Higher Proportion Of Admissions Research Articles

Exploring Antibacterial Usage and Pathogen Surveillance over Five Years in a Tertiary Referral Teaching Hospital Adult General Intensive Care Unit (ICU)

Antimicrobial resistance is a globally recognised health emergency. Intensive care is an area with significant antimicrobial consumption, particularly increased utilisation of broad-spectrum antibacterials, making stewardship programmes essential. We aimed to explore antibacterial consumption, partnered with pathogen surveillance, over a five-year period (2018 to 2023) in a tertiary referral adult general intensive care unit (ICU). The mean number of admissions was 1645 per annum. A comparison between the ICU populations admitted before and after the COVID-19 pandemic peak (2020/21) identified several notable differences with increased average daily unit bed occupancy (21.6 vs. 25.2, respectively) and a higher proportion of admissions with sepsis (28.4% vs. 32.5%, respectively) in the post-pandemic period. Over the entire five years, the overall proportion of antibacterial use by the WHO AWaRe classification was 42.6% access, 54.7% watch and 2.6% reserve. One hundred and forty-seven positive blood culture isolates were reported, with the most concerning antibacterial resistance identified in 7.5% (9 Escherichia coli and 2 Klebsiella pneumoniae isolates). The COVID-19 pandemic peak year was associated with increased ICU bed occupancy, as well as a greater number of positive blood cultures but lower antibacterial consumption. Despite an increasingly complex workload, a large proportion of overall antibacterial consumption remained within the access category. However, the mortality rate and the incidence of most concerning antimicrobial resistance with respect to pathogens remained satisfyingly consistent, suggesting the positive consequences of real-world antibiotic stewardship in an intensive care setting.

Efficacy of Empiric Contact Precautions for Patients from High Risk Facilities

Background: Infection prevention surveillance revealed that patients admitted from two specific long term care facilities comprised the majority of multi-drug resistant organisms (MDRO) and scabies cases at our institution. Current practices include performing active surveillance for Candida auris and methicillin-resistant Staphylococcus aureus (MRSA) for specific high-risk patients, as surveillance for all MDROs and scabies is impractical. We therefore sought to create an admission screening process to efficiently identify patients from high-risk facilities (HRFs) and place them in pre-emptive contact precautions upon admission. Methods: Patients admitted from HRFs were identified on admission as part of the initial nursing assessment. For any positive responses, nursing received a Best Practice Advisory to place the patient in contact precautions and patient placement received an alert that the patient would require a private room. Infection Preventionists reviewed a report of all patients who screened positive and added a “High Risk Facility” banner to the chart. This banner remained for the duration of hospitalization and for every subsequent readmission and outpatient visit. We reviewed the electronic medical records of all patients with a HRF banner placed from March 8, 2023 to September 15, 2023 and abstracted data regarding the presence of scabies or any of the following MDROs before and after placement of the banner: C. auris, carbapenem-resistant enterobacterales (CRE), MRSA, vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Acinetobacter, and MDR Pseudomonas. Results: Of the 93 patients who had a HRF banner added during the study period, 31 (33.33%) were already known to have MDRO colonization at the time of admission to our facility. Thirty-three of the remaining 62 patients (53.22%) without known MDRO colonization were subsequently found to have MDRO colonization/infection or scabies infestation that may have required contact precautions during their index admission or a subsequent admission. This included 14 patients with C. auris, 2 with CRE, 3 with MDR Pseudomonas, 12 with MRSA, 12 with carbapenem-resistant Acinetobacter, and 2 with VRE. Patients were admitted for a median of 9 days before their diagnosis, and 36 of the 93 patients (38.71%) were re-admitted to our hospital during the study period. Conclusion: We found that empiric contact precautions based solely on exposure to specific HRFs facilitated earlier isolation by a median of 9 days. This approach should be considered in acute care hospitals with a high proportion of admissions from HRFs, especially when active and passive surveillance for MDROs is limited.

Length of stay is related to inpatient antipsychotic use in Alzheimer type dementia at a large US based tertiary care hospital.

AbstractBackgroundAntipsychotic(AP) medications carry a black box warning for increased risk of death in the elderly and should be used judiciously in a dementia population. Studies have shown that encounters with healthcare facilities increase the risk of AP exposure1. We wanted to know how admissions at our institution impacted antipsychotic use in patients with Alzheimer’s disease. Here we describe the results of a retrospective analysis of inpatient antipsychotic use in patients with Alzheimer’s disease at Northwestern Memorial Hospital(NMH), Chicago IL.MethodOur cohort was generated using NMH’s Enterprise Data Warehouse, including patients over 65 with a chart diagnosis of AD admitted to the hospital for over 48hrs between May 2005 and March 2018. We excluded patients with schizophrenia, schizotypal disorder, bipolar disorder, or psychotic illness due to primary psychiatric disease, enrollment in hospice, presence of tracheostomy or PEG‐tube and pervasive developmental disorder.Result1712 patients were admitted for a total of 4603 admissions amounting to 25,721 hospital days during the period of analysis. Demographic information is provided in Table 1. A higher proportion of admissions were four days or longer in encounters with an antipsychotic(Figure 1). Though longer LOS becomes progressively less common, this trend continued through a LOS of 20 days. When comparing LOS for encounters with an AP in the home medication list to encounters without, there was no impact on LOS. However, when comparing encounters with an AP prescribed while inpatient to encounters without, inpatient AP administration was associated with a longer length of stay (Table 2).ConclusionThese findings indicate that a longer LOS is associated with antipsychotic use. Because a longer length of stay was associated with new antipsychotic use but not the continuation of a home antipsychotic, our findings suggest that length of stay may contribute to behavioral and psychological symptoms of dementia requiring pharmacological treatment.1. Koponen M, Lavikainen P, Taipale H, et al. Accumulation of Hospital Days Among Antipsychotic Initiators With Alzheimer’s Disease. J Am Med Dir Assoc. 2019;20(12):1488‐1494.e3. https://doi.org/10.1016/j.jamda.2019.07.009

Cost consequences of unscheduled emergency admissions in cancer patients in the last year of life

ObjectivesCancer is a leading cause of death. This paper examines the utilisation of unscheduled emergency end-of-life healthcare and estimates expenditure in this domain. We explore care patterns and quantify the likely benefits from service reconfigurations which may influence rates of hospital admission and deaths.MethodsUsing prevalence-based retrospective data from the Northern Ireland General Registrar’s Office linked by cancer diagnosis to Patient Administration episode data for unscheduled emergency care (1st January 2014 to 31st December 2015), we estimate unscheduled-emergency-care costs in the last year of life. We model potential resources released by reductions in length-of-stay for cancer patients. Linear regression examined patient characteristics affecting length of stay.ResultsA total of 3134 cancer patients used 60,746 days of unscheduled emergency care (average 19.5 days). Of these, 48.9% had ≥1 admission during their last 28 days of life. Total estimated cost was £28,684,261, averaging £9200 per person. Lung cancer patients had the highest proportion of admissions (23.2%, mean length of stay = 17.9 days, mean cost=£7224). The highest service use and total cost was in those diagnosed at stage IV (38.4%), who required 22,099 days of care, costing £9,629,014. Palliative care support, identified in 25.5% of patients, contributed £1,322,328. A 3-day reduction in the mean length of stay with a 10% reduction in admissions, could reduce costs by £7.37 million. Regression analyses explained 41% of length-of-stay variability.ConclusionsThe cost burden from unscheduled care use in the last year of life of cancer patients is significant. Opportunities to prioritise service reconfiguration for high-costing users emphasized lung and colorectal cancers as offering the greatest potential to influence outcomes.

Child characteristics and health conditions associated with paediatric hospitalisations and length of stay: a population-based study

Paediatric hospital length of stay (LoS) is often used as a benchmark for resource use of hospitalisations. Previous studies have mostly focused on LoS of admissions for specific conditions or medical specialties. We aimed to conduct an evaluation of LoS of all paediatric hospitalisations exploring the frequency and characteristics; and associated childhood conditions. This population-based cross-sectional study included all hospital admissions in children aged <16 years between January 2017 and December 2019 in New South Wales, Australia. LoS was categorised into: day or overnight stay, 2-7, 8-21 and≥22 days. Socio-demographic and health service characteristics of each individual admission by LoS and age groups were evaluated. A total of 324,083 children had 518,768 admissions comprising 1,064,032 bed days. Most admissions wereday/overnight stays (71.9%) or 2-7 days (25.3%). While LoS >7 days represented 2.8% of total admissions, they accounted for 27% of total bed days. Children aged 1-4 years had the highest proportion of admissions (35%), with a majority lasting ≤7 days, whereas 45.6% of admissions ≥22 days were for children aged ≥12 years. Respiratory conditions, diseases of the digestive system and traumatic injuries were the most common reasons for hospitalization. LoS >7 days were more common in children from most disadvantaged backgrounds, residing further from hospital and those aged ≥12 years with mental health conditions. The majority of paediatric hospitalizations are for short stay and require programs that target acute conditions that can be managed in primary care. Interventions such as care coordination, tailored models of care and enhanced outpatient/community treatment programs for high-risk groups will help reduce extended LoS and improving child health and well-being. Australian National Health and Medical Research Council.

Tuberculosis Sanatorium of 21st Century Exploring the Admission Pattern and Duration of Stay at TB Sanatorium Bhowali, Uttarakhand, India: A Retrospective Study

Introduction: With time there have been major changes in the management of TB. No longer TB sanatoriums are preferred. However, in this 21st century, few sanatoriums do exist but are no longer in their original forms, to explore the admission patterns and duration of stay at the TB sanatorium Bhowali, Uttarakhand. Methodology: We retrieved the data between 1st January 2018 to 31st July 2021 from the inpatient Department (IPD) of TB sanatorium Bhowali. Data were extracted in an extraction sheet and descriptive data analysis was done to see the admission patterns and duration of stay. The place of residence was analysed as per the district-wise distribution. Results: There were 1247 admissions. These admissions were limited to six states, and the majority were from the state of Uttar Pradesh (50.7%) and Uttarakhand (46.7%). The highest cases were in the year 2018, and during April to July. As per the district-wise distribution, Udham Singh Nagar had the highest proportion of admissions (18.6%), followed by Bareilly (15%), Nainital (11.4%), and Rampur (10.9%). The mean (SD) and median (IQR) duration of stay were 22.7 days (SD–24.7) and 14 (IQR 7– 8) days, respectively. The median duration of stay was significantly higher for females (25.1 days) compared to males (21.6 days). Conclusion: TB sanatorium Bhowali (Uttarakhand) caters majority of the patients from the neighbouring state of Uttar Pradesh. The admissions were high during the spring and summer seasons. The median duration of hospital stay for patients admitted with TB was two weeks.

Outcomes of COVID-19 Admissions in the New York City Public Health System and Variations by Hospitals and Boroughs During the Initial Pandemic Response.

Introduction: In the initial pandemic regional differences may have existed in COVID-19 hospitalizations and patient outcomes in New York City. Whether these patterns were present in public hospitals is unknown. The aim of this brief study was to investigate COVID-19 hospitalizations and outcomes in the public health system during the initial pandemic response.Methods: A retrospective review was conducted on COVID-19 admissions in New York City public hospitals during the exponential phase of the pandemic. All data were collected from an integrated electronic medical records system (Epic Health Systems, Verona, WI). Overall, 5,422 patients with at least one admission each for COVID-19 were reviewed, with a study of demographic characteristics (including age, gender, race, BMI), pregnancy status, comorbidities, facility activity, and outcomes. Data related to hospitalization and mortality trends were also collected from City of New York website. These data often involved more than one facility and/or service line resulting in more location or treatment facility counts than patients due to utilization of services at more than one location and transfers between locations and facilities.Results: Higher mortality was associated with increasing age with the highest death rate (51.9%) noted in the age group >75 years (OR 7.88, 95%CI 6.32–10.08). Comorbidities with higher mortality included diabetes (OR 1.5, 95% CI 1.33–1.70), hypertension (OR 1.62, 95% CI 1.44–1.83), cardiovascular conditions (OR 1.66, 95% CI 1.47–1.87), COPD (OR 1.86, 95% CI 1.39–2.50). It was deduced that 20% of all New York City COVID-19 positive admissions were in public health system during this timeframe. A high proportion of admissions (21.26%) and deaths (19.93%) were at Elmhurst Hospital in Queens. Bellevue and Metropolitan Hospitals had the lowest number of deaths, both in borough of Manhattan. Mortality in public hospitals in Brooklyn was 29.9%, Queens 28.1%, Manhattan 20.4%.Conclusion: Significant variations existed in COVID-19 hospitalizations and outcomes in the public health system in New York City during the initial pandemic. Although outcomes are worse with older age and those with comorbidities, variations in hospitals and boroughs outside of Manhattan are targets to investigate and strategize efforts.

Abstract 15368: Index Admission and Thirty-day Readmission Outcomes of Cancer Patients Presenting With Stemi

Introduction: National-level data of cancer patients’ readmissions after a ST-segment elevation myocardial infarction (STEMI) are lacking. Objectives: The primary aim of this study was to describe rates and causes of 30-day readmissions in this population. Methods: Among patients who were admitted with STEMI in the United States National Readmission Database (NRD) from October 2015-December 2017, we identified patients with the diagnosis of active breast, colorectal, lung or prostate cancer. The primary endpoint was 30-day unplanned readmission rate. Secondary endpoints included in-hospital outcomes during the index admission and causes of readmissions. A propensity score model was used to compare the outcomes of cancer and no cancer patients. Results: A total of 385,522 patients were included in the current analysis (Cancer= 5,956, No Cancer=379,566). After propensity score matching, 23,880 patients were compared (Cancer=5,949, No Cancer=17,931). Cancer patients had higher 30-day readmission (19% vs 14%, p&lt;0.01). The most common causes for readmission among cancer patients were cardiac (31%), followed by infectious (21%), hematological and oncological (17%), respiratory (4%), stroke (4%) and renal (3%). During the first readmission, cancer patients had higher in-hospital mortality (15% vs 7%; p&lt;0.01) and bleeding complications (31% vs 21%; p&lt;0.01). In multivariate logistic regression, cancer status (OR 1.5, 95% CI 1.2-1.6, p&lt;0.01) was an independent predictor for 30-day readmission. Conclusions: About one in five cancer patients presenting with STEMI will be readmitted within 30 days. Cancer patients’ 30-day readmissions are still predominantly cardiac-related but with a higher proportion of admissions for infectious, cancer-related and bleeding and than those without cancer.

Utilization of Social Determinants of Health ICD-10 Z-Codes Among Hospitalized Patients in the United States, 2016-2017.

The inclusion of Z-codes for social determinants of health (SDOH) in the 10th revision of the International Classification of Diseases (ICD-10) may offer an opportunity to improve data collection of SDOH, but no characterization of their utilization exists on a national all-payer level. To examine the prevalence of SDOH Z-codes and compare characteristics of patients with and without Z-codes and hospitals that do and do not use Z-codes. Retrospective cohort study using 2016 and 2017 National Inpatient Sample. Total of 14,289,644 inpatient hospitalizations. Prevalence of SDOH Z-codes (codes Z55-Z65) and descriptive statistics of patients and hospitals. Of admissions, 269,929 (1.9%) included SDOH Z-codes. Average monthly SDOH Z-code use increased across the study period by 0.01% per month (P<0.001). The cumulative number and proportion of hospitals that had ever used an SDOH Z-code also increased, from 1895 hospitals (41%) in January 2016 to 3210 hospitals (70%) in December 2017. Hospitals that coded at least 1 SDOH Z-code were larger, private not-for-profit, and urban teaching hospitals. Compared with admissions without an SDOH Z-code, admissions with them were for patients who were younger, more often male, Medicaid recipients or uninsured. A higher proportion of admissions with SDOH Z-codes were for mental health (44.0% vs. 3.3%, P<0.001) and alcohol and substance use disorders (9.6% vs. 1.1%, P<0.001) compared with those without. The uptake of SDOH Z-codes has been slow, and current coding is likely poorly reflective of the actual burden of social needs experienced by hospitalized patients.

PATTERNS OF CARDIOTHORACIC DISEASES AND PROCEDURES IN A TERTIARY CARE HOSPITAL OF PESHAWAR

Objectives: To determine the common cardiovascular and congenital heart diseases that required admission and surgical intervention in a tertiary care hospital of Peshawar. Methodology: This was a retrospective study at the cardiothoracic surgery ward of Rehman Medical Institute (RMI). All the admissions over the period of 9 years from 2005 to 2014 into the cardiothoracic surgery ward were reviewed. The data acquired was put into Microsoft Excel 2013 and analyzed using pivot tables for frequencies of different procedures and diagnosis. Results: A total of 9343 patients were admitted during the 9-year period. There were 6516 (69.7%) males and 2827 (30.3%) females. The male to female ratio was 2.30:1. The ages ranged from 1 year to 99 years. Mean age was 41.32 ± 20.56 years. The highest proportion of admissions was in the 50-59 years’ age group followed by 60-69 years and 40-49 years. Coronary Artery Bypass Graft (4617) was the most common procedure performed. Triple Vessel Disease (37%) was the most commonly presented disease to the RMI Cardiology Unit. Conclusion: Majority of patients presented with triple vessel disease and male outnumbered female. CABG was the commonest procedure performed at RMI Cardiac Surgery Unit, Peshawar.Keywords: Cardiovascular Diseases, Heart Valves, Coronary Diseases

Differences in hospital admissions practices following self-harm and their influence on population-level comparisons of self-harm rates in South London: an observational study

ObjectivesTo compare the proportions of emergency department (ED) attendances following self-harm that result in admission between hospitals, examine whether differences are explained by severity of harm and examine the impact...

Clinical needs and outcomes of adults with intellectual disabilities accessing an inpatient assessment and treatment service and the implication for development of community services.

The role and future of assessment and treatment units for people with intellectual disabilities is once again the focus of debate and government policy. Reviewing the admissions to inpatient services can provide useful information about the characteristics, needs and clinical outcomes of clients. Data were collected retrospectively for all 36 referrals accepted to an inpatient assessment and treatment unit for people with intellectual disability, between January 2013 and April 2014. Clinical and demographic characteristics of service users were identified through descriptive analysis. Male service users, mild intellectual disability and diagnosis of autistic spectrum disorder were frequent, and a high proportion of admissions had complex and multiple needs. The Health of the Nation Outcome Scale-Intellectual Disabilities was used as a clinical outcome measure. We conclude with recommendations for service development following closure of our inpatient service.

Characteristics of pediatric diabetic ketoacidosis patients in Saudi Arabia

Objectives:To evaluate the clinical and biochemical characteristics of children with diabetic ketoacidosis (DKA).Methods:In this retrospective study conducted between June 2012 and November 2013 at the King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia, we evaluated pediatric DKA admissions from 1995-2008 (Phase 1). From the case files, we obtained information related to patients’ age, gender, weight, presenting complaints, serum biochemical profile, and management.Results:This study included 373 DKA admissions with a median age of 11 years (interquartile range [IQR]:8-13). The patients in the subgroup of age more than 10 years old had the highest proportion of admissions (n=250, 67%, p<0.000). The median duration of diagnosis of diabetes mellitus (DM) was 3 years (IQR:2-6). New-onset DM was 47%. Predominant precipitating cause was acute illness, mostly viral syndrome in 22% of all cases, and non-compliance to insulin regimen was in 79% of the diagnosed diabetic cases. Blood glucose, pH, anion gap, serum osmolality, serum potassium, and serum phosphate showed the highest change during the initial 6 hours of management, while trends of serum bicarbonate and blood urea nitrogen demonstrated a predominant change in the initial 12 hours.Conclusion:The notable findings in this study, such as, higher mean age of presentation, high rate of non-compliance to insulin as the cause of precipitation, and a high prevalence of abdominal pain at presentation should be followed up with further comparative studies.

Cat admissions toRSPCAshelters in Queensland,Australia: description of cats and risk factors for euthanasia after entry

A lack of information limits understanding of the excess cat problem and development of effective management strategies. This study describes cats entering Royal Society for the Prevention of Cruelty to Animals (RSPCA) Queensland shelters and identifies risk factors for euthanasia. Data for cats entering relevant shelters (July 2006-June 2008) were obtained from the RSPCA's electronic database. Univariable and multivariable logistic regression analyses were conducted to identify risk factors for euthanasia. Of 33,736 cats admitted, 46% were adult cats (≥3 months) and 54% were kittens (<3 months). The most common reason for admission was stray (54%), followed by owner surrender (44%). Euthanasia was the most common outcome (65%), followed by adoption (30%). The odds of euthanasia were lower for kittens and for cats that were desexed prior to admission. Of the strays, 8% had been desexed. For cats of similar age, sex, desexed and feral status, stray cats were more likely to be adopted than owner-surrenders. Strategies are needed to reduce numbers of cats admitted and euthanased. Given the high proportion of admissions that were kittens, reducing the incidence of delayed sterilisation of owned cats may be an important strategy for reducing the number of unwanted kittens. Many cats admitted as strays were rehomable, but given the high proportion of admissions that are strays, further research on stray populations is needed. Future studies of cats entering shelters would be enhanced if data collection definitions, categories and methods were standardised.

Do admissions and discharges to long-term care facilities influence hospital burden of Clostridium difficile infection?

Substantial geographical clustering of Clostridium difficile infection (CDI) outbreaks in hospitals in the USA have previously been demonstrated. To test the hypothesis that hospital burden of CDI is associated with admission from and discharge to long-term care facilities (LTCFs). Hospital discharge data from 19 states in the USA were used to identify all patients discharged with a diagnosis of CDI from 1 January 2002 to 31 December 2004. For every hospital, the proportion of discharges with a diagnosis of CDI was calculated, and those above the 90th percentile were classified as 'high CDI' hospitals. We tested the association between this measure of hospital burden of CDI and the rates of admission from and discharges to LTCFs. We adjusted for other hospital level characteristics, case-complexity and local population characteristics. We identified 38,372,951 discharges during the three-year study period. Of all discharges, 274,311 (0.71%) had a primary or secondary diagnosis of CDI. Hospitals had a mean CDI burden of 7.8 cases per 1000 discharges. High CDI hospitals (N = 610; 10.0%) had a mean CDI burden of 34.8 cases per 1000 discharges. Compared to other hospitals, high CDI hospitals were more likely to have a high proportion of admissions from or discharges to LTCFs. This association persisted after adjustments for other hospital characteristics, case-complexity, and area population characteristics. A high rate of admission from or discharge to LTCFs is associated with an increased hospital burden of CDI.

Pattern of admissions to the University of Port Harcourt Teaching Hospital intensive care unit - a 10-year analysis

Objective. To determine the admission pattern and outcome of patients in the Intensive Care Unit (ICU) of University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria. Method. A retrospective review of all patients admitted to the ICU at the UPTH from 1996 to 2005 was carried out. Data were obtained from the ICU admission and discharge registers and nurses’ handover records. Results. A total of 1 447 patients were admitted from 15 departments. There were 658 males and 789 females (male/female ratio 1:1.2). Ages ranged from 4 months to 90 years, the median age was 30 years and the mean age was 31.7±5.6 years. The highest proportion of admissions (48.7%) was from the Department of Obstetrics and Gynaecology, and the lowest from Ophthalmology and Anaesthesia (0.1%). Postoperative cases made up 62.1% of total admissions, with post-caesarean section (CS) contributing 65.7% of these. Non-availability of beds in the ward was the reason for the majority of the post-CS admissions. Up to 41.5% of the patients admitted to the ICU had no justifiable reason for admission. Average length of stay was 8.1±2.8 days, median 4.5 days. One patient was manually ventilated for 5 hours, none was mechanically ventilated, and none had invasive cardiac monitoring. Three children had peritoneal dialysis for acute renal failure. Unconscious patients were fed enterally through a nasogastric tube, while conscious patients ate orally. Analysis of outcomes showed that 597 patients (41.3%) were transferred to the wards, while 352 (24.3%) were discharged home. The outcome was not indicated in 128 cases (8.8%), 16 patients (1.1%) left the ICU against medical advice, 1 patient (0.1%) was referred to another tertiary institution and 1 (0.1%) absconded. Three hundred and fifty-two patients died, giving a mortality rate of 24.3%. Conclusion. The highest percentage of admissions to the ICU was from the Department of Obstetrics and Gynaecology. The majority of the patients did not require intensive care but were admitted because there was no bed in the wards.

Protocolo de revisão de utilização de recursos num hospital público Português.

This paper reports on some important findings of a study conducted in Covilhã/Portugal on appropriateness of hospital admission and in-hospital days in a Portuguese hospital using an adapted version of the Appropriateness Evaluation Protocol--a review tool for hospital utilization. This analysis showed a significant rate of inappropriateness in admission (24.6%) and days of stay (37.4%) and it also suggested a low rate of use of the override options. It was possible to identify the conservative attitude as the most common cause of inappropriate admissions and days of stay. This study demonstrates that a high proportion of admissions and days of stay are related to patients who could have been attended at other levels of the health care system such as outpatient consultations. The analysis made it possible to identify and to explore some variables correlated to the levels of inappropriateness and to the causes of inappropriateness or levels of health care required by the patients.

Hospital Volume Outcome and Discharge Disposition of Burn Patients

The purpose of this investigation was to determine the impact of hospital clinical volume on patient outcomes (i.e., in-hospital mortality, length of stay) and discharge disposition of burn patients using a large nationally representative database. Patient data were obtained from the 1999-2001 National Inpatient Sample using burn diagnosis-related group codes 504 through 511. Hospitals were segregated into high-volume hospitals (treating more than 100 patients per year), medium-volume hospitals (treating 20 to 99 patients per year), and low-volume hospitals (treating fewer than 20 patients per year). Mortality, length of stay, and discharge disposition were catalogued for each diagnosis-related group code and hospital type. In diagnosis-related group pair 504/505 (most severe), the mortality rate in patients admitted to high-volume hospitals (33.5 percent) was significantly higher than in patients admitted to both medium-volume hospitals (28.8 percent) and low-volume hospitals (11.5 percent) (p = 0.002). Within lower severity diagnosis-related groups, where the mortality rate was lower across all admissions, medium-volume hospitals and high-volume hospitals had a higher proportion of routine discharges to home, a lower need for home care, and a lower proportion of transfers compared with low-volume hospitals. Despite shorter length of stay, across most burn diagnosis-related groups, patients admitted to low-volume hospitals had lower rates of routine discharges and a higher proportion of admissions "with complications." Higher-volume facilities, despite receiving the most severe burn patients, may provide better patient outcomes than lower-volume facilities. The patterns of discharges found at lower-volume facilities may result in higher diagnosis-related group reimbursement "capture" by lower-volume facilities and higher postdischarge resource use.

Adverse drug events as a cause of hospital admission in the elderly.

Previous studies of adverse drug events (ADE) as a cause of hospital admission in the elderly have often been limited in their ability to assess fully the impact and potential for prevention because they either did not include all categories of ADE and/or did not assess severity and preventability. To assess the frequency, severity and preventability of ADE causing emergency medical admissions in the elderly. Cross-sectional survey of 219 patients aged 75 years and over who were consecutive unplanned admissions to acute medical units of the Royal Hobart Hospital in an 8-week period during August and September 1998. Seventy-three of 240 (30.4%) admissions may have been a result of ADE. Patients admitted because of ADE were taking more drugs than those admitted for other reasons. Most ADE were adverse drug reactions to a single (46%) or multiple drugs (25%). Non-compliance, omission or cessation of indicated treatment accounted collectively for 26% of admissions. Of all ADE admissions 53.4% were considered definitely preventable. The commonest causative drugs were cardiovascular drugs (48.4%), and the commonest manifestations were falls and postural hypotension (24.1%), heart failure (16.9%) and delirium (14.5%). ADE categories in which a high proportion of admissions was both severe and definitely preventable were non-compliance and omission of indicated treatment. Adverse drug events are a common preventable cause of unplanned medical admissions in the elderly. Non-compliance and omission of indicated treatment are causes of ADE-related admissions that are both preventable and frequently associated with severe ADE.

Annual Report on Access to and Utilization of Health Care for Children and Youth in the United States–1999

The dynamics of health care delivery for children and adolescents have greatly evolved over the last 5 years. The growth of managed care has been especially rapid, and has coincided with other fundamental changes—declines in private coverage, growth of Medicaid, welfare reform, and the creation of the state Child Health Insurance Program (CHIP).1 Over the past 10 years, the number of children covered through employer-sponsored plans and other private plans has dropped.2 During this same period, changes to Medicaid have begun to de-couple eligibility from welfare eligibility, theoretically enabling states to expand coverage. For children, this movement from private to public coverage has accelerated the movement to managed care systems. Between 1991 and 1997, Medicaid enrollment in managed care plans increased from 9.5% to 47.8% of total Medicaid enrollment.3 Recent estimates suggest that over half of these Medicaid managed care enrollees are children.4 However, little is known about the impact of these trends on children's access to and use of services, let alone the quality and outcomes of that care. This report is the first in what is anticipated to be an annual series of reports on access to and use of health care services by America's children and youth. The report capitalizes on the existence of 2 national datasets, the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP), which have not been widely used by the child health services research community. As background to these new sources of data, we have provided a detailed description of the datasets, and review some of the fundamental tabulations. In future years, as more data are accumulated, these reports will focus on delineation of key trends and analyses addressing policy issues. ### MEPS The MEPS is conducted to provide nationally representative estimates of health care use, …