Cardiovascular and cerebrovascular outcomes in elderly hypertensive patients treated with either ARB or ACEI

Background Although angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are equally important in the treatment of hypertension, there is less evidence whether they have equal cardiovascular and cerebrovascular protective effects, especially in elder hypertensive patients. This study aims to clarify this unresolved issue. Methods This cross-sectional study included clinical data on 933 aged male patients with hypertension who received either an ARB or ACEI for more than two months between January 2007 and May 2011. The primary outcome was the composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. The secondary endpoints were unstable angina, new atrial fibrillation, and transient ischemic attack. Results The median follow-up time was 24 months. Age, drug types, cerebral infarction history, renal dysfunction history were the independent predictors of the primary endpoint. The risk of an occurrence of a primary endpoint event was higher in the ARB group than the ACEI group [P = 0.037, hazard ratios (HR): 2.124, 95% confidence interval (95% CI): 1.048–4.306]. The Kaplan-Meier method also suggests that the rate of primary endpoint occurrence was higher in the ARB group than the ACEI group (P = 0.04). In regard to the secondary endpoints, there were no significant differences between the two treatment arms (P = 0.137, HR: 1.454,95% CI: 0.888–2.380). Patient age and coronary heart disease history were independent predictors of the secondary endpoint. Conclusion ACEI were more effective than ARB in reducing cardiovascular and cerebrovascular morbidity and mortality in aged patients with hypertension.     

Optimized Treatment and Heart Rate Reduction in Chronic Heart Failure

Background

Heart failure (HF) is a syndrome that leads to poor outcome in advanced forms. The neurohormonal blockade modifies this natural history; however, it is often suboptimal.

Objective

The aim of this study is to assess at what percentage cardiologists used to treating HF can prescribe target doses of drugs of proven efficacy.

Methods

A total of 104 outpatients with systolic dysfunction were consecutively enrolled, all under stabilized treatment. Demographic and treatment data were evaluated and the doses achieved were verified. The findings are shown as percentages and correlations are made between different variables.

Results

The mean age of patients was 64.1 ± 14.2 years, with SBP =115.4 ± 15.3, HR = 67.8 ± 9.4 bpm, weight = 76.0 ± 17.0 kg and sinus rhythm (90.4%). As for treatment, 93.3% received a RAS blocker (ACEI 52.9%), all received beta-blockers (BB), the most often prescribed being carvedilol (92.3%). As for the doses: 97.1% of those receiving an ARB were below the optimal dose and of those who received ACEI, 52.7% received an optimized dose. As for the BB, target doses were prescribed to 76.0% of them. In this group of patients, most with BB target dose, it can be seen that 36.5% had HR ≥ 70 bpm in sinus rhythm.

Conclusion

Cardiologists used to treating HF can prescribe target doses of ACEI and BB to most patients. Even though they receive the recommended doses, about one third of patients persists with HR > 70 bpm and should have their treatment optimized.     

Mortality of elderly patients in Ontario after hospital admission for chronic obstructive pulmonary disease

BACKGROUND:

Chronic obstructive pulmonary disease (COPD) is associated with significant mortality. It is currently the fourth leading cause of death in Canada and the world.

OBJECTIVES:

To describe the mortality of elderly patients in Ontario after hospital admission for COPD.

METHODS:

A retrospective cohort study was conducted using the Discharge Abstract Database from the Canadian Institute for Health Information. Patients aged 65 years and older who were admitted to hospital between 2001 and 2004 with primary discharge diagnoses labelled with International Classification of Diseases, Ninth Revision codes 491, 492 and 496 were included in the study.

RESULTS:

Mortality rates were 8.81, 12.10, 14.53 and 27.72 per 100 COPD hospital admissions at 30, 60, 90 and 365 days after hospital discharge, respectively. Mortality also increased with age, and men had higher rates than women. No significant differences in mortality rates were found between different socioeconomic groups (P>0.05). Patients with shared care of a family physician or general practitioner and a specialist had significantly lower mortality rates than the overall rate (P<0.05), and their rates were approximately one-half the rate of patients with only one physician.

CONCLUSIONS:

Hospitalization with COPD is associated with significant mortality. Patients who were cared for by both a family physician or general practitioner and a specialist had significantly lower mortality rates than those cared for by only one physician, suggesting that continuous and coordinated care results in better survival.     

Hospital volume and other risk factors for in-hospital mortality among diverticulitis patients: A nationwide analysis

BACKGROUND:

Previous studies have found that a higher volume of colorectal surgery was associated with lower mortality rates. While diverticulitis is an increasingly common condition, the effect of hospital volume on outcomes among diverticulitis patients is unknown.

OBJECTIVE:

To evaluate the relationship between hospital volume and other factors on in-hospital mortality among patients admitted for diverticulitis.

METHODS:

Data from the Nationwide Inpatient Sample (years 1993 to 2008) were analyzed to identify 822,865 patients representing 4,108,726 admissions for diverticulitis. Hospitals were divided into quartiles based on the volume of diverticulitis cases admitted over the study period, adjusted for years contributed to the dataset. Mortality according to hospital volume was modelled using logistic regression adjusting for age, sex, race, comorbidities, health care insurance, admission type, calendar year, colectomy, disease severity and clustering. Risk estimates were expressed as adjusted ORs with 95% CIs.

RESULTS:

Patients at high-volume hospitals were more likely to be admitted emergently, undergo surgical treatment and have more severe disease. In-hospital mortality was higher among the lowest quartile of hospital volume compared with the highest volume (OR 1.13 [95% CI 1.05 to 1.21]). In-hospital mortality was increased among patients admitted emergently (OR 2.58 [95% CI 2.40 to 2.78]) as well as those receiving surgical treatment (OR 3.60 [95% CI 3.42 to 3.78]).

CONCLUSIONS:

Diverticulitis patients admitted to hospitals with a low volume of diverticulitis cases had an increased risk for death compared with those admitted to high-volume centres.     

Reporting on sex-based analysis in clinical trials of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker efficacy

BACKGROUND:

Clinical practice recommendations for hypertension do not make recommendations specific to men or women. However, the sex hormones appear to modulate differently the renin-angiotensin system (RAS), which plays a central role in the regulation of blood pressure. Today, little is known about the effects of sex on the efficacy of therapies that antagonize the RAS, such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).

OBJECTIVE:

To identify randomized controlled trials evaluating the efficacy of ACEIs and ARBs in preventing major cardiovascular outcomes, determine what proportion of the trial participants were female, and evaluate whether there was any evidence of a sex difference in the efficacy of these agents.

METHODS:

A systematic review of the literature was conducted to identify randomized controlled trials that used either ACEIs or ARBs for the treatment of hypertension.

RESULTS:

Thirteen ACEI trials and nine ARB trials were identified. Sex-specific outcome data were available in six of the ACEI trials and three of the ARB trials. These trials enrolled 74,105 patients; 39.1% were women. Seven of the nine trials indicated that ACEIs or ARBs may be slightly more beneficial in men. The magnitude of these differences, in most trials, was small.

CONCLUSIONS:

Sex-specific data are reported in 43% of large hypertension clinical trials. Review of the trials reporting sex-specific effect sizes indicates that ACEIs and ARBs may be more effective in men.     

A multicentre retrospective study to understand anti-platelet treatment patterns and outcomes of acute coronary syndrome patients in India (TRACE)

Background

There is limited available information for treatment of acute coronary syndrome (ACS) with respect to outcomes, therapeutic agents and treatment practices. Our retrospective registry study collected and evaluated varying anti-platelet treatment strategies and outcomes of ACS patients who were admitted to 9 different tertiary care hospitals in India. This study was carried out to provide an insight to anti-platelet treatment patterns and analyze outcomes of ACS patients in India.

Methods

All the relevant data, including anti-platelet treatment strategies, outcomes and patient treatment compliance were collected from 500 ACS (defined as STEMI, NSTEMI and unstable angina [UA]) cases from January 2007 to December 2009. These ACS cases were randomly collected from the hospital records and included in the analysis. The patient follow up data was acquired either from the hospital records or via telephonic contact for a period of one year following the event.

Results

Out of 500 ACS patients, 59.8% had UA/NSTEMI and 40.2% had STEMI. On hospital admission, aspirin, clopidogrel, statins, beta-blockers and angiotensin converting enzyme inhibitors (ACE-Is) were used by 83%, 83%, 68%, 43.2% and 31.6% patients, respectively. On discharge, aspirin, clopidogrel, statins and beta-blockers were used by 90.2%, 88%, 80.6%, and 59% patients, respectively. The average patient compliance to statins, clopidogrel and aspirin was recorded as 74.28%, 69.7% and 68.66%, respectively during discharge and follow-up visits. Greater than 50% of ACS patients after discharge were lost to follow-up and as a result there was significant drop in the number of clinical events reported.

Conclusion

This pilot study conducted in tertiary care centers in India showed that patients with ACS were more often diagnosed with UA/NSTEMI as compared to STEMI and reported maximum compliance to statins, clopidogrel and aspirin after discharge over 1 year follow-up. More ACS patients were lost to follow up that resulted in low reporting of clinical outcomes, following discharge upto 1 year.     

Did Duty Hour Reform Lead to Better Outcomes Among the Highest Risk Patients?

Background

Earlier work demonstrated that ACGME duty hour reform did not adversely affect mortality, with slight improvement noted among specific subgroups.

Objective

To determine whether resident duty hour reform differentially affected the mortality risk of high severity patients or patients who experienced post-operative complications (failure-to-rescue).

Design

Observational study using interrupted time series analysis with data from July 1, 2000 - June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of mortality or failure-to-rescue (FTR) in more versus less teaching-intensive hospitals before and after duty hour reform.

Participants

All unique Medicare patients (n = 8,529,595) admitted to short-term acute care non-federal hospitals and all unique VA patients (n = 318,636 patients) with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, stroke or a DRG classification of general, orthopedic or vascular surgery.

Measurements and Main Results

We measured mortality within 30 days of hospital admission and FTR, measured by death among patients who experienced a surgical complication. The odds of mortality and FTR generally changed at similar rates for higher and lower risk patients in more vs. less teaching intensive hospitals. For example, comparing the mortality risk for the 10% of Medicare patients with highest risk to the other 90% of patients in post-reform year 1 for combined medical an OR of 1.01 [95% CI 0.90, 1.13], for combined surgical an OR of 0.91 [95% CI 0.80, 1.04], and for FTR an OR of 0.94 [95% CI 0.80, 1.09]. Findings were similar in year 2 for both Medicare and VA. The two exceptions were a relative increase in mortality for the highest risk medical (OR 1.63 [95% CI 1.08, 2.46]) and a relative decrease in the high risk surgical patients within VA in post-reform year 1 (OR 0.52 [95% CI 0.29, 0.96]).

Conclusions

ACGME duty hour reform was not associated with any consistent improvements or worsening in mortality or failure-to-rescue rates for high risk medical or surgical patients.KEY WORDS: medical errors internship and residency, education, medical, graduate, personnel staffing and scheduling, continuity of patient care     

Temporal Variation in the Prognosis and Treatment of Advanced Heart Failure - Before and After 2000

Background

The treatment of heart failure has evolved in recent decades suggesting that survival is increasing.

Objective

To verify whether there has been improvement in the survival of patients with advanced heart failure.

Methods

We retrospectively compared the treatment and follow-up data from two cohorts of patients with systolic heart failure admitted for compensation up to 2000 (n = 353) and after 2000 (n = 279). We analyzed in-hospital death, re-hospitalization and death in 1 year of follow-up. We used Mann-Whitney U test and chi-square test for comparison between groups. The predictors of mortality were identified by regression analysis through Cox proportional hazards model and survival analysis by the Kaplan-Meier survival analysis.

Results

The patients admitted until 2000 were younger, had lower left ventricular impairment and received a lower proportion of beta-blockers at discharge. The survival of patients hospitalized before 2000 was lower than those hospitalized after 2000 (40.1% vs. 67.4%; p<0.001). The independent predictors of mortality in the regression analysis were: Chagas disease (hazard ratio: 1.9; 95% confidence interval: 1.3-3.0), angiotensin-converting-enzyme inhibitors (hazard ratio: 0.6; 95% confidence interval: 0.4-0.9), beta-blockers (hazard ratio: 0.3; 95% confidence interval: 0.2-0.5), creatinine ≥ 1.4 mg/dL (hazard ratio: 2.0; 95% confidence interval: 1.3-3.0), serum sodium ≤ 135 mEq/L (hazard ratio: 1.8; 95% confidence interval: 1.2-2.7).

Conclusions

Patients with advanced heart failure showed a significant improvement in survival and reduction in re-hospitalizations. The neurohormonal blockade, with angiotensin-converting-enzyme inhibitors and beta-blockers, had an important role in increasing survival of these patients with advanced heart failure.     

Hospitalization-Associated Disability in Adults Admitted to a Safety-Net Hospital

Background

Little is known about hospitalization-associated disability (HAD) in older adults who receive care in safety-net hospitals.

Objectives

To describe HAD and to examine its association with age in adults aged 55 and older hospitalized in a safety-net hospital.

Design

Secondary post hoc analysis of a prospective cohort from a discharge intervention trial, the Support from Hospital to Home for Elders.

Setting

Medicine, cardiology, and neurology inpatient services of San Francisco General Hospital, a safety-net hospital.

Participants

A total of 583 participants 55 and older who spoke English, Spanish, or Chinese. We determined the incidence of HAD 30 days post-hospitalization and ORs for HAD by age group.

Measurements

The outcome measure was death or HAD at 30 days after hospital discharge. HAD is defined as a new or additional disability in one or more activities of daily living (ADL) that is present at hospital discharge compared to baseline. Participants’ functional status at baseline (2 weeks prior to admission) and 30 days post-discharge was ascertained by self-report of ADL function.

Results

Many participants (75.3 %) were functionally independent at baseline. By age group, HAD occurred as follows: 27.4 % in ages 55–59, 22.2 % in ages 60–64, 17.4 % in ages 65–69, 30.3 % in ages 70–79, and 61.7 % in ages 80 or older. Compared to the youngest group, only the adjusted OR for HAD in adults over 80 was significant, at 2.45 (95 % CI 1.17, 5.15).

Conclusions

In adults at a safety-net hospital, HAD occurred in similar proportions among adults aged 55–59 and those aged 70–79, and was highest in the oldest adults, aged ≥ 80. In safety-net hospitals, interventions to reduce HAD among patients 70 years and older should consider expanding age criteria to adults as young as 55.KEY WORDS: Hospitalization, Hospitalization-associated disability, Activities of daily living, Frail elderly, Vulnerable populations     

Smoking inside Canadian acute care hospitals

OBJECTIVE:

To assess smoking policies at Canadian acute care hospitals.

METHOD:

A questionnaire was designed, piloted and faxed to all acute care hospitals in Canada. The questionnaire was designed to address the following: what is the current policy regarding patient smoking? Are staff and/or visitors allowed to smoke inside the hospital? Is there a separate policy for psychiatric patients? Are smoking cessation products available at the hospital pharmacy? Is the policy governed by regional or municipal legislation?

RESULTS:

A total of 852 hospitals were included in the study. Of these, 476 responded to the questionnaire, for an overall response rate of 56%. Twenty-seven per cent of respondents allowed patient smoking inside the hospital. While staff smoking was not allowed inside most hospitals (93%), 32% of hospitals in Quebec allowed staff to smoke inside the building. Thirty per cent of hospitals had a separate policy for psychiatric patients, and 27% of hospitals had provisions for visitor smoking. Sixty-seven per cent of hospitals were able to offer patients smoking cessation products while they were in hospital.

CONCLUSIONS:

Many Canadian hospitals continue to allow smoking inside their facilities. There is considerable variation in hospital smoking policies across the country.     

Pending Studies at Hospital Discharge: A Pre-post Analysis of an Electronic Medical Record Tool to Improve Communication at Hospital Discharge

Background

Achieving safe transitions of care at hospital discharge requires accurate and timely communication. Both the presence of and follow-up plan for diagnostic studies that are pending at hospital discharge are expected to be accurately conveyed during these transitions, but this remains a challenge.

Objective

To determine the prevalence, characteristics, and communication of studies pending at hospital discharge before and after the implementation of an electronic medical record (EMR) tool that automatically generates a list of pending studies.

Design

Pre-post analysis.

Patients

260 consecutive patients discharged from inpatient general medicine services from July to August 2013.

Intervention

Development of an EMR-based tool that automatically generates a list of studies pending at discharge.

Main Measures

The main outcomes were prevalence and characteristics of pending studies and communication of studies pending at hospital discharge. We also surveyed internal medicine house staff on their attitudes about communication of pending studies.

Key Results

Pre-intervention, 70 % of patients had at least one pending study at discharge, but only 18 % of these were communicated in the discharge summary. Most studies were microbiology cultures (68 %), laboratory studies (16 %), or microbiology serologies (10 %). The majority of study results were ultimately normal (83 %), but 9 % were newly abnormal. Post-intervention, communication of studies pending increased to 43 % (p < 0.001).

Conclusions

Most patients are discharged from the hospital with pending studies, but in usual practice, the presence of these studies has rarely been communicated to outpatient providers in the discharge summary. Communication significantly increased with the implementation of an EMR-based tool that automatically generated a list of pending studies from the EMR and allowed users to import this list into the discharge summary. This is the first study to our knowledge to introduce an automated EMR-based tool to communicate pending studies.KEY WORDS: Applied informatics, Care transitions, Electronic health records, Continuity of care, Health information technology, Hospital medicine, Medical informatics, Patient safety, Quality improvement, Communication     

National hospital volume in acute pancreatitis: analysis of the Nationwide Inpatient Sample 1998–2006

Background:

The optimal management of acute pancreatitis remains controversial and current treatment protocols vary in degrees of medical and surgical management. Our group has previously shown in population-based studies that high-volume (HV) hospitals have lower rates of in-hospital mortality after pancreatectomy. We sought to examine if a similar mortality benefit exists for patients admitted with acute pancreatitis.

Methods:

Using the Nationwide Inpatient Sample (NIS), we examined discharge records for all adult admissions during 1998–2006 with a primary diagnosis of acute pancreatitis of any aetiology. Unique hospital identifiers were used to divide hospital volumes into equal thirds based on the number of admissions for acute pancreatitis per year (lowest tertile [low volume, LV]≤64 admissions/year; medium tertile [medium volume, MV] 65–117 admissions/year; highest tertile [high volume, HV]≥118 admissions/year). Covariates included patient demographics, hospital characteristics and patient co-morbidities using the Elixhauser index. Adjusted mortality represented the primary outcome measure and adjusted length of stay (LOS) and total charges were considered secondary measures.

Results:

There were 416 489 primary admissions for acute pancreatitis during the study period. In-hospital mortality for the cohort amounted to 1.6% (n= 6446). Hospital admissions for acute pancreatitis increased over the study period (P < 0.0001). High-volume hospitals tended to be large (82%), urban (99%) teaching (59%) centres (P < 0.0001), which cared for patients with more co-morbidities (35.9% of patients at HV hospitals vs. 29.1% at LV hospitals had at least three co-morbidities; P < 0.0001). Low-volume centres appeared more likely to perform pancreatic procedures than HV hospitals (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.32–1.70). Patients at HV hospitals had a lower likelihood of a prolonged adjusted LOS compared with those at LV (OR 0.75, 95% CI 0.71–0.79) or MV (OR 0.82, 95% CI 0.79–0.85) hospitals. After adjusting for patient and hospital factors, there was an in-hospital mortality benefit associated with being treated at an HV centre (OR 0.70, 95% CI 0.63–0.77). The decision to operate on a given patient did not alter the mortality benefit of the HV hospital.

Conclusions:

Rates of admissions for acute pancreatitis in the USA are increasing. High annual hospital volume of acute pancreatitis cases confers a shorter LOS, lower adjusted mortality and a lower likelihood of pancreatic procedure for patients admitted with acute pancreatitis. Although HV hospitals were less likely than MV or LV centres to perform pancreatic procedures, the role of surgery remains unclear. Further studies should examine other possible reasons for this mortality benefit, such as the availability of specialists, the quality of critical care facilities and the timing of operative intervention.     

Variation in Inpatient Consultation Among Older Adults in the United States

BACKGROUND

Differences among hospitals in the use of inpatient consultation may contribute to variation in outcomes and costs for hospitalized patients, but basic epidemiologic data on consultations nationally are lacking.

OBJECTIVE

The purpose of the study was to identify physician, hospital, and geographic factors that explain variation in rates of inpatient consultation.

DESIGN

This was a retrospective observational study.

SETTING AND PARTICIPANTS

This work included 3,118,080 admissions of Medicare patients to 4,501 U.S. hospitals in 2009 and 2010.

MAIN MEASURES

The primary outcome measured was number of consultations conducted during the hospitalization, summarized at the hospital level as the number of consultations per 1,000 Medicare admissions, or “consultation density.”

KEY RESULTS

Consultations occurred 2.6 times per admission on average. Among non-critical access hospitals, use of consultation varied 3.6-fold across quintiles of hospitals (933 versus 3,390 consultations per 1,000 admissions, lowest versus highest quintiles, p < 0.001). Sicker patients received greater intensity of consultation (rate ratio [RR] 1.18, 95 % CI 1.17–1.18 for patients admitted to ICU; and RR 1.19, 95 % CI 1.18–1.20 for patients who died). However, even after controlling for patient-level factors, hospital characteristics also predicted differences in rates of consultation. For example, hospital size (large versus small, RR 1.31, 95 % CI 1.25–1.37), rural location (rural versus urban, RR 0.78, CI 95 % 0.76–0.80), ownership status (public versus not-for-profit, RR 0.94, 95 % CI 0.91–0.97), and geographic quadrant (Northeast versus West, RR 1.17, 95 % CI 1.12–1.21) all influenced the intensity of consultation use.

CONCLUSIONS

Hospitals exhibit marked variation in the number of consultations per admission in ways not fully explained by patient characteristics. Hospital “consultation density” may constitute an important focus for monitoring resource use for hospitals or health systems.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3216-7) contains supplementary material, which is available to authorized users.KEY WORDS: consultation, hospital care, variation, medicare     

Hospital Evaluations by Social Media: A Comparative Analysis of Facebook Ratings among Performance Outliers

BACKGROUND

An increasing number of hospitals and health systems utilize social media to allow users to provide feedback and ratings. The correlation between ratings on social media and more conventional hospital quality metrics remains largely unclear, raising concern that healthcare consumers may make decisions on inaccurate or inappropriate information regarding quality.

OBJECTIVES

The purpose of this study was to examine the extent to which hospitals utilize social media and whether user-generated metrics on Facebook^® correlate with a Hospital Compare^® metric, specifically 30-day all cause unplanned hospital readmission rates.

DESIGN AND PARTICIPANTS

This was a retrospective cross-sectional study conducted among all U.S. hospitals performing outside the confidence interval for the national average on 30-day hospital readmission rates as reported on Hospital Compare. Participants were 315 hospitals performing better than U.S. national rate on 30-day readmissions and 364 hospitals performing worse than the U.S. national rate.

MAIN MEASURES

The study analyzed ratings of hospitals on Facebook’s five-star rating scale, 30-day readmission rates, and hospital characteristics including beds, teaching status, urban vs. rural location, and ownership type.

KEY RESULTS

Hospitals performing better than the national average on 30-day readmissions were more likely to use Facebook than lower-performing hospitals (93.3 % vs. 83.5 %; p < 0.01). The average rating for hospitals with low readmission rates (4.15 ± 0.31) was higher than that for hospitals with higher readmission rates (4.05 ± 0.41, p < 0.01). Major teaching hospitals were 14.3 times more likely to be in the high readmission rate group. A one-star increase in Facebook rating was associated with increased odds of the hospital belonging to the low readmission rate group by a factor of 5.0 (CI: 2.6–10.3, p <  0.01), when controlling for hospital characteristics and Facebook-related variables.

CONCLUSIONS

Hospitals with lower rates of 30-day hospital-wide unplanned readmissions have higher ratings on Facebook than hospitals with higher readmission rates. These findings add strength to the concept that aggregate measures of patient satisfaction on social media correlate with more traditionally accepted measures of hospital quality.KEY WORDS: Performance measurement, Patient satisfaction, Consumer health informatics     

An Inpatient Treatment and Discharge Planning Protocol for Alcohol Dependence: Efficacy in Reducing 30-Day Readmissions and Emergency Department Visits

BACKGROUND

Alcohol dependence results in multiple hospital readmissions, but no discharge planning protocol has been studied to improve outcomes. The inpatient setting is a frequently missed opportunity to discuss treatment of alcohol dependence and initiate medication-assisted treatment, which is effective yet rarely utilized.

AIM

Our aim was to implement and evaluate a discharge planning protocol for patients admitted with alcohol dependence.

SETTING

The study took place at the San Francisco General Hospital (SFGH), a university-affiliated, large urban county hospital.

PARTICIPANTS

Learner participants included Internal Medicine residents at the University of California, San Francisco (UCSF) who staff the teaching service at SFGH. Patient participants included inpatients with alcohol dependence admitted to the Internal Medicine teaching service.

PROGRAM DESCRIPTION

We developed and implemented a discharge planning protocol for patients admitted with alcohol dependence that included eligibility assessment and initiation of medication-assisted treatment.

PROGRAM EVALUATION

Rates of medication-assisted treatment increased from 0 % to 64 % (p value < 0.001). All-cause 30-day readmission rates to SFGH decreased from 23.4 % to 8.2 % (p value = 0.042). All-cause emergency department visits to SFGH within 30 days of discharge decreased from 18.8 % to 6.1 % (p value = 0.056).

DISCUSSION

Through implementation of a discharge planning protocol by Internal Medicine residents for patients admitted with alcohol dependence, there was a statistically significant increase in medication-assisted treatment and a statistically significant decrease in both 30-day readmission rates and emergency department visits.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-2968-9) contains supplementary material, which is available to authorized users.KEY WORDS: alcoholism and addictive behavior, care transitions, medical student and residency education, substance abuse, medical education-clinical skills training     

Status of tuberculosis infection control programs in Canadian acute care hospitals, 1989 to 1993 �C Part 1

OBJECTIVE:

To document tuberculosis (TB) prevention and control activities in Canadian acute care hospitals from 1989 to 1993.

DESIGN:

Retrospective questionnaire.

PARTICIPANTS:

All members of the Community and Hospital Infection Control Association-Canada and l’Association des professionnels pour la prévention des infections who lived in Canada and worked in an acute care hospital received a questionnaire. One questionnaire per hospital was completed.

OUTCOME:

The study documented the number of respiratory TB cases admitted to the hospital, the type of engineering and environmental controls available, and the type of occupational tuberculin skin test (TST) screening programs offered by the hospital.

RESULTS:

Questionnaires were received from 319 hospitals. Ninety-nine (32%) hospitals did not admit a respiratory TB case during the study. Thirty-one (10%) hospitals averaged six or more TB cases per year. TST results were reported for 47,181 health care workers, and 819 (1.7%) were reported as TST converters; physicians had a significantly higher TST conversion rate than other occupational groups. Most hospitals did not have isolation rooms with air exhausted outside the building, negative air pressure and six or more air changes per hour. Surgical masks were used as respiratory protection by 74% of staff.

CONCLUSIONS:

Canadian hospitals can expect to admit TB patients. Participating hospitals did not meet TB engineering or environmental recommendations published in 1990 and 1991. In addition, occupational TB screening programs in 1989 to 1993 did not meet Canadian recommendations published in 1988.