Posthospital Outcomes Research Articles

Inpatient Metformin Utilization and Post-hospitalization Clinical Outcomes: An Observational Cohort Study.

Metformin is the first-line treatment for diabetes, with multiple long-term benefits. However, there is limited evidence for its use in the inpatient setting, and clinical guidelines have historically recommended holding oral diabetes medications during acute hospitalization. While studies have not found evidence of harm from continuing metformin during hospitalization, withholding may lead to unnecessary insulin prescriptions, which in turn may lead to hypoglycemia events after discharge and other associated complications. To investigate the association between metformin use during hospitalization and post-hospitalization outcomes. Observational cohort study from January 2016 to January 2022, emulating a target trial. Adults with type 2 diabetes admitted to a Veterans Health Administration hospital for common medical conditions. Continuation of an outpatient metformin prescription during hospitalization. Hypoglycemia within 90 days of discharge. Secondary outcomes included insulin prescriptions at discharge, 90-day readmissions, and 90-day mortality. The propensity-matched cohort included 67,162 hospitalizations, equally split between those who did and did not have metformin continued during hospitalization. Within 90 days of hospital discharge, those that received metformin had lower risk of hypoglycemia (1.5% vs 1.8%; OR 0.83, 95% CI 0.73-0.93; p = 0.003), readmissions (29.4% vs 30.6%; OR 0.96, 95% CI 0.92-1.00; p= 0.03), and mortality (6.4% vs 7.4%; OR 0.86, 95% CI 0.80-0.92; p <0.001). Patients receiving metformin also had lower risk of insulin prescriptions at discharge (18.5% vs 20.3%; OR 0.89, 95% CI 0.84-0.95; p<0.001). Continuation of metformin during hospitalization for patients with type 2 diabetes was associated with decreased risk of post-hospitalization insulin prescriptions and 90-day hypoglycemia, readmissions, and mortality. These findings question clinical guideline recommendations to hold metformin during hospitalization.

Significance of shear wave ultrasound elastography in predicting one-year posthospital outcomes of lower extremity deep vein thrombosis

The aim of the study was to analyze the results of shear wave elastography data of iliac and femoral vein thrombi in the acute period of the disease to identify ultrasound parameters that are prognostically significant for posthospital outcomes.Material and Methods. At the hospitalization stage, 153 patients with iliac and femoral vein thrombosis underwent venous ultrasound with shear wave elastography. Depending on the outcome of the disease 6–12 months after discharge from the hospital, the examined patients were divided into 3 groups: with recanalization, venous retrombosis and death.Results. In those with the outcome “retrombosis” the thrombus stiffness during inpatient treatment was higher than in the groups with the outcomes “recanalization” and “death”. According to the Accuracy and Gini coefficients for iliac vein thrombosis, the values of maximum and mean Young’s moduli of iliac vein thrombus on the first, third and sixth days of hospitalization, whereas in femoral vein thrombosis – maximum, average and minimum Young’s moduli of femoral vein thrombus on the mentioned days and minimum Young’s modulus of sural vein thrombus on the first day of hospitalization. The variables separating the posthospital outcomes “recanalization” and “death” in iliac vein thrombosis were the maximum Young’s modulus of femoral vein thrombus on the first day of hospitalization and the length of the floating part of the thrombus; in femoral vein thrombosis – the maximum Young’s modulus of the saphenous vein on the first day of hospitalization, the PE mass and the duration of the period from the first symptoms to hospitalization.Conclusion. The results of shear wave elastography at the hospital stage of management of patients with DVT allow predicting the recurrence of thrombosis in the following year based on the stiffness values of the proximal part of the venous thrombus and lethal outcome based on the stiffness of the thrombus in the inferior vein of the affected limb.

Changes in Medication Complexity and Post-Hospitalization Outcomes in Older Adults Hospitalized for Heart Failure.

Medication regimen complexity may be an important risk factor for adverse outcomes in older adults with heart failure. However, increasing complexity is often necessary when prescribing guideline-directed medical therapy at the time of a heart failure hospitalization. We sought to determine whether increased medication regimen complexity following a heart failure hospitalization was associated with worse post-hospitalization outcomes. This retrospective cohort study included Reasons for Geographic and Racial Differences in Stroke (REGARDS) participants aged at least 65 years hospitalized for heart failure between 2003 and 2014. We calculated changes between hospital admission and discharge in medication count (Δcount) and in the validated Medication Regimen Complexity Index (ΔMRCI), which incorporates each medication's dosage formulation, frequency, timing, and special instructions. The primary outcome was a composite of 90-day all-cause readmission and all-cause mortality post-discharge. We calculated ΔMRCI and Δcount, identified their predictors, and examined their association with the primary outcome. Among 725 patients hospitalized for heart failure, the mean (SD) age was 77 (7.2) years, 46% were female, and 35% were Black. At discharge, nearly 75% had an increase in their medication regimen complexity and 60% had an increase in their medication count. Patients with the highest ΔMRCI and Δcount were more likely to be female and Black. Predictors of the highest ΔMRCI included Charlson comorbidity index and not being discharged home; predictors of the highest Δcount included intensive care unit stay. Approximately 48% of patients experienced a 90-day readmission or death. Neither ΔMRCI (highest versus lowest tertile; HR 1.14, 95% CI 0.86, 1.50) nor Δcount (HR 0.97, 95% CI 0.73, 1.27) were associated with 90-day outcomes. Following a heart failure hospitalization, increased medication regimen complexity was common but was not associated with 90-day post-hospitalization outcomes. These are reassuring data, suggesting that it is reasonable for clinicians to focus on optimizing medication regimens for patients with heart failure even if it increases regimen complexity.

Influence of patient characteristics and discharge destination on circulatory system diseases readmissions among older heart failure patients

IntroductionHeart failure (HF) prevalence is rising, particularly among older people, constituting a significant cause of hospitalization. Discharge destinations, including nursing homes (NH), play a crucial role in post-hospitalization outcomes but remain underexplored. MethodsA retrospective study utilizing the Spanish National Health System's Minimum Basic Data Set identified older HF patients (≥75 years) discharged from acute hospitals between 2016 and 2019. Patient demographics, comorbidities, and discharge destinations were analyzed. Predictors of 30-day readmissions for circulatory system diseases and NH admission were assessed using multilevel logistic regression models. ResultsOf 157,330 index episodes, 2.8 % were discharged to NH, more frequently in females. Thirty-day readmission incidence was 9.3 %, with HF exacerbations accounting for 80.6 % of cases. Predictors of 30-day readmission included renal failure (OR: 1.38), severe hematological disorders (OR: 1.30), and history of coronary revascularization surgery (OR: 1.23), while discharge to NH lowered the risk (OR: 0.70). Admission to NH was associated with neurological diseases (OR: 3.27), cardiogenic shock (OR: 3.19), stroke (OR: 2.68), advanced cancer (OR: 2.51), with higher likelihood among females (OR: 1.23). After propensity score-matched analysis, patients discharged to NH had significantly lower 30-day readmission rates than those discharged home (6.4 % vs. 28.9 %, adjusted OR: 0.169). ConclusionDischarge to NH is infrequent but associated with lower readmission risk for older HF patients. Female gender, specific comorbidities, and acute conditions influence NH admission. Enhanced collaboration between HF units and NH is crucial for optimizing post-hospitalization outcomes. Further research and policy initiatives are needed to improve care coordination and reduce HF readmissions.

Quantification of muscle recovery in post-ICU patients admitted for acute pancreatitis: a longitudinal single-center study

ObjectivesCritically ill patients with severe pancreatitis exhibit substantial muscle wasting, which limits in-hospital and post-hospital outcomes. Survivors of critical illness undergo extensive recovery processes. Previous studies have explored pancreatic function, quality of life, and costs post-hospitalization for AP patients, but none have comprehensively quantified muscle loss and recovery post-discharge. By applying an AI-based automated segmentation tool, we aimed to quantify muscle mass recovery in ICU patients after discharge.MaterialsMuscle segmentation was performed on 22 patients, with a minimum of three measurements taken during hospitalization and one clinically indicated examination after hospital discharge. Changes in psoas muscle area (PMA) between admission, discharge and follow up were calculated. T-Test was performed to identify significant differences between patients able and not able to recover their muscle mass.ResultsMonitoring PMA shows muscle loss during and gain after hospitalization: The mean PMA at the first scan before or at ICU admission (TP1) was 17.08 cm², at the last scan before discharge (TP2), mean PMA was 9.61 cm². The percentage change in PMA between TP1 and TP2 ranged from − 85.42% to -2.89%, with a mean change of -40.18%. The maximum muscle decay observed during the stay was − 50.61%. After a mean follow-up period of 438.73 days most patients (81%) were able to increase their muscle mass. Compared to muscle status at TP1, only 27% of patients exhibited full recovery, with the majority still presenting a deficit of 31.96%.ConclusionMuscle recovery in ICU patients suffering from severe AP is highly variable, with only about one third of patients recovering to their initial physical status. Opportunistic screening of post-ICU patient recovery using clinically indicated imaging and AI-based segmentation tools enables precise quantification of patients’ muscle status and can be employed to identify individuals who fail to recover and would benefit from secondary rehabilitation. Understanding the dynamics of muscle atrophy may improve prognosis and support personalized patient care.

Evaluation of Posthospital Brain Injury Rehabilitation Outcomes With Quasi-Experimental Controls.

To further evaluate, using quasi-experimental methodologies, posthospital brain injury rehabilitation outcomes described in an accompanying report of a large observational study (n =2120). Data from Intensive Rehabilitation (IR: Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation) and Supported Living (SL) programs serving individuals with acquired brain injury (ABI). Two hundred twenty-eight individuals with traumatic brain injury, stroke, or other ABI in propensity score analysis; 1344 in analysis by extent of recommended treatment completed (TC) rating. Sex, age, time since injury, Mayo-Portland Adaptability Inventory-4th edition (MPAI-4) Rasch-derived T-scores, and TC rating. Analyses of covariance (1) of discharge MPAI-4 Total, index, and subscale T-scores on propensity score-matched samples of IR and SL participants controlling for admission scores and (2) of MPAI-4 T-scores by TC rating and diagnostic category. Propensity score-matched groups showed superior outcomes for IR participants compared to SL participants on MPAI-4 Total T-score (F =77.21, P <.001; partial η2=0.257) and all MPAI-4 index and subscale T-scores controlling for sex, age, and baseline scores. Participants with traumatic brain injury and stroke who completed the recommended course of rehabilitation had superior outcomes on all MPAI-4 T-scores compared to those who completed less than or much less than the recommended treatment. No additional benefit was apparent for those who completed more than the recommended course. The association between TC rating and outcome was not significant for the other ABI group. These analyses using quasi-experimental controls provide more scientifically rigorous evidence of the benefit of IR provided through posthospital brain injury rehabilitation programs after acute inpatient care, consistent with the results of numerous observational studies. However, improved internal validity limits external validity and generalization. The absence of a significant association between TC rating and outcomes for the other ABI group most likely reflects the difficulty prescribing rehabilitation for this highly heterogeneous group.

Identifying prehospital trauma patients from ambulance patient care records; comparing two methods using linked data in New South Wales, Australia

BackgroundLinked datasets for trauma system monitoring should ideally follow patients from the prehospital scene to hospital admission and post-discharge. Having a well-defined cohort when using administrative datasets is essential because they must capture the representative population. Unlike hospital electronic health records (EHR), ambulance patient-care records lack access to sources beyond immediate clinical notes. Relying on a limited set of variables to define a study population might result in missed patient inclusion. We aimed to compare two methods of identifying prehospital trauma patients: one using only those documented under a trauma protocol and another incorporating additional data elements from ambulance patient care records. MethodsWe analyzed data from six routinely collected administrative datasets from 2015 to 2018, including ambulance patient-care records, aeromedical data, emergency department visits, hospitalizations, rehabilitation outcomes, and death records. Three prehospital trauma cohorts were created: an Extended-T-protocol cohort (patients transported under a trauma protocol and/or patients with prespecified criteria from structured data fields), T-protocol cohort (only patients documented as transported under a trauma protocol) and non-T-protocol (extended-T-protocol population not in the T-protocol cohort). Patient-encounter characteristics, mortality, clinical and post-hospital discharge outcomes were compared. A conservative p-value of 0.01 was considered significant ResultsOf 1 038 263 patient-encounters included in the extended-T-population 814 729 (78.5 %) were transported, with 438 893 (53.9 %) documented as a T-protocol patient. Half (49.6 %) of the non-T-protocol sub-cohort had an International Classification of Disease 10th edition injury or external cause code, indicating 79644 missed patients when a T-protocol-only definition was used. The non-T-protocol sub-cohort also identified additional patients with intubation, prehospital blood transfusion and positive eFAST. A higher proportion of non-T protocol patients than T-protocol patients were admitted to the ICU (4.6% vs 3.6 %), ventilated (1.8% vs 1.3 %), received in-hospital transfusion (7.9 vs 6.8 %) or died (1.8% vs 1.3 %). Urgent trauma surgery was similar between groups (1.3% vs 1.4 %). ConclusionThe extended-T-population definition identified 50 % more admitted patients with an ICD-10-AM code consistent with an injury, including patients with severe trauma. Developing an EHR phenotype incorporating multiple data fields of ambulance-transported trauma patients for use with linked data may avoid missing these patients.

Outcomes After Initiation of Medications for Alcohol Use Disorder at Hospital Discharge

US Food and Drug Administration-approved medications for alcohol use disorder (MAUD) are significantly underused. Hospitalizations may provide an unmet opportunity to initiate MAUD, but few studies have examined clinical outcomes of patients who initiate these medications at hospital discharge. To investigate the association between discharge MAUD initiation and 30-day posthospitalization outcomes. This cohort study was conducted among patients with Medicare Part D who had alcohol-related hospitalizations in 2016. Data were analyzed from October 2022 to December 2023. Discharge MAUD initiation was defined as oral naltrexone, acamprosate, or disulfiram pharmacy fills within 2 days of discharge. The primary outcome was a composite of all-cause mortality or return to hospital (emergency department visits and hospital readmissions) within 30 days of discharge. Secondary outcomes included these components separately, return to hospital for alcohol-related diagnoses, and primary care or mental health follow-up within 30 days of discharge. Propensity score 3:1 matching and modified Poisson regressions were used to compare outcomes between patients who received and did not receive discharge MAUD. There were 6794 unique individuals representing 9834 alcohol-related hospitalizations (median [IQR] age, 54 [46-62] years; 3205 hospitalizations among females [32.6%]; 1754 hospitalizations among Black [17.8%], 712 hospitalizations among Hispanic [7.2%], and 7060 hospitalizations among White [71.8%] patients). Of these, 192 hospitalizations (2.0%) involved discharge MAUD initiation. After propensity matching, discharge MAUD initiation was associated with a 42% decreased incidence of the primary outcome (incident rate ratio, 0.58 [95% CI, 0.45 to 0.76]; absolute risk difference, -0.18 [95% CI, -0.26 to -0.11]). These findings were consistent among secondary outcomes (eg, incident rate ratio for all-cause return to hospital, 0.56 [95% CI, 0.43 to 0.73]) except for mortality, which was rare in both groups (incident rate ratio, 3.00 [95% CI, 0.42 to 21.22]). Discharge MAUD initiation was associated with a 51% decreased incidence of alcohol-related return to hospital (incident rate ratio, 0.49 [95% CI, 0.34 to 0.71]; absolute risk difference, -0.15 [95% CI, -0.22 to -0.09]). In this cohort study, discharge initiation of MAUD after alcohol-related hospitalization was associated with a large absolute reduction in return to hospital within 30 days. These findings support efforts to increase uptake of MAUD initiation at hospital discharge.

Transforming Posthospital Stroke Care, Outcomes, and Use of New Innovations Through Implementation Science.

Transforming Posthospital Stroke Care, Outcomes, and Use of New Innovations Through Implementation Science.

Equity-Centered Postdischarge Support for Medicaid-Insured People: Protocol for a Type 1 Hybrid Effectiveness-Implementation Stepped Wedge Cluster Randomized Controlled Trial.

Disparities in posthospitalization outcomes for people with chronic medical conditions and insured by Medicaid are well documented, yet interventions that mitigate them are lacking. Prevailing transitional care interventions narrowly target people aged 65 years and older, with specific disease processes, or limitedly focus on individual-level behavioral change such as self-care or symptom management, thus failing to adequately provide a holistic approach to ensure an optimal posthospital care continuum. This study evaluates the implementation of THRIVE-an evidence-based, equity-focused clinical pathway that supports Medicaid-insured individuals with multiple chronic conditions transitioning from hospital to home by focusing on the social determinants of health and systemic and structural barriers in health care delivery. THRIVE services include coordinating care, standardizing interdisciplinary communication, and addressing unmet clinical and social needs following hospital discharge. The study's objectives are to (1) examine referral patterns, 30-day readmission, and emergency department use for participants who receive THRIVE support services compared to those receiving usual care and (2) evaluate the implementation of the THRIVE clinical pathway, including fidelity, feasibility, appropriateness, and acceptability. We will perform a sequential randomized rollout of THRIVE to case managers at the study hospital in 3 steps (4 in the first group, 4 in the second, and 5 in the third), and data collection will occur over 18 months. Inclusion criteria for THRIVE participation include (1) being Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) residing in Philadelphia; (3) having experienced a hospitalization at the study hospital for more than 24 hours with a planned discharge to home; (4) agreeing to home care at partner home care settings; and (5) being aged 18 years or older. Qualitative data will include interviews with clinicians involved in THRIVE, and quantitative data on health service use (ie, 30-day readmission, emergency department use, and primary and specialty care) will be derived from the electronic health record. This project was funded in January 2023 and approved by the institutional review board on March 10, 2023. Data collection will occur from March 2023 to July 2024. Results are expected to be published in 2025. The THRIVE clinical pathway aims to reduce disparities and improve postdischarge care transitions for Medicaid-insured patients through a system-level intervention that is acceptable for THRIVE participants, clinicians, and their teams in hospitals and home care settings. By using our equity-focused case management services and leveraging the power of the electronic medical record, THRIVE creates efficiencies by identifying high-need patients, improving communication across acute and community-based sectors, and driving evidence-based care coordination. This study will add important findings about how the infusion of equity-focused principles in the design and evaluation of evidence-based interventions contributes to both implementation and effectiveness outcomes. DERR1-10.2196/54211. ClinicalTrials.gov NCT05714605; https://clinicaltrials.gov/ct2/show/NCT05714605.

Linkage Case Management and Posthospitalization Outcomes in People With HIV

Despite the widespread availability of antiretroviral therapy (ART), people with HIV still experience high mortality after hospital admission. To determine whether a linkage case management intervention (named "Daraja" ["bridge" in Kiswahili]) that was designed to address barriers to HIV care engagement could improve posthospital outcomes. Single-blind, individually randomized clinical trial to evaluate the effectiveness of the Daraja intervention. The study was conducted in 20 hospitals in Northwestern Tanzania. Five hundred people with HIV who were either not treated (ART-naive) or had discontinued ART and were hospitalized for any reason were enrolled between March 2019 and February 2022. Participants were randomly assigned 1:1 to receive either the Daraja intervention or enhanced standard care and were followed up for 12 months through March 2023. The Daraja intervention group (n = 250) received up to 5 sessions conducted by a social worker at the hospital, in the home, and in the HIV clinic over a 3-month period. The enhanced standard care group (n = 250) received predischarge HIV counseling and assistance in scheduling an HIV clinic appointment. The primary outcome was all-cause mortality at 12 months after enrollment. Secondary outcomes related to HIV clinic attendance, ART use, and viral load suppression were extracted from HIV medical records. Antiretroviral therapy adherence was self-reported and pharmacy records confirmed perfect adherence. The mean age was 37 (SD, 12) years, 76.8% were female, 35.0% had CD4 cell counts of less than 100/μL, and 80.4% were ART-naive. Intervention fidelity and uptake were high. A total of 85 participants (17.0%) died (43 in the intervention group; 42 in the enhanced standard care group); mortality did not differ by trial group (17.2% with intervention vs 16.8% with standard care; hazard ratio [HR], 1.01; 95% CI, 0.66-1.55; P = .96). The intervention, compared with enhanced standard care, reduced time to HIV clinic linkage (HR, 1.50; 95% CI, 1.24-1.82; P < .001) and ART initiation (HR, 1.56; 95% CI, 1.28-1.89; P < .001). Intervention participants also achieved higher rates of HIV clinic retention (87.4% vs 76.3%; P = .005), ART adherence (81.1% vs 67.6%; P = .002), and HIV viral load suppression (78.6% vs 67.1%; P = .01) at 12 months. The mean cost of the Daraja intervention was about US $22 per participant including startup costs. Among hospitalized people with HIV, a linkage case management intervention did not reduce 12-month mortality outcomes. These findings may help inform decisions about the potential role of linkage case management among hospitalized people with HIV. ClinicalTrials.gov Identifier: NCT03858998.

Post-discharge outcomes of hospitalized children diagnosed with acute SARS-CoV-2 or MIS-C.

Hospitalized children diagnosed with SARS-CoV-2-related conditions are at risk for new or persistent symptoms and functional impairments. Our objective was to analyze post-hospital symptoms, healthcare utilization, and outcomes of children previously hospitalized and diagnosed with acute SARS-CoV-2 infection or Multisystem Inflammatory Syndrome in Children (MIS-C). Prospective, multicenter electronic survey of parents of children <18 years of age surviving hospitalization from 12 U.S. centers between January 2020 and July 2021. The primary outcome was a parent report of child recovery status at the time of the survey (recovered vs. not recovered). Secondary outcomes included new or persistent symptoms, readmissions, and health-related quality of life. Multivariable backward stepwise logistic regression was performed for the association of patient, disease, laboratory, and treatment variables with recovered status. The children [n = 79; 30 (38.0%) female] with acute SARS-CoV-2 (75.7%) or MIS-C (24.3%) had a median age of 6.5 years (interquartile range 2.0-13.0) and 51 (64.6%) had a preexisting condition. Fifty children (63.3%) required critical care. One-third [23/79 (29.1%)] were not recovered at follow-up [43 (31, 54) months post-discharge]. Admission C-reactive protein levels were higher in children not recovered vs. recovered [5.7 (1.3, 25.1) vs. 1.3 (0.4, 6.3) mg/dl, p = 0.02]. At follow-up, 67% overall had new or persistent symptoms. The most common symptoms were fatigue (37%), weakness (25%), and headache (24%), all with frequencies higher in children not recovered. Forty percent had at least one return emergency visit and 24% had a hospital readmission. Recovered status was associated with better total HRQOL [87 (77, 95) vs. 77 (51, 83), p = 0.01]. In multivariable analysis, lower admission C-reactive protein [odds ratio 0.90 (95% confidence interval 0.82, 0.99)] and higher admission lymphocyte count [1.001 (1.0002, 1.002)] were associated with recovered status. Children considered recovered by their parents following hospitalization with SARS-CoV-2-related conditions had less symptom frequency and better HRQOL than those reported as not recovered. Increased inflammation and lower lymphocyte count on hospital admission may help to identify children needing longitudinal, multidisciplinary care. ClinicalTrials.gov (NCT04379089).

The Role of Subjective Age in Predicting Post-Hospitalization Outcomes of Older Adults

Introduction: Studies of community-dwelling older adults find subjective age affects health and functional outcomes. This study explored whether younger subjective age serves as a protective factor against hospital-associated physical, cognitive, and emotional decline, well-known consequences of hospitalization among the elderly. Methods: This study is a secondary data analysis of a subsample (N = 262; age: 77.5 ± 6.6 years) from the Hospitalization Process Effects on Mobility Outcomes and Recovery (HoPE-MOR) study. Psychological and physical subjective age, measured as participants’ reports on the degree to which they felt older or younger than their chronological age, was assessed at the time of hospital admission. Independence in activities of daily living, life-space mobility, cognitive function, and depressive symptoms were assessed at hospital admission and 1 month post-discharge. Results: The odds of decline in cognitive status, functional status, and community mobility and the exacerbation of depressive symptoms were significantly lower in those reporting younger vs. older psychological subjective age (odds ratio [OR] = 0.68, 95% CI = 0.46–0.98; OR = 0.59, 95% CI = 0.36–0.98; OR = 0.64, 95% CI = 0.44–0.93; OR = 0.64, 95% CI = 0.43–0.96, respectively). Findings were significant after controlling for demographic, functional, cognitive, emotional, chronic, and acute health predictors. Physical subjective age was not significantly related to post-hospitalization outcomes. Conclusion: Psychological subjective age can identify older adults at risk for poor hospitalization outcomes and should be considered for preventive interventions.

Comparison of Proxy and Self-Reported Functional Ability in Heart Failure Patients with Cognitive Impairment

Background Heart failure (HF) patients often experience cognitive impairment that negatively impacts self-management ability, predisposing these individuals to worse post-hospitalization outcomes. Patient proxies may have more insight into a patient’s self-management capability especially in the context of patient cognitive impairment. Here, we incorporate proxy input to evaluate associations between patient- and proxy-reported capacity for instrumental activities of daily living (IADL) stratified along a patient’s cognitive function in an older hospitalized heart failure population. Methods We conducted a quality improvement study in older HF inpatients with cognitive impairment determined by Mini-Cog. Functional activity performance has been previously assessed using the Assessment of Living Skills and Resources Revision 2 (ALSAR), a validated index where higher numerical scores associate with increasing dependence in completing IADL and risk for needing a more structured living environment, nursing home placement, hospitalization, and death. We assessed ALSAR with patient self-report and proxy-report (range 0-44 lower scores equate to better performance) and calculated the absolute difference (ALSAR difference, lower scores show stronger agreement between patients and proxies). Patients’ Montreal Cognitive Assessment (MoCA) scores, among which scores less than 26 suggest clinically significant cognitive impairment, were correlated with ALSAR difference. Results Median patient age was 74 years. Forty-two percent were female among our sample of 30 hospitalized HF patients with cognitive impairment. Median patient ALSAR score of 4 (range 2-7) differed from median proxy ALSAR score of 7 (range 4-12) (p&lt;0.01). Lower MoCA correlated with higher ALSAR difference (r=-0.58, p&lt;0.01). Conclusions Assessing ALSAR difference in clinical practice is feasible and it correlates to MoCA score in hospitalized HF patients with cognitive impairment, consistent with prior work. These results support the notion that proxy-input of patient IADL assessment could improve patient needs detection among HF patients with cognitive impairment. This information may enhance risk assessment, disease management and discharge planning when targeting and proactively involving proxies. Prospective studies should evaluate this novel metric and its association with patient-centered outcomes.

MIRROR-TCM TRIAL: THE INFLUENCE OF PATIENT-LEVEL FACTORS ON ACUTE CARE RESOURCE USE OF OLDER ADULTS

Abstract Adverse Social Determinants of Health (SDoH) impact post-hospitalization outcomes (e.g., frequent acute care resource use: emergency department [ED] visits, rehospitalizations). The Transitional Care Model Intervention (TCM), an advanced practice registered nurse–led team-based care-management strategy, has demonstrated improved outcomes among older adults throughout transitions from hospital to home. Yet, little is known about the relationship between specific patient-level factors (i.e., demographic, clinical, SDoH) and acute care resource use (i.e., counts of rehospitalizations and ED visits) among hospitalized older adults with multiple chronic conditions who receive the TCM intervention. A total of 480 patients were randomized to receive the TCM in the MIRROR-TCM trial conducted from September 2020 to March 2023 at three diverse health systems in four states. Using multivariable generalized linear mixed effects regression with backward elimination, we examined the relationship between demographic (e.g., biological sex), clinical (e.g., counts of chronic conditions, etc.), SDoH characteristics (e.g., transportation, etc.), and acute care resource use during the intervention. Compared to those without housing concerns, older adults with housing concerns had 2.4 times higher rates of ED visits (p=0.049) and 2.2 times higher rates of rehospitalizations (p=0.005). Those who lacked transportation for medical appointments had 2.5 times higher ED visit rates (p=0.021) and 1.5 times higher rehospitalization rates (p=0.041). For each additional comorbidity, the rate of rehospitalization increased by a multiple of 1.08 (p=0.008). Understanding the adverse SDoH factors and increasing clinical complexity impacting resource use and tailoring evidence-based transitional care interventions to mitigate these factors to improve posthospitalization outcomes is critical.

DAYS SPENT AT HOME BEFORE AND AFTER HIP FRACTURE AMONG MEDICARE BENEFICIARIES LIVING WITH DEMENTIA: A COHORT STUDY

Abstract Hip fracture is a disabling event experienced disproportionately by older adults with Alzheimer’s disease or related dementias (ADRD). Understanding how to better prognosticate outcomes for this population could drive more tailored clinical decision making. Our objective was to identify distinct trajectories of health before a hip fracture and determine their influences on post-fracture recovery trajectories and 1-year mortality rates among older adults with Alzheimer’s disease or related dementias (ADRD). We conducted a cohort study of 16,576 community-dwelling Medicare beneficiaries living with ADRD who experienced hip fracture between 2010 and 2017. We used latent mixture modeling to evaluate trajectories of days at home assessed monthly up to 180 days prior to hospitalization, and their associations with post-fracture days at home and 1-year mortality. Before a hip fracture, 3 distinct trajectories were identified: Robust (n=14,980, 90.3%), Impaired but Improving (n=809, 5.3%), and Impaired and Declining (n=787, 4.7%). Membership in the Impaired and Declining pre-fracture trajectory was strongly associated with membership in less favorable post-fracture recovery trajectories and 65% higher 1-year mortality rate (hazard ratio 1.65, 95% confidence interval 1.45-1.87) as compared to those in the Robust trajectory group. Similar albeit weaker associations were observed between membership in the Impaired but Improving pre-fracture trajectory and post-fracture outcomes. Overall, our results indicate that pre-fracture days at home trajectories are highly associated with post-hospitalization outcomes among older adults with ADRD and could be used to guide care management decisions.

Prolonged operative time predicts postoperative deep venous thrombosis in head and neck cancer patients who undergo free flap reconstruction.

This study sought to quantify the deep venous thrombosis (DVT) incidence in head and neck cancer (HNC) patients undergoing free tissue transfer and to identify independent predictors of postoperative DVT. This is a cross-sectional study of the National Surgical Quality Improvement Program database from 2010 through 2020. The sample included all HNC surgical patients treated with free flap reconstruction. The study outcome was the presence of a DVT requiring treatment within 30 days of surgery. Univariate analyses were performed using chi-squared and independent t-tests. A multiple logistic regression model was created using all significant univariate predictors. A total of 3954 patients were identified, of whom 53 (1.3%) experienced a postoperative DVT. The only medical comorbidity associated with DVT was COPD (RR = 2.7 [1.3, 5.4]; p < .01). Operative time longer than 9 hours (RR = 1.9 [1.0, 3.2]; p = .04) and length of stay longer than 10 days (RR = 1.9 [1.1, 3.2]; p = .02) were associated with greater DVT rates. In the multivariate analysis, only COPD (p < .01) and operative time (p = .02) were independently associated with DVT risk. The presence of a DVT was found to increase the relative risk of readmission (RR = 2.1 [1.2, 3.6]; p < .01) and non-home disposition (RR = 2.4 [1.7, 3.5]; p < .01). The incidence of DVT in HNC free flap patients was comparable to what has been reported in the general population of HNC surgery patients. Operative time >9 h and COPD history were independent risk factors for DVT in this subset of patients. Symptomatic DVTs necessitating treatment were accompanied by poorer post-hospitalization outcomes. Level 3.

Abstract 11955: Hospital Readmission Outcomes After Myocardial Infarction Among Patients With Myeloproliferative Neoplasms

Introduction: Myeloproliferative neoplasms (MPNs) are chronic leukemias associated with increased risk of arterial and venous thrombotic events. Prior studies suggest patients admitted for acute myocardial infarction (AMI) with MPN have similar in-hospital outcomes but lower rates of invasive management compared with patients without MPN. However, post-hospital outcomes in this patient population have not been well characterized. Methods: Adult MPN patients with a primary admission of AMI from January 2017 to December 2018 were identified using the National Readmission Database. Propensity score matching (PSM) was performed to match 1 MPN for 10 non-MPN controls. Primary outcomes were 30-day all-cause, arterial thrombosis (AT)-related, cardiovascular (CV)-related, and bleeding-related readmissions. Results: After PSM, patient characteristics were well-balanced between groups (Table 1). MPN patients had similar rates of in-hospital mortality but higher rates of bleeding during index hospitalization. MPN patients had increased risk of 30-day all-cause, CV, and AT readmissions but not bleeding (Figure). Conclusions: Among patients hospitalized with AMI, those with MPN are associated with increased risk of CV and AT but not bleeding-related readmissions despite higher rates of index hospitalization bleeding. Further investigation is needed in order to improve post-AMI outcomes in patients with MPN.

Post-hospitalization oncology workflow implementing LACE+ score to stratify and reduce readmissions at Lyndon B. Johnson safety-net hospital.

56 Background: Patients with cancer visit the emergency room (ER) and are hospitalized frequently. Contributing factors may include uncontrolled symptoms (cancer- or treatment-related), caregiver fatigue, concerns about the cancer, and difficulty accessing healthcare elsewhere. It is estimated that nearly 50% of ER and hospital visits by advanced cancer patients may be avoidable. This may represent unmet needs in oncology outpatient care and counseling. The LACE+ index is a validated clinical tool available within EPIC electronic medical record system to predict the risk of 30-day readmission. Here we used LACE+ score, common concerns and demographics observed among cancer patients readmitted to Lyndon B. Johnson Hospital (LBJ), a safety-net hospital in Texas, to determine potential contributors and implement interventions to reduce unplanned admissions. Methods: Retrospective data of ER visits and hospitalizations among cancer patients at LBJ were collected from 6/2022-12/2022. Data included comorbidities, cancer diagnosis and therapy, indication for visit, acuity on arrival, additional visits within 30 days, primary language, and LACE+ score. Descriptive statistics were used to guide intervention(s) to reduce hospital readmission. Specifically, these results led to the development of a triaging system based on LACE+ score to arrange timely post-hospital follow-up in the oncology clinic. Our findings also led to translation of AskMyNurse resources to Spanish. Results: Our group identified 61 oncology patients who had visited the ER or been hospitalized at LBJ from 6/2022-12/2022. From this cohort, 90% had been hospitalized or visited an ER within the past 30 days. LACE+ scores were consistently elevated within this group and visits were largely related to their cancer. Additionally, about 66% spoke primarily Spanish. Presently, oncology patients who are discharged from LBJ Hospital are having follow-up arranged in the clinic by means of risk stratification by their LACE+ score. Those with the highest score are seen the earliest after discharge. At this visit, in addition, AskMyNurse resources are now provided in Spanish. Collection of post-intervention data is ongoing to evaluate whether hospital readmission rates are effectively reduced. Conclusions: Cancer patients, especially those with language barriers and in the context of a safety-net hospital, are a particularly vulnerable group. The ability to triage and accurately identify patients at most risk of adverse post-hospitalization outcomes may help direct proper counseling, cancer treatment, and symptom management in the outpatient setting. Here our group proposes a feasible risk stratification tool using the LACE+ score on EPIC to allow for timely post-hospital follow-up and reduce 30-day hospital readmission.

Strategy of delayed intervention without stent implantation in myocardial infarction with ST segment elevation caused by massive thrombosis of the infarct-related artery

Aim. TIntroduction. To evaluate in-hospital angiographic and five-year posthospital clinical outcomes of percutaneous intervention strategy without stent implantation with immediate coronary artery stenting technique in STEMI patients with massive coronary thrombosis.Material and methods. The study enrolled 116 patients with primary STEMI myocardial infarction with the signs of massive thrombosis in the lumen of the main epicardial coronary artery with TIMI thrombus grade greater than 3 after antegrade blood flow restoration. In the 1st group of delayed intervention at the primary stage the blood flow was restored by small diameter balloon inflation and/ or manual vacuum thrombus aspiration until stable TIMI grade 3 blood flow was achieved, at control CAG on day 5-6 in 36 people the stent was not implanted due to insignificance of infarct-related coronary artery stenosis (stenosis less than 50% according to QCA). Immediate stent implantation was performed in 78 patients (group 2). The primary endpoint was the incidence of adverse cardiovascular events, including total mortality, recurrent myocardial infarction, repeated revascularization of the infarct-responsive artery. Secondary endpoint: frequency of achieving optimal myocardial perfusion as measured by angiography – TIMI blood flow and Myocardial Blush Grade.Results. The median follow-up period was 47 months. The incidence of the primary end point (MACE) was 15,8% in group 1 and 23,1% in group 2, with no statistically significant difference (p=0,408). Overall mortality (10,5% and 11,7%), the rate of repeat myocardial infarction (2,6% and 5,1%), and the rate of repeat target vessel revascularization (2,6% and 6,4%) were without significant advantage between subgroups. Optimal reperfusion (TIMI-3 and Myocardial Blush Grade 2-3 after primary procedure was achieved in significantly (p=0,02) more patients in group 1 (89%) than in group 2 (69,2%) ST segment resolution ≥70% after intervention was achieved in 87% of cases in group 1 and in 64,1% of cases in group 2 (p=0,011).Conclusion. In STEMI patients with massive coronary thrombosis, the method of delayed percutaneous intervention increases the rate of achieving optimal blood flow and allows avoiding stent implantation in the infarct-related artery in 50% of cases as compared to the method of immediate stenting. Both methods have comparable hospital and five-year clinical risks.