Reducing unnecessary hospital days to improve quality of care through physician accountability: a cluster randomised trial.

BACKGROUND: Over 20% of hospital bed use is inappropriate, implying a waste of resources and the increase of patient iatrogenic risk. METHODS: This is a cluster, pragmatic, randomised controlled trial, carried out in a large University Hospital of Northern Italy, aiming to evaluate the effect of a strategy to reduce unnecessary hospital days. The primary outcome was the percentage of patient-days compatible with discharge. Among secondary objectives, to describe the strategy's effect in the long-term, as well as on hospital readmissions, considered to be a marker of the quality of hospital care. The 12 medical wards with the longest length of stay participated. Effectiveness was measured at the individual level on 3498 eligible patients during monthly index days. Patients admitted or discharged on index days, or with stay >90 days, were excluded. All ward staff was blinded to the index days, while staff in the control arm and data analysts were blinded to the trial's objectives and interventions. The strategy comprised the distribution to physicians of the list of their patients whose hospital stay was compatible with discharge according to a validated Delay Tool, and of physician length of stay profiles, followed by audits managed autonomously by the physicians of the ward. RESULTS: During the 12 months of data collection, over 50% of patient-days were judged to be compatible with discharge. Delays were mainly due to problems with activities under medical staff control. Multivariate analysis considering clustering showed that the strategy reduced patient-days compatible with discharge by 16% in the intervention vs control group, (OR=0.841; 95% CI, 0.735 to 0.963; P=0.012). Follow-up at 1 year did not yield a statistically significant difference between the percentages of patient-days judged to be compatible with discharge between the two arms (OR=0.818; 95% CI, 0.476 to 1.405; P=0.47). There was no significant difference in 30-day readmission and mortality rates for all eligible patients (N=3498) between the two arms. CONCLUSIONS: Results indicate that a strategy, involving physician direct accountability, can reduce unnecessary hospital days. Relatively simple interventions, like the one assessed in this study, should be implemented in all hospitals with excessive lengths of stay, since unnecessary prolongation may be harmful to patients. TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT01422811.

The effect of fruits and vegetables on urinary stone risk factors.

BACKGROUND: The overall effect of fruit and vegetable intake on urinary stone risk profile is not yet known. METHODS: We studied the effect of a two-week period of fruit and vegetable elimination on urinary stone risk profile in 12 normal adults, and of supplementing the diet with a fair quantity of low-oxalate fruits and vegetables in 26 idiopathic calcium stone formers characterized by hypocitraturia and a very low fruit and vegetable intake in their usual diet. RESULTS: In the normal subjects, the elimination of fruits and vegetables from the diet decreased the urinary excretion of potassium (-62%), magnesium (-26%), citrate (-44%) and oxalate (-31%), and increased that of calcium (+49%) and ammonium (+12%) (P < 0.05 for all). The relative saturation for calcium oxalate and calcium phosphate increased from 6.33 to 8.24 (P = 0.028), and from 0.68 to 1.58 (P = 0.050), respectively. In the hypocitraturic stone formers, the introduction of these foods in the diet increased urinary volume (+64%), pH (from 5.84 to 6.19), excretion of potassium (+68%), magnesium (+23%), and citrate (+68%), while it decreased the excretion of ammonium (-18%) (P < 0.05 for all). The relative saturation for calcium oxalate and uric acid fell from 10.17 to 4.96 (P < 0.001), and from 2.78 to 1.12 (P = 0.003), respectively. CONCLUSION: The total elimination of fruits and vegetables in normal subjects brings about adverse changes in the urinary stone risk profile that are only partially counterbalanced by a reduction in oxalate. In contrast, the addition of these foods to the diet of hypocitraturic stone formers not used to eating them not only significantly increases citrate excretion without affecting oxalate excretion, but also decreases calcium oxalate and uric acid relative saturation.

[Analysis of the problem of "difficult hospital discharges" in the University Hospital of Parma]. / Analisi del problema "dimissioni difficili" nell'Azienda Ospedaliera-Universitaria di Parma.

We analyzed, in a middle-sized hospital, the problems related to the so-called "difficult discharges", conceived as situations involving an economic, human and organizational burden exceeding patients' and their families' capacities and requiring a specific involvement of territorial services. During a whole year (July 1, 2001-June 30, 2002) the cases found were 591. We demonstrated that the problem concerns mainly elderly patients, almost equally distributed between males and females, a quarter of the sample being represented by patients who had recently undergone surgery and whose discharge difficulties were mostly related to mixed social and sanitary problems. This kind of patients is faced with long-term hospitalization implicating a large number of intra-hospital transfers due to the presence of severe and disabling pathologies, mainly neoplasms and strokes, often associated with other serious diseases, various complications and difficult situations from the health point of view. About half of the patients had the possibility to go back home, while the rest required lodging in territorial structures such as nursing homes and retirement homes. The average time-lapse between the possible discharge indicated by the hospital physician and the actual discharge was 10 days, with global annual 6106 days of "improper" hospitalization. Our conclusion is that the phenomenon of difficult discharges is nowadays a very topical problem and that it should be faced with a new model of continuous and integrated assistance organization.

Body weight, diet and water intake in preventing stone disease.

Nutrition plays a major role in the pathogenesis of the most widespread forms of nephrolithiasis, i.e. calcium (calcium oxalate and phosphate) and uric acid stone disease. For this reason, dietary measures are the first level of intervention in primary prevention, as well as in secondary prevention of recurrences. An unbalanced diet or particular sensitivity to various foods in stone formers can lead to urinary alterations such as hypercalciuria, hyperoxaluria, hyperuricosuria, hypocitraturia and an excessively acid urinary pH. Over the course of time, these conditions contribute to the formation or recurrence of kidney stones, due to the effect they exert on the lithogenous salt profile. The fundamental aspects of the nutritional approach to the treatment of idiopathic nephrolithiasis are body weight, diet and water intake. This paper will present data resulting from our own investigations and the most significant evidence in literature.

Calcium oxalate crystallization in untreated urine, centrifuged and filtered urine and ultrafiltered urine.

Centrifuged and filtered urine is often used to evaluate in vitro the crystallization processes of calcium oxalate (CaOx), but even such simple manipulations can alter the composition of the urine, as regards its protein and lipid concentrations. In urine samples taken from 17 normal male adults, we evaluated CaOx crystallization by simultaneously using three different types of urine: untreated (U), centrifuged at 2000 rpm (800 g) and filtered at 0.22 microm (CF), and centrifuged-filtered and ultrafiltered at 10 000 Da (CFU). The addition of 1.2 mmol/l of oxalate to each type of urine produced notably different results. The total amount of CaOx crystals (expressed as calcium oxalate dihydrate crystals (COD) + oxalate monohydrate crystals (COM) area/total area x 100) was on average 13.2% in U urine, 70.7% in CF urine and 11.1% in CFU urine (CF > U and CFU, U = CFU); the relative prevalence of COD and COM (expressed as COD area/COM area) was on average 71.4 in U urine, 0.0026 in CF urine and 5.5 in CFU urine (U > CF and CFU, CFU > CF); the diameter of COD (expressed in microns) was on average 15.2 in U urine, 3.7 in CF urine and 24.3 in CFU urine (CFU > U and CF, U > CF); the diameter of COM (expressed in microns) was on average 5.2 in U urine, 2.6 in CF urine and 8.9 in CFU urine (CFU > U and CF, U > CF); the total amount of CaOx aggregates (expressed as CaOxAgg area/total area x 100) was on average 8.5% in U urine, 22.1% in CF urine and 2.9% in CFU urine (CF > U and CFU, U > CF). We conclude that CaOx crystallization processes in manipulated urine are extremely different, probably due to changes in macromolecular compounds.

Medical treatment of nephrolithiasis.

The medical treatment of nephrolithiasis is aimed in particular at the prevention of relapses, even though in some cases, such as cystine or uric acid lithiasis, the calculi also can be dissolved on site. When the diagnosis and metabolic profile have been performed correctly, medical treatment is effective in a large number of patients. The greatest difficulty is the patient's compliance with the most suitable prevention measures and the frequency of follow-up controls. This compliance can be influenced significantly by the amount of time that the doctor spends to explain the origin of the disease. This article reviews the main methods available for the medical treatment of various nephrolithiasis types, namely water intake, diet, and drugs, supplying the relevant information about the mechanism of action, metabolic consequences, indications, evidence provided from studies, dosage, efficacy, and side-effects. Finally, brief simplified guidelines are given for the medical treatment of stone disease caused by calcium oxalate or calcium phosphate, uric acid, cystine, and struvite.

Crystalline aggregation in vitro: interaction between urinary macromolecules and the micromolecular environment.

The formation of calcium oxalate (CaOx) crystals, their growth and above all their agglomeration tendency are considered to be decisive factors in the renal stone formation. The aim of this study was to verify whether the formation in vitro of crystalline macroaggregates, induced by increasing loads of oxalate, is different in normal subjects as opposed to CaOx stone formers, free from urinary metabolic abnormalities. The possible interference of the urinary micromolecular environment on the activities of macromolecules with molecular weight greater than 10,000 Daltons was also evaluated. Formation of crystalline macroaggregates took place in controls at a relative CaOx supersaturation equivalent to 32.6 +/- 12.9 and in stone formers at 34 +/- 12.3 (NS); the CaOx RS aggregation--CaOx RS nucleation delta was 11.4 +/- 12.2 in controls and 15.8 +/- 13.9 in stone formers (NS). Leaving aside the stone disease variable, the urine characterized by high baseline CaOx saturation, high ionic strength and high levels of citrate, magnesium and calcium, seemed particularly predisposed to macroaggregates formation; the opposite was true for urine characterized by a totally different micromolecular environment. A very close relationship was found between the CaOx RS aggregation--CaOx RS nucleation delta in urine filtered at 0.22 mu and in metastable solutions containing macromolecules in similar concentrations to those found in the native urine (r = 0.74, P < 0.0001). In conclusion the formation of crystalline macroaggregates in vitro does not present differences in normal subjects compared to CaOx stone formers free from urinary metabolic abnormalities. The urinary macromolecules seem to participate in the formation of the crystalline macroaggregates and their action seems to be affected by the urinary micromolecular environment and, even when they are re-suspended in a completely different medium, their action seems to be preserved intact.

Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria.

BACKGROUND: A low-calcium diet is recommended to prevent recurrent stones in patients with idiopathic hypercalciuria, yet long-term data on the efficacy of a low-calcium diet are lacking. Recently, the efficacy of a low-calcium diet has been questioned, and greater emphasis has been placed on reducing the intake of animal protein and salt, but again, long-term data are unavailable. METHODS: We conducted a five-year randomized trial comparing the effect of two diets in 120 men with recurrent calcium oxalate stones and hypercalciuria. Sixty men were assigned to a diet containing a normal amount of calcium (30 mmol per day) but reduced amounts of animal protein (52 g per day) and salt (50 mmol of sodium chloride per day); the other 60 men were assigned to the traditional low-calcium diet, which contained 10 mmol of calcium per day. RESULTS: At five years, 12 of the 60 men on the normal-calcium, low-animal-protein, low-salt diet and 23 of the 60 men on the low-calcium diet had had relapses. The unadjusted relative risk of a recurrence for the group on the first diet, as compared with the group on the second diet, was 0.49 (95 percent confidence interval, 0.24 to 0.98; P=0.04). During follow-up, urinary calcium levels dropped significantly in both groups by approximately 170 mg per day (4.2 mmol per day). However, urinary oxalate excretion increased in the men on the low-calcium diet (by an average of 5.4 mg per day [60 micromol per day]) but decreased in those on the normal-calcium, low-animal-protein, low-salt diet (by an average of 7.2 mg per day [80 micromol per day]). CONCLUSIONS: In men with recurrent calcium oxalate stones and hypercalciuria, restricted intake of animal protein and salt, combined with a normal calcium intake, provides greater protection than the traditional low-calcium diet.