Risk Analysis Index as a preoperative frailty tool for elective ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus

OBJECTIVE

Idiopathic normal pressure hydrocephalus (iNPH) predominantly occurs in older patients, and ventriculoperitoneal shunt (VPS) placement is the definitive surgical treatment. VPS surgery carries significant postoperative complication rates, which may tip the risk/benefit balance of this treatment option for frail, or higher-risk, patients. In this study, the authors investigated the use of frailty scoring for preoperative risk stratification for adverse event prediction in iNPH patients who underwent elective VPS placement.

METHODS

The Nationwide Readmissions Database (NRD) was queried from 2018 to 2019 for iNPH patients aged ≥ 60 years who underwent VPS surgery. Risk Analysis Index (RAI) and modified 5-item Frailty Index (mFI-5) scores were calculated and RAI cross-tabulation was used to analyze trends in frailty scores by the following binary outcome measures: overall complications, nonhome discharge (NHD), extended length of stay (eLOS) (> 75th percentile), and mortality. Area under the receiver operating characteristic curve analysis was performed to assess the discriminatory accuracy of RAI and mFI-5 for primary outcomes.

RESULTS

A total of 9319 iNPH patients underwent VPS surgery, and there were 685 readmissions (7.4%), 593 perioperative complications (6.4%), and 94 deaths (1.0%). Increasing RAI score was significantly associated with increasing rates of postoperative complications: RAI scores 11-15, 5.4% (n = 80); 16-20, 5.6% (n = 291); 21-25, 7.6% (n = 166); and ≥ 26, 11.6% (n = 56). The discriminatory accuracy of RAI was statistically superior (DeLong test, p < 0.05) to mFI-5 for the primary endpoints of mortality, NHD, and eLOS. All RAI C-statistics were > 0.60 for mortality within 30 days (C-statistic = 0.69, 95% CI 0.68-0.70).

CONCLUSIONS

In a nationwide database analysis, increasing frailty, as measured by RAI, was associated with NHD, 30-day mortality, unplanned readmission, eLOS, and postoperative complications. Although the RAI outperformed the mFI-5, it is essential to account for the potentially reversible clinical issues related to the underlying disease process, as these factors may inflate frailty scores, assign undue risk, and diminish their utility. This knowledge may enhance provider understanding of the impact of frailty on postoperative outcomes for patients with iNPH, while highlighting the potential constraints associated with frailty assessment tools.

Influence of concomitant ablation of nonparoxysmal atrial fibrillation during coronary artery bypass grafting on mortality and readmissions

Objective

We determined the utilization rate of surgical ablation (SA) during coronary artery bypass grafting (CABG) and compared outcomes between CABG with or without SA in a national cohort.

Methods

The January 2016 to December 2018 Nationwide Readmissions Database was searched for all patients undergoing isolated CABG with preoperative persistent or chronic atrial fibrillation by using the International Classification of Diseases, 10th Revision classification. Propensity score matching and multivariate logistic regressions were performed to compare outcomes, and Cox proportional hazards model was used to assess risk factors for 1-year readmission.

Results

Of 18,899 patients undergoing CABG with nonparoxysmal atrial fibrillation, 78% (n = 14,776) underwent CABG alone and 22% (n = 4123) underwent CABG with SA. In the propensity score-matched cohort (n = 8116), CABG with SA (n = 4054) (vs CABG alone [n = 4112]) was not associated with increased in-hospital mortality (3.4% [139 out of 4112] vs 3.9% [159 ut of 4054]; P = .4), index-hospitalization length of stay (10 days vs 10 days; P = .3), 30-day readmission (19.1% [693 out of 3362] vs 17.2% [609 out of 3537]; P = .2), or 90-day readmission (28.9% [840 out of 2911] vs 26.2% [752 out of 2875]; P = .1). Index hospitalization costs were significantly higher for those undergoing SA ($52,556 vs $47,433; P < .001). Rates of readmission at 300 days were similar between patients receiving SA (43.8%) and no SA (42.8%; log-rank P = .3). The 3 most common causes of readmission were not different between groups and included heart failure (24.3% [594 out of 2444]; P = .6), infection (16.8% [411 out of 2444]; P = .5), and arrhythmia (11.7% [286 out of 2444]; P = .2).

Conclusions

In patients with nonparoxysmal atrial fibrillation, utilization of SA during CABG remains low. SA during CABG did not adversely influence mortality or short-term readmissions. These findings support increased use of SA during CABG.

Thirty-Day readmissions among COVID-19 patients hospitalized during the early pandemic in the United States: Insights from the Nationwide Readmissions Database

BACKGROUND

Hospital readmissions are core indicators of the quality of health care provision.

OBJECTIVE

To understand factors associated with 30-day, all-cause hospital readmission rate for patients with COVID-19 in the United States during the early pandemic by utilizing the Nationwide Readmissions Database.

METHODS

This retrospective study characterized the 30-day, all-cause hospital readmission rate for patients with COVID-19 in the United States during the early pandemic by utilizing the Nationwide Readmissions Database.

RESULTS

The 30-day, all-cause hospital readmission rate in this population was 3.2%. We found the most common diagnoses at readmission to be sepsis, acute kidney injury, and pneumonia. Chronic alcoholic liver cirrhosis and congestive heart failure were prominent predictors of readmission among patients with COVID-19. Moreover, we found that younger patients and patients from economically disadvantaged backgrounds were at higher risk of 30-day readmission. Acute complications during index hospitalization, including acute coronary syndrome, congestive heart failure, acute kidney injury, mechanical ventilation, and renal replacement therapy, also increased the risk of 30-day readmission for patients with COVID-19.

CONCLUSION

Based on the results of our study, we advise clinicians to promptly recognize patients with COVID-19 who are at high risk of readmission, and to subsequently manage their underlying comorbidities, to institute timely discharge planning, and to allocate resources to underprivileged patients in order to decrease the risk of 30-day hospital readmissions.

The impact of pulmonary cachexia on inpatient outcomes: A national study

BACKGROUND

Cachexia has been associated with chronic lung disease (pulmonary cachexia syndrome), which is associated with increased mortality. However, studies that looked into this association was relatively small, and national level data are lacking. Herein, we aim to study the association between chronic obstructive lung disease (COPD) and cachexia.

RESEARCH QUESTION

Do patients with COPD and cachexia has worse inpatient outcomes in comparison to those with no cachexia?

STUDY DESIGN AND METHODS

We used the Nationwide Readmissions Database from 2016 to 2019, extracting adult patients with a primary diagnosis of COPD who were admitted between January and November of each year studied. We excluded patients with missing data on event time or length of stay. Furthermore, we excluded all cases with cormobidities associated with cachexia. We used SAS 9.4 for data exploration and analysis.

RESULTS

We included 1,446,431 COPD-related weighted hospitalizations for which 115,276 cases (7.9%) had a concurrent diagnosis of cachexia (or cachexia-related diagnoses). Overall, patients with cachexia (COPD-C), compared to patients with COPD and no cachexia (COPD-NC), were older (mean age 69 vs. 66 years, respectively, P < 0.001) with similar gender distribution (58%). COPD-C patients had more inpatient complications including cardiac arrest, and use of mechanical ventilation (P < 0.001). Furthermore, they had longer mean lengths of stay (5.2 days vs. 3.8 days, P < 0.001). In-hospital mortality during index, admission was significantly higher in these patients at 2.2% compared to 0.5% for COPD-NC (P < 0.001).

CONCLUSION

COPD-related cachexia is associated with increased inpatient mortality, resource utilization, and prolonged hospitalization.

Mental health and substance use disorders at delivery hospitalization and readmissions after delivery discharge

BACKGROUND

The objective was to assess mental health and substance use disorders (MSUD) at delivery hospitalization and readmissions after delivery discharge.

METHODS

This is a population-based retrospective cohort study of persons who had a delivery hospitalization during January to September in the 2019 Nationwide Readmissions Database. We calculated 90-day readmission rates for MSUD and non-MSUD, overall and stratified by MSUD status at delivery. We used multivariable logistic regressions to assess the associations of MSUD type, patient, clinical, and hospital factors at delivery with 90-day MSUD readmissions.

RESULTS

An estimated 11.8% of the 2,697,605 weighted delivery hospitalizations recorded MSUD diagnoses. The 90-day MSUD and non-MSUD readmission rates were 0.41% and 2.9% among delivery discharges with MSUD diagnoses, compared to 0.047% and 1.9% among delivery discharges without MSUD diagnoses. In multivariable analysis, schizophrenia, bipolar disorder, stimulant-related disorders, depressive disorders, trauma- and stressor-related disorders, alcohol-related disorders, miscellaneous mental and behavioral disorders, and other specified substance-related disorders were significantly associated with increased odds of MSUD readmissions. Three or more co-occurring MSUDs (vs one MSUD), Medicare or Medicaid (vs private) as the primary expected payer, lowest (vs highest) quartile of median household income at residence zip code level, decreasing age, and longer length of stay at delivery were significantly associated with increased odds of MSUD readmissions.

CONCLUSION

Compared to persons without MSUD at delivery, those with MSUD had higher MSUD and non-MSUD 90-day readmission rates. Strategies to address MSUD readmissions can include improved postpartum MSUD follow-up management, expanded Medicaid postpartum coverage, and addressing social determinants of health.

Unplanned 30-Day Readmission Rates for Autosomal Dominant Polycystic Kidney Disease: Insight from the Nationwide Readmissions Database

INTRODUCTION

Among end-stage kidney disease (ESKD) patients on dialysis with autosomal dominant polycystic kidney disease (ADPKD), relatively little is known about the epidemiology and risk factors for 30-day readmissions in the USA. Therefore, we evaluated the 30-day unplanned readmission rates and predictors and inpatient care costs among ESKD patients with and without ADPKD using a nationally representative, all-payer database.

METHODS

We utilized the Nationwide Readmissions Database from 2013 to 2018 to identify patients admitted for ESKD on dialysis with and without ADPKD using ICD-9 and ICD-10 codes. The primary outcome was a 30-day, unplanned readmission rate. Secondary outcomes were readmission reasons and timing, mortality, cost of hospitalization and rehospitalization, and adjusted predictors of readmissions. We used χ2 tests, t tests, and Wilcoxon rank-sum tests for descriptive analyses and survey logistic regression to calculate adjusted odds ratios and 95% confidence intervals for associations with readmissions adjusting for confounders.

RESULTS

From 2013 to 2018, in a cohort of 1,404,144 hospitalizations with ESKD on dialysis as the primary and secondary diagnosis on index admission, there were 8,213 (0.58%) patients with ADPKD and 1,395,932 patients without ADPKD. Those who had ADPKD during index admissions had fewer 30 days readmissions (18.8 vs. 23.8%, p < 0.0001). The cost of hospitalizations and readmissions in ESKD on-dialysis patients with ADPKD was higher than non-ADPKD patients. Compared to ESKD patients without ADPKD who were readmitted, readmitted ADPKD patients were more likely to be younger with a lower Elixhauser Comorbidity Index (ECI) score; have received kidney transplant, lower source of income, elective index admissions, private insurance; and be discharged routinely, admitted in hospitals with larger bed size, in teaching hospitals, and less likely to get admitted through the emergency department. Younger age (<75 years), higher ECI score, longer length of stay, Medicare and Medicaid insurance, self-pay, discharge to a short-term hospital, specialized care, home health care, and against medical advice were associated with significantly increased odds of readmission. ADPKD patients were 31% less likely to get readmitted and 43% less likely to die during readmissions.

DISCUSSION/CONCLUSION

Nationwide, ESKD on-dialysis patients with ADPKD were less likely to have 30-day readmission than patients without ADPKD. Inpatient mortality during readmissions in patients admitted with ESKD on dialysis was lower with ADPKD as compared to those without ADPKD at the cost of higher health care expenses.

Mortality, sepsis, and organ failure in hospitalized patients with cirrhosis vary by type of infection

BACKGROUND AND AIM

Infection is associated with substantial morbidity and mortality in cirrhosis, but presumably, not all infections carry the same risk of mortality. We compared outcomes of different sites of infection in a nationally representative sample of inpatients with cirrhosis.

METHODS

We queried the Nationwide Readmissions Database for patients with cirrhosis from 2011 to 2014. Cirrhosis and infection diagnoses were identified by previously used algorithms of ICD-9 codes. The following infections were compared: urinary tract infection (UTI), pneumonia, cellulitis, spontaneous bacterial peritonitis (SBP), and Clostridium difficile infection (CDI). The primary outcome was inpatient mortality. Secondary outcomes included sepsis, any organ failure, multiple organ failures, and 30-day readmission. Outcomes were analyzed using logistic regression and included a priori covariates.

RESULTS

A total of 1 798 830 weighted index admissions were identified. Infection was present in 29.2% overall-including UTI (13.7%), pneumonia (8.9%), cellulitis (5.2%), CDI (2.8%), and SBP (2.0%). Mortality was significantly higher in pneumonia (19.6%), SBP (18.6%), and CDI (17.4%) compared with cellulitis (7.6%) and UTI (11.8%). Sepsis, any, and multiple organ failures were most commonly seen in pneumonia, SBP, and CDI. Multivariable analysis demonstrated that pneumonia had the highest associated mortality (odds ratio [OR] 2.73, confidence interval [CI] 2.68-2.80) and multiple organ failures (OR 3.59, CI 3.50-3.68). Significantly increased 30-day readmission was seen only with SBP (24.9%).

CONCLUSIONS

Outcomes of inpatients with cirrhosis vary significantly depending on the type of infection. The severity and epidemiology of infection in cirrhosis appears to be shifting with pneumonia, not SBP, having the highest prevalence of multiple organ failures and inpatient mortality.

Incidence and Outcomes of Laryngeal Complications Following Adult Cardiac Surgery: A National Analysis

Laryngeal complications (LCs) following cardiac operations contribute to increased morbidity and resource utilization. Using a nationally representative cohort of cardiac surgical patients, we characterized the incidence of LC as well as its associated clinical and financial outcomes. All adults undergoing coronary artery bypass grafting and/or valvular operations were identified using the 2010–2017 Nationwide Readmissions Database. International Classification of Diseases 9th and 10th Revision diagnosis codes were used to identify LC. Trends were analyzed using a rank-based, non-parametric test (nptrend). Multivariable linear and logistic regressions were used to evaluate risk factors for LC, and its impact on mortality, complications, resource use and 30-day non-elective readmissions. Of an estimated 2,319,628 patients, 1.7% were diagnosed with perioperative LC, with rising incidence from 1.5% in 2010 to 1.8% in 2017 (nptrend < 0.001). After adjustment, female sex [adjusted odds ratio 1.08, 95% confidence interval (CI) 1.04–1.12], advancing age, and multi-valve procedures (1.51, 95% CI 1.36–1.67, reference: isolated CABG) were associated with increased odds of LC. Despite no risk-adjusted effect on mortality, LC was associated with increased odds of pneumonia (2.88, 95% CI 2.72–3.04), tracheostomy (4.84, 95% CI 4.44–5.26), and readmission (1.32, 95% CI 1.26–1.39). In addition, LC was associated with a 7.7-day increment (95% CI 7.4–8.0) in hospitalization duration and $24,200 (95% CI 23,000–25,400) in attributable costs. The present study found LC to be associated with increased perioperative sequelae and resource utilization. The development and application of active screening protocols for post-surgical LC are warranted to increase early detection and reduce associated morbidity.

Patient Characteristics and Clinical Outcomes of Type 1 Versus Type 2 Myocardial Infarction

BACKGROUND

Type 2 myocardial infarction (MI) patients may have different characteristics and outcomes when compared with type 1 MI.

OBJECTIVES

The purpose of this study was to compare patients with type 1 MI to those with type 2 MI in the United States.

METHODS

Using the Nationwide Readmissions Database, MI patients were categorized over the 3 months following the introduction of an International Classification of Diseases-10th Revision code specific for type 2 MI. Baseline characteristics and inpatient and post-discharge outcomes among both cohorts were compared.

RESULTS

There were 216,657 patients with type 1 MI, 37,765 patients with type 2 MI, and 1,525 patients with both type 1 and 2 MI. Patients with type 2 MI were older (71 years vs. 69 years; p < 0.001), were more likely to be women (47.3% vs. 40%; p < 0.001), and had higher prevalence of heart failure (27.9% vs. 10.9%; p < 0.001), kidney disease (35.7% vs. 25.7%; p < 0.001), and atrial fibrillation (31% vs. 21%; p < 0.001). Rates of coronary angiography (10.9% vs. 57.3%; p < 0.001), percutaneous coronary intervention (1.7% vs. 38.5%; p < 0.001), and coronary artery bypass grafting (0.4% vs. 7.8%; p < 0.001) were lower among type 2 MI patients. Patients with type 2 MI had lower risk of in-hospital mortality (adjusted odds ratio: 0.57 [95% confidence interval: 0.54 to 0.60]) and 30-day MI readmission (adjusted odds ratio: 0.46 [95% confidence interval: 0.35 to 0.59]). There was no difference in risk of 30-day all-cause or heart failure readmission.

CONCLUSIONS

Patients with type 2 MI have a unique cardiovascular phenotype when compared with type 1 MI, and are managed in a heterogenous manner. Validated management strategies for type 2 MI are needed.

Risk Factors Associated with 90-Day Readmissions Following Occipitocervical Fusion-A Nationwide Readmissions Database Study

BACKGROUND

Occipitocervical fusion (OCF) procedures are increasing due to an aging population and the prevalence of trauma, rheumatoid arthritis, and tumors. Reoperation rates and readmission risk factors for cervical fusions have been established, but in relation to OCF they have not been explored. This study investigates the patterns of readmissions and complications following OCF using a national database.

METHODS

The 2016 U.S. Nationwide Readmissions Database was used for sample collection. Adults (>18 years) who underwent OCF were identified using the 2016 ICD-10 coding system, and we examined the readmission rates (30-day and 90-day) and reoperation rates.

RESULTS

Between January and September 2016, a total of 477 patients underwent OCF; the 30-day and 90-day readmission rates were 10.4% and 22.4%, respectively. The 90-day reoperation rate related to the index surgery was 5.7%. Mean age (68.58 years) was significantly greater in the readmitted group versus nonreadmitted group (61.76 years) (P < 0.001). The readmitted group had a significantly higher Charlson Comorbidity Index and Elixhauser Comorbidity Index (5.00 and 2.41, respectively) than the nonreadmitted group (3.25 and 1.15, respectively; P < 0.001). Nonelective OCF showed a higher readmission rate (29.18%) versus elective OCF (12.23%) (P < 0.001). Medicare and Medicaid patients showed the highest rates of readmission (27.27% and 20.41%, respectively). Readmitted patients had higher total health care costs.

CONCLUSIONS

Nonelective OCF was found to have a readmission rate of almost 2½× that of elective OCF. Understanding risk factors associated with OCF will help with operative planning and patient optimization.

Impact of catheter ablation in patients with atrial flutter and concurrent heart failure

Background

No studies assessed impact of atrial flutter (AFL) ablation on outcomes in patients with AFL and concurrent heart failure (HF).

Objectives

To assess the effect of AFL ablation on mortality and HF readmissions in patients with AFL and HF.

Methods

This retrospective cohort study identified 15,952 patients with AFL and HF from the 2016–17 Nationwide Readmissions Database. The primary outcome was a composite of all-cause mortality and/or HF readmission at 1 year. Secondary outcomes included HF readmission, all-cause mortality, and atrial fibrillation (AF) readmission at 1 year. Propensity score match (1:2) algorithm was used to adjust for confounders. Cox proportional hazard regression was used to generate hazard ratios.

Results

Of the 15,952 patients, 9889 had heart failure with reduced ejection fraction (HFrEF) and 6063 had heart failure with preserved ejection fraction (HFpEF). In the matched HFrEF cohort (n = 5421), the primary outcome was significantly lower in patients undergoing ablation (HR 0.72, 95% CI 0.61–0.85, P < .001). HF readmission (HR 0.73, 95% CI 0.61–0.89, P = .001), all-cause mortality (HR 0.62, 95% CI 0.46–0.85, P = .003), and AF readmission (HR 0.63, 95% CI 0.48–0.82, P = .001) were also significantly reduced. In the matched HFpEF cohort (n = 2439), the primary outcome was lower in the group receiving ablation but was not statistically significant (HR 0.80, 95% CI 0.63–1.01, P = .065).

Conclusion

In patients with AFL and HFrEF, AFL ablation was associated with lower mortality and HF readmissions at 1 year. Patients with AFL and HFpEF did not show a similar significant reduction in the primary outcome.

The association between use of opiates, cocaine, and amphetamines during pregnancy and maternal postpartum readmission in the United States: A retrospective analysis of the Nationwide Readmissions Database

BACKGROUND

Substance use during pregnancy has increased in the United States, with adverse consequences for mother and baby. Similarly, postpartum readmission (PPR) imposes physical, emotional, and financial stressors causing disruption to family functioning and childcare. We used national data to estimate the extent to which women who used opiates, cocaine, and amphetamines during pregnancy are at increased risk of PPR.

METHODS

We analyzed 2010-2014 data from the Nationwide Readmissions Database (NRD). Our exposure, drug use during pregnancy, was identified using diagnosis codes indicative of opioid, cocaine or amphetamine use, abuse, or dependence. The outcome was all-cause PPR, maternal readmission within 42 days following discharge from the delivery hospitalization. Multivariable logistic regression was used to estimate odds ratios (OR) that represented associations between drug use and PPR.

RESULTS

Among 11 million delivery hospitalizations, nearly 1 % had documented use of opiates, cocaine and/or amphetamines. The crude PPR rate was nearly four times higher among users (54.6 per 1000) compared to non-users (14.0 per 1000), and 1 in 10 women who had documented use of more than one drug category experienced postpartum readmission. Even after controlling for sociodemographic and clinical confounders, we observed a two-fold increased odds of PPR among users compared to non-users (OR = 1.95; 95 % CI: 1.82, 2.07).

CONCLUSIONS

The national opioid epidemic should encourage a paradigm shift in health care public policy to facilitate the management of all substance use disorders as chronic medical conditions through evidence-based public health initiatives to prevent these disorders, treat them, and promote recovery.

National trends in hospital readmission following transsphenoidal surgery for pituitary lesions

PURPOSE

Several institutions recently published their experiences with unplanned readmissions rates after transsphenoidal surgery for pituitary lesions. Readmission rates on a national level, however, have not been explored in depth. We investigated nationwide trends in this procedure and associated independent predictors, costs, and causes of 30-day readmission.

METHODS

The Nationwide Readmissions Database was queried to identify patients 18 and older who underwent transsphenoidal surgery for pituitary lesion resection (2010-2015). National trends and statistical variances were calculated based on weighted, clustered, and stratified sample means.

RESULTS

Of the weighted total of 44,759 patients treated over the 6-year period, 4658 (10.4%) were readmitted within 30 days. Readmission rates did not change across the survey period (P = 0.71). Patients readmitted had a higher prevalence of comorbidities than those not readmitted (82.5% vs. 78.4%, respectively, P < 0.001), experienced more postoperative complications (47.2% vs. 31.8%, P < 0.001), and had a longer length of stay (6.59 vs. 4.23 days, P < 0.001) during index admission. The most common causes for readmission were SIADH (17.5%) and other hyponatremia (16.4%). Average total readmission cost was $12,080 with no significant trend across the study period (P = 0.25). Predictors for readmission identified included diabetes mellitus, psychological disorders, renal failure, and experiencing diabetes insipidus during the index admission.

CONCLUSION

Unplanned readmission is an important quality metric. While transsphenoidal pituitary surgery is a relatively safe procedure, 30-day readmission rates and costs have not declined. Future studies on institutional protocols targeting these identified predictors to prevent readmission are necessary to decrease readmission rates on a national scale.

Thirty-day readmission risk after intracranial tumor resection surgeries in children

OBJECTIVE

The risk of readmission after brain tumor resection among pediatric patients has not been defined. The authors' objective was to evaluate the readmission rates and predictors of readmission after pediatric brain tumor resection.

METHODS

Nationwide Readmissions Database (NRD) data sets from 2010 to 2014 were searched for unplanned readmissions within 30 days of the discharge date after pediatric brain tumor resection. Patient demographic variables included sex, age, expected payment source (Medicaid or private insurance), and median annual household income. Readmission events for chemotherapy, radiation therapy, or further tumor resection were not included.

RESULTS

Of 282 patients (12.7%) readmitted within 30 days of the index event, the median time to readmission was 10 days (IQR 5-19 days). The most common reason for readmission was hydrocephalus, which accounted for 19% of readmission events. Other CNS-related complications (24%), surgical site infections or septicemia (14%), seizures (7%), and hematological disorders (7%) accounted for other major readmission events. The median charge for readmission events was $35,431, and the median length of readmission stay was 4 days. In multivariate regression, factors associated with a significant increase in readmission risk included Medicaid as the primary payor, discharge from the index event with home health services, and fluid and electrolyte disorders during the index event.

CONCLUSIONS

More than 10% of pediatric brain tumor patients have unplanned readmission events within 30 days of discharge after tumor resection. Medicaid patients and those with preoperative or early postoperative fluid and electrolyte disturbances may benefit from early or frequent outpatient visits after tumor resection.

Increased complication and mortality among non-index hospital readmissions after brain tumor resection is associated with low-volume readmitting hospitals

OBJECTIVE

Fragmentation of care following craniotomy for tumor resection is increasingly common with the regionalization of neurosurgery. Hospital readmission to a hospital (non-index) other than the one from which patients received their original care (index) has been associated with increases in both morbidity and mortality for cancer patients. The impact of non-index readmission after surgical management of brain tumors has not previously been evaluated. The authors set out to determine rates of non-index readmission following craniotomy for tumor resection and evaluated outcomes following index and non-index readmissions.

METHODS

Retrospective analyses of data from cases involving resection of a primary brain tumor were conducted using data from the Nationwide Readmissions Database (NRD) for 2010-2014. Multivariate logistic regression was used to evaluate the independent association of patient and hospital factors with readmission to an index versus non-index hospital. Further analysis evaluated association of non-index versus index hospital readmission with mortality and major complications during readmission. Effects of readmission hospital procedure volume on mortality and morbidity were evaluated in post hoc analysis.

RESULTS

In a total of 17,459 unplanned readmissions, 84.4% patients were readmitted to index hospitals and 15.6% to non-index hospitals. Patient factors associated with increased likelihood of non-index readmission included older age (75+: OR 1.44, 95% CI 1.19-1.75), elective index admission (OR 1.19, 95% CI 1.08-1.30), increased Elixhauser comorbidity score ≥2 (OR 1.18, 95% CI 1.01-1.37), and malignant tumor diagnosis (OR 1.32, 95% CI 1.19-1.45) (all p < 0.04). Readmission to a non-index facility was associated with a 28% increase in major complications (OR 1.28, 95% CI 1.14-1.43, p < 0.001) and 21% increase in mortality (OR 1.21, 95% CI 1.02-1.44, p = 0.032) in initial analysis. Following a second multivariable logistic regression analysis including the readmitting hospital characteristics, low procedure volume of a readmitting facility was significantly associated with non-index readmission (p < 0.001). Readmission to a lower-procedure-volume facility was associated with a 46%-75% increase in mortality (OR 1.46-1.75, p < 0.005) and a 21%-35% increase in major complications (OR 1.21-1.34, p < 0.005). Following adjustment for volume at a readmitting facility, admission to a non-index facility was no longer associated with mortality (OR 0.90, 95% CI 0.71-1.14, p = 0.378) or major complications (OR 1.09, CI 0.94-1.26, p = 0.248).

CONCLUSIONS

Of patient readmissions following brain tumor resection, 15.6% occur at a non-index facility. Low procedure volume is a confounder for non-index analysis and is associated with an increased likelihood of major complications and mortality, as compared to readmission to high-procedure-volume hospitals. Further studies should evaluate interventions targeting factors associated with unplanned readmission.

Dermatology-specific and all-cause 30-day and calendar-year readmissions and costs for dermatologic diseases from 2010 to 2014

BACKGROUND

Readmissions for skin disease, particularly for the same diagnosis and over time, have not been well studied.

OBJECTIVE

To characterize hospital readmissions for skin disease.

METHODS

A cross-sectional observational study examined the Nationwide Readmissions Database from 2010 to 2014, a national sample of hospital discharges in the United States.

RESULTS

Of the patients in 3,602,599 dermatologic hospitalizations from 2010 to 2014, 9.8% were readmitted for any cause, 3.3% were admitted for the same diagnosis within 30 days, and 7.8% were readmitted for the same diagnosis within the calendar year (CY). The cost of all CY same-cause readmissions was $508 million per year. Mycosis fungoides had the highest 30-day all-cause readmission rate (32%), vascular hamartomas and dermatomyositis had the highest 30-day same-cause readmission rates (21% and 18%, respectively), and dermatomyositis and systemic lupus erythematosus had the highest CY same-cause readmission rates (31% and 24%, respectively). Readmission rates stayed stable from 2010 to 2014. Readmission for the same diagnosis was strongly associated with Medicaid and morbid obesity.

LIMITATIONS

This study is a broad description of hospitalizations for skin disease. Conclusions for individual diseases are not intended.

CONCLUSION

The rates and costs of readmissions for skin diseases remained high from 2010 to 2014. This study identifies diseases associated with high risk of hospital readmission, but disease-specific studies are needed. The diseases and risk factors presented should guide additional studies focused on strategies to reduce readmissions in specific skin diseases.

Suboptimal Use of Inpatient Palliative Care Consultation May Lead to Higher Readmissions and Costs in End-Stage Liver Disease

Background/Aims: Patients with end-stage liver disease (ESLD) have a high risk for readmission. We studied the role of palliative care consultation (PCC) in ESLD-related readmissions with a focus on health care resource utilization in the United States. Methods: We performed a retrospective longitudinal analysis on patients surviving hospitalizations with ESLD from January 2010 to September 2014 utilizing the Nationwide Readmissions Database with a 90-day follow-up after discharge. We analyzed annual trends in PCC among patients with ESLD. We matched PCC to no-PCC (1:1) using propensity scores to create a pseudorandomized clinical study. We estimated the impact of PCC on readmission rates (30- and 90-day), and length of stay (LOS) and cost during subsequent readmissions. Results: Of the 67,480 hospitalizations with ESLD, 3485 (5.3%) received PCC, with an annual increase from 3.6% to 6.7% (p for trend <0.01). The average 30- and 90-day annual readmission rates were 36.2% and 54.6%, respectively. PCC resulted in a lower risk for 30- and 90-day readmissions (hazard ratio: 0.42, 95% confidence interval [CI]: 0.38-0.47 and 0.38, 95% CI: 0.34-0.42, respectively). On subsequent 30- and 90-day readmissions, PCC was associated with decreased LOS (5.6- vs. 7.4 days and 5.7- vs. 6.9 days, p < 0.01) and cost (US $48,752 vs. US $75,810 and US $48,582 vs. US $69,035, p < 0.01). Conclusion: Inpatient utilization of PCC for ESLD is increasing annually, yet still remains low in the United States. More importantly, PCC was associated with a decline in readmission rates resulting in a lower burden on health care resource utilization and improvement in cost savings during subsequent readmissions.

Thirty-day readmission after endovascular or surgical revascularization for chronic mesenteric ischemia: Insights from the Nationwide Readmissions Database

There are limited contemporary data on readmission after revascularization for chronic mesenteric ischemia (CMI). This study aimed to determine the rates, reasons, predictors, and costs of 30-day readmission after endovascular or surgical revascularization for CMI. Patients with CMI discharged after endovascular or surgical revascularization during 2013 to 2014 were identified from the Nationwide Readmissions Database. The rates, reasons, length of stay, and costs of 30-day all-cause, non-elective, readmission were determined using weighted national estimates. Independent predictors of 30-day readmission were determined using hierarchical logistic regression. Among 4671 patients with CMI who underwent mesenteric revascularization, 19.5% were readmitted within 30 days after discharge at a median time of 10 days. More than 25% of readmissions were for cardiovascular or cerebrovascular conditions, most of which were for peripheral or visceral atherosclerosis and congestive heart failure. Independent predictors of 30-day readmission included non-elective index admission, chronic kidney disease (CKD), and discharge to home healthcare or to a skilled nursing facility. Revascularization modality did not independently predict readmission. In a nationwide, retrospective analysis of patients with CMI undergoing revascularization, approximately one in five were readmitted within 30 days. Predictors were largely non-modifiable and included non-elective index admission, CKD, and discharge disposition.

A nationwide analysis of 30-day readmissions related to critical limb ischemia

Objectives There is paucity of information regarding critical limb ischemia-related readmission rates in patients admitted with critical limb ischemia. We studied 30-day critical limb ischemia-related readmission rate, its predictors, and clinical outcomes using a nationwide real-world dataset. Methods We did a secondary analysis of the 2013 Nationwide Readmissions Database. We included all patients with a primary diagnosis of extremity rest pain, ulceration, and gangrene secondary to peripheral arterial disease. From this group, all patients readmitted with similar diagnosis within 30 days were recorded. Results Of the total 25,111 index hospitalization for critical limb ischemia, 1270 (5%) were readmitted with a primary diagnosis of critical limb ischemia within 30 days. The readmission rate was highest (9.5%) for the group that did not have any intervention (revascularization or major amputation) and was lowest for surgical revascularization and major amputation groups (2.6% and 1.3%, P value <0.001 for all groups). Severity of critical limb ischemia at index admission was associated with a significantly higher rate of 30-day readmission. Critical limb ischemia-related readmission was associated with a higher rate of major amputation (29.6% vs. 16.2%, P<0.001), a lower rate of any revascularization procedure (46% vs. 62.6%, P<0.001), and a higher likelihood of discharge to a skilled nursing facility (43.2% vs. 32.2%, P<0.001) compared to index hospitalization. Conclusions In patients with primary diagnosis of critical limb ischemia, 30-day critical limb ischemia-related readmission rate was affected by initial management strategy and the severity of critical limb ischemia. Readmission was associated with a significantly higher rate of amputation, increased length of stay, and a more frequent discharge to an alternate care facility than index admission and thus may serve as a useful quality of care metric in critical limb ischemia patients.