Randy Fransoo

Rates of readmission and death associated with leaving hospital against medical advice: a population-based study

Background: Leaving hospital against medical advice may have adverse consequences. Previous studies have been limited by evaluating specific types of patients, small sample sizes and incomplete determination of outcomes. We hypothesized that leaving hospital against medical advice would be associated with increases in subsequent readmission and death. Methods: In a population-based analysis involving all adults admitted to hospital and discharged alive in Manitoba from Apr. 1, 1990, to Feb. 28, 2009, we evaluated all-cause 90-day mortality and 30-day hospital readmission. We used multivariable regression, adjusted for age, sex, socioeconomic status, year of hospital admission, patient comorbidities, hospital diagnosis, past frequency of admission to hospital, having previously left hospital against medical advice and data clustering (patients with multiple admissions). For readmission, we assessed both between-person and within-person effects of leaving hospital against medical advice. Results: Leaving against medical advice occurred in 21 417 of 1 916 104 index hospital admissions (1.1%), and was associated with higher adjusted rates of 90-day mortality (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.18–2.89), and 30-day hospital readmission (within-person OR 2.10, CI 1.99–2.21; between-person OR 3.04, CI 2.79–3.30). In our additional analyses, elevated rates of readmission and death associated with leaving against medical advice were manifest within 1 week and persisted for at least 180 days after discharge. Interpretation: Adults who left the hospital against medical advice had higher rates of hospital readmission and death. The persistence of these effects suggests that they are not solely a result of incomplete treatment of acute illness. Interventions aimed at reducing these effects may need to include longitudinal interventions extending beyond admission to hospital.

The accuracy of administrative data for identifying the presence and timing of admission to intensive care units in a Canadian province.

Background:A prerequisite for using administrative data to study the care of critically ill patients in intensive care units (ICUs) is that it accurately identifies such care. Only limited data exist on this subject. Objective:To assess the accuracy of administrative data in the Canadian province of Manitoba for identifying the existence, number, and timing of admissions to adult ICUs. Research Design:For the period 1999 to 2008, we compared information about ICU care from Manitoba hospital abstracts, with the criterion standard of a clinical ICU database that includes all admissions to adult ICUs in its largest city of Winnipeg. Comparisons were made before and after a national change in administrative data requirements that mandated specific data elements identifying the existence and timing of ICU care. Results:In both time intervals, hospital abstracts were extremely accurate in identifying the presence of ICU care, with positive predictive values exceeding 98% and negative predictive values exceeding 99%. Administrative data correctly identified the number of separate ICU admissions for 93% of ICU-containing hospitalizations; inaccuracy increased with more ICU stays per hospitalization. Hospital abstracts were highly accurate for identifying the timing of ICU care, but only for hospitalizations containing a single ICU admission. Conclusions:Under current national-reporting requirements, hospital administrative data in Canada can be used to accurately identify and quantify ICU care. The high accuracy of Manitoba administrative data under the previous reporting standards, which lacked standardized coding elements specific to ICU care, may not be generalizable to other Canadian jurisdictions.

THE COMPLETE STORY: A POPULATION‐ BASED PERSPECTIVE ON SCHOOL PERFORMANCE AND EDUCATIONAL TESTING

All children born in Manitoba in 1984 were tracked for 18 years to assess their grade ‐ 12 performance on a provincial examination according to a student’s socio ‐ economic status. The proportion of youths in families receiving social assistance judged to have passed their language arts exam dropped from 80 per cent to 12 per cent, depending on whether one counts only those in the cohort who took the test on time in 2002 or all youths born in 1984 who should have taken the test in 2002. Getting better data on performance and doing something about the discrepancies should become a Canadian priority. Key words: educational opportunity, exam performance, socio ‐ economic status, testing, longitudinal studies Tous les enfants nes au Manitoba en 1984 ont ete suivis sur une periode de 18 ans en vue d’evaluer leur rendement en 12 e annee lors d’un examen provincial, tenant compte de leur statut socioeconomique. La proportion de jeunes issus des familles recevant de l’aide sociale et consideres comme ayant reussi leur examen au plan des competences linguistiques passe de 80 % a 12 %, selon que l’on compte seulement ceux qui, dans la cohorte, ont subi l’examen a temps en 2002 ou tous les jeunes nes en 1984 qui auraient du subir l’examen. En matiere d’egalite des chances, la performance du systeme scolaire actuel au Canada laisse a desirer. Mots cles: possibilites educatives, resultats d’examen, statut socioeconomique, analyse longitudinale.

Health service use in the Winnipeg Regional Health Authority: variations across areas in relation to health and socioeconomic status.

The use of healthcare services in Winnipeg is examined to determine whether groups who appear to have a higher need for medical care actually get more care. Despite universal coverage, considerable variation in service use rates exists. Most of the basic healthcare services are provided in accordance with need as measured by premature mortality rates. Nevertheless, visits to specialist physicians, a variety of high profile procedures, and screening and preventative services appear not to be provided in accordance with need.

A population-based analysis of leaving the hospital against medical advice: incidence and associated variables

BackgroundPrior studies of patients leaving hospital against medical advice (AMA) have been limited by not being population-based or assessing only one type of patient.MethodsWe used administrative data at the Manitoba Centre for Health Policy to evaluate all adult residents of Manitoba, Canada discharged alive from acute care hospitals between April 1, 1990 and February 28, 2009. We identified the rate of leaving AMA, and used multivariable logistic regression to identify socio-demographic and diagnostic variables associated with leaving AMA.ResultsOf 1 916 104 live hospital discharges, 21 417 (1.11%) ended with the patient leaving AMA. The cohort contained 610 187 individuals, of whom 12 588 (2.06%) left AMA once and another 2 986 (0.49%) left AMA more than once. The proportion of AMA discharges did not change over time. Alcohol and drug abuse was the diagnostic group with the highest proportion of AMA discharges, at 11.71%. Having left AMA previously had the strongest association with leaving AMA (odds ratio 170, 95% confidence interval 156–185). Leaving AMA was more common among men, those with lower average household incomes, histories of alcohol or drug abuse or HIV/AIDS. Major surgical procedures were associated with a much lower chance of leaving the hospital AMA.ConclusionsThe rate of leaving hospital AMA did not systematically change over time, but did vary based on patient and illness characteristics. Having left AMA in the past was highly predictive of subsequent AMA events.

Constructing episodes of inpatient care: data infrastructure for population-based research.

BackgroundDatabases used to study the care of patients in hospitals and Intensive Care Units (ICUs) typically contain a separate entry for each segment of hospital or ICU care. However, it is not uncommon for patients to be transferred between hospitals and/or ICUs, and when transfers occur it is necessary to combine individual entries to accurately reconstruct the complete episodes of hospital and ICU care. Failure to do so can lead to erroneous lengths-of-stay, and rates of admissions, readmissions, and death.MethodsThis study used a clinical ICU database and administrative hospital abstracts for the adult population of Manitoba, Canada from 2000–2008. We compared five methods for identifying patient transfers and constructing hospital episodes, and the ICU episodes contained within them. Method 1 ignored transfers. Methods 2–5 considered the time gap between successive entries (≤1 day vs. ≤2 days), with or without use of data fields indicating inter-hospital transfer. For the five methods we compared the resulting number and lengths of hospital and ICU episodes.ResultsDuring the study period, 48,551 hospital abstracts contained 53,246 ICU records. For Method 1 these were also the number of hospital and ICU episodes, respectively. Methods 2–5 gave remarkably similar results, with transfers included in approximately 25% of ICU-containing hospital episodes, and 10% of ICU episodes. Comparison with Method 1 showed that failure to account for such transfers resulted in overestimating the number of episodes by 7-10%, and underestimating mean or median lengths-of-stay by 9-30%.ConclusionsIn Manitoba is it not uncommon for critically ill patients to be transferred between hospitals and between ICUs. Failure to account for transfers resulted in inaccurate assessment of parameters relevant to researchers, clinicians, and policy-makers. The details of the method used to identify transfers, at least among the variations tested, made relatively little difference. In addition, we showed that these methods for constructing episodes of hospital and ICU care can be implemented in a large, complex dataset.

Intensive care unit admission in multiple sclerosis: Increased incidence and increased mortality.

Objective: To compare the incidence of, and mortality after, intensive care unit (ICU) admission as well as the characteristics of critical illness in the multiple sclerosis (MS) population vs the general population. Methods: We used population-based administrative data from the Canadian province of Manitoba for the period 1984 to 2010 and clinical data from 93% of admissions to provincial high-intensity adult ICUs. We identified 5,035 prevalent cases of MS and a cohort from the general population matched 5:1 on age, sex, and region of residence. We compared these populations using incidence rates and multivariable regression models adjusting for age, sex, comorbidity, and socioeconomic status. Results: From January 2000 to October 2009, the age- and sex-standardized annual incidence of ICU admission among prevalent cohorts was 0.51% to 1.07% in the MS population and 0.34% to 0.51% in matched controls. The adjusted risk of ICU admission was higher for the MS population (hazard ratio 1.45; 95% confidence interval [CI] 1.19–1.75) than for matched controls. The MS population was more likely to be admitted for infection than the matched controls (odds ratio 1.82; 95% CI 1.10–1.32). Compared with the matched controls admitted to ICUs, 1-year mortality was higher in the MS population (relative risk 2.06; 95% CI 1.32–3.07) and was particularly elevated in patients with MS who were younger than 40 years (relative risk 3.77; 95% CI 1.45–8.11). Causes of death were MS (9.3%), infections (37.0%), and other causes (52.9%). Conclusions: Compared with the general population, the risk of ICU admission is higher in MS, and 1-year mortality after admission is higher. Greater attention to preventing infection and managing comorbidity is needed in the MS population.

Needs-based planning for generalist physicians.

OBJECTIVES The Manitoba Centre for Health Policy and Evaluation (MCHPE) collaborated with a provincially-appointed Physician Resource Committee in an assessment of provincial physician resources. RESEARCH DESIGN Beginning with map-based analyses of physician supply and contacts across the province, compared with the health and socioeconomic characteristics of local populations, the study moved to a needs-based, regression-based approach to physician resource planning. RESULTS The results challenged the popular belief that Manitoba suffers from an increasing shortage of physicians. A handful of high-need, low-supply and low-use areas are identified, as is the expensive surplus of generalist physicians in Winnipeg. (Generalist physicians include general and family practitioners as well as general internists and pediatricians.) No relationship between physician supply and health characteristics of populations, or between high physician supply and low hospital use patterns were found. Given the Committees interest in what drives high physician contact rates, analyses of visit patterns of hypertensive patients were undertaken. We found that patients who had more complex medical conditions made more contacts, but that after controlling for this and other key patient characteristics, the patients primary care physicians patient recall rate was a strong influence on how frequently visits were made.

Issues in planning for specialist physicians.

OBJECTIVES The Manitoba Centre for Health Policy and Evaluation worked in support of a provincial Physician Resource Committee to address questions pertinent to assessing Manitobas supply of specialist physicians. RESEARCH DESIGN Because there was no direct method of determining whether the provinces supply of specialists was adequate, three types of evidence were reviewed: the supply of specialists relative to recommended population/physician ratios; the supply of specialists relative to other Canadian provinces; and the level of care delivered by specialists in Manitoba relative to other provinces. Four additional questions were addressed: is a problem developing from the aging of Manitobas specialist physicians? and will the supply of specialists be sufficient to keep up with the aging of the population? How well do specialists serve as a provincial resource? and how well do specialists serve high-need populations?

How Many Surgeons Does a Province Need, and How Do We Determine Appropriate Numbers?

The study compared each provinces supply of surgeons in three specialities (ophthalmologists, orthopedic surgeons, and cardiac and thoracic surgeons) with the rates of key procedures (cataract removal, hip and knee replacement, and coronary artery bypass) that residents received. We found little or no relationship between the supply of surgeons and a populations surgery rate. We conclude that the supply of surgical specialists is the wrong focus for health care resource planning.