Is discharge policy a balanced decision between clinical considerations and hospital ownership policy? The CABG example

OBJECTIVES: To explore to what extent patient discharge from the hospital is a balanced decision between clinical considerations and management policy; specifically: (1) to assess the role of patient risk as a determinant of discharge in comparison with administrative factors such as hospital ownership; (2) to evaluate whether variations in discharge policy were translated into differences in clinical outcomes. METHODS: A national study of coronary artery bypass surgery was used as an example. The population included 4778 patients undergoing coronary artery bypass surgery in 14 institutions. The mode of discharge day, rather than the mean, was used as the best indicator of discharge policy. Parametric survival model was used to assess factors associated with the day of discharge. RESULTS: The mode of discharge day varied widely among institutions. This variation between 4 and 7 days after surgery corresponded to hospital ownership. The mode of discharge day was almost invariant to the patients' risk, but serious postoperative complications resulted in prolonged stay for a minority of the patients. The influence of hospital ownership prevailed over patient insurance carriers. Differences in discharge policies were not associated with increased risk of late mortality or rehospitalization. CONCLUSIONS: Discharge policy beyond the rare occurrence of dramatic patient postoperative complications was mainly dependent on hospital owner's cost-effectiveness considerations. However, despite the weight given to administrative factors in the decision-making process, it did not affect the outcome of care.     

Individuals who sustain nonosteoporotic fractures continue to also sustain fragility fractures

Summary This retrospective case control study was done in order to investigate whether patients who sustain a nonosteoporotic fracture early in life also continue to sustain fragility fractures later in life. All patients who had been treated at the Department of Orthopedics in Malmo with a tibial shaft fracture from 1949 to 1963 (n = 767) or an ankle fracture from 1961 to 1965 (n = 786) were included in this study. At the time of follow-up in 1992, 231 of the patients who sustained a tibial shaft fracture and 260 of the patients who sustained an ankle fracture were still living in the city of Malmö. Objective registration was done of all subsequent fractures that these former patients had sustained. Comparison was done with corresponding data from double numbers of age- and sex-matched controls who at that time (1950s and 1960s) had no such fractures. At the time of the fracture as well as today, the controls were living in the area of Malmö. Individuals with earlier tibial or ankle fractures had an increased incidence of fractures generally classified as fragility fractures. There was no difference in this respect between men and women, nor whether the initial fracture had been diaphyseal or metaphyseal. We conclude that sustenance of fractures early in life may serve as a predictor for fragility fractures later in life.     

Managing the 2-week wait for breast patients

INTRODUCTION

Published data suggest that the 2-week wait system and triple assessment at one fast-track clinic visit is an out-dated method of capturing disease from a referral population. These studies report up to 32% of breast cancer coming from routine referrals. It has been recommended, therefore, that all breast referrals should be seen within 2 weeks. The sheer volume of referrals are likely to prevent this target being achieved. The aim of this study was to analyse the performance of our fast-track system.

PATIENTS AND METHODS

The Birmingham Heartlands and Solihull fast-track clinics were set up in 1999 with a prospective audit system. The data from this audit were retrospectively analysed and cross-referenced with the cancer data base to determine the referral origin of breast cancers from November 1999 to February 2005.

RESULTS

A total of 14,303 (fast-track, n = 6678; routine referral, n = 7625) patients were seen over a 5-year period. Overall, 1095 cancers (91.8% of the total) came from the fast-track clinics which had a pick-up rate of 16.4% compared with 98 cancers (8.2% of the total) and a pick-up rate of 1.3% for routine referrals (P < 0.001). The appropriateness of fast-track referral was also analysed which showed that 14.4% of cancers were detected if the referral criteria were met compared to 0.55% if they were inappropriate (P < 0.001).

CONCLUSIONS

The traditional fast-track, triple assessment breast clinic is an efficient and well-structured way of diagnosing disease. We recommend that the two system referral pattern should continue.