Anaemia is highly prevalent among unselected internal medicine inpatients and is associated with increased mortality, earlier readmission and more prolonged hospital stay: an observational retrospective cohort study

Background: Anaemia is associated with adverse outcomes in elderly community‐dwelling individuals, but this problem is less well characterised in the inpatient setting. Aims: To determine the prevalence of anaemia and its associations in a well‐defined cohort of internal medicine inpatients. Methods: A retrospective cohort study of non‐elective admissions under internal medicine at Palmerston North Hospital, New Zealand, was conducted for 4 months of 2008 with outcome analysis on 1 March 2010. Results: At admission, 497 of 1491 (33.3%) patients were anaemic by World Health Organization criteria (haemoglobin <130 g/L for males; <120 g/L for females). Anaemia was more prevalent in males (38.1%) than females (28.2%), P < 0.001, in patients aged 65 years or older (41%) than in those under 65 (21.3%), P < 0.001, in New Zealand Europeans (34.3%) than in Māori and people from the Pacific Islands (26.4%), P= 0.04, and in patients admitted primarily because of malignancy, endocrine/metabolic disease, infection, and acute coronary syndrome/congestive heart failure (P < 0.001). Anaemia was independently associated with increased length of hospital stay (7.3 days vs 5.1 days in non‐anaemic patients; P < 0.001), with mortality (P < 0.001) and unplanned hospital readmission (P < 0.001) during the follow‐up period. Anaemia was infrequently acknowledged or investigated. Secondary analysis using a haemoglobin threshold of 110 g/L showed similar results. Conclusions: Anaemia is highly prevalent among medical inpatients with variation because of gender, age, race and reason for admission. Anaemia independently predicts for prolonged hospital stay, increased mortality and shorter time to readmission, but is usually not documented or investigated in this setting.     

Audit of acute admissions of chronic obstructive pulmonary disease: inpatient management and outcome

Background: Despite the publication of several management guidelines for exacerbations of chronic obstructive pulmonary disease (COPD), there is little information on standards of care in clinical practice. The aim of this audit was to examine the assessment, management and outcome of COPD admissions to a secondary and tertiary referring New Zealand hospital during two different seasons. Compliance to current recommendations was examined and compared with the available international published work. Methods: All COPD‐related admissions to Waikato Hospital during the months of May and October 2004 were reviewed. Ninety‐four cases (from 84 patients) were audited. Results: General characteristics, clinical features and lung function tests were similar to that of other cohorts. Twenty‐three per cent of the admissions were Maori and the mean age of Maori admissions were significantly less than that of the non‐Maori admissions (57 and 72 years, respectively; P = 0.0001). The geometric mean length of stay was 3.4 days, which is significantly less than most other reported hospital lengths of stays related to exacerbations of COPD. Fifty‐five per cent of the cohort was admitted more than once to the hospital for COPD in the 12 months before the index admission. Thirteen per cent of all admissions received assisted ventilation. Overall 30‐day mortality was 8% and the 12‐month mortality was 31%. Decreased body mass index was a risk factor for death as was an increased CURB‐65 (confusion, urea, respiratory rate, blood pressure age) score – a simple bedside assessment score, which has previously been used to predict mortality in patients with community‐acquired pneumonia. Conclusion: This audit documented the general characteristics, assessment, management and outcome of the COPD admissions to a secondary New Zealand hospital. Further investigations into factors contributing to shorter length of stay and predictors of mortality are needed.     

Effect of an inpatient geriatric consultation team on functional outcome, mortality, institutionalization, and readmission rate in older adults with hip fracture: a controlled trial

OBJECTIVES: To evaluate the effect of an inpatient geriatric consultation team (IGCT) on end points of interest in people with hip fracture: length of stay, functional status, mortality, new nursing home admission, and hospital readmission. DESIGN: Controlled trial based on assignment by convenience. SETTING: Trauma ward in a university hospital. PARTICIPANTS: One hundred seventy‐one people with hip fracture aged 65 and older. INTERVENTION: Participants were assigned to a multidisciplinary geriatric intervention (n=94) or usual care (n=77) during hospitalization after hip fracture. MEASUREMENTS: End points were functional status, length of stay, mortality, new nursing home admission, and hospital readmission 6 weeks, 4 months, and 12 months after surgery. RESULTS: Mean length of stay was 11.1 ± 5.1 days in the intervention group and 12.4 ± 8.5 days in the control groups (P=.24). Complete adherence to IGCT recommendations was 56.8%. A significant benefit of intervention on functional status in univariate analyses (P=.02) 8 days after surgery disappeared in a linear mixed model. Participants with dementia had better functional status in a linear mixed model than those without (P=.03), but this effect was no longer significant after Bonferroni correction for multiple testing. After 6 weeks, 4 months, and 12 months, no between‐group differences could be documented for mortality, new nursing home admission, or readmission rate. CONCLUSION: This trial could not document functional benefits of an IGCT intervention in people with hip fracture. More research is needed to investigate whether a more‐intensive approach with more‐direct control over patient management, more‐specific recommendations, and more‐intense education would be effective.     

Bronchiectasis in indigenous and non‐indigenous residents of Australia and New Zealand

Background and objective

Bronchiectasis not associated with cystic fibrosis is an increasingly recognized chronic lung disease. In Oceania, indigenous populations experience a disproportionately high burden of disease. We aimed to describe the natural history of bronchiectasis and identify risk factors associated with premature mortality within a cohort of Aboriginal Australians, New Zealand Māori and Pacific Islanders, and non‐indigenous Australians and New Zealanders.

Methods

This was a retrospective cohort study of bronchiectasis patients aged >15 years at three hospitals: Alice Springs Hospital and Monash Medical Centre in Australia, and Middlemore Hospital in New Zealand. Data included demographics, ethnicity, sputum microbiology, radiology, spirometry, hospitalization and survival over 5 years of follow‐up.

Results

Aboriginal Australians were significantly younger and died at a significantly younger age than other groups. Age‐ and sex‐adjusted all‐cause mortality was higher for Aboriginal Australians (hazard ratio (HR): 3.9), and respiratory‐related mortality was higher for both Aboriginal Australians (HR: 4.3) and Māori and Pacific Islander people (HR: 1.7). Hospitalization was common: Aboriginal Australians had 2.9 admissions/person‐year and 16.9 days in hospital/person‐year. Despite Aboriginal Australians having poorer prognosis, calculation of the FACED score suggested milder disease in this group. Sputum microbiology varied with Aspergillus fumigatus more often isolated from non‐indigenous patients. Airflow obstruction was common (66.9%) but not invariable.

Conclusions

Bronchiectasis is not one disease. It has a significant impact on healthcare utilization and survival. Differences between populations are likely to relate to differing aetiologies and understanding the drivers of bronchiectasis in disadvantaged populations will be key.

     

Waiting times and prioritization for coronary artery bypass surgery in New Zealand.

OBJECTIVES: To review the New Zealand coronary artery bypass priority score instituted in May 1996, and specifically to determine whether it prioritizes patients at high risk of cardiac events while waiting. The New Zealand score is compared with the Ontario urgency rating score, and waiting times for surgery are compared with the maximum times recommended by the Ontario consensus panel. DESIGN: Retrospective review of patients accepted for isolated coronary artery bypass surgery between 1 January 1993 and 31 January 1996. SETTING: Green Lane Hospital, Auckland, New Zealand. MAIN OUTCOME MEASURES: Waiting time, cardiac death, myocardial infarction, and cardiac readmission. RESULTS: The median waiting times were five days for hospital cases (n = 721) and 146 days for out of hospital cases (n = 701). Of the latter group, 28% waited more than a year, 33% had their surgery expedited because of worsening symptoms, and 19% failed to meet the cut off point set by the New Zealand score for acceptance onto the list. Twenty two patients died, 18 on the outpatient waiting list (waiting list mortality 2.6%, risk 0.28% per month of waiting), and 132 were readmitted, 12% with myocardial infarction and 76% with unstable angina. Risk factors for a composite end point of death or myocardial infarction and/or cardiac readmission were: previous coronary artery bypass surgery (p = 0. 001), class III or IV angina (p = 0.002), and hypertension (p = 0. 005). The New Zealand score did not identify those at risk. Excluding hospital cases, 32% had surgery within the time recommended by the Ontario consensus panel. CONCLUSIONS: Waiting times for coronary artery bypass surgery in New Zealand are considerably longer than those in Ontario, Canada. By using a numerical cut off point, implementation of the New Zealand priority scoring system has restricted access to coronary surgery on the basis of funding constraints rather than clinical appropriateness. The score does not add greatly to the clinicians' prioritization in predicting those patients who will suffer events while waiting.     

Trends in three-year survival following acute myocardial infarction, 1983-1992.

AIMS: As part of an investigation into the decline in coronary heart disease mortality rates in New Zealand, we examined long-term survival trends following acute myocardial infarction. METHODS AND RESULTS: A 3-year follow-up of patients on a community-based register of coronary heart disease for the period 1983-1992 in Auckland, New Zealand, part of the World Health Organization's MONICA (multinational Monitoring of Trends and Determinants in Cardiovascular Disease) Project, has been completed. The 3-year survival status of acute myocardial infarction patients aged 25-64 years who were alive 28 days after their first event has been obtained. The 2940 men and women followed for 3 years after an acute myocardial infarction showed significant steady improvement over the 10-year study period (P=0.004). The 3-year survival of patients registered in 1983-1984 was 86% and by 1991-1992 it was 92%. CONCLUSION: The gains in long-term survival following acute myocardial infarction are statistically significant but contribute only marginally to the decline in coronary heart disease death rates in Auckland since most deaths occur in the first 28 days after the event.     

Inflammatory Bowel Disease in Auckland, New Zealand

Abstract: Inflammatory bowel disease in Auckland, New Zealand . R. J. Eason, S. P. Lee and C. Tasman–Jones, Aust. N.Z. J. Med., 1982, 12, pp. 125–131.
Four–hundred–and–fifty–six patients with ulcerative colitis (UC) and 137 patients with Crohn's disease (CD) attended public hospitals within Auckland between 1969 and 1978. Polynesians comprised 15% of the population at risk but accounted for only 0–4% of UC cases and no CD cases. Annual incidence rates were 5–4/100,000 Caucasians for UC and 1–75 for CD. CD was significantly less common in Auckland than in European and North American centres. For patients presenting for the first time between 1969 and 1978, the cumulative probability of surviving 10 years was 93–9% for UC and 89–1% for CD. An excess of observed over expected mortality was limited to the first year of observation in UC and did not occur in CD. Clinical features and local complications of UC and CD have been correlated with the anatomic location of disease. In this first clinical study of inflammatory bowel disease in New Zealand, 61% of CD and 23% of UC patients required at least one surgical resection.     

Evaluation of a New Zealand program to improve transition of care for older high risk adults

Transition interventions aim to improve care and reduce hospital readmissions but evaluations of these interventions have reported inconsistent results. We report on the evaluation of an intervention implemented in Auckland, New Zealand. Participants were people over the age of 65 who had an acute medical admission and were at high risk of readmission. The intervention included an improved discharge process and nurse telephone follow‐up soon after discharge. Outcomes were 28 day readmission rates and emergency attendances. The study is observational, using both interrupted times series and regression discontinuity designs. 5239 patients were treated over a one year period. There was no change in readmission rates or ED attendances or secondary outcomes. Not all patients received all components of the intervention. This transition intervention was not successful. Possible reasons for this and implications are discussed. Although non‐experimental methods were used, we believe the results are robust.     

Does rhythm matter? The prognostic importance of atrial fibrillation in heart failure

BACKGROUND: Atrial fibrillation (AF) and congestive heart failure (HF) often coexist, but there is conflicting data regarding the association of AF with outcome in HF. To examine this further we have evaluated the prognostic effect of AF in two complementary CHF populations; a population based data set of 55,106 patients admitted to hospital with CHF, and a cohort of 197 patients recruited after a hospital admission with HF into a management clinical trial. METHODS: Firstly, data for all hospital admissions in New Zealand from 1988 to 1997 were obtained. Using coding data, 55,106 first admissions for HF were identified, the presence of AF was determined by secondary diagnosis coding, and all cause mortality was obtained. Secondly, patients enrolled in the Auckland Heart Failure Management Study were evaluated for the presence or absence of AF, and for all cause mortality at three years. RESULTS: Mortality at 30 days, 6 and 12 months was significantly lower for AF patients compared to sinus rhythm (SR) in the national admissions cohort. In the clinical trial cohort the presence of AF was also associated with lower three-year mortality, although this difference was not seen when the groups were stratified by Doppler mitral filling pattern (a restrictive filling pattern was associated with reduced longevity compared to SR, non-restrictive or AF). CONCLUSIONS: This data shows that the presence of AF in two general HF populations in New Zealand is not associated with an adverse prognosis. HF severity, and in particular a restrictive filling pattern, remain powerful predictors of mortality.     

Risk factors of hospitalization and readmission of patients with COPD exacerbation �C systematic review

Background:

Chronic obstructive lung disease (COPD) exacerbations are a significant cause of morbidity and mortality. Data regarding factors which causes or prevents exacerbations is very limited. The aim of this systematic review is to summarize the results from available studies to identify potential risk factors for hospital admission and/or re-admission among patients experiencing COPD exacerbations.

Methods:

We undertook a systematic review of the literature. Potential studies were identified by searching the electronic databases: PubMed, EMBASE, BIOSIS, CINAHL, PsycINFO, Cochrane library, reference lists in trial reports, and other relevant articles.

Results:

Seventeen articles that met the predefined inclusion criteria were identified. Heterogeneity of study designs, risk factors and outcomes restrict the result to only a systematic review and precluded a formal meta-analysis. In this review, three predictive factors: previous hospital admission, dyspnea and oral corticosteroids were all found to be significant risk factors of readmissions and variables including using long term oxygen therapy, having low health status or poor health related quality of life and not having routine physical activity were all associated with an increased risk of both admission and readmission to hospital.

Conclusions:

There are a number of potential modifiable factors that are independently associated with a higher risk of COPD exacerbation requiring admission/readmission to the hospital. Identifying these factors and the development of targeted interventions could potentially reduce the number and severity of such exacerbations.     

International comparison of the prevalence of asthma symptoms and bronchial hyperresponsiveness

Potential explanations for the higher rates of asthma mortality and hospital admissions in New Zealand (NZ) include greater prevalence of asthma. To evaluate this further, a large community survey has been undertaken. Rates of respiratory symptoms and bronchial hyperresponsiveness (BHR) for children in Auckland, NZ have been compared to those for children in two locations in New South Wales (NSW), Australia: Wagga Wagga (inland) and Belmont (coastal). The methodology used was the same in both studies: parent-completed questionnaire and BHR measured by response to an abbreviated histamine challenge. In Auckland, 1,084 children participated (84% of those selected) and were compared to 769 inland NSW and 718 coastal NSW children. The prevalence of respiratory symptoms, BHR, severity of BHR, and BHR combined with symptoms was similar among Auckland and inland NSW children but lower among coastal NSW children than those from the other two sites. It is concluded that other unidentified factors must be invoked to explain mortality and admission differences between these regions.     

Exploratory study of the ‘weekend effect’ for acute medical admissions to public hospitals in Queensland,Australia

Aims: To determine whether in‐hospital deaths of patients admitted through emergency departments with acute exacerbations of chronic obstructive pulmonary disease (COPD), acute myocardial infarction, intracerebral haemorrhage and acute hip fracture are increased by weekend versus weekday admission (the ‘weekend effect’). Methods: We performed a retrospective analysis of statewide administrative data from public hospitals in Queensland, Australia, during the 2002/2003–2006/2007 financial years. The primary outcome was 30‐day in‐hospital mortality. The secondary outcome of 2‐day in‐hospital mortality helped determine whether increased mortality of weekend admissions was closely linked to weekend medical care. Results: During the study period, there were 30 522 COPD, 17 910 acute myocardial infarction, 4183 acute hip fracture and 1781 intracerebral haemorrhage admissions. There was no significant weekend effect on 30‐day in‐hospital mortality for COPD (adjusted risk ratio = 0.92, 95% CI: 0.81–1.04, P= 0.222), intracerebral haemorrhage (adjusted risk ratio = 1.01, 95% CI: 0.86–1.16, P= 0.935) or acute hip fracture (adjusted risk ratio = 0.78, 95% CI: 0.54–1.03, P= 0.13). There was a significant weekend effect for acute myocardial infarction (adjusted risk ratio = 1.15, 95% CI: 1.03–1.26, P= 0.007). Two‐day in‐hospital mortality showed similar results. Conclusion: This is the first Australian study on the ‘weekend effect’ (in a cohort other than neonates), and the first study worldwide to assess specifically the weekend effect among COPD patients. Observed patterns were consistent with overseas research. There was a significant weekend effect for myocardial infarction. Further research is needed to determine whether location (e.g. rural), clinical (e.g. disease severity) and service provision factors (e.g. access to invasive procedures) influence the weekend effect for acute medical conditions in Australia.     

Hyponatremia and long-term mortality in survivors of acute ST-elevation myocardial infarction

BACKGROUND: Hyponatremia, a marker of neurohormonal activation, is a common electrolyte disorder among patients with acute ST-elevation myocardial infarction. The long-term prognostic value of hyponatremia during the acute phase of infarction is not known. METHODS: We studied 978 patients with acute ST-elevation myocardial infarction and without a history of heart failure who survived the index event. During the hospital stay, sodium levels were obtained on admission and at 24, 48, and 72 hours. The median duration of follow-up after hospital discharge was 31 months (range, 9-61 months). RESULTS: Hyponatremia, defined as a mean serum sodium level less than 136 mEq/L, was present during admission in 108 patients (11.0%). In a multivariable Cox proportional hazards model adjusting for other potential clinical predictors of mortality and for left ventricular ejection fraction, hyponatremia during admission remained an independent predictor of postdischarge death (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.3-3.2; P = .002). Hyponatremia during admission was also independently associated with postdischarge readmission for heart failure (HR, 1.6; 95% CI, 1.1-2.6; P = .04). When serum sodium level was used as a continuous variable, the adjusted HR for death or heart failure was 1.12 for every 1-mEq/L decrease (95% CI, 1.07-1.18; P<.001). CONCLUSION: Hyponatremia in the early phase of ST-elevation myocardial infarction is a predictor of long-term mortality and admission for heart failure after hospital discharge, independent of other clinical predictors of adverse outcome and left ventricular ejection fraction.     

U-shaped relationship between mortality and admission blood pressure in patients with acute stroke

Objective. To evaluate the relationship between systolic blood pressure (SBP) or diastolic blood pressure (DBP) on admission and early or late mortality in patients with acute stroke. Design. Prospective study of hospitalized first‐ever stroke patients over 8 years. Setting. Stroke unit and medical wards in a University hospital. Subjects. A total of 1121 patients admitted within 24 h from stroke onset and followed up for 12 months. Main outcome measures. Mortality at 1 and 12 months after stroke in relation to admission SBP and DBP. Results. Early and late mortality in patients with acute ischaemic or haemorrhagic stroke in relation to admission SBP and DBP followed a ‘U‐curve pattern’. After adjusting for known outcome predictors, the relative risk of 1‐month and 1‐year mortality associated with a 10‐mmHg SBP increase above 130 mmHg (U‐point of the curve) increased by 10.2% (95% CI: 4.2–16.6%) and 7.2% (95% CI: 2.2–12.3%), respectively. For every 10 mmHg SBP decrease, below the U‐point, the relative risk of 1‐month and 1‐year mortality rose by 28.2% (95% CI: 8.6–51.3%) and 17.5% (95% CI: 3.1–34.0%), respectively. Low admission SBP‐values were associated with heart failure (P < 0.001) and coronary artery disease (P = 0.006), whilst high values were associated with history of hypertension (P < 0.001) and lacunar stroke (P < 0.001). Death due to cerebral oedema was significantly (P = 0.005) more frequent in patients with high admission SBP‐values, whereas death due to cardiovascular disease was more frequent (P = 0.004) in patients with low admission SBP‐values. Conclusion. Acute ischaemic or haemorrhagic stroke patients with high and low admission BP‐values have a higher early and late mortality. Coincidence of heart disease is associated with low initial BP‐values. Death due to neurological damage from brain oedema is associated with high initial BP‐values.     

Readmission and survival following hospitalization for chronic obstructive pulmonary disease: long-term trends

Background: Exacerbations requiring hospital admission for chronic obstructive pulmonary disease (COPD) contribute to a decline in health status and are costly to the community. Long‐term trends in admissions and associated outcomes are difficult to establish because of frequent readmissions, high case fatality and potential diagnostic transfer between COPD and asthma. The Western Australian Data Linkage System provides a unique opportunity to examine admissions for patients with COPD over the long term. Method: Nineteen years of hospital morbidity data, based on International Classification of Diseases‐9 criteria were extracted from the Western Australian Data Linkage System (1980–1998) and merged with mortality records to examine trends in hospital admissions for COPD. Results: The rate of hospital admissions for COPD has declined overall and the rate of first presentation declined in men and remained constant in women. The risk of readmission increased throughout the period (P < 0.0001) and more than half of all admissions were followed by readmission within a year. Median survival following first admission was 6 years (men 5 years; women 8 years). Age, sex and International Classification of Diseases subcategory each showed an independent effect on the risk of mortality (P < 0.0001). The poorest survival was in patients subcategorized as emphysema. For patients with multiple admissions, the likelihood of cross‐over between COPD and asthma was high and increased with the total number of admissions. Conclusion: The rate of admission for COPD has declined in Western Australia; however, the resource burden will continue to increase because of the ageing population. This has policy implications for the development of acute care treatment programmes for COPD.     

Clinical outcomes in heart failure: report from a community hospital-based registry

PURPOSE: Most of the recent information on the prognosis of patients with heart failure has come from large clinical trials or tertiary care centers. This study reports current information from a community hospital-based heart failure registry. SUBJECTS AND METHODS: We compiled data from 2,906 unselected consecutive patients with heart failure who were admitted to 10 acute care community hospitals in New York State between 1995 and 1997. Patients were followed prospectively for 6 months after hospital discharge or until their death. RESULTS: The mean (+/- SI)) age of the sample was 76 +/- 11 years. The majority of the patients were women (56%) and most were white (95%). Hospital length of stay averaged 7.4 +/- 7.6 days; hospital charges averaged $7,460 +/- $6,114. Mortality during the index admission was 5%. Among the 2,508 patients for whom mortality or follow-up data were available, an additional 411 died during follow-up, for a cumulative 6-month mortality of 23%. Progressive pump failure was the predominant cause of death in the hospital and after discharge. Although mean functional class (on a 1 to 4 scale) improved from 3.4 +/- 0.7 at hospital admission to 2.3 +/- 0.9 at 1 month after discharge, 43% of patients had at least one hospital readmission during follow-up and 25% had at least one recurrent admission for heart failure. The mean time from index discharge to first rehospitalization was 60 +/- 56 days. In all, 55% of patients (1,370 of 2,508) were rehospitalized or died during the study period. CONCLUSIONS: Despite advances in the management of heart failure, patients recently hospitalized for this disorder remain at high risk of death, hospital readmission, and poor clinical outcome. Discovery or implementation of new or existing methods of prevention and treatment remain a high priority.     

Management and survival of patients admitted with an exacerbation of COPD: comparison of two Danish patient cohorts

Introduction: The aim of this study was to describe the management and prognosis related to a hospital admission for acute exacerbation of chronic obstructive pulmonary disease and to compare results to an earlier study. Objectives and Methods: This is a retrospective study of 300 consecutively discharged patients admitted in 2006–2007 with an exacerbation of chronic obstructive pulmonary disease from three respiratory departments. Data were collected from patient charts and compared with a replicate study done in 2001. Results: The mean age was 72.1 years; 61.7% were women. Mean forced expiratory volume in 1 s was 37.6% of predicted. On admission, 11.3% were treated with non‐invasive ventilation, and 84.3% were given systemic corticosteroids. In‐hospital mortality was 4.7%. At discharge, treatment with inhaled corticosteroids or at least one long‐acting bronchodilator was given to 86.7% and 89% of patients, respectively, which was significantly higher than for similarly sampled patients in 2001. Mortality in 30 days and 1 year after discharge was 4.5% and 25.5%, respectively, compared with 5.5% and 30.3% in 2001, the 12‐month mortality being significantly lower (P = 0.03). Readmission rate in the 12 months following discharge was 42.3%. Long‐term oxygen treatment, treatment with anti‐dysrhythmic drugs and lack of outpatient follow‐up were independent predictors of 1‐year mortality. Risk of readmission was increased with dependence in self‐care activities, previous admissions and treatment with strong analgesics. Conclusions: Over a period of 6 years, a significantly higher number of patients are being treated according to guidelines. Survival following discharge increased over the same period. Please cite this paper as: Eriksen N and Vestbo J. Management and survival of patients admitted with an exacerbation of COPD: comparison of two Danish patient cohorts. The Clinical Respiratory Journal 2010; 4: 208–214.     

Randomized trial of a nurse-administered, telephone-based disease management program for patients with heart failure

BACKGROUND: Heart failure is a common and important cause of morbidity and mortality. Disease management offers promise in reducing the need for hospitalization and improving quality of life for heart failure patients, but experimental data on the efficacy of such programs are limited. METHODS AND RESULTS: A total of 151 patients hospitalized with heart failure were randomized to usual care or scheduled telephone calls by specially trained nurses promoting self-management and guideline-based therapy as prescribed by primary physicians. Nurses also screened patients for heart failure exacerbations, which they managed with supplemental diuretics or by contacting the primary physician for instructions. Outcomes included time to hospital encounter, mortality, number and cost of hospitalizations, functional status, and satisfaction with care. Intervention patients had a longer time to encounter (hazard ratio [HR] = 0.67; 95% confidence interval [CI] 0.47-0.96; P = .029), hospital readmission (HR = 0.67; CI 0.46-0.99; P = .045), and heart failure-specific readmission (HR = 0.62; CI 0.38-1.03; P = .063). The number of admissions, hospital days, and hospital costs were significantly lower during the first 6 months after intervention but not at 1 year. The intervention had little effect on functional status, mortality, and satisfaction with care. CONCLUSION: A nurse-administered, telephone-based disease management program delayed subsequent health care encounters, but had minimal impact on other outcomes.     

Hospital readmissions after hospital discharge for hip fracture: surgical and nonsurgical causes and effect on outcomes

OBJECTIVES: To examine the causes of hospital readmission after hip fracture and the relationships between hospital readmission and 6-month physical function and mortality. DESIGN: Prospective, multisite, observational cohort study. SETTING: Four hospitals in the New York City metropolitan area. PARTICIPANTS: Five hundred sixty-two patients hospitalized for hip fracture aged 50 and older and discharged alive in 1997-1998. MEASUREMENTS: Patient demographic characteristics, type of fracture and repair, comorbid conditions, postoperative complications, do not resuscitate status, and active clinical problems at the time of hospital discharge. Prefracture and 6-month mobility were measured using the Functional Independence Measure. Hospital readmissions and International Classification of Diseases, Ninth Revision principal diagnoses were ascertained from hospital admission/discharge databases, the New York Statewide Planning and Research Cooperative System, medical record review, and patient self-report. RESULTS: Eighty-two percent of participants were women, and 93% were white. Within 6 months after hospital discharge, 178 (32%) patients were readmitted to the hospital, with 45 (8%) readmitted more than once. Forty-seven of 233 readmissions (20%) occurred within the first 2 weeks after discharge, and 80 (34%) occurred within 4 weeks. Over 6 months, 89% of readmissions were for nonsurgical problems, of which infectious (21%) and cardiac (12%) diseases were the most common. In multivariate analyses, patients who were readmitted were more likely to require total assistance with ambulation at 6 months (odds ratio (OR) = 2.7, 95% confidence interval (CI) = 1.6-4.6) and to die (OR = 4.0, 95% CI = 2.2-7.3) than those not readmitted. CONCLUSION: Hospital readmissions after hip fracture are largely due to nonsurgical illness and are associated with increased morbidity and mortality.