Subsequent Readmission Research Articles

IMPACT OF COVID-19 MEASURES ON SURGICAL SITE INFECTION RATE IN ORTHOPAEDIC PATIENTS

The aim of this study was to assess the impact of Covid-19 measures on the rate of surgical site infections (SSI) and subsequent readmissions in orthopaedic patients.Retrospective, observational study in a level 1 major trauma center comparing rates of SSI in orthopaedic patients who underwent surgery prior to the Covid-19 lockdown versus that of patients who underwent surgery during the lockdown period. A total of 1151 patients were identified using electronic clinical records over two different time periods; 3 months pre Covid-19 lockdown (n=680) and 3 months during the Covid-19 lockdown (n=470). Patients were followed up for 1 year following their initial procedure. Primary outcome was readmission for SSI. Secondary outcomes were treatment received and requirement for further surgeries.The most commonly performed procedures were arthroplasty and manipulation under anaesthesia with 119 in lockdown vs 101 non-lockdown (p=0.001). The readmission rate was higher in the lockdown group with 61 (13%) vs 44 (6.5%) in the non-lockdown group (p <0.001). However, the majority were due to other surgical complications such as dislocations. Interestingly, the SSI rates were very similar with 24 (5%) in lockdown vs 28 (4%) in non-lockdown (p=0.472). Twenty patients (4.2%) required a secondary procedure for their SSI in the lockdown group vs 24 (3.5%) in non-lockdown (p=0.381). Mortality rate was similar at 44 (9.3%) in lockdown vs 61 (9.0%; p=0.836).Whilst Covid-19 precautions were associated with higher readmission rates, there was no significant difference in rate of SSI between the two groups.

Predictors of hospital readmission after trauma: A retrospective cohort study in New Zealand

IntroductionUnderstanding predictors of hospital readmission following major trauma is important as readmissions are costly and some are potentially avoidable. This study describes the incidence of, and sociodemographic, injury-related and treatment-related factors predictive of, hospital readmission related to: a) all-causes, b) the index trauma injury, and c) subsequent injury events in the 30 days and 12 months following discharge for major trauma patients nationally in New Zealand. MethodsData from the New Zealand Trauma Registry (NZTR) was linked with Ministry of Health hospital discharge data. Hospital readmissions were examined for all patients entered into the NZTR for an injury event between 1 January and 31 December 2018. Readmissions were examined for the 12-months following the discharge date for participant's index trauma injury. ResultsOf 1986 people, 42% had ≥1 readmission in the 12 months following discharge; 15% within 30 days. Seven percent had ≥1 readmission related to the index trauma within 30 days of discharge; readmission was 3.43 (95% CI 1.87, 6.29) times as likely if the index trauma was self-inflicted compared to unintentional, and 1.64 (95% CI 1.15, 2.34) times as likely if the index trauma involved intensive care unit admission. Those admitted to hospital for longer for their index trauma were less likely to be readmitted due to their index trauma injury within 30 days compared to those admitted for 0–1 day. Seventeen percent were readmitted for a subsequent injury event within 12 months, with readmission more likely for older people (>65 years), those with comorbidities, Māori compared with non-Māori and those with higher trauma injury severity. ConclusionA substantial proportion of people are readmitted after discharge for major trauma. Factors identified in this study will be useful to consider when developing interventions to reduce preventable readmissions including those related to the index trauma injury, readmissions from other causes and subsequent injury-related readmissions. Further research specifically examining planned and unplanned readmissions is warranted.

Factors associated with subsequent surgery after septic arthritis of the knee in children.

Septic arthritis of the knee in children is a challenging problem. Surgical debridement is an established treatment, but there is a paucity of literature on long-term prognosis. To determine the rates and factors associated with return to surgery (RTS) and readmission after index surgical debridement for septic arthritis of the knee in children. This is a retrospective cohort study that utilizes data from the Healthcare Cost and Utilization Project (HCUP). We included patients between ages 0 to 18 years that underwent surgical debridement for septic arthritis of the knee between 2005 and 2017. Demographic data included age, gender, race, hospital type and insurance type. Clinical data including index admission length of stay (LOS) and Charlson Comorbidity Index (CCI) were available from the HCUP database. Descriptive statistics were used to summarize the data and univariate and multivariate analyses were performed. Nine-hundred thirty-two cases of pediatric septic knee were included. This cohort was 62.3% male, with mean age of 9.0 (± 6.1) years. Approximately 46% of patients were white and approximately half had Medicaid insurance. Thirty-six patients (3.6%) required RTS at a minimum of 2 year after index surgery, and 172 patients (18.5%) were readmitted at any point. The mean readmission LOS was 11.6(± 11.3) d. Higher CCI was associated with RTS (P = 0.041). There were no significant associations in age, gender, race, insurance type, or type of hospital to which patients presented. Multivariate analysis showed that both increased CCI (P = 0.008) and shorter LOS (P = 0.019) were predictive of RTS. Septic arthritis of the knee is an important condition in children. The CCI was associated with RTS at a minimum of 2 years after index procedure. No association was found with age, gender, race, insurance type, or hospital type. Shorter LOS and CCI were associated with RTS in multivariate analysis. Overall, risk of subsequent surgery and readmission after pediatric septic knee arthritis is low, and CCI and shorter LOS are predictive of RTS.

Validation of Brain Injury Guidelines in the Elderly Trauma Patient Presenting at a Level Two Trauma Center.

Retrospective analysis, validating the brain injury guideline (BIG) in the management of traumatic head injury in our level II trauma center after implementation of the protocol, and compare the outcomes to those seen before the protocol, of 542 patients seen in the Emergency Department (ED), with head injury between 2017 and 2021 was completed. Those patients were divided into two groups: Group 1 (pre BIG protocol implementation) and Group 2 (post BIG protocol implementation). Data included age, race, length of stay (hospital and ICU), comorbid conditions, anticoagulant therapy, surgical intervention, GCS, ISS, findings of head CT and any subsequent progression, mortality, and readmission within one month. Student's t-test and Chi-square test were used for statistical analysis. There were 314 patients in group 1 and 228 patients in group 2. Mean age of group 2 was significantly higher than group 1 (67 vs 59years, p=0.0001), however their gender was similar. Data available on 526 patients were classified as BIG 1=122, BIG 2=73, and BIG 3=331 patients. Post-implementation group were older (70 vs 44years, P=0.0001) with more females (67% vs 45%, P=0.05) and had significantly more than 4 comorbid conditions (29% vs 8%, P=0.004), with the majority presented with a size of 4mm or less of acute subdural or subarachnoid hematoma. No patient in either group had progression of their neurological examination, neurosurgical intervention, or readmission.. Elderly trauma patients may benefit from implementation of BIG criteria protocol, thus reducing cost of patient care, however a larger sample size is needed.

Plitidepsin in adult patients with COVID-19 requiring hospital admission: A long-term follow-up analysis.

The APLICOV-PC study assessed the safety and preliminary efficacy of plitidepsin in hospitalized adult patients with COVID-19. In this follow-up study (E-APLICOV), the incidence of post-COVID-19 morbidity was evaluated and any long-term complications were characterized. Between January 18 and March 16, 2022, 34 of the 45 adult patients who received therapy with plitidepsin in the APLICOV-PC study were enrolled in E-APLICOV (median time from plitidepsin first dose to E-APLICOV enrollment, 16.8 months [range, 15.2-19.5 months]). All patients were functionally autonomous with regard to daily living (Barthel index: 100) and had normal physical examinations. From the APLICOV-PC date of discharge to the date of the extension visit, neither Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5) grade 3-4 complications nor QT prolongation or significant electrocardiogram (EKG) abnormalities were reported. Five (14.7%) patients had another COVID-19 episode after initial discharge from APLICOV-PC, and in 2 patients (5.9%), previously unreported chest X-ray findings were documented. Spirometry and lung-diffusion tests were normal in 29 (85.3%) and 27 (79.4%) patients, respectively, and 3 patients needed additional oxygen supplementation after initial hospital discharge. None of these patients required subsequent hospital readmission for disease-related complications. In conclusion, plitidepsin has demonstrated a favorable long-term safety profile in adult patients hospitalized for COVID-19. With the constraints of a low sample size and a lack of control, the rate of post-COVID-19 complications after treatment with plitidepsin is in the low range of published reports. (ClinicalTrials.gov Identifier: NCT05121740; https://clinicaltrials.gov/ct2/show/NCT05121740).

Early vs. Late Readmission following Percutaneous Coronary Intervention: Predictors and Impact on Long-Term Outcomes.

Readmissions within 1 year after percutaneous coronary intervention (PCI) are common (18.6-50.4% in international series) and a burden to patients and health services, however their long-term implications are not well characterised. We compared predictors of 30-day (early) and 31-day to 1-year (late) unplanned readmission and the impact of unplanned readmission on long-term clinical outcomes post-PCI. Patients enrolled in the GenesisCare Cardiovascular Outcomes Registry (GCOR-PCI) from 2008 to 2020 were included in the study. Multivariate logistic regression analysis was performed to identify predictors of early and late unplanned readmission. A Cox proportion hazards regression model was used to explore the impact of any unplanned readmission during the first year post-PCI on the clinical outcomes at 3 years. Finally, patients with early and late unplanned readmission were compared to determine which group was at the highest risk of adverse long-term outcomes. The study comprised 16,911 consecutively enrolled patients who underwent PCI between 2009-2020. Of these, 1422 patients (8.5%) experienced unplanned readmission within 1-year post-PCI. Overall, the mean age was 68.9 ± 10.5 years, 76.4% were male and 45.9% presented with acute coronary syndromes. Predictors of unplanned readmission included increasing age, female gender, previous CABG, renal impairment and PCI for acute coronary syndromes. Unplanned readmission within 1 year of PCI was associated with an increased risk of MACE (adjusted HR 1.84 (1.42-2.37), p < 0.001) and death over a 3-year follow-up (adjusted HR 1.864 (1.34-2.59), p < 0.001) compared with those without readmission within 1-year post-PCI. Late compared with early unplanned readmission within the first year of PCI was more frequently associated with subsequent unplanned readmission, MACE and death between 1 and 3 years post-PCI. Unplanned readmissions in the first year following PCI, particularly those occurring more than 30 days after discharge, were associated with a significantly higher risk of adverse outcomes, such as MACE and death at 3 years. Strategies to identify patients at high risk of readmission and interventions to reduce their greater risk of adverse events should be implemented post-PCI.

The Association Between Family Medicine Appointment Cancellations and Hospital Utilization in 2019 and 2020.

The COVID-19 pandemic caused a disruption in the usual primary care services offered and received by patients. The objective of this study was to compare the impact of family medicine appointment cancellations on hospital utilization metrics both before and during the COVID-19 pandemic within a family medicine residency clinic. This study is a retrospective chart review of cohorts of patients with a family medicine clinic cancellation who presented to the emergency department during a similar time period before and during the pandemic (March-May of 2019 vs March-May 2020). The patient population studied has multiple chronic diagnoses and prescriptions. Hospital admission, hospital readmission, and length of stay for hospitalizations during these periods were compared. The impacts of appointment cancellations on the emergency department presentation with subsequent inpatient admission, readmission, and length of stay were examined using generalized estimating equation (GEE) logistic or Poisson regression models to account for the lack of independence between patient outcomes. A total of 1878 patients were included in the final cohorts. Of these patients, 101 (5.7%) presented to the emergency department and/or hospital in both 2019 and 2020. An increased odds of readmission was associated with family medicine appointment cancellation regardless of year. The effects of appointment cancellations were not associated with admissions or length of stay between 2019 and 2020. Between the 2019 and 2020 cohorts, appointment cancellations were not associated with significant differences in likelihood of admission, readmission, or length of stay. A higher risk of readmission was associated with patients with a recent family medicine appointment cancellation.

Rates of operative intervention for infection after synthetic or autologous cranioplasty: a National Readmissions Database analysis.

The aim of this study was to characterize the clinical utilization and associated charges of autologous bone flap (ABF) versus synthetic flap (SF) cranioplasty and to characterize the postoperative infection risk of SF versus ABF using the National Readmissions Database (NRD). The authors used the publicly available NRD to identify index hospitalizations from October 2015 to December 2018 involving elective ABF or SF cranioplasty after traumatic brain injury (TBI) or stroke. Subsequent readmissions were further characterized if patients underwent neurosurgical intervention for treatment of infection or suspected infection. Survey Cox proportional hazards models were used to assess risk of readmission. An estimated 2295 SF and 2072 ABF cranioplasties were performed from October 2015 to December 2018 in the United States. While the total number of cranioplasty operations decreased during the study period, the proportion of cranioplasties utilizing SF increased (p < 0.001), particularly in male patients (p = 0.011) and those with TBI (vs stroke, p = 0.012). The median total hospital charge for SF cranioplasty was $31,200 more costly than ABF cranioplasty (p < 0.001). Of all first-time readmissions, 20% involved surgical treatment for infectious reasons. Overall, 122 SF patients (5.3%) underwent surgical treatment of infection compared with 70 ABF patients (3.4%) on readmission. After accounting for confounders using a multivariable Cox model, female patients (vs male, p = 0.003), those discharged nonroutinely (vs discharge to home or self-care, p < 0.001), and patients who underwent SF cranioplasty (vs ABF, p = 0.011) were more likely to be readmitted for reoperation. Patients undergoing cranioplasty during more recent years (e.g., 2018 vs 2015) were less likely to be readmitted for reoperation because of infection (p = 0.024). SFs are increasingly replacing ABFs as the material of choice for cranioplasty, despite their association with increased hospital charges. Female sex, nonroutine discharge, and SF cranioplasty are associated with increased risk for reoperation after cranioplasty.

Assessing the Effect of an Inpatient Smoking Cessation Brief Intervention Tool on Long-Term Smoking Cessation Rates and Patient Interest for Nicotine Replacement Therapy: A Retrospective Analysis

Introduction: Smoking cessation among hospital inpatients is essential to reduce risk of surgical complications and all-cause mortality. In the Australian state of Queensland, the Smoking Cessation Clinical Pathway (SCCP), a brief intervention tool, has been used by clinical staff in public hospitals to uniformly support patients to quit smoking since 2015. This study aims to assess the effect of the SCCP on long-term smoking cessation rates recorded in subsequent readmissions, and whether the SCCP as an intervention affects inpatients’ interest in nicotine replacement therapy (NRT) during admission and after discharge. Methods: We retrospectively analysed data provided by the Princess Alexandra Hospital (PAH) on patients who self-identified as a current smoker on admission to any ward and were admitted to the PAH between 1st January 2018 and 31st December 2019. Smoking cessation rates and patient interest in NRT by SCCP completion were analysed using χ2 tests and a multinomial logistic regression. Results: Of 1,902 included patients, NRT was offered to 1,397 patients (73.4%) and accepted by 332 patients (17.5%). Patients who had completed a SCCP were more likely to be offered NRT than those who had not (p < 0.0001). Of the 452 patients with multiple readmissions, 100 (22%) ceased smoking at any point in the 2-year study period. At the end of the 2-year study period, 75 (75%) patients remained abstinent and only 25 (25%) relapsed to smoking as per their final smoking status at the end of the 2-year study period. Patients with a completed SCCP were 1.8 times (RRR: 1.825, p = 0.030) more likely to quit smoking at any point in the 2-year study period, and twice as likely to have quit at the end of the 2-year study period (RRR: 2.064, p = 0.044). Discussion: The SCCP may be effective at increasing smoking cessation rates among hospital inpatients. Future policies promoting long-term smoking cessation should consider implementation of post-discharge follow-up appointments.

Exploring ethnic differences in post-discharge patterns of surgical care for older adults admitted with diverticulitis.

We aimed to evaluate ethnic differences in patterns of care following an index nonoperative admission for acute diverticulitis amongst a universally insured patient cohort. We identified nationwide Medicare beneficiaries aged 65.5 years or older hospitalized between 1 July 2015 and 1 November 2017 for nonoperative management of an index admission for diverticulitis. Patients were followed for 1 year to examine patterns of care. Primary categorical outcomes included receipt of an elective operation, emergency operation, nonoperative readmission or no further hospitalizations for diverticulitis. Multinomial regression was performed to determine the association between ethnicity and receipt of each primary outcome category whilst adjusting for potential confounders. We examined the use of percutaneous drainage during the index admission to better understand its association with subsequent care patterns. Amongst 22 630 study patients, subsequent operative treatment was less common for Black, Hispanic, Asian and American Indian patients relative to White patients. Multinomial logistic regression noted that Black (relative risk 0.40; 95% CI 0.32-0.50) and Asian (relative risk 0.37; 95% CI 0.15-0.91) patients were associated with the lowest relative risk of undergoing an elective interval operation compared to White patients. Black patients were also associated with a 1.43 (95% CI 1.19-1.73) increased risk of requiring subsequent nonoperative readmissions for disease recurrence compared to White patients. The use of percutaneous drainage was higher amongst White patients relative to Black patients (6.9% vs. 4.0%, P value < 0.001). We have identified ongoing inequities in the consumption of medical resources, with White patients being more likely to undergo elective colectomy and percutaneous drainage. Differences in care are not fully alleviated by equal access to insurance.

Ballistic Facial Trauma Reconstruction: Incidence and Practice Patterns in the Civilian Population.

Management of nonfatal ballistic facial trauma is well described in the literature for wounds secondary to military combat. However, there is little literature describing such management in civilian practice. We aimed to describe nonmilitary patients with recent nonfatal facial injuries from ballistic trauma using the California Office of Statewide Health Planning and Development patient database. A retrospective study was performed using the California Office of Statewide Health Planning and Development Ambulatory Surgery and Inpatient datasets. All adults with the International Classification of Diseases, 10th Revision codes of severe nonfatal facial trauma from firearms requiring emergent surgery during 2016-2018 were included. Outcomes assessed include number and type of facial procedures performed, hospital length of stay, number of admissions, timing of definitive management, and lifetime hospitalization costs. A total of 331 traceable patients were identified over this 3-year period. The average age was 35.4 years (SD, 15.2), and 87% were male. The median index admission length of stay was 8 days (interquartile range, 3-15 days). Subsequent readmission was required for 123 (37.2%) patients with 10% mortality in the index admission. Total median charges per patient for all admissions were $257,804 (interquartile range, $105,601-$531,916). A total of 215 patients (65%) had at least 1 facial repair performed. Of all 331 patients, 64.3% underwent musculoskeletal repair (n = 213), 31.4% underwent digestive system repair (n = 104), and 29.6% underwent respiratory system repair (n = 98). The average number of repairs per patient was 2.52 (SD, 3.38), with 35% not having any of the specified International Classification of Diseases, 10th Revision repair codes. A total of 27% of patients had 1 procedure performed, whereas 38% received 2 or more, for an average of 3.87 (SD, 3.5) repairs over the study duration. To our knowledge, this is the first assessment of civilian characteristics of nonfatal ballistic facial trauma in California. Nonfatal facial ballistic trauma results in complex injuries to multiple body systems, requiring long admissions, costly hospital stays, and coordination of care across several surgical specialties. Many patients require a variety of procedures over multiple admissions, highlighting the overall morbidity of these injuries. Future studies will look at how care for these patients differs between various hospitals and geographic regions and whether current civilian management aligns with well-defined military reconstructive protocols for facial ballistic injuries.

Healthcare Utilization and Mortality After Hospice Live Discharge Among Medicare Patients With and Without Alzheimer's Disease and Related Dementias.

Little is known about post-discharge outcomes among patients who were discharged alive from hospice. To compare healthcare utilization and mortality after hospice live discharge among Medicare patients with and without Alzheimer's disease and related dementias (ADRD). Retrospective cohort study using Medicare claims data of a 20% random sample of Medicare fee-for-service (FFS) patients. A total of 153,696 Medicare FFS patients experienced live discharge from hospice between 2014 and 2019. Two types of burdensome transition (type 1: live discharge from hospice followed by hospitalization and subsequent hospice readmission; type 2: live discharge from hospice followed by hospitalization with the patient deceased in the hospital), acute care utilization, hospice readmission, and mortality in the 30 and 180 days after live discharge and between live discharge and death. Compared with non-ADRD patients, ADRD patients were less likely to experience burdensome transitions (type 1: adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.90-0.98; type 2: aOR, 0.70; 95% CI, 0.65-0.75), more likely to have ED visits (aOR, 1.05; 95% CI, 1.01-1.09), less likely to die (aOR, 0.71; 95% CI, 0.69-0.73), and less likely to be readmitted to hospice (aOR, 0.86; 95% CI, 0.84-0.89) 30 days after live discharge. Results of 180-day post-discharge outcomes were largely consistent with results of 30-day outcomes. Among patients who died as of December 31, 2019, ADRD patients were less likely to be hospitalized (aOR, 0.88; 95% CI, 0.85-0.92) and more likely to be readmitted to hospice (aOR, 1.12; 95% CI, 1.08-1.16) between live discharge and death. Significant racial/ethnicity disparities in acute care utilization and mortality after live discharge existed in both ADRD and non-ADRD groups. ADRD patients had lower mortality, a longer survival time, a lower rate of hospitalization, and an initially lower but gradually increasing rate of hospice readmission than non-ADRD patients after hospice live discharge. These different trajectories warrant further investigation of the eligibility of their initial hospice enrollment. Black patients had significantly worse outcomes after hospice live discharge compared with White patients.

Outcomes of a “hospital at home” programme for the supervised home recovery of COVID-19 patients in Singapore

Background The Singapore General Hospital COVID-19 Virtual Ward is a “hospital at home” (HaH) programme for the supervised home recovery of higher-acuity COVID-19 patients from the hospital and the community. Objective To describe how an existing HaH programme was redesigned so that COVID-19 patients could be remotely monitored at home and report the outcomes of the first 100 patients in this Virtual Ward. Methods Patients received an admission package comprising instructions and equipment for home monitoring, and uploaded their parameters into a clinical dashboard via a secure messaging app. Medical staff conducted video or telephone consultations daily. Patients were discharged according to time-based criteria, although some required SARS-CoV-2 PCR testing, which were conducted at home by a third-party medical provider. De-identified data of the first 100 patients were analysed by demographic details, indication for enrolment into the Virtual Ward, and the need for subsequent inpatient readmission. Results Of the first 100 patients admitted into the Virtual Ward, 58 were female, mean age was 63.1 years old (23–95 years), and 76 were fully vaccinated. There were 77 hospital referrals and 23 community referrals. The number of days of inpatient hospitalisation avoided was 717 days (average of 7.9 days per patient). Three hospital referrals (3.9%) were readmitted, while seven community referrals (30.4%) required subsequent hospitalisation. Conclusion The Virtual Ward programme demonstrates that selected COVID-19 patient can safely recover at home with remote medical support and monitoring, thereby expanding hospital capacity.

Individual factors predict substance use treatment course patterns among patients in community-based substance use disorder treatment.

Substance use disorders (SUDs) usually involve a complex natural trajectory of recovery alternating with symptom reoccurrence. This study examined treatment course patterns over time in a community SUD clinic. We examined depressive symptoms level, primary SUD assigned at each admission, and lifetime misuse of multiple substances as potential risk factors for premature treatment termination and subsequent treatment readmission. De-identified longitudinal data were extracted from charts of 542 patients from an SUD treatment center. Survival analysis methods were applied to predict two time-to-event outcomes: premature treatment termination and treatment readmission. Primary opioid (vs alcohol) use disorder diagnosis at admission was associated with higher hazard of premature termination (HR = 1.91, p<0.001). The interaction between depressive symptoms level and substance use status (multiple vs single use) on treatment readmission was significant (p = 0.024), such that higher depressive symptoms level was predictive of readmission only among those with a history of single substance use (marginally significant effect). Lifetime use of multiple (vs single) substances (HR = 1.55, p = 0.002) and age (HR = 1.01, p = 0.019) predicted increased hazard of readmission. Findings did not support a universal role for depressive symptoms level in treatment course patterns. Primary SUD diagnosis, age, and history of substance misuse can be easily assessed and incorporated into treatment planning to support SUD patients and families. This study is the first to our knowledge that afforded a stringent test of these relationships and their interactions in a time-dependent, recurrent event, competing risks survival analysis examining both termination and readmission patterns utilizing a real-world clinic-based sample.

Association of opioid use disorder with outcomes of hospitalizations for acute myocardial infarction in the United States

ObjectiveWhile Opioid Use Disorder (OUD) has been linked to inferior clinical outcomes, studies examining the clinical outcomes and readmission of OUD patients experiencing Acute Myocardial Infarction (AMI) remain lacking. The authors analyze the clinical and financial outcomes of OUD in a contemporary cohort of AMI hospitalizations. MethodsAll non-elective adult (≥ 18 years) hospitalizations for AMI were tabulated from the 2016‒2019 Nationwide Readmissions Database using relevant International Classification of Disease codes. Patients were grouped into OUD and non-OUD cohorts. Bivariate and regression analyses were performed to identify the independent association of OUD with outcomes after non-elective admission for AMI, as well as subsequent readmission. ResultsOf an estimated 3,318,257 hospitalizations for AMI meeting study criteria, 36,057 (1.1%) had a concomitant diagnosis of OUD. While OUD was not significantly associated with mortality, OUD patients experienced superior cardiovascular outcomes compared to non-OUD. However, OUD was linked to increased odds of non-cardiovascular complications, length of stay, costs, non-home discharge, and 30-day non-elective readmission. ConclusionsPatients with OUD presented with AMI at a significantly younger age than non-OUD. While OUD appears to have a cardioprotective effect, it is associated with several markers of increased resource use, including readmission. The present findings underscore the need for a multifaceted approach to increasing social services and treatment for OUD at index hospitalization.

Clostridioides difficile Infection in Patients with Cirrhosis Treated for Hepatic Encephalopathy

Introduction Hospitalizations, proton-pump inhibitors (PPI), and systemic antibiotics increase the risk of Clostridioides difficile infection (CDI) in cirrhosis. We compare the risk of CDI with hepatic encephalopathy (HE) medications, hypothesizing that rifaximin may decrease CDI risk. Materials and Methods A retrospective study of hospitalized HE patients treated with lactulose and/or rifaximin at Mayo Clinic Minnesota, Florida, and Arizona from 2008 to 2013 was conducted. Data on demographics, hospitalizations, antibiotics, and PPI use and CDI were gathered. Univariate and multivariable cox models were constructed. Results We found 1,112 hospitalizations in 1,055 unique patients (55 had 1 subsequent readmission, 1 patient had 2); 428 (40.6%) patients were women (median age: 58 years [interquartile range: 52–65]). CDI developed after 66/1,112 (5.9%) hospitalizations within 12 months post-discharge. Lactulose was administered in 21 (31.8%), rifaximin in 5 (7.6%), both in 40 (60.6%) hospitalizations. Systemic antibiotics were used in 28 (42.4%) patients and PPIs in 60 (90.9%) patients.Univariate analysis using medication (with lactulose alone as the reference group) showed rifaximin was not significantly associated with CDI compared with lactulose (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 0.57–4.33, p = 0.39). Use of both medications was not significant compared with lactulose (HR: 1.41, 95% CI: 0.84–2.38, p = 0.19). Results were similar after controlling for confounders. Multivariable analysis based on length of stay, age, and gender showed no differences between rifaximin versus lactulose and both versus lactulose. Conclusion There is no significant difference between lactulose and rifaximin on CDI development in HE patients. However, CDI should still be considered when managing diarrhea in HE patients.

Days alive and out of hospital after liver transplant: comparing a patient-centered outcome between recipients of grafts from donation after circulatory and brain deaths

We retrospectively compared outcomes between recipients of donation after circulatory death (DCD) and donation after brain death (DBD) liver allografts using days alive and out of hospital (DAOH), a composite outcome of mortality, morbidity, and burden of care from patient perspective. The initial length of stay and duration of any subsequent readmission for the first year after liver transplantation were recorded. Donor category and perioperative and intraoperative characteristics pertinent to liver transplantation were included. The primary outcome was DAOH365. Secondary outcomes included early allograft dysfunction and hepatic arterial and biliary complications. Although the incidence of both early allograft dysfunction (P < .001) and ischemic cholangiopathy (P < .001) was significantly greater in the recipients of DCD, there were no significant differences in the length of stay and DAOH365. The median DAOH365 was 355 days for recipients of DBD allografts and 353 days for recipients of DCD allografts (P = .34). Increased transfusion burden, longer cold ischemic time, and non-White recipients were associated with decreased DAOH. There were no significant differences in graft failure (P = .67), retransplantation (P = .67), or 1-year mortality (P = .96) between the 2 groups. DAOH is a practical and attainable measure of outcome after liver transplantation. This metric should be considered for quality measurement and reporting in liver transplantation.

Ambulance use and subsequent fragmented hospital readmission among older adults.

Interhospital care fragmentation, when a patient is readmitted to a different hospital than they were originally discharged from, occurs in 20%-25% of readmissions. Mode of transport to the hospital, specifically ambulance use, may be a risk factor for fragmented readmissions. Our study seeks to further understand the relationship between ambulance transport and fragmented readmissions in older adults, a population that is at increased risk for poor outcomes following fragmented readmissions. We analyzed inpatient claims from Medicare beneficiaries in 2018 who had a hospital admission for select Hospital Readmission Reduction Program Conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia) as well as dehydration, syncope, urinary tract infection, or behavioral issues. We evaluated the associations between ambulance transport and a fragmented readmission using logistic regression models adjusted for demographic, clinical, and hospital characteristics. The study included 1,186,600 30-day readmissions. Of these, 46.8% (n=555,847) required ambulance transport. In fully adjusted models, taking an ambulance to the readmission hospital increased the odds of a fragmented readmission by 38% (95% CI 1.32, 1.44). When this association was examined by readmission major diagnostic category (MDC), the strongest associations were seen for Factors Influencing Health Status and Other Contacts with Health Services (i.e., rehabilitation, aftercare) (AOR 3.66, 95% CI 3.11, 4.32), Mental Diseases and Disorders (AOR 2.69, 95% CI 2.44, 2.97), and Multiple Significant Trauma (AOR 2.61, 95% CI 1.56, 4.35). When the model was stratified by patient origin, ambulance use remained associated with fragmented readmissions across all locations. Ambulance use is associated with increased odds of a fragmented readmission, though the strength of the association varies by readmission diagnosis and origin. Patient-, hospital-, and system-level interventions should be developed, implemented, and evaluated to address this modifiable risk factor.

Flap Coverage of Infected Ventricular Assist Devices Influences Patient Outcomes.

The use of left ventricular assist devices (LVADs) for patients with end-stage cardiac failure awaiting heart transplantation has become increasingly common. However, ventricular assist device-related infections remain a major problem complicating their long-term use. Poor data exist to determine how to manage these infections after operative debridement. Patients who underwent insertion of a ventricular assist device and had a subsequent readmission for LVAD infection at the University of Rochester Medical Center from 2012 to 2022 were identified through accessing the medical records archives of the hospital. Patients were followed retrospectively for an average of 3.2 years. Patient demographics, preoperative diagnosis/disease state, type of ventricular assist device inserted, postoperative day of ventricular assist device infection onset, infectious organism identified at initial washout, infectious organism identified at time of definitive device coverage, timing of coverage procedure after the initial washout for infection, type of flap used for coverage, 90-day complications after definitive coverage, and lifetime return to operating room for infection were reviewed. Comparison analysis with a χ 2 test was used to analyze outcomes. Of 568 patients admitted with an LVAD-related infection 117 underwent operative debridement. Of these, 34 underwent primary closure, 31 underwent closure with secondary intention (negative pressure wound therapy with split thickness skin grafting), and 52 were closed with a flap (pectoralis, omental, latissimus, or vertical rectus abdominus musculocutaneous flap). There was a statistically significant higher incidence of return to the operating room (RTOR) for infection over a lifetime with primary closure compared with secondary intention and flap reconstruction ( P = 0.01, 0.02), but no difference in 90-day complications ( P = 0.76, P = 0.58). Eighty-three patients had a positive culture upon definitive coverage with 24 having a postsurgical complication, 15 of which required lifetime RTOR for infection. Thirty four were closed with negative cultures with 9 having a complication and 4 requiring RTOR for infection. This was not statistically significant for complications or RTOR ( P = 0.79, 0.40). Culture data were further substratified into bacterial cultures (n = 73) versus fungal cultures (n = 10), and there was no statistically significant difference between these compared with complications or RTOR ( P = 0.40, 0.39). Coverage of infected LVADs with locoregional flaps or allowing to granulate using wound vac therapy has a decreased lifetime RTOR for future infections for these patients without increase in 90-day complications. Timing of RTOR should not be impacted by positive cultures provided there is healthy granulation tissue in the wound.

Association of distance between hospitals and volume of shared admissions

BackgroundTo assess whether decreasing distance between hospitals was associated with the number of shared patients (patients with an admission to one hospital and a readmission to another).MethodsData were from the Healthcare Cost and Utilization Project’s State Inpatient Databases (Florida, Georgia, Maryland, Utah [2017], New York, Vermont [2016]) and the American Hospital Association Annual Survey (2016 & 2017). This was a cross-sectional analysis of patients who had an index admission and subsequent readmission at different hospitals within the same year. We used unadjusted and adjusted linear regression to evaluate the association between the number of shared patients and the distance between admission-readmission hospital pairs.ResultsThere were 691 hospitals in the sample (247 in Florida, 151 in Georgia, 50 in Maryland, 172 in New York, 58 in Utah, and 13 in Vermont), accounting for a total of 596,772 admission-readmission pairs. 32.6% of the admission-readmission pairs were shared between two hospitals. On average, a one-mile decrease in distance between two hospitals was associated with of 3.05 (95% CI, 3.02, 3.07) more shared admissions. However, variability between states was wide, with Utah having 0.37 (95% CI 0.35, 0.39) more shared admissions between hospitals per one-mile shorter distance, and Maryland having 4.98 (95% CI 4.87, 5.08) more.ConclusionsWe found that proximity between hospitals is associated with higher volumes of shared admissions.