Acute Care Inpatient Hospital Research Articles

Admission avoidance hospital at home.

Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period. This is the fourth update of this review. To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL on 24 February 2022, and checked the reference lists of eligible articles. We sought ongoing and unpublished studies by searching ClinicalTrials.gov and WHO ICTRP, and by contacting providers and researchers involved in the field. Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care. We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta-analysis for trials that compared similar interventions, reported comparable outcomes with sufficient data, and used individual patient data when available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes. We included 20 randomised controlled trials with a total of 3100 participants; four trials recruited participants with chronic obstructive pulmonary disease; two trials recruited participants recovering from a stroke; seven trials recruited participants with an acute medical condition who were mainly older; and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias. For an older population, admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.68 to 1.13; P = 0.30; I2 = 0%; 5 trials, 1502 participants; moderate-certainty evidence); little or no difference on the likelihood of being readmitted to hospital after discharge from hospital at home or inpatient care within 3 to 12 months' follow-up (RR 1.14, 95% CI 0.97 to 1.34; P = 0.11; I2 = 41%; 8 trials, 1757 participants; moderate-certainty evidence); and probably reduces the likelihood of living in residential care at six months' follow-up (RR 0.53, 95% CI 0.41 to 0.69; P < 0.001; I2 = 67%; 4 trials, 1271 participants; moderate-certainty evidence). Hospital at home probably results in little to no difference in patient's self-reported health status (2006 patients; moderate-certainty evidence). Satisfaction with health care received may be improved with admission avoidance hospital at home (1812 participants; low-certainty evidence); few studies reported the effect on caregivers. Hospital at home reduced the initial average hospital length of stay (2036 participants; low-certainty evidence), which ranged from 4.1 to 18.5 days in the hospital group and 1.2 to 5.1 days in the hospital at home group. Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only). Admission avoidance hospital at home probably reduces costs to the health service compared with hospital admission (2148 participants; moderate-certainty evidence), though by a range of different amounts and using different methods to cost resource use, and there is some evidence that it decreases overall societal costs to six months' follow-up. Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of older people who have been referred for hospital admission. The intervention probably makes little or no difference to patient health outcomes; may improve satisfaction; probably reduces the likelihood of relocating to residential care; and probably decreases costs.

Hospital cost efficiency: an examination of US acute care inpatient hospitals.

The use of stochastic frontier models for inference on hospital efficiency is complicated by the inability to fully control for quality differences across hospitals. Additionally, the potential existence of cross-sectional dependence due to the presence of unobserved common factors leads to endogeneity problems that can bias both cost function and efficiency estimates. Using a panel consisting of 1518 hospitals for the years 1996-2013 (T=18), I adopt techniques for dealing with long, cross-sectionally dependent panel data in order to estimate cost parameters and hospital specific efficiency. In particular, I employ the estimation technique proposed by Bai (Econometrica 77(4):1229-1279, 2009), which assumes that the unobservable heterogenous effects have a factor structure. I find evidence of considerable scale economies and that hospital cost inefficiencies have been increasing during the period of 1996-2013, and that the growth in expenditures is, in part, driven by spending that increases patient satisfaction, but that does not significantly contribute to improved patient health outcomes.

Patient safety and quality care: Time to focus on nonventilator hospital-acquired pneumonia

Background: A growing body of evidence has reported on the harm and cost of nonventilator hospital-acquired pneumonia (NVHAP), currently the most common hospital-acquired infection (HAI). Although the US Congress and the Center for Medicare and Medicaid Services (CMS) have acted to reduce rates of some HAIs through the Hospital-Acquired Condition Reduction Program (HACRP), NVHAP is not currently included. Thus, most hospitals do not engage in active prevention. Here, we report the findings from our analysis of Medicare claims data on hospital length of stay (LOS), cost for patients with hospital-acquired pneumonia (HAP), including both ventilator-associated pneumonia and NVHAP, and mortality. Methods: We used Medicare claims data for Federal Fiscal Year 2019 for inpatient and postdischarge services. Beneficiaries who died, were without continuous Medicare Part A and B enrollment, and patients eligible for Medicare for end-stage renal disease were excluded. Inpatient payments and 30-, 60-, and 90-day postdischarge episodes for 2,457 beneficiaries with HAP were examined and compared to a non-HAP control group of 2,457 beneficiaries. Groups were matched on age, sex, race, and the diagnosis-related group (DRG) for their index hospitalization. Results: Most HAP was NVHAP (N = 2,222; 89%) versus VAP (N = 275; 11%). LOS stay was significantly (p HAP patients were 2.8 times more likely to die vs non-HAP. Conclusions: These findings provide additional support to previous research on the harm and cost associated with NVHAP. Previous HACRP HAI initiatives, such as catheter-associated urinary tract infection (CAUTI) and surgical-site infection (SSI), have resulted in measurable HAI reductions. Although recent evidence-based NVHAP and initiatives indicate that NVAHP is largely preventable, to date, no acute-care inpatient hospital quality improvement program implemented by Medicare includes measures for NVHAP prevention. The time is right to include NVHAP as an HACRP HAI initiative.Funding: StrykerDisclosures: None

How to minimize infectious health risks for elderly people (based on focus group data)

This literature review focuses on practices aimed at mitigating infectious health risks for elderly people in acute care inpatient hospitals with multiple specializations. We revealed a necessity to create medical information centers; common reference centers for PCR diagnostics, sequencing, plasmid analysis, and MULDI-TOF; as well as to provide support and further development of bacteriological and hygienic service in medical and preventive organizations. Our review also dwells on theoretical solutions to issues related to minimizing infection risks in nursing homes and prospective approaches to providing infectious safety at home. A focus group was organized on May 20, 2021 at the E.A. Wagner’s Perm State Medical University of the RF Public Healthcare Ministry with its aim being to implement theoretical approaches into practices of minimizing infectious health risks for elderly people in Perm region within the “aging in place” paradigm. The sociological explication made it possible to fix the regional agenda on minimizing infectious heath risks for elderly people as per three basic directions: by improving living conditions, by improving care provided for elderly people at home, and by making elderly people’s lives more active as a way to support their immunity. All the discussion participants unanimously agreed both on assigning the primary role to the strengthened immunity as a way to minimize infectious health risks and on obvious absence of any drugs which would be able to resolve the issue. Experts believe adherence to conventional recommendations on how to improve elderly people’s immunity to be fundamental for infection risk mitigation. We should remember that some elderly people live in improper housing which should be renovated and adapted to basic needs of an elderly person. It is also important to develop the city environment taking into account elderly people’s habits and needs (they should be provided with a special place in the yard where they can communicate with each other, play board games or do physical exercises). Financial support should be given to “Inpatient hospital at home” program and to developing tools used to promptly minimize infection risks, for example, telemedicine which allows detecting certain alerting symptoms typical for communicable diseases (fever, complaining about cough and running nose, pains in the lumbar spine, decreased diuresis etc.)

К проблеме минимизации инфекционных рисков здоровью пожилых людей (по материалам фокус-группы)

This literature review focuses on practices aimed at mitigating infectious health risks for elderly people in acute care inpatient hospitals with multiple specializations. We revealed a necessity to create medical information centers; common reference centers for PCR diagnostics, sequencing, plasmid analysis, and MULDI-TOF; as well as to provide support and further development of bacteriological and hygienic service in medical and preventive organizations. Our review also dwells on theoretical solutions to issues related to minimizing infection risks in nursing homes and prospective approaches to providing infectious safety at home. A focus group was organized on May 20, 2021 at the E.A. Wagner’s Perm State Medical University of the RF Public Healthcare Ministry with its aim being to implement theoretical approaches into practices of minimizing infectious health risks for elderly people in Perm region within the “aging in place” paradigm. The sociological explication made it possible to fix the regional agenda on minimizing infectious heath risks for elderly people as per three basic directions: by improving living conditions, by improving care provided for elderly people at home, and by making elderly people’s lives more active as a way to support their immunity. All the discussion participants unanimously agreed both on assigning the primary role to the strengthened immunity as a way to minimize infectious health risks and on obvious absence of any drugs which would be able to resolve the issue. Experts believe adherence to conventional recommendations on how to improve elderly people’s immunity to be fundamental for infection risk mitigation. We should remember that some elderly people live in improper housing which should be renovated and adapted to basic needs of an elderly person. It is also important to develop the city environment taking into account elderly people’s habits and needs (they should be provided with a special place in the yard where they can communicate with each other, play board games or do physical exercises). Financial support should be given to “Inpatient hospital at home” program and to developing tools used to promptly minimize infection risks, for example, telemedicine which allows detecting certain alerting symptoms typical for communicable diseases (fever, complaining about cough and running nose, pains in the lumbar spine, decreased diuresis etc.)

Detecting drug diversion in health-system data using machine learning and advanced analytics.

PurposeThe theft of drugs from healthcare facilities, also known as drug diversion, occurs frequently but is often undetected. This paper describes a research study to develop and test novel drug diversion detection methods. Improved diversion detection and reduction in diversion improves patient safety, limits harm to the person diverting, reduces the public health impact of substance use disorder, and mitigates significant liability risk to pharmacists and their organizations.MethodsTen acute care inpatient hospitals across 4 independent health systems extracted 2 datasets from various health information technology systems. Both datasets were consolidated, normalized, classified, and sampled to provide a harmonious dataset for analysis. Supervised machine learning methods were iteratively used on the initial sample dataset to train algorithms to classify medication movement transactions as involving a low or high risk of diversion. Thereafter, the resulting machine learning model classified the risk of diversion in a historical dataset capturing 8 to 24 months of history that included 27.9 million medication movement transactions by 19,037 nursing, 1,047 pharmacy, and 712 anesthesia clinicians and that included 22 known, blinded diversion cases to measure when the model would have detected the diversion compared to when the diversion was actually detected by existing methods.ResultsThe machine learning model had 96.3% accuracy, 95.9% specificity, and 96.6% sensitivity in detecting transactions involving a high risk of diversion using the initial sample dataset. In subsequent testing using the much larger historical dataset, the analytics detected known diversion cases (n = 22) in blinded data faster than existing detection methods (a mean of 160 days and a median of 74 days faster; range, 7-579 days faster).ConclusionThe study showed that (1) consolidated datasets and (2) supervised machine learning can detect known diversion cases faster than existing detection methods. Users of the technology also noted improved investigation efficiency.

Capacity planning for acute hospital inpatient care and adult critical care in England: a descriptive study using hospital administrative data

BackgroundAt the beginning of the COVID-19 pandemic in March and April, 2020, there was a focus on accommodating an anticipated surge of patients with COVID-19 in acute hospitals. We aimed to estimate the potential for freeing up capacity in acute hospitals in England. MethodsIn this descriptive study, we used admitted patient and adult critical care records from Hospital Episode Statistics (a database containing details of attendances at National Health Service acute hospitals in England) from 2018/19 to estimate historical numbers of inpatients. Each admission was grouped into emergency, maternity, and elective, with elective split by the presence or absence of cancer in the primary diagnosis. We further stratified the population by age and frailty, which we estimated with an index using International Statistical Classification of Diseases and Related Health Problems (tenth revision) codes in diagnosis fields. We used the (then current) National Institute for Health and Care Excellence (NICE) 2020 guidance on critical care pathways as a framework to examine four scenarios that limited access to beds for specific patient groups. This study was approved by the Secretary of State and the Health Research Authority under Regulation 5 of the Health Service (Control of Patient Information) Regulations 2002 to hold confidential data and analyse them for research purposes (CAG ref 15/CAG/0005). We have approval to use these data for research into the quality and safety of health care, from the London–South East Ethics Committee (REC ref 20/LO/0611). FindingsBetween April 1, 2018, and March 31, 2019, 8 957 521 adults were admitted (7 372 040 [82·3%] emergency, 295 598 [3·3%] elective with cancer, 850 964 [9·5%] elective without cancer, and 438 919 [4·9%] maternity admissions), and 974 038 critical care episodes were recorded. Our analysis suggested that up to 70% of all acute inpatient beds could be released if only maternity, cancer, and emergency patients younger than 65 years were admitted; if non-frail patients aged 65 years and older were also admitted, 41% of beds could be freed up. Similarly, if only maternity, cancer, and emergency patients younger than 65 years were admitted to critical care beds, that might free up to 56% of adult critical care beds; if non-frail patients aged 65 years and older were also admitted, 30% of critical care beds could be freed up. InterpretationGiven a crisis in health-care capacity, it seemed appropriate to model some difficult options based on NICE guidelines. We identified scope for freeing up total acute and critical care beds by postponing elective non-cancer admissions as a short-term measure during the first wave of COVID-19 (March to June, 2020) in England. The NICE guidelines were criticised by patient groups and have since been updated (NG191). Administrative data can inform planning for future crises albeit with limitations on estimating individual patient need, and deep social and ethical considerations. Our estimates were incorporated into a modelling tool for hospital provision during the pandemic. FundingDr Foster Intelligence.

Rocuronium reversed with sugammadex for thymectomy in myasthenia gravis: A retrospective analysis of complications from Japan.

Postoperative respiratory failure is a serious problem in the anaesthetic management of patients with myasthenia gravis who undergo thymectomy. Although the classical recommendation is to avoid neuromuscular blockers, there is no strong evidence to support it. To evaluate the postoperative outcomes in patients with myasthenia gravis after thymectomy when anaesthetic management included rocuronium reversed with sugammadex. A retrospective cohort study. Nationwide acute in-patient care database. A total of 1143 patients with myasthenia gravis who underwent thymectomy were included. Data were collected from the medical insurance claims data of acute care in-patient hospitals. The postoperative complications when rocuronium reversed with sugammadex was compared against no muscle relaxant use using propensity score matching. The primary outcomes were the rates of in-hospital mortality, plasma exchange following thymectomy and the use of immunoglobulins. The secondary outcomes were the length of stay in the high dependency/ICUs, the total length of hospital stay and the duration and type of respiratory support following thymectomy. There were no significant differences between the propensity score matched groups in terms of plasma exchange [relative risk, 0.96; 95% confidence interval (CI), 0.64 to 1.43] and use of immunoglobulins (relative risk, 1.09; 95% CI, 0.60 to 1.97). The length of hospital stay was significantly shorter in patients in whom rocuronium and sugammadex were used: 29.0 vs. 35.4 days, P = 0.035. Anaesthetic management with rocuronium reversed by sugammadex was not associated with increased risk of respiratory complications. These findings could help in the anaesthetic management of patients with myasthenia gravis.

Childhood maltreatment severity and suicidal ideation among adults receiving acute-care psychiatric inpatient services: The role of distress tolerance.

Objective: Persons in psychiatric inpatient hospitals represent a unique population with high rates of suicidal ideation and behavior as well as childhood maltreatment. Lower levels of perceived distress tolerance (DT) are associated with a history of childhood maltreatment and suicidal ideation and behavior in adulthood. Our study examined the association of childhood maltreatment severity with self-report and behavioral indices of suicide through perceived DT in a sample of adults in an acute-care psychiatric inpatient unit. We hypothesized that lower levels of perceived DT would account for the association between (a) childhood maltreatment severity and suicidal ideation severity and (b) childhood maltreatment severity and prehospitalization suicidality. Method: The sample was composed of 94 trauma-exposed adults (60% men; Mage = 33.43; SD = 12.06) admitted to a psychiatric acute-care inpatient hospital in a large metropolitan area in the southern United States. Approximately 55% of the sample were hospitalized due to suicidality, with an average number of 1.28 (SD = 2.42) prior suicide attempts; 3% of patients exhibited suicidality during their hospitalization. All patients reported experiencing at least one type of childhood maltreatment, with varying degrees of exposure. We conducted indirect effects analyses using PROCESS Macro for SPSS. Results: Childhood maltreatment severity was indirectly associated with both suicidal ideation severity and prehospitalization suicidality through DT. Conclusions: Findings advance our understanding of the association between childhood maltreatment and increased risk for suicidal ideation and behavior in adulthood, specifically among the psychiatric inpatient population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Machine-learning prediction of unplanned 30-day rehospitalization using the French hospital medico-administrative database.

Predicting unplanned rehospitalizations has traditionally employed logistic regression models. Machine learning (ML) methods have been introduced in health service research and may improve the prediction of health outcomes. The objective of this work was to develop a ML model to predict 30-day all-cause rehospitalizations based on the French hospital medico-administrative database.This was a retrospective cohort study of all discharges in the year 2015 from acute-care inpatient hospitalizations in a tertiary-care university center comprising 4 French hospitals. The study endpoint was unplanned 30-day all-cause rehospitalization. Logistic regression (LR), classification and regression trees (CART), random forest (RF), gradient boosting (GB), and neural networks (NN) were applied to the collected data. The predictive performance of the models was evaluated using the H-measure and the area under the ROC curve (AUC).Our analysis included 118,650 hospitalizations, of which 4127 (3.5%) led to rehospitalizations via emergency departments. The RF model was the most performant model according to the H-measure (0.29) and the AUC (0.79). The performances of the RF, GB and NN models (H-measures ranged from 0.18 to 0. 29, AUC ranged from 0.74 to 0.79) were better than those of the LR model (H-measure = 0.18, AUC = 0.74); all P values <.001. In contrast, LR was superior to CART (H-measure = 0.16, AUC = 0.70), P < .0001.The use of ML may be an alternative to regression models to predict health outcomes. The integration of ML, particularly the RF algorithm, in the prediction of unplanned rehospitalization may help health service providers target patients at high risk of rehospitalizations and propose effective interventions at the hospital level.

Predictive risk score for unplanned 30-day rehospitalizations in the French universal health care system based on a medico-administrative database.

BackgroundReducing unplanned rehospitalizations is one of the priorities of health care policies in France and other Western countries. An easy-to-use algorithm for identifying patients at higher risk of rehospitalizations would help clinicians prioritize actions and care concerning discharge transitions. Our objective was to develop a predictive unplanned 30-day all-cause rehospitalization risk score based on the French hospital medico-administrative database.MethodsThis was a retrospective cohort study of all 2015 discharges from acute-care inpatient hospitalizations in a tertiary-care university center comprising four hospitals. The study endpoint was unplanned 30-day all-cause rehospitalization via emergency departments, and we collected sociodemographic, clinical, and hospital characteristics based on hospitalization database computed for reimbursement of fees. We derived a predictive rehospitalization risk score using a split-sample design and multivariate logistic regression, and we compared the discriminative properties with the LACE index risk-score.ResultOur analysis included 118,650 hospitalizations, of which 4,127 (3.5%) led to rehospitalizations via emergency departments. Variables independently associated with rehospitalization were age, gender, state-funded medical assistance, as well as disease category and severity, Charlson comorbidity index, hospitalization via emergency departments, length of stay (LOS), and previous hospitalizations 6 months before. The predictive rehospitalization risk score yielded satisfactory discriminant properties (C statistic: 0.74) exceeding the LACE index (0.66).ConclusionOur findings indicate that the possibility of unplanned rehospitalization remains high for some patient characteristics, indicating that targeted interventions could be beneficial for patients at the greatest risk. We developed an easy-to-use predictive rehospitalization risk-score of unplanned 30-day all-cause rehospitalizations with satisfactory discriminant properties. Future works should, however, explore if other data from electronic medical records and other databases could improve the accuracy of our predictive rehospitalization risk score based on medico-administrative data.

"Paying it forward": The link between providers' civility climate, civility toward patients and patient experience outcomes.

Interpersonal relationships are increasingly recognized as an important determinant for care performance and quality in the health care context. An unresolved issue in health care research is whether and to which extent providers' perceptions of their work relationships are associated with their interactions with patients and, in turn, patient experience outcomes. The aim of this study was to investigate the extent to which nurses' experiences of their work relationship climate (i.e., civility climate) affect their interactions with patients (i.e., civility towards patients), which in turn contribute to patient experience outcomes (i.e., overall hospital rating, willingness to return, intent to recommend). Furthermore, we analyze the mediating role of civility toward patients in the relation between civility climate and patient experience outcomes. The 2011 study sample comprised responses from 6,019 nurses and 38,619 patients at 123 Veterans Health Administration acute care inpatient hospitals located in the United States. We developed and empirically tested a theoretical model using multilevel regression modeling and assessing multilevel mediation. The results indicate a positive association between civility climate and civility toward patients. With regard to patient experience outcomes, the analyses reveal a direct effect of civility climate on overall hospital rating, intent to recommend, and willingness to return and an indirect effect mediated by civility toward patients. This is one of the first studies theorizing and testing the extent to which relationship climate among providers affect their interactions with patients. The findings provide support that providers who experience a positive civility climate are more likely to pay forward this relationship experience and engage in civility toward patients. The results point to the importance of a civility climate for ensuring and potentially improving patient experience of care.

Admission rates in a general practitioner-based versus a hospital specialist based, hospital-at-home model: ACCESS, an open-labelled randomised clinical trial of effectiveness

BackgroundHospital at home (HaH) is an alternative to acute admission for elderly patients. It is unclear if should be cared for a primarily by a hospital intern specialist or by the patient’s own general practitioner (GP).The study assessed whether a GP based model was more effective than a hospital specialist based model at reducing number of hospital admissions without affecting the patient’s recovery or number of deaths.MethodsPragmatic, randomised, open-labelled multicentre parallel group trial with two arms in four municipalities, four emergency departments and 150 GPs in Southern Denmark, including + 65 years old patients with an acute medical condition that required acute hospital in-patient care. The patients were randomly assigned to hospital specialist based model or GP model of HaH care. Five physical and cognitive performance tests were performed at inclusion and after 7 days. Primary outcome was number of hospital admissions within 7 days. Secondary outcomes were number of admissions within 14, 21 and 30 days, deaths within 30 and 90 days and changes in performance tests.ResultsSixty seven patients were enrolled in the GP model and 64 in the hospital specialist model. 45% in the hospital specialist arm versus 24% in the GP arm were admitted within 7 days (effect size 2.7, 95% CI 1.3–5.8; p = 0.01) and this remained significant within 30 days. No differences were found in death or changes in performance tests from day 0–7 days between the two groups.ConclusionsThe GP based HaH model was more effective than the hospital specialist model in avoiding hospital admissions within 7 days among elderly patients with an acute medical condition with no differences in mental or physical recovery rates or deaths between the two models.RegistrationNo. NCT02422849 Registered 27 March 2015. Retrospectively registered

Posttraumatic Stress and Mindfulness Facets in Relation to Suicidal Ideation Severity Among Psychiatric Inpatients

Traumatic life events and posttraumatic stress disorder (PTSD) symptomatology are associated with suicidality, including suicidal ideation and behavior. The current study investigates the moderating role of mindfulness facets, as measured by the Five Facet Mindfulness Questionnaire, in the association between PTSD symptom severity and suicidal ideation severity in a sample of acute-care psychiatric inpatients. Participants were comprised of 119 adults (42.9% women; Mage = 33.3, SD = 11.0) admitted to a public, university-affiliated, psychiatric acute-care inpatient hospital in a large metropolitan area. Results indicated significant interactive effects of PTSD symptom severity and observing (ΔR 2 = 0.032, β = 0.19, p < 0.05), acting with awareness (ΔR 2 = 0.071, β = − 0.27, p = 0.002), and nonjudging of inner experience (ΔR 2 = 0.066, β = − 0.27, p = 0.002) with regard to suicidal ideation severity. These effects were documented after controlling for theoretically relevant covariates, including number of traumatic event types experienced and number of prior suicide attempts. A significant main effect was also present for PTSD symptom severity with regard to suicidal ideation severity. In addition, there was a significant main effect for nonjudging of inner experience with regard to suicidal ideation severity; no other mindfulness facets demonstrated significant main effects with regard to suicidal ideation severity.

Posttraumatic Stress and Distress Tolerance: Associations With Suicidality in Acute-Care Psychiatric Inpatients.

Trauma and posttraumatic stress disorder (PTSD) symptomatology have been associated with suicidality, including ideation and behavior. The current investigation evaluated, in acute-care psychiatric inpatients, the mediating role of perceived (self-reported) distress tolerance in the association between PTSD symptom severity and suicidality, defined as a) suicidal ideation, intent, or behavior leading to current psychiatric hospitalization; b) self-reported severity of suicidal desire; and c) percentage of days of suicidality during current hospitalization. Participants were composed of 105 adults (55.2% women; mean age, 33.9; SD, 10.9) admitted to a public psychiatric acute-care inpatient hospital in a large metropolitan area; 52.3% of the participants were hospitalized for suicidality. Results indicated that PTSD symptom severity (and severity of each PTSD symptom cluster) may exert an indirect effect on suicidality, specifically suicidality as a basis for current hospital admission and self-reported severity of suicidal desire, through perceived distress tolerance. Effects were documented after controlling for theoretically relevant covariates.

Early discharge hospital at home.

'Early discharge hospital at home' is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would require acute hospital in-patient care. If hospital at home were not available then the patient would remain in an acute hospital ward.To determine, in the context of a systematic review and meta-analysis, the effectiveness and cost of managing patients with early discharge hospital at home compared with in-patient hospital care.We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register , MEDLINE (1950 to 2008), EMBASE (1980 to 2008), CINAHL (1982 to 2008) and EconLit through to January 2008. We checked the reference lists of articles identified for potentially relevant articles.Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing early discharge hospital at home with acute hospital in-patient care. Evaluations of obstetric, paediatric and mental health hospital at home schemes are excluded from this review.Two authors independently extracted data and assessed study quality. Our statistical analyses were done on an intention-to-treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. For the IPD meta-analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set. The calculated log hazard ratios were combined using fixed-effect inverse variance meta-analysis.Twenty-six trials were included in this review [n = 3967]; 21 were eligible for the IPD meta-analysis and 13 of the 21 trials contributed data [1899/2872; 66%]. For patients recovering from a stroke and elderly patients with a mix of conditions there was insufficient evidence of a difference in mortality between groups (adjusted HR 0.79, 95% CI 0.32 to 1.91; N = 494; and adjusted HR 1.06, 95% CI 0.69 to 1.61; N = 978). Readmission rates were significantly increased for elderly patients with a mix of conditions allocated to hospital at home (adjusted HR 1.57; 95% CI 1.10 to 2.24; N = 705). For patients recovering from a stroke and elderly patients with a mix of conditions respectively, significantly fewer people allocated to hospital at home were in residential care at follow up (RR 0.63; 95% CI 0.40 to 0.98; N = 4 trials; RR 0.69, 95% CI 0.48 to 0.99; N =3 trials). Patients reported increased satisfaction with early discharge hospital at home. There was insufficient evidence of a difference for readmission between groups in trials recruiting patients recovering from surgery. Evidence on cost savings was mixed.Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.

Admission avoidance hospital at home.

Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital inpatient care, and always for a limited time period. This is the third update of the original review. To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, two other databases, and two trials registers on 2 March 2016. We checked the reference lists of eligible articles. We sought unpublished studies by contacting providers and researchers who were known to be involved in the field. Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care. We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta-analysis for trials that compared similar interventions and reported comparable outcomes with sufficient data, requested individual patient data from trialists, and relied on published data when this was not available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes. We included 16 randomised controlled trials with a total of 1814 participants; three trials recruited participants with chronic obstructive pulmonary disease, two trials recruited participants recovering from a stroke, six trials recruited participants with an acute medical condition who were mainly elderly, and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias. Admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.60 to 0.99; P = 0.04; I2 = 0%; 912 participants; moderate-certainty evidence), little or no difference on the likelihood of being transferred (or readmitted) to hospital (RR 0.98, 95% CI 0.77 to 1.23; P = 0.84; I2 = 28%; 834 participants; moderate-certainty evidence), and may reduce the likelihood of living in residential care at six months' follow-up (RR 0.35, 95% CI 0.22 to 0.57; P < 0.0001; I2 = 78%; 727 participants; low-certainty evidence). Satisfaction with healthcare received may be improved with admission avoidance hospital at home (646 participants, low-certainty evidence); few studies reported the effect on caregivers. When the costs of informal care were excluded, admission avoidance hospital at home may be less expensive than admission to an acute hospital ward (287 participants, low-certainty evidence); there was variation in the reduction of hospital length of stay, estimates ranged from a mean difference of -8.09 days (95% CI -14.34 to -1.85) in a trial recruiting older people with varied health problems, to a mean increase of 15.90 days (95% CI 8.10 to 23.70) in a study that recruited patients recovering from a stroke. Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of elderly patients requiring hospital admission. However, the evidence is limited by the small randomised controlled trials included in the review, which adds a degree of imprecision to the results for the main outcomes.

Concurrent alcohol and medication poisoning hospital admissions among older rural and urban residents

ABSTRACTBackground: Alcohol and medication interactions are projected to increase due to the growth of older adults that are unsafely consuming alcohol and medications. Plus, aging adults who reside in rural areas are at the highest risk of experiencing medication interactions. Objective: Estimate concurrent alcohol and medication (alcohol/medication) hospitalizations in adults 50+ years, comparing age groups and rural/urban regions. Methods: Kentucky nonfederal, acute care inpatient hospital discharge electronic records for individuals aged 50+ years from 2001 to 2012 were examined. Rate differences were estimated across age and regional strata. Differences in the underlying principal diagnosis, intent, and medications were also examined. Results: There were 2168 concurrent alcohol/medication hospitalizations among 50+ year olds identified. There was a 187% increase in alcohol/medication hospitalizations from 2001 (n = 104) to 2012 (n = 299). The per capita alcohol/medication hospitalization rate increased from 8.91 (per 100,000) in 2001 to 19.98 (per 100,000) in 2012, a 124% increase. The characteristics of the hospitalizations included 75% principal diagnosis as medication poisoning, self-harm as the primary intent (55%) in 50–64-year olds, and unintentional intent (41%) in 65+ adults. Benzodiazepines were most often involved in the poisonings (36.5%). Conclusions: Concurrent alcohol/medication hospitalizations in Kentucky are increasing among aging adults. Greater increases in rural areas and the 65+ aged adults were seen, although there were also higher alcohol/medication hospitalizations in urban and 50–64 aged adults. These findings indicate the need for public-health prevention and clinical intervention to better educate and manage alcohol consuming older adults on safe medication and alcohol practices.

Contribution of Preventable Acute Care Spending to Total Spending for High-Cost Medicare Patients

A small proportion of patients account for the majority of US health care spending, and understanding patterns of spending among this cohort is critical to reducing health care costs. The degree to which preventable acute care services account for spending among these patients is largely unknown. To quantify preventable acute care services among high-cost Medicare patients. We summed standardized costs for each inpatient and outpatient service contained in standard 5% Medicare files from 2009 and 2010 across the year for each patient in our sample, and defined those in the top decile of spending in 2010 as high-cost patients and those in the top decile in both 2009 and 2010 as persistently high-cost patients. We used standard algorithms to identify potentially preventable emergency department (ED) visits and acute care inpatient hospitalizations. A total of 1,114,469 Medicare fee-for-service beneficiaries aged 65 years or older were included. Proportion of acute care hospital and ED costs deemed preventable among high-cost patients. The 10% of Medicare patients in the high-cost group were older, more often male, more often black, and had more comorbid illnesses than non-high-cost patients. In 2010, 32.9% (95% CI, 32.9%-32.9%) of total ED costs were incurred by high-cost patients. Based on validated algorithms, 41.0% (95% CI, 40.9%-41.0%) of these costs among high-cost patients were potentially preventable compared with 42.6% (95% CI, 42.6%-42.6%) among non-high-cost patients. High-cost patients accounted for 79.0% (95% CI, 79.0%-79.0%) of inpatient costs, 9.6% (95% CI, 9.6%-9.6%) of which were due to preventable hospitalizations; 16.8% (95% CI, 16.8%-16.8%) of costs within the non-high-cost group were due to preventable hospitalizations. Comparable proportions of ED spending (43.3%; 95% CI, 43.3%-43.3%) and inpatient spending (13.5%; 95% CI, 13.5%-13.5%) were preventable among persistently high-cost patients. Regions with high primary care physician supply had higher preventable spending for high-cost patients. Among a sample of patients in the top decile of Medicare spending in 2010, only a small percentage of costs appeared to be related to preventable ED visits and hospitalizations. The ability to lower costs for these patients through better outpatient care may be limited.

1825 OPERATION TIME AND POSTOPERATIVE SEVERE ADVERSE EVENTS IN URETERORENOSCOPIC LITHOTORIPSY

You have accessJournal of UrologyStone Disease: New Technology/SWL, Ureteroscopic or Percutaneous Stone Removal III1 Apr 20121825 OPERATION TIME AND POSTOPERATIVE SEVERE ADVERSE EVENTS IN URETERORENOSCOPIC LITHOTORIPSY Toru Sugihara, Hideo Yasunaga, Hiromasa Horiguchi, Hiroaki Nishimatsu, Akira Ishikawa, Haruki Kume, Shinya Matsuda, Kiyohide Fushimi, and Yukio Homma Toru SugiharaToru Sugihara Iwata, Japan More articles by this author , Hideo YasunagaHideo Yasunaga Tokyo, Japan More articles by this author , Hiromasa HoriguchiHiromasa Horiguchi Tokyo, Japan More articles by this author , Hiroaki NishimatsuHiroaki Nishimatsu Tokyo, Japan More articles by this author , Akira IshikawaAkira Ishikawa Tokyo, Japan More articles by this author , Haruki KumeHaruki Kume Tokyo, Japan More articles by this author , Shinya MatsudaShinya Matsuda Tokyo, Japan More articles by this author , Kiyohide FushimiKiyohide Fushimi Tokyo, Japan More articles by this author , and Yukio HommaYukio Homma Tokyo, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1913AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To our knowledge, there is no quantitative analysis to show the relation between operation time of ureterorenoscopic lithotripsy (URS) and its postoperative severe adverse events (sAE) such as urosepsis. In this study, we analyzed this correlation using the Japanese nationwide administrative claims database; the Diagnosis Procedure Combination (DPC) database. METHODS The DPC database contains information on diagnoses, medical resources/procedures, and discharge status. The database covered more than 40% (about 2.8 million in about 850 hospitals per year) of all acute care inpatient hospitalizations in Japan. As study samples, we extracted cases with a Japanese operation code K781 (URS for urolithiasis) during 2006-2010. In order to exclude cases whose preoperative status is emergency or irregular, ambulance users and delayed-operation cases (URS date > 2 business days since admission) were excluded. Adjusting variables are age, sex, Charlson comorbidity index and operative time. SAE were defined as i) morality; ii) medications comprised of anti-DIC drugs, gamma-globulin and catecholamine; and iii) interventions including an intensive care unit use, central intravenous catheterization, mechanical ventilation, dialysis and cardiac pumping support. Multivariate logistic regression analysis on sAE was performed. RESULTS Among 7323 URS cases, 179 sAE (2.4%) including 4 morality were detected. SAE incidences of operative time<60 minutes, 60-120, >120 were 1.5%, 2.4% and 4.5%, respectively. (Figure) Multivariate regression analysis on sAE resulted in as follow: female (odds ratio (OR), 1.64; p<0.01), age (p=0.37), Charlson comorbidity index (one point increment, OR, 1.26; p<0.01), operative time (30 min increment, OR 1.44; p<0.01). CONCLUSIONS SAE incidence increases in proportion to operative time. To set a certain limitation for URS operation time would be relevant for patient safety. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e737 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Toru Sugihara Iwata, Japan More articles by this author Hideo Yasunaga Tokyo, Japan More articles by this author Hiromasa Horiguchi Tokyo, Japan More articles by this author Hiroaki Nishimatsu Tokyo, Japan More articles by this author Akira Ishikawa Tokyo, Japan More articles by this author Haruki Kume Tokyo, Japan More articles by this author Shinya Matsuda Tokyo, Japan More articles by this author Kiyohide Fushimi Tokyo, Japan More articles by this author Yukio Homma Tokyo, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...