Hospital Readmission Outcomes Research Articles

P-1883. Evaluation of IVEnsure Device and Care Platform for Remote Therapeutic Monitoring in OPAT: Interim Analysis of a Pilot Study

Abstract Background Data on medication non-adherence in outpatient parenteral antimicrobial therapy (OPAT) and the implications on clinical outcomes are lacking. Remote therapeutic monitoring (RTM) might offer additional insights into OPAT adherence. We present here a pre-planned interim analysis of a pilot study of IVEnsure, an RTM device, in patients receiving OPAT. Methods This prospective study is recruiting adult patients discharged from a tertiary care center on OPAT starting July 2023. After consent, patients are enrolled in an RTM program, including the use of the IVEnsure device, and follow up with a case management team (Figure 1). This FDA-exempt and Medicare-approved healthcare remote monitoring device attaches to the tubing set of any IV medication and transmits infusion-related data in real-time via cellular transmission to generate weekly adherence reports. The study aims to analyze the effect of RTM on hospital readmission outcomes in patients on OPAT, compared to contemporaneous controls in an intention-to-treat analysis. Results The interim analysis includes 44 patients (out of 90 planned) and 74 controls. Baseline characteristics are overall similar between both groups (Table 1). Adjusted for patient age at discharge, insurance status, infection class, presence of diabetes, and discharging service, RTM with IVEnsure is associated with a significant decrease in 90-day readmission rate related to the original infection or OPAT (4% vs. 23%, adjusted OR 0.14, 95% CI 0.02-0.54, p=0.01, Tables 2-3), leading to estimated cost savings of $213,825 in the IVEnsure arm, or $4,860 per patient (Table 4). Within the IVEnsure group, 45% of the patients required an intervention by the study team, 75% of which occurred in the first week of OPAT, resulting in improved or sustained adherence in 73% of the patients (Table 5). Conclusion RTM with IVEnsure significantly reduced infection-related readmissions and associated costs in patients on OPAT. Study accrual continues to evaluate additional readmission-related outcomes. Disclosures Mitchell Berenson, MPH, Community Infusion Solutions: CEO|IVEnsure, Inc.: CEO Jacob K. Dozier, BS, Community Infusion Solutions: COO|IVEnsure, Inc.: COO Debbie N. Meyer, MS, IVEnsure, Inc.: Chief Technology Officer Joseph Sassine, MD, Ansun BioPharma: Grant/Research Support|Cidara Therapeutics: Grant/Research Support|Community Infusion Solutions: Grant/Research Support|F2G: Grant/Research Support|Shionogi: Grant/Research Support

Cardiovascular mortality with oral potassium-binders in patients with CKD and heart failure

Abstract Introduction Hyperkalemia is an inherent consequence of advancing chronic kidney disease (CKD) as a result of the kidney’s decreased ability to excrete potassium. Heart failure patients with concomitant CKD may not tolerate maximum doses of guideline-directed medical therapies (GDMT) like ACE inhibitors (ACEi), angiotensin receptor blockers (ARB), angiotensin receptor/neprilysin inhibitors (ARNI) and mineralocorticoid receptor antagonists (MRA) due to dose-limiting hyperkalemia. Many randomized controlled trials in heart failure exclude patients with advanced CKD. Two oral therapies exist to manage hyperkalemia - patiromer sorbitex calcium and sodium zirconium cyclosilicate. This study aims to identify the potassium-binder with better outcomes as defined by less readmissions, hyperkalemia episodes, and death. Purpose This project was undertaken to better understand the impact of using potassium-binders in CKD patients with heart failure. Improved management of hyperkalemia will be an avenue for optimization of GDMT in this population. Methods and materials The TriNetX research network was used for this study. Two cohorts of patients were created by using International Classification of Disease 10 (ICD-10) codes and CPT codes. Both cohorts consisted of patients with no prior history of hyperkalemia within 30 days of hospital discharge at which time one cohort was prescribed patiromer and the other received sodium zirconium cyclosilicate. Each cohort was prohibited from exposure to the other medication. The cohorts were balanced by propensity score matching and the greedy nearest neighbor algorithm for age, race, gender, ethnicity. They were also balanced for systolic and diastolic heart failure diagnoses, and for each individual stage of CKD (1 through 5 and end stage). They were also balanced for use of ACEi, ARBs, and MRAs. This resulted in 8,921 patients in each arm. They were then evaluated for the outcomes of hospital readmission, hyperkalemia episodes (>6.1 mmol/L), and death within 12 months. Results Patients treated with patiromer were more likely to be hospitalized over the following twelve months (44% vs 40%, RR 1.11, 95% CI (1.07,1.15), p value <0.0001). They were also more likely to experience hyperkalemia (11.7% vs 9.2%, RR 1.27, 95% CI (1.16,1.38), p value <0.0001). Patiromer was also associated with slightly greater all cause mortality (27% vs 25%, RR 1.08, 95% CI (1.03,1.13), p value 0.0021). Discussion This study demonstrates patiromer has more readmissions and hyperkalemia episodes along with greater mortality. In conclusion, sodium zirconium cyclosilicate was found to have better outcomes compared to that of patiromer. Further studies are necessary to better understand the utility of using sodium zirconium cyclosilicate as maintenance therapy for hyperkalemia in order to maximize GDMT in CKD patients with heart failure.

Abstract 11955: Hospital Readmission Outcomes After Myocardial Infarction Among Patients With Myeloproliferative Neoplasms

Introduction: Myeloproliferative neoplasms (MPNs) are chronic leukemias associated with increased risk of arterial and venous thrombotic events. Prior studies suggest patients admitted for acute myocardial infarction (AMI) with MPN have similar in-hospital outcomes but lower rates of invasive management compared with patients without MPN. However, post-hospital outcomes in this patient population have not been well characterized. Methods: Adult MPN patients with a primary admission of AMI from January 2017 to December 2018 were identified using the National Readmission Database. Propensity score matching (PSM) was performed to match 1 MPN for 10 non-MPN controls. Primary outcomes were 30-day all-cause, arterial thrombosis (AT)-related, cardiovascular (CV)-related, and bleeding-related readmissions. Results: After PSM, patient characteristics were well-balanced between groups (Table 1). MPN patients had similar rates of in-hospital mortality but higher rates of bleeding during index hospitalization. MPN patients had increased risk of 30-day all-cause, CV, and AT readmissions but not bleeding (Figure). Conclusions: Among patients hospitalized with AMI, those with MPN are associated with increased risk of CV and AT but not bleeding-related readmissions despite higher rates of index hospitalization bleeding. Further investigation is needed in order to improve post-AMI outcomes in patients with MPN.

Risk Factors for Hospital Re-admission for Diabetes Related Foot Disease: A Prospective Cohort Study

Diabetes related foot disease (DFD) is a common reason for admission to hospital, but the predictive factors for repeat admission are poorly defined. The primary aim of this study was to identify rates and predictive factors for DFD related hospital re-admission. Patients admitted to hospital for treatment of DFD at a single regional centre were recruited prospectively between January 2020 and December 2020. Participants were followed for 12 months to evaluate the primary outcome of hospital re-admission. The relationship between predictive factors and re-admission were examined using non-parametric statistical tests and Cox proportional hazard analyses. The median age of the 190 participants was 64.9 (standard deviation 13.3) years and 68.4% were male. Forty-one participants (21.6%) identified themselves as Aboriginal or Torres Strait Islander people. One hundred participants (52.6%) were re-admitted to hospital at least once over 12 months. The commonest reason for re-admission was for treatment of foot infection (84.0% of first re-admission). Absent pedal pulses (unadjusted hazard ratio [HR] 1.90; 95% confidence interval [CI] 1.26 - 2.85), loss of protective sensation (LOPS) (unadjusted HR 1.98; 95% CI 1.08 - 3.62), and male sex (unadjusted HR 1.62; 95% CI 1.03 - 2.54) increased the risk of re-admission. After risk adjustment, only absence of pedal pulses (HR 1.92, 95% CI 1.27 - 2.91) and LOPS (HR 2.02, 95% CI 1.09 - 3.74) significantly increased the risk of re-admission. Over 50% of patients admitted to hospital for treatment of DFD are re-admitted within one year. Patients with absent pedal pulses and those with LOPS are twice as likely to be re-admitted.

The Impact of Surgeon Volume on Hysterectomy Risk: A Concentration Curve Analysis

<h3>Study Objective</h3> To evaluate the relationship between surgeon volume and the outcomes of hospital readmission and return to the operating room in women who underwent hysterectomy. <h3>Design</h3> Retrospective cohort study <h3>Setting</h3> Multicenter community healthcare system <h3>Patients or Participants</h3> 2,730 women who underwent hysterectomy from July 1, 2015, to June 30, 2019. Patients of the resident practice and hysterectomies for obstetric indications were excluded. <h3>Interventions</h3> Surgeon volume greater than 25 hysterectomies per year. <h3>Measurements and Main Results</h3> A concentration curve was used to evaluate the impact of annual surgeon hysterectomy volume on 30-day all-cause readmission or return to the operating room. The concentration curve suggested a disproportionate number of complications attributed to lower volume surgeons. The peak difference between the curve and the line of equality was used to identify a surgeon volume of 25 hysterectomies per year as the cutoff between low- and high-volume surgeons. Demographics and outcomes were compared using Chi-squared and Mann-Whitney U tests where appropriate. Logistic regression was used to correct for confounders. Low-volume surgeons had a higher rate of reoperation or readmission within 30 days compared to those who underwent surgery by high-volume surgeons (4.9% vs 2.9%, <i>P</i>=0.02). After adjusting for confounders, the adjusted odds ratio was 1.67 (95% CI: 1.03 - 2.81). High-volume surgeons performed a greater percentage of laparoscopic hysterectomies (75% vs 45%), had a shorter length of stay (0.4 days vs 1.2 days, <i>P<</i>0.00001), and a greater total operating room cost ($9,827 vs $9,551, <i>P</i>=0.005). <h3>Conclusion</h3> High-volume surgeons performing more than 25 hysterectomies per year had lower rates of reoperation or readmission within 30 days compared to low-volume surgeons. Concentration curve analysis can be useful in determining if outcome differences can be seen based on volume, and helpful in selecting potential cutoffs to analyze surgeon groups by volume. Surgeon grouping is likely not bimodal, and differences are likely to be detectable at many different volume levels.

Weekend Admission Increases Risk of Readmissions Following Elective Thoracolumbar Spinal Fusion.

Retrospective database study. The goal of this study was to assess the influence of weekend admission on patients undergoing elective thoracolumbar spinal fusion by investigating hospital readmission outcomes and analyzing differences in demographics, comorbidities, and postoperative factors. The 2016-2018 Nationwide Readmission Database was used to identify adult patients who underwent elective thoracolumbar spinal fusion. The sample was divided into weekday and weekend admission patients. Demographics, comorbidities, complications, and discharge status data were compiled. The primary outcomes were 30-day and 90-day readmission. Univariate logistic regression analyzed the relationship between weekday or weekend admission and 30- or 90-day readmission, and multivariate regression determined the impact of covariates. 177,847 patients were identified in total, with 176,842 in the weekday cohort and 1005 in the weekend cohort. Multivariate regression analysis found that 30-day readmissions were significantly greater for the weekend cohort after adjusting for sex, age, Medicare or Medicaid status, and comorbidity status (OR 2.00, 95% CI: 1.60-2.48; P < .001), and 90-day readmissions were also greater for the weekend cohort after adjustment (OR 2.01, 95% CI: 1.68-2.40, P < .001). Patients undergoing elective thoracolumbar spinal fusion surgery who are initially admitted on weekends are more likely to experience hospital readmission. These patients have increased incidence of deep vein thrombosis, postoperative infection, and non-routine discharge status. These factors are potential areas of focus for reducing the impact of the "weekend effect" and improving outcomes for elective thoracolumbar spinal fusion.

Outcomes After Direct Discharge Home From Critical Care Units: A Population-Based Cohort Analysis.

To compare health service use and clinical outcomes for patients with and without direct discharge to home (DDH) from ICUs in Ontario. Population-based, observational, cohort study using propensity scoring to match patients who were DDH to those not DDH and a preference-based instrumental variable (IV) analysis using ICU-level DDH rate as the IV. ICUs in Ontario. Patients discharged home from a hospitalization either directly or within 48 hours of care in an ICU between April 1, 2015, and March 31, 2017. DDH from ICU. Among 76,737 patients in our cohort, 46,859 (61%) were DDH from the ICU. In the propensity matched cohort, the odds for our primary outcome of hospital readmission or emergency department (ED) visit within 30 days were not significantly different for patients DDH (odds ratio [OR], 1.00; 95% CI, 0.96-1.04), and there was no difference in mortality at 90 days for patients DDH (OR, 1.08; 95% CI, 0.97-1.21). The effect on hospital readmission or ED visits was similar in the subgroup of patients discharged from level 2 (OR, 0.98; 95% CI, 0.92-1.04) and level 3 ICUs (OR, 1.02; 95% CI, 0.96-1.09) and in the subgroups with cardiac conditions (OR, 1.03; 95% CI, 0.96-1.12) and noncardiac conditions (OR, 0.98; 95% CI, 0.94-1.03). Similar results were obtained in the IV analysis (coefficient for hospital readmission or ED visit within 30 d = -0.03 ± 0.03 ( se ); p = 0.3). There was no difference in outcomes for patients DDH compared with ward transfer prior to discharge when two approaches were used to minimize confounding within a large health systemwide observational cohort. We did not evaluate how patients are selected for DDH. Our results suggest that with careful patient selection, this practice might be feasible for routine implementation to ensure efficient and safe use of limited healthcare resources.

Outpatient Parenteral Antimicrobial Therapy (OPAT) Program for Infective Endocarditis in North Queensland

Optimal treatment of infective endocarditis is an ongoing challenge. Evidence from Victoria in Australia has suggested outpatient parenteral antimicrobial therapy (OPAT) is safe for use in infective endocarditis (IE). However, data from Townsville and Darwin regions demonstrated solution temperatures from home intravenous infusions significantly differ from stability data, tested at room temperature [1]. It is not clear if this is clinically significant; therefore, it is prudent to examine the outcomes of hospital readmission and mortality of OPAT patient cohorts living in high temperature climates.

Decreases in daily ambulation forecast post-surgical re-admission

Surgical readmissions are clinically and financially problematic. Our purpose is to determine if a decrease in postoperative ambulation (steps/day) is associated with hospital readmission. In this prospective cohort study, patients undergoing elective operations wore an accelerometer activity tracker to measure steps/day for 28 consecutive postoperative days. The primary outcome was hospital readmission. The change in steps/day over two consecutive days prior to the day of the readmission were examined. Predetermined thresholds for decreases of consecutive daily ambulation levels were used to calculate sensitivity and specificity for the outcome of hospital readmission. 215 patients (aged 63±12 years) were included. Readmission occurred in 10% (n=21). For each of the first 28-postoperative days, the entire cohort had an average daily step increase of 136±146 steps/day (Spearman correlation rho=0.990; p<0.001). A decrease in steps for two consecutive days of >50% from the prior day had a 79% sensitivity and 90% specificity for hospital readmission. A decrease of >50% daily ambulation (steps/day) over two consecutive post-discharge days accurately forecasts hospital readmission. The implications of these findings are that monitoring daily ambulation could serve as a form of outpatient telemetry aiding to forecast post-surgical readmissions.

Frequency, risk factors, and outcomes of hospital readmissions of COVID-19 patients

To determine the proportion of patients with COVID-19 who were readmitted to the hospital and the most common causes and the factors associated with readmission. Multicenter nationwide cohort study in Spain. Patients included in the study were admitted to 147 hospitals from March 1 to April 30, 2020. Readmission was defined as a new hospital admission during the 30 days after discharge. Emergency department visits after discharge were not considered readmission. During the study period 8392 patients were admitted to hospitals participating in the SEMI-COVID-19 network. 298 patients (4.2%) out of 7137 patients were readmitted after being discharged. 1541 (17.7%) died during the index admission and 35 died during hospital readmission (11.7%, p = 0.007). The median time from discharge to readmission was 7 days (IQR 3–15 days). The most frequent causes of hospital readmission were worsening of previous pneumonia (54%), bacterial infection (13%), venous thromboembolism (5%), and heart failure (5%). Age [odds ratio (OR): 1.02; 95% confident interval (95% CI): 1.01–1.03], age-adjusted Charlson comorbidity index score (OR: 1.13; 95% CI: 1.06–1.21), chronic obstructive pulmonary disease (OR: 1.84; 95% CI: 1.26–2.69), asthma (OR: 1.52; 95% CI: 1.04–2.22), hemoglobin level at admission (OR: 0.92; 95% CI: 0.86–0.99), ground-glass opacification at admission (OR: 0.86; 95% CI:0.76–0.98) and glucocorticoid treatment (OR: 1.29; 95% CI: 1.00–1.66) were independently associated with hospital readmission. The rate of readmission after hospital discharge for COVID-19 was low. Advanced age and comorbidity were associated with increased risk of readmission.

Hospital Readmission Outcomes by Frailty Risk in Adults in Behavioral Health Acute Care.

The purpose of the current retrospective study was to determine whether frailty is predictive of 30-day readmission in adults aged ≥50 years who were admitted with a psychiatric diagnosis to a behavioral health hospital from 2013 to 2017. A total of 1,063 patients were included. A 26-item frailty risk score (FRS-26-ICD) was constructed from electronic health record (EHR) data. There were 114 readmissions. Cox regression modeling for demographic characteristics, emergent admission, comorbidity, and FRS-26-ICD determined prediction of time to readmission was modest (incremental area under the receiver operating characteristic curve = 0.671). The FRS-26-ICD was a significant predictor of readmission alone and in models with demographics and emergent admission; however, only the Elixhauser Comorbidity Index was significantly related to hazard of readmission adjusting for other factors (adjusted hazard ratio = 1.26, 95% confidence interval [1.17, 1.37]; p < 0.001), whereas FRS-26-ICD became non-significant. Frailty is a relevant syndrome in behavioral health that should be further studied in risk prediction and incorporated into care planning to prevent hospital readmissions. [Journal of Psychosocial Nursing and Mental Health Services, 59(10), 27-39.].

Abstract 17301: Safety of Direct Oral Anticoagulants Compared to Warfarin for Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis

Introduction: The evidence for use of direct oral anticoagulants (DOACs) in the management of post-operative cardiac surgery atrial fibrillation (POAF) is limited and mostly founded on clinical trials that excluded this patient population. Hypothesis: We performed a systematic review and meta-analysis of clinical trials and observational studies to evaluate the hypothesis that DOACs are safe compared to warfarin for the anticoagulation of patients with POAF. Methods: We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and the Cochrane Library for clinical trials and observational studies comparing DOAC with warfarin in patients ≥18 years old who had post-cardiac surgery atrial fibrillation. Primary outcomes included stroke, systemic embolization, bleeding, and mortality, with secondary outcome of hospital readmission. We performed a random-effects meta-analysis. Results: We found 3 clinical trials, 1 prospective and 12 retrospective cohort studies eligible for inclusion with a total of 10,538 patients (3,207 DOAC patients and 7,331 warfarin patients). The meta-analysis for the primary outcomes showed significantly lower risk of stroke with DOAC use (6 studies, 7143 patients, RR 0.64; 95% CI 0.50 to 0.81, I2: 0.0%) compared to warfarin, a trend towards lower risk of systemic embolization (4 studies, 7289 patients, RR 0.64, 95% CI 0.41 to 1.01, I2: 31.99%) and similar risks of bleeding (14 studies, 10182 patients, RR 0.91; 95% CI 0.74 to 1.10, I2: 26.6%) and mortality (12 studies, 9843 patients, relative risk [RR] 1.01; 95% CI 0.74 to 1.37, I2: 26.5%) The secondary outcome of hospital readmission had similar risk between groups. Conclusions: Current evidence suggests that DOACs, compared to warfarin, in the management of atrial fibrillation after cardiac surgery is associated with lower risk of stroke and a strong trend for lower risk of systemic embolization, and no evidence of increased risk for hospital readmission, bleeding or mortality.

Cognitive Tests and Stool Frequency at Hospital Discharge Do Not Predict Outcomes in Hepatic Encephalopathy.

Hepatic encephalopathy (HE) is associated with hospital readmissions and mortality. We sought to determine whether cognitive testing and stool frequency at discharge predicted 30-day readmission or death in cirrhotic patients admitted with overt HE. We approached consecutive inpatients with cirrhosis and overt HE when they were within 48 hours of discharge. Patients underwent cognitive tests, including Psychometric Hepatic Encephalopathy Score (PHES), and stool frequency was documented. Chart review identified Model for End-Stage Liver Disease-sodium (MELD-Na) and the presence of non-HE extrahepatic organ failures. Cox proportional hazards models were used to evaluate predictors of time to the primary composite outcome of hospital readmission for HE or death within 30 days, censoring for liver transplantation. Of 51 patients consented and enrolled, 14 patients met the primary composite outcome. In unadjusted Cox models, 4 variables predicted HE readmission or death: MELD-Na (hazard ratio [HR] 1.10 [1.01-1.20], P = 0.03), respiratory failure (HR 4.26 [1.47-12.35], P = 0.008), total number of HE extrahepatic organ failures (HR 1.79 [1.12-2.88], P = 0.02), and score on a PHES subtest, Number Connection Test A (per 30 seconds; HR 1.25 [1.06-1.47], P = 0.01). PHES and 24-hour stool frequency did not predict the primary outcome. When controlling for MELD-Na, respiratory failure predicted the primary outcome (HR 3.67 [1.24-10.86], P = 0.02). Cognitive testing and stool frequency at discharge did not predict poor outcomes in patients admitted with HE, while respiratory failure appeared to be a strong predictor.

Readmission Outcomes of Sliding Scale Insulin Compared to Basal-Bolus Insulin Prescribed at Discharge in an Insulin-Naive Patient Population

Background: Limited data are available that examine hospital readmission outcomes of sliding scale compared to basal-bolus insulin in indigent and insulin-naive patients. Objective: To evaluate hospital readmission outcomes in patients who are insulin naive with type 2 diabetes mellitus who are initiated on either sliding scale or basal-bolus insulin upon hospital discharge. Methods: A retrospective chart review was conducted of adult patients with a history of type 2 diabetes mellitus, who were insulin naive, had a hemoglobin A1c (HbA1c) 10% or greater, and were discharged with a prescription for sliding scale or basal-bolus insulin from January 2015 to July 2018. The primary objective measured all-cause 30-day hospital readmissions. The secondary objectives measured diabetes-related 30-day hospital readmissions and HbA1c change after 3 months of initial hospital admission. Data were analyzed using descriptive statistics, χ2 test, paired sample t test, and logistic regression. Results: Forty-one patients were prescribed sliding scale insulin and 105 patients were prescribed basal-bolus insulin. The majority were male (60%), spoke English (84%), were self-pay (39%), and had a mean age of 51 ± 10.2 years, initial HbA1c of 13% ± 1.9%, and LACE+ score of 51 ± 15.6 upon discharge. All-cause 30-day hospital readmissions occurred in 14.6% of sliding scale and 6.7% of basal-bolus insulin groups (odds ratio [OR]: 2.40, 95% confidence interval [CI]: 0.75-7.63). Hyperglycemia occurred in 7.3% of sliding scale and 0.9% of basal-bolus insulin groups. Mean HbA1c difference for basal-bolus and sliding scale insulin was 3.3 ± 3.1 and 2.9 ± 2.7, respectively (P = 0.459). Conclusion: There was no significant difference in all-cause 30-day hospital readmissions comparing sliding scale to basal-bolus insulin.

Tele-transitions of care (TTOC): a 12-month, randomized controlled trial evaluating the use of Telehealth to achieve triple aim objectives

BackgroundPoor transitions of care leads to increased health costs, over-utilization of emergency room departments, increased re-hospitalizations and causes poor patient experiences and outcomes. This study evaluated Telehealth feasibility in improving transitions of care.MethodsThis is a 12-month randomized controlled trial, evaluating the use of telehealth (remote patient monitoring and video visits) versus standard transitions of care with the primary outcomes of hospital readmission and emergency department utilization and secondary outcomes of access to care, medication management and adherence and patient engagement. Electronic Medical Record data, Health Information Exchange data and phone survey data was collected. Multi-variable logistic regression models were created to evaluate the effect of Telehealth on hospital readmission, emergency department utilization, medication adherence. Chi-square tests or Fisher’s exact tests were used to compare the percentages of categorical variables between the Telehealth and control groups. T tests or Wilcoxon rank sum tests were used to compared means and medians between the two randomized groups.ResultsThe study conducted between June 2017 and 2018, included 102 patients. Compared with the standard of care, Telehealth patients were more likely to have medicine reconciliation (p = 0.013) and were 7 times more likely to adhere to medication than the control group (p = 0.03). Telehealth patients exhibited enthusiasm (p = 0.0001), and confidence that Telehealth could improve their healthcare (p = 0.0001). Telehealth showed no statistical significance on emergency department utilization (p = 0.691) nor for readmissions (p = 0.31). 100% of Telehealth patients found the intervention to be valuable, 98% if given the opportunity, reported they would continue using telehealth to manage their healthcare needs, and 94% reported that the remote patient monitoring technology was useful.ConclusionsTelehealth can improve transitions of care after hospital discharge improving patient engagement and adherence to medications. Although this study was unable to show the effect of Telehealth on reduced healthcare utilization, more research needs to be done in order to understand the true impact of Telehealth on preventing avoidable hospital readmission and emergency department visits.Trial registrationClinicalTrials.Gov ID: NCT03528850 Date Registered (Retrospective): 5/18/2018.Status: Completed.IRB #: 970227.

Reducing Hospital Readmissions Through a Skilled Nursing Facility Discharge Intervention: A Pragmatic Trial

To determine if implementation of Project Re-Engineered Discharge (RED), designed for hospitals but adapted for skilled nursing facilities (SNFs), reduces hospital readmissions after SNF discharge to the community in residents admitted to the SNF following an index hospitalization. A pragmatic trial. SNFs in southeastern Massachusetts, and residents discharged to the community. We compared SNFs that deployed an adapted RED intervention to a matched control group from the same region. The primary outcome was hospital readmission within 30days after SNF discharge, among residents who had been admitted to the SNF following an index hospitalization and then discharged home. January 2016 through March 2017 was the baseline period; April 2017 through June 2018 was the follow-up period (after implementation of the intervention). We used a difference-in-differences analysis to compare the intervention SNFs to the control group, using generalized estimating equation regression and controlling for facility characteristics. After implementation of RED, readmission rates were lower across all 4 measures in the intervention group; control facilities' readmission rates remained stable or increased. The relative decrease was 0.9% for the primary outcome of hospital readmission within 30days after SNF discharge and 1.7% for readmission within 30days of the index hospitalization discharge date (P≤.001 for both comparisons). We found that a systematic discharge process developed for the hospital can be adapted to the SNF environment and can reduce readmissions back to the hospital, perhaps through improved self-management skills and better engagement with community services. This work is particularly timely because of Medicare's new Value-Based Purchasing Program, in which nursing homes can receive incentive payments if their hospital readmission rates are low relative to their peers. To verify its scalability and broad potential, RED should be validated across a broader diversity of SNFs nationally.

Thirty-day medical and surgical readmission following prenatal versus postnatal myelomeningocele repair.

Hospital readmission is an important quality metric that has not been evaluated in prenatal versus postnatal myelomeningocele (MMC) repair. This study compares hospital readmission outcomes between these two groups as well as their etiologies. The medical records of patients who had undergone MMC repair in the period from 2011 to 2017 at a single academic medical center were retrospectively reviewed. Collected clinical data included surgery and defect details, neonatal intensive care unit (NICU) stay, and any readmissions or surgical procedures up to 1 year after surgery. Patient and defect characteristics, readmission outcomes at 30 and 60 days and 1 year after discharge from the NICU, and cerebrospinal fluid (CSF) diversion surgery rates were analyzed with the two-tailed t-test and/or k-sample test on the equality of medians. A total of 24 prenatal and 34 postnatal MMC repairs were completed during the study period. Prenatally repaired patients were born more prematurely (p < 0.001) and with lower birth weights (p < 0.001), although the NICU stay was similar between the two groups (p = 0.59). Fewer prenatally repaired patients were readmitted at 30 days (p = 0.005), 90 days (p = 0.004), and 1 year (p = 0.007) than the postnatal repair group. Hydrocephalus was the most common readmission etiology, and 29% of prenatal repair patients required CSF diversion at 1 year versus 81% of the postnatal repair group (p < 0.01). Prenatal patients who required CSF diversion had a higher body weight (p = 0.02) and an older age (p = 0.01) at the time of CSF diversion surgery than the postnatal group. Patients with prenatal MMC repair had fewer hospital readmissions at 30 days, 60 days, and 1 year than the postnatal repair group, despite similar NICU lengths of stay. The prenatal repair group had lower requirements for CSF diversion at 1 year and was older with greater body weights at the time of CSF diversion surgery, compared to those of the postnatal repair group. Future study of hospital quality metrics such as readmissions should be performed to better understand outcomes of these two procedures.

Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge

Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization. To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge. In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019. Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge. The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge. The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg). Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.

Abstract P131: Sex Specific Patterns of Heart Rate Variability Following Acute Coronary Syndrome Do Not Drive 2-Year Hospital Readmission Outcomes

Introduction: Women experience poorer clinical outcomes after Acute Coronary Syndrome (ACS). While the reason for this differential is unclear, autonomic function -indicative of vagal and sympathetic modulation directed to the sinus node- is a candidate mechanism. Hypothesis: That sex-specific differences in heart rate variability (HRV) in the year following ACS drive all-cause readmission outcomes after 2-years. Methods: 416 ACS patients were enrolled in the ADVENT longitudinal cohort study after admission to a large cardiology hospital (January 2013 to June 2014). At 1 and 12 months following discharge, autonomic functioning was measured by HRV using time and spectral analysis via 3-lead electrocardiogram at the Study Centre. All-cause hospital readmission was collected from an audit of hospital records by medically trained researcher fellows. Hierarchical linear regression analyses were used to determine the extent to which HRV parameters (Standard Deviation of RR, Median RR (millisecond), Low Frequency Power, Very Low Frequency Power), drive sex-specific readmission outcomes (yes/no) over 2-years. Interaction terms (sex x individual HRV parameter) were used to determine the extent to which HRV was a modifier of the main effects model. Results: Women were more likely to be rehospitalized for all cause morbidity over the ensuing 2-years, however this was not statistically significant (Coef: 0.09; 95% CIs: -0.03, 0.21). The inclusion of only one of the HRV parameters (Median RR (ms)) substantially ameliorated the chance of women being readmitted (adj. Coef -0.47, 95% CIs: -1.38, 0.43; ns). Conclusion: Women experience significantly poorer autonomic functioning in the year following ACS, but this does not appear to influence sex-specific all-cause readmission over 2 years in a statistically meaningful way.

1868. Successful Use of Telemedicine vs. On-site Infectious Diseases Consultation After Implementation of a System-Wide Antimicrobial Stewardship-Led Staphylococcus aureus Bacteremia Care Bundle

BackgroundTelemedicine (TM) programs have been effectively implemented to deliver specialty care through virtual platforms to overcome geographic and resource constraints. Yet, few data exist to describe outcomes associated with TM-based management of patients with infectious diseases (ID). The purpose of this study was to compare adherence and other outcomes associated with TM and on-site (SOC) ID consultation (IDC) implementation strategies of an antimicrobial stewardship (ASP)-led S. aureus bacteremia (SAB) bundle.MethodsWe launched an SAB bundle at 10 acute care hospitals in the metro Charlotte, NC area in September 2016 for adult patients admitted with SAB and conducted a retrospective cohort study using data collected through 2017. Bundle components included (1) mandatory IDC, (2) appropriate antibiotics within 24 hours of S. aureus speciation, (3) repeat blood cultures at least every 72 hours until clearance, (4) obtainment of an echocardiogram, and (5) appropriate duration of intravenous antibiotic therapy based on SAB severity. ASP facilitated bundle initiation and assisted with compliance for all patients. The primary outcome was bundle adherence. Secondary outcomes included time to culture clearance and persistent SAB (i.e., positive blood cultures for >7 days). We used Wilcoxon rank-sum and chi-squared tests to compare outcomes.ResultsWe evaluated 872 patients with SAB during the study interval. After excluding 126 patients (prematurely discharged or died/transitioned to comfort care within 48 hours of S. aureus speciation), we analyzed 583 SOC and 163 TM group patients. There were no differences observed in overall SAB bundle adherence (SOC 86% vs. TM 88%, P = 0.52), or its individual components. No differences were found in time to culture clearance (median days: SOC = 2.9 vs. TM = 2.8, P = 0.96) and persistent SAB (SOC 11% vs. TM 11%, P = 0.77).ConclusionOur findings provide preliminary evidence to support TM-based strategies for IDC and ASP-led care bundles in resource-limited settings. Future analyses will compare mortality and hospital readmission outcomes. Disclosures All authors: No reported disclosures.