Mortality Variations of COVID-19 from Different Hospital Settings During Different Pandemic Phases: A Multicenter Retrospective Study.

INTRODUCTION: Diverse coronavirus disease 2019 (COVID-19) mortalities have been reported but focused on identifying susceptible patients at risk of more severe disease or death. This study aims to investigate the mortality variations of COVID-19 from different hospital settings during different pandemic phases. METHODS: We retrospectively included adult (≥18 years) patients who visited emergency departments (ED) of five hospitals in the state of Texas and who were diagnosed with COVID-19 between March-November 2020. The included hospitals were dichotomized into urban and suburban based on their geographic location. The primary outcome was mortality that occurred either during hospital admission or within 30 days after the index ED visit. We used multivariable logistic regression to investigate the associations between independent variables and outcome. Generalized additive models were employed to explore the mortality variation during different pandemic phases. RESULTS: A total of 1,788 adult patients who tested positive for COVID-19 were included in the study. The median patient age was 54.6 years, and 897 (50%) patients were male. Urban hospitals saw approximately 59.5% of the total patients. A total of 197 patients died after the index ED visit. The analysis indicated visits to the urban hospitals (odds ratio [OR] 2.14, 95% confidence interval [CI], 1.41, 3.23), from March to April (OR 2.04, 95% CI, 1.08, 3.86), and from August to November (OR 2.15, 95% CI, 1.37, 3.38) were positively associated with mortality. CONCLUSION: Visits to the urban hospitals were associated with a higher risk of mortality in patients with COVID-19 when compared to visits to the suburban hospitals. The mortality risk rebounded and showed significant difference between urban and suburban hospitals since August 2020. Optimal allocation of medical resources may be necessary to bridge this gap in the foreseeable future.

Mistriaged Advanced Life Support Patients in a Two-Tiered, Suburban Emergency Medical Services System.

INTRODUCTION: Emergency medical services (EMS) systems exist to provide prehospital care in diverse environments throughout the world. Advanced Life Support (ALS) services can provide advanced care including 12-lead electrocardiogram (ECG), endotracheal intubation and parenteral medication administration. Basic Life Support (BLS) can provide basic care such as splinting, wound care and cardiopulmonary resuscitation. ALS can release patients to BLS for transport to the hospital, and this is an area of high risk. Our study examines patients who were triaged and admitted to a critical care location, including an intensive care unit (ICU), cardiac catheterization laboratory, or operating room (OR). METHODS: The analysis included data from 2007-2015 of all patients who were triaged. We evaluated demographics, admission diagnoses, and dispositions using descriptive statistics. Diagnoses were grouped into categories based on the system. RESULTS: We found that 372/17,639 (2%) of patients were mistriaged to BLS and admitted to a critical care location. The average age was 64. The most common diagnosis categories were neurological (24%), gastrointestinal (GI)/abdominal pain (15%), respiratory (12%), and cardiac (12%). CONCLUSION: It is uncommon for patients triaged from ALS to BLS to be admitted to an ICU, catheterization lab or OR, with a rate of 2%. Neurological, GI, respiratory, and cardiac diagnoses were the most frequent categories of patient complaints that were mistriaged. This study should lead to further studies to examine this patient population.

Outcomes After Prehospital Endotracheal Intubation in Suburban/Rural Pediatric Trauma.

BACKGROUND: Trauma is the leading cause of death in pediatric patients over 1 y of age. Controversy exists regarding prehospital airway management for these patients, with some studies suggesting that endotracheal intubation in the field or at a referring hospital is associated with increased mortality and complication rate. These studies were largely performed at urban centers, and it is unclear whether the results apply to suburban/rural networks with longer transport times and more stops at referring hospitals. The purpose of this study is to evaluate differential outcomes in pediatric trauma patients who underwent endotracheal intubation at the scene of injury, referring hospital, or pediatric trauma center in a predominantly rural/suburban setting. MATERIALS AND METHODS: A retrospective review was performed evaluating trauma patients age 18 y or younger at a single institution over 10 y (2004-2014). Patients were selected who underwent endotracheal intubation and were classified based on location of intubation (scene, referring hospital, or trauma center). Fischer's exact test and t-tests were performed for comparison. Univariate and multivariate regression analyses were performed. RESULTS: 288 patients were identified. 155 (53.8%) were intubated at the scene of injury, 55 (19.1%) at a referring hospital, and 72 (25%) at the trauma center. Overall mortality was 21.9%, which was highest in the scene intubation group (29.7%) compared with the referring hospital (20%) and trauma center (5.6%) groups (P < 0.01). Patients intubated at the scene had higher Injury Severity Scores and lower Glasgow Coma Scale scores (P < 0.01). Duration of intubation was lowest in the trauma center group (P < 0.01). Complication rate was highest in the referring hospital group (P < 0.05). Multivariate analysis revealed that age, injury severity, and neurologic status were the key drivers of mortality rather than location of intubation. CONCLUSIONS: Mortality and duration of intubation were lowest in trauma patients intubated at a pediatric trauma center. However, location of intubation was not a significant independent predictor of mortality or complications on multivariate analysis, suggesting that age, injury severity, and neurologic status are the main indicators of prognosis in severe pediatric trauma.

Use of Mechanical Cardiopulmonary Resuscitation Devices for Out-of-Hospital Cardiac Arrest, 2010-2016.

Importance: Out-of-hospital cardiac arrest is a common scenario facing prehospital emergency medical services (EMS) professionals and nearly always involves either manual or mechanical cardiopulmonary resuscitation (CPR). Mechanical CPR devices are expensive and prior clinical trials have not provided evidence of benefit for patients when compared with manual CPR. Objectives: To investigate the use of mechanical CPR in the prehospital setting and determine whether patient demographic characteristics or geographical location is associated with its use. Design, Setting, and Participants: A retrospective cross-sectional study was performed using the 2010 through 2016 National Emergency Medical Services Information System data. Participants included all patients identified by EMS professionals as having out-of-hospital cardiac arrest. Main Outcomes and Measures: Use of CPR, categorized as manual or mechanical. Results: From 2010 to 2016, 892 022 patients (38.6% female, 60.4% male, missing for 1%; mean [SD] age, 61.1 [20.5] years) with out-of-hospital cardiac arrest were identified by EMS professionals. Overall, manual CPR was used for 618 171 patients (69.3%) and mechanical CPR was used for 45 493 patients (5.1%). The risk-standardized rate of mechanical CPR use, accounting for patient demographic and geographical characteristics, rose from 1.9% in 2010 to 8.0% in 2016 (P < .001). In multivariable analyses, use of mechanical CPR devices was increasingly likely over time among patients identified with out-of-hospital cardiac arrest treated by EMS professionals, increasing from an adjusted odds ratio of 1.58 (95% CI, 1.42-1.77; P < .001) when comparing 2011 with 2010, to an adjusted odds ratio of 11.32 (95% CI, 10.22-12.54; P < .001) when comparing 2016 with 2010. In addition, several other patient demographic and geographical characteristics were associated with a higher likelihood of receiving mechanical CPR, including being 65 years or older, being male, being Hispanic, as well as receiving treatment in the Northeast Census Region, in a suburban location, or in a zip code with a median annual income greater than $20 000. Conclusions and Relevance: Mechanical CPR device use increased more than 4-fold among patients with out-of-hospital cardiac arrest treated by EMS professionals. Given the high costs of mechanical CPR devices, better evidence is needed to determine whether these devices improve clinically meaningful outcomes for patients treated for out-of-hospital cardiac arrest by prehospital EMS professionals to justify the significant increase in their use.

Poor Access to Breast Reconstruction: A Geographical Shortage of Plastic Surgeons Relative to Breast Surgeons in the United States.

BACKGROUND: Breast cancer surgery involves removal of cancer performed by a breast surgeon and reconstruction performed by a plastic surgeon. Historically, many women have not undergone breast reconstruction surgery (BRS), with current literature suggesting that geographic barriers may play a role. Our objective was to determine if there is a geographic shortage of plastic surgeons in the United States and to assess for trends in access to BRS for rural, suburban, and urban populations. METHODS: A database investigation of the 2018 membership for the American Society of Breast Surgeons and the American Society of Plastic Surgeons was performed. We searched for a breast surgeon's geographic presence by zip code and looked for the presence of a plastic surgeon within 10 and 20 miles. Zip codes were then categorized as urban, suburban, or rural. Within each population category, the average numbers of breast surgeons and plastic surgeons were quantified. RESULTS: Twenty-five percent of breast surgeon zip codes had no plastic surgeons located within 10 miles; 10% of breast surgeon zip codes had no plastic surgeon within 20 miles. There were on average 7.03 breast surgeons in each urbanized area. Suburban and rural areas had an average of 1.14 and 1.00 breast surgeons, respectively. There were on average 10.97 plastic surgeons per urbanized area. Suburban and rural areas had, on average, 0.23 and 0.06 plastic surgeons, respectively. CONCLUSIONS: A national comparison of the geographical distribution between breast surgeons and plastic surgeons indicates a shortage of plastic surgeons, especially in rural and suburban areas.

Induced Abortion Provision Among a National Sample of Obstetrician-Gynecologists.

OBJECTIVE: To estimate the proportion of obstetrician-gynecologists (ob-gyns) who provided induced abortion in the prior year, disaggregated by surgical and medication methods, and document barriers to provision of medication abortion. METHODS: In 2016-2017, we conducted a cross-sectional survey of a national sample of American College of Obstetricians and Gynecologists Fellows and Junior Fellows who were part of the Collaborative Ambulatory Research Network. We sent the survey by email, and mailed nonresponders paper surveys. We performed descriptive statistics, χ tests, and logistic regression analyses. RESULTS: Sixty-seven percent (655/980) of Collaborative Ambulatory Research Network members responded. Ninety-nine percent reported seeing patients of reproductive age, and 72% reported having a patient in the prior year who needed or wanted an abortion. Among those seeing patients of reproductive age, 23.8% (95% CI 20.5%-27.4%) reported performing an induced abortion in the prior year; 10.4% provided surgical and medication abortion, 9.4% surgical only, and 4.0% medication only. In multivariable analysis, physicians practicing in the Midwest (adjusted odds ratio [AOR] 0.31, 95% CI 0.16-0.60) or South (AOR 0.22, 95% CI 0.11-0.42) had lower odds of provision compared with those practicing in the Northeast, whereas those practicing in an urban inner city (AOR 2.71, 95% CI 1.31-5.60) or urban non-inner-city area (AOR 2.89, 95% CI 1.48-5.64 vs midsize towns, rural areas, or military settings) had higher odds of provision. The most common reasons for not providing medication abortion were personal beliefs (34%) and practice restrictions (19%). Among those not providing medication abortion, 28% said they would if they could write a prescription for mifepristone. CONCLUSION: Compared with the previous national survey in 2008-2009, abortion provision may be increasing among practicing ob-gyns, although important geographic disparities persist. Few provide medication abortion, but uptake might increase if mifepristone could be prescribed.

Life With HIV in a Canadian Suburban Community: A Qualitative Inquiry of Health Care and Social Services Access.

HIV has been examined in urban and rural contexts, but the suburban gradient has not been sufficiently described, despite the fact that many Canadians live in suburbia. Using qualitative description, we investigated how people living with HIV in a suburban community in Ontario, Canada, accessed health care and social services. Posters at the regional AIDS Service Organization and snowball sampling were used to recruit and interview 13 adult participants with various experiences and perspectives. A content analysis identified three meta-themes in the interviews: (a) transportation cost and time: barriers to access, (b) isolation, and (c) defective primary care: unmet and deflected needs. The findings have implications for the (a) development of community-based groups, (b) the role of transportation in health care and social services utilization, (c) community-based, interprofessional health and social care services, and (d) aging with HIV.

Effects of a Community-Based Healthy Lifestyle Intervention Program (Co-HELP) among Adults with Prediabetes in a Developing Country: A Quasi-Experimental Study.

BACKGROUND: The prevalence of type 2 diabetes among Malaysian adults has increased by more than two folds over the past two decades. Strategies to collaborate with the existing community partners may become a promising channel for wide-scale dissemination of diabetes prevention in the country. The objectives of this study were to determine the effects of community-based lifestyle interventions delivered to adults with prediabetes and their health-related quality of life as compared to the usual care group. METHODS: This was a quasi-experimental study conducted in two sub-urban communities in Seremban, Malaysia. A total of 268 participants with prediabetes aged between 18 to 65 years old were assigned to either the community-based lifestyle intervention (Co-HELP) (n = 122) or the usual care (n = 146) groups. The Co-HELP program was delivered in partnership with the existing community volunteers to incorporate diet, physical activity, and behaviour modification strategies. Participants in the Co-HELP group received twelve group-based sessions and two individual counselling to reinforce behavioural change. Participants in the usual care group received standard health education from primary health providers in the clinic setting. Primary outcomes were fasting blood glucose, 2-hour plasma glucose, and HbA1C. Secondary outcomes included weight, BMI, waist circumference, total cholesterol, triglyceride, LDL cholesterol, HDL cholesterol, systolic and diastolic blood pressure, physical activity, diet, and health-related quality of life (HRQOL). RESULTS: An intention-to-treat analysis of between-groups at 12-month (mean difference, 95% CI) revealed that the Co-HELP participants' mean fasting plasma glucose reduced by -0.40 mmol/l (-0.51 to -0.28, p<0.001), 2-hour post glucose by -0.58 mmol/l (-0.91 to -0.24, p<0.001), HbA1C by -0.24% (-0.34 to -0.15, p<0.001), diastolic blood pressure by -2.63 mmHg (-3.79 to -1.48, p<0.01), and waist circumference by -2.44 cm (-4.75 to -0.12, p<0.05) whereas HDL cholesterol increased by 0.12 mmol/l (0.05 to 0.13, p<0.01), compared to the usual care group. Significant improvements were also found in HRQOL for both physical component (PCS) by 6.51 points (5.21 to 7.80, p<0.001) and mental component (MCS) by 7.79 points (6.44 to 9.14, p<0.001). Greater proportion of participants from the Co-HELP group met the clinical recommended target of 5% or more weight loss from the initial weight (24.6% vs 3.4%, p<0.001) and physical activity of >600 METS/min/wk (60.7% vs 32.2%, p<0.001) compared to the usual care group. CONCLUSIONS: This study provides evidence that a culturally adapted diabetes prevention program can be implemented in the community setting, with reduction of several diabetes risk factors and improvement of HRQOL. Collaboration with existing community partners demonstrated a promising channel for the wide-scale dissemination of diabetes prevention at the community level. Further studies are required to determine whether similar outcomes could be achieved in communities with different socioeconomic backgrounds and geographical areas. TRIAL REGISTRATION: IRCT201104106163N1.

Spatial Distribution Balance Analysis of Hospitals in Wuhan.

The spatial distribution pattern of hospitals in Wuhan indicates a core in the central urban areas and a sparse distribution in the suburbs, particularly at the center of suburbs. This study aims to improve the gravity and Huff models to analyze healthcare accessibility and resources. Results indicate that healthcare accessibility in central urban areas is better than in the suburbs, where it increasingly worsens for the suburbs. A shortage of healthcare resources is observed in large-scale and high-class hospitals in central urban areas, whereas the resources of some hospitals in the suburbs are redundant. This study proposes the multi-criteria evaluation (MCE) analysis model for the location assessment in constructing new hospitals, which can effectively ameliorate healthcare accessibility in suburban areas. This study presents implications for the planning of urban healthcare facilities.

A comparative analysis of vaccine administration in urban and non-urban skilled nursing facilities.

BACKGROUND: The U.S. population is aging at an unprecedented rate, resulting in an increased demand for skilled nursing facilities (SNFs) and long-term care. Residents of these facilities are at a high risk for pneumococcal disease or severe influenza-related illnesses and death. For these reasons, the Centers for Medicare and Medicaid Services use influenza and pneumococcal vaccination rates as a quality measure in the assessment of SNFs, as complications related to these infections increase morbidity and mortality rates. METHODS: Disparities have been reported amongst vaccination with increased rates in urban areas as compared to their non-urban counterparts. Statistical analyses were performed to compare influenza and pneumococcal vaccination in urban and non-urban SNFs to determine variables that may influence vaccination status. RESULTS: Of the 15,639 nursing homes included in the study, 10,107 were in urban areas, while 5532 were considered non-urban. We found the percent of eligible and willing residents with up-to-date influenza and pneumococcal vaccinations increased with overall five-star ratings of SNFs. Somewhat paradoxically, although urban SNFs had higher mean overall five-star ratings, they showed lower rates of influenza and pneumococcal vaccination compared to non-urban SNFs. Ordinary least squares regression analysis comparing overall ratings, type of ownership, and geographic location by region yielded statistically significant results in which the overall rating, ownership-type and certificate-type favored urban SNFs (p < 0.001). CONCLUSIONS: This is the first systematic and comparative analysis to use the Nursing Home Compare database to assess vaccine administration of urban and non-urban SNFs. The findings of this study may be used to encourage the development of programs to improve vaccination rates and the quality of care in these facilities.

Finding the Perfect Match: Factors That Influence Family Medicine Residency Selection.

BACKGROUND AND OBJECTIVES: Residency program selection is a significant experience for emerging physicians, yet there is limited information about how applicants narrow their list of potential programs. This study examines factors that influence residency program selection among medical students interested in family medicine at the time of application. METHODS: Medical students with an expressed interest in family medicine were invited to participate in a 37-item, online survey. Students were asked to rate factors that may impact residency selection on a 6-point Likert scale in addition to three open-ended qualitative questions. Mean values were calculated for each survey item and were used to determine a rank order for selection criteria. Logistic regression analysis was performed to identify factors that predict a strong interest in urban, suburban, and rural residency programs. Logistic regression was also used to identify factors that predict a strong interest in academic health center-based residencies, community-based residencies, and community-based residencies with an academic affiliation. RESULTS: A total of 705 medical students from 32 states across the country completed the survey. Location, work/life balance, and program structure (curriculum, schedule) were rated the most important factors for residency selection. Logistic regression analysis was used to refine our understanding of how each factor relates to specific types of residencies. CONCLUSIONS: These findings have implications for how to best advise students in selecting a residency, as well as marketing residencies to the right candidates. Refining the recruitment process will ensure a better fit between applicants and potential programs. Limited recruitment resources may be better utilized by focusing on targeted dissemination strategies.

Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas - United States, 2013.

Reducing human immunodeficiency virus (HIV) infection rates in persons who inject drugs (PWID) has been one of the major successes in HIV prevention in the United States. Estimated HIV incidence among PWID declined by approximately 80% during 1990-2006 (1). More recent data indicate that further reductions in HIV incidence are occurring in multiple areas (2). Research results for the effectiveness of risk reduction programs in preventing hepatitis C virus (HCV) infection among PWID (3) have not been as consistent as they have been for HIV; however, a marked decline in the incidence of HCV infection occurred during 1992-2005 in selected U.S. locations when targeted risk reduction efforts for the prevention of HIV were implemented (4). Because syringe service programs (SSPs)* have been one effective component of these risk reduction efforts for PWID (5), and because at least half of PWID are estimated to live outside major urban areas (6), a study was undertaken to characterize the current status of SSPs in the United States and determine whether urban, suburban, and rural SSPs differed. Data from a recent survey of SSPs(†) were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services(§) were less available to PWID outside urban settings. Because increases in substance abuse treatment admissions for drug injection have been observed concurrently with increases in reported cases of acute HCV infection in rural and suburban areas (7), state and local jurisdictions could consider extending effective prevention programs, including SSPs, to populations of PWID in rural and suburban areas.

Retrospective analysis of a suburban out-of-hours clinic in Belgium.

INTRODUCTION: In many countries, out-of-hours medical care is under scrutiny. The aim of this article is to study the activities recorded by the first out-of-hours clinic that has been opened, as a pilot study, in two Walloon communes. MATERIAL AND METHOD: A retrospective analysis of anonymized data was conducted for 2009. Coding of diagnoses was conducted using the International Classification of Primary Care (ICPC-2). RESULTS: A total of 3949 contacts were recorded in 2009 with the out-of-hours clinic, 3294 related to inhabitants of the two communes covered, which was equivalent to 13% of the total population in question. Compared to 7·2% of contacts between midnight and 8 a.m., 82·9% of contacts took place between 8 a.m. and 9 p.m., and 91·6% of contacts were handled locally, with only 8·4% resulting in hospitalization. In addition, 52% of contacts were with patients aged between 25 and 65; 29·9% of contacts were with paediatric patients (<15 years). Patients over the age of 65 made up 18% of contacts. The most common pathologies were respiratory (R). Analysis of flu diagnoses identified two epidemic peaks. DISCUSSION: The suburban out-of-hours clinic studied fulfilled an important role in managing the demand for health care. The large majority of health problems were resolved locally, and the inhabitants did not need to go to hospital. Appointments between midnight and 8 a.m. were in the minority, which points towards adjusting the organization of the out-of-hours service during the night. The geriatric population is not highly over-represented contrary to what might be expected considering its largest number of pathologies. The on-call doctor's skills profile should take account of the populations and morbidities encountered. Out-of-hours clinics could possibly play a sentinel role in terms of flu epidemics. CONCLUSION: This study describes a pilot suburban out-of-hours clinic which met three of recommendations set by the KCE in its report on out-of-hours care in general medicine: the organization of an out-of-hours clinic with logistical support, the use of a single telephone number and merging out-of-hours areas. While debate exists on the management of out-of-hours care, this study provides evidence on the role of the physician during these hours.

Associations between injection risk and community disadvantage among suburban injection drug users in southwestern Connecticut, USA.

Increases in drug abuse, injection, and opioid overdoses in suburban communities led us to study injectors residing in suburban communities in southwestern Connecticut, US. We sought to understand the influence of residence on risk and injection-associated diseases. Injectors were recruited by respondent-driven sampling and interviewed about sociodemographics, somatic and mental health, injection risk, and interactions with healthcare, harm reduction, substance abuse treatment, and criminal justice systems. HIV, hepatitis B and C (HBV and HCV) serological testing was also conducted. Our sample was consistent in geographic distribution and age to the general population and to the patterns of heroin-associated overdose deaths in the suburban towns. High rates of interaction with drug abuse treatment and criminal justice systems contrasted with scant use of harm reduction services. The only factors associated with both dependent variables-residence in less disadvantaged census tracts and more injection risk-were younger age and injecting in one's own residence. This contrasts with the common association among urban injectors of injection-associated risk behaviors and residence in disadvantaged communities. Poor social support and moderate/severe depression were associated with risky injection practices (but not residence in specific classes of census tracts), suggesting that a region-wide dual diagnosis approach to the expansion of harm reduction services could be effective at reducing the negative consequences of injection drug use.

Defining, quantifying, and characterizing adult frequent users of a suburban Canadian emergency department.

INTRODUCTION: Frequent emergency department (ED) users are inconsistently defined and poorly studied in Canada. The purpose of this study was to develop uniform definitions, quantify ED burden, and characterize adult frequent users of a suburban community ED. METHODS: We retrospectively reviewed the administrative database of the WestView ED in Alberta for patients ≥ 18 years of age presenting during the fiscal year of 2010. Adult frequent users and extreme frequent users were defined as patients with yearly visit numbers greater than the 95th and 99th percentiles, respectively. Demographic information including age, sex, ED length of stay, diagnoses, Canadian Triage and Acuity Scale (CTAS) level, and disposition were collected and stratified by ED frequency of use categories. RESULTS: The study included 22,333 ED visits by 14,223 patients. Frequent users represented 3.1% of patients and 13.8% of visits. Extreme frequent users represented 0.8% of patients, 5.4% of visits, and 568,879 cumulative ED minutes (395 days). Nonfrequent users had one to four, frequent users had five or more, and extreme frequent users had eight or more visits over a 12-month period. Frequent users and extreme frequent users had a significantly longer ED length of stay overall and in most age categories. Alcohol-related behavioural disorders, anxiety, nausea/vomiting, and chronic obstructive pulmonary disease were prominent diagnoses, suggesting that psychiatric, somatic, and chronic illnesses may underlie recurrent visits. Admission rates were significantly higher for frequent compared to nonfrequent users. CONCLUSIONS: We propose reproducible definitions for adult frequent and extreme frequent ED users and provide information on the characteristics and burden of care of these groups at a community Canadian suburban ED. Adoption of these definitions would allow comparison across centres in future research and facilitate targeted interventions for frequent and extreme frequent ED users.

Acute hospital admissions from nursing homes: predictors of unwarranted variation?

BACKGROUND: The geriatric nursing home population is frail and vulnerable to sudden changes in their health condition. Very often, these incidents lead to hospitalization, in which many cases represent an unfavourable discontinuity of care. Analysis of variation in hospitalization rates among nursing homes where similar rates are expected may identify factors associated with unwarranted variation. OBJECTIVES: To 1) quantify the overall and diagnosis specific variation in hospitalization rates among nursing homes in a well-defined area over a two-year period, and 2) estimate the associations between the hospitalization rates and characteristics of the nursing homes. METHOD: The acute hospital admissions from 38 nursing homes to two hospitals were identified through ambulance records and linked to hospital patient journals (n = 2451). Overall variation in hospitalization rates for 2 consecutive years was tested using chi-square and diagnosis-specific variation using Systematic Component of Variation. Associations between rates and nursing home characteristics were tested using multiple regression and ANOVA. RESULTS: Annual hospitalization rates varied significantly between 0.16 and 1.49 per nursing home. Diagnoses at discharge varied significantly between the nursing homes. The annual hospitalization rates correlated significantly with size (r = -0.38) and percentage short-term beds (r = 0.41), explaining 32% of the variation observed (R (2) = 0.319). No association was found for ownership status (r = 0.05) or location of the nursing home (p = 0.52). CONCLUSION: A more than nine-fold variation in annual hospitalization rates among the nursing homes in one municipality suggests the presence of unwarranted variation. This finding demands for political action to improve the premises for a more uniform practice in nursing homes.

Multivariate analysis of successful intravenous line placement in the prehospital setting.

BACKGROUND: Intravenous (IV) line placement is an important prehospital advanced life support skill, but IV success rates are variable among providers. Little is known about what factors are associated with successful IV placement, limiting the ability to develop benchmarks for skill maintenance, such as requiring a specific number of IV placements per year. OBJECTIVE: We aimed to identify whether first-pass IV success was associated with the number of attempted or successful previous IV attempts. We hypothesized that IV success is associated with the number of successful IV placements in the preceding year. METHODS: We retrospectively studied 800 consecutive charts with an IV attempt from 11 suburban and rural emergency medical services (EMS) agencies over a one-month period. Cases involving pediatric patients (age <18 years) and those with incomplete data were excluded. Success of the first IV attempt was identified. Potential predictor variables were collected and analyzed by univariate logistic regression, including patient age, systolic blood pressure, history of IV drug abuse or renal disease, traumatic event, catheter size, and location of IV attempt, as well as the individual provider's numbers of total and successful IV attempts in the preceding year. Variables significantly associated with IV success at the p < 0.10 level were included in a multivariate regression model using a p-value of 0.05. RESULTS: Of 602 cases meeting the study criteria, 469 (77.9%) had a successful first-pass IV placement. Significantly associated with IV success in the univariate regression were patient age (p = 0.054), trauma (p = 0.074), IV catheter size (p < 0.001), IV location (p = 0.056), and the number of previous successful IV attempts (p = 0.039), whereas the number of total previous IV attempts was not significantly associated (p = 0.871). In the multivariate logistic regression model, only IV catheter size had a significant association (p < 0.001), with a larger-bore IV catheter size associated with higher success. CONCLUSION: In this retrospective study, larger IV catheter size, but not the prehospital providers' previous year's experience, was associated with successful IV placement in adult patients. These data fail to support requirements for a minimum number of yearly IV placements by full-time paramedics to improve success rates.

Cost and resource use of patients on antiretroviral therapy in the urban and semiurban public sectors of South Africa.

BACKGROUND: South Africa has the world's largest number of patients on antiretroviral treatment (ART). As coverage expands beyond urban environments, the cost of care is becoming increasingly important. METHODS: Health care cost data for the first year after initiation were analyzed for cohorts of patients in a semiurban and an urban public sector ART clinic in South Africa. We compared mean cost by CD4 cell count and time on ART between clinics. RESULTS: Patients in both clinics had comparable CD4 cell counts at initiation and under treatment. In the urban clinic, mean cost per patient-year on ART in 2011 USD was $1040 [95% confidence interval (CI): $800 to $1280], of which outpatient cost was $692 (67%) and inpatient cost was $348 (33%). Fourteen percent of urban patients required inpatient care at a mean length of stay of 9 days and mean cost per hospitalized patient of $1663 (95% CI: $1103 to $2041). In the semiurban clinic, mean cost per patient-year on ART was $1115 (95% CI: $776 to $1453), of which outpatient cost was $697 (63%) and inpatient cost $418 (37%). Seven percent of semiurban patients required inpatient care at a mean length of stay of 28 days and mean cost per hospitalized patient of $3824 (95% CI: $1143 to $6505). CONCLUSIONS: Outpatient ART provision in the semiurban setting cost the same as in the urban setting, but inpatient costs are higher in the semiurban clinic because of longer hospitalizations. Cost in both clinics was highest in the first 3 months on ART and at CD4 cell counts <50 cells/µL.

MRSA rates and antibiotic susceptibilities from skin and soft tissue cultures in a suburban ED.

BACKGROUND: Prior studies suggest that more than half of all skin and soft tissue infections (SSTIs) are caused by methicillin-resistant Staphylococcus aureus (MRSA). These data mainly represent inner-city urban centers. OBJECTIVE: We determined the bacteriologic etiologies and antibiotic susceptibilities from wound cultures in the emergency department (ED). We hypothesized that in a suburban ED, MRSA would not represent the major pathogen. METHODS: The study design was a retrospective, electronic medical record review in a suburban tertiary care ED with 80,000 annual visits. Subjects included ED patients of all ages who had skin or soft tissue cultures obtained in 2005-2008. Demographics and clinical data, including type of SSTI (MRSA or methicillin-sensitive S. aureus [MSSA]), culture results, and antibiotic susceptibility, were analyzed using descriptive statistics. RESULTS: From the 1246 cultures obtained during the study period, 252 (20.2%) were MSSA and 270 (21.6%) were MRSA. The rates of MRSA infections over time increased from 13.5% to 25.7% during 2005-2008. The rates of MRSA in males and females were comparable at 23.3% and 19.6%, respectively. In 2008, MRSA was 97-100% susceptible to vancomycin, linezolid, rifampin, nitrofurantoin, chloramphenicol, gentamycin, tetracycline, and trimethoprim-sulfamethoxazole (TMP-SMZ). To a lesser extent it was susceptible to clindamycin (75%), erythromycin (62%), and levofloxacin (50%). CONCLUSIONS: There has been a significant increase in the rates of MRSA SSTIs in a suburban ED, yet only 1 in 4 SSTIs are caused by MRSA. Both MRSA and MSSA are completely susceptible to vancomycin, linezolid, rifampin, nitrofurantoin, and chloramphenicol. Gentamicin, tetracycline, and TMP-SMZ cover > 97% of both isolates.

The periodontal examination profile of general dentists in Nova Scotia, Canada.

BACKGROUND: In this cross-sectional study we investigate the extent to which general dentists in Nova Scotia carry out periodontal examinations of their patients. In addition, factors that significantly influence performing a periodontal examination by a dentist are identified. METHODS: A survey questionnaire was mailed to all 443 general dentists practicing in the province of Nova Scotia in the summer of 2009. The survey included questions on demographics and the various components of the periodontal examination. Simple and multiple logistic regression tests were used to analyze the results. RESULTS: Of the 279 (63%) responses received, 272 (61%) responses were eligible to be included in the analyses. The majority of responders (94.8%) reported performing periodontal examinations of their patients. However, only 37.8% and 43.3% of the dentists reported performing full-mouth and selective probing depth measurements, respectively. Dentists who practiced in urban locations (P = 0.05), dentists whose practices were situated <5 km from a periodontist (P = 0.08), and dentists who planned to take a continuing education course in periodontal plastic surgery in the next 2 years (P = 0.07) were more likely to perform a periodontal examination. CONCLUSIONS: Although the majority of dentists in our study report performing periodontal examinations of their patients, only a small portion report recording complete probing depth measurements or using appropriate radiographs in their examinations. These practices could lead to an underestimation of diagnosis and treatment of periodontal disease.