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Daly B, Cracchiolo J, Holland J, Ebstein AM, Flynn J, Duck E, Moy M, Walters CB, Giacomazzo L, Huang J, Fahy R, Bernal C, Ackerman J, Salvaggio R, Begue A, Raj N, Kuperman G, Mao JJ, Panageas K. Digitally Enabled Transitional Care Management in Oncology. JCO Oncol Pract 2024; 20:657-665. [PMID: 38382002 DOI: 10.1200/op.23.00565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/20/2023] [Accepted: 01/03/2024] [Indexed: 02/23/2024] Open
Abstract
PURPOSE Improving care transitions for patients with cancer discharged from the hospital is considered an important component of quality care. Digital monitoring has the potential to better the delivery of transitional care through improved patient-provider communication and enhanced symptom management. However, remote patient monitoring (RPM) interventions have not been widely implemented for oncology patients after discharge, an innovative setting in which to apply this technology. METHODS We implemented a RPM intervention which identifies medical oncology patients at discharge, monitors their symptoms for 10 days, and intervenes as necessary to manage symptoms. We evaluated the feasibility (>50% patient engagement with symptom assessment), appropriateness (symptom alerts), and acceptability (net promoter score >0.7) of the intervention and the initial effect on acute care visits and return on investment. RESULTS During the study period, January 1, 2021, to December 31, 2022, we evaluated 2,257 medical oncology discharges representing 1,857 unique patients. We found that 65.9% of patients discharged (N = 1,489) completed at least one symptom assessment postdischarge and of them, 45.5% (n = 678) generated a severe symptom alert that we helped to manage. Patients expressed high satisfaction with the intervention with a net promoter score of 84%. In preliminary analysis of patients with GI malignancies (n = 449), we found a nonsignificant decrease in 30-day readmissions for the intervention cohort (n = 269) by 5.8% as compared with the control (n = 180; from 33.3% to 27.5%; P = .22). CONCLUSION Digital transitional care management was feasible and demonstrated that patients transitioning from the hospital to home have a substantial symptom burden. The intervention was associated with high patient satisfaction but will require further refinement and evaluation to increase its impact on 30-day readmission.
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Affiliation(s)
- Bobby Daly
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Jessica Flynn
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elaine Duck
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Morgan Moy
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Jennie Huang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Camila Bernal
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jill Ackerman
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Aaron Begue
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nitya Raj
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Jun J Mao
- Memorial Sloan Kettering Cancer Center, New York, NY
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Setiati S, Ardian LJ, Fitriana I, Azwar MK. Improvement of scoring system used before discharge to predict 30-day all-cause unplanned readmission in geriatric population: a prospective cohort study. BMC Geriatr 2024; 24:281. [PMID: 38528454 DOI: 10.1186/s12877-024-04875-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/05/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Data taken from tertiary referral hospitals in Indonesia suggested readmission rate in older population ranging between 18.1 and 36.3%. Thus, it is crucial to identify high risk patients who were readmitted. Our previous study found several important predictors, despite unsatisfactory discrimination value. METHODS We aimed to investigate whether comprehensive geriatric assessment (CGA) -based modification to the published seven-point scoring system may increase the discrimination value. We conducted a prospective cohort study in July-September 2022 and recruited patients aged 60 years and older admitted to the non-surgical ward and intensive coronary care unit. The ROC curve was made based on the four variables included in the prior study. We conducted bivariate and multivariate analyses, and derived a new scoring system with its discrimination value. RESULTS Of 235 subjects, the incidence of readmission was 32.3% (95% CI 26-38%). We established a new scoring system consisting of 4 components. The scoring system had maximum score of 21 and incorporated malignancy (6 points), delirium (4 points), length of stay ≥ 10 days (4 points), and being at risk of malnutrition or malnourished (7 points), with a good calibration test. The C-statistic value was 0.835 (95% CI 0.781-0.880). The optimal cut-off point was ≥ 8 with a sensitivity of 90.8% and a specificity of 54.7%. CONCLUSIONS Malignancy, delirium, length of stay ≥ 10 days, and being at risk of malnutrition or malnourished are predictors for 30-day all-cause unplanned readmission. The sensitive scoring system is a strong model to identify whether an individual is at higher risk for readmission. The new CGA-based scoring system had higher discrimination value than that of the previous seven-point scoring system.
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Affiliation(s)
- Siti Setiati
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
| | - Laurentius Johan Ardian
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Ika Fitriana
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Muhammad Khifzhon Azwar
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Khayyat SM. Consensus methodology to investigate the crucial referral criteria to pharmacist-led counseling clinics in Makkah City. Saudi Pharm J 2024; 32:101981. [PMID: 38370133 PMCID: PMC10869262 DOI: 10.1016/j.jsps.2024.101981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 02/01/2024] [Indexed: 02/20/2024] Open
Abstract
Aim Identifying and prioritizing criteria for referring patients to a counseling clinic managed by hospital pharmacists in the tertiary care setting in Saudi Arabia (SA). Method A two-phase consensus Delphi methodological approach was adopted in this study. Data was collected from physicians and pharmacists from different specialties working in different hospitals in Makkah City. In Phase 1, semi-structured interviews were conducted with physicians and pharmacists to discuss and develop the initial list of potential referral criteria for post-discharge counseling. Phase 2 consisted of two rounds of online surveys where participants were asked to independently rank the referral criteria using a 5-point Likert Scale. Results In Phase 1, four participants undertook the interviews (two physicians and two pharmacists). Overall, no major comments were given on the suggested criteria. In Phase 2, most suggested referral criteria to the counseling clinic reached participants' consensus agreement of >70 % in both rounds for all three domains. Among all criteria that achieved consensus agreement, two demographic criteria were top-ranked by the participants; the elderly patients (100 %) and those who needed help with their devices (96 %). These were followed by five medication-related criteria, which are medication-related problems, polypharmacy, medication that needs monitoring, high-risk medication, and medication with special formulations. All had a consensus agreement of 96 %. Conclusion This study suggests that a counseling clinic led by pharmacists is particularly advisable for the elderly, individuals requiring assistance with their devices, and those encountering medication issues. It is essential to prioritize specific patient demographics when contemplating the extensive establishment and integration of such clinics across various hospitals in SA.
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Affiliation(s)
- Sarah M. Khayyat
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
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Wang Y, Jiao T, Muschett MR, Brown JD, Guo SJ, Kulshreshtha A, Zhang Y, Winterstein AG, Shao H. Associations Between Postdischarge Care and Cognitive Impairment-Related Hospital Readmissions for Ketoacidosis and Severe Hypoglycemia in Adults With Diabetes. Diabetes Care 2024; 47:225-232. [PMID: 38048487 PMCID: PMC11148625 DOI: 10.2337/dca23-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/01/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE Patients with severe hypoglycemia (SH) or diabetic ketoacidosis (DKA) experience high hospital readmission after being discharged. Cognitive impairment (CI) may further increase the risk, especially in those experiencing an interruption of medical care after discharge. This study examined the effect modification role of postdischarge care (PDC) on CI-associated readmission risk among U.S. adults with diabetes initially admitted for DKA or SH. RESEARCH DESIGN AND METHODS We used the Nationwide Readmissions Database (NRD) (2016-2018) to identify individuals hospitalized with a diagnosis of DKA or SH. Multivariate Cox regression was used to compare the all-cause readmission risk at 30 days between those with and without CI identified during the initial hospitalization. We assessed the CI-associated readmission risk in the patients with and without PDC, an effect modifier with the CI status. RESULTS We identified 23,775 SH patients (53.3% women, mean age 65.9 ± 15.3 years) and 140,490 DKA patients (45.8% women, mean age 40.3 ± 15.4 years), and 2,675 (11.2%) and 1,261 (0.9%), respectively, had a CI diagnosis during their index hospitalization. For SH and DKA patients discharged without PDC, CI was associated with a higher readmission risk of 23% (adjusted hazard ratio [aHR] 1.23, 95% confidence interval 1.08-1.40) and 35% (aHR 1.35, 95% confidence interval 1.08-1.70), respectively. However, when patients were discharged with PDC, we found PDC was an effect modifier to mitigate CI-associated readmission risk for both SH and DKA patients (P < 0.05 for all). CONCLUSIONS Our results suggest that PDC can potentially mitigate the excessive readmission risk associated with CI, emphasizing the importance of postdischarge continuity of care for medically complex patients with comorbid diabetes and CI.
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Affiliation(s)
- Yehua Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Tianze Jiao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Matthew R. Muschett
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Joshua D. Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Serena Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Ambar Kulshreshtha
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA
| | - Yongkang Zhang
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
| | - Hui Shao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA
- Hubert Department of Global Health, Rollin School of Public Health, Emory University, Atlanta, GA
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Tsai YC, Chen YM, Wen CJ, Wu MC, Chou YC, Chen JH, Lin KP, Chan DC, Lu FP. Multimorbidity and prior falls correlate with risk of 30-day hospital readmission in aged 80+: A prospective cohort study. J Formos Med Assoc 2023; 122:1111-1116. [PMID: 36990860 DOI: 10.1016/j.jfma.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 02/16/2023] [Accepted: 03/07/2023] [Indexed: 03/28/2023] Open
Abstract
BACKGROUND/PURPOSE Thirty-day hospital readmission rate significantly raised with advanced age. The performance of existing predictive models for readmission risk remained uncertain in the oldest population. We aimed to examine the effect of geriatric conditions and multimorbidity on readmission risk among older adults aged 80 and over. METHODS This prospective cohort study enrolled patients aged 80 and older discharged from a geriatric ward at a tertiary hospital, with phone follow-up for 12 months. Demographics, multimorbidity, and geriatric conditions were assessed before hospital discharge. Logistic regression models were conducted to analyse risk factors for 30-day readmission. RESULTS Patients readmitted had higher Charlson comorbidity index scores, and were more likely to have falls, frailty, and longer hospital stay, compared to those without 30-day readmission. Multivariate analysis revealed that higher Charlson comorbidity index score was associated with readmission risk. Older patients with a fall history within 12 months had a near 4-fold increase in readmission risk. Severe frailty status before index admission was associated with a higher 30-day readmission risk. Functional status at discharge was not associated with readmission risk. CONCLUSION In addition to multimorbidity, history of falls and frailty were associated with higher hospital readmission risk in the oldest.
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Affiliation(s)
- Yu-Chieh Tsai
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Yung-Ming Chen
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chiung-Jung Wen
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan; Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Meng-Chen Wu
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Chun Chou
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan; Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jen-Hau Chen
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kun-Pei Lin
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ding-Cheng Chan
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Feng-Ping Lu
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Ebhohon E, Khoshbin K, Shaka H. Rates and predictors of 30-day hospital readmissions in adults for drug-induced acute pancreatitis: A retrospective study from the United States National Readmission Database. J Gastroenterol Hepatol 2023; 38:1277-1282. [PMID: 36914611 DOI: 10.1111/jgh.16177] [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] [Received: 12/06/2022] [Revised: 02/27/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND AND AIM Drug-induced acute pancreatitis (DIAP) linked to several medications is a diagnosis of exclusion and is associated with significant morbidity and mortality, contributing to the US healthcare cost burden. Existing studies on DIAP focus on the drug classes that can cause acute pancreatitis. Hence, our retrospective study aims to determine the rates and predictors for 30-day readmissions (30-DR) in patients with index hospitalization for DIAP. METHODS From the Nationwide Readmissions Database, we followed adults admitted for DIAP who were discharged alive for 30 days. During 30-DR, we evaluated the rates, predictors, and outcomes of DIAP. RESULTS Of the 4457 DIAP patients surviving at discharge, 12.5% were readmitted at 30 days. During readmissions, the predictors of 30-DR for DIAP were young age, the Charlson-Deyo Comorbidity Index of 2 and 3, protein-energy malnutrition, and dyslipidemia. During 30-DR, DIAP had a higher mortality rate (2.4% vs. 0.7%; P < 0.020), extended hospital stays (5.6 days vs. 4 days, 0.000), and higher hospital charges ($12 983.6 vs. $8 255.6; P 0.000). CONCLUSIONS DIAP has high 30-DR rates and poorer outcomes.
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Affiliation(s)
- Ebehiwele Ebhohon
- Department of Internal Medicine, Lincoln Medical Center, Bronx, New York, USA
| | - Katayoun Khoshbin
- Department of Internal Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Hafeez Shaka
- Department of Internal Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, USA
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Costa MLM, Mafra ACCN, Cendoroglo MS, Rodrigues PS, Ferreira MS, Studenski SA, Franco FGDM. Development and validation of predictive model for long-term hospitalization, readmission, and in-hospital death of patients over 60 years old. EINSTEIN-SAO PAULO 2022; 20:eAO8012. [PMID: 35730807 PMCID: PMC9239538 DOI: 10.31744/einstein_journal/2022ao8012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/06/2022] [Indexed: 11/16/2022] Open
Abstract
Objective To develop and validate a high-risk predictive model that identifies, at least, one common adverse event in older population: early readmission (up to 30 days after discharge), long hospital stays (10 days or more) or in-hospital deaths. Methods This was a retrospective cohort study including patients aged 60 years or older (n=340) admitted at a 630-beds tertiary hospital, located in the city of São Paulo, Brazil. A predictive model of high-risk indication was developed by analyzing logistical regression models. This model prognostic capacity was assessed by measuring accuracy, sensitivity, specificity, and positive and negative predictive values. Areas under the receiver operating characteristic curve with 95% confidence intervals were also obtained to assess the discriminatory power of the model. Internal validation of the prognostic model was performed in a separate sample (n=168). Results Statistically significant predictors were identified, such as current Barthel Index, number of medications in use, presence of diabetes mellitus, difficulty chewing or swallowing, extensive surgery, and dementia. The study observed discrimination model acceptance in the construction sample 0.77 (95% confidence interval: 0.71-0.83) and good calibration. The characteristics of the validation samples were similar, and the receiver operating characteristic curve area was 0.687 (95% confidence interval: 0.598-0.776). We could assess an older patient’s adverse health events during hospitalization after admission. Conclusion A predictive model with acceptable discrimination was obtained, with satisfactory results for early readmission (30 days), long hospital stays (10 days), or in-hospital death.
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Patel N, Swami J, Pinkhasova D, Karslioglu French E, Hlasnik D, Delisi K, Donihi A, Siminerio L, Rubin DJ, Wang L, Korytkowski MT. Sex differences in glycemic measures, complications, discharge disposition, and postdischarge emergency room visits and readmission among non-critically ill, hospitalized patients with diabetes. BMJ Open Diabetes Res Care 2022; 10:10/2/e002722. [PMID: 35246452 PMCID: PMC8900035 DOI: 10.1136/bmjdrc-2021-002722] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/09/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The purpose of this prospective observational cohort study was to examine sex differences in glycemic measures, diabetes-related complications, and rates of postdischarge emergency room (ER) visits and hospital readmissions in non-critically ill, hospitalized patients with diabetes. RESEARCH DESIGN AND METHODS Demographic data including age, body mass index, race, blood pressure, reason for admission, diabetes medications at admission and discharge, diabetes-related complications, laboratory data (hematocrit, creatinine, hemoglobin A1c, point-of-care blood glucose measures), length of stay (LOS), and discharge disposition were collected. Patients were followed for 90 days following hospital discharge to obtain information regarding ER visits and readmissions. RESULTS 120 men and 100 women consented to participate in this study. There were no sex differences in patient demographics, diabetes duration or complications, or LOS. No differences were observed in the percentage of men and women with an ER visit or hospital readmission within 30 (39% vs 33%, p=0.40) or 90 (60% vs 49%, p=0.12) days of hospital discharge. More men than women experienced hypoglycemia prior to discharge (18% vs 8%, p=0.026). More women were discharged to skilled nursing facilities (p=0.007). CONCLUSIONS This study demonstrates that men and women hospitalized with an underlying diagnosis of diabetes have similar preadmission glycemic measures, diabetes duration, and prevalence of diabetes complications. More men experienced hypoglycemia prior to discharge. Women were less likely to be discharged to home. Approximately 50% of men and women had ER visits or readmissions within 90 days of hospital discharge. TRIAL REGISTRATION NUMBER NCT03279627.
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Affiliation(s)
- Neeti Patel
- Department of Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Janya Swami
- Department of Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | | | | | | | - Kristin Delisi
- Department of Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Amy Donihi
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Linda Siminerio
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel J Rubin
- Department of Medicine/Endocrinology, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mary T Korytkowski
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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OUP accepted manuscript. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:116-128. [DOI: 10.1093/ijpp/riac009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 02/02/2022] [Indexed: 11/12/2022]
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Yen HY, Lin SC, Chi MJ. Exploration of risk factors for high-risk adverse events in elderly patients after discharge and comparison of discharge planning screening tools. J Nurs Scholarsh 2021; 54:7-14. [PMID: 34841651 DOI: 10.1111/jnu.12705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 05/12/2021] [Accepted: 07/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Discharge planning is an effective strategy to prevent adverse health events and reduce medical expenditures. The high-risk target populations of discharged elderly patients and important predictors for the occurrence of adverse events are still not clear. Therefore, the purposes of this study were to examine the validity of discharge planning screening tools in sufficiently identifying high-risk adverse events to health after discharge and to compare two screening tools with our study model. DESIGN We conducted a prospective study and recruited elderly patients who had had no hospitalization within 3 months before admission to 13 general wards of a medical center in northern Taiwan from November 2018 to May 2020. METHODS Elderly patients were randomly selected during the study period. Within 24 h of admission, patients were asked to consent to join this study. After the patient was discharged, the patient's health and hospitalization for the next year were tracked by telephone interviews. RESULTS In total, 300 participants were recruited for this study. Incidences of high-risk adverse events within 30 days, 60 days, and 12 months after discharge were 20.3%, 25.7%, and 48.7% respectively. A logistic regression showed that an increased age, physical or mental disabilities or a major illness, a low body-mass index, and having been hospitalized in the past year were significantly related to the occurrence of high-risk events among elderly discharge patients. The pooled sensitivity of the Pra was 52% and the specificity was 72%; the pooled sensitivity of the LACE index was 67% and the specificity was 36%. The predictive model of this study had a higher discriminatory power than the Pra and LACE index for high-risk events after discharge. CONCLUSIONS Elderly patients are more vulnerable to high-risk adverse events after discharge. Both the LACE index and Pra are useful discharge planning screening tools to screen for high-risk adverse events after discharge. Elderly patients need more-active and complete continuity of care plans and discharge planning services to ensure that the overall quality of patient care can be improved and readmissions and mortality reduced. CLINICAL RELEVANCE The findings of this study can provide information for discharge planning managers to identify high-risk elderly patients during hospitalization and promptly offer care education or resources to improve care management.
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Affiliation(s)
- Hsin-Yen Yen
- School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Siou-Chun Lin
- Master Program in Long-term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan.,Department of Preventive and Community Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Mei-Ju Chi
- School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan.,Master Program in Long-term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
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Smith JM, Lin H, Thomas-Hawkins C, Tsui J, Jarrín OF. Timing of Home Health Care Initiation and 30-Day Rehospitalizations among Medicare Beneficiaries with Diabetes by Race and Ethnicity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:5623. [PMID: 34070282 PMCID: PMC8197411 DOI: 10.3390/ijerph18115623] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 01/02/2023]
Abstract
Older adults with diabetes are at elevated risk of complications following hospitalization. Home health care services mitigate the risk of adverse events and facilitate a safe transition home. In the United States, when home health care services are prescribed, federal guidelines require they begin within two days of hospital discharge. This study examined the association between timing of home health care initiation and 30-day rehospitalization outcomes in a cohort of 786,734 Medicare beneficiaries following a diabetes-related index hospitalization admission during 2015. Of these patients, 26.6% were discharged to home health care. To evaluate the association between timing of home health care initiation and 30-day rehospitalizations, multivariate logistic regression models including patient demographics, clinical and geographic variables, and neighborhood socioeconomic variables were used. Inverse probability-weighted propensity scores were incorporated into the analysis to account for potential confounding between the timing of home health care initiation and the outcome in the cohort. Compared to the patients who received home health care within the recommended first two days, the patients who received delayed services (3-7 days after discharge) had higher odds of rehospitalization (OR, 1.28; 95% CI, 1.25-1.32). Among the patients who received late services (8-14 days after discharge), the odds of rehospitalization were four times greater than among the patients receiving services within two days (OR, 4.12; 95% CI, 3.97-4.28). Timely initiation of home health care following diabetes-related hospitalizations is one strategy to improve outcomes.
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Affiliation(s)
- Jamie M. Smith
- College of Nursing, Thomas Jefferson University, Philadelphia, PA 19107, USA;
- School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ 07108, USA; (H.L.); (C.T.-H.)
| | - Haiqun Lin
- School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ 07108, USA; (H.L.); (C.T.-H.)
- School of Public Health, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA
| | - Charlotte Thomas-Hawkins
- School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ 07108, USA; (H.L.); (C.T.-H.)
| | - Jennifer Tsui
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA 90033, USA;
| | - Olga F. Jarrín
- School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ 07108, USA; (H.L.); (C.T.-H.)
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, NJ 08901, USA
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Robbins T, Sankaranarayanan S, Randeva H, Keung SNLC, Arvanitis TN. Association between glycosylated haemoglobin and outcomes for patients discharged from hospital with diabetes: A health informatics approach. Digit Health 2021; 7:20552076211007661. [PMID: 33948220 PMCID: PMC8054217 DOI: 10.1177/20552076211007661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 03/13/2021] [Indexed: 11/16/2022] Open
Abstract
Aims/Objectives Extensive research considers associations between inpatient glycaemic control and outcomes during hospital admission; this cautions against overly tight glycaemic targets. Little research considers glycaemic control following hospital discharge. This is despite a clear understanding that people with diabetes are at increased risk of negative outcomes, following discharge. We evaluate absolute and relative Hba1c values, and frequency of Hba1c monitoring, on readmission and mortality rates for people discharged from hospital with diabetes. Methods All discharges (n = 46,357) with diabetes from a major tertiary referral centre over 3 years were extracted, including biochemistry data. We conducted an evaluation of association between Hba1c, mortality and readmission, statistical significance and standardised Cohen's D effect size calculations. Results 399 patients had a Hba1c performed during their admission. 3,138 patients had a Hba1c within 1 year of discharge. Mean average Hba1c for readmissions was 57.82 vs 60.39 for not readmitted (p = 0.009, Cohen's D 0.28). Mean average number of days to Hba1c testing in readmitted was 97 vs 113 for those not readmitted (p = 0.00006, Cohen's D 0.39). Further evaluation of mortality outcomes, cohorts of T1DM and T2DM and association of relative change in Hba1c was performed. Conclusions Lower Hba1c values following discharge from hospital are significantly associated with increased risk of readmission, as is a shorter duration until testing. Similar patterns observed for mortality. Findings particularly prominent for T1DM. Further research needed to consider underlying causation and design of appropriate risk stratification models.
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Affiliation(s)
- Tim Robbins
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK.,Institute of Digital Healthcare, WMG, University of Warwick, Coventry, UK
| | | | - Harpal Randeva
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK.,Warwick Medical School, University of Warwick, Coventry, UK
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13
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Bergenstal RM, Kerr MSD, Roberts GJ, Souto D, Nabutovsky Y, Hirsch IB. Flash CGM Is Associated With Reduced Diabetes Events and Hospitalizations in Insulin-Treated Type 2 Diabetes. J Endocr Soc 2021; 5:bvab013. [PMID: 33644623 PMCID: PMC7901259 DOI: 10.1210/jendso/bvab013] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Indexed: 12/20/2022] Open
Abstract
Purpose Suboptimal glycemic control among individuals with diabetes is a leading cause of hospitalizations and emergency department utilization. Use of flash continuous glucose monitoring (flash CGM) improves glycemic control in type 1 and type 2 diabetes, which may result in lower risk for acute and chronic complications that require emergency services and/or hospitalizations. Methods In this retrospective, real-world study, we analyzed IBM MarketScan Commercial Claims and Medicare Supplemental databases to assess the impact of flash CGM on diabetes-related events and hospitalizations in a cohort of 2463 individuals with type 2 diabetes who were on short- or rapid-acting insulin therapy. Outcomes were changes in acute diabetes-related events (ADE) and all-cause inpatient hospitalizations (ACH), occurring during the first 6 months after acquiring the flash CGM system compared with event rates during the 6 months prior to system acquisition. ICD-10 codes were used to identify ADE for hypoglycemia, hypoglycemic coma, hyperglycemia, diabetic ketoacidosis, and hyperosmolarity. Results ADE rates decreased from 0.180 to 0.072 events/patient-year (hazard ratio [HR]: 0.39 [0.30, 0.51]; P < 0.001) and ACH rates decreased from 0.420 to 0.283 events/patient-year (HR: 0.68 [0.59 0.78]; P < 0.001). ADE reduction occurred regardless of age or gender. Conclusions Acquisition of the flash CGM system was associated with reductions in ADE and ACH. These findings provide support for the use of flash CGM in type 2 diabetes patients treated with short- or rapid-acting insulin therapy to improve clinical outcomes and potentially reduce costs.
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Affiliation(s)
- Richard M Bergenstal
- International Diabetes Center, Park Nicollet and HealthPartners, Minneapolis, MN, USA
| | | | | | | | | | - Irl B Hirsch
- University of Washington School of Medicine, Seattle, WA, USA
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14
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Zhao H, Tanner S, Golden SH, Fisher SG, Rubin DJ. Common sampling and modeling approaches to analyzing readmission risk that ignore clustering produce misleading results. BMC Med Res Methodol 2020; 20:281. [PMID: 33238884 PMCID: PMC7687737 DOI: 10.1186/s12874-020-01162-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/11/2020] [Indexed: 12/18/2022] Open
Abstract
Background There is little consensus on how to sample hospitalizations and analyze multiple variables to model readmission risk. The purpose of this study was to compare readmission rates and the accuracy of predictive models based on different sampling and multivariable modeling approaches. Methods We conducted a retrospective cohort study of 17,284 adult diabetes patients with 44,203 discharges from an urban academic medical center between 1/1/2004 and 12/31/2012. Models for all-cause 30-day readmission were developed by four strategies: logistic regression using the first discharge per patient (LR-first), logistic regression using all discharges (LR-all), generalized estimating equations (GEE) using all discharges, and cluster-weighted (CWGEE) using all discharges. Multiple sets of models were developed and internally validated across a range of sample sizes. Results The readmission rate was 10.2% among first discharges and 20.3% among all discharges, revealing that sampling only first discharges underestimates a population’s readmission rate. Number of discharges was highly correlated with number of readmissions (r = 0.87, P < 0.001). Accounting for clustering with GEE and CWGEE yielded more conservative estimates of model performance than LR-all. LR-first produced falsely optimistic Brier scores. Model performance was unstable below samples of 6000–8000 discharges and stable in larger samples. GEE and CWGEE performed better in larger samples than in smaller samples. Conclusions Hospital readmission risk models should be based on all discharges as opposed to just the first discharge per patient and utilize methods that account for clustered data. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-020-01162-0.
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Affiliation(s)
- Huaqing Zhao
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA
| | - Samuel Tanner
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA
| | - Sherita H Golden
- Division of Endocrinology, Diabetes, and Metabolism, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine, 1620 McElderry Street, Reed Hall, Room 420, Baltimore, MD, 21287, USA
| | - Susan G Fisher
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA
| | - Daniel J Rubin
- Lewis Katz School of Medicine at Temple University, Section of Endocrinology, Diabetes, and Metabolism, 3322 N. Broad ST., Ste 205, Philadelphia, PA, 19140, USA.
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15
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The Early Impact of the Centers for Medicare & Medicaid Services State Innovation Models Initiative on 30-Day Hospital Readmissions Among Adults With Diabetes. Med Care 2020; 58 Suppl 6 Suppl 1:S22-S30. [PMID: 32412950 DOI: 10.1097/mlr.0000000000001276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services (CMS) State Innovation Models (SIM) Initiative funds states to accelerate delivery system and payment reforms. All SIM states focus on improving diabetes care, but SIM's effect on 30-day readmissions among adults with diabetes remains unclear. METHODS A quasi-experimental research design estimated the impact of SIM on 30-day hospital readmissions among adults with diabetes in 3 round 1 SIM states (N=671,996) and 3 comparison states (N=2,719,603) from 2010 to 2015. Difference-in-differences multivariable logistic regression models that incorporated 4-group propensity score weighting were estimated. Heterogeneity of SIM effects by grantee state and for CMS populations were assessed. RESULTS In adjusted difference-in-difference analyses, SIM was associated with an increase in odds of 30-day hospital readmission among patients in SIM states in the post-SIM versus pre-SIM period relative to the ratio in odds of readmission among patients in the comparison states post-SIM versus pre-SIM (ratio of adjusted odds ratio=1.057, P=0.01). Restricting the analyses to CMS populations (Medicare and Medicaid beneficiaries), resulted in consistent findings (ratio of adjusted odds ratio=1.057, P=0.034). SIM did not have different effects on 30-day readmissions by state. CONCLUSIONS We found no evidence that SIM reduced 30-day readmission rates among adults with diabetes during the first 2 years of round 1 implementation, even among CMS beneficiaries. It may be difficult to reduce readmissions statewide without greater investment in health information exchange and more intensive use of payment models that promote interorganizational coordination.
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16
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Soh JGS, Wong WP, Mukhopadhyay A, Quek SC, Tai BC. Predictors of 30-day unplanned hospital readmission among adult patients with diabetes mellitus: a systematic review with meta-analysis. BMJ Open Diabetes Res Care 2020; 8:8/1/e001227. [PMID: 32784248 PMCID: PMC7418689 DOI: 10.1136/bmjdrc-2020-001227] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023] Open
Abstract
Adult patients with diabetes mellitus (DM) represent one-fifth of all 30-day unplanned hospital readmissions but some may be preventable through continuity of care with better DM self-management. We aim to synthesize evidence concerning the association between 30-day unplanned hospital readmission and patient-related factors, insurance status, treatment and comorbidities in adult patients with DM. We searched full-text English language articles in three electronic databases (MEDLINE, Embase and CINAHL) without confining to a particular publication period or geographical area. Prospective and retrospective cohort and case-control studies which identified significant risk factors of 30-day unplanned hospital readmission were included, while interventional studies were excluded. The study participants were aged ≥18 years with either type 1 or 2 DM. The random effects model was used to quantify the overall effect of each factor. Twenty-three studies published between 1998 and 2018 met the selection criteria and 18 provided information for the meta-analysis. The data were collected within a period ranging from 1 to 15 years. Although patient-related factors such as age, gender and race were identified, comorbidities such as heart failure (OR=1.81, 95% CI 1.67 to 1.96) and renal disease (OR=1.69, 95% CI 1.34 to 2.12), as well as insulin therapy (OR=1.45, 95% CI 1.24 to 1.71) and insurance status (OR=1.41, 95% CI 1.22 to 1.63) were stronger predictors of 30-day unplanned hospital readmission. The findings may be used to target DM self-management education at vulnerable groups based on comorbidities, insurance type, and insulin therapy.
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Affiliation(s)
- Jade Gek Sang Soh
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Health and Social Sciences, Singapore Institute of Technology, Singapore
| | - Wai Pong Wong
- Health and Social Sciences, Singapore Institute of Technology, Singapore
| | - Amartya Mukhopadhyay
- Respiratory and Critical Care Medicine, National University Hospital, Singapore
- National University Singapore, Yong Loo Lin School of Medicine, Singapore
| | - Swee Chye Quek
- Department of Paediatrics, National University Hospital, Singapore
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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17
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Casten R, Rovner B, Chang AM, Hollander JE, Kelley M, Leiby B, Nightingale G, Pizzi L, White N, Rising K. A randomized clinical trial of a collaborative home-based diabetes intervention to reduce emergency department visits and hospitalizations in black individuals with diabetes. Contemp Clin Trials 2020; 95:106069. [PMID: 32561466 DOI: 10.1016/j.cct.2020.106069] [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: 01/09/2020] [Revised: 05/29/2020] [Accepted: 06/12/2020] [Indexed: 01/22/2023]
Abstract
The prevalence of diabetes mellitus (DM) in black individuals (blacks) is twice that of white individuals (whites), and blacks are more likely to have worse glycemic control, less optimal medication regimens, and higher levels of mistrust in the medical system. These three factors account for higher rates of acute medical care use in blacks with DM. To address this disparity, we developed DM I-TEAM (Diabetes Interprofessional Team to Enhance Adherence to Medical Care), a home-based multidisciplinary behavioral intervention that integrates care from a community health worker (CHW), the participant's primary care physician (PCP), a DM nurse educator, and a clinical pharmacist. Treatment is delivered during 9 sessions over 1 year, and includes diabetes education and goal setting, telehealth visits with participants' PCP and a DM nurse educator, and comprehensive medication reviews by a pharmacist. We describe the rationale and methods for a randomized controlled trial to test the efficacy of DM I-TEAM to reduce emergency department (ED) visits and hospitalizations. We are enrolling 200 blacks with DM during an ED visit. Participants are randomized to DM I-TEAM or Usual Medical Care (UMC). Follow-up assessments are conducted at 6 and 12 months. The primary outcome is the number of ED visits and hospitalizations over 12 months, and is measured by participant self-report and medical record review. Secondary outcomes include hemoglobin A1c (HbA1c), number of potentially inappropriate medications (PIMs), and trust in health care.
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Affiliation(s)
- Robin Casten
- Department of Psychiatry and Human Behavior, Sidney Kimmel Medical College at Thomas, Jefferson University, United States of America.
| | - Barry Rovner
- Departments of Neurology, Psychiatry, and Ophthalmology, Sidney Kimmel Medical College at Thomas Jefferson University, United States of America
| | - Anna Marie Chang
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, United States of America
| | - Judd E Hollander
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, United States of America
| | - Megan Kelley
- Department of Neurology, Sidney Kimmel Medical College at Thomas Jefferson University, United States of America
| | - Benjamin Leiby
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College at Thomas Jefferson University, United States of America
| | - Ginah Nightingale
- Jefferson College of Pharmacy at Thomas Jefferson University, United States of America
| | - Laura Pizzi
- Center for Health Outcomes, Policy, and Economics, Ernest Mario School of Pharmacy, Rutgers University, United States of America
| | - Neva White
- Center for Urban Health, Thomas Jefferson University Hospital, United States of America
| | - Kristin Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, United States of America
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18
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Ossai CI, Wickramasinghe N. Intelligent therapeutic decision support for 30 days readmission of diabetic patients with different comorbidities. J Biomed Inform 2020; 107:103486. [PMID: 32561445 DOI: 10.1016/j.jbi.2020.103486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 01/22/2023]
Abstract
The significance of medication therapy in managing comorbid diabetes is vital for maintaining the overall wellness of patients and reducing the cost of healthcare. Thus, using appropriate medication or medication combinations will be necessary for improved person-centred care and reduce complications associated with diagnosis and treatment. This study explains an intelligent decision support framework for managing 30 days unplanned readmission (30_URD) of comorbid diabetes using the Random Forest (RF) algorithm and Bayesian Network (BN) model. After the analysis of the medical records of 101,756 de-identified diabetic patients treated with 21 medications for 28 comorbidity combinations, the optimal medications for minimizing the likelihood of early readmissions were determined. This approach can help for identifying and managing most vulnerable patients thereby giving room to enhance post-discharge monitoring through clinical specialist supports to build critical-self management skills that will minimize the cost of diabetes care.
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Affiliation(s)
- Chinedu I Ossai
- Faculty of Health, Arts and Design, School of Health Sciences, Department of Health and Medical Sciences, Swinburne University, John Street, Hawthorn, Victoria 3122, Australia.
| | - Nilmini Wickramasinghe
- Faculty of Health, Arts and Design, School of Health Sciences, Department of Health and Medical Sciences, Swinburne University, John Street, Hawthorn, Victoria 3122, Australia; Epworth HealthCare, Australia
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19
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Klinge M, Aasbrenn M, Öztürk B, Christiansen CF, Suetta C, Pressel E, Nielsen FE. Readmission of older acutely admitted medical patients after short-term admissions in Denmark: a nationwide cohort study. BMC Geriatr 2020; 20:203. [PMID: 32527311 PMCID: PMC7291666 DOI: 10.1186/s12877-020-01599-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/01/2020] [Indexed: 12/02/2022] Open
Abstract
Background Knowledge of unplanned readmission rates and prognostic factors for readmission among older people after early discharge from emergency departments is sparse. The aims of this study were to examine the unplanned readmission rate among older patients after short-term admission, and to examine risk factors for readmission including demographic factors, comorbidity and admission diagnoses. Methods This cohort study included all medical patients aged ≥65 years acutely admitted to Danish hospitals between 1 January 2013 and 30 June 2014 and surviving a hospital stay of ≤24 h. Data on readmission within 30 days, comorbidity, demographic factors, discharge diagnoses and mortality were obtained from the Danish National Registry of Patients and the Danish Civil Registration System. We examined risk factors for readmission using a multivariable Cox regression to estimate adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for readmission. Results A total of 93,306 patients with a median age of 75 years were acutely admitted and discharged within 24 h, and 18,958 (20.3%; 95% CI 20.1 - 20.6%) were readmitted with a median time to readmission of 8 days (IQR 3 - 16 days). The majority were readmitted with a new diagnosis. Male sex (aHR 1.15; 1.11 - 1.18) and a Charlson Comorbidity Index ≥3 (aHR 2.28; 2.20 - 2.37) were associated with an increased risk of readmission. Discharge diagnoses associated with increased risk of readmission were heart failure (aHR 1.26; 1.12 - 1.41), chronic obstructive pulmonary disease (aHR 1.33; 1.25 - 1.43), dehydration (aHR 1.28; 1.17 - 1.39), constipation (aHR 1.26; 1.14 - 1.39), anemia (aHR 1.45; 1.38 - 1.54), pneumonia (aHR 1.15; 1.06 - 1.25), urinary tract infection (aHR 1.15; 1.07 - 1.24), suspicion of malignancy (aHR 1.51; 1.37 - 1.66), fever (aHR 1.52; 1.33 - 1.73) and abdominal pain (aHR 1.12; 1.05 - 1.19). Conclusions One fifth of acutely admitted medical patients aged ≥65 were readmitted within 30 days after early discharge. Male gender, the burden of comorbidity and several primary discharge diagnoses were risk factors for readmission.
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Affiliation(s)
- M Klinge
- Geriatric Research Unit, Department of Geriatrics, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - M Aasbrenn
- Geriatric Research Unit, Department of Geriatrics, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - B Öztürk
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - C F Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - C Suetta
- Geriatric Research Unit, Department of Geriatrics, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.,Geriatric Research Unit, Department of Medicine, Herlev-Gentofte Hospitals, Copenhagen, Denmark.,CopenAge - Copenhagen Center for Clinical Age Research, University of Copenhagen, Copenhagen, Denmark
| | - E Pressel
- Geriatric Research Unit, Department of Geriatrics, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | - F E Nielsen
- Department of Emergency Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark. .,Department of Emergency Medicine, Slagelse Hospital, Bispebjerg and Frederiksberge, Denmark. .,Copenhagen Center for Translational Research, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.
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20
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Richards BG, Hajduk AM, Perry J, Krumholz HM, Khan AM, Chaudhry SI. Patient-Reported Quality of Hospital Discharge Transitions: Results from the SILVER-AMI Study. J Gen Intern Med 2020; 35:808-814. [PMID: 31654359 PMCID: PMC7080904 DOI: 10.1007/s11606-019-05414-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Transitions from hospital to home in older patients are a high-risk period for adverse outcomes in a population that may have more challenges navigating the healthcare system. There is little information about the association of patient-reported quality of hospital discharge processes with clinical outcomes. OBJECTIVES We evaluated whether patient-reported quality of hospital discharge processes was associated with emergency department utilization and rehospitalization within 30 days of discharge after hospitalization for acute myocardial infarction (AMI) in older adults. DESIGN Multi-center, prospective cohort study. PATIENTS The ComprehenSIVe Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarction (SILVER-AMI) study was a longitudinal study of 3006 adults age 75 and older hospitalized with AMI recruited from 94 academic and community hospitals from across the USA. INTERVENTION N/A MAIN MEASURES: Patients answered a subset of questions from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Readmissions and emergency department utilization within 30 days of discharge were ascertained through medical record review. KEY RESULTS A total of 2132 patients were included in the study. Patients' median age was 81 years and the response rate to the survey of discharge quality was 87%. Patients who reported being asked about having the help they needed at home were significantly less likely to have emergency room utilization within 30 days of discharge in both the unadjusted (0.65, 95% CI 0.43-0.99) and adjusted (0.65, 95% CI 0.42-0.997) models, though there was no significant association with readmission. CONCLUSION Report of an assessment of help needed at home during hospitalization was associated with lower post-discharge emergency department utilization. Efforts to improve outcomes after hospital discharge in older patients may benefit from greater focus on assessing need of help at home.
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Affiliation(s)
- Bradley G Richards
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Alexandra M Hajduk
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Julia Perry
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Ali M Khan
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA.,CareMore Health System, Cerritos, CA, USA.,Department of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Sarwat I Chaudhry
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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21
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Komagamine J, Yabuki T, Kobayashi M. Association between potentially inappropriate medications at discharge and unplanned readmissions among hospitalised elderly patients at a single centre in Japan: a prospective observational study. BMJ Open 2019; 9:e032574. [PMID: 31699748 PMCID: PMC6858212 DOI: 10.1136/bmjopen-2019-032574] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To determine the prevalence of potentially inappropriate medication (PIM) use at admission and discharge among hospitalised elderly patients and evaluate the association between PIMs at discharge and unplanned readmission in Japan. DESIGN A prospective observational study conducted by using electronic medical records. PARTICIPANTS All consecutive patients aged 65 years or older who were admitted to the internal medicine ward were included. Patients who were electively admitted for diagnostic procedures were excluded. MAIN OUTCOME MEASURES The primary outcome was 30-day unplanned readmissions. The secondary outcome was the prevalence of any PIM use at admission and discharge. PIMs were defined based on the Beers Criteria. The association between any PIM use at discharge and the primary outcome was evaluated by using logistic regression. RESULTS Seven hundred thirty-nine eligible patients were included in this study. The median patient age was 82 years (IQR 74-88); 389 (52.6%) were women, and the median Charlson Comorbidity Index was 2 (IQR 0-3). The proportions of patients taking any PIMs at admission and discharge were 47.2% and 32.2%, respectively. Of all the patients, 39 (5.3%) were readmitted within 30 days after discharge for the index hospitalisation. The use of PIMs at discharge was not associated with an increased risk of 30-day readmission (OR 0.93; 95% CI 0.46 to 1.87). This result did not change after adjusting for patient age, sex, number of medications, duration of hospital stay and comorbidities (OR 0.78; 95% CI 0.36 to 1.66). CONCLUSION The prevalence of any PIM use at discharge was high among hospitalised elderly patients in a Japanese hospital. Although the use of PIMs at discharge was not associated with an increased risk of unplanned readmission, given a lack of power of this study due to a low event rate, further studies investigating this association are needed. TRIAL REGISTRATION NUMBER UMIN000027189.
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Affiliation(s)
- Junpei Komagamine
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
| | - Taku Yabuki
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
| | - Masaki Kobayashi
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
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22
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Al-Musawe L, Martins AP, Raposo JF, Torre C. The association between polypharmacy and adverse health consequences in elderly type 2 diabetes mellitus patients; a systematic review and meta-analysis. Diabetes Res Clin Pract 2019; 155:107804. [PMID: 31376400 DOI: 10.1016/j.diabres.2019.107804] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/22/2019] [Accepted: 07/29/2019] [Indexed: 02/08/2023]
Abstract
AIM To summarize the existing literature concerning the association between polypharmacy and adverse health consequences in elderly patients with type 2 diabetes mellitus. METHODS We searched four literature databases (PubMed/Medline, ScienceDirect and Web of Science) through April 2019. We included all studies that addressed the association between polypharmacy and all-cause of mortality, glycemic control, macrovacular complications, hospitalization, potentially inappropriate medicines, drug-drug interactions and fall. A statistical program OpenMeta [Analyst] was used. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with a random effects model. I2 statistics was performed to assess heterogeneity. RESULTS Out of sixteen studies, three studies were used for meta-analysis. A statistically significant association was found between polypharmacy and all-cause mortality (OR = 1.622, 95% CI (1.606-1.637) P < 0.001), and myocardial infarction (OR = 1.962, 95% CI (1.942-1.982), P < 0.001. Non-statistically significant association with evidence of moderate heterogeneity was found between polypharmacy and stroke (OR = 1.335; 95% CI (0.532-3.346), P = 0.538, I2 = 45%), and hospitalization (OR = 1.723; 95% CI (0.983-3.021), P = 0.057, I2 = 57%). CONCLUSIONS Pooled risk estimates reveal that polypharmacy is associated with increased all-cause mortality, macrovacular complications and hospitalization using categorical definitions. These findings assert the need for interventions that optimize the balance of benefits and harms in medicines prescribing.
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Affiliation(s)
- Labib Al-Musawe
- Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal.
| | | | - Joao Filipe Raposo
- Nova Medical School, New University of Lisbon, Lisbon, Portugal; Portuguese Diabetes Association (APDP), Lisbon, Portugal
| | - Carla Torre
- Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
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23
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The Impact of Case Management on Reducing Readmission for Patients Diagnosed With Heart Failure and Diabetes. Prof Case Manag 2019; 24:177-193. [DOI: 10.1097/ncm.0000000000000359] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Robbins TD, Lim Choi Keung SN, Sankar S, Randeva H, Arvanitis TN. Risk factors for readmission of inpatients with diabetes: A systematic review. J Diabetes Complications 2019; 33:398-405. [PMID: 30878296 DOI: 10.1016/j.jdiacomp.2019.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/04/2019] [Accepted: 01/22/2019] [Indexed: 12/16/2022]
Abstract
AIM We have limited understanding of which risk factors contribute to increased readmission rates amongst people discharged from hospital with diabetes. We aim to complete the first review of its kind, to identify, in a systematic way, known risk factors for hospital readmission amongst people with diabetes, in order to better understand this costly complication. METHOD The review was prospectively registered in the PROSPERO database. Risk factors were identified through systematic review of literature in PubMed, EMBASE & SCOPUS databases, performed independently by two authors prior to data extraction, with quality assessment and semi-quantitative synthesis according to PRISMA guidelines. RESULTS Eighty-three studies were selected for inclusion, predominantly from the United States, and utilising retrospective analysis of local or regional data sets. 76 distinct statistically significant risk factors were identified across 48 studies. The most commonly identified risk factors were; co-morbidity burden, age, race and insurance type. Few studies conducted power calculations; unstandardized effect sizes were calculated for the majority of statistically significant risk factors. CONCLUSION This review is important in assessing the current state of the literature and in supporting development of interventions to reduce readmission risk. Furthermore, it provides an important foundation for development of rigorous, pre-specified risk prediction models.
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Affiliation(s)
- Tim D Robbins
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom; Warwickshire Institute for the Study of Diabetes, Endocrinology & Metabolism, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - S N Lim Choi Keung
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - S Sankar
- Warwickshire Institute for the Study of Diabetes, Endocrinology & Metabolism, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom
| | - H Randeva
- Warwickshire Institute for the Study of Diabetes, Endocrinology & Metabolism, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom
| | - T N Arvanitis
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom
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Haltbakk J, Graue M, Harris J, Kirkevold M, Dunning T, Sigurdardottir AK. Integrative review: Patient safety among older people with diabetes in home care services. J Adv Nurs 2019; 75:2449-2460. [PMID: 30835874 DOI: 10.1111/jan.13993] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 11/29/2018] [Accepted: 12/21/2018] [Indexed: 12/01/2022]
Abstract
AIMS To identify diabetes specific patient safety domains that need to be addressed to improve home care of older people; to assess research from primary studies to review evidence on patient safety in home care services for older people with diabetes. DESIGN An integrative review. DATA SOURCES Domains for patient safety in diabetes home care settings were identified by conducting two searches. We performed searches in: CINAHL, Medline, Embase, and Cochrane Library for the years 2000-2017. REVIEW METHODS The first search identified frameworks or models on patient safety in home care services published up to October 2017. The second search identified primary studies about older people with diabetes in the home care setting published between 2000-2017. RESULTS Data from the 21 articles populated and refined 13 predetermined domains of patient safety in diabetes home care. These were used to explore how the domains interact to either increase or reduce risk. The domains constitute a model of associations between aspects of diabetes home care and adverse events. The results highlight a knowledge gap in safety for older persons with diabetes, influenced by e.g. hypoglycaemia, falls, pain, foot ulcers, cognitive impairment, depression, and polypharmacy. Moreover, providers' inadequate diabetes-specific knowledge and assessment skills contribute to the risk of adverse events. CONCLUSION Older persons with diabetes in home care are at risk of adverse events due to their reduced ability to self-manage their condition, adverse medication effects, the family's ability to take responsibility or home care service's suboptimal approaches to diabetes care.
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Affiliation(s)
- Johannes Haltbakk
- Department of Health- and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Marit Graue
- Department of Health- and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Centre for Evidence Based Practice, Western Norway University of Applied Sciences, Bergen, Norway
| | - Janet Harris
- MPH in International Health Management & Leadership, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marit Kirkevold
- Centre for Evidence Based Practice, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Nursing Science, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Trisha Dunning
- Centre for Quality and Patient Safety Research, Deakin University and Barwon Health Partnership, Geelong, Melbourne, Australia
| | - Arun K Sigurdardottir
- School of Health Sciences, University of Akureyri, Akureyri, Iceland.,Akureyri Hospital, Akureyri, Iceland
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Improving Care Transitions for Hospitalized Veterans Discharged to Skilled Nursing Facilities: A Focus on Polypharmacy and Geriatric Syndromes. Geriatrics (Basel) 2019; 4:geriatrics4010019. [PMID: 31023987 PMCID: PMC6473365 DOI: 10.3390/geriatrics4010019] [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: 12/30/2018] [Revised: 01/31/2019] [Accepted: 02/05/2019] [Indexed: 11/17/2022] Open
Abstract
Geriatric syndromes and polypharmacy are common in older patients discharged to skilled nursing facilities (SNFs) and increase 30-day readmission risk. In a U.S.A. Department of Veterans Affairs (VA)-funded Quality Improvement study to improve care transitions from the VA hospital to area SNFs, Veterans (N = 134) were assessed for geriatric syndromes using standardized instruments as well as polypharmacy, defined as five or more medications. Warm handoffs were used to facilitate the transfer of this information. This paper describes the prevalence of geriatric syndromes, polypharmacy, and readmission rates. Veterans were prescribed an average of 14.7 medications at hospital discharge. Moreover, 75% of Veterans had more than two geriatric syndromes, some of which began during hospitalization. While this effort did not reduce 30-day readmissions, the high prevalence of geriatric syndromes and polypharmacy suggests that future efforts targeting these issues may be necessary to reduce readmissions among Veterans discharged to SNF.
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Abstract
An estimated 30.2 million Americans have diabetes, and this number is expected to increase based on trends over recent decades and compounded by an aging U.S. POPULATION As reviewed in this article, type 2 diabetes mellitus (T2DM) is associated with impaired health-related quality of life (HRQoL) and with a substantial socioeconomic burden. Compared with individuals without T2DM, those with T2DM have worse HRQoL, greater decrements in HRQoL over time, and possibly greater depressive symptomology. Diabetes-related complications and comorbidities (e.g., obesity and cardiovascular disease) are associated with worse HRQoL. Hypoglycemic episodes are associated with reduced HRQoL and greater levels of depression; they can also interfere with social and occupational activities. In turn, low HRQoL can be a driver for poor glycemic control. In 2012, the total estimated cost associated with diagnosed diabetes in the United States was $245 billion. Factors contributing to increased health care resource utilization and costs in patients with T2DM include medical comorbidities, diabetes-related complications, inadequate glycemic control, and hypoglycemic episodes. Readmission is a key driver of hospital-related costs and is more common among elderly patients with T2DM. Elderly patients with T2DM represent a particularly vulnerable population given that these patients may have varying degrees of physical and mental comorbidities that can increase their risk of hypoglycemia, falls, and depression. This review demonstrates that T2DM imposes a considerable burden on both the individual and society. Treatment strategies should consider the effects of treatment on HRQoL and on outcomes (e.g., complications and hypoglycemia) that affect both HRQoL and costs. Management strategies that maximize HRQoL while minimizing the risk of hypoglycemia and other treatment-related complications are particularly critical in the elderly. DISCLOSURES This supplement was funded by Novo Nordisk. Cannon reports speaker fees and owns stock in Novo Nordisk. Handelsman reports research grants from Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Grifols, Janssen, Lexicon, Merck, Novo Nordisk, Regeneron, and Sanofi; speaker fees from Amarin, Amgen, AstraZeneca, Boehringer Ingelheim-Lilly, Janssen, Merck, Novo Nordisk, Regeneron, and Sanofi; and has served in advisory capacity to Amarin, Amgen, AstraZeneca, Boehringer Ingelheim, Eisai, Intarcia, Janssen, Lilly, Merck, Merck-Pfizer, Novo Nordisk, Regeneron, and Sanofi. Heile reports speaker fees from and has served as advisor to Novo Nordisk. Shannon reports consultant and speaker fees from Novo Nordisk and Boehringer Ingelheim-Lilly Alliance.
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28
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Karunakaran A, Zhao H, Rubin DJ. Predischarge and Postdischarge Risk Factors for Hospital Readmission Among Patients With Diabetes. Med Care 2018; 56:634-642. [PMID: 29750681 PMCID: PMC6082658 DOI: 10.1097/mlr.0000000000000931] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospital readmission within 30 days of discharge (30-d readmission) is an undesirable outcome. Readmission of patients with diabetes is common and costly. Most of the studies that have examined readmission risk factors among diabetes patients did not include potentially important clinical data. OBJECTIVES To provide a more comprehensive understanding of 30-day readmission risk factors among patients with diabetes based on predischarge and postdischarge data. RESEARCH DESIGN In this retrospective cohort study, 48 variables were evaluated for association with readmission by multivariable logistic regression. SUBJECTS In total, 17,284 adult diabetes patients with 44,203 hospital discharges from an urban academic medical center between January 1, 2004 and December 1, 2012. MEASURES The outcome was all-cause 30-day readmission. Model performance was assessed by c-statistic. RESULTS The 30-day readmission rate was 20.4%, and the median time to readmission was 11 days. A total of 27 factors were statistically significant and independently associated with 30-day readmission (P<0.05). The c-statistic was 0.82. The strongest risk factors were lack of a postdischarge outpatient visit within 30 days, hospital length-of-stay, prior discharge within 90 days, discharge against medical advice, sociodemographics, comorbidities, and admission laboratory values. A diagnosis of hypertension, preadmission sulfonylurea use, admission to an intensive care unit, sex, and age were not associated with readmission in univariate analysis. CONCLUSIONS There are numerous risk factors for 30-day readmission among patients with diabetes. Postdischarge factors add to the predictive accuracy achieved by predischarge factors. A better understanding of readmission risk may ultimately lead to lowering that risk.
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Affiliation(s)
- Abhijana Karunakaran
- Lewis Katz School of Medicine at Temple University, Section of Endocrinology, Diabetes, and Metabolism
| | - Huaqing Zhao
- Department of Clinical Sciences, Temple Clinical Research Institute, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Daniel J Rubin
- Lewis Katz School of Medicine at Temple University, Section of Endocrinology, Diabetes, and Metabolism
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29
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Bloomgarden Z, Handelsman Y. Transition from hospital to outpatient diabetes care. J Diabetes 2018; 10:538-540. [PMID: 29655199 DOI: 10.1111/1753-0407.12664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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30
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Whitehouse CR, Sharts-Hopko NC, Smeltzer SC, Horowitz DA. Supporting Transitions in Care for Older Adults With Type 2 Diabetes Mellitus and Obesity. Res Gerontol Nurs 2018; 11:71-81. [PMID: 29498747 PMCID: PMC6026545 DOI: 10.3928/19404921-20180223-02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/15/2018] [Indexed: 01/08/2023]
Abstract
The aim of the current study was to compare outcomes for older adults with type 2 diabetes mellitus and obesity following participation in a transitional care intervention that included diabetes self-management education (DSME) and homecare. The three groups analyzed comprised an inpatient DSME plus homecare group (n = 35); an inpatient DSME only group (n = 100); and a group who received usual care (n = 45). Outcomes of interest included rehospitalization rates and hemoglobin A1C (A1C) for up to 1-year post hospital discharge. Rates of rehospitalization and A1C improved for older adults who received nurse-led inpatient DSME and homecare during transitions of care from hospital to home. Rehospitalization rates up to 90 days were decreased for the DSME plus homecare group (10%) compared to DSME only (20%) and usual care groups (26.7%) (p < 0.05). A decrease of -0.4 and -2.3 A1C units was observed for the DSME group and DSME plus homecare group, respectively, at 90 days. These results support a transitional care educational intervention for older adults with type 2 diabetes mellitus and obesity. TARGETS Older adults with type 2 diabetes mellitus and obesity. INTERVENTION DESCRIPTION Transitional care intervention including diabetes self-management education and homecare. MECHANISMS OF ACTION Inpatient diabetes education and homecare helps improve rates of rehospitalization and hemoglobin A1C during care transitions from hospital to home. OUTCOMES Rehospitalization rates, glycemic control (i.e., A1C level). [Res Gerontol Nurs. 2018; 11(2):71-81.].
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McCoy RG, Lipska KJ, Herrin J, Jeffery MM, Krumholz HM, Shah ND. Hospital Readmissions among Commercially Insured and Medicare Advantage Beneficiaries with Diabetes and the Impact of Severe Hypoglycemic and Hyperglycemic Events. J Gen Intern Med 2017; 32:1097-1105. [PMID: 28685482 PMCID: PMC5602759 DOI: 10.1007/s11606-017-4095-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/19/2017] [Accepted: 05/31/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hospital readmission is common among patients with diabetes. Some readmissions, particularly for hypoglycemia and hyperglycemia, may be avoidable with better care transitions and post-discharge management. OBJECTIVE To ascertain the most common reasons and risk factors for readmission among adults with diabetes, with specific consideration of severe dysglycemia. DESIGN Retrospective analysis of data from the OptumLabs Data Warehouse, an administrative data set of commercially insured and Medicare Advantage beneficiaries across the U.S. PARTICIPANTS Adults ≥18 years of age with diabetes, discharged from a hospital between January 1, 2009, and December 31, 2014 (N = 342,186). MAIN MEASURES Principal diagnoses and risk factors for 30-day unplanned readmissions, subset as being for severe dysglycemia vs. all other causes. KEY RESULTS We analyzed 594,146 index hospitalizations among adults with diabetes: mean age 68.2 years (SD, 13.0), 52.9% female, and 67.8% white. The all-cause 30-day readmission rate was 10.8%. Heart failure was the most common cause for index hospitalization (5.5%) and readmission (8.9%). Severe dysglycemia accounted for 2.6% of index hospitalizations (48.1% hyperglycemia, 50.4% hypoglycemia, 1.5% unspecified) and 2.5% of readmissions (38.3% hyperglycemia, 61.0% hypoglycemia, 0.7% unspecified). Younger patient age, severe dysglycemia at index or prior hospitalization, and the Diabetes Complications Severity Index (DCSI) were the strongest risk factors predisposing patients to severe dysglycemia vs. other readmissions. Prior episodes of severe dysglycemia and the DCSI were also independent risk factors for other-cause readmissions, irrespective of the cause of the index hospitalization. CONCLUSIONS Adults with diabetes are hospitalized and readmitted for a wide range of health conditions, and hospitalizations for severe hypoglycemia and hyperglycemia remain common, with high rates of recurrence. Severe dysglycemia is most likely to occur among younger patients with multiple diabetes complications and prior history of such events.
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Affiliation(s)
- Rozalina G McCoy
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA.
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA.
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, 55905, USA.
| | - Kasia J Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06520, USA
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06520, USA
- Health Research and Educational Trust, Chicago, IL, 60606, USA
| | - Molly M Jeffery
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, 55905, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06520, USA
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06520, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, 06520, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, 06520, USA
| | - Nilay D Shah
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, 55905, USA
- OptumLabs, Cambridge, MA, 02142, USA
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32
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Collins J, Abbass IM, Harvey R, Suehs B, Uribe C, Bouchard J, Prewitt T, DeLuzio T, Allen E. Predictors of all-cause 30 day readmission among Medicare patients with type 2 diabetes. Curr Med Res Opin 2017; 33:1517-1523. [PMID: 28498094 DOI: 10.1080/03007995.2017.1330258] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Readmission is costly among patients with type 2 diabetes (T2DM) in Medicare Advantage Prescription Drug Plans; identifying high-risk patients is necessary for targeting reduction programs. The objective of this study was to develop a claims-based algorithm to predict all-cause 30 day readmission among patients with T2DM. METHODS This study used administrative data from 1 January 2012 through 31 January 2014. The cohort included hospitalized T2DM patients, aged 18-90 with ≥12 months' continuous enrollment before an unplanned hospital admission and ≥1 month of enrollment post-discharge, excluding patients in long-term care >30 days pre-index. Multivariate logistic regression predicted the likelihood of readmission following hospitalization in 2013. The analytic file was randomly split into training and test datasets to build and validate the model. Candidate variables included physician and patient demographics, baseline clinical conditions, and healthcare utilization metrics. Clinical conditions were classified using the Healthcare Cost and Utilization Project clinical classification system for ICD-9-CM. RESULTS Of 63,237 individuals, 17.1% experienced a readmission. Of nearly 200 candidate variables, 14 were predictors of readmission, including total cumulative number of days for inpatient stays and the number of emergency department visits in the baseline period. Male gender, older age, and certain comorbidities were associated with higher likelihood of readmission. The final model demonstrated good discriminant ability (c-statistic = 0.82). CONCLUSIONS This study provided evidence that certain patient characteristics and healthcare utilization are predictive of readmission. An algorithm with good discriminant ability was developed which could be used to target readmission reduction programs. Physician gender, specialty, and ownership status did not appear to influence the likelihood of readmission.
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Affiliation(s)
- Jenna Collins
- a Humana Comprehensive Health Insights Inc. , Louisville , KY , USA
| | - Ibrahim M Abbass
- a Humana Comprehensive Health Insights Inc. , Louisville , KY , USA
| | - Raymond Harvey
- a Humana Comprehensive Health Insights Inc. , Louisville , KY , USA
| | - Brandon Suehs
- a Humana Comprehensive Health Insights Inc. , Louisville , KY , USA
| | - Claudia Uribe
- a Humana Comprehensive Health Insights Inc. , Louisville , KY , USA
| | | | | | - Tony DeLuzio
- b Novo Nordisk Pharmaceuticals Inc. , Plainsboro , NJ , USA
| | - Elsie Allen
- b Novo Nordisk Pharmaceuticals Inc. , Plainsboro , NJ , USA
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Morath B, Mayer T, Send AFJ, Hoppe-Tichy T, Haefeli WE, Seidling HM. Risk factors of adverse health outcomes after hospital discharge modifiable by clinical pharmacist interventions: a review with a systematic approach. Br J Clin Pharmacol 2017; 83:2163-2178. [PMID: 28452063 DOI: 10.1111/bcp.13318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 12/19/2022] Open
Abstract
The present review assessed the evidence on risk factors for the occurrence of adverse health outcomes after discharge (i.e. unplanned readmission or adverse drug event after discharge) that are potentially modifiable by clinical pharmacist interventions. The findings were compared with patient characteristics reported in guidelines that supposedly indicate a high risk of drug-related problems. First, guidelines and risk assessment tools were searched for patient characteristics indicating a high risk of drug-related problems. Second, a systematic PubMed search was conducted to identify risk factors significantly associated with adverse health outcomes after discharge that are potentially modifiable by a clinical pharmacist intervention. After the PubMed search, 37 studies were included, reporting 16 risk factors. Only seven of 34 patient characteristics mentioned in pertinent guidelines corresponded to one of these risk factors. Diabetes mellitus (n = 11), chronic obstructive lung disease (n = 9), obesity (n = 7), smoking (n = 5) and polypharmacy (n = 5) were the risk factors reported most frequently in the studies. Additionally, single studies also found associations of adverse health outcomes with different drug classes {e.g. warfarin [hazard ratio 1.50; odds ratio (OR) 3.52], furosemide [OR 2.25] or high beta-blocker starting doses [OR 3.10]}. Although several modifiable risk factors were found, many patient characteristics supposedly indicating a high risk of drug-related problems were not part of the assessed risk factors in the context of an increased risk of adverse health outcomes after discharge. Therefore, an obligatory set of modifiable patient characteristics should be created and implemented in future studies investigating the risk for adverse health outcomes after discharge.
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Affiliation(s)
- Benedict Morath
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Hospital Pharmacy, Heidelberg University, Im Neuenheimer Feld 670, 69120, Heidelberg, Germany
| | - Tanja Mayer
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Alexander Francesco Josef Send
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Torsten Hoppe-Tichy
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Hospital Pharmacy, Heidelberg University, Im Neuenheimer Feld 670, 69120, Heidelberg, Germany
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Hanna Marita Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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Enomoto LM, Shrestha DP, Rosenthal MB, Hollenbeak CS, Gabbay RA. Risk factors associated with 30-day readmission and length of stay in patients with type 2 diabetes. J Diabetes Complications 2017; 31:122-127. [PMID: 27838101 DOI: 10.1016/j.jdiacomp.2016.10.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 10/14/2016] [Accepted: 10/17/2016] [Indexed: 01/16/2023]
Abstract
AIMS Patients with type 2 diabetes mellitus (type 2 DM) are at greater risk of poor hospital outcomes. The purpose of this study was to determine the impact of type 2 DM on 30-day hospital readmission and length of stay (LOS). METHODS We studied all inpatient admissions in Pennsylvania during 2011 using data from the Pennsylvania Health Care Cost Containment Council. Outcomes included 30-day readmission and inpatient LOS. We estimated the impact of type 2 DM on readmission and LOS, and identified risk factors for readmission and prolonged LOS. RESULTS Among inpatient admissions, patients with diabetes were more likely to be readmitted (AOR=1.17, P<0.001) and have longer LOS (0.19days, P<0.001) compared to patients without diabetes. Among those with diabetes, several factors were associated with readmission, including demographics, source of admission, and comorbidities. Patients with diabetes were more likely to be readmitted for infectious complications (9.4% vs. 7.7%), heart failure (6.0% vs. 3.1%), and chest pain/MI (5.5% vs. 3.3%) than patients without diabetes. CONCLUSIONS Diabetes is associated with risk of 30-day readmission and LOS, and several patient-specific factors are associated with outcomes for patients with diabetes. Future studies may target risk factors to develop strategies to reduce readmissions and LOS.
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Affiliation(s)
- Laura M Enomoto
- The Pennsylvania State University, College of Medicine, Department of Medicine, 500 University Drive, Hershey, PA 17033, USA.
| | - Deepika P Shrestha
- The Pennsylvania State University, College of Medicine, Department of Medicine, 500 University Drive, Hershey, PA 17033, USA.
| | - Meredith B Rosenthal
- Harvard School of Public Health, Health Policy and Management, 677 Huntington Avenue, Boston, MA 02115, USA.
| | - Christopher S Hollenbeak
- The Pennsylvania State University, College of Medicine, Department of Medicine, 500 University Drive, Hershey, PA 17033, USA.
| | - Robert A Gabbay
- Joslin Diabetes Center, One Joslin Place, Boston, MA 02215, USA.
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