Non-elective Hospital Readmission Research Articles

Functional Status and Hospital Readmission After Pediatric Critical Disease: A Year Follow-Up.

To evaluate the association between pediatric functional status at hospital discharge after PICU admission and hospital readmission within 1 year. Prospective longitudinal study. Two PICUs in tertiary hospitals in South Brazil. Children and adolescents admitted to the PICU. None. We evaluated the following: clinical and sociodemographic characteristics, functional status using the Functional Status Scale-Brazil (FSS-Brazil) at baseline and at hospital discharge, and hospital readmission within 1 year. Hospital readmission risk was associated with possible related factors using Cox regression to estimate the hazard ratio (HR). A total of 196 patients completed the follow-up. At hospital discharge, 39.3% of children had some degree of decline in FSS-Brazil, and 38.3% had at least one nonelective hospital readmission within 1 year. FSS-Brazil rating at hospital discharge was associated with the risk of hospital readmission within 1 year (HR, 1.698; 95% CI, 1.016-2.838). FSS-Brazil rating at hospital discharge, age, and length of stay were associated with greater hazard of nonelective hospital readmission within 1 year of discharge.

Frailty in older people: Rehabilitation Treatment Research Examining Separate Settings (FORTRESS): protocol for a hybrid type II stepped wedge, cluster, randomised trial

BackgroundFrailty in older people is associated with increased risk of falls, longer length of stay in hospital, increased risk of institutionalisation and death. Frailty can be measured using validated tools. Multi-component frailty interventions are recommended in clinical practice guidelines but are not routinely implemented in clinical practice.MethodsThe Frailty in Older people: Rehabilitation, Treatment, Research Examining Separate Settings (FORTRESS) trial is a multisite, hybrid type II, stepped wedge, cluster, randomised trial with blinded assessment and intention-to-treat analysis being conducted in Australia. The study aims to determine the effectiveness and cost-effectiveness of an embedded individualised multicomponent frailty intervention (commencing in hospital and continuing in the community) on readmissions, frailty and quality of life when compared with usual care. Frail older people admitted to study wards with no significant cognitive impairment, who are expected to return home after discharge, will be eligible to participate. Participants will receive extra sessions of physiotherapy, pharmacy, and dietetics during their admission. A Community Implementation Facilitator will coordinate implementation of the frailty management strategies and primary network liaison. The primary outcome is number of days of non-elective hospital readmissions during 12 month follow-up period. Secondary outcomes include frailty status measured using the FRAIL scale; quality of life measured using the EQ-5D-5L; and time-to-event for readmission and readmission rates. The total cost of delivering the intervention will be assessed, and cost-effectiveness analyses will be conducted. Economic evaluation will include analyses for health outcomes measured in terms of the main clinical outcomes. Implementation outcomes will be collected as part of a process evaluation. Recruitment commenced in 2020 and we are aiming to recruit 732 participants over the three-year duration of the study.DiscussionThis study will reveal whether intervening with frail older people to address factors contributing to frailty can reduce hospital readmissions and improve frailty status and quality of life. If the FORTRESS intervention provides a clinically significant and cost-effective result, it will demonstrate an improved approach to treating frail patients, both in hospital and when they return home.Trial RegistrationAustralian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12620000760976p. ANZCTR registered 24 July 2020.

Effectiveness of dietary counseling with or without nutrition supplementation in hospitalized patients who are malnourished or at risk of malnutrition: A systematic review and meta‐analysis

BackgroundNutrition support is associated with improved survival and nonelective hospital readmission rates among malnourished medical inpatients; however, limited evidence supporting dietary counseling is available. We intend to determine the effect of dietary counseling with or without oral nutrition supplementation (ONS), compared with standard care, on hospitalized adults who are malnourished or at risk of malnutrition.MethodsWe searched MEDLINE/PubMed, CINAHL, Embase, Scopus, The Cochrane Library, and Google Scholar for studies listed from January 1, 2011, to August 31, 2021. Meta‐analysis was performed to obtain pooled risk ratios (RRs) and 95% CIs to estimate the effect. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of the evidence.ResultsSixteen studies were identified. Compared with standard care, dietary counseling with or without ONS probably does not reduce inpatient rates of 30‐day mortality (RR = 1.24; 0.60–2.55; I 2 = 45%; P = 0.56; moderate certainty), slightly reduces 6‐month mortality (RR = 0.83; 0.69–1.00; I 2 = 16%; P = 0.06; high certainty), reduces complications (RR = 0.85; 0.73–0.98; I 2 = 0%; P = 0.03; high certainty), and may slightly reduce readmission (RR = 0.83; 0.66–1.03; I 2 = 55%; P = 0.10; low certainty) but may not reduce length of stay (mean difference: −0.75 days; −1.66‐0.17; I 2 = 70%; P = 0.11; low certainty). Intervention may result in slight improvements in nutrition status/intake and weight/body mass index (low certainty).ConclusionsThere is an increase in the certainty of evidence regarding the positive impact of dietary counseling on outcomes. Future studies should standardize and provide details/frequencies of counseling methods and ONS adherence to determine dietary counseling effectiveness.

Accuracy of the Simplified HOSPITAL Score to Predict Nonelective Readmission in a Brazilian Tertiary Care Public Teaching Hospital.

Predictive models to identify patients at high risk of readmission have gained the attention of health care teams, which have focused the strategies to reduce unnecessary readmissions on the "at-risk" patients. The HOSPITAL score includes 7 predictor variables with a C-statistic of 0.70 or more when applied to international datasets. Its simplified version retains a C-statistic at around the same level, but only incipient external validation has been attempted to date. The primary objective of this study was to evaluate the prognostic accuracy of the simplified HOSPITAL score to predict nonelective hospital readmissions in a tertiary care public teaching hospital in Brazil. We used a retrospective cohort that included all patients discharged from the internal medicine service of a Brazilian tertiary care public teaching hospital in 2018. We excluded patients who died before index discharge, were transferred to another institution, left against medical advice, or were readmitted electively. We calculated the simplified HOSPITAL score for each admission, and admissions were divided into low (0-4 points) or high risk (≥ 5 points) of nonelective 30-day readmission. We estimated accuracy, area under the receiver operating characteristic curve (AUC), and observed/expected (O/E) readmission ratio; the latter using the mid-P exact test with Miettinen's modification at a 95% confidence interval (CI). A P value < .05 was considered significant. A total of 4472 hospital discharges were analyzed during the study period after application of the exclusion criteria. The nonelective 30-day readmission rate was 14.0% (n = 625). Of all patients discharged, 3173 (71.0%) were considered to be at low risk and 1299 (29.0%) at high risk of readmission according to the simplified HOSPITAL score. The AUC was 0.68 (95% CI: 0.66-0.71; P < .001). The nonelective 30-day readmission rate was 9.2% in the low-risk group (expected: 9.2%; O/E: 1.0 [95% CI: 0.89-1.12]) and 25.7% in the high-risk group (expected: 27.2%; O/E: 0.95 [95% CI: 0.85-1.05]) ( P < .001). At a cut-off of 5 points, the score had a sensitivity of 53.4%, specificity of 74.9%, positive predictive value of 25.7%, and negative predictive value (NPV) of 90.8%. The parameters of the score were almost identical to the original study, with better applicability to exclude low-risk patients given its high NPV. Additional adjustments are still needed for better applicability in daily clinical practice.

Association between the combined effect of frailty and the estimated glomerular filtration rate and non-elective hospital readmission in elderly inpatients: a cohort study.

This study aims to explore the combined effect of frailty and the estimated glomerular filtration rate (eGFR) and non-elective hospital readmission in elderly inpatients. A total of 400 elderly patients were selected. The Fried scale was used to assess frailty. The patients were divided into a non-frailty group and a frailty group. They were divided into a normal eGFR group and a eGFR decreased group. Finally, the patients were divided into the following four groups: Group A (no frailty + eGFR normal); Group B (no frailty + eGFR decreased); Group C (frailty + eGFR normal); and Group D (frailty + eGFR decreased). The results of the follow-up survival analysis showed the non-elective hospital readmission within 6 months of discharge. Group A, Group B, Group C, and Group D had an incidence of 21%, 26%, 24%, and 36%, respectively. The Kaplan-Meier curves showed the event-free survival rates of Group A and Group C were higher than that of Group D, and there was no significant difference between Group B and Group D. The risk of non-elective hospital readmission within 6 months in patients with a decreased eGFR was 1.777 times higher than that in patients with a normal eGFR [95% confidence interval (CI): 1.001-3.154], while the risk of non-elective hospital readmission within 6 months in frail patients and non-frail patients did not differ significantly. The multivariate Cox regression analysis showed that the risk of non-elective hospital readmission in Group D was 2.295 times higher than that in Group A (95% CI: 1.096-4.810), and the difference was statistically significant. The risk of non-elective hospital readmission in Group B was 1.401 times of that in Group A (95% CI: 0.665-2.953), while that in Group C was 91.8% (95% CI: 0.403-2.092), but the differences were not statistically significant. A decline in eGFR is associated with non-elective hospital readmission in elderly inpatients within 6 months; however, frailty is not associated with non-elective hospital readmission. The combined effect of frailty and eGFR in elderly inpatients is related to non-elective hospital readmission.

Hospital readmission within 30 days of older adults hospitalized in a public hospital

Older adults have difficulty monitoring their drug therapy in the first thirty days following hospital discharge. This transition care period may trigger hospital readmissions. The study aims to identify the factors associated with the readmission of older adults 30 days after discharge from the perspective of drug therapy. This is a cross-sectional study and hospital admission within 30 days was defined as readmission to any hospital 30 days after discharge. The complexity of the drug therapy was established by the Medication Regimen Complexity Index (MRCI).. Readmission risks were predicted by the “Readmission Risk Score - RRS”. The multivariate logistic regression was used to identify factors associated with readmission within 30 days after discharge. Two hundred fifty-five older adults were included in the study, of which 32 (12.5%) had non-elective hospital readmission. A higher number of readmissions was observed with increased RRS value, suggesting a linear gradient effect. The variables included in the final logistic regression model were the diagnosis of cancer (OR=2.9, p=0.031), pneumonia (OR=2.3, p=0.055), and High MRCI (> 16.5) following discharge (OR=1.9, p=0.119). The cancer diagnosis is positively associated with hospital readmissions of older adults within 30 days.

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.

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.

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

Six-month outcomes after individualized nutritional support during the hospital stay in medical patients at nutritional risk: Secondary analysis of a prospective randomized trial

Among medical inpatients at risk of malnutrition, the use of individualized nutritional support during the hospital stay was found to reduce complications and improve mortality at short-term. We evaluated clinical outcomes at 6-months follow-up. We randomly assigned 2028 patients to receive protocol-guided individualized nutritional support to reach protein and energy goals (intervention group) or hospital food as usual (control group) during the hospital stay. The intervention was discontinued at hospital discharge and further nutritional support was based on the discretion of the treating team. We had complete follow-up information of 1995 patients (98%), which were included in the final analysis. The primary endpoint was all-cause mortality at 6-months. Prespecified secondary end points included non-elective hospital readmissions, functional outcome and quality of life. At 6-month, 231 of 994 (23.2%) intervention group patients had died compared to 246 of 999 (24.6%) control group patients, resulting in a hazard ratio for death of 0.90 (95%CI 0.76 to 1.08, p=0.277). Compared to control patients, intervention group patients had similar rates of hospital readmission (27.3% vs. 27.6%, HR 1.00 (95%CI 0.84 to 1.18), p=0.974), falls (11.2% vs. 10.9%, HR 0.96 (95%CI 0.72 to 1.27), p=0.773) and similar quality of life and activities of daily living scores. While individualized nutritional support during the hospital stay significantly reduced short-term mortality, there was no legacy effect on longer term outcomes. Future trials should investigate whether continuation of nutritional support after hospital discharge reduces the high malnutrition-associated mortality rates in this vulnerable patient population. ClinicalTrials.gov number, NCT02517476.

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

BackgroundWe aimed to assess the utility of the combination of the mini-mental state examination (MMSE) + clock drawing test (CDT) and the Fried phenotype for predicting non-elective hospital readmission or death within 6 months in elderly inpatients with cardiovascular disease (CVD).MethodsA single-center prospective cohort was conducted from September 2018 to February 2019. Inpatients ≥65 years old were recruited. Predictive validity was tested using a Cox proportional hazards regression model analysis, and the discriminative ability was evaluated by the receiver operating characteristic (ROC) curve.ResultsA total of 542 patients were included. Overall, 12% (64/542) screened positive for cognitive impairment, 16% (86/542) were physically frail and 8% (44/542) had cognitive impairment combined with physical frailty, showing an older age (P < 0.001) and a lower education level (P < 0.001) than physically frail patients. A total of 113 patients (20.9%) died or were readmitted at 6 months. Frail participants with a normal (hazard ratio [HR]: 1.73, 95% confidence interval [CI]: 1.06–2.82, P = 0.028) or 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 adjusting for the age, sex, education level, marital status, the presence of diabetes mellitus, heart failure, and history of stroke. The area under the ROC curve (AUC) showed that the discriminative ability in relation to 6 months readmission and death for the MMSE + CDT + Fried phenotype was 0.65 (95% CI: 0.60–0.71), and the AUC for men was 0.71 (95% CI: 0.63–0.78), while that for women was 0.60 (95% CI: 0.51–0.69).ConclusionsAccounting for cognitive impairment in the frailty phenotype may allow for the better prediction of non-elective hospital readmission or death in elderly inpatients with CVD in the short term.Trial registrationChiCTR1800017204; date of registration: 07/18/2018.

Predictor Biomarkers of Nonelective Hospital Readmission and Mortality in Malnourished Hospitalized Older Adults

Background90-day mortality and rehospitalizations are important hospital quality metrics. Biomarkers that predict these outcomes among malnourished hospitalized patients could identify those at risk and help direct care plans.ObjectivesTo identify biomarkers that predict 90-day (primary) and 30-day (secondary) mortality or nonelective rehospitalization.Design and ParticipantsAn analysis of the ability of biomarkers to predict 90- and 30-day mortality and rehospitalization among malnourished hospitalized patients.Setting52 blood biomarkers were measured in 193 participants in NOURISH, a randomized trial that determined the effects of a nutritional supplement on 90-day readmission and death in patients >65 years. Composite outcomes were defined as readmission or death over 90-days or 30-days. Univariate Cox Proportional Hazards models were used to select best predictors of outcomes. Markers with the strongest association were included in multivariate stepwise regression. Final model of hospital readmission or death was derived using stepwise selection.MeasurementsNutritional, inflammatory, hormonal and muscle biomarkers.ResultsMean age was 76 years, 51% were men. In univariate models, 10 biomarkers were significantly associated with 90-day outcomes and 4 biomarkers with 30-day outcomes. In multivariate stepwise selection, glutamate, hydroxyproline, tau-methylhistidine levels, and sex were associated with death and readmission within 90-days. In stepwise selection, age-adjusted model that included sex and these 3 amino-acids demonstrated moderate discriminating ability over 90-days (C-statistic 0.68 (95%CI 0.61, 0.75); age-adjusted model that included sex, hydroxyproline and Charlson Comorbidity Index was predictive of 30-day outcomes (C-statistic 0.76 (95%CI 0.68, 0.85).ConclusionsBaseline glutamate, hydroxyproline, and tau-methylhistidine levels, along with sex and age, predict risk of 90-day mortality and nonelective readmission in malnourished hospitalized older patients. This biomarker set should be further validated in prospective studies and could be useful in prognostication of malnourished hospitalized patients and guiding in-hospital care.

Association of Nutritional Support With Clinical Outcomes Among Medical Inpatients Who Are Malnourished or at Nutritional Risk

Malnutrition affects a considerable proportion of the medical inpatient population. There is uncertainty regarding whether use of nutritional support during hospitalization in these patients positively alters their clinical outcomes. To assess the association of nutritional support with clinical outcomes in medical inpatients who are malnourished or at nutritional risk. For this updated systematic review and meta-analysis, a search of the Cochrane Library, MEDLINE, and Embase was conducted from January 1, 2015, to April 30, 2019; the included studies were published between 1982 and 2019. A prespecified Cochrane protocol was followed to identify trials comparing oral and enteral nutritional support interventions with usual care and the association of these treatments with clinical outcomes in non-critically ill medical inpatients who were malnourished. Two reviewers independently extracted data and assessed risk of bias; data were pooled using a random-effects model. The primary outcome was mortality. The secondary outcomes included nonelective hospital readmissions, length of hospital stay, infections, functional outcome, daily caloric and protein intake, and weight change. A total of 27 trials (n = 6803 patients) were included, of which 5 (n = 3067 patients) were published between 2015 and 2019. Patients receiving nutritional support compared with patients in the control group had significantly lower rates of mortality (230 of 2758 [8.3%] vs 307 of 2787 [11.0%]; odds ratio [OR], 0.73; 95% CI, 0.56-0.97). A sensitivity analysis suggested a more pronounced reduction in the risk of mortality in recent trials (2015 or later) (OR, 0.47; 95% CI, 0.28-0.79) compared with that in older studies (OR, 0.94; 95% CI, 0.72-1.22), in patients with established malnutrition (OR, 0.52; 95% CI, 0.34-0.80) compared with that in patients at nutritional risk (OR, 0.85; 95% CI, 0.62-1.18), and in trials with high protocol adherence (OR, 0.67; 95% CI, 0.54-0.84) compared with that in trials with low protocol adherence (OR, 0.88; 95% CI, 0.44-1.76). Nutritional support was also associated with a reduction in nonelective hospital readmissions (14.7% vs 18.0%; risk ratio, 0.76; 95% CI, 0.60-0.96), higher energy intake (mean difference, 365 kcal; 95% CI, 272-458 kcal) and protein intake (mean difference, 17.7 g; 95% CI, 12.1-23.3 g), and weight increase (0.73 kg; 95% CI, 0.32-1.13 kg). No significant differences were observed in rates of infections (OR, 0.86; 95% CI, 0.64-1.16), functional outcome (mean difference, 0.32; 95% CI, -0.51 to 1.15), and length of hospital stay (mean difference, -0.24; 95% CI, -0.58 to 0.09). This study's findings suggest that despite heterogeneity and varying methodological quality among trials, nutritional support was associated with improved survival and nonelective hospital readmission rates among medical inpatients who were malnourished and should therefore be considered when treating this population.

Evaluating the Connect with Pharmacy web-based intervention to reduce hospital readmission for older people

Background The patient transition from a hospital to a post-discharge healthcare setting has potential to disrupt continuity of medication management and increase the risk of harm. “Connect with Pharmacy” is a new electronic web-based transfer of care initiative employed by Leeds Teaching Hospitals NHS Trust. This allows the sharing of discharge information between the hospital and a patient’s chosen community pharmacy. Objective We investigated whether the timely sharing of discharge information with community pharmacies via “Connect with Pharmacy” reduced hospital readmission rates in older patients. Method To evaluate intervention efficacy, hospital admission data was retrospectively collected. For primary analysis, admission rates were tracked 6-months prior (baseline) and 6-months post-intervention. Secondary measures included effect on total length of stay if readmitted, emergency department attendance and duration, and impact of polypharmacy. Main outcome measure The rate of non-elective hospital readmissions, 6-months post-intervention. Results In the sample (n = 627 patients; Mean age = 81 years), emergency readmission rates following the intervention (M = 1.1, 95% CI [0.98, 1.22]) reduced by 16.16% relative to baseline (M = 1.31, 95% CI [1.21, 1.42]) (W = 54,725; p < 0.001). There was no reduction in total length of stay. Subsidiary analysis revealed a post-intervention reduction in number of days spent in hospital lasting more than three days (χ2 = 13.37, df = 1, p < 0 .001). There were no statistically reliable differences in the remaining secondary measures. Conclusion The results showed a reduction in readmissions and potential post-intervention length of stay, indicating there may be further benefits for our older patients’ experiences and hospital flow.

Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial

Guidelines recommend the use of nutritional support during hospital stays for medical patients (patients not critically ill and not undergoing surgical procedures) at risk of malnutrition. However, the supporting evidence for this recommendation is insufficient, and there is growing concern about the possible negative effects of nutritional therapy during acute illness on recovery and clinical outcomes. Our aim was thus to test the hypothesis that protocol-guided individualised nutritional support to reach protein and caloric goals reduces the risk of adverse clinical outcomes in medical inpatients at nutritional risk. The Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) is a pragmatic, investigator-initiated, open-label, multicentre study. We recruited medical patients at nutritional risk (nutritional risk screening 2002 [NRS 2002] score ≥3 points) and with an expected length of hospital stay of more than 4 days from eight Swiss hospitals. These participants were randomly assigned (1:1) to receive either protocol-guided individualised nutritional support to reach protein and caloric goals (intervention group) or standard hospital food (control group). Randomisation was done with variable block sizes and stratification according to study site and severity of malnutrition using an interactive web-response system. In the intervention group, individualised nutritional support goals were defined by specialist dietitians and nutritional support was initiated no later than 48 h after admission. Patients in the control group received no dietary consultation. The composite primary endpoint was any adverse clinical outcome defined as all-cause mortality, admission to intensive care, non-elective hospital readmission, major complications, and decline in functional status at 30 days, and it was measured in all randomised patients who completed the trial. This trial is registered with ClinicalTrials.gov, number NCT02517476. 5015 patients were screened, and 2088 were recruited and monitored between April 1, 2014, and Feb 28, 2018. 1050 patients were assigned to the intervention group and 1038 to the control group. 60 patients withdrew consent during the course of the trial (35 in the intervention group and 25 in the control group). During the hospital stay, caloric goals were reached in 800 (79%) and protein goals in 770 (76%) of 1015 patients in the intervention group. By 30 days, 232 (23%) patients in the intervention group experienced an adverse clinical outcome, compared with 272 (27%) of 1013 patients in the control group (adjusted odds ratio [OR] 0·79 [95% CI 0·64-0·97], p=0·023). By day 30, 73 [7%] patients had died in the intervention group compared with 100 [10%] patients in the control group (adjusted OR 0·65 [0·47-0·91], p=0·011). There was no difference in the proportion of patients who experienced side-effects from nutritional support between the intervention and the control group (162 [16%] vs 145 [14%], adjusted OR 1·16 [0·90-1·51], p=0·26). In medical inpatients at nutritional risk, the use of individualised nutritional support during the hospital stay improved important clinical outcomes, including survival, compared with standard hospital food. These findings strongly support the concept of systematically screening medical inpatients on hospital admission regarding nutritional risk, independent of their medical condition, followed by a nutritional assessment and introduction of individualised nutritional support in patients at risk. The Swiss National Science Foundation and the Research Council of the Kantonsspital Aarau, Switzerland.

Effectiveness of a financial incentive to physicians for timely follow-up after hospital discharge: a population-based time series analysis.

Timely follow-up after hospital discharge may decrease readmission to hospital. Financial incentives to improve follow-up have been introduced in the United States and Canada, but it is unknown whether they are effective. Our objective was to evaluate the impact of an incentive program on timely physician follow-up after hospital discharge. We conducted an interventional time series analysis of all medical and surgical patients who were discharged home from hospital between Apr. 1, 2002, and Jan. 30, 2015, in Ontario, Canada. The intervention was a supplemental billing code for physician follow-up within 14 days of discharge from hospital, introduced in 2006. The primary outcome was an outpatient visit within 14 days of discharge. Secondary outcomes were 7-day follow-up and a composite of emergency department visits, nonelective hospital readmission and death within 14 days. We included 8 008 934 patient discharge records. The incentive code was claimed in 31% of eligible visits by 51% of eligible physicians, and cost $17.5 million over the study period. There was no change in the average monthly rate of outcomes in the year before the incentive was introduced compared with the year following introduction: 14-day follow-up (66.5% v. 67.0%, overall p = 0.5), 7-day follow-up (44.9% v. 44.9%, overall p = 0.5) and composite outcome (16.7% v. 16.9%, overall p = 0.2). Despite uptake by physicians, a financial incentive did not alter follow-up after hospital discharge. This lack of effect may be explained by features of the incentive or by extra-physician barriers to follow-up. These barriers should be considered by policymakers before introducing similar initiatives.

Senior services in US hospitals and readmission risk in the Medicare population.

There is a little understanding of the association between hospital organizational characteristics and hospital readmissions. We previously developed a Senior Care Services Scale (SCSS) that describes hospital availability of services relevant to the care of older adults. Determine whether hospitals' SCSS scores were associated with risk of readmission among Medicare beneficiaries. Retrospective cohort analysis. Medicare beneficiaries ≥65 years of age (n = 3 553 367), admitted to 5568 US acute-care hospitals in 2006, discharged alive. Medicare data were linked to the American Hospital Association database of hospital characteristics. All-cause non-elective hospital readmission, or death without readmission, within 30 days of hospital discharge. We examined the association between high and low scores of each of two hospital SCSS service groups: inpatient specialty care (IP) and post-acute (PA) community care. There was no association between high IP scores and readmission (RR 1.00, 95% CI 0.98-1.02). Older adults admitted to hospitals with high PA scores had lower risk of experiencing hospital readmission when compared to older adults admitted to hospitals with low PA scores (RR 0.97, 95% CI 0.95-0.98). High PA scores were associated with increased mortality (RR 1.09, 95% CI 1.06-1.13). In sensitivity analyses exploring relationships at 90 days, both the IP and PA subcomponents were associated with older adults' reduced risk of hospital readmission (IP: RR 0.97, 95% CI 0.95-0.99; PA: RR 0.97, 95% CI 0.95-0.99). Senior services at the hospital-level represents a modifiable risk factor with important impact. Employing organization-level characteristics in readmission risk prediction tools should be expanded.

Tertiary paediatric hospital admissions in children and young people with cerebral palsy.

Many previous studies that have investigated hospital admissions in children and young people with cerebral palsy lack information on cerebral palsy severity and complexity. Consequently, little is known about factors associated with the frequency and type of hospital admissions in this population. This study used hospital admission data available for all children and young people known to a population-based cerebral palsy register to describe the patterns of use of tertiary paediatric hospital services over a 5-year period. This was a retrospective cohort analysis of routinely collected admission data from the two tertiary paediatric hospitals in the Australian state of Victoria. Data on admissions of individuals born between 1993 and 2008 registered on the Victorian Cerebral Palsy Register were analysed (n = 2183). Between 2008 and 2012, 53% of the cohort (n = 1160) had at least one same-day admission, and 46% (n = 996) had one or more multi-day admissions. Those with a moderate to severe motor impairment and those with a co-diagnosis of epilepsy had more admissions, and for multi-day admissions, longer lengths of stay, P < 0.05. Across all severity levels, respiratory and musculoskeletal diseases were the most frequently reported reasons for medical and surgical admissions, respectively. All-cause readmission rates for urgent multi-day stays within 7, 30 and 365 days of an index admission were 10%, 23% and 63%, respectively. The reasons for hospital admissions reported here reflect the range of comorbidities experienced by children and young people with cerebral palsy. This study highlights priority areas for prevention, early diagnosis and medical management in this group. Improved primary and secondary prevention measures may decrease non-elective hospital admissions and readmissions in this group and reduce paediatric inpatient resource use and healthcare expenditure attributable to cerebral palsy.

Oral nutritional supplements during acute illness and recovery reduced non-elective hospital readmissions in older patients

Oral nutritional supplements during acute illness and recovery reduced non-elective hospital readmissions in older patients

Comprehensive geriatric assessment and home-based rehabilitation for elderly people with a history of recurrent non-elective hospital admissions

To determine whether a co-ordinated programme of geriatric assessment and multidisciplinary home-based rehabilitation reduces disability and prevents non-elective hospital readmission in high-risk elderly patients. Nested case-control study comparing usual post-discharge care versus usual care plus a comprehensive geriatric assessment and home-based rehabilitation service, comprising nursing, occupational therapy and physiotherapy with geriatric medical review. Patients were >or=65 years with >or=2 non-elective hospital admissions within the previous 12 months. Disability was assessed using the 100-point Barthel index and Nottingham extended activities of daily living (EADL) score. Non-elective hospital admissions were recorded over 1-year follow-up. We studied 84 patients; 56 receiving the new service were matched to 28 controls. Intervention subjects received a median of 19 h [interquartile range (IQR) (7,35)] rehabilitation over 19 [IQR (6,42)] domiciliary visits. At 3 months, there was improvement in median Barthel and Nottingham EADL scores in the intervention group of 3 and 2 points, respectively, compared with reductions in controls of 3 and 6 points (both P<0.001, changes in intervention group versus controls); similar differences persisted in survivors at 12 months. There was a non-significant trend for reduction in the proportion of patients with further non-elective hospital admission in the intervention group (36/56, 64%) compared with controls (21/28, 75%; OR 0.70, 95% CI 0.34, 1.46). A co-ordinated programme of geriatric assessment and multidisciplinary home-based rehabilitation reduced disability in elderly patients at high risk for non-elective hospital admission. Further research is required to determine whether this approach can reduce the need for hospital admission.