Outpatient Status Research Articles

Prevalence of antibiotic use for dogs and cats in United States veterinary teaching hospitals, August 2020.

Awareness of prescribing practices helps identify opportunities to improve antibiotic use (AU). To estimate AU prevalence in dogs and cats in U.S. veterinary teaching hospitals (VTHs) and identify antibiotic drugs commonly prescribed, indications for use, and evidence of bacterial infection. Medical record data were collected from dogs and cats examined at 14 VTHs. Data were collected from VTH medical records of dogs and cats examined by primary care, urgent care, emergency and critical care, internal medicine, and surgery services on a single day during August 13-September 3, 2020. Data included signalment; clinical service; inpatient or outpatient status; clinical conditions; diagnostic tests; evidence of bacterial infection; intended reason for AU; name and route of antibiotics prescribed. Of 883 dogs and cats, 322 (36.5%) were prescribed at least 1 antibiotic. Among 285 antibiotics administered systemically intended for treatment of infection, 10.9% were prescribed without evidence of infection. The most common class of antibiotics presribed for systemic administration was potentiated penicillin for dogs (115/346, 33.3%) and cats (27/80, 33.8%). For dogs and cats, first-generation cephalosporins (93/346, 26.9% and 11/80, 13.8%, respectively) and fluoroquinolones (51/346, 14.7% and 19/80, 23.8%, respectively) was second or third most-prescribed. Common AU indications included skin, respiratory, and urinary conditions, and perioperative use. Collaborative data collection provides a sustainable methodology to generate national AU prevalence estimates and bring attention to areas requiring additional research and detailed data collection. These efforts can also identify practice improvement opportunities in settings where future veterinarians are trained.

Prevalence of poor nutrition status in multiple sclerosis patients assessed by different diagnostic tools

147 patients were included in the study. The nutritional status was assessed by NRS 2002, GLIM, and body composition analysis. The routine biochemical parameters were measured. Deterioration of the nutritional status was observed in 87.8% of patients. GLIM criteria indicated that 20% of patients were malnourished and 80% were at risk. The percentage of patients with excess body mass was 46.8%, and of underweight patients was 6.6%. The risk of malnutrition was positively associated with low content of adipose tissue (R=-0.24; p=0.00), low BMI (R=-0.22; p=0.00), and higher weight loss in the last 6 months (R=0.47; p=0.00). Additionally, a significant (p<0.05) correlation between malnutrition state and s-albumin (R=-0.2) and CRP (R=0.23) was observed. Overweight and obesity concerned a large proportion of the studied group of MS patients, but this does not exclude the risk of malnutrition. Dietary care and regular outpatient nutritional status assessment should be provided throughout the disease.

Exploring Factors Affecting the Occurrence of Hypersensitivity Reactions Induced by Nonionic Iodine Contrast Media.

Hypersensitivity reactions induced by nonionic iodine contrast media sometimes occur and can be life threatening. However, independent factors affecting their occurrence remain to be fully established. Therefore, the purpose of this study was to clarify independent factors affecting the occurrence of hypersensitivity reactions induced by nonionic iodine contrast media. Patients who received nonionic iodine contrast media at Keiyu Hospital from April 2014 to December 2019 were included. The adjusted odds ratio (OR) and 95% confidence interval (CI) for factors affecting hypersensitivity reactions induced by contrast media were calculated by logistic regression analysis. The multiple imputation method was used to impute missing data. Hypersensitivity reactions occurred in 0.72% (163 cases) of 22,695 cases enrolled in this study. In univariate analysis, 10 variables met the criteria of P <.05 and proportion of missing data <50%. In multivariate analysis, age (OR, 0.98; 95% CI, 0.97-0.99), outpatient status (OR, 2.08; 95% CI, 1.20-3.60), contrast medium iodine content (OR, 1.02; 95% CI, 1.01-1.04), history of drug allergy (OR, 2.41; 95% CI, 1.50-3.88), and asthma (OR, 17.4; 95% CI, 7.53-40.1) were identified as independent factors affecting contrast media-induced hypersensitivity reactions. Among these factors, history of drug allergy and asthma appear to be clinically relevant and reliable due to their high OR and plausible biological mechanisms, but the other three factors require further validation.

180. Did The National Ban On Bacitracin Irrigation Affect Infection Rates In Implant-based Breast Reconstruction? An Analysis Of A National Database

PURPOSE: The current standard of practice in implant-based breast reconstruction is irrigation of the mastectomy pocket with antimicrobial solution before implant placement. Prior to being banned and formally recalled in January 2020, bacitracin was a very commonly utilized antibiotic. This study characterizes the effects of the national bacitracin ban on implant-based breast reconstruction infection rates by using a nationwide database to compare complication rates before and after bacitracin was banned. METHODS: The American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried retrospectively for all patients who underwent implant-based breast reconstruction before the bacitracin ban (2012-2019) and afterwards (2020). Demographics, comorbidities, and complications were collected. Univariate analysis and multivariate analysis were conducted to determine if there were significant changes in wound complications, local wound infections, and systemic infections between the two case-control matched cohorts. RESULTS: A total of 37,126 patients were in the pre-ban cohort and 6,333 patients were in the post-ban cohort. Before matching, there were significant differences in race distribution, BMI, ASA class, inpatient versus outpatient status, preoperative smoking, and preoperative diabetes mellitus (all p<0.05). After case-control matching, there were 6,313 patients in each cohort. Univariate analysis revealed differences in postoperative superficial and organ space surgical site infection, wound complications/infections, all cause complications, and reoperations (all p<0.05). Multivariate analysis showed that patients who underwent breast reconstruction before the ban had decreased odds of having wound infections, related infections, all cause complications, and reoperations (all p<0.05). CONCLUSION: This study provides a macroscopic view into the effects of the formal injectable bacitracin ban on breast reconstruction outcomes. Patients who underwent implant-based breast reconstruction after the ban of injectable bacitracin had higher odds of developing wound infections, related infections, and reoperations. More study into suitable alternatives to injectable bacitracin for surgical site antimicrobial irrigation is warranted.

Epidemiology, real-world treatment and mortality of patients with status epilepticus in Germany: insights from a large healthcare database.

Status epilepticus is a life-threatening emergency, and to date, few studies have reported on its long-term treatment and outcomes. This study aimed to estimate the incidence, the treatment and outcomes, the healthcare resource utilization and the costs of status epilepticus in Germany. Data from 2015 to 2019 were obtained from German claims (AOK PLUS). Patients with ≥1 status epilepticus event and no event in the preceding 12 months (baseline) were included. A subgroup of patients with an epilepsy diagnosis during baseline was also analysed. Of the 2782 status epilepticus patients (mean age = 64.3 years; 52.3% female), 1585 (57.0%) were previously diagnosed with epilepsy. The age- and sex-standardized incidence was 25.5 cases/100 000 persons in 2019. The mortality rate after 12 months was 39.8% overall (19.4% and 28.2% after 30 and 90 days, respectively) and 30.4% in the epilepsy patient subgroup. Factors associated with higher mortality were age, comorbidity status, presence of brain tumours and an acute stroke. An epilepsy-related hospitalization at onset of or 7 days prior to the status epilepticus event as well as prescription of antiseizure medication during baseline was associated with a better survival rate. Overall, 71.6% of patients (85.6% in the epilepsy subgroup) were prescribed with out-patient antiseizure medication and/or rescue medication within 12 months. All patients sustained on average 1.3 status epilepticus-related hospitalizations (20.5% had more than one) during a mean follow-up period of 545.2 days (median 514 days); total direct costs including in-patient and out-patient status epilepticus treatments were 10 826€ and 7701€ per patient-year overall and for the epilepsy patient subgroup, respectively. The majority of status epilepticus patients received an out-patient treatment in line with epilepsy guidelines, and patients previously diagnosed with epilepsy have a higher likelihood to receive it. The mortality in the affected patient population is high; risk factors were older age, higher comorbidity burden, the presence of brain tumours or an acute stroke.

35. Effect of Inpatient Status in Patients Undergoing Hand Surgery: A Propensity-score Matched Analysis

PURPOSE: There has been a rise in outpatient hand surgery as many of these procedures can now be performed under local anesthesia. This study examines postoperative complication differences between outpatient and inpatient hand surgery patients. METHODS: Using the National Surgical Quality Improvement Program Database from 2005 to 2018, all hand surgical CPT codes (26010 - 26952) were queried. Patients were divided into inpatient or outpatient status. A probability score based on demographic and comorbidity characteristics was used to match similar patients for comparison. RESULTS: Overall, 28,830 (90.8%) of patients undergoing hand procedures were outpatient and 2,924 (9.2%) were inpatient. After matching patients by probability score (n = 5,083), inpatients were more likely to be male, underweight, non-White, and have a history of hypertension, cardiac comorbidity, steroid use, and American Society of Anesthesiologists Classification ≥ 3. After further adjustment for these seven variables, inpatients were more likely to experience death (p < 0.001), unplanned reoperation (p = 0.010), unplanned readmission (p < 0.001), and a major complication (p < 0.001). CONCLUSION: Outpatient hand surgery is less associated with death, unplanned reoperation, unplanned readmission, major complications, and minor complications than inpatient hand surgery after controlling for pre-operative variance.

Financial vulnerability of trauma centers: A national analysis.

Trauma centers function as an essential safeguard in the United States health care system. However, there has been minimal study of their financial health or vulnerability. We sought to perform a nationwide analysis of trauma centers using detailed financial data and a recently developed Financial Vulnerability Score (FVS) metric. The RAND Hospital Financial Database was used to evaluate all American College of Surgeons-verified trauma centers nationwide. The composite FVS was calculated for each center using six metrics. Financial Vulnerability Score tertiles were used to classify centers as high, medium, or low vulnerability, and hospital characteristics were analyzed and compared. Hospitals were also compared by US Census region and teaching versus nonteaching hospitals. A total of 311 American College of Surgeons-verified trauma centers were included in the analysis, with 100 (32%) Level I, 140 (45%) Level II, and 71 (23%) Level III. The largest share of the high FVS tier was consisted of Level III centers (62%), with the majority of Level I (40%) and Level II (42%) in the middle and low FVS tier, respectively. The most vulnerable centers had fewer beds, negative operating margins, and significantly less cash on hand. Lower FVS centers had greater asset/liability ratios, lower outpatient shares, and three times less uncompensated care. Nonteaching centers were statistically significantly more likely to have high vulnerability compared with teaching centers (46% vs. 29%). Statewide analysis showed high discrepancy among individual states. With approximately 25% of Levels I and II trauma centers at high risk for financial vulnerability, disparities in characteristics, including payer mix and outpatient status, should be targeted to reduce vulnerabilities and bolster the health care safety net. Prognostic and Epidemiological; Level IV.

Can a community hospital successfully transition to outpatient total knee arthroplasty in unselected patients?

BackgroundThe removal of total knee arthroplasty (TKA) from the Inpatient-Only list in 2018 created pressure on community hospitals to develop rapid discharge protocols (RAP) to increase outpatient discharge. The purpose of this study, therefore, was to compare the efficacy, safety and barriers in achieving outpatient discharge between the standard discharge protocol and newly developed RAP in unselected, unilateral TKA patients. MethodsThis retrospective chart review included 288 standard protocol patients and the first 289 RAP patients following unilateral TKA in a community hospital. The RAP focused on patient discharge expectations and post-operative patient management, with no change in post-operative nausea or pain management. Non-parametric tests were performed to compare demographics, perioperative variables and 90-readmission/complication rates between standard and RAP groups, as well as between inpatient and outpatient discharged RAP patients. Multivariate, stepwise logistic regression was performed to evaluate patient demographics and discharge status, presented as odds ratios (OR) and 95% confidence intervals (CI). ResultsDemographics were similar between groups, however, outpatient discharge significantly increased from 22.2% to 85.8% for standard discharge and RAP, respectively (p < 0.001), with no significant difference in post-operative complications. For RAP patients, age (OR:1.062, CI:1.014–1.111; p = 0.011) and female gender (OR:2.224, CI:1.042–4.832; p = 0.039) increased the risk of inpatient and 85.1% of RAP outpatients were discharged home. ConclusionsWhile RAP was successful, 15% of patients required inpatient care and 15% of patients achieving outpatient discharged were not discharged to their home environment, emphasizing the difficulties of achieving true outpatient status in 100% of patients from a community hospital.

Chronic Neurocognitive, Neuropsychological, and Pulmonary Symptoms in Outpatient and Inpatient Cohorts After COVID-19 Infection.

Neuropsychological symptoms associated with post-COVID-19 conditions may prevent patients from resuming normal activities at home or work. We report a retrospective, cross-sectional evaluation of neuropsychological and cardiopulmonary outcomes in 2 groups of patients: outpatients with mild enough infection to be spared from hospitalization and those who required inpatient admission. We hypothesized a dose-response model of post-COVID symptom severity in which persistent consequences would be more severe in those who experienced worse acute infections. In a dedicated COVID clinic, 321 patients were seen (33% outpatient, 67% inpatient). Outpatients skewed female, White, non-Hispanic, and younger. Outpatients had worse insomnia (measured with insomnia severity index) and were less able to resume their usual activities (EQ-5D-5L usual activities scale), despite inpatients experiencing worse cognition (Montreal Cognitive Assessment), having greater obesity (body mass index), decreased exercise tolerance (6-minute-walk distance), and more exertional oxygen desaturation. In both groups, insomnia worsened while cognition improved significantly with time from infection to testing while controlling for patient age; other variables did not. In logistic regression, female sex, higher MoCA score, EQ-5D-5L "usual activities" subscore, less oxygen desaturation with exertion, and longer time from infection remained as significant associations with outpatient status. Our study demonstrated that the functional sequelae of post-COVID-19 conditions in patients with mild acute disease have the potential to be as severe as that in patients who have recovered from severe illness.

Did the National Ban on Bacitracin Irrigation Affect Infection Rates in Implant-Based Breast Reconstruction? An Analysis of a National Database

IntroductionThe current standard of practice in implant-based breast reconstruction is irrigation of the mastectomy pocket with antimicrobial solution before implant placement. Prior to being banned and formally recalled in January 2020, bacitracin was a very commonly utilized antibiotic. This study characterizes the effects of the national bacitracin ban on implant-based breast reconstruction infection rates by using a nationwide database to compare complication rates before and after bacitracin was banned. Materials and MethodsThe American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried retrospectively for all patients who underwent implant-based breast reconstruction before the bacitracin ban (2012-2019) and afterwards (2020). Demographics, comorbidities, and complications were collected. Univariate analysis and multivariate analysis were conducted to determine if there were significant changes in wound complications, local wound infections, and systemic infections between the 2 case-control matched cohorts. ResultsA total of 37,126 patients were in the pre-ban cohort and 6333 patients were in the post-ban cohort. Before matching, there were significant differences in race distribution, BMI, ASA class, inpatient vs. outpatient status, preoperative smoking, and preoperative diabetes mellitus (all P < .05). After case-control matching, there were 6313 patients in each cohort. Univariate analysis revealed differences in postoperative superficial and organ space surgical site infection, wound complications/infections, all cause complications, and reoperations (all P < .05). Multivariate analysis showed that patients who underwent breast reconstruction before the ban had decreased odds of having wound infections, related infections, all cause complications, and reoperations (all P < .05). ConclusionThis study provides a macroscopic view into the effects of the formal injectable bacitracin ban on breast reconstruction outcomes. Patients who underwent implant-based breast reconstruction after the ban of injectable bacitracin had higher odds of developing wound infections, related infections, and reoperations. More study into suitable alternatives to injectable bacitracin for surgical site antimicrobial irrigation is warranted.

Over Half of All Medicare Total Knee Arthroplasty Patients Are Now Classified as an Outpatient–Three-Year Impact of the Removal From the Inpatient-Only List

BackgroundIn 2018, Centers for Medicare & Medicaid Services removed total knee arthroplasty (TKA) from its inpatient-only list, triggering many unintended consequences. The purpose of this study was to determine how the impact of TKA removal affected the number of outpatient TKA patients, which patients were being labeled outpatient, and how outpatient classification affected discharge location and readmission rates. MethodsUsing a large administrative claims database, we reviewed a consecutive series of 216,365 primary TKA Medicare patients from 2015 to 2020. Patients who had an inpatient status (n = 63,356) were compared to patients who had an outpatient status (n = 38,510) from 2018 to 2020 based on demographics, comorbidities, discharge dispositions, and readmissions. ResultsIn 2015, only 1.8% of TKA patients were designated as outpatients, but by 2020, 57.2% of Medicare TKA patients were classified as outpatients. A majority of patients (72%) who had an outpatient designation remained in the hospital for >24 hours (average length of stay was 2.7 days). Patients who had an outpatient status were discharged to skilled nursing facilities more frequently than patients who had an inpatient status (3.1 versus 2.0%, P < .001) with increased emergency visits (5.1 versus 3.9%, P < .001) and 90-day readmissions (2.2 versus 0.9%, P < .001). ConclusionOver half of all Medicare TKA patients are being classified as outpatients 3 years following the policy to remove TKA from the inpatient-only list. Patients designated as outpatients had higher readmissions than those designated as inpatients. This policy should be re-evaluated in the context of failure to demonstrate safer discharge of Medicare patients who undergo TKA.

Replace the advance directive with a patient activation approach to serious illness communication.

Replace the advance directive with a patient activation approach to serious illness communication.

555. Early Outcomes of Penicillin and Cephalosporin Allergy Assessment Tool

Abstract Background Penicillin allergy is reported in approximately 10% of the US population and is one of the most frequent medication allergies in children. Penicillin allergy labels are associated with more expensive care and adverse outcomes, such as MRSA and C. Diff infection. Studies suggest up to 90% of these patients could safely tolerate this class of drugs. Our team at M Health Fairview University of Minnesota Masonic Children’s Hospital (UMMCH) implemented an allergy assessment tool for inpatient use in January of 2020 to create an effective and accessible path for delabeling pediatric patients with penicillin and cephalosporin allergies. Methods Our pharmacists conducted the allergy assessment on inpatient pediatric patients with penicillin/cephalosporin allergies. Those deemed low to moderate risk for having a true IgE-mediated allergy by our assessment were recommended for outpatient allergy testing. Those deemed no risk were recommended for immediate delabeling. We performed manual chart reviews to describe pediatric patient risk stratification, allergy label status after assessment, outpatient allergy follow-up, and status and results of allergy testing. Results From January, 2020 to present, 140 patients received a pharmacist allergy assessment. During the 2020 calendar year, 51 allergy assessments were performed on 49 patients. 58 allergies were recorded, with penicillins as the most common (62%), followed by cephalosporins (24%), and penicillin combination drugs (14%). 1.9% of allergies were high risk, 68.8% moderate, 15.7% low, 9.8% no risk, and 3.8% difficult to determine. Of 42 patients deemed low to moderate risk, 8 (17%) were seen by an outpatient allergist. Of these, 5 proceeded with allergy testing and were found to be not allergic. Out of 58 allergy labels, 9 (15.5%) were removed, 5 after allergy testing, 2 immediately due to no risk, and 2 after further history review. Conclusion Our preliminary data show allergy assessments can inform pediatric allergy risk prior to outpatient allergy testing and assist with imminent delabeling. Next steps include analysis of our 2021 assessments as well as patient caregiver surveys to assess perception of the allergy assessment process and to elucidate on barriers to testing/delabeling. Disclosures Beth K. Thielen, MD, PhD, Horizon: Advisor/Consultant|Horizon: Honoraria|Merck: Grant/Research Support.

Impact de la pandémie de COVID-19 sur les urgences ophtalmologiques du CHU de Toulouse lors du premier confinement du 17 mars au 10 mai 2020

We conducted this study to assess the impact of the COVID-19 pandemic and the lockdown in France from March 17, 2020 to May 10, 2020, on the ophthalmic emergency department at Toulouse University Hospital, compared to the period from March 2 to March 16, 2020. This was a retrospective observational study, conducted in the ophthalmic emergency department of Toulouse University Hospital. We included the patients presenting to the emergency department from March 2 to May 10, 2020. We recorded age, sex, day of visit, time until care was received, past ocular history, outpatient or inpatient status, final diagnosis and its severity, outpatient or inpatient disposition, and medical or surgical treatment after the emergency department visit. We found a substantial decrease in the number of patients per day, mostly during the first month of the lockdown: 44 patients per day before the lockdown compared to 23 patients per day during the first month, followed by 38 patients per day for the second month of lockdown; more patients visiting promptly; and elderly patients represented a higher proportion of patients. The first lockdown in France due to the COVID-19 pandemic had an impact on the Toulouse ophthalmic emergency department, especially concerning the number of patients per day; this study helps to assess individual behavior in this context of a public health crisis.

Association Between Body Mass Index and 30-Day Mortality in Patients with Pulmonary Hypertension Undergoing Non-cardiothoracic, Non-obstetric Surgery.

Evidence regarding the association between body mass index (BMI) and outcomes in non-cardiothoracic, non-obstetric surgery patients with pulmonary hypertension (PHTN) is limited. We aimed to investigate the association between BMI and 30-day mortality in non-cardiothoracic, non-obstetric surgery patients with pulmonary hypertension. We performed a secondary analysis of non-cardiothoracic, non-obstetric procedures on patients with PHTN between 2007 and 2013 at a single institution. Multivariable logistic regression models were used to estimate the association between BMI and 30-day mortality. Interaction and stratified analyses were conducted according to age, sex, PHTN medical therapy, anticipated inpatient or outpatient post-procedure status, procedure length > 2h, open surgical approach, and PHTN severity class. A total of 513 participants were included, with men accounting for 55.8% of the sample; the 30-day mortality was 1.9%. In the multivariate regression models, BMI was significantly associated with 30-day mortality after adjusting for potential covariates. A 1kg/m2 increase in BMI was associated with a 15% decrease in 30-day mortality (adjusted OR = 0.85, 95% CI: 0.73-0.98, P = 0.03). Stratified analyses indicated that this negative correlation was robust. In this study, we found that low BMI is associated with increased risk of death in patients undergoing non-cardiothoracic, non-obstetric surgery requiring general anesthesia. Further studies are needed to confirm our findings.

PROFILE OF SKIN DISEASES IN ELDERLY AT DERMATOLOGY AND VENEROLOGY DR SOETOMO GENERAL ACADEMIC HOSPITAL OUTPATIENT CLINIC

Introduction: Skin diseases in elderly are often not recorded and are not complained of by elderly patients, but the more we let it become a problem in decreasing the quality of life of elderly patients, it can be seen in the current global situation that the biggest problem in elderly is degenerative diseases, with increasing age the function Physiological human and health changes will decrease due to degenerative processes (aging) which will have an impact on changes in humans, not only physical changes, but also cognitive, emotional, social and sexual changes and it is predicted that by 2050 around (75%) elderly who suffer from this degenerative disease will not suffer from this disease can work and have to stay at home. Objective To know the profile of skin disease in the elderly population who visited the Dermatology and Venereology Outpatient clinic Dr. Soetomo General Academic Surabaya period of 2019-2020. Methods This study is a retrospective descriptive study based on medical records at the Dermatology and Venereology Outpatient clinic Dr. Soetomo General Academic Surabaya, data collection was carried out in July 2021 - November 2021. In this study an evaluation of the profile of elderly patients with outpatient status was carried out by noting gender, age, domicile, chief complaint, comorbidities, fluorescence, diagnosis, examination of vital signs, therapy, and response to therapy. Results Based on the incidence in elderly patients at the Dermatology and Venereology Outpatient clinic Dr. Soetomo General Academic Surabaya for the 2019-2020 period. 299 patients were found the most were men (51.51%), the age group 66-74 years (58.86%), the most domiciled in Surabaya (82.27%), the most common chief complaint was itching (60.87%) , the most frequent diagnosis was xerosis cutis (29.10%) and the most common lesion was erythematous macules (46.25%). Conclusion : The most common disease on the elderlys skin is in the form of xerosis cutis which requires special management to prevent a decreases in the quality of life of individuals.

Enhanced recovery after surgery improves postdischarge recovery after pulmonary lobectomy

ObjectiveEnhanced recovery after surgery protocols are known to accelerate immediate postoperative recovery and to facilitate healing. Our purpose was to further characterize benefits after discharge from the hospital. MethodsAn institutional database was queried to identify patients with clinical stage I non–small cell lung cancer who were classified as Eastern Cooperative Oncology Group performance status 0 and received a lobectomy between January 1, 2000, and August 31, 2020. The presence or absence of symptoms (ie, pain, shortness of breath, fatigue, among others) and performance status were recorded by clinic staff at the time of follow-up. Cox proportional hazards regression was used to identify factors associated with postdischarge recovery, which was defined as a return to Eastern Cooperative Oncology Group performance status 0 in the follow-up clinic. ResultsA total of 935 patients were identified (pre-enhanced recovery after surgery, 523; transition period, 222; enhanced recovery after surgery, 190). Outpatient performance status data were recorded in 774 of 935 patients (83%). The number of patients reporting symptoms at the 1-month follow-up appointment decreased from the pre-enhanced recovery after surgery to transition to the enhanced recovery after surgery period (60%, 50%, and 33%, respectively, P < .001), predominately due to less pain reported (43%, 35%, and 23%, respectively, P = .001). At 6-month follow-up, these differences were no longer statistically significant. Surgery during the enhanced recovery after surgery period was independently associated with significant improvements in postdischarge recovery (hazard ratio, 1.60, 95% confidence interval, 1.29-2.00), and the presence of coronary artery disease (hazard ratio, 0.69, P = .006) and receipt of thoracotomy (hazard ratio, 0.84, P = .036) were independently associated with delayed postdischarge recovery. ConclusionsEnhanced recovery is associated with significant improvements in postdischarge recovery of performance status.

Patients Who Die by Suicide: A Study of Treatment Patterns and Patient Safety Incidents in Norway.

Underlying patterns and factors behind suicides of patients in treatment are still unclear and there is a pressing need for more studies to address this knowledge gap. We analysed 278 cases of suicide reported to The Norwegian System of Patient Injury Compensation, drawing on anonymised data, i.e., age group, gender, diagnostic category, type of treatment provided, inpatient vs. outpatient status, type of treatment facility, and expert assessments of medical errors. The data originated from compensation claim forms, expert assessments, and medical records. Chi-square tests for independence, multinominal logistic regression, and Bayes factors for independence were used to analyse whether the age group, gender, diagnostic category, inpatient/outpatient status, type of institution, and type of treatment received by patients that had died by suicide were associated with different types of medical errors. Patients who received medication tended to be proportionally more exposed to an insufficient level of observation. Those who received medication and psychotherapy tended to be proportionally more exposed to inadequate treatment, including inadequate medication. Inpatients were more likely to be exposed to inappropriate diagnostics and inadequate treatment and follow up while outpatients to insufficient level of observation and inadequate suicide risk assessment. We conclude that the patients who had received medication as their main treatment tended to have been insufficiently observed, while patients who had received psychotherapy and medication tended to have been provided insufficient treatment, including inadequate medication. These observations may be used as learning points for the suicide prevention of patients in treatment in Norwegian psychiatric services.

Hospital Revenue, Cost, and Contribution Margin in Inpatient Versus Outpatient Primary Total Joint Arthroplasty

BackgroundRemoval of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty. MethodsWe reviewed all patients who underwent TKA or THA after these procedures were removed from the inpatient-only list. Patients were statistical significance into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-squared tests. ResultsAmong Medicare patients receiving THA, CM was 96.1% lower for the inpatient cohort when compared to outpatient (P < .001), although the difference between groups for TKA was not significant (P = .163). For patients covered by Medicaid or Government-managed plans, CM was 807% higher for THA inpatients (P < .001), and 143.7% higher for TKA inpatients (P < .001). ConclusionOur analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at a risk of losing access to care. Level III EvidenceRetrospective Cohort Study.

What’s New in Hip Replacement

What’s New in Hip Replacement