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Rural cancer patients receive lower-quality care and experience worse outcomes than urban patients. Commission on Cancer (CoC) accreditation requires hospitals to monitor performance on evidence-based quality measuresPlease confirm the list of authors is correc, but the impact of accreditation is not clear due to lack of data from non-accredited facilities and confounding between patient rurality and hospital accreditation, rurality, and size.This retrospective, observational study assessed associations between rurality, accreditation, size, and performance rates for four CoC quality measures (breast radiation, breast chemotherapy, colon chemotherapy, colon nodal yield). Iowa Cancer Registry data were queried to identify all eligible patients diagnosed between 2011 and 2017. Cases were assigned to the surgery hospital to calculate performance rates. Univariate and multivariate regression models were fitted to identify patient- and hospital-level predictors and assess trends.The study cohort included 10,381 patients; 46% were rural. Compared with urban patients, rural patients more often received treatment at small, rural, and non-accredited facilities (p 0.001 for all). Rural hospitals had fewer beds and were far less likely to be CoC-accredited than urban hospitals (p 0.001 for all). On multivariate analysis, CoC accreditation was the strongest, independent predictor of higher hospital performance for all quality measures evaluated (p 0.05 in each model). Performance rates significantly improved over time only for the colon nodal yield quality measure, and only in urban hospitals.CoC accreditation requires monitoring and evaluating performance on quality measures, which likely contributes to better performance on these measures. Efforts to support rural hospital accreditation may improve existing disparities in rural cancer treatment and outcomes.

To elucidate risk factors for 90-day readmission in anterior cervical discectomy and fusion (ACDF) for small, medium, and large hospitals. To assess differences in length of stay, charges, and complication rates across hospitals of different size.A retrospective analysis was performed using elective, single-level ACDF data from 2016 to 2018 in the Healthcare Cost and Utilization Project Nationwide Readmissions Database. Elective single-level ACDF cases were stratified into 3 groups by hospital bed size (small, medium, and large). All-cause complication rates, mean charges, length of stay, and 90-day readmission rates were compared across hospital size. Frequencies of specific comorbidities were compared between readmitted and nonreadmitted patients for each hospital size. Comorbidities significant on univariate analysis were evaluated as independent risk factors for 90-day readmission for each hospital size using multivariate regression.The overall 90-day readmission rate was 6.43% in 36,794 patients, and the rates for small, medium, and large hospitals were 6.25%, 6.28%, and 6.56%, respectively (P = 0.537). Length of stay increased significantly with hospital size (P0.001), and small hospitals had the lowest charges (P0.001). Although different independent predictors of 90-day readmission were identified for each hospital size, cardiac arrhythmia, chronic pulmonary disease, neurologic disorders, and rheumatic disease were identified as risk factors for hospitals of all sizes.Hospital size is a determining factor for charges and length of stay associated with elective single-level ACDF. Variation in risk factors for readmission exists across hospital size in context of similar 90-day readmission rates.

The outcomes of patients with incident kidney failure who start hemodialysis are influenced by several factors. Whether hemodialysis facility characteristics are associated with patient outcomes is unclear. We included adults diagnosed as having kidney failure requiring hemodialysis during January 1, 2001 to December 31, 2013 from the Taiwan National Health Insurance Research Database to perform this retrospective cohort study. The exposures included different sizes and levels of hemodialysis facilities. The outcomes were all-cause mortality, cardiovascular death, infection-related death, hospitalization, and kidney transplantation. During 2001–2013, we identified 74,406 patients and divided them in to three groups according to the facilities where they receive hemodialysis: medical center (n = 8263), non-center hospital (n = 40,008), and clinic (n = 26,135). The multivariable Cox model demonstrated that a larger facility size was associated with a low mortality risk (hazard ratio [HR] 0.991, 95% confidence interval [95% CI] 0.984–0.998; every 20 beds per facility). Compared with medical centers, patients in non-center hospitals and clinics had higher mortality risks (HR 1.13, 95% CI 1.09–1.17 and HR 1.11, 95% CI 1.06–1.15, respectively). Patients in medical centers and non-center hospitals had higher risk of hospitalization (subdistribution HR [SHR] 1.11, 95% CI 1.10–1.12 and SHR 1.22, 95% CI 1.21–1.23, respectively). Patients in medical centers had the highest rate of kidney transplantation among the three groups. In patients with incident kidney failure, a larger hemodialysis facility size was associated with lower mortality. Overall, medical center patients had a lower mortality rate and higher transplantation rate, whereas clinic patients had a lower hospitalization risk.

There is limited research in prognosticators of hospital transfer in acute pancreatitis (AP). Hence, we sought to determine the predictors of hospital transfer from small/medium-sized hospitals and outcomes following transfer to large acute-care hospitals.Using the 2010-2013 Nationwide Inpatient Sample (NIS), patients ≥18 years of age with a primary diagnosis of AP were identified. Hospital size was classified using standard NIS Definitions. Multivariable analyses were performed for predictors of "transfer-out" from small/medium-sized hospitals and mortality in large acute-care hospitals.Among 381,818 patients admitted with AP to small/medium-sized hospitals, 13,947 (4%) were transferred out to another acute-care hospital. Multivariable analysis revealed that older patients (OR = 1.04; 95%CI 1.03-1.06), men (OR = 1.15; 95%CI 1.06-1.24), lower income quartiles (OR = 1.54; 95%CI 1.35-1.76), admission to a non-teaching hospital (OR = 3.38; 95%CI 3.00-3.80), gallstone pancreatitis (OR = 3.32; 95%CI 2.90-3.79), pancreatic surgery (OR = 3.14; 95%CI 1.76-5.58), and severe AP (OR = 3.07; 95%CI 2.78-3.38) were predictors of "transfer-out". ERCP (OR = 0.53; 95%CI 0.43-0.66) and cholecystectomy (OR = 0.14; 95%CI 0.12-0.18) were associated with decreased odds of "transfer-out". Among 507,619 patients admitted with AP to large hospitals, 31,058 (6.1%) were "transferred-in" from other hospitals. The mortality rate for patients "transferred-in" was higher than those directly admitted (2.54% vs. 0.91%, p 0.001). Multivariable analysis revealed that being "transferred-in" from other hospitals was an independent predictor of mortality (OR = 1.47; 95% CI 1.22-1.77).Patients with AP transferred into large acute-care hospitals had a higher mortality than those directly admitted likely secondary to more severe disease. Early implementation of published clinical guidelines, triage, and prompt transfer of high-risk patients may potentially offset these negative outcomes.

OBJECTIVE To describe variations in COVID-19 confirmed cases and deaths among assisted living (AL) residents and examine their associations with key AL characteristics. DESIGN Observational study employing data on confirmed COVID-19 cases and deaths in ALs from seven states, through May 29, 2020. SETTING Information on COVID-19 cases/deaths in ALs was obtained from state government websites. A national inventory of ALs was used to identify communities with and without COVID-19 cases/deaths. Medicare Beneficiary Summary File identifying AL residents was employed to develop AL characteristics. County-level COVID-19 laboratory-confirmed cases/deaths were obtained from publicly available data. PARTICIPANTS We found 4,865 ALs (2,647 COVID-19 cases and 777 deaths) in the seven states. After excluding missing data, the sample consisted of 3,994 ALs (82.1%) with 2,542 cases (96.0%) and 675 deaths (86.9%). MAIN OUTCOMES AND MEASURES Outcomes were AL-level counts of cases and deaths. Covariates were AL characteristics and county-level confirmed COVID-19 cases/deaths. Multivariable two-part models determined the associations of independent variables with the likelihood of at least one case and death in the AL, and with the count of cases (deaths). RESULTS State case fatality ranged from 3.32% in North Carolina to 9.26% in Connecticut, but for ALs in these states it was 12.89% and 31.59%, respectively. Among ALs with at least one case, midsize communities had fewer cases (incidence rate ratio (IRR) = 0.829; P = .004) than small ALs. ALs with higher proportions of racial/ethnic minorities had more COVID-19 cases (IRR = 1.08; P

Background & Aims of the Study: The present study investigates the factors affecting the implementation of health strategies for the development of student sports in public universities. This study aims to show how the necessary contexts and opportunities are provided for students to achieve a healthy, dynamic, vibrant, recreational, and competitive environment. Also, student sports participation, pleasure, and subsequent attractiveness prevent social deviations, abnormal behaviors, and unhealthy entertainment. Materials and Methods: The statistical sample of this study consisted of 19 former and current general managers of the General Department of Physical Education, experts, faculty members, and PhD students in the sports management of public universities with a significant role and sufficient experience in the field of sports activities and occupations. The collected data were analyzed using descriptive statistics, mean comparison test, and Friedman test. Results: The findings of the present study showed that out of 1 million public university students, less than 2% of the students participated in student sports. The importance of multiple educational centers in the field of physical education, large student population in different age ranges, highest coverage of university centers across the country, and largest budget excluding had made the position of student sports in the Directorate General of Physical Education in the domain of strengths and opportunities in the SWOT matrix. It means using the strengths to get the most out of opportunities. Conclusion: It is possible to highlight the health and well-being strategies for the development of student sports based on the analysis of the obtained results and provide them to the directors and officials of university sports.

Despite numerous indications for perioperative benzodiazepine use, associated risks may be exacerbated in elderly and comorbid patients. In the absence of national utilization data, we aimed to describe utilization patterns using national claims data from total hip/knee arthroplasty patients (THA/TKA), an increasingly older and vulnerable surgical population.We included data on 1,863,996 TKAs and 985,471 THAs (Premier Healthcare claims data, 2006-2019). Benzodiazepine utilization (stratified by long- and short-acting agents) was assessed by patient- and health care characteristics, and analgesic regimens. Given the large sample size, standardized differences instead of P values were utilized to signify meaningful differences between groups (defined by value0.1).Among 1,863,996 TKA and 985,471 THA patients, the utilization rate of benzodiazepines was 80.5% and 76.1%, respectively. In TKA, 72.6% received short-acting benzodiazepines, while 7.9% received long-acting benzodiazepines, utilization rates 68.4% and 7.7% in THA, respectively. Benzodiazepine use was particularly more frequent among younger patients (median age [interquartile range {IQR}]: 66 [60-73]/64 [57-71] among short/long-acting compared to 69 [61-76] among nonusers), White patients (80.6%/85.4% short/long-acting versus 75.7% among nonusers), commercial insurance (36.5%/34.0% short/long-acting versus 29.1% among nonusers), patients receiving neuraxial anesthesia (56.9%/56.5% short/long-acting versus 51.5% among nonusers), small- and medium-sized (≤500 beds) hospitals (68.5% in nonusers, and 74% and 76.7% in short- and long-acting benzodiazepines), and those in the Midwest (24.6%/25.4% short/long-acting versus 16% among nonusers) in TKA; all standardized differences ≥0.1. Similar patterns were observed in THA except for race and comorbidity burden. Notably, among patients with benzodiazepine use, in-hospital postoperative opioid administration (measured in oral morphine equivalents [OMEs]) was substantially higher. This was even more pronounced in patients who received long-acting agents (median OME with no benzodiazepines utilization 192 [IQR, 83-345] vs 256 [IQR, 153-431] with short-acting, and 329 [IQR, 195-540] with long-acting benzodiazepine administration). Benzodiazepine use was also more frequent in patients receiving multimodal analgesia (concurrently 2 or more analgesic modes) and regional anesthesia. Trend analysis showed a persistent high utilization rate of benzodiazepines over the last 14 years.Based on a representative sample, 4 of 5 patients undergoing major orthopedic surgery in the United States receive benzodiazepines perioperatively, despite concerns for delirium and delayed postoperative neurocognitive recovery. Notably, benzodiazepine utilization was coupled with substantially increased opioid use, which may project implications for perioperative pain management.

Background: Substance use disorder (SUD) treatment centers serve a population of clients who have diverse needs, and may desire or require access to varied treatments while seeking care for their SUDs. While pharmacotherapies have increased in popularity for the treatment of SUDs, adoption rates do remain quite low. But a wider array of pharmacotherapies has become available in recent years which may shift the trend. This article helps shed light on how variations in SUD treatment centers develop and persist with regard to the adoption and delivery of off-label medications. Methods: We use a nationally representative and longitudinal sample of SUD treatment centers in the US ( N = 196). We use a logistic regression to analyze the relationship between organizational characteristics and offering any medications, off-label. We also use a negative binomial regression to analyze the relationship between organizational characteristics and the number of medications that were used off-label. Results: Our findings reveal that older centers, accredited centers, and centers that offer mental health screenings are all positively associated with the provision of off-label medication in SUD treatment. We also find a positive relationship between private funding and offering a greater number of off-label medications. Conclusions: Our results suggest that SUD clients who seek treatment from centers that offer medications off-label, may have access to a greater number of medication-assisted treatment options.

The purpose of this study was to investigate the outcomes after appendectomy in children according to hospital size. The records of 11,565 patients with the diagnosis-related group code for appendectomy were extracted from HIRA-Pediatric Patient Sample from 2012 to 2016. The number of hospital visits and the length of stay in hospital within 30 days after appendectomy were analyzed. Patients who were treated at large-sized hospitals were more likely to be younger, more likely to reside in metropolitan areas, and tended to receive laparoscopic surgery. The number of hospital visits within 30 days in patients managed by medium- and large-sized hospitals decreased in comparison to small-sized hospitals. The length of hospital stay in large-sized hospitals was decreased in comparison to small- and medium-sized hospitals. A subgroup analysis revealed that complicated appendectomy did not have a significant impact on the difference in the length of hospital stay between hospital sizes. The number of hospital visits and the length of hospital stay was higher in small-sized hospitals in comparison to large-sized hospitals. Appendectomy performed in the larger hospital showed better outcomes in pediatric patients. We recommend that pediatric surgical procedures be performed in large hospitals, and that proper incentives be given for procedures to be performed by pediatric specialists.

Introduction: Bloodstream Infections has become in one of the priorities for the antimicrobial stewardship teams due to their high mortality and morbidity rates. Usually, the first antibiotic treatment for this pathology must be empirical, without microbiology data about the microorganism involved. For this reason, the population studies about the etiology of bacteremia are a key factor to improve the selection of the empirical treatment, because they describe the main microorganisms associated to this pathology in each area, and this data could facilitate the selection of correct antibiotic therapy. Material and methods: This study describes the etiology of bloodstream infections in the Southeast of Spain. The etiology of bacteremia was analysed by a retrospective review of all age-ranged patients from every public hospital in the Autonomous Community of Valencia (approximately 5,000,000 inhabitants) for five years. Results: A total of 92,097 isolates were obtained, 44.5% of them were coagulase-negative staphylococci. Enterobacteriales was the most prevalent group and an increase in frequency was observed along the time. Streptococcus spp. were the second microorganisms more frequently isolated. Next, the most prevalent were Staphylococcus aureus and Enterococcus spp., both with a stable incidence along the study. Finally, Pseudomonas aeruginosa was the fifth microorganism more frequently solated. Conclusions: These data constitute a useful tool that can help in the choice of empirical treatment for bloodstream infections, since the knowledge of local epidemiology is key to prescribe a fast and appropriate antibiotic therapy, aspect capital to improve survival. RESUMEN: Introducción: Las bacteriemias se han convertido en una de las prioridades de los Programas de Optimización de uso de Antimicrobianos (PROA) debido a sus altas tasas de morbimortalidad. Normalmente, el tratamiento antibiótico tiene que ser pautado de forma empírica, sin datos del microorganismo implicado. Por esto, los estudios poblacionales sobre la etiología de las bacteriemias son un factor clave para mejorar la elección del tratamiento empírico, ya que describen los principales microorganismos asociados a esta patología en cada área, lo que facilita en gran medida la selección del antibiótico correcto. Material y métodos: Este estudio describe la etiología de las bacteriemias en el sureste de España durante los años 2013-2017. La etología fue analizada de forma retrospectiva estudiando los microorganismos implicados en todas las bacteriemias diagnosticadas en la Comunidad Valenciana (5.000.000 de habitantes). Resultados. Se obtuvieron un total de 92.097 aislados clínicos, de los cuales un 44,5% fueron Staphylococcus coa-gulasa negativos. Las enterobacterias fueron el grupo más prevalente, su frecuencia se incrementó durante el estudio. Los cocos grampositivos, tipo Streptococcus, fueron los siguientes microorganismos que se aislaron de forma más frecuente, su frecuencia disminuyó a lo largo del periodo estudiado. A continuación, Staphylococcus aureus y Enterococcus spp. les siguieron en prevalencia, manteniéndose sus tasas estables a lo largo del estudio. Por último, el quinto microorganismo más prevalente fue Pseudomonas aeruginosa. Conclusiones: Los datos obtenidos en este estudio constituyen una herramienta que puede facilitar la elección correcta del tratamiento empírico inicial que debe aplicarse en estos procesos.

Background The paper aims to describe the 3-year incidence (2015/17) of aggressive acts against all healthcare workers to identify risk factors associated to violence among a variety of demographic and professional determinants of assaulted, and risk factors related to the circumstances surrounding these events. Methods A retrospective observational study of all 10,970 health workers in a large-sized Italian university hospital was performed. The data, obtained from the “Aggression Reporting Form”, which must be completed by assaulted workers within 72 h of aggression, were collected for the following domains: worker assaulted (sex, age class, years worked); profession (nurses, medical doctors, non-medical support staff, administrative staff, midwives); aggressive acts (activity type during aggressive acts, season, time and location of aggressive acts); and type of aggressive acts (verbal, non-verbal, consequences, aggressors). Results Three hundred sixty-four (3.3%) workers experienced almost one aggression. The majority of the assaulted workers were female (77.5%), had worked for 6/15 years and were Nurses (64.3%). The majority of aggressive acts occurred during assistance and patient care (38.2%), in the spring and during the afternoon/morning shifts and took place in locations where patients were present (47.3%). The most prevalent aggression type was verbal (76.9%). The patient was the most common aggressor (46.7%). 56% of those assaulted experienced interruptions in their work. Being female, being The risk analysis showed that non-verbally aggressive acts were related to assistance and patient care with respect to activity type, to the presence of patients and during the spring and afternoon/evening. Conclusions The findings suggest the parallel use of future qualitative studies to clarify the motivation behind aggression. These suggestions are needed for the implementation of additional adequate prevention strategies on either an organizational or a personal level.

Background: As minimally invasive pediatric surgery becomes standard approach to many surgical solutions, access has become an important point for improvement. Laparoscopic cholecystectomy (LC) is ...

BACKGROUND As the utilization of reverse total shoulder arthroplasty (RSA) grows, it is increasingly important to examine the relationship between hospital volume and RSA outcomes. We hypothesized that hospitals that perform a higher volume of RSAs would have improved outcomes. We also performed stratum-specific likelihood ratio (SSLR) analysis with the aim of delineating concrete definitions of hospital volume for RSA. METHODS The Nationwide Readmissions Database was queried for patients who had undergone elective RSA from 2011 to 2015. Annual hospital volume and 90-day outcome data were collected, including readmission, revision, complications, hospital length of stay (LOS), supramedian cost, and discharge disposition. SSLR analysis was performed to determine hospital volume cutoffs associated with increased risks for adverse events. Cutoffs generated through SSLR analysis were confirmed via binomial logistic regression. RESULTS The proportion of patients receiving care at high-volume centers increased from 2011 to 2015. SSLR analysis produced hospital volume cutoffs for each outcome, with higher-volume centers showing improved outcomes. The volume cutoffs associated with the best rates of 90-day outcomes ranged from 54 to 70 RSAs/year, whereas cost and resource utilization cutoffs were higher, with the best outcomes in hospitals performing >100 RSAs/year. SSLR analysis of 90-day readmission produced 3 hospital volume categories (1 to 16, 17 to 69, and ≥70 RSAs/year), each significantly different from each other. These were similar to the strata for 90-day revision (1 to 16, 17 to 53, and ≥54 RSAs/year) and 90-day complications (1 to 9, 10 to 68, and ≥69 RSAs/year). SSLR analysis produced 6 hospital volume categories for cost of care over the median value (1 to 5, 6 to 25, 26 to 47, 48 to 71, 72 to 105, and ≥106 RSAs/year), 5 categories for an extended LOS (1 to 10, 11 to 25, 26 to 59, 60 to 105, and ≥106 RSAs/year), and 4 categories for non-home discharge (1 to 31, 32 to 71, 72 to 105, and ≥106 RSAs/year). CONCLUSIONS We have defined hospital surgical volumes that maximize outcomes after RSA, likely related to surgical experience, ancillary staff familiarity, and protocolized pathways. This information may be used in future policy decisions to consolidate complex procedures, such as RSA, at high-volume destinations, or to encourage lower-volume institutions to strategize an approach to function as a higher-volume center. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Ontario Government funded the development and implementation of a standardized adult emergency department (ED) asthma care pathway (EDACP). We aimed to describe baseline patterns of ED use by adults for asthma in Ontario, Canada, and determine site characteristics associated with the EDACP implementation workshop attendance and subsequent pathway implementation.All Ontario EDs were offered EDACP implementation workshops by the Lung Assocation-Ontario between 2008 and 2011, and were surveyed regarding site implementation status as of October, 2013. Survey data were linked by site to Ontario's administrative health databases. Logistic regression models investigated the association between site and patient characteristics and: a) workshop attendance; b) pathway implementation.In the 2 years prior to EDACP implementation, there were 41 143 asthma visits to 167 sites by adults (62.3% female). Asthma-related return visits within 72 h varied by hospital type (teaching 2.1%, community 2.8%, small 4.0%;Ontario adult asthma ED visitors are more often women. Asthma-related return visits are uncommon, but significantly higher in small community hospitals. This provincial QI initiative reached almost 75% of Ontario EDs, and achieved almost 50% implementation rate within 2 years. Factors other than workshop attendance, such as hospital size, were associated with EDACP implementation.

Background There is a lack of contemporary data on cardiogenic shock (CS) in‐hospital mortality trends. Methods and Results Patients with CS admitted January 1, 2004 to December 31, 2018, were identified from the US National Inpatient Sample. We reported the crude and adjusted trends of in‐hospital mortality among the overall population and selected subgroups. Among a total of 563 949 644 hospitalizations during the period from January 1, 2004, to December 30, 2018, 1 254 358 (0.2%) were attributed to CS. There has been a steady increase in hospitalizations attributed to CS from 122 per 100 000 hospitalizations in 2004 to 408 per 100 000 hospitalizations in 2018 ( P trend P trend P trend P trend Conclusions Hospitalizations attributed to CS have tripled in the period from January 2004 to December 2018. However, there has been a slow decline in CS in‐hospital mortality during the studied period. Further studies are necessary to determine if the recent adoption of treatment algorithms in treating patients with CS will further impact in‐hospital mortality.

Background Extracorporeal Membrane Oxygenation (ECMO) use is increasing despite limited evidence. The aim of this study was to demonstrate heterogeneity of ECMO use and its association with hospital size and annual frequency in Germany. Methods This is a database analysis of all ECMO cases in Germany from 2010 to 2016 using the German Diagnosis Related Groups (DRG) coding system for ECMO. Results During the study period, 510 hospitals performed 29,929 ECMO runs (12,572 vvECMO, 11,504 vaECMO, 1993 pECLA) with an increase over time. Mortality ranged between 58% and 66% for vaECMO cases and 66% and 53% for vvECMO cases. 304 (61%) hospitals performed only one ECMO per year. 78%% of all ECMO runs were performed in centres with more than 20 cases per year and more than half of all ECMO runs were performed in hospitals with >1.000 beds. Mortality for vv and vaECMO was highest in very small hospitals (< 200 beds; 70%; 74%) and very large hospitals (>1000 beds; 60%; 62%). Conclusions Use of ECMO is still increasing and a substantial proportion of hospitals performs very few ECMO runs. Small hospitals had a significantly higher mortality, but dependence on hospital size and ECMO mortality was irregular.

The contemporary scope of practice of interventional cardiologists (ICs) in the United States and recent trends are unknown. Using Medicare claims from 2013 to 2017, we categorized ICs into 4 practice categories (only percutaneous coronary intervention [PCI], PCI with noninvasive imaging, PCI with specialized interventions [peripheral/structural], and all 3 services) and evaluated associations with region, hospital bed size and teaching status, gender, and graduation year. Of 6,083 ICs in 2017, 10.9% performed only PCI, 68.3% PCI with noninvasive imaging, 5.7% PCI with specialized interventions, and 15.1% all 3 services. A higher proportion of Northeast ICs (vs South ICs) were performing only PCI (24.8% vs 7.3%) and PCI with specialized interventions (12% vs 3.4%), but lower PCI and noninvasive imaging (53.8% vs 71.7%) and all 3 services (9.3% and 17.6%). Regarding ICs at larger hospitals (bed size575 vs218), a higher proportion was performing only PCI (23.8% vs 5.2%) or PCI with specialized interventions (13.5% vs 1.7%) and lower proportion was performing PCI with noninvasive imaging (48.8% vs 78%), similar to teaching hospitals. Female ICs (vs male ICs) more frequently performed only PCI (18.9% vs 10.6%) and less frequently all 3 services (8.3% vs 15.4%). A lower proportion of recent graduates (2001 to 2016) performed only PCI (9.8% vs 13.8%) and PCI with noninvasive imaging (66.3% vs 72.6%) but a higher proportion performed all 3 services (18% vs 8.4%) than earlier graduates (1959 to 1984). From 2013 to 2017, only PCI and PCI with noninvasive imaging decreased, whereas PCI and specialized interventions and all 3 services increased (all p0.001). In conclusion, there is marked heterogeneity in practice responsibilities among ICs, which has implications for training and competency assessments.

Background: Hospital trustees, administrators, and their consultants must base important budget decisions upon a projection of the size of proposed construction projects. The anticipated functions and an estimate of the space required are generally provided in a project program or project brief. The programming consultant, often part of the architect’s team, will calculate the physical area (square feet or square meters) required to perform the desired functions based on an understanding of demographics in the service area, services offered, the volumes of service required, and a historical understanding of space required to perform those services. Hospitals and hospital designs in North America have been changing. Plans must now address far higher percentages of outpatient care, accommodate new equipment modalities, and provide space to account for family presence in patient rooms. Aim: A study was undertaken to better understand whether the allocation of space in recently constructed hospital projects is different from the amounts of area devoted to various departments and functions in older projects. Method: In order to assure measurement consistency, a measurement methodology was developed and is reported elsewhere. Thirty-six recently constructed hospitals were measured. Results: The results provide new information about the allocation of space for nondepartmental functions within the overall building gross calculation. Many of the departmental space allocations fell within an expected range. Ultimately, significant detailed information about hospital area calculations is made available to the public because of this study.

Background There is sparse literature regarding K-9 (legal intervention) dog bites. It was the purpose of this study to analyze the demographics of K-9 dog bites using a national data base. Methods This was a retrospective study of prospectively collected data from National Electronic Injury Surveillance System - All Injury Program for years 2005–2013. Patients with dog bites were identified and those due to legal intervention were analyzed. Statistical analyses were performed with SUDAAN 11.0.01™ software. A p Results There were an estimated 32, 951 K-9 dog bite ED visits, accounting for 1.1% of all ED dog bite visits. The K-9 group was nearly all male (95.0 vs 52.1%) and more commonly Black (42.0 vs 13.0%) compared to the non K-9 group. Bites to the head/neck and upper extremity were less frequent and lower extremity bites more frequent in the K-9 group; K-9 bites more commonly occurred outside the home. Within the K-9 group, the proportion of White patients increased with increasing age and smaller hospital size. Patients seen in small and medium size hospitals were in the middle age ranges, while those in the very young and >64 years of age were only seen at large hospitals. The average annual incidence of K-9 dog bites seen in the ED for US was 2.43 per 100,000 males with no changes over time. Conclusions In the US, 1.1% of all ED visits for dog bites are due to K-9 intervention with no change in incidence, even though this study spanned the time when it was encouraged to change K-9 intervention; from “find and bite” to “find and bark”. The K-9 dog bite patient is nearly always male, more commonly Black, occurred away from home, and has a 3.7% hospital admission rate. Bites to the head/neck are less common compared to the non K-9 dog bite group.

Background The American College of Radiology Dose Index Registry for CT enables evaluation of radiation dose as a function of patient characteristics and examination type. The hypothesis of this study was that academic pediatric CT facilities have optimized CT protocols that may result in a lower and less variable radiation dose in children. Materials and Methods A retrospective study of doses (mean patient age, 12 years; age range, 0-21 years) was performed by using data from the National Radiology Data Registry (year range, 2016-2017) (n = 239 622). Three examination types were evaluated: brain without contrast enhancement, chest without contrast enhancement, and abdomen-pelvis with intravenous contrast enhancement. Three dose indexes-volume CT dose index (CTDIvol), size-specific dose estimate (SSDE), and dose-length product (DLP)-were analyzed by using six different size groups. The unequal variance t test and the F test were used to compare mean dose and variances, respectively, at academic pediatric facilities with those at other facility types for each size category. The Bonferroni-Holm correction factor was applied to account for the multiple comparisons. Results Pediatric radiation dose in academic pediatric facilities was significantly lower, with smaller variance for all brain, 42 of 54 (78%) chest, and 48 of 54 (89%) abdomen-pelvis examinations across all six size groups, three dose descriptors, and when compared with that at the other three facilities. For example, abdomen-pelvis SSDE for the 14.5-18-cm size group was 3.6, 5.4, 5.5, and 8.3 mGy, respectively, for academic pediatric, nonacademic pediatric, academic adult, and nonacademic adult facilities (SSDE mean and variance P < .001). Mean SSDE for the smallest patients in nonacademic adult facilities was 51% (6.1 vs 11.9 mGy) of the facility's adult dose. Conclusion Academic pediatric facilities use lower CT radiation dose with less variation than do nonacademic pediatric or adult facilities for all brain examinations and for the majority of chest and abdomen-pelvis examinations. © RSNA, 2019 See also the editorial by Strouse in this issue.

The use of reverse shoulder arthroplasty (RSA) continues to grow with expanding indications and increased surgeon awareness. Previous data for other lower extremity joint replacements indicate that high-volume centers have better outcomes, with lower complication rates, decreased length of stay, and complications for both hemiarthroplasty and total shoulder arthroplasty. The purpose of this study is to evaluate the effects of hospital size and setting on adverse events for RSA. The National Inpatient Sample database was queried for RSA performed using ICD-9 codes. Primary outcomes included length of stay (LOS), total hospital charges, discharge disposition, and postoperative complications. Odds ratios were used to assess the risk of inpatient postoperative complications. A weighted national estimate of 24,056 discharges for patients undergoing RSA was included in the study. Patients at larger hospitals experienced higher total charges, increased average LOS, and slightly higher complication rates compared to those of small and medium hospitals. Patients in larger hospitals had significantly increased rates of genitourinary and central nervous system complications, while patients in small/medium hospitals experienced higher rates of hematoma/seroma. Results from this study indicate that large and non-teaching hospitals overall tend to burden the patients with higher hospital charges, longer hospital stay, and more frequent non-routine discharges. Also, larger hospitals are associated with higher risk of genitourinary and central nervous system complications rates, whereas non-teaching hospitals are associated with lower risk of infection and higher risk of anemia after RSA. With the growth in RSA in the USA, continued attention needs to be placed on improving outcomes and resource utilization for RSA patients even in larger hospitals.

Purpose To determine whether patients with severe acute kidney injury who receive dialysis (AKI-D) experience better outcomes at centres that care for more patients with AKI-D. Materials and methods Linked administrative datasets where used to perform a retrospective cohort study of all critically ill patients in Ontario, Canada, who had a first episode of AKI-D between 2002 and 2011. Centre volume for a given year, was designated by calculating the mean number of patients treated with acute dialysis at that centre during that year and the one preceding it. Patients treated at that centre were then assigned to a centre volume quartile for that year. Results We identified 19,658 critically ill patients with AKI-D treated at 54 Ontario hospitals. Mortality and dialysis dependence at 90-days were 46% and 31%, respectively. Centre volume was not associated with mortality at 90 days (with quartile 1 as the reference, adjusted odds ratio (aOR) 1.16 (95% CI, 0.87 - 1.54) in quartile 2, aOR 1.17 (95% CI, 0.91 - 1.50) in quartile 3, and aOR 1.06 (95% CI, 0.81 - 1.41) in quartile 4). Conclusions There are no Centre volume survival associations in the management of AKI-D despite high mortality and dependence rate.

Objectives Green House and other small nursing home (NH) models are considered “nontraditional” due to their size (10–12 beds), universal caregivers, and other home-like features. They have garnered great interest regarding their potential benefit to limit Coronavirus Disease 2019 (COVID-19) infections due to fewer people living, working, visiting, and being admitted to Green House/small NHs, and private rooms and bathrooms, but this assumption has not been tested. If they prove advantageous compared with other NHs, they may constitute an especially promising model as policy makers and providers reinvent NHs post-COVID. Design This cohort study compared rates of COVID-19 infections, COVID-19 admissions/readmissions, and COVID-19 mortality, among Green House/small NHs with rates in other NHs between January 20, 2020 and July 31, 2020. Setting and Participants All Green House homes that held a skilled nursing license and received Medicaid or Medicare payment were invited to participate; other small NHs that replicate Green House physical design and operational practices were eligible if they had the same licensure and payer sources. Of 57 organizations, 43 (75%) provided complete data, which included 219 NHs. Comparison NHs (referred to as “traditional NHs”) were up to 5 most geographically proximate NHs within 100 miles that had

Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown.Is prolonged prehospital time an independent risk factor for pneumonia?We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and 2016.Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (P .001). This association was primarily driven by patients with low Glasgow Coma Scale scores. Post-trauma pneumonia was uncommon (1.5% incidence) but was associated with a significant increase in mortality (P .001, 4.3% mortality without pneumonia vs 12.1% mortality with pneumonia). Other pneumonia risk factors included age, sex, race, primary payor, trauma center teaching status, bed size, geographic region, intoxication, comorbid lung disease, steroid use, lower Glasgow Coma Scale score, higher Injury Severity Scale score, blood product transfusion, chest trauma, and respiratory burns.Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important, because prolonged prehospital time may need to be considered in subsequent decision-making.

Antimicrobial resistance in Staphylococcus pseudintermedius (SP) and the prevalence of meticillin-resistant SP (MRSP) is increasing in dogs worldwide.To evaluate the influence of hospital size on antimicrobial resistance of SP and whether restricted use of antimicrobials based on antibiograms could reduce the identification of antimicrobial resistance in SP from infected dogs.In Study 1, a total of 2,294 SP isolates from dogs with pyoderma (n = 1,858, 52 hospitals) or otitis externa (OE; n = 436, 44 hospitals) taken between 2017 and 2019 were analysed. Clinics were categorised into small, medium and large based on numbers of practicing veterinary surgeons. In Study 2, a cumulative antibiogram was constructed for 12 antimicrobials from one large veterinary clinic from 2017 to 2018. Referring to this antibiogram, the clinic introduced strict antimicrobial selection criteria to treat dogs with pyoderma and OE, starting in 2018.MRSP was identified in 981 dogs (42.8%). In large clinics, the isolation rate of MRSP was 51.1% (404 of 791), which was significantly higher (P 0.01) than in small clinics with less than two veterinary practitioners (34.0%, 154 of 453). In the antibiogram study, the susceptibility rates of oxacillin (MPIPC, 61.5%), cefpodoxime (CPDX, 55.8%) and minocycline (MINO, 55.8%) were significantly higher in 2019 (n = 52) than in 2017 to 2018 (n = 54; MPIPC, 37.0%; CPDX, 33.3%; MINO, 20.4%; P 0.05).Hospital size could affect the isolation rate of MRSP in dogs. Restricted use of antimicrobials for over a year based on cumulative antibiograms could reduce the resistance rate of multiple antimicrobials in SP isolated from dogs with pyoderma and OE.La résistance antimicrobienne de Staphylococcus pseudintermedius (SP) et la prévalence des SP résistant à la méticiline (MRSP) est en augmentation chez les chiens à travers le monde.Evaluer l’influence de la taille d’hôpital sur la résistance antimicrobienne de SP et si l’utilisation restreinte des antimicrobiens basée sur les antibiogrammes pourrait réduire l’identification des résistances antimicrobiennes des SP des chiens infectés. MATÉRIELS ET MÉTHODES: Dans l’étude 1, un total de 2 294 Souches de SP de chiens avec pyodermite (n = 1,858, 52 hôpitaux) ou otite externe (OE; n = 436, 44 hôpitaux) pris entre 2017 et 2019 a été analysé. Les cliniques étaient catégorisées en petite, moyenne et large, selon le nombre de vétérinaires praticiens. Dans l’étude 2, un antibiogramme cumulatif a été construit pour 12 antimicrobiens d’une grande clinique vétérinaire de 2017 à 2018. Se référant à cet antibiogramme, la clinique a introduit des critères de sélection des antimicrobiens pour traiter les chiens avec pyodermite et OE, à partir de 2018. RÉSULTATS: MRSP a été identifié chez 981 chiens (42,8%). Dans les grandes cliniques, le taux d’isolement des MRSP était de 51.1% (404 sur 791), qui était significativement plus élevé (P 0.01) que dans les petites cliniques avec moins de deux vétérinaires (34.0%, 154 de 453). Dans l’étude antibiogramme, les taux de sensibilité de l’oxacilline (MPIPC, 61.5%), cefpodoxime (CPDX, 55.8%) et minocycline (MINO, 55.8%) étaient significativement plus élevés en 2019 (n = 52) que 2017 à 2018 (n = 54; MPIPC, 37.0%; CPDX, 33.3%; MINO, 20.4%; P 0.05).La taille de l’hôpital pourrait affecter le taux d’isolement des MRSP chez les chiens. L’utilisation restreinte des antimicrobiens sur une année basée sur les antibiogrammes cumulatifs pourrait réduire les taux de résistance de multiples antimicrobiens des souches de SP des chiens avec pyodermite et OE.INTRODUCCIÓN: la resistencia a los antimicrobianos en Staphylococcus pseudintermedius (SP) y la prevalencia de SP resistente a la meticilina (MRSP) está aumentando en perros en todo el mundo. OBJETIVOS: Evaluar la influencia del tamaño del hospital en la resistencia antimicrobiana de SP y si el uso restringido de antimicrobianos basado en antibiogramas podría reducir la identificación de resistencia antimicrobiana en SP de perros infectados. MÉTODOS Y MATERIALES: en el Estudio 1 se analizaron un total de 2294 aislamientos de SP de perros con pioderma (n = 1858, 52 hospitales) u otitis externa (OE; n = 436, 44 hospitales) obtenidos entre 2017 y 2019. Las clínicas se clasificaron en pequeñas, medianas y grandes según el número de veterinarios en ejercicio. En el Estudio 2, se construyó un antibiograma acumulativo para 12 antimicrobianos de una gran clínica veterinaria de 2017 a 2018. En referencia a este antibiograma, la clínica introdujo criterios estrictos de selección de antimicrobianos para tratar perros con pioderma y OE, a partir de 2018. RESULTADOS: se identificó MRSP en 981 perros (42,8%). En las clínicas grandes, la tasa de aislamiento de MRSP fue del 51,1% (404 de 791), que fue significativamente más alta (P0,01) que en las clínicas pequeñas con menos de dos médicos veterinarios (34,0%, 154 de 453). En el estudio de antibiograma, las tasas de susceptibilidad de oxacilina (MPIPC, 61,5%), cefpodoxima (CPDX, 55,8%) y minociclina (MINO, 55,8%) fueron significativamente más altas en 2019 (n = 52) que en 2017 a 2018 (n = 54; MPIPC, 37,0%; CPDX, 33,3%; MINO, 20,4%; P0,05). CONCLUSIONES Y RELEVANCIA CLÍNICA: el tamaño del hospital podría afectar la tasa de aislamiento de MRSP en perros. El uso restringido de antimicrobianos durante más de un año basado en antibiogramas acumulativos podría reducir la tasa de resistencia de múltiples antimicrobianos en SP aislado de perros con pioderma y OE.Die antimikrobielle Resistenz auf Staphylococcus pseudintermedius (SP) und die Prävalenz von Methicillin-resistenten SP (MRSP) nimmt bei den Hunden weltweit zu.Eine Evaluierung des Einflusses der Spitalsgröße auf die antimikrobielle Resistenz gegenüber SP und eine Feststellung, ob ein restriktiver Einsatz der Antibiotika basierend auf einem Antibiogramm die Identifizierung antimikrobieller Resistenzen auf SP bei infizierten Hunden reduzieren könnte.In Studie 1 wurden insgesamt 2.294 SP Isolate von Hunden mit einer Pyodermie (n = 1.858; 52 Kliniken) oder Otitis externa (OE; n = 436; 44 Kliniken), die zwischen 2017 und 2019 genommen wurden, analysiert. Die Kliniken wurden anhand der praktizierenden Tierärzte in klein, medium und groß eingeteilt. In Studie 2 wurde ein kumulatives Antibiogramm für 12 Antibiotika aus einer großen Veterinärmedizinischen Klinik aus den Jahren 2017 bis 2018 konstruiert. Bezugnehmend auf dieses Antibiogramm führte die Klinik ab 2018 strikte antimikrobielle Selektionskriterien zur Behandlung von Hunden mit Pyodermie und OE ein.Ein MRSP wurde bei 981 Hunden (42,8%) identifiziert. In großen Kliniken betrug die Isolationsrate für MRSP 51,1% (404 von 791), was signifikant höher war (P0,01) als in kleinen Kliniken mit weniger als zwei praktizierenden TierärztInnen (34,0%, 154 von 453). In der Antibiogramm Studie lagen die Empfindlichkeitswerte von Oxacillin (MPIPC; 61,5%), Cefpodixim (CPDX; 55,8%) und Minocyclin (MINO; 55,8%) 2019 signifikant höher (n = 52) als 2017 bis 2018 (n = 54; MPIPC; 37,0%; CPDX; 33,3%; MINO; 20,4%; P0,05).Die Klinikgröße könnte die Isolationsrate von MRSP bei Hunden beeinflussen. Ein restriktiver Einsatz von Antibiotika für über ein Jahr basierend auf einem kumulativen Antibiogramm könnte die Resistenzrate von multiplen Antibiotika auf SP, welcher von Hunden mit Pyodermie und OE isoliert wird, reduzieren.背景: Staphylococcus pseudintermedius（SP）の抗菌薬耐性およびメチシリン耐性SP（MRSP）の有病率は、世界中の犬で増加している。 目的: 本研究の目的は、SPの抗菌薬耐性に対する病院規模の影響を評価し、アンチバイオグラムに基づく抗菌薬の使用制限が感染犬のSPにおける抗菌薬耐性の確認を低減できるかどうかを検討することであった。 材料と方法: 研究1では、2017年から2019年の間に採取された、膿皮症（n＝1,858、52病院）または外耳炎（OE；n＝436、44病院）の犬から分離された合計2,294個のSPを解析した。診療所は、開業している獣医外科医の数に基づいて、小、中、大規模に分類した。研究2では、2017年から2018年にかけて、1つの大規模な動物病院から12種類の抗菌薬について累積的なアンチバイオグラムを構築した。このアンチバイオグラムを参考に、同クリニックは2018年から膿皮症やOEの犬の治療に厳格な抗菌薬選択基準を導入した。 結果: 981頭（42.8％）の犬でMRSPが確認された。大規模クリニックにおけるMRSPの分離率は51.1％（791頭中404頭）であり、獣医師が2名以下の小規模クリニック（34.0％、453頭中154頭）よりも有意に高かった（P＜0.01）。アンチバイオグラム調査では、オキサシリン（MPIPC、61.5％）、セフポドキシム（CPDX、55.8％）、ミノサイクリン（MINO、55.8％）の感受性率は、2017～2018年（n＝54、MPIPC、37.0％、CPDX、33.3％、MINO、20.4％、P＜0.05）に比べ、2019年（n＝52）は有意に高かった。 結論と臨床的関連性: 病院の規模は、犬のMRSPの分離率に影響を与える可能性がある。累積アンチバイオグラムに基づいて1年以上抗菌薬の使用を制限することで、犬の膿皮症やOEから分離されたSPの複数の抗菌薬に対する耐性率を低下させることができた。.背景: 假中间型葡萄球菌(SP)的抗菌药物耐药性和耐甲氧西林SP(MRSP)的流行率在全球犬中不断增加。 目的: 评估医院规模对SP抗菌药物耐药性的影响，以及根据抗菌谱限制使用抗菌药，是否可减少感染犬SP抗菌药物耐药性。 方法和材料: 在研究1中，对2017年至2019年间从脓皮病（n = 1,858，52家医院）或外耳炎（OE；n = 436，44家医院）犬中采集的总计2,294株SP分离株进行了分析。根据执业兽医的数量，将诊所分为小、中和大。在研究2中，从2017年至2018年，一家大型兽医诊所通过积累经验，构建了12种抗菌剂的抗菌谱。参考该抗菌谱，该诊所从2018年开始引入严格的抗菌药物选择标准来治疗脓皮病和OE犬。 结果: 981只犬(42.8%)鉴定出MRSP。在大诊所中，MRSP的分离率为51.1%（791人中的404人），显著高于(P0.01)兽医从业人员少于2人的小诊所（34.0%，453人中的154人）。在抗菌谱研究中，2019年(n = 52)苯唑西林(MPIPC，61.5%)、头孢泊肟(CPDX，55.8%)和米诺环素(MINO，55.8%)的敏感率显著高于2017年至2018年(n = 54；MPIPC，37.0%；CPDX，33.3%；MINO，20.4%；P0.05)。 结论和临床相关性: 医院规模可能影响犬MRSP的分离率。根据累积抗菌谱限制使用抗菌药一年以上，可降低脓皮病和OE犬分离SP对多种抗菌药的耐药率。.A resistência a antimicrobianos em Staphylococcus pseudintermedius (SP) e a prevalência de SP resistente à meticilina (MRSP) vem aumentando em cães em todo o mundo.Avaliar a influência do tamanho do hospital na resistência antimicrobiana de SP e se o uso restrito de antimicrobianos com base em antibiogramas poderia reduzir a identificação de resistência a antimicrobianos em SP de cães infectados. MÉTODOS E MATERIAIS: No Estudo 1, um total de 2.294 isolados de SP de cães com piodermite (n = 1.858, 52 hospitais) ou otite externa (OE; n = 436, 44 hospitais) coletados entre 2017 e 2019 foram analisados. As clínicas foram categorizadas em pequenas, médias e grandes com base no número de cirurgiões veterinários em atividade. No Estudo 2, um antibiograma cumulativo foi elaborado para 12 antimicrobianos de uma grande clínica veterinária de 2017 a 2018. Referindo-se a este antibiograma, a clínica introduziu critérios de seleção de antimicrobianos estritos para tratar cães com piodermite e OE, a partir de 2018.A MRSP foi identificada em 981 cães (42,8%). Em grandes clínicas, a taxa de isolamento de MRSP foi de 51,1% (404 de 791), que foi significativamente maior (P0,01) do que em pequenas clínicas com menos de dois médicos veterinários (34,0%, 154 de 453). No estudo de antibiograma, as taxas de suscetibilidade de oxacilina (MPIPC, 61,5%), cefpodoxima (CPDX, 55,8%) e minociclina (MINO, 55,8%) foram significativamente maiores em 2019 (n = 52) do que em 2017-2018 (n = 54; MPIPC, 37,0%; CPDX, 33,3%; MINO, 20,4%; P0,05). CONCLUSÕES E RELEVÂNCIA CLÍNICA: O tamanho do hospital pode afetar a taxa de isolamento de MRSP em cães. O uso restrito de antimicrobianos por mais de um ano com base em antibiogramas cumulativos pode reduzir a taxa de resistência de vários antimicrobianos em SP isolados de cães com piodermite e OE.

Background Patient satisfaction studies have explored domains of patient satisfaction, the determinants of domains, and score differences of domains by patient/hospital structural measures but reports on the structure of patient satisfaction with respect to similarities among domains are scarce. This study is to explore by distance-based analysis whether similarities among patient-satisfaction domains are influenced by hospital structural measures, and to design a model evaluating relationships between the structure of patient satisfaction and hospital structural measures. Methods The Hospital Consumer Assessment of Healthcare Providers and Systems 2012 survey scores and their structural measures from the Hospital Compare website reported adjusted percentages of scale for each hospital. Contingency tables of nine measures and their ratings were designed based on hospital structural measures, followed by three different distance-based analyses - clustering, correspondence analysis, and ordinal multidimensional scaling – for robustness to identify homogenous groups with respect to similarities. Results Of 4,677 hospitals, 3,711 (79.3%) met the inclusion criteria and were analyzed. The measures were divided into three groups plus cleanliness. Certain combinations of these groups were shown to be dependent on hospital structural measures. High value ratings for communication and low value ratings for medication explanation, quietness and staff responsiveness were not influenced by hospital structural measures, but the varied-ratings domain group similarities, including items such as global evaluation and pain management, were affected by hospital structural measures. Conclusions Distance-based analysis can reveal the hidden structure of patient satisfaction. This study suggests that hospital structural measures including hospital size, the ability to provide acute surgical treatment, and hospital interest in improving medical care quality are factors which may influence the structure of patient satisfaction.

Importance Thirty-day home time, defined as time spent alive and out of a hospital or facility, is a novel, patient-centered performance metric that incorporates readmission and mortality. Objectives To characterize risk-adjusted 30-day home time in patients discharged with heart failure (HF) as a hospital-level quality metric and evaluate its association with the 30-day risk-standardized readmission rate (RSRR), 30-day risk-standardized mortality rate (RSMR), and 1-year RSMR. Design, Setting, and Participants This hospital-level cohort study retrospectively analyzed 100% of Medicare claims data from 2 968 341 patients from 3134 facilities from January 1, 2012, to November 30, 2017. Exposures Home time, defined as time spent alive and out of a short-term hospital, skilled nursing facility, or intermediate/long-term facility 30 days after discharge. Main Outcomes and Measures For each hospital, a risk-adjusted 30-day home time for HF was calculated similar to the Centers for Medicare & Medicaid Services risk-adjustment models for 30-day RSRR and RSMR. Hospitals were categorized into quartiles (lowest to highest risk-adjusted home time). The correlations between hospital rates of risk-adjusted 30-day home time and 30-day RSRR, 30-day RSMR, and 1-year RSMR were estimated using the Pearson correlation coefficient. Distribution of days lost from a perfect 30-day home time were calculated. Reclassification of hospital performance using 30-day home time vs 30-day RSRR was also evaluated. Results Overall, 2 968 341 patients (mean [SD] age, 81.0 [8.3] years; 53.6% female) from 3134 hospitals were included in this study. The median hospital risk-adjusted 30-day home time for patients with HF was 21.77 days (range, 8.22-28.41 days). Hospitals in the highest quartile of risk-adjusted 30-day home time (best-performing hospitals) were larger (mean [SD] number of beds, 285 [275]), with a higher volume of patients with HF (median, 797 patients; interquartile range, 395-1484) and were more likely academic hospitals (59.9%) with availability of cardiac surgery (51.1%) and cardiac rehabilitation (68.8%). A total of 72% of home time lost was attributable to stays in an intermediate- or long-term care facility (mean [SD], 2.65 [6.44] days) or skilled nursing facility (mean [SD], 3.96 [9.04] days), 13% was attributable to short-term readmissions (mean [SD], 1.25 [3.25] days), and 15% was attributable to death (mean [SD], 1.37 [6.04] days). Among 30-day outcomes, the 30-day RSRR and 30-day RSMR decreased in a graded fashion across increasing 30-day home time categories (correlation coefficients: 30-day RSRR and 30-day home time, -0.23, P

Background and Purpose: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. Methods: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0–5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. Results: Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59–79] years; median NIHSS score of 2 [interquartile range, 1–4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71–2.13], P P Conclusions: In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.

Purpose Utilization of hydroxychloroquine, chloroquine, and supportive therapy drugs in hospitals in New York during the early weeks of the coronavirus disease 2019 (COVID-19) pandemic was analyzed. Summary Drug utilization trends for 7 medications used to treat patients with suspected or confirmed COVID-19 at 47 New York hospitals were identified. The data demonstrated sharp increases in aggregate utilization of hydroxychloroquine and chloroquine and the number of patients receiving either drug beginning on March 15, with a notable 20% median increase per day through March 31. The net quantity of drug charge units per day for midazolam, propofol, ketamine, cisatracurium, and fentanyl also increased during the study period. Following peak utilization, use of all study drugs decreased at different times throughout April 2020. The data were used to provide information to various stakeholders in the drug supply chain during the initial surge of the pandemic. Conclusion This analysis describes the increased use, beginning in mid-March 2020, of hydroxychloroquine, chloroquine, midazolam, propofol, ketamine, cisatracurium, and fentanyl in 47 hospitals in New York State. The increased utilization of supportive therapy drugs was consistent with the surge in patients with presumed or confirmed COVID-19 during the study period. These data and observations can help clinicians, health-system leaders, manufacturers, wholesalers, and policymakers understand the impact of current and future pandemics on the drug supply chain.

Critical Care Medicine is a specialty dealing with the comprehensive management of patients having, or at risk of developing, acute, life threatening organ dysfunction The glaring need of critical care services and human resources for critical care have become more evident in the face of the current COVID-19 Pandemic At this juncture, when the world is facing threat to humanity with an increasing number of deaths due to COVID 19 pandemic, the discussion about the need for ICU beds and human resources for critical care management has re-surfaced and is being increasingly realized In Nepal, as of 15supth/sup April, 2020, there are 194 hospitals with ICU facilities The total ICU bed strength is 1595 in 194 hospitals (which is approximately 6% of all hospital beds) and only around 50% of them are equipped with ventilators (840) These figures indicate that Nepal has approximately 2 8 ICU beds per 100,000 population As Nepal braces to contain a major COVID-19 outbreak, the hospital capacities of the country have already come under huge pressure If the number of confirmed cases of COVID-19 continue to rise at the current pace, the shortage of critical care facilities will become more glaring than ever before The current pandemic is a tremendous opportunity for health planners to accelerate action and ensure that the country is well-equipped to contain the COVID-19 pandemic We need to be working towards infrastructure and human resource strengthening and expansion in critical care, in order to efficiently contain the pandemic Copyright © 2020, Nepal Medical Association All rights reserved