Risk-adjustment models for heart failure patients’ 30-day mortality and readmission rates: the incremental value of clinical data abstracted from medical charts beyond hospital discharge record

BACKGROUND: Hospital discharge records (HDRs) are routinely used to assess outcomes of care and to compare hospital performance for heart failure. The advantages of using clinical data from medical charts to improve risk-adjustment models remain controversial. The aim of the present study was to evaluate the additional contribution of clinical variables to HDR-based 30-day mortality and readmission models in patients with heart failure. METHODS: This retrospective observational study included all patients residing in the Local Healthcare Authority of Bologna (about 1 million inhabitants) who were discharged in 2012 from one of three hospitals in the area with a diagnosis of heart failure. For each study outcome, we compared the discrimination of the two risk-adjustment models (i.e., HDR-only model and HDR-clinical model) through the area under the ROC curve (AUC). RESULTS: A total of 1145 and 1025 patients were included in the mortality and readmission analyses, respectively. Adding clinical data significantly improved the discrimination of the mortality model (AUC = 0.84 vs. 0.73, p < 0.001), but not the discrimination of the readmission model (AUC = 0.65 vs. 0.63, p = 0.08). CONCLUSIONS: We identified clinical variables that significantly improved the discrimination of the HDR-only model for 30-day mortality following heart failure. By contrast, clinical variables made little contribution to the discrimination of the HDR-only model for 30-day readmission. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12913-016-1731-9) contains supplementary material, which is available to authorized users

Mental health services use and management of eating disorders in an Italian Department of Mental Health.

OBJECTIVE: To investigate the clinical characteristics of patients with eating disorders referred to Community Mental Health Centers (CMHCs) in the Department of Mental Health of Bologna, Italy, and to evaluate the number and type of interventions delivered. METHODS: Adult patients with eating disorders who had a first contact with CMHCs between January 1, 2007 and December 31, 2012 were extracted from Bologna Local Health Authority database. Moreover, the hospital discharge records of patients were linked to the mental health information system of Bologna. RESULTS: Among the 276 patients with eating disorders identified, 59 (21.4 %) were diagnosed as anorexia nervosa, 77 (27.9 %) as bulimia nervosa and 140 (50.7 %) as eating disorders not otherwise specified. The mean age of the sample was 37.3 (SD = 13.4), with no significant differences among the three diagnostic groups. The number of CMHCs outpatients increased each year from 2007 to 2011 and decreased in 2012. The proportion of new patients by year comprised about 50 % of the total of patients. Psychotherapy accounted for about 10 % of the interventions. Day-hospital and hospital admissions concerned 6.1 and 11.6 % of the sample. CONCLUSIONS: CMHCs are part of the system of care outlined by the Regional policies for eating disorders and are responsible for providing the first level of outpatient care to adults. To date, there is the need to extend our monitoring across the whole system of care, to assess the implementation of specific and effective strategies to decrease the age of access of patients and to improve the quality of care delivered with the inclusion of evidence-based treatments in the process of car

Characteristics and outcomes of acute coronary syndrome in migrant and Italian-born population

Background. Disparities among ethnic groups are reported in the epidemiology and outcomes of cardiovascular diseases. Given the growing prevalence of migrant populations in Italy and the \u201cepidemic\u201d of cardiovascular diseases, the aim of this study was to evaluate the characteristics and outcomes of patients with acute coronary syndrome (ACS) in relation to country of origin. Methods. This retrospective study includes patients living in Emilia-Romagna, Italy, and discharged from 2012 to 2014 with a diagnosis of acute myocardial infarction (AMI, STEMI and non-STEMI). Primary outcomes were percutaneous coronary intervention (PTCA) within 48 hours of admission for STEMI and 30-day all-cause mortality, and secondary outcomes 1-year adherence to post-AMI medications, major adverse cardiac and cerebrovascular event (MACCE) and all-cause mortality. The relationship between outcomes and citizenship was analyzed using multiple regression models. Potential confounders were age, gender and comorbidities recorded in the index and prior two years hospitalizations. Results. The study population comprised 23,884 patients of which 647 (2.7%) are migrants. The mean age of onset of ACS was lower among migrants than among Italians (56 vs 73 years) and immigrants had a higher prevalence of STEMI (50.1% vs 44.9%; \u3c72 = 6.8, p = 0.009). Compared with Italians, patients from Africa and Asia had a lower likelihood of undergoing PTCA and were less adherent to medications. Adjusted mortality rates were similar between Italians and migrants, however patients from Asia had a 62% increased probability of experiencing a MACCE at 1 year. Conclusions. Migrants with ACS were younger, less likely to undergo PTCA, and less adherent to drug treatment after discharge compared with Italians. Further studies are needed to investigate in depth the determinants of these differences and to develop organizational models tailored to the specific needs of migrant patients

How do Community Hospitals respond to the healthcare needs of elderly patients? A population-based observational study in the Emilia-Romagna Region

BACKGROUND: Intermediate Care Services have been developed to provide high-quality and sustainable care to the elderly patients with chronic diseases. Italian Community Hospitals, inspired by the British model, are an example of Intermediate Care. The aim of this study was: (1) to describe the healthcare needs met by the Community Hospitals of Emilia-Romagna, Northern Italy, by depicting the characteristics of hospitalized patients, and (2) to evaluate process and outcome indicators by conducting a comparative assessment of the quality of care. STUDY DESIGN: Observational retrospective cohort study. METHODS: The study population included patients living in Emilia-Romagna who were discharged during 2016 from the 14 Community Hospitals of the region. Data were retrieved from the Regional Informative System of Community Hospitals database; multi-morbidity profiles were identified through the Hospital Discharge Records Database and the Outpatient Pharmaceutical Database. In-hospital variation of the 5-level Modified Barthel Index and hospital readmissions within 3 months of discharge were retrieved for each patient. The presence of recurrent patterns of multi-morbidity, i.e., clinical conditions that tend to co-occur, was investigated using unsupervised cluster analysis. RESULTS: The study population included 2,121 patients. Mean age was 79.5 years, mean Community Hospital stay was 22.4 days (range 13.1 - 31.5 days) and 62.5% of the patients were females. The most common sources of admission were hospital (71.8%) and home (27.0%). Routine discharges were 60.0%, planned home discharges were 13.6%, and transfers to public or private hospitals were 10.8%. We identified two multi-morbidity clusters unevenly distributed across Community Hospitals. Mean number of co-occurring chronic conditions per patient was different in the two clusters (3.0 vs. 4.7, p < 0.004). Mean Modified Barthel Index at admission and discharge was 32.2 and 47.6, respectively. Mean difference of 15.3 between values at admission and discharge was statistically significant (p < 0.001). Three-month hospital readmissions occurred for 20.2% of patients. CONCLUSION: The development of Intermediate Care Services, and in particular Community Hospitals, requires guidelines and protocols to define who among the patients can benefit more from this type of care. It is necessary to assess the quality of care provided by these facilities through appropriate and internationally comparable measures, including patient experience indicators

Cure specialistiche in ospedale: impatto su mortalit\ue0 e riammissioni a 30 giorni nei pazienti con scompenso cardiaco

Introduzione: Lo scompenso cardiaco (SC) \ue8 una sindrome complessa che si manifesta prevalentemente nella popolazione anziana ed \ue8 tra le pi\uf9 frequenti cause di ricovero ospedaliero. Diversi studi in letteratura affermano che la gestione del paziente con SC da parte dello specialista cardiologo migliora gli esiti del paziente. Questo studio si propone di valutare, in tre degli ospedali dell\u2019Azienda Unit\ue0 Sanitaria Locale (AUSL) di Bologna, l\u2019impatto del tipo di unit\ue0 operativa di ricovero (Cardiologia vs altre specialit\ue0) sulla mortalit\ue0 e sulle riammissioni a 30 giorni nei pazienti ricoverati per SC. Metodi: La popolazione comprende i pazienti residenti nell\u2019AUSL di Bologna e dimessi da uno dei tre ospedali in studio tra il 2 dicembre 2011 e il 1\ub0 dicembre 2012, con una diagnosi principale di SC, identificati attraverso le schede di dimissione ospedaliera (SDO). \uc8 stato costruito un modello di regressione logistica multivariata per ciascuno dei due esiti in studio con i dati delle SDO, delle cartelle cliniche e delle prescrizioni farmacologiche nei tre mesi precedenti il ricovero. Risultati: I pazienti studiati sono 1145, di cui il 56,9% \ue8 stato ricoverato in Medicina interna, il 15,4% in Geriatria e il 9,2% in Cardiologia. Prendendo come riferimento l\u2019ammissione in Cardiologia, la Medicina interna (OR = 10,72; 95% IC = 2,59-44,42) e la Geriatria (OR = 16,23; 95% IC = 4,68-56,33) sono associate a un pi\uf9 alto rischio di mortalit\ue0 a 30 giorni. Al contrario, non sono emerse differenze significative tra i reparti per quanto riguarda l\u2019esito riammissioni a 30 giorni. Conclusioni. La gestione del ricovero per SC da parte del cardiologo \ue8 associata ad una diminuzione della mortalit\ue0 a 30 giorni. I nostri risultati suggeriscono la necessit\ue0 di implementare modelli organizzativi che prevedano il coinvolgimento dei cardiologi nella gestione ospedaliera dei pazienti con SC

The association between general practitioner regularity of care and 'high use' hospitalisation

Background: In Australia, as in many high income countries, there has been a movement to improve out-of-hospital care. If primary care improvements can yield appropriately lower hospital use, this would improve productive efficiency. This is especially important among 'high cost users', a small group of patients accounting for disproportionately high hospitalisation costs. This study aimed to assess the association between regularity of general practitioner (GP) care and 'high use' hospitalisation. Methods: This retrospective, cohort study used linked administrative and survey data from the 45 and Up Study, conducted in New South Wales, Australia. The exposure was regularity of GP care between 1 July 2005 and 30 June 2009, categorised by quintile (lowest to highest). Outcomes were 'high use' of hospitalisation (defined as ≥3 and ≥ 5 admissions within 12 months), extended length of stay (LOS, ≥30 days), a combined metric (≥3 hospitalisations in a 12 month period where ≥1 hospitalisation was ≥30 days) and 30-day readmission between 1 July 2009 and 31 December 2017. Associations were assessed using multivariable logistic regression. Potential for outcome prevention in a hypothetical scenario where all individuals attain the highest GP regularity was estimated via the population attributable fraction (PAF). Results: Of 253,500 eligible participants, 15% had ≥3 and 7% had ≥5 hospitalisations in a 12-month period. Five percent of the cohort had a hospitalisation lasting ≥30 days and 25% had a readmission within 30 days. Compared with lowest regularity, highest regularity was associated with between 6% (p < 0.001) and 11% (p = 0.027) lower odds of 'high use'. There was a 7-8% reduction in odds for all regularity levels above 'low' regularity for LOS ≥30 days. Otherwise, there was no clear sequential reduction in 'high use' with increasing regularity. The PAF associated with a move to highest regularity ranged from 0.05 to 0.13. The number of individuals who could have had an outcome prevented was estimated to be between 269 and 2784, depending on outcome. Conclusions: High GP regularity is associated with a decreased likelihood of 'high use' hospitalisation, though for most outcomes there was not an apparent linear association with regularity

Real world heart failure epidemiology and outcome: a population-based analysis of 88,195 patients

BACKGROUND: Heart failure (HF) is frequent and its prevalence is increasing. We aimed to evaluate the epidemiologic features of HF patients, the 1-year follow-up outcomes and the independent predictors of those outcomes at a population level. METHODS AND RESULTS: Population-based longitudinal study including all prevalent HF cases in Catalonia (Spain) on December 31st, 2012. Patients were divided in 3 groups: patients without a previous HF hospitalization, patients with a remote (>1 year) HF hospitalization and patients with a recent (<1 year) HF admission. We analyzed 1year all-cause and HF hospitalizations, and all-cause mortality. Logistic regression was used to identify the independent predictors of each of those outcomes. A total of 88,195 patients were included. Mean age was 77 years, 55% were women. Comorbidities were frequent. Fourteen percent of patients had never been hospitalized, 71% had a remote HF hospitalization and 15% a recent hospitalization. At 1-year follow-up, all-cause and HF hospitalization were 53% and 8.8%, respectively. One-year all-cause mortality rate was 14%, and was higher in patients with a recent HF hospitalization (24%). The presence of diabetes mellitus, atrial fibrillation or chronic kidney disease was independently associated with all-cause and HF hospitalization and all-cause mortality. Hospital admissions and emergency department visits the previous year were also found to be independently associated with the three study outcomes. CONCLUSIONS: Outcomes are different depending on the HF population studied. Some comorbidity, an all-cause hospitalization or emergency department visit the previous year were associated with a worse outcome