Comprehensive versus standard care in post-severe acute kidney injury survivors, a randomized controlled trial.

BACKGROUND: Currently, there is a lack of evidence to guide optimal care for acute kidney injury (AKI) survivors. Therefore, post-discharge care by a multidisciplinary care team (MDCT) may improve these outcomes. This study aimed to demonstrate the outcomes of implementing comprehensive care by a MDCT in severe AKI survivors. METHODS: This study was a randomized controlled trial conducted between August 2018 to January 2021. Patients who survived severe AKI stage 2-3 were enrolled and randomized to be followed up with either comprehensive or standard care for 12 months. The comprehensive post-AKI care involved an MDCT (nephrologists, nurses, nutritionists, and pharmacists). The primary outcome was the feasibility outcomes; comprising of the rates of loss to follow up, 3-d dietary record, drug reconciliation, and drug alert rates at 12 months. Secondary outcomes included major adverse kidney events, estimated glomerular filtration rate (eGFR), and the amount of albuminuria at 12 months. RESULTS: Ninety-eight AKI stage 3 survivors were enrolled and randomized into comprehensive care and standard care groups (49 patients in each group). Compared to the standard care group, the comprehensive care group had significantly better feasibility outcomes; 3-d dietary record, drug reconciliation, and drug alerts (p < 0.001). The mean eGFR at 12 months were comparable between the two groups (66.74 vs. 61.12 mL/min/1.73 m2, p = 0.54). The urine albumin: creatinine ratio (UACR) was significantly lower in the comprehensive care group (36.83 vs. 177.70 mg/g, p = 0.036), while the blood pressure control was also better in the comprehensive care group (87.9% vs. 57.5%, p = 0.006). There were no differences in the other renal outcomes between the two groups. CONCLUSIONS: Comprehensive care by an MDCT is feasible and could be implemented for severe AKI survivors. MDCT involvement also yields better reduction of the UACR and better blood pressure control. Trial registration Clinicaltrial.gov: NCT04012008 (First registered July 9, 2019).

Evaluation of an intervention targeted with predictive analytics to prevent readmissions in an integrated health system: observational study.

OBJECTIVES: To determine the associations between a care coordination intervention (the Transitions Program) targeted to patients after hospital discharge and 30 day readmission and mortality in a large, integrated healthcare system. DESIGN: Observational study. SETTING: 21 hospitals operated by Kaiser Permanente Northern California. PARTICIPANTS: 1 539 285 eligible index hospital admissions corresponding to 739 040 unique patients from June 2010 to December 2018. 411 507 patients were discharged post-implementation of the Transitions Program; 80 424 (19.5%) of these patients were at medium or high predicted risk and were assigned to receive the intervention after discharge. INTERVENTION: Patients admitted to hospital were automatically assigned to be followed by the Transitions Program in the 30 days post-discharge if their predicted risk of 30 day readmission or mortality was greater than 25% on the basis of electronic health record data. MAIN OUTCOME MEASURES: Non-elective hospital readmissions and all cause mortality in the 30 days after hospital discharge. RESULTS: Difference-in-differences estimates indicated that the intervention was associated with significantly reduced odds of 30 day non-elective readmission (adjusted odds ratio 0.91, 95% confidence interval 0.89 to 0.93; absolute risk reduction 95% confidence interval -2.5%, -3.1% to -2.0%) but not with the odds of 30 day post-discharge mortality (1.00, 0.95 to 1.04). Based on the regression discontinuity estimate, the association with readmission was of similar magnitude (absolute risk reduction -2.7%, -3.2% to -2.2%) among patients at medium risk near the risk threshold used for enrollment. However, the regression discontinuity estimate of the association with post-discharge mortality (-0.7% -1.4% to -0.0%) was significant and suggested benefit in this subgroup of patients. CONCLUSIONS: In an integrated health system, the implementation of a comprehensive readmissions prevention intervention was associated with a reduction in 30 day readmission rates. Moreover, there was no association with 30 day post-discharge mortality, except among medium risk patients, where some evidence for benefit was found. Altogether, the study provides evidence to suggest the effectiveness of readmission prevention interventions in community settings, but further research might be required to confirm the findings beyond this setting.

Does access to acute intensive trauma rehabilitation (AITR) programs affect the disposition of brain injury patients?

Early incorporation of rehabilitation services for severe traumatic brain injury (TBI) patients is expected to improve outcomes and quality of life. This study aimed to compare the outcomes regarding the discharge destination and length of hospital stay of selected TBI patients before and after launching an acute intensive trauma rehabilitation (AITR) program at King Saud Medical City. It was a retrospective observational before-and-after study of TBI patients who were selected and received AITR between December 2018 and December 2019. Participants' demographics, mechanisms of injury, baseline characteristics, and outcomes were compared with TBI patients who were selected for rehabilitation care in the pre-AITR period between August 2017 and November 2018. A total of 108 and 111 patients were managed before and after the introduction of the AITR program, respectively. In the pre-AITR period, 63 (58.3%) patients were discharged home, compared to 87 (78.4%) patients after AITR (p = 0.001, chi-squared 10.2). The pre-AITR group's time to discharge from hospital was 52.4 (SD 30.4) days, which improved to 38.7 (SD 23.2) days in the AITR (p < 0.001; 95% CI 6.6-20.9) group. The early integration of AITR significantly reduced the percentage of patients referred to another rehabilitation or long-term facility. We also emphasize the importance of physical medicine and rehabilitation (PM&R) specialists as the coordinators of structured, comprehensive, and holistic rehabilitation programs delivered by the multi-professional team working in an interdisciplinary way. The leadership and coordination of the PM&R physicians are likely to be effective, especially for those with severe disabilities after brain injury.

The effect of a mobile integrated health program on health care cost and utilization.

OBJECTIVE: To measure the effect of a mobile integrated health community paramedicine (MIH-CP) transitional care program on hospital utilization, emergency department visits, and charges. DATA SOURCES: Retrospective secondary data from the electronic health record and regional health information exchange were used to analyze patients discharged from a large academic medical center and an affiliated community hospital in Baltimore, Maryland, May 2018-October 2019. STUDY DESIGN: We performed an observational study comparing patients enrolled in an MIH-CP program to propensity-matched controls. Propensity scores were calculated using measures of demographics, clinical characteristics, social determinants of health, and prior health care utilization. The primary outcome is inpatient readmission within 30 days of discharge. Secondary outcomes include excess days in acute care 30 days after discharge and emergency department visits, observation hospitalizations, and total health care charges within 30 and 60 days of discharge. DATA COLLECTION: Included patients were over 18 years old, discharged to home from internal/family medicine services, and live in eligible ZIP codes. The intervention group was enrolled in the MIH-CP program; controls met inclusion criteria but were not enrolled during the study period. PRINCIPAL FINDINGS: The adjusted model showed no difference in 30-day inpatient readmission between 464 enrolled patients and propensity-matched controls (adjusted incidence rate ratio = 1.19, 95% confidence interval [CI] [0.89, 1.60]). There was a higher rate of observation hospitalizations within 30 days of index discharge for MIH-CP patients (adjusted incidence rate ratio = 1.78, 95% CI = [1.01, 3.14]). This difference did not persist at 60 days, and there were no differences in other secondary outcomes. CONCLUSIONS: We found no significant difference in short-term health care utilization or charges between patients enrolled in an MIH-CP transitional care program and propensity-matched controls. This highlights the importance of well-controlled, robust evaluations of effectiveness in novel care-delivery systems.

Prevalence of patients "at risk of malnutrition" and nutritional routines among surgical and non-surgical patients at a large university hospital during the years 2008-2018.

BACKGROUND & AIMS: Being "at risk of malnutrition", which includes both malnutrition and the risk to be so, is associated with increased morbidity and mortality in both surgical and non-surgical patients. Several strategies and guidelines have been introduced to prevent and treat this, but the effects are scarcely investigated. This study aims to evaluate the long-term effects of these efforts by examining trends concerning: 1) the prevalence of patients «at risk of malnutrition¼ and 2) the use of nutritional support and diagnostic coding related to malnutrition over an 11-year period in a large university hospital. Moreover, we wanted to investigate if there was a difference in trends between surgical and non-surgical patients. METHODS: From 2008 to 2018, Haukeland University Hospital, Norway, conducted 34 point-prevalence surveys to investigate the prevalence of patients «at risk of malnutrition¼, as defined by Nutritional Risk Screening 2002, and the use of nutritional support at the hospital. Diagnostic coding included ICD-10 codes related to malnutrition (E43, E44 and E46) at hospital discharge, which were extracted from the electronic patient journal. Trend analysis by calendar year was investigated using logistic regression models with and without adjustment for age (continuous), gender (male/female) and Charlson Comorbidity Index (none, mild, moderate or severe). RESULTS: The number of patients included in the study was 18 933, where 52.1% were male and the median (25th, 75th percentile) age was 65 (51, 76) years. Of these, 5121 (27%) patients were identified to be «at risk of malnutrition¼. Fewer surgical patients (21.2%) were «at risk of malnutrition¼, as compared to non-surgical patients (30.9%) (p < 0.001). Adjusted trend analysis did not identify any change in the prevalence of patients «at risk of malnutrition¼ from 2008 to 2018. The percentage of patients «at risk of malnutrition¼ who received nutritional support increased from 61.6% in 2008 to 71.9% in 2018 (p < 0.001), with a range from 55.6 to 74.8%. This trend was seen for both surgical and non-surgical patients (p < 0.001 for both). Similarly, dietitians were more involved in the patients' treatment (range: 3.8-16.7%), and there was increased use of ICD-10 codes related to malnutrition during the study period (range: 13.0-41.8%) (p < 0.001). These trends were seen for both surgical patients and non-surgical patients (p < 0.001), despite use being less common for surgical patients, as compared to non-surgical patients (p < 0.001). CONCLUSIONS: This large hospital study shows no apparent change in the prevalence of patients «at risk of malnutrition¼ from 2008 to 2018. However, more patients «at risk of malnutrition¼, both surgical and non-surgical, received nutritional support, treatment from a dietitian and a related ICD-10 code over the study period, indicating improved nutritional routines as a result of the implementation of nutritional guidelines and strategies.

Thirty-day hospital readmission rate, reasons, and risk factors after acute inpatient cancer rehabilitation.

OBJECTIVES: To evaluate the 30-day hospital readmission rate, reasons, and risk factors for patients with cancer who were discharged to home setting after acute inpatient rehabilitation. DESIGN, SETTING, AND PARTICIPANTS: This was a secondary retrospective analysis of participants in a completed prospective survey study that assessed the continuity of care and functional safety concerns upon discharge and 30 days after discharge in adults. Patients were enrolled from September 5, 2018, to February 7, 2020, at a large academic quaternary cancer center with National Cancer Institute Comprehensive Cancer Center designation. MAIN OUTCOMES AND MEASURES: Thirty-day hospital readmission rate, descriptive summary of reasons for readmissions, and statistical analyses of risk factors related to readmission. RESULTS: Fifty-five (21%) of the 257 patients were readmitted to hospital within 30 days of discharge from acute inpatient rehabilitation. The reasons for readmissions were infection (20, 7.8%), neoplasm (9, 3.5%), neurological (7, 2.7%), gastrointestinal disorder (6, 2.3%), renal failure (3, 1.1%), acute coronary syndrome (3, 1.1%), heart failure (1, 0.4%), fracture (1, 0.4%), hematuria (1, 0.4%), wound (1, 0.4%), nephrolithiasis (1, 0.4%), hypervolemia (1, 0.4%), and pain (1, 0.4%). Multivariate logistic regression modeling indicated that having a lower locomotion score (OR = 1.29; 95% CI, 1.07-1.56; p = 0.007) at discharge, having an increased number of medications (OR = 1.12; 95% CI, 1.01-1.25; p = 0.028) at discharge, and having a lower hemoglobin at discharge (OR = 1.31; 95% CI, 1.03-1.66; p = 0.031) were independently associated with 30-day readmission. CONCLUSION AND RELEVANCE: Among adult patients with cancer discharged to home setting after acute inpatient rehabilitation, the 30-day readmission rate of 21% was higher than that reported for other rehabilitation populations but within the range reported for patients with cancer who did not undergo acute inpatient rehabilitation.

Association of Positive Fluid Balance at Discharge After Sepsis Management With 30-Day Readmission.

Importance: Although early fluid administration has been shown to lower sepsis mortality, positive fluid balance has been associated with adverse outcomes. Little is known about associations in non-intensive care unit settings, with growing concern about readmission from excess fluid accumulation in patients with sepsis. Objective: To evaluate whether positive fluid balance among non-critically ill patients with sepsis was associated with increased readmission risk, including readmission for heart failure. Design, Setting, and Participants: This multicenter retrospective cohort study was conducted between January 1, 2012, and December 31, 2017, among 57 032 non-critically ill adults hospitalized for sepsis at 21 hospitals across Northern California. Kaiser Permanente Northern California is an integrated health care system with a community-based population of more than 4.4 million members. Statistical analysis was performed from January 1 to December 31, 2019. Exposures: Intake and output net fluid balance (I/O) measured daily and cumulatively at discharge (positive vs negative). Main Outcomes and Measures: The primary outcome was 30-day readmission. The secondary outcomes were readmission stratified by category and mortality after living discharge. Results: The cohort included 57 032 patients who were hospitalized for sepsis (28 779 women [50.5%]; mean [SD] age, 73.7 [15.5] years). Compared with patients with positive I/O (40 940 [71.8%]), those with negative I/O (16 092 [28.2%]) were older, with increased comorbidity, acute illness severity, preexisting heart failure or chronic kidney disease, diuretic use, and decreased fluid administration volume. During 30-day follow-up, 8719 patients (15.3%) were readmitted and 3639 patients (6.4%) died. There was no difference in readmission between patients with positive vs negative I/O (HR, 1.00; 95% CI, 0.95-1.05). No association was detected between readmission and I/O using continuous, splined, and quadratic function transformations. Positive I/O was associated with decreased heart failure-related readmission (HR, 0.80 [95% CI, 0.71-0.91]) and increased 30-day mortality (HR, 1.23 [95% CI, 1.15-1.31]). Conclusions and Relevance: In this large observational study of non-critically ill patients hospitalized with sepsis, there was no association between positive fluid balance at the time of discharge and readmission. However, these findings may have been limited by variable recording and documentation of fluid intake and output; additional studies are needed to examine the association of fluid status with outcomes in patients with sepsis to reduce readmission risk.

Travel time to emergency care not by geographic time, but by optimal time: A nationwide cross-sectional study for establishing optimal hospital access time to emergency medical care in South Korea.

Increase in travel time, beyond a critical point, to emergency care may lead to a residential disparity in the outcome of patients with acute conditions. However, few studies have evaluated the evidence of travel time benchmarks in view of the association between travel time and outcome. Thus, this study aimed to establish the optimal hospital access time (OHAT) for emergency care in South Korea. We used nationwide healthcare claims data collected by the National Health Insurance System database of South Korea. Claims data of 445,548 patients who had visited emergency centers between January 1, 2006 and December 31, 2014 were analyzed. Travel time, by vehicle from the residence of the patient, to the emergency center was calculated. Thirteen emergency care-sensitive conditions (ECSCs) were selected by a multidisciplinary expert panel. The 30-day mortality after discharge was set as the outcome measure of emergency care. A change-point analysis was performed to identify the threshold where the mortality of ECSCs changed significantly. The differences in risk-adjusted mortality between patients living outside of OHAT and those living inside OHAT were evaluated. Five ECSCs showed a significant threshold where the mortality changed according to their OHAT. These were intracranial injury, acute myocardial infarction, other acute ischemic heart disease, fracture of the femur, and sepsis. The calculated OHAT were 71-80 min, 31-40 min, 70-80 min, 41-50 min, and 61-70 min, respectively. Those who lived outside the OHAT had higher risks of death, even after adjustment (adjusted OR: 1.04-7.21; 95% CI: 1.03-26.34). In conclusion, the OHAT for emergency care with no significant increase in mortality is in the 31-80 min range. Optimal travel time to hospital should be established by optimal time for outcomes, and not by geographic time, to resolve the disparities in geographical accessibility to emergency care.

Demographic differences in the initiation and maintenance of statins in the first year post ACS in New Zealand: a data linkage study (ANZACS-QI 57).

INTRODUCTION: Prior New Zealand studies suggest that only approximately two-thirds of patients who present with an acute coronary syndrome (ACS) are adequately maintained on a statin post-discharge. This could be due to low initiation and/or poor longer-term adherence. AIM: To identify the pattern and adequacy of statin maintenance following ACS from initial prescription to one-year post-discharge. METHODS: All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry data for consecutive New Zealand residents (2015-2017) who were hospitalised with ACS and managed with coronary angiography were anonymously linked to national datasets to derive a medication possession ratio (MPR) to assess medication maintenance. An MPR ≥0.8 is considered adequate maintenance and ≥1 is considered optimal. RESULTS: Of the 16,557 patients who survived their ACS, 15,431 (93.2%) were prescribed a statin at discharge and 89.8% were dispensed a statin within three months. 79.8% (13,219/16,557) of patients had an MPR ≥0.8 during the first year, but only 61.0% (10,096/16,557) had optimal dispensing over this period. Regression analysis identified the independent predictors of sub-optimal maintenance over the first year as age <45 years, no prior statin and Maori and Pacific ethnicity. CONCLUSION: After ACS discharge, the gap between prescribing and dispensing rates was small with only minor demographic variation. One in ten patients were not initially dispensed a statin. Although eight in ten patients were adequately maintained, only six in ten had optimal maintenance with clear ethnic and age differences, which may reflect more general disparities in healthcare.

Effect of a Nurse-Led, Patient-Centered, Gratitude Intervention on Patient Hospitalization Experience.

OBJECTIVE: Objectives were to evaluate patient perceptions of a nurse-led, patient-centered gratitude intervention and if nurses identified actionable items to improve patient's hospitalization experience. BACKGROUND: Research demonstrates positive effects of gratitude and caring interventions on patient health and well-being. Evidence is sparse regarding nurse-led gratitude interventions improving hospitalized patient's experiences. METHODS: In this pilot study, 91 adult medical patients completed gratitude forms twice daily for up to 6 shifts and a study discharge form documenting intervention perceptions. In response to the patients' gratitude-related feedback, RNs recorded patient experience-related actions they and interprofessional teams could implement. RESULTS: On average, patients perceived the nurse-led gratitude intervention as helpful (4.2) (1 = very unhelpful, 5 = very helpful) and improved hospitalization experiences (4.3) (1 = seldom, 5 = never). Most of the time actions were required or to be taken, based on patient gratitude intervention responses. CONCLUSIONS: Patient perceptions of nurse-led gratitude intervention demonstrated helpfulness and improved hospitalization experience.

Factors associated with under-reporting of head and neck squamous cell carcinoma in cause-of-death records: A comparative study of two national databases in France from 2008 to 2012.

OBJECTIVE: To date, no study has evaluated the detection rate of head and neck squamous cell carcinoma (HNSCC) in cause-of-death records in Europe. Our objectives were to compare the number of deaths attributable to HNSCC from two national databases in France and to identify factors associated with under-reporting of HNSCC in cause-of-death records. METHODS: The national hospital discharge database and the national underlying cause-of-death records were compared for all HNSCC-attributable deaths in adult patients from 2008 to 2012 in France. Factors associated with under-reporting of HNSCC in cause-of-death records were assessed using multivariate Poisson regression. RESULTS: A total of 41,503 in-hospital deaths were attributable to HNSCC as compared to 25,647 deaths reported in national UCoD records (a detection rate of 62%). Demographics at death were similar in both databases with respect to gender (83% men), age (54% premature deaths at 25-64 years), and geographic distribution. In multivariate Poisson regression, under-reporting of HNSCC in cause-of-death records significantly increased in 2012 compared to 2010 (+7%) and was independently associated with a primary HNSCC site other than the larynx, a former primary or second synchronous cancer other than HNSCC, distant metastasis, palliative care, and death in hospitals other than comprehensive cancer care centers. The main study results were robust in a sensitivity analysis which also took into account deaths outside hospital (overall, 51,129 HNSCC-attributable deaths; a detection rate of 50%). For the year 2012, the age-standardized mortality rate for HNSCC derived from underlying cause-of-death records was less than half that derived from hospital discharge summaries (14.7 compared to 34.1 per 100,000 for men and 2.7 compared to 6.2 per 100,000 for women). CONCLUSION: HNSCC is largely under-reported in cause-of-death records. This study documents the value of national hospital discharge databases as a complement to death certificates for ascertaining cancer deaths.

Potential prescribing omissions according to START criteria at the time of hospital discharge

The purpose of this study is to describe the frequency of potential drug prescribing omissions (PPOs) for elderly patients at the time of hospital discharge and to compare the frequency PPOs among different medical specialities. This cross-sectional study examined data from elderly patients when they were admitted for >24 h to a northeastern Brazil teaching hospital during June-December 2016. Were included in the study 227 patients, of whom 36.9% had at least one PPO. The highest number of PPOs was identified among those with at least 5 prescribed drugs. In total, 153 PPOs were identified at hospital discharge. In most cases (78.4%), patients were not evaluated by the specialist physician.The most commonly identified PPOs on discharge were: the omission of statin therapy in cases of diabetes mellitus plus one or more cardiovascular-associated factor; calcium and vitamin D supplements in patients with known osteoporosis; and angiotensin converting enzyme inhibitors in cases of chronic heart failure. The results of this study suggest that the frequency of prescribing omissions PPOs during patient discharge was high. This can be avoided by the careful evaluation by prescribers with experience in certain specialties where several prescribed omissions would be common.

Evaluation of a Transitional Care Program After Hospitalization for Heart Failure in an Integrated Health Care System.

Importance: Prompted by null findings from several care transition trials and practice changes for heart failure in recent years, leaders from a large integrated health care system aimed to reassess the outcomes of its 10-year multicomponent transitional care program for heart failure (HF-TCP). Objective: To examine the association of the individual HF-TCP components and their bundle with the primary outcome of all-cause 30-day inpatient or observation stay readmissions. Design, Setting, and Participants: This retrospective cohort study included patients enrolled in the HF-TCP during an inpatient encounter for heart failure at 13 Kaiser Permanente Southern California hospitals from January 1, 2013, to October 31, 2018, who were followed up from discharge until 30 days, readmission, or death. Data were analyzed from May 7, 2019, to May 1, 2020, with additional review from September 2 to October 1, 2020. Exposures: Patients received 1 home health visit or telecare (telephone) visit from a registered nurse within 2 days of hospital discharge, a heart failure care manager call within 7 days, and a clinic visit with a physician or a nurse practitioner within 7 days. Main Outcomes and Measures: Multivariable proportional hazards regression models were used to estimate the probability of 30-day readmission for those who received the individual or bundled HF-TCP components compared with those who did not. Results: A total of 26 128 patients were included; 57.0% were male, and the mean (SD) age was 73 (13) years. The 30-day readmission rate was 18.1%. Both exposure to a home health visit within 2 days of discharge (hazard ratio [HR], 1.03; 95% CI, 0.96-1.10) and a 7-day heart failure case manager call (HR, 1.08; 95% CI, 0.99-1.18) compared with no visit or call were not associated with a lower rate of readmission. Completion of a 7-day clinic visit was associated with a lower readmission rate (HR, 0.88; 95% CI, 0.81-0.94) compared with no clinic visit. There were no synergistic effects of all 3 components compared with clinic visit alone (HR, 1.05; 95% CI, 0.87-1.28). Conclusions and Relevance: This study found that HF-TCP as a whole was not associated with a reduction in 30-day readmission rates, although a follow-up clinic visit within 7 days of discharge may be helpful. These findings highlight the importance of continuous quality improvement and refinement of existing clinical programs.

Analysis of hospital management of chronic respiratory diseases in light of the "Maps of Health Needs" project in Poland.

INTRODUCTION: The "Maps of Health Needs" project has been carried out in Poland since 2016 and its purpose is to implement quality-promoting and organisational solutions in the Polish healthcare system. This paper is the analysis of hospitalisations for chronic respiratory diseases recorded in Polish National Health Fund databases in 2014. MATERIAL AND METHODS: The study included 122,000 hospitalisations of adults and 22,000 hospitalisations of children. Epidemio-logical parameters (incidence and prevalence) and major hospitalisation parameters were determined through statistical analysis. RESULTS: The highest registered incidence was observed in asthma patients (548 per 100,000 inhabitants) followed by COPD patients (233 per 100,000 inhabitants). Asthma patients were also characterised by the highest prevalence, with lower values being observed in COPD patients. In the group of adults, patients aged 65 years or older and 80 years or older accounted for 44% and 14% of hospitalised adults respectively. The analysis also revealed that 66% of hospitalisations of adults included patients with asthma, COPD and respiratory failure. The development of respiratory failure prolongs hospitalisation and increases both in-hospital and post-discharge mortality. In children, 90% of the identified hospitalisations were for asthma, chronic inflammatory lung diseases and cystic fibrosis. CONCLUSIONS: The results of the study demonstrate that pulmonary obstructive diseases are associated with a considerable burden. Therefore, corrective actions within the Polish healthcare system are required to decrease the number of hospitalisations for these diseases.

Assessment of Costs of Avoidable Delays in Intensive Care Unit Discharge.

Importance: Delays in transfer for discharge-ready patients from the intensive care unit (ICU) are increasingly described and contribute to strained capacity. Objective: To describe the epidemiological features and health care costs attributable to potentially avoidable delays in ICU discharge in a large integrated health care system. Design, Setting, and Participants: This population-based cohort study was performed in 17 adult ICUs in Alberta, Canada, from June 19, 2012, to December 31, 2016. Participants were patients 15 years or older admitted to a study ICU during the study period. Data were analyzed from October 19, 2018, to May 20, 2020. Exposures: Avoidable time in the ICU, defined as the portion of total ICU patient-days accounted for by avoidable delay in ICU discharge (eg, waiting for a ward bed). Main Outcomes and Measures: The primary outcome was health care costs attributable to avoidable time in the ICU. Secondary outcomes were factors associated with avoidable time, in-hospital mortality, and measures of use of health care resources, including the number of hours in the ICU and the number of days of hospitalization. Multilevel mixed multivariable regression was used to assess associations between avoidable time and outcomes. Results: In total, 28 904 patients (mean [SD] age, 58.3 [16.8] years; 18 030 male [62.4%]) were included. Of these, 19 964 patients (69.1%) had avoidable time during their ICU admission. The median avoidable time per patient was 7.2 (interquartile range, 2.4-27.7) hours. In multivariable analysis, male sex (odds ratio [OR], 0.92; 95% CI, 0.87-0.98), comorbid hemiplegia or paraplegia (OR 1.47; 95% CI, 1.23-1.75), liver disease (OR 1.20; 95% CI, 1.04-1.37), admission Acute Physiology and Chronic Health Evaluation II score (OR, 1.03; 95% CI, 1.02-1.03), surgical status (OR, 0.90; 95% CI, 0.82-0.98), medium community hospital type (OR, 0.12; 95% CI, 0.04-0.32), and admission year (OR, 1.16; 95% CI, 1.13-1.19) were associated with avoidable time. The cumulative avoidable time was 19 373.9 days, with estimated attributable costs of CAD$34 323 522. Avoidable time accounted for 12.8% of total ICU bed-days and 6.4% of total ICU costs. Patients with avoidable time before ICU discharge showed higher unadjusted in-hospital mortality (1115 [5.6%] vs 392 [4.4%]; P < .001); however, in multivariable analysis, avoidable time was associated with reduced in-hospital mortality (adjusted hazard ratio, 0.74; 95% CI, 0.64-0.85). Results were similar in sensitivity analyses. Conclusions and Relevance: In this study, potentially avoidable discharge delay occurred for most patients admitted to ICUs across a large integrated health system and translated into substantial associated health care costs.

Immediate effects of urgent reorganisation of emergency department-based treatment pathway in nonperforated appendicitis: a retrospective study.

BACKGROUND: Acute appendicitis is a global disease and a very common indication for emergency surgery worldwide. The need for hospital resources is therefore constantly high. The administration in Kanta-Häme Central Hospital, Southern Finland, called for an urgent reorganisation due to shortage of hospital beds at the department of general surgery. Postoperative treatment pathway of patients with nonperforated acute appendicitis was ordered to take place in the Emergency Department (ED). The aim of this study was to assess, whether this reorganisation was feasible and safe, i.e. did it affect the length of in-hospital stay (LOS) and the 30-day complication rate. METHODS: This is a retrospective pre- and post-intervention analysis. After the reorganisation, most patients with nonperforated appendicitis were followed postoperatively at the 24-h observation unit of the ED instead of surgical ward. Patients operated during the first 3 months after the reorganisation were compared to those operated during the 3 months before it. A case met inclusion criteria if there were no signs of appendiceal perforation during surgery. Exclusion criteria comprised age < 18 years and perforated disease. RESULTS: Appendicectomy was performed on 112 patients, of whom 62 were adults with nonperforated appendicitis. Twenty-seven of the included patients were treated before the reorganisation, and 35 after it. Twenty of the latter were followed only at the ED. Postoperative LOS decreased significantly after the reorganisation. Median postoperative time till discharge was 15.7 h for all patients after the reorganisation compared to 24.4 h before the reorganisation (standard error 6.2 h, 95% confidence interval 2.3-15.2 h, p < 0.01). There were no more complications in the group treated postoperatively in the ED. CONCLUSIONS: Early discharge of patients with nonperforated appendicitis after enforced urgent reorganisation of the treatment pathway in the ED observation unit is safe and feasible. Shifting the postoperative monitoring and the discharge policy of such patients to the ED - instead of the surgical ward - occurred in the majority of the cases after the reorganisation. This change may spare resources as in our series it resulted in a significantly shorter LOS without any increase in the 30-day complication rate.

Proportionate Postnatal Growth in Preterm Neonates on Expressed Breast Milk Feeding With Selected Fortification.

BACKGROUND: Preterm neonates not fed an exclusive human-milk diet in the neonatal intensive care unit (NICU) show disproportionate postnatal growth. There are scant data on postnatal growth in neonates from India fed an exclusive expressed breast milk (EBM) diet. This study describes the postnatal changes in weight, length, and head circumference in preterm neonates given EBM with selected fortification. METHODS: The study had a prospective observational design. Exclusive EBM feeding, early initiation, and standardized progression of feeds was followed. Fortification of breast milk with human milk fortifier (HMF) or liquid calcium phosphate and multivitamins (CALVIT) or hindmilk (HM) was done based on the gestational age. Monitoring for weight, length, and head circumference was done from admission to discharge. RESULTS: Ninety-three preterm neonates were included in the study, of which 34 (36.6%) were small for gestational age. Thirty-two (34.3%) neonates received EBM with HMF, 35 (35.7%) received EBM fortified with CALVIT and 26 (28%) neonates received HM fortification. There was a significant difference in the change in z-scores from birth to discharge for the weight, length, and head circumference (P = .001). The mean increase in daily weight ranged from 8.8 to 9.5 g/d, whereas weekly change in length was 0.8-0.9 cm/wk, and head circumference was 0.7 cm/wk. CONCLUSION: Postnatal growth of preterm neonates during NICU admission on exclusive EBM feeding with selected fortification resulted in a proportionate increase in weight, length, and head circumference.

The Center for Trauma Survivorship: Addressing the great unmet need for posttrauma center care.

BACKGROUND: Returning patients to preinjury status is the goal of a trauma system. Trauma centers (TCs) provide inpatient care, but postdischarge treatment is fragmented with clinic follow-up rates of <30%. Posttraumatic stress disorder (PTSD) and depression are common, but few patients ever obtain necessary behavioral health services. We postulated that a multidisciplinary Center for Trauma Survivorship (CTS) providing comprehensive care would meet patient's needs, improve postdischarge compliance, deliver behavioral health, and decrease unplanned emergency department (ED) visits and readmissions. METHODS: Focus groups of trauma survivors were conducted to identify issues following TC discharge. Center for Trauma Survivorship eligible patients are aged 18 to 80 years and have intensive care unit stay of >2 days or have a New Injury Severity Score of ≥16. Center for Trauma Survivorship visits were scheduled by a dedicated navigator and included physical and behavioral health care. Patients were screened for PTSD and depression. Patients screening positive were referred for behavioral health services. Patients were provided 24/7 access to the CTS team. Outcomes include compliance with appointments, mental health visits, unplanned ED visits, and readmissions in the year following discharge from the TC. RESULTS: Patients universally felt abandoned by the TC after discharge. Over 1 year, 107 patients had 386 CTS visits. Average time for each appointment was >1 hour. Center for Trauma Survivorship "no show" rate was 17%. Eighty-six percent screening positive for PTSD/depression successfully received behavioral health services. Postdischarge ED and hospital admissions were most often for infections or unrelated conditions. Emergency department utilization was significantly lower than a similarly injured group of patients 1 year before the inception of the CTS. CONCLUSION: A CTS fills the vast gaps in care following TC discharge leading to improved compliance with appointments and delivery of physical and behavioral health services. Center for Trauma Survivorship also appears to decrease ED visits in the year following discharge. To achieve optimal long-term recovery from injury, trauma care must continue long after patients leave the TC. LEVEL OF EVIDENCE: Therapeutic, Level III.

Older-Adult Marijuana Users in Substance Use Treatment: Characteristics Associated with Treatment Completion.

More older adults are using marijuana and receiving substance use treatment. We used the 2015-2017 Treatment Episode Data Set-Discharges (TEDS-D) to identify characteristics associated with treatment discharge among those aged 50+ whose admission involved marijuana use. Among these discharges (N = 130,287), 7.0% had been admitted for marijuana use only and 93.0% for polysubstance use (13.0% marijuana-primary, 57.7% marijuana-secondary, and 22.3% marijuana-tertiary), and the overall treatment completion rate was 45%. Using logistic regression, we examined associations of detoxification, residential rehabilitation, and outpatient treatment completion with type of marijuana and other substance involvement. Compared to marijuana-only cases, marijuana-tertiary cases had higher odds of completing detoxification (AOR = 1.54, 95% CI = 1.16-2.03), marijuana-secondary cases had higher odds of completing residential rehabilitation (AOR = 1.19, CI = 1.01-1.40), and all polysubstance cases had lower odds of completing outpatient treatment. Of the polysubstance cases, treatment completion odds were higher for those with alcohol problems but lower for those with other illicit drug problems. Previous treatment, referral source, psychiatric problems, first age of marijuana use, and racial/ethnic minority status were significant factors in treatment completion. Better strategies are needed to promote treatment retention and completion among older adults admitted for marijuana use problems, especially those who also have other illicit drug problems.

Vitamin A and iron status of children before and after treatment of uncomplicated severe acute malnutrition.

BACKGROUND & AIMS: Treatment of children with uncomplicated severe acute malnutrition (SAM) is based on ready-to-use therapeutic foods (RUTF) and aims for quick regain of lost body tissues while providing sufficient micronutrients to restore diminished body stores. Little evidence exists on the success of the treatment to establish normal micronutrient status. We aimed to assess the changes in vitamin A and iron status of children treated for SAM with RUTF, and explore the effect of a reduced RUTF dose. METHODS: We collected blood samples from children 6-59 months old with SAM included in a randomised trial at admission to and discharge from treatment and analysed haemoglobin (Hb) and serum concentrations of retinol binding protein (RBP), ferritin (SF), soluble transferrin receptor (sTfR), C-reactive protein (CRP) and α1-acid glycoprotein (AGP). SF, sTfR and RBP were adjusted for inflammation (CRP and AGP) prior to analysis using internal regression coefficients. Vitamin A deficiency (VAD) was defined as RBP < 0.7 µmol/l, anaemia as Hb < 110 g/l, storage iron deficiency (sID) as SF < 12 µg/l, tissue iron deficiency (tID) as sTfR > 8.3 mg/l and iron deficiency anaemia (IDA) as both anaemia and sID. Linear and logistic mixed models were fitted including research team and study site as random effects and adjusting for sex, age and outcome at admission. RESULTS: Children included in the study (n = 801) were on average 13 months of age at admission to treatment and the median treatment duration was 56 days [IQR: 35; 91] in both arms. Vitamin A and iron status markers did not differ between trial arms at admission or at discharge. Only Hb was 1.7 g/l lower (95% CI -0.3, 3.7; p = 0.088) in the reduced dose arm compared to the standard dose, at recovery. Mean concentrations of all biomarkers improved from admission to discharge: Hb increased by 12% or 11.6 g/l (95% CI 10.2, 13.0), RBP increased by 13% or 0.12 µmol/l (95% CI 0.09, 0.15), SF increased by 36% or 4.4 µg/l (95% CI 3.1, 5.7) and sTfR decreased by 16% or 1.5 mg/l (95% CI 1.0, 1.9). However, at discharge, micronutrient deficiencies were still common, as 9% had VAD, 55% had anaemia, 35% had sID, 41% had tID and 21% had IDA. CONCLUSION: Reduced dose of RUTF did not result in poorer vitamin A and iron status of children. Only haemoglobin seemed slightly lower at recovery among children treated with the reduced dose. While improvement was observed, the vitamin A and iron status remained sub-optimal among children treated successfully for SAM with RUTF. There is a need to reconsider RUTF fortification levels or test other potential strategies in order to fully restore the micronutrient status of children treated for SAM.