Magnitude of Anemia at Discharge Increases 30-Day Hospital Readmissions.

BACKGROUND: Anemia during hospitalization is associated with poor health outcomes. Does anemia at discharge place patients at risk for hospital readmission within 30 days of discharge? Our objectives were to examine the prevalence and magnitude of anemia at hospital discharge and determine whether anemia at discharge was associated with 30-day readmissions among a cohort of hospitalizations in a single health care system. METHODS: From January 1, 2009, to August 31, 2011, there were 152,757 eligible hospitalizations within a single health care system. The endpoint was any hospitalization within 30 days of discharge. The University HealthSystem Consortium's clinical database was used for demographics and comorbidities; hemoglobin values are from the hospitals' electronic medical records, and readmission status was obtained from the University HealthSystem Consortium administrative data systems. Mild anemia was defined as hemoglobin of greater than 11 to less than 12 g/dl in women and greater than 11 to less than 13 g/dl in men; moderate, greater than 9 to less than or equal to 11 g/dl; and severe, less than or equal to 9 g/dl. Logistic regression was used to assess the association of anemia and 30-day readmissions adjusted for demographics, comorbidity, and hospitalization type. RESULTS: Among 152,757 hospitalizations, 72% of patients were discharged with anemia: 31,903 (21%), mild; 52,971 (35%), moderate; and 25,522 (17%), severe. Discharge anemia was associated with severity-dependent increased odds for 30-day hospital readmission compared with those without anemia: for mild anemia, 1.74 (1.65-1.82); moderate anemia, 2.76 (2.64-2.89); and severe anemia, 3.47 (3.30-3.65), P < 0.001. CONCLUSIONS: Anemia at discharge is associated with a severity-dependent increased risk for 30-day readmission. A strategy focusing on anemia treatment care paths during index hospitalization offers an opportunity to influence subsequent readmissions.

From Bad to Worse: Anemia on Admission and Hospital-Acquired Anemia.

BACKGROUND: Anemia at hospitalization is often treated as an accompaniment to an underlying illness, without active investigation, despite its association with morbidity. Development of hospital-acquired anemia (HAA) has also been associated with increased risk for poor outcomes. Together, they may further heighten morbidity risk from bad to worse. OBJECTIVES: The aims of this study were to (1) examine mortality, length of stay, and total charges in patients with present-on-admission (POA) anemia and (2) determine whether these are exacerbated by development of HAA. DESIGN/SETTING/PATIENTS: In this cohort investigation, from January 1, 2009, to August 31, 2011, a total of 44,483 patients with POA anemia were admitted to a single health system compared with a reference group of 48,640 without POA anemia or HAA. MEASUREMENTS: Data sources included the University HealthSystem Consortium database and electronic medical records. Risk-adjustment methods included logistic and linear regression models for mortality, length of stay, and total charges. Present-on-admission anemia was defined by administrative coding. Hospital-acquired anemia was determined by changes in hemoglobin values from the electronic medical record. RESULTS: Approximately one-half of the patients experienced worsening of anemia with development of HAA. Risk for death and resource use increased with increasing severity of HAA. Those who developed severe HAA had 2-fold greater odds for death; that is, mild POA anemia with development of severe HAA resulted in greater mortality (odds ratio, 2.57; 95% confidence interval, 2.08-3.18; P < 0.001), increased length of stay (2.23; 2.16-2.31; P < 0.001), and higher charges (2.09; 2.03-2.15; P < 0.001). CONCLUSIONS: Present-on-admission anemia is associated with increased mortality and resource use. This risk is further increased from bad to worse when patients develop HAA. Efforts to address POA anemia and HAA deserve attention.

Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value.

BACKGROUND: Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric work group's results. METHODS: A work group of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below. RESULTS: The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. CONCLUSION: We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.

Hospital-acquired anemia: prevalence, outcomes, and healthcare implications.

BACKGROUND: Evidence suggests that patients with normal hemoglobin (Hgb) levels on hospital admission who subsequently develop hospital-acquired anemia (HAA) may be at risk for adverse outcomes. Our objectives were to (1) determine the prevalence of HAA and (2) examine whether HAA is associated with increased mortality, length of stay (LOS), and total hospital charges. METHODS: The population consisted of 417,301 adult hospitalizations from January 1, 2009 to August 31, 2011, in an academic medical center and 9 community hospitals. Patients with anemia on admission, and hospitals in the health system without available laboratory data were excluded; 188,447 hospitalizations were included in the analysis. Demographics, comorbidities, and outcomes were retrieved from administrative data; Hgb values were taken from the electronic medical record. Regression modeling was used to examine the association between demographics, comorbidity, hospitalization type, and HAA variables (mild: Hgb >11 and <12 g/dL for women, and >11 and <13 g/dL for men; moderate: Hgb 9.1 to ≤ 11.0 g/dL; severe: Hgb ≤ 9.0 g/dL) on mortality, LOS, and hospital charges. RESULTS: Among 188,447 hospitalizations, 139,807 patients (74%) developed HAA: mild, 40,828 (29%); moderate, 57,184 (41%); and severe, 41,795 (30%). Risk-adjusted odds ratios and 95% confidence intervals for in-hospital mortality with HAA were: mild, 1.0 (0.88-1.17; P = 0.8); moderate, 1.51 (1.33-1.71, P < 0.001); and severe, 3.28 (2.90-3.72, P < 0.001). Risk-adjusted relative mean LOS and hospital charges relative to no HAA were higher with HAA: LOS: mild, 1.08 (1.08-1.10, P < 0.001); moderate, 1.28 (1.26-1.29, P < 0.001); severe, 1.88 (1.86-1.89, P < 0.001). Hospital charges: mild, 1.06 (1.06-1.07, P < 0.001); moderate, 1.18 (1.17-1.19, P < 0.001); severe, 1.80 (1.79-1.82, P < 0.001). CONCLUSIONS: HAA is common and associated with increased mortality and resource utilization. Factors related to its development necessitate further study.