Randomized intervention and outpatient follow-up lowers 30-d readmissions for patients with hepatic encephalopathy,decompensated cirrhosis

BACKGROUND We previously reported national 30-d readmission rates of 27% in patients with decompensated cirrhosis(DC).AIM To study prospective interventions to reduce early readmissions in DC at our tertiary center.METHODS Adults with DC admitted July 2019 to December 2020 were enrolled and randomized into the intervention(INT) or standard of care(SOC) arms. Weekly phone calls for a month were completed. In the INT arm, case managers ensured outpatient follow-up, paracentesis, and medication compliance. Thirty-day readmission rates and reasons were compared.RESULTS Calculated sample size was not achieved due to coronavirus disease 2019;240 patients were randomized into INT and SOC arms. 30-d readmission rate was 33.75%, 35.83% in the INT vs 31.67% in the SOC arm(P = 0.59). The top reason for 30-d readmission was hepatic encephalopathy(HE, 32.10%). There was a lower rate of 30-d readmissions for HE in the INT(21%) vs SOC arm(45%, P = 0.03). There were fewer 30-d readmissions in patients who attended early outpatient follow-up(n = 17, 23.61% vs n = 55, 76.39%, P = 0.04).CONCLUSION Our 30-d readmission rate was higher than the national rate but reduced by interventions in patients with DC with HE and early outpatient follow-up. Development of interventions to reduce early readmission in patients with DC is needed.

Strategies to Reduce Heart Failure Hospitalizations and Readmissions:How Low Can We Go?

It is estimated that more than one million heart failure hospitalizations occur each year.Systolic heart failure and heart failure with preserved ejection fraction contribute equally to heart failure hospitalizations.Heart failure readmission rates continue to be about 25%.Strategies to reduce heart failure readmission are key to reducing hospitalization rates.The strategies to reduce heart failure hospitalization are as follows:(1)During hospitalization,diuresis to the euvolemic state is essential.Fifty percent of discharged heart failure patients have minimal weight loss during the hospitalization,representing minimal diuresis,but still fl uid overload.(2)During hospitalization,interrogate the defi brillator or biventricular pacemaker(if applicable)to ensure that there is no right ventricular pacing and there is appropriate biventricular pacing.Interrogation of devices can identify arrhythmia or suboptimal biventricular pacing,which can contribute to decompensation.(3)Before discharge,identify the reason for decompensation,such as atrial fibrillation,infection,pulmonary embolism,or noncompliance.(4)Before discharge a multidisciplinary team is needed to educate the patient on diet,medications,fl uid weight surveillance,and exercise.(5)A postdischarge visit should occur within 10 days and with emphasis on uptitration of neurohormonal blockers and continued congestion management.Such interventions conducted by a multidisciplinary team have the potential to reduce heart failure hospitalization rates.

Trends of alcoholic liver cirrhosis readmissions from 2010 to 2018:Rates and healthcare burden associated with readmissions

BACKGROUND Alcoholic liver cirrhosis(ALC)is a chronic liver disease with varying disease severity.Readmissions of ALC are associated with poor outcomes.AIM To identify and assess trends of readmissions for ALC over an eight-year period.METHODS This retrospective interrupted trend study analysed 30-d readmissions of ALC in the United States from 2010 to 2018 using the National Readmissions Database.Hospitalization for ALC was the reason for index admission obtained using the International Classification of Diseases codes(571.2 and K70.3X).Biodemographic characteristics and hospitalization trends were highlighted over time.A multivariate regression analysis model was used to calculate the trend for riskadjusted odds of 30-d all-cause ALC readmissions,ALC specific readmission rate,ALC readmission proportion,inpatient mortality,mean length of stay(LOS)and mean total hospital cost(THC)following adjustments for age,gender,grouped Charlson Comorbidity Index,insurance,mean household income,and hospital characteristics.RESULTS There was a trend towards increasing total 30-d readmissions of ALC from 7660 in 2010 to 15085 in 2018(P<0.001).Patients readmitted for ALC were noted to have an increasing comorbidity burden over time.We noted a rise in the risk-adjusted 30-d all-cause readmission of ALC from 24.9%in 2010 to 29.9%in 2018(P<0.001).ALC-specific readmission rate increased from 6.3%in 2010 to 8.4%in 2018(P<0.001)while ALC readmission proportion increased from 31.4%in 2010 to 36.3%in 2018(P<0.001).Inpatient mortality for 30-d readmissions of ALC declined from 10.5%in 2010 to 8.2%in 2018(P=0.0079).However,there was a trend towards increasing LOS from 5.6 d in 2010 to 6.3 d in 2018(P<0.001)and increasing THC from 13790 dollars in 2010 to 17150 dollars in 2018(P<0.001).The total days of hospital stay attributable to 30-d readmissions of ALC increased by 119.2%while the total attributable hospital costs increased by 149%by the end of 2018.CONCLUSION There was an increase in the 30-d readmission rate and comorbidity burden for ALC;however,inpatient mortality declined.Additionally,there was a trend towards increasing LOS and THC for these readmissions.

Causes of Hospital Readmissions at the Community Level

Reducing inpatient hospital readmissions has been an important component of efforts to improve outcomes and reduce health care costs. This study focused on evaluation of the clinical causes of hospital readmissions of adult medical/surgical patients within 30 days between October 2015 and September 2016. It was based on the principal diagnoses of readmissions, a definition that is used throughout the health care industry in the United States. The study focused on adult medicine and adult surgery readmissions in Syracuse, New York, a small metropolitan area, during a twelve month period. It included almost 4000 individual readmissions. The study data demonstrated that only about 22 percent of inpatient readmissions were for the same diagnoses as the initial admissions that preceded them. The study data also indicated that another 20 percent of hospital readmissions involved a diagnosis different from that of the initial admission but in the same body system. Most importantly, the study demonstrated that a consistent majority of inpatient readmissions were caused by diagnoses in different body systems than the initial. The data suggested that efforts to address the causes of hospital readmissions should be based on management of a broad range of adult medicine conditions, rather than individual diagnoses.

Evaluating Changes in Drivers of Hospital Readmissions at the Community Level

This study involved evaluation of the impact of drivers of changes in adult medicine readmission rates in the hospitals of Syracuse, New York. The study focused on this population because adult medicine readmissions were the largest source of medical-surgical and aggregate inpatient readmissions in the local hospitals. The study focused on identifying and correlating readmission rates for specific indicators over a twenty seven month period. Probably, the most important findings identified in the data were the high readmission rates for patients with high severity of illness and the strong correlations between readmission rates for these patients and total adult medicine readmission rates. Correlations between these readmission rates over the twenty seven month period exceeded 0.7000 for each of the hospitals. The study also identified readmission rates and correlations between rates for specific indicators including patient origin and chronic care diagnoses with readmission rates for all of adult medicine. The results of the study identified challenges facing hospital efforts to reduce readmissions including the need to provide alternative services for patients with high severity of illness and the need to address the impacts of multiple chronic diagnoses.

Increasing thirty-day readmissions of Crohn’s disease and ulcerative colitis in the United States:A national dilemma

BACKGROUND The prevalence of Crohn’s disease(CD)and ulcerative colitis(UC)is on the rise worldwide.This rising prevalence is concerning as patients with CD and UC may frequently relapse leading to recurrent hospitalizations and increased healthcare utilization.AIM To identify trends and adverse outcomes for 30 d readmissions for CD and UC.METHODS This was a retrospective,interrupted trends study involving all adult(≥18 years)30 d readmissions of CD and UC from the National Readmission Database(NRD)between 2008 and 2018.Patients<18 years,elective,and traumatic hospitalizations were excluded from this study.We identified hospitalization characteristics and readmission rates for each calendar year.Trends of inpatient mortality,mean length of hospital stay(LOS)and mean total hospital cost(THC)were calculated using a multivariate logistic trend analysis adjusting for age,gender,insurance status,comorbidity burden and hospital factors.Furthermore,trends between CD and UC readmissions were compared using regression of the interaction coefficient after adjusting for age and gender to determine relative trends between the two populations.Stata®Version 16 software(StataCorp,TX,United States)was used for statistical analysis and P value≤0.05 were considered statistically significant.RESULTS Total number of 30 d readmissions increased from 6202 in 2010 to 7672 in 2018 for CD and from 3272 in 2010 to 4234 in 2018 for UC.We noted increasing trends for 30-day all-cause readmission rate of CD from 14.9%in 2010 to 17.6%in 2018(P-trend<0.001),CD specific readmission rate from 7.1%in 2010 to 8.2%in 2018(P-trend<0.001),30-day all-cause readmission rate of UC from 14.1%in 2010 to 15.7%in 2018(P-trend=0.003),and UC specific readmission rate from 5.2%in 2010 to 5.6%in 2018(P-trend=0.029).There was no change in the risk adjusted trends of inpatient mortality and mean LOS for CD and UC readmissions.However,we found an increasing trend of mean THC for UC readmissions.After comparison,there was no statistical difference in the trends for 30 d all-cause readmission rate,inpatient mortality,and mean LOS between CD and UC readmissions.CONCLUSION There was an increase in total number of 30 d readmissions for CD and UC with a trend towards increasing 30 d all-cause readmission rates.

Medicare Hospital Readmissions at the Community Level

The Medicare Hospital Readmissions Reduction Program has been implemented in the United States for a five-year period. This study reviewed data associated with Medicare readmissions in the metropolitan area of Syracuse, New York during 2015 and 2016, the latest years available. The study data demonstrated that the total number of annual Medicare readmissions for the Syracuse hospitals increased from 2132 to 2202, while chain readmission rates declined from 8.30 to 7.65 as the at-risk population increased. The data also demonstrated that readmissions for diagnosis and procedure categories used in the Medicare program accounted for only 15 - 21 percent of total Medicare readmissions. The study suggested that the program should be expanded by including all Medicare readmissions and that it should employ more current data.

Trends in hospital readmissions and emergency room visits 60 days after robotic-assisted and laparoscopic hysterectomy

Objective:Hospital readmission after surgery is one of the major contributors to the increased healthcare cost.Robotic-assisted hysterectomy(RAH)is an innovative surgical procedure most commonly performed within the last decade.The purpose of this study was to analyze the effects on hospital readmission patterns and emergency room(ER)visits within 60 days of discharge for women who had RAH versus laparoscopic hysterectomy(LH)in an academic community hospital in Texas.Method:We performed a retrospective study of women with RAH or LH.We used the univariate and multivariate logistic regression to examine the impact of patients'risk factors,the type of surgery,age,number of comorbidities,and duration of surgery on the 60-day hospital readmissions and ER visits.Results:A total of 291 cases with RAH or LH for benign and malignant indications were examined.The number of comorbidities and duration of surgery were similar between the two treatment groups(p>0.05).Patients in the RAH group were younger than the LH group(RAH:45.4±9.9 y,LH:49.8±11.5 y,p<0.05).No significant difference neither in hospital readmission or ER visits between the two groupswas observed(p?0.544 and p=0.109,respectively).Younger age and longer duration of surgery were significantly associated with a higher risk of ER visits(p<0.05).Conclusion:RAH is comparable with LH in hospital readmissions and ER visits.The younger age and longer operation time could lead to ER visits.

Ninety-day readmissions after inpatient cholecystectomy: A 5-year analysis

AIM To determine the incidence of readmission after cholecystectomy using 90 d as a time limit. METHODS We retrospectively reviewed all patients undergoing cholecystectomy at the General Surgery and Digestive System Service of the University Hospital of Guadalajara, Spain. We included all patients undergoing cholecystectomy for biliary pathology who were readmitted to hospital within 90 d. We considered readmission to any hospital service as cholecystectomyrelated complications. We excluded ambulatory cholecystectomy, cholecystectomy combined with other procedures, oncologic disease active at the time of cholecystectomy, finding of malignancy in the resection specimen, and scheduled re-admissions for other unrelated pathologies. RESULTS We analyzed 1423 patients. There were 71 readmissions in the 90 d after discharge, with a readmission rate of4.99%. Sixty-four point seven nine percent occurred after elective surgery(cholelithiasis or vesicular polyps) and 35.21% after emergency surgery(acute cholecystitis or acute pancreatitis). Surgical non-biliary causes were the most frequent reasons for readmission, representing 46.48%; among them, intra-abdominal abscesses were the most common. In second place were non-surgical reasons, at 29.58%, and finally, surgical biliary reasons, at 23.94%. Regarding time for readmission, almost 50% of patients were readmitted in the first week and most second readmissions occurred during the second month. Redefining the readmissions rate to 90 d resulted in an increase in re-hospitalization, from 3.51% at 30 d to 4.99% at 90 d. CONCLUSION The use of 30-d cutoff point may underestimate the incidence of complications. The current tendency is to use 90 d as a limit to measure complications associated with any surgical procedure.

Risk factors for hospital readmissions in pneumonia patients: A systematic review and meta-analysis

BACKGROUND Factors that are associated with the short-term rehospitalization have been investigated previously in numerous studies.However,the majority of these studies have not produced any conclusive results because of their smaller sample sizes,differences in the definition of pneumonia,joint pooling of the in-hospital and post-discharge deaths and lower generalizability.AIM To estimate the effect of various risk factors on the rate of hospital readmissions in patients with pneumonia.METHODS Systematic search was conducted in PubMed Central,EMBASE,MEDLINE,Cochrane library,ScienceDirect and Google Scholar databases and search engines from inception until July 2021.We used the Newcastle Ottawa(NO)scale to assess the quality of published studies.A meta-analysis was carried out with random-effects model and reported pooled odds ratio(OR)with 95%confidence interval(CI).RESULTS In total,17 studies with over 3 million participants were included.Majority of the studies had good to satisfactory quality as per NO scale.Male gender(pooled OR=1.22;95%CI:1.16-1.27),cancer(pooled OR=1.94;95%CI:1.61-2.34),heart failure(pooled OR=1.28;95%CI:1.20-1.37),chronic respiratory disease(pooled OR=1.37;95%CI:1.19-1.58),chronic kidney disease(pooled OR=1.38;95%CI:1.23- 1.54) and diabetes mellitus (pooled OR = 1.18;95%CI: 1.08-1.28) had statistically significantassociation with the hospital readmission rate among pneumonia patients. Sensitivity analysisshowed that there was no significant variation in the magnitude or direction of outcome,indicating lack of influence of a single study on the overall pooled estimate.CONCLUSIONMale gender and specific chronic comorbid conditions were found to be significant risk factors forhospital readmission among pneumonia patients. These results may allow clinicians and policymakersto develop better intervention strategies for the patients.

What Happens after the Puerperium? Analysis of “Late” Postpartum Readmissions in California

Objective: Admissions to acute care hospitals represent a significant portion of healthcare utilization. Little is known regarding hospitalization in the first postpartum year beyond the traditional 6 weeks of the puerperium. We sought to investigate whether there are identifiable risk factors for hospital readmission during this time period. Study Design: We conducted a retrospective population-based study using all California birth records between 1999 and 2003. These records were linked with hospital discharge data for all admissions to California hospitals in the first 365 days after delivery. For women with a first birth during the study period, we assessed the likelihood of readmission to an acute care hospital between 42 and 365 days post-delivery. Univariate and multivariable logistic regression were used to determine risk factors for these “late postpartum” admissions. Results: Of 951,570 maternal birth admissions during the time period, 15,727 (1.7%) women were admitted in the late postpartum period. Women with an early postpartum readmission, antepartum admission, extremes of maternal age, black race, diabetes, hypertension, early preterm delivery and cesarean delivery had higher rates of late postpartum readmission. Of women with an antepartum admission for gestational diabetes or pre-existing diabetes, 6.6% and 18.5% of these women experienced a late postpartum admission for a diabetes-related diagnosis. Conclusion: Hospital readmission rates in the first year postpartum, remote from delivery, are significant. Women are at a higher risk of requiring hospital admission in the first year postpartum with select demographics and pregnancy-related diagnoses.

Modelling and predicting low count child asthma hospital readmissions using General Additive Models

Background: Daily paediatric asthma readmissions within 28 days are a good example of a low count time series and not easily amenable to common time series methods used in studies of asthma seasonality and time trends. We sought to model and predict daily trends of childhood asthma readmissions over time inVictoria,Australia. Methods: We used a database of 75,000 childhood asthma admissions from the Department ofHealth,Victoria,Australiain 1997-2009. Daily admissions over time were modeled using a semi parametric Generalized Additive Model (GAM) and by sex and age group. Predictions were also estimated by using these models. Results: N = 2401 asthma readmissions within 28 days occurred during study period. Of these, n = 1358 (57%) were boys. Overall, seasonal peaks occurred in winter (30.5%) followed by autumn (28.6%) and then spring (24.6%) (p

Early systemic anticoagulation reduces hospital readmission in acute necrotizing pancreatitis patients:A retrospective cohort study

Background:Early systemic anticoagulation(SAC)is a common practice in acute necrotizing pancreatitis(ANP),and its impact on in-hospital clinical outcomes had been assessed.However,whether it affects long-term outcomes is unknown.This study aimed to evaluate the effect of SAC on 90-day readmission and other long-term outcomes in ANP patients.Methods:During January 2013 and December 2018,ANP patients admitted within 7 days from the onset of abdominal pain were screened.The primary outcome was 90-day readmission after discharge.Cox proportional-hazards regression model and mediation analysis were used to define the relationship between early SAC and 90-day readmission.Results:A total of 241 ANP patients were enrolled,of whom 143 received early SAC during their hospitalization and 98 did not.Patients who received early SAC experienced a lower incidence of splanchnic venous thrombosis(SVT)[risk ratio(RR)=0.40,95%CI:0.26-0.60,P<0.01]and lower 90-day readmission with an RR of 0.61(95%CI:0.41-0.91,P=0.02)than those who did not.For the quality of life,patients who received early SAC had a significantly higher score in the subscale of vitality(P=0.03)while the other subscales were all comparable between the two groups.Multivariable Cox regression model showed that early SAC was an independent protective factor for 90-day readmission after adjusting for potential confounders with a hazard ratio of 0.57(95%CI:0.34-0.96,P=0.04).Mediation analysis showed that SVT mediated 37.0%of the early SAC-90-day readmission causality.Conclusions:The application of early SAC may reduce the risk of 90-day readmission in the survivors of ANP patients,and reduced SVT incidence might be the primary contributor.

Effect of aliskiren on postdischarge mortality and heart failure readmissions among patients hospitalized for heart failure:The ASTRONAUT randomized trial

ABSTRACT Importance Hospitalizations for heart failure （HHF） represent a major health burden, with high rates of early postdischarge rehospitalization and mortality. Objective To investigate whether aliskiren, a direct renin inhibitor, when added to standard therapy, would reduce the rate of cardiovascular （CV） death or HF rehospitalization among HHF patients. Design, Setting, and Participants International, double-blind, placebo-controlled study that randomized hemodynamically stable HHF patients a median 5 days after admission. Eligible patients were 18 years or older with left ventricular ejection fraction （LVEF） 40% or less,

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy

Objective:We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre-and peri-operative variables associated with length of stay(LOS)greater than 3 days and readmission within 30 days.Methods:Records from 2008 to 2018 for“laparoscopy,surgical;partial nephrectomy”for prolonged LOS and readmission cohorts were compiled.Univariate analysis with Chi-square,t-tests,and multivariable logistic regression analysis with odds ratios(ORs),p-values,and 95%confidence intervals assessed statistical associations.Results:Totally,20306 records for LOS greater than 3 days and 15854 for readmission within 30 days were available.Univariate and multivariable analysis exhibited similar results.For LOS greater than 3 days,undergoing non-elective surgery(OR=5.247),transfusion of greater than four units within 72 h prior to surgery(OR=5.072),pre-operative renal failure or dialysis(OR=2.941),and poor pre-operative functional status(OR=2.540)exhibited the strongest statistically significant associations.For hospital readmission within 30 days,loss in body weight greater than 10%in 6 months prior to surgery(OR=2.227)and bleeding disorders(OR=2.081)exhibited strongest statistically significant associations.Conclusion:Multiple pre-and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data.Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection,optimization strategies,and patient education.

Impact of index admission cholecystectomy vs interval cholecystectomy on readmission rate in acute cholangitis: National Readmission Database survey

BACKGROUND Elective cholecystectomy(CCY)is recommended for patients with gallstone-related acute cholangitis(AC)following endoscopic decompression to prevent recurrent biliary events.However,the optimal timing and implications of CCY remain unclear.AIM To examine the impact of same-admission CCY compared to interval CCY on patients with gallstone-related AC using the National Readmission Database(NRD).METHODS We queried the NRD to identify all gallstone-related AC hospitalizations in adult patients with and without the same admission CCY between 2016 and 2020.Our primary outcome was all-cause 30-d readmission rates,and secondary outcomes included in-hospital mortality,length of stay(LOS),and hospitalization cost.RESULTS Among the 124964 gallstone-related AC hospitalizations,only 14.67%underwent the same admission CCY.The all-cause 30-d readmissions in the same admission CCY group were almost half that of the non-CCY group(5.56%vs 11.50%).Patients in the same admission CCY group had a longer mean LOS and higher hospitalization costs attrib-utable to surgery.Although the most common reason for readmission was sepsis in both groups,the second most common reason was AC in the interval CCY group.CONCLUSION Our study suggests that patients with gallstone-related AC who do not undergo the same admission CCY have twice the risk of readmission compared to those who undergo CCY during the same admission.These readmis-sions can potentially be prevented by performing same-admission CCY in appropriate patients,which may reduce subsequent hospitalization costs secondary to readmissions.

Association between acute peripancreatic fluid collections and early readmission in acute pancreatitis:A propensity-matched analysis

BACKGROUND Patients with acute pancreatitis(AP)frequently experience hospital readmissions,posing a significant burden to healthcare systems.Acute peripancreatic fluid collection(APFC)may negatively impact the clinical course of AP.It could worsen symptoms and potentially lead to additional complications.However,clinical evidence regarding the specific association between APFC and early readmission in AP remains scarce.Understanding the link between APFC and readmission may help improve clinical care for AP patients and reduce healthcare costs.AIM To evaluate the association between APFC and 30-day readmission in patients with AP.METHODS This retrospective cohort study is based on the Nationwide Readmission Database for 2016-2019.Patients with a primary diagnosis of AP were identified.Participants were categorized into those with and without APFC.A 1:1 propensity score matching for age,gender,and Elixhauser comorbidities was performed.The primary outcome was early readmission rates.Secondary outcomes included the incidence of inpatient complications and healthcare utilization.Unadjusted analyses used Mann-Whitney U andχ2 tests,while Cox regression models assessed 30-day readmission risks and reported them as adjusted hazard ratios(aHR).Kaplan-Meier curves and log-rank tests verified readmission risks.RESULTS A total of 673059 patients with the principal diagnosis of AP were included.Of these,5.1%had APFC on initial admission.After propensity score matching,each cohort consisted of 33914 patients.Those with APFC showed a higher incidence of inpatient complications,including septic shock(3.1%vs 1.3%,P<0.001),portal venous thrombosis(4.4%vs 0.8%,P<0.001),and mechanical ventilation(1.8%vs 0.9%,P<0.001).The length of stay(LOS)was longer for APFC patients[4(3-7)vs 3(2-5)days,P<0.001],as were hospital charges($29451 vs$24418,P<0.001).For 30-day readmissions,APFC patients had a higher rate(15.7%vs 6.5%,P<0.001)and a longer median readmission LOS(4 vs 3 days,P<0.001).The APFC group also had higher readmission charges($28282 vs$22865,P<0.001).The presence of APFC increased the risk of readmission twofold(aHR 2.52,95%confidence interval:2.40-2.65,P<0.001).The independent risk factors for 30-day readmission included female gender,Elixhauser Comorbidity Index≥3,chronic pulmonary diseases,chronic renal disease,protein-calorie malnutrition,substance use disorder,depression,portal and splenic venous thrombosis,and certain endoscopic procedures.CONCLUSION Developing APFC during index hospitalization for AP is linked to higher readmission rates,more inpatient complications,longer LOS,and increased healthcare costs.Knowing predictors of readmission can help target high-risk patients,reducing healthcare burdens.

Head and neck cancer readmission reduction(HANCARRE)project:Reducing 30-day readmissions

Objective:Unplanned 30-day readmissions result in increased costs and decreased patient satisfaction.The objective of this study was to compare readmission rates before and after a multidisciplinary quality improvement initiative that focused on patient and staff education,use of targeted skilled nursing facilities,and appropriate use of patient observation status.Methods:This was a quality improvement study of all unplanned admissions to the Head and Neck Oncology service at a tertiary care facility during a 3-year period between October 2015 and September 2018.In October 2016,the Head and Neck Oncology service revised its discharge practices for patients undergoing extirpative and/or reconstructive surgery.These changes included enhancing patient education,increasing the use of a skilled nursing facility with directed staff education and patient handoffs by advanced practice nurses,and appropriate utilization of 23-h observation status for returning patients.The readmission rate from the pre-intervention era(October 2015 through September 2016)was compared to the readmission rate from the post-intervention era(October 2016 through September 2018).Secondary outcomes were the rates of 23-h observation within 30 days of the discharge as well as emergency room visits within 30 days of discharge.Results:In this sample of 449 patients,161(35.9%)were observed before the change-in-practice(before October 2016),and 288(64.1%)were observed following the change-in-practice(after September 2016).On univariable analysis,the risk of readmission declined by approximately 41.4%from the pre-intervention era,though this conclusion was not statistically significant(P=0.06).On multivariable analysis,patients at moderate or high risk of death were 2.31 times more likely than those at minor risk of death to readmit within 30 days(P=0.03).Similarly,those with recurrent or persistent cancer were 3.33 times more likely than those undergoing initial curative surgical management of cancer to readmit within 30 days(P=0.001).No patient characteristics were associated with a 23-h observation following discharge(allP>0.05).Conclusions were similar for emergency room visits following discharge.Conclusions:A three-part quality improvement strategy resulted in a clinically important decrease in 30-day readmissions,though the decline was not statistically significant.There were no significant changes in 23-h observation within 30 days of discharge or emergency room visits within 30 days of discharge.

Outcomes of early hospital readmission after kidney transplantation: Perspectives from a Canadian transplant centre

BACKGROUND Early hospital readmissions(EHRs)after kidney transplantation range in incidence from 18%-47%and are important and substantial healthcare quality indicators.EHR can adversely impact clinical outcomes such as graft function and patient mortality as well as healthcare costs.EHRs have been extensively studied in American healthcare systems,but these associations have not been explored within a Canadian setting.Due to significant differences in the delivery of healthcare and patient outcomes,results from American studies cannot be readily applicable to Canadian populations.A better understanding of EHR can facilitate improved discharge planning and long-term outpatient management post kidney transplant.AIM To explore the burden of EHR on kidney transplant recipients(KTRs)and the Canadian healthcare system in a large transplant centre.METHODS This single centre cohort study included 1564 KTRs recruited from January 1,2009 to December 31,2017,with a 1-year follow-up.We defined EHR as hospitalizations within 30 d or 90 d of transplant discharge,excluding elective procedures.Multivariable Cox and linear regression models were used to examine EHR,late hospital readmissions(defined as hospitalizations within 31-365 d for 30-d EHR and within 91-365 d for 90-d EHR),and outcomes including graft function and patient mortality.RESULTS In this study,307(22.4%)and 394(29.6%)KTRs had 30-d and 90-d EHRs,respectively.Factors such as having previous cases of rejection,being transplanted in more recent years,having a longer duration of dialysis pretransplant,and having an expanded criteria donor were associated with EHR post-transplant.The cumulative probability of death censored graft failure,as well as total graft failure,was higher among the 90-d EHR group as compared to patients with no EHR.While multivariable models found no significant association between EHR and patient mortality,patients with EHR were at an increased risk of late hospital readmissions,poorer kidney function throughout the 1st year post-transplant,and higher hospital-based care costs within the 1st year of follow-up.CONCLUSION EHRs are associated with suboptimal outcomes after kidney transplant and increased financial burden on the healthcare system.The results warrant the need for effective strategies to reduce post-transplant EHR.

Readmission rates and outcomes in adults with and without COVID-19 following inpatient chemotherapy admission:A nationwide analysis

BACKGROUND The coronavirus disease 2019(COVID-19)pandemic has received considerable attention in the scientific community due to its impact on healthcare systems and various diseases.However,little focus has been given to its effect on cancer treatment.AIM To determine the effect of COVID-19 pandemic on cancer patients’care.METHODS A retrospective review of a Nationwide Readmission Database(NRD)was conducted to analyze hospitalization patterns of patients receiving inpatient chemotherapy(IPCT)during the COVID-19 pandemic in 2020.Two cohorts were defined based on readmission within 30 d and 90 d.Demographic information,readmission rates,hospital-specific variables,length of hospital stay(LOS),and treatment costs were analyzed.Comorbidities were assessed using the Elixhauser comorbidity index.Multivariate Cox regression analysis was performed to identify independent predictors of readmission.Statistical analysis was conducted using Stata■Version 16 software.As the NRD data is anonymous and cannot be used to identify patients,institutional review board approval was not required for this study.RESULTS A total of 87755 hospitalizations for IPCT were identified during the pandemic.Among the 30-day index admission cohort,55005 patients were included,with 32903 readmissions observed,resulting in a readmission rate of 59.8%.For the 90-day index admission cohort,33142 patients were included,with 24503 readmissions observed,leading to a readmission rate of 73.93%.The most common causes of readmission included encounters with chemotherapy(66.7%),neutropenia(4.36%),and sepsis(3.3%).Comorbidities were significantly higher among readmitted hospitalizations compared to index hospitalizations in both readmission cohorts.The total cost of readmission for both cohorts amounted to 1193000000.00 dollars.Major predictors of 30-day readmission included peripheral vascular disorders[Hazard ratio(HR)=1.09,P<0.05],paralysis(HR=1.26,P<0.001),and human immunodeficiency virus/acquired immuno-deficiency syndrome(HR=1.14,P=0.03).Predictors of 90-day readmission included lymphoma(HR=1.14,P<0.01),paralysis(HR=1.21,P=0.02),and peripheral vascular disorders(HR=1.15,P<0.01).CONCLUSION The COVID-19 pandemic has significantly impacted the management of patients undergoing IPCT.These findings highlight the urgent need for a more strategic approach to the care of patients receiving IPCT during pandemics.