Hospital Admissions in Children with Down Syndrome: Experience of a Population-Based Cohort Followed from Birth

Objective

Children with Down syndrome, the most common genetic cause of intellectual disability, are prone to multiple and varied health-related problems. This study describes patterns of hospitalisations for children and young people with Down syndrome in Western Australia.

Methods

Birth records were linked to the Western Australian population-based Intellectual Disability database to identify all children born with Down syndrome in Western Australia between 1 January, 1983 and 31 December, 1999. These records were linked to the Hospital Morbidity Data System to provide information on all hospitalisations up to 31 December, 2004. Hospitalisation data, coded using ICD-9CM or ICD-10 (v0.5) were grouped into clinically relevant categories using the primary diagnosis. Rates of hospital admission for all and specific diagnoses were expressed in 1000-person-years at-risk and median age at first admission and length of stay were calculated.

Results

Of the 405 children, 395 had one or more hospital admissions, totalling 3786 admissions for all children and an estimated 39.5 person-years in hospital. On average, children were admitted 9.7 times, with an estimated rate of 757.2 admissions per 1000pyr (95% CI: 680, 843). A quarter of all admissions occurred in the first year of life. The average hospital length of stay was 3.8 days (95% CI: 3.7, 4.1). Upper respiratory tract conditions affected the most children (58.5%) and accounted for 12.1% of all admissions. Other disorders which affected a high percentage of children were ear/hearing conditions (50.6%), disorders of the oral cavity (38.0%) and lower respiratory tract conditions (37.5%). Overall, children with Down syndrome were hospitalised at a rate five times (95% CI = 4.3–6.2) that of the general population.

Conclusion

Children with Down syndrome are at increased risk of morbidity for varied causes underlining the importance of comprehensive and targeted primary care for this group.     

The Contribution of Geography to Disparities in Preventable Hospitalisations between Indigenous and Non-Indigenous Australians

Objectives

To quantify the independent roles of geography and Indigenous status in explaining disparities in Potentially Preventable Hospital (PPH) admissions between Indigenous and non-Indigenous Australians.

Design, setting and participants

Analysis of linked hospital admission data for New South Wales (NSW), Australia, for the period July 1 2003 to June 30 2008.

Main outcome measures

Age-standardised admission rates, and rate ratios adjusted for age, sex and Statistical Local Area (SLA) of residence using multilevel models.

Results

PPH diagnoses accounted for 987,604 admissions in NSW over the study period, of which 3.7% were for Indigenous people. The age-standardised PPH admission rate was 76.5 and 27.3 per 1,000 for Indigenous and non-Indigenous people respectively. PPH admission rates in Indigenous people were 2.16 times higher than in non-Indigenous people of the same age group and sex who lived in the same SLA. The largest disparities in PPH admission rates were seen for diabetes complications, chronic obstructive pulmonary disease and rheumatic heart disease. Both rates of PPH admission in Indigenous people, and the disparity in rates between Indigenous than non-Indigenous people, varied significantly by SLA, with greater disparities seen in regional and remote areas than in major cities.

Conclusions

Higher rates of PPH admission among Indigenous people are not simply a function of their greater likelihood of living in rural and remote areas. The very considerable geographic variation in the disparity in rates of PPH admission between Indigenous and non-Indigenous people indicates that there is potential to reduce unwarranted variation by characterising outlying areas which contribute the most to this disparity.     

Effects of Meteorological Factors on Daily Hospital Admissions for Asthma in Adults: A Time-Series Analysis

Background

There is limited evidence for the impacts of meteorological changes on asthma hospital admissions in adults in Shanghai, China.

Objectives

To quantitatively evaluate the short-term effects of daily mean temperature on asthma hospital admissions.

Methods

Daily hospital admissions for asthma and daily mean temperatures between January 2005 and December 2012 were analyzed. After controlling for secular and seasonal trends, weather, air pollution and other confounding factors, a Poisson generalized additive model (GAM) combined with a distributed lag non-linear model were used to explore the associations between temperature and hospital admissions for asthma.

Results

During the study periods, there were 15,678 hospital admissions for asthma by residents of Shanghai, an average 5.6 per day. Pearson correlation analysis found a significant negative correlation (r = −0.174, P<0.001) between asthma hospitalizations and daily mean temperature (DMT). The DMT effect on asthma increased below the median DMT, with lower temperatures associated with a higher risk of hospital admission for asthma. Generally, the cold effect appeared to be relatively acute, with duration lasting several weeks, while the hot effect was short-term. The relative risk of asthma hospital admissions associated with cold temperature (the 25^th percentile of temperature relative to the median temperature) was 1.20 (95% confidence interval [CI], 1.01∼1.41) at lag0-14. However, warmer temperatures were not associated with asthma hospital admissions.

Conclusions

Cold temperatures may trigger asthmatic attacks. Effective strategies are needed to protect populations at risk from the effects of cold.     

Increasing Short-Stay Unplanned Hospital Admissions among Children in England; Time Trends Analysis ’97–‘06

Background

Timely care by general practitioners in the community keeps children out of hospital and provides better continuity of care. Yet in the UK, access to primary care has diminished since 2004 when changes in general practitioners'' contracts enabled them to ‘opt out’ of providing out-of-hours care and since then unplanned pediatric hospital admission rates have escalated, particularly through emergency departments. We hypothesised that any increase in isolated short stay admissions for childhood illness might reflect failure to manage these cases in the community over a 10 year period spanning these changes.

Methods and Findings

We conducted a population based time trends study of major causes of hospital admission in children <10 years using the Hospital Episode Statistics database, which records all admissions to all NHS hospitals in England using ICD10 codes. Outcomes measures were total and isolated short stay unplanned hospital admissions (lasting less than 2 days without readmission within 28 days) from 1997 to 2006. Over the period annual unplanned admission rates in children aged <10 years rose by 22% (from 73.6/1000 to 89.5/1000 child years) with larger increases of 41% in isolated short stay admissions (from 42.7/1000 to 60.2/1000 child years). There was a smaller fall of 12% in admissions with length of stay of >2 days. By 2006, 67.3% of all unplanned admissions were isolated short stays <2 days. The increases in admission rates were greater for common non-infectious than infectious causes of admissions.

Conclusions

Short stay unplanned hospital admission rates in young children in England have increased substantially in recent years and are not accounted for by reductions in length of in-hospital stay. The majority are isolated short stay admissions for minor illness episodes that could be better managed by primary care in the community and may be evidence of a failure of primary care services.     

Inaccurate Ascertainment of Morbidity and Mortality due to Influenza in Administrative Databases: A Population-Based Record Linkage Study

Background

Historically, counting influenza recorded in administrative health outcome databases has been considered insufficient to estimate influenza attributable morbidity and mortality in populations. We used database record linkage to evaluate whether modern databases have similar limitations.

Methods

Person-level records were linked across databases of laboratory notified influenza, emergency department (ED) presentations, hospital admissions and death registrations, from the population (∼6.9 million) of New South Wales (NSW), Australia, 2005 to 2008.

Results

There were 2568 virologically diagnosed influenza infections notified. Among those, 25% of 40 who died, 49% of 1451 with a hospital admission and 7% of 1742 with an ED presentation had influenza recorded on the respective database record. Compared with persons aged ≥65 years and residents of regional and remote areas, respectively, children and residents of major cities were more likely to have influenza coded on their admission record. Compared with older persons and admitted patients, respectively, working age persons and non-admitted persons were more likely to have influenza coded on their ED record. On both ED and admission records, persons with influenza type A infection were more likely than those with type B infection to have influenza coded. Among death registrations, hospital admissions and ED presentations with influenza recorded as a cause of illness, 15%, 28% and 1.4%, respectively, also had laboratory notified influenza. Time trends in counts of influenza recorded on the ED, admission and death databases reflected the trend in counts of virologically diagnosed influenza.

Conclusions

A minority of the death, hospital admission and ED records for persons with a virologically diagnosed influenza infection identified influenza as a cause of illness. Few database records with influenza recorded as a cause had laboratory confirmation. The databases have limited value for estimating incidence of influenza outcomes, but can be used for monitoring variation in incidence over time.     

Risk of Maltreatment-Related Injury: A Cross-Sectional Study of Children under Five Years Old Admitted to Hospital with a Head or Neck Injury or Fracture

Objectives

To determine the predictive value and sensitivity of demographic features and injuries (indicators) for maltreatment-related codes in hospital discharge records of children admitted with a head or neck injury or fracture.

Methods

Study design: Population-based, cross sectional study. Setting: NHS hospitals in England. Subjects: Children under five years old admitted acutely to hospital with head or neck injury or fracture. Data source: Hospital Episodes Statistics, 1997 to 2009. Main outcome measure: Maltreatment-related injury admissions, defined by ICD10 codes, were used to calculate for each indicator (demographic feature and/or type of injury): i) the predictive value (proportion of injury admissions that were maltreatment-related); ii) sensitivity (proportion of all maltreatment-related injury admissions with the indicator).

Results

Of 260,294 childhood admissions for fracture or head or neck injury, 3.2% (8,337) were maltreatment-related. With increasing age of the child, the predictive value for maltreatment-related injury declined but sensitivity increased. Half of the maltreatment-related admissions occurred in children older than one year, and 63% occurred in children with head injuries without fractures or intracranial injury.

Conclusions

Highly predictive injuries accounted for very few maltreatment-related admissions. Protocols that focus on high-risk injuries may miss the majority of maltreated children.     

Health Behaviours and Potentially Preventable Hospitalisation: A Prospective Study of Older Australian Adults

Objective

Several studies have demonstrated the effects of health behaviours on risk of chronic diseases and mortality, but none have investigated their contribution to potentially preventable hospitalisation (PPH). We aimed to quantify the effects on risk of PPH of six health behaviours: smoking; alcohol consumption; physical activity; fruit and vegetables consumption; sitting time; and sleeping time.

Design/Setting

Prospective observational study in New South Wales, Australia.

Subjects

267,006 men and women aged 45 years and over.

Outcome Measures

PPH admissions and mortality during follow-up according to individual positive health behaviours (non-smoking, <14 alcoholic drinks per week, ≥2.5 hours of physical activity per week, ≥2 servings of fruit and 5 servings of vegetables per day, <8 hours sitting and ≥7 hours sleeping per day) and the total number of these behaviours.

Results

During an average of 3 years follow-up, 20971 (8%) participants had at least one PPH admission. After adjusting for potential confounders, participants who reported all six positive health behaviours at baseline had 46% lower risk of PPH admission (95% CI 0.48–0.61), compared to those who reported having only one of these behaviours. Based on these risk estimates, approximately 29% of PPH admissions in Australians aged 45 years and over were attributable to not adhering to the six health behaviours. Estimates were similar for acute, chronic and vaccine-preventable categories of PPH admissions.

Conclusions

Individual and combined positive health behaviours were associated with lower risk of PPH admission. These findings suggest that there is a significant opportunity to reduce PPH by promoting healthy behaviours.     

The Effect of a Smoking Ban on Hospitalization Rates for Cardiovascular and Respiratory Conditions in Prince Edward Island,Canada

Background

This is the first study to have examined the effect of smoking bans on hospitalizations in the Atlantic Canadian socio-economic, cultural and climatic context. On June 1, 2003 Prince Edward Island (PEI) enacted a province-wide smoking ban in public places and workplaces. Changes in hospital admission rates for cardiovascular (acute myocardial infarction, angina, and stroke) and respiratory (chronic obstructive pulmonary disease and asthma) conditions were examined before and after the smoking ban.

Methods

Crude annual and monthly admission rates for the above conditions were calculated from April 1, 1995 to December 31, 2008 in all PEI acute care hospitals. Autoregressive Integrated Moving Average time series models were used to test for changes in mean and trend of monthly admission rates for study conditions, control conditions and a control province after the comprehensive smoking ban. Age- and sex-based analyses were completed.

Results

The mean rate of acute myocardial infarctions was reduced by 5.92 cases per 100,000 person-months (P = 0.04) immediately after the smoking ban. The trend of monthly angina admissions in men was reduced by −0.44 cases per 100,000 person-months (P = 0.01) in the 67 months after the smoking ban. All other cardiovascular and respiratory admission changes were non-significant.

Conclusions

A comprehensive smoking ban in PEI reduced the overall mean number of acute myocardial infarction admissions and the trend of angina hospital admissions.     

Association between depression and hospital outcomes among older men

Background:

Studies that have investigated the relation between depression and the type, nature, extent and outcome of general hospital admissions have been limited by their retrospective designs and focus on specific clinical populations. We explored this relation prospectively in a large, community-based sample of older men.

Methods:

A cohort of 5411 men aged 69 years and older enrolled in the Health in Men Study was assessed at baseline for depressive symptoms, defined as a score of 7 or higher on the 15-item Geriatric Depression Scale. Participants were followed for 2 years for occurrence and number of hospital admissions, type of hospital admission, length of hospital stay and inpatient death as recorded in the Western Australian Data Linkage System.

Results:

Of 339 men with depressive symptoms, 152 (44.8%) had at least 1 emergency hospital admission, compared with 1164 of 5072 (22.9%) nondepressed men (p < 0.001). In multivariate analyses, the presence of depressive symptoms was a significant independent predictor of hospital admission (hazard ratio 1.67, 95% confidence interval [CI] 1.38–2.01), number of hospital admissions (incidence rate ratio [IRR] 1.22, 95% CI 1.07–1.39) and total length of hospital stay (IRR 1.65, 95% CI 1.36–2.01).

Interpretation:

Participants with depressive symptoms were at higher risk of hospital admission for nonpsychiatric conditions and were more likely to have longer hospital stays and worse hospital outcomes, compared with nondepressed participants. These results highlight the potential to target this high-risk group to reduce the burden of health care costs in an aging population.Older people are the most frequent users of health services, and the progressive aging of the world’s population may lead to a saturation of available services. Therefore, we must find ways to reduce preventable admissions to hospital and uncover the factors associated with potentially preventable use of health services. An association between depression and hospital admission for nonpsychiatric conditions has been postulated, although the data have been limited to specific clinical populations and the interpretation of the results hampered by the retrospective study design and the use of self-reported outcomes.^1–8 Consequently, these findings cannot be easily generalized or used to develop data-driven interventions.We addressed this gap in the literature by using a community-based population survey with prospective data linkage to measure important health-related outcomes. Our main objective was to investigate whether community-dwelling older men with depressive symptoms were more likely than nondepressed men to be admitted to general hospitals. Our other aims were to determine whether the long-term clinical outcomes of these 2 groups differed in relation to the number of future hospital admissions, length of hospital stay and inpatient deaths.     

Life Course Impact of School-Based Promotion of Healthy Eating and Active Living to Prevent Childhood Obesity

Background

The Alberta Project Promoting active Living and healthy Eating in Schools (APPLE Schools) is a comprehensive school health program that is proven feasible and effective in preventing obesity among school aged children. To support decision making on expanding this program, evidence on its long-term health and economic impacts is particularly critical. In the present study we estimate the life course impact of the APPLE Schools programs in terms of future body weights and avoided health care costs.

Method

We modeled growth rates of body mass index (BMI) using longitudinal data from the National Population Health Survey collected between 1996–2008. These growth rate characteristics were used to project BMI trajectories for students that attended APPLE Schools and for students who attended control schools (141 randomly selected schools) in the Canadian province of Alberta.

Results

Throughout the life course, the prevalence of overweight (including obesity) was 1.2% to 2.8% (1.7 on average) less among students attending APPLE Schools relative to their peers attending control schools. The life course prevalence of obesity was 0.4% to 1.4% (0.8% on average) less among APPLE Schools students. If the APPLE Schools program were to be scaled up, the potential cost savings would be $33 to 82 million per year for the province of Alberta, or $150 to 330 million per year for Canada.

Conclusions

These projected health and economic benefits seem to support broader implementation of school-based health promotion programs.     

Trends in Severity of Illness on ICU Admission and Mortality among the Elderly

Background

There is an increase in admission rate for elderly patients to the ICU. Mortality rates are lower when more liberal ICU admission threshold are compared to more restrictive threshold. We sought to describe the temporal trends in elderly admissions and outcomes in a tertiary hospital before and after the addition of an 8-bed medical ICU.

Methods

We conducted a retrospective analysis of a comprehensive longitudinal ICU database, from a large tertiary medical center, examining trends in patients’ characteristics, severity of illness, intensity of care and mortality rates over the years 2001–2008. The study population consisted of elderly patients and the primary endpoints were 28 day and one year mortality from ICU admission.

Results

Between the years 2001 and 2008, 7,265 elderly patients had 8,916 admissions to ICU. The rate of admission to the ICU increased by 5.6% per year. After an eight bed MICU was added, the severity of disease on ICU admission dropped significantly and crude mortality rates decreased thereafter. Adjusting for severity of disease on presentation, there was a decreased mortality at 28- days but no improvement in one- year survival rates for elderly patient admitted to the ICU over the years of observation. Hospital mortality rates have been unchanged from 2001 through 2008.

Conclusion

In a high capacity ICU bed hospital, there was a temporal decrease in severity of disease on ICU admission, more so after the addition of additional medical ICU beds. While crude mortality rates decreased over the study period, adjusted one-year survival in ICU survivors did not change with the addition of ICU beds. These findings suggest that outcome in critically ill elderly patients may not be influenced by ICU admission. Adding additional ICU beds to deal with the increasing age of the population may therefore not be effective.     

Effects of Italian smoking regulation on rates of hospital admission for acute coronary events: a country-wide study

Background

Several studies have reported a reduction in acute coronary events (ACEs) in the general population after the enforcement of smoking regulations, although there is uncertainty concerning the magnitude of the effect of such interventions. We conducted a country-wide evaluation of the health effects of the introduction of a smoking ban in public places, using data on hospital admissions for ACEs from the Italian population after the implementation of a national smoking regulation in January 2005.

Methods and Findings

Rates of admission for ACEs in the 20 Italian regions from January 2002 to November 2006 were analysed using mixed-effect regression models that allowed for long-term trends and seasonality. Standard methods for interrupted time-series were adopted to assess the immediate and gradual effects of the smoking ban. Effect modification by age was investigated, with the assumption that exposure to passive smoking in public places would be greater among young people. In total, 936,519 hospital admissions for ACEs occurred in the Italian population during the study period. A 4% reduction in hospital admissions for ACEs among persons aged less than 70 years was evident after the introduction of the ban (Rate Ratio [RR], 0.96; 95% Confidence Interval [CI], 0.95–0.98). No effect was found among persons aged at least 70 years (RR 1.00; 95% CI 0.99–1.02). Effect modification by age was further suggested by analyses using narrower age categories.

Conclusions

Smoke-free policies can constitute a simple and inexpensive intervention for the prevention of cardiovascular diseases and thus should be included in prevention programmes.     

Ischemic Stroke Hospital Admission Associated with Ambient Temperature in Jinan,China

Background

This study estimated the effects of ambient temperature and relative humidity on hospital admissions for ischemic stroke during 1990–2009 in Jinan, China.

Methods

To account for possible delayed effects and harvesting effect, we examined the impact of meteorological factors up to 30 days before each admission using a distributed lag non-linear model; we controlled for season, long-term trend, day of week and public holidays in the analysis. Stratified analyses were also done for summer and winter.

Results

A total of 1,908 ischemic stroke hospital admissions were observed between 1990 and 2009. We found a strong non-linear acute effect of daily temperatures on ischemic stroke hospital admission. With the mean temperature 15°C as the reference, the relative risk (RR) was 1.43 (95% confidence interval (CI): 1.10–1.85) for 0°C daily temperature on the same day, and 0.43 (95% CI: 0.31–0.59) for 30°C daily temperature on the same day, respectively. The effect of ambient temperature was similar in summer and winter. No significant association was observed between relative humidity and ischemic stroke hospitalization.

Conclusions

Low temperature might be a risk factor for ischemic stroke, and high temperature might be protective factor of ischemic stroke occurrence in Jinan, China.     

Family caregivers' experiences of involuntary psychiatric hospital admissions of their relatives--a qualitative study

Background

Family caregivers of people with mental disorders are frequently involved in involuntary hospital admissions of their relatives.

Objective

To explore family caregivers'' experience of involuntary admission of their relative.

Method

30 in-depth interviews were conducted with family caregivers of 29 patients who had been involuntarily admitted to 12 hospitals across England. Interviews were analysed using thematic analysis.

Results

Four major themes of experiences were identified: relief and conflicting emotions in response to the relative''s admission; frustration with a delay in getting help; being given the burden of care by services; and difficulties with confidentiality.Relief was a predominant emotion as a response to the relative''s admission and it was accompanied by feelings of guilt and worry. Family caregivers frequently experienced difficulties in obtaining help from services prior to involuntary admission and some thought that services responded to crises rather than prevented them. Family caregivers experienced increased burden when services shifted the responsibility of caring for their mentally unwell relatives to them. Confidentiality was a delicate issue with family caregivers wanting more information and a say in decisions when they were responsible for aftercare, and being concerned about confidentiality of information they provided to services.

Conclusion

Compulsory admission of a close relative can be a complex and stressful experience for family caregivers. In order for caregivers to be effective partners in care, a balance needs to be struck between valuing their involvement in providing care for a patient and not overburdening them.     

Trends in 1-year survival of people admitted to hospital in Ontario, 1994–2009

Background:

Changes in the long-term survival of people admitted to hospital is unknown. This study examined trends in 1-year survival of patients admitted to hospital adjusted for improved survival in the general population.

Methods:

One-year survival after admission to hospital was determined for all adults admitted to hospital in Ontario in 1994, 1999, 2004, or 2009 by linking to vital statistics datasets. Annual survival in the general population was determined from life tables for Ontario.

Results:

Between 1994 and 2009, hospital use decreased (from 8.8% to 6.3% of the general adult population per year), whereas crude 1-year mortality among people with hospital admissions increased (from 9.2% to 11.6%). During this time, patients in hospital became significantly older (median age increased from 51 to 58 yr) and sicker (the proportion with a Charlson comorbidity index score of 0 decreased from 68.2% to 60.0%), and were more acutely ill on admission (elective admissions decreased from 47.4% to 42.0%; proportion brought to hospital by ambulance increased from 16.1% to 24.8%). Compared with 1994, the adjusted odds ratio (OR) for death at 1 year in 2009 was 0.78 (95% confidence interval [CI] 0.77–0.79). However, 1-year risk of death in the general population decreased by 24% during the same time. After adjusting for improved survival in the general population, risk of death at 1 year for people admitted to hospital remained significantly lower in 2009 than in 1994 (adjusted relative excess risk 0.81, 95% CI 0.80–0.82).

Interpretation:

After accounting for both the increased burden of patient sickness and improved survival in the general population, 1-year survival for people admitted to hospital increased significantly from 1994 to 2009. The reasons for this improvement cannot be determined from these data. Hospitals have a special place in most health care systems. Hospital staff care for the people with the most serious illnesses and the most vulnerable. They are frequently the location of many life-defining moments — including birth, surgery, acute medical illness and death — of many people and their families. Hospitals serve as a focus in the training of most physicians. In addition, they consume a considerable proportion of health care expenditures worldwide. ¹ Given the prominence of hospitals in health care systems, measuring outcomes related to hospital care is important. In particular, the measurement of trends for outcomes of hospital care can help us to infer whether the care provided to hospital patients is improving. Previous such studies have focused on survival trends for specific diseases or patients who received treatment in specific departments. ^{2 – 12} None of these studies have adjusted for survival trends in the general population, the adjustment for which is important to determine whether changes in survival of patients in hospital merely reflect changes in the overall population. In this study, whether or not patient outcomes have changed over time was determined by examining trends in 1-year survival in all patients admitted to hospital, adjusting for improved survival in the general population.     

Trend of Urban-Rural Disparities in Hospital Admissions and Medical Expenditure in China from 2003 to 2011

Objectives

To assess the trend of urban-rural disparities in hospital admissions and medical expenditure between 2003 and 2011 in the context of Chinese health-care system reform.

Methods

The data were from three different national surveys: the Third National Health Services Survey in 2003, the Fourth National Health Services Survey in 2008 and the national health-care reform phased assessment survey in 2011. There were 151421, 143380 and 48356 respondents aged 15 years or older in 2003, 2008 and 2011, respectively.

Results

The health insurance coverage expanded considerably from 27.7% in 2003 to 96.4% in 2011 among respondents aged 15 years or older. Hospitalization rate increased rapidly from 4.1% in 2003 to 9.6% in 2011. Urban respondents had higher hospital admissions than rural respondents, and the RR (95% CI) of hospitalization was 1.23 (1.17–1.30), 1.06 (1.02–1.10) and 1.16 (1.10–1.23) in 2003, 2008 and 2011, respectively. The urban-rural disparity in hospital admissions significantly narrowed over time. Urban respondents had a higher admission rate if insured and a lower admission if not insured than their rural counterparts. Of the six medical expenditure measures, the disparities in reimbursement rate and the proportion of hospitalization direct cost to the total consumer spending significantly narrowed.

Conclusions

The health insurance coverage has been continually expanding and health service utilization has been substantially improved. Urban-rural disparities have been narrowed but still exist. Therefore, policy-makers should focus on increasing investment and reimbursement levels, developing a uniform standard health insurance system for urban and rural residents and improving the medical assistance system.     

Are AMI Patients with Comorbid Mental Illness More Likely to be Admitted to Hospitals with Lower Quality of AMI Care?

Objective

Older patients with comorbid mental illness are shown to receive less appropriate care for their medical conditions. This study analyzed Medicare patients hospitalized for acute myocardial infarction (AMI) and determined whether those with comorbid mental illness were more likely to present to hospitals with lower quality of AMI care.

Methods

Retrospective analyses of Medicare claims in 2008. Hospital quality was measured using the five “Hospital Compare” process indicators (aspirin at admission/discharge, beta-blocker at admission/discharge, and angiotension-converting enzyme inhibitor or angiotension receptor blocker for left ventricular dysfunction). Multinomial logit model determined the association of mental illness with admission to low-quality hospitals (rank of the composite process score <10^th percentile) or high-quality hospitals (rank>90^th percentile), compared to admissions to other hospitals with medium quality. Multivariate analyses further determined the effects of hospital type and mental diagnosis on outcomes.

Results

Among all AMI admissions to 2,845 hospitals, 41,044 out of 287,881 patients were diagnosed with mental illness. Mental illness predicted a higher likelihood of admission to low-quality hospitals (unadjusted rate 2.9% vs. 2.0%; adjusted odds ratio [OR]1.25, 95% confidence interval [CI] 1.17–1.34, p<0.01), and an equal likelihood to high-quality hospitals (unadjusted rate 9.8% vs. 10.3%; adjusted OR 0.97, 95% CI 0.93–1.01, p = 0.11). Both lower hospital quality and mental diagnosis predicted higher rates of 30-day readmission, 30-day mortality, and 1-year mortality.

Conclusions

Among Medicare myocardial infarction patients, comorbid mental illness was associated with an increased risk for admission to lower-quality hospitals. Both lower hospital quality and mental illness predicted worse post-AMI outcomes.     

Maternal and neonatal separation and mortality associated with concurrent admissions to intensive care units

Background:

Concurrent admission of a mother and her newborn to separate intensive care units (herein referred to as co-ICU admission), possibly in different centres, can magnify family discord and stress. We examined the prevalence and predictors of mother–infant separation and mortality associated with co-ICU admissions.

Methods:

We completed a population-based study of all 1 023 978 singleton live births in Ontario between Apr. 1, 2002, and Mar. 31, 2010. We included data for maternal–infant pairs that had co-ICU admission (n = 1216), maternal ICU admission only (n = 897), neonatal ICU (NICU) admission only (n = 123 236) or no ICU admission (n = 898 629). The primary outcome measure was mother–infant separation because of interfacility transfer.

Results:

The prevalence of co-ICU admissions was 1.2 per 1000 live births and was higher than maternal ICU admissions (0.9 per 1000). Maternal–newborn separation due to interfacility transfer was 30.8 (95% confidence interval [CI] 26.9–35.3) times more common in the co-ICU group than in the no-ICU group and exceeded the prevalence in the maternal ICU group and NICU group. Short-term infant mortality (< 28 days after birth) was higher in the co-ICU group (18.1 per 1000 live births; maternal age–adjusted hazard ratio [HR] 27.8, 95% CI 18.2–42.6) than in the NICU group (7.6 per 1000; age-adjusted HR 11.5, 95% CI 10.4–12.7), relative to 0.7 per 1000 in the no-ICU group. Short-term maternal mortality (< 42 days after delivery) was also higher in the co-ICU group (15.6 per 1000; age-adjusted HR 328.7, 95% CI 191.2–565.2) than in the maternal ICU group (6.7 per 1000; age-adjusted HR 140.0, 95% CI 59.5–329.2) or the NICU group (0.2 per 1000; age-adjusted HR 4.6, 95% CI 2.8–7.4).

Interpretation:

Mother–infant pairs in the co-ICU group had the highest prevalence of separation due to interfacility transfer and the highest mortality compared with those in the maternal ICU and NICU groups.Admission of a newborn to a neonatal intensive care unit (NICU) produces a great deal of stress for the parents.¹ A new mother who also falls ill may be unable to care for, or bond with, her newborn during the time of her illness.² Although the father will experience a sense of loss of control when his infant is admitted to the NICU,^3,4 this feeling is conceivably worsened when the mother too requires intensive care. In this situation of concurrent ICU admission (herein referred to as “co-ICU”), the mother and newborn may be in different areas of the same hospital or in different facilities. This separation would magnify the degree of mother–infant and family discord and stress and could create competing priorities for family members in terms of decision-making and support. Moreover, the situation would be made more devastating if the mother or newborn died in hospital and the other remained critically ill, or after discharge of one, the other required continuing hospital care or died.Because of the serious, potentially negative consequences of co-ICU admissions, we examined the prevalence and predictors of mother–infant separation and mortality associated with co-ICU admissions.