Emergency Readmission Rates Research Articles

Defining growth potential and barriers to same day discharge total knee arthroplasty

Outpatient arthroplasty programs are becoming well established. Adverse event rates have been demonstrated to be no worse than inpatient arthroplasty in the literature for selected patients. The purpose of this study was to determine our rate of outpatient total knee arthroplasty (TKA), examine justification for exclusions, and estimate the proportion of TKAs that can occur safely on an outpatient basis. Retrospective case series of 400 consecutive TKAs from Oct 2014 to Mar 2017. Patient demographics, allocation to outpatient surgery vs standard admission, and reason for exclusion from outpatient surgery were recorded. Ninety-day Emergency department (ED) visits, readmission rates, and length of stay (LOS) were compared between groups using independent sample t test and Chi-squared test. Outpatients were younger (p = 0.001), had lower BMI (p < 0.001), and ASA scores (p < 0.001) than inpatients. One hundred twenty-five (31%) TKAs were assigned to outpatient surgery and 123 achieved discharge on the same day. There was no difference in 90-day ED visits (p = 0.889) or readmission rates (p = 0.338) between groups. Reasons for exclusion from outpatient surgery included medical (absolute 43% and relative 31%), distance > one hour from hospital (18%), no help (7%), and other/unclear (10%). LOS was significantly longer for medical than non-medical exclusions (p < 0.001) and for the absolute compared to relative medical exclusions (p = 0.004). Outpatient TKA is safe in selected patients, and inclusion can likely be broadened by addressing modifiable exclusions and narrowing medical exclusions. We found that 55% of our TKA population could be appropriate for outpatient surgery.

Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study

BackgroundHeart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplanned hospital activity, but our understanding of what drives this is incomplete.ObjectivesTo model patient, primary care and hospital factors associated with readmission and mortality for patients with HF and COPD, to assess the statistical performance of post-discharge emergency department (ED) attendance compared with readmission metrics and to compare all the results for the two conditions.DesignObservational study.SettingEnglish NHS.ParticipantsAll patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.InterventionsNone.Main outcome measuresOne-year mortality and 30-day emergency readmission following the patient’s first unplanned admission (‘index admission’) for HF or COPD.Data sourcesPatient-level data from Hospital Episodes Statistics were combined with publicly available practice- and hospital-level data on performance, patient and staff experience and rehabilitation programme website information.ResultsOne-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were 19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factors predicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long) index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS and comorbidities also predicted readmission. Of the practice and hospital factors we considered, only more doctors per 10 beds [odds ratio (OR) 0.95 per doctor;p &lt; 0.001] was significant for both cohorts for mortality, with staff recommending to friends and family (OR 0.80 per unit increase;p &lt; 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP;p = 0.004) important for COPD. For readmission, only hospital size [OR per 100 beds = 2.16, 95% confidence interval (CI) 1.34 to 3.48 for HF, and 2.27, 95% CI 1.40 to 3.66 for COPD] and doctors per 10 beds (OR 0.98;p &lt; 0.001) were significantly associated. Some factors, such as comorbidities, varied in importance depending on the readmission diagnosis. ED visits were common after the index discharge, with 75% resulting in admission. Many predictors of admission at this visit were as for readmission minus comorbidities and plus attendance outside the day shift and numbers of admissions that hour. Hospital-level rates for ED attendance varied much more than those for readmission, but the omega statistics favoured them as a performance indicator.LimitationsData lacked direct information on disease severity and ED attendance reasons; NHS surveys were not specific to HF or COPD patients; and some data sets were aggregated.ConclusionsFollowing an index admission for HF or COPD, older age, prior missed outpatient appointments, LOS and many comorbidities predict both mortality and readmission. Of the aggregated practice and hospital information, only doctors per bed and numbers of hospital beds were strongly associated with either outcome (both negatively). The 30-day ED visits and diagnosis-specific readmission rates seem to be useful performance indicators.Future workHospital variations in ED visits could be investigated using existing data despite coding limitations. Primary care management could be explored using individual-level linked databases.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Rising Emergency Admission and Readmission Rates—a Retrospective Study of Demographic and Socio-economic Factors

Rising Emergency Admission and Readmission Rates—a Retrospective Study of Demographic and Socio-economic Factors

Abstract P-372: ESTABLISHMENT OF PAEDIATRIC INTENSIVE CARE REGISTRY IN LATVIA

Aims & Objectives: Latvia is an Eastern European country with a population of just less than 2 million. There is a single eight-bed PICU where all critically ill children are admitted. A recent retrospective audit of paediatric critical care outcomes in Latvia revealed high number of unplanned extubations and excess crude mortality. In 2017 our centre joined UK and Ireland based Paediatric Intensive Care Audit Network (PICANet) as a pilot project for paediatric critical care registry. Methods Riga Stradins University Ethics Committee approved the study. Anonymized data of all patients admitted to our unit from 1st of June to 30th of November, 2017 were prospectively entered in PICANet WEB site. Results A total of 399 PICU admissions were analyzed; 43% of admissions were elective. The median length of stay was 0.94 days (IQR: 0.79–1.94). 20% required mechanical ventilation. There were 8.65 expected deaths as calculated by Paediatric Index of Mortality 3; 7 patients (1.8%) died. Emergency readmission rate within 48 hours after PICU discharge was 0.5%. There were 2.7 unplanned extubations per 100 invasive ventilation days. On 30-day follow-up 339 patients were alive and outside hospital, 45 were inpatients, 3 had died, 2 were lost to the follow-up. Conclusions This project explored possibility of paediatric critical care audit in Latvia by joining established international network. This allowed direct comparison of outcomes between the countries. Excess mortality was not observed during this short data collection period, however high rate of unplanned extubations was revealed. Different case mix, particularly, large proportion of low intensity care, complicated the comparison.

Postdischarge Unscheduled Care Burden After Lower Limb Arthroplasty

BackgroundIn contrast to postdischarge arthroplasty readmission rates, the unscheduled reattendance burden to primary care is under-reported. Understanding reasons for reattendance would allow for implementation of strategies to reduce this burden. The present study aims to quantify the out-of-hours (OOH) general practitioner and emergency department (ED) service reattendance burden and readmission rate after primary total hip arthroplasty and total knee arthroplasty, with estimation of the associated costs. MethodsThis is a prospective consecutive cohort study. A prospective audit of all total hip arthroplasty and total knee arthroplasty patients in 2016 in a single high-volume UK arthroplasty unit was performed. Incidence and reasons for reattendance to OOH and ED service, as well as readmission rates, at both 30 and 90 days following discharge are reported. A multivariate analysis was performed to determine patient characteristics, which results in increased reattendance and readmission rates. ResultsA total of 2351 procedures resulted in 374 attendances of OOH service and 665 to ED with a total estimated cost of £190,000 within 90 days. The readmission rate was 6.8%. Risk factors for reattendance and readmission were increasing age and a prolonged length of stay. The use of a 5-day postdischarge phone call and a dedicated Arthroplasty Care Practitioner favors reduced reattendances but not the readmission rate, with the additional benefit of being cost-effective. ConclusionThe postdischarge arthroplasty reattendance burden is associated with significant costs, and strategies to reduce this should be developed. Further research is required to assess the effectiveness and cost-effectiveness of multicomponent strategies to reduce reattendance operating at scale.

Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods

Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months. We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures. The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found. Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.

Association Between Postdischarge Emergency Department Visitation and Readmission Rates.

Hospital readmission rates are publicly reported by the Centers for Medicare & Medicaid Services (CMS); however, the implications of emergency department (ED) visits following hospital discharge on readmissions are uncertain. We describe the frequency, diagnoses, and hospital-level variation in ED visitation following hospital discharge, including the relationship between risk-standardized ED visitation and readmission rates. This is a cross-sectional analysis of Medicare beneficiaries hospitalized for acute myocardial infarction (AMI), heart failure, and pneumonia between July 2011 and June 2012. We used Medicare Standard Analytic Files to identify admissions, readmissions, and ED visits consistent with CMS measures. Postdischarge ED visits were defined as treat-and-discharge ED services within 30 days of hospitalization without readmission. We utilized hierarchical generalized linear models to calculate hospital risk-standardized postdischarge ED visit rates and readmission rates. We included 157,035 patients hospitalized at 1656 hospitals for AMI, 391,209 at 3044 hospitals for heart failure, and 342,376 at 3484 hospitals for pneumonia. After hospitalization for AMI, heart failure, and pneumonia, there were 14,714 (9%), 31,621 (8%), and 26,681 (8%) ED visits, respectively. Hospital-level variation in postdischarge ED visit rates was substantial: AMI (median: 8.3%; 5th and 95th percentile: 2.8%-14.3%), heart failure (median: 7.3%; 5th and 95th percentile: 3.0%-13.3%), and pneumonia (median: 7.1%; 5th and 95th percentile: 2.4%-13.2%). There was statistically significant inverse correlation between postdischarge ED visit rates and readmission rates: AMI (-0.23), heart failure (-0.29), and pneumonia (-0.18). Following hospital discharge, ED treatand- discharge visits are half as common as readmissions for Medicare beneficiaries. There is wide hospital-level variation in postdischarge ED visitation, and hospitals with higher ED visitation rates demonstrated lower readmission rates.

National trends in emergency readmission rates: a longitudinal analysis of administrative data for England between 2006 and 2016

ObjectiveTo assess trends in 30-day emergency readmission rates across England over one decade.DesignRetrospective study design.Setting150 non-specialist hospital trusts in England.Participants23 069 134 patients above 18 years of age who were...

Emergency Room Visits and Readmissions Following Implementation of an Enhanced Recovery After Surgery (iERAS) Program

BackgroundEnhanced Recovery After Surgery (ERAS) guidelines have been widely promoted and supported largely due to several studies showing decreased post-operative complications and length of stay. The objective of this study was to review the emergency room (ER) visits and readmission rates and reasons for both in patients who were part of the Implementation of an Enhanced Recovery After Surgery (iERAS) program for colorectal surgery. MethodsAll patients having elective colorectal surgery at 15 academic hospitals were enrolled in the iERAS program. All patients were prospectively followed until 30 days post-discharge. Data were analyzed using descriptive statistics and multivariable analysis. ResultsA total of 2876 patients (48% female; mean 60 years old) were enrolled. Cancer was the most frequent indication (68.2%) for surgery. Overall, the median length of stay (LOS) was 5 days. Post-discharge, 359 (11.6%) of patients had a visit to the ER not requiring admission. The most common reasons for visiting the ER were surgical site infections (SSI) (34.5%), other wound complications (10.0%), and urinary tract infections (UTI) (8.6%). In addition, a smaller proportion of patients, 260 (8.2%) required readmission. The most common reasons for readmission were ileus and nausea/vomiting (26.1%), intra-abdominal abscess (23.9%), and SSI (11.5%). Patient and disease factors associated with ER visits, on multivariable analysis, included extremes of BMI (RR 1.02, 95%CI 1.01–1.04, p = 0.002), rectal surgery versus colon surgery (RR 1.34, 95%CI 1.14–1.58, p < 0.001), and open operative approach (RR 1.63, 95%CI 1.28–2.09, p < 0.001). Independent factors associated with hospital readmissions included rectal surgery (RR 1.89, 95%CI 1.34–2.77, p < 0.001), formation of a stoma (RR 1.34, 95%CI 1.04–1.74, p = 0.026), and reoperation during first admission (RR 4.60, 95%CI 3.50–6.05, p < 0.001). Length of stay of 5 days or less was not associated with ER visits or readmission (RR 0.99, 95%CI 0.72–1.35 and RR 0.91, 95%CI 0.71–1.18, respectively). ConclusionFollowing colorectal surgery using an ERAS pathway, shortened length of stay is not associated with an increased return to the ER or hospital readmission. The majority of return visits to the hospital are ER visits not requiring readmission and the predominant reason for return are surgical site infections and wound complications.

Improvements in Patient and Health System Outcomes Using an Integrated Oncology and Palliative Medicine Approach on a Solid Tumor Inpatient Service.

Early palliative care (PC) improves outcomes for outpatients with advanced cancer. Its effect on hospitalized patients with cancer is unknown. Herein, we report on the influence of a novel, fully integrated inpatient medical oncology and PC partnership at a tertiary medical center during its first year of implementation. We conducted a retrospective, longitudinal, pre- and postintervention cohort study at Duke University Hospital. Pre- and postintervention cohorts were defined as all patients admitted to the solid tumor inpatient service from September 1, 2009, to June 30, 2010, and September 1, 2011 to June 30, 2012, respectively. We extracted patient data, including demographics, cancer diagnosis, disease status, length of stay, intensive care unit transfer rate, discharge disposition, time to emergency department return, time to readmission, and 7- and 30-day emergency department return and readmission rates. Nursing and physician surveys assessed satisfaction. Descriptive statistics, and Kruskal-Wallis and Χ2 tests were used to describe and compare cohorts. A generalized estimating equation accounted for repeated measures. Pre- and postintervention analysis cohorts included 731 and 783 patients, respectively, representing a total of 1,514 patients and 2,353 encounters. Cohorts were similar in baseline characteristics. Statistically significant lower odds in 7-day readmission rates were observed in the postintervention cohort (adjusted odds ratio, 0.76; 95% CI, 0.58 to 1.00; P = .0482). Patients in the postintervention group had a decrease in mean length of stay (-0.30 days; 95% CI, -0.62 to 0.02); P = .0651). We observed a trend for increasing hospice referrals ( P = .0837) and a 15% decrease in intensive care unit transfers ( P = .61). Physicians and nurses universally favored the model. A fully integrated inpatient partnership between PC and medical oncology is associated with significant and clinically meaningful improvements in key health system-related outcomes and indicators of quality cancer care.

Association Between Physician Teamwork and Health System Outcomes After Coronary Artery Bypass Grafting.

Patients undergoing coronary artery bypass grafting (CABG) must often see multiple providers dispersed across many care locations. To test whether teamwork (assessed with the bipartite clustering coefficient) among these physicians is a determinant of surgical outcomes, we examined national Medicare data from patients undergoing CABG. Among Medicare beneficiaries who underwent CABG between 2008 and 2011, we mapped relationships between all physicians who treated them during their surgical episodes, including both surgeons and nonsurgeons. After aggregating across CABG episodes in a year to construct the physician social networks serving each health system, we then assessed the level of physician teamwork in these networks with the bipartite clustering coefficient. Finally, we fit a series of multivariable regression models to evaluate associations between a health system's teamwork level and its 60-day surgical outcomes. We observed substantial variation in the level of teamwork between health systems performing CABG (SD for the bipartite clustering coefficient was 0.09). Although health systems with high and low teamwork levels treated beneficiaries with comparable comorbidity scores, these health systems differed over several sociocultural and healthcare capacity factors (eg, physician staff size and surgical caseload). After controlling for these differences, health systems with higher teamwork levels had significantly lower 60-day rates of emergency department visit, readmission, and mortality. Health systems with physicians who tend to work together in tightly-knit groups during CABG episodes realize better surgical outcomes. As such, delivery system reforms focused on building teamwork may have positive effects on surgical care.

Preliminary Results of a Prospective Trial of Endovascular Aortic Aneurysm Repair as Day Surgery

Endovascular aortic aneurysm repair (EVAR) allows reduced perioperative morbidity, mortality, and length of stay while maintaining long-term results equivalent to those of open repair. Currently, most patients are admitted to the hospital after EVAR; however, there are no standard observation periods, and timing of discharge is based on clinical judgment. The aim of this study was to validate criteria for targeting patients for outpatient EVAR and to assess the safety of outpatient EVAR. We developed criteria to target patients for potential outpatient EVAR (infrarenal aneurysm, low perioperative risk, to be accompanied for first 24 hours). We then prospectively selected patients for planned outpatient EVAR and compared them with a historical control group (patients who had undergone EVAR during the previous 3 years and met outpatient criteria). We collected demographic and operative data, length of stay, complications, emergency department visits, readmissions, reinterventions, and deaths. The primary outcome was the 30-day complication rate, and this study was designed to assess noninferiority. Prospectively, we have assessed 159 patients and planned 60 (38%) for outpatient EVAR (57% of historical controls met outpatient criteria). Compared with controls, planned outpatients are younger (75 ± 1 vs 79 ± 1 years; P < .01) but have otherwise similar demographics. In planned outpatients, hospital stay is significantly shorter (0.7 ± 0.4 vs 2.8 ± 0.9 days; P < .05), and 47 (78%) were discharged the same day. The 30-day follow-up was available for 88% of both groups; there were no differences in complication (15% vs 15%), emergency department visit (21% vs 12%), readmission (4% vs 7%), reintervention (6% vs 8%), or mortality (2% vs 1%) rates. In well-selected patients, preliminary results suggest that outpatient EVAR is feasible without increasing complication rates or health care resource utilization. However, these data represent early results of an ongoing study designed to establish noninferiority of outpatient EVAR.

Implementation of a Telephone Postoperative Clinic in an Integrated Health System

Earlier work suggested that telephone follow-up could be used in lieu of in-person follow-up after surgery, saving patients time and travel and maximizing use of scarce surgeon and facility resources. We report our experience implementing and evaluating telephone postoperative follow-up within an integrated health system. We conducted a pre-post evaluation of a general surgery telephone postoperative clinic at a tertiary care Veterans Affairs facility from April 2015 to February 2016. Patients were offered a telephone postoperative visit from a surgical provider in lieu of an in-person clinic visit. Telephone clinic operating procedures were refined through iterative cycles of change using the Plan-Do-Study-Act method. The study period included 2 months pre-intervention and 9 months post-intervention. The primary end point was mean number of clinic visits per eligible patient before and after telephone clinic implementation. Secondary outcomes were rates of emergency department visits and readmissions before vs after telephone clinic implementation and complication rates in patients scheduled for telephone vs in-person postoperative care. During the study period, 200 patients underwent eligible operations, 29 pre-intervention and 171 post-intervention. In-person clinic use decreased from 0.83 visits per eligible patient pre-intervention to 0.40 after implementation of the telephone clinic (p < 0.01). There was no difference in rates of emergency department presentation or readmission in eligible patients (0.17 visits/patient pre-intervention vs 0.12 post-intervention; p= 0.36). Complication rates were comparable for eligible patients who were and were not scheduled for telephone care (6% vs 8%; p= 0.31). Telephone postoperative care can be used in select populations as a triage tool to identify patients who require in-person care and decrease overall in-person clinic use.

OC-075 Outcomes of Percutaneous Transhepatic Cholangiography for the Palliative Relief of Malignant Jaundice in England Between 2001 and 2014

Introduction Percutaneous transcutaneous cholangiography (PTC) is widely used to relieve malignant obstructive jaundice, especially when endoscopic retrograde cholangiopancreatography (ERCP) has failed. Decompression of the biliary tree in patients who are not suitable for surgical resection may improve quality of life and facilitate palliative chemotherapy. Methods Using Hospital Episode Statistics (HES), patients with cancer of the pancreas, biliary tree, gallbladder, small intestine and liver that underwent PTC were identified. Patients who underwent curative resection post PTC were excluded. Mortality, complication rates, readmissions and variation in outcomes between healthcare providers were examined. Associations between age, sex, comorbidity, cancer type and mortality were examined using multivariate regression analysis. Results Between April 2001 and March 2014, 16,363 subjects were identified (50.2% male and mean age 73). Pancreatic cancer was the most common site at 58% and 61.1% of patients had undergone a previous ERCP. In-hospital and 30 day mortality was 15.3% (CI14.8–15.9%) and 23.1% (CI 22.5–23.8%) respectively and median survival was 92 days (IQR 33–244). There was no reduction in mortality over the study period. The percentage of patients receiving chemotherapy after their PTC was 40.7% in those aged under 60 but fell to 2.5% in those aged over 80. Emergency readmission rate was 20.6%. 35.7% of patients suffered a serious complication after their procedure, the most common being infective (16.2%), stent blockage or displacement (6.2%) and acute kidney injury (4.7%). 30 day mortality was associated with increasing age (80+ years, OR 2.91 (95% CI 2.53–3.33) p Conclusion In subjects undergoing PTC for the palliative relief of malignant jaundice, 30 day mortality is 23.1%, major complications occur in 35.7% and readmission occurs in 20.6%. Mortality is highest in older males with increasing co-morbidity and in trusts performing low volumes of procedures. Careful multidisciplinary selection of patients who will benefit from PTC for relief of significant symptoms from jaundice or as a bridge to chemotherapy is clearly merited. Disclosure of Interest None Declared

Variations in Performance of Mental Health Providers in the English NHS: An Analysis of the Relationship Between Readmission Rates and Length-of-Stay.

Length-of-stay (LOS) for inpatient mental health care is a major driver of variation in resource use internationally. We explore determinants of LOS in England, focusing on the impact of emergency readmission rates which can serve as a measure of the quality of care. Data for 2009/2010 and 2010/2011 are analysed using hierarchical and non-hierarchical models. Unexplained residual variation among providers is quantified using Empirical Bayes techniques. Diagnostic, treatment and patient-level demographic variables are key drivers of LOS. Higher emergency readmission rates are associated with shorter LOS. Ranking providers by residual variation reveals significant differences, suggesting some providers can improve performance.

Hospital-Based Acute Care After Total Hip and Knee Arthroplasty: Implications for Quality Measurement

BackgroundAlthough hospital readmissions are being adopted as a quality measure after total hip or knee arthroplasty, they may fail accurately capture the patient’s postdischarge experience. MethodsWe studied 272,853 discharges from 517 hospitals to determine hospital emergency department (ED) visit and readmission rates. ResultsThe hospital-level, 30-day, risk-standardized ED visit (median = 5.6% [2.4%-13.7%]) and hospital readmission (5.0% [2.6%-9.2%]) rates were similar and varied widely. A hospital’s risk-standardized ED visit rate did not correlate with its readmission rate (r = −0.03, P = .50). If ED visits were included in a broader “readmission” measure, 246 (47.6%) hospitals would change perceived performance groups. ConclusionIncluding ED visits in a broader, hospital-based, acute care measure may be warranted to better describe postdischarge health care utilization.

The effect of new oral anticoagulants and extended thromboprophylaxis policy on hip and knee arthroplasty outcomes: observational study.

The efficacy and safety of the new oral anticoagulants (NOAC) and the benefits of extended duration thromboprophylaxis following hip and knee replacements remain uncertain. This observational study describes the relations between thromboprophylaxis policies following hip and knee replacements across England's NHS and patient outcomes between January 2008 and December 2011. From the national administrative database, we analyzed mortality, thromboembolic complications, emergency readmission, and bleeding rates for 201,418 hip and 230,282 knee replacements. There were no differences in outcomes for either LMWH or NOAC. We found no advantage in favor of any single anticoagulation policy or in changing policy. This study supports the American Academy of Orthopaedic Surgeons' recommendation that the choice and duration of thromboprophylaxis prophylaxis be decided by the treating surgeon.

Hospital Volume Does Not Influence the Safety of Percutaneous Nephrolithotomy in England: A Population-Based Cohort Study.

This study aims to investigate the relationship between hospital case volume and safety-related outcomes after percutaneous nephrolithotomy (PCNL) within the English National Health Service (NHS). The study used the Hospital Episode Statistics (HES) database, a routine administrative database, recording information on operations, comorbidity, and outcomes for all NHS hospital admissions in England. Records for all patients undergoing an initial PCNL between April 1, 2006 and March 31, 2012 were extracted. NHS trusts were divided into low-, medium-, and high-volume groups, according to the average annual number of PCNLs performed. We used multiple regression analyses to examine the associations between hospital volume and outcomes incorporating risk adjustment for sex, age, comorbidity, and hospital teaching status. Postoperative outcomes included: Emergency readmission, infection, and hemorrhage. Mean length of stay was also measured. There were 7661 index elective PCNL procedures performed in 163 hospital trusts, between April 2006 and March 2012. There were 2459 patients who underwent PCNL in the 116 units performing fewer than 10 PCNL procedures per year; 2643 patients in the 37 units performing 10 to 19 procedures per year; and 2459 patients in the 9 hospitals performing more than 20 procedures per year. For low-, medium-, and high-volume trusts, there was little variation in the rates of emergency readmission (L 9.7%, M 9.3%, H 8.4%), infection (3.0%, 4.2%, 3.8%), or hemorrhage (1.3%, 1.5%, 1.5%), and there was no statistical evidence that volume was associated with adjusted outcomes. Mean length of stay was slightly shorter in the medium- (5.0 days) and high-volume (5.0) groups compared with the low-volume group (5.3). The effect remained statistically significant after adjusted for confounding. Hospital volume was not associated with emergency readmission, infection, or hemorrhage. Length of stay appears to be shorter in higher volume units.

Do post discharge phone calls improve care transitions? A cluster-randomized trial.

ImportanceThe transition from hospital to home can expose patients to adverse events during the post discharge period. Post discharge care including phone calls may provide support for patients returning home but the impact on care transitions is unknown.ObjectiveTo examine the effect of a 72-hour post discharge phone call on the patient's transition of care experience.DesignCluster-randomized control trial.SettingUrban, academic medical center.ParticipantsGeneral medical patients age 18 and older discharged home after hospitalization.Main Outcomes and MeasuresPrimary outcome measure was the Care Transition Measure (CTM-3) score, a validated measure of the quality of care transitions. Secondary measures included self-reported adherence to medication and follow up plans, and 30-day composite of emergency department (ED) visits and hospital readmission.Results328 patients were included in the study over an 6-month period. 114 (69%) received a post discharge phone call, and 214 of all patients in the study completed the follow outcome survey (65% response rate). A small difference in CTM-3 scores was observed between the intervention and control groups (1.87 points, 95% CI 0.47–3.27, p = 0.01). Self-reported adherence to treatment plans, ED visits, and emergency readmission rates were similar between the two groups (odds ratio 0.57, 95% CI 0.13–2.45, 1.20, 95% CI 0.61–2.37, and 1.18, 95% CI 0.53–2.61, respectively).Conclusions and RelevanceA single post discharge phone call had a small impact on the quality of care transitions and no effect on hospital utilization. Higher intensity post discharge support may be required to improve the patient experience upon returning home.Trial RegistrationClinicalTrials.gov NCT01580774

Assisted early mobility for hospitalized older veterans: preliminary data from the STRIDE program.

An important contributor to hospital-associated disability is immobility during hospitalization. Preliminary results from STRIDE, a clinical demonstration program of supervised walking for older adults admitted to the hospital with medical illness, are reported. The STRIDE program consisted of a targeted gait and balance assessment by a physical therapist, followed by daily walks supervised by a recreation therapy assistant for the duration of the hospital stay. To examine program effectiveness, STRIDE participants (n = 92) were compared with individuals referred but not enrolled (because of refusal or because program was at capacity, n = 35). Median length of stay was 4.7 days for STRIDE participants and 5.7 days for individuals receiving usual care (P = .31). There was one inpatient fall in each group (not associated with a STRIDE walk). Overall, 92% of STRIDE participants were discharged to home (rather than a skilled nursing facility (SNF)) compared to 74% of individuals receiving usual care (P = .007). Thirty-day emergency department visit rates and readmission rates were not significantly different between the two groups. STRIDE, a supervised walking program for hospitalized older adults, was feasible and safe, and program participants were less likely to be discharged to a SNF than a demographically similar comparison group. STRIDE is a promising interdisciplinary approach to promoting mobility and improving outcomes in hospitalized older adults.