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1.  Predictors of Rehospitalization among Elderly Patients admitted to a Rehabilitation Hospital: the Role of Polypharmacy, Functional Status and Length of Stay 
Rehospitalizations for elderly patients are an increasing health care burden. Nonetheless, we have limited information on unplanned rehospitalizations and the related risk factors in elderly patients admitted to in-hospital rehabilitation facilities after an acute hospitalization.
In-hospital Rehabilitation and Aged Care Unit
Retrospective cohort study
Elderly patients ≥65 years admitted to an in-hospital rehabilitation hospital after an acute hospitalization between January 2004 and June 2011.
The rate of 30-day unplanned rehospitalization to hospitals was recorded. Risk factors for unplanned rehospitalization were evaluated at rehabilitation admission: age, comorbidity, serum albumin, number of drugs, decline in functional status, delirium, Mini Mental State Examination score, length of stay in the acute hospital. A multivariable Cox proportional regression model was used to identify the effect of the above-mentioned risk factors for time to event within the 30-day follow-up.
Among 2,735 patients, with a median age of 80 years (Interquartile Range 74–85), 98 (4%) were rehospitalized within 30 days. Independent predictors of 30-day unplanned rehospitalization were the use of 7 or more drugs (Hazard Ratio [HR], 3.94; 95% Confidence Interval, 1.62–9.54; P=.002) and a significant decline in functional status (56 points or more at the Barthel Index) compared to the month prior to hospital admission (HR 2.67, 95% CI: 1.35–5.27; P=.005). Additionally, a length of stay in the acute hospital ≥13 days carried a 2 fold higher risk of rehospitalization (HR 2.67, 95% CI: 1.39–5.10); P=.003).
The rate of unplanned rehospitalization was low in this study. Polypharmacy, a significant worsening of functional status compared to the month prior to acute hospital admission and hospital length of stay are important risk factors.
PMCID: PMC4100936  PMID: 23664484
rehospitalization; elderly; in-hospital rehabilitation; risk factors
2.  Very Low Birth Weight Preterm Infants With Surgical Short Bowel Syndrome: Incidence, Morbidity and Mortality, and Growth Outcomes at 18 to 22 Months 
Pediatrics  2008;122(3):e573-e582.
The objective of this study was to determine the (1) incidence of short bowel syndrome in very low birth weight (<1500 g) infants, (2) associated morbidity and mortality during initial hospitalization, and (3) impact on short-term growth and nutrition in extremely low birth weight (<1000 g) infants.
Infants who were born from January 1, 2002, through June 30, 2005, and enrolled in the National Institute of Child Health and Human Development Neonatal Research Network were studied. Risk factors for developing short bowel syndrome as a result of partial bowel resection (surgical short bowel syndrome) and outcomes were evaluated for all neonates until hospital discharge, death, or 120 days. Extremely low birth weight survivors were further evaluated at 18 to 22 months’ corrected age for feeding methods and growth.
The incidence of surgical short bowel syndrome in this cohort of 12 316 very low birth weight infants was 0.7%. Necrotizing enterocolitis was the most common diagnosis associated with surgical short bowel syndrome. More very low birth weight infants with short bowel syndrome (20%) died during initial hospitalization than those without necrotizing enterocolitis or short bowel syndrome (12%) but fewer than the infants with surgical necrotizing enterocolitis without short bowel syndrome (53%). Among 5657 extremely low birth weight infants, the incidence of surgical short bowel syndrome was 1.1%. At 18 to 22 months, extremely low birth weight infants with short bowel syndrome were more likely to still require tube feeding (33%) and to have been rehospitalized (79%). Moreover, these infants had growth delay with shorter lengths and smaller head circumferences than infants without necrotizing enterocolitis or short bowel syndrome.
Short bowel syndrome is rare in neonates but has a high mortality rate. At 18 to 22 months’ corrected age, extremely low birth weight infants with short bowel syndrome were more likely to have growth failure than infants without short bowel syndrome.
PMCID: PMC2848527  PMID: 18762491
short bowel syndrome; preterm; necrotizing enterocolitis; nutrition
3.  Early Rehospitalization after Kidney Transplantation: Assessing Preventability and Prognosis 
Early rehospitalization after kidney transplantation (KT) is common and may predict future adverse outcomes. Previous studies using claims data have been limited in identifying preventable rehospitalizations. We assembled a cohort of 753 adults at our institution undergoing KT from January 1, 2003—December 31, 2007. Two physicians independently reviewed medical records of 237 patients (32%) with early rehospitalization and identified 1) primary reason for and 2) preventability of rehospitalization. Mortality and graft failure were ascertained through linkage to the Scientific Registry of Transplant Recipients. Leading reasons for rehospitalization included surgical complications (15%), rejection (14%), volume shifts (11%), and systemic and surgical wound infections (11% and 2.5%). Reviewer agreement on primary reason (85% of cases) was strong (kappa=0.78). Only 19 rehospitalizations (8%) met preventability criteria. Using logistic regression, weekend discharge (OR 1.59, p=0.01), waitlist time (OR 1.10, p=0.04), and longer initial length of stay (OR 1.42, p=0.03) were associated with early rehospitalization. Using Cox regression, early rehospitalization was associated with mortality (HR 1.55; p=0.03) but not graft loss (HR 1.33; p=0.09). Early rehospitalization has diverse causes and presents challenges as a quality metric after KT. These results should be validated prospectively at multiple centers to identify vulnerable patients and modifiable processes-of-care.
PMCID: PMC4108077  PMID: 24165498
Kidney; rehospitalization; survival; preventability
4.  Selecting the Best Prediction Model for Readmission 
This study aims to determine the risk factors predicting rehospitalization by comparing three models and selecting the most successful model.
In order to predict the risk of rehospitalization within 28 days after discharge, 11 951 inpatients were recruited into this study between January and December 2009. Predictive models were constructed with three methods, logistic regression analysis, a decision tree, and a neural network, and the models were compared and evaluated in light of their misclassification rate, root asymptotic standard error, lift chart, and receiver operating characteristic curve.
The decision tree was selected as the final model. The risk of rehospitalization was higher when the length of stay (LOS) was less than 2 days, route of admission was through the out-patient department (OPD), medical department was in internal medicine, 10th revision of the International Classification of Diseases code was neoplasm, LOS was relatively shorter, and the frequency of OPD visit was greater.
When a patient is to be discharged within 2 days, the appropriateness of discharge should be considered, with special concern of undiscovered complications and co-morbidities. In particular, if the patient is admitted through the OPD, any suspected disease should be appropriately examined and prompt outcomes of tests should be secured. Moreover, for patients of internal medicine practitioners, co-morbidity and complications caused by chronic illness should be given greater attention.
PMCID: PMC3412989  PMID: 22880158
Patient readmission; Quality of health care; Risk factors
5.  Diagnosing Diabetes and Preventing Rehospitalizations 
Medical care  2006;44(3):292-296.
Patients with diabetes frequently are hospitalized, and quality of inpatient care for diabetes is of great concern. Rehospitalization after hospital discharge is a frequent adverse outcome experienced by patients with diabetes.
We assessed the frequency of and risk factors for rehospitalization among all Philadelphia residents with diabetes.
Individual histories of hospitalization were ascertained from hospital discharge summaries for Philadelphia residents ages 25–84 who had at least 1 diabetes hospitalization from 1994 through 2001. Logistic regression was used to assess predictors of nonelective rehospitalization within 30 days of discharge, including recording of diabetes diagnosis.
Nonelective rehospitalizations within 30 days of hospital discharge were ascertained for 58,308 (20.0%) of 291,752 discharges. The proportion rehospitalized was 9.4% after a patient’s first diabetes diagnosis hospitalization; after later discharges for which a diabetes diagnosis was not recorded, rehospitalizations occurred in 30.6% of all cases. The absence of a diabetes diagnosis was a highly significant predictor of rehospitalization after adjustment for age, year, gender, race/ethnicity, insurance status, admission type, severity code, length of stay, discharge status, and number of previous hospitalizations.
Failure to record a diabetes diagnoses in administrative hospital discharge data may reflect lack of attention to the critical needs of patients with diabetes who are being treated for other conditions, whereas the attention to patient education and follow-up planning for patients with incident diabetes diagnoses may reduce the risk of rehospitalization.
PMCID: PMC1618792  PMID: 16501402
administrative data; diabetes; diagnosis; readmissions
6.  Hospital Charges at Birth and Frequency of Rehospitalizations and Acute Care Visits over the First Year of Life 
The American journal of nursing  2005;105(7):56-65.
The proportion of preterm and low-birth-weight infants has been growing steadily for two decades. Most of the more than $10 billion spent on neonatal care in the United States in 2003 was spent on the 12.3% of infants who were born preterm. Research has shown higher initial hospital costs and a higher rate of acute care visits and rehospitalization for preterm and low-birth-weight infants, but only a limited number of studies of the cost of prematurity that follow infants through the first year of life have been conducted.
This study is a secondary analysis of data on a subset of infants drawn from a randomized clinical trial that examined health outcomes and health care costs in women with high-risk pregnancies and their infants. For the current study, a sample of 84 singleton infants was chosen. Forty-three infants (51 %) were full term (37 weeks’ gestation or more) and 41 (49%) were born preterm (less than 37 weeks’ gestation). Fifty-five infants (65.5%) were born at normal birth weights (2,500 g or greater), 24 (28.5%) were born at low birth weights (1,501 to 2,499 g), and five (6%) were born at very low birth weights (less than 1,500 g).
Data on the initial hospital charges and the rates of rehospitalization and acute care visits in the first year of life in relation to gestational age and birth weight were collected. The results clearly demonstrated that the charges for initial hospitalizations increased as birth weights and gestational ages decreased. Low-birth-weight infants were less likely to have unscheduled acute care visits than normal-birth-weight infants.
Interventions to improve prenatal care targeted to women at high risk for delivering preterm or low-birth-weight infants would reduce health care costs and improve health outcomes of infants as well.
PMCID: PMC3575194  PMID: 15995395
7.  Risk Factors for Post-NICU Discharge Mortality Among Extremely Low Birth Weight Infants 
The Journal of Pediatrics  2012;161(1):70-74.e2.
To evaluate maternal and neonatal risk factors associated with post-neonatal intensive care unit (NICU) discharge mortality among ELBW infants.
Study design
This is a retrospective analysis of extremely low birth weight (<1,000 g) and <27 weeks' gestational age infants born in the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network sites from January 2000 to June 2007. Infants were tracked until death or 18–22 months corrected age. Infants who died between NICU discharge and the 18–22 month follow-up visit were classified as post-NICU discharge mortality. Association of maternal and infant risk factors with post-NICU discharge mortality was determined using logistic regression analysis. A prediction model with six significant predictors was developed and validated.
5,364 infants survived to NICU discharge. 557 (10%) infants were lost to follow-up, and 107 infants died following NICU discharge. Post-NICU discharge mortality rate was 22.3 per 1000 ELBW infants. In the prediction model, African-American race, unknown maternal health insurance, and hospital stay ≥120 days significantly increased risk, and maternal exposure to intra-partum antibiotics was associated with decreased risk of post-NICU discharge mortality.
We identified African-American race, unknown medical insurance and prolonged NICU stay as risk factors associated with post-NICU discharge mortality among ELBW infants.
PMCID: PMC3366175  PMID: 22325187
extremely preterm infants; discharge; mortality; predictive model
8.  Predictive Value of the Short Physical Performance Battery Following Hospitalization in Older Patients 
Hospitalization represents a stressful and potentially hazardous event for older persons. We evaluated the value of the Short Physical Performance Battery (SPPB) in predicting rates of functional decline, rehospitalization, and death in older acutely ill patients in the year after discharge from the hospital.
Prospective cohort study of 87 patients aged 65 years and older who were able to walk and with a Mini-Mental State Examination score ≥18 and admitted to the hospital with a clinical diagnosis of congestive heart failure, pneumonia, chronic obstructive pulmonary disease, or minor stroke. Patients were evaluated with the SPPB at hospital admission, were reevaluated the day of hospital discharge, and 1 month later. Subsequently, they were followed every 3 months by telephone interviews to ascertain functional decline, new hospitalizations, and vital status.
After adjustment for potential confounders, including self-report activity of daily living and comorbidity, the SPPB score at discharge was inversely correlated with the rate of decline in activity of daily living performance over the follow-up (p < .05). In a multivariable discrete-time survival analysis, patients with poor SPPB scores at hospital discharge (0–4) had a greater risk of rehospitalization or death (odds ratio: 5.38, 95% confidence interval: 1.82–15.9) compared with those with better SPPB scores (8–12). Patients with early decline in SPPB score after discharge also had steeper increase in activity of daily living difficulty and higher risk of rehospitalization or death over the next year.
In older acutely ill patients who have been hospitalized, the SPPB provides important prognostic information. Lower extremity performance-based functional assessment might identify older patients at high risk of poor outcomes after hospital discharge.
PMCID: PMC3011958  PMID: 20861145
SPPB; Hospitalization; Disability; Mortality; Prognosis
9.  Hospitalization Subsequent to Diagnosis in Young Patients With Diabetes in Chicago, Illinois 
Pediatrics  2009;124(3):926-934.
Rehospitalization after a diabetes diagnosis in youth signals the failure of outpatient management. We examined risk factors for rehospitalization among young patients with diabetes.
We queried 535 participants diagnosed before 18 years of age from the Chicago Childhood Diabetes Registry. Demographic, social, and clinical data were used in logistic models of diabetes-related rehospitalization, as well as, among those rehospitalized, frequent (≥ once per 2 years’ duration) versus infrequent rehospitalization rates.
Mean (range) duration was 5.1 years (0.1–19.2 years). The sample was 55% non-Hispanic black, 11% non-Hispanic white, 26% Hispanic, and 7% other/mixed race; 86% had presumed type 1 diabetes; and 47% were underinsured. Overall, 46% reported rehospitalization for diabetes. In multivariable logistic regression, ever being rehospitalized was significantly associated with diabetes duration (per year, odds ratio [OR]: 1.26; P < .01), female gender (OR: 1.67; P = .01), underinsurance (versus private insurance; OR: 1.79; P < .01), presumed phenotype (non–type 1 diabetes versus type 1; OR: 0.32; P < .01), and diagnosis at a community hospital (versus tertiary care facility; OR: 1.96; P < .01) and tended to be higher for those of nonwhite race (OR: 1.94; P = .07). Among those rehospitalized, multivariable associations with frequent rehospitalization were presumed phenotype (non–type 1 diabetes versus type 1; OR: 2.74; P = .04), head of house hold not working (versus employed; OR: 1.88; P = .02), and younger age at questionnaire (per year; OR: 0.94; P = .01).
Rehospitalization is common in young patients with diabetes, especially for those with limited resources, indicating the need for improved outpatient services. Comprehensive initial education and support available to young patients with diabetes diagnosed at tertiary care facilities and their families may have lasting protective effects.
PMCID: PMC2888679  PMID: 19706582
hospitalization; diabetes; children; adolescents
10.  Depression and Rehospitalization Following Acute Myocardial Infarction 
Elevated scores on depression symptom questionnaires predict rehospitalization after acute myocardial infarction (AMI). Whether DSM-IV depressive disorders predict rehospitalization after AMI is unknown.
Methods and Results
Participants (n=766) in an ENRICHD ancillary study were classified by diagnostic interview as having no depression, minor depression, or major depression after AMI. Cardiac rehospitalizations were tracked for up to 42 months. Cox proportional hazards regression was used to model the effect of depressive disorder on time to first cardiac rehospitalization, controlling for mortality risk factors. Logistic regression was used to compare the accuracy with which rehospitalization could be predicted by depression diagnosis or by the Beck Depression Inventory (BDI). Secondary analyses examined the effects of depression on the cumulative number of all-cause rehospitalizations, length of stay, and emergency department visits. Compared to nondepressed patients, those with either major or minor depression were hospitalized sooner (minor: adjusted HR, 2.22; 95% CI, 1.59 to 3.08; P<.001; major: adjusted HR, 2.54; 95% CI, 1.84 to 3.53; P<.001), had more hospitalizations (minor: P<.001; major: P<.001) and emergency department visits (minor: P=.003; major: P<.001), and spent more days in the hospital (minor: P<.001; major: P<.001). The interview and questionnaire methods of assessing depression did not significantly differ in their overall accuracy of predicting rehospitalization.
Depressive disorders increase the risk of rehospitalization after AMI. Future work should focus on developing multivariable models to predict risk of rehospitalization after AMI, and depression should be included in these.
PMCID: PMC3229921  PMID: 22010201
myocardial Infarction; depression; depressive disorder; patient readmission
11.  Interaction Between Cognitive Impairment and Discharge Destination and its Impact on Rehospitalizations 
Journal of the American Geriatrics Society  2013;61(11):10.1111/jgs.12501.
Rehospitalizations are common among older patients and cognitive function may influence rehospitalizations.
Evaluate the impact of cognitive impairment (CI) on rehospitalization among older patients.
One year longitudinal study of 976 patients, aged 65 and older, admitted intothe medical services of an urban, 340-bed, public hospital in Indianapolis between July 2006 and March 2008.
Rehospitalizationwas defined as any hospital admission following the index admission.
Patients were considered to have CI if they made two or more errors on the Short Portable Mental Status Questionnaire.
Patient demographics, Discharge destination, Charlson Comorbidity Index, Acute Physiology Scores, and priorhospitalizations.
After adjusting for confounders a significant interaction between CI and discharge location was found to predict both rehospitalization rate and time to 1-year rehospitalization (P = .008 and .028 respectively).CI Patients, discharged to a facilityhad a longer time to rehospitalization compared with patients with no CI (HR = 0.77 [0.58, 1.02] p=0.068, median days: 142 vs. 98), while CIpatients, discharged to home had a slightly shorter time to rehospitalization than those without CI (HR=1.15 [0.92, 1.43] p=0.230; median days: 182 vs. 224). These two non-significant hazard ratios in opposite directions were significantly different from each other (p=0.028).
Discharge destination modifies the association between CI and rehospitalizations. Of those discharged to a facility, patients without CI had higher rehospitalization rates, whereas the rates were similar between cognitively impaired and intact patients that were discharged to the community.
PMCID: PMC3845411  PMID: 24219196
Rehospitalizations; Cognitive Impairment; Discharge Destination
12.  For-Profit Hospital Status and Rehospitalizations to Different Hospitals: An Analysis of Medicare Data 
Annals of internal medicine  2010;153(11):718-727.
About one-quarter of rehospitalized Medicare patients are admitted to hospitals different from their original. The extent to which this practice is related to for-profit hospital status, and impacts payments and mortality, is unknown.
To describe and examine predictors of and payments for rehospitalization to a different hospital within 30 days among Medicare beneficiaries in for-profit and in not-for-profit/public hospitals.
Retrospective cohort study.
Medicare fee-for-service hospitals throughout the United States.
Random 5% national sample of Medicare beneficiaries with acute-care rehospitalizations within 30-days of discharge, 2005–2006 (N=74,564).
30-day rehospitalizations to different hospitals; total payments/mortality over subsequent 30-days. Multivariate logistic and quantile regression models included index hospital for-profit status, discharge counts, geographic region, rural-urban commuting area, and teaching status; and patient sociodemographics, disabled status, comorbidities, and a measure of risk-adjustment.
22% (16,622) of the sample was rehospitalized to a different hospital. Factors associated with increased risk for rehospitalization to a different hospital included being hospitalized within a for-profit, major medical school-affiliated, or low volume index hospital, and having a Medicare-defined disability. When compared to those rehospitalized to the same hospital, patients rehospitalized to different hospitals had significantly higher adjusted 30-day total payments (median additional $1,308/patient, p-value<0.001), but no significant differences in 30-day mortality, regardless of index hospital for-profit status.
The analysis lacked detailed clinical data, and did not assess specific provider practice motivations or the role of patient choice.
Rehospitalizations to different hospitals are common among Medicare beneficiaries, more likely among those initially hospitalized at a for-profit hospital, and related to increased overall payments without improved mortality.
PMCID: PMC3058683  PMID: 21135295
13.  The prevalence and risk factors of allergic and respiratory symptoms in a regional cohort of extremely low birth weight children (<1000 g) 
Children who were <1000 g (ELBW extremely low birth weight) at birth more frequently present with wheezing which is the most common reason that pediatric consultation is sought. Therefore asthma is diagnosed very often. However is the asthma that is diagnosed in ELBW subjects atopic in origin, or is there a different etiology?
To determine if ELBW infants are at higher risk for the development of allergic and respiratory symptoms and to establish if there were any specific risk factors for these symptoms.
81 children born with a mean birthweight of 845 g (91% of available cohort) were evaluated at the mean age 6.7 years. The control group included 40 full-term children. The children were examined for clinical signs of allergy, and were subjected to the following tests: serum total IgE, skin prick tests (SPT), exhaled nitric oxide measurement (FeNO) and spirometry.
ELBW children had wheezing episodes more often (64% vs. 25%; OR (odds ratio): 5.38; 95% CI (confidence interval): 2.14-13.8) and were diagnosed more frequently with asthma (32% vs. 7.5%; OR: 5.83, 95% CI: 1.52-26) than their term born peers. The most important risk factors for wheezing persistence were hospitalization and wheezing episodes in first 24 months of life. Mean serum tIgE level (geometric mean: 32+/−4 vs. 56+/−4 kU/L; p=0.002) was higher and the number of children with positive results of tIgE level (12% vs. 32%; p=0.02) were more frequent in the control group. Children from the control group also more frequently had SPT, however this data was not statistically significant (11% vs. 24%; p=0.09). All of the ELBW had normal FeNO level (<=20 ppb), but 5 children from the control group had abnormal results (p=0.02). There was no difference between the groups in the occurrence of allergic symptoms.
ELBW children have more frequent respiratory, but not allergic problems at the age of 6–7 years compared to children born at term. The need for rehospitalization in the first 2 years of life, was a more important risk factor of future respiratory problems at the age of 7 than perinatal factors, the diagnosis of bronchopulmonary dysplasia or allergy.
PMCID: PMC3567980  PMID: 23332103
Prematurity; Follow-up; Spirometry; IgE; FeNO; Skin prick tests
14.  The crucial factor of hospital readmissions: a retrospective cohort study of patients evaluated in the emergency department and admitted to the department of medicine of a general hospital in Italy 
Early hospital readmissions, defined as rehospitalization within 30 days from a previous discharge, represent an economic and social burden for public health management. As data about early readmission in Italy are scarce, we aimed to relate the phenomenon of 30-day readmission to factors identified at the time of emergency department (ED) visits in subjects admitted to medical wards of a general hospital in Italy.
We performed a retrospective 30-month observational study, evaluating all patients admitted to the Department of Medicine of the Hospital of Ferrara, Italy. Our study compared early and late readmission: patients were evaluated on the basis of the ED admission diagnosis and classified differently on the basis of a concordant or discordant readmission diagnosis in respect to the diagnosis of a first hospitalization.
Out of 13,237 patients admitted during the study period, 3,631 (27.4%) were readmitted; of those, 656 were 30-day rehospitalizations (5% of total admissions). Early rehospitalization occurred 12 days (median) later than previous discharge. The most frequent causes of rehospitalization were cardiovascular disease (CVD) in 29.3% and pulmonary disease (PD) in 29.7% of cases. Patients admitted with the same diagnosis were younger, had lower length of stay (LOS) and higher prevalence of CVD, PD and cancer. Age, CVD and PD were independently associated with 30-day readmission with concordant diagnosis and kidney disease with 30-day rehospitalization with a discordant diagnosis.
Comorbid patients are at higher risk for 30-day readmission. Reduction of LOS, especially in elderly subjects, could increase early rehospitalization rates.
PMCID: PMC4314760  PMID: 25623952
Hospitalization; Readmission; Length of stay; Mortality; Comorbidity; Internal medicine
15.  Caregiver Status: A Simple Marker to Identify Patients at Risk for Longer Post-Operative Length of Stay, Rehospitalization or Death 
Patients who have undergone cardiac surgery, especially those with greater comorbidities, may be cared for by family members or paid aides.
The purpose of this study was to evaluate the association between caregiving among post-operative cardiac patients and clinical outcomes at 1-year. We hypothesized that patients with a caregiver would have longer length-of-stays, and higher rehospitalization or death rates 1-year after surgery.
We studied 665 consecutively admitted cardiac surgery patients as part of the NHLBI-sponsored Family Cardiac Caregiver Investigation To Evaluate Outcomes (FIT-O). Participants (mean age 65 years; 35% female; 21% racial/ethnic minorities) completed an interviewer-assisted questionnaire to determine caregiver status. Outcomes were documented by a hospital-based information system; demographics/comorbidities by electronic records. Associations between caregiving and outcomes were evaluated by logistic regression, adjusted for demographic and comorbid conditions.
At baseline, 28% of patients (n=183) had a caregiver (8% paid; 20% informal only). Having a caregiver was associated with longer (>7 days) post-operative length-of-stay in univariate analysis among patients with paid (OR=3.00;95%CI=1.57–5.74) or informal (OR=1.55;95%CI=1.04–2.31) caregivers versus none; the association remained significant for patients with paid (OR=2.13;95%CI=1.00–4.55), but not informal (OR=1.12; 95%CI=0.70–1.80) caregivers after adjustment. Having a paid caregiver was significantly associated with rehospitalization/death at 1-year in univariate analysis (OR=2.09;95%CI=1.18–3.69), informal caregiving was not (OR=1.39;95%CI=0.94–2.06). Increased odds of rehospitalization/death associated with paid caregiving attenuated after adjustment (OR=1.39;95%CI=0.74–2.62).
Post-operative cardiac patients who had a paid caregiver had significantly longer length-of-stay independent of comorbidity. The increased risk of rehospitalization/death associated with paid caregiving was explained by demographics and comorbidity. These data suggest caregiver status assessment may be a simple method to identify cardiac patients at risk for adverse outcomes.
PMCID: PMC4041366  PMID: 23321779
16.  Chorioamnionitis and Early Childhood Outcomes among Extremely Low-Gestational-Age Neonates 
JAMA pediatrics  2014;168(2):137-147.
Chorioamnionitis is strongly linked to preterm birth and to neonatal infection. The association between histological and clinical chorioamnionitis and cognitive, behavioral and neurodevelopmental outcomes among extremely preterm neonates is less clear. We evaluated the impact of chorioamnionitis on 18-22 month neurodevelopmental outcomes in a contemporary cohort of extremely preterm neonates.
To compare the neonatal and neurodevelopmental outcomes of three groups of extremely-low-gestational-age infants with increasing exposure to perinatal inflammation: no chorioamnionitis, histological chorioamnionitis alone, or histological plus clinical chorioamnionitis.
Longitudinal observational study.
Sixteen centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network.
2390 extremely preterm infants born <27 weeks' gestational age between January 1, 2006 and December 31, 2008 with placental histopathology and 18-22 months' corrected age follow-up data were eligible.
Main exposure
Main Outcome Measures
Outcomes included cerebral palsy, gross motor functional limitation, behavioral scores (according to the Brief Infant-Toddler Social and Emotional Assessment), cognitive and language scores (according to the Bayley Scales of Infant Development, 3rd-Edition) and composite measures of death/neurodevelopmental impairment. Multivariable logistic and linear regression models were developed to assess the association between chorioamnionitis and outcomes while controlling for important variables known at birth.
Neonates exposed to chorioamnionitis had a lower gestational age (GA) and had higher rates of early-onset sepsis and severe periventricular-intraventricular hemorrhage as compared with unexposed neonates. In multivariable models evaluating death and neurodevelopmental outcomes, inclusion of gestational age in the model diminished the association between chorioamnionitis and adverse outcomes. Still, histological+clinical chorioamnionitis was associated with increased risk of cognitive impairment as compared with no chorioamnionitis (Adjusted OR 2.4, [1.3- 4.3] without GA; Adjusted OR 2.0, [1.1-3.6] with GA as a covariate). Histological chorioamnionitis alone was associated with lower odds of death/neurodevelopmental impairment as compared with histological+clinical chorioamnionitis (Adjusted OR 0.68, [0.52-0.89] without GA; 0.66, [0.49-0.89] with GA). Risk of behavioral problems did not differ statistically between groups.
Conclusions and Relevance
Antenatal exposure to chorioamnionitis is associated with altered odds of cognitive impairment and death/neurodevelopmental impairment in extremely preterm infants.
PMCID: PMC4219500  PMID: 24378638
chorioamnionitis; preterm; neurodevelopmental impairment; outcome
17.  Differential Gender Response to Respiratory Infections and to the Protective Effect of Breast Milk in Preterm Infants 
Pediatrics  2008;121(6):e1510-e1516.
The protective role of breastfeeding against severe acute lung disease in infants is well established, but its mechanism is unclear. Most hypotheses assume that breastfeeding confers similar passive protection to every infant; however, a few observations have suggested that the benefits of breast milk against severe lung disease may differ according to gender. The objective of this study was to determine whether the effect of breastfeeding on susceptibility to severe acute lung disease among infants at high risk is different for girls and boys.
A cohort was analyzed prospectively by use of 2 different strategies: (1) predictors of first episode of rehospitalization by univariate and multivariate analyses using robust Poisson regression and (2) mean number of rehospitalizations between groups using multiple regression negative binomial models.
A total of 119 high-risk, very low birth weight infants were enrolled. Breast milk protected girls but not boys against severe acute lung disease. The interaction between breastfeeding and gender was clinically and statistically significant, even after adjustment for variables that can affect severity of acute lung disease. Disease was most severe in formula-fed girls (versus formula-fed boys).
Breastfeeding decreased the risk for severe acute lung disease in girls but not in boys. These findings suggest that breast milk protection is not universally conferred by passive transfer of humoral immunity (which should be gender indifferent), show that respiratory symptoms may be amenable to nonspecific modulation, and identify nonbreastfed preterm infant girls as an at-risk group for severe acute lung disease.
PMCID: PMC2631928  PMID: 18519454
lower respiratory infection; breast milk; respiratory syncytial virus; prematurity; gender
18.  Bouncing-Back: Rehospitalization in Patients with Complicated Transitions in the First Thirty Days After Hospital Discharge for Acute Stroke 
“Bounce-backs” (movements from a less intense to a more intense care setting) soon after hospital discharge for acute stroke are common and are influenced by the initial discharge destination. However the reasons patients bounce-back from particular discharge settings remain unknown.
To examine how the primary diagnosis for initial rehospitalization relates to thirty-day bounce-back number and initial hospitalization discharge destination in acute stroke patients
Retrospective analysis of administrative data
422 hospitals, southern and eastern United States
5,250 Medicare beneficiaries ≥65 years discharged with acute ischemic stroke in 1998–2000 to a rehabilitation center, skilled nursing facility or home with home health care and with at least one thirty day rehospitalization.
Adjusted probabilities calculated using models which included age, sex, race, Medicaid/HMO status, census block group percentages for college education and poverty, prior hospitalization, prior stroke, comorbidities, stroke severity, length of stay and discharge site.
Infections and aspiration pneumonitis tended to be the most common reasons for rehospitalization after acute stroke, regardless of the initial discharge site, accounting for 15–43% of rehospitalizations depending on bounce-back category. Stroke patients initially discharged to skilled nursing facilities were the most strongly affected by these particular diagnoses (25–43%).
Aspiration pneumonitis and infections, the complications of immobility, are the most important reasons for thirty day rehospitalization in acute stroke patients. Prevention efforts specifically targeting populations at high risk for aspiration and infection may prove extremely valuable in decreasing bounce-backs.
PMCID: PMC2205988  PMID: 18032199
Transition; Stroke; Rehospitalization
19.  Impact of Depression on Sex Differences in Outcome After Myocardial Infarction 
Women have an unexplained worse outcome after myocardial infarction (MI) compared with men in many studies. Depressive symptoms predict adverse post-MI outcomes and are more prevalent among women than men. We examined whether depressive symptoms contribute to women’s worse outcomes after MI.
Methods and Results
In a prospective multicenter study (PREMIER), 2411 (807 women) MI patients were enrolled. Depressive symptoms were assessed with the Patient Health Questionnaire. Outcomes included 1-year rehospitalization, presence of angina using the Seattle Angina Questionnaire, and 2-year mortality. Multivariable analyses were used to evaluate the association between sex and these outcomes, adjusting for clinical characteristics. The depressive symptoms score was added to the models to evaluate whether it attenuated the association between sex and outcomes. Depressive symptoms were more prevalent in women compared with men (29% versus 18.8%, P<0.001). After adjusting for demographic factors, comorbidities, and MI severity, women had a mildly higher risk of rehospitalization (hazard ratio, 1.20; 95% CI, 1.04 to 1.40), angina (odds ratio, 1.32; 95% CI, 1.00 to 1.75), and mortality (hazard ratio, 1.27; 95% CI, 0.98 to 1.64). After adding depressive symptoms to the multivariable models, the relationship further declined toward the null, particularly for rehospitalization (hazard ratio, 1.14; 95% CI, 0.98 to 1.34) and angina (odds ratio, 1.22; 95% CI, 0.91 to 1.63), whereas there was little change in the estimate for mortality (hazard ratio, 1.24; 95% CI, 0.95 to 1.62). Depressive symptoms were significantly associated with each of the study outcomes with a similar magnitude of effect in both women and men.
A higher prevalence of depressive symptoms in women modestly contributes to their higher rates of rehospitalization and angina compared with men but not mortality after MI. Our results support the recent recommendations of improving recognition of depressive symptoms after MI.
PMCID: PMC4283585  PMID: 20031810
sex; depression; myocardial infarction; women
20.  Socioeconomic Status, Medicaid Coverage, Clinical Comorbidity and Rehospitalization or Death following an Incident Heart Failure Hospitalization: ARIC Cohort (1987–2004) 
Circulation. Heart failure  2011;4(3):308-316.
Among heart failure (HF) patients, early readmission or death and repeat hospitalizations may be indicators of poor disease management or more severe disease.
Methods and Results
We assessed the association of neighborhood median household income (nINC) and Medicaid status with rehospitalization or death in the Atherosclerosis Risk in Communities cohort study (1987–2004) following an incident HF hospitalization in the context of individual socioeconomic status, and evaluated the relationship for modification by demographic and comorbid factors. We used generalized linear Poisson mixed models to estimate rehospitalization rate ratios and 95% confidence intervals (RR, 95% CI) and Cox regression to estimate hazard ratios (HR, 95% CI) of rehospitalization or death. In models controlling for race/study community, gender, age at HF diagnosis, body mass index, hypertension, educational attainment, alcohol use and smoking, persons with a high burden of comorbidity who were living in low nINC areas at baseline had an elevated hazard of all-cause rehospitalization (1.40, 1.10–1.77), death (1.36, 1.02–1.80), and rehospitalization or death (1.36, 1.08–1.70)—as well as increased rates of hospitalizations—compared to those with a high burden of comorbidity living in high nINC areas. Medicaid recipients with a low level of comorbidity had an increased hazard of all-cause rehospitalization (1.19, 1.05–1.36) and rehospitalization or death (1.21, 1.07–1.37), and a higher rate of repeat hospitalizations compared to non-Medicaid recipients.
Comorbidity burden appears to influence the association between nINC, Medicaid status and rehospitalization and death among HF patients.
PMCID: PMC3098576  PMID: 21430286
hospital readmission follow-up studies; socioeconomic position heart failure; mortality; comorbidities heart failure
21.  The Association between Neighborhood Socioeconomic Status and Clinical Outcomes among Patients 1 Year after Hospitalization for Cardiovascular Disease 
Journal of community health  2013;38(4):690-697.
Residing in lower socioeconomic status neighborhoods is associated with increased risk of morbidity and mortality. Few studies have examined this association for cardiovascular disease (CVD) outcomes in a treated population in New York City (NYC). The purpose of this study was to determine the relationship between neighborhood level poverty and one-year clinical outcomes (rehospitalization and/or death) among hospitalized patients with CVD. Data on rehospitalization and/or death at one-year were collected from consecutive patients admitted at a university medical center in NYC from November 2009 to September 2010. NYC residents totaled 2,198. U.S. Census 2000 zip code data was used to quantify neighborhood SES into quintiles of poverty (Q1=lowest poverty to Q5=highest poverty). Univariate analyses were used to determine associations between neighborhood poverty and baseline characteristics and comorbidities. A logistic regression analysis was used to calculate odds ratios for the association between quintiles of poverty and rehospitalization/death at one year. Fifty-five percent of participants experienced adverse outcomes. Participants in Q5 (9%) were more likely to be female (odds ratio [OR]=0.49,95% confidence interval [CI] 0.33–0.73), younger (OR=0.50,95% CI 0.34–0.74), of minority race/ethnicity (OR=18.24,95% CI 11.12=29.23), and have no health insurance (OR=4.79,95% CI 2.92–7.50). Living in Q5 was significantly associated with increased comorbidities, including diabetes mellitus and hypertension, but was not a significant predictor of rehospitalization/death at one year. Among patients hospitalized with CVD, higher poverty neighborhood residence was significantly associated with a greater prevalence of comorbidities, but not of rehospitalization and/or death. Affordable, accessible resources targeted at reducing the risk of developing CVD and these comorbidities should be available in these communities.
PMCID: PMC3706565  PMID: 23468321
cardiovascular disease; neighborhood; socioeconomic; prevention
22.  Ten-Year Review of Major Birth Defects in VLBW Infants 
Pediatrics  2013;132(1):49-61.
Birth defects (BDs) are an important cause of infant mortality and disproportionately occur among low birth weight infants. We determined the prevalence of BDs in a cohort of very low birth weight (VLBW) infants cared for at the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) centers over a 10-year period and examined the relationship between anomalies, neonatal outcomes, and surgical care.
Infant and maternal data were collected prospectively for infants weighing 401 to 1500 g at NRN sites between January 1, 1998, and December 31, 2007. Poisson regression models were used to compare risk of outcomes for infants with versus without BDs while adjusting for gestational age and other characteristics.
A BD was present in 1776 (4.8%) of the 37 262 infants in our VLBW cohort. Yearly prevalence of BDs increased from 4.0% of infants born in 1998 to 5.6% in 2007, P < .001. Mean gestational age overall was 28 weeks, and mean birth weight was 1007 g. Infants with BDs were more mature but more likely to be small for gestational age compared with infants without BDs. Chromosomal and cardiovascular anomalies were most frequent with each occurring in 20% of affected infants. Mortality was higher among infants with BDs (49% vs 18%; adjusted relative risk: 3.66 [95% confidence interval: 3.41–3.92]; P < .001) and varied by diagnosis. Among those surviving >3 days, more infants with BDs underwent major surgery (48% vs 13%, P < .001).
Prevalence of BDs increased during the 10 years studied. BDs remain an important cause of neonatal morbidity and mortality among VLBW infants.
PMCID: PMC3691532  PMID: 23733791
birth defects; prematurity; Neonatal Research Network; low birth weight
23.  Rehospitalization following percutaneous coronary intervention for commercially insured patients with acute coronary syndrome: a retrospective analysis 
BMC Research Notes  2012;5:342.
While prior research has provided important information about readmission rates following percutaneous coronary intervention, reports regarding charges and length of stay for readmission beyond 30 days post-discharge for patients in a large cohort are limited. The objective of this study was to characterize the rehospitalization of patients with acute coronary syndrome receiving percutaneous coronary intervention in a U.S. health benefit plan.
This study retrospectively analyzed administrative claims data from a large US managed care plan at index hospitalization, 30-days, and 31-days to 15-months rehospitalization. A valid Diagnosis Related Group code (version 24) associated with a PCI claim (codes 00.66, 36.0X, 929.73, 929.75, 929.78–929.82, 929.84, 929.95/6, and G0290/1) was required to be included in the study. Patients were also required to have an ACS diagnosis on the day of admission or within 30 days prior to the index PCI. ACS diagnoses were classified by the International Statistical Classification of Disease 9 (ICD-9-CM) codes 410.xx or 411.11. Patients with a history of transient ischemic attack or stroke were excluded from the study because of the focus only on ACS-PCI patients. A clopidogrel prescription claim was required within 60 days after hospitalization.
Of the 6,687 ACS-PCI patients included in the study, 5,174 (77.4%) were male, 5,587 (83.6%) were <65 years old, 4,821 (72.1%) had hypertension, 5,176 (77.4%) had hyperlipidemia, and 1,777 (26.6%) had diabetes. At index hospitalization drug-eluting stents were the most frequently used: 5,534 (82.8%). Of the 4,384 patients who completed the 15-month follow-up, a total of 1,367 (31.2%) patients were rehospitalized for cardiovascular (CV)-related events, of which 811 (59.3%) were revascularization procedures: 13 (1.0%) for coronary artery bypass graft and 798 (58.4%) for PCI. In general, rehospitalizations associated with revascularization procedures cost more than other CV-related rehospitalizations. Patients rehospitalized for revascularization procedures had the shortest median time from post-index PCI to rehospitalization when compared to the patients who were rehospitalized for other CV-related events.
For ACS patients who underwent PCI, revascularization procedures represented a large portion of rehospitalizations. Revascularization procedures appear to be the most frequent, most costly, and earliest cause for rehospitalization after ACS-PCI.
PMCID: PMC3493265  PMID: 22747631
24.  Maternal Overweight and Obesity and Risks of Severe Birth-Asphyxia-Related Complications in Term Infants: A Population-Based Cohort Study in Sweden 
PLoS Medicine  2014;11(5):e1001648.
Martina Persson and colleagues use a Swedish national database to investigate the association between maternal body mass index in early pregnancy and severe asphyxia-related outcomes in infants delivered at term.
Please see later in the article for the Editors' Summary
Maternal overweight and obesity increase risks of pregnancy and delivery complications and neonatal mortality, but the mechanisms are unclear. The objective of the study was to investigate associations between maternal body mass index (BMI) in early pregnancy and severe asphyxia-related outcomes in infants delivered at term (≥37 weeks).
Methods and Findings
A nation-wide Swedish cohort study based on data from the Medical Birth Register included all live singleton term births in Sweden between 1992 and 2010. Logistic regression analyses were used to obtain odds ratios (ORs) with 95% CIs for Apgar scores between 0 and 3 at 5 and 10 minutes, meconium aspiration syndrome, and neonatal seizures, adjusted for maternal height, maternal age, parity, mother's smoking habits, education, country of birth, and year of infant birth. Among 1,764,403 term births, 86% had data on early pregnancy BMI and Apgar scores. There were 1,380 infants who had Apgar score 0–3 at 5 minutes (absolute risk  = 0.8 per 1,000) and 894 had Apgar score 0–3 at 10 minutes (absolute risk  = 0.5 per 1,000). Compared with infants of mothers with normal BMI (18.5–24.9), the adjusted ORs (95% CI) for Apgar scores 0–3 at 10 minutes were as follows: BMI 25–29.9: 1.32 (1.10–1.58); BMI 30–34.9: 1.57 (1.20–2.07); BMI 35–39.9: 1.80 (1.15–2.82); and BMI ≥40: 3.41 (1.91–6.09). The ORs for Apgar scores 0–3 at 5 minutes, meconium aspiration, and neonatal seizures increased similarly with maternal BMI. A study limitation was lack of data on effects of obstetric interventions and neonatal resuscitation efforts.
Risks of severe asphyxia-related outcomes in term infants increase with maternal overweight and obesity. Given the high prevalence of the exposure and the severity of the outcomes studied, the results are of potential public health relevance and should be confirmed in other populations. Prevention of overweight and obesity in women of reproductive age is important to improve perinatal health.
Please see later in the article for the Editors' Summary
Editors' Summary
Economic, technologic, and lifestyle changes over the past 30 years have created an abundance of cheap, accessible, high-calorie food. Combined with fewer demands for physical activity, this situation has lead to increasing body mass throughout most of the world. Consequently, being overweight or obese is much more common in many high-income and low-and middle-income countries compared to 1980. Worldwide estimates put the percentage of overweight or obese adults as increasing by over 10%, between 1980 and 2008.
As being overweight becomes a global epidemic, its prevalence in women of reproductive age has also increased. Pregnant women who are overweight or obese are a cause for concern because of the possible associated health risks to both the infant and mother. Research is necessary to more clearly define these risks.
Why Was This Study Done?
In this study, the researchers investigated the complications associated with excess maternal weight that could hinder an infant from obtaining enough oxygen during delivery (neonatal asphyxia). All fetuses experience a loss of oxygen during contractions, however, a prolonged loss of oxygen can impact an infant's long-term development. To explore this risk, the researchers relied on a universal scoring system known as the Apgar score. An Apgar score is routinely recorded at one, five, and ten minutes after birth and is calculated from an assessment of heart rate, respiratory effort, and color, along with reflexes and muscle tone. An oxygen deficit during delivery will have an impact on the score. A normal score is in the range of 7–10. Body mass index (BMI) a calculation that uses height and weight, was used to assess the weight status (i.e., normal, overweight, obese) of the mother during pregnancy.
What Did the Researchers Do and Find?
Using the Swedish medical birth registry (a database including nearly all the births occurring in Sweden since 1973) the researchers selected records for single births that took place between 1992 to 2010. The registry also incorporates prenatal care data and researchers further selected for records that included weight and height measurement taken during the first prenatal visit. BMI was calculated using the weight and height measurement. Based on BMI ranges that define weight groups as normal, overweight, and obesity grades I, II, and III, the researchers analyzed and compared the number of low Apgar scoring infants (Apgar 0–3) in each group. Mothers with normal weight gave birth to the majority of infants with Apgar 0–3. In comparison the proportion of low Apgar scores were greater in babies of overweight and obese mothers. The researchers found that the rates of low Apgar scores increased with maternal BMI: the authors found that rates of low Apgar score at 5 minutes increased from 0.4 per 1,000 among infants of underweight women (BMI <18.5) to 2.4 per 1,000 among infants of women with obesity class III (BMI ≥40). Furthermore, overweight (BMI 25.0–29.9) was associated with a 55% increased risk of low Apgar scores at 5 minutes; obesity grade I (BMI 30–34.9) and grade II (BMI 35.0–39.9) with an almost 2-fold and a more than 2-fold increased risk, respectively; and obesity grade ΙΙΙ (BMI ≥40.0) with a more than 3-fold increase in risk. Finally, maternal overweight and obesity also increase the risks for seizures and meconium aspiration in the neonate.
What Do These Findings Mean?
These findings suggest that the risk of experiencing an oxygen deficit increases for the babies of women who are overweight or obese. Given the high prevalence of overweight and obesity in many countries worldwide, these findings are important and suggest that preventing women of reproductive age from becoming overweight or obese is therefore important to the health of their children.
A limitation of this study is the lack of data on the effects of clinical interventions and neonatal resuscitation efforts that may have been performed at the time of birth. Also Apgar scoring is based on five variables and a low score is not the most direct way to determine if the infant has experienced an oxygen deficit. However, these findings suggest that early detection of perinatal asphyxia is particularly relevant among infants of overweight and obese women although more studies are necessary to confirm the results in other populations.
Additional Information
Please access these Web sites via the online version of this summary at
The US National Institutes of Health explains and calculates body mass index
The NIH also defines the Apgar scoring system
The United Kingdom's National Health Service has information for pregnant woman who are overweight
The UK-based Overseas Development Institute discusses how changes in diet have led to a worldwide health crisis in its “Future Diets” publication
Information about the Swedish health care system is available
Information in English is available from the National Board of Health and Welfare in Sweden
PMCID: PMC4028185  PMID: 24845218
25.  Neonatal Outcomes of Extremely Preterm Infants From the NICHD Neonatal Research Network 
Pediatrics  2010;126(3):443-456.
This report presents data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network on care of and morbidity and mortality rates for very low birth weight infants, according to gestational age (GA).
Perinatal/neonatal data were collected for 9575 infants of extremely low GA (22–28 weeks) and very low birth weight (401–1500 g) who were born at network centers between January 1, 2003, and December 31, 2007.
Rates of survival to discharge increased with increasing GA (6% at 22 weeks and 92% at 28 weeks); 1060 infants died at ≤ 12 hours, with most early deaths occurring at 22 and 23 weeks (85% and 43%, respectively). Rates of prenatal steroid use (13% and 53%, respectively), cesarean section (7% and 24%, respectively), and delivery room intubation (19% and 68%, respectively) increased markedly between 22 and 23 weeks. Infants at the lowest GAs were at greatest risk for morbidities. Overall, 93% had respiratory distress syndrome, 46% patent ductus arteriosus, 16% severe intraventricular hemorrhage, 11% necrotizing enterocolitis, and 36% late-onset sepsis. The new severity-based definition of bronchopulmonary dysplasia classified more infants as having bronchopulmonary dysplasia than did the traditional definition of supplemental oxygen use at 36 weeks (68%, compared with 42%). More than one-half of infants with extremely low GAs had undetermined retinopathy status at the time of discharge. Center differences in management and outcomes were identified.
Although the majority of infants with GAs of ≥24 weeks survive, high rates of morbidity among survivors continue to be observed.
PMCID: PMC2982806  PMID: 20732945
extremely low gestation; very low birth weight; morbidity; death

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