Age trends in 30 day hospital readmissions: US national retrospective analysis

The burden and predictors of 30-day unplanned readmission in patients with acute liver failure: a national representative database study

BACKGROUND

Liver diseases were significant source of early readmission burden. This study aimed to evaluate the 30-day unplanned readmission rates, causes of readmissions, readmission costs, and predictors of readmission in patients with acute liver failure (ALF).

METHODS

Patients admitted for ALF from 2019 National Readmission Database were enrolled. Weighted multivariable logistic regression models were applied and based on Directed Acyclic Graphs. Incidence, causes, cost, and predictors of 30-day unplanned readmissions were identified.

RESULTS

A total of 3,281 patients with ALF were enrolled, of whom 600 (18.3%) were readmitted within 30 days. The mean time from discharge to early readmission was 12.6 days. The average hospital cost and charge of readmission were $19,629 and $86,228, respectively. The readmissions were mainly due to liver-related events (26.6%), followed by infection (20.9%). The predictive factors independently associated with readmissions were age, male sex (OR 1.227, 95% CI 1.023-1.472; P = 0.028), renal failure (OR 1.401, 95% CI 1.139-1.723; P = 0.001), diabetes with chronic complications (OR 1.327, 95% CI 1.053-1.672; P = 0.017), complicated hypertension (OR 1.436, 95% CI 1.111-1.857; P = 0.006), peritoneal drainage (OR 1.600, 95% CI 1.092-2.345; P = 0.016), etc. CONCLUSIONS: Patients with ALF are at relatively high risk of early readmission, which imposes a heavy medical and economic burden on society. We need to increase the emphasis placed on early readmission of patients with ALF and establish clinical strategies for their management.

Quantitative Analysis of Characteristics Associated with Patient-Directed Discharges, Representations, and Readmissions: a Safety-Net Hospital Experience

BACKGROUND

No clinical tools currently exist to stratify patients' risks of patient-directed discharge (PDD).

OBJECTIVE

This study aims to identify trends and factors associated with PDD, representation, and readmission.

DESIGN

This was an IRB-approved, single-centered, retrospective study.

PARTICIPANTS

Patients aged > 18, admitted to medicine service, were included from January 1st through December 31st, 2019. Patients admitted to ICU or surgical services were excluded.

MAIN MEASURES

Demographics, insurance information, medical history, social history, rates of events occurrences, and discharge disposition were obtained.

KEY RESULTS

Of the 16,889 encounters, there were 776 (4.6%) PDDs, 4312 (25.5%) representations, and 2924 (17.3%) readmissions. Of those who completed PDDs, 42.1% represented and 26.4% were readmitted. Male sex, age ≤ 45, insurance type, homelessness, and substance use disorders had higher rates of PDD (OR = 2.0; 4.2; 4.5; 6.2; 5.2; p < 0.0001, respectively). Patients with homelessness, substance use disorders, mental health disorders, or prior history of PDD were more likely to represent (OR = 3.6; 2.0; 2.0; 1.5; p < 0.0001, respectively) and be readmitted (OR = 2.2; 1.6; 1.9; 1.5; p < 0.0001, respectively). Patients aged 30-35 had the highest PDD rate at 16%, but this was not associated with representations or readmissions. Between July and September, the PDD rate peaked at 5.5% and similarly representation and readmission rates followed. The rates of subsequent readmissions after PDDs were nearly two-fold compared to non-PDD patients in later half of the year. 51% of all subsequent readmissions occur within 7 days of PDD, compared to 34% in the non-PDD group (OR = 2.0; p < 0.0001). Patients with primary diagnosis of abscess had 16% PDDs.

CONCLUSIONS

Factors associated with PDD include male, younger age, insurance type, substance use, homelessness, and primary diagnosis of abscess. Factors associated with representation and readmission are homelessness, substance use disorders, mental health disorders, and prior history of PDD. Further research is needed to develop a risk stratification tool to identify at-risk patients.

Improvement of scoring system used before discharge to predict 30-day all-cause unplanned readmission in geriatric population: a prospective cohort study

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.

Burden of chickenpox complications in Poland, 2006 to 2021: A comprehensive registry-based study

BackgroundChickenpox, a vaccine-preventable disease caused by the varicella zoster virus, generally presents with mild symptoms but can cause complications necessitating hospitalisation. In Poland, since 2009, vaccination has been obligatory for children up to 12 years of age who are particularly vulnerable to infection and for children in their vicinity.AimTo examine the burden of chickenpox complications and the trends of hospitalisation arising from these complications over time in the Polish population.MethodsData spanning 2006-21 were sourced from the Polish Infectious Diseases Surveillance System, the Nationwide General Hospital Morbidity Study and the Statistics Poland death registry. Standardised and age-specific incidence rates, hospital discharge rates and number of deaths because of chickenpox were calculated. Moreover, the joinpoint regression model was used to analyse trends of annual hospital discharge rates.ResultsOver the analysed timeframe, 25,804 hospitalisations and 52 deaths attributable to chickenpox complications were documented, and 1.0% of chickenpox cases required hospitalisation because of chickenpox. Age-standardised hospitalisation rates varied between 2.3 and 9.6 per 100,000 population. The analysis revealed no statistically significant trend in overall hospital discharge rates from chickenpox complications. However, a notable increase in hospitalisation rates was observed in children aged 0-4 and among inhabitants of rural areas, with annual percentage changes of 4.9% and 3.4% respectively.ConclusionsOur findings suggest that the implementation of a universal chickenpox immunisation programme, supported by health education, should be considered to reduce the number of hospitalisations and nearly eliminate deaths because of chickenpox.

Impact of a hospital service for adults with chronic childhood-onset disease: A propensity weighted analysis

BACKGROUND

Young adults with chronic childhood-onset diseases (CCOD) transitioning care from pediatrics to adult care are at high risk for readmission after hospital discharge. At our institution, we have implemented an inpatient service, the Med-Peds (MP) line, to improve transitions to adult care and reduce hospital utilization by young adults with CCOD.

OBJECTIVE

This study aimed to assess the effect of the MP line on length of stay (LOS) and 30-day readmission rates compared to other inpatient services.

METHODS

This was an observational, retrospective cohort analysis of patients admitted to the MP line compared to other hospital service lines over a 2-year period. To avoid potential confounding by indication for admission to the MP line, propensity score weighting methods were used.

RESULTS

The MP line cared for 302 patients with CCOD from June 2019 to July 2021. Compared to other service lines, there was a 33% reduction in relative risk of 30-day readmission (26.9% compared to 40.3%, risk ratio = 0.67, 95% confidence interval [CI] 0.55-0.81). LOS was 10% longer for the MP line (event time ratio (ETR): 1.10 95% CI 1.0-1.21) with median LOS 4.8 versus 4.5 days. Patients with sickle cell disease had less of a reduction in 30-day readmissions and longer LOS.

CONCLUSION

Hospitalization for young adults with CCOD on a MP service line was associated with lower 30-day readmission rates and longer LOS than hospitalization on other services. Further research is needed to assess which components of the line most contribute to decreased utilization.

Intensive Case Management to Reduce Hospital Readmissions: A Pilot Quality Improvement Project

PURPOSE OF STUDY

Hospital readmissions burden the U.S. health care system, and they have negative effects on patients and their families. The primary aim of this study was to pilot an intensive case management (ICM) intervention to reduce 30-day hospital readmissions. A secondary aim was to obtain patient- and caregiver-reported reasons for readmission.

PRIMARY PRACTICE SETTING

The setting was a vertically integrated health care system located in Northern California.

METHODOLOGY AND SAMPLE

This pilot quality improvement project occurred over a 4-month period. The intervention was delivered by master's degree students in nurse case management through an academic-clinical partnership. Patients hospitalized with a 30-day readmission were offered the ICM intervention. A total of 36 patients were identified and 20 accepted. Patient and/or caregiver was interviewed to identify reasons for their readmission. Data were collected about pre-/post-health care utilization including subsequent 30-day readmission. Mixed methods were used to analyze the findings.

RESULTS

Thirteen of 20 enrolled patients received the weekly ICM intervention for at least 30 days. Seven declined further contact before 30 days. Patient-reported reasons for readmission included being discharged too soon, poor communication among providers and with patients/families, lack of understanding about disease management and/or treatment options, and inadequate support. Several patients believed that their readmission was unavoidable due to the complexity of their illnesses. We compared 30-day readmissions for those who participated in and those who declined the ICM intervention, finding that those who received the ICM intervention had a lower readmission rate than those who did not receive the intervention (35% vs. 37.5%).

Obesity Metabolic Phenotypes and Unplanned Readmission Risk in Diabetic Kidney Disease: An Observational Study from the Nationwide Readmission Database

BACKGROUND AND AIM

Obesity is a potentially modifiable factor for reducing readmissions, with heterogeneity that varies according to the metabolic status. Our objective was to examine the independent or mutual relationship between obesity and metabolic abnormalities and diabetic kidney disease (DKD)-related hospitalizations.

METHODS

493,570 subjects with DKD were enrolled in the 2018 Nationwide Readmission Database (NRD, United States). The at-risk population was reclassified into refined obesity subtypes based on the body mass index (BMI) classification of metabolic abnormalities (hypertension and/or dyslipidemia) to investigate the 180 d readmission risk and hospitalization costs related to DKD.

RESULTS

The overall readmission rate was 34.1%. Patients with metabolic abnormalities, regardless of obesity, had a significantly higher risk of readmission compared to non-obese counterparts (adjusted HR, 1.11 [95% CI, 1.07-1.14]; 1.12 [95% CI, 1.08-1.15]). Hypertension appeared to be the only metabolic factor associated with readmission among individuals with DKD. Obesity without metabolic abnormalities was independently associated with readmission (adjusted HR,1.08 [1.01,1.14]), especially among males and those >65 years (adjusted HR,1.10 [1.01-1.21]; 1.20 [1.10-1.31]). Women or those ≤65 years with metabolic abnormalities (all p <0.050) had elevated readmission rates, regardless of obesity; however, no such trend was observed in obese subjects without metabolic abnormalities (adjusted HR, 1.06 [0.98,1.16]). Additionally, obesity and metabolic abnormalities were associated with elevated hospitalization costs (all p <0.0001).

CONCLUSIONS

Increased BMI and hypertension are positively associated with readmissions and related costs among patients with DKD, which should be considered in future studies.

Associations between source-apportioned PM2.5 and 30-day readmissions in heart failure patients

BACKGROUND

Air pollution exposure is a significant risk factor for morbidity and mortality, especially for those with pre-existing chronic disease. Previous studies highlighted the risks that long-term particulate matter exposure has for readmissions. However, few studies have evaluated source and component specific associations particularly among vulnerable patient populations.

OBJECTIVES

Use electronic health records from 5556 heart failure (HF) patients diagnosed between July 5, 2004 and December 31, 2010 that were part of the EPA CARES resource in conjunction with modeled source-specific fine particulate matter (PM2.5) to estimate the association between exposure to source and component apportioned PM2.5 at the time of HF diagnosis and 30-day readmissions.

METHODS

We used zero-inflated mixed effects Poisson models with a random intercept for zip code to model associations while adjusting for age at diagnosis, year of diagnosis, race, sex, smoking status, and neighborhood socioeconomic status. We undertook several sensitivity analyses to explore the impact of geocoding precision and other factors on associations and expressed associations per interquartile range increase in exposures.

RESULTS

We observed associations between 30-day readmissions and an interquartile range increase in gasoline- (16.9% increase; 95% confidence interval = 4.8%, 30.4%) and diesel-derived PM2.5 (9.9% increase; 95% confidence interval = 1.7%, 18.7%), and the secondary organic carbon component of PM2.5 (SOC; 20.4% increase; 95% confidence interval = 8.3%, 33.9%). Associations were stable in sensitivity analyses, and most consistently observed among Black study participants, those in lower income areas, and those diagnosed with HF at an earlier age. Concentration-response curves indicated a linear association for diesel and SOC. While there was some non-linearity in the gasoline concentration-response curve, only the linear component was associated with 30-day readmissions.

DISCUSSION

There appear to be source specific associations between PM2.5 and 30-day readmissions particularly for traffic-related sources, potentially indicating unique toxicity of some sources for readmission risks that should be further explored.

Predictors of readmission in a medical department of a tertiary university hospital in the Philippines

BACKGROUND

Identifying factors that increase the risk for hospital readmission helps in determining potential targets for quality improvement efforts. The main objective of this study was to examine factors that predict increased risk of hospital readmission within 30 days of hospital discharge of patients under the General Medicine service of a tertiary government hospital in Manila, Philippines.

METHODS

We performed a retrospective cohort study which included service patients 19 years old and above readmitted within 30 days following discharge. A total of 324 hospital readmissions within 30 days of discharge from January 1 to December 31, 2019 were reviewed. We estimated the rate of 30-day readmission and identified factors associated with preventable readmissions using multivariable logistic regression.

RESULTS

Of the 4,010 hospitalizations under General Medicine service in 2019, 602 (18%) were readmissions within 30 days of discharge, majority of which were related to the index admission (90%) and unplanned (68%). Predictors of preventable readmission were emergency readmission (OR 3.37, 95% CI 1.72 to 6.60), having five to ten medications at discharge (OR 1.78, 95% CI 1.10 to 2.87), and presence of nosocomial infection (OR 1.86, 95% CI 1.09 to 3.17). The most frequent reason for readmission among preventable ones is health-care related infection (42.9%).

CONCLUSIONS

We identified factors which increased the likelihood of preventable readmissions such as type of readmission, number of medications per day, and presence of nosocomial infections. We propose that these issues be addressed to improve healthcare delivery and reduce readmission-related expenditures. Further studies should be pursued to identify impactful evidence-based practices.

Association of Hospital Readmission Rates With Discharge Disposition for Patients With Psychotic Disorders

GOAL

We explored how readmissions may result from patients' lack of access to aftercare services, failure to adhere to psychotropic medication plans, and inability to understand and follow hospital discharge recommendations. We also investigated whether insurance status, demographics, and socioeconomic status are associated with hospital readmissions. This study is important because readmissions contribute to increased personal and hospital expenses and decreased community tenure (the ability to maintain stability between hospital admissions). Addressing hospital readmissions will promote optimal discharge practices beginning on day one of hospital admission.

METHODS

The study examined the differences in hospital readmission rates for patients with a primary psychotic disorder diagnosis. Discharge data were drawn in 2017 from the Nationwide Readmissions Database. Inclusion criteria included patients aged 0-89 years who were readmitted to a hospital between less than 24 hr and up to 30 days from discharge. Exclusion criteria were principal medical diagnoses, unplanned 30-day readmissions, and discharges against medical advice. The sampling frame included 269,906 weighted number of patients diagnosed with a psychotic disorder treated at one of 2,355 U.S. community hospitals. The sample size was 148,529 unweighted numbers of patients discharged.

PRINCIPAL FINDINGS

In a logistic regression model, weighted variables were calculated and used to determine an association between the discharge dispositions and readmissions. After controlling for hospital characteristics and patient demographics, we found that the odds for readmission for routine and short-term hospital discharge dispositions decreased for home health care discharges, which indicated that home health care can prevent readmissions. The finding was statistically significant when controlling for payer type and patient age and gender.

PRACTICAL APPLICATIONS

The findings support home health care as an effective option for patients with severe psychosis. Home health care reduces readmissions and is recommended, when appropriate, as an aftercare service following inpatient hospitalization and may enhance the quality of patient care. Improving healthcare quality involves optimizing, streamlining, and promoting standardized processes in discharge planning and direct transitions to aftercare services.

The Impact of Potentially Inappropriate Medications and Polypharmacy on 3-Month Hospital Readmission among Older Patients: A Retrospective Cohort Study from Malaysia

INTRODUCTION

Potentially inappropriate medications (PIMs) use and polypharmacy are two issues that are commonly encountered among older people. They are associated with several negative outcomes including adverse drug reactions and medication-related hospitalization. There are insufficient studies regarding the impact of both PIMs and polypharmacy on hospital readmission, especially in Malaysia.

AIM

To investigate the possible association between polypharmacy and prescribing PIMs at discharge and 3-month hospital readmission among older patients.

MATERIALS AND METHOD

A retrospective cohort study involved 600 patients ≥60 years discharged from the general medical wards in a Malaysian teaching hospital. The patients were divided into two equal groups: patients with or without PIMs. The main outcome was any readmission during the 3-month follow-up. The discharged medications were assessed for polypharmacy (≥five medications) and PIMs (using 2019 Beers' criteria). Chi-square test, Mann-Whitney test, and a multiple logistic regression were conducted to study the impact of PIMs/polypharmacy on 3-month hospital readmission.

RESULTS

The median number for discharge medications were six and five for PIMs and non-PIMs patients, respectively. The most frequently prescribed PIMs was aspirin as primary prevention of cardiovascular diseases (33.43%) followed by tramadol (13.25%). The number of medications at discharge and polypharmacy status were significantly associated with PIMs use. Overall, 152 (25.3%) patients were re-admitted. Polypharmacy and PIMs at discharge did not significantly impact the hospital readmission. After applying the logistic regression, only male gender was a predictor for 3-month hospital readmission (OR: 2.07, 95% CI: 1.022-4.225).

CONCLUSION

About one-quarter of the patients were admitted again within three months of discharge. PIMs and polypharmacy were not significantly associated with 3-month hospital readmissions while male gender was found to be an independent risk factor for readmission.

Hospital length of stay and 30-day readmissions in older people: their association in a 20-year cohort study in Italy

BACKGROUND

There are conflicting data on whether hospital length of stay (LOS) reduction affects readmission rates in older adults. We explored 20-year trends of hospital LOS and 30-day rehospitalizations in a cohort of Italian older people, and investigated their association.

METHODS

Participants in the Pro.V.A. project (n = 3099) were followed-up from 1996 to 2018. LOS and 30-day rehospitalizations, i.e. new hospitalizations within 30 days from a previous discharge, were obtained from personal interviews and regional registers. Rehospitalizations in the 6 months before death were also assessed. Linear regressions evaluated the associations between LOS and the frequency of 30-day rehospitalizations, adjusting for the mean age of the cohort within each year.

RESULTS

Over 20 years, 2320 (74.9%) participants were hospitalized. Mean LOS gradually decreased from 17.3 days in 1996 to 11.3 days in 2018, while 30-day rehospitalization rates increased from 6.6% in 1996 to 13.6% in 2018. LOS was inversely associated with 30-day rehospitalizations frequency over time (β = -2.33, p = 0.01), similarly in men and women. A total of 1506 individuals was hospitalized within 6 months before death. The frequency of 30-day readmissions at the end of life increased from 1.4% in 1997 to 8.3% in 2017 and was associated with mean LOS (β = -1.17, p = 0.03).

CONCLUSIONS

The gradual LOS reduction observed in the latter decades is associated with higher 30-day readmission rates in older patients in Italy. This suggests that a careful pre-discharge assessment is warranted in older people, and that community healthcare services should be improved to reduce the risk of readmission.

All-cause unplanned readmissions in the United States: insights from the Nationwide Readmission Database

BACKGROUND

There are few studies looking into adult, all-cause and age-group-specific unplanned readmissions. The predictors of such unplanned readmissions for all inpatient encounters remain obscure.

AIMS

To describe the incidence and factors associated with unplanned readmissions in all inpatient encounters in the United States.

METHODS

The US Nationwide Readmission Database (NRD) is a representative sample of hospitalisations in the United States (from approximately 28 states) accounting for approximately 60% of the US population. All inpatient encounters during January-November 2017 in the NRD were evaluated for the rates, predictors and costs of unplanned 30 days readmissions for age groups 18-44 years, 45-64 years, 65-75 years and ≥75 years. Elective readmissions and those patients who died on their index hospitalisations were excluded. Weighted analysis was performed to obtain nationally representative data.

RESULTS

We identified 28 942 224 inpatient encounters with a total of 3 051 189 (10.5%) unplanned readmissions within 30 days. The age groups 18-44 years, 45-64 years, 65-74 years and ≥75 years had 7.0%, 12.0%, 11.7% and 12.3% readmissions respectively. Female gender, private insurance and elective admissions were negative predictors for readmissions. For the group aged 18-44 years, schizophrenia and diabetes mellitus complications were the most frequent primary diagnosis for readmissions, while in all older age groups septicaemia and heart failure were the most frequent primary diagnosis for readmissions.

CONCLUSIONS

Thirty-day unplanned readmissions are common in patients over age 45 years, leading to significant morbidity. Effective strategies for reducing unplanned readmission may help to improve quality of care, outcomes and higher value care.

Family caregivers' perspectives on the acceptability of four interventions proposed for rural transitional care: A multi-method study

BACKGROUND

There is a critical need for hospital-to-home transitional care interventions to prepare family caregivers for patients' post-discharge care in rural communities. Four evidence-based interventions (named discharge planning, treatments, warning signs, and physical activity) have the potential to meet this need but family caregivers' perspectives on the acceptability of the interventions have not been examined. This gap is significant because unacceptable interventions are unlikely to be used or used as designed, thereby undermining outcome achievement. Accordingly, this study examined the perceived acceptability of the four interventions to rural family caregivers.

MATERIALS AND METHODS

A multi-method descriptive design was used. The quantitative method entailed the administration of an established scale to assess the interventions' perceived acceptability to family caregivers. The qualitative method involved semi-structured interviews to explore family caregivers' perceived acceptability of the interventions in greater depth, including acceptable and unacceptable aspects, in the context of their own transitional care experience. Participants were the family caregivers of a relative who had been discharged home in a rural community from an acute care hospital in Ontario, Canada.

RESULTS

The purposive sample included 16 participants who were mostly middle-aged women (n = 14; 87.5%) caring for a parent (n = 9; 56.3%) at high risk for hospital readmission. The mean scores on the acceptability measure were 3 or higher for all interventions, indicating that, on average, the four interventions were perceived as acceptable. In terms of acceptable aspects, four themes were identified: the interventions: 1) involve family caregivers and proactively prepare them for discharge, 2) provide clear, written, and detailed guidance, 3) place the onus on healthcare providers to initiate communication, and 4) ensure post-discharge follow-up. In terms of unacceptable aspects, one theme was identified: the physical activity intervention would be challenging to implement.

DISCUSSION

The findings support implementing the four interventions in practice throughout the hospital-to-home transition. Healthcare providers should assess family caregivers' comfort in participating in the physical activity intervention and tailor their role accordingly.

Thirty-Day Readmission Rate Among Patients With Hypertensive Crisis: A Nationwide Analysis

BACKGROUND

Hypertensive crisis is a life-threatening condition, further classified as hypertensive emergency and hypertensive urgency based on the presence or absence of acute or progressive end-organ damage, respectively. Readmissions in hypertensive emergency have been studied before. We aimed to analyze 30-day readmissions using recent data and more specific ICD-10-CM coding in patients with hypertensive crisis.

METHODS

In a retrospective study using the National Readmission Database 2018, we collected data on 129,239 patients admitted with the principal diagnosis of hypertensive crisis. The primary outcome was the all-cause 30-day readmission rate. Secondary outcomes were common causes of readmission, in-hospital mortality, resource utilization, and independent predictors of readmission. We also compared outcomes between patients with hypertensive urgency and hypertensive emergency.

RESULTS

Among 128,942 patients discharged alive, 13,768 (10.68%) were readmitted within 30 days; the most common cause of readmission was hypertensive crisis (19%). In-hospital mortality for readmissions (1.5%) was higher than for index admissions (0.2%, P < 0.01). Mean length of stay for readmissions was 4.5 days. The mean hospital cost associated with readmissions was $10,950, and total hospital costs were $151 million. Age <65 years and female sex were independent predictors of higher readmission rates. Subgroup analysis revealed a higher readmission rate for hypertensive emergency than hypertensive urgency (11.7% vs. 10%, P < 0.01).

CONCLUSIONS

All-cause 30-day readmission rates are high in patients admitted with hypertensive crisis, especially patients with hypertensive emergency. Higher in-hospital mortality and resource utilization are associated with readmission in these patients.

Substance Use Disorders Are Independently Associated with Hospital Readmission Among Patients with Brain Tumors

BACKGROUND

Research on the effects of substance use disorders (SUDs) on postoperative outcomes within neurosurgical oncology has been limited. Therefore, the present study sought to quantify the effect of having a SUD on hospital length of stay, postoperative complication incidence, discharge disposition, hospital charges, 90-day readmission rates, and 90-day mortality rates following brain tumor surgery.

METHODS

The present study used data from patients who received surgical resection for brain tumor at a single institution between January 1, 2017, and December 31, 2019. The Mann-Whitney U test was used for bivariate analysis of continuous variables and Fisher exact test was used for bivariate analysis of categorical variables. Multivariate analysis was conducted using logistic regression models.

RESULTS

Our study cohort included a total of 2519 patients, 124 (4.9%) of whom had at least 1 SUD. More specifically, 90 (3.6%) patients had an alcohol use disorder, 27 (1.1%) had a cannabis use disorder, and 12 (0.5%) had an opioid use disorder. On bivariate analysis, 90-day hospital readmission was the only postoperative outcome significantly associated with a SUD (odds ratio 2.21, P = 0.0011). When controlling for patient age, sex, race, marital status, insurance, brain tumor diagnosis, 5-factor modified frailty index score, American Society of Anesthesiologists score, and surgery number, SUDs remained significantly and independently associated with 90-day readmission (odds ratio 1.82, P = 0.013).

CONCLUSIONS

In patients with brain tumor, SUDs significantly and independently predict 90-day hospital readmission after surgery. Targeted management of patients with SUDs before and after surgery can optimize patient outcomes and improve the provision of high-value neurosurgical care.

Variation in Condition-Specific Readmission Rates Across US Children's Hospitals

OBJECTIVE

Despite extensive efforts, overall readmission rates at US children's hospitals have not materially declined over the past decade, raising questions about how to direct future efforts. Using measures of prevalence and performance variation we describe readmission rates by condition and identify priority conditions for future intervention.

METHODS

Retrospective cohort study of 49 US children's hospitals in the Pediatric Health Information System in 2017. Conditions were classified using All Patients Refined Diagnosis Related Groups. 30-day unadjusted and risk-adjusted readmission rates were calculated for each hospital/condition using the Pediatric All Cause Readmission measure. We ranked the highest volume conditions by rate variation (RV, interquartile range divided by the median) for each condition across hospitals.

RESULTS

The sample included 811,434 index hospitalizations with 50,196 (6.2%) 30-day readmissions. The RV across hospitals/conditions was between 0 and 2.8 (median = 0.7). Common reasons for admission had low RVs across hospitals, for example, bronchiolitis (readmission rate = 5.6%, RV = 0.4), seizure (readmission rate = 6.6%, RV = 0.3), and asthma (readmission rate = 3.1%, RV = 0.4). We identified 33 conditions with high variation in readmission rates across hospitals, which accounted for 18% of all discharges and 11% of all pediatric readmissions. These conditions may serve as candidates for future readmission reduction activities.

CONCLUSIONS

Many common childhood conditions have little variation in readmission rates across children's hospitals, suggesting limited future improvement opportunities. Conditions with high rate variation may provide opportunities for quality improvement; however, these conditions account for a relatively small share of total discharges suggesting modest potential impacts on national rates.

Frailty in older people: Rehabilitation Treatment Research Examining Separate Settings (FORTRESS): protocol for a hybrid type II stepped wedge, cluster, randomised trial

Background

Frailty in older people is associated with increased risk of falls, longer length of stay in hospital, increased risk of institutionalisation and death. Frailty can be measured using validated tools. Multi-component frailty interventions are recommended in clinical practice guidelines but are not routinely implemented in clinical practice.

Methods

The Frailty in Older people: Rehabilitation, Treatment, Research Examining Separate Settings (FORTRESS) trial is a multisite, hybrid type II, stepped wedge, cluster, randomised trial with blinded assessment and intention-to-treat analysis being conducted in Australia. The study aims to determine the effectiveness and cost-effectiveness of an embedded individualised multicomponent frailty intervention (commencing in hospital and continuing in the community) on readmissions, frailty and quality of life when compared with usual care. Frail older people admitted to study wards with no significant cognitive impairment, who are expected to return home after discharge, will be eligible to participate. Participants will receive extra sessions of physiotherapy, pharmacy, and dietetics during their admission. A Community Implementation Facilitator will coordinate implementation of the frailty management strategies and primary network liaison. The primary outcome is number of days of non-elective hospital readmissions during 12 month follow-up period. Secondary outcomes include frailty status measured using the FRAIL scale; quality of life measured using the EQ-5D-5L; and time-to-event for readmission and readmission rates. The total cost of delivering the intervention will be assessed, and cost-effectiveness analyses will be conducted. Economic evaluation will include analyses for health outcomes measured in terms of the main clinical outcomes. Implementation outcomes will be collected as part of a process evaluation. Recruitment commenced in 2020 and we are aiming to recruit 732 participants over the three-year duration of the study.

Discussion

This study will reveal whether intervening with frail older people to address factors contributing to frailty can reduce hospital readmissions and improve frailty status and quality of life. If the FORTRESS intervention provides a clinically significant and cost-effective result, it will demonstrate an improved approach to treating frail patients, both in hospital and when they return home.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12620000760976p. ANZCTR registered 24 July 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03178-1.

Re-admission following discharge from a Geriatric Evaluation and Management Unit: identification of risk factors

ObjectiveTo establish independent factors that influence the likelihood of re-admission within 30 days of discharge from a Geriatric Evaluation and Management Unit.MethodsAn observational prospective cohort design using clinical data extracted from the medical charts of eligible patients discharged from a tertiary public hospital Geriatric Evaluation and Management Unit between July 2017 and April 2019. Binary logistic regression was undertaken to determine variables that increased the likelihood of hospital re-admission (dependent variable).ResultsA total of 367 patients were eligible for inclusion, with 69 patients re-admitted within 30 days of discharge. Univariate analysis demonstrated significant differences between groups (re-admission vs non-re-admission) with respect to Charlson Comorbidity Index (CCI) (7.4 [2.4] vs 6.3 [2.2], P = 0.001), Clinical Frailty Scale (CFS) (5.6 [1.1] vs 5.2 [1.34], P = 0.02), and documented malnourishment (36.2% vs 23.6%, P = 0.04). All three variables remained significant when entered into the regression model (X2 = 25.095, P < 0.001). A higher score for the CFS (OR 1.3; 95% CI 1.03-1.64; P = 0.03) and CCI (OR 1.2; 95% CI 1.06-1.33; P = 0.004), and documented malnourishment (OR 1.92; 95% CI 1.06-3.47; P = 0.03) were all independent factors that increased the likelihood of patient re-admission within 30 days of discharge.ConclusionsThis study supports the formal inclusion of the CCI and CFS into routine practice in Geriatric Evaluation and Management Units. The inclusion of the measures can help inform future discharge planning practices. Clinicians should use malnourishment status, CCI and CFS to identify at risk patients and target discharge planning interventions accordingly.

Establishing and evaluating a quality improvement collaborative to address hospital to home transitions for older people

Introduction

Hospital use increases with age. Older people and their families have reported poor experiences of care at the time of discharge home from hospital. As part of a larger project, we established and evaluated a quality improvement collaborative to address hospital to home transitions for older people.

Methods

We convened an expert panel of 34 stakeholders to identify modifiable issues in the hospital-home transition period. We established a collaborative involving health professionals across a range of agencies working to common goals. Teams were supported by a network manager, three learning sessions and quality improvement methodology to address their identified area for improvement. We used mixed methods to evaluate whether the establishment of the quality improvement collaborative built networks, built capacity in the health professionals and improved the quality of care for older people. Evaluation methods included interviews, surveys, network mapping and case studies.

Results

Nine teams (n=41 participants) formed the collaborative and attended all meetings. Mapping showed an increase in networks between participants and organisations at the conclusion of the collaborative. Interview data showed that building relationships across services was one of the most important parts of the collaborative. Survey results revealed that most (77%) believed their quality improvement skills had developed through participation. Advice and regular meetings to progress project work were considered important in ensuring teams stayed focused. In terms of improving the quality of care, some participants indicated that they achieved the stated aims of their project better than expected (21%), most (41%) felt they achieved their aim as expected, 26% got close to their aim and the rest did not know the outcome (13%).

Conclusions

Establishing a quality improvement collaborative was a positive activity in terms of building a network across organisations and progressing quality improvement projects which aimed to achieve the same overall goal.

Development and validation of an interpretable machine learning scoring tool for estimating time to emergency readmissions

BACKGROUND

Emergency readmission poses an additional burden on both patients and healthcare systems. Risk stratification is the first step of transitional care interventions targeted at reducing readmission. To accurately predict the short- and intermediate-term risks of readmission and provide information for further temporal risk stratification, we developed and validated an interpretable machine learning risk scoring system.

METHODS

In this retrospective study, all emergency admission episodes from January 1st 2009 to December 31st 2016 at a tertiary hospital in Singapore were assessed. The primary outcome was time to emergency readmission within 90 days post discharge. The Score for Emergency ReAdmission Prediction (SERAP) tool was derived via an interpretable machine learning-based system for time-to-event outcomes. SERAP is six-variable survival score, and takes the number of emergency admissions last year, age, history of malignancy, history of renal diseases, serum creatinine level, and serum albumin level during index admission into consideration.

FINDINGS

A total of 293,589 ED admission episodes were finally included in the whole cohort. Among them, 203,748 episodes were included in the training cohort, 50,937 episodes in the validation cohort, and 38,904 in the testing cohort. Readmission within 90 days was documented in 80,213 (27.3%) episodes, with a median time to emergency readmission of 22 days (Interquartile range: 8-47). For different time points, the readmission rates observed in the whole cohort were 6.7% at 7 days, 10.6% at 14 days, 13.6% at 21 days, 16.4% at 30 days, and 23.0% at 60 days. In the testing cohort, the SERAP achieved an integrated area under the curve of 0.737 (95% confidence interval: 0.730-0.743). For a specific 30-day readmission prediction, SERAP outperformed the LACE index (Length of stay, Acuity of admission, Charlson comorbidity index, and Emergency department visits in past six months) and the HOSPITAL score (Hemoglobin at discharge, discharge from an Oncology service, Sodium level at discharge, Procedure during the index admission, Index Type of admission, number of Admissions during the last 12 months, and Length of stay). Besides 30-day readmission, SERAP can predict readmission rates at any time point during the 90-day period.

INTERPRETATION

Better performance in risk prediction was achieved by the SERAP than other existing scores, and accurate information about time to emergency readmission was generated for further temporal risk stratification and clinical decision-making. In the future, external validation studies are needed to evaluate the SERAP at different settings and assess their real-world performance.

FUNDING

This study was supported by the Singapore National Medical Research Council under the PULSES Center Grant, and Duke-NUS Medical School.

Association Between Neighborhood Disadvantage and Pediatric Readmissions

OBJECTIVE

Although individual-level social determinants of health (SDH) are known to influence 30-day readmission risk, contextual-level associations with readmission are poorly understood among children. This study explores associations between neighborhood disadvantage measured by Area Deprivation Index (ADI) and pediatric 30-day readmissions.

METHODS

This retrospective cohort study included discharges of patients aged < 20 years from Maryland's 2013-2016 all-payer dataset. The ADI, which quantifies 17 indicators of neighborhood socioeconomic disadvantage within census block groups, is used as a proxy for contextual-level SDH. Readmissions were identified with the 30-day Pediatric All-Condition Readmissions measure. Associations between ADI and readmission were identified with generalized estimating equations adjusted for patient demographics and clinical severity (Chronic Condition Indicator [CCI], Pediatric Medical Complexity Algorithm [PMCA], Index Hospital All Patients Refined Diagnosis Related Groups [APR-DRG]), and hospital discharge volume.

RESULTS

Discharges (n = 138,998) were mostly female (52.7%), publicly insured (55.1%), urban-dwelling (93.0%), with low clinical severity levels (0-1 CCIs [82.3%], minor APR-DRG severity [48.4%]). Overall readmission rate was 4.0%. Compared to the least disadvantaged ADI quartile, readmissions for the most disadvantaged quartile were significantly more likely (aOR 1.19, 95% CI 1.09-1.30). After adjustment, readmissions were associated with public insurance and indicators of medical complexity (higher number of CCIs, complex-chronic disease PMCA, and APR-DRG severity).

CONCLUSION

In this all-payer, statewide sample, living in the most socioeconomically disadvantaged neighborhoods independently predicted pediatric readmission. While the relative magnitude of neighborhood disadvantage was modest compared to medical complexity, disadvantage is modifiable and thus represents an important consideration for prevention and risk stratification efforts.

Essential information for transition of care for frail elderly patients in Japan: A qualitative study

BACKGROUND

Information exchange between hospitals and primary care physicians is suboptimal. Most physicians are dissatisfied with the current referral process, and poor communication leads to negative care transition outcomes.

METHOD

To identify the key information needed for a successful transition of care, we conducted a qualitative study using consecutive, semistructured in-person interviews and focus group sessions. We recruited five participants engaged in clinical work for individual interviews and 16 participants for focus groups. We analyzed all data using qualitative thematic analysis. All results were returned to the participants and modified based on their feedback.

RESULTS

The five individual interviews provided a general picture of the current referral process and an interview guide for the following focus group sessions. The focus group discussions were used to identify the essential information needed at admission and discharge from the hospital. Essential information on hospital admission was as follows: (1) basic medical and care information, (2) care resources available at home, (3) the purpose of admission and the goals of care during hospitalization, and (4) status of advance care planning (ACP) and patient's will in an emergency. Essential information on hospital discharge was as follows: (1) clinical course, (2) explanation of medical condition during hospitalization, (3) status of ACP and patient's will in an emergency, and (4) medical procedures to be continued at home.

CONCLUSIONS

We identified the essential information needed for a successful transition of care in Japan. The clinical effectiveness of a template that contains the information identified in our study warrants further investigation.

Predictors of Rehospitalization and Mortality in Diabetes-Related Hospital Admissions

The risk factors of rehospitalization and death post-discharge in diabetes-related hospital admissions are not fully understood. To determine them, a population-based retrospective epidemiological survey was performed on diabetes-related admissions from the Polish national database. Logistic regression models were used, in which the dependent variables were rehospitalization due to diabetes complications and death within 90 days after the index hospitalization. In 2017, there were 74,248 hospitalizations related to diabetes. A total of 11.3% ended with readmission. Risk factors for rehospitalization were as follows: age < 35 years; male sex; prior hospitalization due to acute diabetic complications; weight loss; peripheral artery disease; iron deficiency anemia; kidney failure; alcohol abuse; heart failure; urgent, emergency, or weekend admission; length of hospitalization; and hospitalization in a teaching hospital with an endocrinology/diabetology unit. Furthermore, 7.3% of hospitalizations resulted in death within 90 days following discharge. Risk factors for death were as follows: age; neoplastic disease with/without metastases; weight loss; coagulopathy; alcohol abuse; acute diabetes complications; heart failure; kidney failure; iron deficiency anemia; peripheral artery disease; fluid, electrolytes, and acid–base balance disturbances; urgent or emergency and weekend admission; and length of hospitalization. We concluded that of all investigated factors, only hospitalization within an experienced specialist center may reduce the frequency of the assessed outcomes.

Readmission, healthcare consumption, and mortality in Clostridioides difficile infection hospitalizations: a nationwide cohort study

OBJECTIVE

Despite being the most common healthcare-related infection in the US, nationwide data on readmission, healthcare consumption, and mortality in Clostridioides difficile infection (CDI) remain limited. We examined these outcomes in a US-based cohort of patients with CDI.

METHODS

We queried the 2017 Nationwide Readmission Database using ICD-10-CM codes to identify all adult patients admitted with a principal diagnosis of CDI. Primary outcomes were 30- and 90-day readmission rates. Secondary outcomes included mortality rates and healthcare consumption.

RESULTS

Of the 83,865 patients discharged from an index hospitalization for CDI, 22.37% were readmitted within 30 days, and an additional 15.01% were readmitted within 90 days. Recurrent CDI was responsible for more than 30% of readmissions at both 30 and 90 days. Compared to the index hospitalization, readmissions were characterized by higher mortality (1.41% index vs. 4.86% 30-day vs. 4.40% 90-day) and increased hospital length of stay and charges. Medicaid insurance (HR 1.16), cirrhosis (HR 1.31), Type 1 diabetes mellitus (HR 1.38), and end-stage renal disease (HR 1.36) were independently associated with 30-day readmission (all p < 0.01), with similar findings in 90-day readmissions.

CONCLUSIONS

In a large cohort of patients hospitalized for CDI, we found that approximately 1 in 5 were readmitted within 30-days, and more than 1 in 3 within 90-days. Readmission was characterized by increased mortality and greater healthcare consumption. Additionally, we found independent associations for readmission that may help identify patients at high-risk. Prospective investigation is needed to identify means to reduce the healthcare consumption and mortality in CDI.

Increasing Prevalence of Frailty and Its Association with Readmission and Mortality Among Hospitalized Patients with IBD

BACKGROUND

Although age is often used as a clinical risk stratification tool, recent data have suggested that adverse outcomes are driven by frailty rather than chronological age.

AIMS

In this nationwide cohort study, we assessed the prevalence of frailty, and factors associated with 30-day readmission and mortality among hospitalized IBD patients.

METHODS

Using the Nationwide Readmission Database, we examined all patients with IBD hospitalized from 2010 to 2014. Based on index admission, we defined IBD and frailty using previously validated ICD codes. We used univariable and multivariable regression to assess risk factors associated with all-cause 30-day readmission and 30-day readmission mortality.

RESULTS

From 2010 to 2014, 1,405,529 IBD index admissions were identified, with 152,974 (10.9%) categorized as frail. Over this time period, the prevalence of frailty increased each year from 10.20% (27,594) in 2010 to 11.45% (33,507) in 2014. On multivariable analysis, frailty was an independent predictor of readmission (aRR 1.16, 95% CI: 1.14-1.17), as well as readmission mortality (aRR 1.12, 95% CI 1.02-1.23) after adjusting for relevant clinical factors. Frailty also remained associated with readmission after stratification by IBD subtype, admission characteristics (surgical vs. non-surgical), age (patients ≥ 60 years old), and when excluding malnutrition, weight loss, and fecal incontinence as frailty indicators. Conversely, we found older age to be associated with a lower risk of readmission.

CONCLUSIONS

Frailty, independent of age, comorbidities, and severity of admission, is associated with a higher risk of readmission and mortality among IBD patients, and is increasing in prevalence. Given frailty is a potentially modifiable risk factor, future studies prospectively assessing frailty within the IBD patient population are needed.

Association Rules Mining for Hospital Readmission: A Case Study

As an indicator of healthcare quality and performance, hospital readmission incurs major costs for healthcare systems worldwide. Understanding the relationships between readmission factors, such as input features and readmission length, is challenging following intricate hospital readmission procedures. This study discovered the significant correlation between potential readmission factors (threshold of various settings for readmission length) and basic demographic variables. Association rule mining (ARM), particularly the Apriori algorithm, was utilised to extract the hidden input variable patterns and relationships among admitted patients by generating supervised learning rules. The mined rules were categorised into two outcomes to comprehend readmission data; (i) the rules associated with various readmission length and (ii) several expert-validated variables related to basic demographics (gender, race, and age group). The extracted rules proved useful to facilitate decision-making and resource preparation to minimise patient readmission.

Patient Satisfaction with a Psychology Consultation-Liaison Service at an Academic Medical Center

One to two-thirds of all medically admitted patients have comorbid psychiatric concerns. To address the cognitive, behavioral, and emotional factors that affect medical hospitalization, psychological or psychiatric consultation-liaison (CL) services are consulted. The current study was designed to understand patient satisfaction with a CL psychology service and how it was associated with satisfaction with overall hospitalization, taking into consideration relevant factors. Adults medically admitted to an academic teaching hospital (N = 220), who were seen at least once by the CL psychology service, completed satisfaction and demographic questionnaires. Most patients reported being satisfied with the CL psychology service, with women reporting higher satisfaction than men. Satisfaction with the CL psychology service was associated with satisfaction with overall hospitalization, but did not differ based on age, race/ethnicity, education, income, length of stay, number of visits, or presence of psychiatric diagnosis. The results suggest that CL psychology services may contribute to improving overall patient experience.

Incidence and predictors of 30-day hospital readmissions for liver cirrhosis: insights from the United States National Readmissions Database

Background

Cirrhosis is associated with substantial inpatient morbidity and mortality. This study aimed to determine the trends in 30-day hospital readmission rates among patients with cirrhosis and identify factors associated with these readmissions.

Methods

We conducted a retrospective analysis of data retrieved from the Nationwide Readmissions Database to determine trends in 30-day readmission for patients discharged with a diagnosis of cirrhosis in 2010 through 2014. Multivariate logistic regression analysis was used to identify predictors of readmission.

Results

Among 303,346 patients identified from the database, the 30-day readmission rate for patients with a discharge diagnosis of cirrhosis was 31.4% (n=95,298). The trends in the readmission rates remained steady during the study period. On multivariate analysis, female sex, age 45 years or older, esophagogastroduodenoscopy (EGD) during admission, and disposition to a short-term care facility or skilled nursing facility protected against readmissions. In contrast, coverage by Medicaid insurance, admission during a weekend, nonalcoholic cause of cirrhosis, and history of hepatic encephalopathy and ascites were associated with readmission.

Conclusions

We found an exceptionally high 30-day readmission rate in patients with cirrhosis, although it remained stable during the study period. This study identified some modifiable factors such as disposition to a short-term care facility or skilled nursing facility and patients’ attendance of alcohol rehabilitation facilities that could decrease the likelihood of readmission and could inform local and national healthcare policymakers.

A simple index predicting 30-day readmissions in acutely hospitalized patients

BACKGROUND

There are various models attempting to predict 30-day readmissions of acutely admitted internal medicine patients. However, it is uncertain how to create a parsimonious index that has equivalent predictive ability and can be extrapolated to other settings.

METHODS

We developed a regression equation to predict 30-day readmissions from all acute hospitalizations in internal medicine departments in a regional hospital in 2015-2016 and validated the model in 2019. The independent (predictor) variables were age, past hospitalizations, admission laboratory test results, length of stay in hospital and discharge diagnoses. We compared the predictive value of a logistic regression model and index that included discharge diagnoses and admission laboratory test results with one that included only age, past hospitalizations, and hospital length of stay.

RESULTS

Readmission rates were associated with age, time since last hospitalization, number of previous hospitalizations, and length of stay, as well as with a diagnosis of chronic obstructive lung disease and congestive heart failure and several laboratory data. Logistic regressions of the independent variables for 30-day readmission rates were similar in 2015-2016 and 2019. An index was derived from number of previous admissions to hospitals, time since last admission, age, and length of stay. In 2019, for every unit of the index, the odds of readmission increased by 1.33 (95% CI- 1.30-1.37), and ranged from 2.1% to 37.1%. Addition of discharge diagnoses and laboratory variables did not significantly improve the risk differentiation of the index. The c-statistic for the final parsimonious model was 0.704.

CONCLUSIONS

An index derived from the number of previous hospital admissions, days since last admission, age, and length of stay in days differentiated between the risks of readmission within 30 days without the need for discharge diagnosis and laboratory variables.

Nurse-led care management models for patients with multimorbidity in hospital settings: a scoping review protocol

OBJECTIVE

The aim of this scoping review is to map the nurse-led care management models for patients with multimorbidity in hospital settings.

INTRODUCTION

The increase of chronic diseases and the associated multimorbidity create challenges for health care resources and services. Considering their role and skill set, nurses are in a position to lead the transformation of health care for patients with chronic illness. Several nurse-led care management models in the community have been identified in the literature, but little is known about these models in hospital settings. It is necessary to map the existing nurse-led care management models and describe their characteristics, differences, and similarities, and the implications for patients with multimorbidity in a hospital environment.

INCLUSION CRITERIA

This scoping review will consider studies focusing on nurse-led care management models for adult patients with multimorbidity in hospital settings, including readmissions, discharges, and visits to emergency services.

METHODS

The search will include Web of Science, CINAHL, MEDLINE, Nursing and Allied Health Collection, and gray literature through OpenGrey. This review will be restricted to studies published in English. A three-step search strategy will be used, and the articles identified in the databases will be organized and the duplicates removed. The titles and abstracts will be analyzed by two independent reviewers. Full texts will be imported into a bibliographic reference management system. The findings will be presented in tables and descriptive summary.

Preventability of 7-Day Versus 30-Day Readmissions at an Academic Children's Hospital

BACKGROUND AND OBJECTIVES

The 30-day readmission rate is a common quality metric used by Medicare for adult patients. However, studies in pediatrics have shown lower readmission rates and potentially less preventability. Therefore, some question the utility of the 30-day readmission time frame in pediatrics. Our objective was to describe the characteristics of patients readmitted within 30 days of discharge over a 1-year period and determine the preventability of readmissions occurring 0 to 7 vs 8 to 30 days after discharge from a pediatric hospitalist service at an academic children's hospital.

METHODS

Retrospective chart review and hospital administrative data were used to gather medical characteristics, demographics, and process-level metrics for readmitted patients between July 1, 2015, and June 30, 2016. All readmissions were reviewed by 2 senior authors and assigned a preventability category. Subgroup analysis comparing preventability in 0-to-7- and 8-to-30-day readmissions groups was performed. Qualitative thematic analysis was performed on readmissions deemed preventable.

RESULTS

Of 1523 discharges that occurred during the study period, 49 patients, with 65 distinct readmission encounters, were readmitted for an overall 30-day readmission rate of 4.3% (65 of 1523). Twenty-eight percent (9 of 32) of readmissions within 7 days of discharge and 12.1% (4 of 33) occurring 8 to 30 days after discharge were deemed potentially preventable (P = .13). Combined, the 30-day preventable readmission rate was 20% (13 of 65).

CONCLUSIONS

We identified a possible association between preventability and time to readmission. If confirmed by larger studies, the 7-day, rather than 30-day, time frame may represent a better quality metric for readmitted pediatric patients.

Risk of 30-day hospital readmission associated with medical conditions and drug regimens of polymedicated, older inpatients discharged home: a registry-based cohort study

OBJECTIVES

The present study analysed 4 years of a hospital register (2015-2018) to determine the risk of 30-day hospital readmission associated with the medical conditions and drug regimens of polymedicated, older inpatients discharged home.

DESIGN

Registry-based cohort study.

SETTING

Valais Hospital-a public general hospital centre in the French-speaking part of Switzerland.

PARTICIPANTS

We explored the electronic records of 20 422 inpatient stays by polymedicated, home-dwelling older adults held in the hospital's patient register. We identified 13 802 hospital readmissions involving 8878 separate patients over 64 years old.

OUTCOME MEASURES

Sociodemographic characteristics, medical conditions and drug regimen data associated with risk of readmission within 30 days of discharge.

RESULTS

The overall 30-day hospital readmission rate was 7.8%. Adjusted multivariate analyses revealed increased risk of hospital readmission for patients with longer hospital length of stay (OR=1.014 per additional day; 95% CI 1.006 to 1.021), impaired mobility (OR=1.218; 95% CI 1.039 to 1.427), multimorbidity (OR=1.419 per additional International Classification of Diseases, 10th Revision condition; 95% CI 1.282 to 1.572), tumorous disease (OR=2.538; 95% CI 2.089 to 3.082), polypharmacy (OR=1.043 per additional drug prescribed; 95% CI 1.028 to 1.058), and certain specific drugs, including antiemetics and antinauseants (OR=3.216 per additional drug unit taken; 95% CI 1.842 to 5.617), antihypertensives (OR=1.771; 95% CI 1.287 to 2.438), drugs for functional gastrointestinal disorders (OR=1.424; 95% CI 1.166 to 1.739), systemic hormonal preparations (OR=1.207; 95% CI 1.052 to 1.385) and vitamins (OR=1.201; 95% CI 1.049 to 1.374), as well as concurrent use of beta-blocking agents and drugs for acid-related disorders (OR=1.367; 95% CI 1.046 to 1.788).

CONCLUSIONS

Thirty-day hospital readmission risk was associated with longer hospital length of stay, health disorders, polypharmacy and drug regimens. The drug regimen patterns increasing the risk of hospital readmission were very heterogeneous. Further research is needed to explore hospital readmissions caused solely by specific drugs and drug-drug interactions.

Long-Term Exposure to Particulate Air Pollution Is Associated With 30-Day Readmissions and Hospital Visits Among Patients With Heart Failure

Background

Long‐term air pollution exposure is a significant risk factor for inpatient hospital admissions in the general population. However, we lack information on whether long‐term air pollution exposure is a risk factor for hospital readmissions, particularly in individuals with elevated readmission rates.

Methods and Results

We determined the number of readmissions and total hospital visits (outpatient visits+emergency room visits+inpatient admissions) for 20 920 individuals with heart failure. We used quasi‐Poisson regression models to associate annual average fine particulate matter at the date of heart failure diagnosis with the number of hospital visits and 30‐day readmissions. We used inverse probability weights to balance the distribution of confounders and adjust for the competing risk of death. Models were adjusted for age, race, sex, smoking status, urbanicity, year of diagnosis, short‐term fine particulate matter exposure, comorbid disease, and socioeconomic status. A 1‐µg/m³ increase in fine particulate matter was associated with a 9.31% increase (95% CI, 7.85%–10.8%) in total hospital visits, a 4.35% increase (95% CI, 1.12%–7.68%) in inpatient admissions, and a 14.2% increase (95% CI, 8.41%–20.2%) in 30‐day readmissions. Associations were robust to different modeling approaches.

Conclusions

These results highlight the potential for air pollution to play a role in hospital use, particularly hospital visits and readmissions. Given the elevated frequency of hospitalizations and readmissions among patients with heart failure, these results also represent an important insight into modifiable environmental risk factors that may improve outcomes and reduce hospital use among patients with heart failure.

An integrated knowledge translation approach to address avoidable rehospitalisations and unplanned admissions for older people in South Australia: implementation and evaluation program plan

Background

Repeated admission to hospital can be stressful for older people and their families and puts additional pressure on the health care system. While there is some evidence about strategies to better integrate care, improve older patients’ experiences at transitions of care, and reduce preventable hospital readmissions, implementing these strategies at scale is challenging. This program of research comprises multiple, complementary research activities with an overall goal of improving the care for older people after discharge from hospital. The program leverages existing large datasets and an established collaborative network of clinicians, consumers, academics, and aged care providers.

Methods

The program of research will take place in South Australia focusing on people aged 65 and over. Three inter-linked research activities will be the following: (1) analyse existing registry data to profile individuals at high risk of emergency department encounters and hospital admissions; (2) evaluate the cost-effectiveness of existing ‘out-of-hospital’ programs provided within the state; and (3) implement a state-wide quality improvement collaborative to tackle key interventions likely to improve older people’s care at points of transitions. The research is underpinned by an integrated approach to knowledge translation, actively engaging a broad range of stakeholders to optimise the relevance and sustainability of the changes that are introduced.

Discussion

This project highlights the uniqueness and potential value of bringing together key stakeholders and using a multi-faceted approach (risk profiling; evaluation framework; implementation and evaluation) for improving health services. The program aims to develop a practical and scalable solution to a challenging health service problem for frail older people and service providers.

Predictors of 30-Day Mortality Among Dutch Patients Undergoing Colorectal Cancer Surgery, 2011-2016

IMPORTANCE

Quality improvement programs for colorectal cancer surgery have been introduced with benchmarking based on quality indicators, such as mortality. Detailed (pre)operative characteristics may offer relevant information for proper case-mix correction.

OBJECTIVE

To investigate the added value of machine learning to predict quality indicators for colorectal cancer surgery and identify previously unrecognized predictors of 30-day mortality based on a large, nationwide colorectal cancer registry that collected extensive data on comorbidities.

DESIGN, SETTING, AND PARTICIPANTS

All patients who underwent resection for primary colorectal cancer registered in the Dutch ColoRectal Audit between January 1, 2011, and December 31, 2016, were included. Multiple machine learning models (multivariable logistic regression, elastic net regression, support vector machine, random forest, and gradient boosting) were made to predict quality indicators. Model performance was compared with conventionally used scores. Risk factors were identified by logistic regression analyses and Shapley additive explanations (ie, SHAP values). Statistical analysis was performed between March 1 and September 30, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome of this cohort study was 30-day mortality. Prediction models were trained on a training set by performing 5-fold cross-validation, and outcomes were measured by the area under the receiver operating characteristic curve on the test set. Machine learning was further used to identify risk factors, measured by odds ratios and SHAP values.

RESULTS

This cohort study included 62 501 records, most patients were male (35 116 [56.2%]), were aged 61 to 80 years (41 560 [66.5%]), and had an American Society of Anesthesiology score of II (35 679 [57.1%]). A 30-day mortality rate of 2.7% (n = 1693) was found. The area under the curve of the best machine learning model for 30-day mortality (0.82; 95% CI, 0.79-0.85) was significantly higher than the American Society of Anesthesiology score (0.74; 95% CI, 0.71-0.77; P < .001), Charlson Comorbidity Index (0.66; 95% CI, 0.63-0.70; P < .001), and preoperative score to predict postoperative mortality (0.73; 95% CI, 0.70-0.77; P < .001). Hypertension, myocardial infarction, chronic obstructive pulmonary disease, and asthma were comorbidities with a high risk for increased mortality. Machine learning identified specific risk factors for a complicated course, intensive care unit admission, prolonged hospital stay, and readmission. Laparoscopic surgery was associated with a decreased risk for all adverse outcomes.

CONCLUSIONS AND RELEVANCE

This study found that machine learning methods outperformed conventional scores to predict 30-day mortality after colorectal cancer surgery, identified specific patient groups at risk for adverse outcomes, and provided directions to optimize benchmarking in clinical audits.

Risk Factors Associated With Hospital Readmission and Costs for Pouchitis

Background

Pouchitis is the most common long-term complication in patients with restorative proctocolectomy and ileal pouch-anal anastomosis. This study aimed to identify readmission rates for pouchitis and risk factors associated with readmissions in an extensive national database.

Methods

We performed a retrospective analysis using the National Readmission Database to determine if patient demographics and clinical characteristics were predictors of hospital readmission within 30 days for adult patients (age >18 years) discharged with a principal diagnosis of pouchitis (ICD-9 code-569.71) from January 2013 to December 2013. Both univariable and multivariable analyses were performed to assess factors associated with 30-day readmission.

Results

A total of 1538 patients with pouchitis who were discharged alive were identified. 10.2% [95% confidence interval: 7.6, 12.7] of these were readmitted within 30 days of discharge. The average days to readmission were 18.6 ± 1.01. Multivariable analysis of risk factors associated with readmission showed older age as a protective factor for readmission [odds ratio (OR) = 0.88 (0.81, 0.96); P < 0.005]. Sex and the presence of permanent ileostomy were not associated with readmission in patients with pouchitis. The length of stay during readmissions was associated with postoperative wound infection [OR = 7.7 (94.0, 11.30); P < 0.001], ileus [OR = 4.5 (1.6, 7.4); P < 0.002], permanent ileostomy [OR = 3.7 (1.7, 5.7); P < 0.001], and long-term use of nonsteroidal anti-inflammatory drugs [OR = 3.2 (1.06, 5.3); P < 0.003].

Conclusions

Readmissions in pouchitis patients are frequent. Long-term use of nonsteroidal anti-inflammatory drugs, ileus, permanent ileostomy, and postoperative wound infection is associated with increased length of stay in readmissions.

Pharmaceutical Discharge Management: Implementation in Swiss Hospitals Compared to International Guidelines

Readmissions to the hospital are frequent after hospital discharge. Pharmacist-led interventions have been shown to reduce readmissions. The objective of this study was to describe pharmacist-led interventions to support patients’ medication management at hospital discharge in Switzerland and to compare them to international guidelines. We conducted a national online survey among chief hospital pharmacists focusing on medication management at hospital discharge. To put our findings in perspective, Cochrane reviews and guidelines were searched for summarised evidence and recommendations on interventions. Based on answers in the survey, hospitals with implemented models to support patients at discharge were selected for in-depth interviews. In semi-structured interviews, they were asked to describe pharmacists’ involvement in the patients’ pathway throughout the hospital stay. In Swiss hospitals (n = 44 survey participants), interventions to support patients at discharge were frequently implemented, mostly “patient education” (n = 40) and “communication to primary care provider” (n = 34). These interventions were commonly recommended in guidelines. Overall, pharmacists were rarely involved in the interventions on a regular basis. When pharmacists were involved, the services were provided by hospital pharmacies or collaborating community pharmacies. In conclusion, interventions recommended in guidelines were frequently implemented in Swiss hospitals, however pharmacists were rarely involved.

Timing of Co-occurring Chronic Conditions in Children With Neurologic Impairment

BACKGROUND

Children with neurologic impairment (NI) are at risk for developing co-occurring chronic conditions, increasing their medical complexity and morbidity. We assessed the prevalence and timing of onset for those conditions in children with NI.

METHODS

This longitudinal analysis included 6229 children born in 2009 and continuously enrolled in Medicaid through 2015 with a diagnosis of NI by age 3 in the IBM Watson Medicaid MarketScan Database. NI was defined with an existing diagnostic code set encompassing neurologic, genetic, and metabolic conditions that result in substantial functional impairments requiring subspecialty medical care. The prevalence and timing of co-occurring chronic conditions was assessed with the Agency for Healthcare Research and Quality Chronic Condition Indicator system. Mean cumulative function was used to measure age trends in multimorbidity.

RESULTS

The most common type of NI was static (56.3%), with cerebral palsy (10.0%) being the most common NI diagnosis. Respiratory (86.5%) and digestive (49.4%) organ systems were most frequently affected by co-occurring chronic conditions. By ages 2, 4, and 6 years, the mean (95% confidence interval [CI]) numbers of co-occurring chronic conditions were 3.7 (95% CI 3.7-3.8), 4.6 (95% CI 4.5-4.7), and 5.1 (95% CI 5.1-5.2). An increasing percentage of children had ≥9 co-occurring chronic conditions as they aged: 5.3% by 2 years, 10.0% by 4 years, and 12.8% by 6 years.

CONCLUSIONS

Children with NI enrolled in Medicaid have substantial multimorbidity that develops early in life. Increased attention to the timing and types of multimorbidity in children with NI may help optimize their preventive care and case management health services.

Risk of 28-day readmissions among stroke patients in Malaysia (2008-2015): Trends, causes and its associated factors

BACKGROUND AND OBJECTIVES

Risk of readmissions is an important quality indicator for stroke care. Such information is limited among low- and middle-income countries. We assessed the trends for 28-day readmissions after a stroke in Malaysia from 2008 to 2015 and evaluated the causes and factors associated with readmissions in 2015.

METHODS

Using the national hospital admission records database, we included all stroke patients who were discharged alive between 2008 and 2015 for this secondary data analysis. The risk of readmissions was described in proportion and trends. Reasons were coded according to the International Classification of Diseases, 10th Edition. Multivariable logistic regression was performed to identify factors associated with readmissions.

RESULTS

Among 151729 patients, 11 to 13% were readmitted within 28 days post-discharge from their stroke events each year. The trend was constant for ischemic stroke but decreasing for hemorrhagic stroke. The leading causes for readmissions were recurrent stroke (32.1%), pneumonia (13.0%) and sepsis (4.8%). The risk of 28-day readmission was higher among those with stroke of hemorrhagic (adjusted odds ratio (AOR): 1.52) and subarachnoid hemorrhage (AOR: 2.56) subtypes, and length of index admission >3 days (AOR: 1.48), but lower among younger age groups of 35-64 (AORs: 0.61-0.75), p values <0.001.

CONCLUSION

The risk of 28-day readmission remained constant from 2008 to 2015, where one in eight stroke patients required readmission, mainly attributable to preventable causes. Age, ethnicity, stroke subtypes and duration of the index admission influenced the risk of readmission. Efforts should focus on minimizing potentially preventable admissions, especially among those at higher risk.

Readmission rate reduction strategies in general hospital setting

Hospital readmissions are vital to patients, families, healthcare providers, and policymakers throughout the world. However, limited information is available about strategies to prevent readmissions in Qatar and the Middle East region in general; hence, there is a gap in business practice. The objective of this study was to explore the strategies used by hospital leaders and administrators in managing and reducing patient readmissions.

Effect of health insurance program for the poor on out-of-pocket inpatient care cost in India: evidence from a nationally representative cross-sectional survey

BACKGROUND

In India, Out-of-pocket expenses accounts for about 62.6% of total health expenditure - one of the highest in the world. Lack of health insurance coverage and inadequate coverage are important reasons for high out-of-pocket health expenditures. There are many Public Health Insurance Programs offered by the Government that cover the cost of hospitalization for the people below poverty line (BPL), but their coverage is still not complete. The objective of this research is to examine the effect of Public Health Insurance Programs for the Poor on hospitalizations and inpatient Out-of-Pocket costs.

METHODS

Data from the recent national survey by the National Sample Survey Organization, Social Consumption in Health 2014 are used. Propensity score matching was used to identify comparable non-enrolled individuals for individuals enrolled in health insurance programs. Binary logistic regression model, Tobit model, and a Two-part model were used to study the effects of enrolment under Public Health Insurance Programs for the Poor on the incidence of hospitalizations, length of hospitalization, and Out-of- Pocket payments for inpatient care.

RESULTS

There were 64,270 BPL people in the sample. Individuals enrolled in health insurance for the poor have 1.21 higher odds of incidence of hospitalization compared to matched poor individuals without the health insurance coverage. Enrollment under the poor people health insurance program did not have any effect on length of hospitalization and inpatient Out-of-Pocket health expenditures. Logistic regression model showed that chronic illness, household size, and age of the individual had significant effects on hospitalization incidence. Tobit model results showed that individuals who had chronic illnesses and belonging to other backward social group had significant effects on hospital length of stay. Tobit model showed that days of hospital stay, education and age of patient, using a private hospital for treatment, admission in a paying ward, and having some specific comorbidities had significant positive effect on out-of-pocket costs.

CONCLUSIONS

Enrolment in the public health insurance programs for the poor increased the utilization of inpatient health care. Health insurance coverage should be expanded to cover outpatient services to discourage overutilization of inpatient services. To reduce out-of-pocket costs, insurance needs to cover all family members rather than restricting coverage to a specific maximum defined.

Ability of the LACE index to predict 30-day hospital readmissions in patients with community-acquired pneumonia

Background and objective

Hospital readmissions within 30 days are used as an indicator of quality of hospital care. We aimed to evaluate the ability of the LACE (Length of stay, Acuity of admission, Comorbidities based on Charlson comorbidity score and number of Emergency visits in the last 6 months) index to predict the risk of 30-day readmissions in patients hospitalised for community-acquired pneumonia (CAP).

Methods

In this retrospective cohort study a LACE index score was calculated for patients with a principal diagnosis of CAP admitted to a tertiary hospital in Sydney, Australia. The predictive ability of the LACE score for 30-day readmissions was assessed using receiver operator characteristic curves with C-statistic.

Results

Of 3996 patients admitted to hospital for CAP at least once, 8.0% (n=327) died in hospital and 14.6% (n=584) were readmitted within 30 days. 17.8% (113 of 636) of all 30-day readmissions were again due to CAP, followed by readmissions for chronic obstructive pulmonary disease, heart failure and chest pain. The LACE index had moderate discriminative ability to predict 30-day readmission (C-statistic=0.6395) but performed poorly for the prediction of 30-day readmissions due to CAP (C-statistic=0.5760).

Conclusions

The ability of the LACE index to predict all-cause 30-day hospital readmissions is comparable to more complex pneumonia-specific indices with moderate discrimination. For the prediction of 30-day readmissions due to CAP, the performance of the LACE index and modified risk prediction models using readily available variables (sex, age, specific comorbidities, after-hours, weekend, winter or summer admission) is insufficient.

The LACE index is easy to use and its ability to predict all-cause 30-day hospital readmissions for patients hospitalised with community-acquired pneumonia is comparable to more complex pneumonia-specific indices with moderate discriminationhttps://bit.ly/2SYkxam

Home care nurses' identification of patients at risk of infection and their risk mitigation strategies: A qualitative interview study

BACKGROUND

There is an increase in the number of individuals who receive care at home. A significant proportion of these patients acquire infections during their care episode. Whilst there has been significant focus on strategies for infection prevention and control in acute care environments, there is a lack of research into infection prevention in a home care setting.

OBJECTIVES

To understand (1) if and how home care nurses identify patients at high risk of infection and (2) the strategies they use to mitigate that risk.

DESIGN

A qualitative descriptive study, using semi-structured interviews.

SETTING

A large not for profit home care agency located in the New York region of the United States.

PARTICIPANTS

Fifty nurses with a range of experience in home care nursing.

METHODS

Purposive and snowball sampling was used to recruit nurses from across the home care agency with varied years of work experience. Interviews were audio recorded and transcribed. The interviews explored how home care nurses evaluate their patients' risk of developing an infection and if/how they modify the plan of care based on that risk. Data were analysed using thematic analysis.

RESULTS

Three themes were derived from the data; assessing a patient's risk of infection, the risk assessment process, and strategies for mitigating infection risk. Factors identified by nurses as putting a patient at higher risk of infection included being older, having diabetes, inadequate nutrition; along with inadequate clinical information available at start of care. The patient's knowledge and understanding of infection prevention, and the availability and knowledge of caregivers were also important, as was the cleanliness of the home environment. Given the context of home care, where nurses have little control over the environment and care processes in-between visits, the main strategy for infection prevention was patient and caregiver education. Nurses also discussed the importance of their own infection prevention behaviours, and the ability to adjust a patient's plan of care according to their infection risk.

CONCLUSIONS

The study highlights the complexity of the risk assessment process in relation to infection. Existing guidelines for infection prevention and control do not adequately cover the home care environment and more research needs to determine which interventions (such as patient/caregiver education) would be most effective to prevent infections in the home care setting.

Association between comprehensive geriatric assessment and short-term outcomes among older adult patients with stroke: A nationwide retrospective cohort study using propensity score and instrumental variable methods

BACKGROUND

Comprehensive geriatric assessment (CGA) is a multidimensional and multidisciplinary method to identify geriatric conditions among older patients. The aim of the present study was to examine the associations between CGA and short-term outcomes among older adult inpatients with stroke.

METHODS

The study was a nationwide, retrospective cohort study. We used the Diagnosis Procedure Combination database, a national Japanese inpatient database, to identify older adult stroke patients from 2014 to 2017. The associations between CGA and in-hospital mortality, length of hospital stay, readmission rate, rehabilitation intervention, and introduction of home health care were evaluated using propensity score matching and instrumental variable analysis.

FINDINGS

We identified 338,720 patients, 21·3% of whom received CGA. A propensity score-matched analysis of 53,861 pairs showed that in-hospital mortality was significantly lower in the CGA group than in the non-CGA group (3·6% vs. 4·1%, p < 0·001). The rate of long-term hospitalization (> 60 days) was significantly lower in the CGA group than in the non-CGA group (8·7% vs. 10·1%, p < 0·001), and the rates of rehabilitation intervention (30·3% vs. 24·9%, p < 0·001) and home health care (8·3% vs. 7·6%, p = 0·001) were both higher in the CGA group than in the non-CGA group. Instrumental variable analysis showed similar results.

INTERPRETATION

CGA was significantly associated with the examined short-term outcomes. These findings from Japan, one of the most aged countries worldwide, highlight the possible benefits of CGA for short-term outcomes and can be of use for health policy in other international contexts.

FUNDING

This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141).