Post-discharge Management Research Articles

Medicare Transitional Care Management Service Association with Readmissions and Mortality

Abstract In 2013 CMS introduced codes to reimburse outpatient providers for post-discharge Transitional Care Management (TCM). Understanding the implications of TCM reimbursement on outcomes is crucial for evaluating CMS’s investment and guiding future policy. We analyzed the association between physician organization (PO) TCM code use and post-discharge readmissions and mortality using 100% fee-for-service Medicare claims. Employing a difference-in-differences approach we compared 1131 “high-TCM” POs (top quartile of TCM code use from 2015-2017) to 1133 “low-TCM” POs (bottom quartile) from before (2012) and after (2015-2017) TCM code implementation, controlling for PO and beneficiary attributes and readmission risk. TCM code use was associated with decreased 30- and 90-day readmissions [-0.31 (95%CI -0.52, -0.09) and -0.42 (95%CI -0.71, -0.14) percentage points, respectively], but no significant difference in mortality. Year-by-year, 2017 saw greatest readmission reduction, with a slight mortality reduction in that year only. Readmission reductions were greatest in POs not affiliated with health systems, Accountable Care Organizations (ACOs), or academic medical centers, and least in those with fewer primary care physicians. Narrow, indirect interventions like fee-for-service TCM billing code reimbursement may have limited potential to improve post-discharge outcomes overall. However, small independent practices may derive somewhat greater benefit from this support for post-discharge care.

Development and validation of a predicting model for risk of mortality in heart failure patients with mildly reduced ejection fraction post discharge

Abstract Background Prognostic prediction for heart failure with mildly reduced ejection fraction (HFmrEF) patients remains challenging. We aimed to create and validate a mortality risk prediction model for HFmrEF patients at 6-month, 1-year, and 3-year post discharge. Methods Clinical data of 1691 HFmrEF patients registered in the heart failure registry from 2015 to 2020 at the Heart Center of our hospital were analyzed. Patients were assigned into a training (1183 patients) and validation cohort (508 patients) at 7:3 ratio. Predictive variables for mortality at various period post discharge were identified by the Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis. The predicting model was then established based on these variables. Model performance was evaluated with ROC curve and Decision Curve Analysis (DCA). Results Eight predictors were identified including age, NT-proBNP, hemoglobin levels, use of beta-blockers, ACEI/ARB, invasive ventilation, PCI procedures, and pulmonary artery systolic pressure values. The model achieved a C-index of 0.748 (training set) and 0.755 (validation set). Area Under the Curve (AUC) for training set at 6 months, 1 year, and 3 years were 0.813, 0.784, and 0.774, and AUC for validation set were 0.775, 0.744, and 0.770, respectively. The DCA analysis confirmed the favorable net benefit of the established nomogram model. Conclusion This predicting model might be used for post-discharge risk stratification and individual decision-making of post-discharge management in HFmrEF patients.

Pharmacist-led hospital intervention reduces unintentional patient-generated medication discrepancies after hospital discharge

BackgroundMedication reconciliation can significantly reduce clinically important medication errors at hospital discharge, but its impact on post-discharge medication management has not been investigated. We aimed to investigate the incidence of patient-generated medication discrepancies 30 days after hospital discharge and the impact of a pharmacist-led medication reconciliation coupled with patient counselling on clinically important discrepancies caused by patients.MethodsA pragmatic, prospective, controlled clinical trial was conducted at the University Clinic Golnik, Slovenia. Adult patients were divided into an intervention group and a control group. The intervention group received pharmacist-led medication reconciliation at admission and discharge, plus patient counselling at discharge. Medication discrepancies were identified by comparing the therapy prescribed in the discharge letters with the therapy 30 days after discharge, obtained through telephone patient interviews. Discrepancies were classified as intentional or unintentional, and their clinical importance was assessed.ResultsThe study included 254 patients (57.9% male, median age 71 years), with 136 in the intervention group and 118 in the control group. Discrepancies occurred with a quarter of the medicines (617/2,441; 25.3%) at 30 days after hospital discharge, and patients themselves caused half of the discrepancies (323/617; 52.4%), either intentionally (171/617; 27.7%) or unintentionally (152/617; 24.6%). Clinically important discrepancies occurred in 18.7% of intentional and 45.4% of unintentional patient-generated changes. The intervention significantly reduced the likelihood of clinically important unintentional patient-generated discrepancies (OR 0.204; 95%CI: 0.093–0.448), but not clinically important intentional patient-generated discrepancies (OR 2.525; 95%CI: 0.843–7.563). The latter were more frequent among younger, male patients and patients hospitalized for respiratory diseases.ConclusionThe study emphasizes the importance of addressing discrepancies made by patients after hospital discharge, which can result in potentially harmful outcomes. It also shows that a pharmacist-led hospital intervention can significantly reduce discrepancies in the early post-discharge period. These findings can guide the development of future services to improve patient support for medication management after hospitalization.

Guideline-directed medical therapy implementation during hospitalization for cardiogenic shock.

Despite significant morbidity and mortality, recent advances in cardiogenic shock (CS) management have been associated with increased survival. However, little is known regarding the management of patients who survive CS with heart failure (HF) with reduced left ventricular ejection fraction (LVEF, HFrEF), and the utilization of guideline-directed medical therapy (GDMT) in these patients has not been well described. To fill this gap, we investigated the use of GDMT during an admission for CS and short-term outcomes using the Inova single-centre shock registry. We investigated the implementation of GDMT for patients who survived an admission for CS with HFrEF using data from our single-centre shock registry from January 2017 to December 2019. Baseline characteristics, discharge clinical status, data on GDMT utilization and 30day, 6month and 12month patient outcomes were collected by retrospective chart review. Among 520 patients hospitalized for CS during the study period, 185 (35.6%) had HFrEF upon survival to discharge. The median age was 64years [interquartile range (IQR) 56, 70], 72% (n=133) were male, 22% (n=40) were Black and 7% (n=12) were Hispanic. Forty-one per cent of patients (n=76) presented with shock related to acute myocardial infarction (AMI), while 59% (n=109) had HF-related CS (HF-CS). The median length of hospital stay was 12days (IQR 7, 18). At discharge, the proportions of patients on beta-blockers, angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs)/angiotensin receptor/neprilysin inhibitors (ARNIs) and mineralocorticoid receptor antagonists (MRAs) were 78% (n=144), 58% (n=107) and 55% (n=101), respectively. Utilization of three-drug GDMT was 33.0% (n=61). Ten per cent of CS survivors with HFrEF (n=19) were not prescribed any component of GDMT at discharge. Multivariable logistic regression adjusted for baseline GDMT use revealed that patients with lower LVEF and those who transferred to our centre from an outside hospital were more likely to experience GDMT addition (P<0.05). Patients prescribed at least one additional class of GDMT during admission had higher odds of 6month and 1year survival (P<0.01): On average, 6month survival odds were 7.1 times greater [confidence interval (CI) 1.9, 28.5] and 1year survival odds were 6.0 times greater than those who did not have at least one GDMT added (CI 1.9, 20.5). Most patients who survived CS admission with HFrEF in this single-centre CS registry were not prescribed all classes or goal doses of GDMT at hospital discharge. These findings highlight an urgent need to augment multidisciplinary efforts to enhance the post-discharge medical management and outcomes of patients who survive CS with HFrEF.

Effect of Hospital-to-Home Transitional Care for COPD on Patient-Centered Outcomes.

Appropriate hospital-to-home transitional care has been recognized for its positive impact on health care usage and health outcomes in patients with COPD. However, there is limited research assessing its effects on patient-centered outcomes, focusing on patient symptoms and experiences. This single-blind randomized controlled trial included subjects diagnosed with COPD at one of 2 university hospitals in South Korea. The study included 179 subjects (transitional care group [transitional care], 87; usual care group [usual care], 92). The transitional care received transitional care comprising post-discharge care planning, personalized education, breathing exercises, telephone counseling, home visits, and referral to social services. We analyzed the effects of these interventions by comparing breathing symptoms and various patient-centered outcomes between the 2 groups. The Modified Medical Research Council scores (mean [SD], transitional care 1.3 [1.06], usual care 1.82 [1.1], P = .002) and COPD Assessment Test scores (transitional care 6.32 [5.5], usual care 9.43 [7.16], P = .001) in the intervention group demonstrated more significant improvement than did those in the usual care. Following intervention, the subjects exhibited enhanced awareness of their disease, an increased frequency of inhaler use (transitional care 49.69 [1.67], usual care 46.86 [7.92], P = .002), and lower depression and anxiety scores. Additionally, the transitional care outperformed the usual care in the domain of subject experience during hospitalization (transitional care 39.34 [6.14], usual care 37.5 [5.61], P = .036), preparedness before discharge (transitional care 34.54 [4.96], usual care 32.3 [5.09], P = .003), and post-discharge management (transitional care 34.72 [4.36], usual care 30.29 [4.26], P = .003). Evidence-based transitional care services can exert positive effects on patient-centered indices. Our findings can be used as evidence of the need to establish patient-centered transitional care as a form of universal care for patients with COPD.

Optimizing Comprehensive Care for the Hospitalized Hip Fracture Patients: Time to Surgery and Bone Health at Discharge

Background: Approximately 300,000 older people ( 65 years and older) are hospitalized yearly for hip fractures, according to the CDC. Hip fracture is considered a life-altering event with increased morbidity and up to 30% mortality. The Clinical Practice Guidelines by the American Academy of Orthopedic Surgeons highlight the importance of an interdisciplinary team approach while caring for these patients and recommend surgery within 24 hours for improved outcomes. Most of these fractures are considered fragility fractures occurring from a simple ground-level fall and, thus, a manifestation of osteoporosis. Yet, only a few patients, 26%, receive osteoporosis treatment within 30 days of surgery, as per a recent study. ACP recommends replenishing Vitamin D and Calcium in all fragility fracture patients, followed by the initiation of bisphosphonates. At our institution, hip fracture patients used to be admitted to internal medicine or orthopedic services based on their complexity. There was a perceived feeling that those admitted to primarily internal medicine service received less comprehensive care and were likely delayed in getting to the OR given the competing priorities of a sick internal medicine service load. Vitamin D levels were not being checked or replaced despite having it be part of the admission order set used for hip fracture patients. Our project aimed at improving overall care for hospitalized hip fracture patients. Our goal was to increase the percentage of hospitalized hip fracture patients going to the operating room within 24 hours to 85% by the end of 2023. Additional goals were to improve the percentage of checking vitamin D levels and supplementing them at discharge by 25% by the end of 2023. Methods: Our intervention was to build a fragility fracture orthopedic and internal medicine co-management service where hip fracture patients were admitted. We collected outcome, process, and balancing measures, including time to surgery, unnecessary cardiac testing and consultation before surgery, percentage of ordering vitamin-D levels, and vitamin-D supplementation at discharge. Qualitative satisfaction with the process was also included. Data was collected biweekly from Jan 2023 to Dec 2023. Run chart analysis was utilized for statistical analysis. Results: Our results showed that the percentage of patients going to surgery within 24 hours did not differ (median of approximately 80%). Patients rarely got unnecessary cardiac testing or consultations, so we stopped following this measure. The median of vitamin-D level checking and supplementation at discharge had improved from 45% to 77% and 35% to 50%, respectively, sustaining a shift using run chart analysis rules. Conclusions: Our project shows that establishing a dedicated service for hospitalized fragility hip fractures has improved care for our patients. While time to surgery had not improved, it had been within the reported national average. Time to surgery is being delayed mostly when further medical optimization is required. However, having this service improved bone-focused care with vitamin-D testing and supplementation. The future PDSA cycle will focus on post-discharge osteoporosis management and treatment when appropriate.

General practice management after transition events: protocol for an experience-based co-design study.

Discharge from hospital is a critical part of the patient journey, particularly for older patients with multimorbidity and polypharmacy. General practice has a key role in managing the post-discharge course of patients. A communication intervention for use in general practice in the immediate post-discharge period has great potential to improve shared decision making, enhancing patient experiences of post-discharge care. General Practice Management After Transition Events (GP-MATE) aims to produce a tool for older patients and their carers (GP-MATE), which will assist better communication with their general practice about their care after discharge, thereby improving patient safety outcomes. Experience-based co-design (EBCD) study involving general practices across the West Midlands. A slightly modified approach to EBCD will be followed to create GP-MATE. A focused ethnography undertaken at general practices will provide an understanding of practices' systems for post-discharge management of older patients. Semi-structured video interviews with recently discharged older patients or their carers will be edited into a trigger film. Finally, co-design workshops with older people, carers, and healthcare staff working in general practices will take place with participants from three regions across England. EBCD will be used to take a patient-centric approach towards creating GP-MATE; patients' and carers' priorities will be directly reflected within the tool. GP-MATE will be a low-cost intervention that improves health literacy, empowering patients to fill the emerging gap in continuity in the post-discharge period and enhancing patient experiences of post-discharge care.

Unplanned Rehospitalisation due to Medication Harm following an Acute Myocardial Infarction

Introduction: The contribution of medication harm to rehospitalisation and adverse patient outcomes after an acute myocardial infarction (AMI) needs exploration. Rehospitalisation is costly to both patients and the healthcare facility. Following an AMI, patients are at risk of medication harm as they are often older and have multiple comorbidities and polypharmacy. This study aimed to quantify and evaluate medication harm causing unplanned rehospitalisation after an AMI. Methods: This was a retrospective cohort study of patients discharged from a quaternary hospital post-AMI. All rehospitalisations within 18 months were identified using medical record review and coding data. The primary outcome measure was medication harm rehospitalisation. Preventability, causality, and severity assessments of medication harm were conducted. Results: A total of 1,564 patients experienced an AMI, and 415 (26.5%) were rehospitalised. Eighty-nine patients (5.7% of total population; 6.0% of those discharged) experienced a total of 101 medication harm events. Those with medication harm were older (p = 0.007) and had higher rates of heart failure (p = 0.005), chronic kidney disease (p = 0.046), chronic obstructive pulmonary disease (p = 0.037), and a prior history of ischaemic heart disease (p = 0.005). Gastrointestinal bleeding, acute kidney injury, and hypotension were the most common medication harm events. Forty percent of events were avoidable, and 84% were classed as “serious.” Furosemide, antiplatelets, and angiotensin-converting enzyme inhibitors were the most commonly implicated medications. The median time to medication harm rehospitalisation was 79 days (interquartile range: 16–200 days). Conclusion: Medication harm causes unplanned rehospitalisation in 5.7% of all AMI patients (1 in 17 patients; 6.0% of those discharged). The majority of harm was serious and occurred within the first 200 days of discharge. This study highlights that measures to attenuate the risk of medication harm rehospitalisation are essential, including post-discharge medication management.

30-day and one-year readmission rate in 11,270 patients with surgical treatment for proximal femoral fractures across Austria.

Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria. Data from 11,270 patients with PFFs, treated surgically (osteosyntheses, n = 6,435; endoprostheses, n = 4,835) at Austrian hospitals within a one-year period (January to December 2021) was retrieved from the Leistungsorientierte Krankenanstaltenfinanzierung (Achievement-Oriented Hospital Financing). The 30-day and one-year readmission rates were reported. Readmission risk for any complication, as well as general medicine-, internal medicine-, and surgery/injury-associated complications, and factors associated with readmissions, were investigated. The 30-day and one-year readmission rates due to any complication were 15% and 47%, respectively. The 30-day readmission rate (p = 0.001) was higher in endoprosthesis than osteosynthesis patients; this was not the case for the one-year readmission rate (p = 0.138). Internal medicine- (n = 2,273 (20%)) and surgery/injury-associated complications (n = 1,612 (14%)) were the most common reason for one-year readmission. Regardless of the surgical procedure, male sex was significantly associated with higher readmission risk due to any, as well as internal medicine-associated, complication. Advanced age was significantly associated with higher readmission risk after osteosynthesis. In both cohorts, treatment at mid-sized hospitals was significantly associated with lower readmission risk due to any complication, while prolonged length of stay was associated with higher one-year readmission risks due to any complication, as well as internal-medicine associated complications. Future health policy decisions in Austria should focus on optimization of perioperative and post-discharge management of this vulnerable patient population.

Development and Feasibility Evaluation of Smart Cancer Care 2.0 Based on Patient-Reported Outcomes for Post-Discharge Management of Patients with Cancer.

A "Smart Cancer Care" platform that integrates patient-reported outcomes (PROs) with management has been established in Korea. This study focused on improving health behaviors and connecting patients to welfare services by introducing and assessing the feasibility of "Smart Cancer Care 2.0," an enhanced version designed for monitoring complications post-cancer treatment. Smart Cancer Care 2.0 was developed by conducting a literature review and consulting with expert panels to identify symptoms or variables requiring monitoring and management guidelines based on the treatment type. Qualitative and quantitative surveys were conducted to assess the feasibility of the app and web system based on the experiences of patients with cancer and healthcare workers. A total of 81 symptoms or variables (chemotherapy-, surgery-, radiotherapy-, rehabilitation-, and health management-related) were selected for management in Smart Cancer Care 2.0. PROs for these symptoms were basically categorized into three severity grades: preventive management, self-treatment, and consultation with a healthcare worker or visit to a healthcare institution. The overall mean scores in the feasibility evaluation by patients and healthcare workers were 3.83 and 3.90 points, respectively, indicating high usefulness. Smart Cancer Care 2.0 leverages the existing information and communication technologies-based platform, Smart Cancer Care, and further includes health behaviors and welfare services. Smart Cancer Care 2.0 may play a crucial role in establishing a comprehensive post-discharge management system for patients with cancer as it provides suitable interventions based on patients' responses and allows the regularly collected PROs to be easily viewed for streamlined care.

N-terminal pro-B-type natriuretic peptide post-discharge monitoring in the management of patients with heart failure and preserved ejection fraction-a randomized trial: The NICE study.

There is a lack of specific studies assessing the impact of natriuretic peptide monitoring in the post-discharge management of patients with heart failure (HF) and preserved ejection fraction (HFpEF), throughout the vulnerable phase following acute HF hospitalization. The NICE study aims to assess the clinical benefit of incorporating N-terminal pro-B-type natriuretic peptide (NT-proBNP) into the post-discharge management of HFpEF patients. Individuals admitted with HFpEF (left ventricular ejection fraction >50%) were included in a multicentre randomized controlled study employing an open-label design with event blinding (NCT02807168). Upon discharge, 157 patients were randomly allocated to either NT-proBNP monitoring (n = 79) or no access to NT-proBNP (control group, n = 78) during pre-scheduled visits at 2, 4 and 12 weeks. Clinical endpoints were evaluated at 6 months. The primary endpoint of HF rehospitalizations occurred in 12.1% patients, without significant differences observed between the NT-proBNP monitoring group (12.8%) and the control group (11.4%) (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.47-2.81, p = 0.760). Regarding secondary endpoints, the NT-proBNP monitoring group demonstrated a significantly lower risk of death (1.3% vs. 10.1%; HR 0.12, 95% CI 0.02-0.98; p = 0.048), whereas non-HF hospitalizations (12.8% vs. 19.0%, p = 0.171) and any adverse clinical event (26.9% vs. 36.7%, p = 0.17) did not reach statistical significance [Correction added on 29 April 2024, after first online publication: In the preceding sentence, "95% CI 0.02 - 0.09" has been corrected to "95% CI 0.02 - 0.98; p = 0.048" in this version.]. Awareness of NT-proBNP levels were associated with higher doses of diuretics and renin-angiotensin system inhibitors (angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers) in the NT-proBNP monitoring group. Post-discharge monitoring of NT-proBNP in HFpEF patients did not exhibit an association with reduced rates of HF hospitalization in this study. Nonetheless, it appears to enhance global clinical management by optimizing medical therapies and contributing to improved overall survival.

Predicting Hospital Readmission in Medicaid Patients With COPD Using Administrative and Claims Data.

The goals of this study were to develop a model that predicts the risk of 30-d all-cause readmission in hospitalized Medicaid patients diagnosed with COPD and to create a predictive model in a retrospective study of a population cohort. We analyzed 2016-2019 Medicaid claims data from 7 United States states. A COPD admission was one in which either the admission diagnosis or the first or second clinical (discharge) diagnosis bore an International Classification of Diseases, Tenth Revision code for COPD. A readmission was an admission for any condition (not necessarily COPD) that occurred within 30 d of a COPD discharge. We estimated a mixed-effects logistic model to predict 30-d readmission from patient demographic data, comorbidities, past health care utilization, and features of the index hospitalization. We evaluated model fit graphically and measured predictive accuracy by the area under the receiver operating characteristic (ROC) curve. Among 12,283 COPD hospitalizations contributed by 9,437 subjects, 2,534 (20.6%) were 30-d readmissions. The final model included demographics, comorbidities, claims history, admission and discharge variables, length of stay, and seasons of admission and discharge. The observed versus predicted plot showed reasonable fit, and the estimated area under the ROC curve of 0.702 was robust in sensitivity analyses. Our model identified with acceptable accuracy hospitalized Medicaid patients with a diagnosis of COPD who are at high risk of readmission. One can use the model to develop post-discharge management interventions for reducing readmissions, for adjusting comparisons of readmission rates between sites/providers or over time, and to guide a patient-centered approach to patient care.

Post-discharge nutritional management for patients with coronary heart disease and frailty: a qualitative study

BackgroundFrail elderly patients experience physiological function and reserve depletion, leading to imbalances in their internal environment, which increases the risk of coronary heart disease recurrence and malnutrition. However, the majority of these patients, who primarily have a low level of education and lack self-management skills, face difficulties actively dealing with obstacles during the transition period after their discharge from hospitalization. Therefore, it is necessary to understand and discuss in depth the nutrition management experience of discharged elderly patients with coronary heart disease and frailty (ages 65-80 years old) and to analyze the promoting and hindering factors that affect scientific diet behavior during the discharge transition period.MethodsFifteen elderly patients with coronary heart disease and frailty who had been discharged from the hospital for 6 months were interviewed using a semistructured method. The directed content analysis approach to descriptive research was used to extract topics from the interview content.ResultsAll participants discussed the problems in health nutrition management experience of discharged. Five topics and ten subtopics were extracted, such as ①Weak perceptions and behaviors towards healthy eating (personal habit solidification, negative attitudes towards nutrition management), ②Lack of objective factors for independently adjusting dietary conditions (reliance on subjective feelings, times of appetite change), ③Personal hindrance factors (memory impairment, deficiencies in self-nutrition management), ④Expected external support (assistance care support, ways to obtain nutritional information), ⑤Lack of continuous nutrition management (interruption of professional guidance, avoidance of medical treatment behavior).ConclusionsNutrition management after discharge places a burden on elderly patients with coronary heart disease and frailty. According to the patients' physical conditions, we should develop a diet support system that is coordinated by individuals, families and society.

Improving the Quality and Completeness of Discharge Summaries at a Tertiary Care Hospital in Pakistan: A Quality Improvement Project.

Introduction Discharge summaries (DS) allow continued patient care after being discharged from the hospital. Only a few quality improvement projects (QIPs) focused on assessing and improving the quality and completeness of DS at tertiary care hospitals have been undertaken in Pakistan. This QIPaimed to evaluate and enhance the quality and completeness of DS at a tertiary care hospital in Pakistan to facilitate seamless healthcare transitions. Methods A QIP was conducted in the medical unit of a tertiary care hospital in Rawalpindi, Pakistan. The DS were assessed using the e-discharge summary self-assessment checklist devised by the Royal College of Physicians (RCP). This QIP was done by the plan, do, study, act (PDSA) cycle. The PDSA cycle comprised two audit cycles and an intervention in between them. The first audit cycle (AC) was conducted on 150 DS. Its duration was from March 2023 to June 2023. An educational workshop was conducted before the re-audit cycle (RAC) to address deficiencies and reinforce the implementation of the guidelines provided by the RCP. The RAC was conductedfrom June 2023 to August 2023. 100 DS were studied and analyzed to assess for improvement in the completeness of DS. Frequencies and percentages were calculated in each audit cycle. The Chi-squared test was applied to compare the statistical difference between the results of both audit cycles. Results A total of 150 DS were analyzed in the first AC and 100 DS in the RAC. The results of the first AC show that the details of any allergies were recorded only in 3% of the DS; this percentage significantly improved to 51% after the RAC (p-value <0.05). Relevant past medical history was included in 52% and 88% of the DS during the first AC and RAC, respectively (p-value <0.05). Secondary diagnoses were written in 54% and 71% of the DS during the firstAC and RAC, respectively (p-value <0.05). Details of relevant investigations were included in 60% and 88% of the DS during the first AC and RAC, respectively (p-value <0.05). The post-discharge management plan was written in 90% and 98% of the DS during the first AC and RAC, respectively (p-value <0.05).The follow-up plan was written clearly in 65% and 93% of the DS during the first AC and RAC, respectively (p-value <0.05). Conclusion The DS was found to be incomplete after analyzing the results of the first AC. The details related to allergies, medications, operations, and procedures were found to be missing in the majority of the cases. No mention of the patient's concerns or expectations was made in the DS. The results of the RAC showed improvement in the level of completeness of DS. The majority of the weak points observed after the first AC seemed to haveimproved after the RAC, which shows that intervention proved to be quite effective in improving the completeness and quality of DS. The RAC showed significant improvement in the completeness of the details relating toinvestigations, allergies, past medical history, secondary diagnoses, and the post-discharge follow-up plan. QIP must be routinely carried out to assess and improve the completeness and quality of DS at hospitals.

The effect of frailty on post-discharge management and outcomes of acute glycaemic crises: Analysis of admissions for hypoglycaemia and hyperglycaemia in Australia

ObjectiveTo describe changes in glucose-lowering drug (GLD) dispensing by frailty status for people with diabetes following admission for hypoglycaemia or hyperglycaemia. MethodsThis study included all people with probable type 2 diabetes in the state of Victoria, Australia, admitted to hospital for hypoglycaemia (n = 2,506 admissions) or hyperglycaemia (n = 1,693) between 1 July 2013 and 29 June 2017. Frailty was defined via the Hospital Frailty Risk Score (HFRS). We examined differences in dispensing of GLDs in the year before and after admission using linear regression models adjusted for age, sex, comorbidities, and socioeconomic status. ResultsDispensing of GLDs decreased following hypoglycaemia admission. Decreased dispensing was strongly associated with frailty status, with a change in mean annual GLD dispensing count of −4.11 (−5.05, −3.17) for an HFRS of 15 vs. −0.99 (−1.47, −0.50) for an HFRS of 0. Changes were greatest for metformin and sulfonylureas. Following hyperglycaemia admission, the mean number of annual GLD dispensings increased, with a smaller increase with increasing frailty: 2.44 (1.32, 3.56) for an HFRS of 0 vs. 1.16 (0.18, 2.14) for an HFRS of 15. ConclusionsFrailty was associated with more conservative diabetes medication management following hypoglycaemia and hyperglycaemia admissions.

Re-Admissions of 'Unknown' Traumatic Brain Injury Patients - Inadequacy of Rehabilitative Services in a Developing Country.

In neurosurgical practice, continuous care after discharge and the ability to detect subtle indicators of clinical deterioration are mandatory to prevent the progression of a disease. The care of 'unknown' patients discharged to rehabilitation homes may not have this privilege, especially in resource-poor countries such as India. We have attempted to study the causes and outcomes of re-admissions of 'unknown' patients with previous traumatic brain injury (TBI) to estimate the quality of nursing care in our rehabilitation centers. The electronic hospital records of all consecutive 'unknown' TBI patients with unplanned re-admissions at our institute from January 2014 to December 2018 were retrospectively reviewed and analyzed for the factors determining the risk and outcomes of re-admission. Out of 245 patients sent to rehabilitation homes at discharge, 47 patients (19.18%) were re-admitted. A total of 33 patients (70%) were re-admitted between 1 month and 1 year. Out of these, 38 patients (80.9%) were re-admitted because of preventable causes. Fifteen patients (31.9%) died during the hospital stay. The rest of the 32 (68%) patients were discharged after the management of the concerned condition with an average hospital stay of 9 ± 11.1 days. The average Glasgow coma scale (GCS) at re-admission of the patients who died was 6 (range 3-11). Two patients were brought in the brain dead status, whereas 20 patients (42.6%) had a GCS of 5 or below at the time of re-admission. The risk of mortality among patients with non-preventable causes was 88.9% (8/9) compared to preventable causes 18.4% (7/38). However, preventable causes for re-admission are much more common, resulting in nearly a similar overall contribution to mortality. There is a high rate of mortality and morbidity in 'unknown' patients with TBI because of poor post-discharge care in developing countries. Because preventable causes are the major contributor to re-admissions, the re-admission rate is a good indicator of a lack of adequate rehabilitative services. The need for improving the post-discharge management of 'unknown' patients with TBI in resource-poor countries cannot be over-emphasized.

Cost-effectiveness of a multidimensional post-discharge disease management program for heart failure patients-economic evaluation along a one-year observation period.

This study aimed to assess the cost-effectiveness of the telemedically assisted post-discharge management program (DMP) HerzMobil Tirol (HMT) for heart failure (HF) patients in clinical practice in Austria. We conducted a cost-effectiveness analysis along a retrospective cohort study (2016-2019) of HMT with a propensity score matched cohort of 251 individuals in the HMT and 257 in the usual care (UC) group and a 1-year follow-up. We calculated the effectiveness (hospital-free survival, hospital-free life-years gained, and number of avoided rehospitalizations), costs (HMT, rehospitalizations), and the incremental cost-effectiveness ratio (ICER). We performed a nonparametric sensitivity analysis with bootstrap sampling and sensitivity analyses on costs of HF rehospitalizations and on costs per disease-related diagnosis (DRG) score for rehospitalizations. Base-case analysis showed that HMT resulted in an average of 42 additional hospital-free days, 40 additional days alive, and 0.12 avoided hospitalizations per patient-year compared with UC during follow-up. The average HMT costs were EUR 1916 per person. Mean rehospitalization costs were EUR 5551 in HMT and EUR 6943 in UC. The ICER of HMT compared to UC was EUR 4773 per life-year gained outside the hospital. In a sensitivity analysis, HMT was cost-saving when "non-HF related costs" related to the DMP were replaced with average costs. The economic evaluation along the cohort study showed that the HerzMobil Tirol is very cost-effective compared to UC and cost-saving in a sensitivity analysis correcting for "non-HF related costs." These findings promote a widespread adoption of telemedicine-assisted DMP for HF.

Age shock index and age-modified shock index are valuable bedside prognostic tools for postdischarge mortality in ST-elevation myocardial infarction patients

Background The incidence of mortality is considerable after ST-elevation myocardial infarction (STEMI) hospitalization; risk assessment is needed to guide postdischarge management. Age shock index (SI) and age modified shock index (MSI) were described as useful prognosis instruments; nevertheless, their predictive effect on short and long-term postdischarge mortality has not yet been sufficiently confirmed. Methods This analysis included 3389 prospective patients enrolled from 2016 to 2018. Endpoints were postdischarge mortality within 30 days and from 30 days to 1 year. Hazard ratios (HRs) were evaluated by Cox proportional-hazards regression. Predictive performances were assessed by area under the curve (AUC), integrated discrimination improvement (IDI), net reclassification improvement (NRI) and decision curve analysis (DCA) and compared with TIMI risk score and GRACE score. Results The AUCs were 0.753, 0.746 for age SI and 0.755, 0.755 for age MSI for short- and long-term postdischarge mortality. No significant AUC differences and NRI were observed compared with the classic scores; decreased IDI was observed especially for long-term postdischarge mortality. Multivariate analysis revealed significantly higher short- and long-term postdischarge mortality for patients with high age SI (HR: 5.44 (2.73–10.85), 5.34(3.18–8.96)), high age MSI (HR: 4.17(1.78–9.79), 5.75(3.20–10.31)) compared to counterparts with low indices. DCA observed comparable clinical usefulness for predicting short-term postdischarge mortality. Furthermore, age SI and age MSI were not significantly associated with postdischarge prognosis for patients who received fibrinolysis. Conclusions Age SI and age MSI were valuable instruments to identify high postdischarge mortality with comparable predictive ability compared with the classic scores, especially for events within 30 days after hospitalization.

Abstract 31: Let Me Be Your Guide: The Impact of Stroke Navigators on Post-Acute Stroke Follow Up

Introduction: Stroke patients often require complex post-discharge management in an outpatient setting. At this Comprehensive Stroke Center, stroke patients are to receive a 30-day, 90 day, and 1 year follow up with the stroke clinic. Post-acute follow up appointments are typically established after discharge, leading to scheduling delays for the 30-day appointment, patients lost to follow up, or no showing to appointments. Stroke Navigators are an emerging role that can bridge the gap between acute and post-acute care settings and integral to ensuring stroke patients receive optimal follow up care. Methods: In 2022, a Stroke Navigator was added to the care team and collaborated with the Stroke Clinic to project volume of clinic slots needed for ischemic and TIA hospital discharges. The Stroke Navigator implemented follow up scheduling with patient/family prior to discharge and emphasized the importance of the 30-day appointment. Pre and postintervention data was then collected and analyzed from Q2 2022 to Q1 2023 regarding timeliness of scheduling, appointment type, and rate of no shows for all ischemic stroke/TIA patients. Results: The pre-intervention scheduling process resulted in an average wait time of 19 days to schedule appointments. Post intervention, no wait time identified as appointments were scheduled prior to discharge. Pre-intervention data on 30-day appointments showed only 23% of patients were scheduled and attended their provider visit, while post-intervention data showed 60% (Table 1). The clinic no show rate went from 19%, down to 10% in the post intervention phase. Conclusion: The Stroke Navigator has made a significant impact on the number of patients with 30-day visits, eliminated the wait time for appointments due to scheduling prior to discharge, and decreased the no show rate for patients at 30 days. Further financial analysis will be critical to validate the impact of a Stroke Navigator, as they are critical to closing the gap in post-acute care.

Disentangling organizational levers and economic benefits in transitional care programs: a systematic review and configurational analysis

BackgroundPromoting safe and efficient transitions of care is critical to reducing readmission rates and associated costs and improving the quality of patient care. A growing body of literature suggests that transitional care (TC) programs are effective in improving quality of life and reducing unplanned readmissions for several patient groups. TC programs are highly complex and multidimensional, requiring evidence on how specific practices and system characteristics influence their effectiveness in patient care, readmission reduction and costs.MethodsUsing a systematic review and a configurational approach, the study examines the role played by system characteristics (size, ownership, professional skills, technology used), the organizational components implemented, analyzing their combinations, and the potential economic impact of TC programs.ResultsThe more organizational components are implemented, the greater the likelihood that a TC program will be successful in reducing readmission rates. Not all components have the same effect. The results show that certain components, ‘post-discharge symptom monitoring and management’ and ‘discharge planning’, are necessary but not sufficient to achieve the outcome. The results indicate the existence of two different combinations of components that can be considered sufficient for the reduction of readmissions. Furthermore, while system characteristics are underexplored, the study shows different ways of incorporating the skill mix of professionals and their mode of coordination in TC programs. Four organizational models emerge: the health-based monocentric, the social-based monocentric, the multidisciplinary team and the mono-specialist team. The economic impact of the programs is generally positive. Despite an increase in patient management costs, there is an overall reduction in all post-intervention costs, particularly those related to readmissions.ConclusionsThe results underline the importance of examining in depth the role of system characteristics and organizational factors in facilitating the creation of a successful TC program. The work gives preliminary insights into how to systematize organizational practices and different coordination modes for facilitating decision-makers’ choices in TC implementation. While there is evidence that TC programs also have economic benefits, the quality of economic evaluations is relatively low and needs further study.