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Background Community-acquired pneumonia (CAP) is a leading cause of hospital admissions and antimicrobial use. Clinical practice guidelines recommend switching from intravenous (IV) to oral antibiotics once patients are clinically stable. Methods We conducted a retrospective cohort study of adults admitted with CAP and initially treated with IV antibiotics at 642 US hospitals from 2010 through 2015. Switching was defined as discontinuation of IV and initiation of oral antibiotics without interrupting therapy. Patients switched by hospital day 3 were considered early switchers. We compared length of stay (LOS), in-hospital 14-day mortality, late deterioration (intensive care unit [ICU] transfer), and hospital costs between early switchers and others, controlling for hospital characteristics, patient demographics, comorbidities, initial treatments, and predicted mortality. Results Of 378 041 CAP patients, 21 784 (6%) were switched early, most frequently to fluoroquinolones. Patients switched early had fewer days on IV antibiotics, shorter duration of inpatient antibiotic treatment, shorter LOS, and lower hospitalization costs, but no significant excesses in 14-day in-hospital mortality or late ICU admission. Patients at a higher mortality risk were less likely to be switched. However, even in hospitals with relatively high switch rates, <15% of very low–risk patients were switched early. Conclusions Although early switching was not associated with worse outcomes and was associated with shorter LOS and fewer days on antibiotics, it occurred infrequently. Even in hospitals with high switch rates, <15% of very low–risk patients were switched early. Our findings suggest that many more patients could be switched early without compromising outcomes. [ABSTRACT FROM AUTHOR]

Background Previous infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) provides strong protection against future infection. There is limited evidence on whether such protection extends to the Omicron variant. Methods This retrospective cohort study included 635 341 patients tested for SARS-CoV-2 via polymerase chain reaction from 9 March 2020 to 1 March 2022. Patients were analyzed according to the wave in which they were initially infected. The primary outcome was reinfection during the Omicron period (20 December 2021–1 March 2022). We used a multivariable model to assess the effects of prior infection and vaccination on hospitalization. Results Among the patients tested during the Omicron wave, 30.6% tested positive. Protection of prior infection against reinfection with Omicron ranged from 18.0% (95% confidence interval [CI], 13.0–22.7) for patients infected in wave 1 to 69.2% (95% CI, 63.4–74.1) for those infected in the Delta wave. In adjusted models, previous infection reduced hospitalization by 28.5% (95% CI, 19.1–36.7), whereas full vaccination plus a booster reduced it by 59.2% (95% CI, 54.8–63.1). Conclusions Previous infection offered less protection against Omicron than was observed in past waves. Immunity against future waves will likely depend on the degree of similarity between variants. [ABSTRACT FROM AUTHOR]

Background: Influenza is a leading cause of community-acquired pneumonia (CAP), and results of influenza tests can direct therapy. However, among adults hospitalized with CAP, little is known about the frequency and timing of influenza testing, treatment, and their associations with outcomes.Research Question: In patients with CAP, is testing for influenza associated with antiviral treatment and shorter antibiotic courses, and is early treatment associated with better clinical outcomes?Study Design and Methods: This study included adults admitted with pneumonia in 2010 to 2015 to 179 US hospitals contributing to the Premier database. We assessed influenza testing and compared antimicrobial utilization and the outcomes of test-positive, test-negative, and untested patients. Associations of early antiviral treatment (oseltamivir) with 14-day in-hospital mortality, hospital length of stay, and cost were studied.Results: Among 166,268 patients with CAP, 38,703 (23.3%) were tested for influenza, of whom 11.5% tested positive. Testing increased from 15.4% to 35.6% from 2010 to 2015 and was 28.9% during flu season (October-May) vs 8.2% in June to September. Patients testing positive for influenza received antiviral agents more often and antibacterial agents less often and for shorter courses than patients testing negative (5.3 vs 6.4 days; P < .001). Influenza-positive patients receiving oseltamivir on hospital day 1 (n = 2,585) experienced lower 14-day in-hospital mortality (adjusted OR, 0.75; 95% CI, 0.59-0.96), lower costs (adjusted ratio of means, 0.88; 95% CI, 0.81-0.95), and shorter length of stay (adjusted ratio of means, 0.88; 95% CI, 0.84-0.93) vs patients receiving oseltamivir later or not at all (n = 1,742).Interpretation: Even during flu season, most patients with CAP in this study went untested for influenza. A positive influenza test result was associated with antiviral treatment, and early treatment was associated with lower mortality, suggesting that more widespread testing might improve patient outcomes. [ABSTRACT FROM AUTHOR]

This study describes oral temperatures in a large sample of nonsurgical inpatients without infections to inform evaluation of fever in the hospital. [ABSTRACT FROM AUTHOR]

BACKGROUND: The pneumonia 30-d readmission rate has been endorsed by the National Quality Forum as a quality metric. Hospital readmissions can potentially be lowered by improving inhospital care, transitions of care, and post-discharge disease management programs. The purpose of this study was to create an accurate prediction model for determining the risk of 30-d readmission at the point of discharge. METHODS: The model was created using a data set of 1,295 hospitalizations at the Cleveland Clinic Main Campus with pneumonia over 3 y. Candidate variables were limited to structured variables available in the electronic health record. The final model was compared with the Centers for Medicare and Medicaid Services (CMS) model among subjects 65 y of age and older (n = 628) and was externally validated. RESULTS: Three hundred thirty subjects (25%) were readmitted within 30 d. The final model contained 13 variables and had a bias-corrected C statistic of 0.74 (95% CI 0.71- 0.77). Number of admissions in the prior 6 months, opioid prescription, serum albumin during the first 24 h, international normalized ratio and blood urea nitrogen during the last 24 h were the predictor variables with the greatest weight in the model. In terms of discriminative performance, the Cleveland Clinic model outperformed the CMS model on the validation cohort (C statistic 0.69 vs 0.60, P = .042). CONCLUSIONS: The proposed risk prediction model performed better than the CMS model. Accurate readmission risk prediction at the point of discharge is feasible and can potentially be used to focus post-acute care interventions in a high-risk group of patients. [ABSTRACT FROM AUTHOR]

Background/Objectives Off-label use of antipsychotics is common in hospitals, most often for delirium management. Antipsychotics have been associated with aspiration pneumonia in community and nursing home settings, but the association in hospitalized individuals is unexplored. We aimed to investigate the association between antipsychotic exposure and aspiration pneumonia during hospitalization. Design Retrospective cohort study. Setting Large academic medical center. Participants All adult hospitalizations between January 2007 and July 2013. We excluded outside hospital transfers, hospitalizations shorter than 48 hours, and psychiatric hospitalizations. Measurements Antipsychotic use defined as any pharmacy charge for an antipsychotic medication. Aspiration pneumonia was defined according to a discharge diagnosis code for aspiration pneumonia not present on admission and validated using chart review. A generalized estimating equation was used to control for 43 potential confounders. Results Our cohort included 146,552 hospitalizations (median age 56; 39% male). Antipsychotics were used in 10,377 (7.1%) hospitalizations (80% atypical, 35% typical, 15% both). Aspiration pneumonia occurred in 557 (0.4%) hospitalizations. The incidence of aspiration pneumonia was 0.3% in unexposed individuals and 1.2% in those with antipsychotic exposure (odds ratio ( OR) = 3.9, 95% confidence interval ( CI) = 3.2-4.8). After adjustment, antipsychotic exposure was significantly associated with aspiration pneumonia (adjusted OR = ( aOR) = 1.5, 95% CI = 1.2-1.9). Similar results were demonstrated in a propensity-matched analysis and in an analysis restricted to those with delirium or dementia. The magnitude of the association was similar for typical ( aOR = 1.4, 95% CI = 0.94-2.2) and atypical ( aOR = 1.5, 95% CI = 1.1-2.0) antipsychotics. Conclusion Antipsychotics were associated with greater odds of aspiration pneumonia after extensive adjustment for participant characteristics. This risk should be considered when prescribing antipsychotics in the hospital. [ABSTRACT FROM AUTHOR]

Rationale: Randomized trials suggest that assessment of serum procalcitonin (PCT) levels can be used to safely limit antibiotic use among patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD).Objectives: To determine the impact of PCT testing on antibiotic treatment of patients hospitalized for exacerbations of COPD in routine practice.Methods: We conducted a series of cross-sectional and longitudinal multivariable analyses using data from 2009 to 2011 and 2013 to 2014 from a sample of 505 U.S. hospitals.Results: Of 203,177 patients hospitalized for COPD exacerbation in 2013 to 2014, nearly 9 out of 10 were treated with antibiotics. Hospital PCT testing rates ranged from 0 to 83%. In cross-sectional analysis, there was a weak negative association between the rate of PCT testing and risk-adjusted rates of antibiotic initiation (Spearman correlation, -0.12; P = 0.005); each 10-point increase in the percentage of patients undergoing PCT testing was associated with a 0.7% decline in risk-adjusted antibiotic use (P = 0.001). There was no association between hospital rates of PCT testing and duration of antibiotic treatment. In a longitudinal analysis, comparing treatment patterns in 2009 to 2011 and 2013 to 2014, we did not observe a significant difference in the change in antibiotic treatment rates or duration of therapy between hospitals that had adopted PCT testing compared with those that had not.Conclusions: As currently implemented, PCT testing appears to have had little impact on decisions to initiate antibiotic therapy or on duration of treatment for COPD exacerbations. Implementation research is necessary to translate the promising outcomes from PCT testing observed in randomized trials into clinical practice. [ABSTRACT FROM AUTHOR]

Background: Understanding resource utilization patterns among high-cost patients may inform cost reduction strategies.Objective: To identify patterns of high-cost healthcare utilization and associated clinical diagnoses and to quantify the significance of hot-spotters among high-cost users.Design: Retrospective analysis of high-cost patients in 2012 using data from electronic medical records, internal cost accounting, and the Centers for Medicare and Medicaid Services. K-medoids cluster analysis was performed on utilization measures of the highest-cost decile of patients. Clusters were compared using clinical diagnoses. We defined "hot-spotters" as those in the highest-cost decile with ≥4 hospitalizations or ED visits during the study period.Participants and Exposure: A total of 14,855 Medicare Fee-for-service beneficiaries identified by the Medicare Quality Resource and Use Report as having received 100 % of inpatient care and ≥90 % of primary care services at Cleveland Clinic Health System (CCHS) in Northeast Ohio. The highest-cost decile was selected from this population.Main Measures: Healthcare utilization and diagnoses.Key Results: The highest-cost decile of patients (n = 1486) accounted for 60 % of total costs. We identified five patient clusters: "Ambulatory," with 0 admissions; "Surgical," with a median of 2 surgeries; "Critically Ill," with a median of 4 ICU days; "Frequent Care," with a median of 2 admissions, 3 ED visits, and 29 outpatient visits; and "Mixed Utilization," with 1 median admission and 1 ED visit. Cancer diagnoses were prevalent in the Ambulatory group, care complications in the Surgical group, cardiac diseases in the Critically Ill group, and psychiatric disorders in the Frequent Care group. Most hot-spotters (55 %) were in the "frequent care" cluster. Overall, hot-spotters represented 9 % of the high-cost population and accounted for 19 % of their overall costs.Conclusions: High-cost patients are heterogeneous; most are not so-called "hot-spotters" with frequent admissions. Effective interventions to reduce costs will require a more multi-faceted approach to the high-cost population. [ABSTRACT FROM AUTHOR]

The article presents comments on de-escalation of empiric antibiotics following negative cultures in hospitalized patients with pneumonia. Topics include empiric therapy for community-acquired pneumonia should include broad-spectrum coverage only when there are associated risk factors; and patients with risk factors for multidrug-resistant pneumonia received antimicrobial therapy that was guideline concordant.

Background: Rates of preventable admissions will soon be publicly reported and used in calculating performance-based payments. The current method of assessing preventable admissions, the Agency of Healthcare Research and Quality (AHRQ) Preventable Quality Indicators (PQI) rate, is drawn from claims data and was originally designed to assess population-level access to care.Objective: To identify the prevalence and causes of preventable admissions by attending physician review and to compare its performance with the PQI tool in identifying preventable admissions.Design: Cross-sectional survey.Setting: General medicine service at an academic medical center.Participants: Consecutive inpatient admissions from December 1-15, 2013.Main Measures: Survey of inpatient attending physicians regarding the preventability of the admissions, primary contributing factors and feasibility of prevention. For the same patients, the PQI tool was applied to determine the claims-derived preventable admission rate.Key Results: Physicians rated all 322 admissions and classified 122 (38 %) as preventable, of which 31 (25 %) were readmissions. Readmissions were more likely to be rated preventable than other admissions (49 % vs. 35 %, p = 0.04). Application of the AHRQ PQI methodology identified 75 (23 %) preventable admissions. Thirty-one admissions (10 %) were classified as preventable by both methods, and the majority of admissions considered preventable by the AHRQ PQI method (44/78) were not considered preventable by physician assessment (K = 0.04). Of the preventable admissions, physicians assigned patient factors in 54 (44 %), clinician factors in 36 (30 %) and system factors in 32 (26 %).Conclusions: A large proportion of admissions to a general medicine service appeared preventable, but AHRQ's PQI tool was unable to identify these admissions. Before initiation of the PQI rate for use in pay-for-performance programs, further study is warranted. [ABSTRACT FROM AUTHOR]

Objectives To investigate patterns and predictors of use of antipsychotics in hospitalized adults. Design Retrospective cohort study. Setting Academic medical center. Participants Individuals aged 18 and older hospitalized from August 2012 to August 2013, excluding those admitted to obstetrics and gynecology or psychiatry or with a psychotic disorder. Measurements Use was ascertained from pharmacy charges. Potentially excessive dosing was defined using guidelines for long-term care facilities. A review of 100 records was performed to determine reasons for use. Results The cohort included 17,775 admissions with a median age 64; individuals could have been admitted more than once during the study period. Antipsychotics were used in 9%, 55% of which were initiations. The most common reasons for initiation were delirium (53%) and probable delirium (12%). Potentially excessive dosing occurred in 16% of admissions exposed to an antipsychotic. Of admissions with antipsychotic initiation, 26% were discharged on these medications. Characteristics associated with initiation included age 75 and older (relative risk ( RR) = 1.4, 95% confidence interval ( CI) = 1.2-1.7), male sex ( RR = 1.2, 95% CI = 1.1-1.4), black race ( RR = 0.8, 95% CI = 0.6-0.96), delirium ( RR = 4.8, 95% CI = 4.2-5.7), dementia ( RR = 2.1, 95% CI = 1.7-2.6), admission to a medical service ( RR = 1.2, 95% CI = 1.1-1.4), intensive care unit stay ( RR = 2.1, 95% CI = 1.8-2.4), and mechanical ventilation ( RR = 2.0, 95% CI = 1.7-2.4). In individuals who were initiated on an antipsychotic, characteristics associated with discharge on antipsychotics were age 75 and older ( RR = 0.6, 95% CI = 0.4-0.7), discharge to any location other than home ( RR = 2.5, 95% CI = 1.8-3.3), and class of in-hospital antipsychotic exposure ( RR = 1.6, 95% CI = 1.1-2.3 for atypical vs typical; RR = 2.7, 95% CI = 1.9-3.8 for both vs typical). Conclusion Antipsychotic initiation and use were common during hospitalization, most often for delirium, and individuals were frequently discharged on these medications. Several predictors of use on discharge were identified, suggesting potential targets for decision support tools that would be used to prompt consideration of ongoing necessity. [ABSTRACT FROM AUTHOR]

Objectives To determine how well healthcare proxies ( HCPs) understand do-not-hospitalize ( DNH) orders and why they may or may not initiate them. Design Semistructured qualitative interviews. Setting Two nursing homes in western Massachusetts. Participants HCPs of nursing home residents with advanced dementia. Measurement In-depth interviews were audiotaped and transcribed verbatim. Data were qualitatively analyzed in an iterative process, and emergent concepts were conceptually ordered into explanatory categories. Pertinent demographic and clinical information was collected from the Minimum Data Set ( MDS) and patient charts. Results Sixteen of 31 eligible HCPs were interviewed. Major findings included barriers to and facilitators of initiating DNH orders. Barriers included a perceived lack of physician involvement in decision-making and limited understanding of DNH orders and the resident's prognosis. Facilitators included a HCPs' personal experience in health care, understanding the prognosis of advanced dementia, and a desire to limit resident distress. Conclusion The potential barriers to and facilitators of HCPs initiating DNH orders identified in this study suggest that HCPs may benefit from more in-depth discussions with healthcare providers when making this decision. Interventions to address these barriers may improve the capacity of HCPs to make informed decisions about DNH orders that reflect individuals' values and wishes. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The aim of this study was to examine treatments of septic shock in a sample of US hospitals and to assess whether patient and hospital characteristics are associated with use of sepsis therapies. Materials and Methods: We studied 192 hospitals that treated 50 or more adults with septic shock between 2004 and 2006. We examined hospital-level variation in commonly used therapies including mechanical ventilation, activated protein C (APC), hydrocortisone, central venous pressure (CVP) monitoring, albumin/colloid, and pulmonary artery catheters. We calculated interquartile range to assess the hospital-level variation in treatment. We developed hierarchical mixed-effects logistic regression models to examine the association between patient and hospital characteristics and selected treatments. Results: A total of 22 702 patients met the inclusion criteria. When compared with patients younger than 45 years, patients 75 years or older were as likely to receive mechanical ventilation but less likely to receive APC (odds ratio [OR], 0.35 [95% confidence interval, 0.27-0.45]), hydrocortisone (OR, 0.65 [0.56-0.75]), or CVP monitoring (OR, 0.73 [0.63-0.84]). Compared with whites, black patients were more likely to be mechanically ventilated (OR, 1.15 [1.05-1.25]) but less likely to receive hydrocortisone (OR, 0.86 [0.78-0.95]) or APC (0.70 [0.58-0.86]). Conclusion: Treatment of septic shock varies across hospitals. In contrast to mechanical ventilation, treatments with weaker supporting evidence showed greater variation, especially among black and older patients. [Copyright &y& Elsevier]

The article provides information on a study which examined changes in the incidence, number of hospitalization, outcomes and costs of hospitalization for severe and nonsevere sepsis in the U.S. from 2003 to 2007. The study focused on the changes in occurrence of specific organ dysfunctions, the impact of changes in coding and documentation and changes in costs of care over time. The weighted frequency of patients hospitalized with severe sepsis was determined.

The article offers information on a pharmacoepidemiological cohort study which compared the outcomes of patients with chronic obstructive pulmonary disease (COPD) who were treated with low doses of steroids administered orally from those who were treated with higher doses administered intravenously. Main outcome measures included length of stay, hospital costs and a composite measure of treatment failure, which is defined as the initiation of mechanical ventilation following the second day of hospital stay, inpatient mortality or readmission for acute exacerbation of COPD within a month of discharge. A discussion on the research findings is offered.

Background: Chemoprophylaxis is recommended for medical patients at moderate to high risk of venous thromboembolism (VTE) and is now a requirement of the Joint Commission on Accreditation of Healthcare Organizations. To see who receives prophylaxis and how far hospitals will need to go to meet this requirement, we examined VTE prophylaxis patterns at US hospitals.Methods: We conducted a retrospective cohort study of adult patients with seven medical diagnoses considered to carry moderate to high risk of VTE at 376 acute care facilities in 2004-2005. We excluded patients on warfarin or with hospital stays of <2 days. VTE prophylaxis was assessed by billing codes for any heparin or compression device. We classified patient risk using a VTE risk prediction model.Results: Of 351,535 patients included, 36% received prophylaxis by hospital day 2. Prophylaxis rates were highest among patients with certain VTE risk factors, including mechanical ventilation (67%), restraints (57%), central lines (55%), obesity (46%), and prior VTE (44%). The median hospital rate was 31% (IQR 19% to 42%); only 3% of hospitals had rates >70%. Compared to patients at low risk of VTE (<0.05%), patients at high risk (>1.0%) were more likely to receive prophylaxis (52% vs. 34%, p < 0.001). Hospitals with high rates of prescribing for high-risk patients also had high rates for low-risk patients.Conclusions: VTE prophylaxis rates at US hospitals are substantially below Joint Commission targets, even for patients at highest risk of VTE. [ABSTRACT FROM AUTHOR]

Background: The hospitalist model is rapidly altering the landscape for inpatient care in the United States, yet evidence about the clinical and economic outcomes of care by hospitalists is derived from a small number of single-hospital studies examining the practices of a few physicians. Methods: We conducted a retrospective cohort study of 76,926 patients 18 years of age or older who were hospitalized between September 2002 and June 2005 for pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease, or acute myocardial infarction at 45 hospitals throughout the United States. We used multivariable models to compare the outcomes of care by 284 hospitalists, 993 general internists, and 971 family physicians. Results: As compared with patients cared for by general internists, patients cared for by hospitalists had a modestly shorter hospital stay (adjusted difference, 0.4 day; P<0.001) and lower costs (adjusted difference, $268; P=0.02) but a similar inpatient rate of death (odds ratio, 0.95; 95% confidence interval [CI], 0.85 to 1.05) and 14-day readmission rate (odds ratio, 0.98; 95% CI, 0.91 to 1.05). As compared with patients cared for by family physicians, patients cared for by hospitalists had a shorter length of stay (adjusted difference, 0.4 day; P<0.001), and the costs (adjusted difference, $125; P=0.33), rate of death (odds ratio, 0.95; 95% CI, 0.83 to 1.07), and 14-day readmission rate (odds ratio, 0.95; 95% CI, 0.87 to 1.04) were similar. Conclusions: For common inpatient diagnoses, the hospitalist model is associated with a small reduction in the length of stay without an adverse effect on rates of death or readmission. Hospitalist care appears to be modestly less expensive than that provided by general internists, but it offers no significant savings as compared with the care provided by family physicians. N Engl J Med 2007;357:2589-600. [ABSTRACT FROM AUTHOR]

Several letters to the editor are presented in response the article "Antibiotic Therapy and Treatment Failure in Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease," by M. B. Rothberg and colleagues, published in previous issue, including a comment on the methods used in the study, a clarification on the impact of immortal time bias on chronic obstructive pulmonary disease (COPD) exacerbation, and a response from the authors.

Abstract: Purpose: The aim of the study was to compare estimates of hospitalizations, outcomes, and costs produced by 2 approaches for defining severe sepsis. Methods: We used the Nationwide Inpatient Sample to study adults hospitalized in the United States in 2007. We defined severe sepsis using 2 previously published algorithms: (1) the presence of a principal or secondary diagnosis of septicemia combined with organ dysfunction or (2) the presence of a principal or secondary diagnosis of septicemia or another infection (eg, pneumonia) combined with organ dysfunction. For each approach, we calculated the weighted frequency of hospitalizations, population-based mortality rates, and geometric mean costs. Results: A total of 719 099 (SD, 16 676) hospitalizations had a diagnosis of septicemia and a diagnosis of organ dysfunction. A total of 2.5 million hospitalizations were recorded, with a diagnosis code for either septicemia or infection combined with a diagnosis code for organ dysfunction. Hospitalizations without a diagnosis code for septicemia had lower rates of respiratory failure (35% vs 51%, P < .001) or shock (20% vs 46%, P < .001), lower in-hospital mortality (8% vs 29%, P < .001), and lower mean costs. Conclusions: An approach that requires a diagnosis code for septicemia and a diagnosis code for organ dysfunction yields estimates of disease burden and outcomes that are more consistent with chart-based studies. [Copyright &y& Elsevier]

To identify factors associated with 30-day all-cause readmission rates in surgical patients discharged to skilled nursing facilities (SNFs), and derive and validate a risk score. Retrospective cohort. Patients admitted to 1 tertiary hospital's surgical services between January 1, 2011, and December 31, 2014 and subsequently discharged to 110 SNFs within a 25-mile radius of the hospital. The first 2 years were used for the derivation set and the last 2 for validation. Data were collected on 30-day all cause readmissions, patient demographics, procedure and surgical service, comorbidities, laboratory tests, and prior health care utilization. Multivariate regression was used to identify risk factors for readmission. During the study period, 2405 surgical patients were discharged to 110 SNFs, and 519 (21.6%) of these patients experienced readmission within 30 days. In a multivariable regression model, hospital length of stay [odds ratio (OR) per day: 1.03, 95% confidence interval (CI) 1.02-1.04], number of hospitalizations in past year (OR 1.24 per hospitalization, 95% CI 1.18-1.31), nonelective surgery (OR 1.33, 95% CI 1.18-1.65), low-risk service (orthopedic/spine service) (OR 0.32, 95% CI 0.25-0.42), and intermediate-risk service (cardiothoracic surgery/urology/gynecology/ear, nose, throat) (OR 0.69, 95% CI 0.53-0.88) were associated with all-cause readmissions. The model had a C index of 0.71 in the validation set. Using the following risk score [0.8 × (hospital length of stay) + 7 × (number of hospitalizations in past year) +10 for nonelective surgery, +36 for high-risk surgery, and +20 for intermediate-risk surgery], a score of >40 identified patients at high risk of 30-day readmission (35.8% vs 12.6%, P <.001). Among surgical patients discharged to an SNF, a simple risk score with 4 parameters can accurately predict the risk of 30-day readmission. [ABSTRACT FROM AUTHOR]

Objectives To validate the HOSPITAL score for predicting 30-day all-cause readmission rates in a cohort of medical patients discharged to skilled nursing facilities (SNFs). Design Retrospective cohort. Setting Cleveland Clinic Main Campus. Participants Cleveland Clinic Main Campus medicine services patients who were admitted between January 1, 2011, and December 31, 2012, and subsequently discharged to 110 SNFs within a 25-mile radius of the hospital. Measurements Thirty-day all-cause readmissions to any hospital in the Cleveland Clinic Health System and the HOSPITAL score. Results During the study period, 4208 medical patients were discharged to 110 SNFs; 30-day all-cause readmission rates were 40.9% for high-risk patients, 28.1% for intermediate-risk patients, and 15.4% for low-risk patients. Compared to intermediate- and low-risk patients, high-risk patients had more hospitalizations in the past year (3.6 vs 1.1 vs 0.8; P < .0001), longer hospital stays (12.0 days vs 9.9 days vs 4.9 days; P < .0001) and more comorbidities, including end-stage renal disease (18.5% vs 9.3% vs 2.5%; P < .0001), congestive heart failure (39.9% vs 33.1% vs 26.1%; P < .0001), chronic obstructive pulmonary disease (26.9% vs 21.5% vs 20.2%; P < .0001), and diabetes (46.5% vs 38.6% vs 35.3%; P < .0001). The c--statistic for the HOSPITAL score was 0.65. Conclusions Among patients discharged to an SNF, the HOSPITAL score may be used to identify those at highest risk of readmission within 30 days. [ABSTRACT FROM AUTHOR]