Retrospective cross‐sectional pilot study of rifaximin dosing for the prevention of recurrent hepatic encephalopathy

Standard treatment for hepatic encephalopathy (HE) includes medications that reduce ammonia and bacterial translocation in the gut. Rifaximin can be used off‐label for the reduction of overt HE. The study purpose was to determine efficacy of traditional rifaximin dosing (400 mg three times daily) compared with newer dosing (550 mg twice daily) via readmission rates for the prevention of recurrent HE. This was a retrospective, observational, cross‐sectional pilot study conducted in a tertiary medical center. A total of 226 patients 18–89 years of age with documentation of HE via ICD‐9 code who started rifaximin therapy while inpatient between April 2009 and June 2014 were evaluated. Data collected included rifaximin dosing, other medications used to treat HE, duration of therapy, time to readmission, and various laboratory values. There were no differences in readmission rates at 30 days, 60 days, or 6 months between treatment groups. Additionally, there was no difference in the odds of readmission between the treatment groups (OR = 0.77, 95% CI: [0.201, 4.365], P = 0.718). Patients had a low overall probability of readmission over the observational period. Based on average wholesale price data, the cost for a 9‐day supply of rifaximin for the 400‐mg dosing regimen is $952.56 versus $605.16 for the 550‐mg dosing regimen. The rifaximin 550‐mg dosing strategy should be utilized in hospitalized patients for the prevention of recurrent HE as there was no difference in readmission rate or time to readmission between dosing groups. The 550‐mg regimen had a lower acquisition cost for a 9‐day duration of treatment in the studied institution.     

Nutritional status: its influence on the outcome of patients undergoing liver transplantation

Background: Malnutrition is frequently present in case of end‐stage liver diseases, and in cirrhotic patients, a poor nutritional status is considered to be one of the predictive factors for increased morbidity and mortality rates after surgery. The impact of the recipients' malnutrition on the outcome of liver transplantation (LT) is still under debate and recent studies have shown controversial results. Patients and methods: We prospectively analysed the nutritional status of 38 consecutive patients undergoing LT in our University Hospital. Subjective global nutritional assessments (SGA) and anthropometry were used for the evaluation of the nutritional status. Energy expenditure, dietary intake and energy balance were also evaluated. After LT, multiple short‐term outcomes that could be influenced by the nutritional status, such as number of episodes of infections (bacterial, viral and fungal) until discharge from hospital, length of stay in intensive care unit (ICU), length of hospital stay and in‐hospital graft and patient's survival, were recorded. Results: Malnutrition was identified in 53% of cases according to the SGA. Pretransplant nutritional status, haemoglobin levels and disease severity were independently associated with the number of infection episodes during the hospital stay. The presence of malnutrition was the only independent risk factor for the length of stay in the ICU and the total number of days spent in hospital. Conclusion: The present data suggest that recipients' malnutrition should be taken into account as a factor that increases complications and costs after LT.     

Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals

Abstract Aims: The objectives of the present study were to determine: (i) the prevalence of malnutrition in two Sydney teaching hospitals using Subjective Global Assessment (SGA), (ii) the effect of malnutrition on 12‐month mortality and (iii) the proportion of patients previously identified to be at nutritional risk. Methods: A prospective study using SGA to assess nutritional status of eligible inpatients, from April to September 1997, with a 12‐month follow‐up to assess mortality. A total of 819 patients was systematically selected from 2194 eligible patients. Patients were excluded if they were under the age of 18, had dementia or communication difficulties, or were under obstetric or critical care. The main outcome measures were prevalence of malnutrition, 12‐month incidence of mortality, proportion of patients identified with malnutrition, and hospital length of stay (LOS). Results: The prevalence rate of malnutrition was 36%. The proportion of malnourished patients was not significantly different between the two hospitals (P = 0.4). The actuarial incidence of mortality at 12 months after assessment was 29.7% in malnourished subjects compared with 10.1% in well‐nourished subjects (P < 0.0005). Malnourished subjects had a significantly longer median LOS (17 days vs 11 days, P < 0.0005) and were significantly older (median 71 years vs 63 years, P < 0.0005) than well‐nourished subjects. Only 36% of the malnourished patients had been previously identified as being at nutritional risk. Conclusions: Malnutrition in Australian hospitals is a continuing health concern and is associated with increased LOS and decreased survival after 12 months. The present study revealed that malnourished patients were not regularly identified. Further studies are required to determine whether routine identification of malnutrition and subsequent nutritional intervention are effective in improving clinical outcomes in these individuals. (Intern Med J 2001; 31: 455–461)     

Racial/ethnic and socioeconomic variations in hospital length of stay: A state-based analysis

Disparities by race/ethnicity and socioeconomic status (SES) exist in rehospitalization rates and inpatient mortality rates. Few studies have examined how length of stay (LOS, a measure of hospital efficiency/quality) differs by race/ethnicity and SES.This study''s objective was to determine whether differences in risk-adjusted LOS exist by race/ethnicity and SESUsing a retrospective cohort of 1,432,683 medical and surgical discharges, we compared risk-adjusted LOS, in days, by race/ ethnicity and SES (median household income by patient ZIP code in quartiles), using generalized linear models controlling for demographic and clinical factors, and differences between hospitals and between diagnoses.White patients were on average older than both Black and Hispanic patients, had more chronic conditions, and had a higher inpatient mortality risk. In adjusted analyses, Black patients had a significantly longer LOS than White patients (0.25-day difference when discharged to home and 0.23-day difference when discharged to non-home destinations, both P<.001); there was no difference between Hispanic and White patients. Wealthier patients had a shorter LOS than poorer patients (0.16-day difference when discharged to home and 0.06-day difference when discharged to nonhome destinations, both P<.001). These differences by race/ethnicity reversed for Medicaid patients.Disparities in LOS exist based on a patient''s race/ethnicity and SES. Black and poorer patients, but not Hispanic patients, have longer LOS compared to White and wealthier patients. In aggregate, these differences may be related to trust and implicit bias and have implications for use of LOS as a quality metric. Future research should examine the drivers of these disparities.     

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.     

高钠血症对神经重症患者的影响

目的探讨高钠血症在神经重症患者中的发生率,及其对住院患者病死率、住院时间和住院费用的影响。方法回顾性分析2011年1¹2月本院收治的神经ICU重症患者274例,死亡52例,存活222例。将血清钠>150mmol/L定义为高钠血症,并进行统计学分析。结果死亡患者中高钠血症26例,存活患者23例,两者比较差异有统计学意义(50.0%vs 10.4%,P=0.000)。高钠血症是神经重症患者死亡的独立风险因素(OR=5.08,95%CI:2.2112月本院收治的神经ICU重症患者274例,死亡52例,存活222例。将血清钠>150mmol/L定义为高钠血症,并进行统计学分析。结果死亡患者中高钠血症26例,存活患者23例,两者比较差异有统计学意义(50.0%vs 10.4%,P=0.000)。高钠血症是神经重症患者死亡的独立风险因素(OR=5.08,95%CI:2.21¹1.63,P=0.000)。高钠血症患者与住院费用呈正相关,但差异无统计学意义(β=0.023,P=0.756);高钠血症患者与住院天数呈正相关,差异无统计学意义(β=0.094,P=0.200)。结论高钠血症在神经重症患者中具有更高的发生率,而且是神经重症患者死亡的独立风险因素,且与患者住院时间与住院费用呈正相关。     

In-hospital mortality and length of stay of patients with hypertensive crisis treated at public hospitals in Harari Regional State,Eastern Ethiopia

Hypertensive crisis poses substantial cardiovascular morbidity and mortality. This study aimed to assess in-hospital mortality, length of stay (LOS), and their predictors among patients with hypertensive crisis treated at public hospitals in Harari Regional State, Eastern Ethiopia. An institutional-based retrospective cohort study was conducted from October 1 to 31, 2022. The medical records of 328 patients with hypertensive crisis treated at two public hospitals between September 1, 2017 and August 31, 2022 were reviewed. Cox proportional hazards regression and negative binomial regression were used to identify predictors of in-hospital mortality and LOS, respectively. The in-hospital mortality rate of patients with hypertensive crisis was 18.94 (95% confidence interval (CI): 12.08–29.70) per 1000 person-day observation. The median (interquartile range) LOS of these patients was 10 (4–120) hours. Age ≥65 years (adjusted hazard ratio (AHR): 3.30; 95% CI: 1.17– 9.33); increment in initial systolic blood pressure (AHR: 1.040; 95% CI: 1.014–1.066); and having acute brain-related damage (AHR: 4.02; 95% CI: 1.48–10.88) were predictors of in-hospital mortality. Rural residence (adjusted incident-rate ratio (IRR): 1.34; 95% CI: 1.03–1.75); having a history of medication discontinuation (adjusted IRR: 1.59; 95% CI: 1.16–2.18); comorbidity (adjusted IRR: 1.90; 95% CI: 1.49–2.43); acute brain-related damage (adjusted IRR: 13.32; 95% CI: 9.22–19.24), acute cardiac-related damage (adjusted IRR: 7.40; 95% CI: 4.90–11.16); and acute kidney injury (adjusted IRR: 7.64; 95% CI: 5.46–10.69) were predictors of LOS. Thus, it is necessary to develop strategies that allow early screening and follow-up of patients at risk.     

The effect of English language proficiency on length of stay and in-hospital mortality

BACKGROUND: In ambulatory care settings, patients with limited English proficiency receive lower quality of care. Limited information is available describing outcomes for inpatients. OBJECTIVE: To investigate the effect of English proficiency on length of stay (LOS) and in-hospital mortality. DESIGN: Retrospective analysis of administrative data at 3 tertiary care teaching hospitals (University Health Network) in Toronto, Canada. PARTICIPANTS: Consecutive inpatient admissions from April 1993 to December 1999 were analyzed for LOS differences first by looking at 23 medical and surgical conditions (59,547 records) and then by a meta-analysis of 220 case mix groups (189,119 records). We performed a similar analysis for in-hospital mortality. MEASUREMENTS: LOS and odds of in-hospital death for limited English-proficient (LEP) patients relative to English-proficient (EP) patients. RESULTS: LEP patients stayed in hospital longer for 7 of 23 conditions (unstable coronary syndromes and chest pain, coronary artery bypass grafting, stroke, craniotomy procedures, diabetes mellitus, major intestinal and rectal procedures, and elective hip replacement), with LOS differences ranging from approximately 0.7 to 4.3 days. A meta-analysis using all admission data demonstrated that LEP patients stayed 6% (approximately 0.5 days) longer overall than EP patients (95% confidence interval, 0.04 to 0.07). LEP patients were not at increased risk of in-hospital death (relative odds, 1.0; 95% confidence interval, 0.9 to 1.1). CONCLUSIONS: Patients with limited English proficiency have longer hospital stays for some medical and surgical conditions. Limited English proficiency does not affect in-hospital mortality. The effect of communication barriers on outcomes of care in the inpatient setting requires further exploration, particularly for selected conditions in which length of stay is significantly prolonged.     

Emergency department admissions,older people,functional decline,and length of stay in hospital

Objective: Early identification of patients at risk of a prolonged admission to the hospital may allow targeted management decisions and discharge planning to begin in the emergency department. The aim of this study was to evaluate the effect of recent decline in function, measured in the emergency department, on length of stay (LOS) in the hospital. Methods: A total of 469 patients with a mean age of 79.4 years presenting to the emergency department of a tertiary hospital were comprehensively assessed by a nurse practitioner. The Modified Barthel Index (MBI) was used to measure recent decline in function (MBI‐change, the decline in MBI in the month before the emergency visit). Other measures included recent decline in instrumental activities of daily living (IADL‐change, using the Lawton IADL Scale), Folstein Mini Mental State Examination, Geriatric Depression Scale (GDS), Waterlow Scale, Social Support Instrument (SSI), principal medical diagnosis, living arrangement, care needs, and self‐rated health. Using multivariate survival analysis, the influence of MBI‐change on LOS was modelled in 249 randomly selected patients, and validated in the remaining 220. Results: In total, 327 patients (69.7%) were admitted to the hospital, for a median LOS of 10 days. In the modelling sample, variables significantly associated with LOS included MBI‐change (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.85–0.98), IADL‐change (HR 1.14, 95% CI 1.02–1.28), whether known to the Aged Care Assessment Team (ACAT) (HR 1.65, 95% CI 1.04–2.59) and Waterlow score (HR 0.95, 95% CI 0.90–0.99). MBI‐change (HR 0.94, 95% CI 0.88–0.99) and Waterlow score (HR 0.95, 95% CI 0.91–0.99) were also significant predictors of LOS in the validation sample. Conclusions: Recent decline in function predicts LOS in the hospital, is easy to measure in the emergency department, and may prove useful across the full spectrum of disease. It should be considered when formulating diagnostic and management plans, and when developing funding models.     

Impact of COVID-19 pandemic on emergency department length of stay and clinical outcomes of patients with severe pneumonia: A single-center observational study

We examined the impact of COVID-19 pandemic on the emergency department length of stay (EDLOS) and clinical outcomes of patients with severe pneumonia admitted to the intensive care unit (ICU) through the emergency department (ED). This single-center retrospective observational study included adult patients with pneumonia admitted to the ICU through the ED between January and December 2019 (pre-pandemic) and between March 2020 and February 2021 (during-pandemic). We compared and analyzed the EDLOS by dividing it into pre-, mid-, and post-EDLOS and in-hospital mortality of patients with pneumonia admitted to the ICU according to the time of ED visits before and during the COVID-19 pandemic. Risk factors for in-hospital mortality according to the time of ED visits were analyzed using multiple logistic regression analysis. In total, 227 patients (73 patients pre-pandemic and 154 patients during the pandemic) with pneumonia admitted to the ICU through the ED were analyzed. During the COVID-19 pandemic, pre-, mid-, and post-EDLOS increased (P < .05), and the in-hospital mortality rate increased by 10.4%; however, this was not significant (P = .155). Multivariate logistic regression analysis revealed post-EDLOS (ED waiting time after making ICU admission decision) as an independent risk factor for in-hospital mortality of patients with pneumonia admitted to the ICU, pre-pandemic (odds ratio [OR] = 2.282, 95% confidence interval [CI]: 1.367–3.807, P = .002) and during the pandemic (OR = 1.126, 95% CI: 1.002–1.266, P = .047). Mid-EDLOS (ED time to assess, care, and ICU admission decision) was an independent risk factor for in-hospital mortality of patients with pneumonia admitted to the ICU during the COVID-19 pandemic (OR = 1.835, 95% CI: 1.089–3.092, P = .023). During the pandemic of emerging respiratory infectious diseases, to reduce in-hospital mortality of severe pneumonia patients, it is necessary to shorten the ED waiting time for admission by increasing the number of isolation ICU beds. It is also necessary to accelerate the assessment and care process in the ED, and make prompt decisions regarding admission to the ICU.     

Impact of varying wave periods of COVID‐19 on in‐hospital mortality and length of stay for admission through emergency department: A territory‐wide observational cohort study

BackgroundThe COVID‐19 pandemic has been associated with excess mortality and reduced emergency department attendance. However, the effect of varying wave periods of COVID‐19 on in‐hospital mortality and length of stay (LOS) for non‐COVID disease for non‐COVID diseases remains unexplored.MethodsWe examined a territory‐wide observational cohort of 563,680 emergency admissions between January 1 and November 30, 2020, and 709,583 emergency admissions during the same 2019 period in Hong Kong, China. Differences in 28‐day in‐hospital mortality risk and LOS due to COVID‐19 were evaluated.ResultsThe cumulative incidence of 28‐day in‐hospital mortality increased overall from 2.9% in 2019 to 3.6% in 2020 (adjusted hazard ratio [aHR] = 1.22, 95% CI 1.20 to 1.25). The aHR was higher among patients with lower respiratory tract infection (aHR: 1.30 95% CI 1.26 to 1.34), airway disease (aHR: 1.35 95% CI 1.22 to 1.49), and mental disorders (aHR: 1.26 95% CI 1.15 to 1.37). Mortality risk in the first‐ and third‐wave periods was significantly greater than that in the inter‐wave period (p‐interaction < 0.001). The overall average LOS in the pandemic year was significantly shorter than that in 2019 (Mean difference = −0.40 days; 95% CI −0.43 to −0.36). Patients with mental disorders and cerebrovascular disease in 2020 had a 3.91‐day and 2.78‐day shorter LOS than those in 2019, respectively.ConclusionsIncreased risk of in‐hospital deaths was observed overall and by all major subgroups of disease during the pandemic period. Together with significantly reduced LOS for patients with mental disorders and cerebrovascular disease, this study shows the spillover effect of the COVID‐19 pandemic.     

Simple clinical score is associated with mortality and length of stay of acute general medical admissions to an Australian hospital

Background: In a rural Irish hospital, a simple clinical score (SCS) determined at the time of admission enabled stratification of acute general medical admissions into five categories that were associated incrementally with patients' immediate and 30‐day mortality. The aim of this study was to examine the representative performance of this SCS in predicting the outcomes of general medical admissions to an Australian teaching hospital. Methods: A retrospective chart review was undertaken of a representative sample from 480 admissions in 2007 to an urban university teaching hospital in Australia. The SCS was calculated and related to that patient's outcome in terms of mortality, length of stay, nursing home placement on discharge, the occurrence of medical emergency team call and intensive care unit transfer. These data were compared, where possible, with the outcomes reported in the Irish hospital. Results: Four hundred and seventeen complete sets of data allowed calculation of the SCS. There were significant linear correlations of the SCS (divided into quintiles) and patients' in‐hospital and 30‐day mortality, their length of stay and their discharge to a nursing home. There was no association of the SCS and the patients' readmission rate, intensive care unit transfer rate or likelihood of a medical emergency team call. The significant trends replicated those from the Irish hospital. Conclusion: The SCS can predict significant outcomes for general medical admissions in an Australian hospital despite obvious differences to the hospital of its derivation. A wider study of Australasian hospitals and the performance of the SCS as a predictor of general medical admission outcomes is underway.     

The effect of emergency department delay on outcome in critically ill medical patients: evaluation using hospital mortality and quality of life at 6 months

OBJECTIVE: To assess the impact of delay in emergency department (ED) on outcome of critically ill patients admitted to the medical intensive care unit (MICU). Outcome was defined as hospital mortality and as health-related quality of life (HRQoL) at 6 months after intensive care assessed by the 15D measure. The 15D is a generic, 15-dimensional, standardized measure of HRQoL. We hypothesized that prolonged stay in the ED is related to worse outcome. DESIGN AND SETTING: A prospective follow-up cohort study in university hospital. SUBJECTS: All consecutive 1675 patients admitted to the MICU between July 2002 and June 2004. RESULTS: The 15D questionnaire was mailed to all patients alive at 6 months after admission. Of all MICU patients, 64% were admitted from ED. The mean length of stay in the ED was 6.2 h (95%CI 5.9-6.5 h). The hospital mortality rate was 24.4% (20.0% in the ED vs. 33.0% in the non-ED cohort, P < 0.001) and it was associated with higher age and degree of physiological derangement at admission. Neither the length of ED stay was associated with hospital mortality (P = 0.82) nor with HRQoL at 6 months after MICU admission (P = 0.34). Altogether, HRQoL at 6 months was significantly lower compared with the age- and sex-matched general population (P < 0.001). CONCLUSIONS: In a university hospital, the length of ED stay was not associated with the outcome of critically ill medical patients. However, we feel that the effect of ED treatment and delay on outcome and outcome prediction in the critically ill patients deserves further evaluation.     

Burden of mental illness on hospital and patient outcomes among asthma hospitalizations

Objective: Empirical evidence demonstrates the comorbidity of asthma and mental illness, though limited studies have evaluated the patient and hospital outcomes associated with such conditions. As such, this study evaluated the burden of this comorbidity on health resource utilization and patient disposition among asthma hospitalizations. Methods: A secondary analysis of the Nationwide Inpatient Sample (2009–2011) was conducted, with study population of asthma hospitalizations limited to those 18 years of age and older. International Classification of Disease, 9th Revision, Clinical Modification codes were utilized to identify asthma and mental illness discharges. Length of stay was defined as number of days stayed in the hospital, total charges were inflation-adjusted, and patient disposition was defined as routine versus not routine. All analyses were survey-weighted and adjusted for patient and hospital characteristics. Results: Approximately 29% of the asthma hospitalizations reported mental illness. Any mental illness was associated with increased length of stay in the hospital (10% increase), total costs (11% increase), and lower odds of routine disposition (21% decrease). Substance-related disorder also increased length of stay in the hospital (4% increase), costs (9% increase), and lower odds of routine disposition (29% decrease). Age-stratified analyses further demonstrated similar trends among most age groups. Conclusion: The results of this study complement the extant literature by demonstrating the burden of the asthma-mental health nexus on health resource utilization and patient outcomes. The increased length of stay, cost, and decreased likelihood of routine disposition associated with mental illness highlight the need for integrated care to address mental illness as part of routine care.