Abstract P320: Congestive Heart Failure Readmissions: Relationship Between Preadmission Patient Determinants and 30 Day Rehospitalization
Sula MazimbaJessica TanNakash GrantLata ParvathaneniVikas KalraTrupti PatelRadha KothapalliDiklar MakolaCristina RedkoHarvey S. Hahn
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Introduction Congestive heart failure (CHF) is the most costly disease in the US. Readmission costs contribute significantly to this healthcare expenditure. While adherence to published guidelines has increased, readmission rates have not improved. There is an urgent need to identify clinical and process measures that improve care for CHF patients. Thirty day readmission rates have often been used by third party payers as a surrogate index for quality of care in the inpatients settings. This study looked at the relationship between preadmission patient characteristics and 30 day readmissions. Methods: This was a single center retrospective case-control study that evaluated 6063 consecutive patients admitted with a diagnosis of CHF from December 2001 through December 2008. Data was abstracted for independent and dependent variables, including heart failure performance measures at discharge. This Ad hoc analysis focused on the relationship between patient determinants on 30 day readmissions. Statistical comparison was made between readmitted and non readmitted cohorts. Results: There were 6063 total patients admitted with the principal diagnosis of CHF. A total of 19.6% (1191 of 6063) of the patients were readmitted within 30 days of discharge. Another 19.9% (1211 of 6063) served as control cohort. The mean age for readmitted and non readmitted patients was 77.8(+/- 11.6) and 75.7 (+/- 11.8) years respectively. Mean duration of initial hospital stay for readmitted patients was 5.7 (+/- 4) days and 6.0 (+/-4) days for the control group. Readmitted patients were more likely to be smokers than their counterparts. (O.R= 1.5, 95% CI 1.2-1.9 p=0.002).Non usage of ACEI medication prior to hospitalization was associated with higher rates of readmission (O.R 1.30, 95% CI 1.1-1.6, p=0.003).However beta blocker therapy did not correlate with 30 day readmissions. (O.R 1.0, 95% CI 0.89- 1.19, p=0.970). Conclusions: In patients admitted with CHF, non usage of ACEI prior to hospitalization and smoking history may serve as indicators for early readmissions. Preadmission beta blocker use was not associated with reduced early readmissions. More studies need to be done to stratify determinants that identify patients at risk for early readmissions.Keywords:
Post-hoc analysis
Hospital Readmission
Background Over a quarter of Medicare patients admitted to the hospital are discharged to post‐acute care ( PAC ) facilities, but face high rates of readmission. Timing of readmission may be an important factor in identifying both risk for and preventability of future readmissions. This study aims to define factors associated with readmission within the first week of discharge to PAC facilities following hospitalization. Design and Measurements This was a secondary analysis of the 2011 Healthcare Cost and Utilization Project ( HCUP ) State Inpatient Databases ( SID ) for California, Massachusetts, and Florida. The primary outcome was all‐cause readmission within 7 days after hospital discharge, compared to readmission on days 8–30, for patients aged 65 and older who were discharged from the hospital to a PAC facility. Predictor variables included patient, index hospitalization, and hospital characteristics; multivariable logistic regression was used to identify significant predictors of readmission within 7 days. Results There were 81,173 hospital readmissions from PAC facilities in the first 30 days after hospital discharge. Patients readmitted within the first week were older, white, urban, had fewer comorbid illnesses, had a higher number of previous hospital admissions, and less commonly had Medicare as a payer. Longer index hospital length of stay (LOS) was associated with decreased risk of early readmission ( OR 0.74; 95% CI 0.70–0.74 for LOS 4–7 days and 0.60; 95% CI 0.56–0.64 for LOS ≥8 days). Conclusions Shorter length of index hospital stay is associated with earlier readmission and suggests that for this comorbid, older population, a shorter hospital stay may be detrimental. Readmission after 1 week is associated with increased chronic disease burden, suggesting they may be associated with factors that are less modifiable.
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Hospitalization and readmission rates have decreased in recent years, with the possible consequence that hospitals are increasingly filled with high-risk patients.We studied whether readmission reduction has affected the risk profile of hospitalized patients and whether readmission reduction was similarly realized among hospitalizations with low, medium, and high risk of readmissions.Retrospective study of hospitalizations between January 2009 and June 2015.Hospitalized fee-for-service Medicare beneficiaries, categorized into 1 of 5 specialty cohorts used for the publicly reported hospital-wide readmission measure.Each hospitalization was assigned a predicted risk of 30-day, unplanned readmission using a risk-adjusted model similar to publicly reported measures. Trends in monthly mean predicted risk for each cohort and trends in monthly observed to expected readmission for hospitalizations in the lowest 20%, middle 60%, and highest 20% of risk of readmission were assessed using time series models.Of 47,288,961 hospitalizations, 16.2% (n = 7,642,161) were followed by an unplanned readmission within 30 days. We found that predicted risk of readmission increased by 0.24% (P = .03) and 0.13% (P = .004) per year for hospitalizations in the surgery/ gynecology and neurology cohorts, respectively. We found no significant increase in predicted risk for hospitalizations in the medicine (0.12%, P = .12), cardiovascular (0.32%, P = .07), or cardiorespiratory (0.03%, P = .55) cohorts. In each cohort, observed to expected readmission rates steadily declined, and at similar rates for patients at low, medium, and high risk of readmission.Hospitals have been effective at reducing readmissions across a range of patient risk strata and clinical conditions. The risk of readmission for hospitalized patients has increased for 2 of 5 clinical cohorts.
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A retrospective cohort study was performed of the Hospital-to-Home (H2H) program, a rapid clinic follow-up program for patients with recent heart failure (HF) admissions at the University of Virginia Health System. There were 6761 hospitalizations among 4685 patients (age 67.5 ± 14.2 years, 43.9% female), and 759 had H2H follow-up. Thirty day mortality after the initial HF hospitalization was lower in H2H patients (1.84% vs 3.13%; P = .049), and this difference remained significant after adjustment in a multivariable logistic regression model (odds ratio = 0.56 [95% CI = 0.31-099]; P = .046). There also was a 24% reduction in readmission days within the first 30 days after the index admission (P < .0001), and readmission cost savings were found to be greater than the costs of staffing the H2H clinic. In summary, the H2H program is cost-effective, with significant improvements in survival, readmission days, and readmission costs over 30 days.
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It is widely believed that timely follow-up decreases hospital readmissions; however, the literature evaluating time to follow-up is limited. The authors conducted a retrospective analysis of patients discharged from a tertiary care academic medical center and evaluated the relationship between outpatient follow-up appointments made and 30-day unplanned readmissions. Of 1044 patients discharged home, 518 (49.6%) patients had scheduled follow-up ≤14 days after discharge, 52 (4.9%) patients were scheduled ≥15 days after discharge, and 474 (45.4%) had no scheduled follow-up. There was no statistical difference in 30-day readmissions between patients with follow-up within 14 days and those with follow-up 15 days or longer from discharge (P = .36) or between patients with follow-up within 14 days and those without scheduled follow-up (P = .75). The timing of postdischarge follow-up did not affect readmissions. Further research is needed to determine such factors and to prospectively study time to outpatient follow-up after discharge and the decrease in readmission rates.
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The Centers for Medicare & Medicaid Services (CMS) readmission measure is based on all-cause readmissions to any hospital within 30 days of discharge. Whether a measure based on same-hospital readmission, an outcome that is easier for hospitals and some systems to track, could serve as a proxy for the all-hospital measure is not known.Evaluate whether same-hospital readmission rate is a good surrogate for all-hospital readmission rate.The study population was derived from the Medicare inpatient, outpatient, and carrier (physician) Standard Analytic Files. Thirty-day risk-standardized readmission rates (RSRRs) for heart failure (HF) for both all-hospital readmission and same-hospital readmission were assessed by using hierarchical logistic regression models.The sample consisted of 501,234 hospitalizations in 4674 hospitals with at least 1 hospitalization.Thirty-day readmission was defined as occurrence of at least 1 hospitalization in any US acute care hospital for any cause within 30 days of discharge after an index hospitalization. Same-hospital readmission was considered if the patient was admitted to the hospital that produced the original discharge within 30 days.Overall, 80.9% of all HF readmissions occurred in the same- hospital, whereas 19.1% of readmissions occurred in a different hospital. The mean difference between all- versus same-hospital RSRR was 4.7 +/- 1.0%, ranging from 0.9% to 10.5% across these hospitals with 25th, 50th, and 75th percentiles of 4.1%, 4.7%, and 5.2%, respectively, and was variable across the range of average RSRR.Same-hospital readmission rate is an unreliable and biased indicator of all-hospital readmission rate with limited value as a benchmark for quality of care processes.
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