Inpatient Metrics Research Articles

Abstract TP144: Telemedicine Appointments early after Acute Ischemic Stroke may Reduce 30-day Emergency Department Visits

Introduction: Limiting the rate of unplanned emergency department (ED) revisits for patients with acute ischemic stroke is an important aspect of secondary stroke prevention. This is influenced by patients’ demographics, comorbidities, stroke severity, disposition destination, and may be impacted by early outpatient follow-up where stroke risk factors and etiology continue to be evaluated. Methods: We retrospectively identified all acute ischemic stroke patients discharged from an 11-hospital network, the largest healthcare system in the state of Georgia, from October 1, 2022 to March 31, 2024; we excluded patients who were discharged to a long-term acute care or hospice facility. Baseline characteristics, inpatient metrics and post-discharge outpatient follow-up were assessed to identify factors associated with ED visits within 30- and 90-days after discharge. Results: Of 2,191 patients, 143 (6.5%) had ED visits within 30 days and 296 (13.5%) within 90 days. The median age was 68 [IQR 57, 77]. History of heart failure (HF), atrial fibrillation (AF), chronic kidney disease and end stage renal disease each increased the likelihood of an ED re-visit within 30 and 90 days whereas diabetes mellitus increased the likelihood of an ED re-visit at 90 days only. In multiple logistic regression analyses, factors independently associated with 30-day ED visit was a history of HF (OR 1.57, 95% CI 1.07-2.28; p=0.02) and AF (OR 1.49, 95% CI 1.00-2.19; p=0.04); at 90 days, only an increased Charlson Comorbidity Index score was associated with ED visit (OR 1.09, 95% CI 1.02-1.16; p=0.01). There were 501 (23%) patients who completed an outpatient neurology clinic follow-up within 30 days of discharge, including 81 patients (4%) who completed a telemedicine outpatient visit; patients completing a telemedicine visit were less likely to have a 30-day ED visit than those who had an in-person visit (OR= 0.13, 95% CI 0.01-0.62; p=0.05). Conclusion: ED revisits after hospitalization for acute ischemic stroke are relatively common and associated with patients who have comorbid conditions including HF and AF. Our study suggests that telemedicine-based follow-ups were associated with lower rates of unplanned ED revisits within 30 days. Efforts to increase outpatient neurology clinic access through telemedicine may reduce ED visits after discharge for acute ischemic stroke patients.

Abstract TP118: Early Outpatient Follow-up After Acute Ischemic Stroke Reduces 30-day and 90-day Inpatient Readmissions

Introduction: Despite advancements in the management of acute ischemic strokes, readmissions continue to impact both healthcare costs and patient outcomes. The objective of our study was to evaluate factors associated with 30- and 90-day readmissions after acute ischemic stroke including the impact of early transitional care outpatient follow-up by a centralized specialty stroke clinic. Methods: We retrospectively identified all acute ischemic stroke patients discharged from the largest healthcare system in the state of Georgia from October 1, 2022 to March 31, 2024; we excluded patients who were discharged to a long-term acute care or hospice facility. Baseline characteristics, inpatient metrics and post-discharge outpatient follow-up were assessed to identify factors associated with 30- and 90-day inpatient readmission. Results: Of 2191 acute ischemic stroke patients discharged during the study period, 177 (8.1%) and 304 (13.9%) had 30- and 90-day all cause readmissions to the healthcare system, respectively. Increasing age, Charlson Comorbidity Index score, and history of diabetes were independently associated with 30- and 90-day readmission; history of heart failure, obesity, and discharge to inpatient rehabilitation or skilled nursing facility (versus home) were also independently associated with 90-day readmission. Completion of a subspecialty stroke clinic follow-up within 30 days of discharge was associated with a lower likelihood of 30-day (OR 0.64, 95% CI 0.41-0.96; p=0.04) and 90-day readmission (OR 0.69, 95% CI 0.49-0.94; p=0.02). Conclusion: While acute ischemic stroke patients who are older, have comorbid conditions and disability are at an increased likelihood of 30- and 90-day readmission after acute ischemic stroke, our study found that early (<30 day) outpatient follow-up in a subspecialty stroke clinic was associated with a significant reduction in 30- and 90-day readmission. Efforts should be made to ensure early outpatient specialty stroke clinic follow-up for acute ischemic stroke patients after discharge.

Increasing Local Productivity Through a Regional Antimicrobial Stewardship Collaborative.

Antimicrobial stewardship programs (ASPs) are vital to improving patient safety and ensuring quality of care but are often underresourced, limiting their effectiveness and reach. While barriers to ASP success have been well documented, approaches to address these barriers with limited resources are needed. Stewardship networks and collaboratives have emerged as possible solutions. In January 2020, 5 US Department of Veterans Affairs facilities created a regional ASP collaborative. In this article, we describe the impact of this collaborative on the productivity of the facilities' ASPs. ASP annual reports for each of the 5 facilities provided retrospective data. Reports from fiscal year (FY) 2019 and reports from FY 2020-2022 were reviewed. Staffing, inpatient and outpatient stewardship reporting, individual and collaborative initiatives, and publications data were collected to measure productivity. Yearly results were trended for each facility and for the region. Additionally, the COVID-19 antibiotic use dashboard and upper respiratory infection dashboard were used to review the impact of initiatives on antibiotic prescribing during the collaborative. Regular reporting of outpatient metrics increased; 27% of measures showed improvement in 2019 and increased to 60% in 2022. For all 5 facilities, ASP initiatives increased from 33 in 2019 to 41 in 2022 (24% increase) with a corresponding increase in collaborative initiatives from 0 to 6. Likewise, publications increased from 2 in 2019 to 17 in 2022 (750% increase). Rates of reporting and improvement in inpatient metrics did not change significantly. The ASP collaborative aided in efficiency and productivity within the region by sharing improvement practices, distributing workload for initiatives, and increasing publications.

Association between Race and Social Deprivation in Patients with Hematologic Malignancies

Background: Recent therapeutic advances including biologics, immunomodulators, and cellular therapies have transformed management paradigms for hematologic malignancies. Nevertheless, disparities exist in terms of access to care, and non-White individuals are historically underrepresented in clinical trials. As it remains unknown whether there are inequalities in care related to adverse events of these therapeutic approaches, in this study we explored whether racial and social differences are related to outcomes of patients with hematologic malignancies. Methods: This was a retrospective chart review from January 2011 to December 2021 that included adult patients across our cancer center network with diagnostic codes for malignant neoplasms of lymphoid, myeloid, and hematopoietic origin who were receiving an immunologic therapy at the time of an emergency department visit. Data were compared according to White and non-White individuals. The non-White group comprised of Black or African American, Asian Indian, Chinese, Asian, or unspecified/other. Differences in continuous variables between groups were assessed using the Wilcoxon rank-sum test, and Chi-square or Fisher's exact test was used to compare categorical variables. Outcomes included time to admission, length of stay within the hospital, ICU admissions, and differences in social deprivation index (SDI). SDI is a composite measure of a geographic region's socioeconomic variation in health outcomes based on demographic characteristics collected by the U.S Census Bureau (www.census.gov/programs-surveys/acs). Higher SDI scores indicate more severe social deprivation. Results: 180 patients were identified with 142 patients meeting inclusion criteria. Among these, 43% were non-White patients. The median age for the White group was 71.6 and for the non-White group 65.8 (P=.001). The most common immunotherapies were lenalidomide (50%), pomalidomide (19.7%), daratumumab (12.7%), methotrexate (9.9%), and rituximab (8.5%). The main chief complaint that was statistically different between the two groups was musculoskeletal complaints; the incidence among the White group was 8.6% and 29.5% among the non-White group (P=0.001). Other reasons for presentation included neurological complaints (21)%, infection/sepsis (16%), respiratory issues (12%), and abnormal laboratory values (3.5%). There were no differences in time to hospitalization for White versus non-White patients (5 versus 6 hours, P=0.12). Differences in ICU admissions, 30 day-readmissions, and length of stay were also not statistically significant between the two groups. However, the median SDI for the White group was statically greater among the non-White group (p<0.001). Discussion: In this retrospective study, non-White patients with hematologic malignancies were found to have greater social deprivation than White patients, however this did not impact inpatient metrics. We found that non-White patients with hematologic malignancies were more likely to originate from socially disadvantaged backgrounds, although there were no differences in hospitalization outcomes among the two groups. Results suggest that social determinants may impact factors unrelated to access to acute care in patients with hematologic therapies receiving immunologic therapies.

Preoperative Malnutrition and Metabolic Markers May Predict Periprosthetic Fractures in Total Hip Arthroplasty

BackgroundPeriprosthetic fractures are a devastating complication of total hip arthroplasty (THA) and are associated with significantly higher mortality rates in the postoperative period. Given the strain that periprosthetic fractures place on the patient as well as the healthcare system, identifying and optimizing medical comorbidities is essential in reducing complications and improving outcomes. MethodsAll THA with primary indications of osteoarthritis from 2007 to 2020 were queried from the National Surgical Quality Improvement Program database. Demographic data, preoperative laboratory values, medical comorbidities, hospital course, and acute complications were collected and compared between patients with and without readmission for a periprosthetic fracture. A multivariate logistic regression analysis was performed to determine associated independent risk factors for periprosthetic fractures after index THA. ResultsThe analysis included 275,107 patients, of which 2539 patients were readmitted for periprosthetic fractures. Patients with postoperative fractures were more likely to be older (>65 years), females, BMI >40, and increased medical comorbidities. Preoperative hypoalbuminemia, hyponatremia, and abnormal estimated glomerular filtration rates were independent risk factors for sustaining a periprosthetic fracture and readmission within 30 days. Modifiable patient-related factors of concurrent smoking and chronic steroid use at the time of index THA were also independent risk factors for periprosthetic fractures. Inpatient metrics of longer length of stay, operative time, and discharge to rehab predicted postarthroplasty fracture risk. Readmitted fracture patients subsequently had increased risks of developing a surgical site infection, urinary tract infection, and requiring blood transfusions. ConclusionsPatients with hypoalbuminemia, hyponatremia, and abnormal estimated glomerular filtration rate are at increased risk for sustaining periprosthetic fractures after THA. Preoperative optimization with close monitoring of metabolic markers and modifiable risk factors may help not only prevent acute periprosthetic fractures but also associated infection and bleeding risk with fracture readmission.

Global outcomes and lessons learned in the management of Fournier's gangrene from high-volume centres: findings from a literature review over the last two decades.

Fournier's Gangrene (FG) carries a high mortality and morbidity with underreported short and long-term outcomes. Our aim was to perform a review of the recent literature to evaluate the short and long-term outcomes in patients with FG in the acute setting from large-scale studies. A PubMed search was performed between January 2000 and December 2021 for studies reporting on patients with FG. Exclusion criteria included small samples (n < 100), review articles and animal studies. Primary outcomes of interest were mortality, number of operative episodes for surgical debridement and admission to intensive care unit (ICU). Other outcomes assessed included rate of faecal and urinary diversion, orchidectomy rate, penectomy rate and length of hospital stay. From a total of 1182 studies, 18 were eligible for inclusion and included in this review. In total, data were analysed from 13,903 FG patients. Mean inpatient mortality rate was 7.3% (range 4.7-40.4%). Mean number of surgical debridement operations performed was 1.8 (range 1.5-4.2). On average, 6.8% (range 3.6-50.5%) and 7% (range 1.2-53.2%) underwent faecal and urinary diversions, respectively. Mean rate of orchidectomy was 5.6%, with rate of penectomy being lower at 0.2%. The mean length of hospital stay was 18.5days (range 13.0-26.6). On average, 17.5% (range 10.1%-67.5%) required ICU admission for at least a single-system support. Our review from the past twenty years of literature suggests that the mortality for FG, whilst still high, has fallen compared to previous years. Whilst inpatient metrics are well-covered in the literature there is a lack of large-scale studies detailing long-term patient outcomes.

Bed downtime: the novel use of a quality metric allows inpatient providers to improve patient flow from the emergency department

BackgroundEmergency department (ED) boarding time is associated with increased length of stay (LOS) and inpatient mortality. Despite the documented impact of ED boarding on inpatient outcomes, a disparity continues to...

Evaluation of a comprehensive diabetic foot ulcer care quality model

AimsDiabetes-related amputations are typically preceded by a diabetic foot ulcer (DFU) but models to assess the quality of care are lacking. We investigated a model to measure inpatient and outpatient quality. MethodsCohort study among adults hospitalized with a DFU to a safety-net hospital during 2016. We measured adherence to DFU-related quality metrics based on guidelines during and 12 months following hospitalization. Inpatient metrics included ankle-brachial index measurement during or 6 months prior to hospitalization, receiving diabetes education and a wound offloading device prior to discharge. Outpatient metrics included wound care ≤30 days of discharge, in addition to hemoglobin A1c (HbA1c) ≤8%, tobacco cessation, and retention in care (≥2 clinic visits ≥90 days apart) 12 months following discharge. Results323 patients were included. Regarding inpatient metrics, 8% had an ankle brachial index measurement, 37% received diabetes education, and 20% received offloading prior to discharge. Regarding outpatient metrics, 33% received wound care ≤30 days of discharge. Twelve months following discharge, 34% achieved a HbA1c ≤8%, 13% quit tobacco, and 52% were retained in care. Twelve-month amputation-free survival was 71%. ConclusionsOur model demonstrated large gaps in DFU guideline-adherent care. Implementing measures to close these gaps could prevent amputations.

Does value-based purchasing affect US hospital utilization pattern: A comparative study

ABSTRACTWe evaluated the effect US hospital performance as measured by the Medicare hospital value-based purchasing (HVBP) program has on the volume of hospitals inpatient and outpatient services. We analyzed data from the 2013 to 2014 American Hospital Association database, HVBP total performance scores database through Centers for Medicare and Medicaid Services (CMS) and the area health resources files database through CMS. This study utilized a multinomial logistic regression and transaction cost economic theory, adjusting for the Herfindahl–Hirschman Index, number of facility beds, beds per thousand, individuals 65+, teaching status, location, ownership, and system affiliation. The prominent study findings indicate a significant relationship between percent utilization of inpatient, outpatient and HVBP score. Furthermore, environmental factors such as the Herfindahl–Hirschman Index, and system participation were found to significantly impact hospitals ratio of inpatient to outpatient. Relative risk ratios show that hospitals with overall lower HVB are more likely to be in the top 25 percentile for outpatient services. With the decline in inpatient volume of services and the rise in outpatient utilization, inpatient metrics will continue to be relevant as key indicators of quality of care. Inpatient services will never become irrelevant to the overall financial profile of hospital performance.

Hospital Care of Assisted Living Residents by an Assisted Living Based Primary Care Team

The objective of this article is to characterize inpatient-related outcomes and measures of efficiency for hospitalized assisted living residents managed by an assisted living-based primary care (ALPC) team. Between 2010 and 2012, 1594 assisted living residents received ALPC. An ALPC team member served as hospital attending physician to 377 assisted living residents at three community hospitals. Several inpatient metrics were compared between the hospitalized ALPC cohort and those reported in the National Hospital Discharge Survey. Hospitalized assisted living residents who received inpatient hospital care by an ALPC team member had lower inpatient mortality, 30-day readmission rates, and shorter length of stay compared to published averages. The authors determined that an ALPC team who follows its patients in the hospital may achieve improved inpatient outcomes.