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Griffin O, Li T, Beveridge A, Ní Chróinín D. Higher levels of multimorbidity are associated with increased risk of readmission for older people during post-acute transitional care. Eur Geriatr Med 2023:10.1007/s41999-023-00770-5. [PMID: 37010792 DOI: 10.1007/s41999-023-00770-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/08/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE Older patients are at high risk for poor outcomes after an acute hospital admission. The Transitional Aged Care Programme (TACP) was established by the Australian government to provide a short-term care service aiming to optimise functional independence following hospital discharge. We aim to investigate the association between multimorbidity and readmission amongst patients on TACP. METHODS Retrospective cohort study of all TACP patients over 12 months. Multimorbidity was defined using the Charlson Comorbidity Index (CCI), and prolonged TACP (pTACP) as TACP ≥ 8 weeks. RESULTS Amongst 227 TACP patients, the mean age was 83.3 ± 8.0 years, and 142 (62.6%) were females. The median length-of-stay on TACP was 8 weeks (IQR 5-9.67), and median CCI 7 (IQR 6-8). 21.6% were readmitted to hospital. Amongst the remainder, 26.9% remained at home independently, 49.3% remained home with supports; < 1% were transferred to a residential facility (0.9%) or died (0.9%). Hospital readmission rates increased with multimorbidity (OR 1.37 per unit increase in CCI, 95% CI 1.18-1.60, p < 0.001). On multivariable logistic regression analysis, including polypharmacy, CCI, and living alone, CCI remained independently associated with 30-day readmission (aOR 1.43, 95% CI 1.22-1.68, p < 0.001). CONCLUSIONS CCI is independently associated with a 30-day hospital readmission in TACP cohort. Identifying vulnerability to readmission, such as multimorbidity, may allow future exploration of targeted interventions.
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Affiliation(s)
- Ornagh Griffin
- Department of Geriatric Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Tracy Li
- Department of Geriatric Medicine, Liverpool Hospital, Corner of Elizabeth and Goulburn St, Liverpool, NSW, Australia.
- South Western Sydney Clinical School, UNSW Sydney, Sydney, NSW, Australia.
| | - Alexander Beveridge
- Department of Geriatric Medicine, St Vincent's Hospital, Sydney, NSW, Australia
- St. Vincent's Clinical School, UNSW Sydney, Sydney, NSW, Australia
| | - Danielle Ní Chróinín
- Department of Geriatric Medicine, Liverpool Hospital, Corner of Elizabeth and Goulburn St, Liverpool, NSW, Australia
- South Western Sydney Clinical School, UNSW Sydney, Sydney, NSW, Australia
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Wei D, Sun Y, Chen R, Meng Y, Wu W. The Charlson comorbidity index and short-term readmission in patients with heart failure: A retrospective cohort study. Medicine (Baltimore) 2023; 102:e32953. [PMID: 36820540 PMCID: PMC9907905 DOI: 10.1097/md.0000000000032953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
The relationship between the Charlson comorbidity index (CCI) and short-term readmission is as yet unknown. Therefore, we aimed to investigate whether the CCI was independently related to short-term readmission in patients with heart failure (HF) after adjusting for other covariates. From December 2016 to June 2019, 2008 patients who underwent HF were enrolled in the study to determine the relationship between CCI and short-term readmission. Patients with HF were divided into 2 categories based on the predefined CCI (low < 3 and high > =3). The relationships between CCI and short-term readmission were analyzed in multivariable logistic regression models and a 2-piece linear regression model. In the high CCI group, the risk of short-term readmission was higher than that in the low CCI group. A curvilinear association was found between CCI and short-term readmission, with a saturation effect predicted at 2.97. In patients with HF who had CCI scores above 2.97, the risk of short-term readmission increased significantly (OR, 2.66; 95% confidence interval, 1.566-4.537). A high CCI was associated with increased short-term readmission in patients with HF, indicating that the CCI could be useful in estimating the readmission rate and has significant predictive value for clinical outcomes in patients with HF.
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Affiliation(s)
- Dongmei Wei
- Department of Cardiovascular, Guangzhou University of Chinese Medicine First Affiliated Hospital, Guangzhou, China
- Department of Cardiovascular, Liuzhou Traditional Chinese Medical Hospital, Liuzhou, China
| | - Yang Sun
- Guangxi University of Chinese Medicine, Nanning, China
| | - Rongtao Chen
- Guangxi University of Chinese Medicine, Nanning, China
| | - Yuanting Meng
- Guangxi University of Chinese Medicine, Nanning, China
| | - Wei Wu
- Department of Cardiovascular, Guangzhou University of Chinese Medicine First Affiliated Hospital, Guangzhou, China
- * Correspondence: Wei Wu, Department of Cardiovascular, Guangzhou University of Chinese Medicine First Affiliated Hospital, Guangzhou 510405, China (e-mail: )
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Rageth L, Leuppi JD, Leuppi-Taegtmeyer AB, Lüthi-Corridori G, Boesing M. [Predictors for Early Unplanned Readmissions]. PRAXIS 2023; 112:75-81. [PMID: 36722109 DOI: 10.1024/1661-8157/a003992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Predictors for Early Unplanned Readmissions Abstract. Unplanned rehospitalizations represent a major burden for patients, their relatives and the healthcare system. Since the introduction of the SwissDRG in 2012, financial incentives for hospitals have been promoted to forestall readmissions. Not every patient is at risk for rehospitalization. Affected patients can be identified by predictors from various areas in order to implement adequate interventions and avoid readmissions. Predictors can be directly related to patients as in the case of polypharmacy, multiple comorbidities or related to gender, but also provider-related and system-related. Early follow-up visits or a pre-discharge medication review are cited as effective interventions.
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Affiliation(s)
- Luana Rageth
- Medizinische Universitätsklinik, Kantonsspital Baselland, Liestal, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Jörg D Leuppi
- Medizinische Universitätsklinik, Kantonsspital Baselland, Liestal, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Anne B Leuppi-Taegtmeyer
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
- Klinische Pharmakologie und Toxikologie, Universitätsspital Basel, Basel, Schweiz
| | - Giorgia Lüthi-Corridori
- Medizinische Universitätsklinik, Kantonsspital Baselland, Liestal, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Maria Boesing
- Medizinische Universitätsklinik, Kantonsspital Baselland, Liestal, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
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Dunlea S, McCombe G, Broughan J, Carroll Á, Fawsitt R, Gallagher J, Melin K, Cullen W. Priorities in integrating primary and secondary care: a multimethod study of GPs. JOURNAL OF INTEGRATED CARE 2022. [DOI: 10.1108/jica-06-2022-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PurposeThroughout the world, healthcare policy has committed to delivering integrated models of care. The interface between primary–secondary care has been identified as a particularly challenging area in this regard. To that end, this study aimed to examine the issue of integrated care from general practitioners’ (GPs) perspectives in Ireland.Design/methodology/approachThis multimethod study involved a cross-sectional survey and semi-structured interviews with GPs in the Ireland East region. A total of 1,274 GPs were identified from publicly available data as practising in the region, of whom the study team were able to identify 430 GPs with email addresses. An email invite was sent to 430 potential participants asking them to complete a 34-item online questionnaire and, for those who were willing, an in-depth interview was conducted with a member of the study team.FindingsIn total, 116 GPs completed the survey. Most GPs felt that enhancing integration between primary and secondary care in Ireland was a priority (n = 109, 93.9%). Five themes concerning the state of integrated care and initiatives to improve matters were identified from semi-structured interviews with 12 GPs.Originality/valueThe uniqueness of this study is that it uses a multimethod approach to provide insight into current GP views on the state of integrated care in Ireland, as well as their perspectives on how to improve integration within the Irish healthcare system.
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Piñeiro-Fernández JC, Fernández-Rial Á, Suárez-Gil R, Martínez-García M, García-Trincado B, Suárez-Piñera A, Pértega-Díaz S, Casariego-Vales E. Evaluation of a patient-centered integrated care program for individuals with frequent hospital readmissions and multimorbidity. Intern Emerg Med 2022; 17:789-797. [PMID: 34714486 DOI: 10.1007/s11739-021-02876-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/18/2021] [Indexed: 11/27/2022]
Abstract
Managing patients with multimorbidity and frequent hospital readmissions is a challenge. Integrated care programs that consider their needs and allow for personalized care are necessary for their early identification and management. This work aims to describe these patients' clinical characteristics and evaluate a program designed to reducing readmissions. This prospective study analyzed all patients with ≥ 3 admissions to a medical department in the previous year who were included in the Internal Medicine Department chronic care program at the Lucus Augusti University Hospital (Lugo, Spain) between April 1, 2019 and April 30, 2021. A multidimensional assessment, personalized care plan, and proactive follow-up with a case manager nurse were provided via an advanced hospital system. Clinical and demographic variables and data on healthcare system use were analyzed at 6 and 12 months before and after inclusion. Descriptive and survival analyses were performed. One hundred sixty-one patients were included. Program participants were elderly (mean 81.4 (SD 11) years), had multimorbidity (10.2 (3) chronic diseases) and polypharmacy (10.6 (3.5) drugs), frequently used the healthcare system, and were highly complex. Most were included for heart failure. The program led to significant reductions in admissions and emergency department visits (p = .0001). A total of 44.7% patients died within 1 year. The PROFUND Index showed good predictive ability (p = .013), with high values associated with mortality (RR 1.15, p = .001). Patients with frequent hospital readmissions are highly complex and need special care. A personalized integrated care program reduced admissions and allowed for individualized decision-making.
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Affiliation(s)
- Juan Carlos Piñeiro-Fernández
- Department of Internal Medicine, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain.
| | - Álvaro Fernández-Rial
- Department of Internal Medicine, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain
| | - Roi Suárez-Gil
- Department of Internal Medicine, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain
| | - Mónica Martínez-García
- Case Manager Nurse, Medical Day Hospital, Lucus Augusti University Hospital, SERGAS, Lugo, Spain
| | - Beatriz García-Trincado
- Department of Internal Medicine, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain
| | - Adrián Suárez-Piñera
- Department of Internal Medicine, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain
| | - Sonia Pértega-Díaz
- Clinical Epidemiology and Biostatistics Research Group, A Coruña Biomedical Research Institute (INIBIC), University of A Coruña, A Coruña, Spain
| | - Emilio Casariego-Vales
- Department of Internal Medicine, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain
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Xie F, Liu N, Yan L, Ning Y, Lim KK, Gong C, Kwan YH, Ho AFW, Low LL, Chakraborty B, Ong MEH. Development and validation of an interpretable machine learning scoring tool for estimating time to emergency readmissions. EClinicalMedicine 2022; 45:101315. [PMID: 35284804 PMCID: PMC8904223 DOI: 10.1016/j.eclinm.2022.101315] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/22/2022] [Accepted: 02/07/2022] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
- Feng Xie
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
| | - Nan Liu
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore
- Institute of Data Science, National University of Singapore, Singapore
- Corresponding author at: Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore.
| | - Linxuan Yan
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
| | - Yilin Ning
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
| | - Ka Keat Lim
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Changlin Gong
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Heng Kwan
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
| | - Andrew Fu Wah Ho
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Lian Leng Low
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore
- Department of Post-Acute and Continuing Care, Outram Community Hospital, Singapore
- SingHealth Duke-NUS Family Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Bibhas Chakraborty
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
- Department of Statistics and Data Science, National University of Singapore, Singapore
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States
| | - Marcus Eng Hock Ong
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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Vallini V, Venturini L, Andreini R, Sibilia G, Rinaldi E, Bassu R, Mura M, Meini S. Skin Ulcers are Predictors of 30-Day Hospital Readmission, But are Under-represented in the DRG Coding: A Retrospective Case-Control Study From an Italian Internal Medicine Unit. INT J LOW EXTR WOUND 2021; 22:307-313. [PMID: 33909481 DOI: 10.1177/15347346211009427] [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] [Indexed: 12/30/2022]
Abstract
This study retrospectively analyzes all consecutive patients who underwent during a year hospital readmissions, defined as an admission to a hospital within 30 days of discharge, to an Italian Internal Medicine ward. All these data were compared with those from patients who underwent only 1 hospital admission in the same period. The aim of this study was to identify potential novel risk factors for hospital readmissions. In 2018, a total of 3012 patients were hospitalized. Among these, 14.1% (n = 426; mean age, 79.7 ± 11.9; range, 23-100) were defined as readmissions; data were compared with controls (n = 420; 13.9%; mean age, 75.9 ± 14.7; range, 22-99) who had only 1 hospitalization. Cases showed a significantly higher prevalence than controls regarding cerebrovascular disease (77.2% vs 48.1%), cognitive impairment (51.8% vs 26.9%), congestive heart failure (47.6% vs 20.2%), chronic kidney disease (31.7% vs 13.1%), and chronic obstructive pulmonary disease (23.0% vs 14.5%). Skin ulcers were significantly more prevalent among cases (45.1% vs 17.6%). Diagnosis-related group (DRG) analysis showed a higher proportion of "infectious disease" (24.4% vs 15.0%) among the cases than in controls. Despite skin ulcers were very frequent among cases and controls (45.1% vs 17.6%), they were codified as "skin wound" DRG only in 1.4% and 0.2%, respectively. At the DRGs analysis, sepsis (31.6% vs 19.1%), pneumonia (17.1% vs 7.6%), and kidney failure (9.6% vs 3.8%) represented the main significant cause of death in cases compared to controls. Our study confirms that readmissions to Internal Medicine departments are related to the severity of chronic diseases affecting patients. Skin ulcers are present in about half of patients who will be early readmitted within 30 days, but they are almost never reported in DRGs, so more accurate coding is needed. Key challenges for the future are sepsis prevention measures and investing resources in chronic disease assistance, including skin ulcer chronic management.
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Affiliation(s)
- Valerio Vallini
- Azienda USL Toscana Nord Ovest, U.O. Medicina Interna, Felice Lotti Hospital, Pontedera, Pisa, Toscana, Italy
| | - Luigi Venturini
- Azienda USL Toscana Nord Ovest, U.O. Medicina Interna, Felice Lotti Hospital, Pontedera, Pisa, Toscana, Italy
| | - Roberto Andreini
- Azienda USL Toscana Nord Ovest, U.O. Medicina Interna, Felice Lotti Hospital, Pontedera, Pisa, Toscana, Italy
| | - Gabriella Sibilia
- Azienda USL Toscana Nord Ovest, U.O. Medicina Interna, Felice Lotti Hospital, Pontedera, Pisa, Toscana, Italy
| | - Elisabetta Rinaldi
- Azienda USL Toscana Nord Ovest, U.O. Medicina Interna, Felice Lotti Hospital, Pontedera, Pisa, Toscana, Italy
| | - Raffaella Bassu
- Azienda USL Toscana Nord Ovest, U.O. Medicina Interna, Felice Lotti Hospital, Pontedera, Pisa, Toscana, Italy
| | - Maddalena Mura
- 9257Azienda Ospedaliero-Universitaria Pisana, U.O. Medicina Interna, Ospedale Santa Chiara, Pisa, Toscana, Italy
| | - Simone Meini
- Azienda USL Toscana Nord Ovest, U.O. Medicina Interna, Felice Lotti Hospital, Pontedera, Pisa, Toscana, Italy
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Jönsson M, Holmefur M, Fredriksson C. Everyday activities at home: Experiences of older repeatedly readmitted people. Scand J Occup Ther 2020; 29:555-562. [PMID: 33222567 DOI: 10.1080/11038128.2020.1849393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Limitations in everyday activities are a risk factor for hospital readmission. Despite this, few studies have focussed on everyday activities of repeatedly readmitted older people. The experiences and specific needs of this group have been poorly described regarding their everyday activities at home. A deeper understanding may help occupational therapists and other health professions to facilitate readiness for this group at and after discharge. The aim of this study was, therefore, to describe the experiences of performing everyday activities of older people repeatedly readmitted to hospital and discharged to home. METHODS A qualitative interview study was used to collect data from sixteen participants (75 years and older). Data were analysed using qualitative content analysis. RESULTS One theme 'trying to manage an unpredictable everyday life' and two categories describe experiences of everyday activities at home. The participants expressed the importance of continuing everyday activities after discharge where support from relatives and healthcare seemed to be of importance. CONCLUSION It was found that performance of everyday activities and contact with family members were of importance in their everyday life. Therefore, assessments and support were of particular importance for the group of older people who do not have close social relations at home.
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Affiliation(s)
- Marie Jönsson
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Marie Holmefur
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Carin Fredriksson
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Wang Y, Ghislandi S, Torbica A. Investigating the geographic disparity in quality of care: the case of hospital readmission after acute myocardial infarction in Italy. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1149-1168. [PMID: 32894412 PMCID: PMC7561553 DOI: 10.1007/s10198-020-01221-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/21/2020] [Indexed: 05/04/2023]
Abstract
Unwarranted variation in the quality of care challenges the sustainability of healthcare systems. Especially in decentralised healthcare systems, it is crucial to understand the drivers behind regional differences in hospital qualities such as unplanned readmissions. This paper examines the factors that influence the risk of unplanned hospital readmission and the geographic disparity of readmission rate in Italy. We use hospital discharge data from 2010 to 2015 for patients above 65 years old admitted with Acute Myocardial Infarction. Employing hierarchical models, we identified the patient and hospital-level determinants for unplanned readmission. In line with the literature, the risk of readmission increases with age and being male, while hospitals with higher patient volume and capacity tend to have lower unplanned readmission. In particular, we find that after patient risk-adjustments, there are differential effects of hospitalisation length-of-stay on the probability of readmission across the hospitals that are governed by different payment systems. For hospitals under a prospective payment system, the effect of length-of-stay in reducing the probability of readmission is weaker than hospitals under an ex-post global budget, but the overall readmission rates are the lowest. Moreover, there are substantial geographic variations in readmission rate across Local Health Authority and regions, and these variations of unplanned readmission are explained by differences in hospital length-of-stay and surgical procedures used. Our results demonstrate that differential hospital behaviours can be one of the potential mechanisms that drive geographic quality disparities.
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Affiliation(s)
- Yuxi Wang
- Centre for Research on Health and Social Care Management (CERGAS), Department of Social and Political Science, Bocconi University, Via Guglielmö Röntgen 1, 20136, Milan, MI, Italy.
| | - Simone Ghislandi
- Centre for Research on Health and Social Care Management (CERGAS), Department of Social and Political Science, Bocconi University, Via Guglielmö Röntgen 1, 20136, Milan, MI, Italy
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Department of Social and Political Science, Bocconi University, Via Guglielmö Röntgen 1, 20136, Milan, MI, Italy
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Ng SHX, Rahman N, Ang IYH, Sridharan S, Ramachandran S, Wang DD, Tan CS, Toh SA, Tan XQ. Characterization of high healthcare utilizer groups using administrative data from an electronic medical record database. BMC Health Serv Res 2019; 19:452. [PMID: 31277649 PMCID: PMC6612067 DOI: 10.1186/s12913-019-4239-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 06/10/2019] [Indexed: 12/11/2022] Open
Abstract
Background High utilizers (HUs) are a small group of patients who impose a disproportionately high burden on the healthcare system due to their elevated resource use. Identification of persistent HUs is pertinent as interventions have not been effective due to regression to the mean in majority of patients. This study will use cost and utilization metrics to segment a hospital-based patient population into HU groups. Methods The index visit for each adult patient to an Academic Medical Centre in Singapore during 2006 to 2012 was identified. Cost, length of stay (LOS) and number of specialist outpatient clinic (SOC) visits within 1 year following the index visit were extracted and aggregated. Patients were HUs if they exceeded the 90th percentile of any metric, and Non-HU otherwise. Seven different HU groups and a Non-HU group were constructed. The groups were described in terms of cost and utilization patterns, socio-demographic information, multi-morbidity scores and medical history. Logistic regression compared the groups’ persistence as a HU in any group into the subsequent year, adjusting for socio-demographic information and diagnosis history. Results A total of 388,162 patients above the age of 21 were included in the study. Cost-LOS-SOC HUs had the highest multi-morbidity and persistence into the second year. Common conditions among Cost-LOS and Cost-LOS-SOC HUs were cardiovascular disease, acute cerebrovascular disease and pneumonia, while most LOS and LOS-SOC HUs were diagnosed with at least one mental health condition. Regression analyses revealed that HUs across all groups were more likely to persist compared to Non-HUs, with stronger relationships seen in groups with high SOC utilization. Similar trends remained after further adjustment. Conclusion HUs of healthcare services are a diverse group and can be further segmented into different subgroups based on cost and utilization patterns. Segmentation by these metrics revealed differences in socio-demographic characteristics, disease profile and persistence. Most HUs did not persist in their high utilization, and high SOC users should be prioritized for further longitudinal analyses. Segmentation will enable policy makers to better identify the diverse needs of patients, detect gaps in current care and focus their efforts in delivering care relevant and tailored to each segment. Electronic supplementary material The online version of this article (10.1186/s12913-019-4239-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sheryl Hui-Xian Ng
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Nabilah Rahman
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Ian Yi Han Ang
- Regional Health System Office, National University Health System, Singapore, Singapore
| | - Srinath Sridharan
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Sravan Ramachandran
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Debby D Wang
- Centre for Health Services and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Sue-Anne Toh
- Regional Health System Office, National University Health System, Singapore, Singapore
| | - Xin Quan Tan
- Regional Health System Office, National University Health System, Singapore, Singapore. .,Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.
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11
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Tarumi Y, Harada T, Saito T, Hiroshige J, Dohi K. Usefulness of bounce-back admission in monitoring the quality of practice in the emergency department. Ther Clin Risk Manag 2019; 15:647-658. [PMID: 31190845 PMCID: PMC6511631 DOI: 10.2147/tcrm.s193863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 03/19/2019] [Indexed: 11/29/2022] Open
Abstract
Background: Recently, unscheduled readmissions after discharge from the emergency department (ED) (bounce-back admissions, BBAs) have been monitored as a hospital performance measure in countries other than Japan. It has been suggested that BBAs may be caused by errors in diagnoses or treatments. Purpose: This retrospective cohort study aimed to evaluate BBAs and improve the quality of medical care in the ED of Showa University Hospital by analyzing the data of adult patients (≥18 years) with index visits to the ED of Showa University Hospital between June 2011 and May 2013 (n=15,069). Patients and methods: Patients were registered and followed up for unscheduled admissions to this hospital within 7 days. In order to understand the reasons for BBAs, individual diagnoses upon BBA were compared to the corresponding diagnoses upon discharge. Results: Among the 11,669 discharged patients, 180 patients were admitted within 3 days after discharge (3-day BBAs), and 257 were admitted within 7 days after discharge (7-day BBAs). The main diagnoses upon admission (BBA) were pneumonia or exacerbation of chronic obstructive pulmonary disease (COPD) or asthma (n=40, 16%), cholecystitis or cholangitis (n=21, 8.2%), and urinary tract infection (n=16, 6.2%). Among the 7-day BBA cases, 117 patients had similar and 110 patients had different diagnoses upon discharge and admission; in the remaining 30 cases, the results could not be ascertained owing to incomplete diagnostic data. In the cases of pneumonia, exacerbation of COPD or asthma, and colitis or enterocolitis, there was a significantly higher “similar” diagnoses than “different”, while the reverse was true for cases of stroke, ileus or bowel obstruction, and meningitis. These results were shared with the ED staff, and similar surveillances were periodically conducted. The frequency of admission within 7 days after discharge continuously declined from 2013 to 2016. Conclusion: Analyzing the discharge and admission diagnoses may help ED staff to understand the reasons for common errors in order to follow the plan-do-check-act cycle of medical care in the ED.
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Affiliation(s)
- Yoko Tarumi
- Department of General Medicine, Showa University, Tokyo 142-8555, Japan
| | - Taku Harada
- Department of General Medicine, Showa University, Tokyo 142-8555, Japan
| | - Tsukasa Saito
- Department of General Medicine, Showa University, Tokyo 142-8555, Japan
| | - Juichi Hiroshige
- Department of General Medicine, Showa University, Tokyo 142-8555, Japan
| | - Kenji Dohi
- Department of Emergency, Disaster and Critical Care Medicine, Showa University, Tokyo 142-8555, Japan
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12
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Fabbian F, De Giorgi A, Boari B, Misurati E, Gallerani M, Cappadona R, Cultrera R, Manfredini R, Rodrìguez Borrego MA, Lopez-Soto PJ. Infections and internal medicine patients: Could a comorbidity score predict in-hospital mortality? Medicine (Baltimore) 2018; 97:e12818. [PMID: 30334978 PMCID: PMC6211916 DOI: 10.1097/md.0000000000012818] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Infectious diseases (ID) are frequently cause of internal medicine wards (IMW) admission. We aimed to evaluate risk factors for in-hospital mortality (IHM) in IMW patients with ID, and to test the usefulness of a comorbidity score (CS).This study included ID hospital admissions between January 2013, and December 2016, recorded in the database of the local hospital. ICD-9-CM codes were selected to identify infections, development of sepsis, and to calculate a CS.We analyzed 12,173 records, (age 64.8 ± 25.1 years, females 66.2%, sepsis 9.3%). Deceased subjects (1545, 12.7%) were older, had higher percentage of sepsis, pulmonary infections, and endocarditis. Mean value of CS was also significantly higher. At multivariate analysis, the odds ratio (OR) for sepsis (OR 5.961), endocarditis (OR 4.247), pulmonary infections (OR 1.905), other sites of infection (OR 1.671), and urinary tracts infections (OR 0.548), were independently associated with IHM. The CS (OR 1.070 per unit of increasing score), was independently associated with IHM as well. The calculated weighted risk, obtained by multiplying 1.070 for the mean score value in deceased patients, was 19.367. Receiver operating characteristic (ROC) analysis showed that CS and development of sepsis were significant predictors for IHM (area under the curve, AUC: 0.724 and 0.670, respectively).Careful evaluation of comorbidity in internal medicine patients is nowadays matter of extreme importance in IMW patients hospitalized for ID, being IHM related to severity of disease, type and site of infection, and also to concomitant comorbidities. In these patients, a careful evaluation of CS should represent a fundamental step in the disease management.
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Affiliation(s)
- Fabio Fabbian
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara
- Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba & Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Alfredo De Giorgi
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara
| | - Benedetta Boari
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara
| | - Elisa Misurati
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara
| | - Massimo Gallerani
- First Internal Medicine Unit, Department of Internal Medicine, General Hospital of Ferrara
| | - Rosaria Cappadona
- Obstetrics and Gynecology Unit, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara
| | - Rosario Cultrera
- Infectious Diseases University Unit, Department of Medical Sciences, University of Ferrara, Italy
| | - Roberto Manfredini
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara
- Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba & Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Maria A. Rodrìguez Borrego
- Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba & Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Pablo J. Lopez-Soto
- Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba & Hospital Universitario Reina Sofía, Córdoba, Spain
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13
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Tan RRQ, Toh HJ, Yap PLK, Jiao N, Wang W. 90-Day Hospital Readmissions of Patients in a Geriatric Acute Care Ward in Singapore. Clin Nurs Res 2018; 29:200-209. [PMID: 30227723 DOI: 10.1177/1054773818801483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of the study is to examine the 90-day readmission rate and identify the predictors for 90-day readmissions at a geriatric ward in a tertiary hospital in Singapore. A secondary analysis of case-control data was performed. Data of patients discharged from a geriatric ward between January 2015 and January 2016 were retrieved from an existing data set. Out of 564 index admissions involving older adults, the 90-day geriatric readmission rate was 10.1%. Activities of daily living dependency (odds ratio [OR]: 0.988, 95% confidence interval [CI]: [0.978, 0.999]) and living with the spouse (OR: 2.988, 95% CI: [1.388, 6.432]) were identified as significant predictors of 90-day geriatric readmissions. The study suggests that rehabilitation to restore the geriatric patient's ability to perform daily activities and adequate caregiver training for the spouse are essential in reducing geriatric readmissions. Also, postdischarge follow-up with both the patient and caregiver can greatly reduce the risk of readmission in geriatric patients.
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Affiliation(s)
| | | | | | - Nana Jiao
- National University of Singapore, Singapore
| | - Wenru Wang
- National University of Singapore, Singapore
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14
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Lawn S, Zabeen S, Smith D, Wilson E, Miller C, Battersby M, Masman K. Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program. AUST HEALTH REV 2018; 42:542-549. [DOI: 10.1071/ah17099] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 07/10/2017] [Indexed: 11/23/2022]
Abstract
Objective
The study aimed to determine the impact of the Flinders Chronic Condition Management Program for chronic condition self-management care planning and how to improve its use with Bendigo Health’s Hospital Admission Risk Program (HARP).
Methods
A retrospective analysis of hospital admission data collected by Bendigo Health from July 2012 to September 2013 was undertaken. Length of stay during admission and total contacts post-discharge by hospital staff for 253 patients with 644 admissions were considered as outcome variables. For statistical modelling we used the generalised linear model.
Results
The combination of the HARP and Flinders Program was able to achieve significant reductions in hospital admissions and non-significant reduction in emergency department presentations and length of stay. The generalised linear model predicted that vulnerable patient groups such as those with heart disease (P = 0.037) and complex needs (P < 0.001) received more post-discharge contacts by HARP staff than those suffering from diabetes, renal conditions and psychosocial needs when they lived alone. Similarly, respiratory (P < 0.001), heart disease (P = 0.015) and complex needs (P = 0.050) patients had more contacts, with an increased number of episodes than those suffering from diabetes, renal conditions and psychosocial needs.
Conclusion
The Flinders Program appeared to have significant positive impacts on HARP patients that could be more effective if high-risk groups, such as respiratory patients with no carers and respiratory and heart disease patients aged 0–65, had received more targeted care.
What is known about the topic?
Chronic conditions are common causes of premature death and disability in Australia. Besides mental and physical impacts at the individual level, chronic conditions are strongly linked to high costs and health service utilisation. Hospital avoidance programs such as HARP can better manage chronic conditions through a greater focus on coordination and integration of care across primary care and hospital systems. In support of HARP, self-management interventions such as the Flinders Program aim to help individuals better manage their medical treatment and cope with the impact of the condition on their physical and mental wellbeing and thus reduce health services utilisation.
What does this paper add?
This paper sheds light on which patients might be more or less likely to benefit from the combination of the HARP and Flinders Program, with regard to their impact on reductions in hospital admissions, emergency department presentations and length of stay. This study also sheds light on how the Flinders Program could be better targeted towards and implemented among high-need and high-cost patients to lessen chronic disease burden on Australia’s health system.
What are the implications for practitioners?
Programs targeting vulnerable populations and applying evidence-based chronic condition management and self-management support achieve significant reductions in potentially avoidable hospitalisation and emergency department presentation rates, though sex, type of chronic condition and living situation appear to matter. Benefits might also accrue from the combination of contextual factors (such as the Flinders Program, supportive service management, clinical champions in the team) that work synergistically.
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15
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Fløjstrup M, Henriksen DP, Brabrand M. An acute hospital admission greatly increases one year mortality - Getting sick and ending up in hospital is bad for you: A multicentre retrospective cohort study. Eur J Intern Med 2017; 45:5-7. [PMID: 28988718 DOI: 10.1016/j.ejim.2017.09.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND For most of the population a serious acute illness that require an emergency admission to hospital is a rare "once in a life time" event. This paper reports the one year mortality of patients admitted to hospital as acute emergencies compared to the general population. METHOD This is a post-hoc retrospective multicentre cohort study of acutely admitted patients from October 2008 to December 2013 aged 40 or higher. It compares the observed one-year mortality of both acute medical and surgical patients with the overall mortality in the general population at comparable age bands. RESULTS We included 18,375 patients and 4037 (22.0%) died within one year. For all age groups the one year mortality of those admitted to hospital for acute illness was markedly greater than for the general population. Although the odds ratio of death was highest in younger patients (e.g. odds ratio >20 for 40year olds), the absolute risk of death was greatest in the elderly (e.g. 20% mortality rate for men admitted to hospital over 65years of age, compared to 1.7% for the general population). DISCUSSION Admission to hospital for an acute illness is associated with a greatly increased risk of death within a year and for many elderly patients may be a seminal event.
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Affiliation(s)
- Marianne Fløjstrup
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark.
| | - Daniel Pilsgaard Henriksen
- Department of Respiratory Medicine, Odense University Hospital, Denmark; Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark; Department of Emergency Medicine, Odense University Hospital, Denmark; University of Southern Denmark, Institute of Regional Health Research, Esbjerg, Denmark
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16
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Ekerstad N, Bylin K, Karlson BW. Early rehospitalizations of frail elderly patients - the role of medications: a clinical, prospective, observational trial. Drug Healthc Patient Saf 2017; 9:77-88. [PMID: 28860862 PMCID: PMC5571818 DOI: 10.2147/dhps.s139237] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Early readmissions of frail elderly patients after an episode of hospital care are common and constitute a crucial patient safety outcome. Our purpose was to study the impact of medications on such early rehospitalizations. PATIENTS AND METHODS This is a clinical, prospective, observational study on rehospitalizations within 30 days after an acute hospital episode for frail patients over the age of 75 years. To identify adverse drug reactions (ADRs), underuse of evidence-based treatment and avoidability of rehospitalizations, the Naranjo score, the Hallas criteria and clinical judgment were used. RESULTS Of 390 evaluable patients, 96 (24.6%) were rehospitalized. The most frequent symptoms and conditions were dyspnea (n = 25) and worsened general condition (n = 18). The most frequent diagnoses were heart failure (n = 17) and pneumonia/acute bronchitis (n = 13). By logistic regression analysis, independent risk predictors for rehospitalization were heart failure (odds ratio [OR] = 1.8; 95% CI = 1.1-3.1) and anemia (OR = 2.3; 95% CI = 1.3-4.0). The number of rehospitalizations due to probable ADRs was 13, of which two were assessed as avoidable. The number of rehospitalizations probably due to underuse of evidence-based drug treatment was 19, all of which were assessed as avoidable. The number of rehospitalizations not due to ADRs or underuse of evidence-based drug treatment was 64, of which none was assessed as avoidable. CONCLUSION One out of four frail elderly patients discharged from hospital was rehospitalized within 1 month. Although ADRs constituted an important cause of rehospitalization, underuse of evidence-based drug treatment might be an even more frequent cause. Potentially avoidable rehospitalizations were more frequently associated with underuse of evidence-based drug treatment than with ADRs. Efforts to avoid ADRs in frail elderly patients must be balanced and combined with evidence-based drug therapy, which can benefit these patients.
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Affiliation(s)
- Niklas Ekerstad
- Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Linköping
| | - Kristoffer Bylin
- Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Trollhättan
| | - Björn W Karlson
- Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Trollhättan
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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17
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Fabbian F, De Giorgi A, Maietti E, Gallerani M, Pala M, Cappadona R, Manfredini R, Fedeli U. A modified Elixhauser score for predicting in-hospital mortality in internal medicine admissions. Eur J Intern Med 2017; 40:37-42. [PMID: 28187963 DOI: 10.1016/j.ejim.2017.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/03/2017] [Accepted: 02/05/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND In-hospital mortality (IHM) is an indicator of the quality of care provided. The two most widely used scores for predicting IHM by International Classification of Diseases (ICD) codes are the Elixhauser (EI) and the Charlson Comorbidity indexes. Our aim was to obtain new measures based on internal medicine ICD codes for the original EI, to detect risk for IHM. MATERIAL AND METHODS This single-center retrospective study included hospital admissions for any cause in the department of internal medicine between January 1, 2000, and December 31, 2013, recorded in the hospital database. The EI was calculated for evaluation of comorbidity, then we added age, gender and diagnosis of ischemic heart disease. IHM was our outcome. Only predictors positively associated with IHM were taken into consideration and the Sullivan's method was applied in order to modify the parameter estimates of the regression model into an index. RESULTS We analyzed 75,586 admissions (53.4% females) and mean age was 72.7±16.3years. IHM was 7.9% and mean score was 12.1±7.6. The points assigned to each condition ranged from 0 to 16, and the possible range of the score varied between 0 and 89. In our population the score ranged from 0 to 54, and it was higher in the deceased group. Receiver operating characteristic curve of the new score was 0.721 (95% CI 0.714-0.727, p<0.001). CONCLUSIONS In order to make prognostic assessment, the use of a score could be of help in targeting interventions in older adults, identifying subjects at high risk for IHM.
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Affiliation(s)
- Fabio Fabbian
- Department of Medical Sciences, Clinica Medica Unit, University of Ferrara, Italy.
| | - Alfredo De Giorgi
- Department of Medical Sciences, Clinica Medica Unit, University of Ferrara, Italy
| | - Elisa Maietti
- Center for Clinical Epidemiology, University of Ferrara, Ferrara, Italy
| | | | - Marco Pala
- Department of Internal Medicine, Hospital of Ferrara, Italy
| | - Rosaria Cappadona
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Roberto Manfredini
- Department of Medical Sciences, Clinica Medica Unit, University of Ferrara, Italy
| | - Ugo Fedeli
- SER - Epidemiological Department, Veneto Region, Padua, Italy
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18
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Chao CT, Tsai HB, Chiang CK, Huang JW. Thrombocytopenia on the first day of emergency department visit predicts higher risk of acute kidney injury among elderly patients. Scand J Trauma Resusc Emerg Med 2017; 25:11. [PMID: 28187736 PMCID: PMC5303206 DOI: 10.1186/s13049-017-0355-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 01/30/2017] [Indexed: 12/31/2022] Open
Abstract
Background Few studies have addressed risk factors for acute kidney injury (AKI) in geriatric patients. We investigated whether thrombocytopenia was a risk factor for AKI in geriatric patients with medical illnesses. Methods A prospective cohort study was conducted, by recruiting elderly (≥65 years) patients who visited the emergency department (ED) for medical illnesses during 2014. They all received hemogram for platelet count determination, and were stratified according to the presence of thrombocytopenia (platelets, <150 K/μL) during their initial ED evaluation. They were prospectively followed up during their ED stay. We analyzed the relationship between the diagnosis of thrombocytopenia and subsequent AKI after ED stay, using Cox proportional hazard modeling, with platelet count as a continuous variable or thrombocytopenia as a categorical variable. Results Of 136 elderly patients (mean age of 80.7 ± 8.2 years, 40% with chronic kidney disease, and 39% with diabetes) enrolled, 22.8% presented with thrombocytopenia, without differences in baseline renal function. After a mean ED stay of 4.4 ± 2.1 days, 41.9% developed AKI (52.6% Kidney Disease Improving Global Outcomes [KDIGO] grade 1, 24.6% grade 2, and 22.8% grade 3). Patients with higher AKI severity had stepwise lower platelet counts compared to those without AKI. The Cox proportional hazard model revealed that lower platelet count as a continuous variable (hazard ratio [HR] 0.984, 95% confidence interval [CI] 0.975–0.994) and as a categorical variable (presence of thrombocytopenia) (HR 1.86, 95% CI 1.06–3.27) increased the risk of AKI. The sensitivity analyses accounting for nephrotoxic medications use, including non-steroidal anti-inflammatory drugs, vancomycin, and contrast, yielded similar results. Discussion Thrombocytopenia is common among ED-visiting elderly, and the potential relationship between platelet counts and the risk of AKI suggests the utility of checking hemogram for those at-risk ofdeveloping adverse renal events. Conclusion Thrombocytopenia on initial presentation might indicate an increased risk of AKI among elderly patients with medical illnesses.
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Affiliation(s)
- Chia-Ter Chao
- Department of Medicine, National Taiwan University Hospital Jinshan Branch, New Taipei City, Taiwan.,Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Hung-Bin Tsai
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Kang Chiang
- Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Integrative Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jenq-Wen Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100, Taiwan.
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19
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Alyahya MS, Hijazi HH, Alshraideh HA, Al-Nasser AD. Using decision trees to explore the association between the length of stay and potentially avoidable readmissions: A retrospective cohort study. Inform Health Soc Care 2017; 42:361-377. [PMID: 28084856 DOI: 10.1080/17538157.2016.1269105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a growing concern that reduction in hospital length of stay (LOS) may raise the rate of hospital readmission. This study aims to identify the rate of avoidable 30-day readmission and find out the association between LOS and readmission. METHODS All consecutive patient admissions to the internal medicine services (n = 5,273) at King Abdullah University Hospital in Jordan between 1 December 2012 and 31 December 2013 were analyzed. To identify avoidable readmissions, a validated computerized algorithm called SQLape was used. The multinomial logistic regression was firstly employed. Then, detailed analysis was performed using the Decision Trees (DTs) model, one of the most widely used data mining algorithms in Clinical Decision Support Systems (CDSS). RESULTS The potentially avoidable 30-day readmission rate was 44%, and patients with longer LOS were more likely to be readmitted avoidably. However, LOS had a significant negative effect on unavoidable readmissions. CONCLUSIONS The avoidable readmission rate is still highly unacceptable. Because LOS potentially increases the likelihood of avoidable readmission, it is still possible to achieve a shorter LOS without increasing the readmission rate. Moreover, the way the DT model classified patient subgroups of readmissions based on patient characteristics and LOS is applicable in real clinical decisions.
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Affiliation(s)
- Mohammad S Alyahya
- a Department of Health Management and Policy. Faculty of Medicine , Jordan University of Science and Technology , Irbid , Jordan
| | - Heba H Hijazi
- a Department of Health Management and Policy. Faculty of Medicine , Jordan University of Science and Technology , Irbid , Jordan
| | - Hussam A Alshraideh
- b Industrial Engineering , Jordan University of Science and Technology , Irbid , Jordan
| | - Amjad D Al-Nasser
- c Department of Statistics, Faculty of Science , Yarmouk University , Irbid , Jordan
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20
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Mundal L, Veierød MB, Halvorsen T, Holven KB, Ose L, Iversen PO, Tell GS, Leren TP, Retterstøl K. Cardiovascular disease in patients with genotyped familial hypercholesterolemia in Norway during 1994–2009, a registry study. Eur J Prev Cardiol 2016; 23:1962-1969. [DOI: 10.1177/2047487316666371] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Liv Mundal
- The Lipid Clinic, Oslo University Hospital Rikshospitalet, Norway
| | - Marit B Veierød
- Department of Nutrition, University of Oslo, Norway
- Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Norway
| | - Thomas Halvorsen
- Department of Health Research, SINTEF Technology and Society, Norway
| | - Kirsten B Holven
- Department of Nutrition, University of Oslo, Norway
- National Advisory Unit for Familial Hypercholesterolemia, Oslo University Hospital, Norway
| | - Leiv Ose
- Department of Nutrition, University of Oslo, Norway
| | - Per Ole Iversen
- Department of Nutrition, University of Oslo, Norway
- Department of Hematology, Oslo University Hospital Rikshospitalet, Norway
| | - Grethe S Tell
- Department of Global Public Health and Primary Care, University of Bergen, Norway
- Department of Health Registries, Norwegian Institute of Public Health, Norway
| | - Trond P Leren
- Unit for Cardiac and Cardiovascular Genetics, Oslo University Hospital Ullevaal, Norway
| | - Kjetil Retterstøl
- The Lipid Clinic, Oslo University Hospital Rikshospitalet, Norway
- Department of Nutrition, University of Oslo, Norway
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21
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Wallace AS, Perkhounkova Y, Bohr NL. Quality of Transition From Hospital to Home: The Influence of Nurse- and Patient-Reported Readiness. Clin Nurs Res 2016; 27:129-147. [PMID: 27635034 DOI: 10.1177/1054773816669449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Identifying those at risk of poor outcomes after hospital discharge is a central focus of health care systems. Our purpose was to better understand whether and how patient- and nurse-assessed readiness for discharge (Pt- and RN-RHDS) is related to patient experiences after discharge. We conducted a prospective survey of 70 Veterans and their assigned nurses on the day of, and again with Veterans 2 weeks after, hospital discharge. The predictive model for post-discharge coping difficulty included educational level ( p = .05) and an interaction between Pt-RHDS ratings and Pt-RN RHDS discordance ( p = .01). The predictive model for patient-reported quality of hospital to home transition experience included Pt-RN RHDS discordance and an interaction between Pt-RHDS and the number of people living with the patient ( p = .05). Our findings demonstrate that agreement between Pt- and RN-RHDS may be an important measure in work aiming to improve patient outcomes post-hospitalization.
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22
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Magdelijns FJH, Schepers L, Pijpers E, Stehouwer CDA, Stassen PM. Unplanned readmissions in younger and older adult patients: the role of healthcare-related adverse events. Eur J Med Res 2016; 21:35. [PMID: 27634174 PMCID: PMC5025596 DOI: 10.1186/s40001-016-0230-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 09/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Readmissions are a burden for patients and increase healthcare costs. In Europe, factors associated with readmissions have not yet been extensively investigated. This study aimed to discover factors associated with readmissions in both young and older adult internal medicine patients. Furthermore, we explored the role of healthcare-related adverse events (AEs) in readmissions. METHODS All patients admitted through the emergency department to the internal medicine department in the last 2 weeks of each month (2011) were included. Information on index admissions and readmissions, defined as an unplanned admission within 30 days after discharge, was obtained from the electronic patient record system. Demographic, clinical, and organizational factors were evaluated for their association with readmissions. RESULTS Of all patients (n = 940), 17.3 % were readmitted; 16.9 % of the younger (<65 years, n = 485), and 17.8 % of the older patients (≥65 years, n = 455). Dependency in activities of daily living (ADL) was the only factor associated with readmissions in both all ages (OR 2.43) and in older patients (OR 3.19), while age was associated with readmissions in younger patients (OR 1.03 per year). AEs leading to 35.4 % of all index admissions were not associated with readmissions. CONCLUSIONS Readmissions are common in medical patients, and, thus, remain a reason for concern in terms of patient safety and quality of care. AEs, responsible for to the index admission, were not associated with readmissions. ADL dependency was the only factor associated with readmission in patients of all ages and older patients, indicating that determining which patients are at risk for readmissions is not easy.
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Affiliation(s)
- Fabienne J H Magdelijns
- Division of General Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht University, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Larissa Schepers
- Division of General Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht University, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Evelien Pijpers
- Section Clinical Geriatric Medicine, Division of General Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands
| | - Coen D A Stehouwer
- Division of General Medicine, Department of Internal Medicine, and Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands
| | - Patricia M Stassen
- Section of Acute Medicine, Division of General Medicine, Department of Internal Medicine, School of CAPHRI, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands
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Meschi T, Ticinesi A, Prati B, Montali A, Ventura A, Nouvenne A, Borghi L. A novel organizational model to face the challenge of multimorbid elderly patients in an internal medicine setting: a case study from Parma Hospital, Italy. Intern Emerg Med 2016; 11:667-76. [PMID: 26846233 DOI: 10.1007/s11739-016-1390-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 01/09/2016] [Indexed: 11/25/2022]
Abstract
Continuous increase of elderly patients with multimorbidity and Emergency Department (ED) overcrowding are great challenges for modern medicine. Traditional hospital organizations are often too rigid to solve them without consistently rising healthcare costs. In this paper we present a new organizational model achieved at Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, a 106-bed internal medicine area organized by intensity of care and specifically dedicated to such patients. The unit is partitioned into smaller wards, each with a specific intensity level of care, including a rapid-turnover ward (mean length of stay <4 days) admitting acutely ill patients from the ED, a subacute care ward for chronic critically ill subjects and a nurse-managed ward for stable patients who have socio-economic trouble preventing discharge. A very-rapid-turnover ("come'n'go") ward has also been instituted to manage sudden ED overflows. Continuity, effectiveness, safety and appropriateness of care are guaranteed by an innovative figure called "flow manager," with skilled clinical experience and managerial attitude, and by elaboration of an early personalized discharge plan anticipating every patient's needs according to lean methodology principles. In 2012-2014, this organizational model, compared with other peer units of the hospital and of other teaching hospitals of the region, showed a better performance, efficacy and effectiveness indexes calculated on Regional Hospital Discharge Records database system, allowing a capacity to face a massive (+22 %) rise in medical admissions from the ED. Further studies are needed to validate this model from a patient outcome point of view.
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Affiliation(s)
- Tiziana Meschi
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy.
| | - Andrea Ticinesi
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
| | - Beatrice Prati
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
| | | | - Antonio Ventura
- Business Management Control Unit, General Management Direction, Parma University Hospital, Parma, Italy
| | - Antonio Nouvenne
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
| | - Loris Borghi
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
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