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.

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.

Effects of a nurse-led heart failure clinic on hospital readmission and mortality in Hong Kong

Background Heart failure （HF） is a physically and socially debilitating disease that carries the burden of hospital re-admission and mortality. As an aging society, Hong Kong urgently needs to find ways to reduce the hospital readmission of HF patients. This study evaluates the effects of a nurse-led HF clinic on the hospital readmission and mortality rates among older HF patients in Hong Kong. Methods This study is a retrospective data analysis that compares HF patient in a nurse-led HF clinic in Hong Kong compared with HF patients who did not attend the clinic. The nurses of this clinic provide education on lifestyle modification and symptom monitoring, as well as titrate the medications and measure biochemical markers by following established protocols. This analysis used the socio-demographic and clinical data of HF patients who were aged 〉 65 years old and stayed in the clinic over a six-month period. Results The data of a total of 78 HF patients were included in this data analysis. The mean age of the patients was 77.38 ± 6.80 years. Approximately half of the HF patients were male （51.3%）, almost half were smokers （46.2%）, and the majority received 〈 six years of formal education. Most of the HF patients （87.2%） belonged to classes II and III of the New York Heart Association Functional Classification, with a mean ejection fraction of 47.15± 20.31 mL. The HF patients who attended the clinic （n = 38, 75.13 ± 5.89 years） were significantly younger than those who did not attend the clinic （n = 40, 79.53 ± 6.96 years） （P = 0.04）, and had lower recorded blood pressure. No other statistically significant difference existed between the socio-demographic and clinical characteristics of the two groups. The HF patients who did not attend the nurse-led HF clinic demonstrated a significantly higher risk of hospital readmission [odd ratio （OR）： 7.40; P 〈 0.01] than those who attended after adjusting for the effect of age and blood pressure. In addition, HF patients who attended the clinic had lower mortality （n = 4） than those who did not attend （n = 14）. However, such a difference did not reach statistical significance when the effects of age and blood pressure were adjusted. A signifi- cant reduction in systolic blood pressure IF （2, 94） = 3.39, P = 0.04] and diastolic blood pressure [F （2, 94） = 8.48, P 〈 0.01] was observed among the HF patients who attended the clinic during the six-month period. Conclusions The finding of this study suggests the important role of nurse-led HF clinics in reducing healthcare burden and improving patient outcomes among HF patients in Hong Kong.

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.

Hospital readmission following transjugular intrahepatic portosystemic shunt:a 14-year single-center experience

Background:Placement of a transjugular intrahepatic portosystemic shunt(TIPS)is a relatively common procedure used to treat complications of portal hypertension.However,only limited data exist regarding the hospital-readmission rate after TIPS placement and no studies have addressed the causes of hospital readmission.We therefore sought to identify the 30-day hospital-readmission rate after TIPS placement at our institution and to determine potential causes and predictors of readmission.Methods:We reviewed our electronic medical-records system at our institution between 2004 and 2017 to identify patients who had undergone primary TIPS placement with polytetrafluoroethylene-covered stents and to determine the 30-day readmission rate among these patients.A series of univariable logistic-regression models were fit to assess potential predictors of 30-day readmission.Results:A total of 566 patients were included in the analysis.The 30-day readmission rate after TIPS placement was 36%.The most common causes for readmission were confusion(48%),infection(15%),bleeding(11%),and fluid overload(7%).A higher Model for End-Stage Liver Disease(MELD)score corresponded with a higher rate of readmission(odds ratio associated with each 1-unit increase in MELD score:1.06;95%confidence interval:1.02–1.09;P=0.001).Other potential predictors,including indication for TIPS placement,were not significantly associated with a higher readmission rate.Conclusions:The 30-day readmission rate after TIPS placement with covered stents is high,with nearly half of these readmissions due to hepatic encephalopathy—a known complication of TIPS placement.Novel interventions to help reduce the TIPS readmission rate should be prioritized in future research.

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.

Predictive modeling of 30-day readmission risk of diabetes patients by logistic regression,artificial neural network,and EasyEnsemble

Objective:To determine the most influential data features and to develop machine learning approaches that best predict hospital readmissions among patients with diabetes.Methods:In this retrospective cohort study,we surveyed patient statistics and performed feature analysis to identify the most influential data features associated with readmissions.Classification of all-cause,30-day readmission outcomes were modeled using logistic regression,artificial neural network,and Easy Ensemble.F1 statistic,sensitivity,and positive predictive value were used to evaluate the model performance.Results:We identified 14 most influential data features(4 numeric features and 10 categorical features)and evaluated 3 machine learning models with numerous sampling methods(oversampling,undersampling,and hybrid techniques).The deep learning model offered no improvement over traditional models(logistic regression and Easy Ensemble)for predicting readmission,whereas the other two algorithms led to much smaller differences between the training and testing datasets.Conclusions:Machine learning approaches to record electronic health data offer a promising method for improving readmission prediction in patients with diabetes.But more work is needed to construct datasets with more clinical variables beyond the standard risk factors and to fine-tune and optimize machine learning models.

Estimating the Potential for Reduction of Hospital Capacity at the Community Level

This study estimated the potential impact of the nationwide shift from inpatient to outpatient care in the hospitals of Syracuse, New York, a small metropolitan area with a relatively stable population. The study employed the 3MTM All Patients Refined Diagnosis Group Severity of Illness system to identify inpatients and related utilization with the greatest potential for movement from inpatient to outpatient settings. The study data suggested that the development of additional ambulatory care capacity in Syracuse could support the reduction of an average daily census of approximately 60 - 125 patients with low severity of illness, excluding readmissions. The study data also identified the potential for shifting an average daily census of approximately 9 - 19 patients who were readmitted to hospitals within 30 days of their initial admissions from inpatient to outpatient care. The study data also identified the potential for reduction of an average daily census of approximately 20 - 70 adult medicine and adult surgery patients through continued initiatives for inpatient length of stay reduction. The impact of initiatives in each of these areas could result in a reduction of the combined average daily adult medicine and adult surgery census of the Syracuse hospitals from approximately 90 to 215 patients. This would amount to between 8 and 20 percent of the current inpatient census for adult medicine and adult surgery. These data suggest that planning for initiatives such as ambulatory care development and reduction of readmissions should also include evaluation of their impact on inpatient acute care and related services.

Does endoscopic intervention prevent subsequent gastrointestinal bleeding in patients with left ventricular assist devices?A retrospective study

BACKGROUND Patients with left ventricular assist devices(LVADs)are at increased risk for recurrent gastrointestinal bleeding(GIB)and repeat endoscopic procedures.We assessed the frequency of endoscopy for GIB in patients with LVADs and the impact of endoscopic intervention on preventing a subsequent GIB.AIM To evaluate for an association between endoscopic intervention and subsequent GIB.Secondary aims were to assess the frequency of GIB in our cohort,describe GIB presentations and sources identified,and determine risk factors for recurrent GIB.METHODS We conducted a retrospective cohort study of all patients at a large academic institution who underwent LVAD implantation from January 2011–December 2018 and assessed all hospital encounters for GIB through December 2019.We performed a descriptive analysis of the GIB burden and the outcome of endoscopic procedures performed.We performed multivariate logistic regression to evaluate the association between endoscopic intervention and subsequent GIB.RESULTS In the cohort of 295 patients,97(32.9%)had at least one GIB hospital encounter.There were 238 hospital encounters,with 55.4%(132/238)within the first year of LVAD implantation.GIB resolved on its own by discharge in 69.8%(164/235)encounters.Recurrent GIB occurred in 55.5%(54/97)of patients,accounting for 59.2%(141/238)of all encounters.Of the 85.7%(204/238)of encounters that included at least one endoscopic evaluation,an endoscopic intervention was performed in 34.8%(71/204).The adjusted odds ratio for subsequent GIB if an endoscopic intervention was performed during a GIB encounter was not significant(odds ratio 1.18,P=0.58).CONCLUSION Patients implanted with LVADs whom experience recurrent GIB frequently undergo repeat admissions and endoscopic procedures.In this retrospective cohort study,adherence to endoscopic guidelines for performing endoscopic interventions did not significantly decrease the odds of subsequent GIB,thus suggesting the uniqueness of the LVAD population.A prospective study is needed to identify patients with LVAD at risk of recurrent GIB and determine more effective management strategies.

High Severity of Illness Patients in a Small Metropolitan Area

This study evaluated the impact of high severity of illness patients on hospital utilization in the metropolitan area of Syracuse, New York between 2012 and 2015. It employed the All Patients Refined Severity of Illness system developed by 3M&#8482 Health Information Systems. These patients are important for the management and practice of nursing in acute hospitals. The study demonstrated that patients at extreme and major severity of illness generated 60 - 70 percent of the inpatient days for adult medicine and adult surgery in the combined Syracuse hospitals. Mean lengths of stay for patients at extreme severity of illness were two to four times the stays for these services. Inpatient readmission rates for extreme severity of illness patients were more than double the rates for these services. The study data also indicated that the impact of patients at high severity of illness was increasing over time. The study also demonstrated that recent efforts of the Syracuse hospitals have produced reductions in the numbers of excess patient days for adult medicine and surgery, but limited reductions in the mean lengths of stay for these patients. The data suggested that meeting the needs of these patients is especially challenging in a small metropolitan area without an additional level of care within the continuum.

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,