Impact of Program Changes Including Telemedicine and Telephonic Care During the COVID-19 Pandemic in Preventing 30-Day Hospital Readmission for Patients in a Care Transitions Program.

INTRODUCTION/OBJECTIVES: To describe health outcomes of older adults enrolled in the Mayo Clinic Care Transitions (MCCT) program before and during the COVID-19 pandemic compared to unenrolled patients. METHODS: We conducted a retrospective cohort study of adults (age >60 years) in the MCCT program compared to a usual care control group from January 1, 2019, to September 20, 2022. The MCCT program involved a home, telephonic, or telemedicine visit by an advanced care provider. Outcomes were 30- and 180-day hospital readmissions, emergency department (ED) visit, and mortality. We performed a subgroup analysis after March 1, 2020 (during the pandemic). We analyzed data with Cox proportional hazards regression models and hazard ratios (HRs) with 95% CIs. RESULTS: Of the 1,012 patients total, 354 were in the MCCT program and 658 were in the usual care group with a mean (SD) age of 81.1 (9.1) years overall. Thirty-day readmission was 16.9% (60 of 354) for MCCT patients and 14.7% (97 of 658) for usual care patients (HR, 1.24; 95% CI, 0.88-1.75). During the pandemic, the 30-day readmission rate was 15.1% (28 of 186) for MCCT patients and 14.9% (68 of 455) for usual care patients (HR, 1.20; 95% CI, 0.75-1.91). There was no difference between groups for 180-day hospitalization, 30- or 180-day ED visit, and 30- or 180-day mortality. CONCLUSIONS: Numerous factors involving patients, providers, and health care delivery systems during the pandemic most likely contributed to these findings.

Risk Prediction Model for 6-Month Mortality for Patients Discharged to Skilled Nursing Facilities.

OBJECTIVE: Hospitalized patients discharged to skilled nursing facilities (SNFs) for post-acute care are at high risk for adverse outcomes. Yet, absence of effective prognostic tools hinders optimal care planning and decision making. Our objective was to develop and validate a risk prediction model for 6-month all-cause death among hospitalized patients discharged to SNFs. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Patients discharged from 1 of 2 hospitals to 1 of 10 SNFs for post-acute care in an integrated health care delivery system between January 1, 2009, and December 31, 2016. METHODS: Gradient-boosting machine modeling was used to predict all-cause death within 180 days of hospital discharge with use of patient demographic characteristics, comorbidities, pattern of prior health care use, and clinical parameters from the index hospitalization. Area under the receiver operating characteristic curve (AUC) was assessed for out-of-sample observations under 10-fold cross-validation. RESULTS: We identified 9803 unique patients with 11,647 hospital-to-SNF discharges [mean (SD) age, 80.72 (9.71) years; female sex, 61.4%]. These discharges involved 9803 patients alive at 180 days and 1844 patients who died between day 1 and day 180 of discharge. Age, comorbid burden, health care use in prior 6 months, abnormal laboratory parameters, and mobility status during hospital stay were the most important predictors of 6-month death (model AUC, 0.82). CONCLUSION AND IMPLICATIONS: We derived a robust prediction model with parameters available at discharge to SNFs to calculate risk of death within 6 months. This work may be useful to guide other clinicians wishing to develop mortality prediction instruments specific to their post-acute SNF populations.

Telehealth Use and Hospital Readmission Rates in Long-term Care Facilities in Southeastern Minnesota During the COVID-19 Pandemic.

Objective: To determine whether the length of a telehealth visit predicted the risk of hospital readmission at 30 days in skilled nursing facilities (SNFs) in southeastern Minnesota during the coronavirus disease 2019 pandemic. Patients and Methods: This was a retrospective cohort study conducted in SNFs located in southeastern Minnesota from March 1, 2020 through July 15, 2020. The primary outcomes included hospitalization within 30 days of a video visit, and the secondary outcome was the number of provider video visits during the stay at an SNF. The primary predictor was the duration of video visits, and we collected the data regarding other known predictors of hospitalization. We used the χ2 test for categorical variables and multivariate conditional logistic regression. Results: We included 722 patients (mean age, 82.8 years [SD, 10.8 years]). Of those, 76 SNF residents (10.5%) were rehospitalized within 30 days. The average length of a video visit was 34.0 minutes (SD, 22.7 minutes) in admitted residents compared with 30.0 minutes (SD, 15.9 minutes) in nonadmitted residents. After full adjustment, there was no difference in the video visit duration between admitted and nonadmitted residents (odds ratio, 1.01; 95% CI, 0.99-1.03). The number of subsequent provider video visits was 2.26 (SD, 1.9) in admitted residents vs 1.58 (SD, 1.6), which was significant after adjustment (odds ratio, 1.17; 95% CI, 1.02-1.34). Conclusion: There was no difference in the length of video visits for hospitalized SNF residents vs those who were not hospitalized within 30 days of a video visit. There were more visits in residents with hospital readmission. This may reflect the acuity of care for patients requiring a hospital stay. More research is needed to determine the ideal use of telehealth during the coronavirus disease 2019 pandemic in the postacute and long-term care environment.

Outcomes of a Nursing Home-to-Community Care Transition Program.

OBJECTIVES: Most transitional care initiatives to reduce rehospitalization have focused on the transition that occurs between a patient's hospital discharge and return home. However, many patients are discharged from a skilled nursing facility (SNF) to their homes. The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT) program (hereafter called program) among patients discharged from SNFs to their homes. DESIGN: Propensity-matched control-intervention trial. INTERVENTION: Patients in the intervention group received care management following nursing stay (a home visit and nursing phone calls). SETTING AND PARTICIPANTS: Patients enrolled after discharge from an SNF to home were matched to patients who did not receive intervention because of refusal, program capacity, or distance. Patients were aged ≥60 years, at high risk for hospitalization, and discharged from an SNF. METHODS: Program enrollees were matched through propensity score to nonenrollees on the basis of age, sex, comorbid health burden, and mortality risk score. Conditional logistic regression analysis examined 30-day hospitalization and emergency department (ED) use; Cox proportional hazards analyses examined 180-day hospital stay and ED use. RESULTS: Each group comprised 160 patients [mean (standard deviation) age, 85.4 (7.4) years]. Thirty-day hospitalization and ED rates were 4.4% and 10.0% in the program group and 3.8% and 10.0% in the group with usual care (P = .76 for hospitalization; P > .99 for ED). At 180 days, hospitalization and ED rates were 30.6% and 46.3% for program patients compared with 11.3% and 25.0% in the comparison group (P < .001). CONCLUSIONS AND IMPLICATIONS: We found no evidence of reduced hospitalization or ED visits by program patients vs the comparison group. Such findings are crucial because they illustrate how aggressive stabilization care within the SNF may mitigate the program role. Furthermore, we found higher ED and hospitalization rates at 180 days in program patients than the comparison group.

Design and Implementation of a Skilled Nursing Facility COVID-19 Unit.

Coronavirus disease 2019 (COVID-19) has challenged the health care system's capacity to care for acutely ill patients. In a collaborative partnership between a health system and a skilled nursing facility (SNF), we developed and implemented an SNF COVID-19 unit to allow expedited hospital discharge of COVID-positive older adults who are clinically improving, and to provide an alternative to hospitalization for those who require SNF care but do not require or necessarily desire aggressive disease-modifying interventions.

Health Care Costs and Utilization Predictions by the Skilled Nursing Facility Readmission Risk Instrument.

OBJECTIVES: Health care providers at hospitals and skilled nursing facilities (SNFs) are increasingly expected to optimize care of post-acute patients to reduce hospital readmissions and contain costs. To achieve these goals, providers need to understand their patients' risk of hospital readmission and how this risk is associated with health care costs. A previously developed risk prediction model identifies patients' probability of 30-day hospital readmission at the time of discharge to an SNF. With a computerized algorithm, we translated this model as the Skilled Nursing Facility Readmission Risk (SNFRR) instrument. Our objective was to evaluate the relationship between 30-day health care costs and hospital readmissions according to the level of risk calculated by this model. DESIGN: This retrospective cohort study used SNFRR scores to evaluate patient data. SETTING AND PARTICIPANTS: The patients were discharged from Mayo Clinic Rochester hospitals to 11 area SNFs. METHODS: We compared the outcomes of all-cause 30-day standardized direct medical costs and hospital readmissions between risk quartiles based on the distribution of SNFRR scores for patients discharged to SNFs for post-acute care from April 1 through November 30, 2017. RESULTS: Mean 30-day all-cause standardized costs were positively associated with SNFRR score quartiles and ranged from $9199 in the fourth quartile (probability of readmission, 0.27-0.66) to $2679 in the first quartile (probability of readmission, 0.07-0.13) (P ≤ .05). Patients in the fourth SNFRR score quartile had 5.68 times the odds of 30-day hospital readmission compared with those in the first quartile. CONCLUSIONS AND IMPLICATIONS: The SNFRR instrument accurately predicted standardized direct health care costs for patients on discharge to an SNF and their risk for 30-day hospital readmission. Therefore, it could be used to help categorize patients for preemptive interventions. Further studies are needed to confirm its validity in other institutions and geographic areas.

Use of a Computerized Algorithm to Evaluate the Proportion and Causes of Potentially Preventable Readmissions Among Patients Discharged to Skilled Nursing Facilities.

OBJECTIVES: Older patients discharged to skilled nursing facilities (SNFs) for post-acute care are at high risk for hospital readmission. Yet, as in the community setting, some readmissions may be preventable with optimal transitional care. This study examined the proportion of 30-day hospital readmissions from SNFs that could be considered potentially preventable readmissions (PPRs) and evaluated the reasons for these readmissions. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Post-acute practice of an integrated health care delivery system serving 11 SNFs in the US Midwest. Patients discharged from the hospital to an SNF and subsequently readmitted to the hospital within 30 days from January 1, 2009, through November 31, 2016. METHODS: A computerized algorithm evaluated the relationship between initial and repeat hospitalizations to determine whether the repeat hospitalization was a PPR. We assessed for changes in PPR rates across the system over the study period and evaluated the readmission categories to identify the most prevalent PPR categories. RESULTS: Of 11,976 discharges to SNFs for post-acute care among 8041 patients over the study period, 16.6% resulted in rehospitalization within 30 days, and 64.8% of these rehospitalizations were considered PPRs. Annual proportion of PPRs ranged from 58.2% to 66.4% [mean (standard deviation) 0.65 (0.03); 95% confidence interval CI 0.63-0.67; P = .36], with no discernable trend. Nearly one-half (46.2%) of all 30-day readmissions were classified as potentially preventable medical readmissions related to recurrence or continuation of the reason for initial admission or to complications from the initial hospitalization. CONCLUSIONS AND IMPLICATIONS: For this cohort of patients discharged to SNFs, a computerized algorithm categorized a large proportion of 30-day hospital readmissions as potentially preventable, with nearly one-half of those linked to the reason for the initial hospitalization. These findings indicate the importance of improvement in postdischarge transitional care for patients discharged to SNFs.

Plasma Trans Fatty Acid Levels, Cardiovascular Risk Factors and Lifestyle: Results from the Akershus Cardiac Examination 1950 Study.

Intake of industrially produced trans fatty acids (iTFAs) has previously been associated with dyslipidemia, insulin resistance, hypertension and inflammation, as well as increased cardiovascular (CV) morbidity and mortality. iTFA intake declined in Norway after the introduction of legislative bans against iTFA consumption. However, the relationship between the current iTFA intake and CV health is unclear. The aim of the present study was to investigate the association between current iTFA intake, reflected by plasma iTFA levels, and established CV risk factors. We also examined the associations between plasma ruminant TFA levels and CV risk factors. In this cross-sectional study, we included 3706 participants from a Norwegian general population, born in 1950 and residing in Akershus County, Norway. The statistical method was multivariable linear regression. Plasma iTFA levels were inversely associated with serum triglycerides (p < 0.001), fasting plasma glucose (p < 0.001), body mass index (p < 0.001), systolic and diastolic blood pressure (p = 0.001 and p = 0.03) and C-reactive protein (p = 0.001). Furthermore, high plasma iTFA levels were associated with higher education and less smoking and alcohol consumption. We found that plasma ruminant trans fatty acids (rTFA) levels were favorably associated with CV risk factors. Furthermore, plasma iTFA levels were inversely associated with CV risk factors. However, our results might have been driven by lifestyle factors. Overall, our findings suggest that the current low intake of iTFAs in Norway does not constitute a threat to CV health.

Plasma linoleic acid levels and cardiovascular risk factors: results from the Norwegian ACE 1950 Study.

BACKGROUND: A high intake of linoleic acid (LA), the major dietary polyunsaturated fatty acid (PUFA), has previously been associated with reduced cardiovascular (CV) morbidity and mortality in observational studies. However, recent secondary analyses from clinical trials of LA-rich diet suggest harmful effects of LA on CV health. METHODS: A total of 3706 participants, all born in 1950, were included in this cross-sectional study. We investigated associations between plasma phospholipid levels of LA and CV risk factors in a Norwegian general population, characterized by a relative low LA and high marine n-3 PUFA intake. The main statistical approach was multivariable linear regression. RESULTS: Plasma phospholipid LA levels ranged from 11.4 to 32.0 wt%, with a median level of 20.8 wt% (interquartile range 16.8-24.8 wt%). High plasma LA levels were associated with lower serum low-density lipoprotein cholesterol levels (standardized regression coefficient [Std. ß-coeff.] -0.04, p = 0.02), serum triglycerides (Std. ß-coeff. -0.10, p < 0.001), fasting plasma glucose (Std. ß-coeff. -0.10, p < 0.001), body mass index (Std. ß-coeff. -0.13, p < 0.001), systolic and diastolic blood pressure (Std. ß-coeff. -0.04, p = 0.03 and Std. ß-coeff. -0.02, p = 0.02, respectively) and estimated glomerular filtration rate (Std. ß-coeff. -0.09, p < 0.001). We found no association between plasma LA levels and high-density lipoprotein cholesterol levels, glycated hemoglobin, carotid intima-media thickness, or C-reactive protein. CONCLUSION: High plasma LA levels were favorably associated with several CV risk factors in this study of a Norwegian general population.

Associations of Skilled Nursing Facility Quality Ratings With 30-Day Rehospitalizations and Emergency Department Visits.

Skilled nursing facilities (SNFs) increasingly provide care to patients after hospitalization. The Centers for Medicare & Medicaid Services reports ratings for SNFs for overall quality, staffing, health inspections, and clinical quality measures. However, the relationship between these ratings and patient outcomes remains unclear. In this retrospective cohort study, we reviewed the electronic health records of 3,923 adult patients discharged from the hospital and admitted to 9 SNFs served by a health care delivery system. We used Cox proportional hazards models to examine associations between the overall quality and individual ratings and our primary outcomes of 30-day rehospitalizations and 30-day emergency department visits. Patients in higher-rated facilities had a 13% lower risk of 30-day rehospitalization than patients in lower-rated facilities (hazard ratio, 0.87; 95% CI, 0.76-0.99). The risk of emergency department visits was also lower for patients in facilities with a higher overall quality rating and a higher quality measures rating. Staffing and health inspection ratings were not associated with our primary outcomes. These findings may help inform providers and nursing home policy makers.

Plasma marine n-3 polyunsaturated fatty acids and cardiovascular risk factors: data from the ACE 1950 study.

PURPOSE: A high intake of marine n-3 polyunsaturated fatty acids (PUFAs) might improve cardiovascular (CV) health. We conducted a cross-sectional study to investigate associations between plasma phospholipid levels of marine n-3 PUFAs and CV risk factors, educational level, physical activity and smoking habits. METHODS: A total of 3706 individuals from a general population, all born in 1950 and residing in Akershus County, Norway, were included in this study. The main statistical approach was multivariable adjusted linear regression. RESULTS: Plasma marine n-3 PUFA levels ranged from 2.7 to 20.3 wt%, with a median level of 7.7 wt% (interquartile range 4.3-11.1 wt%). High levels of plasma marine n-3 PUFAs were associated with lower serum triglycerides [Standardized regression coefficient (Std.ß-coeff.) - 0.14, p < 0.001], body mass index (Std. ß-coeff. -0.08, p < 0.001), serum creatinine (Std. ß-coeff. -0.03, p = 0.05), C-reactive protein levels (Std. ß-coeff. - 0.03, p = 0.04), higher levels of serum high-density lipoprotein cholesterol (Std. ß-coeff. 0.08, p < 0.001) and low-density lipoprotein cholesterol (Std. ß-coeff. 0.04, p = 0.003). High levels of plasma marine n-3 PUFAs were also associated with lower glycated hemoglobin (Std. ß-coeff. - 0.04, p = 0.01), however, only in individuals without diabetes. We found no associations between plasma marine n-3 PUFA levels and fasting plasma glucose or carotid intima-media thickness. High levels of plasma marine n-3 PUFAs were associated with higher educational level, more physical activity and lower prevalence of smoking. CONCLUSION: In this cross-sectional study of Norwegian individuals born in 1950, high levels of plasma marine n-3 PUFAs were favourably associated with several CV risk factors, suggesting that fish consumption might improve CV health.

Immunosuppression and Reproductive Health After Kidney Transplantation.

Following successful kidney transplantation, recipients usually regain fertility. Post-engraftment pregnancies should be planned and the teratogenic mycophenolic acid should be replaced with azathioprine before conception. To avoid unintentional pregnancies, pre-conception counseling is mandatory in women of reproductive age who are scheduled for a kidney transplant. Counseling should be repeated after transplantation. Female recipients should receive advice to use long-acting reversible contraception and avoid pregnancy for a minimum of 1 year following transplantation. Conception should be deferred even longer in female recipients with moderate to severe proteinuria, uncontrolled hypertension or reduced graft function and be very carefully discussed in highly HLA-sensitized patients. The recipient wishes, values and acceptance of pregnancy-related risk should receive attention. Assisted fertilization increases the risk of pre-eclampsia, but still result in live births. Pregnancy management in kidney transplant recipients should be provided by a multidisciplinary team consisting of a nephrologist, a midwife and an obstetrician with expertise in high-risk pregnancies. Until measurement of unbound fraction of calcineurin inhibitors becomes clinically available, we recommend to adjust calcineurin inhibitor dose according to whole blood trough level, even though it overestimates the effective drug concentration during pregnancy. If nephrotoxicity is suspected, the calcineurin inhibitor dose should be reduced. Breastfeeding should be accepted after kidney transplantation since infant immunosuppressive drug exposure via breastmilk is extremely low. The prevalence of congenital malformations in children fathered by male recipients, including patients on mycophenolic acid therapy at the time of conception, is at level with the general population.

Risk of 30-Day Hospital Readmission Among Patients Discharged to Skilled Nursing Facilities: Development and Validation of a Risk-Prediction Model.

OBJECTIVES: Patients discharged to a skilled nursing facility (SNF) for post-acute care have a high risk of hospital readmission. We aimed to develop and validate a risk-prediction model to prospectively quantify the risk of 30-day hospital readmission at the time of discharge to a SNF. DESIGN: Retrospective cohort study. SETTING: Ten independent SNFs affiliated with the post-acute care practice of an integrated health care delivery system. PARTICIPANTS: We evaluated 6032 patients who were discharged to SNFs for post-acute care after hospitalization. MEASUREMENTS: The primary outcome was all-cause 30-day hospital readmission. Patient demographics, medical comorbidity, prior use of health care, and clinical parameters during the index hospitalization were analyzed by using gradient boosting machine multivariable analysis to build a predictive model for 30-day hospital readmission. Area under the receiver operating characteristic curve (AUC) was assessed on out-of-sample observations under 10-fold cross-validation. RESULTS: Among 8616 discharges to SNFs from January 1, 2009, through June 30, 2014, a total of 1568 (18.2%) were readmitted to the hospital within 30 days. The 30-day hospital readmission prediction model had an AUC of 0.69, a 16% improvement over risk assessment using the Charlson Comorbidity Index alone. The final model included length of stay, abnormal laboratory parameters, and need for intensive care during the index hospitalization; comorbid status; and number of emergency department and hospital visits within the preceding 6 months. CONCLUSIONS AND IMPLICATIONS: We developed and validated a risk-prediction model for 30-day hospital readmission in patients discharged to a SNF for post-acute care. This prediction tool can be used to risk stratify the complex population of hospitalized patients who are discharged to SNFs to prioritize interventions and potentially improve the quality, safety, and cost-effectiveness of care.

Care Transitions Program for High-Risk Frail Older Adults is Most Beneficial for Patients with Cognitive Impairment.

BACKGROUND: Although posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success. OBJECTIVE: To identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30-day readmissions. DESIGN: Retrospective cohort. PATIENTS: A total of 315 community-dwelling, hospitalized, older adults (≥60 years) at high risk for readmission (Elder Risk Assessment score ≥16), discharged home over the period of January 1, 2011 to June 30, 2013. SETTING: Midwest primary care practice in an integrated health system. INTERVENTION: Enrollment in a CTP during acute hospitalization. MEASUREMENTS: The primary outcome was all-cause readmission within 30 days of the first CTP evaluation. Logistic regression was used to examine independent variables, including patient demographics, comorbidities, number of medications, completion, and timing of program fidelity measures, and prior utilization of healthcare. RESULTS: The overall 30-day readmission rate was 17.1%. The intensity of follow-up varied among patients, with 17.1% and 50.8% of the patients requiring one and ≥3 home visits, respectively, within 30 days. More than half (54.6%) required visits beyond 30 days. Compared with patients who were not readmitted, readmitted patients were less likely to exhibit cognitive impairment (29.6% vs 46.0%; P = .03) and were more likely to have high medication use (59.3% vs 44.4%; P = .047), more emergency department (ED; 0.8 vs 0.4; P = .03) and primary care visits (4.0 vs 3.0; P = .018), and longer cumulative time in the hospital (4.6 vs 2.5 days; P = .03) within 180 days of the index hospitalization. Multivariable analysis indicated that only cognitive impairment and previous ED visits were important predictors of readmission. CONCLUSIONS: No single CTP component reliably predicted reduced readmission risk. Patients with cognitive impairment and polypharmacy derived the most benefit from the program.

Trans-fatty Acids and Survival in Renal Transplantation.

OBJECTIVE: High consumption of trans-fatty acids (TFAs) is associated with increased mortality. DESIGN AND METHODS: Observational cohort study of 1.988 Norwegian renal transplant recipients with a median follow-up time of 9.6 years. We assessed multivariable adjusted associations between plasma levels of industrial and ruminant TFAs with patient and graft survival. Plasma phospholipid fatty acid levels were determined by gas chromatography at 10 weeks after transplantation. RESULTS: During follow-up, there were 595 deaths, and 805 grafts were lost. Plasma industrial TFA levels dropped from 0.3 wt% in years 1999-2004 to reach a plateau of 0.2 wt% from year 2005 and beyond, whereas plasma levels of ruminant TFAs remained stable throughout the study period. In the former era (years 1999 to 2004, n = 902), we found multivariable adjusted associations between plasma industrial TFA levels and mortality (hazard ratio 4.44, P = .02) and graft loss (hazard ratio 4.22, P = .01). In the latter era (years 2005 to 2011, n = 1,086), there were no associations between plasma industrial TFA levels and patient or graft survival. Plasma ruminant TFAs were not associated with mortality or graft loss in either eras. CONCLUSION: In this Norwegian transplant cohort, plasma industrial TFA levels dropped from around 0.3 wt% in the former era to 0.2 wt% in the latter era. While plasma industrial TFA was significantly associated with survival in the former era, no associations were found with survival in the latter era. This finding suggests that lowering industrial TFA consumption from modest to low levels could possibly influence health beneficially after renal transplantation.

Which Readmissions May Be Preventable? Lessons Learned From a Posthospitalization Care Transitions Program for High-risk Elders.

BACKGROUND: Care transitions programs have been shown to reduce hospital readmissions. OBJECTIVES: The main objective of this study was to evaluate effects of the Mayo Clinic Care Transitions (MCCTs) Program on potentially preventable and nonpreventable 30-day unplanned readmissions among high-risk elders. RESEARCH DESIGN: This was a retrospective cohort study of patients enrolled in MCCT following hospitalization and propensity score-matched controls receiving usual primary care. SUBJECTS: The subjects were primary care patients, who were 60 years or older, at high-risk for readmission, and hospitalized for any cause between January 1, 2011 and June 30, 2013. MEASURES: Hospital readmission within 30 days. The 3M algorithm was used to identify potentially preventable readmissions. Readmissions for ambulatory care sensitive conditions, a subset of preventable readmissions identified by the 3M algorithm, were also assessed. RESULTS: The study cohort included 365 pairs of MCCT enrollees and propensity score-matched controls. Patients were similar in age (mean 83 y) and other baseline demographic and clinical characteristics, including reason for index hospitalization. MCCT enrollees had a significantly lower all-cause readmission rate [12.4% (95% confidence interval: CI, 8.9-15.7) vs. 20.1% (15.8-24.1); P=0.004] resulting from a decrease in potentially preventable readmissions [8.4% (95% CI, 5.5-11.3) vs. 14.3% (95% CI, 10.5-17.9); P=0.01]. Few potentially preventable readmissions were for ambulatory care sensitive conditions (6.7% vs. 12.0%). The rates of nonpotentially preventable readmissions were similar [4.3% (95% CI, 2.2-6.5) vs. 6.7% (95% CI, 4.0-9.4); P=0.16]. Potentially preventable readmissions were reduced by 44% (hazard ratio, 0.56; 95% CI, 0.36-0.88; P=0.01) with no change in other readmissions. CONCLUSIONS: The MCCT significantly reduces preventable readmissions, suggesting that access to multidisciplinary care can reduce readmissions and improve outcomes for high-risk elders.

Plasma n-6 Polyunsaturated Fatty Acid Levels and Survival in Renal Transplantation.

OBJECTIVE: The major n-6 polyunsaturated fatty acids linoleic acid (LA) and arachidonic acid (AA) play a role in inflammation and glucose metabolism, which could affect patient and renal transplant survival. DESIGN AND METHODS: In this single center cohort study of 1988 Norwegian renal transplant recipients, we assessed associations between plasma levels of LA and AA at baseline, measured by gas chromatography, and patient and graft survival, as well as inflammation and cardiovascular risk markers. RESULTS: During follow-up (median of 9.6 years), 595 patients died and 805 renal transplants were lost, either due to recipient death or graft failure. In multivariable survival analysis, we found no associations with mortality for plasma levels of LA (hazard ratios: 0.99, 95% confidence intervals: 0.96-1.01) or AA (hazard ratios: 1.01, 95% confidence intervals: 0.96-1.06). No associations were found for cardiovascular mortality, overall graft loss, or death-censored graft loss. Plasma glucose, proglycemic marker chemerin, and proinflammatory marker growth differentiation factor 15 were inversely associated with plasma LA and positively associated with plasma AA levels in multivariable analysis. CONCLUSIONS: We found no associations between plasma levels of LA or AA and patient or graft survival. Plasma levels of LA and proglycemic indices were inversely associated, signaling a possible beneficial effect of LA consumption for prevention of posttransplantation diabetes mellitus.

Imaging findings of mammary and systemic silicone deposition secondary to breast implants.

In patients with silicone breast implants, implant rupture can occur, which can be intra- or extracapsular. Following implant rupture, silicone can travel through the lymphatic system into regional and distant lymph nodes. The purpose of this pictorial essay is to present findings of silicone implant rupture with intramammary and systemic silicone deposition as seen on dual energy CT, ultrasound, mammogram, PET/CT and MRI. We include imaging findings of silicone deposition in the breast in cases of intra- and extracapsular rupture. We also present silicone deposition in mediastinal, axillary, and internal mammary lymph nodes, as well as in the liver and spleen. To our knowledge, deposition of silicone in the liver and spleen has not been previously demonstrated on cross-sectional imaging. While all imaging modalities were able to detect silicone in the spleen, ultrasound appeared to be more sensitive than dual energy CT or MRI for detection of silicone deposition in the liver.

Health Outcomes From Assisted Living Facilities: A Cohort Study of a Primary Care Practice.

The population of older adults residing in assisted living facilities (ALF) in the United States is growing, yet health data about this population is relatively sparse. We aimed to compare health outcomes of ALF residents with those of age- and sex-matched community dwelling adults in a retrospective cohort study of 808 older adults. Linear regression analyses were conducted to describe the relationship between ALF residency and our outcomes of hospitalizations within 1 year of the index date (earliest recorded date in the ALF), 30-day rehospitalization following index hospitalization, emergency department (ED) visits, and mortality at 1 year. Hospitalizations were significantly greater for ALF residents than for controls. The odds of death for ALF residents were approximately twice that of controls. Falls and ED visits were also significantly greater for ALF residents. The ALF population requires targeted geriatric and primary care models if we are to effectively meet the needs of this growing population.