Borkenhagen, Lynn S.

BACKGROUNDAlthough posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success.OBJECTIVETo identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30‐day readmissions.DESIGNRetrospective cohort.PATIENTSA 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.SETTINGMidwest primary care practice in an integrated health system.INTERVENTIONEnrollment in a CTP during acute hospitalization.MEASUREMENTSThe 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.RESULTSThe 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.CONCLUSIONSNo single CTP component reliably predicted reduced readmission risk. Patients with cognitive impairment and polypharmacy derived the most benefit from the program.

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.

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.

Objective. Guidelines on antiplatelet medication use during endoscopy are based on limited evidence. We investigate the risk of bleeding and ischemic events in patients undergoing endoscopic mucosal resection (EMR) of esophageal lesions in the setting of scheduled cessation and prompt resumption of clopidogrel. Design. Single centre retrospective review. Patients. Patients undergoing EMR of esophageal lesions. Interventions. Use of clopidogrel before EMR and resumption after EMR. Patients cease antiplatelets and anticoagulants 7 days before EMR and resume clopidogrel 2 days after EMR in average risk patients. Main Outcomes. Gastrointestinal bleeding (GIB) and ischemic events (IE) within 30 days of EMR. Results. 798 patients underwent 1716 EMR. 776 EMR were performed on patients on at least 1 antiplatelet/anticoagulant (APAC). 17 EMR were performed following clopidogrel cessation. There were 14 GIB and 2 IE. GIB risk in the setting of recent clopidogrel alone (0%) was comparable to those not on APAC (1.1%) (P=1.0). IE risk on clopidogrel (6.3%) was higher than those not on APAC (0.1%) (P=0.03). Limitations. Retrospective study. Conclusions. Temporary cessation of clopidogrel before EMR and prompt resumption is not associated with an increased risk of gastrointestinal bleeding but may be associated with increased ischemic events.