Impact of Social Factors on Risk of Readmission or Mortality in Pneumonia and Heart Failure: Systematic Review

BACKGROUND

Readmission and mortality after hospitalization for community-acquired pneumonia (CAP) and heart failure (HF) are publically reported. This systematic review assessed the impact of social factors on risk of readmission or mortality after hospitalization for CAP and HF—variables outside a hospital’s control.

METHODS

We searched OVID, PubMed and PSYCHINFO for studies from 1980 to 2012. Eligible articles examined the association between social factors and readmission or mortality in patients hospitalized with CAP or HF. We abstracted data on study characteristics, domains of social factors examined, and presence and magnitude of associations.

RESULTS

Seventy-two articles met inclusion criteria (20 CAP, 52 HF). Most CAP studies evaluated age, gender, and race and found older age and non-White race were associated with worse outcomes. The results for gender were mixed. Few studies assessed higher level social factors, but those examined were often, but inconsistently, significantly associated with readmissions after CAP, including lower education, low income, and unemployment, and with mortality after CAP, including low income. For HF, older age was associated with worse outcomes and results for gender were mixed. Non-Whites had more readmissions after HF but decreased mortality. Again, higher level social factors were less frequently studied, but those examined were often, but inconsistently, significantly associated with readmissions, including low socioeconomic status (Medicaid insurance, low income), living situation (home stability rural address), lack of social support, being unmarried and risk behaviors (smoking, cocaine use and medical/visit non-adherence). Similar findings were observed for factors associated with mortality after HF, along with psychiatric comorbidities, lack of home resources and greater distance to hospital.

CONCLUSIONS

A broad range of social factors affect the risk of post-discharge readmission and mortality in CAP and HF. Future research on adverse events after discharge should study social determinants of health.     

Variation in Length of Stay and Outcomes among Hospitalized Patients Attributable to Hospitals and Hospitalists

BACKGROUND

There have been no prior population-based studies of variation in performance of hospitalists.

OBJECTIVE

To measure the variation in performance of hospitalists.

DESIGN

Retrospective research design of 100 % Texas Medicare data using multilevel, multivariable models.

SUBJECTS

131,710 hospitalized patients cared for by 1,099 hospitalists in 268 hospitals from 2006–2009.

MAIN MEASURES

We calculated, for each hospitalist, adjusted for patient and disease factors (case mix), their patients' average length of stay, rate of discharge home or to skilled nursing facility (SNF) and rate of 30-day mortality, readmissions and emergency room (ER) visits.

KEY RESULTS

In two-level models (admission and hospitalist), there was significant variation in average length of stay and discharge location among hospitalists, but very little variation in 30-day mortality, readmission or emergency room visit rates. There was stability over time (2008–2009 vs. 2006–2007) in hospitalist performance. In three-level models including admissions, hospitalists and hospitals, the variation among hospitalists was substantially reduced. For example, hospitals, hospitalists and case mix contributed 1.02 %, 0.75 % and 42.15 % of the total variance in 30-day mortality rates, respectively.

CONCLUSIONS

There is significant variation among hospitalists in length of stay and discharge destination of their patients, but much of the variation is attributable to the hospitals where they practice. The very low variation among hospitalists in 30-day readmission rates suggests that hospitalists are not important contributors to variations in those rates among hospitals.     

Skilled nursing facility referral and hospital readmission rates after heart failure or myocardial infarction

BackgroundSubstantial hospital-level variation in the risk of readmission after hospitalization for heart failure (HF) or acute myocardial infarction (AMI) has been reported. Prior studies have documented considerable state-level variation in rates of discharge to skilled nursing facilities (SNFs), but evaluation of hospital-level variation in SNF rates and its relationship to hospital-level readmission rates is limited.MethodsHospital-level 30-day all-cause risk-standardized readmission rates (RSRRs) were calculated using claims data for fee-for-service Medicare patients hospitalized with a principal diagnosis of HF or AMI from 2006-2008. Medicare claims were used to calculate rates of discharge to SNF following HF-specific or AMI-specific admissions in hospitals with ≥25 HF or AMI patients, respectively. Weighted regression was used to quantify the relationship between RSRRs and SNF rates for each condition.ResultsMean RSRR following HF admission among 4101 hospitals was 24.7%, and mean RSRR after AMI admission among 2453 hospitals was 19.9%. Hospital-level SNF rates ranged from 0% to 83.8% for HF and from 0% to 77.8% for AMI. No significant relationship between RSRR after HF and SNF rate was found in adjusted regression models (P = .15). RSRR after AMI increased by 0.03 percentage point for each 1 absolute percentage point increase in SNF rate in adjusted regression models (P = .001). Overall, HF and AMI SNF rates explained <1% and 4% of the variation for their respective RSRRs.ConclusionSNF rates after HF or AMI hospitalization vary considerably across hospitals, but explain little of the variation in 30-day all-cause readmission rates for these conditions.     

Anemia and chronic kidney disease are associated with poor outcomes in heart failure patients

Background

Chronic kidney disease (CKD) has been linked to higher heart failure (HF) risk. Anemia is a common consequence of CKD, and recent evidence suggests that anemia is a risk factor for HF. The purpose of this study was to examine among patients with HF, the association between CKD, anemia and inhospital mortality and early readmission.

Methods

We performed a retrospective cohort study in two Swiss university hospitals. Subjects were selected based the presence of ICD-10 HF codes in 1999. We recorded demographic characteristics and risk factors for HF. CKD was defined as a serum creatinine ≥ 124 956;mol/L for women and ≥ 133 μmol/L for men. The main outcome measures were inhospital mortality and thirty-day readmissions.

Results

Among 955 eligible patients hospitalized with heart failure, 23.0% had CKD. Twenty percent and 6.1% of individuals with and without CKD, respectively, died at the hospital (p < 0.0001). Overall, after adjustment for other patient factors, creatinine and hemoglobin were associated with an increased risk of death at the hospital, and hemoglobin was related to early readmission.

Conclusion

Both CKD and anemia are frequent among older patients with heart failure and are predictors of adverse outcomes, independent of other known risk factors for heart failure.     

Hospital Performance Measures and 30-day Readmission Rates

BACKGROUND

Lowering hospital readmission rates has become a primary target for the Centers for Medicare & Medicaid Services, but studies of the relationship between adherence to the recommended hospital care processes and readmission rates have provided inconsistent and inconclusive results.

OBJECTIVE

To examine the association between hospital performance on Medicare’s Hospital Compare process quality measures and 30-day readmission rates for patients with acute myocardial infarction (AMI), heart failure and pneumonia, and for those undergoing major surgery.

DESIGN, SETTING AND PARTICIPANTS

We assessed hospital performance on process measures using the 2007 Hospital Inpatient Quality Reporting Program. The process measures for each condition were aggregated in two separate measures: Overall Measure (OM) and Appropriate Care Measure (ACM) scores. Readmission rates were calculated using Medicare claims.

MAIN OUTCOME MEASURE

Risk-standardized 30-day all-cause readmission rate was calculated as the ratio of predicted to expected rate standardized by the overall mean readmission rate. We calculated predicted readmission rate using hierarchical generalized linear models and adjusting for patient-level factors.

RESULTS

Among patients aged ≥ 66 years, the median OM score ranged from 79.4 % for abdominal surgery to 95.7 % for AMI, and the median ACM scores ranged from 45.8 % for abdominal surgery to 87.9 % for AMI. We observed a statistically significant, but weak, correlation between performance scores and readmission rates for pneumonia (correlation coefficient R?=?0.07), AMI (R?=?0.10), and orthopedic surgery (R?=?0.06). The difference in the mean readmission rate between hospitals in the 1st and 4th quartiles of process measure performance was statistically significant only for AMI (0.25 percentage points) and pneumonia (0.31 percentage points). Performance on process measures explained less than 1 % of hospital-level variation in readmission rates.

CONCLUSIONS

Hospitals with greater adherence to recommended care processes did not achieve meaningfully better 30-day hospital readmission rates compared to those with lower levels of performance.     

Trends in Hospital Readmission of Medicare-Covered Patients With Heart Failure

Background

The Medicare Hospital Readmissions Reduction Program has led to fewer readmissions following hospitalizations with a principal diagnosis of heart failure (HF). Patients with HF are frequently hospitalized for other causes.

The impact of shortened postgraduate surgical training on colorectal cancer outcome

Background

Shortened postgraduate surgical training reforms, known as Calman, have altered delivery of surgical training in the UK with reduced working hours and training time aiming to produce a more subspecialised workforce.

Aims

This study aims to compare rectal cancer surgical outcomes of Calman-trained consultants in a single institution to published data. Additionally, the study compared colorectal cancer surgical outcome between Calman-trained consultants (CTCs) and non-Calman consultants (NCTCs) in a national dataset.

Methods

Local dataset Clinicopathological outcome of rectal cancer resection undertaken by CTCs in a single institution (2006–2010) were compared against NCTC counterparts. National dataset All elective colorectal cancer resections between 2004 and 2008 in English NHS hospitals were included. CTCs (present from 2004 onwards) were compared to NCTCs (present prior to 2004). Outcome measures included 30-day in-hospital mortality, reoperation and readmission rates.

Results

Local dataset One hundred thirteen patients were operated under five CTC. The 30-day in-hospital mortality for CTCs (1 %) was favourable compared to published rates (3–5 %). Local recurrence rate (4.4 %) was comparable to NCTC (3.6 %). National dataset Between 2004 and 2008, 44,106 patients underwent elective colorectal resection. Multiple regression demonstrated CTC patients had a reduced length of stay and reduced reoperation rate. No difference in mortality and unplanned readmission rates were seen.

Conclusion

CTCs have similar safety outcome to NCTCs for colorectal cancer resection procedures. Further work is needed to assess the impact of further training reductions on clinical outcome.     

Readmission after living donor liver transplantation: Predictors,causes, and outcomes

Background

Complications following liver transplantation requiring readmission may be serious and potentially life threatening. Most reports on readmission have been about after deceased donor liver transplantation (DDLT). We hypothesized that readmission after living donor liver transplantation (LDLT) is due to different reasons and analyzed our experience.

Methods

We retrospectively analyzed the records of 172 consecutive patients who underwent liver transplantation at our institute between January 2010 and June 2012. The primary outcome measure was readmission. We classified readmission into early (<3 months after discharge) and late (>3 months).

Results

The study population was 140 after excluding pediatric patients (12), DDLT recipients (2), and those who died during the index admission (18). Their median age was 42 years, and there were 117 males and 23 females. Thirty-eight patients were readmitted (56 episodes) after LDLT. There were 35 early and 21 late readmission episodes. The most common cause for early readmissions was infection (46 %) and that for late readmissions was biliary stricture (62 %). On univariate analysis, pretransplant portal vein thrombosis, more than one bile duct in the liver graft, revised arterial anastomosis or two arteries in the graft, and higher serum alkaline phosphatase levels at discharge were significantly associated with readmission. Readmission was also significantly associated with a higher overall mortality than non-readmission in which there was no mortality.

Conclusion

Pretransplant portal vein thrombosis, more than one bile duct in the liver graft, revision of the arterial anastomosis or two arteries in the graft, and higher serum alkaline phosphatase levels at discharge were significantly associated with readmission. Infective and biliary complications were the commonest causes of early and late readmission after LDLT.     

Intracorporeal versus extracorporeal anastomosis after laparoscopic right hemicolectomy for cancer: a systematic review and meta-analysis

Purpose

The aim of this systematic review was to compare intracorporeal (IA) versus extracorporeal anastomosis (EA) after laparoscopic right hemicolectomy for cancer.

Methods

The meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Studies published from 2009 to 2012 that compare IA and EA after laparoscopic right hemicolectomy were identified. The included non-randomized studies were assessed for their methodological quality using the revised and modified grading system of the Scottish Intercollegiate Guidelines Network. Intraoperative, early postoperative, and postoperative recovery outcomes were compared using weighted mean differences and odds ratios.

Results

Five non-randomized controlled trials published between 2009 and 2011, comprising 425 patients, were included in this analysis. IA was associated with significant faster bowel movement, faster first flatus, shorter time to solid diet, decreased use of analgesics, and shorter duration of the hospital stay. No differences were observed for nasogastric tube reintroduction rate, operative time, incision length, number of nodes harvested, intraoperative complications, mortality, non-surgical site complications, surgical site complications (anastomotic leakage, anastomotic bleeding, wound infection, ileus), reintervention, and readmission rate.

Conclusions

Even when the limitations are taken into account due to the observational nature of the included studies, the results suggest that the IA after laparoscopic right hemicolectomy for cancer results in better postoperative recovery outcomes, such as shorter hospital stay, faster bowel movement recovery, faster first flatus, faster time to solid diet, and lesser analgesic usage.     

No increased mortality in patients with rheumatoid arthritis treated with biologics: results from the biologics register of six rheumatology institutes in Japan

Objective

To investigate the influence of biologics on mortality and risk factors for death in rheumatoid arthritis (RA) patients.

Methods

RA patients treated with at least one dose of biologics in daily practice in six large rheumatology institutes (“biologics cohort”) were observed until 15 May 2010 or death, whichever occurred first. Mortality of the biologics cohort and the “comparator cohort” (comprising patients among the IORRA cohort who had never been treated with biologics) was compared to that of the Japanese general population. Factors associated with mortality were assessed by a Cox model.

Results

Among 2683 patients with 6913.0 patient-years of observation, 38 deaths were identified in the biologics cohort. The probability of death in patients lost to follow-up, calculated using the weighted standardized mortality ratio (SMR), was 1.08 [95 % confidence interval (CI) 0.77–1.47] in the biologics cohort and 1.28 (95 % CI 1.17–1.41) in the comparator cohort. Pulmonary involvement was the main cause of death (47.4 %), and the disease-specific SMR of pneumonia was 4.19 (95 % CI 1.81–8.25). Risk factors for death included male gender [hazard ratio (HR) 2.78 (95 % CI 1.24–6.22)], advanced age (HR 1.07, 95 % CI 1.03–1.11), and corticosteroid dose (HR 1.08, 95 % CI 1.01–1.17).

Conclusion

Mortality in RA patients exposed to biologics did not exceed that in patients not exposed to biologics, but death from pulmonary manifestations was proportionally increased in RA patients exposed to biologics.     

Mortality trends in patients with and without diabetes in Ontario, Canada and the UK from 1996 to 2009: a population-based study

Aims/hypothesis

The aim of this study was to determine the contemporary rate ratio of mortality and changes over time in individuals with vs without diabetes.

Methods

Annual age- and sex-adjusted mortality rates were compared for adults (>20 years) with and without diabetes in Ontario, Canada, and the UK from January 1996 to December 2009 using The Health Improvement Network (THIN) and Ontario databases. The total number of individuals evaluated increased from 8,757,772 in 1996 to 12,696,305 in 2009.

Results

The excess risk of mortality for individuals with diabetes in both cohorts was significantly lower during later vs earlier years of the follow-up period (1996–2009). In Ontario the diabetes mortality rate ratio decreased from 1.90 (95% CI 1.86, 1.94) in 1996 to 1.51 (1.48, 1.54) in 2009, and in THIN from 2.14 (1.97, 2.32) to 1.65 (1.57, 1.72), respectively. In Ontario and THIN, the mortality rate ratios among diabetic patients in 2009 were 1.67 (1.61, 1.72) and 1.81 (1.68, 1.94) for those aged 65–74 years and 1.11 (1.10, 1.13) and 1.19 (1.14, 1.24) for those aged over 74 years, respectively. Corresponding rate ratios in Ontario and THIN were 2.45 (2.36, 2.54) and 2.64 (2.39, 2.89) for individuals aged 45–64 years, and 4.89 (4.35, 5.45) and 5.18 (3.73, 6.69) for those aged 20–44 years.

Conclusions/interpretation

The excess risk of mortality in individuals with vs without diabetes has decreased over time in both Canada and the UK. This may be in part due to earlier detection and higher prevalence of early diabetes, as well as to improvements in diabetes care.     

The effect of the introduction of the ERAS protocol in laparoscopic total mesorectal excision for rectal cancer

Objective

The aim of the study was to determine whether the introduction of the Enhanced Recovery after Surgery (ERAS) protocol in laparoscopic total mesorectal excision (TME) for rectal cancer offers additional advantages concerning postoperative hospital stay compared to laparoscopy and conventional care.

Methods

A consecutive series of patients that underwent a laparoscopic TME for rectal cancer in a single institution between January 2004 and July 2009 were retrospectively included in this study. The ERAS protocol was introduced in this cohort in January 2007. The study cohort was divided in a conventional care group and an ERAS group. Both groups were compared for primary and secondary outcome measures. The primary outcome measure was postoperative length of hospital stay.

Results

Seventy-six patients were included: 43 in the ERAS group and 33 in the conventional care (control) group. Median hospital stay was 7?days (range 2–83?days) in the ERAS group and 10?days (range 4–74?days) in the control group (p?=?0.04). Return of bowel function occurred on days 2 and 3 respectively (p?Conclusion These results suggest that the introduction of the ERAS protocol in laparoscopic TME leads to a further reduction in length of hospital stay.     

The Impact of Hospitalist Discontinuity on Hospital Cost,Readmissions, and Patient Satisfaction

BACKGROUND

Achieving patient–physician continuity is difficult in the inpatient setting, where care must be provided continuously. Little is known about the impact of hospital physician discontinuity on outcomes.

OBJECTIVE

To determine the association between hospital physician continuity and percentage change in median cost of hospitalization, 30-day readmission, and patient satisfaction with physician communication.

DESIGN

Retrospective observational study using various multivariable models to adjust for patient characteristics.

PARTICIPANTS

Patients admitted to a non-teaching hospitalist service in a large, academic, urban hospital between 6 July 2008 and 31 December 2011.

MAIN MEASURES

We used two measures of continuity: the Number of Physicians Index (NPI), and the Usual Provider of Continuity (UPC) index. The NPI is the total number of unique physicians caring for a patient, while the UPC is calculated as the largest number of patient encounters with a single physician, divided by the total number of encounters. Outcome measures were percentage change in median cost of hospitalization, 30-day readmissions, and top box responses to satisfaction with physician communication.

KEY RESULTS

Our analyses included data from 18,375 hospitalizations. Lower continuity was associated with modest increases in costs (range 0.9–12.6 % of median), with three of the four models used achieving statistical significance. Lower continuity was associated with lower odds of readmission (OR?=?0.95–0.98 across models), although only one of the models achieved statistical significance. Satisfaction with physician communication was lower, with less continuity across all models, but results were not statistically significant.

CONCLUSIONS

Hospital physician discontinuity appears to be associated with modestly increased hospital costs. Hospital physicians may revise plans as they take over patient care responsibility from their colleagues.     

Comparison of Readmission and Death Among Patients With Cardiac Disease in Northern vs Southern Ontario

Background

Geographic factors may influence cardiovascular disease outcomes in Canada. Circulatory diseases are a major reason for higher population mortality rates in Northern Ontario, but it is unknown if hospitalized patients with cardiovascular disease experience differential outcomes compared with those in the South.

Short-term effects of an educational intervention on physical restraint use: a cluster randomized trial

Background

Hospitalization for older patients with community-acquired pneumonia (CAP) is associated with functional decline. Little is know about the relationship between inflammatory markers and determinants of functional status in this population. The aim of the study is to investigate the association between tumor necrosis factor (TNF)-α, C-reactive protein (CRP) and Activities of Daily Living, and to identify risk factors associated with one year mortality or hospital readmission.

Methods

301 consecutive patients hospitalized for CAP (mean age 73.9 ± 5.3 years) in a University affiliated hospital over 18 month period were included. All patients were evaluated on admission to identify baseline demographic, microbiological, cognitive and functional characteristics. Serum levels for TNF-α and CRP were collected at the same time. Reassessment of functional status at discharge, and monthly thereafter till 3 months post discharge was obtained and compared with preadmission level to document loss or recovery of functionality. Outcome was assessed by the composite endpoint of hospital readmission or death from any cause up to one year post hospital discharge.

Results

36% of patients developed functional decline at discharge and 11% had persistent functional impairment at 3 months. Serum TNF-α (odds ratio [OR] 1.12, 95% CI 1.08–1.15; p < 0.001) and the Charlson Index (OR = 1.39, 95% CI 1.14 to 1.71; p = 0.001) but not age, CRP, or cognitive status were independently associated with loss of functionality at the time of hospital discharge. Lack of recovery in functional status at 3 months was associated with impaired cognitive ability and preadmission comorbidities. In Cox regression analysis, persistent functional impairment at 3 months, impaired cognitive function, and the Charlson Index were highly predictive of one year hospital readmission or death.

Conclusion

Serum TNF-α levels can be useful in determining patients at risk for functional impairment following hospitalization from CAP. Old patients with impaired cognitive function and preexisting comorbidities who exhibit delay in functional recovery at 3 months post discharge may be at high risk for hospital readmission and death. With the scarcity of resources, a future risk stratification system based on these findings might be proven helpful to target older patients who are likely to benefit from interventional strategies.     

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.     

Diagnostic utility of surgical lung biopsies in elderly patients with indeterminate interstitial lung disease

Background and objective

Idiopathic pulmonary fibrosis (IPF) is increasingly diagnosed by clinical and computed tomography (CT) criteria; however, surgical lung biopsy (SLB) may still be required in patients who lack definite CT features of usual interstitial pneumonia (UIP). We reviewed a cohort of elderly patients who underwent SLB, to evaluate the benefit of SLB in diagnosing idiopathic interstitial pneumonia (IIP).

Methods

We searched the pathology records of Mayo Clinic for ambulatory patients at least 75 years old, who underwent SLB between 2000 and 2012 for indeterminate IIP. Histologic slides were reviewed and clinical data were extracted from the record.

Results

A total of 55 patients (35 male) were enrolled. Median (interquartile range) age was 77 (76–80) years. Forced vital capacity was 70 (61–76)% and diffusing capacity of the lungs for carbon monoxide was 48 (42–54)% of predicted. In total, 37 (67%) patients had IPF, including 61% of those with HRCT findings inconsistent with UIP. Thirty‐day mortality was 10% and 90‐day mortality was 15%.

Conclusion

The high mortality rate of SLB complicates the risk–benefit analysis in elderly patients with IIP. The expected value of the SLB is probably highest when the HRCT features are inconsistent with UIP, due to the frequent (39%) retrieval of patterns other than UIP.