In This Edition
Literature At A Glance
A guide to this month’s studies
- Hospitalist views on readmission prevention
- Characteristics of hospital ICU readmission
- Effect of clopidogrel on bleeding outcomes in vascular surgery
- Time-versus tissue-based diagnosis of TIA
- ETT versus ETT with imaging for the diagnosis of CAD in women
- Effect of high urine output with adequate hydration on contrast-induced nephropathy
- Stroke rate in CABG patients with severe carotid artery stenosis
- Effect of cardiac arrest on long-term cognition
Hospitalists View Readmissions as Potentially Preventable by Team-Based Care
Clinical question: How do front-line hospitalists perceive the preventability of early hospital readmissions?
Background: Hospital readmission has received national attention as an indicator of poor healthcare quality and unnecessary costs. While some studies suggest that some readmissions are preventable, the exact number is unknown. Understanding preventability and the views of front-line clinicians might help hospitalists balance multifactorial compromise between throughput and length of stay.
Study design: Retrospective cohort study.
Setting: Two community tertiary-care hospitals and two suburban hospitals staffed by a single hospitalist group in Portland, Ore.
Synopsis: A group of 17 hospitalists analyzed the inpatient and outpatient charts of 300 consecutive patients readmitted within 21 days of discharge using a structured data collection tool to record patient characteristics, process measures, and perceived preventability of the readmission. Patients were either discharged by internal-medicine hospitalists or had an internal-medicine consultation during their initial stay.
Characteristics of readmitted patients and initial hospital stays were similar to those previously reported in other studies. More than 60% of readmissions were deemed preventable (15%) or possibly preventable (46%). As prevention strategies for these readmissions, hospitalists most frequently suggested interventions under their control, such as longer initial hospital stay (23%). Other potential interventions focused on system approaches, including outpatient appointments, case management, palliative care, and home health.
In most cases (96%), the reviewer was not the discharging hospitalist. Only six hospitalists performed 83% of the reviews, and inter-reviewer reliability was not assessed. Other limitations included confounding biases, such as timing of review, source hospital reviewed, reviewer optimism, and previous primary-care experience of reviewer.
Bottom line: Prevention of hospital readmissions will require a balance between increased length of stay and system-based team approaches beyond the direct control of hospitalists.
Citation: Koekkoek D, Bayley KB, Brown A, Rustvold DL. Hospitalists assess the causes of early hospital readmissions. J Hosp Med. 2011;6:383-388.
Patients with Complex, Severe Illnesses and Persistent Physiologic Abnormalities Have Higher Risk of Intensive-Care-Unit Readmission
Clinical question: Which patient characteristics increase the risk for intensive-care-unit (ICU) readmission?
Background: Patients are often discharged from the ICU based on subjective criteria, workload, and bed demand, making ICU readmission a tempting quality indicator. Studies have examined institutional characteristics leading to ICU readmission, but few have shown how patient case mix affects longer lengths of ICU and hospital stays and higher in-hospital mortality.
Study design: Retrospective observational cohort study using a large, multi-institutional U.S. database.
Setting: Computerized data collection and analysis system from 97 intensive- and cardiac-care units at 35 hospitals in the United States.
Synopsis: Patient-level characteristics and outcomes of 229,375 initial ICU admissions from 2001 to 2009 were compared for patients with and without ICU readmission using the Acute Physiology and Chronic Health Evaluation (APACHE) IV database (Cerner Corporation, Kansas City, Mo.). Multivariable logistic regression analysis identified potential characteristics increasing the risk for ICU readmission. Case-mix adjusted outcomes for mortality and length of stay were calculated.