Late Readmission Research Articles

Association Between Antibiotic Treatment and Outcomes in Patients Hospitalized With Acute Exacerbation of COPD Treated With Systemic Steroids

Antibiotics are widely used in acute exacerbations of COPD (AE-COPD), but their additional benefit to a therapeutic regimen that already includes steroids is uncertain. We evaluated the association between antibiotic therapy and outcomes among a large cohort of patients treated with steroids who were hospitalized with AE-COPD and compared the effectiveness of three commonly used antibiotic regimens. We conducted a retrospective cohort study of patients aged 40 years hospitalized for AE-COPD from January 1, 2006, through December 1, 2007, at 410 acute care hospitals throughout the United States. Of the 53,900 patients who met the inclusion criteria, 85% were treated with antibiotics in the first 2 hospital days; 50% were treated with a quinolone, 22% with macrolides plus cephalosporin, and 9% with macrolide monotherapy. Compared with patients not treated with antibiotics, those who received antibiotics had lower mortality (1% vs 1.8%, P < .0001). In multivariable analysis, receipt of antibiotics was associated with a 40% reduction in the risk of in-hospital mortality (RR, 0.60; 95% CI, 0.50-0.73) and a 13% reduction in the risk of 30-day readmission for COPD (RR, 0.87; 95% CI, 0.79-0.96). The risk of late ventilation and readmission for Clostridium difficile colitis was not significantly different between the two groups. We found little difference in the outcomes associated with three common antibiotic treatment choices. Our results suggest that the addition of antibiotics to a regimen that includes steroids may have a beneficial effect on short-term outcomes for patients hospitalized with AE-COPD.

The Great Pretenders: Utilizing Evidence-Based Practice to Optimize Clinical Outcomes for the Late Preterm Infant

The late preterm infant faces many challenges associated with prematurity. In 2010, 99 late preterm infants (approximately 5% of the total birth volume) were born at Peninsula Regional Medical Center. Nearly 29% of these infants were admitted to the neonatal intensive care unit (NICU), and 12.8% were readmitted to the pediatric unit for complications associated with prematurity. The purpose of this program was to determine if adopting an evidence-based model of care utilizing the Association of Women's Health, Obstetric and Neonatal Nurses’ Assessment and Care of the Late Preterm Infant Guideline will improve clinical outcomes and reduce late preterm infant neonatal intensive care unit admissions and readmissions to the pediatric unit.

546: What happens after the puerperium? Analysis of late postpartum admissions in California

Objective: Admissions to acute care hospitals represent a significant portion of healthcare utiliza- tion. Little is known regarding hospitalization in the first postpartum year beyond the traditional 6 weeks of the puerperium. We sought to investigate whether there are identifiable risk factors for hospital readmission during this time period. Study Design: We conducted a retrospective population-based study using all California birth records between 1999 and 2003. These records were linked with hospital discharge data for all admissions to California hospitals in the first 365 days after delivery. For women with a first birth during the study period, we assessed the likeli- hood of readmission to an acute care hospital between 42 and 365 days post-delivery. Univariate and multivariable logistic regression were used to determine risk factors for these postpar- admissions. Results: Of 951,570 maternal birth admissions during the time period, 15,727 (1.7%) women were admitted in the late postpartum period. Women with an early postpartum readmission, antepartum admission, extremes of maternal age, black race, diabetes, hypertension, early preterm delivery and cesarean delivery had higher rates of late postpartum readmission. Of women with an antepartum admission for gestational diabetes or pre-existing diabetes, 6.6% and 18.5% of these women experienced a late postpartum admission for a diabetes-related diagnosis. Conclusion: Hospital readmission rates in the first year postpartum, remote from delivery, are significant. Women are at a higher risk of requiring hospital admission in the first year postpar- tum with select demographics and pregnancy-related diagnoses. * Corresponding author.

Factors related to readmission to a ward for dementia patients: Sex differences

The aim of this study was to investigate the factors related to readmission to a ward for dementia patients with special attention to sex-related issues. We reviewed the data of 326 patients who were hospitalized in a ward for dementia patients between 1 April 2000 and 31 March 2008, and followed up for 24 months after discharge. For univariate and multivariate analyses, patients were divided into: (i) patients who were not readmitted to our ward within 24 months (control); (ii) patients who were readmitted to our ward within 3 months (early readmission); and (iii) patients readmitted within 4 to 24 months (late readmission). Factors related to readmission differed between sexes as well as between the early and late stage. A small number of cohabitants and outcome (hospital) were factors related to early readmission in men, while outcome (hospital) and long stay in the ward were related to early readmission in women. High physical function, care distress and short stay in the ward were the factors related to late readmission in women. Most patients who were transferred to another hospital were readmitted within 3 months. Some women were readmitted in the late stage. They had relatively high cognitive and physical functions and most of their caregivers had care distress. The causes of readmission were not due to a decline in cognitive function. It is important to prevent complications in dementia patients and to establish a caregiving system for dementia patients that decreases the burden on caregivers in order to reduce the rate of readmission.

End-Stage Renal Disease Status and Critical Illness in the Elderly

Elderly patients (> 65 years old) are a rapidly growing demographic in the ESRD and intensive care unit (ICU) populations, yet the effect of ESRD status on critical illness in elderly patients remains unknown. Reliable estimates of prognosis would help to inform care and management of this frail and vulnerable population. The effect of ESRD status on survival and readmission rates was examined in a retrospective cohort of 14,650 elderly patients (>65 years old) admitted to 11 ICUs in Winnipeg, Manitoba, Canada between 2000 and 2006. Logistic regression models were used to adjust odds of mortality and readmission to ICU for baseline case mix and illness severity. Elderly ESRD patients had twofold higher crude in-hospital mortality (22% versus 13%, P < 0.0001) and readmission rate (6.4 versus 2.7%, P = 0.001). After adjustment for illness severity alone or illness severity and case mix, the odds ratio for mortality decreased to 0.85 (95% CI: 0.57 to 1.25) and 0.82 (95% CI: 0.55 to 1.23), respectively. In contrast, ESRD status remained significantly associated with readmission to ICU after adjustment for other risk factors (OR 2.06 [95% CI: 1.32, 3.22]). Illness severity on admission, rather than ESRD status per se, appears to be the main driver of in-hospital mortality in elderly patients. However, ESRD status is an independent risk factor for early and late readmission, suggesting that this population might benefit from alternative strategies for ICU discharge.

Early and Late Perioperative Outcomes Following Radical Cystectomy: 90-Day Readmissions, Morbidity and Mortality in a Contemporary Series

Radical cystectomy remains associated with significant morbidity. Most series report outcomes with relatively short-term followup that may underestimate the true magnitude of the procedure and many report length of hospital stay but ignore readmission rates. We analyzed the predictors of early (30 days or less), late (31 to 90 days) and cumulative 90-day hospital readmissions, as well as morbidity and mortality rates. We reviewed our prospectively collected database of 753 patients who underwent radical cystectomy for urothelial cancer between January 2001 and December 2007. We examined the relationship between clinical variables and readmission rates during the early, late and 90-day postoperative period, and reviewed mortality and perioperative morbidity rates. There were 200 (26.6%) patients readmitted in the first 90 days following radical cystectomy. Of these patients 148 (19.7%) were readmitted early, 81 (10.8%) were readmitted late, and 29 (3.9%) had an early and late readmission. Logistical regression revealed gender (OR 1.50, 95% CI 1.00-2.27, p = 0.05), age adjusted Charlson comorbidity index (OR 1.19, 95% CI 1.06-1.34, p = 0.003) and any postoperative complications before discharge home (OR 1.84, 95% CI 1.19-2.83, p = 0.006) as independent predictors of 90-day readmission. The 30 and 90-day mortality rates were 2.1% (16) and 6.9% (52), respectively. Readmission rates after radical cystectomy are significant, approaching 27% within the first 90 days. Gender and age adjusted Charlson comorbidity index were independent predictors providing preoperative information identifying patients more likely to require readmission or possibly to benefit from a longer initial hospital stay.

Unidad de corta estancia médica. Causas de reingreso

Introduction Hospital readmissions reflect the quality of the Sanitary Attention given. Aim To identify the factors that predict readmission in patients who are admitted to a Short Stay Medical Unit. Material and methods Prospective cohort study. Readmission was defined by an urgent admission after discharge caused by the same main diagnosis. The predicting factors for readmission were calculated by means of log regression. Results 335 patients were included. Readmission rates at 10, 28 and 90 days was 2.1, 8.4 and 17.0%, respectively. The independent factor of readmission at 10 days was the previous hospitalizations; at 28 days were previous hospitalizations, the length of stay and the educational status; at 90 days were comorbidities and the health related quality of life. Conclusions The factors predicting early hospital readmissions were the previous admissions and the length of stay of index admission, while late readmission was related to comorbidities and health related quality of life.

Readmission After Pancreatectomy for Pancreatic Cancer in Medicare Patients

ObjectiveThe objective of this study was to use a population-based dataset to evaluate the number of readmissions and reasons for readmission in Medicare patients undergoing pancreatectomy for pancreatic cancer. MethodsWe used Surveillance, Epidemiology, and End Results–Medicare linked data (1992–2003) to evaluate the initial hospitalization, readmission rates within 30 days (early), and between 30 days and 1 year (late) after initial discharge and reasons for readmission in patients 66 years and older undergoing pancreatectomy. ResultsWe identified 1,730 subjects who underwent pancreatectomy for pancreatic cancer. The in-hospital mortality was 7.5%. The overall Kaplan–Meier readmission rate was 16% at 30 days and 53% at 1 year, accounting for 15,409 additional hospital days. Early readmissions were clearly related to operative complications in 80% of cases and unrelated diagnoses in 20% of cases. Late readmissions were related to recurrence in 48%, operative complications in 25%, and unrelated diagnoses in 27% of cases. In a multivariate analysis, only distal pancreatic resection (P = 0.02) and initial postoperative length of stay ≥10 days (P = 0.03) predicted early readmission. When compared to patients not readmitted, patients readmitted early had worse median survival (11.8 vs.16.5 months, P = 0.04), but the 5-year survival was identical (18%). Late readmission was associated with worse median and 5-year survival (19.4 vs. 12.1 months, 12% vs. 21%, P < 0.0001). ConclusionsOur study demonstrates overall 30-day and 1-year readmission rates of 16% and 53%. The majority of early readmissions were related to postoperative complications but not related to patient and tumor characteristics. Complications causing early readmission are a cause of early mortality and are potentially preventable. Conversely, late readmissions are related to disease progression and are a marker of early mortality and not the cause.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation is an alternative to open heart surgery in patients with aortic stenosis. However, long-term data on a programmatic approach to aortic valve implantation remain sparse. Transcatheter aortic valve implantation was performed in 168 patients (median age, 84 years) in the setting of severe aortic stenosis and high surgical risk. Access was transarterial (n=113) or, in the presence of small iliofemoral artery diameter, transapical (n=55). The overall success rate was 94.1% in this early experience. Intraprocedural mortality was 1.2%. Operative (30-day) mortality was 11.3%, lower in the transarterial group than the transapical group (8.0% versus 18.2%; P=0.07). Overall mortality fell from 14.3% in the initial half to 8.3% in the second half of the experience, from 12.3% to 3.6% (P=0.16) in transarterial patients and from 25% to 11.1% (P=0.30) in transapical patients. Functional class improved over the 1-year postprocedure period (P<0.001). Survival at 1 year was 74%. The bulk of late readmission and mortality was not procedure or valve related but rather was due to comorbidities. Paravalvular regurgitation was common but generally mild and remained stable at late follow-up. At a maximum of >3 years and a median of 221 days, structural valve failure was not observed. Transcatheter aortic valve implantation can result in early and sustained functional improvement in high-risk aortic stenosis patients. Late outcome is determined primarily by comorbidities unrelated to aortic valve disease.

Readmission to the intensive care unit: An indicator that reflects the potential risks of morbidity and mortality of surgical patients in the intensive care unit

To investigate the characteristics and outcomes of surgical patients who were readmitted to the intensive care unit (ICU). The data were collected for all readmissions to the surgical ICUs in a tertiary hospital in the year 2003. Of all the 945 ICU discharges, 110 patients (11.6%) were readmitted. They had a longer initial ICU stay (8.05 +/- 7.17 vs 5.22 +/- 4.95, P < 0.001) and were older and in a more severe condition than those not readmitted, but with a longer hospital stay and higher mortality rate (40% vs 3.6%, P < 0.001). A total of 26.4% of the readmission patients had an early readmission (<48 h), with a lower mortality rate than those with a late readmission (24.1% vs 45.7%, P = 0.049). A total of 46.4% of the patients were readmitted with the same diagnosis while the rest were readmitted with a new complication. Respiratory disease was the most common diagnosis for patients readmitted with a new complication (66.1%). The nonsurvivors had a significantly higher second Acute Physiology and Chronic Health Evaluation (APACHE II) score (22.1 +/- 8.8 vs.14.6 +/- 7.4, P < 0.001) and second Therapeutic Intervention Scoring System (TISS) score (30.1 +/- 8.7 vs 24.7 +/- 7.6, P = 0.001) and a longer stay in the first ICU admission (10.4 +/- 9 days vs 6.4 +/- 5 days, P = 0.010). A multivariate analysis showed that the first ICU length of stay and the APACHE II score at the time of readmission were the two risk factors for mortality. The mortality of surgical patients with ICU readmission was high with respiratory complications being the most important issue.

Cost-effectiveness analysis of ED decision making in patients with non–high-risk heart failure

Background The ED disposition of patients with non–high-risk acute decompensated heart failure (ADHF) is challenging. To help address this problem, we investigated the cost-effectiveness of different ED disposition strategies. Methods We constructed a decision analytic model evaluating the cost-effectiveness of 3 possible ED ADHF disposition strategies in a 60-year-old man: (1) discharge home from the ED; (2) observation unit (OU) admission; (3) inpatient admission. Base case patients had no high-risk features. We used Medicare costs and the national physician fee schedule to capture ED, OU, and hospital costs, including costs of complications and death. All analyses were conducted using Decision Maker software (University of Medicine and Dentistry of New Jersey, Newark, NJ). Results Compared to ED discharge, OU admission had a reasonable marginal cost-effectiveness ratio ($44 249/quality adjusted life year), whereas hospital admission had an unacceptably high marginal cost-effectiveness ratio ($684 101/quality adjusted life year). Sensitivity analyses demonstrated that as the risk of early (within 5 days) and late (within 30 days) readmission exceeded 36% and 74%, respectively, in those discharged from the ED, OU admission became less costly and more effective than ED discharge. Similarly, an increase in relative risk of both early and late death in those discharged from the ED improves the marginal cost-effectiveness ratio of OU admission. Finally, as postdischarge event rates increase in those discharged from the OU, hospital admission became more cost-effective. Conclusion Observation unit admission for patients with non–high-risk ADHF has a societally acceptable marginal cost-effectiveness ratio compared to ED discharge. However, as ED and OU discharge event rates increase, hospital admission becomes the more cost-effective strategy.

Selective Treatment Algorithm for Mitral Valve Annuloplasty in Nonischemic Functional Mitral Regurgitation

Background The success rate of mitral annuloplasty (MA) for functional mitral regurgitation (FMR) varies. This study evaluated the effectiveness of this procedure in nonischemic dilated cardiomyopathy (DCM) patients after a selective treatment protocol was followed. Methods and Results This study analyzed 42 patients with nonischemic DCM and FMR (mean regurgitation grade, 3.6 ± 0.3), aged a mean 56.5 ± 15 years (range, 25 to 78 years), who underwent MA from April 2003 to December 2007. The analysis excluded patients with coronary artery disease, or mitral leaflets or subvalvular pathologies. All patients had taken maximal medications for at least 3 months and were still in New York Heart Association (NYHA) functional class III to IV (mean, 3.2 ± 0.4). Mean ejection fraction (EF) was 31.4% ± 12.9% (range, 8% to 58%), and left ventricular end-diastolic diameter (LVEDD) was 66.0 ± 8.3 mm (range, 55 to 85 mm). Downsized Carpentier Physio ring (Carpentier-Edwards, Irvine, California) annuloplasty, mean size 26.3 ± 2.3 (range, 24 to 30), was the preferred procedure. Concomitant procedures included 23 tricuspid valve repairs and 10 Maze operations for atrial fibrillation. Echocardiography was performed at early (≤3 months; mean 1.6 ± 1.5), short-term (6 to 12 months; mean 6.9 ± 3.4), and midterm (>12 months; mean 29.5 ± 13.4 months) follow-up. All late deaths and readmissions were recorded. One (2.4%) in-hospital death occurred due to low cardiac output. Follow-up was completed in 40 of 41 (97.6%) patients (mean duration, 31.9 ± 16.1; range, 3.9 to 59.2 months). Eight (19.5%) patients were readmitted for heart failure, including 2 late MRs due to ring dehiscence and infective endocarditis. Three of 5 deaths during the follow-up period were attributed to cardiac death. Actuarial survival after 1 and 3 years was 88.9% and 79.2%, respectively. The number of patients treated with β-blockers increased after operation, from 52.4% to 75.6% ( P = .028). NYHA class decreased from 3.2 ± 0.4 to 1.3 ± 0.6 ( P < .0001). Echo examination revealed left heart reverse remodeling and improved performance in all follow-up time frames. Conclusion This study shows that MA in patients with non-ischemic DCM and FMR is feasible and associated with reasonable short and long term outcomes.

The effect of comorbidities on risk of intensive care readmission during the same hospitalization: A linked data cohort study ,

Purpose The aim of this study is to assess the effect of comorbidities on risk of readmission to an intensive care unit (ICU) and the excess hospital mortality associated with ICU readmissions. Materials and Methods A cohort study used clinical data from a 22-bed multidisciplinary ICU in a university hospital and comorbidity data from the Western Australian hospital morbidity database. Results From 16 926 consecutive ICU admissions between 1987 and 2002, and 654 (3.9%) of these patients were readmitted to ICU readmissions within the same hospitalization. Patients with readmission were older, more likely to be originally admitted from the operating theatre or hospital ward, had a higher Acute Physiology and Chronic Health Evaluation (APACHE)-predicted mortality, and had more comorbidities when compared with patients without readmission. The number of Charlson comorbidities was significantly associated with late readmission (>72 hours) but not early readmission (≤72 hours) in the multivariate analysis. Both early and late ICU readmissions were associated with an increased risk of hospital mortality (odds ratio, 1.68; 95% confidence interval, 1.18-2.39; P = .004; odds ratio, 1.45; 95% confidence interval, 1.05-1.99; P = .022, respectively) after adjusting for age, admission source, type of admission, the APACHE-predicted mortality, and the number of Charlson comorbidities and APACHE chronic health conditions. Conclusions Comorbidity was a risk factor for late ICU readmission. Comorbidities could not account for the excess mortality associated with ICU readmissions.

Edge-to-Edge Mitral Repair Without Annuloplasty in Combination With Surgical Ventricular Restoration

Functional mitral regurgitation is common in ischemic dilated cardiomyopathy. Edge-to-edge repair is an option for correction and can be performed through the ventriculotomy during surgical ventricular restoration (SVR). This report describes the durability of the edge-to-edge repair without annuloplasty in combination with SVR. From March 1997 to July 2002, 31 patients with left ventricular aneurysm or ischemic dilated cardiomyopathy and functional ischemic mitral regurgitation grade II (n = 18), III (n = 10), and IV (n = 3) underwent SVR and edge-to-edge repair without annuloplasty with concomitant coronary artery bypass grafting. Long-term valve competence was assessed by echocardiography. Early and late survival and hospital readmission for heart failure were analyzed. Early mortality was 5 (16%) of 31 patients. At 1, 3, and 5 years, actuarial survival was 77%, 55%, and 48%. The cumulative follow-up was 117 patient-years (4.5 years mean follow-up). Late echocardiograms performed at a mean of 3.1 years postoperatively showed patients had mitral regurgitation at grade 0 (n = 4), I (n = 10), II (n = 9), and III (n = 1). Two patients underwent reoperation owing to grade III-IV recurrent mitral regurgitation. Freedom from hospital readmission or cardiac death was 56% at 1 year and 48% at 3 years. Combined mitral valve repair and SVR carries high operative risk and long-term prognosis is worse than after SVR alone. The edge-to-edge repair without annuloplasty for functional ischemic mitral regurgitation seems to be fairly durable in conjunction with SVR. To improve results a transventricular annuloplasty may be added.

Prosthesis–Patient Mismatch is Not Clinically Relevant in Aortic Valve Replacement Using the Carpentier-Edwards Perimount Valve

Previous studies have shown that prosthesis-patient mismatch (PPM) results in higher early and late mortality after bioprosthetic aortic valve replacement. Careful selection of stented bioprostheses was recommended to avoid inadequate effective orifice area. We studied the incidence of PPM and its potential effects on clinical outcome in patients undergoing aortic valve replacement using the Carpentier-Edwards Perimount bioprosthesis. Independent predictors of early and late mortality and hospital readmission for cardiac reasons were defined in 506 patients (mean age, 73 years; range, 57 to 87 years) by multivariate analysis. Mean follow-up was 6.1 +/- 4.8 years; maximum follow-up was 18.6 years. The incidence of severe PPM (effective orifice area index < 0.65 cm2/m2) was 0.2% and of moderate PPM (effective orifice area index > 0.65 and < 0.85) was 20%. Multivariate analysis revealed that moderate PPM was not an independent predictor of early mortality, late mortality, or hospital readmission for cardiac reasons. Reduction of septal hypertrophy was similar in patients with and without moderate PPM. The incidence of severe PPM is virtually nonexistent after aortic valve replacement using the Carpentier-Edwards Perimount valve. Moderate PPM is found in 20% of cases and is clinically irrelevant in this population.

Early and Late Residual Renal Function and Surgical Complications in Living Donors: A 15-Year Experience at a Single Institution

Living donation in the field of renal transplantation has increased over time as well as the use of laparoscopic nephrectomy. We present a 15-year experience on 162 living donors (105 women, 57 men; mean age, 46.7 years; range, 31–74 years) who underwent nephrectomy using different surgical approaches as open lombotomic nephrectomy (OLN), open transperitoneal nephrectomy (OTN), and laparoscopic hand-assisted nephrectomy (LHAN). We collected data on residual donor and recipient renal function, as well as early versus late medical and surgical complications. With a mean follow-up of about 8 years, we observed normal residual renal function in all donors and similar results of early and late graft function independent of the surgical procedure. Long-term incidence of hypertension and noninsulin-dependent diabetes in living donors was similar to the general population. OLN and OTN donors showed higher incidences of early and late complications, readmissions, and reoperations than LHAN donors. Our results confirmed that living donor nephrectomy is a safe procedure without serious side effects in terms of renal function and long-term quality of life. LHAN should be the preferred technique because of a lower incidence of early and late complications.

Myocardial bridge, surgery or stenting?

This report reviews the clinical experience of surgical treatment and stent implantation for myocardial bridge over the past 7 years at Fu Wai Hospital. Operations were performed on 15 patients for myocardial bridge. There were 10 male and 5 female patients aged from 35 to 67 years (mean age, 49.2 years). Nine of them were associated with other cardiac diseases and the remaining six were MB only. Another 4 patients accepted stent implantation. There were 3 male patients and 1 female patient with a mean age of 57.6 years ranging from 46 to 66 years. All of them were for MB only. In the surgical group 8 patients underwent coronary artery bypass grafting by using the other internal mammary artery and the 7 underwent myotomy on myocardial bridge. All patients survived the operation and recovered uneventfully. Follow-up showed no late death, readmission, or angina complaint. The patients in the stenting group got excellent angiography results after intervention. Follow-up showed that two patients had typical angina within 3 months and 7 months, respectively, after stenting and readmission. The post-angiography showed that moderate intimal proliferation and systolic compression still existed in these patients. Excellent early and late surgical results were obtained in all patients. Compared with stenting, surgical treatment may be a better choice.

Do minitransplants have minicosts? A cost comparison between myeloablative and nonmyeloablative allogeneic stem cell transplant in patients with acute myeloid leukemia

Allogeneic hematopoietic stem cell transplantation (SCT) is a widely used, cost-intensive procedure. Although pretransplant nonmyeloablative (NMA) or reduced-intensity conditioning regimens appear very promising, prospective studies comparing this approach with the conventional myeloablative (MA) approach in specific hematologic diseases are necessary, especially in patients in whom the conventional approach is not contraindicated. Cost may be an important factor in the decision-making process. We compared the costs of MA and NMA transplants in patients with acute myeloid leukemia (AML). We estimated 1-year resource utilization in 12 consecutive MA patients (median age: 39 years) and in 11 consecutive NMA patients (median age: 58 years) who underwent HLA-identical sibling SCT for AML. Resources care expenses were valued using the average daily rate for personnel costs, supplies, and room costs. Other data were directly collected from the patients' charts. Despite a trend for lower costs in NMA patients during the first 6 months, costs during the 6-12-month period were significantly higher after NMA due to late complications and readmissions (P=0.03). Finally, mean 1-year costs were not different in MA and NMA patients (P=0.75). Prospective studies comparing conventional and NMA approaches in homogeneous populations should include economic items.

Readmission patterns in patients with chronic obstructive pulmonary disease, chronic heart failure and diabetes mellitus: an administrative dataset analysis

Comprehensive disease management programmes for chronic disease aim to improve patient outcomes and reduce health-care utilization. Readmission rates are often used as an outcome measure of effectiveness. This study aimed to document readmission rates, and risk for early and late readmission, for patients discharged from the Royal Melbourne Hospital with a disease diagnosis of chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) or diabetes mellitus compared to those with other general medical conditions. Eighty five (8.6%) of patients were readmitted within 28 days and 183 (20.8%) were readmitted between 29 and 180 days. No risk factors for early readmission were identified. Patients with a primary disease diagnosis of CHF and COPD are at increased risk of late readmissions (29-180 days).