Search results for: readmission rates

Authors: Harini Chakkera

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Background: Inpatient hyperglycemia is an established independent risk factor among several patient cohorts with hospital readmission. This has not been studied after kidney transplantation. Nearly one-third of patients who have undergone a kidney transplant reportedly experience 30-day readmission. Methods: Data on first-time solitary kidney transplantations were retrieved between September 2015 to December 2018. Information was linked to the electronic health record to determine a diagnosis of diabetes mellitus and extract glucometeric and insulin therapy data. Univariate logistic regression analysis and the XGBoost algorithm were used to predict 30-day readmission. We report the average performance of the models on the testing set on five bootstrapped partitions of the data to ensure statistical significance. Results: The cohort included 1036 patients who received kidney transplantation, and 224 (22%) experienced 30-day readmission. The machine learning algorithm was able to predict 30-day readmission with an average AUC of 77.3% (95% CI 75.30-79.3%). We observed statistically significant differences in the presence of pretransplant diabetes, inpatient-hyperglycemia, inpatient-hypoglycemia, and minimum and maximum glucose values among those with higher 30-day readmission rates. The XGBoost model identified the index admission length of stay, presence of hyper- and hypoglycemia and recipient and donor BMI values as the most predictive risk factors of 30-day readmission. Additionally, significant variations in the therapeutic management of blood glucose by providers were observed. Conclusions: Suboptimal glucose metrics during hospitalization after kidney transplantation is associated with an increased risk for 30-day hospital readmission. Optimizing the hospital blood glucose management, a modifiable factor, after kidney transplantation may reduce the risk of 30-day readmission.

Keywords: kidney, transplant, diabetes, insulin

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Authors: Vincent Liu

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Machine learning algorithms (ML) can achieve high accuracy in predicting outcomes compared to classical models. Metaheuristic, nature-inspired algorithms can enhance traditional ML algorithms by optimizing them such as by performing feature selection. We compare ten ML algorithms to predict 30-day hospital readmission rates for diabetes patients in the US using a dataset from UCI Machine Learning Repository with feature selection performed by Greywolf nature-inspired algorithm. The baseline accuracy for the initial random forest model was 65%. After performing feature engineering, SMOTE for class balancing, and Greywolf optimization, the machine learning algorithms showed better metrics, including F1 scores, accuracy, and confusion matrix with improvements ranging in 10%-30%, and a best model of XGBoost with an accuracy of 95%. Applying machine learning this way can improve patient outcomes as unnecessary rehospitalizations can be prevented by focusing on patients that are at a higher risk of readmission.

Keywords: diabetes, machine learning, 30-day readmission, metaheuristic

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Authors: Eduardo Costa

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Hospital strikes in the Portuguese National Health Service (NHS) are becoming increasingly frequent, raising concerns in what respects patient safety. In fact, data shows that mortality rates for patients admitted during strikes are up to 30% higher than for patients admitted in other days. This paper analyses the effects of hospital strikes on patients’ outcomes. Specifically, it analyzes the impact of different strikes (physicians, nurses and other health professionals), on in-hospital mortality rates, readmission rates and length of stay. The paper uses patient-level data containing all NHS hospital admissions in mainland Portugal from 2012 to 2017, together with a comprehensive strike dataset comprising over 250 strike days (19 physicians-strike days, 150 nurses-strike days and 50 other health professionals-strike days) from 135 different strikes. The paper uses a linear probability model and controls for hospital and regional characteristics, time trends, and changes in patients’ composition and diagnoses. Preliminary results suggest a 6-7% increase in in-hospital mortality rates for patients exposed to physicians’ strikes. The effect is smaller for patients exposed to nurses’ strikes (2-5%). Patients exposed to nurses strikes during their stay have, on average, higher 30-days urgent readmission rates (4%). Length of stay also seems to increase for patients exposed to any strike. Results – conditional on further testing, namely on non-linear models - suggest that hospital operations and service levels are partially disrupted during strikes.

Keywords: health sector strikes, in-hospital mortality rate, length of stay, readmission rate

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Authors: Yongrong Liu, Xin Tang

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Background: Persistent atrial fibrillation is a common arrhythmia closely related to heart failure. Heart rate control is an essential strategy for treating persistent atrial fibrillation. Still, the understanding of the relationship between different heart rate control levels and the risk of heart failure rehospitalization is limited. Objective: The objective of the study is to determine the relationship between different levels of heart rate control in patients with persistent atrial fibrillation and the risk of readmission for heart failure. Methods: We conducted a retrospective dual-centre cohort study, collecting data from patients with persistent atrial fibrillation who received outpatient treatment at two tertiary hospitals in central and western China from March 2019 to March 2020. The collected data included age, gender, body mass index (BMI), medical history, and hospitalization frequency due to heart failure. Patients were divided into three groups based on their heart rate control levels: Group I with a resting heart rate of less than 80 beats per minute, Group II with a resting heart rate between 80 and 100 beats per minute, and Group III with a resting heart rate greater than 100 beats per minute. The readmission rates due to heart failure within one year after discharge were statistically analyzed using propensity score matching in a 1:1 ratio. Differences in readmission rates among the different groups were compared using one-way ANOVA. The impact of varying levels of heart rate control on the risk of readmission for heart failure was assessed using the Cox proportional hazards model. Binary logistic regression analysis was employed to control for potential confounding factors. Results: We enrolled a total of 1136 patients with persistent atrial fibrillation. The results of the one-way ANOVA showed that there were differences in readmission rates among groups exposed to different levels of heart rate control. The readmission rates due to heart failure for each group were as follows: Group I (n=432): 31 (7.17%); Group II (n=387): 11.11%; Group III (n=317): 90 (28.50%) (F=54.3, P<0.001). After performing 1:1 propensity score matching for the different groups, 223 pairs were obtained. Analysis using the Cox proportional hazards model showed that compared to Group I, the risk of readmission for Group II was 1.372 (95% CI: 1.125-1.682, P<0.001), and for Group III was 2.053 (95% CI: 1.006-5.437, P<0.001). Furthermore, binary logistic regression analysis, including variables such as digoxin, hypertension, smoking, coronary heart disease, and chronic obstructive pulmonary disease as independent variables, revealed that coronary heart disease and COPD also had a significant impact on readmission due to heart failure (p<0.001). Conclusion: The correlation between the heart rate control level of patients with persistent atrial fibrillation and the risk of heart failure rehospitalization is positive. Reasonable heart rate control may significantly reduce the risk of heart failure rehospitalization.

Keywords: heart rate control levels, heart failure rehospitalization, persistent atrial fibrillation, retrospective cohort study

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Authors: Brandon Knopp, Matthew Harris

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Purpose: Tip-apex distance (TAD) has long been discussed as a metric for determining risk of failure in the fixation of peritrochanteric fractures. TAD measurements over 25 millimeters (mm) have been associated with higher rates of screw cut out and other complications in the first several months after surgery. However, there is limited evidence for the efficacy of this measurement in predicting the long-term risk of negative outcomes following hip fixation surgery. The purpose of our study was to investigate risk factors including TAD for hospital readmission, loss of pre-injury ambulation and development of complications within 1 year after hip fixation surgery. Methods: A retrospective review of proximal hip fractures treated with single screw intramedullary devices between 2016 and 2020 was performed at a 327-bed regional medical center. Patients included had a postoperative follow-up of at least 12 months or surgery-related complications developing within that time. Results: 44 of the 67 patients in this study met the inclusion criteria with adequate follow-up post-surgery. There was a total of 10 males (22.7%) and 34 females (77.3%) meeting inclusion criteria with a mean age of 82.1 (± 12.3) at the time of surgery. The average TAD in our study population was 19.57mm and the average 1-year readmission rate was 15.9%. 3 out of 6 patients (50%) with a TAD > 25mm were readmitted within one year due to surgery-related complications. In contrast, 3 out of 38 patients (7.9%) with a TAD < 25mm were readmitted within one year due to surgery-related complications (p=0.0254). Individual TAD measurements, averaging 22.05mm in patients readmitted within 1 year of surgery and 19.18mm in patients not readmitted within 1 year of surgery, were not significantly different between the two groups (p=0.2113). Conclusions: Our data indicate a significant improvement in hospital readmission rates up to one year after hip fixation surgery in patients with a TAD < 25mm with a decrease in readmissions of over 40% (50% vs 7.9%). This result builds upon past investigations by extending the follow-up time to 1 year after surgery and utilizing hospital readmissions as a metric for surgical success. With the well-documented physical and financial costs of hospital readmission after hip surgery, our study highlights a reduction of TAD < 25mm as an effective method of improving patient outcomes and reducing financial costs to patients and medical institutions. No relationship was found between TAD measurements and secondary outcomes, including loss of pre-injury ambulation and development of complications.

Keywords: hip fractures, hip reductions, readmission rates, open reduction internal fixation

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Authors: Induja R. Nimma, Anand Reddy Maligireddy, Artur Schneider, Melissa Lyle

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Background: Although heart failure is one of the most common causes of hospitalization in adult patients, there is limited knowledge on outcomes following initial hospitalization for COVID-19 with heart failure (HCF-19). We felt it pertinent to analyze 30-day readmission causes and outcomes among patients with HCF-19 using the United States using real-world big data via the National readmission database. Objective: The aim is to describe the rate and causes of readmissions and morbidity of heart failure with coinciding COVID-19 (HFC-19) in the United States, using the 2020 National Readmission Database (NRD). Methods: A descriptive, retrospective study was conducted on the 2020 NRD, a nationally representative sample of all US hospitalizations. Adult (>18 years) inpatient admissions with COVID-19 with HF and readmissions in 30 days were selected based on the International Classification of Diseases-Tenth Revision, Procedure Code. Results: In 2020, 2,60,372 adult patients were hospitalized with COVID-19 and HF. The median age was 74 (IQR: 64-83), and 47% were female. The median length of stay was 7(4-13) days, and the total cost of stay was 62,025 (31,956 – 130,670) United States dollars, respectively. Among the index hospital admissions, 61,527 (23.6%) died, and 22,794 (11.5%) were readmitted within 30 days. The median age of patients readmitted in 30 days was 73 (63-82), 45% were female, and 1,962 (16%) died. The most common principal diagnosis for readmission in these patients was COVID-19= 34.8%, Sepsis= 16.5%, HF = 7.1%, AKI = 2.2%, respiratory failure with hypoxia =1.7%, and Pneumonia = 1%. Conclusion: The rate of readmission in patients with heart failure exacerbations is increasing yearly. COVID-19 was observed to be the most common principal diagnosis in patients readmitted within 30 days. Complicated hypertension, chronic pulmonary disease, complicated diabetes, renal failure, alcohol use, drug use, and peripheral vascular disorders are risk factors associated with readmission. Familiarity with the most common causes and predictors for readmission helps guide the development of initiatives to minimize adverse outcomes and the cost of medical care.

Keywords: Covid-19, heart failure, national readmission database, readmission outcomes

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Authors: Mary Farrell, Maria Soubra, Sandra Vega, Dorothy Kakraba, Joanne Fontanilla, Moira Kendra, Danielle Tonzola, Stephanie Chiu

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Pneumonia is the most common infectious cause of hospitalizations in the United States, with more than one million admissions annually and costs of $10 billion every year, making it the 8th leading cause of death. Aspiration pneumonia is an aggressive type of pneumonia that results from inhalation of oropharyngeal secretions and/or gastric contents and is preventable. The authors hypothesized that an evidence-based aspiration pneumonia clinical care pathway could reduce 30-day hospital readmissions and mortality rates, while improving the overall care of patients. We conducted a retrospective chart review on 979 patients discharged with aspiration pneumonia from January 2021 to December 2022 at Overlook Medical Center. The authors identified patients who were coded with aspiration pneumonia and/or stable sepsis. Secondarily, we identified 30-day readmission rates for aspiration pneumonia from a SNF. The Aspiration Pneumonia Clinical Care Pathway starts in the emergency department (ED) with the initiation of antimicrobials within 4 hours of admission and early recognition of aspiration. Once this is identified, a swallow test is initiated by the bedside nurse, and if the patient demonstrates dysphagia, they are maintained on strict nothing by mouth (NPO) followed by a speech and language pathologist (SLP) referral for an appropriate modified diet recommendation. Aspiration prevention techniques included the avoidance of straws, 45-degree positioning, no talking during meals, taking small bites, placement of the aspiration wrist band, and consuming meals out of the bed in a chair. Nursing education was conducted with a newly created online learning module about aspiration pneumonia. The authors identified 979 patients, with an average age of 73.5 years old, who were diagnosed with aspiration pneumonia on the index hospitalization. These patients were reviewed for a 30-day readmission for aspiration pneumonia or stable sepsis, and mortality rates from January 2021 to December 2022 at Overlook Medical Center (OMC). The 30-day readmission rates were significantly lower in the cohort that received the clinical care pathway (35.0% vs. 27.5%, p = 0.011). When evaluating the mortality rates in the pre and post intervention cohort the authors discovered the mortality rates were lower in the post intervention cohort (23.7% vs 22.4%, p = 0.61) Mortality among non-white (self-reported as non-white) patients were lower in the post intervention cohort (34.4% vs. 21.0% , p = 0.05). Patients who reported as a current smoker/vaper in the pre and post cohorts had increased mortality rates (5.9% vs 22%). There was a decrease in mortality for the male population but an increase in mortality for women in the pre and post cohorts (19% vs. 25%). The authors attributed this increase in mortality in the post intervention cohort to more active smokers, more former smokers, and more being admitted from a SNF. This research identified that implementation of an Aspiration Pneumonia Clinical Care Pathway showed a statistically significant decrease in readmission rates and mortality rates in non-whites. The 30-day readmission rates were lower in the cohort that received the clinical care pathway (35.0% vs. 27.5%, p = 0.011).

Keywords: aspiration pneumonia, mortality, quality improvement, 30-day pneumonia readmissions

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Authors: Sıdıka Kaya, Gülay Sain Güven, Seda Karsavuran, Onur Toka

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This study is part of an ongoing research project supported by the Scientific and Technological Research Council of Turkey (TUBITAK) under Project Number 114K404, and participation to this conference was supported by Hacettepe University Scientific Research Coordination Unit under Project Number 10243. Evaluation of hospital readmissions is gaining importance in terms of quality and cost, and is becoming the target of national policies. In Turkey, the topic of hospital readmission is relatively new on agenda and very few studies have been conducted on this topic. The aim of this study was to determine 30-day readmission rates and risk factors for readmission. Whether readmission was planned, related to the prior admission and avoidable or not was also assessed. The study was designed as a ‘prospective cohort study.’ 472 patients hospitalized in internal medicine departments of a university hospital in Turkey between February 1, 2015 and April 30, 2015 were followed up. Analyses were conducted using IBM SPSS Statistics version 22.0 and SPSS Modeler 16.0. Average age of the patients was 56 and 56% of the patients were female. Among these patients 95 were readmitted. Overall readmission rate was calculated as 20% (95/472). However, only 31 readmissions were unplanned. Unplanned readmission rate was 6.5% (31/472). Out of 31 unplanned readmission, 24 was related to the prior admission. Only 6 related readmission was avoidable. To determine risk factors for readmission we constructed Chi-square automatic interaction detector (CHAID) decision tree algorithm. CHAID decision trees are nonparametric procedures that make no assumptions of the underlying data. This algorithm determines how independent variables best combine to predict a binary outcome based on ‘if-then’ logic by portioning each independent variable into mutually exclusive subsets based on homogeneity of the data. Independent variables we included in the analysis were: clinic of the department, occupied beds/total number of beds in the clinic at the time of discharge, age, gender, marital status, educational level, distance to residence (km), number of people living with the patient, any person to help his/her care at home after discharge (yes/no), regular source (physician) of care (yes/no), day of discharge, length of stay, ICU utilization (yes/no), total comorbidity score, means for each 3 dimensions of Readiness for Hospital Discharge Scale (patient’s personal status, patient’s knowledge, and patient’s coping ability) and number of daycare admissions within 30 days of discharge. In the analysis, we included all 95 readmitted patients (46.12%), but only 111 (53.88%) non-readmitted patients, although we had 377 non-readmitted patients, to balance data. The risk factors for readmission were found as total comorbidity score, gender, patient’s coping ability, and patient’s knowledge. The strongest identifying factor for readmission was comorbidity score. If patients’ comorbidity score was higher than 1, the risk for readmission increased. The results of this study needs to be validated by other data–sets with more patients. However, we believe that this study will guide further studies of readmission and CHAID is a useful tool for identifying risk factors for readmission.

Keywords: decision tree, hospital, internal medicine, readmission

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Authors: Soha A. Bahanshal, Byung G. Kim

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Identification of patients at high risk for hospital readmission is of crucial importance for quality health care and cost reduction. Predicting hospital readmissions among diabetic patients has been of great interest to many researchers and health decision makers. We build a prediction model to predict hospital readmission for diabetic patients within 30 days of discharge. The core of the prediction model is a modified k Nearest Neighbor called Hybrid Fuzzy Weighted k Nearest Neighbor algorithm. The prediction is performed on a patient dataset which consists of more than 70,000 patients with 50 attributes. We applied data preprocessing using different techniques in order to handle data imbalance and to fuzzify the data to suit the prediction algorithm. The model so far achieved classification accuracy of 80% compared to other models that only use k Nearest Neighbor.

Keywords: machine learning, prediction, classification, hybrid fuzzy weighted k-nearest neighbor, diabetic hospital readmission

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Authors: Xuan Hua Huang, Shu Fen Wu, Yi Ting Huang, Pi Yueh Lee

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Background: In Taiwan, the Taiwan healthcare care Indicator Series regards the rate of hospital readmission as an important indicator of healthcare quality. Unplanned readmission not only effects patient’s condition but also increase healthcare utilization rate and healthcare costs. Purpose: The purpose of this study was explored the effects of adult unplanned readmission within 14 days of discharge at a regional teaching hospital in South Taiwan. Methods: The retrospectively review design was used. A total 495 participants of unplanned readmissions and 878 of non-readmissions within 14 days recruited from a regional teaching hospital in Southern Taiwan. The instruments used included the Charlson Comorbidity Index, and demographic characteristics, and disease-related variables. Statistical analyses were performed with SPSS version 22.0. The descriptive statistics were used (means, standard deviations, and percentage) and the inferential statistics were used T-test, Chi-square test and Logistic regression. Results: The unplanned readmissions within 14 days rate was 36%. The majorities were 268 males (54.1%), aged >65 were 318 (64.2%), and mean age was 68.8±14.65 years (23-98years). The mean score for the comorbidities was 3.77±2.73. The top three diagnosed of the readmission were digestive diseases (32.7%), respiratory diseases (15.2%), and genitourinary diseases (10.5%). There were significant relationships among the gender, age, marriage, comorbidity status, and discharge planning services (χ2: 3.816-16.474, p: 0.051~0.000). Logistic regression analysis showed that old age (OR = 1.012, 95% CI: 1.003, 1.021), had the multi-morbidity (OR = 0.712~4.040, 95% CI: 0.559~8.522), had been consult with discharge planning services (OR = 1.696, 95% CI: 1.105, 2.061) have a higher risk of readmission. Conclusions: This study finds that multi-morbidity was independent risk factor for unplanned readmissions at 14 days, recommended that the interventional treatment of the medical team be provided to provide integrated care for multi-morbidity to improve the patient's self-care ability and reduce the 14-day unplanned readmission rate.

Keywords: unplanned readmission, comorbidities, Charlson comorbidity index, logistic regression

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Authors: Hui-Yen Lee, Hsiu-Yun Wei, Guey-Jen Lin, Pi-Yueh Lee Lee

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Background: Unplanned hospital readmissions increase healthcare costs and have been considered a marker of poor healthcare performance. The elderly face a higher risk of unplanned readmission due to elderly-specific characteristics such as deteriorating body functions and the relatively high incidence of complications after treatment of acute diseases. Purpose: The aim of this study was exploring the factors that relate to the unplanned readmission of elderly within 14 days of discharge at our hospital in southern Taiwan. Methods: We retrospectively reviewed the medical records of patients aged ≥65 years who had been re-admitted between January 2018 and December 2018.The Charlson Comorbidity score was calculated using previous used method. Related factors that affected the rate of unplanned readmission within 14 days of discharge were screened and analyzed using the chi-squared test and logistic regression analysis. Results: This study enrolled 829 subjects aged more than 65 years. The numbers of unplanned readmission patients within 14 days were 318 cases, while those did not belong to the unplanned readmission were 511 cases. In 2018, the rate of elderly patients in unplanned 14 days readmissions was 38.4%. The majority patients were females (166 cases, 52.2%), with an average age of 77.6 ± 7.90 years (65-98). The average value of Charlson Comorbidity score was 4.42±2.76. Using logistic regression analysis, we found that the gastric or peptic ulcer (OR=1.917 , P< 0.002), diabetes (OR= 0.722, P< 0.043), hemiplegia (OR= 2.292, P< 0.015), metastatic solid tumor (OR= 2.204, P< 0.025), hypertension (OR= 0.696, P< 0.044), and skin ulcer/cellulitis (OR= 2.747, P< 0.022) have significantly higher risk of 14-day readmissions. Conclusion: The results of the present study may assist the healthcare teams to understand the factors that may affect unplanned readmission in the elderly. We recommend that these teams give efficient approach in their medical practice, provide timely health education for elderly, and integrative healthcare for chronic diseases in order to reduce unplanned readmissions.

Keywords: unplanning readmission, elderly, Charlson comorbidity score, logistic regression analysis

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Authors: Saniya Ablatt, Matthew Jacobsson, Jamie Whisler, Austin Forbes

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Postoperative pancreatic fistula (POPF) is a complication that occurs in up to 41% of patients after pancreaticoduodenectomy. Although certain characteristics such as individual patient anatomy are known risk factors for POPF, the effect of barbed suture techniques remains underexplored. This study examines whether the use of Stratafix barbed suture versus PDS impacts the risk of developing POPF. After obtaining IRB exemption, a retrospective chart review was initiated involving patients who underwent pancreaticoduodenectomy for the treatment of malignant or premalignant lesions of the pancreas at our institution between April 1st 2020 and April 30th 2022. Patients were stratified into 2 groups respective to the technique used to suture the pancreatico-jejunal anastomosis: Group 1 was composed to patients in which 4.0 Stratafix® suture was used n=41. Group 1 was composed to patients in which 4.0 PDS suture was used n=42. Data regarding patient age, sex, BMI, presence or absence of biochemical leak, presence or absence of grade B & C postoperative pancreatic fistulas, rate and type of in hospital complication, rate of reoperation, 30 day readmission rate, 90 day mortality, and total mortality were compared between groups. 83 patients were included in our study with 42 receiving Stratafix and 41 receiving PDS (50.6% vs 49.4%). Stratafix patients had less biochemical leaks (0.0% vs 4.8%, p=0.19) and higher rates of POPF but this was not statistically significant (7.2% vs 2.4%, p=0.26). Additionally, there was no difference between the use of stratafix versus PDS on the risk of clinically relevant grade B or C POPF (p=0.26, OR=3.25 [CI= 0.74-16.43]). Of the independent variables including age, race, sex, BMI, and ASA class, BMI greater than 25 increased the risk of clinically relevant POPF by 7.7 times compared to patients with BMI less than 25 (p=0.03, OR=7.79 [1.04-88.51]). Despite no significant difference in primary outcomes, the Stratafix group had lower rates of secondary outcomes including 90-day mortality; bleeding, cardiac, and infectious complications; reoperation; and 30-day readmission. On statistical analysis, Stratafix decreased the risk of 30-day readmission (p=0.04, OR=0.21, CI=0.04-0.97) and had a marginally significant effect on the risk of reoperation (p=0.08, OR=0.24, CI=0.04-1.26). There was no difference between the use of Stratafix versus PDS on the risk of POPF (p=0.26). However, Stratafix decreased the risk of 30-day readmission (p=0.04) and BMI greater than 25 increased the risk of clinically relevant POPF (p=0.03).

Keywords: pancreas, hepatobiliary surgery, hepatobiliary, pancreatic leak, biochemical leak, fistula, pancreatic fistula

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Authors: John Kosmeh

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Introduction – For years, senior health care and skilled nursing facilities have been plagued with the dilemma of not having the necessary tools and equipment to adequately care for senior residents in their communities. This has led to high transport rates to emergency departments and high 30-day readmission rates, costing billions of unnecessary dollars each year, as well as quality assurance issues. Our Senior care telemedicine program is designed to solve this issue. Methods – We conducted a 1-year pilot program using our technology coupled with our 24/7 telemedicine program with skilled nursing facilities in different parts of the United States. We then compared transports rates and 30-day readmission rates to previous years before the use of our program, as well as transport rates of other communities of similar size not using our program. This data was able to give us a clear and concise look at the success rate of reducing unnecessary transport and readmissions as well as cost savings. Results – A 94% reduction nationally of unnecessary out-of-facility transports, and to date, complete elimination of 30-day readmissions. Our virtual platform allowed us to instruct facility staff on the utilization of our tools and system as well as deliver treatment by our ER-trained providers. Delay waiting for PCP callbacks was eliminated. We were able to obtain lung, heart, and abdominal ultrasound imaging, 12 lead EKG, blood labs, auscultate lung and heart sounds, and collect other diagnostic tests at the bedside within minutes, providing immediate care and allowing us to treat residents within the SNF. Are virtual capabilities allowed for loved ones, family members, and others who had medical power of attorney to virtually connect with us at the time of visit, to speak directly with the medical provider, providing increased confidence in the decision to treat the resident in-house. The decline in transports and readmissions will greatly reduce governmental cost burdens, as well as fines imposed on SNF for high 30-day readmissions, reduce the cost of Medicare A readmissions, and significantly impact the number of patients visiting overcrowded ERs. Discussion – By utilizing our program, SNF can effectively reduce the number of unnecessary transports of residents, as well as create significant savings from loss of day rates, transportation costs, and high CMS fines. The cost saving is in the thousands monthly, but more importantly, these facilities can create a higher quality of life and medical care for residents by providing definitive care instantly with ER-trained personnel.

Keywords: senior care, long term care, telemedicine, technology, senior care communities

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Authors: Misbah Nizamani, Saira Malik

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Introduction: Bariatric surgery is the most effective treatment for patients suffering from morbid obesity. Laparoscopic sleeve gastrectomy (LSG) accounts for over 50% of total bariatric procedures. The aim of our meta-analysis is to investigate the effectiveness and safety of Enhanced Recovery After Surgery (ERAS) protocols for patients undergoing laparoscopic sleeve gastrectomy. Method: To gather data, we searched PubMed, Google Scholar, ScienceDirect, and Cochrane Central. Eligible studies were randomized controlled trials and cohort studies involving adult patients (≥18 years) undergoing bariatric surgeries, i.e., Laparoscopic sleeve gastrectomy. Outcome measures included LOS, postoperative narcotic usage, postoperative pain score, postoperative nausea and vomiting, postoperative complications and mortality, emergency department visits and readmission rates. RevMan version 5.4 was used to analyze outcomes. Results: Three RCTs and three cohorts with 1522 patients were included in this study. ERAS group and control group were compared for eight outcomes. LOS was reduced significantly in the intervention group (p=0.00001), readmission rates had borderline differences (p=0.35) and higher postoperative complications in the control group, but the result was non-significant (p=0.68), whereas postoperative pain score was significantly reduced (p=0.005). Total MME requirements became significant after performing sensitivity analysis (p= 0.0004). Postoperative mortality could not be analyzed on account of invalid data showing 0% mortality in two cohort studies. Conclusion: This systemic review indicated the effectiveness of the application of ERAS protocols in LSG in reducing the length of stay, post-operative pain and total MME requirements postoperatively, indicating the feasibility and assurance of its application.

Keywords: eras protocol, sleeve gastrectomy, bariatric surgery, enhanced recovery after surgery

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Authors: Teagan Fink, Lynn Chong, Michael Hii, Brett Knowles

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Background: Telemedicine is a rapidly advancing field providing healthcare to patients at a distance from their treating clinician. There is a paucity of high-quality evidence detailing the safety and acceptability of telemedicine for postoperative outpatient follow-up. This randomized controlled trial – conducted prior to the COVID 19 pandemic – aimed to assess patient satisfaction and safety (as determined by readmission, reoperation and complication rates) of telephone compared to face-to-face clinic follow-up after uncomplicated general surgical procedures. Methods: Patients following uncomplicated laparoscopic appendicectomy or cholecystectomy and laparoscopic or open umbilical or inguinal hernia repairs were randomized to a telephone or face-to-face outpatient clinic follow-up. Data points including patient demographics, perioperative details and postoperative outcomes (eg. wound healing complications, pain scores, unplanned readmission to hospital and return to daily activities) were compared between groups. Patients also completed a Likert patient satisfaction survey following their consultation. Results: 103 patients were recruited over a 12-month period (21 laparoscopic appendicectomies, 65 laparoscopic cholecystectomies, nine open umbilical hernia repairs, six laparoscopic inguinal hernia repairs and two laparoscopic umbilical hernia repairs). Baseline patient demographics and operative interventions were the same in both groups. Patient or clinician-reported concerns on postoperative pain, use of analgesia, wound healing complications and return to daily activities at clinic follow-up were not significantly different between the two groups. Of the 58 patients randomized to the telemedicine arm, 40% reported high and 60% reported very high patient satisfaction. Telemedicine clinic mean consultation times were significantly shorter than face-to-face consultation times (telemedicine 10.3 +/- 7.2 minutes, face-to-face 19.2 +/- 23.8 minutes, p-value = 0.014). Rates of failing to attend clinic were not significantly different (telemedicine 3%, control 6%). There was no increased rate of postoperative complications in patients followed up by telemedicine compared to in-person. There were no unplanned readmissions, return to theatre, or mortalities in this study. Conclusion: Telemedicine follow-up of patients undergoing uncomplicated general surgery is safe and does not result in any missed diagnosis or higher rates of complications. Telemedicine provides high patient satisfaction and steps to implement this modality in inpatient care should be undertaken.

Keywords: general surgery, telemedicine, patient satisfaction, patient safety

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Authors: Nicholas Bayfield, Liam Bibo, Charley Budgeon, Robert Larbalestier, Tom Briffa

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Introduction: Stress hyperglycaemia is common following cardiac surgery. Its optimal management is uncertain and may differ by diabetic status. This study assesses the in-hospital glycaemic management of cardiac surgery patients and associated postoperative outcomes. Methods: A retrospective cohort analysis of all patients undergoing cardiac surgery at Fiona Stanley Hospital from February 2015 to May 2019 was undertaken. Management and outcomes of hyperglycaemia following cardiac surgery were assessed. Follow-up was assessed to 1 year postoperatively. Multivariate regression modelling was utilised. Results: 1050 non-diabetic patients and 689 diabetic patients were included. In the non-diabetic cohort, patients with mild (peak blood sugar level [BSL] < 14.3), transient stress hyperglycaemia managed without insulin were not at an increased risk of wound-related morbidity (P=0.899) or mortality at 1 year (P=0.483). Insulin management was associated with wound-related readmission to hospital (P=0.004) and superficial sternal wound infection (P=0.047). Prolonged or severe stress hyperglycaemia was predictive of hospital re-admission (P=0.050) but not morbidity or mortality (P=0.546). Diabetes mellitus was an independent risk factor 1-year mortality (OR; 1.972 [1.041–3.736], P=0.037), graft harvest site wound infection (OR; 1.810 [1.134–2.889], P=0.013) and wound-related readmission (OR; 1.866 [1.076–3.236], P=0.026). In diabetics, postoperative peak BSL > 13.9mmol/L was predictive of graft harvest site infections (OR; 3.528 [1.724-7.217], P=0.001) and wound-related readmission OR; 3.462 [1.540-7.783], P=0.003) regardless of modality of management. A peak BSL of 10.0-13.9 did not increase the risk of morbidity/mortality compared to a peak BSL of < 10.0 (P=0.557). Diabetics with a peak BSL of 13.9 or less did not have significantly increased morbidity/mortality outcomes compared to non-diabetics (P=0.418). Conclusion: In non-diabetic patients, transient mild stress hyperglycaemia following cardiac surgery does not uniformly require treatment. In diabetic patients, postoperative hyperglycaemia with peak BSL exceeding 13.9mmol/L was associated with wound-related morbidity and hospital readmission following cardiac surgery.

Keywords: cardiac surgery, pulmonary embolism, pulmonary embolectomy, cardiopulmonary bypass

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Authors: Ivory A. Rulona, Jarungchai Anton S. Vatanagul

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Background: Depression is common after stroke with quoted rates ranging from 18% to 61%. 8 Mood disturbance is common after stroke and may present as depression or anxiety. Psychological mood disturbance is associated with higher rates of mortality, long term disability, and hospital readmission. Objectives: To investigate the incidence of post-stroke depression in a tertiary hospital in Cebu City, Philippines and to determine its associated factors. The study is designed to be prospective, descriptive, cross-sectional survey. Participants: Adult patients seen and diagnosed to have stroke either infarct or hemorrhage within the period of January 1 to July 31, 2014. Results: A total of 100 patients with stroke were interviewed using the 17-item Hamilton Depression Rating Scale (HDRS) questionnaire. The average age of the respondents was 60.50 years old ±1.18, majority were males (55%), 83% were married, and 81% were employed. The most common co-morbidity was hypertension 78% followed by diabetes mellitus at 50%. Moreover, 39% of these patients had stroke in months, 26% in years, and 18% in weeks. The average functional capacity based on Modified Rankin Scale was 2.14+/-0.14. Among 100 patients, a total of 30 patients (30%) had depression: 2 (2%) very severe, 5 (5%) moderate and 23 (23%) had mild depression while 70 patients (70%) had no depression. Stroke located at the dominant hemisphere was not associated with severe depression (p=0.102). A similar trend was also noted among those with stroke at the right side (p=0.183), pons (p=0.634), bilateral (p=0.776), and midbrain (p=0.336). Conclusion: This study showed that majority of stroke patients were males with average age of 60.50 years. Hypertension was the most common co-morbidity. There was no association between stroke location and depression. The incidence of PSD was 30%.

Keywords: post-stroke depression, co-morbidity, disturbance, bilateral

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Authors: Ishwor Paudel, Pratima Gautam, Sandeep Bhattarai

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Bile spillage occurs frequently during laparoscopic cholecystectomy yet its impact on postoperative outcomes remains unknown. It might not be as innocuous as some surgeons tend to believe and in fact, might be associated with post-operative surgical site infections (SSI). It often leads to patient dissatisfaction, emergency department visits, with subsequent readmission and additional procedures. While some authors found no increase in SSI following bile spillage (BS) compared to non-bile spillage cases, others found bile spillage to be associated with SSI. Therefore we sought to examine whether bile spillage is indeed associated with an increased risk of postoperative wound infections after laparoscopic cholecystectomy. I hypothesize that patients who experience BS during operation, have an increased risk of SSI compared to those who do not. This is a prospective observational study conducted in the Department of Surgery, Patan Hospital over a period of one year. Patients undergoing Laparoscopic cholecystectomy were included and bile spillage, if happened was noted. All cases were followed up for 30 days and SSI was diagnosed as per CDC-defined criteria. Fisher’s test was applied to compare SSI in bile spillage versus non-bile spillage cases. A total of 112 patients were included in the final analysis. Bile spillage occurred in 20 cases and was absent in the rest i.e.92 cases. Among bile spillage cases, SSI was found in 4 cases (20%), whereas in nonbile spillage cases, SSI was found in 8 cases (8.7%). However, it was statistically not significant (p-value>0.05). Eleven (92%) cases were superficial SSI and one was an organ-space infection. No mortality or 30-day readmission. Spillage of Gallbladder content does not lead to an increase in SSIs. However as the rate of SSI is still higher, Surgeons should be careful to avoid iatrogenic gallbladder perforation and in case of bile spillage thorough peritoneal irrigation with normal saline should be done.

Keywords: organ space infection, Laparoscopic cholecystectomy, biliary spillage, surgical site infection

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Authors: Said Fares, Mary Fares

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It is well documented that introductory computer programming courses are difficult and that failure rates are high. The aim of this project was to reduce the high failure and withdrawal rates in learning to program. This paper presents a number of changes in module organization and instructional delivery system in teaching CS1. Daily out of class help sessions and tutoring services were applied, interactive lectures and laboratories, online resources, and timely feedback were introduced. Five years of data of 563 students in 21 sections was collected and analyzed. The primary results show that the failure and withdrawal rates were cut by more than half. Student surveys indicate a positive evaluation of the modified instructional approach, overall satisfaction with the course and consequently, higher success and retention rates.

Keywords: failure rate, interactive learning, student engagement, CS1

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Authors: Kina Kim

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Background: There are two types of interferon-gamma release assays (IGRAs) in use for the detection of latent tuberculosis infection (LTBI), QuantiFERON-TB Gold In-tube (QFT-GIT) and T-SPOT.TB. There are some reports that IGRA results are affected by the patient's age. This study aims to compare the results of both IGRA tests according to age groups. Methods: We reviewed 54,882 samples referred to an independent reference laboratory (Seegene Medical Foundation, Seoul, Korea) for the diagnosis of LTBI from January 1, 2021, to December 31, 2021. This retrospective study enrolled 955 patients tested using QFT-GIT and 53,927 patients tested using T-SPOT.TB. The results of both IGRAs were divided in three age groups (0-9, 10-17, and ≥18-year old). The positive rates and the indeterminate rates between QFT-GIT and T-SPOT.TB were compared. We also evaluated the differences in positive and indeterminate rates by age-group. Results: The positive rate of QFT-GIT was 20.1% (192/955) and that of T-SPOT.TB was 8.7% (4704/53927) in overall patients. The positive rates of QFT-GIT in individuals aged 0-9, 10-17, and over 18-year old were 15.4%, 13.3%, and 22.0%, respectively. The positive rates of T-SPOT.TB were 8.9%, 2.0% and 8.8%,in each agegroup, respectively.The overall prevalence of indeterminate results was 2.1% (20/955) of QFT-GIT and 0.5% (270/53927) of T-SPOT.TB. The indeterminate rates of QFT-GIT in individuals aged 0-9, 10-17, and over 18 years were 0.4%, 6.7%, and 2.6%, respectively. The indeterminate rate of T-SPOT.TB were 0.5%, 0.7% and 0.5%,in each age group, respectively. Conclusion: Our findings suggest that T-SPOT.TB has a lower rate of positive results in overall patients and a lower rate of indeterminate results than those of QFT-GIT. The highest positive rate was found in the over 18 years group for QFT-GIT, but the positive rates of T-SPOT.TB was not significantly different among groups by age. QFT-GIT showed variable and higher indeterminate rates according to age group, but T-SPOT.TB showed lower rates in all age groups(<1%).

Keywords: LTBI, IGRA, QFT-GIT, T-SPOT. TB

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Authors: Chueh Chi-An, Chan Hui-Ya

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Background and Aim: National Health Insurance (NHI) Administration released a new reimbursement policy for hospital patients who received a superior discharge plan on April 1, 2016. Each case could be claimed 1,500 points for fee-of service with related documents. The policy is considered a solution to help reducing the crowding in the emergency department, the length of stay of hospital, unplanned readmission rate and unplanned ER visit. This study aim is to explore the effect of the new reimbursement policy for discharge planning service in a medical center. Methods: The discharge team explained to general wards the new policy and encouraged early assessment, communication and connecting to community care for patients. They stated the benefit from the policy and asked documenting for reimbursement claiming from April to May 2016. The imbursement fee of NHI declaration from June 2015 to October 2017 was collected. The indicators included hospital occupancy rate, hospital bed turnover rate, long-term hospitalization rate, and patients’ satisfaction were analyzed after the policy implemented. Results: The results showed that the amount of service declaration was increasing from 2 cases in February 2016 to 110 cases in October 2017, the application rate was increasing from 0.029% to 1.576% of all inpatient cases, and the average payment from NHI was around 148,500 NT dollars per month in 2017. There are no significant differences in the indicators among hospital occupancy rate, hospital bed turnover rate, long-term hospitalization rate, and patients’ satisfaction. Conclusion: To provide a good discharge plan require a specialized case manager, the new reimbursement policy is too complicated and the total fee-of-service hospital could claim is too limited to hiring one. The results suggest more strategies combine with the new reimbursement policy will be needed.

Keywords: discharge planning, reimbursement, unplanned ER visit, readmission rate

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Authors: Mohamed S. Sasi, Adel M. Mlitan, Abdulfattah M. Alkherraz

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This research project aims to investigate difference in relative rates concerning phosphoryl transfer relevant to biological catalysis of DNA and RNA in the pH-independent reactions. Activated Models of DNA and RNA for alkyl-aryl phosphate diesters (with 4-nitrophenyl as a good leaving group) have successfully been prepared to gather kinetic parameters. Eyring plots for the pH–independent hydrolysis of 1 and 2 were established at different temperatures in the range 100–160 °C. These measurements have been used to provide a better estimate for the difference in relative rates between the reactivity of DNA and RNA cleavage. Eyring plot gave an extrapolated rate of kH2O = 1 × 10-10 s -1 for 1 (RNA model) and 2 (DNA model) at 25°C. Comparing the reactivity of RNA model and DNA model shows that the difference in relative rates in the pH-independent reactions is surprisingly very similar at 25°. This allows us to obtain chemical insights into how biological catalysts such as enzymes may have evolved to perform their current functions.

Keywords: DNA and RNA models, relative rates, reactivity, phosphoryl transfe

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Authors: Dena Alhaloul

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The Middle East and North Africa (MENA) region is characterized by diverse cultures, economies, and social structures. Fertility rates in MENA have seen significant changes over time, with variations among countries and subregions. Understanding fertility patterns in this region is essential due to its impact on demographic dynamics, healthcare, labor markets, and social policies. Rising or declining fertility rates have far-reaching consequences for the region's socioeconomic development. The main thrust of this study is to comprehensively examine fertility rates in the Middle East and North Africa (MENA) region. It aims to understand the distribution, determinants, and temporal trends of fertility rates in MENA countries. The study seeks to provide insights into the factors influencing fertility decisions, assess how fertility rates have evolved over time, and potentially develop statistical models to characterize these trends. As for the methodology of the study, the study uses descriptive statistics to summarize and visualize fertility rate data. It also uses regression analyses to identify determinants of fertility rates as well as statistical modeling to characterize temporal trends in fertility rates. The conclusion of this study The research will contribute to a deeper understanding of fertility dynamics in the MENA region, shedding light on the distribution of fertility rates, their determinants, and historical trends.

Keywords: fertility, distribution, modeling, regression

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Authors: Xiaoying Guo, Xiangyun Wang

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Access rates is a key indicator of reflecting the popularity of web pages. Having high access rates are very important for web pages, especially for news web pages, online shopping sites and searching engines. In this paper, we analyzed the influences of visual fluency and cognitive fluency on access rates of Chinese web pages. Firstly, we conducted an experiment of scoring the web pages. Twenty-five subjects were invited to view top 50 web pages of China, and they were asked to give a score in a 5-point Likert-scale from four aspects, including complexity, comfortability, familiarity and usability. Secondly, the obtained results was analyzed by correlation analysis and factor analysis in R. By factor analysis; we analyzed the contributions of visual fluency and cognitive fluency to the access rates. The results showed that both visual fluency and cognitive fluency affect the access rate of web pages. Compared to cognitive fluency, visual fluency play a more important role in user’s accessing of web pages.

Keywords: visual fluency, cognitive fluency, visual complexity, usability

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Authors: Karolína Vozková, Matěj Kuc

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This paper deals with the impact of decrease in interest rates on the performance of commercial and cooperative banks in the Eurozone measured by net interest margin. The analysis was performed on balanced dataset of 268 commercial and 726 cooperative banks spanning the 2008-2015 period. We employed Fixed Effects estimation panel method. As expected, we found a negative relationship between market rates and net interest margin. Our results suggest that the impact of negative interest income differs across individual banking business models. More precisely, those cooperative banks were much more hit by the decrease of market interest rates which might be due to their ownership structure and more restrictive business regulation.

Keywords: cooperative banks, performance, negative interest rates, risk management

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Authors: Adem Atmaca

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More than 500 million COVID-19 cases were noted in February 2022 in Turkey. The country is one of the most impacted countries all around the world with twenty million cases. The cement industry in Turkey ranks among the most energy-intensive sectors with huge production capacities among the biggest exporter countries. The purpose of this paper is to clarify the effects of the pandemic on the cement industry in Turkey by showing the changes in manufacturing capacities and export rates of all facilities in the country. The investigation has revealed that the epidemic has slight effects on the factory production capacities and export rates. Even though the capacity usage rates of the factories decreased dramatically in 2019, it seems that Turkish cement companies turned the pandemic to their advantage by increasing their production capacities, capacity usage rates and export rates gradually by reaching new markets during the pandemic.

Keywords: energy, emissions, cement industry, COVID-19

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Authors: Jalal Sharib@Sarip, Dainee nor Fardzila Ahmad Tugi, Mohd Tarmizi Ishak, Mohd Izwan Abdul Adziz

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This research paper aims to determine the rate of soil erosion and sedimentation by using Cesium-137,137Cs as a medium-term tracer in the Sembrong catchment, Malaysia, over two different study seasons. The results of the analysis show that rates of soil erosion and sedimentation for both seasons were variable. This can be clearly seen where the dry season only gives the value of the rate of soil erosion. Meanwhile, the wet season has given both soil erosion and sedimentation rate values. The dry season had rates of soil erosion between 5.09 t/ha/y to 51.03 t/ha/y. The wet season had soil erosion and sedimentation rates between 8.02 t/ha/y to 39.78 t/ha/y and -4.81 t/ha/y to - 50.81 t/ha/y, each, respectively. rubber and oil palm plantations referring to Station 17 and station 4/6, located near Semberong Lake and Sembrong River, had the highest rates of soil erosion and sedimentation at 51.03 t/ha/y and -50.81 t/ha/y, respectively. Various factors must also be taken into account, such as soil types, the total volume of rainfall received for both seasons, as well as differences in land use at the study stations. In conclusion, 137Cs as a medium-term tracer was successfully used to determine rates of soil erosion and sedimentation in two different seasons for the Sembrong catchment area. The data on soil erosion and sedimentation rates for this study will be very useful for present, and future land and water management in the Sembrong catchment area and may be compared with other similar catchments in Malaysia.

Keywords: soil erosion, sedimentation, cesium-137, catchment management

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Authors: Mouldi Djelassi, Jamel Boukhatem

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Background: A relation has been established between Islamic banks' activities and interest rates. The aim of this study was to explore the impact of interest rates on the deposits and loans held by Islamic and conventional banks in Saudi Arabia. Methods: A time series data was performed over the period 2008Q1-2020Q2 on eight conventional banks and four Islamic banks. The impacts of interest rate shocks on deposits and loans were identified through panel vector autoregressive models. Results: Impulse response function analysis showed that increasing interest rates reduce loans and conventional deposits. For Islamic banks, deposits are more affected by interest rates than lending. Variance decomposition analysis revealed that deposits contribute to 61% of the Islamic financing variation and only 25% of the conventional loans. Conclusion: Interest rates impacted Islamic banks especially through deposits, which is inconsistent with the theoretical framework. Islamic deposits played an important role in Islamic financing variation and may provide to be a channel for the transmission of the monetary policy in a dual banking system. Monetary policy in Saudi Arabia works in part through “credits” (conventional bank credits) as well as through “money” (conventional and Islamic bank deposits).

Keywords: Islamic banking, interest rates, monetary policy transmission, panel VAR

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Authors: Shih-Kuei Lin

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The characterization of the arbitrage-free dynamics of interest rates is developed in this study under the presence of Markov jump risks, when the term structure of the interest rates is modeled through simple forward rates. We consider Markov jump risks by allowing randomness in jump sizes, independence between jump sizes and jump times. The Markov jump diffusion model is used to capture empirical phenomena and to accurately describe interest jump risks in a financial market. We derive the arbitrage-free model of simple forward rates under the spot measure. Moreover, the analytical pricing formulas for a cap and a floor are derived under the forward measure when the jump size follows a lognormal distribution. In our empirical analysis, we find that the LIBOR market model with Markov jump risk better accounts for changes from/to different states and different rates.

Keywords: arbitrage-free, cap and floor, Markov jump diffusion model, simple forward rate model, volatility smile, EM algorithm

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Authors: Tadashi Watanabe, Jinya Katsuyama, Akihiro Mano

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The estimation of leak flow rates through narrow cracks in structures is of importance for nuclear reactor safety, since the leak flow could be detected before occurrence of loss-of-coolant accidents. The two-phase critical leak flow rates are calculated using the system analysis code, and two representative non-homogeneous critical flow models, Henry-Fauske model and Ransom-Trapp model, are compared. The pressure decrease and vapor generation in the crack, and the leak flow rates are found to be larger for the Henry-Fauske model. It is shown that the leak flow rates are not affected by the structural temperature, but affected largely by the roughness of crack surface.

Keywords: crack, critical flow, leak, roughness

Procedia PDF Downloads 180