Sara J. Knight

Postoperative 30-day Readmission: Time to Focus on What Happens Outside the Hospital.

Objective: The aim of this study is to understand the relative contribution of preoperative patient factors, operative characteristics, and postoperative hospital course on 30-day postoperative readmissions. Background: Determining the risk of readmission after surgery is difficult. Understanding the most important contributing factors is important to improving prediction of and reducing postoperative readmission risk. Methods: National Veterans Affairs Surgical Quality Improvement Program data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital signs, prior healthcare utilization, and postoperative complications data. Variables were categorized as preoperative, operative, postoperative/predischarge, and postdischarge. Logistic models predicting 30-day readmission were compared using adjusted R2 and c-statistics with cross-validation to estimate predictive discrimination. Results: Our study sample included 237,441 surgeries: 43% orthopedic, 39% general, and 18% vascular. Overall 30-day unplanned readmission rate was 11.1%, differing by surgical specialty (vascular 15.4%, general 12.9%, and orthopedic 7.6%, P < 0.001). Most common readmission reasons were wound complications (30.7%), gastrointestinal (16.1%), bleeding (4.9%), and fluid/electrolyte (7.5%) complications. Models using information available at the time of discharge explained 10.4% of the variability in readmissions. Of these, preoperative patient-level factors contributed the most to predictive models (R2 7.0% [c-statistic 0.67]); prediction was improved by inclusion of intraoperative (R2 9.0%, c-statistic 0.69) and postoperative variables (R2 10.4%, c-statistic 0.71). Including postdischarge complications improved predictive ability, explaining 19.6% of the variation (R2 19.6%, c-statistic 0.76). Conclusions: Postoperative readmissions are difficult to predict at the time of discharge, and of information available at that time, preoperative factors are the most important.

Military and veteran health behavior research and practice: challenges and opportunities

There are 2.1 million current military servicemembers and 21 million living veterans in the United States. Although they were healthier upon entering military service compared to the general U.S. population, in the longer term veterans tend to be of equivalent or worse health than civilians. One primary explanation for the veterans’ health disparity is poorer health behaviors during or after military service, especially areas of physical activity, nutrition, tobacco, and alcohol. In response, the Department of Defense and Department of Veterans Affairs continue to develop, evaluate, and improve health promotion programs and healthcare services for military and veteran health behavior in an integrated approach. Future research and practice is needed to better understand and promote positive health behavior during key transition periods in the military and veteran life course. Also paramount is implementation and evaluation of existing interventions, programs, and policies across the population using an integrated and person centered approach.

Selecting post-acute care settings after abdominal surgery: Are we getting it right?

BACKGROUND We investigated whether variation in post-acute care (PAC) services could be explained by surgeons discharging clinically similar patients to different PAC destinations, including home health (HH), skilled nursing facilities (SNF), and inpatient rehabilitation (IR). METHODS We studied patients having colectomy, pancreatectomy or hepatectomy in the 2008-2011 Nationwide Inpatient Sample. We used propensity matching to determine: 1. Proportion of patients discharged to SNF/IR who could be matched to clinically similar patients discharged with HH. 2. Potential cost savings from greater use of HH. RESULTS 30,843 patients were discharged with HH and 23,172 to SNF or IR. 14,163 (61%) SNF/IR patients could be matched to similar patients discharged with HH. Potential cost savings from increasing use of HH as an alternative to SNF/IR ranged from

Incongruence between women's survey- and interview-determined decision control preferences: A mixed methods study of decision-making in metastatic breast cancer

2.5-

Planning post-discharge destination for gastrointestinal surgery patients: Room for improvement?

438 million annually. CONCLUSIONS There is considerable potential for reducing variation in PAC use and costs by better understanding how surgeons make decisions about PAC placement.

The Clinical Sequencing Evidence-Generating Research Consortium: Integrating Genomic Sequencing in Diverse and Medically Underserved Populations

Women with metastatic breast cancer face numerous, complex treatment and advance care planning (ACP) decisions. Our aim was to develop a better understanding of women with metastatic breast cancers decision‐making preferences overtime and relative to specific types of decisions.

The Language of Stewardship: Is the “Low-Value” Label Overused?

BACKGROUND We compared short-term recovery for patients discharged to inpatient rehabilitation versus skilled nursing facilities after gastrointestinal surgery. MATERIALS & METHODS We conducted a propensity-matched cohort study of 12,939 adults discharged to inpatient rehabilitation or skilled nursing facilities after colectomy, pancreatectomy or hepatectomy at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2014. Primary outcomes were readmission and mortality rates 30 days after surgery. RESULTS 9259 (72%) patients were discharged to skilled nursing facilities and 3680 (28%) to inpatient rehabilitation. Median age in both groups was 76 years and 82% of patients were white. There was no difference in 30-day readmission rates (16% for skilled nursing vs 16.8% for inpatient rehabilitation) but post-discharge mortality was higher for patients discharged to skilled nursing facilities (4.4%) compared to inpatient rehabilitation (1.6%, p < 0.001). CONCLUSIONS Increased utilization of inpatient rehabilitation services after gastrointestinal surgery may improve postoperative outcomes.

Using the Veterans Health Administration as a Laboratory for Integrated Decision Tools for Patients and Clinicians

The Clinical Sequencing Evidence-Generating Research (CSER) consortium, now in its second funding cycle, is investigating the effectiveness of integrating genomic (exome or genome) sequencing into the clinical care of diverse and medically underserved individuals in a variety of healthcare settings and disease states. The consortium comprises a coordinating center, six funded extramural clinical projects, and an ongoing National Human Genome Research Institute (NHGRI) intramural project. Collectively, these projects aim to enroll and sequence over 6,100 participants in four years. At least 60% of participants will be of non-European ancestry or from underserved settings, with the goal of diversifying the populations that are providing an evidence base for genomic medicine. Five of the six clinical projects are enrolling pediatric patients with various phenotypes. One of these five projects is also enrolling couples whose fetus has a structural anomaly, and the sixth project is enrolling adults at risk for hereditary cancer. The ongoing NHGRI intramural project has enrolled primarily healthy adults. Goals of the consortium include assessing the clinical utility of genomic sequencing, exploring medical follow up and cascade testing of relatives, and evaluating patient-provider-laboratory level interactions that influence the use of this technology. The findings from the CSER consortium will offer patients, healthcare systems, and policymakers a clearer understanding of the opportunities and challenges of providing genomic medicine in diverse populations and settings, and contribute evidence toward developing best practices for the delivery of clinically useful and cost-effective genomic sequencing in diverse healthcare settings.

Shared decision-making in chronic lymphocytic leukemia: Preferences and perceptions of patients, providers, and navigators.

From the Division of Preventive Medicine, University of Alabama at Birmingham, and Birmingham VA Medical Center, Birmingham, AL. V alue, a construct for describing the economic efficiency of specific health care services or entire delivery systems, has become amajor focus in US health care. The United States spends more on health care than any other nation and ranks poorly on numerous health measures, so increasing the value of care delivered has appropriately been the foundation of recent health care reforms. One approach to increasing the value of US health care is to limit the use of interventions that do little to improve health, which may account for more than one-third of all health care spending. To that end, physicians have recently been leading a stewardship movement, arguing that the ability to continue delivering high-quality care requires recognizing that resources are limited and ensuring that those resources are used efficiently. A notable example is the Choosing Wisely campaign, which has enlisted professional societies to develop lists of tests and treatments that may be unnecessary. Not surprisingly, the services targeted by the stewardship movement generally and Choosing Wisely specifically are often labeled as “low-value.” Despite the needed attention on value, the application of the low-value label to specific servicesmay be overused. The label is not necessarily warranted for all services with small and uncertain benefit, may convey that cost containment is the primary rationale for discouraging services when there are potentially more compelling reasons, and may constrain the scope of the entire stewardship movement.

Enhanced Recovery After Surgery (ERAS) Eliminates Racial Disparities in Postoperative Length of Stay After Colorectal Surgery

The Department of Veterans Affairs (VA) healthcare system emphasizes patient-centered, evidence-based, collaborative health care in a system that seeks continuous quality improvement. Integrated decision support is central to realizing this vision. Decision support systems provide a platform to engage clinicians and patients in making health decisions that incorporate the best evidence on diagnostic and treatment options, the patient’s clinical information and risk factors, and patient values, goals, and preferences for care. The early adoption of health information technology systems in the VA, such as the electronic health record (EHR), has provided the infrastructure for highly innovative research on applied decision making. This chapter highlights contributions of VA investigators using these technologies to advance clinical decision support tools and improve shared decision making in the VA healthcare system and beyond.