Increase In 30-day Readmissions Research Articles

Impact of enhanced recovery program on clinical outcomes after elective colorectal surgery in a rural hospital. A single center experience

BackgroundThe main purpose was to determine the impact on postoperative outcomes of a standardized enhanced recovery program (ERP) for elective colorectal surgery in a rural hospital. MethodsA prospective series of patients (N = 80) undergoing elective colorectal resection completing a standardized ERP protocol in 2018–2020 (ERP group) was compared to patients (N = 80) operated at the same rural hospital in 2013–2015 (pre-ERP group), before the implementation of the program. The exclusion criteria for both groups were: ASA score IV, TNM stage IV, inflammatory bowel disease, emergency surgery, and rectal cancer. The primary outcome was hospital length of stay (LoS) which was used as an estimate of functional recovery. Secondary outcomes included 30-day readmission and mortality rates as well as associated factors with both postoperative complications and prolonged hospital LoS. ResultsBaseline characteristics were comparable in both groups. The median adherence to ERP protocol elements was 68 % versus 12 % in the retrospective control group. The median hospital LoS in the ERP-group was significantly lower than in the pre-ERP group (5 vs. 10 days) with no increase in 30-day readmission and mortality rates. The Body Mass Index ≥30 and the traditional peri-operative protocol were the associated factors to postoperative complications, while following a traditional peri-operative protocol was the only factor associated with a prolonged hospital LoS (p < 0.0001). ConclusionsAlthough limited hospital resources are perceived as a barrier to ERP implementation, the current experience demonstrates how adopting an ERP program in a rural area is feasible and effective, despite it requires greater effort.

1180. Empiric treatment of uncomplicated intraabdominal infection with cefazolin with or without metronidazole

Abstract Background Treatment guidelines for management of intra-abdominal infection (IAI) differ on whether cefazolin should be used first line to treat uncomplicated infection. In an effort to reduce unnecessary fluoroquinolone and piperacillin/tazobactam use, protocols were implemented with which recommendations were made to narrow to cefazolin ± metronidazole for uncomplicated IAI. The purpose of this study was to determine if there is a difference in outcomes with cefazolin +/- metronidazole versus broader-spectrum antibiotics for treatment of uncomplicated IAI. Methods This was a retrospective cohort study that reviewed inpatients at three acute-care community teaching hospitals from January 1, 2017, through December 31, 2021. Treatment groups were patients treated with cefazolin +/- metronidazole (study group) compared to those treated with piperacillin/tazobactam or ceftriaxone, ciprofloxacin, or cefepime each +/- metronidazole (control group). Inclusion criteria were age ≥ 18 years old; admission diagnosis of uncomplicated cholecystitis, diverticulitis, or appendicitis; and received as empiric inpatient treatment either cefazolin ± metronidazole, piperacillin/tazobactam, or ceftriaxone, ciprofloxacin, or cefepime ± metronidazole for at least 24 hours. Exclusion criteria were presence of perforation or abscess for cholecystitis or diverticulitis, cholangitis or pregnancy. The primary outcome measure was all-cause 30-day readmission rate. Results A total of 779 patients were included in the cefazolin group and 2269 patients were included in the broader-spectrum group. All-cause 30-day readmission rate was 5.8% in the cefazolin +/- metronidazole compared to 12.1% in the broader-spectrum group (OR 0.38, 95% CI 0.27-0.53, p &amp;lt; 0.001). Average length of stay was 3.6 days for the cefazolin group vs. 4.4 days for the broader-spectrum group (cefazolin group range 1 to 35 days, broader-spectrum group range 1 to 59 days, p &amp;lt; 0.0001). Conclusion Empiric treatment of uncomplicated intra-abdominal infection with cefazolin +/- metronidazole did not result in an increase in 30-day readmissions compared to broader-spectrum empiric antibiotics. Disclosures All Authors: No reported disclosures

Predictors of 30-Day Readmission in Patients Hospitalized With Heart Failure as a Primary Versus Secondary Diagnosis

Short-term rehospitalizations are common, costly, and detrimental to patients with heart failure (HF). Current research and policy have focused primarily on 30-day readmissions for patients with HF as a primary diagnosis at index hospitalization, whereas a much larger population of patients are admitted with HF as a secondary diagnosis. This study aims to compare patients initially hospitalized for HF as either a primary or a secondary diagnosis, and to identify the most important factors in predicting 30-day readmission. Patients admitted with HF between 2014 and 2016 in the Nationwide Readmissions Database were included and divided into 2 cohorts: those admitted with a primary and secondary diagnosis of HF. Multivariable logistic regression was performed to predict 30-day readmission. Statistically significant predictors in multivariable logistic regression were used for dominance analysis to rank these factors by relative importance. Co-morbidities were the major driver of increased risk of 30-day readmission in both groups. Individual Elixhauser co-morbidities and the Elixhauser co-morbidity indexes were significantly associated with an increase in 30-day readmission. The 5 most important predictors of 30-day readmission according to dominance analysis were age, Elixhauser co-morbidity indexes of co-morbidity complications and readmission, number of diagnoses, and renal failure. These 5 factors accounted for 68% of the 30-day readmission risk. Measures of patient co-morbidities were among the strongest predictors of readmission risk. This study highlights the importance of expanding predictive models to include a broader set of clinical measures to create better-performing models of readmission risk for HF patients.

Improved Operative Efficiency and Surgical Times in Autologous Breast Reconstruction: A 15-year Single-center Retrospective Review.

Autologous breast reconstruction using a free deep inferior epigastric perforator (DIEP) flap is a complex procedure that requires a dedicated approach to achieve operative efficiency. We analyzed data for DIEP flaps at a single center over 15 years to identify factors contributing to operative efficiency. A single-center, retrospective cohort analysis was performed of consecutive patients undergoing autologous breast reconstruction using DIEP free flaps between January 1, 2005, and December 31, 2019. Data were abstracted a priori from electronic medical records. Analysis was conducted by a medical statistician. Analysis of 416 unilateral and 320 bilateral cases (1056 flaps) demonstrated reduction in operative times from 2005 to 2019 (11.7-8.2 hours for bilateral and 8.4-6.2 hours for unilateral, P < 0.000). On regression analysis, factors significantly correlating with reduced operative times include the use of venous couplers (P < 0.000), and the internal mammary versus the thoracodorsal recipient vessels (P < 0.000). Individual surgeon experience correlated with reduced OR times. Post-operative length of stay decreased significantly, without an increase in 30-day readmission or emergency presentations. Flap failure occurred in two cases. Flap take-back rate was 2% (n = 23) with no change between 2005 and 2019. Operative times for breast reconstruction have decreased significantly at this center over 15 years. The introduction of venous couplers, use of the internal mammary system, and year of surgery significantly correlated with decreased operative times. Surgeon experience and a shift in surgical workflow for DIEP flap reconstruction likely contributed to the latter finding.

Changing disposition patterns in the era of COVID-19 after colon resections: A National Surgical Quality Improvement Program colectomy study

BackgroundThe COVID-19 pandemic severely impacted post-hospitalization care facilities in the United States and hindered their ability to accept new patients for various reasons. This study aimed to assess the impact of the pandemic on discharge disposition after colon surgery and associated postoperative outcomes. MethodsA retrospective cohort study was performed using the National Surgical Quality Improvement Participant Use File and targeted colectomy. Patients were divided into the following 2 cohorts: (1) pre-pandemic (2017–2019) and (2) pandemic (2020). The primary outcomes included discharge disposition—post-hospitalization facility versus home. The secondary outcomes were rates of 30-day readmissions and other postoperative outcomes. The multivariable analysis assessed for confounders and effect modification on discharge to home. ResultsDischarge to posthospitalization facilities decreased by 30% in 2020 compared to 2017 to 2019 (7% vs 10%, P < .001). This occurred despite an increase in emergency cases (15% vs 13%, P < .001) and open surgical approach (32% vs 31%, P < .001) in 2020. Multivariable analysis revealed that patients in 2020 had 38% lower odds of going to post-hospitalization facilities (odds ratio 0.62, P < .001) after adjusting for surgical indications and underlying comorbidities. This decrease in patients going to a post-hospitalization facility was not associated with an increased length of stay or an increase in 30-day readmissions or postoperative complications. ConclusionDuring the pandemic, patients undergoing colonic resection were less likely to be discharged to a post-hospitalization facility. This shift was not associated with an increase in 30-day complications. This should prompt further research to assess the reproducibility of these associations, especially in a setting without a global pandemic.

Outcomes on an inpatient oncology service after the introduction of hospitalist comanagement.

Smilow Cancer Hospital (SCH) introduced hospitalist comanagement to the inpatient oncology service to address long lengths of stay and oncologist burnout. To determine the impact of hospitalists on inpatient quality outcomes and oncologist experience. Hospitalists were introduced to one of two inpatient oncology services at SCH. Patients were assigned to teams equally based on capacity. Outcomes on the oncologist-led, traditional service (TS) were compared with outcomes on the hospitalist service (HS) 6 months after program implementation. Outcomes included patient volume, length of stay (LOS), early discharge, discharge time, and 30-day readmission rate. Mixed linear or Poisson models that accounted for multiple admissions during the study duration were used. Oncologist experience was measured by survey. During the study period, there were 713 discharges, 400 from the HS and 313 from the TS (p = .0003). There was no difference in demographics or severity of illness (SOI) between services. Following adjustment for age, sex, race/ethnicity, cancer type, and discharge disposition, the average LOS was 4.71 on the HS and 5.47 on the TS (p = .01). Adjusted early discharge rate was 6.22% on the HS and 2.06% on the TS (p = .01). Adjusted mean discharge time was 3:45 p.m. on HS and 4:16 p.m. on TS (p = .009). There was no difference in readmission rates. Oncologists reported less stress (p = .001) and a better ability to manage competing responsibilities (p < .0001) while working on the HS. Hospitalist comanagement significantly improved LOS, early discharge, time of discharge, and oncologist experience without an increase in 30-day readmissions.

Safety of craniotomy for brain tumor resection in octogenarians and older patients – a matched - cohort analysis

Introduction The incidence of brain tumors has increased in elderly population overtime. Their eligibility to a major surgery remains a questionable subject. This study evaluated prognostic factors and 30-days morbidity and mortality in octogenarian population who underwent craniotomy for resection of brain tumor. Materials and methods A total of 154 patients were divided into two different groups: patients above 80 years old and patients below 65 years old. In both groups, patients were stratified based on diagnosis with benign tumors [meningioma] and malignant tumors [high-grade gliomas and metastases]. Multivariable logistic regression model with backward elimination method was utilized to identify the independent risk factors for 30-days readmission and post-operative complications. Results The analysis revealed no significant difference in 30-day readmission (p = 0.7329), 30-day mortality (0.6854) or in post-operative complication (p = 0.3291) between age ≥ 80 and age ≤ 65 groups. A longer length of stay (LOS) was observed in the older patients (p = 0.0479). There was a significant difference in the pre-post KPS between the two groups (p < 0.0001). ASA (p = 0.0315) and KPS (p = 0.071) were found as important prognostic factors associated with post-operative mortality in both groups. Conclusion Octogenarians can withstand craniotomy without any significant increase in 30-day readmission, 30-day mortality and post-operative complications as compared to patients younger than age 65. The ASA score (>3) and/or KPS (<70) were the most important prognostic factors for 30-days readmission and mortality.

Development of an acute medical unit to optimize patient flow and early discharges in a tertiary care hospital in the United Arab Emirates

BackgroundHospitals worldwide are seeing an increased number of acute admissions, with resultant emergency department (ED) crowding and increased length of stay (LOS). Acute Medical Units (AMUs) have developed throughout the United Kingdom and other Western countries to reduce the burden on EDs and improve patient flow. Limited information is available on AMUs in the Middle East. The purpose of this study is to describe the development of the first AMU in the United Arab Emirates (UAE) for general medical patients and its impact on LOS, early discharges, ED boarders, and readmission rates.MethodsWe established a consultant-led AMU in a tertiary hospital in the UAE. A retrospective comparative review of all general medical admissions to the AMU between August 1, 2020 and December 31, 2020 and all admissions to the traditional medical wards between August 1, 2019 and December 31, 2019 was conducted.ResultsThe average LOS reduced from 10 to 5 days (95% CI [4.14–6.25], p < 0.001) after the introduction of AMU. Early discharges increased by 22%. The number of outliers and number of patients boarding in ED reduced significantly (111 in 2019 vs. 60 in 2020, p < 0.05; 938 in 2019 vs. 104 in 2020, p < 0.001 respectively), with a decrease in ED waiting time from 394 min to 134 min (95% CI [229.25–290.75], p < 0.001). There was no increase in 30-day readmission rates.ConclusionRestructuring the system of care can reduce LOS, overcome discharge barriers and improve patient flow. Similar units can be developed in hospitals throughout the UAE and the region to reduce LOS and improve patient flow through acute care units.

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

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

A Breakthrough Improvement Collaborative Significantly Reduces Hospital Stay After Elective Colectomy for Cancer Across a Healthcare System.

Objective:This multicenter study aimed to assess (1) the effect of an improvement collaborative on enhanced recovery after surgery (ERAS) protocol adherence after elective colectomy and (2) the association between adherence and patient outcomes.Background:ERAS pathways provide a framework to standardize care processes and improve postoperative outcomes in patients after colon surgery. Despite growing evidence of its effectiveness, adherence to these guidelines remains a challenge.Methods:This prospective, multicenter collaborative was initiated throughout 11 hospitals in Flanders, Belgium. A structured audit tool was used to study patient outcomes and adherence to 12 ERAS components, defined by the collaborative. Three retrospective audits (based on patient record analysis) were conducted in 2017, 2019, and 2021, respectively.Results:Overall, 740 patients were included (45.4% female; mean±SD age, 71±12 years). The overall adherence increased from 42.8% in 2017 to 58.4% in 2019 and 69.2% in 2021. Compared with low adherence, length of stay was increasingly reduced by 1.3 days for medium [95% confidence interval (95% CI): −2.5; 0.0], 3.6 days for high (95% CI: −4.9; −2.2), and up to 4.4 days for very high adherence (95% CI: −6.1; −2.7). Corresponding odds ratios for postoperative complications were 0.62 (95% CI: 0.33; 1.17), 0.19 (95% CI: 0.09; 0.43), and 0.14 (95% CI: 0.05; 0.39), respectively. No increase in 30-day readmissions was observed.Conclusions:A peer-constructed improvement collaborative effectively increases adherence to an ERAS protocol in individual hospitals. Across time, length of stay and postoperative complications decreased significantly, and a dose-response relationship was observed.

Effects of the COVID-19 pandemic on hip fracture volume, disposition, and readmission rates

Our study aimed to assess the effects COVID had on the incidence of hip fractures. Hip fracture cases (from March 1 to September 1) were compared in 2018, 2019, and 2020. Data were analyzed for surgical volume, discharge location, and readmission rates. There was a statistically significant decrease in hip fractures during 2020 (P < 0.01) and a decrease in patients placed in skilled nursing facilities (P = 0.04), with no increase in 30-day readmission (P = 0.776). Findings suggest that COVID-19 has impacted the volume and composition of hip fracture cases. Although additional research on the subsequent survival impact is necessary, these placement patterns of hip fracture patients into facilities may be an opportunity to optimize cost and care.

Demographics and Risk Factors of Pediatric Pulmonary Hypertension Readmissions

Background and Objectives: Pulmonary hypertension (PH) leads to significant morbidity and mortality in pediatric patients and increases the readmission rates for hospitalizations. This study evaluates the risk factors and comorbidities associated with an increase in 30-day readmissions among pediatric PH patients.Methods: National Readmission Database (NRD) 2017 was searched for patients less than 18 years of age who were diagnosed with PH based on the International Classification of Diseases, 10th Revision (ICD-10). Statistical Package for the Social Sciences (SPSS) software v25.0 (IBM Corp., Armonk, NY) was used for statistical analysis.Results: Of 5.52 million pediatric encounters, 10,501 patients met the selection criteria. The 30-day readmission rate of 14.43% (p < 0.001) was higher than hospitalizations from other causes {Odds Ratio (OR) 4.02 (3.84-4.20), p < 0.001}. The comorbidities of sepsis {OR 0.75 (0.64-0.89), p < 0.02} and respiratory infections {OR 0.75 (0.67-0.85), p < 0.001} were observed to be associated with lower 30-day readmissions. Patients who required invasive mechanical ventilation via endotracheal tube {OR 1.66 (1.4-1.96), p < 0.001} or tracheostomy tube {OR 1.35 (1.15-1.6), p < 0.001} had increased unplanned readmissions. Patients with higher severity of illness based on All Patients Refined Diagnosis Related Groups (APR-DRG) were more likely to get readmitted {OR 7.66 (3.13-18.76), p < 0.001}.Conclusion: PH was associated with increased readmission rates compared to the other pediatric diagnoses, but the readmission rate in this study was lower than one previous pediatric study. Invasive mechanical ventilation, Medicaid insurance, higher severity of illness, and female gender were associated with a higher likelihood of readmission within 30 days.

Association of same-day discharge with hospital readmission after pediatric thyroidectomy.

Studies have demonstrated that same-day discharge (SDD) following thyroid resection is safe and feasible in adults but there are no similar studies in the pediatric age group. The purpose of this study is to evaluate the influence of SDD on 30-day readmission rates following thyroid surgery in pediatric patients. This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database to evaluate 30-day readmission rates among patients < 19years of age who underwent thyroid resection between 2012 and 2017. Patients excluded were those discharged more than 2days after surgery. The main exposure variable was SDD and the primary outcome was 30-day readmission. Secondary outcomes included wound complications, unplanned reoperation and death. Patient characteristics were compared using chi-squared testing and odds ratios for readmission were calculated using multivariate logistic regression. Of the 1125 patients (79% female, median age 15years), 122 (11%) were discharged on the day of surgery. Total or near-total thyroidectomy represented the majority of operations (714, 63.5%) and patients undergoing these operations were less likely to be discharged on the same day as surgery compared to those undergoing thyroid lobectomy (4.3 vs. 22.1%, P < 0.001). Twenty-nine patients were readmitted within 30days (3 in the same day group, 26 in the later group). There was no difference in the odds of readmission between the two groups (adjusted odds ratio in SDD compared to later discharge 1.04 [95% CI 0.29-3.75, P = 0.96; readmission rate, 2.46 vs. 2.59%). Wound complications were reported in two patients, both in the later discharge group. Same-day discharge in pediatric patients undergoing thyroidectomy is not associated with an increase in 30-day readmissions or wound complications when compared to patients discharged 1 or 2days after surgery. In selected patients, SDD may be an appropriate alternative to traditional overnight stay.

Institutional Postacute Care Use May Help Reduce Readmissions for Ischemic Stroke Patients.

Readmissions for Medicare patients initially admitted for stroke are common and costly. Rehabilitation in an institutional postacute care (PAC) setting is an evidence-based component of recovery for stroke. Under current Medicare payment reforms, care coordination across hospitals and PAC providers is key to improving quality and efficiency of care. We examined the causal impact of institutional PAC use on 30-day readmission rates for Medicare fee-for-service patients initially admitted for ischemic stroke. The 2010-2016 Medicare Provider Analysis and Review files. We used the method of instrumental variable (IV) analysis to control for unobserved differences in the types of patients admitted to each PAC facility. We chose the distance from the patient's residence to the closest institutional PAC provider and the number of PAC providers of each type within a county where the patient resides as IVs. In the naive model, an increase in institutional PAC use was significantly associated with an increase in 30-day readmission by 0.03 percentage points. However, using IV analysis to control for endogeneity bias, an increase in institutional PAC use was associated with a decrease in 30-day readmission rate by 0.19 percentage points. Our findings indicate that reducing institutional PAC use among patients typically requiring rehabilitation in institutional settings for recovery may potentially lead to adverse postdischarge outcomes that require rehospitalization. Thus, payment incentives to reduce institutional PAC use should be balanced with postdischarge outcomes among ischemic stroke patients.

Impact of an Antimicrobial Stewardship Program-bundled initiative utilizing Accelerate Pheno\u2122 system in the management of patients with aerobic Gram-negative bacilli bacteremia

PurposeGram-negative bacteria (GNB) are a leading cause of bloodstream infections (BSI) and management is complicated by antibiotic resistance. The Accelerate Pheno™ system (ACC) can provide rapid organism identification and antimicrobial susceptibility testing (AST).MethodsA retrospective, pre-intervention/post-intervention study was conducted to compare management of non-critically ill patients with GNB BSI before and after implementation of a bundled initiative. This bundled initiative included dissemination of a clinical decision algorithm, ACC testing on all GNB isolated from blood cultures, real-time communication of results to the Antimicrobial Stewardship Program (ASP), and prospective audit with feedback by the ASP. The pre-intervention period was January 2018 through December 2018, and the post-intervention period was May 2019 through February 2020.ResultsSeventy-seven and 129 patients were included in the pre-intervention and post-intervention cohorts, respectively. When compared with the pre-intervention group, the time from Gram stain to AST decreased from 46.1 to 6.9 h (p < 0.001), and the time to definitive therapy (TTDT) improved from 32.6 to 10.5 h (p < 0.001). Implementation led to shorter median total duration of antibiotic therapy (14.2 vs 9.5 days; p < 0.001) and mean hospital length of stay (7.9 vs 5.3 days; p = 0.047) without an increase in 30-day readmissions (22.1% vs 14%; p = 0.13).ConclusionImplementation of an ASP-bundled approach incorporating the ACC aimed at optimizing antibiotic therapy in the management GNB BSI in non-critically ill patients led to reduced TTDT, shorter duration of antibiotic therapy, and shorter hospital length of stay without adversely affecting readmission rates.

Abstract 16021: Troponin Testing and One-year Hospital Readmission

Introduction: Troponin I (TnI) elevation is an important tool for detecting cardiac injury, though it is not disease specific and can be elevated in other conditions such as sepsis or heart failure. Predictive models suggest that TnI elevation correlates with increased mortality, however, it is unclear if TnI testing or elevation has value for predicting readmissions. Hypothesis: We hypothesized inpatient TnI testing would correlate with 30-day hospital readmissions. Methods: Patient data was collected from January 1st , 2016 through December 31st , 2016 and was comprised of 54,039 patients. Analysis was performed on TnI positive patients and correlated with 30-day hospital readmission rates among the entire cohort as well as those subdivided by ICD-10 codes into acute myocardial infarction (AMI), sepsis, pulmonary disease, and cardiac non-AMI. A subsequent propensity-matched logistic regression was performed among the entire cohort with TnI testing as well as resultant positive TnI to calculate odds ratios (OR) and 95% confidence intervals (CI). Results: Among the entire cohort, 4,572 patients (8.5%) were readmitted within 30 days. TnI testing was associated with increased readmission within 30 days (3,428/30,173; 11.4%; p&lt;0.0001). Logistic regression analysis revealed an increased odds ratio for 30-day readmission of 2.24 (95% CI [2.08-2.41]; p&lt;0.0001) among those with TnI draw. In those with a resultant positive troponin, however, the odds of 30-day readmission were 1.04 (95% CI [0.95-1.14]; p=0.4006). Although there was no significant increase in 30-day readmission among the AMI cohort who had troponin draw (n=1,722; OR 3.66, 95% CI [0.97-32.53], p=0.12), there were significant increases among those admitted for sepsis (n=4,834; OR 2.41, 95% CI [1.84-3.22], p&lt;0.0001), pulmonary disease (n=2,120; OR 3.92, 95% CI [2.07-8.55], p&lt;0.0001), and cardiac non-AMI (n=9,808; OR 2.34, 95% CI [2.15-2.56], p&lt;0.0001). Conclusions: Hospital readmission within 30 days is associated with TnI testing and may be further predictive in non-AMI ICD-10 diagnoses such as sepsis, pulmonary disease, and non-AMI cardiac disease. However, a positive TnI may not be a useful objective data point for prediction of hospital readmission within 30 days.

Long-term PM2.5 exposure as a risk factor for 30-day hospital readmissions among heart failure patients

Background: Hospital readmissions represent a health and economic burden to patients and the healthcare system. We understand little about the relationship between long-term environmental exposures and hospital readmission risk. Here, we use electronic health records linked to exposure data (EPA CARES) to quantify the associations between long-term PM2.5 exposure at the time of heart failure (HF) diagnosis and the number of hospital readmissions – a key outcome metric for quality of care for hospitals and healthcare systems. Methods: Annual average PM2.5 was estimated at 1x1 km resolution for each primary residence. We used stabilized inverse probability weights to account for imbalanced confounder distributions and the competing risk of death. We adjusted for age at HF diagnosis, race, sex, year of HF diagnosis, and neighborhood socioeconomic status in quasi-Poisson regression models with an offset of log(follow-up time). Associations are presented as the percent increase from the mean and associated 95% confidence interval (CI). Results: Among 34,459 HF patients, 18,078 had an inpatient or emergency admission, thus qualifying them to have a readmission and enter this analysis. A 1 µg/m3 increase in annual average PM2.5 was associated with an 11% (95% CI = 6 – 16) increase in 30-day readmissions; independent of short-term (5-day average) exposures prior to the readmissions. PM2.5 exposure was also associated with a 13% (95% CI = 4 – 22) and 14% (95% CI = 10 – 18) increase in 7 and 90 day readmissions, respectively. Conclusion: Long-term PM2.5 exposure is associated with increased hospital readmissions, including 30-day readmissions, a closely tracked metric by which hospitals and healthcare systems are evaluated. Associations were independent of short-term variations in PM2.5 prior to readmission, indicating that long-term exposures may be an important contributor to hospital readmission risk that should be further explored. This abstract does not necessarily represent EPA policy.

Safe implementation of enhanced recovery after surgery protocol in transfemoral transcatheter aortic valve replacement

Enhanced recovery after surgery (ERAS) protocols are gaining wide acceptance. We evaluated ERAS protocol implementation in transfemoral transcatheter aortic valve replacement (TAVR) patients. The ERAS protocol included (1) moderate sedation or general anesthesia with on-table extubation, (2) no pulmonary artery or urinary catheters, (3) arterial line removal within 4 hours, (4) no postoperative narcotics, (5) mobilization at 4 hours and ambulation within 8 hours, and (6) antihypertensive reinstitution without nodal blockers. Patients who received TAVR before and after ERAS implementation were compared (N = 121 and N = 368, respectively). The primary endpoint was total hospital length of stay (LOS). ERAS patients had a lower mean Society of Thoracic Surgeons predicted risk of mortality (6.7% vs 7.5%; P = 0.04). Unadjusted analysis demonstrated that ERAS was associated with significantly decreased mean LOS (2.8 vs 4.0 days, P < 0.001), decreased 30-day mortality (0.8% vs 5.0%; P = 0.003), and increased discharge home (90.2% vs 79.3%, P = 0.002) with no increase in 30-day readmission (11.1% vs 14.0%, P = 0.39). After risk adjustment, ERAS patients had a 1.87-day shorter LOS (P = 0.001) and trended toward increased discharge home (odds ratio 1.76, P = 0.078) without increased readmission (odds ratio 0.74, P = 0.4). An ERAS protocol for TAVR is safe and is associated with shorter LOS without increased readmission.

Outcomes Associated With Antibiotic Cessation in Oncology Patients With Positive Respiratory Viral Panel Polymerase Chain Reaction Results

Background The discontinuation of antibiotics is ideal if a viral infection is diagnosed. However, it remains uncertain whether in clinical practice, this applies to immunocompromised patients. Purpose The purpose of this study was to evaluate the outcomes of hospitalized febrile oncology patients that cease or continue antibiotics with positive respiratory viral panels (RVP) with negative bacterial cultures. Methods This retrospective study evaluated hospitalized febrile oncology patients divided into 2 groups: patients with antibiotics discontinued within 72 hours of a positive RVP and those continued on antibiotics beyond 72 hours of a positive RVP. Patients were included if they were at least 18 years of age, had active malignant disease, a positive RVP result, and negative bacterial cultures. The primary endpoint was a composite of readmissions, escalation of care to intensive care unit, or death. Results A total of 243 charts were reviewed with 127 admissions meeting inclusion criteria. Sixty-three patients were included in the antibiotics discontinued within 72 hours group and 64 patients were included in the antibiotics continued after 72 hours group. The most common defined malignancy was lymphoma (22%), and the 3 most common viruses identified were rhinovirus/enterovirus (56.7%), influenza A (12.6%), and human metapneumovirus (12.6%). The composite primary outcome occurred in 26.2% of patients in the antibiotic-continued group compared with 27% in the antibiotic-discontinued group. Conclusions Discontinuing antibiotics in oncology patients with a positive RVP result without concurrent bacterial infections did not lead to a significant increase in 30-day readmission, intensive care unit admission, or death.

Health Care Reform, Length of Stay, and Readmissions for Child Mental Health Hospitalizations.

Health care reform may impact inpatient mental health services by increasing access and changing insurer incentives. We examined whether implementation of the 2014 Affordable Care Act (ACA) was associated with changes in psychiatric length of stay (LOS) and 30-day readmissions for pediatric patients. We conducted an interrupted time-series analysis to evaluate LOS and 30-day readmissions during the 30 months before and 24 months after ACA implementation, with a 6-month wash-out period, on patients aged 4 to 17 years who were discharged from the psychiatry unit of a children's hospital. Differences by payer (Medicaid versus non-Medicaid) were examined in moderated interrupted time series. Logistic regression was used to examine the association between psychiatric LOS and 30-day readmissions. There were 1874 encounters in the pre-ACA period and 2186 encounters in the post-ACA period. Compared with pre-ACA implementation, post-ACA implementation was associated with LOS that was significantly decreasing over time (pre-ACA versus post-ACA slope difference: -0.10 days per encounter per month [95% confidence interval -0.17 to -0.02]; P = .01), especially for Medicaid-insured patients (pre-ACA versus post-ACA slope difference: -0.14 days per encounter per month [95% confidence interval -0.26 to -0.01]; P = .03). The overall proportion of 30-day readmissions increased significantly (pre-ACA 6%, post-ACA 10%; P < .05 for the difference). We found no association between LOS and 30-day readmissions. ACA implementation was associated with a decline in psychiatric inpatient LOS over time, especially for those on Medicaid, and an increase in 30-day readmissions. LOS was not associated with 30-day inpatient readmissions. Further investigation to understand the drivers of these patterns is warranted.