Reduce Hospital Readmission Rates Research Articles

Effective Patient Engagement in Private Healthcare Institutions in Riyadh: An Analysis of Management Strategies

The healthcare sector in Saudi Arabia is undergoing a remarkable transformation driven by factors such as population growth and rising disposable income. This has led to a significant surge in demand for private healthcare services, particularly in major cities like Riyadh. While catering to the needs of a growing patient base, there is an urgent need to ensure patient-centered care to enhance service quality and satisfaction. Multiple research studies have affirmed the positive impact of patient engagement. Studies consistently demonstrate that patients actively involved in their healthcare decisions experience improved quality of life, better adherence to treatment, and reduced hospital readmission rates. This ultimately leads to improved health outcomes and reduced overall healthcare costs. Despite these well-established benefits, many private healthcare institutions in Riyadh struggle to effectively integrate patient engagement strategies into their practices. This implementation gap necessitates a deeper understanding of the factors influencing these efforts. This study aims to address this pressing need by investigating the factors affecting patient engagement initiatives within private healthcare institutions in Riyadh. The study will explore the influence of three key domains: Digital Technology: The increasing reliance on digital tools in healthcare holds the potential to revolutionize patient engagement. This study will explore how technology platforms, telemedicine applications, and patient portals can facilitate patient engagement. Organizational Leadership: Leadership plays a pivotal role in fostering a patient-centered care culture. This research will examine how leadership styles, commitment to patient engagement, and resource allocation impact patient engagement initiatives. Organizational Culture: The overall culture of a healthcare institution significantly influences patient interactions. This study will explore how factors such as communication practices, staff training, and patient empowerment within the organizational culture shape patient engagement. By examining these three domains, the study aims to provide valuable insights into the factors that influence patient engagement in private healthcare settings in Riyadh. The findings will contribute to the development of effective strategies for enhancing patient engagement and improving overall healthcare quality.

Interventions to Reduce Hospital Readmissions: A Scoping‎ Review

Context: In response to the growing strain on healthcare resources, urgent measures are needed to encourage early discharge and prevent unnecessary hospital readmissions. This review aimed to systematically assess studies of interventions designed to reduce readmissions. Methods: The search was conducted between February 20 and March 20, 2023. Original articles focusing on interventions to reduce hospital readmission rates were reviewed. Two researchers were separately responsible for selecting articles, extracting data, and conducting qualitative assessments using the STROBE and CONSORT guidelines. Results: The study included a total of seventy-two articles. The proposed interventions for minimizing readmission rates were classified into 14 distinct groups. Conclusions: Patient follow-up after discharge and education emerge as two effective approaches in this context. Moreover, robust evidence exists to support the efficacy of community-based interventions in decreasing hospital readmissions.

The Impact of Value-based Purchasing on Rural and Urban Healthcare Systems in the United States

Since the 2010s, the U.S. government has adopted value-based purchasing, and many states has utilized this program to reduce hospital readmission rates and improve performance of urban hospitals. Nonetheless, the lack of participation in this program among rural hospitals has contributed to the growing urban-rural health disparities. This paper aims to identify policy solutions to improve health outcomes of vulnerable populations who reside in resource-poor at-home healthcare agencies, nursing homes, and hospitals in rural regions. This paper finds that rural health outcomes are significantly worse than urban parts. At the same time, it also shows that African Americans and Hispanics have higher mortality and morbidity rates than that of their White counterparts, demonstrating the need for policymakers to further address the unmet medical needs of vulnerable populations, such as racial minorities and those with chronic conditions. Therefore, this paper proposes that the government allocates more healthcare funding toward resource-poor urban hospitals. Moreover, insurers should not penalize rural hospitals with a higher proportion of high-risk patients for having higher-than-average hospital readmission rates.

Utilization of Discharge Checklist and Improved Education Reduces Hospital Readmission Rates in Childhood Leukemia Patients Receiving Induction Therapy.

The aim is to identify preventable cause for hospital readmissions during induction and implement interventions to decreased preventable treatment-associated complications. Multiple factors contribute to patients with acute lymphoblastic leukemia (ALL) requiring readmissions during induction. A dashboard monitored features of newly diagnosed patients with ALL. Readmission causes were stratified as preventable, possibly preventable, or unpreventable. A discharge checklist, including standardized education, and change of discharge date were implemented. Initially, there were 57 hospital readmissions of 98 patients (9 intensive care unit admissions and 2 deaths). Sixteen preventable (28.1%) and 32 unpreventable (56.1%) readmissions. After the interventions were initiated, including improved education, discharge checklist utilization, and standardized discharge date, there were 23 readmissions (78.3% were unpreventable, 6 intensive care unit admissions). Intervention implementation reduced readmission rates of induction patients with ALL by 20%.

Clinical impact of medication review and deprescribing in older inpatients: A systematic review and meta-analysis.

Polypharmacy is a primary risk factor for the prescription of potentially inappropriate medications (PIMs), drug-drug interactions (DDIs), and ultimately, adverse drug reactions (ADRs). Medication review and deprescribing represent effective strategies to simplify therapeutic regimens, minimize risks, and reduce PIM prescriptions. This systematic review and meta-analysis of experimental and observational studies aimed to evaluate the impact of different medication review and deprescribing interventions in hospitalized older patients. Experimental and observational prospective cohort studies evaluating the clinical effects of medication review and deprescribing strategies in older hospitalized patients were searched in the bibliographic databases, PubMed, Embase, and Scopus, from inception until January 8, 2024. A narrative synthesis of the results was provided, along with a meta-analysis of dichotomous data (i.e., re-hospitalizations and mortality). Overall, 21 randomized controlled trials, 7 non-randomized interventional studies, and 2 prospective cohort studies were included in the systematic review. Of these, 14 (46.7%) assessed medication appropriateness as the primary outcome, while the remaining evaluated clinical outcomes (e.g., length of hospital stay, hospital readmissions, emergency department visits, and incidence of ADRs) and/or quality of life. The meta-analysis revealed a slight but statistically significant 8% reduction in hospital readmissions (HR: 0.92; 95% CI: 0.85-0.99) following medication review and deprescribing, but no significant impact on mortality (HR: 0.98; 95% CI: 0.96-1.00). Of the 30 included studies, 21 were considered at high risk of bias, mostly due to potential deviations from intended interventions and randomization processes. The remaining nine studies had "some concerns" (eight studies) or were considered at "low" risk of bias (one study). Medication review and deprescribing are associated with potential benefits in reducing hospital readmission rates among hospitalized older patients, particularly through the reduction of PIM prescriptions. The integration of thorough medication review and deprescribing protocols in hospital settings may improve post-discharge outcomes and reduce overall healthcare costs.

Rapid access nurse-led atrial fibrillation clinics reduce hospital readmissions

Abstract Background Atrial Fibrillation (AF) is the most common cardiac arrhythmia and in the UK accounts for about 1.5% of healthcare expenditure mainly through recurrent hospital admissions (1). The European Society of Cardiology 2020 AF guidelines (2) provides a clear framework of all the different components required to provide good patient-centred integrated AF management of which very little is done well within an emergency inpatient setting. Purpose We have developed a nurse led Rapid Access AF (RAAF) clinic aiming to prevent repeat admissions and improve patients overall AF care. Methods All patients discharged from our institution's emergency department (ED) or acute medical ward with a primary diagnosis of atrial fibrillation are suitable for the Rapid Access AF clinic. At the clinic the patients are given patient education, advise about risk factor modification, access to an "AF hotline" and a simple initial management plan should symptoms worsen with advise about when to attend the emergency department. Patients are then reviewed at a weekly multidisciplinary meeting with the local AF doctors where longer term strategies are made. The clinics have been operating now for 2 years and we have audited the 3 months from January to March 2022 with further follow up at 6 months. Results 41 out of 64 patients presenting to the emergency department with AF were admitted. However, whether in the ED or subsequent medical ward, treatment as a whole was very simple AF management, similar to that of outpatient care ( e.g. in ED Beta Blockers 34%, Digoxin 16%, oral Flecainide 5%, IV Amiodarone 12.5%, direct current cardioversion 1.5%, no clear AF treatment 16%, anticoagulation in patients with CHADSVASC 2+ 92%). 36 out of 64 patients were discharged to RAAF clinic and were seen on average 22 days post discharge. Readmission rates were 11% vs 32% at 30 days in patients discharged to RAAF compared to standard care and 14% vs 60% at 6 months. Conclusion Patients admitted to hospital with a primary diagnosis of AF are at high risk of early readmission. A rapid access AF clinic is effective at significantly reducing hospital readmission rates whilst also providing more holistic integrated AF management.

Prognostic Significance of Lung Ultrasound for Heart Failure Patient Management in Primary Care: A Systematic Review.

Background: Heart failure (HF) affects around 60 million individuals worldwide. The primary aim of this study was to evaluate the efficacy of lung ultrasound (LUS) in managing HF with the goal of reducing hospital readmission rates. Methods: A systematic search was conducted on PubMed, Embase, Google Scholar, Web of Science, and Scopus, covering clinical trials, meta-analyses, systematic reviews, and original articles published between 1 January 2019 and 31 December 2023, focusing on LUS for HF assessment in out-patient settings. There is a potential for bias as the effectiveness of interventions may vary depending on the individuals administering them. Results: The PRISMA method synthesized the findings. Out of 873 articles identified, 33 were selected: 19 articles focused on prognostic assessment of HF, 11 centred on multimodal diagnostic assessments, and two addressed therapeutic guidance for HF diagnosis. LUS demonstrates advantages in detecting subclinical congestion, which holds prognostic significance for readmission and mortality during out-patient follow-up post-hospital-discharge, especially in complex scenarios, but there is a lack of standardization. Conclusions: there are considerable uncertainties in their interpretation and monitoring changes. The need for an updated international consensus on the use of LUS seems obvious.

Palliative Care Reduces Hospital Readmission Rates for Heart Failure Patients

Palliative Care Reduces Hospital Readmission Rates for Heart Failure Patients

Total laryngectomy and readmission: causes, rates and predictors

BackgroundTotal laryngectomy (TL) is a complex procedure, and patients undergoing TL are at high risk for readmission, which exposes them to hospital-acquired complications. Readmission rate is a metric for quality of care. We aimed to identify the rate, causes, and predictors of hospital readmission within 60 days after discharge following TL.MethodsThis is a 12-year retrospective study where we included all patients undergoing TL in a single tertiary care center between 2008 and 2022. Patient charts were reviewed for demographics, comorbidities, and causes for readmission.ResultsOf 83 patients who underwent TL, 12 (14.50%) were readmitted within 60 days. Common causes were surgical site infection (33.33%) and mucocutaneous fistula (25%). Significant predictors for readmission were tobacco use (P = 0.003), African ethnicity (P = 0.004), being unmarried (P < 0.001), lower preoperative serum albumin (P < 0.001), higher preoperative TSH (P = 0.03), higher preoperative neutrophil count (P = 0.035), higher American Society of Anesthesiology (ASA) score (P = 0.028), and higher Cumulative Illness Rating Scale (CIRS) score (P = 0.029).ConclusionOne in every seven patients were readmitted following TL. Frequent causes include wound infection and fistulas. Predictors include preoperative hypoalbuminemia, hypothyroidism, African ethnicity, being unmarried, tobacco use, and a higher baseline burden of comorbidities. Such factors can be targeted to reduce hospital readmission rates.

A Targeted Discharge Pathway to Reduce Hospital Readmission and Dying in Hospital in Cancer Patients at the End of Life

ObjectivesThere is a need for better information exchange between primary and secondary care healthcare professionals in cancer patients with limited life expectancy, most of whom prefer to be at home but are admitted frequently at the end of life (EoL). We conducted a file search to assess this among our patients and developed a discharge pathway to decrease readmission rate and dying in hospital. Data SourcesWe performed an in-depth file search among 150 patients who died within 1 month after hospital admission (July 2013 to January 2014); 60 were admitted once, and 90 were admitted twice or more. Mean time spent in hospital at EoL was 12 days; 37% died in hospital, and 49% died at home. We included 31 admitted cancer patients at the EoL in whom home-discharge was planned for the intervention (February 2017 to December 2018). Median survival was 24 days, time spent in hospital decreased from 15.5 to 2.5 days, and number of readmissions fell from 2.8 to 0.57. One patient (3.1%) died in hospital, and 77% died at home. And 78% of general practitioners found the provided information useful. ConclusionA proactive discharge pathway may reduce hospital readmission rates, time spent in hospital, and in-hospital death. Implications for Nursing PracticeEver more patients with complex care needs at the EoL are being discharged early. Being informed about patients’ wishes, preferences, and treatment options for symptom management at home is essential for doctors and nurses in primary care. A systematic discharge pathway can be useful for information transfer when admitted patients are discharged home.

The Impact of Transitional Care for Geriatric Patients with Chronic Diseases

Indonesia has gradually become an aging society as socio-demographic changes happen in the last decades, affected the health care system in many countries. An increased hospital readmission rate and prolonged hospitalization in elderly patients due to chronic illness have been a new challenge. A comprehensive plan to ensure the coordination and continuity of health care after hospital discharge is needed to improve the sustainability of long-term management. In 2021, literature was searched on the PubMed, ScienceDirect, and Cochrane electronic databases with keywords for transitional care, geriatric, and chronic disease. Inclusion criteria were randomized controlled trial (RCT), systematic review, or meta-analysis studies that implemented transitional care intervention (TCis) for people older than 60 with chronic diseases. Studies were limited to those published in the past ten years and published in Bahasa/English. Critical appraisal was assessed using the PRISMA guideline. We identified 107 records. Seven articles met the inclusion criteria. Outcome assessments were conducted from one to 12 months after discharge. TCis were divided into 3 points: before discharge, after discharge at home, and throughout the entire period. Readmission was measured in most studies (n=7), mortality (n=4), and emergency department (ED) visit (n=3). Most of the study showed a positive impact in the intervention groups (IG) compared to the control groups (CG). Transitional care is beneficial for geriatrics with chronic disease as it reduces hospital readmission rates, mortality, and ED visit. Five domains should be addressed to have effective transitional care: comprehensive assessment, planning and communication, support for self-care and the caregiver, access facilitation, and a competent healthcare team.

Continuity of Care Versus Language Concordance as an Intervention to Reduce Hospital Readmissions From Home Health Care.

Language concordance between health care practitioners and patients have recently been shown to lower the risk of adverse health events. Continuity of care also been shown to have the same impact. The purpose of this paper is to examine the relative effectiveness of both continuity of care and language concordance as alternative or complementary interventions to improve health outcomes of people with limited English proficiency. A multivariable logistic regression model using rehospitalization as the dependent variable was built. The variable of interest was created to compare language concordance and continuity of care. The final sample included 22,103 patients from the New York City area between 2010 and 2015 who were non-English-speaking and admitted to their home health site following hospital discharge. The odds ratio (OR) average marginal effect (AME) of each included variable was calculated for model analysis. When compared with low continuity of care and high language concordance, high continuity of care and high language concordance significantly decreased readmissions (OR=0.71, 95% CI: 0.62-0.80, P<0.001, AME=-4.95%), along with high continuity of care and low language concordance (OR=0.80, 95% CI: 0.74-0.86, P<0.001, AME=-3.26%). Low continuity of care and high language concordance did not significantly impact readmissions (OR=1.04, 95% CI: 0.86-1.26, P=0.672, AME=0.64%). In the US home health system, enhancing continuity of care for those with language barriers may be helpful to address disparities and reduce hospital readmission rates.

The Path to Sustainable Healthcare: Implementing Care Transition Teams to Mitigate Hospital Readmissions and Improve Patient Outcomes.

Introduction Hospital readmissions within 30 days suggest care quality issues and increased mortality risks. They result from ineffective initial treatment, poor discharge planning, and inadequate post-acute care. These high readmission rates harm patient outcomes and financially strain healthcare institutions, inviting penalties and discouraging potential patients. Enhancing inpatient care, care transitions, and case management is crucial to lowering readmissions. Our research underscores the role of care transition teams in reducing readmissions and financial stress in hospitals. By consistently applying transition strategies and focusing on high-quality care, we can improve patient outcomes and ensure hospital success in the long run. Methods This two-phase study investigated readmission rates and risk factors in a community hospital from May 2017 to November 2022. Phase 1 determined a baseline readmission rate and identified individual risk factors using logistic regression. In phase 2, a care transition team addressed these factors by providing post-discharge patient support through phone calls and assessing social determinants of health (SDOH). Readmission data from the intervention period was compared to baseline data using statistical tests. Data, including demographics, medical conditions, and comorbidities, were collected via electronic medical records and the International Classification of Diseases (ICD-10 codes). The study focused on patients aged 20-80 with readmissions within 30 days. Exclusions were made to minimize confounding effects from unmeasured comorbidities and ensure an accurate representation of factors affecting readmissions. Results In the study's initial phase, 74,153 patients participated, with an 18% mean readmission rate. Women accounted for 46% of readmissions, and the white population had the highest rate (49%). The 40-59 age group showed a higher readmission rate than other age groups, and certain health factors were identified as risk factors for 30-day readmission. In the subsequent phase, a care transition team intervened with high-risk groups using an SDOH questionnaire. They contacted 432 patients, resulting in a reduced overall readmission rate of 9%. The 60-79 age group and the Hispanic population experienced higher readmission rates, and the previously identified health factors remained significant risk factors. Conclusion This study emphasizes the crucial role of care transition teams in reducing hospital readmission rates and easing the financial strain on healthcare institutions. By identifying and addressing individual risk factors, the care transition team effectively lowered the overall readmission rate from 18% to 9%. Continually implementing transition strategies and prioritizing high-quality care focused on minimizing readmissions are essential for improving patient outcomes and long-term hospital success. Healthcare providers should consider utilizing care transition teams and social determinants of health assessments to better understand and manage risk factors and tailor post-discharge support for patients at higher risk of readmission.

Socioeconomic Determinants of Remote Patient Monitoring Implementation Among Rural and Urban Hospitals.

Introduction: Remote patient monitoring (RPM) is a form of telehealth that improves quality of care for chronic disease treatment and reduces hospital readmission rates. Geographical proximity to health care is important for individuals of low socioeconomic status (SES) who face additional financial and transportation barriers. The goal of this study was to assess the association between social determinants of health and adoption of RPM. Methods: This cross-sectional study analyzed data from hospitals that responded to the American Hospital Association's Annual Survey (2018) and spatially linked census tract-level environmental and social determinants of health obtained from the Social Vulnerability Index (2018). Results: A total of 4,206 hospitals (1,681 rural and 2,525 urban hospitals) met study criteria. Rural hospitals near households in the lower middle quartile SES were associated with a 33.5% lower likelihood of having adopted RPM for chronic care management compared with rural hospitals near households in the highest quartile SES (adjusted odds ratios [aOR] = 0.665; 95% confidence interval [CI]: 0.453-0.977). Urban hospitals near households in the lowest quartile SES were associated with a 41.9% lower likelihood of having adopted RPM for chronic care management compared with urban hospitals near households in the highest quartile SES (aOR = 0.581; 95% CI: 0.435-0.775). Similar trends in accessibility were found with RPM for postdischarge services among urban hospitals. Conclusion: Our findings highlight the importance of hospital responsibility and state and federal policy approaches toward ensuring equitable access to RPM services for patients characterized by lower SES.

The impact of electronic health records on healthcare delivery and patient outcomes: A review

This review examines the impact of Electronic Health Records (EHRs) on healthcare delivery and patient outcomes, highlighting the benefits and challenges associated with their use. EHRs enhance healthcare efficiency, improve the quality of care through clinical decision support, and foster better collaboration among healthcare providers. They also contribute to patient safety, engagement, and improved health outcomes, including reduced hospital readmission rates and better chronic disease management. However, data privacy concerns, interoperability issues, and the digital divide pose significant hurdles. The review underscores the critical role of ongoing research and innovation in health informatics to address these challenges, ensuring EHRs continue to evolve positively. This analysis aims to provide a comprehensive overview of the current state of EHRs, offering insights into their potential to transform healthcare delivery and outcomes.

Associations between continuity of care, perceived control and self-care and their impact on health-related quality of life and hospital readmission-A structural equation model.

The aim of this study is to examine whether a conceptual model including the associations between continuity of care, perceived control and self-care could explain variations in health-related quality of life and hospital readmissions in people with chronic cardiac conditions after hospital discharge. Correlational design based on cross-sectional data from a multicentre survey study. People hospitalized due to angina, atrial fibrillation, heart failure or myocardial infarction were included at four hospitals using consecutive sampling procedures during 2017-2019. Eligible people received questionnaires by regular mail 4-6 weeks after discharge. A tentative conceptual model describing the relationship between continuity of care, self-care, perceived control, health-related quality of life and readmission was developed and evaluated using structural equation modelling. In total, 542 people (mean age 75 years, 37% females) were included in the analyses. According to the structural equation model, continuity of care predicted self-care, which in turn predicted health-related quality of life and hospital readmission. The association between continuity of care and self-care was partly mediated by perceived control. The model had an excellent model fit: RMSEA=0.06, 90% CI, 0.05-0.06; CFI=0.90; TLI=0.90. Interventions aiming to improve health-related quality of life and reduce hospital readmission rates should focus on enhancing continuity of care, perceived control and self-care. This study reduces the knowledge gap on how central factors after hospitalization, such as continuity of care, self-care and perceived control, are associated with improved health-related quality of life and hospital readmission in people with cardiac conditions. The results suggest that these factors together predicted the quality of life and readmissions in this sample. This knowledge is relevant to researchers when designing interventions or predicting health-related quality of life and hospital readmission. For clinicians, it emphasizes that enhancing continuity of care, perceived control and self-care positively impacts clinical outcomes. People and healthcare personnel evaluated content validity and were included in selecting items for the short version.

Self-care Practices of Patients With Heart Failure Using Wearable Electronic Devices: A Systematic Review.

Heart failure (HF) is the fastest growing cardiovascular condition globally; associated management costs and hospitalizations place an immense burden on healthcare systems. Wearable electronic devices (WEDs) may be useful tools to enhance HF management and mitigate negative health outcomes. We aimed to perform a systematic review to examine the potential of WEDs to support HF self-care in ambulatory patients at home. Five databases were searched for studies published between 2007 and May 2022, including OVID MEDLINE, EMBASE (OVID), APA PsycINFO (OVID), Cochrane Central Register of Controlled Trials (OVID), and CINAHL Plus with Full Text (Ebsco). After 6210 duplicates were removed, 4045 records were screened and 6 were included for review (2 conference abstracts and 4 full-text citations). All studies used WEDs as 1 component of a larger intervention. Outcome measures included quality of life, physical activity, self-efficacy, self-care, functional status, time to readmission, social isolation, and mood. Studies were of moderate to high quality and mixed findings were reported. Enhanced exercise habits and motivational behavior to exercise, as well as decreased adverse symptoms of fatigue and dyspnea, were identified in 2 studies. However, improvements in exercise capacity and increased motivational behavior did not lead to exercise adherence in another 2 studies. The findings from this review suggest that WEDs may be a viable health behavior improvement strategy for patients with HF. However, studies of higher quality, with the primary intervention being a WED, and consistent outcome measures are needed to replicate the positive findings of studies identified in this review.

Constrained optimization for stratified treatment rules in reducing hospital readmission rates of diabetic patients

Diabetic patients can receive multiple/different treatments. However, there is no universal solution for all patients, i.e., one prescription can treat some patients, but it may not be effective for others. Therefore, if we can stratify those patients into several sub-classes, the patients in each sub-class can receive the optimal treatment. There are two main challenges: (1) counterfactual inference when a patient can only take one treatment at a time, i.e., a long time is required to collect an adequate amount of patient data for analysis; (2) the confounding effects of covariates on the treatment. To address these challenges, we propose a method entitled constrained optimization for stratified treatment rules (COSTAR). The proposition is to view the realized treatment outcome as observable but the unrealized as missing values. Thus, the problem becomes finding the optimal treatment with missing outcomes and covariate balance constraints. Through the method COSTAR, the experiment results with real-world data suggest that our results perform better than the related methods in reducing the hospital readmission rate within 30 days. Our solution also guarantees the robustness of the estimation of the mean treatment response in each sub-class.

Impact of a COPD care bundle on hospital readmission rates

BackgroundChronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality worldwide and contributes considerably to morbidity and health care costs. In October 2014, the Centers for Medicare and Medicaid Services introduced financial penalties followed by bundled payments for care improvement initiatives in patients hospitalized with COPD. ObjectivesThis study seeks to evaluate whether an evidence-based interprofessional COPD care bundle focused on inpatient, transitional, and outpatient care would reduce hospital readmission rates. MethodsA pre- and postintervention analysis comparing readmission rates after a hospitalization for COPD in subjects who received standard of care versus an interprofessional team–led COPD care bundle was conducted. The primary outcome was 30-day all-cause readmissions; secondary outcomes included 60- and 90-day all-cause readmissions, escalation of pharmacotherapy, interprofessional interventions, and hospital length of stay. ResultsA total of 189 subjects were included in the control arm and 127 subjects in the COPD care bundle arm. A reduction in 30-day all-cause readmissions between the control arm and COPD care bundle arm (21.7% vs. 11.8%, P = 0.017) was seen. Similar outcomes were seen in 60-day (18% vs. 8.7%, P = 0.013) and 90-day all-cause readmissions (19.6% vs. 4.7%, P < 0.001). Pharmacists consulted with 68.5% of subjects and assisted with access to outpatient medications in 45.7% of subjects in the COPD care bundle arm. An escalation in maintenance therapy occurred more often in the COPD care bundle arm (22.2% vs. 44.9%, P < 0.001) than the control arm. ConclusionsAn interprofessional team–led COPD care bundle resulted in significant reductions in all-cause hospital readmissions at 30, 60, and 90 days.

Real-world outcomes of telehealth initiative to reduce readmissions for patients with cancer.

387 Background: Unplanned readmissions in patients with cancer increase both financial toxicity and mortality. It adversely impacts their quality of life by increasing distress for the patient and caregivers. Improving the transition from inpatient to outpatient care has shown to reduce readmissions. The goal of our study is to reduce hospital readmission rate for patients with solid malignancies by implementing a Telehealth transitional care visit for patients with a high EPIC readmission score at the time of discharge. Methods: A pilot study of patients with thoracic and gastrointestinal malignancies who had a high (≥23%) EPIC readmission score at discharge home between March 2021 and May 2022 were included. Patients who were discharged to a skilled nursing facility/rehabilitation center and patients who were admitted for scheduled chemotherapy were excluded. Telehealth visit with an Advanced Practice Provider (APP) was scheduled within seven days after discharge. It included evaluation of medications, addressing reasons for the index admission, review of symptoms, concerns and reminders for follow up appointments with the primary oncologist team. Readmission rates were compared to a control cohort. Results: A total of 44 patients with high readmission score underwent a Telehealth visit following discharge home. The median age was 63.5 years (range 38-83). Of the 44 patients, 36% (16) were male and 64% (28) were female. Fourteen (32%) patients had thoracic malignancy and 30 (68%) had gastrointestinal malignancy. All patients had received at least one line of chemotherapy. Twelve of the 44 patients (27.3%) had a true 30-day readmission which was lower compared to the control group (31.8%, 14/44 patients) who did not have a Telehealth intervention. Conclusions: A timely Telehealth visit within seven days of the index admission can positively impact the true 30-day readmission rate for patients with cancer.