Thirty-day Readmission Rates Research Articles

Abstract 288: Payments, Mortality and Readmission Rates in US News and World Report “Best Hospitals” in Cardiology

Background: Little is known regarding how well the U.S. News & World Report “Top-Ranked Hospitals for Cardiology and Heart Surgery” rankings reflect performance on key measures such as thirty-day risk-standardized mortality, readmissions, and payment. Methods: We used publicly available US News and World Report rankings of the top 50 best hospitals from 2014 to 2017 to stratify hospitals into ranked and unranked hospitals and utilized data from Medicare’s Hospital Compare database. Risk-standardized measures for payments, mortality rates, and readmission rates for Acute Myocardial Infarction (AMI) and Heart Failure (HF) in ranked and unranked hospitals were compared using two-tailed t-tests. Results: There were n=66 ranked hospitals and n=1846 unranked hospitals included in the analysis. As compared with unranked hospitals, top ranked hospitals had significantly lower thirty-day mortality rates for both AMI and HF (p<.001 for both; Table 1). There were no differences in thirty-day readmission rates. Thirty-day payments were significantly higher for top ranked hospitals for AMI (2014 and 2015) and HF (2015) over the study period. Conclusion: We found that US News and World Report “Best Hospitals” performed significantly better on mortality measures but not on readmission measures. While payment in ranked hospitals may have been significantly higher in 2014 and 2015, greater increases in payments of unranked hospitals closed the gap between payments in ranked and unranked hospitals. As cost-efficiency is an important component of hospital performance, future research should explore how “Best Hospitals” are keeping costs down, and future ranking algorithms should incentivize decreased payments.

Sex-based differences in outcomes, 30-day readmissions, and costs following catheter ablation of atrial fibrillation: the United States Nationwide Readmissions Database 2010–14

Although catheter ablation has emerged as an important therapy for patients with symptomatic atrial fibrillation (AF), there are limited data on sex-based differences in outcomes. We sought to compare in-hospital outcomes and 30-day readmissions of women and men undergoing AF ablation. Using the United States Nationwide Readmissions Database, we analysed patients undergoing AF ablation between 2010 and 2014. Based on ICD-9-CM codes, we identified co-morbidities and outcomes. Multivariable logistic regression and inverse probability-weighting analysis were performed to assess female sex as a predictor of endpoints. Of 54597 study patients, 20623 (37.7%) were female. After adjustment for age, co-morbidities, and hospital factors, women had higher rates of any complication [adjusted odds ratio (aOR) 1.39; P < 0.0001], cardiac perforation (aOR 1.39; P = 0.006), and bleeding/vascular complications (aOR 1.49; P < 0.0001). Thirty-day all-cause readmission rates were higher for women compared to men (13.4% vs. 9.4%; P < 0.0001). Female sex was independently associated with readmission for AF/atrial tachycardia (aOR 1.48; P < 0.0001), cardiac causes (aOR 1.40; P < 0.0001), and all causes (aOR 1.25; P < 0.0001). Similar findings were confirmed with inverse probability-weighting analysis. Despite increased complications and readmissions, total costs for AF ablation were lower for women than men due to decreased resource utilization. Independent of age, co-morbidities, and hospital factors, women have higher rates of complications and readmissions following AF ablation. Sex-based differences and disparities in the management of AF need to be explored to address these gaps in outcomes.

Outpatient and Inpatient Readmission Rates of 1- and 2-Level Anterior Cervical Discectomy and Fusion Surgeries

This study looks at the various comorbidities and postoperative complications and their impact on readmission rates of patients undergoing outpatient versus inpatient 1- and 2-level anterior cervical discectomy and fusion (ACDF). With increasing costs within the United States medical system, one emerging cost-saving strategy is to evolve traditional inpatient procedures into outpatient same-day surgeries. However, patient safety remains a crucial priority. A total of 28,427 patients were analyzed, with 26,368 undergoing inpatient ACDF surgery and 2059 undergoing outpatient ACDF surgery. Age, sex, comorbidities, postoperative complications, readmission rates, and overall financial cost were compared between both cohorts. Data from 28,427 one- and two-level ACDF procedures that were split between inpatient and outpatient were collected. Thirty-day readmission rates were significantly lower in outpatients than inpatients (4% vs. 10.1%, P < 0.001). Inpatients had higher rates of urinary tract infection (2.4% vs. 1.4%), deep vein thrombosis (0.6% vs. 0%), and myocardial infarction (0.2% vs. 0%), whereas outpatients had higher rates of pulmonary embolism (7.7% vs. 0.4%). Outpatients had increased readmission risk with comorbidities of diabetes (odds ratio [OR], 48.93; P < 0.001), smoking (OR, 4.6; P < 0.001), body mass index ≥30 (OR, 2392; P < 0.001). The average cost of outpatient surgery was less than that of inpatient surgery ($7774.8 vs. $7956.75, P=0.0444). This study suggests that in the appropriately selected patients, ACDF can safely be performed in an outpatient setting.

Association of Surgical and Hospital Volume and Patient Characteristics With 30-Day Readmission Rates

Thirty-day readmission rates have been suggested as a marker for quality of care. By investigating the factors associated with readmissions in all otolaryngology subspecialties we provide data relevant for the development of risk stratification systems to improve outcomes. To establish the association of surgical and hospital volume and patient characteristics with 30-day readmission rates to guide the development of otolaryngology-specific risk stratification models. A retrospective cohort study including adult patients who underwent inpatient otolaryngology surgery in New York State between 1995 and 2015 was conducted using the Statewide Planning and Research Cooperative System (SPARCS). Regression techniques were used to describe relationships of patient-level factors, hospital, and surgeon volume to 30-day readmission rates in New York State. The main outcome measures were patient-, surgeon-, and hospital-level risk factors for readmission. Secondary outcome measures were rate of readmissions by subspecialty procedure and by diagnosis on readmission. We identified 254 257 cases of otolaryngology surgery (147 065 women [58%], mean [SD] age 50 [17] years). The 30-day readmission rate was 6%. In a multivariable model, odds ratios (ORs) identified Medicaid insurance (OR, 1.46; 99% CI, 1.36-1.57), Medicare insurance (OR, 1.32; 99% CI, 1.24-1.42), bottom quartile income (OR, 1.08; 99% CI, 1.01-1.15), patient comorbidities measured by the Charlson Comorbidity Index (CCI) (CCI >1; OR, 2.31; 99% CI, 2.16-2.47), length of stay (LOS) (LOS >10 days; OR, 2.29; 99% CI, 2.00-2.45), rhinology (OR, 1.37; 99% CI, 1.24-1.51), laryngology (OR, 1.98; 99% CI, 1.62-2.43), and head and neck cancer (OR, 1.27; 99% CI, 1.17-1.37) procedures as readmission predictors. High-volume surgeons were protective of 30-day readmission (OR, 0.67; 99% CI, 0.635-0.708) relative to low volume. Hospital volume was not significantly associated to readmissions. The most common causes of readmission included wound- (2682 patients, 18%), respiratory- (1776 patients, 12%), cardiovascular- (1210 patients, 8%), and volume- (1089 patients, 7%) related disorders. This study evaluated the combined effects of patient-, surgeon-, and hospital-level factors on 30-day readmission after otolaryngology surgery. Socioeconomic factors, patient comorbidities, surgeon volumes, and procedure were significantly associated with 30-day readmission. Though the cause of 30-day readmission is multifactorial, a large portion is driven by socioeconomic factors. Addressing these disparities at the system level is necessary to address the described readmission disparities. The development of risk-stratification models based on patient-, procedure-, and surgeon-level factors may help facilitate resource distribution.

A validated preoperative score for predicting 30-day readmission after 1-2 level elective posterior lumbar fusion.

To develop a model to predict 30-day readmission rates in elective 1-2 level posterior lumbar spine fusion (PSF) patients. In this retrospective case control study, patients were identified in the State Inpatient Database using ICD-9 codes. Data were queried for 30-day readmission, as well as demographic and surgical data. Patients were randomly assigned to either the derivation or the validation cohort. Stepwise multivariate analysis was conducted on the derivation cohort to predict 30-day readmission. Readmission after posterior spinal fusion (RAPSF) score was created by including variables with odds ratio (OR) > 1.1 and p < 0.01; value assigned to each variable was based on the OR and calibrated to 100. Linear regression was performed between readmission rate and RAPSF score to test correlation in both cohorts. There were 92,262 and 90,257 patients in the derivation and validation cohorts. Thirty-day readmission rates were 10.9% and 11.1%, respectively. Variables in RAPSF included: age, female gender, race, insurance, anterior approach, cerebrovascular disease, chronic pulmonary disease, congestive heart failure, diabetes, hemiplegia/paraplegia, rheumatic disease, drug abuse, electrolyte disorder, osteoporosis, depression, obesity, and morbid obesity. Linear regression between readmission rate and RAPSF fits the derivation cohort and validation cohort with an adjusted r2 of 0.92 and 0.94, respectively, and a coefficient of 0.011 (p < 0.001) in both cohorts. The RAPSF can accurately predict readmission rates in PSF patients and may be used to guide an evidence-based approach to preoperative optimization and risk adjustment within alternative payment models for elective spine surgery. 3. These slides can be retrieved under Electronic Supplementary Material.

Thirty-day readmissions in aneurysmal subarachnoid hemorrhage: A good metric for hospital quality?

Thirty-day readmission rates has been increasingly used by clinicians, hospital administrators, and policy makers as a metric for the quality of care. However, the 30-day readmission rates may be affected by other factors intrinsic to the patient and may not be a good measure of the quality of care provided by the hospital. In this review, we examined the quality of the 30-day readmissions rate as a quality metric for the quality of care provided to patients with aneurysmal subarachnoid hemorrhage (SAH). It has been shown that in this patient population, 30-day readmission rate primarily captures values, such as the number of comorbidities, disease severity, and discharge dispositions. There is little association between SAH 30-day readmission rates and mortality. However, 30-day readmissions may be reduced by increasing early discharge surveillance, providing readmission reduction programs to patients discharged to medical facilities as well as to home, and identifying patients most at risk for readmission.

Methicillin-susceptible and Methicillin-resistant Staphylococcus aureus Bacteremia: Nationwide Estimates of 30-Day Readmission, In-hospital Mortality, Length of Stay, and Cost in the United States.

Information on outcomes of methicillin-susceptible and -resistant Staphylococcus aureus (MSSA and MRSA, respectively) bacteremia, particularly readmission, is scarce and requires further research to inform optimal patient care. We performed a retrospective analysis using the 2014 Nationwide Readmissions Database, capturing 49.3% of US hospitalizations. We identified MSSA and MRSA bacteremia using International Classification of Diseases, Ninth Revision, Clinical Modification among patients aged ≥18 years. Thirty-day readmission, mortality, length of stay, and costs were assessed using Cox proportional hazards regression, logistic regression, Poisson regression, and generalized linear model with gamma distribution and log link, respectively. Of 92 089 (standard error [SE], 1905) patients with S. aureus bacteremia, 48.5% (SE, 0.4%) had MRSA bacteremia. Thirty-day readmission rate was 22% (SE, 0.3) overall with no difference between MRSA and MSSA, but MRSA bacteremia had more readmission for bacteremia recurrence (hazard ratio, 1.17 [95% confidence interval {CI}, 1.02-1.34]), higher in-hospital mortality (odds ratio, 1.15 [95% CI, 1.07-1.23]), and longer hospitalization (incidence rate ratio, 1.09 [95% CI, 1.06-1.11]). Readmission with bacteremia recurrence was particularly more common among patients with endocarditis, immunocompromising comorbidities, and drug abuse. The cost of readmission was $12 425 (SE, $174) per case overall, and $19 186 (SE, $623) in those with bacteremia recurrence. Thirty-day readmission after S. aureus bacteremia is common and costly. MRSA bacteremia is associated with readmission for bacteremia recurrence, increased mortality, and longer hospitalization. Efforts should continue to optimize patient care, particularly for those with risk factors, to decrease readmission and associated morbidity and mortality in patients with S. aureus bacteremia.

Adherence to Guideline Directed Medical Therapy of Patients Admitted to Hospital with Acute Heart Failure

Background: National guidelines for the management of heart failure (HF) inform clinical practice. However, translation into clinical practice is suboptimal, denying patients the full benefit of evidence-based therapy. This study evaluated the translation of clinical guidelines in the management of patients admitted to hospital with acute HF. Methods: Sixteen Victorian hospitals participated in a prospective state-wide HF study of patients admitted to hospital with acute HF over one month and followed up for 30 days post-discharge. The project was conducted annually over three consecutive years from 2015–2017. Results: Of the 1222 patients, 56.5% were male with an average age of 77 years (SD 13.17 years) and 73.6% had HFrEF. Hypertension and chronic renal disease were the most common comorbidities (75.5% and 63.6% respectively). In patients with HFrEF, 73.1% were prescribed, at discharge, an ACEI/ARB, 74.8% a beta-blocker and 46.6% an aldosterone antagonist. On average, these patients were prescribed 10.46 ± 4.03 medications. At 30 days, 53.6% of all patients had been seen in outpatients with median time to appointment of 21 (IQR 12–30) days. A third of all patients had been referred to a HF home visiting program. Of these patients, 49% were seen within 30 days post-discharge with median time to first visit of 13 (IQR 6.25–27) days. Thirty-day readmission rates were 24.4% and mortality was 4.8%. Conclusion: Rates of guideline directed medical therapy remain suboptimal in HFrEF patients. Post-discharge follow-up was also inadequate. Strategies to improve rapid review post-discharge and translation of evidence into clinical practice are urgently needed.

A 20-year multicenter analysis of dialysis-dependent patients who had aortic or mitral valve replacement: Implications for valve selection

ObjectiveValve selection in dialysis-dependent patients can be difficult because long-term survival is diminished and bleeding risks during anticoagulation treatment are greater in patients with renal failure. In this study we analyzed long-term outcomes of dialysis-dependent patients who underwent valve replacement to help guide optimal prosthetic valve type selection. MethodsDialysis-dependent patients who underwent aortic and/or mitral valve replacement at 3 institutions over 20 years were examined. The primary outcome was long-term survival. A Cox regression model was used to estimate survival according to 5 ages, presence of diabetes, and/or heart failure symptoms. ResultsFour hundred twenty-three available patients were analyzed; 341 patients had biological and 82 had mechanical valves. Overall complication and 30-day mortality rates were similar between the groups. Thirty-day readmission rates for biological and mechanical groups were 15% (50/341) and 28% (23/82; P = .005). Five-year survival was 23% and 33% for the biological and mechanical groups, respectively. After adjusting for age, New York Heart Association (NYHA) class, and diabetes using a multivariable Cox regression model, survival was similar between groups (hazard ratio, 0.93; 95% confidence interval, 0.66-1.29; P = .8). A Cox regression model on the basis of age, diabetes, and heart failure, estimated that patients only 30 or 40 years old, with NYHA class I-II failure without diabetes had a >50% estimated 5-year survival (P < .001). ConclusionsDialysis-dependent patients who underwent valve replacement surgery had poor long-term survival. Young patients without diabetes or NYHA III or IV symptoms might survive long enough to justify placement of a mechanical valve; however, a biological valve is suitable for most patients.

1941. Comparison of Patient Outcomes in a Pharmacist-Led Outpatient Parenteral Antimicrobial Therapy (OPAT) Program

BackgroundDespite the benefits of OPAT programs, readmission rates of up to 20% have been reported. In November 2016 at Franciscan Alliance Indianapolis, a dedicated pharmacist was assigned to build a formal OPAT program for all patients discharged on IV antimicrobials under the care of the infectious disease physician group. This study juxtaposed 30-day readmission rates and other patient outcomes for patients with and without an OPAT consult in order to assess how the program impacted patient care.MethodsThis was a retrospective cohort study comparing patients discharged on IV antimicrobials between December 1, 2016 and May 31, 2017. These patients were grouped based on whether they had a consult from the OPAT program. Thirty-day readmission rate, antimicrobial selection, discharge disposition, and treatment duration were collected and compared between groups. For the primary objective, at least 87 patients were needed to attain a power of 80% and detect a 30% difference between treatment groups.ResultsOut of 1,502 patients screened, 117 were deemed eligible and included (95 patients with a consult and 22 patients without). No statistically significant difference between the readmission rates of the consult group and the nonconsult group was observed (14.74% vs. 31.80%, P = 0.07). However, the consult group exhibited lower utilization of antipseudomonal coverage (38.95% vs. 86.40%, P < 0.0001) and ceftriaxone (9.47% vs. 45.45%, P < 0.001). Use of agents requiring closer therapeutic drug monitoring was higher in the nonconsult group, specifically vancomycin (86.36% vs. 41.05%, P < 0.001) and gentamicin (6.32% vs. 22.73%, P < 0.05), despite the diminished intensity of follow-up for patients not followed by the service.ConclusionThe OPAT service did not show a statistically significant reduction in 30-day readmission rate during the first 6 months of the program. However, this may have been due to insufficient power to detect the true difference between treatment arms. Additionally, use of the program was associated with improved antimicrobial stewardship through reduced use of antipseudomonal coverage and ceftriaxone. Disclosures All authors: No reported disclosures.

Clinical characteristics of obstructive sleep apnea versus infectious adenotonsillar hyperplasia in children

IntroductionChildren who undergo adenotonsillectomy have a range of symptoms. Some present with infective symptoms, others with obstructive symptoms, and many with a combination of both. The most common surgical indication has changed over the past several decades from infective symptoms to obstructive symptoms. However, there are few data available to differentiate these groups of children in terms of their clinical characteristics. This study aimed to determine the clinical characteristics of children with obstructive sleep apnea versus infectious adenotonsillar hyperplasia. MethodsData were obtained from the medical records of two district health boards in Auckland, New Zealand. Extraction of clinical information was performed following the identification of all patients under the age of 16 years undergoing adenotonsillectomy between December 2015 and December 2017. ResultsA total of 1538 children were included in this study. There were 112 (7.3%) with recurrent tonsillitis (RT) symptoms only, 624 (40.6%) with RT and sleep-disordered breathing symptoms (SDB), and 802 (52.1%) with symptoms suggestive of obstructive sleep apnea (OSA). Children with OSA were more likely to be male (p < 0.001), younger (p < 0.001), and have lower body mass indexes at time of surgery (p < 0.001). There was no difference between groups in the number of antibiotic courses prescribed in the year before surgery (p = 0.7). There was no significant difference in tonsil or adenoid grade between groups (p = 0.2). Children with OSA were more likely to have a diagnosis of asthma (p < 0.001) and allergic rhinitis (p < 0.001), but less likely than those with RT to have a diagnosis of eczema (p < 0.001). Children with OSA were more likely to have otitis media with effusion requiring ventilation tube insertion (p < 0.001) and a documented history of speech delay (p < 0.001). Thirty-day readmission rates were higher in the OSA (8.5%) and SDB/RT (9.3%) groups when compared to those with RT (1.8%) (p = 0.03). ConclusionChildren with OSA have different perioperative characteristics than those with recurrent tonsillitis, including increased risk of postoperative bleeding and need for post op readmission. Therefore, management strategy may vary according to the indications for tonsillectomy and adenoidectomy.

Thirty-day Complications and Readmission Rates in Elderly Patients After Shoulder Arthroplasty.

Introduction:Shoulder arthroplasty procedures are increasingly being performed in older patients despite an increased perioperative risk. The purpose of this study is to determine the complications and 30-day readmission rates in the elderly population after shoulder arthroplasty and hemiarthroplasty.Methods:Total shoulder arthroplasty, reverse total shoulder arthroplasty, and hemiarthroplasty cases were collected from the National Surgical Quality Improvement Program database from 2006 to 2015. The 30-day complication and readmission rates, surgical time, discharge destination, and total hospital length of stay were calculated, comparing patients by age (elderly: ≥80 years; older: 65 to 79 years; younger: <65 years). Multivariable logistic regression analysis was performed to identify variables associated with any complication within 30 days of surgery.Results:Of 11,450 patients, 1,956 (17.1%) underwent shoulder hemiarthroplasty and 9,494 (82.9%) underwent total shoulder arthroplasty. By age group, 1,708 (14.9%) were ≥80, 6,073 (53.0%) were 65 to 79, and 3,669 (32.0%) were <65. The overall 30-day postoperative complication rate was significantly higher in elderly patients (15.3% versus 8.2% versus 6.8%; P < 0.001), length of stay (2.6 versus 2.1 versus 1.8 days; P < 0.001), and unplanned readmissions (5.5% versus 2.6% versus 2.3%; P < 0.001). The strongest independent variables significantly associated with any complication included revision arthroplasty indication (odds ratio [OR], 4.34; P < 0.001), fracture indication (OR, 4.14; P < 0.001), and history of cardiac disease (OR, 2.33; P < 0.001), followed by elderly age (OR, 2.01; P < 0.001).Conclusions:The 15.3% complication rate (major, 4.8%; minor, 10.7%), 2.6 days of average length of stay, and 5.5% unplanned readmission among elderly patients (>80) are significantly higher than younger patients. Although surgical indications and comorbidities are higher-quality predictors of complications, elderly patients should be appropriately counseled and medically optimized according to the perioperative risk profile before surgery.

Thirty-day Readmission Rates for Carotid Endarterectomy Versus Carotid Artery Stenting

BackgroundBecause of the emergence of readmission-related Medicare penalties, efforts are being made to identify and reduce patient readmissions. The purpose of this study was to compare rates and risk factors for 30-d readmission and hospital length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) among patients treated for carotid artery stenosis in Pennsylvania. Materials and methodsData were from the Pennsylvania Health Care Cost Containment Council (PHC4). We identified 15,966 patients who underwent CEA (n = 13,557) or CAS (n = 2409) in Pennsylvania between 2011 and 2014. Logistic regression was used to determine risk factors for 30-d readmission, whereas linear regression was used to model factors influencing LOS. Propensity score analysis was used to control for imbalanced covariates between procedures. ResultsThirty-day readmission rates in Pennsylvania after CEA and CAS for carotid artery stenosis were similar (9.8% and 9.6%, respectively; P = 0.794). Not home discharge destination, Charlson comorbidity index ≥2, and LOS >1 d were all significantly associated with readmission risk. Procedure type (CEA or CAS) did not significantly influence risk. A significant difference in LOS was found between CEA and CAS, but the magnitude of the difference was small (2.38 for CAS versus 2.59 for CEA; P = 0.007). Black race, urgent and emergent cases, and not home discharges significantly increased LOS by notable amounts (1, 1.5, 3.9, and 1.9 d, respectively). ConclusionsCarotid artery stenosis patients in Pennsylvania undergoing CEA or CAS had similar 30-d readmission rates. Although LOS was significantly different, the magnitude of the difference was not large.

Fall injuries, associated deaths, and 30-day readmission for subsequent falls are increasing in the elderly US population: a query of the WHO mortality database and National Readmission Database from 2010 to 2014.

PurposeClinicians anecdotally noted that elderly patients who suffered from traumatic injuries (falls or other injuries) often re-present and are readmitted with fall injuries. Herein, we hypothesized that fall injuries and fall-related deaths and readmissions are increasing over time, and assessed whether the overall rates of death, hospital admission, and 30-day readmission due to falls increased from 2010 to 2014 in the elderly population (≥65) in the US.Patients and methodsThe WHO mortality database and the National Readmission Database (NRD) were queried to assess rates of deaths and hospital admissions and 30-day readmissions associated with fall injuries in the elderly population that presented with trauma. Descriptive statistics were obtained. The generalized linear mixed modeling (GLMM) framework was utilized to examine the relationship between fixed-effect predictor variables and the dichotomous outcome, indicating readmission within 30 days of previous discharge while accounting for hospital clustering with a random intercept.ResultsFall-related death increased by 1.4% from 2010 to 2014. Similarly, the hospital admission rate increased by 2% and was mainly associated with increased admission of elderly 65–74 years old. Approximately 55% of the fall patients were placed in nursing facilities in 2010, and this rate increased by 3% from 2010 to 2014. Thirty-day readmission rates for fall and trauma patients remained stable from 2010 to 2014. However, the rate of fall patients readmitted within 30 days for a subsequent fall increased from 15.6% to 17.4% between 2010 and 2014.ConclusionOur data indicate a steady increase in deaths and admissions for fall injuries in the elderly population. Strikingly, the incidence of readmission for a subsequent fall is increasing. With the aging population, this trend is likely to continue and highlights the need for elderly social support systems and fall prevention programs.

Outcomes of Catheter-Directed Therapy Plus Anticoagulation Versus Anticoagulation Alone for Submassive and Massive Pulmonary Embolism

BackgroundCatheter-directed therapy (CDT) offers an alternative treatment to systemic thrombolysis for patients with massive and submassive pulmonary embolism. MethodsA retrospective review of 105 consecutive massive and submassive pulmonary embolisms over 2 years was performed. Thirty-six patients (9 massive, 27 submassive) were treated with CDT, consisting of aspiration thrombectomy (18), ultrasound-assisted thrombolysis (8), or both (10). Forty-three patients (8 massive, 35 submassive) were treated with heparin anticoagulation alone. Primary outcome was improvement of RV/LV ratio 24-48 hours after treatment. Safety outcomes included 90-day mortality, bleeding complications, and hospital readmissions. Subgroup analysis based on severity of RV dilation was performed. ResultsMean RV/LV ratio decreased from 1.91±0.61 to 1.28±0.45 (P < .001) in the CDT group and from 1.40 ± 0.37 to 1.25 ± 0.32 (P = .01) in the anticoagulation group. In submassive pulmonary embolisms with mild and moderate RV dilation (RV/LV ratio 0.9-1.9), RV/LV ratio was significantly lower in the CDT group at 24-48 hours (1.05 ± 0.38 vs 1.20 ± 0.31, P < .001). In submassive pulmonary embolisms with severe RV dilation (RV/LV ratio >1.9), no difference was noted between the 2 treatment groups. Ninety-day mortality (11% and 14%, p = 0.7) and incidence of major bleeding complications did not significantly differ between the 2 groups. Thirty-day readmission rates were 8% in the CDT group and 26% in the anticoagulation group (P = .04). ConclusionCDT for acute massive and submassive pulmonary embolism significantly improves RV/LV ratio at 24-48 hours compared with anticoagulation alone and may lower hospital readmission rates. CDT may be more advantageous in patients with mild to moderate RV dilation.

Readmission Patterns Over 90-Day Episodes of Care Among Medicare Fee-for-Service Beneficiaries Discharged to Post-acute Care

ObjectiveExamine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings. DesignRetrospective cohort study. SettingAcute care hospitals. ParticipantsMedicare fee-for-service enrollees (N = 686,877) discharged from hospitals to post-acute care in 2013-2014. The cohort included beneficiaries >65 years of age hospitalized for stroke, joint replacement, or hip fracture and who survived for 90 days following discharge. Measurements90-day unplanned readmissions. ResultsThe cohort included 127,680 individuals with stroke, 442,195 undergoing joint replacement, and 117,002 with hip fracture. Thirty-day readmission rates ranged from 3.1% for knee replacement patients discharged to home health agencies (HHAs) to 14.4% for hemorrhagic stroke patients discharged to skilled nursing facilities (SNFs). Ninety-day readmission rates ranged from 5.0% for knee replacement patients discharged to HHAs to 26.1% for hemorrhagic stroke patients discharged to SNFs. Differences in readmission rates decreased between stroke subconditions (hemorrhagic and ischemic) and increased between joint replacement subconditions (knee, elective hip, and nonelective hip) from 30 to 90 days across all initial post-acute discharge settings. ConclusionsWe observed clear patterns in readmissions over 90-day episodes of care across post-acute discharge settings and subconditions. Our findings suggest that patients with hemorrhagic stroke may be more vulnerable than those with ischemic over the first 30 days after hospital discharge. For patients receiving nonelective joint replacements, readmission prevention efforts should start immediately after discharge and continue, or even increase, over the 90-day episode of care.

Thirty-Day Readmission Rate Using an Outpatient Infusion Pathway after Laparoscopic Roux-en-Y Gastric Bypass

The objective of this study was to determine whether implementing an outpatient infusion pathway (OIP) resulted in a decreased 30-day readmission rate after laparoscopic Roux-en-Y gastric bypass (LRYGB). Data were retrospectively gathered on all patients who underwent LRYGB at our institution between April 1, 2015, and March 31, 2016, after instituting an OIP (postinfusion group). Thirty-day readmission rate, length of stay, and 30-day mortality rate were compared with patients who underwent LRYGB between January 1, 2014, and December 31, 2014, before implementing the OIP (preinfusion group). Patients not able to take 40 ounces of fluid orally at discharge after surgery were enrolled in the OIP. One OIP session would include an antiemetic, 1 liter bolus of 0.9 per cent saline, and intravenous multivitamin, thiamine, and folic acid. A total of 174 patients were included for analysis. Seventy-nine patients were in the preinfusion group and 95 patients in the postinfusion group. Of the 95 patients in the postinfusion group, 18 patients (18.9%) met inclusion criteria for the OIP. There was a 45 per cent decrease in 30-day readmission rate after the institution of the OIP for patients who underwent LRYGB, however this was not statistically significant (11.39% vs 6.31%; OR 1.907; 95% confidence interval: 0.648-5.613, P = 0.235). There was no difference in postoperative length of hospital stay (1.65 vs 1.41 days, P = 0.114) or mortality (0.7% vs 0%, P = 0.454), in the pre- and postinfusion groups, respectively. Implementation of an OIP decreased 30-day readmission rate after LRYGB by 45 per cent; however, this was not statistically significant.

Validity of Performance and Outcome Measures for Heart Failure.

Background Numerous quality metrics for heart failure (HF) care now exist based on process and outcome. What remains unclear, however, is if the correct quality metrics are being emphasized. To determine the validity of certain measures, we compared correlations between measures and reliability over time. Measures assessed include guideline-recommended β-blocker (BB), any BB, angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker, mineralocorticoid receptor antagonist, and hydralazine/isosorbide dinitrate (in blacks) use among candidates, 30-day mortality, 1-year mortality, and 30-day readmission. Methods and Results This was an observational cohort analysis using chart review and electronic resources for 55 735 patients from 102 Veterans Affairs medical centers hospitalized with HF from 2008 to 2013. Assessments of convergent validity and reliability were performed. Significant correlations were found between in-hospital rates of ACE inhibitor use and the following measures: BB use, 30-day mortality, and 1-year mortality. Guideline-recommended BB use was also significantly correlated with mineralocorticoid receptor antagonists, 30-day mortality, and 1-year mortality. There was no correlation between 30-day readmission rates and any therapy or mortality. Measure reliability over time was seen for guideline-recommended BBs ( r=0.57), mineralocorticoid receptor antagonists ( r=0.50), 30-day mortality ( r=0.29), and 1-year mortality ( r=0.31). ACE inhibitor and readmission rates were not reliable measures over time. Conclusions BB use, ACE inhibitor use, mortality, and mineralocorticoid receptor antagonist use are valid measures of HF quality. Thirty-day readmission rate did not seem to be a valid measure of HF quality of care. If the goal is to identify high-quality HF care, the emphasis on decreasing readmission rates might be better directed towards improving usage of the recommended therapies.

TCT-87 Thirty-Day Readmission Rate & Etiologies after Endovascular Repair of Abdominal Aortic Aneurysm: A Nationwide Analysis

Endovascular aneurysm repair (EVAR) is one of the most commonly performed vascular interventions for abdominal aortic aneurysm (AAA). Data regarding 30-day readmission rates after EVAR are poorly reported in the literature. The Nationwide Readmission Database (NRD) from 2010 to 2014 was queried

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Understanding Lumbar Stenosis/Spondylolisthesis: 12. A preoperative score for predicting 30-day readmission after elective 1- or 2-level posterior lumbar fusion

BACKGROUND CONTEXT Posterior lumbar fusion is one of the most commonly performed procedures in the United States. Readmission rates are an important metric of quality of care and directly tied to reimbursement. Identification of factors that influence readmission rates is valuable for preoperative optimization and for appropriate risk stratification of patients. PURPOSE To develop a model to predict 30-day readmission in elective 1- or 2-level posterior lumbar fusion patients. STUDY DESIGN/SETTING Case control study. PATIENT SAMPLE Patients undergoing elective 1- or 2-level posterior lumbar spine fusion in the state inpatient databases (SID) of New York, Florida, North Carolina, Utah, and California. OUTCOME MEASURES Creation of the readmission after posterior spinal fusion (RAPSF) scoring system. METHODS Data were queried for 30-day readmission, as well as demographic and surgical data. Patients were randomly assigned to a derivation cohort and a validation cohort. A stepwise multivariate analysis was conducted to create a model to predict 30-day readmission. Variables with p 1.1 and p RESULTS There were 92,262 patients in the derivation cohort and 90,257 in the validation cohort. Thirty-day readmission rates were 10.9% and 11.1% respectively. The following variables were significant in the multivariate model and included in the RAPSF (point value in parentheses): age (50-59: 4, 60-69: 4, 70-79:6,>90: 8), gender (female: 3), race (Hispanic: 4, black: 5), insurance (Medicare: 4, Medicaid: 5, other–non-commercial: 3), anterior approach (4), cerebrovascular disease (3), chronic pulmonary disease (3), congestive heart failure (4), diabetes without chronic complications (4), diabetes with chronic complication (4), hemiplegia/paraplegia (7), rheumatic disease 3), drug abuse (4), electrolyte disorder (4), osteoporosis (3), depression (3), obesity (4), morbid obesity (5). Linear regression between readmission rate and RAPSF fit the derivation cohort with an adjusted r2 of 0.92 and a coefficient of 0.011 (p CONCLUSIONS We developed an easy-to-use tool, the RAPSF, to accurately predict readmission rates in patients undergoing elective 1-2 level posterior lumbar fusion. The RAPSF may be useful to empower informed choice regarding the risks of surgery and to guide an evidence-based approach to preoperative optimization and risk adjustment within alternative payment models for elective spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.