Impact of diabetes on inpatient mortality and length of stay for elderly patients presenting with fracture of the proximal femur

INTRODUCTION

Osteoporosis-related fractures of the proximal femur cause significant morbidity and result in an economic burden on societies. It remains debatable whether diabetic patients with proximal fracture of the femur demonstrate poorer outcomes in terms of hospital stay and mortality compared to non-diabetic controls.

METHODS

All patients over 65years old admitted to the University Hospital Birmingham during 2007-2010 with a diagnosis of a fracture of the proximal femur (total 1468 including 197 patients with diabetes) were analysed. Eligibility and case definitions were ascertained using electronic records. Multivariate analyses were conducted to control for the confounding effect of covariates, which may be associated with the outcomes of interest on the basis of biological plausibility and known risks.

RESULTS

In-patient mortality was estimated at 14.2% and 12% for the diabetic and non-diabetic patients respectively. Diabetes was not found to be a significant predictor of in-patient mortality, before and after adjustment for the covariates [Adjusted odds ratio 1.01 (95% CI 0.62-1.65)], in contrast to advancing age, male gender, co-morbidity score, low albumin and high creatinine concentrations. Similarly, median length of stay was greater in the diabetes patients, yet only by a day (20 versus 19 days). This was not statistically significant in either the unadjusted (p=0.17) or in the multivariate analysis (p=0.06).

CONCLUSIONS

Diabetic patients admitted with fracture of the proximal femur did not demonstrate significantly poorer outcomes in terms of in-patient mortality and length of stay compared to non-diabetic patients.

Inpatient electronic prescribing data can be used to identify 'lost' discharge codes for diabetes

AIM

Accurate assessment of missed discharge codes for diabetes is critical for effective planning of hospital diabetes services. We wished to estimate the frequency of missed discharge diagnostic codes for diabetes and the impact missed codes would have on diabetes-related payments to the hospital.

METHODS

We linked Patient Administration System data to the Prescribing Information and Communication System. We defined diabetes as those having a discharge code for diabetes in the Patient Administration System and those on anti-diabetic medication in the Prescribing Information and Communication System. Based on the two sources, we calculated the estimated missed discharge codes for diabetes using the capture-recapture technique. We generated the Healthcare Resource Group for a given admission before and after correction for the missed code to estimate the impact that correction would make on payments to the hospital.

RESULTS

Among the 171 067 admissions linked, 22 412 (13.1%) had a code for diabetes at discharge. An additional 2706 admissions were classified as having diabetes based on prescription data. The capture-recapture technique estimated there were 4588 (2.7% of all admissions) admissions with diabetes missed by current coding, of which 2706 (60%) would be obtained from prescription data. After adding a diabetes diagnostic code, 12.8% of the missed admissions with diabetes resulted in a change to the Healthcare Resource Group tariff code and payment.

CONCLUSION

The use of electronic prescription data is a simple solution to correct for missed discharge diagnostic codes.

Hypoglycaemia is associated with increased length of stay and mortality in people with diabetes who are hospitalized

AIM

To study the length of stay and inpatient mortality of patients with diabetes who had an episode of hypoglycaemia in a non critical care setting at University Hospital Birmingham, UK.

METHODS

Retrospective analysis of routinely available electronic data of 6374 admissions with a recording of either laboratory or point-of-care blood glucose value. Based on the lowest recorded blood glucose values, patients were categorized into a group without hypoglycaemia (> 3.9 mmol/l), a group with mild to moderate hypoglycaemia (2.3-3.9 mmol/l) and a group with severe hypoglycaemic (≤ 2.2 mmol/l). Length of stay and inpatient mortality were compared between the three groups, adjusting for age, gender, ethnicity, deprivation, admission type, use of insulin and modified Charlson co-morbidity score.

RESULTS

There were 148 admissions (2.3%) with severe hypoglycaemia (≤ 2.2 mmol/l), 500 admissions (7.8%) with mild to moderate hypoglycaemia (2.2-3.9 mmol/l) and 5726 admissions with no recorded hypoglycaemic episode (> 3.9 mmol/l). After adjustment, length of stay, when compared with those without a recorded hypoglycaemic episode, was 1.51 (95% CI 1.35-1.68) times higher in the group with blood glucose values of 2.3-3.9 mmol/l and 2.33 (95% CI 1.91-2.84) higher in the group with blood glucose values ≤ 2.2 mmol/l. Adjusted odds ratio of inpatient mortality when compared with the group without hypoglycaemia was 1.62 (95% CI 1.16-2.27) in the group with blood glucose values of 2.3-3.9 mmol/l and 2.05 (95% CI 1.24-3.38) in the group with blood glucose values ≤ 2.2 mmol/l.

CONCLUSION

Hypoglycaemia is associated with increased length of stay and inpatient mortality. Whilst causative evidence is lacking, our data are consistent with the need to avoid hypoglycaemia in our current and continued approach for optimal glycaemic control in people with diabetes admitted to hospital.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of screening older women for the prevention of fractures: rationale, design and methods for the SCOOP study

SCOOP is a UK seven-centre, pragmatic, randomised controlled trial with 5-year follow-up, including 11,580 women aged 70 to 85 years, to assess the effectiveness and cost-effectiveness of a community-based screening programme to reduce fractures. It utilises the FRAX algorithm and DXA to assess the 10-year probability of fracture. Introduction Osteoporotic, or low-trauma, fractures present a considerable burden to the National Health Service and have major adverse effects on quality of life, disability and mortality for the individual. Methods Given the availability of efficacious treatments and a risk assessment tool based upon clinical risk factors and bone mineral density, a case exists to undertake a community-based controlled evaluation of screening for subjects at high risk of fracture, under the hypothesis that such a screening programme would reduce fractures in this population. Results This study is a UK seven-centre, unblinded, pragmatic, randomised controlled trial with a 5-year follow-up period. A total of 11,580 women, aged 70 to 85 years and not on prescribed bone protective therapy will be consented to the trial by post via primary care providing 90% power to detect an 18% decrease in fractures. Conclusions Participants will be randomised to either a screening arm or control. Those undergoing screening will have a 10-year fracture probability computed from baseline risk factors together with bone mineral density measured by DXA in selected subjects. Individuals above an age-dependent threshold of fracture probability will be recommended for treatment for the duration of the trial. Subjects in the control arm will receive 'usual care'. Participants will be followed up 6 months after randomisation and annually by postal questionnaires with independent checking of hospital and primary care records. The primary outcome will be the proportion of individuals sustaining fractures in each group. An economic analysis will be carried out to assess cost-effectiveness of screening. A qualitative evaluation will be conducted to examine the acceptability of the process to participants.

Clinical decision support systems in the care of inpatients with diabetes in non-critical care setting: systematic review

BACKGROUND

Computerized clinical decision support systems have been claimed to reduce prescription errors and improve patient care. They may play an important role in the care of hospitalized patients with diabetes.

AIM

To collate evidence for the use of clinical decision support systems in improving the care of hospitalized patients with diabetes in a non-critical care setting and to assess their effectiveness.

METHODS

We searched four databases from 1980 to 2010 without language restrictions. All types of studies other than case reports were included. Data extraction and quality assessment were carried out based on the Centre for Review and Dissemination guidance. A narrative synthesis was conducted.

RESULTS

Fourteen studies met the inclusion criteria, including two cluster randomized controlled trials, eight before-and-after studies and four other descriptive studies. Generally, the quality of the studies was not very high. Nine out of 10 studies reported reduction in mean blood glucose or similar measures (patient-day-weighted mean blood glucose) during inpatient stay. The reduction using computerized physician order entry system in patient-day-weighted mean blood glucose ranged from 0.6 to 0.8 mmol/l (10.8-15.6 mg/dl). Other beneficial effects during inpatient stay included reduced use of sliding scale insulin and greater use of basal-bolus insulin regimen. Only one study found a significant increase in hypoglycaemic events.

CONCLUSIONS

Clinical decision support systems have been used, often as part of a complex programme, to improve the care of hospitalized patients with diabetes. There is some evidence that they may have a beneficial effect, but this needs further confirmation.

Impact of metabolic syndrome on ischemic heart disease - a prospective cohort study in an Iranian adult population: Isfahan Cohort Study

BACKGROUND

The impact of the metabolic syndrome among populations in the Middle East region is unknown; we therefore examined the association between the syndrome and the risk of ischemic heart disease (IHD) in an Iranian population.

METHODS AND RESULTS

The Isfahan Cohort Study (ICS) prospectively followed 6146 Iranian people (51.8% women, aged 35-75 years) from three cities and their rural districts who were initially free of ischemic heart disease. During the 5 year follow-up, 209 (56% men) cases of ischemic heart disease were detected. The metabolic syndrome was defined by the modified criteria of the National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATPIII). End points were defined as fatal and nonfatal myocardial infarction, sudden cardiac death and unstable angina. A clear dose-response relationship was found between the number of metabolic risk factors and the incidence of IHD, with the hazard ratios increasing dose-dependently from 1.72 (95% CI 0.86-3.46) for only one to 1.97 (1.00-3.90), 2.85 (1.45-5.58) and 4.44 (2.25-8.76) for 2, 3 and ≥4 metabolic syndrome component respectively, relative to those with no component. The adjusted hazard ratio (95% CI) associated with the metabolic syndrome was 1.58 (1.06-2.35) in men and 1.72 (1.08-2.74) in women for IHD. The contribution of metabolic syndrome to the IHD risk was particularly strong among smokers although there was no significant interaction.

CONCLUSIONS

The metabolic syndrome by NCEP/ATPIII definition is a major determinant of ischemic heart disease in this middle-aged Iranian population, especially among smokers.

Injury prevention and recreational all-terrain vehicle use: the impact of helmet use in West Virginia

All-terrain vehicles (ATVs) are a popular source of outdoor activity in the United States, particularly in West Virginia. During the period of time from 1999 to 2007, deaths associated with ATVs in West Virginia increased by 28%. Helmet use among bicycle and motorcycle riders has been shown to decrease morbidity and mortality following trauma.

METHODS

We performed a retrospective observational study to compare injury patterns, hospital course, and resource utilization of non-helmeted and helmeted riders involved in ATV accidents using data from the West Virginia Trauma Center System. Descriptive statistics were calculated for all study variables and comparisons were made between helmeted and non-helmeted riders.

RESULTS

In 2010, there were 1,059 patients aged 18 and over with traumas resulting from ATV accidents within the System. Riders involved in ATV trauma occurring on farms and streets were significantly more likely to be non-helmeted, while those using ATVs for recreational purposes were more likely to be helmeted. Non-helmeted riders were significantly more likely to arrive to the hospital via helicopter than helmeted riders, and were less likely to be discharged home from the ED compared to helmeted riders. Non-helmeted riders sustained significantly more head, neck, soft tissue injuries, concussions, intracranial hemorrhages, facial fractures, skull fractures, and thoracic spine fractures than helmeted riders.

DISCUSSION

The findings of the current study support previous studies documenting that helmet use is protective against intracranial injury and other injuries of the head and neck. ATV use continues to be a significant contribution to trauma morbidity and mortality in West Virginia.

CONCLUSION

Efforts that focus on increased helmet use have the potential to significantly reduce morbidity and mortality following ATV trauma. Enforcement of the current West Virginia ATV Law should be encouraged. Legislation expanding the mandatory use of safety equipment and rider training should be enacted in West Virginia.

Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices

BACKGROUND

In primary care frequent attenders with medically unexplained symptoms (MUS) pose a clinical and health resource challenge. We sought to understand these presentations in terms of the doctor-patient relationship, specifically to test the hypothesis that such patients have insecure emotional attachment.

METHOD

We undertook a cohort follow-up study of 410 patients with MUS. Baseline questionnaires assessed adult attachment style, psychological distress, beliefs about the symptom, non-specific somatic symptoms, and physical function. A telephone interview following consultation assessed health worry, general practitioner (GP) management and satisfaction with consultation. The main outcome was annual GP consultation rate.

RESULTS

Of consecutive attenders, 18% had an MUS. This group had a high mean consultation frequency of 5.24 [95% confidence interval (CI) 4.79-5.69] over the follow-up year. The prevalence of insecure attachment was 28 (95% CI 23-33) %. A significant association was found between insecure attachment style and frequent attendance, even after adjustment for sociodemographic characteristics, presence of chronic physical illness and baseline physical function [odds ratio (OR) 1.96 (95% CI 1.05-3.67)]. The association was particularly strong in those patients who believed that there was a physical cause for their initial MUS [OR 9.52 (95% CI 2.67-33.93)]. A possible model for the relationship between attachment style and frequent attendance is presented.

CONCLUSIONS

Patients with MUS who attend frequently have insecure adult attachment styles, and their high consultation rate may therefore be conceptualized as pathological care-seeking behaviour linked to their insecure attachment. Understanding frequent attendance as pathological help seeking driven by difficulties in relating to caregiving figures may help doctors to manage their frequently attending patients in a different way.

[Introduction to preventive and predictive medicine: past experience and future reality]

The active practical introduction of the achievements of genomics, proteomics, metabolomics, and bioinformatics brought about a fundamental change in views on the role and place of medicine in the structure of healthcare at the turn of the 1980s-1990s, by giving impetus to the development of the radically new health care area--preventive, predictive, and personalized medicine (PPPM).

Cardiovascular screening for men at high risk in Heart of Birmingham Teaching Primary Care Trust: the 'Deadly Trio' programme

BACKGROUND

The Deadly Trio programme offered cardiovascular health checks to men over 40 in inner-city Birmingham. The aim was to increase diagnosis of diabetes, cardiovascular and kidney disease among this deprived and ethnically diverse population. Either patients' own general practitioners (GPs) were paid to provide health checks or patients were invited to an alternative provider.

METHODS

Routine data were sought from 68 participating practices. Logistic regression analysis was undertaken to determine the patient and practice factors associated with being screened and with being added to a disease register.

RESULTS

Data were obtained from 58 practices; 5871 (24.3%) of 24 166 eligible men were screened. Screening uptake was higher in those with a recorded phone number, South Asians and Blacks but lower in smokers. Compared to the alternative provider, uptake was higher among men registered with single-handed (but not multi-partner) GPs paid to provide health checks. South Asian, older and screened men were more often added to disease registers. Men with missing information and GP-screened men were less likely to be added to registers.

CONCLUSIONS

The programme achieved higher screening uptake and diagnosis of disease among minority ethnic men. Single-handed GPs paid to provide screening (and their patients) were more responsive than multi-partner practices.

Electronic Transport Properties of ZnSe Layers on GaAs

The electronic transport properties of ZnSe layers grown by MBE on GaAs sub- strates are studied by small-signal ac admittance, dc current-voltage, and Hall effect measurements. This work is supplemented by a study of TEM and x-ray rocking curve data. We find that the transport characteristics are strongly affected by the proper- ties of the ZnSe/GaAs interface. From the dc and ac measurements, we determine the total barrier height at the interface of thick (1-6 µm) ZnSe layers on n+-GaAs, and find that it is in general voltage dependent. While some samples are found to have a very high peak mobility (> 10,000cm2 /Vsec), an anomalous reduction in the mobility in a large fraction of the samples is found, and attributed to the presence of non- uniform space charge regions.

The Isfahan cohort study: rationale, methods and main findings

A 10-year longitudinal population-based study, entitled the Isfahan Cohort Study (ICS) is being conducted. The ICS commenced in 2001, recruiting individuals aged 35+ living in urban and rural areas of three counties in central Iran, to determine the individual and combined impact of various risk factors on the incidence of cardiovascular events. After 24379 person-years of follow-up with a median follow-up of 4.8 years, we documented 219 incident cases of ischemic heart disease (IHD) (125 in men and 94 in women) and 57 incident cases of stroke (28 in men and 29 in women). The absolute risk of IHD was 8.9 (7.8-10.2) per 1000 person-years for all participants, 10.6 (8.8-12.5) per 1000 person-years for men and 7.4 (6.0-9.0) per 1000 person-years for women. The respective risk of ischemic stroke was 2.3 (1.7-3.0), 2.3 (1.6-3.3) and 2.3 (1.5-3.2) per 1000 person-years. The risk of IHD was approximately 3.5-fold higher in the presence of hypertension, followed by diabetes mellitus and hypercholesterolemia with near 2.5- and twofold higher risk, respectively. This cohort provides confirmatory evidence of the ethnic differences in the magnitude of the impact of various risk factors on cardiovascular events. The differences may be due to varying absolute risk levels among populations and the existing ethnic disparities for using western risk equations to local requirements.

A pilot double-blind randomised placebo-controlled trial of the effects of fixed-dose combination therapy ('polypill') on cardiovascular risk factors

AIM

Our objective was to investigate the effects and tolerability of fixed-dose combination therapy on blood pressure and LDL in adults without elevated blood pressure or lipid levels.

METHODS

This was a double-blind randomised placebo-controlled trial in residents of Kalaleh, Golestan, Iran. Following an 8-week placebo run-in period, 475 participants, aged 50 to 79 years, without cardiovascular disease, hypertension or hyperlipidaemia were randomised to fixed-dose combination therapy with aspirin 81 mg, enalapril 2.5 mg, atorvastatin 20 mg and hydrochlorothiazide 12.5 mg (polypill) or placebo for a period of 12 months. The primary outcomes were changes in LDL-cholesterol, systolic and diastolic blood pressure and adverse reactions. Analysis was by intention-to-treat basis.

RESULTS

At baseline, there were differences in systolic blood pressure (6 mmHg). Taking account of baseline differences, at 12 months, polypill was associated with statistically significant reductions in blood pressure (4.5/1.6 mmHg) and LDL-cholesterol (0.46 mmol/l). The study drug was well tolerated, but resulted in the modest reductions in blood pressure and lipid levels.

CONCLUSION

The effects of the polypill on blood pressure and lipid levels were less than anticipated, raising questions about the reliability of the reported compliance. There is a case for a fully powered trial of a polypill for the prevention of cardiovascular disease.