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Health plans develop predictive models to predict key clinical events (eg, admissions, readmissions, emergency department visits). The authors developed predictive models of admissions and readmissions for a quality improvement organization with many large government and private health plan clients. Its membership and authorization data were used to develop models predicting 2019 inpatient stays, and 2019 readmissions following 2019 admissions, based on patients' age and sex, diagnoses identified and procedures requested in 2018 authorizations, and 2018 admission authorizations. In addition to testing multivariate models, risk scores were calculated for admission and readmission for all patients in the model. The admissions model (C = 0.8491) is much more accurate than the readmissions model (C = 0.6237). Measures of risk score central tendency and skewness indicate that the vast majority of members had little risk of hospitalization in 2019; the mean (standard deviation) was 0.042 (0.074), and the median was 0.018. These risk scores can be used to identify members at risk of admission and to support proactive risk management (eg, design of health management programs). Different risk thresholds can be used to identify different subsets of members for follow-up, depending on overall strategy and available resources. This model development project was novel in employing authorization data rather than utilization data. Advantages of authorization data are their timeliness, and the fact that they are sometimes the only data available, but disadvantages of authorization data are that authorized services are not always actually performed, and diagnoses are often "rule out" rather than final diagnoses. [ABSTRACT FROM AUTHOR]

Background: Influenza and respiratory syncytial virus (RSV) contribute significantly to the burden of acute lower respiratory infection (ALRI) inpatient care, but heterogeneous coding practices and availability of inpatient data make it difficult to estimate global hospital utilization for either disease based on coded diagnoses alone. Methods: This study estimates rates of influenza and RSV hospitalization by calculating the proportion of ALRI due to influenza and RSV and applying this proportion to inpatient admissions with ALRI coded as primary diagnosis. Proportions of ALRI attributed to influenza and RSV were extracted from a meta-analysis of 360 total sources describing inpatient hospital admissions which were input to a Bayesian mixed effects model over age with random effects over location. Results of this model were applied to inpatient admission datasets for 44 countries to produce rates of hospital utilization for influenza and RSV respectively, and rates were compared to raw coded admissions for each disease. Results: For most age groups, these methods estimated a higher national admission rate than the rate of directly coded influenza or RSV admissions in the same inpatient sources. In many inpatient sources, International Classification of Disease (ICD) coding detail was insufficient to estimate RSV burden directly. The influenza inpatient burden estimates in older adults appear to be substantially underestimated using this method on primary diagnoses alone. Application of the mixed effects model reduced heterogeneity between countries in influenza and RSV which was biased by coding practices and between-country variation. Conclusions: This new method presents the opportunity of estimating hospital utilization rates for influenza and RSV using a wide range of clinical databases. Estimates generally seem promising for influenza and RSV associated hospitalization, but influenza estimates from primary diagnosis seem highly underestimated among older adults. Considerable heterogeneity remains between countries in ALRI coding (i.e., primary vs non-primary cause), and in the age profile of proportion positive for influenza and RSV across studies. While this analysis is interesting because of its wide data utilization and applicability in locations without laboratory-confirmed admission data, understanding the sources of variability and data quality will be essential in future applications of these methods. [ABSTRACT FROM AUTHOR]

Objective 'Sensible on Strength' (SoS), a local public health initiative, is aimed at reducing high-strength beer and cider availability. The objective of this study was to assess its impact on local hospital admissions with alcohol-related liver disease (ALD) and on drinking behaviour. Design This was a retrospective cohort study in patients admitted with decompensated ALD, 3 years before and 3 years after the introduction of the SoS initiative. Hospital records of 143 index admissions with decompensated ALD were reviewed. Outcomes measures were the severity of liver disease on admission and mortality (inpatient and long-term), and change (if any) in alcohol drinking behaviour. Results Comparing patients admitted in both phases, there were no significant differences in liver prognostic scores, liverrelated complications, length of stay and inpatient/long-term mortality (p>0.05). However, the SoS initiative was associated with a 33% move away from beer and cider consumption (36.3% vs 54.0%; p=0.034), but without a significant change in units of alcohol consumed. The Model for End-stage Liver Disease (MELD) score was the only independent predictor of inpatient mortality (odds ratio 1.25; p=0.025). Conclusion Despite having no apparent impact on the clinical spectrum of local ALD admissions, it is conceivable that longer follow-up is needed to determine the true impact of this initiative. [ABSTRACT FROM AUTHOR]

This study aimed to assess the impact of the latest smoke-free legislation on hospital admission rates due to smoking-related diseases in Spain. A retrospective cohort study was conducted to evaluate changes in hospital admission rates for cardiovascular, respiratory diseases, and smoking-related cancer in Valencia, Spain, during the period 1995–2013. Law 28/2005 and then law 42/2010 prohibited smoking in bars and restaurants as well as playgrounds and access points to schools and hospitals. General population data by age and sex were obtained from the National Institute of Statistics census. Data on hospital admissions were obtained from the Minimum Basic Data Set. Diagnoses were codified according to the International Classification of Diseases-9th revision. Data from all hospitals of the Valencian Community from 1995 to 2013 were analysed. Trend analyses in the periods before and after the approval of the 2005 law were conducted using least-squares linear regression models. Adjusted hospital admission rates per 100,000 inhabitants for cardiovascular diseases significantly decreased after the 2005 Law (from 550.0/100,000 in 2005 to 500.5/100,000 in 2007), with a further decrease (to 434.6/100,000) in 2013, after the 2010 Law. Reductions in hospital admissions were seen in men and women, although declining trends were more marked in men. Hospital admission rates for respiratory diseases showed a reduction of a lower magnitude, whereas for smoking-related cancer admissions there was a slight decline only among men. The Spanish comprehensive smoking ban resulted in a remarkable reduction of the adjusted rate of hospital admissions mainly associated to cardiovascular diseases. The decrease in the number of persons requiring in-patient care is relevant and may be viewed as an improvement of the public's health. • Epidemiological study of almost 20 years, legislative changes towards greater tobacco control. • Not only considering cardiovascular consequences, but also cancer and respiratory diseases. • The study analyses the impact that public health regulatory measures promoted by governments. • The attribution of the positive results to legislation is always complex. [ABSTRACT FROM AUTHOR]

The consumption of medications with anticholinergic activity has been suggested to result in the adverse effects of mental confusion, visual disturbance, and muscle weakness, which may lead to falls. Existing published evidence linking anticholinergic drugs with falls, however, remains weak. This study was conducted to evaluate the relationship between anticholinergic cognitive burden (ACB) and the long-term risk of hospitalization with falls and fractures in a large population study. The dataset comprised information from 25,639 men and women (aged 40–79 years) recruited from 1993 to 1997 from Norfolk, United Kingdom into the European Prospective Investigation into Cancer (EPIC)-Norfolk study. The time to first hospital admission with a fall with or without fracture was obtained from the National Health Service hospital information system. Cox-proportional hazards analyses were conducted to adjust for confounders and competing risks. The fall hospitalization rate was 5.8% over a median follow-up of ~ 19.4 years. The unadjusted incidence rate ratio for the use of any drugs with anticholinergic properties was 1.79 (95% CI 1.66–1.93). The hazard ratios (95% CI) for ACB scores of 1, 2–3, and ≥ 4 compared with ACB = 0 for fall hospitalization were 1.20 (1.09–1.33), 1.42 (1.25–1.60), and 1.39 (1.21–1.60) after adjustment for age, gender, medical conditions, physical activity, and blood pressure. Medications with anticholinergic activity are associated with an increased risk of subsequent hospitalization with a fall over a 19-year follow-up period. The biological mechanisms underlying the long-term risk of hospitalization with a fall or fracture following baseline ACB exposure remains unclear and requires further evaluation. [ABSTRACT FROM AUTHOR]

Background: The main indication for transoral robotic surgery (TORS) has been the primary treatment of oropharyngeal squamous cell carcinoma (OPSCC). In the western world this is highly relevant due to the increasing incidence of human papillomavirus (HPV)-positive OPSCC. In Denmark, TORS was implemented in 2013 for use in the protocolled primary treatment of OPSCC. Aims/objectives: To perform a year-by-year comparative analysis of indications for TORS, hospitalization and complication rates to identify optimal future indications for TORS. Methods and materials: This is a retrospective single-centre case review from 2013-2017. Data were collected from patient files through electronic health care systems. Results: Since 2013, there has been a change of indications from performing benign and salvage surgery to mainly primary treatment of OPSCC and diagnostic use in patients with cancer of unknown primary (CUP). The overall complication rates have reduced considerably over time. Conclusions and significance: Lower complication rates may be explained by improved surgical experience, through better patient selection and changes in indications for TORS. Future applications of TORS will be in the management of CUP and as part of a Danish national randomized clinical trial aiming to compare long-term functional outcomes after treatment of early-stage OPSCC with TORS versus radiation treatment. [ABSTRACT FROM AUTHOR]

Objective: to analyze the profile of obstetric patients admitted to the Intensive Care Unit. Method: quantitative, descriptive and retrospective study, developed through searches and retrieval of data referring to socioeconomic and clinical profile of pregnant or postpartum patients' records admitted for obstetric cause, between January 2017 and December 2018, in the Intensive Care Unit of a public hospital in Pernambuco, Brazil. The results were analyzed using the Statistical Package for the Social Sciences. Results: most women were between 19 and 29 years (56.1%), and pardas (88.6%). The majority was hospitalized in the postpartum (75.6%), the most prevalent delivery type was cesarean section (87.2%), hypertensive syndromes were the major cause of hospitalization (61.8%). The main hypertensive disorder was pre-eclampsia (39.8%). Conclusion: the young adult puerperal patients, whose delivery route was cesarean section, with hypertensive syndromes are hospitalized more frequently in the Intensive Care Unit. [ABSTRACT FROM AUTHOR]

Objective: To describe the characteristics of hospital admissions for dental conditions, by Australian Statistical Geography Standard remoteness area for the 5 years 2010/2011 to 2014/2015. Design: Retrospective analysis of preventable hospital admissions due to dental conditions. Setting: National data set provided by the Australian Institute of Health and Welfare. Participants: Every hospital admission for patients who were admitted for dental conditions over five financial years, from 2010/2011 to 2014/2015. Main outcome measures: The number (and rate per 1000 population) of hospital admissions due to dental conditions in each Australian Statistical Geography Standard remoteness area (major city, inner regional, outer regional, remote and very remote). Results: There were 316 937 hospital admissions for dental conditions over the 5‐year period. The rate of potentially preventable dental hospital admissions ranged from an average of 2.5 per 1000 population in major cities to 3.2 in inner regional areas, 3.1 in outer regional areas, and 4.1 per 1000 in remote and very remote areas. The rate of admissions was highest among those aged 0‐14 years living in remote (9.0‐10.0 per 1000) and very remote (9.8‐12.5 per 1000) areas. Dental caries was the most common reason for admissions. Conclusions: There is an urgent need to address the social determinants of oral health in children aged 0‐14 years living in remote and very remote Australia. The delivery of mobile primary dental care services needs to be expanded in remote and very remote areas to prevent and treat dental caries. [ABSTRACT FROM AUTHOR]

PURPOSE: The Oncology Care Model (OCM) is an alternative payment model administered by the Centers for Medicare & Medicaid Services (CMS) that is structured around 6-month chemotherapy treatment episodes. This report describes the CMS-sponsored OCM evaluation and summarizes early evaluation findings. METHODS: The OCM evaluation examines health care spending and use, quality of care, and patient experience during chemotherapy treatment episodes. Because OCM participation is voluntary, the evaluation compares participating physician practices with a propensity-matched group of nonparticipating practices by using a difference-in-differences approach. This report examines 6-month episodes initiated during the first OCM performance period (July 1, 2016, through January 1, 2017). RESULTS: During the first OCM performance period, there was no statistically significant impact of OCM on total episode payments. There were small declines in intensive care unit (ICU) admissions (7 per 1,000 episodes) and emergency department visits (15 per 1,000 episodes); there was no statistically significant impact on hospitalizations or 30-day readmissions. Analyses of care quality and end-of-life care showed statistically significant impacts of OCM on the proportion of patients with inpatient hospitalizations in the last 30 days of life (1.5% absolute decrease) and ICU admissions in the last 30 days of life (2.1% decrease). There was no significant OCM impact on measures of hospice use. CONCLUSION: Early findings from the OCM evaluation demonstrate modest program-related impacts on some acute care services and no change in total episode payments. Early findings may not reflect practice redesign efforts that were phased in after the beginning of OCM. [ABSTRACT FROM AUTHOR]

Study Objective: Many policymakers believe that expanding access to outpatient care will reduce emergency department (ED) use. However, outpatient health care providers often refer their patients to EDs for evaluation and management. We examine the factors underlying outpatient provider referral, its effect on ED visit volume, and whether referred ED visits are more likely to result in hospitalization than self-referred visits.Methods: We conducted a cross-sectional study of 19,342 adult (>18 years) respondents to the 2012 to 2014 National Health Interview Survey who reported they had visited an ED at least once in the past 12 months, representing an estimated 44,152,870 US adults. We categorized individuals as having been referred to the ED by an outside health care provider if they responded affirmatively to "your health care provider advised you to go" as a reason for their most recent ED visit. We performed descriptive analyses and logistic regressions to examine factors associated with outpatient health care provider referral to the ED. Respondents could choose multiple other reasons for their most recent ED visit, and we used existing Centers for Disease Control and Prevention guidelines to group these reasons into 2 categories: seriousness of the medical condition and lack of access to other providers. Our 2 main outcomes were whether an outpatient health care provider referred an individual to the ED and whether that ED visit resulted in hospitalization.Results: Of the 44,152,870 US adults (18.58%; 95% confidence interval [CI] 18.21% to 18.95%) with one or more ED visits in the previous 12 months, 10,913,271 (24.72%; 95% CI 23.80% to 25.64%) were referred to the ED by an outpatient provider. Respondents who reported their ED visit was due to the seriousness of their medical condition were more likely to be referred to the ED (odds ratio [OR] 2.18; 95% CI 1.91 to 2.49), whereas those reporting a lack of access to other providers were less likely to be referred (OR 0.58; 95% CI 0.52 to 0.64). Visits referred to the ED were more likely to result in hospitalization than self-referrals (OR 2.07; 95% CI 1.87 to 2.31).Conclusion: Almost one quarter of individuals' most recent ED visits were driven by referrals from outpatient health care providers. Being referred to the ED by an outpatient provider is strongly associated with the seriousness of one's medical condition, which also increases the odds of hospitalization compared with ED discharge. After controlling for seriousness of medical condition, ED referral by an outpatient provider continues to have an independent association with hospitalization. [ABSTRACT FROM AUTHOR]

Aim To examine discharges of octogenarians, nonagenarians and centenarians from Portuguese public hospitals, namely admission type, principal diagnoses, comorbidities and length of stay. Methods The present study used administrative data from public acute care hospitals in the Portuguese National Health Service. All discharges of persons aged ≥80 years between 2000 and 2014 were analyzed. HCUP Clinical Classifications Software was considered to aggregate principal diagnosis, and comorbidities were assessed using the Charlson Comorbidity Index computed using International Classification of Diseases 9th Revision Clinical Modification codes. Results A total of 2 494 924 discharges of persons aged 80 years or older were registered. Most (73.7%) referred to inpatient episodes, of which 73% were unplanned and medical (non-surgical). Pneumonia (12.2%), acute cerebrovascular disease (7.1%) and non-hypertensive cardiac heart failure (5.3%) were the most common principal diagnoses among inpatient episodes. Congestive heart failure and diabetes without chronic complications were the two most frequent comorbidities (16.6%), and discharge diagnoses with higher median length of stay were tuberculosis, burns, and infective arthritis and osteomyelitis. Conclusions The number of hospitalizations of the oldest old has suffered a significant increase in the past few years, reinforcing the need for healthcare services being prepared to the specificities of the oldest old population. Geriatr Gerontol Int 2017; 17: 2255-2265. [ABSTRACT FROM AUTHOR]

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We aimed to evaluate care for leukemia and lymphoma patients during their last hospitalization from the perspective of the bereaved family. Questionnaires were sent to the bereaved family members of adult leukemia and lymphoma patients. We used the Care Evaluation Scale (CES) and asked the bereaved family members about care satisfaction and “good death” factors during the patient’s last week of life or last admission period. We distributed 177 questionnaires and were able to analyze 103 (58.2%) responses. Compared with the results of a previous study of palliative care units in Japan, the CES scores were significantly lower in 9 out of 10 domains. Assessment of the “good death” components revealed that only 33% of respondents agreed that the patient had been relieved as far as possible of pain and physical distress during the last week of life. Only 21.4% of respondents agreed that the patient had been relieved as far as possible of psychological distress, and 57% of caregivers were not satisfied with the level of care. During the last hospitalizations of leukemia or lymphoma patients, their care was insufficient and a good death was not often achieved. Improvement of end-of-life care for leukemia and lymphoma patients is needed. [ABSTRACT FROM AUTHOR]

Avoidable hospitalizations for ambulatory care sensitive conditions (AH-ACSCs) identify health problems that could be avoided by improving primary health care (PHC). On the basis of hospital discharges from Argentine public sector facilities, an expert panel convened to define a list of AH-ACSCs for children and adults. AH-ACSCs represented less than 30% of hospitalizations. Compared with country averages, poorer districts showed large differences in trends for adults but not for children. Despite that AH-ACSCs have demonstrated empirical validity to evaluate health system performance, its implementation to assess PHC in countries like Argentina, with pluralistic and fragmented health care systems, remains a big challenge. [ABSTRACT FROM AUTHOR]

Objective To assess the effects on hospital utilization rates of a major health system reform - a family physician programme and a social protection scheme - undertaken in rural areas of the Islamic Republic of Iran in 2005. Methods A "tracer" province that was not a patient referral hub was selected for the collection of monthly hospitalization data over a period of about 10 years, beginning two years before the rural health system reform (the "intervention") began. An interrupted time series analysis was conducted and segmented regression analysis was used to assess the immediate and gradual effects of the intervention on hospitalization rates in an intervention group composed of rural residents and a comparison group composed of urban residents primarily. Findings Before the intervention, the hospitalization rate in the rural population was significantly lower than in the comparison group. Although there was no significant increase or decline in hospitalization rates in the intervention or comparison group before the intervention, after the intervention a significant increase in the hospitalization rate - of 4.6 hospitalizations per 100 000 insured persons per month on average - was noted in the intervention group (P < 0.001). The monthly increase in the hospitalization rate continued for over a year and stabilized thereafter. No increase in the hospitalization rate was observed in the comparison group. Conclusion The primary health-care programme instituted as part of the health system reform process has increased access to hospital care in a population that formerly underutilized hospital services. It has not reduced hospitalizations or hospitalization-related expenditure. [ABSTRACT FROM AUTHOR]

Abstract: This research explores how elective surgical patients make sense of their hospitalization experiences. We explore sensemaking using longitudinal narrative interviews (n =72) with 38 patients undergoing elective surgical procedures between June 2010 and February 2011. We consider patients' narratives, the stories they tell of their prior expectations, and subsequent post-surgery experiences of their care in a United Kingdom (UK) hospital. An emergent pre-surgery theme is that of a paradoxical position in which they choose to make themselves vulnerable by agreeing to surgery to enhance their health, this necessitating trust of clinicians (doctors and nurses). To make sense of their situation, patients draw on technical (doctors' expert knowledge and skills), bureaucratic (National Health Service as a revered institution) and ideological (hospitals as places of safety), discourses. Post-operatively, themes of ‘chaos’ and ‘suffering’ emerge from the narratives of patients whose pre-surgery expectations (and trust) have been violated. Their stories tell of unmet expectations and of inability to make shared sense of experiences with clinicians who are responsible for their care. We add to knowledge of how patients play a critical part in the co-construction of safety by demonstrating how patient–clinician intersubjectivity contributes to the type of harm that patients describe. Our results suggest that approaches to enhancing patients' safety will be limited if they fail to reflect patients' involvement in the negotiated process of healthcare. We also provide further evidence of the contribution narrative inquiry can make to patient safety. [Copyright &y& Elsevier]

Patients with acute myeloid leukemia (AML) are at risk for sudden clinical deterioration. We aimed to describe the incidence of medical emergency team (MET) activation, intensive care unit (ICU) admissions and outcomes for patients with AML. We performed a 5-year retrospective cohort study of patients hospitalized with AML. One hundred and seventy patients were divided into three groups: (1) MET activated ( n = 34); (2) MET criteria present but MET not activated ( n = 17); and (3) all other patients with AML ( n = 119). MET activation incidence was 200 calls/1000 admissions (95% confidence interval [CI], 138-279), compared with a hospital-wide rate of 29.3 calls/1000 admissions (95% CI, 28.2-30.4) (relative risk 6.90; 95% CI, 4.77-9.67, p < 0.0001). Some 77% ( n = 26) were triaged to the ICU. Hospital mortality was higher in MET activated and MET fulfilled without activation groups compared with all others (27% vs. 12% vs. 7%, p = 0.007). Changes to goals of care were more common with MET activation. Patients with AML commonly receive MET activation. Approximately one in 10 fulfill MET criteria, however do not receive MET activation. [ABSTRACT FROM AUTHOR]

Aims The ADVANCE trial recruited participants from 20 countries worldwide. We analyse here regional variations and causes of hospitalization for people with Type 2 diabetes from Asia, Established Market Economies and Eastern Europe. Methods A cohort analysis examining the effects of region on causes of first hospitalization, and the association of participant characteristics on all-cause first hospitalization across regions, using multivariable (adjusted for clinical, physiological, behavioural and socio-demographic factors) Cox models. Results Of 11 140 individuals (6407 men), all-cause hospitalization rates were highest in Established Market Economies, followed by Eastern Europe then Asia. Eastern Europe had rates of hospitalization for diabetic causes four times greater than Established Market Economies [multivariable-adjusted hazard ratio 4.02 (95% CI 2.86-5.63)]. There were no significant regional variations in hospitalization rates for cardiovascular disease ( P = 0.534), but much lower rates for musculoskeletal and non-specific causes in Eastern Europe [multivariable-adjusted hazard ratio 0.44 (95% CI 0.32-0.60) and 0.19 (95% CI 0.12-0.29)] and Asia [hazard ratio 0.21 (95% CI 0.16-0.29) and 0.09 (95% CI 0.06-0.14)] compared with Established Market Economies. In all regions, participants hospitalized for any cause were more likely to be older, male, hypertensive, smokers, have higher glycated haemoglobin and a history of macrovascular or macrovascular disease. Conclusions Across three markedly different regions of the world, regional rates and causes of hospitalization varied widely in patients with Type 2 diabetes. Adjustment for a range of patient characteristics did not explain these regional differences in hospitalization, which appear to be attributable to health system factors. [ABSTRACT FROM AUTHOR]

Purpose: Interhospital critical care transfers are common, yet few studies address the underlying reasons for transfers. We examined clinician and patient/surrogate perceptions about interhospital transfers and assessed their agreement on these transfers. Materials and methods: This is a mixed-mode survey of 3 major stakeholders in interhospital transfers to an academic medical intensive care unit from August 2007 to April 2008. Results: Sixty-two hospitals transferred 138 patients during the study period. Response rates varied among stakeholders (accepting physician, 90%; referring physicians, 20%; patients/surrogates, 33%). All 3 groups frequently endorsed quality of care and need for a specific test/procedure as important. Referring hospital reputation and quality were rarely endorsed. Accepting physicians and patients/ surrogates substantially agreed on the need for a specific test (κ = 0.70) and increased survival (κ = 0.78) but, otherwise, had fair to poor agreement. Referring physicians and patients/surrogates rarely agreed and sometimes disagreed greater than expected by chance (κ < 0). Physician pairs strongly agreed on the importance of accepting hospital experience (κ = 0.96) but agreed less on patient satisfaction at the referring hospital (κ = 0.37) and referring hospital reputation (κ = 0.35). Conclusions: Stakeholders do not always agree on the reasons for critical care transfers. Efforts to improve communication are warranted to ensure informed patient choices. [ABSTRACT FROM AUTHOR]

Objective. To evaluate the effect of a Medical Assessment Unit (MAU) on older patients. Methods. Retrospective case-control study of patients 65 years and above admitted to the MAU (study group) and the general medical wards (control group) in Bankstown-Lidcombe Hospital from 1 October 2008 to 31 March 2009 with four most common Diagnosis-Related Groups (DRG) ('falls and gait disorder', 'chronic obstructive pulmonary disease (COPD)', 'other major respiratory diseases and 'cellulitis'). Main outcome measures. Length of stay (LOS) in Emergency Department (ED) and in the hospital, mortality, readmissions within 1 month, and discharge destination. Results. Eighty-nine patients were studied; 47 in the MAU group and 42 in the non-MAU group. The MAU cohort was significantly older (84.1±7.9 years v. 80.4±7.8 years, respectively, P=0.03); and had shorter ED LOS (4.9±3.0h v. 6.5±2.8h, P=0.012). Overall hospital LOS did not differ except for patients with 'cellulitis', (5.7±4.9 days for MAU cohort v. 14.8±6.8 days for non-MAU cohort, P=0.022). There was no significant difference in mortality, readmission rate or discharge destination. Conclusions. The MAU can be an effective service model for older patients. More research is required to confirm this and to define the key elements that are essential for its effectiveness. What is known about the topic? The Medical Assessment Unit is a model of care that has been developed in response to increasing Emergency Department presentations and rising demand on hospital beds. There has been some evidence that this model of care improves efficiency by reducing Emergency Department length of stay and overall hospital length of stay, but little published data targeting the Aged Care population group, who account for a high proportion of Emergency Department admissions. What does this paper add? This paper is a case-control study and provides additional evidence on the benefit of the Medical Assessment Unit model in the elderly population, specifically the benefits in the reduction of Emergency Department length of stay and overall hospital length of stay. This paper also assists in identifying key elements essential for the success of the Medical Assessment Unit model. What are the implications for practitioners? With increasing demand on healthcare, practitioners need to continually redesign how they deliver healthcare to maximise cost efficiency and effectiveness. We believe the Medical Assessment Unit is an effective new model of care. However, more research is required to further refine this model and also identify target patient groups who can most benefit from this model of care.

Vanderloo SE, Johnson JA, Reimer K, McCrea P, Nuernberger K, Krueger H, Aydede SK, Collet J-P, Amed S. Validation of classification algorithms for childhood diabetes identified from administrative data. Objective: Type 1 diabetes is the most common form of diabetes among children; however, the proportion of cases of childhood type 2 diabetes is increasing. In Canada, the National Diabetes Surveillance System (NDSS) uses administrative health data to describe trends in the epidemiology of diabetes, but does not specify diabetes type. The objective of this study was to validate algorithms to classify diabetes type in children <20 yr identified using the NDSS methodology. Patients and methods: We applied the NDSS case definition to children living in British Columbia between 1 April 1996 and 31 March 2007. Through an iterative process, four potential classification algorithms were developed based on demographic characteristics and drug-utilization patterns. Each algorithm was then validated against a gold standard clinical database. Results: Algorithms based primarily on an age rule (i.e., age <10 at diagnosis categorized type 1 diabetes) were most sensitive in the identification of type 1 diabetes; algorithms with restrictions on drug utilization (i.e., no prescriptions for insulin ± glucose monitoring strips categorized type 2 diabetes) were most sensitive for identifying type 2 diabetes. One algorithm was identified as having the optimal balance of sensitivity (Sn) and specificity (Sp) for the identification of both type 1 (Sn: 98.6%; Sp: 78.2%; PPV: 97.8%) and type 2 diabetes (Sn: 83.2%; Sp: 97.5%; PPV: 73.7%). Conclusions: Demographic characteristics in combination with drug-utilization patterns can be used to differentiate diabetes type among cases of pediatric diabetes identified within administrative health databases. Validation of similar algorithms in other regions is warranted. [ABSTRACT FROM AUTHOR]

Purpose – This paper aims to develop a conceptual resilience-based model that takes account of the competing success factors of patient safety, finance, improvement targets and staff workload in NHS hospitals in the UK. Design/methodology/approach – A safe working envelope model was developed from the literature and adapted for use in the NHS. The proposition that finance and targets receive greater management attention was then tested by a pilot study using content analysis of risk management documents of four NHS hospitals. Findings – The need to succeed on finance and targets received greater attention in the risk management documents than patient safety and staff workload. Research limitations/implications – This is a pilot study only, using content analysis of risk management documents from four hospitals to see whether the model developed from the literature warrants further study. Practical implications – Using the proposed safe working model will allow the setting and monitoring of failure and marginal boundaries and make more explicit the pressures from the competing success factors in public sector hospitals in the UK. Originality/value – The development of the conceptual model using ideas from resilience engineering and applying them to NHS hospital management provides a policy and practical approach to improving patient safety. [ABSTRACT FROM AUTHOR]

The study aimed to identify patient characteristics associated with differences in outcomes of acute treatment in day hospitals and conventional hospital wards. Methods: Data were from the European Day Hospital Evaluation (EDEN) (2000-2003), a multicenter randomized controlled trial comparing acute treatment in day hospitals and conventional wards in five European countries. All 880 adult patients in the EDEN study who had a diagnosis of schizophrenia, mood disorders, neurotic disorders, and behavioral syndromes (ICD-10 codes F20-F59) and complete data on baseline variables were included. Outcomes were symptom levels (Brief Psychiatric Rating Scale), subjective quality of life (Manchester Short Assessment of Quality of Life), and social disability (Groningen Social Disabilities Schedule) assessed at discharge and at three and 12 months postdischarge. Mixed- and main-effects models of interaction effects between patient characteristics and outcomes were generated. Results: Patients' age, diagnostic category, and living status (alone or not) did not predict differences in outcomes between the two settings. However, patients with higher symptom levels at baseline experienced greater symptom improvements after treatment on a ward, and those with more years of education had greater symptom improvements after day hospital treatment. Female patients had more favorable social disability outcomes after day hospital treatment, but no difference between the two settings was found for male patients. Conclusions: More severe symptoms may be a reason for admission to acute treatment on a conventional ward rather than a day hospital. Female patients and those with more education may benefit more from acute treatment in day hospitals. [ABSTRACT FROM AUTHOR]

Background and objectives: Because of late effects among survivors of cancer in young people, increased hospitalisations would be expected. This study determined the occurrence, frequency and days in hospital (DIH) of hospital admissions among 5-year survivors of childhood and adolescent cancer diagnosed in British Columbia (BC), compared hospitalisation risk with the general population and examined the impact of sociodemographic, health care system and clinical factors. Design: This population-based study frequency matched 1157 survivors of cancer diagnosed before 20years of age from 1970 to 1992 from the BC Cancer Registry with 11,570 randomly selected individuals from BC’s health insurance plan Client Registry. Administrative hospitalisation records from 1998 to 2000 were linked to study cohorts, and regression and trend analyses were carried out. Results: From 1998 to 2000, 240 (21%) of survivors and 614 (5.3%) of the population sample were admitted to hospital at least once [adjusted OR=4.36 (95% CI 3.68–5.16)]. Hospitalised survivors had a higher average number of admissions (2.0 versus 1.5 admissions, respectively) and longer mean DIH (10.9 versus 7.8d, respectively) than hospitalised population controls. Female gender and older age increased the risk of hospitalisation, as did the presence of a relapse or second cancer by 5years post-diagnosis. Conclusion: Our cohort of child and adolescent cancer survivors had higher odds of hospitalisation, more admissions among those hospitalised and longer stay in hospital compared to the population sample. This has implications for health care system resources and appropriate management of late effects of survivors. [Copyright &y& Elsevier]

There is no consensus on the best method to assess the nutritional status of hospitalized adults although many methods are available. This study evaluated the prevalence of malnutrition in adults at different times of hospitalization (admission, 7th, 14th, 21st, and 28th days) in two years (2002 and 2006). All patients were submitted to anthropometric assessment, Subjective Global Assessment (SGA), determination of serum albumin, and lymphocyte count. There were no differences in prevalence of malnutrition between the years of assessment, but great variability was found when different methods were used. An increase in malnutrition was detected when the diagnostic criterion was the total count of lymphocytes, while a decrease was detected in the case of the Body Mass Index (BMI). In both years, the increase in malnutrition was not statistically significant over the weeks of hospitalization. Over the years, malnutrition remains an important health problem of hospitalized adults, requiring appropriate diagnosis and management. Each institution is recommended to adopt one or more appropriate methods of nutritional assessment, which have been validated for the population under their care. [ABSTRACT FROM AUTHOR]

Patients value the interpersonal aspects of their health care experiences,. However, faced with multiple resource demands, primary care practices may question the value of collecting and acting upon survey data that measure patients' experiences of care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) suite of surveys and quality improvement tools supports the systematic collection of data on patient experience. Collecting and reporting CAHPS data can improve patients' experiences, along with producing tangible benefits to primary care practices and the health care system. We also argue that the use of patient experience information can be an important strategy for transforming practices as well as to drive overall system transformation. [ABSTRACT FROM AUTHOR]

Objective: To translate, to test inter-rater and intra-rater reliability and concurrent validity of the Basic Care Needs (BCN) section of the Northwick Park Dependency Score (NPDS). Design: Test–retest reliability and validity testing. Observed data were collected by the staff (nursing staff, occupational therapists). Setting: Three rehabilitation units. Subjects: Forty inpatients between 16 and 65 years of age with brain injury were included. Main measures: Inter-rater and intra-rater reliability was calculated by percentage agreement (PA) and unweighted kappa measure. Concurrent validity was examined by computing Goodman–Kruskal's gamma, a nonparametric statistic for degree of association between the BCN score and the total score of the Functional Independence Measure (FIM). Results: Inter-rater reliability showed a good percentage agreement between nursing staff. Between nursing staff and occupational therapists the percentage agreement was lower especially in one item. Intra-rater reliability showed a good percentage agreement for all assessors. Concordance was good with a gamma -0.83 and an asymptotic error (ase) of 0.04, for nursing staff and for occupational therapists -0.87, ase 0.04. Conclusion: The BCN section of NPDS was found to be inter-rater and intra-rater reliable, to have concurrent validity. Further studies are needed on clinical utility. The instrument can be used for assessment of dependency for individual patients with brain injury, and information when transferring between different caregivers. Further studies need to investigate the sensitivity of the instrument. [ABSTRACT FROM AUTHOR]

In this study we describe the development of the Individualized Care Scale (ICS) and evaluate its validity, psychometric properties and feasibility. The ICS was designed to measure patients’ views on how individuality is supported through specific nursing interventions (ICA) and how they perceive individuality in their own care (ICB) during hospitalization.Three different data sets were collected among patients being discharged from hospital (n1 = 203,n2 = 279,n3 = 454). This bipartite 38-item ICS promises to be a brief, timely, easy to administer and useful self-completion measure for evaluating clinical nursing practice from the patient's point of view.The findings supported the internal consistency reliability of the ICS (alpha 0.94 for ICA and ICB 0.93) and the three subscales (alphas 0.85–0.90). Item analysis supported the item construction of each scale. Content validity was furthered by a critical literature review and four expert analyses. Principal component analysis (Promax with Kaiser normalization) among earlier factor analyses supported construct validity by generating a three-factor solution which accounted for 65% of the variance in the ICA and 61% in the ICB. Pearson's correlation coefficients were at least 0.88 between the subscales and the total domain ICA or ICB.The ICS has demonstrated promise as a tool for measuring patients’ evaluations of their hospital experience and individuality in care. [ABSTRACT FROM AUTHOR]

Purpose: To determine if early unplanned readmissions of patients hospitalized for heart failure are associated with suboptimal in-hospital care or with the clinical and demographic characteristics of the patient.Subject and Methods: We performed a case-control study among patients discharged with a principal diagnosis of heart failure. Cases included all patients unexpectedly readmitted within 31 days of discharge; controls were randomly selected from among those not readmitted. Quality of care was measured using explicit criteria reflecting the admission work-up, evaluation and treatment, and readiness for discharge.Results: Ninety-one cases and 351 controls were included. There was no significant association between early unplanned readmissions and the scores for quality of the admission work-up or evaluation and treatment during the stay. There was a significant association between readiness for discharge and subsequent early readmission: for each 10% decrease in the proportion of fulfilled criteria, the odds of readmission increased by 14% (95% confidence interval [CI] 1. 01 to 1.28, P = 0.04) for all-cause readmissions and by 19% (95% CI: 1.04 to 1.36, P = 0.01) for heart-failure-related readmissions. In a multiple logistic regression model, previous diagnosis of heart failure (odds ratio [OR] = 2.9, 95% CI: 1.7 to 4.8, P <0.001), age (OR = 3.3, 95% CI: 1.3 to 8.5, P = 0.01 for patients aged 65 to 79 years and OR = 4.1, 95% CI: 1.6 to 11, P = 0.004 for patients aged 80 years and older), and history of cardiac revascularization (OR = 2.1, 95% CI: 1.2 to 3.9, P = 0.01) showed a stronger association with early unplanned all-cause readmissions than the readiness-for-discharge score (OR = 1.16, 95% CI: 1.02 to 1.31, P = 0.02). Similar findings were seen for heart failure-related readmissions.Conclusions: Among patients with heart failure, early unplanned readmissions were not associated with suboptimal admission work-up or evaluation and treatment but were weakly associated with readiness for discharge. However, they were strongly associated with the patients' clinical and demographic characteristics. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the editor discusses the comprehensive understanding of emergency department (ED) transfer patterns in the U.S.

Aim: The aim of this study was to understand how people evaluate and make sense of their experience of hospital care. Method: Narrative interviews were conducted with 18 patients between 4-6 weeks after an episode of inpatient care or day surgery. Participants were deliberately sampled from a population who participated in a hospital-wide audit which took place during 1 week in June 1995. Sampling criteria ensured a mix of age, gender, type of, and reason for, admission. The interviews were audiotaped, transcribed and analysed using grounded theory. Findings: Three categories: 'feeling informed', 'valued as an individual', and 'at home' contributed to a core category: 'building confidence, faith and trust'. Notably, confidence and trust were determined as much by observations of the care given to other people, as the care the participants themselves had received. Conclusions: More attention needs to be given to understanding the complex social and reflective process which underpin patient judgements about quality of care. [ABSTRACT FROM AUTHOR]

Provides information on a clinical trial which tests the clinical equivalence and resource consequences of day care and conventional inpatient care for active rheumatoid arthritis. Subjects and methodology used in conducting the study; Results of the study; Resource costs of day care. INSET: Key messages.

• Recently, a Hospital Frailty Risk Score (HFRS) was developed and validated using routinely collected hospital data. • This study aimed to validate HFRS to predict hospital use in older Australian using longitudinal data that was collected for more than 15 years. • This study confirms the ability of HFRS to identify older, frail people at higher risk of prolonged hospital length of stay and increased mortality risk. Frailty is among the most serious global public health challenges due to the rapid increase in the ageing population and age-associated declines in health. We aimed to validate hospital frailty risk score (HFRS) for its ability to predict prolonged hospital length of stay, 28-day unplanned readmission, repeated admission, and mortality in older people over a 15-year follow-up period. We linked data from the Australian Longitudinal Study on Women's Health (ALSWH) with hospital admission and National Death Index datasets to identify admitted patients and death dates. This study included patients with an index unplanned admission resulting in an overnight hospital stay in 2001–2016 and aged 75–95 years at the time of admission. HFRS and Charlson comorbidity index (CCI) were calculated from the hospital data using the International Statistical Classification of Diseases, Australia Modification (ICD-10-AM) diagnostic codes. Of 2740 older women aged 75 years and over with unplanned admission, the proportions of patients with low, intermediate, and high frailty risks were 77.15 % (n = 2114), 20.95 % (n = 574), and 1.90 % (n = 52), respectively. The 15-year follow-up revealed that high frailty risk patients increased 5-fold in 2015 (15.67 % patients, mean age = 92.26 years) compared to 2001 (2.56 % patients, mean age = 77.96 years). Prolonged hospital length of stay was higher in the intermediate (AOR = 2.86, 95 %CI: 2.26, 3.62) and high frailty risk group (AOR = 4.26, 95 %CI: 2.32, 7.63) compared to the low frailty risk group. Frailty risk was not associated with unplanned or repeated hospital admission. However, the intermediate frailty risk group (AHR = 1.78, 95 %CI: 1.47, 2.17) and the high frailty risk group (AHR = 4.17, 95 %CI: 2.00, 8.66) had a significant risk of mortality compared to the low frailty risk group. This study confirms the ability of HFRS to identify older, frail people at higher risk of prolonged hospital length of stay and increased mortality risk. However, we did not observe a significant association between HFRS and 28-day unplanned readmission or repeated hospital admission. [ABSTRACT FROM AUTHOR]

Topic: Some care home residents are admitted to hospital when they either do not wish for admission or will not benefit from admission. Meeting residents and their next of kin to explore the person’s goals and priorities can facilitate the completion of a good quality Treatment Escalation Plan (TEP). Intervention: A pilot service was commenced in November 2018 to complete and review TEPs in the top ten admitting care homes to Musgrove Park Hospital. A small team of clinicians (1.5 full time equivalent) worked in the selected care homes completing and reviewing TEPs, with an aim to see 80% of residents. Clinicians met residents and their next of kin to discuss the person’s wishes. Completed TEPs were left in the care home, shared with GPs and uploaded to the IT system in the acute hospital. The number of Emergency Department (ED) attendances and inpatient admissions from care homes were recorded and compared to data from 2017/18. Improvement: Over 5months, 492 residents had TEPs reviewed or completed by the team; this was 76% of the total bed base of the selected care homes. Data were compared to the same period a year earlier. During the final two months of the pilot, attendances to ED from care homes with the intervention were reduced by 24%, whilst the control group saw an 8% decrease. In the same period, inpatient admissions from the intervention group were reduced by 35%, compared to an 11% decrease in the control care homes. Discussion: Whilst there are too few data to provide conclusive evidence, early indications suggest that facilitating the discussion of good quality TEPs in care homes reduces attendances to ED and inpatient admissions. Further evaluation is required as the service continues. There were challenges to the implementation of the pilot; these included communication and engagement with GPs, in addition to access to GP IT systems. [ABSTRACT FROM AUTHOR]

Purpose: To determine the effect of hospitalization on intraocular pressure (IOP) in glaucoma patients. Design: Prospective case series. Methods: IOP was measured on three consecutive days in 26 high-tension (HTG) and 13 normal-tension (NTGwm) glaucoma patients under IOP-lowering treatment, and in 28 normal-tension glaucoma patients without IOP-lowering treatment (NTGnm), and change was compared by analysis of variance. Results: IOP decreased significantly, but comparably, in the three groups and between right and left eyes, although, the relative change to IOP on day 1 was significantly less pronounced in the group without treatment on day 2 and 3 compared with the treated groups. Conclusions: Glaucoma patients showed a significant decrease in IOP during hospitalization. Although this decrease was more pronounced among the treated patients, it was also present in nontreated patients. Consequently, other factors than improved compliance during hospitalization must play a role in this phenomenon. [Copyright &y& Elsevier]

The authors discuss the importance of risk stratification tool to identify emergency department (ED) patients with acute heart failure (AHF). They comment on the limitations that should be considered for interpreting the results. They suggest that recalibration of approach towards an implementation of risk-stratification tool is needed for ED patients with AHF.

Background: Wide geographic variation in the use of coronary angiography after myocardial infarction has been documented internationally and within the United States. An associated variation in clinical outcomes has not been consistently demonstrated. Methods: We assessed the risk of death from heart disease and of any heart disease event (death, reinfarction, or rehospitalization) over a follow-up period of one to four years in 6851 patients hospitalized with acute myocardial infarction at 16 Kaiser Permanente hospitals from 1990 through 1992. The percentage of patients who underwent angiography within three months after infarction ranged from 30 to 77 percent. We selected a subcohort of 1109 patients from three hospitals with higher rates of angiography and four with lower rates for a record review to assess the severity of infarction, the number of coexisting conditions, treatments received, and the appropriateness and necessity of angiography, using established criteria. Results: The rates of angiography were inversely related to the risk of death from heart disease (P = 0.03) and the risk of heart disease events (P<0.001) among the 16 hospitals after adjustment for age, sex, race, coexisting conditions, and the location of the infarction (subendocardial vs. transmural). In the subcohort, 440 patients met criteria indicating that angiography was necessary and 669 did not. Among the former, patients treated at hospitals with higher rates of angiography had a lower risk of death and of any heart disease event than those treated at hospitals with lower rates (hazard ratios, 0.67 and 0.72, respectively). Among the latter, the apparent benefits of being treated at hospitals with higher angiography rates were smaller (hazard ratios, 0.85 to 0.90 for death and any heart disease event, respectively). Conclusions: During the one to four years after myocardial infarction, patients treated at hospitals with higher rates of angiography had more favorable outcomes than those treated at hospitals with lower rates. This association was stronger among patients for whom published criteria indicated that angiography was necessary. (N Engl J Med 1996;335:1888-96.) [ABSTRACT FROM AUTHOR]