Preventable Readmissions Research Articles

Transitions of care at an ambulatory care clinic: An implementation science approach.

Transitions of care (TOC) issues contribute to approximately 76% of preventable hospital readmissions. Centers for Medicare and Medicaid Services (CMS) focus on improvement of quality of care through TOC services. Studies have not used both implementation science and patient input to develop a TOC program that fulfills CMS criteria and satisfies patients' reported needs. The study objectives were to I) develop the TOC program in alignment with CMS criteria, identifying and remedying barriers during the process, and II) conduct a needs assessment and obtain patient perspectives on TOC service. The implementation science approach was chosen to refine the TOC service at one university medical center ambulatory care clinic. Barriers within the TOC program that prevented CMS criteria from being followed were identified on site during patient care. Changes were implemented in a timely manner by the pharmacy resident and TOC team. A prospective nine-item open-answer survey was administered to patients discharged less than 90 days from inpatient care. Data was collected, categorized, and presented to the TOC team for incorporation into the TOC service. Barriers and gaps in care were identified in the sample of 19 patients undergoing service from November 2019 to January 2020. CMS criteria and established TOC protocol had not been fulfilled for all patients. Eight barriers were revealed throughout the TOC process. Solutions were implemented through an in-service, monthly reminders, and communication to staff from the resident pharmacist. Patient responses (n=22) to the needs assessment indicated a desire for enhanced TOC education (discharge medications and therapy). Through implementation science, the TOC program was adapted to fulfill CMS criteria and TOC protocol. The needs assessment highlighted desired changes by TOC patients. Long-term outcomes will need to be studied to determine if the implemented changes at this site are sustainable.

Factors Associated with Readmission Among Individuals with One Previous Episode of Schizophrenia in Southern Thailand: A University Hospital-based Retrospective Study

Objective: Schizophrenia is a chronic disease that has residual symptoms and relapse. The study aims to explore factors associated with readmission from symptom relapse among individuals with schizophrenia. Material and Methods: Medical records of patients who had their first schizophrenia diagnosis, in the Songklanagarind hospital’s inpatient psychiatric unit, were retrospectively reviewed for the period from January 2007 to December 2019. This yielded data outlining demographic information, profiles of schizophrenia, and treatment. Descriptive statistical analysis was utilized to process all data, and factors associated with readmission were investigated using bivariate and multivariate analyses. Results: Reviewed medical records identified a sample size of 156 individuals with schizophrenia. The majority were male (50.6%), Buddhist (85.9%), unmarried (80.1%), unemployed (50.6%), and living with their families (90.4%). Mean age was 39.2 years. From the 156 patients, they were divided into two groups; the readmission group and the non-readmission group. Readmission was defined as rehospitalization to a psychiatric unit within 5 years after their first schizophrenia diagnosis. Of all of them, 84 (53.8%) featured readmission whereas 72 (46.2%) were non-readmission. The first to fifth readmission rate was 22.4%, 12.8%, 9.6%, 5.1%, 3.8%, respectively. Multivariate analysis indicated that individuals with schizophrenia having stressful life events, non-adherence to medication, prescription changes, and lack of insight were all factors with a statistically significant association to readmission. Conclusion: Stressful life events, adverse events, non-adherence, change the prescription, and lack of insight were related to readmission. Emphasizing multimodality of treatment could be key to successful readmission prevention for individuals with schizophrenia.

Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty.

Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk. (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization? Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included. When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization. We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions. Level III, therapeutic study.

Reducing Heart Failure Hospitalizations Through Enhancement Of Multidisciplinary Roles And Targeted Patient Oversight

Reducing Heart Failure Hospitalizations Through Enhancement Of Multidisciplinary Roles And Targeted Patient Oversight

The Influence of Nurse Education Level on Hospital Readmissions-A Cost-Effectiveness Analysis.

Background: Readmissions are adverse, costly, and potentially preventable. The study aimed to evaluate the cost-effectiveness of reducing readmissions resulting from missed care, depending on the level of education of nurses, from the perspective of the service provider. Methods: We calculated missed care resulting in additional readmissions based on the longitudinal study conducted between 2012 and 2014, as well as readmissions that could have been potentially prevented by adding a 10% increase in hours of nursing care provided by BSN/MSc nurses for 2014. The cost-effectiveness analysis (CEA) was performed to calculate the cost-effectiveness of preventing one hospitalization in non-surgical and surgical wards by increasing the number of nursing hours provided by BSN/MSc nurses. Cost–benefit analysis (CBA) was performed, and the CBR (cost–benefit ratio) and BCR (benefit–cost ratio) were calculated. Results: Increasing the number of hours of nursing care (RN) by 10% decreased the chance for an unplanned readmission by 11%; (OR = 0.89; 95% CI: 0.78−1.01; p = 0.08) in non-surgical wards and 43% (OR = 0.57; 95% CI: 0.49−0.67; p < 0.001) in surgical wards. In non-surgical wards, the number of readmissions that were preventable with extra hours provided by BSN/MSc nurses was 52, and the cost-effectiveness ratio (CER) was USD 226.1. The number of preventable readmissions in surgical wards was 172, and the CER was USD 54.96. In non-surgical wards, the CBR was USD 0.07, while the BCR was USD 1.4. In surgical wards, the CBR was USD 0.02, and the BCR was USD 4.4. Conclusions: The results of these studies broaden the understanding of the relationship among nursing education, patient readmission, and the economic outcomes of hospital care. According to the authors, the proposed intervention has an economic justification. Hence, the authors recommend it for approval by the service provider.

30-Day Readmission and Outcomes after Fenestrated Versus Traditional Endovascular Aortic Aneurysm Repair

Fenestrated endovascular aneurysm repair (FEVAR) has emerged as a minimally invasive alternative for repairing complex abdominal aortic aneurysms (AAA). Comparisons of outcomes for FEVAR and traditional endovascular aneurysm repair (EVAR) are limited. We evaluated outcomes following elective endovascular AAA repair with FEVAR or EVAR. Hospitalizations for elective nonruptured AAA repair from 2014 to 2016 were selected from the Nationwide Readmissions Database (NRD) using ICD-9 and ICD-10 procedure and diagnosis codes. In-hospital mortality, length of stay (LOS), complications, 30-day readmission, and charges were evaluated. Multivariable logistic regression was used to control for confounding between groups. We identified 23,262 EVAR and 2,373 FEVAR with nonruptured elective procedures. In-hospital mortality was 0.14% for both groups (P = 0.99). Of those at risk for readmission (21,152 EVAR, 1,915 FEVAR), index LOS was greater for FEVAR compared to EVAR, 1.8 days versus 1.7 days (P = 0.028). There was no difference in procedure type based on hospital location (P = 0.37), teaching status (P = 0.17) or hospital size (P = 0.26). During the index hospitalization, pneumonia, renal, and respiratory complications were similar between groups (all P > 0.05). FEVAR patients were more likely to experience cardiac complications (P = 0.0098) or hemorrhage (P = 0.029). Total charges for the index stay were greater for FEVAR compared to EVAR ($125,381 vs. $113,513, P < 0.0001). All-cause 30-day readmission was similar between groups (7.0% EVAR vs. 8.0% FEVAR, P = 0.37), as were time to readmission (11.9 vs. 13.3 days, P = 0.16) and readmission charges ($53,967 vs. $56,617, P = 0.75). Renal failure was the most common readmission stay complication, with similar rates for EVAR and FEVAR patients (P = 0.22). Pneumonia was a more common complication during the readmission stay for EVAR patients (P = 0.004). Renal disease and chronic pulmonary disease were the most common comorbidities in the readmission stay for both groups. For patients with nonruptured elective AAA, FEVAR was not associated with increased mortality, length of stay, readmission, or most complications compared to traditional EVAR. Despite the increased technical complexity of cannulating and stenting visceral arteries with FEVAR, these data demonstrate that FEVAR carries a similar risk of renal, respiratory, and infectious complications compared to traditional EVAR. FEVAR patients were more likely to experience hemorrhagic and cardiac complications during the index hospitalization. EVAR patients were more likely to have pneumonia during readmission. The overall risk for readmission after an endovascular aortic repair was associated with female sex, greater age, chronic pulmonary disease, malignancy, and loss of function. Further investigations into the causes and prevention of 30-day readmissions are needed for both procedures.

Why reducing avoidable hospital readmissions is a 'wicked' problem for leaders: A qualitative exploration of nursing and allied health perceptions.

To investigate nursing and allied health professional perceptions of the interrelationship between avoidable hospital readmissions and fundamental care delivery. A qualitative, exploratory study using a critical realist approach. One-to-one semi-structured interviews with 14 nursing and allied health professionals conducted between May and September 2019. Several tensions and contradictions were identified in the data, which demonstrated clinicians' perceptions about the priority of both fundamental care and two avoidable readmission conditions (aspiration pneumonia and constipation). These tensions are illustrated in two major themes: Avoidable versus inevitable; and everyone versus no one. The first theme demonstrates clinicians' perceptions that readmissions for aspiration pneumonia and constipation are not common, despite acknowledging that they generally lacked knowledge on readmission rates; and that these conditions may not be preventable in acute settings. The second theme demonstrates clinicians' perception that preventing readmissions is everyone's responsibility, however, this was coupled with a lack of articulation around how this multidisciplinary approach could be achieved, leading to a distinct lack of agency for care delivery. Articulating the tensions described in the results provides vital knowledge for understanding how clinicians may respond to initiatives designed to reduce avoidable readmissions. Avoidable hospital readmissions may be usefully understood as a wicked problem: one that is complex and requires adaptive, not linear, solutions. Wicked problems pose a challenge for leaders and managers in healthcare because top-down, hierarchical strategies are unlikely to be successful. Effective prevention of avoidable readmissions requires leaders to enable facilitator-led change through relational leadership strategies. Avoidable hospital readmissions are a global problem increasingly addressed via funding changes and the introduction of penalties to hospitals. This study provides insights on clinicians' perspectives of avoidable hospital readmissions and their prevention, demonstrating the complexity of this challenge and the need for healthcare leaders to enable individual and organizational readiness for change.

Managing deteriorating patients with a physiotherapy critical care outreach service: A mixed-methods study

BackgroundCritical care outreach teams support ward staff to manage patients who are seriously ill or after discharge from the intensive care unit (ICU). Respiratory deterioration is a common reason for (re)admission to the ICU. Physiotherapists are health professionals with skills to address acute respiratory concerns. Experienced respiratory physiotherapists play a role in supporting junior clinicians, particularly in managing deteriorating patients on the ward. ObjectivesThe objective of this study was to evaluate a novel respiratory physiotherapy critical care outreach–style service. The primary objective was to describe service referrals and the patient cohort. Other objectives were to compare the effects of this model of care on ICU readmission rates to a historical cohort and explore clinician perceptions of the model of care and its implementation. MethodsA new physiotherapy model of care worked alongside an existing nurse-led outreach service to support physiotherapists with the identification and management of patients at risk of respiratory deterioration or ICU (re)admission. Purpose-built and pre-existing databases were used for prospective data collection and for a historical ICU readmissions control group. Questionnaires and semistructured group interviews were utilised to evaluate clinician satisfaction and perceptions. ResultsThe service accepted referrals for 274 patients in 6 months (on average 2.25/working day; commonly after trauma [29%] and abdominal surgery [19%]). During the implementation period of the model of care, fewer preventable respiratory ICU readmissions were reported (n = 1/20) than in the historical cohort (n = 6/19: Fisher's exact test, p < 0.05). Likelihood of respiratory ICU readmission, compared to all-cause readmissions, was not affected (intervention: 31%, historical control: 41%; odds ratio: 0.63 [95% confidence interval: 0.29 to 1.4]). Postimplementation surveys and focus groups revealed clinicians highly valued the support and perceived a positive impact on patient care. ConclusionsCritical care outreach–style physiotherapy services can be successfully implemented and are positively perceived by clinicians, but any effect on ICU readmissions is unclear.

A Readmission Risk Prediction Model for Elderly Patients with Coronary Heart Disease

Objective: To analyze the independent risk factors and establish a risk prediction model by investigating the readmission of elderly patients with coronary heart disease (CHD) within 1 year after discharge. Methods: A total of 480 CHD patients, who were hospitalized in the Affiliated Hospital of Hebei University from October 2019 to December 2020, were included in this study. A general data scale, mental health status scale, the Clinical Frailty Scale, Pittsburgh Sleep Quality Index, as well as the Family Adaptability and Cohesion Evaluation Scale were used to collect data. According to the number of readmissions due to CHD within 1 year after discharge, the patients were divided into two groups: the readmission group (n = 212) and the no readmission group (n = 268). General data, laboratory examination indicators, frailty, mental health status, sleep status, as well as family intimacy and adaptability were compared between the two groups. Logistic regression was used to analyze the independent risk factors for the readmission of these patients, and R software was used to construct a line diagram model for predicting readmission of elderly patients with CHD. Results: Five factors including body mass index (OR = 1.045), low density lipoprotein (OR = 1.123), frailty (OR = 1.946), mental health (OR = 1.099), as well as family intimacy and adaptability (OR = 0.928) were included to construct the risk prediction model for the readmission of elderly patients with CHD within 1 year after discharge. The ROC curve showed that the area under the curve for predicting readmission of elderly patients with CHD was 0.816; Hosmer-Lemeshow goodness of fit test showed X2 = 1.456 and P = 0.989; the maximum Youden index corresponding to the predicted value of risk was 0.526. The results showed that the model could accurately predict the risk of readmission in elderly patients with CHD within 1 year after discharge. Conclusion: This study constructed a line diagram model based on five independent risk factors of the readmission of elderly patients with CHD: body mass index, low density lipoprotein, frailty, mental health status, as well as family intimacy and adaptability. This model has good discrimination, accuracy, and predictive efficiency, providing reference for the early prevention and intervention of readmission in elderly patients with CHD recurrence.

Medication-Related Readmissions: Documentation of the Medication Involved and Communication in the Care Continuum.

Background: Of all readmissions, 21% are medication-related readmissions (MRRs). However, it is unknown whether MRRs are recognized at the time of readmission and are communicated in the care continuum. Objectives: To identify the prevalence of MRRs that contain a documentation on the medication involved (and therefore are regarded as recognized), and the proportion of communicated MRRs. Setting: The study was performed in a teaching hospital. Methods: In a previous study, a multidisciplinary team of physicians and pharmacists assessed the medication-relatedness, the medication involved and preventability of unplanned readmissions from seven departments. In the current cross-sectional study, two pharmacy team members evaluated the patient records independently. An MRR was regarded as recognized when the medication involved was documented in patient records. An MRR was regarded as communicated to the patient and/or the next healthcare provider when the medication involved or a description was mentioned in discharge letters or discharge prescriptions. The relationship between documented MRRs and whether the MRR was preventable as well as the relationship between (un)documented MRRs and the length of stay (LOS) were assessed. Descriptive data analysis was used. Results: Of 181 included MRRs, 72 (40%) were deemed preventable by the multidisciplinary team. For 159 of 181 MRRs (88%), a documentation on the medication involved was present. Of 159 documented MRRs, 93 (58%) were communicated to patients and/or caregivers, 137 (86%) to the general practitioner, and 4 (3%) to the community pharmacy. The medication involved was documented less often for potentially preventable MRRs than for non-preventable MRRs (78 vs. 95%; p = 0.002). The LOS was longer for MRRs where the medication involved was undocumented (median 8 vs. 5 days; p = 0.062). Conclusion: The results of this study imply that MRRs are not always recognized, which could impact patients’ well-being. In this study an increased LOS was observed with unrecognized MRRs. Communication of MRRs to the patients and/or the next healthcare providers should be improved.

Potentially preventable hospital readmissions after patients\u2019 first stroke in Taiwan

Readmission is an important indicator of the quality of care. The purpose of this study was to explore the probabilities and predictors of 30-day and 1-year potentially preventable hospital readmission (PPR) after a patient’s first stroke. We used claims data from the National Health Insurance (NHI) from 2010 to 2018. Multinomial logistic regression was used to assess the predictors of 30-day and 1-year PPR. A total of 41,921 discharged stroke patients was identified. We found that hospital readmission rates were 15.48% within 30-days and 47.25% within 1-year. The PPR and non-PPR were 9.84% (4123) and 5.65% (2367) within 30-days, and 30.65% (12,849) and 16.60% (6959) within 1-year, respectively. The factors of older patients, type of stroke, shorter length of stay, higher Charlson Comorbidity Index (CCI), higher stroke severity index (SSI), regional hospital, public and private hospital, and hospital in the lower urbanized area were associated significantly with the 30-day PPR. In addition, the factors of male, hospitalization year, and monthly income were associated significantly with 1-year PPR. The ORs of long-term PPR showed a decreasing trend since implementing the national health insurance post-acute care (PAC) program in 2014 and a dramatic drop in 2018 after the government expanded the long-term care plan-LTC 2.0 in 2017. The results showed that better discharge planning, implementing post-acute care programs and long-term care plan-LTC 2.0 may benefit the care of stroke patients and help reduce long-term readmission in Taiwan.

Disease Severity and Risk Factors of 30-Day Hospital Readmission in Pediatric Hospitalizations for Pneumonia.

Pneumonia is the leading cause of hospitalization in pediatric patients. Disease severity greatly influences pneumonia progression and adverse health outcomes such as hospital readmission. Hospital readmissions have become a measure of healthcare quality to reduce excess expenditures. The aim of this study was to examine 30-day all-cause readmission rates and evaluate the association between pneumonia severity and readmission among pediatric pneumonia hospitalizations. Using 2018 Nationwide Readmissions Database (NRD), we conducted a cross-sectional study of pediatric hospitalizations for pneumonia. Pneumonia severity was defined by the presence of respiratory failure, sepsis, mechanical ventilation, dependence on long-term supplemental oxygen, and/or respiratory intubation. Outcomes of interest were 30-day all-cause readmission, length of stay, and cost. The rate of 30-day readmission for the total sample was 5.9%, 4.7% for non-severe pneumonia, and 8.7% for severe pneumonia (p < 0.01). Among those who were readmitted, hospitalizations for severe pneumonia had a longer length of stay (6.5 vs. 5.4 days, p < 0.01) and higher daily cost (USD 3246 vs. USD 2679, p < 0.01) than admissions for non-severe pneumonia. Factors associated with 30-day readmission were pneumonia severity, immunosuppressive conditions, length of stay, and hospital case volume. To reduce potentially preventable readmissions, clinical interventions to improve the disease course and hospital system interventions are necessary.

Locally weighted factorization machine with fuzzy partition for elderly readmission prediction

The mitigation of preventable readmissions is the key to enhance the quality and efficiency of healthcare services in Hong Kong’s aging society. A general predictor like factorization machine (FM) can efficiently capture non-linear interactions among patient characteristics for readmission prediction. However, FM cannot formulate local patient heterogeneity that commonly exists due to different demographics and hospitalization characteristics. This study proposes a locally weighted factorization machine (WFM) by developing a locally weighting scheme that assigns differentiated weights for training instances in accordance with their local similarities with high-readmission-risk ones. Io account for global heterogeneity among patient groups, we further extend WFM and propose a fuzzy partition enhanced WFM model (i.e., WFMFP), which (I) splits the dataset into multiple training subsets with fuzzy partition approach, (II) fits the WFM model on the basis of each training subset, and (III) combines the sub-prediction WFM models by using Takagi–Sugeno–Kang fuzzy weighting mechanism. We collected a territory-wide cohort with electronic health records in Hong Kong during 2008 to 2017. We demonstrated that the proposed WFMFP model outperforms several baselines, including standard FM, XGBoost, Lightgbm, Catboost, Gradient boosting machine, random forests, SVMs with different kernels, and multilayer perceptron. Comparative analysis results demonstrate the effectiveness of applying the locally weighting notion into FM to improve readmission prediction for clinical resource management.

Abstract 34: A Stroke Transition Of Care Intervention With Stroke Nurse Navigator And Early Stroke Clinic Follow-up Reduces Readmissions For Stroke At 12 Months

Introduction: Stroke is a leading cause of disability in the United States, and one in four occur in people who have already had a stroke. Preventable hospital readmissions contribute to the high medical costs of stroke. Transition of care programs have been successful in reducing hospital readmissions in other diseases, but the data on such programs for stroke is mixed. A transition of care program was implemented at a large urban stroke center, utilizing interventions shown to be effective in the literature, with the goal of reducing recurrent strokes and hospital readmissions. Methods: The transition of care program consisted of: two Stroke Nurse Navigators, personalized stroke education in the hospital, two-day phone call reinforcing education and reviewing medications, early follow-up within 7-10 business days with a Stroke Neurologist, and further education on personalized risk factors in the clinic. Baseline data from the year prior to intervention, and each quarter of the three-year project period were obtained on the following measures: Rate of recurrent stroke admissions within one year, all-cause readmission within one year, all-cause readmission within 30 days, patient scheduled for initial follow-up within 7-10 days, compliance with follow up in the stroke clinic, and percent of patients receiving two-day post discharge phone call. Discharge data were reviewed on 949 patients in 2016 (year 0) and on 2,328 patients in the three-year project period (starting in July 2017). Results: The rate of readmission for stroke was 8.5%, 9.0%, 6.6%, and 4.2% for year 0, 1, 2, and 3, respectively. This represents a reduction of 50% from the year prior to the intervention to year 3 of the grant. All-cause readmission remained stable, at 38.9%, 42.6%, 36.6%, and 37.4% for year 0, 1, 2, and 3 respectively. An improvement was seen in process measures: patients scheduled for early follow up in the stroke clinic, adherence to follow-up, and two-day post-discharge phone calls. Conclusions: In conclusion, the transition of care intervention led to a reduction from baseline in readmissions for stroke within one year, but did not impact all cause readmission at one year or 30 days. This is a meaningful outcome for those who have suffered strokes. This program can serve as a model.

Causes and timing of 30-day rehospitalization from skilled nursing facilities after a hospital admission for pneumonia or sepsis.

BackgroundPneumonia and sepsis are among the most common causes of hospitalization in the United States and often result in discharges to a skilled nursing facility (SNF) for rehabilitation. We described the timing and most common causes of 30-day unplanned hospital readmission following an index hospitalization for pneumonia or sepsis.Methods and findingsThis national retrospective cohort study included adults ≥65 years who were hospitalized for pneumonia or sepsis and were discharged to a SNF between July 1, 2012 and July 4, 2015. We quantified the ten most common 30-day unplanned readmission diagnoses and estimated the daily risk of first unplanned rehospitalization for four causes of readmission (circulatory, infectious, respiratory, and genitourinary). The index hospitalization was pneumonia for 92,153 SNF stays and sepsis for 452,254 SNF stays. Of these SNF stays, 20.9% and 25.9%, respectively, resulted in a 30-day unplanned readmission. Overall, septicemia was the single most common readmission diagnosis for residents with an index hospitalization for pneumonia (16.7% of 30-day readmissions) and sepsis (22.4% of 30-day readmissions). The mean time to unplanned readmission was approximately 14 days overall. Respiratory causes displayed the highest daily risk of rehospitalization following index hospitalizations for pneumonia, while circulatory and infectious causes had the highest daily risk of rehospitalization following index hospitalizations for sepsis. The day of highest risk for readmission occurred within two weeks of the index hospitalization discharge, but the readmission risk persisted across the 30-day follow-up.ConclusionAmong older adults discharged to SNFs following a hospitalization for pneumonia or sepsis, hospital readmissions for infectious, circulatory, respiratory, and genitourinary causes occurred frequently throughout the 30-day post-discharge period. Our data suggests further study is needed, perhaps on the value of closer monitoring in SNFs post-hospital discharge and improved communication between hospitals and SNFs, to reduce the risk of potentially preventable hospital readmissions.

The Severity of Postoperative Pancreatic Fistula Predicts 30-Day Unplanned Hospital Visit and Readmission after Pancreaticoduodenectomy: A Single-Center Retrospective Cohort Study.

Background: Unplanned hospital visits (UHV) and readmissions after pancreaticoduodenectomy (PD) impact patients’ postoperative recovery and are associated with increased financial burden and morbidity. The aim of this study is to identify predictive factors related to these events and target the potentially preventable UHV and readmissions. Methods: We enrolled 518 patients in this study. Characteristics were compared between patients with or without UHV and readmissions. Results: The unplanned visit and readmission rate was 23.4% and 15.8%, respectively. Postoperative pancreatic fistula (POPF) grade B or C, the presence of postoperative biliary drainage, and reoperation were found to be predictive factors for UHV, whereas POPF grade B or C and the presence of postoperative biliary drainage were independently associated with hospital readmission. The most common reason for readmission was an infection, followed by failure to thrive. The overall mortality rate in the readmission group was 4.9%. Conclusions: UHV and readmissions remain common among patients undergoing PD. Patients with grade B or C POPF assessed during index hospitalization harbor an approximately two-fold increased risk of subsequent unplanned visits or readmissions compared to those with no POPF or biochemical leak. Proper preventive strategies should be adopted for high-risk patients in this population to maintain the continuum of healthcare and improve quality.

COPD Readmissions and Hospital Primary Care Physicians

The Centers for Medicare &amp; Medicaid Services (CMS) collects data on hospital 30-day Chronic Obstructive Pulmonary Disease (COPD) readmission rates to reduce preventable readmissions and prevent wasteful use of Medicare dollars. Hospitals have begun exploring different strategies to reduce their COPD-related 30-day readmissions. One key strategy has been the use of primary care providers (PCPs). This study examined the association between the percentage of PCPs at the hospital and Medicare COPD 30-day readmissions from 2014 to 2019. Results demonstrate a slight positive association between PCP percentage and COPD 30-day readmission. Further, hospitals in rural areas and those in less competitive environments are also associated with increased COPD readmission rates; yet, hospitals that are part of a system, provide medical education, or are larger, tend to have lower readmission rates.

Reducing Hospital Readmissions of Older Adults Pursuing Postacute Care at Skilled Nursing Facilities: A Scoping Review.

Unplanned hospital readmissions can profoundly affect older adults' quality of life and the financial status of skilled nursing facilities (SNFs). Although many clinical practices focus on reforming these issues, occupational therapy's involvement remains unclear. To explore clinical practices aimed at reducing hospital readmissions of older adults pursuing postacute care (PAC) at SNFs and describe how they align with occupational therapy's scope of practice. We searched CINAHL, Scopus, PubMed, and OTseeker for articles published from January 2011 to February 2020. Study Selection and Data Collection: We conducted a scoping review of peer-reviewed articles with functional outcomes of clinical practices reducing unplanned hospital readmissions of patients older than age 65 yr pursuing PAC services in SNFs. Trained reviewers completed the title and abstract screens, full-text reviews, and data extraction. Thirteen articles were included and focused on five areas: risk and medical disease management and follow-up, hospital-to-SNF transition, enhanced communication and care, function, and nutrition. Early coordination of care and early identification of patients' needs and risk of readmission were common features. All clinical practices aligned with occupational therapy domains and processes, but only 1 study specified occupational therapy as part of the research team. Comprehensive, multipronged clinical practices encompassing care coordination and early identification and management of acute conditions are critical in reducing preventable readmissions among older adults pursuing PAC services in SNFs. Further research is needed to support occupational therapy's value in preventing hospital readmissions of older adults in this setting. What This Article Adds: This scoping review maps the presence of occupational therapy's domains and processes in the clinical practices that reduce hospital readmissions of older adults pursuing PAC services in SNFs. Findings provide occupational therapy practitioners with opportunities to assume roles beyond direct patient care, research, advocate, and publish more, thereby increasing their presence and adding value to occupational therapy interventions that reduce hospital readmissions.

Occupational Therapy and the IMPACT Act: Part 1. A Systematic Review of Evidence for Fall Prevention and Reduction, Community Discharge and Reintegration, and Readmission Prevention Interventions.

Interventions that prevent falls, facilitate discharge after hospitalization, and reduce hospital readmissions assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing costs. In this systematic review, we address three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: prevention and reduction of falls, facilitation of community discharge and reintegration, and prevention of hospital readmission. We conducted a search of the literature published between 2009 and 2019. Study Selection and Data Collection: We developed operational definitions to help us identify articles that answered the search question for each outcome area. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We found 53 articles that address the three outcome areas. Regarding the prevention and reduction of falls, low strength of evidence is available for interventions focusing on a single fall risk and for customized interventions addressing multiple risks. Moderate strength of evidence supports structured community fall risk prevention interventions. Low strength of evidence was found for community discharge and reintegration interventions that include physical activity and educational programming. Low to moderate strength of evidence was found for readmission prevention interventions for patients with four types of condition. Conclusion and Relevance: Several intervention themes in the three outcome areas of interest are supported by few studies or by studies with a moderate risk of bias. Additional research is needed that supports the value of occupational therapy interventions in these outcome areas. What This Article Adds: Our study provides important insights into the state of the evidence related to occupational therapy interventions to address three outcome areas of the IMPACT Act.

Occupational Therapy and the IMPACT Act: Part 1. A Systematic Review of Evidence for Fall Prevention and Reduction, Community Discharge and Reintegration, and Readmission Prevention Interventions.

Interventions that prevent falls, facilitate discharge after hospitalization, and reduce hospital readmissions assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing costs. In this systematic review, we address three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: prevention and reduction of falls, facilitation of community discharge and reintegration, and prevention of hospital readmission. We conducted a search of the literature published between 2009 and 2019. Study Selection and Data Collection: We developed operational definitions to help us identify articles that answered the search question for each outcome area. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We found 53 articles that address the three outcome areas. Regarding the prevention and reduction of falls, low strength of evidence is available for interventions focusing on a single fall risk and for customized interventions addressing multiple risks. Moderate strength of evidence supports structured community fall risk prevention interventions. Low strength of evidence was found for community discharge and reintegration interventions that include physical activity and educational programming. Low to moderate strength of evidence was found for readmission prevention interventions for patients with four types of condition. Conclusion and Relevance: Several intervention themes in the three outcome areas of interest are supported by few studies or by studies with a moderate risk of bias. Additional research is needed that supports the value of occupational therapy interventions in these outcome areas. What This Article Adds: Our study provides important insights into the state of the evidence related to occupational therapy interventions to address three outcome areas of the IMPACT Act.