Pediatric Hospitalization Trends at Children's and General Hospitals, 2000-2019.

This study examines whether pediatric inpatient care has been redistributed from general hospitals into children's hospitals.

The experience of Hamad General Hospital collaborative anticoagulation clinic in Qatar during the COVID-19 pandemic.

Hamad General Hospital Anticoagulation Clinic is one of the largest collaborative-practice clinics of its type in Qatar. The patients being followed at this clinic are typically complex and vulnerable. During the coronavirus disease 2019 pandemic, measures were implemented at the clinic to minimize the exposure of patients and healthcare providers to the acute respiratory syndrome coronavirus-2 and to promote social distancing. These measures included extending INR-recall period, transitioning to direct oral anticoagulant drugs whenever feasible, home visits to elderly and immunocompromised patients for INR testing, establishing an anticoagulation hotline, and relocation of warfarin dispensing from the main pharmacy to the anticoagulation clinic. In addition, the clinic shifted its multidisciplinary team meetings onto an online platform using Microsoft Teams. Telehealth consultations were extensively utilized to closely follow up with the patients and ensure that anticoagulation efficacy and safety remained optimal. The aim of this paper is to share our experience and describe the measures adopted by the clinic as part of the Hamad Medical Corporation response to the emerging situation.

The adjustment of neurosurgical procedures during the COVID-19 pandemic: a case study at Dr. Sardjito General Hospital as a part of an academic health system.

OBJECTIVE: The recent COVID-19 outbreak has forced notable adjustments to surgical procedure preparation, including neurosurgical services. However, due to the uniqueness of the recent situation, neurosurgical centers, especially those located in low-resource settings, are facing several challenges such as a lack of coordination, poor equipment, and shortage of medical personnel. Therefore, several guidelines from local authorities and international neurosurgical bodies have been published to help clinicians manage their patients. In addition, the academic health system (AHS), which is an integrated system containing a medical institution, universities, and a teaching hospital, may play some role in the management of patients during COVID-19. The objective of this study was to describe how each hospital in the authors' network adjusted their neurosurgical practice and how the AHS of the Universitas Gadjah Mada (UGM) played its role in the adaptation process during the pandemic. METHODS: The authors gathered both local and national data about the number of COVID-19 infections from the government's database. To assess the contribution of the AHS to the efforts of each hospital to address the pandemic, questionnaires were given to 6 neurosurgeons, 1 resident, and 2 general surgeons about the management of neurosurgical cases during the pandemic in their hospitals. RESULTS: The data illustrate various strategies to manage neurosurgical cases by hospitals within the authors' networks. The hospitals were grouped into three categories based on the transmission risk in each region. Most of these hospitals stated that UGM AHS had a positive impact on the changes in their strategies. In the early phase of the outbreak, some hospitals faced a lack of coordination between hospitals and related stakeholders, inadequate amount of personal protective equipment (PPE), and unclear regulations. As the nation enters a new phase, almost all hospitals had performed routine screening tests, had a sufficient amount of PPE for the medical personnel, and followed both national and international guidelines in caring for their neurosurgical patients. CONCLUSIONS: The management of neurosurgical procedures during the outbreak has been a challenging task and a role of the AHS in improving patient care has been experienced by most hospitals in the authors' network. In the future, the authors expect to develop a better collaboration for the next possible pandemic.

Is Consultation-Liaison Psychiatry 'Getting Old'? How Psychiatry Referrals in the General Hospital Have Changed over 20 Years.

There is an ever-growing awareness of the health-related special needs of older patients, and Consultation-Liaison Psychiatry Services (CLPS) are significantly involved in providing such age-friendly hospital care. CLPS perform psychiatric assessment for hospitalized patients with suspected medical-psychiatric comorbidity and support ward teams in a bio-psycho-social oriented care management. Changes in features of the population referred to a CLPS over a 20-year course were analysed and discussed, especially comparing older and younger referred subjects. Epidemiological and clinical data from all first psychiatric consultations carried out at the Modena (North of Italy) University Hospital CLPS in the period 2000-2019 (N = 19,278) were included; two groups of consultations were created according to the age of patients: OV65 (consultations for patients older than 64 years) and NONOV65 (all the rest of consultations). Consultations for OV65 were about 38.9% of the total assessments performed, with an average of approximately 375 per year, vs. the 589 performed for NOV65. The number of referrals for older patients significantly increased over the 20 years. The mean age and the male/female ratio of the sample changed significantly across the years in the whole sample as well as both among OV65 and NOV65. Urgent referrals were more frequent among NOV65 and the rate between urgent/non urgent referrals changed differently in the two subgroups. The analysis outlined recurring patterns that should guide future clinical, training and research activities.

Characteristics of mass lesion presentation of primary angiitis of the central nervous system: A single center 11-year retrospective case-series study.

OBJECTIVE: Mass lesion presentation of primary angiitis of the central nervous system (ML-PACNS) is a special subtype of primary central nervous system vasculitis, which is difficult to be differentiated from other space-occupying disorders. We aimed to summarize our experience and improve diagnostic techniques of ML-PACNS. PATIENTS AND METHODS: Case records for 16 patients treated in the Department of Neurology of Six Medical Center of Chinese PLA General Hospital from December 2008 to November 2019 were examined. All patients were diagnosed with ML-PACNS by pathology. Clinical manifestations, neuroimaging results and pathological features were retrospectively analyzed. RESULTS: The 16 patients with ML-PACNS in the cohort (8 males) had a median age of 32 (range 19-56 years). On T1WI and T2WI, 12 cases showed mixed signals and 4 cases showed T1WI hypointense and T2WI hyperintense. Fifteen patients showed DWI hyperintense, of which 9 cases showed hypointense in the middle of the lesion. Gadolinium enhancement of all cases was irregular. All patients had a brain biopsy (stereotactic procedure in 10 and open-wedge surgery in 6) which showed lymphocytic vasculitis in the majority of patients (15/16) and necrotizing vasculitis in one patient. CONCLUSIONS: ML-PACNS is an important differential candidate for tumefactive demyelinating lesions, CNS infections and brain tumors. Mixed T1WI and T2WI signals as well as central hypointense surrounded by hyperintense lesions on DWI may be useful imaging features for the diagnosis of ML-PACNS which has implications for those who have not yet had a biopsy. ML-PACNS may have different pathological type from PACNS.

Changes in Emergency General Surgery During Covid-19 in Scotland: A Prospective Cohort Study.

INTRODUCTION: Covid-19 has had a significant impact on all aspects of health care. We aimed to characterise the trends in emergency general surgery at a district general hospital in Scotland. METHODS: A prospective cohort study was performed from 23/03/20 to 07/05/20. All emergency general surgery patients were included. Demographics, diagnosis and management were recorded along with Covid-19 testing and results. Thirty-day mortality and readmission rates were also noted. Similar data were collected on patients admitted during the same period in 2019 to allow for comparison. RESULTS: A total of 294 patients were included. There was a 58.3 per cent reduction in admissions when comparing 2020 with 2019 (85 vs 209); however, there was no difference in age (53.2 vs 57.2 years, p = 0.169) or length of stay (4.8 vs 3.7 days, p = 0.133). During 2020, the diagnosis of appendicitis increased (4.3 vs 18.8 per cent, p = < 0.05) as did severity (0 per cent > grade 1 vs 58.3 per cent > grade 1, p = < 0.05). The proportion of patients undergoing surgery increased (19.1 vs 42.3 per cent, p = < 0.05) as did the mean operating time (102.4 vs 145.7 min, p = < 0.05). Surgery was performed in 1 confirmed and 1 suspected Covid-19 patient. The latter died within 30 days. There were no 30-day readmissions with Covid-19 symptoms. CONCLUSION: Covid-19 has significantly impacted the number of admissions to emergency general surgery. However, emergency operating continues to be needed at pre-Covid-19 levels and as such provisions need to be made to facilitate this.

Drug Use Evaluation of Beta-Blockers in Medical Wards of Nedjo General Hospital, Western Ethiopia.

INTRODUCTION: Beta-blocker use evaluation is a performance method that focuses on the evaluation of beta-blocker use processes to achieve optimal patient outcomes. Several studies conducted in different hospitals revealed a high incidence of inappropriate prescription of beta-blockers among hospitalized patients. Therefore, it is important to identify inappropriate beta-blocker prescribing since they may increase the risk of hospitalizations. Despite this, there was no study conducted related to drug use evaluation of beta-blockers in Nedjo general hospital (NGH). Thus, this study was aimed at assessing the use evaluation of beta-blockers in medical wards of NGH. METHODS: A retrospective cross-sectional study was conducted at medical wards of NGH from January 1, 2016, to December 31, 2017. RESULTS: Out of the total of 149 medical record of patients that contains beta-blockers, 84 (56.37%) were males and about one-third (31.54%) of the patients ages were between 41 and 50 years. Propranolol was the most commonly prescribed beta-blocker (62.76%), and 94.56% of beta-blockers were prescribed with correct indication. There were about 51%, 46.31%, 64.43%, and 46.98% of beta-blockers prescribed with the correct dose, duration, frequency, and route of administration, respectively. Regarding the routes of administration, 70 (46.98%) of them were prescribed with the correct route. Most drugs interacting were propranolol with cimetidine 26 (68.42%), and the most frequent condition for which beta-blockers were prescribed was hypertension (32.89%). CONCLUSION: Overall, there was an inappropriate use of beta-blockers in terms of dosage and durations. So, prescribers of NGH should strictly adhere to the national treatment guideline when prescribing medications. Additionally, drug information centers have proved useful and effective in promoting rational drug use. Hence, it should be recommended for general use.

The mystery of "missing" visits in an emergency cardiology department, in the era of COVID-19.; a time-series analysis in a tertiary Greek General Hospital.

BACKGROUND: In the era of the current COVID-19 health crisis, the aim of the present study was to explore population behavior as regards the visits in the Εmergency Cardiology department (ECD) of a tertiary General Hospital that does not hospitalize SARS-CoV-2 infected patients METHODS AND RESULTS: Daily number of visits at the EDC and admissions to Cardiology Wards and Intensive Care Unit of a tertiary General Hospital, in Athens, Greece, were retrieved from hospital's database (January 1st-April 30th 2018, 2019 and 2020). A highly significant reduction in the visits at ECD of the hospital during March and April 2020 was observed as compared with January and February of the same year (p for linear trend < ·001); in particular the number of visits was 41.1% lower in March 2020 and 32.7% lower in April 2020, as compared to January 2020. As the number of confirmed COVID-19 cases throughout the country increased (i.e., from February 26th to April 2nd) the number of visits at ECD decreased (p = 0.01), whereas, the opposite was observed in the period afterwards (p = 0.01).The number of acute Myocardial infarctions (MI) cases in March 2020 was the lowest compared to the entire three year period (p < 0·001); however, the number of acute MI cases in April 2020 was doubled as compared to March 2020, but still was lower than the preceding years (p < 0·001). CONCLUSIONS: It is hard to explain the mystery of the "missing" emergency hospital visits. However, if this decline in cardiovascular disease related hospital visits is "true", it is something that needs to be rigorously studied, to learn how to keep these rates down.

Trends in the delivery of elective general paediatric surgery.

INTRODUCTION: There has been regular dialogue regarding the importance of developing clinical networks to compensate for the steady decline in general paediatric surgery performed by adult surgeons. Despite this dialogue, there are no contemporary published data to quantify the issue. This report documents patterns in delivery of general paediatric surgery in England and shows what is being performed where and by whom. MATERIALS AND METHODS: Using the Surgical Workload Outcome Database, we compared hospital-level data between 2009 and 2017. Inclusion criteria were children under 18 years admitted to NHS hospitals in England for elective general paediatric surgery. Data were analysed with an online statistical package performing paired t-tests. RESULTS: There was no real change in the overall number of elective general paediatric surgical marker cases, but the type mix has changed. The number of marker cases performed by adult surgeons fell by 34% (4699 vs 3090 p < 0.05). The number of marker cases performed by specialist paediatric surgeons increased by 21% (8184 vs 9862 p < 0.05). This increase in workload occurred in both tertiary (21% increase) and peripheral (18% increase) centres. When analysing data by operation type it was apparent that 78% of the increased workload was attributable to an increase in orchidopexy rate. CONCLUSION: Best practice is to treat children close to home by staff with the right skills. This study shows significant shifts in the general paediatric surgical workload. It is important to monitor these trends for successful succession planning as well as configuration of services.

Incidence of anti-NMDAR encephalitis in patients undergoing resection of ovarian teratoma in a single institution.

OBJECTIVE: The objective of this study was to determine the incidence of anti-NMDAR encephalitis in patients in whom a teratoma was removed. As far as we know, there has been no report on the incidence of anti-NMDAR encephalitis in patients in whom a teratoma was removed. METHODS: This study was a single-institutional observational study. We enrolled patients who were diagnosed with teratoma in the Department of Pathology, Sapporo City General Hospital during a nine-year period between January 2008 and December 2016. RESULTS: In Sapporo City General Hospital, 6 NMDAR encephalitis cases were detected during the 9-year period. In the same 9-year period, a pathological diagnosis of teratoma was made in 343 cases in the hospital. Anti-NMDAR encephalitis patients with a teratoma accounted for only 1.17% of all teratoma patients. Three of the 4 anti-NMDAR encephalitis patients with a teratoma underwent second removal of a teratoma, and no nervous tissue was detected pathologically. CONCLUSIONS: In this study, we determined the association between teratoma with anti-NMDAR encephalitis and teratoma without anti-NMDAR encephalitis in cases in a single institution. As far as we know, this report is the first report on the incidence of anti-NMDAR encephalitis in teratoma patients.

Impact of shortened length of stay for delivery on the required bed capacity in maternity services: results from forecast analysis on administrative data.

BACKGROUND: We examine the implications of reducing the average length of stay (ALOS) for a delivery on the required capacity in terms of service volume and maternity beds in Belgium, using administrative data covering all inpatient stays in Belgian general hospitals over the period 2003-2014. METHODS: A projection model generates forecasts of all inpatient and day-care services with a time horizon of 2025. It adjusts the observed hospital use in 2014 to the combined effect of three evolutions: the change in population size and composition, the time trend evolution of ALOS, and the time trend evolution of the admission rates. In addition, we develop an alternative scenario to evaluate the impact of an accelerated reduction of ALOS. RESULTS: Between 2014 and 2025, we expect the number of deliveries to increase by 4.41%, and the number of stays in maternity services by 3.38%. At the same time, a reduction in ALOS is projected for all types of deliveries. The required capacity for maternity beds will decrease by 17%. In case of an accelerated reduction of the ALOS to reach international standards, this required capacity for maternity beds will decrease by more than 30%. CONCLUSIONS: Despite an expected increase in the number of deliveries, future hospital capacity in terms of maternity beds can be considerably reduced in Belgium, due to the continuing reduction of ALOS.

Evolving trends in the surgical management of renal masses over the past two decades: A contemporary picture from a large prospectively-maintained database.

OBJECTIVES: To investigate the trends in the presentation and surgical management of renal tumors at Singapore General Hospital, Singapore. METHODS: We accessed our uro-oncological registry to extract the clinicopathological data of patients with renal tumors who underwent nephrectomy from 2000 to 2015. Binary logistic regression was used to identify predictors of nephron-sparing surgery utilization, Clavien-Dindo grade ≥III complications and progression to stage ≥3 chronic kidney disease. Cox regression models were created to evaluate the proportional hazards of the risk factors for overall survival and cancer-specific survival. RESULTS: A total of 1208 cases of nephrectomy were carried out between 2000 and 2015. The proportion of cT1a tumors increased from 2000-2004 to 2010-2015, which was accompanied by the doubling of utilization rates of nephron-sparing surgery and minimally invasive surgery. Charlson Comorbidity Index score <2, asymptomatic presentation, clinical T1a tumors and having an estimated glomerular filtration rate ≥30 mL/min/1.73 m2 were all independent predictors of nephron-sparing surgery utilization. Age, symptomatic presentation and nephron-sparing surgery utilization were all significantly associated with greater odds of having Clavien-Dindo grade ≥III complications, whereas minimally invasive surgery was associated with decreased risk. The utilization of partial nephrectomy and minimally invasive surgery was significantly associated with a decreased risk of developing postoperative stage ≥3 chronic kidney disease. Both overall survival and cancer-specific survival were not significantly affected by whether nephron-sparing surgery was utilized. CONCLUSIONS: There has been an increasing proportion of small renal masses diagnosed incidentally with a shift towards nephron-sparing surgery for clinically localized tumors. With the adoption of nephron-sparing surgery, progression to stage 3 chronic kidney disease has decreased, without any compromise in oncological and survival outcomes.

Making a bridge between general hospital and specialised community-based treatment for alcohol use disorder-A pragmatic randomised controlled trial.

AIM: To investigate if more patients in the intervention group attended specialized alcohol treatment compared with a treatment-as-usual group (TAU). METHODS: Pragmatic randomized controlled trial where consecutive patients, admitted to somatic hospitals, filled out a lifestyle questionnaire with the Alcohol Use Disorder Identification Test (AUDIT) embedded. Patients scoring 8+ on AUDIT were included in the study. Included patients were randomized to either a Danish screening brief intervention and referral to treatment (SBIRT) called the Relay model or TAU depending on date of admission. The Relay group was offered a brief alcohol intervention by an outreach alcohol therapist. Patients scoring 16 points and above on the AUDIT test also received referral to alcohol treatment. Outcome was attendance at specialized outpatient alcohol treatment centres after discharge from hospital. Information on patients was gathered from municipal databases at 18 months follow-up. RESULTS: A total of 3534 patients completed the questionnaire, and 609 patients (17%) scored AUDIT 8+. 48 patients were lost to follow-up, and the final sample had 561 patients. Only 33 patients (6%) attended outpatient treatment at 18-months follow-up, but significantly more patients in the Relay group sought alcohol treatment than in the TAU group (OR = 2.5 [1.2;5.2] (p = 0.017)). Number needed to treat (NNT) was 20 [95% CI 11.2;112.3]. CONCLUSION: The Relay intervention was associated with more patients attending specialized treatment, but further research is needed to establish if general hospitals are an excellent platform for performing SBIRT.

Crohn's & Colitis Australia inflammatory bowel disease audit: measuring the quality of care in Australia.

BACKGROUND: Australia has among the highest prevalence of Crohn disease and ulcerative colitis in the world. Management of the chronic gastrointestinal disorders results in significant societal costs and the standard of care is inconsistent across Australia. AIM: To audit the quality of care received by patients admitted for inflammatory bowel disease (IBD) across Australia against national IBD standards. METHODS: A retrospective cross-sectional survey and clinical audit was undertaken assessing organisational resources, clinical processes and outcome measures. This study was conducted in Australian hospitals that care for inpatients with Crohn disease or ulcerative colitis. The main outcome measures were adherence to national IBD standards and comparison of quality of care between hospitals with and without multidisciplinary IBD services. RESULTS: A total of 71 hospitals completed the organisational survey. Only one hospital had a complete multidisciplinary IBD service and 17 had a partial IBD service (IBD nurse, helpline and clinical lead). A total of 1440 inpatient records was reviewed from 52 hospitals (mean age 37 years; 51% female, 53% Crohn disease), approximately 26% of IBD inpatient episodes over a 12-month period in Australia. These patients were chronically unwell with high rates of anaemia (30%) and frequent readmissions (40% within 2 years). In general, care was inconsistent, and documentation was poor. Hospitals with a partial IBD service performed better in many processes and outcome measures: for example, 22% reduction in admissions through emergency departments and greater adherence to standards for safety monitoring of biological (89% vs 59%) and immunosuppressive drugs (79% vs 55%) in those hospitals than those without. CONCLUSION: Patients admitted to hospital suffering from IBD are young, chronically unwell and are subject to substantial variations in clinical documentation and quality of care. Only one hospital met accepted standards for multidisciplinary care; hospitals with even a minimal IBD service provided improved care.

Trends and Drivers of Inpatient Antibiotic Consumption among 89 China Tertiary General Hospitals from 2011Q1 to 2015Q4.

Antibacterial surveillance is an essential measure for strengthening the management of clinical antibiotic use. This study aimed to determine the trends and drivers of inpatient antibiotic consumption in China. A sample of 89 hospitals with complete data from 2011Q1 to 2015Q4 was included. Accumulative defined daily doses (DDDs), antibiotic use density (AUD), and drug variety were calculated to evaluate antibiotic consumption. From 2011Q1 to 2015Q4, the median values of DDDs, AUD, and drug variety dropped by 10.49%, 39.19%, and 27.96%, respectively. Panel regression results showed, for each additional quarter, DDDs reduced by 6.714 DDDs, AUD reduced by 0.013 DDDs per 100 inpatients per day, and drug variety reduced by 0.012 types (p < 0.001). National hospitals were more likely to use antibiotics, with the highest number of DDDs (106 709 DDDs) and AUD (60 DDDs per 100 inpatients per day) and a large number of drug variety (71 types of drug) all reported from national hospitals. Overall, a downward trend of inpatient antibiotic consumption was observed in competitive tertiary general hospitals in China. However, antibiotic use in China, especially in national hospitals, continues to exceed the guidelines set forth by the nationwide antibiotic stewardship program. China must continue to improve surveillance of antibiotic consumption by constructing a more comprehensive, continuous, and targeted stewardship program. Policy interventions in China should be made in consideration of unbalanced regional development and the consequences this may have on antibiotic consumption.

Gender differences in the prevalence and clinical correlates of sleep disturbance in general hospital outpatients.

This study investigated gender differences in the prevalence of sleep disturbance and related demographic and clinical characteristics, including quality of life (QOL), in Chinese outpatients. Up to 4399 adult outpatients (2896 females, 1503 males) who visited the neurological, cardiovascular, gastrointestinal, and gynaecological outpatient clinics in four general hospitals were recruited. Demographic and clinical data including QOL were collected by using self-report questionnaires. The prevalence of sleep disturbance in female outpatients (671/2896, 23.2%) was significantly higher than in male outpatients (302/1503, 20.1%) and remained significant after adjusting for significant confounders in the regression analysis. In the regression analysis, divorced/widowed and unemployed status were independently associated with a higher frequency of sleep disturbance in females, while educational level was independently associated with males only. Among these factors, depressive symptoms and older age were the most common risk factors for sleep disturbance in both genders. Sleep disturbance was not associated with the mental domains of the QOL assessments in both genders. This study suggests that sleep disturbance is more frequent in female outpatients and is associated with multiple factors in both genders. A longitudinal study is warranted to confirm the current findings.

Prevalence of insomnia symptoms and their associated factors in patients treated in outpatient clinics of four general hospitals in Guangzhou, China.

BACKGROUND: Data on the prevalence of insomnia symptoms in medical outpatient clinics in China are lacking. This study examined the prevalence of insomnia symptoms and their socio-demographic correlates in patients treated at medical outpatient clinics affiliated with four general hospitals in Guangzhou, a large metropolis in southern China. METHOD: A total of 4399 patients were consecutively invited to participate in the study. Data on insomnia and its socio-demographic correlates were collected with standardized questionnaires. RESULTS: The prevalence of any type of insomnia symptoms was 22.1% (95% confidence interval (CI): 20.9-23.3%); the prevalence of difficulty initiating sleep was 14.3%, difficulty maintaining sleep was 16.2%, and early morning awakening was 12.4%. Only 17.5% of the patients suffering from insomnia received sleeping pills. Multiple logistic regression analysis revealed that male gender, education level, rural residence, and being unemployed or retired were negatively associated with insomnia symptoms, while lacking health insurance, older age and more severe depressive symptoms were positively associated with insomnia symptoms. CONCLUSIONS: Insomnia symptoms are common in patients attending medical outpatient clinics in Guangzhou. Increasing awareness of sleep hygiene measures, regular screening and psychosocial and pharmacological interventions for insomnia are needed in China. TRIAL REGISTRATION: ChiCTR-INR-16008066 . Registered 8 March 2016.

Inappropriate anticholinergic drugs prescriptions in older patients: analysing a hospital database.

Background Although many anticholinergics are inappropriate in older patients, the prescription of these drugs in a hospital setting has not been extensively studied. Objective To describe prescriptions of anticholinergic drugs in terms of frequency, at risk situations and constipation in hospitalized, older adults. Setting Using a database from a French general hospital (period 2009-2013), we extracted information on 14,090 hospital stays by patients aged 75 and over. Methods Anticholinergic drug prescriptions were automatically detected, with a focus on prescriptions in three well-known at-risk situations: falls, dementia, and benign prostatic hyperplasia. Cases of constipation that might have been causally related to the administration of anticholinergic drugs were screened for and reviewed. Main outcome measure Prescriptions with a high associated risk of anticholinergic related adverse reactions. Results Administration of an anticholinergic drug was detected in 1412 (10.0%) of the hospital stays by older patients. At-risk situations were identified in 413 (36.5%) of these stays: 137 (9.7%) for falls, 243 (17.2%) for dementia, and 114 (8.1%) for benign prostatic hyperplasia; 78 (18.9%) of these 413 stays featured a combination of two or three at-risk situations. Cases of constipation induced by anticholinergic drug administration were identified in 188 (13.3%) patient stays by using validated adjudication rules for adverse drug reactions: 85 and 103 cases were respectively evaluated as "possible" or "probable" adverse drug reactions. Conclusions Anticholinergic drugs prescription was found in 10.0% of hospitalized, older patients. More than one third of these prescriptions occurred in at-risk situations and more than one in ten prescriptions induced constipation.

Variation in the Echocardiographic Surveillance of Primary Mitral Regurgitation.

BACKGROUND: Clinical outcomes after surgical treatment of mitral regurgitation are worse if intervention occurs after deterioration of left ventricular size and function. Transthoracic echocardiographic (TTE) surveillance of patients with mitral regurgitation is indicated to avoid adverse ventricular remodeling. Overly frequent TTEs can impair patient access and reduce value in care delivery. This balance between timely surveillance and overutilization of TTE in valvular disease provides a model to study variation in the delivery of healthcare services. We investigated patient and provider factors contributing to variation in TTE utilization and hypothesized that variation was attributable to provider practice even after adjustment for patient characteristics. METHODS AND RESULTS: We obtained records of all TTEs from 2001 to 2016 completed at a large echocardiography laboratory. The outcome variable was time interval between TTEs. We constructed a mixed-effects linear regression model with the individual physician as the random effect in the model and used intraclass correlation coefficient to assess the proportion of outcome variation because of provider practice. Our study cohort was 55 773 TTEs corresponding to 37 843 intervals ordered by 635 providers. The mean interval between TTEs was 12.4 months, 17.0 months, 18.3 months, and 17.4 months for severe, moderate, mild, and trace mitral regurgitation, respectively, with 20% of providers deemed overutilizers of TTEs and 25% underutilizers. CONCLUSIONS: We conclude that there is substantial variation in follow-up intervals for TTE assessment of mitral regurgitation, despite risk-adjustment for patient variables, likely because of provider factors.