PATIENT READMISSION: Home visits help post-discharge

Adult patients discharged from hospitals in the Cleveland Clinic Health System who were thought to be at high risk of readmission were studied. These patients were offered different combination of home visits made by advanced practice nurses and/or paramedics. No significant difference was found with 90-day readmissions, 180-day readmissions, emergency visits or patient mortality, but the 30-day readmission rate was lower in the study group compared to a matched group that did not receive the home visits.

Source: Anita D. Misra-Hebert, and others. “Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission.” Healthcare 9(1) (Mar. 2021). Full text free here: https://www.sciencedirect.com/science/article/pii/S2213076420301172

READMISSIONS: Diabetics with low blood sugar on last day of inpatient hospital stay are more likely to be readmitted

Potential approaches that may reduce the risk for readmission or death after discharge [for diabetes patients] include delaying patient release from the hospital until normoglycemia is achieved, modifying outpatient [diabetes] medications or advise patients to perform frequent glucose monitoring or use continuous glucose-monitoring devices.”

The relationship between low blood glucose levels and hospital readmission was studied in this large-scale analysis of over 800,000 admissions to Veteran Affairs hospitals over a period of 14 years. An inverse relationship was found – diabetic patients with low blood glucose levels (hypoglycemia) on the last day of a hospital inpatient stay were more likely to be readmitted to the hospital or to die within 180 days after discharge.

Source: Spanakis, E.K., and others. (2019, September). Association of glucose concentrations at hospital discharge with readmissions and mortality: A nationwide cohort study. JCEM. The Journal of Clinical Endocrinology & Metabolism, 104(9), 3679-3691. Click here for free full text:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6642668/?report=printable  Posted by AHA Resource Center, (312) 422-2003, rc@aha.org

 

 

 

READMISSIONS: Hospital revisits data trends including emergency department visits and observation visits

Although readmissions for target conditions decreased from 2012 to 2015 in the US, total hospital revisits within 30 days of discharge steadily increased over that same period.”

Changes in total 30-day hospital revisits (including emergency department treat-and-discharge visits and observation stays as well as hospital readmissions) were studied for Medicare patients hospitalized with pneumonia, heart failure or acute myocardial infarction from January 2012 to September 2015.  A total of over 3 million original hospitalizations were studied.  Hospital readmissions decreased over the study period, but treat-and-discharge visits and observation stays increased.

Source: Wadhera, R.K., and others. (2019). Hospital revisits within 30 days after discharge for medical conditions targeted by the Hospital Readmissions Reduction Program in the United States: National retrospective analysis. BMJ. 366.  Click here for free full text:https://www.bmj.com/content/bmj/366/bmj.l4563.full.pdf  Posted by AHA Resource Center (312) 422-2050 rc@aha.org

STROKE: Patients who receive physical therapy (PT) services are less likely to be readmitted

Our findings clearly demonstrate that higher intensity of rehabilitation services in the acute setting has a major impact on downstream outcomes, such as hospital readmission.”

Older patients who have suffered an ischemic stroke are less likely to be readmitted to the hospital within 30 days if they participate in physical therapy while in the hospital for the stroke.  This was a study of nearly 89,000 Medicare fee-for-service patients who were hospitalized nationwide in 2010.  Overall, the 30-day readmission rate was found to be 14 percent.

Source: Kuman, A., Resnik, L., Karmarkar, A., and others. (2019, July). Archives of Physical and Medical Rehabilitation, 100(7), 1218-1225. Click here for free full text:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6599551/pdf/nihms-1013343.pdf   Posted by AHA Resource Center (312) 422-2003, rc@aha.org

READMISSIONS: 7-day and 30-day rates for U.S., 2014

In 2014, the U.S. 7-day readmission rate was 5 percent and the 30-day rate was 14 percent, according to this new report released by the U.S. Agency for Healthcare Research and Quality (AHRQ).  The data are derived from the Healthcare Cost and Utilization Project (HCUP) and are based on all-payer data – not limited to Medicare data.

This Statistical Brief provides data on the most frequent causes of readmission at both of those points in time.  The most frequent causes are similar at 7 days and at 30 days.  Here is the list for 7-day readmissions, in rank order:

1. Schizophrenia and other psychotic disorders (9 percent)
2. Alcohol-related disorders (7.5 percent)
3. Congestive heart failure, nonhypertensive (7.4 percent)
4. Heart valve disorders (7.3 percent)
5. Hypertension with complications, secondary hypertension (7.2 percent)

Here is the list for 30-day readmissions, in rank order:

1. Congestive heart failure (23.2 percent)
2.  Schizophrenia and other psychotic disorders (22.9 percent)
3. Respiratory failure; insufficiency; arrest, adult (21.6 percent)
4. Alcohol-related disorders (21.5 percent)
5. Deficiency and other anemia (21.2 percent)

This report also provides a breakout of the most common causes of readmission by payer type (Medicare, Medicaid, private insurance and uninsured).

Note: These readmission rate percents represent readmissions per 100 index inpatient stays.

Source: Fingar, K.R., Barrett, M.L., and Jiang, H.J. (2017, October). A comparison of all-cause 7-day and 30-day readmissions, 2014. Statistical Brief, 230.  Click here for free full text: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb230-7-Day-Versus-30-Day-Readmissions.jsp  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

 

ORTHOPEDICS: 30-day readmission rates for total hip and total knee replacement

The readmission rate for total hip replacement and total knee replacement procedures performed recently on patients in California, Florida and Massachusetts was studied.  Here are the findings for the percent of these patients readmitted within 30 days:

• 4.29 percent (California during the period 2009 to 2011)
• 4.7 percent (Florida during the period 2009 to 2013)
• 3.92 percent (Massachusetts during the period 2009 to 2012)

The authors analyzed the role of infection in these 30-day readmissions, finding that in about one-third of the total hip and total knee arthroplasty patients, infection was listed as the primary or secondary reason for readmission.

Source: A retrospective study. Medicine, 96(38). Click here for free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617700/pdf/medi-96-e7961.pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

PERIOPERATIVE: Enhanced recovery after surgery

Enhanced recovery after surgery (ERAS) refers to redesigned perioperative care, sometimes also referred to as fast-track recovery after surgery.  Among the objectives are to reduce readmissions and avoid opioid abuse.  Changes include early ambulation, multi-modal analgesia and careful attention to nutrition.  The Cleveland Clinic includes ERAS in a list of the top 10 medical innovations for 2018.  The Gramlich article describes how the ERAS guidelines for colorectal surgery were implemented in six Canadian hospitals by the Alberta Health Services.  More information can also be obtained from the ERAS Society.

Sources:

Cleveland Clinic. Top 10 medical innovations.  Click here: http://innovations.clevelandclinic.org/Summit/Top-10-Medical-Innovations.aspx

Gramlich, L.M., and others. (2017). Implementation of enhanced recovery after surgery: A strategy to transform surgical care across a health system. Implementation Science. 12(67). Click here:  https://implementationscience.biomedcentral.com/track/pdf/10.1186/s13012-017-0597-5?site=implementationscience.biomedcentral.com

ERAS Society. Click here: http://erassociety.org/   Posted by AHA Resource Center (312) 422-2050, rc@aha.org

READMISSIONS: Continuity of care in 12 months before hospital admission reduces 30-day readmission rate

This study of over 14,000 Mayo Clinic patients cared for under a patient-centered medical home (PCMH) model looked at the concept of visit entropy, which pertains to the degree of what the authors term “disorganization” of patient care.  What this refers to is whether a patient is seen always by the same primary physician (perfect continuity of care) or whether a patient is seen by different physicians on different visits.

Statistics About These Mayo Clinic PCMH Patients

• 14,662 patients admitted to hospital (and included in this analysis)
• 11.6 percent readmitted within 30 days
• 8 outpatient visits (median patient visits in 12 months before hospital admission) – this excludes any ED visits on the day of admission
• 5 different clinicians seen (median patient during 12 months before hospital admission)

CONCLUSION

Patients with higher [visit entropy] in the 12 months before hospital admission were more likely to be readmitted or die within 30 days of hospital discharge.

Source: Garrison, G.M., and others. (2017, January-February). Visit entropy associated with hospital readmission rates. Journal of the American Board of Family Medicine, 30(1), 63-70. Click here for free full text: http://www.jabfm.org/content/30/1/63.full.pdf  Posted by AHA Resource Center (312) 422-2050 rc@aha.org

READMISSIONS: How to reduce bounce back from SNFs

After an inpatient stay in the hospital, some patients are discharged to skilled nursing facilities (SNFs) for continued recuperation and therapy.  This article summarizes the findings of a literature search of studies on how to avoid bounce back – readmission of these patients from the SNF to the hospital within 30 days.  Learnings about barriers and strategies from the 10 studies are compared in this article.

Source: Mileski, M., and others. (2017). An investigation of quality improvement initiatives in decreasing the rate of avoidable 30-day, skilled nursing facility-to-hospital readmissions: A systematic review. Clinical Interventions in Aging, 12, 213-222. Click here for free full text: https://www.dovepress.com/getfile.php?fileID=34598.  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

READMISSIONS: Community health workers help reduce

A readmission reduction program established by the University of Maryland St. Joseph Medical Center (Towson, Md.) in partnership with Maxim Healthcare is described in this brief article.  Prior to establishment of this home-based service, the hospital had 30-day readmission rates of 25 percent for high risk patients – which dropped to 10 percent about a year or so later.  It is staffed by nurse practitioners, RNs, and community health workers – who are considered key to the success of the program.

Planning Statistics: Program Experience (based on first 17 months)

• 1600 assessments of high risk patients
• 1200 of those patients agreed to participate in the program
• 5 percent of hospital’s total discharges opt into the program
• 15 community health workers were employed to care for the 1200 patients

Source: Whitman, E. (2016, Oct. 24). Deploying community health workers to reduce readmission rates. Modern Healthcare, 46(43), 32.  Click here for article published in slightly different version: http://www.modernhealthcare.com/article/20161022/magazine/310229996   Posted by AHA Resource Center (312) 422-2050, rc@aha.org