Time to antibiotic administration and patient outcomes in community-acquired pneumonia: results from a prospective cohort study

ObjectivesCommunity-acquired pneumonia (CAP) is a frequently occurring disease linked to high mortality and morbidity. Previous studies indicated that the administration of antibiotics within 4 hrs of admission can improve key patient outcomes associated with CAP, such as mortality and time to clinical stability. However, the results have been heterogeneous and may not be applicable to all healthcare settings. Therefore, we designed a cohort study to estimate the impact of timely antibiotic administration on outcomes in patients admitted with CAP.MethodsThe impact of antibiotic administration within 4 hrs of admission and other covariates were estimated for 30-day mortality, stability within 72 hrs, 30-day readmission and time to discharge, using multivariable regression models. Sensitivity analyses were performed on a subset of patients with the most severe CAP and a propensity score matched cohort.ResultsIn total, 2264 patients were included. Of these, 273 (12.1%) died within 30 days of admission, 1277 (56.4%) were alive and stable within 72 hrs and 334 (14.8%) were discharged alive and readmitted within 30 days. Median length of hospital stay was 5 days (interquartile range 3–8). In all models, the administration of antibiotics within 4 hrs of admission had no significant effect on the outcomes. The adjusted odds ratios (OR) derived from the multivariable models for 30-day mortality, stability within 72 hrs and 30-day readmission were 1.01 (95% confidence interval (CI) 0.76; 1.33), 0.88 (95% CI 0.74; 1.05) and 1.05 (95% CI 0.82; 1.34). The adjusted hazard ratio (HR) for time to discharge was 1.00 (95% CI 0.91; 1.10).DiscussionA strict 4-hr threshold for antibiotic administration in all patients admitted with CAP is not reasonable. Instead, our results suggested that patients should be triaged and prioritized according to age, comorbidities, clinical condition and pneumonia severity.     

Suicide among psychiatric patients of a district general hospital

Twenty-two psychiatric patients who committed suicide while receiving hospital treatment or within 3 months of discharge from psychiatric care were studied using general population statistics, a random sample of 100 psychiatric patients and a control group matched individually with the hospital suicides. The rate of suicide among psychiatric in-patients was over 50 times that in the general population. A higher vulnerability to suicide was detected among in-patients (v. other patient groups), men (v. women) and middle-aged patients (v. older and younger patients). Suicides were differentiated from controls in having suffered more losses (P less than 0.05), being psychiatrically ill for the first time (P less than 0.05), having a past history of deliberate self-harm (P less than 0.05), and not receiving a schizophrenic diagnosis (P less than 0.02). People with mid-life crises, patients who swing rapidly into depression while receiving treatment, and individuals who are judged to be depressed because of personal problems may carry a particularly high suicide risk during psychiatric treatment.     

Factors associated with the non-assessment of self-harm patients attending an Accident and Emergency Department: results of a national study

BACKGROUND: Psychosocial assessment of self-harm patients by mental health service staff is an important aspect of their care. Nevertheless, in England around half of those attending a general hospital following a self-harm episode do not receive such an assessment. We have investigated the reasons for this and the characteristics of patients associated with self-discharge or planned discharge without a psychosocial assessment. METHOD: 8-week audits of self-harm attendances were carried out in 32 Accident and Emergency Departments in England. Where a specialist psychosocial assessment by mental health services was not carried out, information on the reason for this was requested. Due to incomplete data 10 of the 32 hospitals were excluded from analysis. RESULTS: There were 2780 self-harm attendances at the 22 hospitals. Psychosocial assessments were carried out on 59% of episodes. Among those not assessed, 57% discharged themselves and the remainder were discharged by hospital staff. In multivariable models, being male, taking illegal drugs/alcohol, attendance out of office hours and not being admitted to a hospital bed were associated with an increased risk of self-discharge. Younger subjects were more likely to self-discharge, but this association was explained by age-related admission patterns. Young age (<45 years), no previous self-harm and not being admitted were associated with an increased likelihood of discharge by hospital staff without a psychosocial assessment. The apparent increased risk of discharge without an assessment for those who self-lacerated was attenuated after allowing for their lower admissions rates. LIMITATIONS: Missing data from 10 hospitals led to their exclusion from analysis. Only the primary reason for discharge was reported on the audit forms. CONCLUSIONS: Those at elevated risk of suicide--older patients and those with a history of self-harm--were the least likely to be discharged by hospital staff without a psychosocial assessment. However, males (at increased risk of suicide compared with females), those who had taken illegal drugs or/and alcohol and those attending 'out of hours' were more likely to self-discharge. Services need to be modified and evaluated, based on further information about why such individuals are not currently engaging in services.     

The influence of media reporting of a celebrity suicide on suicidal behavior in patients with a history of depressive disorder

BACKGROUND: Few studies have directly assessed the impact of a specific media report in vulnerable people. This study investigates possible influences of media reporting of a celebrity suicide on subsequent suicidal behaviors and associated risk factors among depressive patients. METHODS: Depressive patients (N=461) were assessed through a structured interview soon after extensive media reporting of a celebrity suicide. RESULTS: Among 438 depressive patients exposed to the media report, 38.8% reported an influence on subsequent suicidal behaviors, including 24 (5.5%) with a suicide attempt. The risk of such influence was highest among patients in a severe depressive state just prior to the media report (adjusted OR 7.81, 95% CI 3.28-18.59). Such influence on a subsequent suicide attempt was highest in patients with a most recent suicide attempt within one month prior to the media reports (adjusted hazard ratio 11.91, 95% CI 3.76-37.72). LIMITATIONS: Our finding of the significant media influence may reflect adverse thoughts among more suicidal and depressed individuals. The possible influence of other factors on the findings cannot be ruled out. CONCLUSIONS: This study has provided more convincing evidence suggesting negative influences of media reporting of a celebrity suicide on subsequent suicidal behaviors among depressive patients. Particular attention in terms of potential negative media influences should be paid to patients who are younger and currently depressed and have made a recent suicide attempt.     

Excess length of stay and readmission following hospital-acquired bacteraemia: a population-based cohort study applying a multi-state model approach

ObjectivesPopulation-based estimates of excess length of stay after hospital-acquired bacteraemia (HAB) are few and prone to time-dependent bias. We investigated the excess length of stay and readmission after HAB.MethodsThis population-based cohort study included the North Denmark Region adult population hospitalized for ≥48 hours, from 2006 to 2018. Using a multi-state model with 45 days of follow-up, we estimated adjusted hazard ratios (aHRs) for end of stay and discharge alive. The excess length of stay was defined as the difference in residual length of stay between infected and uninfected patients, estimated using a non-parametric approach with HAB as time-dependent exposure. Confounder effects were estimated using pseudo-value regression. Readmission after HAB was investigated using the Cox regression.ResultsWe identified 3457 episodes of HAB in 484 291 admissions in 205 962 unique patients. Following HAB, excess length of stay was 6.6 days (95% CI, 6.2–7.1 days) compared with patients at risk. HAB was associated with decreased probability of end of hospital stay (aHR, 0.60; 95% CI, 0.57–0.62) driven by the decreased hazard for discharge alive; the aHRs ranged from 0.30 (95% CI, 0.23–0.40) for bacteraemia stemming from ‘heart and vascular’ source to 0.72 (95% CI, 0.69–0.82) for the ‘urinary tract’. Despite increased post-discharge mortality (aHR, 2.76; 95% CI, 2.38–3.21), HAB was associated with readmission (aHR, 1.42; 95% CI, 1.31–1.53).ConclusionHAB was associated with considerably excess length of hospital stay compared with hospitalized patients without bacteraemia. Among patients discharged alive, HAB was associated with increased readmission rates.     

Patients' ratings of the in-hospital discharge briefing and post-discharge primary care follow-up: The association with 30-day readmissions

ObjectiveWe examined whether patients' ratings of their in-hospital discharge briefing and their post-discharge Primary Care Physicians' (PCP) review of the discharge summary are associated with 30-day readmissions.MethodsA prospective study of 594 internal-medicine patients at a tertiary medical-center in Israel. The in-hospital baseline questionnaire included sociodemographic characteristics, physical, mental, and functional health status. Patients were surveyed by phone about the discharge and post-discharge processes. Clinical data and health-service use was retrieved from a central data-warehouse. Multivariate regressions modeled the relationship between in-hospital baseline characteristics, discharge briefing, PCP visit indicator, the PCP discharge summary review, and 30-day readmissions.ResultsThe extent of the PCPs' review of the hospital discharge summary at the post-discharge visit was rated higher than the in-hospital discharge briefing (3.46 vs. 3.17, p = 0.001) and was associated with lower odds of readmission (OR=0.35, 95% CI 0.26–0.45). The model that included this assessment performed better than the in-hospital baseline, the in-hospital discharge-briefing, and the PCP visit models (C-statistic = 0.87, compared with: 0.70, 0.81, 0.81, respectively).ConclusionsProviding extensive post-discharge explanations by PCPs serves as a significant protective factor against readmissions.Practice implicationsPCPs should be encouraged to thoroughly review the discharge summary letter with the patient.     

Post-discharge oral antimicrobial use among hospitalized patients across an integrated national healthcare network

ObjectivesAntimicrobial stewardship programmes have focused on reducing inappropriate inpatient antimicrobial prescribing, but several small studies have found a large portion of antimicrobial exposure occurs immediately after hospital discharge. In this study, we describe the prescribing of oral antimicrobials at hospital discharge across an integrated national healthcare system. At the hospital level, we also compare total inpatient antimicrobial use and post-discharge oral antimicrobial use.MethodsThis retrospective cross-sectional study used national administrative data to identify all acute-care admissions during 2014–2016 within the Veterans Health Administration (VHA). We evaluated inpatient days of therapy (DOT) and post-discharge DOT, defined as oral outpatient antimicrobials dispensed at the time of hospital discharge. At the hospital level, inpatient DOT/100 admissions were compared with post-discharge DOT/100 admissions using Spearman's rank-order correlation.ResultsThere were 1 681 701 acute-care admissions across 122 hospitals, and 335 369 (19.9%) were prescribed an oral antimicrobial at discharge. Fluoroquinolones (38.3%) were the most common post-discharge antimicrobial. At the hospital level, median inpatient antimicrobial use was 331.3 (interquartile range (IQR) 284.9–367.9) DOT/100 admissions and median post-discharge use was 209.5 (IQR 181.5–239.6) DOT/100 admissions. Thirty-nine per cent of the total duration of antimicrobial exposure occurred after discharge. At the hospital-level, the metrics of inpatient DOT/100 admissions and post-discharge DOT/100 admissions were weakly positively correlated with rho=0.44 (p < 0.001).ConclusionsA large proportion of antimicrobial exposure among hospitalized patients occurred immediately following discharge. Antimicrobial-prescribing at hospital discharge provides an opportunity for antimicrobial stewardship. Hospital-level stewardship metrics need to include both inpatient and post-discharge antimicrobial-prescribing to provide a comprehensive assessment of hospital-associated antimicrobial use.     

Repositive RT-PCR test in discharged COVID-19 patients during medical isolation observation

Objectives: The epidemiological and clinical characteristics of patients with coronavirus disease 2019 (COVID-19) have been researched. However, the prevalence of repositivity by real-time PCR for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains unclear.Methods: A retrospective study was conducted involving 599 discharged patients with COVID-19 in a single medical centre. The clinical features of patients during their hospitalization and 14-day post-discharge quarantine were collected.Results: A total of 122 patients (20.4%) out of 599 patients retested positive after discharge. Specifically, 94 (15.7%) retested positive within 24 h of discharge, and another 28 patients (4.7%) were repositive on day 7 after discharge, although none showed any clinical symptomatic recurrence. Both repositives and non‑repositives have similar patterns of IgG and IgM. Notably, the length of hospitalization of non-repositive patients was longer than that of 24-h repositive patients and 7-day repositive patients. In addition, the length of hospitalization of 24-h repositive patients was shorter than that of 7-day repositive patients, indicating that the length of hospitalization was also a determinant of viral shedding.Conclusion: Our study provides further information for improving the management of recovered and discharged patients, and further studies should be performed to elucidate the infectiveness of individuals with prolonged or RNA repositivity.     

Responses to depression in unipolar depressed patients: an investigation of Nolen-Hoeksema's response styles theory

BACKGROUND: The response styles theory suggests that rumination in response to depressed mood exacerbates and prolongs depression, while distraction ameliorates and shortens it. Gender differences in response styles are said to contribute to the observed gender differences in the prevalence of unipolar depression. While empirical support for the theory has been found from a variety of non-clinical studies, its generalizability to clinically depressed patient populations remains unclear. METHODS: A cohort of 52 unipolar depressed in-patients was assessed with the Response Styles Questionnaire during in-patient stay (T1) and 4 weeks after discharge (T2). The patients were followed up 4 months after discharge (T3). Clinical assessment included the SCAN-PSE-10. RESULTS: Moderate and statistically significant retest-stabilities for rumination and distraction were found, comparable for patients with stable and changing depression status from T1 to T2. A cross-sectional diagnosis of a major depressive episode was associated with rumination, while gender was not. Post-discharge baseline rumination (T2), adjusted for concurrent depression, predicted follow-up levels of depression (T3), and, in patients who were non-remitted at post-discharge baseline, it predicted presence of a major depressive episode at follow-up (T3). Results on distraction were more ambiguous. CONCLUSIONS: Our results suggest that rumination is likely to have a deteriorating impact on the course of clinical episodes of depression in unipolar depressed patients. Larger longitudinal patient studies are needed to validate these findings.     

Smoking cessation after discharge among Japanese patients with established ischemic heart disease: a prospective cohort study

In this prospective cohort study for Japanese patients with established ischemic heart disease (IHD), the authors investigated the rate of success of smoking cessation 3 months after hospital discharge and its related factors. The subjects included 90 current smokers admitted for IHD. A total of 58 subjects (64%) had quit smoking for 3 months after being discharged. In comparison with subjects with acute myocardial infarction, those with stable angina (SA) showed a significantly lower frequency of smoking cessation (relative risk of resuming smoking (95% confidence interval):2.06 (1.09, 3.92), p=0.036). This relationship remained significant even after controlling for sex, age, and scores of the Fagerstrom Test for Nicotine Dependence (adjusted odds ratio:3.39 (1.01, 11.37), p=0.048). However, it became insignificant when hospital admission followed by emergency medical service (EMS) care was additionally adjusted (adjusted odds ratio:2.48 (0.36, 16.97), p=0.356). The smoking cessation rate in this study was identical to that observed in studies conducted in Japan prior to the recent social changes with regard to tobacco use. SA still appears to be a risk factor for smoking resumption after discharge. Experiencing EMS care would be an intermediate variable in this relationship.     

Risk factors for 30-day hospital readmission following myeloablative allogeneic hematopoietic cell transplantation (allo-HCT)

Patient readmission within 30 days from discharge has been perceived by the Centers for Medicare and Medical Services as an indicator of poor healthcare quality for specific high-cost medical conditions. Patients who undergo allogeneic hematopoietic cell transplantation (allo-HCT) are often being readmitted. Our study identified the risk factors for 30-day readmission among 618 adult recipients of myeloablative allo-HCT from 1990 to 2009. Two hundred forty-two (39%) of 618 patients (median age = 42 years [range: 18-66]) were readmitted a median of 10 days (range: 1-30) from their hospital discharge. Median duration of readmission was 8 days (range: 0-103). Infections (n = 68), fever with or without identified source of infection (n?= 63), gastrointestinal complications (n = 44), graft-versus-host disease (GVHD) (n = 38), and other reasons (n = 29) accounted for 28%, 26%, 18%, 16%, and 12% of readmissions, respectively. During their index admission, patients who were subsequently readmitted had more documented infections (P < .001), higher hematopoietic cell transplantation comorbidity index (HCT-CI) (P < .01), total body irridiation (TBI)-based conditioning (P < .001), unrelated donor (P < .001), and peripheral stem cell (P = .014) transplantation. In multivariable analysis, HCT-CI (odds ratio [OR] = 1.78; 95% confidence interval [CI], 1.25-2.52), TBI-based preparative regimen (OR = 2.63; 95% CI, 1.67-4.13), and infection during admission for allo-HSCT (OR = 2.00; 95% CI, 1.37-2.92) predicted 30-day readmission. Thirty-day readmission itself was an independent predictor of all-cause mortality (hazard ratio [HR](Adj) = 1.66; 95% CI, 1.36-2.10). Our data emphasize the importance of a risk-standardized approach to 30-day hospital readmission if it is used as a quality-of-care metric for bone marrow transplantation.     

Associations between biomarkers at discharge and co-morbidities and risk of readmission after community-acquired pneumonia: a retrospective cohort study

To investigate whether hemoglobin, white blood cell count (WBC), urea, sodium, albumin, and C-reactive protein at discharge in patients hospitalized for community-acquired pneumonia (CAP) are associated with 30-day readmission. This study is a retrospective cohort study, which included all adult patients discharged after hospitalization for CAP from three Danish hospitals between January 2011 and July 2012. The outcome was all-cause, unplanned, 30-day readmission. Biomarker concentrations at discharge were transformed into binary variables by using either upper or lower quartiles as cut-off; the upper quartile was used for WBC, urea, and C-reactive protein, and the lower quartile was used for hemoglobin, sodium, and albumin. The study population consisted of 1149 patients. One hundred eighty-four (16.0%) patients were readmitted. Independent risk factors of readmission were WBC?≥?10.6 cells?×?10⁹/L (hazard ratio 1.50; 95% CI, 1.07–2.11) and albumin <32 g/L (hazard ratio 1.78; 95% CI, 1.24–2.54) at discharge and the presence of ≥?2 co-morbidities (hazard ratio 1.74; 95% CI, 1.15–2.64). When WBC, albumin, and co-morbidities were combined into a risk-stratification tool, there was a step-wise increase in risk of readmission for patients with 1, 2, or 3 risk factors with hazard ratios of 1.76 (95% CI, 1.25–2.49), 2.59 (95% CI, 1.71–3.93), and 6.15 (95% CI 3.33–11.38), respectively. WBC?≥?10.6 cells?×?10⁹/L and albumin <?32 g/L at discharge and the presence of ≥?2 co-morbidities were independently associated with increased risk of 30-day readmission.     

CALIPSO: A Randomized Controlled Trial of Calfactant for Acute Lung Injury in Pediatric Stem Cell and Oncology Patients

To assess if calfactant reduces mortality among children with leukemia/lymphoma or after hematopoietic cell transplantation (HCT) with pediatric acute respiratory distress syndrome (PARDS), we conducted a multicenter, randomized, placebo-controlled, double-blinded trial in 17 pediatric intensive care units (PICUs) of tertiary care children's hospitals. Patients ages 18 months to 25 years with leukemia/lymphoma or having undergone HCT who required invasive mechanical ventilation for bilateral lung disease with an oxygenation index (OI) > 10 and <37 were studied. Interventions used were intratracheal instillation of either calfactant or air placebo (1 or 2 doses). Forty-three subjects were enrolled between November 2010 and June 2015: 26 assigned to calfactant and 17 to placebo. There were no significant differences in the primary outcome, which was survival to PICU discharge (adjusted hazard ratio of mortality for calfactant versus placebo, 1.78; 95% confidence interval, .53 to 6.05; P?=?.35), OI, functional outcomes, or ventilator-free days, adjusting for risk strata and Pediatric Risk of Mortality (PRISM) score. Despite the risk-stratified randomization, more allogeneic HCT patients received calfactant (76% and 39%, respectively) due to low recruitment at various sites. This imbalance is important because independent of treatment arm and while adjusting for PRISM score, those with allogeneic HCT had a nonsignificant higher likelihood of death at PICU discharge (adjusted odds ratio, 3.02; 95% confidence interval, .76 to 12.06; P?=?.12). Overall, 86% of the patients who survived to PICU discharge also were successfully discharged from the hospital. These data do not support the use of calfactant among this high mortality group of pediatric leukemia/lymphoma and/or HCT patients with PARDS to increase survival. In spite of poor enrollment, allogeneic HCT patients with PARDS appeared to be characterized by higher mortality than even other high-risk immunosuppressed groups. Conducting research among these children is challenging but necessary, because survival to PICU discharge usually results in successful discharge to home.     

Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes

BACKGROUND: A discharge against medical advice (AMA) after an asthma hospitalization is a frustrating problem for health care providers, yet little is known about this occurrence. OBJECTIVE: To determine the baseline characteristics, reasons for leaving, and clinical outcomes of patients with asthma who leave AMA. METHODS: A retrospective study from 1999 to 2004 of all asthma discharges from 3 large hospitals in Detroit compared those who left AMA with those who left with medical approval. RESULTS: There were 180 patients who left AMA and 3457 patients who had a standard discharge. Patients with asthma who left AMA were more likely to be younger, male, have Medicaid or lack insurance, require intensive care unit admission, and have a lower socioeconomic status than patients with asthma discharged with approval (P < .05 for all comparisons). There was no difference in race, day of the week admitted, or month admitted. Among records that documented a reason for leaving AMA, the most common was dissatisfaction with care, although a variety of motives were found. Finally, patients who left AMA were more likely to have an asthma relapse within 30 days. This included both emergency department revisits (21.7% vs 5.4%; P < .001) and readmission to the hospital (8.5% vs 3.2%; P < .001). CONCLUSION: Patients with asthma who leave AMA have demographic and hospital admission characteristics that differ from those who leave with approval. The reasons why patients with asthma leave AMA are varied. Within 30 days, patients with asthma who leave AMA have much higher readmission and emergency department return rates. CLINICAL IMPLICATIONS: Patients with asthma who leave AMA are at increased risk of relapse.     

Retrospective controlled study of inpatient ECT: does it prevent suicide?

BACKGROUND: This study examined the use of ECT among inpatients who committed suicide at a provincial psychiatric hospital. METHODS: A total of 45 psychiatric in-patients who committed suicide at a provincial psychiatric hospital were compared with a gender, age and admission diagnosis matched group of 45 hospitalized patients to examine the use of electroconvulsive therapy during the last 3 months of hospitalization. RESULTS: No difference in the utilization of ECT was found in the two groups. LIMITATIONS: Retrospective design and small sample size. CONCLUSIONS: We failed to demonstrate that ECT had prevented suicide in hospitalized patients. Future prospective studies with large sample size are needed to further examine this question.     

The effect of short-course gentamicin therapy on kidney function in patients with bacteraemia—a retrospective cohort study

The nephrotoxic potential of aminoglycosides is primarily correlated to the duration of therapy. However, there are discrepancies between previous studies regarding the effect of short course treatment. The aim of this study was to compare renal function, renal recovery and mortality in a large cohort of patients with bacteraemia, who were empirically treated with regimens with and without a short course (≤?3 days) of once daily dosing of gentamicin. This was a retrospective propensity score-matched cohort study based on all patients with bacteraemia in a Danish hospital in the period 2010–2013. We included 702 patients who received gentamicin, and 702 who did not receive gentamicin. To determine the impact of gentamicin on renal function, we used a modified version of the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for acute kidney injury (AKI), and the resulting data were analyzed by logistic regression. We used Cox regression analysis to compare the adjusted mortality rates between the two groups. According to the KDIGO criteria, we found no significant difference in the occurrence of AKI between the two groups (odds ratio (OR) 0.90 (95% CI 0.68–1.20)). We found that recovery of renal function was similar in the two groups, OR 1.00 (95% CI 0.63–1.60). The hazard ratio for 90-day all-cause mortality was 1.02 (95% CI 0.84–1.25). Short-course empirical gentamicin treatment of patients with bacteraemia was not associated with an increased incidence of AKI nor all-cause mortality in this study, and we observed similar reversibility of renal function.     

Predictors of psychiatric readmissions in the short- and long-term: a population-based study in taiwan

OBJECTIVES

To explore the risks and rates of readmission and their predictors 14 days, one year, and five years after discharge for the psychiatric population in Taiwan.

METHODS

This was a prospective study based on claims from 44,237 first-time hospitalized psychiatric patients discharged in 2000, who were followed for up to five years after discharge. The cumulative incidence and incidence density of readmission were calculated for various follow-up periods after discharge, and Cox proportional hazard models were generated to identify the significant predictors for psychiatric readmission.

RESULTS

The less than 14-day, one-year, and five-year cumulative incidences were estimated at 6.1%, 22.3%, and 37.8%, respectively. The corresponding figures for incidence density were 4.58, 1.04, and 0.69 per 1,000 person-days, respectively. Certain factors were significantly associated with increased risk of readmission irrespective of the length of follow-up, including male gender, length of hospital stay >15 days, economic poverty, a leading discharge diagnosis of schizophrenia/affective disorders, and residence in less-urbanized regions. Compared to children/adolescents, young adults (20–39 years) were significantly associated with increased risks of CONCLUSIONSThis study found that the significant predictors for psychiatric readmission 14 days to five years after discharge were essentially the same except for patient’s age and hospital accreditation level. This study also highlighted the importance of socioeconomic factors in the prediction of readmission.     

Short term patient outcomes after total knee arthroplasty: Does the implant matter?

BackgroundNewer implants for total knee arthroplasty (TKA) often gain market share at higher cost with little patient-reported and long-term clinical data. We compared outcomes after TKA using two different implants: DePuy PFC Sigma and Attune.MethodsUsing a prospective data repository from an academic tertiary medical center, we analyzed 2116 TKAs (1603 Sigma and 513 Attune) from April 2011 through July 2016. Outcomes included length of surgery, length of stay, facility discharge, 90-day reoperation, range of motion (ROM) change, and patient-reported physical function (PCS).ResultsThere was no difference in length of surgery (Attune ? 2.87 min, P = 0.143). Implant type was not associated with extended LOS (> 3 days) (OR 0.80, P = 0.439). There was no difference in facility discharge (OR 0.65, P = 0.103). Unadjusted 90-day reoperations were 0.3% for Sigma and 1.0% for Attune cohorts (P = 0.158). Sigma implants were associated with more ROM improvement in unadjusted analyses (+ 2.1 degree improvement P = 0.031). Fifty nine percent of the Sigma cohort and 49% of the Attune cohort achieved the minimal clinically important (MCID) change for PCS improvement, although there was no adjusted difference in achieving MCID (Attune OR 0.84, P = 0.435). There was no adjusted difference in absolute PCS improvement (Attune + 0.12 score, P = 0.864).ConclusionsOur data show no difference in physical function and most outcomes between Sigma and Attune. Attune implants had shorter absolute LOS, but there were no differences in extended LOS.     

Association between treatment duration and mortality or relapse in adult patients with Staphylococcus aureus bacteraemia: a retrospective cohort study

ObjectivesThe aim was to evaluate the effect of duration of therapy (DOT) on mortality and relapse for patients with Staphylococcus aureus bacteraemia (SAB).MethodsWe performed a retrospective single-centre cohort study including adult patients with SAB. We determined the association between DOT (≤14 days versus >14 days) and mortality by adjusted hazard ratios (aHR) and 95% confidence intervals through Cox regression adjusted for immortal-time bias and confounding by indication, stratified by presence of complicated SAB (any of: endocarditis, implant, duration of SAB >2 days, fever >3 days). The primary outcome was 90-day all-cause mortality, and the secondary outcome was 90-day relapse.ResultsBetween January 2010 and December 2015, we included 530 patients, of whom 94 out of 530 (17.7%) had methicillin-resistant SAB and 305 out of 530 (57.6%) had complicated SAB. Ninety-day mortality was 27.0% (143/530), with no significant trend across the study period; median time to death was 17 days (interquartile range (IQR) 8–30) after onset of SAB. Median DOT was 20 days (IQR 13–39). Patients with complicated SAB had significantly reduced mortality with DOT >14 days (aHR 0.32, 95% CI 0.16–0.64). DOT was not associated with mortality in patients with uncomplicated SAB (aHR 0.85; 0.41–1.78). Eighteen (18/530) patients (3.4%) relapsed; on univariate analysis, DOT was not associated with relapse (HR 1.01; 0.97–1.06).ConclusionsDOT >14 days is associated with higher survival in patients with complicated SAB, but not for patients with uncomplicated SAB. No association was found for relapse, but 90-day relapse was very low in this cohort. Importantly, 90-day mortality remained high across the study period.     

Impact of a Novel Post-Discharge Transitions of Care Clinic on Hospital Readmissions

BackgroundThe Center for Medicare and Medicaid Services (CMS) has targeted hospital readmissions, which cost $17 billion per year, as one potential solution to reduce rising health care costs. Studies have documented the ability of Transitions of care (TOC) services to reduce readmissions in high risk patients. However, the vast majority of studies have not explored TOC services for all-cause admissions nor TOC clinics led by hospitalists. The goal of this study is to provide preliminary data regarding the potential effectiveness of a hospitalist-led TOC clinic servicing all patients on hospital readmission rates.MethodsThis cross-sectional feasibility study analyzed patients on a tertiary hospital teaching service. All discharged patients from January 2016 to September 2018 were given an appointment at the TOC clinic within 14 days of discharge. The control group consisted of patients assigned to the teaching service from January 2018 to November 2018 that were not offered a TOC appointment.ResultsOverall, 1373 patients (n = 1373) were included in this study between January 2016 and September 2018. The control group consisted of 1000 patients who were not offered follow up in the TOC clinic while the TOC group consisted of 373 patients who did attend a follow up appointment in the TOC clinic. The study participants (n = 1373) included patients admitted to the hospital for any diagnosis and were analyzed for all cause readmission rates. The TOC group consisted of 52% African Americans, 52% Medicare patients and 8% Medicaid patients. Demographic information for the control group was not available. The TOC group had a statistically significant 42% decreased risk of being readmitted within 30 days of discharge (RR = 0.58, 95% CI: 0.40-0.83). These data showed a statistically significant difference between the TOC group and control group in relation to the incidence of 30-day readmissions (p-value = 0.002).ConclusionAmong Medicare and Medicaid beneficiaries and commercial health insurance patients, this hospitalist-led TOC intervention was associated with a statistically significant reduction in 30-day readmissions following discharge for all-cause hospital admissions.