Inpatient Episodes Research Articles

The limited clinical utility of a routine creatine kinase (CK) on admission to a psychiatric inpatient unit

BackgroundCreatine kinase (CK) is an intracellular enzyme expressed most commonly in tissues such as skeletal muscle. CK can be used as an investigation to support the diagnosis of conditions such as neuroleptic malignant syndrome (NMS), a rare idiosyncratic drug reaction – classically to antipsychotic medications – which can be fatal. Routine screening of CK in psychiatric inpatients is a known practice, but its value is uncertain. We aimed to ascertain whether such screening resulted in new diagnoses of NMS or other conditions, and changes in clinical management.MethodsUsing an electronic case register, we conducted a descriptive retrospective cohort study, identifying all psychiatric inpatient admissions in a South London mental health trust over a four-year period where a CK test was conducted within 48 h of admission. We extracted the demographic and clinical characteristics (e.g., diagnosis) of those who met inclusion criteria. Free-text review was performed on all those with a CK potentially suggestive of NMS (CK ≥ 4x upper limit of normal reference range (ULN)) to determine the impact of this abnormal result on subsequent management and diagnosis (including NMS if identified).ResultsOf 14,236 inpatient episodes in the specified window, 2358 (16.6%) had a CK test within 48 h of admission. This was ≥ 4x ULN in 327 (13.8%) cases (free-text successfully reviewed in 318). There were no cases of NMS identified. An abnormal CK result led to a new alternative diagnosis, such as dehydration or catatonia, in only 14 patients (4.4% raised CK sample, 0.6% total CK sample). Impact on subsequent management appeared limited, with the most common adjustment being an increase in frequency of physical observations in 47 instances (14.8%).ConclusionsThe clinical utility of untargeted screening using a serum CK for psychiatric inpatients appears limited, with poor specificity in detection of NMS and a minimal impact on subsequent clinical management.

The Financial Burden of Patient Comorbidities on Total Knee Arthroplasty Procedures: A Matched Cohort Analysis of Patients Who Have a High and Non-High Comorbidity Burden

IntroductionRecent literature has suggested a trend toward a higher comorbidity burden in patients undergoing total knee arthroplasty (TKA). However, there is a lack of data on the impact of increased comorbidities on the cost-effectiveness of TKA. The purpose of this study was to compare the financial implications and perioperative outcomes of patients who do and do not have a high comorbidity burden (HCB). MethodsWe retrospectively reviewed 10,647 patients who underwent an elective, unilateral TKA between 2012 and 2021 and had available financial data. Patients were stratified into HCB (Charlson Comorbidity Index [CCI] ≥ 5) and American Society of Anesthesiology [ASA] scores of 3 or 4) and non-HCB groups and were 1:1 propensity-matched based on baseline characteristics. Perioperative data, revenue, costs, and contribution margins (CM) of the inpatient episode were compared between groups. The 90-day readmissions and revisions were also compared. Of the 10,647 patients reviewed (1,186 HCB, 9,461 non-HCB), 1,536 patients were included in the matched analyses (768 per group). ResultsThe HCB patients had significantly greater total (P < 0.001) and direct (P < 0.001) costs, yet hospital revenue did not differ between cohorts (P = 0.638). This resulted in a significantly decreased CM for the HCB group (P = 0.009). The HCB cohort also had a significantly greater length of stay (P < 0.001) and 90-day readmissions (P = 0.005). ConclusionsIncreased inpatient costs for HCB patients undergoing TKA were not met with increased revenue to cover these costs, leading to a decreased CM. Furthermore, greater 90-day readmissions in the HCB cohort add to the already disproportionate financial burden of these patients. The capacity of hospitals to cover indirect expenses might be impacted, jeopardizing the accessibility of care for HCB patients who need TKA. Current reimbursement models should be modified to adequately consider the increased financial burden associated with HCB patients undergoing TKA.

BS SO12 - Long-term impacts of emergency presentations following bariatric health tourism on patients and health services: A UK perspective

Abstract Background Bariatric surgery is an effective treatment for obesity. Whilst short-term complication rates are low, little is known about the longer-term impacts on patients and health services. Even less is known about the true impact of the increasing trend of Health Tourism (HT) in this field. This study aimed to explore this topic further to quantify the impact of HT on UK healthcare services and to subsequently inform future service planning. Method This was a retrospective study of consecutive emergency inpatient episodes related to bariatric surgery (presenting to ED or transferred from other hospitals) at a regional bariatric centre. The study included patients between January 2018- April 2023. Data on index procedure (type, time to presentation, location), complications (and associated management), and subsequent readmissions, diagnostic investigations, and interventions (surgical, radiological, endoscopic) following first discharge from our centre was collected. Results 308 patients (489 episodes) were included (188 patients had surgery in the UK, 77 HT, 43 unknown origin). Gastric band (50%) and gastric sleeve (39%) were the commonest causes for admission in UK and HT patients, respectively. 86 surgical interventions post discharge were required. An average of 2.0 diagnostic investigations were undertaken following discharge per patient (UK 2.3 vs HT 1.9). Following discharge, similar average rates of further readmissions (UK 0.6 v HT 0.6), surgical (UK 0.3 v HT 0.4), radiological (UK 0.2 v HT 0.2) and endoscopic interventions (UK 0.6 v HT 0.6) were seen between cohorts. Conclusion Patients presenting with emergencies following bariatric surgery require significant ongoing investigation and management following discharge from hospital. This ongoing burden is often overlooked in health services research. In our study, this demand was significantly increased by bariatric health tourism. This highlights the critical need to recognise this additional burden, improve service planning to accommodate increased service demand, and address underlying factors contributing to health tourism.

The shift from inpatient to outpatient settings of a surgical DRG for pediatric patients in Portugal

Abstract Background The shift of selected surgical procedures from inpatient to outpatient settings has been seen as a solution to improve health care provision. These shifts often occur under pay-for-performance schemes, pay-for-efficiency schemes, or other forms of financial incentives. For this study, we aimed to assess the effect of Decree 132/2009, implemented on February 1, 2009, which increased the relative weights of DRG 60 (“tonsillectomy and/or adenoidectomy, age &amp;lt;18”) performed in outpatient settings, thus acting as a financial incentive. Methods We performed a quasi-experimental study and employed interrupted time series (ITS) and controlled interrupted time series (CITS) designs, using monthly pediatric data provided by The Central Administration of the Health System (ACSS), with discharges between January 2006 and February 2012 (having 37 months pre- and post-decree implementation) of inpatient and outpatient episodes for DRG 60 (affected group) and DRG 163 (“hernia procedures age &amp;lt;18”, the selected control group). We used as study outcomes proportions (number of outpatient episodes divided by the sum of outpatient and inpatient episodes) to quantify increases in outpatient episodes and ratios (number of outpatient episodes divided by the number of inpatient episodes) to quantify decreases in inpatient episodes. Fourier terms were included to adjust for seasonality. Results We obtained statistically significant results only at the trend level for ratios when using the ITS model (0.01574) and for proportions only when using the CITS model (0.00310), although small non-statistically significant increases were obtained for the employed ITS as well as for the CITS design. Conclusions Decree 132/2009, which created financial incentives for the shift from inpatient to outpatient for DRG 60, showed low and non-statistically significant increases using both ITS and CITS models. Key messages • We analyzed the impact of Decree 132/2009 on the pediatric surgeries under DRG 60 performed in outpatient settings in Portugal using interrupted time series and control interrupted time series. • The decree had a small effect at the national level for DRG 60.

Impact of heart failure diagnosis on recorded healthcare resource use by older people in Wales; is primary care shouldering a hidden burden?

Abstract Background Heart failure (HF) is associated with high healthcare resource use and mortality. Most of the evidence focuses on hospital admission data. The impact on primary care interactions and outpatient attendance is less well described, but this information is important in understanding resource utilisation, patient pathways, and in planning services. Purpose To examine how a diagnosis of HF impacts healthcare resource use and outcomes for older people in Wales. Methods We conducted a retrospective, population-level, observational study using linked anonymised electronic health record (EHR) data in Wales (2015-22). 737,230 individuals were aged 65y+ in the study period in primary and secondary care data. Of these, 65,010 had a code for HF in their primary or secondary care records. To evaluate changes in resource use, we excluded 13,990 individuals with fewer than 12 months health data pre- and post-diagnosis. We summarised general practice (GP) interactions, emergency department (ED) attendance, outpatient (OP) attendance, inpatient (IP) episodes and days, time between HF diagnosis and death, and place of death. Results The final cohort comprised 51,020 individuals 65y and over with a diagnosis of HF between 2015-2022. Incidence and prevalence of HF increased across the study period (1.4-1.5% and 8.5-9.1% respectively). Figure 1 shows the percentage change in healthcare resource use for the cohort when HF was diagnosed (12 months pre-and post-diagnosis comparison). Table 1 shows the average number of healthcare utilisation events per person. After a diagnosis of HF, there are fewer ED attendances (-28.2%) and IP admissions (-9.3%) but more OP appointments (31%) and GP interactions (20.3%). When admissions occur, hospital stays tend to be longer (55.4%). Median time (IQR) from HF diagnosis to death from any cause was 247(34-840) days, and with HF listed as a cause 186(25-780) days. In this cohort, the place of death was recorded as NHS establishment (20,379, 67.8%), community (5,450, 18.1%), non-NHS establishment (3,789,12.6%) and unknown (450, 1.5%). Conclusions In Wales, a diagnosis of HF in those 65y+ increases primary care interactions and OP attendances. The change in volume of primary care interactions is considerable (increase from 1,047,920 to 1,315,080). Longer hospital stays may suggest difficulty in managing patients or discharging back to community settings. Majority of those with HF die in NHS establishments. It is unclear whether this reflects deficits in end-of-life care. These results are important in planning effective health service delivery and in establishing baseline data from which to monitor quality improvements.

Common viral respiratory infections in children with cancer during the COVID-19 pandemic: a multicenter study from Türkiye.

Microbiologic confirmation of respiratory tract infections gained importance during the coronavirus disease 2019 (COVID-19) pandemic. This study retrospectively evaluated seasonal distribution, clinical presentation, and complications of respiratory viral infections (RVIs) other than COVID-19 in children with cancer during and after the pandemic lockdown. Two hundred and sixty-five inpatient and outpatient RVI episodes in 219 pediatric cancer patients confirmed by multiplex reverse transcriptase polymerase chain reaction (RT-PCR) panels from 13 centers were enrolled. Eighty-six (32.5%) of the total 265 episodes occurred in 16 months corresponding to the lockdowns in Türkiye, and the remaining 67.5% in 10 months thereafter. Human rhinovirus/enterovirus (hRE) (48.3%) was the most common agent detected during and after lockdown. Parainfluenza virus (PIV) (23.0%), influenza virus (9.8%), and respiratory syncytial virus (RSV) (9.1%) were the other common agents. The 28.7% of episodes were lower respiratory tract infections (LRTIs), and complications and mortality were higher than upper respiratory tract infections (URTIs) (25.0% vs 5.3%). Bacteremia was identified in 11.5% of culture-drawn episodes. Treatment delay in one-third and death within four weeks after RVI in 4.9% of episodes were observed. During the pandemic, fewer episodes of RVIs occurred during the lockdown period. Respiratory viruses may cause complications, delays in treatment, and even death in children with cancer. Therefore, increased awareness of RVIs and rapid detection of respiratory viruses will benefit the prevention and, in some cases, abrupt supportive and some antiviral treatment of RVI in children with cancer.

Value of Pharmacogenetic Testing Assessed with Real-World Drug Utilization and Genotype Data.

Implementation of pharmacogenetic testing in clinical care has been slow and with few exceptions is hindered by the lack of real-world evidence on how to best target testing. In this retrospective register-based study, we analyzed a nationwide cohort of 1,425,000 patients discharged from internal medicine or surgical wards and a cohort of 2,178 university hospital patients for purchases and prescriptions of pharmacogenetically actionable drugs. Pharmacogenetic variants were obtained from whole genome genotype data for a subset (n = 930) of the university hospital patients. We investigated factors associated with receiving pharmacogenetically actionable drugs and developed a literature-based cost-benefit model for pre-emptive pharmacogenetic panel testing. In a 2-year follow-up, 60.4% of the patients in the nationwide cohort purchased at least one pharmacogenetically actionable drug, most commonly ibuprofen (25.0%) and codeine (19.4%). Of the genotyped subset, 98.8% carried at least one actionable pharmacogenetic genotype and 23.3% had at least one actionable gene-drug pair. Patients suffering from musculoskeletal or cardiovascular diseases were more prone to receive pharmacogenetically actionable drugs during inpatient episode. The cost-benefit model included frequently dispensed drugs in the university hospital cohort, comprising ondansetron (19.4%), simvastatin (7.4%), clopidogrel (5.0%), warfarin (5.1%), (es)citalopram (5.3%), and azathioprine (0.5%). For untargeted pre-emptive pharmacogenetic testing of all university hospital patients, the model indicated saving €17.49 in direct healthcare system costs per patient in 2 years without accounting for the cost of the test itself. Therefore, it might be reasonable to target pre-emptive pharmacogenetic testing to patient groups most likely to receive pharmacogenetically actionable drugs.

Identifying factors associated with post-hospital falls in older patients: a territory-wide cohort study

ObjectivesPost-hospital falls impose a substantial healthcare burden on older adults, yet contributing factors remain inadequately examined. This study aimed to investigate underinvestigated factors associated with post-hospital falls. Study designRetrospective territory-wide cohort study. MethodsWe examined the electronic medical records of patients aged ≥65 who were discharged from public hospitals in Hong Kong (2007–2018). During the 12 months following discharge, participants were monitored to identify falls based on diagnosis codes or clinical notes from inpatient episodes, the emergency department (ED) visits, and death records. Falls were categorized into two groups: those only requiring ED visits and those requiring hospitalizations. Binary logistic and multinomial logistic regressions examined the associated factors for post-hospital falls and subcategories of falls, respectively. ResultsAmong 606,392 older patients, 28,593 (4.71%; 95% CI = 4.66%–4.77%) experienced falls within 12 months after discharge. Of those, 8438 (29.5%) only required ED visits, and 20,147 (70.5%) required hospitalizations. Discharge from non-surgical wards, length of stay over two weeks, receiving the Geriatric Day Hospital and Rehabilitation Day Program, advancing age, being female, having more comorbidities, taking more fall risk increasing drugs, previous admission for falls, and living in Hong Kong Island were associated with increased fall risk. Receiving allied health service or nurse service was associated with reduced risk. The same factors were more associated with falls requiring hospitalizations rather than falls only requiring ED visits. ConclusionsOlder patients with identified factors were particularly vulnerable to post-hospital falls leading to rehospitalizations. Fall risk assessment and tailored prevention should prioritize this group.

Do Early Supported Discharge Teams Increase the Proportion of Stroke Patients Discharged Directly Home from Acute Hospitals in Ireland?

Abstract Background Early Supported Discharge teams for stroke are associated with improved patient, rehabilitative outcomes, quality of life and potentially reduced mortality. Over the last 5 years the number of ESD teams and the proportion of patients discharge under their care has increased. What is unclear is to what extent has the growth in discharges with ESD support from acute hospitals represent additional discharges or patients who would have been discharged anyway but now receive rehabilitation and support post discharge. Methods Data on patients discharged directly home from the Irish National Stroke Audit (INAS) between January 2018 and December 2022 were analysed along with ESD data. This is the five-year period for which comprehensive data on ESD has been collected by INAS. Data used were available on public platforms and ethics approval was not necessary. Chi Square Statistics were performed, using proprietary software to compare proportions. Results Data on 23183 inpatient episodes were analysed, 57% of patients were male. INAS cases increased 34% from 3730 in 2018 to 4999 in 2022. Proportion of patients with unknown discharge destination (2.5%-2.9%) and who died (11.0%-10.8%) remained stable across the period. Proportion discharged home increased from 55.6% in 2018 to 59.5% in 2022 (Chi Sq 13.0, p=0.0003), (4.9% absolute, 7.0% relative). Proportion of ESD discharges increased from 3.7% to 9.8% of all patients (Chi Sq 117.3, p&amp;lt;0.0001) and from 6.7% to 16.5% of direct discharges home (Chi Sq 106.6, p&amp;lt;0.0001). However, direct discharges home without ESD support declined from 51.9% to 49.7% of the total population (Chi Sq 4.16, p=0.04). This suggests that, compared to 2018, 64% of ESD discharges in 2022 were additional and contingent on ESD availability. Conclusion ESD is an effective way of increasing direct discharges of people with stroke home from hospital. The proportion of patients with access to ESD remains low.

Health Care Utilisation in a Cohort of Patients with Primary and Secondary Antibody Deficiency in the United Kingdom

IntroductionThis study investigates the frequency of hospital attendances, emergency care attendances and geographical influences on service interaction in cohorts of patients with primary and secondary antibody deficiency, to inform future service planning and delivery.MethodsThe COVID-19 in Antibody Deficiency (COV-AD) study was a United Kingdom study that enrolled 525 participants between April 2021 and September 2022. Data on health care utilisation was extracted from a screening cohort of participants at one participating site (Birmingham, UK). Hospital attendance (i.e. all outpatient and inpatient care episodes, including hospital-based IVIG treatment) and emergency care attendance patterns were analysed. Geographical differences in travel times to hospitals and associated costs were considered for all participants at all recruiting sites.ResultsIndividuals with antibody deficiency had a median of 7 hospital attendances per year. A diagnosis of secondary antibody deficiency, and antibody deficiency severe enough to require treatment with immunoglobulin replacement were associated with an increased frequency of hospital attendance. 12.7% of the cohort attended the Emergency Department at least once in the preceding twelve months. Individuals with secondary antibody deficiency were at greater risk of requiring emergency care over the preceding one-year and five-year periods. Individuals receiving subcutaneous immunoglobulin lived further from their local immunology centre and were more likely to engage with the COV-AD research study remotely, via dried blood spots sampling.ConclusionThis study highlights the utilisation of emergency and secondary care usage amongst patient with immunodeficiency and may inform service adaptation and development to better accommodate patient needs and circumstances.

Has multimorbidity and frailty in adult hospital admissions changed over the last 15 years? A retrospective study of 107 million admissions in England

BackgroundFew studies have quantified multimorbidity and frailty trends within hospital settings, with even fewer reporting how much is attributable to the ageing population and individual patient factors. Studies to date have tended to focus on people over 65, rarely capturing older people or stratifying findings by planned and unplanned activity. As the UK’s national health service (NHS) backlog worsens, and debates about productivity dominate, it is essential to understand these hospital trends so health services can meet them.MethodsHospital Episode Statistics inpatient admission records were extracted for adults between 2006 and 2021. Multimorbidity and frailty was measured using Elixhauser Comorbidity Index and Soong Frailty Scores. Yearly proportions of people with Elixhauser conditions (0, 1, 2, 3 +) or frailty syndromes (0, 1, 2 +) were reported, and the prevalence between 2006 and 2021 compared. Logistic regression models measured how much patient factors impacted the likelihood of having three or more Elixhauser conditions or two or more frailty syndromes. Results were stratified by age groups (18–44, 45–64 and 65 +) and admission type (emergency or elective).ResultsThe study included 107 million adult inpatient hospital episodes. Overall, the proportion of admissions with one or more Elixhauser conditions rose for acute and elective admissions, with the trend becoming more prominent as age increased. This was most striking among acute admissions for people aged 65 and over, who saw a 35.2% absolute increase in the proportion of admissions who had three or more Elixhauser conditions. This means there were 915,221 extra hospital episodes in the last 12 months of the study, by people who had at least three Elixhauser conditions compared with 15 years ago. The findings were similar for people who had one or more frailty syndromes. Overall, year, age and socioeconomic deprivation were found to be strongly and positively associated with having three or more Elixhauser conditions or two or more frailty syndromes, with socioeconomic deprivation showing a strong dose–response relationship.ConclusionsOverall, the proportion of hospital admissions with multiple conditions or frailty syndromes has risen over the last 15 years. This matches smaller-scale and anecdotal reports from hospitals and can inform how hospitals are reimbursed.

Economic burden of respiratory syncytial virus in adults in Germany – a health claims analysis between 2015 and 2018

Aims Respiratory syncytial virus (RSV) causes severe lower respiratory tract infections (LRTI) in infants and adults. While the clinical burden was recently estimated in adults in Germany, little is known about the economic burden. To fill this gap, this study aimed to assess hospital and outpatient healthcare resource utilization (HRU) and costs of RSV infections in adults in Germany. Methods In this retrospective, observational study on nationwide, representative, anonymized claims data (2015–2018), we identified patients ≥18 years with ICD-10-GM-codes specific to RSV (“RSV-specific”). To increase sensitivity, patients with unspecified LRTIs (including unspecified bronchitis, bronchiolitis, bronchopneumonia, and pneumonia) during RSV seasons were also included as cases potentially caused by RSV (“RSV-possible”). RSV-related HRU (hospital days, ICU and ventilation treatment, drug dispensation) and direct costs were estimated per episode. Excess costs per episode and for follow-up periods were compared to a matched control cohort. All outcomes were reported per healthcare sector and stratified by age and risk groups as well as disease severity (ICU admission/ventilation). Results Direct inpatient and outpatient mean episode costs were 3,473€ and 82€, respectively, with substantially higher costs for severe cases requiring intensive care and/or ventilation (10,801€). Direct costs for RSV-specific cases were higher than for RSV-possible cases (inpatients: 6,247€ vs. 3,450€; outpatients: 127€ vs. 82€). Moreover, costs were significantly higher for RSV patients than for controls and increased over time (inpatients: 5,140€ per episode vs 10,093€ per year; outpatients: 46€ per quarter vs 114€ per year). Limitations While the number of RSV-specific cases was low, inclusion of seasonal LRTI cases likely increased the sensitivity to detect RSV cases and allowed a better estimation of the total costs of RSV. Conclusions The economic burden of RSV-LRTI in adults in Germany is substantial, persists long-term, and is particularly high in the elderly. This highlights the need for cost-effective prevention measures.

The incidence of pleural infections in Finland

BackgroundThe incidence of pleural infections appears to be increasing in Western countries for unclear reasons. The aim of the study was to describe the incidence and treatment patterns of pleural infections in Finland over three decades. MethodsData regarding each treatment episode for pleural infections in the Finnish special medical care between January 1994 and December 2016 was obtained from a national database and compared to the demographics of Finnish residents obtained from the national census bureau. The annual incidence rates, type of treatment given, as well as the lengths of the hospitalization were analyzed. ResultsA total of 28,463 episodes were reported, of which 55% were inpatient episodes. Of these, 76% concerned males, and the median age of patients was 60 (interquartile range 49–70) years. The overall incidence of pleural infections was 23.4 per 100.000 patient-years, with a male-to-female -ratio of 3.3:1. The annual incidence rates increased throughout the study period with an average annual percentage change of +11.4% (95% CI ±7.4%). The highest incidence rates (>200 per 100.000 patient-years) were observed in men aged 80 or more. Altogether 88% of patients were treated conservatively. The proportion of patients treated by mini-invasive surgery significantly increased during study period (0–5.9%, p < 0.001) and was associated with shorter hospitalization (median 6 [interquartile range 4–12] days) than open surgery (median 7 [4.5–13] days) (p < 0.001). ConclusionThe incidence of pleural infections has increased significantly over the previous decades in Finland and appears to be higher than previously reported, particularly in elderly men.

The Association between the Substitution of Red Meat with Legumes and the Risk of Primary Liver Cancer in the UK Biobank: A Cohort Study.

Primary liver cancer is globally on the rise, partially due to poor diets and sedentary lifestyles. Shifting to more plant-based diets may lower the risk. We aimed to estimate the effect of replacing total red meat, unprocessed red meat and processed red meat with legumes on primary liver cancer in a free-living population. We analyzed data from 126,744 UK Biobank participants who completed ≥ two 24 h diet recalls. Baseline characteristics were collected from the initial assessment visit. Information on liver cancer diagnoses was collected via external linkage to inpatient hospital episodes or central cancer registries. Cox proportional hazards regression models were used to estimate the substitution of 15 g/day of legumes with 15 g/day of total red meat, unprocessed red meat or processed red meat on liver cancer risk, using the leave-one-out food substitution model. During a median follow-up time of 11.1 years, 173 participants developed liver cancer. In the fully adjusted models, no association was observed when substituting 15 g/day of legumes with total red meat (HR: 1.02 (95% CI 0.96-1.08)), unprocessed red meat (HR: 1.00 (95% CI 0.94-1.06)) or processed red meat (HR: 1.09 (95% CI 0.99-1.21)). Overall, little evidence of an association between replacing red meat with legumes and liver cancer was observed. Further research in other study populations with longer follow-up time is warranted.

Disparities by Socioeconomic Status and Diagnosis of Dementia in the Prescribing of Antipsychotics in a Real-World Data Population Over 60 Years of Age.

Antipsychotics are widely used in the elderly due to the high prevalence of neuropsychiatric associated with dementia. To analyze potential disparities in antipsychotic use in the general population of Gipuzkoa by socioeconomic status (SES) and diagnosis of Alzheimer's disease and related dementia (ADRD) adjusting for somatic and psychiatric comorbidities, age, and sex. A retrospective observational study was carried out in all the 221,777 individuals over 60 years of age (Gipuzkoa, Spain) to collect diagnosis of ADRD, the Charlson Comorbidity Index, and psychiatric comorbidities considering all primary, outpatient, emergency and inpatient care episodes and first- and second-generation antipsychotics, and sociodemographic variables, namely, age, sex, SES and living in a nursing home. Logistic regression was used for multivariate statisticalanalysis. Use of any antipsychotic was greater in women, individuals over 80 years old, living in a nursing home, with a diagnosis of dementia, somatic and psychiatric comorbidities, and low SES. Quetiapine was the most used drug. The likelihood of any antipsychotic use was significantly associated with low SES (odds ratio [OR]: 1.60; confidence interval [CI]: 1.52-1.68), age over 80 years (OR: 1.56; CI: 1.47-1.65), institutionalization (OR: 12.61; CI: 11.64-13.65), diagnosis of dementia (OR: 10.18; CI: 9.55-10.85) and the comorbidities of depression (OR: 3.79; CI: 3.58-4.01) and psychosis (OR: 4.96; CI: 4.64-5.30). The greater levels of antipsychotic use and institutionalization in people of low SES indicate inequity in the management of neuropsychiatric symptoms. Increasing the offer of non-pharmacological treatments in the health system might help reduce inequity.

Economic Burden of Medically Attended Respiratory Syncytial Virus Infections Among Privately Insured Children Under 5 Years of Age in the USA.

The cost of medically attended RSV LRI (lower respiratory infection) is critical in determining the economic value of new RSV immunoprophylaxes. However, most studies have focused on intermittent RSV encounters, not the episode of care that captures the entirety of RSV illness. We created age- and condition-specific cohorts of children under 5 years of age using MarketScan® data (2015-2019). We contrasted aggregating healthcare costs over RSV-LRTI episodes to ascertaining costs based on RSV-specific encounters only. Economic burden was estimated by multiplying costs per encounter or per episode by their respective incidence rates. Average cost was higher per episode than per encounter regardless of settings (inpatient: $28,586 vs. $18,056 and outpatient/ED: $2099 vs. $407 for infants). Across ages, the economic burden was highest for infants and RSV-LRTI requiring inpatient care, but the burden in outpatient/ED settings was disproportionately higher than costs due to higher incidence rates (for inpatient vs. outpatient episodes: $226,403 vs. $101,269; for inpatient vs. outpatient encounters: $151,878 vs. $38,819 per 1000 infant-years). For high-risk children, cost and burden were up to 3-10 times higher, respectively. With a comprehensive stratification by settings and risk condition, the encounter- versus episode-based estimates provide a robust range for policymakers' economic appraisal of new RSV immunoprophylaxes.

Multidisciplinary rehabilitation following recreational nitrous oxide (N2O) misuse: evaluating service provision and rehabilitation outcomes in a cohort with serious disability

Purpose: Recreational nitrous oxide (N2O) misuse is increasing globally. Chronic misuse can cause neurological impairments that require rehabilitation, though literature characterising rehabilitation is limited. This study aimed to evaluate rehabilitation service provision for impairments resulting from N2O misuse. Methods: A retrospective audit of hospitalised patients referred for rehabilitation for N2O toxicity was conducted between 2015 and 2022 at a single metropolitan hospital. Data were collected via medical record audit and analysed via descriptive and non-parametric statistics. Results: 16 eligible cases were identified, aged 18–43 years (50% female/male), with increasing case frequency. 12 cases received inpatient rehabilitation episodes for multifactorial sensorimotor, cognitive and psychosocial impairments. Cases articulated diverse rehabilitation goals and received intervention from a median of 6 clinical disciplines. All cases required assistance to mobilise or perform self-care activities on admission. Functional Independence Measure (FIM) scores significantly improved with rehabilitation (median FIM 84[75–93] to 117[112–123], p < .001). Despite gains in independence, all cases required referral for ongoing rehabilitation post-discharge. Conclusions: Demand for inpatient rehabilitation for disabling N2O toxicity appears to be increasing. In this series, cases were young, exhibited serious impairments, and had multidisciplinary rehabilitation needs. Inpatient rehabilitation led to significant functional improvements, though ongoing disability was evident post-discharge.

An evaluation of outpatient service provision in the National Health Service in Great Britain: A freedom of information request.

The National Health Service (NHS) Long Term Plan was published in January 2019. One of its objectives was restructuring outpatient services, as part of an Outpatient Transformation initiative. Monitoring of trusts' adherence to the objectives of the Long Term Plan is therefore required to benchmark progress against national objectives. We aimed to explore whether outpatient transformation initiatives and phlebotomy services that are managed by outpatients are appropriately staffed and to evaluate trusts' adherence to the objectives outlined in the Long Term Plan. A freedom of information (FOI) request was sent in January 2023 to 153 trusts across Great Britain (time span: 1 January 2022-31 December 2022). Parameters requested included number of outpatients seen/discharged, phlebotomy episodes, number of sites/wards covered by phlebotomy, target/actual did not attend (DNA) rates, time since inception of the outpatient transformation project (OTP), advice and refer (A&R) and patient-initiated follow-up (PIFU), phlebotomy and outpatient managerial establishment and use of electronic notes and patient portals. A total of 117 trusts (76.5%) provided responses to the FOI request. The mean number of new outpatients seen face-to-face was 185,810. Of 73 trusts reporting both actual and target DNA rates, 62 (84.9%) did not meet their DNA targets. The actual DNA rate was significantly greater than the target DNA rate across trusts (p < 0.001, mean: 8.8% vs. 6.5%, respectively). A total of 58 different electronic systems and 29 patient portals were utilised across trusts. Thirty-six trusts (30.3%) did not have an outpatient transformation project manager and 16 trusts (13.7%) did not initiate an OTP. With phlebotomy provision, the mean number of outpatient phlebotomy episodes was lower than inpatient episodes (83,383 vs. 91,020, respectively). There are deficiencies in current outpatient establishments that may hinder the achievement of objectives set in the NHS Long Term Plan. Changes at all levels of healthcare are required, with increased reliance on technologies and investment in support for transformation management.

How Does the Burden of Respiratory Syncytial Virus Compare to Influenza in Spanish Adults?

ABSTRACTBackgroundRespiratory syncytial virus (RSV) and influenza infections cause significant annual morbidity and mortality worldwide in at‐risk populations. This study is aimed at assessing hospital burden and healthcare resource utilization (HRU) of RSV and influenza in adults in Spain.MethodsData were obtained from the Projected Hospitalisation Database of inpatient episodes (ages: younger adults 18–50 and 51–64 years; older adults 65–74, 75–84, and ≥ 85 years) during 2015, 2017, and 2018 in Spanish public hospitals. Incidence, mean hospitalization, and HRU assessments, including length of stay (LOS), intensive care unit (ICU) usage, and age‐standardized mortality rates, were collected and stratified by age group, with analyses focusing on the adult population (≥ 18 years old).ResultsMean hospitalization rate in the population across all years was lower in individuals with RSV versus influenza (7.2/100,000 vs. 49.7/100,000 individuals). ICU admissions and median LOS were similar by age group for both viruses. Age‐standardized mortality was 6.3/100,000 individuals and 6.1/100,000 individuals in patients with RSV and influenza, respectively, and mortality rates were similar in older adults (≥ 65 years) for both viruses.ConclusionsRSV and influenza infection were associated with considerable HRU. There is a substantial disease burden for RSV infection in older adults ≥ 65 years. While RSV hospitalization rates in adults reported here appeared lower than influenza, RSV is still underdiagnosed in the hospital setting and its incidence might be similar to, or higher than, influenza.

Enhancing the accuracy of register-based metrics: Comparing methods for handling overlapping psychiatric register entries in Finnish healthcare registers.

Healthcare registers are invaluable resources for research. Partly overlapping register entries and preliminary diagnoses may introduce bias. We compare various methods to address this issue and provide fully reproducible open-source R scripts. We used all Finnish healthcare registers 1969-2020, including inpatient, outpatient and primary care. Four distinct models were formulated based on previous reports to identify actual admissions, discharges, and discharge diagnoses. We calculated the annual number of treatment events and patients, and the median length of hospital stay (LOS). We compared these metrics to non-processed data. Additionally, we analyzed the lifetime number of individuals with registered mental disorders. Overall, 2,130,468 individuals had a registered medical contact related to mental disorders. After processing, the annual number of inpatient episodes decreased by 5.85%-10.87% and LOS increased by up to 3days (27.27%) in years 2011-2020. The number of individuals with lifetime diagnoses reduced by more than 1 percent point (pp) in two categories: schizophrenia spectrum (3.69-3.81pp) and organic mental disorders (1.2-1.27pp). The methods employed in pre-processing register data significantly impact the number of inpatient episodes and LOS. Regarding lifetime incidence of mental disorders, schizophrenia spectrum disorders require a particular focus on data pre-processing.