Medical complexity and pediatric emergency department and inpatient utilization.

OBJECTIVES: To characterize the use of and disposition from a tertiary pediatric emergency department (PED) by children with chronic conditions with varying degrees of medical complexity. METHODS: We conducted a retrospective cohort study using a dataset of all registered PED patient visits at Seattle Children's Hospital from January 1, 2008, through December 31, 2009. Children's medical complexity was classified by using a validated algorithm (Clinical Risk Group software) into nonchronic and chronic conditions: episodic chronic, lifelong chronic, progressive chronic, and malignancy. Outcomes included PED length of stay (LOS) and disposition. Logistic regression generated age-adjusted odds ratios (AOR) of admission with 95% confidence intervals (CIs). RESULTS: PED visits totaled 77 748; 20% (15 433) of which were for children with chronic conditions. Compared with visits for children without chronic conditions, those for children with chronic conditions had increased PED LOS (on average, 79 minutes longer; 95% CI 77-81; P < .0001) and hospital (51% vs 10%) and PICU (3.2% vs 0.1%) admission rates (AOR 10.3, 95% CI 9.9-10.7 to hospital and AOR 25.0, 95% CI 17.0-36.0 to PICU). Admission rates and PED LOS increased with increasing medical complexity. CONCLUSIONS: Children with chronic conditions comprise a significant portion of annual PED visits in a tertiary pediatric center; medical complexity is associated with increased PED LOS and hospital or PICU admission. Clinical Risk Group may have utility in identifying high utilizers of PED resources and help support the development of interventions to facilitate optimal PED management, such as pre-arrival identification and individual emergency care plans.

Appropriate prescribing in the elderly: an investigation of two screening tools, Beers criteria considering diagnosis and independent of diagnosis and improved prescribing in the elderly tool to identify inappropriate use of medicines in the elderly in primary care in Ireland.

BACKGROUND: Elderly patients are particularly vulnerable to inappropriate prescribing, with increased risk of adverse drug reactions and consequently higher rates of morbidity and mortality. A large proportion of inappropriate prescribing is preventable by adherence to prescribing guidelines, suitable monitoring and regular medication review. As a result, screening tools have been developed to help clinicians improve their prescribing. OBJECTIVES: To compare identification rates of inappropriate prescribing in elderly patients in primary care using two validated screening tools: Beers' criteria and improved prescribing in the elderly tool (IPET); to calculate the net ingredient cost (NIC) per month (euro) of the potentially inappropriate medicines in this population of patients. METHOD: A consecutive cohort of 500 patients 65 years of age and over were recruited prospectively from primary care over a 6 month period in a provincial town in Ireland. Patients' medical records (electronic and paper) were screened and all relevant information concerning current illnesses and medications was recorded on a standardized data collection form to which Beers' criteria [considering diagnosis (CD) and independent of diagnosis (ID)] and IPET tools were applied. The NIC was calculated from an edition of the Irish monthly index of medical specialities published concurrently with the data collection. RESULTS: Beers' criteria identified a total of 69 medicines that were prescribed inappropriately (eight CD and 61 ID) in 65 patients (13%), costing euro824.88 per month while IPET identified 63 potentially inappropriate medicines in 52 (10.4%) patients costing euro381.28 per month. CONCLUSIONS: Potentially inappropriate medications are prescribed in a significant proportion of elderly people in primary care, with significant economic implications.

STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation.

OBJECTIVE: Older people experience more concurrent illnesses, are prescribed more medications and suffer more adverse drug events than younger people. Many drugs predispose older people to adverse events such as falls and cognitive impairment, thus increasing morbidity and health resource utilization. At the same time, older people are often denied potentially beneficial, clinically indicated medications without a valid reason. We aimed to validate a new screening tool of older persons' prescriptions incorporating criteria for potentially inappropriate drugs called STOPP (Screening Tool of Older Persons' Prescriptions) and criteria for potentially appropriate, indicated drugs called START (Screening Tool to Alert doctors to Right, i.e. appropriate, indicated Treatment). METHODS: A Delphi consensus technique was used to establish the content validity of STOPP/START. An 18-member expert panel from academic centers in Ireland and the United Kingdom completed two rounds of the Delphi process by mail survey. Inter-rater reliability was assessed by determining the kappa-statistic for measure of agreement on 100 data-sets. RESULTS: STOPP is comprised of 65 clinically significant criteria for potentially inappropriate prescribing in older people. Each criterion is accompanied by a concise explanation as to why the prescribing practice is potentially inappropriate. START consists of 22 evidence-based prescribing indicators for commonly encountered diseases in older people. Inter-rater reliability is favorable with a kappa-coefficient of 0.75 for STOPP and 0.68 for START. CONCLUSION: STOPP/START is a valid, reliable and comprehensive screening tool that enables the prescribing physician to appraise an older patient's prescription drugs in the context of his/her concurrent diagnoses.

The Lifeways Cross-Generation Study: design, recruitment and data management considerations.

The Lifeways Cross-Generation Cohort Study was first established in 2001 and is a unique longitudinal database in Ireland, with currently over three and a half thousand family participants derived from 1124 mothers recruited initially during pregnancy, mainly during 2002. The database comprises a) baseline self-reported health data for all mothers, a third of fathers and at least one grandparent b) clinical hospital data at recruitment, c) three year follow-up data from the families' General Practitioners, and d) linkage to hospital and vaccination databases. Data collection for the five-year follow-up with parents is underway, continuing through 2007. Because there is at present no single national/regional health information system in Ireland, original data instruments were designed to capture data directly from family members and through their hospitals and healthcare providers. A system of relational databases was designed to coordinate data capture for a complex array of study instruments and to facilitate tracking of family members at different time points.

Dietary habits of pregnant women in Ireland.

This analysis of the Lifeways Cohort study mothers during pregnancy (n = 1124), utilises information from a standard food frequency questionnaire completed at baseline recruitment during early pregnancy. We demonstrate that 76% of women achieved recommended intakes of 5 plus portions of fruit and vegetables daily, though this is strongly socially patterned, inversely associated with age and positively associated with level of education. Achievement of the other recommended shelf intakes of the Food Pyramid is much lower, ranging from 12% achieving the recommended sparing intake of foods high in fat, salt or sugar, to 45% consuming the recommended 3 portions per day of meat and poultry. General medical services eligible respondents are generally less likely to achieve recommended intakes. While 61% of women under 25 years old stopped drinking during pregnancy, this dropped to 38% of expectant mothers over 35 years. Less than half (45%) of those (n = 860) who responded specifically to the question reported peri-conceptual folate supplement intake, again strongly socially patterned. These findings both provide important prevalence data and highlight the need for more concerted and supportive health promotion interventions during pregnancy.

Primary care utilisation rates in pre-school children.

A key objective of the Lifeways cross generation cohort study is to examine health and healthcare, according to socio-economic indicators, during the first five years of life. GP contact details were available for 1032 children. 772 GPs in 589 practices were approached and data were obtained on 640 children (59% of original cohort). The mean follow-up time was 3.0 years (95% CI 2.5-3.5). 20.5% of children had a medical card. The mean GP consultation rate was 5.5 visits per child per year, 6.6 visits for children with a medical card and 5.1 for those without (95% CI 1.1 to 1.9) p = 0.001. 68 had a diagnosis of asthma; 19.10% with a medical card and 8.9% without (95% CI 3.0-17.5) p = 0.0001. 138 children had ever been admitted to hospital; 26.2% with a medical card and 21.0% without (95% CI -3.3% to 13.6%) p = 0.2. Incremental increases in parental income significantly decreased both the risk of asthma (p = 0.02) or hospital admission (p = 0.008).

START (screening tool to alert doctors to the right treatment)--an evidence-based screening tool to detect prescribing omissions in elderly patients.

BACKGROUND: Inappropriate prescribing encompasses acts of commission i.e. giving drugs that are contraindicated or unsuitable, and acts of omission i.e. failure to prescribe drugs when indicated due to ignorance of evidence base or other irrational basis e.g. ageism. There are considerable published data on the prevalence of inappropriate prescribing; however, there are no recent published data on the prevalence of acts of omission. The aim of this study was to calculate the prevalence of acts of prescribing omission in a population of consecutively hospitalised elderly people. METHODS: A screening tool (screening tool to alert doctors to the right treatment acronym, START), devised from evidence-based prescribing indicators and arranged according to physiological systems was prepared and validated for identifying prescribing omissions in older adults. Data on active medical problems and prescribed medicines were collected in 600 consecutive elderly patients admitted from the community with acute illness to a teaching hospital. On identification of an omitted medication, the patient's medical records were studied to look for a valid reason for the prescribing omission. RESULTS: Using the START list, we found one or more prescribing omissions in 57.9% of patients. In order of prevalence, the most common prescribing omissions were: statins in atherosclerotic disease (26%), warfarin in chronic atrial fibrillation (9.5%), anti-platelet therapy in arterial disease (7.3%) and calcium/vitamin D supplementation in symptomatic osteoporosis (6%). CONCLUSION: Failure to prescribe appropriate medicines is a highly prevalent problem among older people presenting to hospital with acute illness. A validated screening tool (START) is one method of systematically identifying appropriate omitted medicines in clinical practice.

The financial implications of falls in older people for an acute hospital.

BACKGROUND: Falls are a common occurrence in older people and frequently lead to hospital admission. There is a current lack of cohesive fall prevention strategies in the Republic of Ireland. AIM: To demonstrate the cost of fall-related admissions to an acute hospital. METHODS: A review of Hospital Inpatient Enquiry (HIPE) data and medical case notes was performed for all fall-related admissions over a one-year period. The cost of fall-related admissions was calculated. In addition a detailed cost analysis was performed to determine the true cost of a hip fracture admission. RESULTS: There were 810 fall-related admissions, resulting in 8,300 acute bed days, and 6,220 rehabilitation bed days, costing euros 10.3 million. Fall-related readmissions resulted in 650 bed-days, bringing the total cost to euros 10.8 million. A typical hip fracture incident admission episode costs euros 14,300. CONCLUSION: Fall-related admissions of olderpeople are a significant financial burden to the health service.

A memory clinic for the assessment of mild dementia.

The aims and experience of work in a specialist memory clinic' are described with reference to the first 200 patients attending the service. 93.5% of attenders were found to suffer from dementia. 67.9% of these fulfilled criteria for probable/possible Alzheimer's disease or other primary degenerative dementias and 8.6% fulfilled criteria for vascular dementia. In the remaining cases the aetiology of the dementia was considered to be multifactorial. The memory clinic proved to be an important resource for demented patients, their carers, and for research projects.

A population-based survey of obstetric practices among rural women in the Bizana district, Transkei.

OBJECTIVE: To determine for the Bizana district, Transkei, the proportion of deliveries that occur at home, home delivery practices, the proportion of women with high-risk pregnancies delivered at home, attendance for antenatal care at the health services and at traditional healers, and the reasons why mothers choose to deliver at home or in the health services. DESIGN: Questionnaire survey. SETTING: Rural community, South Africa. PARTICIPANTS: Two hundred women from randomly selected clusters, obtained from a multistage random sampling process. MAIN OUTCOME MEASURES: Place of delivery, home delivery practices and antenatal care for the most recent delivery (within the previous 5 years). RESULTS: Two-thirds had delivered at home and one-third within the health services. Of those who delivered at home, 62 (47%) were alone at the time of delivery while the remainder were assisted by a close relative or neighbour; 38% had one or more risk factors for obstetric complications. Ninety-seven per cent attended at least once for antenatal care. Home delivery practices and reasons for place of delivery are described. CONCLUSIONS: Antenatal care should include education about the home management of a normal childbirth. Waiting areas for mothers should be established at hospital level for high-risk pregnant mothers.