Dunn Hospital Medicine Research Program

Preventing Readmissions Using Nurse Practitioners

Patients with complex medical illness are often readmitted soon after an initial hospitalization. The readmission rates for Medicare patients in the U.S. are approximately 20% and is higher for patients with congestive heart failure (CHF). The readmission rate is particularly high in New York City, which may be due to patient or hospital related factors. One contributing factor across the nation is the emphasis on reducing length of stay, which results in a more acutely ill hospitalized patient population, and relies on a seamless transition to the outpatient venue. In practice, these transitions are often difficult, as the patient may not understand changes to their medication regimen, may not have a readily identifiably primary care provider (PCP), or may have difficulty accessing their PCP. Efforts to reduce readmission rates have focused on enhancing the transition process from hospital to home. These efforts have met with mixed results. In recognition of the high acuity of patients discharged home and of the difficulty providers have of ensuring patients safely transition back to their PCP, the Mount Sinai Hospital and the Visiting Nurse Service of NY (VNSNY) have partnered together on an initiative to provide patients with the needed services. This study will provide a Nurse Practitioner who will assess patients risk for readmission, identify patients who are at high risk for readmission, provide telephone and at-home follow-up and management, facilitate communication with the inpatient physician and the primary care physician, and ensure the patient is seen by their PCP in a  timely manner after discharge.  Patients enrolled I the Transitions Study will be compared to a matched control population who receive usual care. the primary outcome will be the 30-day readmission rate. Secondary outcomes will include ED visits, time to PCP appointment, and patient satisfaction.

Peri-operative Warfarin Management - The Bridge Trial

In this randomized controlled trial, Dr. Dunn is investigating  the risks and benefits of “bridging” anticoagulation versus no “bridging” in patients with atrial fibrillation on chronic warfarin undergoing surgical procedures.

The results of this investigation could have a significant impact on current clinical practice and significant cost-benefit implications.  It could affect the current clinical practice since a large number of patients undergo bridging in the peri-operative period.  With bridging often done with low molecular weight heparin, an expensive therapy associated with post-operative bleeding and prolonged hospital stays, the results of the trial could also have significant cost-benefit implications.

Temporary interruption of warfarin therapy for an elective surgical or other invasive procedure is a common clinical problem. Clinicians often employ a low molecular weight heparin (LMWH) as a “bridge” before and after surgery or a procedure, when warfarin is withheld and anticoagulation are otherwise sub-therapeutic. This empiric strategy has several drawbacks, including lack of proven efficacy to prevent arterial thromboembolism, additional cost to the healthcare system, and the potential for increased peri-operative bleeding. Unfortunately, there are no high-quality clinical trials to provide Level 1A evidence to guide patient care.

We are performing a multi-center, prospective, double-blind, placebo-controlled randomized clinical trial that randomly allocates 3,282 patients with atrial fibrillation and/or a mechanical aortic valve to either therapeutic dose LMWH or matching placebo before and after surgery (1641 patients per arm). Forty-five enrolling centers in North America will recruit patients over 44 months.