High mortality of older patients admitted to hospital from care homes and insight into potential interventions to reduce hospital admissions from care homes: the Norfolk experience

There is a high mortality rate in patients admitted to hospitals acutely from care homes. In a retrospective case analysis study of 3772 older people admitted to the Department of Medicine for the Elderly between January and June 2005, 340 (9.0%) were from care homes, and 93 (27.3%) of the residents died during the index admission. Nearly 40% of these deaths occurred within 24 h of admission indicating a high level of less appropriate admissions. Investigating eight nursing homes which admitted the highest number of patients from one primary care trust revealed that the most cited reasons for admission were the lack of advance care plans, access to General Practitioners (GPs) out of hours, as well as general access to palliative care and specialist nurses, and poor communication between patient, relatives, GPs, hospitals and care home staff. Our findings provide some useful insight into the factors that need to be addressed to avoid unnecessary or inappropriate admissions from care homes for better end of life care in aging societies.     

Dependency in older people recently admitted to care homes

OBJECTIVE: to investigate dependency and general health status of a cohort of older people admitted to residential or nursing homes for long-term care. METHOD: we assessed 308 people aged over 65 years within 2 weeks of admission for long-term care to one of 30 nursing or residential homes in north-west England. Dependency was assessed using the Barthel activities of daily living index and the Crichton Royal Behaviour Rating Scale. We collected information from the homes' records on diagnosed conditions and current medication. RESULTS: 50% of the cohort were in a 'low dependency' band (Barthel score 13 - 20): 31% of those in nursing homes and 71% of those in residential homes. In nursing homes, low-dependency residents were more likely to be self-funding than those with higher dependency. Of a number of broad diagnostic groupings, only a diagnosis of dementia was associated with nursing- rather than residential-home admission. Of 47 residents who scored 9 or less on the Mini-Mental State Examination (indicating severe cognitive impairment), 85% had no diagnosis of dementia, neurological disorder or other psychiatric disorder. DISCUSSION: the high proportion of new admissions of subjects with low dependency needs raises questions about the effective targeting of resources and about management of the boundary between home-based and institutional care. The existence of an important group of self-funded, low-dependency new admissions to nursing homes suggests a need to provide better assessment and placement services for those who are financially independent of local authorities. Many new admissions had conditions which might benefit from rehabilitation but there were almost no therapy staff in the studied homes. In some cases where severe cognitive impairment was evident, there was no evidence that the result of any formal pre-admission psychiatric evaluation had been communicated to nursing or care staff.     

Variability in the organisation and management of hospital care for COPD exacerbations in the UK

Previous smaller UK audits have demonstrated wide variation in organisation, resources, and process of care for acute chronic obstructive pulmonary disease (COPD) admissions. Smallest units appeared to do less well. UK acute hospitals supplied information on (1) resources and organisation of care, (2) clinical data on process of care and outcomes for up to 40 consecutive COPD admissions. Comparisons were made against national recommendations. Eight thousand and thirteen admissions involved 7529 patients from 233 units (93% of UK acute Trusts). Twenty-six percent of units had at most one whole-time equivalent respiratory consultant while 12% had at least four. Thirty percent patients were admitted under a respiratory specialist and 48% discharged under their care whilst 28% had no specialist input at all. Variation in care provision was wide across all hospitals but patients in smaller hospitals had less access to specialist respiratory or admission wards, pulmonary rehabilitation programs, specialty triage or an early discharge scheme. Six percent of units did not have access to NIV and 18% to invasive ventilatory support. There remains wide variation in all aspects of acute hospital COPD care in the UK, with smaller hospitals offering fewest services. Those receiving specialist input are more likely to be offered interventions of proven effect. Management guidelines alone are insufficient to address inequalities of care and a clear statement of minimum national standards for resource provision and organisation of COPD care are required. This study provides a unique insight into the current state of care for patients admitted with COPD exacerbations in the UK.     

A community-wide effort to reduce hospital utilization by patients requiring nursing home placement

Described is an effort by health care providers to reduce hospital utilization by increasing admissions to skilled nursing facilities from hospitals. For a 6-month period, there were increased admissions from hospitals to nursing homes and a reduced number of hospital nonacute patients who required long-term care placement. Eventually, however, the nursing homes shifted their admission patterns to accept more persons from non-hospital settings. As a result, admissions from hospitals declined and the number of nonacute patients in hospitals increased.     

Geriatrician input into nursing homes reduces emergency hospital admissions

Nursing home residents are often very dependent, very frail and have complex care needs. Effective partnerships between primary and secondary care will be of benefit to these residents. We looked at 1954 admission episodes to our Trust from April 2006 to March 2009 inclusive. 3 nursing homes had the highest number of multiple admissions (≥ 4). Four strategies to reduce hospital admissions were used at these nursing homes for 3 months. An alert was also sent to the geriatrician if one of the residents was admitted so that their discharge from hospital could be expedited. The project was then extended for another 4 months with 6 nursing homes. The results showed that geriatrician input into nursing homes had a significant impact on admissions from nursing homes (χ(2)(2)=6.261, p < 0.05). The second part of the project also showed significant impact on admissions (χ(2)(2) = 12.552, p < 0.05). Furthermore, in both parts of the project the length of stay in hospital for the residents was reduced. Geriatricians working together with co-ordinated multidisciplinary teams are well placed to manage the care needs of frail, elderly care home residents.     

Providing long-term care for persons with AIDS. Results from a survey of nursing homes in the United States

In this pilot study, a random sample of 50 nursing homes located in each of the five U.S. cities with the highest AIDS incidence were surveyed (total N = 250) to determine: (1) the frequency of admission inquiries by, and actual admissions of PWAs, (2) the frequency of adoption of formal AIDS admission policies, (3) the industry's concerns regarding provision of care in traditional nursing homes, and (4) the industry's preferred way of delivering long-term care (LTC) to PWAs. The majority of the facilities cited ability to meet special care needs, the costs of this care, and inadequate reimbursement as important admission policy issues. The majority indicated a preference for either special care units for AIDS or AIDS-specific skilled nursing facilities as the most appropriate setting for the provision of LTC to persons living with AIDS. While almost half (48.2 percent) of the facilities had been approached, at least informally, about admitting a PWA, only 15.4 percent of the nursing homes had admitted a resident with AIDS.     

Changes in hospitalization patterns among patients with congenital heart disease during the transition from adolescence to adulthood.

OBJECTIVES: This study was designed to evaluate hospitalization patterns of congenital heart disease (CHD) patients surrounding the transition from adolescence to adulthood. BACKGROUND: Few population data exist on hospitalizations among adolescent and adult CHD patients. METHODS: Patients ages 12 to 44 years with CHD were selected from the 2000 to 2003 California hospital discharge database. Patient demographics, hospitalization patterns, emergency department (ED) admissions, CHD complexity, and insurance patterns were described. Data were analyzed in 3-year age increments and compared between patients over and under age 21. Predictors of admission via the ED were determined using multivariate regression analysis. RESULTS: There were 9,017 hospitalizations at 368 hospitals. For patients ages 12 to 20 years, 12 hospitals accounted for 70% of hospitalizations; for patients ages 21 to 44 years, 25 hospitals accounted for only 44.8% of cases. Regarding insurance, 53% of admissions were private, 44% public, and <4% were self-pay. Sixty-five percent of patients had complex CHD and 19% had a cardiac procedure during hospitalization. The proportion of patients admitted via the ED nearly doubled surrounding the transition to adulthood. The positive predictors of admission via the ED included public insurance, self-pay, and age >17 years, whereas having a procedure and being female decreased the likelihood. CONCLUSIONS: Congenital heart disease hospitalizations occur at a wide variety of hospitals and disperse as patients enter adulthood. Those without private insurance and >17 years old are at higher risk of being admitted via the ED. These findings require further investigation to examine access to care and possible disparities, as they are important for future healthcare planning.     

Improving primary care in nursing homes.

We conducted a quasi-experiment to evaluate the impact of a Medicare waiver which allowed the use of nurse practitioners (NPs) and physicians assistants (PAs) to deliver primary care to Massachusetts nursing home patients and removed the limits on the reimbursable numbers of visits per month. A carefully matched set of 1,327 Medicaid patients from 95 non-participating homes in the same areas of Massachusetts was compared to 1,324 Medicaid demonstration patients from 75 homes. Information came from specially designed record reviews and the Medicaid and Medicare information systems. Separate analyses were done for newly admitted cases and rollovers. Comparisons of quality of care suggested that the medical groups using NPs and PAs provided as good or better care than did the physicians in the control group. There were no differences in functional status changes or in the use of medications. The demonstration patients received more attention, as reflected in more orders written and an average of one additional visit a month. Demonstration patients showed higher scores on three of seven specially designed quality tracers, congestive heart failure and hypertension for both new administrations and rollovers, and new urinary incontinence for new admissions. Rollovers had significantly fewer emergency and total hospital days. A cost analysis suggests that the use of NPs and PAs saves at least as much as it costs and may save additional money with more sustained use.     

Intensive care unit admitting patterns in the veterans affairs health care system

BACKGROUND Critical care resource use accounts for almost 1% of US gross domestic product and varies widely among hospitals. However, we know little about the initial decision to admit a patient to the intensive care unit (ICU). METHODS To describe hospital ICU admitting patterns for medical patients after accounting for severity of illness on admission, we performed a retrospective cohort study of the first nonsurgical admission of 289?310 patients admitted from the emergency department or the outpatient clinic to 118 Veterans Affairs acute care hospitals between July 1, 2009, and June 30, 2010. Severity (30-day predicted mortality rate) was measured using a modified Veterans Affairs ICU score based on laboratory data and comorbidities around admission. The main outcome measure was direct admission to an ICU. RESULTS Of the 31?555 patients (10.9%) directly admitted to the ICU, 53.2% had 30-day predicted mortality at admission of 2% or less. The rate of ICU admission for this low-risk group varied from 1.2% to 38.9%. For high-risk patients (predicted mortality >30%), ICU admission rates also varied widely. For a 1-SD increase in predicted mortality, the adjusted odds of ICU admission varied substantially across hospitals (odds ratio?=?0.85-2.22). As a result, 66.1% of hospitals were in different quartiles of ICU use for low- vs high-risk patients (weighted κ?=?0.50). CONCLUSIONS The proportion of low- and high-risk patients admitted to the ICU, variation in ICU admitting patterns among hospitals, and the sensitivity of hospital rankings to patient risk all likely reflect a lack of consensus about which patients most benefit from ICU admission.     

Completeness of admission of residents assessments in teaching nursing homes

In order to assess one aspect of the quality of care within teaching nursing homes, we examined how well these homes conform to geriatric experts' expectations for the admission assessment of elderly nursing home residents. Four hundred-sixty records representing new admissions to five teaching nursing homes over a 1-year period were assessed for completion of items considered important parts of the admission assessment by geriatric experts. Univariate and multivariate analyses both suggest the following four findings. First, the admission assessments performed at teaching nursing homes reflect geriatric experts' priority areas with two exceptions: (1) the assessment of affective disorders and (2) the identification of advance directives. Second, physician-nurse practitioner teams perform the high priority parts of the admission assessment to a degree similar to that of physicians alone. Third, resident's age and expected length of stay partially determine the extent of the admission assessment, as patients with shorter lengths of stay generally received a more complete assessment. Fourth, even among teaching nursing homes, there are significant differences between nursing homes in the performance of comprehensive admission assessment by nursing home clinicians.     

Advance care planning and hospital in the nursing home

BACKGROUND: the number of nursing home residents (NHRs) in hospital is increasing although hospital admission may be deleterious to their health. OBJECTIVE: to evaluate a system of educating residents, their families, staff and general practitioners about outcomes of dementia, advance care planning (ACP) and hospital in the home. METHODS: we employed one clinical nurse consultant, who utilised the 'Let Me Decide' Advance Care Directive. The intervention area consisted of two hospitals and the 21 nursing homes (NHs) around them compared with another, geographically separate, hospital and the 13 homes around it. We conducted a controlled evaluation monitoring emergency admissions to hospital. RESULTS: emergency calls to the ambulance service from intervention NHs decreased (intervention versus control; -1 versus +21%; P = 0.0019). The risk of a resident being in an intervention hospital bed for a day compared with in a control hospital bed, per NH bed, fell by a quarter from being initially similar [Relative Risk (RR) = 1.01; 95% confidence interval (CI) 0.98-1.04; P = 0.442] to being lower (RR = 0.74; 95% CI 0.72-0.77; P<0.0001). There was no significant change in mortality in the intervention homes, but in the control homes mortality rose in the third year to be 11.2 per 100 beds higher than in the intervention area (P<0.05). CONCLUSION: ACP and hospital in the home can result in decreased hospital admission and mortality of NHRs.     

Direct hospital costs for patients with inflammatory bowel disease in a Canadian tertiary care university hospital

OBJECTIVE: We set out to determine the direct costs of hospitalizations of patients with Crohn's disease and ulcerative colitis admitted to a university-affiliated tertiary care hospital and to contrast the costs of medical versus surgical inpatient care, Crohn's disease versus ulcerative colitis, and to identify dominant components of inpatient costs. METHODS: We used a patient-specific case costing system at Saint Boniface General Hospital, Winnipeg, Manitoba, for fiscal years 1994 and 1995. We extracted all inpatients whose hospital discharge abstracts included ICD-9-CM codes 555 (Crohn's disease) and 556 (ulcerative colitis) among the top eight discharge diagnoses, and performed a chart review on all cases to ensure that the hospitalization was for inflammatory bowel disease and the diagnoses were accurate. We analyzed cases based on their disease diagnosis, primary mode of therapy associated with the hospitalization (medical vs surgical), and their major diagnosis-related group (DRG). This study evaluated direct patient care costs only and costs are expressed in Canadian dollars. RESULTS: Of 362 hospital admissions, 325 were eligible and of these admissions 275 belonged to the digestive system DRGs. Seventy-one (37%) were admitted more than once during the 2 yr of the study, accounting for 202 (62%) of the total number of admissions. The mean cost per admission of all cases of Crohn's disease was $3,149 (95% confidence interval [CI], $2,665-$3,634) and for ulcerative colitis was $3,726 (95% CI $3,008-$4,445). Surgical therapy cases accounted for 49.8% of all admissions, 57.8% of all hospital days, and 60.5% of all costs. Patients treated surgically had more costly hospitalizations than those treated medically, particularly when analyzing only nontotal parenteral nutrition (TPN) cases. Surgical treatment admissions were significantly more costly for ulcerative colitis digestive DRG admissions than Crohn's disease. The nondigestive DRG admissions were more costly than the digestive DRGs in all categories although this was only statistically different among medically treated Crohn's disease. Patients treated medically were similarly costly whether they had Crohn's disease or ulcerative colitis. There was no significant difference in cost per admission among cases admitted multiple times, compared with those admitted only once. TPN cases accounted for 9.5% of cases but 27.1% of costs. TPN-associated hospitalizations were more costly than non-TPN-use hospitalizations but these costs were primarily driven by duration of stay rather than TPN use itself. For all cases, the top five cost categories in descending order were nursing unit bed-days, drugs and pharmacy, diagnostic lab tests, operating room, and diagnostic imaging and endoscopy. CONCLUSIONS: Using our system we could determine direct costs for inpatients with inflammatory bowel disease and the factors that determined increased costs. Medical therapy admissions were similarly costly between Crohn's disease and ulcerative colitis; however, surgical therapy admissions were costlier among ulcerative colitis patients. Admissions for nondigestive DRGs were more costly than those for digestive DRGs. TPN use identified a sicker group of patients who remained in the hospital longer than nonusers and, not surprisingly, these were the costliest patients.     

Appropriateness of patient transfer from a nursing home to an acute-care hospital: a study of emergency room visits and hospital admissions

OBJECTIVE: To determine the appropriateness of transfers to acute care hospitals from a nursing home. DESIGN: Nursing home and hospital records of all the nursing home residents during the 3-year study period were reviewed retrospectively to determine: number and type of transfers; problems identified in the nursing home justifying the transfers; diagnoses made at the hospitals; length of hospital stays; outcome of hospital visits. SETTING: An 80-bed public nursing home. SUBJECTS: 112 residents in the nursing home over the 3-year study period. MAIN OUTCOME MEASURES: Based on the decision of the hospital physician, those transfers resulting in hospital admissions were considered appropriate. As well, transfers to the emergency room with return to the nursing home without hospital admission were also judged to be appropriate if the problems required diagnostic and therapeutic procedures not available in the nursing home. RESULTS: During the 3-year study period, 55 residents (49%) were transferred a total of 102 times. An average of 26% of patients were transferred each year. Direct admissions to acute hospitals accounted for 17% of the transfers, transfers to the emergency room with subsequent admission for 34%, and transfers to the emergency room with subsequent return to the nursing home without admission for 45%. Four percent of patients transferred died in the emergency room. On the basis of the outcome measure, 7% of all transfers could have been diagnosed and treated in the nursing home and were considered inappropriate. CONCLUSIONS: The majority of transfers from this nursing home to acute-care hospitals were appropriate.     

A regional evaluation of variation in low-severity hospital admissions

Objective

Determine patient and hospital-level variation in proportions of low-severity admissions.

Design

Retrospective cohort study.

Setting

Thirty hospitals in a large metropolitan region.

Patients

A total of 43,209 consecutive eligible patients discharged in 1991 through 1993 with congestive heart failure (n=25.213) or pneumonia (n=17,996).

Measurements and main results

Admission severity of illness was measured from validated multivariable models that estimated the risk of in-hospital death; models were based on clinical data abstracted from patients' medical based on clinical data abstracted from patients' medical records. Admissions were categorized as “low severity” if the predicted risk of death was less than 1%. Nearly 15% of patients (n=6,382) were categorized as low-severity admissions. Compared with other patients, low-severity admissions were more likely (p<.001) to be nonwhite and to have Medicaid or be uninsured. Low-severity admissions had shorter median length of stay (4 vs 7 days; p<.001), but accounted for 10% of the total number of hospital days. For congestive heart failure, proportions of low-severity admissions across hospitals ranged from 10% to 25%; 12 hospitals had rates that were significantly different (p<.01) than the overall rate of 17%. For pneumonia, proportions ranged from 3% to 22%; 12 hospitals had rates different from the overall rate of 12%. Variation across hospitals remained after adjusting for patient sociodemographic factors.

Conclusions

Rates of low-severity admissions for congestive heart failure and pneumonia varied across hospitals and were higher among nonwhite and poorly insured patients. Although the current study does not identify causes of this variability, possible explanations include differences in access to ambulatory services, decisions to admit patients for clinical indications unrelated to the risk of hospital mortality, and variability in admission practices of individual physicians and hospitals. The development of protocols for ambulatory management of low-severity patients and improvement of access to outpatient care would most likely decrease the utilization of more costly hospital services.     

Seasonal variation in asthma-related hospital and intensive care unit admissions.

Seasonal trends in asthma-related hospitalizations are widely recognized; however, little is known about trends in asthma-related intensive care unit (ICU) admissions or intubations. The objective of this study is to examine monthly rates of asthma-related ICU admissions and/or intubations as a percent of total asthma-related admissions and to identify seasonality. This analysis was performed in a database of 285 hospitals representing > 3 million annual inpatient visits. Asthma-related hospital admissions for patients aged 5 and older were identified with a primary diagnosis of asthma (493.xx) during calendar years 2001-2002. The percents of the total admissions per month were compared. Monthly means were calculated and data were presented as moving averages. A total of 76,916 hospital admissions were identified with a primary diagnosis of asthma. Just over 10% (n = 7,803) were admitted to the ICU and/or intubated, with the majority among patients > 35 years of age (> 70%). A peak in asthma-related hospitalizations occurred in the winter months (10.3%) and a nadir in the summer months (5.9%; p < 0.004) with similar trends for ICU admissions. Despite this finding, ICU admissions and intubations remained relatively constant as a percent of total asthma-related hospitalizations, ranging from 9.2 to 10.9% and did not dip during the summer months when the overall asthma-related hospitalization rates were lowest. Significant differences in seasonal variation were also noted by age group and by region, but not by gender. These findings suggest a need for year-round vigilance and improved compliance with asthma therapy, especially during the summer when asthma attacks are perceived to be infrequent.     

Common guidelines and equitable service: variation between adjacent districts regarding admissions to elderly care institutions

With the increasing number of older people, the cost of providing institutional care has become a major issue. In 1993 the introduction of care management and a needs-led approach aimed to remove the existing 'perverse incentive' to institutional care and to ensure equality in the dependency levels of those who were admitted to care. To test this consistency, we examined the dependency levels of all persons aged > or = 65 years admitted to residential and nursing homes in two adjacent Health and Social Services (HSS) Community Trusts in Belfast, Northern Ireland, in the year following the introduction of care management. We measured differences between the Trusts with respect to number of admissions, levels of dependency as determined by several standard scoring systems, financial support, source of admission and demographic information. A total of 389 people were surveyed. Trust A had significantly higher levels of physical dependency and mental impairment in both residential and nursing homes than Trust B. We also identified differences in dependency with respect to funding status, with those who were self-funding in Trust B having lower physical dependency in residential and nursing homes and less mental impairment in nursing homes than supplemented residents. This study reports the existence of variations between adjacent Community Trusts operating under the same policy guidelines with respect to the dependency levels of admissions to residential and nursing care. These differences may relate to number of places available, the economic status of the population, and the assessment procedures of the two Community Trusts. The need for standard assessment and eligibility criteria is highlighted.     

Hospital volume-outcome relationships among medical admissions to ICUs

BACKGROUND: Positive relationships between hospital volume and outcomes have been demonstrated for several surgeries and medical conditions. However, little is known about the volume-outcome relationship in patients admitted to medical ICUs. OBJECTIVE: To determine the relationship between hospital volume and risk-adjusted in-hospital mortality for patients admitted to ICUs with respiratory, neurologic, and GI disorders. DESIGN: Retrospective cohort study. SETTING: Twenty-nine hospitals in a single metropolitan area. PATIENTS: Adult ICU admissions from 1991 through 1997. METHODS: Using Cox proportional hazards models, we compared in-hospital mortality between tertiles of hospital volume (high, medium, and low) for respiratory (n = 16,949), neurologic (n = 13,805), and GI (n = 12,881) diseases after adjusting for age, gender, admission severity of illness, admitting diagnosis, and source. Severity of illness was measured using the APACHE (acute physiology and chronic health evaluation) III methodology. RESULTS: Among respiratory and neurologic ICU admissions, hazard ratios were similar (p > or = 0.05) in patients in low-, medium-, and high-volume hospitals. However, among GI diagnoses, risk of mortality was lower in high-volume hospitals, relative to low-volume hospitals (hazard ratio, 0.68; 95% confidence interval [CI], 0.54 to 0.85; p < 0.001), and was somewhat lower in medium-volume hospitals (hazard ratio, 0.83; 95% CI, 0.68 to 1.01; p = 0.06). Among subgroups based on severity of illness, high-volume hospitals had lower mortality, relative to low-volume hospitals, among sicker patients (APACHE III score > 57) in the respiratory cohort (hazard ratio, 0.77; 95% CI, 0.59 to 0.99) and the GI cohort (hazard ratio, 0.67; 95% CI, 0.53 to 0.85). CONCLUSIONS: Associations between ICU volume and risk-adjusted mortality were significant for patients with GI diagnoses and for sicker patients with respiratory diagnoses. However, associations were not significant for patients with neurologic diagnoses. The lack of a consistent volume-outcome relationship may reflect unmeasured patient complexity in higher-volume hospitals, relative standardization of care across ICUs, or lack of efficacy of some accepted ICU processes of care.     

Current status of inpatient HIV care at a tertiary care center in Nepal

The success of the WHO's '3 by 5' programme will depend on the ability of developing countries to provide antiretroviral therapy. The purpose of this study was to determine the current status of HIV care at a major teaching hospital in eastern Nepal. A retrospective cohort study was conducted of admitted HIV-infected patients at BPKIHS between 1993 and 2003, evaluating reasons for admission and the care received. There were 2, 2, 2, 3, 5 and 18 admissions, respectively, from 1998 to 2003. Only 4 were female patients. Two were children, both admitted in the last y studied. 10 admissions (31% of the total) were for opportunistic infections (OIs). Seven patients were prescribed OI prophylaxis, with incorrect dosages in 6. Four patients were prescribed antiretroviral therapy, all in inappropriate dosages or combinations. 13 patients were rapidly discharged without further care as soon as a diagnosis of HIV was made. Hospital admissions of HIV-infected individuals are increasing rapidly. Important segments of the HIV-infected population such as women and children are not receiving medical services. Most admissions are not due to OIs. The care of HIV-infected patients even at a major tertiary care teaching hospital in Nepal is sub-optimal.     

Delay in diagnosis among hospitalized patients with active tuberculosis--predictors and outcomes

Delayed diagnosis of active pulmonary tuberculosis (TB) among hospitalized patients is common and believed to contribute significantly to nosocomial transmission. This study was conducted to define the occurrence, associated patient risk factors, and outcomes among patients and exposed workers of delayed diagnosis of active pulmonary TB. Among 429 patients newly diagnosed to have active pulmonary TB between June 1992 and June 1995 in 17 acute-care hospitals in four Canadian cities, initiation of appropriate treatment was delayed 1 week or more in 127 (30%). This was associated with atypical clinical and demographic patient characteristics, and after adjustment for these characteristics, with admission to hospitals with low TB admission rate of 0.2-3.3 per 10,000 admissions (odds ratio [OR]: 7.4; 95% confidence interval [CI]: 3.2,17.5) or intermediate TB admissions of 3.4-9.9/10,000 (OR: 2.3; CI: 1.6,3.2) as well as potentially preventable (late) intensive care unit admission (OR: 16.8; CI: 2.0,144) and death (OR: 3.3; CI: 1.7,6.5]). In hospitals with low TB admission rates, initially missed diagnosis, smear-positive patients undergoing bronchoscopy, late intensive care unit admission (OR: 2.3; CI: 0.1,56), and death (OR: 3.8; CI: 1.2,12.1) were more common than in hospitals with high TB admissions (> 10/ 10,000); a similar trend was seen in hospitals with intermediate TB admissions. Even after adjustment for workers' characteristics and ventilation in patients' rooms tuberculin conversions were disproportionately high in hospitals with low and intermediate TB admission rates and significantly higher in hospitals with overall TB mortality rate above 10% (OR: 2.5; CI: 1.6,3.7). In the hospitals studied, as the rate of TB admissions decreased, the likelihood of poor outcomes and risk of transmission of TB infection per hospitalized patient with TB increased. Institutional risk of TB transmission was poorly correlated with number of patients with TB and better correlated with indicators of patient care such as delayed diagnosis and treatment and overall TB-related patient mortality.