Rapid Readmissions Research Articles

Increasing person-centeredness in psychosis inpatient care: care consumption before and after a person-centered care intervention

Background Patients with psychotic disorders often need hospitalization with long stays. Person-centered care (PCC) has been shown to improve care quality and decrease the length of hospital stay in non-psychiatric settings. We carried out an educational intervention for inpatient staff, aiming to increase person-centeredness at a major Swedish psychosis clinic. The aim of this study was to test if the intervention could be associated with decreased length of hospital stay (LoS), involuntary stay (LoIS), and reduction in rapid readmissions. Methods Data from the clinic’s administrative registry were compared for patients with a discharge diagnosis within the schizophrenia-spectrum treated during the one-year periods before and after the PCC intervention. Results Contrary to our hypotheses, a quantile regression estimated longer LoS post-intervention, median difference 10.4 d (CI 4.73–16.10). Neither age, sex nor diagnostic category were associated with LoS. Of all inpatient days, ∼80% were involuntary. While LoIS was numerically longer post-intervention, the difference did not reach significance in the final regression model (median difference 7.95 d, CI −1.40 to 17.31). Proportions with readmission within 2 weeks of discharge did not differ (7.7% vs 5.2%, n.s.). Conclusions Increased length of inpatient care was observed after the PCPC intervention. This could reflect an increased focus on the unmet needs of persons with serious psychotic conditions, but it needs to be explored in future research using a more rigorous study design. Trial registration This study is part of a larger evaluation of Person-Centered Psychosis Care (PCPC), registered during data collection (after the study start, before analysis) at clinicaltrials.gov, identifier NCT03182283.

Phase III, two arm, multi-centre, open label, parallel-group randomised designed clinical investigation of the use of a personalised early warning decision support system to predict and prevent acute exacerbations of chronic obstructive pulmonary disease: ‘Predict & Prevent AECOPD’ – study protocol

IntroductionWith 65 million cases globally, chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death and imposes a heavy burden on patients’ lives and healthcare resources worldwide. Around...

Rapid (7-Day) Readmissions to an Inpatient Medical Service at a Tertiary, Academic Medical Center

Background: Rapid readmissions, occurring within 7 days of hospital discharge, are associated with significant morbidity and mortality. Objectives: Identify causes of rapid readmissions with a focus on clinical judgement errors and improve discharge practices. Methods: Records of 371 patients discharged from an inpatient medical service and readmitted within 7 days were reviewed. Causes for readmission were identified and classified into 10 categories, including diagnostic and/or therapeutic error leading to readmission. Results: Fifty percent of rapid readmissions were related to severity of underlying disease/failure to respond to treatment. Adherence challenges, patients with known high hospital utilization, and substance use disorder/uncontrolled psychiatric conditions accounted for 32.4% of 7-day readmissions. Readmissions related to clinical judgement accounted for 24 (6.5%) of the total readmissions. Clinical judgement errors were comprised of 6 diagnostic and 18 therapeutic errors, involving infections, diabetic medications and anticoagulation agents. Conclusions: Most rapid readmissions are related to the severity of the condition during the index hospitalization. Clinical judgement errors are a rare cause for rapid readmission and involve certain high-risk medications and symptoms which require a high degree of awareness from the discharging provider.

Higher admission and rapid readmission rates among medically hospitalized youth with anorexia nervosa/atypical anorexia nervosa during COVID-19

The COVID-19 pandemic has had sweeping and deleterious effects on the well-being of individuals worldwide. Eating disorders (EDs) are no exception, with incidence and prevalence of EDs rising since COVID-19 onset. The current study examined inpatient census and readmission rates among youth (aged 8–18) hospitalized for medical complications of anorexia nervosa (AN) or atypical anorexia nervosa (AAN) throughout distinct periods of the COVID-19 pandemic, including pre-COVID-19 (n = 136), COVID-19 lockdown (n = 3), and post COVID-19 lockdown (n = 24). Data from the COVID-19 lockdown period was excluded from analyses due to low sample size. Youth hospitalized during post COVID-19 lockdown were over 8-times more likely to be readmitted within 30-days of discharge compared to patients hospitalized before the pandemic (p = .002). Further, the inpatient census of youth with AN/AAN was significantly higher during post COVID-19 lockdown compared to pre-COVID-19 (p = .04). One-third of patients hospitalized since the pandemic identified COVID-19 consequences as a primary correlate of their ED. Our findings, although not causal, suggest an association between COVID-19 and AN/AAN development and exacerbation in youth, thus prompting more medical admissions and rapid readmissions among this demographic. This study has important implications for understanding how AN/AAN onset and exacerbation in youth has been affected by the COVID-19 pandemic and can inform new efforts to support individuals navigating treatment during a global crisis.

Quantifying Psychopathology in Rapid Readmissions

Psychiatric readmissions contribute to a significant cost and healthcare burden to physicians, hospitals, and the healthcare system as an entity. Furthermore, as part of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) began to reduce financial coverage to hospitals with overwhelming rehospitalization rates. The purpose of this study was to do a systematic analysis on inpatient psychiatric readmission data and identify co-morbidities and risk factors that lead to high readmission rates. The data collection includes 163 patients with a total of 348 readmissions over the span of 90 days at one inner-city hospital in the Chicagoland area. Study findings suggest that higher rates of readmission are linked to cocaine abuse in both male and female populations. Diagnosis of bipolar in females and schizoaffective disorder in male populations were the among the highest for readmission. Key social factors such as homelessness and low socioeconomic status were identified to contribute to a large proportion of psychiatric readmission burden. However, an overwhelming amount of information was missing due to unobtained labs and lack of current patient social history. By using this data as well as data from electronic medical records (EMRs) to further investigate and identify other features of at-risk patients, hospitals can potentially address these markers to lower readmission rates. Ultimately, a higher understanding of the patients' needs can be understood and can help develop standardized plans of care for prevalent psychiatric illnesses in these populations.

Unplanned medicines and their link to mental health ward readmissions

Readmission following discharge is relatively common in mental health services​[1]​. In 2016, Donisi et al. reported that the overall 30-day unplanned readmission rate was 13 per 100 discharged patients for schizophrenia and 11 per 100 discharged patients for bipolar disorder​[1]​. Unplanned hospital readmission figures are frequently used within healthcare as an indicator of quality, with rapid readmissions — […]

Variation in length of stay after minimally invasive lung resection: a reflection of perioperative care routines?

Good perioperative care is aimed at rapid recovery, without complications or readmissions. Length of stay (LOS) is influenced not only by perioperative care routines but also by patient factors, tumour factors, treatment characteristics and complications. The present study examines variation in LOS between hospitals after minimally invasive lung resections for both complicated and uncomplicated patients to assess whether LOS is a hospital characteristic influenced by local perioperative routines or other factors. Dutch Lung Cancer Audit (surgery) data were used. Median LOS was calculated on hospital level, stratified by the severity of complications. Lowest quartile (short) LOS per hospital, corrected for case-mix factors by multivariable logistic regression, was presented in funnel plots. We correlated short LOS in complicated versus uncomplicated patients to assess whether short LOS clustered in the same hospitals regardless of complications. Data from 6055 patients in 42 hospitals were included. Median LOS in uncomplicated patients varied from 3 to 8 days between hospitals and increased most markedly for patients with major complications. Considerable between-hospital variation persisted after case-mix correction, but more in uncomplicated than complicated patients. Short LOS in uncomplicated and complicated patients were significantly correlated (r = 0.53, P < 0.001). LOS after minimally invasive anatomical lung resections varied between hospitals particularly in uncomplicated patients. The significant correlation between short LOS in uncomplicated and complicated patients suggests that LOS is a hospital characteristic potentially influenced by local processes. Standardizing and optimizing perioperative care could help limit practice variation with improved LOS and complication rates.

Predictors of 30-day Postdischarge Readmission to a Multistate National Sample of State Psychiatric Hospitals.

ABSTRACTBackground:Early discharge from psychiatric inpatient care may pose challenges for the patient's recovery and may incite a rapid return to the hospital. This study identified demographic, clinical, and the continuing of care characteristics associated with rapid readmission into a sample of psychiatric inpatient hospitals.Methods:Cross-sectional analysis of 60,254 discharges from state psychiatric hospitals. Logistic regression explored the relationship between predictors of rapid readmission.Results:Eight percent of discharges were readmitted to the same hospital within 30 days after discharge. Factors significantly related with rapid readmission included white (odds ratio, 1.23; 95% confidence interval, 1.13–1.34), non-Hispanic (1.48, 1.26–1.73), not married (1.53, 1.32–1.76), voluntarily admitted (1.18, 1.05–1.33), with length of stay (LOS) ≤ 7 days (3.52, 3.04–4.08), or LOS 8–31 days (3.20, 2.79–3.66), or LOS 32–92 days (1.91, 1.65–2.22), with a schizophrenia or other psychotic disorders (1.69, 1.46–1.96) or personality disorder (1.76, 1.50–2.06), referred to a setting different from the outpatient (1.27, 1.16–1.40), or with a living arrangement different from private residence (1.54, 1.40–1.68).Conclusions:Disparities in rapid readmission rates exist among state psychiatric hospitals. A national overview of the individuals with mental illness at risk of being prematurely discharged may suggests insights into quality initiatives aimed at reducing rapid readmissions into psychiatric inpatient care.

The ethics of caring for hospital-dependent patients

BackgroundHospital-dependent patients are individuals who are repeatedly readmitted to the hospital because their acute medical needs cannot be met elsewhere. Unlike the chronically critically ill, these patients do not have a continuous need for life-sustaining equipment and can experience periods of relative stability where they have a good quality of life. However, some end up spending months or even years in the hospital receiving resource-intensive care because they are unable to be safely discharged, despite an initial optimistic prognosis. It is hard to reliably identify these patients on admission and more research is needed to better understand the unique medical needs of this population. But the inability to safely discharge these patients to their home or to a skilled nursing facility without rapid readmissions also creates ethical implications for the physicians who care for them. The aim of this paper is to clarify some of the ethical considerations involved in caring for hospital-dependent patients.Main bodyAmong physicians, the care of hospital-dependent patients is likely to disproportionately affect hospitalists and intensivists, whose care is often evaluated in terms of reducing patient length of stay and readmissions. Because hospital-dependent patients’ medical needs thwart the traditional goal of safe discharge, both clinical ethics and physicians’ professional obligations are implicated by their care. The inability to reliably identify these patients early can complicate discussions about treatment goals and informed consent. Similarly, the tremendous dedication of limited resources to these patients without safe discharge back to the community may raise concerns about the just allocation of healthcare resources.ConclusionOur current acute care hospitals are not designed to provide long-term care for hospital-dependent patients. Unfortunately, safe discharge options remain elusive for these patients. Further research and support of this population is needed to more reliably identify hospital-dependent patients on admission, better inform the discussions of short- and long-term treatment goals, and more wisely allocate resources both within our acute care hospitals and larger healthcare system.

Challenge accepted: Confronting readmissions for our patients with cirrhosis

Challenge accepted: Confronting readmissions for our patients with cirrhosis

Reasons and Factors for Rapid Psychiatry Readmissions: an Analysis over a 36 Months Period

Introduction The patient readmission is commonly associated with the failure of the previous hospitalization/admission and is an important psychiatric and economic issue. Furthermore, it is still source of frustration to patients, their families and the teams treating them. Methods The authors propose a retrospective study investigating all the readmissions within 28 days of the last discharge in the general adult psychiatry ward of a portuguese hospital (Aveiro Hospital) from 2011 to 2013 in order to characterize the reasons and factors (social, demographic and clinical) involved. Results Over the total 1994 discharges, 88 were readmited, yielding a readmission rate of 4.4%. The main diagnose was Schizophrenia, schizotypal and delusional disorders, according to icd 10, and the main reasons for readmission were suicide and psychosis. Most previous hospitalizations have lasted less than the average length of stay during the considered period of time. Conclusions Evaluating the characteristics of readmissions promotes a better understanding of the whole process in order to devise a strategy for prevention and improvement of mental health services.

EHR in Emergency Rooms: Exploring the Effect of Key Information Components on Main Complaints

This study characterizes the information components associated with improved medical decision-making in the emergency room (ER). We looked at doctors' decisions to use or not to use information available to them on an electronic health record (EHR) and a Health Information Exchange (HIE) network, and tested for associations between their decision and parameters related to healthcare outcomes and processes. Using information components from the EHR and HIE was significantly related to improved quality of healthcare processes. Specifically, it was associated with both a reduction in potentially avoidable admissions as well as a reduction in rapid readmissions. Overall, the three information components; namely, previous encounters, imaging, and lab results emerged as having the strongest relationship with physicians' decisions to admit or discharge. Certain information components, however, presented an association between the diagnosis and the admission decisions (blood pressure was the most strongly associated parameter in cases of chest pain complaints and a previous surgical record for abdominal pain). These findings show that the ability to access patients' medical history and their long term health conditions (via the EHR), including information about medications, diagnoses, recent procedures and laboratory tests is critical to forming an appropriate plan of care and eventually making more accurate admission decisions.

Evaluation of a Discharge Medication Service on an Acute Psychiatric Unit

BackgroundNonadherence with medication is a major factor that influences acute psychiatric hospital readmission. Pharmacists can positively influence rapid psychiatric readmission due to nonadherence by counseling patients and providing filled prescriptions on discharge.ObjectiveThis study is a retrospective evaluation of a pharmacist-driven discharge medication service for hospitalized psychiatric patients. Measured outcomes include a comparison of rapid readmissions pre and post implementation. Rapid readmissions between the concurrent study group and excluded group were also compared.MethodsFrom October 2010 to November 2011, home-destined subjects being discharged from the hospital's behavioral health unit were provided filled psychiatric prescriptions for self-administration upon discharge, coupled with medication counseling. A series of statistical comparisons were made between the 2 prior years' overall rapid readmissions. This was subsequently compared with the overall rapid readmission rate during the study year. The study group's rapid readmissions were then compared to the overall rapid readmission rate of the study year as well as to the concurrent excluded group.ResultsThirty-day hospital readmissions were found to be significantly decreased in studied subjects compared to total rapid readmissions during the previous year ( P = .004) and to the excluded group ( P = .020).ConclusionImmediate availability of prescriptions upon discharge, coupled with development of therapeutic alliances with patients, removes some of the barriers to patient medication adherence in the discharged, acute psychiatric patient. The program provided positive outcomes with regard to decreased frequent, rapid readmission to the acute care psychiatric unit due to medication nonadherence.

Stronger instruments via integer programming in an observational study of late preterm birth outcomes

In an optimal nonbipartite match, a single population is divided into matched pairs to minimize a total distance within matched pairs. Nonbipartite matching has been used to strengthen instrumental variables in observational studies of treatment effects, essentially by forming pairs that are similar in terms of covariates but very different in the strength of encouragement to accept the treatment. Optimal nonbipartite matching is typically done using network optimization techniques that can be quick, running in polynomial time, but these techniques limit the tools available for matching. Instead, we use integer programming techniques, thereby obtaining a wealth of new tools not previously available for nonbipartite matching, including fine and near-fine balance for several nominal variables, forced near balance on means and optimal subsetting. We illustrate the methods in our on-going study of outcomes of late-preterm births in California, that is, births of 34 to 36 weeks of gestation. Would lengthening the time in the hospital for such births reduce the frequency of rapid readmissions? A straightforward comparison of babies who stay for a shorter or longer time would be severely biased, because the principal reason for a long stay is some serious health problem. We need an instrument, something inconsequential and haphazard that encourages a shorter or a longer stay in the hospital. It turns out that babies born at certain times of day tend to stay overnight once with a shorter length of stay, whereas babies born at other times of day tend to stay overnight twice with a longer length of stay, and there is nothing particularly special about a baby who is born at 11:00 pm.

Transitional Care for Older Adults: The Need for New Approaches to Support Family Caregivers

The importance of high quality transitional care in improving the outcomes of patients and families has gained increased attention. Transitional care is defined as actions designed to ensure coordination and continuity of care between levels of health care and across care settings. It is well known that when patients move between care settings untoward events often occur. For example, poor transitions in care can result in low patient satisfaction, serious medication errors, and increased use of emergency room services and unnecessary ambulatory care visits. In addition, lack of quality transitional care can result in high rates of rapid hospital readmissions -- the majority of which are potentially preventable. Older adults are particularly vulnerable to breakdown in continuity and coordination of care between settings, because they have multiple chronic diseases and complicated therapies.

Reasons for rapid readmission to general adult psychiatry wards

AbstractRapid readmission to psychiatry wards (the ‘revolving doors’ scenario) is a common source of frustration to both patients and the teams treating them. However, the reasons behind these rapid readmissions have not been closely studied previously.Here, the authors describe their retrospective study investigating the reasons behind the readmissions that had taken place in the general adult psychiatry wards of a Scottishhospital within 30 days of the last discharge. Copyright © 2008 Wiley Interface Ltd

A 10-year follow-up study of an adolescent psychiatric clientele and early predictors of readmission

Over a period of 20 years (from 1968 to 1988) all inpatients (n = 839) who were admitted for the first time to the adolescent psychiatric unit in Copenhagen were registered, and 40 social and psychiatric variables were recorded, to investigate early predictors of later readmission. Overall, 44.8% of the patients were readmitted within a certain observation period (range, 1.5-21.5 years). Among a subsample of 488 patients (58%) who could be followed up for more than l0 years after their first admission 26% became heavy users of psychiatric services, defined as long-term inpatients or revolving-door patients. Severe early diagnoses (schizophrenia and affective psychoses) were strongly associated with rapid relapses and frequent readmissions. A statistical estimate of the risk of later heavy use based on 12 independent variables is presented.

The Relationship Between Length of Hospital Stay and Rapid-Readmission Rates

The average length of stay for patients on the psychiatric service of a large VA hospital in California was nine days in mid-1977. Such brief hospitalizations often led to insufficient discharge planning and rapid readmissions, within one month of discharge. VA policy changed in July 1977, and longer lengths of hospital stay were initiated. The experiences with brief and longer-term hospitalization enabled the authors to study the rapid-readmission rates for each length of stay. Their data showed that an increase in length of stay from nine to 26 days was associated with a 55 per cent reduction in the rate of rapid readmission. They admit that it is too early to conclude that the longer patient stay was responsible for the decrease, and feel that additional longitudinal study is necessary.

The characteristics of psychiatric patients readmitted within a month of discharge.

From the Camberwell Register it was found that 9-14% of all admissions in the years 1965-70 were readmissions within a month of discharge. The characteristics of these patients were compared with the total population admitted. No particular diagnostic category was associated with rapid readmissions but the rapidly readmitted group contained a high proportion of young patients and divorced or separated patients. The case notes of rapidly readmitted patients were examined and compared with the case notes of a control group. The circumstance which predisposed patients to require rapid readmission was the degree of socially disruptive behaviour of the patient. Patients benefited from readmission and the reasons for this are discussed.