Factors affecting unplanned readmissions from community hospitals to acute hospitals: a prospective observational study

<p><b>INTRODUCTION</b>While the readmission rate from community hospitals is known, the factors affecting it are not. Our aim was to determine the factors predicting unplanned readmissions from community hospitals (CHs) to acute hospitals (AHs).</p><p><b>MATERIALS AND METHODS</b>This was an observational prospective cohort study, involving 842 patients requiring post-acute rehabilitation in 2 CHs admitted from 3 AHs in Singapore. We studied the role of the Cumulative Illness Rating Scale (CIRS) organ impairment scores, the Mini-mental State Examination (MMSE) score, the Shah modified Barthel Index (BI) score, and the triceps skin fold thickness (TSFT) in predicting the rate of unplanned readmissions (UR), early unplanned readmissions (EUPR) and late unplanned readmissions (LUPR). We developed a clinical prediction rule to determine the risk of UR and EUPR.</p><p><b>RESULTS</b>The rates of EUPR and LUPR were 7.6% and 10.3% respectively. The factors that predicted UR were the CIRS-heart score, the CIRS-haemopoietic score, the CIRS-endocrine / metabolic score and the BI on admission. The MMSE was predictive of EUPR. The TSFT and CIRS-liver score were predictive of LUPR. Upon receiver operator characteristics analysis, the clinical prediction rules for the prediction of EUPR and UR had areas under the curve of 0.745 and 0.733 respectively. The likelihood ratios of the clinical prediction rules for EUPR and UR ranged from 0.42 to 5.69 and 0.34 to 3.16 respectively.</p><p><b>CONCLUSIONS</b>Patients who have UR can be identified by the admission BI, the MMSE, the TSFT and CIRS scores in the cardiac, haemopoietic, liver and endocrine/metabolic systems.</p>

Evaluation of dementia: the case for neuroimaging all mild to moderate cases

<p><b>INTRODUCTION</b>The aim of this study was to assess the usefulness of 4 clinical prediction rules, the neuroimaging guidelines from the Canadian Consensus Conference on Dementia (CCCAD) and the modified Hachinski's Ischaemic Score (HIS) in identifying patients with suspected dementia who will benefit from neuroimaging.</p><p><b>MATERIALS AND METHODS</b>Two hundred and ten consecutive patients were referred to the memory clinic in a geriatric unit for the evaluation of possible dementia. Sensitivity, specificity and likelihood ratios (LR) were calculated for each of the prediction rules and the CCCAD guidelines, in terms of their ability to identify patients with significant lesions [defined firstly as space-occupying lesions (SOL) alone and secondly as SOL or strokes] on neuroimaging. Similar analyses were applied for the HIS in the detection of strokes.</p><p><b>RESULTS</b>When considering SOL alone, sensitivities ranged from 28.6% to 100% and specificities ranged from 21.7% to 88.4%. However, when strokes were included in the definition of significant lesions, sensitivities ranged from 16.2% to 79.0% and specificities ranged from 20.9% to 92.4%. The modified HIS had a similarly poor sensitivity and specificity (43.3% and 78.9% respectively). The LR for the clinical decision tools did not support the use of any particular instrument.</p><p><b>CONCLUSIONS</b>Clinical decision tools do not give satisfactory guidance for determining the need for neuroimaging patients with suspected dementia, when the detection of strokes, in addition to SOL, is regarded as important. We recommend therefore that neuroimaging be considered for all patients with suspected mild or moderate dementia in whom the potential benefits of any treatment outweigh the potential risks.</p>