Determinants for hospitalization in " low-risk" community acquired pneumonia

BACKGROUND: A variable decision in managing community acquired pneumonia (CAP) is the initial site of care; in-patient versus outpatient. These variations persist despite comprehensive practice guidelines. Patients with a Pneumonia Severity Index (PSI) score lower than seventy have low risk for complications and outpatient antibiotic management is recommended in this group. These patients are generally below the age of fifty years, non-nursing home residents, HIV negative and have no major cardiac, hepatic, renal or malignant diseases. METHODS: A retrospective analysis of 296 low-risk CAP patients evaluated within a year one period at St. Agnes Hospital, Baltimore, Maryland was undertaken. All patients were assigned a PSI score. 208 (70%) were evaluated and discharged from the emergency department (E.D.) to complete outpatient antibiotic therapy, while 88 (30%) were hospitalized. Patients were sub-stratified into classes I-V according to PSI. A comparison of demographic, clinical, social and financial parameters was made between the E.D. discharged and hospitalized groups. RESULTS: Statistically significant differences in favor of the hospitalized group were noted for female gender (CI: 1.46-5.89, p= 0.0018), African Americans (CI: 0.31-0.73, p= 0.004), insurance coverage (CI: 0.19-0.63, p= 0.0034), temperature (CI: 0.04-0.09, p= 0.0001) and pulse rate (CI: 0.03-0.14, p= 0.0001). No statistically significant differences were observed between the two groups for altered mental status, hypotension, tachypnea, laboratory/radiological parameters and social indicators (p>0.05). The average length of stay for in-patients was 3.5 days at about eight time's higher cost than outpatient management. There was no difference in mortality or treatment failures between the two groups. The documentation rate and justifications for hospitalizing low risk CAP patients by admitting physicians was less than optimal. CONCLUSIONS: High fever, tachycardia, female gender, African- American race and medical insurance coverage are determinants for hospitalization among low risk CAP patients in our study. The average length of stay for in-patients was 3.5 days (3 to 5 days). The cost of in-patient care was about eight times higher than outpatient management. This study supports the recommendation of using the PSI for E.D evaluation of patients in appropriate social settings

Policy mapping for establishing a national emergency health policy for Nigeria

BACKGROUND: The number of potential life years lost due to accidents and injuries though poorly studied has resulted in tremendous economic and social loss to Nigeria. Numerous socio-cultural, economic and political factors including the current epidemic of ethnic and religious conflicts act in concert in predisposing to and enabling the ongoing catastrophe of accident and injuries in Nigeria. METHODS: Using the "policymaker", Microsoft-Windows(®) based software, the information generated on accidents and injuries and emergency health care in Nigeria from literature review, content analysis of relevant documents, expert interviewing and consensus opinion, a model National Emergency Health Policy was designed and analyzed. A major point of analysis for the policy is the current political feasibility of the policy including its opportunities and obstacles in the country. RESULTS: A model National Emergency Health Policy with policy goals, objectives, programs and evaluation benchmarks was generated. Critical analyses of potential policy problems, associated multiple players, diverging interests and implementation guidelines were developed. CONCLUSIONS: "Political health modeling" a term proposed here would be invaluable to policy makers and scholars in developing countries in assessing the political feasibility of policy managing. Political modeling applied to the development of a NEHP in Nigeria would empower policy makers and the policy making process and would ensure a sustainable emergency health policy in Nigeria

Assessing compliance of cardiologists with the national cholesterol education program (NCEP) III guidelines in an ambulatory care setting

INTRODUCTION: The NCEP III -ATP guidelines provide clear clinical directives for lipid management especially statins therapy in appropriate patient groups. Compliance of primary care physicians with these guidelines especially in ambulatory care settings has been shown to be poor. The compliance of cardiologist to these guidelines is less documented. METHODS: A retrospective chart review of 386 patients managed in a large urban cardiology practice was undertaken. Patients with documented contraindications to use of statins were excluded from the study. Only patients with two or more years of follow-up in the practice were included. Demographic variables and medical history including CAD or its equivalent and its major risk factors were identified. The proportion of patients on statins and adequacy of statins therapy were recorded. The lipid profiles of all patients were also analyzed. RESULTS: Fifteen patients with documented contraindications to statins therapy including persistent/severe LFT abnormalities, allergies, and gastrointestinal intolerance were excluded. A total of 371 patients were included in the analysis. The mean age for patients in the study was 65 years (range: 42–84). 236 (64%) were males while 141 (36%) were females. 161 (43%) patients were on statins while 210 (57%) weren't. 88 (62%) of females were on stain compared to 116 (49%) of males (p = 0.001). 68% of patients below the age of 50 yrs were not on statins compared with 55% of those greater than 50 yrs (p = 0.01). 38% of patients on statins therapy had sub-optimal lipid profile despite greater than two years of therapy. No statistically significant differences in race and use of satins were noted. CONCLUSION: This study demonstrates a higher than expected prevalence of sub-optimal management of dyslipidemia among patients with established coronary heart disease without contraindications to statins managed by cardiologists. Cardiology and primary care practices require similar comprehensive routine lipid management program that is assiduously maintained and evaluated at both in-patient and out patient settings to ensure most patients receive optimal therapy with statins and other lipid lowering agents

Establishing an employee baseline purified protein derivative status in the division of immigration health service processing centers

While the incidence of reportable tuberculosis in United States born persons declined, the number of cases among foreign-born persons increased by 6 percent in 1998. The Immigration and Naturalization Service (INS) processes about 95,000 undocumented aliens annually from countries with a high prevalence of tuberculosis. An effort was made to establish a baseline Purified Protein Derivative (PPD) status of employees of the Division of Immigration Health (DIH) and INS, Services Processing Centers (SPC). This was achieved through a special operation (project) of a one time, two-step, mass PPD testing of all SPC employees on all eleven sites in the United States and Puerto Rico. A reading of \u3e 10mm was considered positive. The operation was optional and open to all SPC employees. Exclusion criteria for the study included a history of PPD skin testing within six months of the operation, past history of positive PPD test and past history of tuberculosis. Preliminary results from El Paso SPC, Texas, which is the largest SPC, showed that of the 148 employees which were tested (67 percent of all employees), 17 (11 percent) were PPD positive. Security officers constituted 100 percent of all positive cases. Eighty-one percent of the employees at El Paso are security officers, eighty-seven percent of whom participated in the study. Only 20 (23 percent) of administrative staff participated in the study. Results from El Paso are suggestive of differences in the pattern PPD positivity among SPC employees. The complete results of the study should provide sound evidence for formulating appropriate policies for establishing an effective employee tuberculosis prevention and surveillance program in the Service Processing Centers. © 2001 Human Sciences Press, Inc

Sickle cell disease and pulmonary hypertension in Africa: A global perspective and review of epidemiology, pathophysiology, and management

Secondary pulmonary hypertension (PAH) has been shown to have a prevalence of 30% in patients with sickle cell disease (SCD) with mortality rates of 40% at 40 months after diagnosis in the United States. The burden of SCD is highest in sub-Saharan Africa, especially in Nigeria (West Africa), where approximately 6 million people are afflicted. The true global incidence, prevalence, and burden of SCD and Its associated end organ complications however remain unknown. Chronic hemolysis represents a prominent mechanistic pathway in the pathogenesis of SCD-associated pulmonary hypertension via a nitric oxide (NO) scavenging and abrogation of NO salutatory effects on vascular function, including smooth muscle relaxation, downregulation of endothelial adhesion molecules and inhibition of platelet activation. Many known infectious risk factors for PAH are also hyperendemic in Africa, including Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), chronic hepatitis B and C, and possibly malaria. Interactions between these infectious complications and SCD-related hemolysis could yield an even higher prevalence of pulmonary hypertension and compound the existing global health systems challenges in managing SCD. Indeed, our preliminary analysis of African immigrants currently in the United States suggests that pulmonary hypertension represents a significant complication of SCD in the African subcontinent. There is clearly a need to include Africa and other parts of the world with high SCD prevalence in future comprehensive studies on the epidemiology and treatment of end organ complications of an aging SCD population world-wide