Swiss University Hospital Research Articles

Coronary artery disease screening in diabetic patients: how good is guideline adherence?

Diabetic patients are at high risk for coronary artery disease (CAD), which is the leading cause of death in this population. The Swiss Society of Endocrinology-Diabetology (SSED) recommends CAD screening for diabetic patients with > or = 2 additional cardiovascular risk factors (CVRF), by stress echocardiography (SE) or myocardial perfusion imaging (MPI). The aim of this study was to assess the application of these guidelines and the treatment of CVRF in the diabetes outpatient clinics of the five Swiss University Hospitals. The study was initiated in Lausanne and the study questionnaires were circulated to the endocrinologists of the five Swiss University Hospitals. Practitioners were asked to include consecutive patients attending the diabetes outpatient clinics over one month. Prevalence of CAD, screening methods for CAD, prevalence of CVRF, biological analyses over the last 6 months and medical therapy were recorded. A total of 302 subjects were included. The mean age was 53 +/- 14 years, 68% had type 2 diabetes, 27% type 1 and 5% other types. Among T2DM with > or = 2 CVRF, 45% were screened for CAD according to SSED guidelines. In T2DM 25% had blood pressure < or = 130/80 mm Hg, 15% a lipid profile within target, 23% HbA1c < or = 7.0%. Overall, 2% achieved all 3 targets. Only 45% of T2DM with > or = 2 CVRF were screened for CAD according to SSED guidelines and 2% of T2DM had proper control over all CVRF. Efforts are still necessary to improve CAD prevention and screening of diabetic patients in Swiss University Hospitals.

Empirical use of antibiotics and adjustment of empirical antibiotic therapies in a university hospital: a prospective observational study

BackgroundSeveral strategies to optimise the use of antibiotics have been developed. Most of these interventions can be classified as educational or restrictive. Restrictive measures are considered to be more effective, but the enforcement of these measures may be difficult and lead to conflicts with prescribers. Any intervention should be aimed at targets with the highest impact on antibiotic prescribing. The aim of the present study was to assess the adequacy of empirical and adjusted antibiotic therapies in a Swiss university hospital where no antibiotic use restrictions are enforced, and to identify risk factors for inadequate treatment and targets for intervention.MethodsA prospective observational study was performed during 9 months. All patients admitted through the emergency department who received an antibiotic therapy within 24 hours of admission were included. Data on demographic characteristics, diagnoses, comorbidities, systemic inflammatory response syndrome (SIRS) parameters, microbiological tests, and administered antibiotics were collected prospectively. Antibiotic therapy was considered adequate if spectrum, dose, application modus, and duration of therapy were appropriate according to local recommendations or published guidelines.Results2943 admitted patients were evaluated. Of these, 572 (19.4%) received antibiotics within 24 hours and 539 (94%) were analysed in detail. Empirical antibiotic therapy was inadequate in 121 patients (22%). Initial therapy was adjusted in 168 patients (31%). This adjusted antibiotic therapy was inadequate in 46 patients (27%). The main reason for inadequacy was the use of antibiotics with unnecessarily broad spectrum (24% of inadequate empirical, and 52% of inadequate adjusted therapies). In 26% of patients with inadequate adjusted therapy, antibiotics used were either ineffective against isolated pathogenic bacteria or antibiotic therapy was continued despite negative results of microbiological investigations.ConclusionThe rate of inadequate antibiotic therapies was similar to the rates reported from other institutions despite the absence of a restrictive antibiotic policy. Surprisingly, adjusted antibiotic therapies were more frequently inappropriate than empirical therapies. Interventions aiming at improving antibiotic prescribing should focus on both initial empirical therapy and streamlining and adjustment of therapy once microbiological results become available.

P1711 Reduction of healthcare-associated infection rates in a Swiss university hospital following hand hygiene promotion

P1711 Reduction of healthcare-associated infection rates in a Swiss university hospital following hand hygiene promotion

P2006 The use of QuantiFERON-TB Gold In-Tube to screen for tuberculosis infection in employees of a Swiss university hospital

P2006 The use of QuantiFERON-TB Gold In-Tube to screen for tuberculosis infection in employees of a Swiss university hospital

P1027 Plasmid-mediated AmpC β-lactamases in Enterobacteri-aceae lacking a chromosomal ampC gene and E. coli: prevalence at a Swiss university hospital and distribution of the different molecular types in the northern part of Switzerland

P1027 Plasmid-mediated AmpC β-lactamases in Enterobacteri-aceae lacking a chromosomal ampC gene and E. coli: prevalence at a Swiss university hospital and distribution of the different molecular types in the northern part of Switzerland

Gambling and suicidal behaviours: A Swiss study in a treatment center in Switzerland

Background and aim: Excessive gambling touch between 1 and 3% of the adult population (Shaffer et al. 1999). Studies of treatment-seeking gamblers establish a relationship between gambling and suicide. We investigated clinical characteristics in excessive gamblers of a Swiss University Hospital(CHUV). The aim of this study is to compare gamblers with prior suicide attempts (GPSA) with gamblers without prior suicide attempts (Non-GPSA) and with the international literature. Hypothesis: - GPSA are confronted with a higher problem load than Non-GPSA. - GPSA lack social networks and family support as compared to Non-GPSA. Method: Patients treated for gambling disorders typically show a high level of co-morbidity. Bourget, Data are based on medical files of our treatment center. Among our consecutively admitted patients (2002-2006), we identified pathological gamblers who reported prior suicide attempts directly or not directly linked with gambling. Results and discussion: - GPSA were more likely to be women, separated or divorced, referred by the forensic network. - GPSA were more likely to be disabled and had a history of alcohol abuse. GPSA showed no difference with respect to age at intake or employment status as compared to NON-GPSA. Discussion: Further research is needed to find out whether the higher proportion of women with prior suicide attempts is due to the fact that men are more likely to complete suicide.

Prevalence and associated factors of viral hepatitis and transferrin elevations in 5036 patients admitted to the emergency room of a Swiss university hospital: cross-sectional study

BackgroundThe epidemiology of liver disease in patients admitted to emergency rooms is largely unknown. The current study aimed to measure the prevalence of viral hepatitis B and C infection and pathological laboratory values of liver disease in such a population, and to study factors associated with these measurements.MethodsCross-sectional study in patients admitted to the emergency room of a university hospital. No formal exclusion criteria. Determination of anti-HBs, anti-HCV, transferrin saturation, alanine aminotransferase, and obtaining answers from a study-specific questionnaire.ResultsThe study included 5'036 patients, representing a 14.9% sample of the target population during the study period. Prevalence of anti-HBc and anti-HCV was 6.7% (95%CI 6.0% to 7.4%) and 2.7% (2.3% to 3.2%), respectively. Factors independently associated with positive anti-HBc were intravenous drug abuse (OR 18.3; 11.3 to 29.7), foreign country of birth (3.4; 2.6 to 4.4), non-white ethnicity (2.7; 1.9 to 3.8) and age ≥60 (2.0; 1.5 to 2.8). Positive anti-HCV was associated with intravenous drug abuse (78.9; 43.4 to 143.6), blood transfusion (1.7; 1.1 to 2.8) and abdominal pain (2.7; 1.5 to 4.8). 75% of all participants were not vaccinated against hepatitis B or did not know their vaccination status. Among anti-HCV positive patients only 49% knew about their infection and 51% reported regular alcohol consumption. Transferrin saturation was elevated in 3.3% and was associated with fatigue (prevalence ratio 1.9; 1.2 to 2.8).ConclusionEmergency rooms should be considered as targets for public health programs that encourage vaccination, patient education and screening of high-risk patients for liver disease with subsequent referral for treatment if indicated.

Bedürfnisse und Erwartungen von tamilischen Frauen in der Schwangerenvorsorge eines Schweizer Universitätsspitals

It has been noted that immigrant women often initiate prenatal care late in their pregnancy and thus may be inadequately prepared for their birth experience. This leads to poorer maternal outcomes and higher morbidity statistics compared to Swiss women. Tamil women of Sri Lanka represent the largest group of immigrant women being seen at the antenatal care clinic of a Swiss University Hospital. To get a deeper understanding of their needs and expectations relative to their antenatal care, a qualitative study was undertaken. Problem centred interviews were conducted with seven Tamil women before and after delivery. An interpreter was consulting. Data were analyzed using content analysis methods as described by Mayring. Four main themes emerged, demonstrating the need of the women and their resulting expectation: 1) to receive esteem--to show respect and attention; 2) to consult with somebody--to ensure communication; 3) to alleviate worries and fear--to give a sense of security and be in charge; and 4) to make up for lack of experience and knowledge--to pass on experience and knowledge. The quality of the relationships to caregivers is viewed as pivotal and seems to influence Tamil women's satisfaction and their motivation to receive prenatal care.

Pratique du scanner en Suisse : fréquence et évolution temporelle

Purpose This study analyzes CT examinations in Switzerland. Materials and methods Using different sources (administrative data on the equipment, a 1998 nationwide inquiry into practices, and data provided by the Swiss University Hospitals of Basel, Zurich, and Lausanne), we determined the frequency of CT examinations (hospitals and private radiologists) in 1998 according to different descriptive variables and studied the progression in CT use over time. Results CT scanners increased by 7% between 1998 and 2004. The average annual number of CT examinations in 1998 was 46.3/1000 population, 3.4% of all radiological examinations in Switzerland in 1997–1998. The most frequent examination was CT of the skull (24%), while private radiology institutes perform more CTs of the spine. More CT examinations were performed for men than for women (sex ratio M/F=1.17). The average annual increase in CT in Swiss hospitals varied from 8% for Basel to 18% for Lausanne. Finally, the proportion of pediatric examinations was 5%;their numbers appear to be stabilizing. Conclusion There is a significant increase in CT examinations. It is hoped that our study will heighten awareness among doctors of CT examinations in order to optimize their use.

Treatment options of invasive fungal infections in adults.

A panel of infectious disease specialists, clinical microbiologists and hospital epidemiologists of the five Swiss university hospitals reviewed the current literature on the treatment of invasive fungal infections in adults and formulated guidelines for the management of patients in Switzerland. For empirical therapy of Candida bloodstream infection, fluconazole is the drug of choice in non-neutropenic patients with no severe sepsis or septic shock or recent exposure to azoles. Amphotericin B deoxycholate or caspofungin would be the treatment option for patients with previous azole exposure. In neutropenic patients, empirical therapy with amphotericin B deoxycholate is considered first choice. In patients with severe sepsis and septic shock, caspofungin is the drug of first choice. For therapy of microbiologically-documented Candida infection, fluconazole is the drug of choice for infections due to C. albicans, C. tropicalis or C. parapsilosis. When infections are caused by C. glabrata or by C. krusei, caspofungin or amphotericin B deoxycholate are first line therapies. Treatment guidelines for invasive aspergillosis (IA) were stratified into primary therapy, salvage therapy and combination therapy in critically ill patients. Voriconazole is recommended for primary (ie upfront) therapy. Caspofungin, voriconazole (if not used for primary therapy) or liposomal amphotericin B are recommended for salvage therapy for refractory disease. Combination therapy with caspofungin plus voriconazole or liposomal amphotericin B should be considered in critically ill patients. Amphotericin B deoxycholate is recommended as initial therapy for the empirical therapy in patients with neutropenia and persistent fever with close monitoring of adverse events.

Treatment options of invasive fungal infections in adults.

A panel of infectious disease specialists, clinical microbiologists and hospital epidemiologists of the five Swiss university hospitals reviewed the current literature on the treatment of invasive fungal infections in adults and formulated guidelines for the management of patients in Switzerland. For empirical therapy of Candida bloodstream infection, fluconazole is the drug of choice in non-neutropenic patients with no severe sepsis or septic shock or recent exposure to azoles. Amphotericin B deoxycholate or caspofungin would be the treatment option for patients with previous azole exposure. In neutropenic patients, empirical therapy with amphotericin B deoxycholate is considered first choice. In patients with severe sepsis and septic shock, caspofungin is the drug of first choice. For therapy of microbiologically-documented Candida infection, fluconazole is the drug of choice for infections due to C. albicans, C. tropicalis or C. parapsilosis. When infections are caused by C. glabrata or by C. krusei, caspofungin or amphotericin B deoxycholate are first line therapies. Treatment guidelines for invasive aspergillosis (IA) were stratified into primary therapy, salvage therapy and combination therapy in critically ill patients. Voriconazole is recommended for primary (ie upfront) therapy. Caspofungin, voriconazole (if not used for primary therapy) or liposomal amphotericin B are recommended for salvage therapy for refractory disease. Combination therapy with caspofungin plus voriconazole or liposomal amphotericin B should be considered in critically ill patients. Amphotericin B deoxycholate is recommended as initial therapy for the empirical therapy in patients with neutropenia and persistent fever with close monitoring of adverse events.

Anemia and chronic kidney disease are associated with poor outcomes in heart failure patients.

BackgroundChronic kidney disease (CKD) has been linked to higher heart failure (HF) risk. Anemia is a common consequence of CKD, and recent evidence suggests that anemia is a risk factor for HF. The purpose of this study was to examine among patients with HF, the association between CKD, anemia and inhospital mortality and early readmission.MethodsWe performed a retrospective cohort study in two Swiss university hospitals. Subjects were selected based the presence of ICD-10 HF codes in 1999. We recorded demographic characteristics and risk factors for HF. CKD was defined as a serum creatinine ≥ 124 956;mol/L for women and ≥ 133 μmol/L for men. The main outcome measures were inhospital mortality and thirty-day readmissions.ResultsAmong 955 eligible patients hospitalized with heart failure, 23.0% had CKD. Twenty percent and 6.1% of individuals with and without CKD, respectively, died at the hospital (p < 0.0001). Overall, after adjustment for other patient factors, creatinine and hemoglobin were associated with an increased risk of death at the hospital, and hemoglobin was related to early readmission.ConclusionBoth CKD and anemia are frequent among older patients with heart failure and are predictors of adverse outcomes, independent of other known risk factors for heart failure.

Hospital patients' preferences for involvement in decision-making. A questionnaire survey of 1040 patients from a Swiss university hospital.

Assessing patients' preferences for shared decision-making and receiving information. Cross-sectional cohort study. University Hospital in Northwest Switzerland. 1825 in-patients (mean age: 58 years, 48.7% female) were asked to participate, 1040 patients responded (59%). Proportion of positive answers to two questions depicting typical elements of shared decision-making plus a question asking for patients' information needs. These questions were embedded in a questionnaire sent to patients two weeks after discharge from the hospital, asking for perceived deficits during their hospital stay and socio-demographic characteristics. 779/947 (79.1%) agreed to the statement: "One should stick to the physician's advice even if one is not fully convinced of his ideas". 620/945 (65.6%) agreed to the statement: "It should completely be left to physicians to decide on a patient's treatment." 914/952 (96%) agreed to the statement: "Even when the news is bad the patient must be informed." Older patients and less educated patients are more likely to agree with the first two statements, patients with a non-Swiss cultural background favour the information needs statement slightly less than other patients (92.4 vs 96.7% agreement). The severity of illness had no influence on agreeing or not. However, patients who disagreed on any statement were more likely to report a lack of information from the hospital. A substantial number of patients in this study wanted the physician to take medical decisions. Yet, almost all patients wanted honest information about their health status. Health professionals have to find out to what extent an individual patient wants to be involved in decision-making.

Prospective Surveillance of Nosocomial Infections in a Swiss NICU: Low Risk of Pneumonia on Nasal Continuous Positive Airway Pressure?

This study assessed the rate of invasive nosocomial infections in very low birth weight (VLBW) </= 1,500 g infants in a Swiss university hospital neonatal intensive care unit (NICU). Device-association and devicerelated infection rates were prospectively evaluated. From October 1999 to September 2000, 76 hospitalized neonates with VLBW were included, plus 60 neonates > 1,500 g, who had received a central venous or umbilical catheter, or assisted ventilation. Nosocomial infections (sepsis, pneumonia, necrotizing enterocolitis [NEC]) were defined according to Centers for Disease Control (CDC) recommendations with slight modifications and their rates measured longitudinally. Among VLBW neonates, 16 nosocomial infections for an overall infection rate of 6 per 1,000 patient days were found. Infants with infection were of lower birth weight, a greater proportion was male, received lipid infusions, and on average had a higher severity of illness (CRIB) score. Interestingly, the ventilator-associated pneumonia (VAP) rate (12.5/1,000 ventilator days) seemed significantly higher than the pneumonia rate during nasal continuous positive airway pressure (NCPAP) treatment (1.8/1,000 NCPAP days; p = 0.04). The sepsis rate associated with peripheral catheters almost equaled the central line-associated rate, although numbers for both device-related infections were small. Further studies are needed to confirm the observation that the NCPAP-associated pneumonia rate might be lower than the VAP rate in VLBW infants, as well as to confirm the second observation that the sepsis rates on peripheral catheters compared to central venous catheters might be almost equal in VLBW infants. Reducing the exposure to ventilation via endotracheal tube, but not using peripheral as opposed to central catheters, might reduce the incidence of device-associated infection in this patient population.

Variations in the quality of care of patients with acute myocardial infarction among Swiss university hospitals

The objective of our study was to assess hospital variations in the quality of care delivered to acute myocardial infarction (AMI) patients among three Swiss academic medical centres. Cross-sectional study. Three Swiss university hospitals. We selected 1129 eligible patients discharged from these hospitals from 1 January to 31 December 1999, with a primary or secondary diagnosis code [International Classification of Diseases, 10th revision (ICD-10)] of AMI. We abstracted medical records for information on demographic characteristics, risk factors, symptoms, and findings at admission. We also recorded the main ECG and laboratory findings, as well as hospital and discharge management and treatment. We excluded patients transferred to another hospital and who did not meet the clinical definition of AMI. Percentage of patients receiving appropriate intervention as defined by six quality of care indicators derived from clinical practical guidelines. Among 577 eligible patients with AMI in this study, the mean (SD) age was 68.2 (13.9), and 65% were male. In the assessment of the quality indicators we excluded patients who were not eligible for the procedure. Among cohorts of 'ideal candidates' for specific interventions, 64% in hospital A and 73% in hospital C had reperfusion within 12 hours either with thrombolytics or percutaneous transluminal coronary angioplasty (P = 0.367). Further, in hospitals A, B, and C, respectively 97, 94, and 84% were prescribed aspirin during the initial hospitalization (P = 0.0002), and respectively 68, 91, and 75% received angiotensin converting enzyme inhibitors at discharge in the case of left ventricular systolic dysfunction (P = 0.003). Our results showed important hospital-to-hospital variations in the quality of care provided to patients with AMI between these three university hospitals.

Hospital health care resource utilization and costs of colorectal cancer during the first 3‐year period following diagnosis in Switzerland

In industrialized countries, colorectal cancer is a leading cause of morbidity and mortality. Decisions on colorectal cancer screening are based on cost-effectiveness analyses that rely on colorectal cancer cost studies. Additionally, the study of the resource utilization pattern may lead to cost-saving strategies in the care of colorectal cancer. To estimate hospital resource utilization, the use of various therapy modalities and costs of colorectal cancer cases undergoing surgery during the first 3 years following the diagnosis at a Swiss university hospital. Consecutive colorectal cancer patients from 1997 to 1998 were identified using the surgery database of the University Hospital of Basel and followed for a period of 3 years. In-hospital resource utilization and costs were retrieved from the computerized administrative records. Treatment outside of the hospital during the study period constituted an exclusion criterion. Eighty-three (94%) of 89 patients undergoing surgery for colorectal cancer were included in the study, 58 with colon cancer and 25 with rectal cancer. The average ages were 70.3 and 63.6 years, respectively. Overall, 59% of the patients were treated with surgery alone, 27% also had chemotherapy and 15% received additional chemoradiotherapy. These percentages and resource utilization varied broadly between the two colorectal cancer groups. On average, patients were admitted to the hospital 2.7 times and the hospital length of stay amounted to 35 days. They were visited by doctors 69 times, and examined with colonoscopy, ultrasonography and computerized tomography 2.7, 3.2 and 2.4 times, respectively. Mean costs incurred for rectal cancer (US dollars 40,230) were about 22% higher than for colon cancer patients (US dollars 33,079). Hospitalization and surgical therapy generated the greatest costs. Expenses were highest for the first year and with more severe disease stages at diagnosis. Colorectal cancer is an expensive disease. Economic analyses on screening should take into account the large resource utilization and cost variability by performing sensitivity analysis on broad cost ranges. Furthermore, they should consider stage shifting at diagnosis and include stage-specific costs.

Effect of postpartum iron supplementation on red cell and iron parameters in non‐anaemic iron‐deficient women: a randomised placebo‐controlled study

To investigate the effect of oral iron on postpartum red cell and iron parameters in non-anaemic women with iron deficiency. Randomised study of supplementation with oral iron sulphate 80 mg daily or placebo for 12 weeks starting 24-48 hours after delivery, with visits antepartum and 1, 4, 6 and 12 weeks postpartum. Swiss university hospital obstetric unit. Fifty-two women with antenatal iron deficiency (serum ferritin <15 microg/L) and no antenatal or postnatal anaemia (haemoglobin >11 g/dL up to 48 hours before delivery, and >10 g/dL postpartum), divided into two groups comparable in antenatal iron status. Supplementation was started 24-48 hours after delivery (visit 1:V1). Additional tablets were issued one week after V1 (V2), four weeks after V1 (V3) and six weeks after V1 (V4). The last visit took place 12 weeks after visit 1 and 6 weeks after visit 4 (V5). Patients were required to return blisters and boxes whether they were used and unused at each visit and compliance was assessed by counting the tablets. Blood samples for haematology and iron status testing were taken before delivery and at each visit. Iron status (serum ferritin, hypochromic red cells, iron, transferrin saturation, soluble transferrin receptor concentration); erythropoiesis (standard parameters, including reticulocyte indices); and inflammatory response (serum neopterin, C-reactive protein, white cell count) in five-datapoint profiles. Increased ferritin (P= 0.0004) and transferrin saturation (P= 0.03), decreased soluble transferrin receptors (P= 0.02); increased haemoglobin (P= 0.02) and decreased hypochromic red cells (P= 0.04) compared with placebo at 12 weeks, with no differences in other red cell or reticulocyte parameters. There was a positive correlation between C-reactive protein and postpartum ferritin. No correlation was observed in the puerperium between C-reactive protein and hypochromic red cells or soluble transferrin receptors. Haemoglobin levels and iron stores in women with term gestational iron deficiency benefit significantly from iron supplementation compared with placebo, even in an industrialised population.

Outcomes and the quality of care for patients hospitalized with heart failure

The purpose of this study was to determine whether process quality indicators derived from evidence-based guidelines for heart failure patients were associated with outcome indicators (hospital mortality and readmissions). A retrospective cohort-study among patients discharged with a primary or secondary International Classification of Disease, 10th revision (ICD-10) heart failure code from 1 January to 31 December 1999. The study was implemented in three Swiss academic medical centers. Records of 1634 patients hospitalized with heart failure were abstracted. Demographic characteristics, risk factors, symptoms and findings at admission, and discharge characteristics were recorded. Main outcome measure. Process quality indicators were derived from evidence-based guidelines, related to appropriate management and treatment of heart failure patients. Hospital mortality was measured in a chart abstraction process. Thirty-day readmissions were calculated using administrative data from hospitals. Among the three hospitals, 1153 patients with heart failure were eligible for this study. Mean age was 75.3 years (standard deviation 12.7) and 45.7% of patients were female. Ventricular function (VF) was determined in 69% of patients. The adjusted odds-ratios (OR) for the VF not determined were 1.74 [95% confidence interval (CI) 1.06-2.84] for hospital mortality and 0.75 (95% CI 0.47-1.18) for 30-day readmissions. Among patients with left ventricular systolic dysfunction and no contraindication to angiotensin-converting enzyme inhibitor (ACEI), 54% were prescribed target-dose ACEI or angiotensin receptor blockers at discharge, 32% received ACEI at less then target dose, and 14% received no ACEI at discharge. Adjusted ORs (95% CI) for readmissions were 0.89 (0.28-2.84) for no ACEI and 1.17 (0.56-2.43) for less than target ACEI compared with target dose. Among patients with heart failure, the determination of VF was associated with hospital mortality. However, process indicators derived from evidence-based guidelines were not related to early readmissions in three Swiss university hospitals.

Changes in the Epidemiology of Pneumococcal Bacteremia in a Swiss University Hospital During a 15-Year Period, 1986-2000

To evaluate changes in epidemiological characteristics and outcome of patients with pneumococcal bacteremia during a 15-year period in a Swiss university hospital. We reviewed the medical records of all hospitalized adults at the University Hospital Basel, Basel, Switzerland, whose blood culture yielded Streptococcus pneumoniae from January 1, 1986, through December 31, 2000. We analyzed 405 episodes of pneumococcal bacteremia in 394 patients. The mean annual incidence of 1.78 episodes per 1000 hospital admissions was inversely related to the mean atmospheric temperature of the area. During the study period, penicillin nonsusceptibility increased from 0% to 17%. The overall case-fatality rate was 25%, which decreased from 33% to 17% between the first and the second half of the study period (P<.001). The proportion of women with pneumococcal bacteremia increased from 37% to 52%. Independent risk factors for fatal outcome were coronary artery disease (P<.001; relative risk [RR], 4.3; 95% confidence interval [CI], 3.4-5.1), neutropenia (P=.001; RR, 3.2; 95% CI, 1.9-4.8), and age 65 years or older (P=.001; RR, 2.9; 95% CI, 1.8-4.2), whereas prior respiratory tract infection (P=.03; RR, 0.3; 95% CI, 0.1-0.5) and the occurrence of pneumococcal bacteremia in the second half of the study period (P=.01; RR, 0.4; 95% CI, 0.2-0.6) were independent predictors of survival. The case-fatality rate in human immunodeficiency virus (HIV)-infected patients was significantly lower than in patients not infected with HIV or in those with unknown HIV status (9% vs 27%; P=.006), which correlated with the younger mean +/- SD age of HIV-infected patients (33.2+/-6.6 years) compared with patients not infected with HIV (63.1+/-18.1 years) (P<.001). The case-fatality rate of patients with pneumococcal bacteremia decreased significantly between the first and second half of the study period, despite the increased prevalence of penicillin-nonsusceptible isolates. Independent risk factors for fatal outcome were coronary artery disease, neutropenia, and age 65 years or older, whereas prior respiratory tract infection and the occurrence of pneumococcal bacteremia in the second half of the study period were independent predictors of survival. HIV infection was a predisposing factor for pneumococcal bacteremia but was not a risk factor for fatal outcome.

Is readmission to hospital an indicator of poor process of care for patients with heart failure?

<b>Background:</b> Controversy exists about the appropriateness of using readmission as an indicator of the quality of care. A study was undertaken to measure the validity and predictive ability of readmission in this context. <b>Methods:</b> An evaluation study was performed in patients discharged alive with heart failure from three Swiss academic medical centres. Process quality indicators were derived from evidence based guidelines for the management and treatment of heart failure. Readmissions were calculated from hospital administrative data. The predictive ability of readmissions was evaluated using bivariate and multivariate analyses, and validity by calculating sensitivity, specificity, positive and negative predictive value, using process indicators as the “gold standard”. <b>Results:</b> Of 1055 eligible patients discharged alive, 139 (13.2%) were readmitted within 30 days. The adjusted odds ratio (OR) for absence of measurement of left ventricular function was 0.70 (95% CI 0.45 to 1.08) for readmissions. In patients with left ventricular systolic dysfunction, three dose categories of angiotensin converting enzyme inhibitor were examined using ordinal logistic regression. The adjusted OR for these categories was 1.07 (95% CI 0.56 to 2.06) for readmissions. When using process indicators as the gold standard to assess the validity of readmissions, sensitivity ranged from 0.08 to 0.17 and specificity from 0.86 to 0.93. <b>Conclusions:</b> Readmission did not predict and was not a valid indicator of the quality of care for patients with heart failure admitted to three Swiss university hospitals.