned readmission were also assessed.ResultsOne hundred fifty-eight patients met inclusion criteria (n=158). The mean age of patients was 55 years with a median Charlson comorbidity score of 3. Most patients utilized a non-UUH infusion service (116, 73% vs 42, 27%) and utilized vancomycin as their sole antibiotic (83, 53%). The majority of patients were being treated for orthopedic infections (78, 49%). Twenty-eight patients discontinued vancomycin OPAT due to an ADR (18%). The most common ADR leading to discontinuation was acute kidney injury (10, 36%). Variables associated with ADRs leading to discontinuation included utilization of UUH home infusion services (54% vs 21%, P < 0.001) and initial vancomycin plasma concentrations obtained less than 7 days after discharge (92% vs 71%, P < 0.001). The overall 30 day readmission rate was 10% and the rate among patients who experienced an ADR leading to discontinuation was higher than those who did not (25% vs 8%, P < 0.001).ConclusionThe overall rate of discontinuation of vancomycin OPAT due to ADR in the UUH population is similar to what has been described in previous literature. The higher rate of unplanned readmission in the population of patients who experienced ADRs warrants further study. The results of this study will be utilized for future quality improvement interventions at our institution.DisclosuresRussell J. Benefield, PharmD, Merck and Co (Grant/Research Support)Paratek Pharmaceuticals (Grant/Research Support)Rempex Pharmaceuticals (Grant/Research Support)

A Contemporary Analysis of the 30-day Morbidity and Mortality Associated With Cytoreductive Nephrectomy

ObjectiveTo examine the rates of adverse surgical outcomes in patients undergoing cytoreductive nephrectomy (CN) compared to patients undergoing radical nephrectomy in the nonmetastatic setting using a large administrative database. MethodsPatients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) who underwent a radical nephrectomy between 2011 and 2016 were included. Patients were stratified by the preoperative variable of presence or absence of metastatic cancer. Perioperative outcomes were compared. A multivariable logistic regression analysis was performed to test the association between patients with metastatic cancer and perioperative morbidity and 30-day mortality. ResultsThere were 15,869 total patients included in this analysis of whom 1322 (8%) patients had metastatic cancer. Of the entire cohort, the majority of patients were over 60 years old (58%) and 9621 (61%) were male. Seventy-three of the patients were Caucasian. Patients with metastatic cancer had more minor (P< .01) and major (P< .01) complications, a higher rate of reoperation (P< .01), and a higher rate of unplanned readmissions (P< .01). Finally, the cohort with metastatic cancer had a higher rate of postoperative 30-day mortality (P< .01) than patients without metastatic cancer. ConclusionPatients undergoing a CN have significantly worse perioperative outcomes than patients undergoing a radical nephrectomy without evidence of metastases. Careful surgical risk stratification and appropriate patient counseling should be undertaken when selecting candidates for CN.

Group B Streptococcus Infected Tenosynovitis in Diabetic Foot Ulcers

Category:Diabetes; OtherIntroduction/Purpose:The incidence of Streptococcus agalactiae (Group B Streptococcus, GBS) infection in diabetic foot ulcers (DFU) has been on the rise. Severe soft tissue damage, which often leads to septicemia and amputation, has been reported in many cases. With the paucity of literature, we aimed to investigate the clinical outcome of GBS infected DFU patients. We hypothesize that GBS patients have a greater severity of infection as indicated by elevated inflammatory markers, more frequent wound complication, and a higher rate of unplanned readmission and reoperation.Methods:Data was retrospectively collected in a single academic orthopedic surgeon’s practice from February 2015 to October 2019. Seventy-eight patients with infected DFUs who underwent surgical treatment formed the basis of this study. Infected bone samples were obtained intraoperatively and sent for standard culture. The microbe data, demographic data (age, gender, race, ethnicity, and BMI), comorbidities, and initial lab values (HgA1C, CRP, ESR, WBC, and glucose) were recorded for all patients. Sixteen GBS infected DFU patients (20.5%) were identified. Among them, GBS infection occurred in 9 acute (<2 wks), 2 subacute (4-6 wks), and 5 chronic (>6 wks) DFUs. Clinical outcome was assessed by surgical outcome, wound healing status, post-operative complications, unplanned readmission, and unplanned reoperation within 3 months following initial surgery. Mean, standard deviation, percentage and range were calculated for patient demographics and inflammatory markers. Statistical significance of inflammatory markers between patients with and without GBS was also calculated.Results:The initial procedures were irrigation and debridement (n=11), toe amputation (n=1), ray amputation (n=2), transmetatarsal amputation (n=1), and a partial calcanectomy (n=1). Five GBS patients (31.3%), as compared to eighteen (29%) DFU patients without GBS, developed post-surgical complications (wound dehiscence, recurrent infection, septicemia) which required unplanned readmission and reoperation. Repeat operations were irrigation and debridement (n=1), metatarsal ray amputation (n=1), ray amputation (n=1), and below knee amputation (n=2) with average number of 2 repeat operations (range: 1 - 5). Hemoglobin A1C (p=.0067) was statistically higher in GBS patients. When comparing acute GBS ulcers (n=9) and acute ulcers without GBS (n=18), CRP (p=.037), HgA1C (p=.026), and blood glucose (p=.046) were all found to be significantly higher in patients with GBS DFUs.Conclusion:GBS infected DFU patients generally showed more extensive and severe soft tissue inflammation, as indicated by higher inflammatory markers at initial presentation. Compared to other patients with DFUs, GBS patients had significantly higher HgA1C values, and in those experiencing acute ulcers, had higher CRP, HgA1C, and blood glucose values. They have higher rates of post-operative complications that required unplanned readmission and reoperation at more proximal level. Surgeons should consider time sensitive and aggressive surgical treatment for GBS infected DFUs and counsel patients on the high risk of post- operative complications and repeat surgery.

792 Assessment of use of Beta-blockers Post PCI for Difference in Adherence by Sex and Effect on Outcome. Results from a National Multicenter Outcome Registry in Australia (GCOR)

Adherence to secondary prevention medication has a potential significant benefit on outcome and mortality. We examined whether adherence to betablockers differ by sex and the effect of adherence to beta-blockers on outcome using data from the Genesis Cardiovascular Outcome Registry (GCOR). Data was prospectively collected on 8255 patients (1866 women and 6386 men). Patients were assessed for 1-year adherence and effect on outcome measured by death, MACE, MI, TVR, and unplanned readmission. Drug adherence at 1-year was significantly lower in men compared to women (47.9% vs 51.3%, p=0.01). Patients adherent to beta-blockers at 1-year had a significant reduction in the risk of death (HR 0.30; 95% CI 0.14-0.61, p=0.001), with the benefit similar for both women (HR 0.17; 95% CI 0.04-0.79, p=0.02) and men (HR 0.37; 95% CI 0.16-0.86, p=0.02). A significant increase in risk for myocardial infarction at 1-year was noted for the whole cohort (HR 2.72; 95% CI 1.44-5.15, p=0.002), with the highest risk of myocardial infarction noted in men (HR 3.30; 95% CI 1.55-7.02, p=002). An increased risk for unplanned readmission was noted (HR 1.20; 95% CI 1.03-1.39, p=0.02), with similar rates seen for women and men. Adherence to betablockers at 1-year was associated with a significant reduction in death. The increase risk of MI in men and higher rate of unplanned readmission needs further investigation.

Comparison of clinical outcomes in diabetic and non-diabetic burns patients in a national burns referral centre in southeast Asia: A 3-year retrospective review

ObjectiveDiabetic burns patients may be at risk of worse clinical outcomes. This study aims to further investigate the impact of diabetes mellitus on clinical outcomes in burns patients in Singapore. MethodsA 3-year retrospective review was performed at the Singapore General Hospital Burns Centre (2011–2013). Pure inhalational burns were excluded. Diabetic (N=53) and non-diabetic (N=533) patients were compared, and the impact of diabetes on clinical outcomes, adjusting for confounders, was investigated using multivariate logistic regression. ResultsThe diabetic group had a significantly higher incidence of wound infection and severe renal impairment, as well as a longer length of stay, higher number of operations and higher rate of unplanned readmission. ICU admission was significantly associated with hyperglycaemia (OR 5.44 [2.61–11.35], p<0.001) and a higher total body surface area of burn (OR per 1% TBSA 1.07 [1.05–1.09], p<0.001). Unplanned readmission was significantly associated with wound infection (OR 4.29 [1.70–10.83], p=0.002), and mortality associated with a higher TBSA (OR per 1% TBSA 1.1 [1.07–1.14], p<0.001). After adjusting for confounders, diabetes mellitus was not significantly associated with unplanned readmission or mortality. ConclusionsDiabetic burns patients have an increased risk of worse clinical outcomes, including wound infections, renal impairment and longer length of stay.

The Relationship Between Acute and Chronic Hyperglycemia and Outcomes in Burn Injury

A significant proportion of patients with burn injury have diabetes. Although hyperglycemia during critical illness has been associated with poor outcomes, patients with chronic hyperglycemia based on elevated hemoglobin A1c (HbA1c) measurements at admission have been shown to tolerate higher glucose levels during hospitalization. This relationship has not been evaluated in the burn population. The objective of this study was to examine the impact of chronic glucose control on outcomes in the acute period after burn. This is a retrospective analysis comparing outcomes in patients with chronic hyperglycemia (HbA1c ≥ 6.5%) and euglycemia (HbA1c <6.5%). Patients aged 18 to 89 years, admitted for initial burn care between January 1, 2009, and June 30, 2010, with an HbA1c measurement at admission were included. The primary endpoint was unplanned readmissions, with secondary endpoints of length of stay and mortality. We included 258 patients (32 with chronic hyperglycemia and 226 with euglycemia). Burn severity was similar between the groups. Patients with chronic hyperglycemia were significantly older and were more likely to have diabetes, respiratory disease, and hypertension. Chronic hyperglycemia was associated with significantly higher time-weighted glucose and glucose variability. Survival rates were similar, but the chronic hyperglycemia group had a significantly longer length of stay (13 vs 9 days; P = .038) and a higher rate of unplanned readmission (18.8 vs 3.6%; P = .001). Chronic hyperglycemia before burn injury is associated with altered glycemic response after burn injury and worse outcomes. Further research is needed to identify whether chronic hyperglycemia necessitates a modified approach to burn care or glycemic management.

Integrated postdischarge transitional care in a hospitalist system to improve discharge outcome: an experimental study

BackgroundThe postdischarge period is a vulnerable time for patients, with high rates of adverse events that may cause unnecessary readmissions, especially in the elderly. Because postdischarge care continuity is often interrupted after hospitalist care, close follow-up may decrease patient readmission. In this study, we aimed to investigate the impact of a quality improvement program, integrated postdischarge transitional care (PDTC), in Taiwan's hospitalist system.MethodsFrom December 2009 to May 2010, patients admitted to the hospitalist ward of a medical center in Taiwan and later discharged alive to home care were included. Efforts to improve the quality of interventions in the PDTC program, including a disease-specific care plan, telephone monitoring, hotline counseling and referral to a hospitalist-run clinic, were implemented in the latter four months in the intervention group, while the control group was recruited during the first two months of the study period. The primary end point was unplanned readmission or death within 30 days after discharge.ResultsThere were 94 and 219 patients in the control and intervention groups, respectively. Both groups had similar characteristics at the time of admission and at discharge. In the intervention group, 18 patients with worsening disease-specific indicators recorded during telephone monitoring and 21 patients with new or worsening symptoms recorded during hotline counseling had higher rates of unplanned readmission than those without worsening disease-specific indicators (P = 0.031) and worsening symptoms (P = 0.019), respectively. Patients who received PDTC had lower rates of readmission and death than the control group within 30 days after discharge (15% vs. 25%; P = 0.021). Nonuse of a hospitalist-run clinic and presence of underlying malignancy were other independent risk factors for readmission and death within 30 days after discharge.ConclusionIntegrated PDTC using disease-specific care, telephone monitoring, hotline counseling and a hospitalist-run clinic can reduce rates of postdischarge readmission and death.