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Hospital Admission Risk Factors for Older HF Patients

Hospital Admission Risk Factors for Older HF Patients

The number of older people with heart failure (HF) has increased considerably over the past 20 years. Currently, 80% of patients with HF are 65 or older. The costs associated with HF are more than $35 billion per year in the United States, and these costs are largely driven by hospital stays. Yet, relatively little is known about the long-term risk for hospital admission after an HF diagnosis in older people. In addition, few data are available on the role that geriatric conditions—slow gait, muscle weakness, and cognitive impairment—play in driving HF hospitalizations. Addressing Heart Failure Knowledge Gaps My colleagues and I conducted a study in which we evaluated data from a population-based sample of people aged 65 and older who were followed for up to 20 years after being diagnosed with HF. Published in the Journal of the American College of Cardiology, the study sought to identify risk factors for lifetime hospital utilization after a new HF diagnosis and to identify risk factors for hospitalization.     Three geriatric conditions—muscle weakness, slow gait, and depression—emerged as independent risk factors for hospital admission after a diagnosis of HF, even after considering other traditional cardiovascular factors. Our analysis also found that depressed ejection fraction, New York Heart Association class III or IV symptoms, diabetes, and chronic kidney disease were other independent risk factors for admission after an HF diagnosis in older patients. Implications for Future Care After HF Diagnosis The prognostic information revealed by our study may be used to help with clinical decision making and to identify potential targets for interventions after an HF diagnosis in older patients. Muscle weakness,...
How ED Crowding Affects Outcomes

How ED Crowding Affects Outcomes

Previous studies have sought to establish a definitive relationship between ED crowding and subsequent mortality, but these investigations often have shortcomings, such as small hospital samples and a lack of adjustment for comorbidities, primary illness diagnoses, and potential hospital-level confounders. In addition, many of these analyses restrict data to specific subgroups, such as patients with acute myocardial infarction, trauma, pneumonia, or critical illness. New Evidence on Inpatient Death In an effort to address these limitations, my colleagues and I conducted a study to assess the effect of ED crowding on patient outcomes. Our study, which was published in the Annals of Emergency Medicine, looked at nearly 1 million admissions through EDs across California. Daily ambulance diversion was the measure of ED crowding. According to our results, ED crowding was associated with 5% greater odds of inpatient death. Patients who were admitted on days with high ED crowding had 0.8% longer hospital stays and 1.0% increased costs per admission. Periods of high ED crowding were associated with 300 excess inpatient deaths, 6,200 hospital days, and $17 million in costs. These findings persisted after extensively adjusting for patient demographics, comorbidities, and primary discharge diagnosis. Although other analyses have reported similar associations, our study generalizes these findings to a larger sample of hospitals and unselected admissions from the ED. ED Crowding: A Marker of Poor Quality Care Our findings support the notion that ED crowding is a marker of poor quality of care. Unfortunately, factors underlying the issue of ED crowding are likely to become worse. As Americans are living longer than ever, this has increased the volume, complexity, and acuity of...
The Impact of Hospitalist Workload on Patient Care

The Impact of Hospitalist Workload on Patient Care

The workload for hospitalists has increased significantly, thanks in part to increased residency work-hour restrictions, greater access for patients to healthcare, and a general focus among hospitals to improve patient volume and throughput. Further complicating matters is that hospitalists are adept at functioning in different hospital environments and capacities, which has increased their use and workload. To assess the impact of workload on patient safety and quality measures, my colleagues and I conducted a national survey of hospitalists that was published in JAMA Internal Medicine. Hospitalists Reporting Unsafe Workloads According to our results, about 40% of hospitalists reported that their workload exceeded safe levels (more than 15 patients per shift) at least monthly, and 36% said it happened more than once a week. Approximately one-quarter of respondents reported that excessive workload delayed the admission or discharge of patients until the next shift or hospital day, which in turn impacted length of stay and workloads among ED providers. In addition, 25% of respondents reported that they failed to fully discuss treatment options or to answer questions from patients and family members, and 19% said patient satisfaction soured due to unsafe workloads. Furthermore, 18% reported that it adversely affected patient handoffs. More than 20% of physicians reported that their average workload likely contributed to patient transfers, morbidity, or even mortality. High Hospital Admissions Taking a Toll High levels of admissions and unexpected health changes among admitted patients can dramatically affect the workload of hospitalists and ED physicians. In turn, these changes can increase lengths of stay and clog processes of care in the ED. To overcome these issues, a mutual understanding...

The ED’s Expanding Role in Hospital Admissions

Although research has focused heavily on increased use of EDs, little attention has been paid to the changing role that these facilities play in the entire healthcare system. In a study published in the New England Journal of Medicine, Arjun Venkatesh, MD, MBA, and I examined the proportion of hospital admissions that came through the ED to determine trends in general use and to confirm the experiences of emergency physicians and hospital administrators in these situations. ED Admissions on the Rise Focusing on the 13 conditions for which patients are most commonly admitted to the hospital, our analysis revealed that hospital admissions increased by 15.0%, rising from 34.3 million in 1993 to 39.5 million in 2006, but admissions from the ED increased by 50.4% (rising from 11.5 million to 17.3 million) during that same timeframe. The proportion of all inpatient stays that came through the ED increased significantly, rising from 33.5% to 43.8%. Only one of the 13 conditions studied in our analysis—coronary atherosclerosis— had a proportion that didn’t increase. More and more patients are being evaluated for coronary atherosclerosis in the ED and not admitted thanks to newer rapid “rule-out” protocols and ED-based chest-pain observation units. Our observation that more admissions are coming through the ED is likely due to several factors, most notably the advancing diagnostic and treatment capabilities of EDs and the convenience that EDs offer. As rapid and accurate diagnoses and treatments become standard, evaluating symptoms like chest pain and shortness of breath have become de facto reasons for ED referral. It has also become more difficult for outpatient providers to admit people directly to...

Weekend Vs Weekday Admissions for AF

A review of more than 86,000 discharges with a primary diagnosis of atrial fibrillation (AF) sug­gests that patients admitted on weekends appear to be less likely to undergo a cardioversion procedure and more likely to die resulting from AF when compared with patients admitted on weekdays. Cardioversion procedures were performed in 7.6% of AF patients during weekend admissions, compared with 16.2% for those being admitted during weekdays. The in-hospital mortality odds ratio was 1.23 for AF patients admitted during weekends. Abstract: American Journal of Cardiology, July 15,...
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