Reply - Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality

Dear Editor We thank Dr Klek for his interest in our article and giving us the opportunity to clarify our study and share our thoughts. Our study looks at the prevalence of malnutrition in an acute tertiary hospital and tracked the outcomes prospectively.1 There are a number of reasons why we chose Subjective Global Assessment (SGA) to determine the nutritional status of patients. Firstly, we took the view that nutrition assessment tools should be used to determine nutrition status and diagnose presence and severity of malnutrition; whereas the purpose of nutrition screening tools are to identify individuals who are at risk of malnutrition. Nutritional assessment rather than screening should be used as the basis for planning and evaluating nutrition interventions for those diagnosed with malnutrition. Secondly, Subjective Global Assessment (SGA) has been well accepted and validated as an assessment tool to diagnose the presence and severity of malnutrition in clinical practice.2, 3 It has been used in many studies as a valid prognostic indicator of a range of nutritional and clinical outcomes.4, 5, 6 On the other hand, Malnutrition Universal Screening Tool (MUST)7 and Nutrition Risk Screening 2002 (NRS 2002)8 have been established as screening rather than assessment tools.

Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality

Background & aims The confounding effect of disease on the outcomes of malnutrition using diagnosis-related groups (DRG) has never been studied in a multidisciplinary setting. This study aims to determine the impact of malnutrition on hospitalisation outcomes, controlling for DRG. Methods Subjective Global Assessment was used to assess the nutritional status of 818 patients within 48 hours of admission. Prospective data were collected on cost of hospitalisation, length of stay (LOS), readmission and mortality up to 3 years post-discharged using National Death Register data. Mixed model analysis and conditional logistic regression matching by DRG were carried out to evaluate the association between nutritional status and outcomes, with the results adjusted for gender, age and race. Results Malnourished patients (29%) had longer hospital stays (6.9±7.3 days vs. 4.6±5.6 days, p<0.001) and were more likely to be readmitted within 15 days (adjusted relative risk = 1.9, 95%CI 1.1–3.2, p=0.025). Within a DRG, the mean difference between actual cost of hospitalisation and the average cost for malnourished patients was greater than well-nourished patients (p=0.014). Mortality was higher in malnourished patients at 1 year (34% vs. 4.1 %), 2 years (42.6% vs. 6.7%) and 3 years (48.5% vs. 9.9%); p<0.001 for all. Overall, malnutrition was a significant predictor of mortality (adjusted hazard ratio = 4.4, 95%CI 3.3-6.0, p<0.001). Conclusions Malnutrition was evident in up to one third of inpatients and led to poor hospitalisation outcomes, even after matching for DRG. Strategies to prevent and treat malnutrition in the hospital and post-discharge are needed.

Optimising the length of Random Breath Tests : results from the Queensland Community Engagement Trial

Research suggests that the length and quality of police-citizen encounters affect policing outcomes. The Koper Curve, for example, shows that the optimal length for police presence in hot spots is between 14 and 15 minutes, with diminishing returns observed thereafter. Our study, using data from the Queensland Community Engagement Trial (QCET), examines the impact of encounter length on citizen perceptions of police performance. QCET involved a randomised field trial, where 60 random breath test (RBT) traffic stop operations were randomly allocated to an experimental condition involving a procedurally just encounter or a business-as-usual control condition. Our results show that the optimal length of time for procedurally just encounters during RBT traffic stops is just less than 2 minutes. We show, therefore, that it is important to encourage and facilitate positive police–citizen encounters during RBTat traffic stops, while ensuring that the length of these interactions does not pass a point of diminishing returns.

Survival models of community tenure and length of hospital stay for the seriously mentally ill : a 10-year perspective

Objective: To examine the effects of personal and community characteristics, specifically race and rurality, on lengths of state psychiatric hospital and community stays using maximum likelihood survival analysis with a special emphasis on change over a ten year period of time. Data Sources: We used the administrative data of the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) from 1982-1991 and the Area Resources File (ARF). Given these two sources, we constructed a history file for each individual who entered the state psychiatric system over the ten year period. Histories included demographic, treatment, and community characteristics. Study Design: We used a longitudinal, population-based design with maximum likelihood estimation of survival models. We presented a random effects model with unobserved heterogeneity that was independent of observed covariates. The key dependent variables were lengths of inpatient stay and subsequent length of community stay. Explanatory variables measured personal, diagnostic, and community characteristics, as well as controls for calendar time. Data Collection: This study used secondary, administrative, and health planning data. Principal Findings: African-American clients leave the community more quickly than whites. After controlling for other characteristics, however, race does not affect hospital length of stay. Rurality does not affect length of community stays once other personal and community characteristics are controlled for. However, people from rural areas have longer hospital stays even after controlling for personal and community characteristics. The effects of time are significantly smaller than expected. Diagnostic composition effects and a decrease in the rate of first inpatient admissions explain part of this reduced impact of time. We also find strong evidence for the existence of unobserved heterogeneity in both types of stays and adjust for this in our final models. Conclusions: Our results show that information on client characteristics available from inpatient stay records is useful in predicting not only the length of inpatient stay but also the length of the subsequent community stay. This information can be used to target increased discharge planning for those at risk of more rapid readmission to inpatient care. Correlation across observed and unobserved factors affecting length of stay has significant effects on the measurement of relationships between individual factors and lengths of stay. Thus, it is important to control for both observed and unobserved factors in estimation.

Increasing the length of single-wall carbon nanotubes in a magnetically enhanced arc discharge

It is demonstrated that a magnetic field has a profound effect on the length of a single-wall carbon nanotube (SWCNT) synthesized in the arc discharge. The average length of SWCNT increases by a factor of 2 in discharge with magnetic field as compared with the discharge without magnetic field, and the yield of long nanotubes with lengths above 5 μm also increases. A model of SWCNT growth on metal catalyst in arc plasma was developed. Monte-Carlo simulations confirm that the increase of the plasma density in the magnetic field leads to an increase in the nanotube growth rate and thus leads to longer nanotubes.

Ways to increase the length of single wall carbon nanotubes in a magnetically enhanced arc discharge

Ability to control the properties of single-wall nanotubes produced in the arc discharge is important for many practical applications. Our experiments suggest that the length and purity of single-wall nanotubes significantly increase when the magnetic field is applied to the arc discharge. A model of a single wall carbon nanotube interaction and growth in the thermal plasma was developed which considers several important effects such as anode ablation that supplies the carbon plasma in an anodic arc discharge technique, and the momentum, charge and energy transfer processes between nanotube and plasma. The numerical simulations based on Monte-Carlo technique were performed, which explain an increase of the nanotubes produced in the magnetic field - enhanced arc discharge.

Prognostic validity of 3-Minute Nutrition Screening (3-MinNS) in predicting length of hospital stay, readmission, cost of hospitalisation and mortality : a cohort study

Background: It is important to identify patients who are at risk of malnutrition upon hospital admission as malnutrition results in poor outcomes such as longer length of hospital stay, readmission, hospitalisation cost and mortality. The aim of this study was to determine the prognostic validity of 3-Minute Nutrition Screening (3-MinNS) in predicting hospital outcomes in patients admitted to an acute tertiary hospital through a list of diagnosis-related groups (DRG). Methods: In this study, 818 adult patients were screened for risk of malnutrition using 3-MinNS within 24 hours of admission. Mortality data was collected from the National Registry with other hospitalisation outcomes retrieved from electronic hospital records. The results were adjusted for age, gender and ethnicity, and matched for DRG. Results: Patients identified to be at risk of malnutrition (37%) using 3-MinNS had significant positive association with longer length of hospital stay (6.6 ± 7.1 days vs. 4.5 ± 5.5 days, p<0.001), higher hospitalisation cost (S$4540 ± 7190 vs. S$3630 ± 4961, p<0.001) and increased mortality rate at 1 year (27.8% vs. 3.9%), 2 years (33.8% vs. 7.2%) and 3 years (39.1% vs. 10.5%); p<0.001 for all. Conclusions: The 3-MinNS is able to predict clinical outcomes and can be used to screen newly admitted patients for nutrition risk so that appropriate nutrition assessment and early nutritional intervention can be initiated.

The prolongation of length of stay because of Clostridium difficile infection

Background Clostridium difficile infection (CDI) possibly extends hospital length of stay (LOS); however, the current evidence does not account for the time-dependent bias, ie, when infection is incorrectly analyzed as a baseline covariate. The aim of this study was to determine whether CDI increases LOS after managing this bias. Methods We examined the estimated extra LOS because of CDI using a multistate model. Data from all persons hospitalized >48 hours over 4 years in a tertiary hospital in Australia were analyzed. Persons with health care-associated CDIs were identified. Cox proportional hazards models were applied together with multistate modeling. Results One hundred fifty-eight of 58,942 admissions examined had CDI. The mean extra LOS because of infection was 0.9 days (95% confidence interval: −1.8 to 3.6 days, P = .51) when a multistate model was applied. The hazard of discharge was lower in persons who had CDI (adjusted hazard ratio, 0.42; P < .001) when a Cox proportional hazard model was applied. Conclusion This study is the first to use multistate models to determine the extra LOS because of CDI. Results suggest CDI does not significantly contribute to hospital LOS, contradicting findings published elsewhere. Conversely, when methods prone to result in time-dependent bias were applied to the data, the hazard of discharge significantly increased. These findings contribute to discussion on methods used to evaluate LOS and health care-associated infections.

Impact of a stroke unit on length of hospital stay and in-hospital case fatality

Background and Purpose Randomized trials have demonstrated reduced morbidity and mortality with stroke unit care; however, the effect on length of stay, and hence the economic benefit, is less well-defined. In 2001, a multidisciplinary stroke unit was opened at our institution. We observed whether a stroke unit reduces length of stay and in-hospital case fatality when compared to admission to a general neurology/medical ward. Methods A retrospective study of 2 cohorts in the Foothills Medical Center in Calgary was conducted using administrative databases. We compared a cohort of stroke patients managed on general neurology/medical wards before 2001, with a similar cohort of stroke patients managed on a stroke unit after 2003. The length of stay was dichotomized after being centered to 7 days and the Charlson Index was dichotomized for analysis. Multivariable logistic regression was used to compare the length of stay and case fatality in 2 cohorts, adjusted for age, gender, and patient comorbid conditions defined by the Charlson Index. Results Average length of stay for patients on a stroke unit (n=2461) was 15 days vs 19 days for patients managed on general neurology/medical wards (n=1567). The proportion of patients with length of stay >7 days on general neurology/medical wards was 53.8% vs 44.4% on the stroke unit (difference 9.4%; P<0.0001). The adjusted odds of a length of stay >7 days was reduced by 30% (P<0.0001) on a stroke unit compared to general neurology/medical wards. Overall in-hospital case fatality was reduced by 4.5% with stroke unit care. Conclusions We observed a reduced length of stay and reduced in-hospital case-fatality in a stroke unit compared to general neurology/medical wards.

Implementation of a chest pain management service improves patient care and reduces length of stay

Objective Chest pain is one of the most common complaints in patients presenting to an emergency department. Delays in management due to a lack of readily available objective tests to risk stratify patients with possible acute coronary syndromes can lead to an unnecessarily lengthy admission placing pressure on hospital beds or inappropriate discharge. The need for a co-ordinated system of clinical management based on enhanced communication between departments, timely and appropriate triage, clinical investigation, diagnosis, and treatment was identified. Methods An evidence-based Chest Pain Management Service and clinical pathway were developed and implemented, including the introduction of after-hours exercise stress testing. Results Between November 2005 and March 2013, 5662 patients were managed according to a Chest Pain Management pathway resulting in a reduction of 5181 admission nights by more timely identification of patients at low risk who could then be discharged. In addition, 1360 days were avoided in high-risk patients who received earlier diagnosis and treatment. Conclusions The creation of a Chest Pain Management pathway and the extended exercise stress testing service resulted in earlier discharge for low-risk patients; and timely treatment for patients with positive and equivocal exercise stress test results. This service demonstrated a significant saving in overnight admissions.

Factors influencing hospital readmission and length of stay of Vietnamese patients with type 2 diabetes and cardiac disease

Background: Increased hospital readmission and longer stays in the hospital for patients with type 2 diabetes and cardiac disease can result in higher healthcare costs and heavier individual burden. Thus, knowledge of the characteristics and predictive factors for Vietnamese patients with type 2 diabetes and cardiac disease, at high risk of hospital readmission and longer stays in the hospital, could provide a better understanding on how to develop an effective care plan aimed at improving patient outcomes. However, information about factors influencing hospital readmission and length of stay of patients with type 2 diabetes and cardiac disease in Vietnam is limited. Aim: This study examined factors influencing hospital readmission and length of stay of Vietnamese patients with both type 2 diabetes and cardiac disease. Methods: An exploratory prospective study design was conducted on 209 patients with type 2 diabetes and cardiac disease in Vietnam. Data were collected from patient charts and patients' responses to self-administered questionnaires. Descriptive statistics, bivariate correlation, logistic and multiple regression were used to analyse the data. Results: The hospital readmission rate was 12.0% among patients with both type 2 diabetes and cardiac disease. The average length of stay in the hospital was 9.37 days. Older age (OR= 1.11, p< .05), increased duration of type 2 diabetes (OR= 1.22, p< .05), less engagement in stretching/strengthening exercise behaviours (OR= .93, p< .001) and in communication with physician (OR= .21, p< .001) were significant predictors of 30-dayhospital readmission. Increased number of additional co-morbidities (β= .33, p< .001) was a significant predictor of longer stays in the hospital. High levels of cognitive symptom management (β= .40, p< .001) significantly predicted longer stays in the hospital, indicating that the more patients practiced cognitive symptom management, the longer the stay in hospital. Conclusions: This study provides some evidence of factors influencing hospital readmission and length of stay and argues that this information may have significant implications for clinical practice in order to improve patients' health outcomes. However, the findings of this study related to the targeted hospital only. Additionally, the investigation of environmental factors is recommended for future research as these factors are important components contributing to the research model.

Influence of adhesive non-linearities on the performance and optimal length of adhesive bonded joints

An analytical study for the static strength of adhesive lap joints is presented. The earlier solutions of Volkersen [i], DeBruyne[2] and others were limited to linear adhesives. The influence of adhesive non-linearity was first considered by Grimes' et al[3] and Dickson et al [4]. Recently Hart-Smith[5] successfully introduced elastic-plastic behaviour of the adhesive. In the present study the problem is formulated for general non-linear adhesive behaviour and an efficient numerical algorithm is written for the solution. Bilinear and trilinear models for the nonlinearity yield closed form analytical solutions.

Morbid obesity in total hip arthroplasty: Redefining outcomes for operative time, length of stay, and readmission

Background The incidence of obesity amongst patients presenting for elective Total Hip Arthroplasty (THA) has increased in the last decade and the relationship between obesity and the need for joint replacement has been demonstrated. This study evaluates the effects of morbid obesity on outcomes following primary THA by comparing short-term outcomes in THA between a morbidly obese (BMI ≥40) and a normal weight (BMI 18.5 - <25) cohort at our institution between January 2003 and December 2010. Methods Thirty-nine patients included in the morbidly obese group were compared with 186 in the normal weight group. Operative time, length of stay, complications, readmission and length of readmission were compared. Results Operative time was increased in the morbidly obese group at 122 minutes compared with 100 minutes (p=0.002). Post-operatively there was an increased 30-day readmission rate related to surgery of 12.8% associated with BMI ≥40 compared with 2.7% (p= 0.005) as well as a 5.1 fold increase in surgery related readmitted bed days - 0.32 bed days per patient for normal weight compared with 1.64 per patient for the morbidly obese (p=0.026). Conclusion Morbidly obese patients present a technical challenge and likely this and the resultant complications are underestimated. More work needs to be performed in order to enable suitable allocation of resources.

Effect of Chain Length of Alcohol on the Lipase-Catalyzed Esterification of Propionic Acid in Supercritical Carbon Dioxide

The esterification of propionic acid was investigated using three different alcohols, namely, isopropyl alcohol, isobutyl alcohol, and isoamyl alcohol. The variation of conversion with time for the synthesis of isoamyl propionate was investigated in the presence of five enzymes. Novozym 435 showed the highest activity, and this was used as the enzyme for investigating the various parameters that influence the esterification reaction. The Ping-Pong Bi-Bi model with inhibition by both acid and alcohol was used to model the experimental data and determine the kinetics of the esterification reaction.