Mini-Navigation Utilization in THA Results in Shorter Length of Stay, Increased Home Discharge, and Higher Physical Therapy Mobilization Scores Compared to THA Without Navigation.

BACKGROUND: As volume of total hip arthroplasty (THA) continues to increase, the utilization and availability of in-traoperative advanced technologies to arthroplasty surgeons continues to rise as well. Our primary goal was to determine whether the use of a mini navigation technology extended operative times and secondarily if it affected postoperative outcomes following elective THA. METHODS: A single-institution total joint arthroplasty da-tabase was utilized to identify adult patients who underwent elective THA from 2017 to 2019. Baseline demographic data along with surgical operative time, length of stay (LOS) and discharge disposition were collected. The Activity Measure for Post-Acute Care (AM-PAC) was used to determine physi-cal therapy progress. RESULTS: A total of 1,162 THAs were performed of which 69.1% (803) used navigation while 30.9% (359) did not. Baseline demographics including age, sex, body mass index (BMI), insurance, and smoking status were not statistically different between groups. The operative time was shorter in the navigation group compared to THA without navigation (115.1 vs. 118.9 min, p < 0.0001). Mean LOS was signifi-cantly shorter in the navigation THA group as compared to THA without navigation (2.1 vs. 2.6 days, p < 0.0001). Postoperative AM-PAC scores were higher in the navigation group on postoperative day 1 as compared to patients with-out navigation (18.87 vs. 17.52, p < 0.0001). Additionally, a greater percentage of patients were discharged directly home after THA with navigation as compared to THA without navigation (89.54% vs. 83.57%, p < 0.0001). CONCLUSION: Our study demonstrates that hip navigation technology in the setting of THA is associated with reduced operative times and higher AM-PAC mobilization scores. Hip mini navigation technology shortens operative times while improving early patient outcome scores in association with shorter LOS and greater home-based discharge.

Hospital Readmission Rates for Patients Receiving In-Person vs. Telemedicine Discharge Follow-Up Care.

INTRODUCTION: Unplanned readmissions can be avoided by standardizing and improving the coordination of care after discharge. Telemedicine has been increasingly utilized; however, the quality of this care has not been well studied. Standardized measures can provide an objective comparison of care quality. The purpose of our study was to compare quality performance transitions of care management in the office vs telemedicine. METHODS: The Epic SlicerDicer tool was used to compare the percentage of encounters that were completed via telemedicine (video visits); or via in-person for comparison, Chi-squared tests were used. RESULTS: A total of 13,891 patients met the inclusion criteria during the study time frame. There were 12,846 patients in the office and 1,048 in the telemedicine cohort. The office readmission rate was 11.9% with 1,533 patients out of 12,846 compared with telemedicine with the rate of readmission at 12.1% with 126 patients out of 1,045 patients. The P-value for the Chi-squared test between the prepandemic and study time frame was 0.15 and 0.95, respectively. Demographic comparability was seen. DISCUSSION: Our study found a comparable readmission rate between patients seen via in-office and telemedicine for Transitions of Care Management (TCM) encounters. The findings of this study support the growing body of evidence that telemedicine augments quality performance while reducing cost and improving access without negatively impacting HEDIS performance in health care systems. CONCLUSION: Telemedicine poses little threat of negatively impacting HEDIS performance and might be as effective as posthospitalization traditional office care transitions of care management.

Inflammatory subphenotypes previously identified in ARDS are associated with mortality at intensive care unit discharge: a secondary analysis of a prospective observational study.

BACKGROUND: Intensive care unit (ICU)-survivors have an increased risk of mortality after discharge compared to the general population. On ICU admission subphenotypes based on the plasma biomarker levels of interleukin-8, protein C and bicarbonate have been identified in patients admitted with acute respiratory distress syndrome (ARDS) that are prognostic of outcome and predictive of treatment response. We hypothesized that if these inflammatory subphenotypes previously identified among ARDS patients are assigned at ICU discharge in a more general critically ill population, they are associated with short- and long-term outcome. METHODS: A secondary analysis of a prospective observational cohort study conducted in two Dutch ICUs between 2011 and 2014 was performed. All patients discharged alive from the ICU were at ICU discharge adjudicated to the previously identified inflammatory subphenotypes applying a validated parsimonious model using variables measured median 10.6 h [IQR, 8.0-31.4] prior to ICU discharge. Subphenotype distribution at ICU discharge, clinical characteristics and outcomes were analyzed. As a sensitivity analysis, a latent class analysis (LCA) was executed for subphenotype identification based on plasma protein biomarkers at ICU discharge reflective of coagulation activation, endothelial cell activation and inflammation. Concordance between the subphenotyping strategies was studied. RESULTS: Of the 8332 patients included in the original cohort, 1483 ICU-survivors had plasma biomarkers available and could be assigned to the inflammatory subphenotypes. At ICU discharge 6% (n = 86) was assigned to the hyperinflammatory and 94% (n = 1397) to the hypoinflammatory subphenotype. Patients assigned to the hyperinflammatory subphenotype were discharged with signs of more severe organ dysfunction (SOFA scores 7 [IQR 5-9] vs. 4 [IQR 2-6], p < 0.001). Mortality was higher in patients assigned to the hyperinflammatory subphenotype (30-day mortality 21% vs. 11%, p = 0.005; one-year mortality 48% vs. 28%, p < 0.001). LCA deemed 2 subphenotypes most suitable. ICU-survivors from class 1 had significantly higher mortality compared to class 2. Patients belonging to the hyperinflammatory subphenotype were mainly in class 1. CONCLUSIONS: Patients assigned to the hyperinflammatory subphenotype at ICU discharge showed significantly stronger anomalies in coagulation activation, endothelial cell activation and inflammation pathways implicated in the pathogenesis of critical disease and increased mortality until one-year follow up.

Discharge within 24 h, transvaginal natural orifice transluminal endoscopic surgery- more suitable for ambulatory surgery in gynecology procedures: a retrospective study.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) is an achievement in the field of minimally invasive surgery. However, the vantage point of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecologicalprocedures remains unclear. The main purpose of this study was to compare vNOTES with laparo-endoscopic single-site surgery, and to determine which procedure is more suitable for ambulatory surgery in gynecologic procedures. METHODS: This retrospective observational study was conducted at the Department of Gynecology, Chengdu Women's and Children's Central Hospital. The 207 enrolled patients had accepted vNOTES and laparo-endoscopic single-site surgery in gynecology procedures from February 2021 to March 2022. Surgically relevant information regarding patients who underwent ambulatory surgery was collected, and 64 females underwent vNOTES. RESULTS: Multiple outcomes were analyzed in 207 patients. The Wilcoxon Rank-Sum test showed that there were statistically significant differences between the vNOTES and laparo-endoscopic single-site surgery groups in terms of postoperative pain score (0 vs. 1 scores, p = 0.026), duration of anesthesia (90 vs. 101 min, p = 0.025), surgery time (65 vs. 80 min, p = 0.015), estimated blood loss (20 vs. 40 mL, p < 0.001), and intestinal exhaustion time (12.20 vs. 17.14 h, p < 0.001). Treatment with vNOTES resulted in convenience, both with respect to time savings and hemorrhage volume in surgery and with respect to the quality of the prognosis. CONCLUSION: These comprehensive data reveal the capacity of vNOTES to increase surgical efficiency. vNOTES in gynecological procedures may demonstrate sufficient feasibility and provide a new medical strategy compared with laparo-endoscopic single-site surgery for ambulatory surgery in gynecological procedures.

Interpretable (not just posthoc-explainable) medical claims modeling for discharge placement to reduce preventable all-cause readmissions or death.

We developed an inherently interpretable multilevel Bayesian framework for representing variation in regression coefficients that mimics the piecewise linearity of ReLU-activated deep neural networks. We used the framework to formulate a survival model for using medical claims to predict hospital readmission and death that focuses on discharge placement, adjusting for confounding in estimating causal local average treatment effects. We trained the model on a 5% sample of Medicare beneficiaries from 2008 and 2011, based on their 2009-2011 inpatient episodes (approximately 1.2 million), and then tested the model on 2012 episodes (approximately 400 thousand). The model scored an out-of-sample AUROC of approximately 0.75 on predicting all-cause readmissions-defined using official Centers for Medicare and Medicaid Services (CMS) methodology-or death within 30-days of discharge, being competitive against XGBoost and a Bayesian deep neural network, demonstrating that one need-not sacrifice interpretability for accuracy. Crucially, as a regression model, it provides what blackboxes cannot-its exact gold-standard global interpretation, explicitly defining how the model performs its internal "reasoning" for mapping the input data features to predictions. In doing so, we identify relative risk factors and quantify the effect of discharge placement. We also show that the posthoc explainer SHAP provides explanations that are inconsistent with the ground truth model reasoning that our model readily admits.

Prevalence and factors associated with inappropriate continuation of stress ulcer prophylaxis at discharge.

Stress ulcer prophylaxis is started in the critical care unit to decrease the risk of upper gastrointestinal ulcers in critically ill persons and to decrease mortality caused by stress ulcer complications. Unfortunately, the drugs are often continued after recovery through discharge, paving the way for unnecessary polypharmacy. STUDY DESIGN: We conducted a retrospective cross-sectional study including patients admitted to the adult critical care unit and started on the stress ulcer prophylaxis with a proton pump inhibitor (PPI) or histamine receptor 2 blocker (H2 blocker) with an aim to determine the prevalence of inappropriate continuation at discharge and associated factors. RESULT: 3200 people were initiated on stress ulcer prophylaxis, and the medication was continued in 1666 patients upon discharge. Indication for long-term use was not found in 744 of 1666, with a 44% prevalence of inappropriate continuation. A statistically significant association was found with the following risk factors: discharge disposition (home vs other medical facilities, p=0.002), overall length of stay (more than 10 days vs less than or equal to 10 days, p<0.0001), mechanical ventilator use (p<0.001), number of days on a mechanical ventilator (more than 2 days vs less than or equal to 2 days, p<0.001) and class of stress ulcer prophylaxis drug used (H2 blocker vs PPI, p<0.001). CONCLUSION: The prevalence of inappropriate continuation was found to be higher than prior studies. Given the risk of unnecessary medication intake and the associated healthcare cost, a web-based quality improvement initiative is being considered.

Rethinking postoperative care: same-day ileostomy closure discharge improves patient outcomes.

BACKGROUND: The evolution of enhanced recovery pathways (ERPs) in colon and rectal surgery has led to the development of same-day discharge (SDD) procedures for selected patients. Early discharge after diverting loop ileostomy (DLI) closure was first described in 2003. However, its widespread adoption remains limited, with SDD accounting for only 3.2% of all DLI closures in 2005-2006, according to the American College of Surgeons National Surgical Quality Improvement Program database, and rising to just 4.1% by 2016. This study aimed to compare the outcomes of SDD DLI closure with those of DLI closure after the standard ERP. METHODS: A retrospective case-matched study compared 125 patients undergoing SDD DLI closure with 250 patients undergoing DLI closure after the standard ERP based on age (±1 year), sex, American Society of Anesthesiologists score, body mass index, surgery date (±2 months), underlying disease, and hospital site. The primary outcome was comparative 30-day complication rates. RESULTS: Patients in the traditional ERP group received more intraoperative fluids (1221.1 ± 416.6 vs 1039.0 ± 368.3 mL, P < .001) but had similar estimated blood loss. Ten patients (8%) in the SDD-ERP group failed SDD. The 30-day postoperative complication rate was significantly lower in the SDD group (14.8%) than the standard ERP group (25.7%, P = .025). This difference was primarily driven by a lower incidence of ileus in the SDD group (9.6% vs 14.8%, P = .034). There were no significant differences in readmission rate (9.6% of SDD-ERP vs 9.2% of standard ERP, P = .900) and reoperation rates (3.2% of SDD-ERP vs 2.4% of standard ERP, P = .650). CONCLUSION: SDD ileostomy closure is a safe, feasible, and effective procedure associated with fewer complications than the present study's standard ERP. This could represent a new standard of care. Further prospective trials are required to confirm the findings of this study.

Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice.

Importance: Transitions in care settings following live discharge from hospice care are burdensome for patients and families. Factors contributing to risk of burdensome transitions following hospice discharge are understudied. Objective: To identify factors associated with 2 burdensome transitions following hospice live discharge, as defined by the Centers for Medicare & Medicaid Services. Design, Setting, and Participants: This population-based retrospective cohort study included a 20% random sample of Medicare fee-for-service beneficiaries using 2014 to 2019 Medicare claims data. Data were analyzed from April 22, 2023, to March 4, 2024. Exposure: Live hospice discharge. Main Outcomes and Measures: Multivariable logistic regression examined associations among patient, health care provision, and organizational characteristics with 2 burdensome transitions after live hospice discharge (outcomes): type 1, hospice discharge, hospitalization within 2 days, and hospice readmission within 2 days; and type 2, hospice discharge, hospitalization within 2 days, and hospital death. Results: This study included 115 072 Medicare beneficiaries discharged alive from hospice (mean [SD] age, 84.4 [6.6] years; 71892 [62.5%] female; 5462 [4.8%] Hispanic, 9822 [8.5%] non-Hispanic Black, and 96 115 [83.5%] non-Hispanic White). Overall, 10 381 individuals (9.0%) experienced a type 1 burdensome transition and 3144 individuals (2.7%) experienced a type 2 burdensome transition. In adjusted models, factors associated with higher odds of burdensome transitions included identifying as non-Hispanic Black (type 1: adjusted odds ratio [aOR], 1.47; 95% CI, 1.36-1.58; type 2: aOR, 1.70; 95% CI, 1.51-1.90), hospice stays of 7 days or fewer (type 1: aOR, 1.13; 95% CI, 1.06-1.21; type 2: aOR, 1.71; 95% CI, 1.53-1.90), and care from a for-profit hospice (type 1: aOR, 1.78; 95% CI, 1.62-1.96; type 2: aOR, 1.32; 95% CI, 1.15-1.52). Nursing home residence (type 1: aOR, 0.66; 95% CI, 0.61-0.72; type 2: aOR, 0.47; 95% CI, 0.40-0.54) and hospice stays of 180 days or longer (type 1: aOR, 0.63; 95% CI, 0.59-0.68; type 2: aOR, 0.60; 95% CI, 0.52-0.69) were associated with lower odds of burdensome transitions. Conclusion and Relevance: This retrospective cohort study of burdensome transitions following live hospice discharge found that non-Hispanic Black race, short hospice stays, and care from for-profit hospices were associated with higher odds of experiencing a burdensome transition. These findings suggest that changes to clinical practice and policy may reduce the risk of burdensome transitions, such as hospice discharge planning that is incentivized, systematically applied, and tailored to needs of patients at greater risk for burdensome transitions.

The impact of hospitalization on inappropriate prescribing and polypharmacy in older patients: A descriptive cross-sectional study.

BACKGROUND: Polypharmacy and the use of potentially inappropriate medications (PIMs) in older individuals are widespread phenomena that are associated with an increase in morbidity and mortality. The Beers Criteria is a tool that helps to identify patients that are prescribed with PIMs, thereby reducing the risk of associated harm. Amongst other populations, the criteria identify drugs that should not be used by the majority of older patients. AIM: Determining the proportion of older inpatients who were discharged from hospitalization with polypharmacy (a prescription for more than seven drugs), or with a PIM as defined by the Beers Criteria. METHODS: A descriptive cross-sectional study based on patients aged 65 and over who were hospitalized in the years 2019-2021 in the internal medicine, orthopedic and surgical wards at a medium-size hospital. Demographic information and details about drug treatment were collected from the electronic patient records system. Patients who died during hospitalization were excluded from the study group. MAIN OUTCOME MEASURES: The proportion of inpatients with polypharmacy or a PIM as part of their regular prescription, at the time of admission and at discharge. RESULTS: 49 564 patients were included in the study cohort. At discharge, 19% of the patients were given a prescription for a PIM, with a small but significant decrease compared with the rate admission (22.1%). At discharge, 42.8% of patients had polypharmacy, representing a small but significant increase compared with the rate on admission (40.6%). CONCLUSIONS: The study demonstrated high baseline rates of PIM prescription and polypharmacy. Hospitalization was associated with a decrease in PIM prescription and an increase in polypharmacy. This highlights the importance of medication review during admission to reduce the potential risk to older adults from polypharmacy and PIM prescription.

Re-Admissions of 'Unknown' Traumatic Brain Injury Patients - Inadequacy of Rehabilitative Services in a Developing Country.

BACKGROUND: In neurosurgical practice, continuous care after discharge and the ability to detect subtle indicators of clinical deterioration are mandatory to prevent the progression of a disease. The care of 'unknown' patients discharged to rehabilitation homes may not have this privilege, especially in resource-poor countries such as India. OBJECTIVE: We have attempted to study the causes and outcomes of re-admissions of 'unknown' patients with previous traumatic brain injury (TBI) to estimate the quality of nursing care in our rehabilitation centers. MATERIAL AND METHODS: The electronic hospital records of all consecutive 'unknown' TBI patients with unplanned re-admissions at our institute from January 2014 to December 2018 were retrospectively reviewed and analyzed for the factors determining the risk and outcomes of re-admission. RESULTS: Out of 245 patients sent to rehabilitation homes at discharge, 47 patients (19.18%) were re-admitted. A total of 33 patients (70%) were re-admitted between 1 month and 1 year. Out of these, 38 patients (80.9%) were re-admitted because of preventable causes. Fifteen patients (31.9%) died during the hospital stay. The rest of the 32 (68%) patients were discharged after the management of the concerned condition with an average hospital stay of 9 ± 11.1 days. The average Glasgow coma scale (GCS) at re-admission of the patients who died was 6 (range 3-11). Two patients were brought in the brain dead status, whereas 20 patients (42.6%) had a GCS of 5 or below at the time of re-admission. The risk of mortality among patients with non-preventable causes was 88.9% (8/9) compared to preventable causes 18.4% (7/38). However, preventable causes for re-admission are much more common, resulting in nearly a similar overall contribution to mortality. CONCLUSIONS: There is a high rate of mortality and morbidity in 'unknown' patients with TBI because of poor post-discharge care in developing countries. Because preventable causes are the major contributor to re-admissions, the re-admission rate is a good indicator of a lack of adequate rehabilitative services. The need for improving the post-discharge management of 'unknown' patients with TBI in resource-poor countries cannot be over-emphasized.

Investigation of pre-discharge learning needs and affecting factors in individuals with burns.

BACKGROUND: In discharge phase process, supporting patients to develop their own self-care strategies will increase their self-management skills and reduce complications and other health problems that may arise. AIM: The aim of the study is to examine the learning needs of individuals with burns regarding pre-discharge care and treatment and the factors affecting them. METHOD: Data from this cross-sectional study was collected with the "Descriptive Characteristics Form" and "Patient Learning Needs Scale (PLNS)". The study population consisted of patients hospitalized in the adult burn unit of a university hospital in eastern Turkey between May and October 2021. RESULTS: In the present study, it was observed that the pre-discharge learning needs of the patients were at a high level according to the mean score of the general score of the PLNS. Education level, marital status, companion experience and body mass index effected PLNS. CONCLUSIONS: In light of the results, it is recommended that discharge training be planned individually and determined according to the individual's learning needs and affecting factors.

Primary anastomosis with diverting loop ileostomy vs. Hartmann's procedure for acute diverticulitis: what happens after discharge? Results of a nationwide analysis.

BACKGROUND: Current guidelines recommend resection with primary anastomosis with diverting loop ileostomy over Hartmann's procedure if deemed safe for acute diverticulitis. The primary objective of the current study was to compare the utilization of these strategies and describe nationwide ostomy closure patterns and readmission outcomes within 1 year of discharge. METHODS: This was a retrospective, population-based, cohort study of United States Hospitals reporting to the Nationwide Readmissions Database from January 2011 to December 2019. There were 35,774 patients identified undergoing non-elective primary anastomosis with diverting loop ileostomy or Hartmann's procedure for acute diverticulitis. Rates of ostomy closure, unplanned readmissions, and complications were compared. Cox proportional hazards and logistic regression models were used to control for patient and hospital-level confounders as well as severity of disease. RESULTS: Of the 35,774 patients identified, 93.5% underwent Hartmann's procedure. Half (47.2%) were aged 46-65 years, 50.8% female, 41.2% publicly insured, and 91.7% underwent open surgery. Primary anastomosis was associated with higher rates of 1-year ostomy closure (83.6% vs. 53.4%, p < 0.001) and shorter time-to-closure [median 72 days (Interquartile range 49-103) vs. 115 (86-160); p < 0.001]. Primary anastomosis was associated with increased unplanned readmissions [Hazard Ratio = 2.83 (95% Confidence Interval 2.83-3.37); p < 0.001], but fewer complications upon stoma closure [Odds Ratio 0.51 (95% 0.42-0.63); p < 0.001]. There were no differences in complications between primary anastomosis and Hartmann's procedure during index admission [Odds Ratio = 1.13 (95% Confidence Interval 0.96-1.33); p = 0.137]. CONCLUSION: Patients who undergo primary anastomosis for acute diverticulitis are more likely to undergo ostomy reversal and experience fewer postoperative complications upon stoma reversal. These data support the current national guidelines that recommend primary anastomosis in appropriate cases of acute diverticulitis requiring operative treatment.

Enhanced recovery after surgery after radical gastrectomy: Improved compliance over time is associated with a shorter postoperative hospital stay.

BACKGROUND: Changing adherence over time to enhanced recovery after surgery (ERAS) protocols following radical gastrectomy and the impact this has on length of stay (LoS) is not well described. This study aimed to explore the changes in adherence to core ERAS elements over time and the relationship between compliance and LoS. METHODS: A retrospective, single center cohort study was performed between 01/2016-12/2021. An ad hoc analysis revealed the point at which a significant difference in the number of patients being discharge on postoperative day (PoD) 3 was noted allowing allocation of patients to Group A (01/2016-12/2019) or B (01/2020-12/2021). Compliance with core ERAS elements was compared and the relationship between compliance and discharge by (PoD) 3 assessed. Variables significant on univariate analysis were assessed using binary multivariate regression. RESULTS: Of the 268 patients identified, 187 met the inclusion criteria (Group A 112 and Group B 75). More patients in Group B mobilized on PoD 1 (60.0 vs. 31.3%, p = <0.001), tolerated postgastrectomy diet by PoD 3 (84.6 vs. 62.5%, p = 0.049), and were discharged by PoD 3 (34.7 vs. 20.5%, p = 0.002). Protocol compliance of >75% was associated with discharge on PoD 3 (area under the curve, 0.726). Active mobilization on PoD 1 (OR 3.5, p = 0.009), compliance ≥75% (OR 3.3, p = 0.036), and preoperative nutritional consult (OR 0.2, p = 0.002) were independently associated with discharge on PoD 3. Discharge on PoD 3 did not increase readmission or representation to hospital. CONCLUSION: Early mobilization, protocol compliance >75%, and preoperative nutritional consult were associated with discharge on PoD 3 after radical gastrectomy.

Outcomes of a same day discharge protocol in patients undergoing mastectomy and implant reconstruction.

BACKGROUND: Finite hospital resources has required a closer look at resource allocation. This has prompted a shift toward same day surgeries and a focus on reducing hospital readmissions. Following the institution of a same day discharge protocol for mastectomy and mastectomy with immediate reconstruction, we sought to assess differences in the length of stay and readmission rates. METHODS: This retrospective review evaluates all cases of mastectomy with or without immediate reconstruction performed at a single high-volume center between June 2019 and March 2021. Average length of stay, 30-day readmission rates, Anesthesia Society Assessment class, and type of immediate reconstruction were assessed. Autologous reconstructions were excluded. RESULTS: A total of 413 patients underwent mastectomy with or without reconstruction (n = 148 pre protocol and n = 265 during protocol) between June 2019 and March 2021. Of those 413 patients, 180 underwent reconstruction (n = 62 pre protocol and n = 118 during protocol). The average length of stay after mastectomy following the implementation of the same day discharge protocol was decreased at 0.6 days (n = 265) compared to preimplementation at 1.02 days (n = 148), p < 0.001. The 30-day readmission rate was not significant between the groups, p = 0.13. A total of 180 patients underwent immediate reconstruction after mastectomy. The average length of stay after mastectomy with immediate reconstruction following implementation of the same day discharge protocol was shorter than preimplementation at 1.05 days preimplementation (n = 62) versus 0.58 days following implementation (n = 118), p < 0.001; this finding was significant for both prepectoral and subpectoral implants, p < 0.001. There was no significant difference in 30-day readmission rates between the groups with immediate reconstruction, p = 0.34. CONCLUSION: Same day discharge for mastectomy with reconstruction is as safe as the more widely recognized same day discharge practice for patients with mastectomy alone.

Early Discharge after Enhanced Recovery Colectomy Does Not Increase Emergency Department Visits and Readmissions: A Single Institution Analysis.

BACKGROUND: Same-day discharge after colorectal surgery in enhanced recovery pathways is increasing. This study aimed to determine if discharge on postoperative days (POD) one or two is associated with increased rates of emergency department (ED) visits and hospital readmissions after left and right colectomy. METHODS: Single institution retrospective analysis of prospective institutional colorectal surgery database between 07/01/2018 and 07/15/2022. Primary outcomes were ED visit and readmission rates for enhanced recovery open and minimally invasive right and left colectomy using logistic regressions models. RESULTS: 820 patients met inclusion criteria. There were significant differences in discharge-day by diagnosis-58.5% of patients with Crohn's disease were discharged on POD ≥4 and 21.6% with benign colon neoplasia were discharged on POD-0-1 (P < .001). ED visits occurred in 12.9% of the study population and were not significantly different between discharge-day groups (P = .096). Overall readmission rate was 8.5% and significantly different between discharge-day groups (0% POD-0 vs 8.3% POD-1 vs 5.8% POD-2 vs 6.9% POD-3 vs 12.9% POD ≥4, P = .041). Logistic regression showed that ED visits and readmissions for longer discharge-days (POD-2, POD-3, POD ≥4) were not significantly different than POD-0-1. Readmission diagnoses for the study population were higher for ileus (17.1%) and surgical site infection (SSI) type-III (22.9%) than for acute kidney injury (1.4%) and SSI type-I/II (1.4%). CONCLUSION: Early discharge after left and right colectomy is not associated with increased rates of ED visits and readmissions. Same-day discharge may be feasible in selected enhanced recovery patients. Standardized post-discharge resources that safely allow same-day discharge require further investigation.

Sociodemographic and treatment-related determinants of recent substance use among adults with comorbid substance misuse and psychotic disorders discharged from substance use treatment.

INTRODUCTION: Rates of alcohol and illicit substance use are higher among persons with psychotic disorders relative to the general population. The adverse health and psychological effects of substance use behaviors disproportionately impact persons with psychotic disorders. Prior research has shown that persons with psychotic disorders experience increased difficulty in reducing substance use behaviors, and interventions targeting substance use behavior change among this population have demonstrated limited effectiveness. One reason for this is that little is known about the factors that influence substance use and behavior change among this population. To address these disparities, the present study investigated sociodemographic and treatment-related factors of substance use recurrence among persons with psychotic disorders who received substance use treatment services. METHODS: Data came from the 2015-2018 Treatment Episode Dataset-Discharges (TEDS-D). TEDS-D collects annual data on adolescent and adult discharges from state-certified substance use treatment centers in the United States. The study conducted all analyses with a subsample of 1956 adult discharges with a psychotic disorder who received services from an outpatient substance use treatment center for at least one month. χ2 tests of independence and multivariable logistic regression analyses were used to examine associations of sociodemographic and treatment-related characteristics with substance use recurrence while in treatment (α < 0.05 analyses). The study presents results from multivariable logistic regression models as adjusted odds ratios (AORs) with 95 % confidence intervals (CI). RESULTS: Those who were age 50 or older, were referred to treatment by the criminal justice system, and attended substance use self-help groups had lower odds of substance use recurrence while in treatment. Sex, educational attainment, employment status, living situation, type of substance use, and treatment history were not significantly associated with substance use recurrence. CONCLUSIONS: In designing treatment services, providers should consider whether focusing on sociodemographic, including cultural, factors can affect more positive substance use behavior change and other desired treatment outcomes among those with psychotic disorders and comorbid substance misuse. Further study is needed to identify these factors among specific subpopulations of those with psychotic disorders and substance misuse.

[Discharge management strategies in German general hospitals : A nationwide survey of professionals responsible for clinical risk management]. / Strategien des Entlassmanagements in deutschen Allgemeinkrankenhäusern : Deutschlandweite Befragung von Verantwortlichen des klinischen Risikomanagements.

BACKGROUND: Transitions from inpatient care are associated with risks for the safety of patients. In 2017, the framework agreement on discharge management was legally defined. There is currently a lack of empirical data in Germany on the implementation of measures to ensure safe transitions of patients after inpatient care. The aim of this study is to provide an overview of the discharge management strategies implemented by German general hospitals. METHODS: Between March and May 2022, specific discharge management strategies as well as structural and organizational characteristics were assessed in a nationwide survey of 401 general hospitals, and descriptive statistics and group comparisons were performed. RESULTS: Seven of nine strategies surveyed were implemented in > 95% of all hospitals. The evaluation of discharge planning was only implemented in 61% of the hospitals, and systematic documentation, analysis, and evaluation of readmissions in 54%. Hospitals with a higher number of hospital beds reported significantly less often about "early contact with follow-up care providers" and "organization of a seamless transition to follow-up care." DISCUSSION: A large part of the strategies in discharge management from inpatient treatment is implemented in German general hospitals. However, measures for evaluation and the systematic analysis of discharge processes and readmissions of patients have only been partially implemented. However, these are necessary to systematically evaluate and potentially improve the discharge processes.

Emulated Trial for Discharge Prescription of Guideline-Directed Medical Therapy and 15-Year Survival After Coronary Artery Bypass Graft Surgery.

OBJECTIVES: To explore admission and discharge prescription rates of guideline-directed medical therapy (GDMT), defined as aggregate antiplatelet agents, statins, and ß-blockers, after coronary artery bypass graft (CABG) surgery and to reveal its association with long-term survival. PATIENTS AND METHODS: This is a prospective cohort study-based emulated trial of patients undergoing elective or semi-elective isolated CABG surgery in 7 cardiothoracic units in Israel from January 1, 2004, to December 31, 2007, and followed up until December 31, 2020, for all-cause mortality. RESULTS: Only 59.2% of 968 patients (n=573) were discharged on GDMT after CABG surgery. Admission GDMT use conferred a 7 times greater likelihood of discharge GDMT prescription (odds ratio, 7.07; 95% CI, 5.04 to 9.91; P<.001), with no sex differences observed. After applying inverse probability of treatment weighting, baseline characteristics were well balanced between groups. During a median follow-up of 13.7 years, a Cox regression model with propensity score-adjusted inverse probability of treatment weighting revealed lower mortality in patients with discharge GDMT prescription who underwent CABG surgery than in their counterparts (hazard ratio, 0.75; 95% CI, 0.60 to 0.93; P=.008). CONCLUSION: The use of aggregate GDMT before surgery conferred a greater likelihood of GDMT prescription upon discharge, which, in turn, is associated with better long-term survival. Educational efforts of pertinent medical professionals are needed to minimize preventive treatment gaps. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00356863.

Perioperative Morbidity Associated with Same-day Discharge in Elderly Patients.

INTRODUCTION AND HYPOTHESIS: We compared postoperative complications in elderly patients discharged on POD#0 versus POD#1 after prolapse repair. METHODS: Data were obtained from the National Surgical Quality Improvement database. A total of 20,984 women 65 years and older who underwent prolapse repair between 2014 and 2020 were analyzed. Patient demographics, comorbidities, readmission, reoperation, and 30-day postoperative complications were compared in patients discharged on POD#0 versus POD#1. A sensitivity analysis was completed to examine outcomes in patients who underwent an apical prolapse repair. Multivariate logistic regression was performed to evaluate for potential confounders. RESULTS: Age, race, ethnicity, American Society of Anesthesiologists class, prolapse repair type, and operative time were significantly different in patients discharged on POD#0 vs POD#1 (all p < 0.01). Patients discharged on POD#0 had significantly fewer postoperative complications (2.63% vs 3.44%) and readmissions (1.56% vs 2.18%, all p < 0.01). On multivariate regression modeling, postoperative discharge day was independently associated with complications, but not with readmissions or reoperation after. Patients who underwent an apical prolapse repair and were discharged on POD#0 had significantly more postoperative complications (3.5% vs 2.5%, p = 0.02) and readmissions (2.42% vs 10.08%, p < 0.01) than those discharged on POD#1. In this group, multivariate regression modeling demonstrated that postoperative discharge day was independently associated with any postoperative complication. CONCLUSIONS: For elderly women undergoing prolapse repair, the type of surgery should be considered when determining postoperative admission versus same-day discharge. Admission overnight does not seem to benefit women undergoing vaginal repairs but may decrease overall morbidity and risk of readmission in women undergoing an apical prolapse repair.