Recent temporal trends, characteristics and outcomes of patients with non-COVID-19 community-acquired pneumonia at two tertiary hospitals in Australia: an observational study.

BACKGROUND: Community-acquired pneumonia (CAP) leads to considerable morbidity and mortality globally. However, data on CAP burden in Australia, especially during the coronavirus disease 2019 (COVID-19) pandemic, are limited. AIMS: We characterised and assessed clinical outcomes of non-COVID-19 CAP hospitalisations over a 6-year period at two major hospitals in South Australia. METHODS: All non-COVID-19 CAP hospitalisations were identified using the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian modification (ICD-10-AM) codes, between 1 January 2018 and 31 December 2023, at two tertiary hospitals in Adelaide. Clinical outcomes included in-hospital and 30-day mortality, length of stay (LOS) in, intensive care unit (ICU) admission and 30-day readmissions. Multilevel regression models were utilised to identify predictors of clinical outcomes. RESULTS: Over the 6-year period, there were 7853 non-COVID-19 CAP hospitalisations, with a temporal increase from 100 per 100 000 population in 2018 to 208 per 100 000 population in 2023 (P < 0.001). The mean (SD) age was 75.1 (17.6) years, and 54.6% were males. The mean age declined over time (P < 0.05), while other characteristics remained stable. Streptococcus pneumoniae was the most commonly identified bacterium (21.8% of cases). In-hospital mortality occurred in 7.8% of patients, with 30-day mortality and readmission rates of 14.3% and 16.9% respectively. LOS declined significantly during the pandemic years; however, mortality remained stable over time. Frailty status, malnutrition and number of comorbidities significantly predicted 30-day mortality and LOS, in addition to pneumonia severity and ICU admission. CONCLUSIONS: There has been an increasing trend of hospitalisations for non-COVID-19 CAP during the COVID-19 pandemic, with a concomitant trend towards shorter LOS and no significant shift in other clinical outcomes.

The value of distinguishing patients with isolated subsegmental pulmonary embolism presenting to two tertiary hospitals in Australia: an observational study.

Isolated-subsegmental-pulmonary-embolism (SSPE) is increasingly diagnosed with the use of computed-tomography-pulmonary-angiogram (CTPA). There remains clinical equipoise for management of SSPE with previous studies not accounting for frailty while determining clinical outcomes. Clinical outcomes among patients with isolated SSPE were compared with those with a more proximal PE after accounting for frailty and other risk-factors. This study included all patients with a positive CTPA for pulmonary embolism (PE) admitted between 2017 and 2021 to two Australian-tertiary-hospitals. Frailty was determined by use of the hospital-frailty-risk-score (HFRS). Competing-risk-analysis and Cox-proportional hazard models determined the cumulative-risk of VTE and mortality within 3 months and 1 year of index PE event after adjustment for frailty and other variables. Of 334 patients with positive CTPA for PE, 111 (33.2%) had isolated-SSPE. The mean (SD) age was 64.3 (17.7) years, 50.9% were males and 9.6% were frail. The risk of recurrent VTE within 3-months (0.9% vs. 1.8%, P = 0.458) and within 1-year of follow-up (2.7% vs. 6.3%, P = 0.126) did not differ significantly between patients with isolated SSPE and those with more proximal PE. After adjusted analyses, the cumulative-incidence of recurrent VTE was not different among patients with isolated SSPE within 1 year of index event [subdistribution-hazard-ratio (HR) 0.84, 95% CI 0.19 to 3.60]. Similarly, mortality within 1 year of index event was also not different between the two groups (aHR 1.72, 95% CI 0.92-3.23). The prevalence of SSPE was 33.2% and even after adjustment for frailty these patients had no different clinical outcomes than those with proximal PE.

Impact of Malnutrition on Clinical Outcomes of Acutely Hospitalised Heart Failure Patients at Two Tertiary Hospitals in Australia: An Observational Study.

BACKGROUND: Malnutrition is common in patients with heart failure (HF) but is often neglected, despite guidelines suggesting that all hospitalised patients should undergo nutritional screening within 24-hours of admission. AIMS: This study investigated the nutritional screening rates and determined the immediate and long-term clinical outcomes in patients with HF admitted at two tertiary hospitals in Australia. METHODS: Nutritional screening was assessed by the Malnutrition Universal Screening Tool (MUST) completion rates. Patients were classified into two categories based on their MUST scores (0=low malnutrition risk and ≥1=at risk of malnutrition). Propensity-score-matching (PSM) was used to match 20 variables depending upon the risk of malnutrition. Clinical outcomes included the days-alive-and-out-of-hospital at 90 days of discharge (DAOH90), length of hospital stay, in-hospital, 30-day and 180-day mortality and 30-day readmissions. RESULTS: There were 5,734 HF admissions between 2013-2020, of whom, only 789 (13.8%) patients underwent MUST screening. The mean (SD) age was 76.2 (14.0) years and 51.9% were males. Five-hundred and fifty-four (554) (70.2%) patients were at low malnutrition risk and 235 (29.8%) at risk of malnutrition. In HF patients, who were at risk of malnutrition, the DAOH90 were lower by 5.9 days (95% CI -11.49 to -0.42, p=0.035) and 180-day mortality was significantly worse (coefficient 0.10, 95% CI 0.02-0.18, p=0.007) compared to those who were at low risk of malnutrition. However, other clinical outcomes were similar between the two groups. CONCLUSION: Nutrition screening is poor in hospitalised HF patients and long-term but not short-term clinical outcomes were worse in malnourished HF patients.

Prevalence, characteristics and risk factors of frequently readmitted patients to an internal medicine service.

BACKGROUND: Unplanned hospital readmissions (HRA), which have been used as key performance index of healthcare quality, are becoming more prevalent. They are associated with substantial financial burden to hospital systems and considerable impacts on patients' physical and mental health. Patients with frequent readmissions are not well studied. AIMS: To determine the prevalence, characteristics and risk factors associated with frequent readmissions (FRA) to an internal medicine service at a tertiary public hospital. METHOD: A retrospective observational study was conducted at an internal medicine service in a tertiary teaching hospital between 1 January 2010 and 30 June 2016. FRA was defined as four or more readmissions within 12 months of discharge from the index admission (IA). Demographic and clinical characteristics and potential risk factors were evaluated. RESULTS: A total of 50 515 patients was included; 1657 (3.3%) had FRA and were associated with nearly 2.5 times higher in 12-month mortality rates. They were older, had higher rates of indigenous Australians (3.2%), more disadvantaged status (index of relative socio-economic disadvantage decile of 5.3) and more comorbidities (mean Charlson comorbidity index 1.4) in comparison, to infrequent readmission group. The mean length of hospital stay during the IA was 6 days for FRA group (21.4% staying more than 7 days) with higher incidence of discharge against medical advice (2.0% higher). Intensive care unit admission rate was 6.6% for FRA group compared with 3.9% for infrequent readmission group. Multivariate analysis showed mental disease and disorders, neoplastic, alcohol/drug use and alcohol/drug-induced organic mental disorders are associated with FRA. CONCLUSION: The risk factors associated with FRA were older age, indigenous status, being socially disadvantaged, having higher comorbidities and discharging against medical advice. Conditions that lead to FRA were mental disorders, alcohol/drug use and alcohol/drug-induced organic mental disorders and neoplastic disorders.

Nutritional risk assessed by the Malnutrition Universal Screening Tool as a predictor of frailty in acutely hospitalised older patients: An observational study.

BACKGROUND AND OBJECTIVES: Frailty and malnutrition are overlapping geriatric syndromes and leads to poor clinical outcomes in older patients. This study determined whether Malnutrition Universal Screening Tool (MUST) can predict frailty in older hospitalised patients. METHODS AND STUDY DESIGN: This prospective study recruited 243 patients ≥65 years in a tertiary-teaching hospital in Australia. Frailty assessment was performed by use of the Edmonton-Frail-Scale (EFS), while malnutrition-risk was determined by use of the MUST. Patients with an EFS score >8 were classified as frail, while patients with a MUST score of 1 as at moderate malnutritionrisk and ≥2 as at high malnutrition-risk. Multivariable logistic regression determined whether malnutrition-risk predicts frailty after adjustment for various co-variates. RESULTS: The mean (SD) age was 83.9 (6.5) years) and 126 (51.9%) were females. One-hundred and forty-nine (61.3%) patients were classified as frail, while 66 (27.2%) were found to be at high malnutrition-risk according to the MUST. Frail patients were more likely to be older with a higher Charlson-index and on polypharmacy than non-frail patients. Patients who were at high malnutrition- risk were more likely to be living alone and on vitamin D supplementation than those at low malnutritionrisk. Patients who were at a high malnutrition-risk but not those who were at moderate malnutrition-risk, were more likely to be deemed frail (aOR 2.6, 95% CI 1.2-5.5, p=0.015) when compared to those who were at low malnutrition-risk. CONCLUSIONS: Only patients who were classified as at high malnutrition-risk according to the MUST are more likely to be deemed frail.

The overlap of frailty and malnutrition in older hospitalised patients: An observational study.

BACKGROUND AND OBJECTIVES: Frailty and malnutrition are geriatric syndromes with common risk-factors. Limited studies have investigated these two conditions simultaneously in hospitalised patients. This study investigated the overlap of frailty and malnutrition in older hospitalised patients. METHODS AND STUDY DESIGN: This prospective study enrolled 263 patients ≥65 years in a tertiary-teaching hospital in Australia. Frailty status was assessed by use of the Edmonton-Frail-Scale (EFS) and malnutrition risk was determined by use of the Malnutrition Universal Screening Tool (MUST). Patients were divided into four categories for comparison: normal, at malnutrition- risk only, frail-only and both frail and at malnutrition risk. Multivariable regression models compared clinical outcomes: length of hospital stay (LOS), in-hospital mortality, health-related quality of life (HRQoL) and 30- day readmissions after adjustment for age, sex, Charlson comorbidity index (CCI) and living-status. RESULTS: The mean (SD) age was 84.1 (6.6) years and 51.2% were females. The prevalence of patients who were at malnutrition- risk only was 14.8%, frailty only 27.8% and 33.5% were both frail and at malnutrition-risk. Frail-only patients were more likely to be older, from a nursing home and with a higher CCI than malnourished only patients. Frail patients had a worse HRQoL (coefficient -0.08, 95% -0.0132--0.031, p=0.002) and were more likely to have a longer LOS (coefficient 5.91, 95% CI 0.77-11.14, p=0.024) than patients at-risk of malnutrition. Other clinical outcomes were similar between the two groups. CONCLUSIONS: There is a substantial overlap of frailty and malnutrition in older hospitalised patients and frailty is associated with worse clinical outcomes than malnutrition.

Clinical characteristics and outcomes of influenza A and B virus infection in adult Australian hospitalised patients.

BACKGROUND: Influenza B is often perceived as a less severe strain of influenza. The epidemiology and clinical outcomes of influenza B have been less thoroughly investigated in hospitalised patients. The aims of this study were to describe clinical differences and outcomes between influenza A and B patients admitted over a period of 4 years. METHODS: We retrospectively collected data of all laboratory confirmed influenza patients ≥18 years at two tertiary hospitals in South Australia. Patients were confirmed as influenza positive if they had a positive polymerase-chain-reaction (PCR) test of a respiratory specimen. Complications during hospitalisation along with inpatient mortality were compared between influenza A and B. In addition, 30 day mortality and readmissions were compared. Logistic regression model compared outcomes after adjustment for age, Charlson index, sex and creatinine levels. RESULTS: Between January 2016-March 2020, 1846 patients, mean age 66.5 years, were hospitalised for influenza. Of whom, 1630 (88.3%) had influenza A and 216 (11.7%) influenza B. Influenza B patients were significantly younger than influenza A. Influenza A patients were more likely be smokers with a history of chronic obstructive pulmonary disease (COPD) and ischaemic heart disease (IHD) than influenza B. Complications, including pneumonia and acute coronary syndrome (ACS) were similar between two groups, however, septic shock was more common in patients with influenza B. Adjusted analyses showed similar median length of hospital stay (LOS), in hospital mortality, 30-day mortality and readmissions between the two groups. CONCLUSIONS: Influenza B is less prevalent and occurs mostly in younger hospitalised patients than influenza A. Both strains contribute equally to hospitalisation burden and complications. TRIAL REGISTRATION: Australia and New Zealand Clinical Trial Registry (ANZCR) no ACTRN12618000451202 date of registration 28/03/2018.

Similar outcomes for general medicine patients discharged on any day of the week.

BACKGROUND: Hospital congestion is worsened by fewer patients being discharged on the weekend than on weekdays. Weekend admissions fare worse in hospital than weekday admissions. Understanding the fate of patients discharged on the weekend, or any particular weekday, may help optimise hospital discharge processes. AIM: To determine the effects of weekend and specific weekday discharges on adverse outcomes (mortality and readmission to hospital). METHODS: Electronic records were used to identify unplanned admissions to two large public hospitals across a 5-year period. Day of week of discharge, the inpatient length of stay, unplanned readmissions and mortality rate were determined. RESULTS: There was a significant reduction in discharges on the weekend (49%), particularly for patients who were older or with significant comorbidity (P < 0.001). Adjusting for these differences, there was no difference in readmission and mortality between weekday and weekend discharges within two (OR 0.97; 95% CI 0.83-1.14; P < 0.76) or seven (OR 0.91; 95% CI 0.82-1.01; P < 0.07) days of discharge. By 30 days, there were significantly fewer adverse outcomes for those discharged on the weekend (OR 0.89; 95% CI 0.83-0.96; P < 0.001). There was no difference in adverse outcome rates for patients discharged on Mondays, Wednesdays or Fridays. CONCLUSION: Fewer patients are discharged on the weekend and these are typically younger, less complex patients. Patients discharged on the weekend fare similarly or better than those discharged on a weekday. Therefore, a push to discharge more patients on the weekend could improve hospital efficiency without compromising patient care.

Vitamin C deficiency in Australian hospitalised patients: an observational study.

BACKGROUND: Vitamin C has anti-oxidant properties and acts as a cofactor for several enzymes. Hypovitaminosis C has been associated with bleeding, endothelial dysfunction and death. The prevalence of hypovitaminosis C is unknown in Australian hospitalised patients, and its clinical relevance is uncertain. AIMS: To determine the prevalence, characteristics and clinical outcomes of hospitalised patients with hypovitaminosis C. METHODS: This observational study included general-medical inpatients in a tertiary-level hospital in Australia. High-performance liquid chromatography (HPLC) was used to determine plasma vitamin C levels. As per Johnston's criteria, vitamin C levels of ≥28 µmol/L were classified as normal and <28 µmol/L as low. Clinical outcomes determined included length of hospital stay (LOS), nosocomial complications, intensive care unit admission and in-hospital mortality. RESULTS: A total of 200 patients participated in this study, and vitamin C levels were available for 149 patients, of whom 35 (23.5%) had normal vitamin C levels, and 114 (76.5%) had hypovitaminosis C. Patients with hypovitaminosis C were older and had higher C-reactive protein (CRP) levels. Median LOS was 2 days longer in patients with hypovitaminosis C (6 days (interquartile range (IQR) 4, 8) vs 4 days (IQR 3, 6), P = 0.02), and they had fourfold higher odds of staying in hospital for >5 days than those with normal vitamin C levels. Other clinical outcomes were similar between the two groups. CONCLUSIONS: Hypovitaminosis C is common in hospitalised patients and is associated with prolonged LOS. Further research is needed to ascertain the benefits of vitamin C supplementation in vitamin C-depleted patients.

Economic evaluation of an extended nutritional intervention in older Australian hospitalized patients: a randomized controlled trial.

BACKGROUND: Prevalence of malnutrition in older hospitalized patients is 30%. Malnutrition is associated with poor clinical outcomes in terms of high morbidity and mortality and is costly for hospitals. Extended nutrition interventions improve clinical outcomes but limited studies have investigated whether these interventions are cost-effective. METHODS: In this randomized controlled trial, 148 malnourished general medical patients ≥60 years were recruited and randomized to receive either an extended nutritional intervention or usual care. Nutrition intervention was individualized and started with 24 h of admission and was continued for 3 months post-discharge with a monthly telephone call whereas control patients received usual care. Nutrition status was confirmed by Patient generated subjective global assessment (PG-SGA) and health-related quality of life (HRQoL) was measured using EuroQoL 5D (EQ-5D-5 L) questionnaire at admission and at 3-months follow-up. A cost-effectiveness analysis was conducted for the primary outcome (incremental costs per unit improvement in PG-SGA) while a cost-utility analysis (CUA) was undertaken for the secondary outcome (incremental costs per quality adjusted life year (QALY) gained). RESULTS: Nutrition status and HRQoL improved in intervention patients. Mean per included patient Australian Medicare costs were lower in intervention group compared to control arm (by $907) but these differences were not statistically significant (95% CI: -$2956 to $4854). The main drivers of higher costs in the control group were higher inpatient ($13,882 versus $13,134) and drug ($838 versus $601) costs. After adjusting outcomes for baseline differences and repeated measures, the intervention was more effective than the control with patients in this arm reporting QALYs gained that were higher by 0.0050 QALYs gained per patient (95% CI: -0.0079 to 0.0199). The probability of the intervention being cost-effective at willingness to pay values as low as $1000 per unit improvement in PG-SGA was > 98% while it was 78% at a willingness to pay $50,000 per QALY gained. CONCLUSION: This health economic analysis suggests that the use of extended nutritional intervention in older general medical patients is likely to be cost-effective in the Australian health care setting in terms of both primary and secondary outcomes. TRIAL REGISTRATION: ACTRN No. 12614000833662 . Registered 6 August 2014.

Malnutrition screening in acutely unwell elderly inpatients.

BACKGROUND: The rate of malnutrition among hospitalised elderly patients in Australia is 42.3%. Malnutrition is known to lead to significant adverse outcomes for the patients and increase hospital costs through increased use of resources. AIM: This study assessed nutrition screening adequacy and investigated factors associated with missed opportunity to diagnose malnutrition. METHODS: A prospective cross-sectional study involving 205 general medical patients aged ≥60 years admitted acutely in a tertiary hospital over a period of 1 year. Patients who were not given initial nutritional screening were noted and all patients underwent nutritional assessment. The researchers assessed demographic data and performed univariate analysis of factors responsible for missed nutritional screening. RESULTS: Only 99 patients (49.5%) were screened for malnutrition and 100 (50.3%) missed initial nutritional screening (data incomplete for 6 patients). Of those screened, more were malnourished (n=64; 61.5%) than those not screened (n=40; 38.5%), p<0.001. There was no significant difference in screening rates over the weekends and public holidays compared with weekdays (p=0.14). Time of day (p=0.03) and ward location (p=0.001) were significant factors, which determined nutrition screening. CONCLUSION: This study indicates common associations that might explain low inpatient screening rates for malnutrition; these include apparently adequate nutritional status, lower staff to patient ratios and outlier ward locations. Ensuring consistent nutrition screening with appropriate therapeutic interventions for patients and educational interventions for staff could pay dividends not only in terms of improved patient health but also in terms of hospital reimbursement.

External validation and comparative analysis of the HOSPITAL score and LACE index for predicting readmissions among patients hospitalised with community-acquired pneumonia in Australia.

ObjectiveCommunity-acquired pneumonia (CAP) is a leading cause of emergency hospitalisations globally and is associated with high readmission rates. Specific score systems developed for all medical conditions such as the HOSPITAL score and the LACE index can also usefully predict CAP readmissions. However, there is limited evidence regarding their performance in the Australian healthcare settings.MethodsThis multicentre retrospective study analysed adult CAP discharges from two metropolitan hospitals in South Australia between 1 January 2018 and 31 December 2023. Data for determining the HOSPITAL score and the LACE index were derived from electronic medical records. Demographic characteristics of patients readmitted within 30 days were compared with those who were not readmitted. The scores were evaluated for overall performance, discriminatory power and calibration, with discriminatory power assessed using the concordance statistic (C-statistic).ResultsOver 6years, 7245 CAP discharges were recorded, with 1329 (18.3%) readmissions within 30days. The mean (s.d.) age of the cohort was 74.4 (17.8) years. Readmitted patients were more likely to have multiple morbidities and frailty than those not readmitted (P<0.05). They also had a higher mean number of emergency department presentations and hospital admissions in the previous year and a longer initial hospital stay (P<0.05). Overall, the mean (s.d.) HOSPITAL score and LACE index were 3.4 (2.1) and 9.3 (3.6), respectively. Among readmissions, 28.4% occurred in patients with a HOSPITAL score >4 (intermediate and high-risk group), while 25.8% occurred in patients in the high-risk LACE category (LACE index>10). The C-statistic for the HOSPITAL score and LACE index was 0.62 (95% CI 0.61-0.64) and 0.63 (95% CI 0.61-0.65), respectively, with no significant difference in the area under the receiver operating characteristic curves (P>0.05).ConclusionsThe predictive abilities of the HOSPITAL score and the LACE index for CAP readmissions are modest and comparable in an Australian setting.

Comparing Outcomes of Community-Acquired Pneumonia Patients Discharged from General Medicine and Respiratory Units in Australia: A Propensity Score-Matched Analysis.

Background/Objectives: Community-acquired pneumonia (CAP) is a common emergency presentation in Australia, with the choice of admitting specialty unit often influenced by pneumonia severity and comorbidities. However, it remains unclear whether there are between-specialty differences in patient characteristics and outcomes. We sought to address this issue by investigating the characteristics and outcomes of CAP patients admitted to General Medicine (GM) versus Respiratory units. Methods: This retrospective observational study utilised data from the two largest metropolitan hospitals in South Australia, encompassing all non-COVID-19-related CAP admissions throughout 2021 to 2023. The hospital length of stay (LOS), in-patient and 30-day mortality, and 30-day readmission rates were assessed by propensity score matching (PSM) using 17 variables. Results: Of the 3004 cases of non-COVID-19 CAP admitted across the two hospitals during the study period, 2673 (71.8%) were admitted under GM units and 331 (9.1%) under Respiratory units. GM patients were, on average, a decade older, presented with a significantly higher burden of comorbidities, exhibited a greater prevalence of frailty, and had higher pneumonia severity compared to those admitted under a Respiratory unit (p < 0.05). Unadjusted analysis revealed a shorter median LOS among GM-admitted patients (5.9 vs. 4.1 days, p < 0.001). After PSM adjustment, patients admitted under the Respiratory units had an 8-fold higher odds of a longer LOS compared to GM (adjusted odds ratio [aOR] 8.53, 95% CI 1.96-37.25, p = 0.004). Other clinical outcomes were comparable between the two groups. Conclusions: Our findings indicate that GM units compared to Respiratory units provide efficient and safe care for patients requiring hospitalisation for CAP.

The impact of standardised goals of care documentation on the use of cardiopulmonary resuscitation, mechanical ventilation, and intensive care unit admissions in older patients: a retrospective observational analysis.

Background In South Australian hospitals, 'Do Not Resuscitate' orders have been replaced by '7-Step Pathway Acute Resuscitation Plans', a standardised form and approach that encourages shared decision-making while providing staff with clarity about goals of care. This initiative has led to increased rates of documentation about treatment preferences, including 'Not-For-Cardiopulmonary Resuscitation'. Aim To quantify any effect of the 7-Step Pathway form versus previous 'Do Not Resuscitate' orders on cardiopulmonary resuscitation, mechanical ventilation, and/or intensive care unit admission during hospitalisation. Methods We completed a retrospective, observational study in two Australian tertiary hospitals using interrupted time-series analysis. We examined the number of medical inpatients aged 70 years and over who received one or more Intensive Treatments-cardiopulmonary resuscitation, mechanical ventilation, or intensive care unit admission-in the 2 years before and 2 years after the introduction of the form. Results There were 2759 Intensive Treatments across 66 051 inpatient admissions; 1304/32 489 (4.0%) pre-intervention and 1455/33 562 post-intervention (4.3%). Sub-group analysis of those who died in hospital showed 400/1669 (24%) received Intensive Treatments pre-intervention and 382/1624 post-intervention (24%). Interrupted time-series analysis suggested that the intervention did not significantly alter Intensive Treatments over time at Hospital 1 and was associated with a significant slowing of the already decreasing use of Intensive Treatments at Hospital 2. Among patients who died in hospital, there was minimal change at either site. Conclusions There was no reduction in Intensive Treatments in older medical inpatients following the introduction of standardised goals of care documentation.

Benefits of heart failure-specific pharmacotherapy in frail hospitalised patients: a cross-sectional study.

OBJECTIVES: Up to 50% of heart failure (HF) patients may be frail and have worse clinical outcomes than non-frail patients. The benefits of HF-specific pharmacotherapy (beta-blockers, ACE-inhibitors/angiotensin-receptor-blockers and mineralocorticoid-receptor-antagonist) in this population are unclear. This study explored whether HF-specific pharmacotherapy improves outcomes in frail hospitalised HF patients. DESIGN: Observational, multicentre, cross-sectional study. SETTINGS: Tertiary care hospitals. PARTICIPANTS: One thousand four hundred and six hospitalised frail HF patients admitted between 1 January 2013 and 31 December 2020. MEASURES: The Hospital Frailty Risk Score (HFRS) determined frailty status and patients with HFRS ≥5 were classified as frail. The primary outcomes included the days alive and out of hospital (DAOH) at 90 days following discharge, 30-day and 180-day mortality, length of hospital stay (LOS) and 30-day readmissions. Propensity score matching (PSM) compared clinical outcomes depending on the receipt of HF-specific pharmacotherapy. RESULTS: Of 5734 HF patients admitted over a period of 8 years, 1406 (24.5%) were identified as frail according to the HFRS and were included in this study. Of 1406 frail HF patients, 1025 (72.9%) received HF-specific pharmacotherapy compared with 381 (27.1%) who did not receive any of these medications. Frail HF patients who did not receive HF-specific pharmacotherapy were significantly older, with higher creatinine and brain natriuretic peptide but with lower haemoglobin and albumin levels (p<0.05) when compared with those frail patients who received HF medications. After PSM frail patients on treatment were more likely to have an increased DAOH (coefficient 16.18, 95% CI 6.32 to 26.04, p=0.001) than those who were not on treatment. Both 30-day (OR 0.30, 95% CI 0.23 to 0.39, p<0.001) and 180-day mortality (OR 0.43, 95% CI 0.33 to 0.54, p<0.001) were significantly lower in frail patients on HF treatment but, there were no significant differences in LOS and 30-day readmissions (p>0.05). CONCLUSION: This study found an association between the use of HF-specific pharmacotherapy and improved clinical outcomes in frail HF hospitalised patients when compared to those who were not on treatment. TRIAL REGISTRATION NUMBER: ANZCTRN383195.

External Validation of the Hospital Frailty-Risk Score in Predicting Clinical Outcomes in Older Heart-Failure Patients in Australia.

Frailty is common in older hospitalised heart-failure (HF) patients but is not routinely assessed. The hospital frailty-risk score (HFRS) can be generated from administrative data, but it needs validation in Australian health-care settings. This study determined the HFRS scores at presentation to hospital in 5735 HF patients ≥ 75 years old, admitted over a period of 7 years, at two tertiary hospitals in Australia. Patients were classified into 3 frailty categories: HFRS < 5 (low risk), 5−15 (intermediate risk) and >15 (high risk). Multilevel multivariable regression analysis determined whether the HFRS predicts the following clinical outcomes: 30-day mortality, length of hospital stay (LOS) > 7 days, and 30-day readmissions; this was determined after adjustment for age, sex, Charlson index and socioeconomic status. The mean (SD) age was 76.1 (14.0) years, and 51.9% were female. When compared to the low-risk HFRS group, patients in the high-risk HFRS group had an increased risk of 30-day mortality and prolonged LOS (adjusted OR (aOR) 2.09; 95% CI 1.21−3.60) for 30-day mortality, and an aOR of 1.56 (95% CI 1.01−2.43) for prolonged LOS (c-statistics 0.730 and 0.682, respectively). Similarly, the 30-day readmission rate was significantly higher in the high-risk HFRS group when compared to the low-risk group (aOR 1.69; 95% CI 1.06−2.69; c-statistic = 0.643). The HFRS, derived at admission, can be used to predict ensuing clinical outcomes among older hospitalised HF patients.

Relationship between Vitamin C Deficiency and Cognitive Impairment in Older Hospitalised Patients: A Cross-Sectional Study.

Vitamin C is a powerful antioxidant and facilitates neurotransmission. This study explored association between vitamin C deficiency and cognitive impairment in older hospitalised patients. This prospective study recruited 160 patients ≥ 75 years admitted under a Geriatric Unit in Australia. Cognitive assessment was performed by use of the Mini-Mental-State-Examination (MMSE) and patients with MMSE scores <24 were classified as cognitively-impaired. Fasting plasma vitamin C levels were determined using high-performance-liquid-chromatography. Patients were classified as vitamin C deficient if their levels were below 11 micromol/L. Logistic regression analysis was used to determine whether vitamin C deficiency was associated with cognitive impairment after adjustment for various covariates. The mean (SD) age was 84.4 (6.4) years and 60% were females. A total of 91 (56.9%) were found to have cognitive impairment, while 42 (26.3%) were found to be vitamin C deficient. The mean (SD) MMSE scores were significantly lower among patients who were vitamin C deficient (24.9 (3.3) vs. 23.6 (3.4), p-value = 0.03). Logistic regression analysis suggested that vitamin C deficiency was 2.9-fold more likely to be associated with cognitive impairment after adjustment for covariates (aOR 2.93, 95% CI 1.05−8.19, p-value = 0.031). Vitamin C deficiency is common and is associated with cognitive impairment in older hospitalised patients.

Using electronic admission data to monitor temporal trends in local medication use: Experience from an Australian tertiary teaching hospital.

Background and aims: Medication usage varies according to prescribing behavior, professional recommendations, and the introduction of new drugs. Local surveillance of medication usage may be useful for understanding and comparing prescribing practices by healthcare providers, particularly in countries such as Australia that are in the process of enhancing nationwide data linkage programs. We sought to investigate the utility of electronic hospital admission data to investigate local trends in medication use, to determine similarities and differences with other Australian studies, and to identify areas for targeted interventions. Methods: We performed a retrospective longitudinal analysis using combined data from a hospital admissions administrative dataset from a large tertiary teaching hospital in Adelaide, South Australia and a hospital administrative database documenting medication usage matched for the same set of patients. All adult admissions over a 12-year period, between 1 January 2007 and 31st December 2018, were included in the study population. Medications were categorized into 21 pre-defined drug classes of interest according to the ATC code list 2021. Results: Of the 692,522 total admissions, 300,498 (43.4%) had at least one recorded medication. The overall mean number of medications for patients that were medicated increased steadily from a mean (SD) of 5.93 (4.04) in 2007 to 7.21 (4.98) in 2018. Results varied considerably between age groups, with the older groups increasing more rapidly. Increased medication usage was partly due to increased case-complexity with the mean (SD) Charlson comorbidity index increasing from 0.97 (1.66) in 2007-to-2012 to 1.17 (1.72) in 2013-to-2018 for medicated patients. Of the 21 medication classes, 15 increased (p < 0.005), including antithrombotic agents; OR = 1.18 [1.16-1.21], proton pump inhibitors; OR = 1.14 [1.12-1.17], statins; OR = 1.12; [1.09-1.14], and renin-angiotensin system agents; OR = 1.06 [1.04-1.08], whilst 3 decreased (p < 0.005) including anti-inflammatory drugs (OR = 0.55; 99.5% CI = 0.53-0.58), cardiac glycosides (OR = 0.81; 99.5% CI = 0.78-0.86) and opioids (OR = 0.82; 99.5% CI = 0.79-0.83). The mean number of medications for all admissions increased between 2007 and 2011 and then declined until 2018 for each age group, except for the 18-to-35-year-olds. Conclusion: Increased medication use occurred in most age groups between 2007 and 2011 before declining slightly even after accounting for increased comorbidity burden. The use of electronic hospital admission data can assist with monitoring local medication trends and the effects of initiatives to enhance the quality use of medicines in Australia.

Validity of the Malnutrition Universal Screening Tool for Evaluation of Frailty Status in Older Hospitalised Patients.

The malnutrition-universal-screening-tool (MUST) is commonly used for screening malnutrition in hospitalised patients but its utility in the detection of frailty is unknown. This study determined the utility of MUST in detection of frailty in older hospitalised patients. This prospective-study enrolled 243 patients ⩾65 years in a tertiary-teaching hospital in Australia. Patients with a MUST score of ⩾1 were classified as at-risk of malnutrition. Frailty status was determined by the Edmonton-Frail-Scale (EFS) and patients with an EFS score of >8 were classified as frail. We validated the MUST against the EFS by plotting a receiver-operating-characteristic-curve (ROC) curve and area-under-the-curve (AUC) was determined. The mean (SD) age was 83.9 (6.5) years and 126 (51.8%) were females. The EFS determined 149 (61.3%) patients as frail, while 107 (44.1%) patients were at-risk of malnutrition according to the MUST. There was a positive linear but weak association between the MUST and the EFS scores (Pearson's correlation coefficient= .22, 95% CI .12- .36, p < .001). The sensitivity, specificity, positive and negative predictive value of MUST in the detection of frailty was 51%, 67%, 78.5% and 37%, respectively and the AUC was .59 (95% CI .53-.65, p < .001). The MUST is moderately sensitive in detection of frailty in older-hospitalised patients.

Effectiveness of Oseltamivir in reducing 30-day readmissions and mortality among patients with severe seasonal influenza in Australian hospitalized patients.

BACKGROUND: Worldwide, seasonal influenza causes significant mortality and poses a significant economic burden. Oseltamivir is an effective treatment, but benefits beyond immediate hospitalization are unknown. METHODS: This retrospective multicenter study included adult hospitalized influenza patients from two major teaching hospitals in Australia. Patients who received Oseltamivir <48 h of admission (prompt-treatment group) were compared with those who either did not receive treatment or if treatment was delayed by >48 h (delayed/no-treatment group). Propensity-score matching was used to balance confounders between two groups. Primary outcomes included 30-day readmissions, 30-day mortality, composite-outcome (30-day mortality and readmissions), in-hospital mortality, and hospital length of stay (LOS). RESULTS: Between January 2016-March 2020, 1828 adult patients mean (SD) age 66.4 (20.1), 52.9% females, were hospitalized with influenza. Four hundred and forty-eight (24.5%) received prompt-treatment with Oseltamivir, while 1380 (75.5%) patients were in the delayed/no-treatment group. The median (IQR) time from onset of symptoms to the administration of Oseltamivir was three (1-5) days. The propensity-score model included 245 matched patients in each group (standardized mean difference of <10%). Both 30-day readmissions and the composite-outcome were, respectively, 5.7% (P = 0.03) and 6.5% (P = 0.02) lower in patients who received prompt-treatment with Oseltamivir when compared to the delayed/no-treatment group. LOS showed a significant reduction, and in-hospital mortality showed a trend towards improvement among patients who received prompt-treatment when compared to the other group. CONCLUSIONS: Early administration of Oseltamivir was associated with a reduction in 30-days readmissions and composite-outcome of 30-day readmissions and mortality in adult hospitalized influenza patients when compared to delayed/no-treatment.