The Influence of Primary Care Quality on Hospital Admissions for People with Dementia in England: A Regression Analysis

Objectives

To test the impact of a UK pay-for-performance indicator, the Quality and Outcomes Framework (QOF) dementia review, on three types of hospital admission for people with dementia: emergency admissions where dementia was the primary diagnosis; emergency admissions for ambulatory care sensitive conditions (ACSCs); and elective admissions for cataract, hip replacement, hernia, prostate disease, or hearing loss.

Methods

Count data regression analyses of hospital admissions from 8,304 English general practices from 2006/7 to 2010/11. We identified relevant admissions from national Hospital Episode Statistics and aggregated them to practice level. We merged these with practice-level data on the QOF dementia review. In the base case, the exposure measure was the reported QOF register. As dementia is commonly under-diagnosed, we tested a predicted practice register based on consensus estimates. We adjusted for practice characteristics including measures of deprivation and uptake of a social benefit to purchase care services (Attendance Allowance).

Results

In the base case analysis, higher QOF achievement had no significant effect on any type of hospital admission. However, when the predicted register was used to account for under-diagnosis, a one-percentage point improvement in QOF achievement was associated with a small reduction in emergency admissions for both dementia (-0.1%; P=0.011) and ACSCs (-0.1%; P=0.001). In areas of greater deprivation, uptake of Attendance Allowance was consistently associated with significantly lower emergency admissions. In all analyses, practices with a higher proportion of nursing home patients had significantly lower admission rates for elective and emergency care.

Conclusion

In one of three analyses at practice level, the QOF review for dementia was associated with a small but significant reduction in unplanned hospital admissions. Given the rising prevalence of dementia, increasing pressures on acute hospital beds and poor outcomes associated with hospital stays for this patient group, this small change may be clinically and economically relevant.     

Inappropriate hospital use by patients receiving care for medical conditions: targeting utilization review

OBJECTIVE: To describe characteristics associated with inappropriate hospital use by patients in Manitoba in order to help target concurrent utilization review. Utilization review was developed to reduce inappropriate hospital use but can be a very resource-intensive process. DESIGN: Retrospective chart review of a sample of adult patients who received care for medical conditions in a sample of Manitoba hospitals during the fiscal year 1993-94; assessment of patients at admission and for each day of stay with the use of a standardized set of objective, nondiagnosis-based criteria (InterQual). PATIENTS: A total of 3904 patients receiving care at 26 hospitals. OUTCOME MEASURES: Acute (appropriate) and nonacute (inappropriate) admissions and days of stay for adult patients receiving care for medical conditions. RESULTS: After 1 week, 53.2% of patients assessed as needing acute care at admission no longer required acute care. Patients 75 years of age or older consumed more than 50% of the days of stay, and 74.8% of these days of stay were inappropriate. Four diagnostic categories accounted for almost 60% of admissions and days, and more than 50% of those days of stay were inappropriate. Patients admitted through the emergency department were more likely to require acute care (60.9%) than others (41.7%). Patients who were Treaty Indians had a higher proportion of days of stay requiring acute care than others (45.9% v. 32.8%). Patients'' income and day of the week on admission (weekday v. weekend) were not predictive factors of inappropriate use. CONCLUSION: Rather than conducting a utilization review for every patient, hospitals might garner more information by targeting patients receiving care for medical conditions with stays longer than 1 week, patients with nervous system, circulatory, respiratory or digestive diagnoses, elderly patients and patients not admitted through the emergency department.     

Similar Outcomes Achieved Between Anterior and Posterior Approach Total Hip Arthroplasty Using Dual Mobility Implants

BackgroundDual mobility (DM) bearings for total hip arthroplasty (THA) have been proposed to reduce the risk of instability in high-risk patients; however, their utility in primary THA remains relatively unexplored. No previous reports have described whether surgical approach influences outcomes associated with DM implant systems. This study aims to compare patient reported outcomes and post-operative groin pain between patients undergoing anterior approach versus posterior approach following primary THA with DM implants.MethodsWe retrospectively reviewed all patients who underwent primary THA and received a DM implant between 2011-2021. Patients were stratified into two cohorts based on surgical approach (anterior vs. posterior approach). Primary outcomes included the presence of substantial postoperative groin pain as well as readmission and revision rates. Demographic differences were assessed using chi-square and independent sample t-tests. Outcomes were compared using multilinear and logistic regressions.ResultsOf the 495 patients identified, 55 (11%) underwent THA via the anterior approach and 440 (89%) via the posterior approach. Surgical time (100.24 vs. 109.42 minutes, p=0.070), length of stay (2.19vs.2.67 days,p=0.072), discharge disposition (p=0.151), and significant postoperative groin pain (1.8%vs.0.7%,p=0.966) did not statistically differ between the cohorts. 90-day readmission (9.1%vs.7.7%,p=0.823) and revision rate (0.0%vs.3.0%,p=0.993) did not significantly differ as well. Specifically, readmission (p=0.993) and revision (p=0.998) for instability did not significantly differ between the cohorts. We found no statistical difference in HOOS, JR (p=0.425), VR-12 PCS (p=0.718), and VR-12 MCS (p=0.257) delta score improvement from preoperative to 1-year follow-up between the two groups.ConclusionComparable outcomes following implantation of DM constructs may be achievable irrespective of the surgical approach employed. The incidence of iliopsoas injections for groin pain did not significantly differ between anterior and posterior approaches. Future investigation is needed to determine whether surgical approach influences long-term outcomes in patients receiving DM implants. Level of Evidence: III     

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.     

Factores pronósticos de mortalidad al año de una fractura de cadera por fragilidad ósea. Estudio Maluc Anoia

IntroductionMost of the patients who had a hip fragility fracture are characterized by advanced age, frailty, multimorbidity and high mortality rate into the first year. Our aim is to describe the prognostic factors of mortality one year after a hip fragility fracture.Material and methodsObservational prospective study. During the study period we included patients older than 69 years with hip fragility fracture who were admitted to the Acute Geriatric Unit.ResultsWe have followed 364 patients, 100 of them died (27.5%). The independent prognostic factors of mortality one year after a hip fragility fracture had been: have a less basis score in Lawton and Brody Scale 0.603 (0.505-0.721) (p< 0.001); have a higher score in Charlson Comorbidity Index 2.332 (1.308-4.157) p = 0.04); have a surgical waiting time ≥ 3 days 3.013 (1.330-6.829) p = 0.008); finding hydroelectrolytic disorders and/or deterioration of glomerular filtration 1.212 (1.017-1.444) p = 0.031) during hospital stay; discriminatory capacity of the area under the curve (AUC) (± 95%): 0.888 (0.880-0.891).ConclusionsPrognostic predictors of mortality at one year after a hip fragility fracture are those variables that reflect a worse state of health, complications during hospital stay and a longer surgical waiting time.     

Impact of assessment and intervention by a health and social care professional team in the emergency department on the quality,safety, and clinical effectiveness of care for older adults: A randomised controlled trial

BackgroundOlder adults frequently attend the emergency department (ED) and experience high rates of adverse events following ED presentation. This randomised controlled trial evaluated the impact of early assessment and intervention by a dedicated team of health and social care professionals (HSCPs) in the ED on the quality, safety, and clinical effectiveness of care of older adults in the ED.Methods and findingsThis single-site randomised controlled trial included a sample of 353 patients aged ≥65 years (mean age = 79.6, SD = 7.01; 59.2% female) who presented with lower urgency complaints to the ED a university hospital in the Mid-West region of Ireland, during HSCP operational hours. The intervention consisted of early assessment and intervention carried out by a HSCP team comprising a senior medical social worker, senior occupational therapist, and senior physiotherapist. The primary outcome was ED length of stay. Secondary outcomes included rates of hospital admissions from the ED; hospital length of stay for admitted patients; patient satisfaction with index visit; ED revisits, mortality, nursing home admission, and unscheduled hospital admission at 30-day and 6-month follow-up; and patient functional status and quality of life (at index visit and follow-up). Demographic information included the patient’s gender, age, marital status, residential status, mode of arrival to the ED, source of referral, index complaint, triage category, falls, and hospitalisation history. Participants in the intervention group (n = 176) experienced a significantly shorter ED stay than the control group (n = 177) (6.4 versus 12.1 median hours, p < 0.001). Other significant differences (intervention versus control) included lower rates of hospital admissions from the ED (19.3% versus 55.9%, p < 0.001), higher levels of satisfaction with the ED visit (p = 0.008), better function at 30-day (p = 0.01) and 6-month follow-up (p = 0.03), better mobility (p = 0.02 at 30 days), and better self-care (p = 0.03 at 30 days; p = 0.009 at 6 months). No differences at follow-up were observed in terms of ED re-presentation or hospital admission. Study limitations include the inability to blind patients or ED staff to allocation due to the nature of the intervention, and a focus on early assessment and intervention in the ED rather than care integration following discharge.ConclusionsEarly assessment and intervention by a dedicated ED-based HSCP team reduced ED length of stay and the risk of hospital admissions among older adults, as well as improving patient satisfaction. Our findings support the effectiveness of an interdisciplinary model of care for key ED outcomes.Trial registrationClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT03739515","term_id":"NCT03739515"}}NCT03739515; registered on 12 November 2018.

Marica Cassarino and colleagues evaluate an intervention for early assessment of older patients in emergency care.     

Explaining differences in English hospital death rates using routinely collected data

ObjectivesTo ascertain hospital inpatient mortality in England and to determine which factors best explain variation in standardised hospital death ratios.DesignWeighted linear regression analysis of routinely collected data over four years, with hospital standardised mortality ratios as the dependent variable.SettingEngland.SubjectsEight million discharges from NHS hospitals when the primary diagnosis was one of the diagnoses accounting for 80% of inpatient deaths.ResultsThe four year crude death rates varied across hospitals from 3.4% to 13.6% (average for England 8.5%), and standardised hospital mortality ratios ranged from 53 to 137 (average for England 100). The percentage of cases that were emergency admissions (60% of total hospital admissions) was the best predictor of this variation in mortality, with the ratio of hospital doctors to beds and general practitioners to head of population the next best predictors. When analyses were restricted to emergency admissions (which covered 93% of all patient deaths analysed) number of doctors per bed was the best predictor.ConclusionAnalysis of hospital episode statistics reveals wide variation in standardised hospital mortality ratios in England. The percentage of total admissions classified as emergencies is the most powerful predictor of variation in mortality. The ratios of doctors to head of population served, both in hospital and in general practice, seem to be critical determinants of standardised hospital death rates; the higher these ratios, the lower the death rates in both cases.

Key messages

• Between 1991-2 and 1994-5 average standardised hospital mortality ratios in English hospitals reduced by 2.6% annually, but the ratios varied more than twofold among the hospitals
• After adjustment for the percentage of emergency cases and for age, sex, and primary diagnosis, the best predictors of standardised hospital death rates were the numbers of hospital doctors per bed and of general practitioners per head of population in the localities from which hospital admissions were drawn
• England has one of the lowest number of physicians per head of population of the OECD countries, being only 59% of the OECD average
• It is now possible to control for factors outside the direct influence of hospital policy and thereby produce a more valid measure of hospital quality of care

     

Characteristics and outcomes of hospital admissions for COVID-19 and influenza in the Toronto area

BACKGROUND:Patient characteristics, clinical care, resource use and outcomes associated with admission to hospital for coronavirus disease 2019 (COVID-19) in Canada are not well described.METHODS:We described all adults with COVID-19 or influenza discharged from inpatient medical services and medical–surgical intensive care units (ICUs) between Nov. 1, 2019, and June 30, 2020, at 7 hospitals in Toronto and Mississauga, Ontario. We compared patient outcomes using multivariable regression models, controlling for patient sociodemographic factors and comorbidity level. We validated the accuracy of 7 externally developed risk scores to predict mortality among patients with COVID-19.RESULTS:There were 1027 hospital admissions with COVID-19 (median age 65 yr, 59.1% male) and 783 with influenza (median age 68 yr, 50.8% male). Patients younger than 50 years accounted for 21.2% of all admissions for COVID-19 and 24.0% of ICU admissions. Compared with influenza, patients with COVID-19 had significantly greater in-hospital mortality (unadjusted 19.9% v. 6.1%, adjusted relative risk [RR] 3.46, 95% confidence interval [CI] 2.56–4.68), ICU use (unadjusted 26.4% v. 18.0%, adjusted RR 1.50, 95% CI 1.25–1.80) and hospital length of stay (unadjusted median 8.7 d v. 4.8 d, adjusted rate ratio 1.45, 95% CI 1.25–1.69). Thirty-day readmission was not significantly different (unadjusted 9.3% v. 9.6%, adjusted RR 0.98, 95% CI 0.70–1.39). Three points-based risk scores for predicting in-hospital mortality showed good discrimination (area under the receiver operating characteristic curve [AUC] ranging from 0.72 to 0.81) and calibration.INTERPRETATION:During the first wave of the pandemic, admission to hospital for COVID-19 was associated with significantly greater mortality, ICU use and hospital length of stay than influenza. Simple risk scores can predict in-hospital mortality in patients with COVID-19 with good accuracy.

International studies report that patients admitted to hospital with coronavirus disease 2019 (COVID-19) have high rates of critical illness and mortality.^1–5 Two small Canadian case series have described care for critically ill patients with COVID-19 and found mortality rates of up to 25%.^6,7 However, outcomes of patients admitted to hospital for COVID-19 in Canada are not well described, particularly outside of intensive care units (ICUs). Case fatality rates for COVID-19 vary dramatically worldwide,⁸ and outcomes of patients admitted to hospital for COVID-19 in Canada may differ from other countries because of differences in populations, public health and health care systems.Seasonal influenza is a useful comparator for COVID-19^9–11 as it is another respiratory virus, familiar to the general public, with high rates of morbidity and mortality. The purpose of this study was to describe patient characteristics, resource use, clinical care and outcomes for patients admitted to hospital with COVID-19 in Ontario, Canada, using influenza as a comparator. We also validated the performance of various prognostic risk scores for in-hospital mortality among patients with COVID-19.     

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.     

Repercusión de un sistema centralizado de ingresos sobre la eficacia y eficiencia de una unidad geriátrica de recuperación funcional

ObjectiveTo evaluate the influence of a change in the management of admissions on the activity and care outcomes of a Geriatric Functional Recovery Unit (GFRU).Material and methodsA retrospective observational study was conducted. Since 2000, the Hospital Central Cruz Roja GFRU has been collecting data grouped into periods of 4 years, except for the centralised admissions (September 2016-December 2018). The data collected on admission included the Red Cross Functional and Mental scales, the Barthel index, the main diagnosis of the functional decline (grouped into stroke, orthopaedic problem, and multifactorial immobility episodes), and comorbidity evaluated by the Charlson index. The following outcome variables were analysed: the overall and relative functional gain at discharge; length of hospital stay; the functional efficiency, discharges to nursing homes, and transfers to acute care units. An analysis was made of the relationship between the admissions from the centralised unit and the previous period (directly admission managed by GFRU), using multivariate analysis (linear regression for continuous outcome variables and logistic regression for the dichotomous ones), adjusted for admission variables.ResultsPatients admitted from the centralised unit showed a greater overall and relative functional gain (difference between both means: 3.49 points, 95% CI; 1.65-5.33, and 12.41%, 95% CI; 0.74-24.08, respectively), longer stay (12.92 days, 95% CI; 11.54-14.30) and lower efficiency (−0.36, 95% CI; −0.16 to −0.57), higher risk of institutionalisation (OR 1.61, 95% CI; 1.19-2.16), and transfers to acute care units (OR 3.16, 95% CI; 2.24-4.47).ConclusionsA centralised admissions system had an influence on the improvement of functional parameters in the patients, but with a longer length of hospital stay, and lower efficiency. Increases in institutionalisation at discharge and transfers to acute care units were also observed.     

A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits

BACKGROUND:Reduced use of the emergency department during the COVID-19 pandemic may result in increased disease acuity when patients do seek health care services. We sought to evaluate emergency department visits for common abdominal and gynecologic conditions before and at the beginning of the pandemic to determine whether changes in emergency department attendance had serious consequences for patients.METHODS:We conducted a population-based analysis using administrative data to evaluate the weekly rate of emergency department visits pre-COVID-19 (Jan. 1–Mar. 10, 2020) and during the beginning of the COVID-19 pandemic (Mar. 11–June 30, 2020), compared with a historical control period (Jan. 1–July 1, 2019). All residents of Ontario, Canada, presenting to the emergency department with appendicitis, cholecystitis, ectopic pregnancy or miscarriage were included. We evaluated weekly incidence rate ratios (IRRs) of emergency department visits, management strategies and clinical outcomes.RESULTS:Across all study periods, 39 691 emergency department visits met inclusion criteria (40.2 % appendicitis, 32.1% miscarriage, 21.3% cholecystitis, 6.4% ectopic pregnancy). Baseline characteristics of patients presenting to the emergency department did not vary across study periods. After an initial reduction in emergency department visits, presentations for cholecystitis and ectopic pregnancy quickly returned to expected levels. However, presentations for appendicitis and miscarriage showed sustained reductions (IRR 0.61–0.80), with 1087 and 984 fewer visits, respectively, after the start of the pandemic, relative to 2019. Management strategies, complications and mortality rates were similar across study periods for all conditions.INTERPRETATION:Although our study showed evidence of emergency department avoidance in Ontario during the first wave of the COVID-19 pandemic, no adverse consequences were evident. Emergency care and outcomes for patients were similar before and during the pandemic.

Avoidance of the emergency department for conditions that may require urgent surgery has been a global concern during the COVID-19 pandemic, and could result in higher case severity and morbidity.^1–3 Resource constraints and provider concerns around the safety of surgery^4–6 may influence rates of nonoperative management for abdominal and gynecological emergencies,⁷ even when existing nonoperative options are not optimal. Limited data suggest that patients with appendicitis and cholecystitis, the 2 most common abdominal emergencies that routinely require operative management,^8,9 may be more likely to avoid the hospital,¹⁰ present with more severe illness^9,10 and be managed nonoperatively during the pandemic, with uncertain consequences for patient outcomes.^10–13 Similarly, the management of early pregnancy complications (i.e., miscarriage and ectopic pregnancy) may be medical or surgical, depending on patient preference and pregnancy characteristics (e.g., stability, gestational age).¹⁴ Up to 80% of women experiencing miscarriage routinely access emergency services; however, there are concerns that women requiring emergency care for miscarriages are avoiding the emergency department.¹⁵ Reduced access to emergency care for early pregnancy complications may result in more adverse outcomes; a study in Italy found an increased rate of ruptured ectopic pregnancy in the early months of the pandemic.¹⁶We sought to characterize the impact of COVID-19 on emergency department visits for and management of appendicitis, cholecystitis, miscarriage and ectopic pregnancy. We aimed to determine if there was a difference in the rate of patients presenting to the emergency department before and during the pandemic, whether a reduction in emergency department visits for these conditions resulted in adverse patient outcomes and whether the proportion of patients undergoing operative management differed before and during the pandemic.     

Inpatient Hyperglycemia and Transitions of Care: A Systematic Review

ObjectiveThe transition of diabetes care from home to hospital, within the hospital, and upon discharge is fraught with gaps that can adversely affect patient safety and length of stay. We aimed to highlight the variability in care during these transitions and point out areas where research is needed.MethodsA PubMed search was performed with a combination of search terms that pertained to diabetes, hyperglycemia, hospitalization, locations in the hospital, discharge to home or a nursing facility, and diabetes medications. Studies with at least 50 patients that were written in the English language were included.ResultsWith the exception of transitioning from intravenous insulin infusion to subcutaneous insulin and perhaps admission to the regular floors, few studies pointedly focused on transitions of care, leading us to extrapolate recommendations based on data from disparate areas of care in the hospital. There is evidence at every stage of care, starting from the entry into the hospital and ending with discharge home or to a facility, that patients benefit from having protocols in place guiding overall care.ConclusionPockets of care exist in hospitals where methods of effective diabetes management have been studied and implemented. However, there is no sustained continuum of care. Protocols and care teams that follow patients from one physical location to the other may result in improved clinical outcomes during and following a hospital stay.     

Hospital Utilisation in Indigenous and Non-Indigenous Infants under 12 Months of Age in Western Australia,Prospective Population Based Data Linkage Study

BackgroundIndigenous infants (infants aged under 12 months) have the highest hospital admission and emergency department presentation risks in Australia. However, there have been no recent reports comparing hospital utilisation between Indigenous and non-Indigenous infants.MethodsOur primary objective was to use a large prospective population-based linked dataset to assess the risk of all-cause hospital admission and emergency department presentation in Indigenous compared to non-Indigenous infants in Western Australia (WA). Secondary objectives were to assess the effect of socio-economic status (Index of Relative Socio-Economic Disadvantage [IRSD]) on hospital utilisation and to understand the causes of hospital utilisation.FindingsThere were 3,382 (5.4%) Indigenous and 59,583 (94.6%) non-Indigenous live births in WA from 1 January 2010 to 31 December 2011. Indigenous infants had a greater risk of hospital admission (adjusted odds ratio [aOR] 1.90, 95% confidence interval [95% CI] 1.77–2.04, p = <0.001) and emergency department presentation (aOR 2.15, 95% CI 1.98–2.33, p = <0.001) compared to non-Indigenous infants. Fifty nine percent (59.0%) of admissions in Indigenous children were classified as preventable compared to 31.2% of admissions in non-Indigenous infants (aOR 2.12, 95% CI 1.88–2.39). The risk of hospital admission in the most disadvantaged (IRSD 1) infants in the total cohort (35.7%) was similar to the risk in the least disadvantaged (IRSD 5) infants (30.6%) (aOR 1.04, 95% CI 0.96–1.13, p = 0.356).InterpretationWA Indigenous infants have much higher hospital utilisation than non Indigenous infants. WA health services should prioritise Indigenous infants regardless of their socio economic status or where they live.     

Frequency of Hypoglycemia and its Impact on Length of Stay,Mortality, and Short-Term Readmission in Patients with Diabetes Hospitalized In Internal Medicine Wards

ObjectiveTo evaluate whether hypoglycemia is associated with increases in length of stay (LOS), inpatient mortality, and readmission among patients with diabetes hospitalized in internal medicine wards.MethodsA retrospective cohort study was carried out using the Basic Minimum Data Set registry of the Spanish National Health System, which contains clinical and administrative information for every patient discharged from system hospitals. The analysis included patients discharged between January 2005 and December 2010 and had a primary (i.e., reason for the admission) or secondary diagnosis of diabetes and a secondary diagnosis of hypoglycemia. The associations between hypoglycemia and the study outcomes (mortality, readmission, and LOS) were evaluated using multivariate and multilinear regression models that included age, sex, and the Charlson index as covariates.ResultsDuring the study period, 3,361,104 patients were admitted to internal medicine wards in the National Health System. Of these, 921,306 (27.4%) had diagnoses of diabetes, and among these patients, 46,408 (5%) had secondary hypoglycemia. A total of 4,754 (10.2%) patients with secondary hypoglycemia died during their hospital stays, compared with 83,508 (9.5%) patients without hypoglycemia. The multivariate/multilinear regression models demonstrated significant associations between the presence of secondary hypoglycemia and greater inpatient mortality (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.20-1.28), a greater likelihood of readmission (OR 1.20, 95% CI 1.17-1.23), and an increased LOS (b 1.24, 95% CI 1.15-1.35).ConclusionHypoglycemia in patients with diabetes hospitalized in internal medicine wards is associated with increases in the LOS, inpatient mortality, and early readmission. (Endocr Pract. 2014;20:870-875)     

Ponderal somatograms assess changes in anthropometric measurements over an academic year in Division III collegiate football players

Ponderal somatograms evaluate body size and shape by converting muscular (shoulders, chest, biceps, forearm, thigh, calf) and nonmuscular (abdomen, hips, knee, ankle, wrist) girths into ponderal equivalent (PE) values. Anthropometric measurements, including stature, body mass, girths, and percent body fat by densitometry were collected in 54 Division III football players in preseason camp (fall) and at the beginning (winter) and end (spring) of the team strength and conditioning program. PE values were calculated for each girth as PE, kg = (girth, cm / k)(2) x stature, dm, where k = k constant from Behnke's reference man. PE values were compared to body mass to indicate overdevelopment (PE > body mass) and underdevelopment (PE < body mass) at specific girth sites. From fall to winter, body mass (+1.6 kg), percent fat (+1.3%), fat mass (+1.6 kg), nonmuscular abdominal and hip girths (+2.1 cm, +1.5 cm), and PE values (+5.3 kg, +2.6 kg) increased significantly (p < 0.05). From winter to spring, percent fat (-1.5%), fat mass (-1.4 kg), nonmuscular abdominal girth (-1.0 cm), and PE value (-2.5 kg) decreased significantly (p < 0.05). Fat-free mass (+1.5 kg), muscular biceps girth (+0.4 cm), and PE value (+2.6 kg) increased significantly (p < 0.05) from winter to spring. Ponderal somatogram muscular components were generally overdeveloped, with the greatest overdevelopment at the biceps in fall (+14.7 kg), winter (+14.9 kg), and spring (+17.4 kg). Nonmuscular components generally were underdeveloped, except abdomen and hips that were overdeveloped. The abdomen remained the greatest nonmuscular overdevelopment in fall (+6.8 kg), winter (+10.5 kg), and spring (+7.9 kg). Ponderal somatograms provide a relatively simple, practical method to track specific changes in body size and shape over time.     

Effectiveness of intrapartum fetal surveillance to improve maternal and neonatal outcomes: a systematic review and network meta-analysis

BACKGROUND:Cesarean delivery is the most common surgical procedure worldwide. Intrapartum fetal surveillance is routinely offered to improve neonatal outcomes, but the effects of different methods on the risk of emergency cesarean deliveries remains uncertain. We conducted a systematic review and network meta-analysis to evaluate the effectiveness of different types of fetal surveillance.METHODS:We searched MEDLINE, Embase and CENTRAL until June 1, 2020, for randomized trials evaluating any intrapartum fetal surveillance method. We performed a network meta-analysis within a frequentist framework. We assessed the quality and network inconsistency of trials. We reported primarily on intrapartum emergency cesarean deliveries and other secondary maternal and neonatal outcomes using risk ratios (RRs) and 95% confidence intervals (CIs).RESULTS:We included 33 trials (118 863 patients) evaluating intermittent auscultation with Pinard stethoscope/handheld Doppler (IA), cardiotocography (CTG), computerized cardiotocography (cCTG), CTG with fetal scalp lactate (CTG-lactate), CTG with fetal scalp pH analysis (CTG-FBS), CTG with fetal pulse oximetry (FPO-CTG), CTG with fetal heart electrocardiogram (CTG-STAN) and their combinations. Intermittent auscultation reduced the risk of emergency cesarean deliveries compared with other types of surveillance (IA v. CTG: RR 0.83, 95% CI 0.72–0.97; IA v. CTG-FBS: RR 0.71, 95% CI 0.63–0.80; IA v.CTG-lactate: RR 0.77, 95% CI 0.64–0.92; IA v. FPO-CTG: RR 0.75, 95% CI 0.65–0.87; IA v.FPO-CTG-FBS: RR 0.81, 95% CI 0.67–0.99; cCTG-FBS v. IA: RR 1.21, 95% CI 1.04–1.42), except STAN-CTG-FBS (RR 1.17, 95% CI 0.98–1.40). There was a similar reduction observed for emergency cesarean deliveries for fetal distress. None of the evaluated methods was associated with a reduced risk of neonatal acidemia, neonatal unit admissions, Apgar scores or perinatal death.INTERPRETATION:Compared with other types of fetal surveillance, intermittent auscultation seems to reduce emergency cesarean deliveries in labour without increasing adverse neonatal and maternal outcomes.

Cesarean delivery is the most common surgical procedure worldwide, performed to expedite delivery and avoid neonatal complications. Fetal surveillance is routinely offered to patients in labour to reduce the risk of adverse neonatal outcomes, as well as the risk of unnecessary emergency cesarean deliveries and other maternal interventions. Fetal surveillance aims to detect intrapartum hypoxia from acute or subacute adverse events in labour requiring medical intervention and to reduce the risk of serious complications such as neonatal cerebral palsy, hypoxic–ischemic encephalopathy or stillbirth.Monitoring the fetal heart rate to detect intrapartum hypoxia using simple surveillance techniques, such as the Pinard stethoscope, has been practised for decades.¹ Over the last 50 years, several newer surveillance methods have been evaluated, with varied uptake in practice.² Cardiotocography (CTG) remains the most common surveillance method used in high-risk pregnancies.³ However, given its limited accuracy, many researchers have evaluated its use in combination with other surveillance methods, such as fetal heart electrocardiogram (STAN), fetal scalp pH analysis (FBS) or fetal pulse oximetry (FPO), and with computer-aided decision models (cCTG) to improve its diagnostic value.^4–6 Despite extensive investment in clinical research, the overall effectiveness of such methods in improving maternal and neonatal outcomes remains debatable as stillbirth rates have plateaued worldwide, while cesarean delivery rates continue to rise.^7,8Existing meta-analyses evaluating different intrapartum fetal surveillance methods remain limited to head-to-head comparisons of monitoring techniques, without a comprehensive assessment of their effectiveness in improving maternal and neonatal pregnancy outcomes.^4,9–13 We conducted a systematic review of randomized trials and a network meta-analysis to evaluate the effectiveness of all available fetal surveillance methods in improving maternal and neonatal outcomes.     

Downsizing of acute inpatient beds associated with private finance initiative: Scotland's case study

ObjectivesTo evaluate whether the projected 24% reduction in acute bed numbers in Lothian hospitals, which formed part of the private finance initiative (PFI) plans for the replacement Royal Infirmary of Edinburgh, is being compensated for by improvements in efficiency and greater use of community facilities, and to ascertain whether there is an independent PFI effect by comparing clinical activity and performance in acute specialties in Lothian hospitals with other NHS hospitals in Scotland.DesignComparison of projected and actual trends in acute bed capacity and inpatient and day case admissions in the first five years (1995-6 to 2000-1) of Lothian Health Board''s integrated healthcare plan. Population study of trends in bed rate, hospital activity, length of stay, and throughput in Lothian hospitals compared with the rest of Scotland from 1990-1 to 2000-1.ResultsBy 2000-1, rates for inpatient admission in all acute, medical, surgical, and intensive therapy specialties in Lothian hospitals were respectively 20%, 6%, 28%, and 38% below those in the rest of Scotland. Day case rates in all acute and acute surgical specialties were 13% and 33% lower. The proportion of delayed discharges in staffed acute and post-acute NHS beds in Lothian hospitals exceeded the Scottish average (15% and 12% respectively; P<0.001).ConclusionThe planning targets and increase in clinical activity in acute specialties in Lothian hospitals associated with PFI had not been achieved by 2000-1. The effect on clinical activity has been a steeper decline in the number of acute beds and rates of admission in Lothian hospitals compared with the rest of Scotland between 1995-6 and 2000-1.

What is already known on this topic

The full business cases for the 15 first wave private finance initiative (PFI) hospitals in England and Scotland projected reductions in acute beds of about 30% in the five years before the opening of the new replacement hospitalsThe new PFI Royal Infirmary of Edinburgh, which will fully open in 2003, is the cornerstone of Lothian Health Board''s healthcare plan for its acute hospitals

What this study adds

Compared with other Scottish NHS hospitals, service delivery has been reduced across Lothian associated with PFI developmentThe planning targets and increase in clinical activity in acute specialties in Lothian hospitals had not been achieved by 2000-1There is evidence of an independent “PFI effect” on hospital downsizing and bed reductions, which in Lothian has resulted in severe capacity constraints across all acute specialties with a need for immediate expansion in acute and community provisionFurther hospital and community service downsizing may be required to meet the financial deficit, which is principally due to the high costs of PFI     

Inpatient admissions and outpatient appointments in the first year post cancer diagnosis: A population based study from England

BackgroundTime spent in hospital (length of stay) is an important component of patient experience and the financial cost of cancer care. This study documents the length of stay across English cancer diagnoses at a national level and reports on variation by patient demographics and tumour characteristics.MethodsData on all diagnoses of malignant neoplasms from the English National Cancer Registration and Analysis Service for 252,202 patients first diagnosed in 2015 was linked with NHS Digital’s Admitted Patient Care and Outpatient Hospital Episode Statistics datasets to quantify length of stay within one year following diagnosis. Length of stay was modelled using linear regression adjusted for sex, age, tumour type, stage, time spent alive during the study period, vital status at end of study period, region, deprivation and ethnicity.ResultsPatients spend a mean of 25 days (median = 17 days; IQR = 8–34 days) in hospital in their first year. Tumour type, stage, age and vital status corrections had the strongest effects in the model adjusting for other independent variables. Younger patients tended towards longer stays.ConclusionLength of stay varies among patients by tumour type, age and stage. Estimating future health service demands should account for changes in incident tumour characteristics.     

Do Pediatric Hospitals Improve Operative Efficiency?

BackgroundIn recent years there has been a push towards developing free standing pediatric facilities to provide care specifically towards pediatric patients. The purpose of this study was to determine if moving pediatric cases from a general hospital to a dedicated pediatric facility improved the quality and efficiency of surgical procedures.MethodsA retrospective review of pediatric patients undergoing posterior spinal fusion (PSF) was performed. All procedures were performed by one orthopaedic surgeon (SLW) from 2015 to 2019. The procedures were performed at a general hospital (GH) the first two years, and at a pediatric hospital (PH) the subsequent years. Data extracted included patient sex, age, and procedure type as well as procedure duration, operative turnover time, hospital length of stay, transfusion requirements, and operative delay. Exclusively pediatric adolescent idiopathic scoliosis (AIS) patients undergoing PSF were included due to the high volume and consistent surgical procedures therefore limiting confounding variables.ResultsA total of five hundred PSF pediatric procedures were performed during the time period. After excluding non-adolescent idiopathic scoliosis cases, a total of 208 procedures were reviewed (105 at GH; 103 at PH). There was no statistical difference between the groups in regards to operative time (GH: 200 min, PH: 200 min; p=0.91), room turnover time (GH: 38 min, PH: 38 min; p=0.801), or rate of transfusion (GH: 20% PH: 30%; p=0.09). Length of stay was significantly shorter in the PH cohort compared to the GH cohort (4.35 vs. 3.84 days, p=0.0001). However, a smaller proportion of cases at the PH started on time compared to the GH (34% vs. 58%; p=0.0005).ConclusionOverall, this study demonstrated that AIS procedures at the PH did show a statistically significant reduction in hospital length of stay. However, timely start of the procedure was less likely at this particular facility. Level of Evidence: III     

Health Outcomes in US Children with Abdominal Pain at Major Emergency Departments Associated with Race and Socioeconomic Status

Objective

Over 9.6 million ED visits occur annually for abdominal pain in the US, but little is known about the medical outcomes of these patients based on demographics. We aimed to identify disparities in outcomes among children presenting to the ED with abdominal pain linked to race and SES.

Methods

Data from 4.2 million pediatric encounters of abdominal pain were analyzed from 43 tertiary US children’s hospitals, including 2.0 million encounters in the emergency department during 2004-2011. Abdominal pain was categorized as functional or organic abdominal pain. Appendicitis (with and without perforation) was used as a surrogate for abdominal pain requiring emergent care. Multivariate analysis estimated likelihood of hospitalizations, radiologic imaging, ICU admissions, appendicitis, appendicitis with perforation, and time to surgery and hospital discharge.

Results

Black and low income children had increased odds of perforated appendicitis (aOR, 1.42, 95% CI, 1.32- 1.53; aOR, 1.20, 95% CI 1.14 – 1.25). Blacks had increased odds of an ICU admission (aOR, 1.92, 95% CI 1.53 - 2.42) and longer lengths of stay (aHR, 0.91, 95% CI 0.86 – 0.96) than Whites. Minorities and low income also had lower rates of imaging for their appendicitis, including CT scans. The combined effect of race and income on perforated appendicitis, hospitalization, and time to surgery was greater than either separately.

Conclusions

Based on race and SES, disparity of health outcomes exists in the acute ED setting among children presenting with abdominal pain, with differences in appendicitis with perforation, length of stay, and time until surgery.