Hospital Admission Research Articles

IOT-Enabled Smart Healthcare: Developing Predictive Models for Chronic Disease Management Using Wearable Sensors

Abstract: Real-time monitoring and prediction models will be used to assess the efficiency of the IoT-enabled smart healthcare solutions in managing chronic diseases. From this study, in addition to the quantitative data, including the performance of the model, patient engagement, and cost savings, qualitative information obtained from the patients and healthcare professionals will be employed using a mixed-methods research approach. This collected rich data from surveys, performance measurements, real-time monitoring data, and cost analyses with 50 health professionals and 200 chronic disease patients. The results of the study indicate that predictive models, more particularly the Neural Network, enhanced the ability to identify cases of chronic illness with an accuracy of 92.4%. Extremely high patient satisfaction rates: 9.0 out of 10. Real-time monitoring shows hospital admissions falling by as much as 50% among those suffering with respiratory disease. Cost-benefit analysis also documented financial sustainability, with overall annual cost reduction at 43.3%. Soon after implementation, usage metrics also revealed that the average user uses it three times a day, while patient-provider interactions increased by 150%. This study highlights how IoT technologies would benefit patients' clinical conditions, improve chronic disease management, and save healthcare expenses.

The patient's medical home: A meta-analysis of case studies exploring its impact on patient outcomes

This meta-analysis investigates the impact of the Patient's Medical Home (PMH) model on healthcare delivery, focusing on quality of care, patient satisfaction, accessibility, and cost-effectiveness. Utilizing a comprehensive search across multiple databases, studies relevant to the PMH model were identified and analyzed, adhering to strict inclusion and exclusion criteria. The findings reveal significant improvements in the adherence to practice guidelines for chronic disease management, patient satisfaction scores, access to primary care services, and reductions in overall healthcare costs, with a notable reduction in emergency department visits and hospital admissions. Despite moderate heterogeneity among studies, indicating variability in PMH implementation, the analysis underscores the PMH model's potential to enhance healthcare delivery. This study contributes to the growing body of evidence supporting the PMH model's effectiveness in improving healthcare outcomes and efficiency, advocating for its broader adoption and adaptation across diverse healthcare settings. The research highlights the importance of addressing implementation challenges to fully realize the PMH model's benefits, marking a significant step towards patient-centered, sustainable healthcare reform.

A prospective study on etiology and clinical profile of chronic Cor pulmonale

Background: Cor pulmonale accounts for approximately 6% to 7% of all adult heart disease cases in the United States and is involved in 10% to 30% of hospital admissions for congestive heart failure nationwide. Materials and Methods: This prospective study was conducted at Al-Ameen Medical College and Hospital in Vijayapura, adhering to specific inclusion and exclusion criteria. The sample included 73 cases, with detailed medical histories and symptom analyses collected from each participant. A thorough clinical examination was also performed. Results: Among the 73 patients, 25 (34.3%) were aged 40 to 50 years, while another 25 (34.3%) were over 60 years. The majority were male (80.8%), and 50 patients (68.5%) had a history of smoking. All participants presented with symptoms of breathlessness, cough, and swelling of the feet. Physical examinations showed tachypnea, crepitations, and rhonchi in all individuals. Chronic bronchitis and emphysema were identified as the leading causes of chronic cor pulmonale in 44 patients (60.2%). Conclusion: This study found that chronic bronchitis and emphysema were common causes of chronic cor pulmonale, primarily affecting middle-aged and older individuals, with males affected more than females and smoking identified as a major contributing factor. Common symptoms included breathlessness, cough, and lower extremity swelling. Physical examinations frequently revealed tachypnea, crepitations, rhonchi, and notable signs such as epigastric pulsations, loud P2, pansystolic murmur of tricuspid regurgitation, and parasternal heave. Chronic cor pulmonale has a substantial impact on both pulmonary and cardiac function; 53.7% of patients are at risk of readmission within one year of discharge. The condition is generally associated with a poor prognosis. This highlights the importance of early detection of signs and symptoms to enhance management outcomes.

Low-Value Clinical Practices in Pediatric Trauma Care.

Reducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to interhospital variation; evidence on low-value practices in pediatric trauma care is lacking. To estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation. A retrospective multicenter cohort study in a Canadian provincial trauma system was conducted. Children younger than 16 years admitted to any of the 59 provincial trauma centers from April 1, 2016, to March 31, 2022, were included. Low-value practices were identified from systematic reviews of clinical practice guidelines on pediatric trauma. The frequencies of low-value practices were evaluated by estimating incidence proportions and cases per 1000 admissions (low if ≤10% and ≤10 cases, moderate if >10% or >10 cases, and high if >10% and >10 cases) were identified. Interhospital variation with intraclass correlation coefficients (ICCs) were assessed (low if <5%, moderate if 5%-20%, and high if >20%). A total of 10 711 children were included (mean [SD] age, 7.4 [4.9] years; 6645 [62%] boys). Nineteen low-value practices on imaging, fluid resuscitation, hospital/intensive care unit admission, specialist consultation, deep vein thrombosis prophylaxis, and surgical management of solid organ injuries were identified. Of these, 14 (74%) could be evaluated using trauma registry data. Five practices had moderate to high frequencies and interhospital variation: head computed tomography in low-risk children (7.1%; 33 per 1000 admissions; ICC, 8.6%), pretransfer computed tomography in children with a clear indication for transfer (67.6%; 4 per 1000 admissions; ICC, 5.7%), neurosurgical consultation in children without clinically important intracranial lesions (11.6%; 13 per 1000 admissions; ICC, 15.8%), hospital admission in isolated mild traumatic brain injury (38.8%; 98 per 1000 admissions; ICC, 12.4%), and hospital admission in isolated minor blunt abdominal trauma (10%; 5 per 1000 admissions; ICC, 31%). In this cohort study, low-value practices appeared to be frequent and subject to interhospital variation. These practices may represent priority targets for deimplementation interventions, particularly as they can be measured using routinely collected data.

How was the impact of heatwaves on daily hospital admissions in Portugal (2000-2018)?

Abstract Background Climate change has increased the frequency, intensity, and duration of heatwaves, posing a serious threat to public health. While the link between high temperatures and premature mortality has been extensively studied, the comprehensive quantification of heatwave impacts on morbidity remains understudied. Methods We assessed the relationship between heatwaves and daily hospital admissions at a county level in Portugal, considering all major diagnostic categories and age groups, over a 19-year period from 2000 to 2018. Our nationwide study included a comprehensive geospatial analysis, integrating over 12 million hospital admission records with heatwave events indexed by the Excess Heat Factor (EHF), covering all 278 mainland counties. To estimate the impact of heatwaves on hospital admissions, we applied negative binomial regression models at both national and county levels. Results A statistically significant overall 18·9% increase in daily hospital admissions was found during heatwave days (IRR=1·189, 95% CI: 1·179-1·198). This impact affected all age groups, with pediatric ages being the most affected (21·7%), followed by the working-age (19·7%) and elderly individuals (17·2%). All 25 Major Disease Diagnostic Categories experienced significant increases, particularly Burns (34·3%), Multiple Significant Trauma (26·8%), and Infectious and Parasitic Diseases (25·4%). Notable rises were also observed in Endocrine, Nutritional, and Metabolic (25·1%), Mental (23%), Respiratory (22·4%), and Circulatory (15·8%) diseases. Conclusions Our results provide statistically significant evidence of the association between heatwaves and increased hospitalizations across all age groups and for all major causes of disease. This is the first study to estimate the full extent of heatwaves’ impact on hospitalizations using the EHF index over a comprehensive 19-year period, encompassing an entire country, and spanning 25 disease categories during multiple heatwave events. Key messages • There is a clear association between heatwaves and increased hospital admissions across all age groups and Major Diagnostic Categories. • Our data offer crucial information to guide policymakers in effectively and efficiently allocating resources to address the profound healthcare consequences resulting from climate change.

Using Existing Clinical Data to Measure Older Adult Inpatients’ Frailty at Admission and Discharge: Hospital Patient Register Study

Background Frailty is a widespread geriatric syndrome among older adults, including hospitalized older inpatients. Some countries use electronic frailty measurement tools to identify frailty at the primary care level, but this method has rarely been investigated during hospitalization in acute care hospitals. An electronic frailty measurement instrument based on population-based hospital electronic health records could effectively detect frailty, frailty-related problems, and complications as well be a clinical alert. Identifying frailty among older adults using existing patient health data would greatly aid the management and support of frailty identification and could provide a valuable public health instrument without additional costs. Objective We aim to explore a data-driven frailty measurement instrument for older adult inpatients using data routinely collected at hospital admission and discharge. Methods A retrospective electronic patient register study included inpatients aged ≥65 years admitted to and discharged from a public hospital between 2015 and 2017. A dataset of 53,690 hospitalizations was used to customize this data-driven frailty measurement instrument inspired by the Edmonton Frailty Scale developed by Rolfson et al. A 2-step hierarchical cluster procedure was applied to compute e-Frail-CH (Switzerland) scores at hospital admission and discharge. Prevalence, central tendency, comparative, and validation statistics were computed. Results Mean patient age at admission was 78.4 (SD 7.9) years, with more women admitted (28,018/53,690, 52.18%) than men (25,672/53,690, 47.81%). Our 2-step hierarchical clustering approach computed 46,743 inputs of hospital admissions and 47,361 for discharges. Clustering solutions scored from 0.5 to 0.8 on a scale from 0 to 1. Patients considered frail comprised 42.02% (n=19,643) of admissions and 48.23% (n=22,845) of discharges. Within e-Frail-CH’s 0-12 range, a score ≥6 indicated frailty. We found a statistically significant mean e-Frail-CH score change between hospital admission (5.3, SD 2.6) and discharge (5.75, SD 2.7; P&lt;.001). Sensitivity and specificity cut point values were 0.82 and 0.88, respectively. The area under the receiver operating characteristic curve was 0.85. Comparing the e-Frail-CH instrument to the existing Functional Independence Measure (FIM) instrument, FIM scores indicating severe dependence equated to e-Frail-CH scores of ≥9, with a sensitivity and specificity of 0.97 and 0.88, respectively. The area under the receiver operating characteristic curve was 0.92. There was a strong negative association between e-Frail-CH scores at hospital discharge and FIM scores (rs=–0.844; P&lt;.001). Conclusions An electronic frailty measurement instrument was constructed and validated using patient data routinely collected during hospitalization, especially at admission and discharge. The mean e-Frail-CH score was higher at discharge than at admission. The routine calculation of e-Frail-CH scores during hospitalization could provide very useful clinical alerts on the health trajectories of older adults and help select interventions for preventing or mitigating frailty.

Impact of a clinician-to-clinician electronic consultation program in heart failure patients with previous hospitalization. Implications for heart failure multidisciplinary management

Abstract Background A clinician-to-clinician electronic consultation (e-consultation) programme may not only improve the accessibility to care but may also impact patient outcomes, particularly in heart failure (HF) patients with a previous episode of hospitalization (HFH), group of patients associated with a worse outcome. Purpose To evaluate the impact of an outpatient care management programme that includes a clinician-to-clinician e-consultation on delay time in care, hospital admissions, and mortality in a high-risk group of patients with heart failure (HF) and previous episodes of HF hospitalization (HFH). Materials and methods We selected 6444 HF patients who visited the cardiology service at least once between 2010 and 2021. Of these, 4146 were attended in e-consultation, and 2230 had previous HFH (Fig 1a). Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the healthcare model in the group of patients with HFH and evaluated the elapsed time to cardiology care, HF, cardiovascular (CV), and all-cause hospital admissions and mortality, calculating the incidence relative risk (iRR). We performed a multivariate logistic regression for each of these outcomes in both groups. Results Patients with HFH had a higher prevalence of men (P &amp;lt; 0.001) but had a similar age (P = 0.267) compared to patients without HFH. Patients with HFH had a higher prevalence of diabetes (P &amp;lt; 0.001), ischaemic heart disease (P = 0.036), and peripheral arterial disease (P = 0.008) (Fig 1b). In the group of patients with HFH, the introduction of e-consult substantially decreased waiting times to cardiology care (8.6 [8.7] vs. 55.4 [79.9] days, P &amp;lt; 0.001) (Fig 2a). In that group of patients, after e-consult implantation, hospital admissions for HF were reduced (iRR [95%CI]: 0.837 [0.840–0.833]), 0.900 [0.862–0.949] for CV and 0.699 [0.678–0.726] for all-cause hospitalizations (Fig 2b). There was also lower mortality (iRR [95%CI]: 0.715 [0.657–0.798] due to HF, 0.737 [0.764–0.706] for CV and 0.687 [0.652–0.718] for all-cause) (Fig 2c). The improved outcomes after e-consultation implementation were significantly higher in the group of patients with previous HFH. The multivariate analyses showed a higher risk of hospitalizations in men, patients with HFH, and those who required more emergency department assistance (Fig 2d). Conclusions In patients with HFH, an outpatient care programme that includes an e-consultation significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year. Our results may have implications for optimize the heart failure care organization.Figure 1Figure 2

Increased frailty is associated with risk of hospital-acquired infections and death during heart failure hospital admissions

Abstract Background Frailty is common in patients admitted with acute decompensation of heart failure (ADHF) and it is unclear how the frailty syndrome affects heart failure (HF) patients during their acute hospital admission. Understanding the interplay between frailty, impaired renal function, hospital-acquired infections (HAI), and death may be useful in optimising patient care and prognosis. Purpose The aim of this analysis was to explore the relationship between admission frailty levels and the incidence of HAI, acute kidney injury (AKI), and mortality in acute HF hospital admissions. Methods This is a retrospective analysis of data submitted from a single centre to the National HF audit between January and June 2023. Additional frailty and baseline renal function data was retrospectively collected from electronic patient health records. Patients were categorised into three groups according to their Rockwood Clinical Frailty Scale (CSF) (1): no/mild frailty (CFS 1-3), moderate frailty (CFS 4-6) and severe frailty (CFS 7-9). AKI was defined based on baseline and admission creatinine, as per KDIGO guidelines (2). Chi-squared and t-tests were used to compare baseline characteristics between frailty groups. Chi-squared tests were used to compare frailty groups in terms of: HAI, AKI, mortality. Results Between 1st January and 22nd June 2023, there were 344 acute HF hospital admissions in our centre. Most patients had moderate frailty on admission (n=256, 74.4%). Frail patients were significantly older, had a lower admission mean haemoglobin and more were female, compared to non-frail patients (Figure 1A). Patients who were more frail were more likely to experience HAI during their admission; p=0.035 (figure 1B). Furthermore, patients with HAI had a greater risk of mortality, at a median follow-up of 171 (IQR 100.25) days after admission, compared to those without HAI (p&amp;gt;0.001). 41.9% of acute HF admissions were associated with an AKI, and although numerically more frail patients had an AKI, this did not achieve statistical significance (p=0.084). Patients who were more frail were more likely to die, both during hospital admission and at 3 months following discharge; p&amp;lt;0.001 (Figure 1B). Furthermore, this trend persisted after follow-up; p&amp;lt;0.001 (Figure 2). Conclusions Patients with moderate or severe frailty are at greater risk of adverse events (HAI, death) during an acute HF hospital admission, than patients with no or mild frailty. It is imperative to consider the frailty status of all patients with ADHF, to be aware of the frailty-associated risks, and act proactively with targeted interventions (screen for infections, daily bloods, early conversations with patients and their families about treatment escalation plans and patient priorities) to improve outcomes and enhance the quality of care for this vulnerable patient population. Further research is warranted to explore potential interventions to address frailty-related risks in HF management.

Insights from a hospital database: injuries among children under 6 years old due to falls

Abstract Background Pediatric injuries represent a significant public health concern globally, contributing to substantial morbidity and mortality among children. In Georgia, limited data exists regarding pediatric injuries. The aim of the study was to analyze epidemiological characteristics and trends of pediatric injuries among children aged under 6 years who received treatment in hospitals across whole country. Methods NCDC hospitalization database for 2015-2022 was used for the study. Results Over the study period, a total of 5979 children under the age of 6 received treatment in all hospitals across Georgia. The highest number of hospital admissions were registered in 2019. 60% were boys and 40% were girls of the hospitalized patients. Boys were predominant across all age groups, with the highest proportion among children aged 5 years old. There was a significant variation in hospital admissions according to the seasons, with the highest admissions occurrence in summer. As for the cause of admission, 37% resulted from falls on the same level, 10% from falls between different levels, 7% involved falling from a bed, 4% from falling out or through a building, and 4% from falling down stairs. The cause of falls was unspecified in 23%. In 72% of cases, the injured body part was the head, 17% were upper extremity injuries, and 7% were lower extremity injuries. Of the patients, 90% recovered, 2% discontinued treatment, 8% were transferred, and the outcome was fatal for 0.23% of patients. Among the fatal cases, 36% resulted from falls from, out of, or through a building, 29% from falls between different levels, 14% from falling or jumping, 7% from falls involving a bed, and 7% from falls on the same level. Conclusions These findings underscore the importance of preventive measures, especially regarding fall prevention, to reduce the incidence of pediatric injuries in Georgia. Key messages • There was a significant variation in hospital admissions according to the seasons, with the highest admissions occurrence in summer. • These findings underscore the importance of preventive measures, especially regarding fall prevention, to reduce the incidence of pediatric injuries in Georgia.

Clinical characteristics and outcomes of patients presenting with acute coronary syndromes and suspected plaque erosion

Abstract Background Plaque erosion (PE) is the second most common pathology of acute coronary events after plaque rupture. PE is characterized by endothelial denudation and formation of neutrophil extracellular traps. Patients with PE may have a different prognosis as compared to those with plaque rupture. Specific clinical and laboratory predictors were validated to suspect PE among acute coronary syndrome (ACS) patients. Purpose The objectives of this study were to compare both clinical and laboratory findings, and outcomes of ACS patients with high probability of PE and those with less likely PE. Methods Six hundred ninety-six ACS patients were divided into two groups (suspected PE vs less likely PE) based on 5 reported predictors of PE. The predictors were: age &amp;lt;68, anterior ischemia, no diabetes mellitus, hemoglobin &amp;gt;15 g/dL and normal renal function (eGFR&amp;gt; 60 ml/min) as assessed at hospital admission. Patients with 4 or 5 of these 5 predictors were included in the suspected PE group, while patients with 0 or 1 entered less likely PE group. Baseline clinical features and laboratory analyses at hospital admission were compared between the two groups. Major adverse cardiac events (MACE), defined as death from any cause, non-fatal myocardial infarction or unplanned revascularization, were compared between the two groups at 20 months after hospital discharge. Results Among 696 patients, 283 (41%) composed the suspected PE group, while 413 (59%) entered into less likely PE group. The suspected PE group had a higher prevalence of current smokers and had a higher BMI. They showed higher values of both LDL cholesterol and triglycerides, while C-reactive protein and fibrinogen levels were significantly lower. The suspected PE group showed a higher frequency of single vessel disease (Table). The suspected PE group showed a significantly lower rate of MACEs at 20 months (7.4% vs 28.8%, p=0.0001) as well as death from any cause was significantly lower (2.1% vs 24.9%, p=0.0001). The median time from the index ACS episode to recurrent myocardial infarction or unplanned coronary revascularization tended to be longer in the suspected PE group as compared to the less likely PE group (15 months [9-20] vs 9 months [6-13], p=0.062) (Figure). Conclusions In a cohort of ACS population, the suspected PE group showed distinctive clinical characteristics with less coronary plaque burden and low grade of systemic inflammation. The suspected PE group had a better prognosis at 20-month follow-up time with a significantly lower rate of death from any cause, and non-fatal coronary events tended to occur later.Table.Baseline characteristicsFigure.Non fatal coronary events

National Early Warning Score 2 to Predict ICU Admission of COVID-19 Patients in Bangladeshi Cohort

Objective: To assess the predictive accuracy of the National Early Warning Score 2 (NEWS 2) for early prediction of clinical deterioration (ICU admission) of COVID-19- infected patients in Bangladesh. Methods: Data from 244 patients with COVID-19 infection admitted from July 2021- September 2021, to the Aichi Hospital Ltd, Bangladesh, were retrospectively reviewed. Consecutive adult patients with laboratory-confirmed COVID-19 initially admitted to non- ICU wards were included. Categorical and quantitative variables were expressed as numbers (percentages) and median (interquartile range, IQR). We evaluated the predictive performance of NEWS2 to predict ICU admission by comparing the area under the receiver operating characteristics curve (AUROC) at thresholds 5 and 7 and assessed its association with ICU admission by performing multivariate logistic analyses. STATA conducted all the statistical analyses. Results: Among the included 218 patients, 68 patients were transferred to ICU. The AUROC was 0.96 (Standard error 0.01, 95% confidence interval 0.93-0.98), revealing that NEWS2 at hospital admission was a good predictor of ICU admission. A NEWS2 threshold of 5 had higher sensitivity than a threshold of 7 (72.06% and 29.41%). A point of 7 also had high specificity (99.33% and 63.33%) and a high positive predictive value than a threshold of 5 (95.24% vs. 47.12%). The NEWS2 entries 5 and 7 were related to ICU admission found in multivariate logistic regression analysis. Conclusion: Our results suggest that NEWS2 at hospital admission is a good predictor for ICU admission of COVID-19 patients in Bangladesh. Screening patients at admission with this tool may identify patients at risk of clinical deterioration and help in better management. EWMCJ Vol. 12, No. 1&amp;2, January-July 2024: 60-65

Myocarditis prognostic score: a new risk assessment tool in patients with myocarditis

Abstract Background Myocarditis is an inflammatory disease of the myocardium with multiple causes and evolutions. The aim of our study was to design a prognostic multiparametric score in patients with myocarditis, to identify those at higher risk of adverse cardiovascular events (AE). Methods A prospective study was performed enrolling 98 patients with myocarditis: 72 M, 26 F; median age 27 [IQR 20–40]. Patients were divided into 2 groups: complicated (CM) and uncomplicated myocarditis (UM). Six months after hospital admission, cardiac magnetic resonance (CMR) and cardiological consultation were repeated. AE (death, hospitalization for heart failure, heart transplant, ICD implantation, heart failure development) were evaluated at 6 months and after 3 years. Results We found 67 UM and 31 CM. AE were significantly higher in patients with complicated myocarditis. We found a significant correlation between AE and reduced left ventricular ejection fraction (LVEF) at hospital admission, increased GLS, septal LGE at CMR, longer persistence time of increased troponin, LGE extension progression or persistence 6-month CMR. A myocarditis prognostic score was developed on the basis of these parameters. A score ≥ 5 showed higher sensitivity (100%) and specificity (87%) - AUC 1, to identify AE in patients with myocarditis. A score between 3 and 4 showed high sensitivity but low specificity. A score ≤ 2 was associated with low probability of events. Conclusion Our study confirms the high probability of AE in patients with CM and it suggests a myocarditis prognostic score to identify patients at higher risk of AE.

Value-based versus usual care for heart failure patients leads to reduction in cost, hospital admissions and improved survival

Abstract Background OptumCare (OC) in our city, Nevada established a heart failure (HF) program comprised of a team of outpatient cardiologists including two who are board certified in advanced heart failure. Referred patients are enrolled in the HF program once HF is diagnosed by a cardiologist. Patients are managed by an interdisciplinary team of cardiologists, advanced practice clinicians (APC), registered nurse case managers (RNCM), and a social worker. Patients at higher risk for HF admissions are enrolled in remote patient telemonitoring. In contrast, OC in Arizona utilizes a "usual" care approach of fee-for-service contracted cardiology groups to manage HF patients in outpatient and in-patient settings. Purpose A head-to-head comparison was performed between the cohort of patients enrolled in HF program in OC Nevada (treatment group) and patients with HF diagnosis in OC Arizona (control group). The groups were compared on the following measures: medical cost, hospital admissions, and survival rates. Methods In this retrospective study, a 1:1 iterative propensity score (PS) matching was performed to closely approximate patient demographics and comorbidities, which resulted in 818 matched pairs (total n=1,636) of the patients with program enrollment or 1st HF diagnosis between March 1, 2019 and June 30, 2022. For Difference-in-Difference Analysis (Diff-in-Diff), generalized linear models were used on PS matched data to test the difference in difference in medical cost and utilizations changes between control and treatment group over a six month period. Log-Binomial regression was used to estimate the relative risk of post period 30-day readmission and hospice enrollment. Kaplan Meier Estimator was used to test the difference in survival rates over time. Results Average age of patients was 77.6 years old, and 49% were female. The treatment group resulted in significantly lower overall medical costs per member per month (PMPM), significantly less emergency room (ER) visits, less acute hospital and skilled nursing facility (SNF) admissions, and shorter overall hospital length of stays. The control group was twice as likely to be readmitted to the hospital. Lastly, the treatment group had a significantly better survival rate than the control group. 19% of the patients in the control group expired within 12 months of enrollment vs. 10% of the patients in the treatment group expired during the same time period. Average survival was 142 days in the control group vs. 200 days in the treatment group. Conclusions A value-based care approach involving a multidisciplinary team in an outpatient-based cardiology HF program resulted in statistically significant improvement in medical costs, acute care visits/admissions, and survival rates compared to "usual" care approach for HF patients.

Electronic consultation from primary care to a cardiology department improves outcomes in patients with cancer

Abstract Background The number of cancer patients with known cardiovascular (CV) disease is increasing due to improved cancer prognosis. Purpose The objective of this study is to assess the long-term results of cancer patients referred to a cardiology department by primary care using electronic consultation (e-consultation). Methods We analysed the patients with previous diagnosis of cancer referred to a cardiology department (CD) from 2010 to 2021 (n=6.889), selected from a total of 68.518 patients (61.629 without cancer), and compared two assistance models: in-person practice (from 2010 to 2012) and e-consultation (from 2013 to 2021). In the first period, all the patients referred by primary care physicians (PCPs) were seen in an in-person consultation and in the e-consultation model the cardiologist reviewed the electronic records (e-consultation) and decided to solve without any visit or, if it was necessary, with an in-person consultation. The outcomes between both periods were analysed using an interrupted time series regression model: 1) delay time to cardiology assistance; 2) all-cause and cardiovascular hospital admissions, and 3) all-cause and cardiovascular mortality during the first year after the initial consultation or e-consultation to the CD. Results Among cancer patients referred to cardiology consultation, the introduction of e-consultation decreased waiting times to cardiology care by 51,8% (95% CI: 51,7%-51,9%) (Fig 1). Over 60% of referrals were resolved in less than 8 days, with this proportion significantly higher after the e-consultation program was introduced (p&amp;lt;0,001). Furthermore, we observed a reduction in the one-year rate of outcomes, with an incidence rate ratio (iRR) [IC 95%] of 0,75 [0,73-0,77] for CV-related hospitalizations (Fig 2b), 0,43 [0,42-0,44] for all-cause hospitalization (Fig 2a), and 0,87 [0,86-0,88] for all-cause mortality. In the multivariate analysis, the delay in receiving cardiology care was significantly associated with an independent increase in 1-year mortality (OR [95% CI] 1,39 [1,06-1,83]) and hospital admission (OR [95% CI] 1,25 [1,02-1,52]). Furthermore, the implementation of the e-consult model was associated with a reduction in hospital admission rates (OR [95% CI] 0,19 [0,14-0,25]). Conclusions In comparison to the in-person consultation period, an outpatient care program that incorporates e-consultation for cancer patients significantly reduced waiting times for cardiology care and shown to be safe, associated with lower rates of hospital admissions.Figure 1Figure 2

What does routine healthcare data tell us about the diagnostic pathway for older people with heart failure in Wales: under-testing, problems with access, or poor coding?

Abstract Background United Kingdom guidelines (NICE, NG106) for suspected chronic heart failure (HF) recommend that NT pro-BNP is performed as a first-line test. The result is also used to triage individuals; when NT pro-BNP is &amp;lt;400ng/L, a diagnosis of HF is less likely, echocardiography (echo) and specialist assessment should be performed within 6 weeks when the result is 400-2000ng/L, and within 2 weeks if &amp;gt;2000ng/L. How accurately this guidance is followed in clinical practice in Wales is not known. Purpose To examine how the current diagnostic pathway is recorded in routinely-collected electronic health record (EHR) data for older people in Wales with a diagnosis of heart failure. Methods We conducted a retrospective, population-level, observational study using linked anonymised EHR data in Wales (2015-22). We included patients aged 65y+ with a HF diagnosis in their primary or secondary care records and with a minimum of 12m pre and post-diagnosis data (for assessment of diagnostic pathway). We looked back from the point of HF diagnosis for codes associated with prior cardiovascular conditions (any time prior), symptoms (within 3 years), and key diagnostic tests (within 90 days). Results The final cohort comprised 51,020 individuals 65y and over with a diagnosis of heart failure between 2015-2022. Incidence and prevalence of heart failure increased across the study period (1.4-1.5% and 8.5-9.1% respectively). HF diagnosis was first evident in secondary care records in 54.9%, in primary care 36.3%, and in both data sources on the same day in 8.8%. Preceding cardiovascular diagnoses included hypertension (69.5%), atrial fibrillation (36.7%), myocardial infarction (30.5%), coronary artery disease (25.7%), and valve disease (17.7%). The most common recorded symptoms preceding diagnosis were breathlessness (41.4%), ankle oedema (9.8%), and fatigue (8.8%). Searched for symptoms were not recorded in 43.8%. In the 90 days preceding the diagnosis, 7-30% had recorded NT pro-BNP with the number of tests increasing throughout the study period (Figure 1). In the 90 days prior to HF diagnosis, 28-31% had an echo recorded. NT pro-BNP was &amp;gt;2000ng/L in 51.8%, 400-2000ng/L in 38.6% and &amp;lt;400ng/L in 9.6%. Conclusions In Wales, a greater number of individuals with heart failure appear to be diagnosed during hospital admission, compared with primary care. Many individuals with a code for HF in their records, do not have recorded objective evidence of cardiac dysfunction. The proportion of first-line and definitive tests appears low. It is unclear whether this is because of under-referral, difficulty accessing tests in primary care, or inaccurate coding of test referrals and results. These results are important in evaluating health service delivery and workforce planning.

Risks of high temperature exposure on infectious diseases in Portuguese hospitals

Abstract Background The convergence of climate change and infectious diseases presents a growing public health challenge. As global temperatures continue to climb, the geographical spread of climate-sensitive diseases is shifting, underscoring the necessity for comprehensive early warning systems grounded in a One Health framework. Methods This retrospective observational study analyzed daily maximum temperature from May to September, between 2000 and 2018, in mainland Portugal, at a county level, obtained from a European-level gridded observations dataset. Hospital admissions with a primary diagnosis of infectious and parasitic diseases were sourced from the Hospital Morbidity Database. A distributed lag non-linear model was developed to estimate the immediate and lagged relative risks (RR) of temperature exposure on admissions, focused on a lag of 10 days. Results Our research reveals a 16% (95% CI: 9% - 23%) rise in the RR of hospital admissions due to infectious and parasitic diseases after exposure to extremely high temperatures (39 °C). This elevated risk persists for up to 2 days following exposure, with the second day exhibiting the largest increase at 53% (31% - 80%). Furthermore, our findings indicate a subsequent resurgence in RR, reaching 6% (2% - 11%) 9 days after exposure. Conclusions Our results highlight a short-term effect of extreme temperature exposure on infectious and parasitic disease admissions. This data provides valuable insights to guide policymakers in identifying critical periods of vulnerability and implementing this knowledge into heat early warning systems, contributing to developing effective public health strategies against climate change. Acknowledgments The authors thank Fundação para a Ciência e a Tecnologia (FCT, Portugal) for research grant UIDP/04923/2020 and NOVA National School of Public Health for access to the Hospital Morbidity Database made available for research purposes by Administração Central do Sistema de Saúde, IP (ACSS). Key messages • Exposure to extremely high temperatures increases the risk of admission due to infectious and parasitic diseases by 16%, with a peak occurring two days after exposure. • This data is essential for policymakers to identify and integrate vulnerable periods into early heat warning systems, enhancing effective public health strategies against climate change.

Increased miRNA-related inflammation markers and pro-inflammatory circulating cell profile in patients with poor neurological outcome after out-of-hospital cardiac arrest

Abstract Background Out-of-Hospital Cardiac Arrest (OHCA) supposes a main cause of disability and mortality worldwide. Between patients suffering OHCA, only a 10-20% can be successfully resuscitated and, between them, a 50% suffers of neurological sequelae. Mechanisms underlying brain damage seems to be strongly related with neuroinflammation, mediated by classical (PCR, NLR) and novel (miRNAs) agents at play. Even there are studies suggesting the relevance of miRNA-mediated inflammatory response in ECA, no consistent conclusions about its role in ECA outcomes have been obtained. Purpose The aim of the present investigation is to study the temporal patterns of classical (PCR, NLR) and novel (miRNAs) inflammation markers during hospitalization of ECA patients and to correlate them with neurological outcome. Methods Consecutive OHCA patients were prospectively recruited at the Acute Cardiac Care Unit (ACCU) of the hospital Clinic of Barcelona from March 2019 to December 2023. Serum samples were obtained at 0, 24 and 72 hours after hospital admission. Patients were grouped according to their neurological outcome, measured by Cerebral Performance Category (CPC), at hospital discharge. Classical inflammation markers (PCR and NLR) were measured and in silico pre-targeted serum circulating-miRNAs were analysed by qPCR. Results A total of 120 patients (60 ± 13 years, 20% female) were included for the analysis. At hospital discharge, 55 (45%) patients survived with good NO (GNO; CPC 1-2) and 65 (55%) patients presented a poor NO (PNO; CPC 3-5). Classical inflammation markers such as PCR and NLR were significant higher in PNO than in GNO Group (P-value = 0.0042 and p-ANOVA = 0.0444, respectively) (Figure 1A). 11 inflammation-related miRNAs with strong correlation with OHCA-related conditions such as cardiovascular and coronary artery disease, hypoxic encephalopathy and neuro-inflammation were pre-targeted by in silico analysis. Five of the pre-targetedmiRNAs (miR-21-5p, miR-23a-3p, miR-146-5p, miR-155-5p and miR-181a-5p) presented significant differences between GNO and PNO groups (p-ANOVA = 0.0001, 0.0027, 0.0001, 0.0023 and 0.0002 respectively) in at least one time point, with an reduced expression in all cases in the PNO respect the GNO group (Figure 1B). Conclusions Patients with PNO after OHCA presents a downregulation of inflammation-regulatory miRNAs that leads an increase of clinical inflammation-related mediators such as PCR and NLR, with potential neuro-inflammatory consequences.

Assessing one-year risk of heart failure following first time myocardial infarction and subsequent five-year mortality risk: a nationwide study of 34,401 patients

Abstract Introduction A comprehensive understanding of the post-myocardial infarction (MI) trajectory leading to heart failure (HF) and its profound impact on long-term mortality is imperative for effective secondary prevention and risk assessment. Methods We conducted a registry-based nationwide cohort study of all Danish patients with a first MI during 2014 to 2020. Excluding patients with prior HF, individuals were followed for one year post-MI, assessing HF incidence through hospital admissions and visits to elective HF ambulatory clinics. Among those who survived one year, long-term mortality 1-6 years post-index MI was assessed using landmark analysis and Cox proportional hazards models adjusting for age, gender and comorbidities and hazard. Patients were categorized into three groups: not HF, referred for elective HF outpatient follow-up, and acute admission for HF. Results Among 34,301 individuals with a first MI and surviving the first year (median age 67.5, and 66.9 % male), 3.3 % were admitted acute for HF while 11.2 % had an elective HF outpatient follow-up within one year of the MI event (see Figure 1a). We observed a significant association between acute HF admissions post-MI and increased five-year mortality risk (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.40-1.90, p-value &amp;lt;0.001, see Figure 1b) (absolute 5-year risk: 18.4 %). In contrast, the five-year mortality risk for patients with elective outpatient HF follow-up was comparable to that of individuals without HF (HR 1.06 [0.94-1.19], p-value 0.34) (absolute 5-year risk: 9.6 vs 8.5 %). Conclusion Our findings suggest that acute admission for HF after a first time MI occur in 3.3 % of the patients with a subsequent significantly increased mortality risk compared to patients that do not develop clinical HF. Admission for HF in patients with a first time MI should be considered as a relatively rare but fatal complication.

N-terminal prohormone of brain natriuretic peptide predicts recurrent cardiovascular events in patients with acute coronary syndrome both in the acute and post-discharge setting: a TRACER substudy

Abstract Background N-terminal prohormone of brain natriuretic peptide (NT-proBNP) is a circulating peptide released by the heart in response to increased wall tension and stretching, for example, occurring during myocardial and/or atrial dysfunction. NT-proBNP is a diagnostic and prognostic marker in patients with heart failure but might also have prognostic utility in the acute phase of patients with acute coronary syndrome (ACS) and at one month after ACS. Purpose To assess the prognostic value of NT-proBNP over time in patients with ACS both in the acute setting and when re-assessed after one month. Methods The TRACER study randomized 12,944 patients with non-ST-segment elevation ACS (NSTE-ACS) to treatment with vorapaxar vs. placebo. Plasma samples for biomarker analyses were obtained at randomization (median 21 hours after hospital admission) in 6,800 patients and at an outpatient visit after one month in 5,313 patients. NT-proBNP was analysed using the Elecsys electrochemiluminescence immunoassays method. The primary composite endpoint in this substudy was the one-year risk of cardiovascular (CV) mortality, myocardial infarction, or ischaemic stroke. Associations between continuous natural log-transformed NT-proBNP levels and outcomes were assessed using Cox regression models accounting for study treatment and established risk factors. Results The median concentration of NT-proBNP during hospitalization for ACS and after one month was 496 ng/L and 264 ng/L, respectively. Higher age, female sex, a history of heart failure, and lower body mass index were independently associated with higher levels of NT-proBNP among patients in the acute setting, with renal disease also being an important factor after one month. The composite outcome of CV mortality, MI, or ischaemic stroke occurred in 901 patients (incidence rate 10.1 per 100 person-years) included at baseline and in 381 patients (incidence rate 5.4 per 100 person-years) included at one month. Higher circulating levels of NT-proBNP were independently associated with a higher risk of the composite endpoint at baseline (adjusted hazard ratio with 95% confidence interval comparing the third vs. the first sample quartile: 1.25 [1.03 – 1.51]) and at one month (1.56 [1.15 – 2.11]) (Figure 1 and 2). Incorporating NT-proBNP at baseline into a model with other established risk factors increased the concordance index of the multivariable model from 0.656 to 0.660 (p &amp;lt; 0.001), and after one month, from 0.711 to 0.733 (p &amp;lt; 0.001). These findings remained consistent across the various components of the composite endpoint. Conclusions In patients with ACS, the level of NT-proBNP is an indicator of increased risk of CV outcomes both in the acute setting and, even more pronounced, one month after the index ACS. Measuring NT-proBNP provided incremental prognostic information beyond established risk factors, both in the acute and post-discharge settings.Fig 1.NT-proBNP quartile groupsFig 2.NT-proBNP and CV outcome

8.E. Skills building seminar: Methods for measuring the true health cost of pollution

Abstract Healthy environments are essential for physical and mental wellbeing. Air pollution is considered to be one of the most significant environmental risk factors for ill health and premature death within the European Union. Poor air and noise quality have been linked to the exacerbation of symptoms, hospital admissions, and even premature deaths, especially for those with cardiorespiratory diseases. The associated medical costs and productivity losses therefore also impose a large economic cost. Exposure to environmental stressors disproportionately affects socially disadvantaged groups, and therefore contributes to the large socioeconomic inequities in health observed persistently in Europe. The EU has prioritised action on causes of pollution. For example, its Green Deal outlines ambitious plans to address climate challenges such as pollution and align air quality ambitions closer to the World Health Organization guidelines. Likewise, the European Environmental Agency routinely monitors the mortality burden associated with air pollution, while the impact of environmental noise on European citizens is examined through the Environmental Noise Directive. While in the political scene there is interest to advance the reduction of pollution, efforts are hindered by the lack of an harmonized methodology to quantify the socioeconomic cost of environmental stressors. Currently, researchers working with the burden of disease framework face many challenges in its application in the context of environmental stressors. Among others, these challenges include unmet data needs and major lack of transparency in methodological developments. In this skills-building seminar, we will outline an integrated approach for measuring the true health cost of pollution. This approach is currently being trialled in the EU-funded BEST-COST project, which sets out to improve methodologies for understanding the socioeconomic cost of environmental stressors, focusing on air and noise pollution. The project brings together a consortium of 17 partners from Europe and the USA, and is led by Sciensano, the Belgian institute for health. Through a synergy of theoretical outlines and real-life examples, seminar participants will gain methodological insights in the three key components of this integrated approach - i.e., the quantification of the health burden of environmental stressors via comparative risk assessment, the monetization of Disability-Adjusted Life Years to assess economic impact, and the quantification of environmental health inequalities via a novel area-level based framework. Key messages • There are significant unmet needs with respect to both data and methodologies for quantifying the socioeconomic cost of environmental stressors. • We outline an integrated approach for measuring the true health cost of pollution, combining health burden, economic burden, and environmental health inequalities.