AIM To assess the effect of early vs late endoscopic retrograde cholangiopancreatography(ERCP) on mortality and readmissions in acute cholangitis, using a nationally representative sample.METHODS We used the 2014 Nati...AIM To assess the effect of early vs late endoscopic retrograde cholangiopancreatography(ERCP) on mortality and readmissions in acute cholangitis, using a nationally representative sample.METHODS We used the 2014 National Readmissions Database to identify adult patients hospitalized with acute cholangitis who underwent therapeutic ERCP within one week of admission. Early ERCP was defined as ERCP performed on the same day of admission or the next day(days 0 or 1, < 48 h), and late ERCP was performed on days 2 to 7 of admission. Patients with severe cholangitis had any of the following additional diagnoses: Severe sepsis, septic shock, acute renal failure,acute respiratory failure, or thrombocytopenia. Multivariate logistic regression was used to calculate the adjusted odds of association of ERCP timing with inhospital mortality, 30-d mortality, and 30-d readmissions, controlling for age, sex,severe disease and comorbidities.RESULTS Four thousand five hundred and seventy patients satisfied the inclusion criteria;with a mean age of 64.1 years. Of these, 66.6% had early ERCP, while 33.4% had late ERCP. Early ERCP was associated with lower in-hospital mortality [1.2% vs2.4%, adjusted odds ratio(aOR) = 0.50, 95%CI: 0.76-0.83, P = 0.001] and lower 30-d mortality(1.5% vs 3.3%, aOR = 0.48, 95%CI: 0.33-0.69, P < 0.0001) compared to the late ERCP group. Similarly, early ERCP was associated with lower 30-d readmissions(9.7% vs 15.1%, aOR = 0.58, 95%CI: 0.49-0.7, P < 0.0001). When stratified by severity of cholangitis, there was a similar benefit of early ERCP on all outcomes in those with and without severe cholangitis. The mean length of stay was higher in the late ERCP group compared to the early ERCP group(6.9 d vs 4.5 d, P < 0.0001). The mean hospitalization cost was higher in the late ERCP group($21459 vs $16939, P < 0.0001).CONCLUSION Early ERCP is associated with lower in-hospital and 30-d mortality in those with or without severe cholangitis. Regardless of severity, we suggest performing early ERCP.展开更多
AIM To reduce readmissions and improve patient outcomes in cirrhotic patients through better understanding of readmission predictors.METHODS We performed a single-center retrospective study of patients admitted with d...AIM To reduce readmissions and improve patient outcomes in cirrhotic patients through better understanding of readmission predictors.METHODS We performed a single-center retrospective study of patients admitted with decompensated cirrhosis from January 1, 2011 to December 31, 2013(n = 222). Primary outcomes were time to first readmission and 30-d readmission rate due to complications of cirrhosis. Clinical and demographic data were collected to help describe predictors of readmission, along with care coordination measures such as post-discharge status and outpatient follow-up. Univariate and multivariateanalyses were performed to describe variables associated with readmission.RESULTS One hundred thirty-two patients(59.4%) were readmitted at least once during the study period. Median time to first and second readmissions were 54 and 93 d, respectively. Thirty and 90-d readmission rates were 20.7 and 30.1 percent, respectively. Predictors of 30-d readmission included education level, hepatic encephalopathy at index, ALT more than upper normal limit and Medicare coverage. There were no statistically significant differences in readmission rates when stratified by discharge disposition, outpatient follow-up provider or time to first outpatient visit.CONCLUSION Readmissions are challenging aspect of care for cirrhotic patients and risk continues beyond 30 d. More initiatives are needed to develop enhanced, longitudinal post-discharge systems.展开更多
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 w...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.展开更多
AIM: To investigate inpatient length of stay(LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach.METHODS: All patients who presented to a large tertiary care center...AIM: To investigate inpatient length of stay(LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach.METHODS: All patients who presented to a large tertiary care center with isolated sacral fractures in an 11-year period were included in a retrospective chart review. Operative approach(open reduction internal fixation vs percutaneous) was noted, as well as age, gender, race, and American Society of Anesthesiologists' score. Complications included infection, nonunion and malunion, deep venous thrombosis, and hardware problems; 90-d readmissions were broken down into infection, surgical revision of the sacral fracture, and medical complications. LOS was collected for the initial admission and readmission visits if applicable. Fisher's exact and non-parametric t-tests(Mann-Whitney U tests) were employed to compare LOS, complications, and readmissions between open and percutaneous approaches.RESULTS: Ninety-four patients with isolated sacral fractures were identified: 31(30.4%) who underwentopen reduction and internal fixation(ORIF) vs 63(67.0%) who underwent percutaneous fixation. There was a significant difference in LOS based on operative approach: 9.1 d for ORIF patients vs 6.1 d for percutaneous patients(P = 0.043), amounting to a difference in cost of $13590. Ten patients in the study developed complications, with no significant difference in complication rates or reasons for complications between the two groups(19.4% for ORIF patients vs 6.3% for percutaneous patients). Eight patients were readmitted, with no significant difference in readmission rates or reasons for readmission between the two groups(9.5% percutaneous vs 6.5% ORIF).CONCLUSION: There is a significant difference in LOS based on operative approach for sacral fracture patients. Given similar complications and readmission rates, we recommend a percutaneous approach.展开更多
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 Illne...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™ 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.展开更多
This study focused on hospital populations which account for large amounts of health care utilization at the community level in the metropolitan area of Syracuse, New York. It demonstrated that, between the two larges...This study focused on hospital populations which account for large amounts of health care utilization at the community level in the metropolitan area of Syracuse, New York. It demonstrated that, between the two largest hospital inpatient services, adult medicine patients accounted for a larger number of excess hospital patient days than adult surgery over a two-year period. Adult medicine stays increased while adult surgery stays declined. Adult medicine also accounted for a larger number of excess inpatient days, an average daily census of 52.7 patients in 2013, although adult medicine outliers comprised only 2.4 - 2.5 percent of discharges while adult surgery patients comprised 4.4 - 4.5 percent of discharges for these services. Adult medicine readmissions accounted for 79 - 81 percent of these adverse events for the combined hospital during the two-year period. Adult medicine complications accounted for 60 - 62 percent of complications in the two hospitals for which data were available. These data clearly demonstrate the challenges that adult medicine patients carry for providers as they attempt to improve the efficiency and outcomes of care in local communities. In the United States, payer reimbursement for the care of these patients frequently does not match the resources required as funding emphasizes surgical specialties and healthier patients. In metropolitan areas such as Syracuse, where local populations are aging or declining, the expenses of caring for these patients can become a major challenge for community providers.展开更多
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 empl...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 3M<sup>TM</sup> 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.展开更多
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...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.展开更多
Introduction: Performance monitoring and performance improvement (PI) are increasingly important. Little is known regarding unplanned re-admission (UPR) in trauma patients. This study characterizes UPRs at one institu...Introduction: Performance monitoring and performance improvement (PI) are increasingly important. Little is known regarding unplanned re-admission (UPR) in trauma patients. This study characterizes UPRs at one institution. Methods: Retrospective descriptive review of UPR to a Level I Trauma Center Information was obtained on: initial trauma diagnoses, diagnosis precipitating UPR, discharge interval, treatment rendered and length of stay (LOS) during both encounters, and PI committee judgments. Characteristics of UPR patients were determined and compared to those of all discharged patients. Descriptive statistics were applied. Results: Over 2.5 years there were 2827 discharges and 58 UPR(2%). The majority of original diagnoses were related to blunt trauma and head injuries. UPR occurred at a median of 3 days, with 54% re-admitted to the trauma service. Operative rate for UPR patients during the initial admission was 48% with 28%requiring operation on the UPR. Headache and wound issues were responsible for 42% of UPR. Diagnosis precipitating UPR was primarily related to post-operative complications in 26% of all UPR and 57% of those undergoing operation on the initial admission. Median LOS for UPR was 3days with ICU care being required by 13%. Of all UPRs,33% were attributable to opportunities for improved care (OFI) during the first admission. Identified OFIs were related to errors in technique (53%), errors in judgment (27%), and system issues (20%). Of UPR without OFI, 87% were related to disease and13% systems issues. Conclusion: UPR at a Level I trauma center is rare, occurs shortly after discharge, is brief in duration and usually related to postoperative wound issues or headache. Post operative patients seem at greater risk for UPR. While most UPR are considered non-preventable, attention to discharge instructions,patient education, resident education and supervisionand outpatient support, may obviate a number of preventable UPRs.展开更多
This study focused on tracking the sustainability of improvements in inpatient outcomes in the hospitals of Syracuse, New York. It involved evaluation of inpatient complications during a six-year period for two of the...This study focused on tracking the sustainability of improvements in inpatient outcomes in the hospitals of Syracuse, New York. It involved evaluation of inpatient complications during a six-year period for two of the Syracuse hospitals and inpatient readmissions during a three-year period for three hospitals. The study employed the Potentially Preventable Complications and Potentially Preventable Readmissions software developed by 3MTM Health Information Systems. The study demonstrated that two of the Syracuse hospitals produced reductions in aggregate complication rates between 2009 and 2012. This was followed by an increase in complications during 2013 and 2014. The decline in complications and the increase that followed were supported by developments in high volume complications and some lower volume complications. Hospital readmissions for adult medicine, the largest inpatient service, both increased and declined at the aggregate level and for individual hospitals during the three-year period. Hospital readmission rates for adult surgery declined, however, individual hospital rates increased and declined. The study identified sustained reductions in readmission rates for the combined hospitals for congestive heart failure and COPD during the three-year period. The study identified the challenges related to sustaining reductions in hospital outcomes over time. In the Syracuse hospitals, these challenges involved inpatient clinical management for complications and system-wide issues for readmissions.展开更多
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 Syracus...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.展开更多
Heart failure (HF) is the most common hospital discharge diagnosis among the elderly. It accounts for nearly 1.4 million hospitalizations and $21 billion in spending per year in the United States. Readmission rates re...Heart failure (HF) is the most common hospital discharge diagnosis among the elderly. It accounts for nearly 1.4 million hospitalizations and $21 billion in spending per year in the United States. Readmission rates remain high with estimates ranging from 15-day readmission rates of 13%, 30- day readmission rates of 25%, to 6-month readmission rates of 50%. The Center for Medicare and Medicaid Services (CMS) has started penalizing hospitals with higher than expected readmission rates. Objective: To identify factors associated with increased 30-day readmission among heart failure patients in an inner-city community-based teaching hospital. Methods: A retrospective cohort study of patients with principal discharge diagnosis of acute Heart Failure between 2008 and 2010. Demographic, clinical characteristics, length of stay, discharge medications, disposition and all-cause 30-day readmission were abstracted from the hospital’s administrative database and analyzed. Results: Almost 8 out of 10 patients were 65 years or older (mean age 75.4 ± 14.3) and 51% were female. The in-hospital mortality rate was 2.7% (95% confidence interval [CI], 1.6% - 4.3%) with a median length of stay of 5.0 days (Interquartile range of 3 - 7). The all-cause 30-day readmission rate was 17.7% (95% CI 14.9% - 20.8%). By univariate analysis, readmissions were predicted by black race, prior history of HF, length of stay of more than 7 days and discharge to extended care facility (ECF). By logistic regression analysis, black race (OR 2.4, 95% CI 1.4 - 3.8), prior history of HF (OR 1.7, 95% CI 1.5 - 2.6) and discharge to an ECF (OR 2.4, 95% CI 1.5 - 3.7) were the independent predictors of 30-day readmission. HF accounted for 43.7% of the readmissions. Conclusion: Prior diagnosis of HF, black race, and discharge to an ECF were independent predictors of 30-day readmission in this cohort, and over half of the readmissions were for reasons other than HF.展开更多
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 a...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,an展开更多
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 s...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.展开更多
In a prior practice and policy article published in Healthcare Science,we introduced the deployed application of an artificial intelligence(AI)model to predict longer‐term inpatient readmissions to guide community ca...In a prior practice and policy article published in Healthcare Science,we introduced the deployed application of an artificial intelligence(AI)model to predict longer‐term inpatient readmissions to guide community care interventions for patients with complex conditions in the context of Singapore's Hospital to Home(H2H)program that has been operating since 2017.In this follow on practice and policy article,we further elaborate on Singapore's H2H program and care model,and its supporting AI model for multiple readmission prediction,in the following ways:(1)by providing updates on the AI and supporting information systems,(2)by reporting on customer engagement and related service delivery outcomes including staff‐related time savings and patient benefits in terms of bed days saved,(3)by sharing lessons learned with respect to(i)analytics challenges encountered due to the high degree of heterogeneity and resulting variability of the data set associated with the population of program participants,(ii)balancing competing needs for simpler and stable predictive models versus continuing to further enhance models and add yet more predictive variables,and(iii)the complications of continuing to make model changes when the AI part of the system is highly interlinked with supporting clinical information systems,(4)by highlighting how this H2H effort supported broader Covid‐19 response efforts across Singapore's public healthcare system,and finally(5)by commenting on how the experiences and related capabilities acquired from running this H2H program and related community care model and supporting AI prediction model are expected to contribute to the next wave of Singapore's public healthcare efforts from 2023 onwards.For the convenience of the reader,some content that introduces the H2H program and the multiple readmissions AI prediction model that previously appeared in the prior Healthcare Science publication is repeated at the beginning of this article.展开更多
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 patie...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 ident展开更多
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 hospitali...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 trend展开更多
文摘AIM To assess the effect of early vs late endoscopic retrograde cholangiopancreatography(ERCP) on mortality and readmissions in acute cholangitis, using a nationally representative sample.METHODS We used the 2014 National Readmissions Database to identify adult patients hospitalized with acute cholangitis who underwent therapeutic ERCP within one week of admission. Early ERCP was defined as ERCP performed on the same day of admission or the next day(days 0 or 1, < 48 h), and late ERCP was performed on days 2 to 7 of admission. Patients with severe cholangitis had any of the following additional diagnoses: Severe sepsis, septic shock, acute renal failure,acute respiratory failure, or thrombocytopenia. Multivariate logistic regression was used to calculate the adjusted odds of association of ERCP timing with inhospital mortality, 30-d mortality, and 30-d readmissions, controlling for age, sex,severe disease and comorbidities.RESULTS Four thousand five hundred and seventy patients satisfied the inclusion criteria;with a mean age of 64.1 years. Of these, 66.6% had early ERCP, while 33.4% had late ERCP. Early ERCP was associated with lower in-hospital mortality [1.2% vs2.4%, adjusted odds ratio(aOR) = 0.50, 95%CI: 0.76-0.83, P = 0.001] and lower 30-d mortality(1.5% vs 3.3%, aOR = 0.48, 95%CI: 0.33-0.69, P < 0.0001) compared to the late ERCP group. Similarly, early ERCP was associated with lower 30-d readmissions(9.7% vs 15.1%, aOR = 0.58, 95%CI: 0.49-0.7, P < 0.0001). When stratified by severity of cholangitis, there was a similar benefit of early ERCP on all outcomes in those with and without severe cholangitis. The mean length of stay was higher in the late ERCP group compared to the early ERCP group(6.9 d vs 4.5 d, P < 0.0001). The mean hospitalization cost was higher in the late ERCP group($21459 vs $16939, P < 0.0001).CONCLUSION Early ERCP is associated with lower in-hospital and 30-d mortality in those with or without severe cholangitis. Regardless of severity, we suggest performing early ERCP.
文摘AIM To reduce readmissions and improve patient outcomes in cirrhotic patients through better understanding of readmission predictors.METHODS We performed a single-center retrospective study of patients admitted with decompensated cirrhosis from January 1, 2011 to December 31, 2013(n = 222). Primary outcomes were time to first readmission and 30-d readmission rate due to complications of cirrhosis. Clinical and demographic data were collected to help describe predictors of readmission, along with care coordination measures such as post-discharge status and outpatient follow-up. Univariate and multivariateanalyses were performed to describe variables associated with readmission.RESULTS One hundred thirty-two patients(59.4%) were readmitted at least once during the study period. Median time to first and second readmissions were 54 and 93 d, respectively. Thirty and 90-d readmission rates were 20.7 and 30.1 percent, respectively. Predictors of 30-d readmission included education level, hepatic encephalopathy at index, ALT more than upper normal limit and Medicare coverage. There were no statistically significant differences in readmission rates when stratified by discharge disposition, outpatient follow-up provider or time to first outpatient visit.CONCLUSION Readmissions are challenging aspect of care for cirrhotic patients and risk continues beyond 30 d. More initiatives are needed to develop enhanced, longitudinal post-discharge systems.
文摘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.
文摘AIM: To investigate inpatient length of stay(LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach.METHODS: All patients who presented to a large tertiary care center with isolated sacral fractures in an 11-year period were included in a retrospective chart review. Operative approach(open reduction internal fixation vs percutaneous) was noted, as well as age, gender, race, and American Society of Anesthesiologists' score. Complications included infection, nonunion and malunion, deep venous thrombosis, and hardware problems; 90-d readmissions were broken down into infection, surgical revision of the sacral fracture, and medical complications. LOS was collected for the initial admission and readmission visits if applicable. Fisher's exact and non-parametric t-tests(Mann-Whitney U tests) were employed to compare LOS, complications, and readmissions between open and percutaneous approaches.RESULTS: Ninety-four patients with isolated sacral fractures were identified: 31(30.4%) who underwentopen reduction and internal fixation(ORIF) vs 63(67.0%) who underwent percutaneous fixation. There was a significant difference in LOS based on operative approach: 9.1 d for ORIF patients vs 6.1 d for percutaneous patients(P = 0.043), amounting to a difference in cost of $13590. Ten patients in the study developed complications, with no significant difference in complication rates or reasons for complications between the two groups(19.4% for ORIF patients vs 6.3% for percutaneous patients). Eight patients were readmitted, with no significant difference in readmission rates or reasons for readmission between the two groups(9.5% percutaneous vs 6.5% ORIF).CONCLUSION: There is a significant difference in LOS based on operative approach for sacral fracture patients. Given similar complications and readmission rates, we recommend a percutaneous approach.
文摘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™ 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.
文摘This study focused on hospital populations which account for large amounts of health care utilization at the community level in the metropolitan area of Syracuse, New York. It demonstrated that, between the two largest hospital inpatient services, adult medicine patients accounted for a larger number of excess hospital patient days than adult surgery over a two-year period. Adult medicine stays increased while adult surgery stays declined. Adult medicine also accounted for a larger number of excess inpatient days, an average daily census of 52.7 patients in 2013, although adult medicine outliers comprised only 2.4 - 2.5 percent of discharges while adult surgery patients comprised 4.4 - 4.5 percent of discharges for these services. Adult medicine readmissions accounted for 79 - 81 percent of these adverse events for the combined hospital during the two-year period. Adult medicine complications accounted for 60 - 62 percent of complications in the two hospitals for which data were available. These data clearly demonstrate the challenges that adult medicine patients carry for providers as they attempt to improve the efficiency and outcomes of care in local communities. In the United States, payer reimbursement for the care of these patients frequently does not match the resources required as funding emphasizes surgical specialties and healthier patients. In metropolitan areas such as Syracuse, where local populations are aging or declining, the expenses of caring for these patients can become a major challenge for community providers.
文摘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 3M<sup>TM</sup> 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.
文摘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.
文摘Introduction: Performance monitoring and performance improvement (PI) are increasingly important. Little is known regarding unplanned re-admission (UPR) in trauma patients. This study characterizes UPRs at one institution. Methods: Retrospective descriptive review of UPR to a Level I Trauma Center Information was obtained on: initial trauma diagnoses, diagnosis precipitating UPR, discharge interval, treatment rendered and length of stay (LOS) during both encounters, and PI committee judgments. Characteristics of UPR patients were determined and compared to those of all discharged patients. Descriptive statistics were applied. Results: Over 2.5 years there were 2827 discharges and 58 UPR(2%). The majority of original diagnoses were related to blunt trauma and head injuries. UPR occurred at a median of 3 days, with 54% re-admitted to the trauma service. Operative rate for UPR patients during the initial admission was 48% with 28%requiring operation on the UPR. Headache and wound issues were responsible for 42% of UPR. Diagnosis precipitating UPR was primarily related to post-operative complications in 26% of all UPR and 57% of those undergoing operation on the initial admission. Median LOS for UPR was 3days with ICU care being required by 13%. Of all UPRs,33% were attributable to opportunities for improved care (OFI) during the first admission. Identified OFIs were related to errors in technique (53%), errors in judgment (27%), and system issues (20%). Of UPR without OFI, 87% were related to disease and13% systems issues. Conclusion: UPR at a Level I trauma center is rare, occurs shortly after discharge, is brief in duration and usually related to postoperative wound issues or headache. Post operative patients seem at greater risk for UPR. While most UPR are considered non-preventable, attention to discharge instructions,patient education, resident education and supervisionand outpatient support, may obviate a number of preventable UPRs.
文摘This study focused on tracking the sustainability of improvements in inpatient outcomes in the hospitals of Syracuse, New York. It involved evaluation of inpatient complications during a six-year period for two of the Syracuse hospitals and inpatient readmissions during a three-year period for three hospitals. The study employed the Potentially Preventable Complications and Potentially Preventable Readmissions software developed by 3MTM Health Information Systems. The study demonstrated that two of the Syracuse hospitals produced reductions in aggregate complication rates between 2009 and 2012. This was followed by an increase in complications during 2013 and 2014. The decline in complications and the increase that followed were supported by developments in high volume complications and some lower volume complications. Hospital readmissions for adult medicine, the largest inpatient service, both increased and declined at the aggregate level and for individual hospitals during the three-year period. Hospital readmission rates for adult surgery declined, however, individual hospital rates increased and declined. The study identified sustained reductions in readmission rates for the combined hospitals for congestive heart failure and COPD during the three-year period. The study identified the challenges related to sustaining reductions in hospital outcomes over time. In the Syracuse hospitals, these challenges involved inpatient clinical management for complications and system-wide issues for readmissions.
文摘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.
文摘Heart failure (HF) is the most common hospital discharge diagnosis among the elderly. It accounts for nearly 1.4 million hospitalizations and $21 billion in spending per year in the United States. Readmission rates remain high with estimates ranging from 15-day readmission rates of 13%, 30- day readmission rates of 25%, to 6-month readmission rates of 50%. The Center for Medicare and Medicaid Services (CMS) has started penalizing hospitals with higher than expected readmission rates. Objective: To identify factors associated with increased 30-day readmission among heart failure patients in an inner-city community-based teaching hospital. Methods: A retrospective cohort study of patients with principal discharge diagnosis of acute Heart Failure between 2008 and 2010. Demographic, clinical characteristics, length of stay, discharge medications, disposition and all-cause 30-day readmission were abstracted from the hospital’s administrative database and analyzed. Results: Almost 8 out of 10 patients were 65 years or older (mean age 75.4 ± 14.3) and 51% were female. The in-hospital mortality rate was 2.7% (95% confidence interval [CI], 1.6% - 4.3%) with a median length of stay of 5.0 days (Interquartile range of 3 - 7). The all-cause 30-day readmission rate was 17.7% (95% CI 14.9% - 20.8%). By univariate analysis, readmissions were predicted by black race, prior history of HF, length of stay of more than 7 days and discharge to extended care facility (ECF). By logistic regression analysis, black race (OR 2.4, 95% CI 1.4 - 3.8), prior history of HF (OR 1.7, 95% CI 1.5 - 2.6) and discharge to an ECF (OR 2.4, 95% CI 1.5 - 3.7) were the independent predictors of 30-day readmission. HF accounted for 43.7% of the readmissions. Conclusion: Prior diagnosis of HF, black race, and discharge to an ECF were independent predictors of 30-day readmission in this cohort, and over half of the readmissions were for reasons other than HF.
基金The study was reviewed and approved by the University Health Network Institutional Review Board.
文摘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,an
基金supported in part by the Key Research and Development Program for Guangdong Province(No.2019B010136001)in part by Hainan Major Science and Technology Projects(No.ZDKJ2019010)+3 种基金in part by the National Key Research and Development Program of China(No.2016YFB0800803 and No.2018YFB1004005)in part by National Natural Science Foundation of China(No.81960565,No.81260139,No.81060073,No.81560275,No.61562021,No.30560161 and No.61872110)in part by Hainan Special Projects of Social Development(No.ZDYF2018103 and No.2015SF 39)in part by Hainan Association for Academic Excellence Youth Science and Technology Innovation Program(No.201515)
文摘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.
文摘In a prior practice and policy article published in Healthcare Science,we introduced the deployed application of an artificial intelligence(AI)model to predict longer‐term inpatient readmissions to guide community care interventions for patients with complex conditions in the context of Singapore's Hospital to Home(H2H)program that has been operating since 2017.In this follow on practice and policy article,we further elaborate on Singapore's H2H program and care model,and its supporting AI model for multiple readmission prediction,in the following ways:(1)by providing updates on the AI and supporting information systems,(2)by reporting on customer engagement and related service delivery outcomes including staff‐related time savings and patient benefits in terms of bed days saved,(3)by sharing lessons learned with respect to(i)analytics challenges encountered due to the high degree of heterogeneity and resulting variability of the data set associated with the population of program participants,(ii)balancing competing needs for simpler and stable predictive models versus continuing to further enhance models and add yet more predictive variables,and(iii)the complications of continuing to make model changes when the AI part of the system is highly interlinked with supporting clinical information systems,(4)by highlighting how this H2H effort supported broader Covid‐19 response efforts across Singapore's public healthcare system,and finally(5)by commenting on how the experiences and related capabilities acquired from running this H2H program and related community care model and supporting AI prediction model are expected to contribute to the next wave of Singapore's public healthcare efforts from 2023 onwards.For the convenience of the reader,some content that introduces the H2H program and the multiple readmissions AI prediction model that previously appeared in the prior Healthcare Science publication is repeated at the beginning of this article.
基金Supported by National Institute of Diabetes and Digestive and Kidney Diseases,No.T32DK007740 and No.K08DK120902.
文摘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 ident
文摘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 trend
