Higher Hospital Admission Rates Research Articles

Frequent avoidable admissions amongst Aboriginal and non-Aboriginal people with chronic conditions in New South Wales, Australia: a historical cohort study

BackgroundAboriginal and Torres Strait Islander people have high rates of avoidable hospital admissions for chronic conditions, however little is known about the frequency of avoidable admissions for this population. This study examined trends in avoidable admissions among Aboriginal and non-Aboriginal people with chronic conditions in New South Wales (NSW), Australia.MethodsA historical cohort analysis using de-identified linked administrative data of Aboriginal patients and an equal number of randomly sampled non-Aboriginal patients between 2005/06 to 2013/14. Eligible patients were admitted to a NSW public hospital and who had one or more of the following ambulatory care sensitive chronic conditions as a principal diagnosis: diabetic complications, asthma, angina, hypertension, congestive heart failure and/or chronic obstructive pulmonary disease. The primary outcomes were the number of avoidable admissions for an individual in each financial year, and whether an individual had three or more admissions compared with one to two avoidable admissions in each financial year. Poisson and logistic regression models and a test for differences in yearly trends were used to assess the frequency of avoidable admissions over time, adjusting for sociodemographic variables and restricted to those aged ≤75 years.ResultsOnce eligibility criteria had been applied, there were 27,467 avoidable admissions corresponding to 19,025 patients between 2005/06 to 2013/14 (71.2% Aboriginal; 28.8% non-Aboriginal). Aboriginal patients were 15% more likely than non-Aboriginal patients to have a higher number of avoidable admissions per financial year (IRR = 1.15; 95% CI: 1.11, 1.20). Aboriginal patients were almost twice as likely as non-Aboriginal patients to experience three or more avoidable admissions per financial year (OR = 1.90; 95% CI = 1.60, 2.26). There were no significant differences between Aboriginal and non-Aboriginal people in yearly trends for either the number of avoidable admissions, or whether or not an individual experienced three or more avoidable admissions per financial year (p = 0.859; 0.860 respectively).ConclusionAboriginal people were significantly more likely to experience frequent avoidable admissions over a nine-year period compared to non-Aboriginal people. These high rates reflect the need for further research into which interventions are able to successfully reduce avoidable admissions among Aboriginal people, and the importance of culturally appropriate community health care.

Complicating Infections Associated with Common Endemic Human Respiratory Coronaviruses.

Coronaviruses OC43, 229E, NL63, and HKU1 are endemic human respiratory coronaviruses that typically cause mild to moderate upper respiratory infections, similar to the common cold. They also may cause simple and complicated lower respiratory infections, otitis media, asthma exacerbations, gastroenteritis, and a few systemic complications. These viruses are usually seasonal (with winter dominance) and affect nearly all age groups. The seasonal and annual variation in virus prevalence has implications for understanding the concept of acquired immunity and its persistence or diminution. Coronaviruses generally have outbreak potential in susceptible populations of any age, particularly in patients with comorbidities, who tend to have increased clinical disease. These 4 coronaviruses are often found in the context of what appears to be coinfection with other pathogens, but especially other viruses. If coronaviruses are not specifically tested for, the sole detection of a viral copathogen would suggest the pathogen is the causative agent, when a coronavirus may be culpable, or both. The detection of these viruses in circumstances where respiratory viruses are generally sought in clinical samples is, therefore, justified. These pathogens can be chronically shed from the respiratory tract, which is more likely to occur among immunocompromised and complicated patients. These viruses share the potential for genetic drift. The genome is among the largest of RNA viruses, and the capability of these viruses to further change is likely underestimated. Given the potential disease among humans, it is justified to search for effective antiviral chemotherapy for these viruses and to consider uses in niche situations should effective therapy be defined. Whereas SARS-CoV-2 may follow the epidemiological pattern of SARS-CoV and extinguish slowly over time, there is yet concern that SARS-CoV-2 may establish itself as an endemic human respiratory coronavirus similar to OC43, 2299E, NL63, and HKU1. Until sufficient data are acquired to better understand the potential of SARS-CoV-2, continued work on antiviral therapy and vaccination is imperative.

Outcomes in Patients with Hematologic Malignancies Infected with Sars-Cov-2: The Northwestern University Experience

Outcomes in Patients with Hematologic Malignancies Infected with Sars-Cov-2: The Northwestern University Experience

COVID-19 Pandemic Highlights Health Disparities in Latinos in San Diego

Introduction:Minority healthcare disparities are well known in many areas of medicine. Higher mortality has been reported in minorities with different cancer types despite adjusting for income or education. In hematological malignancies the trend persists. Despite favorable prognostic factors upon diagnosis of acute myelogenous leukemia, the mortality risk for Latinos and African Americans is higher by 12% and 7%, respectively. Both incidence and mortality in acute lymphoblastic leukemia are highest in Latinos. In Hodgkin's Lymphoma, Latino and African American adolescents and young adults have a higher risk of death at 35% and 62%, respectively.The COVID-19 pandemic has drawn attention to the immense disparities in healthcare outcomes in minority communities. Disproportionate rates of hospitalization and death related to COVID-19 have been reported across the nation, highlighting the stark consequences of historic racial and economic injustices. With these findings comes a call to action and an urgency to create systemic change to promote health equity.Methods:Patients hospitalized at any Scripps Health hospital in San Diego County from March 1, 2020 to July 30, 2020 with a PCR confirmed diagnosis of COVID-19 and blood type were included in the analysis (n = 316). Demographic, laboratory and clinical data were extracted from the electronic medical record and included age, ethnicity, BMI, sex, medications, co-morbidities, blood type, white blood cell count, lymphocyte count, hemoglobin, platelets, ESR, CRP and D-dimer. Outcomes of interest included length of say (LOS), intensive care unit (ICU) admission, intubation and mortality. Analysis was performed with an a priori predictor of Latin American ethnicity. Linear regression analysis of LOS, logistic regression of other variables and age-adjusted regression was done. Demographic characteristics that were predictive in univariate analysis with p< 0.1 were included in a multiple regression model for each outcome with Latin American ethnicity as a predictor. If the potentially predictive demographic characteristic maintained trends toward significance (p<0.1), the predictor was retained in the model to produce the final regression results for each outcome.Results:Hospitalized COVID patients were predominantly male, obese (BMI 30.6) and average age was 63 years. 69.3% of patients were Hispanic. 65.51% of patients were diabetic, 26.27% had chronic kidney disease and 23.10% had congestive heart failure. Additional patient characteristics are included in Table 1. Median length of hospital stay was 16.5 days, 59% were admitted to the ICU, 37% were intubated, and 27% died. Blood type was not found to be a predictor of outcomes. The odds ratio (OR) of age adjusted LOS for Latinos was 1.01 days (p-value 0.60), 1.06 for ICU admission (p-value 0.80) and 0.82 for death (p-value 0.50). After adjusting for age and other potentially predictive characteristics, Hispanic ethnicity was not predictive of poor outcomes.Conclusion:In this retrospective analysis of patients hospitalized for COVID-19 in San Diego County, there was a strikingly high rate of hospitalizations in Latino patients. While the 2019 United States Census estimates the Latino population in San Diego to be 34.1%, Latinos comprised nearly 70% of patients hospitalized with COVID-19 in the Scripps Health system. Despite the high rate of admissions in Latino patients, Latin American ethnicity was not a predictor of poor outcomes as previously reported in other populations. The underlying etiology of the high rates of COVID-19 hospital admission in Latinos is likely multifactorial due to overcrowding, lack of access to healthcare and higher prevalence of chronic illness as demonstrated by our cohort's increased incidence of co-morbid conditions.DisclosuresNo relevant conflicts of interest to declare.

The Causal Effect of PM2.5 Exposure on Hospital Admissions Among Medicare Enrollees with Chronic Debilitating Brain Disorders: A National Study.

Background: Although long-term exposure to particulate matter&lt;2.5µm (PM2.5) has been linked to chronic debilitating brain disorders (CDBD), the role of short-term exposure in health care demand, and increased susceptibility for PM2.5 -related health conditions, among people with CDBD has received little attention. We used a causal modeling approach to assess the effect of short-term high PM2.5 exposure on all-cause admissions, and prevalent cause-specific admissions among Medicare enrollees with CDBD (Parkinson’s disease-PD and dementia). Methods: We constructed daily zipcode counts of hospital admissions of Medicare beneficiaries older than 65 across the United-States (2000-2014). We obtained daily PM2.5 estimates from a satellite-based model. A propensity score matching approach was applied to match high-pollution (PM2.5 &gt;17.4 μg/m3) to low-pollution zip code-days with similar background characteristics. Then, we estimated the percent change in admissions attributable to high pollution. We repeated the models restricting the analysis to zip code days with PM2.5 below 35 µg/m3.Results: We observed significant increases in all-cause hospital admissions (2.53% (2.40%; 2.63%) in PD and 2.49% (2.38%; 2.60%) in dementia) attributable to high PM2.5 exposure. The largest observed effect for common causes was for pneumonia and urinary tract infection. All the effects were larger in CDBD compared to the general Medicare population, and similarly strong at levels of exposure considered safe by the EPA.ConclusionsWe found Medicare beneficiaries with CDBD to be at higher risk of being admitted to the hospital following acute exposure to PM2.5 levels well below the National Ambient Air Quality Standard defined as safe by the EPA. CDBD is known to be associated with higher rates of hospital admissions for causes such as pneumonia, dehydration, or UTI. It is therefore important to find preventable exposures that are associated with risk for emergency admissions due to various causes, rather than restricting the analysis to CDBD-related admission codes.

Injury Patterns and Demographics in Child and Adolescent Assault Victims Presenting to US Emergency Departments.

Objective To correlate injury patterns with patient demographics in child and adolescent assault victims. Methods The National Electronic Injury Surveillance System-All Injury Program data for the years 2005 through 2015 was used. Injuries due to assault were identified and analyzed with SUDAAN 11.0.01™ software to account for the weighted, stratified nature of the data. Results There were an estimated 4,407,009 ED visits for assault in patients ≤ 19 years of age. With increasing age, the percentage of females decreased. Sexual assaults were more common in females (87.4%), and robbery/burglary was more common in males (79.8%). When the perpetrator was a spouse/partner, the assault victim was most commonly female (88.8%), and when a stranger, the assault victim was most commonly male (71.5%). With increasing age, the percentage of sexual assaults decreased while the reason for the assault being unknown increased. The assault occurred in the home in 59.6% of those ≤ 4 years of age, decreasing to 18.7% in those 15 to 19 years of age. The anatomic location was the head/neck in 32.8% of those ≤ 4 years of age, increasing to 60.6% in those 15-19 years old. Those ≤ 4 years old had the highest hospital admission rate (8.3%). The main diagnoses were concussion (3.0%), contusion/abrasion (33.3%), fracture (11.5%), laceration (11.5%), internal organ injury (11.5%), puncture (2.8%), and strain/sprain (20.7%). The number of assaults from 2005 to 2015 decreased for all age groups except for those ≤ 4 years old. Conclusions These data provide a comprehensive overview of child and adolescent assault victims presenting to the ED in the USA and can be used as background data for further study. The decreasing numbers of assaults over the 11 years of the study are encouraging, and challenges still exist in decreasing the number for those ≤ 4 years old.

Risk of discharge against medical advice among hospital inpatients with a history of opioid agonist therapy in New South Wales, Australia: A cohort study and nested crossover-cohort analysis

BackgroundPeople who use illicit opioids have high rates of hospital admission. We aimed to measure the risk of discharge against medical advice among inpatients with a history of opioid agonist therapy (OAT), and test whether OAT is associated with lower risk of discharge against medical advice. MethodsWe conducted a cohort study of patients admitted to hospital in an emergency between 1 August 2001 and 30 April 2018 in New South Wales, Australia. All patients had a previous episode of OAT in the community. The main outcome was discharge against medical advice, and the main exposure was whether patients had an active OAT permit at the time of admission. Results14,035/116,957 admissions (12 %) ended in discharge against medical advice. Admissions during periods of OAT had 0.79 (0.76−0.83; p < 0.001) times the risk of discharge against medical advice, corresponding to an absolute risk reduction of 3.0 percentage points. Risk of discharge against medical advice was higher among patients who were younger, male, identified as Aboriginal and/or Torres Strait Islander, and those admitted for accidents, drug-related reasons, or injecting-related injuries (such as cutaneous abscesses). In a subsample of 7793 patients included in a crossover-cohort analysis, OAT was associated with 0.84 (95 % CI 0.76−0.93; p < 0.001) times the risk of discharge against medical advice. ConclusionsAmong patients with a history of OAT, one in eight emergency hospital admissions ends in discharge against medical advice. OAT enrolment at the time of admission is associated with a reduction of this risk.

The Emerging Role of Police in Facilitating Psychiatric Evaluation Since the 2013 Implementation of the First Chinese Mental Health Law.

In 2013, China's first Mental Health Law (MHL) took effect, with the goal of better protecting patients' rights. Under the law the police, with appropriate training, rather than family members, employers or medical staff sent from a hospital, are the ones who bring persons in behavioral crises to medical facilities for psychiatric assessment for possible involuntary hospitalization. We examined the proportion and distinctive characteristics of persons brought to psychiatric emergency services (PES) by the police since the implementation of MHL. We used medical records to document demographic and clinical characteristics of all persons evaluated at the PES of the Guangzhou Psychiatric Hospital, the largest psychiatric hospital in China's fourth largest city, from April 2017 to August 2017. Bivariate and multivariate statistical analyses were performed to identify characteristics of patients brought to the PES by the police. Among 1515 PES visits, 166 (11.0%) were brought by the police as compared to virtually none in the years before the law took effect. Compared to non-police referrals, police referrals were associated with male gender, age greater than 30, more documented violent behavior, greater likelihood of having been restrained, and higher rates of hospital admission after assessment. Assessed risk of suicidality and diagnoses of substance use disorder were not significantly associated with police referral. A modest but increased and noteworthy proportion of patients evaluated at the PES after implementations of China's MHL were brought by the police, especially those with violent behavior requiring restraint and hospitalization resulting from mental illness.

288 Characteristics and Outcomes of Patients with Ventricular Assist Devices Presenting to a Pediatric Emergency Department

Ventricular assist devices (VADs) are being used more frequently in pediatric patients with advanced heart failure. Outpatient management of children with VAD implantations also is becoming more common. However, no study exists that describes Emergency Department (ED) care of these patients. This study aims to identify patient characteristics and outcomes of children with VADs presenting to the ED. This is a retrospective descriptive study of all patients ages 0 to 18 years in the Stanford Children’s outpatient VAD program who presented to our pediatric ED between 2010 (year of first discharged VAD patient) and 2020. Patient data was abstracted from electronic medical records. Adverse events were defined according to the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) registry guidelines. Adverse events were included if they occurred during the ED visit or associated hospitalization. A total of 30 children with VAD implantations were transitioned to outpatient care in the study period. All were implanted with continuous flow devices. Among children in the outpatient VAD program, 20/30 (66.7%) had 38 visits to our pediatric ED over 141.5 patient-months. Median age of patients at time of ED visit was 12.5 (range 7.3-17.4) years. Median number of ED visits per discharged child was 1 (range 0-4). The most common complaints on arrival to ED included fever (7/38; 18.4%), abdominal pain or vomiting (7/38; 18.4%), headache (6/38; 15.8%), bleeding from any site (4/38; 10.5%), chest pain (4/38; 10.5%), device malfunction or alarm (3/38; 7.9%), dizziness (3/38; 7.9%), and dyspnea (3/38; 7.9%). Adverse events occurred during 14/38 (36.8%) ED visits or associated hospitalizations, including 3/38 (7.9%) instances each of hypertension, major infection, or right heart failure, 2/38 (5.3%) instances of major bleeding, and 1/38 (2.6%) instances each of hemolysis, renal dysfunction, or device malfunction. Hospital admission occurred in 27/38 (71.1%) of visits, including 10/27 (37.0%) to a cardiac intensive care unit. No patients died during an ED visit or associated hospitalization. Mortality of all children in the outpatient VAD program during the study period was 3/30 (10.0%) including one patient on destination therapy, one with hemorrhagic stroke, and one with multi-system organ failure due to cardiogenic shock. In a single outpatient pediatric VAD program, patients had high utilization of ED care and had a high rate of hospital admission following ED presentation. The youngest patient transitioned to outpatient VAD care was 7 years old. Fever, abdominal pain/vomiting, and headache were the most frequent initial complaints. The most common adverse events were hypertension, major infection, and right heart failure.

S0084 Epidemiology, Etiology, and Outcomes of Acute Pancreatitis in a Predominantly Hispanic Patient Population: A Retrospective Study

INTRODUCTION: Acute pancreatitis (AP) is the most frequent gastrointestinal cause for hospital admission in the United States with over 130,000 cases per year (0.8% of all inpatient admissions). Epidemiology and outcomes data influence health care resource allocation and clinical decision-making, which are particularly important for county and safety net institutions. Nevertheless, there are limited data on AP in minority populations. This study assessed the burden of disease of AP and its associated clinical characteristics and outcomes in a large, predominantly Hispanic, county population. METHODS: Patients from the three county hospitals comprising the Los Angeles Department of Health Services (LADHS), the second largest municipal healthcare system in the country, were considered for inclusion. Using a combination of International Classification of Disease (ICD) codes and lipase values, patients admitted with AP in LADHS between January and December 2016 were identified. Electronic medical records were individually abstracted for pertinent data and to exclude patients without AP. The primary outcomes were all cause mortality and readmission. Statistical analyses were performed with student’s t and chi-squared tests, as well as general linear model and logistic regression. RESULTS: During the study period, 356 patients were admitted to a LADHS hospital with AP, representing 1.2% of all hospital admissions. Of these 356 patients, 78% of patients self-identified as Hispanic. The majority of patients were men (56.2%), with mean age of 43.9 years and body mass index of 32.4 kg/m2. and 21% reported a prior history of AP. The median hematocrit and BISAP score on admission were 40.6% and 2 (mortality <2% predicted), respectively. The most common etiologies of AP were gallstones (40.2%) and alcohol (22.8%). Median length of stay was 5 days. All-cause mortality rate at 30 days and 1 year were 3.9% and 4.7%, respectively. Notably, 19.4% of patients required re-admission within 30 days, 39% of which were for AP. CONCLUSION: Based on this study of a large, predominantly Hispanic population, there appears to be a 50% higher rate of hospital admission for AP as compared to national data (1.2% vs 0.8%). Obesity was a prominent feature, and gallstones were the most common etiology, similar to national statistics. Mortality and length of stay were comparable to those in the published literature, though nearly 20% of patients experienced re-admission, a rate higher than expected based on national data (11.9%–16.2%).

Challenges and Strategies for Inpatient Diabetes Management in Older Adults.

Adults older than 65 years of age are the fastest growing segment of the U.S. population. Aging is also one of the most important risk factors for diabetes, and about one-third of all individuals with diabetes are in this age-group. Older people with diabetes are more likely to have comorbidities such as hypertension, ischemic heart disease, chronic kidney disease, and cognitive impairment, which lead to higher rates of hospital admissions compared with individuals without diabetes. Professional organizations have recommended patient-centric individualized glycemic reduction approaches, with an emphasis on potential harms of intensive glycemic control and overtreatment in older adults. Insulin therapy remains a mainstay of diabetes management in the inpatient setting regardless of patients' age; however, there is uncertainty about optimal glycemic targets during the hospital stay. Increasing evidence supports selective use of dipeptidyl peptidase-4 inhibitors, alone or in combination with low-dose basal insulin, in older noncritically ill patients with mild to moderate hyperglycemia. This article reviews the prevalence, diagnosis, and monitoring of, and the available treatment strategies for, diabetes among elderly patients in the inpatient setting.

Guidelines for Redeploying Psychiatrists to Medicine During a Pandemic Crisis

In January 2020, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus, was identified as the causative agent for pneumonia cases in the Hubei Province of China. By March 11, 2020, coronavirus disease 2019 (COVID-19) reached pandemic levels and had spread to nearly every continent. Due to an exponential growth of cases and high rate of hospital admission, patient volume rapidly exceeded capacity. To meet demand, physicians in Asia, Europe, and the United States, regardless of their specialty, were redeployed to COVID-19 units. Redeployment of physicians involves complex decisions, such as whom to reassign, where to reassign, and how to balance needs of frontline services with those of other critical services. Guidelines for these challenging decisions are scarce. To address this critical gap in policy, we present general recommendations for redeploying psychiatrists to the medical front lines. We address levels of preparedness, complexity of the medical settings, use of house staff, medical supervision, emotional support, risk management, back-filling psychiatric services, provider diversity, and ethical, legal, and regulatory challenges. Our guidelines are general and not intended to be “one size fits all,” as we recognize that local conditions will necessitate adaptation. [ Psychiatr Ann . 2020;50(7):301–305.]

Malnutrition Prevalence and Burden on Healthcare Resource Use Among Spanish Community-Living Older Adults: Results of a Longitudinal Analysis.

PurposeLittle is known about the economic burden that malnutrition or its risk imposes on community-dwelling older adults. Using cross-sectional and longitudinal analyses, we assessed the impact of malnutrition risk on healthcare utilization and costs in a cohort of older adults living in Spanish community.Patients and MethodsData from 1660 older (range 66–98 years), community-living adults participating in the Toledo Study on Healthy Ageing, waves 2 (year 2011–2013) and 3 (year 2015), were analyzed. Nutritional status categories were defined according to the Global Leadership Initiative on Malnutrition (GLIM) criteria, using a two-step approach. First, screening for malnutrition risk. Once positive, individuals were classified as malnourished according to some phenotypic (body mass index, grip strength, and unintentional weight loss) and etiologic (disease burden/inflammation and reduced food intake or assimilation) criteria. Outcomes assessed included healthcare resources (hospital admissions, number of hospitalizations, length of hospital stay per hospitalization, and number of medications).ResultsFifteen percent of the population was found to be at risk of malnutrition, while 12.6% was malnourished. Overall, patients from both groups were older, had lower functional status, and had more comorbidities compared to well-nourished counterparts (p<0.05). Results of our cross-sectional analysis showed that being at-risk/malnourished was associated with greater medication utilization, higher rates of hospital admission and longer stays, and higher hospitalization costs. However, when adjusting for covariates, malnutrition/risk was associated only with higher hospitalization costs (range: 11–13%). Longitudinal analysis results indicated that malnutrition/risk was significantly associated with more frequent hospitalizations, longer lengths of stay, higher hospitalization costs, and polypharmacy at follow-up.ConclusionMalnutrition or its risk, found in over one of four older adults in the Toledo community, was associated with higher healthcare resource use and increased costs. Such findings suggest that malnutrition risk-screening for older adults, and provision of nutrition counseling and care when needed, hold potential to improve their health and to lower costs of care in the Spanish healthcare system.

Clinical burden of diabetes in Italy in 2018: a look at a systemic disease from the ARNO Diabetes Observatory

IntroductionDiabetes is a highly prevalent disease worldwide and represents a challenge for patients and healthcare systems. This population-based study evaluated diabetes burden in Italy in 2018 by assessing all aspects...

Validity of the Emergency Severity Index (Version 4) in Postpartum Women After Cesarean Delivery [40P

INTRODUCTION: To examine the validity of the Emergency Severity Index version 4 (ESI v.4) in women who presented to an Emergency Department within 6 weeks after cesarean delivery. METHODS: This was a retrospective cohort study of all women who presented to MedStar Washington Hospital Center Emergency Department from July 2013 to June 2018 within 6 weeks after cesarean delivery. Acuity level was assigned by triage nurses using the ESI v.4 algorithm (1 being the highest acuity and 5 being the lowest acuity). To analyze the validity of ESI v.4, women were divided into 3 groups: high-acuity (ESI levels 1 and 2), medium-acuity (ESI level 3), and low-acuity (ESI levels 4 and 5). We examined the rates of readmission, specialty consultations such as gynecologists, and high resource use (2 or more). RESULTS: Of 439 women who presented to the Emergency Department, the distribution of acuity levels was as follows: low-acuity 20.1%; medium-acuity 56.0%; and high-acuity 23.9%. High-acuity and medium-acuity groups had higher rates of hospital admission compared to low-acuity group (2.3% vs. 19.1% vs. 47.6%; P&lt;.001). High-acuity and medium-acuity groups had higher rates of specialty consultation compared to low-acuity group (12.5% vs. 47.2% vs. 69.5%; P&lt;.001). High-acuity and medium-acuity groups had higher rates of high resource use compared to low-acuity group (15.5% vs. 70.8% vs. 86.0%; P&lt;.001). CONCLUSION: The ESI v.4 was predictive of readmission, specialty consultation, and high resource use in women who presented to the Emergency Department within 6 weeks after cesarean delivery.

Health-Related Quality of Life and Use of Hospital Services by Patients with Heart Failure and Their Family Caregivers: A Multicenter Case-Control Study.

Heart failure (HF) causes high rates of hospital admissions. It is known that disease progression impacts the health-related quality of life (HRQoL) of both patients and caregivers, yet to date, this finding is based on cross-sectional studies with limited samples. The study aim is to analyze the relationship between HF patients' use of hospital services (a proxy for disease progression) and the HRQoL of their family caregivers. This work is a multicenter nested case-control study on a population of patients admitted to hospitals in southern Spain due to heart failure. The sample comprised 530 patient-caregiver dyads. Hospital admission data were retrospectively collected for the 5 years prior to inclusion in the study. Bivariate analyses and multivariate logistic regression were used to determine associations between patient deterioration and caregivers' quality of life. Patients' use of hospital services was associated with worsened quality of life for family caregivers, with an overall OR of 1.48 (95% CI: 1.23-1.79). A positive correlation was found between patients' perceptions of their physical health and the perceived mental health of caregivers (r = 0.127, p = 0.004) and between the perceived mental health of both (r = 0.291; p <0.0001). Greater use of hospital services by patients with HF is an independent predictor of deterioration of family caregivers' HRQoL. The physical and mental components of patients' and their family caregivers' HRQoL interact and influence each other. Additional factors, such as the nature and intensity of care provided, also determine the worsening of a family caregiver's HRQoL. These results can be used to identify family caregivers of people with heart failure at risk of suffering a deterioration in their health-related quality of life.Increased use of hospital services is an independent predictor of the deterioration of the family caregivers' health-related quality of life. Since clinical nurses are the main provider who gives support and education to family caregivers, they should be alert to this situation and individualize interventions to prevent this deterioration.

Association of Initiation of Dialysis With Hospital Length of Stay and Intensity of Care in Older Adults With Kidney Failure

Comparative outcome data examining the association of dialysis initiation with hospital length of stay and intensity of care in older adults with kidney failure are scarce, and prior studies are limited to patients treated by nephrology teams. To compare in-hospital days and intensity of care among older adults with kidney failure who were treated vs not treated with maintenance dialysis. This population-based, retrospective cohort study included adults in Alberta, Canada, 65 years or older with kidney failure, defined by at least 2 consecutive outpatient estimated glomerular filtration rate values of less than 10 mL/min/1.73 m2 spanning a period of at least 90 days from May 15, 2002, to March 31, 2014. Data were analyzed from August 1, 2017, to August 29, 2019. Time-varying exposure to maintenance dialysis for treatment of kidney failure. The primary outcome was rate of in-hospital days. Secondary outcomes included rates of hospital admissions, intensive care unit admissions, cardiopulmonary resuscitations, inpatient palliative care, and emergency department visits; risk of in-hospital death; and time to admission to long-term care. A total of 968 patients (median age, 78.5 [interquartile range, 72.4-84.7] years; 489 men [50.5%]; median follow-up, 2.0 [interquartile range, 0.8-3.9] years) were included in the analysis. Patients who underwent dialysis spent more adjusted in-hospital days per person-year (36.25 [95% CI, 30.72-41.77] vs 14.65 [95% CI, 12.28-17.02]; incidence rate ratio [IRR], 2.47 [95% CI, 1.99-3.08]). However, the dialysis group did not have a higher rate of hospital admissions (1.18 [95% CI 1.07-1.29] vs 1.32 [95% CI 1.17-1.48] per year; IRR, 0.89 [95% CI, 0.77-1.03]). Patients in the dialysis group had a higher rate of intensive care unit admissions per 1000 hospitalizations (98.37 [95% CI, 81.09-115.65] vs 54.51 [95% CI, 37.76-71.26]; IRR, 1.80 [95% CI, 1.28-2.54]) and lower rates of inpatient palliative care per 1000 in-hospital days (3.92 [95% CI, 3.13-4.72] vs 8.60 [95% CI, 6.3-11.0]; IRR, 0.45 [95% CI, 0.32-0.64]). In this cohort study, compared with nondialysis care, patients who received maintenance dialysis spent more time in the hospital and were more likely to be admitted to intensive care units. This finding suggests trade-offs between longer survival and higher intensity of use of health care services as a function of dialysis initiation. Maintenance dialysis may be a proxy for the type of philosophy of care driving increased in-hospital time and intensive care and less use of palliative care.

Resource utilization across the continuum of HIV care: An emergency department-based cohort study.

The objective of this study was to determine the healthcare resource utilization for people living with HIV (PLWH) presenting to the emergency department (ED) across the HIV Care Continuum. This prospective study enrolled PLWH presenting to an urban ED between June 2016 and March 2017. Subjects were categorized as being linked to care, retained in care, on antiretroviral therapy (ART), and virally suppressed (<200 copies/ml). Data on ED visit rates, duration of stay, and hospital admission rates were compared to local metrics. Overall, 94.3% of 159 enrollees had been linked to care, 75.5% retained in care, 81.1% on ART, and 62.8% virally suppressed. Compared to the general population of the city and of the ED, participants had a higher ED visit rate (3.0 v. 1.2 visits per person-per year) in the past two years, a higher median duration of ED stay (12.6 v. 7.6h), and a higher hospital admission rate (36.5% v. 24.9%) during their index ED visit. Viral suppression was negatively associated with admission (OR=0.35, 95% CI: 0.17, 0.72). Forty-eight (30.2%) participants who had at least eight ED visits in the past two years were more likely to have a diagnosed mental health disorder (79.2% v. 62.2%, p=0.036). Our results showed that PLWH use more ED resources than the general population and a better engagement in HIV care is linked to lesser ED resource utilization for PLWH, indicating the importance of improved HIV care engagement in healthcare utilization management.

Evaluation of a follow-up program for diabetes after hospital discharge

Given the higher rate of hospital admissions among diabetic patients, discharge should be used to optimize outpatient treatment. We evaluate a follow-up program for diabetic patients after hospital discharge to determine the evolution of glycemic control. Retrospective collection of data on 375 diabetic patients enrolled in the follow-up program for optimization treatment: telephonic follow-up where treatment was adjusted if needed; and three months after discharge an in-person consultation was scheduled. Factors potentially associated with a 1% improvement in HbA1c were studied by multivariate logistic regression. Seventy-three percent of enrolled patients completed the follow-up program; each patient received an average of 4.6 phone calls. Globally, basal mean HbA1c was significantly lower three months later regarding the initial value (8.6 vs. 7.2%); the most relevant lowering was found in the group of hyper-glycemia by poor metabolic control (from 9.9 to 7.7%), combined hyperglycemia (from 9.3 to 7.3%) and debut (from 8.3 to 6.4%). Twenty percent of patients reported capillary hypoglycemia, with two severe events. A shorter duration of diabetes, absence of corticotherapy and absence of hypoglycemia during the follow-up period were independent predictors for a 1% reduction in three-months HbA1c. In patients whose treatment is changed on hospital discharge, a program allowing frequent treatment adjustment would improve HbA1c levels. These results could help to organize health resources more rationally.

Screening Heroin Smokers Attending Community Drug Clinics for Change in Lung Function: A Cohort Study

BackgroundHeroin smokers have high rates of COPD, respiratory morbidity, hospital admission, and mortality. We assessed the natural history of symptoms and lung function in this population over time.MethodsA cohort of heroin smokers with COPD was followed for 18 to 24 months. At baseline and follow-up, respiratory symptoms were measured by the Medical Research Council Dyspnea Scale (MRC) and the COPD Assessment Tool (CAT), and postbronchodilator spirometry was performed. Frequency of health-care-seeking episodes was extracted from routine health records. Parametric, nonparametric, and linear regression models were used to analyze the change in symptoms and lung function over time.ResultsOf 372 participants originally recruited, 161 were assessed at follow-up (mean age, 51.0 ± 5.3 years; 74 women [46%]) and 106 participants completed postbronchodilator spirometry. All participants were current or previous heroin smokers, and 122 (75.8%) had smoked crack. Symptoms increased over time (MRC score increased by 0.48 points per year, P < .001; CAT score increased by 1.60 points per year, P < .001). FEV1 declined annually by 90 ± 190 mL (P < .001). This deterioration was not associated with change in tobacco or heroin smoking status or use of inhaled medications.ConclusionsHeroin smokers experience a high and increasing burden of chronic respiratory symptoms and a decline in FEV1 that exceeds the normal age-related decline observed among tobacco smokers with COPD and healthy nonsmokers. Targeted COPD diagnostic and treatment services hosted within opiate substitution services could benefit this vulnerable, relatively inaccessible, and underserved group of people.