Proportion Of In-hospital Deaths Research Articles

Abstract 18801: Impact of COVID-19 Pandemic on Cardiovascular Diseases Hospitalisation, Management and Mortality in Brazil

Introduction: The COVID-19 pandemic led to a reduction in cardiovascular (CVD) hospital admissions in many countries. We aimed to assess the effect of the COVID-19 pandemic on CVD hospitalizations, management, and mortality in Brazil. Methods: Hospitalization data for the years 2020 and 2021 for Brazil and regions were analyzed using the Datasus hospital admission system. We analyzed the number of hospitalizations, the number and proportion of intensive care unit (ICU) utilization, and the number and proportion of in-hospital deaths. The observed data were compared to the average of the previous three years (2017 to 2019). Absolute differences and risk ratios (RR) were calculated, with the RR obtained by dividing the observed values by the expected ones for each period studied. Results: There was a reduction in CVD hospital admissions, with 184,727 (95% CI 157,579 to 211,876) fewer hospitalizations than expected, representing a decrease of 16.2% (RR 0.838; 95% CI 0.836-0.839). There were two valleys of reduction in CVD hospitalizations, the first before the first peak of Covid-19 hospitalizations and the second simultaneous to the second peak of Covid-19 hospitalizations in 2021. There was a 9% decrease in the absolute number of CVD admissions in the ICU (RR 0.910; 95% CI 0.907-0.912), associated with a 4.7% absolute decrease in the number of CVD admissions that resulted in in-hospital deaths (RR 0.953; 95% CI 0.949-0.957). However, there was an 8.6% increase in the proportion of ICU admissions due to CVD (RR 1.086; 95% CI 1.084-1.088) and a significant increase of 14.4% in the proportion of admissions due to CVD that resulted in in-hospital death. Conclusions: Brazil′s data reveal that the Covid-19 pandemic reduced the number of CVD hospitalizations, but with a higher proportion of ICU use and higher in-hospital mortality.

Abstract WMP62: Stroke Severity Is The Primary Mediator Of Increased Stroke Mortality In The Elderly

Background: The risk of ischemic stroke mortality increases with age, but the impact of stroke severity on this relationship has not been fully examined. Methods: We included adults in the National Inpatient Sample from 2016-2019 who had a primary discharge diagnosis of ischemic stroke (I63*) and a baseline NIH Stroke Scale (NIHSS). The primary outcome was in-hospital death. The exposure of age had left skew, so we transformed it into deciles. We fit a logistic regression model adjusted for sex, race/ethnicity, diabetes, atrial fibrillation, hypertension, thrombolytic therapy, and endovascular therapy. We report the predicted probability of the primary outcome with and without NIHSS and use structural equation modeling (SEM) to estimate the proportion of age’s effect on the primary outcome that is mediated by stroke severity. Results: We included 138,637 individuals, of which 3.5% died in-hospital. The proportion of in-hospital death and an NIHSS violinplot by decile of age are seen in Figure 1, both of which had a positive linear relationship. The AUC of the multivariable model without NIHSS was 0.70 and with NIHSS was 0.86 (p<0.001). The predicted probability of death is seen without and with NIHSS in Figure 2, illustrating the importance of adjusting for NIHSS. In the SEM model, we observed that 57.7% of age’s effect on in-hospital death is mediated by stroke severity. Conclusions: We found that elderly individuals in the United States have more severe stroke and higher stroke mortality, but the effect of age on stroke mortality is primarily mediated by elderly individuals having more severe stroke. Additional research is needed to better understand this novel finding.

1877. COVID-19-Associated Hospitalizations among Long-Term Care Facility Residents Ages ≥65 Years — COVID-NET, 14 U.S. States, March 2020–January 2022

Abstract Background Adults aged ≥65 years and those with underlying medical conditions, including residents of long-term care facilities (LTCF), are at increased risk for COVID-19-associated hospitalizations and other severe outcomes. Methods Hospitalizations among LTCF residents aged ≥ 65 years from March 2020–January 2022 were described using data on a representative sample of hospitalizations from the CDC’s COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), a population-based surveillance network of > 250 acute care hospitals in 99 counties across 14 states. A Poisson regression model adjusting for age, race/ethnicity, underlying medical conditions, vaccination status, month of admission, and do-not-resuscitate/intubate-or-provide comfort-measures-only (DNR/DNI/CMO) code status examined the relationship of LTCF residency to death during COVID-19-associated hospitalization. Results Of 11,901 hospitalizations among adults aged ≥ 65 years reported during the study period, 2,965 (24.9%) were LTCF residents; most resided in nursing homes (53.8%) or assisted living facilities (26.8%). LTCF residents hospitalized with COVID-19 were older and more likely to have cardiovascular disease, congestive heart failure, a neurologic condition, dementia, or ≥ 3 underlying medical conditions than non-residents (Figure). The proportion of LTCF residents vs non-residents who required intensive care unit admission or invasive mechanical ventilation were not statistically different (23.2% vs 23.5% and 10.7 vs 13.5%, respectively). The proportion of in-hospital death was higher among LTCF residents than non-residents (22.8% vs 14.4%, p < 0.01). More LTCF residents have a DNR/DNI/CMO code status (48%) compared to non-residents (19%). The fully adjusted regression model found the risk ratio for death was 1.03 (95% CI, 1.01–1.05) among LTCF residents compared to non-residents. Conclusion Compared to non-residents, LTCF residents were older, had more underlying conditions, and had a higher risk of in-hospital death. After adjusting for multiple potential confounders, results suggest that LTCF residency is a weak but significant independent risk factor for death during COVID-19-associated hospitalization. Disclosures All Authors: No reported disclosures.

Characteristics and place of death in home care recipients in Germany – an analysis of nationwide health insurance claims data

BackgroundMost care-dependent people live at home, where they also would prefer to die. Unfortunately, this wish is often not fulfilled. This study aims to investigate place of death of home care recipients, taking characteristics and changes in care settings into account.MethodsWe retrospectively analysed a cohort of all home-care receiving people of a German statutory health insurance who were at least 65 years and who deceased between January 2016 and June 2019. Next to the care need, duration of care, age, sex, and disease, care setting at death and place of death were considered. We examined the characteristics by place of care, the proportion of dying in hospital by care setting and characterised the deceased cohort stratified by their actual place of death.ResultsOf 46,207 care-dependent people initially receiving home care, 57.5% died within 3.5 years (n = 26,590; mean age: 86.8; 66.6% female). More than half of those moved to another care setting before death with long-term nursing home care (32.3%) and short-term nursing home care (11.7%) being the most frequent transitions, while 48.1% were still cared for at home. Overall, 36.9% died in hospital and in-hospital deaths were found most often in those still receiving home care (44.7%) as well as care in semi-residential arrangements (43.9%) at the time of death. People who died in hospital were younger (mean age: 85.5 years) and with lower care dependency (low care need: 28.2%) as in all other analysed care settings.ConclusionIn Germany, changes in care settings before death occur often. The proportion of in-hospital death is particularly high in the home setting and in semi-residential arrangements. These settings should be considered in interventions aiming to decrease the number of unwished care transitions and hospitalisations at the end of life.

Prognostic Factors Related to In-hospital Death in Children with Biliary Atresia: Analysis of a Nationwide Inpatient Database.

Patients with biliary atresia (BA) are prone to hepatic decompensation, which might eventually lead to death. This study aimed to identify the possible risk factors affecting in-hospital death in BA patients in China. We collected data from the Hospital Quality Monitoring System, a national inpatient database. All patients aged up to 2 years old with a diagnosis of BA were included. The subjects were divided to three groups, including Kasai portoenterostomy (KP), liver transplantation (LT), and no surgery. Logistic regression with Firth's method was performed to identify potential influencing variables associated with in-hospital death. During the year 2013 to 2017, there were 14,038 pediatric admissions with a diagnosis of BA. The proportion of in-hospital death in pediatric BA admissions was 1.08%. Compared with patients under six months, there was a higher risk of in-hospital death for children aged six months to 1 year and 1-2 years old. Clinical signs, including cirrhosis, variceal bleeding, and hepatic encephalopathy, were significantly associated with the risk of in-hospital death. In no surgery group, compared to those in Beijing and Shanghai, BA patients admitted in other districts had a lower risk of in-hospital death (OR=0.39, 95% CI: 0.21, 0.70). However, in the LT group, patients admitted in other districts had a higher risk of in-hospital death (OR=9.13, 95% CI: 3.99, 20.87). In-hospital survival remains unsatisfactory for pediatric BA patients with severe complications. Furthermore, more resources and training for BA treatment, especially LT, are essential for districts with poor medical care in the future.

National trends in the proportion of in-hospital deaths by cause of death among older adults with long-term care: a nationwide observational study in Japan from 2007 to 2017

BackgroundJapan has promoted end-of-life care at home and in long-term care facilities, and the total proportion of in-hospital deaths has decreased recently. However, the difference in trends of in-hospital deaths by the cause of death remains unclear. We investigated the variation in trends of in-hospital deaths among older adults with long-term care from 2007 to 2017, by cause of death and place of care.MethodsUsing the national long-term care insurance registry, long-term care claims data, and national death records, we identified people aged 65 years or older who died between 2007 and 2017 and used long-term care services in the month before death. Using a joinpoint regression model, we evaluated time trends of the proportion of in-hospital deaths by cause of death (cancer, heart diseases, cerebrovascular diseases, pneumonia, and senility) and place of care (home, long-term care health facility, or long-term care welfare facility).ResultsOf the 3,261,839 participants, the mean age was 87.0 ± 8.0 years, and 59.2% were female. Overall, the proportion of in-hospital deaths decreased from 66.2% in 2007 to 55.3% in 2017. By cause of death, the proportion of in-hospital deaths remained the highest for pneumonia (81.6% in 2007 and 77.2% in 2017) and lowest for senility (25.5% in 2007 and 20.0% in 2017) in all types of places of care. The joinpoint regression analysis showed the steepest decline among those who died of senility, especially among long-term care health facility residents.ConclusionsThe findings of this nationwide study suggest that there was a decreasing trend of in-hospital deaths among older adults, although the speed of decline and absolute values varied widely depending on the cause of death and place of care.

SARS-CoV-2 and influenza virus coinfection among patients with severe acute respiratory infection during the first wave of COVID-19 pandemic in Bangladesh: a hospital-based descriptive study

ObjectiveTo estimate the proportion of SARS-CoV-2 and influenza virus coinfection among severe acute respiratory infection (SARI) cases-patients during the first wave of COVID-19 pandemic in Bangladesh.DesignDescriptive study.SettingNine tertiary level hospitals...

Quantifying the direct secondary health care cost of seasonal influenza in England

BackgroundThe winter pressure often experienced by NHS hospitals in England is considerably contributed to by severe cases of seasonal influenza resulting in hospitalisation. The prevention planning and commissioning of the influenza vaccination programme in the UK does not always involve those who control the hospital budget. The objective of this study was to describe the direct medical costs of secondary care influenza-related hospital admissions across different age groups in England during two consecutive influenza seasons.MethodsThe number of hospital admissions, length of stay, and associated costs were quantified as well as determining the primary costs of influenza-related hospitalisations. Data were extracted from the Hospital Episode Statistics (HES) database between September 2017 to March 2018 and September 2018 to March 2019 in order to incorporate the annual influenza seasons. The use of international classification of disease (ICD)-10 codes were used to identify relevant influenza hospitalisations. Healthcare Resource Group (HRG) codes were used to determine the costs of influenza-related hospitalisations.ResultsDuring the 2017/18 and 2018/19 seasons there were 46,215 and 39,670 influenza-related hospital admissions respectively. This resulted in a hospital cost of £128,153,810 and £99,565,310 across both seasons. Results showed that those in the 65+ year group were associated with the highest hospitalisation costs and proportion of in-hospital deaths. In both influenza seasons, the HRG code WJ06 (Sepsis without Interventions) was found to be associated with the longest average length of stay and cost per admission, whereas PD14 (Paediatric Lower Respiratory Tract Disorders without Acute Bronchiolitis) had the shortest length of stay.ConclusionThis study has shown that influenza-related hospital admissions had a considerable impact on the secondary healthcare system during the 2017/18 and 2018/19 influenza seasons, before taking into account its impact on primary health care.

Three-Month Mortality and Related Risk Factors in Delirium Patients: A Prospective Cohort Study

Background: Delirium is a common problem in elderly patients. Recently, therapists have shifted their attention away from treatment towards prevention; therefore, investigation of related risk factors is essential in these patients. Methods: In this prospective cohort study, newly admitted elderly patients, with a Glasgow Coma Scale score above 10, were screened and enrolled. The patients were evaluated for delirium using the Neecham Confusion Scale (NCS). The risk factors included four major domains: patient characteristics (age, gender, and substance abuse), chronic diseases, acute diseases, and blood biochemical factors. Results: A total of 100 patients were assessed for delirium. The mean age of the participants was 79.9 ± 15.1 years (24% female). The proportion of in-hospital deaths was 12%, with a cumulative three-month mortality of 40%. The rate of delirium development was significantly associated with underlying factors, including cancer, hypertension, cerebrovascular accident, cirrhosis, dementia, and substance abuse. The laboratory results showed a blood urea nitrogen (BUN) level ≥ 50 mg/dL in 33% of patients with delirium. There was a significant association between BUN level and NSC score (P < 0.05). Among other laboratory variables, higher erythrocyte sedimentation rate and C-reactive protein level were significantly associated with delirium. Moreover, Kaplan-Meier survival curves for effective factors, such as drug effect, cancer, cirrhosis, dementia, and BUN, showed significant differences. Conclusions: In elderly patients, symptoms of delirium persist for three months after diagnosis. Private nursing care at home or nursing home placement, besides the assessment of delirium risk factors, is important for optimal care of elderly patients after hospitalization.

Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006–2015

ObjectivesWe investigated trends in end-of-life hospitalizations among nursing home residents (NHR) over 10 years and looked at differences between age groups and sexes as well as the length of terminal hospital stays. Study designRetrospective cohort study based on health insurance claims data of the AOK Bremen/Bremerhaven. All NHR aged 65 years or more who died between 2006 and 2015 were included. Main outcome measuresWe assessed the proportions of decedents who were in hospital on the day of death and during the last 3, 7, 14 and 30 days of life, stratified by two-year periods. Multiple logistic regressions were conducted to study changes over time, adjusting for covariates. ResultsA total of 10,781 decedents were included (mean age 86.1 years, 72.1 % females). Overall, 29.2 % died in hospital, with a slight decrease from 30.3 % in 2006–2007 to 28.3 % in 2014–2015 (OR 0.86; 95 % CI 0.75–0.98). Of the 3150 terminal hospitalizations, 35.5 % lasted up to 3 days and the mean length of stay decreased from 9.0 (2006–2007) to 7.5 days (2014–2015). When looking at the last 7, 14 and 30 days of life, no changes over time were found. Male sex and younger age were associated with a higher chance of end-of-life hospitalization in almost all analyses. ConclusionsEnd-of-life hospitalizations of NHR are common in Germany. There has been a small decrease during recent years in the proportion of in-hospital deaths, but not of hospitalizations during the last 7, 14 and 30 days of life. This might be explained by shorter durations of hospital stays.

Acute kidney injury in non-critical care setting: elaboration and validation of an in-hospital death prognosis score

BackgroundAcute kidney injury (AKI) is still characterized by a high mortality rate. While most patients with AKI are admitted in conventional medical units, current available data are still obtained from studies designed for patients admitted in intensive care units (ICU). Our study aimed to elaborate and validate an in-hospital death prognosis score for AKI admitted in conventional medical care units.MethodsWe included two prospective cohorts of consecutive patients with AKI admitted between 2001 and 2004 (elaboration cohort (EC)) and between 2010 and 2014 (validation cohort (VC)). We developed a scoring system from clinical and biological parameters recorded at admission from the EC to predict in-hospital mortality. This score was then tested for validation in the VC.ResultsThree-hundred and twenty-three and 534 patients were included in the EC and VC cohorts, respectively. The proportion of in-hospital death were 15.5% (EC) and 8.9% (VC), mainly due to sepsis. The parameters independently associated with the in-hospital death in the EC were Glasgow score, oxygen requirement, fluid overload, blood diastolic pressure, multiple myeloma and prothrombin time. The in-hospital death prognosis score AUC was 0.845 +/− 0.297 (p < 0.001) after validation in the VC.ConclusionsOur in-hospital death prognosis score is the first to be prospectively developed and validated for AKI admitted in a conventional medical care unit. Based on current parameters, easily collected at time of admission, this score could be a useful tool for physicians and nephrologists to determine the in-hospital death prognosis of this AKI population.

Indoor Versus Outdoor Occurrence in Mortality of Accidental Hypothermia in Japan: The J-Point Registry.

The impact of the location where accidental hypothermia (AH) occurs has not been fully investigated thus far. This was a multicenter retrospective study of patients with a body temperature ≤35°C obtained at the emergency department of 12 hospitals in Japan between April 2011 and March 2016. We divided the patients into two groups according to the location where AH occurred (indoor group versus outdoor group). The association between each location of the occurrence of AH and in-hospital mortality was evaluated via a multivariable logistic regression analysis. The primary outcome of this study was in-hospital death. The secondary outcomes were the lengths of ICU and hospital stay. A total of 572 patients were enrolled in the hypothermia database, and 537 patients were included in the analyses. A total of 119 and 418 patients experienced hypothermia with outdoor and indoor occurrence, respectively. The indoor group was older and had worse activities of daily living compared with the outdoor group. With regard to the outcome, the proportion of in-hospital death was higher in the indoor group than in the outdoor group (28.2% [118/418] vs. 10.9% [13/119], p < 0.001). The multivariable logistic regression analysis showed that the adjusted odds ratio of the indoor group was 2.48 (95% confidence interval, 1.18-5.17). In terms of secondary outcomes, both the lengths of ICU and hospital stay of the survivors were longer in the indoor group than in the outdoor group. Hypothermia with indoor occurrence accounts for ∼78% of the total AH cases in this study, and the proportion of in-hospital deaths was higher in the indoor group than in the outdoor group. Warnings about the indoor onset of AH must be provided, and countermeasures for the prevention and early recognition of AH with indoor occurrence must be taken.

Prognostic effects of delirium motor subtypes in hospitalized older adults: A prospective cohort study.

ObjectivesTo investigate the association between delirium motor subtypes and hospital mortality and 12-month mortality in hospitalized older adults.DesignProspective cohort study conducted from 2009 to 2015.SettingGeriatric ward of a university hospital in Sao Paulo, Brazil.ParticipantsWe included 1,409 consecutive admissions of acutely ill patients aged 60 years and over. We excluded admissions for end-of-life care, with missing data on the main variables, length of stay shorter than 48 hours, or when consent to participate was not given.Main outcomes and measuresDelirium was detected using the Confusion Assessment Method and categorized in hypoactive, hyperactive, or mixed delirium. Primary outcomes were time to death in the hospital, and time to death in 12 months (for the discharged sample). Comprehensive geriatric assessment was performed at admission and included socio-demographic, clinical, functional, cognitive, and laboratory variables. Further clinical data were documented upon death or discharge. Multivariate analyses used Cox proportional hazards models adjusted for possible confounders.ResultsWe included 1,409 admissions, with a mean age of 80 years. The proportion of in-hospital deaths was 19%, with a cumulative mortality of 38% in 12 months. Delirium occurred in 47% of the admissions. Hypoactive delirium was the predominant motor subtype (53%), followed by mixed delirium (30%) and hyperactive delirium (17%). Hospital mortality rates were respectively 33%, 34% and 15%. We verified that hypoactive and mixed delirium were independently associated with hospital mortality, with respective hazard ratios of 2.43 (95%CI = 1.64–3.59) and 2.31 (95%CI = 1.53–3.50). Delirium motor subtypes were not independently predictive of 12-month mortality.ConclusionsOne in three acutely ill hospitalized older adults who suffered hypoactive or mixed delirium died in the hospital. Clinicians should be aware that hypoactive symptoms of delirium, whether shown exclusively or in alternation with hyperactive symptoms, are indicative of a worse prognosis in this population.

The Influence of Gender on Evidence-Based Practice for Patients with Acute Coronary Syndrome: A Retrospective Multi-Site Australian Study

Background: Death from acute coronary syndrome (ACS) is prevented with access to gender-neutral evidence-based guidelines. Evidence-based ACS care usually begins in the emergency department (ED) and should be provided through to patient discharge. Aim: We aimed to evaluate if ACS management was different in women and men admitted to hospital through EDs against Australian ACS evidence-based guidelines. Methods: We undertook retrospective analysis on patient level data for adults with ACS from three Australian public hospitals with EDs from 1 Jan 2013 to 30 June 2015. Results: The study included 288 eligible patients, stratified by gender. Women were older than men (79 vs 75.5 years; p = 0.009). In the ED, women received less urgent triage scores (58.3 vs 71.5%; p = 0.026) than men and waited longer for their electrocardiographs (18.5 vs 15 mins; p = 0.001). Women were less likely to have been admitted to coronary care units (52.4 vs 65.3%; p = 0.023), instead, more often admitted to general medicine units (39.6 versus 22.9%; p = 0.003) than men. Although there was no statistical difference in the proportion of inhospital deaths between genders (p = 0.286), the percentage of women (10.4%) who died was observably higher than that for men (6.3%). Conclusions: Maximising treatment for patients with ACS saves lives. We found several differences in ACS care by gender that were not explained satisfactorily by patient level data. Further research needs to clarify reasons for these gender differences and whether they can or should be reduced. Our findings are guiding subsequent research through which we aim to reduce ACS practice variation between genders.

Variation in the place of death among nursing home residents in France.

recent studies have reported that hospitals have become a common place of death for nursing home residents. This study aimed to (i) measure variations in the proportion of in-hospital deaths across regions after adjustment for facility-level characteristics and (ii) identify environmental risk factors that might explain these variations in France. a cross-sectional retrospective survey was conducted in 2013. coordinating physicians in 3,705 nursing homes in France. a regression model was used to construct risk-adjusted rates of in-hospital deaths considering the facilities' characteristics. At the regional level, the outcome was defined as the difference between the observed rate of in-hospital deaths and the expected risk-adjusted rate. Values exceeding zero indicated rates that exceeded the national predicted rate of in-hospital deaths and thus highlighted regions in which the risk-adjusted probability for nursing home residents to die in a hospital was greater than average. among 70,119 nursing home decedents, 25.4% (n = 17,789) died in hospitals. The characteristics of the facilities had a significant influence on the proportion of in-hospital deaths among the nursing home decedents. However, after adjustment for these facility-level risk factors, the proportion of nursing homes that reported worse-than-average outcomes showed significant variation (range 26.0-79.6%). At the regional level, both the rate of acute hospital beds and the rate of general practitioners were found to be strongly correlated with the probability of reporting worse-than-average outcomes (P < 0.001). our study demonstrates the existence of major differences across regions in France and highlights the need for targeted interventions regarding end-of-life care in nursing home facilities.

Abstract 11409: Comparison of National Cardiovascular Data Registry to an Administrative Database

Introduction: Public reporting of cardiovascular outcomes from registries has been useful in monitoring and improving quality of care. However, participation in registries such as National Cardiovascular Data Registry (NCDR) is voluntary and information could be biased due to self-selection of the participating hospitals thus limiting the external validity. Administrative databases usually do not include detailed information, but include all patients. Hypothesis: To compare in-hospital mortality following admission for acute myocardial infarction (AMI) between NCDR and a statewide database of all admissions to nonfederal hospitals in New Jersey (Myocardial Infarction Data Acquisition System, MIDAS) for the year 2011. Methods: We compared the proportion of in-hospital deaths for patients admitted for AMI between NCDR (published data) and MIDAS (unadjusted and adjusted for age, gender and cardiac catheterization (CATH) or percutaneous coronary intervention (PCI). MIDAS data were derived by direct standardization using the 2011 National Inpatient Sample (NIS) as the standard population. Results: The in-hospital mortality rates were lower in NCDR than MIDAS (4.56% vs. 6.37% crude, 5.92 adjusted). NCDR patients were younger and received more CATH (84.97% vs. 62.07%) PCI (64.17% vs. 41.67%). Adjustment for demographics and PCI explained 33% (1.36 vs. 1.81) of the mortality difference between NCDR and MIDAS. Similar findings were obtained when mortality was adjusted for demographics and CATH (40%, 1.81 vs. 1.29, of the mortality difference explained). Conclusions: Prospective registries and administrative databases provide complementary information. The significant differences in patient profiles, frequency of procedures and in-hospital mortality rates between NCDR and MIDAS imply that the care in NCDR hospitals is better. The magnitude of the differences warrants caution in generalizing the NCDR data to the entire nation.

Variation in cancer surgical outcomes associated with physician and nurse staffing: a retrospective observational study using the Japanese Diagnosis Procedure Combination Database

BackgroundLittle is known about the effects of professional staffing on cancer surgical outcomes. The present study aimed to investigate the association between cancer surgical outcomes and physician/nurse staffing in relation to hospital volume.MethodsWe analyzed 131,394 patients undergoing lung lobectomy, esophagectomy, gastrectomy, colorectal surgery, hepatectomy or pancreatectomy for cancer between July and December, 2007–2008, using the Japanese Diagnosis Procedure Combination database linked to the Survey of Medical Institutions data. Physician-to-bed ratio (PBR) and nurse-to-bed ratio (NBR) were determined for each hospital. Hospital volume was categorized into low, medium and high for each of six cancer surgeries. Failure to rescue (FTR) was defined as a proportion of inhospital deaths among those with postoperative complications. Multi-level logistic regression analysis was performed to examine the association between physician/nurse staffing and FTR, adjusting for patient characteristics and hospital volume.ResultsOverall inhospital mortality was 1.8%, postoperative complication rate was 15.2%, and FTR rate was 11.9%. After adjustment for hospital volume, FTR rate in the group with high PBR (≥19.7 physicians per 100 beds) and high NBR (≥77.0 nurses per 100 beds) was significantly lower than that in the group with low PBR (<19.7) and low NBR (<77.0) (9.2% vs. 14.5%; odds ratio, 0.76; 95% confidence interval, 0.68–0.86; p < 0.001).ConclusionsWell-staffed hospitals confer a benefit for cancer surgical patients regarding reduced FTR, irrespective of hospital volume. These results suggest that consolidation of surgical centers linked with migration of medical professionals may improve the quality of cancer surgical management.

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Mature trauma systems have evolved to respond to major injury-related morbidity and mortality. Studies of mature trauma systems have demonstrated improved survival, especially among seriously injured patients. From 1995 to 1998, a province-wide trauma system was implemented in the province of Nova Scotia. We measured the proportion of admissions to a tertiary level trauma centre and the proportion of in-hospital deaths among patients with major injuries as a result of a motor vehicle collisions (MVCs) before and 10 years after provincial trauma systems implementation. We identified major trauma patients aged 16 years and older using external cause of injury codes pertaining to MVCs from population-based hospital claims and vital statistics data. Individuals who were admitted to hospital or died because of an MVC in 1993-1994 (preimplementation), were compared with those who were admitted to hospital or died in 2003-2005 (postimplementation). Postimplementation, there was a 9% increase in the number of seriously injured individuals with primary admission to tertiary care. This increase was statistically significant even after we adjusted for age, head injury and municipality of residence (relative risk [RR] 1.09, 95% confidence interval [CI] 1.04-1.14). The probability of dying while in hospital in the postimplementation period decreased by 29% (adjusted RR 0.57, 95% CI 0.32-1.03), although this difference was not statistically significant. Individuals seriously injured in MVCs in Nova Scotia were more likely to be admitted to tertiary care after the implementation of a province-wide trauma system. There was a trend toward decreased mortality, but further research is warranted to confirm the survival benefit and delineate other contributing factors.

Proportion of in-hospital deaths in multiple sclerosis patients related to septicaemia and upper respiratory infection exceeds that in non-multiple sclerosis patients

Proportion of in-hospital deaths in multiple sclerosis patients related to septicaemia and upper respiratory infection exceeds that in non-multiple sclerosis patients

Clinical Outcomes among Stroke Patients Receiving Tissue Plasminogen Activator Therapy Beyond the 3-hour Time Window

Tissue plasminogen activator therapy (t-PA) is associated with improved neurologic outcomes and reduced disability from ischemic stroke. The current guidelines stipulate that patients receive t-PA within 3 hours of symptom onset. However, actual practice patterns vary, and little is known about patient outcomes when t-PA is received outside of the recommended time window. We examined mean length of hospital stay, t-PA-related complications, and in-hospital death by time of t-PA administration in North Carolina Stroke Care Collaborative (NCSCC) patients. The NCSCC includes 53 hospitals that enroll patients presenting with stroke-like symptoms. Of 40,907 patients enrolled between January 2005 and February 2010, 1070 (2.6%) received t-PA. Of these, 88.2% received t-PA within 3 hours of symptom onset ("early") and 30.3% received t-PA between 3 and 6 hours after symptom onset ("late"). Unadjusted mean length of stay (days) was longer among early patients (5.0 days; 95% confidence interval [CI], 4.7-5.3) than late patients (3.6 days; 95% CI, 3.1-4.2). t-PA-related complications were similar among early (7.0%; 55/781) and late patients (6.7%; 7/102; P = .89). The proportion of in-hospital deaths was similar among late (10.5%) and early patients (12.0%). We used multivariable logistic regression to estimate odds ratios (ORs) and 95% CIs for the associations between late t-PA status and patient outcomes. In models controlling for age, race, sex, arrival mode, and ambulatory status on admission, late t-PA was not associated with increased odds of complications or in-hospital deaths (OR, 0.89; 95% CI, 0.49-1.62). The risks and benefits of expansion of the t-PA time window in stroke patients merit further investigation.