Reduction In 30-day Readmissions Research Articles

Trends in management and outcomes of colon cancer in the United States over 15 years: Analysis of the National Cancer Database.

Management of colon cancer has changed over the last few decades. We assessed the trends in management and outcomes using the US National Cancer Database (NCDB). A retrospective analysis of all patients with colonic adenocarcinoma between 2005 and 2019 was conducted. The cohort was divided into three equal time periods: Period 1 (2005-2009), Period 2 (2010-2014), and Period 3 (2015-2019) to examine treatment and outcomes trends. The primary outcome was 5-year overall survival (OS). The study included 923,275 patients. A significant increase in patients with stage IV disease was noted in Period 3 compared to Period 1 (47.9% vs. 27.9%, respectively), whereas a reciprocal reduction was seen in patients with locally advanced disease (stage II: 20.8%-12%; stage III: 14.5%-7.7%). Use of immunotherapy significantly increased from 0.3% to 7.6%. Mean 5-year OS increased (43.6 vs. 42.1 months) despite the increase in metastatic disease and longer time from diagnosis to definitive surgery (7 vs. 14 days). A reduction in 30-day readmission (5.1%-4.2%), 30- (3.9%-2.8%), and 90-day mortality (7.1%-5%) was seen. Laparoscopic and robotic surgery increased from 45.8% to 53.1% and 2.9% to 12.7%, respectively. Median postoperative length of hospital stay decreased by 2 days. Rate of positive resection margins (7.2%-6%) and median number of examined lymph nodes (14-16) also improved. Minimally invasive surgery and immunotherapy for colon cancer significantly increased in recent years. Patient outcomes including OS improved over time.

Decision Making in an Academic Department of Medicine: The Role of a Management Control System

Academic Departments of Medicine have several challenges in managing resources, meeting academic goals and clinical demands. In this paper, we describe a management control system installed in 2014: the Strategic Plan, a Balanced Scorecard reflecting clinical research and educational performance, Annual feedback and review by Departmental and Divisional Chairs, and Improvement Plans.
 This system over 8 years resulted in a reduction in 30-day re-admissions of 14%, a decline in length of stay of 0.55 days, and reduced absolute in-hospital mortality of nearly 2%. Clinical revenue increased 42% from 2016 to 2022 largely due to increased ambulatory and procedural volumes. Teaching time and ratings were unaffected by the installation of this system. Return on investment for newly hired researchers and scientists was 67.5% with a 12.7% increase in peer-reviewed funding. We conclude that the Decision Management Control System was feasible to create and allowed capable monitoring of performance and informed decision-making. Major metrics improved after its implementation.

Technologic Transformation of Perioperative Cardiac Care and Outcomes

BackgroundThe “Perfect Care” initiative engages, educates, and enrolls adult cardiac surgery patients into a comprehensive program that incorporates remote perioperative monitoring (RPM). This study investigated the impact of RPM on postoperative length of stay, 30-day readmission and mortality, and other outcomes. MethodsThis quality improvement project compared outcomes in 354 consecutive patients who underwent isolated coronary artery bypass and who were enrolled in RPM between July 2019 and March 2022 at 2 centers against outcomes in propensity-matched control patients from a pool of 1301 patients who underwent isolated coronary artery bypass from April 2018 to March 2022 without RPM. Data were extracted from The Society of Thoracic Surgeons Adult Cardiac Surgery Database, and outcomes were analyzed according to its definitions. RPM used perioperative standard practice routines, a digital health kit for remote monitoring, a smartphone application and platform, and nurse navigators. Propensity scores were generated with RPM as the outcome measure, and a 2:1 match was generated using a nearest-neighbor matching algorithm. ResultsPatients who underwent isolated coronary artery bypass and who were participating in RPM showed a statistically significant, 15.4% (1 day) reduction in postoperative length of stay (P < .0001) and a 44% reduction in 30-day readmission and mortality (P < .039) compared with matched control patients. Significantly more RPM participants were discharged directly home instead of to a facility (99.4% vs 92.0%; P < .0001). ConclusionsThe RPM platform and associated efforts to engage and monitor adult cardiac surgery patients remotely is feasible, is embraced by patients and clinicians, and transforms perioperative cardiac care by significantly improving outcomes and reducing variation.

1772. Evaluating the Impact of a Pilot Structured Antimicrobial Stewardship Prospective Audit and Feedback Program in Emergency General Surgery in a Community Hospital

Abstract Background The benefits of prospective audit and feedback (PAF) are established in critical care settings but not in the surgical population. We piloted once-weekly structured face-to-face PAF with the Acute Care Surgery (ACS) Service surgeon(s) and compared outcomes to usual care which comprised of ad-hoc PAF on targeted antimicrobials once or twice weekly with recommendations made to ACS surgeon(s) using written or verbal methods. Methods Interrupted time series segmented negative binomial regression analysis was used to evaluate the change in the primary outcome of antimicrobial usage measured in Days of Therapy/1000 patient days (DOT/1000-PD) for all systemic and targeted antimicrobials ordered by the ACS team. The structured PAF period was from August 1, 2017- April 30, 2019 while the ad-hoc PAF period was from May 1, 2019-January 31, 2021. Targeted antimicrobials included 3rd generation cephalosporins, piperacillin/tazobactam, carbapenems and clindamycin. Secondary outcomes included C. difficile infections, length of stay and readmission within 30 days. The first two secondary outcomes were analyzed using a logistic regression model while a negative binomial regression model was used to evaluate readmission within 30 days. Results There were 776 ACS patients in the structured PAF period with 783 patients in the ad-hoc PAF period. = No significant changes in level or trend of the primary outcome of DOT/1000-PD in both periods was found for all and targeted antimicrobials. However, there was a trend to small reduction in DOT/1000-PD of 0.9% per month (rate ratio 1.0, CI 0.99-1.02) for all antimicrobials and 0.3% per month (rate ratio 1.0, CI 0.98-1.03) for targeted antimicrobials in the ad-hoc PAF period. Similarly, there were no significant differences with respect to any of the secondary outcomes. There was a trend of 10% increase in length of stay (rate ratio 1.07, CI 0.98-1.17) and 13% reduction in 30-day readmission (OR 0.87, CI 0.56-1.35) in the ad-hoc PAF period. Rates by Time Using Negative Binomial Models for All and Targeted Antimicrobials Conclusion Structured PAF showed similar clinical outcomes to ad-hoc PAF for the Acute Care Surgery Service at our institution. Other antimicrobial stewardship interventions can be explored to better support judicious antimicrobial use in General Surgery. Disclosures All Authors: No reported disclosures.

Abstract 13786: Effectiveness of Ambulatory Pulmonary Artery Pressure-Guided Therapy in Reducing Readmissions in Patients With Heart Failure With Reduced Ejection Fraction versus Heart Failure With Preserved Ejection Fraction

Introduction: The cardio-microelectromechanical system (CardioMEMS) is an implantable pulmonary artery pressure monitoring device that aims to avoid decompensated heart failure (HF) admissions through hemodynamic-guided care. The aim of our study was to compare the impact of CardioMEMS implantation on hospital readmissions between HFrEF and HFpEF patients. Methods: Data from the National Readmission Database 2015 to 2019 were analyzed. International Classification of Diseases codes were used to identify patients hospitalized for HF and those with CardioMEMS implantation. The outcome of interest was the 30-day readmission rate. Multivariate logistic regression analysis was done to account for possible confounders. Results: We identified 3,801,661 admissions with a primary diagnosis of HF. Of these, 2,279,203 (59.95%) patients carried a diagnosis of HFrEF, while 1,522,458 (40.05%) had HFpEF. Patient characteristics are shown in the table. CardioMEMS was implanted in 1100 patients with HFrEF, and 297 patients with HFpEF. Among patients with HFrEF, those who received CardioMEMS implantation during the index admission had a significantly lower 30-day readmission rate compared to those who did not (16.4% vs 21.0%, adjusted odds ratio [OR] 0.74, 95% confidence interval [CI] 0.63-0.87, p &lt;0.01) (Figure). However, among HFpEF patients, there was no significant reduction in 30-day readmissions after CardioMEMS implantation (19.8% vs 20.7%, adjusted OR 0.95, 95% CI 0.72-1.27, p = 0.37) (Figure). CardioMEMS implantation was not associated with a higher rate of complications such as major bleeding, acute kidney injury, or stroke, in both HFrEF and HFpEF groups. Conclusions: Our findings suggest that ambulatory pulmonary artery pressure-guided therapy may be more effective in reducing HF readmissions in patients with HFrEF than in those with HFpEF. This may have significant clinical implication in appropriate patient selection for CardioMEMS implantation.

A multidisciplinary program based on early care in a day hospital after heart failure hospitalizations. Reduction of 30-day readmissions in patients discharged from cardiology departments

Abstract Introduction and objectives Readmission rates at 30 days after admission for heart failure (HF) are high. Patients admitted in Cardiology are usually younger and with lower comorbidity than the total population with HF. Our department leads a multidisciplinary program for the management of HF (MHFP), based on early post-discharge follow-up in a day hospital, for clinical-analytical assessment, optimization and titration of pharmacological treatment, structured education, promotion of self-care and intravenous treatment if appropriate. The objective of this study is to assess the impact of the MHFP on all cause 30-day readmission rate in our patients (MHFP group), compared with the rest of the Cardiology units in our region (control group). Methods All discharges with HF main diagnosis in our region were analyzed through anonymized consultation of the Minimum Basic Data Set (a public administrative data base) in the period 2009–2015. The first admission of each patient in the period was identified as index admission, excluding patients who died at that admission and selecting only discharges by Cardiology. Epidemiological characteristics, comorbidities and hospital length of stay were compared in the two groups. The outcome variable was the time to first readmission for any cause in the first 30 days after discharge from index admission. Quantitative variables were compared using Student's t and categorical variables with χ2. For the multivariate analysis, Cox method was used. Results We included 15,440 patients, 474 in the MHFP group and 14,966 in the control group. The epidemiological characteristics and main comorbidities were compared, and the results are shown in the table. Readmission rate was significantly lower in the MHFP group (9.9 vs 14.2%, HR 0.72, 95% CI: 0.54–0.96 in multivariate analysis). The variables independently associated with an increase in 30-day readmissions were the age-adjusted Charlson index and chronic kidney disease. Conclusions Over a period of 6 years, in patients with HF, discharged by Cardiology, a MHFP significantly reduced all cause 30-day readmissions. Funding Acknowledgement Type of funding sources: None.

A multidisciplinary program based on early follow-up in a day hospital after heart failure hospitalizations. Reduction of 30-day readmissions in a population analysis over a 6-year period

Abstract Introduction and objectives Readmission rates at 30 days after heart failure (HF) hospitalizations are high. Disease management programs have shown to reduce them; however, the results of clinical trials are difficult to extrapolate to the entire population with HF. Our hospital has a multidisciplinary program for HF management (MHFP) led by the Cardiology Department, based on early post-discharge follow-up in a day hospital, for clinical-analytical assessment, optimization and titration of pharmacological treatment, structured education, promotion of self-care and intravenous treatment if appropriate. The objective of this study is to assess the impact of the MHFP on our patients all cause 30-day readmission rate (MHFP group), compared with the rest of our region (control group). Methods All discharges with HF as main diagnosis in our region were analysed through anonymized consultation of the Minimum Basic Data Set (an administrative public data base) in the period 2009–2015. The first admission of each patient in the period was identified as index admission. Patients who died in the index admission were excluded. Epidemiological characteristics, comorbidities and hospital stay were compared in the two groups. The outcome variable was the time to first readmission in the first 30 days after discharge. Quantitative variables were compared using Student's t and categorical variables with χ2. Cox method was used for multivariate analysis. Results We included 62,162 patients, 1,447 in the MHFP group and 60,715 in the control group. Epidemiological characteristics and main comorbidities were compared, and the results are shown in the table. Readmission rate was significantly lower in the MHFP group (13.5 vs 16%, HR 0.85, 95% CI 0.74–0.98 in multivariate analysis). The variables independently associated with an increase in readmissions at 30 days were age adjusted Charlson index, hospital length of stay in index admission and several comorbidities (obstructive pulmonary disease, myocardial infarction, and renal failure) Conclusions Over a period of 6 years, a MHFP significantly reduced 30-day readmissions after admission for HF, in its reference area. The generalization of these programs could have a relevant impact on costs reduction. Funding Acknowledgement Type of funding sources: None.

Optimizing healthcare utilization in atrial fibrillation complicated by cancer

Abstract Funding Acknowledgements Type of funding sources: None. Background Previous studies have shown that atrial fibrillation is a significant cause of healthcare utilization and readmissions. Cancer is also an extenuating burden and has been shown to complicate management strategies, inducing higher utilization.1 We aimed to discover the impact of atrial fibrillation in the setting of non-metastatic cancer and managements which optimize healthcare consumption. Methods We queried the 2016-2018 National Readmission Database (NRD) for adults with a primary atrial fibrillation diagnosis and a secondary non-metastatic cancer diagnosis using ICD-10-CM codes and the Elixhauser Comorbidity Software. Patients were included if the admission was between January and November. Patients were excluded if the index admission was in December (to allow for 30-day readmissions), included cardiac arrest, cardiogenic shock, or they previously had a cardiac pacemaker inserted. Survey weighting methodology was used in accordance with NRD best practices. Propensity score matching was implemented to assess the average treatment effect on the treated (ATET) using a percutaneous loop recorder. Patients were matched on socioeconomic and hospital characteristics, in-hospital medical or procedural complications, and comorbidities. Results From 2016-2018, 21,922 patients met the inclusion criteria for index admissions. The average index admission age was 74.7 years, and 47.3% were female. Length of stay for index admissions was not significantly different between the two groups (4.33 days versus 4.90 days; p = 0.496). In-hospital mortality occurred in 1.65% of admissions, none of which had undergone insertion of a loop recorder. Overall, 18.8% of index admissions were readmitted within 30-days. The readmission rate for patients receiving a loop recorder was 5.5%, compared to 18.9% in the control group. Propensity score matching revealed a 70.2% reduction in 30-day readmissions (OR, 0.099 to 0.907; p = 0.033) for patients discharged with a loop recorder. Patients with a loop recorder have no significant difference in length of stay (5.72 days versus 5.79 days; p = 0.944) when readmitted. Conclusions Patients admitted for atrial fibrillation complicated by cancer had significantly lower readmission rates when discharged with a loop recorder. This phenomenon may be related to the increased ambulatory monitoring and early intervention ability. In the absence of increased length of stays or in-patient mortality, the decrease in healthcare utilization may be of significant benefit. The mechanisms involving factors between atrial fibrillation and cancer are yet to be understood.2,3 Further studies are needed to confirm these findings and evaluate the mechanism by which readmission rates are decreased.

Inpatient Addiction Medicine Consultation Service Impact on Post-discharge Patient Mortality: a Propensity-Matched Analysis.

Inpatient addiction medicine consultation services (AMCS) have grown rapidly, but there is limited research of their impact on patient outcomes. To examine whether AMCS is associated with all-cause mortality and hospital utilization post-discharge. This was a propensity-score-matchedcase-control study from 2018 to 2020. The intervention group included patients referred to the AMCS from October 2018 to March 2020. Matched control participants included patients hospitalized from October 2017 to September 2018 at an urban academic hospital with a large suburban and rural catchment area. The effect of treatment was estimated as the difference between the proportion of subjects experiencing the event (7-day and 30-day readmission, emergency department visits, and mortality within 90 days) for each group in the matched sample. There were 711 patients in the intervention group and 2172 patients in the control group. The most common substance use disorders among the intervention group were primary alcohol use disorder (n=181; 25.5%) and primaryopioid use disorder (n=175, 24.6%) with over a third with polysubstance use (n=257, 36.1%). Intervention patients showed a reduction in 90-day mortality post-hospital discharge (average treatment effect [ATE]: -2.35%, 95% CI: -3.57, -1.13; p-value <0.001) compared to propensity-matched controls. We found a statistically significant reduction in 7-day hospital readmission by 2.15% (95% CI: -3.65, -0.65; p=0.005) and a nonsignificant reduction in 30-day readmission (ATE: -2.38%, 95% CI: -5.20, 0.45; p=0.099). There was a statistically significant increase in 30-day emergency department visits (ATE: 5.32%, 95% CI: 2.19, 8.46; 0.001) compared to matched controls. There was a reduction in 90-day all-cause mortality for the AMCS intervention group compared to matched controls, although the impact on hospital utilization was mixed. AMCS are systems interventions that are effective tools to improve patient health and reduce all-cause mortality.

Outcomes of Patients With Hematologic Malignancies Who Received Inpatient Palliative Care Consultation.

Palliative care (PC) plays an established role in improving outcomes in patients with solid tumors, yet these services are underutilized in hematologic malignancies (HMs). We reviewed records of hospitalized patients with active HM to determine associations between PC consultation and length of stay, intensive care unit stay, 30-day readmission, and 6-month mortality compared with those who were not seen by PC. We reviewed all oncology admissions at our institution between 2013 and 2019 and included patients with HM actively on treatment, stratified by those seen by PC to controls not seen by PC. Groups were compared using Wilcoxon rank-sum, chi-square, and Fisher's exact tests on the basis of the type and distribution of data. Multiple logistic regression models with stepwise variable selection methods were used to find predictors of outcomes. Three thousand six hundred fifty-four admissions were reviewed, among which 370 unique patients with HM were included. Among these, 102 (28%) patients saw PC, whereas the remaining 268 were controls with similar comorbidities. When compared with controls, PC consultation was associated with a statistically significant reduction in 30-day readmissions (16% v 27%; P = .024), increased length of stay (11.5 v 6 days; P < .001), increased intensive care unit admission (28% v 9%; P < .001), and increased 6-month mortality (67% v 15%; P < .001). These data were confirmed in multivariable models. In this retrospective study, more than two thirds of patients with HM did not receive PC consultation despite having similar comorbidities, suggesting that inpatient PC consultation is underutilized in patients with HM, despite the potential for decreased readmission rates.

The Pharmacist Discharge Care (PHARM-DC) study: A multicenter RCT of pharmacist-directed transitional care to reduce post-hospitalization utilization

BackgroundOlder adults commonly face challenges in understanding, obtaining, administering, and monitoring medication regimens after hospitalization. These difficulties can lead to avoidable morbidity, mortality, and hospital readmissions. Pharmacist-led peri-discharge interventions can reduce adverse drug events, but few large randomized trials have examined their effectiveness in reducing readmissions. Demonstrating reductions in 30-day readmissions can make a financial case for implementing pharmacist-led programs across hospitals. Methods/DesignThe PHARMacist Discharge Care, or the PHARM-DC intervention, includes medication reconciliation at admission and discharge, medication review, increased communication with caregivers, providers, and retail pharmacies, and patient education and counseling during and after discharge. The intervention is being implemented in two large hospitals: Cedars-Sinai Medical Center and the Brigham and Women's Hospital. To evaluate the intervention, we are using a pragmatic, randomized clinical trial design with randomization at the patient level.The primary outcome is utilization within 30 days of hospital discharge, including unforeseen emergency department visits, observation stays, and readmissions. Randomizing 9776 patients will achieve 80% power to detect an absolute reduction of 2.5% from an estimated baseline rate of 27.5%. Qualitative analysis will use interviews with key stakeholders to study barriers to and facilitators of implementing PHARM-DC. A cost-effectiveness analysis using a time-and-motion study to estimate time spent on the intervention will highlight the potential cost savings per readmission. DiscussionIf this trial demonstrates a business case for the PHARM-DC intervention, with few barriers to implementation, hospitals may be much more likely to adopt pharmacist-led peri-discharge medication management programs.Trial registration: ClinicalTrials.gov Identifier: NCT04071951

Emergency Department Peer Support Specialist Program.

Emergency Department Peer Support Specialist Program.

126. evaluation of Addition of Outpatient Parenteral Antimicrobial Therapy and Orthopedic ID Resources to Transitions-of-care Outcomes

BackgroundOur large academic medical center initiated both an Outpatient Parenteral Antimicrobial Therapy (OPAT) program supported by an infectious disease trained pharmacist, along with an Orthopedic Infectious Disease (OID) consult service to assist in caring for these specialized populations. We measured the impact of these services.MethodsPatients discharged on parenteral antimicrobial therapy were divided into two groups. The pre-OPAT cohort included all patient receiving OPAT from 4/1/18 - 10/31/18; the post-OPAT cohort included all patients who received OPAT from 4/1/19 - 10/31/19 with OPAT consult (Fig 1). The OID consult service began in September 2018 prior to initiation of the OPAT program. The primary outcome was 30-day hospital readmission. Secondary outcomes included: length of stay (LOS), 90-day readmission, clinical outcomes, and identification of predictors of hospital readmission. Clinical outcomes included: time from final OR visit to discharge for OID patients and optimal treatment (cefazolin, oxacillin, or nafcillin) for MSSA. ResultsIntroduction of these programs was associated with a reduction in all-cause 30-day readmission from 39.3% to 22.9%, and a reduction in 30-day readmission for patients on-treatment from 24.6% to 15.6% (p< 0.01 for both). No difference was seen in hospital LOS (8 days in each cohort). In a subgroup analysis (Fig 2), OID patients in the post-OPAT cohort saw a median reduction of 2 days (7 days to 5 days, p=0.002) in time from final OR visit to discharge. Use of optimal treatments for MSSA increased in the post-OPAT cohort compared to pre-OPAT (65.2% to 80.9%; p=0.06). The 90-day hospital readmission rate were higher in the post-OPAT cohort among patients who lived in metro-area zip codes (p=0.03). Having an established primary care physician was associated with lower 90-day hospital readmission in both the pre-and post-OPAT cohorts (p=0.05 and 0.01, respectively).ConclusionThirty-day readmission rates among patients discharged on OPAT significantly lowered following initiation of a combination of both a pharmacist-led OPAT program and OID consult service. OPAT and OID programs accrue additional efficiencies and clinical benefits to both patients and hospitals, which can be further evaluated and used to justify such service additions.Disclosures All Authors: No reported disclosures

S0740 Economic Impact and Health-Care Utilization Trends Related to Hospitalization and Hospital Readmissions in Patients With Inflammatory Bowel Disease (IBD): A U.S. Population Cohort Study

INTRODUCTION: Hospitalization and readmissions (RAs) are considered poor quality outcomes in IBD patients (pts). However, the financial impact of RAs and predictors of this outcome are less well characterized in IBD. We hypothesized that since newer biologics have improved care of pts with IBD over the past years then there should be a beneficial impact on the cost of care, length of stay (LOS) and mortality during the index and RA hospitalization and reduction in 30-day RAs in pts with IBD. METHODS: This is a retrospective cohort study using the National Readmission Database (data on 17 million discharges each year in 27 states, accounting for 56% of all U.S. hospitalization). We identified pts admitted with IBD from 2010 to 2014 using ICD-9-CM codes. We excluded patients with age <18 yrs or who died during their index hospitalization or had elective RA. Trends of the total cost, LOS and in-hospital mortality was assessed in both the index and the RA hospitalization. Trend analysis was performed using the Cochrane Armitage Trend test. The cost was inflation-adjusted in reference to 2020. We also evaluated risk factors associated with 30-day hospital RA using multivariable logistic regression. RESULTS: The total number of index IBD admissions were 1,350,428, of which 234,216 (17.3%) were readmitted to the hospital within 30 days. From 2010 to 2014, 30-day RA trends remained stable at ∼17% (Figure 1A) and the in-hospital mortality trend in readmitted pts remained stable at 0.5%. (Figure 1B). While the mean LOS of the index hospitalization was stable at 5.5 days from 2010 to 2014 (Figure 2A), the aggregate cost of hospitalization decreased from 59 million to 55 million USD. There was a simultaneous rise in RA cost from 9.4 million to 12.5 million USD (Figure 2B). Table 1 shows the independent predictors of 30-days hospital RA. Younger age, male sex, longer index hospital LOS, higher comorbidities, the presence of VTE and C. diff infection during the index hospitalization were associated with an increased risk of 30-days RA. CONCLUSION: Despite the advent of new biologics and their widespread use, we found that the 30-day hospital RA rate, index and RA LOS and in-hospital mortality were unchanged in a nationwide cohort of IBD pts from 2010 to 2014, and interestingly the economic burden related to RA is increasing. We identified risk factors associated with 30-days RA. Pts at risk for RA need to be targeted during their index hospitalization in order to attempt to lessen the economic burden.Figure 1.: A) Trend of 30-day all-cause readmission B) Trend of 30-day inpatient mortality.Figure 2.: A) The trend of the length of stay on index hospitalization and following readmission B) The trend of aggregate cost of hospitalization on index hospitalization and following readmission.Table 1.: Factors associated with 30-day readmission in IBD patients

Impact of a Novel Post-Discharge Transitions of Care Clinic on Hospital Readmissions

BackgroundThe Center for Medicare and Medicaid Services (CMS) has targeted hospital readmissions, which cost $17 billion per year, as one potential solution to reduce rising health care costs. Studies have documented the ability of Transitions of care (TOC) services to reduce readmissions in high risk patients. However, the vast majority of studies have not explored TOC services for all-cause admissions nor TOC clinics led by hospitalists. The goal of this study is to provide preliminary data regarding the potential effectiveness of a hospitalist-led TOC clinic servicing all patients on hospital readmission rates. MethodsThis cross-sectional feasibility study analyzed patients on a tertiary hospital teaching service. All discharged patients from January 2016 to September 2018 were given an appointment at the TOC clinic within 14 days of discharge. The control group consisted of patients assigned to the teaching service from January 2018 to November 2018 that were not offered a TOC appointment. ResultsOverall, 1373 patients (n = 1373) were included in this study between January 2016 and September 2018. The control group consisted of 1000 patients who were not offered follow up in the TOC clinic while the TOC group consisted of 373 patients who did attend a follow up appointment in the TOC clinic. The study participants (n = 1373) included patients admitted to the hospital for any diagnosis and were analyzed for all cause readmission rates. The TOC group consisted of 52% African Americans, 52% Medicare patients and 8% Medicaid patients. Demographic information for the control group was not available. The TOC group had a statistically significant 42% decreased risk of being readmitted within 30 days of discharge (RR = 0.58, 95% CI: 0.40-0.83). These data showed a statistically significant difference between the TOC group and control group in relation to the incidence of 30-day readmissions (p-value = 0.002). ConclusionAmong Medicare and Medicaid beneficiaries and commercial health insurance patients, this hospitalist-led TOC intervention was associated with a statistically significant reduction in 30-day readmissions following discharge for all-cause hospital admissions.

Readmissions Reduction Program: Mortality and Readmissions for Chronic Obstructive Pulmonary Disease.

Rationale: Implementation of the Hospital Readmissions Reduction Program (HRRP) following discharge of patients with chronic obstructive pulmonary disease (COPD) has led to a reduction in 30-day readmissions with unknown effects on postdischarge mortality.Objectives: To examine the association of HRRP with 30-day hospital readmission and 30-day postdischarge mortality rate in patients after discharge from COPD hospitalization.Methods: Retrospective cohort study of readmission and mortality rates in a national cohort (N = 4,587,542) of admissions of Medicare fee-for-service beneficiaries 65 years or older with COPD from 2006 to 2017.Measurements and Main Results: Data were analyzed for three nonoverlapping periods based on implementation of the HRRP specific to COPD: 1) preannouncement (December 2006 to March 2010), 2) announcement (April 2010 to August 2014), and 3) implementation (October 2014 to November 2017). The 30-day readmission rate decreased from 20.54% in the preannouncement period (December 2006 to July 2008) to 18.74% in the implementation period (May 2016 to November 2017). The 30-day risk-standardized postdischarge mortality rates were 6.91%, 6.59%, and 7.30% for the preannouncement, announcement, and implementation periods, respectively. Generalized estimating equations analyses estimated an additional 1,196 deaths (October 2014 to April 2016) and 3,858 deaths (May 2016 to November 2017) during the HRRP implementation period.Conclusions: We found a reduction in 30-day all-cause readmission rate during the implementation period compared with the preannouncement phase. HRRP implementation was also associated with a significant increase in 30-day mortality after discharge from COPD hospitalization. Additional research is necessary to confirm our findings and understand the factors contributing to increased mortality in patients with COPD in the HRRP implementation period.

Association of an Acute Myocardial Infarction Readmission-Reduction Program With Mortality and Readmission.

Reducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated. We started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119). An AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.

Pharmacist-led transitions-of-care program reduces 30-day readmission rates for Medicare patients in a large health system.

This report describes the growth and development of the Pharmacy Transitions of Care (PTOC) program at a Florida health system and examines its impact on 30-day readmission rates for Medicare core-measure patients. BayCare Health System is a large not-for-profit community health system with 15 hospitals in central Florida. In 2015, the PTOC program was developed to integrate 2 pharmacists into the transitions-of-care space to reduce readmissions, enhance patient care, and improve medication safety. The PTOC program focuses on traditional Medicare beneficiaries 65 years of age or older with the goal of preventing 30-day readmissions. The service model includes integration of a pharmacist into the discharge medication reconciliation process, as well as postacute care telephonic follow-up. Data and outcomes have been carefully tracked since program inception and consistently demonstrate a reduction in 30-day readmissions, with a 63% relative risk reduction during the beginning phases of the program and a ratio of observed to expected readmissions of 0.77. As a result, in less than 3 years the PTOC program has grown from 2 to 23 pharmacists and is a key component of BayCare Health System's patient care strategy. Medication reconciliation, clinical interventions, and patient education by pharmacists after hospital discharge reduced 30-day readmission rates for Medicare core-measure patients across a large health system. The adaptability of this program to other health systems and hospitals of varying size to achieve similar outcomes is valuable to share with the profession.

Improvement in the medication reconciliation postdischarge quality measure after implementation of a pharmacist-run service

ObjectiveThis study aimed to evaluate the impact of a pharmacist-led postsurgical discharge medication reconciliation program in an accountable care organization–like setting. SettingMultidisciplinary primary care network in Central Ohio. Practice descriptionAmbulatory care pharmacists are integrated in a primary care network, which includes a centralized focus on assistance with population health metrics, along with an interdisciplinary team. Practice innovationIn May 2018, a pharmacist-led medication reconciliation postdischarge (MRP) program was initiated focused on a postsurgical discharge population. EvaluationA retrospective chart review was conducted to compare the 2 primary end points of overall MRP rates from 4 payers in 2017 and 2018, and the postsurgical MRP rates from May 25 to November 30 of 2017 and 2018. Secondary outcomes included description of pharmacist interventions in pharmacy-led service and 30-day readmission or emergency department (ED) utilization rates for postsurgical population. ResultsA total of 5837 hospitalizations were identified as eligible for overall MRP completion in 2017 (n = 2621) and 2018 (n = 3216). A 20% relative increase in overall MRP completion was reported in 2018 (P < 0.001). In 2017, 55.9% of postsurgical MRPs were completed. The implementation of the pharmacy-led MRP program led to a 41% relative increase in postsurgical MRP completion (78.9% in 2018, P < 0.001). Pharmacists completed 220 postsurgical MRPs in the 6-month study period, including 765 total recommendations for intervention and an average of 3 recommendations and 4 medication list updates per MRP. There was no statistically significant reduction in 30-day readmission and ED utilization rates in 2018 (6.8% in 2017 vs. 6.2% in 2018, P = 0.74). ConclusionA pharmacy-led postsurgical discharge program led to an increase in MRP completion rates in the target postsurgical MRP population, which also positively affected the overall MRP completion rate. Pharmacists can be key players in the improvement and quality of MRP measures.

Abstract 185: The Expanded Benefit of Neprilysin Inhibitor Therapy on 30 Day Readmissions: A Useful Tool at a Safety Net Hospital

Introduction: Heart failure (HF) related hospitalizations contribute to the ever-increasing financial burden of chronic disease. There are approximately 6.5 million individuals in the US with HF, with an estimated annual cost of $39 billion. Within the arsenal of strategies developed to curb this trend, pharmacological therapy has shown to be very effective. Whilst many drugs are favored for their ability to reduce mortality and morbidity, neprilysin-inhibitors (ARNI) have recently shown to reduce 30-day readmissions in patients with HF, presenting an expanded indication to favor its usage. Methods: A retrospective review of patients discharged from the Kings County Hospital Center from October 1 st 2017 to June 30 th 2018 with a diagnosis of heart failure was conducted. Inclusion required follow up in the Heart Health Clinic at Kings County Hospital and discharge therapy with a beta-blocker and either an ACE-I, ARB or ARNI. Patients were divided into 2 groups, those continued on an ACE-i/ARB versus those who were transitioned to an ARNI. The end outcome was a 30-day all-cause readmission for heart failure at any point after enrollment. Time to event was calculated using the date the drug was started. If the drug was started prior to being enrolled, we used the date that the patient was enrolled in the study. Demographic data was extracted via chart review and analyzed by descriptive statistics. A Kaplan-Meier survival analysis was done to compare the time-to-event between both study cohorts. Results: There were 101 patient discharges. There was no statistically significant age or gender difference between cohorts. The mean age in the ARNI group was 60.4 and in the ACE-i/ARB group was 64.7. A 30-day readmission occurred in 3 (10.7%) of the 28 patients in the intervention group, compared with 21 (28.8%) of the 73 patients with ACE-i/ARB therapy. The patients transitioned to ARNI therapy had a better event free survival with a 62.8% reduction in 30-day readmission events (log rank p=0.046). Conclusion: There is statistically significant reduction in 30-day all-cause readmission following the initiation of ARNI therapy in the treatment for HF. While this trend was shown in a prospective post-hoc analysis of the initial PARADIGM-HF trial, our study presents a unique patient benefit group. Kings County Hospital serves as a safety net hospital that has a large volume of uninsured, low socioeconomic status patients, with a large African American influence, and compounded social and environmental factors that make them highly prone to CHF readmissions. It underscores the need for clinically useful strategies to reduce the burden of CHF related readmissions especially for hospitals located in low socioeconomic areas at risk for penalties.