RESUMO
OBJECTIVES: We compared and validated the performance accuracy of simplified comorbidity evaluation compared to the Charlson Comorbidity Index (CCI) predicting COVID-19 severity. In addition, we also determined whether risk prediction of COVID-19 severity changed during different COVID-19 pandemic outbreaks. METHODS: We enrolled all patients whose SARS-CoV-2 PCR tests were performed at six different hospital Emergency Departments in 2020. Patients were divided into three groups based on the various COVID-19 outbreaks in the US (first wave: March-May 2020, second wave: June-September 2020, and third wave: October-December 2020). A simplified comorbidity evaluation was used as an independent risk factor to predict clinical outcomes using multivariate logistic regressions. RESULTS: A total of 22,248 patients were included, for which 7023 (32%) patients tested COVID-19 positive. Higher percentages of COVID-19 patients with more than three chronic conditions had worse clinical outcomes (i.e., hospital and intensive care unit admissions, receiving invasive mechanical ventilations, and in-hospital mortality) during all three COVID-19 outbreak waves. CONCLUSIONS: This simplified comorbidity evaluation was validated to be associated with COVID clinical outcomes. Such evaluation did not perform worse when compared with CCI to predict in-hospital mortality.
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COVID-19 , COVID-19/epidemiologia , Comorbidade , Humanos , Pandemias , Estudos Retrospectivos , SARS-CoV-2RESUMO
OBJECTIVE: To develop a novel model for predicting Emergency Department (ED) prolonged length of stay (LOS) patients upon triage completion, and further investigate the benefit of a targeted intervention for patients with prolonged ED LOS. MATERIALS AND METHODS: A two-step model to predict patients with prolonged ED LOS (>16â¯h) was constructed. This model was initially used to predict ED resource usage and was subsequently adapted to predict patient ED LOS based on the number of ED resources using binary logistic regressions and was validated internally with accuracy. Finally, a discrete event simulation was used to move patients with predicted prolonged ED LOS directly to a virtual Clinical Decision Unit (CDU). The changes of ED crowding status (Overcrowding, Crowding, and Not-Crowding) and savings of ED bed-hour equivalents were estimated as the measures of the efficacy of this intervention. RESULTS: We screened a total of 123,975 patient visits with final enrollment of 110,471 patient visits. The overall accuracy of the final model predicting prolonged patient LOS was 67.8%. The C-index of this model ranges from 0.72 to 0.82. By implementing the proposed intervention, the simulation showed a 12% (1044/8760) reduction of ED overcrowded status - an equivalent savings of 129.3 ED bed-hours per day. CONCLUSIONS: Early prediction of prolonged ED LOS patients and subsequent (simulated) early CDU transfer could lead to more efficiently utilization of ED resources and improved efficacy of ED operations. This study provides evidence to support the implementation of this novel intervention into real healthcare practice.
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Serviço Hospitalar de Emergência , Tempo de Internação/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , TriagemRESUMO
BACKGROUND: It is critical to understand whether providing health insurance coverage, assigning a dedicated Primary Care Physician (PCP), and arranging timely post-Emergency Department (ED) clinic follow-up can improve compliance with clinic visits and reduce ED discharge failures. We aim to determine the benefits of providing these common step-wise interventions and further investigate the necessity of urgent PCP referrals on behalf of ED discharged patients. METHODS: This is a single-center retrospective observational study. All patients discharged from the ED over the period Jan 1, 2015 through Dec 31, 2017 were included in the study population. Step-wise interventions included providing charity health insurance, assigning a dedicated PCP, and providing ED follow-up clinics. PCP clinic compliance and ED discharge failures were measured and compared among groups receiving different interventions. RESULT: A total of 227,627 patients were included. Fifty-eight percent of patients receiving charity insurance had PCP visits in comparison to 23% of patients without charity insurance (p < 0.001). Seventy-seven percent of patients with charity insurance and PCP assignments completed post-ED discharge PCP visits in comparison to only 4.5% of those with neither charity insurance nor PCP assignments (p < 0.001). CONCLUSIONS: Step-wise interventions increased patient clinic follow-up compliance while simultaneously reducing ED discharge failures. Such interventions might benefit communities with similar patient populations.
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Assistência Ambulatorial/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente , Melhoria de Qualidade , Estudos RetrospectivosRESUMO
OBJECTIVE: To review 10 years of clinical practice of cardiac electrophysiology study and radiofrequency catheter ablation in the treatment of supraventricular tachycardia. METHODS: The retrospective chart review was conducted at the National Institute of Cardiovascular Diseases, Karachi, and comprised records of all patients who underwent electrophysiological study and / or radiofrequency catheter ablation from January2007 to December 2016. SPSS 21 was used for data analysis. RESULTS: Of the 627 patients, 335(53.4%) were females. The overall mean age was 40.99}13.59 years. The major indication for procedure was supraventricular tachycardia 376(59.97%). Final electrophysiological study diagnosis was typical slow fast atrioventricular nodal re-entrant tachycardia in 303(48.3%) patients. The overall success rate was 472(75.3%). Procedure-related complications were reported in 25(4%) patients, and there was 1(0.15%) mortality. CONCLUSIONS: Cardiac electrophysiology studies and radiofrequency catheter ablation were found to be an effective and safe method for diagnosis and treatment of supraventricular tachycardia.
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Ablação por Cateter , Técnicas Eletrofisiológicas Cardíacas , Taquicardia por Reentrada no Nó Sinoatrial , Taquicardia Supraventricular , Síndrome de Wolff-Parkinson-White , Adulto , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Ablação por Cateter/estatística & dados numéricos , Diagnóstico Diferencial , Técnicas Eletrofisiológicas Cardíacas/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas/métodos , Técnicas Eletrofisiológicas Cardíacas/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Paquistão/epidemiologia , Taquicardia por Reentrada no Nó Sinoatrial/diagnóstico , Taquicardia por Reentrada no Nó Sinoatrial/epidemiologia , Taquicardia por Reentrada no Nó Sinoatrial/terapia , Taquicardia Supraventricular/diagnóstico , Taquicardia Supraventricular/epidemiologia , Taquicardia Supraventricular/terapia , Síndrome de Wolff-Parkinson-White/diagnóstico , Síndrome de Wolff-Parkinson-White/epidemiologia , Síndrome de Wolff-Parkinson-White/terapiaRESUMO
BACKGROUND: Prolonged hospital discharge boarding can impact patient flow resulting in upstream Emergency Department crowding. We aim to determine the risks predicting prolonged hospital discharge boarding and their direct and indirect effects on patient flow. METHODS: Retrospective review of a single hospital discharge database was conducted. Variables including type of disposition, disposition boarding time, case management consultation, discharge medications prescriptions, severity of illness, and patient homeless status were analyzed in a multivariate logistic regression model. Hospital charges, potential savings of hospital bed hours, and whether detailed discharge instructions provided adequate explanations to patients were also analyzed. RESULTS: A total of 11,527 admissions was entered into final analysis. The median discharge boarding time was approximately 2 h. Adjusted Odds Ratio (AOR) of patients transferring to other hospitals was 7.45 (95% CI 5.35-10.37), to court or law enforcement custody was 2.51 (95% CI 1.84-3.42), and to a skilled nursing facility was 2.48 (95% CI 2.10-2.93). AOR was 0.57 (95% CI 0.47-0.71) if the disposition order was placed during normal office hours (0800-1700). AOR of early case management consultation was 1.52 (95% CI 1.37-1.68) versus 1.73 (95% CI 1.03-2.89) for late consultation. Eighty-eight percent of patients experiencing discharge boarding times within 2 h of disposition expressed positive responses when questioned about the quality of explanations of discharge instructions and follow-up plans based on satisfaction surveys. Similar results (86% positive response) were noted among patients whose discharge boarding times were prolonged (> 2 h, p = 0.44). An average charge of $6/bed/h was noted in all hospital discharges. Maximizing early discharge boarding (≤ 2 h) would have resulted in 16,376 hospital bed hours saved thereby averting $98,256.00 in unnecessary dwell time charges in this study population alone. CONCLUSION: Type of disposition, case management timely consultation, and disposition to discharge dwell time affect boarding and patient flow in a tertiary acute care hospital. Efficiency of the discharge process did not affect patient satisfaction relative to the perceived quality of discharge instruction and follow-up plan explanations. Prolonged disposition to discharge intervals result in unnecessary hospital bed occupancy thereby negatively impacting hospital finances while delivering no direct benefit to patients.
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Serviço Hospitalar de Emergência/organização & administração , Hospitalização/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Adulto , Aglomeração , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Satisfação do Paciente , Estudos Retrospectivos , Fatores de RiscoRESUMO
STUDY OBJECTIVE: Emergency department (ED) crowding is a barrier to timely care. Several crowding estimation tools have been developed to facilitate early identification of and intervention for crowding. Nevertheless, the ideal frequency is unclear for measuring ED crowding by using these tools. Short intervals may be resource intensive, whereas long ones may not be suitable for early identification. Therefore, we aim to assess whether outcomes vary by measurement interval for 4 crowding estimation tools. METHODS: Our eligible population included all patients between July 1, 2015, and June 30, 2016, who were admitted to the JPS Health Network ED, which serves an urban population. We generated 1-, 2-, 3-, and 4-hour ED crowding scores for each patient, using 4 crowding estimation tools (National Emergency Department Overcrowding Scale [NEDOCS], Severely Overcrowded, Overcrowded, and Not Overcrowded Estimation Tool [SONET], Emergency Department Work Index [EDWIN], and ED Occupancy Rate). Our outcomes of interest included ED length of stay (minutes) and left without being seen or eloped within 4 hours. We used accelerated failure time models to estimate interval-specific time ratios and corresponding 95% confidence limits for length of stay, in which the 1-hour interval was the reference. In addition, we used binomial regression with a log link to estimate risk ratios (RRs) and corresponding confidence limit for left without being seen. RESULTS: Our study population comprised 117,442 patients. The time ratios for length of stay were similar across intervals for each crowding estimation tool (time ratio=1.37 to 1.30 for NEDOCS, 1.44 to 1.37 for SONET, 1.32 to 1.27 for EDWIN, and 1.28 to 1.23 for ED Occupancy Rate). The RRs of left without being seen differences were also similar across intervals for each tool (RR=2.92 to 2.56 for NEDOCS, 3.61 to 3.36 for SONET, 2.65 to 2.40 for EDWIN, and 2.44 to 2.14 for ED Occupancy Rate). CONCLUSION: Our findings suggest limited variation in length of stay or left without being seen between intervals (1 to 4 hours) regardless of which of the 4 crowding estimation tools were used. Consequently, 4 hours may be a reasonable interval for assessing crowding with these tools, which could substantially reduce the burden on ED personnel by requiring less frequent assessment of crowding.
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Aglomeração , Coleta de Dados/métodos , Precisão da Medição Dimensional , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estatística como Assunto/métodos , Adulto , Estudos de Coortes , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Valor Preditivo dos Testes , Carga de Trabalho/estatística & dados numéricosRESUMO
BACKGROUND: Schizophrenia (SCZ) is a chronic severe neuropsychiatric disorder, where pharmacological treatment has been hindered by adverse effects, including antipsychotic-induced weight gain (AIWG) and related complications. Genetic studies have been exploring the appetite regulation and energy homeostasis pathways in AIWG with some promising leads. The serotonin system has been shown to participate in these pathways. METHODS: In the current study, we examined single nucleotide polymorphisms across the serotonin receptor genes HTR3A and HTR3B. Prospective weight change was assessed for a total of 149 SCZ patients of European ancestry. RESULTS: We did not find the tested HTR3A or HTR3B gene markers to be associated with AIWG in our sample. CONCLUSION: Our preliminary findings suggest that these receptors may not play a major role in predicting AIWG.
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Antipsicóticos/efeitos adversos , Peso Corporal/efeitos dos fármacos , Predisposição Genética para Doença/genética , Receptores 5-HT3 de Serotonina/genética , Aumento de Peso/efeitos dos fármacos , Aumento de Peso/genética , Adolescente , Adulto , Feminino , Estudos de Associação Genética , Genótipo , Humanos , Masculino , Pessoa de Meia-Idade , Subunidades Proteicas/genética , Esquizofrenia/tratamento farmacológico , Estatísticas não Paramétricas , População Branca , Adulto JovemRESUMO
Schizophrenia treatment has been hampered by undesirable adverse effects, including weight gain and associated complications. Recent candidate gene studies have been exploring the appetite regulation pathways in antipsychotic-associated weight gain (AAWG) with some promising leads. Genome-wide association studies of obesity have pointed to a number of potential candidate genes, such as MC4R, that were later found to be shared with AAWG. GABAA α2 receptor subunit (GABRA2) was another potential candidate gene for obesity from genome-wide association studies; however, it has not been explored in AAWG. We examined 9 single nucleotide polymorphisms across the GABRA2 gene. Prospective weight change was assessed for a total of 160 schizophrenia patients of European ancestry. The rs279858 marker was associated with percent weight change, with the patients homozygous for the TT genotype experiencing higher percentage weight gain on average than the C allele carriers (P = 0.009). When we performed the analysis considering each clinical site using a meta-analytic method, the results remained statistically significant (P = 1.4e-4). These findings became even more significant when we considered only patients taking clozapine or olanzapine, the 2 medications with higher risk for weight gain (P < 1e-10). GABRA2 genetic variants may play a role in predicting AAWG. However, replication in larger and independent samples is required.
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Antipsicóticos/efeitos adversos , Variação Genética/genética , Estudo de Associação Genômica Ampla/métodos , Receptores de GABA-A/genética , Aumento de Peso/efeitos dos fármacos , Aumento de Peso/genética , Adulto , Método Duplo-Cego , Feminino , Humanos , Masculino , Estudos Prospectivos , Subunidades Proteicas/genética , Esquizofrenia/tratamento farmacológico , Esquizofrenia/genética , Adulto JovemRESUMO
BACKGROUND: Schizophrenia is a severe neuropsychiatric disorder where the role of γ-aminobutyric acid (GABA), an inhibitory neurotransmitter, has been implicated in its aetiopathophysiology. Several genes coding for GABAA subunits, including the GABRG2 gene that encodes the γ2 subunit, are clustered at 5q31-q35, a chromosomal region that is associated with schizophrenia in genome scan studies. We recently reported GABRG2 to be associated with schizophrenia in our case-control and family samples. METHODS: We tested eight single-nucleotide polymorphisms spanning the GABRG2 gene for an association with suicidal behaviour in our schizophrenia sample of European ancestry (n = 197), taking into account history of alcohol abuse or dependence. RESULTS: We found the haplotypes of the rs183294 and rs209356 markers to be significantly associated with history of suicide attempt (p < 0.01) as well as suicide specifier scores (p < 0.05). The association appeared to be originating in patients with a history of alcohol dependence or abuse. CONCLUSIONS: Taken together, the results of the present study suggest that GABRG2 may be involved in suicidal behaviour in schizophrenia patients with alcohol dependence or abuse, but replications are required. These results may help in the discovery of novel treatments for alcoholism and/or prevention of suicide.
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Transtornos Relacionados ao Uso de Álcool/complicações , Transtornos Relacionados ao Uso de Álcool/genética , Predisposição Genética para Doença/genética , Polimorfismo de Nucleotídeo Único/genética , Receptores de GABA-A/genética , Esquizofrenia/complicações , Esquizofrenia/genética , Tentativa de Suicídio , Adulto , Diagnóstico Duplo (Psiquiatria) , Estudos de Associação Genética , Haplótipos/genética , Humanos , Masculino , Psicologia do Esquizofrênico , População Branca/genética , Adulto JovemRESUMO
BACKGROUND: Previous studies have shown that antipsychotics with high propensity for antipsychotic-induced weight gain (AIWG) influence glucose transporter type 4 (GLUT4) mediated glucose intake. Variation in the gene encoding TBC1 domain family member 1 (TBC1D1), a Rab-GTPase activating protein regulating GLUT4 trafficking, has been associated with obesity. Therefore, we investigated the impact of TBC1D1 polymorphisms on AIWG. METHODS: We analyzed rs9852 and rs35859249 in TBC1D1 in 195 schizophrenia subjects treated mostly with clozapine or olanzapine for up to 14 weeks. Association was tested using analysis of variance and analysis of covariance with change (%) from baseline weight as the dependent variable. RESULTS: Analysis of covariance showed a non-significant trend for lower weight gain in carriers of the T-allele of rs9852 than in C-allele homozygotes (p = 0.063). This effect was more pronounced in the subgroup of patients treated with clozapine or olanzapine (p = 0.024). For rs35859249, no significant association with AIWG could be detected. CONCLUSIONS: This is the first study examining the association between TBC1D1 and AIWG. The moderate association of rs9852, located in the 3'UTR near a miRNA binding site, indicates an influence of TBC1D1 on AIWG. Further investigations remain necessary to elucidate the role of this gene in AIWG.
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Antipsicóticos/efeitos adversos , Proteínas Ativadoras de GTPase/genética , Variação Genética/genética , Esquizofrenia/genética , Aumento de Peso/efeitos dos fármacos , Aumento de Peso/genética , Adulto , Feminino , Estudos de Associação Genética/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Esquizofrenia/tratamento farmacológicoRESUMO
Suicide is a prominent public health problem. Its aetiology is complex, and the brain-derived neurotrophic factor (BDNF) has been implicated. We performed the first meta-analysis of the functional BDNF marker Val66Met (rs6265, 196G>A) in suicidal behaviour using data from 11 previously published samples plus our present sample (total n=3352 subjects, 1202 with history of suicidal behaviour. The meta-analysis including all 12 studies showed a trend for the Met-carrying genotypes and Met allele conferring risk for suicide (random-effects model p=0.096; ORMet-carrier=1.13, 95% CI 0.98-1.30, and random-effects model p=0.032; ORMet=1.16, 95% CI 1.01-1.32, respectively). Furthermore, we found the Met allele and the Met allele-carrying genotypes to be associated with history of suicide attempt (eight studies; allelic meta-analysis--random-effects model: p=0.013; fixed-effects model: p=0.006; genotypic meta-analysis--random-effects model: p=0.017; fixed-effects model: p=0.008). Taken together, the results from our study suggest that BDNF Val66Met is involved in suicidality. Further studies are required to elucidate its role in suicidal behaviour.
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Fator Neurotrófico Derivado do Encéfalo/genética , Suicídio , Frequência do Gene , Genótipo , Humanos , Metionina/genética , Razão de Chances , Valina/genéticaRESUMO
OBJECTIVE: Childhood onset aggression can cause major suffering to affected families and is associated with many negative outcomes in the child's later life, including poor academic performance, adolescent delinquency, drug abuse, depression and antisocial personality disorder. Currently available prevention and intervention strategies have limited efficacy, but a better understanding of underlying genetic and neurobiological factors can lead to more effective prevention and treatment strategies, through genetic screening programs and novel therapies. METHOD: This study examined the RS1 (n = 299 aggression, n = 192 controls) and RS3 (n = 291 aggression, n = 189 controls) microsatellite repeats within the promoter region of the vasopressin receptor 1A gene (AVPR1A) and their association with extreme childhood aggression, as assessed by the Child Behavior Checklist (CBCL), as well as the Teacher Report Form (TRF) and Youth Self Report (YSR). Binary logistic regression was used to model the relationship between microsatellite length and childhood aggression. Age and sex were used as covariates. RESULTS: Logistic regression revealed a nominally significant association between one specific RS3 repeat and non-aggressive status. No association was found for any of the RS1 repeats. In a separate model, grouping repeats into short and long, carriers of long RS3 repeats were nominally significantly associated with non-aggressive status. CONCLUSIONS: These findings suggest a role for AVPR1A and its RS3 microsatellite in extreme childhood aggression and could lead to a better understanding of the biological pathways of aggressive behavior. However, independent replication and further research into the functionality of studied genetic variants is required.
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Agressão , Receptores de Vasopressinas , Adolescente , Criança , Humanos , Repetições de Microssatélites/genética , Polimorfismo Genético , Regiões Promotoras Genéticas/genética , Receptores de Vasopressinas/genéticaRESUMO
OBJECTIVE: We aimed to examine the role of the HEART (history, EKG, age, risk factors, and troponin) score in the evaluation of six clinical outcomes among three groups of patients in the emergency department (ED). METHODS: We performed a retrospective observational study among three ED patient groups including White, Black, and Hispanic patients. ED providers used the HEART score to assess the need for patient hospital admission and for emergent cardiac imaging tests (CITs). HEART scores were measured using classification accuracy rates. Performance accuracies were measured in terms of HEART score in relation to four clinical outcomes (positive findings of CITs, ED returns, hospital readmissions, and 30-day major adverse cardiac events [MACE]). RESULTS: A high classification accuracy rate (87%) was found for use of the HEART score to determine hospital admission. HEART scores showed moderate accuracy (area under the receiver operating characteristic curve 0.66-0.78) in predicting results of emergent CITs, 30-day hospital readmissions, and 30-day MACE outcomes. CONCLUSIONS: Providers adhered to use of the HEART score to determine hospital admission. The HEART score may be associated with emergent CIT findings, 30-day hospital readmissions, and 30-day MACE outcomes, with no differences among White, Black, and Hispanic patient populations.
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Dor no Peito , Serviço Hospitalar de Emergência , Humanos , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) have shown a range of clinical outcomes. Previous studies have reported that patient comorbidities are predictive of worse clinical outcomes, especially when patients have multiple chronic diseases. We aim to: 1) derive a simplified comorbidity evaluation and determine its accuracy of predicting clinical outcomes (i.e., hospital admission, intensive care unit (ICU) admission, ventilation, and in-hospital mortality); and 2) determine its performance accuracy in comparison to well-established comorbidity indexes. METHODS: This was a single-center retrospective observational study. We enrolled all emergency department (ED) patients with COVID-19 from March 1, 2020, to December 31, 2020. A simplified comorbidity evaluation (COVID-related high-risk chronic condition (CCC)) was derived to predict different clinical outcomes using multivariate logistic regressions. In addition, chronic diseases included in the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) were scored, and its accuracy of predicting COVID-19 clinical outcomes was also compared with the CCC. RESULTS: Data were retrieved from 90,549 ED patient visits during the study period, among which 3,864 patients were COVID-19 positive. Forty-seven point nine percent (1,851/3,864) were admitted to the hospital, 9.4% (364) patients were admitted to the ICU, 6.2% (238) received invasive mechanical ventilation, and 4.6% (177) patients died in the hospital. The CCC evaluation correlated well with the four studied clinical outcomes. The adjusted odds ratios of predicting in-hospital death from CCC was 2.84 (95% confidence interval (CI): 1.81 - 4.45, P < 0.001). C-statistics of CCC predicting in-hospital all-cause mortality was 0.73 (0.69 - 0.76), similar to those of the CCI's (0.72) and ECI's (0.71, P = 0.0513). CONCLUSIONS: CCC can accurately predict clinical outcomes among patients with COVID-19. Its performance accuracies for such predictions are not inferior to those of the CCI or ECI's.
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The HEART score is used to effectively risk stratify undifferentiated chest pain patients in the Emergency Department (ED). It is unclear whether such risk stratification can be applied among ED high utilizers. We aim to determine the efficacy and safety of using the HEART score to predict 30-day short-term major adverse cardiac events (MACE) in ED high utilizers. We conducted a retrospective, observational study in which ED high utilizers were defined as patients who had four or more ED visits within the past 12 months. ED high utilizers presenting at the study ED with chest pain were enrolled. Patients in which the HEART score was utilized were placed in the HEART group and patients with no HEART scores documented were placed to the usual care group. Hospital admissions and cardiac stress tests performed during the index hospitalizations, and 30-day MACE rates were analyzed and compared between the HEART and usual care groups. From January 1, 2017 to December 31, 2019, a total of 8,315 patient visits from ED high utilizers were enrolled. In the HEART group, 49% of ED visits were admitted with 20% receiving stress tests. A 30-day MACE outcome occurred among 1.4% of visits. In the usual care group, 44% of ED visits were admitted, with only 9% receiving index stress tests and a 1.5% of 30-day MACE occurrence (p=0.727). The study showed that similar short-term MACE outcomes occurred between patients using HEART scores and usual care to risk stratify chest pain among ED high utilizers.
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Angina Pectoris/diagnóstico , Técnicas de Apoio para a Decisão , Serviço Hospitalar de Emergência , Indicadores Básicos de Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Adulto , Angina Pectoris/etiologia , Angina Pectoris/terapia , Registros Eletrônicos de Saúde , Feminino , Testes de Função Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
Emerging evidence indicates that the DRD1-BDNF-DRD3 cluster plays an important role in nicotine addiction. We have performed an association analysis of 42 SNPs within these genes with cigarette consumption in a group of 341 schizophrenia patients. The ACCG haplotype consisting of four BDNF markers (Val66Met (rs6265), rs11030104, rs2049045 and rs7103411) showed an association with the risk of smoking (p = 0.0002). Both DRD1 markers tested (rs4532 and rs686) and the DRD3 marker (rs1025398) showed association with quantity of tobacco smoked (p = 0.01, 0.005 and 0.002, respectively). Our findings are preliminary; however, they support the involvement of the DRD1, BDNF and DRD3 genes in smoking behaviour.
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Fator Neurotrófico Derivado do Encéfalo/genética , Polimorfismo de Nucleotídeo Único , Receptores de Dopamina D1/genética , Receptores de Dopamina D3/genética , Esquizofrenia/genética , Fumar/genética , Estudos de Associação Genética , Predisposição Genética para Doença , Humanos , RiscoRESUMO
BACKGROUND: The homeless patient population is known to have a high occurrence of inappropriate emergency department (ED) utilization. The study hospital initiated a dedicated homeless clinic targeting patients experiencing homelessness with a combination of special features. We aim to determine whether this mode of care can reduce inappropriate ED utilization among homeless patients. METHODS: We conducted a retrospective observational study from July 1, 2017 to Dec 31, 2017. The study enrolled all homeless patients who visited any hospital regular clinic, dedicated homeless clinic, and ED at least once during the study period. ED homeless patients were divided into four groups (A: no clinic visits; B: those who only visited hospital regular clinic; C: those who only visited dedicated homeless clinic; and D: those who visited both hospital regular clinic and dedicated homeless clinic). The New York University algorithm was used to determine appropriate ED utilization. We compared inappropriate ED utilization among patients from these groups. Multivariate logistic regression was used to determine the risks of different clinical visits in association with inappropriate ED utilization. RESULTS: A total of 16,323 clinic and 8511 ED visits occurred among 5022 unique homeless patients, in which 2450 unique patients were seen in hospital regular clinic, 784 patients in dedicated homeless clinic, 688 patients in both hospital regular clinic and dedicated homeless clinic, and 1110 patients with no clinic visits. Twenty-nine percent (230/784) of patients from dedicated homeless clinic utilized the ED, among which 21% (175/844) of their ED visits were considered inappropriate. In contrast, 40% of patients from hospital regular clinic utilized the ED, among which 29% were inappropriate (P < 0.001). The adjusted odds ratio (OR) was 0.61 (95% confidence interval [CI] = 0.50-0.74, P < 0.001) on dedicated homeless clinic predicting inappropriate ED visits in multivariate logistic regression. CONCLUSION: Implementing a dedicated homeless clinic with these features can reduce ED inappropriate utilization among patients experiencing homelessness.
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BACKGROUND AND OBJECTIVE: Attending physician productivity and efficiency can be affected when working simultaneously with Residents. To gain a better understanding of this effect, we aim to compare productivity, efficiency, and overall performance differences among Attendings working solo versus working with Residents in an Emergency Department (ED). METHODS: Data were extracted from the electronic medical records of all patients seen by ED Attendings and/or Residents during the period July 1, 2014 through June 30, 2017. Attending productivity was measured based on the number of new patients enrolled per hour per provider. Attending efficiency was measured based on the provider-to-disposition time (PDT). Attending overall performance was measured by Attending Performance Index (API). Furthermore, Attending productivity, efficiency, and overall performance metrics were compared between Attendings working solo and Attendings working with Residents. The comparisons were analyzed after adjusting for confounders via propensity score matching. RESULTS: A total of 15 Attendings and 266 Residents managing 111,145 patient encounters over the study period were analyzed. The mean (standard deviation) of Attending productivity and efficiency were 2.9 (1.6) new patients per hour and 2.7 (1.8) hours per patient for Attendings working solo, in comparison to 3.3 (1.9) and 3.0 (2.0) for Attendings working with Residents. When paired with Residents, the API decreased for those Attendings who had a higher API when working solo (average API dropped from 0.21 to 0.19), whereas API increased for those who had a lower API when working solo (average API increased from 0.13 to 0.16). CONCLUSION: In comparison to the Attending working solo staffing model, increased productivity with decreased efficiency occurred among Attendings when working with Residents. The overall performance of Attendings when working with Residents varied inversely against their performance when working solo.
Assuntos
Eficiência , Serviço Hospitalar de Emergência/estatística & dados numéricos , Internato e Residência , Corpo Clínico Hospitalar/estatística & dados numéricos , Admissão e Escalonamento de Pessoal , Feminino , Humanos , Masculino , Corpo Clínico Hospitalar/psicologia , Estudos RetrospectivosRESUMO
OBJECTIVES: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models. DESIGN, SETTING AND PARTICIPANTS: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days. METHODS: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models. RESULTS: A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80). CONCLUSION: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.
Assuntos
Serviço Hospitalar de Emergência/normas , Alta do Paciente/estatística & dados numéricos , Assistência ao Convalescente/normas , Assistência ao Convalescente/estatística & dados numéricos , Feminino , Hospitais Urbanos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária , Estados UnidosRESUMO
OBJECTIVES: Provider efficiency has been reported in the literature but there is a lack of efficiency analysis among emergency medicine (EM) residents. We aim to compare efficiency of EM residents of different training levels and determine if EM resident efficiency is affected by emergency department (ED) crowding. METHODS: We conducted a single-center retrospective observation study from July 1, 2014, to June 30, 2017. The number of new patients per resident per hour and provider-to-disposition (PTD) time of each patient were used as resident efficiency markers. A crowding score was assigned to each patient upon the patient's arrival to the ED. We compared efficiency among EM residents of different training levels under different ED crowding statuses. Dynamic efficiency changes were compared monthly through the entire academic year (July to next June). RESULTS: The study enrolled a total of 150,920 patients. A mean of 1.9 patients/hour was seen by PGY-1 EM residents in comparison to 2.6 patients/hour by PGY-2 and -3 EM residents. Median PTD was 2.8 hours in PGY-1 EM residents versus 2.6 hours in PGY-2 and -3 EM residents. There were no significant differences in acuity across all patients seen by EM residents. When crowded conditions existed, residency efficiency increased, but such changes were minimized when the ED became overcrowded. A linear increase of resident efficiency was observed only in PGY-1 EM residents throughout the entire academic year. CONCLUSION: Resident efficiency improved significantly only during their first year of EM training. This efficiency can be affected by ED crowding.