Total Inpatient Days Research Articles

Geospatial Analysis of Social Determinants of Health Identifies Neighborhood Hot Spots Associated With Pediatric Intensive Care Use for Life-Threatening Asthma

Social determinants of health are associated with asthma prevalence and healthcare use in children with asthma, but are multifactorial and complex. Whether social determinants similarly influence exacerbation severity is not clear. Composite measures of social determinants of health and readmission outcomes were evaluated in a large regional cohort of 1,403 school-age children admitted to a pediatric intensive care unit (PICU) for asthma. Residential addresses were geocoded and spatially joined to census tracts. Composite measures of social vulnerability and childhood opportunity, PICU readmission rates, and hospital length of stay were compared between neighborhood hot spots, where PICU admission rates per 1,000 children are at or above the 90th percentile, versus non-hot spots. A total of 228 children resided within a neighborhood hot spot (16%). Hot spots were associated with a higher (ie, poorer) composite Social Vulnerability Index ranking, reflecting differences in socioeconomic status, household composition and disability, and housing type and transportation. Hot spots also had a lower (ie, poorer) composite Childhood Opportunity Index percentile ranking, reflecting differences in the education, health and environment, and social and economic domains. Higher social vulnerability and lower childhood opportunity were associated with PICU readmission. Residing within a hot spot was further associated with a longer duration of hospital stay, individual inpatient bed days, and total census tract inpatient bed days. Social determinants of health identified by geospatial analyses are associated with more severe asthma exacerbation outcomes in children. Outpatient strategies that address both biological and social determinants of health are needed to care for and prevent PICU admissions optimally inchildren with asthma.

Mental Health Conservatorship Among Homeless People With Serious Mental Illness.

The purpose of this study was to examine associations between homelessness and length of psychiatric hospitalization and to explore the role of mental health conservatorship in determining discharge location for patients who are homeless and have a grave disability from serious mental illness. This observational study used administrative data from a safety-net psychiatric hospital in Los Angeles. The sample included 795 adults (≥18 years) who were hospitalized on an involuntary psychiatric hold between 2016 and 2018. The outcome variables were length of stay (days) and discharge location (home, locked psychiatric facility, unlocked psychiatric facility, unhoused). The predictor variables were homelessness status and whether a mental health conservatorship was initiated during hospitalization. Multiple regression models were used to estimate associations between variables. Homelessness status was associated with 27.5 additional days (SE=3.5 days) of hospitalization in adjusted models. Homeless patients for whom conservatorship was initiated comprised 6% of the sample but 41% of total inpatient days. Among people who were homeless, initiation of a conservatorship was associated with significantly longer length of inpatient stay (mean=154.8 days versus 25.6 days for the whole sample) but also with lower odds of being unhoused at the time of discharge (risk ratio=0.19, 95% confidence interval=0.09-0.34). A mental health conservatorship can be a mechanism for helping homeless people with a grave disability from mental illness to transition from the streets to residential psychiatric treatment, but it requires substantial resources from facilities that initiate such conservatorships and does not guarantee resolution of long-term supportive housing needs.

The increasing impact of length of stay \u201coutliers\u201d on length of stay at an urban academic hospital

BackgroundAs healthcare systems strive for efficiency, hospital “length of stay outliers” have the potential to significantly impact a hospital’s overall utilization. There is a tendency to exclude such “outlier” stays in local quality improvement and data reporting due to their assumed rare occurrence and disproportionate ability to skew mean and other summary data. This study sought to assess the influence of length of stay (LOS) outliers on inpatient length of stay and hospital capacity over a 5-year period at a large urban academic medical center.MethodsFrom January 2014 through December 2019, 169,645 consecutive inpatient cases were analyzed and assigned an expected LOS based on national academic center benchmarks. Cases in the top 1% of national sample LOS by diagnosis were flagged as length of stay outliers.ResultsFrom 2014 to 2019, mean outlier LOS increased (40.98 to 45.11 days), as did inpatient LOS with outliers excluded (5.63 to 6.19 days). Outlier cases increased both in number (from 297 to 412) and as a percent of total discharges (0.98 to 1.56%), and outlier patient days increased from 6.7 to 9.8% of total inpatient plus observation days over the study period.ConclusionsOutlier cases utilize a disproportionate and increasing share of hospital resources and available beds. The current tendency to exclude such outlier stays in data reporting due to assumed rare occurrence may need to be revisited. Outlier stays require distinct and targeted interventions to appropriately reduce length of stay to both improve patient care and maintain hospital capacity.

Evaluating the relationship between clinical and demographic characteristics of insulin-using people with diabetes and their health outcomes: a cluster analysis application

BackgroundThe aim of this study was to determine how clusters or subgroups of insulin-treated people with diabetes, based upon healthcare resource utilization, select social demographic and clinical characteristics, and diabetes management parameters, are related to health outcomes including acute care visits and hospital admissions.MethodsThis was a non-experimental, retrospective cluster analysis. We utilized Aetna administrative claims data to identify insulin-using people with diabetes with service dates from 01 January 2015 to 30 June 2018. The study included adults over the age of 18 years who had a diagnosis of type 1 (T1DM) or type 2 diabetes mellitus (T2DM) on insulin therapy and had Aetna medical and pharmacy coverage for at least 18 months (6 months prior and 12 months after their index date, defined as either their first insulin prescription fill date or their earliest date allowing for 6 months’ prior coverage). We used K-means clustering methods to identify relevant subgroups of people with diabetes based on 13 primary outcome variables.ResultsA total of 100,650 insulin-using people with diabetes were identified in the Aetna administrative claims database and met study criteria, including 11,826 (11.7%) with T1DM and 88,824 (88.3%) with T2DM. Of these 79,053 (78.5%) people were existing insulin users. Seven distinct clusters were identified with different characteristics and potential risks of diabetes complications. Overall, clusters were significantly associated with differences in healthcare utilization (emergency room visits, inpatient admissions, and total inpatient days) after multivariable adjustment.ConclusionsThis analysis of healthcare claims data using clustering methodologies identified meaningful subgroups of patients with diabetes using insulin. The subgroups differed in comorbidity burden, healthcare utilization, and demographic factors which could be used to identify higher risk patients and/or guide the management and treatment of diabetes.

Health Care Utilization and Cost of Allogeneic Hematopoietic Cell Transplantation in Children with Malignant and Non-Malignant Diseases

Introduction: Allogeneic hematopoietic cell transplant (alloHCT) represents a potentially life-saving treatment for patients with both malignant and non-malignant diseases. AlloHCT related costs accounted for the most rapid increase in total hospital cost, with a growth rate of 84.9%, from 2004 to 2007 according to an Agency for Health Care Research and Quality report (Stranges, HCUP Statistical Briefs, 2006). Higher cost has been associated with use of alternative donor sources and post-transplant complications. Transplant care improvements have led to better outcomes (Gooley, NEJM, 2010) but the effect on cost is not known.Methods: We obtained data for 240 patients who received an alloHCT at Columbia University Medical Center between 1/1/05 and 6/30/16 and were <21 years old at the time of alloHCT for the first year post-transplant. Patient clinical characteristics and outcomes were obtained from retrospective review of medical records. Hospitalization cost data was estimated from charges obtained from the Pediatric Health Information System (PHIS) database using hospital specific cost-to-charge ratios and adjusted for inflation. To analyze changes over time, patients were divided into three time periods 2005-08 (n=103 patients), 2009-12 (n=73 patients), 2013-16 (n=64 patients). Primary outcomes were overall survival (OS), transplant related complications (liver injury: total bilirubin >2, kidney injury (decrease in creatinine clearance by >50%), viremia, bacteremia, acute graft-versus-host-disease (aGVHD) and inpatient resource utilization. The comparisons among groups were carried out by Kruskal-Wallis test for continuous variables and Chi-square test for categorical variables.Results: There were no differences over time with respect to patient age, sex, related vs. unrelated donor, myeloablative vs. reduced intensity conditioning. The median age was 10.32 (range 0.34-20.96) years. There were significant differences in number of patients with nonmalignant disease (2005-08: 42%, 2009-12: 45%, 2013-16: 63%, p=0.027) and full HLA match (2005-08:44%, 2009-12: 56%, 2013-16: 64%, p=0.026). Liver injury in the first 30 days occurred in 2005-08: 30%, 2009-12: 32%, 2013-16: 27%, p=0.81. Kidney injury occurred in the first 30 days in 2005-08: 28%, 2009-12: 40%; 2013-16: 27%, p=0.22 and in the first year post-transplant in 2005-08: 85%, 2009-12: 78%, 2013-16: 66%, p=0.011 respectively. Viral infections were 2005-08: 27%, 2009-12: 51%, 2013-16: 41%, p=0.006, and there was a significant difference in mean days with bacteremia 2005-08: 3.4, 2009-12: 2.1, 2013-16: 1.8, p<0.001. There was also a significant difference in incidence of aGVHD 2005-08: 33%, 2009-12: 45%; 2013-16: 20%, p=0.009. There was no difference in OS 2005-08: 69%, 2009-12: 74%, 2013-16: 81%, p=0.21. There were significant differences in hospitalization lengths and costs between the three time periods with the lowest median inpatient days and costs for the 2013-16 group. The median lengths of transplant admission were 2005-08: 52 days, 2009-12: 48 days and 2013-16: 41 days (p<0.001). The median total inpatient days for the first year post-transplant were 2005-08: 98 days, 2009-12: 93 days, and 2013-16: 53 days (p<0.001). The median cost of the first transplant hospitalization was 2005-08: $184,450, 2009-12: $156,020, 2013-16: $130,244 (p<0.001), and median total one-year inpatient cost was 2005-08: $344,424, 2009-12: $308,826, 2013-16: $181,205 (p<0.001). The median cost per day survived was 2005-08: $433, 2009-12: $371, 2013-16: $202 (p<0.001). Stratifying the cohort by disease type and donor source, the median cost of alloHCT for matched related donors was 2005-08: $271,674, 2009-12: $213,546, 2013-16: $163,251 (p=0.012), for unrelated donors was 2005-08: $377,484, 2009-12: $380,211, 2013-16: $219,208 (p=0.007), for malignant diseases was 2005-08: $341,989, 2009-12: $363,676, 2013-16: $219,208 (p=0.07) and for non-malignant diseases was 2005-08: $344,424, 2009-12: $262,814, 2013-16: $184,280 (p<0.001).Conclusion: Cost of alloHCT for pediatric patients treated at our center from 2005 to 2016 appears to have decreased. This is most likely related to improved care practices stemming from various quality improvement projects, leading to decreased lengths of hospitalization as well as decreased incidence of complications most significantly kidney injury, aGVHD and bacterial infection. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Population and Resource Utilization Among Patients With Adult Congenital Heart Disease: A Snapshot View of a Moderate-Size Canadian Regional Centre

BackgroundHealth care resource utilization for patients with adult congenital heart disease (ACHD) has not been well characterized outside of large Canadian specialized regional centres. We sought to describe the ACHD population and resource utilization patterns seen in a medium regional Canadian centre providing specialized ACHD care. MethodsA cross-sectional retrospective study was done from a sample of patients seen in 2018 at the ACHD clinic in Manitoba, Canada. Demographic data were collected along with cardiac anatomy and repair type. Health care resource utilization, clinic visits, hospital admissions, unexpected hospital presentations, and cardiac interventions were measured over a 5-year period. ResultsA random sample of 262 patients was selected from our specialized ACHD clinic. Mean age was 33.5 (±13.7) years; 48% of the population was female, and >50% resided within the major city limits. A total of 21% of the population had simple anatomy, 44% had moderate anatomy, and 35% had complex anatomy. The most commonly used imaging modality was echocardiography, followed by cardiac magnetic resonance imaging, with more frequent imaging done in patients with complex anatomy. Unexpected hospital encounters occurred at a rate of 16 per 100 person-years. Total inpatient hospital days occurred at a rate of 33 per 100 person-years, and visits to the congenital clinic occurred at a rate of 90 per 100 person-years. ConclusionsHealth care resource utilization appears to be highest in older adults and those with more complex ACHD anatomy. As the overall cohort of adults with ACHD continues to age, resource needs are likely to increase.

Tolvaptan Use in SIAD (Syndrome of Inappropriate Antidiuresis)

Abstract Background: SIAD (Syndrome of Inappropriate Antidiuresis) is the commonest cause of hyponatraemia in hospital inpatients. Hyponatraemia is associated with increased length of stay and worse primary clinical outcomes. Our study aimed to evaluate the effectiveness of Tolvaptan, a selective, non-peptide, Vasopressin receptor antagonist, treatment in hospitalised patients with SIAD. Method and Baseline Characteristics: A Retrospective analysis of 9 patients treated with Tolvaptan for a confirmed diagnosis of SIAD was carried out. Information was collected from the inpatient records and biochemical test results. Serum Sodium levels on admission ranged between 104- 124mmol/ L (Normal range 136 -145 mmol/L). Average inpatient days solely due to hyponatraemia was 24 days. The number of in-patient days on fluid restriction ranged from 8-22 days depending on timing of referral to endocrine department. Tolvaptan was only started at a stable serum sodium at 118 mmol/L or greater. Four patients also had a prior trial of demeclocycline. Tolvaptan was started at its smallest dose of 7.5mg OD under strict monitoring of serum sodium with locally agreed protocol. Aetiology of SIAD included lung malignancy, acute demyelinating polyneuropathy, listeria meningitis, autoimmune encephalitis, SSRI (Selective Serotonin Reuptake inhibitor) use, Aspergillosis and Idiopathic (n=3). Results: Serum sodium level improved to &amp;gt;128 mmol/L in 2 days of starting Tolvaptan in all cases. After discharge, there was remote virtual clinic monitoring from the endocrinology team at 2 weeks, 4- 6 weeks and 3 months with a view to stop the medication. No adverse events were observed during use of Tolvaptan in the patient population. Tolvaptan 7.5mg OD was either stopped completely after 4-6 weeks or switched to 7.5mg alternate days depending on the clinical course of underlying pathology. Average duration of Tolvaptan treatment was 4.5 months excluding one patient with chronic lung pathology. 3 patients had further hospital admission on stopping Tolvaptan treatment and treatment with Tolvaptan had to be re-initiated. Conclusion: This study confirms the efficacy of Tolvaptan use in SIAD related hyponatremia. Tolvaptan serves as a cost effective treatment option for hospitalised patients who have either failed to respond to demeclocycline or fluid restriction. In our case cohorts, cost comparison of Low dose Tolvaptan with retrospective calculation of total inpatient days of fluid restriction and use of demeclocycline showed a better outcome and clinical effectiveness with low dose Tolvaptan. We recommend earlier use of Tolvaptan in SIAD under guidance from specialist team as a safe, cost effective and in some cases, as a hospital admission-avoidance strategy.

Business as unusual: medical oncology services adapt and deliver during COVID-19.

BackgroundThe COVID‐19 pandemic has challenged cancer care globally, introducing resource limitations and competing risks into clinical practice.AimsTo describe the COVID‐19 impact on medical oncology care provision in an Australian setting.MethodsCalvary Mater Newcastle and Newcastle Private Hospital medical oncology data from 1 February to 31 April 2019 versus 2020 were retrospectively analysed.ResultsThree hundred and sixty‐four inpatient admissions occurred in 2020, 21% less than in 2019. Total inpatient days decreased by 22% (2842 vs 2203). April was most impacted (36% and 44% fewer admissions and inpatient days respectively). Mean length of stay remained unchanged (6.4 vs 6.2 days, P = 0.7). In all, 5072 outpatient consultations were conducted, including 417 new‐patient consultations (4% and 6% increase on 2019 respectively). Telephone consultations (0 vs 1380) replaced one‐quarter of face‐to‐face consultations (4859 vs 3623, −25%), with minimal telehealth use (6 vs 69). Day Treatment Centre encounters remained stable (3751 vs 3444, −8%). The proportion of new patients planned for palliative treatment decreased (35% vs 28%, P = 0.04), observation increased (16% vs 23%, P = 0.04) and curative intent treatment was unchanged (both 41%). Recruiting clinical trials decreased by one‐third (45 vs 30), two trials were activated (vs 5 in 2019) and 45% fewer patients consented to trial participation (62 vs 34).ConclusionOur medical oncology teams adapted rapidly to COVID‐19 with significant changes to care provision, including fewer hospital admissions, a notable transition to telephone‐based outpatient clinics and reduced clinical trial activity. The continuum of care was largely defended despite pandemic considerations and growing service volumes.

Telepsychiatry adoption across hospitals in the United States: a cross-sectional study

BackgroundAccess to psychiatric care is critical for patients discharged from hospital psychiatric units to ensure continuity of care. When face-to-face follow-up is unavailable or undesirable, telepsychiatry becomes a promising alternative. This study aimed to investigate hospital- and county-level characteristics associated with telepsychiatry adoption.MethodsCross-sectional national data of 3475 acute care hospitals were derived from the 2017 American Hospital Association Annual Survey. Generalized linear regression models were used to identify characteristics associated with telepsychiatry adoption.ResultsAbout one-sixth (548 [15.8%]) of hospitals reported having telepsychiatry with a wide variation across states. Rural noncore hospitals were less likely to adopt telepsychiatry (8.3%) than hospitals in rural micropolitan (13.6%) and urban counties (19.4%). Hospitals with both outpatient and inpatient psychiatric care services (marginal difference [95% CI]: 16.0% [12.1% to 19.9%]) and hospitals only with outpatient psychiatric services (6.5% [3.7% to 9.4%]) were more likely to have telepsychiatry than hospitals with neither psychiatric services. Federal hospitals (48.9% [32.5 to 65.3%]), system-affiliated hospitals (3.9% [1.2% to 6.6%]), hospitals with larger bed size (Quartile IV vs. I: 6.2% [0.7% to 11.6%]), and hospitals with greater ratio of Medicaid inpatient days to total inpatient days (Quartile IV vs. I: 4.9% [0.3% to 9.4%]) were more likely to have telepsychiatry than their counterparts. Private non-profit hospitals (− 6.9% [− 11.7% to − 2.0%]) and hospitals in counties designated as whole mental health professional shortage areas (− 6.6% [− 12.7% to − 0.5%]) were less likely to have telepsychiatry.ConclusionsPrior to the Covid-19 pandemic, telepsychiatry adoption in US hospitals was low with substantial variations by urban and rural status and by state in 2017. This raises concerns about access to psychiatric services and continuity of care for patients discharged from hospitals.

Reducing pharmacy medication errors using Lean Six Sigma: A Thai hospital case study

Hospital medication errors are costly and contribute to patient mortality, morbidity, and decreased health care quality. Errors result from poor systems design more commonly than from healthcare staff performance. As such, a focus should be directed to process design. This action research study examines the application of Lean Six Sigma to reduce inpatient pharmacy dispensing errors in a Thai public hospital. Through the successful application of multiple Lean Six Sigma tools, the implementation of Lean Six Sigma reduced monthly dispensing errors from 29 incidents to 6 incidents over 14,000 total inpatient days between March 2018 and November 2019, and improved patient safety. Lean Six Sigma tools used in this study were cause-and-effect diagrams, spaghetti diagrams, five-why analysis, project charters, brainstorming, control charts, and hypothesis testing. This case study can improve hospital manager and medical director awareness of Lean Six Sigma and its benefits relative to the prevention and reduction of medication errors.

Drastic reduction of orthopaedic services at an urban tertiary hospital in South Africa during COVID-19: Lessons for the future response to the pandemic.

The COVID-19 pandemic has impacted on the global surgery landscape. To analyse and describe the initial impact of the COVID-19 pandemic on orthopaedic surgery at Groote Schuur Hospital, a tertiary academic hospital in South Africa. The number of orthopaedic surgical cases, emergency theatre patient waiting times, and numbers of outpatient clinic visits, ward admissions, bed occupancies and total inpatient days for January - April 2019 (pre-COVID-19) were compared with the same time frame in 2020 (COVID-19). The COVID-19 timeframe included initiation of a national 'hard lockdown' from 26 March 2020, in preparation for an increasing volume of COVID-19 cases. April 2020, the time of the imposed hard lockdown, was the most affected month, although the number of surgical cases had started to decrease slowly during the 3 preceding months. The total number of surgeries, outpatient visits and ward admissions decreased significantly during April 2020 (55.2%, 69.1% and 60.6%, respectively) compared with April 2019 (p&lt;0.05). Trauma cases were reduced by 40% in April 2020. Overall emergency theatre patient waiting time was 30% lower for April 2020 compared with 2019. COVID-19 and the associated lockdown has heavily impacted on both orthopaedic inpatient and outpatient services. Lockdown led to a larger reduction in the orthopaedic trauma burden than in international centres, but the overall reduction in surgeries, outpatient visits and hospital admissions was less. This lesser reduction was probably due to local factors, but also to a conscious decision to avoid total collapse of our surgical services.

Improved outcomes in CABG patients with atrial fibrillation associated with surgical left atrial appendage exclusion.

We sought to determine the impact of left atrial appendage clip exclusion (LAACE) on coronary artery bypass grafting (CABG) outcomes among patients with pre-existing atrial fibrillation (AF). From October 1, 2015 to October 1, 2017, 4210 Medicare beneficiaries with pre-existing AF underwent isolated CABG (i.e., without ablation) with (n = 931) or without (n = 3279) LAACE. Inverse probability of treatment weighting was used to evaluate the effect of concomitant LAACE on short- and long-term outcomes after CABG. Long term risks of thromboembolism and mortality were assessed using competing-risk regression and Cox proportional hazard models. Operative mortality, length of stay, and 30-day readmission did not differ between groups. Thromboembolism risk was 26% lower for the CABG + LAACE group compared with isolated CABG over a 2-year time-to-event analysis (sub hazard ratio [sHR] 0.74, 95% confidence interval [CI] 0.54-1.00, p = .049). There were no differences in ischemic stroke rates. All-cause mortality risk was 45% lower for CABG + LAACE during the late follow-up period (91-730 days; HR 0.55, 95% CI 0.32-0.95, p = .031). The late period annual absolute all-cause mortality rate was 3.7% for CABG + LAACE and 6.9% for isolated CABG. There were lower readmission rates (31% vs. 43%, p < .001) and total inpatient days (4.0 days vs. 7.2 days, p < .01.) for the CABG + LAACE during follow-up. Total hospital in and out-patient treatment costs were similar between groups through one year. Concomitant LAA exclusion via an epicardial closure device is associated with reduced CABG mortality, thromboembolic events, and readmissions in patients with pre-existing atrial fibrillation.

Quantifying the difference in risk of adverse events by induction treatment regimen in pediatric acute lymphoblastic leukemia

The differences in overall morbidity by induction treatment regimen for pediatric acute lymphoblastic leukemia (ALL) are unknown. We examined a cohort of children with ALL who received induction chemotherapy between January 2010 and May 2018. We evaluated 20 clinically relevant adverse events (AEs) and readmission and ICU admission rates. Outcomes were compared between standard 3- and 4-drug treatment regimens in multivariate analyses using Cox proportional hazard ratios. Among 486 eligible patients, the risks of sepsis (HR = 2.16, 95% CI = 1.11–4.19), hypoxia (HR = 2.08, 95% CI = 1.03–4.18), hyperbilirubinemia (HR = 2.48, 95% CI = 1.07–5.74), hyperglycemia (HR = 2.65, 95% CI = 1.29–5.42), thromboembolic event (HR = 4.50, 95% CI = 1.30–15.6), and hyponatremia (HR = 7.88, 95% CI = 1.26–49.4) were significantly higher during 4-drug induction. Despite no differences in readmission or ICU admission rates, 4-drug induction patients had greater total inpatient days (12 vs. 4 days; p<.0001). In conclusion, pediatric patients receiving 4-drug induction for ALL experience higher morbidity. These results inform care practices and patient guidance during induction therapy.

The effect of flexible assertive community treatment in Denmark: a quasi-experimental controlled study

Flexible assertive community treatment (FACT) is a community-based treatment model for patients with severe mental illness that has been widely implemented despite little evidence for its effectiveness. We aimed to evaluate the effect of FACT on mental health care outcomes compared with treatment from standard community mental health teams (CMHTs) or assertive community treatment (ACT) teams in Denmark. We did a quasi-experimental, propensity-score matched, controlled study in five FACT teams, four ACT teams, and five CMHTs in the Capital Region of Denmark. The FACT teams were established on May 1, 2016 (the index date). Patients were identified through the Danish Psychiatric Register and the study population consisted of all patients receiving care from any of these teams on the index date. Assignment to treatment was based on administrative considerations and was not done by the researchers. Patient data were collected from Danish registers. The primary outcome was analysed in the intention-to-treat population and compared mental health care outcomes (psychiatric admissions and bed days, outpatient contacts, self-harm, coercion, and death by any cause) for patients under the care of CMHTs or ACT teams that were reconfigured to FACT teams (CMHT-FACT or ACT-FACT) with patients who remained under the care of CMHTs and ACT teams. Patients who received FACT were matched using propensity scores with control patients from CMHTs and ACT teams to balance differences in baseline characteristics. On May 1, 2016, 2034 individuals (887 in the CMHT-FACT group, 887 in the matched CMHT group, 130 in the ACT-FACT group, 130 in the matched ACT group) were enrolled and were followed up from Nov 1, 2016, to Nov 1, 2018. The number of outpatient contacts was higher for patients receiving FACT than for those in the control groups (CMHT-FACT vs CMHT: incidence rate ratio 1·15; 95 % CI 1·10-1·20; ACT-FACT vs ACT: 1·15; 1·03-1·29). Patients receiving FACT had fewer admissions than those in the control groups (CMHT-FACT vs CMHT: 0·84; 0·76-0·92; ACT-FACT vs ACT: 0·71; 0·59-0·85). However, there were no significant differences in total inpatient days, use of coercion, episodes of self-harm, or deaths. To our knowledge, this is the first study to investigate the effect of FACT compared with treatment from a CMHT or ACT team. Our results suggest that FACT can provide a more intensive approach in terms of increased outpatient contacts than CMHT care or ACT. FACT requires further evaluation through randomised controlled trials that include a cost-effectiveness component before wider implementation. Mental Health Services in the Capital Region of Denmark.

Inspire - HF Manifesto Reduces Readmissions And Improves Outcomes In Chronic Heart Failure

Introduction Multiple co-morbidity is common in patients with HF increasing their risk for poor health outcomes. In the US, approximately 40% of Medicare beneficiaries with HF have >5 non-cardiac conditions and this group accounts for >80% of the total inpatient HF-related hospital days in the US. Annual total costs for HF is more than $ 40 B and the majority (61%) of hospital readmissions are attributable to multimorbidity and occur within 15-days of discharge. Most of these HF admissions and readmissions are preventable. A proactive management strategies are needed to address all comorbidities such as hypertension, diabetes, dyslipidemia, metabolic derangement, worsening renal function, and repetitive hospitalizations that ultimately lead to loss of psychosocial and financial independence, anxiety, depression, poor coping skills, falls, sarcopenia and death. Hypothesis Use of a novel framework such as INSPIRE -HF will address multiple comorbidities and improve outcomes Methods A comprehensive, multidisciplinary, nurse-directed, physician guided heart failure management program including those with CKD was started in 2017. The goal of the Cardiorenal center is to reduce 30-day hHF, 90-day hHF, optimize GDMT, improve QOL, prevent CKD progression, and enhance survival .The program consists of intensive face to face weekly or bimonthly encounters in patients enrolled at this clinic within a week after discharge from the hospital for CHF. The multicomponent program consists of the INSPIRE HF framework: 1) Identify individualized priorities and nature of multimorbidity, 2) Nutrition intervention including management of diabetes, obesity, hypertension, dyslipidemia and poor functional capacity, 3) Stabilize fluid status 4) Psychosocial motivational empowerment and financial assistance as needed, 5) Initiate GDMT 6) Revisit comorbidities with biomarker assessments and 7) Education and exercise programs including EECP therapy for those who qualify. A total of 162 patients discharged from the hospital enrolled within a week at the clinic were followed for 30 months on a weekly or bimonthly basis. Results A total of 162 patients (Men 66 %, Systolic HF 69%, Ischemic etiology 55%, 35 % with diabetes, 27 % hypertensive and 58 % with CKD) were started on the INSPIRE Strategy driven protocol. Total of 27 patients (16 %) were admitted during the 30-month period of which 8 patients (5%) were readmitted within 30 days and 19 patients (11%) were readmitted in the subsequent 180 days. Twenty-seven patients have died (16.7%) during this period. Fifty-nine patients received IV diuretics at some point during their visits and averted readmission (37%). More than 90% improved by at least 1 NYHA functional class. Conclusion A comprehensive multiple comorbidity management strategy in a nurse directed physician guided outpatient cardiometabolic renal center using the INSPIRE HF manifesto improves HF outcomes.

Real-world effectiveness of admissions to a tertiary treatment-resistant psychosis service: 2-year mirror-image study.

Treatment-resistant schizophrenia is a major disabling illness which often proves challenging to manage in a secondary care setting. The National Psychosis Unit (NPU) is a specialised tertiary in-patient facility that provides evidence-based, personalised, multidisciplinary interventions for complex treatment-resistant psychosis, in order to reduce the risk of readmission and long-term care costs. This study aimed to assess the long-term effectiveness of treatment at the NPU by considering naturalistic outcome measures. Using a mirror image design, we compared the numbers of psychiatric and general hospital admissions, in-patient days, acuity of placement, number of psychotropic medications and dose of antipsychotic medication prescribed before and following NPU admission. Data were obtained from the Clinical Records Interactive Search system, an anonymised database sourced from the South London and Maudsley NHS Trust electronic records, and by means of anonymous linkage to the Hospital Episode Statistics system. Compared with the 2 years before NPU admission, patients had fewer mental health admissions (1.65 ± 1.44 v. 0.87 ± 0.99, z = 5.594, P < 0.0001) and less mental health bed usage (335.31 ± 272.67 v. 199.42 ± 261.96, z = 5.195 P < 0.0001) after NPU admission. Total in-patient days in physical health hospitals and total number of in-patient days were also significantly reduced (16.51 ± 85.77 v. 2.83 ± 17.38, z = 2.046, P = 0.0408; 351.82 ± 269.09 v. 202.25 ± 261.05, z = 5.621, P < 0.0001). The reduction in level of support required after treatment at the NPU was statistically significant (z = -8.099, P < 0.0001). This study demonstrates the long-term effectiveness of a tertiary service specialising in treatment-resistant psychosis.

Is bed turnover rate a good metric for hospital scale efficiency? A measure of resource utilization rate for hospitals in Southeast Nigeria

BackgroundNigeria health sector, like that of other sub-Saharan African countries, increasingly faces critical resource constraints. Thus, there is need to seek for ways of improving efficient use of scarce health resources. The aim of this study was to determine resource utilization rate of teaching hospitals in Southeast Nigeria as a means of estimating their efficiency.MethodsThe study is a longitudinal cross sectional study. It applied ratio indicators and Pabon Lasso model using data on the number of hospital bed, number of inpatients and total inpatient-days from purposefully selected teaching hospitals in Southeast Nigeria to measure efficiency over a period of 6 years (2011–2011).ResultsThe hospitals’ mean bed occupancy rate was as low as 42.14%, far below standard benchmark of 80–85%. The mean average length of stay was as high as 8.15 days and observed mean bed turnover was 21.27 patients/bed/year. These findings portrayed high level of inefficiency in Nigeria teaching hospitals, which was further illustrated by Pabon Lasso graph, with only 10–20% of the hospital-years located within or near the efficient zone or quadrant.ConclusionThe study was able to show that health ratio indicators such as hospital bed turnover rate (BTR) and bed occupancy rate (BOR), as well as patients’ average length of stay (ALS) can be used as tools for assessing hospital performance or its efficiency in resource utilization. Thus, in low and middle income countries where medical record keeping may be inadequate or poor, ratio indicators used alone or with Pabon Lasso graph/chart could be an optional metrics for hospital efficiency.

The Economic Burden of End-Organ Damage Among Medicaid Patients with Sickle Cell Disease in the United States: A Population-Based Longitudinal Claims Study.

The management of sickle cell disease (SCD), an inherited, chronic, and multifaceted condition, is associated with considerable health care resource utilization (HRU) and costs, especially for Medicaid. Anemia affects most patients with SCD and correlates with end-organ damage (EOD), such as stroke, chronic kidney disease (CKD), end-stage renal disease (ESRD), and pulmonary hypertension (PH). Limited research has been conducted to quantify the economic burden of EOD among patients with SCD. To estimate the effect of EOD on HRU and direct costs and productivity loss incurred by patients with SCD on Medicaid. Patients with ≥ 3 nondiagnostic SCD ICD-9-CM/ICD-10-CM codes in ≤ 5 years (January 1, 2013-December 31, 2017) were identified in the MarketScan Medicaid claims database. The earliest SCD diagnosis date was the index date. Continuous enrollment at least 3 months before and 1 month after the index date were required. Patients' post-index periods were divided into 3-month intervals (referred to as "intervals"). History of stroke, CKD, ESRD, and PH were identified in patients' claims histories from January 1, 2008. Intervals within 1 year and more than 1 year after an acute stroke event were also defined. All-cause HRU, direct costs, and productivity losses were summed across intervals and stratified by EOD type. Multivariate regression models were used to estimate the effect of stroke, CKD, ESRD, and PH on annual total cost, inpatient days, and number of emergency department visits by controlling for patients' demographic characteristics and other SCD complications. In total, 10,784 Medicaid patients with SCD (average age: 18.5 years; female: 54.5%) contributed to 152,455 intervals. Approximately 12% of the intervals had EOD. Patients with EOD had higher all-cause health care costs and more inpatient days, emergency department visits, outpatient visits, laboratory tests, and outpatient pharmacy claims than patients without EOD. After controlling for patient characteristics, among Medicaid patients with SCD annual costs within 1 year after stroke were 4.68-fold versus patients with no EOD (more than 1 year after stroke: 2.08-fold; CKD: 2.19-fold; ESRD: 3.40-fold; PH: 2.32-fold). Adjusted mean annual costs for adult patients with SCD on Medicaid were $285,816 and $127,393 within 1 year and more than 1 year after stroke and $135,493, $209,172, and $148,174 for CKD, ESRD, and PH, respectively. Patients with multiple SCD complications had even higher costs. The mean annual time patients with SCD spent receiving health care services ranged from 56 to 62 days for those with EOD versus 21 to 25 days among those without EOD, which created additional economic burden. When Medicaid patients with SCD experience EOD, the economic burden is significantly increased through direct costs to the health care system and indirect costs from productivity loss to society. SCD management strategies that potentially reduce the risk of EOD offer clinical and economic value to patients and society. Funding for this study was provided by Global Blood Therapeutics (GBT). Campbell is a consultant for GBT, Bluebird Bio, and Cyclerion and receives research funding from Novartis, GBT, and Cyclerion. Cong and Agodoa are employees of and have equity ownership in GBT. Song, Martinez, Black, Lew, Varker, and Chan are employees of IBM Watson Health, which received research funding from GBT for this study. Lanzkron receives research funding from GBT, Pfizer, Ironwood, HRSA, and NIH. A poster based on this study was presented at the 61st ASH Annual Meeting and Exposition; December 7-10, 2019; Orlando, FL.

Postdischarge Health Care Costs and Readmission in Patients With Hyperkalemia-Related Hospitalizations

IntroductionLimited evidence is available regarding the postdischarge economic and readmission burdens of hyperkalemia.MethodsUsing the IBM MarketScan Commercial and Medicare-Supplemental Claims database (January 1, 2010–December 31, 2014), adult patients with a hospitalization with a hyperkalemia diagnosis (ICD-9-CM 276.7, hyperkalemia cohort) were 1:1 matched with patients with a hospitalization without evidence of hyperkalemia (nonhyperkalemia cohort) on age, chronic kidney disease stage, heart failure, dialysis, renin-angiotensin-aldosterone system inhibitor use, and major diagnostic categories of the hospitalization. All-cause health care costs and health care resource utilization measures were compared between cohorts during the 1-year postdischarge period. Postdischarge readmission and length of stay (LOS) were compared between hyperkalemia-related hospitalizations from the hyperkalemia cohort and matched hospitalizations unrelated to hyperkalemia from the nonhyperkalemia cohort.ResultsPatients with hyperkalemia-related hospitalizations (n = 4426) incurred $30,379 (95% confidence interval, $25,423–$35,335) higher 1-year total all-cause costs ($68,861 vs. $38,482) and had higher rates of inpatient admissions (1.0 vs. 0.4), emergency department visits (2.0 vs. 1.2), and outpatient visits (49.6 vs. 39.1) than the nonhyperkalemia cohort during the 1-year postdischarge study period (all P < 0.001). Hyperkalemia-related hospitalizations (n = 5377) were associated with significantly higher readmission rates (within 30 days: 0.15 vs. 0.09; 60 days: 0.25 vs. 0.16; 90 days: 0.36 vs. 0.23; all P < 0.001), longer LOS per readmission (8.1 vs. 7.1 days), and longer total inpatient days (10.5 vs. 5.8 days) compared with hospitalizations unrelated to hyperkalemia (all P < 0.001). Similar trends were observed across comorbidity subgroups.ConclusionHyperkalemia-related hospitalizations were associated with significant economic and readmission burdens during the 1-year postdischarge period.

Five-year surveillance and correlation of antibiotic consumption and resistance of Gram-negative bacteria at an intensive care unit in Serbia

A surveillance study was performed in an intensive care unit in the largest tertiary health care center in Vojvodina, Serbia from 2014 to 2018. Antibiotic prescription data were collated in the WHO anatomical therapeutic chemical (ATC)/defined daily dose (DDD) format, while antibiotic resistance was expressed as incidence density adjusted for total inpatient-days. Individual trends were determined by linear regression, while possible associations between antibiotic prescription and resistance were evaluated using cross-correlation analysis. An overall decrease in antibiotic utilization was observed. The prescription rates of piperacillin-tazobactam increased significantly, while consumption of 3rd and 4th generation cephalosporins and fluoroquinolones decreased. There were rising incidence densities of doripenem resistant Acinetobacter spp., piperacillin-tazobactam resistant Pseudomonas aeruginosa and carbapenem and colistin resistant Klebsiella pneumoniae. These results can serve as a basis for the development of antimicrobial stewardship strategies in the current setting.