The Relationship Between Short-Term Mortality and Quality of Care for Hip Fracture: A Meta-Analysis of Clinical Pathways for Hip Fracture

OBJECTIVES: To assess the association between use of clinical pathways for hip fracture and changes in the rates of five inpatient complications and short-term mortality.
DESIGN: Meta-analysis of published studies examining clinical pathways for hip fracture, identified through systematic searches of electronic databases (MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials) and hand searches of selected article bibliographies.
SETTING: Observational and interventional studies of clinical pathways for hip fracture examining rates of deep venous thrombosis, pressure ulcer, surgical site infection, urinary tract infection, pneumonia, and inpatient or 30-day mortality.
PARTICIPANTS: Two reviewers.
MEASUREMENTS: Reviewers independently assessed eligibility and quality of studies and extracted data for outcomes of interest.
RESULTS: Meta-analysis of nine studies (4,637 patients) demonstrated lower odds of deep venous thrombosis (odds ratio (OR)=0.33, 95% CI=0.14–0.75), pressure ulcer (OR=0.48, 95% CI=0.30–0.75), surgical site infection (OR=0.48, 95% CI=0.25–0.89), and urinary tract infection (OR=0.71, 95% CI=0.52–0.98) in patients managed according to clinical pathways than in those receiving usual care. Statistically significant differences were not observed in the odds of pneumonia (OR=1.01, 95% CI=0.67–1.53) or in a combined outcome of in-hospital or 30-day mortality (OR=0.86, 95% CI=0.66–1.13).
CONCLUSION: An association was observed between clinical pathway use and lower odds of four common complications of hospitalization after hip fracture; only a small, statistically insignificant association was observed between pathway use and changes in short-term mortality, suggesting that assessments of hospital quality based on short-term mortality may not reflect important improvements in patient outcomes that hospitals may achieve using clinical pathways.     

Use of inhaled and oral glucocorticoids, severity of inflammatory disease and risk of hip/femur fracture: a population-based case-control study

BACKGROUND: Patients using higher dosages of inhaled or oral glucocorticoids (GCs) have an increased risk of hip/femur fractures. The role of the underlying disease in the aetiology of this increased risk has not been widely studied. OBJECTIVE: To evaluate the contribution of the underlying disease to the risk of hip/femur fracture in patients using inhaled or oral GCs. DESIGN AND SUBJECTS: A case-control study within the Dutch PHARMO-RLS database was conducted. Cases (n = 6763) were adult patients with a first hip/femur fracture during enrolment. Each case was matched to four controls by age, gender and region. RESULTS: The risk of hip/femur fracture increased with current use of inhaled GCs (crude OR 1.30, 95% CI:1.16-1.47) and with current use of oral GCs (crude OR 1.66, 95% CI: 1.46-1.90). After adjustment for disease severity, the risk of hip/femur fracture was no longer statistically significantly increased in inhaled GC users (adjusted OR 1.08, 95% CI: 0.91-1.27), whilst it remained elevated in oral GC users (adjusted OR 1.43, 95% CI: 1.22-1.67). Patients using inhaled GCs without any exposure to oral GCs had no increased risk of fracture (adjusted OR 0.98, 95% CI: 0.79-1.22). CONCLUSION: Inhaled GC users had no increased risk of femur/hip fracture after adjustment for underlying disease severity. Our data suggest that, even at higher dosages, inhaled GC use is not an independent risk factor for fracture. In contrast, oral GC use was associated with an increased risk of fracture, which was not fully explained by the underlying disease severity.     

Physician consultation, multidisciplinary care, and 1-year mortality in Medicare recipients hospitalized with hip and lower extremity injuries

OBJECTIVE: To determine whether routine surgeon consultation with medicine specialists and multidisciplinary care conferences—potentially modifiable hospital characteristics—are associated with lower 1‐year mortality in older adults with hip and lower extremity injuries. DESIGN: Retrospective cohort study. SETTING: Oregon hospitals. PARTICIPANTS: Two thousand five hundred thirty‐eight Medicare recipients aged 67 and older hospitalized in Oregon hospitals in 2002 with hip or lower extremity injuries. MEASUREMENTS: Demographic, injury, comorbidity, and survival information were gathered from Medicare records for 2000 to 2003. All Oregon hospitals with a qualifying case were surveyed using a structured telephone interview to collect information about routine surgeon consultations and multidisciplinary care conferences for older adult orthopedic patients. Multivariable generalized estimating equation models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between hospital characteristics and mortality. RESULTS: After adjusting for age, injury severity, comorbid conditions, trauma center status, and hospital annual volume of patients with hip fracture, the relative odds of dying in the year after injury for inpatients treated in settings with routine surgeon consultation with medical staff was 0.69 (95% CI 0.57–0.83) compared with patients not treated in such settings. Inpatient treatment in settings with routine multidisciplinary care conferences did not significantly affect the relative odds of dying in the year after injury (OR=1.06, 95% CI=0.89–1.26). CONCLUSION: Routine consultation by attending orthopedic surgeons with medicine or primary care specialists for Medicare inpatients is associated with better survival 1 year after injury.     

Mortality and length of stay in a veterans affairs hospital and private sector hospitals serving a common market

OBJECTIVE: To compare severity-adjusted in-hospital mortality and length of stay (LOS) in a Veterans Administration (VA) hospital and private sector hospitals serving the same health care market. DESIGN: Retrospective cohort study. SETTING: A large VA hospital and 27 private sector hospitals in the same metropolitan area. PATIENTS: Consecutive VA (N = 1,960) and private sector (N = 157,147) admissions in 1994 to 1995 with 9 high-volume diagnoses. MEASUREMENTS: Severity of illness was measured using validated multivariable models that were based on data abstracted from medical records. Outcomes were adjusted for severity and compared in VA and private sector patients using multiple logistic or linear regression analysis. MAIN RESULTS: Unadjusted mortality was similar in VA and private sector patients (5.0% vs 5.6%, respectively; P =.26), although mean LOS was longer in VA patients (12.7 vs 7.0 days; P <.001). Adjusting for severity, the odds of death in VA patients was similar (odds ratio [OR] 1.07; 95% confidence interval [95% CI], 0.74 to 1.54; P =.73). However, a larger proportion of deaths in VA patients occurred later during hospitalization (P <.001), and the odds of death in VA patients were actually lower (P <.05) in analyses limited to deaths during the first 7 (OR, 0.56) or 14 (OR, 0.63) days. Adjusted LOS was longer (P <.001) in VA patients for all 9 diagnoses. CONCLUSIONS: If the current findings generalizable to other markets, hospital mortality, a widely used performance measure, may be similar or lower in VA and private sector hospitals serving the same markets. The longer LOS of VA patients may reflect differences in practice patterns and may be an important source of bias in comparisons of VA and private sector hospitals.     

Prevalence rate of urinary incontinence in community-dwelling elderly individuals: the Veneto study

BACKGROUND: Urinary incontinence (UI) is a common problem in elderly people, due mainly to functional impairments and concurrent medical diseases. Few studies, however, have assessed the prevalence of UI in noninstitutionalized individuals. The objectives of the present work were to estimate the prevalence of UI in a community-based population of elderly Italians and to determine the associated physical, social, and psychological factors. METHODS: A random sample of noninstitutionalized men (n = 867) and women (n = 1531), aged 65 years and older, from the Veneto region of northeastern Italy, were interviewed at home, using an extensive multidisciplinary questionnaire, to assess their quality of life and social, biological, and psychological correlates. RESULTS: The prevalence rate of UI was of 11.2% among men and of 21.6% among women. Among those reporting the condition, approximately 53% of women and 59% of men reported experiencing incontinence daily or weekly. Association of UI was found for participants older than 70 years in both men (odds ratio [OR] 2.49, 95% confidence interval [CI] 1.45-4.28) and women (OR 1.49, 95% CI 1.11-2.02). Three of the medical conditions investigated were associated with increases in the odds in women, namely chronic obstructive pulmonary disease (OR 1.53, 95% CI 1.11-2.12), Parkinsonism (OR 2.27, 95% CI 1.14-4.54), and hip fracture (OR 1.38,95% CI 1.02-1.88), whereas chronic diarrhea was the only condition associated with UI in men (OR 6.92, 95% CI 2.22-21.5). Participants with a physical disability were two times more likely to report incontinence, and the odds were increased by 50% in women who had sleep disturbances. CONCLUSIONS: Incontinence is highly prevalent in the Italian elderly population, and several common chronic conditions are significantly associated with it. Moreover, very few people with incontinence seek health care or are aware of potential treatments.     

Quality-of-life impact and treatment of urinary incontinence in ethnically diverse older women

OBJECTIVE: To identify the factors associated with greater quality-of-life impact, treatment seeking, and use of treatments for urinary incontinence in ethnically diverse older women. METHODS: Cross-sectional analysis of a population-based cohort of 2109 middle-aged and older women who were randomly selected from age and race/ethnicity strata. Data were collected by self-report questionnaires and in-person interviews. Multivariable logistic regression was used to identify predictors of high quality-of-life impact (Incontinence Impact Questionnaire [IIQ] score > or =75th percentile), treatment seeking, and use of treatments for incontinence. RESULTS: More than one fourth (n = 603) of the study participants (including 96 black [16%], 123 Latina [20%], 65 Asian [11%], and 309 white [51%] women) reported weekly incontinence. After clinical severity and other factors were adjusted for, women were more likely to experience high quality-of-life impact if they had nighttime incontinence (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.3-4.9), coital incontinence (OR, 1.9; 95% CI, 1.1-3.3), or comorbid fecal incontinence (OR, 2.2; 95% CI, 1.2-4.2). Predictors of treatment seeking included older age (OR, 1.6 per 10 years; 95% CI, 1.2-2.0); higher IIQ score (OR, 4.6 for highest IIQ quartile vs lowest IIQ quartile; 95% CI, 2.5-8.4), and higher household income (OR, 2.6 for income > or = US dollars 100 000/y vs < US dollars 20 000/y; 95% CI, 1.0-2.7). CONCLUSIONS: Clinicians seeking to evaluate the impact of incontinence on women's lives should assess not only the clinical severity of their symptoms but also the specific context in which symptoms occur. The prevalence of treatment seeking for incontinence is low across all ethnic groups, even when women have clinically severe symptoms and access to a health provider.     

Preoperative status and risk of complications in patients with hip fracture

BACKGROUND: Limited information is available on preoperative status and risks for complications for older patients having surgery for hip fracture. Our objective was to identify potentially modifiable clinical findings that should be considered in decisions about the timing of surgery. METHODS: We conducted a prospective cohort study with data obtained from medical records and through structured interviews with patients. A total of 571 adults with hip fracture who were admitted to 4 metropolitan hospitals were included. RESULTS: Multiple logistic regression was used to identify risk factors (including 11 categories of physical and laboratory findings, classified as mild and severe abnormalities) for in-hospital complications. The presence of more than 1 (odds ratio [OR] 9.7, 95% confidence interval [CI] 2.8 to 33.0) major abnormality before surgery or the presence of major abnormalities on admission that were not corrected prior to surgery (OR 2.8, 95% CI 1.2 to 6.4) was independently associated with the development of postoperative complications. We also found that minor abnormalities, while warranting correction, did not increase risk (OR 0.70, 95% CI 0.28 to 1.73). CONCLUSIONS: In this study of older adults undergoing urgent surgery, potentially reversible abnormalities in laboratory and physical examination occurred frequently and significantly increased the risk of postoperative complications. Major clinical abnormalities should be corrected prior to surgery, but patients with minor abnormalities may proceed to surgery with attention to these medical problems perioperatively.     

Delirium is independently associated with poor functional recovery after hip fracture

OBJECTIVE: To evaluate the role of delirium in the natural history of functional recovery after hip fracture surgery, independent of prefracture status. DESIGN: Prospective cohort study. SETTING: Orthopedic surgery service at a large academic tertiary hospital, with follow-up extending into rehabilitation hospitals, nursing homes, and the community. PARTICIPANTS: One hundred twenty-six consenting subjects older than 65 years (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment at enrollment to ascertain prefracture status through interviews with the patient and designated proxy and review of the medical record. Interviews included administration of standardized instruments (Activities of Daily Living (ADL) Scale, Blessed Dementia Rating Scale, Delirium Symptom Interview) and assessment of ambulation, and prefracture living situation. Medical comorbidity, the nature of the hip fracture, and the surgical repair were obtained from the medical record. All subjects underwent daily interviews for the duration of the hospitalization, including the Mini-Mental State Examination and Delirium Symptom Interview, and delirium was diagnosed using the Confusion Assessment Methods algorithm. Patients and proxies were recontacted 1 and 6 months after fracture, and underwent interviews similar to those at enrollment to determine death, persistent delirium, decline in ADL function, decline in ambulation, or new nursing home placement. RESULTS: Delirium occurred in 52/126 (41%) of patients, and persisted in 20/52 (39%) at hospital discharge, 15/52 (32%) at 1 month, and 3/52 (6%) at 6 months. Patients aged 80 years or older, and those with prefracture cognitive impairment, ADL functional impairment, and high medical comorbidity were more likely to develop delirium. However, after adjusting for these factors, delirium was still significantly associated with outcomes indicative of poor functional recovery 1 month after hip fracture: ADL decline (odds ratio (OR) = 2.6; 95% confidence interval (95% CI), 1.1- 6.1), decline in ambulation (OR = 2.6; 95% CI, 1.03-6.5), and death or new nursing home placement (OR = 3.0; 95% CI, 1.1-8.4). Patients whose delirium persisted at 1 month had worse outcomes than those whose delirium had resolved. CONCLUSIONS: Delirium is common, persistent, and independently associated with poor functional recovery 1 month after hip fracture even after adjusting for prefracture frailty. Further research is necessary to identify the mechanisms by which delirium contributes to poor functional recovery, and to determine whether interventions designed to prevent or reduce delirium can improve recovery after hip fracture.     

Risk factors for early hospital readmission in patients with AIDS and pneumonia

OBJECTIVE: To determine risk factors for early readmission to the hospital in patients with AIDS and pneumonia. DESIGN: Case-control analysis. SETTING: A municipal teaching hospital serving an indigent population. PATIENTS: Case patients were all AIDS patients hospitalized with Pneumocystis carinii pneumonia or bacterial pneumonia between January 1992 and March 1995 who were readmitted for any nonelective reason within 2 weeks of discharge (n = 90). Control patients were randomly selected AIDS patients admitted during the study period who were not early readmissions (n = 87), matched by proportion of Pneumocystis carinii to bacterial pneumonia. MEASUREMENTS AND MAIN RESULTS: Demographics, social support, health-related behaviors, clinical aspects of the acute hospitalization, and general medical status were the main predictors measured. RESULTS: Patients were at significantly increased risk of early readmission if they left the hospital unaccompanied by family or friend (odds ratio [OR] 4.76; 95% confidence interval [CI] 2.06, 11.0; p =.0003), used crack cocaine (OR 3.40; 95% CI 1.02, 11.3; p =. 046), had one or more coincident AIDS diagnoses (OR 3.65; 95% CI 1. 44, 9.26; p =.0065), or had been admitted in the preceding 6 months (OR 2.82; 95% CI 1.21, 6.57; p =.016). Demographic characteristics, alcoholism, intravenous drug use, illness severity on admission, and length of hospitalization did not predict early readmission. CONCLUSIONS: Absence of companion at discharge and crack use were important risk factors for early readmission in patients with AIDS and pneumonia. Additional AIDS comorbidity and recent antecedent hospitalization were also risk factors; however, demographics and measures of acute illness during index hospitalization did not predict early readmission.     

Associations of serum sex hormone-binding globulin and sex hormone concentrations with hip fracture risk in postmenopausal women

CONTEXT: Endogenous estradiol, testosterone, and SHBG may influence the risk of hip fracture. DESIGN AND METHODS: From the Women's Health Initiative Observational Study, 39,793 eligible postmenopausal women did not have a previous hip fracture and were not using estrogen or other bone-active therapies. Of these, 400 who had a first-time nonpathological hip fracture (median follow-up, 7 yr) were matched to 400 controls by age, ethnicity, and baseline blood draw date. Estradiol, testosterone, and SHBG were measured in banked baseline serum. RESULTS: Compared with women in the lowest tertiles, those with bioavailable testosterone in the highest tertile had a lower risk [odds ratio (OR) = 0.62; 95% confidence interval (CI) = 0.44-0.88]; those with bioavailable estradiol in the highest tertile had a lower risk (OR = 0.44; 95% CI = 0.29-0.66), and those with SHBG in the highest tertile had a higher risk (OR = 1.90; 95% CI = 1.31-2.74) of hip fracture. In models with all three hormones and potential confounders, high SHBG remained a strong independent risk factor (OR = 1.76; 95% CI = 1.12-2.78), high bioavailable testosterone remained protective (OR = 0.64; 95% CI = 0.40-1.00), but estradiol no longer was associated (OR = 0.72; 95% CI = 0.42-1.23). CONCLUSIONS: High serum SHBG is associated with an increased risk of subsequent hip fracture and high endogenous testosterone with a decreased risk, independent of each other, serum estradiol concentration, and other putative risk factors. But endogenous estradiol has no independent association with hip fracture.     

Inflammatory bowel disease and the risk of fracture

Although patients with inflammatory bowel disease (IBD) have reduced bone mass, there is controversy whether there is an increased risk of fracture. This study examines the risk of fracture and its predictors in patients with IBD. In a primary care- based nested case-control study, 231,778 fracture cases and 231,778 age- and sex-matched controls were recruited. A history of IBD was assessed from medical records. The prevalence of IBD was 156 and 282 per 100,000 for Crohn’s disease (CD) and ulcerative colitis (UC), respectively. Patients with IBD had an increased risk of vertebral fracture (odds ratio [OR], 1.72; 95% confidence interval [CI], 1.13-2.61) and hip fracture (OR, 1.59; 95% CI, 1.14-2.23). The risk of hip fracture was greater in patients with CD (OR, 1.86; 95% CI, 1.08-3.21) compared with UC (OR, 1.40; 95% CI, 0.92-2.13). Disease severity, assessed by the number of symptoms, predicted fracture even after adjusting for corticosteroid use (OR, 1.46; 95% CI, 1.04-2.04). Only 13% of patients with IBD who had already sustained a fracture were on any form of antifracture treatment. Patients with IBD have a higher risk of fracture due to both disease activity and use of oral corticosteroids. However, few of these patients are receiving optimal bone-sparing therapy, highlighting the importance of increasing awareness of osteoporosis in those managing these patients.     

Depression: a predictor of smoking relapse in a 6-month follow-up after hospitalization for acute coronary syndrome.

OBJECTIVE: The objective of the study was to investigate whether depression is a predictor of postdischarge smoking relapse among patients hospitalized for myocardial infarction (MI) or unstable angina (UA), in a smoke-free hospital. METHODS: Current smokers with MI or UA were interviewed while hospitalized; patients classified with major depression (MD) or no humor disorder were reinterviewed 6 months post discharge to ascertain smoking status. Potential predictors of relapse (depression; stress; anxiety; heart disease risk perception; coffee and alcohol consumption; sociodemographic, clinical, and smoking habit characteristics) were compared between those with MD (n=268) and no humor disorder (n=135). RESULTS: Relapsers (40.4%) were more frequently and more severely depressed, had higher anxiety and lower self-efficacy scale scores, diagnosis of UA, shorter hospitalizations, started smoking younger, made fewer attempts to quit, had a consort less often, and were more frequently at the 'precontemplation' stage of change. Multivariate analysis showed relapse-positive predictors to be MD [odds ratio (OR): 2.549; 95% confidence interval (CI): 1.519-4.275] (P<0.001); 'precontemplation' stage of change (OR: 7.798; 95% CI: 2.442-24.898) (P<0.001); previous coronary bypass graft surgery (OR: 4.062; 95% CI: 1.356-12.169) (P=0.012); and previous anxiolytic use (OR: 2.365; 95% CI: 1.095-5.107) (P=0.028). Negative predictors were diagnosis of MI (OR: 0.575; 95% CI: 0.361-0.916) (P=0.019); duration of hospitalization (OR: 0.935; 95% CI: 0.898-0.973) (P=0.001); smoking onset age (OR: 0.952; 95% CI: 0.910-0.994) (P=0.028); number of attempts to quit smoking (OR: 0.808; 95% CI: 0.678-0.964) (P=0.018); and 'action' stage of change (OR: 0.065; 95% CI: 0.008-0.532) (P=0.010). CONCLUSION: Depression, no motivation, shorter hospitalization, and severity of illness contributed to postdischarge resumption of smoking by patients with acute coronary syndrome, who underwent hospital-initiated smoking cessation.     

Urinary incontinence and its association with death, nursing home admission, and functional decline

OBJECTIVES: To determine whether urinary incontinence (UI) is an independent predictor of death, nursing home admission, decline in activities of daily living (ADLs), or decline in instrumental activities of daily living (IADLs). DESIGN: A population-based prospective cohort study from 1993 to 1995. SETTING: Community-dwelling within the United States. PARTICIPANTS: Six thousand five hundred six of the 7,447 subjects aged 70 and older in the Asset and Health Dynamics Among the Oldest Old study who had complete information on continence status and did not require a proxy interview at baseline. MEASUREMENTS: The predictor was UI, and the outcomes were death, nursing home admission, ADL decline, and IADL decline. Potential confounders considered were comorbid conditions, baseline function, sensory impairment, cognition, depressive symptoms, body mass index, smoking and alcohol, demographics, and socioeconomic status. RESULTS: The prevalence of UI was 14.8% (18.5% in women; 8.5% in men). At 2-year follow-up, subjects incontinent at baseline were more likely to have died (10.9% vs 8.7%; unadjusted odds ratio (OR)=1.29, 95% confidence interval (CI)=1.02-1.64), be admitted to a nursing home (4.4% vs 2.6%, OR=1.77; 95% CI=1.18-2.63), and to have declined in ADL function (13.6% vs 8.1%; OR=1.78, 95% CI=1.36-2.33) and IADL function (21.2% vs 13.8%; OR 1.69, 95% CI 1.39-2.05). However, after adjusting for confounders, UI was not an independent predictor of death (adjusted OR (AOR)= 0.90, 95% CI=0.67-1.21), nursing home admission (AOR=1.33, 95% CI=0.86-2.04), or ADL decline (AOR=1.24, 95% CI=0.92-1.68). Incontinence remained a predictor of IADL decline (AOR=1.31; 95% CI=1.05-1.63), although adjustment markedly reduced the strength of this association. CONCLUSION: Higher levels of baseline illness severity and functional impairment appear to mediate the relationship between UI and adverse outcomes. The results suggest that, although UI appears to be a marker of frailty in community-dwelling elderly, it is not a strong independent risk factor for death, nursing home admission, or functional decline.     

Factors influencing the prevalence of gallstones in liver disease: the beneficial and harmful influences of alcohol

OBJECTIVE: The Patient Treatment File of the Department of Veterans Affairs comprises the computerized records of all inpatients treated in all Veterans Affairs hospitals distributed throughout the United States. This database was used to study the association between liver disease and clinically manifest cholelithiasis. METHODS: The computerized medical records of 38,459 patients with various forms of liver disease and 69,336 controls without the diagnosis were extracted from the annual files between 1990 and 1993. In a multiple logistic regression analysis, the occurrence of cholelithiasis served as the outcome variable, whereas different forms of liver disease and demographic characteristics, such as age, gender, and ethnicity, served as predictor variables. RESULTS: Among the control population, cholelithiasis was reported in 5.2% (3,571 of 69,336) of subjects. Cholelithiasis occurred in 7.5% (2,898 of 38,459) of patients with all liver disease, 9.5% (1,642 of 17,287) of patients with alcoholic liver cirrhosis, 13.7% (981 of 7,149) of patients with nonalcoholic liver cirrhosis, and 9.1% (66 of 728) of patients with alcoholic fatty liver (chi2 = 1059, df = 4, p < 0.001). In the logistic regression, the odds ratios (ORs) for cholelithiasis associated with various forms of liver disease were: in all liver diseases combined (OR = 1.31, 95% CI = 1.25-1.38), in alcoholic liver cirrhosis (OR = 1.62, 95% CI = 1.54-1.72), in nonalcoholic liver cirrhosis (OR = 2.07, 95% CI = 1.94-2.21), and in alcoholic fatty liver (OR = 1.40, 95% CI = 1.11-1.75). Other risk factors for cholelithiasis besides liver disease were: female gender (OR = 1.43, 95% CI = 1.25-1.63), older age (OR = 1.28 per age decade, 95% CI = 1.26-1.30), Native American (OR = 1.38, 95% CI = 1.12-1.72) or Hispanic ethnicity (OR = 1.25, 95% CI = 1.15-1.35), and presence of diabetes mellitus (OR = 1.43, 95% CI = 1.35-1.52). A history of alcoholism exerted a protective influence (OR = 0.92, 95% CI = 0.87-0.97). CONCLUSION: Gallstone disease occurs frequently in hospitalized patients with chronic liver disease or liver cirrhosis and contributes to the burden of the disease.     

Factors associated with length of stay for pediatric asthma hospitalizations

Objective: Asthma is a leading cause of pediatric hospitalizations, but little is known about factors associated with length of stay (LOS) for asthma hospitalizations. The aim of this study was to identify factors associated with LOS for pediatric asthma hospitalizations. Methods: The Pediatric Health Information System (PHIS) was used to cohort patients 2–17 years old with a primary asthma diagnosis discharged from 42 PHIS hospitals in 2011. Sociodemographic, temporal and health-status factors were examined. Bivariate and generalized-estimating-equation logistic regression analyses were performed to identify factors associated with LOS, after adjusting for severity of illness (SOI). Results: In total, 25?900 children were hospitalized, with a mean LOS of 1.9 days. In bivariate analysis, mean LOS was longer (p?<?0.01) for patients with complex chronic conditions (CCC) (3.1 days versus 1.8 for non-CCC) and adolescents (2.3 versus 1.8 for 2–5 years old). In multivariable analysis, obstructive sleep apnea (OSA; OR 2.3; 95% CI: 1.8–2.9), older age (OR 1.3; 95% CI: 1.2–1.4), obesity (OR 1.3; 95% CI: 1.1–1.4), CCC (OR 1.3; 95% CI: 1.1–1.4), winter admissions (OR 1.2; 95% CI: 1.1–1.4), female gender (OR 1.1; 95% CI: 1.1–1.3), and weekend admissions (OR 1.1; 95% CI: 1.03–1.2) had higher odds of asthma LOS >2 days. Conclusions: OSA, older age, obesity, CCC, winter and weekend admissions, and female gender are associated with longer LOS for pediatric asthma hospitalizations, after adjustment for SOI. The study findings suggest that interventions focused on these at-risk groups may prove most useful in reducing LOS for pediatric asthma hospitalizations.     

Contribution of the collagen I alpha1 and vitamin D receptor genes to the risk of hip fracture in elderly women

CONTEXT AND OBJECTIVE: Hip fracture is partially genetically determined. The present study was designed to examine the contributions of vitamin D receptor (VDR) and collagen I alpha1 (COLIA1) genotypes to the liability to hip fracture in postmenopausal women. DESIGN: The study was designed as a prospective population-based cohort investigation. SUBJECTS: Six hundred seventy-seven postmenopausal women of Caucasian background, aged 70 +/- 7 yr (mean +/- SD), have been followed for up to 14 yr. Sixty-nine women had sustained a hip fracture during the period. MAIN OUTCOME: Atraumatic hip fractures were prospectively identified through radiologists' reports. Bone mineral density (BMD) at the hip and lumbar spine was measured by dual-energy x-ray absorptiometry. GENOTYPES: The TaqI and SpI COLIA1 polymorphisms of the VDR and COLIA1 genes were determined. Using the Single Nucleotide Polymorphism database, VDR TT, Tt, and tt genotypes were coded as TT, TC, and CC, whereas COLIA1 SS, Ss, and ss were coded as GG, GT, and TT. RESULTS: Women with VDR CC genotype (16% prevalence) and COLIA1 TT genotype (5% prevalence) had an increased risk of hip fracture [odds ratio (OR) associated with CC, 2.6; 95% confidence interval (CI), 1.2-5.3; OR associated with TT, 3.8; 95% CI, 1.3-10.8] after adjustment for femoral neck BMD (OR, 3.4 per SD; 95% CI, 2.3-5.0) and age (OR, 1.4 per 5 yr; 95% CI, 1.1-1.7). Approximately 20 and 12% of the liability to hip fracture was attributable to the presence of the CC genotype and TT genotype, respectively. CONCLUSION: The VDR CC genotype and COLIA1 TT genotype were associated with increased hip fracture risk in Caucasian women, and this association was independent of BMD and age.