Wait times for cancer surgery in Ontario have increased over the last decade. We reviewed trends in wait times for endometrial cancer surgery from 1996 to 2000 and identified determinants that may need to be addressed in order to reduce these wait times.
The study population included women diagnosed with endometrial cancer (ICD-9 codes 179 or 182) prior to surgery. Surgical wait time was defined as the interval between date of diagnosis and hospital admission for surgery. Univariate analyses assessed demographic, treatment, and hospital factors associated with wait times. A multilevel linear regression model was created to account for clustering of patients at the hospital level and regional level defined by local health integration networks (LHINs). Effects of covariates were expressed as estimates of the median proportional change in wait time.
There were 2042 cases in this analysis. Mean wait time increased from 32 to 40 days (P = 0.0012). Prolonged wait times were associated with age > 70 years, presence of comorbidities, and surgery performed at a teaching hospital and by a gynaecologic oncologist. Wait times were not associated with income level or region of residence defined by LHIN.
Wait times for endometrial cancer surgery have increased significantly in Ontario. Determinants of these prolonged wait times need to be addressed, and criteria for referral to a teaching hospital and gynaecologic oncologist should be developed to ensure that local health integration networks provide equal and timely access to care.
To determine whether seeking advice prior to an unscheduled visit to a pediatric emergency department (PED) influences appropriate use of this setting for minor illnesses.
Cross-sectional questionnaire survey.
The medical emergency department of the Montreal (Quebec) Children's Hospital, a major referral and urban teaching hospital.
Four hundred eighty-nine of 562 consecutive parents visiting the PED over two periods, one in February and the other in July 1989.
Parents of children between 0 and 18 years of age visiting the PED were asked whether they had previously sought advice from family, friends, or a physician. Other factors possibly related to the decision to seek care were also measured. Appropriateness was rated, blind to discharge diagnosis, by two pediatricians using a structured series of questions incorporating the child's age, time of the visit, clinical state, and problem at presentation. Thirty-four percent of visits among respondents were judged appropriate. In bivariate analysis, appropriate visits occurred significantly more often when a parent spoke to both a physician and a nonphysician (47%) prior to visiting the PED than when no advice was sought (29%; P
Hospitalization can significantly disrupt sleeping patterns. In consideration of the previous reports of insomnia and apparent widespread use of benzodiazepines and other hypnotics in hospitalized patients, we conducted a study to assess quality of sleep and hypnotic drug use in our acute care adult patient population. The primary objectives of this study were to assess sleep disturbance and its determinants including the use of drugs with sedating properties.
This single-centre prospective study involved an assessment of sleep quality for consenting patients admitted to the general medicine and family practice units of an acute care Canadian hospital. A validated Verran and Snyder-Halpern (VSH) Sleep Scale measuring sleep disturbance, sleep effectiveness, and sleep supplementation was completed daily by patients and scores were compared to population statistics. Patients were also asked to identify factors influencing sleep while in hospital, and sedating drug use prior to and during hospitalization was also assessed.
During the 70-day study period, 100 patients completed at least one sleep questionnaire. There was a relatively even distribution of males versus females, most patients were in their 8th decade of life, retired, and suffered from multiple chronic diseases. The median self-reported pre-admission sleep duration for participants was 8 hours and our review of PharmaNet profiles revealed that 35 (35%) patients had received a dispensed prescription for a hypnotic or antidepressant drug in the 3-month period prior to admission. Benzodiazepines were the most common sedating drugs prescribed. Over 300 sleep disturbance, effective and supplementation scores were completed. Sleep disturbance scores across all study days ranged 16-681, sleep effectiveness scores ranged 54-402, while sleep supplementation scores ranged between 0-358. Patients tended to have worse sleep scores as compared to healthy non-hospitalized US adults in all three scales. When compared to US non-hospitalized adults with insomnia, our patients demonstrated sleep disturbance and supplementation scores that were similar on Day 1, but lower (i.e. improved) on Day 3, while sleep effectiveness were higher (i.e. better) on both days. There was an association between sleep disturbance scores and the number of chronic diseases, the presence of pain, the use of bedtime tricyclic antidepressants, and the number of chronic diseases without pain. There was also an association between sleep effectiveness scores and the length of hospitalization, the in hospital use of bedtime sedatives and the presence of pain. Finally, an association was identified between sleep supplementation scores and the in hospital use of bedtime sedatives (tricyclic antidepressants and loxapine), and age. Twenty-nine (29%) patients received a prescription for a hypnotic drug while in hospital, with no evidence of pre-admission hypnotic use. The majority of these patients were prescribed zopiclone, lorazepam or another benzodiazepine.
The results of this study reveal that quality of sleep is a problem that affects hospitalized adult medical service patients and a relatively high percentage of these patients are being prescribed a hypnotic prior to and during hospitalization.
Cites: Med Lett Drugs Ther. 2000 Aug 7;42(1084):71-210932303
How well can hospital discharge abstracts be used to estimate patient health status? This paper compares information on comorbidity obtained from hospital discharge abstracts for patients undergoing prostatectomy or cholecystectomy at a Winnipeg teaching hospital with clinical data on preoperative medical conditions prospectively collected during an Anesthesia Follow-up study. The diagnostic information on cardiovascular disease, respiratory disease, and metabolic disorders showed considerable agreement, ranging from 65 to over 90% correspondence across the two data sets. Certain conditions noted by the anesthesiologist were often absent from the claims data; cardiovascular disease was recorded in the clinical data but absent from the claims for 31% of prostatectomy and 17% of cholecystectomy cases. Such patients were less likely to have been assigned a high score on the ASA Physical Status measure or to have high-risk diagnoses on the hospital file. Similar findings resulted from comparing the two sources in their ability to predict such adverse outcomes as mortality and readmission to hospital: the anesthesia file generally included less serious comorbidity.
This paper reports a prospective study of the incidence and magnitude of delays in the discharge of 80 elderly (65+ years old) patients admitted to two general medical services in teaching hospitals in Edmonton, Alberta. The average length of stay was 16.6 days. Discharges were delayed in 14% (11/80) patients, accounting for 21% of the total days stay. Patients whose discharge was delayed tended to be older, to have delirium and/or dementia, to more often come from or require transfer to long term care (LTC) institutions, and/or to be dependent in essential activities of daily living. The 4-Score, an index for predicting non-medical days, was useful in identifying patients at risk for delays in discharge, and had a sensitivity of 0.82, and a specificity of 0.90. Interventions to reduce delays in discharge must address the frail nature of the patients, their lack of support and existing administrative relationships with LTC institutions. Acute care hospitals will likely need to undertake formal programs for the long term care of many of these patients.
The authors tried to determine whether housestaff are systematically assigned clinic patients who are more "difficult": the elderly, the poor, those with many problems, and those who cannot speak English. This cross-sectional study was carried out in the outpatient department of a university health care insurance. A systematic sample of 1,870 patient visits to the medical clinic from 1980 to 1986 was studied. Housestaff were more likely to see patients who did not speak English, who had four or more medical problems, who had visited the clinic five or more times, who had been admitted to the hospital or emergency ward, or who had a skin problem. Multivariate analysis of these individual factors, allowing for the effect of each upon the others, showed that only previous hospital or emergency ward admission, native language, and skin disease retained a significant association with housestaff physicians. None of these factors was strongly associated with physician status, as shown by poor predictive accuracy when the multivariate models were used to predict accuracy when the multivariate models were used to predict physician status in 105 patient visits in 1987. While some factors were statistically associated with physician status, the magnitude of the effect of each was small. An explantation, other than bias in patient assignment, was usually apparent. It is possible to organize an outpatient clinic where housestaff care for patients who are similar to those seen by faculty.
To assess factors influencing length of stay in a 12-bed rheumatic disease unit of a university associated teaching hospital with secondary and tertiary care responsibilities for a geographically broad referral base.
Patient discharges over a 12-month period were studied and divided into 3 categories.
In Category 1, 167 patients with a mean age of 47.12 had a hospital stay of 1-14 days. Within this group was a subgroup of 30 patients with systemic lupus erythematosus, mean age of 30.13 receiving iv pulse cyclophosphamide who had multiple admissions. Their omission elevated the mean age to 50.87. In Category 2, 81 patients with a mean age of 59, had a hospital stay of 15-28 days and in Category 3, 24 patients with a mean age of 50.9 were hospital stay of 15-28 days and in Category 3, 24 patients with a mean age of 50.9 were hospitalized more than 29 days. Principal diagnosis, major complications of disease, complications of procedure and treatment and concurrent nonrheumatologic pathologies were analyzed for each group. The presence of a large number of comorbid pathologies in Groups 1 and 2 relate to the tertiary referral nature of the practice. Category 2, the group with the higher mean age had more treatment related complications in the form of adverse reactions to 2nd line agents and nonsteroidal antiinflammatory drugs. The 24 patients in Category 3 showed an equal sex distribution and are noted for the presence of infectious agent arthritis, requiring longterm iv antibiotics, both as a principal diagnosis, and as a complication of other pathologies. Vasculitis as a complication of preexisting disease and as a principal diagnosis was also a feature of this group.
Length of stay above the 14 day mean relates to disease severity and serious complications such as vasculitis or joint sepsis requiring prolonged treatment.
The average length of in-patient stay (LOS) in Japan is longer than that of the other Organization for Economic Cooperation and Development (OECD) countries. The tendency towards long LOS is also apparent in teaching hospitals in Japan. This paper examines factors responsible for the long LOS in teaching hospitals, focusing on conditions of residency training. The study was conducted as a part of the first nation-wide study of teaching hospitals for postgraduate medical education in Japan and covered most teaching hospitals (61 university hospitals out of 80 and 153 non-university general hospitals out of 193). The multivariate analysis suggested that longer LOS was more common in the hospitals with lower autopsy rate per bed, higher operation rate per admission, and smaller number of in-patients (P