Hospital Readmission Following Discharge From Inpatient Rehabilitation for Older Adults With Debility

Risk factors for readmission of patients with amputation to acute care from inpatient rehabilitation: A retrospective cohort study

INTRODUCTION

Amputation is a major condition that requires inpatient rehabilitation. Some research has been conducted to explore the risk factors for readmission of patients from inpatient rehabilitation facilities to acute care hospitals. However, few studies have included patients with amputation in the study population.

OBJECTIVE

To identify the risk factors for readmission of patients with amputation to acute care hospitals from an inpatient rehabilitation facility.

DESIGN

Retrospective cohort study.

SETTING

An acute rehabilitation hospital associated with a community-based tertiary medical center.

PATIENTS

A retrospective review of 156 independent admissions of 145 patients from June 2019 to July 2022.

MAIN OUTCOME MEASURE

The study outcome measure was readmission to acute care from an acute rehabilitation unit.

RESULTS

Of the 156 independent admissions, the readmission rate was 19% (29/156). The most common cause of transfer was incision-site complications (9/29, 31%), including wound infection and wound dehiscence. Patients with amputation readmitted to acute care are more likely to be receiving dialysis (p < .001), have a longer length of stay in acute care before admission to the rehabilitation facility (p = .039), and have a lower Section GG score on admission (p < .001). Age, sex, ethnicity, amputation level, and history of diabetes mellitus were not associated with acute care hospital readmission. The logistic regression model revealed that patients being on dialysis was the only significant risk factor predictive of readmission to acute care (odds ratio [OR] 4.82, p = .006).

CONCLUSIONS

This study showed that incision-site complications were the most common cause of disruption in inpatient rehabilitation via acute hospital readmission in patients with amputation. Being on dialysis was associated with a higher risk of readmission to acute care hospitals. Based on the results of this study, specific rehabilitation plans might be required for patients with amputation who carry certain risk factors to reduce rehospitalization to the acute care unit.

Factors associated with emergency readmissions after acute stroke: A retrospective audit of two hospitals

RATIONALE, AIMS AND OBJECTIVES

Emergency hospital readmissions within 30 days of discharge from hospital are considered a marker for the quality of hospital care, patient experience, the discharge process and integration with community services. This paper describes the frequency and variations in cause of emergency readmissions at 30 and 90 days following discharge after acute stroke from two stroke units.

METHODS

Retrospective data collection of Hospital Episodes Statistics (HES) and Sentinel Stroke National Audit Programme (SSNAP) of consecutive acute stroke hospital discharges over 24 months from 2017 to 2019 from two specialist stroke units in England. HES data were used to calculate the Charlson comorbidity index (CCI). Covariates were analysed for their association with readmission rate, including: age; gender; CCI; length of stay for first stroke admission; living alone; discharge to a care home; discharge receiving stroke specialist early supported discharge (ESD) rehabilitation and stroke severity as determined by National Institute for Health Stroke Scale on stroke admission.

RESULTS

From 2017 to 2019 there were 1999 live discharges with a primary diagnosis of stroke. Both hospitals had a trend of increasing readmission rates with increasing stroke severity and comorbidity. Longer length of stroke admission, especially for patients with increasing stroke severity, and patients receiving ESD rehabilitation after discharge reduced 90-day readmissions. This association was stronger at 90 days than at 30 days. Different readmission event rates were found at 30 and 90 days and when events were compared between the two hospitals.

CONCLUSION

Understanding differences in readmission event rates between hospitals at 30 and 90 days can support local planning of patient needs in the first weeks after stroke discharge and to investigate ways for hospital to reduce the impact of readmission. It is recommended that stroke services use both 30 and 90-day readmissions to inform service evaluation and improvement.

Behavioral Health Services with Short-Stay Residents in Skilled Nursing Facilities: A Qualitative Study of Clinicians and Administrators

OBJECTIVES

The perspectives of professionals involved in behavioral health (BH) services with short-stay residents in skilled nursing facilities (SNFs) are rarely captured in the literature. This study examines the real-world experiences of BH clinicians and administrators in post-acute/subacute care units in SNFs.

METHODS

This qualitative study used semi-structured interviews with 18 clinicians (e.g., psychologists and social workers) and five administrators (e.g., directors of social services or BH company executives) involved in BH services with short-stay SNF residents. Interviews were recorded, transcribed, and analyzed by two independent coders using conventional thematic content analysis.

RESULTS

Three themes emerged from the data: (1) BH needs are high among short-stay residents and families during post-acute care transitions; (2) BH services offer multiple unique opportunities to enhance post-acute/subacute care in SNFs; and (3) barriers to providing optimal BH care exist at multiple levels and require action from BH clinicians and stakeholders.

CONCLUSIONS

Variability in clinician roles and barriers to optimized care suggest the need for future research targeting best practices and implementation strategies for BH services with short-stay SNF residents.

CLINICAL IMPLICATIONS

Results identified multiple ways in which BH services may enhance resident, family, and staff outcomes, as well as the milieu in SNFs.

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.

Frailty Among Older Individuals with and without COPD: A Cohort Study of Prevalence and Association with Adverse Outcomes

Rationale

Frailty prevalence estimates among individuals with COPD have varied widely, and few studies have investigated relationships between frailty and adverse outcomes in a COPD population.

Objective(s)

Describe frailty prevalence among individuals with and without COPD and examine associations between frailty and mortality and other adverse outcomes in the next two years.

Methods

This was an observational cohort study using Health and Retirement Study data (2006–2018) of community living individuals ages 50–64 and ≥65 with and without COPD (non-COPD). Frailty (Fried phenotype [5 items], and a modified Frailty Index-Comprehensive Geriatric Assessment [Enhanced FI-CGA] [37 items], and debility (modified BODE Index [4 items]) were assessed. Two-year post-assessment outcomes (mortality, ≥1 inpatient stay, home health and skilled nursing facility (SNF) use) were reviewed in a population matched 3:1 (non-COPD: COPD) on age, sex, race, and year using univariate and multivariate logistic regression (adjusted for morbidities). Area-under-the-curve (AUC) was used to evaluate regressions.

Results

The study included 18,979 survey observations for age 50–64, and 24,162 age ≥65; 7.8% and 12.0% respectively reporting a diagnosis of COPD. Fried phenotype frailty prevalence for age ≥65 was 23.1% (COPD) and 9.4% (non-COPD), and for the Enhanced FI-CGA, 45.9% (COPD) and 22.4% (non-COPD). Two-year mortality for COPD was more than double non-COPD for age 50–64 (95% CI: 3.8–5.9% vs 0.7–1.3%) and age ≥65 (95% CI: 11.9–14.3% vs 5.6–6.6%). Inpatient utilization, home health care use, or at least temporary SNF placement were also more frequent for COPD. Measures were predictive of adverse outcomes. In adjusted models, the Fried phenotype and modified BODE score performed similarly, and both performed better than the Enhanced FI-CGA index. AUC values were higher for morality regressions.

Conclusion

Frailty prevalence among individuals with COPD in this national survey is substantially greater than without COPD, even at pre-retirement (50–64 years). These measures identify patients with increased risk of poor outcomes.

Ability of 3 Frailty Measures to Predict Short-Term Outcomes in Older Patients Admitted for Post-Acute Inpatient Rehabilitation

OBJECTIVES

To evaluate the ability of 3 commonly used frailty measures to predict short-term clinical outcomes in older patients admitted for post-acute inpatient rehabilitation.

DESIGN

Observational cohort study.

SETTING AND PARTICIPANTS

Consecutive patients (n = 207) admitted to a geriatric inpatient rehabilitation facility.

METHODS

Frailty on admission was assessed using a frailty index, the physical frailty phenotype, and the Clinical Frailty Scale (CFS). Predictive capacity of the frailty instruments was analyzed for (1) nonhome discharge, (2) readmission to acute care, (3) functional decline, and (4) prolonged length of stay, using multivariate logistic regression models and receiver operating characteristic (ROC) curves.

RESULTS

The number of patients classified as frail was 91 (44.0%) with the frailty index, 134 (64.7%) using the frailty phenotype, and 151 (73.0%) with the CFS. The 3 frailty measures revealed acceptable discriminatory accuracy for nonhome discharge (area under the curve ≥ 0.7) but differed in their predictive ability: the adjusted odds ratio (OR) for nonhome discharge was highest for the CFS [6.2, 95% confidence interval (CI) 1.8-21.1], compared to the frailty index (4.1, 95% CI 2.0-8.4) and the frailty phenotype (OR 2.9, 95% CI 1.2-6.6). For the other outcomes, discriminatory accuracy based on ROC tended to be lower and predictive ability varied according to frailty measure. Readmission to acute care from inpatient rehabilitation was predicted by all instruments, most pronounced by the frailty phenotype (OR 5.4, 95% CI 1.6-18.8) and the frailty index (OR 2.5, 95% CI 1.1-5.6), and less so by the CFS (OR 1.4, 95% CI 0.5-3.8).

CONCLUSIONS AND IMPLICATIONS

Frailty measures may contribute to improved prediction of outcomes in geriatric inpatient rehabilitation. The choice of the instrument may depend on the individual outcome of interest and the corresponding discriminatory ability of the frailty measure.

Psychological interventions with older adults during inpatient postacute rehabilitation: A systematic review

Objective: Older adults in inpatient postacute care settings report high rates of depression and anxiety. Psychological interventions address these symptoms through educational, cognitive, behavioral, relaxation, and/or psychosocial approaches. The purpose of this study was to systematically evaluate the quality of existing literature on psychological interventions for depression and/or anxiety among older adults during an inpatient postacute care stay. Method: Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Google Scholar were searched for key concepts. Studies were included that (a) sampled skilled nursing facility or inpatient rehabilitation facility patients, (b) evaluated a psychological intervention, (c) measured depression and/or anxiety symptoms before and after interventions, and (d) had a mean or median age of 65+. Two raters assessed articles for inclusion and risk of bias. Results: Search strategies identified 7,506 articles for screening; nine met inclusion criteria. Included studies varied by study design, intervention type, and methodological quality. Only one study had low overall risk of bias. Four studies demonstrated preliminary treatment benefits for depression symptoms; none reported benefits for anxiety symptoms. Conclusions: Most of the included studies were limited by small sample size and high risk of bias. Thus, currently, there is insufficient evidence to support the effectiveness of psychological interventions for depression or anxiety among older adults during an inpatient postacute care stay. The authors offer a detailed discussion of methodological limitations, empirical gaps, and future directions to develop this body of literature. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Thirty-day hospital readmission rate, reasons, and risk factors after acute inpatient cancer rehabilitation

Objectives

To evaluate the 30‐day hospital readmission rate, reasons, and risk factors for patients with cancer who were discharged to home setting after acute inpatient rehabilitation.

Design, Setting, and Participants

This was a secondary retrospective analysis of participants in a completed prospective survey study that assessed the continuity of care and functional safety concerns upon discharge and 30 days after discharge in adults. Patients were enrolled from September 5, 2018, to February 7, 2020, at a large academic quaternary cancer center with National Cancer Institute Comprehensive Cancer Center designation.

Main Outcomes and Measures

Thirty‐day hospital readmission rate, descriptive summary of reasons for readmissions, and statistical analyses of risk factors related to readmission.

Results

Fifty‐five (21%) of the 257 patients were readmitted to hospital within 30 days of discharge from acute inpatient rehabilitation. The reasons for readmissions were infection (20, 7.8%), neoplasm (9, 3.5%), neurological (7, 2.7%), gastrointestinal disorder (6, 2.3%), renal failure (3, 1.1%), acute coronary syndrome (3, 1.1%), heart failure (1, 0.4%), fracture (1, 0.4%), hematuria (1, 0.4%), wound (1, 0.4%), nephrolithiasis (1, 0.4%), hypervolemia (1, 0.4%), and pain (1, 0.4%). Multivariate logistic regression modeling indicated that having a lower locomotion score (OR = 1.29; 95% CI, 1.07–1.56; p = 0.007) at discharge, having an increased number of medications (OR = 1.12; 95% CI, 1.01–1.25; p = 0.028) at discharge, and having a lower hemoglobin at discharge (OR = 1.31; 95% CI, 1.03–1.66; p = 0.031) were independently associated with 30‐day readmission.

Conclusion and Relevance

Among adult patients with cancer discharged to home setting after acute inpatient rehabilitation, the 30‐day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation.

Research is needed to determine the rates of and risk factors for 30‐day hospital readmission after acute inpatient cancer rehabilitation to understand the nature of this problem and to decrease costs associated with readmissions. Among adult patients with cancer discharged to a home setting after acute inpatient rehabilitation, the 30‐day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation. Cancer rehabilitation patients may have unique risk factors for readmission.

Predictors of activities of daily living at discharge in elderly patients with heart failure with preserved ejection fraction

The purpose of this study was to clarify the predictive factors of activities of daily living (ADL) at discharge in elderly patients with heart failure with preserved ejection fraction (HFpEF). Participants were selected from among 598 consecutive hospitalized HF patients based on certain criteria. We investigated patient characteristics, and ADL with the motor and cognitive items of the Functional Independence Measure (FIM). We analyzed the data with the unpaired t test, Mann-Whitney U test, χ² test, logistic regression analysis, and receiver operating characteristic (ROC) curves. We included 154 patients for further analyses who were divided into the low ADL group (n = 75) and high ADL group (n = 79). There were significant differences between the two groups in age, long-term care insurance (LTCI) level, New York Heart Association class, creatinine level, albumin level, β-blocker, sitting, standing and walking exercise start days, length of hospital stay, and motor- and cognitive-FIM scores at admission and discharge (p < 0.05). The cutoff values of the ROC curves predicting ADL at discharge were LTCL: support level 2 (area under the curve [AUC]: 0.672, p < 0.001, sensitivity: 0.573, false-positive rate: 0.278); walking exercise start day: 4.5 days (AUC 0.694, p < 0.001, sensitivity: 0.609, false-positive rate: 0.299); motor FIM score: 34.5 points (AUC 0.710, p < 0.001, sensitivity: 0.633, false-positive rate: 0.280); and cognitive FIM score: 28.5 points (AUC 0.806, p < 0.001, sensitivity: 0.759, false-positive rate: 0.227). This study revealed several predictors of ADL at discharge and their associated cutoff values in elderly patients with HFpEF.

Relationship among Activities of Daily Living, Nutritional Status, and 90 Day Readmission in Elderly Patients with Heart Failure

Purpose: This investigation aimed to examine the relationship among activities of daily living (ADL), nutritional status and 90-day hospital readmission in elderly heart failure (HF) patients. Methods: Participants were selected from 634 HF patients consecutively hospitalized at one institution. We investigated patient characteristics, ADL (motor and cognitive items of Functional Independence Measure (FIM)) and nutritional status (Geriatric Nutritional Risk Index (GNRI)). Data were analyzed using unpaired t-test, χ² test, Cox proportional hazard model, and Kaplan-Meier method. Results: The 169 participants that met inclusion criteria were divided into two groups based on hospital readmission within 90 days of discharge. Body mass index (BMI) (p = 0.03), hemoglobin (p = 0.047), GNRI (p = 0.02) and motor-FIM (p = 0.007) were significantly different between the readmission (n = 31) and non-readmission (n = 138) groups. After Cox proportional hazard model analysis, GNRI (HR: 0.96; p = 0.048) and motor-FIM (HR: 0.97; p = 0.03) scores remained statistically significant. Participants were then classified into four groups based on a previous study’s cut-off values of prognosis for GNRI and motor-FIM. Readmission avoidance rate was significantly lower (p = 0.002) in the group with GNRI <92 and motor FIM <75. Conclusions: This study showed that motor-FIM and GNRI scores for hospitalized elderly HF patients were predictors of readmission within 90 days of discharge.

A mixed methods thematic review: Health-related decision-making by the older person

AIMS AND OBJECTIVES

To undertake a mixed methods thematic literature review that explored how elderly adults approached decision-making in regard to their health care following discharge.

BACKGROUND

A critical time for appropriate health decisions occurs during hospital discharge planning with nursing staff. However, little is known how the 89% of elderly living at home make decisions regarding their health care. Research into older adults' management of chronic conditions emerges as an important step to potentially encourage symptom monitoring, prevent missed care and detect deterioration. All should reduce the risk of hospital re-admission.

DESIGN

A mixed methods thematic literature review was undertaken. The structure followed the PRISMA reporting guidelines for systematic reviews recommended by the EQUATOR network.

METHODS

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus online databases were searched using keywords, inclusion and exclusion criteria. References drawn from relevant publications, identified by experts and published between 1995 and 2017 were also considered. Twenty-five qualitative, quantitative and mixed methods studies and reviews were critically appraised (CASP 2013) before inclusion in the review. Analysis of each study's findings was undertaken using Braun and Clarke's (2006) steps to identify major themes and sub-themes.

RESULTS

Four main themes associated with health-related decision-making in the elderly were identified: "the importance of maintaining independence," "decision making style," "management of conditions at home" and "discharge planning."

CONCLUSION

Health care decision preferences in the elderly emerged as highly complex and influenced by multiple factors. Development of a tool to assess these components has been recommended.

RELEVANCE TO CLINICAL PRACTICE

Nurses play a vital role in exploring and understanding the influence that maintaining independence has with each patient. This understanding provides an initial step toward development of a tool to assist collaboration between patients and healthcare professionals involved in their care.

Functional Status Is Associated With 30-Day Potentially Preventable Hospital Readmissions After Inpatient Rehabilitation Among Aged Medicare Fee-for-Service Beneficiaries

OBJECTIVES

To determine the association between patients' functional status at discharge from inpatient rehabilitation and 30-day potentially preventable hospital readmissions. A secondary objective was to examine the conditions resulting in these potentially preventable readmissions.

DESIGN

Retrospective cohort study.

SETTING

Inpatient rehabilitation facilities submitting claims to Medicare.

PARTICIPANTS

National cohort (N=371,846) of inpatient rehabilitation discharges among aged Medicare fee-for-service beneficiaries in 2013 to 2014. The average age was 79.1±7.6 years. Most were women (59.7%) and white (84.5%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

(1) Observed rates and adjusted odds of 30-day potentially preventable hospital readmissions after inpatient rehabilitation and (2) primary diagnoses for readmissions.

RESULTS

The overall rate of any 30-day hospital readmission after inpatient rehabilitation was 12.4% (n=46,265), and the overall rate of potentially preventable readmissions was 5.0% (n=18,477). Functional independence was associated with lower observed rates and adjusted odds ratios for potentially preventable readmissions. Observed rates for the highest versus lowest quartiles within each functional domain were as follows: self-care: 3.4% (95% confidence interval [CI], 3.3-3.5) versus 6.9% (95% CI, 6.7-7.1), mobility: 3.3% (95% CI, 3.2-3.4) versus 7.2% (95% CI, 7.0-7.4), and cognition: 3.5% (95% CI, 3.4-3.6) versus 6.2% (95% CI, 6.0-6.4), respectively. Similarly, adjusted odds ratios were as follows: self-care: .70 (95% CI, .67-.74), mobility: .64 (95% CI, .61-.68), and cognition: .84 (95% CI, .80-.89). Infection-related conditions (44.1%) were the most common readmission diagnoses followed by inadequate management of chronic conditions (31.2%) and inadequate management of other unplanned events (24.7%).

CONCLUSIONS

Functional status at discharge from inpatient rehabilitation was associated with 30-day potentially preventable readmissions in our sample of aged Medicare beneficiaries. This information may help identify at-risk patients. Future research is needed to determine whether follow-up programs focused on improving functional independence will reduce readmission rates.

Hospital readmission risks in older adults following inpatient subacute care: A six-month follow-up study

BACKGROUND

High rates of unplanned hospital readmissions are a burden on healthcare systems and individuals. This study examined factors at, and after initial hospital discharge and their associations with unplanned hospital readmission for older adults up to six months post-discharge from subacute care.

METHODS

Older subacute care patients were surveyed prior to discharge, and assessed monthly post-discharge for six months. Data included the Geriatric Depression Scale, Phone-Fitt sub-scales, Friendship Scale, modified Lubben Social Network Scale, unplanned hospital readmission, self-reported physical capacity and falls in the last month were collected. Regression analyses were used to examine relationships between unplanned hospital readmission and variables that may predispose this outcome.

RESULTS

Participants (n = 311) completed the baseline assessment. N = 218 (70%) completed all at six-month post-discharge. Eighty-nine (29%) participants shared 143 readmissions. Those with cancer history (adjusted OR [95% CI]) (1.97 [1.15, 3.39]), neurological disease other than stroke (2.95 [1.32, 6.57]) and dependence on others to assist in bending tasks (1.94 [1.14, 3.29]) at initial discharge were associated with readmission within six months post-discharge. Those who fell in the last month (adjusted OR [robust 95% CI]) (2.28 [1.43, 3.64]), being less physical active (0.98 [0.96, 0.99]), and dependence on others in moving around residence (2.63 [1.37, 5.06]) after initial discharge were associated with a readmission in the next month within six months post-discharge.

CONCLUSION

Trials investigating the effectiveness of strategies to reduce falls, build physical capacity, increase physical activity level, and connection with health care services after discharge to prevent readmission are warranted.

Therapy Caps and Variation in Cost of Outpatient Occupational Therapy by Provider, Insurance Status, and Geographic Region

OBJECTIVE

This article describes the cost of occupational therapy by provider, insurance status, and geographic region and the number of visits allowed and out-of-pocket costs under proposed therapy caps.

METHOD

This retrospective, population-based study used Medicare Provider Utilization and Payment Data for occupational therapists billing in 2012 and 2013 (Ns = 3,662 and 3,820, respectively). We examined variations in outpatient occupational therapy services with descriptive statistics and the impact of therapy caps on occupational therapy visits and patient out-of-pocket costs.

RESULTS

Differences in cost between occupational and physical therapists were minimal. The most frequently billed service was therapeutic exercises. Wisconsin had the most inflated outpatient costs in both years. Under the proposed therapy cap, patients could receive an evaluation plus 12-14 visits.

DISCUSSIO

. Wide variation exists in potential patient out-of-pocket costs for occupational therapy services on the basis of insurance coverage and state. Patients without insurance pay a premium.

Frailty in a Post-Acute Care Population: A Scoping Review

Frailty is a complex and growing phenomenon facing health care providers throughout the continuum of care. Frailty is not well understood in post-acute care (PAC) settings. The purpose of this scoping review was to summarize current evidence of frailty impact on outcomes and frailty mitigation initiatives in PAC. Three major publication databases were searched from January 2000 to June 2017 that identified 18 articles specifically addressing frailty in PAC. Three themes were identified: scales used to measure frailty, factors that led to an adverse outcome or diagnosis of frailty, and interventions to address frailty in PAC. Scales used to measure frailty were dominated by physical factors and scarce on nutrition and social support. Functional decline, grip strength, gait speed, polypharmacy, and nutrition were identified in the studies as factors that identify frailty and are associated with poor outcomes. All these frailty characteristics compromise patients' ability to benefit from rehabilitation, which further establishes the importance of PAC providers to identify, prevent, and treat frailty. Intervention studies had mixed outcomes, suggesting a need for further development in this area. The findings of this scoping review highlight the need for a comprehensive multidimensional assessment of frailty risks in PAC. LEVEL OF EVIDENCE: IV.

National trends in emergency readmission rates: a longitudinal analysis of administrative data for England between 2006 and 2016

OBJECTIVE

To assess trends in 30-day emergency readmission rates across England over one decade.

DESIGN

Retrospective study design.

SETTING

150 non-specialist hospital trusts in England.

PARTICIPANTS

23 069 134 patients above 18 years of age who were readmitted following an initial admission (n=62 584 297) between April 2006 and February 2016.

PRIMARY AND SECONDARY OUTCOMES

We examined emergency admissions that occurred within 30 days of discharge from hospital ('emergency readmissions') as a measure of healthcare quality. Presented are overall readmission rates, and disaggregated by the nature of the indexed admission, including whether it was elective or emergency, and by clinical health condition recorded. All rates were risk-adjusted for patient age, gender, ethnicity, socioeconomic status, comorbidities and length of stay.

RESULTS

The average risk-adjusted, 30-day readmission rate increased from 6.56% in 2006/2007 to 6.76% (P<0.01) in 2012/2013, followed by a small decrease to 6.64% (P<0.01) in 2015/2016. Emergency readmissions for patients discharged following elective procedures decreased by 0.13% (P<0.05), whereas those following emergency admission increased by 1.27% (P<0.001). Readmission rates for hip or knee replacements decreased (-1.29%; P<0.001); for acute myocardial infarction (-0.04%; P<0.49), stroke (+0.62%; P<0.05), chronic obstructive pulmonary disease (+0.41%; P<0.05) and heart failure (+0.15%; P<0.05) remained stable; and for pneumonia (+2.72%; P<0.001), diabetes (+7.09%; P<0.001), cholecystectomy (+1.86%; P<0.001) and hysterectomy (+2.54%; P<0.001) increased.

CONCLUSIONS

Overall, emergency readmission rates in England remained relatively stable across the observation period, with trends of slight increases contained post 2012/2013. However, there were large variations in trends across clinical areas, with some experiencing marked increases in readmission rates. This highlights the need to better understand variations in outcomes across clinical subgroups to allow for targeted interventions that will ensure highest standards of care provided for all patients.

[The associations between readmission within 30 days and the medical institute factors among older patients receiving home medical care]

AIM

To improve preventive strategies for readmission within 30 days after discharge among older patients receiving home medical care services, we examined the associations between readmission within 30 days and the medical institute factors among patients over 75 years of age.

METHODS

All patients over 75 years of age receiving home medical care services and who had been admitted to hospital or clinic and discharged between September 2013 and July 2014 in Tokyo, Japan, were participants of this study (n=7,213). The primary outcome was readmission within 30 days after discharge. We performed generalized estimating equations (GEEs) using a model with logit link and binominal sampling distribution to examine the associations of sociodemographic variables, the prevalence of chronic diseases and medical institute factors with readmission within 30 days.

RESULTS

Approximately 11.2% of the patients receiving home medical care services who had been discharged were readmitted within 30 days after discharge. Men, cancer patients, and emergency admission were positively associated with readmission within 30 days according to the GEEs. The rate of readmission within 30 days was lower in patients receiving home medical care services at home care support clinics/hospitals after discharge (adjusted odds ratio [aOR] = 0.205, p value < 0.001) and in patients discharged from hospitals with over 200 beds (aOR = 0.447, p value < 0.001, vs. clinics) than in others.

CONCLUSION

Home care support clinics/hospitals, which can provide home medical care services around the clock, may help reduce the rate of readmission within 30 days.

Relationship between Activities of Daily Living and Readmission within 90 Days in Hospitalized Elderly Patients with Heart Failure

Aims

To examine the relationship between activities of daily living (ADL) and readmission within 90 days and assess the cutoff value of ADL to predict readmission in hospitalized elderly patients with heart failure (HF).

Methods

This cohort study comprised 589 consecutive patients with HF aged ≥65 years, who underwent cardiac rehabilitation from May 2012 to May 2016 and were discharged home. We investigated patients' characteristics, basic attributes, and ADL (motor and cognitive Functional Independence Measure [FIM]). We analyzed the data using the unpaired t-test, χ² test, Cox proportional hazard model, receiver operating characteristic (ROC) curve, and Kaplan-Meier method.

Results

Of 589 patients, 113 met the criteria, and they were divided into the nonreadmission (n = 90) and readmission groups (n = 23). Age, body mass index, New York Heart Association class, hemoglobin level, and motor FIM score were significantly different between the two groups (p < 0.05). The body mass index (hazard ratio [HR]: 0.87; p < 0.05) and motor FIM score (HR: 0.94; p < 0.01) remained statistically significant. The cutoff value for the motor FIM score determined by ROC curve analysis was 74.5 points (area under the curve = 0.78; p < 0.001).

Conclusion

The motor FIM score in elderly patients with HF was an independent predictor of rehospitalization within 90 days.

A Guide to Inpatient Cancer Rehabilitation: Focusing on Patient Selection and Evidence-Based Outcomes

Cancer inpatients commonly suffer from impairments that can prohibit safe discharge home from the acute care inpatient medical service and thus require transfer to a postacute inpatient rehabilitation facility. It has been demonstrated in multiple studies that cancer rehabilitation inpatients are able to make statistically significant functional improvements and at a similar pace as their noncancer counterparts. Medical fragility and reimbursement regulations are concerns that affect acceptance and triage of cancer rehabilitation inpatients. Strategies to rehabilitate these challenging patients include considering risk factors for medical complications, consult-based inpatient rehabilitation, and improved communication and coordination with oncology teams.