Factors influencing inpatient mortality of medical patients

OBJECTIVE: To investigate factors influencing inpatient mortality and length of stay among medical patients at a public hospital. METHODS: A case-control study involving a 10 percent sample of medical admissions who died (n=109) was done at the Kingston Regional Hospital during 1998. These were matched for age, gender and admission date to 2 controls (n=180) where death did not occur. Trained personnel abstracted information from personnel records. RESULTS: The sample comprised 147 men and 139 women of mean/Standard Deviation (SD) age 61.3ñ18.1 years and range of 12 to 94 years. The mean/SD length of stay was 6.3ñ6.0 days with a median of 5 days. Length of stay did not differ by gender (p=0.69) or mortality (p=0.86). Re-admission accounted for 34.3 percent of admissions occuring at a median of 174 days. There was 70 percent agreement between the provisional diagnosis at admission and the primary discharge diagnosis. The commonest primary diagnoses were diabetes mellitus and hypertension (14 percent each). Stroke, pneumonia and cancer each accounted for over 5 percent of primary diagnoses. Risk of death was greater in women who were alone (single or widowed/divorced/separated) than in those in a union - odds ratio (OR) and 95 percent confidence interval (95 percent CI) 3.63 (1.36, 9.67). In men the OR (95 percent CI) was 0.94 (0.38-2.31). Cancer, stroke chronic renal failure and pneumonia were associated with an increased risk of in-hospital mortality and so was documentation of examination by a consultant. There was an inverse association between the number of entries per day in patients' notes and the risk of death. Less than 2 percent of admissions had a record of patient satisfaction. Nurses notes were judged to be adequate in 76.5 percent of admissions but only 19.2 percent of patient records were rated as good overall. Good quality records were not associated with better survival or shorter hospitalization. CONCLUSION: The relationship between process of care and inpatient mortality is complex and clear associations were not demonstrated for overall mortality. Cause-specific mortality may be a more informative outcome for quality of care studies. (AU)

Coronary artery bypass graft outcome: the Trinidad and Tobago experience

The study is a retrospective review of the demographic, clinical, angiographic, and operative data of the first 205 consecutive CABG operations performed by Caribbean Heart Care at the Eric Williams Medical Sciences Complex (EWMSC), Trinidad and Tobago, between November 1993 and December 1997. The aim of the study was to determine the in hospital and intermediate term follow up results. The mean age of patients was 59 ñ 10 years and 78 percent male. Sixty-four percent were of East Indian descent, whereas, 16 percnt were of Africian descent. Forty-eight percent of the patients were hypertensive, 46 percent were diabetic, 33 percent had hyperlipidaemia, 20 percent had a recent history of cigarette smoking and 16 percent were obese. Sixty-five percent had a positive family history of ischaemic heart disease. The average time interval between angiography and surgery was 2.3 months. At the time of angiography, 63.5 percent of patients had Canadian Cardiac Society (CCS) class 3 or 4 angina. The mean ejection fraction was 61 ñ 15 percent. Wall motion abnormalities were seen in 67 pecent of patients. Significant stenoses of the left anterior descending artery, right circumflex artery, circumflex and ramus coronary arteries were present in 91 percent, 78 percent, 54 percent and 5 percent, respectively. Many patients (67 percent) had severe diffuse disease on angiography. The mean intensive care stay was 2.2 ñ 0.8 days. In hospital mortality was 3.9 percent (8/205). THe most frequent post operative complicaton was haemorrhage (2.6 percent). Acute renal failure occurred in 2.1 percent; pulmonary collapse, 1.6 percent; 1 percent and cardiac arrest , 1 percent. Both sternal wound infections and systemic sepsis occurred in 0.5 percent. Intermediate term follow-up data were obtained for 92 percent (189/205). The duration of follow-up ranged from 1 to 5 years (mean 3.7 years). During the follow up period, 7 patients (3.4 percent) died. Angina severity was reduced from a mean CCS score of 2.61 ñ 0.95 before CABG ot 1.22 ñ 0.55 at the time of follow up (p<0.0001). Overall 4-year mortality compared favourably with data from international studies. Among survivors, quality of life improved as evidenced by the reduction in the mean angina score.(Au)

Trends in hospitalization and mortality pattern among children in Barbados, 1987-1998 - Poster abstract

OBJECTIVE: To describe the trends in the admission pattern, the reason for hospitalization and the inpatient mortality among children with medical illnesses in Barbados during 1987-1998. DESIGN AND METHODS: The admission and the discharge records for children under 16 admitted to the paediatric medical ward were reviewed. The admission and discharge register and the data from records were used. Inpatient death records were obtained from the Medical Records Department. RESULTS: The annual admission rate declined from 24.45 t0 14.11 per thousand in the under 14 population during 1987-94, and thereafter increased to 22.0 per thousand in the under- 14 population in 1998. Admission increased during the months October to January, with peaks mostly in November (50 percent of the times). Peak increase in admission varied between 15.0 percent and 63.2 percent, compared to the admissions in September. Respiratory illnesses were the commonest (24.1 to 37.5 percent) reason for children's hospitalization. Respiratory illnesses with gastroenteritis, febrile seizures, seizure disorders, poisoning and sickle cell accounted for 56.9 to 66.8 percent of all discharge diagnoses. Asthma admission rate decrease significantly (P<0.001) from 58.8 to 11.8 per 100,000 in the under 14 population during 1987-94, thereafter increase significantly (p<0.005) to 43.7 per 100,000 in the under 14 population in 1998. A significant decrease was also observed in hospitalization for seizure disorders. Admissions for malignancies have increased while admissions for diabetes have significantly decreased (P<0.01). The death rates varied between 11.5 to 15.6 per thousand admissions. CONCLUSION: Hospital admissions have increases since 1994 after the decline during 1987-94. Peak admissions are seen during the October to January months. Respiratory illnesses account for the majority of the hospitalizations, asthma being the commonest discharge diagnosis for hospitalized children. Death rate has been more or less constant during 1987-98. Severe bacterial infections, congenital heart disease and malignancy were the major causes of death.(AU)

Clinical and demographic determinants of mortality in patients admitted to an internal medicine service

OBJECTIVE: To identify clinical and demographic patient variables on admission which function as determinants of hospital mortality and to use these determinants to stratify the risks of death. METHODS: All admissions in 1998 to one of two medical firms were examined and the presence or absence of 20 variables was noted. The outcome of hospitalization was recorded as "dead" or "not dead". The data were stored and analyzed in a computerized database (EpiInfo version 6). RESULTS: Sixty-eight patients, 8.5 percent of 803 admissions died. Abnormal mental status (odds ratio (OR) 7.9, 95 percent CI, 4.5-113.9), old age (OR 3.5, 95 percent CI, 2.0-6.0), history in present illness of dyspnoea (OR 2.3, 95 percent CI, 1.3-4.1), neurological deficit (OR 5.1, 95 percent CI, 2.8-9.1), and weight loss (OR 2.2, 95 percent CI, 1.2-4.2) were independent predictors of death. In 636 patients with a normal mental status, excessive alcohol use (OR 5.66, 95 percent CI, 1.8-1.29), old age (OR 4.6, 95 percent CI, 1.9-11.9), and dyspnoea were stronger predictors than neurological deficit (OR 3.5, 95 percent CI, 1.1-9.6). A risk index based on these variables stratified risk of death into low (2.2 percent), intermediate (15.5 percent), and high (41.4 percent) risk. The data strongly suggest an independent role for excessive alcohol use. Bad feelings, chest pain, syncope, fever, headache, vomitting, past history of diabetes, hypertension, stroke and myocardial infarction were not associated with increased mortality. CONCLUSIONS: Abnormal mental status, old age, dyspnoea, neurological deficit, and weight loss are independent predictors of mortality in medical inpatients and are potentially useful, at admission, in stratifying risk of death before a medical diagnosis is known.(Au)

Stroke in Trinidad and Tobago: burden of illness and risk factors

This study describes the burden of stroke on hospital services in a Caribbean community. The settings are the two main acute general hospitals in Trinidad observed over a 12-month period. All subjects were admitted with a clinical diagnosis of acute stroke. The measures were hospital admission rates, length of hospital stay, case-fatality rates, disability at discharge, and risk factors for stroke. There were 1 105 hospital admissions with a diagnosis of stroke. The median length of stay was 4 days, with an interquartile range of 2 to 9, and stroke accounted for approximately 9 478 bed days per annum. The hospital admission fatality rate was 29 percent. Among surviving patients, 437 (56 percent) were severely disabled at discharge. Age-standardized admission rates for first strokes in persons aged 35-64 years were 114 (95 percent CI: 83 to 145) per 100 000 in Afro-Trinidadian men and 144 (109 to 179) in Indo-Trinidadian men. The equivalent rates for women were 115 (84 to 146) and 152 (118 10186). Among patients with first strokes, 348/531 (66 percent) reported physician-diagnosed hypertension, but only 226 (65 percent) of these reported being on antihypertensives at admission. Stroke in Trinidad and Tobago is associated with a high case-fatality rate and severe disability in survivors. Modifiable risk factors were reported in a majority of stroke cases, and there is a need to develop effective preventive strategies (AU)

Myocardial infarction in Antigua: 1990 to 1995

Between January 1990 and May 1995, 117 patients were admitted to the Intentsive Care at Holberton Hospital, Antigua, for chest pain due to suspected acute myocardial infarction. 39 (45 percent) of 86 patients whose records were available for retrospective review had confirmed (27 patients) or probable (12 patients) acute myocardial infarction. Risk factors identified among the patients included hypertension, diabetes, tobacco smoking, hypercholesterolaemia and obesity. On admission, 82 percent were Killip class I and 18 percent were Killip class II. Medications in the Intensive Care Unit included nitrates, aspirin, calcium and channel blockers, beta-adrenergic blockers, heparin and angiotensin converting enzyme inhibitors (21 percent). No thrombolytic agents were available. THe average hospital stay was 10 days and the in-hospital mortality rate was 13 percent. These data indicate that early mortality from acute myocardial infarction can be reduced in developing countries by early admission to an Intensive Care Unit and use of drugs known to be effective in its treatment.(AU)

Trends in admission and case fatality for acute malnutrition: Kingston 1892-1991

The case fatality ratio (CFR) in acute protein-energy malnutrition (PEM) achieved in the Tropical Metabolism Research Unit (TMRU) was compared with that of other tertiary care facilities in Kingston. Trends in admission and fatality rates, case severity and complications were also examined. From ward admission registers for Bustamante Hospital for Children (BHC), the University Hospital of the West Indies (UHWI), children's wards and the TMRU all cases of PEM admitted from 1982 through 1991 were enumerated and there was a docket search for random subsamples. Ten-year mean CFR percent for BHC was 8.8 (n=1974); for UHWI wards 5.5 (n=658); for TMRU 7.1 (n=662). BHC has the least restrictions on admission and showed most clearly that the peak time in Kingston for admission of PEM was around 1985, falling to a minimum in 1988 - 1990 and rising again in 1991; however, the other sites also showed similar trends. BHC had a range of CFR precent p.a. of 20.0 to 3.0, with a striking fall in the second half of the decade. There was no temporal CFR trend for the UHWI or TMRU. The latter institution had the highest proportion of admissions with marasmic-kwashiorkor and the lowest proportion with recorded infection. The annual variation in numbers of PEM deaths at BHC was best accounted for by (a) percentage change in consumer price index and (b) percentage change in the US$ value of the Jamaican $, in the preceding year, and (c) annual number of admissions, together. Generally, our findings suggest a minor role for expert in-patient management in reducing deaths from PEM (AU)

Counting the cost of diabetic hospital admissions from a multi-ethnic population in Trinidad

Many middle-income countries are experiencing an increase in diabetes mellitus but patterns of morbidity and resource use from diabetes in developing countries have not been well described. We evaluated hospital admission with diabetes among different ethnic groups in Trinidad. We compiled a register of all patients with diabetes admitted to adult medical, general surgical, and ophthalmology wards at Port of Spain Hospital, Trinidad. During 26 weeks, 1447 patients with diabetes had 1722 admissions. Annual admission rates, standardized to the world population, for the catchment population aged 30-64 years were 1031 (95 percent CI 928 to 1134) per 100,000 in men and 1354 (1240 to 1468) per 100,000 in women. Compared with the total population, admission rates were 33 percent higher in the Indian origin population and 47 percent lower in those of mixed ethnicity. The age-standardized rate of amputation with diabetes in the general population aged 30-60 years was 54 (37 to 71) per 100,000. The hospital admission fatality rate was 8.9 percent (95 percent CI 7.6 percent to 10.2 percent). Mortality was associated with increasing age, admission with hyperglycaemia, elevated serum creatinine, cardiac failure or stroke and with lower-limb amputation during admission. Diabetes accounted for 13.6 percent of hospital admissions and 23 percent of hospital bed occupancy. Admissions associated with disorders of blood glucose control or foot problems accounted for 52 percent of diabetic hospital bed occupancy. The annual cost of admissions with diabetes was conservatively estimated at TT10.66 million (UK 1.24 million pounds). In this community diabetes admission rates were high and varied according to the prevalence of diabetes. Admissions, fatalities and resource use were associated with acute and chronic complications of diabetes. Investing in better quality preventive clinical care for diabetes might provide an economically advantageous policy for countries like Trinidad and Tobago. (AU)

The quality of death certificate at the University of the West Indies

A study was undertaken to look at the death certification practices of doctors at the University Hospital of the West Indies. Records of the deaths occurring between 1st August, 1992 and 31st July, 1993 were examined. Case notes studied amounted to 502-246 males and 256 females (stillbirths excluded). Ther were 153 adequately completed certificates (30.5 percent); 157 (31.3 percent) had insufficient information and 41 (8.2 percent) had ill-defined or vague cause of death statements. Seventy (13.9 per cent) had blank death certificates or the certificates could not be found. Seventy-eight (15.5 percent) were considered to be inaccurate or misleading. Three (0.6 percent) were found to be illegible. From records found, the post mortem rate was calculated to be 40.4 percent and post mortem findings contributed significantly to the quality of death certification. The confirmation rate of admission diagnoses compared with post mortem findings for all disease categories together was 57 percent. The point is made that the medical students and doctors need to familiarise themselves with the World Health Organization ICD Manual 9th Revision (1975) and other revisions that may come on stream in the future. Education on the importance of death ceritification and the proper certification process to be followed needs to be included in the curriculum of medical students. Doctors and medical records personnel also need ongoing education on this subject, so that all concerned will work together to provide more meaningful information on which sound health planning can be based (AU)