Home enteral tube feeding following cerebrovascular accident

BACKGROUND AND AIMS: In the UK, cerebrovascular accident (CVA) is the third commonest cause of death and the commonest diagnosis in patients receiving home enteral feeding (HETF). This study aimed to use data from the British Artificial Nutrition Survey (BANS) collected between 1996 and 1999 to assess the outcome of patients on HETF, including mortality, return to oral feeding, level of physical activity, and level of dependency, which has resource implications. RESULTS: it is estimated that about 1.7% of all patients suffering a CVA in the UK between 1996 and 1999 received HETF. At one year, 29.6% died while receiving HETF and another 13% returned to oral feeding. Mortality increased with age and was twice as high in those managed in nursing homes compared to those in their own homes. The patients receiving tube feeding spent only 0.6% of their time in hospital. A total of 43.9% of patients were bed-bound at home (1.9% unconscious) and an additional 30.3% were house-bound. Only 21.2% were independent, and the majority were totally dependent on their carers. In CVA patients on HETF the level of dependency was greater than for those with all types of diagnoses (n=12,997). CONCLUSION: This study has described the outcome of a large number of patients receiving HETF in the UK. Since patients spent less than 1% of their time in hospital, HETF relieves pressure on the expensive hospital environment, but places more demands on the carers, who have to deal with severely disabled patients. Recovery of swallowing function should be assessed intermittently to prevent unnecessary HETF.     

Modifiable determinants of hearing impairment in adults

ObjectiveTo identify factors contributing to the declining prevalence of hearing impairment in more recent generations.MethodsWe used data on hearing thresholds and potential risk factors of hearing impairment collected from studies in Beaver Dam, Wisconsin, the Epidemiology of Hearing Loss Study (1993–1995, n = 3753; 1998–2000, n = 2800 and 2003–2005, n = 2395), the concurrent Beaver Dam Eye Study on the same cohort, and a subgroup (n = 2173) of the Beaver Dam Offspring Study (2005–2008).ResultsEducational attainment significantly reduced the odds ratio (OR) of the birth cohort effect on hearing impairment from 0.90 to 0.93, while a history of ear infection had a reverse effect on the decreasing trend (significantly changing the OR from 0.93 to 0.94). Occupational noise exposure, smoking, and a history of cardiovascular disease, while associated with hearing impairment, did not attenuate the cohort effect. The cohort effect remained significant after known risk factors were adjusted (OR = 0.93; 95% confidence interval, 0.89–0.97).ConclusionThese data provide strong evidence that environmental, lifestyle, or other modifiable factors contribute to the etiology of hearing impairment and add support to the idea that hearing impairment in adults may be prevented or delayed.     

Future numbers of patients with a cerebrovascular accident in The Netherlands]

Based on future population size estimates, and sex and age specific CVA incidence rates, the yearly number of new cases of CVA in the Netherlands is projected up to 2020. Compared with 1991 the number of patients with a first CVA will increase by at least 4 and at most 6 per cent in 1995, to 41-62 per cent in 2020. Because the prevalence and the number of handicapped patients will probably be much lower, future attention should primarily be directed at support of early phase care facilities.     

Demand for hospital services following admission with suspected myocardial infarction in 1983 and 1989

Formulation of business plans by National Health hospitals requires information on likely demands for the services they provide. Two cohorts of patients admitted to the Nottingham hospitals in 1983 and 1989 with suspected myocardial infarction were sampled to determine the workload implications due to initial in-hospital tests, subsequent readmission and outpatient investigations. The results show that attendance in the first year after discharge related principally to cardiac problems, while in subsequent years non-cardiac problems predominated. An estimation of the total workload, based upon 1,000 patients admitted in 1989, suggests that demands for hospital services in the following year include over 4,000 electrocardiographs, 1,400 chest X-rays and 18,000 laboratory tests, and only 118 exercise tests and 37 cardiac catheterisations. Admission with suspected myocardial infarction makes great demand on hospital services in the year after discharge. Any change in practice, which increases the potential demand for cardiac investigations, could have important financial implications for Nottingham hospitals.     

Markers of risk of asthma death or readmission in the 12 months following a hospital admission for asthma.

A case-control study has previously been reported of asthma deaths in people aged 5-45 years who had a hospital admission for asthma (the index admission) in New Zealand during 1981-1987. The study has been re-analysed to examine the association between markers of asthma severity and risk of asthma death or hospital admission; patients prescribed fenoterol were excluded from this re-analysis because of the previously reported interaction between fenoterol, asthma severity, and asthma deaths. The re-analysis included 39 patients who died of asthma during the 12 months after their index admission, 226 patients who had a readmission for asthma during the 12 months after their index admission, and 263 controls chosen from all index admissions. An admission in the previous 12 months was the strongest marker of subsequent risk of death (odds ratio (OR) = 3.5, 95% confidence interval (CI): 1.8-6.9, P less than 0.01), and was also a strong marker of subsequent risk of readmission (OR = 3.0, 95% CI: 2.1-4.2, P less than 0.01); the risk increased with the number of previous admissions. Three or more categories of prescribed asthma drugs was also associated with subsequent death (OR = 1.7, 95% CI: 0.9-3.3, P = 0.13) or readmission (OR = 1.9, 95% CI: 1.3-2.7, P less than 0.01); prescribed oral corticosteroids was only weakly associated with subsequent death (OR = 1.3, 95% CI: 0.6-2.8, P = 0.59), but was more strongly associated with subsequent readmission (OR = 1.9, 95% CI: 1.2-2.8, P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of a hospital admission HIV antibody voluntary screening program

Voluntary screening for the presence of human immunodeficiency virus (HIV) is recommended by the healthcare profession. The optimal settings to accomplish screening have not been established. We evaluated an admission HIV screening program in a large private hospital to assess advantages and disadvantages in this setting. In a three-month study period, 4,535 of 8,868 patients (51%) admitted to the hospital agreed to HIV testing. Serum specimens from 500 patients who refused testing were blindly, anonymously tested. The seroprevalence of the patients agreeing to (0.26%) and refusing (0.60%) testing was not statistically different (p = .12). There were 12 HIV cases discovered; ten (83%) of these were known to be in a high-risk group at the time of admission. Eighty-five percent of patients interviewed were in favor of this screening program. Difficulties associated with confidentiality or consent were not evident. Calculated charges of testing for each HIV case discovery was $14,550. There was no evidence that this screening program provided for a more effective infection control policy to prevent nosocomial HIV transmission. A hospital admission HIV screening program can be implemented, can meet with favorable patient opinion and can detect previously unknown HIV-positive patients. Hospitals are an efficient and practical setting for HIV testing. The benefit of this program appears to be greater for the patient than hospital or healthcare worker. Cost-benefit analyses will identify optimal candidates to be screened in different hospital populations.     

Waiting for placement: an exploratory analysis of determinants of delayed discharges of elderly hospital patients.

This article examines the causes of delayed hospital discharge for 3,111 patients waiting for alternative placement in 80 North Carolina acute care general hospitals during May 1989. Almost all of the patients were elderly: their average age was 77. Delay is defined as the period between the day a patient was judged medically ready for discharge by a discharge planner and the day the patient was discharged (or May 31 if unplaced). The average delay was 16.7 days. The policy-relevant patient characteristics associated with delay are requirement for heavy care, race, source of reimbursement, and whether or not there was a financial problem in arranging discharge. The patient's age and whether or not a problem with behavior or family cooperativeness was noted also were predictors. Along with patient characteristics, hospital features such as bed size, occupancy rate, and total revenues were correlated with delay. Local nursing and rest home (domiciliary) bed supply were insignificant predictors, possibly because of their limited variance: the number of nursing home beds in all North Carolina counties is below the national mean; the number of rest home beds exceeds it. The conclusion reached is that the delay problem warrants more intensive analysis, particularly regarding financial problems encountered at discharge, and race. Guidelines for such an endeavor are provided. Further, there is a need to recognize the increasing preponderance of a new type of heavy care patient via more appropriate reimbursement levels and "transitional care" services.     

The correlation of transient ischemic attack and cerebrovascular accident

Correlation exists between the occurrence of a transient ischemic attack (TIA) and a cerebrovascular accident (CVA). The strength of this correlation however is a point for debate. We studied the sequential relation between the occurrence of TIA and CVA in patients over 50 years in general practice. Based on Continuous Morbidity Registration (CMR) in four general practices we analysed the morbidity in patients who presented symptoms of TIA and (or) CVA during the period 1971-1983. In this period a TIA was diagnosed in 134 persons and a CVA in 214 persons. The maximal observation period of the TIA patients after presentation of the symptoms was 12 1/2 years. In 8% of the CVA cases a TIA had been diagnosed in the period preceding the CVA. Of the TIA patients 13% developed a CVA in the subsequent observation period, half of them within two years after the TIA diagnosis. Comparison of the incidence rate of CVA in the general population with that in the population with a TIA reveals that a CVA development is about six times more frequent in the latter. This higher risk has only a relative meaning because the absolute number of cases is small.     

Assessment of HCFA''s 1992 Medicare hospital information report of mortality following admission for hip arthroplasty.

OBJECTIVE. The Health Care Financing Administration (HCFA) produced annually from 1987 through 1994 mortality data information as part of the Medicare Hospital Information Project (MHIP) report. We assessed the validity of these data for hip arthroplasty for one state Medicare population and we analyzed the accuracy of the predictions derived from the Bailey-Makeham mortality model for this procedure. DATA SOURCES AND STUDY SETTING. The study sample consisted of claims and model data from 1,421 Medicare patients who underwent hip arthroplasty at acute care Arkansas hospitals from October 1990 through September 1991. STUDY DESIGN. Patients were stratified into two groups based on reason for surgery (fracture status): reconstruction or fracture management. Patient survival experience was compared between the two groups. The effect of fracture status on the HCFA model's predictive ability was examined empirically and via a simulation study. RESULTS. Our results indicate that hip arthroplasty patients are not uniform with regard to outcome, depending on the reason for the surgery. Patients with fracture had a much higher 30-day mortality rate than those who underwent reconstruction (p < .001). The empirical data and the simulation study suggest that the Bailey-Makeham model underestimates mortality for reconstructive surgery in fracture patients, providing a false benchmark for those institutions that perform hip arthroplasty on predominantly one category of patients. CONCLUSION. Published HCFA data concerning mortality for hip arthroplasty combines two different patient populations into one statistic. Casual examination of these data could result in a false benchmark for analysis of institutional performance. An important implication from this study for policymakers who base decisions on "report cards" or performance measurement reports is that, although they are necessary,generic case-mix, comorbidity, and severity of illness adjustments may not be sufficient to achieve accurate representations of outcomes, and that more disease/procedure--specific adjustments may be needed to avoid inappropriate conclusions.     

The determinants of hospital profitability

Although numerous studies related to hospital costs and financial condition have been conducted, no studies have specifically attempted to identify the underlying determinants of hospital profitability. If these factors are identified, hospital executives can focus their efforts on those aspects of operations that most affect profitability, and public policymakers can gain insights into the potential effects of alternative policy decisions on hospital financial viability. Our study uses multiple regression analysis with 22 hypothesized profitability determinants as independent variables and five profitability measures as dependent variables. The data set consists of 1989 data from 169 investor-owned and private not-for-profit general acute care hospitals in the state of Florida. The results provide evidence that selected managerial and patient-mix variables are predictors of profitability. Structural factors that are beyond the control of managers (organizational and community characteristics) appear to be less important in influencing profitability. These findings may be viewed positively by hospital executives since it appears profitability is not dictated by organizational or market factors but more strongly influenced by factors that, to some extent, can be influenced by hospital policies and practices.     

Handgrip strength as a hospital admission nutritional risk screening method

OBJECTIVE: To investigate if handgrip strength (HGS) could be used as a single screening procedure in identifying patients who are classified as being undernourished or nutritionally-at-risk at hospital admission. DESIGN: Cross-sectional study. In the second day of hospital admission, HGS was evaluated and results were compared with Nutritional Risk Screening (NRS-2002). SETTING: Two public hospitals in Porto, Portugal, a university and a district one. SUBJECTS: A probabilistic sample of 50% in-patients from each hospital of 314 patients (age range of 18-96) was studied. Patients were considered eligible if they were >or=18 years old and able to give informed consent. Hand pain, upper limb deformities, incapacity to perform muscle strength measurements and pregnancy were considered further exclusion criteria. RESULTS: Patients identified as undernourished by NRS-2002 (37.9%) were older, shorter and lighter, with a lower functional capacity, a longer length of stay and a lower HGS (P<0.001). When comparing patients with lower HGS (first quartile) with those with the highest HGS (fourth quartile), this parameter revealed good sensitivity (86.7%) and specificity (70.2%) and a k=0.56. Multivariate analysis showed that patients with higher HGS had an independent decreased risk of being at nutritional risk (P for trend <0.001) odds ratio=0.19 (95% confidence interval=0.08-0.48). Our entire sample of hospitalized patients was -1.96 Z-score below the HGS cutoff of distribution data for healthy individuals. CONCLUSIONS: HGS identifies a high proportion of nutritionally-at-risk patients and can be a reliable first screening tool for nutritional risk in hospitals.     

Dosimetry by ESR spectroscopy following a radiation accident

On 2 September, 1982, one of the employees of the gamma-irradiation facility at The Institute for Energy and Technology (Kjeller, Norway) entered the irradiation cell with a 65.7-kCi 60Co source in unshielded position. The victim received an unknown radiation dose and died after 13 days. Using electron-spin resonance spectroscopy (ESR), the radiation dose in this accident was subsequently determined based on the production of long-lived free radicals in nitroglycerol tablets carried by the operator during accident. He used nitroglycerol for heart problems and free radicals are easily formed and trapped in sugar which is the main component of the tablets. Calibration experiments were carried out and the dose given to the tablets during the accident was determined to be 39 Gy. Phantom experiments based on this result indicate an average whole-body dose in the accident of 22.5 Gy.