Changes in Coagulation Testing During a National Shortage of Blue-Top Tubes.

OBJECTIVES: Manufacturer recalls and altered supply chains during the coronavirus disease 2019 (COVID-19) pandemic caused a nationwide shortage of blue-top tubes (BTTs). Most non-point-of-care coagulation tests use these tubes, leaving laboratories and health care facilities in short supply. The Department of Pathology and Laboratory Medicine at Cedars-Sinai Medical Center implemented interventions to conserve supply without sacrificing patient safety. METHODS: In a retrospective quality improvement analysis, we examined coagulation testing and BTT utilization over the 3-month interval during which our interventions were applied. Our study assessed the interventions' effectiveness by evaluating changes in BTT utilization, coagulation testing volume, and patient impact. RESULTS: Average daily use (ADU) of BTT before and after the intervention were 476 and 403, respectively-a 15.2% reduction. Notably, the Emergency Department had a reduction in ADU of 43.3%. Average daily volumes of coagulation assays performed decreased from 949 to 783-a 17.5% reduction. No adverse events from the Pharmacy Department were identified during the study period. CONCLUSIONS: Interventions resulting in significant reductions were in divisions with effective management and supervision. Success in navigating the BTT shortage stemmed from timely announcements, action, and effective communication. Our recommendations established more effective coagulation assay utilization, decreased overall BTT use, and prevented patients with coagulopathic disorders from experiencing adverse consequences.

Seasonal COVID-19 surge related hospital volumes and case fatality rates.

BACKGROUND: Seasonal and regional surges in COVID-19 have imposed substantial strain on healthcare systems. Whereas sharp inclines in hospital volume were accompanied by overt increases in case fatality rates during the very early phases of the pandemic, the relative impact during later phases of the pandemic are less clear. We sought to characterize how the 2020 winter surge in COVID-19 volumes impacted case fatality in an adequately-resourced health system. METHODS: We performed a retrospective cohort study of all adult diagnosed with COVID-19 in a large academic healthcare system between August 25, 2020 to May 8, 2021, using multivariable logistic regression to examine case fatality rates across 3 sequential time periods around the 2020 winter surge: pre-surge, surge, and post-surge. Subgroup analyses of patients admitted to the hospital and those receiving ICU-level care were also performed. Additionally, we used multivariable logistic regression to examine risk factors for mortality during the surge period. RESULTS: We studied 7388 patients (aged 52.8 ± 19.6 years, 48% male) who received outpatient or inpatient care for COVID-19 during the study period. Patients treated during surge (N = 6372) compared to the pre-surge (N = 536) period had 2.64 greater odds (95% CI 1.46-5.27) of mortality after adjusting for sociodemographic and clinical factors. Adjusted mortality risk returned to pre-surge levels during the post-surge period. Notably, first-encounter patient-level measures of illness severity appeared higher during surge compared to non-surge periods. CONCLUSIONS: We observed excess mortality risk during a recent winter COVID-19 surge that was not explained by conventional risk factors or easily measurable variables, although recovered rapidly in the setting of targeted facility resources. These findings point to how complex interrelations of population- and patient-level pandemic factors can profoundly augment health system strain and drive dynamic, if short-lived, changes in outcomes.

Seroprevalence of antibodies to SARS-CoV-2 in healthcare workers: a cross-sectional study.

OBJECTIVE: We sought to determine the extent of SARS-CoV-2 seroprevalence and the factors associated with seroprevalence across a diverse cohort of healthcare workers. DESIGN: Observational cohort study of healthcare workers, including SARS-CoV-2 serology testing and participant questionnaires. SETTINGS: A multisite healthcare delivery system located in Los Angeles County. PARTICIPANTS: A diverse and unselected population of adults (n=6062) employed in a multisite healthcare delivery system located in Los Angeles County, including individuals with direct patient contact and others with non-patient-oriented work functions. MAIN OUTCOMES: Using Bayesian and multivariate analyses, we estimated seroprevalence and factors associated with seropositivity and antibody levels, including pre-existing demographic and clinical characteristics; potential COVID-19 illness-related exposures; and symptoms consistent with COVID-19 infection. RESULTS: We observed a seroprevalence rate of 4.1%, with anosmia as the most prominently associated self-reported symptom (OR 11.04, p<0.001) in addition to fever (OR 2.02, p=0.002) and myalgias (OR 1.65, p=0.035). After adjusting for potential confounders, seroprevalence was also associated with Hispanic ethnicity (OR 1.98, p=0.001) and African-American race (OR 2.02, p=0.027) as well as contact with a COVID-19-diagnosed individual in the household (OR 5.73, p<0.001) or clinical work setting (OR 1.76, p=0.002). Importantly, African-American race and Hispanic ethnicity were associated with antibody positivity even after adjusting for personal COVID-19 diagnosis status, suggesting the contribution of unmeasured structural or societal factors. CONCLUSION AND RELEVANCE: The demographic factors associated with SARS-CoV-2 seroprevalence among our healthcare workers underscore the importance of exposure sources beyond the workplace. The size and diversity of our study population, combined with robust survey and modelling techniques, provide a vibrant picture of the demographic factors, exposures and symptoms that can identify individuals with susceptibility as well as potential to mount an immune response to COVID-19.

Identification of Functional Limitations and Discharge Destination in Patients With COVID-19.

OBJECTIVES: The objectives of this study were to identify functional limitations in patients with coronavirus 2019 (COVID-19) admitted to acute care hospitals; to evaluate functional limitations by demographic, medical, and encounter characteristics; and to examine functional limitations in relation to discharge destination. DESIGN: and Setting:This is a cross-sectional, retrospective study of adult patients with COVID-19 who were discharged from 2 different types of hospitals (academic medical center and a community hospital) within 1 health care system from January 1 to April 30, 2020. PARTICIPANTS: Patients were identified from the Cedars-Sinai COVID-19 data registry who had a new-onset positive test for severe acute respiratory syndrome coronavirus 2. A total of 273 patients were identified, which included 230 patients who were discharged alive and 43 patients who died and were excluded from the study sample. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional limitations in patients with COVID-19 in acute care hospitals and the predictors for discharge disposition. RESULTS: A total of 230 records were analyzed including demographic, encounter, medical, and functional variables. In a propensity score-matched cohort based on age and comorbidity, 88.2% had functional physical health deficits, 72.5% had functional mental health deficits, and 17.6% experienced sensory deficits. In the matched cohort, individuals discharged to an institution experienced greater physical (62.7% vs 25.5%, P<.001) and mental health (49.0% vs 23.5%, P=.006) deficits than patients discharged home. Marital status (odds ratio, 3.17; P=.011) and physical function deficits (odds ratio, 3.63; P=.025) were associated with an increase odds ratio of discharge to an institution. CONCLUSIONS: This research highlights that functional status is a strong predictor for discharge destination to an institution for patients with COVID-19. Patients who were older, in the acute care hospital longer, and with comorbidities were more likely to be discharged to an institution. Rehabilitation is a significant aspect of the health care system for these vulnerable patients. The challenges of adjusting the role of rehabilitation providers and systems during the pandemic needs further exploration. Moreover, additional research is needed to look more closely at the many facets and timing of functional status needs, to shed light in use of interdisciplinary rehabilitation services, and to guide providers and health care systems in facilitating optimal recovery and patient outcomes.

Patient-Initiated Data: Our Experience with Enabling Patients to Initiate Incorporation of Heart Rate Data into the Electronic Health Record.

BACKGROUND: Provider organizations increasingly allow incorporation of patient-generated data into electronic health records (EHRs). In 2015, we began allowing patients to upload data to our EHR without physician orders, which we henceforth call patient-initiated data (PAIDA). Syncing wearable heart rate monitors to our EHR allows for uploading of thousands of heart rates per patient per week, including many abnormally low and high rates. Physician informaticists expressed concern that physicians and their patients might be unaware of abnormal heart rates, including those caused by treatable pathology. OBJECTIVE: This study aimed to develop a protocol to address millions of unreviewed heart rates. METHODS: As a quality improvement initiative, we assembled a physician informaticist team to meet monthly for review of abnormally low and high heart rates. By incorporating other data already present in the EHR, lessons learned from reviewing records over time, and from contacting physicians, we iteratively refined our protocol. RESULTS: We developed (1) a heart rate visualization dashboard to identify concerning heart rates; (2) experience regarding which combinations of heart rates and EHR data were most clinically worrisome, as opposed to representing artifact; (3) a protocol whereby only concerning heart rates would trigger a cardiologist review revealing protected health information; and (4) a generalizable framework for addressing other PAIDA. CONCLUSION: We expect most PAIDA to eventually require systematic integration and oversight. Our governance framework can help guide future efforts, especially for cases with large amounts of data and where abnormal values may represent concerning but treatable pathology.

Measuring Frailty in Inpatient Rehabilitation.

BACKGROUND: In response to the global aging population, there has been increasing research on frailty. How frailty is conceptualized is shifting with the development of frailty models, especially in the acute care arena. OBJECTIVE: To explore frailty/vulnerability risk factors available at admission that were associated with salient patient outcomes within the context of inpatient rehabilitation. DESIGN: Methodologies in acute care are not easily adapted for a typical admission evaluation or a rehabilitation patient. In this study, the concept of frailty among patients admitted to rehabilitation was developed from risk factors available at admission that were associated with two patient outcomes, adverse hospital outcomes and 30-day hospital readmissions. SETTING: Inpatient rehabilitation. PATIENTS: Data were included on all patients (n = 768) discharged from an inpatient rehabilitation unit of an academic medical center from 1 January 2012 through 31 December 2012. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Adverse events within the inpatient rehabilitation stay and 30-day hospital readmissions. RESULTS: Significant independent factors associated with adverse events in the rehabilitation unit included African American (1.77 OR; 95% CI 1.06-2.96), Hispanic (3.17 OR; 95% CI 1.13-8.94), having >9 total comorbid conditions (1.44 OR; 95% CI 1.244-1.66), and sphincter control domain (including bladder and bowel management) ≤ 9 FIM (0.92 OR; 95% CI 0.86-0.98). For 30-day readmission three variables were found to be significant: onset ≥7 days (2.31 OR; 95% CI 1.28-4.22), requiring a tube for feeding (3.45 OR; 95% CI 1.433-11.12), and being obese (4.72 OR; 95% CI 1.433-15.58). CONCLUSIONS: The findings highlight the need for early admission screening and identification of risk factors which can provide the time in the rehabilitation setting for the clinical team to treat and prevent the potential for poor outcomes.

Calculating maximum morphine equivalent daily dose from prescription directions for use in the electronic health record: a case report.

To demonstrate a process of calculating the maximum potential morphine milligram equivalent daily dose (MEDD) based on the prescription Sig for use in quality improvement initiatives. To calculate an opioid prescription's maximum potential Sig-MEDD, we developed SQL code to determine a prescription's maximum units/day using discrete field data and text-parsing in the prescription instructions. We validated the derived units/day calculation using 3000 Sigs, then compared the Sig-MEDD calculation against the Epic-MEDD calculator. Of the 101 782 outpatient opioid prescriptions ordered over 1 year, 80% used discrete-field Sigs, 7% used free-text Sigs, and 3% used both types. We determined units/day and calculated a Sig-MEDD for 98.3% of all the prescriptions, 99.99% of discrete-Sig prescriptions, and 81.5% of free-text-Sig prescriptions. Analyzing opioid prescription Sigs to determine a maximum potential Sig-MEDD provides greater insight into a patient's risk for opioid exposure.

Frailty in a Post-Acute Care Population: A Scoping Review.

Frailty is a complex and growing phenomenon facing health care providers throughout the continuum of care. Frailty is not well understood in post-acute care (PAC) settings. The purpose of this scoping review was to summarize current evidence of frailty impact on outcomes and frailty mitigation initiatives in PAC. Three major publication databases were searched from January 2000 to June 2017 that identified 18 articles specifically addressing frailty in PAC. Three themes were identified: scales used to measure frailty, factors that led to an adverse outcome or diagnosis of frailty, and interventions to address frailty in PAC. Scales used to measure frailty were dominated by physical factors and scarce on nutrition and social support. Functional decline, grip strength, gait speed, polypharmacy, and nutrition were identified in the studies as factors that identify frailty and are associated with poor outcomes. All these frailty characteristics compromise patients' ability to benefit from rehabilitation, which further establishes the importance of PAC providers to identify, prevent, and treat frailty. Intervention studies had mixed outcomes, suggesting a need for further development in this area. The findings of this scoping review highlight the need for a comprehensive multidimensional assessment of frailty risks in PAC. LEVEL OF EVIDENCE: IV.

A conceptual model for vision rehabilitation.

Vision impairments are highly prevalent after acquired brain injury (ABI). Conceptual models that focus on constructing intellectual frameworks greatly facilitate comprehension and implementation of practice guidelines in an interprofessional setting. The purpose of this article is to provide a review of the vision literature in ABI, describe a conceptual model for vision rehabilitation, explain its potential clinical inferences, and discuss its translation into rehabilitation across multiple practice settings and disciplines.

Temporomandibular Disorder Diagnostic Groups Affect Outcomes Independently of Treatment in Patients at Risk for Developing Chronicity: A 2-Year Follow-Up Study.

AIMS: To evaluate whether a biobehavioral intervention would be more effective than a self-care intervention or no intervention in reducing psychosocial distress, reducing pain, and improving functioning in patients with an acute myofascial temporomandibular disorder (m-TMD). METHODS: Participants (n = 435) were from community dental clinics in the Dallas-Fort Worth Metroplex who were seeking treatment for their acute TMD symptoms and were recruited between 2008 and 2013. The participants were diagnosed using the Research Diagnostic Criteria for TMD (RDC/TMD) and assigned to a biobehavioral intervention, self-care intervention, or no intervention. Three outcomes were assessed: psychosocial distress, pain, and functioning; and treatment effectiveness was assessed according to TMD diagnosis. Outcome evaluations were conducted immediately postintervention as well as at 1 and 2 years postintervention. Analyses were conducted using two-level hierarchical multilevel linear models (MLMs). RESULTS: Contrary to expectations, patients did not respond differently to the intervention based on their TMD diagnosis. Acute m-TMD patients, especially those with other comorbid TMD diagnoses, reported the highest levels of pain and pain-related symptoms and disability. They also exhibited poorer jaw functioning, especially if they were at high risk for chronic TMD. CONCLUSION: This study indicates that acute m-TMD tends to result in more severe symptom presentations, particularly if diagnosed in combination with other TMD comorbidities. Additionally, patients do not appear to respond better to biobehavioral or self-care intervention on the basis of their TMD diagnosis.

Using Functional Status in the Acute Hospital to Predict Discharge Destination for Stroke Patients.

OBJECTIVE: The aim of this study was to determine whether functional status, as measured by the AcuteFIM instrument, can be used to predict discharge destination of stroke patients from the acute hospital setting. DESIGN: A retrospective cohort study was carried out in an urban academic medical center. Data were collected on 481 new-onset stroke patients 18 yrs or older in an acute hospital between January 1 and September 30, 2013. Functional Independence Measure (FIM) instrument data were linked to a subset of 54 patients who received additional services at an inpatient rehabilitation facility. A receiver operator characteristic curve was constructed to validate the predictive ability of the AcuteFIM instrument and to determine the optimal cutoff score associated with discharge to a community setting. RESULTS: All AcuteFIM items in stroke patients at admission demonstrated strong interitem correlation coefficients (all above 0.6) and high internal consistency (Cronbach α = 0.94). The AcuteFIM total score was positively associated with discharge to the community from the acute hospital (odds ratio, 1.06; 95% confidence interval, 1.05-1.07). Receiver operator characteristic curve analysis generated a c statistic of 0.89 (95% confidence interval, 0.87-0.92), indicating that the AcuteFIM instrument is predictive of patient discharge to the community setting. CONCLUSION: This study suggests that the AcuteFIM instrument is a reliable tool that can be used to predict discharge destination from the acute hospital among stroke patients.

Transferring inpatient rehabilitation facility cancer patients back to acute care (TRIPBAC).

OBJECTIVE: To determine predictive factors for TRansferring Inpatient rehabilitation facility (IRF) cancer Patients Back to Acute Care (TRIPBAC). DESIGN: A retrospective chart review of patients with cancer admitted to an IRF from 2009 to 2010 because of a functional impairment that developed as a direct consequence of their cancer or its treatment. SETTING: IRF of a community-based, academic, tertiary care facility. METHODS: The characterization of patients with cancer in the IRF was primarily based on analysis of the IRF Patient Assessment Instrument and other internal IRF data logs. MAIN OUTCOME MEASUREMENT: Frequency and reasons for TRIPBAC. RESULTS: The TRIPBAC rate in our IRF was 17.4%. The most common reasons for TRIPBAC were postneurosurgical complications (31%). Factors associated with TRIPBAC were a motor Functional Independence Measure score of 35 points or lower on admission (odds ratio 4.01, 95% confidence interval 1.79-8.98; P = .001) and the presence of a feeding tube or a modified diet (odds ratio 3.18, 95% confidence interval 1.44-7.04; P = .004). CONCLUSIONS: Motor Functional Independence Measure score on admission is the best predictor for TRIPBAC in patients with cancer admitted to our IRF, followed by the presence of a feeding tube or a modified diet.

The impact of inpatient rehabilitation on function and survival of newly diagnosed patients with glioblastoma.

OBJECTIVE: To examine the impact of an inpatient rehabilitation program on functional improvement and survival among patients with newly diagnosed glioblastoma multiforme (GBM) who underwent surgical resection of the brain tumor. DESIGN: A retrospective cohort study of newly diagnosed patients with GBM between 2003 and 2010, with survival data updated through January 23, 2013. SETTING: An urban academic nonprofit medical center that included acute medical and inpatient rehabilitation. PARTICIPANTS: Data for newly diagnosed patients with GBM were examined; of these patients, 100 underwent inpatient rehabilitation after resection, and 312 did not undergo inpatient rehabilitation. MAIN OUTCOME MEASUREMENTS: Overall functional improvement and survival time for patients who participated in the inpatient rehabilitation program. RESULTS: A total of 89 patients (93.7%) who underwent inpatient rehabilitation improved in functional status from admission to discharge, with the highest gain observed in mobility (96.8%), followed by self-care (88.4%), communication/social cognition (75.8%), and sphincter control (50.5%). The median overall survival among inpatient rehabilitation patients was 14.3 versus 17.9 months for patients who did not undergo inpatient rehabilitation (P = .03). However, after we adjusted for age, extent of resection, and Karnofsky Performance Status Scale scores, we found no statistical difference in the survival rate between patients who did and did not undergo inpatient rehabilitation (hazard ratio [HR], 0.84; P = .16). Among the patients who underwent inpatient rehabilitation, older age (HR, 2.24; P = .0006), a low degree of resection (HR, 1.67; P = .02), and lack of a Stupp regimen (HR, 1.71; P = .05) were associated with greater hazard of mortality. CONCLUSIONS: Patients who undergo inpatient rehabilitation demonstrate significant functional improvements, primarily in the mobility domain. Confounder adjusted multivariate analysis showed no survival difference between patients who did and did not undergo inpatient rehabilitation; this finding suggests that a structured inpatient rehabilitation program may level the survival field in lower-functioning patients who otherwise may be faced with a dismal prognosis.

Perceptions of inpatient rehabilitation changes after the Centers for Medicare and Medicaid Service 2010 regulatory updates contrasted with actual performance.

OBJECTIVES: To compare and contrast subjective perceptions with objective compliance of the impact of the 2010 Centers for Medicare and Medicaid Service updates of the Medicare Benefit Policy Manual. DESIGN OR SETTING: Cross-sectional survey. PARTICIPANTS AND METHODS: An electronic survey was sent by the Uniform Data System for Medical Rehabilitation to all enrolled inpatient rehabilitation facility subscribers (n = 817). The survey was sent April 15, 2011, and responses were tabulated if they were received by May 15, 2011. MAIN OUTCOME MEASUREMENTS: Comparing and contrasting of the subjective perception to objective evaluation and/or compliance with the Medicare Benefit Policy Manual on case mix index, length of stay, admissions by diagnostic category as well as perception of preadmission screening, postadmission evaluation, plan of care, and interdisciplinary conferencing. RESULTS: Twenty-five percent of the 817 facilities responded, for a total of 209 responses. Complete data were present in 148 of the respondents. For most diagnostic categories, perception of change did not mirror reality of change; neither did the perception between change in case mix index and length of stay. Perception did match reality in stroke and multiple trauma cases; respondents perceived an increase in admissions for the 2 impairments, and there was an overall increase in reality. CONCLUSION: Comparison with actual data identified that gaps exist between diagnostic category perceptions and actual diagnostic category admission performance. Regulations such as the 75%-60% rule and audit focus on non-neurologic conditions as well as actual inpatient rehabilitation facility program payment reports may have influenced respondents perceptions to change associated with the Medicare Benefit Policy Manual modifications. This disparity between perception and actual data may have implications for programmatic planning, forecasting, and resource allocation.

Risk factors for discharge to an acute care hospital from inpatient rehabilitation among stroke patients.

OBJECTIVE: To identify medical and functional health risk factors for being discharged directly to an acute-care hospital from an inpatient rehabilitation facility among patients who have had a stroke. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PARTICIPANTS: A total of 783 patients with a primary diagnosis of stroke seen from 2008 to 2012; 60 were discharged directly to an acute-care hospital and 723 were discharged to other settings, including community and other institutional settings. METHODS OR INTERVENTIONS: Logistic regression analysis. MAIN OUTCOME MEASUREMENTS: Direct discharge to an acute care hospital compared with other discharge settings from the inpatient rehabilitation unit. RESULTS: No significant differences in demographic characteristics were found between the 2 groups. The adjusted logistic regression model revealed 2 significant risk factors for being discharged to an acute care hospital: admission motor Functional Independence Measure total score (odds ratio 0.97, 95% confidence interval 0.95-0.99) and enteral feeding at admission (odds ratio 2.87, 95% confidence interval 1.34-6.13). The presence of a Centers for Medicare and Medicaid-tiered comorbidity trended toward significance. CONCLUSION: Based on this research, we identified specific medical and functional health risk factors in the stroke population that affect the rate of discharge to an acute-care hospital. With active medical and functional management, early identification of these critical components may lead to the prevention of stroke patients from being discharged to an acute-care hospital from the inpatient rehabilitation setting.

Biopsychosocial factors associated with the subcategories of acute temporomandibular joint disorders.

AIMS: To assess the biopsychosocial factors associated with acute temporomandibular disorders (TMD) based on the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). METHODS: Participants were assessed in community-based dental clinics and evaluated by trained clinicians using physical and psychosocial measures. A total of 207 subjects were evaluated. Patients' high-risk versus low-risk status for potentially developing chronic TMD was also determined. Analyses of variance and chi square analyses were applied to these data. RESULTS: Participants' characteristic pain intensity differed among RDC/TMD Axis I diagnoses. They also significantly varied in their self-reported graded chronic pain, depression, somatization (pain inclusive), somatization (pain excluded), and physical well-being. In addition, participants with differing RDC/TMD Axis I diagnoses varied in self-reported pain during their chewing performance. Finally, there were also significant differences in chewing performance between high-risk versus low-risk (for developing chronic TMD) patients. CONCLUSION: Participants with multiple diagnoses reported higher pain, as well as other symptoms, relative to participants without a TMD diagnosis. For chewing performance, participants with mutual diagnoses reported more pain compared to other participants. Finally, the risk-status of patients significantly affected chewing performance.

The contribution of recess to children's school-day physical activity.

BACKGROUND: Recess is an important component of a Comprehensive School Physical Activity Program, providing approximately 1268 and 914 steps for boys and girls, respectively, within a 15-minute time period. The purpose of this study was to determine the contribution of unstructured recess on children's school-day physical activity levels and to examine if recess and school-day physical activity levels varied by BMI, gender, and grade level. METHODS: One-hundred sixty third- to fifth-grade students from 2 elementary schools wore pedometers during 4 recess periods. RESULTS: Recess accounted for 17% to 44% of school-day step counts. There was a significant main effect for grade level, but not for BMI or gender, on the percentage of school-day steps accumulated during recess. CONCLUSIONS: A 15-minute recess makes a valuable contribution to children's school-day physical activity, especially for the least active children. More research is warranted to determine environmental influences on children's recess physical activity.

Medicare's recovery audit contractor program: inpatient rehabilitation facilities are taking back takebacks, but enough?

A perfect storm had been brewing in the last decade: Medicare payment mistakes; Medicare waste, fraud, and abuse; fuzzy medical necessity definitions; erroneous coding; and a strained national budget. The United States Congress responded by inserting Section 306 into the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Section 306 called for the correction of Medicare payment problems by establishing the Recovery Audit Contractor program as the vehicle for the Centers for Medicare & Medicaid Services to recoup Medicare overpayments as far back as 3 yrs from its healthcare providers and to return underpayments to them. The legislation allowed for Medicare to contract with private firms to follow the money and earn a cut. Caught in the eye of the storm, Medicare providers combined are giving back more than they get back. Inpatient Rehabilitation Facilities are taking back takebacks-but enough to remain viable?

Joint replacement and hip fracture readmission rates: impact of discharge destination.

OBJECTIVE: To determine if discharge destination after hospitalization for hip replacement or repair influences the hospital readmission rate. DESIGN: A retrospective cohort study that included consecutive patients with a primary diagnosis of hip replacement or repair who were discharged from the acute hospital in a 3-year period. SETTING: Urban academic nonprofit hospital. PATIENTS: Data for 606 orthopedic patients discharged alive from the acute hospital between January 2004 and September 2006 were abstracted from the University Health-System Consortium (UHC) Clinical DataBase/Resource Manager clinical database for the study hospital. MAIN OUTCOME MEASURES: Unplanned readmission rate to the study-site hospital within 180 days after discharge after hip replacement or repair. RESULTS: Unplanned readmission within 180 days occurred at a rate of 8.3% and varied significantly by discharge destination: home 5.1%, home with home health care services 10.5%, skilled nursing facility 12.3%, inpatient rehabilitation 4.2%, and other 42.9%. Variables from the surgical admission that were significantly associated with higher risk of readmission included admission severity, burden of comorbidities, any days in the intensive care unit, long length of stay, and cost. When controlling for multiple independent risk factors, discharge to inpatient rehabilitation (P = .015) remained a significant independent predictor of lower risk of readmission within 180 days. CONCLUSION: Discharge to acute inpatient rehabilitation was associated with a lower risk of hospital readmission. Identification of patients with orthopedic procedures who may benefit from inpatient rehabilitation and further medical management before discharge from the acute hospital may be an important strategy in prevention of hospital readmission.