Distribution of hospital admissions in a middle-income country of the African region

Introduction: Few studies have reported the distribution of all hospital admissions at the entire country level in low and middle-income countries (LMICs). We examined this question in Seychelles, a rapidly developing small island state in the Africa region, in which access to health care is provided free of charge to all inhabitants through a national health system and all hospital admissions are routinely registered. Methods: Based on all admissions to all hospitals in Seychelles in 2005-2008, we calculated the distribution of hospital admissions, age at admission, length of stay and bed occupancy (i.e. cumulated number of patients * number of days spent in all hospitals) according to both hospital departments and broad causes of diseases (using codes of the ICD-10 classification of diseases). Results: Bed occupancy was largest in the surgical wards (36.7% of all days spent in all hospitals), followed by the medical wards (24.3%), gynecology/obstetrics wards (18.4%), pediatric wards (11.2%), and psychiatric wards (7.2%). According to broad causes of diseases/conditions, bed occupancy was highest for obstetrics/gynecology conditions (19.9% of all days spent at hospital), mental diseases (8.6%), cardiovascular diseases (8.1%), upper aerodigestive/pulmonary diseases (8%), infectious/parasitic diseases (8%), gastrointestinal diseases (7.2%), and urogenital diseases (6.7%). Adjusted to 100'000 population, 153 hospital beds are needed every day, including 31 for obstetrics/gynecologic conditions, 13 for mental diseases, 12 for cardiovascular diseases, 12 for upper aerodigestive diseases, 12 for infectious/parasitic diseases, and 11 for gastrointestinal diseases. Conclusion: Our findings give a good indication of the overall distribution of admissions according to both hospital departments and broad causes of diseases in a middle-income country. These findings provide important information for health care planning at the national level

Respiratory symptoms in preterm infants: burden of disease in the first year of life.

OBJECTIVE: While respiratory symptoms in the first year of life are relatively well described for term infants, data for preterm infants are scarce. We aimed to describe the burden of respiratory disease in a group of preterm infants with and without bronchopulmonary dysplasia (BPD) and to assess the association of respiratory symptoms with perinatal, genetic and environmental risk factors. METHODS: Single centre birth cohort study: prospective recording of perinatal risk factors and retrospective assessment of respiratory symptoms during the first year of life by standardised questionnaires. MAIN OUTCOME MEASURES: Cough and wheeze (common symptoms), re-hospitalisation and need for inhalation therapy (severe outcomes). PATIENTS: 126 preterms (median gestational age 28.7 weeks; 78 with, 48 without BPD) hospitalised at the University Children's Hospital of Bern, Switzerland 1999-2006. RESULTS: Cough occurred in 80%, wheeze in 44%, re-hospitalisation in 25% and long term inhalation therapy in wheezers in 13% of the preterm infants. Using logistic regression, the main risk factor for common symptoms was frequent contact with other children. Severe outcomes were associated with maximal peak inspiratory pressure, arterial cord blood pH, APGAR- and CRIB-Score. CONCLUSIONS: Cough in preterm infants is as common as in term infants, whereas wheeze, inhalation therapy and re-hospitalisations occur more often. Severe outcomes are associated with perinatal risk factors. Preterm infants who did not qualify for BPD according to latest guidelines also showed a significant burden of respiratory disease in the first year of life.

Global alcohol exposure estimates by country, territory and region for 2005--a contribution to the Comparative Risk Assessment for the 2010 Global Burden of Disease Study.

AIMS: This study aimed to estimate the prevalence of life-time abstainers, former drinkers and current drinkers, adult per-capita consumption of alcohol and pattern of drinking scores, by country and Global Burden of Disease region for 2005, and to forecast these indicators for 2010. DESIGN: Statistical modelling based on survey data and routine statistics. SETTING AND PARTICIPANTS: A total of 241 countries and territories. MEASUREMENTS: Per-capita consumption data were obtained with the help of the World Health Organization's Global Information System on Alcohol and Health. Drinking status data were obtained from Gender, Alcohol and Culture: An International Study, the STEPwise approach to Surveillance study, the World Health Survey/Multi-Country Study and other surveys. Consumption and drinking status data were triangulated to estimate alcohol consumption across multiple categories. FINDINGS: In 2005 adult per-capita annual consumption of alcohol was 6.1 litres, with 1.7 litres stemming from unrecorded consumption; 17.1 litres of alcohol were consumed per drinker, 45.8% of all adults were life-time abstainers, 13.6% were former drinkers and 40.6% were current drinkers. Life-time abstention was most prevalent in North Africa/Middle East and South Asia. Eastern Europe and Southern sub-Saharan Africa had the most detrimental pattern of drinking scores, while drinkers in Europe (Eastern and Central) and sub-Saharan Africa (Southern and West) consumed the most alcohol. CONCLUSIONS: Just over 40% of the world's adult population consumes alcohol and the average consumption per drinker is 17.1 litres per year. However, the prevalence of abstention, level of alcohol consumption and patterns of drinking vary widely across regions of the world.

Overall Burden of Healthcare-Associated Infections Among Surgical Patients: Results of a National Study.

OBJECTIVE:: To assess the overall burden of healthcare-associated infections (HAIs) in patients exposed and nonexposed to surgery. BACKGROUND:: Targeted HAI surveillance is common in healthcare institutions, but may underestimate the overall burden of disease. METHODS:: Prevalence study among patients hospitalized in 50 acute care hospitals participating in the Swiss Nosocomial Infection Prevalence surveillance program. RESULTS:: Of 8273 patients, 3377 (40.8%) had recent surgery. Overall, HAI was present in 358 (10.6%) patients exposed to surgery, but only in 206 (4.2%) of 4896 nonexposed (P < 0.001). Prevalence of surgical site infection (SSI) was 5.4%. Healthcare-associated infections prevalence excluding SSI was 6.5% in patients with surgery and 4.7% in those without (P < 0.0001). Patients exposed to surgery carried less intrinsic risk factors for infection (age >60 years, 55.6% vs 63.0%; American Society of Anesthesiologists score >3, 5.9% vs 9.3%; McCabe for rapidly fatal disease, 3.9% vs 6.6%; Charlson comorbidity index >2, 12.3% vs 20.9%, respectively; all P < 0.001) than those nonexposed, but more extrinsic risk factors (urinary catheters, 39.6% vs 14.1%; central venous catheters, 17.8% vs 7.1%; mechanical ventilation, 4.7% vs 1.3%; intensive care stay, 18.3% vs 8.8%, respectively; all P < 0.001). Exposure to surgery independently predicted an increased risk of HAI (odds ratio 2.43; 95% CI 2.0-3.0). CONCLUSIONS:: Despite a lower intrinsic risk, patients exposed to surgery carried more than twice the overall HAI burden than those nonexposed; almost half was accountable to SSI. Extending infection control efforts beyond SSI prevention in these patients might be rewarding, especially because of the extrinsic nature of risk factors.

Comparison of in-hospital mortality for acute myocardial infarction in Switzerland with admission during routine duty hours versus admission during out of hours (insight into the AMIS plus registry).

To improve long-term survival, prompt revascularization of the infarct-related artery should be done in patients with acute myocardial infarction (AMI); therefore, a large proportion of these patients would be hospitalized during out of hours. The clinical effects of out-of-hours AMI management were already questioned, with conflicting results. The purpose of this investigation was to compare the in-hospital outcome of patients admitted for AMI during out of hours and working hours. All patients with AMI included in the AMIS Plus Registry from January 1, 1997, to March 30, 2006, were analyzed. The working-hours group included patients admitted from 7 a.m. to 7 p.m. on weekdays, and the out-of-hours group included patients admitted from 7 p.m. to 7 a.m. on weekdays or weekends. Major cardiac events were defined as cardiovascular death, reinfarction, and stroke. The study primary end points were in-hospital death and major adverse cardiac event (MACE) rates. A total of 12,480 patients met the inclusion criteria, with 52% admitted during normal working hours, and 48%, during out of hours. Patients admitted during weekdays included more women (28.1% vs 26%; p = 0.009), older patients (65.5 +/- 13 vs 64.1 +/- 13 years; p = 0.0011), less current smokers (40.1% vs 43.5%; p <0.001), and less patients with a history of ischemic heart disease (31.5% vs 34.5%; p = 0.001). A significantly higher proportion of patients admitted during out of hours had Killip's class III and IV. No differences in terms of in-hospital survival rates between the 2 groups (91.5% vs 91.2%; p = 0.633) or MACE-free survival rates (both 88.5%; p = 1.000) were noted. In conclusion, the outcome of patients with AMI admitted out of hours was the same compared with those with a weekday admission. Of predictors for in-hospital outcome, timing of admission had no significant influence on mortality and/or MACE incidence.

Predictors of early hospital readmission after acute pulmonary embolism.

BACKGROUND: Risk factors for early mortality after pulmonary embolism (PE) are widely known. However, it is uncertain which factors are associated with early readmission after PE. We sought to identify predictors of readmission after an admission for PE. METHODS: We studied 14 426 patient discharges with a primary diagnosis of PE from 186 acute care hospitals in Pennsylvania from January 1, 2000, to November 30, 2002. The outcome was readmission within 30 days of presentation for PE. We used a discrete proportional odds model to study the association between time to readmission and patient factors (age, sex, race, insurance, discharge status, and severity of illness), thrombolysis, and hospital characteristics (region, teaching status, and number of beds). RESULTS: Overall, 2064 patient discharges (14.3%) resulted in a readmission within 30 days of presentation for PE. The most common reasons for readmission were venous thromboembolism (21.9%), cancer (10.8%), pneumonia (5.2%), and bleeding (5.0%). In multivariable analysis, African American race (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.02-1.38), Medicaid insurance (OR, 1.54; 95% CI, 1.31-1.81), discharge home with supplemental care (OR, 1.40; 95% CI, 1.27-1.54), leaving the hospital against medical advice (OR, 2.84; 95% CI, 1.80-4.48), and severity of illness were independently associated with readmission; readmission also varied by hospital region. CONCLUSIONS: Early readmission after PE is common. African American race, Medicaid insurance, severity of illness, discharge status, and hospital region are significantly associated with readmission. The high readmission rates for venous thromboembolism and bleeding suggest that readmission may be linked to suboptimal quality of care in the management of PE.

Cardiovascular disease, chronic kidney disease, and diabetes mortality burden of cardiometabolic risk factors from 1980 to 2010: a comparative risk assessment.

BACKGROUND: High blood pressure, blood glucose, serum cholesterol, and BMI are risk factors for cardiovascular diseases and some of these factors also increase the risk of chronic kidney disease and diabetes. We estimated mortality from cardiovascular diseases, chronic kidney disease, and diabetes that was attributable to these four cardiometabolic risk factors for all countries and regions from 1980 to 2010. METHODS: We used data for exposure to risk factors by country, age group, and sex from pooled analyses of population-based health surveys. We obtained relative risks for the effects of risk factors on cause-specific mortality from meta-analyses of large prospective studies. We calculated the population attributable fractions for each risk factor alone, and for the combination of all risk factors, accounting for multicausality and for mediation of the effects of BMI by the other three risks. We calculated attributable deaths by multiplying the cause-specific population attributable fractions by the number of disease-specific deaths. We obtained cause-specific mortality from the Global Burden of Diseases, Injuries, and Risk Factors 2010 Study. We propagated the uncertainties of all the inputs to the final estimates. FINDINGS: In 2010, high blood pressure was the leading risk factor for deaths due to cardiovascular diseases, chronic kidney disease, and diabetes in every region, causing more than 40% of worldwide deaths from these diseases; high BMI and glucose were each responsible for about 15% of deaths, and high cholesterol for more than 10%. After accounting for multicausality, 63% (10·8 million deaths, 95% CI 10·1-11·5) of deaths from these diseases in 2010 were attributable to the combined effect of these four metabolic risk factors, compared with 67% (7·1 million deaths, 6·6-7·6) in 1980. The mortality burden of high BMI and glucose nearly doubled from 1980 to 2010. At the country level, age-standardised death rates from these diseases attributable to the combined effects of these four risk factors surpassed 925 deaths per 100 000 for men in Belarus, Kazakhstan, and Mongolia, but were less than 130 deaths per 100 000 for women and less than 200 for men in some high-income countries including Australia, Canada, France, Japan, the Netherlands, Singapore, South Korea, and Spain. INTERPRETATION: The salient features of the cardiometabolic disease and risk factor epidemic at the beginning of the 21st century are high blood pressure and an increasing effect of obesity and diabetes. The mortality burden of cardiometabolic risk factors has shifted from high-income to low-income and middle-income countries. Lowering cardiometabolic risks through dietary, behavioural, and pharmacological interventions should be a part of the global response to non-communicable diseases. FUNDING: UK Medical Research Council, US National Institutes of Health.

Determinants and burden of chronic kidney disease in the population-based CoLaus study: a cross-sectional analysis.

BACKGROUND: Chronic kidney disease (CKD) represents an increasing health burden. We present the population-based prevalence of CKD and compare the CKD Epidemiology collaboration (CKD-EPI) and modification of diet in renal disease (MDRD) equations to estimate the glomerular filtration rate, using the revised CKD classification with three albuminuria classes. We also explore factors associated with CKD. METHODS: The Swiss population-based, cross-sectional CoLaus study conducted in Lausanne (2003-2006) included 2810 men and 3111 women aged 35-75. CKD prevalence was assessed using CKD-EPI and MDRD equations and albuminuria estimated by the albumin-to-creatinine ratio in spot morning urine. Multivariate logistic regression was used to analyse determinants of CKD. RESULTS: Prevalence [95% confidence interval (CI)] of all stages CKD was 10.0% (9.2-10.8%) with CKD-EPI and 13.8% (12.9-14.6%) with MDRD. Using the revised CKD classification, the prevalence of low-, medium-, high- and very high-risk groups was 90.0, 8.46, 1.18 and 0.35% with CKD-EPI, respectively. With MDRD, the corresponding values were 86.24, 11.86, 1.55 and 0.35%. Using the revised classification, CKD-EPI systematically reclassified people in a lower risk category than MDRD. Age and obesity were more strongly associated with CKD in men [odds ratio (95% CI): 2.23(1.95; 2.56) per 10 years and 3.05(2.08;4.47), respectively] than in women [1.46 (1.29; 1.65) and 1.78 (1.30;2.44), respectively]. Hypertension, type 2 diabetes, serum homocysteine and uric acid were positively independently associated with CKD in men and women. CONCLUSIONS: One in 10 adults suffers from CKD in the population of Lausanne. CKD-EPI systematically reclassifies people in a lower CKD risk category than MDRD. Serum homocysteine and uric acid levels are associated with CKD independently of classical risk factors such as age, hypertension and diabetes.

Smoking, prevalence of disease and health service utilization among the Swiss population.

The data of the 1981-83 Swiss National Health Survey "SOMIPOPS", based on a randomly selected sample of 4,235 individuals aged 20 or over representative of the whole Swiss population, were used to investigate the relation between smoking, prevalence of disease and frequency of health care utilization. The risks of several conditions, including hypertension, myocardial infarction and other heart diseases, asthma, tuberculosis and kidney disease were elevated among ex-smokers. The diseases showing elevated risks among current smokers and significantly positive dose-risk trends included acute bronchitis (relative risk, RR = 3.2 for heavy cigarette smokers vs never smokers), chronic bronchitis or lung emphysema (RR = 2.0), gastro-duodenal ulcer (RR = 1.8) and bone fractures (RR = 1.6). For respiratory conditions, the risk of pipe or cigar smokers was comparable to that of moderate cigarette smokers, whereas for ulcer (RR = 4.1) or fractures (RR = 2.0) the point estimates were even higher than for heavy cigarette smokers. Smokers tended to consult more frequently general practitioners, used more other outpatients services, and were more frequently admitted to hospital during the year preceding the interview. These effects were consistent across strata of age, socio-economic indicators, and persisted after allowance for major identified potential distorting factors. Thus, the results of this survey confirm that smoking is an important cause of morbidity and a major contributory factor to the use of health services.

The size and burden of mental disorders and other disorders of the brain in Europe 2010.

Aims: To provide 12-month prevalence and disability burden estimates of a broad range of mental and neurological disorders in the European Union (EU) and to compare these findings to previous estimates. Referring to our previous 2005 review, improved up-to-date data for the enlarged EU on a broader range of disorders than previously covered are needed for basic, clinical and public health research and policy decisions and to inform about the estimated number of persons affected in the EU. Method: Stepwise multi-method approach, consisting of systematic literature reviews, reanalyses of existing data sets, national surveys and expert consultations. Studies and data from all member states of the European Union (EU-27) plus Switzerland, Iceland and Norway were included. Supplementary information about neurological disorders is provided, although methodological constraints prohibited the derivation of overall prevalence estimates for mental and neurological disorders. Disease burden was measured by disability adjusted life years (DALY). Results: Prevalence: It is estimated that each year 38.2% of the EU population suffers from a mental disorder. Adjusted for age and comorbidity, this corresponds to 164.8 million persons affected. Compared to 2005 (27.4%) this higher estimate is entirely due to the inclusion of 14 new disorders also covering childhood/adolescence as well as the elderly. The estimated higher number of persons affected (2011: 165 m vs. 2005: 82 m) is due to coverage of childhood and old age populations, new disorders and of new EU membership states. The most frequent disorders are anxiety disorders (14.0%), insomnia (7.0%), major depression (6.9%), somatoform (6.3%), alcohol and drug dependence (>4%), ADHD (5%) in the young, and dementia (1-30%, depending on age). Except for substance use disorders and mental retardation, there were no substantial cultural or country variations. Although many sources, including national health insurance programs, reveal increases in sick leave, early retirement and treatment rates due to mental disorders, rates in the community have not increased with a few exceptions (i.e. dementia). There were also no consistent indications of improvements with regard to low treatment rates, delayed treatment provision and grossly inadequate treatment. Disability: Disorders of the brain and mental disorders in particular, contribute 26.6% of the total all cause burden, thus a greater proportion as compared to other regions of the world. The rank order of the most disabling diseases differs markedly by gender and age group; overall, the four most disabling single conditions were: depression, dementias, alcohol use disorders and stroke. Conclusion: In every year over a third of the total EU population suffers from mental disorders. The true size of "disorders of the brain" including neurological disorders is even considerably larger. Disorders of the brain are the largest contributor to the all cause morbidity burden as measured by DALY in the EU. No indications for increasing overall rates of mental disorders were found nor of improved care and treatment since 2005; less than one third of all cases receive any treatment, suggesting a considerable level of unmet needs. We conclude that the true size and burden of disorders of the brain in the EU was significantly underestimated in the past.Concerted priority action is needed at all levels, including substantially increased funding for basic, clinical and public health research in order to identify better strategies for improved prevention and treatment for isorders of the brain as the core health challenge of the 21st century. (C) 2011 Published by Elsevier B.V.

Changing healthcare: stakeholder perceptions of the burden of chronic disease and the value of teams, measurements and communication.

Canadian healthcare is changing. Over the course of the past decade, the Health Care in Canada Survey (HCIC) has annually measured the reactions of the public and professional stakeholders to many of these change forces. In HCIC 2008, for the first time, the public's perception of their health status and all stakeholders' views of the burden and effective management of chronic diseases were sought. Overall, Canadians perceive themselves as healthy, with 84% of adults reporting good-to-excellent health. However, good health decreased with age as the occurrence of chronic illness rose, from 12% in the age group 18-24 to 65% for the population =65 years. More than 70% of all stakeholders were strongly or somewhat supportive of the implementation of coordinated care, or disease management programs, to improve the care of patients with chronic illnesses. Concordant support was also expressed for key disease management components, including coordinated interventions to improve home, community and self-care; increased wellness promotion; and increased use of clinical measurements and feedback to all stakeholders. However, there were also important areas of non-concordance. For example, the public and doctors consistently expressed less support than other stakeholders for the value of team care, including the use of non-physician professionals to provide patient care; increased patient involvement in decision-making; and the use of electronic health records to facilitate communication. The actual participation in disease management programs averaged 34% for professionals and 25% for the public. We conclude that chronic diseases are common, age-related and burdensome in Canada. Disease management or coordinated intervention often delivered by teams is also relatively common, despite its less-than-universal acceptance by all stakeholders. Further insights are needed, particularly into the variable perceptions of the value and efficacy of team-delivered healthcare and its important components.