Nonfederal Hospitals In California Research Articles

Patient and Hospital Characteristics Associated With the Interhospital Transfer of Adult Patients With Sepsis.

The interhospital transfer (IHT) of patients with sepsis to higher-capability hospitals may improve outcomes. Little is known about patient and hospital factors associated with sepsis IHT. We evaluated patterns of hospitalization and IHT and determined patient and hospital factors associated with the IHT of adult patients with sepsis. Retrospective cohort study. A total of 349,938 adult patients with sepsis at 329 nonfederal hospitals in California, 2018-2019. We evaluated patterns of admission and outward IHT between low sepsis-, intermediate sepsis-, and high sepsis-capability hospitals. We estimated odds of IHT using generalized estimating equations logistic regression with bootstrap stepwise variable selection. Among the cohort, 223,202 (66.4%) were initially hospitalized at high-capability hospitals and 10,870 (3.1%) underwent IHT. Nearly all transfers (98.2%) from low-capability hospitals were received at higher-capability hospitals. Younger age (< 65 yr) (adjusted odds ratio [aOR] 1.54; 95% CI, 1.40-1.69) and increasing organ dysfunction (aOR 1.22; 95% CI, 1.19-1.25) were associated with higher IHT odds, as were admission to low-capability (aOR 2.79; 95% CI, 2.33-3.35) or public hospitals (aOR 1.35; 95% CI, 1.09-1.66). Female sex (aOR 0.88; 95% CI, 0.84-0.91), Medicaid insurance (aOR 0.59; 95% CI, 0.53-0.66), home to admitting hospital distance less than or equal to 10 miles (aOR 0.92; 95% CI, 0.87-0.97) and do-not-resuscitate orders (aOR 0.48; 95% CI, 0.45-0.52) were associated with lower IHT odds, as was admission to a teaching hospital (aOR 0.83; 95% CI, 0.72-0.96). Most patients with sepsis are initially hospitalized at high-capability hospitals. The IHT rate for sepsis is low and more likely to originate from low-capability and public hospitals than from high-capability and for-profit hospitals. Transferred patients with sepsis are more likely to be younger, male, sicker, with private medical insurance, and less likely to have care limitation orders. Future studies should evaluate the comparative benefits of IHT from low-capability hospitals.

Emergency department visits respond nonlinearly to wildfire smoke

Air pollution negatively affects a range of health outcomes. Wildfire smoke is an increasingly important contributor to air pollution, yet wildfire smoke events are highly salient and could induce behavioral responses that alter health impacts. We combine geolocated data covering all emergency department (ED) visits to nonfederal hospitals in California from 2006 to 2017 with spatially resolved estimates of daily wildfire smoke PM[Formula: see text] concentrations and quantify how smoke events affect ED visits. Total ED visits respond nonlinearly to smoke concentrations. Relative to a day with no smoke, total visits increase by 1 to 1.5% in the week following low or moderate smoke days but decline by 6 to 9% following extreme smoke days. Reductions persist for at least a month. Declines at extreme levels are driven by diagnoses not thought to be acutely impacted by pollution, including accidental injuries and several nonurgent symptoms, and declines come disproportionately from less-insured populations. In contrast, health outcomes with the strongest physiological link to short-term air pollution increase dramatically in the week following an extreme smoke day: We estimate that ED visits for asthma, COPD, and cough all increase by 30 to 110%. Data from internet searches, vehicle traffic sensors, and park visits indicate behavioral changes on high smoke days consistent with declines in healthcare utilization. Because low and moderate smoke days vastly outweigh high smoke days, we estimate that smoke was responsible for an average of 3,010 (95% CI: 1,760-4,380) additional ED visits per year 2006 to 2017. Given the increasing intensity of wildfire smoke events, behavioral mediation is likely to play a growing role in determining total smoke impacts.

Machine learning-driven identification of novel patient factors for prediction of major complications after posterior cervical spinal fusion.

Posterior cervical fusion is associated with increased rates of complications and readmission when compared to anterior fusion. Machine learning (ML) models for risk stratification of patients undergoing posterior cervical fusion remain limited. We aim to develop a novel ensemble ML algorithm for prediction of major perioperative complications and readmission after posterior cervical fusion and identify factors important to model performance. This is a retrospective cohort study of adults who underwent posterior cervical fusion at non-federal California hospitals between 2015 and 2017. The primary outcome was readmission or major complication. We developed an ensemble model predicting complication risk using an automated ML framework. We compared performance with standard ML models and logistic regression (LR), ranking contribution of included variables to model performance. Of the included 6822 patients, 18.8% suffered a major complication or readmission. The ensemble model demonstrated slightly superior predictive performance compared to LR and standard ML models. The most important features to performance include sex, malignancy, pneumonia, stroke, and teaching hospital status. Seven of the ten most important features for the ensemble model were markedly less important for LR. We report an ensemble ML model for prediction of major complications and readmission after posterior cervical fusion with a modest risk prediction advantage compared to LR and benchmark ML models. Notably, the features most important to the ensemble are markedly different from those for LR, suggesting that advanced ML methods may identify novel prognostic factors for adverse outcomes after posterior cervical fusion.

Impact of ST-Segment-Elevation Myocardial Infarction Regionalization Programs on the Treatment and Outcomes of Patients Diagnosed With Non-ST-Segment-Elevation Myocardial Infarction.

BackgroundMany communities have implemented systems of regionalized care to improve access to timely care for patients with ST‐segment–elevation myocardial infarction. However, patients who are ultimately diagnosed with non–ST‐segment–elevation myocardial infarctions (NSTEMIs) may also be affected, and the impact of regionalization programs on NSTEMI treatment and outcomes is unknown. We set out to determine the effects of ST‐segment–elevation myocardial infarction regionalization schemes on treatment and outcomes of patients diagnosed with NSTEMIs.Methods and ResultsThe cohort included all patients receiving care in emergency departments diagnosed with an NSTEMI at all nonfederal hospitals in California from January 1, 2005 to September 30, 2015. Data were analyzed using a difference‐in‐differences approach. The main outcomes were 1‐year mortality and angiography within 3 days of the index admission. A total of 293 589 patients with NSTEMIs received care in regionalized and nonregionalized communities. Over the study period, rates of early angiography increased by 0.5 and mortality decreased by 0.9 percentage points per year among the overall population (95% CI, 0.4–0.6 and −1.0 to −0.8, respectively). Regionalization was not associated with early angiography (−0.5%; 95% CI, −1.1 to 0.1) or death (0.2%; 95% CI, −0.3 to 0.8).ConclusionsST‐segment–elevation myocardial infarction regionalization programs were not statistically associated with changes in guideline‐recommended early angiography or changes in risk of death for patients with NSTEMI. Increases in the proportion of patients with NSTEMI who underwent guideline‐directed angiography and decreases in risk of mortality were accounted for by secular trends unrelated to regionalization policies.

Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage.

Do-not-resuscitate (DNR) orders are commonly used after intracerebral hemorrhage (ICH) and have been shown to be a predictor of mortality independent of disease severity. We determined the frequency of early DNR orders in ICH patients and whether a previously reported association with increased mortality still exists. We performed a retrospective analysis of patients discharged from non-federal California hospitals with a primary diagnosis of ICH from January 2013 through December 2014. Characteristics included hospital ICH volume and type and whether DNR order was placed within 24h of admission (early DNR order). The risk of in-hospital mortality was evaluated both on the individual and hospital level using multivariable analyses. A case mix-adjusted hospital DNR index was calculated for each hospital by comparing the actual number of DNR cases with the expected number of DNR cases from a multivariate model. A total of 9,958 patients were treated in 180 hospitals. Early DNR orders were placed in 20.1% of patients and 54.2% of these patients died during their hospitalization compared to 16.0% of patients without an early DNR order. For every 10% increase in a hospital's utilization of early DNR orders, there was a corresponding 26% increase in the likelihood of in-hospital mortality. Patients treated in hospitals within the highest quartile of adjusted DNR use had a higher relative risk of death compared to the lowest quartile (RR 3.9 vs 5.2) though the trend across quartiles was not statistically significant. The use of early DNR orders for ICH continues to be a strong predictor of in-hospital mortality. However, patients treated at hospitals with an overall high or low use of early DNR had similar relative risks of death whether or not there was an early DNR order, suggesting that such orders may not be a proxy for less aggressive care as seen previously.

Racial/ethnic disparities in the risk of intracerebral hemorrhage recurrence.

To estimate the risk of intracerebral hemorrhage (ICH) recurrence in a large, diverse, US-based population and to identify racial/ethnic and socioeconomic subgroups at higher risk. We performed a longitudinal analysis of prospectively collected claims data from all hospitalizations in nonfederal California hospitals between 2005 and 2011. We used validated diagnosis codes to identify nontraumatic ICH and our primary outcome of recurrent ICH. California residents who survived to discharge were included. We used log-rank tests for unadjusted analyses of survival across racial/ethnic groups and multivariable Cox proportional hazards regression to determine factors associated with risk of recurrence after adjusting for potential confounders. We identified 31,355 California residents with first-recorded ICH who survived to discharge, of whom 15,548 (50%) were white, 6,174 (20%) were Hispanic, 4,205 (14%) were Asian, and 2,772 (9%) were black. There were 1,330 recurrences (4.1%) over a median follow-up of 2.9 years (interquartile range 3.8). The 1-year recurrence rate was 3.0% (95% confidence interval [CI] 2.8%-3.2%). In multivariable analysis, black participants (hazard ratio [HR] 1.22; 95% CI 1.01-1.48; p = 0.04) and Asian participants (HR 1.29; 95% CI 1.10-1.50; p = 0.001) had a higher risk of recurrence than white participants. Private insurance was associated with a significant reduction in risk compared to patients with Medicare (HR 0.60; 95% CI 0.50-0.73; p < 0.001), with consistent estimates across racial/ethnic groups. Black and Asian patients had a higher risk of ICH recurrence than white patients, whereas private insurance was associated with reduced risk compared to those with Medicare. Further research is needed to determine the drivers of these disparities.

Why Don’t We Kill 2 Birds with 1 Stone?

Article, see p 1698 In this issue of Circulation , Goldstone and colleagues1 report the early and midterm outcomes of more than 59 000 patients who underwent primary isolated multivessel coronary artery bypass grafting (CABG) at 126 nonfederal hospitals in California from 2006 to 2011. They found that after propensity matching, receipt of a second arterial conduit was associated with significantly lower all-cause mortality, myocardial infarction, and coronary reintervention at a median follow-up of more than 5 years. It is interesting to note that compared with radial artery (RA) grafting, right internal thoracic artery (RITA) grafting did not confer a survival or cardiovascular advantage, but was associated with increased risk of sternal wound infection. During the study period, use of a second arterial conduit decreased from 10.7% to 9.1%, mirroring a national trend reported by the Society of Thoracic Surgeons Adult Cardiac Surgery Database (11.6% in 2000–2009 versus 6.7% in 2010–2013).2 Notably, 30% of cardiac surgeons in California did not use a second arterial graft for the duration of the study. So why is there a reluctance to use multiple arterial grafts in multivessel CABG despite the potential benefit? As for the 70% of California’s surgeons who use 2 arteries, why do they do so only in a small percentage of patients? The answers to those questions are complex but not elusive. Barriers to multiarterial grafting are diverse, ranging from perceptions about available scientific evidence, to surgical expertise, to health economics and more (Table). View this table: Table. Barriers to Multiarterial Grafting, Proposed Solutions, and Responsible Parties Starting with the scientific evidence, the California study is the largest study to date and an important addition to other large …

Outcomes After Vena Cava Filter Use in Noncancer Patients With Acute Venous Thromboembolism: A Population-Based Study.

Evidence that vena cava filters (VCFs) are beneficial is limited. We retrospectively analyzed all noncancer patients admitted to nonfederal California hospitals for acute venous thromboembolism from 2005 to 2010. Analysis was stratified by the presence/absence of a contraindication to anticoagulation (active bleeding, major surgery). Outcomes were death within 30 or 90 days of admission and the 1-year incidence of recurrent venous thromboembolism manifested as pulmonary embolism or deep vein thrombosis. Propensity score methods were used to account for observed systematic differences in baseline characteristics between patients treated and those not treated with a VCF. Among 80 697 patients with no contraindication to anticoagulation, VCF use (n=7762, 9.6%) did not significantly reduce the 30-day risk of death (hazard ratio [HR], 1.12; 95% confidence interval [CI], 0.98-1.28). Among 3017 patients with active bleeding, VCF use (n=1095, 36.3%) reduced the 30-day risk of death by 32% (HR, 0.68; 95% CI, 0.52-0.88) and the 90-day risk by 27% (HR, 0.73; 95% CI, 0.59-0.90). VCF use (n=489, 33.8%) did not reduce mortality among 1445 patients who underwent major surgery (HR, 1.1; 95% CI, 0.71-1.77). In all subgroups, filter use did not reduce the risk of subsequent pulmonary embolism. However, the risk of subsequent deep vein thrombosis increased by 50% among VCF patients with no contraindication (HR, 1.53; 95% CI, 1.34-1.74) and by 135% among VCF patients with active bleeding (HR, 2.35; 95% CI, 1.56-3.52). VCF use significantly reduced the short-term risk of death only among patients with acute venous thromboembolism who had a contraindication to anticoagulation because of active bleeding. These results support the findings of a randomized clinical trial and current guidelines that recommend VCF use only in patients who cannot receive anticoagulation treatment.

Abstract TMP97: The Frequency of ED Visits for Headache Preceding a Subsequent Hospitalization for Subarachnoid Hemorrhage

Introduction: The incidence of sentinel headache (SH) in the days or weeks prior to a aneurysmal subarachnoid hemorrhage (SAH) has been reported to be as high as 10-43% and SH has been linked with early re-bleeding risk. Hypothesis: We evaluated whether ED visits for headache were more common in the month preceding a hospitalization for SAH and if this was associated with increased mortality after SAH. Methods: We identified all hospital discharges for SAH at all licensed nonfederal hospitals in California from 2008 -11 using comprehensive data from the Office of Statewide Healthcare Planning and Development. Encounters with invalid or missing record linkage numbers (based on social security number) or for non-California residents, and those with concurrent trauma diagnoses or external injury codes were excluded. We identified the first hospitalization for SAH during the study period for each distinct patient. We then identified any ED encounters for headache without SAH during the month prior to the admission for SAH and during a one-month period exactly one year prior to the index admission for SAH. Results: A total of 7,723 patients that were hospitalized for non-traumatic SAH during the study period met study eligibility criteria (mean age 59 years [SD 16], 62% female). A majority were white (62%) and non-Hispanic (73%), and 14% were Asian/Pacific Islander and 9% were black. Just 33 (0.4%) SAH patients had had an ED visit for headache in the preceding month compared to 2 ED visits (0.03%) for headache during a month-long period one-year prior to the hospitalization for SAH (RR 16.5, 95% CI 4.0-68, p&lt;0.0001). SAH patients with a recent ED visit for headache had a similar length of hospital stay (10 vs 9.1 days, p=0.27), but were younger (59 vs 49 years, p=0.0002) had lower 30-day mortality (3.0% vs. 22%, p= 0.005), and were more likely to be discharged directly home (81% vs. 44%, p&lt;0.001). Conclusion: We identified very few ED visits for headache in the month prior to a hospitalization for aneurysmal SAH, and SAH patients who had visited the ED for headache had lower mortality and better outcomes, though SAH patients with sentinel headache who did not visit the ED were not captured in our analysis.

Association Between Race and Case Fatality Rate in Hospitalizations for Sepsis.

Differentiating whether disparities in outcomes for sepsis among racial groups are due to differences in hospital care versus pre-hospitalization factors is an important step in developing effective strategies to reduce these disparities. As such, we examined the association between race and case fatality rates among hospitalizations for sepsis. This was a case-control study of hospitalizations for sepsis in all acute-care, non-federal California hospitals during 2011. The association between hospital mortality and race was examined using hierarchical logistic regression analysis. Among 131,831 hospitalizations for sepsis, the unadjusted case fatality rates were 15.1% in whites, 14.0% in blacks, 13.8% in Hispanics, and 16.2% in Asians (P<0.001). Compared to whites, the odds of hospital mortality was 0.84 (95% CI 0.79-0.89) for blacks, 0.88 (95% CI 0.84-0.92) for Hispanics, and 0.93 (95% CI 0.87-0.98) for Asians after controlling for patient, healthcare systems, and hospital-level factors. There was no difference in the variability of sepsis mortality across hospitals between racial groups. The range of case fatality rates for sepsis among hospitals was 8.3-22.9% for whites, 9.1-20.5% for blacks, 7.0-19.1% for Hispanics, and 10.0-23.0% for Asians. Case fatality rates for sepsis hospitalizations are lower in minority racial groups in California. Future studies and interventions that seek to reduce racial disparities in sepsis need to focus on pre-hospitalization factors that contribute to population-level racial differences in sepsis outcomes.

Predictors of admission after emergency department discharge in older adults.

To identify predictors of hospital inpatient admission of older Medicare beneficiaries after discharge from the emergency department (ED). Retrospective cohort study. Nonfederal California hospitals (n = 284). Visits of Medicare beneficiaries aged 65 and older discharged from California EDs in 2007 (n = 505,315). Using the California Office of Statewide Health Planning and Development files, predictors of hospital inpatient admission within 7 days of ED discharge in older adults (≥65) with Medicare were evaluated. Hospital inpatient admissions within 7 days of ED discharge occurred in 23,340 (4.6%) visits and were associated with older age (70-74: adjusted odds ratio (AOR) = 1.12, 95% confidence interval (CI) = 1.07-1.17; 75-79: AOR = 1.18, 95% CI = 1.13-1.23; ≥80: AOR = 1.4, 95% CI = 1.35-1.46), skilled nursing facility use (AOR = 1.82, 95% CI = 1.72-1.94), leaving the ED against medical advice (AOR = 1.82, 95% CI = 1.67-1.98), and the following diagnoses with the highest odds of admission: end-stage renal disease (AOR = 3.83, 95% CI = 2.42-6.08), chronic renal disease (AOR = 3.19, 95% CI = 2.26-4.49), and congestive heart failure (AOR = 3.01, 95% CI = 2.59-3.50). Five percent of older Medicare beneficiaries have a hospital inpatient admission after discharge from the ED. Chronic conditions such as renal disease and heart failure were associated with the greatest odds of admission.

Variation in charges for 10 common blood tests in California hospitals: a cross-sectional analysis

ObjectivesTo determine the variation in charges for 10 common blood tests across California hospitals in 2011, and to analyse the hospital and market-level factors that may explain any observed variation.Design,...

Risk predictors of stroke and mortality after ablation for atrial fibrillation: the California experience 2005-2009.

Ablation (ABL) is a second-line therapy for the management of atrial fibrillation (AF). Single-center studies have demonstrated the safety and efficacy of ABL; however, the low event rates render it difficult to assess predictors of major adverse events. The purpose of this study was to determine the population-based incidence of data and risk factors for both stroke <30 days and death after AF ABL. Patients (n = 6207) identified as having undergone AF ABL between 2005 and 2009 by the California Ambulatory Surgery Database in 97 nonfederal hospitals in California were linked to the California Patient Discharge Database and to a master death registry. Data from these patients were analyzed for primary outcomes of 30-day death and ischemic stroke. Independent risk factors for these end-points were determined. Mean patient age was 61.9 years, and the majority of the patients were men. Thirty-day mortality and stroke after ABL were 0.39% and 0.61%, respectively. Independent predictors of death were age ≥80 years (odds ratio [OR] 8.2, 95% confidence interval [CI] 1.5-43) and heart failure (OR 9.2, 95% CI 3.0-28). Prior stroke/transient ischemic attack/stroke was the only independent predictor for stroke (OR 6.3, 95% CI 3-13). In our large population-based study, we found higher procedure-related mortality but comparable stroke rate after AF ABL than previously reported. Age ≥80 years and heart failure was each independently associated with >8-fold increase in odds of death. The only significant predictor of stroke was prior stroke/transient ischemic attack. These findings may aid in patient selection for AF ABL.

Abstract T P163: Influenza-Like Illness is Associated With Risk of Ischemic Stroke: A Case-Crossover Analysis

Background: Acute triggers of ischemic stroke (IS) remain poorly characterized. Emerging evidence suggests infections may promote short-term pro-inflammatory, pro-coagulant states that precipitate stroke. Objective: We hypothesized that exposure to influenza-like illness (ILI) is associated with increased risk of IS, as time intervals between events decrease. Methods: HCUP/AHRQ administrative claims from all nonfederal hospitals in California (2009) were queried for IS, using a published ICD-9-CM surveillance algorithm, identifying 41,148 unique individuals. A patient identifier was used to link IS patients across hospitalizations with a validated algorithm for ILI using inpatient and emergency department records. For each IS case, ILI events within 15, 30, and 90-day risk periods preceding IS in 2009, were compared to the same time periods one and two calendar years prior (i.e., 2007 and 2008). A 4-day buffer period was used to ensure ILI preceded IS. Conditional logistic regression models, matched on individuals, were used to calculate odds ratios and 95% confidence intervals (OR, 95%CI) for given risk period, after adjusting for monthly prevalence and mean age of ILI hospitalizations. Effects stratified by age are also explored. Results: Median (IQR) age of cases was 74 (62-83) years; 52.4% were female. There were more ILI during the 90-days preceding strokes in 2009 (n=439) than in the same stroke-free calendar period one year prior (n=303) and two years prior (n=81). ILI was associated with IS with decreasing magnitude of effect using windows of 15-days (adjusted OR 6.5, 95%CI, 2.2-19.7), 30-days (adjusted OR=3.7, 95%CI 1.7-8.3), and 90-days (adjusted OR=3.3, 95%CI, 1.9-5.8). The risk associated with ILI was higher among younger patients. Using the 30-day window, the association between ILI and IS was strongest among those 45-to-65-years (n=27,545, adjusted OR=2.53, 95%CI, 0.95-6.8). Conclusion: Influenza-like illness may contribute to a heightened risk of ischemic stroke during short term periods post-infection, especially among younger patients. Presentation with influenza represents an opportunity for targeted prevention of stroke.

204 Short-Term Readmission Following Discharge From California Emergency Departments

Study Objectives: Hospitalizations that occur shortly after emergency department (ED) discharge may indicate opportunities to improve ED care. There currently is limited population-level information about such events. In this hypothesis-generating analysis, we identified hospital- and visit-level predictors of 7-day unscheduled hospital admission after ED discharge.Methods: We conducted a retrospective cohort analysis of adult (age>18 years) ED visits resulting in discharge from all non-federal California hospitals in 2007. The primary outcome was unscheduled hospital admission within 7 days of ED discharge. Candidate predictors included hospital structural characteristics, patient demographic information, and ED primary discharge diagnosis. We fit multivariable, hierarchical logistic regression to account for clustering of ED visits by hospitals.Results: The study cohort contained a total of 5,035,833 visits to 288 facilities in 2007. Readmission within 7 days of ED discharge occurred in 130,526 (2.6%). In multivariate analysis, 7-day readmission was associated with having Medi-Cal, California's Medicaid program, (OR 1.4, 95% CI 1.4-1.5) or Medicare insurance (OR 1.5, 95% CI 1.5-1.6), and eloping or leaving against medical advice (OR 1.9, 95% CI 1.9-2.0). The 6 most common ED discharge diagnoses associated with the outcome were renal disease (OR 4.1, 95% CI 3.6-4.6), congestive heart failure (OR 3.2, 95% CI 3.0-3.4), diseases of the blood which include a diagnosis of anemia and sickle cell disease (OR 3.2, 95% CI 3.0-3.4), neoplasms (OR 2.9, 95% CI 2.7-3.1), mental illness (OR 2.6, 95% CI 2.6-2.7), and non-infectious lung disease including pleurisy, pneumothorax, and pneumonitis (OR 2.6, 95% CI 2.4-2.9). Hospital characteristics associated with readmission were for-profit status (OR 1.2, 95% CI 1.1-1.3) and teaching affiliation (OR 1.2, 95% CI 1.0-1.3).Conclusion: We found that 2.6% of patients discharged from California emergency departments were readmitted to a hospital bed within 7 days. We identified several hospital structural features, patient characteristics, and ED discharge diagnoses that are associated with increased risk of early readmissions. Further studies of causal pathways are needed to identify interventions to reduce potentially avoidable readmissions. Study Objectives: Hospitalizations that occur shortly after emergency department (ED) discharge may indicate opportunities to improve ED care. There currently is limited population-level information about such events. In this hypothesis-generating analysis, we identified hospital- and visit-level predictors of 7-day unscheduled hospital admission after ED discharge. Methods: We conducted a retrospective cohort analysis of adult (age>18 years) ED visits resulting in discharge from all non-federal California hospitals in 2007. The primary outcome was unscheduled hospital admission within 7 days of ED discharge. Candidate predictors included hospital structural characteristics, patient demographic information, and ED primary discharge diagnosis. We fit multivariable, hierarchical logistic regression to account for clustering of ED visits by hospitals. Results: The study cohort contained a total of 5,035,833 visits to 288 facilities in 2007. Readmission within 7 days of ED discharge occurred in 130,526 (2.6%). In multivariate analysis, 7-day readmission was associated with having Medi-Cal, California's Medicaid program, (OR 1.4, 95% CI 1.4-1.5) or Medicare insurance (OR 1.5, 95% CI 1.5-1.6), and eloping or leaving against medical advice (OR 1.9, 95% CI 1.9-2.0). The 6 most common ED discharge diagnoses associated with the outcome were renal disease (OR 4.1, 95% CI 3.6-4.6), congestive heart failure (OR 3.2, 95% CI 3.0-3.4), diseases of the blood which include a diagnosis of anemia and sickle cell disease (OR 3.2, 95% CI 3.0-3.4), neoplasms (OR 2.9, 95% CI 2.7-3.1), mental illness (OR 2.6, 95% CI 2.6-2.7), and non-infectious lung disease including pleurisy, pneumothorax, and pneumonitis (OR 2.6, 95% CI 2.4-2.9). Hospital characteristics associated with readmission were for-profit status (OR 1.2, 95% CI 1.1-1.3) and teaching affiliation (OR 1.2, 95% CI 1.0-1.3). Conclusion: We found that 2.6% of patients discharged from California emergency departments were readmitted to a hospital bed within 7 days. We identified several hospital structural features, patient characteristics, and ED discharge diagnoses that are associated with increased risk of early readmissions. Further studies of causal pathways are needed to identify interventions to reduce potentially avoidable readmissions.

Surgical Site Infection Prevention Policies and Adherence in California Hospitals, 2010

Surgical Site Infection Prevention Policies and Adherence in California Hospitals, 2010

Increased Admissions for Pyelonephritis: Contributing Factors

Research Article| January 01 2012 Increased Admissions for Pyelonephritis: Contributing Factors AAP Grand Rounds (2012) 27 (1): 6. https://doi.org/10.1542/gr.27-1-6 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Increased Admissions for Pyelonephritis: Contributing Factors. AAP Grand Rounds January 2012; 27 (1): 6. https://doi.org/10.1542/gr.27-1-6 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: pyelonephritis Source: Copp HL, Halpern MS, Maldonado Y, et al. Trends in hospitalization for pediatric pyelonephritis: a population based study of California from 1985 to 2006. J Urol. 2011; 186(3): 1028– 1034; doi: https://doi.org/10.1016/j.juro.2011.04.101Google Scholar To identify trends in hospitalizations for children with pyelonephritis, investigators from the University of California, San Francisco systematically examined the Office of Statewide Health Planning and Development (OSHPD) database using multivariable logistic regression to evaluate factors associated with admissions. The study focused on hospitalizations in California from 1985 to 2006. The OSHPD database included all nonfederal hospitals in California. Admissions were identified based on the ICD-9 codes for acute, chronic, and unspecified pyelonephritis. While the total number of pediatric hospitalizations (all causes) decreased, hospitalizations for children with pyelonephritis increased from 17 per 100,000 children to 31 per 100,000 over the 21- year study period.... You do not currently have access to this content.

Preoperative Transfusion Practices and Outcomes in Sickle Cell Patients Admitted to California Hospitals,

Abstract 4189 Introduction:Surgery in patients with Sickle Cell Disease (SCD) is associated with a high rate of postoperative complications, including acute chest syndrome (ACS). Some early reports have suggested that the overall complication rate may be as high as 50% and the mortality rate 10%. In 1995, a large multicenter trial conducted at SCD centers in the U.S. showed that preoperative transfusion reduced complications related to sickling. Despite transfusions, 10% of the patients in this study developed ACS. Recently, smaller studies in the US and other countries have suggested that not all SCD patients who undergo surgery need a transfusion. Practices may vary depending on surgical risk and the clinical history of the patient. For example, while most SCD centers use preoperative transfusions, practices outside of centers (where the majority of patients are being followed) are not well understood. To describe the transfusion practices in our state as well some of the outcomes of SCD patients who undergo surgery, we queried California's statewide hospital discharge database to describe the frequency of preoperative transfusions for SCD patients as well as the frequency of ACS following surgery. Methods:This was a retrospective cohort study using 2005–2008 public data from the California Office of Statewide Health Planning and Development (OSHPD). Data included all inpatient discharges from all non-federal California hospitals. Inclusion criteria included the presence of a sickle cell disease ICD-9 code in the primary or a secondary diagnosis (282.60–282.69, 282.41–282.42) and the presence of ICD-9 codes for one of the six most common surgical procedures performed in SCD: tonsillectomy, cholecystectomy, splenectomy, hysterectomy, therapeutic abortion, and hip arthroplasty. A variable summarizing the temporal sequence of transfusion and surgery was created by comparing the number of days to surgery with the number of days to transfusion. Cases were coded for the presence of ACS (517.3) or respiratory diagnoses (including pneumonia, pulmonary edema, acute respiratory distress syndrome, hypoxia and respiratory failure) in any primary or secondary diagnosis. Transfusion, ACS diagnosis, and mortality frequencies were described, and differences in outcome between patients treated with or without transfusion were assessed with chi-square tests. Results:Between 2005 and 2008, 468 visits to California hospitals by patients with SCD were associated with one of the six targeted surgical procedures. Of these visits, 222 cases (47.4%) were associated with a transfusion. Of the 179 cases in which the timing of transfusion could be determined, 145 visits (81%) were associated with a preoperative transfusion, and 34 visits (19%) were associated with a transfusion given after surgery. ACS was documented in 59 (12.6%) surgical patients. Forty three cases of ACS occurred in the transfused patients(19%). Sixteen cases(6.5%) occurred in the non transfused group. The timing of transfusion was available in 32 of the ACS cases, of which 21 had a transfusion either before or on the same day of surgery and 11 were transfused after surgery. There were four deaths in the cohort: three patients had been transfused and developed ACS.The fourth patient was never transfused and did not develop ACS. Conclusions:Over half of the SCD patients in California are not transfused in association with a surgical procedure. The majority of transfused patients received preoperative transfusions and were more likely to develop ACS or a related pulmonary complication following surgery, whereas the frequency of ACS was lower in the nontransfused group. This latter finding could be consistent with a group of patients with less severe disease. Similarly, the increased frequency of death in transfused patients likely reflects the clinical severity of this group. Although we were unable to determine if preoperative transfusions were administered prior to hospital admission, the data suggests that many patients are not being given what many sickle cell providers in the US consider standard preoperative treatment. Finally, the frequency of ACS in transfused patients was nearly twice that of the study performed in academic sickle cell centers in 1995. This finding is consistent with the notion that many California patients do not receive care at a sickle cell center and thus may have poorer outcomes Disclosures:No relevant conflicts of interest to declare.

Hospital Determinants of Emergency Department Left Without Being Seen Rates

The proportion of patients who leave without being seen in the emergency department (ED) is an outcome-oriented measure of impaired access to emergency care and represents the failure of an emergency care delivery system to meet its goals of providing care to those most in need. Little is known about variation in the amount of left without being seen or about hospital-level determinants. Such knowledge is necessary to target hospital-level interventions to improve access to emergency care. We seek to determine whether hospital-level socioeconomic status case mix or hospital structural characteristics are predictive of ED left without being seen rates. We performed a cross-sectional study of all acute-care, nonfederal hospitals in California that operated an ED in 2007, using data from the California Office of Statewide Health Planning and Development database and the US census. Our outcome of interest was whether a visit to a given hospital ED resulted in left without being seen. The proportion of left without being seen was measured by the number of left without being seen cases out of the total number of visits. We studied 9.2 million ED visits to 262 hospitals in California. The percentage of left without being seen varied greatly over hospitals, ranging from 0% to 20.3%, with a median percentage of 2.6%. In multivariable analyses adjusting for hospital-level socioeconomic status case mix, visitors to EDs with a higher proportion of low-income and poorly insured patients experienced a higher risk of left without being seen. We found that the odds of an ED visit resulting in left without being seen increased by a factor of 1.15 for each 10-percentage-point increase in poorly insured patients, and odds of left without being seen decreased by a factor of 0.86 for each $10,000 increase in household income. When hospital structural characteristics were added to the model, county ownership, trauma center designation, and teaching program affiliation were positively associated with increased probability of left without being seen (odds ratio 2.09; 1.62, and 2.14, respectively), and these factors attenuated the association with insurance status. Visitors to different EDs experience a large variation in their probability of left without being seen, and visitors to hospitals serving a high proportion of low-income and poorly insured patients are at disproportionately higher risk of leaving without being seen. Our findings suggest that there is room for substantial improvement in this outcome, and regional interventions can be targeted toward certain at-risk hospitals to improve access to emergency care.

Use of Transfusion to Treat Acute Chest In Sickle Cell Disease:California Hospital Practice Patterns

AbstractAbstract 253 Introduction:Acute chest syndrome (ACS) is a leading cause of morbidity and mortality in patients with Sickle Cell Disease (SCD). Although the NIH recommends transfusion as standard of care therapy for this diagnosis, practice patterns vary. In 2000, the National Acute Chest Study group found that 72% of patients with ACS were transfused. This study, which was perfomed at academic medical centers with sickle cell treatment programs, used specific diagnostic inclusion criteria. As ACS may be difficult to distinguish from pneumonia, recognition and treatment of the diagnosis may vary by hospital and by presence or absence of a sickle cell specialist. With access to hospital discharge data from all California hospitals seeing SCD patients, we aimed to describe transfusion practices in ACS. Methods:This retrospective cohort study uses 2005–2008 public data from the California Office of Statewide Health Planning and Development (OSHPD). Data included all inpatient and emergency department (ED) discharges from all non-federal California hospitals. Cases were selected based on discharge from or admission via an ED and the presence of a sickle cell disease ICD-9 code in the primary or a secondary diagnosis (282.60-282.69, 282.41–282.42). Further inclusion criteria included presence of ACS (517.3) or respiratory diagnoses including pneumonia, pulmonary edema, acute respiratory distress syndrome, hypoxia and respiratory failure in any primary or secondary diagnosis. Frequency of transfusion, intubation and mortality were described and chi-square tests were performed to determine the statistical significance of differences between groups of patients treated with or without transfusion as well as between groups of adults and children. Results:Between 2005–2008, 4306 ED visits by Californians with SCD were associated with either ACS or a related respiratory diagnosis and only 42.5% of these cases were associated with transfusion. Limiting the diagnosis to ACS only, 1399 cases were identified, and still only 50.4% of these cases were associated with transfusion. Among patients with ACS or a related diagnosis, the majority were admitted to the hospital (90.9%); only 59.2% of intubated cases (n=238) were transfused; and of the 92 deaths during this period, only 46.7% were associated with transfusion. Patients who were 18 and over were transfused more often than young children (43.2% vs. 35.7%; 2(1)=12.37, p<0.001). Conclusions:Despite transfusion being the standard of care for treatment of ACS as well as other sickle–related complications, many ACS cases in California are not being treated in this manner. Surprisingly, the most severely ill patients, those who were either intubated or died during the study period, had a lower transfusion frequency than the cohort as a whole. Although some mild pediatric cases may not be transfused, a minority of the total cohort was under 18 years old. Recent studies imply that patients transitioning out of pediatric SCD programs have an increased risk of dying due to ACS and other serious SCD complications. Our study suggests that underutilization of transfusion may play a role in these poor adult outcomes in SCD. These findings prompt further investigation into the role of transition to adult care and appropriate medical homes in access to quality SCD care. Disclosures:No relevant conflicts of interest to declare.