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Objectives To determine for each basic, instrumental, and mobility activity after hospitalization for acute medical illness: (1) disability prevalence immediately before and monthly for 6 months after hospitalization; (2) disability incidence 1 month after hospitalization; and (3) recovery time from incident disability during months 2 to 6 after hospitalization. Design Prospective cohort study. Setting New Haven, Connecticut. Participants A total of 515 community-living persons, mean age 82.7 years, hospitalized for acute noncritical medical illness and alive within 1 month of hospital discharge. Measurements Disability was defined monthly for each basic (bathing, dressing, walking, transferring), instrumental (shopping, housework, meal preparation, taking medications, managing finances), and mobility activity (walking a quarter mile, climbing flight of stairs, lifting/carrying 10 pounds, driving) if help was needed to perform the activity or if a car was not driven in the prior month. Results Disability was common 1 and 6 months after hospitalization for activities frequently involved in leaving the home to access care including walking a quarter mile (prevalence 65% and 53%, respectively) and driving (65% and 61%). Disability was also common for activities involved in self-managing chronic health conditions including meal preparation (53% and 41%) and taking medications (41% and 31%). New disability was common and often prolonged. For example, 43% had new disability walking a quarter mile, and 30% had new disability taking medications, with mean recovery time of 1.9 months and 1.7 months, respectively. Findings were similar for the subgroup of persons residing at home (ie, not in a nursing home) at the first monthly follow-up interview after hospitalization. Conclusion Disability in specific functional activities important to leaving home to access care and self-managing health conditions is common, often new, and present for prolonged time periods after hospitalization for acute medical illness. Post-discharge care should support patients through extended periods of vulnerability beyond the immediate transitional period. J Am Geriatr Soc 68:486-495, 2020.

BACKGROUND/OBJECTIVE Heart failure (HF) readmission rates have plateaued despite scrutiny of hospital discharge practices. Many HF patients are discharged to skilled nursing facility (SNF) after hospitalization before returning home. Home healthcare (HHC) services received during the additional transition from SNF to home may affect readmission risk. Here, we examined whether receipt of HHC affects readmission risk during the transition from SNF to home following HF hospitalization. DESIGN Retrospective cohort study. SETTING Fee-for-service Medicare data, 2012 to 2015. PARTICIPANTS Beneficiaries, aged 65 years and older, hospitalized with HF who were subsequently discharged to SNF and then discharged home. MEASUREMENTS The primary outcome was unplanned readmission within 30 days of discharge to home from SNF. We compared time to readmission between those with and without HHC services using a Cox model. RESULTS Of 67 585 HF hospitalizations discharged to SNFs and subsequently discharged home, 13 257 (19.6%) were discharged with HHC, and 54 328 (80.4%) were discharged without HHC. Patients discharged home from SNFs with HHC had lower 30-day readmission rates than patients discharged without HHC (22.8% vs 24.5%; P

Disparities in health outcome exist among patients according to socioeconomic status. However, little is known regarding the differences in healthcare experiences across the various levels of income of patients. In a nationally representative US adult population, we evaluate the differences in healthcare experiences based on patient level of income. To evaluate the differences in patient healthcare experiences based on level of income. We identified 68,447 individuals (mean age, 48 ± 18 years; 55% female) representing 176.8 million US adults, who had an established healthcare provider in the 2010–2013 Medical Expenditure Panel Survey cohort. This retrospective study examined the differences in all five patient-reported healthcare experience measures (access to care, provider responsiveness, patient-provider communication, shared decision-making, and patient satisfaction) under the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We examined the relationship between patient income and their healthcare experience. Overall, 32% of the study participants were high-income earners while 23% had very-low income. Lower income was consistently associated with poor patient report on healthcare experience. Compared with those with high income, very-low-income-earning participants had 1.63 times greater odds (OR 1.63, 95% CI 1.45–1.82) of experiencing difficulty accessing care, had 1.34 times higher odds (OR 1.34, 95% CI 1.25–1.45) of experiencing poor communication, had higher odds (OR 1.68, 95% CI 1.46–1.92) of experiencing delays in healthcare delivery, and were more likely to report poor provider satisfaction (OR 1.48, 95% CI 1.37–1.61). Lower income-earning patients have poorer healthcare experience in all aspects of access and quality of care. Targeted policies focusing on improving communication, engagement, and satisfaction are needed to enhance patient healthcare experience for this vulnerable population.

Characterization of the dynamic nature of posthospital risk in chronic obstructive pulmonary disease (COPD) is needed to provide counseling and plan clinical services.To analyze risk of readmission and death after discharge for COPD among Medicare beneficiaries aged 65 years and older and to determine the association between ventilator support and risk trajectory.We computed daily absolute risks of hospital readmission and death for 1 year after discharge for COPD, stratified by ventilator support. We determined the time required for risks to decline by 50% from maximum daily values after discharge and for daily risks to plateau. We compared risks with those found in the general elderly population.Among 2,340,637 hospitalizations, the readmission rate at 1 year was 64.2%, including 63.5%, 66.0%, and 64.1% among those receiving invasive, noninvasive, and no ventilation, respectively. Among 1,283,069 hospitalizations, mortality at 1 year was 26.2%, including 45.7%, 41.8%, and 24.4% among those same respective groups. Daily risk of readmission declined by 50% within 28, 39, and 43 days and plateaued at 46, 54, and 61 days among those receiving invasive, noninvasive, and no ventilation, respectively. Risk of death declined by 50% by 3, 4, and 17 days and plateaued by 21, 18, and 24 days in the same respective groups. Risks of hospitalization and death were significantly higher after discharge for COPD than among the general Medicare population.Discharge from the hospital is associated with prolonged risks of readmission and death that vary with need for ventilator support. Interventions limited to the first month after discharge may be insufficient to improve longitudinal outcomes.

Recognizing and understanding the risk factors for mortality after acute myocardial infarction (AMI) provide clinicians and patients important information to determine prognosis and guide treatment. Most risk stratification models use demographic and clinical information that exists prior to hospitalization plus clinical presentation characteristics to estimate a patient's risk of mortality. In this review, we summarize the most important risk factors and discuss current models to predict mortality.

To determine if hospitals that routinely discharge patients early after lobectomy have increased readmissions.Hospitals are increasingly motivated to reduce length of stay (LOS) after lung cancer surgery, yet it is unclear if a routine of early discharge is associated with increased readmissions. The relationship between hospital discharge practices and readmission rates is therefore of tremendous clinical and financial importance.The National Cancer Database was queried for patients undergoing lobectomy for lung cancer from 2004 to 2013 at Commission on Cancer-accredited hospitals, which performed at least 25 lobectomies in a 2-year period. Facility discharge practices were characterized by a facility's median LOS relative to the median LOS for all patients in that same time period.In all, 59,734 patients met inclusion criteria; 2687 (4.5%) experienced an unplanned readmission. In a hierarchical logistic regression model, a routine of early discharge (defined as a facility's tendency to discharge patients faster than the population median in the same time period) was not associated with increased risk of readmission (odds ratio 1.12, 95% confidence interval 0.97-1.28, P = 0.12). In a risk-adjusted hospital readmission rate analysis, hospitals that discharged patients early did not experience more readmissions (P = 0.39). The lack of effect of early discharge practices on readmission rates was observed for both minimally invasive and thoracotomy approaches.It is possible for hospitals to develop early discharge practices without increasing readmissions. Further study is needed to identify the critical practice elements that have enabled hospitals to aggressively discharge patients without increasing readmission risk.

BACKGROUND: Patients with heart failure having a low expected probability of arrhythmic death may not benefit from implantable cardioverter defibrillators (ICDs). OBJECTIVE: The objective was to validate models to identify cardiac resynchronization therapy (CRT) candidates who may not require CRT devices with ICD functionality. METHODS: Heart failure (HF) patients with CRT-Ds and non-CRT ICDs from the National Cardiovascular Data Registry and others with no device from 3 separate registries and 3 heart failure trials were analyzed using multivariable Cox proportional hazards regression for survival with the Seattle Heart Failure Model (SHFM; estimates overall mortality) and the Seattle Proportional Risk Model (SPRM; estimates proportional risk of arrhythmic death). RESULTS: Among 60,185 patients (age 68.6±11.3 years, 31.9% female) meeting CRT-D criteria, 38,348 had CRT-Ds, 11,389 had non-CRT ICDs, and 10,448 had no device. CRT-D patients had a prominent adjusted survival benefit (HR 0.52, 95% CI 0.50–0.55, pmedian had substantially more ICD-attributable benefit (absolute risk reduction of 2.6%/year combined; p

Objectives (1) To determine the relationship of incident delirium during hospitalization with 90-day mortality; (2) to identify potential in-hospital mediators through which delirium increases 90-day mortality. Design Analysis of data from Project Recovery, a controlled clinical trial of a delirium prevention intervention from 1995 to 1998 with follow-up through 2000. Setting Large academic hospital. Participants Patients ≥70 years old without delirium at hospital admission who were at intermediate-to-high risk of developing delirium and received usual care only. Measurements (1) Incident delirium; (2) potential mediators of delirium on death including use of restraining devices (physical restraints, urinary catheters), development of hospital acquired conditions (HACs) (falls, pressure ulcers), and exposure to other noxious insults (sleep deprivation, acute malnutrition, dehydration, aspiration pneumonia); (3) death within 90 days of admission. Results Among 469 patients, 70 (15%) developed incident delirium. These patients were more likely to experience restraining devices (37% vs 16%, P < .001), HACs (37% vs 12%, P < .001), other noxious insults (63% vs 49%, P = .03), and 90-day mortality (24% vs 6%, P < .001). The inverse probability weighted hazard of death due to delirium was 4.2 (95% CI = 2.8–6.3) in bivariable analyses, increased in a graded manner with additional exposures to restraining devices, HACs, and other noxious insults, and declined by 10.9% after addition of these potential mediator categories, providing evidence of mediation. Conclusion Restraining devices, HACs, and additional noxious insults were more frequent among patients with delirium, increased mortality in a graded manner, and were responsible for a significant percentage of the association of delirium with death. Additional efforts to prevent potential downstream mediators through which delirium increases mortality may help to improve outcomes among hospitalized older adults.

Older adults are frequently readmitted to the hospital soon after hospitalization for common cardiovascular conditions. Yet there are few high-quality data on the best strategies to reduce short-term readmissions because most studies have involved small numbers of participants, single-centre design, and strong susceptibility to bias. Despite these limitations in the literature, a clear signal exists that most studies involving a singular type of intervention, a singular type of health provider, or a low intensity of intervention have failed to reduce readmissions. In contrast, interventions that are most likely to lower readmissions have used comprehensive approaches, including combined hospital and postacute care, multimodal interventions, multidisciplinary teams, or frequent longitudinal contact. Components of a comprehensive approach with the highest level of evidence include high-quality, disease-specific care; multiple transitional care interventions; involvement of multidisciplinary teams; early and frequent outpatient follow-up; and, when possible, home visits. These findings are consistent with data demonstrating that older adults have multiple sources of vulnerability and experience elevated readmission risk from a broad spectrum of medical conditions for an extended time after hospital discharge. Because readmission reduction is difficult and requires new ways of conceptualizing links between inpatient and postacute care, financial incentives may ultimately be required to motivate hospitals and health systems to redesign care processes, deploy new resources, and collaborate with out-of-hospital providers and organizations.

Programs from the Centers for Medicare and Medicaid Services simultaneously promote strategies to lower hospital admissions and readmissions. However, there is concern that hospitals in communities that successfully reduce admissions may be penalized, as patients that are ultimately hospitalized may be sicker and at higher risk of readmission. We therefore examined the relationship between changes from 2010 to 2013 in admission rates and thirty-day readmission rates for elderly Medicare beneficiaries. We found that communities with the greatest decline in admission rates also had the greatest decline in thirty-day readmission rates, even though hospitalized patients did grow sicker as admission rates declined. The relationship between changing admission and readmission rates persisted in models that measured observed readmission rates, risk-standardized readmission rates, and the combined rate of readmission and death. Our findings suggest that communities can reduce admission rates and readmission rates in parallel, and that federal policy incentivizing reductions in both outcomes does not create contradictory incentives.

Multimorbidity is common among older adults with heart failure and creates diagnostic and management challenges. Diagnosis of heart failure may be difficult, as many conditions commonly found in older persons produce dyspnea, exercise intolerance, fatigue, and weakness; no singular pathognomonic finding or diagnostic test differentiates them from one another. Treatment may also be complicated, as multimorbidity creates high potential for drug-disease and drug-drug interactions in settings of polypharmacy. The authors suggest that management of multimorbid older persons with heart failure be patient, rather than disease-focused, to best meet patients' unique health goals and minimize risk from excessive or poorly-coordinated treatments.

Key Points Question Was the announcement or implementation of the Hospital Readmissions Reduction Program (HRRP) associated with an increase in mortality following hospitalization for acute myocardial infarction, heart failure, or pneumonia among Medicare beneficiaries? Findings In this cohort study, between 2006 and 2014, in-hospital mortality decreased for the 3 conditions while 30-day postdischarge mortality decreased for acute myocardial infarction but increased for heart failure and pneumonia. Before the announcement of the HRRP, postdischarge mortality was stable for acute myocardial infarction and increasing for heart failure and pneumonia, and there were no inflections in slope around the announcement or implementation of the HRRP. Meaning There was no evidence for increase in in-hospital or postdischarge mortality associated with the HRRP announcement or implementation—a period with substantial reductions in readmissions., Importance The US Hospital Readmissions Reduction Program (HRRP) was associated with reduced readmissions among Medicare beneficiaries hospitalized for acute myocardial infarction (AMI), heart failure (HF), and pneumonia. It is important to assess whether there has been a signal for concomitant harm with an increase in mortality. Objective To evaluate whether the announcement or the implementation of HRRP was associated with an increase in either in-hospital or 30-day postdischarge mortality following hospitalization for AMI, HF, or pneumonia. Design, Setting, and Participants In this cohort study, using Medicare data, all hospitalizations for AMI, HF, and pneumonia were identified among fee-for-service Medicare beneficiaries aged 65 years and older from January 1, 2006, to December 31, 2014. These were assessed for changes in trends for risk-adjusted rates of in-hospital and 30-day postdischarge mortality after announcement and implementation of the HRRP using an interrupted time series framework. Analyses were done in November 2017 and December 2017. Exposures Announcement of the HRRP in March 2010, and implementation of its penalties in October 2012. Main Outcomes and Measures Monthly risk-adjusted rates of in-hospital and 30-day postdischarge mortality. Results The sample included 1.7 million AMI, 4 million HF, and 3.5 million pneumonia hospitalizations. Between 2006 and 2014, in-hospital mortality decreased for the 3 conditions (AMI, from 10.4% to 9.7%; HF, from 4.3% to 3.5%; pneumonia, from 5.3% to 4.0%) while 30-day postdischarge mortality decreased from 7.4% to 7.0% for AMI (P for trend .05 for all). In contrast, there were significant negative deflections in slopes for readmission rates at HRRP announcement for all conditions. Conclusions and Relevance Among Medicare beneficiaries, there was no evidence for an increase in in-hospital or postdischarge mortality associated with HRRP announcement or implementation—a period with substantial reductions in readmissions. The improvement in readmission was therefore not associated with any increase in in-hospital or 30-day postdischarge mortality., This cohort study uses Medicare data to evaluate whether the announcement or implementation of the Hospital Readmissions Reduction Program (HRRP) was associated with an increase in either in-hospital or 30-day postdischarge mortality following hospitalization for acute myocardial infarction (AMI), heart failure (HF), or pneumonia.

Objective Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less. Design Retrospective cohort study. Setting and participants All Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home. Measures Patients were followed for 30 days following SNF discharge. We categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, we modeled time to a composite outcome of unplanned readmission or death after SNF discharge. Our model examined 0-2 days and 3-30 days post-SNF discharge. Results Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home. Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The hazard rate of the composite outcome for each group was significantly increased on days 0 to 2 after SNF discharge compared to days 3 to 30, as reflected in their hazard rate ratios: for patients with SNF length of stay 1 to 6 days, 4.60 (4.23-5.00); SNF length of stay 7 to 13 days, 2.61 (2.45-2.78); SNF length of stay 14 to 30 days, 1.70 (1.62-1.78). Conclusions/implications The hazard rate of readmission after SNF discharge following HF hospitalization is highest during the first 2 days home. This risk attenuated with longer SNF length of stay. Interventions to improve postdischarge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition.

A key quality metric for Accountable Care Organizations (ACOs) is the rate of hospitalization among patients with heart failure (HF). Among this patient population, non-HF-related hospitalizations account for a substantial proportion of admissions. Understanding the types of admissions and the distribution of admission types across ACOs of varying performance may provide important insights for lowering admission rates.We examined admission diagnoses among 220 Medicare Shared Savings Program ACOs in 2013. ACOs were stratified into quartiles by their performance on a measure of unplanned risk-standardized acute admission rates (RSAARs) among patients with HF. Using a previously validated algorithm, we categorized admissions by principal discharge diagnosis into: HF, cardiovascular/non-HF, and noncardiovascular. We compared the mean admission rates by admission type as well as the proportion of admission types across RSAAR quartiles (Q1-Q4).Among 220 ACOs caring for 227,356 patients with HF, the median (IQR) RSAARs per 100 person-years ranged from 64.5 (61.7-67.7) in Q1 (best performers) to 94.0 (90.1-99.9) in Q4 (worst performers). The mean admission rates by admission types for ACOs in Q1 compared with Q4 were as follows: HF admissions: 9.8 (2.2) vs 14.6 (2.8) per 100 person years (P.0001); cardiovascular/non-HF admissions: 11.1 (1.6) vs 15.9 (2.6) per 100 person-years (P.0001); and noncardiovascular admissions: 42.7 (5.4) vs 69.6 (11.3) per 100 person-years (P.0001). The proportion of admission due to HF, cardiovascular/non-HF, and noncardiovascular conditions was 15.4%, 17.5%, and 67.1% in Q1 compared with 14.6%, 15.9%, and 69.4% in Q4 (P.007).Although ACOs with the best performance on a measure of all-cause admission rates among people with HF tended to have fewer admissions for HF, cardiovascular/non-HF, and noncardiovascular conditions compared with ACOs with the worst performance (highest admission rates), the largest difference in admission rates were for noncardiovascular admission types. Across all ACOs, two-thirds of admissions of patients with HF were for noncardiovascular causes. These findings suggest that comprehensive approaches are needed to reduce the diverse admission types for which HF patients are at risk.

BACKGROUND: Temporal changes in the readmission rates for patient groups and conditions that were not directly under the purview of Hospital Readmissions Reduction Program (HRRP) can help assess whether efforts to lower readmissions extended beyond targeted patients and conditions. METHODS: Using Nationwide Readmissions Database (2010–2015), we assessed trends in all-cause readmission rates for one of the 3 HRRP conditions (acute myocardial infarction, heart failure, pneumonia) or conditions not targeted by HRRP in 6 age-insurance groups defined by age-groups (≥65 or

After discharge from the hospital, patients face a transient period of generalized susceptibility to disease as well as an elevated risk for adverse events, including hospital readmission and death. The term posthospital syndrome (PHS) has been used to describe this time of enhanced vulnerability. Based on data from bench to bedside, this narrative review examines the hypothesis that hospitalrelated allostatic overload is a plausible etiology of PHS. Resulting from extended exposure to stress, allostatic overload is a maladaptive state driven by overuse and dysregulation of the hypothalamic-pituitary-adrenal axis and the autonomic nervous system that ultimately generates pathophysiologic consequences to multiple organ systems. Markers of allostatic overload, including elevated levels of cortisol, catecholamines, and inflammatory markers, have been associated with adverse outcomes after hospital discharge. Based on the evidence, we suggest a possible mechanism for postdischarge vulnerability, encourage critical contemplation of traditional hospital environments, and suggest interventions that might improve outcomes.

Heart failure (HF) is a common, serious chronic condition with high morbidity, hospitalisation and mortality. The healthcare systems of England and the northern Italian region of Lombardy share important similarities and have comprehensive hospital administrative databases linked to the death register. We used them to compare admission for HF and mortality for patients between 2006 and 2012 (n = 37,185 for Lombardy, 234,719 for England) with multistate models. Despite close similarities in age, sex and common comorbidities of the two sets of patients, in Lombardy, HF admissions were longer and more frequent per patient than in England, but short- and medium-term mortality was much lower. English patients had more very short stays, but their very elderly also had longer stays than their Lombardy counterparts. Using a three-state model, the predicted total time spent in hospital showed large differences between the countries: women in England spent an average of 24 days if aged 65 at first admission and 19 days if aged 85; in Lombardy these figures were 68 and 27 days respectively. Eight-state models suggested disease progression that appeared similar in each country. Differences by region within England were modest, with London patients spending more time in hospital and having lower mortality than the rest of England. Whilst clinical practice differences plausibly explain these patterns, we cannot confidently disentangle the impact of alternatives such as coding, casemix, and the availability and use of non-hospital settings. We need to better understand the links between rehospitalisation frequency and mortality.

BackgroundPublicly reported hospital risk-standardized mortality rates (RSMRs) for acute myocardial infarction (AMI) are calculated for Medicare beneficiaries. Outcomes for older patients with AMI may not reflect general outcomes.ObjectiveTo examine the relationship between hospital 30-day RSMRs for older patients (aged ≥65 years) and those for younger patients (aged 18 to 64 years) and all patients (aged ≥18 years) with AMI.DesignRetrospective cohort study.Setting986 hospitals in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-Get With the Guidelines.ParticipantsAdults hospitalized for AMI from 1 October 2010 to 30 September 2014.MeasurementsHospital 30-day RSMRs were calculated for older, younger, and all patients using an electronic health record measure of AMI mortality endorsed by the National Quality Forum. Hospitals were ranked by their 30-day RSMRs for these 3 age groups, and agreement in rankings was plotted. The correlation in hospital AMI achievement scores for each age group was also calculated using the Hospital Value-Based Purchasing (HVBP) Program method computed with the electronic health record measure.Results267763 and 276031 AMI hospitalizations among older and younger patients, respectively, were identified. Median hospital 30-day RSMRs were 9.4%, 3.0%, and 6.2% for older, younger, and all patients, respectively. Most top- and bottom-performing hospitals for older patients were neither top nor bottom performers for younger patients. In contrast, most top and bottom performers for older patients were also top and bottom performers for all patients. Similarly, HVBP achievement scores for older patients correlated weakly with those for younger patients (R= 0.30) and strongly with those for all patients (R= 0.92).LimitationMinority of U.S. hospitals.ConclusionHospital mortality rankings for older patients with AMI inconsistently reflect rankings for younger patients. Incorporation of younger patients into assessment of hospital outcomes would permit further examination of the presence and effect of age-related quality differences.Primary funding sourceAmerican College of Cardiology.

Given persistently high 30-day readmission rates among patients hospitalized for heart failure, there is an ongoing need to identify new interventions to reduce readmissions. Although exercise programs can improve outcomes among ambulatory heart failure patients, it is not clear whether this benefit extends to reducing readmissions following heart failure hospitalization. We therefore conducted a systematic review of the literature to identify randomized controlled trials examining the impact of exercise programs on hospital readmissions among patients recently hospitalized for heart failure. We searched Ovid MEDLINE, EMBASE, and the Wiley Cochrane Library for studies that fulfilled pre-defined criteria, including that the exercise program pre-specify activity type and exercise frequency, duration, and intensity. Exercise interventions could occur at any location including within the hospital, at an outpatient facility, or at home. Among 1213 unique publications identified, only one study fulfilled inclusion criteria. This study was a single-site randomized controlled trial that consisted of a 12-week exercise program in a cohort of 105 patients with a principal diagnosis of heart failure at a metropolitan hospital in Australia. This study revealed a reduction in 12-month all-cause and cardiovascular-related hospitalization rates. However, inferences were limited by its single-site study design, small sample size, premature termination, and high risk for selection, performance, and detection bias. As no studies have built upon the findings of this study, it remains unknown whether exercise programs can improve readmission rates among patients recently hospitalized for heart failure, a significant gap in the literature.

Objective To characterize rates and trends over time of emergency department treatment-and-discharge stays, repeat observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from observation stays. Design Retrospective cohort study. Setting 4750 hospitals in the USA. Participants Nationally representative sample of Medicare fee for service beneficiaries aged 65 or over discharged after 363 037 index observation stays, 2 540 000 index emergency department treatment-and-discharge stays, and 2 667 525 index inpatient stays from 2006-11. Main outcome measures Rates of emergency department treatment-and-discharge stays, observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from index observation stays. Rates were compared with corresponding outcomes within 30 days of discharge from both index emergency department treatment-and-discharge stays and index inpatient stays. Results Among 363 037 index observation stays resulting in discharge from 2006-11, 30 day rates of emergency department treatment-and-discharge stays were 8.4%, repeat observation stays were 2.9%, inpatient stays were 11.2%, any hospital revisit was 20.1%, and death was 1.8%. Of all revisits, 49.7% were for inpatient stays. Revisit rates for emergency department treatment-and-discharge stays, repeat observation stays, and any hospital revisit increased from 2006-11 (P

Background— Women have an increased risk of rehospitalization in the immediate postdischarge period; however, few studies have determined how readmission risk dynamically changes on a day-to-day basis over the full year after hospitalization by sex and how these differences compare with the risk for mortality. Methods and Results— We identified >3 000 000 hospitalizations of patients with a principal discharge diagnosis of heart failure, acute myocardial infarction, or pneumonia and estimated sex differences in the daily risk of rehospitalization/death 1 year after discharge from a population of Medicare fee-for-service beneficiaries aged 65 years and older. We calculated the (1) time required for adjusted rehospitalization/mortality risks to decline 50% from maximum values after discharge, (2) time required for the adjusted readmission risk to approach plateau periods of minimal day-to-day change, and (3) extent to which adjusted risks are greater among recently hospitalized patients versus Medicare patients. We identified 1 392 289, 530 771, and 1 125 231 hospitalizations for heart failure, acute myocardial infarction, and pneumonia, respectively. The adjusted daily risk of rehospitalization varied by admitting condition (hazard rate ratio for women versus men, 1.10 for acute myocardial infarction; hazard rate ratio, 1.04 for heart failure; and hazard rate ratio, 0.98 for pneumonia). However, for all conditions, the adjusted daily risk of death was higher among men versus women (hazard rate ratio women versus with men, Conclusions— Although the association of sex with daily risk of rehospitalization varies across conditions, women are at highest risk after discharge for acute myocardial infarction. Future studies should focus on understanding the determinants of sex differences in rehospitalization risk among conditions.

Background— Consumer-reported patient–provider communication (PPC) assessed by Consumer Assessment of Health Plans Survey in ambulatory settings is incorporated as a complementary value metric for patient-centered care of chronic conditions in pay-for-performance programs. In this study, we examine the relationship of PPC with select indicators of patient-centered care in a nationally representative US adult population with established atherosclerotic cardiovascular disease. Methods and Results— The study population consisted of a nationally representative sample of 6810 individuals (aged ≥18 years), representing 18.3 million adults with established atherosclerotic cardiovascular disease (self-reported or International Classification of Diseases, Ninth Edition diagnosis) reporting a usual source of care in the 2010 to 2013 pooled Medical Expenditure Panel Survey cohort. Participants responded to questions from Consumer Assessment of Health Plans Survey that assessed PPC, and we developed a weighted PPC composite score using their responses, categorized as 1 (poor), 2 (average), and 3 (optimal). Outcomes of interest were (1) patient-reported outcomes: 12-item Short Form physical/mental health status, (2) quality of care measures: statin and ASA use, (3) healthcare resource utilization: emergency room visits and hospital stays, and (4) total annual and out-of-pocket healthcare expenditures. Atherosclerotic cardiovascular disease patients reporting poor versus optimal were over 2-fold more likely to report poor outcomes; 52% and 26% more likely to report that they are not on statin and aspirin, respectively, had a significantly greater utilization of health resources (odds ratio≥2 emergency room visit, 1.41 [95% confidence interval, 1.09–1.81]; odds ratio≥2 hospitalization, 1.36 [95% confidence interval, 1.04–1.79]), as well as an estimated $1243 ($127–$2359) higher annual healthcare expenditure. Conclusions— This study reveals a strong relationship between PPC and patient-reported outcomes, utilization of evidence-based therapies, healthcare resource utilization, and expenditures among those with established atherosclerotic cardiovascular disease.

Background Little is known about patients with severe symptomatic aortic stenosis (AS) who receive medical management despite evaluation at a heart valve treatment center. Objective We identified patient characteristics associated with medical management, physician-reported reasons for selecting medical management, and patients’ perceptions of their involvement and satisfaction with treatment selection. Methods and results Of 454 patients evaluated for AS at 9 established heart valve treatment centers from December 12, 2013 to August 19, 2014, we included 407 with severe symptomatic AS. Information was collected using medical record review and survey of patients and treating physicians. Of 407 patients, 212 received transcatheter aortic valve replacement (TAVR), 124 received surgical aortic valve replacement (SAVR), and 71 received medical management (no SAVR/TAVR). Thirty-day predicted mortality was higher in patients receiving TAVR (8.7%) or medical management (9.8%) compared with SAVR (3.4%) (P

Background: It is unknown if financial pressures to reduce hospital readmission rates following passage of the Affordable Care Act (ACA) have had the unintended effect of increasing mortality rates after hospitalization. We therefore examined correlations between paired changes in hospital 30-day readmission rates and 30-day mortality rates among Medicare fee-for-service beneficiaries hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia from 2008 to 2014. Methods: We used linear regression to calculate monthly changes in hospitals’ 30-day risk-adjusted readmission rates (RARRs) and 30-day risk-adjusted mortality rates (RAMRs) after discharge for HF, AMI, and pneumonia from 2008 to 2014. Adjustment was made for patient age, sex, comorbidities, hospital length of stay, and season. We then examined the correlation of hospitals’ paired monthly changes in 30-day RARRs and monthly changes in 30-day RAMRs after discharge. Results: From 2008 to 2014, we identified 2,962,554, 1,229,939, and 2,544,530 hospitalizations for HF, AMI, and pneumonia at 5,016, 4,772, and 5,057 hospitals, respectively. Hospital 30-day RARRs declined for all three conditions from 2008 to 2014; the monthly change in RARRs was -0.053 (95% CI -0.055, -0.051) for HF, -0.044 (95% CI -0.047, -0.041) for AMI, and -0.033 (95% CI -0.035, -0.031) for pneumonia. In contrast, the monthly change in hospital 30-day RAMRs after discharge varied by admitting condition and was 0.008 (95% CI 0.007, 0.010) for HF, -0.003 (95% CI -0.006, -0.001) for AMI, and 0.001 (95% CI -0.001, 0.003) for pneumonia. The correlation between monthly changes in hospitals’ 30-day RARRs and 30-day RAMRs after discharge was 0.060 for HF (p Conclusion: Changes in hospital readmission rates for HF, AMI, and pneumonia were poorly correlated with changes in mortality rates after hospitalization between 2008 and 2014. These findings suggest that financial incentives to improve hospitals’ readmission performance have not increased mortality after hospitalization.

Background: While it is well established that significant health outcome disparities exist across patients of varying socio-economic status (SES) with established atherosclerotic cardiovascular disease (ASCVD), disparities in patients’ healthcare experiences are not well investigated. We explore income level differences in four central tenets of patient-reported healthcare experience (access to care, provider communication, shared decision making and provider satisfaction) as measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, in a nationally representative adult US population with established ASCVD. Methods: The study population consisted of 8223 individuals (age ≥ 18 years) representing 21.6 million with established ASCVD (self-reported or ICD-9 diagnosis) reporting a usual source of care in the 2010-2013 pooled Medical Expenditure Panel Survey (MEPS) cohort. We assessed the responses for each item as: a) difficult access to care (always/almost difficult), b) ineffective communication and shared decision making (never/sometimes), and c) poor provider satisfaction (lowest quartile on a scale of 0-10). We examined the relationship between scores in the lowest quartile of each domain composite scores, derived using the weighted average response from each items scores, with patients’ SES, using the high-income group as reference. Results: Lower SES was consistently associated with greater perceived difficulties in access, poor provider-patient communication, less shared decision making, as well as lower provider satisfaction (Table). Participants classified as poor vs. high income were 47% (95% CI 1.17-1.83) more likely to report difficulty accessing care, 39% (95% CI 1.09-1.78) and 26% (95% CI 0.99-1.60) reported a higher likelihood of experiencing poor communication and shared decision making respectively, as well as a 66% (95% CI 1.31-2.11) higher likelihood of reporting lower provider satisfaction. Conclusion: Among patients with established ASCVD, significant SES disparities exist in all domains of patient reported healthcare experience quality of care metrics. Targeted policies focusing on improving communication, engagement and satisfaction are needed to enhance patient healthcare experience among high-risk vulnerable populations.

Importance Studies of public hospitals have reported increasing incidence of emergency department (ED) transfers of uninsured patients for hospitalization, which is perceived to be associated with financial incentives. Objective To examine the differences in risk-adjusted transfer and discharge rates by patient insurance status among hospitals capable of providing critical care. Design, Setting, and Participants A cross-sectional analysis of the 2015 National Emergency Department Sample was conducted, including visits between January 2015 and December 2015. Adult ED visits throughout 2015 (n = 215 028) for the 3 common medical conditions of pneumonia, chronic obstructive pulmonary disease, and asthma, at hospitals with intensive care capabilities were included. Only hospitals with advanced critical care capabilities for pulmonary care were included. Main Outcomes and Measures The primary outcomes were patient-level and hospital-level risk-adjusted ED discharges, ED transfers, and hospital admissions. Adjusted odds of discharge or transfer compared with admission among uninsured patients, Medicaid and Medicare beneficiaries, and privately insured patients are reported. Hospital ownership status was used for the secondary analysis. Results Of the 30 542 691 ED visits to 953 hospitals included in the 2015 National Emergency Department Sample, 215 028 visits (0.7%) were for acute pulmonary diseases to 160 intensive care–capable hospitals. These visits were made by patients with a median (interquartile range [IQR]) age of 55 (40-71) years and who were predominantly female (124 931 [58.1%]). Substantial variation in unadjusted and risk-standardized ED discharge, ED transfer, and hospital admission rates was found across EDs. Compared with privately insured patients, uninsured patients were more likely to be discharged (odds ratio [OR], 1.66; 95% CI, 1.57-1.76) and transferred (adjusted OR [aOR], 2.41; 95% CI, 2.08-2.79). Medicaid beneficiaries had comparable odds of discharge (aOR, 1.00; 95% CI, 0.97-1.04) but higher odds of transfer (aOR, 1.19; 95% CI, 1.05-1.33). Conclusions and Relevance After accounting for hospital critical care capability and patient case mix, the study found that uninsured patients and Medicaid beneficiaries with common medical conditions appeared to have higher odds of interhospital transfer.

Importance Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care for patients both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity would enable development and monitoring of more effective treatment approaches for the condition. Objectives To present a comprehensive review of delirium severity instruments, conduct a methodologic quality rating of the original validation study of the most commonly used instruments, and select a group of top-rated instruments. Evidence Review This systematic review was conducted using literature from Embase, PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature, from January 1, 1974, through March 31, 2017, with the key wordsdelirium,severity,tests,measures, andintensity. Inclusion criteria were original articles assessing delirium severity and using a delirium-specific severity instrument. Final listings of articles were supplemented with hand searches of reference listings to ensure completeness. At least 2 reviewers independently completed each step of the review process: article selection, data extraction, and methodologic quality assessment of relevant articles using a validated rating scale. All discrepancies between raters were resolved by consensus. Findings Of 9409 articles identified, 228 underwent full text review, and we identified 42 different instruments of delirium severity. Eleven of the 42 tools were multidomain, delirium-specific instruments providing a quantitative rating of delirium severity; these instruments underwent a methodologic quality review. Applying prespecified criteria related to frequency of use, methodologic quality, construct or predictive validity, and broad domain coverage, an expert panel used an iterative modified Delphi process to select 6 final high-quality instruments meeting these criteria: the Confusion Assessment Method–Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale. Conclusions and Relevance The 6 instruments identified may enable accurate measurement of delirium severity to improve clinical care for patients with this condition. This work may stimulate increased usage and head-to-head comparison of these instruments.

ObjectivesThis study sought to analyze recent trends over time in heart failure (HF) hospital stay rates, length of stay (LOS), and in-hospital mortality by age groups with a large national dataset of U.S. hospital discharges.BackgroundHeart failure hospital stay rates, LOS, and mortality have fallen over the past decade for older Medicare beneficiaries, but whether this holds true for younger adults is unknown.MethodsFrom the National Inpatient Sample, we calculated HF hospital stay rates, LOS, and in-hospital mortality from 2001 to 2009 with survey data analysis techniques.ResultsHospital stays (n = 1,686,089) with a primary discharge diagnosis of HF were identified from National Inpatient Sample data between 2001 and 2009. The overall national hospital stay rate decreased from 633 to 463 hospital stays/100,000 persons, (−26.9%, p-for-trend

Readmission rates declined after announcement of the Hospital Readmission Reduction Program (HRRP), which penalizes hospitals for excess readmissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia.To compare trends in readmission rates for target and nontarget conditions, stratified by hospital penalty status.Retrospective cohort study of Medicare fee-for-service beneficiaries older than 64 years discharged between January 1, 2008, and June 30, 2015, from 2214 penalty hospitals and 1283 nonpenalty hospitals. Difference-interrupted time-series models were used to compare trends in readmission rates by condition and penalty status.Hospital penalty status or target condition under the HRRP.Thirty-day risk adjusted, all-cause unplanned readmission rates for target and nontarget conditions.The study included 48 137 102 hospitalizations of 20 351 161 Medicare beneficiaries. In January 2008, the mean readmission rates for AMI, HF, pneumonia, and nontarget conditions were 21.9%, 27.5%, 20.1%, and 18.4%, respectively, at hospitals later subject to financial penalties and 18.7%, 24.2%, 17.4%, and 15.7% at hospitals not subject to penalties. Between January 2008 and March 2010, prior to HRRP announcement, readmission rates were stable across hospitals (except AMI at nonpenalty hospitals). Following announcement of HRRP (March 2010), readmission rates for both target and nontarget conditions declined significantly faster for patients at hospitals later subject to financial penalties compared with those at nonpenalized hospitals (for AMI, additional decrease of -1.24 [95% CI, -1.84 to -0.65] percentage points per year relative to nonpenalty discharges; for HF, -1.25 [95% CI, -1.64 to -0.86]; for pneumonia, -1.37 [95% CI, -1.80 to -0.95]; and for nontarget conditions, -0.27 [95% CI, -0.38 to -0.17]; P .001 for all). For penalty hospitals, readmission rates for target conditions declined significantly faster compared with nontarget conditions (for AMI, additional decline of -0.49 [95% CI, -0.81 to -0.16] percentage points per year relative to nontarget conditions [P = .004]; for HF, -0.90 [95% CI, -1.18 to -0.62; P .001]; and for pneumonia, -0.57 [95% CI, -0.92 to -0.23; P .001]). In contrast, among nonpenalty hospitals, readmissions for target conditions declined similarly or more slowly compared with nontarget conditions (for AMI, additional increase of 0.48 [95% CI, 0.01-0.95] percentage points per year [P = .05]; for HF, 0.08 [95% CI, -0.30 to 0.46; P = .67]; for pneumonia, 0.53 [95% CI, 0.13-0.93; P = .01]). After HRRP implementation in October 2012, the rate of change for readmission rates plateaued (P .05 for all except pneumonia at nonpenalty hospitals), with the greatest relative change observed among hospitals subject to financial penalty.Medicare fee-for-service patients at hospitals subject to penalties under the HRRP had greater reductions in readmission rates compared with those at nonpenalized hospitals. Changes were greater for target vs nontarget conditions for patients at the penalized hospitals but not at the other hospitals.

Objectives To characterize the magnitude and duration of risk of rehospitalization according to age after hospitalization for heart failure (HF), acute myocardial infarction (AMI), or pneumonia. Design Retrospective cohort study. Setting U.S. hospitals (n = 4,767). Participants All Medicare fee-for-service beneficiaries aged 65 and older surviving hospitalization for HF, AMI, or pneumonia between October 2012 and December 2013. Measurements Daily risk of first rehospitalization for 1 year after hospital discharge was calculated according to age category (65–74, 75–84, ≥85) after adjustment for sex, race, comorbidities, and median ZIP code income. Time required for adjusted rehospitalization risk to decline 50% from maximum value after discharge, time required for adjusted risk to approach a plateau period of minimal day-to-day change, and degree to which adjusted risk was higher in recently hospitalized individuals than in the general elderly population were identified. Results There were 414,720 hospitalizations for HF, 177,752 for AMI, and 568,304 for pneumonia. The adjusted risk of rehospitalization declined with increasing age after HF hospitalization (P < .001), rose with increasing age after AMI hospitalization (P < .001), and was slightly lower with increasing age after pneumonia hospitalization (P = .002). Adjusted risks of rehospitalization were high beyond 30 days after hospitalization for all ages. Conclusion Although older age has heterogeneous relationships with rehospitalization risk, risk of readmission remains high for an extended time after discharge regardless of age or admitting condition. Condition-specific data on risk can be used to guide discussions on advanced care planning and strategies for longitudinal follow-up after hospitalization.

Background: Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI. Methods: We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction. Results: One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12−1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08−1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96−1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women. Conclusions: Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference.

Objectives To determine how often hospitalized older adults principally diagnosed with pneumonia, chronic obstructive pulmonary disease (COPD), or heart failure (HF) are concurrently treated for two or more of these acute cardiopulmonary conditions. Design Retrospective cohort study. Setting 368 U.S. hospitals in the Premier research database. Participants Individuals aged 65 and older principally hospitalized with pneumonia, COPD, or HF in 2009 or 2010. Measurements Proportion of diagnosed episodes of pneumonia, COPD, or HF concurrently treated for two or more of these acute cardiopulmonary conditions during the first 2 hospital days. Results Of 91,709 diagnosed pneumonia hospitalizations, 32% received treatment for two or more acute cardiopulmonary conditions (18% for HF, 18% for COPD, 4% for both). Of 41,052 diagnosed COPD hospitalizations, 19% received treatment for two or more acute cardiopulmonary conditions (all of which involved additional HF treatment). Of 118,061 diagnosed HF hospitalizations, 38% received treatment for two or more acute cardiopulmonary conditions (34% for pneumonia, 9% for COPD, 5% for both). Conclusion Hospitalized older adults diagnosed with pneumonia, COPD, or HF are frequently treated for two or more acute cardiopulmonary conditions, suggesting that clinical syndromes often fall between traditional diagnostic categories. Research is needed to evaluate the risks and benefits of real-world treatment for the many older adults whose presentations elicit diagnostic uncertainty or concern about coexisting acute conditions.

Background— The current ability to predict readmissions in patients with heart failure is modest at best. It is unclear whether machine learning techniques that address higher dimensional, nonlinear relationships among variables would enhance prediction. We sought to compare the effectiveness of several machine learning algorithms for predicting readmissions. Methods and Results— Using data from the Telemonitoring to Improve Heart Failure Outcomes trial, we compared the effectiveness of random forests, boosting, random forests combined hierarchically with support vector machines or logistic regression (LR), and Poisson regression against traditional LR to predict 30- and 180-day all-cause readmissions and readmissions because of heart failure. We randomly selected 50% of patients for a derivation set, and a validation set comprised the remaining patients, validated using 100 bootstrapped iterations. We compared C statistics for discrimination and distributions of observed outcomes in risk deciles for predictive range. In 30-day all-cause readmission prediction, the best performing machine learning model, random forests, provided a 17.8% improvement over LR (mean C statistics, 0.628 and 0.533, respectively). For readmissions because of heart failure, boosting improved the C statistic by 24.9% over LR (mean C statistic 0.678 and 0.543, respectively). For 30-day all-cause readmission, the observed readmission rates in the lowest and highest deciles of predicted risk with random forests (7.8% and 26.2%, respectively) showed a much wider separation than LR (14.2% and 16.4%, respectively). Conclusions— Machine learning methods improved the prediction of readmission after hospitalization for heart failure compared with LR and provided the greatest predictive range in observed readmission rates.

Background— Patients with an unused or malfunctioning implantable cardioverter–defibrillator (ICD) lead may have the lead either abandoned or explanted; yet there are limited data on the comparative acute and longer-term safety of these 2 approaches. Methods and Results— We examined in-hospital events among 24 908 subject encounters using propensity score 1:1 matching for ICD lead abandonment or explantation in the National Cardiovascular Data Registry (NCDR) ICD Registry (April 2010 to June 2014). Relative to patients undergoing lead abandonment, patients undergoing lead explantation had more in-hospital procedure-related complications: 2.19% (n=273) versus 3.77% (n=469; P P P =0.06). In the Medicare subset analyzed for postprocedure complications, there was no difference with respect to 6-month bleeding (4.80% in both the groups), tamponade (0.38% versus 0.58%), infection (1.34% versus 3.07%), upper extremity thrombosis (0.77% versus 0.96%), pulmonary embolism (0.38% versus 0.96%), or urgent surgery (1.15% for both the groups; P >0.05 for all). Conclusions— After matching, patients undergoing removal of an unused or malfunctioning ICD lead had slightly higher in-hospital complications and deaths than those with a lead abandonment strategy. Although the 1-year mortality risk was slightly higher in the lead explantation group, this difference was not statistically significant and may be explained by chance.

Background The risk of rehospitalization is elevated in the immediate post-discharge period and declines over time. It is not known if the extent and timing of risk vary across readmission diagnoses, suggesting that recovery and vulnerability after discharge differ by physiologic system. Objective We compared risk trajectories for major readmission diagnoses in the year after discharge among all Medicare fee-for-service beneficiaries hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia from 2008–2010. Methods We estimated the daily risk of rehospitalization for 12 major readmission diagnostic categories after accounting for the competing risk of death after discharge. For each diagnostic category, we identified (1) the time required for readmission risk to peak and then decline 50% from maximum values after discharge; (2) the time required for readmission risk to approach plateau periods of minimal day-to-day change; and (3) the extent to which hospitalization risks are higher among patients recently discharged from the hospital compared with the general elderly population. Results Among >3,000,000 hospitalizations, the yearly rate of rehospitalization was 67.0%, 49.5%, and 55.3% after hospitalization for HF, AMI, and pneumonia, respectively. The extent and timing of risk varied by readmission diagnosis and initial admitting condition. Risk of readmission for gastrointestinal bleeding/anemia peaked particularly late after hospital discharge, occurring 10, 6, and 7 days after hospitalization for HF, AMI, and pneumonia, respectively. Risk of readmission for trauma/injury declined particularly slowly, requiring 38, 20, and 38 days to decline by 50% after hospitalization for HF, AMI, and pneumonia, respectively. Conclusions Patterns of vulnerability to different conditions that cause rehospitalization vary by time after hospital discharge. This finding suggests that recovery of various physiologic systems occurs at different rates and that post-discharge interventions to minimize vulnerability to specific conditions should be tailored to their underlying risks.

Background During a myocardial infarction, no single best approach of systemic anticoagulation is recommended, likely due to a lack of comparative effectiveness studies and trade‐offs between treatments. Methods and Results We investigated the patterns of use and site‐level variability in anticoagulant strategies (unfractionated heparin [ UFH ] only, low‐molecular‐weight heparin [ LMWH ] only, UFH + LMWH , any bivalirudin) of 63 796 patients with a principal diagnosis of myocardial infarction treated with an early invasive strategy with percutaneous coronary intervention at 257 hospitals. About half (47%) of patients received UFH only, 6% UFH + LMWH , 7% LMWH only, and 40% bivalirudin. Compared with UFH , the median odds ratio was 2.90 for LMWH + UFH , 4.70 for LMWH only, and 3.09 for bivalirudin, indicating that 2 “identical” patients would have a 3‐ to 4‐fold greater likelihood of being treated with anticoagulants other than UFH at one hospital compared with another. We then categorized hospitals as low‐ or high‐users of LMWH and bivalirudin. Using hierarchical, multivariate regression models, we found that low bivalirudin‐using hospitals had higher unadjusted bleeding rates, but the risk‐adjusted and anticoagulant‐adjusted bleeding rates did not differ across the hospital anticoagulation phenotypes. Risk‐standardized mortality and risk‐standardized length of stay also did not differ across hospital phenotypes. Conclusions We found substantial site‐level variability in the choice of anticoagulants for invasively managed acute myocardial infarction patients, even after accounting for patient factors. No single hospital‐use pattern was found to be clinically superior. More studies are needed to determine which patients would derive the greatest benefit from various anticoagulants and to support consistent treatment of patients with the optimal anticoagulant strategy.

Objective To characterize the absolute risks for older patients of readmission to hospital and death in the year after hospitalization for heart failure, acute myocardial infarction, or pneumonia. Design Retrospective cohort study. Setting 4767 hospitals caring for Medicare fee for service beneficiaries in the United States, 2008-10. Participants More than 3 million Medicare fee for service beneficiaries, aged 65 years or more, surviving hospitalization for heart failure, acute myocardial infarction, or pneumonia. Main outcome measures Daily absolute risks of first readmission to hospital and death for one year after discharge. To illustrate risk trajectories, we identified the time required for risks of readmission to hospital and death to decline 50% from maximum values after discharge; the time required for risks to approach plateau periods of minimal day to day change, defined as 95% reductions in daily changes in risk from maximum daily declines after discharge; and the extent to which risks are higher among patients recently discharged from hospital compared with the general elderly population. Results Within one year of hospital discharge, readmission to hospital and death, respectively, occurred following 67.4% and 35.8% of hospitalizations for heart failure, 49.9% and 25.1% for acute myocardial infarction, and 55.6% and 31.1% for pneumonia. Risk of first readmission had declined 50% by day 38 after hospitalization for heart failure, day 13 after hospitalization for acute myocardial infarction, and day 25 after hospitalization for pneumonia; risk of death declined 50% by day 11, 6, and 10, respectively. Daily change in risk of first readmission to hospital declined 95% by day 45, 38, and 45; daily change in risk of death declined 95% by day 21, 19, and 21. After hospitalization for heart failure, acute myocardial infarction, or pneumonia, the magnitude of the relative risk for hospital admission over the first 90 days was 8, 6, and 6 times greater than that of the general older population; the relative risk of death was 11, 8, and 10 times greater. Conclusions Risk declines slowly for older patients after hospitalization for heart failure, acute myocardial infarction, or pneumonia and is increased for months. Specific risk trajectories vary by discharge diagnosis and outcome. Patients should remain vigilant for deterioration in health for an extended time after discharge. Health providers can use knowledge of absolute risks and their changes over time to better align interventions designed to reduce adverse outcomes after discharge with the highest risk periods for patients.

Importance The Affordable Care Act has led to US national reductions in hospital 30-day readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Whether readmission reductions have had the unintended consequence of increasing mortality after hospitalization is unknown. Objective To examine the correlation of paired trends in hospital 30-day readmission rates and hospital 30-day mortality rates after discharge. Design, Setting, and Participants Retrospective study of Medicare fee-for-service beneficiaries aged 65 years or older hospitalized with HF, AMI, or pneumonia from January 1, 2008, through December 31, 2014. Exposure Thirty-day risk-adjusted readmission rate (RARR). Main Outcomes and Measures Thirty-day RARRs and 30-day risk-adjusted mortality rates (RAMRs) after discharge were calculated for each condition in each month at each hospital in 2008 through 2014. Monthly trends in each hospital’s 30-day RARRs and 30-day RAMRs after discharge were examined for each condition. The weighted Pearson correlation coefficient was calculated for hospitals’ paired monthly trends in 30-day RARRs and 30-day RAMRs after discharge for each condition. Results In 2008 through 2014, 2 962 554 hospitalizations for HF, 1 229 939 for AMI, and 2 544 530 for pneumonia were identified at 5016, 4772, and 5057 hospitals, respectively. In January 2008, mean hospital 30-day RARRs and 30-day RAMRs after discharge were 24.6% and 8.4% for HF, 19.3% and 7.6% for AMI, and 18.3% and 8.5% for pneumonia. Hospital 30-day RARRs declined in the aggregate across hospitals from 2008 through 2014; monthly changes in RARRs were −0.053% (95% CI, −0.055% to −0.051%) for HF, −0.044% (95% CI, −0.047% to −0.041%) for AMI, and −0.033% (95% CI, −0.035% to −0.031%) for pneumonia. In contrast, monthly aggregate changes across hospitals in hospital 30-day RAMRs after discharge varied by condition: HF, 0.008% (95% CI, 0.007% to 0.010%); AMI, −0.003% (95% CI, −0.005% to −0.001%); and pneumonia, 0.001% (95% CI, −0.001% to 0.003%). However, correlation coefficients in hospitals’ paired monthly changes in 30-day RARRs and 30-day RAMRs after discharge were weakly positive: HF, 0.066 (95% CI, 0.036 to 0.096); AMI, 0.067 (95% CI, 0.027 to 0.106); and pneumonia, 0.108 (95% CI, 0.079 to 0.137). Findings were similar in secondary analyses, including with alternate definitions of hospital mortality. Conclusions and Relevance Among Medicare fee-for-service beneficiaries hospitalized for heart failure, acute myocardial infarction, or pneumonia, reductions in hospital 30-day readmission rates were weakly but significantly correlated with reductions in hospital 30-day mortality rates after discharge. These findings do not support increasing postdischarge mortality related to reducing hospital readmissions.

Background There are few data characterizing temporal changes in hospitalization for recurrent acute myocardial infarction ( AMI ) after AMI . Methods and Results Using a national sample of 2 305 441 Medicare beneficiaries hospitalized for AMI from 1999 to 2010, we evaluated changes in the incidence of 1‐year recurrent AMI hospitalization and mortality using Cox proportional hazards models. The observed recurrent AMI hospitalization rate declined from 12.1% (95% CI 11.9 to 12.2) in 1999 to 8.9% (95% CI 8.8 to 9.1) in 2010, a relative decline of 26.4%. The observed recurrent AMI hospitalization rate declined by a relative 27.7% in whites, from 11.9% (95% CI 11.8 to 12.1) to 8.6% (95% CI 8.5 to 8.8) versus a relative decline in blacks of 13.6% from 13.2% (95% CI 12.6 to 13.8) to 11.4% (95% CI 10.9 to 12.0). The risk‐adjusted rate of annual decline in recurrent AMI hospitalizations was 4.1% ( HR 0.959; 95% CI 0.958 to 0.961), and whites experienced a higher rate of decline ( HR 0.957, 95% CI 0.956 to 0.959) than blacks ( HR 0.974, 95% CI 0.970 to 0.979).The overall, observed 1‐year mortality rate after hospitalization for recurrent AMI declined from 32.4% in 1999 to 29.7% in 2010, a relative decline of 8.3% ( P AMI hospitalization declined 1.8% per year ( HR , 0.982; 95% CI 0.980 to 0.985). Conclusions In a national sample of Medicare beneficiaries hospitalized for AMI from 1999 to 2010, hospitalization for recurrent AMI decreased, as did subsequent mortality, albeit to a lesser extent. The risk of recurrent AMI hospitalization declined less in black patients than in whites, increasing observed racial disparities by the end of the study period.

Isuru Ranasinghe and colleagues compare readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia in adults aged 18 to 64 years with readmissions in those aged 65 and older. Please see later in the article for the Editors' Summary, Background Patients aged ≥65 years are vulnerable to readmissions due to a transient period of generalized risk after hospitalization. However, whether young and middle-aged adults share a similar risk pattern is uncertain. We compared the rate, timing, and readmission diagnoses following hospitalization for heart failure (HF), acute myocardial infarction (AMI), and pneumonia among patients aged 18–64 years with patients aged ≥65 years. Methods and Findings We used an all-payer administrative dataset from California consisting of all hospitalizations for HF (n = 206,141), AMI (n = 107,256), and pneumonia (n = 199,620) from 2007–2009. The primary outcomes were unplanned 30-day readmission rate, timing of readmission, and readmission diagnoses. Our findings show that the readmission rate among patients aged 18–64 years exceeded the readmission rate in patients aged ≥65 years in the HF cohort (23.4% vs. 22.0%, p, Editors' Summary Background Many elderly people who are admitted to hospital, successfully treated, and discharged are readmitted soon after, often for an unrelated illness. In the US, for example, nearly a fifth of Medicare beneficiaries are readmitted to hospital within 30 days of discharge (Medicare is a national insurance program that primarily pays for health care services for Americans aged 65 and older). Experts have recently coined the term “post-hospital syndrome” for the transient period of increased susceptibility to a range of adverse health events that elderly patients seem to experience and have suggested that exposure to stress during hospital stays may underlie the syndrome. For example, hospital patients frequently have their sleep disrupted because of hospital routines, they are often in pain, they may have insufficient food intake (sometimes because they are waiting for an operation), and they may lose physical conditioning because they are confined to bed. These and other stressors can reduce individuals' natural reserves and increase their vulnerability to a range of illnesses and conditions. Why Was This Study Done? Although stress is one possible determinant of the post-hospital syndrome, the underlying causes and patterns of hospital readmission are generally poorly understood. In particular, it is not known whether the post-hospital syndrome affects young and middle-aged patients as well as elderly patients. Importantly, a better understanding of the post-hospital syndrome is needed before effective strategies to reduce hospital readmissions can be developed. In this retrospective observational cohort study, the researchers compare readmission rates, timing, and diagnoses after hospitalization for heart failure (HF), acute myocardial infarction (AMI; heart attack), and pneumonia among patients aged 18–64 years living in California with readmission rates, timing, and diagnoses among patients aged 65 years or older hospitalized for the same conditions. A retrospective observational cohort study analyzes data that has been already been collected for a group (cohort) of people. Readmission is common among people of all ages who are admitted to hospital for HF, AMI, and pneumonia, and readmissions after hospitalization for these conditions among elderly Medicare patients are used in the US as a measure of hospital quality; hospitals with high readmission rates are subject to a Medicare reimbursement penalty. What Did the Researchers Do and Find? The researchers used the Healthcare Cost and Utilization Project inpatient dataset for California to identify all the hospitalizations for HF, AMI, and pneumonia in California in 2007–2009 and to obtain data on the 30-day unplanned rehospitalization rate, timing of readmission, and readmission diagnoses for the identified patients (more than half a million patients). Nearly 30% of all hospital readmissions after hospitalization for HF, AMI, and pneumonia in California occurred among patients aged 18–64. After hospitalization for AMI, pneumonia, and HF, 11.2%, 14.4%, and 23.4%, respectively, of young and middle-aged patients were readmitted. Notably, the 30-day readmission rate among patients aged 18–64 admitted for HF exceeded the readmission rate among elderly patients admitted for the same condition. After allowing for other factors likely to affect the risk of readmission such as other illnesses, the 30-day readmission risk in patients aged 18–64 was similar to that in patients aged 65 years or older admitted for HF and pneumonia and only marginally lower among patients admitted for AMI. Finally, the timing of readmission was similar in both age groups and diagnoses other than the index admission diagnosis accounted for a substantial proportion of readmissions in both age groups. What Do These Findings Mean? This study shows that after adjusting for differences in patient characteristics, the 30-day hospital readmission rates among young and middle-aged patients after hospitalization for HF, AMI, and pneumonia were similar to those among elderly patients. Moreover, the timing of readmission and the reasons for readmission among young and middle-aged patients were similar to those among elderly patients. These findings may not apply to other US states or to other countries and may not reflect the pattern of hospital readmissions following conditions other than HF, AMI, and pneumonia. Nevertheless, these findings suggest that the post-hospital syndrome affects young and middle-aged as well as elderly patients. Hospital readmission should therefore be considered as a potential problem for people of all ages and broad-based, multidisciplinary strategies that target patients of all ages should be developed to mitigate the risk of hospital readmissions. Additional Information Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001737. The Institute for Healthcare Improvement provides information about reducing avoidable hospital readmissions Information about the US Centers for Medicare & Medicaid Services readmissions reduction program is available An article written by one of the study authors about the post-hospital syndrome is available

The use of coronary catheterization and percutaneous coronary intervention (PCI) is increasing in China, but, to date, there are no nationally representative assessments of the quality of care and outcomes in patients undergoing these procedures.To assess the quality of care and outcomes of patients undergoing coronary catheterization and PCI in China.In a clinical observational study (China PEACE [Patient-Centered Evaluative Assessment of Cardiac Events]-Retrospective CathPCI Study), we used a 2-stage, random sampling strategy to create a nationally representative sample of 11 241 patients undergoing coronary catheterization and PCI at 55 urban Chinese hospitals in calendar years 2001, 2006, and 2011. Data analysis was performed from July 11, 2014, to November 20, 2015.Patient characteristics, treatment patterns, quality of care, and outcomes associated with these procedures and changes over time.Of the 11 241 patients included in the study, the samples included, for 2001, 285 women (weighted percentage, 28.6%); for 2006, 826 women (weighted percentage, 32.2%), and for 2011, 2588 women (weighted percentage, 35.7%). Mean (SD) ages were 58 (8), 60 (11), and 61 (11) years, respectively. Between 2001 and 2011, estimated national rates of hospitalizations for coronary catheterization increased from 26 570 to 452 784 and for PCI, from 9678 to 208 954 (17-fold and 21-fold), respectively. More than half of stable patients undergoing coronary catheterization had nonobstructive coronary artery disease; this amount did not change significantly over time (2001: 60.3% [95% CI, 56.1%-64.5%]; 2011: 57.5% [95% CI, 55.8%-59.3%], P = .05 for trend). The proportion of PCI procedures performed via radial approach increased from 3.5% (95% CI, 1.7%-5.3%) in 2001 to 79.0% (95% CI, 77.7%-80.3%) in 2011 (P . 001 for trend). The use of drug-eluting stents (DESs) increased from 18.0% (95% CI, 14.2%-21.7%) in 2001 to 97.3% (95% CI, 96.9%-97.7%) in 2011 (P .001 for trend) largely owing to increased use of domestic DESs. The median length of stay decreased from 14 days (interquartile range [IQR], 9-20) in 2001 to 10 days (IQR, 7-14) in 2011 (P .001 for trend). In-hospital mortality did not change significantly, but both adjusted risk of any bleeding (odds ratio [OR], 0.53 [95% CI, 0.36-0.79], P .001 for trend) and access bleeding (OR, 0.23 [95% CI, 0.12-0.43], P .001) were decreased between 2001 and 2011. The medical records lacked documentation needed to calculate commonly used process metrics including door to balloon times for primary PCI and the prescription of evidence-based medications at discharge.Although the use of catheterization and PCI in China has increased dramatically, we identified critical quality and documentation gaps that represent opportunities to improve care. Our findings can serve as a foundation to guide future quality improvement initiatives in China.

The immediate period after hospital discharge is dangerous. Patients’ health, often marginal at best, frequently deteriorates, sending them to the emergency department,1 back to the hospital in-patient service,2 or into a period of functional decline.3,4 Among older patients hospitalized with heart failure, for example, death is even more common in the month following discharge than during the initial hospital stay.5,6 Vulnerabilities in this period are many, and patients are susceptible to deterioration in health from a broad spectrum of conditions, not just the initial illness that triggered hospitalization.7 This period has been labeled post-hospital syndrome, as it appears that patients have an acquired, transient period of generalized risk to a wide range of medical problems.8 As recognition of these risks has increased, the goal of improved short-term outcomes after hospitalization has become a focus for providers, payers, and policymakers.9 In this issue of the Journal, McAlister and colleagues ask whether short-term vulnerability after hospitalization is related to weekend versus weekday discharge. After examining almost 8,000 patients discharged from the general medical wards of 7 teaching hospitals in Alberta, Canada, the authors found that only 1 in 7 were discharged on weekends, defined as Saturday or Sunday. Patients discharged on the weekend were younger, had fewer chronic health conditions, and shorter average lengths of stay. In analyses adjusted for patient demographics and a measure of short-term risk after hospitalization (LACE score), weekend discharge was not associated with higher rates of unplanned readmission or death at 30 days. Most strikingly, only the healthiest patients were discharged on weekends. These results are similar to findings from the authors’ previous work on patients hospitalized with heart failure.10 Yet the implications for discharge planning are much less clear, as the few analyses of discharge day from the authors10 and others11 do not account for the range of factors that may influence risk after hospitalization such as patients’ clinical characteristics, the quality of both hospital and transitional care, and the post-hospital environments to which patients are discharged. Not surprisingly, different methodologic approaches have shown weekend discharge to be associated with a range of outcomes including lower,11 identical,12 and higher10 rates of unplanned readmission and death. Moreover, the influence of discharge timing itself is likely to involve further complexities including patients’ readiness for discharge,13 the specific days of the week on which both admission and discharge occur,14 and the outpatient resources made available to patients by specific health insurance carriers.14 These studies illustrate a fundamental issue with our efforts to reduce short-term readmission, namely, that we do not understand which factors most influence risk.15 Prediction models have generally focused on traditional markers of risk including patients’ demographic characteristics, their physical examination findings, and laboratory test results. While models based on these variables are often excellent at discriminating between patients who are likely to die soon after hospitalization, their ability to identify specific patients who will be rehospitalized has been mediocre.16,17 This difficulty with prediction suggests that readmission has far more complex determinants than death in the short-term period after hospitalization. Unfortunately, we have yet to identify and model the factors that matter most. Where should we look to find these additional sources of vulnerability after hospitalization? Previous research has made clear that we are unlikely to find single markers of risk that adequately predict the future. Rather, we will need to develop more complete understandings of patients including their dynamics of recovery, the role of the hospital environment in prolonging or instigating further vulnerability, the manners by which organizational context and implementation strategies impact transitional care, and the ways in which social and environmental factors hasten or retard recovery. For each of these categories, there are multiple specific questions to address. The following are illustrative examples