Differences In Admission Rates Research Articles

Outcomes of hyperglycemia in patients with and without diabetes hospitalized for infectious diseases.

To examine the prognostic implications of diabetes mellitus (DM) and the importance of glycemic control during hospitalization for infectious diseases. Historical prospectively collected data of patients hospitalized between 2011 and 2013. Infection-related hospitalizations were classified according to site of infection. Median follow-up was 4.5years. Outcome measures included in-hospital and end-of-follow-up mortality. The cohort included 8051 patients (50% female, mean age±SD, 68±20years) with a primary diagnosis of an infectious disease. Of these, 2363 patients (29%) had type 2 DM. The most common infectious sites included respiratory tract (n=3285), genitourinary tract (n=1804), skin and soft tissue (n=934) and gastrointestinal tract (n=571). There was no difference in admission rates of patients with and without DM according to the site of infection, except for skin and soft tissue infection which were more common among patients with DM (16% vs 10%). In-hospital mortality risk was greater in patients with DM (aOR=1.3, 95% CI=1.1-1.7). In the entire cohort, adjusted mortality risk (aHR, 95% CI) at the end-of-follow-up was greater among patients with DM (1.2, 1.1-1.4), with increased mortality risk following hospitalization for respiratory (1.1, 1.0-1.4) and skin and soft tissue infections (1.7, 1.3-2.3). In-hospital and end-of-follow-up mortality risk were highest among patients with and without DM with median glucose >180mg/dL during hospitalization. In patients hospitalized for infectious diseases, DM is associated with increased long-term mortality risk, specifically following hospitalization for respiratory and skin and soft tissue infections. Poor glycemic control during hospitalization is associated with increased long-term mortality.

Size and clustering of ethnic groups and rates of psychiatric admission in England.

There was an eightfold difference in admission rates between ethnic groups for schizophreniform and mania admissions, and a fivefold variation in depression admissions. On average, Black and minority ethnic (BME) groups had higher rates of admission for schizophreniform and mania admissions but not for depression. This increased rate was greatest in the teenage years and early adulthood. Larger ethnic group size was associated with lower admission rates. However, greater clustering was associated with higher admission rates.Clinical implicationsOur findings support the hypothesis that larger ethnic groups have lower rates of admission. This was a between-group comparison rather than within each group. Our findings do not support the hypothesis that more clustered groups have lower rates of admission. In fact, they suggest the opposite: groups with low clustering had lower admission rates. The BME population in the UK is increasing in size and becoming less clustered. Our results suggest that both of these factors should ameliorate the overrepresentation of BME groups among psychiatric in-patients. However, this overrepresentation continues, and our results suggest a possible explanation, namely, changes in the delivery of mental health services, particularly the marked reduction in admissions for depression.Declaration of interestNone.

A Population-Based Study Evaluating Differences in Admission Rates and Outcomes Between Men and Women Presenting to Emergency Departments with a Primary Diagnosis of Syncope

Syncope is a common reason for Emergency Department (ED) visits. It is currently not known whether sex-differences exist in the management and outcomes of patients who present to the ED with syncope.

Impact of the HEART Pathway on Admission Rates for Emergency Department Patients with Chest Pain: An External Clinical Validation Study

BackgroundChest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful. ObjectiveTo compare admission rates prior to and after implementation of an accelerated disposition pathway for ED patients with low-risk chest pain based upon the HEART (History, ECG, Age, Risk factors, Troponin) score (HEART pathway). MethodsWe conducted an impact analysis of the HEART pathway. Patients with a HEART score ≥ 4 underwent hospital admission for cardiac risk stratification and monitoring. Patients with a HEART score ≤ 3 could opt for discharge with 72-h follow-up in lieu of admission. We collected data on cohorts prior to and after implementation of the new disposition pathway. For each cohort, we screened the charts of 625 consecutive chest pain patients. We measured patient demographics, past medical history, vital signs, HEART score, disposition, and 6-week major adverse cardiac events (MACE) using chart review methodology. We compared our primary outcome of hospital admission between the two cohorts. ResultsThe admission rate for the preintervention cohort was 63.5% (95% confidence interval [CI] 58.7–68.2%), vs. 48.3% (95% CI 43.7–53.0%) for the postintervention cohort. The absolute difference in admission rates was 15.3% (95% CI 8.7–21.8%). The odds ratio of admission for the postintervention cohort in a logistic regression model controlling for demographics, comorbidities, and vital signs was 0.48 (95% CI 0.33–0.66). One postintervention cohort patient leaving the ED against medical advice (HEART Score 4) experienced 6-week MACE. ConclusionsThe HEART pathway may provide a safe mechanism to optimize resource allocation for risk-stratifying ED chest pain patients.

Gender differences in hospital admissions for major cardiovascular events and procedures in people with and without diabetes in England: a nationwide study 2004\u20132014

BackgroundSecondary prevention of cardiovascular disease (CVD) has improved immensely during the past decade but controversies persist on cardiovascular benefits among women with diabetes. We investigated 11-year trends in hospital admission rates for acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in people with and without diabetes by gender in England.MethodsWe identified all hospital admissions for cardiovascular disease causes among people aged 17 years and above between 2004 and 2014 in England. We calculated diabetes-specific and non-diabetes-specific rates for study outcomes by gender. To assess temporal changes, we fitted negative binomial regression models.ResultsDiabetes-related admission rates remained unchanged for AMI (incidence rate ratio (IRR) 0.99 [95% CI 0.98–1.01]), increased for stroke by 2% (1.02 [1.01–1.03]) and PCI by 3% (1.03 [1.01–1.04]) and declined for CABG by 3% (0.97 [0.96–0.98]) annually. Trends did not differ significantly by diabetes status. Women with diabetes had significantly lower rates of AMI (IRR 0.46 [95% CI 0.40–0.53]) and stroke (0.73 [0.63–0.84]) compared with men with diabetes. However, gender differences in admission rates for AMI attenuated in diabetes compared with the non-diabetic group. While diabetes tripled admission rates for AMI in men (IRR 3.15 [95% CI 2.72–3.64]), it increased it by over fourfold among women (4.27 [3.78–4.93]). Furthermore, while the presence of diabetes was associated with a threefold increased rates for PCI and fivefold increased rates for CABG (IRR 3.14 [2.83–3.48] and 5.01 [4.59–5.05], respectively) in men, among women diabetes was associated with a 4.4-fold increased admission rates for PCI and 6.2-fold increased rates for CABG (4.37 [3.93–4.85] and 6.24 [5.66–6.88], respectively). Proportional changes in rates were similar in men and women for all study outcomes, leaving the relative risk of admissions unchanged.ConclusionsDiabetes still confers a greater increase in risk of hospital admission for AMI in women relative to men. However, the absolute risk remains higher in men. These results call for intensified CVD risk factor management among people with diabetes, consideration of gender-specific treatment targets and treatment intensity to be aligned with levels of CVD risk.

Opioid doses and acute care utilization outcomes for adults with sickle cell disease: ED versus acute care unit

BackgroundAcute care units (ACUs) with focused sickle cell disease (SCD) care have been shown to effectively address pain and limit hospitalizations compared to emergency departments (ED), the reason for differences in admission rates is understudied. Our aim was compare effects of usual care for adult SCD pain in ACU and ED on opioid doses and discharge pain ratings, hospital admission rates and lengths of stay. MethodsIn a retrospective, comparative cohort, single academic tertiary center study, 148 adults with sickle cell pain received care in the ED, ACU or both. From the medical records we documented opioid doses, unit discharge pain ratings, hospital admission rates, and lengths of stay. FindingsPain on admission to the ED averaged 8.7±1.5 and to the ACU averaged 8.0±1.6. The average pain on discharge from the ED was 6.4±3.0 and for the ACU was 4.5±2.5. 70% of the 144 ED visits resulted in hospital admissions as compared to 37% of the 73 ACU visits. Admissions from the ED or ACU had similar inpatient lengths of stay. Significant differences between ED and ACU in first opioid dose and hourly opioid dose were noted. ConclusionsApplying guidelines for higher dosing of opioids for acute painful episodes in adults with SCD in ACU was associated with improved pain outcomes and decreased hospitalizations, compared to ED. Adoption of this approach for SCD pain in ED may result in improved outcomes, including a decrease in hospital admissions.

Intra-urban differences in rates of admissions for ambulatory care sensitive conditions in Brazil's Center-West region.

Admissions for ambulatory care sensitive conditions (ACSCs) represent a useful indicator of assess to and the effectiveness of primary health care. This article examined rates of admissions for ACSCs and the main causes of admissions in intra-urban areas of the municipality of Goiânia, capital of the State of Goiás. An ecological study was conducted to determine rates of admissions in Goiânia's seven health districts between 2008 and 2013 using data from Hospital Admission Authorization forms obtained from the municipality's Hospital Information System. Admissions were georeferenced throughout the seven health districts. Age-adjusted rates of admissions for ACSCs were calculated and the most common causes of admissions were identified for each age group. A 95% confidence interval was calculated as a measure of precision of the rates. The average overall rate of admissions for ACSCs was 155.5 per 10,000 population. Rates were highest in the Southern District and lowest in the Southwest District. Rates were highest in the youngest and oldest age groups. The Northwest District showed the highest rates in nine groups of causes, notably chronic non-communicable diseases among adults. Our findings showed that there are major differences in rates across health districts, pointing to shortfalls in primary health coverage, quality problems and an inadequate care model in districts with high coverage.

Advanced Imaging Lacks Clinical Utility in Treating Geriatric Pelvic Ring Injuries Caused by Low-Energy Trauma.

Is advanced imaging necessary in the evaluation of pelvic fractures caused by low-energy trauma in elderly patients? Retrospective review. Single institution, Level 1 Trauma Center. Age ≥60 years old treated for low-energy traumatic pelvic ring injuries. None. Posterior pelvic ring injuries diagnosed on advanced imaging, radiographic displacement, admission status, hospital length of stay, change in weight-bearing status recommendations, and whether operative treatment was pursued. Eighty-seven patients met the inclusion criteria, of which 42 had advanced imaging to evaluate the posterior pelvic ring (10 magnetic resonance imaging, 32 computed tomography). More posterior pelvic ring injuries were identified with advanced imaging compared with radiographs alone (P < 0.001). There was no statistically significant difference in rate of admission (P = 0.5) or hospital length of stay (P = 0.31) between patients with radiographs alone compared with patients evaluated with radiographs plus advanced imaging. The rate of displacement >1 cm at presentation and 6-week follow-up was unaffected by the presence of a posterior injury diagnosed on advanced imaging. Treatment for all 87 patients remained weight-bearing as tolerated with assist device irrespective of advanced imaging findings, and no patient underwent surgical intervention by 12-week follow-up. Despite frequent identification of posterior pelvic ring injuries in patients evaluated with advanced imaging, admission status, length of hospital stay, radiographic displacement, and treatment recommendations were unaffected by these findings. The use of advanced imaging in elderly patients with low-energy traumatic pelvic ring fractures may not be necessary. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Abstract WP323: Association between Demographic Characteristics and Hospital Admission in Patients Presenting to the Emergency Department for Transient Neurological Attack

Introduction: Significant demographic differences in the management of ischemic stroke and transient ischemic attack exist in the United States. Transient neurological attack (TNA) is a common neurological diagnosis that can result from cerebral ischemia, and is associated with recurrent stroke. Demographic factors may be associated with differences in admission rates for patients that present to the emergency department (ED) with a diagnosis of TNA. Methods: In a population-based, retrospective, administrative claims-based cohort study, we identified patients who presented to a non-federal ED in Florida from 2005 through 2013 with a complaint consistent with TNA, which was defined as a poorly-localized, non-specific neurological symptom. Our predictor variables were race (white vs. non-white) and sex. Our outcome variable was admission to the hospital. We used multiple logistic regressions to characterize the relationship between the predictor variables and our chosen outcome while adjusting for age, insurance status, income, and vascular risk factors. Results: We identified 1,231,046 patients presenting to the ED with TNA. Female patients in this cohort were less often white, and had fewer vascular comorbidities than men, including alcohol abuse. Non-white patients were younger, more often had Medicaid or no insurance, less often had atrial fibrillation, coronary heart disease or alcohol abuse, and more commonly had diabetes. Among all patients, 22,300 (1.8%) were admitted. After adjustment for age, insurance status, income, and vascular comorbidities, we found lower odds of hospital admission in female patients (odds ratio [OR], 0.69; 95% confidence interval [CI]; 0.67-0.70) and non-white patients (OR, 0.65; 95% CI, 0.63-0.67). Conclusions: Among patients presenting to the ED with TNA, female sex and race are associated with decreased odds of admission, even after adjusting for age, income, insurance status, and vascular risk factors. Further studies are warranted to reproduce these findings in other states, and to determine the public health impact of our results.

Predictors of Hospital Length and Cost of Stay in a National Sample of Adult Patients with Psychotic Disorders

This study examined effects of patient-level and hospital-level characteristics on length and cost of hospital stays among adult patients with psychotic disorders. A subsample of 677,684 adult patients with a primary diagnosis of a psychotic disorder was drawn from the 2003-2011 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. A nationally representative survey design and census data were used to calculate hospitalization rates. Multilevel models examined variation in length and cost of stay in relation to individual (age, sex, race-ethnicity, household income, payer source, and illness severity) and hospital (region, urban or rural location, ownership, teaching status, and size) characteristics. Admission rates differed dramatically by region, with higher rates in the Northeast. Compared with white patients, African Americans had higher admission rates but shorter stays and lower costs, and Asians/Pacific Islanders and Native Americans had longer stays. Longer stays were also associated with higher versus lower illness severity and use of Medicaid and Medicare versus private insurance. Length and cost of stays were greater in Northeast hospitals and in public hospitals. Strong differences were noted in use of hospitalization to treat psychotic disorders. Higher admission rates and longer stays in the Northeast were striking, as were differences in admission rates and length of stay for African-American patients compared with white patients. Future research should investigate the appropriateness of acute care use from an overuse (Northeast) and underuse (West) perspective. Findings raise questions about the effects of health reform on adult acute care use and have implications for mental health and hospital policy.

Frailty as a Predictor of Institutionalization Among Adults With Intellectual and Developmental Disabilities.

Adults with intellectual and developmental disabilities (IDD) frequently become frail earlier than the general population, resulting in higher care needs. This population is at risk for institutionalization, or re-institutionalization, into long-term care (LTC). Using a retrospective cohort design to follow 3,034 individuals (18-99 years) living in Ontario, Canada, and assessed with the Resident Assessment Instrument-Home Care, individuals were characterized with a frailty index (FI) for persons with IDD. Survival analyses determined differences in rates of admission to LTC and survival in the community. Frail individuals had greater rates of admission than non-frail individuals, adjusted HR = 2.19, 95% CI [1.81, 2.64]. The FI predicts institutionalization.

Evaluating Hospital Admission/Discharge Rates at the Community Level

Hospital admission/discharges rates are generating increased attention from health care providers and payors. This study focused on evaluation of inpatient hospital admission/discharge rates for Syracuse and other New York State metropolitan areas during 2014 and 2015. It provided comparative information concerning this subject and suggested how this approach to analysis of hospital utilization could be carried out using publicly available data. The study data demonstrated that hospital admission/discharge rates per 1000 population increased with patient age in all of these areas. The study data suggested that differences in hospital admission/discharge rates among the New York State metropolitan areas were generally consistent between 2014 and 2015. Utica and New York City produced the highest rates. Rochester and Albany produced the lowest rates. Utilization rates for Syracuse were considerably lower than for Utica and New York City and slightly higher than for Rochester and Albany. This analysis demonstrated that most of the differences between aggregate rates for Syracuse and Rochester were produced by elderly patients, especially those aged 75 years and over. The analysis demonstrated that most of these differences in admission rates for the elderly were produced by adult medicine patients aged 75 years and over. Most of these differences were generated by patients with respiratory, digestive, and orthopedic disorders. Additional data suggested that the highest readmission rates for adult medicine and adult surgery were produced by patients aged 75 years and over.

Analysis of the impact of limitation of medical treatment orders during unplanned transfers from sub-acute care to Emergency Departments

The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear. Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010. Common reasons for transfer were respiratory (18.9%) or neurological (19.0%) conditions; 35.7% (154/431) were transferred within one week of sub-acute care admission. LOMT orders were in place for 37.8% (n=163) patients who were older (p<0.001), with more comorbidities (p<0.005), specifically cardiac, renal and pulmonary disease than patients without LOMT. Patients with LOMT orders had more physiological abnormalities before transfer; tachypnoea (43.7% vs 28.6%), hypoxaemia (63.5% vs 48.4%) and severe hypoxaemia (27.6% vs 14.5%). There were no differences in rates of admission, cardiac arrest, Medical Emergency Team activation or ICU admission. For admitted patients, those with LOMT orders had significantly (p≤0.005) higher mortality: in-hospital (21.9% vs 11.3%); 30 days (23.9% vs 12.3%) and 60 days (28.2% vs 13.4%). Patients with LOMT had higher levels of comorbidity and were more acutely ill during their sub-acute care admission. Once transferred those with a LOMT had similar rates of cardiac arrest, MET activation and unplanned ICU admission, but higher mortality.

The mortality and hospitalization rates associated with the long interdialytic gap in thrice-weekly hemodialysis patients

Excess mortality and hospitalization have been identified after the 2-day gap in thrice-weekly hemodialysis patients compared with 1-day intervals, although findings vary internationally. Here we aimed to identify factors associated with mortality and hospitalization events in England using an incident cohort of 5864 hemodialysis patients from years 2002 to 2006 inclusive in the UK Renal Registry linked to hospitalization data. Higher admission rates were seen after the 2-day gap irrespective of whether thrice-weekly dialysis sequence commenced on a Monday or Tuesday (2.4 per year after the 2-day gap vs. 1.4 for the rest of the week, rate ratio 1.7). The greatest differences in admission rates were seen in patients admitted with fluid overload or with conditions associated with a high risk of fluid overload. Increased mortality following the 2-day gap was similarly independent of session pattern (20.5 vs. 16.7 per 100 patient years, rate ratio 1.22), with these increases being driven by out-of-hospital death (rate ratio 1.59 vs. 1.06 for in-hospital death). Non-white patients had an overall survival advantage, with the increased mortality after the 2-day gap being found only in whites. Thus, fluid overload may increase the risk of hospital admission after the 2-day gap and that the increased out-of-hospital mortality may relate to a higher incidence of sudden death. Future work should focus on exploring interventions in these subgroups.

Scientists Admitting to Plagiarism: A Meta-analysis of Surveys.

We conducted a systematic review and meta-analysis of anonymous surveys asking scientists whether they ever committed various forms of plagiarism. From May to December 2011 we searched 35 bibliographic databases, five grey literature databases and hand searched nine journals for potentially relevant studies. We included surveys that asked scientists if, in a given recall period, they had committed or knew of a colleague who committed plagiarism, and from each survey extracted the proportion of those who reported at least one case. Studies that focused on academic (i.e. student) plagiarism were excluded. Literature searches returned 12,460 titles from which 17 relevant survey studies were identified. Meta-analysis of studies reporting committed (N = 7) and witnessed (N = 11) plagiarism yielded a pooled estimate of, respectively, 1.7% (95% CI 1.2-2.4) and 30% (95% CI 17-46). Basic methodological factors, including sample size, year of survey, delivery method and whether survey questions were explicit rather than indirect made a significant difference on survey results. Even after controlling for these methodological factors, between-study differences in admission rates were significantly above those expected by sampling error alone and remained largely unexplained. Despite several limitations of the data and of this meta-analysis, we draw three robust conclusions: (1) The rate at which scientists report knowing a colleague who committed plagiarism is higher than for data fabrication and falsification; (2) The rate at which scientists report knowing a colleague who committed plagiarism is correlated to that of fabrication and falsification; (3) The rate at which scientists admit having committed either form of misconduct (i.e. fabrication, falsification and plagiarism) in surveys has declined over time.

A retrospective study of the impact of a telephone alert service (Healthy Outlook) on hospital admissions for patients with chronic obstructive pulmonary disease.

Background:Healthy Outlook is a service delivered by the UK Met Office directly to patients with chronic obstructive pulmonary disease (COPD) that has been in place since 2006. Its objective is to reduce the severity and length of COPD exacerbations, hence improving the quality of life and life expectancy.Aims:To assess the effect of the Healthy Outlook service on hospital admission rates of all general practitioners that have used the service.Methods:Control practices were selected for each of the 661 participating practices. The number of hospital admissions for each practice was extracted from the Hospital Episode Statistics database. The differences in admission rates per practice between the first year of use of the Healthy Outlook service and the previous year were compared by paired t-test analyses.Results:For admissions with a primary diagnosis of COPD, the difference between participating and control practices was −0.8% (95% confidence interval (CI)=−1.8 to 0.2%; P=0.13). For admissions with a primary or co-morbid diagnosis of COPD, the difference was −2.3% (95% CI=−4.2 to −0.4%; P=0.02).Conclusions:Participation in the Healthy Outlook service reduces hospital admission rates for patients coded on discharge with COPD (including co-morbid).

Summary of: International benchmarking of hospitalisations for impacted teeth: a 10-year retrospective study from the United Kingdom, France and Australia.

The United Kingdom and its national healthcare system represent a unique comparison for many other developed countries (such as Australia and France), as the practice of prophylactic removal of third molars in the United Kingdom has been discouraged for nearly two decades, with clear guidelines issued by the National Institute of Health and Care Excellence (NICE) in 2000 to limit third molar removal to only pathological situations. No such guidelines exist in Australia or France. The healthcare systems in England, France and Australia all use the International Classification of Disease (ICD) coding system for diagnostic categorising of all admissions to hospitals. This study rested upon the opportunity of a universal coding system and semi-open access data to complete the first comparative study on an international scale of hospitalisations for removal of impacted teeth (between 99/00 and 08/09). Our international comparison revealed significant differences in rates of admission, with England having rates approximately five times less than France, and seven times less than Australia. Those results could be explained by the implementation of guidelines in the United Kingdom, and the absence of similar guidelines in France and Australia.

International benchmarking of hospitalisations for impacted teeth: a 10-year retrospective study from the United Kingdom, France and Australia.

The United Kingdom and its national healthcare system represent a unique comparison for many other developed countries (such as Australia and France), as the practice of prophylactic removal of third molars in the United Kingdom has been discouraged for nearly two decades, with clear guidelines issued by the National Institute of Health and Care Excellence (NICE) in 2000 to limit third molar removal to only pathological situations. No such guidelines exist in Australia or France. The healthcare systems in England, France and Australia all use the International Classification of Disease (ICD) coding system for diagnostic categorising of all admissions to hospitals. This study rested upon the opportunity of a universal coding system and semi-open access data to complete the first comparative study on an international scale of hospitalisations for removal of impacted teeth (between 99/00 and 08/09). Our international comparison revealed significant differences in rates of admission, with England having rates approximately five times less than France, and seven times less than Australia. Those results could be explained by the implementation of guidelines in the United Kingdom, and the absence of similar guidelines in France and Australia.

Corticosteroid Timing and Length of Stay for Children With Asthma in the Emergency Department

To determine if early treatment with oral corticosteroids to pediatric patients with asthma exacerbations in the emergency department could decrease their length of stay.Children between the ages of 2 and 18 years who presented to the emergency department with acute asthma exacerbations and received oral corticosteroids, either prednisolone or dexamethasone, were included.Retrospective chart review of 882 children who were seen over the 12-month study period was performed. A standardized asthma treatment algorithm was used as a guide based on severity of exacerbation, but the treating physician decided medications used. Timing of corticosteroid administration and length of stay was calculated by the electronic medical record. Children receiving corticosteroids within 60 minutes of triage were compared with those receiving corticosteroids ≥61 minutes after triage. The 2 groups were compared using either Student’s t test or χ2 test, based on the level of measurement.Children treated with corticosteroids within 60 minutes had a mean length of stay of 157 minutes, whereas children treated later than 60 minutes had a mean length of stay of 182 minutes (P < .0001). The greatest decrease in length of stay was among children who were categorized as having a moderate exacerbation and had a mean 38-minute decrease in length of stay if treated with corticosteroids in the first hour. Both study groups had similar baseline characteristics; however, the group receiving corticosteroids within 60 minutes had a higher percentage of severe exacerbations. Subjects who received dexamethasone had a 19-minute shorter length of stay compared with patients treated with prednisolone. Of the subjects treated with dexamethasone, those who received it in the first 60 minutes had a mean 34-minute decrease in length of stay compared with those treated with prednisolone. Early treatment with albuterol within 60 minutes or after did not affect length of stay.Early corticosteroid administration within 60 minutes of triage in pediatric patients with asthma exacerbations was associated with a significant decrease in the overall length of stay. This study suggested that choice of oral corticosteroid, dexamethasone over prednisolone, may also affect the length of stay.Previous studies have found early corticosteroid administration to lessen admission rates to the hospital. Although this study did not show a difference in admission rates, this study did support early corticosteroid administration within the emergency department to help lessen length of stay. Properties of dexamethasone make it appear superior to prednisolone, but prospective randomized trials are necessary, as previous studies did not show significant improvements for decrease in length of stay or in admissions. As treatment protocols become more common, a prospective study that validates early use of oral corticosteroids and choice of oral steroid may help to both lessen the length of stay and decrease hospital admissions for asthma exacerbations. A limitation of this study was that type of oral steroid medication and other asthma medication use was left to the discretion of the treating physician, which may affect length of stay as well.

Geography Lessons: Scrutinizing State-by-State Differences in Inpatient Gastroparesis Care

Gastroparesis is defined as a slowing of gastric emptying, a condition that has been associated with nausea, vomiting, and related symptoms. Few papers have addressed its prevalence and incidence and have characterized factors related to health care utilization for this condition. A recent population-based analysis reported prevalence per 100,000 for definite gastroparesis (defined by typical symptoms with documented delayed gastric emptying) of 9.6 for men versus 37.8 for women [1]. Age-adjusted incidences per 100,000 person-years calculated from the same population were 2.4 for men and 9.8 for women. Nevertheless, these data may not be generalizable due to its unique locale, Olmsted County, Minnesota, a highly educated, relatively homogeneous population medically well served by the Mayo Clinic. Furthermore, the impact of geography, demographics, and socioeconomic factors on hospitalization rates for gastroparesis and on other parameters of health resource usage has not heretofore been reported in the medical literature. The article by Bielefeldt in this issue represents an important addition to the literature, providing voluminous new information relating to regional profiles of inpatient care for gastroparesis (Table 1). The study utilized the State Inpatient Databases, which accumulate demographic and clinical information from 90 % of hospitalizations in 46 states. For this investigation, the International Diagnosis Code (ICD-9) for gastroparesis (536.3) was queried from 2007 through 2010 for 35 states. The most striking findings were the greater-than-fourfold differences in admission rates for this condition. It is possible that states with high admission percentages are the main contributors to the previously reported increase in hospitalizations for gastroparesis [2]. Twofold geographic differences in length of stay and nursing home transfers were also observed. Among demographic factors, higher hospitalization rates were related to female sex, greater state population, lower incomes, admission to large centers, and Medicare coverage. Clinically, heart failure was associated with increased admissions, whereas diabetes was inversely related to hospitalizations. Admission data correlated roughly with rates of endoscopy and in older individuals, gastrostomy placement, both of which also showed wide state-to-state variability. Conversely, enteral or parenteral nutrition initiation did not strictly relate to hospitalization rates. Finally, higher numbers of overall admissions but lower percentages of admissions with gastroparesis as a primary diagnosis were associated with inpatient mortality as were age [65 years, female sex, poverty, and endoscopies. The author concluded that disease-dependent and socioeconomic factors contribute to regional differences in inpatient health care for gastroparesis. Although the analyses by Bielefeldt were broad-ranging, other administrative factors related to differences in coding may have contributed to apparent regional variations in inpatient care of gastroparesis. The author did attempt to address this issue by comparing ICD-9 coding for gastroparesis versus dyspepsia. Yet, annual admissions for dyspepsia were only 2–3 % of those for gastroparesis in this study. Although hospitalization data for functional dyspepsia are lacking for the United States, its prevalence in the community exceeds 5 % and its inpatient costs are greater than threefold higher than for non-dyspeptics [3]. Thus, it is likely the coding of this disorder within this database did not consistently capture all functional W. L. Hasler (&) Division of Gastroenterology, University of Michigan Health System, 3912 Taubman Center, 5362, Ann Arbor, MI 48109, USA e-mail: whasler@med.umich.edu; whasler@umich.edu