Abstract 13658: Factors Associated With the Unnecessary Continuation of Cardiac Telemetry Through Discharge

Background: Inpatient cardiac telemetry remains over-utilized. Even when ordered judiciously, telemetry may be unnecessarily continued through discharge, adding cost, complexity, and inconvenience to care. Objective: To determine the rate of continuation of cardiac telemetry through time of hospital discharge, and the factors associated with its prolonged use. Methods: We analyzed 37,779 telemetry admissions between January 1 and December 31, 2019 at a 6-hospital healthcare system in the Chicago metropolitan area. We sought to evaluate whether hospital setting, location at time of telemetry order, ICU admission, major diagnostic category, cardiology consultation, or discharge disposition affected telemetry continuation through discharge. Results: In total, 47.1% of all telemetry admissions retained an active telemetry order through hospital discharge. The median and mean durations on telemetry were 71 hours and 101 hours, respectively. Patients admitted to a community hospital, hospitalized with a cardiac-related Medicare Severity-Diagnosis Related Group (MS-DRG), consulted on by cardiology, started on telemetry in the cardiac catheterization lab, or discharged home were more likely to be continued on telemetry through discharge. Odds ratios are shown in the figure, with an odds ratio > 1 indicating increased likelihood of being continued on telemetry through time of discharge. Conclusions: Once started on cardiac telemetry, nearly half of all patients remained on telemetry until discharge. Those with substantial cardiovascular-related care - as evidenced by procedure in the catheterization lab, cardiology consultation, or a cardiac MS-DRG - were more likely to be continued on telemetry through discharge. Quality improvement interventions aiming to reduce telemetry duration should focus on strengthening daily reviews of telemetry need, perhaps leveraging the electronic health record to link telemetry indications and duration.

Frequency and patient attributes associated with ED visits within 30 days after discharge

Background About 20%-25% of patients return to the emergency department (ED) within 30 days after inpatient discharge. This outcome is relevant since it may signal failures in inpatient care and care transitions. However, literature on the topic is still scarce. Our study aims to describe frequency and patient attributes associated with ED visits within 30 days (30d) of inpatient discharge in one public Portuguese hospital. Methods The study included adult patients discharged in 2016. Admissions of deceased or transferred patients were excluded. The rate of 30d ED visits after discharge was computed for selected patient (gender and age) and admission attributes [urgent, Major Diagnostic Category (MDC)]. Number of days from discharge to ED visit was determined. Logistic regression was used to compute crude and age-gender adjusted odds-ratios (cOR, aOR) for each selected admission attribute. Results From the 21744 admissions included (median age: 58y; 40% male), for 5058 there was at least one ED visit within 30d after discharge (23%). The majority of ED visits were triaged urgent (n = 2286; 45%) or very urgent (n = 1499; 30%). Time to first ED visit was, on average, 11 days. The risk of ED visit was increased among men (cOR = 1.180; 95% confidence interval - 95%CI: 1.103-1.262) and patients aged 75 or older (cOR = 1.704; 95%CI: 1.557-1.866). After controlling for gender and age differences, admissions with mental diseases (aOR = 1.807; 95%CI: 1.452-2.247), respiratory diseases (aOR = 1.786; 95%CI: 1.535-2.078), endocrine diseases (aOR = 1.758; 95%CI: 1.374-2.250) showed increased risk of visiting ED after discharge. Conclusions ED visits after inpatient discharge are frequent and mostly due to urgent and very urgent needs. Older age, mental, respiratory and endocrine conditions are relevant patient risk factors for returning hospital for ED care shortly after discharge. Key messages Improved quality of inpatient care and care transitions that reduce ED visits after discharge may benefit a significant part of patients. Future initiatives to reduce adverse events after discharge may target patients with older age or with mental conditions.

Describing Serbian Hospital Activity Using Australian Refined Diagnosis Related Groups: A Case Study in Vojvodina Province

Introduction AR-DRG system for classification hospital episodes was implemented in Serbia to improve efficiency and transparency in the health system. Methods L3H3, IQR, and 10th–95th percentile methods were used to identify outlier episodes in the classification. Classification efficiency and within-group homogeneity were measured by an adjusted reduction in variance (R2) and a coefficient of variation (CV). Results There were 246,131 hospital episodes with a total 1,651,913 bed days from 14 hospitals. All episodes were classified into 652 groups of which 441 had CV lower than 100%. “Medical groups” accounted for 51% of groups and for 72% of episodes. Chemotherapy and vaginal delivery were the highest volume groups, with 5% and 4% of total episodes. Major diagnostic category 6 (MDC 6, Diseases of the digestive system) was the highest volume MDC, accounting for 11% of episodes. “Day-cases” and “prolonged hospitalisation” accounted for 21% and 3% of episodes, respectively. The average length of stay varied from 5.6 to 8.2 days. Adjusted R2 was 0.3 for untrimmed data. Trimming by L3H3, IQR, and 10th–95th percentile method improved the value of adjusted R2 to 0.61, 0.49, and 0.51, identifying 24%, 7%, and 7% of total cases as outliers, respectively. Mental diseases (MDC 19) remained the lowest adjusted R2 in untrimmed and trimmed datasets. Conclusion A long length of stay and a small percentage of “day-cases” characterized hospital activity in Vojvodina. Trimming methods significantly improved DRG efficiency. Future studies should consider cost data.

Prevalence of HIV Status and CD4 Counts in a Surgical Cohort: Their Relationship to Clinical Outcome

INTRODUCTION HIV positivity alone as a predictor of surgical outcome has not been extensively studied in regions of high prevalence. The aim was to determine the prevalence of HIV infection in surgical patients, and compare differences in their clinical course based on their serological status and CD4 counts. PATIENTS AND METHODS A prospective cohort of 350 patients, enrolled over 6 weeks, were studied. HIV status was determined in all patients. HIV-positive patients had CD4 counts. Clinical details were collated with HIV data after completion of enrolment. RESULTS Of the 350 patients, all but 6 were black South Africans. The median age was 31 years (range, 18–82 years). There were 143 trauma and 207 non-trauma patients. The male:female ratio was 1.4:1. The overall HIV seropositivity rate was 39% (females, 46%; males, 36%). Overall, 228 patients had surgical intervention and 96 patients had drainage of sepsis. The hospital stay (HIV negative, 11.9 ± 15.9 days; HIV positive, 11.0 ± 15 days) and mortality (HIV positive, 3.6%; HIV negative, 3.7%) did not differ by major diagnostic category. For HIV-positive patients, the male:female ratio was 1.2:1. There were 54 trauma and 83 non-trauma patients. An operation for the drainage of a septic focus was commoner in the HIV-positive admissions. Thirty-two (24%) patients had CD4 counts less than 200 cells/mm3, (i.e. AIDS). The hospital mortality, hospital stay and severity of sepsis were not related to CD4 counts. CONCLUSIONS HIV status does not influence the outcome of general surgical admissions and should not influence surgical management decisions. In HIV-positive surgical patients, CD4 counts have no relation to in-hospital outcome in a heterogeneous group of surgical patients.

Using endoscopic procedures forAN-DRG assignment:Australia leads the way

The study reported in this article sought to develop Australian National Diagnosis Related Groups (AN-DRGs) using endoscopic procedures in Major Diagnostic Category (MDC) 6 (Digestive System) and MDC 7 (Hepatobiliary System and Pancreas) through statistical analysis of the Australian Casemix Clinical Committee's recommendations. Five ANOVA were undertaken on final recommendations for gastroscopy and colonoscopy in MDC 6. The Reduction in Variance (RIV) for the AN-DRGs in version 3 relative to version 2 increased by up to 14.6%, representing RIV of between 25.28% to 32.30%. For all ANOVAs, F>100, alpha < .0001, Coefficient of Variation (CV) was generally lower in version 3 by between 0.4% to 22.9%, except for AN-DRGs for other gastroscopy for major gastro-intestinal disease, which increased by 8.7%. Two ANOVA for Endoscopic Retrograde Cholangio-pancreatography Procedures (ERCP) recommendations resulted in RIV of up to 18.67%, F>100, alpha <- .0001 and CV up to 0.8091. MDC 6, in AN-DRG versions 3 and 3.1, has 11 AN-DRGs following the surgical hierarchy involving gastroscopy and colonoscopy. Patients assigned will not have an operating room procedure; they will have anon-operating room procedure that is either a complex therapeutic or other(diagnostic or therapeutic) procedure. Similar AN-DRGs are in MDC 7 for ERCP. Version 3.1 has expanded the definition of Common Bile Duct Exploration (CDE) to include ERCP. There is no separate AN-DRG for laparoscopy cholecystectomy.

Revising Diagnosis-Related Groups for Neonates

Groups of neonates who are usually treated at hospitals that provide specialized pediatric care are not adequately classified by the use of diagnosis-related groups (DRGs). Therefore, a set of revised DRGs, pediatric modified DRGs (PM-DRGs), have been developed. Use of PM-DRGs substantially improves the classification of neonates in the following ways: a single pediatric modified major diagnostic category has been defined to include only and all neonates (patients younger than 29 days of age when admitted to the hospital); deaths and transfers of newborns are no longer combined into a single group; birth weight (rather than diagnosis) is used as the primary variable to differentiate categories of neonates; and duration of mechanical ventilation, presence of major problems, and surgery are used to define specific PM-DRGs. A total of 46 PM-DRGs have been developed to replace the 7 DRGs for neonates. Based on a sample of discharged patients from 13 children's hospitals, the overall variance reduction in duration of stay for neonates using PM-DRGs was 38.7% compared with 20.4% for DRGs. Variance reduction for PM-DRGs was 45.9% compared with 16.3% for DRGs when operating cost per case was used instead of duration of stay. After removing outliers at 150 days, the duration of stay variance reduction was 53.3% vs 23.6%, respectively, and the operating cost variance reduction was 58.8% vs 17.8%, respectively.

A Comparison of the Resource Intensity of Inpatients in Urban and Rural Nonteaching Hospitals

PL 98–21 mandated a prospective payment system based on diagnosis related groups (DRGs) for all Medicare inpatients. The predetermined payment for each DRG is intended to reflect the resources used to treat patients within the DRG. Eventually, the system will allow for one payment level for each DRG in rural hospitals and a higher payment level for the same DRG in urban hospitals. This represents an equitable approach, provided there is not a predominance of high severity cases in rural hospitals and that higher costs in urban hospitals are reflective of higher priced exogenous factors beyond the control of the hospital. Equitability also requires that DRGs capture the resource intensity of treatment for a given classification of patients, equally for urban and rural patients. This work compares the pediatric population of urban hospitals without a pediatric residency program with that of rural hospitals in terms of major diagnostic category, DRG, disease severity, length of stay, and charges. It also compares the capacity of DRGs to explain the variation in resource consumption in urban and rural hospitals. A sample of 116,721 discharges from 130 urban hospitals and a sample of 54,073 discharges from 97 rural hospitals are used in this work. The results indicate that there is no difference in the patient populations of these two hospital groups. The results also indicate that DRGs explain only 50 percent of the variance in the resource variables, but this obtains equally for both populations.

Psychiatric morbidity among West Africans and West Indians living in London

synopsisAll West Africans and West Indians living in Camberwell who made a psychiatric contact between 1 January 1965 and 31 December 1968 were selected using the Camberwell Psychiatric Register as a sampling frame. Inception rates of psychiatric illness were then calculated using the 1966 10% census figures for West Africans and West Indians in Camberwell. The rates found were compared to those among the British living in Camberwell. For each major diagnostic category, with the exception of reactive depression and paranoid states, the inception rates are significantly higher among West Africans than West Indians. They are also significantly higher among West Indians than the British. However, the differences in inception rates are generally greater between West Africans and West Indians than between the latter and the British.