Post-Acute Care Use and Hospital Readmission after Sepsis.

RATIONALE: The epidemiology of post-acute care use and hospital readmission after sepsis remains largely unknown. OBJECTIVES: To examine the rate of post-acute care use and hospital readmission after sepsis and to examine risk factors and outcomes for hospital readmissions after sepsis. METHODS: In an observational cohort study conducted in an academic health care system (2010-2012), we compared post-acute care use at discharge and hospital readmission after 3,620 sepsis hospitalizations with 108,958 nonsepsis hospitalizations. We used three validated, claims-based approaches to identify sepsis and severe sepsis. MEASUREMENTS AND MAIN RESULTS: Post-acute care use at discharge was more likely after sepsis, driven by skilled care facility placement (35.4% after sepsis vs. 15.8%; P < 0.001), with the highest rate observed after severe sepsis. Readmission rates at 7, 30, and 90 days were higher postsepsis (P < 0.001). Compared with nonsepsis hospitalizations (15.6% readmitted within 30 d), the increased readmission risk was present regardless of sepsis severity (27.3% after sepsis and 26.0-26.2% after severe sepsis). After controlling for presepsis characteristics, the readmission risk was found to be 1.51 times greater (95% CI, 1.38-1.66) than nonsepsis hospitalizations. Readmissions after sepsis were more likely to result in death or transition to hospice care (6.1% vs. 13.3% after sepsis; P < 0.001). Independent risk factors associated with 30-day readmissions after sepsis hospitalizations included age, malignancy diagnosis, hospitalizations in the year prior to the index hospitalization, nonelective index admission type, one or more procedures during the index hospitalization, and low hemoglobin and high red cell distribution width at discharge. CONCLUSIONS: Post-acute care use and hospital readmissions were common after sepsis. The increased readmission risk after sepsis was observed regardless of sepsis severity and was associated with adverse readmission outcomes.

Usability and impact of a computerized clinical decision support intervention designed to reduce urinary catheter utilization and catheter-associated urinary tract infections.

OBJECTIVE: To evaluate the usability and effectiveness of a computerized clinical decision support (CDS) intervention aimed at reducing the duration of urinary tract catheterizations. DESIGN: Retrospective cohort study. SETTING: Academic healthcare system. PATIENTS: All adult patients admitted from March 2009 through May 2012. INTERVENTION: A CDS intervention was integrated into a commercial electronic health record. Providers were prompted at order entry to specify the indication for urinary catheter insertion. On the basis of the indication chosen, providers were alerted to reassess the need for the urinary catheter if it was not removed within the recommended time. Three time periods were examined: baseline, after implementation of the first intervention (stock reminder), and after a second iteration (homegrown reminder). The primary endpoint was the usability of the intervention as measured by the proportion of reminders through which providers submitted a remove urinary catheter order. Secondary endpoints were the urinary catheter utilization ratio and the rate of hospital-acquired catheter-associated urinary tract infections (CAUTIs). RESULT: The first intervention displayed limited usability, with 2% of reminders resulting in a remove order. Usability improved to 15% with the revised reminder. The catheter utilization ratio declined over the 3 time periods (0.22, 0.20, and 0.19, respectively; P < .001), as did CAUTIs per 1,000 patient-days (0.84, 0.70, and 0.51, respectively; P < .001). CONCLUSIONS: A urinary catheter removal reminder system was successfully integrated within a healthcare system's electronic health record. The usability of the reminder was highly dependent on its user interface, with a homegrown version of the reminder resulting in higher impact than a stock reminder.

Timeliness and quality of surgical discharge summaries after the implementation of an electronic format.

BACKGROUND: As electronic discharge summaries (EDS) become more prevalent and health care systems increase their focus on transitions of care, analysis of EDS quality is important. The objective of this study was to assess the timeliness and quality of EDS compared with dictated summaries for surgical patients, which has not previously been evaluated. METHODS: A retrospective study was conducted of a sample of discharge summaries from surgical patients at an urban university teaching hospital before and after the implementation of an EDS program. Summaries were evaluated on several dimensions, including time to summary completion, summary length, and summary quality, which was measured on a 13-item scoring tool. RESULTS: After the exclusion of 5 patients who died, 195 discharge summaries were evaluated. Discharge summaries before and after EDS implementation were similar in admission types and discharge destinations of the patients. Compared with dictated summaries, EDS had equivalent overall quality (P = .11), with higher or equivalent scores on all specific quality aspects except readability. There was a highly significant statistical and clinical improvement in timeliness for electronic summaries (P < .01). Obvious use of copying and pasting was identified in 8% of discharge summaries and was associated with decreased readability (P = .02). CONCLUSIONS: The implementation of EDS can improve the timeliness of summary completion without sacrificing quality for surgical patients. Excessive copying and pasting can reduce the readability of discharge summaries, and strategies to discourage this practice without the use of appropriate editing should be used.

The readmission risk flag: using the electronic health record to automatically identify patients at risk for 30-day readmission.

BACKGROUND: Identification of patients at high risk for readmission is a crucial step toward improving care and reducing readmissions. The adoption of electronic health records (EHR) may prove important to strategies designed to risk stratify patients and introduce targeted interventions. OBJECTIVE: To develop and implement an automated prediction model integrated into our health system's EHR that identifies on admission patients at high risk for readmission within 30 days of discharge. DESIGN: Retrospective and prospective cohort. SETTING: Healthcare system consisting of 3 hospitals. PATIENTS: All adult patients admitted from August 2009 to September 2012. INTERVENTIONS: An automated readmission risk flag integrated into the EHR. MEASURES: Thirty-day all-cause and 7-day unplanned healthcare system readmissions. RESULTS: Using retrospective data, a single risk factor, ≥ 2 inpatient admissions in the past 12 months, was found to have the best balance of sensitivity (40%), positive predictive value (31%), and proportion of patients flagged (18%), with a C statistic of 0.62. Sensitivity (39%), positive predictive value (30%), proportion of patients flagged (18%), and C statistic (0.61) during the 12-month period after implementation of the risk flag were similar. There was no evidence for an effect of the intervention on 30-day all-cause and 7-day unplanned readmission rates in the 12-month period after implementation. CONCLUSIONS: An automated prediction model was effectively integrated into an existing EHR and identified patients on admission who were at risk for readmission within 30 days of discharge.

The complexity and cost of drug regimens of older patients hospitalized with heart failure in the United States, 1998-2001.

BACKGROUND: Polypharmacy-the concurrent prescription of multiple medications-is a salient consideration in the care of older patients with heart failure. Little is known, however, about the complexity and financial burden of medical therapy in this population. METHODS: This is a study of the chronic medications prescribed at hospital discharge to patients 65 years or older hospitalized for heart failure in 2 cohorts separated by 27 months (April 1998-March 1999, n = 31 602; July 2000-June 2001, n = 30,774). Three utilization measures were assessed: the number of drugs, the estimated number of doses per day, and the estimated annual costs using the same cost standard (2003 average wholesale prices) for both samples. Utilization associated with population characteristics and between time frames was assessed in multivariable models. RESULTS: In 1998-1999, the mean number of drugs was 6.8, representing 10.1 doses daily at a cost of 3142 dollars/y, increasing to 7.5 drugs, 11.1 doses daily and 3823 dollars/y in 2000-2001 (P<.001 for all comparisons). After adjustment, the number of drugs increased by 12% and costs by 24% between samples. Factors associated with greater complexity and cost included diabetes (1.6 additional drugs and 1094 dollars/y additional cost), prior revascularization (1.3 drugs, 1154 dollars/y), and chronic lung disease (1.2 drugs, 814 dollars/y). Younger age and white race were also associated with more drugs and higher costs. CONCLUSIONS: The drug treatment of older patients with heart failure is characterized by rapidly increasing complexity and cost. Efforts should be directed toward optimizing the complex drug regimens of elderly patients with heart failure and multiple comorbidities.