Insulin-like growth factor I as an indicator of protein-energy undernutrition among metabolically stable hospitalized elderly.

The primary objective of this cross-sectional study was to test the hypothesis that the plasma concentration of insulin-like growth factor I (IGF-I) correlates with the risk of in-hospital morbidity among metabolically stable elderly. The secondary objective was to determine whether IGF-I correlates with other putative indicators of protein-energy nutritional status.

To meet these objectives, 110 randomly selected admissions to a Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital were studied. The average age of the study patients was 76 years; 98% were male, and 78% were white.

At admission, each patient completed a comprehensive medical, functional, neuropsychological, and nutritional assessment including the attainment of a plasma IGF-I determination. While in the hospital, each subject was monitored daily for development of complications.

Subsequent to GRU admission, 44 patients (40%) experienced at least one complication; 36 patients (33%) experienced an infectious complication, 8 patients (7%) experienced a life-threatening complication, and 5 patients (5%) experienced a life-threatening infectious complication. There was no correlation between IGF-I and development of a non-life-threatening complication (”any complication” or “any infectious complication”). However, IGF-I was a strong predictor of “life-threatening” and “life-threatening infectious” complications. The logistic regression model incorporating the independent variable IGF-I differentiated the patients who would develop a “life-threatening” complication from those who would not with a sensitivity of 75%, a specificity of 76%, and an overall predictive accuracy of 76%. IGF-I was highly correlated with admission serum albumin, transferrin, and cholesterol, triceps skinfold thickness, body weight expressed as a percent of ideal, and body mass index. There was no correlation between IGF-I and the Katz Index of Activities of Daily Living score, age, or anergy status.

IGF-I is a strong predictor of “life-threatening” and “life-threatening infectious” complications and may be a clinically useful marker for protein-energy undernutrition among metabolically stable hospitalized elderly patients.     

Influencia de la duración de la estancia hospitalaria sobre la mortalidad tras el alta en pacientes mayores con patología médica aguda

ObjectiveTo analyse whether hospital length of stay is associated with mortality at six months after discharge in the elderly.MethodsAn observational longitudinal study of patients surviving at hospital discharge. A binary logistic regression analysis was performed to study factors related to extended stay (> 12 days). The relationship between mortality at 6 months and length-of-stay quartiles was studied using a Cox regression analysis.Results1180 patients were studied with a mean age of 86.6 years (standard deviation: 6.9). The median length of stay was 8 days (interquartile range: 5-12). Six-month mortality was 26.1%. After adjusting for age, gender, main diagnosis, comorbidity, albumin at admission, functional deterioration at admission and functional and mental status at discharge, hospital stay above the median was associated with mortality at 6 months: 9-12 days, HR = 1.79, 95% CI: 1.01-3.14; and > 12 days, HR = 2.04, 95% CI: 1.19-3.53.ConclusionsProlonged hospital stay is an independent risk factor for mortality at 6 months after discharge.     

Sleep Quality in the Survival of Elderly Taiwanese: Roles for Dietary Diversity and Pyridoxine in Men and Women

Objectives: The purpose of this study was to investigate dietary contributors to relationships between sleep and all-cause mortality among elderly men and women using a prospective cohort study.

Setting: The representative Nutrition and Health Survey in Taiwan (NAHSIT) for elders during 1999–2000.

Subjects: One thousand eight hundred sixty-five individuals aged ≥65 years from NAHSIT (942 men and 923 women).

Measures of Outcome: Dietary diversity scores (DDS) were from 24-hour dietary recalls. Participants were examined and fasting blood was taken. Sleep quality was assessed by questionnaire and classified as poor, fair, or good. Death registry linkage was made until December 31, 2008.

Results: For women, poor sleepers had significantly lower vegetable and vitamin B-6 intakes compared to good sleepers (p < 0.05). For men, good and fair sleepers had a lower risk of death compared to poor sleepers after adjustment with hazards ratios (HRs) and 95% confidence intervals (CIs) of 0.60 (0.42–0.87) and 0.55 (0.36–0.86). The joint HRs for “DDS > 4 and good sleep” were 0.38 (0.22–0.66) for men and 0.52 (0.30–0.88) for women compared to “DDS ≤ 4 and poor sleep.” The joint HRs for “plasma pyridoxal phosphate (PLP) adequate and fair sleep” were 0.27 (0.11–0.65) and 0.49 (0.23–1.07) compared to “insufficient and poor sleep” for men and women; for women, PLP adequacy provided significantly reduced HRs for good and poor sleep.

Conclusions: Sleep quality played a more important role in mortality for men than for women. Sufficient dietary diversity in men could offset the adverse effect on mortality of poor sleep. In women, PLP predicts mortality more than sleep does.     

Healthcare Resource Utilization of Patients With COVID-19 Visiting US Hospitals

ObjectivesSevere cases of COVID-19 have overwhelmed hospital systems across the nation. This study aimed to describe the healthcare resource utilization of patients with COVID-19 from hospital visit to 30 days after discharge for inpatients and hospital-based outpatients in the United States.MethodsA retrospective cohort study was conducted using Premier Healthcare Database COVID-19 Special Release, a large geographically diverse all-payer hospital administrative database. Adult patients (age ≥ 18 years) were identified by their first, or “index,” visit between April 1, 2020, and February 28, 2021, with a principal or secondary discharge diagnosis of COVID-19.ResultsOf 1 454 780 adult patients with COVID-19, 33% (n = 481 216) were inpatients and 67% (n = 973 564) were outpatients. Among inpatients, mean age was 64.4 years and comorbidities were common. Most patients (80%) originated from home, 10% from another acute care facility, and 95% were admitted through the emergency department. Of these patients, 23% (n = 108 120) were admitted to intensive care unit and 14% (n = 66 706) died during index hospitalization; 44% were discharged home, 15% to nursing or rehabilitation facility, and 12% to home health. Among outpatients, mean age was 48.8 years, 44% were male, and 60% were emergency department outpatients (n = 586 537). During index outpatient visit, 79% were sent home but 10% had another outpatient visit and 4% were hospitalized within 30 days.ConclusionsCOVID-19 is associated with high level of healthcare resource utilization and in-hospital mortality. More than one-third of inpatients required post hospital healthcare services. Such information may help healthcare providers better allocate resources for patients with COVID-19 during the pandemic.     

Meningococcal vaccines and protein-energy undernutrition in children in the African meningitis belt

BackgroundVaccines to prevent meningococcal meningitis in the African meningitis belt include PsACWY, a polysaccharide-only vaccine; and PsA-TT, a polysaccharide-protein conjugate vaccine. Protein-energy undernutrition, a condition where children do not receive enough macro- or micronutrients, is related to increased risk of infectious diseases and poor immune function. Reduced immune function could affect vaccine immunogenicity. We investigated connections between protein-energy undernutrition and vaccine immunogenicity and antibody waning to PsACWY and PsA-TT in children in the African meningitis belt.MethodsThis is a secondary analysis of data collected as part of four clinical trials testing the safety and efficacy of PsA-TT in children in Mali, Ghana, and Senegal. We identified whether anthropometric growth indices (low height-for-age, weight-for-height, or weight-for-age Z-score categories) were related to reduced vaccine-elicited antibody (measured with rabbit complement) from pre- to 1 month post-vaccination, in linear regression models. We also identified whether these growth indices were related to increased waning for vaccine-elicited antibody over time, in linear regression models.ResultsA total of 697 children were included in our analysis, of which 350 (50.2%) were female; the mean (SD) age was 1.0 (1.1) years, and 578 (83.0%) received PsA-TT. In linear regression models, no consistent statistical relationship was seen between pre-vaccination anthropometric Z-score categories and vaccine immunogenicity, or decline in antibody over time, for either vaccine, although children with low weight-for-height had a greater decline in antibody from 1 to 6 months post-vaccination.ConclusionsOur analysis did not find protein-energy undernutrition to be associated with immunogenicity or waning of PsACWY- or PsA-TT-elicited antibody in children living in the African meningitis belt. Future studies should consider measuring antibody titers at additional time points post-vaccination, and for longer periods of time, to determine if the rate of antibody waning over a period of several years is associated with protein-energy undernutrition.     

Unexplained differences between hospital and mortality data indicated mistakes in death certification: an investigation of 1,094 deaths in Sweden during 1995

ObjectiveMortality statistics are important for epidemiological research. We examine if discrepancies between death certificate (DC) and hospital discharge condition (HDC) indicate certification errors.Study Design and SettingFrom 39,872 hospital deaths in Sweden in 1995, we randomly selected 600 “cases,” where DC and HDC were incompatible, and 600 compatible “controls,” matched on sex, age, and underlying cause of death. We obtained case summaries for 1,094 (91%) of these. Using a structured protocol, we assessed the accuracy of DCs.ResultsRegression analysis indicated diagnostic group and “case” or “control” as the variables that most affected the accuracy. Malignant neoplasm “controls” had the highest accuracy (92%), and benign and unspecified tumor “cases,” the lowest (20%). For all diagnostic groups except one, compatible “controls” had better accuracy than incompatible “cases.” The exception, chronic obstructive lung disease, had low accuracy for both “cases” (54%) and “controls” (52%).ConclusionIncompatibility between DC and HDC indicates a greater risk of certification errors. For some diagnostic groups, however, DCs are often inaccurate even when DC and HDC are compatible. By requesting additional information on incompatible cases and all deaths in high-risk diagnostic groups, producers of mortality statistics could improve the accuracy of the statistics.     

Lean intervention improves patient discharge times,improves emergency department throughput and reduces congestion

Objective: To determine if a lean intervention improved emergency department (ED) throughput and reduced ED boarding by improving patient discharge efficiency from a tertiary care children’s hospital.

Methods: The study was conducted at a tertiary care children’s hospital to study the impact lean that changes made to an inpatient pediatric service line had on ED efficiency. Discharge times from the general pediatrics’ service were compared to patients discharged from all other pediatric subspecialty services. The intervention was multifaceted. First, team staffing reconfiguration permitted all discharge work to be done at the patient’s bedside using a new discharge checklist. The intervention also incorporated an afternoon interdisciplinary huddle to work on the following day’s discharges. Retrospectively, we determined the impact this had on median times of discharge order entry, patient discharge, and percent of patients discharged before noon. As a marker of ED throughput, we determined median hour of day that admitted patients left the ED to move to their hospital bed. As marker of ED congestion we determined median boarding times.

Results: For the general pediatrics service line, the median discharge order entry time decreased from 1:43pm to 11:28am (p < 0.0001) and the median time of discharge decreased from 3:25pm to 2:25pm (p < 0.0001). The percent of patients discharged before noon increased from 14.0% to 26.0% (p < 0.0001). The discharge metrics remained unchanged for the pediatric subspecialty services group. Median ED boarding time decreased by 49 minutes (p < 0.0001). As a result, the median time of day admitted patients were discharged from the ED was advanced from 5 PM to 4 PM.

Conclusion: Lean principles implemented by one hospital service line improved patient discharge times enhanced patient ED throughput, and reduced ED boarding times.     

Use of Subjective Global Assessment to Identify Nutrition-Associated Complications and Death in Geriatric Long-Term Care Facility Residents

Objective: The primary objective of this study was to assess the use of Subjective Global Assessment to identify nutrition-associated complications and death in a geriatric population. A secondary objective was to evaluate the ability of Subjective Global Assessment to identify geriatric residents of long-term care facilities who were undernourished or at risk for developing undernutrition.

Methods: Fifty-three consecutive residents who were ≥ 65 years of age and had been residing in a long-term care facility for < 2 weeks were enrolled in the study. The Subjective Global Assessment Classification technique was performed according to the procedure outlined by Detsky and colleagues. Residents were classified as well-nourished (A), mild/moderately undernourished (B) or severely undernourished (C). In addition, a Subjective Global Assessment Composite Score was derived. Subjective Global Assessment measures were compared with two traditional objective measurements of nutritional status: serum albumin and serum total cholesterol. Outcome measurements of nutrition-associated complications were determined over a 3-month period by recording the incidence of major infections, decubitus ulcers, nutrition-related hospital readmissions, and mortality.

Results: Sixteen residents (30.2%) were categorized as Subjective Global Assessment class A, 28 residents (52.8%) were class B, and 9 residents (17%) were class C. A significant association was found between nutritional status as determined by Subjective Global Assessment Composite Score and nutrition-associated complications (p<0.05). Subjective Global Assessment Classification was related to death (p<0.05) with severely undernourished residents having the highest mortality rate. Hypoalbuminemia only demonstrated a significant relationship with nutrition-associated complications (p<0.05), whereas hypocholesterolemia was associated with death (p<0.05).

Conclusions: Subjective Global Assessment of nutritional status appears to be a simple, noninvasive and cost-effective tool for assessing nutritional status of geriatric residents in long-term care facilities. This assessment tool is also beneficial for identifying patients with increased risk of nutrition-associated complications as well as death.     

Incomplete Home Health Care Referral After Hospitalization Among Medicare Beneficiaries

ObjectivesPatients who are referred to home health care after an acute care hospitalization may not receive home health care, resulting in incomplete home health referrals. This study examines the prevalence of incomplete referrals to home health, defined as not receiving home health care within 7 days after an initial hospital discharge, and investigates the relationship between home health referral completion and patient outcomes.DesignRetrospective cohort study.Setting and ParticipantsMedicare beneficiaries who are discharged from short-term acute care hospitals between October 2015 and December 2016 with a discharge status code on the hospital claim indicating home health care.MethodsPatient characteristics and outcomes were compared between Medicare beneficiaries with complete and incomplete home health referrals after hospital discharge. The outcomes included mortality, readmission rate, and total spending over a 1-year episode following hospitalization. These outcomes were risk-adjusted using patient demographic, socioeconomic, clinical characteristic, hospital characteristic, and state fixed effects.ResultsApproximately 29% of the 724,700 hospitalizations in the analytic dataset had incomplete home health referrals after discharge. The rate of incomplete home health referrals varied among clinical conditions, ranging from 17% among joint/musculoskeletal patients and 38% among digestive/endocrine patients. Risk-adjusted 1-year mortality and readmission rates were 1.4 and 2.4 percentage points lower and total spending was $1053 higher among patients with complete home health referrals as compared with those with incomplete home health referrals after hospital discharge.Conclusions and ImplicationsThe analysis revealed that almost 1 in 3 patients discharged from a hospital with a discharge status of home health does not receive home health care. In addition, complete home health referrals are associated with lower mortality and readmission rates and higher spending. As home health care utilization increases, policymakers should pay attention to the tradeoff between quality and cost when implementing alternative policies and payment models.     

Routinely Assessed Biochemical Markers Tested on Admission as Predictors of Adverse Outcomes in Hospitalized Elderly Patients

Abstract

Aim: To explore whether routinely assessed biochemical markers tested on admission will predict 3 predefined adverse outcomes for hospitalized elderly patients: discharge to a long-term care facility, in-hospital mortality, and prolonged hospital length of stay (> 14 days). Methods: A prospective observational study of elderly patients (aged ≥ 75 years) admitted to an acute-care geriatric ward over a 6-month period. Patients were assessed on admission and baseline characteristics were collected. Activities of daily living were assessed by the Barthel Index and cognitive function by the abbreviated mental test. Results from biochemical markers tested on admission were downloaded from the pathology laboratory database using patient details. Patients were folio wed-up with until discharge or in-hospital mortality. Results: A total of 392 patients formed the study population. Mean (standard deviation) age was 83.2 (± 5.5) years and 283 (72%) patients were men. Thirty-eight (10%) patients were discharged to a long-term care facility, 134 (34%) had a prolonged hospital length of stay, and 33 (8%) died in the hospital. Results from testing 5 biochemical markers independently predicted in-hospital mortality: hypoalbuminemia (adjusted odds ratio [OR], 2.5; 95% CI, 0.9–6.7; P = 0.04), low total cholesterol level (adjusted OR, 2.9; 95% CI, 1.3–6.3; P = 0.01), hyperglycemia (adjusted OR, 2.9; 95% CI, 1.2–7.4; P = 0.02), high C-reactive protein level (adjusted OR, 4.2; 95% CI, 1.3–13.4; P = 0.01), and renal impairment (adjusted OR, 3.8; 95% CI, 1.7–8.7; P = 0.002). High C-reactive protein level independently predicted prolonged hospital length of stay (OR, 1.7; 95% CI, 1.1–2.9; P = 0.03). Hypoalbuminemia predicted discharge to a long-term care facility independent of confounding factors except for physical dysfunction (OR, 2.4; 95% CI, 1.1–5.1; P = 0.03). Significance was reduced after adjustment for Barthel Index score (OR, 1.9; 95% CI, 0.9–4.1; P = 0.08). Conclusion: Testing of routinely assessed biochemical markers on admission predicted adverse hospital outcomes for elderly patients. Their inclusion in a standardized prediction tool may help to create interventions to improve such outcomes.     

Undernutrition Risk and Undernutrition in Pulmonology Department Inpatients: A Systematic Review and Meta-Analysis

Pulmonology patients are predisposed to be undernourished and a wide variability in the estimates of frequency of undernutrition risk and undernutrition is found in the literature. The aim of this systematic review and meta-analysis was to investigate the prevalence of undernutrition risk and undernutrition on hospital admission in pulmonology department inpatients. We also intend to take into account the different methodologies used to evaluate undernutrition risk and undernutrition in this population.

Pubmed, ISI-Web of Science, and Scopus were searched until January 2015. The evidence regarding the prevalence of undernutrition risk and undernutrition was summarized.

Twenty-two studies were included in the qualitative analysis and 21 in meta-analysis. The overall prevalence of undernutrition risk (32.73%; 95% confidence interval [CI], 31.29%–34.17%, I² = 97.6%) was lower than undernutrition prevalence (36.95%; 95% CI, 34.80%–39.10%, I² = 99.7%). The subtotal prevalence of undernutrition risk was similar using the Malnutrition Universal Screening Tool and Nutritional Risk Screening–2002. The studies using only anthropometric parameters for the assessment of undernutrition reported lower prevalence of undernutrition than the studies that used Subjective Global Assessment. Cross-sectional studies reported higher prevalence of undernutrition risk and undernutrition than cohort studies. Studies including larger samples reported a prevalence estimate similar to the overall prevalence for undernutrition risk and undernutrition. Studies conducted in non-pulmonology departments showed lower prevalence of undernutrition risk than those from pulmonology departments, contrary to the estimates for undernutrition prevalence.

Undernutrition risk and undernutrition prevalence at hospital admission are high among pulmonology inpatients, but the heterogeneity between the studies illustrates the lack of standardized methods to assess nutritional status in this population. The assessment of undernutrition must always be preceded by nutritional screening, according to guidelines, which did not take place in some analyzed studies.

Teaching Points

? Undernutrition risk and undernutrition prevalence are high among pulmonology inpatients.

? The heterogeneity between the analyzed studies reveals that there is no standard pattern in the choice of methods for nutritional status assessment in these patients.

? Timely screening and identification of undernutrition is of the utmost relevance in earlier nutritional interventions and implementation of nutritional support.

? The assessment of undernutrition must always be preceded by nutritional screening, in accordance with guidelines, which did not occur in some of the analyzed studies.     

Systematic comparative content analysis of 17 psychosocial work environment questionnaires using a new taxonomy

Background: Many questionnaires have been developed to measure how psychosocial characteristics are perceived in a work environment. But the content validity of these questionnaires has rarely been questioned due to the absence of a reference taxonomy for characteristics of work environments.

Objectives: To propose an exhaustive taxonomy of work environment characteristics involved in psychosocial risks and to apply this taxonomy to questionnaires on workplace psychosocial factors.

Methods: The taxonomy was developed by categorizing factors present in the main theoretical models of the field. Questionnaire items most frequently cited in scientific literature were retained for classification.

Results: The taxonomy was structured into four hierarchical levels and comprises 53 categories. The 17 questionnaires analyzed included 927 items: 59 from the “physical environment” category, 116 from the “social environment” category, 236 from the “work activity” category, 255 from the “activity management” category, and 174 from the “organizational context” category.

Conclusions: There are major content differences among analyzed questionnaires. This study offers a means for selecting a scale on the basis of content.     

Anticholinergic Burden is Associated With Increased Mortality in Older Patients With Dependency Discharged From Hospital

ObjectivesTo determine whether anticholinergic burden may predict differently 1-year mortality in older patients discharged from acute care hospitals with or without dependency in basic activities of daily living (BADL).DesignProspective observational study.Setting and participantsOur series consisted of 807 patients aged 65 years or older consecutively discharged from 7 acute care geriatric wards throughout Italy between June 2010 and May 2011.MeasuresOverall anticholinergic burden was assessed by the anticholinergic cognitive burden (ACB) score. Dependency was rated by BADL, and dependency in at least 1 BADL was considered as a potential mediator in the analysis. The study outcome was all-cause mortality during 12-months of follow-up.ResultsPatients included in the study were aged 81.0 ± 7.4 years, and 438 (54.3%) were female. During the follow-up period, 177 out of 807 participants (21.9%) died. After adjusting for potential confounders, discharge ACB score = 2 or more was significantly associated with the outcome among patients with dependency in at least 1 BADL [hazard ratio (HR) 2.25 95% confidence (CI) 1.22‒4.14], but not among independent ones (HR 1.06 95% CI 0.50‒2.34). The association was confirmed among dependent patients after adjusting for the number of lost BADL at discharge (HR 2.20 95% CI 1.18‒4.04) or ACB score at 3-month follow-up (HR 2.18 95% CI 1.20‒3.98), as well as when considering ACB score as a continuous variable (HR 1.28 95% CI 1.11‒1.49). The interaction between ACB score at discharge and BADL dependency was highly significant (P < .001).Conclusions/ImplicationsACB score at discharge may predict mortality among older patients discharged from an acute care hospital carrying at least 1 BADL dependency. Hospital physicians should be aware that prescribing anticholinergic medications in this population may have negative prognostic implications and they should try to reduce anticholinergic burden at discharge whenever possible.     

Undernutrition at PICU Admission Is Predictor of 60-Day Mortality and PICU Length of Stay in Critically Ill Children

BackgroundThere are few studies that assess the role of different nutritional assessment variables at pediatric intensive care unit (PICU) admission in predicting clinical outcomes.ObjectiveTo identify nutritional variables in the first 4 days of PICU stay that predict 60-day mortality and time to discharge alive from the PICU.DesignSingle-center prospective study in Southern Brazil, conducted between July 2013 and February 2016. At PICU admission, children with z scores <−2 for body mass index (BMI)-for-age, mid-upper arm circumference (MUAC)-for-age, and triceps skinfold thickness (TSF)-for-age were considered as undernourished.Participants/settingThere were 199 patients, aged <15 years, with PICU stay >48 hours.Main outcome measuresSixty-day mortality and time to discharge alive from the PICU.Statistical analysis performedCox regression model was applied to determine predictors of 60-day mortality and time to discharge alive from the PICU.ResultsMedian age was 23.1 months (interquartile range=3.9 to 89.1), and 63% were male, with 18% prevalence of undernutrition at admission by BMI-for-age. Median PICU stay was 7 days (interquartile range=4 to 12), and 60-day mortality was 12%. After adjusting for sex, age, Pediatric Index of Mortality 2, and presence of complex chronic conditions, undernutrition based on BMI-for-age (hazard ratio [HR]=3.75; 95% CI=1.41 to 9.95; P=0.008), MUAC-for-age (HR=7.62; 95% CI=2.42 to 23.97; P=0.001), and TSF-for-age (HR=4.01; 95% CI=1.14 to 14.15; P=0.031) was associated with higher risk of 60-day mortality. Based on MUAC-for-age with the same adjustment model, undernourished children had longer time to discharge alive from the PICU (HR=0.45; 95% CI=0.21 to 0.98; P=0.045).ConclusionsUndernutrition at PICU admission based on different anthropometric variables was predictive of 60-day mortality and longer time to discharge alive from the PICU.     

“Doing It Properly”: The Experience of First Mothering Over 35 Years

First mothering over 35 years is an increasing phenomenon in developed countries, and this “greying” of maternity raises some interesting questions and dilemmas for clinical care. In a qualitative study conducted in Melbourne, Australia, the motherhood experiences of 22 primiparous women were explored. Participant age ranged from 35 to 48 years. Women were interviewed over three junctures: at 35–38 weeks gestation, 10–14 days postpartum, and 8 months postpartum.

Becoming a mother was found to occur in a temporally ordered sequence, with clear markers at 1–4 weeks, 1–4 months, 4–6 months, and 6–8 months. Themes that emerged from the analysis included the project “doing it properly,” vulnerability, “finding my own way,” and “being older.”

The continuing and increasing trend of primiparity older than 35 years makes this account of interest globally. Findings from this study offer an alternative explanation of early mothering over 35 years and offers direction to health professionals for easing early motherhood experiences for this growing group of childbearing women.     

Risk Prediction Model for 6-Month Mortality for Patients Discharged to Skilled Nursing Facilities

ObjectiveHospitalized patients discharged to skilled nursing facilities (SNFs) for post-acute care are at high risk for adverse outcomes. Yet, absence of effective prognostic tools hinders optimal care planning and decision making. Our objective was to develop and validate a risk prediction model for 6-month all-cause death among hospitalized patients discharged to SNFs.DesignRetrospective cohort study.Setting and ParticipantsPatients discharged from 1 of 2 hospitals to 1 of 10 SNFs for post-acute care in an integrated health care delivery system between January 1, 2009, and December 31, 2016.MethodsGradient-boosting machine modeling was used to predict all-cause death within 180 days of hospital discharge with use of patient demographic characteristics, comorbidities, pattern of prior health care use, and clinical parameters from the index hospitalization. Area under the receiver operating characteristic curve (AUC) was assessed for out-of-sample observations under 10-fold cross-validation.ResultsWe identified 9803 unique patients with 11,647 hospital-to-SNF discharges [mean (SD) age, 80.72 (9.71) years; female sex, 61.4%]. These discharges involved 9803 patients alive at 180 days and 1844 patients who died between day 1 and day 180 of discharge. Age, comorbid burden, health care use in prior 6 months, abnormal laboratory parameters, and mobility status during hospital stay were the most important predictors of 6-month death (model AUC, 0.82).Conclusion and ImplicationsWe derived a robust prediction model with parameters available at discharge to SNFs to calculate risk of death within 6 months. This work may be useful to guide other clinicians wishing to develop mortality prediction instruments specific to their post-acute SNF populations.     

Impact of Nutritional Intervention on Length of Hospital Stay and Mortality among Hospitalized Patients with Malnutrition: A Clinical Randomized Controlled Trial

Objective: The objective of this study was to evaluate the impact of a nutritional intervention on hospital stay and mortality among hospitalized patients with malnutrition.

Methods: Hospitalized patients with a diagnosis of malnutrition were enrolled and randomly allocated to either an intervention or control group. Participants in the intervention group received an individualized nutrition plan according to energy and protein (1.0–1.5 g/kg) intake requirements as well as dietary advice based on face-to-face interviews with patients and their caregivers or family members. Individuals in the control group received standard nutritional management according to the Hospital Nutrition Department. Nutritional status and disease severity were assessed using nutritional risk screening. Length of hospital stay was defined by the number of days of hospitalization from hospital admission to medical discharge. Reference to another service or death were criteria for study withdrawal. To evaluate mortality, individuals were followed up for 6 months after hospital discharge. Hospital stay and mortality were the intention-to-treat analysis.

Results: A total of 55 patients with an average age of 57.1 ± 20.7 years were included into intervention (n = 28) and control (n = 27) groups, respectively. At basal condition, nutritional status, measured by nutritional risk screening score, was similar between the study groups (4.1 ± 0.8 vs 4.2 ± 1.2, p = 0.6). The average hospital stay was lower in the intervention group compared to the control group (6.4 ± 3.0 vs 8.4 ± 4.0 days, p = 0.03). Finally, the mortality rate at 6 months of follow-up was similar in both groups (hazard ratio [HR] = 0.85; 95% confidence interval [CI], 0.17–4.21).

Conclusions: Results of this study suggest that, in hospitalized patients with malnutrition, nutritional intervention and dietary advice decrease hospital stay but not mortality.