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Discharge Hemoglobin Level and 30-Day Readmission Rates After Coronary Artery Bypass Surgery.

ABSTRACT: BACKGROUND:Restrictive transfusion strategies supported by large randomized trials are resulting in decreased blood utilization in cardiac surgery. What remains to be determined, however, is the impact of lower discharge hemoglobin (Hb) levels on readmission rates. We assessed patients with higher versus lower Hb levels on discharge to compare 30-day readmission rates after coronary artery bypass grafting (CABG). METHODS:We retrospectively evaluated 1552 patients undergoing isolated CABG at our institution from January 2013 to May 2016. We evaluated 2 Hb cohorts: "high" (above) and "low" (below) the mean discharge Hb level of 9.4 g/dL, comparing patient characteristics, blood utilization, and clinical outcomes including 30-day readmission rates. We further evaluated the effects of the lowest (<8 g/dL) discharge Hb levels on 30-day readmission rates by dividing the patients into 4 anemia cohorts based on discharge Hb levels: "no anemia" (>12 g/dL), "mild anemia" (10-11.9 g/dL), "moderate anemia" (8-9.9 g/dL), and "severe anemia" (<8 g/dL). Risk adjustment accounted for age, sex, Charlson comorbidity index, preoperative comorbidities, revision sternotomy, and patient blood management program implementation. RESULTS:The "high" and "low" groups had similar patient characteristics except for Hb levels (mean discharge Hb was 10.4 ± 0.9 vs 8.5 ± 0.6 g/dL, respectively). Notably, no evidence for a difference in 30-day readmission rates was noted between the "high" (76/746; 10.2%) and "low" (97/806; 12.0%) (P = .25) Hb cohorts. The 4 anemia cohorts had differences in age, revision sternotomy incidence, Hb levels, certain patient comorbidities, and time to readmission. On multivariable analysis, the risk-adjusted odds of readmission in the "low" Hb cohort (odds ratio, 1.16; 95% confidence interval, 0.84-1.61; P = .36) was not significant compared to the "high" Hb cohort. Compared to patients with discharge Hb ?8 g/dL, patients with Hb <8 g/dL had a higher incidence of readmission (22/129; 17.1% vs 151/1423; 10.6%; P = .036). On multivariable analysis, Hb <8 g/dL on discharge was predictive of readmission (odds ratio, 1.77; 95% confidence interval, 1.05-2.88; P = .03). The most common reason for readmission was volume overload, followed by infection and arrhythmias. CONCLUSIONS:A discharge Hb level below the institution mean for CABG patients does not provide evidence for an association with an increased 30-day readmission rate. In the small number of patients discharged with Hb <8 g/dL, there is a suggestion of increased risk for readmission and larger more controlled studies are needed to verify or refute this finding.

SUBMITTER: Cho BC

PROVIDER: S-EPMC6533067 | biostudies-literature | 2019 Feb

REPOSITORIES: biostudies-literature

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Discharge Hemoglobin Level and 30-Day Readmission Rates After Coronary Artery Bypass Surgery.

Cho Brian C BC DeMario Vincent M VM Grant Michael C MC Hensley Nadia B NB Brown Charles H CH Hebbar Sachidanand S Mandal Kaushik K Whitman Glenn J GJ Frank Steven M SM

Anesthesia and analgesia 20190201 2

<h4>Background</h4>Restrictive transfusion strategies supported by large randomized trials are resulting in decreased blood utilization in cardiac surgery. What remains to be determined, however, is the impact of lower discharge hemoglobin (Hb) levels on readmission rates. We assessed patients with higher versus lower Hb levels on discharge to compare 30-day readmission rates after coronary artery bypass grafting (CABG).<h4>Methods</h4>We retrospectively evaluated 1552 patients undergoing isolat ...[more]

PMID: 30059402

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Project description:BackgroundSeveral care transition interventions propose that post-discharge phone calls can reduce adverse events and decrease costly return visits to the hospital. However, given the multi-faceted nature of most care transitions interventions, the true relationship between post-discharge phone calls and readmissions in a real world setting is uncertain.ObjectiveTo determine the effect of receiving a post-discharge telephone call on all-cause 30-day readmission in a general medicine population.DesignRetrospective observational study.ParticipantsPatients discharged home from the Medicine Service at a tertiary care academic medical center between November 2010 and May 2012.InterventionPatients received two telephone call attempts by a nurse within 72 h of discharge. Nurses followed a standard script to address issues associated with readmission.Main outcome and measuresBilling data captured readmissions. We used logistic regression-adjusted patient and clinical covariates as well as a propensity score representing likelihood of being called to determine the association between call receipt and risk for readmission.Key resultsThere were 5,507 eligible patients. In unadjusted analyses, patients who received a call and completed the intervention were significantly less likely to be readmitted compared to those who did not [155 (5.8 %) vs 123 (8.6 %), p < 0.01]. In multivariable models adjusting for socio-demographic and clinical covariates alone, completing a post-discharge telephone call intervention was associated with lower odds for readmission (AOR 0.71; 95 % CI: 0.55-0.91). However, when models adjusted for the likelihood of receiving the phone call using the propensity score, no association between call receipt and readmission was observed (AOR 0.91; 95%CI: 0.69-1.20).ConclusionsEffectiveness of post-discharge phone call programs may be more related to whether patients are able to answer a phone call than to the care delivered by the phone call. Programs would benefit from improving their ability to perform phone outreach while simultaneously improving on the care delivered during the calls.

Project description:BackgroundLowering 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.ObjectiveTo 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 participantsWe 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 measureRisk-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.ResultsAmong 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.ConclusionsHospitals 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.

Project description:BACKGROUND:Risk-prediction indices are one category of the many tools implemented to guide efforts to decrease readmissions. However, using fied models to predict a complex process can prove challenging. In addition, no risk-prediction index has been developed for patients undergoing colorectal surgery. Therefore, we evaluated the performance of a widely utilized simplified index developed at the hospital level - LACE (length of stay, acute admission, Charlson comorbidity index score, and emergency department visits) and developed and evaluated a novel index in predicting readmissions in this patient population. METHODS:Using a retrospective split-sample cohort, patients discharged after colorectal surgery were identified within the inpatient databases of the Healthcare Cost and Utilization Project for the states of New York, California, and Florida (2006-2014). The primary outcome was death or readmission within 30 days after discharge. Multivariable logistic regression models incorporated patient comorbidities, postoperative complications, and hospitalization details, and were evaluated using the C statistic. RESULTS:A total of 440,742 patients met eligibility criteria. The rate of death or readmission within 30 days after discharge was 14.0% (n = 61,757). When applied to surgical patients, the LACE index demonstrated a poor model fit (C = 0.631). The model fit improved significantly-but remained poor (C = 0.654; P < .001)-with the addition of the following variables, which are known to be associated with readmission after colorectal surgery: age, indication for surgery, and creation of a new ostomy. A novel, simplified model also yielded a poor model fit (C = 0.660). CONCLUSION:Postdischarge death or readmission after colorectal surgery is not accurately modeled using existing, modified, or novel simplified risk prediction models. Payers and providers must ensure that quality improvement efforts applying simplified models to complex processes, such as readmissions following colorectal surgery, may not be appropriate, and that models reflect the relevant patient population.

Project description:BackgroundPost-hospital discharge follow-up appointments are intended to evaluate patients' recovery following a hospitalization, but it is unclear how appointment statuses are associated with readmissions.ObjectiveTo examine the association between post-discharge ambulatory follow-up status, (1) having a scheduled appointment and (2) arriving to said appointment, and 30-day readmission.Design and settingA retrospective cohort study of patients hospitalized at 12 hospitals in an Integrated Delivery Network and their ambulatory appointments in that same network.Patients and main measuresWe included 50,772 patients who had an ambulatory appointment within 18 months of an inpatient admission in 2018. Primary outcome was readmission within 30 days post-discharge.Key resultsThere were 32,108 (63.2%) patients with scheduled follow-up appointments and 18,664 (36.8%) patients with no follow-up; 28,313 (88.2%) patients arrived, 3149 (9.8%) missed, and 646 (2.0%) were readmitted prior to their scheduled appointments. Overall 30-day readmission rate was 7.3%; 6.0% [5.75-6.31] for those who arrived, 8.8% [8.44-9.25] for those without follow-up, and 10.3% [9.28-11.40] for those who missed a scheduled appointment (p < 0.001). After adjusting for covariates, patients who arrived at their appointment in the first week following discharge were significantly less likely to be readmitted than those not having any follow-up scheduled (medical adjusted hazard ratio (aHR) 0.57 [0.47-0.69], p < 0.001; surgical aHR 0.58 [0.44-0.75], p < 0.001) There was an increased risk at weeks 3 and 4 for medical patients who arrived at a follow-up compared to those with no follow-up scheduled (week 3 aHR 1.29 [1.10-1.51], p = 0.001; week 4 aHR 1.46 [1.26-1.70], p < 0.001).ConclusionsThe benefit of patients arriving to their post-discharge appointments compared with patients who missed their follow-up visits or had no follow-up scheduled, is only significant during first week post-discharge, suggesting that coordination within 1 week of discharge is critical in reducing 30-day readmissions.

Project description:Background Limited data exist on long-term readmission and its association with patient and procedural characteristics after coronary artery bypass grafting. We aimed to investigate 5-year readmission after coronary artery bypass grafting and specifically focus on the role of sex and off-pump surgery. Methods and Results We performed a post hoc analysis of the CORONARY (Coronary Artery Bypass Grafting [CABG] Off or On Pump Revascularization) trial, involving 4623 patients. The primary outcome was all-cause readmission, and the secondary outcome was cardiac readmission. Cox models were used to investigate the association of outcomes with sex and off-pump surgery. Hazard function for sex was studied over time using a flexible, fully parametric model, and time-segmented analyses were performed accordingly. Rho coefficient was calculated for the correlation between readmission and long-term mortality. Median follow-up was 4.4 years (interquartile range, 2.9-5.4 years). The cumulative incidence rates of all-cause and cardiac readmission were 29.4% and 8.2% at 5 years, respectively. Off-pump surgery was not associated with either all-cause or cardiac readmission. The hazard for all-cause readmission in women over time was constantly higher than the hazard for men (hazard ratio [HR], 1.21 [95% CI, 1.04-1.40]; P=0.011). Time-segmented analyses confirmed the higher risk for all-cause (HR, 1.21 [95% CI, 1.05-1.40]; P<0.001) and cardiac (HR, 1.26 [95% CI, 1.03-1.69]; P=0.033) readmission in women after the first 3 years of follow-up. All-cause readmission was strongly correlated with long-term all-cause mortality (Rho, 0.60 [95% CI, 0.48-0.66]), whereas cardiac readmission was strongly correlated with long-term cardiovascular mortality (Rho, 0.60 [95% CI, 0.13-0.86]). Conclusions Readmission rates are substantial at 5 years after coronary artery bypass grafting and are higher in women but not with off-pump surgery. Registration URL: http://www.clinicaltrials.gov/; Unique identifier: NCT00463294.

Dataset Information

Discharge Hemoglobin Level and 30-Day Readmission Rates After Coronary Artery Bypass Surgery.

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Discharge Hemoglobin Level and 30-Day Readmission Rates After Coronary Artery Bypass Surgery.

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