住院患者出院后家庭肠外支持的三十天再入院率高

　　美国克利夫兰医院基金会对出院后行家庭肠外支持（HPS）的患者进行随访，发现30天再入院率很高，36%患者在30天内再住院1～3次。但是，营养不良的存在和严重程度与再入院率无显著相关性，并且一些棘手患者，如炎性肠病（IBD）、小肠切除术后、肠造口和高HPS供给量的患者，其30天再入院率反而降低。

JPEN J Parenter Enteral Nutr. 2016;40(4):137.

Thirty-Day Readmission Rates Are High in Hospitalized Patients Discharged on Home Parenteral Support.

Denise M. Konrad; Hiren Vallabh; Robert DeChicco; Rocio Lopez; Ezra Steiger; Donald F. Kirby.

Cleveland Clinic Foundation, Cleveland, OH, USA.

Purpose: Clinicians, payers, and policy makers have increased focus on reducing hospital readmissions to reduce healthcare costs and improve quality of care. There are no published studies examining the 30-day readmission rate in patients discharged on home parenteral support (HPS; parenteral nutrition or intravenous fluids) and which risk factors are associated with increased readmission risk. The objective was to determine 30-day readmission rates for patients discharged on HPS and if various factors had an associated effect on readmission risk. We hypothesized that patients with a higher degree of malnutrition would be more likely to be readmitted within 30 days of being discharged on HPS.

Methods: A retrospective case series was completed using an IRB-approved database to identify patients followed by the home nutrition support service (HNSS) who were discharged on HPS for the first time from a large tertiary care hospital between July 1, 2013, and June 30, 2014. Data collected included HPS indication, presence of an enterostomy, HPS formula volume, comorbidities, inflammatory markers, and presence and degree of malnutrition at discharge among other variables. A comprehensive nutrition assessment was performed by trained clinicians on all patients using a combination of the Academy/A.S.P.E.N. guidelines and our institution's guidelines for diagnosing adult malnutrition.

Results: There were 239 patients included, with an average age of 50.4 years. Twenty-seven percent of patients had cancer; 25% had inflammatory bowel disease (IBD); and the remaining had other underlying diseases. Indications for HPS were short bowel syndrome (28.6%), motility disorder (26.1%), fistula (21%), obstruction (20.6%), mucosal disorder (2.9%), and pancreatitis (0.8%). Thirty-six percent (n = 86) of patients were readmitted between 1 and 3 times within 30 days of initial hospital discharge. Of the 86 initial readmissions, 14% (n = 12) were HPS-related, and 86% (n = 74) were not. Of the HPS-related readmissions, 6 were related to metabolic reasons; 5 were catheter-related bloodstream infections (CRBSIs); and 1 was a mechanical complication. All patients readmitted with CRBSIs were prescribed ethanol lock. The majority of patients (84.5%) were diagnosed with some degree of malnutrition, including 13.4% with mild, 24.2% with moderate, and 46.9% with severe, but the presence or degree of malnutrition was not associated with readmission rates (P = .27). On univariable analysis, patients with IBD had a 45% lower hazard of 30-day readmission than those without IBD (HR = 0.55, P = .44). Compared with subjects that underwent small bowel resections, those with the entire small bowel had twice the risk of 30-day readmission (HR = 2.2, P = .006). Patients with an enterostomy had 39% lower risk of readmission than those with bowel in continuity (HR = 0.61, P = .046). Last, for every 100-mL increase in HPS volume, the hazard of readmission decreased by 5% (HR = 0.95, P < .001).

Conclusions: Patients discharged with HPS for the first time who were cared for by an experienced HNSS have a high 30-day readmission rate. Surprisingly, the presence and degree of malnutrition were not associated with readmission rates. Also unexpectedly, challenging patients to manage (eg, those with IBD, small bowel resections, enterostomies, and patients with higher HPS volumes at discharge) had lower rates of 30-day readmissions.

Financial support: None.