BACKGROUND: There has been an enormous rise in total joint arthroplasties (TJA) in the United States over the past several years. Researchers have documented the increase in healthcare costs associated with unplanned hospital readmissions among patients post-TJA, specifically total hip and total knee arthroplasties. Additionally, researchers have reported the burden that these costs place on the healthcare system, private payers and on patients and their caregivers. Social routines, quality of life and occupational functioning are often interrupted because of a patient’s unplanned hospital readmission after receiving a total hip or total knee arthroplasty. Investigators have identified the major causes of costly unexpected hospital readmissions among patients with a TJA; they include surgical site infections, blood clots, joint dislocations and periprosthetic fractures. The Occupational Therapy Practice Framework: Domain and Process describes the practice of occupational therapy as promoting health, well-being, and engagement in meaningful occupation. Nonetheless, there is limited literature in the occupational therapy field directed towards reducing hospital readmissions among patients with a total hip or knee arthroplasty, thus suggesting an area that is well-positioned for intervention development and testing. PURPOSE: This Occupational Therapy Doctoral Project entitled Teaching Intervention to Reduce Readmissions-Post Surgery (TIRR-PS) is a proposed program for an acute care hospital setting which: (a) described the problem of hospital readmissions among patients with a total hip or total knee arthroplasty, (b) investigated evidence and best practices for imparting knowledge and/or teaching skills to hospital administrators, healthcare professionals, occupational therapy staff, patients, and caregivers, (c) proposed an intervention based on empirically supported strategies and theoretical frameworks, (d) recommended activities to include as part of the program evaluation, the funding plan and the dissemination plan to promote this multi-level, multi-component pilot program. TIRR-PS will aim to reduce unplanned 30-day hospital readmissions and their associated healthcare costs. Unplanned readmissions are in part caused by inadequate education of hospital administrators, occupational therapy staff, patients, and caregivers. The TIRR-PS program will raise awareness about how to address common medical complication risks and promote the support of hospital administration for the education and skill building activities directed towards healthcare professionals with an emphasis on occupational therapy. CONCLUSION: TIRR-PS was designed for an acute care setting to reduce hospital readmission rates, to reduce healthcare costs, to improve patient quality of life, and to reduce the societal burden of unplanned hospital care. TIRR-PS is an innovative program designed to be comprehensive and to impart knowledge and skills to all relevant professionals in an acute care setting with a particular emphasis on the contribution of the OT profession. TIRR-PS, once evaluated, will provide a standardized, systematic approach to reducing unexpected hospitalizations post-TJA and shows promise for contributing to routine orthopaedic rehabilitative practice in acute care hospitals. This in turn will not only reduce healthcare costs, but will improve the post-surgery quality of life for patients with a recent total hip or total knee arthroplasty.

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)

BACKGROUND: Individuals with serious mental illness face a significant burden of disease, yet experience lower quality care across a range of services (1). Hospital readmission within 30 days of discharge is an important, if imperfect, proxy for quality of care. Factors contributing to readmission are well documented (2–5), yet successful interventions to decrease readmissions have been slow to take shape (6–9). To effectively develop and incorporate evidence-based interventions to reduce 30-day psychiatric readmissions into large, geographically diverse inpatient systems; there is a need to conduct in-depth implementation analyses to better understand the relationship between patient-, hospital-, health system-, and community-level factors and their net impact on readmissions. This research addresses this need. METHODS: Using a modified Consolidated Framework for Implementation Research (CFIR), two state-based case studies were conducted within a large U.S. hospital system. Two hospitals per state were selected-- one with a high and one with a lower readmission rate. We conducted document reviews and semi-structured interviews (N=52) with corporate, clinical and community stakeholders, using the CFIR to identify key themes within each construct. We scored and compared hospitals with lower vs. higher readmission rates. An analysis of EMR data from the hospital system contextualized case study findings. RESULTS: In one state a complex interplay of factors at all levels contributed to readmission rates in both hospitals. In the second, constructs within the inner hospital setting contribute to differences in hospital readmission rates. Facilities with high readmission rates scored lowest among CFIR constructs “Patient Needs and Resources in the Community” and “External Policies and Incentives.” CONCLUSIONS: Ours is the first known study to explore a broad range of factors that influence readmission rates among patients with serious mental illness and a range of comorbidities. Findings from two state-based case studies indicate that readmission rates are determined by multiple, interrelated factors which vary in importance based on hospital and community context and political environment. To be effective, systemic interventions to reduce readmissions must be tailored to the specific context at targeted hospitals.

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

No description available.

No description available.

In the European Union asylum and migration policy, the expressions “exclusion” and “externalization” are often used and encountered because the EU transfers the responsibility of migration control to non-EU states through readmission agreements. The EU does not have the capacity to receive all migrants, refugees and asylum seekers that seek protection in Europe, hence the agreements are constituted between the EU and other countries outside the EU on the basis of returning nationals and third country nationals who have been denied asylum. The purpose of this thesis is to explore how and to what extent are human rights embedded in the readmission agreements and in the materials that constitute the basis for the decision to enter into readmission agreements. This thesis also tends to analyze if and on what basis the readmission agreements pose potential consequences for asylum seekers, refugees and migrants. In order to answer the posed research questions, I have used a qualitative research method of case study and text analysis. I have used a theoretical framework of externalization and studied the cases of the EU-Ukraine agreement and the EU-Pakistan agreement. Today, the EU cannot guarantee the safety individuals that are being returned to either Ukraine or Pakistan, because both Ukraine and Pakistan lack functional human rights institutions and cannot practice what human rights instruments ordain because they lack the capacity to do so. The EU’s failing of safe returns for asylum seekers, refugees and migrants has consequently created situations of orbit and chain refoulment where migrants, refugees and asylum seekers risks being returned to their country of origin or passed around between countries.

Bakgrund: Hjärtsvikt är ett relativt utbrett och allvarligt tillstånd. Återinläggning är vanligt förekommande bland patienter med hjärtsvikt. Patientutbildning är centralt för god vård hos hjärtsviktpatienter, där huvudsyftet med utbildningen är att förbättra patientens egenvård. Syfte: Syftet med studien var att undersöka utbildningsinterventioner utförda av sjuksköterskor som kan minska risken för att patienter med hjärtsvikt återinläggs. Metod: Detta var en litteraturöversikt med en kvantitativ ansats. Litteraturöversikten inkluderade nio kvantitativa RCT studier. Sökningarna gjordes i databaserna Cinahl, the Cochrane Library och PubMed. De valda studierna genomgick kvalitetsgranskning, analys och en sammanställning. Resultat: Fem av nio artiklar kunde visa på en signifikant skillnad mellan grupperna för utfallsmåttet återinläggning efter utbildningsintervention. Gemensamt för studierna var att återinläggning kontrollerades efter en månad. Vissa studier redovisade även ytterligare tidsintervaller. De centrala komponenterna i de olika utbildningsinterventionen och utfallsmåttet återinläggning vid olika tidsintervaller sammanställdes och redovisades i tabell. Konklusion: Utbildningsåtgärder i samband med utskrivning av hjärtsviktspatienter utförda av sjuksköterskor kan vara mångfacetterade och därigenom bestå av flertalet komponenter. Vilka av dessa komponenter i interventionerna som var effektiva och kunde leda till en signifikant skillnad mellan grupperna var oklart. Däremot indikerade fem av nio studier att det kan vara möjligt att minska återinläggning bland patienter med hjärtsvikt genom undervisning. / Background: Heart failure is a common and serious condition. Readmission is frequently common among patients with heart failure. Patient education is central for good care for heart failure patients, where the primary aim of the education is to improve patient self-care. Aim: The aim of the study was to investigate educational interventions conducted by nurses aimed at reducing the risk of readmission among patients with heart failure. Methods: This was a literature review employing a quantitative approach. The literature review included nine quantitative RCT studies. Searches were conducted in the databases Cinahl, the Cochrane Library and PubMed. The selected studies underwent quality assessment, analysis, and synthesis. Results: Five out of nine articles were able to demonstrate a significant difference between the groups in the outcome measure of readmission following educational intervention. A common feature among the studies was that readmission was monitored after one month. Some studies also reported additional time intervals. The central components of the various educational interventions and the outcome measure of readmission at different time intervals were compiled and presented in a table. Conclusion: Education interventions conducted by nurses during the discharge of heart failure patients can be multifaceted and consisting of multiple components. Which of these components were effective and could lead to a significant difference between the groups was unclear. However, five out of nine studies indicated that it may be possible to reduce readmissions among patients with heart failure through education conducted by the nurse.

Ao se considerar a importância da busca de indicadores que determinam, tanto a alta dos pacientes das unidades de terapia intensiva (UTIs) como o risco de óbito e readmissão dos internados nessa unidade, este estudo teve como objetivos: caracterizar os pacientes internados em UTIs de hospitais que tenham unidades intermediárias quanto aos dados demográficos e clínicos; descrever a mortalidade e a unidade de destino após a alta da UTI e a freqüência de readmissão nessas unidades; comparar as médias do Nursing Activities Score (NAS), Simplified Acute Physiology (SAPS II) e Logistic Organ Dysfunction (LODS) no primeiro e último dia de internação na UTI; identificar os fatores associados com a alta, óbito e readmissão dos pacientes em UTI na mesma internação hospitalar. Trata-se de um estudo prospectivo longitudinal de pacientes adultos internados em UTIs gerais de dois hospitais governamentais e dois não governamentais do Município de São Paulo que possuíam unidades intermediárias. A casuística compôs-se de 500 pacientes adultos admitidos nessas UTIs. Os dados coletados foram referentes as primeiras e últimas 24 horas de permanência na UTI, porém os pacientes foram acompanhados até a alta hospitalar para identificação das readmissões. Os resultados mostraram predomínio de indivíduos idosos (55,80%), do sexo feminino (56,60%), a maior parte procedente do Pronto-Socorro/Atendimento (37,60%) e tempo de permanência na UTI entre um e dois dias (36,60%). Os antecedentes e os motivos de internação mais freqüentes foram relacionados às doenças do aparelho circulatório. As médias dos escores, no primeiro dia de internação na UTI, foram SAPS II, 37,41, LODS, 4,32 e NAS, 62,13. No último dia de internação, o valor médio do SAPS II foi de 36,15, do LODS, 4,2 e do NAS, 52,17. Os pacientes com alta da UTI apresentaram no último dia de internação, a média desses escores inferior à de admissão. Nos indivíduos que morreram, as médias dos escores SAPS II e LODS foram superiores no último dia de internação na UTI em relação aos valores de admissão; já as médias do NAS foram similares. Os pacientes readmitidos apresentaram na alta da UTI diminuição da média dos escores, porém essa diferença só alcançou níveis significativos quando o NAS foi o indicador utilizado. A mortalidade foi 20,60% durante a internação na UTI, a maioria dos pacientes foi transferida para unidade intermediária e aproximadamente, 9% foram readmitidos. Os pacientes que foram encaminhados à unidade intermediária diferiram dos que foram para unidade de internação em relação à idade, procedência, antecedentes, motivo de internação, SAPS II na admissão e NAS na admissão e alta. Os pacientes que morreram, apresentaram maior tempo de internação, escores de gravidade mais altos na admissão e, imediatamente, antes do óbito. No último dia de internação na UTI, o NAS foi mais elevado entre os que morreram. Para o grupo de readmitidos, somente antecedentes relacionados a doenças infecciosas e parasitárias, doenças do aparelho geniturinário e o LODS na admissão foram diferentes se comparados aos não readmitidos / Considering the relevance of collecting indicators to define either the discharge of patients from the Intensive Care Units (ICUs) or risk of death and readmission of interned patients into these units, this study had as objectives: - to characterize the patients interned in ICUs in hospitals with intermediate care units according to demographical and clinical data; - to describe mortality, unit of destination after ICU discharge and frequency of readmission into these units - to compare the averages of the Nursing Activities Score (NAS), Simplified Acute Physiology (SAPS II) and Logistic Organ Dysfunction (LODS) during the first and the last day of internment in the ICU; - to identify the factors associated with the discharge, death and readmission of patients into the ICU, during the same hospital internment. This is a longitudinal prospective study of adult patients interned in general ICUs of two public hospitals and two private hospitals of the City of São Paulo, which had intermediate care units. The casuistry was composed of 500 adult patients who were interned in these ICUs. The collected data referred to the first and the last 24 hours spent in the ICU, however, a follow-up of the patients was made until their discharge in order to identify readmissions. The results show a predominance of elderly individuals (55.8%), of female gender (56.6%), with the larger number coming from the Emergency Room (37.6%) and patients who spent between one and two days in the ICU (36.6%). The previous problems and the main motives for internment were related to circulatory system diseases. The average scores during the first day in the ICU were SAPS II (37.41), LODS (4.32) and NAS (62.13%). During the last day of internment, the average scores were SAPS II (36.15), LODS (4.2), and NAS (52.17%). Patients who had been discharged from the ICU presented, during the last day of internment, an average in these scores inferior to those registered on their entry day. For the individuals who died, the average SAPS II and LODS scores were superior to those of the entry day in the ICU, nevertheless, the NAS averages were similar. The readmitted patients had, at the time of discharge from the ICU, less than average scores in SAPS II, LODS and NAS. This difference, however, only reached significant levels when the NAS indicator was applied. The death rate was 20.6% during the ICU internment, the majority of the patients were transferred to an intermediate care unit and approximately 9% were readmitted. Patients, who were transferred to the intermediate care unit, differed from those who went to a general nursing unit according to age, origin, antecedents, motive for internment, SAPS II during their entry, NAS during their entry and discharge. Patients who died presented longer internment time and had more severe scores at their entry into the ICU and immediately before death. The NAS during the last internment day in the ICU was higher for those who died. For the readmitted group, only antecedents related to contagious and parasitic diseases, genitourinary system diseases, and LODS at entry were different when compared to those of patients who were not readmitted into the ICU

As reinternações psiquiátricas são consequência de uma complexa combinação de situações que vão além da severidade do próprio transtorno mental. Vários fatores relacionados ao paciente, comunidade e ao sistema de saúde têm sido associados com admissões psiquiátricas recorrentes. A Reforma Psiquiátrica determinou uma mudança da base assistencial fortalecendo modalidades de tratamento comunitário. Neste contexto, a análise das readmissões assumiu um papel de destaque para a organização das redes de saúde mental, pois a dinâmica das re-internações poderá ser um indicador de qualidade dos serviços hospitalares e comunitários possibilitando a compreensão das relações entre estes serviços. Como a região de Ribeirão Preto passou a enfrentar problemas pelo aumento do número de internações e pela falta de leitos psiquiátricos disponíveis para admissão de novos pacientes, organizamos esta pesquisa objetivando verificar eventuais mudanças nas características clínicas e sócio-demográficas dos pacientes admitidos pela primeira vez além de analisar possíveis fatores preditores de re-internações psiquiátricas. Nesse estudo, todos os pacientes admitidos nos serviços de internação entre os anos de 2000 e 2007 foram analisados utilizando banco de dados único criado para a pesquisa de modo que todas as admissões e readmissões do período pudessem ser estudadas. A análise dos pacientes internados no decorrer dos anos foi realizada utilizando a razão dos pacientes em relação ao ano índice para cada variável e com análise bivariada utilizando o teste do qui-quadrado. Para analisar o risco de readmissão, foi utilizada regressão logística para estimar as razões de risco relativo com seus respectivos intervalos de confiança. A análise do tempo entre a primeira e a segunda internação (readmissão) foi executada com curvas de sobrevivência. Durante o período estudado, 6.261 pacientes foram admitidos sendo verificado aumento na proporção de pacientes com algumas características sócio-demográficas (jovens, idosos e inativos profissionalmente) e clínicas (internações breves e com diagnósticos de transtornos depressivos, transtornos de personalidade e os transtornos relacionados ao uso de substâncias psicoativas). Cerca de 1/3 dos pacientes admitidos sofreram readmissões durante o estudo e os principais preditores para re-internação foram faixas etárias menores, internações prolongadas e diagnósticos transtornos psicóticos e afetivos bipolares. O risco de re-internação precoce esteve relacionado com fatores de desproteção social (menor faixa etária e ausência de vínculos conjugais e ocupacionais) e de gravidade clínica (diagnósticos mais severos, tempo de permanência prolongado e internação nas enfermarias do hospital geral e do hospital psiquiátrico). Nossos dados alcançaram os objetivos propostos e novas pesquisas são necessárias para definição de preditores pera re-internações, pois usuários frequentes do sistema hospitalar geram custos para a rede de saúde. Portanto, as políticas de saúde mental devem priorizar estes pacientes. / Psychiatric readmissions are mainly due to a complex combination of factors which go beyond the mental illness itself. Several factors associated to the patient, community and health care system have been associated to recurrent psychiatric admissions. The Psychiatric Reform has determined a shift in the basic services strengthening community treatment modalities. In this context, re-admission analyses have taken a major role in organizing mental health networks, because the dynamics of re-admissions could be an indicator of the quality of the hospital and community-based services offered allowing a better understanding of the relations between these services. As the Ribeirão Preto region has suffered from the increase of admissions and the lack of beds in psychiatric wards, we organized this research aiming at verifying possible changes in the socio-demographic and clinical characteristics of patients admitted for the first time besides analyzing possible factors for re-admissions. In this study, all patients admitted to psychiatric wards between 2000 and 2007 were analyzed using a single data base created for this research so that all admissions and re-admissions during the period could be studied. The hospitalized patients analysis along the years was accomplished using the ratio patient/index year for each variable and through a bivariant analysis using the chi-square test. In order to analyze the re-admission risk, logistic regression was used to evaluate the relative risk reasons with their respective confidence interval. Analysis of the time between first and second admission (re-admission) was made according to survival curves. During the time under study, 6.261 patients were admitted. It occurred an increase in the proportion of patients with some socio-demographic (young and elderly people clinically affected as well as professionally inactive) and clinical characteristics (short stays due to depressive, personality and psychoactive substance abuse diagnostics). About 1/3 of admitted patients went through a re-admission during the research and the main predictors for re-admission were: younger age group, prolonged length of stay in hospitals and psychotic or bipolar affective disorder diagnoses. Precocious re-admission risk was related to a lack of social protection (younger age group and absence of occupational and marital bonds) as well as the clinical seriousness (more severe dignoses, longer stay in hospital (general or psychiatric). Our data has reached the proposed goals but new researches are needed in order to define better the re-admission predictors, because frequent users of the health care system entail higher costs. Therefore, mental health policies must prioritize these patients.