A hospital readmission can occur due to insufficient treatment or the emergence of an underlying disease that was not apparent at the initial hospital stay. The unplanned readmission rate is often viewed as an indicator of the health system performance and may reflect the quality of clinical care provided during hospitalization. Readmissions have also been reported to account for a significant portion of inpatient care expenditures. In an effort to improve treatment quality, clinical outcomes, and hospital operating costs, we present machine learning methods for identifying and predicting potentially preventable readmissions (PPR). In the first part of the thesis, we use logistic regression, extreme gradient boosting, and neural network to predict 30-day unplanned readmissions. In the second part, we apply association rule analysis to assess the clinical association between initial admission and readmission, followed by employing counterfactual analysis to identify potentially preventable readmissions. This comprehensive analysis can assist health care providers in targeting interventions to effectively reduce preventable readmissions. / Thesis / Master of Science (MSc)

Older people living with frailty are at a higher risk of medication-related incidents due to frequent hospitalisation, complex health needs and polypharmacy. There is evidence that identifying patients at high risk of hospital readmission can enhance the impact of interventions to prevent readmission. However, there is insufficient evidence of the role of medication in readmission in this vulnerable patient group, and what pharmacists can do to reduce readmissions. This research used a mixed-method approach to examine the association between medicines-related risks and readmissions, and the pharmacists’ interventions thought to be important by key stakeholders to reduce readmissions. Medicines-related risks such as polypharmacy, potentially inappropriate medicines and high risk medicines did not have a strong association with repeated hospital admission in multivariable logistic regression. Patients who had multi-morbidities, and non-supported discharge, had a higher risk of repeated hospital admissions. A consensus survey study with three iterative rounds identified a list of pharmacists’ interventions viewed as high priority for reducing readmissions in frail elderly patients. The interventions with the highest scores included medicines reconciliation at discharge, on admission, preparation of discharge summary, provision of tailored patient education about medicines and inter-disciplinary working in ward rounds. A systematic intervention development method was used to further develop an intervention, underpinned by the theoretical domains framework. There is a need to further explore the role of medication-related risks in contributing to readmission using other validated tools and larger datasets. This could be used to inform development of future risk stratification tools to identify high risk patients in order to target interventions to maximise its impact. / University of Bradford and Sheffield Teaching Hospital studentship

Communication of hospital discharge instructions between patient and provider is an important component of hospital discharge to ensure that patients have the information they need to manage their post-acute care. Patient perception of this interaction is a key indicator of the quality of services provided. This study examined whether there is a correlation between hospital continuity and transition scores (a measure of patient perceptions of hospital discharge instructions) and hospital readmissions in Ontario. The final regression model for the outcome of all medical readmissions within three days of hospital discharge, showed a significant positive relationship (coefficient=0.0090, p=0.011). The estimate was smaller and not significant once the data was restricted to only community hospitals located outside of Toronto (coefficient=0.0085, p=0.060), and when restricted to urban community hospitals outside of Toronto (coefficient=0.0041, p=0.384). For the outcome of specific medical readmissions within 28 days of hospital discharge, no statistically significant relationship was found.

Communication of hospital discharge instructions between patient and provider is an important component of hospital discharge to ensure that patients have the information they need to manage their post-acute care. Patient perception of this interaction is a key indicator of the quality of services provided. This study examined whether there is a correlation between hospital continuity and transition scores (a measure of patient perceptions of hospital discharge instructions) and hospital readmissions in Ontario. The final regression model for the outcome of all medical readmissions within three days of hospital discharge, showed a significant positive relationship (coefficient=0.0090, p=0.011). The estimate was smaller and not significant once the data was restricted to only community hospitals located outside of Toronto (coefficient=0.0085, p=0.060), and when restricted to urban community hospitals outside of Toronto (coefficient=0.0041, p=0.384). For the outcome of specific medical readmissions within 28 days of hospital discharge, no statistically significant relationship was found.

No description available.

Background: The 30-day readmission rate is considered a quality of care measure for providers and has become important because providers might face reduced reimbursement from any increase in unplanned readmissions Objective: The aim of the first chapter is to investigate the waiting-length of stay (WLOS) and post-length of stay (PLOS) on the 30-day readmission. In the second chapter, we examined the hospital procedural volume and hospital quality on the 30-day readmission. Our objective in the third chapter is to examine the zip code-level SES factors on the 30-day readmission rates. Participants: patients undergoing isolated coronary artery bypass grafting (CABG) in Virginia Methods: A retrospective study design has been conducted using a multi-level logistic model of increasing complexity for all three chapters. The sample used was from the Virginia Cardiac Surgery Quality Initiative (VCSQI) of the periods 2008-2014, the dataset included patient characteristics. Afterward, we merged the sample with both the Virginia Health Information (VHI) to obtain hospital characteristics (ownership, teaching status, and location), and Agency for Healthcare Research and Quality (AHRF) to obtain county-socio-economic status (SES) characteristics (education, employment, and median household income), the previous SES was used for chapter’s one and two. In chapter three, instead of AHRF, we merged the sample with the American Community Survey (ACS) to obtain zip code-SES characteristics (employment, median household income, education, median house price). The main outcome was the 30-day readmission rate. The analytical sample of chapter one n = 22,097, in chapter two the sample n = 25,531, while in chapter three the sample n= 25,829. We conducted a sensitivity analysis in all three chapters. In chapter one we analyzed the data at the patient level, in chapter two we analyzed the data at the hospital level, while in chapter three we conducted the analysis at the area zip code level. Results: In chapter one, we found that readmitted patients after a prolonged PLOS had increased odds of readmission, by 68.7%, compared to readmitted patients with a shorter PLOS in the fully adjusted model; while, WLOS was not significant at the P < 0.05. In chapter two, the fully adjusted model displayed significant results with a reduced odds in readmissions by 22.8% in the middle-volume hospitals compared to the low-volume hospitals, while the middle-quality hospitals had increased odds of readmission by 23.5% compared to the low-quality hospitals. In chapter three, statistically, we did not find that area zip code-SES had an effect on the 30-day readmission rate. While, geographically, we found that addresses of individuals were clustered in certain areas of Virginia. Conclusion: In chapter one, patients undergoing CABG and experience a prolonged PLOS of > 6 days are at risk to be readmitted within 30-days of the procedure. In chapter two, the higher volume hospitals (middle-volume) compared to low-volume hospitals showed a significant reduction in odds in the 30-day readmissions, especially after adjusting the model with hospital quality. In chapter three, even though, there was no association of area-SES with 30-day readmission, in the maps, we found a cluster of patient addresses in the southern parts of Virginia with an increased readmission, which is considered underprivileged area; and the fact might be due to the proximity of these areas to cardiovascular hospitals. Policy Implication: In chapter one, the study provided a model for clinicians to stratify patients at risk of readmission, especially patients with risks of staying longer in the hospital after CABG. In chapter two, policymakers and the CMS should find new ways to help hospitals with low-volumes to reduce their isolated-CABG readmission rates and be able to compete with high-volume hospitals. In chapter three, no significant correlation between area-SES and readmission for patients who underwent CABG was found; these backs prior notion that SES should not be adjusted for the reimbursement penalties of the Hospital Readmission Reductions Program (HRRP) on hospitals

Submitted by Renata Lopes (renatasil82@gmail.com) on 2018-08-14T11:39:55Z No. of bitstreams: 1 flaviaamaralfreitas.pdf: 2912984 bytes, checksum: 01e8966b900325a7e1dbc5c04e13617f (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2018-09-03T16:31:03Z (GMT) No. of bitstreams: 1 flaviaamaralfreitas.pdf: 2912984 bytes, checksum: 01e8966b900325a7e1dbc5c04e13617f (MD5) / Made available in DSpace on 2018-09-03T16:31:03Z (GMT). No. of bitstreams: 1 flaviaamaralfreitas.pdf: 2912984 bytes, checksum: 01e8966b900325a7e1dbc5c04e13617f (MD5) Previous issue date: 2017-06-09 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / A taxa de readmissão hospitalar é frequentemente proposta como um indicador de qualidade porque está relacionada ao resultado para o paciente e à eficiência organizacional. É definida como a repetida internação hospitalar de um paciente, após sua alta. A identificação do comportamento das readmissões hospitalares é informação valiosa para a organização de intervenções que diminuam a frequência desses eventos bem como o impacto negativo na qualidade de vida dos pacientes e de suas famílias. Além disso, o conhecimento dos fatores relativos aos hospitais associados a readmissões pode servir como subsídio para o aprimoramento do cuidado hospitalar e, ainda, eliminar custos desnecessários para o sistema de saúde. Desta forma, o objetivo deste estudo foi avaliar as readmissões hospitalares pagas pelo SUS em uma capital brasileira, por meio de pesquisa exploratória. Os dados das internações e readmissões foram obtidos a partir da Autorização de Internação Hospitalar (AIH) do Sistema de Informações Hospitalares do SUS (SIH-SUS) do município do Rio de Janeiro do ano de 2015. As readmissões foram identificadas através de método determinístico com uso do CNS. Foram analisados 331.067 registros, a taxa ajustada de readmissão hospitalar do município foi de 11,6%. As readmissões ocorreram com maior frequência em até sete dias após a alta da internação inicial, em mulheres, de 20 a 29 anos. O diagnóstico principal para as causas obstétricas apresentou alta proporção, seguido pelos pacientes com câncer. Entretanto, alguns diagnósticos e procedimentos executados sugeriram a ocorrência de eventos adversos, refletindo que as readmissões podem estar associadas a problemas na segurança do paciente e qualidade da assistência. Conclui-se que este é campo que deve ser explorado de modo a garantir a prestação de um cuidado seguro, efetivo e de qualidade. / The hospital readmission rate is often proposed as an indicator of quality because it is related to the outcome of the patient and organizational efficiency. It is defined as the repeated hospitalization of a patient, after discharge from hospital. The identification of the behavior of hospital readmissions is valuable information for interventions to reduce the frequency of these events as well as the reduction of negative impact on quality of life of patients and their families. In addition, knowledge of the factors relating to the hospitals associated with readmissions may serve as an aid for the improvement of hospital care and the elimination of unnecessary costs to the health system. Thus, the objective of this study was to evaluate the hospital readmissions paid by SUS on a Brazilian capital, through exploratory research. The data concerning hospital admissions and readmissions were obtained from the Hospital Admission Authorization (AIH) of the hospital information system of SUS (SIH-SUS) of the municipality of Rio de Janeiro for the year 2015. The readmissions were identified deterministically with the use of the CNS (Cartão Nacional de Saúde – National Health Card) identification. 331.067 records were analyzed, the adjusted rate of hospital readmission for the municipality was 11.6%. The readmissions occurred more frequently in up to seven days after the initial hospitalization, in women of 20 to 29 years. The main diagnosis for obstetric causes presented high proportion, followed by patients with cancer. However, some diagnoses and procedures performed suggested the occurrence of adverse events, indicating that the readmissions may be associated with problems in patient safety and quality of care. It is concluded that this is the field that should be explored in order to ensure the provision of safe, effective care and quality.

Health policy makers are struggling to manage health care and spending. To identify strategies for improving health quality and reducing health spending, policy makers need to first understand health risks and outcomes. Despite lacking some desirable clinical detail, existing health care databases, such as national health surveys and claims and enrollment data for insured populations, are often rich in information relating patient characteristics to heath risks and outcomes. They typically encompass more inclusive populations than can feasibly be achieved with new data collection and are valuable resources for informing health policy. This dissertation illustrates how the Medicare Current Beneficiary Survey (MCBS) and MassHealth data can be used to develop models that provide useful estimates of risks and health quality measures. It provides insights into: 1) the benefits of a proxy for the Framingham cardiovascular disease (CVD) risk score, that relies only on variables available in the MCBS, to target health interventions to policy-relevant subgroups, such as elderly Medicare beneficiaries, based on their risk of developing CVD, 2) the importance of setting appropriate risk-adjusted quality of care standards for accountable care organizations (ACOs) based on the characteristics of their enrolled members, and 3) the outsized effect of high- frequency hospital users on re-admission measures and possibly other quality measures. This work develops tools that can be used to identify and support care of vulnerable patients to both improve their health outcomes and reduce spending – an important step on the road to health equity.

No description available.

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2015-10-13T20:00:18Z No. of bitstreams: 1 LUANA CARDOSO PESTANA [DISSERTAÇÃO 2012].pdf: 1216169 bytes, checksum: 3dc793ff9d802cd1780b06aede4494a7 (MD5) / Made available in DSpace on 2015-10-13T20:00:18Z (GMT). No. of bitstreams: 1 LUANA CARDOSO PESTANA [DISSERTAÇÃO 2012].pdf: 1216169 bytes, checksum: 3dc793ff9d802cd1780b06aede4494a7 (MD5) Previous issue date: 2011 / Mestrado Acadêmico em Ciências do Cuidado em Saúde / Trata-se de um estudo com abordagem quantitativa, com delineamento descritivo retrospectivo e transversal, tendo como objetivo caracterizar idosos em situação de readmissão hospitalar, associar tais características ao desfecho readmissão hospitalar e discutir as implicações para a Enfermagem Gerontológica. A pesquisa foi realizada em um hospital universitário, localizado em Niterói, RJ. Os sujeitos foram 94 pacientes com idade igual ou superior a 60 anos que, entre janeiro e dezembro de 2010, sofreram readmissão hospitalar em enfermarias de clínica médica. A média de idade foi de 72,3 ± 10,7 anos, idosos do sexo masculino, procedentes do Município de Niterói, RJ; casados, com média de 2,8 ± 2,4 filhos e composição familiar de 2,8 ± 1,1 pessoas, aposentados e com cuidador familiar. As doenças prevalentes foram cardiovasculares, gastrointestinais, neoplásicas e respiratórias. A maioria dos idosos apresentou até 2 comorbidades; o tempo de permanência hospitalar foi de 19,9 ± 18,8 dias; a média de internações em 4 anos foi de 2 internações, ocorrendo, em geral, nos últimos 12 meses precedentes a última internação; a maioria dos idosos apresentou dependência parcial ou total dos cuidados de Enfermagem, não recebeu orientações de Enfermagem para a alta hospitalar, realizou acompanhamento através do ambulatório hospitalar e utilizou serviços de emergência entre as internações. A referida população exige mais cuidados de Enfermagem e por consequência, maior conhecimento do processo do envelhecimento e das peculiaridades do cuidado ao idoso com múltiplas patologias. Os fatores de risco para readmissão entre idosos identificados foram internação prévia no último ano e tempo de permanência hospitalar de 8 a 30 dias. Os resultados desta investigação fornecem subsídios para o planejamento de programas de atenção à saúde do idoso no contexto hospitalar e para acompanhamento comunitário. Recomenda-se a capacitação dos profissionais de saúde e implantação de programas de planejamento de alta hospitalar, com base em ações educativas que promovam o autocuidado, bem como orientações aos cuidadores, de forma integrada junto aos demais níveis de atenção. Tais intervenções têm o propósito de otimizar a assistência prestada, os recursos investidos sejam eles humanos, materiais ou financeiros, diminuir as readmissões hospitalares e promover melhoria na qualidade de vida do idoso e sua família / It is a study with quantitative approach, with retrospective descriptive and transversal profile, having as objective to characterize elders in situation of hospital readmission, to associate such characteristics to closing of readmission and to discuss the implications to the Gerontology Nursing. The research was performed at a university hospital, located in Niterói, RJ. The subjects were 94 patients who were 60 years old or more and that, between January and December 2010, had experienced hospital readmission in medical clinical wards. The age average was 72.3 ± 10.7 years, male elderly patients, from the Niterói/ RJ; married, with an average of 2.8 ± 2.4 sons and family composition of 2.8 ± 1.1 persons, retired and with family caretaker. The prevailing illnesses were cardiovascular, gastrointestinal, neoplastic and respiratory. Most of the elders had up to 2 comorbidities; the time of hospital stay was of 19.9 ± 18.8 days; institutionalization average in 4 years was of 2 institutionalizations, generally occurring in last 12 months preceding the last institutionalization; most of elders presented partial or total dependency of the Nursing cares, did not received guidelines from the Nursing for the hospital discharging, had follow-up through the hospital ambulatory and used emergency services between the institutionalizations. The mentioned population requires more Nursing care and, therefore, a better knowledge of the aging process and singularities of the multiple-pathology elders care-taking. Risk factors of the readmission among identified elders have been previous institutionalization in the last year and the term of hospital stay from 8 up to 30 days. The results of this investigation provide subsidies to the planning of health attention programs to the elders in the hospital context and to community follow up. It is recommended the qualification of health professionals and implantation of hospital discharge, based in educative actions that promote self-care, as well as guidelines to the care-takers, in an integrated way in relation to the other levels of care-taking. Such interventions have the objective to optimize the assistance offered and the resources invested – being humane, material or financial -, to reduce hospital readmissions and to promote the improvement in life quality of elders and their families