Racial and Ethnic Differences in 30-Day Hospital Readmissions Among US Adults With Diabetes.

Importance: Differences in readmission rates among racial and ethnic minorities have been reported, but data among people with diabetes are lacking despite the high burden of diabetes and its complications in these populations. Objectives: To examine racial/ethnic differences in all-cause readmission among US adults with diabetes and categorize patient- and system-level factors associated with these differences. Design, Setting, and Participants: This retrospective cohort study includes 272 758 adult patients with diabetes, discharged alive from the hospital between January 1, 2009, and December 31, 2014, and stratified by race/ethnicity. An administrative claims data set of commercially insured and Medicare Advantage beneficiaries across the United States was used. Data analysis took place between October 2016 and February 2019. Main Outcomes and Measures: Unplanned all-cause readmission within 30 days of discharge and individual-, clinical-, economic-, index hospitalization-, and hospital-level risk factors for readmission. Results: A total of 467 324 index hospitalizations among 272 758 adults with diabetes (mean [SD] age, 67.7 [12.7]; 143 498 [52.6%] women) were examined. The rates of 30-day all-cause readmission were 10.2% (33 683 of 329 264) among white individuals, 12.2% (11 014 of 89 989) among black individuals, 10.9% (4151 of 38 137) among Hispanic individuals, and 9.9% (980 of 9934) among Asian individuals (P < .001). After adjustment for all factors, only black patients had a higher risk of readmission compared with white patients (odds ratio, 1.05; 95% CI, 1.02-1.08). This increased readmission risk among black patients was sequentially attenuated, but not entirely explained, by other demographic factors, comorbidities, income, reason for index hospitalization, or place of hospitalization. Compared with white patients, both black and Hispanic patients had the highest observed-to-expected (OE) readmission rate ratio when their income was low (annual household income <$40 000 among black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; among Hispanic patients: OE ratio, 1.11; 95% CI, 1.07-1.16) and when they were hospitalized in nonprofit hospitals (black patients: OE ratio, 1.10; 95% CI, 1.08-1.12; among Hispanic patients: OE ratio, 1.08; 95% CI, 1.05-1.12), academic hospitals (black patients: OE ratio, 1.16; 95% CI, 1.13-1.20; Hispanic patients: OE ratio, 1.12; 95% CI, 1.06-1.19), or large hospitals (ie, with ≥400 beds; black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; Hispanic patients: OE ratio, 1.09; 95% CI, 1.04-1.14). Conclusions and Relevance: In this study, black patients with diabetes had a significantly higher risk of readmission than members of other racial/ethnic groups. This increased risk was most pronounced among lower-income patients hospitalized in nonprofit, academic, or large hospitals. These findings reinforce the importance of identifying and addressing the many reasons for persistent racial/ethnic differences in health care quality and outcomes.

Hospital occupancy and discharge strategies: a simulation-based study.

BACKGROUND: Increasing demand for hospital services has resulted in more arrivals to emergency department (ED), increased admissions, and, quite often, access block and ED congestion, along with patients' dissatisfaction. Cost constraints limit an increase in the number of hospital beds, so alternative solutions need to be explored. AIMS: To propose and test different discharge strategies, which, potentially, could reduce occupancy rates in the hospital, thereby improving patient flow and minimising frequency and duration of congestion episodes. METHODS: We used a simulation approach using HESMAD (Hospital Event Simulation Model: Arrivals to Discharge) - a sophisticated simulation model capturing patient flow through a large Australian hospital from arrival at ED to discharge. A set of simulation experiments with a range of proposed discharge strategies was carried out. The results were tabulated, analysed and compared using common hospital occupancy indicators. RESULTS: Simulation results demonstrated that it is possible to reduce significantly the number of days when a hospital runs above its base bed capacity. In our case study, this reduction was from 281.5 to 22.8 days in the best scenario, and reductions within the above range under other scenarios considered. CONCLUSION: Some relatively simple strategies, such as 24-h discharge or discharge/relocation of long-staying patients, can significantly reduce overcrowding and improve hospital occupancy rates. Shortening administrative and/or some treatment processes have a smaller effect, although the latter could be easier to implement.

Clinical Weighting of Drug-Drug Interactions in Hospitalized Elderly.

Adverse drug reactions impact on patient health, effectiveness of pharmacological therapy and increased health care costs. This investigation intended to detect the most critical drug-drug interactions in hospitalized elderly patients, weighting clinical risk. We conducted a cross-sectional study between January and April 2014; all patients 70 years or older, hospitalized for >24 hr and prescribed at least one medication were included in the study. Drug-drug interactions were estimated by combining Stockley's, Hansten and Tatro drug interactions. Drug-drug interactions were weighted using a risk-analysis method based on failure modes, effects and criticality analysis. We calculated a criticality index for each drug involved in the drug-drug interactions based on the severity of the interaction mechanism, the frequency the drug was involved in drug-drug interactions and the risk of drug-drug interactions in patients with impaired renal function. The average number of drugs consumed in the hospital was 6 ± 2.69, involving 160 active ingredients. The most frequent were as follows: Furosemide, followed by Enalapril. Of drug-drug interactions, 2% were classified as contraindicated, 14% advised against and 83% advised caution during the hospital stay. Thirty-four drug-drug interactions were assessed, of which 23 were pharmacodynamic drug-drug interactions and 12 were pharmacokinetic drug-drug interactions (1 was both). The clinical risk calculated for each drug-drug interaction included heparins + non-steroidal anti-inflammatory drugs (NSAIDs) or Digoxin + Calcium Gluconate, cases which are pharmacodynamic drug-drug interactions with agonist effect and clinical risk of bleeding, one of the most common clinical risks in the hospital. An index of clinical risk for drug-drug interactions can be calculated based on severity by the interaction mechanism, the frequency that the drug is involved in drug-drug interactions and the risk of drug-drug interactions in an elderly patient with impaired renal function.

[Follow-up of analytical parameters in Internal Medicine patients to detect adverse events]. / Seguimiento de parámetros analíticos en pacientes de medicina.

OBJECTIVE: To analyze the prevalence of prescription drugs, previously selected, that should be monitored by their analytical test, and the rate of alteration in these tests, with the aim of establishing priorities to facilitate monitoring. METHOD: Prospective observational study in the Internal Medicine department of a referral hospital of 350 beds. In a first phase, we selected some drugs which analytical monitoring is recommended for the medical literature, and after that, we reviewed the pharmacological treatment of all patients admitted with any of these drugs. The study was conducted in the last two month of 2011. RESULTS: We included 271 patients, 128 (47%) were women. The mean age was 74.5 ± 14.4 years and the average stay of 7 ± 5.8 days. These patients accounted for 83% of all patients admitted to Internal Medicine during the study period. There were 828 drugs that must be monitored; each patient had an average of 3.1 ± 2.3. We reviewed 1837 analytical test, of which 401 (22%) were altered and 154 patients (57%) were affected for it. The pairs drug-analytical test altered most frequently found were creatinine increased and nephrotoxic drugs, hypokalemia in patients taking high efficiency diuretics and thrombocytopenia in patients treated with low molecular weight heparins. CONCLUSIONS: Our study highlights the importance of monitoring laboratory test associated with some drugs from the pharmacy department, as it demonstrates a high incidence of warning results. Our proposal for selection of drugs makes monitoring easier, and reaches large numbers of patients.

Development and application of evaluation indices for hospital infection surveillance and control programs in the Republic of Korea.

OBJECTIVE: To develop new evaluation indices of infection control and to use them to evaluate Korean infection surveillance and control programs (ISCPs). DESIGN: We performed a questionnaire-based survey to 164 acute care general hospitals throughout the Republic of Korea that had more than 300 beds. Study methods were based completely on those of the Study on the Efficacy of Nosocomial Infection Control (SENIC). Four SENIC indices (hospital epidemiologist index, infection control nurse index, surveillance index, and control index) and 4 newly developed indices (healthcare worker index, quality improvement index, resource index, and hand hygiene facilities index) were used to evaluate Korean ISCPs. Data were collected by questionnaire from June 17 to October 11, 2003. SETTING: One hundred sixty-four general hospitals with more than 300 beds in the Republic of Korea. RESULTS: Personnel from 85 general hospitals responded to the study questionnaire. The reliability and validity of the evaluation indices were statistically significant (P<.05). The 8 evaluation indices were categorized into 2 factor groups: personnel factors (hospital epidemiologist index and infection control nurse index) and activity factors (the remaining 6 indices). Korean ISCPs showed a major weakness in surveillance. The scores for the newly developed evaluation indices were better than those for the SENIC evaluation indices. However, most Korean hospitals were estimated to have had only slight reductions in nosocomial infection rates. The evaluation indices were influenced significantly by the number of beds in the hospital, whether the hospital was located in the Seoul-Gyonggi region, the presence of full-time infection control nurses at the hospital, the education level of the infection control nurses, and the nurses' experience in infection control (P<.05). CONCLUSIONS: The reliability and validity of the SENIC evaluation indices and the newly developed evaluation indices were satisfactory in evaluating Korean ISCPs. However, surveillance should be improved to increase the efficacy of Korean ISCPs.

Análisis del manejo de la meningitis bacteriana en un servicio de urgencias hospitalario: demora del inicio del tratamiento y factores relacionados / Handling of bacterial meningitis on a hospital emergency room: delays at the beginning of treatment and related factors

Fundamento. Conocer el tiempo de retraso en la administración de antibióticos en la meningitis bacteriana desde la llegada del paciente al servicio de urgencias e identificar los factores que muestran relación con el mismo. Métodos. Serie de 73 casos de pacientes con él diagnostico de meningitis bacteriana atendidos en el servicio de urgencias e ingresados en el hospital. Los datos se recogieron retrospectivamente. Se estudiaron las características de los pacientes, factores predisponentes para meningitis, clínica, exploración física, datos de laboratorio, estudios radiológicos y tratamiento ambulatorio previo. Tiempos de llegada, de realización de los procedimientos diagnósticos y de administración de la primera dosis de antibiótico y lugar de administración. Se recogió la evolución de los pacientes y se analizaron los factores que influyeron en la demora de la administración de antibióticos. Resultados. La mediana de edad fue de 17 años, la atención a los pacientes se repartió a lo largo de la jornada, el riesgo de base fue leve en el 80%, el 29% tuvo al menos un factor de riesgo para meningitis, el 22 porciento recibió antibiótico ambulatoriamente, la presentación clínica fue la clásica en mas del 71% de los pacientes. El hemocultivo fue positivo en 41% y el cultivo de LCR en el 63 porciento. El 43% de los casos fueron debidos a Neisseria meningitidis, 20% Streptococcus pneumoniae y a germen desconocido en el 31,5 porciento. Se realizaron 9 Tomografías axiales computarizadas (TAC). El tiempo medio desde la llegada al servicio de urgencias hasta la administración de antibióticos fue de 5 horas y 25 minutos. Cuando se administró antes de la punción lumbar fue de 2 horas 50 minutos; de 5 horas 20 minutos; cuando se administró después de la punción lumbar y de 7 horas 22 minutos cuando se realizo TAC cerebral antes de la punción. El único factor que demostró relación estadísticamente significativa con la demora en la administración de antibiótico fue el hecho de que el paciente fuese remitido por su medico de cabecera con sospecha de meningitis bacteriana (1 hora 20 minutos vs 5 horas 51 minutos). Conclusiones. Sólo en una pequeña parte de los casos de meningitis bacteriana se inicia el tratamiento antibiótico en los primeros 30 minutos. La demora media es elevada y aún más cuando se realizan determinadas pruebas diagnósticas (AU)

Hospital Dr. Julio C. Perrando: estudio descriptivo de la atención a la comunidad entre 1983 - 1992/1993 / Hospital Dr. Julio C. Perrando: epidemiology descriptive of the atention at the comunity between 1983 - 1992/1993

Se detallan estadísticas hospitalarias del Hospital Dr. J. C. Perrando (Resistencia, Chaco, República Argentina) entre 1983 - 1992/1993 junto con un marco de datos demográficos, económicos, sociales y sanitarios (defunciones, tasa de hechos vitales, producción de centros de salud del Gran Resistencia) de la provincia del Chaco. Cada capítulo va acompañado de un sintético comentario. Contenido: Historia. Consultorios externos. Atención ambulatoria (evolución comparativa con centros de salud). Hospitalización. Morbilidad en egresos. Cirugía. Mortalidad en egresos. Datos demográficos. Tasas de hechos vitales. Defunciones. Ocupación. Costo de vida. Encuesta socio-sanitaria de familias. Centros de salud

[Utilization of the National Hospital 1985-89. How many beds should there be in a new National Hospital?]. / Bruk av Rikshospitalet 1985-89. Hvor mange senger bør det vaere i et nytt rikshospital?

The Norwegian Parliament (Stortinget), has approved a proposal for construction of a new national hospital in Oslo. White Paper no. 38 (1987/88) proposes a hospital with 610 beds. The number of inpatient days at the present Rikshospitalet (The National Hospital) has declined by 19.4% during the period 1985 to 1989. In 1989 the use of inpatient services was equivalent to 530 beds with an occupancy rate of 80%. Based on an assumed further reduction in hospital use in the years to come, we estimate the need for beds to be 340 at the new national hospital. This lower number is assumed to cover local hospital functions (54 beds), regional hospital functions (220 beds) and national services (65 beds). The authors assert that the White Paper is based on outdated assumptions. The construction of a 610-bed national hospital involves a health care structure which could obstruct the reorganization of hospital care (more use of outpatient services) elsewhere in Norway. The County Councils responsible for financing hospitals will be forced to fund a hospital use that is motivated essentially by teaching and research rather than by caring for patients.

Historical trends in public general hospitals.

This article examines utilization trends in Canadian public general hospitals from 1976 to 1986-87. These trends are then compared with a previous period, and with hospital trends in the United States. Findings for this report are based on both provincial and national data. There was an overall decline in the number of hospitals with a decrease in small (1-49 beds) and an increase in large (300+ beds) hospitals. The net result is a 7% increase in the number of beds, though due to the larger population there was a 3% decrease in the bed rate per population. The bed occupancy rate increased from 77% to 83% and the average length of stay also increased. The number of separations increased slightly but rates per population declined. Patient-days per population increased in most provinces and there was a significant increase in long-stay units. Despite general uniformity amongst the provinces there were some notable variations. The trends indicate a reversal of the situation in the 1953-1973 period which was marked by an expansion in the hospital system. Hospitals in the United States showed somewhat similar trends with the exception of length of stay. The trends may be ascribed to factors such as increased efficiency, the development of alternatives to inpatient care, technical improvements, demographic changes and the individuality of the provincial health care systems.