Thirty-day Readmission Rates Research Articles

Postoperative Emergency Department Utilization and Hospital Readmission After Cervical Spine Arthrodesis: Rates, Trends, Causes, and Risk Factors.

Retrospective state database analysis. To quantify the 30- and 90-day emergency department (ED) utilization and inpatient readmission rates after primary cervical arthrodesis, to stratify these findings by surgical approach, and to describe risk factors and conditions precipitating these events. Limited data exist on ED utilization and hospital readmission rates after cervical spine arthrodesis. The New York State all-payer health-care database was queried to identify all 87,045 patients who underwent primary subaxial cervical arthrodesis from 1997 through 2012. Demographic data and clinical information were extracted. Readmission data were available for the entire study period, whereas ED utilization data collection began later and was therefore analyzed starting in 2005. Incidences of these events within 30 and 90 days of discharge as well as trends over time were tabulated. The conditions prompting these encounters were also collected. Data were analyzed with respect to surgical approach. The hospital readmission rate was 4.2% at 30 days and 6.2% at 90 days postoperatively. Approximately 6.2% of patients were managed in the ED without inpatient admission within 30 days and 11.3% within 90 days of surgery. The most common conditions prompting such events were dysphagia or dysphonia, respiratory complications, and infection. ED utilization and readmission rates were lowest after anterior surgeries. A preoperative Charlson Comorbidity Index of 1 or greater and traumatic pathologies were associated with increased risk of subsequent ED utilization or hospital readmission. Thirty-day hospital readmission rates declined after 2010, whereas 30-day ED utilization continued to increase. Patient comorbidities, traumatic pathologies, and surgical approach are associated with increased postoperative complications. Anterior procedures carry the lowest risk, followed by posterior and then circumferential. Awareness of these findings should help to encourage development of strategies to minimize the rate of postoperative ED utilization and hospital readmission. 3.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P22. Single-center, matched-pair comparative study of spine surgery in patients with solid organ transplantation: short- and long-term clinical outcomes

BACKGROUND CONTEXT Solid organ transplant is the mainstay of treatment for a wide variety of several end-stage organ diseases. The number of patients who will benefit from it is expected to increase due to improvement in distribution system for organs from donors, the discovery of novel immunosuppressive treatment/regimens, and better per- and post-operative management of these patients in general. Hence, an increasing number of these patients are becoming reasonable candidates for subsequent, elective surgeries such as spine surgery. Even though these patients are considered to be a high-risk group for surgery generally, clinical outcomes of spine surgery in patients with solid organ transplantation are not well-documented in the current literature partly due to its substantially rare incidence. Furthermore, prolonged use of steroids as well as immunosuppressant such as cyclosporine is associated with a decrease in bone mineral density. Thus, these outcome data might be of particular importance to consider surgical options for this high-risk cohort and inform them of specific risks and complications associated with spinal surgery after organ transplantation. PURPOSE Summarize clinical outcomes of spine surgery in solid organ recipients, such as readmission rate, infectious complications, and mortality, to facilitate clinical decision-making processes for this specific cohort. STUDY DESIGN/SETTING Retrospective, single-center, propensity-matched cohort. PATIENT SAMPLE Patients who underwent spine surgery at a single institution with previous history of solid organ transplantation were included and compared with a matched-cohort without solid organ transplantation. OUTCOME MEASURES Thirty-day readmission rate, 90-day medical complication rate, one-year infectious complication rate, one-year mortality, and functional outcomes such as ambulatory status, which was rated on a four-point scale (4, independently ambulatory; 3, requiring a cane; 2, requiring a walker; and 1, wheelchair bound). METHODS Single-center, retrospective data review from 2010 to 2016 yielded a total of 4,968 patients who underwent spine surgery. Amongst those, 28 patients had a previous history of solid organ transplantation. Patients from the database were propensity-matched for age, sex, body mass index (BMI), smoking status, diagnoses, procedures, co-morbidities other than diseases which had prompted organ transplantation at 1:2 ratio, which yielded 56 matched-patients. Clinical outcomes of (A) 28 patients with organ transplantation and (B) 56 matched-patients were compared and statistically analyzed. Intergroup comparison of binary variables was performed via Fisher's exact test. Intergroup comparison of continuous variables was achieved using unpaired t-tests. All reported p values are 2-sided and p values RESULTS Baseline characteristics including age, sex, BMI, smoking, diagnoses, procedures, and co-morbidities (ASA scale) were similar between the two groups with no statistically significant difference, which validated our matching methods. There were no statistically significant intergroup differences in operative data such as operative time, estimated blood loss, operated levels, and use of bone morphogenetic protein-2. In terms of functional outcomes, postoperative improvement in ambulatory status was comparable between the two groups (A) 16.7% vs. (B) 18.1%, p>.99). However, the organ-recipient group resulted in longer hospital stays (A) 7.2days vs. (B) 4.3days, p CONCLUSIONS Spinal surgery after solid organ transplantation resulted in substantially increased complication rates when compared with the matched-control group, while other variables such as baseline characteristics, operative data, and functional outcomes were similar between the two groups. Careful patient selection, meticulous perioperative care, and thorough informed consent of potential complications would be imperative when performing spine surgery on this cohort.

Limitations of Using Pediatric Respiratory Illness Readmissions to Compare Hospital Performance.

Adult hospital readmission rates can reliably identify meaningful variation in hospital performance; however, pediatric condition-specific readmission rates are limited by low patient volumes. To determine if a National Quality Forum (NQF)-endorsed measure for pediatric lower respiratory illness (LRI) 30-day readmission rates can meaningfully identify high- and low-performing hospitals. Observational, retrospective cohort analysis. We applied the pediatric LRI measure and several variations to evaluate their ability to detect performance differences. Administrative claims from all hospital admissions in California (2012-2014). Children (age <18 years) with LRI (primary diagnosis: bronchiolitis, influenza, or pneumonia; or LRI as a secondary diagnosis with a primary diagnosis of respiratory failure, sepsis, bacteremia, or asthma). Thirty-day hospital readmission rates and costs. Hierarchical regression models adjusted for age, gender, and chronic conditions were used. Across all California hospitals admitting children (n = 239) using respiratory readmission rates, no outlier hospitals were identified with (1) the NQF-endorsed metric, (2) inclusion of primary asthma or secondary asthma exacerbation diagnoses, or (3) inclusion of 30-day emergency revisits. By including admissions for asthma, adding emergency revisits, and merging 3 years of data, we identified 9 outlier hospitals (2 high-performers, 7 low-performers). There was no association of hospital readmission rates with costs. Using a nationally-endorsed quality measure of inpatient pediatric care, we were unable to identify meaningful variation in hospital performance without broadening the metric definition and merging multiple years of data. Utilizers of pediatric-quality measures should consider modifying metrics to better evaluate the quality of pediatric care at low-volume hospitals. Supported by the Agency for Healthcare Research and Quality (K08 HS24592 to SVK and U18HS25297 to MDC and NSB) and the National Institute of Child Health and Human Development (K23HD065836 to NSB). The funding agency played no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the manuscript for publication.

Thirty-Day Readmission Rate in Acute Heart Failure Patients Discharged Against Medical Advice in a Matched Cohort Study

ObjectiveTo determine the readmission rate in patients with acute heart failure (AHF) discharged against medical advice (AMA). MethodsWe performed a retrospective analysis using the 2014 National Readmission Database. Patients admitted with a primary diagnosis of AHF were selected. Only those discharged to home and who left AMA were included in the study. The primary outcome was 30-day readmission. We compared the readmission rates among those discharged AMA vs routinely discharged patients using propensity score matching (PSM) to address imbalance in variables between the 2 groups. We matched 3 routinely discharged patients to 1 patient who left AMA. ResultsWe identified 273,489 patients with AHF, of whom 116,869 qualified for further study analysis. A total of 2014 patients (1.7%) were in the AMA group and 114,855 (98.3%) were in the routinely discharged group. After PSM, 6042 routinely discharged patients were matched with 2014 patients from the AMA group. The standard mean difference for each variable was less than 10% postmatching. The 30-day readmission rate among those who left AMA was higher than among those routinely discharged (33% vs 20.1%; P<.001). Heart failure (44.8%) was the most common cause of readmission in the AMA group. Patients who left AMA were more likely to be readmitted to a different hospital compared with those routinely discharged (37.4 vs 23.1%; P<.001). They also had a high rate of leaving AMA during the readmission (18 vs 2%; P<.001). ConclusionPatients with AHF discharged AMA had a significantly higher 30-day readmission rate than did the routinely discharged group.

High hospital readmission rates for patients aged ≥65 years associated with low socioeconomic status in a Swedish region: a cross-sectional study in primary care

Objective: There is a presumption that hospital readmission rates amongst persons aged ≥65 years are mainly dependent on the quality of care. In this study, our primary aim was to explore the association between 30-day hospital readmission for patients aged ≥65 years and socioeconomic characteristics of the studied population. A secondary aim was to explore the association between self-reported lack of strategies for working with older patients at primary health care centres and early readmission.Design: A cross-sectional ecological study and an online questionnaire sent to the heads of the primary health care centres. We performed correlation and regression analyses.Setting and subjects: Register data of 283,063 patients in 29 primary health care centres in the Region Örebro County (Sweden) in 2014.Main outcome measure: Thirty-day hospital readmission rates for patients aged ≥65 years. Covariates were socioeconomic characteristics among patients registered at the primary health care centre and eldercare workload.Results: Early hospital readmission was found to be associated with low socioeconomic status of the studied population: proportion foreign-born (r = 0.74; p < 0.001), proportion unemployed (r = 0.73; p < 0.001), Care Need Index (r = 0.74; p < 0.001), sick leave rate (r = 0.51; p < 0.01) and average income (r = −0.40; p = 0.03). The proportion of unemployed alone could explain up to 71.4% of the variability in hospital readmission (p < 0.001). Primary health care centres reporting lack of strategies to prevent readmissions in older patients did not have higher hospital readmission rates than those reporting they had such strategies.Conclusion: Primary health care centres localized in neighbourhoods with low socioeconomic status had higher rates of hospital readmission for patients aged ≥65. Interventions aimed at reducing hospital readmissions for older patients should also consider socioeconomic disparities.Key PointsIn Sweden, hospital readmission within 30 days among patients aged ≥65 has been used as a measure of quality of primary care for the elderly.However, in our study, elderly 30-day readmission was associated with low neighbourhood socioeconomic status.A simple survey in one Swedish region showed that the primary health care centres that lacked active strategies for working with aged patients did not have higher hospital readmission rates than those that reported having strategies.Interventions aimed at reducing elderly hospital readmissions should therefore also consider the socioeconomic disparities in the elderly.

Thirty-day readmission rate as a surrogate marker for quality of care in neurosurgical patients: a single-center Canadian experience.

Readmission to the hospital within 30 days of discharge is used as a surrogate marker for quality and value of care in the United States (US) healthcare system. Concern exists regarding the value of 30-day readmission as a quality of care metric in neurosurgical patients. Few studies have assessed 30-day readmission rates in neurosurgical patients outside the US. The authors performed a retrospective review of all adult neurosurgical patients admitted to a single Canadian neurosurgical academic center and who were discharged to home to assess for the all-cause 30-day readmission rate, unplanned 30-day readmission rate, and avoidable 30-day readmission rate. A retrospective review was performed assessing 30-day readmission rates after discharge to home in all neurosurgical patients admitted to a single academic neurosurgical center from January 1, 2011, to December 31, 2011. The primary outcomes included rates of all-cause, unplanned, and avoidable readmissions within 30 days of discharge. Secondary outcomes included factors associated with unplanned and avoidable 30-day readmissions. A total of 184 of 950 patients (19.4%) were readmitted to the hospital within 30 days of discharge. One-hundred three patients (10.8%) were readmitted for an unplanned reason and 81 (8.5%) were readmitted for a planned or rescheduled operation. Only 19 readmissions (10%) were for a potentially avoidable reason. Univariate analysis identified factors associated with readmission for a complication or persistent/worsening symptom, including age (p = 0.009), length of stay (p = 0.007), general neurosurgery diagnosis (p < 0.001), cranial pathology (p < 0.001), intensive care unit (ICU) admission (p < 0.001), number of initial admission operations (p = 0.01), and shunt procedures (p < 0.001). Multivariate analysis identified predictive factors of readmission, including diagnosis (p = 0.002, OR 2.4, 95% CI 1.4-5.3), cranial pathology (p = 0.002, OR 2.7, 95% CI 1.4-5.3), ICU admission (p = 0.004, OR 2.4, 95% CI 1.3-4.2), and number of first admission operations (p = 0.01, OR 0.51, 95% CI 0.3-0.87). Univariate analysis performed to identify factors associated with potentially avoidable readmissions included length of stay (p = 0.03), diagnosis (p < 0.001), cranial pathology (p = 0.02), and shunt procedures (p < 0.001). Multivariate analysis identified only shunt procedures as a predictive factor for avoidable readmission (p = 0.02, OR 5.6, 95% CI 1.4-22.8). Almost one-fifth of neurosurgical patients were readmitted within 30 days of discharge. However, only about half of these patients were admitted for an unplanned reason, and only 10% of all readmissions were potentially avoidable. This study demonstrates unique challenges encountered in a publicly funded healthcare setting and supports the growing literature suggesting 30-day readmission rates may serve as an inappropriate quality of care metric in neurosurgical patients. Potentially avoidable readmissions can be predicted, and further research assessing predictors of avoidable readmissions is warranted.

The Association of Glucose Values at Hospital Discharge with 30-Day Readmission and Post-discharge Mortality Rates in Patients with Diabetes

Objective: Thirty-day readmission and post-discharge mortality rates reflect quality of care. Little is known about the association of glucose values of the last day of the inpatient stay with the risk of readmission and mortality after discharge. Design: Nationwide cohort of 836,189 admissions of DM patients admitted to non ICU setting in 110 Veteran Affairs hospitals, between 2000-2014. Demographic, social economic variables and several comorbidities were collected. General estimating equations were used to determine if the minimum glucose values of the last 24 hours of hospital stay were associated with 30-day readmission rate, 30, 90 and 180-day mortality rates, and combined 30-day readmission/mortality. Results: The 30-day readmission rate was 17.2% and the 30, 90 and 180-day mortality rates were 2.3%, 6.1% and 10% respectively, with a combined 18.8% for 30-day mortality/readmission rates. There was a sharp increase of the 30-day readmission rate with glucose values below 98 mg/dl. The post-discharge mortality rates increased with glucose values below 68.3 mg/dl, and the combined 30-day readmission/mortality rate increased with glucose values below 86.4 mg/dl (Figure). Conclusions: DM patients with glucose values below 98 mg/dl and 68.3 mg/dl at the last day of hospitalization in the non ICU setting are at a higher risk for 30-day readmission and 180-day mortality. Disclosure E. Spanakis: Research Support; Self; Dexcom, Inc. G.E. Umpierrez: Research Support; Self; Sanofi US, Merck &amp; Co., Inc., Novo Nordisk Inc., AstraZeneca. Advisory Panel; Self; Sanofi, Intarcia Therapeutics, Inc.. T. Siddiqui: None. M. Zhan: None. S. Snitker: Employee; Self; Novo Nordisk Inc.. J.C. Fink: None. J.D. Sorkin: None.

Implementation of robotic rectal surgery training programme: importance of standardisation and structured training

PurposeA structured training programme is essential for the safe adoption of robotic rectal cancer surgery. The aim of this study is to describe the training pathway and short-term surgical outcomes of three surgeons in two centres (UK and Portugal) undertaking single-docking robotic rectal surgery with the da Vinci Xi and integrated table motion (ITM).MethodsProspectively, collected data for consecutive patients who underwent robotic rectal cancer resections with the da Vinci Xi and ITM between November 2015 and September 2017 was analysed. The short-term surgical outcomes of the first ten cases of each surgeon (supervised) were compared with the subsequent cases (independent). In addition, the Global Assessment Score (GAS) forms from the supervised cases were analysed and the GAS cumulative sum (CUSUM) charts constructed to investigate the training pathway of the participating surgeons.ResultsData from 82 patients was analysed. There were no conversions to open, no anastomotic leaks and no 30-day mortality. Mean operation time was 288 min (SD 63), median estimated blood loss 20 (IQR 20–20) ml and median length of stay 5 (IQR 4–8) days. Thirty-day readmission and reoperation rates were 4% (n = 3) and 6% (n = 5) respectively. When comparing the supervised cases with the subsequent solo cases, there were no statistically significant changes in any of the short-term outcomes with the exception of mean operative time, which was significantly shorter in the independent cases (311 vs 275 min, p = 0.038). GAS form analysis and GAS CUSUM charting revealed that ten proctoring cases were enough for trainee surgeons to independently perform robotic rectal resections with the da Vinci Xi.ConclusionsOur results show that by applying a structured training pathway and standardising the surgical technique, the single-docking procedure with the da Vinci Xi is a valid, reproducible technique that offers good short-term outcomes in our study population.

Thirty-day complication and readmission rates associated with resection of metastatic spinal tumors: a single institutional experience.

This study aims to assess 30-day complication and unplanned readmission rates associated with resection of metastatic spinal tumors. Medical records were reviewed for 135 adults who underwent elective resection of a spinal cord tumor. Patient demographics, comorbidities, and tumor characteristics were collected. Tumor pathology was analyzed and diagnosed by a pathologist. The primary outcomes were intra- and 30-day post-operative complication and readmission rates. Of the 135 spinal tumor resections, 30 (22.2%) cases were metastatic. The most common tumor pathology was bone (13.3%) and the most common locations were thoracic (45.2%), and cervical (32.7%). Most patients had an open surgery (96.7%), with a mean laminectomy/laminoplasty level of 1.9±1.5 and mean operative time of 328.4±658.0 min. There was a 3.3% incidence rate of intraoperative durotomies, with no spinal cord or nerve root injuries. Post-operatively, 44.8% of patients were transferred to the intensive care unit (ICU). The most common post-operative complications were weakness (20.0%), new sensory deficits (16.7%), and hypotension (13.3%). The mean length of stay was 8.8±7.6 days, with the majority of patients discharged home (96.7%). The 30-day readmission rate was 9.7%, with the most common 30-day complications being uncontrolled pain (16.7%), sensory-motor deficits (13.3%), and fever (10.0%). Our study suggests that weakness, sensory deficits, and uncontrolled pain are the most common complications after resection of spinal metastases, with a relatively high associated 30-day readmission rate. Further studies are necessary to corroborate our findings and identify strategies to reduce complication and readmission rates after resection of spinal metastases.

Evaluation of the Cincinnati Veterans Affairs Medical Center Hospital-in-Home Program.

To examine hospital readmissions, costs, mortality, and nursing home admissions of veterans who received Hospital-in-Home (HIH) services. Retrospective cohort study. Cincinnati Veterans Affairs Medical Center (VAMC). Study cohort included veterans who received HIH services as an alternative to inpatient care between October 1, 2012, and November 30, 2015, and non-HIH veterans who were hospitalized for similar conditions in the Cincinnati VAMC during the same period. We identified 138 veterans who used HIH services and 694 non-HIH veterans. HIH veterans received hospital-equivalent care at home. Non-HIH veterans received traditional inpatient services in the Cincinnati VAMC. Total costs of care for treating an acute episode (HIH services vs inpatient) and likelihood of hospital readmission, death, or nursing home admission within 30 days of discharge from HIH services or hospitalization. Average per person costs were $7,792 for HIH services and $10,960 for traditional inpatient care (P<0.001). HIH veterans were less likely to use a nursing home within 30 days of discharge (3.1%) than non-HIH veterans (12.6%) (P<0.001). Thirty-day readmission rates and mortality were not statistically different between HIH and non-HIH veterans. The substitutive HIH model implemented in the Cincinnati VAMC delivered acute services in veterans' homes at lower cost and with lower likelihood of postdischarge nursing home use. Broader implementation of this innovative delivery model may benefit older adults in need of care while reducing healthcare system costs.

Medicare Program Associated With Narrowing Hospital Readmission Disparities Between Black And White Patients.

The Hospital Readmissions Reduction Program has been associated with improvements in readmission rates, yet little is known about its effect on racial disparities. We compared trends in thirty-day readmission rates for congestive heart failure, acute myocardial infarction, and pneumonia among non-Hispanic whites versus non-Hispanic blacks, and among minority-serving hospitals versus others. During the penalty-free implementation period (April2010-September2012), readmission rates improved over pre-implementation trends (January2007-March2010) for both whites and blacks, with a significantly greater decline among blacks than among whites (-0.45percent versus -0.36percent per quarter, respectively). In the period October2012-December2014, after penalties began, readmission improvements slowed for both races. Following a similar pattern, minority-serving hospitals saw greater reductions in readmissions than other hospitals did. Despite the narrowing of the two race-based gaps after announcement of the Hospital Readmissions Reduction Program, both persist. It remains to be seen whether new policy efforts will narrow these gaps and reduce the disproportionately high penalties that minority-serving hospitals face.

Robotic rectal cancer surgery in obese patients may lead to better short-term outcomes when compared to laparoscopy: a comparative propensity scored match study

PurposeLaparoscopic rectal surgery in obese patients is technically challenging. The technological advantages of robotic instruments can help overcome some of those challenges, but whether this translates to superior short-term outcomes is largely unknown. The aim of this study is to compare the short-term surgical outcomes of obese (BMI ≥ 30) robotic and laparoscopic rectal cancer surgery patients.MethodsAll consecutive obese patients receiving laparoscopic and robotic rectal cancer resection surgery from three centres, two from the UK and one from Portugal, between 2006 and 2017 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for ASA grade, neoadjuvant radiotherapy and pathological T stage. Their short-term outcomes were examined.ResultsA total of 222 patients were identified (63 robotic, 159 laparoscopic). The 63 patients who received robotic surgery were matched with 61 laparoscopic patients. Cohort characteristics were similar between the two groups. In the robotic group, operative time was longer (260 vs 215 min; p = 0.000), but length of stay was shorter (6 vs 8 days; p = 0.014), and thirty-day readmission rate was lower (6.3% vs 19.7%; p = 0.033).ConclusionsIn this study population, robotic rectal surgery in obese patients resulted in a shorter length of stay and lower 30-day readmission rate but longer operative time when compared to laparoscopic surgery. Robotic rectal surgery in the obese may be associated with a quicker post-operative recovery and reduced morbidity profile. Larger-scale multi-centre prospective observational studies are required to validate these results.

Characteristics of Female Genital Restoration Surgery for Congenital Adrenal Hyperplasia Using a Large-scale Administrative Database

To analyze nationwide information on the timing of surgical procedures, cost of surgery, hospital length of stay following surgery, and surgical complications of female genital restoration surgery (FGRS) in females with congenital adrenal hyperplasia (CAH). We used the Pediatric Health Information System database to identify patients with CAH who underwent their initial FGRS in 2004-2014. These patients were identified by an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for adrenogenital disorders (255.2) in addition to a vaginal ICD-9 procedure code (70.x, excluding vaginoscopy only) or perineal ICD-9 procedure code (71.x), which includes clitoral operations (71.4). A total of 544 (11.8%) females underwent FGRS between 2004 and 2014. Median age at initial surgery was 9.9 months (interquartile range 6.8-19.1 months). Ninety-two percent underwent a vaginal procedure, 48% underwent a clitoral procedure, and 85% underwent a perineal procedure (non-clitoral). The mean length of stay was 2.5 days (standard deviation 2.5 days). The mean cost of care was $12,258 (median $9,558). Thirty-day readmission rate was 13.8%. Two percent underwent reoperation before discharge, and 1 (0.2%) was readmitted for a reoperation within 30 days. Four percent had a perioperative surgical complication. Overall, 12% of girls with CAH underwent FGRS at one of a national collaborative of freestanding children's hospitals. The majority underwent a vaginoplasty as a part of their initial FGRS for CAH. Clitoroplasty was performed on less than half the patients. Overall, FGRS for CAH is performed at a median age of 10 months and has low 30-day complication and immediate reoperation rates.

Nonadherence to CPAP Associated With Increased 30-Day Hospital Readmissions.

The primary objective of this study was to determine if nonadherence to continuous positive airway pressure (CPAP) is associated with increased 30-day all-cause, cardiovascular-cause, and pulmonary-cause hospital readmissions. Retrospective cohort study at a Veterans Affairs hospital of patients with obstructive sleep apnea (OSA) who were hospitalized from January 1, 2007 to December 31, 2015. Odds ratio of 30-day readmission was calculated for all-cause, cardiovascular-cause, and pulmonary-cause readmissions. Logistic regression model was used to evaluate odds of nonadherent versus adherent group while adjusting for age, sex, body mass index, living situation, race, comorbidities, and medication adherence. Out of 2,077 records reviewed, 345 patients (183 adherent and 162 nonadherent) met our inclusion criteria. The adherent group had a total of 215 initial admissions, and the nonadherent group had a total of 268 index admissions. Thirty-day all-cause readmission rate was significantly higher in the nonadherent group, with an adjusted odds ratio (OR) of 3.52 (95% confidence interval [CI], 2.04-6.08, P < .001). Thirty-day cardiovascular-cause readmission rate was significantly higher in the nonadherent group, with an adjusted OR of 2.31 (95% CI, 1.11-4.78, P = .024). Difference in 30-day pulmonary-cause readmissions was not statistically significant, with an adjusted OR of 3.66 (95% CI, 0.41-32.76, P = .25). Nonadherence to CPAP is associated with increased 30-day all-cause and cardiovascular-cause readmission in patients with OSA. Ensuring CPAP adherence is crucial in addressing general and cardiovascular-related healthcare utilization and morbidity in patients with OSA. A commentary on this article appears in this issue on page 161.

CRT-700.05 Impact of Spironolactone on Heart Failure Readmission after Transcatheter Aortic Valve Replacement

Thirty-day readmission rates are a performance benchmark in contemporary evaluation of cardiovascular procedures. Trans-catheter aortic valve replacement (TAVR) has been widely adopted since initial Food and Drug Administration approval in 2011; however, re-admission rate following TAVR remains high

Effect of Gender on Unplanned Readmissions After Percutaneous Coronary Intervention (from the Nationwide Readmissions Database)

Women who undergo percutaneous coronary intervention (PCI) are at higher risk of adverse outcomes compared with men, but it is unknown whether gender affects early unplanned rehospitalization. We analyzed 832,753 patients who underwent PCI from 2013 to 2014 in the Nationwide Readmissions Database. We compared gender differences in incidences, predictors, causes, and cost of unplanned 30-day readmissions and examined the effect of co-morbidity. A total of 832,753 men and women who survived the index PCI and were not admitted for a planned readmission were included in the analysis. Overall, 9.4% of patients had an unplanned readmission within 30 days. Thirty-day readmission rates were higher in women compared with men (11.5% vs 8.4%, p <0.001) even after multivariate adjustment (odds ratio 1.19, 95% confidence interval 1.16 to 1.22, p <0.001), although women had significantly lower costs associated with the readmission ($11,927 vs $12,758, p <0.001). The cause of readmission for women and men were similar and the majority of the readmissions were due to noncardiac causes (58% vs 55%), the most common of which were nonspecific chest pain, gastrointestinal disease, and infections. In contrast, for cardiac readmissions, women are more likely to be readmitted for heart failure (29.64% vs 22.34%), whereas men are more likely to be readmitted for coronary artery disease, including angina (33.47% vs 28.54%). In conclusion, gender disparities exist in rates of unplanned rehospitalization after PCI, where more than 1 in 10 women who undergo PCI are readmitted within 30 days. Gender differences were not observed for causes of noncardiac readmissions, whereas important differences were observed for cardiovascular causes.

Safety of prone jackknife position in ambulatory anorectal surgery

Background and Objectives: The objectives of this study were to determine morbidity and mortality rates of ambulatory anorectal surgeries in prone jackknife position. Patients and Methods: Retrospective chart analysis on 210 patients undergoing ambulatory anorectal surgery in the prone jackknife position. The primary endpoint studied was mortality and complication rates. Other factors analyzed were age, sex, clinical diagnosis, procedure, past medical history, American Society of Anesthesiologists physical status classification, current smoking status, mean pre- and post-operative mean arterial pressure (MAP), mean minimum intraoperative MAP, minimum intraoperative O2saturation, estimated blood loss, fluids given, anesthesia duration, antibiotic administration, and days to discharge and whether there were any readmissions within 30 days. To assess significant differences between pre-, intra-, and post-operative mean arterial pressure, one-way ANOVA was used. Results: There was no mortality within 30 days of surgery. Complication rate was 3.3% with urinary retention being the most common, comprising 42% of all complications. Thirty-day readmission rate from surgery was 1%. Mean pre- and post-operative MAP was 88.4 ± 11.4 and 90.6 ± 11.9, respectively. Mean minimum intraoperative MAP and O2saturation was 70.6 ± 9.5 and 98.7% ± 1.6%, respectively. Mean minimum intraoperative MAP was significantly decreased compared to mean pre- and post-operative MAP (P

Preoperative Scale to Determine All-Cause Readmission After Coronary Artery Bypass Operations

Coronary artery bypass graft (CABG) operations are associated with all-cause readmission rates of approximately 15%. In attempts to reduce readmission rates, the Hospital Readmission Reduction Program expanded to include CABG operations in 2015. The aim of this study was therefore to develop a predictive readmission scale that would identify patients at higher risk of readmission after CABG using commonly available administrative data. Data of 126,519 patients from California and New York (derivation cohort) and 94,318 patients from Florida and Washington (validation cohort) were abstracted from the State Inpatient Database (2006 to 2011). The readmission after CABG scale was developed to predict 30-day readmission risk and was validated against a separate cohort. Thirty-day CABG readmission rates were 23% in the derivation cohort and 21% in the validation cohort. Predictive factors included older age, female gender (odds ratio [OR], 1.34), African American ethnicity (OR, 1.13), Medicare or Medicaid insurance, and comorbidities, including renal failure (OR, 1.56) and congestive heart failure (OR, 2.82). These were independently predictive of increased readmission rates (p < 0.01). The readmission scale was then created with these preoperative factors. When applied to the validation cohort, it explained 98% of the readmission variability. The readmission after CABG scale reliably predicts a patient's 30-day CABG readmission risk. By identifying patients at high-risk for readmission before their procedure, risk reduction strategies can be implemented to reduce readmissions and healthcare expenditures.

Safety and Effectiveness of Single-Anastomosis Duodenal Switch Procedure: 2-Year Result from a Single US Institution.

Single-anastomosis duodenal switch (DS) was introduced by Sanchez-Pernaute et al. as a modification of the biliopancreatic diversion with duodenal switch. We have published preliminary results of the loop DS as the first report of the procedure in the USA. This study aims to evaluate the loop DS procedures again, in terms of weight loss, comorbidity resolution, complication rate, and address the nutritional concerns. A retrospective chart review was performed on initial 128 patients who underwent laparoscopic or robot-assisted laparoscopic single-stage loop DS between December 17, 2013 and September 23, 2016. Sixteen additional patients were prospectively enrolled from September 24, 2016 to May 4, 2017. A total of 102 female and 38 male patients were included in this study with a mean age of 41.2 ± 9.6years. The mean body mass index (BMI) at the time of procedure was 57.3 ± 9.2kg/m2. Percentage of total weight loss was 23.1, 37.1, 42.9, and 44.7% at 6, 12, 18, and 24months, respectively. Percentage of excess BMI loss was 41.9, 68.1, 76.6, and 80.8% at 6, 12, 18, and 24months, respectively. Mean levels of HbA1c, triglyceride, and LDL-cholesterol decreased significantly after the loop DS. Regarding the fat-soluble vitamins, majority of patients had vitamin A and E levels in the normal range. However, 42 to 56% of the patients had low levels of vitamin D at 6, 12, and 24months following the procedure. Mean length of hospital stay was 4.1 ± 2.7days. Thirty-day readmission rate was 7.6% (n = 11), and 30-day reoperation rate was 6.9% (n = 10). Loop DS seems to be effective in weight loss and is a feasible operation in the super-obese population. However, close monitoring of liver enzymes is warranted in addition to nutritional follow-up.

Decreased Hospital Readmissions for Vaso Occlusive Crisis with Implementation of a Sickle Cell Pain Action Plan (SPAP)

Background: Vaso occlusive crisis (VOC) is the most common reason for hospital admissions and emergency room visits in sickle cell disease (SCD). Education of patients, caregivers, and the healthcare team are a key factor in reducing readmission rates following hospitalization for children with VOC. There is a paucity of data on parental understanding of pain medications on hospital discharge, a confusing and intense time for families. This quality improvement (QI) project addresses provider and patient/parent knowledge gaps by incorporating a sickle cell pain action plan (SPAP) into the discharge process.Objectives: The global aim was to decrease the 7 and 30-day readmission rates for VOC by 15% in a pediatric sickle cell population in one year. A multi-disciplinary team initiated a QI project at a single institution between April 2016 and May 2017.Methods: The key drivers comprised of pharmacy, nursing, pediatric residents, patient representatives and pediatric hematologists. The SPAP was modeled on the success of the asthma action plan and helps distinguish patients degree of pain, with specific medical instructions for treatment. PDSA cycles included implementation of the SPAP with medication teaching at bedside, nursing teaching with SPAP during admission and pharmacy consults. The QI leader performed monthly educational modules to the house staff, pharmacists and nursing, and sent weekly email reminders to leaders of the inpatient team. Monthly run charts were created to assess 7 and 30- day readmissions. There are 14 months of data reported to capture both 7 and 30-day readmissions in the total study period. Readmissions were compared monthly to the year prior to implementation of the SPAP. Process measures were the number of documented pharmacy consults, documented SPAPs in the chart and surveys (5 point Likert scale) on patients understanding of their medications post discharge.Results: There were 230 admissions for VOC the 12 months prior to implementation of the SPAP and 293 VOC admissions during the study period. Thirty-day readmission rates from April-July 2016 had a 36% reduction compared to 2015 data. The rise in readmissions during August, November and December of 2016 prompted implementation of new team champions and reeducation of staff, and subsequent months had reduction in readmissions. The cumulative decrease at completion of the project was an 18% reduction in thirty-day readmission rates and 13% reduction in 7-day readmission rates, whether or not there was a documented SPAP. Patients that had a documented SPAP in their chart (n=33) had a 65% reduction in thirty-day readmissions and 22% reduction in seven-day readmissions. Of the patients/parents surveyed (n=20 pre-implementation, n=34 post implementation) 91% and 74% strongly agreed they knew which pain medications to administer and how to escalate care compared to 56% and 47% prior to the project. Ninety percent of the surveyed families agreed that the SPAP: helped them understand their pain medications, remember medication names, was easy to understand and would be used again in the future. Pareto charts showed the following barriers to implementation of the QI intervention: pharmacy consults not performed due to lack of adequate staffing, SPAP documentation lacking despite a pharmacy consult being requested, and difficulties of staff adjusting to a new electronic medical record.Conclusion: VOC readmission rates can be decreased by using a teaching tool to enforce medication understanding upon discharge. The SPAP was highly accepted in our patient population and empowered patients and families to treat their pain crisis at home once discharged. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.