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Heidinger M, Lang W, Boehme C, Knoflach M, Kiechl S, Willeit P, Kleyhons R, Tuerk S. Reconstruction of pseudonymized patient-trajectories in Austria's stroke cohort using medical record-linkage of in-patient routine documentation to establish a nation-wide acute stroke cohort of 102,107 pseudonymized patients between 2015 and 2019. Eur Stroke J 2022; 7:456-466. [PMID: 36478759 PMCID: PMC9720851 DOI: 10.1177/23969873221107619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/26/2022] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Administrative health data are increasingly used for disease surveillance, quality assurance and research purposes. In Austria, reporting of a standardized dataset is mandatory for each patient. PATIENTS AND METHODS Routine documentation includes administrative and medical data, including admission and discharge characteristics, disease-diagnosis using ICD-10, medical procedure codes, and coding of involved hospital departments. Since 2015, a three-step pseudonymization on these data is provided including a pseudonym using secure hash algorithm 256, a non-recalculable record-ID, and age-groups of 5 years, allowing the reconstruction of individual patient-trajectories. We included persons aged ⩾20 years with an in-patient treatment in Austrian hospitals for acute stroke or transient ischemic attack (TIA) between 01.01.2015 and 31.12.2019 using medical record-linkage. RESULTS This totals 102,107 patients (49.3% women) with 107,055 treatment episodes. An ischemic stroke (IS) occurred in 60.9% (n = 65,133), 27.1% (n = 29,019) had a TIA, 3.3% (n = 3488) a subarachnoid hemorrhage, and 8.8% (n = 9415) an intracerebral hemorrhage (ICH). The study period covers 35.2 million person-years at risk, with a hospitalization rate for acute stroke of 221.8 per 100,000 person-years (95% CI 220.2-223.3), and 185.1 per 100,000 person-years (95% CI 183.7-186.5) for IS. Unscheduled re-admissions within 1 year occurred in 29.2% (95% CI 28.8-29.7) after IS, and 41.7% (95% CI 40.0-43.3) after ICH. Recurrent stroke occurred in 5.3% (95% CI 5.1-5.5) after IS, and 5.6% (95% CI 4.9-6.4) after ICH. DISCUSSION We present herein the details of a novel methodology to establish a nation-wide unselected Austrian stroke cohort, and to reconstruct pseudonymized individual longitudinal patient-trajectories on a national level. This approach shows potential applications in epidemiological research, quality assessment and outcome measurement. CONCLUSION This novel approach opens new research fields, facilitates international comparison, and is needed for national benchmarking to assess the achievement of goals according to the Stroke Action Plan for Europe and augment the quality of Austria's integrated stroke care.
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Affiliation(s)
- Martin Heidinger
- Austrian Federal Ministry for Social
Affairs, Health, Care and Consumer Protection, Vienna, Austria
| | - Wilfried Lang
- Department of Neurology, St. John’s of
God Hospital, Vienna, Austria
- Austrian Stroke Society, Vienna,
Austria
| | - Christian Boehme
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
| | - Michael Knoflach
- Austrian Stroke Society, Vienna,
Austria
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
- VASCage – Research Centre on Vascular
Ageing and Stroke, Innsbruck, Austria
| | - Stefan Kiechl
- Austrian Stroke Society, Vienna,
Austria
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
- VASCage – Research Centre on Vascular
Ageing and Stroke, Innsbruck, Austria
| | - Peter Willeit
- Austrian Stroke Society, Vienna,
Austria
- Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
- Department of Public Health and Primary
Care, University of Cambridge, Cambridge, UK
| | - Rainer Kleyhons
- Austrian Federal Ministry for Social
Affairs, Health, Care and Consumer Protection, Vienna, Austria
| | - Silvia Tuerk
- Austrian Federal Ministry for Social
Affairs, Health, Care and Consumer Protection, Vienna, Austria
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Observation on the Effect of Solution-Focused Approach Combined with Family Involvement in WeChat Platform Management on Inpatients with Intracerebral Hemorrhage. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:9951374. [PMID: 35345652 PMCID: PMC8957417 DOI: 10.1155/2022/9951374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 11/17/2022]
Abstract
Objective. To explore the effect of the solution-focused approach combined with family involvement in the WeChat platform management on inpatients with intracerebral hemorrhage (ICH). Methods. A total of 80 ICH patients hospitalized in our hospital from June 2018 to June 2021 were split into the control group (CG) and the study group (SG) according to the clinical nursing modes, with 40 cases in each group. Both groups received routine intervention, while SG additionally received the solution-focused approach combined with family involvement in the WeChat platform management to compare the self-care ability, psychological status, and hope levels between the two groups after intervention. Results. No significant differences in general data were observed between the two groups (
). The SAS and SDS scores before intervention showed mild depression and anxiety in both groups, which improved after intervention. In addition, the SAS and SDS scores after intervention were remarkably lower in SG than in CG (
). After intervention, the scores of ICH-related knowledge, self-care skills, self-care responsibility, and rehabilitation knowledge in SG were notably higher compared with CG (
). After intervention, the Herth scores of both groups increased, with a higher score in SG than in CG (
). After intervention, SG had higher quality of life (QOL) scores in general health, physiological function, physiological role, body pain, vitality, social function, emotional role, and physiological health than CG (
). Conclusion. The implementation of the solution-focused approach combined with family involvement in the WeChat platform management for ICH inpatients can effectively improve their psychological status, enhance their self-care ability and hope levels, promote body recovery, and improve their QOL after intervention.
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Xu S, Du B, Shan A, Shi F, Wang J, Xie M. The risk factors for the postoperative pulmonary infection in patients with hypertensive cerebral hemorrhage: A retrospective analysis. Medicine (Baltimore) 2020; 99:e23544. [PMID: 33371078 PMCID: PMC7748187 DOI: 10.1097/md.0000000000023544] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/09/2020] [Accepted: 11/01/2020] [Indexed: 12/12/2022] Open
Abstract
ABSTRACT The risk factors for the pulmonary infections after hypertensive cerebral hemorrhage remains unclear. We aimed to investigate the potential risk factors for the postoperative pulmonary infection in patients with hypertensive cerebral hemorrhage.Patients with hypertensive cerebral hemorrhage undergone surgery from January 2018 to December 2019 were included. Related personal and medical information were collected. Univariate and multivariate logistic regression analyses were performed to identify the potential risk factors for the postoperative pulmonary infection.A total of 264 patients were included, and the incidence of pulmonary infection for patients with hypertensive cerebral hemorrhage after surgery was 19.70%. Escherichia coli is the most common bacteria of pulmonary infection. Multivariate regression analysis revealed that the preoperative hypoalbuminemia (OR2.89, 1.67∼4.78), tracheotomy (OR5.31, 1.24∼11.79), diabetes (OR4.92, 1.32∼9.80), preoperative GCS (OR5.66, 2.84∼11.21), and the duration of mechanical ventilation (OR2.78, 2.32∼3.61) were the independent risk factors for the pulmonary infection in patients with hypertensive cerebral hemorrhage (all P < .05).Patients with hypertensive intracerebral hemorrhage after surgery have a higher risk of postoperative pulmonary infections, and there are many related risk factors, which should be taken seriously in clinical practice.
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Lekoubou A, Bishu KG, Ovbiagele B. Early-hospital readmission after generalized status epilepticus during stroke hospitalization. J Neurol Sci 2020; 420:117258. [PMID: 33278662 DOI: 10.1016/j.jns.2020.117258] [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: 04/26/2020] [Revised: 11/15/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the relationship between generalized convulsive status epilepticus (GCSE) during an index stroke hospitalization and occurrence of 30-day hospital readmission. METHODS Retrospective analysis of data within the 2014 National Readmission Database, a national dataset tracking readmissions in the United States. We identified patients with an index discharge diagnosis of stroke using the International Classification of Disease, Ninth Revision, Clinical Modification (433.X1, 434.X1, and 436 for ischemic stroke and 430, 431, 432.0, 432.1, and 432.9 for hemorrhagic stroke) and a subset of patients with GCSE (345.3). We explored the association between GCSE and 30-day readmission using multivariable logistic regression, while applying recommended survey weights. RESULTS Of 271,148 adults with a primary diagnosis of stroke hospitalizations in the US in 2014, 591 (0.21%) had GCSE. The prevalence of GCSE was 0.14% among ischemic stroke patients and 0.64% among hemorrhagic stroke patients. Readmission rates were 11.9% for all strokes, 11.6% for ischemic strokes, and 14.2% for hemorrhagic strokes. Readmission rates were significantly higher for those with GCSE vs. without GCSE regardless of stroke type. Adjusted odds ratios for the association of GCSE with 30-day readmission were 1.30 (95% CI: 1.02-1.65) for all strokes, 1.19 (95% CI: 0.84-1.71) for ischemic strokes, and 1.39 (95% CI: 0.92-2.10 0.09) for hemorrhagic stroke. CONCLUSION Approximately one in eight hospitalized stroke patients who experience in-hospital GCSE are re-admitted to a hospital within 30 days with a nominally higher rate of readmissions among those with hemorrhagic stroke.
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Affiliation(s)
- Alain Lekoubou
- Department of Neurology, Penn State University, Hershey, PA, USA.
| | - Kinfe G Bishu
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA; Section of Health Systems Research and Policy, Medical University of South Carolina, Charleston, SC, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, USA
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Bondi S, Yang D, Croll L, Torres J. Patient Characteristics Associated With Readmission to 3 Neurology Services at an Urban Academic Center. Neurohospitalist 2020; 11:25-32. [PMID: 33868553 DOI: 10.1177/1941874420953320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose Hospital 30-day readmissions in patients with primary neurological problems are not well characterized. We sought to determine patient characteristics associated with readmission across 3 different inpatient neurology services at New York University Langone Hospital. Methods We retrospectively reviewed all 30-day readmissions from the General Neurology, Epilepsy, and Stroke services at NYULH Brooklyn and Manhattan campuses from 2016-2017 and compared them to a random sample of non-readmitted neurology patients. We used univariate analyses to compare demographics, clinical characteristics, disease specific metrics, and discharge factors of non-readmitted and readmitted groups and binomial logistic regression to examine specific variables with adjustment for confounders. Results We included 284 patients with 30-day readmissions and 306 control patients without readmissions matched by discharge location and service. After adjusting for confounders, we found that the following factors were associated with increased readmission risk: a recent hospital encounter increased risk for all services, increased number of medications at discharge, intensive care unit stay, higher length of stay, and prior history of seizure for the General Neurology Service, increased number of medications at discharge for the Epilepsy Service, and active malignancy and higher discharge modified Rankin Scale score for the Stroke Service. Conclusion This study identifies potential risk factors for readmission in patients across multiple neurology services. Further research is needed to establish whether these risk factors hold across multiple institutions.
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Affiliation(s)
- Steven Bondi
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Dixon Yang
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Leah Croll
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Jose Torres
- Department of Neurology, New York University Langone Health, New York, NY, USA
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van Nieuwenhuizen KM, Vaartjes I, Verhoeven JI, Rinkel GJ, Kappelle LJ, Schreuder FH, Klijn CJ. Long-term prognosis after intracerebral haemorrhage. Eur Stroke J 2020; 5:336-344. [PMID: 33598551 PMCID: PMC7856590 DOI: 10.1177/2396987320953394] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 07/29/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction The aim of this study was to determine the risk of recurrent intracerebral haemorrhage (ICH), ischaemic stroke, all stroke, any vascular event and all-cause mortality in 30-day survivors of ICH, according to age and sex. Patients and methods We linked national hospital discharge, population and cause of death registers to obtain a cohort of Dutch 30-day survivors of ICH from 1998 to 2010. We calculated cumulative incidences of recurrent ICH, ischaemic stroke, all stroke and composite vascular outcome, adjusted for competing risk of death and all-cause mortality. Additionally, we compared survival with the general population. Results We included 19,444 ICH-survivors (52% male; median age 72 years, interquartile range 61–79; 78,654 patient-years of follow-up). First-year cumulative incidence of recurrent ICH ranged from 1.5% (95% confidence interval 0.9–2.3; men 35–54 years) to 2.4% (2.0–2.9; women 75–94 years). Depending on age and sex, 10-year risk of recurrent ICH ranged from 3.7% (2.6–5.1; men 35–54 years) to 8.1% (6.9–9.4; women 55–74 years); ischaemic stroke 2.6% to 7.0%, of all stroke 9.9% to 26.2% and of any vascular event 15.0% to 40.4%. Ten-year mortality ranged from 16.7% (35–54 years) to 90.0% (75–94 years). Relative survival was lower in all age-groups of both sexes, ranging from 0.83 (0.80–0.87) in 35- to 54-year-old men to 0.28 (0.24–0.32) in 75- to 94-year-old women. Discussion ICH-survivors are at high risk of recurrent ICH, of ischaemic stroke and other vascular events, and have a sustained reduced survival rate compared to the general population. Conclusion The high risk of recurrent ICH, other vascular events and prolonged reduced survival-rates warrant clinical trials to determine optimal secondary prevention treatment after ICH.
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Affiliation(s)
- Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ilonca Vaartjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jamie I Verhoeven
- Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gabriel Je Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Floris Hbm Schreuder
- Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Catharina Jm Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
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Abreu P, Magalhães R, Baptista D, Azevedo E, Silva MC, Correia M. Readmissions and Mortality During the First Year After Stroke-Data From a Population-Based Incidence Study. Front Neurol 2020; 11:636. [PMID: 32793092 PMCID: PMC7393181 DOI: 10.3389/fneur.2020.00636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background: After a first-ever-in-a-lifetime stroke (FELS), hospital readmissions are common and associated with increased mortality and morbidity of stroke survivors, thus, raising the overall health burden of stroke. Population-based stroke studies on hospital readmissions are scarce despite it being an important healthcare service quality indicator. We evaluated unplanned readmissions or death during the first year after a FELS and their potential factors, based on a Portuguese community register. Methods: Data were retrieved from a population-based prospective register undertaken in Northern Portugal (ACIN2) in 2009–2011. Retrospective information about unplanned hospital readmissions and case fatality within 1 year after FELS index hospitalization (FELS-IH) was evaluated. Readmission/death-free survival 1 year after discharge was estimated using the Kaplan–Meyer method. Independent risk factors for readmission/death were identified using Cox proportional hazard models. Results: Unplanned readmission/death within 1 year occurred in 120 (31.6%) of the 389 hospitalized FELS survivors. In 31.2% and 33.5% of the cases, it occurred after ischemic stroke or intracerebral hemorrhage, respectively. Infections and cerebrovascular and cardiovascular diseases were the main causes of readmission. Of the readmissions, 65.3% and 52.5% were potentially avoidable or stroke related, respectively. The main cause of potentially avoidable readmissions was the continuation/recurrence of the event responsible for the initial admission or a closely related condition (71.2%). Male sex, age, previous and post-stroke functional status, and FELS-IH length of stay were independent factors of readmission/death within 1 year. Conclusions: Almost one-third of FELS survivors were readmitted/dead 1 year after their FELS-IH. This outcome persisted after the first months after stroke hospitalization in all stroke subtypes. More than half of readmissions were considered potentially avoidable or stroke related.
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Affiliation(s)
- Pedro Abreu
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade Do Porto, Porto, Portugal
| | - Rui Magalhães
- Instituto de Ciências Biomédicas Abel Salazar, Universidade Do Porto, Porto, Portugal
| | - Diana Baptista
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade Do Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade Do Porto, Porto, Portugal
| | - Maria Carolina Silva
- Instituto de Ciências Biomédicas Abel Salazar, Universidade Do Porto, Porto, Portugal
| | - Manuel Correia
- Instituto de Ciências Biomédicas Abel Salazar, Universidade Do Porto, Porto, Portugal.,Department of Neurology, Hospital Santo António-Centro Hospitalar Universitário Do Porto, Porto, Portugal
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Sennfält S, Petersson J, Ullberg T, Norrving B. Patterns in hospital readmissions after ischaemic stroke - An observational study from the Swedish stroke register (Riksstroke). Eur Stroke J 2020; 5:286-296. [PMID: 33072883 PMCID: PMC7538769 DOI: 10.1177/2396987320925205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/14/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction While acute treatment and secondary prevention in stroke have undergone major
improvements, hospital readmission after index stroke remains high. However,
there are few reports on long-term readmission patterns. Patients and methods For this prospective observational study, data on demographics, functional
status and living conditions were obtained from the Swedish Stroke Register
(Riksstroke). Data on comorbidity and hospital readmissions up to five years
post-index stroke were obtained from the Swedish National Patient Register.
Patients were grouped based on number of readmissions: low (0–1)
intermediate (2–4), high (5–9) or very high (≥10). Results Of the 10,092 patients included, 43.7% had been readmitted within 12 months
and 74.0% within 5 years. There was an average of three readmissions per
individual during the five-year interval. A small group of patients with a
high-comorbidity burden accounted for the majority of readmissions:
approximately 20% of patients accounted for 60% of readmissions, and 5% of
patients accounted for 25%. Circulatory conditions were the most common
cause followed by infectious disease, stroke, trauma and diseases of the
nervous system other than stroke. The proportion of readmissions due to
stroke decreased sharply in the first six months. Conclusion A small number of patients with a high degree of comorbidity accounted for
the majority of hospital readmissions after index stroke. Our results
highlight the need for further development of strategies to support
high-risk comorbid stroke patients in the community setting. Further
research describing characteristics and healthcare utilisation patterns in
this group is warranted.
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Affiliation(s)
- Stefan Sennfält
- Stroke Policy and Quality Register Research Group, Lund university, Sweden.,Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Jesper Petersson
- Stroke Policy and Quality Register Research Group, Lund university, Sweden.,Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Teresa Ullberg
- Stroke Policy and Quality Register Research Group, Lund university, Sweden.,Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Bo Norrving
- Stroke Policy and Quality Register Research Group, Lund university, Sweden.,Department of Neurology, Skåne University Hospital, Lund, Sweden
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Png ME, Yoong J, Chen C, Tan CS, Tai ES, Khoo EYH, Wee HL. Risk factors and direct medical cost of early versus late unplanned readmissions among diabetes patients at a tertiary hospital in Singapore. Curr Med Res Opin 2018; 34:1071-1080. [PMID: 29355431 DOI: 10.1080/03007995.2018.1431617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine the risk factors and direct medical costs associated with early (≤30 days) versus late (31-180 days) unplanned readmissions among patients with type 2 diabetes in Singapore. METHODS Risk factors and associated costs among diabetes patients were investigated using electronic medical records from a local tertiary care hospital from 2010 to 2012. Multivariable logistic regression was used to identify risk factors associated with early and late unplanned readmissions while a generalized linear model was used to estimate the direct medical cost. Sensitivity analysis was also performed. RESULTS A total of 1729 diabetes patients had unplanned readmissions within 180 days of an index discharge. Length of index stay (a marker of acute illness burden) was one of the risk factors associated with early unplanned readmission while patient behavior-related factors, like diabetes-related medication adherence, were associated with late unplanned readmission. Adjusted mean cost of index admission was higher among patients with unplanned readmission. Sensitivity analysis yielded similar results. CONCLUSIONS Existing routinely captured data can be used to develop prediction models that flag high risk patients during their index admission, potentially helping to support clinical decisions and prevent such readmissions.
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Affiliation(s)
- May Ee Png
- a National University of Singapore , Saw Swee Hock School of Public Health , Singapore
| | - Joanne Yoong
- a National University of Singapore , Saw Swee Hock School of Public Health , Singapore
- b University of Southern California, Center for Economic and Social Research , Washington , DC , USA
| | - Cynthia Chen
- a National University of Singapore , Saw Swee Hock School of Public Health , Singapore
| | - Chuen Seng Tan
- a National University of Singapore , Saw Swee Hock School of Public Health , Singapore
| | - E Shyong Tai
- a National University of Singapore , Saw Swee Hock School of Public Health , Singapore
- c National University of Singapore , Yong Loo Lin School of Medicine , Singapore
- d National University Health System , Division of Endocrinology , University Medicine Cluster , Singapore
| | - Eric Y H Khoo
- c National University of Singapore , Yong Loo Lin School of Medicine , Singapore
- d National University Health System , Division of Endocrinology , University Medicine Cluster , Singapore
| | - Hwee Lin Wee
- a National University of Singapore , Saw Swee Hock School of Public Health , Singapore
- e National University of Singapore , Department of Pharmacy, Faculty of Science , Singapore
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Nzwalo H, Nogueira J, Guilherme P, Abreu P, Félix C, Ferreira F, Ramalhete S, Marreiros A, Tatlisumak T, Thomassen L, Logallo N. Hospital readmissions after spontaneous intracerebral hemorrhage in Southern Portugal. Clin Neurol Neurosurg 2018; 169:144-148. [PMID: 29665499 DOI: 10.1016/j.clineuro.2018.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Spontaneous intracerebral hemorrhage (SICH) survivors are at risk of hospital readmissions. Data on readmissions after SICH is scarce. We aimed to study the frequency and predictors of readmissions after SICH in Algarve, Portugal. PATIENTS AND METHODS Retrospective study of a community representative cohort of SICH survivors (2009-2015). The first unplanned readmission in the first year after discharge was the outcome. Cox regression analysis was performed to identify predictors of 1-year readmission. RESULTS Of the 357 SICH survivors followed, 116 (32.5%) were readmitted within the first-year. Sixty-seven (18.8%) of the survivors were early readmitted (<90 days), corresponding to 57.8% or all readmissions. Common causes were pneumonia, endocrine/nutritional/metabolic and cardiovascular complications. The risk of readmission was increased by prior to index SICH history of ≥ 3 previous emergency department visits (hazards ratio (HR) = 2.663 (1.770-4.007); P < 0.001), pneumonia during index hospitalization (HR = 2.910 (1.844-4.592); P < 0.001) and reduced in patients discharge home (HR = 0.681 (0.366-0.976); P = 0.048). CONCLUSIONS The rate of readmissions after SICH is high, predictors are identifiable and causes are potentially preventable. Improvement of care can potentially reduce this burden.
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Affiliation(s)
- Hipólito Nzwalo
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal.
| | - Jerina Nogueira
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Patrícia Guilherme
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Pedro Abreu
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Catarina Félix
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Fátima Ferreira
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Sara Ramalhete
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Ana Marreiros
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Thomassen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
| | - Nicola Logallo
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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Bjerkreim AT, Khanevski AN, Glad SB, Thomassen L, Naess H, Logallo N. Thirty-day readmission after spontaneous intracerebral hemorrhage. Brain Behav 2018; 8:e00935. [PMID: 29541545 PMCID: PMC5840449 DOI: 10.1002/brb3.935] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is the most severe form of stroke, but data on readmission after ICH are sparse. We aimed to determine frequency, causes, and predictors of 30-day readmission after ICH. MATERIALS AND METHODS This retrospective cohort study includes all spontaneous ICH survivors admitted to the stroke unit at Haukeland University Hospital in Bergen in Norway from July 2007 to December 2013. Patients were followed by review of electronic medical charts, and the first unplanned readmission within 30 days after discharge was used as final outcome. Cox regression analysis was performed to identify predictors of 30-day readmission. RESULTS We identified 226 patients with spontaneous ICH, 70 (31.0%) of whom died before discharge or were discharged to palliative care. Of the remaining 156 ICH survivors, 28 (18.0%) were readmitted within 30 days. Median time to readmission was 12 days (IQR 4.5 - 18.5). Most patients were readmitted due to infections (N = 13). None of the patients were readmitted with recurrent stroke. Pneumonia and enteral feeding during the index hospitalization were associated with readmission for infections (both p < .01). Age was the only independent predictor of readmission (HR 1.06, 95% CI 1.02 - 1.11, p = .006). CONCLUSIONS Almost one in five of our spontaneous ICH survivors was readmitted within 30 days, and most readmissions were caused by infections.
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Affiliation(s)
- Anna Therese Bjerkreim
- Department of Clinical Medicine University of Bergen Bergen Norway.,Department of Neurology Haukeland University Hospital Bergen Norway
| | - Andrej Netland Khanevski
- Department of Neurology Haukeland University Hospital Bergen Norway.,Norwegian Health Association Oslo Norway
| | | | - Lars Thomassen
- Department of Clinical Medicine University of Bergen Bergen Norway.,Department of Neurology Haukeland University Hospital Bergen Norway
| | - Halvor Naess
- Department of Clinical Medicine University of Bergen Bergen Norway.,Department of Neurology Haukeland University Hospital Bergen Norway.,Centre for age-related medicine Stavanger University Hospital Stavanger Norway
| | - Nicola Logallo
- Department of Clinical Medicine University of Bergen Bergen Norway.,Department of Neurology Haukeland University Hospital Bergen Norway.,Department of Neurosurgery Haukeland University Hospital Bergen Norway
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12
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Schmidt LB, Goertz S, Wohlfahrt J, Melbye M, Munch TN. Recurrent Intracerebral Hemorrhage: Associations with Comorbidities and Medicine with Antithrombotic Effects. PLoS One 2016; 11:e0166223. [PMID: 27832176 PMCID: PMC5104445 DOI: 10.1371/journal.pone.0166223] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 10/25/2016] [Indexed: 11/18/2022] Open
Abstract
Background Intracerebral hemorrhage (ICH) is a disease with high mortality and a substantial risk of recurrence. However, the recurrence risk is poorly documented and the knowledge of potential predictors for recurrence among co-morbidities and medicine with antithrombotic effect is limited. Objectives 1) To estimate the short- and long-term cumulative risks of recurrent intracerebral hemorrhage (ICH). 2) To investigate associations between typical comorbid diseases, surgical treatment, use of medicine with antithrombotic effects, including antithrombotic treatment (ATT), selective serotonin reuptake inhibitors (SSRI’s), and nonsteroidal anti-inflammatory drugs (NSAID’s) with recurrent ICH. Methods The cohort consisted of all individuals diagnosed with a primary ICH in Denmark 1996–2011. Information on comorbidities, surgical treatment for the primary ICH, and the use of ATT, SSRI’s and NSAID’s was retrieved from the Danish national health registers. The cumulative recurrence risk of ICH was estimated using the Aalen-Johansen estimator, thus taking into account the competing risk of death. Associations with potential predictors of recurrent ICH were estimated as rate ratios (RR’s) using Poisson regression. Propensity score matching was used for the analyses of medicine with antithrombotic effects. Results Among 15,270 individuals diagnosed with a primary ICH, 2,053 recurrences were recorded, resulting in cumulative recurrence risk of 8.9% after one year and 13.7% after five years. Surgical treatment and renal insufficiency were associated with increased recurrence risks (RR 1.64, 95% CI 1.39–1.93 and RR 1.72, 95% CI 1.34–2.17, respectively), whereas anti-hypertensive treatment was associated with a reduced risk (RR 0.82, 95% CI 0.74–0.91). We observed non-significant associations between the use of any of the investigated medicines with antithrombotic effect (ATT, SSRI’s, NSAID’s) and recurrent ICH. Conclusions The substantial short-and long-term recurrence risks warrant aggressive management of hypertension following a primary ICH, particularly in patients treated surgically for the primary ICH, and patients with renal insufficiency.
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Affiliation(s)
| | - Sanne Goertz
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Jan Wohlfahrt
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Mads Melbye
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Tina Noergaard Munch
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
- * E-mail:
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13
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Le ST, Josephson SA, Puttgen HA, Gibson L, Guterman EL, Leicester HM, Graf CL, Probasco JC. Many Neurology Readmissions Are Nonpreventable. Neurohospitalist 2016; 7:61-69. [PMID: 28400898 DOI: 10.1177/1941874416674409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Reducing unplanned hospital readmissions has become a national focus due to the Centers for Medicare and Medicaid Services' (CMS) penalties for hospitals with high rates. A first step in reducing unplanned readmission is to understand which patients are at high risk for readmission, which readmissions are planned, and how well planned readmissions are currently captured in comparison to patient-level chart review. METHODS We examined all 5455 inpatient neurology admissions over a 2-year period to University of California San Francisco Medical Center and Johns Hopkins Hospital via chart review. We collected information such as patient age, procedure codes, diagnosis codes, all-payer diagnosis-related group, observed length of stay (oLOS), and expected length of stay. We performed multivariate logistic modeling to determine predictors of readmission. Discharge summaries were reviewed for evidence that a subsequent readmission was planned. RESULTS A total of 353 (6.5%) discharges were readmitted within 30 days. Fifty-five (15.6%) of the 353 readmissions were planned, most often for a neurosurgical procedure (41.8%) or immunotherapy (23.6%). Only 8 of these readmissions would have been classified as planned using current CMS methodology. Patient age (odds ratio [OR] = 1.01 for each 10-year increase, P < .001) and estimated length of stay (OR = 1.04, P = .002) were associated with a greater likelihood of readmission, whereas index admission oLOS was not. CONCLUSIONS Many neurologic readmissions are planned; however, these are often classified by current CMS methodology as unplanned and penalized accordingly. Modifications of the CMS lists for potentially planned neurological and neurosurgical procedures and for acute discharge neurologic diagnoses should be considered.
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Affiliation(s)
- Sidney T Le
- University of California San Francisco, San Francisco, CA, USA
| | | | - Hans A Puttgen
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lorrie Gibson
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elan L Guterman
- University of California San Francisco, San Francisco, CA, USA
| | | | - Carla L Graf
- University of California San Francisco, San Francisco, CA, USA
| | - John C Probasco
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Lord AS, Lewis A, Czeisler B, Ishida K, Torres J, Kamel H, Woo D, Elkind MSV, Boden-Albala B. Majority of 30-Day Readmissions After Intracerebral Hemorrhage Are Related to Infections. Stroke 2016; 47:1768-71. [PMID: 27301933 PMCID: PMC4927367 DOI: 10.1161/strokeaha.116.013229] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Infections are common after intracerebral hemorrhage, but little is known about the risk of serious infection requiring readmission after hospital discharge. METHODS To determine if infections are prevalent in patients readmitted within 30 days of discharge, we performed a retrospective cohort study of patients discharged from nonfederal acute care hospitals in California with a primary diagnosis of intracerebral hemorrhage between 2006 and 2010. We excluded patients who died during the index admission, were discharged against medical advice, or were not California residents. Our main outcome was 30-day unplanned readmission with primary infection-related International Classification of Diseases, Ninth Revision, Clinical Modification code. RESULTS There were 24 540 index intracerebral hemorrhage visits from 2006 to 2010. Unplanned readmissions occurred in 14.5% (n=3550) of index patients. Of 3550 readmissions, 777 (22%) had an infection-related primary diagnosis code. When evaluating primary and all secondary diagnosis codes, infection was associated with 1826 (51%) of readmissions. Other common diagnoses associated with readmission included stroke-related codes (n=840, 23.7%) and aspiration pneumonitis (n=154, 4.3%). The most common infection-related primary diagnosis codes were septicemia (n=420, 11.8%), pneumonia (n=124, 3.5%), urinary tract infection (n=141, 4.0%), and gastrointestinal infection (n=42, 1.2%). Patients with a primary infection-related International Classification of Diseases, Ninth Revision, Clinical Modification code on readmission had higher in-hospital mortality compared with other types of readmission (15.6% versus 8.0%, P<0.001). After controlling for other predictors of mortality, primary infection-related readmissions remained associated with in-hospital mortality (relative risk, 1.7; 95% confidence interval, 1.3-2.2). CONCLUSIONS Infections are associated with a majority of 30-day readmissions after intracerebral hemorrhage and increased mortality. Efforts should be made to reduce infection-related complications after hospital discharge.
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Affiliation(s)
- Aaron S Lord
- From the Department of Neurology, New York University School of Medicine (A.S.L., A.L., B.C., K.I., J.T., B.B.-A.); Department of Neurology, Weill Cornell Medical College, New York, NY (H.K.); Department of Neurology and Rehabilitation, University of Cincinnati College of Medicine, OH (D.W.); Departments of Neurology and Epidemiology, Columbia University, New York, NY (M.S.V.E.); and Division of Epidemiology, College of Global Public Health, New York University (B.B.-A.).
| | - Ariane Lewis
- From the Department of Neurology, New York University School of Medicine (A.S.L., A.L., B.C., K.I., J.T., B.B.-A.); Department of Neurology, Weill Cornell Medical College, New York, NY (H.K.); Department of Neurology and Rehabilitation, University of Cincinnati College of Medicine, OH (D.W.); Departments of Neurology and Epidemiology, Columbia University, New York, NY (M.S.V.E.); and Division of Epidemiology, College of Global Public Health, New York University (B.B.-A.)
| | - Barry Czeisler
- From the Department of Neurology, New York University School of Medicine (A.S.L., A.L., B.C., K.I., J.T., B.B.-A.); Department of Neurology, Weill Cornell Medical College, New York, NY (H.K.); Department of Neurology and Rehabilitation, University of Cincinnati College of Medicine, OH (D.W.); Departments of Neurology and Epidemiology, Columbia University, New York, NY (M.S.V.E.); and Division of Epidemiology, College of Global Public Health, New York University (B.B.-A.)
| | - Koto Ishida
- From the Department of Neurology, New York University School of Medicine (A.S.L., A.L., B.C., K.I., J.T., B.B.-A.); Department of Neurology, Weill Cornell Medical College, New York, NY (H.K.); Department of Neurology and Rehabilitation, University of Cincinnati College of Medicine, OH (D.W.); Departments of Neurology and Epidemiology, Columbia University, New York, NY (M.S.V.E.); and Division of Epidemiology, College of Global Public Health, New York University (B.B.-A.)
| | - Jose Torres
- From the Department of Neurology, New York University School of Medicine (A.S.L., A.L., B.C., K.I., J.T., B.B.-A.); Department of Neurology, Weill Cornell Medical College, New York, NY (H.K.); Department of Neurology and Rehabilitation, University of Cincinnati College of Medicine, OH (D.W.); Departments of Neurology and Epidemiology, Columbia University, New York, NY (M.S.V.E.); and Division of Epidemiology, College of Global Public Health, New York University (B.B.-A.)
| | - Hooman Kamel
- From the Department of Neurology, New York University School of Medicine (A.S.L., A.L., B.C., K.I., J.T., B.B.-A.); Department of Neurology, Weill Cornell Medical College, New York, NY (H.K.); Department of Neurology and Rehabilitation, University of Cincinnati College of Medicine, OH (D.W.); Departments of Neurology and Epidemiology, Columbia University, New York, NY (M.S.V.E.); and Division of Epidemiology, College of Global Public Health, New York University (B.B.-A.)
| | - Daniel Woo
- From the Department of Neurology, New York University School of Medicine (A.S.L., A.L., B.C., K.I., J.T., B.B.-A.); Department of Neurology, Weill Cornell Medical College, New York, NY (H.K.); Department of Neurology and Rehabilitation, University of Cincinnati College of Medicine, OH (D.W.); Departments of Neurology and Epidemiology, Columbia University, New York, NY (M.S.V.E.); and Division of Epidemiology, College of Global Public Health, New York University (B.B.-A.)
| | - Mitchell S V Elkind
- From the Department of Neurology, New York University School of Medicine (A.S.L., A.L., B.C., K.I., J.T., B.B.-A.); Department of Neurology, Weill Cornell Medical College, New York, NY (H.K.); Department of Neurology and Rehabilitation, University of Cincinnati College of Medicine, OH (D.W.); Departments of Neurology and Epidemiology, Columbia University, New York, NY (M.S.V.E.); and Division of Epidemiology, College of Global Public Health, New York University (B.B.-A.)
| | - Bernadette Boden-Albala
- From the Department of Neurology, New York University School of Medicine (A.S.L., A.L., B.C., K.I., J.T., B.B.-A.); Department of Neurology, Weill Cornell Medical College, New York, NY (H.K.); Department of Neurology and Rehabilitation, University of Cincinnati College of Medicine, OH (D.W.); Departments of Neurology and Epidemiology, Columbia University, New York, NY (M.S.V.E.); and Division of Epidemiology, College of Global Public Health, New York University (B.B.-A.)
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Flythe JE, Katsanos SL, Hu Y, Kshirsagar AV, Falk RJ, Moore CR. Predictors of 30-Day Hospital Readmission among Maintenance Hemodialysis Patients: A Hospital's Perspective. Clin J Am Soc Nephrol 2016; 11:1005-1014. [PMID: 27151893 PMCID: PMC4891757 DOI: 10.2215/cjn.11611115] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/23/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Over 35% of patients on maintenance dialysis are readmitted to the hospital within 30 days of hospital discharge. Outpatient dialysis facilities often assume responsibility for readmission prevention. Hospital care and discharge practices may increase readmission risk. We undertook this study to elucidate risk factors identifiable from hospital-derived data for 30-day readmission among patients on hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were taken from patients on maintenance hemodialysis discharged from University of North Carolina Hospitals between May of 2008 and June of 2013 who received in-patient hemodialysis during their index hospitalizations. Multivariable logistic regression models with 30-day readmission as the dependent outcome were used to identify readmission risk factors. Models considered variables available at hospital admission and discharge separately. RESULTS Among 349 patients, 112 (32.1%) had a 30-day hospital readmission. The discharge (versus admission) model was more predictive of 30-day readmission. In the discharge model, malignancy comorbid condition (odds ratio [OR], 2.08; 95% confidence interval [95% CI], 1.04 to 3.11), three or more hospitalizations in the prior year (OR, 1.97; 95% CI, 1.06 to 3.64), ≥10 outpatient medications at hospital admission (OR, 1.69; 95% CI, 1.00 to 2.88), catheter vascular access (OR, 1.82; 95% CI, 1.01 to 3.65), outpatient dialysis at a nonuniversity-affiliated dialysis facility (OR, 3.59; 95% CI, 2.03 to 6.36), intradialytic hypotension (OR, 3.10; 95% CI, 1.45 to 6.61), weekend discharge day (OR, 1.82; 95% CI, 1.01 to 3.31), and serum albumin <3.3 g/dl (OR, 4.28; 95% CI, 2.37 to 7.73) were associated with higher readmission odds. A decrease in prescribed medications from admission to discharge (OR, 0.20; 95% CI, 0.08 to 0.51) was associated with lower readmission odds. Findings were robust across different model-building approaches. CONCLUSIONS Models containing discharge day data had greater predictive capacity of 30-day readmission than admission models. Identified modifiable readmission risk factors suggest that improved medication education and improved transitions from hospital to community may potentially reduce readmissions. Studies evaluating targeted transition programs among patients on dialysis are needed.
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Affiliation(s)
- Jennifer E. Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine and
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Suzanne L. Katsanos
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine and
| | - Yichun Hu
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine and
| | - Abhijit V. Kshirsagar
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine and
| | - Ronald J. Falk
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine and
| | - Carlton R. Moore
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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16
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Prevalence, causes and risk factors of hospital readmissions after acute stroke and transient ischemic attack: a systematic review and meta-analysis. Neurol Sci 2016; 37:1195-202. [DOI: 10.1007/s10072-016-2570-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 03/17/2016] [Indexed: 11/25/2022]
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