Declining length of stay for patients hospitalized with AMI: impact on mortality and readmissions

Background

Length of hospital stay after acute myocardial infarction decreased significantly in the 1980s and 1990s. Whether length of stay has continued to decrease during the 2000s, and the impact of decreasing length of stay on rehospitalization and mortality, is unclear. We describe decade-long (1995-2005) trends in length of stay after acute myocardial infarction, and examine whether declining length of stay has impacted early rehospitalization and postdischarge mortality in a population-based sample of hospitalized patients.

Methods

The study sample consisted of 4184 patients hospitalized with acute myocardial infarction in a central New England metropolitan area during 6 annual periods (1995, 1997, 1999, 2001, 2003, 2005).

Results

The average age of the study sample was 71 years, and 54% were men. The average length of stay decreased by nearly one third over the 10-year study period, from 7.2 days in 1995 to 5.0 days in 2005 (P <.001). Younger patients (<65 years), men, and patients with an uncomplicated hospital stay had significantly shorter lengths of stay than respective comparison groups. Lengths of stay shorter than the median were not associated with significantly higher odds of hospital readmission at 7 or 30 days postdischarge, or with mortality in the year after discharge. In contrast, longer lengths of stay were associated with significantly higher odds of short-term mortality. These findings did not vary by year under study.

Conclusions

Length of stay in patients hospitalized for acute myocardial infarction decreased significantly between 1995 and 2005. Declining length of stay is not associated with an increased risk for early readmission or all-cause mortality.     

Impact of guideline-concordant empiric antibiotic therapy in community-acquired pneumonia

Purpose

We evaluated the impact of guideline-concordant empiric antibiotic therapy on time to clinical stability, time to switch therapy, length of hospital stay, and mortality among patients with community-acquired pneumonia.

Methods

This is a retrospective cohort study of all adult community-acquired pneumonia patients managed at 5 community hospitals from November 1, 1999 to April 30, 2000. Patients were stratified into guideline-concordant and discordant groups as defined by the 2001 American Thoracic Society and the 2003 Infectious Diseases Society of America guidelines. Time to clinical stability, time to switch therapy, length of hospital stay, and in-hospital mortality were evaluated in per-protocol and intention-to-treat stepwise regression models that included the outcome as the dependent variable, guideline-concordant antibiotic therapy as the independent variable, and Pneumonia Severity Index score as a covariate.

Results

Of the 631 evaluable patients, 357 (57%) received guideline-concordant empiric antibiotic therapy. Groups were similar with respect to age, sex, comorbidities, severity of illness, and processes of care. Guideline-concordant antibiotic therapy was associated with a significant decrease in time to switch therapy (P ≤.01), length of hospital stay (P ≤.01), and in-hospital mortality (P = .04) for both per-protocol and intention-to-treat analyses. In addition, guideline-concordant antibiotic therapy was associated with a significant decrease in time to clinical stability for intention-to-treat analysis only (P = .03).

Conclusions

Among hospitalized community-acquired patients, guideline-concordant antibiotic therapy is associated with improved in-hospital survival and shorter time to clinical stability, time to switch therapy, and length of hospital stay.     

Low-risk patients admitted with community-acquired pneumonia

Purpose

To describe the natural history of community-acquired pneumonia in the subset of a large cohort of patients at low risk for mortality who were admitted to the hospital.

Methods

Prospective observational study of all patients at low risk for mortality (risk classes I and II) who presented to 6 hospitals and 1 emergency department in Edmonton, Alberta, Canada with a diagnosis of possible community-acquired pneumonia from November 15, 2000, to November 14, 2002.

Results

A total of 586/3065 (19.1%) low-risk patients (Fine criteria) were admitted, 48.4% of whom stayed more than 5 days. Multivariate analysis revealed that patients who were admitted were more likely to be female, to have presented at Site B, which serves an inner city population, to have diminished premorbid functional status, to have comorbidities likely to be made worse by pneumonia (chronic obstructive pulmonary disease, asthma, heart disease, inflammatory bowel disease), and to suffer from substance abuse or psychiatric illness. A respiratory rate of ≥28 breaths per minute, and symptoms of shaking chills, shortness of breath, nausea or diarrhea were the remaining factors predicting admission. Nineteen percent of the patients suffered one or more complications, the most serious of which was progression of the pneumonia, resulting in respiratory failure necessitating mechanical ventilation in 2.4% and empyema in 1.4%. Four patients had lung cancer, and 1 had cancer of the vocal cords. Thirty-one percent of those who were admitted were still unable to eat or drink enough to maintain hydration by hospital day 5 or on discharge day.

Conclusions

One in 5 patients at low risk for mortality were admitted to the hospital and half stayed more than 5 days; 19% suffered 1 or more complications. Our data emphasize the need for better rules to guide the admission decision and the importance of physician judgment in this decision.     

Depression and Clinical Outcomes in Heart Failure: An OPTIMIZE-HF Analysis

Background

Depression is a risk factor of excessive morbidity and mortality in heart failure. We examined in-hospital treatment and postdischarge outcomes in hospitalized heart failure patients with a documented history of depression from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure.

Methods

We identified patient factors associated with depression history and evaluated the association of depression with hospital treatments and mortality, and early postdischarge mortality, emergency care, and rehospitalization.

Results

In 48,612 patients from 259 hospitals, depression history was present in 10.6% and occurred more often in females, whites, and those with common heart failure comorbidities, including chronic pulmonary obstructive disease (36% vs 27%), anemia (27% vs 16.5%), insulin-dependent diabetes mellitus (20% vs 16%), and hyperlipidemia (38% vs 31%), all P <.001. Patients with depression history were less likely to receive coronary interventions and cardiac devices, all P <.01; or be referred to outpatient disease management programs, P <.001. Length of hospital stay was longer with depression history (7.0 vs 6.4 days, P <.001). In 5791 patients followed-up at 60-90 days postdischarge, those with depression history had higher mortality (8.8% vs 6.4%; P = .025). After multivariable modeling, depression history remained a predictor of length of hospital stay, P <.001 and postdischarge mortality, P = .02.

Conclusions

Depression history at heart failure hospitalization may be a predictor of prolonged length of hospital stay, less use of cardiac procedures and postdischarge disease management, and increased 60-90 day mortality. Patients with depression might represent a vulnerable group in which improved use of evidence-based treatment should be considered.     

In-hospital observation after antibiotic switch in pneumonia: a national evaluation

Purpose

To evaluate the clinical benefit of in-hospital observation after the switch from intravenous (IV) to oral antibiotics in a large Medicare population. Retrospective studies of relatively small size indicate that the practice of in-hospital observation after the switch from IV to oral antibiotics for patients hospitalized with community-acquired pneumonia (CAP) is unnecessary.

Methods

We performed a retrospective examination of the US Medicare National Pneumonia Project database. Eligible patients were discharged with an ICD-9-CM diagnosis consistent with community-acquired pneumonia and divided into 2 groups: 1) a “not observed” cohort, in which patients were discharged on the same day as the switch from IV to oral antibiotics and 2) an “observed for 1 day” cohort, in which patients remained hospitalized for 1 day after the switch from IV to oral antibiotics. We compared clinical outcomes between these 2 cohorts.

Results

A total of 39,242 cases were sampled, representing 4341 hospitals in all 50 states and the District of Columbia. There were 5248 elderly patients who fulfilled eligibility criteria involving a length of stay of no more than 7 hospital days (2536 “not observed” and 2712 “observed for 1 day” patients). Mean length of stay was 3.8 days for the “not observed” cohort and 4.5 days for the “observed for 1 day” cohort (P <.0001). There was no significant difference in 14-day hospital readmission rate (7.8% in the “not observed” cohort vs 7.2% “observed for 1 day” cohort, odds ratio 0.91; 95% confidence interval [CI] 0.74-1.12; P =.367) and 30-day mortality rate (5.1% “not observed” cohort vs 4.4% in the “observed for 1 day” cohort, odds ratio 0.86; 95% CI, 0.67-1.11; P =.258) between the “not observed” and “observed for 1 day” cohorts.

Conclusions

Our analysis of the US Medicare Pneumonia Project database provides further evidence that the routine practice of in-hospital observation after the switch from IV to oral antibiotics for patients with CAP may be avoided in patients who are clinically stable although these findings should be verified in a large randomized controlled trial.     

Admission Hypoglycemia and Increased Mortality in Patients Hospitalized with Pneumonia

Background

The relationship between spontaneous admission hypoglycemia and mortality in patients hospitalized with community-acquired pneumonia is unclear.

Methods

From 2000 to 2002, clinical data were prospectively collected on all patients with community-acquired pneumonia who were admitted to all 6 hospitals in Edmonton, Alberta, Canada. Patients with admission glucose greater than 6.1 mmol/L (n = 1996) were excluded; the remaining patients were categorized as having admission hypoglycemia (<4.0 mmol/L [n = 54]) or normoglycemia (4.0 to ≤ 6.1 mmol/L [n = 902]). Multivariable Cox proportional hazards models were used to examine the relationship between hypoglycemia and all-cause mortality in-hospital, at 30 days, and at 1 year.

Results

The mean age was 65 (standard deviation = 20) years, 48% were female, 8% had diabetes, and 56% had severe pneumonia. Overall, admission hypoglycemia was present in 2% (54/2990) of the entire cohort and 6% of those with glucose of 6.1 mmol/L or less. Total deaths were 89 (9%) in-hospital, 96 (10%) at 30 days, and 247 (26%) at 1 year. In-hospital mortality was higher among patients with admission hypoglycemia (11 [20%] deaths) compared with those with normoglycemia (78 [9%]; adjusted hazards ratio [aHR] 2.96; 95% confidence interval [CI], 1.39-6.31; P = .005). An increased risk of mortality was observed at 30 days (11 [20%] vs 85 [10%]; aHR 2.89; 95% CI, 1.32-6.29) and remained elevated at 1 year (19 [35%] vs 228 [25%]; aHR1.80; 95% CI, 1.02-3.17). These results were not influenced by treatment for diabetes (P > .4 for interaction).

Conclusion

In a population-based sample of patients with community-acquired pneumonia, spontaneous admission hypoglycemia was independently associated with increased mortality during hospitalization that persisted to 1 year. Patients with hypoglycemia are an easily identified group that may warrant more intensive inpatient and postdischarge follow-up.     

A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness

Purpose

The study tested whether nutritional support of older patients during acute illness leads to a clinical benefit.

Methods

In this randomized, double-blind, placebo-controlled study, we randomly assigned 445 hospitalized patients aged 65 to 92 years to receive either a normal hospital diet plus 400 mL oral nutritional supplements (223 subjects) or a normal hospital diet plus a placebo (222 subjects) daily for 6 weeks. The composition of the supplement was such as to provide 995 kcal of energy and 100% of the Reference Nutrient Intakes for vitamins and minerals for a healthy older person. Patients had three assessments: at baseline, at 6 weeks, and at 6 months post-randomization. Outcome measures were 6 months of disability, non-elective readmission and length of hospital stay, discharge destination, morbidity, and mortality.

Results

Randomization to the supplement group led to a significant improvement in nutritional status. Over 6 months, 65 patients (29%) in the supplements group were readmitted to the hospital compared with 89 patients (40%) in the placebo group (adjusted hazard ratio 0.68 [95% confidence interval 0.49-0.94]). The mean length of hospital stay was 9.4 days in the supplements group compared with 10.1 days in the placebo group. Thirty-two people (14%) died in the supplement group compared with 19 people (9%) in the placebo group at 6 months (adjusted hazard ratio 1.65 [95% confidence interval, 0.93-2.92]).

Conclusion

Oral nutritional supplementation of acutely ill patients improved nutritional status and led to a statistically significant reduction in the number of non-elective readmissions.     

Are shock index and adjusted shock index useful in predicting mortality and length of stay in community-acquired pneumonia?

Background

Community Acquired Pneumonia (CAP) is a common infection which is associated with a significant mortality. Shock index, heart rate divided by blood pressure, has been shown to predict mortality in several conditions including sepsis, acute myocardial infarction and traumatic injuries. Very little is known about the prognostic value of shock index in community acquired pneumonia (CAP).

Objective

To examine the usefulness of shock index (SI) and adjusted shock index (corrected to temperature) (ASI) in predicting mortality and hospital length of stay in patients admitted to hospital with CAP.

Methods

A prospective study was conducted in three hospitals in Norfolk & Suffolk, UK. We compared risk of mortality and longer length of stay for low (=<1.0, i.e. heart rate =< systolic BP) and high (> 1.0, i.e. heart rate > systolic BP) SI and ASI adjusting for age, sex and other parameters which have been shown to be associated with mortality in CAP.

Results

A total of 190 patients were included (males = 53%). The age range was 18-101 years (median = 76 years). Patients with SI & ASI > 1.0 had higher likelihood of dying within 6 weeks from admission. The adjusted odds ratio for 30 days mortality were 2.48 (1.04-5.92; p = 0.04) for SI and 3.16 (1.12-8.95; p = 0.03) for ASI. There was no evidence to suggest that they predict longer length of stay.

Conclusion

Both SI and ASI of > 1.0 predict 6 weeks mortality but not longer length of stay in CAP.     

Recurrent Community-acquired Pneumonia in Patients Starting Acid-suppressing Drugs

Background

Several studies suggest that proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H2s) increase risk of community-acquired pneumonia. To test this hypothesis, we examined a prospective population-based cohort predisposed to pneumonia: elderly patients (≥65 years) who had survived hospitalization for pneumonia.

Methods

This study featured a nested case-control design where cases were patients hospitalized for recurrent pneumonia (≥30 days after initial episode) and controls were age, sex, and incidence-density sampling matched but never had recurrent pneumonia. PPI/H2 exposure was classified as never, past, or current use before recurrent pneumonia. The association between PPI/H2s and pneumonia was assessed using multivariable conditional logistic regression.

Results

During 5.4 years of follow-up, 248 recurrent pneumonia cases were matched with 2476 controls. Overall, 71 of 608 (12%) current PPI/H2 users had recurrent pneumonia, compared with 130 of 1487 (8%) nonusers (adjusted odds ratio [aOR] 1.5; 95% confidence interval [CI], 1.1-2.1). Stratifying the 608 current users according to timing of PPI/H2 initiation revealed incident current-users (initiated PPI/H2 after initial pneumonia hospitalization, n = 303) bore the entire increased risk of recurrent community-acquired pneumonia (15% vs 8% among nonusers, aOR 2.1; 95% CI, 1.4-3.0). The 305 prevalent current-users (PPI/H2 exposure before and after initial community-acquired pneumonia hospitalization) were equally likely to develop recurrent pneumonia as nonusers (aOR 0.99; 95% CI, 0.63-1.57).

Conclusion

Acid-suppressing drug use substantially increased the likelihood of recurrent pneumonia in high-risk elderly patients. The association was confined to patients initiating PPI/H2s after hospital discharge. Our findings should be considered when deciding to prescribe these drugs in patients with a recent history of pneumonia.     

Predictors of long-term mortality in patients with ventilator-associated pneumonia

Purpose

To determine the long-term outcome of ventilator-associated pneumonia (VAP) and identify factors associated with increased mortality.

Methods

We retrospectively studied 671 patients with VAP admitted to an intensive care unit between 1994 and 2000. We determined long-term and out-of-hospital mortality for these patients.

Results

The in-hospital mortality was 42.3%; 19.8% of patients had concomitant bacteremia, the mortality was 59.7% versus 38.0% for those without bacteremia (P <.001). The factors associated with increased hospital mortality by univariable analysis were: diagnosis on admission, the need of vasopressors during the stay in the intensive care unit, not undergoing a tracheostomy, the absence of fever, the presence of concomitant bacteremia, and renal failure or the need for dialysis. Patients transferred from an outside hospital and patients with normal serum bicarbonate, serum total bilirubin <2 mg/dL, and platelets >120 × 4> 10³/μL had a lower in-hospital mortality. All of these factors except bilirubin level, platelet count, transfer from outside hospital, and serum bicarbonate remained significant on multivariable analysis. The estimated mortality at 1, 3 and 5 years is 25.9% (95% confidence interval [CI], 20.2-30.1%), 33.6% (95% CI, 27.4-39.2%) and 44.7% (95% CI, 38.1-50.6%), respectively.

Conclusions

VAP is associated with a high rate of hospital and long-term mortality. The presence of bacteremia is associated with a high mortality. The 5-year estimated mortality of the survivors is less than 50%.     

Antibiotic therapy and 48-hour mortality for patients with pneumonia

Purpose

Although numerous articles have demonstrated that recommended empiric antimicrobial regimens are associated with decreased mortality at 30 days, there is controversy over whether appropriate antibiotic selection has a beneficial impact on mortality within the first 48 to 96 hours after admission. Our aim was to determine whether the use of guideline-concordant antibiotic therapy is associated with decreased mortality within the first 48 hours after admission for patients with pneumonia.

Methods

A retrospective cohort study was conducted at two tertiary teaching hospitals in San Antonio, Texas. A propensity score was used to balance the covariates associated with the use of guideline-concordant antimicrobial therapy. A multivariable logistic regression model was used to assess the association between mortality within 48 hours and the use of guideline-concordant antibiotic therapy, after adjusting for potential confounders including the propensity score.

Results

Information was obtained on 787 patients with community-acquired pneumonia. The median age was 60 years, 79% were male, and 20% were initially admitted to the intensive care unit. At presentation 52% of subjects were low risk, 34% were moderate risk, and 14% were high risk. Within the first 48 hours, 20 patients died. After adjustment for potential confounders, the use of guideline-concordant antimicrobial therapy (odds ratio 0.37, 95% confidence interval, 0.14-0.95) was significantly associated with decreased mortality at 48 hours after admission.

Conclusion

Using initial empiric guideline-concordant antimicrobial therapy is associated with decreased mortality at 48 hours. Further research needs to investigate methods to ensure that patients with community-acquired pneumonia are treated with appropriate antimicrobial therapies.     

Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis

Purpose

There is little consensus on the most appropriate duration of antibiotic treatment for community-acquired pneumonia. The goal of this study is to systematically review randomized controlled trials comparing short-course and extended-course antibiotic regimens for community-acquired pneumonia.

Methods

We searched MEDLINE, Embase, and CENTRAL, and reviewed reference lists from 1980 through June 2006. Studies were included if they were randomized controlled trials that compared short-course (7 days or less) versus extended-course (>7 days) antibiotic monotherapy for community-acquired pneumonia in adults. The primary outcome measure was failure to achieve clinical improvement.

Results

We found 15 randomized controlled trials matching our inclusion and exclusion criteria comprising 2796 total subjects. Short-course regimens primarily studied the use of azithromycin (n = 10), but trials examining beta-lactams (n = 2), fluoroquinolones (n = 2), and ketolides (n = 1) were found as well. Of the extended-course regimens, 3 studies utilized the same antibiotic, whereas 9 involved an antibiotic of the same class. Overall, there was no difference in the risk of clinical failure between the short-course and extended-course regimens (0.89, 95% confidence interval [CI], 0.78-1.02). In addition, there were no differences in the risk of mortality (0.81, 95% CI, 0.46-1.43) or bacteriologic eradication (1.11, 95% CI, 0.76-1.62). In subgroup analyses, there was a trend toward favorable clinical efficacy for the short-course regimens in all antibiotic classes (range of relative risk, 0.88-0.94).

Conclusions

The available studies suggest that adults with mild to moderate community-acquired pneumonia can be safely and effectively treated with an antibiotic regimen of 7 days or less. Reduction in patient exposure to antibiotics may limit the increasing rates of antimicrobial drug resistance, decrease cost, and improve patient adherence and tolerability.     

Impact of the choice of benchmark on the conclusions of hospital report cards

Background

Hospital report cards for outcomes following acute myocardial infarction (AMI) are being produced with increasing frequency. Implicit in the statistical methods used is the fact that hospitals are being compared with an average hospital. Prior research has demonstrated that institutional characteristics such as a high annual volume of AMI patients and academic status are associated with improved outcomes. This raises the important issue of what is an appropriate benchmark against which hospitals should be compared. The objective of the current study was to determine whether the number of hospitals identified as mortality outliers depended upon the benchmark against which hospitals are compared.

Methods

We examined all patients discharged with a diagnosis of AMI from 163 Ontario hospitals between April 1, 2000, and March 30, 2001. Logistic regression models that incorporated random provider effects were used to identify hospitals with a mortality rate significantly higher than average. The initial model included only patient characteristics, whereas additional models incorporated both patient and hospital characteristics.

Results

After adjusting for patient characteristics only, 3 hospitals had significantly higher mortality compared to an average-mortality hospital, while 4 hospitals had significantly lower mortality than an average-mortality hospital. However, after further adjusting for peer group, only 1 hospital was identified as having significantly lower mortality than an average-mortality institution in its peer group.

Conclusions

The use of peer-group-defined rather than overall benchmarks has a substantial impact on the identification of mortality outliers. The choice of the appropriate benchmark is related to the underlying purpose of the comparison.     

Cuidados respiratorios intermedios: un año de experiencia

Background

The aim of this study was to describe the characteristics and results of patients admitted to an intermediate respiratory care unit (IRCU).

Patients and Methods

We performed a 12-month prospective observational study of all the patients admitted to our IRCU during the study period. We analyzed sociodemographic and clinical variables, the APACHE-II score, blood gas parameters, duration of stay in hospital, mortality, and readmission to hospital.

Results

We evaluated 190 patients (64.2% men), with a mean age of 69.4 years. A score of greater than 2 on the Charlson index was recorded in 43.2% of patients. The mean APACHE-II score was 16.3 in the emergency department and 14.3 on entering the IRCU. Fifty percent of the patients were admitted to receive ventilation and, of these, only 6 (5.7%) were admitted for disconnection of the ventilator. The mean duration of stay in the IRCU was 3.7 days. The readmission rate was 12.7% Mortality was 12.6% during hospitalization and 11.6% 90 days after discharge.

Conclusions

The patients admitted to our IRCU were elderly, with considerable comorbidity and high mortality, both during hospitalization and 90 days after discharge from hospital. The results revealed no statistically significant differences (mean length of stay, readmission, mortality) according to the type of care administered to the patients (ventilation compared to monitoring).     

Orthostatic hypotension-related hospitalizations in the United States

Background

Orthostatic hypotension has been commonly described in elderly persons and is associated with an increased risk of falls, syncope, and cerebrovascular events. Nevertheless, the precise burden of this condition in the US is currently unknown.

Methods

We analyzed discharge data from the Nationwide Inpatient Sample to identify orthostatic hypotension-related hospitalizations and associated comorbidities after excluding acute causes of this condition. National hospitalization rates were estimated using US census population estimates, and the medical conditions most frequently associated with orthostatic hypotension were assessed.

Results

In 2004, there were an estimated 80,095 orthostatic hypotension-related hospitalizations, yielding an overall rate of 36 (95% confidence interval, 34 to 38) hospitalizations per 100,000 US adults. Orthostatic hypotension was the primary diagnosis in 35% of these hospitalizations. The number of orthostatic hypotension-related hospitalizations increased steadily with age, and patients aged 75 years or older had the highest annual hospitalization rate, 233 per 100,000 (95% confidence interval, 217 to 249). The median length of hospital stay was 3 days (IQR 2-6) and the overall in-hospital mortality was 0.9%. Caucasian males were most likely to be hospitalized with orthostatic hypotension. Syncope was the most common comorbid condition reported among orthostatic hypotension patients.

Conclusions

Orthostatic hypotension is a relatively common condition among hospitalized US elderly patients. In light of the progressive aging of the US population, the contribution of orthostatic hypotension to morbidity and mortality is likely to increase, and deserves further scrutiny.     

Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta-analysis

Purpose

The study purpose was to compare differences in mortality and the duration of hospitalization in patients with chronic kidney disease who are referred early versus late to nephrologists.

Methods

We searched English-language literature from 1980 through December 2005, along with national conference proceedings, the Web of Science Citation Index, and reference lists of all included studies. Twenty-two studies with a total sample size of 12,749 met inclusion criteria.

Results

There was significantly increased overall mortality in the late referral group as compared with the early referral group (relative risk 1.99; 95% confidence interval [CI], 1.66 to 2.39, P <.0001). The duration of hospital stay, at the time of initiation of renal replacement therapy, was greater in the late referred group by an average of 12 days (95% CI, 8.0 to 16.1, P = .0007). Significant heterogeneity was detected for both outcomes.

Conclusion

Timing of referral emerged to be a significant factor impacting homogeneity in the mortality outcome. Our results suggest significantly higher mortality and increased early hospitalization of chronic kidney disease subjects referred late to nephrologists as compared with earlier referred subjects.     

Trends in management, hospital and long-term outcomes of elderly patients with acute myocardial infarction

Purpose

The number of elderly patients with acute myocardial infarction (AMI) is growing rapidly, and their early and postdischarge mortality is high. Several studies have reported a decline in mortality after myocardial infarction; however, the magnitude of the decline among the elderly has not been fully investigated.

Methods

We assessed trends in management, in-hospital, and long-term outcomes of 1475 elderly patients (aged ≥75 years, 42% women) hospitalized with AMI in all 25 operating coronary care units in Israel between 1992 and 2002, from our prospective nationwide biennial surveys.

Results

Between 1992 and 2002, a significant increase was observed in the use of acute reperfusion therapy (27%-48%), coronary angiography (6%-47%), percutaneous coronary intervention (3%-33%), coronary bypass (2%-8%), aspirin (53%-88%), beta-blockers (18%-65%), angiotensin-converting enzyme inhibitors (26%-63%), and lipid-lowering drugs (0%-43%). These changes were associated with a 42% reduction in 30-day mortality (27.6%-16.1%; adjusted odds ratio 0.57; 95% confidence interval [CI], 0.36-0.93). One-year cumulative mortality declined by 20% (37%-29%; adjusted odds ratio 0.74; 95% CI, 0.49-1.13).

Conclusions

The management of elderly patients with AMI changed substantially during the last decade. This change was associated with a significant reduction in early mortality, whereas cumulative 1-year mortality improved only slightly. Better adherence to in-hospital management guidelines and better implementation of postdischarge health policy may further decrease mortality and morbidity in the elderly after AMI.     

National trends in outcomes among elderly patients with heart failure

Purpose

Despite dramatic changes in heart failure management during the 1990s, little is known about the national heart failure mortality trends during this time period, particularly among the elderly. The purpose of this study was to determine temporal trends in outcomes of elderly patients with heart failure between 1992 and 1999.

Subjects and methods

We analyzed a national sample of 3,957,520 Medicare beneficiaries aged 65 years or more who were hospitalized with heart failure between 1992 and 1999, assessing temporal trends in 30-day and 1-year all-causemortality and 30-day and 6-month all-cause hospital readmission. In risk-adjusted analyses, mortality and readmission for each year between 1994 and 1999 were compared with the referent year of 1993.

Results

Crude 30-day and 1-year mortality decreased slightly (range for 1992-1999: 11.0%-10.3% and 32.5%-31.7%, respectively), whereas 30-day and 6-month readmission increased (10.2%-13.8% and 35.4%-40.3%, respectively). After risk adjustment, there was no change in 30-day mortality between 1993 and 1999 (eg, for 1999 vs 1993, odds ratio [OR] 1.01, 95% confidence interval [CI], 1.00-1.02). One-year mortality was lower in 1994 compared with 1993 (OR 0.91, 95% CI, 0.90-0.92), but data from subsequent years suggested no continuous improvement after 1994 (1999 vs 1993: OR 0.93, 95% CI, 0.92-0.94). Thirty-day readmission increased (1999 vs 1993: OR 1.09, 95% CI, 1.07-1.10), but there was no change in 6-month readmission (1999 vs 1993: OR 1.00, 95% CI, 0.99-1.01).

Conclusion

We found no substantial improvement in mortality and hospital readmission during the 1990s among elderly patients hospitalized with heart failure. These findings suggest that recent innovations in heart failure management have not yet translated into better outcomes in this population.     

Mid-term survival of patients undergoing major cardiac surgery

Introduction and objectives

Evaluating patient outcomes following cardiac surgery is a means of measuring the quality of that surgery. The present study analyzes survival and the risk factors associated with mid-term mortality of patients undergoing cardiac surgery in Son Dureta University Hospital (Palma, Balearic Islands, Spain).

Methods

From November 2002 thru December 2007, 1938 patients underwent interventions. Patients were stratified in 4 age groups. Of 1900 patients discharged from hospital, 1844 were followed until December 31, 2008. Following discharge, we constructed Kaplan-Meier survival curves and performed Cox regression analysis to determine which variables associated with mid-term mortality.

Results

In-hospital mortality of the 1,938 patients was 1.96% (CI 95%, 1.36%-2.6%). Survival probability at 1, 3 and 5 years follow-up was 98%, 94% and 90%, respectively. Mean follow-up was 3.2 (0.01-6.06) years. Patients aged ≥70 years showed a lower survival rate than those aged <70 (log rank test, P <.0001). At the end of follow-up, mortality was 6.5% (CI 95%, 5.4%-7.7%). Age ≥70 years, a history of severe ventricular dysfunction (ejection fraction <30%), severe pulmonary hypertension, diabetes mellitus, preoperative anemia, postoperative stroke, and hospital stay were independently associated with mid-term mortality.

Conclusions

Mid-term survival after discharge was highly satisfactory. Mid-term mortality varied with age and other pre- and postoperative factors.Full English text available from: www.revespcardiol.org     

Thoracic empyema in patients with community-acquired pneumonia

Purpose

The objective of this study was to update the incidence and natural history of empyema in patients admitted to hospital with community-acquired pneumonia (CAP).

Methods

A prospective population-based study of 3675 patients with a diagnosis of CAP was carried out. Patients were classified as “definite empyema” based on one or more of the following criteria: presence of microorganisms in pleural fluid Gram stain or culture, pleural pH less than 7.2 associated with radiographic features of empyema, or frank pus in the pleural space at the time of thoroscopy. All others were classified as either “suspected empyema” or CAP. We then compared characteristics and outcomes between subgroups.

Results

A diagnosis of empyema was made in 47 patients (1.3%) by the attending physician; 24 patients (0.7%) met criteria for definite cases. Few clinical, laboratory, or radiographic features were useful in differentiating patients with definite empyema. The most commonly isolated pathogen from pleural fluid of patients with definite empyema was Streptococcus milleri group (50%). The in-hospital mortality rate for patients with definite empyema was 4.2%.

Conclusion

In the 21st century, empyema is an uncommon complication of CAP with an incidence of 0.7%. The S. milleri group has emerged as the most common causative microbial pathogen. The diagnosis remains difficult, although outcomes have improved from that previously reported.