Readmission In Adults Research Articles

Implementation of an enhanced discharge teaching protocol to reduce 30-day hospital readmissions in adults diagnosed with Sickle Cell Disease

Background and objectives: Sickle Cell Disease is a painful genetic disorder characterized by abnormal hemoglobin that affects 1-in-365 African American births. Individuals with Sickle Cell Disease often experience frequent hospitalizations, resulting in 30-day readmission rates 2.5 times higher than those without Sickle Cell Disease. Discharge education programs have shown to improve 30-day readmissions and improve health outcomes.Methods: This advanced practice nurse-led initiative incorporated components of the Re-Engineered Discharge (Project RED) protocol, which included patient and medication education, specific discharge teaching, and post-discharge follow-up phone calls over a 12-week period. A pre/posttest design was used to evaluate 30-day readmission. Analyses included descriptive statistics and Fisher’s exact test.Results: Of the (N = 10) participants, eight (80%) were female, with a mean age of 31.08 (± 4.33) and all were African Americans. Although not statistically significant, there was a 48% reduction in 30-day readmissions rates between the pre/post intervention periods.Conclusions: The utilization of an enhanced discharge teaching protocol is a practical solution to increase patients’ readiness for discharge and to reduce 30-day readmission rates. Project RED discharge teaching protocol is an effective strategy for nurses to employ to improve patient outcomes and quality of care for persons with Sickle Cell Disease.

Validity of the LACE index for identifying frequent early readmissions after hospital discharge in children

The LACE index scoring tool has been designed to predict hospital readmissions in adults. We aimed to evaluate the ability of the LACE index to identify children at risk of frequent readmissions. We analysed data from alive-discharge episodes (1 April 2017 to 31 March 2019) for 6546 males and 5875 females from birth to 18 years. The LACE index predicted frequent all-cause readmissions within 28 days of hospital discharge with high accuracy: the area under the curve = 86.9% (95% confidence interval = 84.3–89.5%, p < 0.001). Two-graph receiver operating characteristic curve analysis revealed the LACE index cutoff to be 4.3, where sensitivity equals specificity, to predict frequent readmissions. Compared with those with a LACE index score = 0–4 (event rates, 0.3%), those with a score > 4 (event rates, 3.7%) were at increased risk of frequent readmissions: age- and sex-adjusted odds ratio = 12.4 (95% confidence interval = 8.0–19.2, p < 0.001) and death within 30 days of discharge: OR = 5.0 (95% CI = 1.5–16.7). The ORs for frequent readmissions were between 6 and 14 for children of different age categories (neonate, infant, young child and adolescent), except for patients in the child category (6–12 years) where odds ratio was 2.8.Conclusion: The LACE index can be used in healthcare services to identify children at risk of frequent readmissions. Focus should be directed at individuals with a LACE index score above 4 to help reduce risk of readmissions.What is Known:• The LACE index scoring tool has been widely used to predict hospital readmissions in adults.What is New:• Compared with children with a LACE index score of 0–4 (event rates, 0.3%), those with a score > 4 are at increased risk of frequent readmissions by 14-fold.• The cutoff of a LACE index of 4 may be a useful level to identify children at increased risk of frequent readmissions.

30-day readmission rate in pediatric otorhinolaryngology inpatients: a retrospective population-based cohort study

ObjectivesAnalysis of frequency and reasons for planned and unplanned 30-day readmission in hospitalized pediatric otorhinolaryngology patients using German Diagnosis Related Group (G-DRG) system data.MethodsA retrospective population-based cohort study in Thuringia, Germany, was performed for the year 2015 with 2440 cases under 18 years (55.6% male) out of a total number of 15.271 inpatient cases. The majority of pediatric patients were from 2 to 5 years old (54.5%). The most frequent diagnoses were hyperplasia of adenoids or/and tonsils (26.6%). 36 cases (1.5%) experienced readmission within 30-days.Results30-day readmission was planned in 9 cases (25% of all readmission) and was unplanned in 27 cases (75%). The median interval between index and readmission treatment was 8 days. Postoperative bleeding after adenoidectomy, tonsillotomy/tonsillectomy or tracheostomy (33.4%) and infectious complications after surgery like acute otitis media, abscess formation or fever (36.2%) were the most frequent reasons for 30-day readmission. Compared to adults treated in 2015 in Thuringia, the readmission rate was higher in adult patients (8.9%) than in this pediatric cohort. In contrast to children, readmissions in adults were mainly planned (65.1%) with a different spectrum of underlying diseases and reasons for readmission.ConclusionThe 30-day readmission rate seemed to be lower for pediatric otolaryngology patients compared to adult patients. Unplanned readmissions dominated in pediatric patients, whereas planned readmissions dominated in adults.

Beyond the Biomedical Paradigm! The Biomedical, Socioeconomic and Demographic Predictors of Heart Failure Readmissions

Heart failure (HF) hospitalisations are a significant clinical and economic burden internationally. While there are a range of biomedical and socio-demographic factors predictive of readmissions in adults with HF, there are a paucity of studies synthesising the research on this topic.

1514. Mortality and Readmission in Adults during the First Year Following Hospitalization for Community-Acquired Pneumonia in the US

BackgroundIncreasing evidence suggests that the impact of community-acquired pneumonia (CAP) extends beyond discharge from the hospital and the acute phase of illness. We sought to characterize mortality and hospital readmission across the adult age span and spectrum of comorbidities.MethodsA retrospective cohort design and data from Optum’s de-identified Integrated Claims-Clinical dataset (2009-2018) were employed. Study population comprised all adults who, between 1.1.2013 and 12.31.2017, had ≥ 1 acute-care hospitalization for CAP; each qualifying CAP hospitalization separated by ≥ 365 days was included as a unique observation in analyses. Study outcomes included acute-care hospital readmission for any reason and death for any reason. Hospital readmission was ascertained during the 360-day period following discharge from the CAP hospitalization; death was ascertained during the CAP hospitalization as well as during the same 360-day period. Cumulative rates of mortality and readmission were summarized for all patients as well as subgroups defined on age and comorbidity profile (i.e., healthy, at-risk, high-risk).ResultsStudy population totaled 37,006 patients who contributed 38,809 CAP hospitalizations; mean age was 71 years, 51% were female, and 88% had an at-risk (33%) or high-risk (55%) condition. Hospital readmission was 12.5% during the 30-day post-discharge period, and 42.3% during the 360-day post-discharge period. Mortality was 3.5% in hospital, 8.2% from admission to 30 days post-discharge, and 17.7% from admission to 360 days post-discharge. Mortality rates increased with age and severity of comorbidity profile; readmission rates were highest for persons aged 65-74 years and high-risk persons.Rates of readmission and mortality among adults hospitalized for CAP ConclusionAll-cause mortality up to 1 year following hospital admission for CAP was substantial, and was associated with increasing age and worsening comorbidity profile. Both readmission and mortality were greater at all ages in high-risk and at-risk groups compared with their healthy counterparts. Strategies that prevent pneumonia and/or the pathophysiologic changes that follow CAP, especially among individuals with comorbid conditions, have the potential to reduce morbidity and mortality following CAP as well as healthcare costs associated with readmission.Disclosures Reiko Sato, PhD, Pfizer, Inc (Employee, Shareholder) Derek Weycker, PhD, Pfizer Inc. (Consultant, Grant/Research Support, Scientific Research Study Investigator, Research Grant or Support) Melody Shaff, BA, Pfizer, Inc. (Consultant, Grant/Research Support, Scientific Research Study Investigator, Research Grant or Support) Ahuva Hanau, BS, Pfizer, Inc. (Consultant, Grant/Research Support, Scientific Research Study Investigator, Research Grant or Support) Alexander Lonshteyn, PhD, Pfizer, Inc. (Consultant, Grant/Research Support, Scientific Research Study Investigator, Research Grant or Support) Stephen I. Pelton, MD, Merck vaccine (Consultant, Grant/Research Support)Pfizer (Consultant, Grant/Research Support)Sanofi Pasteur (Consultant, Other Financial or Material Support, DSMB)Seqirus Vaccine Ltd. (Consultant)

Association between neuraxial anaesthesia or general anaesthesia for lower limb revascularisation surgery in adults and clinical outcomes: population based comparative effectiveness study

ObjectiveTo examine the associations between neuraxial anaesthesia or general anaesthesia and clinical outcomes, length of hospital stay, and readmission in adults undergoing lower limb revascularisation surgery.DesignComparative effectiveness study using linked,...

Risk factors for 30-day readmission in adults hospitalized for pulmonary hypertension.

Readmissions for pulmonary hypertension are poorly understood and understudied. We sought to determine national estimates and risk factors for 30-day readmission after pulmonary hypertension-related hospitalizations. We utilized the Healthcare Cost and Utilization Project Nationwide Readmission Database, which has weighted estimates of roughly 35 million discharges in the US. Adult patients with primary International Classification of Disease, Ninth Revision, Clinical Modification diagnosis codes of 416.0 and 416.8 for primary and secondary pulmonary hypertension with an index admission between 2012 and 2014 and any readmission within 30 days of the index event were identified. Predictors of 30-day readmission were identified using multivariable logistic regression with adjustment for covariates. Results showed that the national estimate for Primary Pulmonary Hypertension vs Secondary Pulmonary Hypertension-related index events between 2012 and 2014 with 30-day readmission was 247 vs 2550 corresponding to a national readmission risk estimate of 17% vs 18.3%, respectively. The presence of fluid and electrolyte disorders, renal failure, and alcohol abuse were associated with increased risk of readmission in Primary Pulmonary Hypertension, while factors associated with Secondary Pulmonary Hypertension readmissions included anemia, congestive heart failure, lung disease, fluid and electrolyte disorders, renal failure, diabetes, and liver disease. The median cost of Primary Pulmonary Hypertension admissions and readmissions were $46,132 (IQR: $25,384–$85,647) and $41,604.50 (IQR: $22,481.50–$84,420.50), respectively. The median costs of Secondary Pulmonary Hypertension admissions and readmissions were $34,893 (IQR: $19,670–$66,143) and $36,279 (IQR: $19,059–$74,679), respectively. In conclusion, approximately 19% of Primary Pulmonary Hypertension and Secondary Pulmonary Hypertension hospitalizations result in 30-day readmission, with significant costs accrued during the index hospitalization and readmission. With evolving clinical terminology and diagnostic codes, future study will need to better clarify underlying factors associated with readmissions amongst pulmonary hypertension sub-types, and identify methods and procedures to minimize readmission risk.

Association of CKD with Early Heart Failure Readmissions in Adults

Association of CKD with Early Heart Failure Readmissions in Adults

Impact of antibiotic choice on readmission in adults experiencing an acute COPD exacerbation.

The impact of antibiotic therapy in managing acute chronic obstructive pulmonary disease (COPD) exacerbations requiring hospitalization remains unclear. We conducted a study to assess the impact of antibiotic therapy on the rate of 30-day readmission after discharge from a hospital stay for an acute COPD exacerbation. Additional study outcomes analyzed included the effects of antibiotic therapy on hospital length of stay, in-hospital mortality, 90-day and 12-month readmission rates, and time to next COPD exacerbation. The study was an institutional review board-approved, retrospective, observational review of adult patients at a tertiary academic medical center. The medical records of patients 18 years of age or older who were hospitalized for an acute COPD exacerbation between January 2008 and December 2014 were evaluated. Included patients were stratified by receipt of guideline-appropriate, guideline-inappropriate, or no antibiotic therapy. Nonparametric data were analyzed using the Kruskal-Wallis test (nonparametric) and categorical data via χ 2 test, respectively. Three hundred twenty-five subjects were included; there were no significant differences in baseline characteristics in the 3 study groups. Sixty-eight percent of patients (n = 223) received antibiotics. The percentage of patients readmitted within 30 days did not differ between cohorts: 11.9% (appropriate therapy) vs 13.2% (nonappropriate therapy) vs 12.2% (no antibiotics) (P = 0.95 for all comparisons). Additionally, no detectable differences in 90-day or 12-month readmission rate, length of hospital day, or in-hospital mortality were found. However, a trend toward increased time to next COPD exacerbation was noted in those receiving antibiotics vs no antibiotics (352 days vs 192 days, P = 0.07). Treatment of COPD exacerbations with antibiotics did not impact readmission rates, length of hospital stay, in-hospital mortality, or time to next exacerbation. More investigation is warranted to assess the effect of antibiotics on time to next exacerbation, as well as comparative effectiveness between antibiotic classes.

HOSPITAL Score, LACE Index and LACE+ Index as predictors of 30-day readmission in patients with heart failure

This study aimed to evaluate the accuracy of the HOSPITAL Score (Haemoglobin level at discharge, Oncology at discharge, Sodium level at discharge, Procedure during hospitalization, Index admission, number of hospital...

Derivation of age-adjusted LACE index thresholds in the prediction of mortality and frequent hospital readmissions in adults

The LACE index has been shown to predict hospital readmissions and death with variable accuracy. A LACE index ≥ 10 is considered as high risk in the existing literature. We aimed to derive age-specific LACE index thresholds in the prediction of mortality and frequent readmissions. Analysis of prospectively collected data of consecutive alive-discharge episodes between 01/04/2017 and 31/03/2019 to a single hospital was conducted. The derivation of LACE index thresholds for predicting all-cause mortality within 6 months of hospital discharge or frequent readmissions (≥ 2 times within 28 days) was examined by receiver operating characteristics (ROC) in 32270 patients (14878 men, 17392 women) aged 18–107 year (mean = 64.0 years, SD = 20.5). For all patients with a LACE index ≥ 10, the area under the curve (AUC) for predicting mortality was 80.5% (95% CI 79.7–81.3) and for frequent readmissions was 84.0% (83.0–85.1). Two-graph ROC plots showed that the LACE index threshold where sensitivity equates specificity was 9.5 (95% intermediate range = 5.6–13.5) for predicting mortality and 10.3 (95% intermediate range = 6.6–13.6) for frequent readmissions. These thresholds were lowest among youngest individuals and rose progressively with age for mortality prediction: 18–49 years = 5.0, 50–59 years = 6.5, 60–69 years = 8.0, 70–79 years = 9.8 and ≥ 80 years = 11.6, and similarly for frequent readmissions: 18–49 years = 5.1, 50–59 years = 7.5, 60–69 years = 9.1, 70–79 years = 10.6 and ≥ 80 years = 12.0. Positive and negative likelihood ratios (LRs) ranged 1.5–3.3 and 0.4-0.6 for predicting mortality, and 2.5–4.4 and 0.3–0.6 for frequent readmissions, respectively, with stronger evidence in younger than in older individuals (LRs further from unity). In conclusion, the LACE index predicts mortality and frequent readmissions at lower thresholds and stronger in younger than in older individuals. Age should be taken into account when using the LACE index for identifying patients at high risk.

Association of glucose variability at the last day of hospitalization with 30-day readmission in adults with diabetes

ObjectiveTo evaluate whether increased glucose variability (GV) during the last day of inpatient stay is associated with increased risk of 30-day readmission in patients with diabetes.Research design and methodsA comprehensive...

Potentially Modifiable Risk Factors for 30‐Day Readmission in Adults with Sickle Cell Disease: A National Database Study

Introduction The overall impact of morbidity related to sickle cell disease (SCD) is enormous due to decreased quality of life, high health care utilization and immense financial strain on the patients and health care system. Patients with SCD have also been found have high hospital readmission rates compared to other medical conditions, further leading to increased health care burden. The objective of this study was to explore the common reasons, healthcare utilization and identify modifiable factors associated with 30-day readmission in patients with SCD using the most recently available national data in the United States. Methods Cohort selection. 2016 Nationwide Readmission Database (NRD) from the Healthcare Cost and Utilization Project (HCUP) by the Agency for Healthcare Research and Quality (AHRQ) was queried for analysis. NRD captures discharge data from 22 states, representing about 50% of all hospitalizations in the United States. National estimates can be produced by using sampling weights provided by the NRD. Patients with SCD were identified by using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code D57. Patients younger than 18 years were excluded. Readmission was defined as any admission within 30 days of index hospitalization discharge. Statistical Analysis. Sampling weights were used throughout all calculations, facilitating appropriate national projections. Percentages in all figures reflect national estimates. Chi-square test and Student's t-test were used for univariate analysis. Multivariable logistic regression analysis was done to determine independent predictors of 30-day readmission in patients with SCD. Data analyses was performed using SAS v9.4 (SAS Institute, Cary, NC). Results In a total of 83,692 hospitalizations for SCD in 2016, 15,880 (18.9%) had at least one 30-day readmission and 40% of the readmissions occurred within the first two weeks of discharge. The most common reason for 30-day readmission was due to complications of SCD (29.8%) with sickle-cell pain crisis (18.4%) being the most frequent one. The other common causes for readmission were sepsis (10.3%), cardiac related (9.7%), respiratory failure (6.2%), renal failure (4.3%) and mood related (4.04%). Female sex (P&lt;0.001), younger age (p&lt;0.01) and patients with public insurance (P &lt;.001) were more likely to be readmitted. Multivariable logistic regression analysis showed age 31-45 years (OR 1.28, 95% CI 1.16 - 1.40, P&lt;0.01), alcohol abuse (OR 1.39, 95% CI 1.17 - 1.66, P&lt;0.001), opioid abuse (OR 2.66, 95% CI 2.34 - 3.02, P&lt;0.0001), depression (OR: 1.59, 95% CI 1.45 - 1.73, P&lt;0.01), substance abuse (OR: 1.35, 95% CI 1.21 -1.50, P&lt;0.001), tobacco use (OR: 1.35, 95% CI 1.24 - 1.46, P&lt;0.01), heart failure (OR: 1.81, 95% CI 1.66 - 1.97, P&lt;0.002), COPD (OR: 1.74, 95% CI 1.55 - 1.96, P&lt;0.03) were significantly associated with 30-day readmission while adjusting other co-morbidities. The mean cost of readmission was an additional $39,259 (±182). Conclusion This study showed that the 30-day readmission rate in patients with SCD in 2016 has decreased to less than 20% compared to previously published rates (31.9%, Elixhauser A, 2013). While this decrease in readmission rate is encouraging, further studies are needed to investigate the reasons for this trend. Several modifiable risk factors were identified in this study such as alcohol, tobacco, opioid, substance abuse and depression which can be addressed to potentially bring down the readmission rate further and improve patient care. Disclosures No relevant conflicts of interest to declare.

1245-P: The Association of Glucose Variability during the Last Day of Hospitalization and 30-Day Readmission in Adults with Diabetes

Objective: Thirty-day hospital readmission (30-day RA) rates are a metric of healthcare quality. Limited data is available, whether increased glucose variability (GV) during the last day of hospital stay is associated with an increased risk of 30-day RA. Design: Nationwide cohort of 1,042,859 admissions of patients with diabetes in the non-critical care setting in 129 Veteran Affairs hospitals, between 2001-2014. Coefficient of Variation (CV) was measured using point of care- glucometer values and was used as measurement of GV, divided into ten equal categories (tentiles). Covariates, including demographics, socio-economic and hospital related factors and up to 30 comorbidities were collected. Poisson regression was used to determine if CV during the last stay day of the hospitalization was associated with 30-day RA. Results: After adjusting for age, gender and race (Model 1), there was a gradual increase in 30-day RA ratio among admissions with higher CV. Following adjusting for all the covariates collected (Model 2), only admissions with the highest CV demonstrated an increased 30-day RA. The rate ratios and 95% CIs were 1.049 (1.026, 1.073, p&amp;lt;0.0001), 1.038 (1.015,1.061, p=0.0011), 1.065 (1.042,1.089, p&amp;lt;0.0001), for the 8th, 9th and the 10th tentiles respectively, compared to those with CV in the 1st tentile. In Model 3, after adjusting for covariates used in Model 2 and for hypoglycemia, results remained statistically significant for those admissions with the highest CV [rate ratios and 95% CIs are 1.044 (1.021,1.068, p=0.0001), 1.028 (1.006,1.052, p=0.014), 1.042 (1.018,1.067, p=0.0005) for the 8th, 9th and the 10th tentiles]. Conclusions: Higher glucose variability during the last day of hospitalization was associated with increased 30-day RA rates after adjustment for multiple covariates and hypoglycemia. Disclosure E. Spanakis: None. L.G. Singh: None. T. Siddiqui: None. J.D. Sorkin: None. G. Notas: None. M.F. Magee: Consultant; Self; Mytonomy. Research Support; Self; Lilly Diabetes, Mytonomy, Sanofi. Speaker's Bureau; Self; PRIMED. J.C. Fink: None. M. Zhan: None. G.E. Umpierrez: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, Merck &amp; Co., Inc., Novo Nordisk Inc., Sanofi US. Funding U.S. Department of Veterans Affairs (1I01CX001825-01)

Posthospital Fall Injuries and 30-Day Readmissions in Adults 65 Years and Older

Falls are common among older adults, particularly those with previous falls and cognitive impairment and in the postdischarge period. Hospitals have financial incentives to reduce both inpatient falls and hospital readmissions, yet little is known about whether fall-related injuries (FRIs) are common diagnoses for 30-day hospital readmissions. To compare fall-related readmissions with other leading rehospitalization diagnoses, including for patients at greatest risk of readmission. Retrospective cohort study of the Hospital Cost and Utilization Project's Nationwide Readmissions Database of nationally representative US hospital discharges among Medicare beneficiaries aged 65 years and older from January 1, 2013, to November 30, 2014. The prevalence and ranking of FRIs compared with other diagnostic factors for 30-day unplanned hospital-wide readmissions were determined, overall and for 2 acute geriatric cohorts, classified by fall injury or cognitive impairment diagnoses observed at the index admission. Analyses were also stratified by patient discharge disposition (home, home health care, skilled nursing facility). Analyses were conducted from February 1, 2018, to February 26, 2018. Unplanned hospital-wide readmission within 30 days of discharge. From the database, 8 382 074 eligible index admissions were identified, including 746 397 (8.9%) in the FRI cohort and 1 367 759 (16.3%) in the cognitive impairment cohort. Among the entire 8 382 074-discharge cohort, mean (SD) age was 77.7 (7.8) years and 4 736 281 (56.5%) were female. Overall, 1 205 962 (14.4%) of index admissions resulted in readmission, with readmission rates of 12.9% for those with a previous fall and 16.0% for patients with cognitive impairment. Overall, FRIs ranked as the third-leading readmission diagnosis, accounting for 60 954 (5.1%) of all readmission diagnoses. Within the novel acute geriatric cohorts, FRIs were the second-leading diagnosis for readmission both for patients with an FRI at index admission (10.3% of all readmission diagnoses) and those with cognitive impairment (7.0% of all readmission diagnoses). For those with an FRI at index admission and discharged home or to home health care, FRIs were the leading readmission diagnosis. This study found that posthospital FRIs were a leading readmission diagnosis, particularly for patients originally admitted with a FRI or cognitive impairment. Targeting at-risk hospitalized older adults, particularly those discharged to home or home health care, is an underexplored, cost-effective mechanism with potential to reduce readmissions and improve patient care.

Association of socioeconomic status and DKA readmission in adults with type 1 diabetes: analysis of the US National Readmission Database

ObjectiveTo identify patient and hospital predictors of recurrent diabetic ketoacidosis (DKA) admissions in adults in the USA with type 1 diabetes, focusing on socioeconomic indicators.Research design and methodsThis cross-sectional study...

Early Readmission After Ventricular Shunting in Adults with Hydrocephalus: A Nationwide Readmission Database Analysis

Ventricular shunting is one of the primary modalities for addressing hydrocephalus in both children and adults. Despite advances in shunt technology and surgical practices, shunt failure is a persistent challenge for neurosurgeons, and shunt revisions account for a substantial proportion of all shunt-related procedures. There are a wealth of studies elucidating failure patterns and patient demographics in pediatric cohorts; however, data in adults are less uniform. We sought to determine the rates of all-cause and shunt failure readmission in adults who underwent the insertion of a ventricular shunt. We queried the Nationwide Readmissions Database from 2010 to 2014 to evaluate new ventricular shunts placed in adults with hydrocephalus. We sought to determine the rates of all-cause and shunt revision-related readmissions and to characterize factors associated with readmissions. We analyzed predictors including patient demographics, hospital characteristics, shunt type, and hydrocephalus cause. Analysis included 24,492 initial admissions for shunt placement in patients with hydrocephalus. Of patients, 9.17% required a shunt revision within the first 6 months; half of all revisions occurred within the first 41 days. There were 4044 (16.50%) 30-day and 5758 (28.8%) 90-day all-cause readmissions. In multivariable analysis, patients with a ventriculopleural shunt, Medicare insurance, and younger age had increased likelihood for shunt revision. Notable predictors for all-cause readmission were insurance type, length of hospitalization, age, comorbidities, and hydrocephalus cause. Most shunt revisions occurred during the first 2 months. Readmissions occurred frequently. We identified patient factors that were associated with all-cause and shunt failure readmissions.

Exercise for Preventing Hospitalization and Readmission in Adults With Congestive Heart Failure.

We critically appraised all available evidence regarding exercise interventions for improving patient survival and reducing hospital admissions in adults with chronic heart failure (HF). We searched 4 databases up to April 2018 and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation working group approach. We reviewed 7 meta-analyses and the publications of 48 randomized controlled trials (RCTs). In HF with reduced ejection fraction, low-quality evidence suggests that exercise prevents all-cause hospitalizations [Relative risk (RR), 0.77; 95% confidence interval (CI), 0.63 to 0.93; 1328 patients in 15 RCTs] and hospitalizations due to HF (RR, 0.57; 95% CI, 0.37 to 0.88; 1073 patients in 13 RCTs) and improves quality of life (standardized mean difference, -0.37; 95% CI, -0.60 to -0.14; 1270 patients in 25 RCTs) but has no effect on mortality. In HF with preserved ejection fraction, low-quality evidence suggests that exercise improves peak oxygen uptake (mean difference, 2.36; 95% CI, 1.16 to 3.57; 171 patients in 3 RCTs) and quality of life (mean difference, -4.65; 95% CI, -8.46 to -0.83; 203 patients in 4 RCTs). In patients after heart transplantation, low-quality evidence suggests that exercise improves peak oxygen uptake (standardized mean difference, 0.68; 95% CI, 0.43 to 0.93; 284 patients in 9 RCTs) but does not improve quality of life. In order to reduce hospitalization and improve quality of life for adults with HF and reduced ejection fraction, clinicians should recommend exercise interventions. For adults with HF and preserved ejection fraction and in those undergoing heart transplantation, clinicians may recommend exercise interventions in order to improve peak oxygen uptake.

Association of Inpatient Opioid Utilization and Readmission Risk in Sickle Cell Disease

Abstract Background: Vaso-occlusive crisis (VOC) is the hallmark complication of sickle cell disease (SCD). The majority of SCD-related healthcare costs in the United States, estimated at $2.4 billion annually, are attributed to frequent healthcare utilization due to recurrent VOC (1-3). Risk factors such as the prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) only without opioids, older age, and steroid treatment have been identified to be associated with readmissions in pediatric SCD patients (4, 5), but limited data exist about potential predictors for readmission in adults (6). The impact of inpatient opioid utilization on readmission was evaluated in this study. Methods: Seventy SCD adults treated at the University of Illinois Hospital from 2012-2016 had at least one hospitalization for uncomplicated VOC that was followed by a 30-day readmission (30-DR) and at least one hospitalization without a 30-DR. One hospitalization with a 30-DR and one hospitalization without a 30-DR from each patient were used to form the discovery cohort (a total of 140 hospitalizations from 70 unique patients). Patient characteristics, inpatient laboratory values, outpatient daily opioid use before admission, and inpatient daily opioid use were collected from the electronic medical records, and the ratio of the last inpatient day opioid dose/home opioid dose before admission was calculated. Among the 70 patients in the discovery cohort, 22 patients had more than one hospitalization with a 30-DR. The additional hospitalizations with a 30-DR and matched hospitalizations from the same patient without a 30-DR were used to form a validation cohort (a total of 62 hospitalizations from 22 unique patients). A Wilcoxon signed-rank test was performed to compare the ones with a 30-DR to the ones without. The study was approved by the Institutional Review Board prior to the initiation of chart review. Results: Among the 70 SCD patients identified, the median (IQR) age was 32.5 (25-44) years by the time of the first admission included in this cohort, and 67% were females, 76% were HbSS or Sbeta0 genotype, and 46% were on hydroxyurea before admission. The median (IQR) dose of daily outpatient opioids before the first admission was 170 (64-280) mg oral morphine equivalents (OME). When the hospitalizations without a 30-DR were compared to the ones with in the discovery cohort (Table 1), the ratio of last inpatient day opioid dose/home opioid dose was lower (1.5 vs. 1.9, p=0.024), whereas other relevant clinical variables including length of stay, pain score upon discharge, and hemoglobin or WBC upon discharge were not significantly different between the two groups (Table 1). The proportion of patients who used patient controlled analgesia (PCA) during admission, or underwent opioid dose tapering during hospitalizations, or converted IV opioids to oral ones before discharge was also comparable. In the validation cohort (Table 1), the ratio of last inpatient day opioid dose/home opioid dose in the group without a 30-DR was also lower than the ones with a 30-DR (1.4 vs. 2.0, p=0.033), whereas other clinical variables were comparable. Summary: Here we showed that a high ratio of last inpatient day opioid dose/home opioid dose is associated with readmission risk for sickle cell patients treated for uncomplicated VOC. The results suggest that proper tapering of inpatient opioid dose in reference to patient's home opioid dose before discharge may reduce the readmission risk. Reference: K. L. Hassell, Am J Prev Med38, S512 (Apr, 2010). S. Lanzkron, C. P. Carroll, C. Haywood, Jr., Am J Hematol85, 797 (Oct, 2010). T. L. Kauf, T. D. Coates, L. Huazhi, N. Mody-Patel, A. G. Hartzema, Am J Hematol84, 323 (Jun, 2009). L. M. Okorji, D. S. Muntz, R. I. Liem, Pediatr Blood Cancer64, (May, 2017). A. Sobota, D. A. Graham, E. J. Neufeld, M. M. Heeney, Pediatr Blood Cancer58, 61 (Jan, 2012). M. A. Brodsky et al., Am J Med130, 601 e9 (May, 2017). Disclosures No relevant conflicts of interest to declare.

Anti-cholinergic burden and patient related clinical outcomes in an emergency general surgical setting

The impact of medications with anti-cholinergic properties on morbidity and mortality of unselected adult patients admitted to the emergency general surgical setting has not been investigated. All cases were identified prospectively from unselected adult patients admitted to the emergency general surgical ward between May to July 2016 in a UK centre with a catchment population circa 500,000. Prescribed medication lists were ascertained from case notes and electronic medical records. Anti-Cholinergic Burden (ACB) was calculated from medication lists. Patients were categorised into three groups based on ACB; none (ACB score of 0); moderate (up to ACB score of two); high (ACB score more than two). The effect of increasing ACB on selected outcomes of 30- and 90-day mortality, hospital readmission within 30-days of discharge and increased length of hospital stay were examined using multivariable logistic regression models. The 452 patients had a mean age (SD) of 51.7 (±20.6) years, 273 (60.4%) patients had no ACB burden, 106 (23.5%) had a ACB burden of up to two; and 73 (16.2%) had an ACB burden of > 2. Multivariable analyses showed no association between high ACB burden and 90-day (fully adjusted odds ratio [OR] 0.56 (95%CI 0.12-2.85); P=0.48) and 30-day mortality (fully adjusted OR=0.75 (95%CI 0.05-11.04); P=0.84). A significant association was observed between moderate ACB burden and 30-day hospital readmission (fully adjusted OR=2.01 (95%CI 1.09-3.71); P=0.03). Anti-cholinergic burden may be linked to hospital readmission in adults admitted to an emergency general surgical ward.