Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.

With advances in the effectiveness of treatment and disease management, the contribution of chronic comorbid diseases (comorbidities) found within the Charlson comorbidity index to mortality is likely to have changed since development of the index in 1984. The authors reevaluated the Charlson index and reassigned weights to each condition by identifying and following patients to observe mortality within 1 year after hospital discharge. They applied the updated index and weights to hospital discharge data from 6 countries and tested for their ability to predict in-hospital mortality. Compared with the original Charlson weights, weights generated from the Calgary, Alberta, Canada, data (2004) were 0 for 5 comorbidities, decreased for 3 comorbidities, increased for 4 comorbidities, and did not change for 5 comorbidities. The C statistics for discriminating in-hospital mortality between the new score generated from the 12 comorbidities and the Charlson score were 0.825 (new) and 0.808 (old), respectively, in Australian data (2008), 0.828 and 0.825 in Canadian data (2008), 0.878 and 0.882 in French data (2004), 0.727 and 0.723 in Japanese data (2008), 0.831 and 0.836 in New Zealand data (2008), and 0.869 and 0.876 in Swiss data (2008). The updated index of 12 comorbidities showed good-to-excellent discrimination in predicting in-hospital mortality in data from 6 countries and may be more appropriate for use with more recent administrative data.

Translation and psychometric evaluation of a French version of the Readiness for Hospital Discharge Scale.

AIMS AND OBJECTIVES: To evaluate the reliability and the factor structure of the Readiness for Hospital Discharge Scale - French version. BACKGROUND: The patient's perspective is essential when assessing risk for adverse events at hospital discharge. Developed in the USA, the Readiness for Hospital Discharge Scale is the only instrument that measures an individual's self-perception of readiness before leaving the hospital. A French version of the Readiness for Hospital Discharge Scale was developed and validated. DESIGN: Cross-sectional study. METHODS: A convenience sample of 265 older inpatients from four medical units was selected. The translation and cultural adaptation of the scale involved experts in gerontology and the French language and included back translation. The items were semantically evaluated and pretested in 10 older inpatients. The scale's psychometric properties were internally validated by using confirmatory and exploratory factor analyses. Reliability was assessed by examining the internal consistency of its items. RESULTS: Goodness-of-fit indices of the confirmatory factor analyses were not adequate, but reliability was acceptable (Cronbach's α = 0·80). Exploratory factor analysis of the French version provided results close to those described for the English version, with three similar subscales (physical and emotional readiness, coping with medical treatment and personal care), whereas the initially described Expected Support subscale was not identified in the French version. CONCLUSION: The Readiness for Hospital Discharge Scale - French version appears to be partially consistent with its original English version, but requires additional adaptation to fully take into account the Swiss context and culture to achieve its original aim. RELEVANCE TO CLINICAL PRACTICE: Assessing patient readiness for hospital discharge before leaving hospital could help nurses to improve the discharge planning process and achieve better patient preparedness and care coordination.

Hospital volume and patient outcomes in pulmonary embolism.

BACKGROUND: In numerous high-risk medical and surgical conditions, a greater volume of patients undergoing treatment in a given setting or facility is associated with better survival. For patients with pulmonary embolism, the relation between the number of patients treated in a hospital (volume) and patient outcome is unknown. METHODS: We studied discharge records from 186 acute care hospitals in Pennsylvania for a total of 15 531 patients for whom the primary diagnosis was pulmonary embolism. The study outcomes were all-cause mortality in hospital and within 30 days after presentation for pulmonary embolism and the length of hospital stay. We used logistic models to study the association between hospital volume and 30-day mortality and discrete survival models to study the association between in-hospital mortality and time to hospital discharge. RESULTS: The median annual hospital volume for pulmonary embolism was 20 patients (interquartile range 10-42). Overall in-hospital mortality was 6.0%, whereas 30-day mortality was 9.3%. In multivariable analysis, very-high-volume hospitals (> or = 42 cases per year) had a significantly lower odds of in-hospital death (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.51-0.99) and of 30-day death (OR 0.71, 95% CI 0.54-0.92) than very-low-volume hospitals (< 10 cases per year). Although patients in the very-high-volume hospitals had a slightly longer length of stay than those in the very-low-volume hospitals (mean difference 0.7 days), there was no association between volume and length of stay. INTERPRETATION: In hospitals with a high volume of cases, pulmonary embolism was associated with lower short-term mortality. Further research is required to determine the causes of the relation between volume and outcome for patients with pulmonary embolism.

Trends in hospital discharges, management and in-hospital mortality from acute myocardial infarction in Switzerland between 1998 and 2008.

BACKGROUND: Since the late nineties, no study has assessed the trends in management and in-hospital outcome of acute myocardial infarction (AMI) in Switzerland. Our objective was to fill this gap. METHODS: Swiss hospital discharge database for years 1998 to 2008. AMI was defined as a primary discharge diagnosis code I21 according to the ICD10 classification. Invasive treatments and overall in-hospital mortality were assessed. RESULTS: Overall, 102,729 hospital discharges with a diagnosis of AMI were analyzed. The percentage of hospitalizations with a stay in an Intensive Care Unit decreased from 38.0% in 1998 to 36.2% in 2008 (p for trend < 0.001). Percutaneous revascularizations increased from 6.0% to 39.9% (p for trend < 0.001). Bare stents rose from 1.3% to 16.6% (p for trend < 0.001). Drug eluting stents appeared in 2004 and increased to 23.5% in 2008 (p for trend < 0.001). Coronary artery bypass graft increased from 1.0% to 3.0% (p for trend < 0.001). Circulatory assistance increased from 0.2% to 1.7% (p for trend < 0.001). Among patients managed in a single hospital (not transferred), seven-day and total in-hospital mortality decreased from 8.0% to 7.0% (p for trend < 0.01) and from 11.2% to 10.1%, respectively. These changes were no longer significant after multivariate adjustment for age, gender, region, revascularization procedures and transfer type. After multivariate adjustment, differing trends in revascularization procedures and in in-hospital mortality were found according to the geographical region considered. CONCLUSION: In Switzerland, a steep rise in hospital discharges and in revascularization procedures for AMI occurred between 1998 and 2008. The increase in revascularization procedures could explain the decrease in in-hospital mortality rates.

Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review.

CONTEXT: Symptomatic venous thromboembolism (VTE) after total or partial knee arthroplasty (TPKA) and after total or partial hip arthroplasty (TPHA) are proposed patient safety indicators, but its incidence prior to discharge is not defined. OBJECTIVE: To establish a literature-based estimate of symptomatic VTE event rates prior to hospital discharge in patients undergoing TPHA or TPKA. DATA SOURCES: Search of MEDLINE, EMBASE, and the Cochrane Library (1996 to 2011), supplemented by relevant articles. STUDY SELECTION: Reports of incidence of symptomatic postoperative pulmonary embolism or deep vein thrombosis (DVT) before hospital discharge in patients who received VTE prophylaxis with either a low-molecular-weight heparin or a subcutaneous factor Xa inhibitor or oral direct inhibitor of factors Xa or IIa. DATA EXTRACTION AND SYNTHESIS: Meta-analysis of randomized clinical trials and observational studies that reported rates of postoperative symptomatic VTE in patients who received recommended VTE prophylaxis after undergoing TPHA or TPKA. Data were independently extracted by 2 analysts, and pooled incidence rates of VTE, DVT, and pulmonary embolism were estimated using random-effects models. RESULTS: The analysis included 44,844 cases provided by 47 studies. The pooled rates of symptomatic postoperative VTE before hospital discharge were 1.09% (95% CI, 0.85%-1.33%) for patients undergoing TPKA and 0.53% (95% CI, 0.35%-0.70%) for those undergoing TPHA. The pooled rates of symptomatic DVT were 0.63% (95% CI, 0.47%-0.78%) for knee arthroplasty and 0.26% (95% CI, 0.14%-0.37%) for hip arthroplasty. The pooled rates for pulmonary embolism were 0.27% (95% CI, 0.16%-0.38%) for knee arthroplasty and 0.14% (95% CI, 0.07%-0.21%) for hip arthroplasty. There was significant heterogeneity for the pooled incidence rates of symptomatic postoperative VTE in TPKA studies but less heterogeneity for DVT and pulmonary embolism in TPKA studies and for VTE, DVT, and pulmonary embolism in TPHA studies. CONCLUSION: Using current VTE prophylaxis, approximately 1 in 100 patients undergoing TPKA and approximately 1 in 200 patients undergoing TPHA develops symptomatic VTE prior to hospital discharge.

TRENDS IN HOSPITAL MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION IN SWITZERLAND, 1998 TO 2008 THE REGION MAKES THE DIFFERENCE: DISPARITIES IN MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION WITHIN SWITZERLAND

The aim of this master's thesis was to assess the ten- year trends and regional differences in management and outcome of acute myocardial infarction (AMI) within Switzerland. The thesis is composed of two articles. First, in the article "Trends in hospital management of acute myocardial infarction in Switzerland, 1998 to 2008" over 102,700 cases of AMI with corresponding management and revascularization procedures were assessed. The results showed a considerable increase in the numbers of hospital discharges for AMI, namely due to the increase of between- hospital transfers. Rates of intensive care unit admissions remained stable. All types of revascularization procedures showed an increase. In particular, overall stenting rates increased with drug-eluting stents partly replacing bare stents. Second, in the article "The region makes the difference: disparities in management of acute myocardial infarction within Switzerland" around 25,600 cases of AMI with corresponding management were assessed for the period of 2007-2008 and according to seven Swiss regions. As reported by our results, considerable regional differences in AMI management were stated within Switzerland. Although each region showed different trends regarding revascularization interventions, Leman and Ticino contrast significantly by presenting the minimum and maximum rates in almost all assessed parameters. As a consequence these two regions differ the most from the Swiss average. The impact of the changes in trends and the regional differences in AMI management on Swiss patient's outcome and economics remains to be assessed. Purpose: To assess ten-year trends in management and outcome of acute myocardial infarction (AMI) in Switzerland. Methods: Swiss hospital discharge database for the 1998 to 2008 period. AMI was defined as a primary discharge diagnosis code I21 according to the CIM-10 classification of the World Health Organization. Management and revascularization procedures were assessed. Results: Overall, 102,729 hospital discharges with a diagnosis of AMI were analyzed. The number of hospital discharges increased almost three-fold from 5530 in 1998 to 13,834 in 2008, namely due to a considerable increase in between-hospital transfers (1352 in 1998, 6494 in 2008). Relative to all hospital discharges, Intensive Care Unit admission rate was 38.0% in 1998 and remained stable (36.2%) in 2008 (p for trend=0.25). Percutaneous revascularization rates increased from 6.0% to 39.9% (p for trend<0.001). Non-drug-eluting stent use increased from 1.3% to 16.6% (p for trend<0.05). Drug eluting stents appeared in 2004 and increased to 23.5% of hospital discharges in 2008 (p for trend=0.07). Coronary artery bypass graft increased from 1.0% to 3.0% (p for trend<0.001). Circulatory assistance increased from 0.2% to 1.7% (p for trend<0.001). Thrombolysis showed no significant changes, from 0.5% to 1.9% (p for trend=0.64). Most of these trends were confirmed after multivariate adjustment. Conclusion: Between 1998 and 2008 the number of hospital discharges for AMI increased considerably in Switzerland, namely due to between-hospital transfers. Overall stenting rates increased, drug-eluting stents partly replacing bare stents. The impact of these changes on outcome and economics remains to be assessed.

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence.

BACKGROUND: We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI). METHODS: We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15,335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case-control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge. RESULTS: In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation. CONCLUSIONS: Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.

Hospital transfers between Swiss cantons: a first look

Objective: To assess the importance of hospital transfers between Swiss cantons and the factors associated with them. Methods: Hospital discharge data, mean number of hospitals, hospital beds and corresponding density per 100.000 inhabitants for period 1998-2008 were provided by the Federal Office of Statistics. Inclusion criteria were: >=18 years; transferred from one hospital to another and living in a canton different from the one they were transferred to. Cumulative data for the study period was used. Results: Between 1998 and 2008, 247.355 hospital transfers occurred between cantons, representing 17.7% of all hospital transfers. This value ranged between 2.7% (Geneva) and 81.6% (Appenzell Innerrhoden). The main diagnoses were: circulatory system (20.1%); musculoskeletal system (9.3%); mental and behavioural disorders (6.5%); oncology (4.6%) and repertories diseases (2.6%). Factors influencing health status (28.7%) and injuries and external causes (12%) were not included in the analysis. Cantons with a university hospital received more patients than they transferred to other cantons. The other cantons were either "senders" or "receivers" according to the disease considered. German-speaking cantons transferred patients more easily than the others. Most transfers were made between geographically or linguistically close cantons. The number of patients received was associated with the number of hospitals (r = 0.82, p <0.001) or beds (r = 0.85, p <0.001)in the canton; bed density (r = 0.51, p <0.01), but not with hospital density(r = 0.08, p <0.7). Conclusions: in Switzerland, over one-sixth of hospital transfers occur between cantons. Several cantons are dependent of others for the treatment of specific diseases. Cantons with a university hospital attract more patients, suggesting an optimisation of health resources.

Nursing discharge planning for older medical inpatients in Switzerland: A cross-sectional study.

Nursing discharge planning for elderly medical inpatients is an essential element of care to ensure optimal transition to home and to reduce post-discharge adverse events. The objectives of this cross-sectional study were to investigate the association between nursing discharge planning components in older medical inpatients, patients' readiness for hospital discharge and unplanned health care utilization during the following 30 days. Results indicated that no patients benefited from comprehensive discharge planning but most benefited from less than half of the discharge planning components. The most frequent intervention recorded was coordination, and the least common was patients' participation in decisions regarding discharge. Patients who received more nursing discharge components felt significantly less ready to go home and had significantly more readmissions during the 30-day follow-up period. This study highlights large gaps in the nursing discharge planning process in older medical inpatients and identifies specific areas where improvements are most needed.

Prognostic importance of anaemia in patients with acute pulmonary embolism.

Although associated with adverse outcomes in other cardiopulmonary diseases, limited evidence exists on the prognostic value of anaemia in patients with acute pulmonary embolism (PE). We sought to examine the associations between anaemia and mortality and length of hospital stay in patients with PE. We evaluated 14,276 patients with a primary diagnosis of PE from 186 hospitals in Pennsylvania, USA. We used random-intercept logistic regression to assess the association between anaemia at the time of presentation and 30-day mortality and discrete-time logistic hazard models to assess the association between anaemia and time to hospital discharge, adjusting for patient (age, gender, race, insurance type, clinical and laboratory variables) and hospital (region, size, teaching status) factors. Anaemia was present in 38.7% of patients at admission. Patients with anaemia had a higher 30-day mortality (13.7% vs. 6.3%; p <0.001) and a longer length of stay (geometric mean, 6.9 vs. 6.6 days; p <0.001) compared to patients without anaemia. In multivariable analyses, anaemia remained associated with an increased odds of death (OR 1.82, 95% CI: 1.60-2.06) and a decreased odds of discharge (OR 0.85, 95% CI: 0.82-0.89). Anaemia is very common in patients presenting with PE and is independently associated with an increased short-term mortality and length of stay.

Reduced ejection fraction after myocardial infarction: is it sufficient to justify implantation of a defibrillator?

BACKGROUND: Improved survival after prophylactic implantation of a defibrillator in patients with reduced left ventricular ejection fraction (EF) after myocardial infarction (MI) has been demonstrated in patients who experienced remote MIs in the 1990s. The absolute survival benefit conferred by this recommended strategy must be related to the current risk of arrhythmic death, which is evolving. This study evaluates the mortality rate in survivors of MI with impaired left ventricular function and its relation to pre-hospital discharge baseline characteristics. METHODS: The clinical records of patients who had sustained an acute MI between 1999 and 2000 and had been discharged from the hospital with an EF of < or = 40% were included. Baseline characteristics, drug prescriptions, and invasive procedures were recorded. Bivariate and multivariate analyses were performed using a primary end point of total mortality. RESULTS: One hundred sixty-five patients were included. During a median follow-up period of 30 months (interquartile range, 22 to 36 months) 18 patients died. The 1-year and 2-year mortality rates were 6.7% and 8.6%, respectively. Variables reflecting coronary artery disease and its management (ie, prior MI, acute reperfusion, and complete revascularization) had a greater impact on mortality than variables reflecting mechanical dysfunction (ie, EF and Killip class). CONCLUSIONS: The mortality rate among survivors of MIs with reduced EF was substantially lower than that reported in the 1990s. The strong decrease in the arrhythmic risk implies a proportional increase in the number of patients needed to treat with a prophylactic defibrillator to prevent one adverse event. The risk of an event may even be sufficiently low to limit the detectable benefit of defibrillators in patients with the prognostic features identified in our study. This argues for additional risk stratification prior to the prophylactic implantation of a defibrillator.

Weekend versus weekday admission and mortality after acute pulmonary embolism.

BACKGROUND: Optimal management of acute pulmonary embolism (PE) requires medical expertise, diagnostic testing, and therapies that may not be available consistently throughout the entire week. We sought to assess whether associations exist between weekday or weekend admission and mortality and length of hospital stay for patients hospitalized with PE. METHODS AND RESULTS: We evaluated patients discharged with a primary diagnosis of PE from 186 acute care hospitals in Pennsylvania (January 2000 to November 2002). We used random-effect logistic models to study the association between weekend admission and 30-day mortality and used discrete survival models to study the association between weekend admission and time to hospital discharge, adjusting for hospital (region, size, and teaching status) and patient factors (race, insurance, severity of illness, and use of thrombolytic therapy). Among 15 531 patient discharges with PE, 3286 patients (21.2%) had been admitted on a weekend. Patients admitted on weekends had a higher unadjusted 30-day mortality rate (11.1% versus 8.8%) than patients admitted on weekdays, with no difference in length of stay. Patients admitted on weekends had significantly greater adjusted odds of dying (odds ratio 1.17, 95% confidence interval 1.03 to 1.34) than patients admitted on weekdays. The higher mortality among patients hospitalized on weekends was driven by the increased mortality rate among the most severely ill patients. CONCLUSIONS: Patients with PE who are admitted on weekends have a significantly higher short-term mortality than patients admitted on weekdays. Quality-improvement efforts should aim to ensure a consistent approach to the management of PE 7 days a week.

La mort subite: de l' épidémiologie à la prévention [Sudden cardiac death: epidemiology and modern therapy].

Sudden Cardiac Death (SCD) has become an important public health challenge in the Western World. In Switzerland near 10,000 people suffer each year from SCD. The survival from SCD to hospital discharge is discouraging (near 5%). Large majority of events occur unexpectedly in the out-of-hospital environment and are not predicted with great accuracy by risk profiling. Because the majority of SCD occur by the mechanism of ventricular fibrillation, community-based defibrillation strategies have emerged as one approach to SCD problem. Newer strategies of defibrillation designed to respond faster to out-of-hospital cardiac arrest, including public access defibrillation, as well as aggressive primary and secondary prevention of coronary artery disease appears as the best approach for successful management of SCD.

Appropriate drug treatment for status epilepticus does not influence its prognosis

Objective: Status epilepticus (SE) prognosis, is mostly related to non-modifiable factors (especially age, etiology), but the specific role of treatment appropriateness (TA) has not been investigated. Methods: In a prospective cohort with incident SE (excluding postanoxic), TA was defined, after recent European recommendations, in terms of drug dosage (630% deviation) and sequence. Outcome at hospital discharge was categorized into mortality, new handicap, or return to baseline. Results: Among 225 adults, treatment was inappropriate in 37%. In univariate analyses, age, etiology, SE severity and comorbidity, but not TA, were significantly related to outcome. Etiology (95% CI 4.3-82.8) and SE severity (95% CI 1.2-2.4) were independent predictors of mortality, and of lack of return to baseline conditions (etiology: 95% CI 3.9-14.0; SE severity: 95% CI 1.4-2.2). Moreover, TA did not improve outcome prediction in the corresponding ROC curves. Conclusions: This large analysis suggests that TA plays a negligible prognostic role in SE, probably reflecting the outstanding importance of the biological background. Awaiting treatment trials in SE, it appears questionable to apply further resources in refining treatment protocols involving existing compounds; rather, new therapeutic approaches should be identified and tested.

Ombres et lumières de l'accès public a la défibrillation [Public access defibrillation]

La stratégie d'accès public à la défibrillation (APD) comprend l'installation de défibrillateurs automatiques externes (DAE) dans les lieux publics et l'entraînement de sauveteurs non professionnels à la réanimation cardio pulmonaire et à la défibrillation (RCP-D). Cette approche est recommandée pour le traitement des arrêts cardiaques (ACR) dans les lieux publics. Beaucoup d'études d'observation, mais peu d'études randomisées s'intéressant à cette approche ont été publiées. Cet article résume les différentes approches proposées dans le cadre d'APD. A notre avis, l'installation de DAE dans des lieux publics ou le choix d'une stratégie alternative doivent être précédés d'une étude de la démographie locale des ACR et de l'entraînement du plus grand nombre possible de laïcs à la reconnaissance des signes précurseurs d'ACR et au massage cardiaque externe. Placement of automated external defibrillators (AED) in public facilities and training of the lay persons in basic life support-defibrillation (BLS-D) was recommended by the American Heart Association for the treatment of out-of-hospital cardiac arrest (OHCA). Immediate use of AED result in increase of survival to hospital discharge. Many observation and much less randomized trials describe clinical efficacy of this approach. However, "negative" trials have also been published and some recent data suggest that public access defibrillation (PAD) will have a minimal impact on population survival. In this article various PAD strategies were briefly reviewed. In our opinion installation of AED in public places should be based on the long-term study of local OHCA demography and preceded by widespread BLS training of lay population.