Background: Hospital readmissions are frequent and can represent low-quality, high-cost care. Timely post-hospital follow-up has been described as an important element of high-quality transitions of care and readmissions prevention (1-3), yet exactly what type of follow-up is most successful is unclear. We sought to understand the relationship between timing, hospital follow-up visit provider specialty and [...]

Background: Hospital readmissions are frequent and can represent low-quality, high-cost care. Timely post-hospital follow-up has been described as an important element of high-quality transitions of care and readmissions prevention (1-3), yet exactly what type of follow-up is most successful is unclear. We sought to understand the relationship between timing, hospital follow-up visit provider specialty and [...]

Background: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus that is increasing in frequency, and yet is preventable with adequate outpatient management. Studies have shown that children with diabetes in minority populations experience more frequent DKA admissions, possibly due to inequities in healthcare access. We examined whether disparities by race/ethnicity exist in DKA [...]

Background: Social needs are associated with poor medical outcomes, including increased readmissions. Several studies compare demographic or ICD-10 code indices of social risk and readmissions, or social needs in disease-specific readmissions. Others found that addressing needs is associated with decreased readmissions. However, little is known about how needs differ between patients who are readmitted to [...]

Background: Heart failure (HF) hospital readmissions are a leading cause of US 30-day hospital readmissions. Factors related to clinical complexity and unmet social needs are among the key drivers associated with HF negative clinical outcomes. Digital platforms have shown promise in improving HF outcomes but limitations like patient lack of familiarity with technology and unmet [...]

Background: Shifting dynamics present unique opportunities for inpatient providers to enhance outcomes during transitions of care (TOC) as hospital medicine rises as a specialized field. It is well established that gaps in TOC can lead to unfavorable outcomes for patients and healthcare systems alike including increased morbidity, complications, readmissions, and costs. While TOC visits are [...]

Background: Healthcare institutions face a narrow operating budget to provide patient care. Centers for Medicare and Medicaid Services (CMS) evaluate healthcare institutions based on efficiency, quality and customer experience–in other words: length of stay, readmission rate and patients’ perception of the care they received. The effectiveness of decreased readmission is based on multiple variables, and [...]