Use Of Hospital Resources Research Articles

Comparison of Clinical and Economic Outcomes of an Optimized Lean Versus a Standard Transcatheter Aortic Valve Implantation Program (from SOLAR [Safe Outcomes Lean And Resourceful] Study)

The increasing prevalence of aortic stenosis (AS) and the increasing number of patients indicated for transcatheter aortic valve implantation (TAVI) can lead to increased hospital constraints. This study aimed to compare, from the hospital perspective, the costs, resource use, and 30-day clinical outcomes of patients who underwent TAVI under an optimized or standard clinical pathway. A single-center, retrospective study was conducted among patients with native AS who underwent TAVI between January 2018 and March 2021. Patients who underwent optimized lean TAVI were propensity-score matched 1:1 to those who underwent standard TAVI. In-hospital costs and 30-day clinical outcomes were compared between the 2 groups. A total of 182 patients (91 in each group) were included in the final analysis. Baseline covariates were well balanced after matching. Patients who underwent lean TAVI had shorter length of stay (median [interquartile range] 3.0 days [2.0 to 6.0] vs 6.0 days [5.0 to 9.0], p <0.001). Patients in the lean TAVI group incurred lower total costs than did those in the standard TAVI group (mean ± SD: $41,346 ± 10,062 vs $50,471 ± 15,115, p=0.002). There was no between-group difference in 30-day all-cause mortality (2.2% vs 1.1%, p=0.573) and pacemaker implantations (5.5% vs 6.6%, p=0.788). Rates of procedural complications were comparable between groups. In conclusion, lean TAVI leads to hospital efficiencies without compromising patient safety. Efforts to streamline the TAVI procedure should be encouraged to improve access to TAVI for patients with AS, amid resource constraints.

Complications in acute coronary syndrome with contemporary care, and predictors of high risk

Abstract Introduction With the implementation of early reperfusion therapy, the number of complications in patients with acute coronary syndrome (ACS) has diminished significantly. However, ACS patients are still routinely admitted to units with high-level monitoring such as the coronary or intensive care unit (CCU/ICU). The cost of these admissions is high and there is often a shortage of beds. Purpose The aim of this study was to map the complications in contemporary ACS patients, and to explore the possibility of creating simple decision rules for risk assessment. Methods This observational study included 26547 chest pain patients ≥18 years at five Swedish emergency departments (ED) from the ESC-TROP trial. Complications were defined as the following within 30 days: Death, cardiac arrest, cardiogenic shock, respiratory failure, ventricular arrythmia, high-degree AV-block that required a pacemaker, and mechanical complications such as ventricular septum defects (VSD). Logistic regression including age, sex, history of myocardial infarction, hypertension, hypercholesterolemia, angina pectoris, diabetes mellitus was used to identify factors predicting high risk of complications. Results Of all 26547 patients, 2463 (9.3%) were diagnosed with ACS, and 146 of these (5.9%) suffered any complication within 30 days. Mean age was higher in patients with (78.9 years) than without (69.4 years) complications, and more were female (39.7% vs 33.1%). Seventy-nine (3.2%) patients died, 33 (1.3%) had cardiac arrest, 10 (0.4%) cardiogenic shock, 20 (0.9%) respiratory failure, 6 (0.2%) ventricular arrythmia, 13 (0.5%) high-degree AV block, and 2 (&amp;lt;0.1%) VSD. More than 40% of the complications were present already at the ED, and 40% of patients with complications were not admitted to the CCU/ICU. Only 78 (53%) of the patients with complications underwent coronary angiography and 62 were revascularized (PCI or CABG). Sixty-two patients (42%) were managed without coronary angiography and 6 (4%) had palliative care from the start. Only age &amp;gt;80 years (OR 4.8, p&amp;lt;0.001) appeared to be a significant factor for increased risk of complications. Conclusion With current care, serious complications occurred in only 6 out of 100 ACS patients, and the complications were often present already at the ED. Many patients with complications were not admitted to the CCU/ICU and did not undergo coronary angiography. Algorithms to improve the identification of ACS patients with a need of high-level monitoring could help optimize the use of hospital resources. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ALF research grantSwedish Research Council

S1276 Frailty Is Associated With Worse Outcomes in Patients Hospitalized With Non-Alcoholic Steatohepatitis (NASH)

Introduction: Frailty is an important predictor of morbidity and mortality in hospitalized patients. Concurrently, nonalcoholic steatohepatitis (NASH) is the most rapidly growing etiology for liver failure-related hospitalization and use of hospital resources. The Hospital Frailty Risk Score (HFRS) is a validated algorithmic score using International Classification of Diseases codes (ICD-10) for identification of frailty in hospitalized patients. We aimed to study the role of HFRS as a predictor of outcomes and healthcare resource utilization in patients with NASH. Methods: We performed a retrospective cohort study of hospitalized patients in the National Inpatient Sample (NIS) 2017 to 2019, with a primary discharge diagnosis of NASH. Based on HFRS, we classified patients into 2 groups: NASH with frailty (NASH+frailty, HFRS ≥5) or NASH without frailty (NASH-frail, HFRS < 5). Our primary outcomes were all-cause in-hospital mortality and hospitalization cost. Secondary outcomes included hospital complications and ICU admissions. We performed multivariable logistic regression for outcomes, and discharge-level weights were applied to provide national estimates. Results: 13,830 hospitalizations met inclusion criteria, of which 49.1% (6,790) were identified as NASH+frailty and 50.9% (7,040) as NASH-frailty. After adjusting for age, gender, race, hospital location and teaching status, insurance, median household income and Charlson Comorbidity Index, patients with NASH+frailty were at higher risk for all-cause inpatient mortality [OR: 4.66, 95% CI (2.70 – 8.05); p< 0.001] and organ-specific complications: cardiac [OR: 1.32, 95% CI (1.08 – 1.61); p=0.006], pulmonary [OR: 1.66, 95% CI (1.35 – 2.04); p< 0.001], and infectious [OR: 12.47, 95% CI (9.01 – 17.08); p< 0.001]. NASH+frailty was associated with higher odds of requiring intensive care [OR: 4.24, 95% CI (2.86 – 6.28); p< 0.001] and had longer length of stay [9.5 days versus 4.4 days (p< 0.001)] along with higher total charges [Difference: $70,087, 95% CI (59,882 – 89,292); p< 0.001] when compared to NASH-frailty (Table). Conclusion: Frailty was independently associated with worse outcomes and higher health care utilization in patients with NASH, even after adjustment for age and comorbidity. NASH patients with frailty might benefit from more aggressive approach during hospitalization to prevent adverse outcomes. Table 1. - Baseline characteristics and outcomes of the frail NASH and non-frail NASH group Variable NASH without Frailty n=7,040 NASH with Frailty* n= 6,790 p-value Female, % 59.80 64.58 0.011 Age (years), mean ± SD 62.16 ± 12.10 64.61 ± 11.10 < 0.001 Age >=65 years, % 46.45 52.80 < 0.001 Charlson Comorbidity Index, mean ± SD 3.89 ± 2.15 5.23 ± 2.30 < 0.001 Hospital Frailty Risk Score, mean ± SD 2.36 ± 1.54 8.51 ± 2.98 < 0.001 In-hospital all-cause mortality, % 1.35 6.19 < 0.001 Length of Stay (days), mean ± SD 4.47 ± 5.32 9.5 ± 11.65 < 0.001 Total Charges ($), mean ± SD 68,086 ± 185,054 141,708 ± 288,832 < 0.001 Cardiac complications, % 17.83 29.31 < 0.001 Pulmonary complications, % 17.47 27.76 < 0.001 Gastrointestinal complications, % 7.81 15.61 < 0.001 Infectious complications, % 3.76 29.23 < 0.001 Vasopressor use, % 0.71 3.02 < 0.001 Required intensive care unit care, % 2.63 9.79 < 0.001 Multivariate Regression Outcomes# Outcome Adjusted Odds Ratio (NASH+frailty vs non-frail) 95% CI p-value In-hospital mortality 4.66 [2.70 – 8.05] < 0.001 Length of stay (Days) 4.75& [3.72 – 5.58] < 0.001 Total charges ($) 70,087& [50,882.42 – 89,292.91] < 0.001 Cardiac complications 1.32 [1.08 – 1.61] 0.006 Pulmonary complications 1.66 [1.35 – 2.04] < 0.001 Gastrointestinal complications 2.31 [1.75 – 3.04] < 0.001 Infectious complications 12.47 [9.10 – 17.08] < 0.001 Vasopressor use 4.74 [2.12 – 10.63] < 0.001 Required intensive care unit care 4.24 [2.86 – 6.28] < 0.001 *Frail =Hospital Frailty Risk Score (HFRS)≥5.#Analysis adjusted for age, gender, race, hospital location and teaching status, insurance, median household income and Charlson co-morbidity index.&Adjusted co-efficient representing the average difference in this outcome between NASH+frailty and NASH-frailty.

Cardiac surgery in children with trisomy 13 or trisomy 18: How safe is it?

ObjectiveSurgery for heart defects in children with trisomy 13 or 18 is controversial. We analyzed our 20-year experience. MethodsSince 2002, we performed 21 operations in 19 children with trisomy 13 (n = 8) or trisomy 18 (n = 11). Age at operation was 4 days to 12 years (median, 154 days). Principal diagnosis was ventricular septal defect in 10 patients, tetralogy of Fallot in 7 patients, arch hypoplasia in 1 patient, and patent ductus arteriosus in 1 patient. ResultsThe initial operation was ventricular septal defect closure in 9 patients, tetralogy of Fallot repair in 7 patients, pulmonary artery banding in 1 patient, patent ductus arteriosus ligation in 1 patient, and aortic arch/coarctation repair in 1 patient. There were no operative or hospital deaths. Median postoperative intensive care and hospital stays were 189 hours (interquartile range, 70-548) and 14 days (interquartile range, 8.0-37.0), respectively, compared with median hospital stays in our center for ventricular septal defect repair of 4.0 days and tetralogy of Fallot repair of 5.0 days. On median follow-up of 17.4 months (interquartile range, 6.0-68), 1 patient was lost to follow-up after 5 months. Two patients had reoperation without mortality. There have been 5 late deaths (4 with trisomy 18, 1 with trisomy 13) predominately due to respiratory failure from 4 months to 9.4 years postoperatively. Five-year survival was 66.6% compared with 24% in a group of unoperated patients with trisomy 13 or 18. ConclusionsCardiac operation with an emphasis on complete repair can be performed safely in carefully selected children with trisomy 13 or trisomy 18. Hospital resource use measured by postoperative intensive care and hospital stays is considerably greater compared with nontrisomy 13 and 18.

Ambulatory Pathway for the Management of Superficial Abscesses: Criteria for Safe Provision of Care.

BackgroundSuperficial abscesses are common surgical emergencies and unless complicated, are considered a low-priority emergency often leading to delayed primary treatment. Patients who are clinically stable benefit more from an ambulatory-care approach to their treatment.Aim of studyThis is a retrospective study to investigate the current practice of treatment of superficial abscesses at West Suffolk Hospital, United Kingdom, and evaluate the potential impact of implementing care via the ambulatory pathway to improve patients' experience, optimise the use of hospital resources and identify areas for service improvement.Patients and methodsA total of 76 patients who required inpatient care for drainage of their superficial abscess under general anaesthesia over six months were a part of the study. Admission, procedure, and hospital stay characteristics were evaluated as well as our proposed superficial abscess ambulatory-care pathway (SAAP) criteria.ResultsThe mean age was 39 ± 18 years. Perianal and pilonidal abscesses accounted for 53% of the procedures. Only 24% of the patients had a C-reactive protein (CRP) >100 at admission. The average waiting time before intervention was 19 hours (± 16.25) with patients spending two days on average in the hospital for a procedure that lasted an average of 31 minutes. Overall, 39.5% of the patients received drainage of their abscess on the same day of presentation to the hospital with only five discharges on the same day of admission. Of the total patients, 52.6% met our SAAP criteria for ambulatory care and could have avoided inpatient care and benefitted from same-day discharges.ConclusionAmbulatory care of a superficial abscess is a safe, feasible approach. We recommend establishing an ambulatory care pathway for the management of superficial abscess cases with our SAAP criteria serving as a useful objective guide for effective and safe triage of patients with reduced hospital stay and more efficient utilisation of resources.

Plasma-induced nanoparticle aggregation for stratifying COVID-19 patients according to disease severity

Stratifying patients according to disease severity has been a major hurdle during the COVID-19 pandemic. This usually requires evaluating the levels of several biomarkers, which may be cumbersome when rapid decisions are required. In this manuscript we show that a single nanoparticle aggregation test can be used to distinguish patients that require intensive care from those that have already been discharged from the intensive care unit (ICU). It consists of diluting a platelet-free plasma sample and then adding gold nanoparticles. The nanoparticles aggregate to a larger extent when the samples are obtained from a patient in the ICU. This changes the color of the colloidal suspension, which can be evaluated by measuring the pixel intensity of a photograph. Although the exact factor or combination of factors behind the different aggregation behavior is unknown, control experiments demonstrate that the presence of proteins in the samples is crucial for the test to work. Principal component analysis demonstrates that the test result is highly correlated to biomarkers of prognosis and inflammation that are commonly used to evaluate the severity of COVID-19 patients. The results shown here pave the way to develop nanoparticle aggregation assays that classify COVID-19 patients according to disease severity, which could be useful to de-escalate care safely and make a better use of hospital resources.

Cost-Utility Analysis of Major System Change in Specialist Cancer Surgery in London, England, Using Linked Patient-Level Electronic Health Records and Difference-in-Differences Analysis.

BackgroundStudies have shown that centralising surgical treatment for some cancers can improve patient outcomes, but there is limited evidence of the impact on costs or health-related quality of life.ObjectivesWe report the results of a cost-utility analysis of the RESPECT-21 study using difference-in-differences, which investigated the reconfiguration of specialist surgery services for four cancers in an area of London, compared to the Rest of England (ROE).MethodsElectronic health records data were obtained from the National Cancer Registration and Analysis Service for patients diagnosed with one of the four cancers of interest between 2012 and 2017. The analysis for each tumour type used a short-term decision tree followed by a 10-year Markov model with 6-monthly cycles. Costs were calculated by applying National Health Service (NHS) Reference Costs to patient-level hospital resource use and supplemented with published data. Cancer-specific preference-based health-related quality-of-life values were obtained from the literature to calculate quality-adjusted life-years (QALYs). Total costs and QALYs were calculated before and after the reconfiguration, in the London Cancer (LC) area and in ROE, and probabilistic sensitivity analysis was performed to illustrate the uncertainty in the results.ResultsAt a threshold of £30,000/QALY gained, LC reconfiguration of prostate cancer surgery services had a 79% probability of having been cost-effective compared to non-reconfigured services using difference-in-differences. The oesophago-gastric, bladder and renal reconfigurations had probabilities of 62%, 49% and 12%, respectively, of being cost-effective at the same threshold. Costs and QALYs per surgical patient increased over time for all cancers across both regions to varying degrees. Bladder cancer surgery had the smallest patient numbers and changes in costs, and QALYs were not significant. The largest improvement in outcomes was in renal cancer surgery in ROE, making the relative renal improvements in LC appear modest, and the probability of the LC reconfiguration having been cost-effective low.ConclusionsProstate cancer reconfigurations had the highest probability of being cost-effective. It is not clear, however, whether the prostate results can be considered in isolation, given the reconfigurations occurred simultaneously with other system changes, and healthcare delivery in the NHS is highly networked and collaborative. Routine collection of quality-of-life measures such as the EQ-5D-5L would have improved the analysis.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40258-022-00745-w.

Safety and Cost Savings Associated with Reduced Inpatient Hospitalization for Microvascular Decompression

Microvascular decompression (MVD) has grown as a first-line surgical intervention for severe facial pain from trigeminal neuralgia and/or hemifacial spasm. We sought to examine the safety and cost-benefits of discharging patients with MVD within 1 day of admission. We retrospectively reviewed patients undergoing MVD at our institution from 2008 to 2020. Patients were sorted by 1 day, 2 days, or >2 days until discharge and by year from 2008 to 2013, 2014 to 2018, or 2019 to 2020. Patient presenting characteristics, intraoperative measures, and complications were documented. Statistical differences were calculated by one-way analysis of variance and χ2 analyses. Our cohort included 976 patients undergoing MVD, with 231 (23.6%) between 2008 and 2013, 517 (52.9%) between 2014 and 2018, and 228 (23.3%) between 2019 and 2020. Over time, postoperative admission rates to the critical care unit, total inpatient hospital admission times, and Barrow Neurological Institute scores at first follow-up decreased. Postoperative complications, including cerebrospinal fluid leak, decreased significantly. In addition, patients discharged within 1 day of admission incurred a total hospital cost of $26,689, which was $3588 lower than patients discharged within more than 1 day of admission, P< 0.0001. Discharging carefully selected patients who are appropriate for discharge within 1 day of admission could translate to a potential cost-savings of $255,346 per year in our clinical practice. In our experience, MVDs are a safe, elective intervention. Our findings suggest that postoperative day 1 discharge in patients with an uncomplicated postoperative course may be safe while improving hospital resource use.

Pneumonia after hip surgery in children with neurological complex chronic conditions.

In children with neurological complex chronic conditions (CCC) undergoing hip surgery we aimed to: estimate the rate of postoperative pneumonia, determine the effect of pneumonia on postoperative hospital resource use, and identify predictors of postoperative pneumonia. A retrospective cohort study was conducted utilizing the Pediatric Health Information System database for 2609 children (1081 females, 1528 males) aged 4 years and older with a neurological CCC who underwent hip surgery (i.e. reconstruction surgery or salvage procedure) between 2016 and 2018 in 41 US children's hospitals. Multivariable, mixed-effects logistic regression was used to assess patient characteristics and risk of pneumonia. Mean age at hip surgery was 10 years 1 month (SD 4y 8mo). The postoperative pneumonia rate was 1.6% (n=42). Median length of stay (LOS) was longer for children with pneumonia and the 30-day all-cause unplanned readmission rate and costs were higher. Variability in rates of pneumonia ranged from 1.1% to 2.8% across hospitals. Significant predictors of postoperative pneumonia were osteotomy type (p=0.005) and number of chronic conditions (p≤0.001). Postoperative pneumonia after hip surgery in children with a neurological CCC is associated with longer LOS, readmissions, and higher costs. Children undergoing pelvic osteotomies and who have multimorbidity need additional clinical support to prevent postoperative pneumonia and decrease resource utilization. Pneumonia is a major postoperative complication in children with neurological complex chronic conditions (CCC). Forty-two (1.6%) children with neurological CCC developed pneumonia after hip surgery. Length of stay, readmissions, and costs were significantly higher in the group with pneumonia. Variability in pneumonia rates existed across hospitals. Predictors of developing pneumonia include osteotomy type and number of CCC.

Cancellations and delays of emergent orthopedic operations at a Canadian level 1 trauma centre.

Background:Day-of surgery cancellation (DOSC) is considered to be a very inefficient use of hospital resources and results in emotional stress for the patient. To examine opportunities to minimize the incidence of preventable cancellations — an indicator of quality of care — we assessed the incidence of and reasons for DOSCs over 3 months among inpatients and outpatients at a trauma orthopedic service.Methods:This was a prospective study of 2 cohorts of patients, inpatients and outpatients, scheduled for emergent orthopedic surgery at a Canadian tertiary level 1 trauma centre from Jan. 1 to Mar. 31, 2020. Patient demographic characteristics, injury characteristics, delays until surgery and reasons for DOSCs were recorded.Results:A total of 185 patients (100 males and 85 females with a mean age of 54 yr) were included in the study. There were 98 outpatients and 87 inpatients. Seventy-five (40%) of the scheduled procedures in the outpatient group and 34 (30%) of those in the inpatient group were cancelled. In both groups, more than 85% of the cancellations were because of prioritization of a more urgent orthopedic or nonorthopedic surgical case. The average operative delay for the outpatient group was 11.4 days, compared to 3.8 days for the inpatient group (p < 0.001).Conclusion:High DOSC rates were observed among both outpatients and inpatients. The main reason for delaying surgery was prioritization of a more urgent surgical case. Providing the orthopedic trauma service with a dedicated OR opened 6 days per week, along with extended hours of OR services to 1700 daily, might be effective at minimizing DOSCs.

Prognostic indicators and outcomes of hospitalised COVID-19 patients with neurological disease: An individual patient data meta-analysis.

BackgroundNeurological COVID-19 disease has been reported widely, but published studies often lack information on neurological outcomes and prognostic risk factors. We aimed to describe the spectrum of neurological disease in hospitalised COVID-19 patients; characterise clinical outcomes; and investigate factors associated with a poor outcome.MethodsWe conducted an individual patient data (IPD) meta-analysis of hospitalised patients with neurological COVID-19 disease, using standard case definitions. We invited authors of studies from the first pandemic wave, plus clinicians in the Global COVID-Neuro Network with unpublished data, to contribute. We analysed features associated with poor outcome (moderate to severe disability or death, 3 to 6 on the modified Rankin Scale) using multivariable models.ResultsWe included 83 studies (31 unpublished) providing IPD for 1979 patients with COVID-19 and acute new-onset neurological disease. Encephalopathy (978 [49%] patients) and cerebrovascular events (506 [26%]) were the most common diagnoses. Respiratory and systemic symptoms preceded neurological features in 93% of patients; one third developed neurological disease after hospital admission. A poor outcome was more common in patients with cerebrovascular events (76% [95% CI 67–82]), than encephalopathy (54% [42–65]). Intensive care use was high (38% [35–41]) overall, and also greater in the cerebrovascular patients. In the cerebrovascular, but not encephalopathic patients, risk factors for poor outcome included breathlessness on admission and elevated D-dimer. Overall, 30-day mortality was 30% [27–32]. The hazard of death was comparatively lower for patients in the WHO European region.InterpretationNeurological COVID-19 disease poses a considerable burden in terms of disease outcomes and use of hospital resources from prolonged intensive care and inpatient admission; preliminary data suggest these may differ according to WHO regions and country income levels. The different risk factors for encephalopathy and stroke suggest different disease mechanisms which may be amenable to intervention, especially in those who develop neurological symptoms after hospital admission.

Evaluation of the Community Support Programme applied at the Intensive Psychiatric Rehabilitation Unit at the Parc Sanitari Sant Joan de Déu, Sant Boi

IntroductionOur hospital has chosen a model that goes beyond long-term hospital inpatient care to a community support for people with severe and persisting mental illnesses. This programme is called Community Support Programme (CSP) and focuses mainly on connecting patients who are being discharged from long-term hospitalization to a community based rehabilitation service.ObjectivesTo evaluate the effectiveness of the CSP among people with severe and persisting mental illness, as a method to support the positive outcomes and reduce the use of hospital resources after a discharge.MethodsThis is a retrospect, observational descriptive study. We reviewed 55 cases between 2017 and May of 2021. We analyzed demographic information, diagnosis, duration of stay in the CSP, number of hospitalizations before and after the program, number of emergency visits before and after this program and what kind of community rehabilitation services are connected after the discharge.ResultsWe found 58,2% male and 41,8% female. The main diagnoses were schizophrenia; schizoaffective and bipolar disorder. Before the CSP 85.4% of the patients had been hospitalized, and 76% had attended in a psychiatric emergency unit. After the discharge 36,36% required hospitalization, and 40% visited the psychiatric emergencies units. 54,54% of patients didn’t require hospital resources after their discharge from CSP.ConclusionsThe results suggest that the CSP helps to avoid hospitalization, reduce the use of hospital resources and drop outs. It helps the transition from hospitalization to a community based rehabilitation service.DisclosureNo significant relationships.

P54 MORTALITY AFTER CORONARY ARTERY BYPASS GRAFT IN PATIENTS WITH PRIOR PERCUTANEOUS CORONARY INTERVENTION

Abstract Background The clinical impact of prior percutaneous coronary intervention (PCI) in patients requiring surgical revascularization (CABG) is not well investigated. We explore whether prior PCI is associated with adverse outcome after CABG. Methods and Results Operations conducted between October 2014 and July 2021 at Magna Graecia University were analyzed using propensity weighted methodology to adjust for confounding. Of a total of 1410 adult patients included in the study, (24%) patients had a history of PCI. At multivariable level, prior PCI was not associated with an increased hospital mortality in both unweighted and weighted patient groups (odds ratio, 0.77; 95%; P = 0.41 and odds ratio, 0.93; 95% confidence interval; P = 0.84, respectively). Subgroup analyses confirmed that prior PCI had no impact on hospital mortality and morbidity, including reexploration for bleeding, blood transfusion, hospital resource use, and neurological, renal, and cardiac complications. Conclusions Our study showed that prior PCI was not associated with an increased risk of mortality or other adverse outcomes in patients undergoing CABG. Further studies are needed to ascertain the prognostic impact of prior PCI in the outcome after CABG.

Association of frailty with outcomes after elective colon resection for diverticular disease

BackgroundFrailty has been associated with greater postoperative morbidity and mortality but its impact has not been investigated in patients with diverticulitis undergoing elective colon resection. Therefore, the present study examined the association of frailty with perioperative outcomes following elective colectomy for diverticular disease. MethodsThe 2017–2019 American College of Surgeons-National Surgical Quality Improvement Program data registry was queried to identify patients (aged ≥18 years) undergoing elective colon resection for diverticular disease. The 5-factor modified frailty index (mFI-5) was used to stratify patients into non-frail (mFI 0), prefrail (mFI 1), and frail (mFI ≥2) cohorts. Major adverse events, surgical site infection, and postoperative ileus as well as prolonged length of stay, nonhome discharge, and unplanned readmission were evaluated using multivariable logistic models. ResultsOf the 20,966 patients, 10.0% were frail. Compared to others, frail patients were generally older (non-frail: 55 years, [46–63], prefrail: 62, [54–70], frail: 64, [57–71]) and more commonly female (non-frail: 53.1%, prefrail: 58.6, frail: 64.4, P < .001). Frail patients more frequently underwent open colectomy and stoma creation compared with others. Frailty was associated with greater adjusted odds of major adverse event (adjusted odds ratio 1.25, 95% confidence interval 1.06–1.48), surgical site infection (adjusted odds ratio 1.28, 95% confidence interval 1.06–1.54), and postoperative ileus (adjusted odds ratio 1.59, 95% confidence interval 1.27–1.98). Similarly, frailty portended greater odds of prolonged length of stay, nonhome discharge, and unplanned readmission. ConclusionFrailty as defined by the mFI-5 was associated with greater morbidity and hospital resource use. Deployment of frailty instruments may augment traditional risk calculators and improve patient selection for elective colectomy.

Ultrasound localization of central vein catheter tip by contrast-enhanced transthoracic ultrasonography: a comparison study with trans-esophageal echocardiography

BackgroundTo assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard.MethodsA prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients.ResultsAs per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p < 0.001) for CE-TTE via epigastric bicaval acoustic view.ConclusionsThe concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure.

Association between periodontal care and hospitalization with acute myocardial infarction

BackgroundEach year there are 800,000 myocardial infarctions in the United States. There is an increased risk of hospitalization for acute myocardial infarction (AMI) for those with periodontal disease. Yet, there is a paucity of knowledge about downstream care of AMI and how this varies with periodontal care status. The authors' aim was to examine the association between periodontal care and AMI hospitalization and 30 days after acute care. MethodsUsing the MarketScan database, the authors conducted a retrospective cohort study among patients with both dental insurance and medical insurance in 2016 through 2018 who were hospitalized for AMI in 2017. ResultsThere were 2,370 patients who had dental and medical coverage for 2016 through 2018 and received oral health care in 2016 through 2017 and had an AMI hospitalization in 2017. Forty-seven percent received regular or other oral health care, 7% received active periodontal care, and 10% received controlled periodontal care. More than one-third of patients (36%) did not have oral health care before the AMI hospitalization. After adjusting for patient characteristics, we found that patients in the controlled periodontal care group were significantly more likely to have visits during the 30 days after AMI hospitalization (adjusted odds ratio, 1.63; 95% CI, 1.07 to 2.47; P = .02). ConclusionsWe found that periodontal care was associated with more after AMI visits. This suggests that there is a benefit to incorporating oral health care and medical care to improve AMI outcomes. Practical ImplicationsNeeding periodontal care is associated with more favorable outcomes related to AMI hospitalization. Early intervention to ensure stable periodontal health in patients with risk factors for AMI could reduce downstream hospital resource use.

Machine learning approaches to predicting no-shows in pediatric medical appointment

Patients’ no-shows, scheduled but unattended medical appointments, have a direct negative impact on patients’ health, due to discontinuity of treatment and late presentation to care. They also lead to inefficient use of medical resources in hospitals and clinics. The ability to predict a likely no-show in advance could enable the design and implementation of interventions to reduce the risk of it happening, thus improving patients’ care and clinical resource allocation. In this study, we develop a new interpretable deep learning-based approach for predicting the risk of no-shows at the time when a medical appointment is first scheduled. The retrospective study was conducted in an academic pediatric teaching hospital with a 20% no-show rate. Our approach tackles several challenges in the design of a predictive model by (1) adopting a data imputation method for patients with missing information in their records (77% of the population), (2) exploiting local weather information to improve predictive accuracy, and (3) developing an interpretable approach that explains how a prediction is made for each individual patient. Our proposed neural network-based and logistic regression-based methods outperformed persistence baselines. In an unobserved set of patients, our method correctly identified 83% of no-shows at the time of scheduling and led to a false alert rate less than 17%. Our method is capable of producing meaningful predictions even when some information in a patient’s records is missing. We find that patients’ past no-show record is the strongest predictor. Finally, we discuss several potential interventions to reduce no-shows, such as scheduling appointments of high-risk patients at off-peak times, which can serve as starting point for further studies on no-show interventions.

Advance care planning and use of hospital resources among COVID-19 nursing home patients in an integrated care programme for the elderly

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Treatments, resource utilization, and outcomes of COVID-19 patients presenting to emergency departments across pandemic waves: an observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN)

BackgroundTreatment for coronavirus disease 2019 (COVID-19) evolved between pandemic waves. Our objective was to compare treatments, acute care utilization, and outcomes of COVID-19 patients presenting to emergency departments (ED) across pandemic waves.MethodsThis observational study enrolled consecutive eligible COVID-19 patients presenting to 46 EDs participating in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) between March 1 and December 31, 2020. We collected data by retrospective chart review. Our primary outcome was in-hospital mortality. Secondary outcomes included treatments, hospital and ICU admissions, ED revisits and readmissions. Logistic regression modeling assessed the impact of pandemic wave on outcomes.ResultsWe enrolled 9,967 patients in 8 provinces, 3,336 from the first and 6,631 from the second wave. Patients in the second wave were younger, fewer met criteria for severe COVID-19, and more were discharged from the ED. Adjusted for patient characteristics and disease severity, steroid use increased (odds ratio [OR] 7.4; 95% confidence interval [CI] 6.2–8.9), and invasive mechanical ventilation decreased (OR 0.5; 95% CI 0.4–0.7) in the second wave compared to the first. After adjusting for differences in patient characteristics and disease severity, the odds of hospitalization (OR 0.7; 95% CI 0.6–0.8) and critical care admission (OR 0.7; 95% CI 0.6–0.9) decreased, while mortality remained unchanged (OR 0.7; 95% CI 0.5–1.1).InterpretationIn patients presenting to cute care facilities, we observed rapid uptake of evidence-based therapies and less use of experimental therapies in the second wave. We observed increased rates of ED discharges and lower hospital and critical care resource use over time. Substantial reductions in mechanical ventilation were not associated with increasing mortality. Advances in treatment strategies created health system efficiencies without compromising patient outcomes.Trial registrationClinicaltrials.gov, NCT04702945.

COVID-19-associated hospitalizations among children less than 12 years of age in the United States

Objectives To describe the characteristics, healthcare resource use and costs associated with initial hospitalization and readmissions among pediatric patients with COVID-19 in the US. Methods Hospitalized pediatric patients, 0–11 years of age, with a primary or secondary discharge diagnosis code for COVID-19 (ICD-10 code U07.1) were selected from 1 April 2020 to 30 September 2021 in the US Premier Healthcare Database Special Release (PHD SR). Patient characteristics, hospital length of stay (LOS), in-hospital mortality, hospital costs, hospital charges, and COVID-19-associated readmission outcomes were evaluated and stratified by age groups (0–4, 5–11), four COVID-19 disease progression states based on intensive care unit (ICU) and invasive mechanical ventilation (IMV) usage, and three sequential calendar periods. Sensitivity analyses were performed using the US HealthVerity claims database and restricting the analyses to the primary discharge code. Results Among 4,573 hospitalized pediatric patients aged 0–11 years, 68.0% were 0–4 years and 32.0% were 5–11 years, with a mean (median) age of 3.2 (1) years; 56.0% were male, and 67.2% were covered by Medicaid. Among the overall study population, 25.7% had immunocompromised condition(s), 23.1% were admitted to the ICU and 7.3% received IMV. The mean (median) hospital LOS was 4.3 (2) days, hospital costs and charges were $14,760 ($6,164) and $58,418 ($21,622), respectively; in-hospital mortality was 0.5%. LOS, costs, charges, and in-hospital mortality increased with ICU admission and/or IMV usage. In total, 2.1% had a COVID-19-associated readmission. Study outcomes appeared relatively more frequent and/or higher among those 5–11 than those 0–4. Results using the HealthVerity data source were generally consistent with main analyses. Limitations This retrospective administrative database analysis relied on coding accuracy and inpatient admissions with validated hospital costs. Conclusions These findings underscore that children aged 0–11 years can experience severe COVID-19 illness requiring hospitalization and substantial hospital resource use, further supporting recommendations for COVID-19 vaccination.