Takahashi, Paul

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.

Background and Purpose— We aimed at providing estimates of mortality associated with cardiometabolic comorbidity and incident readmission from cardiometabolic as compared with noncardiometabolic conditions after a first transient ischemic attack. Methods— Between 2000 and 2015, patients hospitalized for a first transient ischemic attack were examined for cardiometabolic comorbidities (diabetes mellitus, coronary artery disease, heart failure, and atrial fibrillation), 5-year incident hospitalization, and time to death. Results— Of 251 patients with transient ischemic attack, 134 (53%) had at least 1 and 55 (22%) had at least 2 cardiometabolic conditions. By 5 years, 491 readmissions (134 [27%] cardiometabolic and 357 [73%] noncardiometabolic) and 75 deaths (27 [36%] cardiometabolic and 47 [64%] noncardiometabolic) were observed. Mortality was increased with any concurrent cardiometabolic comorbidity (hazard ratio, 1.89; 95% confidence interval, 1.17–3.03; P =0.0089) with multiplicative mortality risk from a combination of coronary artery disease and heart failure. Each hospitalization was associated with a 1.5-fold risk of death (95% confidence interval, 1.37–1.64; P <0.0001). Risk of cardiometabolic and noncardiometabolic mortality was correlated with the corresponding category-specific readmission. Conclusions— Among patients hospitalized for first transient ischemic attack, 5-year mortality is associated with concurrent cardiometabolic comorbidity and rates of subsequent hospitalization.

Objectives To assess the degree to which self‐reported symptoms predict unplanned readmission or emergency department ( ED ) care within 30 days of high‐risk, elderly adults enrolled in a posthospitalization care transition program ( CTP ). Design Retrospective cohort study. Setting Posthospitalization CTP at Mayo Clinic, Rochester, Minnesota, from January 1, 2013, through March 3, 2015. Participants Frail, elderly adults (N = 230; mean age 83.5 ± 8.3, 46.5% male). Measurements Charlson Comorbidity Index ( CCI ) and self‐reported symptoms, measured using the Edmonton Symptom Assessment System ( ESAS ), were ascertained upon CTP enrollment. Results Mean CCI was 3.9 ± 2.3. Of 51 participants returning to the hospital within 30 days of discharge, 13 had ED visits, and 38 were readmitted. Age, sex, and CCI were not significantly different between returning and nonreturning participants, but returning participants were significantly more likely to report shortness of breath ( P = .004), anxiety ( P = .02), depression ( P = .02), and drowsiness ( P = .01). Overall ESAS score was also a significant predictor of hospital return ( P = .01). Conclusion Four self‐reported symptoms and overall ESAS score, but not CCI , ascertained after hospital discharge were strong predictors of hospital return within 30 days. Including symptoms in risk stratification of high‐risk elderly adults may help target interventions and reduce readmissions.

Background/Objectives Facing penalties for preventable 30‐day hospital readmissions, many provider groups have implemented programs to remedy this problem, but the cost efficacy and value of such programs are not well delineated. The objective was to compare total cost of care over 30 days of individuals enrolled in the Mayo Clinic Care Transitions ( MCCT ) program and individuals not enrolled. Design Retrospective cohort study using secondary data analysis of a previously published cohort study. Setting Mayo Clinic, Rochester, Minnesota. Participants MCCT participants (n = 363) and individuals in a propensity‐matched referent cohort (n = 365). Intervention MCCT program enrollment. Measurements The primary outcome was total cost of care over 30 days after hospital discharge. A 2‐part modeling strategy was used to analyze 30‐day costs: whether individuals had non‐zero costs during the 30 days after discharge and a generalized linear model for individuals who incurred costs. Potential heterogeneous effects of the MCCT program were examined according to decile of 30‐day costs using quantile regression. Results Mean age was 83 in both groups. Adjusted mean 30‐day cost after hospitalization was $3,363 (95% confidence interval ( CI ) = $2,512−4,213) in the MCCT group and $4,161 (95% CI = $3,096−5,226) in the control group ( P = .25). Cost savings of $2,744 ( P = .008) at the eighth decile and $3,388 ( P = .20) at the ninth decile were demonstrated. Thus, the only statistically significant differences were in the post hoc subgroup analysis in the highest‐cost subgroups. Conclusion We did not find a difference in overall mean costs between the MCCT group and the control group, although intervention participants in the upper deciles of costs appeared to experience lower costs than controls. A larger study cohort might better determine the value of the intervention.

AbstractBackgroundThe implications of early readmission on long‐term mortality after transient ischemic attack (TIA) are not known. We aimed at examining the effect of 180‐day readmission on subsequent long‐term mortality after index hospitalization for TIA.MethodsA retrospective study of patients hospitalized for first‐ever TIA at Mayo Clinic from 2000 through 2017. Patients readmitted within 180 days postdischarge were compared with those not readmitted in long‐term risk of death.ResultsOf 251 TIA patients aged 73 ± 15 years with 1509 person‐years of follow‐up, 65 (26%) were readmitted within 180 days of discharge and 125 died during a median follow‐up of 5.7 years. The mortality was 10 vs. 7 deaths per 100 person‐years in patients who were readmitted compared to those who were not readmitted with hazard ratio (HR) 1.73 (95% confidence interval [CI] 1.13–2.66). Other competing predictors of mortality were age ≥65 years (HR 5.70, 95% CI 2.72–11.96), cancer (HR 1.65, 95% CI 1.03–3.38), chronic obstructive pulmonary disease (HR 1.90, 95% CI 1.07–3.38), heart failure (HR 3.03, 95% CI 1.82–5.06), dementia (HR 5.87, 95% CI 3.27–10.52), creatinine ≥1.4 mg/dl (HR 1.89, 95% CI 1.17–3.06), and hemoglobin level <10 g/dl (HR 2.80, 95% CI 1.20–6.66).ConclusionsHospital readmission within 180 days of discharge from index TIA was associated with increased risk of death several years after initial readmission. Older age and several comorbidities identified during index hospitalization also confer increased risk for long‐term mortality.

Context Studies on 24-h cortisol secretion are rare. The impact of sex, age and adiposity on cortisol levels, often restricted to one or a few samples, are well recognized, but conflicting. Objective To investigate cortisol dynamics in 143 healthy men and women, spanning 7 decades and with a 2-fold body mass index (BMI) range with different analytic tools. Setting Clinical Research Unit. Design Cortisol concentrations in 10-min samples collected for 24 h. Outcomes were mean levels, deconvolution parameters, approximate entropy (ApEn, regularity statistic) and 24-h rhythms. Results Total 24-h cortisol secretion rates estimated by deconvolution analysis were sex, age and BMI independent. Mean 24-h cortisol concentrations were lower in premenopausal women than those in men of comparable age (176 ± 8.2 vs 217 ± 9.4 nmol/L, P = 0.02), but not in subjects older than 50 years. This was due to lower daytime levels in women, albeit similar in the quiescent overnight period. Aging increased mean cortisol by 10 nmol/L per decade during the quiescent secretory phase and advanced the acrophase of the diurnal rhythm by 24 min/decade. However, total 24-h cortisol secretion rates estimated by deconvolution analysis were sex, age and BMI independent. ApEn of 24-h profiles was higher (more random) in premenopausal women than those in men (1.048 ± 0.025 vs 0.933 ± 0.023, P = 0.001), but not in subjects older than 50 years. ApEn peaked during the daytime. Conclusion Sex and age jointly determine the 24-h cortisol secretory profile. Sex effects are largely restricted to age <50 years, whereas age effects elevate concentrations in the late evening and early night and advance the timing of the peak diurnal rhythm.

Background: Systemic concentrations of T, estradiol (E2), GH, IGF-1, and IGF binding protein-3 decline in healthy aging individuals. Conversely, T and E2 stimulate GH and IGF-1 production in hypogonadal patients. Hypothesis: Because E2 stimulates GH secretion, putatively via the nuclear estrogen receptor-α and E2 and GH fall with menopause, we postulated that diminished endogenous E2 contributes to low GH output in older women. Location: The study was conducted at the Mayo Center for Clinical and Translational Science. Study Design: This was a randomized, double-blind, controlled study in 60 healthy postmenopausal women treated with the following: 1) double placebo; 2) anastrozole, a potent inhibitor of aromatase-enzyme activity, which mediates E2 synthesis from T; and/or 3) fulvestrant, a selective estrogen receptor-α antagonist. Methods: GH pulse generation was quantified by frequent GH sampling before and after short-term iv somatostatin infusion, thought to induce hypothalamic GHRH-mediated rebound-like GH secretion. Results: On anastrozole, E2 fell from 3.1 ± 0.35 pg/mL to 0.36 ± 0.04 pg/mL, and estrone from 13 ± 1.4 pg/mL to 1.9 ± 0.01 pg/mL (P &lt; .001) by mass spectrometry. Estrogen values were unchanged by fulvestrant. T concentrations did not change. One-hour peak GH rebound after somatostatin infusion declined markedly during both estrogen-deprivation schedules (P &lt; .001). Mean (150 min) maximal GH rebound decreased comparably (P &lt; .001). Measures of GH rebound correlated negatively with computed tomography-estimated abdominal visceral fat (all P &lt; .05). Conclusion: These data suggest a previously unrecognized dependence of hypothalamo-pituitary GH regulation on low levels of endogenous estrogen after menopause.

Background Socioeconomic status (SES) is an important predictor for outcomes of chronic diseases. However, it is often unavailable in clinical data. We sought to determine whether an individual housing-based SES index termed HOUSES can influence the likelihood of multiple chronic conditions (MCC) and hospitalisation in a community population. Methods Participants were residents of Olmsted County, Minnesota, aged >18 years, who were enrolled in Mayo Clinic Biobank on 31 December 2010, with follow-up until 31 December 2011. Primary outcome was all-cause hospitalisation over 1 calendar-year. Secondary outcome was MCC determined through a Minnesota Medical Tiering score. A logistic regression model was used to assess the association of HOUSES with the Minnesota tiering score. With adjustment for age, sex and MCC, the association of HOUSES with hospitalisation risk was tested using the Cox proportional hazards model. Results Eligible patients totalled 6402 persons (median age, 57 years; 25th–75th quartiles, 45–68 years). The lowest quartile of HOUSES was associated with a higher Minnesota tiering score after adjustment for age and sex (OR (95% CI) 2.4 (2.0 to 3.1)) when compared with the highest HOUSES quartile. Patients in the lowest HOUSES quartile had higher risk of all-cause hospitalisation (age, sex, MCC-adjusted HR (95% CI) 1.53 (1.18 to 1.98)) compared with those in the highest quartile. Conclusions Low SES, as assessed by HOUSES, was associated with increased risk of hospitalisation and greater MCC health burden. HOUSES may be a clinically useful surrogate for SES to assess risk stratification for patient care and clinical research.