Drug-related hospital admissions in older adults: comparison of the Naranjo algorithm and an adjusted version of the Kramer algorithm

PURPOSE

Drug-related admissions (DRAs) are an important cause of preventable harm in older adults. Multiple algorithms exist to assess causality of adverse drug reactions, including the Naranjo algorithm and an adjusted version of the Kramer algorithm. The performance of these tools in assessing DRA causality has not been robustly shown. This study aimed to evaluate the ability of the adjusted Kramer algorithm to adjudicate DRA causality in geriatric inpatients.

METHODS

DRAs were assessed in a convenience sample of patients admitted to the acute geriatric wards of an academic hospital. DRAs were identified by expert consensus and causality was evaluated using the Naranjo and the adjusted Kramer algorithms. Positive agreement with expert consensus was calculated for both algorithms. A multivariable logistic regression analysis was performed to explore determinants for a DRA.

RESULTS

A total of 218 geriatric inpatients was included of whom 65 (29.8%) experienced a DRA. Positive agreement was 72.3% (95% confidence interval (CI), 59.6-82.3%) and 100% (95% CI, 93.0-100%) for the Naranjo and the adjusted Kramer algorithm, respectively. Diuretics were the main culprits and most DRAs were attributed to a fall (n = 18; 27.7%). A fall-related principal diagnosis was independently associated with a DRA (odds ratio 20.11; 95% CI, 5.60-72.24).

CONCLUSION

The adjusted Kramer algorithm demonstrated a higher positive agreement with expert consensus in assessing DRA causality in geriatric inpatients compared to the Naranjo algorithm. Our results further support implementation of the adjusted Kramer algorithm as part of a standardized DRA assessment in older adults.

Symptoms and risk factors for hospitalization of COVID-19 presented in primary care : An exploratory retrospective study

OBJECTIVE

To increase knowledge of discrete symptoms shall help to avoid misinterpretation of test results and to gain better understanding of associations between early symptoms and severe disease to provide additional criteria for targeted early interventions.

DESIGN

Retrospective observational study.

SETTING

Austrian GP practices in the year 2020, patients above 18 years were included.

PARTICIPANTS

We recruited 25 practices which included 295 participants with a positive SARS-CoV‑2 test.

MAIN OUTCOME MEASURES

Data collection comprised basic demographic data, risk factors and the recording of symptoms at several points in time in the course of the illness. Descriptive analyses for possible associations between demographics and symptoms were conducted by means of cross tabulation. Group differences (hospitalized yes/no) were assessed using Fisher's exact test. The significance level was set to 0.05; due to the observational character of the study, no adjustment for multiplicity was performed.

RESULTS

Only one third of patients report symptoms generally understood to be typical for COVID‑19. Most patients presented with unspecific complaints. We found symptoms indicating complicated disease, depending on when they appear. The number of symptoms may be a predictor for the need of hospital care. More than 50% of patients still experience symptoms 14 days after onset.

CONCLUSION

Unspecific symptoms are valuable indicators in the detection of early COVID‑19 disease that practitioners and the general public should be aware of also in the interpretation of low sensitivity tests. Monitoring patients using the indicators we identified may help to identify patients who are likely to profit from early intervention.

Is Home Treatment for Everyone? Characteristics of Patients Receiving Intensive Mental Health Care at Home

We aimed at determining differential characteristics of patients treated by a home treatment (HT) team compared to patients treated on hospital wards. Of 412 consecutively admitted patients, 194 (47.1%) were at least partially treated at home, whereas 218 (52.9%) received inpatient treatment only during an episode of acute illness. A multivariate logistic regression model identified current employment to increase the odds of HT (p < 0.001). A primary diagnosis of anxiety or stress-related disorder (p < 0.001), other rare primary diagnoses such as personality disorders (p < 0.001), and more pronounced clinician-rated social problems (p = 0.041) decreased the odds of HT. Overall, it remained difficult to clearly specify suitability for HT based on available sociodemographic and clinical characteristics. This might indicate that responsible clinicians consider HT to be a viable alternative to hospital care and hence initiate HT for a relatively broad spectrum of patients.

Association of short-term exposure to air pollution with recurrent ischemic cerebrovascular events in older adults

The acute effects of ambient air pollution on recurrence of ischemic cerebrovascular events (ICEs) remains largely unknown. We therefore conducted a time-stratified case-crossover study of 43,896 patients who were 60 years or older and were admitted to hospital for recurrent ICEs including ischemic stroke and transient ischemic attack in Guangzhou, China during 2016-2019. Based on each patient's home address and pollutant data from its neighboring air quality monitoring stations, we used an inverse distance weighting method to assess exposures to particulate matter with an aerodynamic diameter ≤2.5 μm (PM_2.5), particulate matter with an aerodynamic diameter ≤10 μm (PM₁₀), sulfur dioxide (SO₂), nitrogen dioxide (NO₂), carbon monoxide (CO) and ozone (O₃). Conditional logistic regression models were used to quantify exposure-response associations. During the study period, there were 43,896 case days and 149,131 control days. In single-pollutant models, each 10 μg/m³ increase in exposure to PM₁₀, NO₂ and CO (mean exposure on date of admission and 1 day prior) was significantly associated with a 0.74% (95% confidence interval [CI]: 0.13-1.36%), 2.15% (1.38-2.93%) and 0.14% (0.07-0.21%) increase in odds of hospital admissions for recurrent ICEs, respectively, and no significant departures from linearity were detected. The association for NO₂ exposure remained consistent in 2-pollutant models, while the associations for PM₁₀ and CO disappeared or changed materially with adjustment for other pollutants. Stronger association for NO₂ exposure was observed in cool season than that in warm season. We found that short-term exposure to ambient air pollutants, especially NO₂, was associated with increased risk of hospital admissions for recurrent ICEs in older adults.

Current and future burdens of heat-related dementia hospital admissions in England

INTRODUCTION

The impacts of a changing climate on current and future dementia burdens have not been widely explored.

METHODS

Time-series negative binomial regression analysis was used to assess acute associations between daily ambient temperature and counts of emergency admissions for dementia in each Government region of England, adjusting for season and day-of-week. Using the latest climate and dementia projections data, we then estimate future heat-related dementia burdens under a high emission scenario (Representative Concentration Pathway (RCP8.5), where global greenhouse gas (GHG) emissions continue to rise, and a low emissions scenario (RCP2.6), where GHG emissions are sizeably reduced under a strong global mitigation policy.

RESULTS

A raised risk associated with high temperatures was observed in all regions. Nationally, a 4.5% (95% Confidence interval (CI) 2.9%-6.1%) increase in risk of dementia admission was observed for every 1 °C increase in temperature above 17 °C associated with current climate. Under a high emissions scenario, heat-related admissions are projected to increase by almost 300% by 2040 compared to baseline levels.

CONCLUSIONS

People living with dementia should be considered a high-risk group during hot weather. Our results support arguments for more stringent climate change mitigation policies.

Effects of particulate matter on hospital admissions for respiratory diseases: an ecological study based on 12.5 years of time series data in Shanghai

BACKGROUND

Previous epidemiological studies on the association between short-term exposure to particulate matter (PM) with hospital admission in major cities in China were limited to shorter study periods or a single hospital. The aim of this ecological study based on a 12.5-year time series was to investigate the association of short-term exposure to PM with aerodynamic diameter ≤ 2.5 μm (PM_2.5) and aerodynamic diameter ≤ 10 μm (PM₁₀) with hospital admissions for respiratory diseases.

METHODS

Daily hospital admissions data were from the Shanghai Medical Insurance System for the period January 1, 2008 to July 31, 2020. We estimated the percentage change with its 95% confidence interval (CI) for each 10 μg/m³ increase in the level of PM_2.5 and PM₁₀ after adjustment for calendar time, day of the week, public holidays, and meteorological factors applying a generalized additive model with a quasi-Poisson distribution.

RESULTS

There were 1,960,361 hospital admissions for respiratory diseases in Shanghai during the study period. A 10 μg/m³ increase in the level of each class of PM was associated with increased total respiratory diseases when the lag time was 0 day (PM_2.5: 0.755%; 95% CI: 0.422, 1.089%; PM₁₀: 0.250%; 95% CI: 0.042, 0.459%). The PM_2.5 and PM₁₀ levels also had positive associations with admissions for COPD, asthma, and pneumonia. Stratified analyses demonstrated stronger effects in patients more than 45 years old and during the cold season. Total respiratory diseases increased linearly with PM concentration from 0 to 100 μg/m³, and increased more slowly at higher PM concentrations.

CONCLUSIONS

This time-series study suggests that short-term exposure to PM increased the risk for hospital admission for respiratory diseases, even at low concentrations. These findings suggest that reducing atmospheric PM concentrations may reduce hospital admissions for respiratory diseases.

Predicting post-radiation genitourinary hospital admissions in patients with localised prostate cancer

PURPOSE

The risk of treatment-related toxicity is important for patients with localised prostate cancer to consider when deciding between treatment options. We developed a model to predict hospitalisation for radiation-induced genitourinary toxicity based on patient characteristics.

METHODS

The prospective South Australian Prostate Cancer Clinical Outcomes registry was used to identify men with localised prostate cancer who underwent curative intent external beam radiotherapy (EBRT) between 1998 and 2019. Multivariable Cox proportional regression was performed. Model discrimination, calibration, internal validation and utility were assessed using C-statistics and area under ROC, calibration plots, bootstrapping, and decision curve analysis, respectively.

RESULTS

There were 3,243 patients treated with EBRT included, of which 644 (20%) patients had a treated-related admission. In multivariable analysis, diabetes (HR 1.35, 95% CI 1.13-1.60, p < 0.001), smoking (HR 1.78, 95% CI 1.40-2.12, p < 0.001), and bladder outlet obstruction (BOO) without transurethral resection of prostate (TURP) (HR 7.49, 95% CI 6.18-9.08 p < 0.001) followed by BOO with TURP (HR 4.96, 95% CI 4.10-5.99 p < 0.001) were strong independent predictors of hospitalisation (censor-adjusted c-statistic = 0.80). The model was well-calibrated (AUC = 0.76). The global proportional hazards were met. In internal validation through bootstrapping, the model was reasonably discriminate at five (AUC 0.75) years after radiotherapy.

CONCLUSIONS

This is the first study to develop a predictive model for genitourinary toxicity requiring hospitalisation amongst men with prostate cancer treated with EBRT. Patients with localised prostate cancer and concurrent BOO may benefit from TURP before EBRT.

Temperature might increase the hospital admission risk for rheumatoid arthritis patients in Anqing, China: a time-series study

Temperature has been studied in relation to many health outcomes. However, few studies have explored its effect on the risk of hospital admission for rheumatoid arthritis (RA). A distributed lag non-linear model (DLNM) was used to analyze associations between mean temperature, diurnal temperature range (DTR), temperature change between neighboring days (TCN), and daily admissions for RA from 2015 to 2019 in Anqing, China. Subgroup analyses based on age, gender, rheumatoid factors, and admission route were performed. In total, 1456 patients with RA were hospitalized. Regarding the cumulative-lag effects of extreme cold temperature (5th percentile = 3℃), the risks of admissions for RA were increased and highest at lag 0-11 (RR = 2.68, 95% CI: 1.23-5.86). Exposing to low (5th percentile = 1.9℃) and high (95th percentile = 14.2℃) DTRs both had increased risks of RA admission, with highest RRs of 1.40 (95% CI: 1.03-1.91) and 1.24 (95% CI: 1.0-1.53) at lag 0 day, respectively. As for TCN, the marginal risk of admission in RA patients was found when exposed to high TCN (95th percentile = 2.9℃) with the largest single-day effect at lag 10 (RR = 1.11, 95% CI: 1.01-1.23). In subgroup analyses, females were more susceptible to extreme cold temperature, low and high DTRs, and high TCN. In regard to extreme cold temperature, significant risk of hospital admission in females only appeared at lag 2 (RR = 1.48, 95% CI: 1.02-2.15) and lag 0-2 (RR = 2.35, 95% CI: 1.11-4.95). It is clear that RA patients exposed to changing temperature may increase risks of admission.

Prognostic Value of Stress Hyperglycemia in Patients Admitted to Medical/Geriatric Departments for Acute Medical Illness

INTRODUCTION

Hyperglycemia is common in patients admitted to Italian medical/geriatric units and is associated with a poorer outcome. We tested the significance of diabetes and stress-induced hyperglycemia in clinical outcome.

MATERIALS AND METHODS

Three hundred seventy-eight consecutive patients with hyperglycemia at entry (≥ 126 mg/dl) (206 without known diabetes) were included, with a wide range of underlying diseases requiring hospital admission and independent of the presence of diabetes. Relative hyperglycemia was calculated as admission glucose divided by average glucose, estimated based of glycosylated hemoglobin. Values ≥ 1.20 were considered indicative of stress hyperglycemia (SHR). The association of SHR with outcome variables (all-cause complications, infections, non-infectious events, deaths) was tested by logistic regression analysis, adjusted for sex, BMI, age-adjusted comorbidities (Charlson index) and known diabetes.

RESULTS

During hospital stay, one or more events were registered in 96 patients (25.4%); 44 patients died in hospital, and fatality rate was borderline higher in patients without diabetes (14.6% vs. 8.1% in diabetes; P = 0.052) and nearly three times higher in patients with stress hyperglycemia (15.0%) vs. those with SHR < 1.2 (P = 0.005). Stress hyperglycemia-more common in the absence of diabetes (71% vs. 58%)-and age were the only independent prognostic factors for death. At multivariable analysis, the risks of death (OR 4.31, 95% CI 1.25-14.81), of all complications (OR 5.90, 95% CI 2.22-15.71) and of newly developed systemic infections (OR 5.67, 95% CI 1.61-19.92) were associated with stress hyperglycemia in subjects without diabetes, as was the risk in non-insulin-treated cases (OR 4.02, 95% CI 1.16-13.92; OR 5.47, 95% CI 2.21-13.52; OR 5.15, 95% CI 1.70-15.62, respectively).

CONCLUSION

The study confirms the prognostic value of stress-related hyperglycemia in patients requiring hospital admission to a geriatric/medical unit for a variety of acute medical conditions, contributing to adverse outcomes not limited to events commonly associated with hyperglycemia (e.g., infections).

Ambient sulfur dioxide and hospital expenditures and length of hospital stay for respiratory diseases: A multicity study in China

BACKGROUND

Ambient sulfur dioxide (SO2) has been associated with morbidity and mortality of respiratory diseases, however, its effect on length of hospital stays (LOS) and cost for these diagnoses remain unclear.

METHODS

We collected hospital admission information for respiratory diseases from all 11 cities in the Shanxi Province of China during 2017-2019. We assessed individual-level exposure by using an inverse distance weighting approach based on geocoded residential addresses. A generalized additive model was built to delineate city-specific effects of SO2 on hospitalization, hospital expenditure, and length of hospital stay for respiratory diseases. The overall effects were obtained by random-effects meta-analysis. We further estimated the respiratory burden attributable to SO2 by comparing different reference concentrations.

RESULTS

We observed significant effects of SO2 exposure on respiratory diseases. At the provincial level, each 10 μg/m3 increase in SO2 on lag03 was associated with a 0.63% (95% CI: 0.14-0.11) increase in hospital admission, an increase of 4.56 days (95% CI: 1.16-7.95) of hospital stay, and 3647.97 renminbi (RMB, Chinese money) (95% CI: 1091.05-6204.90) in hospital cost. We estimated about 6.13 (95% CI: 1.33-11.10) thousand hospital admissions, 65.77 million RMB (95% CI: 19.67-111.87) in hospital expenditure, and 82.13 (95% CI: 20.87-143.40) thousand days of hospital stay could have potentially been avoided had the daily SO2 concentrations been reduced to WHO's reference concentration (40 µg/m3). Variable values in correspondence with this reference concentration could reduce the hospital cost and LOS of each case by 52.67 RMB (95% CI: 15.75-89.59) and 0.07 days (95% CI: 0.02-0.117).

CONCLUSION

This study provides evidence that short-term ambient SO2 exposure is an important risk factor of respiratory diseases, indicating that continually tightening policies to reduce SO2 levels could effectively reduce respiratory disease burden in Shanxi Province.

Assessing short-term impacts of PM2.5 constituents on cardiorespiratory hospitalizations: Multi-city evidence from China

Apart from concentrations of particulate mass, PM_2.5-associated effects on health may largely depend on its chemical components. However, little is known regarding the underlying effects of specific PM_2.5 constituents. The study included nearly 1 million hospital admissions from five Chinese cities during 2015-2017. Based on the modified Community Multiscale Air Quality model, our study simulated daily concentrations of PM_2.5 and five main components. We used a time-stratified case-crossover design with conditional logistic regression models to estimate short-term effects of PM_2.5 constituents on cause-specific hospital admissions. Per interquartile range increase in exposure to PM_2.5, elemental carbon, organic carbon, nitrate, sulfate and ammonium at lag 04-day was related to an excess risk (ER%) for non-accidental admissions of 1.6% [95% confidence interval: 1.1-2.0], 1.9% [1.3-2.4], 1.0% [0.5-1.6], 1.2% [0.4-2.0], 1.2% [0.9-1.5] and 1.4% [0.9-1.9], respectively. Great heterogeneities of constituents-admission associations existed in diverse causes and constituents. This study provided multi-center high-quality evidence that hospital admissions, particularly those for ischemic heart disease (ER% ranging from 2.3 to 5.4% at lag 04-day) and pneumonia (1.9-5.1% at lag 4-day), could be triggered by short-term exposures to ambient PM_2.5 constituents. Relatively stronger constituents-admission associations were found among females for respiratory causes and the elderly for cardiovascular causes.

Reasons for admission and variance of body weight at referral in female inpatients with anorexia nervosa in Germany

BACKGROUND

Body mass index (BMI) at hospital admission in patients with anorexia nervosa (AN) represents a prognostic marker for mortality, chronicity and future body weight. The current study focused on the associations between BMI standard deviation score (BMI-SDS) at admission and reasons for seeking inpatient treatment. Further interest was given to the relationship between premorbid weight and weight at admission, as well as the effect of both weight at referral and reasons for admission on treatment outcome.

METHODS

Data ascertained in the German Register of Children and Adolescents with AN were analysed to assess the parental and patient overlap for 23 predefined reasons for admission, using factor analyses and regressions models.

RESULTS

Complete parent-patient data sets were available for 360 patients out of 769. The highest consensus rates between parents and patients were obtained for weight and eating behavior related reasons and hyperactivity. Based on factor analysis, four factors emerged. Premorbid BMI-SDS, age and 'low body weight' as stated by patients or parents explained almost 40% of the variance of the BMI-SDS at admission.

CONCLUSIONS

Results underscore the relevance of age and premorbid BMI for BMI at admission. Only single reasons for admission explained further variance, with 'low body weight' having the largest effect. Approximately 40% of the variance of BMI-SDS was explained. For the first time, the effect of premorbid BMI for BMI at admission was robustly demonstrated in a multicenter study. Of the variance in BMI-SDS at discharge, our model could explain 37%, with reasons for admission having a small effect. Further investigation of the reasons for admission would be worthwhile to improve treatment and prognosis.

Associations between cervical dilatation on admission and mode of delivery, a cohort study of Norwegian nulliparous women

OBJECTIVE

To investigate associations between cervical dilatation at hospital admission and mode of delivery.

METHODS

A cohort study with data from a cluster-randomised controlled trial, the Labour Progression Study. The study population of 6511 nulliparous women with a singleton fetus in cephalic presentation with spontaneous onset of labour at term, was divided into two groups: <4 cm and ≥ 4 cm cervical dilatation on admission. Binary logistic regression comparing mode of delivery was used to estimate crude and adjusted OR with associated 95% CI.

RESULTS

Of the total study population, 56.7% were admitted with < 4 cm cervical dilatation and 43.3% with ≥ 4 cm. Women admitted with ≥ 4 cm had a significantly higher chance of spontaneous delivery, with adjusted OR of 1.28 (95% CI: 1.14-1.44), and a significantly lower risk of caesarean sections, with an adjusted OR of 0.51 (95% CI: 0.41-0.64). For operative vaginal delivery, there were no significant difference between the study groups. Intrapartum interventions as epidural analgesia and augmentation with oxytocin were lower among women admitted with ≥ 4 cm cervical dilatation.

CONCLUSION

The study found a significantly higher chance of spontaneous delivery among women admitted with ≥ 4 cm. More research is needed to investigate why so many women are admitted early in labour, and how these women can be better cared for to increase their chances of a spontaneous delivery.

PM2.5-associated risk for cardiovascular hospital admission and related economic burdens in Beijing, China

BACKGROUND

The study of ambient air particulate matter (PM_2.5)-associated health and economic burdens of cardiovascular disease are crucial for air pollution control and disease prevention strategies. Quantified evidence remains inadequate.

OBJECTIVES

This study aimed to estimate the PM_2.5 associated risk in cardiovascular hospital admission as well as attributable health burdens and economic costs.

METHODS

A total of 2,202,244 hospital admission records of cardiovascular disease and six common clinical subtypes in Beijing were included. A time-stratified case-crossover design was applied to estimate the associations and the concentration-response curve. Then, the annual average additional hospital admissions, days of hospital stay, and hospital expenditures were evaluated from 2013 to 2017 and compared between 2017 and 2013.

RESULTS

The results showed that each 10 μg/m³ increase in previous-day PM_2.5 concentration was associated with a risk increase of 0.44% (95%CI: 0.40%, 0.47%) for cardiovascular disease, 0.66% (95%CI: 0.58%, 0.73%) for angina pectoris, 0.53% (95%CI: 0.39%, 0.66%) for chronic ischemic heart disease, 0.48% (95%CI: 0.34%, 0.63%) for myocardial infarction, 0.44% (95%CI: 0.29%, 0.60%) for hypertensive heart disease and 0.40% (95%CI: 0.27%, 0.52%) for ischemic stroke. There were 1938 PM_2.5 attributed additional hospital admissions, resulting in 21,668 additional days in hospital, along with 5527.12 and 1947.04 ten-thousand of additional total hospital cost and self-afforded cost, respectively. Compared with 2013, the above-mentioned four burdens decreased by 18.17%, 28.80%, 18.90% and 13.72% in 2017, respectively.

CONCLUSION

PM_2.5 exposure was significantly associated with substantial burdens of cardiovascular hospital admission and economic expenditures. The results highlight the necessity of continuous PM_2.5 control from the perspective of healthy and sustainable city development in urban China.

Effects of diurnal temperature range on cardiovascular disease hospital admissions in farmers in China's Western suburbs

Cardiovascular disease (CVD), reported to relate with climate change, is the leading cause of global mortality and morbidity. Since the relevant information is quite limited from suburbs and countryside in developing and underdeveloped countries, there are no studies that focused on morbidity through diurnal temperature range (DTR) for these regions. This is the first study to evaluate the short-term effect of DTR on CVD hospital admission in suburban farmers, as well as to identify vulnerable subpopulations. Daily time series data of CVD hospital admissions on suburban farmers of Qingyang, China, and meteorological data from 2011 to 2015 were collected, and a distributed lag non-linear model (DLNM) combined with a quasi-Poisson generalized additive regression model (GAM) was used to examine the exposure-response relationship and delayed effect between DTR and CVD hospital admissions. Stratified analyses by age and gender were performed and extreme DTR effects were examined. Non-linear relation between DTR and CVD hospital admissions was observed, and whether DTR lower or higher than the reference (13 °C, 50^th percentile) had adverse effect while lower DTR have slightly higher impact. Also, both extreme low and extreme high DTR had adverse effect. Besides, adults (age < 65) and males were more vulnerable to the effects of DTR compared with the old (age ≥ 65) and females, respectively. This study provides evidence that not only high DTR but also low DTR had adverse effects on CVD which should be paid attention to. Adults and males were more vulnerable among suburban farmers. The results are inconsistent with the studies from urban and indicate differences between urban and suburban residents. Multiple factors such as occupations, risk awareness, and lifestyles could have a significant influence on CVD morbidity, and further study is needed to explore more evidence.

Impact of the COVID-19 pandemic on provision and outcomes of emergency abdominal surgery in Irish public hospitals

Background

The SARS-CoV-2 pandemic caused severe disruption to scheduled surgery in Ireland but its impact on emergency abdominal surgery (EAS) is unknown.

Aims

The primary objective was to identify changes in volume, length of stay (LOS), and survival outcomes following EAS during the pandemic. A secondary objective was to evaluate differences in EAS patient flow including admission source, ITU utilisation, discharge destination, and readmission rates.

Methods

Using a national administrative dataset, demographic, comorbidity, and patient flow data on 5611 patients admitted for EAS between 2018 and 2020 were extracted. Pre-pandemic and pandemic timeframes were compared using graphic and regression analyses, and bivariate logistic regression, adjusting for demographics and case-mix.

Results

There was a 19.9% decrease in EAS during the 2020 COVID-19 pandemic with no difference in comorbidity, nor in the commonest procedures. Most patients (92.4%) were admitted from home. In-hospital post-operative mortality was unchanged (7.6%). Patients over 80 comprised 16.3% of EAS pre-COVID, but 17.9% during COVID. Average total LOS reduced significantly by 4.9 days and 3.5 days during COVID-19 waves 1 (29 Feb 2020–30 June 2020) and 2 (1 July 2020–30 Nov 2020), respectively. During wave 1, pre-operative LOS reduced (1 day) and ICU LOS was significantly shorter (0.8 days), but similar change was not observed during wave 2.

Conclusions

Significant improvements in patient flow following admission for EAS during the pandemic were observed. These changes were not associated with greater mortality nor increased readmission rates and offer important insights into optimal delivery of EAS services.

Examining the association between paramedic transport to the emergency department and hospital admission: a population-based cohort study

Background

Increasing hospitalization rates present unique challenges to manage limited inpatient bed capacity and services. Transport by paramedics to the emergency department (ED) may influence hospital admission decisions independent of patient need/acuity, though this relationship has not been established. We examined whether mode of transportation to the ED was independently associated with hospital admission.

Methods

We conducted a retrospective cohort study using the National Ambulatory Care Reporting System (NACRS) from April 1, 2015 to March 31, 2020 in Ontario, Canada. We included all adult patients (≥18 years) who received a triage score in the ED and presented via paramedic transport or self-referral (walk-in). Multivariable binary logistic regression was used to determine the association of mode of transportation between hospital admission, after adjusting for important patient and visit characteristics.

Results

During the study period, 21,764,640 ED visits were eligible for study inclusion. Approximately one-fifth (18.5%) of all ED visits were transported by paramedics. All-cause hospital admission incidence was greater when transported by paramedics (35.0% vs. 7.5%) and with each decreasing Canadian Triage and Acuity Scale level. Paramedic transport was independently associated with hospital admission (OR = 3.76; 95%CI = 3.74–3.77), in addition to higher medical acuity, older age, male sex, greater than two comorbidities, treatment in an urban setting and discharge diagnoses specific to the circulatory or digestive systems.

Conclusions

Transport by paramedics to an ED was independently associated with hospital admission as the disposition outcome, when compared against self-referred visits. Our findings highlight patient and visit characteristics associated with hospital admission, and can be used to inform proactive healthcare strategizing for in-patient bed management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00507-2.

Neural networks and hospital length of stay: an application to support healthcare management with national benchmarks and thresholds

Background

The problem of correct inpatient scheduling is extremely significant for healthcare management. Extended length of stay can have negative effects on the supply of healthcare treatments, reducing patient accessibility and creating missed opportunities to increase hospital revenues by means of other treatments and additional hospitalizations.

Methods

Adopting available national reference values and focusing on a Department of Internal and Emergency Medicine located in the North-West of Italy, this work assesses prediction models of hospitalizations with length of stay longer than the selected benchmarks and thresholds. The prediction models investigated in this case study are based on Artificial Neural Networks and examine risk factors for prolonged hospitalizations in 2018. With respect current alternative approaches (e.g., logistic models), Artificial Neural Networks give the opportunity to identify whether the model will maximize specificity or sensitivity.

Results

Our sample includes administrative data extracted from the hospital database, collecting information on more than 16,000 hospitalizations between January 2018 and December 2019. Considering the overall department in 2018, 40% of the hospitalizations lasted more than the national average, and almost 3.74% were outliers (i.e., they lasted more than the threshold). According to our results, the adoption of the prediction models in 2019 could reduce the average length of stay by up to 2 days, guaranteeing more than 2000 additional hospitalizations in a year.

Conclusions

The proposed models might represent an effective tool for administrators and medical professionals to predict the outcome of hospital admission and design interventions to improve hospital efficiency and effectiveness.

Payment mechanism and hospital admission: New evidence from Thailand healthcare reform

In 2007, Thailand's Civil Servant Medical Benefit Scheme (CSMBS), one of the three main public health insurers, adopted a new payment mechanism for hospital admission. There has been a shift from fee-for-service toward Diagnostic Related Group (DRG)-based payment that transfers financial risk from the government to health care providers. This study investigates the effects of this policy change on hospital admission, frequency of admission, length of stay (LOS), type of hospital admitted, and out-of-pocket (OOP) inpatient medical expenditure. By employing nationally representative micro-level data (Health and Welfare surveys) and difference-in-difference approach, this study finds a 1 percentage point decline in hospitalization, a 10% higher chance of admission at community hospitals (the lowest level inpatient public health care facility), and a 7% less chance of admission at higher level public health care facilities like general hospitals. No significant change was observed in LOS, frequency of admission, or OOP inpatient medical expenditure associated with the post-2007 payment mechanism change. Our results emphasize the effectiveness of a close-ended payment mechanism for health care in developing countries. This study also adds to the limited literature on using micro-level data to investigate payment mechanism change in the context of low- and middle-income countries.

Charlson Comorbidity Index as a predictor of repeated hospital admission and mortality among older women diagnosed with cardiovascular disease

BACKGROUND

Comorbidity can complicate cardiovascular diseases (CVDs), increasing the risk of adverse events including hospitalisation and death. This study aimed to assess the Charlson Comorbidity Index (CCI) as a predictor of repeated hospital admission and mortality in older CVD patients.

METHODS

This study linked data from the Australian longitudinal study on women's health (ALSWH) with hospital and National Death Index datasets to identify dates for hospital admission, discharge, and death for women born 1921-26. CCI was calculated using the International Statistical Classification of Diseases, Australia Modification (ICD-10-AM) diagnostic codes.

RESULTS

Women with a higher CCI on index admission had increased risk of repeated hospital admission (AHR = 1.29, 95% CI 1.06, 1.58) and mortality (AHR = 3.05, 95% CI 2.15, 4.31). Older age and hypertension were also significantly associated with a higher risk of repeated hospital admission and mortality. Living in a remote area was associated with a higher risk of mortality.

CONCLUSIONS

The Charlson Comorbidity Index predicts repeated hospital admission and mortality incidences among older women with CVD. Improving management of comorbidities for older CVD patients should be considered as part of a strategy to mitigate subsequent repeated hospitalisation and delay mortality.

Association between Air Pollutants and Initial Hospital Admission for Ischemic Stroke in Korea from 2002 to 2013

OBJECTIVES

There is limited information regarding the association between air pollution exposure and stroke incidence. Therefore, this study aimed to assess the associations between short-term exposure to ambient air pollutants and initial hospital admission for ischemic stroke.

MATERIALS AND METHODS

From the Korea National Health Insurance Service-National Sample Cohort 2002-2013 database in South Korea, 55,852 first hospital admissions for ischemic stroke were identified. A generalized additive Poisson model was used to explore the association between air pollutants, including particulate matter, sulfur dioxide, nitrogen dioxide, and carbon monoxide and admissions for ischemic stroke.

RESULTS

All air pollutant models showed significant associations with ischemic stroke in the single lag model. In all air pollutant models excluding particulate matter 10 μm, a significant association was found between nitrogen dioxide exposure and initial admission for ischemic stroke after adjusting for other pollutants. An increment of 10 μg/m³ in nitrogen dioxide concentration at lag 0 and 14 days corresponded to a 0.259% (95% confidence interval, 0.231-0.287%) and 0.110% (95% confidence interval, 0.097-0.124) increase in initial admission for ischemic stroke, respectively.

CONCLUSIONS

The exposure-response relationship between nitrogen dioxide and initial admissions for ischemic stroke was approximately linear, with a sharper response at higher concentrations. Short-term exposure to nitrogen dioxide was positively associated with initial hospital admission for ischemic stroke.

Characteristics, risk factors and outcomes of gastrointestinal hemorrhage in COVID-19 patients: A meta-analysis

Background:

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a cause of coronavirus disease 2019 (COVID-19), mainly targets the respiratory system. However, recent studies also show its role in causing gastrointestinal hemorrhage, potentially affecting morbidity and mortality-related outcomes of the patients. There is still no consensus on the risk factors, characteristics, and the overall outcome of the gastrointestinal hemorrhage in COVID-19 patients. The main aim of this study was to summarize current evidence, assessing risk factors that promote the onset of gastrointestinal hemorrhage in COVID-19 patients, and to compare the incidences of the different sites of gastrointestinal lesions, the events of abdominal pain, diarrhea, intensive care unit admissions, and mortality between COVID-19 patients with or without gastrointestinal bleeding.

Methods:

A search of the academic literature was performed according to the PRISMA guidelines across five databases i.e., Web of Science, EMBASE, CENTRAL, Scopus, and MEDLINE. A random-effect meta-analysis was conducted to analyze the influence of the history of drugs consumption, gastrointestinal bleeding, the different incidence of gastrointestinal lesions, events of abdominal pain, intensive care unit (ICU) admission, and mortality between COVID-19 patients with/without gastrointestinal bleeding.

Results:

Out of 458 studies, three eligible studies with 663 participants (mean age: 69.7 ± 4.3 years) were included. A meta-analysis showed a medium-to-large influence of the history of gastrointestinal bleeding (Hedge’s g: 1.01) and anticoagulant drug consumption (g: 0.33) on the gastrointestinal bleeding in COVID-19 patients. Moreover, the incidence of gastroduodenal ulcers was higher as compared to esophagitis (37.5% versus 9.9%).

Conclusions:

The study provides preliminary evidence regarding the risk factors associated with the onset of gastrointestinal hemorrhage among COVID-19 patients. The study also outlines the characteristics and the outcomes of gastrointestinal hemorrhage in COVID-19 patients.

After the first wave and beyond lockdown: long-lasting changes in emergency department visit number, characteristics, diagnoses, and hospital admissions

The first wave (FW) of COVID-19 led to a rapid reduction in total emergency department (ED) visits and hospital admissions for other diseases. Whether this represented a transient "lockdown and fear" phenomenon, or a more persisting trend, is unknown. We divided acute from post-wave changes in ED flows, diagnoses, and hospital admissions, in an Italian city experiencing a FW peak followed by nadir. This multicenter, retrospective, cross-sectional study involved five general EDs of a large Italian city (January-August 2020). Percent changes were calculated versus 2019, using four 14-day periods (FW peak, early/mid/late post-wave). ED visits were 147,446 in 2020, versus 214,868 in 2019. During the FW peak, visits were reduced by 66.4% (P < 0.001). The drop was maximum during daytime (69.8%) and for pediatric patients (89.4%). Critical triage codes were unchanged. Reductions were found for all non-COVID-19 diagnoses. Non-COVID-19 hospital admissions were reduced by 39.5% (P < 0.001), involving all conditions except hematologic, metabolic/endocrine, respiratory diseases, and traumas. In the early, mid, and late post-wave periods, visits were reduced by 25.4%, 25.3% and 23.5% (all P < 0.001) respectively. In the late period, reduction was greater for female (27.9%) and pediatric patients (44.6%). Most critical triage codes were unchanged. Oncological, metabolic/endocrine, and hematological diagnoses were unchanged, while other diagnoses had persistent reductions. Non-COVID-19 hospital admissions were reduced by 12.8% (P = 0.001), 6.3% (P = 0.1) and 12.2% (P = 0.001), respectively. Reductions in ED flows, led by non-critical codes, persisted throughout the summer nadir of COVID-19. Hospital admissions for non-COVID-19 diseases had transient changes.

The relationship between 25(OH) vitamin D levels and COVID-19 onset and disease course in Spanish patients

OBJECTIVE

Currently, there are no definitive data on the relationship between low levels of vitamin D in the blood and a more severe disease course, in terms of the need for hospital admission, intensive care unit (ICU) stay, and mortality, in patients with coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We aimed to study the association between levels of circulating 25-hydroxyvitamin D (25(OH)D) and adverse clinical outcomes linked to SARS-CoV-2 infection. We further aimed to observe the incidence of low, below-average, and normal levels of 25(OH)D in patients hospitalized for COVID-19 between March 12, 2020, and May 20, 2020, and assess whether these values differed between these patients and a normal population. Finally, we determined whether the need for transfer to the intensive care unit (ICU) and the mortality rate were related to low levels of 25(OH)D.

STUDY DESIGN

Retrospective observational study.

SETTING

Quironsalud Hospitals in Madrid, Spain.

PARTICIPANTS

We analyzed 1549 patients (mean age, 70 years; range, 21-104 years); 835 were male (53.9 %; mean age, 73.02 years), and 714 were female (46.1 %; mean age, 68.05 years). Subsequently, infected patients admitted to the ICU (n = 112) and those with a fatal outcome (n = 324) were analyzed.

PROCEDURES

Serum concentrations of 25(OH)D were measured by electrochemiluminescence.

RESULTS

More hospitalized patients (66 %, n = 1017) had low baseline levels of 25(OH)D (<20 ng/mL) than normal individuals (45 %) (p < 0.001). An analysis by age group revealed that COVID-19 patients between the ages of 20 and 80 years old had significantly lower vitamin D levels than those of the normal population (p < 0.001). Patients admitted to the ICU tended to have lower levels of 25(OH)D than other inpatients (p < 0.001); if we stratified patients by 25(OH)D levels, we observed that the rate of ICU admission was higher among patients with vitamin D deficiency (p < 0.001), indicating that higher vitamin D levels are associated with a lower risk of ICU admission due to COVID-19. ICU admission was related to sex (higher rates in men, p < 0.001) and age (p < 0.001). When using a logistic regression model, we found that vitamin D levels continued to show a statistically significant relationship with ICU admission rates, even when adjusting for sex and age. Therefore, the relationship found between vitamin D levels and the risk of ICU admission was independent of patient age and sex in both groups. Deceased patients (n = 324 tended to have lower levels of 25 (OH)D that normal population of the same age (p < 0.001).

CONCLUSION

Vitamin D deficiency in patients with COVID-19 is correlated with an increased risk of hospital admission and the need for critical care. We found no clear relationship between vitamin D levels and mortality.

Consequences of the COVID-19 pandemic on admissions to general hospital psychiatric wards in Italy: Reduced psychiatric hospitalizations and increased suicidality

AIMS

The present investigation aimed at evaluating differences in psychiatric hospitalizations in Italy during and after the lockdown due to the novel coronavirus disease 2019 (COVID-19), compared to the same periods in 2018 and 2019.

METHODS

We obtained and analyzed anonymized data on psychiatric admissions (n = 4550) from 12 general hospital psychiatric wards (GHPWs) in different Italian regions (catchment area = 3.71 millions of inhabitants). Using a mixed-effects Poisson regression model, we compared admission characteristics across three periods: (a) March 1-June 30, 2018 and 2019; (b) March 1-April 30, 2020 (i.e., lockdown); and (c) May 1-June 30, 2020 (i.e., post-lockdown).

RESULTS

During the COVID-19 lockdown, there was a 41% reduction (IRR = 0.59; p < 0.001, CI: 0.45-0.79) in psychiatric admissions in the enrolled GHPWs with respect to the 2018 and 2019 control period. Conversely, admission rates in the post-lockdown period were similar to those observed in the control period. Notably, a consistent and significant reduction in psychiatric hospitalizations of older patients (aged >65 years) was observed in the lockdown (40%; IRR = 0.60; 95% CI: 0.44-0.82) and post-lockdown (28%; IRR = 0.72; 95% CI: 0.54-0.96) periods. Long-stay admissions (>14 days) increased (63%; IRR = 1.63; 95% CI: 1.32-2.02) during the lockdown and decreased by 39% thereafter (IRR = 0.61; 95% CI: 0.49-0.75). A significant 35% increase in patients reporting suicidal ideation was observed in the post-lockdown period, compared to the rate observed in the 2018 and 2019 control period (IRR = 1.35; 95% CI: 1.01-1.79).

CONCLUSION

The COVID-19 lockdown was associated with changes in the number of psychiatric admissions, particularly for older patients and long-stay hospitalizations. Increased admission of patients reporting suicidal ideation in the post-lockdown period merits special attention. Further studies are required to gain insight into the observed phenomena.