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Background
The Hospital Readmission Reduction Programme (HRRP) was created to decrease the number of hospital readmissions for acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia (PNA), coronary artery bypass graft (CABG), elective total hip arthroplasty (THA) and total knee arthroplasty.
Objectives
To analyse the impact of the HRRP on readmission rates from 2010 to 2019 and how time to readmission impacted outcomes.
Design
Population-based retrospective study.
Setting
All patients included in the US National Readmission database from 2010 to 2019.
Patients
We recorded demographic and clinical variables.
Measurements
Using linear regression models, we analysed the association between readmission status and timing with death and length of stay (LOS) outcomes. We transformed LOS and charges into log-LOS and log-charges to normalise the data.
Results
There were 31 553 363 records included in the study. Of those, 4 593 228 (14.55%) were readmitted within 30 days. From 2010 to 2019, readmission rates for COPD (20.8%–19.8%), HF (24.9%–21.9%), PNA (16.4%–15.1%), AMI (15.6%–12.9%) and TKR (4.1%–3.4%) decreased whereas CABG (10.2%–10.6%) and THA (4.2%–5.8%) increased. Readmitted patients were at higher risk of mortality (6% vs 2.8%) and had higher LOS (3 (2–5) vs 4 (3–7)). Patients readmitted within 10 days had a mortality 6.4% higher than those readmitted in 11–20 days (5.4%) and 21–30 days (4.6%). Increased time from discharge to readmission was associated with a lower likelihood of mortality, like LOS.
Conclusion
Over the last 10 years, readmission rates decreased for most conditions included in the HRRP except CABG and THA. Patients readmitted shortly after discharge were at higher risk of death.
Tecnologia dell’Università Carlo Bo esplora uso di globuli rossi
Scoperto un meccanismo molecolare che ne aumenta la frequenza
Objective
This national analysis aimed to calculate the diagnostic yield from gastroscopy for common symptoms, guiding improved resource utilisation.
Design
A cross-sectional study was conducted of diagnostic gastroscopies between 1 March 2019 and 29 February 2020 using the UK National Endoscopy Database. Mixed-effect logistic regression models were used, incorporating random (endoscopist) and fixed (symptoms, age and sex) effects on two dependent variables (endoscopic cancer; Barrett’s oesophagus (BO) diagnosis). Adjusted positive predictive values (aPPVs) were calculated.
Results
382 370 diagnostic gastroscopies were analysed; 30.4% were performed in patients aged
Circulation, Ahead of Print. BACKGROUND:Exposure to metals has been associated with cardiovascular disease (CVD) end points and mortality, yet prospective evidence is limited beyond arsenic, cadmium, and lead. In this study, we assessed the prospective association of urinary metals with incident CVD and all-cause mortality in a racially diverse population of US adults from MESA (Multi-Ethnic Study of Atherosclerosis).METHODS:We included 6599 participants (mean [SD] age, 62.1 [10.2] years; 53% female) with urinary metals available at baseline (2000 to 2001) and followed through December 2019. We used Cox proportional hazards models to estimate the adjusted hazard ratio and 95% CI of CVD and all-cause mortality by baseline urinary levels of cadmium, tungsten, and uranium (nonessential metals), and cobalt, copper, and zinc (essential metals). The joint association of the 6 metals as mixture and the corresponding 10-year survival probability was calculated using Cox Elastic-Net.RESULTS:During follow-up, 1162 participants developed CVD, and 1844 participants died. In models adjusted by behavioral and clinical indicators, the HR (95% CI) for incident CVD and all-cause mortality comparing the highest with the lowest quartile were, respectively: 1.25 (1.03, 1.53) and 1.68 (1.43, 1.96) for cadmium; 1.20 (1.01, 1.42) and 1.16 (1.01, 1.33) for tungsten; 1.32 (1.08, 1.62) and 1.32 (1.12, 1.56) for uranium; 1.24 (1.03, 1.48) and 1.37 (1.19, 1.58) for cobalt; 1.42 (1.18, 1.70) and 1.50 (1.29, 1.74) for copper; and 1.21 (1.01, 1.45) and 1.38 (1.20, 1.59) for zinc. A positive linear dose-response was identified for cadmium and copper with both end points. The adjusted HRs (95% CI) for an interquartile range (IQR) increase in the mixture of these 6 urinary metals and the corresponding 10-year survival probability difference (95% CI) were 1.29 (1.11, 1.56) and –1.1% (–2.0, –0.05) for incident CVD and 1.66 (1.47, 1.91) and –2.0% (–2.6, –1.5) for all-cause mortality.CONCLUSIONS:This epidemiological study in US adults indicates that urinary metal levels are associated with increased CVD risk and mortality. These findings can inform the development of novel preventive strategies to improve cardiovascular health.
Studio,connessione tra perdita e problemi salute
Studio, “è una misura contro i sintomi correlati all’invecchiamento”
Objective
To evaluate background incidence rates of 59 health outcomes of interest (HOI) in a diverse population, including important subpopulations, during the pre-COVID-19 era (1 January 2017–31 December 2019) and the COVID-19 era (1 March 2020–31 December 2020), before the introduction of COVID-19 vaccines.
Design
Observational retrospective cohort study. Annual incidence rates and 95% confidence intervals (CIs) of HOIs were estimated for each population of interest, stratified by: age, sex, age and sex and seasonality.
Data source
Optum’s de-identified Clinformatics Data Mart Database (CDM).
Participants
Individuals from the US general population and four subgroups of interest: influenza-vaccinated, paediatric (
Introduction
Central venous access devices (CVADs) are commonly used for the treatment of paediatric cancer patients. Catheter locking is a routine intervention that prevents CVAD-associated adverse events, such as infection, occlusion and thrombosis. While laboratory and clinical data are promising, tetra-EDTA (T-EDTA) has yet to be rigorously evaluated or introduced in cancer care as a catheter lock.
Methods and analysis
This is a protocol for a two-arm, superiority type 1 hybrid effectiveness-implementation randomised controlled trial conducted at seven hospitals across Australia and New Zealand. Randomisation will be in a 3:2 ratio between the saline (heparinised saline and normal saline) and T-EDTA groups, with randomly varied blocks of size 10 or 20 and stratification by (1) healthcare facility; (2) CVAD type and (3) duration of dwell since insertion. Within the saline group, there will be a random allocation between normal and heparin saline. Participants can be re-recruited and randomised on insertion of a new CVAD. Primary outcome for effectiveness will be a composite of CVAD-associated bloodstream infections (CABSI), CVAD-associated thrombosis or CVAD occlusion during CVAD dwell or at removal. Secondary outcomes will include CABSI, CVAD-associated-thrombosis, CVAD failure, incidental asymptomatic CVAD-associated-thrombosis, other adverse events, health-related quality of life, healthcare costs and mortality. To achieve 90% power (alpha=0.05) for the primary outcome, data from 720 recruitments are required. A mixed-methods approach will be employed to explore implementation contexts from the perspective of clinicians and healthcare purchasers.
Ethics and dissemination
Ethics approval has been provided by Children’s Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC) (HREC/22/QCHQ/81744) and the University of Queensland HREC (2022/HE000196) with subsequent governance approval at all sites. Informed consent is required from the substitute decision-maker or legal guardian prior to participation. In addition, consent may also be obtained from mature minors, depending on the legislative requirements of the study site. The primary trial and substudies will be written by the investigators and published in peer-reviewed journals. The findings will also be disseminated through local health and clinical trial networks by investigators and presented at conferences.
Trial registration number
ACTRN12622000499785.
Circulation, Ahead of Print. BACKGROUND:Waitlist mortality (WM) remains elevated in pediatric heart transplantation. Allocation policy is a potential tool to help improve WM. This study aims to identify patients at highest risk for WM to potentially inform future allocation policy changes.METHODS:The Pediatric Heart Transplant Society database was queried for patients 0.7 m2BSA groups. VAD support was associated with lower WM other than in the single ventricle cohort, where VAD was associated with higher WM. Extracorporeal membrane oxygenation and mechanical ventilation were associated with increased risk of WM in all cohorts.CONCLUSIONS:There is significant variability in WM among status-1A patients. Potential refinements to current allocation system should factor in the increased WM risk we identified in patients supported by extracorporeal membrane oxygenation or mechanical ventilation, single ventricle congenital heart disease on VAD support and small children with congenital heart disease, restrictive cardiomyopathy, or hypertrophic cardiomyopathy.
Objective
To explore the gaps in the safe handling, administration, preparation and disposal of chemotherapy agents in low and middle-income countries.
Design
Two surveys comprising a needs assessment survey and an American Cancer Society (ACS) ChemoSafe Facility Assessment.
Setting
2019 African Research Group for Oncology Symposium in South-West Nigeria (needs assessment) and the 2021 virtual engagement (ChemoSafe Assessment).
Participants
Health professionals (n=50 of 98) from multiple institutions across Nigeria (needs assessment survey) and a designated task force of health professionals (n=10) from one teaching hospital in Southwest Nigeria(ChemoSafe Facility Assessment).
Results
In 2019, 75% of survey respondents (n=50) reported a lack of training resources for safe handling of chemotherapy. Additionally, 61% felt dissatisfaction with assessment practices for preparing and administering chemotherapy. ChemoSafe is a programme developed by the ACS to assess the ability of a facility to handle hazardous drugs. The 2021 ACS ChemoSafe survey administered at one teaching hospital indicated several areas for improvement to promote concordance with international standards for safe handling. Thirty-three (19.5%) items received a ‘Yes’ response (ie, met compliance with international standards).
Conclusion
There is a need for the implementation of training resources for handling, administering and disposing of chemotherapy at sites across Nigeria. Strategies to identify and prioritise areas of need must be implemented in the context of available resources.
Background
Hospital electronic patient records (EPRs) offer the opportunity to exploit large-scale routinely acquired data at relatively low cost and without selection. EPRs provide considerably richer data, and in real-time, than retrospective administrative data sets in which clinical complexity is often poorly captured. With population ageing, a wide range of hospital specialties now manage older people with multimorbidity, frailty and associated poor outcomes. We, therefore, set-up the Oxford and Reading Cognitive Comorbidity, Frailty and Ageing Research Database-Electronic Patient Records (ORCHARD-EPR) to facilitate clinically meaningful research in older hospital patients, including algorithm development, and to aid medical decision-making, implementation of guidelines, and inform policy.
Methods and analysis
ORCHARD-EPR uses routinely acquired individual patient data on all patients aged ≥65 years with unplanned admission or Same Day Emergency Care unit attendance at four acute general hospitals serving a population of >800 000 (Oxfordshire, UK) with planned extension to the neighbouring Berkshire regional hospitals ( >1 000 000). Data fields include diagnosis, comorbidities, nursing risk assessments, frailty, observations, illness acuity, laboratory tests and brain scan images. Importantly, ORCHARD-EPR contains the results from mandatory hospital-wide cognitive screening (≥70 years) comprising the 10-point Abbreviated-Mental-Test and dementia and delirium diagnosis (Confusion Assessment Method—CAM). Outcomes include length of stay, delayed transfers of care, discharge destination, readmissions and death. The rich multimodal data are further enhanced by linkage to secondary care electronic mental health records. Selection of appropriate subgroups or linkage to existing cohorts allows disease-specific studies. Over 200 000 patient episodes are included to date with data collection ongoing of which 129 248 are admissions with a length of stay ≥1 day in 64 641 unique patients.
Ethics and dissemination
ORCHARD-EPR is approved by the South Central Oxford C Research Ethics Committee (ref: 23/SC/0258). Results will be widely disseminated through peer-reviewed publications and presentations at conferences, and regional meetings to improve hospital data quality and clinical services.
Stroke, Ahead of Print. BACKGROUND:Extreme temperatures contribute significantly to global mortality. While previous studies on temperature and stroke-specific outcomes presented conflicting results, these studies were predominantly limited to single-city or single-country analyses. Their findings are difficult to synthesize due to variations in methodologies and exposure definitions.METHODS:Within the Multi-Country Multi-City Network, we built a new mortality database for ischemic and hemorrhagic stroke. Applying a unified analysis protocol, we conducted a multinational case-crossover study on the relationship between extreme temperatures and stroke. In the first stage, we fitted a conditional quasi-Poisson regression for daily mortality counts with distributed lag nonlinear models for temperature exposure separately for each city. In the second stage, the cumulative risk from each city was pooled using mixed-effect meta-analyses, accounting for clustering of cities with similar features. We compared temperature-stroke associations across country-level gross domestic product per capita. We computed excess deaths in each city that are attributable to the 2.5% hottest and coldest of days based on each city’s temperature distribution.RESULTS:We collected data for a total of 3 443 969 ischemic strokes and 2 454 267 hemorrhagic stroke deaths from 522 cities in 25 countries. For every 1000 ischemic stroke deaths, we found that extreme cold and hot days contributed 9.1 (95% empirical CI, 8.6–9.4) and 2.2 (95% empirical CI, 1.9–2.4) excess deaths, respectively. For every 1000 hemorrhagic stroke deaths, extreme cold and hot days contributed 11.2 (95% empirical CI, 10.9–11.4) and 0.7 (95% empirical CI, 0.5–0.8) excess deaths, respectively. We found that countries with low gross domestic product per capita were at higher risk of heat-related hemorrhagic stroke mortality than countries with high gross domestic product per capita (P=0.02).CONCLUSIONS:Both extreme cold and hot temperatures are associated with an increased risk of dying from ischemic and hemorrhagic strokes. As climate change continues to exacerbate these extreme temperatures, interventional strategies are needed to mitigate impacts on stroke mortality, particularly in low-income countries.
Objectives
This study aims to examine the prevalence of comorbidities in adult patients with psoriasis and compare them with those in control subjects without psoriasis in Tianjin, China.
Design
The study is a cross-sectionalanalysis.
Participants
The participants were established by identifying all patients (age ≥18 years) who visited hospitals and clinics in Tianjin between 1 January 2016 and 31 October 2019.
Setting
The study group consisted of 20 678 adult patients with psoriasis, and a comparison group was created after 1:1 propensity score matching. Logistic regression analyses were conducted to examine the risk of 22 comorbidities for these two groups.
Results
Patients with psoriasis had a significantly higher prevalence of 11 comorbidities and a lower prevalence of 2 comorbidities within 12 months of follow-up. Our results also showed that the proportion of psoriatic arthritis might account for approximately 2% of all patients with psoriasis. This psoriatic arthritis group had a higher average age and CCI (Charlson Comorbidity Index) index score (2.27 >1.62, p
Objectives
This study aimed to determine whether the association between conventional bystander cardiopulmonary resuscitation (BCPR) and better outcomes in drowning-associated out-of-hospital cardiac arrest (OHCA) differs between young and older people or between non-medical and medical drowning in Japan.
Design
Observational study.
Setting
This study used data from the Japanese Fire and Disaster Management Agency databases.
Participant
Of the 504 561 OHCA cases recorded in the nationwide database between 2016 and 2019, 16 376 (3.2%) were presumably caused by drowning.
Main outcome measure
The main outcomes were a 1-month neurological prognosis defined as cerebral performance category 1 or 2 and 1-month survival as measures.
Result
The incidence of drowning as a presumed cause of OHCA was high in the winter and the middle-aged and older generations in Japan. However, OHCA caused by drowning in the younger generation frequently occurs in the summer. Furthermore, younger patients had higher incidences of bystander-witnessed cardiac arrest (22.0%), BCPR provision (59.3%) and arrest in outdoor settings (54.0%) than middle-aged and older generations (5.9%, 46.1% and 18.7% respectively). If the patient was younger or the arrest was accidental, the conventional BCPR group had better neurological outcomes than the compression-only BCPR group (95% CI of adjusted OR, 1.22 to 12.2 and 1.80 to 5.57, respectively). However, in the case of middle-aged and older generations and medical categories, there was no significant difference in outcomes between the two types of BCPR. This conventional group’s advantage was maintained even after matching.
Conclusion
Conventional bystander CPR yielded a higher neurologically favourable survival rate than compression-only BCPR for OHCA caused by drowning if the patient was younger or the arrest was non-medical. Conventional CPR education for citizens who have the chance to witness drownings should be maintained.
