Non-elective Readmission Research Articles

Impact of Frailty on Clinical Outcomes and Hospitalization Costs Following Elective Colectomy.

Frailty has been increasingly recognized as a risk factor for inferior surgical outcomes and greater resource use. The present study evaluated the impact of a coding-based frailty tool on outcomes of elective colectomy in a national cohort. Adults undergoing elective colectomy were identified in the 2016-17 Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins 10-domain coding-based binary tool. Generalized linear models were used to examine the association of frailty with in-hospital mortality, nonhome discharge, hospitalization duration (LOS), and inflation-adjusted costs. Kaplan-Meier survival analysis and log-rank test was used to compare readmissions up to 1-year. Of 133175 patients, 10.6% were considered frail. The most common resections were sigmoid (43.9%) and right (34.7%) while total colectomy was least common (2.8%). After adjustment, frailty was associated with greater odds of mortality (3.2, 95% CI 2.8-3.8) and nonhome discharge (6.0, 95% CI 5.5-6.4) as well as a $13,400-increment (95% CI 12,400-14,400) in costs and 4.4-day (95% CI 4.1-4.6) increase in LOS. Nonelective readmissions at 30 days were greater in frail than non-frail groups (14.7% vs. 10.4%, P < .001). Frailty is associated with inferior clinical outcomes and increased resource use following elective colectomy. Inclusion of frailty in risk models may facilitate risk stratification and shared decision-making.

Predictors of 30-day readmissions for adrenal insufficiency: A retrospective national database study.

The aim of this study was to describe rates and characteristics of non-elective 30-day readmission among patients hospitalized for adrenal insufficiency and to assess predictors of readmission. We analysed the 2018 National Readmission Database. Adrenal insufficiency hospitalizations were identified using the International Classification of Diseases, Tenth Revisions, Clinical Modification diagnosis codes for principal diagnostic codes of primary adrenal insufficiency, Addisonian crisis, drug-induced adrenocortical insufficiency, and other and unspecified adrenocortical insufficiency. During the study period, 7738 index hospitalizations were identified as patients with AI who met the inclusion criteria. Of these, 7691 were discharged alive. We utilized chi-squared tests to compare baseline characteristics between readmissions and index hospitalizations. Multivariate Cox regression was used to identify independent predictors of readmission. The 30-day all-cause readmission rate for AI was 17.3%. About 1 in 5 readmissions was for AI. Other reasons for readmission included sepsis (10.8%), unspecified pneumonia (3.1%) and acute renal failure unspecified (1.6%). Readmission was associated with significantly higher odds of inpatient mortality. Independent predictors of 30-day all-cause readmissions included index hospitalizations with the Charlson Comorbidity Index (CCI) ≥3 (adjusted hazards ratio (aHR): 2.53, 95% CI: 1.85-3.46, p<.001), protein-energy malnutrition (aHR: 1.28, 95% CI: 1.02-1.60, p=.035) and obesity (aHR: 1.26, 95% CI: 1.02-1.56, p=.035). The 30-day all-cause readmission rate was 17.3%. AI was the most common reason for readmission among other causes. Readmissions were associated with increased mortality. CCIs of 3 or more, protein-energy malnutrition and obesity were significant predictors of readmission.

PRS18 Unplanned 30-Day Hospital Readmissions Among Patients who have an Index Visit for Pneumonia: A National Readmission Database Analysis

Short-term readmission rates are critical quality of care measures valued by both healthcare providers and federal agencies. This study seeks to identify and describe characteristics associated with adult patients having a non-elective or unplanned hospital readmission within 30-days of an initial hospital admission index visit for pneumonia. The 2017 National Readmission Database from the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, was used to identify adult patients who had an eligible non-elective index visit involving hospital admission related to pneumonia. Those who had an unplanned hospital readmission within 30-days were flagged. Descriptive statistics were reported and an adjusted logistic regression was completed to identify patient and treating facility characteristics associated with readmission. 266,576 eligible index visits were identified. Of the total sample of index visits, over 18% were flagged for having a 30-day readmission event. Characteristics associated with having an unplanned readmission included patient age, particularly being between 41-64 years old (aOR: 1.53; 95% CI: 1.39-1.67), those covered by Medicaid (aOR: 1.33; 95% CI: 1.27-1.40), patients whose index visit was for ≥8 days (aOR: 1.83; 95% CI: 1.70-1.97), and those whose index visit discharge was against medical advice (aOR: 1.81; 95% CI: 1.68-1.96). The Elixhauser comorbidity score was also statistically significant (p ≤ 0.001) in all analyses. Older adults made up 65.04% of the patient sample, but they were less likely to have a readmission event compared to younger adults (aOR: 0.87; 95% CI: 0.84-0.90). In a national, weighted representative sample of US pneumonia patients, 30-day readmissions were common. Middle-aged adults and those with comorbidities were at particular risk. Ongoing analysis within these demographics may improve patient care and institutional quality of care in the future.

949-P: Reasons for Nonelective Readmissions among Hospitalizations with Diabetes Complicating Pregnancy and the Perinatal Period: Insights from the U.S. National Readmission Database for 2018

Introduction: With the increasing prevalence of diabetes mellitus (DM), there is an increasing burden of DM among pregnant women. Gestational DM (GDM), is a known complication of pregnancy which could affect the outcome for mother and child. This study looked into the burden of DM related gestations and readmissions. Methods: Data was obtained from the US National Readmissions Database for 2018, the largest database for readmissions in the US, which approximates yearly estimates. Index hospitalizations for DM complicating pregnancy and the postpartum period were obtained using ICD-10 codes. Hospitalizations less than 18 years of age and elective admissions were excluded. Outcomes included the rate of 30-day readmission (30DR) as well as identifying the commonest reasons for readmission among the studied cohort. Results: A total of 61,675 hospitalizations were included in the study as index admissions. Of these hospitalizations, 2,768 (4.50%) were readmitted within 30 days of discharge. The top reasons for readmission included severe pre-eclampsia, gestational DM, pre-existing DM type 1 in pregnancy, maternal care for scar from previous cesarean delivery, pre-existing DM type 2 in pregnancy and endometritis following delivery. Readmission was associated with increased healthcare utilization. Conclusion: Among pregnancies complicated by DM that led to hospitalization, a small proportion of patients get readmitted within 30 days for known complications of pregnancy. These could be associated with mortality, hence, research into factors and predictors of readmission in this population should be encouraged. Disclosure M. C. Aguilera: None. H. Shaka: None. C. D. Corpuz: None. M. Ramirez: None. S. T. Yap: None. P. O. Eseaton: None. M. Murthi: None.

Rate and Predictors of 30-day Readmission Following Diabetic Ketoacidosis in Type 1 Diabetes Mellitus: A US Analysis.

Diabetic ketoacidosis (DKA) is a serious endocrine emergency, associated with morbidity and mortality. Readmissions play a significant but sometimes preventable role in healthcare cost burden on the US. This study aimed to describe rates and characteristics of nonelective 30-day readmission among adult patients with diabetes mellitus type 1 (T1DM) hospitalized for DKA and also identify predictors of readmission. The study analyzed the 2018 Nationwide Readmission Database. DKA hospitalizations in patients with T1DM were classified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We utilized chi-squared tests to compare baseline characteristics between readmissions and index hospitalizations. Multivariable Cox regression was employed to identify independent predictors of readmission. Following this, we developed a 30-day readmission risk scoring system based on independent predictors. The 30-day all-cause readmission rate for DKA was 19.4%. A majority of patients (64.8%) had DKA as the principal diagnosis on readmission. Readmitted patients had a significantly higher mean age (35.3 vs 34.9 years, P = .018) and a higher proportion of females (52.8 vs 49.6%, P < .001) than the index admission. Readmission following DKA was associated with higher odds of inpatient mortality (0.69 vs 0.24%, OR 2.84, 95% CI 1.99-4.06, P < .001). Independent predictors of 30-day all-cause readmission included female sex, index hospitalizations with Charlson Comorbidity Index (CCI) score of 3 or greater, and being discharged against medical advice (AMA). The readmission rate for DKA in T1DM patients is high, and most patients have DKA as the principal diagnosis on readmission. A CCI equal to or greater than 3, hypertension, female sex, and being discharged AMA were significant predictors of readmission.

Readmission after hospitalization with Staphylococcus aureus bacteremia in children

Readmission rate is an important quality measure and can inform patient care. However, readmission of S. aureus bacteremia in children requires further research. We performed a population-based longitudinal observational study using the State Inpatient Database from New York, Florida, and Washington, 2009-2015. Children aged 18 years or younger hospitalized with S. aureus bacteremia were included. The outcome of non-elective readmission was assessed by developing Cox proportional hazards regression models. Of 1240 children with S. aureus bacteremia, 223 (18.0%) and 351 (28.3%) had non-elective readmission within 30 days and 90 days after discharge, respectively. On multivariable analysis, catheter related infection (hazard ratio, HR: 1.79, 95% confidence interval, CI: 1.31-2.45) was associated with 30-day readmission. The median cost of the original hospitalization for S. aureus bacteremia was $29 914 (interquartile range, IQR: $13 276-$71 284), and that of 30 day readmission was $10 956 (IQR: $5765-$24 753). S. aureus bacteremia is associated with a high rate of readmission in children, particularly in those with catheter related infection. Hospitalization with S. aureus bacteremia and readmission are costly. Future research should seek interventions to improve outcomes of S. aureus bacteremia in children, and the results of this study can serve as a benchmark.

Early Risk of Readmission Following Hospitalization for Reversible Cerebral Vasoconstriction Syndrome.

For evaluation of 90-day readmissions after an inpatient admission for reversible cerebral vasoconstriction syndrome (RCVS), hospitalizations due to RCVS were identified from the Nationwide Readmissions Database from 2016 to 2017. The primary outcome of interest was nonelective readmission within 90 days of index hospitalization discharge. Survival analysis was performed, and multivariable Cox proportional hazards regression was used to determine the factors associated with readmission. Among the 1,157 hospitalizations due to RCVS during the study period (mean ± SD age 48.6 ± 16.1 years, women 76.4%), 164 (14.2%) patients had nonelective readmission within 90 days of discharge. The most common reasons for readmissions included acute cerebrovascular events (18.9%), continued or recurrent symptoms of RCVS (13.4%), infections (11.6%), and headache (9.8%). Diabetes, history of tobacco use, opioid use, and longer length of index hospitalization were independent predictors of 90-day readmission. For readmissions, the mean (SD) length of stay was 5.2 (6.1) days, and the mean (SD) cost per hospitalization was $14,214 ($15,140). There was no in-hospital mortality; however, 37.2% of patients were not discharged to home. Nearly 14% of patients with RCVS are readmitted within 90 days of discharge, and a significant proportion of these readmissions are due to the ongoing/recurrent symptoms or neurologic sequelae of RCVS. Given that these patients are at a risk of early recurrence/worsening of their symptoms, an early postdischarge follow-up plan may need to be integrated into their care.

The Impact of Expedited Discharge on 30-Day Readmission After Lung Resection: A National Study

BackgroundExpedited discharge (within 24 hours) after lung resection has received scrutiny because of concerns for higher readmissions and paradoxically increased costs. The present study examined the impact of expedited discharge on hospitalization costs and unplanned readmissions by using a nationally representative sample. In addition, the study sought to determine interhospital practice variation. MethodsAdults undergoing elective lobar or sublobar resection were identified using the 2016 to 2018 Nationwide Readmissions Database, and patients with a postoperative duration of hospitalization longer than 5 days or those who experienced any perioperative complication were excluded. Patients were classified as Expedited if their postoperative hospitalization duration was 0 or 1 day and otherwise were classified as Routine. Inverse probability of treatment weighing was used to adjust for intergroup differences. Hospitals were ranked according to risk-adjusted early discharge rates. Multivariable regression models were developed to assess the association of expedited discharge on nonelective 30-day readmissions, as well as associated mortality and costs. ResultsOf an estimated 84,152 patients, 13,834 (16.4%) comprised the Expedited group. Compared with the Routine group, the Expedited patients were younger and less likely to have chronic obstructive pulmonary disease and to have undergone open procedures. After adjustment, early discharge was associated with lower incremental costs (β coefficient: −$3.6K; 95% confidence interval, −4.4 to −2.8), as well as similar readmissions (odds ratio, 0.89; 95% confidence interval, 0.70 to 1.13) and related-mortality. Nearly one-half (48.1%) of all hospitals performed zero early discharges. ConclusionsExpedited discharge after lung resection is a feasible management strategy and is associated with decreased costs and similar readmission risk compared with the norm. Select individuals should be strongly considered for expedited discharge after lung resection.

Impact of hospital volume on resource use after elective cardiac surgery: A contemporary analysis

BackgroundInstitutional experience has been associated with reduced mortality after coronary artery bypass grafting and valve operations. Using a contemporary, national cohort, we examined the impact of hospital volume on hospitalization costs and postdischarge resource utilization after these operations. MethodsAdults undergoing elective coronary artery bypass grafting or valve operations were identified in the 2016 to 2017 Nationwide Readmissions Database. Institutions were grouped into volume quartiles based on annual elective cardiac surgery caseload, and comparisons were made between the lowest and highest quartiles, using generalized linear models. ResultsOf an estimated 296,510 patients, 24.8% were treated at low-volume hospitals and 25.2% at high-volume hospitals. Compared with patients treated at low-volume hospitals, patients managed at high-volume hospitals were younger, had more comorbidities, and more frequently underwent combined coronary artery bypass grafting valve (13.0% vs 12.3%, P < .001) and multivalve operations (6.2% vs 3.1%, P < .001). After adjustment, operations at high-volume hospitals were associated with a $7,600 reduction (95% confidence interval $4,700–$10,500) in costs. High-volume hospitals were also associated with reduced odds of mortality, non-home discharge, and 30-day non-elective readmission compared to low-volume hospitals. ConclusionDespite increased complexity at high-volume centers, greater operative volume was independently associated with reduced hospitalization costs and mortality after elective cardiac operations. Reduction in non-home discharge and readmissions suggests this effect to extend beyond acute hospitalization, which may guide value-based care paradigms.

Risk factors for hospital readmission among home health care patients at PSMMC, Riyadh, Saudi Arabia, 2019

Background: Worldwide the home health care (HHC) has many benefits. It improves countries health systems and clinical outcomes of patients, it is good solution for bed occupancy in hospitals. Home Health care (HHC) provides nursing services supported with Medicare for patients with chronic medical issues that prevent them from leaving the home. Objectives: This study aimed to describe frequency and rate of readmission to hospital by HHC patients according to diagnoses, and identify the factors associated with non-elective, readmission of HHC patients, at PSMMC, Riyadh, Kingdom of Saudi Arabia, 2019. Methods: Cross-sectional study with a total number of participants 213 done by using self-administered chart review. Result: A total of 213 Saudi health care patients participated, and most of them were in the age group of 75-85 years. The overall prevalence of readmission was 43.66%, and it was significantly higher among males at 55.81%. Poly-pharmacy and diabetes mellitus were the highest frequent causes of readmission at 75.27% and 65.59%, respectively. A significantly higher percentage of readmitted subjects have urinary tract infection and on NGT at 8.60% and 13.89% vs. 1.67% and 5% on the not readmitted group, respectively. On the other hand, the functional disability severity frequency and hypothyroidism were higher in the not readmitted groups compared to the readmitted one at 46.67%, and 27.5% vs. 32.26 and 12.9%, respectively. There was a significant difference between the two groups in the distance 25Km from central Riyadh. Male gender is associated with more than two folds risk of non-elective readmission of HHC compared to females, with OR =2.30, and a P-value of 0.004. Patients with urinary tract infections were more than five folds (OR= 5.55, P= 0.033) at risk of readmission, and those with surgical interventions have 6.91 folds increased risk of readmission. Besides, patients on NGT and those treated with a multidisciplinary team have OR of 3.09, and 3.41to be readmitted with a significant P-value (

A nationwide analysis of maternal morbidity and acute postpartum readmissions in women with epilepsy

ObjectiveTo compare maternal delivery hospitalization characteristics and postpartum outcomes in women with epilepsy (WWE) versus women without common neurological comorbidities. MethodsWe performed a retrospective cohort analysis of index characterizations and short-term postpartum rehospitalizations after viable delivery within the 2015–2017 National Readmissions Database using International Classification of Diseases, Tenth Revision codes. Wald chi-squared testing compared baseline demographic, hospital and clinical characteristics and postpartum complications between WWE and controls. Multivariable logistic regression models examined odds of nonelective readmissions within 30 and 90 days for WWE compared to controls (alpha = 0.05). ResultsA total of 38,518 WWE and 8,136,335 controls had a qualifying index admission for delivery. Baseline differences were most pronounced in Medicare/Medicaid insurance (WWE: 58.2%, controls: 43%, p < 0.0001), alcohol/substance abuse (WWE: 8.3%, controls: 2.5%, p < 0.0001), psychotic disorders (WWE: 1.2%, controls 0.1%, p < 0.0001), and mood disorder (WWE: 15.5%, controls: 3.7%, p < 0.0001). At the time of delivery, WWE were more likely to have edema, proteinuria, and hypertensive disorders (WWE: 19%, controls: 12.9%, p < 0.0001); a history of recurrent pregnancy loss (WWE: 1%, controls: 0.4%, p < 0.0001); preterm labor (WWE: 7.3%, controls: 4.8%, p < 0.0001), or presence of any Center for Disease Control severe maternal morbidity indicator (WWE: 3.2%, controls: 0.6%, p < 0.0001; AOR 5.16, 95% CI 4.70–5.67, p < 0.0001). A higher proportion of WWE were readmitted within 30 days (WWE: 2.4%, controls: 1.1%) and 90 days (WWE: 3.7%, controls: 1.6%). After adjusting for covariates, the odds of postpartum nonelective readmissions within 30 days (AOR 1.86, 95% CI 1.66–2.08, p-value <0.0001) and 90 days (AOR 2.04, 95% CI 1.83–2.28, p-value <0.0001) were higher in WWE versus controls. InterpretationWomen with epilepsy experienced critical obstetric complications and a higher risk of severe maternal morbidity indicators at the time of delivery. Although relatively low, nonelective short-term readmissions after delivery were higher in WWE than women without epilepsy or other common neurological comorbidities. Further research is needed to address multidisciplinary care inconsistencies, improve maternal outcomes, and provide evidence-based guidelines.

Clinical and Financial Outcomes Associated With Vocal Fold Paralysis in Congenital Cardiac Surgery

Vocal fold paralysis (VFP) has proven to increase resource use in several surgical fields. However, its burden in congenital cardiac surgery, a specialty known to be associated with high resource use, has not yet been examined. The authors aimed to assess the impact of VFP on costs, lengths of stay, and readmissions following congenital cardiac surgery. A retrospective analysis of administrative data. The 2010-2017 National Readmissions Database. All pediatric patients undergoing congenital cardiac surgery. None. Vocal fold paralysis was defined using International Classification of Diseases, Ninth and Tenth Revisions, diagnosis codes. The primary outcome of interest was 30-day nonelective readmissions and 90-day readmissions; costs, length of stay, and discharge status also were considered. Of an estimated 124,486 patients meeting study criteria, 2,868 (2.3%) were identified with VFP. Incidence of VFP increased during the study period (0.7% in 2010 to 3.2% in 2017, nptrend < 0.001). Rates of nonhome discharge (30.0% v 16.4%, p < 0.001), 30-day readmission (23.9% v 12.4%, p < 0.001), and 90-day readmission (8.3% v 4.4%, p = 0.03) were increased in the VFP cohort, as were lengths of stay (42.1 v 27.0 days, p < 0.001) and costs ($196,000 v $128,000, p < 0.001). After adjustment for patient and hospital factors, VFP was independently associated with greater odds of nonhome discharge (adjusted odds ratios [AOR], 1.66, 95% CI, 1.14-2.40), 30-day readmission (AOR, 1.58, 95% CI, 1.03-2.42), 90-day readmission (AOR, 2.07, 95% CI, 1.22-3.52), longer lengths of stay (+ 6.1 days, 95% CI, 1.3-10.8), and higher hospitalization costs (+$22,000, 95% CI, 3,000-39,000). Readmission rates after congenital cardiac surgery are significantly greater among those with VFP, as are costs, lengths of stay, and nonhome discharges. Therefore, further efforts are necessary to increase awareness and reduce the incidence of VFP in this vulnerable population to minimize the financial burden of congenital cardiac surgery on the US medical system.

Abstract P290: Predicting Readmission and Mortality After Ischemic Stroke

Background: Stroke patients have high rates of all-cause rehospitalization at 30 days (7-24%) and within one year (30-62%). Limited information is available on how to predict these outcomes. We assessed two existing predictive models and whether adding NIHSS or modified Rankin scale (mRS) score improved their predictive ability for 30-day non-elective rehospitalization and/or mortality post-stroke. Methods: Using a cohort of ischemic stroke patients in a large multi-ethnic integrated healthcare system from June 2010 to December 2017, we tested 2 existing predictive models for a composite outcome (30-day non-elective hospitalization or death). The models were based on administrative data (LACE) as well as a comprehensive model (Transition Support Level, TSL) that included multiple clinical data elements from the electronic health record, including admission acute physiology and discharge care directives. LACE score included information on length of stay, acuity, comorbidities, and emergency department visits. The models, NIHSS and mRS scores were tested independently, and in combination and combined with age and sex. We assessed model performance using the area under the receiver operator characteristic (c statistic), Nagelkerke pseudo-R 2 , and Brier score. Results: The study cohort included 4843 patients with 5,014 stroke hospitalizations. Average age was 71.9 ± 14 years with 50.6% female and 52.1% White. Median initial NIHSS was 4. Median length of stay was 4 days, and 55.6% were discharged home. There were 527 non-elective readmissions within 30 days. The logistic models revealed that the best performing models were TSL (c-statistic = 0.685) and TSL plus mRS score at discharge (c-statistic = 0.694) [Table]. Conclusions: We found that neither the initial NIHSS nor the mRS score at discharge enhanced the predictive ability of the LACE or TSL models. Future efforts at prediction of short-term stroke outcomes will need to incorporate new data elements.

Correction to "Predicting preventable hospital readmissions with causal machine learning".

In Marafino et al.,1 the caption and the third covariate “DCO 4” in Table 1 should have been amended. The correct table is as follows: Count of hospitalizations in the last 8 to 30 d prior to the current admission Length of stay, in days (with stays above 30 d truncated at 30 d) Discharge disposition (home, skilled nursing, home health) Laboratory-based acuity of illness score, recorded at admission Laboratory-based acuity of illness score, recorded at discharge Comorbidity and chronic condition score, updated monthly Outcome: Nonelective readmission within 30 d postdischarge

Complications while awaiting elective inguinal hernia repair in infants: Not as common as you thought

BackgroundThe dogma of early inguinal hernia repair in infants, especially those born prematurely, has dominated clinical practice owing to reports of a high frequency of incarceration and significant complications associated with untreated inguinal hernias. We aim to evaluate the frequency of complications after discharge with delayed surgery for inguinal hernia repair. MethodsThe Nationwide Readmissions Database (2010–2014) was queried to identify infants diagnosed with inguinal hernia. We compared the frequency and characteristics of inguinal hernia repair performed during the index admission, discharge from the index admission without hernia repair, and unplanned readmissions. ResultsWe identified 33,530 infants (16,624 preterm and 16,906 full-term) diagnosed with an inguinal hernia during an index admission. For those infants diagnosed with an inguinal hernia at birth, inguinal hernia repair was performed during the birth admission for only a minority of both preterm (35%) and full-term infants (18%; P < .001). Of the infants discharged without hernia repair, 15% required nonelective readmission up to 1 year later, but only 2% of preterm and 1% of full-term infants actually underwent inguinal hernia repair during these unplanned readmissions. None of the readmitted infants underwent additional procedures suggestive of a strangulated hernia. ConclusionComplications among infants awaiting inguinal hernia repair may be substantially less common than previously reported, and the occurrence of significant associated morbidity is quite rare.

Patients with post-transplant biliary strictures have significantly higher rates of liver transplant failure and rejection: A nationwide inpatient analysis.

Biliary strictures are a common complication of liver transplantation. We assess the impact of post-transplant biliary strictures and describe the outcomes of endoscopic retrograde cholangiopancreatography (ERCP), interventional radiology (IR), and surgical therapies. Using the Nationwide Readmissions Database (NRD), hospitalized liver transplant recipients were identified using the International Classification of Diseases 10th Revision codes. Patients with post-transplant biliary strictures were identified, and outcomes (inpatient mortality, 30-day readmission, transplant rejection/infection/failure, and disposition) were compared with transplant recipients without strictures. Among transplant patients with biliary strictures who underwent therapeutic intervention, corresponding outcomes were compared between IR, surgical interventions, and ERCP. Of the 8300 liver transplant recipients meeting selection criteria, 554 patients (age 48.9±18.2years, mean±SD; 39.5% women) had biliary strictures. Compared with patients without strictures, the adjusted odds ratio (OR) for various outcomes in patients with biliary strictures were as follows: 1.46 (1.20, 1.77; P<0.001) for 30-day non-elective readmission, 2.71 (2.04, 3.59; P<0.001) allograft rejection, 2.32 (1.61, 3.37; P<0.001) liver transplant failure, 3.05 (1.39, 6.73; P<0.01) infection, and 1.41 (1.08, 1.82; P=0.01) disposition to skilled nursing or intermediate care facility. Therapeutic interventions during index hospitalization were performed in 350 patients: ERCP 46.6% (n=163), surgery 41% (n=144), and IR 12.3% (n=43) patients. Compared with ERCP, the adjusted odds for various outcomes were disposition to skilled nursing or intermediate care facility 2.72 (1.08, 6.87; P=0.03) and 2.09 (1.05, 4.15; P=0.036), prolongation of hospitalization 14.4 (3.7, 25.1; P=0.008) and 15.0 (7.4, 22.7; P<0.001), and failure of liver allograft 8.47 (1.47, 48.6; P=0.017) and 12.23 (2.74, 54.4; P=0.001) for IR and surgical interventions, respectively. Post-liver transplant biliary strictures are associated with increased rates of allograft rejection, allograft failure/infections, and readmissions. Compared with ERCP, management of these patients with IR or surgical interventions is associated with significantly higher rates of allograft failure and hospital stay.

The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial.

Transitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission. To develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events. Two-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO). Multicomponent intervention in the 30 days following hospitalization, including inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient "discharge advocate" and a primary care "responsible outpatient clinician," postdischarge phone calls, and postdischarge primary care visit. The primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission. Among patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates. A multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.

Abstract 14920: Predictors of Adverse Outcomes Following Elective Ascending Aortic Aneurysm Repair: A Nationwide Cohort Study

Introduction: Elective surgical intervention for ascending aortic aneurysm (AA) is performed when the risk of a future aortic catastrophe outweighs the risk of surgery; however, the data of complication rates following elective repair are limited. Methods: We analyzed adults &gt;18 years of age hospitalized for elective ascending AA surgical intervention in the 2016 and 2017 Nationwide Readmissions Databases. The primary outcome was in-hospital mortality. Secondary outcomes were acute ischemic stroke (AIS), acute myocardial infarction (AMI) and non-elective 30-day readmission. Bayesian lasso probit regression models were used to identify independent predictors of primary and secondary outcomes. Results: Among 4,073 patients hospitalized for elective surgical repair, 28.9% were female. Mean age was 63.0 ± 12.4 years. Concomitant aortic valve surgery was performed in 67%. Overall, 72 (1.8%) died during the initial hospitalization (Figure A). Predictors of in-hospital mortality are shown in Figure B. Of patients alive at discharge, 482 (11.8%) were readmitted within 30 days, with a mortality rate of 2.3% during readmission. Predictors of non-elective 30-day readmission included non-urban localization (Change in probability: 32.5%, 21.7 - 45.7%), chronic liver disease (18.1%, 11.4 - 27.0%), and chronic neurological disorder (15.9%, 12.1 - 20.1%). Main causes of readmissions were arrythmias (20.3%), procedural complications (14.5%), and peri-, endo-, or myocarditis (9.3%). While procedural volume varied between one and 68 procedures / institution, it was not associated with in-hospital mortality, AIS, AMI, or 30-day readmission (p&gt;0.05 for all). Conclusions: One in 25 patients will have a significant complication or die following elective ascending aortic repair and 1 in 8 will be readmitted within 30 days. The risk of surgery compared to the risk of a future aortic catastrophe should be thoroughly assessed prior to recommendation of an ascending AA repair.

Incidence and Risk Factors for 30-Day Readmission after Inpatient Chemotherapy Among Acute Lymphoblastic Leukemia Patients

Background: chemotherapy for acute lymphoblastic leukemia (ALL) patients is complex and intense, resulting in their high readmission rate. Modifiable risk factors may exist to reduce their readmission. Objectives: To identify the incidence, causes, and risk factors of readmission following inpatient chemotherapy among ALL patients. Design: A retrospective cohort using the 2016 National Readmission Database. Subjects: ALL children and adults receiving inpatient chemotherapy. Measurements: We applied three different definitions of 30-day readmission: (1) nonelective readmission based on readmission type reported by hospitals, (2) unplanned readmission defined by the algorithm developed by the Center for Medicare and Medicaid Services, and (3) unintentional readmission, combining of (1) and (2). We used a weighted survey procedure to calculate incidence and unweighted, multivariable Poisson regression with robust variance estimates for risk factors analysis, including patient-, hospital- and admission-related characteristics. Results: Percentage for nonelective, unplanned, and unintentional readmission were 33.3%, 22.4%, and 18.5%, respectively. Top three causes for unplanned readmissions were neutropenia/agranulocytosis (27.8%), septicemia (15.3%) and pancytopenia (11.5%). Risk ratios for unintentional readmission were 1.21 (1.08-1.36) for nonelective vs elective admission, 1.19 (1.06-1.33) for public vs private insurance enrollees, 0.96 (0.95-0.98) for each day of hospital stay, 0.77 (0.62-0.95) for large, teaching, and 0.87 (0.70-1.08) for small teaching vs non-teaching hospitals. Conclusions: Possible strategies to reduce readmission among ALL patients could be shortening the gap in quality of care among teaching vs non-teaching hospitals, understanding the difference of privately vs publicly insured patients, and avoiding aggressive discharge after chemotherapy. Disclosures No relevant conflicts of interest to declare.

Predicting non-elective hospital readmission or death using a composite assessment of cognitive impairment and frailty in elderly inpatients with cardiovascular diseases

Abstract Background Cardiovascular disease (CVD) and related complications are significant healthcare problems in the growing elderly population. Metabolic factors are the predominant risk factors for CVD, sedentary behaviour and physical inactivity are major modifiable risk factors for CVD. Age-associated cognitive decline and impairment are associated with an increased mortality. Cognitive and physical components of frailty have pathophysiologic rationale as risk factors for CVD. There is a clinical need to identify more practical screens that can assist us to definite cognitive impairment and physical frailty, then to determine which patients with CVD are at high risk of adverse outcomes, early management of these high-risk patients can reduce readmission rates, healthcare spending, and improve quality of care. Purpose We aimed to assess the utility of a combination developed using the mini-mental state examination + clock drawing test and the Fried phenotype for predicting non-elective hospital readmission or death within 6-month in elderly inpatients with CVD. Methods A single center prospective cohort was conducted between September 2018 and February 2019. Inpatients aged 65 years or older were recruited. All enrolled patients received a comprehensive geriatric assessment during hospitalization. The Kaplan-Meier curves were used to estimate the cumulative incidence of events. The multivariate Cox regression model was used to analyze the association between frailty and cognitive status and the non-elective hospital readmission or death. Results A total of 542 patients were included; and a total of 113 patients (20.9%) died or were readmitted at 6-month. Overall 20% screened positive for cognitive impairment, including 8% were cognitive impairment combined with physical frailty, which were more older, more common in women and non-married group, had a lower education and a higher risk of malnutrition. Frail participants with normal (hazard ratio [HR]: 1.73, 95% confidence intervals [CI]: 1.06–2.82, P=0.028) and impaired cognition (HR: 2.50, 95% CI: 1.27–4.91, P=0.008) had a higher risk of non-elective hospital readmission or death than robust patients, after adjustment for age, sex, education level, marital status, the presence of diabetes mellitus, heart failure, and previous stroke. Conclusions The presence of physical frailty and cognitive frailty were powerful predictors of non-elective hospital readmission or death in elderly inpatients with CVD, and taking cognitive impairment into account in the frailty model may allow better prediction of adverse outcomes of frailty in the short time. Kaplan-Meier survival curves Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Beijing Municipal Science &amp; Technology Commission, Chinese Academy of Medical Sciences