Is there excessive troponin testing in clinical practice? Evidence from emergency medical admissions.

AIM: To investigate whether excessive high-sensitivity cardiac troponin T (hscTnT) testing, in non-cardiac presentations, increases hospital length of stay (LOS) by driving down-stream investigations. METHODS: We report on all hscTnT tests in emergency medical admissions, performed over a 9-year period between 2011-2019. Troponin testing frequency in different risk cohorts was determined and related to 30-day in-hospital mortality with a multivariable logistic regression model adjusted for other outcome predictors. Downstream utilization of procedures/services was related to LOS with zero truncated Poisson regression. RESULTS: There were 66,475 admissions in 36,518 patients. hscTnT was tested in 24.4% of admissions, more frequently in the elderly (>70 years 33.4%, >80 years 35.9%), cardiovascular presentations (33.6%) and in those with high comorbidity (42.2%), and reduced in those with neurologic presentations (20%). A hscTnT request predicted increased 30-day in-hospital mortality OR 3.33 (95% CI: 3.06, 3.64). The univariate odds ratio (OR) of hscTnT test result was 1.45 (95% CI: 1.42, 1.49) and was semi-quantative with worsening outcomes as hscTnT increased. It remained predictive in the fully adjusted model OR 1.17 (95% CI: 1.09, 1.26). LOS was linearly related to the number of procedures/services performed. hscTnT testing did not increase LOS or number of procedures/services CONCLUSION: : A clinical request for hscTnT testing is prognostic and risk categorises. Subsequent resource utilization, if increased, appears an epiphenomenon related to risk categorisation, rather than being driven by inappropriate hscTnT testing.

High Risk Subgroups Sensitive to Air Pollution Levels Following an Emergency Medical Admission.

For three cohorts (the elderly, socially deprived, and those with chronic disabling disease), the relationship between the concentrations of particulate matter (PM10), sulphur dioxide (SO2), or oxides of nitrogen (NOx) at the time of hospital admission and outcomes (30-day in-hospital mortality) were investigated All emergency admissions (90,423 episodes, recorded in 48,035 patients) between 2002 and 2015 were examined. PM10, SO2, and NOx daily levels from the hospital catchment area were correlated with the outcomes for the older admission cohort (>70 years), those of lower socio-economic status (SES), and with more disabling disease. Adjusted for acuity and complexity, the level of each pollutant on the day of admission independently predicted the 30-day mortality: for PM10-OR 1.11 (95% CI: 1.08, 1.15), SO2-1.20 (95% CI: 1.16, 1.24), and NOx-1.09 (1.06-1.13). For the older admission cohort (≥70 years), as admission day pollution increased (NOx quintiles) the 30-day mortality was higher in the elderly (14.2% vs. 11.3%: p < 0.001). Persons with a lower SES were at increased risk. Persons with more disabling disease also had worse outcomes on days with higher admission particulate matter (PM10 quintiles). Levels of pollutants on the day of admission of emergency medical admissions predicted 30-day hospital mortality.

Social Factors Determine the Emergency Medical Admission Workload.

We related social factors with the annual rate of emergency medical admissions using census small area statistics. All emergency medical admissions (70,543 episodes in 33,343 patients) within the catchment area of St. James's Hospital, Dublin, were examined between 2002 and 2016. Deprivation Index, Single-Parent status, Educational level and Unemployment rates were regressed against admission rates. High deprivation areas had an approximately fourfold (Incidence Rate Ratio (IRR) 4.0 (3.96, 4.12)) increase in annual admission rate incidence/1000 population from Quintile 1(Q1), from 9.2/1000 (95% Confidence Interval (CI): 9.0, 9.4) to Q5 37.3 (37.0, 37.5)). Single-Parent families comprised 40.6% of households (95% CI: 32.4, 49.7); small areas with more Single Parents had a higher admission rate-IRR (Q1 vs. for Q5) of 2.92 (95% CI: 2.83, 3.01). The admission incidence rate was higher for Single-Parent status (IRR 1.50 (95% CI: 1.46, 1.52)) where the educational completion level was limited to primary level (Incidence Rate Ratio 1.45 (95% CI: 1.43, 1.47)). Small areas with higher educational quintiles predicted lower Admission Rates (IRR 0.85 (95% CI: 0.84, 0.86)). Social factors strongly predict the annual incidence rate of emergency medical admissions.

Effect of social deprivation on the admission rate and outcomes of adult respiratory emergency admissions.

BACKGROUND: Patients with respiratory disorders constitute a major source of activity for Acute Medicine. We have examined the impact of Socio-Economic Status (SES) and weather factors on the outcomes (30-day in-hospital mortality) of emergency hospitalisations with a respiratory presentation. METHODS: All emergency respiratory admissions to St. James Hospital, Dublin, from 2002 to 2014 were evaluated. Patients were categorized by quintile of Deprivation Index, and evaluated against hospital admission rate (/1000 population) and 30-day in-hospital mortality. Univariate and multivariable risk estimates (Odds Ratios (OR) or Incidence Rate Ratios (IRR)) were calculated, using logistic or zero truncated Poisson regression as appropriate. RESULTS: There were 32,538 episodes in 14,093 patients, representing 39.5% of medical emergency episodes over the 13-yr period. Deprivation Quintile independently predicted the admission rate, with incidence rate ratios (IRR) of Q3 2.02 (95% CI: 1.27, 3.23), Q4 2.55 (95% CI: 1.35, 4.83) and Q5 5.68 (95% CI: 3.56, 9.06). The 30-day in-hospital mortality for the highest quintile was increased (p < 0.01), Q5 1.31 (95% CI: 1.07, 1.61). Particulate matter (PM10) was predictive for the top two quintiles (>17.2 and 23.8 µg/m3 respectively) with an OR for a worse outcome of Q4 1.22 (95% CI: 1.07, 1.40) and Q5 1.24 (95% CI: 1.08, 1.42). Weather (season) and the daily temperature did not affect the admission rate but were significantly associated with worse outcome. CONCLUSION: Socio-Economic Status influences the admission rate incidence and hospital mortality of respiratory emergency admissions; local environmental conditions (air pollution and temperature) appear only relevant to the mortality outcomes.

The Relationship Between Social Deprivation and a Weekend Emergency Medical Admission.

BACKGROUND: Deprivation increases admission rates; the specific effect of deprivation with regard to weekend admissions is unknown. METHODS: We calculated annual weekend admission rates for each small area population unit and related these to quintiles of Deprivation Index from 2002-2014. Univariate and multivariable risk estimates were calculated using truncated Poisson regression. RESULTS: There were 30,794 weekend admissions in 16,665 patients. The admission rate was substantially higher for more deprived areas, 12.7 per 1000 (95%CI 9.4, 14.7) vs 4.6 per 1000 (95%CI 3.3, 5.8). More deprived patients admitted at the weekend had a significantly lower 30-day in-hospital mortality (10.3% vs 14.5%, p<0.001). CONCLUSION: Deprivation is a powerful determinant of weekend admissions, however these comprise a group of patients with better outcomes.

Deprivation influences the emergency admission rate of ambulatory care sensitive conditions.

Ambulatory care sensitive conditions (ACSCs) are a group of conditions judged to be suitable for healthcare efficiency initiatives to reduce the rate of hospital admissions. All emergency medical admissions to an Irish hospital between 2002 and 2013 were assessed for ACSCs. They were categorised by quintile of deprivation index and evaluated against hospital admission rate. Univariable and multivariable risk estimates were calculated, using logistic regression or zero-truncated Poisson regression. There were 66,861 admissions in 36,214 patients. ACSCs represented 66.4% of admissions. The rate of ACSC admissions increased with deprivation index, Q1 10.4 (95% confidence interval (CI) 10.2-10.5), Q2 17.3 (95% CI 17.2-17.5), Q3 34.0 (95% CI 33.7-34.2), Q4 30.2 (95% CI 30.0-30.4) and Q5 44.5 (95% CI 43.8- 45.1) (p<0.001), corresponding incidence rate ratios compared with Q1 were: Q2 1.67 (95% CI 1.64-1.70), Q3 3.28 (95% CI 3.22-3.33), Q4 2.92 (95% CI 2.87-2.97) and Q5 4.29 (95% CI 4.20-4.39) (p<0.001). ACSCs are common in acute medical admissions and are strongly influenced by the underlying social demographics of the population.

Social deprivation and hospital admission rates, length of stay and readmissions in emergency medical admissions.

BACKGROUND: Patients from deprived backgrounds have a higher in-patient mortality following an emergency medical admission. How deprivation relates to the admission or readmission incidence rates, episode length of stay (LOS) and ancillary resource utilization is less clear. METHODS: All emergency medical admissions (66,861 episodes in 36,214 patients) between 2002 and 2013, categorized by quintile of Irish National Deprivation Index were assessed against admission or readmission incidence rates (/1000 local population by electoral division), LOS and utilization of five ancillary services. Univariate and multi-variable risk estimates (odds ratios (OR) or incidence rate ratios (IRR)) were calculated, using truncated Poisson regression. RESULTS: The deprivation index quintile was strongly correlated with the emergency medical admission rate with IRR (as compared with quintile 1) as follows: Q2 1.99 (95% CI: 1.96, 2.01), Q3 3.45 (95% CI: 3.41, 3.49), Q4 3.27 (95% CI: 3.23, 3.31) and Q5 4.29 (95% CI: 4.23, 4.35). LOS was not influenced by deprivation status; although increasing deprivation resulted in increased utilization of social services (OR 1.04: 95% CI: 1.03, 1.06), with a lower requirement for occupational therapy (OR 0.94: 95% CI: 0.93, 0.96) and speech/language services (OR 0.83: 95% CI: 0.80, 0.86). There was a rather decreased use of ancillary services with increasing deprivation; however, the readmission rate was strongly predicted by deprivation status. CONCLUSION: Deprivation status strongly influenced the admission and readmission rates for medical patients admitted as emergencies; however, ancillary resource utilization was not increased. Deprivation index will increase demand on hospital resources due to the aggregate effect on both admission and readmission incidence rates.

Social deprivation, population dependency ratio and an extended hospital episode - Insights from acute medicine.

BACKGROUND: Patients from deprived backgrounds have a higher in-patient mortality following an emergency medical admission; this study aimed to investigate the extent to which Deprivation status and the population Dependency Ratio influenced extended hospital episodes. METHODS: All Emergency Medical admissions (75,018 episodes of 41,728 patients) over 12 years (2002-2013) categorized by quintile of Deprivation Index and Population Dependency Rates (proportion of non-working/working) were evaluated against length of stay (LOS). Patients with an Extended LOS (ELOS), >30 days, were investigated, by Deprivation status, Illness Severity and Co-morbidity status. Univariate and multi-variable risk estimates (Odds Rates or Incidence Rate Ratios) were calculated, using truncated Poisson regression. RESULTS: Hospital episodes with ELOS had a frequency of 11.5%; their median LOS (IQR) was 55.0 (38.8, 97.6) days utilizing 57.6% of all bed days by all 75,018 emergency medical admissions. The Deprivation Index independently predicted the rate of such ELOS admissions; these increased approximately five-fold (rate/1000 population) over the Deprivation Quintiles with model adjusted predicted admission rates of for Q1 0.93 (95% CI: 0.86, 0.99), Q22.63 (95% CI: 2.55, 2.71), Q3 3.84 (95% CI: 3.77, 3.91), Q4 3.42 (95% CI: 3.37, 3.48) and Q5 4.38 (95% CI: 4.22, 4.54). Similarly the Population Dependency Ratio Quintiles (dependent to working structure of the population by small area units) independently predicted extended LOS admissions. CONCLUSION: The admission of patients with an ELOS is strongly influenced by the Deprivation status and the population Dependency Ratio of the catchment area. These factors interact, with both high deprivation and Dependency cohorts having a major influence on the numbers of emergency medical admission patients with an extended hospital episode.

Deprivation index and dependency ratio are key determinants of emergency medical admission rates.

BACKGROUND: Patients from deprived backgrounds have a higher in-patient mortality following an emergency medical admission; there has been debate as to the extent to which deprivation and population structure influences hospital admission rate. METHODS: All emergency medical admissions to an Irish hospital over a 12-year period (2002-2013) categorized by quintile of Deprivation Index and Dependency Ratio (proportion of population <15 or ≥ 65 years) from small area population statistics (SAPS), were evaluated against hospital admission rates. Univariate and multivariable risk estimates (Odds Ratios (OR) or Incidence Rate Ratios (IRR)) were calculated, using logistic or zero truncated Poisson regression as appropriate. RESULTS: 66,861 admissions in 36,214 patients occured during the study period. The Deprivation Index quintile independently predicted the admission rate/1000 population, Q1 9.4 (95%CI 9.2 to 9.7), Q2 16.8 (95%CI 16.6 to 17.0), Q3 33.8 (95%CI 33.5 to 34.1), Q4 29.6 (95%CI 29.3 to 29.8) and Q5 45.4 (95%CI 44.5 to 46.2). Similarly the population Dependency Ratio was an independent predictor of the admission rate with adjusted predicted rates of Q1 20.8 (95%CI 20.5 to 21.1), Q2 19.2 (95%CI 19.0 to 19.4), Q3 27.6 (95%CI 27.3 to 27.9), Q4 43.9 (95%CI 43.5 to 44.4) and Q5 34.4 (95%CI 34.1 to 34.7). A high concurrent Deprivation Index and Dependency Ratio were associated with very high admission rates. CONCLUSION: Deprivation Index and population Dependency Ratio are key determinants of the rate of emergency medical admissions.