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Drug shortages during a pandemic can result from sudden increases in demand and disruptions in supply chains. Age-stratified hospital admissions in Canada were reported by the Government of Canada, based on cases reported to the Public Health Agency of Canada to Feb. 18, 2021.[18] Age-stratified hospital admissions in the United States were reported by the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET)[17] to Feb. 13, 2021, which represents about 10% of the US population. Tocilizumab is a life-saving therapy for adults admitted to hospital with COVID-19; demand for this drug is likely to outstrip available supply in Canada. [Extracted from the article]

Background: Acute inpatient hospital admissions account for more than half of all health care costs related to diabetes. We sought to identify the most common and costly conditions leading to hospital admission among patients with diabetes compared with patients without diabetes. Methods: We used data from the General Internal Medicine Inpatient Initiative (GEMINI) study, a retrospective cohort study, of all patients admitted to a general internal medicine service at 7 Toronto hospitals between 2010 and 2015. The Canadian Institute for Health Information (CIHI) Most Responsible Diagnosis code was used to identify the 10 most frequent reasons for admission in patients with diabetes. Cost of hospital admission was estimated using the CIHI Resource Intensity Weight. Comparisons were made between patients with or without diabetes using the Pearson χ2 test for frequency and distribution-free confidence intervals (CIs) for median cost. Results: Among the 150 499 hospital admissions in our study, 41 934 (27.8%) involved patients with diabetes. Compared with patients without diabetes, hospital admissions because of soft tissue and bone infections were most frequent (2.5% v. 1.9%; prevalence ratio [PR] 1.28, 95% CI 1.19–1.37) and costly (Can$8794 v. Can$5845; cost ratio [CR] 1.50, 95% CI 1.37–1.65) among patients with diabetes. This was followed by urinary tract infections (PR 1.16, 95% CI 1.11–1.22; CR 1.23, 95% CI 1.17–1.29), stroke (PR 1.13, 95% CI 1.07–1.19; CR 1.19, 95% CI 1.14–1.25) and electrolyte disorders (PR 1.11, 95% CI 1.03–1.20; CR 1.20, 95% CI 1.08–1.34). Interpretation: Soft tissue and bone infections, urinary tract infections, stroke and electrolyte disorders are associated with a greater frequency and cost of hospital admissions in patients with diabetes than in those without diabetes. Preventive strategies focused on reducing hospital admissions secondary to these disorders may be beneficial in patients with diabetes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities. Methods: We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments. Results: There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each. Interpretation: The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases. [ABSTRACT FROM AUTHOR]

Background: Transthoracic echocardiography is routinely performed in patients with stroke or transient ischemic attack (TIA) to help plan secondary stroke management, but recent data evaluating its usefulness in this context are lacking. We sought to evaluate the value of echocardiography for identifying clinically actionable findings for secondary stroke prevention.Methods: We conducted a multicentre cohort study of patients admitted to hospital with stroke or TIA between 2010 and 2015 at 2 academic hospitals in Toronto, Ontario, Canada. Clinically actionable echocardiographic findings for secondary stroke prevention included cardiac thrombus, patent foramen ovale, atrial myxoma or valvular vegetation. We identified patient characteristics associated with clinically actionable findings using logistic regression.Results: Of the 1862 patients with stroke or TIA we identified, 1272 (68%) had at least 1 echocardiogram. Nearly all echocardiograms were transthoracic; 1097 (86%) were normal, 1 (0.08%) had an atrial myxoma, 2 (0.2%) had a valvular vegetation, 11 (0.9%) had a cardiac thrombus and 66 (5.2%) had a PFO. Patent foramen ovale was less likely among patients older than 60 years (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.20-0.57), with prior stroke or TIA (adjusted OR 0.31, 95% CI 0.09-0.76) or with dyslipidemia (adjusted OR 0.39, 95% CI 0.15-0.84). Among the 130 patients with cryptogenic stroke who had an echocardiogram (n = 110), a PFO was detected in 19 (17%) on transthoracic echocardiogram.Interpretation: Most patients with stroke or TIA had a normal echocardiogram, with few having clinically actionable findings for secondary stroke prevention. Clinically actionable findings, specifically PFO, were more common in patients with cryptogenic stroke. [ABSTRACT FROM AUTHOR]

Background: Short hospital stays may represent opportunities to avert unnecessary admissions or expedite inpatient care. To inform the design of interventions that target patients with potentially avoidable hospital admissions or brief stays, we examined the patient, physician and situational characteristics associated with short stays among patients admitted to general internal medicine wards and describe the use of hospital resources by these patients. Methods: This was a multicentre cross-sectional study conducted between Apr. 1, 2012, and Mar. 31, 2015, at 5 teaching hospitals in Toronto. We included all general internal medicine admissions through the emergency department. We examined patient, physician and situational predictors of a short hospital stay, which was defined as the patient's being discharged home alive in 2 possible time windows: less than 24 hours, or 72 hours or less. Results: The final study sample included 56 055 admissions and 37 700 unique patients. Patients discharged in less than 24 hours and in 72 hours or less accounted for 4245 (7.6%) and 13 442 (31.6%) admissions, respectively. After we controlled for patient factors, patients of female physicians were less likely than those of male physicians to have stays lasting less than 24 hours (adjusted odds ratio [OR] 0.80, 95% confidence interval [CI] 0.74–0.86) or 72 hours or less (adjusted OR 0.82, 95% CI 0.79–0.86). Patients admitted at night or on a weekday were significantly more likely than those admitted at other times to have stays lasting less than 24 hours (night: adjusted OR 2.73, 95% CI 2.44–3.06; weekday: adjusted OR 1.26, 95% CI 1.17–1.36) or 72 hours or less (night: adjusted OR 1.29, 95% CI 1.22–1.37, weekday: adjusted OR 1.05, 95% CI 1.01–1.10). Among stays lasting less than 24 hours and 24–72 hours, intravenously administered medications were ordered for 2788 (65.7%) and 10 722 (79.8%) patients, respectively, and computed tomography scans were performed for 1561 (36.8%) and 5354 (39.1%) patients, respectively. Interpretation: Short general internal medicine hospital stays were common and were associated with patient, physician and situational factors. Interventions to avert hospital admission or reduce length of stay may be more effective if they are accessible outside typical working hours and provide access to intravenous therapy and radiological investigations. [ABSTRACT FROM AUTHOR]

Background: Timely follow-up after hospital discharge may decrease readmission to hospital. Financial incentives to improve follow-up have been introduced in the United States and Canada, but it is unknown whether they are effective. Our objective was to evaluate the impact of an incentive program on timely physician follow-up after hospital discharge.Methods: We conducted an interventional time series analysis of all medical and surgical patients who were discharged home from hospital between Apr. 1, 2002, and Jan. 30, 2015, in Ontario, Canada. The intervention was a supplemental billing code for physician follow-up within 14 days of discharge from hospital, introduced in 2006. The primary outcome was an outpatient visit within 14 days of discharge. Secondary outcomes were 7-day follow-up and a composite of emergency department visits, nonelective hospital readmission and death within 14 days.Results: We included 8 008 934 patient discharge records. The incentive code was claimed in 31% of eligible visits by 51% of eligible physicians, and cost $17.5 million over the study period. There was no change in the average monthly rate of outcomes in the year before the incentive was introduced compared with the year following introduction: 14-day follow-up (66.5% v. 67.0%, overall p = 0.5), 7-day follow-up (44.9% v. 44.9%, overall p = 0.5) and composite outcome (16.7% v. 16.9%, overall p = 0.2).Interpretation: Despite uptake by physicians, a financial incentive did not alter follow-up after hospital discharge. This lack of effect may be explained by features of the incentive or by extra-physician barriers to follow-up. These barriers should be considered by policymakers before introducing similar initiatives. [ABSTRACT FROM AUTHOR]

Background: The precise scope of hospital care delivered under general internal medicine services remains poorly quantified. The purpose of this study was to describe the demographic characteristics, medical conditions, health outcomes and resource use of patients admitted to general internal medicine at 7 hospital sites in the Greater Toronto Area. Methods: This was a retrospective cohort study involving all patients who were admitted to or discharged from general internal medicine at the study sites between Apr. 1, 2010, and Mar. 31, 2015. Clinical data from hospital electronic information systems were linked to administrative data from each hospital. We examined trends in resource use and patient characteristics over the study period. Results: There were 136 208 admissions to general internal medicine involving 88 121 unique patients over the study period. General internal medicine admissions accounted for 38.8% of all admissions from the emergency department and 23.7% of all hospital bed-days. Over the study period, the number of admissions to general internal medicine increased by 32.4%; there was no meaningful change in the median length of stay or cost per hospital stay. The median patient age was 73 (interquartile range [IQR] 57-84) years, and the median number of coexisting conditions was 6 (IQR 3-9). The median acute length of stay was 4.6 (IQR 2.5-8.6) days, and the median total cost per hospital stay was $5850 (IQR $3915-$10 061). Patients received at least 1 computed tomography scan in 52.2% of admissions. The most common primary discharge diagnoses were pneumonia (5.0% of admissions), heart failure (4.7%), chronic obstructive pulmonary disease (4.1%), urinary tract infection (4.0%) and stroke (3.6%). Interpretation: Patients admitted to general internal medicine services represent a large, heterogeneous, resource-intensive and growing population. Understanding and improving general internal medicine care is essential to promote a high-quality, sustainable health care system. [ABSTRACT FROM AUTHOR]

The article analyse the additional treatment costs of acute patients admitted who suffered an adverse event (AE) during in-hospital treatment. It is mentioned that some adverse health care events may not be preventable and can also be naturally occurring conditions. The article discuss the need for a safety culture that can learn from adverse events, describe ways to measure adverse events, and comment on why current adverse event monitoring is unable to demonstrate trends in patient safety.