Jennifer S. Albrecht

Healthcare-Associated Infection and Hospital Readmission

OBJECTIVE Hospital readmissions are a current target of initiatives to reduce healthcare costs. This study quantified the association between having a clinical culture positive for 1 of 3 prevalent hospital-associated organisms and time to hospital readmission. DESIGN Retrospective cohort study. PATIENTS AND SETTING Adults admitted to an academic, tertiary care referral center from January 1, 2001, through December 31, 2008. METHODS The primary exposure of interest was a clinical culture positive for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), or Clostridium difficile obtained more than 48 hours after hospital admission during the index hospital stay. The primary outcome of interest was time to readmission to the index facility. Multivariable Cox proportional hazards models were used to model the adjusted association between positive clinical culture result and time to readmission and to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS Among 136,513 index admissions, the prevalence of hospital-associated positive clinical culture result for 1 of the 3 organisms of interest was 3%, and 35% of patients were readmitted to the index facility within 1 year after discharge. Patients with a positive clinical culture obtained more than 48 hours after hospital admission had an increased hazard of readmission (HR, 1.40; 95% CI, 1.33-1.46) after adjusting for age, sex, index admission length of stay, intensive care unit stay, Charlson comorbidity index, and year of hospital admission. CONCLUSIONS Patients with healthcare-associated infections may be at increased risk of hospital readmission. These findings may be used to impact health outcomes after discharge from the hospital and to encourage better infection prevention efforts.

A Nationwide Analysis of Antibiotic Use in Hospice Care in the Final Week of Life

CONTEXT Antibiotic prescription in hospice patients is complicated by the focus on palliative rather than curative care and concerns regarding increasing antibiotic resistance. OBJECTIVES To estimate the antibiotic use in a national sample of hospice patients and identify facility and patient characteristics associated with antibiotic use in this population. METHODS This was an analysis of data from the 2007 National Home and Hospice Care Survey, a nationally representative sample of U.S. hospice agencies. We included data from 3884 patients who died in hospice care. The primary outcome measure was prevalence of antibiotic use in the last seven days of life. Diagnoses, including potential infectious indications for antibiotic use, were defined using International Classification of Diseases, Ninth Revision (ICD-9) codes. Chi-squared tests and t-tests were used to quantify associations of patient and facility characteristics with antibiotic use. RESULTS During the last seven days of life, 27% (95% CI: 24%-30%) of patients received at least one antibiotic and 1.3% (95% CI: 0.7%-2.0%) received three or more antibiotics. Among patients who received at least one antibiotic, 15% (95% CI: 10%-20%) had a documented infectious diagnosis compared with 9% (95% CI: 7%-11%), who had an infectious diagnosis but received no antibiotics. CONCLUSION In this nationally representative sample, 27% of hospice patients received an antibiotic during the last seven days of life, most without a documented infectious diagnosis. Further research is needed to elucidate the role of antibiotics in this patient population to maintain palliative care goals while reducing unnecessary antibiotic use.

Benefits and risks of anticoagulation resumption following traumatic brain injury.

IMPORTANCE The increased risk of hemorrhage associated with anticoagulant therapy following traumatic brain injury creates a serious dilemma for medical management of older patients: Should anticoagulant therapy be resumed after traumatic brain injury, and if so, when? OBJECTIVE To estimate the risk of thrombotic and hemorrhagic events associated with warfarin therapy resumption following traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of administrative claims data for Medicare beneficiaries aged at least 65 years hospitalized for traumatic brain injury during 2006 through 2009 who received warfarin in the month prior to injury (n = 10,782). INTERVENTION Warfarin use in each 30-day period following discharge after hospitalization for traumatic brain injury. MAIN OUTCOMES AND MEASURES The primary outcomes were hemorrhagic and thrombotic events following discharge after hospitalization for traumatic brain injury. Hemorrhagic events were defined on inpatient claims using International Classification of Diseases, Ninth Revision, Clinical Modification codes and included hemorrhagic stroke, upper gastrointestinal bleeding, adrenal hemorrhage, and other hemorrhage. Thrombotic events included ischemic stroke, pulmonary embolism, deep venous thrombosis, and myocardial infarction. A composite of hemorrhagic or ischemic stroke was a secondary outcome. RESULTS Medicare beneficiaries with traumatic brain injury were predominantly female (64%) and white (92%), with a mean (SD) age of 81.3 (7.3) years, and 82% had atrial fibrillation. Over the 12 months following hospital discharge, 55% received warfarin during 1 or more 30-day periods. We examined the lagged effect of warfarin use on outcomes in the following period. Warfarin use in the prior period was associated with decreased risk of thrombotic events (relative risk [RR], 0.77 [95% CI, 0.67-0.88]) and increased risk of hemorrhagic events (RR, 1.51 [95% CI, 1.29-1.78]). Warfarin use in the prior period was associated with decreased risk of hemorrhagic or ischemic stroke (RR, 0.83 [95% CI, 0.72-0.96]). CONCLUSIONS AND RELEVANCE Results from this study suggest that despite increased risk of hemorrhage, there is a net benefit for most patients receiving anticoagulation therapy, in terms of a reduction in risk of stroke, from warfarin therapy resumption following discharge after hospitalization for traumatic brain injury.

Quality of hospice care for individuals with dementia.

Patients with dementia constitute an increasing proportion of hospice enrollees, yet little is known about the quality of hospice care for this population. The aim of this study was to quantify differences in quality of care measures between hospice patients with and without dementia.

Stability of Postoperative Delirium Psychomotor Subtypes in Individuals with Hip Fracture

To determine the stability of psychomotor subtypes of delirium over time and identify characteristics associated with delirium psychomotor subtypes in individuals undergoing surgical repair of hip fracture.

Serious Mental Illness and Acute Hospital Readmission in Diabetic Patients

Patients with serious mental illness (SMI), particularly those with other chronic illnesses, may be vulnerable to unplanned hospital readmission. The authors hypothesized that SMI would be associated with increased 30-day hospital readmission in a cohort of adult patients with comorbid diabetes admitted to a tertiary care facility from 2005 to 2009. SMI was defined by International Classification of Diseases, Ninth Revision, discharge diagnosis codes for schizophrenia, schizoaffective, bipolar, manic, or major depressive disorders, or other psychosis. The primary outcome was 30-day readmission to the index hospital. Among 26 878 eligible admissions, the prevalence of SMI was 6% and the incidence of 30-day hospital admission was 16%. Among patients aged <35 years, SMI was significantly associated with decreased odds of 30-day hospital readmission (odds ratio [OR] = 0.39; 95% confidence interval [CI] = 0.17, 0.91). However, among patients ≥35 years, SMI was not significantly associated with 30-day hospital readmission (OR = 1.11; 95% CI = 0.86, 1.42). SMI may not be associated with increased odds of 30-day hospital readmission in this population.

Increased Rates of Mild Traumatic Brain Injury Among Older Adults in US Emergency Departments, 2009-2010.

Objective:To estimate rates of emergency department (ED) visits for mild traumatic brain injury (TBI) among older adults. We defined possible mild TBI cases to assess underdiagnoses. Design:Cross-sectional. Setting:National sample of ED visits in 2009-2010 captured by the National Hospital Ambulatory Medical Care Survey. Participants:Aged 65 years and older. Measurements:Mild TBI defined by International Classification of Diseases, Ninth Revision, Clinical Modification, codes (800.0x-801.9x, 803.xx, 804.xx, 850.xx-854.1x, 950.1x-950.3x, 959.01) and a Glasgow Coma Scale score of 14 or more or missing, excluding those admitted to the hospital. Possible mild TBI was defined similarly among those without mild TBI and with a fall or motor vehicle collision as cause of injury. We calculated rates of mild TBI and examined factors associated with a diagnosis of mild TBI. Results:Rates of ED visits for mild TBI were 386 per 100 000 among those aged 65 to 74 years, 777 per 100 000 among those aged 75 to 84 years, and 1205 per 100 000 among those older than 84 years. Rates for women (706/100 000) were higher than for men (516/100 000). Compared with a possible mild TBI, a diagnosis of mild TBI was more likely in the West (odds ratio = 2.31; 95% confidence interval, 1.02-5.24) and less likely in the South/Midwest (odds ratio = 0.52; 95% confidence interval, 0.29-0.96) than in the Northeast. Conclusions:This study highlights an upward trend in rates of ED visits for mild TBI among older adults.

Effect of waiting time on substance abuse treatment completion in pregnant women

Although substance abuse treatment is associated with improved maternal and neonatal outcomes, pregnant women may be at increased risk of attrition. To explore the hypothesis that shorter waiting time for treatment is associated with increased completion, we analyzed all pregnant treatment admissions and discharges in the Treatment Episode Data Set-Discharges. There were 10,661 pregnant admissions in 2006. The effect of waiting time on treatment completion was modified by treatment setting. Immediate entry into ambulatory treatment, where most pregnant women are treated, was significantly associated with completion (odds ratio = 1.27, 95% confidence interval = 1.14-1.41). Criminal justice referral and a high school education were identified as completion predictors in all treatment settings. Waiting time impacts treatment completion in pregnant women. Resources need to be directed to ensure immediate access to treatment, particularly in the ambulatory setting.

Patterns of Depression Treatment in Medicare Beneficiaries with Depression after Traumatic Brain Injury

There are no clinical guidelines addressing the management of depression after traumatic brain injury (TBI). The objectives of this study were to (1) describe depression treatment patterns among Medicare beneficiaries with a diagnosis of depression post-TBI; (2) compare them with depression treatment patterns among beneficiaries with a diagnosis of depression pre-TBI; and (3) quantify the difference in prevalence of use. We conducted a retrospective analysis of Medicare beneficiaries hospitalized with TBI during 2006-2010. We created two cohorts: beneficiaries with a new diagnosis of depression pre-TBI (n=4841) and beneficiaries with a new diagnosis of depression post-TBI (n=4668). We searched for antidepressant medications in Medicare Part D drug event files and created variables indicating antidepressant use in each 30-day period after diagnosis of depression. We used provider specialty and current procedural terminology to identify psychotherapy in any location. We used generalized estimating equations to quantify the effect of TBI on receipt of depression treatment during the year after diagnosis of depression. Average monthly prevalence of antidepressant use was 42% among beneficiaries with a diagnosis of depression pre-TBI and 36% among those with a diagnosis post-TBI (p<0.001). Beneficiaries with a diagnosis of depression post-TBI were less likely to receive antidepressants compared with a depression diagnosis pre-TBI (adjusted odds ratio [OR] 0.87; 95% confidence interval [CI] 0.82, 0.92). There was no difference in receipt of psychotherapy between the two groups (OR 1.08; 95% CI 0.93, 1.26). Depression after TBI is undertreated among older adults. Knowledge about reasons for this disparity and its long-term effects on post-TBI outcomes is limited and should be examined in future work.

Depressive Symptoms and Hospital Readmission in Older Adults

To quantify the risk of 30‐day unplanned hospital readmission in adults aged 65 and older with depressive symptoms.