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Abstract
BACKGROUND Textbook outcome (TO) is a multidimensional measure for quality assurance, reflecting the "ideal" surgical outcome. METHODS Post-hoc analysis of patients who underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between 2014 and 2017, queried from the nationwide prospective Dutch Pancreatic Cancer Audit. An international survey was conducted among 24 experts from 10 countries to reach consensus on the requirements for TO in pancreatic surgery. Univariable and multivariable logistic regression was performed to identify TO predictors. Between-hospital variation in TO rates was compared using observed-versus-expected rates. RESULTS Based on the survey (92% response rate), TO was defined by the absence of postoperative pancreatic fistula, bile leak, postpancreatectomy hemorrhage (all ISGPS grade B/C), severe complications (Clavien-Dindo ≥III), readmission, and in-hospital mortality. Overall, 3341 patients were included (2633 (79%) PD and 708 (21%) DP) of whom 60.3% achieved TO; 58.3% for PD and 67.4% for DP. On multivariable analysis, ASA class 3 predicted a worse TO rate after PD (ASA 3 OR 0.59 [0.44-0.80]), whereas a dilated pancreatic duct (>3 mm) and pancreatic ductal adenocarcinoma (PDAC) were associated with a better TO rate (OR 2.22 [2.05-3.57] and OR 1.36 [1.14-1.63], respectively). For DP, female sex and the absence of neoadjuvant therapy predicted better TO rates (OR 1.38 [1.01-1.90] and OR 2.53 [1.20-5.31], respectively). When comparing institutions, the observed-versus-expected rate for achieving TO varied from 0.71 to 1.46 per hospital after casemix-adjustment. CONCLUSIONS TO is a novel quality measure in pancreatic surgery. TO varies considerably between pancreatic centers, demonstrating the potential benefit of quality assurance programs.
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The Metrics of Acute Care Reentry and Emergency Department Visits by Recently Discharged Inpatients. Adv Emerg Nurs J 2020; 42:150-160. [PMID: 32358431 DOI: 10.1097/tme.0000000000000293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Research on acute care reentry by recently discharged inpatients has generally focused on hospital readmissions, with less attention given to presentations to the emergency department (ED). This omission results in underestimation of the extent of reentry and its impact on ED patient volumes and flow. This project involved an analysis of administrative data to examine the rate of ED presentations by recently discharged inpatients using 3 time metrics-within 0-3 days, 0-7 days, and 0-30 days of discharge. Descriptive-correlational analyses were conducted to examine the rates of reentry and ability to predict ED presentations using patient demographic (age and sex) and clinical profile (length of hospital stay and day of presentation). Approximately 12% of hospital discharges to home involved patients who presented to the ED within 30 days, and almost half occurred within the first week. Results of multivariable analyses suggest that the influences of ED presentations differ depending on the time metric examined. Emergency department presentations within 3 and 7 days of discharge compared with 30 days were not predicted by patient age or sex but were more likely to involve those with shorter hospital stays. A weekend presentation was also more likely among case patients presenting within 3 days of discharge. Only about one third of ED presentations resulted in readmission. Emergency department presentations are an important component of acute care reentry. Establishment of a common reentry metric for ED presentations would facilitate efforts to determine the impact of these events. Emergency nurses working in advanced practice roles are ideally positioned to assume a leadership role in addressing the needs of recently discharged inpatients who present to the ED. By reviewing these cases and collaborating with the inpatient unit staff, it may be possible to identify strategies for augmenting discharge planning and the provision of transitional care.
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Danielsen SO, Moons P, Leegaard M, Solheim S, Tønnessen T, Lie I. Facilitators of and barriers to reducing thirty-day readmissions and improving patient-reported outcomes after surgical aortic valve replacement: a process evaluation of the AVRre trial. BMC Health Serv Res 2020; 20:256. [PMID: 32220252 PMCID: PMC7102432 DOI: 10.1186/s12913-020-05125-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/18/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The Aortic Valve Replacement Readmission (AVRre) randomized control trial tested whether a telephone intervention would reduce hospital readmissions following surgical aortic valve replacement (SAVR). The telephone support provided 30 days of continuous phone-support (hotline) and two scheduled phone-calls from the hospital after discharge. The intervention had no effect on reducing 30-day all-cause readmission rate (30-DACR) but did reduce participants' anxiety compared to a control group receiving usual care. Depression and participant-reported health state were unaffected by the intervention. To better understand these outcomes, we conducted a process evaluation of the AVRre trial to gain insight into the (1) the dose and fidelity of the intervention, (2) mechanism of impacts, and (3) contextual factors that may have influenced the outcomes. METHODS The process evaluation was informed by the Medical Research Council framework, a widely used set of guidelines for evaluating complex interventions. A mix of quantitative (questionnaire and journal records) and qualitative data (field notes, memos, registration forms, questionnaire) was prospectively collected, and retrospective interviews were conducted. We performed descriptive analyses of the quantitative data. Content analyses, assisted by NVivo, were performed to evaluate qualitative data. RESULTS The nurses who were serving the 24/7 hotline intervention desired to receive more preparation before intervention implementation. SAVR patient participants were highly satisfied with the telephone intervention (58%), felt safe (86%), and trusted having the option of calling in for support (91%). The support for the telephone hotline staff was perceived as a facilitator of the intervention implementation. Content analyses revealed themes: "gap in the care continuum," "need for individualized care," and "need for easy access to health information" after SAVR. Differences in local hospital discharge management practices influenced the 30-DACR incidence. CONCLUSIONS The prospective follow-up of the hotline service during the trial facilitated implementation of the intervention, contributing to high participant satisfaction and likely reduced their anxiety after SAVR. Perceived less-than-optimal preparations for the hotline could be a barrier to AVRre trial implementation. Integrating user experiences into a mixed-methods evaluation of clinical trials is important for broadening understanding of trial outcomes, the mechanism of impact, and contextual factors that influence clinical trials. TRIAL REGISTRATION ClinicalTrials.gov, NCT02522663. Registered on 11 August 2015.
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Affiliation(s)
- Stein Ove Danielsen
- Center for Patient-centered Heart and Lung Research, Department of Cardiothoracic Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Building 63, Ullevål, PO Box 4956, Nydalen, 0424 Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- KU Leuven Department of Public Health and Primary Care, KU Leuven-University of Leuven, Leuven, Belgium
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven-University of Leuven, Leuven, Belgium
- Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Marit Leegaard
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Svein Solheim
- Center for Clinical Heart Research, Department of Cardiology, Division of Medicine, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Theis Tønnessen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Cardiothoracic Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Irene Lie
- Center for Patient-centered Heart and Lung Research, Department of Cardiothoracic Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Building 63, Ullevål, PO Box 4956, Nydalen, 0424 Oslo, Norway
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Çetin Aslan E, Ağırbaş İ. Rates, causes, and types of readmissions after total joint arthroplasty. Turk J Phys Med Rehabil 2020; 66:31-39. [PMID: 32318672 PMCID: PMC7171879 DOI: 10.5606/tftrd.2020.3916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/16/2019] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES The aim of the study was to investigate the causes and rates of readmissions within 90 days after primary and revision knee and hip arthroplasties. PATIENTS AND METHODS A total of 1,516 patients (290 males, 1,226 females; mean age 64.7±10.5 years; range, 21 to 91 years) who underwent primary total hip arthroplasty (THA), primary total knee arthroplasty (TKA), revision THA, and revision TKA between January 2013 and December 2014 were retrospectively analyzed. All readmissions within 90 days as of discharge dates of patients were analyzed and were categorized as planned readmissions related to the index admission, unplanned readmissions related to the index admission, planned readmissions unrelated to the index admission and unplanned readmissions unrelated to the index admission. RESULTS Readmission rate in the overall of study group was found to be 5.61%. This rate varied depending on the procedure applied, ranging between 2.35 and 6.74%. Unplanned readmissions related to the index admission within 90 days consisted of 60.0% of total readmissions. A total of 82.0% of readmissions within 90 days was due to surgical reasons. Planned readmissions unrelated to the index admission within 90 days were also frequently seen (31.76%). Totally 48.23% of total readmissions within 90 days occurred within the first 30 days. A total of 48.23% of the total readmissions and 58.82% of the readmissions which were unplanned and related to the index admission occurred within the first 30 days. CONCLUSION After knee and hip arthroplasties, readmissions occur due to various reasons. Therefore, it is of utmost importance to identify the readmission type in the evaluation of readmissions which may increase the effectiveness of precautions to be taken.
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Affiliation(s)
- Emine Çetin Aslan
- Department of Health Management, Uşak University, Vocational School of Health Services, Uşak, Turkey
| | - İsmail Ağırbaş
- Department of Health Institutions Management, Ankara University, Faculty of Health Science, Ankara, Turkey
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Innis J, Barnsley J, Berta W, Daniel I. Do hospital size, location, and teaching status matter? Role of context in the use of evidence-based discharge practices. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2020. [DOI: 10.1080/20479700.2020.1725716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | - Jan Barnsley
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Imtiaz Daniel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Ontario Hospital Association, Toronto, Canada
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Impact of telephone follow-up and 24/7 hotline on 30-day readmission rates following aortic valve replacement -A randomized controlled trial. Int J Cardiol 2020; 300:66-72. [DOI: 10.1016/j.ijcard.2019.07.087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 07/11/2019] [Accepted: 07/29/2019] [Indexed: 12/16/2022]
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Kiran T, Wells D, Okrainec K, Kennedy C, Devotta K, Mabaya G, Phillips L, Lang A, O'Campo P. Patient and caregiver priorities in the transition from hospital to home: results from province-wide group concept mapping. BMJ Qual Saf 2020; 29:390-400. [PMID: 31907325 DOI: 10.1136/bmjqs-2019-009993] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients and caregivers often face significant challenges when they are discharged home from hospital. We sought to understand what influenced patient and caregiver experience in the transition from hospital to home and which of these aspects they prioritised for health system improvement. METHODS We conducted group concept mapping over 11 months with patients-and their caregivers-who were admitted to a hospital overnight in the last 3 years in Ontario, Canada and discharged home. Home included supportive housing, shelters and long-term care. Participants responded to a single focal prompt about what affected their experience during the transition. We summarised responses in unique statements. We then recruited participants to rate each statement on a five-point scale on whether addressing this gap should be a priority for the health system. The provincial quality agency recruited participants in partnership with patient, community and healthcare organisations. Participation was online, in-person or virtual. RESULTS 736 participants provided 2704 responses to the focal prompt. Unique concepts were summarised in 52 statements that were then rated by 271 participants. Participants rated the following three statements most highly as a gap that should be a priority for the health system to address (in rank order): 'Not enough publicly funded home care services to meet the need', 'Home care support is not in place when arriving home from hospital' and 'Having to advocate to get enough home care'. The top priority was consistent across multiple subgroups. CONCLUSIONS In a country with universal health insurance, patients and caregivers from diverse backgrounds consistently prioritised insufficient public coverage for home care services as a gap the health system should address to improve the transition from hospital to home.
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Affiliation(s)
- Tara Kiran
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada .,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Ontario Health, Quality Business Unit (formerly Health Quality Ontario), Toronto, Ontario, Canada
| | - David Wells
- Ontario Health, Quality Business Unit (formerly Health Quality Ontario), Toronto, Ontario, Canada
| | - Karen Okrainec
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Carol Kennedy
- Ontario Health, Quality Business Unit (formerly Health Quality Ontario), Toronto, Ontario, Canada
| | - Kimberly Devotta
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Gracia Mabaya
- Ontario Health, Quality Business Unit (formerly Health Quality Ontario), Toronto, Ontario, Canada
| | - Lacey Phillips
- Ontario Health, Quality Business Unit (formerly Health Quality Ontario), Toronto, Ontario, Canada
| | - Amy Lang
- Ontario Health, Quality Business Unit (formerly Health Quality Ontario), Toronto, Ontario, Canada
| | - Patricia O'Campo
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Vaduganathan M, McCarthy CP, Ayers C, Bhatt DL, Kumbhani DJ, de Lemos JA, Fonarow GC, Pandey A. Longitudinal trajectories of hospital performance across targeted cardiovascular conditions in the USA. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 6:62-71. [PMID: 31124567 DOI: 10.1093/ehjqcco/qcz026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/07/2019] [Accepted: 05/18/2019] [Indexed: 12/23/2022]
Abstract
AIMS Thirty-day risk standardized readmission and mortality rates (RSRR, RSMR) are key determinants for hospital performance for cardiovascular conditions such as acute myocardial infarction (AMI) and heart failure (HF). We evaluated whether individual hospitals in the USA perform similarly for HF and AMI over time based on readmission and mortality metrics. METHODS AND RESULTS A total of 1950 hospitals in the USA with continuous participation in the Centers for Medicare and Medicaid Services (CMS) public reporting programme between 2010 and 2016 were identified. Latent mixture modelling was used to define performance trajectory groups. Overall, there were consistent declines in the RSMR (16.1-14.0%) and RSRR (20.3-16.6%) for AMI from 2010 to 2016. For HF, RSRR declined over time (25.1-21.7%), while there was a modest increase in RSMR (11.3-12.0%); parallel findings were observed across performance trajectory groups. The proportion of best performing centres for HF care that were also best performers for AMI care based on the 30-day RSMR and 30-day RSRR metric was 54% and 35%, respectively. Furthermore, the discordance rate between the best and worst performers for both conditions was low (<2% for both 30-day outcomes). CONCLUSION In the USA, despite variation in baseline hospital-level outcomes, hospitals had consistent longitudinal trajectories (worsening or improvement) across conditions and metrics. Hospitals identified as high performing were frequently similar across target conditions and over time, suggesting that performance may be driven by systems of care influencing different disease states in a comparable manner.
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Affiliation(s)
- Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Cian P McCarthy
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Colby Ayers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Dharam J Kumbhani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - James A de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Gregg C Fonarow
- Ronald Reagan-UCLA Medical Center, 100 Medical Plaza Driveway, Los Angeles, CA 90095, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Lee HY, Shin JY, Lee SA, Ju YJ, Park EC. The 30-day unplanned readmission rate and hospital volume: a national population-based study in South Korea. Int J Qual Health Care 2019; 31:768-773. [PMID: 31089720 DOI: 10.1093/intqhc/mzz044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 04/05/2019] [Accepted: 04/24/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To examine the association between hospital volume and the unplanned 30-day readmission rate as a quality measure. DESIGN A retrospective cross-sectional study. SETTING The Korea healthcare system is operated by a single payer under the National Health Insurance Service. PARTICIPANTS Using national health claims data of the Health Insurance Review and Assessment in South Korea, we examined 1 296 275 adult discharges (≥18 years old) from 90 hospitals (≥500 beds) in the 2013 calendar year. MAIN OUTCOME MEASURES We analysed the 30-day, unplanned, observed-to-expected standardized readmission rate for hospitals and for five specialty cohorts: medicine, surgery/gynaecology, cardiovascular, cardiorespiratory, and neurology. We assessed the association between hospital volume by tertiles and the 30-day standardized readmission rates with and without adjustment for hospital characteristics. RESULTS The rate for the lowest-volume hospitals was 6.10 compared with 6.20 for the highest-volume hospitals. We observed the standardized readmission rates did not differ significantly between the lowest- and highest-volume groups, except for the neurology cohort, which remained significant after adjusting for hospital characteristics. CONCLUSIONS The standardized readmission rates were not associated with hospital volume, except for the neurology cohort, in which the standardized readmission rate was significantly higher in the highest-volume hospitals than in lowest- and intermediate-volume hospitals, which was not consistent with the typical association of greater hospital volume with better outcomes. This association was independent of hospital characteristics. Therefore, the rate of readmissions should be used with caution when gauging the quality of hospital care according to hospital volume.
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Affiliation(s)
- Hoo-Yeon Lee
- Department of Social Medicine, College of Medicine, Dankook University, Chungnam, Korea
| | - Jae Yong Shin
- Departments of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Sang Ah Lee
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.,Departments of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Yeong Jun Ju
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.,Departments of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Eun-Cheol Park
- Departments of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
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Hurtaud A, Lallier F, Heidet M, Arnoult C, Dramé M, Canouï-Poitrine F. Real-life implementation of guidelines on the hospital-to-home transition for older patients: a cohort study in general practice. Age Ageing 2019; 49:46-51. [PMID: 31763676 DOI: 10.1093/ageing/afz143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND hospital discharge is a critical event for older patients. The French guidelines recommended the swift transmission of a discharge summary to the general practitioner (GP) and a primary care consultation within 7 days. The relevance and feasibility of these guidelines have not previously been assessed. OBJECTIVE to perform a real-life assessment of compliance with French guidelines on the transmission of discharge summaries and post-discharge medical reviews and to examine these factors' association with 30-day readmissions. DESIGN a prospective multicentre cohort study. SETTING primary care (general practice) in France. SUBJECTS a sample of GPs and the same number of patients aged 75 or over having consulted within 30 days of hospital discharge. METHODS the main endpoints were the proportion of discharge summaries available and the proportion of patients consulting their GP within 7 days. The 30-day readmission rate was also measured. Factors associated with these endpoints were assessed in univariate and multivariate analyses. RESULTS seventy-one GPs (mean ± standard deviation age: 49 ± 11; males: 62%) and 71 patients (mean age: 84 ± 5; males: 52%; living at home: 94%; cognitive disorders: 22%) were included. Forty-six patients (65%, [95% confidence interval [CI]]: 53-76) consulted their GP within 7 days of hospital discharge. At the time of the consultation, 27 GPs (38% [95% CI]: 27-50) had not received the corresponding hospital discharge summary. Discharge summary availability was associated with a lower risk of 30-day readmission (adjusted odds ratio [95% CI] = 0.25 [0.07-0.91]). CONCLUSIONS compliance with the French guidelines on hospital-to-home transitions is insufficient.
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Affiliation(s)
- Aline Hurtaud
- Clinical Epidemiology and Ageing Unit, Université Paris-Est Créteil, Créteil, France
| | - François Lallier
- General Practice Department, University of Reims-Champagne-Ardenne, Reims Cedex 51086, France
| | - Matthieu Heidet
- SAMU 94 Emergency Medical Services, University Hospital Henri Mondor, Créteil, France
| | - Charline Arnoult
- General Practice Department, University of Reims-Champagne-Ardenne, Reims Cedex 51086, France
| | - Moustapha Dramé
- Department of Clinical Research and Innovation, University Hospitals of Martinique, Martinique, France
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Uitvlugt EB, Janssen MJA, Siegert CEH, Leenders AJA, van den Bemt BJF, van den Bemt PMLA, Karapinar-Çarkit F. Patients' and providers' perspectives on medication relatedness and potential preventability of hospital readmissions within 30 days of discharge. Health Expect 2019; 23:212-219. [PMID: 31733100 PMCID: PMC6978863 DOI: 10.1111/hex.12993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/03/2019] [Accepted: 10/08/2019] [Indexed: 12/02/2022] Open
Abstract
Background Hospital readmissions are increasingly used as an indicator of quality in health care. One potential risk factor of readmissions is polypharmacy. No studies have explored the patients’ perspectives on the medication relatedness and potential preventability of their readmissions. Objective To compare the patients’ perspectives on the medication relatedness and potential preventability of their readmissions with the providers’ perspectives. Methods Patients unplanned readmitted within 30 days after discharge at one of the participating departments of OLVG Hospital in Amsterdam were interviewed during their readmission. Patients’ perspectives regarding medication relatedness of their readmissions, the potential preventability, possible preventable interventions, and satisfaction with medication information were examined. Health‐care providers also reviewed files of these readmitted patients. Primary outcome was the percentage of medication‐related and potentially preventable readmissions according to the patient vs the provider. Descriptive data analysis was used. Results According to patients, 36 of 172 (21%) readmissions were medication‐related, and of these, 21 (58%) were potentially preventable. According to providers, 26 (15%) readmissions were medication‐related and 6 (23%) of these were potentially preventable. Patients and providers agreed on the medication relatedness in 11 of the 172 readmissions, and in two of these, agreement on the potential preventability existed. According to patients, preventive interventions belonged mostly to the hospital level, followed by the primary care level and patient level. Conclusion Patients and providers differ substantially on their perspectives regarding the medication relatedness and preventability of readmissions. Patients were more likely to view medication‐related readmissions as preventable.
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Affiliation(s)
- Elien B Uitvlugt
- Department of Hospital Pharmacy, OLVG, Amsterdam, The Netherlands
| | | | - Carl E H Siegert
- Department of Internal Medicine, OLVG, Amsterdam, The Netherlands
| | | | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis. Int J Nurs Stud 2019; 101:103396. [PMID: 31698168 DOI: 10.1016/j.ijnurstu.2019.103396] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 08/01/2019] [Accepted: 08/06/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hospital readmission after discharge is a frequent, burdensome and costly event, particularly frequent in older people with multiple chronic conditions. Few literature reviews have analysed studies of continuity of care interventions to reduce readmissions of older inpatients discharged home over the short and long term. OBJECTIVE To evaluate the effectiveness of continuity of care interventions in older people with chronic diseases in reducing short and long term hospital readmission after hospital discharge. DESIGN Meta-analysis of randomized controlled trials. DATA SOURCES A comprehensive literature search on the databases PubMed, Medline, CINAHL and EMBASE was performed on 27 January 2019 with no language and time limits. REVIEW METHODS RCTs on continuity of care interventions on older people discharged from hospital having hospital readmission as outcome, were included. Two reviewers independently screened the studies and assessed methodological quality using the Cochrane Risk of Bias tool. Selected outcome data were combined and pooled using a Mantel-Haenszel random-effects model. RESULTS Thirty RCTs, representing 8920 patients were included. Results were stratified by time of readmissions. At 1 month from discharge, the continuity interventions were associated with lower readmission rates in 207/1595 patients in the experimental group (12.9%), versus 264/1645 patients in the control group (16%) (Relative Risk [RR], 0.84 [95% CI, 0.71-0.99]). From 1 to 3 months, readmission rates were lower in 325/1480 patients in the experimental group (21.9%), versus 455/1523 patients in the control group (29.8%) (RR 0.74 [95% CI, 0.65-0.84]). A subgroup analysis showed that this positive effect was stronger when the interventions addressed all of the continuity dimensions. After 3 months this impact became inconclusive with moderate/high statistical heterogeneity. CONCLUSIONS Continuity of care interventions prevent short term hospital readmission in older people with chronic diseases. However, there is inconclusive evidence about the effectiveness of continuity interventions aiming to reduce long term readmission, and it is suggested that stronger focus on it is needed.
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Wadhera RK, Joynt Maddox KE, Kazi DS, Shen C, Yeh RW. Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: national retrospective analysis. BMJ 2019; 366:l4563. [PMID: 31405902 PMCID: PMC6689820 DOI: 10.1136/bmj.l4563] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine any changes in total hospital revisits within 30 days of discharge after a hospital stay for medical conditions targeted by the Hospital Readmissions Reduction Program (HRRP). DESIGN Retrospective cohort study. SETTING Hospital stays among Medicare patients for heart failure, acute myocardial infarction, or pneumonia between 1 January 2012 and 1 October 2015. PARTICIPANTS Medicare fee-for-service patients aged 65 or over. MAIN OUTCOMES Total hospital revisits within 30 days of discharge after hospital stays for medical conditions targeted by the HRRP, and by type of revisit: treat-and-discharge visit to an emergency department, observation stay (not leading to inpatient readmission), and inpatient readmission. Patient subgroups (age, sex, race) were also evaluated for each type of revisit. RESULTS Our study cohort included 3 038 740 total index hospital stays from January 2012 to September 2015: 1 357 620 for heart failure, 634 795 for acute myocardial infarction, and 1 046 325 for pneumonia. Counting all revisits after discharge, the total number of hospital revisits per 100 patient discharges for target conditions increased across the study period (monthly increase 0.023 visits per 100 patient discharges (95% confidence interval 0.010 to 0.035)). This change was due to monthly increases in treat-and-discharge visits to an emergency department (0.023 (0.015 to 0.032) and observation stays (0.022 (0.020 to 0.025)), which were only partly offset by declines in readmissions (-0.023 (-0.035 to -0.012)). Increases in observation stay use were more pronounced among non-white patients than white patients. No significant change was seen in mortality within 30 days of discharge for target conditions (-0.0034 (-0.012 to 0.0054)). CONCLUSIONS In the United States, total hospital revisits within 30 days of discharge for conditions targeted by the HRRP increased across the study period. This increase was due to a rise in post-discharge emergency department visits and observation stays, which exceeded the decline in readmissions. Although reductions in readmissions have been attributed to improvements in discharge planning and care transitions, our findings suggest that these declines could instead be because hospitals and clinicians have intensified efforts to treat patients who return to a hospital within 30 days of discharge in emergency departments and as observation stays.
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Affiliation(s)
- Rishi K Wadhera
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
| | - Karen E Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA
| | - Dhruv S Kazi
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
| | - Changyu Shen
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
| | - Robert W Yeh
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
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Tan AYM, Krishnan JA. How Long Should We Be Vigilant after a Hospitalization for a Chronic Obstructive Pulmonary Disease Exacerbation? Am J Respir Crit Care Med 2019; 197:975-977. [PMID: 29361237 DOI: 10.1164/rccm.201712-2612ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ai-Yui M Tan
- 1 Division of Pulmonary, Critical Care, Sleep, and Allergy University of Illinois at Chicago Chicago, Illinois and
| | - Jerry A Krishnan
- 1 Division of Pulmonary, Critical Care, Sleep, and Allergy University of Illinois at Chicago Chicago, Illinois and.,2 Population Health Sciences Program University of Illinois Hospital & Health Sciences System Chicago, Illinois
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65
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Dunbar P, Hall M, Gay JC, Hoover C, Markham JL, Bettenhausen JL, Perrin JM, Kuhlthau KA, Crossman M, Garrity B, Berry JG. Hospital Readmission of Adolescents and Young Adults With Complex Chronic Disease. JAMA Netw Open 2019; 2:e197613. [PMID: 31339547 PMCID: PMC6659144 DOI: 10.1001/jamanetworkopen.2019.7613] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IMPORTANCE Adolescents and young adults (AYA) who have complex chronic disease (CCD) are a growing population that requires hospitalization to treat severe, acute health problems. These patients may have increased risk of readmission as demands on their self-management increase and as they transfer care from pediatric to adult health care practitioners. OBJECTIVE To assess variation across CCDs in the likelihood of readmission for AYA with increasing age. DESIGN, SETTING, AND PARTICIPANTS Retrospective 1-year cross-sectional study of the 2014 Agency for Healthcare Research and Quality Nationwide Readmissions Database for all US hospitals. Participants were 215 580 hospitalized individuals aged 15 to 30 years with cystic fibrosis (n = 15 213), type 1 diabetes (n = 86 853), inflammatory bowel disease (n = 48 073), spina bifida (n = 7819), and sickle cell anemia (n = 57 622) from January 1, 2014, to December 1, 2014. EXPOSURES Increasing age at index admission. MAIN OUTCOMES AND MEASURES Unplanned 30-day hospital readmission. Readmission odds were compared by patients' ages in 2-year epochs (with age 15-16 years as the reference) using logistic regression, accounting for confounding patient characteristics and data clustering by hospital. RESULTS Of 215 580 participants, 115 982 (53.8%) were female; the median (interquartile range) age was 24 (20-27) years. Across CCDs, multimorbidity was common; the percentages of index hospitalizations with 4 or more coexisting conditions ranged from to 33.4% for inflammatory bowel disease to 74.2% for spina bifida. Thirty-day hospital readmission rates varied significantly across CCDs: 20.2% (cystic fibrosis), 19.8% (inflammatory bowel disease), 20.4% (spina bifida), 22.5% (type 1 diabetes), and 34.6% (sickle cell anemia). As age increased from 15 to 30 years, unadjusted, 30-day, unplanned hospital readmission rates increased significantly for all 5 CCD cohorts. In multivariable analysis, age trends in the adjusted odds of readmission varied across CCDs. For example, for AYA who had cystic fibrosis, the adjusted odds of readmission increased to 1.9 (95% CI, 1.5-2.3) by age 21 years and remained elevated through age 30 years. For AYA who had type 1 diabetes, the adjusted odds of readmission peaked at ages 23 to 24 years (odds ratio, 2.3; 95% CI, 2.1-2.6) and then declined through age 30 years. CONCLUSIONS AND RELEVANCE These findings suggest that hospitalized AYA who have CCDs have high rates of multimorbidity and 30-day readmission. The adjusted odds of readmission for AYA varied significantly across CCDs with increasing age. Further attention is needed to hospital discharge care, self-management, and prevention of readmission in AYA with CCD.
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Affiliation(s)
- Peter Dunbar
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matt Hall
- Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri–Kansas City School of Medicine, Kansas City
- Children’s Hospital Association, Lenexa, Kansas
| | - James C. Gay
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Jessica L. Markham
- Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri–Kansas City School of Medicine, Kansas City
| | - Jessica L. Bettenhausen
- Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri–Kansas City School of Medicine, Kansas City
| | - James M. Perrin
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Karen A. Kuhlthau
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Morgan Crossman
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Brigid Garrity
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jay G. Berry
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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66
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Bricard D, Or Z. Impact of early primary care follow-up after discharge on hospital readmissions. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:611-623. [PMID: 30600468 DOI: 10.1007/s10198-018-1022-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 12/11/2018] [Indexed: 06/09/2023]
Abstract
Reducing repeated hospitalizations of patients with chronic conditions is a policy objective for improving system efficiency. We test the hypothesis that the risk of readmission is associated with the timing and intensity of primary care follow-up after discharge, focusing on patients hospitalized for heart failure in France. We propose a discrete-time model which takes into account that primary care treatments have a lagged and cumulative effect on readmission risk, and an instrumental variable approach, exploiting geographical differences in availability of generalists. We show that the early consultations with a GP after discharge can reduce the 28-day readmission risk by almost 50%, and that patients with higher ambulatory care utilization have smaller odds of readmission. Furthermore, geographical disparities in primary care affect indirectly the readmission risk. These results suggest that interventions which strengthen communication between hospitals and generalists are elemental for reducing readmissions and for developing effective strategies at the hospital level, it is also necessary to consider primary care resources that are available to patients.
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Affiliation(s)
- Damien Bricard
- Institut de Recherche et de Documentation en Economie de la Santé (IRDES), 117 bis rue Manin, 75019, Paris, France.
| | - Zeynep Or
- Institut de Recherche et de Documentation en Economie de la Santé (IRDES), 117 bis rue Manin, 75019, Paris, France
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67
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Gershon AS, Thiruchelvam D, Aaron S, Stanbrook M, Vozoris N, Tan WC, Cho E, To T. Socioeconomic status (SES) and 30-day hospital readmissions for chronic obstructive pulmonary (COPD) disease: A population-based cohort study. PLoS One 2019; 14:e0216741. [PMID: 31112573 PMCID: PMC6528994 DOI: 10.1371/journal.pone.0216741] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 04/26/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) are more likely to be readmitted than patients with other chronic medical conditions, yet knowledge regarding such readmissions is limited. We aimed to determine factors associated with readmission within 30 days of a COPD hospitalization or death with an emphasis on examining aspects of socioeconomic status and specific comorbidities. METHODS A population-based cohort study was conducted using health administrative data from Ontario, Canada. All hospitalizations for COPD between 2004 and 2014 were considered. The primary exposures were socioeconomic status as measured by residential instability (an ecologic variable), and comorbidities such as cardiovascular disease and cancer. Other domains of socioeconomic status were considered as secondary exposures. Logistic regression with generalized estimating equations was used to examine the effect of exposures, adjusting for other patient factors, on 30-day readmission or death. RESULTS There were 126,013 patients contributing to 252,756 index COPD hospitalizations from 168 Ontario hospitals. Of these hospitalizations, 19.4% resulted in a readmission and 2.8% resulted in death within 30 days. After adjusting for other factors, readmissions or death were modestly more likely among people with the highest residential instability compared to the lowest (OR 1.05, 95% CI 1.01-1.09). Comorbidities such as cardiovascular disease and cancer, as well as other aspects of low socioeconomic status also increased readmission or death risk. INTERPRETATION Socioeconomic status, measured in various ways, and many comorbidities predict 30-day readmission or death in patients hospitalized for COPD. Strategies that address these factors may help reduce readmissions and death.
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Affiliation(s)
- Andrea S. Gershon
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- * E-mail:
| | - Deva Thiruchelvam
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Shawn Aaron
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Matthew Stanbrook
- Asthma & Airway Centre, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nicholas Vozoris
- Department of Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Wan C. Tan
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eunice Cho
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Teresa To
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
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68
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Ambugo EA, Hagen TP. Effects of introducing a fee for inpatient overstays on the rate of death and readmissions across municipalities in Norway. Soc Sci Med 2019; 230:309-317. [PMID: 31027865 DOI: 10.1016/j.socscimed.2019.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 02/19/2019] [Accepted: 04/06/2019] [Indexed: 11/29/2022]
Abstract
The Norwegian healthcare coordination reform (Samhandlingsreformen) was implemented from January 1, 2012. In addition to providing municipalities with funding to strengthen their health infrastructure, it required municipalities to pay hospitals a daily fee for patients who, having been declared ready for discharge and in need of municipal health services, were not received by the municipalities on time. This study examines the effects of the reform on the rate of death and readmissions occurring within 60 days of hospitalization. We use aggregated municipal data for years 2009, 2010, 2012-2014 (N = 1646) for Norwegian patients (age 18+) hospitalized in the same years for COPD/asthma, heart failure, hip fracture, and stroke. We stratify our analyses of the municipal data by these patient groups. Our linear regression models test for moderated (interaction) effects whereby associations between the reform and the rate of death and readmissions vary by whether or not patients were classified as ready for discharge and in need of follow-up care in the municipality. The models adjust for municipal sociodemographic and health characteristics. We found no statistically significant moderated effects of the reform across the patient groups, except for patients with stroke (b = .027, SE = 0.109, p < .05). Specifically, compared to the pre-reform period (2009-2010), the post-reform period (2012-2014) was associated with a higher rate of readmissions at high predicted values of needing follow-up care. Even though our analyses of municipal data suggest that patients with stroke are vulnerable to the reform and its incentive scheme, there is no strong evidence overall to suggest that the Norwegian healthcare coordination reform is functioning in a manner that exacerbates the risk of death and readmissions.
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Affiliation(s)
- Eliva Atieno Ambugo
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Postboks 1089 Blindern, 0318, Oslo, Norway.
| | - Terje P Hagen
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Postboks 1089 Blindern, 0318, Oslo, Norway
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69
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Hekkert K, Borghans I, Cihangir S, Westert GP, Kool RB. What is the impact on the readmission ratio of taking into account readmissions to other hospitals? A cross-sectional study. BMJ Open 2019; 9:e025740. [PMID: 30967406 PMCID: PMC6500251 DOI: 10.1136/bmjopen-2018-025740] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Readmissions are used widespread as an indicator of the quality of care within hospitals. Including readmissions to other hospitals might have consequences for hospitals. The aim of our study is to determine the impact of taking into account readmissions to other hospitals on the readmission ratio. DESIGN AND SETTING We performed a cross-sectional study and used administrative data from 77 Dutch hospitals (2 333 173 admissions) in 2015 and 2016 (97% of all hospitals). We performed logistic regression analyses to calculate 30-day readmission ratios for each hospital (the number of observed admissions divided by the number of expected readmissions based on the case mix of the hospital, multiplied by 100). We then compared two models: one with readmissions only to the same hospital, and another with readmissions to any hospital in the Netherlands. The models were calculated on the hospital level for all in-patients and, in more detail, on the level of medical specialties. MAIN OUTCOME MEASURES Percentage of readmissions to another hospital, readmission ratios same hospital and any hospital and C-statistic of each model in order to determine the discriminative ability. RESULTS The overall percentage of readmissions was 10.3%, of which 91.1% were to the same hospital and 8.9% to another hospital. Patients who went to another hospital were younger, more often men and had fewer comorbidities. The readmission ratios for any hospital versus the same hospital were strongly correlated (r=0.91). There were differences between the medical specialties in percentage of readmissions to another hospital and C-statistic. CONCLUSIONS The overall impact of taking into account readmissions to other hospitals seems to be limited in the Netherlands. However, it does have consequences for some hospitals. It would be interesting to explore what causes this difference for some hospitals and if it is related to the quality of care.
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Affiliation(s)
- Karin Hekkert
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Ine Borghans
- Team Risk Detection, Dutch Health and Youth Care Inspectorate (IGJ), Utrecht, The Netherlands
| | - Sezgin Cihangir
- Team Expertise and Support, Dutch Hospital Data, Utrecht, The Netherlands
| | - Gert P Westert
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rudolf B Kool
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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70
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Hekkert K, van der Brug F, Keeble E, Borghans I, Cihangir S, Bardsley M, Clarke A, Westert GP, Kool RB. Re-admission patterns in England and the Netherlands: a comparison based on administrative data of all hospitals. Eur J Public Health 2019; 29:202-207. [PMID: 30445564 DOI: 10.1093/eurpub/cky199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Examining variation in patterns of re-admissions between countries can be valuable for mutual learning in order to reduce unnecessary re-admissions. The aim of this study was to compare re-admission rates and reasons for re-admissions between England and the Netherlands. METHODS We used data from 85 Dutch hospitals (1 355 947 admissions) and 451 English hospitals (5 260 227 admissions) in 2014 (96% of all Dutch hospitals and 100% of all English NHS hospitals). Re-admission data from England and the Netherlands were compared for all hospital patients and for specific diagnosis groups: pneumonia, urinary tract infection, chronic obstructive pulmonary disease, coronary atherosclerosis, biliary tract disease, hip fracture and acute myocardial infarction. Re-admissions were categorized using a classification system developed on administrative data. The classification distinguishes between potentially preventable re-admissions and other reasons for re-admission. RESULTS England had a higher 30-day re-admission rate (adjusted for age and gender) compared to the Netherlands: 11.17% (95% CI 11.14-11.20%) vs. 9.83% (95% CI 9.77-9.88%). The main differences appeared to be in re-admissions for the elderly (England 17.2% vs. the Netherlands 10.0%) and in emergency re-admissions (England 85.3% of all 30-day re-admissions vs. the Netherlands 66.8%). In the Netherlands, however, more emergency re-admissions were classified as potentially preventable compared to England (33.8% vs. 28.8%). CONCLUSIONS The differences found between England and the Netherlands indicate opportunities to reduce unnecessary re-admissions. For England this concerns more expanded palliative care, integrated social care and reduction of waiting times. In the Netherlands, the use of treatment plans for daily life could be increased.
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Affiliation(s)
- Karin Hekkert
- Radboud university medical center, Radboud Institute for Health Sciences, department IQ healthcare, Nijmegen, the Netherlands.,Dutch Health and Youth Care Inspectorate (IGJ), Utrecht, The Netherlands
| | - Femke van der Brug
- Radboud university medical center, Radboud Institute for Health Sciences, department IQ healthcare, Nijmegen, the Netherlands
| | | | - Ine Borghans
- Dutch Health and Youth Care Inspectorate (IGJ), Utrecht, The Netherlands
| | | | | | - Aileen Clarke
- Division of Health Sciences, Warwick University, Coventry, UK
| | - Gert P Westert
- Radboud university medical center, Radboud Institute for Health Sciences, department IQ healthcare, Nijmegen, the Netherlands
| | - Rudolf B Kool
- Radboud university medical center, Radboud Institute for Health Sciences, department IQ healthcare, Nijmegen, the Netherlands
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71
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Hekkert K, Kool RB, Rake E, Cihangir S, Borghans I, Atsma F, Westert G. To what degree can variations in readmission rates be explained on the level of the hospital? a multilevel study using a large Dutch database. BMC Health Serv Res 2018; 18:999. [PMID: 30591058 PMCID: PMC6307249 DOI: 10.1186/s12913-018-3761-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 11/23/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND It is not clear which part of the variation in hospital readmissions can be attributed to the standard of care hospitals provide. This is in spite of their widespread use as an indicator of a lower quality of care. The aim of this study is to assess the variation in readmissions on the hospital level after adjusting for case-mix factors. METHODS We performed multilevel logistic regression analyses with a random intercept for the factor 'hospital' to estimate the variance on the hospital level after adjustment for case-mix variables. We used administrative data from 53 Dutch hospitals from 2010 to 2012 (58% of all Dutch hospitals; 2,577,053 admissions). We calculated models for the top ten diagnosis groups with the highest number of readmissions after an index admission for a surgical procedure. We calculated intraclass correlation coefficients (ICC) per diagnosis group in order to explore the variation in readmissions between hospitals. Furthermore, we determined C-statistics for the models with and without a random effect on the hospital level to determine the discriminative ability. RESULTS The ICCs on the hospital level ranged from 0.48 to 2.70% per diagnosis group. The C-statistics of the models with a random effect on the hospital level ranged from 0.58 to 0.65 for the different diagnosis groups. The C-statistics of the models that included the hospital level were higher compared to the models without this level. CONCLUSIONS For some diagnosis groups, a small part of the explained variation in readmissions was found on the hospital level, after adjusting for case-mix variables. However, the C-statistics of the prediction models are moderate, so the discriminative ability is limited. Readmission indicators might be useful for identifying areas for improving quality within hospitals on the level of diagnosis or specialty.
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Affiliation(s)
- Karin Hekkert
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
- Dutch Health and Youth Care Inspectorate (IGJ), Utrecht, The Netherlands
| | - Rudolf B. Kool
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Ester Rake
- Dutch Hospital Data, Utrecht, The Netherlands
| | | | - Ine Borghans
- Dutch Health and Youth Care Inspectorate (IGJ), Utrecht, The Netherlands
| | - Femke Atsma
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Gert Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
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McCarthy CP, Vaduganathan M, Pandey A. Developing evidence-based and accountable health policy in heart failure. Eur J Heart Fail 2018; 20:1653-1656. [PMID: 30295999 DOI: 10.1002/ejhf.1331] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 01/22/2023] Open
Affiliation(s)
- Cian P McCarthy
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Bambhroliya AB, Donnelly JP, Thomas EJ, Tyson JE, Miller CC, McCullough LD, Savitz SI, Vahidy FS. Estimates and Temporal Trend for US Nationwide 30-Day Hospital Readmission Among Patients With Ischemic and Hemorrhagic Stroke. JAMA Netw Open 2018; 1:e181190. [PMID: 30646112 PMCID: PMC6324273 DOI: 10.1001/jamanetworkopen.2018.1190] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
IMPORTANCE Readmission reduction is linked to improved quality of care, saves cost, and is a desirable patient-centered outcome. Nationally representative readmission metrics for patients with stroke are unavailable to date. Such estimates are necessary for benchmarking performance. OBJECTIVES To provide US nationwide estimates and a temporal trend for overall, planned, and potentially preventable 30-day hospital readmission among patients with ischemic and hemorrhagic stroke; to investigate the association between hospitals' stroke discharge volume, teaching status, and 30-day readmission; and to highlight reasons for 30-day readmission and explore the association of 30-day readmission in terms of mortality, length of stay, and cost of care among patients with stroke. DESIGN, SETTING, AND PARTICIPANTS Cohort, year-wise analysis of the Nationwide Readmissions Database between January 1, 2010, and September 30, 2015. The setting was a population-based cohort study providing national estimates of 30-day readmission. The database represents 50% of all US hospitalizations from 22 geographically dispersed states. Participants were adult (≥18 years) patients with a primary discharge diagnosis of intracerebral hemorrhage, acute ischemic stroke, or subarachnoid hemorrhage. Hospitals were categorized by their annual stroke discharge volume and were classified as teaching hospitals if they had an American Medical Association-approved residency program or had a ratio of full-time equivalent interns and residents to beds of 0.25 or higher. MAIN OUTCOMES AND MEASURES Readmission was defined as any admission within 30 days of index hospitalization discharge. Using Centers for Medicare & Medicaid Services-defined algorithms, events were classified as planned or unplanned and as potentially preventable. RESULTS Based on study criteria, 2 078 854 eligible patients were included (mean [SE] age, 70.02 [0.07] years; 51.9% female). Thirty-day readmission was highest for patients with intracerebral hemorrhage (13.70%; 95% CI, 13.40%-13.99%), followed by patients with acute ischemic stroke (12.44%; 95% CI, 12.33%-12.55%) and patients with subarachnoid hemorrhage (11.48%; 95% CI, 11.01%-11.96%). On average, there was a 3.3% annual decline in readmission between 2010 and 2014, which was statistically significant for the period of investigation (odds ratio, 0.96; 95% CI, 0.95-0.97). Patients discharged from nonteaching hospitals with high stroke discharge volume were at a significantly higher risk of 30-day readmission, and the top 2 reasons for readmission were acute cerebrovascular disease and septicemia. CONCLUSIONS AND RELEVANCE This study suggests that nationally representative readmission metrics can be used to benchmark hospitals' performance, and a temporal trend of 3.3% may be used to evaluate the effectiveness of readmission reduction strategies.
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Affiliation(s)
- Arvind B. Bambhroliya
- Department of Neurology, The Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
| | - John P. Donnelly
- Department of Epidemiology, University of Alabama School of Public Health, Birmingham
| | - Eric J. Thomas
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
| | - Jon E. Tyson
- Center for Clinical Research & Evidence-Based Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
| | - Charles C. Miller
- Center for Clinical Research & Evidence-Based Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
| | - Louise D. McCullough
- Department of Neurology, The Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
| | - Sean I. Savitz
- Department of Neurology, The Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
| | - Farhaan S. Vahidy
- Department of Neurology, The Institute for Stroke and Cerebrovascular Diseases, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
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Garnier A, Rouiller N, Gachoud D, Nachar C, Voirol P, Griesser AC, Uhlmann M, Waeber G, Lamy O. Effectiveness of a transition plan at discharge of patients hospitalized with heart failure: a before-and-after study. ESC Heart Fail 2018; 5:657-667. [PMID: 29757497 PMCID: PMC6073014 DOI: 10.1002/ehf2.12295] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/22/2018] [Accepted: 03/29/2018] [Indexed: 11/26/2022] Open
Abstract
Aims We evaluated the effectiveness of a multidisciplinary transition plan to reduce early readmission among heart failure patients. Methods and results We conducted a before‐and‐after study in a tertiary internal medicine department, comparing 3 years of retrospective data (pre‐intervention) and 13 months of prospective data (intervention period). Intervention was the introduction in 2013 of a transition plan performed by a multidisciplinary team. We included all consecutive patients hospitalized with symptomatic heart failure and discharged to home. The outcomes were the fraction of days spent in hospital because of readmission, based on the sum of all days spent in hospital, and the rate of readmission. The same measurements were used for those with potentially avoidable readmissions. Four hundred thirty‐one patients were included and compared with 1441 patients in the pre‐intervention period. Of the 431 patients, 138 received the transition plan while 293 were non‐completers. Neither the fraction of days spent for readmissions nor the rate of readmission decreased during the intervention period. However, non‐completers had a higher rate of the fraction of days spent for 30 day readmission (19.2% vs. 16.1%, P = 0.002) and for potentially avoidable readmission (9.8% vs. 13.2%, P = 0.001). The rate of potentially avoidable readmission decreased from 11.3% (before) to 9.9% (non‐completers) and 8.7% (completers), reaching the adjusted expected range given by SQLape® (7.7–9.1%). Conclusions A transition plan, requiring many resources, could decrease potentially avoidable readmission but shows no benefit on overall readmission. Future research should focus on potentially avoidable readmissions and other indicators such as patient satisfaction, adverse drug events, or adherence.
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Affiliation(s)
- Antoine Garnier
- Internal Medicine Department, University Hospital of Lausanne CHUV, 46, Rue du Bugnon, 1011, Lausanne, Switzerland
| | - Nathalie Rouiller
- Internal Medicine Department, University Hospital of Lausanne CHUV, 46, Rue du Bugnon, 1011, Lausanne, Switzerland
| | - David Gachoud
- Internal Medicine Department, University Hospital of Lausanne CHUV, 46, Rue du Bugnon, 1011, Lausanne, Switzerland
| | - Carole Nachar
- Pharmacy Division, University Hospital of Lausanne CHUV, 46, Rue du Bugnon, 1011, Lausanne, Switzerland
| | - Pierre Voirol
- Pharmacy Division, University Hospital of Lausanne CHUV, 46, Rue du Bugnon, 1011, Lausanne, Switzerland
| | - Anne-Claude Griesser
- Medical Directorate, University Hospital of Lausanne CHUV, 21, Rue du Bugnon, 1011, Lausanne, Switzerland
| | - Marc Uhlmann
- Department of Internal Medicine, Riviera-Chablais Hospital HRC, Route de Morgins, 1870, Monthey, Switzerland
| | - Gérard Waeber
- Internal Medicine Department, University Hospital of Lausanne CHUV, 46, Rue du Bugnon, 1011, Lausanne, Switzerland
| | - Olivier Lamy
- Internal Medicine Department, University Hospital of Lausanne CHUV, 46, Rue du Bugnon, 1011, Lausanne, Switzerland
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Busse R, van Ginneken E. Cross-country comparative research – Lessons from advancing health system and policy research on the occasion of the European Observatory on Health Systems and Policies’ 20th anniversary. Health Policy 2018; 122:453-456. [DOI: 10.1016/j.healthpol.2018.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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76
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Paying hospital specialists: Experiences and lessons from eight high-income countries. Health Policy 2018; 122:473-484. [DOI: 10.1016/j.healthpol.2018.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 02/09/2018] [Accepted: 03/08/2018] [Indexed: 01/26/2023]
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Baky V, Moran D, Warwick T, George A, Williams T, McWilliams E, Marine JE. Obtaining a follow-up appointment before discharge protects against readmission for patients with acute coronary syndrome and heart failure: A quality improvement project. Int J Cardiol 2018; 257:12-15. [DOI: 10.1016/j.ijcard.2017.10.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 09/01/2017] [Accepted: 10/09/2017] [Indexed: 11/28/2022]
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78
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Fudim M, Mentz RJ. Early versus late readmission during the vulnerable phase following hospitalization for heart failure: reply. Eur J Heart Fail 2018; 20:1166. [PMID: 29600600 DOI: 10.1002/ejhf.1189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/02/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
- Marat Fudim
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC, USA
| | - Robert J Mentz
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC, USA
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Friebel R, Hauck K, Aylin P, Steventon A. National trends in emergency readmission rates: a longitudinal analysis of administrative data for England between 2006 and 2016. BMJ Open 2018. [PMID: 29530912 PMCID: PMC5857687 DOI: 10.1136/bmjopen-2017-020325] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To assess trends in 30-day emergency readmission rates across England over one decade. DESIGN Retrospective study design. SETTING 150 non-specialist hospital trusts in England. PARTICIPANTS 23 069 134 patients above 18 years of age who were readmitted following an initial admission (n=62 584 297) between April 2006 and February 2016. PRIMARY AND SECONDARY OUTCOMES We examined emergency admissions that occurred within 30 days of discharge from hospital ('emergency readmissions') as a measure of healthcare quality. Presented are overall readmission rates, and disaggregated by the nature of the indexed admission, including whether it was elective or emergency, and by clinical health condition recorded. All rates were risk-adjusted for patient age, gender, ethnicity, socioeconomic status, comorbidities and length of stay. RESULTS The average risk-adjusted, 30-day readmission rate increased from 6.56% in 2006/2007 to 6.76% (P<0.01) in 2012/2013, followed by a small decrease to 6.64% (P<0.01) in 2015/2016. Emergency readmissions for patients discharged following elective procedures decreased by 0.13% (P<0.05), whereas those following emergency admission increased by 1.27% (P<0.001). Readmission rates for hip or knee replacements decreased (-1.29%; P<0.001); for acute myocardial infarction (-0.04%; P<0.49), stroke (+0.62%; P<0.05), chronic obstructive pulmonary disease (+0.41%; P<0.05) and heart failure (+0.15%; P<0.05) remained stable; and for pneumonia (+2.72%; P<0.001), diabetes (+7.09%; P<0.001), cholecystectomy (+1.86%; P<0.001) and hysterectomy (+2.54%; P<0.001) increased. CONCLUSIONS Overall, emergency readmission rates in England remained relatively stable across the observation period, with trends of slight increases contained post 2012/2013. However, there were large variations in trends across clinical areas, with some experiencing marked increases in readmission rates. This highlights the need to better understand variations in outcomes across clinical subgroups to allow for targeted interventions that will ensure highest standards of care provided for all patients.
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Affiliation(s)
- Rocco Friebel
- School of Public Health, Imperial College London, London, UK
- Data Analytics, The Health Foundation, London, UK
| | - Katharina Hauck
- School of Public Health, Imperial College London, London, UK
| | - Paul Aylin
- School of Public Health, Imperial College London, London, UK
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80
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Berry JG, Gay JC, Joynt Maddox K, Coleman EA, Bucholz EM, O'Neill MR, Blaine K, Hall M. Age trends in 30 day hospital readmissions: US national retrospective analysis. BMJ 2018; 360:k497. [PMID: 29487063 PMCID: PMC5827573 DOI: 10.1136/bmj.k497] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To assess trends in and risk factors for readmission to hospital across the age continuum. DESIGN Retrospective analysis. SETTING AND PARTICIPANTS 31 729 762 index hospital admissions for all conditions in 2013 from the US Agency for Healthcare Research and Quality Nationwide Readmissions Database. MAIN OUTCOME MEASURE 30 day, all cause, unplanned hospital readmissions. Odds of readmission were compared by patients' age in one year epochs with logistic regression, accounting for sex, payer, length of stay, discharge disposition, number of chronic conditions, reason for and severity of admission, and data clustering by hospital. The middle (45 years) of the age range (0-90+ years) was selected as the age reference group. RESULTS The 30 day unplanned readmission rate following all US index admissions was 11.6% (n=3 678 018). Referenced by patients aged 45 years, the adjusted odds ratio for readmission increased between ages 16 and 20 years (from 0.70 (95% confidence interval 0.68 to 0.71) to 1.04 (1.02 to 1.06)), remained elevated between ages 21 and 44 years (range 1.02 (1.00 to 1.03) to 1.12 (1.10 to 1.14)), steadily decreased between ages 46 and 64 years (range 1.02 (1.00 to 1.04) to 0.91 (0.90 to 0.93)), and decreased abruptly at age 65 years (0.78 (0.77 to 0.79)), after which the odds remained relatively constant with advancing age. Across all ages, multiple chronic conditions were associated with the highest adjusted odds of readmission (for example, 3.67 (3.64 to 3.69) for six or more versus no chronic conditions). Among children, young adults, and middle aged adults, mental health was one of the most common reasons for index admissions that had high adjusted readmission rates (≥75th centile). CONCLUSIONS The likelihood of readmission was elevated for children transitioning to adulthood, children and younger adults with mental health disorders, and patients of all ages with multiple chronic conditions. Further attention to the measurement and causes of readmission and opportunities for its reduction in these groups is warranted.
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Affiliation(s)
- Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - James C Gay
- Monroe Carell Jr Children's Hospital at Vanderbilt Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | | | - Eric A Coleman
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Emily M Bucholz
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Margaret R O'Neill
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA 02115, USA
| | - Kevin Blaine
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA 02115, USA
| | - Matthew Hall
- Children's Hospital Association, Lenexa, KS 66219, USA
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81
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El Morabet N, Uitvlugt EB, van den Bemt BJ, van den Bemt PM, Janssen MJ, Karapinar-Çarkit F. Prevalence and Preventability of Drug-Related Hospital Readmissions: A Systematic Review. J Am Geriatr Soc 2018; 66:602-608. [DOI: 10.1111/jgs.15244] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Najla El Morabet
- Department of Hospital Pharmacy; OLVG; Amsterdam The Netherlands
| | | | - Bart J.F. van den Bemt
- Department of Pharmacy; SintMaartenskliniek; Nijmegen The Netherlands
- Department of Pharmacy; Radboud University Medical Centre; Nijmegen The Netherlands
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82
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Fudim M, O’Connor CM, Dunning A, Ambrosy AP, Armstrong PW, Coles A, Ezekowitz JA, Greene SJ, Metra M, Starling RC, Voors AA, Hernandez AF, Felker GM, Mentz RJ. Aetiology, timing and clinical predictors of early vs. late readmission following index hospitalization for acute heart failure: insights from ASCEND-HF. Eur J Heart Fail 2018; 20:304-314. [PMID: 29082629 PMCID: PMC5826892 DOI: 10.1002/ejhf.1020] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/27/2017] [Accepted: 08/28/2017] [Indexed: 12/24/2022] Open
Abstract
AIMS Patients hospitalized for heart failure (HF) are at high risk for 30-day readmission. This study sought to examine the timings and causes of readmission within 30 days of an HF hospitalization. METHODS AND RESULTS Timing and cause of readmission in the ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide and Decompensated Heart Failure) trial were assessed. Early and late readmissions were defined as admissions occurring within 0-7 days and 8-30 days post-discharge, respectively. Patients who died in hospital or remained hospitalized at day 30 post-randomization were excluded. Patients were compared by timing and cause of readmission. Logistic and Cox proportional hazards regression analyses were used to identify independent risk factors for early vs. late readmission and associations with 180-day outcomes. Of the 6584 patients (92%) in the ASCEND-HF population included in this analysis, 751 patients (11%) were readmitted within 30 days for any cause. Overall, 54% of readmissions were for non-HF causes. The median time to rehospitalization was 11 days (interquartile range: 6-18 days) and 33% of rehospitalizations occurred by day 7. Rehospitalization within 30 days was independently associated with increased risk for 180-day all-cause death [hazard ratio (HR) 2.38, 95% confidence interval (CI) 1.93-2.94; P < 0.001]. Risk for 180-day all-cause death did not differ according to early vs. late readmission (HR 0.99, 95% CI 0.67-1.45; P = 0.94). CONCLUSIONS In this hospitalized HF trial population, a significant majority of 30-day readmissions were for non-HF causes and one-third of readmissions occurred in the first 7 days. Early and late readmissions within the 30-day timeframe were associated with similarly increased risk for death. Continued efforts to optimize multidisciplinary transitional care are warranted to improve rates of early readmission.
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC, USA
| | | | - Allison Dunning
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC, USA
| | - Andrew P. Ambrosy
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC, USA
| | | | - Adrian Coles
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC, USA
| | | | - Stephen J. Greene
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC, USA
| | - Marco Metra
- Division of Cardiology, Department of Medical and Surgical Specialties, University of Brescia, Brescia, Italy
| | | | - Adriaan A. Voors
- Division of Cardiology, University of Groningen, Groningen, the Netherlands
| | | | - G. Michael Felker
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC, USA
| | - Robert J. Mentz
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC, USA
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83
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Telfer P, Kaya B. Optimizing the care model for an uncomplicated acute pain episode in sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:525-533. [PMID: 29222301 PMCID: PMC6142581 DOI: 10.1182/asheducation-2017.1.525] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The pathophysiology, clinical presentation, and natural history of acute pain in sickle cell disease are unique and require a disease-centered approach that also applies general principles of acute and chronic pain management. The majority of acute pain episodes are managed at home without the need to access health care. The long-term consequences of poorly treated acute pain include chronic pain, adverse effects of chronic opioid usage, psychological maladjustment, poor quality of life, and excessive health care utilization. There is no standard protocol for management of an acute pain crisis in either the hospital or the community. The assumptions that severe acute pain must be managed in the hospital with parenteral opioids and that strong opioids are needed for home management of pain need to be questioned. Pain management in the emergency department often does not meet acceptable standards, while chronic use of strong opioids is likely to result in opioid-induced hyperalgesia, exacerbation of chronic pain symptoms, and opioid dependency. We suggest that an integrated approach is needed to control the underlying condition, modify psychological responses, optimize social support, and ensure that health care services provide safe, effective, and prompt treatment of acute pain and appropriate management of chronic pain. This integrated approach should begin at an early age and continue through the adolescent, transition, and adult phases of the care model.
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Affiliation(s)
- Paul Telfer
- Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom; and
| | - Banu Kaya
- Departments of Haematology and Paediatric Haematology, Royal London Hospital, Bart’s Health National Health Service Trust, London, United Kingdom
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84
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Hekkert K, van der Brug F, Borghans I, Cihangir S, Zimmerman C, Westert G, Kool RB. How to identify potentially preventable readmissions by classifying them using a national administrative database. Int J Qual Health Care 2017; 29:826-832. [PMID: 29024960 DOI: 10.1093/intqhc/mzx110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 08/10/2017] [Indexed: 12/12/2022] Open
Abstract
Importance Hospital readmissions are being used increasingly as an indicator of quality of care. However, it remains difficult to identify potentially preventable readmissions. Objectives To evaluate the identification of potentially preventable hospital readmissions by using a classification of readmissions based on administrative data. Design and setting We classified a random sample of 455 readmissions to a Dutch university hospital in 2014 using administrative data. We compared these results to a classification based on reviewing the medical records of these readmissions to evaluate the accuracy of classification by administrative data. Main outcome measures Frequencies of categories of readmissions based on reviewing records versus those based on administrative data. Cohen's kappa for the agreement between both methods. The sensitivity and specificity of the identification of potentially preventable readmissions with classification by administrative data. Results Reviewing the medical records of acute readmissions resulted in 28.5% of the records being classified as potentially preventable. With administrative data this was 44.1%. There was slight agreement between both methods: ƙ 0.08 (95% CI: 0.02-0.15, P < 0.05). The sensitivity of the classification of potentially preventable readmissions by administrative data was 63.1% and the specificity was 63.5%. Conclusions This explorative study demonstrated differences between categorizing readmissions based on reviewing records compared to using administrative data. Therefore, this tool can only be used in practice with great caution. It is not suitable for penalizing hospitals based on their number of potentially preventable readmissions. However, hospitals might use this classification as a screening tool to identify potentially preventable readmissions more efficiently.
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Affiliation(s)
- Karin Hekkert
- Dutch Hospital Data, P.O. Box 9696, 3506 GR, Utrecht, The Netherlands.,Dutch Healthcare Inspectorate (IGZ), Stadsplateau 1, 3521 AZ, Utrecht, The Netherlands.,Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, P.O. Box 9101, IQ Healthcare 114 6500 HB, Nijmegen, The Netherlands
| | - Femke van der Brug
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, P.O. Box 9101, IQ Healthcare 114 6500 HB, Nijmegen, The Netherlands
| | - Ine Borghans
- Dutch Healthcare Inspectorate (IGZ), Stadsplateau 1, 3521 AZ, Utrecht, The Netherlands
| | - Sezgin Cihangir
- Dutch Hospital Data, P.O. Box 9696, 3506 GR, Utrecht, The Netherlands
| | - Cees Zimmerman
- Radboud University Medical Center, Intensive Care Unit 710, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Gert Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, P.O. Box 9101, IQ Healthcare 114 6500 HB, Nijmegen, The Netherlands
| | - Rudolf B Kool
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, P.O. Box 9101, IQ Healthcare 114 6500 HB, Nijmegen, The Netherlands
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85
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Reductions in Readmission Rates Are Associated With Modest Improvements in Patient-reported Health Gains Following Hip and Knee Replacement in England. Med Care 2017; 55:834-840. [PMID: 28742545 PMCID: PMC5555974 DOI: 10.1097/mlr.0000000000000779] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Although many hospital readmission reduction initiatives have been introduced globally, health care systems ultimately aim to improve patients’ health and well-being. We examined whether the hospitals that report greater success in reducing readmissions also see greater improvements in patient-reported outcomes. Research Design: We examined hospital groups (Trusts) that provided hip replacement or knee replacement surgery in England between April 2010 and February 2013. For each Trust, we calculated risk-adjusted 30-day readmission rates from administrative datasets. We also obtained changes in patient-reported health between presurgical assessment and 6-month follow-up, using general health EuroQuol five dimensions questionaire (EQ-5D) and EuroQuol visual analogue scales (EQ-VAS) and procedure-specific (Oxford Hip and Knee Scores) measures. Panel models were used to assess whether changes over time in risk-adjusted readmission rates were associated with changes over time in risk-adjusted health gains. Results: Each percentage point reduction in the risk-adjusted readmission rate for hip replacement was associated with an additional health gain of 0.004 for EQ-5D [95% confidence interval (CI), 0.002–0.006], 0.39 for EQ-VAS (95% CI, 0.26–0.52), and 0.32 for Oxford Hip Score (95% CI, 0.15–0.27). Corresponding figures for knee replacement were 0.003 for EQ-5D (95% CI, 0.001–0.004), 0.21 for EQ-VAS (95% CI, 0.12–0.30), and 0.14 in the Oxford Knee Score (95% CI, 0.09–0.20). Conclusions: Reductions in readmission rates were associated with modest improvements in patients’ sense of their health and well-being at the hospital group level. In particular, fears that efforts to reduce readmission rates have had unintended consequences for patients appear to be unfounded.
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86
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Zafar MA, Panos RJ, Ko J, Otten LC, Gentene A, Guido M, Clark K, Lee C, Robertson J, Alessandrini EA. Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science. BMJ Qual Saf 2017; 26:908-918. [PMID: 28733370 DOI: 10.1136/bmjqs-2017-006529] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Readmissions of chronic obstructive pulmonary disease (COPD) have devastating effects on patient quality-of-life, disease progression and healthcare cost. Effective interventions to reduce COPD readmissions are needed. OBJECTIVES Reduce 30-day all-cause readmissions by (1) creating a COPD care bundle that addresses care delivery failures, (2) using improvement science to achieve 90% bundle adherence. SETTING An 800-bed academic hospital in Ohio, USA. The COPD 30-day all-cause readmission rate was 22.7% from August 2013 to September 2015. METHOD We performed a cross-sectional study of COPD 30-day readmissions from October 2014 to March 2015 to identify care delivery failures. We interviewed readmitted patients with COPD to identify their needs after discharge. A multidisciplinary team created a care bundle designed to mitigate system failures. Using a quasi-experimental study and 'Model for Improvement', we redesigned care delivery to improve bundle adherence. We used statistical process control charts to analyse bundle adherence and all-cause 30-day readmissions. RESULTS Cross-sectional review of the index (first-time) admissions revealed COPD was the most common readmission diagnosis and identified 42 system-level failures. The most prevalent failures were deficient inhaler regimen at discharge, late or non-existent follow-up appointments, and suboptimal discharge instructions. Patient interviews revealed confusing discharge instructions, especially regarding inhaler use. The COPD care-bundle components were: (1) appropriate inhaler regimen, (2) 30-day inhaler supply, (3) inhaler education on the device available postdischarge, (4) follow-up within 15 days (5) standardised patient-centred discharge instructions. The adherence to completing bundle components reached 90% in 5.5 months and was sustained. The COPD 30-day readmission rate decreased from 22.7% to 14.7%. Patients receiving all bundle components had a readmission rate of 10.9%. As a balancing measure for the targeted reduction in readmission rate, we assessed length of stay, which did not change (4.8 days before vs 4.6 days after; p=0.45). CONCLUSION System-level failures and unmet patient needs are modifiable risks for readmissions. Development and reliable implementation of a COPD care bundle that mitigates these failures reduced COPD readmissions.
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Affiliation(s)
- Muhammad Ahsan Zafar
- Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio, USA
| | - Ralph J Panos
- Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Jonathan Ko
- Department of Respiratory Care, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Lisa C Otten
- Department of Respiratory Care, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Anthony Gentene
- Division of Pharmacy Practice and Administration, University of Cincinnati James L Winkle College of Pharmacy, Cincinnati, Ohio, USA.,Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Maria Guido
- Division of Pharmacy Practice and Administration, University of Cincinnati James L Winkle College of Pharmacy, Cincinnati, Ohio, USA.,Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Katherine Clark
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Caroline Lee
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jamie Robertson
- Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Innis J, Barnsley J, Berta W, Daniel I. Measuring health literate discharge practices. Int J Health Care Qual Assur 2017; 30:67-78. [PMID: 28105883 DOI: 10.1108/ijhcqa-06-2016-0080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Health literate discharge practices meet patient and family health literacy needs in preparation for care transitions from hospital to home. The purpose of this paper is to measure health literate discharge practices in Ontario hospitals using a new organizational survey questionnaire tool and to perform psychometric testing of this new survey. Design/methodology/approach This survey was administered to hospitals in Ontario, Canada. Exploratory factor analysis and reliability testing were performed. Findings The participation rate of hospitals was 46 percent. Exploratory factor analysis demonstrated that there were five factors. The survey, and each of the five factors, had moderate to high levels of reliability. Research limitations/implications There is a need to expand the focus of further research to examine the experiences of patients and families. Repeating this study with a larger sample would facilitate further survey development. Practical implications Measuring health literate discharge practices with an organizational survey will help hospital managers to understand their performance and will help direct quality improvement efforts to improve patient care at hospital discharge and to decrease hospital readmission. Originality/value There has been little research into how patients are discharged from hospital. This study is the first to use an organizational survey tool to measure health literate discharge practices.
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Affiliation(s)
- Jennifer Innis
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto , Toronto, Canada
| | - Jan Barnsley
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Imtiaz Daniel
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
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88
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Steventon A, Billings J. Preventing hospital readmissions: the importance of considering ‘impactibility,’ not just predicted risk. BMJ Qual Saf 2017; 26:782-785. [DOI: 10.1136/bmjqs-2017-006629] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2017] [Indexed: 11/03/2022]
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89
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Møller Dahl C, Planck Kongstad L. The costs of acute readmissions to a different hospital – Does the effect vary across provider types? Soc Sci Med 2017; 183:116-125. [DOI: 10.1016/j.socscimed.2017.04.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 04/21/2017] [Accepted: 04/24/2017] [Indexed: 11/24/2022]
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90
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Kristensen SR. Financial Penalties for Performance in Health Care. HEALTH ECONOMICS 2017; 26:143-148. [PMID: 27928846 DOI: 10.1002/hec.3463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 09/25/2016] [Accepted: 11/14/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Søren Rud Kristensen
- Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, Manchester, UK
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91
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Browne C, Lanitis T, Hamilton M, Li X, Horbyluk R, Mardekian J, Kongnakorn T, Cohen A. Impact of apixaban vs low molecular weight heparin/vitamin k antagonist on hospital resource use in patients with venous thromboembolism. J Med Econ 2017; 20:98-106. [PMID: 27822962 DOI: 10.1080/13696998.2016.1258365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The clinical and economic benefits associated with apixaban treatment have been established in clinical trials and published economic evaluations. The benefits associated with apixaban could extend to improving hospital efficiencies, potentially influencing hospital resource use, and bed days. The objective of this study is to estimate the impact of 6-month treatment with apixaban vs low molecular weight heparin/vitamin k antagonist (LMWH/VKA) on hospital resource use among patients with venous thromboembolism (VTE). METHODS A model was developed to assess the impact of apixaban vs LMWH/VKA for treatment of VTE and prevention of recurrences on hospital resource use and costs. Resource use items included total hospitalizations, length of stay (LOS), and emergency department (ED) visits, estimated for all incident VTE patients in the UK over a 5-year time horizon. Rates of hospitalizations, ED visits, and LOS associated with recurrent VTE, major, and clinically relevant non-major bleeding were obtained from the AMPLIFY trial; costs were obtained from UK published sources. RESULTS Over a 5-year time horizon, the model predicted that, compared to 6 months of LMWH/VKA, 6 months of apixaban led to 3,954 fewer hospitalizations (consisting of 2,341 fewer new admissions and 1,613 fewer re-admissions) and 32,214 fewer bed days, among 332,607 incident VTE patients. ED visits were reduced by 1,582. The reduction in hospital resource use led to a cost saving of ∼£4.5 million in a market of patients treated with apixaban as compared to a market treated with LMWH/VKA. Sensitivity analysis indicated these findings were robust over a wide range of inputs. CONCLUSIONS 6-month treatment with apixaban for treatment of VTE and prevention of recurrences on hospital resource use led to a reduction in hospitalizations and LOS in comparison to LMWH/VKA. These findings can help the efforts in reducing the growing burden of preventable re-admissions to hospitals.
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Affiliation(s)
| | | | - M Hamilton
- b Bristol-Myers Squibb , Princeton , NJ , USA
| | - X Li
- b Bristol-Myers Squibb , Princeton , NJ , USA
| | | | | | | | - A Cohen
- d Guy's and St Thomas' Hospitals , London , UK
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92
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93
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Dharmarajan K. Comprehensive Strategies to Reduce Readmissions in Older Patients With Cardiovascular Disease. Can J Cardiol 2016; 32:1306-1314. [DOI: 10.1016/j.cjca.2016.01.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 02/01/2023] Open
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94
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Shah T, Press VG, Huisingh-Scheetz M, White SR. COPD Readmissions: Addressing COPD in the Era of Value-based Health Care. Chest 2016; 150:916-926. [PMID: 27167208 PMCID: PMC5812767 DOI: 10.1016/j.chest.2016.05.002] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 04/19/2016] [Accepted: 05/01/2016] [Indexed: 11/17/2022] Open
Abstract
Of those patients hospitalized for an exacerbation of COPD, one in five will require rehospitalization within 30 days. Many developed countries are now implementing policies to increase care quality while controlling costs for COPD, known as value-based health care. In the United States, COPD is part of Medicare's Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals for excess 30-day, all-cause readmissions after a hospitalization for an acute exacerbation of COPD, despite minimal evidence to guide hospitals on how to reduce readmissions. This review outlines challenges for improving overall COPD care quality and specifically for the HRRP. These challenges include heterogeneity in the literature for how COPD and readmissions are defined, difficulty finding the target population during hospitalizations, and a lack of literature to guide evidence-based programs for COPD readmissions as defined by the HRRP in the hospital setting. It then identifies risk factors for early readmissions after acute exacerbation of COPD and discusses tested and emerging strategies to reduce these readmissions. Finally, we evaluate the current HRRP and future policy changes and their effect on the goal to deliver value-based COPD care. COPD remains a chronic disease with a high prevalence that has finally garnered the attention of health systems and policy makers, but we still have a long way to go to truly deliver value-based care to patients.
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Affiliation(s)
- Tina Shah
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Valerie G Press
- Section of Hospital Medicine, University of Chicago, Chicago, IL
| | - Megan Huisingh-Scheetz
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Steven R White
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.
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95
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Innovative pacing: Recent advances, emerging technologies, and future directions in cardiac pacing. Trends Cardiovasc Med 2016; 26:452-63. [PMID: 27017442 DOI: 10.1016/j.tcm.2016.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/15/2016] [Accepted: 02/17/2016] [Indexed: 11/20/2022]
Abstract
The field of cardiovascular medicine is rapidly evolving as advancements in technology and engineering provide clinicians new and exciting ways to care for an aging population. Cardiac pacing, in particular, has seen a series of game-changing technologies emerge in the past several years spurred by low-power electronics, high density batteries, improved catheter delivery systems and innovative software design. We look at several of these emerging pacemaker technologies, discussing the rationale, current state and future directions of these pioneering developments in electrophysiology.
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96
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Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial. Ann Surg 2016; 263:440-9. [PMID: 26135690 PMCID: PMC4741417 DOI: 10.1097/sla.0000000000001240] [Citation(s) in RCA: 209] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objectives: To assess pancreatic fistula rate and secondary endpoints after pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) for reconstruction in pancreatoduodenectomy in the setting of a multicenter randomized controlled trial. Background: PJ and PG are established methods for reconstruction in pancreatoduodenectomy. Recent prospective trials suggest superiority of the PG regarding perioperative complications. Methods: A multicenter prospective randomized controlled trial comparing PG with PJ was conducted involving 14 German high-volume academic centers for pancreatic surgery. The primary endpoint was clinically relevant postoperative pancreatic fistula. Secondary endpoints comprised perioperative outcome and pancreatic function and quality of life measured at 6 and 12 months of follow-up. Results: From May 2011 to December 2012, 440 patients were randomized, and 320 were included in the intention-to-treat analysis. There was no significant difference in the rate of grade B/C fistula after PG versus PJ (20% vs 22%, P = 0.617). The overall incidence of grade B/C fistula was 21%, and the in-hospital mortality was 6%. Multivariate analysis of the primary endpoint disclosed soft pancreatic texture (odds ratio: 2.1, P = 0.016) as the only independent risk factor. Compared with PJ, PG was associated with an increased rate of grade A/B bleeding events, perioperative stroke, less enzyme supplementation at 6 months, and improved results in some quality of life parameters. Conclusions: The rate of grade B/C fistula after PG versus PJ was not different. There were more postoperative bleeding events with PG. Perioperative morbidity and mortality of pancreatoduodenectomy seem to be underestimated, even in the high-volume center setting.
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97
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Mullen KA, Manuel DG, Hawken SJ, Pipe AL, Coyle D, Hobler LA, Younger J, Wells GA, Reid RD. Effectiveness of a hospital-initiated smoking cessation programme: 2-year health and healthcare outcomes. Tob Control 2016; 26:293-299. [PMID: 27225016 PMCID: PMC5543264 DOI: 10.1136/tobaccocontrol-2015-052728] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 04/20/2016] [Indexed: 11/23/2022]
Abstract
Background Tobacco-related illnesses are leading causes of death and healthcare use. Our objective was to determine whether implementation of a hospital-initiated smoking cessation intervention would reduce mortality and downstream healthcare usage. Methods A 2-group effectiveness study was completed comparing patients who received the ‘Ottawa Model’ for Smoking Cessation intervention (n=726) to usual care controls (n=641). Participants were current smokers, >17 years old, and recruited during admission to 1 of 14 participating hospitals in Ontario, Canada. Baseline data were linked to healthcare administrative data. Competing-risks regression analysis was used to compare outcomes between groups. Results The intervention group experienced significantly lower rates of all-cause readmissions, smoking-related readmissions, and all-cause emergency department (ED) visits at all time points. The largest absolute risk reductions (ARR) were observed for all-cause readmissions at 30 days (13.3% vs 7.1%; ARR, 6.1% (2.9% to 9.3%); p<0.001), 1 year (38.4% vs 26.7%; ARR, 11.7% (6.7% to 16.6%); p<0.001), and 2 years (45.2% vs 33.6%; ARR, 11.6% (6.5% to 16.8%); p<0.001). The greatest reduction in risk of all-cause ED visits was at 30 days (20.9% vs 16.4%; ARR, 4.5% (0.4% to 8.7%); p=0.03). Reduction in mortality was not evident at 30 days, but significant reductions were observed by year 1 (11.4% vs 5.4%; ARR 6.0% (3.1% to 9.0%); p<0.001) and year 2 (15.1% vs 7.9%; ARR, 7.3% (3.9% to 10.7%); p<0.001). Conclusions Considering the relatively low cost, greater adoption of hospital-initiated tobacco cessation interventions should be considered to improve patient outcomes and decrease subsequent healthcare usage.
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Affiliation(s)
- Kerri A Mullen
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Andrew L Pipe
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Laura A Hobler
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jaime Younger
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - George A Wells
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Robert D Reid
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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98
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Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study. BMJ 2016; 353:i2214. [PMID: 27160187 PMCID: PMC4861084 DOI: 10.1136/bmj.i2214] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To determine the impact of the Hospital Value-Based Purchasing (HVBP) program-the US pay for performance program introduced by Medicare to incentivize higher quality care-on 30 day mortality for three incentivized conditions: acute myocardial infarction, heart failure, and pneumonia. DESIGN Observational study. SETTING 4267 acute care hospitals in the United States: 2919 participated in the HVBP program and 1348 were ineligible and used as controls (44 in general hospitals in Maryland and 1304 critical access hospitals across the United States). PARTICIPANTS 2 430 618 patients admitted to US hospitals from 2008 through 2013. MAIN OUTCOME MEASURES 30 day risk adjusted mortality for acute myocardial infarction, heart failure, and pneumonia using a patient level linear spline analysis to examine the association between the introduction of the HVBP program and 30 day mortality. Non-incentivized, medical conditions were the comparators. A secondary outcome measure was to determine whether the introduction of the HVBP program was particularly beneficial for a subgroup of hospital-poor performers at baseline-that may benefit the most. RESULTS Mortality rates of incentivized conditions in hospitals participating in the HVBP program declined at -0.13% for each quarter during the preintervention period and -0.03% point difference for each quarter during the post-intervention period. For non-HVBP hospitals, mortality rates declined at -0.14% point difference for each quarter during the preintervention period and -0.01% point difference for each quarter during the post-intervention period. The difference in the mortality trends between the two groups was small and non-significant (difference in difference in trends -0.03% point difference for each quarter, 95% confidence interval -0.08% to 0.13% point difference, P=0.35). In no subgroups of hospitals was HVBP associated with better outcomes, including poor performers at baseline. CONCLUSIONS Evidence that HVBP has led to lower mortality rates is lacking. Nations considering similar pay for performance programs may want to consider alternative models to achieve improved patient outcomes.
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Affiliation(s)
- Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Yusuke Tsugawa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - E John Orav
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA
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99
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Friebel R, Steventon A. The multiple aims of pay-for-performance and the risk of unintended consequences. BMJ Qual Saf 2016; 25:827-831. [PMID: 27048595 DOI: 10.1136/bmjqs-2016-005392] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Rocco Friebel
- The Health Foundation, London, UK.,Imperial College London, London, UK
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100
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Figueroa JF, Wang DE, Jha AK. Characteristics of hospitals receiving the largest penalties by US pay-for-performance programmes. BMJ Qual Saf 2016; 25:898-900. [PMID: 26939872 DOI: 10.1136/bmjqs-2015-005040] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/05/2016] [Accepted: 02/14/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Jose F Figueroa
- Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - David E Wang
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
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