Hospital practice (1995)最新文献

Objectives: Complex logistics, geographical distance, and waiting times compromise compliance and outcomes for patients with type 1 diabetes (T1D) in Greece. We evaluated guideline adherence of diabetologists and associated costs to outline the rationale for launching an integrated center with an interdisciplinary team, telemedicine, and continuous provider training.

Methods: An expert panel of diabetologists was invited to complete an anonymous survey on routine care of patients aged 18-50 with no major complications. The survey explored (1) guideline adherence and laboratory monitoring, (2) referrals and availability, and (3) perspectives on an integrated center. Annual laboratory costs per patient per provider were estimated and compared with guideline predictions.

Results: Seventeen experts completed the survey, representing over 60% of non-integrated diabetes centers. A high annual cost was estimated [median 183.22 euros vs. 94.8 indicated by guidelines, p = 0.033, 95% CI (77.06, 232.14)]. Most experts reported no telemedicine availability and viewed an integrated center as an effective healthcare improvement.

Conclusion: Our study identified increased costs, limited availability, and lack of remote monitoring, suggesting a centralized approach could reduce costs, streamline referrals, and improve care quality. However, these preliminary findings should be interpreted cautiously due to the small sample size.

Objective: Hospital settings may influence outcomes and resource utilization in end-stage kidney disease (ESKD) patients receiving peritoneal dialysis (PD). However, data on PD outcomes across hospital settings remain limited. This study aims to evaluate characteristics, in-hospital treatments, complications, and healthcare costs for PD patients in urban teaching, urban non-teaching, and rural hospitals across the United States.

Methods: We conducted a cohort study using the National Inpatient Sample database in the United States from 2003 to 2018. Multivariable logistic and linear regression models were employed to compare in-hospital treatment outcomes, mortality, and healthcare costs across hospital settings, adjusting for demographics, comorbidities, and hospital characteristics.

Results: A total of 99,528 hospitalized ESKD patients receiving PD were included. Among these patients, 60,833 (61%) were in urban teaching hospitals, 32,714 (33%) in urban non-teaching hospitals, and 5,981 (6%) were in rural hospitals. In multivariable analysis, patients in urban non-teaching hospitals had lower risk of PD catheter adjustments (OR 0.81, 95% CI 0.68-0.97), hyperkalemia (OR 0.85, 95% CI 0.76-0.95), metabolic acidosis (OR 0.69, 95% CI 0.61-0.78), volume overload (OR 0.82, 95% CI 0.71-0.95), and mortality (OR 0.76, 95% CI 0.63-0.93) but higher risk of PD peritonitis (OR 1.25, 95% CI 1.15-1.36), and sepsis (OR 1.13, 95% CI 1.03-1.24), compared with urban teaching hospitals. Meanwhile, patients in rural hospitals had a lower risk of metabolic acidosis (OR 0.84, 95% CI 0.79-0.90) and volume overload (OR 0.82, 95% CI 0.76-0.89) but higher need for hemodialysis (OR 1.12, 95% CI 1.06-1.19), and risk of PD peritonitis (OR 1.18, 95% CI 1.13-1.24). Urban non-teaching and rural care were associated with lower hospitalization length of stays by 1.5 and 0.5 days and costs by $31632 and $10376, respectively.

Conclusion: Rural and urban non-teaching hospitals experienced fewer metabolic complications and less volume overload but faced higher rates of PD-related peritonitis compared to urban teaching hospitals. These findings highlight clinical and economic differences in PD across hospital settings in the United States and crucial strategies for personalizing PD care and optimize resources. Future research should explore system-level interventions to enhance PD delivery in diverse healthcare settings.

Objectives: Ruxolitinib, a Janus kinase (JAK) inhibitor, can lead to severe ruxolitinib discontinuation syndrome (RDS) upon abrupt cessation in myelofibrosis (MF). Pacritinib, a selective JAK2/IRAK1 inhibitor with minimal JAK1 inhibition, offers an alternative, particularly for patients with thrombocytopenia. This case report presents our experience of successfully switching from ruxolitinib to pacritinib in patients with MF and severe RDS.

Case presentation: Three males in their early 20s, 60s, and 70s of Arab ethnicity presented with diverse clinical presentations, including post-polycythemia vera MF, primary MF, and primary triple-negative MF with multiple comorbidities. Ruxolitinib discontinuation was carefully managed through gradual tapering, concurrent corticosteroid administration, and pacritinib initiation, effectively preventing withdrawal syndrome. All patients demonstrated significant clinical improvements with pacritinib. Notable outcomes included reductions in spleen size (ranging from 7 to 8 cm within 1-6 months), stabilization or improvement in hematologic parameters, and resolution of transfusion dependency in previously transfusion-dependent cases. One patient achieved transfusion independence within six months of treatment, while another exhibited marked symptom relief and improved quality of life within one month. Adverse events, including gastrointestinal symptoms, weight loss, and transient voice changes, were manageable through dose adjustments and supportive care, enabling continued therapy.

Conclusion: Our cases contribute to the growing body of evidence supporting pacritinib's role in the evolving treatment landscape of MF.

Objective: Pharmacologic thrombolytic treatment for acute ischemic stroke has primarily been managed by intravenous alteplase. Tenecteplase is a variant that has been shown to be non-inferior to alteplase in clinical trials. In this study, we present a real-world assessment of patient outcomes with the facility-wide transition to the use of tenecteplase versus altepase for acute ischemic stroke in a large system of community hospitals in the United States.

Methods: This retrospective analysis assessed adult patients who received either alteplase or tenecteplase between 1 April 2020 and 31 March 2023. Propensity matching was used to estimate the covariate-adjusted association with outcomes of discharge expired/hospice, intracranial hemorrhage and readmission to a facility in the same healthcare system within 30, 60, or 90 days.

Results: Among 12,766 patients, gross mortality was 7.6% (n = 285) with tenecteplase and 8.2% (n = 739) with alteplase (p = 0.314); intracranial hemorrhage was 2.4% with either. The propensity match analysis found that the relative risk of mortality/hospice for patients given tenecteplase versus alteplase was 0.993 (95% CI: 0.848-1.162, p = 1.000). When limited to five facilities with the highest volume of thrombolytic use, there were no significant differences in outcomes. While the time from emergency department arrival to thrombolytic administration (door-to-needle) was shorter among patients receiving tenecteplase, there was no significant difference in the odds of mortality based on door-to-needle time.

Conclusion: In alignment with previous studies, these findings demonstrate the lack of potential harm with a transition from alteplase to tenecteplase in clinical practice for acute ischemic stroke patients treated in community hospitals.

Background: While hospitalists play a central role in inpatient care, the association between years of hospitalist experience and patient outcomes remains unclear. This study examined whether hospitalist experience is linked to clinical outcomes, including readmission rates, inpatient mortality, and patient satisfaction scores within a single academic medical center.

Methods: We conducted a retrospective cohort study of 59 hospitalists and 22,098 patient discharges between May and December 2023. Hospitalist experience was grouped as <2 years, 2-5 years, and >5 years. Patient data were extracted from the EPIC Clarity database. Outcomes included length of stay (LOS), 72-hour and 30-day readmissions, inpatient mortality, and patient satisfaction. Unadjusted regression models with provider-level random effects evaluated associations between hospitalist experience and outcomes.

Results: Among 14,804 unique patients, the mean LOS was 5.16 ± 8.15 days, with a 30-day readmission rate of 13.7% and inpatient mortality of 10.8%. Patient satisfaction scores averaged 8.7/10. Hospitalists with >5 years of experience had significantly shorter LOS (-0.67 days; 95% CI: -1.24 to -0.10; p <0.05) compared to those with ≤5 years. No significant associations were observed between hospitalist experience and readmissions, mortality, or satisfaction scores.

Conclusions: Greater hospitalist experience is associated with reduced length of stay, but is not associated with readmission rates, inpatient mortality, or patient satisfaction scores. Future longitudinal, multi-institutional studies are warranted to better understand the relationship between hospitalist experience and diverse performance metrics.

Objectives: In acutely admitted patients, comorbidities, and other patient characteristics known at admission might be risk factors for physiological deterioration during hospitalization. Knowledge of specific risk factors could therefore help clinicians escalate or decrease monitoring practices for selected patient categories. We investigated the association between information obtained at admission and the risk of subsequent severe vital signs deviations in acutely admitted medical patients.

Methods: We analyzed data from three clinical trials using continuous monitoring of vital signs in adults during acute medical hospitalizations. The primary exposure variable was number of comorbidities and were obtained from the medical record along with other potential risk factors at the time of admission. The primary outcome was cumulated duration of severe vital sign deviations (SpO2 < 85%, respiratory rate ≤5 min^-1 or > 24 min^-1, heart rate < 30 min^-1 or > 130 min^-1, or systolic blood pressure < 91 mmHg or > 219 mmHg).

Results: We included data from 553 patients (51% female, median age 72 years), of whom 96% were admitted with respiratory symptoms. Patients with two or more comorbidities had severe vital sign deviations lasting 145 minutes/24 hours as compared with 90 minutes/24 hours in patients with none or one comorbidity, p = 0.07. Patients with severe tachypnea upon arrival ( > 30 brpm) had long duration of deviations (241 minutes per 24 hours [IQR 132;421]) as well as patients with increased CRP > 100 mg/L whose durations of deviations were 175 minutes per 24 hours [IQR 60;339].

Conclusion:  Comorbidity burden, tachypnea, and increased level of CRP upon arrival were to some extent risk factors for subsequent vital sign deviations. Information obtained at acute admissions can be useful in establishing and escalating patient monitoring level.

Background: There is a growing need to provide care for people approaching their end-of-life phase. A fast-track pathway was developed in the UK to speed up funding of care for people expected to die within 3 months. However, the accuracy of doctors' prediction of death is variable.

Aim: To investigate the accuracy of doctors' prediction of death for patients referred to the fast-track pathway and explore clinical criteria predicting early death.

Methods: A retrospective audit of hospitalized patients referred to the fast-track pathway was conducted. Patients were followed up from the date of referral to the date of death. The percentage of patients who died within 3 months was calculated. We compared clinical criteria for patients who died within the first 2 weeks to patients who died later. Multiple logistic regression analysis was performed to identify predictors of death ≤7 days and ≤14 days.

Results: A total of 185 patients were referred to the fast-track pathway. Mean (SD) age was 81.1 (10.2) years, and the majority were females (n = 101; 54.6%). Most patients (n = 169; 91.4%) died within 3 months. Almost half of the patients (n = 84; 46%) died within 2 weeks. For death ≤7 days, predictors were age >85 years, odds ratio (OR) 1.9, 95% confidence interval (CI) 1.1 to 3.6, p = 0.004, and admission with sepsis or acute organ failure, 2.8 (1.2 to 5.7), p = 0.03 and 2.6 (1.1 to 8.1), p = 0.03, respectively. For death ≤14 days, predictors were age >85 years, 2.4 (1.3 to 4.5), p = 0.006, living in care home, 2.7 (1.3 to 5.8), p = 0.01, diagnosis of dementia, 1.7 (1.1 to 3.9), p = 0.04, and admission with sepsis or acute organ failure, 2.1 (1.2 to 5.6), p = 0.03 and 2.1 (1.0 to 8.9), p = 0.01, respectively.

Conclusion: Doctors' prediction of death was good. Significant number of patients died early, especially very old patients with dementia, care home residents, and those presenting with sepsis or acute organ failure.

Objectives: We aim to determine the frequency and causes of hospitalizations prior to an admission with a diagnosis of pulmonary embolism (PE).

Methods: We conducted a retrospective cohort study using the United States National Readmission Database (NRD) from 2018 to 2020 to evaluate hospitalizations with a primary diagnosis of PE and in-hospital outcomes. We identified the number and causes of hospital admissions occurring within the 30 days preceding the PE hospitalization. Factors associated with prior hospitalization and in-hospital mortality during PE admission were examined. This analysis describes the characteristics of PE patients with prior hospitalization but does not assess risk.

Results: A total of 2,651,870 hospital admissions for PE were included in the analysis, of which 16.3% (n = 431,700) had a prior hospitalization within the preceding 30 days. The most common reason for prior admission was sepsis (10.9%). Other notable but less frequent causes included orthopedic conditions associated with reduced mobility, cancer, and cardiovascular diseases. The strongest predictor of prior hospitalization was elective admission (OR 2.89, 95% CI 2.82-2.95). Additional factors associated with increased odds of prior hospitalization included cancer (OR 1.60, 95% CI 1.57-1.63), prior myocardial infarction (OR 1.24, 95% CI 1.20-1.28), and diabetes mellitus (OR 1.19, 95% CI 1.17-1.21). Prior hospitalization was associated with increased odds of in-hospital mortality during the PE admission (OR 1.95, 95% CI 1.89-2.00).

Conclusions: Approximately one in six patients admitted with PE had a hospitalization in the preceding 30 days, and these patients experienced higher in-hospital mortality. Common reasons for prior admissions included sepsis, orthopedic conditions related to immobility, cancer, and cardiovascular disease.

Background: Patients with chronic kidney disease often struggle to control clinical symptoms and need help from the healthcare team. This study aimed to develop a proactive care model for stage 4-5 chronic kidney disease patients and investigate its effectiveness on their clinical outcomes and quality of life in Thailand.

Methods: The study was a comprehensive, collaborative effort conducted in North Thailand involving a multidisciplinary team of healthcare professionals. This team, which included physicians, professional nurses, pharmacists, and nutritionists from the Chronic Kidney Disease Clinic at a secondary hospital, worked together to develop and implement a proactive care model for stage 4-5 chronic kidney disease patients. The research instruments used were a proactive care model for CKD stages 4-5 patients, the clinical outcomes assessment form, and the Kidney Disease Quality of Life Short Form. Quantitative data were analyzed using descriptive statistics, Chi-Square, and dependent t-tests, while qualitative data were analyzed using content analysis.

Results: The proactive care model for patients with chronic kidney disease stage 4-5 consists of 1) a multidisciplinary team providing chronic kidney disease standards, 2) providing knowledge and counseling for behavior change, and 3) supporting self-management of patients with chronic kidney disease. After the experiment, mean systolic blood pressure, diastolic blood pressure, and mean potassium were significantly lower than before, and Hematocrit significantly increased. In contrast, glomerular rate, fasting blood sugar, and hemoglobin A1C did not change after the intervention compared to before (p > .05). After the experiment, patients' overall quality of life significantly increased.

Conclusions: This study demonstrated that the proactive care model for Chronic Kidney Disease stage 4-5 patients significantly improved clinical outcomes and profoundly impacted quality of life. Therefore, all components of the proactive care model should be applied, including working as a multidisciplinary team and helping patients adjust their behaviors and manage their health.