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PubMed1997

Impact of different customization strategies in the performance of a general severity score.

OBJECTIVE: To compare the impact of two different customization strategies in the performance of the admission Mortality Probability Model II (MPM II0) using formal statistical assessment. DESIGN: Analysis of the database of a multicenter, multinational, prospective cohort study, EURICUS-1, involving 89 intensive care units (ICUs) from 12 European countries. SETTING: Eighty-nine ICUs from 12 European countries. PATIENTS: Data from 16,060 patients consecutively admitted to 89 ICUs from 12 European countries were collected during a 4-month period. In accordance with original MPM II0 criteria, the following patients were excluded from analysis: patients <18 yrs of age; patients considered readmissions; patients with acute myocardial infarction or burns; and patients in the postoperative period recovering from coronary artery bypass surgery. A total of 10,397 patients were analyzed. INTERVENTIONS: Collection of the data necessary for the calculation of MPM II0 and basic demographic statistics. Vital status at hospital discharge was registered. Two new logistic regression equations were developed to relate MPM II0 to mortality after splitting the database into development and validation samples, the first with the original logit of MPM II0 as an independent variable (first-level customization), and the second with all 15 original variables (second-level customization). Discrimination (area under the receiver operating curve), Hosmer-Lemeshow goodness-of-fit tests H and C, and observed/expected mortality ratios were evaluated in both samples and within relevant subgroups. MEASUREMENTS AND MAIN RESULTS: The discriminative capability of the models was only slightly affected by customization (0.810 vs. 0.803), remaining lower than in the original description of the MPM II0 (0.824). Calibration improved, with Hosmer-Lemeshow goodness-of-fit tests H and C showing a good fit of the models. However, the formal evaluation of discrimination, calibration, and observed/expected mortality ratios across relevant subgroups appeared to be poor in some groups. CONCLUSIONS: In this ICU patient database, second-level customization was more effective than first-level customization in improving the overall goodness-of-fit of MPM II0 and should probably be chosen as the preferential strategy to improve the fit of a model when the sample size is large enough. However, second level customization had only a slight impact on discrimination. Its effects on the uniformity of fit are insufficient to overcome the problems that can arise when the model is applied in populations in which the case-mix is distinct from the population where it was originally developed.

Adult↗
PubMed1998

The case for clinical audit of emergency readmissions after appendicectomy.

The aim of this study was to examine how the Scottish Office Clinical Outcome Indicator for emergency readmissions within 28 days of appendicectomy could be made more useful. Scottish Morbidity Record One (SMRI) data on all NHS discharges with a primary operative procedure of appendicectomy, and a linked file of all emergency readmissions within 28 days of discharge in 1993/94 were used in this study. It was found that 8783 appendicectomies were performed in 1993 and 1994, with 403 (4.6%) emergency readmissions within 28 days. A significantly higher proportion of emergency readmissions occurred where a 'normal' appendix was removed, and in interval, prophylactic and incidental appendicectomies. Age and length of initial hospital stay did not affect readmission rates. Hospitals performing more appendicectomies tended to have more readmissions [Spearman's rank correlation coefficient 0.639 (95% CI 0.430-0.782]. None of the five hospitals carrying out less than 17 appendicectomies in 2 years had an emergency readmission. Patients from more deprived areas were significantly more likely to be readmitted. The current performance indicator is useful in identifying patients readmitted to any hospital in Scotland, but needs to be supplemental with more clinical information. The numbers of appendicectomy patients would make this a feasible national clinical audit project, and the lessons learnt should be useful in promoting better practice for considerable numbers of patients of all ages.

Adolescent↗
PubMed2000

The impact of utilization management on readmissions among patients with cardiovascular disease.

OBJECTIVE: To determine if prospective utilization reviews that lead to reduced hospital length of stay (LOS) relative to days requested by an attending physician affect the likelihood of readmission for privately insured patients with cardiovascular disease. DATA SOURCES: Data obtained from a private insurance company on utilization management decisions from 1989 through 1993. During this five-year period, 39,117 inpatient reviews were conducted, 4,326 (11.1 percent) on patients with cardiovascular disease. We selected for analysis all 4,326 reviews performed on patients with cardiovascular disease. STUDY DESIGN: We used proportional hazard analysis (Cox regression) to investigate the relationship between LOS reductions relative to days requested by a patient's attending physician and the likelihood of readmission within 60 days of discharge. Separate analyses were performed for medical and procedural admissions. PRINCIPAL FINDINGS: There were 2,813 requests for medical admission, and 1,513 requests for procedural admission. Requests for admission were rarely denied. Length of stay was reduced relative to that requested by the treating physician for 17 percent and 19 percent of medical and procedural admissions, respectively. Cumulative 60-day readmission rates were 9.5 percent for medical admissions and 12.3 percent for procedural admissions. We found no relationship between LOS reduction and the likelihood of readmission for medical admissions. However, patients admitted for procedures who had their length of stay reduced by two or more days were 2.6 times as likely to be readmitted within 60 days as those who had no reduction in their length of stay (95% CI: 1.3-5.1; p < .005). CONCLUSIONS: Utilization management (UM) rarely denies requests for inpatient treatment of cardiovascular disease. The association between LOS reduction and the likelihood of readmission for patients admitted for cardiovascular procedures raises concern that UM may adversely affect clinical outcome for some patients. Further research is needed to definitively elucidate any relationship that might exist between utilization review decisions and quality of care.

Adult↗
PubMedDate not supplied

Readmission of patients after coronary artery bypass graft surgery.

OBJECTIVE: To assess rates, reasons, and predictors of hospital readmission after coronary artery bypass grafting (CABG). METHODS: In this prospective, descriptive, correlational study, 124 subjects responded to a mailed questionnaire 6 weeks after undergoing CABG at Yale New Haven Hospital. RESULTS: The sample was 79% male, 94% white, and had a mean age of 66 +/- 10 years and a mean length of stay of 5.7 +/- 1.8 days. A total of 14.5% had unplanned cardiac-related readmissions (44% to their community hospital). Chest pain with or without shortness of breath was the primary reason for readmission (33%), followed by incisional problems (17%) and analgesic reactions (17%). Logistic regression analysis, based on bivariate analyses, revealed that female sex (odds ratio 4.7; 95% confidence interval, 1. 5-14.6; P =.007) and obesity (odds ratio 3.7; 95% confidence interval, 1.2-11.6; P =.026) predicted hospital readmission. CONCLUSIONS: Effective follow-up, with particular focus on women and the obese, may decrease readmissions. (Heart Lung((R)) 1999;28:243-50).

Adult↗
PubMed2005

Improvement in the outcome indicator of readmission of patients with heart failure: a case analysis.

This article describes the process used by one performance improvement committee to analyze comprehensive assessment data, including OASIS data, and relate it to nursing activities described in the clinical nursing notes. The end goal was to improve, or decrease, the hospital readmission rate of their patients with heart failure. The fit between patient characteristics and the plan of care described and delivered in two groups was evaluated. Differences in patient characteristics and nursing documentation of outcomes provided the data for remediation and for testing of a new intervention.

Aged↗
PubMed1997

A study of the relationship between home care services and hospital readmission of patients with congestive heart failure.

Patients with congestive heart failure (CHF) constitute a substantial portion of the caseloads of home care agencies. Home care is one strategy suggested for delaying or preventing hospital readmissions. This study examined the relationship between home care nursing services and hospital readmissions after 1176 discharges of patients with a primary diagnosis of CHF. It also described the home nursing care of such patients. Findings indicate that patients receiving home care nursing services were readmitted to the hospital significantly less often within a period of 90 days after hospital discharge.

Adult↗
PubMed1991

Predicting elderly cardiac patients at risk for readmission.

Elder patients with cardiac disease are at high risk for physical deterioration during post hospital recovery and suffer frequent early readmission. It is important to identify such patients who frequently need help with discharge planning from social workers during their first admission. This study utilized computerized data on 628 patients, 238 of whom were readmissions. Question was raised as to what factors (functional, psychological, social and environmental), differentiated patients who were readmitted from those who were not. Using logistic regression, three variables: marital status, presence of coping difficulty and age of patients were identified as predictors of readmission within three months. Those who were married were less likely to be readmitted. Those with coping difficulties and older individuals were more likely to be readmitted. The accuracy of prediction, using these three factors, was 61 percent. Of those patients predicted as not being readmitted, sixty-nine percent were correctly predicted, while 39 percent were readmitted. Of patients predicted as readmissions, 49 percent were correctly predicted, while 51 percent were not. The major limitation of this study was that key physiological determinants of readmission were not collected. It is imperative that a valid screening device for predicting who is at risk for readmission should include physiological preconditions as well as functional and psychosocial data.

Adaptation, Psychological↗
PubMed2002

Randomized trial of an education and support intervention to prevent readmission of patients with heart failure.

OBJECTIVES: We determined the effect of a targeted education and support intervention on the rate of readmission or death and hospital costs in patients with heart failure (HF). BACKGROUND: Disease management programs for patients with HF including medical components may reduce readmissions by 40% or more, but the value of an intervention focused on education and support is not known. METHODS: We conducted a prospective, randomized trial of a formal education and support intervention on one-year readmission or mortality and costs of care for patients hospitalized with HF. RESULTS: Among the 88 patients (44 intervention and 44 control) in the study, 25 patients (56.8%) in the intervention group and 36 patients (81.8%) in the control group had at least one readmission or died during one-year follow-up (relative risk = 0.69, 95% confidence interval [CI]: 0.52, 0.92; p = 0.01). The intervention was associated with a 39% decrease in the total number of readmissions (intervention group: 49 readmissions; control group: 80 readmissions, p = 0.06). After adjusting for clinical and demographic characteristics, the intervention group had a significantly lower risk of readmission compared with the control group (hazard ratio = 0.56, 95% CI: 0.32, 0.96; p = 0.03) and hospital readmission costs of $7,515 less per patient. CONCLUSIONS: A formal education and support intervention substantially reduced adverse clinical outcomes and costs for patients with HF.

Aged↗
PubMed1992

Emergency hospital admissions and readmissions of patients aged over 75 years and the effects of a community-based discharge scheme.

This paper reports the results of a retrospective review which analysed emergency admissions and readmissions of elderly patients to a district general hospital. All patients received standard after-care allocated by the community health and social services departments following referral by hospital staff. In addition, half of the cohort was randomly allocated to receive care attendant support for a maximum of 12 hours a week for two weeks following the first and any subsequent discharge from hospital. The effect of this additional community support on emergency readmissions was also reviewed. The findings show that the patients randomly allocated to receive the modest domiciliary after-care service were less likely to have another emergency readmission or multiple readmissions. The results suggest that patients over 75 years-of-age, living alone, or having two or more emergency admissions within six months, should have a domiciliary assessment and follow-up after hospital discharge.

Aftercare↗
PubMed1996

Does increased access to primary care reduce hospital readmissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission.

BACKGROUND: For chronically ill patients, readmission to the hospital can be frequent and costly. We studied the effect of an intervention designed to increase access to primary care after discharge from the hospital, with the goals of reducing readmissions and emergency department visits and increasing patients' quality of life and satisfaction with care. METHODS: In a multicenter randomized, controlled trial at nine Veterans Affairs Medical Centers, we randomly assigned 1396 veterans hospitalized with diabetes, chronic obstructive pulmonary disease, or congestive heart failure to receive either usual care or an intensive primary care intervention. The intervention involved close follow-up by a nurse and a primary care physician, beginning before discharge and continuing for the next six months. RESULTS: The patients were severely ill. Half of those with congestive heart failure (504 patients) had disease in New York Heart Association class III or IV; 30 percent of those with diabetes (751 patients) had end-organ damage; and a quarter of those with chronic obstructive pulmonary disease (583 patients) required home oxygen treatment or oral corticosteroids. The patients had extremely poor quality-of-life scores. Although they received more intensive primary care than the controls, the patients in the intervention group had significantly higher rates of readmission (0.19 vs 0.14 per month, P = 0.005) and more days of rehospitalization (10.2 vs 8.8, P = 0.041). The patients in the intervention group were more satisfied with their care (P < 0.001), but there was no difference between the study groups in quality-of-life scores, which remained very low (P = 0.53). CONCLUSIONS: For veterans discharged from Veterans Affairs hospitals, the primary care intervention we studied increased rather than decreased the rate of rehospitalization, although patients in the intervention group were more satisfied with their care.

Aged↗
PubMed1998

[Predictors of readmission in patients with congestive heart failure].

UNLABELLED: Repeated hospitalizations among patients (pts) with congestive heart failure (CHF) are common. PURPOSE: This retrospective study was designed to determine predictors of readmission. METHODS INCLUSION CRITERIA: admitted to University Hospital with a primary diagnosis of CHF between 10/1/94-9/30/95: lived in Jefferson county. EXCLUSIONS: cardiac transplant during study period; major comorbidity (e.g. malignancy, advanced renal failure). Predictors of readmission were determined by stepwise logistic regression analysis and predictor of time to readmission with Cox Proportionate Hazards modeling p < 0.05 was considered statistically significant. RESULTS: Mean age of the 237 pts was 66.5 yrs; 56% women. Mean left ventricular ejection fraction (LVEF) was 29%; 96% were in NYHA class III/IV. Mean length of stay was 5 days; 52 pts (22%) had > 1 admission. CHF etiologies: Ischemic (42%), hypertensive (37%), idiopathic (12%). Demographic characteristics and insurance status did not predict readmission risk. Predictors of readmission in the logistic and Cox models were similar. Increased risk of readmission was associated with myocardial ischemia (logistic OR 42.7), past NYHA Class III and IV (OR 32.8), plasmatic creatinine at discharge (OR 1.9) and continued smoking (OR 3.26). History of CABG was associated with a decreased risk of rehospitalization (OR 0.12). Beta-blocker use was associated with decreased risk, but did not achieve statistical significance. ACE-I use (prescribed in 78% of pts), did not contribute to the model. Diabetes Mellitus and a lower LVEF were more frequent in the readmitted group, but they did not predict readmission. CONCLUSION: CHF pts who have evidence of ischemia, advanced symptoms, renal dysfunction, and who continue to smoke are at increased risk for hospital readmission. Pts with these characteristics should be identified prior to hospital discharge and considered for intensive outpatient intervention.

Aged↗
PubMed2002

Efficacy of day care treatment against readmission in patients with schizophrenia: A comparison between out-patients with and without day care treatment.

The present study examined the efficacy of day care (DC) treatment against readmission to a mental hospital. Subjects were 65 out-patients with chronic schizophrenia after discharge. Day care treatment was defined as positive if patients were under DC treatment constantly for 4 months or more with a frequency of at least one visit per week. Information regarding demographic and disease-related factors was obtained from medical records at the time of discharge. Logistic regression analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI) with adjustment for confounding variables. The modestly preventive efficacy of DC treatment against readmission was observed within 2 years after discharge (adjusted OR 0.52; 95% CI 0.12-2.35). The present findings suggest that DC treatment may be preventive against readmission for schizophrenic out-patients.

Adult↗
PubMed2002

The impact of follow-up physician visits on emergency readmissions for patients with asthma and chronic obstructive pulmonary disease: a population-based study.

PURPOSE: To examine the relation between follow-up office visits after emergency discharge and the risk of emergency readmissions in patients with asthma or chronic obstructive pulmonary disease (COPD). SUBJECTS AND METHODS: We used population-based data to identify all patients in Alberta, Canada, who had at least one emergency visit for asthma or COPD between April 1, 1996, and March 31, 1997 (N = 25 256). A Cox proportional hazards model was used to estimate the adjusted relative risk (RR) of a repeat visit to an emergency department within 90 days of an initial emergency visit in patients who did or did not have an office follow-up within the first 30 days. RESULTS: There were 7829 patients (31%) who had an office visit during the 30 days after their initial emergency encounter. Follow-up visits were associated with a significant reduction in the 90-day risk of an emergency readmission (RR = 0.79; 95% confidence interval [CI]: 0.73 to 0.86). Sensitivity analyses showed that a follow-up visit was inversely associated with a repeat emergency visit after adjusting for age, sex, area of residence, and income. CONCLUSION: Although these data should be interpreted with caution because of missing information on factors such as quality of care, they suggest that follow-up office visits are effective in reducing early relapses in patients who have been recently treated in emergency departments for asthma or COPD.

Acute Disease↗
PubMed2001

Early unplanned readmission of patients with newly diagnosed tuberculosis discharged from acute hospital to ambulatory treatment.

OBJECTIVE: The aim of this study was to examine whether patients with newly diagnosed tuberculosis (TB) discharged to ambulatory treatment are at risk of unplanned readmission through the emergency department within 28 days of discharge, and the risk factors associated with such readmission. METHODOLOGY: A cohort of 134 patients admitted to an acute medical department with TB, who were subsequently discharged to ambulatory treatment of TB, were studied by a retrospective record review for unplanned readmission in 28 days. Potential risk factors associated with the readmission were recorded during hospital stay and follow-up visits, including age, sex, length of stay, substance abuse, need of assistance in the activities of daily living (ADL), comorbidities, non-compliance, drug complications and use of non-standard drug regimen. RESULTS: Up to 20.1% of patients were readmitted. Factors independently associated with early unplanned readmission were need of assistance in ADL, drug complications, the need to use a non-standard drug regimen and more than three non-chest comorbidities. CONCLUSIONS: A significant readmission rate was found in these patients and potential risk factors were identified. Ambulatory treatment for TB may not be appropriate for selected patients. Local guidelines for the management of TB patients at high risk of readmission is needed.

Activities of Daily Living↗
PubMed1999

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.

Academic Medical Centers↗
PubMed1998

Impact of a chest pain clinic on recurrency of symptoms and readmissions among patients early discharged from hospital after acute myocardial infarction was ruled out.

This paper evaluates the impact of an early revisit including symptom evaluation and an exercise electrocardiogram on recurrency of symptoms and readmissions during 1 year of follow-up among patients coming to hospital with chest pain or an initial suspicion of acute myocardial infarction (AMI) but in whom the suspicion was quickly ruled out. Patients below the age of 65 admitted to the emergency department (ED) at Sahlgrenska Hospital due to chest pain or other symptoms raising a suspicion of AMI who were either directly discharged from the ED or discharged within 1 day after having AMI ruled out. Patients were allocated to two groups: (1) patients being re-evaluated in a chest pain clinic less than a week after discharge from hospital (intervention group) and (2) patients handled routinely with no formalized follow-up (control group). The intervention group (n=484) and the control group (n=374) were comparable at baseline. During 1 year of follow-up, patients in the intervention group had a lower rate of readmissions to the ED than patients in the control group (17.4% versus 24.9%, p < 0.05) and a lower rate of rehospitalizations (15.9% versus 23.3%, p < 0.05). The proportion of patients being on sick leave at any time during the follow-up did not differ and neither did the recurrency of symptoms. The introduction of a chest pain clinic for patients early discharged from hospital after having AMI ruled out indicated beneficiency in terms of a lower rate of readmissions to the ED and a lower requirement of rehospitalizations. However, a methodological weakness in the randomization procedure suggest carefulness in interpretation.

Adolescent↗
PubMed1995

Stay in residential facilities and mental health care as predictors of readmission for patients with substance use disorders.

OBJECTIVES: This study examined the relationship between substance abuse patients' length of stay in community residential facilities and their outpatient mental health aftercare and readmission for inpatient care. METHODS: A national sample of 1,070 substance abuse patients referred to community residential facilities after an episode of inpatient care was assessed and followed over four years. Patients were divided into three groups: those with only alcohol-related diagnoses; those with drug-related diagnoses, most of whom also had alcohol diagnoses; and those with concomitant psychiatric diagnoses. RESULTS: Patients who had longer episodes of care in residential facilities were more likely to obtain outpatient mental health aftercare and were less likely to be readmitted for additional substance abuse or psychiatric care in six-month, one-year, and four-year follow-up intervals. Readmission rates among substance abuse patients with psychiatric diagnoses were much higher than rates among patients who had only substance abuse diagnoses. Length of stay in the community residential facility and postdischarge outpatient mental health care remained significant independent predictors of lower readmission after other risk factors for readmission were considered. CONCLUSIONS: Transitional community residential care can contribute to substance abuse patients' treatment outcome; however, longer-term supportive care is needed for substance abuse patients with more severe and chronic disorders.

Adult↗