Treatment guidelines and early loss from care for people living with HIV in Cape Town, South Africa: A retrospective cohort study.

BACKGROUND: South Africa has undergone multiple expansions in antiretroviral therapy (ART) eligibility from an initial CD4+ threshold of ≤200 cells/µl to providing ART for all people living with HIV (PLWH) as of September 2016. We evaluated the association of programmatic changes in ART eligibility with loss from care, both prior to ART initiation and within the first 16 weeks of starting treatment, during a period of programmatic expansion to ART treatment at CD4+ ≤ 350 cells/µl. METHODS AND FINDINGS: We performed a retrospective cohort study of 4,025 treatment-eligible, non-pregnant PLWH accessing care in a community health center in Gugulethu Township affiliated with the Desmond Tutu HIV Centre in Cape Town. The median age of participants was 34 years (IQR 28-41 years), almost 62% were female, and the median CD4+ count was 173 cells/µl (IQR 92-254 cells/µl). Participants were stratified into 2 cohorts: an early cohort, enrolled into care at the health center from 1 January 2009 to 31 August 2011, when guidelines mandated that ART initiation required CD4+ ≤ 200 cells/µl, pregnancy, advanced clinical symptoms (World Health Organization [WHO] stage 4), or comorbidity (active tuberculosis); and a later cohort, enrolled into care from 1 September 2011 to 31 December 2013, when the treatment threshold had been expanded to CD4+ ≤ 350 cells/µl. Demographic and clinical factors were compared before and after the policy change using chi-squared tests to identify potentially confounding covariates, and logistic regression models were used to estimate the risk of pre-treatment (pre-ART) loss from care and early loss within the first 16 weeks on treatment, adjusting for age, baseline CD4+, and WHO stage. Compared with participants in the later cohort, participants in the earlier cohort had significantly more advanced disease: median CD4+ 146 cells/µl versus 214 cells/µl (p < 0.001), 61.1% WHO stage 3/4 disease versus 42.8% (p < 0.001), and pre-ART mortality of 34.2% versus 16.7% (p < 0.001). In total, 385 ART-eligible PLWH (9.6%) failed to initiate ART, of whom 25.7% died before ever starting treatment. Of the 3,640 people who started treatment, 58 (1.6%) died within the first 16 weeks in care, and an additional 644 (17.7%) were lost from care within 16 weeks of starting ART. PLWH who did start treatment in the later cohort were significantly more likely to discontinue care in <16 weeks (19.8% versus 15.8%, p = 0.002). After controlling for baseline CD4+, WHO stage, and age, this effect remained significant (adjusted odds ratio [aOR] = 1.30, 95% CI 1.09-1.55). As such, it remains unclear if early attrition from care was due to a "healthy cohort" effect or to overcrowding as programs expanded to accommodate the broader guidelines for treatment. Our findings were limited by a lack of generalizability (given that these data were from a single high-volume site where testing and treatment were available) and an inability to formally investigate the effect of crowding on the main outcome. CONCLUSIONS: Over one-quarter of this ART-eligible cohort did not achieve the long-term benefits of treatment due to early mortality, ART non-initiation, or early ART discontinuation. Those who started treatment in the later cohort appeared to be more likely to discontinue care early, and this outcome appeared to be independent of CD4+ count or WHO stage. Future interventions should focus on those most at risk for early loss from care as programs continue to expand in South Africa.

Vascular access type, inflammatory markers, and mortality in incident hemodialysis patients: the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study.

BACKGROUND: Few reports have shown an association between access type and inflammatory marker levels in a longitudinal cohort. We investigated the role of access type on serial levels of inflammatory markers and the role of inflammatory markers in mediating the association of access type and risk of mortality in a prospective study of incident dialysis patients. STUDY DESIGN: Cohort study, post hoc analysis of the CHOICE (Choices for Healthy Outcomes in Caring for ESRD) Study. SETTING & PARTICIPANTS: In 583 participants, inflammation was assessed by measuring serum C-reactive protein (CRP) and interleukin 6 (IL-6) after access placement and at multiple times during 3 years' follow-up. Type of access was categorized as central venous catheter (CVC), arteriovenous graft (AVG), and arteriovenous fistula (AVF), and changes over time were recorded. PREDICTOR: Access type, age, sex, race, body mass index, diabetes, cardiovascular disease, and serum albumin level. OUTCOMES: CRP level, IL-6 level, and mortality. MEASUREMENTS: We used mixed-effects pattern mixture models to study the association between access type and repeated measurements of inflammation and survival analysis to investigate the association of access type and mortality, adjusting for predictors. RESULTS: In a mixed-effects pattern mixture model, compared with AVFs, the presence of CVCs and AVGs was associated with 62% (P=0.02) and 30% (P=0.05) increases in average CRP levels, respectively. A Cox proportional hazards model yielded nonsignificant associations of CVC and AVG use (vs AVFs) with risk of mortality when adjusted for inflammatory marker levels. Higher CRP levels were associated with increased risk of CVC failure than lower CRP levels. LIMITATIONS: CRP and IL-6 measurements not performed for all hemodialysis patients. CONCLUSIONS: CVCs, compared with AVFs, are associated with a greater state of inflammation in incident hemodialysis patients, and the association of catheter use and mortality may be mediated by access-induced inflammation. Our findings support recommendations for the early removal or avoidance of CVC placements.

Natural course of care dependency in residents of long-term care facilities: prospective follow-up study.

BACKGROUND: Insight in the natural course of care dependency of vulnerable older persons in long-term care facilities (LTCF) is essential to organize and optimize individual tailored care. We examined changes in care dependency in LTCF residents over two 6-month periods, explored the possible predictive factors of change and the effect of care dependency on mortality. METHODS: A prospective follow-up study in 21 Dutch long-term care facilities. 890 LTCF residents, median age 84 (Interquartile range 79-88) years participated. At baseline, 6 and 12 months, care dependency was assessed by the nursing staff with the Care Dependency Scale (CDS), range 15-75 points. Since the median CDS score differed between men and women (47.5 vs. 43.0, P = 0.013), CDS groups (low, middle and high) were based on gender-specific 33% of CDS scores at baseline and 6 months. RESULTS: At baseline, the CDS groups differed in median length of stay on the ward, urine incontinence and dementia (all P < 0.001); participants in the low CDS group stayed longer, had more frequent urine incontinence and more dementia. They had also the highest mortality rate (log rank 32.2; df = 2; P for trend <0.001). Per point lower in CDS score, the mortality risk increased with 2% (95% CI 1%-3%). Adjustment for age, gender, cranberry use, LTCF, length of stay, comorbidity and dementia showed similar results. A one point decrease in CDS score between 0 and 6 months was related to an increased mortality risk of 4% (95% CI 3%-6%).At the 6-month follow-up, 10% improved to a higher CDS group, 65% were in the same, and 25% had deteriorated to a lower CDS group; a similar pattern emerged at 12-month follow-up. Gender, age, urine incontinence, dementia, cancer and baseline care dependency status, predicted an increase in care dependency over time. CONCLUSION: The majority of residents were stable in their care dependency status over two subsequent 6-month periods. Highly care dependent residents showed an increased mortality risk. Awareness of the natural course of care dependency is essential to residents and their formal and informal caregivers when considering therapeutic and end-of-life care options.

Socioeconomic status and the likelihood of informal care provision in Japan: An analysis considering survival probability of care recipients.

Studies show that the burden of caregiving tends to fall on individuals of low socioeconomic status (SES); however, the association between SES and the likelihood of caregiving has not yet been established. We studied the relationship between SES and the likelihood of adults providing long-term care for their parents in Japan, where compulsory public long-term insurance has been implemented. We used the following six comprehensive measures of SES for the analysis: income, financial assets, expenditure, living conditions, housing conditions, and education. We found that for some SES measures the probability of care provision for parents was greater in higher SES categories than in the lowest category, although the results were not systematically related to the order of SES categories or consistent across SES measures. The results did not change even after the difference in the probability of parents' survival according to SES was considered. Overall, we did not find evidence that individuals with lower SES were more likely to provide care to parents than higher-SES individuals. Although a negative association between SES and care burden has been repeatedly reported in terms of care intensity, the caregiving decision could be different in relation to SES. Further research is necessary to generalize the results.

Sistema de clasificación en emergencias - Escala canadiense de clasificación y severidad relacionado con aumento en fallecimientos en un hospital general / Emergency Classification System - CTAS is related to an increase in deaths in a tertiary hospital

Resumen Objetivo. El sistema de clasificación en servicios de emergencias fue implementado en todos los servicios de emergencias de la Caja Costarricense de Seguro Social alrededor del 2015, a pesar de que su utilidad y veracidad han sido cuestionadas. El presente estudio pretende establecer si existe una relación entre cambios en la cantidad de fallecimientos y en la mortalidad con la implementación de la Escala Canadiense de Clasificación y Severidad en los servicios de emergencias. Métodos. Se obtuvieron los registros correspondientes a las atenciones del Servicio de Emergencias del 2008 al 2022. Se realizó la comparación de los registros previos y posteriores a la implementación de la Escala Canadiense de Clasificación y Severidad en marzo del 2015. En total se tomaron en cuenta los datos referentes a 1 351 091 consultas, de las cuales 733 318 se dieron antes de la implementación de la escala canadiense de clasificación y severidad. Se compararon ambas poblaciones con respecto a tendencias temporales en fallecimientos, estancias en el servicio antes del fallecimiento, mortalidad y la relación entre fallecimientos y hora-paciente mensuales. Resultados. Se encontró un aumento significativo en los fallecimientos con la implementación de la Escala Canadiense de Clasificación y Severidad en un 19,8 % (p<0,001). La mortalidad en el servicio de emergencias mostró un aumento continuo desde el 2012. Sin embargo, una normalización del número de atenciones permitió observar un aumento de la mortalidad posterior, pero no previo a la implementación de la Escala Canadiense de Clasificación y Severidad (p<0,02). Por su parte, la cuantía de fallecimientos mensuales no ha mostrado relacionarse con cuantía de atenciones mensuales ni con hora-pacientes mensuales. Conclusión. La implementación de la Escala Canadiense de Clasificación y Severidad en el servicio de emergencias de un hospital de tercer nivel en Costa Rica se relacionó con un aumento en los fallecimientos, sin estar relacionado con indicadores de plétora del servicio.

Abstract Aim: The classification system in emergency rooms was implemented in all the emergency services of the Caja Costarricense de Seguro Social around 2015, despite the fact that its usefulness and veracity have been questioned. The present study aimed to establish changes in the number of deaths and in mortality with the implementation of the Canadian Triage and Severity Scale. Methods: The records corresponding to the attentions of the Emergency Service from 2008 to 2022 were obtained and comparisons were made of the records before and after the implementation of the Canadian Triage and Severity Scale in March 2015. In total, the data referring to 1,351,091 consultations were taken into account, of which 733,318 occurred before the implementation of the scale. Both populations were compared with respect to temporal trends in deaths, stays in the service before death, mortality, and the relationship between deaths and monthly patient-hours. Results: A significant increase in deaths was found after the implementation of the Canadian Triage and Severity Scale by 19.8% (p<0.001). Mortality showed a continuous increase since 2012, however a normalization of the number of visits allowed us to observe an increase in mortality after but not before the implementation of the scale (p<0.02). The number of monthly deaths has not been shown to be related to the amount of monthly consults or monthly patient-hours. Conclusions: The implementation of the Canadian Triage and Severity Scale in the emergency room of a third level hospital in Costa Rica was related in the present study to an increase in deaths, without being related to indicators of service plethora.

The In-Hospital Length of Stay after Hip Fracture in Octogenarians: Do Delirium and Dementia Shape a New Care Process?

BACKGROUND: Hip fracture is a major health problem and a patient's biological age, comorbidity, and cognitive vulnerability have an impact on its related outcomes. Length of stay (LOS) for these highly vulnerable patients is rather long and the possible causes have not been clearly identified yet. OBJECTIVE: We aimed to assess the main clinical factors associated with protracted LOS, focusing on delirium with or without dementia in older age hip fractured patients. METHODS: 218 subjects (mean age 86.70±6.18 years), admitted to the Orthogeriatric Unit of the Ospedale Policlinico San Martino (Italy), were recruited. All patients received physical and comprehensive geriatric assessment. Days to surgery, days from surgery to rehabilitation, and LOS were recorded. In-hospital and three months' mortality were reported. RESULTS: Prevalent delirium at hospital admission was of 3.1%. 35% of patients developed incident delirium. 56.4% were affected by dementia of Alzheimer-type. In addition, 52% of patients developed delirium superimposed to dementia. Mean LOS was 13.5±4.99 days. Namely, delirium, time to surgery, and complication rate disproportionally affected LOS. The analysis with 3 months mortality, based on cognitive vulnerability profiles, showed how delirium mainly affect short-term mortality in patients with dementia. CONCLUSION: Our exploratory study originally pointed out the high incidence of delirium superimposed to dementia in orthogeriatric wards and how delirium turns to be a moderator of LOS. The results meet the need for additional research by virtue of a deeper understanding of the impact of delirium and dementia on orthogeriatric clinical management and outcomes.

[Hospital at home: assessment of early discharge in terms of patients mortality and satisfaction]. / L'ospedalizzazione a domicilio: valutazione della dimissione precoce in termini di mortalità e soddisfazione dei pazienti.

New organizational models are essentials for European Hospitals because of restraining budget and ageing of population. Hospital at home is an alternative to inpatient care, effective both in clinical and economic ground. The aim of our study was to evaluate the impact of Hospital at Home in terms of decreased mortality and patient satisfaction. We carried out a meta-analysis of the literature about hospital at home interventions. We searched Medline (to December 2002), the Cochrane Controlled Trials Register (to October 2002) and other bibliographical databases, with a supplementary handsearching of literature. We used the following keywords: hospital at home, home hospitalization, mortality, patient satisfaction, cost, acute hospital care, conventional hospitalization. We included studies respecting the following criteria: analytical or experimental studies aimed at compare early discharge to hospital at home and continued care in an acute hospital. Review Manager 4.2 software was used to collect data and perform statistical analysis. We found 2420 articles searching for the chosen keywords. Twelve studies (2048 patients) were included for death outcome and six studies (1382 patients) were included for satisfaction outcome. The selected studies indicated a greater effect size of patient satisfaction in home patients than hospitalized ones (Odds Ratio: 1.58 95% CI: 1.25, 2.00) and showed no difference in terms of mortality (Risk Difference: -0.01 95% CI: -0.03, 0.02). Our results underline the effectiveness of this organizational model, as an alternative to continued care in an acute hospital. Further useful considerations could be drawn by economic evaluation studies carried out on field.

Admission-time-dependent variation in mortality in a Danish emergency department.

INTRODUCTION: The inflow of patients in emergency departments (ED) varies over time. If variations are not anticipated, accumulation of patients and treatment delay may occur. This may trigger adverse events causing excess mortality. The aim of this study was to determine if attending the ED after hours and during weekends was associated with an increased mortality. METHODS: We examined the medical records of 5,385 patients. Data were retrieved from the Electronic Patient Journal, the Danish National Patient Registry and the Danish Civil Registration System. Multinomial logistic regression and Cox regression were performed to analyse the associations between attendance time and mortality. RESULTS: The inflow of patients differed over the hours of the day and the days of the week. The findings tended towards a higher mortality for patients attending the ED during the evening shift than during the dayshifts, and during weekends than during weekdays. Patients attending the ED during the night shift had no excess mortality compared with the dayshifts. The combination of evening shift and weekday and the combination of dayshift and weekend reached significance. Associations with mortality were strongest for in-hospital mortality. CONCLUSIONS: Indications of excess mortality were found for patients attending in the weekend compared with weekdays and in the evening hours compared with night and daytime hours. The causal mechanism is unknown. FUNDING: none. TRIAL REGISTRATION: not relevant.

Integrated systems of stroke care and reduction in 30-day mortality: A retrospective analysis.

OBJECTIVE: To evaluate the association between the presence of integrated systems of stroke care and stroke case-fatality across Canada. METHODS: We used the Canadian Institute of Health Information's Discharge Abstract Database to retrospectively identify a cohort of stroke/TIA patients admitted to all acute care hospitals, excluding the province of Quebec, in 11 fiscal years from 2003/2004 to 2013/2014. We used a modified Poisson regression model to compute the adjusted incidence rate ratio (aIRR) of 30-day in-hospital mortality across time for provinces with stroke systems compared to those without, controlling for age, sex, stroke type, comorbidities, and discharge year. We conducted surveys of stroke care resources in Canadian hospitals in 2009 and 2013, and compared resources in provinces with integrated systems to those without. RESULTS: A total of 319,972 patients were hospitalized for stroke/TIA. The crude 30-day mortality rate decreased from 15.8% in 2003/2004 to 12.7% in 2012/2013 in provinces with stroke systems, while remaining 14.5% in provinces without such systems. Starting with the fiscal year 2009/2010, there was a clear reduction in relative mortality in provinces with stroke systems vs those without, sustained at aIRR of 0.85 (95% confidence interval 0.79-0.92) in the 2011/2012, 2012/2013, and 2013/2014 fiscal years. The surveys indicated that facilities in provinces with such systems were more likely to care for patients on a stroke unit, and have timely access to a stroke prevention clinic and telestroke services. CONCLUSION: In this retrospective study, the implementation of integrated systems of stroke care was associated with a population-wide reduction in mortality after stroke.

Mortality predictions on admission as a context for organizing care activities.

BACKGROUND: Favorable health outcomes are more likely to occur when the clinical team recognizes patients at risk and intervenes in consort. Prediction rules can identify high-risk subsets, but the availability of multiple rules for various conditions present implementation and assimilation challenges. METHODS: A prediction rule for 30-day mortality at the beginning of the hospitalization was derived in a retrospective cohort of adult inpatients from a community hospital in the Midwestern United States from 2008 to 2009, using clinical laboratory values, past medical history, and diagnoses present on admission. It was validated using 2010 data from the same and from a different hospital. The calculated mortality risk was then used to predict unplanned transfers to intensive care units, resuscitation attempts for cardiopulmonary arrests, a condition not present on admission (complications), intensive care unit utilization, palliative care status, in-hospital death, rehospitalizations within 30 days, and 180-day mortality. RESULTS: The predictions of 30-day mortality for the derivation and validation datasets had areas under the receiver operating characteristic curve of 0.88. The 30-day mortality risk was in turn a strong predictor for in-hospital death, palliative care status, 180-day mortality; a modest predictor for unplanned transfers and cardiopulmonary arrests; and a weaker predictor for the other events of interest. CONCLUSIONS: The probability of 30-day mortality provides health systems with an array of prognostic information that may provide a common reference point for organizing the clinical activities of the many health professionals involved in the care of the patient.

Mortalidad y atención a pacientes hospitalizados durante los fines de semana / Mortality and medical care of patients hospitalized during weekends

Antecedentes y objetivos. Los pacientes hospitalizados durante los fines de semana (FS) tienen peores resultados en salud que los ingresados durante los días entre semana (NFS). El objetivo de este estudio es evaluar el impacto en la mortalidad que puede tener una atención diaria y reglada de los pacientes hospitalizados. Material y métodos. Estudio observacional retrospectivo en el Hospital de Montilla (Córdoba). En este se valora diariamente a todos los pacientes hospitalizados, incluidos los días de fin de semana y los festivos. Analizamos variables epidemiológicas y mortalidad. Resultados. Incluimos 2.565 episodios de ingresos, de los que fueron dados de alta en FS 653 (25,6%). Los pacientes dados de alta en FS eran significativamente más jóvenes respecto a los NFS [53 (27) frente a 56 (27) años, p<0,002)], contaban con menos diagnósticos al alta [(6,2 (3,7) frente a 6,7 (3,9), p<0,003] y se les había realizado menos procedimientos [(3 (1,9) frente a 3,2 (1,8), p<0,005]. La estancia media también era significativamente menor en los pacientes dados de alta en FS frente a los de NFS [3 (2,6) días frente a 3,7 (3,9) días, p<0,001). La mortalidad global fue del 4%, no existiendo diferencias si el ingreso se producía en NFS o en FS (4,3% frente a 3,7%). Las altas al domicilio llevadas a cabo en fin de semana conllevaron una reducción de la estancia media en 0,3 días (de 3,6 a 3,9 días, p<0,001). Conclusiones. La atención a pacientes hospitalizados hace desaparecer el exceso de mortalidad durante los fines de semana (AU)

Background and objectives. It has been shown that patients admitted to hospital during the weekends tend to have less favourable outcomes, including higher mortality rates, compared with those admitted during weekdays. The main objective of this study is to evaluate the impact of on the health outcomes of patients admitted during the weekend. Material and methods. A retrospective observational study was conducted on all patients admitted to Montilla Hospital (Córdoba).. All hospitalised patients were attended to daily, including weekends and holidays. An analysis was performed on the epidemiological variables and health outcomes (total mortality). Results. The study included a total of 2,565 hospital admissions, of whom 653 (25.6%) were discharged during the weekend. Patients discharged during the weekend were significantly younger [53 (27) versus 56 (27) years, P<.002], had fewer diagnoses on discharge [6.2 (3.7) versus 6.7 (3.9), P<.003], and had fewer procedures performed [(3 (1.9) versus 3.2 (1.8), P<.005]. The mean length of stay was shorter for weekend discharges than the weekday discharges [3 (2.6) days versus 3.7 (3.9) days, P<.001). The total mortality was 4%, and there were no differences between weekday and weekend admissions (4.3% versus 3.7%). Home discharges on the weekend were related to a reduction in the mean length of stay by 0.3 days (from 3.6 to 3.9 days, P<.001). Conclusions. Hospitalised patient care has led to the disappearance of increased mortality during weekends (AU)

Patient safety and quality of care continue to improve in NHS North West following early implementation of the European Working Time Directive.

OBJECTIVES: NHS North West aimed to fully implement the European Working Time Directive (EWTD) 1 year ahead of the August 2009 national deadline. Significant debate has taken place concerning the implications of the EWTD for patient safety. This study aims to directly address this issue by comparing parameters of patient safety in NHS North West to those nationally prior to EWTD implementation, and during 'North West-only' EWTD implementation. DESIGN: Hospital standardised mortality ratio (HSMR), average length of stay (ALOS) and standardised readmission rate (SRR) in acute trusts across all specialties were calculated retrospectively throughout NHS North West for the three financial years from 2006/2007 to 2008/2009. These figures were compared to national data for the same parameters. RESULTS: The analysis of HSMR, ALOS and SRR reveal no significant difference in trend across three financial years when NHS North West is compared to England. HSMR and SRR within NHS North West continued to improve at a similar rate to the England average after August 2008. The ALOS analysis shows that NHS North West performed better than the national average for the majority of the study period, with no significant change in this pattern in the period following August 2008. When the HSMRs for NHS North West and England are compared against a fixed benchmark year (2005), the data shows a continuing decrease. The NHS North West figures follow the national trend closely at all times. CONCLUSION: The data presented in this study quantitatively demonstrates, for the first time, that implementation of the EWTD in NHS North West in August 2008 had no obvious adverse impact on key outcomes associated with patient safety and quality of care. Continued efforts will be required to address the challenge posed nationally by the restricted working hour's schedule.

The concentration of hospital care for black veterans in Veterans Affairs hospitals: implications for clinical outcomes.

Where minorities receive their care may contribute to disparities in care, yet, the racial concentration of care in the Veterans Health Administration is largely unknown. We sought to better understand which Veterans Affairs (VA) hospitals treat Black veterans and whether location of care impacted disparities. We assessed differences in mortality rates between Black and White veterans across 150 VA hospitals for any of six conditions (acute myocardial infarction, hip fracture, stroke, congestive heart failure, gastrointestinal hemorrhage, and pneumonia) between 1996 and 2002. Just 9 out of 150 VA hospitals (6% of all VA hospitals) cared for nearly 30% of Black veterans, and 42 hospitals (28% of all VA hospitals) cared for more than 75% of Black veterans. While our findings show that overall mortality rates were comparable between minority-serving and non-minority-serving hospitals for four conditions, mortality rates were higher in minority-serving hospitals for acute myocardial infarction (AMI) and pneumonia. The ratio of mortality rates for Blacks compared with Whites was comparable across all VA hospitals. In contrast to the private sector, there is little variation in the degree of racial disparities in 30-day mortality across VA hospitals, although higher mortality among patients with AMI and pneumonia requires further investigation.

Nationwide patterns of hospitalizations to centers with high volume of admissions for inflammatory bowel disease and their impact on mortality.

BACKGROUND: We sought to determine patterns of hospitalizations for inflammatory bowel disease (IBD) to centers that regularly admit high volumes of IBD patients and whether they impacted health outcomes. METHODS: We queried US hospital discharges in the Nationwide Inpatient Sample to identify admissions with a primary diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) between 1998 and 2004. We determined patterns and predictors of hospitalization at high IBD volume admission centers (HIVACs) (>or=145 IBD admissions annually) and assessed their impact on mortality. RESULTS: Over 7 years the proportion of patients admitted to HIVACs increased from 2.3% to 14.8%. IBD patients were less likely to be admitted to an HIVAC if they were insured by Medicare (odds ratio [OR] 0.74; 95% confidence interval [CI]: 0.65-0.83) or Medicaid (OR 0.71; 95% CI: 0.60-0.84), or were uninsured (OR 0.42; 95% CI: 0.30-0.58) compared with those privately insured. Neighborhood income above the national median favored admission to an HIVAC (OR 1.99; 95% CI: 1.46-2.71). In-hospital mortality was lower among HIVACs compared to non-HIVACs (3.5/1000 versus 7.2/1000, P < 0.0001) and was persistent after adjustment for surgery status, age, comorbidity, and health insurance (OR 0.65; 95% CI: 0.49-0.87). When stratified by diagnosis, mortality was reduced at HIVACs among CD (OR 0.58; 95% CI: 0.37-0.90) but not UC admissions. CONCLUSIONS: There is a rising trend in hospitalizations for IBD at HIVACs, which confers mortality benefit for those with CD. Prospective studies are warranted to further explore the impact of these high-volume centers on IBD health outcomes.

Estado nutricional del paciente críticamente enfermo: implicación en mortalidad / Nutritional status of the critically ill patient: involvement in mortality

En el paciente crítico, la malnutrición puede ser preexistente, manifestarse al ingreso o desarrollarse de forma evolutiva, favorecida por el estado hipercatabólico e hipermetabólico. Por lo que para identificar el estado nutricional del paciente existen parámetros destinado a su valoración. Sin embargo, su aplicación en los pacientes críticos es difícil, debido a la interpretación de los resultados se encuentra alterada por los cambios originados debido a la enfermedad aguda y a las medidas terapéuticas. El objetivo fue determinar si el estado nutricional es un factor pronóstico de mortalidad en el paciente críticamente enfermo...

Do turf wars kill patients?

While physicians are often heard to complain that they are overworked with a heavy patient burden, so-called turf wars lurk under the surface, wherein physicians wrangle for the ability to perform what are generally highly-remunerated and quickly-performed procedures and interventions with excellent patient outcomes. It is very possible that within such turf wars, one specialty is consistently more skilled at performing the procedure than another, and therefore patient lives may be unnecessarily lost. This article hypothesizes that such differences in skills do exist between specialties and proposes a study to determine this.

Impacto sobre el cuidador principal de una intervención realizada a personas mayores dependientes / Impact on the primary carer of an intervention carried out on depenedent elderly people

Objetivos: Evaluar el impacto de un programa de atención domiciliaria de personas mayores dependientes sobre el cuidador principal.DiseñoEstudio de intervención «antes-después».EmplazamientoAtención primaria.ParticipantesCuidadores principales de personas dependientes mayores de 65 años incluidas en un programa de atención domiciliaria (n=156; 7,8% de pérdidas durante el seguimiento).IntervencionesPrograma de atención domiciliaria de personas mayores dependientes.Mediciones principalesSe realizó una medición basal y una evaluación al año de seguimiento. Se evaluaron la salud percibida, la frecuentación, y la satisfacción con la atención recibida, y se administraron los cuestionarios de calidad de vida de Nottingham, de salud psíquica de Golberg, de apoyo social de Duke-UNC y de sobrecarga del cuidador de Zarit).ResultadosNo se observó una modificación significativa de la salud percibida. Mejoraron (p<0,05) las esferas de energía, sueño, emocional y relación social de la calidad de vida. Disminuyó la frecuentación (8,4 vs 7,5; p<0,05) y el porcentaje de hiperfrecuentadores (30,1% vs 6,9%; p<0,01). Se redujo el porcentaje que expresan escaso apoyo social (8,3 vs 2,8%; p<0,05) y sobrecarga del cuidador (56,4 vs 44,4%; p<0,05). El 90,3% consideran que la asistencia mejoró, con mejora significativa de la asistencia recibida global, médica y de enfermería (7,6 vs 8,4; 7,9 vs 8,5 y 7 vs 8,5; p<0,05).ConclusionesLa incorporación a un programa de atención domiciliaria de personas dependientes repercute positivamente sobre su cuidador principal, mejorando su percepción sobre la asistencia recibida, reduciendo su utilización de los servicios sanitarios, disminuyendo el grado de sobrecarga y su percepción de falta de apoyo social(AU)

Objective: To evaluate the impact of joining a home care program on primary caregivers of dependent elderly people.DesignNon-randomised “before-after” intervention study.SettingPrimary Care.ParticipantsPrimary carers of elderly dependent people included in a home care program (n=156; 7.8% loss to follow up).InterventionsInclusion in a home care program for chronically dependent elderly and the assessment of the primary carer in the same year.Variables assessedperceived health, frequency of visits, questionnaires of quality of life (Nottingham questionnaire), psychological health (Goldberg questionnaire), social support (Duke-UNC scale) and overburden of caregivers (Zarit questionnaire) and satisfaction with care received.ResultsThere were no significant changes in perceived health. Improvement in the areas of energy, sleep, emotional and social relationship of the quality of life. Decreased attendance (8.4 vs. 7.5, p<0.05) and the percentage of overusers (30.1 vs 6.9%, P<.01). A reduced percentage of caregivers expressed low social support (8.3 vs 2.8%, P<.05) and caregiver overburden (56.4 vs 44.4%, P<.05). 90.3% of caregivers believed that care had improved at the end of intervention, with a significant improvement of satisfaction of overall medical and nursing care received (7.6 vs 8, 4, 7.9 vs 8.5 and 7 vs 8.5; P<.05).ConclusionsJoining a home care program for dependents has a positive impact on their primary caregiver and improves their perception of care received, reducing their use of health services, reducing the level of overburden and their perceived lack of social support(AU)