Elderly bedridden patients with dementia use over one quarter of resources in internal medicine wards in an Israeli hospital.

BACKGROUND: Elderly bedridden patients with dementia (EBRPD) are a growing segment of the population. We aimed to describe acute care hospitalization of EBRPD in internal medicine wards: the prevalence of EBRPD, their impact on hospital resources and hospital ecology, one-year survival, and one-year readmission-free survival. METHODS: The study setting was the internal medicine division of one tertiary care hospital in Israel. We conducted a point-prevalence survey to measure the prevalence of EBRPD and the prevalence of multidrug-resistant organism (MDRO) carriage. We also conducted a retrospective chart review of EBRPD who were hospitalized in the internal medicine division in order to assess resource use, survival, and readmission. RESULTS: In the point prevalence surveys (N = 1667 patients), EBRPD comprised 24.3% of patients and 59.0% of mechanically ventilated patients. EBRPD were twice as likely to be colonized or infected by MDROs as other patients (39.3% vs. 18%, p < 0.001); thus, 41% of MDRO carriers during the survey days were EBRPD. In the retrospective study (N = 517 EBRPD), 80% of EBRPD received antibiotics; on average, they received an antibiotic on 87.7% of their hospital days. One-year survival was 35.6% and one-year readmission-free survival was 16.4%. CONCLUSIONS: Acute care hospitalization of EBRPD accounted for a high proportion of bed occupancy and ventilator use in internal medicine wards. EBRPD significantly increase the potential for MDRO transmission. Policymakers should seek alternatives to acute care hospitalization for EBRPD.

Effect of infections on 30-day mortality among critically ill patients hospitalized in and out of the intensive care unit.

BACKGROUND: This analysis is part of a multicenter study conducted in Israel to evaluate survival of critically ill patients treated in and out of intensive care units (ICUs). OBJECTIVE: To assess the role of infection on 30-day survival among critically ill patients hospitalized in ICUs and regular wards. DESIGN: All adult inpatients were screened on four rounds for patients meeting ICU admission criteria. Retrospective chart review was used to detect presence and type of infection. Mortality was ascertained from day of meeting study criteria to 30 days thereafter. ANALYSIS: The effect of infection on mortality among patients, treated in and out of the ICU, was compared using Kaplan Meier survival curves. Multivariate Cox models were constructed to adjust interdepartmental comparisons for case-mix differences. RESULTS: Of 641 critically ill patients identified, 36.8% already had an infection on day 0. An additional 40.2% subsequently developed a new infection during the follow-up period, ranging from 64.6% in the ICU to 31.5% in regular wards (p < .001). Resistant infections were more prevalent in ICUs. Infection was independently associated with an increase in mortality, regardless of whether the patient was admitted to the ICU. There was no difference in the adjusted risk of mortality associated with an infection diagnosed on day 0 vs. an infection diagnosed later. Risk of dying was similar in resistant and nonresistant infections. Adjusting for infections, survival of ICU patients was better relative to patients in regular wards (adjusted hazard ratio = 0.7). Among the different types of infection, risk of mortality from pneumonia was significantly lower in ICUs relative to regular wards. There was a protective effect in ICUs among noninfected patients. CONCLUSION: The risk of acquiring a new infection is greater in the ICU. However, risk of mortality among ICU patients was lower for the most serious infections and for those without any infection.

Regional variations in mortality and causes of death in Israel, 2009-2013.

BACKGROUND: Regional variations in mortality can be used to study and assess differences in disease prevalence and factors leading to disease and mortality from different causes. To enable this comparison, it is important to standardize the mortality data to adjust for the effects of regional population differences in age, nationality and country of origin. METHODS: Standardized mortality ratios (SMR) were calculated for the districts and sub-districts in Israel, for total mortality by gender as well as for leading causes of death and selected specific causes. Correlations were assessed between these SMRs, regional disease risk factors and socio-economic characteristics. Implications for health policy were then examined. RESULTS: Total mortality in the Northern District of Israel was not significantly different from the national average; but the Haifa, Tel Aviv, and Southern districts were significantly higher and the Jerusalem, Central, Judea and Samaria districts were lower. Cancer SMR was significantly lower in Jerusalem and not significantly higher in any region. Heart disease and diabetes SMRs were significantly higher in many sub-districts in the north of the country and lower in the south. SMRs for septicemia, influenza/pneumonia, and for cerebrovascular disease were higher in the south. Septicemia was also significantly higher in Tel Aviv and lower in the North, Haifa and Jerusalem districts. SMRs for accidents, particularly for motor vehicle accidents were significantly higher in the peripheral Zefat and Be'er Sheva sub-districts. CONCLUSION: The SMR, adjusted for age and ethnicity, is a good method for identifying districts that differ significantly from the national average. Some of the regional differences may be attributed to differences in the completion of death certificates. This needs to be addressed by efforts to improve reporting of causes of death, by educating physicians. The relatively low differences found after adjustment, show that factors associated with ethnicity may affect mortality more than regional factors. Recommendations include encouraging good eating habits, exercise, cancer screening, control of hypertension, reduction of smoking and improving road infrastructure and emergency care access in the periphery.