Current Status and Hospital-Level Differences in Care and Outcomes of Patients With Acute Non-ST-Segment Elevation Myocardial Infarction in China: Insights From China Acute Myocardial Infarction Registry

BackgroundWith the growing burden of non-ST-elevation myocardial infarction (NSTEMI), developing countries face great challenges in providing equitable treatment nationwide. However, little is known about hospital-level disparities in the quality of NSTEMI care in China. We aimed to investigate the variations in NSTEMI care and patient outcomes across the three hospital levels (province-, prefecture- and county-level, with decreasing scale) in China.MethodsData were derived from the China Acute Myocardial Infarction Registry on patients with NSTEMI consecutively registered between January 2013 and November 2016 from 31 provinces and municipalities throughout mainland China. Patients were categorized according to the hospital level they were admitted to. Multilevel generalized mixed models were fitted to examine the relationship between the hospital level and in-hospital mortality risk.ResultsIn total, 8,054 patients with NSTEMI were included (province-level: 1,698 patients; prefecture-level: 5,240 patients; county-level: 1,116 patients). Patients in the prefecture- and county-level hospitals were older, more likely to be female, and presented worse cardiac function than those in the province-level hospitals (P <0.05). Compared with the province-level hospitals, the rate of invasive strategies was significantly lower in the prefecture- and county-level hospitals (65.3, 43.3, and 15.4%, respectively, P <0.001). Invasive strategies were performed within the guideline-recommended timeframe in 25.4, 9.7, and 1.7% of very-high-risk patients, and 16.4, 7.4, and 2.4% of high-risk patients in province-, prefecture- and county-level hospitals, respectively (both P <0.001). The use of dual antiplatelet therapy in the county-level hospitals (87.2%) remained inadequate compared to the province- (94.5%, P <0.001) and prefecture-level hospitals (94.5%, P <0.001). There was an incremental trend of in-hospital mortality from province- to prefecture- to county-level hospitals (3.0, 4.4, and 6.9%, respectively, P-trend <0.001). After stepwise adjustment for patient characteristics, presentation, hospital facilities and in-hospital treatments, the hospital-level gap in mortality risk gradually narrowed and lost statistical significance in the fully adjusted model [Odds ratio: province-level vs. prefecture-level: 1.23 (0.73–2.05), P = 0.441; province-level vs. county-level: 1.61 (0.80–3.26), P = 0.182; P-trend = 0.246].ConclusionsThere were significant variations in NSTEMI presentation and treatment patterns across the three hospital levels in China, which may largely explain the hospital-level disparity in in-hospital mortality. Quality improvement initiatives are warranted, especially among lower-level hospitals.

Overdiagnosis of urinary tract infection linked to overdiagnosis of pneumonia: a multihospital cohort study

Urinary tract infection (UTI) and community-acquired pneumonia (CAP) are the most common infections treated in hospitals. UTI and CAP are also commonly overdiagnosed, resulting in unnecessary antibiotic use and diagnostic delays. While much is known individually about overdiagnosis of UTI and CAP, it is not known whether hospitals with higher overdiagnosis of one also have higher overdiagnosis of the other. Correlation of overdiagnosis of these two conditions may indicate underlying hospital-level contributors, which in turn may represent targets for intervention. To evaluate the association of overdiagnosis of UTI and CAP, we first determined the proportion of hospitalised patients treated for CAP or UTI at 46 hospitals in Michigan who were overdiagnosed according to national guideline definitions. Then, we used Pearson’s correlation coefficient to compare hospital proportions of overdiagnosis of CAP and UTI. Finally, we assessed for ‘diagnostic momentum’ (ie, accepting a previous diagnosis without sufficient scepticism) by determining how often overdiagnosed patients remained on antibiotics on day 3 of hospitalisation. We included 14 085 patients treated for CAP (11.4% were overdiagnosed) and 10 398 patients treated for UTI (27.8% were overdiagnosed) across 46 hospitals. Within hospitals, the proportion of patients overdiagnosed with UTI was moderately correlated with the proportion of patients overdiagnosed with CAP (r=0.53, p<0.001). Over 80% (81.8% (n=952/1164) of UTI; 89.9% (n=796/885) of CAP) of overdiagnosed patients started on antibiotics by an emergency medicine clinician remained on antibiotics on day 3 of hospitalisation. In conclusion, we found overdiagnosis of UTI and CAP to be correlated at the hospital level. Reducing overdiagnosis of these two common infections may benefit from systematic interventions.

The Economics of a Bed Shortage: Certificate-of-Need Regulation and Hospital Bed Utilization during the COVID-19 Pandemic

Certificate-of-need (CON) laws are intended to restrain health care spending by limiting the acquisition of duplicative capital and the initiation of unnecessary services. Critics contend that need is difficult to objectively assess, especially considering the risks and uncertainty inherent in health care. We compare statewide bed utilization rates and hospital-level bed utilization rates in bed CON and non-bed CON states during the COVID-19 pandemic. Controlling for other possibly confounding factors, we find that states with bed CONs had 12 percent higher bed utilization rates and 58 percent more days in which more than 70 percent of their beds were used. Individual hospitals in bed CON states were 27 percent more likely to utilize all of their beds. States that relaxed CON requirements to make it easier for hospitals to meet the surge in demand did not experience any statistically significant decreases in bed utilization or number of days above 70 percent of capacity. Nor were hospitals in states that relaxed their CON requirements any less likely to use all their beds. Certificate-of-need laws seem to have exacerbated the risk of running out of beds during the COVID-19 pandemic. State efforts to relax these rules had little immediate effect on reducing this risk.

ROLE AND PARTICIPATION OF THE MULTIDISCIPLINARY TEAM IN PROVIDING MEDICAL CARE TO PATIENTS WITH ACUTE CEREBRAL BLOOD CIRCULATION DISORDERS AT THE LEVEL OF A MULTIDISCIPLINARY HOSPITAL

Нами изучены и проанализированы годовые отчеты инсультных центров многопрофильных стационаров города Алматы с 2018 года по 2019 год включительно. За данный период было пролечено всего 8783 пациентов. Поступившие и пролеченные случаи инсульта были распределены по возрастному признаку в 2018 году (средний возраст составил 60,5±1,17 лет %) и половому признаку (мужчины - 46,6±6,4%, женщины - 53,3±6,4%). В 2019 году по возрасту было 61,30±5,8% пациентов, а по полу - 58,4±6,1% составляли женщины, а 41,5±6,1% - мужчины, следовательно, тенденция преобладание инсульта у женщин. Мультидисциплинарная бригада на уровне стационара в полном объеме выполняет свои функциональные обязанности, своевременно диагностируя вид инсульта, определяя тяжесть пациентов, перенесенные инсульт в остром периоде. Роль и место невролога при в мультидисциплинарной бригаде огромная и неоценима. We have studied and analyzed the annual reports of stroke centers of multidisciplinary hospitals in the city of Almaty from 2018 to 2019 inclusive. During this period, a total of 8783 patients were treated. Stroke cases received and treated were distributed by age in 2018 (average age was 60.5 ± 1.17 years%) and gender (men - 46.6 ± 6.4%, women - 53.3 ± 6, 4%). In 2019, by age there were 61.30 ± 5.8% of patients, and by gender - 58.4 ± 6.1% were women, and 41.5 ± 6.1% were men, therefore, the trend is the prevalence of stroke in women. The multidisciplinary team at the hospital level fully fulfills its functional duties, diagnosing the type of stroke in a timely manner, determining the severity of patients suffering from a stroke in the acute period. The role and place of a neurologist in a multidisciplinary team is enormous and invaluable.

Association of treatments for acute appendicitis with pregnancy outcomes in the United States from 2000 to 2016: Results from a multi-level analysis

Background Open appendectomy, laparoscopic appendectomy, and non-surgical treatment are three options to treat acute appendicitis during pregnancy. Previous studies on the association of different treatment methods for acute appendicitis with pregnancy outcomes have been limited by small sample sizes and residual confounding, especially with respect to hospital-level factors. This study aimed to investigate the association of treatment method for acute appendicitis with pregnancy outcomes using a multi-level analysis. Methods A retrospective cohort study was conducted based on a large electronic health records database in the United States during the period 2000 to 2016. All pregnancies diagnosed with acute appendicitis and treated in participating hospitals during the study period were included. We conducted multi-level hierarchical logistic regression to analyze both individual- and hospital-level factors for abortion, preterm labor, and cesarean section. Results A total of 10,271 acute appendicitis during pregnancy were identified during the study period. Of them, 5,872 (57.2%) were treated by laparoscopic appendectomy, 1,403 (13.7%) by open appendectomy, and 2,996 (29.2%) by non-surgical treatment. Compared with open appendectomy, both laparoscopic appendectomy (adjusted OR, 0.6, 95% CI, 0.4, 0.9) and non-surgical treatment (adjusted OR, 0.4; 95% CI, 0.3–0.7) showed a decreased risk of preterm labor. Other important individual-level determinants of adverse pregnancy outcomes included maternal age, gestational hypertension, and anemia during pregnancy, the hospital-level determinant included the number of beds. Conclusions Compared with open appendectomy, both laparoscopic appendectomy and non-surgical treatment may be associated with a lower risk of preterm labor, without increased risks of abortion and cesarean section.

Trends in ED Resource Use for Infants 0 to 60 Days Evaluated for Serious Bacterial Infection

OBJECTIVES We examined trends in resource use for infants undergoing emergency department evaluation for serious bacterial infection, including lumbar puncture (LP), antibiotic administration, hospitalization, and procalcitonin testing, as well as the association between procalcitonin testing and LP, administration of parenteral antibiotics, and hospitalization. METHODS We performed a cross-sectional study of infants aged 0 to 60 days who underwent emergency department evaluation for serious bacterial infection with blood and urine cultures from 2010 to 2019 in 27 hospitals in the Pediatric Health Information System. We examined temporal trends in LP, antibiotic administration, hospitalization, and procalcitonin testing from 2010 to 2019. We also estimated multivariable logistic regression models for 2017–2019, adjusted for demographic factors and stratified by age (&lt;28 and 29–60 days), with LP, antibiotic administration, and hospitalization as dependent variables and hospital-level procalcitonin testing as the independent variable. RESULTS We studied 106 547 index visits. From 2010 to 2019, rates of LP, antibiotic administration, and hospitalization decreased more for infants aged 29 to 60 days compared with infants aged 0 to 28 days (annual decrease in odds of LP, antibiotics administration, and hospitalization: 0 to 28 days: 5%, 5%, and 3%, respectively; 29–60 days: 15%, 12%, and 7%, respectively). Procalcitonin testing increased significantly each calendar year (odds ratio per calendar year 2.19; 95% confidence interval 1.82–2.62), with the majority (91.1%) performed during 2017–2019. From 2017 to 2019, there was no association between hospital-level procalcitonin testing and any outcome studied (all P values &gt; .05). CONCLUSIONS Rates of LP, antibiotic administration, and hospitalization decreased significantly for infants 29 to 60 days during 2010–2019. Although procalcitonin testing increased during 2017–2019, we found no association with hospital-level procalcitonin testing and patterns of resource use.