Social Support and Actual Versus Expected Length of Stay in Inpatient Rehabilitation Facilities

Early Leaves from Inpatient Care Among Individuals with Traumatic Life Events in Ontario, Canada

Psychological trauma is a prevalent mental health concern, with most individuals experiencing at least one traumatic event in their lifetime. Early leaves from inpatient settings are a pertinent challenge among persons who have experienced trauma and may reflect unmet care needs. This study examined patterns of early leaves among persons with trauma from inpatient care in Ontario, Canada. All records for individuals who have experienced trauma with an index admission of over 72 h between January 1, 2015 and December 31, 2019 were included (N = 11,043). Logistic regression using generalized equation estimation was used to assess the association between demographic and clinical characteristics, substance use, social relationships, staff dynamics, and control interventions with the outcome of early leaves. In the final model, alcohol (OR: 1.83, 95% CI: 1.27-2.64), other substances (OR: 2.15, 95% CI: 1.34-3.46), and poly substance use (OR: 2.46, 95% CI: 1.82-3.31) all increased the odds of early leaves after considering possible facility effects, and after adjusting for other demographic and clinical factors. Being older, employed, and having mood disorders reduced odds of early leaves. Early leaves are important within treatment planning, particularly in relation to addressing complex traumas. While challenges related to substance use may be driving some of the early leaves, there may also be challenges to providing complex care within acute mental health settings. Further exploration of policies and practices to prevent early leaves are necessary, including the potential need for longer-term specialized treatment programs.

Predictive Factors of Inpatient Rehabilitation Stay and Post-Discharge Burden of Care After Joint Replacement for Hip and Knee Osteoarthritis: A Retrospective Study on 1678 Patients

The global demand for end-stage hip and knee osteoarthritis surgical treatment is rising, as is the need of optimal postoperative rehabilitation. Patient stratification is key to provide rehabilitation professionals and policy makers with real-life data in support of early discharge planning and continuous care provision. The aim of this retrospective, observational study was to investigate which factors can predict the burden of care at discharge (BCD) and the inpatient rehabilitation length of stay (LOS) based on a set of demographic, societal, clinical and organizational data collected from a high-volume orthopedic hospital. We included 45.306 variables from 1678 patients. All variables were initially tested individually using a linear regression model for inpatient rehabilitation LOS and a logistic regression model for BCD. Variables that resulted significant (p < 0.05) were subsequently considered in a single, comprehensive linear regression model, or a single, logistic regression model, respectively. Age, living with a family, occupational status, baseline Barthel Index and duration of surgery were predictors of inpatient rehabilitation LOS and BCD. Sex, primary or secondary osteoarthritis, American Society of Anesthesiologists score, body mass index, transfusion, biological risk, type of anesthesia, day of surgery, numeric pain rating scale and baseline cognitive function at baseline were not. Including specific patient comorbidities, surgical access technique and chronic use of pharmacological therapy can improve the predictive power of the model.

Frailty Among Total Hip and Knee Arthroplasty Recipients: Epidemiology and Propensity Score-weighted Analysis of Effect on In-hospital Postoperative Outcomes

INTRODUCTION

Total joint arthroplasty (TJA) is one of the most successful and frequently performed procedures in the United States. The number of these procedures is projected to continue growing rapidly in the coming years, and with it comes the demand for more sophisticated perioperative risk and complication assessment. This study examines the effect of frailty on postoperative inpatient complications and hospital resource utilization after TJA.

METHODS

Discharge data from the National Inpatient Sample were used to identify all patients aged 50 years or older who underwent TJA between 2006 and 2015. Nonelective admissions and hip fractures were excluded. Patients were stratified into two groups with and without concomitant ICD-9 diagnostic criteria that qualified them has having frailty. An analysis comparing the 2 groups' epidemiology, medical comorbidities, and propensity score-weighted postoperative clinical and economic outcomes was done.

RESULTS

A total of 7,854,890 TJAs were included in this analysis, with 136,516 meeting the criteria for frailty and 7,718,374 being nonfrail. Among these patients, the average age was 67.3 years and the female distribution was 61.1%. Frail patients were found to have markedly higher rates of all but two individual comorbidities constituting the Modified Elixhauser Profile compared with nonfrail patients. Compared with the control group, frail patients were found to have increased risk of any postoperative complication, central nervous system complications, hematoma/seroma, wound dehiscence, infection, and postoperative anemia. Frail patients also had longer length of stay, higher discharge to rehabilitation facilities, and higher hospital charges.

DISCUSSION

Patients with frailty undergoing TJA procedures are at a markedly higher risk for developing postoperative complications and worse hospital economic outcomes. As this patient population continues to increase, it is imperative for clinicians to use their risk factors in optimizing their perioperative care and support.

A Novel Comorbidity Risk Score for Predicting Post-Operative 30-day Complications in Total Shoulder Arthroplasty & Elucidation of Potential Racial Disparities

Background

Efficient and effective preoperative identification of those patients with elevated risk may allow for more cost-effective interventions, accurate bundled payment adjustments, and overall improved patient care. Few comorbidity indices have provided clinical utility and adequate discriminative ability in the setting of complications after shoulder arthroplasty (SA).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for anatomic and/or reverse SA procedures between 2010 and 2019. A subset of comorbidities were utilized including end-stage renal disease, history of hypertension, chronic obstructive pulmonary disease, functional status, history of bleeding disorder, and disseminated cancer.

Results

A total of 25,927 patients with an average age of 69.2 (standard deviation ±9.5) years were included in the study. Patients with a comorbidity risk score (CRS) at or above 2 were indicated to have at least a 29.6% 30-day postoperative complication rate after undergoing total shoulder arthroplasty, significantly higher than the described average of approximately 15%. The area under receiver operator curve for the novel CRS scoring system was 0.595, indicating fair discriminative ability to predict 30-day postoperative complications after SA. This illustrates a discriminative ability similar to that of the American Society of Anesthesiologists classification (0.584, confidence interval [CI] 0.578-0.589), modified Charlson Comorbidity Index (0.567, CI 0.561-0.573), and modified Frailty Index (0.534, CI 0.529-0.539), each of which are common comorbidity indices used for the National Surgical Quality Improvement Program database. The average CRS for the population was 0.8537 (CI 0.8011-0.8150; P < .05) while that for the Black demographic was 1.08 (CI 1.03-1.13; P < .001). Our results suggest that if the disparity in CRS among races was corrected, the average complication rate would be decreased by 2.0%.

Discussion and Conclusion

A higher CRS score resulted in higher rates of 30-day postoperative complications following SA. Black patients had a higher average CRS than all other races illustrating a racial disparity in comorbidity risk. Although the average complication rate of each race would still be unequal, this could mitigate some of the racial disparities observed and decrease the overall 30-day complication rate in SA. With the rise of bundled payments further increasing the need to preoperatively identify patients at high risk for costly complications, the CRS is based on easily identified, relevant comorbidities that may be an advantageous tool to identify patients at increased risk of complications following SA.

Racial and Ethnic Disparities in Surgical Outcomes after Postmastectomy Breast Reconstruction

BACKGROUND

Women of color with breast cancer are less likely to undergo post-mastectomy reconstruction compared with White women, but it is unclear whether their perioperative outcomes are worse. The goal of this study was to investigate differences in preoperative comorbidities and postoperative complications by race/ethnicity among women with breast cancer undergoing postmastectomy reconstruction.

STUDY DESIGN

Data were collected from the National Inpatient Sample database of the Healthcare Cost and Utilization Project from 2012 to 2016. Patient demographics, types of reconstruction, comorbid conditions, Charlson-Deyo Combined Comorbidity (CDCC) scores, length of stay (LOS), and perioperative complications were abstracted. Multivariate linear and logistic regression were performed to model LOS and likelihood of postoperative complications, respectively.

RESULTS

Compared with White women (n = 19,730), Black women (n = 3,201) underwent autologous reconstruction more frequently (40.7% vs 28.3%), had more perioperative comorbidities (eg diabetes: 12.9% vs 5.8%), higher CDCC scores (% CDCC ≥ 4: 5.5% vs 2.7%), and longer LOS (median 3 vs 2 days, all p < 0.001). Being Black (vs White: +0.13 adjusted days, 95% CI 0.06 to 0.19) was also associated with longer LOS and an increased likelihood of surgical complications (vs White: odds ratio 1.24, 95% CI 1.09 to 1.42, both p < 0.01), but this association did not persist when outcomes were limited to microsurgical complications.

CONCLUSION

Disparities in postmastectomy breast reconstruction between Black and White women extend beyond access to care and include perioperative factors and outcomes. These findings suggest an important opportunity to mitigate inequities in reconstruction through perioperative health optimization and improved access to and co-management with primary care.

Moving Back into the Community: Obstacles for People With an Acquired Brain Injury or Physical Disability

OBJECTIVES

To investigate transitions from long-term institutional care to the community in people with an acquired brain injury (ABI) or a physical disability (PD). Secondary objectives were to identify barriers in each group.

DESIGN

Retrospective observational study based on a person-centered plan and structured interviews to identify potential barriers.

SETTING AND PARTICIPANTS

Long-term institutional care; 2954 Medicaid participants younger than 65 interested in community living.

METHODS

Analysis with SPSS 25 of 445 people with an ABI and 2509 with a PD living in long-term care between December 2008 and November 2017. The main outcome was transition to the community. Secondary measures identified specific barriers such as consumer engagement, gender, and age.

RESULTS

Of the 2954 total cases, 1810 (61.3%) transitioned to the community; 57.5% of the ABI group (n = 256) and 61.9% of the PD group (n = 1554) transitioned. Although the PD group transitioned at a slightly higher rate, no significant association was found between the program (ABI or PD) and the likelihood of transitioning (χ² [df = 1] = 3.096, P = .078). Overall, in the ABI group, difficulties with the funding program, OR = 0.373 ± 0.238, and other individuals, OR = 0.396 ± 0.344, decreased the odds of transitioning more than other challenges, whereas lack of consumer engagement, OR = 0.659 ± 0.100, had the strongest influence on preventing transitions in the PD group.

CONCLUSIONS AND IMPLICATIONS

Living in the community improves quality of life and decreases costs. No previous studies have focused on the major obstacles for 2 specific groups, those with an ABI and those with a PD. Identifying transition rates and specific barriers for different groups is an important step to developing systems that will overcome these obstacles. In addition, the equivalent transition rates between these groups highlights the benefit of increased funding and range of services for those with complex needs and support requirements.

Association Between Racial Disparities in Hospital Length of Stay and the Hospital Readmission Reduction Program

Background:

On average Black patients have longer LOS than comparable White patients. Longer hospital length of stay (LOS) may be associated with higher readmission risk. However, evidence suggests that the Hospital Readmission Reduction Program (HRRP) reduced overall racial differences in 30-day adjusted readmission risk. Yet, it is unclear whether the HRRP narrowed these LOS racial differences.

Objective:

We examined the relationship between Medicare-insured Black-White differences in average, adjusted LOS (ALOS) and the HRRP’s implementation and evaluation periods.

Methods:

Using 2009-2017 data from State Inpatient Dataset from New York, New Jersey, and Florida, we employed an interrupted time series analysis with multivariate generalized regression models controlling for patient, disease, and hospital characteristics. Results are reported per 100 admissions.

Results:

We found that for those discharged home, Black-White ALOS differences significantly widened by 4.15 days per 100 admissions (95% CI: 1.19 to 7.11, P < 0.001) for targeted conditions from before to after the HRRP implementation period, but narrowed in the HRRP evaluation period by 1.84 days per 100 admissions for every year-quarter (95% CI: −2.86 to −0.82, P < 0.001); for those discharged to non-home destinations, there was no significant change between HRRP periods, but ALOS differences widened over the study period. Black-White ALOS differences for non-targeted conditions remained unchanged regardless of HRRP phase and discharge destination.

Conclusion:

Increased LOS for Black patients may have played a role in reducing Black-White disparities in 30-day readmission risks for targeted conditions among patients discharged to home.

Multidiscipline Stroke Post-Acute Care Transfer System: Propensity-Score-Based Comparison of Functional Status

Few studies have investigated the characteristics of stroke inpatients after post-acute care (PAC) rehabilitation, and few studies have applied propensity score matching (PSM) in a natural experimental design to examine the longitudinal impacts of a medical referral system on functional status. This study coupled a natural experimental design with PSM to assess the impact of a medical referral system in stroke patients and to examine the longitudinal effects of the system on functional status. The intervention was a hospital-based, function oriented, 12-week to 1-year rehabilitative PAC intervention for patients with cerebrovascular diseases. The average duration of PAC in the intra-hospital transfer group (31.52 days) was significantly shorter than that in the inter-hospital transfer group (37.1 days) (p < 0.001). The intra-hospital transfer group also had better functional outcomes. The training effect was larger in patients with moderate disability (Modified Rankin Scale, MRS = 3) and moderately severe disability (MRS = 4) compared to patients with slight disability (MRS = 2). Intensive post-stroke rehabilitative care delivered by per-diem payment is effective in terms of improving functional status. To construct a vertically integrated medical system, strengthening the qualified local hospitals with PAC wards, accelerating the inter-hospital transfer, and offering sufficient intensive rehabilitative PAC days are the most essential requirements.

Mortality And Morbidity of Severe Traumatic Brain Injuries; A Pediatric Intensive Care Unit Experience Over 15 Years

Objective

To determine the mortality, morbidity, types of intracranial hemorrhages, and factors associated with length of stay (LOS) associated with accidental traumatic brain injury (TBI) at a pediatric intensive care unit (PICU) of a regional trauma center in an Asian city.

Methods

This study is a retrospective review of types of head injury, mortality and morbidity demographics of patients admitted to a PICU with TBI. All patients with accidental TBI were included, namely road traffic injury (RTI) and fall, and their demographics compared. Non-accidental injuries (NAI) were excluded.

Results

95 children (78% males) were admitted to a PICU with RTI or falls from 2002 to 2017. They accounted for 3.7% of PICU admissions. Comparing with falls, victims of RTI were older (p<0.001) and more likely to suffer from skull fracture (p=0.017). There were 4 deaths with falls (6.8%) but none with RTI. Subarachnoid hemorrhages, extradural hemorrhages, the use of mechanical ventilation, inotropes and neurological supports were associated with longer LOS in PICU in these injuries (p<0.001).

Conclusion

A longer PICU LOS is associated with extradural and subarachnoid hemorrhages, usage of inotropes, mechanical ventilation and neurological supports in falls and RTI. Three-quarters of victims are males. Preventive health education should be especially directed to boys to reduce severe TBI in this Asian city.