Dennis Tsilimingras

Addressing Postdischarge Adverse Events: A Neglected Area

BACKGROUND Postdischarge safety is an area that has long been neglected. Recent studies from the United States and Canada found that about one in five patients discharged home from the general internal medicine services of major teaching hospitals suffered an adverse event. METHODS MEDLINE, Cochrane databases, and reference lists of retrieved articles were used in a literature search of articles published from 1966 through May 2007. FINDINGS Patient safety research has focused mostly on adverse events in hospitalized patients. Although some data are available about the ambulatory setting, even fewer studies have been done focusing on adverse events following hospital discharge. Only two studies conducted in North America have examined the incidence rate of all types of postdischarge adverse events. On the basis of the available evidence, key areas of opportunity to improve postdischarge care are as follows: (1) improving transitional care, (2) improving information transfer through strategic use of electronic health records, (3) medication reconciliation, (4) improving follow-up of test results, and (5) using screening methods to identify patients with adverse events. DISCUSSION Limited evidence suggests that about one in five internal medicine patients suffers an adverse event after discharge from a North American hospital. The risk of postdischarge adverse events should be recognized by patient safety experts as an important area of concern.

Racial disparities in cardiovascular risk factors among diagnosed hypertensive subjects

Racial disparities in cardiovascular disease (CVD) have become a matter of national concern. We investigated racial disparities and trends in glycosylated hemoglobin, high-density lipoprotein (HDL), C-reactive protein, plasma homocysteine, albuminuria, and other risk factors among 4758 diagnosed hypertensive subjects age 18 years or older from the National Health and Nutrition Examination Survey, 1999-2006. Compared with non-Hispanic whites, Hispanics, and non-Hispanic blacks were more likely to have uncontrolled blood pressure (BP) (Hispanics odds ratio [OR]: 1.58, 95% confidence interval [CI]: 1.21-2.07; blacks OR: 1.42, 95% CI: 0.21-1.67), elevated glycosylated hemoglobin (Hispanics OR: 2.70, 95% CI: 1.89-3.87; blacks OR: 2.17, 95% CI: 1.70-2.77), albuminuria (Hispanics OR: 2.36, 95% CI: 1.71-3.27; blacks OR: 1.80, 95% CI: 1.47-2.20), and less likely to have central obesity (Hispanics OR: 0.68, 95% CI: 0.51-0.91; blacks OR: 0.70, 95% CI: 0.58-0.84). Blacks had lower risks of elevated serum cholesterol (OR: 0.81, 95% CI: 0.67-0.98) and low HDL (OR: 0.76, 95% CI: 0.61-0.94) than whites. The risk of high serum homocysteine was lower in Hispanics and higher in blacks compared with whites (Hispanics OR: 0.64, 95% CI: 0.46-0.90; blacks OR: 1.36, 95% CI: 1.14-1.63). These results highlight the need for targeted interventions to aggressively treat uncontrolled BP, elevated glycosylated hemoglobin in Hispanic and black hypertensive subjects, and high serum homocysteine in blacks, to reduce disparities in CVD risk factors and CVD-associated morbidity and mortality.

Microalbuminuria, macroalbuminuria and uncontrolled blood pressure among diagnosed hypertensive patients: the aspect of racial disparity in the NHANES study

Accumulating evidence reveals that albuminuria may exacerbate uncontrolled blood pressure (BP) in hypertensive patients. However, racial differences in the associations of albuminuria with uncontrolled BP among diagnosed hypertensives have not been evaluated. A total of 6147 diagnosed hypertensive subjects aged ⩾18 years were collected from the National Health and Nutrition Examination Survey 1999–2008 with stratified multistage sampling designs. Odds ratios (ORs), relative ORs and 95% confidence intervals (CIs) in uncontrolled BP, and the different effects of microalbuminuria and macroalbuminuria on continuous BP were estimated using weighted logistic models and linear regression models. Hypertensive subjects with microalbuminuria and macroalbuminuria were more likely to have uncontrolled BP and higher average systolic BP (SBP) in all individual racial groups. Microalbuminuria was associated with isolated uncontrolled SBP in non-Hispanic blacks and whites, and macroalbuminuria was associated with isolated uncontrolled SBP and diastolic BP (DBP) and high average DBP only in non-Hispanic blacks. Compared with non-Hispanic whites, non-Hispanic blacks and Mexicans had lower associations of microalbuminuria with uncontrolled BP (relative OR=0.68, 95% CI=0.48–0.97 for blacks vs whites; relative OR=0.62, 95% CI=0.42–0.93 for Mexicans vs. whites) and isolated uncontrolled SBP (relative OR=0.62, 95% CI=0.43–0.90 for blacks vs. whites; relative OR=0.45, 95% CI=0.29–0.71 for Mexicans vs. whites). The association of microalbuminuria with uncontrolled BP was lower in non-Hispanic blacks and Mexicans than in non-Hispanic whites. Health providers need to improve care for mildly elevated albumin excretion rates in non-Hispanic white hypertensive patients while maintaining the quality of care in non-Hispanic blacks and Mexicans.

Prevalence and changes of untreated isolated systolic hypertension among non-Hispanic black adults in the United States

Isolated systolic hypertension (ISH) is a growing health concern in the United States (US) black population. The stratified prevalence of untreated ISH has not been fully investigated in non-Hispanic blacks. Cross-sectional data on 4625 non-Hispanic blacks aged ⩾18 years were collected from the National Health and Nutrition Examination Survey 1999–2010, representing a probability sample of the US civilian noninstitutionalized black population. The 6-year prevalence of ISH and 95% confidence intervals (CIs) were estimated by conducting weighted frequency and logistic procedures. The prevalence of untreated ISH was 11.2% among non-Hispanic black adults in 1999–2010. Individuals who received lower education (high school or below) had higher prevalence of untreated ISH than those with higher education (12.8% (95% CI: 11.3–14.2%) vs. 9.0% (95% CI: 7.5–10.6%)). The prevalence of untreated ISH was higher in young men than in young women (4.3% (95% CI: 3.3–5.4%) vs. 1.8% (95% CI: 0.9–2.7%)), and higher in middle-aged adults with lower education than in middle-aged adults with higher education (14.1% (95% CI: 11.4–16.7%) vs. 7.7% (95% CI: 5.5–9.8%)). Compared with 1999–2004, the prevalence of untreated ISH in 2005–2010 decreased for old individuals (27.7% vs. 40.8%), old men (24.4% vs. 40.0%) and old individuals who received higher education (21.4% vs. 40.7%). Untreated ISH is more prevalent in old blacks, and significant reduction of the prevalence in this group suggests that public health interventions, lifestyle modifications or health awareness are in the right direction.

Post-Discharge Adverse Events Among Urban and Rural Patients of an Urban Community Hospital: A Prospective Cohort Study

ABSTRACTBACKGROUNDThere has been little research to examine post-discharge adverse events (AEs) in rural patients discharged from community hospitals.OBJECTIVEWe aimed to determine the rate of post-discharge AEs, classify the types of post-discharge AEs, and identify risk factors for post-discharge AEs in urban and rural patients.DESIGNThis was a prospective cohort study of patients at risk for post-discharge adverse events from December 2011 through October 2012.PATIENTSSix hundred and eighty-four patients who were under the care of hospitalist physicians and were being discharged home, spoke English, and could be contacted after discharge, were admitted to the medical service. Patients were stratified as urban/rural using zip code of residence. Rural patients were oversampled to ensure equal enrollment of urban and rural patients.MAIN MEASURESThe main outcome of the study was post-discharge AEs based on structured telephone interviews, health record review, and adjudication by two blinded, trained physicians using a previously established methodology.RESULTSOver 28 % of 684 patients experienced post-discharge AEs, most of which were either preventable or ameliorable. There was no difference in the incidence of post-discharge AEs in urban versus rural patients (ARR 1.04 95 % CI 0.82 -1.32 ), but post-discharge AEs were associated with hypertension, type 2 diabetes mellitus, and number of secondary discharge diagnoses only in urban patients.CONCLUSIONSPost-discharge AEs were common in both urban and rural patients and many were preventable or ameliorable. Potentially different risk factors for AEs in urban versus rural patients suggests the need for further research into the underlying causes. Different interventions may be required in urban versus rural patients to improve patient safety during transitions in care.

Postdischarge adverse events in the elderly.

Adverse events that occur after discharge from the hospital are a major public health concern that deservesmuchmore attention. During the last 2 decades, with the emergence ofmanaged care, there has been a progressive shortening of hospitalizations for patients. It is possible that elderly patients may be discharged from the hospital before they have fully recovered from their illness, with the accompanying potential to suffer adverse events. Recently, two studies conducted in theUnited States and Canada examined adverse events in patients discharged home from the general medicine services of major teaching hospitals. Although, these studies did not specifically examine a geriatric population, the United States study had a younger population (mean age, 57 years) and reported a 19% adverse event incidence rate compared with the Canadian study, which had an older population (mean age, 71 years) and reported a 23% adverse event incidence rate. These rates are approximately 5 to 6 times higher than the in-hospital adverse event incidence rates that were reported by the Harvard and the Utah and ColoradoMedical Practice Studies. Thus, adverse events seem to bemore likely to occur after hospital discharge, and as patients age, the rate of postdischarge adverse events is likely to increase. The scientific rationale for the occurrence of these postdischarge adverse events has been linked to discontinuities in care. Discontinuities or gaps in care occur in complex systems, such as the health care system, which involve the interaction of numerous professionals.8,9 The interdependency of health care activity and complexitywithin systems increases the potential for error, especiallywhenmultiple and expedient handoffs are necessary. The system of care may be most vulnerable at transitions, with discontinuities in care arising mainly from poor information transfer and faulty communication. Instances of poor information transfer and faulty communication occur at numerous points in the continuum of care, such as between inpatient and outpatient pharmacies, as a result of unstructured physician discharge summaries and unstructured cross-coverage physician sign-outs, during the discharge planning process and in follow-up of abnormal laboratory test results. The most common types of adverse events identified in the United States and Canadian studies within 3 to 4 weeks after hospital discharge were due to medications (66%Y72%), procedures (7%Y17%), therapeutic errors (16%), nosocomial infections (5%Y11%), pressure ulcers (7%), diagnostic errors (6%), and falls (2%Y4%). In these studies, approximately one-third of these adverse events were preventable (an adverse event injury that could have been avoided as a result of an error or a system design flaw), and another third were ameliorable (an injury whose severity could have been substantially reduced if different actions or procedures had been performed or followed). Twenty-five to thirty percent of adverse events in these studies were associated with a nonpermanent disability, 3% resulted in permanent disabilities, and 3% resulted in death. Of the adverse events resulting in at least a nonpermanent disability, 48% were preventable, and 24% were ameliorable. Also within 3 to 4 weeks after hospital discharge, 9% to 21% of patients in these studies had an additional physician visit, 5% required laboratory monitoring in addition to their physician care, 11% to 12% had an emergency department visit, and 17% to 24% had a hospital readmission. Thus, postdischarge adverse events may lead to serious disability or even death, and most are either preventable or ameliorable. Geriatric syndromes such as falls, delirium, pressure ulcers, and underfeeding have often been viewed as preventable adverse events that may occur in the elderly during transitions of care. For example, the United States study noted above reported 2 of 3 falls experienced by postdischarge patients as preventable. If these geriatric syndromes are to be viewed as preventable adverse events, then their prevention will require a systems-based approach to care. Geriatricians have made substantial efforts to improve systems of care for the elderly by developing innovative management programs. Examples of geriatric management programs include Acute Care for the Elderly units, Delirium Intensive Care, and Delirium and Falls teams, EDITORIAL

The association of post-discharge adverse events with timely follow-up visits after hospital discharge

Objective There has been little research to examine the association of post-discharge adverse events (AEs) with timely follow-up visits after hospital discharge. We aimed to examine whether having a timely follow-up outpatient visit would reduce the risk for post-discharge AEs. Methods This was a methods study of patients at risk for post-discharge AEs from December 2011 through October 2012. Five hundred and forty-five patients who were under the care of hospitalist physicians and were discharged home from a community hospital, spoke English, and could be contacted after discharge were evaluated. The aim of the study was to examine the association of post-discharge AEs with timely follow-up visits after hospital discharge based on structured telephone interviews, health record review, and adjudication by two blinded, trained physicians using a previously established methodology. Results We observed a higher incidence of AEs with patients that had their first follow-up visit within 7 days after hospital discharge (33.5% vs. 23.0%, p = 0.007). This effect was attenuated somewhat but remained significant when adjusted for several patient factors (adjusted OR 1.33, 95% confidence interval 1.16–2.71). Conclusion This observational study paradoxically showed an increase in post-discharge AEs with early follow-up, likely a result of confounding by indication and/or information bias that could not be completely adjusted for. This study illustrates the potential hazards with conducting observational studies to determine the efficacy of various transitional care interventions, such as early follow-up, where risk for confounding by indication is high.

POSTDISCHARGE ADVERSE EVENTS AND REHOSPITALIZATIONS

n 5 465), and obese (BMI 30.0 kg/m, n 5 52). A disability score (mean of physical function scale of RAND-36 shown to reflect mobility disability well) was calculated for each weight-change group and BMI category. On the physical function scale, a higher score reflects better function (less disability). The data were analyzed using Number Crunching Statistical System software (http://www.ncss.com) and adjusted for age, smoking, and comorbidities in 2000 (cardiovascular diseases, cancer, diabetes mellitus, musculoskeletal diseases, chronic obstructive pulmonary disease).

Racial/ethnic disparity in the associations of smoking status with uncontrolled hypertension subtypes among hypertensive subjects

Background Racial/ethnic differences in the associations of smoking with uncontrolled blood pressure (BP) and its subtypes (isolated uncontrolled systolic BP (SBP), uncontrolled systolic-diastolic BP, and isolated uncontrolled diastolic BP (DBP)) have not been investigated among diagnosed hypertensive subjects. Methods A sample of 7,586 hypertensive patients aged ≥18 years were selected from the National Health and Nutrition Examination Survey 1999–2010. Race/ethnicity was classified into Hispanic, non-Hispanic white, and non-Hispanic black. Smoking was categorized as never smoking, ex-smoking, and current smoking. Uncontrolled BP was determined as SBP≥140 or DBP≥90 mm Hg. Isolated uncontrolled SBP was defined as SBP≥140 and DBP<90 mm Hg, uncontrolled SDBP as SBP≥140 and DBP≥90 mm Hg, and isolated uncontrolled DBP as SBP<140 and DBP≥90 mm Hg. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of uncontrolled BP and its subtypes were calculated using weighted logistic regression models. Results The interaction effect of race and smoking was significant after adjustment for the full potential confounding covariates (Adjusted p = 0.0412). Compared to never smokers, current smokers were 29% less likely to have uncontrolled BP in non-Hispanic whites (OR = 0.71, 95% CI = 0.56–0.90), although the likelihood for uncontrolled BP is the same for smokers and never smokers in Hispanics and non-Hispanic blacks. Current smokers were 26% less likely than never smokers to have isolated uncontrolled SBP in non-Hispanic whites (OR = 0.74, 95% CI = 0.58–0.95). However, current smoking is associated with an increased likelihood of uncontrolled systolic-diastolic BP in non-Hispanic blacks, and current smokers in this group were 70% more likely to have uncontrolled systolic-diastolic BP than never smokers (OR = 1.70, 95% CI = 1.10–2.65). Conclusion The associations between current smoking and uncontrolled BP differed over race/ethnicity. Health practitioners may need to be especially vigilant with non-Hispanic black smokers with diagnosed hypertension.

Racial Disparity in the Associations of Microalbuminuria and Macroalbuminuria with Odds of Hypertension: Results from the NHANES Study in the United States

Background. Limited information is available on whether the associations of microalbuminuria and macroalbuminuria with the odds of hypertension differ among non-Hispanic Whites, non-Hispanic Blacks, and Hispanics. Methods. Cross-sectional data of 24,949 participants aged ≥18 years were collected from the National Health and Nutrition Examination Survey (NHANES) 1999–2008. Odds ratios of hypertension for microalbuminuria and macroalbuminuria were estimated by conducting weighted multiple logistic regression models. Results. After adjustment for extensive confounding factors, microalbuminuria is 1.45 (95% confidence interval (CI) [1.17, 1.80]), 2.07 (95% CI [1.52, 2.83]) and 2.81 (95% CI [2.06, 3.84]) times more likely to be associated with hypertension, and macroalbuminuria is 4.08 (95% CI [1.98, 8.38]), 8.62 (95% CI [3.84, 19.35]), and 4.43 (95% CI [2.13, 9.21]) times in non-Hispanic Whites, non-Hispanic Blacks, and Hispanics, respectively. The odds of hypertension for microalbuminuria (versus normalbuminuria) were 52% higher in non-Hispanic Blacks and 98% higher in Hispanics than in non-Hispanic Whites; the odds of hypertension for macroalbuminuria (versus normalbuminuria) did not differ among racial groups. Conclusion. Racial differences in the relation between microalbuminuria and hypertension are prevalent among non-Hispanic Whites, non-Hispanic Blacks, and Hispanics. More screening efforts should be encouraged in normotensive non-Hispanic Blacks and Hispanics with microalbuminuria.