Higher Odds Of Hospitalization Research Articles

The association between employment changes and healthcare use in the year after cancer diagnosis.

6551 Background: Employed adults diagnosed with cancer face difficult decisions about continuing/returning to work and intensity of work following diagnosis. We examined the association between employment changes and healthcare use among cancer survivors. Methods: Data on adults enrolled at two health plans (Kaiser Permanente (KP) Colorado and KP Washington), diagnosed with breast, colorectal, lung, melanoma, and prostate cancers between 2003-2008, who responded to a 2013 survey with items on employment patterns following diagnosis were used. Survey data were linked to electronic health record (EHR) data on healthcare use, demographics, and cancer characteristics. Employment status and changes following diagnosis were measured. Multivariable logistic and negative binomial regression models were used to assess associations between employment changes and healthcare use in the year after diagnosis, adjusting for demographic and cancer characteristics. Results: Among 465 cancer survivors with complete survey and EHR data, 225 (48.4%) reported being employed since diagnosis. Among employed survivors, 126 (56.0%) reported making an employment change. Those who made a change were more likely to be female, diagnosed with AJCC stage 3 or 4 cancer, have received chemotherapy or hormone therapy, and had a caregiver (all p < 0.01). The most common employment changes were taking extended paid time off (53.2%), unpaid time off (39.7%), and switching to a flexible schedule (29.4%). Employment changes were made at initial diagnosis (18.3%), during treatment (70.6%), and ≤12 months post-treatment (26.2%); 28.6% made more than one change. Survivors who made an employment change had significantly more oncology visits (IRR = 1.85 [95% CI: 1.14-3.00]) and higher odds of hospitalization (OR = 5.18 [95% CI: 2.50-10.8]), but not primary care visits (IRR = 1.19 [95% CI: 0.94-1.50]) in the year after diagnosis, compared to those who did not make a change. Conclusions: Employment changes among cancer survivors are common and may be associated with treatment intensity and other healthcare use in the year after diagnosis. Prospective studies are needed to assess the impact of employment and healthcare use patterns on health outcomes.

Impact of Clinical Pathway and Rapid Direct Influenza Polymerase Chain Reaction Test Introduction on Readmissions Among Non-hospitalized Children with Influenza-Like Illness

BackgroundDiagnosing influenza is challenging in children as influenza-like illness (ILI) symptoms are nonspecific. A clinical pathway was introduced in the emergency department (ED) of a large pediatric hospital to screen and treat patients at high risk of influenza-related complications. A new highly accurate, rapid polymerase chain reaction (PCR) influenza test was introduced the next year to provide more timely results. We aimed to measure the impact of the pathway and new PCR test on rates of all-cause ED readmissions and subsequent hospital admissions in all children with ILI discharged from the ED.MethodsWe conducted a retrospective cohort study of non-hospitalized children≤18 years presenting to the ED with ILI over 3 winter seasons. ILI cases were identified using syndromic surveillance definitions. Outcomes included any return ED encounter or hospital admission within 2 weeks of initial ED visit. We compared difference in outcomes between the years before pathway introduction, after pathway introduction, and after rapid PCR test introduction. Multivariate logistic regression adjusted for pertinent sociodemographic and clinical covariates.ResultsAmong 10799 children with ILI, 6.1% had an ED readmission and 2.5% had a hospital admission within 2 weeks of an initial ED visit. Overall rates of ED readmission or hospitalization did not differ significantly by study year (5.7% vs 6.5% vs 6.1%, P = 0.41, and 2.9% vs 2.4% vs 2.3%, P = 0.36). In multivariate analysis, pathway introduction alone was not associated with likelihood of ED readmission or hospitalizations. However, rapid PCR test introduction with the pathway was associated with lower odds of hospitalization (aOR 0.70, 95% CI 0.51–0.97). High-risk status was associated with higher odds of ED readmission (aOR 1.42, 95% CI 1.21–1.68). High-risk status and severity of illness at the initial ED visit were associated with higher odds of hospitalization (aOR 1.51, 95% CI 1.13–2.03; aOR 10.66, 95% CI 6.05–18.79).ConclusionClinical pathway and rapid PCR test introduction does not decrease all-cause ED readmissions but does decrease all-cause hospital admissions in children with ILI. Clinical factors such as severity of illness and high-risk status play a large role in determining outcomes.Disclosures All authors: No reported disclosures.

Costs of Care for Hospitalization for Pemphigus in the United States.

Pemphigus is an autoimmune blistering disorder associated with significant morbidity and mortality. However, little is known about the inpatient burden of pemphigus. To determine the incidence of and risk factors for hospitalization with pemphigus and cost of care. The 2002-2012 Nationwide Inpatient Sample provided by the Healthcare Cost and Utilization Project from the Agency for Healthcare Research and Quality was analyzed. A total of 87 039 711 children and adults (mean [SD] age, 57.7 [0.98] years for those with a primary diagnosis of pemphigus; 70.6 [0.32] years for those with a secondary diagnosis of pemphigus; and 47.9 [0.19] years for those without a diagnosis of pemphigus) were studied. Data analysis was performed from June 1 to August 30, 2015. Hospitalization rates, length of stay, and cost of care. There were 1185 and 5221 patients admitted with a primary or secondary diagnosis of pemphigus, respectively; when factoring in weights that generalize the sample to the entire hospitalized US cohort, these admissions represented weighted frequencies of 5647 and 24 880, respectively. In multivariable logistic regression models with stepwise selection, increasing age (adjusted odds ratios [95% CIs]: 18-39 years: 5.53 [4.28-7.14], P < .001; 40-59 years: 10.98 [8.46-14.24], P < .001; 60-79 years: 7.54 [5.75-9.89], P < .001; ≥80 years: 7.57 [5.71-10.04], P < .001), female sex (1.10 [1.01-1.20], P = .047), nonwhite race/ethnicity (black: 1.94 [1.75-2.14], P < .001; Hispanic: 4.10 [3.74-4.48], P < .001; Asian: 3.16 [2.68-3.73], P < .001; Native American: 2.11 [1.45-3.08], P < .001), lower household income (quartile 2: 1.19 [1.07-1.32], P < .001), being insured with Medicare (1.56 [1.41-1.74], P < .001) or Medicaid (1.55 [1.39-1.73], P < .001), number of chronic conditions (2-5: 2.36 [2.10-2.65], P < .001; ≥6: 1.47 [1.29-1.69], P < .001), hospital location in a metropolitan area (not metropolitan or micropolitan: 0.60 [0.49-0.72], P < .001), and summer season (1.12 [1.02-1.23], P = .02) were all associated with hospitalization for pemphigus. The total inflation-adjusted cost of care for patients with a primary inpatient diagnosis of pemphigus was $74 466 305, with a mean (SD) annual cost of $14 520.93 ($913.22). The inflation-adjusted cost of care for patients with a primary diagnosis of pemphigus increased significantly from 2002 to 2012 (analysis of variance, P < .001). In particular, length of stay was higher in racial/ethnic minorities compared with whites (survey linear regression, log β [95% CI]: black: 0.076 [0.075-0.076]; Hispanic: 0.021 [0.021-0.022]; Asian: 0.037 [0.036-0.039]; Native American: 0.010 [0.0076-0.013]), lower quartile household income (quartile 1: 0.024 [0.023-0.024]; quartile 2: 0.0029 [0.0022-0.0035]), and those without private insurance (Medicare: 0.12 [0.12-0.12]; Medicaid: 0.082 [0.081-0.083]; no charge: 0.051 [0.047-0.055]). There is a significant inpatient burden for pemphigus in the United States. Moreover, there appear to be racial/ethnic and health care disparities with respect to pemphigus, such that poor, nonwhite, and/or uninsured or underinsured patients have higher odds of hospitalization.

Time Trends, Predictors, and Outcome of Emergency Department Use for Gout: A Nationwide US Study.

To assess gout-related emergency department (ED) use/charges and discharge disposition. We used the US National ED Sample (NEDS) data to examine the time trends in total ED visits and charges and ED-related hospitalizations with gout as the primary diagnosis. We assessed multivariable-adjusted predictors of ED charges and hospitalization for gout-related visits using the 2012 NEDS data. There were 180,789, 201,044, and 205,152 ED visits in 2009, 2010, and 2012 with gout as the primary diagnosis, with total ED charges of $195 million, $239 million, and $287 million, respectively; these accounted for 0.14%-0.16% of all ED visits. Mean/median 2012 ED charges/visit were $1398/$956. Of all gout-related ED visits, 7.7% were admitted to the hospital in 2012. Mean/median length of hospital stay was 3.9/2.6 days and mean/median inpatient charge/admission with gout as the primary diagnosis was $22,066/$15,912 in 2012. In multivariable-adjusted analyses, these factors were associated with higher ED charges: older age, female sex, highest income quartile, being uninsured, metropolitan residence, Western United States hospital location, heart disease, renal failure, heart failure, hypertension (HTN), diabetes, osteoarthritis (OA), and chronic obstructive pulmonary disease (COPD). These factors were associated with higher odds of hospitalization: older age, Northeast location, metropolitan teaching hospital, higher income quartile, heart disease, renal failure, heart failure, hyperlipidemia, HTN, diabetes, COPD, and OA, whereas self-pay insurance status was associated with lower odds of hospitalization, following an ED visit for gout. Absolute ED use and charges for gout increased over time, but relative use remained stable. Modifiable comorbidity factors associated with higher gout-related use should be targeted to reduce morbidity and healthcare use.

Examining palliative care program use and place of death in rural and urban contexts: a Canadian population-based study using linked data

Palliative care has been both more available and more heavily researched in urban than in rural areas. This research studies factors associated with palliative care program (PCP) enrollment and place of death across the urban/rural continuum. Importantly, rather than simply comparing urban and rural areas, this article examines how the effects of demographic, geographic, and socioeconomic factors differ across service delivery settings within the Canadian province of Nova Scotia. This study linked PCP patient enrollment files from three districts to Nova Scotia vital statistics death certificate data. Postal codes of the decedents were mapped to 2006 Canadian dissemination area census data. The study examined 23 860 adult residents of three district health authorities, who died from 2003 to 2009 with a terminal illness, organ failure, or frailty and who were not nursing home residents. Demographic, geographic, and socioeconomic predictors of PCP enrollment and place of death were investigated using logistic regression across the entire study area, and stratified by district of residence. Univariate and multivariate (adjusted) odds ratios (OR) and their 95% confidence intervals (CI) are reported. Overall, 40.3% of the study subjects were enrolled in a PCP, and 73.4% died in hospital. Odds of PCP enrollment were highest for females (OR: 1.30; 95%CI: 1.22, 1.39), persons aged 50-64 years (OR: 1.50; 95%CI: 1.35, 1.67), and persons with a terminal disease such as cancer. While in overall multivariate analysis residents of census metropolitan areas and agglomerations had higher odds of enrollment (OR: 1.51; 95%CI: 1.29, 1.77), and those at greater distance from a PCP had lower odds (OR: 0.33; 95%CI: 0.27, 0.40), stratified analysis revealed a more nuanced picture. Within each district, travel time to PCP remained a significant predictor of enrollment but the magnitude of its effect differed markedly. There was no consistent relationship with urban/rural residence, social deprivation, or economic deprivation. Enrollment in a PCP was associated with lower adjusted odds of dying in hospital (OR: 0.78; 95%CI: 0.72, 0.84), and those living at greater distance from a PCP had higher odds of hospitalization (OR: 1.52; 95%CI: 1.28, 1.81), but there was no consistent relationship for urban/rural residence or across districts. Geographic patterns of PCP enrollment and place of death differed by district, as did the impact of economic and social deprivation. Analysis and reporting of population-based indicators of access should be grounded in an understanding of the characteristics of geographic areas and local context of health services. Although more research is needed, these findings show promise that disparities in access between urban and rural settings are not unavoidable, and positive aspects of rural and remote communities may be leveraged to improve care at end of life.

Effect of Multiple Previous Miscarriages on Health Behaviors and Health Care Utilization During Subsequent Pregnancy

BackgroundWomen with a history of miscarriage report feeling emotionally guarded during a subsequent pregnancy and may be at increased risk for pregnancy-related anxiety and greater health care utilization compared with women without a history of miscarriage. However, these behaviors have not been studied in women with a history of multiple miscarriages. MethodsWe examined the effect of a history of multiple miscarriages on health behaviors and health care utilization in 2,854 women ages 18 to 36 years expecting their first live-born baby. Self-reported health behaviors and use of health care resources during pregnancy were compared for women with a history of two or more miscarriages and women with one or no miscarriages. FindingsWomen with a history of multiple miscarriages were more than four times as likely to smoke during pregnancy (adjusted odds ratio [aOR], 4.69; 95% CI, 2.63–8.38) compared with women without a history of multiple miscarriages. They initiated prenatal care earlier (7.0 vs. 8.2 weeks gestation), had higher odds of third trimester emergency department visit (aOR, 2.21; 95% CI, 1.24–3.94), higher odds of hospitalization during pregnancy (aOR, 1.66; 95% CI, 1.01–2.73), and twice the mean number of third trimester emergency department visits and hospitalizations during pregnancy. ConclusionsWomen with a history of multiple miscarriages may be more likely to smoke and may demonstrate increased health care utilization during a subsequent pregnancy. Compassionate, individualized, and supportive counseling by providers may address smoking and other health behaviors as well as increased health care utilization.

Effect of Socioeconomic Position on Patient Outcome After Hysterectomy

Objective To investigate the association between socioeconomic position (assessed by education, employment and income) and complications following hysterectomy and assess the role of lifestyle, co-morbidity and clinical conditions on the relationship. Design Register-based cohort study. Setting and population The study included nearly all Danish women (n = 22 150) registered with a benign elective hysterectomy in the Danish Hysterectomy Database in 2004–2008. Methods Data were analyzed using logistic regression models estimating the odds ratio with 95% confidence intervals. Main outcome measures Complications following hysterectomy. Results Seventeen percent of the women experienced complications in relation to the hysterectomy. Women with less than high school education and unemployed women had higher odds of infection, complications and readmission than women with more than high school education and employed women. Furthermore, unemployed women had higher odds of hospitalization >4 days than women in employment. Lifestyle factors (smoking and body mass index) and co-morbidity status seemed to explain most of the social differences. However, an association between women with less than high school education and all complications remained unexplained. Furthermore, differences in lifestyle and co-morbidity status only partially explained the higher odds of infection, complications and hospitalization >4 days for unemployed than employed women. Conclusion Women with a low socioeconomic position have significantly higher odds of complications following hysterectomy compared with women with a high socioeconomic position. Unhealthy lifestyle and presence of co-morbidity in women with low socioeconomic position partially explains the differences in complications.

Effect of socioeconomic position on patient outcome after hysterectomy.

To investigate the association between socioeconomic position (assessed by education, employment and income) and complications following hysterectomy and assess the role of lifestyle, co-morbidity and clinical conditions on the relationship. Register-based cohort study. The study included nearly all Danish women (n=22150) registered with a benign elective hysterectomy in the Danish Hysterectomy Database in 2004-2008. Data were analyzed using logistic regression models estimating the odds ratio with 95% confidence intervals. Complications following hysterectomy. Seventeen percent of the women experienced complications in relation to the hysterectomy. Women with less than high school education and unemployed women had higher odds of infection, complications and readmission than women with more than high school education and employed women. Furthermore, unemployed women had higher odds of hospitalization >4days than women in employment. Lifestyle factors (smoking and body mass index) and co-morbidity status seemed to explain most of the social differences. However, an association between women with less than high school education and all complications remained unexplained. Furthermore, differences in lifestyle and co-morbidity status only partially explained the higher odds of infection, complications and hospitalization >4days for unemployed than employed women. Women with a low socioeconomic position have significantly higher odds of complications following hysterectomy compared with women with a high socioeconomic position. Unhealthy lifestyle and presence of co-morbidity in women with low socioeconomic position partially explains the differences in complications.

Identifying Cirrhosis Patients for Intensive Disease Management

Our healthcare system is based on the disease model prevalent at the beginning of the 20th century, in which people would typically develop acute illnesses, get hospitalized, and either die or full recover, with little emphasis placed on the management of chronic diseases. In contrast, chronic illnesses now account for more than 75% of total health care expenditures,1 as such, the episodic, symptom-driven nature of our health care system is poorly structured to manage this increasing burden of chronic conditions, of which cirrhosis, affecting approximately 750,000 adults in the United States, with a median time from diagnosis to death of 10 years, serves as a useful disease example.2 In similar conditions such as heart failure, advances in chronic disease management have substantially improved patient outcomes. These advances include relatively simple concepts such as patient education, medication reconciliation, and telephone management between visits.3 Recent pilot data suggests that similar interventions might also improve outcomes in cirrhosis.4,5 (Figure 1) Since none of these interventions come without a cost, they would be most efficiently applied by targeting patients who are most likely to develop problems. Figure 1 Results of a randomized pilot study demonstrating improved survival among cirrhosis patients receiving chronic disease management4 In this issue of Digestive Diseases and Sciences, Johnson et al. present a study that identifies patient characteristics associated with increased likelihood of hospitalization for complications of cirrhosis. Among a cohort of 395 ambulatory cirrhosis patients, 142 (36%) were hospitalized for a cirrhosis-related complication during a median of 3.7 years of follow-up, with 78 (19.7%) being hospitalized within the first year. Using multivariable analysis, independent predictors of hospitalization were Model for End-stage Liver Disease (MELD) score at baseline, the presence of hepatocellular carcinoma, prior hospitalization, marital status, and diuretic usage. As a single-center study performed at a liver transplant center, the patient population may have been somewhat sicker than at non-transplant centers. Despite these usual caveats, however, this study is important because it is the first to predict hospitalization in outpatients with cirrhosis. Hospitalizations not only serve as a marker for many of the important complications of cirrhosis, but can also identify vulnerable patients at risk for mortality.6 Therefore, the risk factors identified in this study may be used in the future to select patients for more intensive disease management interventions. Most of the identified risk factors, such as MELD score, do not come as a surprise to any practicing gastroenterologist, but one that does stand out is marital status. On multivariate analysis, unmarried patients had a 1.9-fold higher odds of hospitalization during the first year of follow-up, which was almost as strong a risk factor as having a MELD score >15. Furthermore, being unmarried was independently associated with a 2.5-fold higher odds of death over a 2- year follow-up period (p=0.01). This is a striking finding that deserves further attention because marital status may be a surrogate for social support, and thus something that is potentially remediable. Several recent studies have documented the burden that friends and family face when caring for a loved one with cirrhosis,7,8 with one other population-based study reporting an association between marital status and survival among patients with cirrhosis.9 With such a major impact on mortality, further investigation of social support systems in cirrhosis management is warranted. For example, at our center, we are currently pilot testing an automated phone management system which sends email updates to caregivers who live geographically distant from the patient – thus potentially broadening the net of social support for unmarried or widowed patients. In summary, the study by Johnson et al. reports that one-fifth of ambulatory patients with cirrhosis will be hospitalized within a year for complications of their disease. Rather than waiting for complications, physicians should try to predict and prevent them. Patients at higher than average risk include those with higher MELD scores, hepatocellular carcinoma, prior hospitalizations, diuretic usage, and single marital status; these individuals may benefit from more intensive outpatient management.

Association between underweight and hospitalization, emergency room visits, and mortality among patients in community medical homes

BackgroundIn older adults, underweight (body mass index [BMI] <18.5) has been associated with increased mortality. This increased mortality risk may be associated with increased health care utilization. We evaluated the relationship between underweight and hospitalization, emergency room visits, and mortality.MethodsAn analysis of a retrospective cohort study was conducted at a multisite academic primary care medical practice in Minnesota. The patients were ≥60 years of age, impaneled within primary care on January 1, 2011, and had a BMI measurement recorded between January 1, 2011, and December 31, 2011. Individuals were excluded if they refused review of their medical record. The primary measurement was BMI, which was categorized as underweight (BMI < 18.5) or normal and obese (BMI ≥ 18.5). The outcomes were hospitalization, emergency room visits, and mortality in the 2011 calendar year. Associations between underweight and each outcome were calculated using logistic regression. Interactions between underweight and gender were assessed in the logistic regression models. The final results were adjusted for age, gender, comorbid health conditions, and single living status.ResultsThe final cohort included 21,019 patients, of whom 220 (1%) were underweight. Underweight patients had a higher likelihood of hospitalization compared with patients with higher BMI (adjusted odds ratio [OR] 1.64; 95% confidence interval [CI] 1.21–2.22). Underweight patients were also more likely to visit the emergency room (adjusted OR 1.70; 95% CI 1.28–2.25) or to die (adjusted OR 3.64; 95% CI 2.33–5.69). Men with a BMI < 18.5 compared with those having a BMI ≥ 18.5 had the highest odds of hospitalization (OR 3.45; 95% CI 1.59–7.48).ConclusionUnderweight older adults, especially men, have higher odds of hospitalization, emergency room visits, and mortality. Future work on underweight might involve improving weight status, which may reduce the risk of hospitalization, emergency room visits, and mortality.

Viral acute respiratory infections among infants visited in a rural hospital of southern Mozambique

To determine the epidemiology and clinical presentation of virus-associated acute respiratory infections (ARI) in Mozambican infants. A systematic selection of nasopharyngeal aspirates (n = 333), collected from infants younger than 12 months who visited Manhiça District Hospital (southern Mozambique) with ARI during a 12 months respiratory syncitial virus surveillance, were tested for other common respiratory viruses. Four different polymerase chain reactions were used to diagnose rhinovirus (RV), influenza (Flu; A and B), adenovirus (ADV), human metapneumovirus (hMPV), parainfluenza (PIV; 1, 2, 3 and 4AB) and enterovirus (EV). At least one study virus was identified in more than half of the samples tested (185/333). Overall, 231 viruses were detected among 185 infants, listed in the order of prevalence: RV (26%), Flu (15%), ADV (14%), hMPV (7%), PIV (5%) and EV (3%). Acute respiratory infections (ARI) cases and viral episodes were seasonal and concentrate during the warm and the rainy season. Clinical features were similar among all study children regardless of the detection of virus, with the exception of ear discharge, which was more frequent among viral cases [6% (11/183) vs. 1% (2/144); P = 0.034]. Children with multiple viral infections had higher odds of severity such as nasal flaring and indrawing (OR = 2.7, P = 0.028 and OR = 3.8, P = 0.007, respectively) and higher odds of hospitalisation (OR = 4.42, P = 0.001, adjusted by age and sex). Viral ARI are frequent among infants visited in MHD. Strategies to prevent mild respiratory infections, and specially their complications, might alleviate health systems of source-limited settings.

Fracture-Associated Hospitalizations in Patients with Inflammatory Bowel Disease

Maintenance of bone health is an important concern in patients with inflammatory bowel disease (IBD). They may frequently have impaired bone density resulting in greater incidence of fractures. To examine fracture-associated hospitalization costs in IBD patients from a nationwide representative sample, and to compare the risk factors for such fractures in IBD and non-IBD patients. We identified discharges with IBD and coexisting codes for hip, vertebral or wrist fractures (IBD-Fr) from the Nationwide Inpatient Sample and compared them with IBD hospitalizations without codes for these fractures. A second analysis was performed using 2008 inpatient data from the Wisconsin Hospital Association (WHA) comparing characteristics of patients with IBD-Fr and non-IBD controls hospitalized for similar fractures. There were 1,653 discharges in the IBD-Fr group accounting for 10,461 days of hospital stay and US $46 million in total hospitalization charges. On multivariate analysis, age>65 years [odds ratio (OR) 28.8, 95% confidence interval (CI) 12.3-67.6] and female sex (OR 1.3, 95%CI 1.0-1.6) were associated with higher odds of hospitalization associated with fractures. We found no differences in age, gender, or race among IBD-Fr and non-IBD fracture controls. However, IBD-fractures were twice as likely to be associated with osteoporosis as non-IBD fractures (OR 2.19, 95%CI 1.10-4.33). Older age, female sex, and osteoporosis were more commonly associated with hospitalization for fractures in IBD patients. Osteoporosis appears to be more common among IBD-Fr patients than non-IBD fracture controls.

Hospitalisations 1998–2000 in a British Columbia population-based cohort of young cancer survivors: Report of the Childhood/Adolescent/Young Adult Cancer Survivors (CAYACS) Research Program

Background and objectives Because of late effects among survivors of cancer in young people, increased hospitalisations would be expected. This study determined the occurrence, frequency and days in hospital (DIH) of hospital admissions among 5-year survivors of childhood and adolescent cancer diagnosed in British Columbia (BC), compared hospitalisation risk with the general population and examined the impact of sociodemographic, health care system and clinical factors. Design This population-based study frequency matched 1157 survivors of cancer diagnosed before 20 years of age from 1970 to 1992 from the BC Cancer Registry with 11,570 randomly selected individuals from BC’s health insurance plan Client Registry. Administrative hospitalisation records from 1998 to 2000 were linked to study cohorts, and regression and trend analyses were carried out. Results From 1998 to 2000, 240 (21%) of survivors and 614 (5.3%) of the population sample were admitted to hospital at least once [adjusted OR = 4.36 (95% CI 3.68–5.16)]. Hospitalised survivors had a higher average number of admissions (2.0 versus 1.5 admissions, respectively) and longer mean DIH (10.9 versus 7.8 d, respectively) than hospitalised population controls. Female gender and older age increased the risk of hospitalisation, as did the presence of a relapse or second cancer by 5 years post-diagnosis. Conclusion Our cohort of child and adolescent cancer survivors had higher odds of hospitalisation, more admissions among those hospitalised and longer stay in hospital compared to the population sample. This has implications for health care system resources and appropriate management of late effects of survivors.

Maintaining Continuity of Care for Nursing Home Residents: Effect of States' Medicaid Bed‐Hold Policies and Reimbursement Rates

Recent public concern in response to states' intended repeal of Medicaid bed-hold policies and report of their association with higher hospitalization rates prompts examination of these policies in ensuring continuity of care within the broader context of Medicaid policies. Minimum Data Set assessments of long-stay nursing home residents in April-June 2000 linked to Medicare claims enabled tracking residents' hospitalizations during the ensuing 5 months and determining hospital discharge destination. Multinomial multilevel models estimated the effect of state policies on discharge destination controlling for resident, hospitalization, nursing home, and market characteristics. Among 77,955 hospitalizations, 5,797 (7.4 percent) were not discharged back to the baseline nursing home. Bed-hold policies were associated with lower odds of transfer to another nursing home (AOR=0.55, 95 percent CI 0.52-0.58) and higher odds of hospitalization (AOR=1.36), translating to 9.5 fewer nursing home transfers and 77.9 more hospitalizations per 1,000 residents annually, and costing Medicaid programs about $201,311. Higher Medicaid reimbursement rates were associated with lower odds of transfer. Bed-hold policies were associated with greater continuity of NH care; however, their high cost compared with their small impact on transfer but large impact on increased hospitalizations suggests that they may not be effective.

Association of intradialytic blood pressure changes with hospitalization and mortality rates in prevalent ESRD patients

The relationship between blood pressure (BP) and clinical outcomes among hemodialysis patients is complex and incompletely understood. This study sought to assess the relationship between blood pressure changes with hemodialysis and clinical outcomes during a 6-month period. This study is a secondary analysis of the Crit-Line Intradialytic Monitoring Benefit Study, a randomized trial of 443 hemodialysis subjects, designed to determine whether blood volume monitoring reduced hospitalization. Logistic regression was used to estimate the association between BP changes with hemodialysis (Deltasystolic blood pressure=postdialysis-predialysis systoic BP (SBP) and the primary outcome of non-access-related hospitalization and death. Subjects whose systolic blood pressure fell with dialysis were younger, took fewer blood pressure medications, had higher serum creatinine, and higher dry weights. After controlling for baseline characteristics, lab variables, and treatment group, subjects whose SBP remained unchanged with hemodialysis (N=150, DeltaSBP -10 to 10 mm Hg) or whose SBP rose with hemodialysis (N=58, DeltaSBP > or =10 mm Hg) had a higher odds of hospitalization or death compared to subjects whose SBP fell with hemodialysis (N=230, DeltaSBP < or =-10 mm Hg) (odds ratio: 1.85, confidence interval: 1.15-2.98; and odds ratio: 2.17, confidence interval: 1.13-4.15). Subjects whose systolic blood pressure fell with hemodialysis had a significantly decreased risk of hospitalization or death at 6 months, suggesting that hemodynamic responses to dialysis are associated with short-term outcomes among a group of prevalent hemodialysis subjects. Further research should attempt to elucidate the mechanisms behind these findings.

Determinations of hospitalization from psychiatric ER from S. Gerardo hospital in Monza: epidemiological cross-sectional study

The study aims to identify the predicting factors of hospitalization in patients who come in Emergency Room with psychiatric symptoms. Cross-sectional study using data collected by E.R. of S. Gerardo Hospital in Monza from 1st of June 1995 to 31 May 1997. Inclusion criteria were age older than 18 and the need for psychiatric evaluation. The influence on disposition decision of demographic, clinical and service variables were assessed. Data were collected by a questionnaire designed for the study and administered by a trained psychiatrist. Statistical analysis was performed by univariate analysis and logistic regression. 2076 cases were evaluated. Univariate analysis yielded higher odds of hospitalization for patients between 39 and 48 years of age, unmarried, unemployed, affected by schizophrenia, mood disorders or personality disorders. A linear trend was reported between hospitalization and severity of illness, siucide risk and aggressiveness. While anxiety proved to be a protective factor, hallucination, delusion, lack of insight, psychomotor inhibition, agitation, confusion, destructive behaviour, odd behaviour, abnormal consciousness and previous hospitalization increase inpatient disposition. On Monday and Friday higher frequency of hospitalization was observed. Logistic regression confirm the role of age, symptoms, aggressive behaviour, severity of illness, suicide risk, and among services variables, days of the week. Clinical variables proved to be the main predictors of hospitalization, and an important role is played by the availability of outpatients services: hospitalization was more frequent in the days closer the week-end, when the outpatient services are closed.