scholarly journals Post-discharge Acute Care and Outcomes in the Era of Readmission Reduction

2019 ◽  
Author(s):  
Rohan Khera ◽  
Yongfei Wang ◽  
Susannah M. Bernheim ◽  
Zhenqiu Lin ◽  
Harlan M. Krumholz
Keyword(s):  
Heart Failure ◽  
Emergency Department ◽  
Acute Care ◽  
Care Utilization ◽  
Post Discharge ◽  
Readmission Rates ◽  
Risk Of Death ◽  
Observation Units ◽  
Acute Care Utilization ◽  
Significant Change

ABSTRACTBackgroundWith incentives to reduce readmission rates, there are concerns that patients who need hospitalization after a recent hospital discharge may be denied access, which would increase their risk of mortality.ObjectiveWe determined whether patients with hospitalizations for conditions covered by national readmission programs who received care in emergency department (ED) or observation units but were not hospitalized within 30 days had an increased risk of death. We also evaluated temporal trends in post-discharge acute care utilization in inpatient units, emergency department (ED) and observation units for these patients.Design, Setting, and ParticipantsIn this observational study, national Medicare claims data for 2008-2016, we identified patients ≥65 years hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia, conditions included in the HRRP.Main Outcomes and MeasuresPost-discharge 30-day mortality according to patients’ 30-day acute care utilization. Acute care utilization in inpatient and observation units, and the ED during the 30-day and 31-90-day post-discharge period.ResultsThere were 3,772,924 hospitalizations for HF, 1,570,113 for AMI, and 3,131,162 for pneumonia. The overall post-discharge 30-day mortality was 8.7% for HF, 7.3% for AMI, and 8.4% for pneumonia. Post-discharge mortality increased annually by 0.16% (95% CI, 0.11%, 0.22%) for HF, decreased by 0.15% (95% CI, -0.18%, -0.12%) for AMI, and did not significantly change for pneumonia. Specifically, mortality only increased for HF patients who did not utilize any post-discharge acute care, increasing at a rate of 0.16% per year (95% CI, 0.11%, 0.22%), accounting for 99% of the increase in post-discharge mortality in heart failure. Concurrent with a reduction in 30-day readmission rates, 30-day observation stays and visits to the ED increased across all 3 conditions during and beyond the post-discharge 30-day period. There was no significant change in overall 30-day post-acute care utilization (P-trend >0.05 for all).Conclusions and RelevanceThe only condition with an increasing mortality through the study period was HF; the increase preceded the policy and was not present among those received ED or observation unit care without hospitalization. Overall, during this period, there was not a significant change in the overall 30-day post-discharge acute care utilization.

scholarly journals Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States

BMJ ◽  
2020 ◽  
pp. l6831 ◽  
Author(s):  
Rohan Khera ◽  
Yongfei Wang ◽  
Susannah M Bernheim ◽  
Zhenqiu Lin ◽  
Harlan M Krumholz
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Acute Myocardial Infarction ◽  
Emergency Department ◽  
Acute Care ◽  
The United States ◽  
Care Utilization ◽  
Post Discharge ◽  
Observation Units ◽  
Acute Care Utilization

Abstract Objectives To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. Design Retrospective cohort study. Setting Medicare claims data for 2008-16 in the United States. Participants Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia—conditions included in the US Hospital Readmissions Reduction Program. Main outcome measures Post-discharge 30 day mortality according to patients’ 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. Results 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (−0.09% to −0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. Conclusions The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.

scholarly journals The Association Between Patient-reported Clinical Factors and 30-day Acute Care Utilization in Chronic Heart Failure

Medical Care ◽  
2020 ◽  
Vol 58 (4) ◽  
pp. 336-343 ◽  
Author(s):  
Jinying Chen ◽  
Rajani Sadasivam ◽  
Amanda C. Blok ◽  
Christine S. Ritchie ◽  
Catherine Nagawa ◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Acute Care ◽  
Care Utilization ◽  
Clinical Factors ◽  
Patient Reported ◽  
Acute Care Utilization

Factors Influencing Emergency Department Utilization and Hospital Re-Admissions in a Predominantly Obese, Racially Diverse Urban Renal Transplant Population

2020 ◽  
pp. 152692482097859
Author(s):  
Alicia B. Lichvar ◽  
Alisha Patel ◽  
Dana Pierce ◽  
Renee Petzel Gimbar ◽  
Ivo Tzvetanov ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Emergency Department ◽  
Renal Transplantation ◽  
Renal Transplant ◽  
Acute Care ◽  
Body Mass ◽  
Care Utilization ◽  
Renal Transplant Recipients ◽  
Transplant Recipients ◽  
Acute Care Utilization

Introduction: Early emergency department and hospital re-admissions are common in renal transplant recipients, but data are lacking in unique populations. Study Aim: The purpose of this study was to identify patient risk factors for multiple acute care utilization events within the first year of renal transplantation. Design: This was a single-center, retrospective cohort study of adult renal transplant recipients between 9/2013-9/2016. Patients were compared across number of emergency department visits and by hospital re-admissions. Diagnoses were categorized. Univariate and multivariate logistic regression was used to assess risk for multiple acute care utilization events within the first 12 months post-transplant. Results: A total of 216 patients were analyzed and were on average 50.5 (SD 13.9) years old, redominantly Black (49.77%) with an average body mass index of 33.33 (9.8) and were recipients of deceased donor renal transplants (61.11%). A total of 105 (48.6%) patients visited the emergency epartment and 119 (55.1%) patients had a hospital readmission. Patients having a body mass index >35 kg/m2 did not differ across emergency department visit or hospitalization groups. Delayed graft function (OR 2.86, 95% CI 1.07-7.65) and previous renal transplant (OR 2.77, 95% CI 1.04-7.39) were significantly associated with multiple acute care utilizations. Discussion: Acute care utilization following renal transplantation was similar to previously reported experiences. Obesity did not impact use of acute care resources or patient outcomes. Strategies addressing potential preventable emergency visits and hospital re-dmissions should be promoted.

scholarly journals Inpatient addiction consultation and post-discharge 30-day acute care utilization

2020 ◽  
Vol 213 ◽  
pp. 108081
Author(s):  
Zoe M. Weinstein ◽  
Debbie M. Cheng ◽  
Maria J. D’Amico ◽  
Leah S. Forman ◽  
Danny Regan ◽  
...  
Keyword(s):  
Acute Care ◽  
Care Utilization ◽  
Post Discharge ◽  
Acute Care Utilization

scholarly journals Cost-Effective Reduction of Acute Care Utilization using Home-Based Heart Failure Program.

2019 ◽  
Author(s):  
Victoria Thomas ◽  
Roopa Rao ◽  
Cathy Schubert ◽  
Andrew Nagel ◽  
Rebecca Kafer
Keyword(s):  
Heart Failure ◽  
Acute Care ◽  
Cost Effective ◽  
Care Utilization ◽  
Home Based ◽  
Effective Reduction ◽  
Acute Care Utilization

Prospectively assessing risk of acute care utilization for patients with an active cancer diagnosis.

2020 ◽  
Vol 38 (29_suppl) ◽  
pp. 208-208
Author(s):  
Valerie Pracilio Csik ◽  
Adam Binder ◽  
Michael Li ◽  
Nathan Handley
Keyword(s):  
Emergency Department ◽  
Acute Care ◽  
Cancer Diagnosis ◽  
Cohort Analysis ◽  
Emergency Department Visits ◽  
Care Utilization ◽  
Significant Variable ◽  
Patients With Cancer ◽  
Acute Care Utilization ◽  
Active Cancer

208 Background: Acute care utilization (ACU)--emergency department visits or hospitalizations--is common in patients with cancer. As many as 83% of all patients with cancer visit the emergency department annually; nearly three quarters of patients with advanced cancer are hospitalized in the year after diagnosis. Much of this ACU may be preventable. Identifying patients at risk for ACU using model-based approaches has shown potential for risk stratifying certain patient subgroups. However, a model applicable to any patient with an active cancer diagnosis is needed. We developed a real time clinical prediction model to assess risk for acute care utilization in patients with an active cancer diagnosis. Methods: We completed a retrospective cohort analysis of patients with an active cancer diagnosis (defined as at least one medical oncology encounter in a 12 month period) at one health system. Clinical factors with potential to impact disease progression and ACU were identified through a clinical review. Significant variables were defined by multivariate logistic regression. Risk of ACU was further characterized through the development of a point scoring system to define the upper decile of patients at highest risk. Results: We included 8,246 patient records in the analysis. Seven variables were determined to be statistically significant: An emergency department visit in the last 90 days, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, low hemoglobin, low albumin, and low absolute neutrophil count. The model produced an overall C-statistic of 0.726 Each significant variable was assigned a score of 0 or 1 (with the exception of ED visits, which were given one point for each visit, with three points maximum). Each patient received a total score, resulting from the summation of the individual variable scores. An evaluation of the distribution of points determined that 10% of the patients achieved a score of 2 or higher and contributed to 46% of ACU in the last 90 days. Patients receiving 0 points were defined as low risk (73% of patients contributing to 30% of ED/admissions). Patients receiving 1 point were deemed intermediate risk (17% of patients contributing to 24% of ED/admissions). Conclusions: Risk of acute care utilization for patients with an active cancer diagnosis can be prospectively assessed. This tool is currently integrated into our clinical practice and is updated every 14 days, or any time the chart is accessed. Assessment of efficacy is ongoing.

scholarly journals Cross‐sectional Analysis of Emergency Department and Acute Care Utilization Among Medicare Beneficiaries

2020 ◽  
Vol 27 (7) ◽  
pp. 570-579
Author(s):  
Arjun K. Venkatesh ◽  
Hao Mei ◽  
Liu Shuling ◽  
Gail D’Onofrio ◽  
Craig Rothenberg ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Care ◽  
Care Utilization ◽  
Medicare Beneficiaries ◽  
Cross Sectional ◽  
Cross Sectional Analysis ◽  
Acute Care Utilization ◽  
Sectional Analysis

scholarly journals Quantitative Lung Ultrasonography for the Nephrologist: Applications in Dialysis and Heart Failure

Kidney360 ◽  
2021 ◽  
pp. 10.34067/KID.0003972021
Author(s):  
Nathaniel Reisinger ◽  
Abhilash Koratala
Keyword(s):  
Heart Failure ◽  
Acute Care ◽  
Extravascular Lung Water ◽  
Lung Ultrasound ◽  
Volume Overload ◽  
Care Utilization ◽  
Lung Ultrasonography ◽  
Lung Water ◽  
Acute Care Utilization ◽  
B Lines

Volume overload and its attendant increase in acute care utilization and cardiovascular morbidity and mortality represents a critical challenge for the practicing nephrologist. This is particularly true among patients with ESKD on HD where pre-dialysis volume overload and intradialytic and postdialytic hypovolemia account for almost a third of all cost for the Medicare dialysis benefit. Quantitative lung ultrasound is a tool for assessing the extent of extravascular lung water which outperforms physical exam and plain chest radiography. B-lines are vertical hyperechoic artifacts present in patients with increased extravascular lung water. B-lines have been shown to decrease dynamically during the hemodialysis treatment in proportion to ultrafiltration volume. Among patients with chronic heart failure, titration of diuretics based on the extent of pulmonary congestion noted on lung ultrasonography has been shown to decrease recurrent acute care utilization. Early data from randomized-controlled trials of lung ultrasound-guided ultrafiltration therapy among patients with ESKD on HD have shown promise for potential reduction in recurrent episodes of decompensated heart failure and cardiovascular events. Ultimately lung ultrasound may predict those who are ultrafiltration tolerant and could be used to decreased acute care utilization and thus cost in this population.

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