Chronic comorbidity and outcomes of hospital care: length of stay, mortality, and readmission at 30 and 365 days

Multiple morbidity combinations impact on medical expenditures among older adults

This study aims to explore the medical needs of patients who have different combinations of multiple chronic diseases in order to improve care strategy for chronic patients. This study was based on a national probability proportional to size (PPS) sampling to older adults over 50 years old. We collaborated the files of the 2000-2001 health insurance claims and selected 8 types of common chronic diseases among seniors, for the discussion of multiple combinations of chronic diseases, including hypertension, diabetes, heart disease, stroke, dementia, cancer, arthritis and chronic obstructive pulmonary disease. Among the NHI users, there are 50.6% of the cases suffering from at least one chronic disease, 27.3% suffering from two types of chronic diseases and above. From possible combinations of eight common chronic diseases, it is found hypertension has the highest prevalence rate (7.5%); arthritis ranks the next (6.2%); the combination of hypertension and heart disease ranks the third (3.4%). In the 22 types of major chronic disease clusters, the average total medical expense for people who have five or more chronic diseases ranks the highest, USD 4465; the combination of hypertension, diabetes, heart disease, and arthritis ranks the next, USD 2703; the combination of hypertension, diabetes, and heart disease ranks the third, USD 2550; cancer only ranks the fourth, USD 2487. Our study may provide statistical data concerning co-morbidity among older adults and their medical needs. Through our analysis, the major population that exhausts the medical resources may be discovered.

Physical disease in schizophrenia: a population-based analysis in Spain

Background

Physical disease remains a challenge in patients with schizophrenia. Our objective was to determine the epidemiological characteristics and burden of physical disease in hospitalized patients with schizophrenia.

Methods

We analyzed the 2004 Spanish National Hospital Discharge Registry, identified records coded for schizophrenia (295.xx) and characterized the physical diseases using the ICD-9 system and the Charlson Index. We also calculated standardized mortality ratios (SMRs) versus the general population adjusted by age and calendar time.

Results

A total of 16, 776 cases (mean age: 43 years, 65% males) were considered for analysis. Overall, 61% of cases had at least one ICD-9 physical code and 32% had more than one ICD-9 code. The Charlson index indicated that 20% of cases had a physical disease of known clinical impact and prognostic significance. Physical disease appeared early in life (50% of cases were 15-31 years of age) and increased rapidly in incidence with age. Thus, for patients aged 53 years or more, 84% had at least one physical ICD-9 code. Apart from substance abuse and addiction, the most prevalent diseases were endocrine (16%), circulatory (15%), respiratory (15%), injury-poisoning (11%), and digestive (10%). There were gender-related differences in disease burden and type of disease. In-hospital mortality significantly correlated with age, the Charlson Index and several ICD-9 groups of physical disease. Physical disease was associated with an overall 3.6-fold increase in SMRs compared with the general population.

Conclusions

This study provides the first nationally representative estimate of the prevalence and characteristics of physical disease in hospitalized patients with schizophrenia in Spain. Our results indicate that schizophrenia is associated with a substantial burden of physical comorbidities; that these comorbidities appear early in life; and that they have a substantial impact on mortality. This information raises concerns about the consequences and causes of physical disorders in patients with schizophrenia. Additionally, it will help to guide the design and implementation of preventive and therapeutic programs from the viewpoint of clinical care and in terms of health-care service planning.

The measurement of multiple chronic diseases--a systematic review on existing multimorbidity indices

BACKGROUND

Multimorbidity, defined as the coexistence of 2 or more chronic diseases, is a common phenomenon especially in older people. Numerous efforts to establish a standardized instrument to assess the level of multimorbidity have failed until now, and indices are primarily characterized by their high heterogeneity. Thus, the objective is to provide a comprehensive overview on existing instruments on the basis of a systematic literature review.

METHODS

The review was performed in MedLine. All articles published between January 1, 1960 and August 31, 2009 in German or English language, with the primary focus either on the development of a weighted index or on the effect of multimorbidity on different outcomes, were identified.

RESULTS

A total of 39 articles met the inclusion criteria. In the majority of studies (59.0%), the list of included diseases was presented without any selection criteria. Only the high prevalence of diseases (17.9%), their impact on mortality, function, and health status served as a point of reference. Information on the prevalence of chronic conditions mostly rely on self-reports. On average, the 39 indices included 18.5 diseases, ranging between 4 and 102 different conditions. Most frequently mentioned diseases were diabetes mellitus (in 97.5% of indices), followed by stroke (89.7%), hypertension, and cancer (each 84.6%). Overall, three different weighting methods could be distinguished.

CONCLUSIONS

The systematic literature further emphasis the heterogeneity of existing multimorbidity indices. However, one important similarity is that the focus is on diseases with a high prevalence and a severe impact on affected individuals.

Nurses joining family doctors in primary care practices: perceptions of patients with multimorbidity

BACKGROUND

Among the strategies used to reform primary care, the participation of nurses in primary care practices appears to offer a promising avenue to better meet the needs of vulnerable patients. The present study explores the perceptions and expectations of patients with multimorbidity regarding nurses' presence in primary care practices.

METHODS

18 primary (health) care patients with multimorbidity participated in semi-directed interviews, in order to explore their perceptions and expectations in regard to the involvement of nurses in primary care practices. Interviews were audio-recorded and transcribed. After reviewing the transcripts, the principal investigator and research assistants performed thematic analysis independently and reached consensus on the retained themes.

RESULTS

Patients with multimorbidity were open to the participation of nurses in primary care practices. They expected greater accessibility, for both themselves and for new patients. However, the issue of shared roles between nurses and doctors was a source of concern. Many patients held the traditional view of the nurse's role as an assistant to the doctor in his or her various duties. In general, participants said they were confident about nurses' competency but expressed concern about nurses performing certain acts that their doctor used to, notwithstanding a close collaboration between the two professionals.

CONCLUSION

Patients with multimorbidity are open to the involvement of nurses in primary care practices. However, they expect this participation to be established using clear definitions of professional roles and fields of practice.

Post-discharge hospital utilization among adult medical inpatients with depressive symptoms

BACKGROUND

Little evidence exists to determine whether depression predicts hospital utilization following discharge among adult inpatients on a general medical service.

OBJECTIVE

We aimed to determine whether a positive depression screen during hospitalization is significantly associated with an increased rate of returning for hospital services.

DESIGN

A secondary analysis was performed using data from 738 English-speaking, hospitalized adults from the Project RED randomized controlled trial (clinicaltrials.gov Identifier: NCT00252057) conducted at an urban academic safety-net hospital.

MEASUREMENTS

We used the nine-item Patient Health Questionnaire (PHQ-9) depression screening tool to identify patients with depressive symptoms. The primary endpoint was hospital utilization, defined as the number of emergency department (ED) visits plus readmissions within 30 days of discharge. Poisson regression was used to control for confounding variables.

RESULTS

Of the 738 subjects included in the analysis, 238 (32%) screened positive for depressive symptoms. The unadjusted hospital utilization within 30 days of discharge was 56 utilizations per 100 depressed patients compared with 30 utilizations per 100 non-depressed patients, incident rate ratio (IRR) (confidence interval [CI]), 1.90 (1.51-2.40). After controlling for potential confounders, a higher rate of post-discharge hospital utilization was observed in patients with depressive symptoms compared to patients without depressive symptoms (IRR [CI], 1.73 [1.27-2.36]).

CONCLUSIONS

A positive screen for depressive symptoms during an inpatient hospital stay is associated with an increased rate of readmission within 30 days of discharge in an urban, academic, safety-net hospital population.

Rehospitalization among elderly patients with thyroid cancer after thyroidectomy are prevalent and costly

BACKGROUND

Thyroid cancer increases in incidence and aggressiveness with age. The elderly are the fastest growing segment of the U.S. population. Reducing rates of rehospitalization would lower cost and improve quality of care. This is the first study to report population-level information characterizing rehospitalization after thyroidectomy among the elderly.

METHODS

The Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database was used to identify patients older than aged 65 years with thyroid cancer who underwent thyroidectomy from 1997-2002. Patient and hospital characteristics were studied to predict the risk of rehospitalization. Outcomes were 30-day unplanned rehospitalization rate, cost, and length of stay (LOS) of readmission.

RESULTS

Of 2,127 patients identified, 69% were women, 84% had differentiated thyroid cancer, and 52% underwent total thyroidectomy. Mean age was 74 years. A total of 171 patients (8%) underwent 30-day unplanned rehospitalization. Rehospitalization was associated with increased comorbidity, advanced stage, number of lymph nodes examined, increased LOS of index admission, and small hospital size (all P < 0.05). Patients with a complication during index hospital stay were more likely to be readmitted (P < 0.001), whereas patients who saw an outpatient medical provider after index discharge returned less frequently (P < 0.001). Forty-seven percent of readmissions were for endocrine-related causes. Mean LOS and cost of rehospitalization were 3.5 days and $5,921, respectively. Unplanned rehospitalization was associated with death at 1 year compared with nonrehospitalized patients (18% vs. 6%; P < 0.001).

DISCUSSION

Rehospitalization among Medicare beneficiaries with thyroid cancer after thyroidectomy is prevalent and costly. Further study of predictors could identify high-risk patients for whom enhanced preoperative triage, improved discharge planning, and increased outpatient support might prove cost-effective.

Learning and caring in communities of practice: using relationships and collective learning to improve primary care for patients with multimorbidity

We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other's goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.

Hospital admissions due to physical disease in people with schizophrenia: a national population-based study

OBJECTIVES

To examine nonpsychiatric hospitalizations in people with schizophrenia and to describe the epidemiological features of these admissions.

METHODS

We analyzed the 2000-2004 Spanish National Hospital Discharge Registry, identified records coded for schizophrenia (295.xx), selected admissions due to non-psychiatric causes and characterized the physical diseases using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) system and the Deyo-Charlson Index.

RESULTS

From all 2000-2004 hospitalizations in subjects with schizophrenia, 21 484 records (34%) were eligible for analysis. The mean age was 53 years, 61% were men. The mean number of ICD-9-CM codes was 2.3. The main diagnoses at discharge were injury-poisoning (19%) and respiratory (15%), digestive (14%) and circulatory diseases (12%), but there were significant age and gender-related differences. Inhospital mortality was 6.9% and the mean age of death was 63 years. Circulatory, respiratory diseases and neoplasms accounted for 21%, 18% and 17% of deaths, respectively. Inhospital mortality significantly correlated with age, the Deyo-Charlson Index and some specific processes.

CONCLUSIONS

Hospitalizations due to physical disease are frequent among people with schizophrenia and associated with a substantial burden and in-hospital mortality in Spain. This information may prove useful for the design and application of preventive and therapeutic programs in the early and silent phases of the most prevalent physical diseases.

Medical healthcare utilization as related to long-term care at home or in special accommodation

This study aimed to investigate medical healthcare utilization 3-5 years following the decision about long-term care at home vs. in special accommodation in older people. A total of 1079 people who were granted long-term care the years 2001, 2002 or 2003 were studied regarding the number of hospital stays and the number of contacts with physicians in outpatient care in the 3-5 subsequent years. Those living at home and those in special accommodation were compared regarding medical healthcare utilization during the 3-5 subsequent years. Data were collected through the study Good Aging in Skåne (GAS) and through the registers, Patient Administrative Support in Skåne (PASiS) and PrivaStat. Utilization of medical healthcare decreased slightly in the years following the decision about long-term care. Despite younger age and less dependency in activities of daily living (ADL), those living at home utilized hospital and outpatient care to a greater extent than those in special accommodation; these differences remained over time. Thus, it seems as long-term care needs to become more effective in the prevention of medical healthcare utilization among those cared for at home. More, older people who are granted long-term care at home may otherwise imply increased utilization of medical healthcare.

Diabetes prevalence and influence on resource use in Washington state inpatient rehabilitation facilities, 2001 to 2007

OBJECTIVE

To determine the prevalence of diabetes in inpatient rehabilitation facilities in Washington State from 2001 to 2007, and to determine the impact of diabetes on length of stay (LOS) and charges per day.

DESIGN

Longitudinal retrospective cohort analysis of inpatient rehabilitation discharge data from the Washington State Department of Health Comprehensive Hospital Abstract Reporting System.

SETTING

Inpatient rehabilitation.

PARTICIPANTS

Adults (N=56,382) who were discharged from inpatient rehabilitation in Washington State between 2001 and 2007.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Evidence of an established diagnosis of diabetes from International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes; comorbid conditions reported in ICD-9-CM codes; LOS; and charges per stay.

RESULTS

For all discharges from 2001 to 2007, diabetes prevalence was 17.8%; prevalence within specific impairment groups was 21.3% for the stroke subgroup, 14.2% for the orthopedic disorders subgroup, and 25% for the medically complex conditions subgroup. For all discharges, and within each impairment subgroup, prevalence did not change significantly from year to year. When adjusted for burden of nondiabetes comorbidities, LOS was significantly shorter for all discharges with diabetes younger than 65 years. The association between a diabetes codiagnosis and LOS in specific impairment groups was complex, ranging from a significantly shorter LOS for discharges with diabetes in the stroke subgroup to a finding of no significant difference in LOS among discharges with or without diabetes in the orthopedic impairments subgroup. Across all discharges, charges per day from 2003 to 2007 were significantly greater in discharges with diabetes. Within each specific impairment subgroup, charges per day across the entire study period were significantly greater for discharges with diabetes.

CONCLUSIONS

The high prevalence of diabetes, coupled with its impact on resource use, suggests that substantial pressures may be placed on the inpatient rehabilitation care system to respond to the needs of those with diabetes.

In-hospital mortality after stomach cancer surgery in Spain and relationship with hospital volume of interventions

BACKGROUND

There is no consensus about the possible relation between in-hospital mortality in surgery for gastric cancer and the hospital annual volume of interventions. The objectives were to identify factors associated to greater in-hospital mortality for surgery in gastric cancer and to analyze the possible independent relation between hospital annual volume and in-hospital mortality.

METHODS

We performed a retrospective cohort study of all patients discharged after surgery for stomach cancer during 2001-2002 in four regions of Spain using the Minimum Basic Data Set for Hospital Discharges. The overall and specific in-hospital mortality rates were estimated according to patient and hospital characteristics. We adjusted a logistic regression model in order to calculate the in-hospital mortality according to hospital volume.

RESULTS

There were 3241 discharges in 144 hospitals. In-hospital mortality was 10.3% (95% CI 9.3-11.4). A statistically significant relation was observed among age, type of admission, volume, and mortality, as well as diverse secondary diagnoses or the type of intervention. Hospital annual volume was associated to Charlson score, type of admission, region, length of stay and number of secondary diagnoses registered at discharge. In the adjusted model, increased age and urgent admission were associated to increased in-hospital mortality. Likewise, partial gastrectomy (Billroth I and II) and simple excision of lymphatic structure were associated with a lower probability of in-hospital mortality. No independent association was found between hospital volume and in-hospital mortality

CONCLUSION

Despite the limitations of our study, our results corroborate the existence of patient, clinical, and intervention factors associated to greater hospital mortality, although we found no clear association between the volume of cases treated at a centre and hospital mortality.

Racial differences in the impact of comorbidities on survival among elderly men with prostate cancer

This study investigates differences in the effects of comorbidities on survival in Medicare beneficiaries with prostate cancer. Medicare data were used to assemble a cohort of 65- to 76-year-old Black (n = 6,402) and White (n = 47,458) men with incident localized prostate cancer in 1999 who survived >or=1 year postdiagnosis. Comorbidities were more prevalent among Blacks than among Whites. For both races, greater comorbidity was associated with decreasing survival rates; however, the effect among Blacks was smaller than in Whites. After adjusting for age, socioeconomic status, and community characteristics, the association between increasing comorbidities and survival remained weaker for Blacks than for Whites, and racial disparity in survival decreased with increasing number of comorbidities. Differential effects of comorbidities on survival were also evident when examining different classes of comorbid conditions. Adjusting for treatment had little impact on these results, despite variation in the racial difference in receipt of prostatectomy with differing comorbidity levels.

[Usefulness of comorbidity indices in operative gastric cancer cases]

OBJECTIVES

The purpose of the current study was to evaluate the usefulness of the following four comorbidity indices in gastric cancer patients who underwent surgery: Charlson Comorbidity Index (CCI), Cumulative Illness rating scale (CIRS), Index of Co-existent Disease (ICED), and Kaplan-Feinstein Scale (KFS).

METHODS

The study subjects were 614 adults who underwent surgery for gastric cancer at K hospital between 2005 and 2007. We examined the test-retest and inter-rater reliability of 4 comorbidity indices for 50 patients. Reliability was evaluated with Spearman rho coefficients for CCI and CIRS, while Kappa values were used for the ICED and KFS indices. Logistic regression was used to determine how these comorbidity indices affected unplanned readmission and death. Multiple regression was used for determining if the comorbidity indices affected length of stay and hospital costs.

RESULTS

The test-retest reliability of CCI and CIRS was substantial (Spearman rho=0.746 and 0.775, respectively), while for ICED and KFS was moderate (Kappa=0.476 and 0.504, respectively). The inter-rater reliability of the CCI, CIRS, and ICED was moderate (Spearman rho=0.580 and 0.668, and Kappa=0.433, respectively), but for KFS was fair (Kappa=0.383). According to the results from logistic regression, unplanned readmissions and deaths were not significantly different between the comorbidity index scores. But, according to the results from multiple linear regression, the CIRS group showed a significantly increased length of hospital stay (p<0.01). Additionally, CCI showed a significant association with increased hospital costs (p<0.01).

CONCLUSIONS

This study suggests that the CCI index may be useful in the estimation of comorbidities associated with hospital costs, while the CIRS index may be useful where estimatation of comorbiditie associated with the length of hospital stay are concerned.

Introducing a clinical pathway for acute peptic ulcer bleeding in general internal medicine wards

OBJECTIVE

Management of acute peptic ulcer bleeding (PUB) is expensive and there is little evidence to prove the cost-effectiveness of a clinical pathway. The purpose of this study was to introduce a clinical pathway in hospitalized patients with acute PUB to evaluate its impact on costs and other outcomes.

MATERIAL AND METHODS

The clinical pathway was designed for and implemented in hospitalized patients, and a physicians reminder system that included chief residents, checklists, and case review meetings was also utilized. Use of medicine for acid suppression, length of hospital stay (LOS), and treatment costs were compared between patients before and after implementation of the clinical pathway. Outcome measures included the rate of recurrent bleeding, rate of repeat upper gastrointestinal (UGI) endoscopy, and rate of readmission within 30 days of discharge.

RESULTS

This clinical pathway significantly reduced the use of intravenous medicine for acid suppression from 88% to 34%, with mean LOS down from 6.7 to 3.6 days, mean cost of medications decreased from New Taiwan Dollars (NTD) 8768 to NTD 3940 (cost down 55.1%), mean cost of diagnostic tests lowered from NTD 12,560 to NTD 9493 (cost down 24.4%), and mean total hospital cost down from NTD 33,142 to NTD 19,519 (cost down 41.1%). Outcome measures were not significantly different.

CONCLUSIONS

Introduction of a clinical pathway is an effective method for reducing costs while maintaining quality of care in the management of PUB.

Impact of surgical approach on complications and resource utilization of cervical spine fusion: a nationwide perspective to the surgical treatment of diffuse cervical spondylosis

BACKGROUND CONTEXT

Cervical spine fusion is performed for various indications in patient populations ranging from young and healthy to aged and frail. The choice of surgical approach is affected not only by disease pathoanatomy, but also by age, medical comorbidities, and the number of involved levels. Anterior fusion is more common for single-level pathology in relatively young, healthy patients; and posterior fusion is typically performed on older, more comorbid patients with multilevel disease. Consequently, retrospective comparisons of surgical approaches for cervical fusion will be impacted by this bias, and the optimal management of multilevel cervical spine pathology remains ambiguous with surgeon preference and experience playing a significant role in choice of procedures.

PURPOSE

To define the complications and resource utilization related to multilevel cervical spine fusion surgery, and to evaluate the impact of surgical approach on these outcomes.

STUDY DESIGN/SETTING

A retrospective nationwide database study of inpatient perioperative complications.

PATIENT SAMPLE

All patients undergoing multilevel (four to eight levels) cervical spine fusion for degenerative disease between 2003 and 2005 at institutions represented in the Nationwide Inpatient Sample database.

OUTCOME MEASURES

Measures of patient periprocedural mortality, selected specific morbidities, and resource utilization were evaluated. Resource utilization included length of hospitalization, inflation-adjusted cost, and likelihood of nonroutine discharge to assisted living.

METHODS

Data for 8,548 patients who underwent cervical fusion of four to eight levels were collected from the Nationwide Inpatient Sample database (2003-2005), and subjects were grouped by surgical approach (anterior vs. posterior). Descriptive statistics compared baseline characteristics, and bivariate analysis and logistic regression modeling evaluated the effect of surgical approach on mortality, selected postoperative complications, length of stay, hospitalization cost, and discharge disposition. All tests were performed at the 0.05 level of significance.

RESULTS

This observational study indicates that a posterior approach to multilevel cervical fusion is associated with more respiratory complications, postoperative infections, symptomatic hematomas, and transfusions when compared with an anterior approach. Resource utilization was nearly double for those undergoing a posterior approach, including hospital length of stay, inflation-adjusted cost, and likelihood of discharge to an assisted-living facility. Not surprisingly, this study confirms that patients fused posteriorly had a lower incidence of symptomatic postoperative dysphagia.

CONCLUSIONS

This nationwide study defines the incidence of mortality and the frequency of inpatient complications encountered during multilevel cervical fusion. The results suggest that immediate morbidity from anterior approaches is less than those undergoing posterior fusion. Prospective analysis is required to evaluate if these findings remain significant in a randomized study population. Further, these results represent only perioperative complications. However, based on the data presented herein, when confronted with the patient requiring a four-level cervical fusion, the anterior approach may offer a less risky and less costly option.

Relationship between multimorbidity and physical activity: secondary analysis from the Quebec health survey

Background

Abundant literature supports the beneficial effects of physical activity for improving health of people with chronic diseases. The relationship between multimorbidity and physical activity levels, however, has been little evaluated. The purpose of the current exploratory study was to examine the relationship between a) multimorbidity and physical activity levels, and b) long-term limitations on activity, self-rated general health, psychological distress, and physical activity levels for each sex in adults, after age, education, income, and employment factors were controlled for.

Methods

Data from the Quebec Health Survey 1998 were used. The sample included 16,782 adults 18–69 yr of age. Independent variables were multimorbidity, long-term limitations on activity, self-rated general health, and psychological distress. The dependent variable was physical activity levels. Links between the independent and dependent variables were assessed separately for men and women with multinomial regressions while accounting for the survey sampling design and household clustering.

Results

About 46% of the participants were men. Multimorbidity was not associated with physical activity levels for either men or women. Men and women with long-term limitations on activity and with poor-to-average self-rated general health were less likely to be physically active. No relationship between psychological distress and physical activity was found for men. Women with high levels of psychological distress were less likely to be physically active.

Conclusion

Multimorbidity was not associated with physical activity levels in either sex, when age, education, income, and employment factors were controlled for. Long-term limitations on activity and poor-to-average self-rated general health seem related to a reduction in physical activity levels for both sexes, whereas psychological distress was associated with a reduction in physical activity levels only among women. Longitudinal studies using a comorbidity or multimorbidity index to account for severity of the chronic diseases are needed to replicate the results of this exploratory study.

Impact of preoperative neurological status on perioperative morbidity associated with anterior and posterior cervical fusion

OBJECT

Cervical spine fusion is performed for various indications in patient populations ranging from young and healthy to aged and frail. Whereas disease pathoanatomy dictates the surgical approach, preoperative neurological status does not necessarily implicate a specific technique. Although one expects anterior decompression to be performed over fewer segments in healthier patients who experience fewer complications and faster recovery, the impact of pre-operative myelopathy on perioperative complications remains unclear. No large-scale study has evaluated rates of common complications for cervical fusion or their association with surgical approach and neurological status.

METHODS

Data for 96,773 patients who underwent cervical fusion for degenerative disease between 1988 and 2003 were collected from the Nationwide Inpatient Sample database. Patients were grouped according to surgical approach (anterior versus posterior) and preoperative neurological status (myelopathic versus nonmyelopathic). Multivariate regression was used to evaluate group effects on selected postoperative complications, length of stay, and disposition at the time of hospital discharge. Although this technique can control for the observed covariates, the absence of key information such as the number of fused levels precludes statistical comparison between patients who underwent anterior or posterior approaches.

RESULTS

In this study the authors confirmed that preoperative neurological status impacts perioperative morbidity. For example, patients who were nonmyelopathic and underwent an anterior approach were 7 years younger than the rest of the cohort, and they had a mortality rate of 0.05%. Transfusion was required in 0.34%, and venous thromboembolism occurred in 0.04%. Conversely, these rates were > 13-fold higher in patients with myelopathy who underwent a posterior approach. Furthermore, independent of approach, preoperative myelopathy is highly prognostic of death, pneumonia, transfusion, infection, length of stay, and posthospital disposition. These outcomes at least doubled, with some increasing > 10-fold.

CONCLUSIONS

This nationwide study clarifies the frequency and associations of inpatient complications encountered when treating cervical spine disease. Whereas immediate complications due to anterior approaches are limited, patients with myelopathy who undergo a posterior approach have a more sobering outlook. This study shows that clinical myelopathy augments rates of complication during cervical fusion, regardless of the approach. The exclusion of pathoanatomical data from the Nationwide Inpatient Sample database, of key importance in guiding the surgical approach, prevents any conclusions being drawn about the merits and disadvantages of anterior versus posterior surgery.

Multimorbidity: prevalence, effect on quality of life and daily functioning, and variation of this effect when one condition is a rheumatic disease

OBJECTIVES

To examine the prevalence and effect of multimorbidity on health-related quality of life (HRQoL) and daily functioning in the general population, and to analyze the influence on HRQoL and daily functioning of multimorbidity including a rheumatic disease.

METHODS

A national health survey was conducted on 2192 randomly selected adults in Spain. Multimorbidity was defined as the co-occurrence of at least 2 chronic diseases, as defined by self-report. All subjects completed the 12-item short form (SF-12) health survey and the Health Assessment Questionnaire (HAQ). Estimates and 95% confidence intervals (CI) of the prevalence of multimorbidity were obtained. The effect on HAQ and SF-12 scores is presented as beta-coefficients obtained from multiple linear regressions.

RESULTS

The estimated prevalence of multimorbidity was 30% (95% CI 25 to 34), and the prevalence of multimorbidity including a rheumatic disease was 17% (95% CI 13 to 20). Multimorbidity was associated with impaired daily functioning [HAQ beta = 0.07 (95% CI 0.02 to 0.11)], and lower HRQoL [SF-12(physical component) beta = -4.2 (95% CI -5.2 to -3.22); SF-12(mental dimension) beta = -3.3 (95% CI -4.5 to -2.2)]. Subjects with multimorbidity including a rheumatic disease reported worse scores than those without a rheumatic disease: HAQ beta 0.13 (95% CI 0.07 to 0.18) versus -0.03 (95% CI -0.08 to 0.02), and SF-12(physical component) beta -6.5 (95% CI -5.2 to -3.2) versus 0.5 (95% CI -0.7 to 1.7).

CONCLUSIONS

Multimorbidity is frequent in the general population and can considerably impair daily functioning and HRQoL. Having a rheumatic disease worsens these outcomes.

KRD. The Charlson comorbidity index (CCI) for adjustment of hip fracture mortality in the elderly: analysis of the importance of recording secondary diagnoses

This study evaluates the role of the number of secondary diagnoses for calculating the Charlson comorbidity index (CCI) in risk adjustment of the 90-day mortality rate after hip fracture surgical repair. Comorbidities were selected by reviewing the medical records of 390 patients 50 years of age or older in a teaching hospital in Rio de Janeiro from 1995 to 2000. Logistic regression models were fitted including the variables age, sex, and CCI. The CCI was calculated based on: (1) all patients' comorbidities; (2) only the comorbidity with the highest weight; and (3) a single randomly selected comorbidity. There was a gradient in the prediction of the CCI mortality rate when all comorbidities were used (OR = 6.53; 95%CI: 2.27-18.77, for scores <FONT FACE=Symbol>³</FONT> 3). The predictive capacity of the CCI was observed even when it was calculated using only one comorbidity: with the highest weight (OR = 2.83; 95%CI: 1.11-7.22); and randomly selected (OR = 2.90; 95%CI: 1.07-7.81). Using all comorbidities for CCI calculation is important. Severity indices based on a single comorbidity can be useful for risk adjustment procedures.

Outcomes at 12 months in a population of elderly patients discharged from a rehabilitation unit

OBJECTIVES

This study investigates the cognitive, functional, and clinical variables associated with the risk of institutionalization, rehospitalization, and death at 12 months among a population of elderly discharged from a Rehabilitation and Aged Care Unit (RACU) within a 1-year period (May 1, 2004 to April 30, 2005). The RACU is a relatively new setting of care providing intensive rehabilitation and clinical support to elderly with highly heterogeneous reasons for admission.

METHODS

There were 1303 patients (> or =65 years old) contacted 12 months after discharge from the RACU. We obtained information about institutionalization, rehospitalization, and death. Predictors were all the demographic and clinical variables potentially related to these outcomes. The relationship among predictors and outcomes was tested with multiple stepwise logistic regression models.

RESULTS

Among the 1072 patients alive at the 12-month follow-up, 90 (8.4%) were institutionalized (3.4% early at discharge and 4.9% within the next period). The logistic regression analysis showed that 2 ranges of age (78 to 83 years and 84 years or more), living alone, occurrence of delirium, cognitive impairment (Mini Mental State Examination lower or equal to 20/30), and poor functional status at discharge (Barthel Index scores ranging from 69 to 85 and Barthel Index scores lower than 68/100) were independently and significantly associated with the risk of institutionalization during the 12 months following discharge from the RACU. Three hundred and twenty-three (30.1%) patients had been rehospitalized once and 86 (8.0%) patients twice at the 12-month follow-up. In the multivariate analysis, comorbidity (Charlson Index scores ranging from 2 to 3 and Charlson Index scores higher than 4) and delirium were significantly and independently associated with this outcome. One hundred and thirty-six (11.3%) patients had died by the 12-month follow-up. The stepwise logistic regression analysis showed that age greater than 83 years, poor functional status (Barthel Index lower than 60/100 at discharge), high comorbidity (Charlson Index scores ranging from 3 to 4 and Charlson Index scores higher than 4, respectively), and albumin serum levels ranging from 3.2 to 2.9 mg/dL and lower than 2.9 mg/dL independently and significantly predicted the 12-month risk of death. Absence of depressive symptoms (Geriatric Depression Scale <2/15) had instead a protective effect.

CONCLUSION

Variables related to the sociodemographic, cognitive, functional, and health status predicted, with different degree of association, the 12-month risk of institutionalization, rehospitalization, and death among a population of elderly patients discharged from a RACU. Accordingly, various clinical and organizational approaches may be planned for prevention.

[Measurement of chronic conditions in a single person as a mortality predictor]

The presence of multiple chronic diseases in a single individual has become an increasing public health problem for two reasons: population aging and the growing prevalence of chronic conditions in the elderly. This article aims to review the various measures of chronic conditions used in different morbidity studies and to provide an example of their application. We present definitions and characteristics of distinct morbidity measures, as well as their advantages and disadvantages, and provide an example of their calculation using real data. The presence of multiple chronic diseases in a single individual can be measured in multiple ways. Thus, morbidity can be expressed as multi-morbidity, co-morbidity, or as a co-morbidity index. Researchers have to select the best option according to the research objectives, study design, information resources, and the main outcome variable selected.

Hospitalised osteoporotic vertebral fractures in Spain: analysis of the national hospital discharge registry

This population-based study reveals clinical and epidemiologic characteristics of hospitalised osteoporosis-related vertebral fractures and indicates an association with a substantial hospital burden in Spain. These data provide a basis for assessing the impact of these fractures on the Spanish health-care system and to estimate future care requirements.

INTRODUCTION

Vertebral fractures (VF) are recognised as the most frequent complication of osteoporosis. Our objective was to determine the clinico-epidemiological characteristics and health-care burden of hospitalised VF in Spain.

METHOD

From the 2002 National Hospital Discharge Register, records for all osteoporosis-related VF in the Spanish population aged >or=30 years and over were retrieved. Diagnostic categories included the ICD-9-CM codes 805 and 733.xx. Population data were drawn from the National Statistics Institute.

RESULTS

In total, 7,100 records were eligible for analysis. According to Deyo-adapted Charlson index, 62% of cases had no associated comorbidity. VF were the cause of hospitalisation in 52% of cases. Overall in-hospital mortality was 3.5%. Men had higher adjusted mortality than women. Mean hospital stay was 11.4+/-0.2 days. Identified cases amounted to a hospitalisation rate of 2.76 cases per 10,000 population aged >or=30 years. Direct inpatient hospital costs exceeded 41 million euros and accounted for 0.078% of Spanish expenditure on hospitalisations and specialised care in 2002.

CONCLUSIONS

The national discharge database reveals epidemiological features of hospitalised osteoporosis-attributable VF and indicates an association with a substantial hospital burden in Spain. Our data provide a basis for assessing the impact of these fractures on the Spanish health-care system and to estimate future care requirements.

Hospital admissions among people 65+ related to multimorbidity, municipal and outpatient care

This study aimed at examine the number of planned and acute hospital admissions during 1 year among people 65+ and its relation to municipal care, outpatient care, multimorbidity, age and sex. Four thousand nine hundred and seven individuals having one or more admissions during 2001 were studied. Data were collected from two registers and comparisons were made between those having one, two and three or more hospital stays and between those with and without municipal care and services. Linear regression was used to examine factors predicting number of acute and planned admissions. Fifteen percent of the sample had three or more hospital stays (range 3-15) accounting for 35% of all admissions. This group had significantly more contacts in outpatient care with physician (median number of contacts (md)=15), compared to those with one (md: 8), or two admissions (md: 11). Main predictors for number of admissions were number of diagnosis groups and number of contacts with physician in outpatient care. Those who are frequently admitted to hospital constitute a small group that consume a great deal of inpatient care and also tend to have frequent contacts in outpatient care. Thus interventions focusing on frequent admissions are needed, and this requires collaboration between outpatient and hospital care.

[Validation of colorectal cancer diagnostic codes in a hospital administration data set]

OBJECTIVES

To validate the ability of a hospital administration data set (minimum data set [MDS]) to detect incident cases of colorectal cancer using the Murcia Cancer Registry (MCR) as the gold standard and to measure agreement between the MDS and registration of colorectal cancer.

MATERIAL AND METHOD

A cross sectional validation study of the MDS of the main hospital in the region of Murcia (Spain) was conducted. The study population consisted of incident cases of colorectal cancer in 2000 obtained from the MCR and cases in the MDS of the above-mentioned hospital for the same year with an ICD-9 diagnostic code between 153.0 and 154.1, eliminating readmissions. During the process, two analyses were performed: one analysis with the principal diagnosis only and another with all the diagnostic codes. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and agreement was calculated with their 95% confidence intervals (CI).

RESULTS

With the first diagnosis only, the MDS detected 80% of the incident cases of colorectal cancer with a PPV of 75%. With all the diagnoses, the MDS detected 85% of the cases with a PPV of 64%. The agreement in codification was high at three digits (kappa 88% [95% CI, 0.79-0.97] first diagnosis, 89% [95% CI, 0.80-0.97] all diagnoses) as well as at four digits (kappa 77% [IC, 0.68-0.85] first diagnosis, 78% [95% CI, 0.70-0.86] all diagnoses) in both analyses.

CONCLUSIONS

Because of its high sensitivity, the MDS is a good source for detecting incident cases of cancer. The high agreement found in the site of colorectal cancer helps to consolidate the MDS as a data source for cancer registration.

Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care

BACKGROUND

The hospital readmission rate has been proposed as an important outcome indicator computable from routine statistics. However, most commonly used measures raise conceptual issues.

OBJECTIVES

We sought to evaluate the usefulness of the computerized algorithm for identifying avoidable readmissions on the basis of minimum bias, criterion validity, and measurement precision.

RESEARCH DESIGN AND SUBJECTS

A total of 131,809 hospitalizations of patients discharged alive from 49 hospitals were used to compare the predictive performance of risk adjustment methods. A subset of a random sample of 570 medical records of discharge/readmission pairs in 12 hospitals were reviewed to estimate the predictive value of the screening of potentially avoidable readmissions.

MEASURES

Potentially avoidable readmissions, defined as readmissions related to a condition of the previous hospitalization and not expected as part of a program of care and occurring within 30 days after the previous discharge, were identified by a computerized algorithm. Unavoidable readmissions were considered as censored events.

RESULTS

A total of 5.2% of hospitalizations were followed by a potentially avoidable readmission, 17% of them in a different hospital. The predictive value of the screen was 78%; 27% of screened readmissions were judged clearly avoidable. The correlation between the hospital rate of clearly avoidable readmission and all readmissions rate, potentially avoidable readmissions rate or the ratio of observed to expected readmissions were respectively 0.42, 0.56 and 0.66. Adjustment models using clinical information performed better.

CONCLUSION

Adjusted rates of potentially avoidable readmissions are scientifically sound enough to warrant their inclusion in hospital quality surveillance.

Length of comorbidity lookback period affected regression model performance of administrative health data

BACKGROUND AND OBJECTIVE

The impact of different comorbidity ascertainment lookback periods on modeling posthospitalization mortality and readmission was examined.

METHODS

Index cases comprised medical (n = 326,456) and procedural (n = 349,686) patients with a hospital admission from 1990-1996. Administrative hospital data were extracted for 102 comorbidities, ascertained at index admission and for 1-, 2-, 3-, and 5-year lookback periods. Deaths and readmissions were identified within 12 months and 30 days of separation, respectively. Hierarchically nested and nonnested Cox regressions as well as Receiver Operator Characteristic Area Under the Curve (ROC-AUC) were used to determine model-fit and predictive ability of lookback period models.

RESULTS

The 1-year lookback period provided the best model-fit for both patient groups when modeling mortality. A similar model-fit was seen at index admission for procedural but not medical patients. The superior readmission model employed 5 years of lookback for both patient groups. With one exception, all lookback period models were superior to those abstracting comorbidity from index admission only. Similar results were evident from ROC-AUC, although greater predictive ability was seen with modeling of mortality (0.847-0.923) compared with readmission (0.593-0.681).

CONCLUSION

The explanatory power of regression models, when adjusting for comorbidity, is influenced by length of lookback, outcome investigated and clinical subgroup. Shorter periods (approximately 1 year) appear appropriate for modeling posthospitalization mortality, whereas longer lookback periods are superior for readmission outcomes.

Case and care complexity in the medically ill

The authors have argued that complexity in general health care is increasingly prevalent because of the increase in patients who have multimorbid conditions, and the increased professional and technical possibilities of medicine. In the increasingly complex care systems, it is necessary-specifically when treating patients in need of integrated care by several providers-that an optimal match between case and care complexity be found in order to prevent poor outcomes in this vulnerable group. The authors discussed several approaches to case complexity that can be identified in the literature. Most of them seem unsuitable for adjusting case and care complexity, and inadequate for designing multidisciplinary care. Theoretic approaches to case complexity may be of interest, but did not result in clinically meaningful information. The INTERMED, which can be considered the first empirically based instrument to link case and care complexity, is an attempt to improve care delivery and outcomes for the complex medically ill.

Charlson Index is associated with one-year mortality in emergency department patients with suspected infection

OBJECTIVES

A patient's baseline health status may affect the ability to survive an acute illness. Emergency medicine research requires tools to adjust for confounders such as comorbid illnesses. The Charlson Comorbidity Index has been validated in many settings but not extensively in the emergency department (ED). The purpose of this study was to examine the utility of the Charlson Index as a predictor of one-year mortality in a population of ED patients with suspected infection.

METHODS

The comorbid illness components of the Charlson Index were prospectively abstracted from the medical records of adult (age older than 18 years) ED patients at risk for infection (indicated by the clinical decision to obtain a blood culture) and weighted. Charlson scores were grouped into four previously established indices: 0 points (none), 1-2 points (low), 3-4 points (moderate), and > or =5 points (high). The primary outcome was one-year mortality assessed using the National Death Index and medical records. Cox proportional-hazards ratios were calculated, adjusting for age, gender, and markers of 28-day in-hospital mortality.

RESULTS

Between February 1, 2000, and February 1, 2001, 3,102 unique patients (96% of eligible patients) were enrolled at an urban teaching hospital. Overall one-year mortality was 22% (667/3,102). Mortality rates increased with increasing Charlson scores: none, 7% (95% confidence interval [CI] = 5.4% to 8.5%); low, 22% (95% CI = 19% to 24%); moderate, 31% (95% CI = 27% to 35%); and high, 40% (95% CI = 36% to 44%). Controlling for age, gender, and factors associated with 28-day mortality, and using the "none" group as a reference group, the Charlson Index predicted mortality as follows: low, odds ratio of 2.0; moderate, odds ratio of 2.5; and high, odds ratio of 4.7.

CONCLUSIONS

This study suggests that the Charlson Index predicts one-year mortality among ED patients with suspected infection.

Evaluation of comorbidity indices for inpatient mortality prediction models

BACKGROUND AND OBJECTIVES

The objectives of the current study were: to compare the predictive capacity of the original Charlson comorbidity index (CCI), the CCI with new assigned diagnostic codes and estimated weights, and a new developed comorbidity index in a Brazilian population; and to study the effect of the number of comorbidity diseases recorded on the predictive capacity of the comorbidity indices.

MATERIALS AND METHODS

The study was limited to the Ribeirão Preto region in the State of São Paulo, Brazil, from January 1996 to December 1998. We included only admissions in which the principal diagnoses were respiratory and circulatory diseases.

RESULTS

Evaluation of the CCI indicates that revision of the clinical conditions studied by Charlson, as well as their weights, increased mortality model predictive capacity. The C statistic was 0.72 for the original CCI, and increased to 0.74 for the CCI with new weights and 0.76 for the new index. The C statistic increases in all the comorbidity indices with the utilization of more diagnostic information. This impact is greater when a second secondary diagnosis is added.

CONCLUSIONS

The results of the validity analysis for comorbidity indices favor the utilization of empirically developed indices. However, the increase in predictive capacity was weak. In addition, age and principal diagnosis are the most important predictors of inpatient mortality.

Underappreciated Predictors for Postdischarge Mortality in Acute Hospitalized Oldest-Old Patients

BACKGROUND

Although oldest-old, those aged 85 years and older, patients are the fastest growing segment, clinical evidences regarding the acute care of oldest-old patients are still lacking. Because acute medical conditions requiring emergent hospitalization is frequently followed by high rate of progressive physical decline and increased mortality after discharge in oldest-old patients, prognostic information collected during hospitalization can provide the basis for discussion about the goals of care and therapy. The aim of our study was to identify predictive factors for postdischarge mortality in oldest-old patients.

METHODS

The study included 403 oldest-old patients discharged from the acute care setting of a general hospital, who were followed-up for 1 year. Predictive values of the patients' characteristics collected during their hospitalization for 1-year mortality were identified utilizing Cox proportional hazard regression analysis.

RESULTS

During 1-year follow-up, 104 patients (25.8%) died. The variables independently associated with 1-year mortality in multivariate analysis were the Charlson Comorbidity Index equal or greater than 2 [HR (hazard ratio) 4.71, 95%CI (confidence interval) 1.09-20.42], six or more prescribed medications at discharge (HR 3.12, 95% CI 1.39-6.99), benzodiazepines use (HR 1.64, 95% CI 1.04-2.60), nonsteroidal anti-inflammatory drugs use (HR 1.70, 95% CI 1.10-2.63), albumin less than or equaling 3.4 g/dl (HR 2.16, 95% CI 1.13-4.14), hemoglobin 10-12 g/dl (HR 2.32, 95% CI 1.22-3.56), hemoglobin less than 10 g/dl (HR 2.67, 95% CI 1.43-4.95), the presence of pressure sores (HR 1.84, 95% CI 1.14-2.97), and a history of delirium (HR 2.24, 95% CI 1.32-3.79). Functional impairment assessed by the Katz Index was only weakly associated with mortality (HR 1.24, 95% CI 0.53-2.91).

CONCLUSION

Although often underappreciated, polypharmacy, particular medication use, anemia, the presence of pressure sores, and a history of delirium were important predictors for postdischarge mortality in oldest-old patients.

Indicadores de calidad relacionados con el reingreso y la muerte precoces tras la hospitalización por insuficiencia cardíaca

BACKGROUND AND OBJECTIVE

To determine wether the quality of care criteria applied and the treatment provided to patients hospitalized after congestive heart failure were appropriate to reduce rates of premature readmission and death.

PATIENTS AND METHOD

We analyzed the epidemiologic, clinical and quality of care data proposed by 3 international organizations: JCAHO, AHA/ACC and ACOVE Project. The dependent variable was defined as readmission or death during the 30 days after discharge. A multivariate analysis was made using multiple binary logistic regression of the parameters of quality of care and treatment appropriateness.

RESULTS

225 hospital discharge records were analyzed. There were 21 readmissions and 3 deaths (i.e., 24 cases [10.7%] with a positive dependent variable). 162 records (72%) corresponded to patients aged 65 years and over, who presented a total of 18 (8%) readmissions or premature deaths. A positive association between readmission or premature death was found with regard to 2 variables: appropriate treatment with beta-blockers (odds ratio [OR] = 0.34) and the Charlson index (OR = 3,79 for score of 3 or more vs. score of 2 or less). In the case of patients aged 65 years and over the same 2 variables were positively associated, with OR similar to those cited (OR = 0.31 and 3.21, respectively). No association was found between premature readmission or death and the overall evaluation of the criteria referred to by AHA/ACC, JCAHO or the ACOVE Project.

CONCLUSIONS

Premature readmission or death of patients with heart failure is more determined by the characteristics of the clinical state of patients (the Charlson comorbidity index) and by the appropriateness of the treatment applied (treatment with beta-blockers) than by the accomplishment of quality of care criteria as proposed by the cited scientific organizations.

Does the addition of functional status indicators to case-mix adjustment indices improve prediction of hospitalization, institutionalization, and death in the elderly?

BACKGROUND

Case-mix adjustment is widely used in health services research to ensure that groups being compared are equivalent on variables predicting outcome. There has been considerable development and testing of comorbidity indices derived from diagnostic codes recorded in administrative databases, but increasingly, the benefit of clinical information and patient reported ratings of health and functional status is being recognized. One type of information that is highly valued but has so far not been captured by administrative health databases is functional status indicators (FSI).

OBJECTIVE

The purpose of this study was to estimate the extent to which prediction of health outcomes can be improved on by including information on functional status indicators (FSI).

RESEARCH DESIGN

The data for the current study was obtained from a clustered randomized trial evaluating computerized decision support for managing drug therapy in the elderly, conducted from 1997 to 1998. A total of 107 primary care physicians participated in this trial and 6465 of their patients (51%) completed a generic health status measure-the SF-12-before the intervention. C statistics and R were used to compare the predictive value of sociodemographic factors, 2 comorbidity indices, and 11 FSI predictor variables derived from the SF-12 and coded (possible for 8) using the International Classification of Functioning (ICF).

RESULTS

Using stepwise logistic regression, FSI, particularly limitation in stair climbing or doing moderate activities like housework, were found to be strong and independent predictors of all outcomes, even after controlling for sociodemographics and comorbidity.

CONCLUSION

This study indicates that FSI provided as robust a prediction of health events as did complex comorbidity indices. Additionally, the ICF coding system provides a mechanism whereby information on FSI could be incorporated into administrative databases through the use of electronic health records that include a health or functional status measure.

Single index of multimorbidity did not predict multiple outcomes

BACKGROUND AND OBJECTIVES

Measurement of multimorbidity and comorbidity is important in epidemiologic and health services research. The aim of this research was to derive a generic multimorbidity index based on patient self-report, incorporating severity, for predicting a range of outcomes.

METHODS

The dataset was obtained from a trial including 1,541 Veterans and war widows aged 70 years and over. The survey included sociodemographics, hospital admissions, SF-36, and information on deaths was obtained. The methods of Charlson were used to derive Multimorbidity Indices.

RESULTS

All indices predicted quality of life, with decreasing quality of life for each increase in multimorbidity category. Multimorbidity scores incorporating severity significantly contributed to the prediction of mortality, hospital admission, and follow-up quality of life, regardless of adjustment for baseline quality of life.

CONCLUSIONS

Our results indicate that a single index cannot predict a variety of relevant outcomes. Consequently, research undertaken to assess the impact of intervention or illness on health outcomes should use an index that is valid for predicting the specific outcome of interest.

Charlson's Index was a poor predictor of quality of life outcomes in a study of patients following joint replacement surgery

OBJECTIVE

We examined the predictive validity of Charlson's Index as a tool to measure and adjust for comorbidity in studies of health-related quality of life(HRQOL) outcomes after joint replacement surgery.

STUDY DESIGN AND SETTING

SF-36 physical component summary scores were available for a cohort of patients who underwent primary hip or knee replacement surgery at one hospital over a 12-month period. Baseline comorbidity was assessed for the same group of patients using longitudinal hospital morbidity data from the Western Australia Department of Health. The presence or absence of individual conditions was determined, and Charlson's Index scores were calculated for each patient, using varying look-back periods.

RESULTS

In regression analysis, Charlson's Index was a poor predictor of the HRQOL outcome scores, explaining a maximum 1.79% of the variance. In contrast, the presence or absence of a small number of individual conditions together explained between 5% and 7% of the variance.

CONCLUSION

The findings suggest that Charlson's Index should not be used to adjust for HRQOL outcomes, particularly in this patient group with low levels of serious comorbidity. Alternative methods are needed for use in this context.

Sex differences in hospital readmission among colorectal cancer patients

BACKGROUND

While several studies have analysed sex and socioeconomic differences in cancer incidence and mortality, sex differences in oncological health care have been seldom considered.

OBJECTIVE

To investigate sex based inequalities in hospital readmission among patients diagnosed with colorectal cancer.

DESIGN

Prospective cohort study.

SETTING

Hospital Universitary in L'Hospitalet (Barcelona, Spain).

PARTICIPANTS

Four hundred and three patients diagnosed with colorectal between January 1996 and December 1998 were actively followed up until 2002. Main outcome measurements and

METHODS

Hospital readmission times related to colorectal cancer after surgical procedure. Cox proportional model with random effect (frailty) was used to estimate hazard rate ratios and 95% confidence intervals of readmission time for covariates analysed.

RESULTS

Crude hazard rate ratio of hospital readmission in men was 1.61 (95% CI 1.21 to 2.15). When other significant determinants of readmission were controlled for (including Dukes's stage, mortality, and Charlson's index) a significant risk of readmission was still present for men (hazard rate ratio: 1.52, 95% CI 1.17 to 1.96).

CONCLUSIONS

In the case of colorectal cancer, women are less likely than men to be readmitted to the hospital, even after controlling for tumour characteristics, mortality, and comorbidity. New studies should investigate the role of other non-clinical variable such as differences in help seeking behaviours or structural or personal sex bias in the attention given to patients.

Trial of a disease management program to reduce hospital readmissions of the chronically critically ill

BACKGROUND

Patients requiring prolonged periods of intensive care and mechanical ventilation are termed chronically critically ill. They are prone to continued morbidity and mortality after hospital discharge and are at high risk for hospital readmission. Disease management (DM) programs have been shown to be effective in improving both coordination and efficiency of care after hospital discharge for populations with single-disease diagnoses, but have not been tested with patients with multiple-disease diagnoses, such as the chronically critically ill.

STUDY OBJECTIVES

To test the effect of a DM program on hospital readmission patterns of chronically critically ill patients during the first 2 months after hospital discharge and to estimate the cost-effectiveness of the DM program.

DESIGN

Randomized, controlled trial.

SETTING

Academic medical center, extended care facilities, and participant homes.

PARTICIPANTS

Three hundred thirty-four consenting adults from one academic medical center who underwent > 3 days of mechanical ventilation and survived to hospital discharge.

INTERVENTION

Two hundred thirty-one patients in the experimental group received care coordination, family support, teaching, and monitoring of therapies from a team of advanced-practice nurses, a geriatrician, and a pulmonologist for 2 months post-hospital discharge.

MEASUREMENTS

Rehospitalization rate, time-to-first rehospitalization, duration of rehospitalization, mortality during rehospitalization, and associated costs.

RESULTS

Patients who received DM services had significantly fewer mean days of rehospitalization (11.4; 95% confidence interval [CI], 9.3 to 12.6) compared with the control group (16.7 days; 95% CI, 12.5 to 21.0; p = 0.03). There were no other significant differences between experimental and control groups, although all measures of rehospitalization risk for the experimental group were in a positive direction. Total cost savings associated with the intervention were approximately $481,811 for the 93 subjects who were readmitted to the hospital.

CONCLUSIONS

Chronic critical illness may have a natural trajectory of continued morbidity following hospital discharge that is not affected by the provision of additional care coordination services. Nevertheless, given the high cost of rehospitalization and the additional burden it imposes on patients and families, interventions that can reduce the duration of rehospitalization are cost-effective and merit continued testing.

In a retrospective study of chronic obstructive pulmonary disease inpatients, respiratory comorbidities were significantly associated with prognosis

BACKGROUND AND OBJECTIVE

Comorbidities may be related to the prognosis for chronic obstructive pulmonary disease (COPD). We examined respiratory comorbidities associated with length of stay and in-hospital mortality among COPD patients.

METHODS

We used the Hospital Person Oriented Information (HPOI) database of Statistics Canada for a 5-year period. Over 4 years (fiscal years 1994-1995 to 1998-1999), 143,135 records listed COPD as the most responsible diagnosis for men and 122,065 records for women aged 40 years or more, and 75,780 men and 69,539 women were admitted to hospital at least once. Logistic regression modeling was used to examine the relationships between respiratory comorbidities and hospital outcomes adjusting for covariates.

RESULTS

Of the COPD patients, 10% had pneumonia-influenza and 3% had asthma as comorbid conditions. Women had a higher prevalence of asthma than men. The median length of stay at hospital was approximately 7 days, and 95% of patients were discharged alive. The odds ratio (95% confidence interval) for pneumonia-influenza in relation to in-hospital death was 3.56 (3.31, 3.83) for men and 3.29 (3.00, 3.61) for women. For comorbid asthma the corresponding odds ratios were 0.56 (0.36, 0.61) and 0.54 (0.35, 0.57), respectively.

CONCLUSIONS

COPD inpatients with pneumonia-influenza had a worse prognosis and those with asthma had a better prognosis.

Barriers to the treatment of hepatitis C. Patient, provider, and system factors

BACKGROUND

Hepatitis C virus (HCV) infection is both prevalent and undertreated.

OBJECTIVE

To identify barriers to HCV treatment in primary care practice.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

A cohort of 208 HCV-infected patients under the care of a primary care physician (PCP) between December 2001 and April 2004 at a single academically affiliated community health center.

MEASUREMENTS

Data were collected from the electronic medical record (EMR), the hospital clinical data repository, and interviews with PCPs.

MAIN RESULTS

Our cohort consisted of 208 viremic patients with HCV infection. The mean age was 47.6 (+/-9.7) years, 56% were male, and 79% were white. Fifty-seven patients (27.4% of the cohort) had undergone HCV treatment. Independent predictors of not being treated included: unmarried status (adjusted odds ratio [aOR] for treatment 0.36, P=.02), female gender (aOR 0.31, P=.01), current alcohol abuse (aOR 0.08, P=.0008), and a higher ratio of no-shows to total visits (aOR 0.005 per change of 1.0 in the ratio of no-shows to total visits, P=.002). The major PCP-identified reasons not to treat included: substance abuse (22.5%), patient preference (16%), psychiatric comorbidity (15%), and a delay in specialist input (12%). For 13% of the untreated patients, no reason was identified.

CONCLUSIONS

HCV treatment was infrequent in our cohort of outpatients. Barriers to treatment included patient factors (patient preference, alcohol use, missed appointments), provider factors (reluctance to treat past substance abusers), and system factors (referral-associated delays). Multimodal interventions may be required to increase HCV treatment rates.