Predictors of 30-day post-discharge unplanned readmission in a subacute geriatric ward in Singapore

BACKGROUND AND OBJECTIVES: Hospital readmission rate helps to highlight the effectiveness of post- discharge care. There remains a paucity of plausible age based categorization especially for ages below one year for hospital readmission rates. METHODS: Data from 2017 Healthcare cost and utilization project National readmissions database was analyzed for ages 0-18 years. Logistic regression analysis was performed to identify predictors for unplanned early readmissions. RESULTS: We identified 5,529,389 inpatient pediatric encounters which were further divided into age group cohorts. The overall rate of readmissions was identified at 3.2%. Beyond infancy, the readmission rate was found to be 6.7%. Across all age groups, the major predictors of unplanned readmission were cancers, diseases affecting transplant recipients and sickle cell patients. It was determined that reflux, milk protein allergy, hepatitis and inflammatory bowel diseases were significant comorbidities leading to readmission. Anxiety, depression and suicidal ideation depicted higher readmission rates in those older than 13 years. Across ages 1-4 yrs, dehydration, asthma and bronchitis were negative predictors of unplanned readmission. CONCLUSIONS: Thirty-day unplanned readmissions remain a problem leading to billions of tax-payer-dollars lost per annum. Effective strategies for mandatory outpatient follow-up may help the financial aspect of care while also enhancing the quality of care.

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The Association between Sleep Duration and Quality with Readmissions: An Exploratory Pilot-Study among Cardiology Inpatients

Clocks & Sleep ◽

10.3390/clockssleep2020011 ◽

2020 ◽

Vol 2 (2) ◽

pp. 120-142

Author(s):

Clementine Labrosciano ◽

Rosanna Tavella ◽

Amy Reynolds ◽

Tracy Air ◽

John F. Beltrame ◽

...

Keyword(s):

Sleep Quality ◽

Total Sleep Time ◽

Sleep Time ◽

Unplanned Readmission ◽

Post Discharge ◽

Increased Risk ◽

Observational Cohort ◽

Patient’S Perception ◽

Study Participants

Background: Readmissions within 30 days of discharge are prominent among patients with cardiovascular disease. Post hospital syndrome hypothesizes that sleep disturbance during the index admission contributes to an acquired transient vulnerability, leading to increased risk of readmission. This study evaluated the association of in-hospital sleep (a) duration and (b) quality with 30-day all-cause unplanned readmission. Methods: This prospective observational cohort study included patients admitted to the coronary care unit of a South Australian hospital between 2016–2018. Study participants were invited to wear an ActiGraph GT3X+ for the duration of their admission and for two weeks post-discharge. Validated sleep and quality of life questionnaires, including the Pittsburgh Sleep Quality Index (PSQI), were administered. Readmission status and questionnaires were assessed at 30 days post-discharge via patient telephone interview and a review of hospital records. Results: The final cohort consisted of 75 patients (readmitted: n = 15, non-readmitted: n = 60), of which 72% were male with a mean age 66.9 ± 13.1 years. Total sleep time (TST), both in hospital (6.9 ± 1.3 vs. 6.8 ± 2.9 h, p = 0.96) and post-discharge (7.4 ± 1.3 h vs. 8.9 ± 12.6 h, p = 0.76), was similar in all patients. Patient’s perception of sleep, reflected by PSQI scores, was poorer in readmitted patients (9.13 ± 3.6 vs. 6.4 ± 4.1, p = 0.02). Conclusions: Although an association between total sleep time and 30-day readmission was not found, patients who reported poorer sleep quality were more likely to be readmitted within 30 days. This study also highlighted the importance of improving sleep, both in and out of the hospital, to improve the outcomes of cardiology inpatients.

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Discharge Against Medical Advice and Risk of Readmission After Sepsis Hospitalization

10.21203/rs.3.rs-73159/v1 ◽

2020 ◽

Author(s):

Zhen Lin ◽

Yinghong Zhai ◽

Hedong Han ◽

Yang Cao ◽

Cheng Wu ◽

...

Keyword(s):

The United States ◽

Medical Advice ◽

Unplanned Readmission ◽

Post Discharge ◽

Readmission Rates ◽

Against Medical Advice ◽

Medical Institutions ◽

Vulnerable Patients ◽

Significant Difference ◽

Hospitalization Costs

Abstract Background: To describe characteristics of sepsis patients who discharged against medical advice (AMA), identify factors associated with AMA discharges in the patients, and evaluate the association of AMA discharge with 30-day unplanned readmission and outcomes of readmission.Methods: Using the National Readmission Database of the United States, we identified inpatients with sepsis who discharged AMA or discharged home between 2010 and 2017. The baseline characteristics were compared between the two groups. Multivariable models were used to identify factors related to AMA discharge, evaluate the association between AMA discharge and 30-day unplanned readmission, and elucidate the relationship between the AMA discharges and in-hospital outcomes.Results: AMA discharges accounted for 2.29% of all the hospitalized sepsis patients. The prevalence of AMA discharge in sepsis patients increased from 1.99% in 2010 to 2.55% in 2014 (p for trend < 0.001).The unplanned 30-day readmission rates of sepsis patients who discharged AMA and who discharged home are 25.51% and 12.26%, respectively. AMA discharge is statistically significantly associated with 30-day [odds ratio (OR), 2.24; 95% confidence interval (CI), 2.15–2.33], 60-day (OR, 2.07; 95% CI, 1.99–2.15), and 90-day (OR, 1.97; 95% CI, 1.90–2.05) readmission. AMA discharge is also associated with longer length of stay in 30 days (0.44 day, 95% CI, 0.12 days-0.76 days, p=0.007), whereas there was no statistically significant difference in hospitalization costs and in-hospital mortality for patients discharged AMA versus those discharged home.Conclusions: Due to the high risk of readmission, vulnerable patients should be early identified. Medical institutions should conduct post-discharge interventions for patients with AMA discharge, such as follow-up visits and psychological counseling, to reduce readmission.

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Abstract 095: Lessons Learned from the BRIDGE Registry: Major Findings From 8 Years of BRIDGE

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.095 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Morgan Bradford ◽

Rachel Krallman ◽

Colin McMahon ◽

Daniel Montgomery ◽

Eva Kline-Rogers ◽

...

Keyword(s):

Transitional Care ◽

The United States ◽

Lessons Learned ◽

Unplanned Readmission ◽

Post Discharge ◽

Care Clinic ◽

Coronary Syndrome ◽

Patient Reported ◽

Comorbidity Scores

Background: Readmissions after cardiac hospitalizations are frequent and costly in the United States. Delays in follow-up and lack of adherence to guidelines may contribute to high unplanned readmission rates. Bridging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner (NP) led, transitional care clinic for cardiac patients, aimed at reducing readmissions. Data on patients referred to BRIDGE has been collected since 2009; herein we report a summary of significant findings from these data. Methods: A qualitative review of results and conclusions from all published abstracts, oral presentations, and papers from the BRIDGE registry (June 2008-August 2015) was conducted. Content analysis was used to synthesize findings across studies. Results: Data from 3982 patients referred to BRIDGE have been collected. Seven themes were identified in the analysis of BRIDGE publications. During BRIDGE, NPs focused on medical history, symptoms, medication management (in 24.8% of visits), patient education, and referrals. In addition to addressing provider priorities, addressing patient concerns (daily living and clinical questions, feelings and fears) was highly salient, resulting in a high level of patient-NP connectedness as evidenced by high patient-reported scores on the Consultation and Relational Empathy scale (mean 43.5 ± 2.8; possible range 0, 50) and the Patient-Doctor Relationship Questionnaire (mean 43.05 ± 3.1; possible range 5, 45). Readmissions within 30 days were consistently lower for acute coronary syndrome (ACS) patients who attended BRIDGE compared to those who did not (6.4% v. 13.1%; p<0.01); similar results were not seen in heart failure (HF) (15.4% v. 15.7%; p=0.944) or atrial fibrillation (AF) (8.5% v. 5.2%; p=0.343) patients. A spike in HF readmissions was seen between 8-14 days post-discharge, suggesting the need for a sooner appointment. However, follow-up within 7 days of discharge did not show reduced readmissions in HF patients. AF readmissions were also difficult to avoid; in a subset of AF patients readmitted within 30 days, 51.1% (n=23) were readmitted for non-AF diagnoses. High risk patients (i.e. those with an adverse event before BRIDGE) were older, had higher Charlson comorbidity scores, and were more likely to have depression. However, marriage was associated with fewer readmissions. Conclusions: Data from the BRIDGE registry have shown that clinic attendance reduced ACS readmissions; has characterized older, depressed patients with higher Charlson comorbidity scores as being those most likely to be readmitted; and has identified areas for improvement in transitional care (e.g. AF and HF) where readmissions are difficult to avoid. Continuous quality improvement and real-time monitoring of patient outcomes have translated this research into more prompt transitional care, illustrating the importance of registry-based research.

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Abstract 16644: Interstage Clinical Outcomes and Resource Utilization Among Babies With Single Ventricle: Results of A Randomized Cross-over Study Comparing Standard of Care (Notebook) to Tablet PC-Based Monitoring

Circulation ◽

10.1161/circ.132.suppl_3.16644 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Girish Shirali ◽

Lori Erickson ◽

Kathy Goggin ◽

Jonathan Apperson ◽

Michael Bingler ◽

...

Keyword(s):

Resource Utilization ◽

Single Ventricle ◽

Standard Of Care ◽

Hospital Charges ◽

Unplanned Readmission ◽

Tablet Pc ◽

Post Discharge ◽

Exit Survey ◽

Interstage Mortality ◽

Access To Data

Interstage outcomes for babies with single ventricle remain suboptimal. We have developed a tablet PC-based platform (CHAMP) for remote monitoring. This provides immediate access to data and instant alerts to the team. This study evaluates the caregiver experience with CHAMP, and its impact on interstage mortality, morbidity and resource utilization. Methods: All neonates with single ventricle who were discharged from 5/2014 to 5/2015 were prospectively enrolled. For 1 month after discharge, they were all monitored using a notebook. They were randomized to receive CHAMP at either 1 or 2 months post discharge. A month after randomization, caregivers had to choose either the notebook or CHAMP for the remainder of the inter-stage period. Charts were reviewed for mortality, unplanned readmissions and hospital charges. Caregiver experience was assessed through an exit survey. Results: We enrolled 24 babies (Norwood, n=11; BT shunt, n=9; no stage I at discharge (balanced circulation), n=3; hybrid, n=1). They were interstage for 3143 days. There was no interstage mortality in either group. While using CHAMP, families transmitted data on 77% of days. Resource utilization is summarized in the Table. CHAMP instant alerts and scheduled daily alerts led to 10 readmissions for issues that were not recognized by caregivers (low saturations (n=6) and poor feeding / weight gain (n=4). When given the option after randomization, 23 of 24 families chose CHAMP. At the end of monitoring, 23 completed an exit survey; when asked what form of monitoring they would choose if they had to do this over, 19 (82%) stated they would choose CHAMP, 3 would choose either, and 1 would choose the notebook. Conclusions: CHAMP monitoring was associated with significant decreases in unplanned readmission days, ICU days and hospital charges. CHAMP was well-accepted by caregivers, and would appear to facilitate outpatient care for the fragile population of interstage babies with single ventricle.

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The Nature and Cost of Readmissions after Work-Related Traumatic Spinal Injuries in New South Wales, Australia

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph16091509 ◽

2019 ◽

Vol 16 (9) ◽

pp. 1509

Author(s):

Lisa N. Sharwood ◽

Holger Möller ◽

Jesse T. Young ◽

Bharat Vaikuntam ◽

Rebecca Q. Ivers ◽

...

Keyword(s):

Health Service ◽

Spinal Injury ◽

New South ◽

New South Wales ◽

Spinal Injuries ◽

Unplanned Readmission ◽

Post Discharge ◽

Major Work ◽

Work Related ◽

South Wales

This study aimed to measure the subsequent health and health service cost burden of a cohort of workers hospitalised after sustaining work-related traumatic spinal injuries (TSI) across New South Wales, Australia. A record-linkage study (June 2013–June 2016) of hospitalised cases of work-related spinal injury (ICD10-AM code U73.0 or workers compensation) was conducted. Of the 824 individuals injured during this time, 740 had sufficient follow-up data to analyse readmissions ≤90 days post-acute hospital discharge. Individuals with TSI were predominantly male (86.2%), mean age 46.6 years. Around 8% (n = 61) experienced 119 unplanned readmission episodes within 28 days from discharge, over half with the primary diagnosis being for care involving rehabilitation. Other readmissions involved device complications/infections (7.5%), genitourinary or respiratory infections (10%) or mental health needs (4.3%). The mean ± SD readmission cost was $6946 ± $14,532 per patient. Unplanned readmissions shortly post-discharge for TSI indicate unresolved issues within acute-care, or poor support services organisation in discharge planning. This study offers evidence of unmet needs after acute TSI and can assist trauma care-coordinators’ comprehensive assessments of these patients prior to discharge. Improved quantification of the ongoing personal and health service after work-related injury is a vital part of the information needed to improve recovery after major work-related trauma.

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Abstract TMP107: Impact of a Stroke Transitional Care Navigator at a Comprehensive Stroke Center

Stroke ◽

10.1161/str.51.suppl_1.tmp107 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Darren T Larsen ◽

Alexandra Lesko ◽

Elizabeth Baraban

Keyword(s):

Transitional Care ◽

Positive Impact ◽

Outpatient Setting ◽

Unplanned Readmission ◽

Post Discharge ◽

Individualized Care ◽

Ed Visits ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: The Stroke Transitional Care Navigator (STCN), was implemented at our Comprehensive Stroke Center (CSC) in January 2017 in order to bridge care from the inpatient to outpatient setting. The STCN nurse meets with patients prior to discharge to address secondary stroke risk factors and discuss the follow up plan in an effort to improve patient outcomes. The purpose of this study was to determine whether implementation of a STCN improved compliance with follow up stroke neurology care and reduced unplanned readmissions and Emergency Department (ED) visits. Methods: Retrospective data review, included ischemic stroke or ICH patients, 18 or over, discharged from February 2017 through February 2018. Subarachnoid hemorrhages and hospice discharges were excluded. Patients were grouped into a “Followed’ cohort if they had documented contact with the STCN prior to discharge or within 30 days; otherwise they were categorized as “Not Followed”. Outcomes of interest were percentage of patients compliant with attending an outpatient visit with a stroke provider within 45 or 120 days post-discharge and percentage of unplanned readmission and ED visits 30 days post-discharge. Analyses comparing those with and without STCN contact were performed using Fisher’s Exact test and Pearson’s chi square test. Results: There were 689 patients that met inclusion criteria with 47.2% (n=325) in the Followed and 52.8% (n=364) in the Not-Followed cohorts. The Followed cohort was more likely to comply with attending a follow-up visit within 45-days (67.2% vs. 32.8%, p<.001) as well as 120 days of discharge (61.0% vs 39.0%, p<.001). No differences were found between the Followed and Not Followed cohorts for readmissions (9.5% vs. 11.5%, p=.394) or ED visits (9.5% vs. 10.2%, p=.783). Conclusion: The STCN had a significant positive impact on patients returning to clinic for follow up stroke neurology care. Though follow up care has been shown to reduce readmission rates in some studies, in this study there was no impact on 30-day readmissions or ED visits. Given the unique, individualized care and coordination provided by the STCN, which is very well received by patients and providers, qualitative measures may be more useful in the future to determine the effectiveness of the STCN.

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SURG-09. SURGICAL AND PERI-OPERATIVE CONSIDERATIONS FOR BRAIN METASTASES: A NATIONWIDE ANALYSIS

Neuro-Oncology Advances ◽

10.1093/noajnl/vdz014.144 ◽

2019 ◽

Vol 1 (Supplement_1) ◽

pp. i32-i32

Author(s):

Saksham Gupta ◽

Alexandra Giantini Larsen ◽

Hassan Dawood ◽

Luis Fandino ◽

Erik Knelson ◽

...

Keyword(s):

Brain Metastases ◽

Cohort Analysis ◽

Medical Complications ◽

Unplanned Readmission ◽

Cardiac Events ◽

Post Discharge ◽

Improvement Project ◽

Improve Risk Stratification ◽

Cerebrospinal Fluid Diversion ◽

Tract Infections

Abstract BACKGROUND: Brain metastases are the most frequent brain tumors in adults, whose management remains nuanced. We aim to improve risk stratification for brain metastases patients who might be candidates for surgical resection. METHODS: We conducted a nationwide, retrospective cohort analysis of adult patients who received craniotomy for resection of brain metastasis using the 2012–2015 American College of Surgeons National Surgical Quality Improvement Project databases. Our primary outcomes of interest were post-operative medical complications, reoperation, readmission, and mortality. RESULTS: 3500 cases were included, of which 17% were considered frail and 24% were infratentorial. The most common 30-day medical complications were pneumonia (4%), venous thromboembolism (VTE;3%), and urinary tract infections (2%). Cardiac events and cerebrovascular accidents tended to occur in the early post-operative period, while VTEs and infections occurred in a more delayed fashion. Reoperation and unplanned readmission occurred in 5% and 12% of patients, respectively. Infratentorial approach and frailty were associated with reoperation before discharge (OR 2.0 for both; p=0.01 and p=0.03 respectively), but not after discharge. Frail patients were especially at risk for surgical evacuation of hematoma (OR 3.6). Infratentorial approaches conferred heightened risk for readmission for hydrocephalus (OR 5.1, p=0.02) and reoperation for cerebrospinal fluid diversion (OR 7.1, p< 0.001). Overall 30-day mortality was 4%, with nearly three-quarters occurring after discharge. Pre-frailty and frailty were associated with increased odds for post-discharge mortality (OR 1.7 and 2.7, p< 0.05), but not pre-discharge mortality. We developed a model to predictors of death, which identified frailty, thrombocytopenia, and high American Society of Anesthesiologists score as the strongest predictors of 30-day mortality (AUROC 0.75). CONCLUSION: Optimization of metrics contributing to patient frailty and heightened surveillance in patients with infratentorial metastases may be considered in the peri-operative period.

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Development and usability of a digital healthcare management ecosystem to reduce hospital readmissions. (Preprint)

10.2196/preprints.20433 ◽

2020 ◽

Author(s):

Prem Prakash Sharma ◽

Christine Hsieh ◽

Khalid Aljabri ◽

Vishnu Vardhan ◽

Elizabeth Bisio ◽

...

Keyword(s):

Patient Engagement ◽

The United States ◽

Healthcare Management ◽

Unplanned Readmission ◽

Proof Of Concept ◽

Post Discharge ◽

Evaluation Period ◽

Testing Period ◽

Discharge Care ◽

Digital Healthcare

BACKGROUND Among 36 million hospitalizations that occur each year in the United States, >5 million return for unplanned readmission within 30 days of discharge. Although, prevention of readmission due to clinical and procedural factors are considered, there has not been a sufficient focus on improving patient engagement to reduce readmissions. Poor patient engagement by the hospital clinical team results in the lack of knowledge of the disease and treatment in patients that further lead to inadequate self-managed care for recovery during the post-discharge period. OBJECTIVE The objective of this study was to assess proof-of-concept of a digital healthcare management ecosystem that allow human and digital interactions to reduce unplanned readmissions by providing comprehensive post-discharge care to individuals discharged after major surgery. METHODS Post-discharge care was through digitized tailored care pathways provided by 19 care coaches (1 for 50 patients) supported by a digital expert medical team. We tested our digital ecosystem from January 01, 2019 to December 31, 2019 in cardiac and orthopedic surgery departments, Fortis Hospital, Bangalore, India. The first six months was the testing period where the system was deployed, tested in real-world, and refined using feedback. The testing period was followed by six months of evaluation period. RESULTS A total of 152 patients were provided digital care during testing and 648 patients during the evaluation period. During a 30-day follow up after discharge, 80/800 (10%) communicated clinical complaints, and 39 were readmitted (4.9%). CONCLUSIONS Our results demonstrate feasibility and proof-of-concept of a comprehensive digital post-discharge care ecosystem, a unique innovative solution to reduce unplanned readmission rates and subsequently reduce healthcare costs. However, an important part of effectiveness of post-discharge care remains in testing our solution in large clinical studies

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30-day readmission among gastrointestinal cancer patients in Texas.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.31_suppl.121 ◽

2013 ◽

Vol 31 (31_suppl) ◽

pp. 121-121

Author(s):

Joanna-Grace Manzano ◽

Ruili Luo ◽

Linda S. Elting ◽

Maria Suarez-Almazor

Keyword(s):

Cancer Patients ◽

Claims Data ◽

Healthcare Delivery ◽

The Elderly ◽

Unplanned Readmission ◽

Electrolyte Disorders ◽

Post Discharge ◽

Readmission Rates ◽

Early Readmission ◽

Tract Infections

121 Background: 30 day readmission has become an important metric in healthcare delivery. Policymakers have started to factor in readmission rates in their recommendations on reimbursement algorithms. It is unclear whether these methods are applicable to cancer patients. More studies are needed in order to understand readmission in the context of cancer patients. A few studies have found that the elderly and those with gastrointestinal (GI) malignancies are at risk. Methods: We conducted a retrospective cohort study using linked Texas Cancer Registry and Medicare claims data to describe the patterns of 30 day unplanned readmission among GI cancer patients in Texas. Only short stays to acute care hospitals were included in the study. Claims data were analyzed for a period of 2 years from the date of cancer diagnosis. Modified Poisson regression model was used to identify factors associated with the outcome. Results: 30,199 patients aged 66 and above were included in our study. The incidence of unplanned readmission in our cohort was 15%. The top 10 reasons for readmission were fluid and electrolyte disorders, secondary malignancies, complications of surgical procedures and medical care, congestive heart failure, intestinal obstruction, pneumonia, sepsis, GI hemorrhage, urinary tract infections, and complications of device, implant or graft. After multivariate analysis, age >80 (OR 0.79, 0.73-0.85), regional (1.19, 1.11-1.27) and distant disease (1.16, 1.07-1.25), living in less affluent neighborhoods (1.10, 1.01-1.19), and increasing comorbidity index (p<0.0001) were associated with 30 day readmission. Esophageal cancer carried the highest risk for 30 day readmission (1.53, 1.38-1.70). Conclusions: Most of the top reasons for readmission appear to be cancer-related. This means that most of these readmissions are likely not preventable. This should be taken into consideration by policymakers when making recommendations. There are, however, some that may be amenable to outpatient management. This further underlines the importance of primary care involvement in the management of cancer patients. Risk factors identified can help risk–stratify patients who may need early follow up post-discharge, in order to prevent early readmission.

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