Number Of Bed Days Research Articles

Using geographic variation in unplanned ambulatory care sensitive condition admission rates to identify commissioning priorities: an analysis of routine data from England.

Objectives To use geographic variation in unplanned ambulatory care sensitive condition admission rates to identify the clinical areas and patient subgroups where there is greatest potential to prevent admissions and improve the quality and efficiency of care. Methods We used English Hospital Episode Statistics data from 2011/2012 to describe the characteristics of patients admitted for ambulatory care sensitive condition care and estimated geographic variation in unplanned admission rates. We contrasted geographic variation across admissions with different lengths of stay which we used as a proxy for clinical severity. We estimated the number of bed days that could be saved under several scenarios. Results There were 1.8 million ambulatory care sensitive condition admissions during 2011/2012. Substantial geographic variation in ambulatory care sensitive condition admission rates was commonplace but mental health care and short-stay (<2 days) admissions were particularly variable. Reducing rates in the highest use areas could lead to savings of between 0.4 and 2.8 million bed days annually. Conclusions Widespread geographic variations in admission rates for conditions where admission is potentially avoidable should concern commissioners and could be symptomatic of inefficient care. Further work to explore the causes of these differences is required and should focus on mental health and short-stay admissions.

Trends in emergency hospital admissions in England due to adverse drug reactions: 2008-2015

Objectives To determine the scale of adverse drug reaction (ADR)-related emergency hospital admissions in England from 2008 to 2015 using the Hospital Episode Statistics (HES) database. Methods Part of the HES database contains information about all hospital admissions in England. Annual data are published online and are publically available. These hospital admission data were analysed to determine how many emergency admissions were due to ADRs. International classification of diseases, 10th edition (ICD-10) codes that indicated a drug was the primary cause of the admission were included in the study. Key findings The total number of emergency hospital admissions increased by 12.1%, from 5 010 670 in 2008/2009 to 5 615 707 in 2014/2015. Over the same period, emergency admissions due to ADRs increased by 53.4%, from 60 055 in 2008/2009 to 92 114 in 2014/2015. These figures indicate an increase in the proportion of emergency hospital admissions due to ADRs over the period of study, from 1.2% in 2008/2009 to 1.6% in 2014/2015. The total number of bed days utilised decreased by 7.1%, from 51 841 443 in 2008/2009 to 48 183 084 in 2014/2015. Despite this overall decrease, the number of bed days that were used due to ADRs increased by 51.5% from 625 011 (1.2% of all bed days) in 2008/2009 to 947 016 (2.0% of all bed days) in 2014/2015. The most common ADRs were mental and behavioural disorders due to drugs and the drugs most commonly implicated in ADRs were systemic agents such as anticancer drugs and immunosuppressants. Conclusions This study demonstrates that emergency hospital admissions due to ADRs are an increasing problem for the National Health Service (NHS) in England and further research is needed to discover which interventions are most likely to reduce them.

The effect of early psychological symptom severity on long-term functional recovery: A secondary analysis of data from a cohort study of minor injury patients

BackgroundThe mental health consequences of injuries can interfere with recovery to pre-injury levels of function and long term wellbeing. ObjectivesThe purpose of this study was to explore the relationship between psychological symptoms after minor injury and long-term functional recovery and disability. DesignThis exploratory study uses secondary data derived from a longitudinal cohort study of psychological outcomes after minor injury. SettingParticipants were recruited from the Emergency Department of an urban hospital in the United States. ParticipantsA cohort of 275 patients was randomly selected from 1100 consecutive emergency department admissions for minor injury. Potential participants were identified as having sustained minor injury by the combination of three standard criteria including: presentation to the emergency department for medical care within 24h of a physical injury, evidence of anatomical injury defined as minor by an injury severity score between 2 and 8 and normal physiology as defined by a triage-Revised Trauma Score of 12. Patients with central nervous system injuries, injury requiring medical care in the past 2 years and/or resulting from domestic violence, and those diagnosed with major depression or psychotic disorders were excluded. MethodsPsychological symptom severity was assessed within 2 weeks of injury, and outcome measures for functional limitations and disability were collected at 3, 6 and 12 months. A quasi-least squares approach was used to examine the relationship between psychological symptom scores at intake and work performance and requirement for bed rest in the year after injury. ResultsAdjusting for demographic and injury covariates, depression symptoms at the time of injury predicted (p≤0.05) both poorer work performance and increased number of days in bed due to health in the year after injury. Anxiety symptoms predicted (p≤0.05) bed days at 3, 6, and 12 months and work performance at 3 months. ConclusionsDepression and anxiety soon after minor injury may help predict important markers of long-term recovery. With further research, simple assessment tools for psychological symptoms may be useful to screen for patients who are at higher risk for poor long-term recoveries and who may benefit from targeted interventions.

The VA Medical Foster Home Program, Ambulatory Care Sensitive Conditions, and Avoidable Hospitalizations.

This quality control study analyzes whether the Veterans Administration Medical Foster Home (VA MFH) program has been successful in improving access and effectiveness of ambulatory care. Individuals hospitalized for one or more of 22 adult ambulatory care sensitive conditions were identified. Pre and post comparisons of a specified population of participants in the program were conducted to determine rates of avoidable hospitalizations for 6 months prior to and following MFH enrollment. The overall rate of avoidable hospitalizations declined from 18.5 to 14.9 per 100 enrollees following enrollment. The number of bed days used declined by 39%, as did the cost associated with avoidable hospitalizations. Enrollment in the VA MFH program resulted in an overall reduction in the rate of avoidable hospitalizations, resource utilization, and costs. Studies are needed comparing these results with other matched cohorts of nursing home eligible veterans.

Implementation of foetal fibronectin testing: Admissions, maternal interventions and costs at 1 year

Foetal fibronectin testing (fFN) has a high negative predictive value for preterm delivery, but it has a cost implication. This two-stage prospective study evaluated the real patient costs and clinical impact of introducing the fFN test in women presenting acutely with threatened preterm labour in a tertiary UK obstetric hospital. Introduction of the fFN test for women with threatened preterm labour reduced antenatal admissions and in utero transfers, and reduced steroid treatment and tocolysis, even at 1 year after implementation. The total number of bed days for women with threatened preterm labour who did not deliver during admission fell from 132 (mean 8.8 days) to 25 days (mean 3.6 days). The mean cost of admission per woman before introduction of the fFN test was £1032 (95% CI £880 to £1184); after it was £339 (95% CI £261 to £417). In this small single centre study, the introduction of the test produced a cost saving of £693 per woman (95% CI, £464 to £922) which over 12 months potentially saves £74844 (95% CI £50,112 to £99,576). Further studies are needed to formally evaluate the cost-effectiveness of the fFN test and its impact on clinical decision-making in large populations.

Factors associated with changes in hospitalisation in patients prescribed clozapine.

The objective of this study was to examine whether delays in clozapine treatment affect outcomes once clozapine is started and identify factors that affect these outcomes. Patients starting clozapine in a four year period at South London and the Maudsley NHS Foundation Trust were included. Clinical details were gathered from clinical notes. Primary outcome was net change in inpatient admissions comparing the periods before and after clozapine was started. There was no significant association between the length of clozapine delay (mean clozapine delay = 3.93 years) and number or length of inpatient admissions once clozapine had been started (mean net change in days of admission = 16.74 days), F value = 0.901, p = 0.345. Clozapine reduced the total number of bed days per year, but only if treatment was continued - stopping resulted in inpatient admissions returning to pre-clozapine levels. Younger patients had a greater reduction in bed days when taking clozapine (p = 0.027). Clozapine reduces the number of inpatient days, regardless of the chronicity of the illness at the time clozapine was started. Continued compliance with clozapine is necessary to maintain this benefit. Reduction in bed days is greater in younger patients, suggesting early initiation of clozapine may be beneficial.

Postoperative applications of the fast track technology in patients with herniated intervertebral discs of the lumbosacral spine

The fast track technology means a complex of targeted measures involving rational preoperative preparation, minimally invasive surgery, regional anesthesia and short-acting anesthetics, and early postoperative rehabilitation. Elucidating the possibility of applying the fast track technology in neurosurgery, in particular in spinal surgery, is extremely topical. This is associated with the epidemiological data and the fact that minimally invasive techniques used in neurosurgery are highly expensive. The study objective was implementation of the fast track technology and subsequent analysis of its use after surgery in patients with herniated intervertebral discs of the lumbosacral spine. The fast track technology following spinal surgery was implemented at the Clinical Hospital of the Presidential Administration of the Russian Federation and the Neurosurgical Department of the Clinical Hospital № 1 of the Presidential Administration of the Russian Federation using an algorithm of technology application. The study included 48 patients who underwent surgical treatment for herniated intervertebral discs of the lumbosacral spine between January and July 2015. An analysis of pain severity using the Visual Analog Scale demonstrated a slight decrease (10%) in a group of patients who were subjected to the fast track technology, at discharge and at 1 month after surgery; there was no difference in longer follow-up. An analysis of the functional status using the Oswestry index and Roland-Morris scale demonstrated that patients of the study group had faster and more efficient recovery and an improvement of the functional activity by 20% (p<0.05) compared to those in the control group. An analysis of patient-reported assessment of treatment quality revealed that indicators, such as awareness and pain control, in the study group were highest and amounted to 95% and higher. An analysis of the hospital stay duration showed a decrease in the number of bed-days in an integrated group by 39%, which saved 34 bed-days. The fast track technology reduces the degree of surgical aggression, increases surgery safety, and decreases the number of intraoperative complications and hospital stay duration.

Antimicrobial use at a multi-disciplinary hospital.

The problem of antimicrobial resistance has become topical and alarming all over the world, including Kazakhstan. Nosocomial strains of microorganisms are widespread, being resistant to the majority of available antimicrobials. This results in longer periods of hospital stay, increases in financial expenditures, and sometimes, in lethal outcomes. The social importance of antimicrobial resistance is preconditioned by the spread of resilient strains of microorganism beyond the hospital environment, which leads to lower effectiveness of antibiotic therapy against infectious diseases and growth in their incidence [1, 2].Our in-patient health facility is a multifunctional one. It provides therapeutic, surgical and oncology and hematology care including organ transplantation. Measures to reduce antibiotic resistance are very important. To develop a standardized approach to the use of antimicrobial drugs aimed at reducing of antimicrobial resistance, postoperative complications and mortality rates along with financial expenditures. The expected result of this approach should be the enhancement of quality of care. In September 2014 we developed and introduced a local protocol of the antimicrobials use, namely antibiotics for surgical prophylaxis and treatment, based on the evidence of international clinical guidelines evidence-based medicine approach, taking into account the microbial landscape and antibiotic resistance patterns to major pathogens: Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae [3]. We planned to assess the effectiveness of this policy by the following criteria: the percentage of post-surgical sequela, the number of bed days, the percentage of resistant cases and antibiotic expenditures. In order to improve the quality of bacteriological studies, together with microbiologists we trained the medical staff on the methods of obtaining of biological material for microbiological testing. We analyzed the indicators of antibiotic resistance from October 2014 to March 2015 (hereafter period I) on the basis of the data from the microbiological laboratory with data of April-August 2015 (hereafter period II). The analysis on the basis of other criteria has yet to be carried out. The bio-material was obtained from different loci, including blood. The results of the oncology and hematology were analyzed separately. We received the following results of sensitivity of the listed microorganisms to various antimicrobials in the period I and the period II respectively expressed as percentages:Staphylococcus aureus: Oxacillin - 95% and 100%, Azythromycin - 62% and 100%, Vancomycin - 100% and 100%, Levofloxacin/Moxifloxacin - 100% and 100%.Pseudomonas aeruginosa: Ceftazidime - 34% and 67%, Piperacillin/Tazobactam - 91% and 84%, Cefepime - 59% and 81%, Amikacin - 95% and 100%, Meropenem - 100% and 100%, Ciprofloxacin - 97% and 100%.Escherichia coli: Gentamicin - 93% and 96%, Piperacillin/Tazobactam - 86% and 92%, Ceftriaxone - 82% and 100%, Amikacin - 99% and 100%,Ciprofloxacin - 69% and 80%, Amoxycillin/Clavulanate - 44% and 46% respectively.Klebsiella pneumoniae: Gentamicin - 50% and 100%, Piperacillin/Tazobactam - 95% and 100%, Cefepime - 100% and 100%, Ceftriaxone - 96% and 100%, Amikacin - 99% and 100%, Ciprofloxacin - 100% and 100%, Amoxycillin/Clavulanate - 22% and 23%.Acinetobacter baumannii: Gentamicin - 83% and 83%, Piperacillin/Tazobactam - 33% and 58%, Cefepime - 0% and 33%, Ceftriaxone - 0% and 33%, Amikacin - 50% and 83%, Ciprofloxacin - 83% and 67%, Meropenem/Imipenem-Cilastin - 83% and 83%. During the analyzed periods we observed some improvement in the sensitivity of the main pathogens to antibiotics. At the same time, the resistance of Acinetobacter baumannii to carbapenems and fluoroquinolones increased.Limitations of the studyThere are many other than antibiotic use factors, which influence these results. Further analysis is planned to be carried out. Nevertheless, this analysis makes us believe that we are, probably, on the right path for improving the use of antibacterial drugs.

Variation in Use of Pediatric Cardiology Subspecialty Care: A Total Population Study in California, 1983 to 2011

BackgroundAmerican Academy of Pediatrics guidelines emphasize regionalized systems of care for pediatric chronic illness. There remains a paucity of information on the status of regionalized systems of care for pediatric congenital heart disease (CHD). ObjectivesThis study evaluated variations in use of pediatric cardiology specialty care centers (PCSCC) for pediatric patients with CHD in California between 1983 and 2011. MethodsWe performed a retrospective, total population analysis of pediatric CHD patients using the California Office of Statewide Health Planning and Development unmasked database. PCSCCs were identified by California's Title V program. ResultsThere were 164,310 discharges meeting inclusion criterion. Discharges from PCSCCs grew from 58% to 88% between 1983 and 2011. Regionalized care was highest for surgical (96%) versus nonsurgical (71%) admissions. Admissions with a public payer increased from 42% (1983) to 61% (2011). Total bed days nearly doubled, and median length of stay increased from 2 to 3 days (nonspecialty care) and from 4 to 5 days (specialty care). There was a decrease in the pediatric CHD in-hospital death rate from 5.1 to 2.3 per 100,000 between 1983 and 2011, and a shift toward a larger percent of deaths occurring in the newborn period. ConclusionsCalifornia’s inpatient regionalized specialty care of pediatric CHD has increased substantially since 1983, especially for surgical CHD discharges. The death rate has decreased, the number of bed days has increased, and a large proportion of these discharges now have public payers. Health care reform efforts must consider these shifts while protecting advances in regionalization of pediatric CHD care.

A retrospective observational study of the effectiveness of paliperidone palmitate on acute inpatient hospitalization rates.

This retrospective mirror-image observational study aimed to establish the effects of the long-acting antipsychotic injection paliperidone palmitate (PP) on acute inpatient hospitalization rates. We utilized routinely collected clinical data to compare the number and length of acute patient admissions 1 year before and 1 year after initiation of PP. A single cohort of 66 patients with a diagnosis of schizophrenia and who had received monthly injections of PP for at least 1 year were included in the analysis. The mean number of acute inpatient admissions fell from 0.86 in the year before PP initiation to 0.23 in the following year (P=0.001), and there was a numerical but nonsignificant decrease in the number of bed days from 32.48 to 31.22 over the study duration. The median number of bed days in the year before PP initiation was 20, and in the year after initiation it was 0. The median number of admissions also fell from 1 to 0 during the same period. The results of the study should be treated cautiously because of the limitations of the study design but suggest that patients with a diagnosis of schizophrenia who continue treatment with PP over 12 months experience a significant reduction in hospital admissions compared with the previous year.

PTH-309 Use of warmed humidified insufflation carbon dioxide to reduce surgical site infections in laparoscopic colorectal surgery: a cohort study

Introduction Surgical Site infections (SSI) are a common complication associated with considerable morbidity. They have a negative impact on recovery time leading to extended hospital stay, reduced patient quality of life and constitute a financial burden to healthcare providers. The aim of this study was to evaluate if using HumiGard warmed, humidified CO 2 insufflation system decreased the incidence of SSI. Method A retrospective cohort study of two patient groups (n = 252 in a 1:1 ratio) undergoing laparoscopic colorectal resections in a specialist unit was undertaken; the first from Sept 2012 – July 2013 pre HumiGard and the second from July 2013–2014 with the HumiGard system. Data was retrieved retrospectively from case notes of all patients who underwent laparoscopic colorectal surgery with the HumiGard system and the same number of patients pre-intervention. The primary outcome was the between-groups difference in incidence of SSI, which was graded according to a standard classification system by an enhanced recovery team. Secondary outcomes were; differences in incidence of post-operative pneumonia, number of bed days and length of time in theatre recovery. In order to identify any change in outcomes, relative risk and odds ratios and their respective 95% confidence intervals were estimated as a measure of association for SSI, while RR was estimated for pneumonia. Bed-days and length of time in theatre recovery were analysed by ANOVA since these were continuous variables. Data was analysed in Genstat V.16. Results Incidence of SSI was significantly reduced from 12% to 4.7% following introduction of Humigard (p = 0.047). A non-significant reduction in pneumonia was observed using HumiGard (4 vs 1, p = 0.21). Mean number of bed days decreased by 1.5 days (7.87 to 6.32) but did not reach significance (p = 0.16). Length of time spent in theatre recovery was similar (186 Vs. 190 mins p = 0.86). Mean body temperature post op was 36.5 ᵒC with Humigard, data was not recorded in the first cohort. Conclusion The introduction of the HumiGard system in laparoscopic colorectal resectional surgery significantly reduced incidence of SSI. A trend was identified that it decreased pneumonia and length of stay, however these did not reach significance, therefore further data are required to more fully assess these outcome measures. With widespread use of laparoscopic surgical techniques now routine across surgical specialties in UK centres this study has identified an important intervention to reduce SSI. A randomised controlled trial to further assess the role of warming and humidifying insufflation gases in reducing the SSI and length of hospital stay is indicated. Disclosure of interest None Declared.

66 The Management of Syncope on the Acute Medical Take. An Experience at a District General Hospital

<h3>Introduction</h3> Syncope accounts for up to 6% of admissions annually.¹ In the over 65 age group, 23% will have an episode of syncope over a 10 year period with a 30% recurrence rate over two years.²Up to 60% of patients presenting to A&amp;E with syncope are admitted, however only 50% will have syncope specific investigations and only 50% will receive a final diagnosis.² Financial restraints and bed pressures in the UK have increased the need for effective management of syncope. We aimed to assess the management of syncope on the acute medical take. <h3>Method</h3> An audit was devised to evaluate the management of patients referred to the medical team over a 50-day period. The medical notes of patients meeting the inclusion criteria were sourced, retrospectively analysed and compared with current NICE guidelines. The project was extended to assess whether development of a pathway with same day syncope services would impact hospital bed stays. <h3>Results</h3> Of 190 patients, 77 randomly sourced notes were analysed; 35 patients were identified as having had a syncopal event. 63% were female and the average age was 85 years (67–98). 11% of patients had a full history recorded and only 3% had a complete initial assessment including history, ECG and postural blood pressure recording. 51% of patients had CT brain imaging of which 74% were not indicated. 34% of patients had 24 h ECG monitoring of which none were indicated and no significant result identified. 29% of patients did not have an inpatient echocardiogram and 34% of patients did not have an inpatient cardiology review despite indications. 37% of patients were discharged with no diagnosis. 29% of all patients had previously been admitted with a similar presentation. 46% of patients admitted could have been discharged on the same day had rapid ECHO, cardiology review and injectable loop recorder services been available. This accounts for 160 days of inappropriate hospital stay and with extrapolation, 1168 days in one year. Thus, 3.2 extra beds could be made available at our DGH. <h3>Conclusion</h3> The initial assessment of syncope is inadequate and investigations are inappropriately requested or not considered. A proportion of patients do not receive a diagnosis and are unnecessarily admitted. A considerable number of bed days could be prevented with a clear syncope pathway including same day ECHO, cardiology review and injectable loop recorder service, thus relieving pressures on acute medical beds and accident and emergency services. This problem is not unique to our trust and represents a pattern currently prevalent across the UK and further afield. <h3>References</h3> Shen WK, Decker WW, Smars PA, <i>et al</i>. Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management. Circulation 2004;110(24):3636-45 Lipsitz L, Wei JY, Rowe JW. Syncope in an elderly, institutionalised population: prevalence, incidence, and associated risk. Q J Med. 1985;55(216):45-54

PTU-261 Surgery for benign colorectal polyps: the impact of an advanced colonic endoscopic mucosal resection (EMR) service in a large tertiary centre

Introduction Advances in endoscopy training and endoscopic resection techniques have facilitated the development of advanced EMR service in few regional centres. This should equate to a reduction in the number of surgery for benign colorectal polyps. Interestingly, a previous study of hospital episode statistics database for national trends in benign colorectal polyp surgery had showed no significant difference in the reduction of surgery over a 10 year period. 1 We aimed to assess the impact of a new advanced EMR service on the need for surgical intervention for benign polyps in a tertiary care centre. Method The advanced EMR service (including level 3 and 4 polyps) 2 was set up in May 2013. We retrospectively looked at the MDT outcomes 20 months prior and after setting up of the service to identify patients requiring external referral or surgery for benign polyps. Hospital electronic records were reviewed to ascertain details concerning polyp size, complications and bed days. Results In the period before the EMR service, 51 patients underwent surgery for benign polyps requiring 285 bed days. 8 complications were encountered. The average polyp size was 3.2 cms (Range 1–8 cms). 6 patients were referred externally for advanced EMR. Between May 2013 and Dec 2014, since the setting up of the service, 8 patients have had surgery requiring 46 bed days. During the same time, 180 polyps were encountered in 168 patients. The mean polyp size varied from 1.5 cms to 12 cms. Excluding patients who had surgery for invasive cancer, 91% of patients avoided surgery. Of 139 completely resected benign polyps, 66 (47%) polyps were level 4 and 89% polyps achieved complete endoscopic clearance with one procedure. 4 complications required 9 bed days. Conclusion An advanced EMR service decreases the need for surgical intervention, reduces the number of bed days and complications. Moreover, such a service also offers important savings for local healthcare economies. This study also emphasise the need for the development of regional benign polyp MDT. Disclosure of interest None Declared. References Almoudaris AM, et al . Surgery for benign colorectal polyps in England – trends and outcomes from 1997 to 2007. Gut 2011; 60 :A4 Gupta S, et al . The “SMSA” scoring system for determining the complexity of a polyp. Gut 2011; 60 :A129

Abstract PD4-4: Prevalence, health care utilization and costs of concomitant depression among breast cancer survivors

Abstract Purpose: Concomitant conditions in a cohort of non-elderly breast cancer survivors (BCS) were examined with a focus on the prevalence, healthcare utilization, and costs of diagnosed depression. Little research has been conducted on how concomitant depression among cancer survivors impacts utilization and costs of care. Methods. Using administrative claims data from the Military Health System Data Repository (MHSDR), a cohort of 2,851 BCS was identified with at least 2 years survival from the time of diagnosis. Concomitant conditions were based on ICD-9 codes; codes 296.2, 296.3, 298.0, and 311 were used to identify depression. Fiscal year 2009 was used as the index year to calculate healthcare utilization and costs. Bivariate analyses and logistic regression analysis were used to examine group differences and predictors of having received a diagnosis of depression. Findings. The most common concomitant chronic conditions in the BCS cohort were hypertension (50.0%), mood disorders or adjustment disorders (37.5%), heart disease (23.0%), diabetes (19.9%), history of tobacco use (19.7%), asthma or chronic obstructive pulmonary disease (16%), and obesity (16.8%). About 15.9% of the BCS were diagnosed with depression in the year prior to, at the time of, or in the 2-year follow up period after the cancer diagnosis. With bivariate analysis, significant differences were found between BCS with and without depression: those with depression had higher mean number of hospital stays (.33 vs .11), mean number of bed days (1.94 vs .58), mean number of ambulatory visits (34.26 vs 20.42), and mean number of pharmacy prescriptions (45.49 vs 27.60). For follow up care, BCS with a diagnosis of depression cost, on average, $7174 more annually then those without a diagnosis of depression ($15,471 vs $8,297). No demographic characteristics significantly increased the likelihood of having received a diagnosis of depression. Discussion. The results show much higher annual health care utilization and costs for BCS diagnosed with depression compared to BCS without a diagnosis of depression. These findings may reflect the health care plan provided to military-related beneficiaries, a plan that has few restrictions for cancer follow up care if medically ordered. Claims data contains no information about cancer stage, a correlate of health care utilization and costs. Overall, the findings provide empirical evidence that there is a fiscal incentive to screen and manage mild symptoms prior to patients meeting diagnostic criteria for clinical depression. Assumedly, timely screening and rapid intervention will lead to improved quality of life for the patient, decreased utilization of health care resources, and cost savings for health care plans. In this respect, the findings support the 2014 ASCO recommendations regarding screening and treatment for depression and anxiety. Conversely, the data intimate that adoption of the ASCO recommendations will lead to higher costs as more individuals are positively screened and referred for treatment. Who, what, or how such services will be afforded merits sustained inquiry. The opinions expressed herein are those of the author and are not necessarily representative of the opinions or policies of the Department of Defense. Citation Format: Diana D Jeffery. Prevalence, health care utilization and costs of concomitant depression among breast cancer survivors [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr PD4-4.

Co‐commissioning: the architecture of integration

Co‐commissioning: the architecture of integration

訪問看護と連携して実施した持続静注投与法を用いた外来静注抗菌薬療法（OPAT : Outpatient Parenteral Antimicrobial Therapy）：10 例の経験

In 2014, we reported the first trial based on outpatient parenteral antimicrobial therapy (OPAT) with continuous infusions in Japan. Following this, we found many patients who were eligible for OPAT but could not undertake it owing to difficulties in accessing the clinic daily. To overcome this problem, we created a model in collaboration with visiting nursing stations and started providing OPAT with the services. We report herein on a summary of the investigation of the first 10 patients treated under this model. We collected data pertaining to diseases, organisms, antimicrobials, treatment duration, bed days saved, outcome, readmission rate, and cost reductions associated with these patients. The most commonly targeted disease was osteomyelitis, followed by infective endocarditis. The condition of nine of the patients was complicated by bacteremia. The most commonly targeted organism was Staphylococcus aureus. Cefazolin was the most frequently prescribed antimicrobial, followed by Penicillin G. The median duration for OPAT was 12 days (range: 5-23 days). The total number of bed days saved was 129. All patients completed the planned OPAT. Eight patients were cured and two showed improvement. Only one patient was readmitted within a month after the completion of therapy. The estimated medical cost reduction was 496,540 yen, which is approximately 4,200 US dollars. Collaboration with visiting nursing stations provided OPAT to the patients who had difficulties in accessing the clinic daily. Our study shows that OPAT administered by continuous infusion in collaboration with home-visit nursing services would be a safe and feasible practice for efficient bed utilization and medical cost saving.

Hospital- and patient-related factors associated with differences in hospital antibiotic use: analysis of national surveillance results.

BackgroundSurveillance data of antibiotic use are increasingly being used for benchmarking purposes, but there is a lack of studies dealing with how hospital- and patient-related factors affect antibiotic utilization in hospitals. Our objective was to identify factors that may contribute to differences in antibiotic use.MethodsBased on pharmacy sales data (2006–2011), use of all antibiotics, all penicillins, and broad-spectrum antibiotics was analysed in 22 Health Enterprises (HEs). Antibiotic utilization was measured in World Health Organisation defined daily doses (DDDs) and hospital-adjusted (ha)DDDs, each related to the number of bed days (BDs) and the number of discharges. For each HE, all clinical specialties were included and the aggregated data at the HE level constituted the basis for the analyses. Fourteen variables potentially associated with the observed antibiotic use – extracted from validated national databases – were examined in 12 multiple linear regression models, with four different measurement units: DDD/100 BDs, DDD/100 discharges, haDDD/100 BDs and haDDD/100 discharges.ResultsSix variables were independently associated with antibiotic use, but with a variable pattern depending on the regression model. High levels of nurse staffing, high proportions of short (<2 days) and long (>10 days) hospital stays, infectious diseases being the main ICD-10 diagnostic codes, and surgical diagnosis-related groups were correlated with a high use of all antibiotics. University affiliated HEs had a lower level of antibiotic utilization than other institutions in eight of the 12 models, and carried a high explanatory strength. The use of broad-spectrum antibiotics correlated strongly with short and long hospital stays. There was a residual variance (30%–50% for all antibiotics; 60%–70% for broad-spectrum antibiotics) that our analysis did not explain.ConclusionsThe factors associated with hospital antibiotic use were mostly non-modifiable. By adjusting for these factors, it will be easier to evaluate and understand observed differences in antibiotic use between hospitals. Consequently, the inter-hospital differences can be more confidently acted upon. The residual variation is presumed to largely reflect prescriber-related factors.

Hospital bed occupancy for rotavirus and all cause acute gastroenteritis in two Finnish hospitals before and after the implementation of the national rotavirus vaccination program with RotaTeq®.

BackgroundVaccination-impact studies of the live-attenuated pentavalent oral vaccine Rotateq® have demonstrated that the burden of rotavirus gastroenteritis has been reduced significantly after the introduction of RotaTeq® vaccination, but less is known about the benefit of this vaccination on hospital overcrowding.MethodsAs part of an observational surveillance conducted during the RV seasons 2000/2001 to 2011/2012, we analysed hospital discharge data collected retrospectively from two Finnish hospitals (Oulu and Tampere), concerning ICD 10 codes A00-09 (acute gastroenteritis, AGE) and A08.0 (rotaviral acute gastroenteritis RV AGE). We estimated the reduction in the number of beds occupied and analysed the bed occupancy rate, for RV AGE and all cause AGE, among 0–16 year-old children, before and after the implementation of the RV immunisation program.ResultsThe rate of bed days occupied for RV AGE was reduced by 86% (95% CI 66%-94%) in Tampere and 79% (95% CI 47%-92%) in Oulu after RV vaccination implementation. For all cause AGE, reduction was 50% (95% CI 29% to 65%) in Tampere and 70% (95% CI 58% to 79%) in Oulu. Results were similar among 0–2 year-old children. This effect was also observed on overcrowding in both hospitals, with a bed occupancy rate for all cause AGE >25% in only 1% of the time in Tampere and 9% in Oulu after the implementation of the immunisation program, compared to 13% and 48% in the pre-vaccination period respectively. After extrapolation to the whole country, the annual number of prevented hospitalizations for all cause AGE in the post-vaccination period in Finland was estimated at 1,646 and 2,303 admissions for 0–2 and 0–16 year-old children respectively.ConclusionsThis study demonstrated that universal RV vaccination is associated with a clear decrease in the number of bed days and occupancy rates for RV AGE and all cause AGE. Positive consequences include increase in quality of care and a better healthcare management during winter epidemics.

P179 Does Day-case Thoracoscopy Reduce The Number Of Hospital Bed Days For Patients Under Investigation For Unilateral Pleural Effusion?

Introduction and objectives Medical thoracoscopy is the investigation of choice for diagnosis of exudative pleural effusions where pleural cytology is negative and malignancy is suspected. Over the past 18 months, our centre has offered day-case thoracoscopy to suitable patients, with the aim of reducing elective admissions and overall hospital bed days for patients undergoing this procedure. A review of practice has been performed to evaluate whether day-case thoracoscopy is effective in reducing bed days in this cohort of patients. Methods Data was retrospectively collected from patients attending our centre for medical thoracoscopy over a 12 month period (Feb 2013 – Feb 2014). Information on the number of bed days required, readmission rates and repeat procedures was reviewed for those attending for day-case thoracoscopy and compared with those electively admitted for overnight stay +/- talc pleurodesis. Results Of 53 patients undergoing medical thoracoscopy at our centre, 31 patients were electively admitted for thoracoscopy, with an average stay of 3.8 bed days. 23 (74%) of this group underwent talc pleurodesis during their initial admission. 13 (42%) patients required readmission within 6 months, extending their total length of stay in this period to 7.3 bed days. 11 (35%) of these patients required further pleural procedure (s) within 6 months of initial thoracoscopy. 22 patients underwent day-case thoracoscopy (initial stay of 0 bed days). 9 (41%) of these patients required re-admission within 6 months, with an average total length of stay of 3.8 bed days. 11 (50%) of these patients went on to require further pleural procedure (s). For the 22 patients attending for day-case thoracoscopy, the number of bed days saved (number of patients x average length of elective admission) was 83.6 bed days. Conclusions Day-case thoracoscopy reduces the number of hospital bed days in patients under investigation for unilateral pleural effusion and does not lead to increased rates of re-admission for this cohort of patients. Those undergoing day-case thoracoscopy are more likely to require a further pleural procedure, as talc pleurodesis is not performed in this group.

P81 The Increasing Secondary Care Burden Of Bronchiectasis In England

Background A recent study suggested that the bronchiectasis is now a relatively common condition in the UK. 1 The healthcare burden of bronchiectasis on secondary care, in terms of hospital admissions is also unknown, yet is essential for allocation of healthcare resources and planning of service pathways. We used data from Hospital Episode Statistics (HES) to determine age standardised annual hospital admission rates in England. Methods We obtained annual number of hospital admissions (finished consultant episodes), total number of bed days and mean age at time of admission where bronchiectasis was the primary reason for admission for all hospital trusts in England. The ONS mid-year England population for 2011 was used as the standard population. Age specific admission rates for bronchiectasis were calculated for each year and these rates were applied to the 2011 population in order to generate annual standardised estimated number of admissions. An estimate of the average length of stay was calculated by dividing the total number of bed days by the total number of admissions for each calendar period. Linear regression was used to test for changes over time in mean age at admission and average length of stay. Results In 2004 the total number of admissions was 8611 (11,147 after standardisation) and this increased progressively up to 2011 when the number was 15,885 (see Figure 1). The overall annual increase was 9% (Rate Ratio [RR] 1.09, 95% Confidence Interval [CI] 1.08 to 1.10; p Conclusions Data on hospital admissions from bronchiectasis suggest that the disease burden is increasing. The cost of inpatient care, combined with outpatient disease monitoring and prescription of antibiotics pose a large burden on healthcare services. Reference Quint J, Millett E, Hurst J, et al . P172 Time Trends in incidence and prevalence of bronchiectasis in the UK. Thorax 2012; 67:A138