The purpose of this study was to investigate whether physicians with larger sepsis caseloads provide better outcomes, defined as lower in-hospital mortality rates, for patients with sepsis.
Retrospective cross-sectional study.
This study used pooled data from the 2002-2004 Taiwan National Health Insurance Research Database. A total of 48,336 patients hospitalized with a principal diagnosis of septicemia were selected and assigned to 1 of 4 caseload groups on the basis of their treating physician's sepsis caseload during the 3 years reflected in the pooled data (low caseload, less than 39 cases; medium caseload, 39-88 cases; high caseload, 89-176 cases; and very high caseload, more than 176 cases). Generalized estimating equation models were used for analysis.
Receipt of treatment from physicians in the very high, high, and medium caseload groups decreased patients' odds of in-hospital mortality by 49% (95% confidence interval [CI], 0.41-0.67; P < .001), 40% (95% CI, 0.53-0.68; P < .001), and 18% (95% CI, 0.73-0.92; P < .001), respectively, compared with the odds for patients treated by low-caseload physicians. These findings persisted after partitioning out systematic physician-specific and hospital-specific variation and isolating the effects of most hospital, physician, and patient confounders.
Patients treated by physicians who had a larger sepsis caseload had a substantially lower in-hospital mortality rate than did patients treated by physicians in the other caseload groups, and the difference was statistically significant. This result supports the "practice makes perfect" hypothesis.
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[Show abstract][Hide abstract]ABSTRACT: Despite the recent attention to patient safety and quality of care, no prior studies have addressed outcomes of hospitalization for pneumonia among patients with schizophrenia. This study investigated the extent to which clinical outcomes of pneumonia were different among patients with schizophrenia. This study used data from the Taiwan National Health Insurance Research Database. Of the total of 81,599 patients admitted with a principal diagnosis of pneumonia from 2002 to 2004, 949 had previously been admitted with a principal or secondary diagnosis of schizophrenia within the 2 years of their index pneumonia admission. We randomly selected 2847 pneumonia patients matched with the study group in terms of gender, age, year of admission, length of stay, and Charlson Comorbidity Index score as the comparison cohort. Conditional logistic regression models were used for analysis. Findings indicated a higher prevalence of adverse outcomes among patients with schizophrenia. Patients with schizophrenia were independently associated with a 1.81 times greater risk of intensive care unit admission (95% confidence interval [CI] = 1.37-2.40), a 1.37 times greater risk of acute respiratory failure (95% CI = 1.08-1.88), and a 1.34-fold greater risk of mechanical ventilation (95% CI = 1.04-1.92) after adjusting for characteristics of patients, physicians, hospitals, and potential clustering effects. Adjusted odds ratios were further evident among those treated in private hospitals and in regional/district hospitals. Significant barriers to prompt and appropriate medical care for pneumonia persist for patients with schizophrenia. Careful monitoring of physical health and proper integration between psychiatrists and physicians should be stressed to reduce poor clinical outcomes in this vulnerable population.
Full-text · Article · Mar 2010 · Schizophrenia Bulletin
[Show abstract][Hide abstract]ABSTRACT: The epidemiologic data of severe sepsis are limited in developing countries. Among patients, the contribution of subsequent severe sepsis episodes to the disease burden is unclear.
We analyzed the hospitalization claims data of a nationally representative sample of 200,000 people, approximately 1% of the population, enrolled in the Taiwan National Health Insurance program. We identified first and subsequent episodes of severe sepsis hospital admissions from 1997 to 2006 based on International Classification of Diseases, 9th ed., Clinical Modification codes for infections and acute organ dysfunction.
During the 10-year period, we identified 5,258 patients having 7,531 hospitalizations for severe sepsis in the study cohort. The age-standardized annual incidence rates of first episodes increased by 1.6-fold from 135 per 100,000 in 1997 to 217 per 100,000 in 2006, with an annual percent change of 3.9% (95% CI, 2.3%-5.5%). Although the proportion of patients with multiorgan (>or= 2) dysfunctions increased from 11.7% in 1997 to 27.6% in 2006, the hospital mortality changed little, averaging 30.8%. Among survivors, 34.4% developed at least one subsequent severe sepsis episode, which contributed 30.2% to the disease burden in 10 years.
The incidence and disease severity of severe sepsis in Taiwan are increasing. One-third of the survivors developed at least one subsequent episode, which contributed substantially to the disease burden over time.
[Show abstract][Hide abstract]ABSTRACT: In-hospital diagnosis delay (IHDD) of pulmonary tuberculosis (TB) has a significant impact on nosocomial TB transmission. We investigated the risk factors associated with prolonged IHDD in Taiwan, a high-resource, mid-incidence area.
Between January 2005 and August 2006, we retrospectively enrolled 193 consecutive hospitalized patients. All of them had culture-proven pulmonary TB and did not receive antitubercular treatment at admission. IHDD was defined as the interval between admission and initiation of antitubercular treatment. Patients were grouped according to the median value of IHDD.
The median IHDD was 7 days. Patients with IHDD > 7 days were considered the prolonged-delay group, and those with IHDD <or= 7 days, the short-delay group. Independent risk factors [with adjusted odd ratios (95% confidence intervals)] for prolonged IHDD were: negative sputum smear [47.53 (13.20-171.18), p < 0.001]; non-cavitary lesions on chest radiographs [14.90 (3.46-64.14), p < 0.001]; admission to hospital departments other than chest medicine/infectious diseases [6.60 (1.95-22.41), p = 0.002]; exposure to fluoroquinolones before antitubercular treatment [5.29 (1.13-24.75), p = 0.034]; underlying malignancy [4.59 (1.13-18.67), p = 0.033); and age > 65 years [3.19 (1.01-10.05), p = 0.048]. Death attributed to tuberculosis was associated with positive sputum smear (hazard ratio = 21.85; 95% CI = 2.74-174.44; p = 0.004) but not prolonged IHDD (p = 0.325).
To minimize IHDD, clinicians should carefully manage hospitalized patients with risk factors for prolonged delay, such as those with negative sputum smears, non-cavitary lesions on chest radiographs, admission to departments other than chest medicine/infectious diseases, exposure to fluoroquinolones before antitubercular treatment, underlying malignancy, and age > 65 years.
No preview · Article · Apr 2010 · Journal of the Formosan Medical Association