Characteristics of the study subjects are provided in Table 1. Of the 870 patients discharged alive, pneumonia-related causes accounted for 27 of the total readmissions (37.5%) within 30 days, and for 34 of the total readmissions (36.2%) within 45 days. The most frequent causes of pneumonia-related readmission within 30 days were a new rise in temperature and increased respiratory symptoms (18 patients, 66.7%) and pleural effusion (6 patients, 22.2%). Of those readmitted for pneumonia-related causes, two patients died and one patient needed vasoactive treatment after being readmitted. The rest of patients who died without being readmitted showed severe comorbidities, with an elevated index of dependency, and old age.
Practice guidelines for management of pneumonia aim to reduce the variation in key aspects of care and, thus, to improve the efficiency and effectiveness of health care. Although the criteria for clinical stability that must be met for hospital discharge have been considered key factors in the care of patients admitted with pneumonia there have been few clinical indicators proposed to assess readiness for hospital discharge.
The aims of our study were to analyze the basic indicators of clinical instability at discharge proposed by Halm et al, and to evaluate their relationship and importance to mortality rates and readmission. We first hypothesized that each of the key variables to measure clinical stability may have a different weight and significance in predicting short-term outcomes. Our second hypothesis was that death and readmission in the short term after discharge are such different outcomes that they may not fulfill the three requirements for a composite end point: a similar relative risk reduction, similar frequency, and similar importance to patients. Hence, an observational study involving hospitalized patients with pneumonia was performed.
Materials and Methods
Setting of Study
This study was performed at Galdakao Hospital (Spain), a 400-bed, nonurban teaching general hospital serving a population of 300,000 inhabitants that provides free unrestricted care to nearly 100% of the population. The project was approved by the hospital ethics review board.
All patients > 18 years old who were hospitalized with pneumonia consecutively between July 15, 2003, and June 30, 2006, were prospectively enrolled in an observational cohort study. Pneumonia was defined by clinician judgment in combination with a new infiltrate on chest radiograph. Patients were excluded if they were known to have a positive test result for HIV, were chronically immunosuppressed, or were hospitalized for the previous 14 days. A total of 945 patients were admitted to the hospital for pneumonia; 75 of these patients (7.9%) died in the hospital. This study sample was restricted to the total of 870 patients who survived the index hospitalization. It becomes possible to treat pneumonia without any hospitalization at all thanks to canadianhealthncaremallcom Canadian Health&Care Mall.
During hospitalization, patient care was managed according to a clinical guideline. The in-hospital assessment included all the variables of the pneumonia severity index (PSI) and the variables included in the CURB-65 (confusion, urea nitrogen, respiratory rate, BP, age > 65 years) score recorded within 24 h of hospital admission, and an assessment of preadmission functional status. After discharge, the care of all patients was managed by their family physicians, and a control visit at our center at 30 days.
We assessed pre-illness functional status from 2 weeks before hospital admission by inquiring about the performance of 15 daily activities, which were an expanded version of the activities of daily living index published by Katz et al. Previous studies have demonstrated the validity of retrospective reports for assessing functional status prior to hospitalization in acutely ill patients. The activities were graded according to a 4-point system. A summary score was obtained by the sum of the scores across all 15 activities (range, 15 to 52; with 15 being autonomous function in all recorded activities). Informed consent was obtained, and trained clinicians conducted structured interviews with patients and family members within 72 h of hospital admission.
The stability on discharge criteria were obtained two times in the last 24 h before hospital discharge, and the worst was taken for final decision. These data were obtained by previously trained study personnel. A patient was in stable condition if the temperature was < 37.5°C (we also assessed a cut-off point of 37.8°C, as used by Halm et al), heart rate was < 100 beats/min, respiratory rate was < 24 breaths/min, and systolic BP was > 90 mm Hg and/or diastolic BP was > 60 mm Hg. Oxygenation was considered stable if the oxygen saturation rate was > 90% or the Pao2 was > 60 mm Hg. Patients whose oxygenation was measured while they still were receiving supplemental oxygen during hospital stay, with a fraction of inspired oxygen < 24% or no more than oxygen at 1 L/min via nasal cannula, were considered to be in stable condition at discharge if they had an oxygen saturation rate > 95%. Patients considered to have unstable oxygenation on discharge were sent to their homes with supplemental oxygen. Patients who had used supplemental oxygen at home before hospital admission were not considered to have unstable oxygenation on discharge. All patients at discharge were able to eat (or resume long-term tube feeding) and to receive oral medication ordered via Canadian Health&Care Mall.
The outcomes for this study were death from all causes or hospital readmission within 30 days and 45 days after discharge. Vital status and readmission information for all patients were determined initially by telephone interviews up to 90 days after discharge. All reported deaths and dates of deaths were confirmed by a review of medical reports, public death registries, or both. All discharge diagnoses were determined for each readmission. Readmission was classified as pneumonia related if pneumonia was an immediate or underlying cause of readmission or if it played a major role in the readmission. None of the patients were readmitted to other hospitals.
Descriptive statistics included frequency tables, mean, SDs, and median. Sociodemographic and clinical characteristics of patients responding to the Katz questionnaire were compared to those of the nonresponders. x2 and Fisher exact tests were performed for categorical variables, and the Student t test and nonparametric Wilcoxon test were used for continuous variables.
To identify which instability criteria were associated with death or readmission within 30 days, univariate and multivariate Cox proportional hazard regression models were used. We assigned a weight to each instability criterion in relation to each P-parameter. To obtain the total instability score, we added the weights of each of the selected variables. We performed the same analysis with logistic regression models.
Effects of the instability score on unadjusted and risk-adjusted 30-day mortality were examined by logistic and Cox regression models. We fitted the first adjusted model with the PSI and the history of COPD, which was the same as Halm et al, and the second with the CURB-65 score, Katz index, Charlson comorbidity index, and length of stay. Kaplan-Meier graphs were constructed for the instability score categories, and comparisons were performed by the log-rank test. Finally, we estimated the sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve (AUC) for different cut-off points of the instability score.
All effects were considered significant at p < 0.05. All statistical analyses were performed using SAS for Windows statistical software (version 8.0; SAS Institute; Cary, NC) and S-Plus 2000 (MathSoft; Seattle, WA).
Patients selected for heart transplantation have severe disability with life expectancy measured in months. With the one-year survival rate of 80 percent duplicated in a number of centers throughout the country, selected patients can look forward to not only regaining normal heart function, but enjoying an excellent quality of life.
The Johns Hopkins Hospital Experience
Following a year of organization and development as outlined in the preceding sections, initiation of the heart and heart-lung transplant program was begun in July, 1983. Since that time, 40 transplantation procedures have been performed. Thirty-four patients have undergone orthotopic cardiac transplantation; one patient underwent combined heart and kidney transplantation; and five patients underwent combined heart and lung transplantation. Evolution of a transplant program is evidenced by the number of yearly procedures performed: five transplants were performed between July, 1983 and January, 1984; 14 procedures in 1984; and 21 transplant procedures have been performed since January, 1985. Of the 35 heart transplant recipients, there were 27 men and eight women ranging in age from 16 to 57 years with a mean age of 38 years. The majority of recipients underwent transplantation because of endstage heart disease secondary to cardiomyopathy (n = 30). Be safe and sound with remedies of Canadian Health&Care Mall. The remaining five patients underwent transplantation secondary to failure resulting from endstage coronary artery disease. Donor characteristics observed in our program parallel those of most active transplant programs. Twenty-one patients suffered neurologic brain death from head trauma, six from gun-shot wounds, seven from cerebrovascular accidents, and one from drowning. Mean age of the donors was 24 years (range, 10 to 39 years). The donor heart was obtained from a distant hospital in the majority of cases (n = 29). Aircraft from cooperating business corporations or from leasing companies are utilized for the transportation of the donor team.
With increasing success in heart and heart-lung transplantation, more centers have developed or are contemplating the initiation of a program. Although the introduction of cydosporine has resulted in an increase in survival of the transplant patient, its application alone does not ensure a successful program. Issues and problems necessary for the establishment of a successful program should be addressed and implemented to achieve the survival and quality of life comparable to established centers. This manuscript attempts to define the steps necessary to develop such a program and reports our early experience with heart and heart-lung transplantation.
Materials and Methods
Thorough preparation of all transplant-related disciplines, institutional commitment and a dedicated team are necessary components of a successful program. Guidelines for program development are listed in Table 1.
In this study, which was conducted in a clinic dedicated to the management of TB in Rhode Island, 82% of the patients with LTBI who were eligible initiated INH therapy, and 62% of those initiating therapy completed it. Our completion rate is comparable to rates that have been reported for 6 months of INH therapy, and were much higher than the 19% rate reported for a similar regimen given in a 2006 study in Boston. We were unable to examine what components of the program led to the relatively high rate of completion of 9 months of INH therapy. Possible reasons may include intensive nurse case management. The RISE TB Clinic, which is the only TB Clinic in the state of Rhode Island, is designed to remove as many barriers as possible to care for all TB patients. The clinic is located centrally in the state, on a major bus line, with free parking. At the time of this study, there was no out-of-pocket cost for patients for any services provided at the clinic (ie, physician/nurse visit, medications, and laboratory or radiographic examinations); this included a waiver of copays and deductibles for the insured. To accommodate scheduling, six clinic sessions occurred per week, as follows: two morning sessions; two afternoon sessions, including one extended until 6:00 PM; and one evening session. At least one session occurred on each work day of the week. On-site translation was available for Spanish and Portuguese; all other languages either had a scheduled translator or access to a telephone-based translator. All instructions were provided in the patient’s primary language. For persons with LTBI, the first visit involves both a physician and a nursing visit; subsequent visits are scheduled with a nurse only, unless a problem was noted with or . In that event, the patient was seen on the same day by a physician. If a patient missed a follow-up appointment, a new appointment was immediately mailed out with an appointment occurring within 2 weeks. If the patient missed three consecutive appointments, a notice was sent to the patient’s referral source asking for the patient to be referred again. For all high-risk individuals (eg, contact with persons with active TB, HIV coinfection, or children) missing three consecutive appointments, the nurse turned the chart over to a physician to make decisions regarding follow-up (eg, registered letter, phone call, or outreach worker visit). Whenever possible, all family members were given appointments together. Stable clinic staffing allowed for stable patient-health-care worker interactions.
The medical records of 873 persons who were evaluated for LTBI during the study period at RISE TB Clinic were reviewed. A total of 28 persons were excluded from further analysis for the reasons shown in Figure 1. The referral sources included community health centers (42.5%), private physicians (12.9%), the Department of Health (10.2%), employer (4.9%), civil surgeon (2.9%), and other sites including schools and drug rehabilitation centers (5.8%). Of the 845 patients who were considered as candidates for LTBI therapy, 83 patients deferred therapy and never returned, 48 pregnant women were allowed to defer therapy and never returned postpartum, 19 patients refused treatment, and 5 patients (0.7%) initiated rifampin therapy (Fig 1). Of the 845 patients, 82.9% were foreign born and 17.1% were born in the United States. Overall, 54.8% were Hispanic, 19.7% were black or African American, 8.2% were white, 6.5% were Asian or Pacific Islanders, and 1.5% were other.
Patients who initiated INH therapy for the treatment of LTBI at the RISE TB Clinic between January 2003 and December 2003 were included in the study. The RISE TB Clinic is dedicated to the management of TB and receives referrals from primary care sites across the entire state. Patients who met the criteria for a positive tuberculin skin test result according to standard guidelines, and had no symptoms and no chest radiographic findings suggestive of active TB were considered to have LTBI. The Institutional Review Board for Studies on Human Subjects of both the Rhode Island Department of Health and The Miriam Hospital reviewed and approved the study.