Reduction in hospital readmission stay of elderly patients by a community based hospital discharge scheme: a randomised controlled trial.

STUDY OBJECTIVE--To compare a community support scheme using care attendants with standard aftercare for their effects on independence and morale of elderly patients discharged from hospital and on their use of health and social services. DESIGN--Randomised controlled study of cohort of patients over 75 discharged to their own homes. SETTING--District general hospital and community. PATIENTS--Total of 903 patients (mean age 82, 25% over 85). INTERVENTIONS--Total of 464 patients received support from care attendants on first day at home and for up to 12 hours a week for two weeks. Support comprised practical care, help with rehabilitation, and organising social help. The remaining 439 patients received standard aftercare. END POINT--Difference between two groups of 7% in hospital readmission rates or one point on activities of daily living scale (power 80%, significance level 5%). MEASUREMENTS AND MAIN RESULTS--Three months after the initial discharge 763 patients were interviewed (84%). There were no significant differences between the two groups in physical independence (activities of daily living scale), in measures of morale (Philadelphia scale), or in death rates. Hospital readmission rates within 18 months of discharge, however, were significantly higher in the control group and they spent more days in hospital (mean; control group 30.6 days, support group 17.1 days; p = 0.014). Of the patients living alone who were followed up for 18 months 21 (15%) receiving standard aftercare were readmitted more than twice compared with 6 (5%) supported by care attendants (p less than 0.01). CONCLUSIONS--If the findings are confirmed, and the policy extended to all patients over the age of 75 living alone, an average health district might expect either to save about 23 hospital beds at a net annual saving of about pounds 220,000 in the short term or to increase available beds by this number.     

General practitioner response to elderly patients discharged from hospital.

OBJECTIVE--To determine the effect of discharge information given to general practitioners on their management of newly discharged elderly patients. DESIGN--A random sample of 133 elderly patients who had unplanned readmission to a district general hospital within 28 days of discharge was compared with a matched control sample of patients who were not readmitted. Information was gathered from the hospital, the patients, the carers, and the general practitioners about the information that the hospital had sent the general practitioner and the general practitioners'' response to this information. SETTING--All specialties in a district general hospital. PATIENTS--266 Patients aged over 65 representative in the main demographic indices of the population of elderly patients admitted to hospital. RESULTS--Ten weeks after discharge the doctors had received notice of discharge about 169 of the patients, but fewer than half the discharge notices were received within the first week. General practitioners were dissatisfied with the information in 60 cases. A general practitioner visited 174 of the patients after their discharge from hospital and three quarters of the visits took place within two weeks of the discharge. These visits were more likely to have been initiated by patients or families than by the doctor, and this was not influenced by the doctor receiving notice of the patient''s discharge. Older patients and those who had carers were the most likely to be visited. Nearly half of the carers were dissatisfied with some aspect of general practitioner care, problems with home visiting being the commonest source of complaint. CONCLUSIONS--Hospital communications to general practitioners about the discharge of elderly patients still cause concern, particularly in the time they take to arrive. Written instruction to vulnerable elderly patients asking them to inform their general practitioner of the discharge might be helpful. Carers complained of lack of support, and it is clearly important for someone (either the general practitioner or another health worker) to visit elderly people shortly after their discharge.     

Risk factors associated with 31-day unplanned readmission in 50,912 discharged patients after stroke in China

Background

Unplanned readmission within 31?days of discharge after stroke is a useful indicator for monitoring quality of hospital care. We evaluated the risk factors associated with 31-day unplanned readmission of stroke patients in China.

Methods

We identified 50,912 patients from 375 hospitals in 29 provinces, municipalities or autonomous districts across China who experienced an unplanned readmission after stroke between 2015 and 2016, and extracted data from the inpatients’ cover sheet data from the Medical Record Monitoring Database. Patients were grouped into readmission within 31?days or beyond for analysis. Chi-squared test was used to analyze demographic information, health system and clinical process-related factors according to the data type. Multilevel logistic modeling was used to examine the effects of patient (level 1) and hospital (level 2) characteristics on an unplanned readmission ≤31?days.

Results

Among 50,912 patients, 14,664 (28.8%) were readmitted within 31?days after discharge. The commonest cause of readmissions were recurrent stroke (34.8%), hypertension (22.94%), cardio/cerebrovascular disease (13.26%) and diabetes/diabetic complications (7.34%). Higher risks of unplanned readmissions were associated with diabetes (OR?=?1.089, P?=?0.001), use of clinical pathways (OR?=?1.174, P?<?0.001), and being discharged without doctor’s advice (OR?=?1.485, P?<?0.001). Lower risks were associated with basic medical insurances (OR ranging from 0.225 to 0.716, P?<?0.001) and commercial medical insurance (OR?=?0.636, P?=?0.021), compared to self-paying for medical services. And patients aged 50?years old and above (OR ranging from 0.650 to 0.985, P?<?0.05), with haemorrhagic stroke (OR?=?0.467, P?<?0.001), with length of stay more than 7?days in hospital (OR ranging from 0.082 to 0.566, P?<?0.001), also had lower risks.

Conclusions

Age, type of stroke, medical insurance status, type of discharge, use of clinical pathways, length of hospital stay and comorbidities were the most influential factors for readmission within 31?days.

     

Prognosis of delirium in elderly hospital patients.

OBJECTIVE: To determine the prognosis of delirium in elderly patients. DATA SOURCES: MEDLINE was searched for relevant articles published from January 1980 to March 1992. The bibliographies of identified articles were searched for additional references. STUDY SELECTION: Eight reports (involving 573 patients with delirium) met the following inclusion criteria: original research, published in English or French, prospective study design, diagnosis based on acute deterioration in mental state, sample of at least 20 patients, patients aged 60 years or over and follow-up of at least 1 week. The validity of the studies was independently assessed according to the criteria for prognostic studies established by McMaster University, Hamilton, Ont. No study met all the criteria. DATA EXTRACTION: Information about the patient sample, length of follow-up and results was systematically abstracted from each report and tabulated. DATA SYNTHESIS: A meta-analysis of the outcomes indicated that elderly patients with delirium had a mean length of stay of 20.7 days. One month after admission 46.5% were in institutions, and 14.2% had died; only 54.9% had improved mentally. Six months after admission 43.2% were in institutions. Compared with unmatched control subjects they had longer hospital stays, higher mortality rates at 1 month and higher rates of institutional care at 1 and 6 months. The presence of severe physical illness or dementia may have been related to some outcomes. CONCLUSIONS: Delirium in the elderly appears to have a poor prognosis. However, this finding may have been confounded by the presence of concomitant dementia or severe physical illness. Future studies must pay attention to methods and design, particularly the composition of study populations and the control of extraneous prognostic factors.     

Factors affecting outcome in free-tissue transfer in the elderly

Free-tissue transfers have become the preferred surgical technique to treat complex reconstructive defects. Because these procedures typically require longer operative times and recovery periods, the applicability of free-flap reconstruction in the elderly continues to require ongoing review. The authors performed a retrospective analysis of 100 patients aged 65 years and older who underwent free-tissue transfers to determine preoperative and intraoperative predictors of surgical complications, medical complications, and reconstructive failures. The parameters studied included patient demographics, past medical history, American Society of Anesthesiology (ASA) status, site and cause of the defect, the free tissue transferred, operative time, and postoperative complications, including free-flap success or failure. The mean age of the patients was 72 years. A total of 46 patients underwent free-tissue transfer after head and neck ablation, 27 underwent lower extremity reconstruction in the setting of peripheral vascular disease, 10 had lower extremity traumatic wounds, nine had breast reconstructions, four had infected wounds, two had chronic wounds, and two underwent transfer for lower extremity tumor ablation. Two patients had an ASA status of 1, 49 patients had a status of 2, 45 patients had a status of 3, and four had a status of 4. A total of 104 flaps were transferred in these 100 patients. There were 49 radial forearm flaps, 34 rectus abdominis flaps, seven latissimus dorsi flaps, seven fibular osteocutaneous flaps, three omental flaps, three jejunal flaps, and one lateral arm flap. Four patients had planned double free flaps for their reconstruction. Mean operative time was 7.8 hours (range, 3.5 to 16.5 hours). The overall flap success rate was 97 percent, and the overall reconstructive success rate was 92 percent. There were six additional reconstructive failures related to flap loss, all of which occurred more than 1 month after surgery. Patients with a higher ASA designation experienced more medical complications (p = 0.03) but not surgical complications. Increased operative time resulted in more surgical complications (p = 0.019). All eight cases of reconstructive failure occurred in patients undergoing limb salvage surgery in the setting of peripheral vascular disease. Free-tissue transfer in the elderly population demonstrates similar success rates to those of the general population. Age alone should not be considered a contraindication or an independent risk factor for free-tissue transfer. ASA status and length of operative time are significant predictors of postoperative medical and surgical morbidity. The higher rate of reconstructive failure in the elderly peripheral vascular disease population compares favorably with other treatment modalities for this disease process.     

Factors affecting retention of early pregnancy in dairy cattle

Potential factors affecting retention of pregnancy during weeks 5-9 of gestation were studied in dairy cows and heifers (N = 211) on two farms. Cows were examined by ultrasonography for presence of a viable embryo, and sizes of the corpus luteum (CL) and of follicles > or = 5mm were recorded. Blood samples were taken at each examination and assayed for progesterone and estradiol. Overall pregnancy loss was 11.4%. Cows with two CL did not have greater concentrations of progesterone than cows with one CL and they retained fewer pregnancies (P < 0.01; 73% versus 91%). Pregnancy retention was associated positively with concentrations of progesterone and estradiol during week 5 (P < 0.05). Embryos that were lost apparently died before CL regression. Retention of pregnancy declined in cows with high body condition and as age of the cow increased. Pregnancy retention was lower in cows bred to one of four frequently-used service sires (P < 0.05). Days postpartum, milk production, parity, service number, inseminator, synchronization of estrus, diameter of follicles and size of CL did not affect pregnancy retention. In conclusion, retention of pregnancy during placentation varied with concentrations of progesterone and estradiol, age of cow, body condition and service sire.     

Factors affecting habituation of PC12 cells to ATP.

Extracellular ATP triggers catecholamine secretion from PC12 cells by activating ionotropic purine receptors. Repeated stimulation by ATP leads to habituation of the secretory response. In this paper, we use amperometric detection to monitor the habituation of PC12 cells to multiple stimulations of ATP or its agonist. Cells habituate to 30 microm ATP slower than they do to 300 or 600 microm ATP. Modifying external Mg2+ affects the response of cells to 30 microm ATP, but does not affect habituation, suggesting that habituation does not necessarily correspond to either stimulus intensity or cellular response. Mg2+ affects the initial response of PC12 cells to 2MeSATP in a manner similar to ATP. Increasing external [Mg2+] to 3.0 mm, however, eliminates habituation to 2MeSATP. This habituation can be partially restored by costimulation with 100 microm UTP. Background application of UTP increases habituation to both ATP and 2MeSATP. This suggests that ATP-sensitive metabotropic (P2Y) receptors play a role in the habituation process. Finally, although Ca2+ influx through voltage-operated calcium channels does not appear to contribute to secretion during ATP stimulation, blocking these channels with nicardipine increases habituation. This suggests a role for voltage-operated calcium channels in the habituation process.     

Comparing methods to calculate hospital-specific rates of early death or urgent readmission

Background:

Hospital readmissions are important patient outcomes that can be accurately captured with routinely collected administrative data. Hospital-specific readmission rates have been reported as a quality-of-care indicator. However, the extent to which these measures vary with different calculation methods is uncertain.

Methods:

We identified all discharges from Ontario hospitals from 2005 to 2010 and determined whether patients died or were urgently readmitted within 30 days. For each hospital, we calculated 4 distinct observed-to-expected ratios, estimating the expected number of events using different adjustments for confounders (age and sex v. complete) and different units of analysis (all admissions v. single admission per patient).

Results:

We included 3 148 648 admissions to hospital for 1 802 704 patients in 162 hospitals. Ratios adjusted for age and sex alone had the greatest variation. Within hospitals, ranges of the 4 ratios averaged 31% of the overall estimate. Readmission ratios adjusted for age and sex showed the lowest correlation (Spearman correlation coefficient 0.48–0.68). Hospital rankings based on the different measures had an average range of 47.4 (standard deviation 32.2) out of 162.

Interpretation:

We found notable variation in rates of death or urgent readmission within 30 days based on the extent of adjustment for confounders and the unit of analysis. Slight changes in the methods used to calculate hospital-specific readmission rates influence their values and the consequent rankings of hospitals. Our results highlight the caution required when comparing hospital performance using rates of death or urgent readmission within 30 days.Readmission rates are used to gauge and compare hospital performance and have been reported around the world.^1–4 These rates create great public interest and concern regarding the local quality of health care. A recently created Canadian website reporting indicators including readmission rates crashed when it experienced 15 times more hits that expected.^5,6 Policy-makers in some jurisdictions have implemented programs linking readmission rates to reimbursement.⁷The influence of the statistical methods used to calculate readmission rates has not been extensively explored. Variation exists in the methods used to calculate readmission rates: in Australia, patient-level covariates are not adjusted for;⁸ in the United States, Medicare uses a hierarchical model to adjust for patient age, sex and comorbidity, in addition to clustering of patients within hospitals.⁹ Furthermore, the patient populations included when calculating readmission rates vary, from a limited group of diagnoses in the US⁴ to almost all admissions to hospital in Great Britain.¹⁰Therefore, the methods used to determine readmission rates vary extensively with no apparent consensus on how these statistics should be calculated. We calculated adjusted hospital-specific rates of death or urgent readmission within 30 days and hospital rankings, varying 2 key factors relevant to generating these statistics: the completeness of confounder adjustment and the inclusion of all admissions to hospital versus a single admission per patient. Our goal was to determine the reliability of early death or urgent readmission rates as an indicator of hospital performance.     

Factors affecting pretreatment immune competence in cancer patients

Summary The assessment of changes in immune competence due to cancer demands carefully controlled studies with simultaneous consideration of other factors such as age, sex, and general ill health. To determine the effect of each factor, immune competence was measured in 112 healthy individuals, 134 patients with benign disease, and 350 patients with cancer (breast, colorectal, and stomach) with a wide spectrum of parameters.In normal subjects, advancing age was associated with a significant reduction in percentage lymphocyte count (LC), absolute and percentage T cell counts, and responses to phytohaemagglutinin (PHA) and pokeweed mitogen (PWM). In patients with benign disease, advancing age was associated with depression of serum IgM levels, absolute and percentage LC, responses to PHA, and delayed cutaneous hypersensitivity (DCH) responses to tuberculin PPD (Mantoux), and dinitrochlorobenzene (DNCB), but elevation of serum IgA levels.No significant sex effects were demonstrated in either group of subjects.The effects of general ill health were determined by comparing individuals in good health (normal subjects and patients with minor benign breast disease) with those who had poor health (patients with significant benign gastrointestinal disease). The latter showed significant depression of DNCB sensitivity and lymphocyte reactivity to PHA, whereas total WBC and LC were significantly elevated.To determine the effects due to cancer, controls were matched for their general state of health and site of disease, in addition to completing all studies prior to any form of therapy. Age differences were corrected for by application of the findings of the above study. This age correction resulted in marked alterations in the significance of observed differences between cancer patients and controls. The previous significance of many differences either disappeared or was reduced, although in two instances significance was attained only after age correction. The only consistent immunodepression observed in the three types of cancer patient tested was impaired reactivity to DNCB. Responses were impaired even in early disease at all three sites.We have shown that the immunodepression exhibited by cancer patients is a summation of the effects due to age, general ill health, and malignancy. Some of the changes previously ascribed to cancer are due to these other factors.     

Factors affecting flow karyotype resolution.

BACKGROUND: One of the major factors which influences the chromosome purity achievable particularly during high speed sorting is the analytical resolution of individual chromosome peaks in the flow karyotype, as well as the amount of debris and fragmented chromosomes. We have investigated the factors involved in the preparation of chromosome suspensions that influence karyotype resolution. METHODS: Chromosomes were isolated from various human and animal cell types using a series of polyamine buffer isolation protocols modified with respect to pH, salt concentration, and chromosome staining time. Each preparation was analyzed on a MoFlo sorter (DAKO) configured for high speed sorting and the resolution of the flow karyotypes compared. RESULTS: High resolution flow cytometric data was obtained with chromosomes optimally isolated using hypotonic solution buffered at pH 8.0 and polyamine isolation buffer (with NaCl excluded) between pH 7.50 and 8.0. Extending staining time to more than 8 h with chromosome suspensions isolated from cell lines subjected to sufficient metaphase arrest times gave the best result with the lowest percentage of debris generated, tighter chromosome peaks with overall lower coefficients of variation, and a 1- to 5-fold increase in the yield of isolated chromosomes. CONCLUSIONS: Optimization of buffer pH and the length of staining improved karyotype resolution particularly for larger chromosomes and reduced the presence of chromosome fragments (debris). However, the most interesting and surprising finding was that the exclusion of NaCl in PAB buffer improved the yield and resolution of larger chromosomes.