Jorge Go

Associations Between Reduced Hospital Length of Stay and 30-Day Readmission Rate and Mortality: 14-Year Experience in 129 Veterans Affairs Hospitals

BACKGROUND Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions. OBJECTIVE To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration. DESIGN Observational study from 1997 to 2010. SETTING All 129 acute care Veterans Affairs hospitals in the United States. PATIENTS 4,124,907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage). MEASUREMENTS Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals. RESULTS For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected). LIMITATIONS This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used. CONCLUSION Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission. PRIMARY FUNDING SOURCE Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.

Update on the management of constipation in the elderly: new treatment options

Constipation disproportionately affects older adults, with a prevalences of 50% in community-dwelling elderly and 74% in nursing-home residents. Loss of mobility, medications, underlying diseases, impaired anorectal sensation, and ignoring calls to defecate are as important as dyssynergic defecation or irritable bowel syndrome in causing constipation. Detailed medical history on medications and co-morbid problems, and meticulous digital rectal examination may help identify causes of constipation. Likewise, blood tests and colonoscopy may identify organic causes such as colon cancer. Physiological tests such as colonic transit study with radio-opaque markers or wireless motility capsule, anorectal manometry, and balloon expulsion tests can identify disorders of colonic and anorectal function. However, in the elderly, there is usually more than one mechanism, requiring an individualized but multifactorial treatment approach. The management of constipation continues to evolve. Although osmotic laxatives such as polyethylene glycol remain mainstay, several new agents that target different mechanisms appear promising such as chloride-channel activator (lubiprostone), guanylate cyclase agonist (linaclotide), 5HT4 agonist (prucalopride), and peripherally acting μ-opioid receptor antagonists (alvimopan and methylnaltrexone) for opioid-induced constipation. Biofeedback therapy is efficacious for treating dyssynergic defecation and fecal impaction with soiling. However, data on efficacy and safety of drugs in elderly are limited and urgently needed.

Do Hospitalists Affect Clinical Outcomes and Efficiency for Patients with Acute Upper Gastrointestinal Hemorrhage (UGIH)

BACKGROUND Care by hospitalists has been associated with improved/similar clinical outcomes and efficiency. However, less is known about their effect on conditions dependent upon specialists for procedures/treatment plans. Our objective was to compare care for upper gastrointestinal hemorrhage (UGIH) patients attended by academic hospitalists and nonhospitalists. METHODS The study included 450 UGIH patients admitted to general medical services of 6 teaching hospitals. Outcomes included in-hospital mortality and complications (ie, recurrent bleeding, intensive care unit [ICU] transfer, decompensation, transfusion, reendoscopy, 30-day readmission). Efficiency was measured by hospital costs and length of stay (LOS). RESULTS Of 450 patients, 40% (177) were cared for by hospitalists with no differences between groups by endoscopic diagnosis, performance of early esophagogastroduodenoscopy (EGD), Rockall risk score, or Charlson comorbidity index. Unadjusted clinical outcomes between hospitalists and nonhospitalists were similar except for 2 outcomes: patients cared for by hospitalists were more likely to receive a transfusion (74% vs. 63%; P = 0.02) or be readmitted within 30 days (7.3% vs. 3.3%; P = 0.05). However, differences in adverse outcomes between providers were not seen after multivariable adjustments. Median LOS was similar for hospitalists and nonhospitalists (4 days; P = 0.69), but patients cared for by hospitalists had higher median costs (

Influence of everyday bolus consistencies in different body positions on high‐resolution esophageal pressure topography (HREPT) parameters

7,359 vs.

Su1149 Lack of Seasonal Variation in the Incidence of Eosinophilic Esophagitis

6,181; P < 0.01). In multivariable analyses, LOS was similar (5.2 vs. 4.7 days; P = 0.15) and costs remained higher for the hospitalist-led teams (P < 0.03). CONCLUSIONS Despite having similar overall outcomes and LOS, costs were higher in UGIH patients attended by hospitalists. These results suggest that the academic hospitalist model may be tempered in patients requiring specialists for procedures or management.

Hereditary Hemochromatosis: Missed Diagnosis or Misdiagnosis?

The standard protocol for esophageal manometry involves placing the patient in the supine position with head turned to left (supine head left [SHL]) while evaluating liquid bolus swallows. Routinely, semisolid or solid boluses are not evaluated. Currently, the daily American diet includes up to 40% solid or semisolid texture. Thus far, the data on the effect of different bolus on high-resolution esophageal pressure topography (HREPT) parameters are scarce. This study aims to evaluate the effect of every day bolus consistencies in different body positions on HREPT variables. HREPT was performed on healthy volunteers with a modified protocol including liquid swallows in the SHL position followed by applesauce (semisolid), cracker (solid), and marshmallow (soft solid) in three different positions (SHL, sitting, and standing). A total of 38 healthy adult subjects (22 males and 16 females, median age = 27, and mean body mass index = 25) were evaluated. The resting upper esophageal sphincter pressure was significantly different while subjects swallowed crackers, applesauce, and marshmallows in most positions compared with liquid SHL (P < 0.05). The lower esophageal sphincter, contractile front velocity, and distal contractile integral pressures did not differ in all different consistencies compared with SHL. The integrated relaxation period was significantly higher with solid bolus compared with liquid bolus only in SHL position. The intrabolus pressure was significantly different with solid and soft solid boluses in all postures compared to liquid SHL. The American diet consistency affects upper esophageal sphincter pressure and partially integrated relaxation period and intrabolus pressure in various positions. Semisolid bolus swallows do not cause substantial pressure changes and are safe for evaluation and maintaining adequate caloric intake in patients with dysphagia who cannot tolerate solids.

Is Biofeedback Therapy Effective in Improving Quality of Life in Dyssynergic Defecation? A Randomized Clinical Trial

Background: Current guidelines indicate obtaining tissue to evaluate for eosinophilic esophagitis (EoE) as an option in patients with dysphagia who receive upper endoscopy evaluation without obvious cause for their complaint. However, the utility of this practice is unclear. The primary aim of the study was to determine the diagnostic yield of pathologic evaluation for EoE in patients with normal and abnormal findings on upper gastrointestinal endoscopy at the University of Oklahoma Health Sciences Center (OUHSC). Methods: All cases with a primary indication of dysphagia from January 2006 to November 2011 were retrospectively identified using the OUHSC electronic endoscopy database. Patients who had endoscopic biopsies for pathologic evaluation of EoE during their procedure were included for analysis. The pathologic reports and endoscopic findings were independently reviewed by different physicians who were not aware of the other results, then correlated by a third investigator to determine diagnostic yield rates for patients with and without endoscopic findings suggestive of EoE. Results: A total of 3,448 upper gastrointestinal endoscopies were performed at OUHSC during the study period. 547 procedures from 527 patients, age 18 to 90, met entry criteria and were analyzed. Review of these exams revealed 284/547 (52%) with a normal upper gastrointestinal endoscopy, 85/547 (16%) with features suggestive of EoE (furrowing or longitudinal rings), 73/547 (13%) with esophagitis, 45/547 (8%) with lower esophageal strictures or Schatzki ring, and 60/547 (11%) with other findings. Pathologic review indicated 303/547 (55%) with esophagitis, 207/547 (38%) with normal mucosa, and 37/547 (7%) with EoE. Among the 37 patients diagnosed with EoE, endoscopy revealed 23 (62%) with features of EoE, 7 (19%) with normal exam, and 7 (19%) with esophageal stenosis or esophagitis. The overall pathologic yield of EoE to endoscopic findings was 23/ 85 (27%) with features suggestive of EoE, 7/284 (2%) with normal exam, and 7/178 (4%) with all other findings. Conclusions: Endoscopic biopsies for pathologic evaluation of EoE often yield positive results in patients with endoscopic features suggestive of EoE. However, the yield of biopsies in those without endoscopic features suggestive of EoE is very low and is unlikely to alter patient management with increased cost.