CONGESTIVE HEART FAILURE, Issue 5 2010
Andria L. Nutter
The objective was to evaluate 6 commonly used heart failure (HF) prognostic models in an elderly, fatal HF population. Predictive models have been established to quantify risk among HF patients. The validation of these models has not been adequately studied, especially in an elderly cohort. Applying a single-center, retrospective study of serially admitted HF patients who died while in the hospital or within 30 days of discharge, the authors evaluated 6 prognostic models: the Seattle Heart Failure Model (SHFM), Heywood's model, Classification and Regression Tree (CART) Analysis, the Heart Failure Survival Score (HFSS), Heart Failure Risk Scoring System, and Pocock's score. Eighty patients were included (mean age, 82.7 ± 8.2 years). Twenty-three patients (28.75%) died in the hospital. The remainder died within 30 days of discharge. The models' predictions varied considerably from one another and underestimated the patients' actual mortality. This study demonstrates that these models underestimate the mortality risk in an elderly cohort at or approaching the end of life. Moreover, the predictions made by each model vary greatly from one another. Many of the models used were not intended for calculation during hospitalization. Development of improved models for the range of patients with HF syndromes is needed. Congest Heart Fail. 2010;16:196,201. © 2010 Wiley Periodicals, Inc. [source]

Affirmative Action in Higher Education: How Do Admission and Financial Aid Rules Affect Future Earnings?

ECONOMETRICA, Issue 5 2005
Peter Arcidiacono
This paper addresses how changing the admission and financial aid rules at colleges affects future earnings. I estimate a structural model of the following decisions by individuals: where to submit applications, which school to attend, and what field to study. The model also includes decisions by schools as to which students to accept and how much financial aid to offer. Simulating how black educational choices would change were they to face the white admission and aid rules shows that race-based advantages had little effect on earnings. However, removing race-based advantages does affect black educational outcomes. In particular, removing advantages in admissions substantially decreases the number of black students at top-tier schools, while removing advantages in financial aid causes a decrease in the number of blacks who attend college. [source]

Admission and Discharge Decisions in Emergency Medicine

EMERGENCY MEDICINE AUSTRALASIA, Issue 3 2002
Betty Chan MBBS FACEM PhD
No abstract is available for this article. [source]

Unfairness of measurement-based admission controls in a heterogeneous environment

INTERNATIONAL JOURNAL OF COMMUNICATION SYSTEMS, Issue 9 2001
Yuan-Cheng Lai
Abstract Admission controls are required to determine whether new connections should be admitted to networks. These controls ensure the quality of service (QoS) for data transmission. This paper introduces three measurement-based admission control algorithms called Measured Sum, Hoeffding Bound, and Adaptive Weight Factor. The unfairness of these algorithms in a heterogeneous environment is investigated. Simulation results indicate that the fairness of the Measured Sum exceeds that of the other methods. Admission of connections with large peak rates or travelling many hops can be difficult. Copyright © 2001 John Wiley & Sons, Ltd. [source]

Predicting Hospital Admission and Returns to the Emergency Department for Elderly Patients

ACADEMIC EMERGENCY MEDICINE, Issue 3 2010
Michael A. LaMantia MD
Abstract Objectives:, Methods to accurately identify elderly patients with a high likelihood of hospital admission or subsequent return to the emergency department (ED) might facilitate the development of interventions to expedite the admission process, improve patient care, and reduce overcrowding. This study sought to identify variables found among elderly ED patients that could predict either hospital admission or return to the ED. Methods:, All visits by patients 75 years of age or older during 2007 at an academic ED serving a large community of elderly were reviewed. Clinical and demographic data were used to construct regression models to predict admission or ED return. These models were then validated in a second group of patients 75 and older who presented during two 1-month periods in 2008. Results:, Of 4,873 visits, 3,188 resulted in admission (65.4%). Regression modeling identified five variables statistically related to the probability of admission: age, triage score, heart rate, diastolic blood pressure, and chief complaint. Upon validation, the c-statistic of the receiver operating characteristic (ROC) curve was 0.73, moderately predictive of admission. We were unable to produce models that predicted ED return for these elderly patients. Conclusions:, A derived and validated triage-based model is presented that provides a moderately accurate probability of hospital admission of elderly patients. If validated experimentally, this model might expedite the admission process for elderly ED patients. Our models failed, as have others, to accurately predict ED return among elderly patients, underscoring the challenge of identifying those individuals at risk for early ED returns. ACADEMIC EMERGENCY MEDICINE 2010; 17:252,259 © 2010 by the Society for Academic Emergency Medicine [source]

The Relationship of Indwelling Urinary Catheters to Death, Length of Hospital Stay, Functional Decline, and Nursing Home Admission in Hospitalized Older Medical Patients

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2007
Jayna M. Holroyd-Leduc MD
OBJECTIVES: To determine the association between indwelling urinary catheterization without a specific medical indication and adverse outcomes. DESIGN: Prospective cohort. SETTING: General medical inpatient services at a teaching hospital. PARTICIPANTS: Five hundred thirty-five patients aged 70 and older admitted without a specific medical indication for urinary catheterization. INTERVENTION: Indwelling urinary catheterization within 48 hours of admission. MEASUREMENTS: Death, length of hospital stay, decline in ability to perform activities of daily living (ADLs), and new admission to a nursing home. RESULTS: Indwelling urinary catheters were placed in 76 of the 535 (14%) patients without a specific medical indication. Catheterized patients were more likely to die in the hospital (6.6% vs 1.5% of those not catheterized, P=.006) and within 90 days of hospital discharge (25% vs 10.5%, P<.001); the greater risk of death with catheterization persisted in a propensity-matched analysis (hazard ratio (HR)=2.42, 95% confidence interval (CI)=1.04,5.65). Catheterized patients also had longer lengths of hospital stay (median, 6 days vs 4 days; P=.001); this association persisted in a propensity-matched analysis (HR=1.46, 95% CI=1.03,2.08). Catheterization was not associated (P>.05) with decline in ADL function or with admission to a nursing home. CONCLUSION: In this cohort of older patients, urinary catheterization without a specific medical indication was associated with greater risk of death and longer hospital stay. [source]

Impact of Collaborative Management and Early Admission in Labor on Method of Delivery

JOURNAL OF OBSTETRIC, GYNECOLOGIC & NEONATAL NURSING, Issue 2 2003
Debra J. Jackson senior researcher
Objective: This study compared the effects of early admission in labor and perinatal care provider on delivery method. Higher spontaneous vaginal delivery rates for certified nurse midwives as compared with physicians have been reported in observational studies and randomized clinical trials. Certified nurse midwives, with their more expectant approach to labor management, would be expected to admit women later in labor than obstetricians. Methods: Prospective cohort study of 2,196 low-risk pregnancies, with singleton, vertex infants admitted in spontaneous labor. Independent and joint effects of perinatal care provider and cervical dilation at admission on delivery method were evaluated. Confounding was addressed using restriction and multiple regression. Results: Fewer (23.4%) women in collaborative care were admitted in early labor (< 4 cm cervical dilation) than women managed by obstetricians (95% CI =,27.6 to ,19.2). Obstetrician care had 9% to 30% fewer spontaneous vaginal deliveries. Women admitted early in labor also had 6% to 34% fewer spontaneous vaginal deliveries. Evaluation of joint effects suggested that interaction between obstetrician provider and earlier admission increased the risk of operative delivery. Conclusion: Later admission in labor (at 4 cm or greater cervical dilation) and management of perinatal care by certified nurse midwives in collaboration with obstetricians increased the rate of spontaneous vaginal delivery in low-risk women. [source]

Opportunistic immunisation of infants admitted to hospital: Are we doing enough?

JOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 6 2008
Kelly-Anne Ressler
Aim: To determine the accuracy and effectiveness of opportunistic immunisation of children admitted to the paediatric unit of a large teaching hospital using retrospectively collected data. Methods: Immunisation status, documented using clinical indicator (CI) forms, of all admissions over a 1-year period was compared with that recorded by the Australian Childhood Immunisation Register. In order to determine the effectiveness of providing catch-up plans, we analysed the difference in catch-up times of the children with and without a catch-up plan on their CI form. Results: The details of 614 admissions in the study period were included. Comparing the Australian Childhood Immunisation Register with the CI for assessing immunisation status, we found that 83 of the 573 (14.5%) were incorrectly recorded, and only 25 of the 82 admissions in which the infant was overdue were identified on the ward. Children were more likely to be vaccinated within 30 days and 90 days of admission if they had been given a catch-up plan. Of the children who had not been given a catch-up plan, almost half were still overdue at 90 days. Conclusions: Admission to hospital provides opportunities for both routine and catch-up immunisation; however, for opportunistic immunisation to be effective, health service screening and immunisation documentation must be accurate. [source]

The Price of Admission: Rethinking How Americans Pay for College

JOURNAL OF POLICY ANALYSIS AND MANAGEMENT, Issue 2 2001
William ZumetaArticle first published online: 19 APR 200
[source]

Underutilization of gastroprotection for at-risk patients undergoing percutaneous coronary intervention: Spain compared with the United States

ALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 5 2010
R. Casado-Arroyo
Aliment Pharmacol Ther 2010; 32: 689,695 Summary Background, Proton pump inhibitors (PPIs) are the preferred agents for the prevention of aspirin-associated upper gastrointestinal bleeding (UGIB). Data are limited to determine whether PPIs are being used to reduce UGIB risk. Aim, To evaluate the implementation of PPI treatment to reduce the GI risk in two cardiology centres from Europe and the United States. Methods, A retrospective cross-sectional study was carried out at the University of Michigan and University Hospital-Zaragoza in 429 consecutive patients hospitalized for percutaneous coronary intervention (PCI) on dual antiplatelet therapy. Results, Admission for PPI co-therapy was similar (34% vs. 30%) in both centres. At discharge, the proportion of high-risk patients receiving PPI therapy in the Spanish centre (75.4%) was higher than their American peers (55.6%) (OR: 2.5; 95% CI; 1.3,4.7). No differences in PPI prescription rates were found among Spanish patients with/without GI risk factors. The opportunity to initiate PPI co-therapy in high-risk patients was missed in 81.8% (36/44) of those not on PPI at admission in US patients vs. 24.1% (19/79) (P < 0.0001) in Spanish patients. Conclusions, There are important differences concerning PPI prescription and risk stratification in the two centres when managing PCI patients. Efforts to stratify risks and utilize appropriate strategies for UGIB prophylaxis in high-risk patients are warranted. [source]

The influence of admissions variables on first year medical school performance: a study from Newcastle University, Australia

MEDICAL EDUCATION, Issue 2 2002
Frances Kay-Lambkin
Aims This study examined the relationship between the performance of first year medical students at the University of Newcastle, Australia, and admission variables: previous educational experience, and entry classification (standard , academic or composite, Aboriginal and Torres Strait Islander, or overseas), age and gender. Methods Admission and demographic information was obtained for students who entered first year medicine at Newcastle between the years 1994 and 1997 inclusive. Academic performance was measured according to results of first assessment (`satisfactory' vs. `not satisfactory') and the final assessment of the first year (`satisfactory' vs. `not satisfactory'). Logistic regression was used to examine the relationship between predictor variables and outcomes. Results Assessment and admissions information was obtained for 278 students, 98% of all students who entered the medical course between 1994 and 1997. Regression analysis of first assessment indicated that Aboriginal and Torres Strait Islander and overseas students were significantly more likely to be `not satisfactory' than all other students (RR=3·1,95% CI: 1·4. , 6 7 and RR=1·5, 95% CI: 1·2,1·8, respectively). Analysis of final assessment indicated these two student groups were also significantly more likely to be `not satisfactory' than all other students (RR=4·5, 95% CI: 1·4,13·5 and RR=3·5, 95% CI: 1·2,10·8, respectively). At first assessment, students entering via the standard academic pathway and older students were less likely to be `not satisfactory' (RR=0·6, 95% CI: 0·5,0·7 and RR=0·8, 95% CI: 0·7,0·9, respectively). However both these differences were not evident at final assessment. There were no significant relationships between performance in first year and the remaining variables. Conclusions Aboriginal and Torres Strait Islander, and overseas medical students had academic difficulties in the first year of the course, suggesting the need for extra course support. The result may reflect the educational and other obstacles these students must overcome in order to enter and progress through their medical degree. More research is warranted to explore the extent to which these differences persist throughout the medical degree. [source]

Soft Tissue Infections and Emergency Department Disposition: Predicting the Need for Inpatient Admission

ACADEMIC EMERGENCY MEDICINE, Issue 12 2009
Alfredo Sabbaj MD
Abstract Objectives:, Little empiric evidence exists to guide emergency department (ED) disposition of patients presenting with soft tissue infections. This study's objective was to generate a clinical decision rule to predict the need for greater than 24-hour hospital admission for patients presenting to the ED with soft tissue infection. Methods:, This was a retrospective cohort study of consecutive patients presenting to a tertiary care hospital ED with diagnosis of nonfacial soft tissue infection. Standardized chart review was used to collect 29 clinical variables. The primary outcome was >24-hour hospital admission (either general admission or ED observation unit), regardless of initial disposition. Patients initially discharged home and later admitted for more than 24 hours were included in the outcome. Data were analyzed using classification and regression tree (CART) analysis and multivariable logistic regression. Results:, A total of 846 patients presented to the ED with nonfacial soft tissue infection. After merging duplicate records, 674 patients remained, of which 81 (12%) required longer than 24-hour admission. Using CART, the strongest predictors of >24-hour admission were patient temperature at ED presentation and mechanism of infection. In the multivariable logistic regression model, initial patient temperature (odds ratio [OR] for each degree over 37°C = 2.91, 95% confidence interval [CI] = 1.65 to 5.12) and history of fever (OR = 3.02, 95% CI = 1.41 to 6.43) remained the strongest predictors of hospital admission. Despite these findings, there was no combination of factors that reliably identified more than 90% of target patients. Conclusions:, Although we were unable to generate a high-sensitivity decision rule to identify ED patients with soft tissue infection requiring >24-hour admission, the presence of a fever (either by initial ED vital signs or by history) was the strongest predictor of need for >24-hour hospital stay. These findings may help guide disposition of patients presenting to the ED with nonfacial soft tissue infections. [source]

Recruitment and Admission of Students with Disabilities

NEW DIRECTIONS FOR STUDENT SERVICES, Issue 91 2000
Barbara J. Palombi
This chapter focuses on the role of student affairs professionals and other administrative offices in assisting students with disabilities in their journey from high school to institutions of higher education. [source]

Reduction in Medication Costs for Patients with Chronic Nonmalignant Pain Completing a Pain Rehabilitation Program: A Prospective Analysis of Admission, Discharge, and 6-Month Follow-Up Medication Costs

PAIN MEDICINE, Issue 5 2009
Julie L. Cunningham PharmD
ABSTRACT Objective., Chronic nonmalignant pain (CNMP) is both a prevalent and a costly health problem in our society. Pain rehabilitation programs have been shown to provide cost-effective treatment. A treatment goal for some rehabilitation programs is reduction in the use of pain-related medication. Medication costs savings from pain rehabilitation programs have not been analyzed in previous studies. Design., This prospective cohort study of 186 patients with CNMP addresses the costs of medications at admission to a 3-week outpatient pain rehabilitation program, at discharge, and at 6-month follow-up. Medication use was determined through a detailed pharmacist interview with patients at admission and discharge. Patients were sent questionnaires 6 months after program completion, which obtained current medication information. Results., Statistically significant medication cost savings were seen for program completers at discharge and at 6-month follow-up (P < 0.05). The mean (standard deviation) daily prescription medication cost reduction from admission to discharge was $9.31 ($12.70) using the average wholesale price of medications. From the original study cohort, 121 patients completed the 6-month follow-up survey. The mean daily prescription medication cost savings from admission to 6-month follow-up was $6.68 ($14.40). Conclusion., Patients benefited from significant medication cost savings at the completion of the 3-week outpatient pain rehabilitation program and maintained significant savings after 6 months. This study adds to the current literature on the economic value of comprehensive pain rehabilitation programs. [source]

Randomized controlled trial of nebulized adrenaline in acute bronchiolitis

PEDIATRIC ALLERGY AND IMMUNOLOGY, Issue 2 2003
Suriyanarayanapillai Hariprakash
Use of both l -epinephrine and racemic epinephrine (adrenaline) has improved clinical symptoms and composite respiratory scores in acute bronchiolitis. The objective of this randomized double-blind placebo-controlled study was to assess whether there was sufficient improvement in clinical state to reduce hospital admissions. Seventy-five infants aged 1 month to 1 year with a clinical diagnosis of acute bronchiolitis were treated with either 2 ml of 1:1000 nebulized adrenaline or 2 ml of nebulized normal saline administered after baseline assessment and 30 min later. Clinical respiratory parameters were recorded at 15-min intervals for a period of 2 h following the baseline assessment. Admission to hospital was the primary end-point and changes in respiratory parameters were secondary end-points. Fifty percent (19/38) of infants treated with adrenaline were discharged home compared with 38 percent (14/37) of those treated with saline. This 12 percent reduction in rate of admission is not statistically significant (95% CI of difference: ,10% to 35%). There was no difference between treated and placebo groups in respiratory rate, oxygen saturation, heart rate or a composite respiratory distress score at 30, 60 or 120 min post-treatment. In this study, nebulized epinephrine did not confer a significant advantage over nebulized saline in the emergency room treatment of acute bronchiolitis. [source]

Accuracy of prediction of walking for young stroke patients by use of the FIM

PHYSIOTHERAPY RESEARCH INTERNATIONAL, Issue 1 2001
Heather Thornton Senior Lecturer
Abstract Background and Purpose Clinical prediction of walking outcome after a stroke is essential for effective discharge planning. However, its accuracy has hardly been explored. This study took place in a regional unit admitting patients with complex neurological disabilities for specialist inpatient rehabilitation. The aim was to compare predicted outcome (goal score) with achieved outcome (discharge score) on the seven-point locomotion subscale of the Functional Independence Measure (FIM), to evaluate its precision and identify factors influencing accuracy. Method Admission, goal and discharge scores were analysed retrospectively for 141 subjects (90 M; 51 F) admitted consecutively to the Unit with median age 54 years (range 15,68 years) with median length of stay 13.6 weeks (range 3,35 weeks). Results Ninety subjects (64%) gained from two to six points; 50 subjects (35%) gained one point or showed no change. One patient deteriorated by two points. Excluding patients admitted with the highest score (FIM level 7), the overall level of agreement between predicted and discharge scores was moderate (weighted kappa 0.47). Prediction was accurate to ±1 point in 113 subjects (80%). Overprediction by ,2 points occurred in 16 subjects (11%) and underprediction by ,2 points in 12 subjects (9%). Analysis of the most-disabled cohort, admitted with FIM levels 1 or 2 scores, revealed a higher sensitivity for predicting ,independence' (FIM levels 5,7) (78%) than ,dependence' (FIM levels 1,4) (65%). Accuracy was not affected by age, gender or side of stroke. Inaccurate predictions were associated with lower admission FIM level scores (p=,0.26;p=0.002) and a greater length of stay (p=0.36;p<0.001). Subjects with quad-riplegia were more likely to have inaccurate outcome predictions made than those with hemiplegia (p=0.025) and those with neglect were more likely to have inaccurate outcome predictions made than those without neglect (p=0.017). Conclusion Further investigation into clinical prediction and the variables which confound accuracy is needed for effective planning. Copyright © 2001 Whurr Publishers Ltd. [source]

,Admission into a helping plan': a watershed between positive and negative experiences in breast cancer

PSYCHO-ONCOLOGY, Issue 8 2010
Sara Lilliehorn
Abstract Cancer patients are in an exposed situation that raises certain psychosocial needs in contact with health care. Previous studies have mainly investigated these needs by assessments on pre-defined categories. Objective: The purpose of the present study is, from the patients' perspective, to identify breast cancer patients' psychosocial needs, and to synthesise them in a model reflecting the core of these needs. Methods: Seventy-one patients treated with radiation therapy were consecutively included and repeatedly interviewed about their experiences of health care. ,Critical incidents' where identified from the interviews and analysed due to the similarities,differences technique in grounded theory. Results: Four categories of needs where detected: ,access', ,information', ,treatment' and ,how approached'. These categories and their properties merged into a core category,,admission into a helping plan'. These findings are well understood in terms of attachment theory. In times of immanent danger and stress people strive to find a ,safe haven' to attach to. Cancer patients' ,safe haven' can be described as ,a helping plan'. It is not the result of a separate patient,caregiver relationship but is created by a pattern of individual experiences from all kind of contacts with the health-care system as a whole. Conclusions: The presented model of patients needs as converging into ,admission into a helping plan' may serve as an easily comprehendible model for caregivers, guiding them to contribute to the patient's feeling of security and trust, and thus to the patient's own ,hope work'. Copyright © 2009 John Wiley & Sons, Ltd. [source]

Mortality and Revascularization Following Admission for Acute Myocardial Infarction: Implication for Rural Veterans

THE JOURNAL OF RURAL HEALTH, Issue 4 2010
Thad E. Abrams MD
Abstract Introduction: Annually, over 3,000 rural veterans are admitted to Veterans Health Administration (VA) hospitals for acute myocardial infarction (AMI), yet no studies of AMI have utilized the VA rural definition. Methods: This retrospective cohort study identified 15,870 patients admitted for AMI to all VA hospitals. Rural residence was identified by either Rural-Urban Commuting Area (RUCA) codes or the VA Urban/Rural/Highly Rural (URH) system. Endpoints of mortality and coronary revascularization were adjusted using administrative laboratory and clinical variables. Results: URH codes identified 184 (1%) veterans as highly rural, 6,046 (39%) as rural, and 9,378 (60%) as urban; RUCA codes identified 1,350 (9%) veterans from an isolated town, 3,505 (22%) from a small or large town, and 10,345 (65%) from urban areas. Adjusted mortality analyses demonstrated similar risk of mortality for rural veterans using either URH or RUCA systems. Hazards of revascularization using the URH classification demonstrated no difference for rural (HR, 0.96; 95% CI, 0.94-1.00) and highly rural veterans (HR, 1.13; 0.96-1.31) relative to urban veterans. In contrast, rural (relative to urban) veterans designated by the RUCA system had lower rates of revascularization; this was true for veterans from small or large towns (HR, 0.89; 0.83-0.95) as well as veterans from isolated towns (HR, 0.86; 0.78-0.93). Conclusion: Rural veterans admitted for AMI care have a similar risk of 30-day mortality but the adjusted hazard for receipt of revascularization for rural veterans was dependent upon the rural classification system utilized. These findings suggest potentially lower rates of revascularization for rural veterans. [source]

Multicenter Validation of the Philadelphia EMS Admission Rule (PEAR) to Predict Hospital Admission in Adult Patients Using Out-of-hospital Data

ACADEMIC EMERGENCY MEDICINE, Issue 6 2009
Zachary F. Meisel MD
Abstract Objectives:, The objective was to validate a previously derived prediction rule for hospital admission using routinely collected out-of-hospital information. Methods:, The authors performed a multicenter retrospective cohort study of 1,500 randomly selected, adult patients transported to six separate emergency departments (EDs; three community and three academic hospitals in three separate health systems) by a city-run emergency medical services (EMS) system over a 1-year period. Patients younger than 18 years or who bypassed the ED to be evaluated by trauma, obstetric, or psychiatric teams were excluded. The score consisted of six weighted elements that generated a total score (0,14): age , 60 years (3 points); chest pain (3); shortness of breath (3); dizzy, weakness, or syncope (2); history of cancer (2); and history of diabetes (1). Receiver operator characteristic (ROC) curves for the decision rule and admission rates were calculated among individual hospitals and for the entire cohort. Results:, A total of 1,102 patients met inclusion criteria. The admission rate for the entire cohort was 40%, and individual hospital admission rates ranged from 28% to 57%. Overall, 34% had a score of ,4, and 29% had a score of ,5. Area under the ROC curve (AUC) for the combined cohort was 0.83 for all admissions and 0.72 for intensive care unit (ICU) admissions; AUCs at individual hospitals ranged from 0.72 to 0.85. The admission rate for a score of ,4 was 77%; for a score of ,5 the admission rate was 80%. Conclusions:, The ability of this EMS rule to predict the likelihood of hospital admission appears valid in this multicenter cohort. Further studies are needed to measure the impact and feasibility of using this rule to guide decision-making. [source]

Predictors of Hospital Admission for Chronic Obstructive Pulmonary Disease Exacerbations in Canadian Emergency Departments

ACADEMIC EMERGENCY MEDICINE, Issue 4 2009
Brian H. Rowe MD, CCFP(EM)
Abstract Objectives:, The objective was to examine predictors of hospital admission among adults presenting to Canadian emergency departments (EDs) for acute exacerbations of chronic obstructive pulmonary disease (COPD). Current acute treatment approaches and outcomes 2 weeks after the ED visit are also described. Methods:, Subjects, aged ,35 years presenting with COPD exacerbations to 16 EDs across Canada, underwent a structured in-ED interview and a telephone interview 2 weeks later. Results:, Of 501 study patients, 247 (49.3%; 95% confidence interval [CI] = 44.9% to 53.6%) were admitted. Admitted patients were older, were more often former smokers, and had more admissions for COPD during the past 2 years. They also reported more days of activity limitation and use of inhaled beta2 -agonists in the previous 24 hours. Canadian Triage and Acuity Scale (CTAS), respiratory rate (RR), and airflow obstruction were more severe in the hospitalized group. Most of the patients received inhaled beta2 -agonists, anticholinergics, oral corticosteroids (CS), and antibiotics; hospitalized patients received more aggressive treatments. The median ED length of stay (LOS) of admitted patients was 13.1 hours (interquartile range [IQR] = 7.4-23.0) compared to 5.6 hours (IQR = 4.2-8.4) in discharged patients. Admission was associated with at least two COPD admissions in the past 2 years (odds ratio [OR] = 2.10; 95% CI = 1.24 to 3.56), receiving oral CS for COPD (OR = 1.72; 95% CI = 1.08 to 2.74), having a CTAS score of 1,2 (OR = 2.04; 95% CI = 1.33 to 3.12), and receiving adjunct ED treatments (OR = 3.95; 95% CI = 2.45 to 6.35). Use of EDs for usual COPD care was associated with a reduced risk of admission (OR = 0.43; 95% CI = 0.28 to 0.66). Conclusions:, Exacerbations of COPD in Canadian EDs result in prolonged ED stays and approximately 50% hospitalization despite aggressive acute treatment approaches. Historical, severity, and treatment-related factors were strongly associated with hospital admission. Validation of these results should be completed prior to widespread use. [source]

Is Hospital Admission and Observation Required after a Normal Abdominal Computed Tomography Scan in Children with Blunt Abdominal Trauma?

ACADEMIC EMERGENCY MEDICINE, Issue 10 2008
Smita Awasthi MD
Abstract Objectives:, The objective was to determine if hospital admission of children with blunt abdominal trauma for observation of possible intraabdominal injury (IAI) is necessary after a normal abdominal computed tomography (CT) scan in the emergency department (ED). Methods:, The authors conducted a prospective observational cohort study of children less than 18 years of age with blunt abdominal trauma who underwent an abdominal CT scan in the ED. Abdominal CT scans were obtained with intravenous contrast but no oral contrast. The decision to hospitalize the patient was made by the attending emergency physician (EP) with the trauma or pediatric surgery teams. An abnormal abdominal CT scan was defined by the presence of any visualized IAI or findings suggestive of possible IAI (e.g., intraperitoneal fluid without solid organ injury). Patients were followed to determine if IAI was later diagnosed and the need for acute therapeutic intervention if IAI was present. Results:, A total of 1,295 patients underwent abdominal CT, and 1,085 (84%) patients had normal abdominal CT scans in the ED and make up the study population. Seven-hundred thirty-seven (68%) were hospitalized, and 348 were discharged to home. None of the 348 patients discharged home and 2 of the 737 hospitalized patients were identified with an IAI after a normal initial abdominal CT. The IAIs in patients with normal initial CT scans included a 10-year-old with a mesenteric hematoma and serosal tear at laparotomy and a 10-year-old with a perinephric hematoma on repeat CT. Neither underwent specific therapy. The negative predictive value (NPV) of a normal abdominal CT scan for IAI was 99.8% (95% confidence interval [CI] = 99.3% to 100%). Conclusions:, Children with blunt abdominal trauma and a normal abdominal CT scan in the ED are at very low risk of having a subsequently diagnosed IAI and are very unlikely to require a therapeutic intervention. Hospitalization of children for evaluation of possible undiagnosed IAI after a normal abdominal CT scan has a low yield and is generally unnecessary. [source]

The Profitability of Medicare Admissions Based on Source of Admission

ACADEMIC EMERGENCY MEDICINE, Issue 10 2008
Megan McHugh PhD
Abstract Objectives:, This study investigates whether admissions from the emergency department (ED) have lower dollar margins than elective admissions under Medicare and explores two possible reasons for differences in margins. Methods:, The authors developed patient-level Medicare dollar margins (calculated as patient revenue minus cost) for 1,159,243 Medicare admissions from 321 hospitals using data from the 2003 Nationwide Inpatient Sample (NIS) and the Medicare Impact File. Differences in margins between ED and elective admissions were explored across a number of diagnosis-related groups (DRGs) using t-tests. Chi-square tests were used explore whether ED admission was more common among patients in low-profit DRGs and/or patients with greater severity of illness. Results:, The average Medicare dollar margins were ,$712 (95% confidence interval [CI] = ,$729 to ,$695) for ED admissions and $22 (95% CI = ,$2 to $47) for elective admissions. Medicare dollar margins for ED admissions were lower than those of elective admission for the most common DRGs. ED admission was associated with greater patient severity of illness. Conclusions:, Source of admission is a financially meaningful classification. Because Medicare payment policy does not recognize differences in cost based on patients' route of admission, hospitals may have a financial incentive to favor elective admissions over ED admissions. [source]

Biomarkers on Admission for the Prediction of Cardiovascular Events After Primary Stenting in Patients with ST-Elevation Myocardial Infarction

CLINICAL CARDIOLOGY, Issue 12 2008
Young-Hoon Jeong MD
Abstract Background Several cardiac biomarkers have been shown to have predictive values for the development of cardiovascular disease and clinical outcome after events, and are now broadly used by clinicians. Little is known about the utility of these biomarker values on admission in ST-elevation myocardial infarction (STEMI) cases of primary drug-eluting stent (DES) implantation and intense medical therapy. Hypothesis Because little is known about the utility of these biomarkers on admission in ST-elevation myocardial infarction (STEMI) in cases primary drug-eluting stent (DES) implantation and intense medical therapy, we evaluated clinical outcomes. Methods We enrolled 207 consecutive STEMI patients treated with primary stenting (mean age, 57.3 ± 12.0 y). We evaluated the association between B-type natriuretic peptide (BNP), cardiac troponin I (cTnI), high-sensitivity C-reactive protein (hs-CRP) on admission, and death, reinfarction, and new or worsening congestive heart failure (CHF) through 1 y. Results In backward-elimination models including all biomarkers, only the cTnI level was retained as a predictor of 1-y CHF (odds ratio [OR]: 1.017, 95% confidence interval [CI]: 1.001,1.034, p = 0.039). There were no predictors in terms of 1-y death, reinfarction, and composite endpoint. When we applied a simple score system, in which patients were categorized on the basis of the number of elevated biomarkers, the 1-y risks of death (p = 0.600), reinfarction (p = 0.185), and composite endpoint (p = 0.620) did not increase in proportion to the number of elevated biomarkers on admission. One-y CHF only tended to increase according to the number of elevated biomarkers (p = 0.067). Conclusions The use of cardiac biomarkers on admission, in each or in combination, had only a minimal impact for the prediction of long-term cardiovascular events after primary stenting in STEMI patients. Copyright © 2008 Wiley Periodicals, Inc. [source]

Factors Associated with Hospital Admission among Emergency Department Patients with Chronic Obstructive Pulmonary Disease Exacerbation

ACADEMIC EMERGENCY MEDICINE, Issue 1 2007
Chu-Lin Tsai MD
Abstract Objectives To determine the patient factors associated with hospital admission among adults who present to the emergency department (ED) with acute exacerbations of chronic obstructive pulmonary disease (COPD) and to determine whether admissions were concordant with recommendations in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Methods The authors performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. By using a standard protocol, consecutive ED patients with COPD exacerbation were interviewed, and their charts were reviewed. Predictors of admission were determined by multivariate logistic regression. Results Of 384 patients, 233 (61%; 95% confidence interval = 56% to 66%) were admitted. Multivariate analysis showed that a higher likelihood of admission was associated with older age, female gender, more pack-years of smoking, recent use of inhaled corticosteroid, self-reported activity limitation in the past 24 hours, higher respiratory rate at ED presentation, and a concomitant diagnosis of pneumonia. Patients who reported the ED as their usual site for problem COPD care, or who had mixed COPD and asthma, were less likely to be admitted. The authors confirmed five of the seven testable indications for hospital admission in the GOLD guidelines. Conclusions Several patient factors were independently associated with hospital admission among ED patients with COPD exacerbations. Overall, concordance with admission recommendations in the GOLD guidelines was high. The authors also identified a few novel predictors of admission (female gender, ED as the usual site for problem COPD care, mixed diagnosis of COPD and asthma, recent use of inhaled corticosteroid) that require replication in future studies. [source]

Surge Capacity Associated with Restrictions on Nonurgent Hospital Utilization and Expected Admissions during an Influenza Pandemic: Lessons from the Toronto Severe Acute Respiratory Syndrome Outbreak

ACADEMIC EMERGENCY MEDICINE, Issue 11 2006
Michael J. Schull MD
Background Current influenza pandemic models predict a surge in influenza-related hospitalizations in affected jurisdictions. One proposed strategy to increase hospital surge capacity is to restrict elective hospitalizations, yet the degree to which this measure would meet the anticipated is unknown. Objectives To compare the reduction in hospitalizations resulting from widespread nonurgent hospital admission restrictions during the Toronto severe acute respiratory syndrome (SARS) outbreak with the expected increase in admissions resulting from an influenza pandemic in Toronto. Methods The authors compared the expected influenza-related hospitalizations in the first eight weeks of a mild, moderate, or severe pandemic with the actual reduction in the number of hospital admissions in Toronto, Ontario, during the first eight weeks of the SARS-related restrictions. Results Influenza modeling for Toronto predicts that there will be 4,819, 8,032, or 11,245 influenza-related admissions in the first eight weeks of a mild, moderate, or severe pandemic, respectively. In the first eight weeks of SARS-related hospital admission restrictions, there were 3,654 fewer hospitalizations than expected in Toronto, representing a modest 12% decrease in the overall admission rate (a reduction of 1.40 admissions per 1,000 population). Therefore, influenza-related admissions could exceed the reduction in admissions resulting from restricted hospital utilization by 1,165 to 7,591 patient admissions, depending on pandemic severity, which corresponds to an excess of 0.44 to 2.91 influenza-related admissions per 1,000 population per eight weeks, and an increase of 4% to 25% in the overall number of admissions, when compared with nonpandemic conditions. Conclusions Pandemic modeling for Toronto suggests that influenza-related admissions would exceed the reduction in hospitalizations seen during SARS-related nonurgent hospital admission restrictions, even in a mild pandemic. Sufficient surge capacity in a pandemic will likely require the implementation of other measures, including possibly stricter implementation of hospital utilization restrictions. [source]

Incidence and characteristics of lower limb amputations in people with diabetes

DIABETIC MEDICINE, Issue 4 2009
S. Fosse
Abstract Aims To estimate the incidence, characteristics and potential causes of lower limb amputations in France. Methods Admissions with lower limb amputations were extracted from the 2003 French national hospital discharge database, which includes major diagnoses and procedures performed during hospital admissions. For each patient, diabetes was defined by its record in at least one admission with or without lower limb amputation in the 2002,2003 databases. Results In 2003, 17 551 admissions with lower limb amputation were recorded, involving 15 353 persons, which included 7955 people with diabetes. The crude incidence of lower limb amputation in people with diabetes was 378/100 000 (349/100 000 when excluding traumatic lower limb amputation). The sex and age standardized incidence was 12 times higher in people with than without diabetes (158 vs. 13/100 000). Renal complications and peripheral arterial disease and/or neuropathy were reported in, respectively, 30% and 95% of people with diabetes with lower limb amputation. Traumatic causes (excluding foot contusion) and bone diseases (excluding foot osteomyelitis) were reported in, respectively, 3% and 6% of people with diabetes and lower limb amputation, and were 5 and 13 times more frequent than in people without diabetes. Conclusions We provide a first national estimate of lower limb amputation in France. We highlight its major impact on people with diabetes and its close relationship with peripheral arterial disease/neuropathy and renal complications in the national hospital discharge database. We do not suggest the exclusion of traumatic causes when studying the epidemiology of lower limb amputation related to diabetes, as diabetes may contribute to amputation even when the first cause appears to be traumatic. [source]

In-patient management of diabetes mellitus and patient satisfaction

DIABETIC MEDICINE, Issue 5 2002
A. Bhattacharyya
Abstract Aims To devise a system for assessing in-patient glycaemic control and care satisfaction in diabetic patients admitted to hospital for reasons other than their diabetes. Methods Consecutive January to March 2001 case-notes were reviewed. Admissions with acute metabolic complications, acute myocardial infarction and pregestational or gestational diabetes were excluded. Glycaemic control, frequency of blood monitoring and management of hyperglycaemia were recorded. The diabetes treatment satisfaction questionnaire was used to assess preadmission satisfaction with care. Post-admission a 12-stem questionnaire was used to assess satisfaction with in-patient diabetes management. Results Hypoglycaemia was common. Although none developed a hyperglycaemic emergency, high blood glucose was prevalent and, frequently, persistent hyperglycaemia or recurrent hypoglycaemia was not acted on appropriately. The overall score for in-patient satisfaction with treatment was fair (4.1 ± 1.8 on a six-point scale; 6 = very satisfied and 1 = very dissatisfied). Scores were higher among patients on surgical wards than on medical wards (P = 0.008), but satisfaction did not vary when patients were stratified according to sex, age and mode of treatment. Conclusion Current systems are not achieving satisfactory in-patient glycaemic control and there is poor satisfaction with medical in-patient diabetes care. Following changes intended to produce improvements, this assessment system can be used recurrently to monitor in-patient care and satisfaction. [source]

Choosing the Student Body: Masculinity, Culture, and the Crisis of Medical School Admissions, 1920,1950

HISTORY OF EDUCATION QUARTERLY, Issue 2 2002
Charlotte G. Borst
First page of article [source]

Role of influenza and other respiratory viruses in admissions of adults to Canadian hospitals

INFLUENZA AND OTHER RESPIRATORY VIRUSES, Issue 1 2008
Dena L. Schanzer
Objective, We sought to estimate age-specific hospitalization rates attributed to influenza and other virus for adults. Methods, Admissions from Canada's national hospitalization database (Canadian Institute of Health Information), from 1994/95 to 1999/2000, were modeled as a function of proxy variables for influenza, respiratory syncytial virus (RSV) and other viral activity, seasonality and trend using a Poisson regression model and stratified by age group. Results, The average annual influenza-attributed hospitalization rate for all adults, 20 years of age or older, over the study period, which included three severe seasons, was an estimated 65/100 000 population (95% CI 63,67). Among persons aged 65 and over, 270,340 admissions per 100 000 population per year were attributed to influenza, while 30,110, 60,90 and 130,350 per 100 000 were attributed to RSV, parainfluenza (PIV) and other respiratory viruses, respectively. Although marked season-to-season variation in age-specific hospitalization rates attributable to influenza was observed in persons 50 years of age and older, increasing risk with age was preserved at all time periods. Conclusions, Influenza, RSV, PIV and other respiratory viruses were all associated with morbidity requiring hospitalization, while influenza was responsible for peak respiratory admissions. The burden of health care utilization associated with respiratory viruses is appreciable beginning in the sixth decade and increases significantly with age. [source]

Rates of Acute Care Admissions for Frail Older People Living with Met Versus Unmet Activity of Daily Living Needs

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2006
Laura P. Sands PhD
OBJECTIVES: To determine whether older people who do not have help for their activity of daily living (ADL) disabilities are at higher risk for acute care admissions and whether entry into a program that provides for these needs decreases this risk. DESIGN: A longitudinal cohort study. SETTING: Thirteen nationwide sites for the Program of All-inclusive Care for the Elderly (PACE). PACE provides comprehensive medical and long-term care to community-living older adults. PARTICIPANTS: Two thousand nine hundred forty-three PACE enrollees with one or more ADL dependencies. MEASUREMENTS: Unmet needs were defined as the absence of paid or unpaid assistance for ADL disabilities before PACE enrollment. Hospital admissions in the 6 months before PACE enrollment and acute admissions in the first 6 weeks and the 7th through 12th weeks after enrollment were determined. RESULTS: Those who lived with unmet ADL needs before enrollment were more likely to have a hospital admission before PACE enrollment (odds ratio (OR)=1.28, 95% confidence interval (CI)=1.01,1.63) and an acute admission in the first 6 weeks after enrollment (OR=1.45, 95% CI=1.00,2.09) but not after 6 weeks of receiving PACE services (OR=0.86, 95% CI=0.53,1.40). CONCLUSION: Frail older people who live without needed help for their ADL disabilities have higher rates of admissions while they are living with unmet ADL needs but not after their needs are met. With state governments under increasing pressure to develop fiscally feasible solutions for caring for disabled older people, it is important that they be aware of the potential health consequences of older adults living without needed ADL assistance. [source]