Hospital Admission Rates Research Articles

Within-trial hospitalization resource utilization and budget impact analysis for darolutamide in metastatic hormone-sensitive prostate cancer using ARASENS.

ARASENS was a randomized, double-blind, phase 3 trial comparing darolutamide + docetaxel + androgen deprivation therapy (ADT) with placebo + docetaxel + ADT in patients with metastatic hormone-sensitive prostate cancer (mHSPC). To use clinical trial data from ARASENS to understand whether the addition of darolutamide to docetaxel + ADT leads to increased hospitalizations and to estimate the budget impact on the US health care system. We used mixed-effects negative binomial regression to estimate hospitalization and intensive care unit (ICU) admission rates and length of hospital stay (LoHS) counts. Hospitalization rates were estimated per treatment arm for the period during and after administration of docetaxel. Based on these estimates, a budget impact analysis evaluated the hospitalization costs (including ICU admissions) and standalone ICU hospitalization costs for the totality of the US population over a 5-year time horizon. The analysis compared a scenario without darolutamide vs one with darolutamide included in the US payer formulary. Hospitalization estimates were varied in a one-way sensitivity analysis. The first 4 months of treatment (when patients were receiving docetaxel) were associated with increased hospitalizations across both arms. The addition of darolutamide was associated with a numerical reduction in the rate of hospitalization (per year) due to any reason both during docetaxel treatment (1.01 visits per year [95% CI = 0.82-1.20] vs 1.18 visits per year [95% CI = 0.96-1.41]) and after docetaxel treatment (0.28 visits per year [95% CI = 0.23-0.34] vs 0.33 visits per year [95% CI = 0.27-0.40]). Darolutamide was associated with a marginally longer LoHS per hospitalization compared with placebo (+1.90 days per year) both during and after docetaxel treatment. ICU admissions were low in the ARASENS data; admission rates were assumed to be the same during and after docetaxel treatment. ICU admission rate estimates were equivalent across arms (0.02 visits per year [95% CI = 0.01-0.03]). The budget impact per treated member per month represents a cost-neutral option after Year 5 with a cumulative budget impact of -$9.71. The addition of darolutamide to docetaxel + ADT was associated with a numerically lower rate of hospitalization but marginally longer LoHS compared with docetaxel + ADT alone. Darolutamide represents a cost-neutral alternative per treated member per month compared with docetaxel + ADT with regard to hospitalizations at the end of a 5-year time horizon.

#1595 Use of machine learning directed interventions to reduce fluid related hospital admissions in hemodialysis patients

Abstract Background and Aims Patients with end-stage kidney disease (ESKD) are hospitalized nearly two times per year on average; volume overload, infections and other cardiovascular complications are amongst the most common causes of hospitalization. We developed a machine learning (ML) model to predict haemodialysis (HD) patients at imminent risk of hospitalization due to fluid overload within the next 7 days. Patients identified as high risk by the model were assessed, intervened, and triaged on by group of telephonic nurses. The goal of this analysis is to evaluate the impact of the ML model-directed interventions on fluid related hospital admissions and all cause hospital admissions. Method We used data from a group of ESKD patients on HD modality who were identified as high risk by the ML model between baseline months April 2022 and June 2023. These high-risk patients were eligible to receive an assessment by telephonic nurses. The follow-up months were defined as the month immediately following the baseline month. Intervention group was identified as the high-risk patients where a clinical chart review was performed with needs identified, clinical chart review was performed and patients were managed by the clinic, some contact was made over phone/mail by the telephonic nurse, or some clinical recommendation was made. High-risk patients without any intervention or activity documented by the telephonic nurse served as the control population. We used linear regression analysis with repeated measures to account for within patient variability to produce estimated outcome rates with 95% confidence intervals adjusting for baseline factors such as average ML model risk score, average albumin, gender, race, age, vintage, comorbidities like chronic heart failure, diabetes, hypertension, ischemic heart disease, and primary insurance. Results There were 15,878 patients (36,932 patient months) in the group that received intervention; there were 51,800 patients (398,594 patient months) in the group that did not receive intervention. The pooled analysis (Table 1) showed a 38% reduction in all cause hospital admission rate between the baseline and follow-up months for the group that received intervention and there was a 34% reduction in all cause hospital admission rate for the group that did not receive any intervention. There was a 36% reduction in the fluid related hospital admission rate between the baseline and follow-up months for the group that received intervention and there was a 32% reduction in the fluid related hospital admission for the group that did not receive any intervention. Conclusion There is a larger magnitude reduction in fluid related hospital admissions and all cause hospital admissions between the baseline and follow-up months for the high-risk group as identified by the ML model that received intervention from the nurses compared to those that did not receive any intervention. Further studies are necessary to prove this association.

#1171 Effect of methoxy polyethylene glycol-epoetin beta on delaying dialysis in anemic patients with Stage 4-5 chronic kidney disease

Abstract Background and Aims The optimal hemoglobin (Hb) target for treating anemia in pre-dialysis chronic kidney disease (CKD) remains controversial. This study investigates the efficacy and safety of methoxy polyethylene glycol-epoetin beta, in delaying the initiation of kidney replacement therapy (KRT), all-cause mortality, CKD progression, and quality of life in stage 4-5 CKD patients. It compares outcomes between patients targeting an Hb level of 10.5-11.5 g/dL versus 8.5-9.5 g/dL. Method This was a single-center, open-label, parallel-group randomized controlled trial. Patients with estimated glomerular filtration rates (eGFR) of 8-15 ml/min/1.73 m2, who had not yet started dialysis, were randomized into two groups based on different Hb targets (Group A: 10.5-11.5 g/dL, Group B: 8.5-9.5 g/dL). Methoxy polyethylene glycol-epoetin beta (MIRCERA®) was prescribed by a pre-specified protocol to achieve these Hb targets. Iron supplements were administered to maintain transferrin saturation >20% or serum ferritin >200 ng/ml. Primary outcomes included a composite of all-cause death and KRT initiation, with secondary outcomes encompassing eGFR slope, hospitalization incidence, blood transfusion necessity, and quality of life measured by the 36-Item Short Form Health Survey (SF-36). Results A total of 62 participants were randomized. The mean age was 64.0 years (SD ±16.0), with 51.6% being female. The mean estimated Glomerular Filtration Rate (eGFR) at enrollment was 12.1 ml/min/1.73 m2 (SD ±3.1). Group A had a significantly higher time-averaged Hemoglobin (Hb) level (10.5 g/dL, SD ±1.2) compared to 8.5 g/dL (SD ±0.9) in the control group (p < 0.001). There was no significant difference in the composite endpoint of all-cause death and Kidney Replacement Therapy (KRT) initiation between the two groups (Hazard Ratio [HR] 0.69; 95% Confidence Interval [CI] 0.32-1.50; p = 0.35, as shown in the Figure). The eGFR slope was similar in both groups (−2.54 vs. −2.53 ml/min/1.73 m2 per year, p = 0.9). Time-averaged ferritin, transferrin saturation, blood pressure, and dietary sodium/protein intake showed no significant differences. Participants in the lower Hb target group required more blood transfusions (11 vs 1 unit, Incidence Rate Ratio [IRR] = 0.075, 95% CI 0.002-0.517, p = 0.001). Rates of hospital admissions, and changes in SF-36 quality of life domains were comparable between the groups, as detailed in the Table. Conclusion The study indicates that using methoxy polyethylene glycol-epoetin beta to maintain a higher Hb target in anemic patients with stage 4-5 CKD does not significantly alter the rate of all-cause mortality, the initiation of KRT, and rate of eGFR decline compared to a lower Hb target. However, a higher Hb target may reduce the need for blood transfusions without adversely affecting the progression of CKD, hospitalization rates, or quality of life. These findings suggest that while higher Hb targets may not dramatically alter key clinical outcomes, they could offer benefits in reducing transfusion requirements, thus providing a more nuanced approach to managing anemia in late-stage CKD.

#1647 Clinical insights into incremental hemodialysis: a retrospective analysis of patient persistence and outcomes

Abstract Background and Aims Incremental haemodialysis has been proposed as an alternative to standard thrice-weekly haemodialysis for incident patients with significant residual kidney function. Definition is not unique, but it is mostly intended as twice weekly dialysis. Its diffusion is not known since there are no public registers in Europe, but it is adopted in some dialysis facilities, while in others is not, with geographical differences. In our centre incremental haemodialysis in adopted for some patients, based on the clinical judgement, without a strict protocol. We retrospectively analysed clinical outcomes of the incident patients of the last 36 months, to understand which patients may benefit more from this approach, how long it is viable and the clinical outcomes. Method Retrospective observational analysis of incident patients of the last 36 months, without serious rapidly evolving disease. Focus was on persistence in twice-weekly dialysis, nutritional parameters, residual kidney function, hospital admissions and economic considerations. 36 patients started haemodialysis with a 2-times per week schedule while 13 with full dose dialysis. At baseline, there were no significant differences on age, sex, serum albumin or vascular access. 5 patients in full dose group were anuric for bilateral nephrectomy or rapidly progressive kidney disease, while all patients in incremental group had significant residual kidney function (average creatinine clearance: 7.1 ml/min). Results During the follow up period, 19/36 patients’ weekly dialysis sessions were incremented to three after a median time of 280 days, and 17/36 were still on 2-dialysis with a median follow-up time of 228 days. The reason for transition to three dialysis per week was residual kidney function loss except for a case of pericarditis. Persistence in incremental dialysis was >80% at 6 months and 44% at 1 year (Fig. 1a). We observed a significantly reduced persistence in patients with low ultrafiltration at 2nd month of dialysis (<1.7% of weight per session – 1 kg for a 60 kg patient-) and a reduced persistence with pre-dialysis systolic blood pressure <150 mmHg at 2nd month (Fig. 1b-c). Persistence was not different in more frail patients (elderly, dialyzed with a central venous line or with lower baseline albumin). Serum albumin increase was higher in patients in incremental haemodialysis at 6 months, with a borderline statistically significant difference, and similar at 1 year (Fig. 2a-b). The average weight was stable in both groups (Fig. 2). Hospital admissions were lower in the incremental group, and number of days of hospitalization per 1000 patients’ days were lower (24 vs 41 days). Thanks to the incremental approach, about 1600 dialysis sessions were avoided for the patients included in the analysis, with significant reduction of economic impact for the public healthcare and the possibility to treat more patients. Data was insufficient to make conclusions on kidney function preservation. Conclusion Incremental approach is valid in our experience. These data give useful information on how long we can expect patients to persist in 2-weekly dialysis and on which patients might benefit more and longer of this approach. The patients with better volume control, which reflect in adequate blood pressure control and low ultrafiltration rate, show a significantly longer persistence in incremental dialysis. The approach is valid also for frail patients. We also found better albumin and lower hospital admission rates that could be related with a reduced health-care exposition and better overall patients’ well-being, with adequate uremic symptoms control. The reduction on the hospital admissions has been already observed, while the albumin better rise is a new finding and should be confirmed in a randomized or at least larger study. Waiting for the results of the on-going randomized clinical trials, incremental haemodialysis might be the new standard-of-care for a subset incident haemodialysis patients.

Hospital admission and mortality rates for ischemic heart disease in Thailand: 2012-2021.

To provide an update on the epidemiology of ischemic heart disease (IHD), including the age-standardized rates of hospital admission and mortality for IHD in Thailand from 2012 to 2021, using the Ministry of Public Health National database. The overall age-standardized hospital admission rate for IHD decreased from 427.5 per 100,000 people in 2012 to 390.5 per 100,000 in 2021. In men, the age-standardized hospital admission rate was 462.7 per 100,000 people in 2012, reaching 485.8 per 100,000 in 2021,pfor trend = 0.141. In women, the age-standardization hospital admission rate for IHD dropped by 24.1% over the decade (pfor trend = 0.008). The overall age-standardized IHD mortality rate in 2012 was 23.4 per 100,000 people, peaked at 28.6 per 100,000 in 2016, and reached 26.9 per 100,000 in 2021, p for trend = 0.181. In men, the age-standardized IHD mortality rate rose by 26.6% over a decade,pfor trend = 0.004. The age-standardized IHD mortality rate among women was consistent from 2012 to 2021,pfor trend = 0.130. However, for people aged < 60, rising trends in IHD mortality rates over a decade were observed; it rose by 59.6% in men and 36.1% in women.

Changes in Emergency Department Utilization in Vulnerable Populations After COVID-19 Shelter-in-Place Orders.

This study aims to compare emergency department (ED) utilization and admission rates for patients with a history of mental health (MH) disorders, substance use disorders (SUDs), and social determinants of health (SDOH) before and after implementing COVID-19shelter-in-place (SIP) orders. This was a retrospective, multicenter study leveraging electronic medical record (EMR) data from 20 EDs across a large Midwest integrated healthcare system from 5/2/2019 to 12/31/2019 (pre-SIP) and from 5/2/2020 to 12/31/2020 (post-SIP). Diagnoses were documented in the patient's medical records. Poisson and logistic regression models were used to evaluate ED utilization and admission rate changes. A total of 871,020 ED encounters from 487,028 unique patients were captured. Overall, 2,572 (0.53%) patients had a documented Z code for SDOH. Patients with previously diagnosed MH disorders or SUDs were more likely to seek ED care after the SIP orders were implemented (risk ratio (RR): 1.20, 95% confidence interval (CI): 1.18-1.22, p<0.001), as were patients with SDOH (RR: 2.37, 95% CI: 2.19-2.55, p<0.001). Patients with both previously diagnosed MHdisorders or SUDs and a documented SDOH had even higher ED utilization (RR: 3.31, 95% CI: 2.83-3.88, p<0.001) than those with either condition alone. Patients with MHdisorders and SUDs (OR: 0.89, 95% CI: 0.86-0.92, p<0.001) or SDOH (OR: 0.67, 95% CI: 0.54-0.83, p<0.001) were less likely to be admitted post-SIP orders, while patients with a history of diseases of physiologic systems were more likely to be admitted. Vulnerable populations with a history of MH disorders,SUDs, and SDOH experienced increased ED utilization but a lower rate of hospital admissions after the implementation of SIP orders. The findings highlight the importance of addressing these needs to mitigate the impact of public health crises on these populations.

Metformin use associated with lower rate of hospitalization for influenza in individuals with diabetes.

To investigate if patients with diabetes taking metformin have better outcomes versus those not taking metformin following an emergency room visit for influenza. Using electronic medical records, we performed a retrospective chart review of all adult patients with a diagnosis of diabetes seen in any Duke University Medical Center-affiliated emergency department for influenza over a 6-year period. We documented patient characteristics and comorbidities, and compared outcomes for patients taking metformin versus patients not taking metformin using both univariable and multivariable analyses. Our primary outcome was hospital admission rate. Secondary outcomes were in-hospital length of stay and in-hospital death. Our cohort included 1023 adult patients with diabetes, of whom 59.9% were female. The mean age was 62.9 years, 58.4% were African American, 36.1% were White, and 81.9% were obese or overweight. Of these patients, 347 (34%) were taking metformin. Patients with diabetes taking metformin were less likely to be hospitalized following an emergency department visit for influenza than patients with diabetes not taking metformin (56.8% vs. 70.1%; p < 0.001). Of those patients admitted, there was no statistically significant difference in length of stay or death. In patients with diabetes, metformin use is associated with lower rate of hospitalization following an emergency department visit for influenza.

Impact of the COVID-19 pandemic on hospital admission rates for arterial hypertension and coronary heart disease: a German database study.

During the SARS-CoV-2 pandemic it was speculated that the virus might be associated with a persistent increase of cardiovascular risk. The present study compares pre- and post-pandemic hospital admission rates for hypertension and coronary artery disease. Systematic multicentric retrospective cohort analysis of 57.795 hospital admissions in an urban region in Germany during two different periods (pre-pandemic 01-06/2019 vs. post-pandemic era 01-06/2023). Information on hospital admissions for arterial hypertension, chronic coronary syndrome, unstable angina pectoris and acute myocardial infarction were extracted from the hospitals data systems. Additionally, six comorbidities and performed coronary interventions were monitored. Compared to the pre-pandemic era, there was no increase in hospitalizations for arterial hypertension (516 vs. 483, -6.8%, p = 0.07) or myocardial infarction (487 vs. 349, -23.8%, p < 0.001), but the total number of patient admissions with chest pain as the presenting symptom increased (chronic coronary syndrome: 759 vs. 943, +24.2%, p < 0.001; unstable angina pectoris: 270 vs. 451, +67.0%, p < 0.001). At the same time, the number of performed coronary angiographies increased, but less patients underwent percutaneous interventions. Patients admitted with chest pain in the post-pandemic era were in general healthier with less comorbidities. The present multicenter cohort study found no evidence for an increase in hospitalizations for arterial hypertension or coronary artery disease after the end of the pandemic. However, further studies with larger sample sizes are needed to confirm our results.

Comprehensive atrial fibrillation package of care to minimise unnecessary hospital admission and improve patient outcome: a quality improvement project

Abstract Funding Acknowledgements None. Introduction Recent studies have highlighted an increasing rate of hospitalisation among atrial fibrillation (AF) patients, despite a relatively low in-hospital mortality rate. This trend carries significant financial implications, with a twofold increase in AF-related expenditures, over 50% of which are associated with inpatient care. Purpose A Quality Improvement Project (QIP) was conducted to enhance AF care, reduce unnecessary admissions, and address the root causes driving increased hospitalisations. Methods The root cause analysis, illustrated in Figure 1, revealed four factors contributing to the increased hospital admission rate of newly diagnosed AF patients: systemic issues, the nature of the disease itself, patient and physician-related factors. The driver diagram (Figure 2) visually presented the primary and secondary drivers with corresponding interventions targeting potential areas for improvement. Plan, Do, Study, Act (PDSA) cycle was conducted using four-pronged approach: 1. Updating local guidelines and designing a stepwise algorithm to align with contemporary standards of care. 2. Establishing an ambulatory care/arrhythmia clinic referral pathway for follow-up of stable AF patients to ensure continuity of care, thus minimizing unnecessary admissions. 3. Implementing a safe discharge toolkit comprising patient education materials, a poster for stroke and bleeding risk assessment tools, and an anticoagulation checklist. 4. Incorporating AF management teaching sessions into the doctors’ induction curriculum to enhance their knowledge and confidence in managing newly diagnosed AF patients and ensuring safe discharges. Results Lack of an ambulatory care or arrhythmia clinic referral pathway, inadequate educational resources, insufficient clinician training were key factors contributing to unwarranted hospitalization of newly diagnosed AF patients. The comprehensive guideline revision process, requiring substantial resources and the support of stakeholders and a multidisciplinary team comprising cardiologists and emergency and acute medical physicians, facilitated the successful implementation of the new AF referral pathway. This QIP resulted in a 16% reduction in avoidable admissions, 24% increase in clinician confidence, and 18% improvement in adherence to stroke and bleeding risk assessment protocols, in addition to reducing the hospital stay duration. Conclusions The collaboration among diverse medical disciplines, evidence-based guideline revision, and the implementation of a streamlined AF referral pathway demonstrated the potential to reduce healthcare resource utilization and financial burdens. This approach aligns with national standards, enhances healthcare providers' knowledge and confidence, ensuring standardised clinical practices. It underscores its potential for implementation of similar pathways to improve patient care. Continuous evaluation to evolving guidelines are recommended for sustainability.Figure 1.Ishikawa fishbone diagramFigure 2.Driver diagram for AF care

Comparison of safety and efficacy between Nirmatrelvir-ritonavir and molnupiravir in the treatment of COVID-19 infection in patients with advanced kidney disease: a retrospective observational study

Nirmatrelvir-ritonavir is used in patients with coronavirus disease 2019 (COVID-19) with normal or mild renal impairment (eGFR ≥30ml/min per 1.73m2). There is limited data regarding its use in advanced kidney disease (eGFR <30ml/min per 1.73m2). We performed a retrospective territory-wide observational study evaluating the safety and efficacy of nirmatrelvir-ritonavir when compared with molnupiravir in the treatment of patients with COVID-19 with advanced kidney disease. We adopted target trial emulation using data from a territory-wide electronic health record database on eligible patients aged ≥18 years with advanced kidney disease (history of eGFR <30ml/min per 1.73m2) who were infected with COVID-19 and were prescribed with either molnupiravir or nirmatrelvir-ritonavir within five days of infection during the period from 16 March 2022 to 31 December 2022. A sequence trial approach and 1:4 propensity score matching was applied based on the baseline covariates including age, sex, number of COVID-19 vaccine doses received, Charlson comorbidity index (CCI), hospitalisation, eGFR, renal replacement therapy, comorbidities (cancer, respiratory disease, myocardial infarction, ischaemic stroke, diabetes, hypertension), and drug use (renin-angiotensin-system agents, beta blockers, calcium channel blockers, diuretics, nitrates, lipid lowering agents, insulins, oral antidiabetic drugs, antiplatelets, immuno-suppressants, corticosteroids, proton pump inhibitors, histamine H2 receptor antagonists, monoclonal antibody infusion) within past 90 days. Individuals were followed up from the index date until the earliest outcome occurrence, death, 90 days from index date or the end of data availability. Stratified Cox proportional hazards regression adjusted with baseline covariates was used to compare the risk of outcomes between nirmatrelvir-ritonavir recipients and molnupiravir recipients which include (i) all-cause mortality, (ii) intensive care unit (ICU) admission, (iii) ventilatory support, (iv) hospitalisation, (v) hepatic impairment, (vi) ischaemic stroke, and (vii) myocardial infarction. Subgroup analyses included age (<70; ≥70 years); sex, Charlson comorbidity index (≤5; >5), and number of COVID-19 vaccine doses received (0-1; ≥2 doses). A total of 4886 patients were included (nirmatrelvir-ritonavir: 1462; molnupiravir: 3424). There were 347 events of all-cause mortality (nirmatrelvir-ritonavir: 74, 5.06%; molnupiravir: 273, 7.97%), 10 events of ICU admission (nirmatrelvir-ritonavir: 4, 0.27%; molnupiravir: 6, 0.18%), 48 events of ventilatory support (nirmatrelvir-ritonavir: 13, 0.89%; molnupiravir: 35, 1.02%), 836 events of hospitalisation (nirmatrelvir-ritonavir: 218, 23.98%; molnupiravir: 618, 28.14%), 1 event of hepatic impairment (nirmatrelvir-ritonavir: 0, 0%; molnupiravir: 1, 0.03%), 8 events of ischaemic stroke (nirmatrelvir-ritonavir: 3, 0.22%; molnupiravir: 5, 0.16%) and 9 events of myocardial infarction (nirmatrelvir-ritonavir: 2, 0.15%; molnupiravir: 7, 0.22%). Nirmatrelvir-ritonavir users had lower rates of all-cause mortality (absolute risk reduction (ARR) at 90 days 2.91%, 95% CI: 1.47-4.36%) and hospitalisation (ARR at 90 days 4.16%, 95% CI: 0.81-7.51%) as compared with molnupiravir users. Similar rates of ICU admission (ARR at 90 days-0.09%, 95% CI:-0.4 to 0.2%), ventilatory support (ARR at 90 days 0.13%, 95% CI:-0.45 to 0.72%), hepatic impairment (ARR at 90 days 0.03%, 95% CI:-0.03 to 0.09%), ischaemic stroke (ARR at 90 days-0.06%, 95% CI:-0.35 to 0.22%), and myocardial infarction (ARR at 90 days 0.07%, 95% CI:-0.19 to 0.33%) were found between nirmatrelvir-ritonavir and molnupiravir users. Consistent results were observed in relative risk adjusted with baseline characteristics. Nirmatrelvir-ritonavir was associated with significantly reduced risk of all-cause mortality (HR: 0.624, 95% CI: 0.455-0.857) and hospitalisation (HR: 0.782, 95% CI: 0.64-0.954). Patients with COVID-19 with advanced kidney disease receiving nirmatrelvir-ritonavir had a lower rate of all-cause mortality and hospital admission when compared with molnupiravir. Other adverse clinical outcomes were similar in both treatment groups. Health and Medical Research Fund (COVID1903010), Health Bureau, The Government of the Hong Kong Special Administrative Region, China.

Clostridioides difficile infection, recurrence and the associated healthcare consumption in Sweden between 2006 and 2019: a population-based cohort study

BackgroundClostridioides difficile infection (CDI) causes a major burden to individuals and society, yet the impact may vary depending on age, sex, underlying comorbidities and where CDI was acquired (hospital or community).MethodsThis Swedish nationwide population-based cohort study (2006–2019) compared all 43,150 individuals with CDI to their 355,172 matched controls (first year and entire follow-up). Negative binomial regression models compared the cumulated length of stay, number of in-hospital admissions, outpatient visits and prescriptions after the first CDI episode expressed as incidence rate ratios (IRR) and 95% confidence intervals for the entire follow-up.ResultsOverall, 91.6% of CDI cases were hospital acquired, and 16.8% presented with recurrence(s); 74.8%of cases were ≥ 65 years and 54.2% were women. Compared to individuals without CDI, in-hospital stay rates were 18.01 times higher after CDI (95% CI 17.40–18.63, first-year: 27.4 versus 1.6 days), 9.45 times higher in-hospital admission (95% CI 9.16–9.76, first-year: 2.6 versus 1.3 hospitalisations), 3.94 times higher outpatient visit (95% CI 3.84–4.05, first-year: 4.0 versus 1.9 visits) and 3.39 times higher dispensed prescriptions rates (95% CI 3.31–3.48, first-year: 25.5 versus 13.7 prescriptions). For all outcomes, relative risks were higher among the younger (< 65 years) than the older (≥ 65 years), and in those with fewer comorbidities, but similar between sexes. Compared to those without recurrence, individuals with recurrence particularly showed a higher rate of hospital admissions (IRR = 1.18, 95% 1.12–1.24). Compared to community-acquired CDI, those with hospital-acquired CDI presented with a higher rate of hospital admissions (IRR = 7.29, 95% CI 6.68–7.96) and a longer length of stay (IRR = 7.64, 95% CI 7.07–8.26).ConclusionCDI was associated with increased health consumption in all affected patient groups. The majority of the CDI burden could be contributed to hospital-acquired CDI (~ 9/10), older patients (~ 3/4) and those with multiple comorbidities (~ 6/10 Charlson score ≥ 3), with 1/5 of the total CDI burden contributed to individuals with recurrence. Yet, relatively speaking the burden was higher among the younger and those with fewer comorbidities, compared to their peers without CDI.

Risk factors for asthma-related hospital and intensive care admissions in children, adolescents and adults: a cohort study using primary and secondary care data

BackgroundAsthma remains a common cause of hospital admissions across the life course. We estimated the contribution of key risk factors to asthma-related hospital and intensive care unit (ICU) admissions in...

Defragmentation of care in complex patients with ESKD improves clinical outcomes.

Given the problematic fragmentation of care for patients with end-stage kidney disease (ESKD), a kidney care organization and an integrated health system within a large accountable care organization partnered to best utilize their individual capabilities to collaborate around their shared patients in a coordinated care approach. Ultimately, the goal of the program is to allow care teams to achieve the triple aim of improving the patient experience, improving clinical outcomes, and reducing the total cost of health care. This is a retrospective examination of the first year of the Shared Patient Care Coordination (SPCC)program. The analysis consisted of 2 parts. First, rates of hospitalizations and emergency department visits were compared between the SPCC patients and other patients of the integrated health system who had ESKD but did not participate in SPCC. Second, rates of clinical indicators-central venous catheter (CVC) use, home dialysis, advance care planning, and missed dialysis treatments-were benchmarked vs normative data taken by bootstrap sampling of the kidney care organization's patient population. Overall, dialysis patients participating in the SPCC program had a 15% lower rate of hospital admissions than those not participating ( P = .02). Additionally, the bootstrap analysis showed that by the second year, dialysis patients in the program had favorable rates (above the 95th percentile) of CVC use, dialysis treatment absenteeism, and completion of advance care plans. Enhanced and structured communication between dialysis providers and patient care teams provides a unique opportunity to coordinate patient-centered care and improve patient outcomes.

Planned and unplanned hospital admissions and health-related school absence rates in children with neurodisability: Protocol for a population-based study using linked education and hospital data from England.

Neurodisability describes a broad set of conditions affecting the brain and nervous system which result in functional limitations. Children with neurodisability have more hospital admissions than their peers without neurodisability and higher rates of school absence. However, longitudinal evidence comparing rates of hospital admission and school absence in children with neurodisability to peers without neurodisability throughout school is limited, as is understanding about whether differences are greatest for planned care (e.g., scheduled appointments) or unplanned care. This study will describe rates of planned and unplanned hospital admissions and school absence due to illness and medical reasons throughout primary school (Reception to Year 6, ages 4 to 11 in England) for children with neurodisability and all other children, using linked individual-level health and education data. We will use the ECHILD (Education and Child Insights from Linked Data) database, which links educational and health records across England. We will define a primary school cohort of children who were born in National Health Service-funded hospitals in England between 1 st September 2003 and 31 st August 2008, and who were enrolled in Reception (age 4/5) at state-funded schools. We will use hospital admissions records to identify children who have recorded indicators of neurodisability from birth up to the end of primary school (Year 6, age 10/11). We will describe rates of planned and unplanned hospital admissions and health-related school absence for three groups of children: those with a neurodisability indicator first recorded before beginning primary school, those with neurodisability first recorded during primary school, and those without a record of neurodisability before end of primary school. We will further explore whether differences between these group vary across primary school years and by socioeconomic and demographic characteristics.

Pregnancy Outcomes in Patients with Prosthetic Heart Valves in Saudi Arabia

Background: Pregnancies in women with heart prostheses are high-risk pregnancies with increased maternal and fetal adverse outcomes. Advances in prosthetic heart valve design and anticoagulation have improved these outcomes over the past decades. Objectives: To study the pregnancy outcomes in pregnancies with heart prostheses and to compare these outcomes between mechanical and biosynthetic heart prostheses in Saudi patients. Methods: In this single centered retrospective study conducted at King Saud Medical City (KSUMC) between January 2011 and February 2020, we have reviewed all pregnant women’s heart prostheses. Fetal and maternal data were obtained, and outcomes were compared between pregnancies with mechanical heart prostheses and bioprostheses. Results: A total of 111 pregnancies were reviewed. A total of 51.4% of pregnancies had bioprostheses, 48.6% had mechanical prostheses, and 64.0% of participants were obese. The majority of the participants had a parity in the range of 2-9 (N=107, 96.4%). The most frequent type of rheumatic heart disease was mitral regurgitation (N=49, 44.1%), followed by mitral stenosis (N=32, 28.8%). There was no maternal mortality and no structural valve failure. There was a high rate of hospital admission in both groups, up to 55% of pregnancies. The rates of abortion, postpartum hemorrhage and transfusions were higher than those in general pregnancies; however, there was no difference in maternal and fetal complications between the two types of prostheses, i.e., bioprostheses and mechanical. Conclusion: Although women with prosthetic heart valves have higher rates of adverse outcomes, they generally tolerate pregnancy well. There was no difference in adverse outcomes between bioprosthetic and mechanical prostheses

Impact of the geriatric emergency medicine specialist intervention on final emergency department disposition.

The Geriatric Emergency Medicine Specialist (GEMS) pilot program is an innovative approach that utilizes geriatric-trained advanced practice providers to facilitate geriatric assessments and care planning for older adults in the emergency department (ED). The objective of this study was to explore the effect of GEMS on the use of observation status and final ED disposition. This was a retrospective study under a target trial emulation framework. Geriatric patients (65+ years old) who presented to two ED sites within a large regional healthcare system between December 2020 and December 2022 were included. The primary outcome was final ED disposition (discharge, hospital inpatient admission, or hospital observation admission). Secondary outcomes included ED observation and ED length of stay. Non-GEMS patients were propensity score matched 5:1 to GEMS patients. Doubly robust regression was used to estimate the odds ratios and 95% confidence intervals of inpatient admission, discharge, hospital observation admission, ED observation admission, and estimate the mean ED length of stay. A total of 427 of 43,064 total patients (1.0%) received a GEMS intervention during the study period. Our analysis included 2,302 geriatric ED patients (410 GEMS, 1,892 non-GEMS) after propensity score matching. Hospital admission rates were 34.1% for GEMS compared to 56.4% for conventional treatment. GEMS patients had decreased odds of inpatient admission (OR: 0.41, 95 CI: 0.34-0.51, p < 0.001), increased odds of discharge (OR: 1.19 95 CI: 1.00-1.42, p = 0.047), hospital observation admission (OR: 2.97, 95 CI: 2.35-3.75, p < 0.001), ED observation admission (OR: 4.84 95 CI: 3.67-6.38, p < 0.001), and had a longer average ED length of stay (170 min, 95 CI: 84.6-256, p < 0.001) compared to non-GEMS patients. Patients seen by GEMS during their ED visit were associated with higher rates of hospital discharge and lower rates of hospital admissions.

What can hospital emergency admissions prior to cancer diagnosis tell us about socio-economic inequalities in cancer diagnosis? Evidence from population-based data in England

BackgroundMore deprived cancer patients are at higher risk of Emergency Presentation (EP) with most studies pointing to lower symptom awareness and increased comorbidities to explain those patterns. With the example of colon cancer, we examine patterns of hospital emergency admissions (HEAs) history in the most and least deprived patients as a potential precursor of EP.MethodsWe analysed the rates of hospital admissions and their admission codes (retrieved from Hospital Episode Statistics) in the two years preceding cancer diagnosis by sex, deprivation and route to diagnosis (EP, non-EP). To select the conditions (grouped admission codes) that best predict emergency admission, we adapted the purposeful variable selection to mixed-effects logistic regression.ResultsColon cancer patients diagnosed through EP had the highest number of HEAs than all the other routes to diagnosis, especially in the last 7 months before diagnosis. Most deprived patients had an overall higher rate and higher probability of HEA but fewer conditions associated with it.ConclusionsOur findings point to higher use of emergency services for non-specific symptoms and conditions in the most deprived patients, preceding colon cancer diagnosis. Health system barriers may be a shared factor of socio-economic inequalities in EP and HEAs.

Strategies to Improve Emergency Transitions From Long-Term Care Facilities: A Scoping Review.

Older adults residing in residential aged care facilities (RACFs) often experience substandard transitions to emergency departments (EDs) through rationed and delayed ED care. We aimed to identify research describing interventions to improve transitions from RACFs to EDs. In our scoping review, we included English language articles that (a) examined an intervention to improve transitions from RACF to EDs; and (b) focused on older adults (≥65 years). We employed content analysis. Dy et al.'s Care Transitions Framework was used to assess the contextualization of interventions and measurement of implementation success. Interventions in 28 studies included geriatric assessment or outreach services (n = 7), standardized documentation forms (n = 6), models of care to improve transitions from RACFs to EDs (n = 6), telehealth services (n = 3), nurse-led care coordination programs (n = 2), acute-care geriatric departments (n = 2), an extended paramedicine program (n = 1), and a web-based referral system (n = 1). Many studies (n = 17) did not define what "improvement" entailed and instead assessed documentation strategies and distal outcomes (e.g., hospital admission rates, length of stay). Few authors reported how they contextualized interventions to align with care environments and/or evaluated implementation success. Few studies included clinician perspectives and no study examined resident- or family/friend caregiver-reported outcomes. Mixed or nonsignificant results prevent us from recommending (or discouraging) any interventions. Given the complexity of these transitions and the need to create sustainable improvement strategies, future research should describe strategies used to embed innovations in care contexts and to measure both implementation and intervention success.

Beyond prevention: Unveiling the benefits of triple vaccination on COVID-19 severity and resource utilization in solid organ transplant recipients

ObjectiveDespite the widespread reduction in COVID-19-related morbidity and mortality attributed to vaccination in the general population, vaccine efficacy in solid organ transplant recipients (SOTR) remains under-characterized. This study aimed to investigate clinically relevant outcomes on double and triple-vaccinated versus unvaccinated SOTR with COVID-19. Study design and settingA retrospective propensity score-matched cohort study was performed utilizing data from the US Collaborative Network Database within TriNetX (n = 117,905,631). We recruited vaccinated and unvaccinated (matched controls) SOTR with COVID-19 over two time periods to control for vaccine availability: December 2020 to October 2022 (bi-dose, double-dose vaccine effectiveness) and December 2020 to April 2023 (tri-dose, triple-dose vaccine effectiveness). A total of 42 factors associated with COVID-19 disease severity were controlled for including age, obesity, diabetes, and hypertension. We monitored 30-day outcomes including acute respiratory failure, intubation, and death following a diagnosis of COVID-19. ResultsSubjects were categorized into two cohorts based on the two time periods: bi-dose cohort (vaccinated, n = 462; unvaccinated, n = 20,998); tri-dose cohort (vaccinated, n = 517; unvaccinated, n = 23,061).Compared to unvaccinated SOTR, 30-day mortality was significantly lower for vaccinated subjects in both cohorts: tri-dose (2.0% vs 7.5%, HR = 0.22 [95% CI: 0.11, 0.46]); bi-dose (3.7% vs 8.2%, HR = 0.43 [95% CI: 0.24, 0.76]). Hospital admission rates were similar between bi-dose vaccinated and unvaccinated subjects (33.1% vs 28.6%, HR = 1.2 [95% CI: 0.95, 1.52]). In contrast, tri-dose vaccinated subjects had a significantly lower likelihood of hospital admission (29.4% vs 36.6%, HR = 0.74 [95% CI: 0.6, 0.91]). Intubation rates were significantly lower for triple-vaccinated- (2.3% vs 5.2%, p < 0.05), but not double-vaccinated subjects (3.0% vs 5.2%, p > 0.05). ConclusionIn solid organ transplant recipients with COVID-19, triple vaccination, but not double vaccination, against SARS-CoV-2 was associated with significantly less hospital resource utilization, decreased disease severity, and fewer short-term complications. These real-world data from extensively matched controls support the protective effects of COVID-19 vaccination with boosters in this vulnerable population.

Impact of immunosuppressive agents on the management of immune-related adverse events of immune checkpoint blockers

BackgroundImmune checkpoint blockers (ICBs) can induce immune-related adverse events (irAEs) whose management is based on expert opinion and may require the prescription of steroids and/or immunosuppressants (ISs). Recent data suggest that these treatments can reduce the effectiveness of ICBs. ObjectiveTo investigate the relationship between the use of steroids and/or ISs and overall survival (OS) and progression-free survival (PFS) among ICB-treated patients with an irAE. MethodsWe prospectively collected data from the medical records of patients with solid tumors or lymphoma in the French REISAMIC cohort and who had been treated with ICBs between June 2014 and June 2020. Results184 ICB-treated patients experienced at least one Common Terminology Criteria for Adverse Events grade ≥ 2 irAE. 107 (58.2%) were treated with steroids alone, 20 (10.9%) with steroids plus IS, 57 (31.0%) not received steroids or IS. The median OS was significantly shorter for patients treated with steroids alone (25.2 months [95% confidence interval (CI): 22.3–32.4] than for patients treated without steroids or IS (63 months [95%CI: 40.4-NA]) and those receiving an IS with steroids (53.4 months [95%CI: 47.3-NA]) (p < 0.001). The median PFS was significantly shorter for patients treated with steroids alone (17.0 months [95%CI: 11.7–22.9]) than for patients treated without steroids or IS (33.9 months [95%CI: 18.0-NA]) and those receiving an IS with steroids (41.1 months [95%CI: 26.2-NA]) (p = 0.006). There were no significant intergroup differences in the hospital admission and infection rates. ConclusionIn a prospective cohort of ICB-treated patients, the use of IS was not associated with worse OS or PFS, contrasting with the use of steroids for the management of irAEs.