Risk Of Hospital Admission Research Articles

Risk of thrombotic events and other complications in anticoagulant users infected with SARS-CoV-2: an observational cohort study in primary health care in SIDIAP (Catalonia, Spain).

BackgroundThe risk of thromboembolic events and COVID-19 complications in anticoagulated patients once hospitalized has been widely analyzed. We aim to assess these outcomes in primary health care (PHC) patients chronically treated with oral anticoagulants (OAC) in comparison with non-treated.MethodsCohort study including adults with COVID-19 diagnosis in the PHC records in Catalonia, Spain; from March to June 2020. Patients were matched between exposed and non-exposed to OAC based on age and gender in a 1:2 design. Data source is the Information System for Research in Primary Care (SIDIAP).ResultsWe included 311,542 individuals with COVID-19. After propensity score matching, we obtained a cohort of 20,360 people, 10,180 exposed and 10,180 non-exposed to OAC. Their mean age was 79.9 and 52.1% were women. Patients exposed to OAC had a higher frequency of comorbidities than non-exposed. Anticoagulated patients had a higher risk of hospital admission (IRR 1.16, 95% CI 1.03–1.29), and of stroke and pulmonary embolism than non-anticoagulated (IRR 1,80, 95% CI 1.06–3.06). The risk of pneumonia was not different between groups (IRR 1.04, 95% CI 0.84–1.30). We found a lower risk of death in patients exposed to OAC (IRR 0.60, 95% CI 0.55–0.65).ConclusionsOAC users in our study had more comorbidities and were older than non-users, well known risks for hospitalization being confirmed with our results. We also found in our study that OAC exposure was not associated to an increased risk in the mortality rate, and it was associated with higher risks of hospital admission and thromboembolic events, although we cannot assess the effect of the interventions applied during hospital admission on the outcomes studied, as our database is a PHC database.Trial registrationEUPAS register: EUPAS37205.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12875-022-01752-5.

Lack of Access to Rifaximin Upon Hospital Discharge Is Frequent and Results in Increased Hospitalizations for Hepatic Encephalopathy.

Hepatic encephalopathy (HE) is a complication of cirrhosis. Rifaximin, added to lactulose, effectively maintains remission and reduces hospitalizations from HE compared with lactulose alone. Although the clinical evidence supports the use of rifaximin, concerns remain regarding the financial implications and subsequent impact on medication access and outcomes. The goal of this study was to determine whether medication access to rifaximin at hospital discharge reduces readmission and office visits related to HE. A retrospective study was conducted in compliance with local institutional review board including cirrhotic patients discharged with a rifaximin prescription for HE. Patients were stratified into 2 groups: those able to obtain rifaximin and those unable to obtain rifaximin upon discharge. The primary outcome was to evaluate the rate of HE recurrence in each group as defined as a composite of readmission or office visit for acute HE within 12 months of discharge. Access to rifaximin significantly reduced the risk of hospital admission and office visit for acute HE over 12 months. A hospitalization or office visit occurred in 24.5% of patients in the medication access group compared with 50% in the group without medication access. Only 58% of patients had access to rifaximin at discharge. Rifaximin use was associated with significantly reduced risk of hospitalization and office visits for HE. At discharge, 42% of patients did not have access to rifaximin regardless of being prescribed the medication, identifying that copay is a significant barrier in allowing patients to have access to rifaximin.

Complications and Healthcare Consumption of Pregnant Women with a Migrant Background: Could There be an Association with Psychological Distress?

ObjectivePrevious studies reported less prenatal healthcare consumption and more perinatal complications in women with a migrant background. Hence, we investigated in a country with free healthcare access whether women with a migrant background differed with respect to pregnancy complications, healthcare consumption and in terms of associations with psychological distress in comparison to native Dutch.MethodsWe included 324 native Dutch and 303 women with a migrant background, who visited two hospitals in Amsterdam for antenatal care between 2014 and 2015. Participants completed the Edinburgh Postnatal Depression Scale, the Hospital Depression and Anxiety Scale, and sociodemographic questions. Complications and healthcare consumption during pregnancy were extracted from medical records. Regression analyses were used with adjustment for covariates.ResultsExcept for gestational diabetes [adjusted OR = 3.09; 95% CI = (1.51, 6.32)], no differences were found between groups in perinatal complications [OR = 1.15; 95% CI = (0.80, 1.64)], nor in healthcare consumption [OR = 0.87; 95% CI = (0.63, 1.19)].Women with a migrant background reported more depressive symptoms [Cohen’s d = 0.25; 95% CI = (0.10, 0.41)], even after adjustment for socio-economic factors. Psychological distress was associated with more hospital admissions during pregnancy. When experiencing depressive symptoms, women with a migrant background had an increased risk to be admitted [OR = 1.11; 95% CI = (1.01, 1.21)].Conclusions for PracticeThis cohort study found no differences in pregnancy-related complications, except for diabetes, nor different healthcare consumption, in women with a migrant background versus native Dutch, in a country with free health care access. However, women with a migrant background experienced more depressive symptoms, and when depressed their risk for hospital admission increased. Additional research is warranted to improve healthcare for this population.

Associations between cold spells and hospital admission and mortality due to diabetes: A nationwide multi-region time-series study in Korea

BackgroundClimate change is predicted to increase the frequency, intensity, and duration of extreme cold events in the mid-latitudes. However, although diabetes is one of the most critical metabolic diseases due to its high and increasing prevalence worldwide, few studies have investigated the short-term association between cold exposure and diabetes-related outcomes. ObjectiveThe aim of this study was to investigate the associations between cold spells and their characteristics (intensity, duration, and seasonal timing) and hospital admission and mortality due to diabetes. MethodsThis study used claims data from the National Health Insurance Service and cause-specific mortality data from Statistics Korea (2010–2019). Cold spells were defined as ≥2 consecutive days with a daily mean temperature lower than the region-specific 5th percentile during the cold season (November–March). Quasi-Poisson regressions combined with distributed lag models were used to assess the associations between exposures and outcomes in 16 regions across the Republic of Korea. Meta-analyses were conducted to pool the region-specific estimates. ResultsExposure to cold spells was associated with an increased risk of hospital admission [relative risk (RR) = 1.45, 95% confidence interval (CI): 1.26, 1.66] and mortality (RR = 2.02, 95% CI: 1.37, 2.99) due to diabetes. The association between cold spells and hospital admission due to diabetes was stronger for cold spells that were more intense, longer, and occurred later during the cold season. The association between cold spells and diabetes-related mortality was stronger for more intense and longer cold spells. ConclusionThis study emphasizes the importance of developing effective interventions against cold spells, including education on the dangers of cold spells and early alarm systems. Further studies are needed to create real-world interventions and evaluate their effectiveness in improving diabetes-related outcomes.

Impact of depression among adolescents and young adults with cancer.

6549 Background: The incidence of adolescent and young adults (AYAs) with cancer continues to increase. The psychosocial burden of early cancer diagnosis within this unique AYA population remains poorly characterized. Without proper resources, these patients are likely to seek care in the acute care setting. For AYA patients, we evaluated the impact of malignancy on concurrent diagnosis with depression and on presenting to the emergency department (ED) with intentional self-injury. We further described the influence of concurrent depression diagnosis on hospital admission and extended length of stay (LOS) for AYA cancer patients. Methods: From the National Emergency Department Sample (NEDS), we identified patients between 15-39 years who presented to an ED in 2019. Diagnosis of cancer and depression were identified using International Classification of Diseases, 10th Revision coding. Separate multivariable logistic regressions evaluated the impact of cancer diagnosis on concurrent depression diagnosis and on presenting with intentional self-injury. For the subset of AYA cancer patients, multivariable logistic regressions evaluated the impact of depression on hospital admission and extended LOS ( > 14 days). Results: We identified 10,570,148 AYA patients, and 35,035 had cancer (0.33%). Among AYA cancer patients, average age was 31 and the cohort skewed White (48.7%), female (58.1%), and with Medicaid insurance (48.4%). The prevalence of depression among AYA cancer patients was 9.6% vs. 4.4% for patients without cancer. On multivariable regression, AYA cancer patients had a 46% increased odds of depression diagnosis (odds ratio (OR), 95% confidence interval (CI): 1.46. [1.43-1.49] P < 0.01) and 32% increased odds of intentional self-injury (OR, 95% CI: 1.32 [1.19-1.47] P < 0.01) when compared to patients without cancer. Additional significant factors associated with depression diagnosis among AYA cancer patients were White race, female gender, and Medicaid insurance. Within AYA cancer patients, a concurrent diagnosis with depression was associated with ̃3-fold increased odds of hospital admission (OR, 95% CI: 3.02 [2.90-3.14] P < 0.01) and a 31% increased odds of extended LOS (OR, 95% CI: 1.31 [1.23-1.39] P < 0.01). Conclusions: From this national sample, we found a significant association between cancer diagnosis and depression within AYA patients, with cancer diagnosis also increasing the risk of intentional self-injury. Furthermore, AYA cancer patients diagnosed with depression had increased risk of both hospital admission and extended LOS. Our results underscore the potential gap in psychological care for AYA cancer patients and highlight the need for stronger mental health resources for this at-risk population.

Diagnosis of malnutrition according to glim criteria predicts complications and six-month survival in cancer outpatients.

e24093 Background: Malnutrition is a condition with great impact in oncology patients. Poor nutritional status is often associated with increased morbidity and mortality, increased toxicity and reduced tolerance to chemotherapy, among other complications. The recent GLIM criteria for malnutrition aim to homogenize its diagnosis, considering the baseline disease status. Due to the few studies that assess the predictive capacity of these new criteria, we aimed to evaluate their performance for the prediction of complications and mortality in patients with cancer. Methods: Prospective, single-centre study. All outpatients under active treatment for head and neck, upper gastrointestinal and colorectal tumors between February and October 2020 were recruited. These patients were followed up for 6 months, assessing the occurrence of complications and survival, based on GLIM diagnosis of malnutrition. Results: We enrolled 165 outpatients 46.66% malnutrition. During 6-month follow-up, patients with malnutrition (46.7%, according to GLIM criteria) had an ̃3-fold increased risk of hospital admission (p < 0.001) and the occurrence of severe infections (considered as such those requiring hospitalization, intravenous antibiotics and/or drainage by interventional procedure) during follow-up (p = 0.002). Similarly, malnourished patients had a 3.5-fold increased risk of poor pain control and a 4.4-fold increased need for a higher dose of opioids (both p < 0.001). They also had a 2.6-fold increased risk of toxicity (p = 0.044) and a 2.5-fold increased likelihood of needing a dose decrease or discontinuation of cancer treatment (p = 0.011). 6-month survival of malnourished patients was significantly lower (p = 0.023) than non-malnourished patients. Conclusions: Diagnosis of malnutrition according to GLIM criteria in oncology patients on active treatment predicts increased complications and worse survival at 6-month follow-up, making them a useful tool to assess the nutritional status of oncology patients.[Table: see text]

Factors Associated with Acute Hospitalizations and Mortality of Older Adults in Long-Term Care Facilities and Long-Term Care Hospitals: A Population-Based, Pubic-Insurance Big-Data Analysis

Purpose: This study examined individual, institutional, and regional factors associated with 90-day acute hospitalizations and 1-year mortality among older people admitted to long-term care facilities (LTCFs) and long-term care hospitals (LTCH) in Korea.Methods: We analyzed the National Health Insurance Services (NHIS) Elderly Cohort Database linked with regional statistics. The sample included 13,839 LTCF residents and 23,962 LTCH patients. Multi-level logistic regression analyses were conducted.Results: The risk for 90-day acute hospital admission was positively associated with being male and having comorbidities among both LTCF residents and LTCH patients. Being 80+ years old and having a severe case-mix (LTCF grade 1/LTCH groups A1 & 2) were positively associated with acute hospitalizations among LTCF residents, but the relationships were negative among LTCH patients. People in urban LTCFs and/or those in facilities located in regions with a higher physician supply had lower acute hospitalizations. The risk for 1-year mortality after LTCF or LTCH admission was positively associated with being an old male, having a severe case-mix, and comorbidities. Among institutional factors, public ownership for LTCFs and being a larger size for LTCHs were negatively associated with mortality.Conclusion: This health and long-term care big data analysis showed various factors influenced adverse health outcomes among older Koreans receiving institutionalized long-term care, and the patterns of the relationships were different for LTCFs and LTCHs. Further investigations are needed into the mechanisms underlying the complex dynamics among the multi-level determinants of acute care utilization and mortality by institution type.

Covid-19, Clinical Manifestations in Pregnant Women, Aftermaths on Timing and Mode of Delivery at Hail, Saudi Arabia

Objectives: The study was performed to identify the clinical manifestation of Covid-19 infection during pregnancy its impact on the pregnancy outcomes, and its presentation in completely/incompletely vaccinated women. Material and Methods: We conducted this cross-sectional study at Ha`il, a northern city in Saudi Arabia, starting from 15th Dec. 2021 till 15th Jan. 2022. The mean differences of background variables were computed by using the Independent-Sample t-test. A Chi-square test was applied to assess the presentation of the disease in pregnant/non–pregnant and vaccinated/ non-vaccinated women. P-value <0.05 was taken as statistically significant. Results: Fatigue followed by fever and cough (65, 42, and 38% respectively) were the most common presentations of infection during pregnancy. Hospitalization (15.4%) and ICU (9.4%) admissions were more in pregnant than in non-pregnant women. Clinical manifestations were the same in the completely and incompletely vaccinated women. The incompletely vaccinated women were at increased risk of hospitalization (p-value 0.01), and pneumonia (p-value 0.05). The covid-19 infection has no significant association with age of the participants, body mass index, and parity. Covid-positive women during pregnancy underwent fewer cesarean- sections than Covid negative (20% vs. 80%, p <0.05). The mean gestational age at delivery, preterm birth, and neonatal weight at birth were the same in both groups. The rate of transmission of the infection to the neonates remained extremely low. Conclusion: Covid disease during pregnancy doesn’t increase the risk of preterm birth, cesarean delivery, or low birth weight of the babies. Complete vaccination against tcovid-19 declines the risk of hospital admission for severe disease and pneumonia in women.

253 Economic burden of care and treatment options for Rett syndrome: two systematic literature reviews

Rett syndrome, a rare disorder caused by MECP2 mutation, causes severe developmental impairment in afflicted girls. We performed two literature reviews in June 2018 to assess Rett syndrome clinical trials (MEDLINE/Embase/ClinicalTrials.gov/Cochrane Library) and the economic burden of care (Medline/Embase/Cochrane Library/Database of Abstracts of Reviews and Effects). The economic burden search yielded 133 articles; intervention type/costs were extracted from 9, representing 4 studies. Enteral feeding/assisted walking increased the risk of respiratory-related hospital admissions, while length-of-stay was lower in younger patients. Mean recovery-stay after scoliosis-correcting surgery was 18.2/12.3 days in each of two studies. Care integration improved outcomes and reduced costs. The clinical trials search yielded 652 articles; efficacy/safety were extracted from 28, representing 20 studies (15 randomized controlled trials, 5 single-arm; N=8–82; follow-up 1–26 months). Nineteen focused on pharmacological symptom treatment; 1 examined environmental enrichment effects; most common primary endpoints: Rett syndrome Gross Motor Scale, Clinical Severity Score, Motor and Behavioral Assessment, and the Anxiety Depression and Mood Scale. Naltrexone, trofinetide, and mecasermin demonstrated clinical benefits, but most treat- ments yielded no significant improvement. Clinical practice guidelines and treatment patterns data were limited. There is demand for treatments targeting the underlying cause, such as gene therapy. Previously presented after 08/2019.jloukes879@avexis.com158

The effect of COVID-19 on routine diabetes care and mortality in people with diabetes

The effect of COVID-19 on routine diabetes care and mortality in people with diabetes

Role of tobacco in pandemic COVID-19 in India

Since the end of 2019, the world has witnessed the spread of a COVID-19, that affects the respiratory system of the body in the form of the novel coronavirus. This pandemic has affected people across all socioeconomic demographics and cultures in high-, middle- and low- income countries. Tobacco is also a major risk factor for many diseases like cardiovascular disease, cancer, respiratory disease and diabetes which put people with these conditions at higher risk for developing severe illness when affected by COVID-19. Minimizing the use of tobacco and smoking might be an important factor for containing COVID-19 infection. On the other side, studies also suggest also that smoking is associated with a decreased risk of hospital admission with a diagnosis of COVID-19, or a decreased risk of occurrence of the disease in the community. These studies have noted 4 to 5 times lower proportions of smokers among patients hospitalized for COVID-19 compared with the underlying source population. A metanalysis of hospital case series confirmed this gap.

Effects of Vitamin D Supplementation on COVID-19 Related Outcomes: A Systematic Review and Meta-Analysis.

The COVID-19 outbreak has rapidly expanded to a global pandemic; however, our knowledge is limited with regards to the protective factors against this infection. The aim of this systematic literature review and meta-analysis was to evaluate the impact of vitamin D supplementation on COVID-19 related outcomes. A systematic search of relevant papers published until January 2022 was conducted to identify randomized controlled trials (RCTs) and non-randomized studies of intervention (NRISs). The primary outcomes included the risk of COVID-19 infection (primary prevention studies on uninfected individuals), hospital admission (secondary prevention studies on mild COVID-19 cases), and ICU admission and mortality rate (tertiary prevention studies on hospitalized COVID-19 patients). We identified five studies (one RCT, four NRISs) on primary prevention, with five (two RCTs, three NRISs) on secondary prevention, and 13 (six RCTs, seven NRISs) on tertiary prevention. Pooled analysis showed no significant effect on the risk of COVID-19 infection. No meta-analysis was possible on hospitalization risk due to paucity of data. Vitamin D supplementation was significantly associated with a reduced risk of ICU admission (RR = 0.35, 95% CI: 0.20, 0.62) and mortality (RR = 0.46, 95% CI: 0.30, 0.70). Vitamin D supplementation had no significant impact on the risk of COVID-19 infection, whereas it showed protective effects against mortality and ICU admission in COVID-19 patients.

Pure and impure tachycardiomiopathy: key differences and long term prognosis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Tachycardiomioathy (TCM) is a reversible cause of left ventricular (LV) dysfunction, secondary to both atrial and ventricular arrhythmias as well as high burden of ectopic beats. Almost 10% of all hospitalizations for acute heart failure (HF) meet the criteria for TCM. TCM is known to frequently recur and therefore cardiovascular related hospitalizations are often needed. While this is true in pure TCM, long term prognosis of impure TCM is still unknown. Purpose To compare long term prognosis of pure TCM to that of impure TCM in terms of survival rate, time free of recurrence and time free of hospitalizations. Methods Prospective, observational study enrolling all consecutive patients admitted for de novo acute heart failure, with a confirmed diagnosis of TCM, which was suspected in all patients admitted for heart failure (HF) with a LV ejection fraction <50% and concomitant persistent atrial or ventricular arrhythmia, and confirmed after clinical and echocardiographic recovery. Pure tachycardiomiopathy was defined as an arrhythmia-induced LV dysfunction in an otherwise healthy heart. Impure tachycardiomiopathy was defined as an arrhythmia-mediated TCM, where the arrhythmia may exacerbate an underlying condition and facilitate LV dysfunction. Results Population included 123 patients with pure TCM and 40 patients with impure TCM. Patients with pure TCM were significantly younger (68±13 vs. 74±10 years; p=0.008) but a with similar risk factor profile and the same prevalence of male gender (63% vs 72%; p=ns). Similarly, echo characteristics did not significantly differ between the two groups, while pure TCM presented a higher HR at admission (124±28 vs. 106±28 bpm; p=0.001) but not at discharge (70±15 vs. 71±14 bpm; p=ns). Pure and impure TCM had similar EF on admission (33±9 vs. 34±7%; p=ns) and time to recovery after the acute event (4.9±0.6 vs. 4.4±1.4 months; p=ns). Pure TCM were more often treated in the acute phase with a rhythm control strategy (81% vs. 67%; p=0.001), mainly electric cardioversion followed by anti-arrhythmic drugs (80% vs. 46%; p<0.001) and AF ablation (16% vs. 3%; p=0.025). Kaplan Meier curves showed that pure TCM present a lower incidence of recurrence (26% vs. 50%; p=0.05; Figure 1) over a 40-month median follow-up. Cumulative incidences of death (24% vs. 30%; p=ns; Figure 2) and thromboembolism (3% vs. 3%; p=ns) were similar between the two groups over the same period. All-cause hospitalizations were similar between the two groups (62% vs. 67%; p=ns) with the impure TCMs experiencing more unplanned hospitalizations for HF recurrences. Conclusions While pure and impure TCM patients differs in terms of baseline characteristics, they present similar risk of death, thromboembolic events, and hospital admission during a long-term follow-up. Treatment strategy of pure TCM is more often rhythm-oriented and this could explain the lower incidence of HF recurrence.

Assessment of mortality and hospital admissions associated with confirmed infection with SARS-CoV-2 Alpha variant: a matched cohort and time-to-event analysis, England, October to December 2020.

BackgroundThe emergence of the SARS-CoV-2 Alpha variant in England coincided with a rapid increase in the number of PCR-confirmed COVID-19 cases in areas where the variant was concentrated.AimOur aim was to assess whether infection with Alpha was associated with more severe clinical outcomes than the wild type.MethodsLaboratory-confirmed infections with genomically sequenced SARS-CoV-2 Alpha and wild type between October and December 2020 were linked to routine healthcare and surveillance datasets. We conducted two statistical analyses to compare the risk of hospital admission and death within 28 days of testing between Alpha and wild-type infections: a matched cohort study and an adjusted Cox proportional hazards model. We assessed differences in disease severity by comparing hospital admission and mortality, including length of hospitalisation and time to death.ResultsOf 63,609 COVID-19 cases sequenced in England between October and December 2020, 6,038 had the Alpha variant. In the matched cohort analysis, we matched 2,821 cases with Alpha to 2,821 to cases with wild type. In the time-to-event analysis, we observed a 34% increased risk in hospitalisation associated with Alpha compared with wild type, but no significant difference in the risk of mortality.ConclusionWe found evidence of increased risk of hospitalisation after adjusting for key confounders, suggesting increased infection severity associated with the Alpha variant. Rapid assessments of the relative morbidity in terms of clinical outcomes and mortality associated with emerging SARS-CoV-2 variants compared with dominant variants are required to assess overall impact of SARS-CoV-2 mutations.

Development and Validation of a New Screening Tool with Non-Invasive Indicators for Assessment of Malnutrition Risk in Hospitalised Children.

There is no evidence of the most effective nutritional screening tool for hospitalized children. The present study aimed to develop a quick, simple, and valid screening tool for identifying malnutrition risk of hospital admission with non-invasive indicators. A cross-sectional study was conducted. Children`s nutritional baseline using a questionnaire, subjective malnutritional risk, and Subjective Global Nutritional Assessment were assessed on admission. Concurrent validity was assessed using American Society for Parenteral and Enteral Nutrition (ASPEN)and Academy of Nutrition and Dietetics assessment and Subjective Global Nutritional Assessment tool. A new screening tool Simple Pediatric Nutritional risk Screening tool (SPENS) was developed, and sensitivity, specificity and reliability were evaluated. A total of 180 children aged from 1 month to 18 years were included (142 in the development phase and 38 in the validation phase). SPENS consist of four variables and shows almost perfect agreement with subjective malnutritional risk assessment (κ = 0.837) with high sensitivity and specificity (93.3% and 91.3% respectively). Compared with Subjective Global Nutritional Assessment and ASPEN and Academy of Nutrition and Dietetics assessment, SPENS had sensitivity 92.9% and 86.7%, a specificity of 87.5% and 87.0%, and an overall agreement of 0.78 and 0.728, respectively. Due to the fast, simple, easy, and practical to use, screening the SPENS can be performed by nurses, physicians, and dieticians.

Air Pollution and Respiratory Hospital Admissions in Kuwait: The Epidemiological Applicability of Predicted PM2.5 in Arid Regions.

Dust is a major component of fine particulate matter (PM2.5) in arid regions; therefore, concentrations of this pollutant in countries such as Kuwait exceed air quality standards. There is limited understanding on the impact and burden of high PM2.5 concentrations on morbidity in these countries. In this study, we explore the association of PM2.5 and the risk of respiratory hospital admissions in Kuwait. A time-series regression model was used to investigate daily variations in respiratory admissions and PM2.5 concentrations from 2010 to 2018. Due to the lack of historical air quality sampling in Kuwait, we used estimated daily PM2.5 levels from a hybrid PM2.5 prediction model. Individual and cumulative lag effects of PM2.5 over a 5-day period were estimated using distributed lag linear models. Associations were stratified by sex, age, and nationality. There were 218,749 total respiratory admissions in Kuwait during the study period. Results indicate that for every 10 μg/m3 increase in PM2.5, a 1.61% (95% CI = 0.87, 2.35%) increase in respiratory admissions followed over a 5-day cumulative lag. Our estimates show that a 10 μg/m3 reduction in average exposure will potentially avert 391 yearly respiratory admissions (95% CI = 211,571), with 265 fewer admissions among Kuwaitis (95% CI = 139,393) and 262 fewer admissions among children under 15 years of age (95% CI = 125,351). Different strata of the Kuwaiti population are vulnerable to respiratory hospitalization with short-term exposure to PM2.5, especially those under 15 years of age. The findings are informative for public health authorities in Kuwait and other dust-prone countries.

Ambient Air Pollution and Risk of Admission Due to Asthma in the Three Largest Urban Agglomerations in Poland: A Time-Stratified, Case-Crossover Study.

Ambient air pollution in urban areas may trigger asthma exacerbations. We carried out a time-series analysis of the association between the concentrations of various air pollutants and the risk of hospital admission due to asthma over 7 days from exposure. We used distributed lag nonlinear models to analyze data gathered between 2010 and 2018 in the three largest urban agglomerations in Poland. Overall, there were 31,919 asthma hospitalizations. Over 7 days since exposure, the rate ratio (95%CI) for admission per 10 µg/m3 was 1.013 (1.002–1.024) for PM10; 1.014 (1.000–1.028) for PM2.5; 1.054 (1.031–1.078) for NO2; and 1.044 for SO2 (95%CI: 0.986–1.104). For all pollutants, the risk of admission was the greatest on the day of exposure (day 0), decreased below baseline on days 1 and 2, and then increased gradually up to day 6. The proportions (95%CI) of hospitalizations attributable to air pollution were 4.52% (0.80%–8.14%) for PM10; 3.74% (0.29%–7.11%) for PM2.5; 16.4% (10.0%–21.8%) for NO2; and 2.50% (−0.75%–5.36%) for SO2. In conclusion, PM2.5, PM10, NO2, and SO2 pollution was associated with an increased risk of hospital admission due to asthma in the three largest urban agglomerations in Poland over nine years.

An objective framework for evaluating unrecognized bias in medical AI models predicting COVID-19 outcomes.

ObjectiveThe increasing translation of artificial intelligence (AI)/machine learning (ML) models into clinical practice brings an increased risk of direct harm from modeling bias; however, bias remains incompletely measured in many medical AI applications. This article aims to provide a framework for objective evaluation of medical AI from multiple aspects, focusing on binary classification models.Materials and MethodsUsing data from over 56 000 Mass General Brigham (MGB) patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), we evaluate unrecognized bias in 4 AI models developed during the early months of the pandemic in Boston, Massachusetts that predict risks of hospital admission, ICU admission, mechanical ventilation, and death after a SARS-CoV-2 infection purely based on their pre-infection longitudinal medical records. Models were evaluated both retrospectively and prospectively using model-level metrics of discrimination, accuracy, and reliability, and a novel individual-level metric for error.ResultsWe found inconsistent instances of model-level bias in the prediction models. From an individual-level aspect, however, we found most all models performing with slightly higher error rates for older patients.DiscussionWhile a model can be biased against certain protected groups (ie, perform worse) in certain tasks, it can be at the same time biased towards another protected group (ie, perform better). As such, current bias evaluation studies may lack a full depiction of the variable effects of a model on its subpopulations.ConclusionOnly a holistic evaluation, a diligent search for unrecognized bias, can provide enough information for an unbiased judgment of AI bias that can invigorate follow-up investigations on identifying the underlying roots of bias and ultimately make a change.

“Emergency Room Evaluation and Recommendations” and Incident Hospital Admissions in Older People with Major Neurocognitive Disorders Visiting Emergency Department: Results of an Experimental Study

Introduction: Older people with major neurocognitive disorders (MNCDs) visiting the emergency department (ED) are at high risk of hospital admissions. The “Emergency Room Evaluation and Recommendations” (ER²) tool decreases the length of stay (LOS) in the hospital when older people visiting ED are hospitalized after an index ED visit, regardless of their cognitive status. Its effect on hospital admissions has not yet been examined in older people with MNCD visiting ED. This study aimed to examine whether ER² recommendations were associated with incident hospital admissions and LOS in ED in older people with MNCD visiting ED. Methods: A total of 356 older people with MNCD visiting ED of the Jewish General Hospital (Montreal, Quebec, Canada) were recruited in this non-randomized, pre-post-intervention, single arm, prospective and longitudinal open label trial. ED staff and patients were blinded of the ER² score, and patients received usual ED care during the observation period, whereas ED staff were informed about the ER² score, and patients had ER² tailor-made recommendations in addition to usual care during the intervention period. Hospital admissions and the LOS in ED were the outcomes. Results: There were less incident hospital admissions (odds ratio ≤ 0.61 with p ≤ 0.022) and longer LOS in ED (coefficient beta ≥4.28 with p ≤ 0.008) during the intervention period compared to the observation period. Discussion/Conclusion: ER² recommendations have mixed effects in people with MNCD visiting ED. They were associated with reduced incident hospital admissions and increased LOS in ED, suggesting that they may have benefits in addition to usual ED care.

Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people.

Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological and functional capability in order to develop a co-ordinated and integrated care plan. CGA is not limited simply to assessment, but also directs a holistic management plan for older people, which leads to tangible interventions. While there is established evidence that CGA reduces the likelihood of death and disability in acutely unwell older people, the effectiveness of CGA for community-dwelling, frail, older people at risk of poor health outcomes is less clear. To determine the effectiveness of CGA for community-dwelling, frail, older adults at risk of poor health outcomes in terms of mortality, nursing home admission, hospital admission, emergency department visits, serious adverse events, functional status, quality of life and resource use, when compared to usual care. We searched CENTRAL, MEDLINE, Embase, CINAHL, three trials registers (WHO ICTRP, ClinicalTrials.gov and McMaster Aging Portal) and grey literature up to April 2020; we also checked reference lists and contacted study authors. We included randomised trials that compared CGA for community-dwelling, frail, older people at risk of poor healthcare outcomes to usual care in the community. Older people were defined as 'at risk' either by being frail or having another risk factor associated with poor health outcomes. Frailty was defined as a vulnerability to sudden health state changes triggered by relatively minor stressor events, placing the individual at risk of poor health outcomes, and was measured using objective screening tools. Primary outcomes of interest were death, nursing home admission, unplanned hospital admission, emergency department visits and serious adverse events. CGA was delivered by a team with specific gerontological training/expertise in the participant's home (domiciliary Comprehensive Geriatric Assessment (dCGA)) or other sites such as a general practice or community clinic (community Comprehensive Geriatric Assessment (cCGA)). Two review authors independently extracted study characteristics (methods, participants, intervention, outcomes, notes) using standardised data collection forms adapted from the Cochrane Effective Practice and Organisation of Care (EPOC) data collection form. Two review authors independently assessed the risk of bias for each included study and used the GRADE approach to assess the certainty of evidence for outcomes of interest. We included 21 studies involving 7893 participants across 10 countries and four continents. Regarding selection bias, 12/21 studies used random sequence generation, while 9/21 used allocation concealment. In terms of performance bias, none of the studies were able to blind participants and personnel due to the nature of the intervention, while 14/21 had a blinded outcome assessment. Eighteen studies were at low risk of attrition bias, and risk of reporting bias was low in 7/21 studies. Fourteen studies were at low risk of bias in terms of differences of baseline characteristics. Three studies were at low risk of bias across all domains (accepting that it was not possible to blind participants and personnel to the intervention). CGA probably leads to little or no difference in mortality during a median follow-up of 12 months (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.76 to 1.02; 18 studies, 7151 participants (adjusted for clustering); moderate-certainty evidence). CGA results in little or no difference in nursing home admissions during a median follow-up of 12 months (RR 0.93, 95% CI 0.76 to 1.14; 13 studies, 4206 participants (adjusted for clustering); high-certainty evidence). CGA may decrease the risk of unplanned hospital admissions during a median follow-up of 14 months (RR 0.83, 95% CI 0.70 to 0.99; 6 studies, 1716 participants (adjusted for clustering); low-certainty evidence). The effect of CGA on emergency department visits is uncertain and evidence was very low certainty (RR 0.65, 95% CI 0.26 to 1.59; 3 studies, 873 participants (adjusted for clustering)). Only two studies (1380 participants; adjusted for clustering) reported serious adverse events (falls) with no impact on the risk; however, evidence was very low certainty (RR 0.82, 95% CI 0.58 to 1.17). CGA had no impact on death or nursing home admission. There is low-certainty evidence that community-dwelling, frail, older people who undergo CGA may have a reduced risk of unplanned hospital admission. Further studies examining the effect of CGA on emergency department visits and change in function and quality of life using standardised assessments are required.