Is early too early? Effect of shorter stays after bypass surgery

Early Discharge After Minimally Invasive Aortic and Mitral Valve Surgery

BACKGROUND

We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery.

METHODS

All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve surgery at a single center between 2012 and 2019 were classified by postoperative length of stay: early discharge (≤3 days) or late discharge (>3 days). The trend in early discharge was investigated over the study period, predictors of early discharge were identified using multivariate logistic regression modeling, and 1:1 propensity score matching was used to determine which patients in the late-discharge cohort had similar health to patients discharged early. Adjusted outcomes of 30-day mortality, readmission, and direct costs were analyzed.

RESULTS

Among 1262 consecutive patients undergoing minimally invasive valve surgery, 618 were elective and uncomplicated, 25% (n = 162) of whom were discharged early. The proportion of early-discharge patients increased over time (P for trend < .05). A history of congestive heart failure, stroke, or smoking and higher Society of Thoracic Surgeons predictive risk of mortality score negatively predicted early discharge (P < .05). Propensity score matching identified 101 (22%) late-discharge patients comparable with early-discharge patients. Adjusted 30-day mortality and readmission rates were comparable between cohorts. The median direct costs per patient ($20,046 vs $22,124, P < .05) were significantly lower in the early-discharge cohort.

CONCLUSIONS

In well-selected patients early discharge after minimally invasive valve surgery was associated with lower costs but comparable postoperative outcomes. About one-fifth of patients who remain in the hospital beyond postoperative day 3 may be candidates for earlier discharge.

Effect of an mHealth self-help intervention on readmission after adult cardiac surgery: Protocol for a pilot randomized controlled trial

Aim

To describe a protocol for the pilot phase of a trial designed to test the effect of an mHealth intervention on representation and readmission after adult cardiac surgery.

Design

A multisite, parallel group, pilot randomized controlled trial (ethics approval: HREC2020.331‐RMH69278).

Methods

Adult patients scheduled to undergo elective cardiac surgery (coronary artery bypass grafting, valve surgery, or a combination of bypass grafting and valve surgery or aortic surgery) will be recruited from three metropolitan tertiary teaching hospitals. Patients allocated to the control group with receive usual care that is comprised of in‐patient discharge education and local paper‐based written discharge materials. Patients in the intervention group will be provided access to tailored ‘GoShare’ mHealth bundles preoperatively, in a week of hospital discharge and 30 days after surgery. The mHealth bundles are comprised of patient narrative videos, animations and links to reputable resources. Bundles can be accessed via a smartphone, tablet or computer. Bundles are evidence‐based and designed to improve patient self‐efficacy and self‐management behaviours, and to empower people to have a more active role in their healthcare. Computer‐generated permuted block randomization with an allocation ratio of 1:1 will be generated for each site. At the time of consent, and 30, 60 and 90 days after surgery quality of life and level of patient activation will be measured. In addition, rates of representation and readmission to hospital will be tracked and verified via data linkage 1 year after the date of surgery.

Discussion

Interventions using mHealth technologies have proven effectiveness for a range of cardiovascular conditions with limited testing in cardiac surgical populations.

Impact

This study provides an opportunity to improve patient outcome and experience for adults undergoing cardiac surgery by empowering patients as end‐users with strategies for self‐help.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000082808.

Prognostic Indicators of Delayed Surgical Recovery in Patients Undergoing Cardiac Surgery

PURPOSE

The purpose of this study was to analyze the prognostic capacity of the clinical indicators of a delayed surgical recovery nursing diagnosis throughout the hospital stay of patients having cardiac surgery.

DESIGN

A prospective cohort design was adopted. A sample of inpatients undergoing elective cardiac surgery was followed during the immediate preoperative period and hospitalization. This research was conducted in the southeast region of Brazil at a national reference institution that treats highly complex diseases and performs cardiac surgeries. Data were collected from July 2017 to July 2018.

METHODS

At the end of 1 year of data collection, 181 patients were followed in this study. The Kaplan-Meier method was used to calculate the survival time related to delayed surgical recovery. In addition, an extended Cox model of time-dependent covariates was adjusted to identify the clinical signs that influenced the change in the nursing diagnosis status.

RESULTS

A delayed surgical recovery nursing diagnosis was present in 23.2% of the sample studied. With an expected length of stay of 8 to 10 days, most new cases of delayed surgical recovery were observed on the 10th postoperative day, and the survival rate after this day was decreased until the 29th postoperative day, when the nursing diagnosis no longer appeared. Interrupted healing of the surgical area, loss of appetite, and atrial flutter were indicators related to an increased risk for delayed surgical recovery.

CONCLUSIONS

Timely recognition of selected clinical indicators demonstrates a promising prognostic capacity for delayed surgical recovery.

CLINICAL RELEVANCE

Accurate identification of prognostic factors allows nurses to identify early signs of postoperative complications. Consequently, the professional can develop an individualized plan of care, aiming at the satisfactory clinical recovery of the patient.

Cost-effectiveness analysis of three methods of surgical-site infection surveillance: Less is more

BACKGROUND

A considerable proportion of surgical site infections (SSI) could be prevented by surveillance. The study aimed to compare the cost-effectiveness of 3 methods of SSI surveillance: Inpatient, phone, and out-patient clinic (OPC); to ensure that the risk of SSI is independent from loss-to-follow-up in phone and OPC surveillances, and to determine the reliability of phone surveillance.

METHODS

A cohort of 351 surgical patients were followed by 3 different surveillance methods: inpatient, follow-up in OPC and over the phone. Costs of nurse time and phone calls were expressed in 2019 USD. Effectiveness of surveillance was assessed using number of detected SSIs.

RESULTS

Phone surveillance was more cost-effective than OPC surveillance. Compared to inpatient surveillance, the OPC method costs USD 15.6 per extra detected SSI, whereas the phone method costs only USD 4.6 In phone and OPC surveillances, the risk of SSI was independent of loss-to-follow-up. However, the higher rate of SSI among OPC attendees raises the suspicion that the incidence of SSI estimated by OPC surveillance could be biased upward. Phone surveillance was reliable with high sensitivity and specificity.

CONCLUSIONS

Phone surveillance was a reliable cost-effective method. Inpatient surveillance was less effective, but it still can be used to detect severe SSI at low cost. While out-patient-clinic surveillance had the highest cost, the incidence estimated by it might be biased upward.

Identifying modifiable and non-modifiable risk factors associated with prolonged length of stay after hysterectomy for uterine cancer

OBJECTIVE

We examined the influence of modifiable (intraoperative factors and complications) and non-modifiable (clinical and demographic characteristics) factors on length of stay (LOS) for women who underwent hysterectomy for uterine cancer.

METHODS

The National Surgical Quality Improvement Program database was used to identify women who underwent hysterectomy for uterine cancer from 2006 to 2015. The association between demographic, preoperative, intraoperative, and postoperative factors and LOS was examined. The primary outcome was prolonged LOS (>75th an3 >90th percentiles). Model fit statistics were used to assess the importance of each group of characteristics.

RESULTS

Of 19,084 women identified, 6082 (31.9%) underwent abdominal and 13,002 (68.1%) underwent minimally invasive hysterectomy. In the abdominal hysterectomy group, the 75th and 90th percentiles for LOS were 5 and 8days, respectively. All risk factors combined accounted for 23.6% of the variation in LOS >75th percentile. Demographic characteristics explained 4.0%, preoperative factors 7.0%, intraoperative factors 7.9%, and postoperative characteristics 9.7% of variation in prolonged LOS. In the minimally invasive group, the 75th and 90th percentiles for LOS were 1 and 2days, respectively. The combined risk factors explained 16.2% of the variation in prolonged LOS. Demographic characteristics accounted for 6.2%, preoperative factors 4.1%, intraoperative factors 6.9%, and postoperative characteristics 1.3% of variation in prolonged LOS. Similar patterns were seen when prolonged LOS was defined as >90th percentile.

CONCLUSION

Perioperative risk factors account for approximately one quarter of the variation in prolonged LOS. Overall, a substantial proportion of the variation in LOS remains unexplained by measurable patient and hospital factors which may limit the utility of LOS as a quality metric for endometrial cancer.

A Comprehensive Risk Score to Predict Prolonged Hospital Length of Stay After Heart Transplantation

BACKGROUND

Prolonged hospital length of stay (PLOS) after heart transplantation increases cost and morbidity. To better inform care, we developed a risk score to identify patients at risk for PLOS after heart transplantation.

METHODS

We queried the United Network for Organ Sharing Scientific Registry of Transplant Recipients database for adult patients who underwent isolated heart transplantation from 2003 to 2012. The population was randomly divided into a derivation cohort (80%) and a validation cohort (20%). The outcome of interest was PLOS, defined as a posttransplant hospital length of stay of more than 30 days. Associated univariables (p < 0.20) in the derivation cohort were included in a multivariable model, and a risk index was derived from the adjusted odds ratios of significant covariates.

RESULTS

During the study period, 16,723 patients underwent heart transplantation with an average PLOS of 19 ± 21 days, and 2,020 orthotopic heart transplant recipients (12%) had PLOS. Baseline characteristics were similar between the derivation and validation cohorts. Twenty-four recipient and nine donor variables, cold ischemic time, and center volume were tested as univariables. Seventeen covariates significantly affected PLOS and comprised the prolonged hospitalization after heart transplant risk score, which was stratified into three risk groups. The risk model was subsequently validated, and predicted rates of PLOS correlated well with observed rates (R = 0.79). Rates of PLOS in the validation cohort were 8.3%, 11%, and 22% for low, moderate, and high risk groups, respectively.

CONCLUSIONS

The risk of PLOS after heart transplantation can be determined at the time of transplant. The prolonged hospitalization after heart transplant score may lead to individualized postoperative management strategies to reduce duration of hospitalization for patients at high risk.

The effect of a peer support intervention on early recovery outcomes in men recovering from coronary bypass surgery: A randomized controlled trial

BACKGROUND AND AIM

Examine the effect of a professionally-guided telephone peer support intervention on recovery outcomes including depression, perceived social support, and health services utilization after coronary artery bypass graft surgery (CABG).

METHODS

A randomized controlled trial was conducted with post-coronary artery bypass graft surgery men ( N=185) who were randomized before hospital discharge. The intervention arm received telephone-based peer support through weekly telephone calls from a peer volunteer over six weeks, initiated within 3-4 days of discharge.

RESULTS

Although a significant difference was detected in pre-intervention depression scores at discharge, there were no differences between groups in changes in depression scores at six weeks ( p=0.08), 12 weeks (0.49) or over time ( p=0.51); and no significant differences in perceived social support scores over time ( p=0.94). At 12 weeks, the intervention group had significantly lower incidence of health services utilization (family physician ( p=0.02) and emergency room ( p=0.04)).

CONCLUSIONS

Healthcare providers need to continue to investigate novel interventions to enhance social support and reduce depression in cardiac patients.

Costs and Consequences of Early Hospital Discharge After Major Inpatient Surgery in Older Adults

Importance

As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions.

Objective

To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions.

Design, Setting, and Participants

This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period.

Exposure

Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers.

Main Outcomes and Measures

Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care.

Results

A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P < .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P < .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P < .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period.

Conclusions and Relevance

Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.

Clinical characteristics associated with readmission among patients undergoing vascular surgery

OBJECTIVE

Readmission after a vascular surgery intervention is frequent, costly, and often considered preventable. Vascular surgery outcomes have recently been scrutinized by Medicare because of the high rates of readmission. We determined patient and clinical characteristics associated with readmission in a cohort of vascular surgery patients.

METHODS

From 2009 to 2013, the medical records of all patients (n = 2505) undergoing interventions by the vascular surgery service at a single tertiary care institution were retrospectively reviewed. Sociodemographic and clinical characteristics were examined for association with 30-day readmission to the same institution.

RESULTS

The 30-day readmission rate to the same institution was 9.7 % (n = 244). Procedures most likely to result in readmission were below-knee (25%), foot (22%), and toe amputations (19%), as well as lower extremity revascularization (22%). Patients covered by Medicaid (16.8%) and Medicare (10.0%) were most likely to be readmitted, followed by fee-for-service (9.5%), self-pay (8.0%), and health maintenance organizations (5.5%; P < .05). Patients urgently admitted were more likely to be readmitted (16.2%) than those electively admitted (9.1%; P < .01). Patient severity as rated using the All Patient Refined Diagnosis Related Groups software (3M Health Information Systems, Wallingford, Conn) predicted readmission (16.2% high vs 6.2% low severity; P < .01). Initial length of stay was longer for readmitted than nonreadmitted patients (8.5 vs 6.1 days, respectively; P < .01). Intensive care unit admission during the initial hospitalization was associated with higher readmission rates in univariable analysis (18.3% with vs 9.5% without intensive care unit stay; P < .05). Discharge destination was also a strong predictor of readmission (rehabilitation, 19.2%; skilled nursing facility, 16.2%; home, 6.2%; P < .01). The effects of urgent admission, proximity to hospital, length of stay, lower extremity open procedure or amputation, and discharge destination persisted in multivariable logistic regression (P < .05).

CONCLUSIONS

To reduce readmission rates effectively, institutions must identify high-risk patients. Efforts should focus on subgroups undergoing selected interventions (amputations, lower extremity revascularization), those with urgent admissions, and patients with extended hospital stays. Patients in need of postacute care upon discharge are especially prone to readmission, requiring special attention to discharge planning and coordination of postdischarge care. By focusing on subgroups at risk for readmission, preventative resources can be efficiently targeted.

Cardiovascular disease hospitalizations in relation to exposure to the September 11, 2001 World Trade Center disaster and posttraumatic stress disorder

Background

A cohort study found that 9/11‐related environmental exposures and posttraumatic stress disorder increased self‐reported cardiovascular disease risk. We attempted to replicate these findings using objectively defined cardiovascular disease hospitalizations in the same cohort.

Methods and Results

Data for adult World Trade Center Health Registry enrollees residing in New York State on enrollment and no cardiovascular disease history (n=46 346) were linked to a New York State hospital discharge–reporting system. Follow‐up began at Registry enrollment (2003–2004) and ended at the first cerebrovascular or heart disease (HD) hospitalization, death, or December 31, 2010, whichever was earliest. We used proportional hazards models to estimate adjusted hazard ratios (AHRs) for HD (n=1151) and cerebrovascular disease (n=284) hospitalization during 302 742 person‐years of observation (mean follow‐up, 6.5 years per person), accounting for other factors including age, race/ethnicity, smoking, and diabetes. An elevated risk of HD hospitalization was observed among women (AHR 1.32, 95% CI 1.01 to 1.71) but not men (AHR 1.16, 95% CI 0.97 to 1.40) with posttraumatic stress disorder at enrollment. A high overall level of World Trade Center rescue and recovery–related exposure was associated with an elevated HD hospitalization risk in men (AHR 1.82, 95% CI 1.06 to 3.13; P for trend=0.05), but findings in women were inconclusive (AHR 3.29, 95% CI 0.85 to 12.69; P for trend=0.09). Similar associations were observed specifically with coronary artery disease hospitalization. Posttraumatic stress disorder increased the cerebrovascular disease hospitalization risk in men but not in women.

Conclusions

9/11‐related exposures and posttraumatic stress disorder appeared to increase the risk of subsequent hospitalization for HD and cerebrovascular disease. This is consistent with findings based on self‐reported outcomes.

[Evaluation of the length of hospital stay in cases of coronary artery bypass graft by payer]

OBJECTIVE

The length of hospital stay (LOS) allows for the evaluation of the efficiency of a given hospital facility, as well as providing a basis for measuring the number of hospital beds required to provide assistance to the population in a specific area.

METHODS

A retrospective survey was conducted on a database of 3,010 patients submitted to coronary artery bypass graft (CABG) from July, 2009 to July, 2010.

RESULTS

Among 2,840 patients that met the inclusion criteria, 92.1% had their surgery paid by the Brazilian Unified Health System (Sistema Único de Saúde - SUS) and 7.9% by health plans or themselves (non-SUS). 70.2% were male, the average age was 61.9 years old, and the average risk score (EuroScore) was 2.9%. The SUS and the non-SUS groups did not differ regarding the waiting time for surgery (WTS) (2.59± 3.10 vs. 3,02±3,70 days for SUS and non-SUS respectively; p=0.790), but did differ with respect to the length of stay in intensive care unit (2.17±3.84 vs. 2.52±2.72 days for SUS and non-SUS respectively; p < 0.001), the postoperative period (8.34±10.32 vs. 9,19±6.97 days for SUS and non-SUS respectively; p < 0.001), and the total LOS (10.93±11.08 vs. 12.21±8.20 days for SUS and non-SUS respectively; p < 0.001). The non-SUS group had more events of non-elective surgery (p=0.002) and surgery without cardiopulmonary bypass (p=0.012). The groups did not differ regarding the associated valve procedure (p=0.057) nor other non-valve procedures (p=0.053), but they did differ with respect to associated non-cardiac procedures (p=0.017). ICU readmission (p=0.636) and postoperative complications rates were similar in both groups (p=0.055).

CONCLUSION

The Non-SUS group showed longer LOS compared to the SUS group.

Impact of length of stay after coronary bypass surgery on short-term readmission rate: an instrumental variable analysis

OBJECTIVE

: To determine the effect of postoperative length of stay (LOS) on 30-day readmission after coronary artery bypass surgery.

DATA SOURCES/STUDY SETTING

: We analyzed a final database consisting of Medicare claims of a cohort (N=157,070) of all fee-for-service beneficiaries undergoing bypass surgery during 2007-2008, the American Hospital Association annual survey file, and the rural urban commuting area file.

STUDY DESIGN

: We regressed the probability of 30-day readmission on postoperative LOS using (1) a (naive) logit model that controlled for observed patient and hospital covariates only; and (2) a residual inclusion instrumental variable (IV) logit model that further controlled for unobserved confounding. The IV was defined using a measure of the hospital's risk-adjusted LOS for patients admitted for gastrointestinal hemorrhage.

PRINCIPAL FINDINGS

: The naive logit model predicted that a 1-day reduction in median postoperative LOS (ie, from a median of 6-5 d) lowered the 30-day readmission rate by 2 percentage points. The IV model predicted that a 1-day reduction in median postoperative LOS increased 30-day readmission rate by 3 percentage points.

CONCLUSIONS

: The findings indicate that a reduction in postoperative LOS is associated with an increased risk for 30-day readmission among Medicare patients undergoing bypass surgery, after both observed and unobserved confounding effects are corrected.

Early discharge does not increase readmission or mortality after high-risk vascular surgery

PURPOSE

Clinical pathways aimed at reducing hospital length of stay following vascular surgery have been broadly implemented to reduce costs. However, early hospital discharge may adversely affect the risk of readmission or mortality. To address this question, we examined the relationship between early discharge and 30-day outcomes among patients undergoing a high-risk vascular surgery procedure, thoracic aortic aneurysm (TAA) repair.

METHODS

Using Medicare claims from 2000 to 2007, we identified all patients who were discharged home following elective thoracic endovascular aneurysm repair (TEVAR) and open repair for nonruptured TAAs. For each procedure, we examined the correlation between early discharge (<3 days for TEVAR, <7 days for open TAA repair) and 30-day readmission, 30-day mortality, and hospital costs. Predictors of readmission were evaluated using logistic regression models controlling for patient comorbidities, perioperative complications, and discharge location.

RESULTS

Our sample included 9764 patients, of which 7850 (80%) underwent open TAA repair, and 1914 (20%) underwent TEVAR. Patients discharged to home early were more likely to be female (66% early vs 56% late), Caucasian (94% early vs 91% late), younger (73 years early vs 74 years late), and have fewer comorbidities (mean Charlson score: 0.7 early vs 1.0 late) than patients discharged home late (all P < .01). As compared with patients who were discharged late, patients discharged home early following uncomplicated open TAA repair and TEVAR had significantly lower 30-day readmission rates ([open: 17% vs 24%; P < .001] [TEVAR: 12% vs 23%; P < .001]) and hospital costs ([open: $73,061 vs $136,480; P < .001] [TEVAR: $58,667 vs $128,478; P < .001]), without an observed increase in 30-day postdischarge mortality. In multivariable analysis, early hospital discharge was associated with a significantly lower likelihood of readmission following both open TAA repair (odds ratio, 0.70; 95% confidence interval, 0.57-0.85; P < .001) and TEVAR (odds ratio, 0.57; 95% confidence interval, 0.38-0.85; P < .01) procedures.

CONCLUSIONS

Discharging patients home early following uncomplicated TEVAR or open TAA repair is associated with reduced hospital costs without adversely impacting 30-day readmission or mortality rates. These data support the safety and cost-effectiveness of programs aimed at early hospital discharge in selected vascular surgery patients.

Early discharge and hospital readmission after colectomy for cancer

BACKGROUND

Early discharge after colectomy has been shown to be feasible in studies from specialty centers, but we hypothesized that benefits of early discharge might be offset by higher risk of readmission in the surgical community as a whole. Minimizing readmissions is a national health policy priority.

OBJECTIVE

This study aimed to determine whether hospitals discharging patients early had increased readmission rates.

DESIGN

Patients undergoing colectomy surgery for cancer were studied using national Medicare data (MEDPAR database). Multiple logistic regression was performed to determine whether hospitals with a pattern of early discharge (median length of stay ≤ 5 d after surgery) had increased readmission rates. Results were adjusted for patient comorbidity, emergency operation, laparoscopic surgery, demographic factors, and complications. A separate analysis at the patient level was conducted to determine risk factors for readmission.

SETTINGS

Early discharge rates at US acute care hospitals were investigated.

PATIENTS

Patients 65 and older undergoing colectomy surgery for cancer (2003-2008, n = 477,461) were included.

MAIN OUTCOME MEASURE

The main outcome measure was 30-day, all hospital readmission rates.

RESULTS

Hospitals with a pattern of early discharge (median length of stay ≤ 5 d) were not found to have a higher risk-adjusted readmission rate than hospitals with the usual median length of stay (16.3% vs 15.7%, P = .077). However, changing the cutoff for "early discharge" to ≤ 4 days revealed an increased risk for readmission among "very early discharge" hospitals (risk-adjusted readmission rate 21.3% vs 15.7%, P < .001). At the patient level, independent risk factors for readmission included older age, male sex, black race, lower socioeconomic status, urgent/emergent surgery, comorbidities, complications, open (vs laparoscopic) surgery, and longer length of stay for the index hospitalization.

LIMITATIONS

Limitations of this study included the limitations of the administrative data and elderly population.

CONCLUSIONS

Hospitals with a pattern of early discharge (median length of stay ≤ 5 d after surgery) do not have a higher risk-adjusted readmission rate than other hospitals. These results support the safety of early discharge programs in the Medicare population.

The impact of hospital utilization on patient readmission rate

We investigate the issue of patient readmission at a large academic hospital in the U.S. Specifically, we look for evidence that patients discharged when post-operative unit utilization is high are more likely to be readmitted. After examining data from 7,800 surgeries performed in 2007, we conclude that patients who are discharged from a highly utilized post-operative unit are more likely to be readmitted within 72 h. Each additional bed utilized at time of discharge increases the odds of readmission on average by 0.35% (Odds Ratio = 1.008, 95% CI [1.003, 1.012]). We propose that this effect is due to an increased discharge rate when the unit is highly utilized.

Expectations, anxiety, depression, and physical health status as predictors of recovery in open-heart surgery patients

BACKGROUND AND OBJECTIVES

Recovery after open-heart surgery is a complex process that presents psychosocial and physical challenges that continue well after discharge. The purpose of this study was to examine the relationship among expectations, anxiety, depression, and physical health status (PHS) and to determine predictors of postoperative PHS in open-heart surgery patients.

PARTICIPANTS AND METHODS

A convenience sample (N = 54) was recruited from 2 hospitals in rural regions from 2 different mid-Atlantic states. The sample included participants who underwent coronary artery bypass graft or valve replacement surgery for the first time. The study used a longitudinal design, and data were collected preoperatively in the hospital or surgeons' offices and 4 weeks postoperatively by telephone interviews. Participants were interviewed using the following questionnaires: the Future Expectations Regarding Life with Heart Disease scale, the Hospital Anxiety and Depression scale, and the Medical Outcomes Study 36-Item Short Form Health Survey. Repeated-measures analysis of variance, Pearson product-moment correlations, and multiple regression were used for data analyses.

RESULTS AND CONCLUSIONS

Statistical analysis revealed that anxiety (P = .002) and depression (P = .026) scores decreased postoperatively. Significant relationships were found among the preoperative and postoperative variables: expectations, anxiety, depression, and PHS. Analyses also found that preoperative expectations, anxiety, depression, and PHS contributed 38% of the variance of postoperative PHS (P < .001). However, the postoperative variables were not significant predictors of postoperative PHS (P = .075). The findings support the need for interventions to assist patients in developing realistic expectations and for clinicians to screen patients for anxiety and depression before and after surgery. Future research needs to measure PHS at various times postoperatively to identify continued limitations after surgery.

Absence of appropriate hospitalization cost control for patients with medical insurance: a comparative analysis study

OBJECTIVE

Expose the weak loops in the Chinese medical insurance coverage and uncover hospitals' role of over-pricing hospitalized insured patients compared with those non-insured.

METHODS

A multi-linear regression method was used to analyze hospitalization expense for insured and uninsured patients with uncomplicated acute appendicitis, cholecystitis, benign uterine tumors, and normal delivery.

RESULTS

Hospitalization cost is higher among insured than uninsured patients due to longer hospitalization lengths of stay, type of disease (highest among cholecystitis patients), type of gender - females, old-aged people, and type of marital status - singles, as well as drugs expenses, surgical expenses, and other medical acts.

CONCLUSION

Require a better government's supervision system over medical insurance expenses such as reforming methods of payments, building up new cost compensation mechanism, and unifying and stabilizing prices for each category of medicines.

Increasing healthcare resource utilization after coronary artery bypass graft surgery in the United States

BACKGROUND

Despite declining lengths of stay, postdischarge healthcare resource utilization may be increasing because of shifts to nonacute care settings. Although changes in hospital stay after coronary artery bypass graft (CABG) surgery have been described, patterns of discharge remain unclear. Our objective was to determine patterns of discharge disposition after CABG surgery in the United States.

METHODS AND RESULTS

We examined discharge disposition after CABG procedures from 1988 to 2005 using the Nationwide Inpatient Sample. Discharges with a "nonroutine" disposition defined patients discharged with continued healthcare needs. Multivariable regression models were constructed to assess trends and factors associated with nonroutine discharge. Median length of stay among 8,398,554 discharges decreased from 11 to 8 days between 1988 and 2005 (P<0.0001). There was a simultaneous increase in nonroutine discharges from 12% in 1988 to 45% in 2005 (P<0.0001), primarily comprising home healthcare and long-term facility use. Multivariable regression models showed age, female gender, comorbidities, concurrent valve surgery, and lower-volume hospitals more likely to be associated with nonroutine discharge.

CONCLUSIONS

We found a significant increase in nonroutine discharges after CABG surgery across the United States from 1988 to 2005. The significant shortening of length of stay during CABG may be counterbalanced by the increased requirement for additional postoperative healthcare services. Nonacute care institutions are playing an increasingly significant role in providing CABG patients with postdischarge healthcare and should be considered in investigations of postoperative healthcare resource utilization. The impact of these changes on long-term outcomes and net resource utilization remain unknown.

Natural history of late discharges from a general medical ward

BACKGROUND

Slow hospital discharges reduce efficiency and compromise care for patients awaiting a bed. Although efficient discharge is a widely held goal, the natural history of the discharge process has not been well studied.

OBJECTIVE

To describe the discharge process and identify factors associated with longer and later discharges.

DESIGN

Prospective cohort study.

SETTING

A general medicine ward without house-staff coverage, in a tertiary care hospital (The Johns Hopkins Hospital) in Baltimore, Maryland, from January 1, 2005 to April 30, 2005.

PATIENTS

Two hundred and nine consecutively discharged adult inpatients.

MEASUREMENTS

Discharge time (primary outcome) and discharge duration (secondary outcome).

RESULTS

Median discharge time was 3:09 PM (25th% to 75th%: 1:08 to 5:00 PM). In adjusted analysis, discharge time was associated with ambulance used on discharge (1.5 hours), prescriptions filled prior to discharge (1.4 hours), subspecialty consult prior to discharge (1.2 hours), and procedure prior to discharge (1.1 hours). Median duration of the discharge process was 7 hours 34 minutes (25th% to 75th%: 4.0 to 22.0 hours). Discharge duration was associated with discharge to a location other than home (28.9 hours), and with need for consultation (14.8 hours) or a procedure (13.4 hours) prior to discharge (all P values <0.05).

CONCLUSIONS

Discharge time and duration have wide variability. Longer and later discharges were associated with procedures and consults. Successful efforts to decrease time of discharge will require broad institutional effort to improve delivery of interdepartmental services.