Impact of Palliative Care Utilization for Surgical Patients Receiving Prolonged Mechanical Ventilation: National Trends (2009–2013)

BackgroundPatients requiring mechanical ventilation (MV) have high morbidity and mortality. Providing palliative care has been suggested as a way to improve comprehensive management. The objective of this retrospective cross-sectional study was to identify predictors for palliative care utilization and the association with hospital length of stay (LOS) among surgical patients requiring prolonged MV (≥ 96 consecutive hours).MethodsNational Inpatient Sample (NIS) data 2009–2013 was used to identify adults (age ≥ 18) who had a surgical procedure and required prolonged MV (≥ 96 consecutive hours), as well as patients who also had a palliative care encounter. Outcomes were palliative care utilization and association with hospital LOS.ResultsUtilization of palliative care among surgical patients with prolonged MV increased yearly, from 5.7% in 2009 to 11.0% in 2013 (p < 0.001). For prolonged MV surgical patients who died, palliative care increased from 15.8% in 2009 to 33.2% in 2013 (p < 0.001). Median hospital LOS for patients with and without palliative care was 16 and 18 days, respectively (p < 0.001). Patients discharged to either short or long term care facilities had a shorter LOS if palliative care was provided (20 vs. 24 days, p < 0.001). Factors associated with palliative care utilization included older age, malignancy, and teaching hospitals. Non-Caucasian race was associated with less palliative care utilization.ConclusionsAmong surgical patients receiving prolonged MV, palliative care utilization is increasing, although it remains low. Palliative care is associated with shorter hospital LOS for patients discharged to short or long term care facilities.     

Hospital Readmissions for Catheter‐Related Bloodstream Infection and Use of Ethanol Lock Therapy

Background: Catheter‐related bloodstream infection (CRBSI) is the most serious long‐term infectious complication of long‐term home parenteral nutrition (PN). Ethanol is being used more commonly as a catheter locking solution in the home PN setting for prevention of CRBSI; however, no current literature reports the use of ethanol lock (ETL) in skilled nursing facility (SNF) patients. Methods: The authors evaluated the number of hospital readmissions for CRBSI and length of stay between SNF (not receiving ETL) and home patients (receiving or not receiving ETL) receiving PN or intravenous fluid therapy. Results: SNF patients had a significantly longer length of stay (LOS) for CRBSI hospital admissions compared with patients receiving PN at home with or without ETL (P < .001; 16 vs 8 vs 8 days). There was no LOS difference for CRBSI between home patients with or without ETL. Home PN patients not receiving ETL were more likely to have a CRBSI from Staphylococcus sp (48% vs 27%; P = .015), whereas SNF PN patients not receiving ETL were more likely to have a CRBSI from Enterococcus sp (16% vs 3%; P = .004). Conclusion: Despite different causative organisms and medical acuity likely affecting the differences observed in LOS, the SNF population is another setting ETL can be used to prevent CRBSI.     

Policy-Driven Post-Acute Care Program Lowers Mortality Rate and Medical Expenditures After Hospitalization for Acute Heart Failure: A Nationwide Propensity Score–Matched Study

ObjectiveThe beneficial effects of multidisciplinary disease management programs have been demonstrated. The present study investigated the effects of a policy-driven, health insurance–reimbursed, heart failure (HF) post-acute care (PAC) program on mortality, health care service utilization, and readmission expenses for patients following hospitalization for HF.DesignThis was a retrospective propensity score–matched cohort study using the Taiwan National Health Insurance Research Database.Setting and ParticipantsIn total, 4346 patients (2173 receiving HF-PAC and 2173 controls) with left ventricular ejection fraction of ≤40% who were discharged following hospitalization for HF were included for analysis.MethodsAll patients were followed up after discharge for all-cause mortality, emergency visits within 30 days, and length of stay and medical expenses for readmission within 180 days after discharge.ResultsAfter propensity score matching, baseline characteristics of the HF-PAC and control groups were similar. During a mean follow-up period of 1.59 ± 0.92 years, according to the Cox multivariable analysis, HF-PAC reduced mortality by 48% compared with the control group, independent of traditional risk factors (hazard ratio = 0.520, 95% CI = 0.452-0.597, P < .001). Kaplan-Meier curves revealed that HF-PAC was associated with a higher cumulative survival rate (log-rank = 96.43, P < .001). HF-PAC also decreased the frequency of emergency visits after discharge by 23% in the 30 days post discharge and decreased length of stay and medical expenses related to readmission by 61% and 63%, respectively, in the 180 days post discharge (all P < .001).Conclusions and ImplicationsHF-PAC reduces short-term all-cause emergency visits, length of stay, and medical expenses for all-cause readmission and all-cause mortality in patients discharged following hospitalization for HF. Our findings suggest that PAC should include care continuity, optimal adaptation of transitional care components, and HF cardiologist engagement with multidisciplinary coordination.     

Machine-Learning Modeling to Predict Hospital Readmission Following Discharge to Post-Acute Care

ObjectivesPrimary purpose was to generate a model to identify key factors relevant to acute care hospital readmission within 90 days from 3 types of post-acute care (PAC) sites: home with home care services (HC), skilled nursing facility (SNF), and inpatient rehabilitation facility (IRF). Specific aims were to (1) examine demographic characteristics of adults discharged to 3 types of PAC sites and (2) compare 90-day acute hospital readmission rate across PAC sites and risk levels.DesignRetrospective, secondary analysis design was used to examine hospital readmissions within 90 days for persons discharged from hospital to SNF, IRF, or HC.Settings and ParticipantsCohort sample was composed of 2015 assessment data from 3,592,995 Medicare beneficiaries, including 1,536,908 from SNFs, 306,878 from IRFs, and 1,749,209 patients receiving HC services.MeasuresInitial level of analysis created multiple patient profiles based on predictive patient characteristics. Second level of analysis consisted of multiple logistic regressions within each profile to create predictive algorithms for likelihood of readmission within 90 days, based on risk profile and PAC site.ResultsTotal sample 90-day hospital readmission rate was 27.48%. Patients discharged to IRF had the lowest readmission rate (23.34%); those receiving HC services had the highest rate (31.33%). Creation of model risk subgroups, however, revealed alternative outcomes. Patients seem to do best (i.e., lowest readmission rates) when discharged to SNF with one exception, those in the very high risk group. Among all patients in the low-, intermediate-, and high-risk groups, the lowest readmission rates occurred among SNF patients.Conclusions and ImplicationsThe proposed model has potential use to stratify patients’ potential risk for readmission as well as optimal PAC destination. Machine-learning modeling with large data sets is a useful strategy to increase the precision accuracy in predicting outcomes among patients who have nonhome discharges from the hospital.     

Thirty‐Day Readmission Rate Is High for Hospitalized Patients Discharged With Home Parenteral Nutrition or Intravenous Fluids

Background: Reducing hospital readmissions decreases healthcare costs and improves quality of care. There are no published studies examining the rate of, and risk factors for, 30‐day readmissions for patients discharged with home parenteral support (HPS). Objective: Determine the rate of 30‐day readmissions for patients discharged with HPS and whether malnutrition and other demographic or clinical factors increase the risk. Materials and Methods: Retrospective review of patients discharged with HPS from the Cleveland Clinic between July 1, 2013, and June 30, 2014, and followed by the Cleveland Clinic Home Nutrition Support Service. Results: Of the 224 patients studied, 31.6% (n = 71) had unplanned readmissions within 30 days of hospital discharge. Of these, 21.1% (n = 15) were HPS related, with catheter‐related bloodstream infection (n = 5) and dehydration (n = 5) the most common. The majority of patients (84.4%) were diagnosed with malnutrition, but the presence or degree did not influence the readmission rate (P = .41). According to univariable analysis, patients with an ostomy (P = .037), a small bowel resection (P = .002), a higher HPS volume at discharge (P < .001), and a shorter period between HPS consult and hospital discharge (P < .026) had a lower risk of 30‐day readmission than their counterparts. On multivariable analysis, patients had a higher risk of 30‐day readmission if they had a history of heart disease (P = .048) and for every 1‐unit increase in white blood cells (P = .026). Conclusions: Patients discharged with HPS have a high 30‐day readmission rate, although most readmissions were not related to the HPS itself. The presence and degree of malnutrition were not associated with 30‐day readmissions.     

山西省大同市2017-2019年布鲁氏菌病患者医疗费用分析

目的 分析山西省大同市布鲁氏菌患者的医疗费用及影响因素。方法 收集2017年1月1日至2019年12月31日期间诊断为布鲁氏菌病患者的人口学信息、就诊信息和费用信息。对患者3年内医疗资源使用情况和医疗费用进行分析;分析不同性别、年龄、基础性疾病、临床分期、并发症对患者医疗资源利用及医疗费用的影响。结果 共2 289例纳入分析,其中门诊1 715例,住院574例;男性占72.0%（1 649/2 289）,年龄（49.6±15.5）岁,45~59岁年龄组为主（36.2%,829/2 289）。住院患者年龄（51.4±16.0）岁高于门诊（49.0±15.2）岁（Z=-4.01,P<0.001）。门诊患者年人均门诊次数（1.6±1.5）次。住院患者次均住院天数（14.6±9.9）d,患有中枢神经系统并发症［（20.8±11.4）d］和心血管系统和造血系统并发症［（16.6±9.5）d］的患者住院时间较长（均P<0.05）。在住院患者中,患有基础性疾病占51.0%（293/574）,其中内分泌代谢疾病占30.3%（174/574）;急性期患者占54.0%（310/574）,慢性期占46.0%（264/574）;患有并发症占64.3%（369/574）,其中,消化系统、骨骼系统并发症分别占30.3%（174/574）和29.1%（167/574）。门诊患者中,年龄是医疗费用的影响因素（P<0.001）;住院患者中,年龄、并发症和疗效是医疗费用的影响因素（P<0.05）,合并骨骼系统和中枢神经系统并发症的患者医疗费用高于无此二系统并发症者（P<0.001）。结论 2017-2019年山西省大同市布鲁氏菌病门诊病例的医疗费用负担尚可,住院患者特别是合并骨骼、神经系统并发症的患者其经济负担较重。病例的早发现、早诊断及早治疗,仍是避免并发症发生和进展,有效降低医疗费用的重要手段。     

A Comprehensive Analysis of the Costs of Severe Maternal Morbidity

IntroductionThe objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases.MethodsCalifornia linked birth certificate-patient discharge data for 2009 through 2011 (n = 1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS.ResultsExcluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME] $3,550) and a 33% increase in LOS (ME 0.9 days). These increased to 70% (ME $5,806) and 46% (ME 1.3 days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9 days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7 days]).ConclusionsPostpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood.     

Medical Costs and Readmissions After Intensive Poststroke Rehabilitation: Japanese Claims Data

ObjectivesThis study examined the association between intensive rehabilitation for subacute stroke patients and medical costs and readmission ratio during the year after discharge.DesignThis was a natural experiment study.Setting and ParticipantsWe identified individuals with a diagnosis of cerebrovascular disorder (ICD-10: I60-I69 cerebrovascular disease) in an insurance claims database in Japan from January 2005 to December 2017. From the database, 980 patients who were admitted to a convalescent rehabilitation unit with stroke were identified. After excluding 575 patients, 405 were eligible for the study.MethodsIn Japan, from April 2011, a new policy was established that allows special costs to be added as rehabilitation time increases. This policy provides an additional medical fee for inpatients in a convalescent rehabilitation unit who receive more than 120 minutes of rehabilitation therapy. We defined high-intensity rehabilitation as transfer from hospitalization to a convalescent rehabilitation unit after April 2011. Outcomes were total direct medical costs and readmission ratio during the year after discharge from the convalescent rehabilitation unit.ResultsDaily rehabilitation time, total rehabilitation time, and total medical costs of the high-intensity rehabilitation group were significantly higher than those of the low-intensity rehabilitation group (P < .001, P < .001, P = .011, respectively). However, there was no significant difference in the medical costs during the year after discharge (P = .653) or in the readmission ratio (hazard ratio: 1.09, 95% confidence interval: 0.55-2.18, P = .804).Conclusions and ImplicationsIntensive rehabilitation did not reduce medical costs or the readmission ratio during the first year after discharge. Future studies should consider the necessary rehabilitation intensity given the severity of the patient's condition, using large sample sizes.     

Derivation and Validation of a Model to Predict 30-Day Readmission in Surgical Patients Discharged to Skilled Nursing Facility

ObjectivesTo identify factors associated with 30-day all-cause readmission rates in surgical patients discharged to skilled nursing facilities (SNFs), and derive and validate a risk score.DesignRetrospective cohort.Setting and participantsPatients admitted to 1 tertiary hospital's surgical services between January 1, 2011, and December 31, 2014 and subsequently discharged to 110 SNFs within a 25-mile radius of the hospital. The first 2 years were used for the derivation set and the last 2 for validation.MethodsData were collected on 30-day all cause readmissions, patient demographics, procedure and surgical service, comorbidities, laboratory tests, and prior health care utilization. Multivariate regression was used to identify risk factors for readmission.ResultsDuring the study period, 2405 surgical patients were discharged to 110 SNFs, and 519 (21.6%) of these patients experienced readmission within 30 days. In a multivariable regression model, hospital length of stay [odds ratio (OR) per day: 1.03, 95% confidence interval (CI) 1.02-1.04], number of hospitalizations in past year (OR 1.24 per hospitalization, 95% CI 1.18-1.31), nonelective surgery (OR 1.33, 95% CI 1.18-1.65), low-risk service (orthopedic/spine service) (OR 0.32, 95% CI 0.25-0.42), and intermediate-risk service (cardiothoracic surgery/urology/gynecology/ear, nose, throat) (OR 0.69, 95% CI 0.53-0.88) were associated with all-cause readmissions. The model had a C index of 0.71 in the validation set. Using the following risk score [0.8 × (hospital length of stay) + 7 × (number of hospitalizations in past year) +10 for nonelective surgery, +36 for high-risk surgery, and +20 for intermediate-risk surgery], a score of >40 identified patients at high risk of 30-day readmission (35.8% vs 12.6%, P < .001).Conclusions/ImplicationsAmong surgical patients discharged to an SNF, a simple risk score with 4 parameters can accurately predict the risk of 30-day readmission.     

Acute Muscle Mass Loss Predicts Long-Term Fatigue,Myalgia, and Health Care Costs in COVID-19 Survivors

ObjectiveWe examined the impact of loss of skeletal muscle mass in post-acute sequelae of SARS-CoV-2 infection, hospital readmission rate, self-perception of health, and health care costs in a cohort of COVID-19 survivors.DesignProspective observational study.Setting and ParticipantsTertiary Clinical Hospital. Eighty COVID-19 survivors age 59 ± 14 years were prospectively assessed.MethodsHandgrip strength and vastus lateralis muscle cross-sectional area were evaluated at hospital admission, discharge, and 6 months after discharge. Post-acute sequelae of SARS-CoV-2 were evaluated 6 months after discharge (main outcome). Also, health care costs, hospital readmission rate, and self-perception of health were evaluated 2 and 6 months after hospital discharge. To examine whether the magnitude of muscle mass loss impacts the outcomes, we ranked patients according to relative vastus lateralis muscle cross-sectional area reduction during hospital stay into either “high muscle loss” (?18 ± 11%) or “low muscle loss” (?4 ± 2%) group, based on median values.ResultsHigh muscle loss group showed greater prevalence of fatigue (76% vs 46%, P = .0337) and myalgia (66% vs 36%, P = .0388), and lower muscle mass (?8% vs 3%, P < .0001) than low muscle loss group 6 months after discharge. No between-group difference was observed for hospital readmission and self-perceived health (P > .05). High muscle loss group demonstrated greater total COVID-19-related health care costs 2 ($77,283.87 vs. $3057.14, P = .0223, respectively) and 6 months ($90,001.35 vs $12, 913.27, P = .0210, respectively) after discharge vs low muscle loss group. Muscle mass loss was shown to be a predictor of total COVID-19-related health care costs at 2 (adjusted β = $10, 070.81, P < .0001) and 6 months after discharge (adjusted β = $9885.63, P < .0001).Conclusions and ImplicationsCOVID-19 survivors experiencing high muscle mass loss during hospital stay fail to fully recover muscle health. In addition, greater muscle loss was associated with a higher frequency of post-acute sequelae of SARS-CoV-2 and greater total COVID-19-related health care costs 2 and 6 months after discharge. Altogether, these data suggest that the loss of muscle mass resulting from COVID-19 hospitalization may incur in an economical burden to health care systems.     

Health Care Costs and Utilization Predictions by the Skilled Nursing Facility Readmission Risk Instrument

ObjectivesHealth care providers at hospitals and skilled nursing facilities (SNFs) are increasingly expected to optimize care of post-acute patients to reduce hospital readmissions and contain costs. To achieve these goals, providers need to understand their patients’ risk of hospital readmission and how this risk is associated with health care costs. A previously developed risk prediction model identifies patients’ probability of 30-day hospital readmission at the time of discharge to an SNF. With a computerized algorithm, we translated this model as the Skilled Nursing Facility Readmission Risk (SNFRR) instrument. Our objective was to evaluate the relationship between 30-day health care costs and hospital readmissions according to the level of risk calculated by this model.DesignThis retrospective cohort study used SNFRR scores to evaluate patient data.Setting and ParticipantsThe patients were discharged from Mayo Clinic Rochester hospitals to 11 area SNFs.MethodsWe compared the outcomes of all-cause 30-day standardized direct medical costs and hospital readmissions between risk quartiles based on the distribution of SNFRR scores for patients discharged to SNFs for post-acute care from April 1 through November 30, 2017.ResultsMean 30-day all-cause standardized costs were positively associated with SNFRR score quartiles and ranged from $9199 in the fourth quartile (probability of readmission, 0.27-0.66) to $2679 in the first quartile (probability of readmission, 0.07-0.13) (P ≤ .05). Patients in the fourth SNFRR score quartile had 5.68 times the odds of 30-day hospital readmission compared with those in the first quartile.Conclusions and ImplicationsThe SNFRR instrument accurately predicted standardized direct health care costs for patients on discharge to an SNF and their risk for 30-day hospital readmission. Therefore, it could be used to help categorize patients for preemptive interventions. Further studies are needed to confirm its validity in other institutions and geographic areas.     

新疆维吾尔自治区2017-2019年布鲁氏菌病患者医疗费用分析

目的 分析新疆维吾尔自治区（新疆）布鲁氏菌病（布病）患者的医疗费用及影响因素。方法 收集2017年1月1日至2019年12月31日期间首要诊断为布病患者的人口学信息、就诊信息和费用信息。通过非参数检验分析不同性别、年龄组、临床分期、并发症对患者医疗资源利用及医疗费用的影响。使用中位数描述布病患者的门诊和住院费用。结果 共13 532例纳入分析,其中门诊8 113例,住院5 419例,男性占67.8%（9 176/13 532）,年龄（42.7±15.4）岁,以18~44岁（46.6%,6 304/13 532）和45~59岁（34.2%,4 622/13 532）年龄组为主。住院患者年龄（43.3±15.7）岁,高于门诊患者年龄（42.3±15.1）岁（Z=-3.85,P < 0.001）。住院患者就诊时,全身症状以发热（36.9%,1 997/5 419）和乏力（36.6%,1 983/5 419）常见,局部症状以关节/肌肉疼痛（68.9%,3 735/5 419）常见;急性期患者占79.1%（4 289/5 419）,慢性期患者占20.9%（1 130/5 419）;患者有并发症占46.5%（2 519/5 419）,主要为骨骼系统并发症。门诊患者人均门诊次数（1.6±1.4）次。住院患者次均住院天数为（11.3±4.2）d,慢性期和有并发症患者住院天数较长（P < 0.05）。住院患者同年也有门诊记录占89.3%（4 840/5 419）,人均门诊次数（3.6±2.6）次。门诊患者医疗费用以化验费和药物费为主（75.1%）,住院患者以药物费、化验费和其他费用为主（74.4%）。2017-2019年门诊患者医疗费用M（Q₁,Q₃）分别为61（52,497）、61（51,346）和58（46,318）元,住院患者医疗费用M（Q₁,Q₃）分别为8 214（6 355,10 721）、9 095（7 018,12 155）和9 492（7 530,12 351）元。患者年龄、临床分期、并发症和关节/肌肉疼痛症状为住院患者医疗费用的影响因素（P < 0.001）。结论 2017-2019年新疆布病住院患者经济负担较重,特别是高年龄组、慢性期、合并骨骼和神经系统并发症的患者。提高患者早期就诊和规范治疗意识,减少慢性化和并发症发生,可降低布病诊治所导致的经济负担。     

The Impact of Palliative Medicine Consultation on Readmission Rates and Hospital Costs in Surgical Patients Requiring Prolonged Mechanical Ventilation

BackgroundThe use of palliative care for critically ill hospitalized patients has expanded. However, it is still underutilized in surgical specialties. Postsurgical patients requiring prolonged mechanical ventilation have increased mortality and costs of care; outcomes from adding palliative care services to this population have been poorly investigated. The objective of this study was to determine the impact of palliative medicine consultation on readmission rates and hospitalization costs in postsurgical patients requiring prolonged mechanical ventilation.MethodsThe Nationwide Readmissions Database was queried for adults (> 18 years) between the years 2010 and 2014 who underwent a major operation (Healthcare Cost and Utilization Project [HCUP] data element ORPROC = 1), required mechanical ventilation for ≥ 96 consecutive hours (ICD-9-CM V46.1), and survived until discharge. Among these, patients who received a palliative medicine consultation during hospitalization were identified using the ICD-9-CM diagnosis code V66.7.ResultsOf 53,450 included patients, 3.4% received a palliative care consultation. Compared to patients who did not receive a palliative care consultation, patients who did receive a consultation had a lower readmission rate (14.8% vs. 24.8%, p < 0.001) and lower average cost of hospitalization during the initial admission ($109,007 vs. $124,218, p < 0.001), findings that persisted after multivariable logistic regression.ConclusionUtilization of palliative care in surgical patients remains low. Palliative care consultation in postsurgical patients requiring prolonged mechanical ventilation was associated with lower cost and rate of readmission. Further work is needed to integrate palliative care services with surgical care.     

Postsurgical Opioid Use Among Veterans Discharged to Skilled Care Facilities Compared to Veterans Discharged to Home After Orthopedic Surgery

ObjectivesTo compare opioid use patterns among Veterans who were discharged to a skilled care facility vs home after orthopedic surgery at a VA hospital.DesignWe conducted a retrospective cohort study of Veterans who had orthopedic surgery at the Salt Lake City VA Medical Center (VAMC) between January 2018 and December 2021 and were followed by a transitional pain service. The principal outcome of interest was the time to stop opioid use after discharge from the hospital.Setting and ParticipantsVeterans not already on chronic opioid therapy who had orthopedic surgery at the Salt Lake City VAMC and were followed by a transitional pain service.Methods448 patients were included in the study, of which 371 (83%) were discharged to home and 77 (17%) were discharged to a skilled care facility. Median days to opioid cessation were estimated using the Kaplan-Meier method with 95% CIs and compared with discharge disposition using a log-rank test. Time to opioid cessation following hospital discharge was compared to baseline characteristics using univariable and multivariable Cox proportional hazards models.ResultsPatients who were discharged to a skilled care facility used opioids for twice as long as those who were discharged home [median days (interquartile range)]: 22 (19, 26) vs 11 (10, 12), P < .001, respectively. When controlling for baseline characteristics in the multivariable analysis, discharge to a skilled care facility was significantly associated with continued opioid use at all time points [hazard ratio 0.63 (95% CI 0.44, 0.89), P = .009].Conclusions and ImplicationsVeterans discharged to a skilled care facility after orthopedic surgery used opioids for twice as long as those who were discharged to home. As postsurgical pain management guidelines change to focus on nonopioid pain modalities and opioid reduction, skilled care providers should adapt those strategies for their facilities.     

Passing the SNF Test: A Secondary Analysis of a Sepsis Transition Intervention Trial Among Patients Discharged to Post-Acute Care

ObjectivesSepsis survivors discharged to post-acute care facilities experience high rates of mortality and hospital readmission. This study compared the effects of a Sepsis Transition and Recovery (STAR) program vs usual care (UC) on 30-day mortality and hospital readmission among sepsis survivors discharged to post-acute care.DesignSecondary analysis of a multisite pragmatic randomized clinical trial.Setting and ParticipantsSepsis survivors discharged to post-acute care.MethodsWe conducted a secondary analysis of patients from the IMPACTS (Improving Morbidity During Post-Acute Care Transitions for Sepsis) randomized clinical trial who were discharged to post-acute care. IMPACTS evaluated the effectiveness of STAR, a nurse-navigator-led program to deliver best practice post-sepsis care. Subjects were randomized to receive either STAR or UC. The primary outcome was 30-day readmission and mortality. We also evaluated hospital-free days alive as a secondary outcome.ResultsOf 691 patients enrolled in IMPACTS, 175 (25%) were discharged to post-acute care [143 (82%) to skilled nursing facilities, 12 (7%) to long-term acute care hospitals, and 20 (11%) to inpatient rehabilitation]. Of these, 87 received UC and 88 received the STAR intervention. The composite 30-day all-cause mortality and readmission endpoint occurred in 26 (29.9%) patients in the UC group vs 18 (20.5%) in the STAR group [risk difference −9.4% (95% CI −22.2 to 3.4); adjusted odds ratio 0.58 (95% CI 0.28 to 1.17)]. Separately, 30-day all-cause mortality was 8.1% in the UC group compared with 5.7% in the STAR group [risk difference −2.4% (95% CI −9.9 to 5.1)] and 30-day all-cause readmission was 26.4% in the UC group compared with 17.1% in the STAR program [risk difference −9.4% (95% CI −21.5 to 2.8)].Conclusions and ImplicationsThere are few proven interventions to reduce readmission among patients discharged to post-acute care facilities. These results suggest the STAR program may reduce 30-day mortality and readmission rates among sepsis survivors discharged to post-acute care facilities.     

Combined Antifungals Produce Less Toxicity,Better Results

Abstract

Background:Intensivists have been associated with decreased mortality in several studies, but in one major study, centers with intensivist-staffed units reported increased mortality compared with controls. We hypothesized that a closed unit, in which a unit-based intensivist directly provides and coordinates care on all cases, has improved mortality and utilization compared with an open unit, in which individual attendings and consultants provide care, while intensivists serve as supervising consultants. Methods: We undertook the retrospective study of outcomes in 2 intensive care units (ICUs)—a traditional open unit managed by faculty intensivists and a second closed unit overseen by the same faculty intensivists who coordinated the care on all patients in a large community hospital. Primary Outcome: In-hospital mortality. Secondary Outcomes: Hospital length of stay (LOS), ICU LOS, and relative costs of hospitalization. Results: From January 2006 to December 2007, we identified 2602 consecutive admissions to the 2 medical ICUs. Of all patients admitted to the closed and open units, 19.2% and 24.7%, respectively, did not survive (P < 0.001, adjusted for severity). Median hospital LOS was 10 days for the closed unit and 12 days for the open unit (P < 0.001). Median ICU LOS was 2.2 days for the closed unit and 2.4 days for the open unit (P = NS). The unadjusted cost index for the open unit was 1.11 relative to the closed unit (1.0) (P < 0.001). However, after adjusting for disease severity, cost differences were not significantly different. Conclusions: We observed significant reductions in mortality and hospital LOS for patients initially admitted to a closed ICU versus an open unit. We did not observe a significant difference in ICU LOS or total cost after adjustment for severity.     

A Nurse-Led Bridging Program to Reduce 30-Day Readmissions of Older Patients Discharged From Acute Care Units

ObjectivesOlder hospitalized patients are at high risk of early readmissions, requiring the implementation of enhanced coordinated transition programs on discharge. The objective of this study was to evaluate the impact of a nurse-led transition bridging program on the rate of unscheduled readmissions of older patients within 30 days from discharge from geriatric acute care units.DesignA stepped-wedge cluster randomized trial.Setting and ParticipantsSeven hundred five patients aged ≥75 years hospitalized in one of 10 acute geriatric units, with at least 2 readmission risk-screening criteria (derived from the Triage Risk Screening Tool), were included from July 2015 to August 2016.MethodsThe intervention condition consisted in a nurse-led hospital-to-home bridging program with 4 weeks postdischarge follow-up (2 home visits and 2 telephone calls). Unscheduled hospital readmission or emergency department (ED) visits were compared in intervention and control condition within 30 days from discharge.ResultsThe rate of 30-day readmission or ED visit was 15.5% in the intervention condition vs 17.6% in the control condition [hazard ratio stratified on clusters: 0.61 (upper limit unilateral 95% confidence interval = 1.11), P = .09]. Rate of presence of professional caregivers was increased in the intervention condition (P < .001).Conclusions and ImplicationsAlthough the intervention resulted in an increase in the rate of implementation of a package of care at the 4-week of follow-up, we could not demonstrate a reduction in the rate of 30-day readmissions or ED visits of older patients at risk of readmission. These findings support the evaluation of this type of program on the longer term.     

Incomplete Home Health Care Referral After Hospitalization Among Medicare Beneficiaries

ObjectivesPatients who are referred to home health care after an acute care hospitalization may not receive home health care, resulting in incomplete home health referrals. This study examines the prevalence of incomplete referrals to home health, defined as not receiving home health care within 7 days after an initial hospital discharge, and investigates the relationship between home health referral completion and patient outcomes.DesignRetrospective cohort study.Setting and ParticipantsMedicare beneficiaries who are discharged from short-term acute care hospitals between October 2015 and December 2016 with a discharge status code on the hospital claim indicating home health care.MethodsPatient characteristics and outcomes were compared between Medicare beneficiaries with complete and incomplete home health referrals after hospital discharge. The outcomes included mortality, readmission rate, and total spending over a 1-year episode following hospitalization. These outcomes were risk-adjusted using patient demographic, socioeconomic, clinical characteristic, hospital characteristic, and state fixed effects.ResultsApproximately 29% of the 724,700 hospitalizations in the analytic dataset had incomplete home health referrals after discharge. The rate of incomplete home health referrals varied among clinical conditions, ranging from 17% among joint/musculoskeletal patients and 38% among digestive/endocrine patients. Risk-adjusted 1-year mortality and readmission rates were 1.4 and 2.4 percentage points lower and total spending was $1053 higher among patients with complete home health referrals as compared with those with incomplete home health referrals after hospital discharge.Conclusions and ImplicationsThe analysis revealed that almost 1 in 3 patients discharged from a hospital with a discharge status of home health does not receive home health care. In addition, complete home health referrals are associated with lower mortality and readmission rates and higher spending. As home health care utilization increases, policymakers should pay attention to the tradeoff between quality and cost when implementing alternative policies and payment models.