Predictors of hospital readmission in a cohort of 236 elderly discharged after surgical repair of hip fracture: one-year follow-up

BACKGROUND AND AIMS: Few studies have investigated predictors for hospital readmission after hip fracture repair. METHODS: In a prospective cohort study we evaluated factors associated with early (within 3 months) and late (between 3-12 months), single and multiple hospital readmission in 236 hip-fractured older adults admitted to an orthopedic unit. Baseline patient characteristics and hospital course (functional and cognitive status, comorbidity, type of fracture, time to surgery, in-hospital stay, complications) were recorded. Hospital readmission over 12 months and ICD-9 principal diagnosis were ascertained from administrative sources. Functional status at the end of the rehabilitation program was assessed by telephone interviews. RESULTS: Seventy-one patients (30.1%) were readmitted to hospital within twelve months of discharge and 22 (9.3%) had two or more readmission. The total number of readmissions was 105, 43 (41%) occurred in the first three months. The most common readmission causes were cardiac, infectious and cerebrovascular; surgical complication accounted for 5.7%. Patients with a single readmission, like those with multiple readmissions, were sicker (CIRS-CI subscore 4.0+/-1.8 vs 3.2+/-1.6, p=0.010) and more functionally impaired at the end of rehabilitation (2 months' Katz index 2.1+/-2 vs 2.9+/-2.3, p=0.007) than controls. In a multiple logistic regression model, comorbidity and functional status at the end of rehabilitation were the only factors associated with the risk of readmission. CONCLUSIONS: Subjects at high risk of readmission can be reliably assessed, since few significant variables were associated with rehospitalization. Subgroups of patients with an elevated risk of rehospitalization after hip fracture may be the target for strategies to reduce the burden of excessive hospital use and improve overall outcomes.     

Trends in and predictors of multiple readmissions following heart failure hospitalization: A National wide analysis from the United States

BackgroundReadmission following Heart failure (HF) hospitalization is common: 25% are readmitted within a month of discharge and ≈50% within 6 months. A small proportion of these patients can have multiple readmissions within this period, adding disproportionately to the health care costs. In this study, we assessed the trends, predictors and costs associated with multiple readmissions using National readmissions database (NRD).MethodsWe queried NRD for HF hospitalizations from 2010 to 2018 using ICD-9/10-CM codes. Multinomial logistic regression was used to compare readmission cohorts, with the multivariable model adjusting for other factors. All analyses accounted for the NRD sampling design were conducted using SAS v. 9.4 with p < 0.05 used to indicate statistical significance.ResultsWithin the study period, an estimated 6,763,201 HF hospitalizations were identified. Of these, 58% had no readmission; 26% had 1 readmission; and 16% had ≥2 readmissions within 90 days of index hospitalization. There was no statistically significant change in readmission rates during the observation period. Multiple readmissions which accounted for 37% of all readmissions contributed to 57% of readmission costs. Younger age was identified as a predictor of multiple readmissions while sex, comorbidities and the type of insurance were not significantly different from those with single readmission.ConclusionsMultiple readmissions in HF are common (16%), have remained unchanged between 2010 and 2018 and impose a significant health care cost burden. Future research should focus on identifying these patients for targeted intervention that may minimize excessive readmissions particularly in those patients who are in the palliation phase of HF.     

Predictors of Early Hospital Readmission for Asthma Among Inner-City Children

Factors associated with early asthma readmission have not been fully studied. To identify predictors of early readmission, we performed a matched case-control study of children discharged with primary diagnosis of asthma. Cases were readmitted with asthma within 30 days of discharge. Controls were not readmitted. Conditional logistic regression analysis was used. History of asthma hospitalization within the past 12 months was an independent predictor of early readmission (OR 1.89, p = 0.021). Modifiable factors such as medical treatment and management during and upon discharge from the index admission did not predict early asthma readmission.     

Predictors of Early Hospital Readmission for Asthma Among Inner-City Children

Factors associated with early asthma readmission have not been fully studied. To identify predictors of early readmission, we performed a matched case-control study of children discharged with primary diagnosis of asthma. Cases were readmitted with asthma within 30 days of discharge. Controls were not readmitted. Conditional logistic regression analysis was used. History of asthma hospitalization within the past 12 months was an independent predictor of early readmission (OR 1.89, p = 0.021). Modifiable factors such as medical treatment and management during and upon discharge from the index admission did not predict early asthma readmission.     

Hospitalization, surgery, and readmission rates of IBD in Canada: a population-based study

BACKGROUND: We aimed to define the rates of hospitalization and readmission for inflammatory bowel disease in Canada. METHODS: The data source was Statistics Canada Person Oriented Information Database (1994-2001). The number of stays for a diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) by ICD-9-CM code 555 or 556 was extracted (and assessed when CD or UC was the first diagnosis or was 1 of 16 diagnoses on the patient discharge abstract). Age-, gender-, and disease-specific rates of hospitalization, length of stay, readmission, and surgery were assessed. RESULTS: The age-adjusted hospitalization rate for CD declined over 1994-2001 from 29.2 to 26.9/100,000 but was stable for UC at 12.6-13.3 per 100,000. In the 7 yr, 39.4% of CD patients (21.3-24.0%/yr) and 33.7% of UC patients (18.5-20.3%/yr) got readmitted at least once. The average length of stay declined from 10.3 (1994-1995) to 9.1 days (2000-2001) (p = 0.029) in CD and in UC declined from 12.2 to 10.1 days (p = 0.054). Of all hospitalizations, major surgery occurred in 48% of CD (44.8-49.8% per yr) and 55% of UC (51.5-59.0% per yr). CONCLUSIONS: Rates of hospitalization declined slightly for CD over the 7 yr but still remained twice as great as the rates for UC. Approximately 20% of CD and UC subjects got readmitted per year and over 7 yr approximately 35% got readmitted. Major surgery was a more common reason for hospitalization in UC than in CD.     

Predictors of 90-Day Readmission and in-Hospital Mortality in Takotsubo Cardiomyopathy: An Analysis of 28,079 Index Admissions

BackgroundTakotsubo cardiomyopathy (TC) is diagnosed in 1% to 2% of patients presenting with suspected acute coronary syndromes. Readmission patterns after TC have been less studied. Thus, we sought to perform a study to evaluate the etiologies, trends, and predictors of 90-day readmission in TC.MethodsThe Nationwide Readmissions Database (NRD), 2014, was used to select the study cohort. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code 429.83 was used to identify TC. Admissions within 90 days of index admission were considered early readmissions. Readmission etiologies were identified by an ICD-9-CM code. Hierarchical multivariate models were used to evaluate predictors of early readmission.ResultsA total of 28,079 patients were identified during the study period, of whom 24.3% (n = 6841) were readmitted within 90 days of discharge. In-hospital mortality during index admissions was 5.69%. The most common etiologies for readmission were cardiac (18.56%), respiratory (17.20%), and infections (13.12%). Among cardiac complications, acute heart failure was the most common etiology (7.48%). The highest number of readmissions happened on the first day after discharge (n = 125). On multivariate analysis, the age of 50–64 years, diabetes, heart failure, chronic pulmonary disease, peripheral vascular disease, anemia, and malignancy were shown to be significant predictors of readmission. Patients of female gender are less likely to be readmitted and have lower in-hospital mortality.ConclusionsPatients with TC are highly likely to be readmitted within the first month after discharge, most likely with secondary to cardiac or respiratory complications. These findings warrant close post-discharge transition to reduce morbidity and improve healthcare outcomes.SummaryThis analysis from the Nationwide Readmission Database outlines a detailed analysis on etiologies, trends, and predictors of 90-day readmission for patients presenting with takotsubo cardiomyopathy.     

False-positive coding for acute myocardial infarction on hospital discharge records: chart audit results from a tertiary centre

Hospital medical records staff enter diagnostic codes on charts using the International Classification of Diseases (Clinically Modified), Ninth Revision (ICD-9-CM). In a downtown Toronto tertiary hospital, 209 consecutive charts coded for acute myocardial infarction as the primary diagnosis in 1987-88 were reviewed. Criteria for documentation of acute myocardial infarction included symptomatic, electrocardiographic and enzymatic elements. Forty-three (21%) false-positives, ie, charts coded acute myocardial infarction where criteria were not fulfilled, were found (95% confidence interval 15 to 26%). Physician diagnosis of acute myocardial infarction appeared on the face sheet of 30 of the false-positive cases. Common reasons for false-positive face sheet entries and chart coding were acute myocardial infarction within the previous eight weeks with transfer or readmission for coronary angiography and other procedures; and presumed acute myocardial infarction on admission subsequently unproven or disproved. The false-positive proportion was similar to a Canadian study drawing on charts from hospitals of various sizes in 1977, lower than in recent reports from various American tertiary teaching hospitals (P less than 0.0001), and higher than in five Boston area community hospitals (P = 0.0005) where procedure-related transfers or readmissions of previous acute myocardial infarction patients were less likely. This audit lends credence to arguments that changes are needed in ICD-9-CM codes for acute myocardial infarction and in the assignation of reasons for hospitalization.     

Etiologies,predictors, and economic impact of readmission within 1 month among patients with takotsubo cardiomyopathy

Background

Limited data exist on readmission among patients with takotsubo cardiomyopathy (TC), a commonly reversible cause of heart failure.

Hypothesis

We sought to identify etiologies and predictors for readmission among TC patients.

Methods

We queried the National Readmissions Database for 2013–2014 to identify patients with primary admission for TC using ICD‐9‐CM code 429.83. Patients readmitted to hospital within 1 month after discharge were further evaluated to identify etiologies, predictors, and resultant economic burden of readmission. Additionally, we analyzed readmission for TC at 6 months.

Results

We studied 5997 patients admitted with TC, of whom 1.2% experienced in‐hospital mortality. Median age was 67 years, with 91.5% being female. Among survivors, 10.3% were readmitted within 1 month; 25% of the initial 1‐month readmissions occurred within 4 days, 50% within 10 days, and 75% within 20 days from discharge. The most common etiologies for readmission were cardiac (26%), respiratory (16%), and gastrointestinal (11%) causes. Heart failure was the most common cardiac etiology. Significant predictors of increased 1‐month readmission included systemic thromboembolic events, length of stay ≥3 days, and underlying psychoses. Obesity and private insurance predicted lower 1‐month readmission. The annual national cost impact for index admission and 1‐month readmissions was ≈$112 million. Recurrent TC was seen among 1.9% of patients readmitted within 6 months.

Conclusions

Though the overall rate of 1‐month readmission following TC is low, associated economic burden from readmission is still significant. Patients are readmitted mostly for noncardiac causes. Readmission for another episode of TC within 6 months was uncommon.     

Major bleeding after hospitalization for deep-venous thrombosis

PURPOSE: Most studies of oral anticoagulant-related bleeding have analyzed the incidence of adverse outcomes among patients with a variety of different conditions and without any comparison with a control group. We determined the incidence, time course, and risk factors associated with major bleeding after hospital discharge among patients with deep-vein thrombosis, and estimated the excess risk of bleeding associated with oral anticoagulant therapy. METHODS: A total of 22,000 adults were hospitalized in California for 3 or more days with a diagnosis of deep-venous thrombosis between January 1, 1992, and September 30, 1994. We determined the risk factors associated with readmission for bleeding. We compared the incidence of readmission for bleeding with comparison cohorts of patients with pneumonia or cellulitis who were matched for age, gender, race, and length of hospital stay. RESULTS: Of 21,250 patients with deep-venous thrombosis who were discharged without bleeding, 1.4% were readmitted for bleeding within 91 days; the rate was 2.7 times greater in the first 30 days than in the next 61 days. Risk factors for bleeding included hospitalization with gastrointestinal bleeding during the previous 18 months (relative hazard [RH] = 2.6, 95% confidence interval [CI]: 1.6 to 4.1), hospitalization with an alcohol-related diagnosis during the previous 18 months (RH = 2.6, 95% CI: 1.4 to 4.8), chronic renal disease (RH = 2.4, 95% CI: 1.4 to 4.2), female gender (RH = 1.7, 95% CI: 1.3 to 2.2), presence of a malignancy (RH = 1.6, 95% CI: 1.2 to 2.2), nonwhite race (RH = 1.6, 95% CI: 1.2 to 2.1), and age over 65 years (RH = 1.3, 95% CI: 1.0 to 1.7). Significantly more women (n = 40) had intracranial bleeding than men (n = 18, P = 0.02). In the comparison cohorts, the incidence of readmission for bleeding within 3 months of discharge was 0.7%, and the relative risk (RR) of readmission was greater in those with deep-venous thrombosis than in those with cellulitis (RR = 2.0, 95% CI: 1.6 to 2.5) or pneumonia (RR = 2.0, 95% CI: 1.7 to 2.5). CONCLUSIONS: The incidence of rehospitalization for bleeding was greatest in the first 30 days after discharge, and was approximately twice that seen in patients hospitalized for cellulitis or pneumonia. Further studies are needed to determine why women and nonwhite patients are at increased risk for anticoagulant-related bleeding.     

Risk factors for hospital readmission of elderly patients

BackgroundThe aim of this study was to identify which factors were associated with a risk of hospital readmission within 3 months after discharge of a sample of elderly patients admitted to internal medicine and geriatric wards.MethodsOf the 1178 patients aged 65 years or more and discharged from one of the 66 wards of the ‘Registry Politerapie SIMI (REPOSI)’ during 2010, 766 were followed up by phone interview 3 months after discharge and were included in this analysis. Univariate and multivariate logistic regression models were used to evaluate the association of several variables with rehospitalization within 3 months from discharge.ResultsNineteen percent of patients were readmitted at least once within 3 months after discharge. By univariate analysis in-hospital clinical adverse events (AEs), a previous hospital admission, number of diagnoses and drugs, comorbidity and severity index (according to Cumulative Illness Rating Scale-CIRS), vascular and liver diseases with a level of impairment at discharge of 3 or more at CIRS were significantly associated with risk of readmission. Multivariate logistic regression analysis showed that only AEs during hospitalization, previous hospital admission, and vascular and liver diseases were significantly associated with the likelihood of readmission.ConclusionsThe results demonstrate the need for increased medical attention towards elderly patients discharged from hospital with characteristics such as AEs during the hospitalization, previous admission, vascular and liver diseases.     

Determinants of Early Readmission After Hospitalization for Heart Failure

Background

Determination of factors increasing the likelihood of early readmission after hospitalization for heart failure (HF) is fundamental for identifying potential targets for intervention. Thus, we studied the characteristics of patients readmitted within 7 and 30 days after hospitalization for HF in Alberta, Canada.

Methods

Using hospital discharge abstract data, we followed patients with incident HF discharged from April 2004-March 2012 and determined their readmission status within 7 and 30 days after an index hospitalization. Logistic regression was used to determine variables associated with readmission.

Results

Of 18,590 patients with HF (49.8% women; mean age 76.4 years), 5.6% were readmitted within 7 days and 18% were readmitted within 30 days. Readmission rates within 7 and 30 days increased significantly with age. Seven-day all-cause readmissions were associated with history of kidney disease (adjusted odds ratio [aOR], 1.28; 95% confidence interval [CI], 1.08-1.53), and 30-day all-cause readmissions were associated with cancer, pulmonary, liver, and kidney disease. Discharge with home care services at the time of discharge was a risk factor for readmission within 7 days (aOR, 1.26; 95% CI, 1.07-1.49) and 30 days (aOR, 1.23; 95% CI, 1.11-1.35). Discharge from a hospital with HF services was associated with lower readmission at both 7 days (aOR, 0.65; 95% CI, 0.57-0.74) and 30 days (aOR, 0.71; 95% CI, 0.65-0.77).

Conclusions

Several factors were associated with increased risk of readmission, whereas patients discharged from hospitals with HF services had a lower risk of readmission within 7 and 30 days of discharge. The interaction of provision of home care and higher early readmission deserves further study.     

Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure

IntroductionHospitals are under pressure to provide care that not only shortens hospital length of stay but also reduces subsequent hospital admissions. Hospital readmissions have received increased attention in outcome reporting. The authors identified survivors of acute respiratory failure who then required subsequent hospitalization. A cohort of acute respiratory failure survivors, who participated in an early intensive care unit (ICU) mobility program, was assessed to determine if variables from the index hospitalization predict hospital readmission or death, within 12 months of hospital discharge.MethodsHospital database and responses to letters mailed to 280 acute respiratory failure survivors. Univariate predictor variables shown to be associated with hospital readmission or death (P < 0.1) were included in a multiple logistic regression. A stepwise selection procedure was used to identify significant variables (P < 0.05).ResultsOf the 280 survivors, 132 (47%) had at least 1 readmission or died within the first year, 126 (45%) were not readmitted and 22 (8%) were lost to follow-up. Tracheostomy [odds ratio (OR), 4.02 (95%CI, 1.72-9.40)], female gender [OR, 1.94 (95%CI, 1.13-3.32)], a higher Charlson Comorbidity Index assessed upon index hospitalization discharge [OR, 1.15 (95%CI, 1.01-1.31)] and lack of early ICU mobility therapy [OR, 1.77 (95%CI, 1.04-3.01)] predicted readmission or death in the first year postindex hospitalization.ConclusionsTracheostomy, female gender, higher Charlson Comorbidity Index and lack of early ICU mobility were associated with readmissions or death during the first year. Although the mechanisms of increased hospital readmission are unclear, these findings may provide further support for early ICU mobility for patients with acute respiratory failure.     

The readmission of elderly people to hospital in an inner-city health district

The hospital sector in Britain has, over the last decade, achieved substantial reductions in the average length of stay for patients aged 65 and over. One consequence of this may be increased readmission rates. Furthermore, readmission rates are increasingly being proposed as a surrogate measure of outcome after hospital treatment. All admissions of people aged 65 + to two inner-London hospitals in May 1988 were monitored for 6 months after discharge and readmission rates calculated. Of the 386 patients discharged, 130 (38%) were readmitted within 6 months. The 1 week readmission rate was 6%; at 1 month it was 18%. Readmissions showed no variation regarding age or sex of patients but were related to specialty of treatment and length of stay. Consistently, those readmitted has a shorter length of stay than those not readmitted. If readmission rates are to have any utility as a surrogate outcome indicator they must be calculated on a common basis which relates to unplanned readmissions occurring fairly rapidly after discharge, and are related to the index admission.     

Risk factors for early hospital readmission in patients with AIDS and pneumonia

OBJECTIVE: To determine risk factors for early readmission to the hospital in patients with AIDS and pneumonia. DESIGN: Case-control analysis. SETTING: A municipal teaching hospital serving an indigent population. PATIENTS: Case patients were all AIDS patients hospitalized with Pneumocystis carinii pneumonia or bacterial pneumonia between January 1992 and March 1995 who were readmitted for any nonelective reason within 2 weeks of discharge (n = 90). Control patients were randomly selected AIDS patients admitted during the study period who were not early readmissions (n = 87), matched by proportion of Pneumocystis carinii to bacterial pneumonia. MEASUREMENTS AND MAIN RESULTS: Demographics, social support, health-related behaviors, clinical aspects of the acute hospitalization, and general medical status were the main predictors measured. RESULTS: Patients were at significantly increased risk of early readmission if they left the hospital unaccompanied by family or friend (odds ratio [OR] 4.76; 95% confidence interval [CI] 2.06, 11.0; p =.0003), used crack cocaine (OR 3.40; 95% CI 1.02, 11.3; p =. 046), had one or more coincident AIDS diagnoses (OR 3.65; 95% CI 1. 44, 9.26; p =.0065), or had been admitted in the preceding 6 months (OR 2.82; 95% CI 1.21, 6.57; p =.016). Demographic characteristics, alcoholism, intravenous drug use, illness severity on admission, and length of hospitalization did not predict early readmission. CONCLUSIONS: Absence of companion at discharge and crack use were important risk factors for early readmission in patients with AIDS and pneumonia. Additional AIDS comorbidity and recent antecedent hospitalization were also risk factors; however, demographics and measures of acute illness during index hospitalization did not predict early readmission.     

Early Hospital Readmission is a Predictor of One-Year Mortality in Community-Dwelling Older Medicare Beneficiaries

BACKGROUND

Hospital readmission within thirty days is common among Medicare beneficiaries, but the relationship between rehospitalization and subsequent mortality in older adults is not known.

OBJECTIVE

To compare one-year mortality rates among community-dwelling elderly hospitalized Medicare beneficiaries who did and did not experience early hospital readmission (within 30?days), and to estimate the odds of one-year mortality associated with early hospital readmission and with other patient characteristics.

DESIGN AND PARTICIPANTS

A cohort study of 2133 hospitalized community-dwelling Medicare beneficiaries older than 64?years, who participated in the nationally representative Cost and Use Medicare Current Beneficiary Survey between 2001 and 2004, with follow-up through 2006.

MAIN MEASURE

One-year mortality after index hospitalization discharge.

KEY RESULTS

Three hundred and four (13.7?%) hospitalized beneficiaries had an early hospital readmission. Those with early readmission had higher one-year mortality (38.7?%) than patients who were not readmitted (12.1?%; p?<?0.001). Early readmission remained independently associated with mortality after adjustment for sociodemographic factors, health and functional status, medical comorbidity, and index hospitalization-related characteristics [HR (95?% CI) 2.97 (2.24-3.92)]. Other patient characteristics independently associated with mortality included age [1.03 (1.02-1.05) per year], low income [1.39 (1.04-1.86)], limited self-rated health [1.60 (1.20-2.14)], two or more recent hospitalizations [1.47 (1.01-2.15)], mobility difficulty [1.51 (1.03-2.20)], being underweight [1.62 (1.14-2.31)], and several comorbid conditions, including chronic lung disease, cancer, renal failure, and weight loss. Hospitalization-related factors independently associated with mortality included longer length of stay, discharge to a skilled nursing facility for post-acute care, and primary diagnoses of infections, cancer, acute myocardial infarction, and heart failure.

CONCLUSIONS

Among community-dwelling older adults, early hospital readmission is a marker for notably increased risk of one-year mortality. Providers, patients, and families all might respond profitably to an early readmission by reviewing treatment plans and goals of care.     

C-Reactive Protein at Discharge,Diabetes Mellitus and ≥1 Hospitalization During Previous Year Predict Early Readmission in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Recurrent hospitalizations in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients have clinical and economic consequences; particularly those readmitted soon after discharge. The aim of our observational study was to determine predictors of early readmission to hospital (30 days from discharge).

Prospective data on 125 hospitalized AECOPD patients were collected over a 30-month period at two Spanish university hospitals. Based on readmission after discharge, patients were divided into non-readmitted (n = 96) and readmitted (n = 29). Measures of serum inflammatory biomarkers were recorded on admission to hospital, at day 3 and at discharge; data on clinical, laboratory, microbiological and severity features were also recorded.

In a multivariate model, C-reactive protein (CRP) at discharge ≥7.6 mg/L, presence of diabetes and ≥1 hospitalization for AECOPD during previous year were significant risk factors for predicting readmission. Presence of all 3 risk factors perfectly identified the readmitted patients (positive and negative predictive values of 1.000; 95% CI, 1.00–1.00).

A combination of 3 readily available clinical and biochemical parameters is accurate in identifying hospitalized AECOPD patients at risk for early readmission.     

Early re-hospitalization of elderly people discharged from a geriatric ward

BACKGROUND AND AIMS: Hospitalized elderly patients generally have a high level of disability and comorbidity. In many cases, at hospital discharge, the achieved health status balance is poor, and consequently the risk of further disability and hospital readmission is great. Identifying factors leading to hospital readmission could be helpful in reducing such events. The aim of the study was to evaluate the incidence and predictive factors of hospital readmission. METHODS: We conducted an observational cohort study of a group of patients discharged from the Geriatric Ward of the San Giovanni Battista Hospital, Torino (Italy). The study sample contained 839 patients aged 80.6 +/- 6.3 years. The average hospital stay was 17.5 +/- 18.9 days (range 1-274 days). RESULTS: Follow-up lasted three months, at the end of which 107 patients (12.8%) had been readmitted, 83 (9.9%) had only one readmission and 24 (2.9%) one or more readmissions. The first readmission took place within 15 days of discharge for 24 patients (2.9%) and within 30 days of discharge for 27 (3.2%). A new hospital admission within 15 days of discharge increased the risk of mortality (RR=3) and also the probability of a second re-hospitalization. 10.1% patients died; 88.2% of the patients who died had at least one readmission, whereas only 4.2% of live patients had a new hospital admission. CONCLUSIONS: Tumors, dementia, comorbidity, high education level, day hospital course and period of convalescence were all significantly and independently related to readmission.     

Hospital readmission for adult acute sickle cell painful episodes: frequency, etiology, and prognostic significance

The acute sickle cell painful episode is the most common cause of hospitalization of patients with sickle cell anemia. Its detailed clinical features and peri-discharge features are not well known. In order to determine the actual pattern of hospital admissions of patients with SS and the causes of frequent hospital readmissions and their prognostic significance, we conducted a prospective longitudinal and observation cohort study of all adult patients with sickle cell anemia admitted to Thomas Jefferson University Hospital between January 1998 and December 2002. Major outcome measures included the frequency, etiology, and prognostic significance of readmissions to the hospital within 1 week and 1 month after discharge. Incidence of mortality among patients during the study period was also determined. Analysis of the data showed that about 50% of hospital admissions for acute painful episodes were readmitted within 1 month after discharge, and about 16% of all admissions were within 1 week after discharge. The intensity of pain score decreased significantly during the first 4 days of hospital admission (P < 0.001) and then reached a plateau until discharge. The mean score of pain intensity was >7 throughout the hospital stay. Causes of hospital readmission included premature discharge, withdrawal syndrome, and recurrence of new acute episodes. Readmission within 1 week after discharge was associated with higher mortality than otherwise. This study shows that hospital readmission of adult patients with sickle cell anemia is common. It suggests that improvement is needed in the management of pain during hospitalization and at home after discharge. Patients who are readmitted frequently within 1 week of discharge have poor prognosis and require careful monitoring.     

Intussusception: trends in clinical presentation and management

BACKGROUND: The association of a rotavirus vaccine and intussusception has renewed interest in understanding the incidence, clinical presentation and outcome of intussusception. METHODS: A retrospective chart review of all patients diagnosed with intussusception at Royal Children's Hospital, Melbourne over a 6.5-year period (1 January 1995-30 June 2001) was conducted using patients identified by a medical record database (ICD-9-CM code 560.0 1993-1997; ICD-10-CM code 56.1 1998-2001). Patient profile, clinical presentation, diagnosis methods, treatment and outcome were analyzed and compared to data previously reported on children with intussusception at the same hospital during 1962-1968. RESULTS: The hospitalization rate for primary idiopathic intussusception increased marginally from 0.19 to 0.27 per 1000 live births during the period 1962-1968 to 1995-2001. Most patients (80%) were <12 months of age (median age 7 months, range 2-72 months). The combination of abdominal pain, lethargy and vomiting was reported in 78% of infants. Air enema confirmed the diagnosis of intussusception in 186 of 191 cases (97%) and air reduction was successful in most cases (82%). Factors associated with increased risk of intestinal resection included abdominal distension (32%), bowel obstruction on abdominal X-ray (27%) and hypovolemic shock (40%). No mortality was observed in the present study. CONCLUSIONS: Over the past 40 years at Royal Children's Hospital, Melbourne the hospitalization rate due to primary idiopathic intussusception has marginally increased from 0.19 to 0.27 per 1000 live births. Diagnosis and treatment using air enema has been highly successful, resulting in a reduction in patients requiring surgery and reduced hospital stays.     

Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan.

PURPOSE: Unplanned hospital readmission within 30 days of discharge is considered a "sentinel event" for poor quality. Patients at high risk for this adverse event could be targeted for interventions designed to reduce their risk of readmission. The purpose of this study was to identify patient characteristics and risk factors at discharge associated with unplanned readmission within 30 days of hospital discharge. SUBJECTS AND METHODS: We performed a matched case-control study among patients in a Medicare managed care plan who had been admitted to an academic hospital. The cases were patients aged 65 years or older who were urgently or emergently readmitted to the hospital within 30 days of discharge. One control patient who was not readmitted within 30 days was matched to each case by principal diagnosis. The medical records of the first admission of the cases and the admission of the controls underwent review (blinded to case-control status) to determine the patient's baseline demographic characteristics, comorbid conditions, previous health care utilization, and functional status. The records were also reviewed to assess risk factors on discharge, including clinical instability, inability to ambulate and feed, mental status changes, number of discharge medications, and discharge disposition. RESULTS: Five factors were independently associated (P < 0.05) with unplanned readmission within 30 days. These included four baseline patient characteristics: age 80 years or older [odds ratio = 1.8; 95% confidence interval (CI), 1.02-3.2], previous admission within 30 days (odds ratio = 2.3; 95% CI, 1.2-4.6), five or more medical comorbidities (odds ratio = 2.6; 95% CI, 1.5-4.7), and history of depression (odds ratio = 3.2; 95% CI, 1.4-7.9); and one discharge factor: lack of documented patient or family education (odds ratio = 2.3; 95% CI, 1.2-4.5). CONCLUSIONS: If validated, these factors may identify patients at high risk of readmission. They suggest that interventions, such as improved discharge education programs, may reduce unplanned readmission.