Post-hospital Discharge Research Articles

Venous and arterial thromboembolism in patients with inflammatory bowel diseases.

The risk of thromboembolism (TE) is increased in patients with inflammatory bowel disease (IBD), mainly due to an increased risk of venous TE (VTE). The risk of arterial TE (ATE) is less pronounced, but an increased risk of cardiovascular diseases needs to be addressed in IBD patients. IBD predisposes to arterial and venous thrombosis through similar prothrombotic mechanisms, including triggering activation of coagulation, in part mediated by impairment of the intestinal barrier and released bacterial components. VTE in IBD has clinical specificities, i.e., an earlier first episode in life, high rates during both active and remission stages, higher recurrence rates, and poor prognosis. The increased likelihood of VTE in IBD patients may be related to surgery, the use of medications such as corticosteroids or tofacitinib, whereas infliximab is antithrombotic. Long-term complications of VTE can include post-thrombotic syndrome and high recurrence rate during post-hospital discharge. A global clot lysis assay may be useful in identifying patients with IBD who are at risk for TE. Many VTEs occur in IBD outpatients; therefore, outpatient prophylaxis in high-risk patients is recommended. It is crucial to continue focusing on prevention and adequate treatment of VTE in patients with IBD.

Recovery from Covid-19 critical illness: A secondary analysis of the ISARIC4C CCP-UK cohort study and the RECOVER trial.

We aimed to compare the prevalence and severity of fatigue in survivors of Covid-19 versus non-Covid-19 critical illness, and to explore potential associations between baseline characteristics and worse recovery. We conducted a secondary analysis of two prospectively collected datasets. The population included was 92 patients who received invasive mechanical ventilation (IMV) with Covid-19, and 240 patients who received IMV with non-Covid-19 illness before the pandemic. Follow-up data were collected post-hospital discharge using self-reported questionnaires. The main outcome measures were self-reported fatigue severity and the prevalence of severe fatigue (severity >7/10) 3 and 12-months post-hospital discharge. Covid-19 IMV-patients were significantly younger with less prior comorbidity, and more males, than pre-pandemic IMV-patients. At 3-months, the prevalence (38.9% [7/18] vs. 27.1% [51/188]) and severity (median 5.5/10 vs 5.0/10) of fatigue were similar between the Covid-19 and pre-pandemic populations, respectively. At 6-months, the prevalence (10.3% [3/29] vs. 32.5% [54/166]) and severity (median 2.0/10 vs. 5.7/10) of fatigue were less in the Covid-19 cohort. In the total sample of IMV-patients included (i.e. all Covid-19 and pre-pandemic patients), having Covid-19 was significantly associated with less severe fatigue (severity <7/10) after adjusting for age, sex and prior comorbidity (adjusted OR 0.35 (95%CI 0.15-0.76, p=0.01). Fatigue may be less severe after Covid-19 than after other critical illness.

Pathway Home™ for High Utilizers of Psychiatric Inpatient Services: Impact on Inpatient Days and Outpatient Engagement.

This study examined the impact of Pathway Home™ (PH) transition services for high utilizers of psychiatric hospitalization on inpatient days and outpatient engagement post-hospital discharge. This case series study of forty PH graduates (5/22/2015-8/31/2018) used Medicaid claims to assess psychiatric inpatient days-per-month, average proportion of months with psychiatric emergency room, outpatient, and health home care management services. T-tests compared three time periods: the year prior, during, and after enrollment. Graduates had significantly fewer psychiatric inpatient days/month during (M = 1.84, p < 0.001) and after PH enrollment (M = 1.88, p < 0.001) compared to prior to enrollment (M = 7.1), while emergency services were stable. Outpatient visits increased from 45% prior to 76% during enrollment (p < 0.001) and was sustained on follow-up (67%, p = 0.008). A similar pattern emerged for health home services (32%, 60%, and 50%). PH is a promising approach for improving outcomes for high utilizers of psychiatric inpatient services, with sustained impact on follow-up.

Mapping the Evidence on Human Milk Fortification and Cardiovascular Risk Factors and Outcomes among Low Birth Weight Infants: A Scoping Review

Introduction: Preterm and low birth weight infants receiving a diet of human milk require fortification with protein, carbohydrates, vitamins, and minerals due to missed growth and nutrient accretion that would otherwise occur in utero. Although rapid catch-up growth improves anthropometric and neurodevelopmental indices, research has suggested that accelerated postnatal growth may be associated with poor long-term cardiometabolic outcomes. Methods: We conducted a scoping review to map the evidence on human milk fortification and cardiometabolic risk factors and outcomes among low birth weight infants. We searched Ovid Medline, Ovid Embase, CINAHL, and Web of Science from inception to June 2021 and examined grey literature for relevant referenced articles. Studies were included if they were a primary study focused on fortified human milk and cardiometabolic risk factors or outcomes among low birth weight infants. A modified version of the Cochrane Collaboration Randomized Controlled Trial data collection form guided data collection. We conducted a narrative synthesis of the results structured around the Population, Concept, Context framework. Results: We included 19 articles (14 randomized controlled trials, three quasi-randomized trials and two cohort studies) on cardiometabolic risk factors among 1,955 low birth weight infants who received fortified human milk. None of the included studies addressed long-term cardiometabolic outcomes. Body weight was the most examined risk factor in all included studies, with 13 studies observing benefit from human milk fortification. Two studies linked rapid growth with cardiometabolic risk factors. Discussion: The focus across the 19 included studies was the anthropometric advantages of fortified HM among LBW infants. A meta-analysis was not performed for this review, but if completed may yield a different inference. Conclusion: Limited evidence is available regarding the long-term cardiometabolic outcomes among low birth weight infants who received fortified human milk. Existing literature is focused on the short-term anthropometric benefits of fortification post-hospital discharge. Yet, some reports have linked rapid early postnatal growth with the development of cardiometabolic risk factors later in life. Future studies should explore the long-term cardiometabolic outcomes among low birth weight infants with the goal of optimizing anthropometric and brain growth while minimizing long-term cardiometabolic risk.

Impact of pulse oximetry screening to detect congenital heart defects: 5\xa0years\u2019 experience in a UK regional neonatal unit

Pulse oximetry screening (POS) has been shown to be an effective, non-invasive investigation that can detect up to 50–70% of previously undiagnosed congenital heart defects (CHDs). The aims of this study were to assess the accuracy of POS in detection of CHDs and its impact on clinical practice. All eligible newborn infants born between 1 Jan 2015 and 31 Dec 2019 in a busy regional neonatal unit were included in this prospective observational study. A positive POS was classified as two separate measurements of oxygen saturation < 95%, or a difference of > 2% between pre- and post-ductal circulations. Overall, 23,614 infants had documented POS results. One hundred eighty nine (0.8%) infants had a true positive result: 6 had critical CHDs, 9 serious or significant CHDs, and a further 156/189 (83%) infants had significant non-cardiac conditions. Forty-three infants who had a normal POS were later diagnosed with the following categories of CHDs post-hospital discharge: 1 critical, 15 serious, 20 significant and 7 non-significant CHDs. POS sensitivity for detection of critical CHD was 85.7%, whereas sensitivity was only 33% for detection of major CHDs (critical and serious) needing surgery during infancy; specificity was 99.3%.Conclusion: Pulse oximetry screening showed moderate to high sensitivity in detection of undiagnosed critical CHDs; however, it failed to detect two-third of major CHDs. Our study further emphasises the significance of adopting routine POS to detect critical CHDs in the clinical practice. However, it also highlights the need to develop new, innovative methods, such as perfusion index, to detect other major CHDs missed by current screening tools.What is Known:• Pulse oximetry screening is cost effective, acceptable, easy to perform and has moderate sensitivity and high specificity in detection of critical congenital heart defects.• Pulse oximetry screening has been implemented many countries including USA for detection of critical congenital heart defects, but it is not currently recommended by the UK National Screening Committee.What is New:• To our knowledge, this is the first study describing postnatal detection and presentation of all the infants with congenital heart defects over a period of 5 years, including those not detected on the pulse oximetry screening, on the clinical practice. • It emphasises that further research required to detect critical congenital heart defects and other major CHDs which can be missed on the screening tools currently employed in clinical practice.

Impact of a pharmacist-inclusive post-discharge clinic on outcomes in heart failure patients with reduced ejection fraction: Rates of hospital readmission, emergency department visits, or death.

Heart failure hospitalization is a hallmark of disease progression associated with increased morbidity and mortality. Benefits of multidisciplinary clinics have been established in the care of heart failure patients and can be particularly impactful post-hospital discharge. This study aimed to investigate the impact of a clinical pharmacist-integrated model of care within a Heart Failure Bridge Clinic (HFBC) at a large tertiary care referral center. In this single-center retrospective study, patients with left ventricular ejection fraction (LVEF) ≤40% discharged from Mission Hospital (Asheville, North Carolina) between August 2018 and July 2019 were screened. Patients in the HFBC arm had a clinic visit inclusive of a clinical pharmacist within 30 days of hospital discharge and were compared with a control group of patients with a usual care provider clinic visit. The HFBC provided clinical assessment, detailed heart failure education, and medication reconciliation and adjustment with an emphasis on optimization of Guideline Directed Medical Therapy (GDMT). Patients were followed for 90 days for the primary end point of hospitalization, emergency department (ED) visit, or death. A total of 1463 patients (HFBC, n = 307; control, n = 1156) comprised our final cohort. After accounting for baseline variables, 90-day cumulative probability of hospitalization, ED visit, or death favored HFBC patients (26% vs 32%, P = .0275). Comprehensive review of medications prior to and after HFBC appointment demonstrated significant alterations to therapies (30% GDMT addition, 27% GDMT titration, 7.2% discontinuation of medications associated with worsening heart failure, and 28% loop diuretic adjustment). Clinical pharmacist-integrated HFBC allows for focused medication review and optimization and is associated with a 19% relative risk reduction in hospitalization, ED visit, or death at 90 days.

Dutch multicentre, prospective follow-up, cohort study comparing the neurological and neuropsychological sequelae of hospitalised non-ICU- and ICU-treated COVID-19 survivors: a study protocol

IntroductionOwing to the novelty of COVID-19, there are still large knowledge gaps concerning its effect on the brain and the resulting impact on peoples’ lives. This large-scale prospective follow-up study...

VV ECMO for Treatment of Severe ARDS in CoVID-19 Patients at UNMC

Introduction: Veno-venous extracorporeal membrane oxygenation (VV ECMO) is an indicated treatment for severe acute respiratory distress syndrome (ARDS) refractory to conventional medical treatment. Severe ARDS is a common complication of CoVID-19 infection. Subsequently, the efficacy of VV ECMO in CoVID-19 severe ARDS patients must be investigated. ECMO is a resource-intensive treatment modality, meaning that its use must be reserved for patients with robust indications and paucity of contraindications. Methods: We performed retrospective chart review of three patients at the University of Nebraska Medical Center that were placed on VV ECMO secondary to severe ARDS from CoVID-19 infection. Results: All patients were male with a median age of 39 years. Two patients were of Hispanic descent, and the third was of Asian descent. No patients had underlying lung disease, and all patients had type II diabetes mellitus. Median time on mechanical ventilation prior to ECMO cannulation was six days. Median duration of ECMO treatment was 21 days with a range of 17 to 27 days. All patients were decannulated from ECMO during their hospital stay, and all patients survived to 60 days post-hospital discharge. Complications while on ECMO included GI bleeding in two patients, hematuria in one patient, necessitation of vasodilator and vasopressor support in all patients, AKI in two patients, secondary bacterial pneumonia in two patients, and blood cultures positive for gram-positive organisms in all patients. No patients suffered DVT or CVA. All patients required pRBC transfusion during ECMO treatment. Two patients were treated with remdesivir and one patient received baricitinib, a JAK-inhibitor. Conclusion: VV ECMO is a viable treatment for patients with severe ARDS secondary to CoVID-19 infection that have failed conventional therapy. Stringent adherence to inclusion and exclusion criteria is imperative. VV ECMO combined with lung protective ventilation strategies with a focus on minimizing driving pressure can provide life-saving treatment to patients with severe ARDS secondary to CoVID-19 infection

45.3 The Utility of Child and Adolescent Mobile Psychiatric Services (CAMPS) for Youth

The incidence rates of mental illness in youth are increasing in the United States; however, structural and cost barriers in accessing treatment result in low treatment rates and high dropout rates. Given the complex, interconnected risk factors affecting youths’ functioning, home-based mental health services can be utilized to address some barriers. In 2019, the Child and Adolescent Mobile Psychiatric Services (CAMPS) team was piloted, comprising a case manager, social worker, and child and adolescent psychiatrist. Referrals included high-risk clinic patients. Frequency of visits and timing of discharge was explored during a weekly collaborative conference. Measures were administered at the start and completion of the program, including parental distress, impairment, barriers to treatment, use of services to date, and an exit survey. All procedures were approved by the University at Buffalo IRB. In the first 15 months, 28 families provided some data and 11 provided complete data. Of the 28, 12 identified as African American, 11 White, 3 Hispanic, and 2 Multiracial. The patients’ age range was 5 to 18 years (mean = 12). Twenty-six families had government-subsidized health insurance. Referrals were for functional impairment (74%), severe mood dysregulation (19%), or posthospital discharge (7%). Since enrollment in CAMPS, families’ overall attendance rate increased from 66% to 84%. A paired t test comparing each family’s pre- to postattendance rate showed significant improvement (t = 4.04; p < 0.001). A paired t test of parent-rated youth impairment (n = 11) suggested marginal reduction (t = 1.96; p = 0.08). Parental stress (pre = 41.1, post = 38.6) and barriers to treatment (mean number of barriers: pre = 1.92, post = 1.77) did not significantly differ. In the presurvey (n = 25), 7 families reported a history of hospitalization, 7 made a prior crisis call, and 15 reported difficulty with attending school. In posttreatment surveys (n = 11), no child was hospitalized, 2 families made a crisis call, and only 1 reported school attendance issues. Ten families found the program helpful, and 100% felt more informed about their child’s mental health needs. While our small sample size is a limitation, data indicate improvements in treatment engagement, school attendance, and decreased hospitalization rates.

Pseudoaneurysms after Le Fort I Osteotomy at a Single High-surgical-volume Institution

The Le Fort I maxillary osteotomy remains a workhorse surgical technique for addressing dentofacial deformities; however, significant complications can arise. One of the most serious complications is a pseudoaneurysm that results from injury to a terminal branch of the internal maxillary artery. The bleeding episodes normally develop 10 days to 4 weeks post-hospital discharge. Typically, these are minor sentinel bleeding preceding a hemorrhagic episode that results in an emergency room visit. While rare, significant morbidity has been reported, and bleeding can be rapid and in some instances mortal. While definitive treatment of pseudoaneurysms via embolization has proven successful, significant postoperative risks to patients exist due to the delay in symptom presentation and identification as well as embolism morbidities. The purpose of this investigation is to determine the incidence of pseudoaneurysms after Le Fort I osteotomy at a single high-surgical-volume institution and to report treatment options and outcomes of patients who experienced this problem.The billing directory for CPT codes corresponding to single, 2- and 3-piece Le Fort I osteotomies was searched from January 1998 to December 2020. All cases of pseudoaneurysm arising post-surgically performed over this 22-year period were identified. Out of 1,768 Le Fort I osteotomies performed, 4 cases of pseudoaneurysm were identified. The calculated incidence rate of this complication was 0.2%, all 4 elected embolization in which embolization was successful with no consequence to any. All 4 patients were male. In all cases, the major bleed was preceded by several smaller bleeds. Two of the 4 patients required blood transfusion; however, 1 of those patients declined administration of blood products for religious reasons. In this patient, pseudoaneurysms developed bilaterally.Although rare, vascular pseudoaneurysms can be life-threatening. Early detection of prodromal symptoms is vital to proper identification and definitive treatment. Patients must also be extensively counseled on the importance of eliminating exertional activity for 6 weeks postoperatively.

Recovery, rehabilitation and follow-up services following critical illness: an updated UK national cross-sectional survey and progress report

ObjectiveTo comprehensively update and survey the current provision of recovery, rehabilitation and follow-up services for adult critical care patients across the UK.DesignCross-sectional, self-administered, predominantly closed-question, electronic, online survey.SettingInstitutions providing adult...

Post-discharge after surgery Virtual Care with Remote Automated Monitoring-1 (PVC-RAM-1) technology versus standard care: randomised controlled trial

ObjectiveTo determine if virtual care with remote automated monitoring (RAM) technology versus standard care increases days alive at home among adults discharged after non-elective surgery during the covid-19 pandemic.DesignMulticentre randomised...

Clinical findings post hospital discharge in patients with covid-19: A telephone interview study

Importance:Active COVID-19 symptoms like cough, shortness of breath, fever, sore throat and others are well established. However, there is limited information on the persistence of symptoms post infection. Objective:To identify the post discharge symptoms amongst adult patients discharged from the hospital after having been hospitalized and treated for COVID-19 from March to the end of May of 2020. Design, setting, and participants:Adult patients discharged from the hospital after admission for COVID-19 infection were contacted via a telephone encounter as a post-discharge follow-up, which ranged from 9 to 92 days with an average of 57 days post discharge. A standardized questionnaire was used during post discharge telephone encounter for the patients to assess presence or absence of symptoms following discharge. Main outcomes and measures:Chi-square statistics were used to calculate unadjusted associations between predictors and the symptom status outcome, and Fisher’s exact statistic was used in the case of rare events/low cell counts. A multivariable logistic regression model was used to determine any association between the predictors and the outcome of still being symptomatic versus having improved symptoms at follow-up date. Firth’s logistic regression was applied to the analysis in order to handle sample bias as well as low cell counts. Results:Out of the 337 patients who were discharged after COVID-19 hospitalization, 180 had successful post discharge telephone encounters. The majorities of the patients were male, 108 (60%) and belonged to the age group, 35-64 years. Out of 180 patients, 151 (83.88%) were asymptomatic and 29 (16.11%) were still symptomatic. Of the 29 symptomatic patients, the most common symptoms reported were persistent fever, 19 (65.52%), shortness of breath, 19 (65.52%) and cough, 25 (86.21%). Conclusion and relevance:The majority of patients discharged from the hospital where they had been attended for COVID-19 were asymptomatic post discharge. Our study identified that a proportion of patients could remain symptomatic after COVID 19 hospitalization. The importance of follow up post hospital discharge is highlighted in this study.

Team VA Video Connect (VVC) to optimize mobility and physical activity in post-hospital discharge older veterans: baseline assessment

BackgroundTelehealth is increasingly used for rehabilitation and exercise but few studies include older adult participants with comorbidities and impairment, particularly cognitive. Using Veterans Administration Video Connect (VVC), the aim of the present study is to present the screening, recruitment, baseline assessment, and initial telehealth utilization of post-hospital discharge Veterans in a VVC home-telehealth based program to enhance mobility and physical activity.MethodsOlder adult Veterans (n = 45, mean age 73), recently discharged from the hospital with physical therapy goals, were VVC-assessed in self-report and performance-based measures, using test adaptations as necessary, by a clinical pharmacy specialist and social worker team.ResultsBasic and instrumental ADL disabilities were common as were low mobility (Short Portable Performance Battery) and physical activity levels (measured by actigraphy). Half had Montreal Cognitive Assessment (MoCA) scores in the mild cognitive impairment range (< 24). Over 2/3 of the participants used VA-supplied tablets. While half of the Veterans were fully successful in VVC, 1/3 of these and an additional group with at least one failed connection requested in-person visits for assistance. One-quarter had no VVC success and sought help for tablet troubleshooting, and half of these eventually “gave up” trying to connect; difficulty with using the computer and physical impairment (particularly dexterity) were described prominently in this group. On the other hand, Veterans with at least mild cognitive impairment (based on MoCA scores) were present in all connectivity groups and most of these used caregiver support to facilitate VVC.ConclusionsDisabled older post-hospital discharged Veterans with physical therapy goals can be VVC-assessed and enrolled into a mobility/physical activity intervention. A substantial proportion required technical support, including in-person support for many. Yet, VVC seems feasible in those with mild cognitive impairment, assuming the presence of an able caregiver. Modifications of assessment tools were needed for the VVC interface, and while appearing feasible, will require further study.Trial registrationClinicalTrials.gov NCT 04045054 05/08/2019.

Impact of Stroke on Quality of Life of Stroke Survivors and Their Caregivers: A Qualitative Study from India.

Objectives Stroke is a significant global public health challenge attributable to an array of disabilities it causes alongside an impairment in cognition. The monetary impact of stroke care includes acute treatment expenses as well as outrageous expenses of postdischarge chronic hospital care and rehabilitation services. The current study aimed to study the perceptions along with experiences of stroke survivors and caregivers. Materials and Methods In-depth interviews (IDIs) of stroke survivors and their primary caregivers were conducted at their home 2 months after their discharge from the hospital in Bhopal, India. These IDIs were later analyzed. Results The following eight themes emerged: pervasive and irreversible, multifunction loss and dependency, holistic impact on the health of person and family, money and matter, nonaccommodative cost and baffled belief, professional paralysis, social crisis, and slow and obscured progress. The added obligation of taking care of a disabled stroke survivor along with adjusting their own lifestyle with financial apprehensions, worry about future, prolonged hours of care, and stress are major factors that increase the burden of the caregivers. Conclusion Caregivers should be sensitized with proper counseling and training through health care institutions to ensure appropriate care and management of stroke survivors at home, as it will also help in addressing their psychosocial needs, and minimizing the knowledge gap, doubts and uncertainties about the disease and its aftereffects.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis.

To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life. Systematic review, without meta-analysis, with vote counting based on direction of effect. Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies. Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness. Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p<.001), assessment and management services (p<.0001) and non-training initiatives involving medical staff (p<.0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p<.001), but the high number of weak-rated studies undermined confidence in this result. This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed. The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.

Occupational therapy intervention for cancer patients following hospital discharge: How and when should we intervene? A systematic review.

Advances in cancer treatment over the last decade have led to increased survival rates. As a result, survivors are living longer with and beyond cancer, often with greater levels of morbidity. Occupational therapists, with their focus on remedial and compensatory strategies to improve function and participation, are well suited to assess and intervene with this population. Despite this, little research exists to demonstrate the efficacy of interventions and value of the occupational therapy role. This systematic review aimed to review how and when occupational therapists provide services for adult patients with cancer and identify where they add the most value. A systematic search was conducted of six electronic databases. Eligible studies reported on occupational therapy interventions targeting management of cancer symptoms, rehabilitation or environmental modifications for adult cancer patients discharged from acute hospital services. Data extraction and quality assessment were undertaken by two reviewers. Narrative synthesis summarised the attributes and treatment outcomes of each intervention. Nine articles were included from a total of 309 articles retrieved. Eight different interventions were reported for people with cancer (n= 531). Small sample sizes and methodological quality precluded any formal analysis; however, intervention components that showed positive results were person-centred, individualised and included regular monitoring and flexibility in care, with input from multidisciplinary health professionals. Therapists also need to reflect upon the optimal duration of interventions and selection of outcome measures that specifically match intervention components. Despite inconclusive support of any particular type of intervention, this systematic review identified several successful intervention components for occupational therapists working with people with or beyond cancer. Overall, findings suggest that monitored tailored programmes compensating for fluctuations in a patient's condition have efficacy to improve patient outcomes and should be considered when delivering intervention with patients post hospital discharge.

Feasibility of Contrasting Brain Connectivity Patterns in Cognitive and Motor Cerebral Networks to Clinical Outcomes in Patients Surviving Acute Respiratory Failure: A Pilot Study.

Background: There is a paucity of research regarding the feasibility and association of cerebral cortex function to patient outcomes after acute respiratory failure (ARF).Purpose: To determine the feasibility of functional connectivity measures and examine the association of functional connectivity to a multifaceted battery of outcomes in survivors of ARF.Methods: Eight ARF patients (age:58±3.7, ICU days:10.4±8.6) completed functional magnetic resonance imaging (fMRI), cognitive, physical-function, anxiety, depression, and driving simulator tests at one month post-hospital discharge. Pearson’s correlations assessed the relationship between functional connectivity within the default mode network (FPN), sensorimotor network (SMN), and frontoparietal network (FPN) to outcomes.Results: Low physical-function (r=0.75, p=0.03) and divided-attention (r=-0.86, p=0.03) during the driving simulator task correlated with low FPN connectivity. Low SMN connectivity demonstrated relationships to slower gait speed (r=0.82, p=0.01) and low short physical performance battery (SPPB) scores (r=0.81, p=0.01).Conclusions: fMRI is feasible to assess ARF patients’ post-ICU limitations, as low post-ARF brain connectivity may be linked to low physical function, providing potential development of therapeutic interventions.

\u201cShe knows me best\u201d: a qualitative study of patient and caregiver views on the role of the primary care physician follow-up post-hospital discharge in individuals admitted with chronic obstructive pulmonary disease or congestive heart failure

BackgroundPatients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are at high-risk of readmission after hospital discharge. There is conflicting evidence however on whether timely follow-up with a primary care provider reduces that risk. The objective of this study is to understand the perspectives of patients with COPD and CHF, and their caregivers, on the role of primary care provider follow-up after hospital discharge.MethodsA qualitative study design with semi-structured interviews was conducted among patients or their family caregivers admitted with COPD or CHF who were enrolled in a randomized controlled study at three acute care hospitals in Ontario, Canada. Participants were interviewed between December 2017 to January 2019, the majority discharged from hospital at least 30 days prior to their interview. Interviews were analyzed independently by three authors using a deductive directed content analysis, with the fourth author cross-comparing themes.ResultsInterviews with 16 participants (eight patients and eight caregivers) revealed four main themes. First, participants valued visiting their primary care provider after discharge to build upon their longitudinal relationship. Second, primary care providers played a key role in coordinating care. Third, there were mixed views on the ideal time for follow-up, with many participants expressing a desire to delay follow-up to stabilize following their acute hospitalization. Fourth, the link between the post-discharge visit and preventing hospital readmissions was unclear to participants, who often self-triaged based on their symptoms when deciding on the need for emergency care.ConclusionsPatients and caregivers valued in-person follow-up with their primary care provider following discharge from hospital because of the trust established through pre-existing longitudinal relationships. Our results suggest policy makers should focus on improving rates of primary care provider attachment and systems supporting informational continuity.

Trends in Post-Acute Care Utilization During the COVID-19 Pandemic.

ObjectiveTo examine the effect of the COVID-19 pandemic on post-acute care utilization and spending.DesignWe used a large national multipayer claims data set from January 2019 through October 2020 to examine trends in posthospital discharge location and spending.Setting and participantsWe identified and included 975,179 hospital discharges who were aged ≥65 years.MethodsWe summarized postdischarge utilization and spending in each month of the study: (1) the percentage of patients discharged from the hospital to home for self-care and to the 3 common post-acute care locations: home with home health, skilled nursing facility (SNF), and inpatient rehabilitation; (2) the rate of discharge to each location per 100,000 insured members in our cohort; (3) the total amount spent per month in each post-acute care location; and (4) the percentage of spending in each post-acute care location out of the total spending across the 3 post-acute care settings.ResultsThe percentage of patients discharged from the hospital to home or to inpatient rehabilitation did not meaningfully change during the pandemic whereas the percentage discharged to SNF declined from 19% of discharges in 2019 to 14% by October 2020. Total monthly spending declined in each of the 3 post-acute care locations, with the largest relative decline in SNFs of 55%, from an average of $42 million per month in 2019 to $19 million in October 2020. Declines in total monthly spending were smaller in home health (a 41% decline) and inpatient rehabilitation (a 32% decline). As a percentage of all post-acute care spending, spending on SNFs declined from 39% to 31%, whereas the percentage of post-acute care spending on home health and inpatient rehabilitation both increased.Conclusions and ImplicationsChanges in posthospital discharge location of care represent a significant shift in post-acute care utilization, which persisted 9 months into the pandemic. These shifts could have profound implications on the future of post-acute care.