A subgroup analysis revealed independent predictors of mortality, including lower bone mineral density, weaker quadriceps, smoking history, and increased sway in female patients; weaker quadriceps and decreased activities were independent predictors in male patients. Apart from the limitation that most subjects were white, the study gives a robust mortality analysis on osteoporotic fractures.
Bottom line: Osteoporotic fractures, initial and subsequent, increase five-year mortality. This is true even for nonhip, nonvertebral fractures, especially in the elderly.
Citation: Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009;301(5): 513-521.
Early Rehospitalization After Pulmonary Embolism Dictated by Clinical Severity and Anticoagulation Practices
Clinical question: What factors portend readmission after acute pulmonary embolism (PE)?
Background: The significant clinical and economic burden of acute pulmonary embolism (PE) has fueled studies to define predictors of early mortality. However, the variables leading to readmission after PE remain uncharted. Knowledge of these factors can provide additional targets to improve the quality of care.
Study design: Prospective population-based cohort study.
Setting: 186 acute-care hospitals in Pennsylvania.
Synopsis: Using ICD-9-CM codes, 14,426 PE patients were selected for the study. Primary outcome was hospital readmission within 30 days; secondary outcomes were venous thromboembolism (VTE) and bleeding.
More than 2,000 patients (14.3%) experienced a 30-day readmission. The predominant reasons were VTE (21.9%) and bleeding (5%), with the rest related to comorbidities, such as cancer (10.8%), pneumonia (5.2%), and chest pain (5.0%).
The discrete proportional odds model showed a significant association of high PE Severity Index score (OR 2.04; 95% CI, 1.73-2.40) and previous home care provision (OR 1.40; 95% CI, 1.27-1.54) with readmission, indicating that sicker patients tend to be readmitted. Black patients and Medicaid recipients were more likely to be readmitted, especially for VTE, which reflects the possible socioeconomic bearing on outcomes. Surprisingly, the few patients leaving the hospital against medical advice (0.4%) had a high OR of 2.84 (95% CI, 1.80-4.48) for readmission. Academic centers were not associated with increased readmissions but had significantly more readmissions for bleeding.
Anticoagulation practices—initial choice of agents, intensity of treatment, and monitoring—were not evaluated, which could affect readmission after PE, especially due to VTE and bleeding.
Bottom line: Apart from severity of illness and demographics, high rates of readmission after PE, especially for bleeding and VTE, might be related to poor anticoagulation practices.
Citation: Aujesky D, Mor MK, Geng M, Stone RA, Fine MJ, Ibrahim SA. Predictors of early hospital readmission after acute pulmonary embolism. Arch Intern Med. 2009;169(3):287-293.
Need for Improved Awareness of Hospital Readmission
Clinical question: What is the frequency of readmission awareness in discharging physicians and the trends in their communications with readmitting physicians?
Background: Rotation-based schedules of inpatient physicians, especially at academic centers, increase the likelihood that patients with complex medical or psychosocial issues requiring readmission will be cared for by a different team.
Though gaps in communication between the successive teams have the potential to hamper the quality of care, these gaps have not been adequately characterized in the literature.
Study design: Prospective cohort study.
Setting: Inpatient general-medicine services at two academic medical centers.
Synopsis: Researchers selected 225 patients readmitted within two weeks. The discharge and readmission teams were surveyed by e-mail within 48 hours of readmission regarding frequency and content of communications.
On analysis, the discharging teams were aware of patient readmissions only 48.5% of the time. Most of the remaining teams acknowledged a desire to be notified.