2011 December 23

Preventable hospitalization among nursing home residents: varying views between medical directors and directors of nursing regarding determinants.

Dec 232011

Preventable hospitalization among nursing home residents: varying views between medical directors and directors of nursing regarding determinants.

J Aging Health. 2010 Mar;22(2):169-82

Authors: Young Y, Inamdar S, Barhydt NR, Colello AD, Hannan EL

Abstract
OBJECTIVE: To compare the perception of the determinants of preventable hospitalization among nursing home residents by surveying medical directors (MDs) and directors of nursing (DONs).
METHODS: A survey (N = 52) was completed in January 2008. Data included resource availability, determinants of hospitalization, and nursing home practice. Multivariate linear regression examined the associations between potential determinants and preventable hospitalization.
RESULTS: Four significant determinants perceived by MDs to influence preventable hospitalization: MD/nurse practitioner (NP) access by pager, family preferences, access to medical history and lab/ electrocardiograph (EKG) reports, and physicians better paid to manage acutely ill residents (R(2) = .58). None of these factors were echoed by DONs (R(2) = .15). Whereas DONs perceived stat lab results on weekends were associated with increased hospitalization (p = .03), MDs did not (p = .28).
CONCLUSIONS: Our analysis showed that communication and consensus are important factors in the hospital transfer decision and that the discord in perceptions among MDs and DONs may complicate interventions to reduce preventable hospitalization.

PMID: 20133957 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

The relationship between hospital admission rates and rehospitalizations.

N Engl J Med Start a Discussion »

Dec 232011

The relationship between hospital admission rates and rehospitalizations.

N Engl J Med. 2011 Dec 15;365(24):2287-95

Authors: Epstein AM, Jha AK, Orav EJ

Abstract
BACKGROUND: Efforts to reduce hospital readmissions have focused primarily on improving transitional care. Yet variation in readmission rates may more closely reflect variation in the underlying hospitalization rates than differences in the quality of care during and after discharge.
METHODS: We used national Medicare data to calculate, for each local hospital referral region (HRR), the 30-day, 60-day, and 90-day readmission rates among patients discharged with congestive heart failure or pneumonia. We also calculated population-based all-cause admission rates among Medicare enrollees in each HRR. We examined the variation in HRR readmission rates that was explained by overall hospitalization rates versus differences in patients' coexisting conditions, quality of discharge planning, physician supply, and bed supply.
RESULTS: HRR readmission rates ranged from 11 to 32% for congestive heart failure and from 8 to 27% for pneumonia. In univariate analyses, all-cause admission rates accounted for the highest proportion of regional variation in readmission rates for congestive heart failure (28%, 34%, and 37% at 30, 60, and 90 days, respectively); the next highest proportions were explained by case mix (11%, 15%, and 18%) and the number of cardiologists per capita (12%, 14%, and 15%). Results for pneumonia were similar, except that the number of pulmonologists per capita accounted for a lower proportion of the variation (6%, 8%, and 7%, respectively). In multivariate analyses, admission rates accounted for 16 to 24% of the variation for congestive heart failure and 11 to 20% for pneumonia; no other factor accounted for more than 6%.
CONCLUSIONS: We found a substantial association between regional rates of rehospitalization and overall admission rates. Programs directed at shared savings from lower utilization of hospital services might be more successful in reducing readmissions than programs initiated to date. (Funded by the Commonwealth Fund.).

PMID: 22168643 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Focal segmental glomerulosclerosis.

N Engl J Med Start a Discussion »

Dec 232011

Focal segmental glomerulosclerosis.

N Engl J Med. 2011 Dec 22;365(25):2398-411

Authors: D'Agati VD, Kaskel FJ, Falk RJ

PMID: 22187987 [PubMed - in process]

Link to Article at PubMed

Status asthmaticus in the medical intensive care unit: A 30-year experience.

Respir Med Start a Discussion »

Dec 232011

Status asthmaticus in the medical intensive care unit: A 30-year experience.

Respir Med. 2011 Dec 20;

Authors: Peters JI, Stupka JE, Singh H, Rossrucker J, Angel LF, Melo J, Levine SM

Abstract
OBJECTIVES: To investigate the characteristics, trends in management (permissive hypercapnia; mechanical ventilation (MV); neuromuscular blockade) and their impact on complications and outcomes in Status Asthmaticus (SA). METHODS: We performed a retrospective observational study of subjects admitted with SA to a single multidisciplinary MICU over a 30-year period. All laboratory, radiologic, respiratory care, physician notes and orders were extracted from an electronic medical record (EMR) maintained during the entire duration of the study. RESULTS: Two hundred and twenty-seven subjects were admitted with 280 episodes of SA. While subjects reflected our regional population (52% Hispanic), African Americans were over-represented (22%) and Caucasians under-represented (21%). Thirty-eight percent reported childhood asthma, 27% were steroid dependent (10% in the last 10 years), and 18% had a recent steroid taper. One hundred and thirty-nine (61.2%) required intubation. The duration of hospitalization was similar between mechanically ventilated and non-ventilated subjects (5.8±4.41 vs. 6.8±7.22 days; p=0.07). The overall complication rate remained low irrespective of the use of permissive hypercapnia or mode of mechanical ventilation (overall mortality 0.4%; pneumothorax 2.5%; pneumonia 2.9%). The frequency of SA declined significantly in the last 10 years of the study (12.4 vs. 3.2 cases/year). CONCLUSIONS: Despite the frequent use of mechanical ventilation, mortality/complication rates remained extremely low. MV did not significantly increase the duration of hospitalization. At our institution, the frequency of SA significantly decreased despite an increase in emergency room visits for asthma.

PMID: 22188845 [PubMed - as supplied by publisher]

Link to Article at PubMed

Dronedarone in high-risk permanent atrial fibrillation.

N Engl J Med Start a Discussion »

Dec 232011

Dronedarone in high-risk permanent atrial fibrillation.

N Engl J Med. 2011 Dec 15;365(24):2268-76

Authors: Connolly SJ, Camm AJ, Halperin JL, Joyner C, Alings M, Amerena J, Atar D, Avezum Á, Blomström P, Borggrefe M, Budaj A, Chen SA, Ching CK, Commerford P, Dans A, Davy JM, Delacrétaz E, Di Pasquale G, Diaz R, Dorian P, Flaker G, Golitsyn S, Gonzalez-Hermosillo A, Granger CB, Heidbüchel H, Kautzner J, Kim JS, Lanas F, Lewis BS, Merino JL, Morillo C, Murin J, Narasimhan C, Paolasso E, Parkhomenko A, Peters NS, Sim KH, Stiles MK, Tanomsup S, Toivonen L, Tomcsányi J, Torp-Pedersen C, Tse HF, Vardas P, Vinereanu D, Xavier D, Zhu J, Zhu JR, Baret-Cormel L, Weinling E, Staiger C, Yusuf S, Chrolavicius S, Afzal R, Hohnloser SH,

Abstract
BACKGROUND: Dronedarone restores sinus rhythm and reduces hospitalization or death in intermittent atrial fibrillation. It also lowers heart rate and blood pressure and has antiadrenergic and potential ventricular antiarrhythmic effects. We hypothesized that dronedarone would reduce major vascular events in high-risk permanent atrial fibrillation.
METHODS: We assigned patients who were at least 65 years of age with at least a 6-month history of permanent atrial fibrillation and risk factors for major vascular events to receive dronedarone or placebo. The first coprimary outcome was stroke, myocardial infarction, systemic embolism, or death from cardiovascular causes. The second coprimary outcome was unplanned hospitalization for a cardiovascular cause or death.
RESULTS: After the enrollment of 3236 patients, the study was stopped for safety reasons. The first coprimary outcome occurred in 43 patients receiving dronedarone and 19 receiving placebo (hazard ratio, 2.29; 95% confidence interval [CI], 1.34 to 3.94; P=0.002). There were 21 deaths from cardiovascular causes in the dronedarone group and 10 in the placebo group (hazard ratio, 2.11; 95% CI, 1.00 to 4.49; P=0.046), including death from arrhythmia in 13 patients and 4 patients, respectively (hazard ratio, 3.26; 95% CI, 1.06 to 10.00; P=0.03). Stroke occurred in 23 patients in the dronedarone group and 10 in the placebo group (hazard ratio, 2.32; 95% CI, 1.11 to 4.88; P=0.02). Hospitalization for heart failure occurred in 43 patients in the dronedarone group and 24 in the placebo group (hazard ratio, 1.81; 95% CI, 1.10 to 2.99; P=0.02).
CONCLUSIONS: Dronedarone increased rates of heart failure, stroke, and death from cardiovascular causes in patients with permanent atrial fibrillation who were at risk for major vascular events. Our data show that this drug should not be used in such patients. (Funded by Sanofi-Aventis; PALLAS ClinicalTrials.gov number, NCT01151137.).

PMID: 22082198 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Hypoglycemia in critically ill adults – association yes, causation not proven.

Crit Care Start a Discussion »

Dec 232011

Hypoglycemia in critically ill adults - association yes, causation not proven.

Crit Care. 2011 Nov 30;15(6):1012

Authors: Finfer S

Abstract
ABSTRACT: Hypoglycemia is consistently associated with an increased risk of death in hospital patients in general, patients treated in intensive care units, and type II diabetes patients recruited to large randomized controlled trials. In 1965, Sir Austin Bradford Hill elucidated nine characteristics that help establish a causal relationship between exposure to a potentially harmful substance or event (in this context, hypoglycemia) and disease onset or death; hypoglycemia exhibits some of those characteristics but others remain to be explored. While we await data that address the outstanding issues, common sense dictates that clinicians avoid causing hypoglycemia whenever possible.

PMID: 22188732 [PubMed - as supplied by publisher]

Link to Article at PubMed

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