Increasing Short-Stay Unplanned Hospital Admissions among Children in England; Time Trends Analysis '97-'06

BACKGROUND: Timely care by general practitioners in the community keeps children out of hospital and provides better continuity of care. Yet in the UK, access to primary care has diminished since 2004 when changes in general practitioners' contracts enabled them to 'opt out' of providing out-of-hours care and since then unplanned pediatric hospital admission rates have escalated, particularly through emergency departments. We hypothesised that any increase in isolated short stay admissions for childhood illness might reflect failure to manage these cases in the community over a 10 year period spanning these changes. METHODS AND FINDINGS: We conducted a population based time trends study of major causes of hospital admission in children 2 days. By 2006, 67.3% of all unplanned admissions were isolated short stays <2 days. The increases in admission rates were greater for common non-infectious than infectious causes of admissions. CONCLUSIONS: Short stay unplanned hospital admission rates in young children in England have increased substantially in recent years and are not accounted for by reductions in length of in-hospital stay. The majority are isolated short stay admissions for minor illness episodes that could be better managed by primary care in the community and may be evidence of a failure of primary care services

Age and sex distribution of adult asthma admission : a study of the five-year cumulative prevalence

The objective of this study is to describe the age and sex distribution of adult patients (ages 15-59) in Malta, admitted because of severe acute asthma. The study was designed using a retrospective review of all acute adult asthma admissions to determine the 5-year cumulative prevalence of acute asthma admission from 1989 to 1993 to St. Luke’s Hospital, the only acute medical facility serving the whole of the island of Malta. The results of this study showed that the female predominance in adult asthma admission rates reflects a larger number of female patients who require hospital admission rather than higher admission rates per person in females as compared to males.peer-reviewe

Using weighted hospital service area networks to explore variation in preventable hospitalization

Objective: To demonstrate the use of multiple-membership multilevel models, which analytically structure patients in a weighted network of hospitals, for exploring between-hospital variation in preventable hospitalizations. Data Sources: Cohort of 267,014 people aged over 45 in NSW, Australia. Study Design: Patterns of patient flow were used to create weighted hospital service area networks (weighted-HSANs) to 79 large public hospitals of admission. Multiple-membership multilevel models on rates of preventable hospitalization, modeling participants structured within weighted-HSANs, were contrasted with models clustering on 72 hospital service areas (HSAs) that assigned participants to a discrete geographic region. Data Collection/Extraction Methods: Linked survey and hospital admission data. Principal Findings: Between-hospital variation in rates of preventable hospitalization was more than two times greater when modeled using weighted-HSANs rather than HSAs. Use of weighted-HSANs permitted identification of small hospitals with particularly high rates of admission and influenced performance ranking of hospitals, particularly those with a broadly distributed patient base. There was no significant association with hospital bed occupancy. Conclusion: Multiple-membership multilevel models can analytically capture information lost on patient attribution when creating discrete health care catchments. Weighted-HSANs have broad potential application in health services research and can be used across methods for creating patient catchments

Performance indicators for primary care management in the NHS

There is increased emphasis on the measurement of performance in the NHS. Following the White Paper, additional high level indicators for measuring primary care performance at Health Authority level have been proposed by the NHS Executive. These include measures based on prescribing and on hospital admission rates for certain acute and chronic conditions. It is suggested that higher hospital admission rates for some conditions may indicate deficiencies in their management in primary care. In this paper we argue that there are difficulties with some of the proposed measures. The difficulties arise because individual single indicators are used to attempt to reflect more than one aspect of performance, may have large year to year variation and be subject to confounding. Using data on Family Health Services Authorities (FHSAs) from 1989/90 to 1994/5 we investigate how admission rates, and the ranking of FHSAs by admission rates, vary as socio-economic and secondary and primary care supply conditions are allowed for. The impact of socio-economic factors on admission rates and rankings is at least as large as the impact of the age and sex structure of FHSA populations. Allowing also for secondary care supply conditions has a smaller, but still noticeable, effect. We suggest that if admission rates are used as performance indicators in primary care they should be standardised for socio-economic and supply conditions, as well as for demographic factors. We also make a number of other suggestions for improving the indicators. Length: 34 pagesperformance indicators; policy implications

Gender differences in time to first hospital admission at age 60 in Denmark, 1995–2014

Women have consistently lower mortality rates than men at all ages and with respect to most causes. However, gender differences regarding hospital admission rates are more mixed, varying across ages and causes. A number of intuitive metrics have previously been used to explore changes in hospital admissions over time, but have not explicitly quantified the gender gap or estimated the cumulative contribution from cause-specific admission rates. Using register data for the total Danish population between 1995 and 2014, we estimated the time to first hospital admission for Danish men and women aged 60. This is an intuitive population-level metric with the same interpretive and mathematical properties as period life expectancy. Using a decomposition approach, we were able to quantify the cumulative contributions from eight causes of hospital admission to the gender gap in time to first hospital admission. Between 1995 and 2014, time to first admission increased for both, men (7.6 to 9.4 years) and women (8.3 to 10.3 years). However, the magnitude of gender differences in time to first admission remained relatively stable within this time period (0.7 years in 1995, 0.9 years in 2014). After age 60, Danish men had consistently higher rates of admission for cardiovascular conditions and neoplasms, but lower rates of admission for injuries, musculoskeletal disorders, and sex-specific causes. Although admission rates for both genders have generally declined over the last decades, the same major causes of admission accounted for the gender gap. Persistent gender differences in causes of admission are, therefore, important to consider when planning the delivery of health care in times of population ageing.Output Status: Forthcoming/Available Onlin

Illness Severity among Non-English, Non-Spanish Speaking Patients in a Public Emergency Department

Background: Patients with limited English proficiency (LEP) have poor health outcomes compared to English proficient patients. Most studies on language proficiency and health disparities focus on Spanish. Objective: This study examines whether non-Spanish speaking LEP patients experience greater disparities than Spanish speaking LEP patients by comparing disease acuity and language proficiency in an emergency department. Design: This is a retrospective case-control study from November 2010 to February 2012 comparing differences between non-English non-Spanish (NENS) speaking patients to English speaking patients with differences between Spanish speaking and English speaking patients. Main outcomes: Primary endpoints include the emergency severity index (ESI) score, area of triage, days in hospital, and the rates of admission, in-hospital surgery, intensive care unit admission, and all-cause mortality. Results: Among all of the study patients, the average age was 55.1 (+/- 12.4). Comparing the NENS sample to the English sample yielded differences in surgery rates (NENS 11.3%, English 1.9%, p=0.002), admission rates (NENS 38.8%, English 24.7%, p=0.025), and days in hospital (NENS 2.49 +/-5.43, English 1.93+/-8.56, p Conclusions and relevance: We were able to demonstrate greater healthcare needs among NENS patients compared to the other two groups. The NENS patients were more likely to be admitted, have surgery, and stay longer than those speaking English or Spanish. These findings are important because they suggest further research, awareness of these disparities by healthcare providers, and public health interventions focusing on this population are warranted

Impact of Geriatric Consult Evaluations on Hospital Admission Rates for Older Adults

Introduction: We examined the impact of a geriatric consult program in the emergency department (ED) and an ED observation geriatric care unit (GCU) setting on hospital admission rates for older ED patients.Methods: We performed a retrospective case control study from June 1–August 31, 2019 (pre-program) to September 24, 2019–January 31, 2020 (post-program). Post-program geriatric consults were readily available in the ED and required in the GCU setting. Hospital admission rates (outcome) are reported for patients who received a geriatric consult evaluation (intervention). We analyzed probability of admission using a mixed-effects logistic regression model that included age, gender, recent ED visit, Charlson Comorbidity Index, referral to ED observation, and geriatric consult evaluation as predictor variables.Results: A total of 9,663 geriatric ED encounters occurred, 4,042 pre-program and 5,621 post-program. Overall, ED admission rates for geriatric patients were similar pre- and post-program (44.8% vs 43.9%, P = 0.39). Of 243 geriatric consults, 149 (61.3%) occurred in the GCU. Overall admission rates post-program for patients receiving geriatric intervention were significantly lower compared to pre-program (23.4% vs 44.9%, P &lt; 0.001). Post-program GCU hospital admission rates were significantly lower than pre-program ED observation unit admission rates (14/149, 9.4%, vs 111/477, 23.3%, P &lt; 0.001). In the logistic regression model, admissions post-program were lower when a geriatric consult evaluation occurred (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.41–0.83). Hospital admissions for older ED observation patients were also significantly decreased when a geriatric consult was obtained (GCU vs pre-program ED observation unit; OR 0.27, 95% CI 0.14–0.50).Conclusion: Geriatric consult evaluations were associated with significantly lower rates of hospital admission and persisted when controlled for age, gender, comorbidities, and ED observation unit placement. This model may allow healthcare systems to decrease potentially avoidable hospital admission rates in older ED patients

Triumph of hope over experience: learning from interventions to reduce avoidable hospital admissions identified through an Academic Health and Social Care Network.

BACKGROUND: Internationally health services are facing increasing demands due to new and more expensive health technologies and treatments, coupled with the needs of an ageing population. Reducing avoidable use of expensive secondary care services, especially high cost admissions where no procedure is carried out, has become a focus for the commissioners of healthcare. METHOD: We set out to identify, evaluate and share learning about interventions to reduce avoidable hospital admission across a regional Academic Health and Social Care Network (AHSN). We conducted a service evaluation identifying initiatives that had taken place across the AHSN. This comprised a literature review, case studies, and two workshops. RESULTS: We identified three types of intervention: pre-hospital; within the emergency department (ED); and post-admission evaluation of appropriateness. Pre-hospital interventions included the use of predictive modelling tools (PARR - Patients at risk of readmission and ACG - Adjusted Clinical Groups) sometimes supported by community matrons or virtual wards. GP-advisers and outreach nurses were employed within the ED. The principal post-hoc interventions were the audit of records in primary care or the application of the Appropriateness Evaluation Protocol (AEP) within the admission ward. Overall there was a shortage of independent evaluation and limited evidence that each intervention had an impact on rates of admission. CONCLUSIONS: Despite the frequency and cost of emergency admission there has been little independent evaluation of interventions to reduce avoidable admission. Commissioners of healthcare should consider interventions at all stages of the admission pathway, including regular audit, to ensure admission thresholds don't change

Reduced level of arousal and increased mortality in adult acute medical admissions: a systematic review and meta-analysis

Abstract Background Reduced level of arousal is commonly observed in medical admissions and may predict in-hospital mortality. Delirium and reduced level of arousal are closely related. We systematically reviewed and conducted a meta-analysis of studies in adult acute medical patients of the relationship between reduced level of arousal on admission and in-hospital mortality. Methods We conducted a systematic review (PROSPERO: CRD42016022048), searching MEDLINE and EMBASE. We included studies of adult patients admitted with acute medical illness with level of arousal assessed on admission and mortality rates reported. We performed meta-analysis using a random effects model. Results From 23,941 studies we included 21 with 14 included in the meta-analysis. Mean age range was 33.4 - 83.8 years. Studies considered unselected general medical admissions (8 studies, n=13,039) or specific medical conditions (13 studies, n=38,882). Methods of evaluating level of arousal varied. The prevalence of reduced level of arousal was 3.1%-76.9% (median 13.5%). Mortality rates were 1.7%-58% (median 15.9%). Reduced level of arousal was associated with higher in-hospital mortality (pooled OR 5.71; 95% CI 4.21-7.74; low quality evidence: high risk of bias, clinical heterogeneity and possible publication bias). Conclusions Reduced level of arousal on hospital admission may be a strong predictor of in-hospital mortality. Most evidence was of low quality. Reduced level of arousal is highly specific to delirium, better formal detection of hypoactive delirium and implementation of care pathways may improve outcomes. Future studies to assess the impact of interventions on in-hospital mortality should use validated assessments of both level of arousal and delirium

Incidence and severity of respiratory syncytial virus pneumonia in rural Kenyan children identified through hospital surveillance

Background.Although necessary for developing a rationale for vaccination, the burden of severe respiratory syncytial virus (RSV) disease in children in resource‐poor settings remains poorly defined. Methods.We conducted prospective surveillance of severe and very severe pneumonia in children aged <5 years admitted from 2002 through 2007 to Kilifi district hospital in coastal Kenya. Nasal specimens were screened for RSV antigen by immunofluorescence. Incidence rates were estimated for the well‐defined population. Results.Of 25,149 hospital admissions, 7359 patients (29%) had severe or very severe pneumonia, of whom 6026 (82%) were enrolled. RSV prevalence was 15% (20% among infants) and 27% during epidemics (32% among infants). The proportion of case patients aged 3 months was 65%, and the proportion aged 6 months was 43%. Average annual hospitalization rates were 293 hospitalizations per 100,000 children aged <5 years (95% confidence interval, 271–371 hospitalizations per 100,000 children aged <5 years) and 1107 hospitalizations per 100,000 infants (95% confidence interval, 1012–1211 hospitalizations per 100,000 infants). Hospital admission rates were double in the region close to the hospital. Few patients with RSV infection had life‐threatening clinical features or concurrent serious illnesses, and the associated mortality was 2.2%. Conclusions.In this low‐income setting, rates of hospital admission with RSV‐associated pneumonia are substantial; they are comparable to estimates from the United States but considerably underestimate the burden in the full community. An effective vaccine for children aged >2 months (outside the age group of poor responders) could prevent a large portion of RSV disease. Severity data suggest that the justification for RSV vaccination will be based on the prevention of morbidity, not mortality