Emergency Admission Rates Research Articles

Outcomes of endovascular stent graft repair for penetrating aortic ulcers with or without intramural hematoma

ObjectiveWe investigated the outcomes of endovascular repair for penetrating aortic ulcers (PAUs) with and without intramural hematoma (IMH). MethodsPatients with PAUs who had undergone thoracic endovascular aortic repair (TEVAR) or endovascular abdominal aortic repair (EVAR) at our center were enrolled. Patient demographics, presenting symptoms, and anatomic characteristics were collected and analyzed to investigate the TEVAR/EVAR indications, perioperative complications, and mortality. ResultsWe identified 138 patients with PAU. Of the 138 patients, 58 (42.0%) had also had IMH. Compared with the patients without IMH, the patients with IMH had had significantly greater emergency admission rates (P < .01), a larger aortic diameter (P = .03), and a greater incidence of stent-induced new entry development (P = .02). No significant differences were found in mortality or freedom from reintervention between patients with PAUs with and without IMH during follow-up. However, the cumulative survival rates calculated using Kaplan-Meier analysis for patients who had undergone TEVAR/EVAR during their first hospitalization were significantly greater than those who had undergone delayed TEVAR/EVAR during follow-up. ConclusionsTEVAR/EVAR was safe and effective, with encouraging outcomes for patients with PAUs with or without IMH, and can be used more aggressively for symptomatic patients. The presence of PAUs with IMH did not seem to adversely affect long-term mortality. However, but stent-induced new entry was more likely to develop.

Effect of ethnicity and rurality on treatment delays in patients with colorectal cancer in Northland, New Zealand

Ethnic and rural disparities in medical treatment and outcomes have been demonstrated across a range of conditions, including colorectal cancer. Timely treatment and investigation of symptoms in patients with suspicion of cancer is likely to improve outcomes and patient experience. Achieving equity in timeliness of care is important in achieving the goal of equitable cancer outcomes outlined in the New Zealand cancer action plan. The aim of this study was to compare treatment times in patients with colorectal cancer, between Māori and non-Māori patients as well as urban and rural patients in Northland, New Zealand. All adult patients diagnosed with colorectal adenocarcinoma from 2011 to 2016 were identified using hospital coding. Further information on the primary cohort was then obtained using the hospitals electronic results system, CONCERTO. The primary outcomes of interest were differences in delays to treatment between Māori and non-Māori as well as Urban versus rural residence. Secondary outcomes of interest included rate of emergency admission and treatment by curative intent in different groups. A total of 511 patients formed the primary cohort; 12% were Māori and were on average 6 years younger than non-Māori. Māori had a 6% higher emergency admission rate and a 5% higher rate of palliative treatment intent. No significant difference in treatment delay times was seen between different ethnicities or different domiciles. Ethnicity and rurality were not shown to affect treatment delays. Further research in this area is needed to help attain equitable outcomes for patients with colorectal cancer in New Zealand.

Prediction of Acquired Morbidity Using Illness Severity Indices in Pediatric Intensive Care Patients.

To assess the ability of two illness severity scores, Pediatric Logistic Organ Dysfunction Score 2 and Pediatric Index of Mortality 3, in predicting PICU-acquired morbidity. Retrospective chart review conducted from April 2015 to March 2016. Single-center study in a multidisciplinary PICU in a tertiary pediatric hospital in Singapore. The study included all index admissions of patients 0-18 years old to the PICU during the study period. None. Three outcomes were assessed at hospital discharge: mortality, survival with new morbidity defined as an increase in the Functional Status Scale score of greater than or equal to 3 points from baseline, and survival without morbidity. Of 577 consecutive admissions, 95 were excluded: 82 readmissions, 10 patients greater than or equal to 18 years old, two patients with missing baseline data, and one transferred to another PICU. Of 482 patients, there were 37 hospital deaths (7.7%) and 39 (8.1%) with acquired new morbidity. Median admission Pediatric Logistic Organ Dysfunction Score 2 and Pediatric Index of Mortality 3 scores differed among the three outcome groups. In addition, differences were found in emergency admission and neurologic diagnosis rates, PICU mechanical ventilation usage rates, and PICU length of stay. The highest proportion of neurologic diagnoses was observed in the new morbidity group. The final model simultaneously predicted risks of mortality, survival with new morbidity and survival without morbidity using admission Pediatric Logistic Organ Dysfunction Score 2 score, admission type, neurologic diagnosis, and preexisting chronic disease. Pediatric Logistic Organ Dysfunction Score 2 was superior to Pediatric Index of Mortality 3 in predicting risks of mortality and new morbidity, as indicated by volume under surface values of 0.483 and 0.362, respectively. Risk of mortality, survival with new morbidity, and survival without morbidity can be predicted simultaneously using admission Pediatric Logistic Organ Dysfunction Score 2, admission type, admission diagnosis, and preexisting chronic disease. Future independent studies will be required to validate the proposed model before clinical implementation.

Emergency paediatric critical care in England: describing trends using routine hospital data

ObjectiveTo determine trends in emergency admission rates requiring different levels of critical care in hospitals with and without a paediatric intensive care unit (PICU).DesignBirth cohort study created from Hospital Episode...

Has the introduction of direct oral anticoagulants (DOACs) in England increased emergency admissions for bleeding conditions? A longitudinal ecological study.

ObjectiveThere is concern about long-term safety of direct oral coagulants (DOACs) in clinical practice. Our aim was to investigate whether the introduction of DOACs compared with vitamin-K antagonists in England was associated with a change in admissions for bleeding or thromboembolic complications.Setting5508 General practitioner (GP) practices in England between 2011 and 2016.ParticipantsAll GP practices in England with a registered population size of greater than 1000 that had data for all 6 years.Main outcome measureThe rate of emergency admissions to hospital for bleeding or thromboembolism, per 100 000 population for each GP practice in England.Main exposure measureThe annual number of DOAC items prescribed for each GP practice population as a proportion of all anticoagulant items prescribed.DesignThis longitudinal ecological study used panel regression models to investigate the association between trends in DOAC prescribing within GP practice populations and trends in emergency admission rates for bleeding and thromboembolic conditions, while controlling for confounders.ResultsFor each additional 10% of DOACs prescribed as a proportion of all anticoagulants, there was a 0.9% increase in bleeding complications (rate ratio 1.008 95% CI 1.003 to 1.013). The introduction of DOACs between 2011 and 2016 was associated with additional 4929 (95% CI 2489 to 7370) emergency admissions for bleeding complications. Increased DOAC prescribing was associated with a slight decline in admission for thromboembolic conditions.ConclusionOur data show that the rapid increase in prescribing of DOACs after changes in National Institute for Health and Care Excellence guidelines in 2014 may have been associated with a higher rate of emergency admissions for bleeding conditions. These consequences need to be considered in assessing the benefits and costs of the widespread use of DOACs.

An observational cohort study of numbers and causes of preventable general hospital admissions in people with and without intellectual disabilities in England.

Hospital admissions for preventable reasons [ambulatory care sensitive (ACS) conditions] can indicate gaps in access to or quality of primary care. This paper seeks to document the numbers and causes of these admissions in England for people with intellectual disabilities (ID) compared with those without. Observational cohort study of number and duration of emergency admitted patient episodes for ACS conditions, overall and by cause, using the Clinical Practice Research Datalink GOLD primary care database and the linked Hospital Episode Statistics Admitted Patient Care dataset. The study covered 5.2% of the population of England from April 2010 to March 2014 giving a total population base of 59280 person-years for people with ID and 11103910 for people without identified ID. The rate of emergency admissions for ACS conditions for people with ID was 77.5 per 1000 person-years. As a crude comparison, this was 3.0 times the rate for those without ID, but standardising for the distinct demography of this group, the number of episodes was 4.8 times that expected if they had the same age-specific and sex-specific rates. Stay durations for these episodes were longer for both young-age and working-age people with ID. Overall people with ID used 399.8 bed-days per 1000 person-years. As a crude comparison, this is 2.8 times the figure for people without ID. Standardising for their age and sex profile, it is 5.4 times the number expected if they had the same age-specific and sex-specific rates. For patients with ID, 16.6% (one in six) of all admitted patient episodes and 24.3% (one in four) of in-patient care days for people with ID were for ACS conditions. Corresponding figures for those without ID were 8.3% (one in 12) and 14.4% (one in seven). The difference in rates between those with and without ID was most marked in people of working age. The three most common causes of emergency episodes for ACS conditions in people with ID were convulsions and epilepsy, influenza pneumonia and aspiration pneumonitis. Influenza pneumonia was also a common cause for people without ID. Episodes for convulsions and epilepsy and aspiration pneumonitis were specifically associated with people with ID. Rates of hospital admissions for ACS conditions provide an important indicator of health literacy, basic self-care (or support by carers) and the accessibility of primary care. High rates are seen for some conditions specifically associated with premature death in people with ID. Local monitoring of these figures could be used to indicate the effectiveness of local primary health services in providing support to people with ID.

A Randomized Controlled Trial of Group Well-Child Care: Improved Attendance and Vaccination Timeliness.

Well-child care has suboptimal outcomes regarding adherence to appointments and recall of guidance, especially among families facing structural barriers to health. Group well-child care (GWCC) aims to improve these outcomes by enhancing anticipatory guidance discussions and peer education. We conducted a randomized controlled trial, comparing GWCC with traditional, individual well-child care (IWCC) and assessed health care utilization, immunization timeliness, recall of anticipatory guidance, and family-centered care. Ninety-seven mother-infant dyads were randomized to GWCC or IWCC. Compared with IWCC infants, GWCC infants attended more of the 6 preventive health visits (5.41 vs 4.87, P < .05) and received more timely immunization at 6 months and 1 year but did not differ in emergency or hospital admission rates. There were no differences in mothers' reports of anticipatory guidance received or family-centered care. As primary care is redesigned for value-based care and structural vulnerabilities are considered, GWCC may be a key option to consider.

Direct assessment of health impacts on hospital admission from traffic intensity in Madrid

In this paper we establish the attributable risk on respiratory and cardiovascular disorders related to traffic intensity in Madrid. In contrast to previous related studies, the proposed approach directly associates road traffic counts to patient emergency admission rates instead of using primary air pollutants. By applying Shapley values over gradient boosting machines, a first selection step is performed among all traffic observation points based on their influence on patient emergency admissions at Gregorio Marañon hospital. A subsequent quantification of the relative risk associated to traffic intensity of the selected point is calculated via ARIMA and log-linear Poisson regression models. The results obtained show that 13% of respiratory cases are related to traffic intensity while, in the case of cardiovascular disorders, the percentage increases to 39%.

Hospital admission for complicated diverticulitis is increasing in Italy, especially in younger patients: a national database study

Epidemiological studies show an increasing trend of hospitalization for acute diverticulitis (AD), but data regarding the trend in hospitalization for complicated AD in Italy are scarce. The aim of this study was to analyze the Italian trend in hospitalization for complicated AD, from 2008 to 2015. Using the Italian Hospital Information System, we identified all patients with complicated colonic AD as a discharge diagnosis. Age- and sex-specific rates for AD as well as type of hospital admission (emergency/elective), type of complication (peritonitis, obstruction, bleeding, abscess, fistula, perforation, sepsis) and type of treatment (medical/surgical), were analyzed. A total of 41,622 patients with a discharge diagnosis of complicated AD were identified. Over the study period the admission rate grew from 8.8 to 11.8 per 100,000 inhabitants. The hospitalization rate was highest for patients ≥ 70years, but the increase in the admission rate was higher among patients aged ≤ 60years. There were more males in the group < 60years and more females in the group ≥ 60years old. The rate of emergency admissions associated with surgery showed a significant mean annual increase (+ 3.9% per year) in the rate of emergency admissions associated with surgery, whereas elective admissions for surgery remained stable. Peritonitis was the most frequent complication (35.5%). The rate of surgery increased in AD complicated by peritonitis (+ 5.1% per year), abscess (+ 5.8% per year) and decreased for obstruction (-1.8% per year). From 2008 to 2015, we documented an increasing rate of hospitalization for complicated AD, especially for younger patients, with an increase in surgery for peritonitis and abscess. Further studies are needed to clearly assess the risk factors for complications and risk of surgery.

Analysis of bed occupancy data on the acute medical unit

Hospitals may struggle to operate effectively and meet quality standards when unscheduled (emergency) admission rates are high in relation to operational capacity. Understanding patterns of ward admission and discharge from acute medical units (AMU) can help inform resource allocation. Discharges early in the day are advocated as a means to improve bed management, but delays may arise from post-AMU bed availability. It is unclear whether any change in AMU discharge patterns pre-dates hospital-wide pressure or whether it is a reaction to it. Anonymous data from 1 Jan 2016 to 31 December 2017 comprising the …

Further Utilization of Emergency Department and Inpatient Psychiatric Services Among Young Adults Admitted at the Emergency Department With Clinical Alcohol Intoxication.

To assess in a cohort of young adults admitted with alcohol intoxication (AI) to the Emergency Department (ED): how many patients are readmitted to the ED or to a Psychiatric Department (PD) inpatient unit; and which characteristics are associated with further ED and PD inpatient admissions. In 630 patients aged 18 to 30 years admitted for AI in 2006 to 2007 to the ED of a Swiss tertiary hospital, further ED and PD inpatient admissions through 2013 were assessed. Patient characteristics at the index (initial) ED visit were assessed using administrative and medical records. Proportion of subjects with at least 1 further ED admission, 1 further ED admission with AI, and any PD admission over the study period.Associations between patients' characteristics at index visit and readmissions were assessed using backward selection multivariate regression analyses. Mean age was 24, 66% were male, 60% had any ED/PD admissions during the study period, 17.9% a PD admission, and 13.8% were re-admitted to ED with AI. Disruptive behavior at the index visit was associated with further ED (odds ratio [OR] 1.69 [1.13; 2.54]) and PD admissions (OR 2.41 [1.44; 4.05]). Psychiatric diagnosis was associated with any further ED admission (OR 2.07 [1.41; 3.05]), with further ED admission with AI (OR 4.56 [2.36; 8.81]) and with PD admission (OR 3.92 [2.40; 6.41]). Female sex predicted any further ED admission (OR 1.65 [1.14; 2.39]). Young adults presenting with alcohol intoxication have high rates of subsequent inpatient emergency and psychiatric admissions. Being female, presenting with disruptive behavior, and having a psychiatric diagnosis at the ED visit were predictors of further admissions.

Prezentacija i lečenje teških COVID pneumonija - aktuelna saznanja i iskustvo Jedinice intenzivne nege Klinike za pulmologiju KCS

Severe COVID infection is most often presented as bilateral pneumonia and, according to current knowledge, can be explained by cytokine storm, hypercoagulability and microvascular thromboses. Patients at risk of poor outcome include obese middle-aged men and persons with cardiovascular and pulmonary comorbidities and diabetes. One of specific traits of COVID 19 pneumonias is frequent discrepancy between clinical presentation, radiographic findings and oxygen saturation. Regular monitoring and use of early warning scores improve survival and decrease rates of emergency admissions to intensive care units. Corner-stone of treatment of critically ill patients include oxygen, anti-inflammatory and anticoagulant therapy. Best results are obtained through administering high flow oxygen and non-invasive mechanical ventilation.

Measuring and optimising the efficiency of community hospital inpatient care for older people: the MoCHA mixed-methods study

BackgroundCommunity hospitals are small hospitals providing local inpatient and outpatient services. National surveys report that inpatient rehabilitation for older people is a core function but there are large differences in key performance measures. We have investigated these variations in community hospital ward performance.Objectives(1) To measure the relative performance of community hospital wards (studies 1 and 2); (2) to identify characteristics of community hospital wards that optimise performance (studies 1 and 3); (3) to develop a web-based interactive toolkit that supports operational changes to optimise ward performance (study 4); (4) to investigate the impact of community hospital wards on secondary care use (study 5); and (5) to investigate associations between short-term community (intermediate care) services and secondary care utilisation (study 5).MethodsStudy 1 – we used national data to conduct econometric estimations using stochastic frontier analysis in which a cost function was modelled using significant predictors of community hospital ward costs. Study 2 – a national postal survey was developed to collect data from a larger sample of community hospitals. Study 3 – three ethnographic case studies were performed to provide insight into less tangible aspects of community hospital ward care. Study 4 – a web-based interactive toolkit was developed by integrating the econometrics (study 1) and case study (study 3) findings. Study 5 – regression analyses were conducted using data from the Atlas of Variation Map 61 (rate of emergency admissions to hospital for people aged ≥ 75 years with a length of stay of &lt; 24 hours) and the National Audit of Intermediate Care.ResultsCommunity hospital ward efficiency is comparable with the NHS acute hospital sector (mean cost efficiency 0.83, range 0.72–0.92). The rank order of community hospital ward efficiencies was distinguished to facilitate learning across the sector. On average, if all community hospital wards were operating in line with the highest cost efficiency, savings of 17% (or £47M per year) could be achieved (price year 2013/14) for our sample of 101 wards. Significant economies of scale were found: a 1% rise in output was associated with an average 0.85% increase in costs. We were unable to obtain a larger community hospital sample because of the low response rate to our national survey. The case studies identified how rehabilitation was delivered through collaborative, interdisciplinary working; interprofessional communication; and meaningful patient and family engagement. We also developed insight into patients’ recovery trajectories and care transitions. The web-based interactive toolkit was established [http://mocha.nhsbenchmarking.nhs.uk/(accessed 9 September 2019)]. The crisis response team type of intermediate care, but not community hospitals, had a statistically significant negative association with emergency admissions.LimitationsThe econometric analyses were based on cross-sectional data and were also limited by missing data. The low response rate to our national survey means that we cannot extrapolate reliably from our community hospital sample.ConclusionsThe results suggest that significant community hospital ward savings may be realised by improving modifiable performance factors that might be augmented further by economies of scale.Future workHow less efficient hospitals might reduce costs and sustain quality requires further research.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

Impact of a community respiratory service on emergency hospital admissions

Abstract Background A community respiratory service was implemented in the North West of Glasgow in January 2013, comprising a team of physiotherapists, occupational therapists and support workers, to provide education, self-management advice, and, where appropriate, treatment at home, for COPD patients, to reduce the risk of hospital admission. This study measures the impact of the service on emergency admission to hospital. Methods COPD EAs were defined as emergency admissions to hospital with a primary diagnosis of COPD. Rate of COPD EAs per 1000 population aged 65 years+ in Glasgow City was compared before and after onset of the service, using segmented linear regression with 21-month pre- and 17-month post-intervention periods. COPD EAs for residents of South and North East Glasgow (S+NE) - areas with no such service in place - were used as a comparison group. The model adjusted for the rate of all-cause emergency admissions. Autoregressive terms were included in the model, as well as a fourier term to adjust for seasonality. Models were similarly run for outcome emergency admissions with COPD in any of the other five fields of diagnosis. Results Adjusting for all cause EAs and changes in S+NE, thus factoring out the impact of other initiatives that may have affected emergency admission to hospital, the impact of the service was found to be a level change of -0.33 (-0.51, -0.16) and a trend change of -0.03 (-0.05, -0.02) COPD EAs per 1000 per month. This is equivalent to a predicted reduction due to the service of -0.88 COPD EAs per 1000 popn per month, in March 2015, and a relative reduction of 35.8%. Rate of COPD EAs per month reduced over time after the introduction of the service (from the point of full staffing). Rate of EAs with COPD in a field of diagnosis other than primary saw no significant change in level or trend associated with the service. Conclusions The community respiratory service was associated with a significant reduction in the rate of COPD EAs. Key messages The Community Respiratory service was associated with reductions in emergency hospital admissions with COPD as a primary diagnosis. There was no significant change in emergency admissions with COPD as a secondary diagnosis, suggesting hospital attendance for patients with COPD overall reduced following the intervention.

Hospital contacts before and after attendance at chronic pain clinics for children in England: a whole-population administrative data cohort study

BackgroundChronic pain (pain lasting >3 months) is common in children, is associated with significant comorbidities, and is probably under-referred owing to low provision of pain clinics. We examined changes in unplanned and planned hospital contacts before and after children's first visit to specialised chronic pain services in England. We aimed to provide indicators for service commissioners of the potential unmet need and the impact of chronic pain clinics on other hospital services. MethodsWe analysed longitudinal hospital admission, outpatient, and Accident and Emergency (A&E) records for children (aged 10–17 years) seen by all National Health Service (NHS) chronic pain services between 2007–08 and 2016–17 in England. Although we could not identify all children with chronic pain, we were able to analyse complete longitudinal histories in NHS hospitals. Clinics were identified using specialty codes. We analysed all hospital contacts; ICD-10 codes indicating comorbid chronic conditions (eg, cancer or mental health) 5 years before the first chronic pain clinic visit (CP1) were used to identify comorbidity. We estimated changes in rates of clinic appointments, planned and unplanned admissions, and A&E attendances. We are using negative binomial, zero-inflated Poisson regression models adjusted for sex, age, ethnicity, deprivation, and comorbidity. FindingsWe identified 3185 (28%) boys and 8330 (72%) girls with at least one attendance at a chronic pain clinic. Comorbidity prevalence was high: 1760 boys (55%) and 4607 girls (55%) had at least one chronic condition within 5 years pre-CP1. Outpatient attendances, unplanned admissions, and attendances to A&E peaked in the months leading up to CP1. For example, the rate of emergency admissions 21–24 months pre-CP1 was 11·7 (95% CI 10·8–12·6) per 100 person-years; in the 3 months pre-CP1, it was 38·3 (36·7–39 ·9). The rate of all these contacts fell sharply immediately after CP1. There was a spike of planned admissions after CP1, whereas the rate was constant pre-CP1. InterpretationMost children seen by chronic pain services had another chronic condition. The rapid reduction in unplanned hospital contacts post-CP1 suggests that earlier referral to chronic pain services might address an unmet need for pain management and could potentially reduce A&E visits and unplanned admissions pre-CP1 and hospital costs. FundingNational Institute for Health Research Children and Families Policy Research Unit.

89 Geographical Variation of Emergency Hospital Admissions for Ambulatory Care Sensitive Conditions in Older Adults in the Republic of Ireland

Abstract Background Hospitalisation for specific conditions considered to be `ambulatory-care sensitive' (ACS) could signify problems with primary or outpatient care access. The aims of this study are to quantify and explore potential causes for geographical variation across emergency hospital admissions for relevant ACS conditions in older adults in Ireland. Methods The number of emergency hospital admissions among adults aged 65+ with a diagnosis of an ACS condition between 2012-2016 were extracted from Ireland’s Hospital Inpatient Enquiry system according to condition, sex, age-group, residence area and year. Conditions included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes complications, angina (excluding therapeutic procedures), pyelonephritis and urinary tract infections (UTI), dehydration and pneumonia. Age-sex standardised discharge rates (SDRs) were calculated for 21 areas. Systematic components of variance (SCV) quantified variation. Regression analyses were conducted between SDRs and year, unemployment rate, % urban population, General Practitioner (GP) supply, and % short emergency hospital stays. Results In total, 147,722 emergency hospital admissions (50 per 1,000 eligible population; 49% male) were included. COPD was the most common condition (31%), followed by pneumonia (22%), pyelonephritis/UTI (21%) and CHF (16%). CHF showed low geographic variation (SCV=2-3). COPD, diabetes, pyelonephritis/UTI and pneumonia showed high variation (SCV=4-12). Angina and dehydration showed very high variation (SCV=12-50). In multivariable analysis, higher unemployment was associated with higher SDRs for COPD. Lower GP supply was associated with higher SDRs for CHF, diabetes and pneumonia. Rurality was associated with SDRs for angina. Conclusion The rate of emergency admissions for ACS conditions studied is in line with research in the United States, although COPD and angina account for a higher proportion of admissions in our study. There is significant geographical variation in ACS admission rates among older adults in Ireland. Further research should explore local factors influencing emergency admission, particularly in socio-economically disadvantaged areas and those with lower GP supply.

Area level impacts on emergency hospital admissions of the integrated care and support pioneer programme in England: difference-in-differences analysis

ObjectiveTo examine whether any differential change in emergency admissions could be attributed to integrated care by comparing pioneer and non-pioneer populations from a pre-pioneer baseline period (April 2010 to March...

Changing hospitalization trends for systemic lupus erythematosus and rheumatoid arthritis in England.

Systemic lupus erythematosus (SLE) is a chronic, multisystemic, immune-mediated disorder associated with a substantial hospitalization risk. As a comparatively rare disease, there is a sparsity of research examining the burden of hospital admission in the contemporary era. We aim to describe national trends in hospitalization rates in England between 1998 and 2015 for SLE, using rheumatoid arthritis (RA) and general population rates as comparison cohorts for benchmarking. Hospital admission rates, emergency and day-case admission rates, length of stay and bed days used were calculated using finished consultant episodes from Hospital Episode Statistics data. Cochran-Armitage tests and linear regression quantified the significance and magnitude of change over time. SLE admissions increased from 8.97 to 9.04 per 100,000 (p < 0.001) between 1998 and 2015. By comparison, RA admissions rose from 71.0 to 171.6 per 100,000 (p < 0.001) and all-cause admissions rose from 24,500 to 34,500 per 100,000 (p < 0.001). Emergency admissions decreased both for SLE (2.6 to 1.2 per 100,000) and RA (12.8 to 4.4 per 100,000) despite all-cause emergency admissions increasing from 9400 to 10,300 per 100,000. SLE and RA day cases increased, whilst median length of stay decreased. Despite increasing admissions, total bed days for SLE and RA fell by 60% and 90%, respectively. Whilst all-cause emergency admissions rose in the general population, those for SLE fell. Length of stay and bed days reduced and day cases increased, probably reflecting changing therapeutic strategies. This potentially large reduction in resource utilization warrants consideration when assessing the impact of new therapies.

The association of hospital emergency admissions due to respiratory-cardiovascular diseases and acute myocardial infarction with air pollution in Tehran during 2005-2014.

Background: Air pollution is one of the main reasons for disease and emergency hospitalizations. Therefore, air pollution control and hospital preparedness are of paramount importance. This study was conducted to determine the association of air pollutant levels with the rate of hospital emergency admissions due to respiratory and cardiovascular diseases and acute myocardial infarction in Tehran during the last decade. Methods: This was a cross sectional study. At first, information on hourly concentration of air pollutants was gathered from Tehran Environmental Protection Agency and Air Quality Control Company. Raw data and meteorological parameters were used in Excel format to prepare an input file. The number of emergency hospital admissions due to pollutant exposure was assessed using the AirQ2.2.3 model. Results: Results of this study revealed that there were 54 352 cases of emergency hospitalizations due to respiratory diseases in a relative risk of 1.0048 [1.0008-1.0112] and 20 990 cases of emergency hospitalizations due to cardiovascular diseases in a relative risk of 1.009[1.006-1.013] during 2005-2014. In addition, 3478 patients were admitted to the emergency department because of acute myocardial infarction with RR of 1.0026 [1.0026-1.0101]. Conclusion: This study demonstrated that a high percentage of hospital emergency admissions was because of respiratory and cardiovascular diseases. Moreover, it was found that acute myocardial infarction could be due to the high level of air pollution and could increase admissions to the emergency department. Therefore, appropriate measures are needed to reduce air pollution and increase hospital preparedness.

Influences of socioeconomic deprivation on GPs' decisions to refer patients to cardiology: a qualitative study.

Variation in GP referral practice may be a factor contributing to the lower uptake of cardiology specialist services for people living in socioeconomic deprivation. Cardiology referrals were chosen for this study due to higher rates of premature death and emergency admissions resulting from coronary heart disease for patients living in more deprived areas. To find out how socioeconomic deprivation influences GP referral practice. A qualitative study of GPs working in affluent and deprived areas of one large city in the UK. The authors used purposive and snowball sampling to recruit 17 GP participants to interviews and a focus group. Participants were asked to reflect on their own experience of making referrals. The authors used a framework approach to the analysis, with differences in themes for GPs working in least and most deprived areas being highlighted. The authors identified four main themes by which socioeconomic deprivation influenced GP referral practice: identifying problems; making decisions about referral; navigating the healthcare system; and external pressures. Using a published framework of consultation complexity, the authors then examined the data in relation to a fifth theme of complexity. Referrals from areas of high socioeconomic deprivation involved greater complexity in the majority of the domains of this framework. Socioeconomic deprivation influences GP referral decisions and navigation of the healthcare system in multiple ways. Referral practice for GPs working in deprived areas is more complex than for their peers working in more affluent areas.