Racial and Ethnic Differences in 30-Day Hospital Readmissions Among US Adults With Diabetes.

Importance: Differences in readmission rates among racial and ethnic minorities have been reported, but data among people with diabetes are lacking despite the high burden of diabetes and its complications in these populations. Objectives: To examine racial/ethnic differences in all-cause readmission among US adults with diabetes and categorize patient- and system-level factors associated with these differences. Design, Setting, and Participants: This retrospective cohort study includes 272 758 adult patients with diabetes, discharged alive from the hospital between January 1, 2009, and December 31, 2014, and stratified by race/ethnicity. An administrative claims data set of commercially insured and Medicare Advantage beneficiaries across the United States was used. Data analysis took place between October 2016 and February 2019. Main Outcomes and Measures: Unplanned all-cause readmission within 30 days of discharge and individual-, clinical-, economic-, index hospitalization-, and hospital-level risk factors for readmission. Results: A total of 467 324 index hospitalizations among 272 758 adults with diabetes (mean [SD] age, 67.7 [12.7]; 143 498 [52.6%] women) were examined. The rates of 30-day all-cause readmission were 10.2% (33 683 of 329 264) among white individuals, 12.2% (11 014 of 89 989) among black individuals, 10.9% (4151 of 38 137) among Hispanic individuals, and 9.9% (980 of 9934) among Asian individuals (P < .001). After adjustment for all factors, only black patients had a higher risk of readmission compared with white patients (odds ratio, 1.05; 95% CI, 1.02-1.08). This increased readmission risk among black patients was sequentially attenuated, but not entirely explained, by other demographic factors, comorbidities, income, reason for index hospitalization, or place of hospitalization. Compared with white patients, both black and Hispanic patients had the highest observed-to-expected (OE) readmission rate ratio when their income was low (annual household income <$40 000 among black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; among Hispanic patients: OE ratio, 1.11; 95% CI, 1.07-1.16) and when they were hospitalized in nonprofit hospitals (black patients: OE ratio, 1.10; 95% CI, 1.08-1.12; among Hispanic patients: OE ratio, 1.08; 95% CI, 1.05-1.12), academic hospitals (black patients: OE ratio, 1.16; 95% CI, 1.13-1.20; Hispanic patients: OE ratio, 1.12; 95% CI, 1.06-1.19), or large hospitals (ie, with ≥400 beds; black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; Hispanic patients: OE ratio, 1.09; 95% CI, 1.04-1.14). Conclusions and Relevance: In this study, black patients with diabetes had a significantly higher risk of readmission than members of other racial/ethnic groups. This increased risk was most pronounced among lower-income patients hospitalized in nonprofit, academic, or large hospitals. These findings reinforce the importance of identifying and addressing the many reasons for persistent racial/ethnic differences in health care quality and outcomes.

The descriptive epidemiology of central line-associated bloodstream infection among patients in non-intensive care unit settings.

OBJECTIVE: To review and describe device utilization and central line-associated bloodstream (CLABSI) events among patients in a non-intensive care unit (ICU) setting and to examine the morbidity and mortality associated with these events. DESIGN: One-year descriptive review. SETTING: A single tertiary center with a 1,200-bed hospital and 209 adult ICU beds. PATIENTS: Hospitalized patients identified as having a CLABSI event attributed to a non-ICU setting. METHODS: The cohort was identified from a prospective infection prevention database. Charts and administrative data sets were reviewed to further characterize the patients. Device utilization ratios (DURs) and CLABSI rates were calculated using National Health and Safety Network (NHSN) CLABSI definitions. Need for ICU stay and crude mortality rates were recorded. RESULTS: A total of 136 patients with 156 CLABSIs were identified, of whom 78 (57%) were being treated for a hematological malignancy (HM). The overall DUR was 0.27. A tunneled line was in place for 118 (76%) of the CLABSI events, and a peripherally inserted central catheter was in place for 32 (21%) of the CLABSI events. The non-ICU CLABSI rate was significantly higher than the concurrent ICU rate (2.1 CLABSIs per 1,000 catheter-days vs 1.5 CLABSIs per 1,000 catheter-days; [Formula: see text]). Hospital mortality was 23% in the affected group and was significantly higher in patients with HM. CONCLUSIONS: CLABSI rates over a 1-year period were higher in patients outside the ICU at our hospital and were associated with significant mortality.

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

OBJECTIVE: To reduce the probability of failure in the oral chemotherapy order, review and administration process and to reduce oral chemotherapy-related prescribing errors intercepted by clinical pharmacists prior to reaching the patient. DESIGN: A before-and-after cohort study. SETTING: A 719-bed multidisciplinary tertiary care institution with a pediatric division and an outpatient cancer center. PARTICIPANTS: A multidisciplinary team characterized key elements of the oral chemotherapy process using healthcare failure modes and effects analysis (HFMEA). INTERVENTION(S): Oral chemotherapy computerized provider order entry (CPOE) was developed and implemented. MAIN OUTCOME MEASURE(S): Pharmacist-intercepted oral chemotherapy prescribing errors over a 24-month period (before) and over a 6-month period (after) were analyzed according to the error type (errors in clinical decision making, errors in transcription or errors related to prescribing policy). The incidence of prescribing errors prior to and following CPOE implementation was compared by calculating the odds ratio (OR) and the 95% confidence interval (CI). RESULTS: HFMEA hazard analysis revealed seven potential failure modes, with the highest hazard scores in the prescribing and administration components of the process. CPOE implementation significantly (P= 0.023) reduced prescribing error risk by 69% [OR (95% CI) = 0.31 (0.11-0.86)] and eliminated certain types of errors that can lead to significant patient harm. CONCLUSIONS: Prescribing oral chemotherapy is a failure mode with significant risk of inducing patient harm. CPOE is effective in reducing prescribing errors of oral chemotherapy and should be considered part of a fail-safe process to improve safety.

Geriatric admissions in a developing country: experience from a tertiary centre in Nigeria.

BACKGROUND: The aging populations in developing countries have brought a demographic and an epidemiological transition, affecting the impact of chronic diseases on the health status of the population. OBJECTIVE: To review the pattern of geriatric admissions in the medical wards of the University of Port Harcourt Teaching Hospital (UPTH). METHOD: Medical records of all geriatric patients aged > or = 60 years admitted in the medical wards between June 2002 and May 2006 were retrieved and reviewed retrospectively. RESULTS: 2736 admissions to the adult medical wards over the period were reported. Among these, 1122 (41%) were geriatric patients aged > or = 60 years. The most common geriatric illnesses were cardiovascular diseases, 622 (43.7%), infections, 268 (18.8%) and endocrine diseases, 220 (15.4%). Malignancies, renal diseases and hematological diseases were few, being responsible for 53 (3.7%) 48 (3.4%) and 35 (2.5%) of medical admissions respectively. Only 1.5% of the patients spent more than 30 days in the hospital. More than half (56.4%) of the patients spent 1-2 weeks, while 33.3% of patients spent less than a week in hospital. Of the total geriatric patients seen, 70.6% recovered and were discharged home, 26.7% died and 2.5% left against medical advice. CONCLUSION: Elderly patients constitute a high proportion of in-patient medical admissions. Chronic diseases were responsible for the majority of morbidity and mortality in the elderly patients.

Prevalence of elevated hemoglobin A1c among patients admitted to the hospital without a diagnosis of diabetes.

CONTEXT: One in four hospitalized patients has diagnosed diabetes. The prevalence of unrecognized, or undiagnosed, diabetes among hospitalized patients is not well established. OBJECTIVE: Our objective was to determine the prevalence of unrecognized probable diabetes in this patient population determined by elevated hemoglobin A1c (HbA1c) level. DESIGN: We conducted a prospective observational cohort trial with retrospective follow-up of patients with elevated HbA1c levels and no diagnosis of diabetes. HbA1c levels were obtained for all patients. SETTING: The study was conducted at an acute care general hospital. PATIENTS: Patients included 695 adult, nonobstetric patients admitted on 11 d in 2006. MAIN OUTCOME MEASURES: Outcome measures included rate of unrecognized probable diabetes, defined as admission HbA1c of more than 6.1% and no diagnosis of diabetes or treatment with antidiabetic medications before or during their admission and rate of unrecognized diabetes 1 yr after discharge. RESULTS: Eighteen percent of hospitalized patients had elevated HbA1c levels without a diagnosis of diabetes. Random glucose levels poorly predicted elevated HbA1c levels (area under receiver operating characteristic curve, 0.60). Neither diagnosed diabetes nor HbA1c level was associated with length of stay or costs (P>0.1 for all comparisons). Only 15% of patients with elevated HbA1c levels who continued to receive care within the system studied had diabetes diagnosed in the year after the index admission. CONCLUSIONS: Nearly one in five adult patients admitted to a large general hospital had unrecognized probable diabetes, based on elevated HbA1c levels. Random glucose levels during the hospital stay were poorly predictive of this condition. Few hospitalized patients with elevated HbA1c levels were diagnosed within the year after admission.

Predictors of adverse events in patients after discharge from the intensive care unit.

BACKGROUND: Patients discharged from the intensive care unit may be at risk of adverse events because of complex care needs. OBJECTIVE: To identify the types, frequency, and predictors of adverse events that occur in the 72 hours after discharge from an intensive care unit when no evidence of adverse events was apparent before discharge. METHODS: A predictive cohort study of 300 patients from an adult intensive care unit was undertaken. An internationally accepted protocol for chart audit was used. Frequency of adverse events was calculated, and logistic regression was used to determine independent predictors of adverse events. RESULTS: A total of 147 adverse events, 17 (11.6%) of which were defined as major, were incurred by 92 patients (30.7%). The 3 most common adverse events, hospital-incurred infection or sepsis (n = 32, 21.8%), hospital-incurred accident or injury (n = 17, 11.6%), and other complication such as deep vein thrombosis, pulmonary edema, or myocardial infarction (n = 17, 11.6%) accounted for 44.9% (n = 66) of all adverse events. Two predictors, respiratory rate less than 10/min or greater than or equal to 25/min and pulse rate exceeding 110/min, were significant independent predictors; requiring a high level of nursing care at the time of discharge was a significant predictor in univariate analysis but not in multivariate analysis. CONCLUSION: Taking, recording, and reporting vital signs are important. Nursing care requirements of patients at discharge from the intensive care unit may be worthy of further investigation in studies of patients after discharge.

Influence of prolonged hospitalization on overall bed occupancy: a five-year single-centre study.

BACKGROUND: Effective bed use is crucial to an efficient NHS. Current targets suggest a decrease in mean occupancy as the most appropriate method of improving overall efficiency. The elderly and those suffering from complex medical problems are thought to account for a high proportion of overall bed occupancy. AIM: To assess the effect of prolonged hospital stay (>100 days) on overall bed occupancy in a modern teaching hospital. DESIGN: Retrospective analysis. METHODS: Analysis of all admission episodes (n = 117,178) over a five-year period in a large teaching hospital in a single UK region, serving a population of approximately 200,000. A logistic regression multi-factorial model was used to assess the effect of demographic and diagnostic variables on duration of stay. RESULTS: A prolonged stay (>100 days) was seen in 648 admission episodes (0.6%). These accounted for 11% of the overall bed occupancy over the 5-year period. Excluding all prolonged admission episodes from our analysis made no difference to the overall median length of stay. DISCUSSION: Prolonged hospitalizations have a significant impact on bed occupancy. Targeting these very long (>100 days) hospital stays may better improve overall efficiency, compared to targeting mean or median length of stay.

Development and application of evaluation indices for hospital infection surveillance and control programs in the Republic of Korea.

OBJECTIVE: To develop new evaluation indices of infection control and to use them to evaluate Korean infection surveillance and control programs (ISCPs). DESIGN: We performed a questionnaire-based survey to 164 acute care general hospitals throughout the Republic of Korea that had more than 300 beds. Study methods were based completely on those of the Study on the Efficacy of Nosocomial Infection Control (SENIC). Four SENIC indices (hospital epidemiologist index, infection control nurse index, surveillance index, and control index) and 4 newly developed indices (healthcare worker index, quality improvement index, resource index, and hand hygiene facilities index) were used to evaluate Korean ISCPs. Data were collected by questionnaire from June 17 to October 11, 2003. SETTING: One hundred sixty-four general hospitals with more than 300 beds in the Republic of Korea. RESULTS: Personnel from 85 general hospitals responded to the study questionnaire. The reliability and validity of the evaluation indices were statistically significant (P<.05). The 8 evaluation indices were categorized into 2 factor groups: personnel factors (hospital epidemiologist index and infection control nurse index) and activity factors (the remaining 6 indices). Korean ISCPs showed a major weakness in surveillance. The scores for the newly developed evaluation indices were better than those for the SENIC evaluation indices. However, most Korean hospitals were estimated to have had only slight reductions in nosocomial infection rates. The evaluation indices were influenced significantly by the number of beds in the hospital, whether the hospital was located in the Seoul-Gyonggi region, the presence of full-time infection control nurses at the hospital, the education level of the infection control nurses, and the nurses' experience in infection control (P<.05). CONCLUSIONS: The reliability and validity of the SENIC evaluation indices and the newly developed evaluation indices were satisfactory in evaluating Korean ISCPs. However, surveillance should be improved to increase the efficacy of Korean ISCPs.

Bed utilization indices at a tertiary care hospital in Goa: an eight year trend analysis.

A retrospective data analysis of records from medical records department of Goa Medical College Hospital was done to analyse the trends of various bed utilisation indices from 1999 - 2006. Average length of stay, bed occupancy rate, turnover interval and bed turnover ratio were the indices calculated. During the eight year period from 1999 to 2006, the average length of stay for the entire hospital registered a small decline from 6.23 to 5.51 days, the overall bed occupancy rate increased from 72.13% to 83.12% and the bed turnover interval declined from 2.41 days to 1.12 days. The Orthopaedics ward had the highest increase in bed occupancy and also fastest decline in turnover interval in 2006. Bed utilization indices are an objective measure of the efficiency of the hospital management system.

Epidemiology of intensive care unit (ICU)-acquired infections in a 14-month prospective cohort study in a single mixed Scandinavian university hospital ICU.

BACKGROUND: Our aim was to evaluate the epidemiology of intensive care unit (ICU)-acquired infections in a prospective cohort study. METHODS: Patients with longer than a 48-h stay in an adult mixed medical-surgical ICU in a tertiary level teaching hospital were included. The incidence (per cent) and incidence density (per 1000 patient days) of ICU-acquired infections and the device-associated infection rates per 1000 device days were analysed prospectively in a 14-month study. RESULTS: Eighty (23.9%) of 335 patients, whose ICU stay was longer than 48 h, acquired a total of 107 infections (1.3 per patient) during their ICU stay, with an infection rate of 48 per 1000 patient days. The most common infections were ventilator-associated pneumonia (VAP) [33.8% (18.8 per 1000 respiratory days)], other lower respiratory tract infections (LRTIs) (20%) and sinusitis (13.8%). The rate of central catheter-related (CRI) or primary bloodstream infections was 6.3% (2.2 per 1000 central venous catheter days), and the rate of urinary tract infections was 1.3% (0.5 per 1000 urinary catheter days). The first ICU infection was observed in 58.8% (47/80) of cases within 6 days after admission. The median time from admission to the diagnosis of an ICU-acquired infection was 4 days (25th-75th percentiles, 4.0-6.0) for VAP, 6.0 days (4.5-7.0) for LRTIs and 9.5 days (6.5-13.0) for CRIs. CONCLUSIONS: The rates of urinary tract infections and bloodstream infections were lower than reported previously, differentiating our results from the classic pattern of ICU-acquired infections, with the exception of the predominance of VAP.

[Descriptive study of bacteremia in a geriatric hospital]. / Etude descriptive des bactériémies dans un hôpital gériatrique universitaire.

OBJECTIVES: To describe clinical features, microbiologic characteristics and outcome of bacteremia in the elderly patients hospitalized in a geriatric hospital. PATIENTS AND METHODS: All episodes of bacteremia diagnosed from January 1(st) to December 31(st) 1998 were analysed, excluding false-positive cases due to skin contamination. The hospital comprises 1084 geriatric beds distributed as 111 in acute care (ACF), 333 in rehabilitation and intermediate-care (RICF), and 516 in long-term-care facilities (LTCF). RESULTS: Sixty-six episodes of bacteremia were observed in 65 patients. Among them 59 (89%) were nosocomial bacteremia distributed as 20 in ACF, 29 in RICF and 10 in LTCF (rates of 0.6, 0.35, and 0.05 episodes per 1000 patient-days, respectively.). Escherichia coli and Staphylococcus aureus were the main bacterial species involved in 31% and 28% of the cases, respectively. E. coli strains were 50% resistant to amoxicillin and 41% resistant to co-amoxiclav, and 68% of S. aureus strains were resistant to methicillin. Portals of entry were urinary tract (44%), respiratory tract (14%), digestive tract (11%), and soft tissue (8%). The same bacterial strain as in bacteremia was isolated from a peripheric site in 30 cases (47%), most of them being urines. For 15% cases, portal of entry cannot be determined. Mortality associated to nosocomial bacteremia was 25%, and death was significantly associated to MRSA, urinary or intravascular devices, chronic wounds and inappropriate antibiotic prescription. CONCLUSION: In geriatric hospitals, bacteremia are mainly nosocomial cases. Prevention should focus on indwelling devices and antibiotic resistance.

Inpatient satisfaction with physician services at King Khalid University Hospital, Riyadh, Saudi Arabia.

The satisfaction of 400 inpatients with physician services at King Khalid University Hospital, Riyadh was evaluated. Patient characteristics and ward of admission were collected and a questionnaire based on the standardized Likert scale was used. The highest mean satisfaction score was for admission and the lowest for communication. Among service items, the highest mean score was for physicians enquiring about patient conditions and opinions when planning care and the lowest for physicians asking for opinions about care quality and problems. Female and less educated patients were more satisfied with their care than male and educated patients. Male surgical and medical ward patients were the most dissatisfied with physicians'services. These findings offer hospital management information about shortcomings requiring remedial intervention.

Re-emergence of Vibrio cholerae O139 in Pakistan: report from a tertiary care hospital.

OBJECTIVE: This study reports re-emergence of Vibrio cholerae O139 in Pakistan in 2000-2001 from a tertiary care hospital in Karachi, Pakistan. METHODS: This descriptive study was conducted from 2000-2001. Stool samples were taken from inpatients or those referred to the laboratory from other hospitals, clinics and general practitioners. Samples were processed and Vibrio cholerae isolates were identified according to standard protocols. Tellurite Taurocholate Gelatin agar was used as a selective medium for Vibrio cholerae. Serogroups were identified by slide agglutination with polyvalent antisera. Antimicrobial sensitivities were performed by Kirby Bauer technique. Data was entered and analyzed using SPSS, p values were calculated using t test and two independent samples test. RESULTS: During the study period, 144 samples were found to be infected with Vibrio cholerae O139 in comparison with 545 Vibrio cholerae O1. Infection with O139 was characteristically observed in the older population (mean age = 40 years) in contrast with Vibrio cholerae O1 strains (mean age = 23 years) (p. value = <0.001). Sensitivity pattern of 2000-2001 Vibrio cholerae isolates was markedly different to that of 1993-1994. The earlier isolates were resistant to Cotrimoxazole (99%) and Chloramphenicol (35%) whereas the recent isolates are almost 100% sensitive. CONCLUSION: In conclusion this re-emergent strain seen 6 years after previous episode infected large number of people especially older population suggesting that prior infection with O1 does not provide immunity against O139 and therefore Vibrio cholerae O139 has a potential to cause a major epidemic in an immunologically naïve population.