Cutting out Cholecystectomy on Index Hospitalization Leads to Increased Readmission Rates, Morbidity, Mortality and Cost

Biliary tract diseases that are not adequately treated on index hospitalization are linked to worse outcomes, including high readmission rates. Delays in care for conditions such as choledocholithiasis, gallstone pancreatitis, and cholecystitis often occur due to multiple reasons, and this delay is under-appreciated as a source of morbidity and mortality. Our study is based on the latest Nationwide Readmissions Database review and evaluated the effects of postponing definitive management to a subsequent visit. The study shows a higher 30-day readmission rate in addition to increased mortality rate, intubation rate, vasopressor use in this patient population and significantly added financial burden.

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Evaluating the effect of inpatient diabetes education on length of stay, readmission rates and mortality rates: a systematic review

British Journal of Diabetes ◽

10.15277/bjd.2020.256 ◽

2020 ◽

Vol 20 (2) ◽

pp. 96-103

Author(s):

Zeeshan Hussain ◽

Mohammed Alkharaiji ◽

Iskandar Idris

Keyword(s):

Mortality Rate ◽

Length Of Stay ◽

Clinical Outcomes ◽

Readmission Rate ◽

Diabetes Education ◽

Free Text ◽

Readmission Rates ◽

Inpatient Diabetes ◽

Hospitalised Patients ◽

Patients With Diabetes

Background: Hospitalised patients with diabetes experience a longer duration of inpatient stay, increased readmission rates and excess mortality compared with patients without diabetes.Objectives: To determine whether inpatient diabetes education (IDE), provided to hospitalised patients with diabetes, is an effective intervention in improving one or all of the following clinical outcomes: length of stay (LOS), readmission rate and mortality rate.Methods: A free-text search on MEDLINE, PubMed, CINAHL, BNI and EMBASE was conducted on literature published from the date of each databases’ inception to March 2019. In addition, grey literature was used to support the search with the following key terms: ‘IDE’, ‘LOS’, ‘readmission’ and ‘mortality’, along with their possible substitutes and alternatives combined.Results: In total, eight studies met the inclusion criteria with a total number of 3,828 participants. Seven studies investigated LOS outcome for which accumulated mean LOS and median LOS were both lower (16.5% and 26.67%, respectively) in the IDE group compared with the non-IDE group. Six studies investigated readmittance rates, for which accumulated readmission rate (up to 12 months) was 15.9% lower in the IDE group than in the non-IDE group. Finally, the mortality rate was 36.6% lower in the IDE group compared with the non-IDE group, but this was non-significant and only one study reported this outcome.Conclusion: The findings of this review support the efficacy of an IDE programme in a hospital setting by reducing LOS and readmission rates in patients with diabetes. In addition, a possible trend towards a decreased mortality rate was observed. IDE is therefore recommended to improve clinical outcomes of hospitalised patients with diabetes.

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Impact of Michigan’s new opioid prescribing laws on spine surgery patients: analysis of the Michigan Spine Surgery Improvement Collaborative

Journal of Neurosurgery Spine ◽

10.3171/2020.7.spine20729 ◽

2020 ◽

pp. 1-6

Author(s):

Paul Park ◽

Victor Chang ◽

Hsueh-Han Yeh ◽

Jason M. Schwalb ◽

David R. Nerenz ◽

...

Keyword(s):

Spine Surgery ◽

Spinal Surgery ◽

Readmission Rate ◽

Rating Scale ◽

Short Term ◽

Readmission Rates ◽

Opioid Prescribing ◽

Number Of Patients ◽

Before And After ◽

The Impact

OBJECTIVEIn 2017, Michigan passed new legislation designed to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery.METHODSPatient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated.RESULTSPatients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323).CONCLUSIONSThere was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.

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709 Covid-19 Pandemic: Audit on The Management of Acute Cholecystitis

British Journal of Surgery ◽

10.1093/bjs/znab134.077 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

M Asarbakhsh ◽

N Lazarus ◽

P Lykoudis

Keyword(s):

Laparoscopic Cholecystectomy ◽

Acute Cholecystitis ◽

Readmission Rate ◽

Adverse Outcomes ◽

Management Option ◽

Management Guidelines ◽

Theatre Staff ◽

The Impact ◽

Definitive Management ◽

Upper Gastrointestinal

Abstract Background The definitive management of acute cholecystitis is laparoscopic cholecystectomy on the same admission if the patient is fit. As the Covid-19 pandemic emerged, evidence suggested adverse outcomes for asymptomatic Covid positive patients undergoing surgery, including increased mortality risk. Risks to theatre staff were also highlighted. This prompted changes in acute cholecystitis management guidelines. Method The audit aim was to assess the impact of guideline change on clinical outcomes and readmission rate for acute cholecystitis. The revised Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) guidelines were the gold standard. All inpatient admissions for acute cholecystitis during the 4-week peak of the pandemic (17/04/2020 – 14/05/2020) were included. Result 24 patients were admitted with acute cholecystitis. 10 patients (41.7%) were managed with antibiotics alone, 4 patients (16.6%) underwent cholecystostomy. 12 patients (50%) were discharged within 3 days. Lack of clinical progress/ongoing symptoms was the indication for laparoscopic cholecystectomy in 5 cases (20.8%). 5 conservatively managed patients (20.8%) were readmitted with ongoing cholecystitis or pancreatitis. Conclusions 19 patients (80%) were managed non-surgically in accordance with AUGIS guidelines. However conservative management was not always appropriate. We recommend that laparoscopic cholecystectomy should remain a management option for acute cholecystitis during the ongoing Covid-19 pandemic.

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Abstract TP300: Implementation of Stroke Pathways to Reduce Length of Stay, Cost, Readmissions, and Mortality

Stroke ◽

10.1161/str.51.suppl_1.tp300 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Jayme Strauss ◽

Andrew Waisbrot ◽

Daniel D'Amour ◽

Amy K Starosciak

Keyword(s):

Mortality Rate ◽

Length Of Stay ◽

Readmission Rate ◽

Clinical Pathways ◽

Transitions Of Care ◽

Fiscal Year ◽

Variable Cost ◽

Total Cost ◽

Iv Tpa ◽

Order Set

Introduction: Acute stroke is a major contributor to healthcare costs. In 2012, estimated direct costs associated with stroke was $71B, which is projected to double to $184B by 2030. As healthcare evolves and reimbursements decrease, cost control in disease specific populations is critical. In November 2017, length of stay (LOS) peaked at 5.78 days, as did variable and total cost/case (Table). In fiscal year 2017 the 30-d readmission rate was 9% and the mortality rate was 12%. Compliance with stroke admission order sets was at 55%. Methods: A multidisciplinary committee was formed in February 2017 to develop standardized, evidence-based clinical pathways for three populations: Ischemic stroke (IS) treated with IV tPA, TIA/IS without IV tPA, and intracerebral hemorrhage. The team met biweekly to standardize clinical pathways, decrease time to follow-up imaging, focus on physician order set utilization, and control costs. A comprehensive education program for all clinical staff was completed; official implementation of the pathways was in November 2017. A stroke financials team meets monthly to continue to look at opportunities and transitions of care. We reviewed a retrospective financial report of all in-hospital cases coded as MS-DRG 61-69 from 12/2017 through 7/31/2019 and compared it the 11/2017 report. Results: A total of 83 cases were available for 12/2017 and 2192 for 1/2018 through 7/2019. There was a reduced LOS by 26% (4.34 days), reduced variable cost/case by 24% ($5,958), reduced total cost/case by 23% ($13,790), reduced the 30-d readmission rate to 6%, and reduced the mortality rate to 4%. Case mix index was 12% higher at 1.3272 (vs. 1.2055 previously). Order set compliance improved to 94% (Table). A total cost saving dollar realization of $4.5 million. Discussion: Standardization of stroke clinical pathways led to improved order set compliance, almost 1/4 reduction in variable and total costs per case, shortened LOS, and reduced mortality and readmission rates.

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Abstract 11906: Heart Failure Admissions to General Medicine Services are Associated With Increased 30-day Readmission Rate

Circulation ◽

10.1161/circ.132.suppl_3.11906 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Parag Goyal ◽

Madeline Sterling ◽

Ashley N Beecy ◽

Savira Kochhar ◽

John T Ruffino ◽

...

Keyword(s):

Heart Failure ◽

Readmission Rate ◽

General Medicine ◽

Structural Heart Disease ◽

Multivariate Regression Analysis ◽

Readmission Rates ◽

Modifiable Factors ◽

Patients With Heart Failure ◽

Hospital Patients ◽

Clinical Indices

Introduction: Hospitalists are increasingly caring for patients with heart failure (HF) at a time when there is need to identify modifiable factors associated with 30-day readmission rates. Hypothesis: Patients admitted to General Medicine services (GM) will have higher 30-day readmission rates than those admitted to Cardiology services. Methods: This retrospective cohort comprised patients with a principal diagnosis of HF discharged from GM or Cardiology services in 2013-2014 at an urban academic hospital. Patients discharged with hospice were excluded. Index hospitalizations and 30-day readmissions were identified via query of the electronic medical records. Demographics, clinical indices, and hospitalization characteristics were collected by chart review. Results: Among 926 patients admitted with HF, 40% were admitted to GM and 60% were admitted to a Cardiology service. Patients on GM were slightly older, more likely female, and more likely to have Medicare (Table). They also had higher LVEF, less RV dysfunction, and less ventricular tachycardia (VT). Rates of non-cardiac comorbidities were comparable between groups. Patients on GM experienced a 1.4-fold increased 30-day readmission rate compared to those on Cardiology services (32% vs. 23%, p=0.023). Multivariate regression analysis showed that admission to GM remained a predictor for 30-day readmission (OR 1.37, [1.01 to 1.87], p=0.048) after controlling for key differences between groups including age, sex, insurance, LVEF, RV dysfunction, VT, and admission blood pressure and hemoglobin. Conclusions: HF patients admitted to General Medicine have less structural heart disease, and yet have a higher rate of 30-day readmission compared to those admitted to Cardiology services. This underscores the importance of ensuring that hospitalists obtain adequate heart failure training (related to both inpatient care and optimization of discharge regimens), so as to avoid un-necessary readmissions.

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Abstract 014: Evaluation of Readmission after Acute Myocardial Infarction for Patients Included in Medicare’s Hospital Readmissions Reduction Program

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.014 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Lila M Martin ◽

Ryan W Thompson ◽

Timothy G Ferris ◽

Jagmeet P Singh ◽

Elizabeth Laikhter ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Hospital Readmissions ◽

Index Hospitalization ◽

Readmission Rates ◽

Troponin Elevation ◽

Reduction Program ◽

Improve Accuracy ◽

Episodes Of Care ◽

Index Hospital

Introduction: Medicare’s Hospital Readmissions Reduction Program assesses financial penalties for hospitals based on risk-standardized readmission rates after specific episodes of care, including acute myocardial infarction (AMI). Whether the algorithm accurately identifies patients with AMI who have preventable readmission is unknown. Methods: Using administrative data from Medicare, we conducted physician-adjudicated chart reviews of all patients considered 30 day readmissions after AMI attributed to one hospital from July 2012-June 2015. We extracted information about revascularization during index hospitalization. For patients readmitted to the index hospital or an affiliate, we also extracted reason for readmission. Results: Of 199 admissions, 66 (33.2%) received PCI and 19 (9.6%) underwent CABG on index hospitalization. The remainder of patients did not receive any intervention, i.e. 39 patients (19.6%) were declined due to procedural risk, 15 (7.5%) because of goals of care and 14 (7.0%) refused revascularization. Forty-six patients (23.1%) had troponin elevation in the absence of an MI and did not have an indication for revascularization. The most common diagnoses of the 161 (80.9%) patients readmitted to the index hospital or an affiliate were infections and cardiac and non-cardiac chest discomfort (Table 1). Conclusions: Our results demonstrate that many AMI patients who count towards the Medicare penalty do not receive revascularization during the index hospitalization because of high procedural risk or patient preference. Focusing on these patients may improve readmission metric performance. Furthermore, adding administrative codes for prohibitive procedural risk may improve accuracy of the metric as a measure of quality.

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Abstract WP374: Implementation of the Stroke Transition Discharge Center Improves 30-day Readmission Rate

Stroke ◽

10.1161/str.48.suppl_1.wp374 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Susan Quimby ◽

Javicia Peterson-Cole

Keyword(s):

Readmission Rate ◽

Inverse Correlation ◽

Signs And Symptoms ◽

Patient Specific ◽

Readmission Rates ◽

Hospital System ◽

Practice Nurses ◽

Time Period ◽

Number Of Patients ◽

Discharge Center

Background: Stroke patients and their caregivers require formalized education, medications, testing and rehabilitation to assist in prevention of recurrence and of post-stroke complications for optimal outcomes. Objective: The purpose of this program was to evaluate the effect of the Stroke Transition Discharge Center (STDC) on stroke readmission. Methods: The Advanced Practice Nurses (APN) see all stroke and TIA patients one week after discharge from hospital to home or one week after discharge from rehab to home. During the hour encounter, the APN reviews medications, test results, signs and symptoms of stroke, complete education including patient specific risk factors and ensure appropriate follow up. The APN coordinates and facilitates multiple services and disciplines impacting the patient, assuring the most efficient and effective goal-directed activities are provided at the right time and in partnership with all other disciplines providing care. Results: Implementation of the STDC enhances patient outcomes and improves 30-day readmission rates. Prior to our intervention, the readmission rate was 15.3%. After the implementation of the STDC, there was a 61% reduction in 30-day readmission rates to 6%, which is significantly below the hospital system benchmark of 11%. There was an increase in the readmission rate in the first two quarters of 2016 noted. There is an inverse correlation with the number of patients seen in the STDC during the same time period. Further analysis demonstrates that only one readmission in this time period had been seen prior in the STDC. Conclusion: Implementing the Stroke Transition Discharge Center demonstrated a dramatic reduction in 30-day readmission rates. Our data suggests that utilization of the clinic and participation by the patients has a direct and inverse effect on readmissions. Further data will need to be collected to determine if this is a sustained response.

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Abstract P216: Heart Failure Readmission Rates: Experience of St John's Physician Group Practice Demonstration

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_2.ap216 ◽

2011 ◽

Vol 4 (suppl_2) ◽

Author(s):

Joseph P Drozda ◽

Donna A Smith ◽

Paul C Freiman ◽

Jeffrey A VanSlette ◽

Timothy R Smith

Keyword(s):

Heart Failure ◽

Readmission Rate ◽

Group Practice ◽

Data Sets ◽

Disease Registry ◽

Readmission Rates ◽

Annual Average ◽

Physician Group ◽

Period 2 ◽

Artery Disease

Objective: The appropriateness of using readmission rates alone as markers of the quality of Heart Failure (HF) care has been questioned. The HF program of St. John's Health System's Physician Group Practice (PGP) Demonstration provided an opportunity to assess a number of outcomes that help to put readmission rates in context. The HF program included disease and case management and a disease registry in the PCP office. Methods: Several data sets were analyzed including the EHR, an inpatient database, the disease registry, and the Social Security Death Master File. Traditional Medicare patients admitted to St. John's Hospital from 2000 to 2010 with a diagnosis of HF, were included resulting in data for 5 years before (Period 1) and 5 years after (Period 2) the 2005 inception of PGP. Results: Total admissions were 3559 in Period 1 and 3514 in Period 2. The prevalence of 3 co-morbid conditions in admitted patients increased during Period 2 [diabetes 35.3% (1256/3559) to 42.7% (1499/3514), p<0.001; hypertension 54.8% (1952/3559) to 70.4% (2475/3514), p<0.0001; and coronary artery disease 62.7% (2253/3559) to 66.4% (2332/3514), p=0.015] indicating that patients were getting more complex. HF admissions trended down significantly from Period 1 (709 annual average) to 2009 (637, p=0.007). The 30 day all cause readmission rate dropped in 2005 [16.9% (137/809)] from Period 1 [annual average 18.8% (671 / 3559), p=0.04] and remained stable thereafter [annual average 16.9% (595/3514)]. The 30 day mortality rate was flat from 2000 to 2009 [2.7(15/550)-5.0% (30/597), p=0.3] and increased in 2010 [8.6% (28/327), p<0.0001]. The use of pacemakers and ICDs was unchanged during Period 2 but ACE inhibitor and beta blocker use increased in PGP practices during 2005 and was constant thereafter. Conclusions: The HF program implemented by this PGP project was associated with decreased HF admissions and with increased clinical complexity of admitted patients. Despite this increasing complexity, the 30 day all cause readmission rate dropped in the first year of the program and remained stable thereafter. Finally, 30 day mortality rates were not adversely affected until the last year of the program. The increased mortality in 2010 may be due to a change in case mix but remains unexplained.

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763. 30 Day Readmission Outcomes in Patients Over 80 Years of Age Enrolled in an Outpatient Parenteral Antibiotic Therapy (OPAT) Program

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.831 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S339-S340

Author(s):

Kathleen R Sheridan ◽

Joshua Wingfield ◽

Lauren McKibben ◽

Natalie Clouse

Keyword(s):

Readmission Rate ◽

Chart Review ◽

Age Groups ◽

Retrospective Chart Review ◽

Model Of Care ◽

Readmission Rates ◽

Parenteral Antibiotic ◽

Patient Demographics

Abstract Background OPAT is a well-established model of care for the monitoring of patients requiring long-term IV antibiotics1. We have previously reported a reduction in the 30-day readmission rate to our facility for patients managed in our OPAT program. However, little has been published to date regarding outcomes in OPAT patients over 80 years of age 2–3. Our OPAT program was established in 2013. Patients can be discharged to a facility or home to complete their course of antibiotics. Methods We conducted a retrospective chart review of all OPAT patients discharged from our facility from 2015 to 2018. Patients were divided into two groups based on age, <80 (n = 4618) and >80 (n = 562). Results Patient demographics are listed in Table 1. The overall 30-day readmission rate for patients older than 80 was 27.8%. For patients over 80 that had a follow-up ID clinic appointment, the 30-day readmission rate decreased to 15.7%. For patients younger than 80, the 30-day readmission rate was 36.0% with a decrease to 16.2% if patients were evaluated in the outpatient clinic. Figure 1. Staphylococcus Aureus was the predominant organism in both age categories. Vancomycin was the most common antibiotic used in both age groups followed by β lactams. Conclusion In general, patients aged over 80 years were more likely to be discharged to a facility to complete their antibiotic course than younger patients. These patients also were more likely to have other comorbidities. The 30-day readmission rate in each age group was relatively similar. OPAT in patients over age 80 can have similar 30-day readmission rates as for patients less than 80 years of age Disclosures All authors: No reported disclosures.

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Trajectory Modelling to Assess Trends in Long-Term Readmission Rate among Abdominal Aortic Aneurysm Patients

Surgery Research and Practice ◽

10.1155/2018/4321986 ◽

2018 ◽

Vol 2018 ◽

pp. 1-10

Author(s):

Ahsan Rao ◽

Alex Bottle ◽

Collin Bicknell ◽

Ara Darzi ◽

Paul Aylin

Keyword(s):

Abdominal Aortic Aneurysm ◽

Readmission Rate ◽

High Impact ◽

Short Term ◽

Readmission Rates ◽

Abdominal Aortic ◽

High Readmission Rate ◽

Trajectory Modelling

Introduction. The aim of the study was to use trajectory analysis to categorise high-impact users based on their long-term readmission rate and identify their predictors following AAA (abdominal aortic aneurysm) repair. Methods. In this retrospective cohort study, group-based trajectory modelling (GBTM) was performed on the patient cohort (2006-2009) identified through national administrative data from all NHS English hospitals. Proc Traj software was used in SAS program to conduct GBTM, which classified patient population into groups based on their annual readmission rates during a 5-year period following primary AAA repair. Based on the trends of readmission rates, patients were classified into low- and high-impact users. The high-impact group had a higher annual readmission rate throughout 5-year follow-up. Short-term high-impact users had initial high readmission rate followed by rapid decline, whereas chronic high-impact users continued to have high readmission rate. Results. Based on the trends in readmission rates, GBTM classified elective AAA repair (n=16,973) patients into 2 groups: low impact (82.0%) and high impact (18.0%). High-impact users were significantly associated with female sex (P=0.001) undergoing other vascular procedures (P=0.003), poor socioeconomic status index (P<0.001), older age (P<0.001), and higher comorbidity score (P<0.001). The AUC for c-statistics was 0.84. Patients with ruptured AAA repair (n=4144) had 3 groups: low impact (82.7%), short-term high impact (7.2%), and chronic high impact (10.1%). Chronic high impact users were significantly associated with renal failure (P<0.001), heart failure (P = 0.01), peripheral vascular disease (P<0.001), female sex (P = 0.02), open repair (P<0.001), and undergoing other related procedures (P=0.05). The AUC for c-statistics was 0.71. Conclusion. Patients with persistent high readmission rates exist among AAA population; however, their readmissions and mortality are not related to AAA repair. They may benefit from optimization of their medical management of comorbidities perioperatively and during their follow-up.

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