Reduction In Number Of Admissions Research Articles

Nutritional status and use of health resources following the implementation of a PEG tube nutrition program for neurological patients in home hospitalization

Objective: the objective of this study was to demonstrate that implementation of enteral nutrition by gastrostomy tube by the Home Hospitalization Unit (HHU) in patients suffering from neurological diseases, significantly improves their nutritional status, both in terms of anthropometric and analytical parameters. Methods: data on admissions, days of hospital stay, emergency room visits and nutritional parameters were collected during the 6 months before and 6 months after placement of a percutaneous endoscopic gastrostomy (PEG) tube in 100 patients from the UHD at General University Hospital in Elda (Alicante). Results: a total of 100 neurological patients were included in the study; 58 % of them were women and with a mean age (standard deviation, SD) of 78.3 (13.3) years, with 60 % of the patients being > 80 years. The monitoring and home treatment of these patients by the HHU of General University Hospital in Elda led to improvement in quality of life and nutritional parameters (weight, body mass index, proteins, albumin, prealbumin, creatinine, and hemoglobin), as well as a decrease in the number of complications derived from the nutritional management of patients at their home, and a significant reduction in number of admissions (90.27 %) and days of hospital stay (94.05 %), as well as of visits to emergency services (79.47 %), with a consequent reduction in healthcare costs. Conclusions: the implementation of a home-based monitoring program for patients with PEG by a HHU improves their nutritional status and reduces healthcare costs.

O-EGS09 Effect of introducing an ambulatory care service on management of patients requiring acute cholecystectomy

Abstract Background Biliary pathology is a large tranche of the emergency surgical take, taking up many bed days, with many patients not receiving definitive management on their primary admission. An Emergency Surgical Ambulatory Care (ESAC) service was established at our hospital in 2019, aiming to provide a streamlined platform for diagnosis and surgical management of patients. Most notably this included patients with symptomatic gallstones which could be managed on a semi-urgent basis without hospital admission. We aim to analyse the efficiency of this novel service in hopes of identifying room for improvement so that we may enhance our patient outcomes. Methods Two time periods were retrospectively assessed; September-December 2018 (pre- ESAC) and September-December 2019 (six months after ESAC started). Patients with Cholelithiasis (ICD-K80) and Cholecystitis (ICD-K81) were identified, and those with either an incidental diagnosis of gallstones without symptoms, with gallstone pancreatitis, severe inflammation (empyema, gangrene, perforation), requiring ERCP or if they were unfit for surgery were excluded. Data was collected on number of admissions, length of stay and rate of cholecystectomy. Patients were divided into 2018 SAU, 2019 SAU and 2019 ESAC to compare the difference in their outcomes. Data are presented as median (range). Results Some 57 patients presented acutely in 2018 compared to 82 in 2019. The median wait to operation of 43.5 days in 2018 was significantly reduced to 7 days in 2019. Conclusions The introduction of an ESAC service in 2019 has allowed a reduction in number of admissions, total length of stay of patients and significantly reduced waiting time for surgery. Use of ESAC has shown to be more efficient in terms of hospital bed occupation and indirectly, utilization of resources. The high surgical success rate also ensures fewer patients re-presenting with the same pathology to the acute take and hence contributes to reducing strain on the on-call team. Further work is being done to reduce the number of patients presenting through the SAU pathway, and preferentially attending through ESAC.

Effect of COVID-19 pandemic on stroke admission rates in a Norwegian population.

ObjectivesThere are concerns that public anxiety around COVID‐19 discourages patients from seeking medical help. The aim of this study was to see how lockdown due to the pandemic affected the number of admissions of acute stroke.MethodsAll patients discharged from Akershus University Hospital with a diagnosis of transient ischemic attack (TIA) or acute stroke were identified by hospital chart review. January 3 to March 12 was defined as before, and March 13 to April 30 as during lockdown.ResultsThere were 21.8 admissions/week before and 15.0 admissions/week during the lockdown (P < .01). Patients had on average higher NIHSS during the lockdown than before (5.9 vs. 4.2, P = .041). In the multivariable logistic regression model for ischemic stroke (adjusted for sex, age, living alone and NIHSS ≤ 5), there was an increased OR of 2.05 (95% CI 1.10‐3.83, P = .024) for not reaching hospital within 4.5 hours during the lockdown as compared to the period before the lockdown.ConclusionThere was a significant reduction in number of admissions for stroke and TIAs during the lockdown due to the COVID‐19 pandemic in Norway.

Association of daily copayments with use of hospital care among medicare advantage enrollees

BackgroundWhile the traditional Medicare program imposes a deductible for hospital admissions, many Medicare Advantage plans have instituted per-diem copayments for hospital care. Little evidence exists about the effects of changes in cost-sharing for hospital care among the elderly. Changing inpatient benefits from a deductible to a per diem may benefit enrollees with shorter lengths of stay, but adversely affect the out-of-pocket burden for hospitalized enrollees with longer lengths of stay.MethodsWe used a quasi-experimental difference-in-differences study to compare longitudinal changes in proportion hospitalized, inpatient admissions and days per 100 enrollees, and hospital length of stay between enrollees in MA plans that changed inpatient benefit from deductible at admission to per diem, intervention plans, and enrollees in matched control plans – similar plans that maintained inpatient deductibles. The study population included 423,634 unique beneficiaries enrolled in 23 intervention plans and 36 matched control plans in the 2007–2010 period.ResultsThe imposition of per-diem copayments were associated with adjusted declines of 1.3 admissions/100 enrollees (95% CI − 1.8 to − 0.9), 6.9 inpatient days/100 enrollees (95% CI − 10.1 to − 3.8) and 0.7 percentage points in the probability of hospital admission (95% CI − 1.0 to − 0.4), with no significant change in adjusted length of stay in intervention plans relative to control plans. For persons with 2 or more hospitalizations in the year prior to the cost-sharing change, adjusted declines were 3.5 admissions/100 (95% CI − 8.4 to 1.4), 31.1 days/100 (95% CI − 75.2 to 13.0) and 2.2 percentage points in the probability of hospitalization (95% CI − 3.8 to − 0.6) in intervention plans relative to control plans.ConclusionsInstituting per-diem copayments was associated with reductions in number of admissions and hospital stays, but not length of stay once admitted. Effects of inpatient cost-sharing changes were magnified for persons with greater baseline use of hospital care.

Brain Natriuretic Peptide as an Additional Metric for Determining Operative Candidates among Veterans with Aortic Stenosis

Objective: As the veteran population ages, the incidence of clinically significant aortic stenosis (AS) is increasing and aortic stenosis has become a veterans’ health issue. This analysis focused on using serum Brain Natriuretic Peptide (BNP) levels as an adjunct to aid decision making for early aortic valve replacement (AVR) in veterans with severe AS to reduce hospital admission rates. Methods: We retrospectively reviewed the charts of patients referred to the heart valve clinic at the Washington DC, Veterans Affairs Medical Center (VAMC) Heart Center between 2004 and 2015 who were diagnosed with severe AS. We identified veterans who had a BNP drawn in addition to traditional echocardiography during their diagnostic workup. This cohort was then stratified based on their serum BNP levels and whether they received medical therapy or aortic valve replacement. The primary endpoint of interest was admission to a VAMC for valvular heart failure. Results: Univariate analysis of BNP quartile and operative status showed a reduction in number of admissions for veterans who underwent AVR with BNP between 101 and 300 (0.64 vs. 3.71, p = 0.054) and 301 and 1000 (1.36 vs. 4.0, p = 0.003) compared to veterans treated medically. There was no difference in number of admissions for veterans with BNP lower than 100 (p = 0.455) or higher than 1000 (p = 0.659). Conclusion: BNP may be a useful adjunct for selecting patients with AS for earlier AVR leading to lower rates of hospital admissions in the veteran population. Continued analysis in a larger cohort will be needed to further validate the utility of BNP stratification as a diagnostic tool to risk stratify patients with AS in a heart valve clinic.

LAST YEAR OF LIFE PROJECT: BRADFORD TEACHING HOSPITALS FOUNDATION TRUST

Aimto improve care of patients identified in their last year of life by increasing the number of patients identified in their last year of life; recording patients' Preferred Place of...

Effectiveness of Assertive Community Management in Singapore

Assertive Community Treatment (ACT) was introduced in the 1970s as a comprehensive and assertive approach to community-based case management of patients with chronic and serious mental illness. Launched in Singapore in 2003, the Assertive Community Management (ACM) was modelled after the ACT, but with the main difference of 24 hour availability for the latter only. In line with the move towards de-institutionalisation of psychiatric patients, ACM was introduced to provide a mobile community-based multidisciplinary team approach to manage patients with severe chronic psychiatric illness. This article aims to evaluate and provide an update on this service programme in Singapore following an earlier study by Fam Johnson in 2007. A naturalistic and retrospective study was conducted. One hundred and fifty-five patients recruited into ACM from 1 September 2008 to 1 September 2009 and had completed 1 year of ACM were included in our study. Outcomes were defined as number of admissions (NOA) and length of stay (LOS) one year before and one year following induction into the programme. Baseline socio-demographic factors were also investigated to see if they predicted outcome with ACM. The mean NOA was 1.9 pre-ACM and 0.6 post-ACM, with mean reduction in NOA of 1.3 (P <0.01). The mean LOS was 72.2 days pre-ACM and 17.1 days post ACM, mean reduction in LOS 55.1 days (P <0.01). In addition, it was found that gender, diagnoses and ethnicity were not predictive of the outcome measures of NOA or LOS. ACM in Singapore had been well established since its inception and continued to show effectiveness in reducing inpatient hospitalisation among the chronically mentally ill.

Smoke-free Legislation and Hospitalizations for Acute Coronary Syndrome

Previous studies have suggested a reduction in the total number of hospital admissions for acute coronary syndrome after the enactment of legislation banning smoking in public places. However, it is unknown whether the reduction in admissions involved nonsmokers, smokers, or both. Since the end of March 2006, smoking has been prohibited by law in all enclosed public places throughout Scotland. We collected information prospectively on smoking status and exposure to secondhand smoke based on questionnaires and biochemical findings from all patients admitted with acute coronary syndrome to nine Scottish hospitals during the 10-month period preceding the passage of the legislation and during the same period the next year. These hospitals accounted for 64% of admissions for acute coronary syndrome in Scotland, which has a population of 5.1 million. Overall, the number of admissions for acute coronary syndrome decreased from 3235 to 2684--a 17% reduction (95% confidence interval, 16 to 18)--as compared with a 4% reduction in England (which has no such legislation) during the same period and a mean annual decrease of 3% (maximum decrease, 9%) in Scotland during the decade preceding the study. The reduction in the number of admissions was not due to an increase in the number of deaths of patients with acute coronary syndrome who were not admitted to the hospital; this latter number decreased by 6%. There was a 14% reduction in the number of admissions for acute coronary syndrome among smokers, a 19% reduction among former smokers, and a 21% reduction among persons who had never smoked. Persons who had never smoked reported a decrease in the weekly duration of exposure to secondhand smoke (P<0.001 by the chi-square test for trend) that was confirmed by a decrease in their geometric mean concentration of serum cotinine from 0.68 to 0.56 ng per milliliter (P<0.001 by the t-test). The number of admissions for acute coronary syndrome decreased after the implementation of smoke-free legislation. A total of 67% of the decrease involved nonsmokers. However, fewer admissions among smokers also contributed to the overall reduction.

Assertive Community Treatment (ACT) in Singapore: A 1-year Follow-up Study

Assertive Community Treatment (ACT) provides community-based treatment to patients with severe and persistent psychiatric illnesses, so that they may continue to live and function in the community as they receive psychiatric care. This study aimed to examine the effects of ACT on the outcome of patients over a 1-year period in an Asian population. This naturalistic and retrospective cohort study examined the effects of ACT on 100 patients who had completed 1 year of ACT. Parameters used to measure primary outcome were i) number of admissions (NOA) and ii) total length of stay (LOS) in days. Secondary outcome compared the employment status of patients before and after ACT. Paired sample analyses were performed using SPSS. The mean reduction in NOA 1 year post-ACT was 57.1%. The mean reduction in LOS 1 year post-ACT was 61.9%. The median reduction for NOA and LOS were both statistically significant (P <0.01). Thirty-seven patients were employed compared to 6 before the programme, a statistically significant effect on employment (odds ratio 9.69, P <0.01). ACT appears effective in reducing the frequency and duration of admissions for patients in Singapore. The employment status of patients also showed improvement over the course of study.

Electric Spinal Cord Stimulation (SCS) in the Treatment of Angina Pectoris: A Cost-Utility Analysis

For the last 15years electric spinal cord stimulation (SCS) has been employed in patients with confirmed ischemic heart disease who suffer from refractory angina pectoris despite maximum medical/surgical treatment. The purpose of this investigation was to assess not only the economic consequences of SCS treatment (cost-utility analysis) but also altered quality of life in SCS patients. The retrospective study includes 18 consecutive patients, six women and 12 men, with an average age of 56.5years (range 50-68), submitted to implantation of a SCS system at Odense University Hospital. Before implantation of the SCS system, the patients were in a transcutaneous electric nerve stimulation (TENS) treatment 2-11months. At the submission all patients were in New York Heart Association functional group III/IV. The results are based on cost data from the year prior to start of TENS treatment compared with the year after implantation of the SCS system. Medical records of the patients were examined and data concerning use of general practitioners and emergency services were collected from a nationwide database. Quality of life data were collected using identical questionnaires (perception of pain, mobility, function in daily life, and physical activity) related to the period immediately before start of the TENS treatment and one year after SCS implant. Savings were found at hospital level (reduction in number of admissions) and for non-hospital related expenses (such as medication and visits at general practitioners). In addition, improvements were registered in all respects which constituted assessment of the quality of life of the patients. The study is a repetition of a similar analysis with identical results made in 1990 and including the 16 first angina pectoris patients treated with SCS at Odense University Hospital. SCS is effective in reducing hospital and non-hospital related expenses and improving quality of life of the patients. SCS is a simple treatment for the patient to use. The implantation technique is not more invasive than permanent cardiac pacing. The decisive part of the procedure is the insertion of the electrode and follow-up with support and adjustments of the stimulation.

The cost-effectiveness of clozapine: a controlled, population-based, mirror-image study.

A retrospective cohort study, with a mirror-image design, was used to measure inpatient service utilization in 63 consecutive patients started on clozapine from a geographical catchment area compared to a control group matched for previous inpatient service use. An intent-to-treat analysis, including those patients (n = 28) who discontinued clozapine during the study period, showed a significant reduction in number of admissions and total time spent in hospital in the 2 years following clozapine initiation compared to the previous 2 years and to the follow-up period in the control group. This translated into a reduction of 7,300 pounds in hospitalization costs per patient started on clozapine, over the 2-year period. In those patients who continued clozapine treatment for the whole of the 2-year period, there was a two-thirds reduction in number of admissions and total time spent in hospital compared to no change in the clozapine discontinuers. These findings suggest that clozapine is a clinically and cost-effective intervention for severe schizophrenia in routine clinical settings.

THE WORK OF A REGIONAL HEAD INJURY SERVICE

A survey was done of the workload involved in conducting a programme in which all degrees of severity of head injury are managed in one unit staffed by neurosurgeons. Of 1919 patients admitted to the unit in 1981, 93 were classed as severe (in coma), 210 as moderate, and 1616 as minor (fully conscious or confused only) on admission. Although the proportion of intracranial haematomas, multiple injuries, life-threatening complications, and deaths was highest in severe cases, the work of looking after the very large numbers of moderate and minor cases was as great as that of looking after severe cases as defined by number of investigations, operations, and complications, morbidity, and duration of hospital stay. In 1982 the admission policy was changed so that temporary loss of consciousness was no longer an indication for admission. This change resulted in a 24% reduction in number of admissions. Seat-belt legislation, enacted early in 1983, was followed by a further 21% reduction in the admission rate and this was maintained in 1984. Not all of this latter reduction can, however, be attributed to the wearing of seat belts.