BackgroundThe use of comorbidities in risk adjustment for health outcomes research is frequently necessary to explain some of the observed variations. Medical charts reviews to obtain information on comorbidities is laborious. Increasingly, electronic health care databases have provided an alternative for health services researchers to obtain comorbidity information. However, the rates obtained from databases may be either over- or under-reported. This study aims to (a) quantify the agreement between administrative data and medical charts review across a set of comorbidities; and (b) examine the factors associated with under- or over-reporting of comorbidities by administrative data.MethodsThis is a retrospective cross-sectional study of patients aged 55 years and above, hospitalized for pneumonia at 3 acute care hospitals. Information on comorbidities were obtained from an electronic administrative database and compared with information from medical charts review. Logistic regression was performed to identify factors that were associated with under- or over-reporting of comorbidities by administrative data.ResultsThe prevalence of almost all comorbidities obtained from administrative data was lower than that obtained from medical charts review. Agreement between comorbidities obtained from medical charts and administrative data ranged from poor to very strong (kappa 0.01 to 0.78). Factors associated with over-reporting of comorbidities were increased length of hospital stay, disease severity, and death in hospital. In contrast, those associated with under-reporting were number of comorbidities, age, and hospital admission in the previous 90 days.ConclusionsThe validity of using secondary diagnoses from administrative data as an alternative to medical charts for identification of comorbidities varies with the specific condition in question, and is influenced by factors such as age, number of comorbidities, hospital admission in the previous 90 days, severity of illness, length of hospitalization, and whether inhospital death occurred. These factors need to be taken into account when relying on administrative data for comorbidity information.

ObjectivesThis study aimed to determine if the risk of adverse outcomes (in-hospital and 60-day mortality, intensive care unit (ICU) and total hospital length of stay (LOS)) was greater for medical ICU (MICU) or high dependency unit (HDU) patients indirectly admitted from the emergency department (ED) than for directly admitted patients.SettingThis study was conducted at a large public acute care hospital in Singapore.ParticipantsIn this retrospective cohort study, hospital records of patients who were admitted directly from the ED, or initially admitted to the general wards from the ED and subsequently transferred to the MICU/HDU within 24 h, were reviewed. Patients were included if they were: (A) discharged from the MICU/HDU in 2009 and were admitted from the ED and (B) transferred to the MICU/HDU within 24 h of presentation at the ED. Data from 706 patients were analysed; 58.4% were men with a median age of 61 years.Primary and secondary outcome measuresThe following outcomes were compared: in-hospital mortality, 60-day mortality, LOS at the MICU/HDU, as well as total hospital LOS.ResultsOf the 706 patients, 491 (69.5%) were directly admitted to the MICU/HDU. After adjusting for demographics, comorbidities, interventions at the ED and clinical parameters at the ED (heart rate, respiration, oxygen saturation, mean arterial pressure), as well as the Apache II score on arrival at the MICU/HDU, indirectly admitted patients had a higher risk of in-hospital mortality (OR=3.07, 95% CI 1.39 to 6.80), death within 60 days (OR=3.09, 95% CI 1.40 to 6.83) and risk of staying >1 day at the MICU/HDU (OR=2.54, 95% CI 1.48 to 4.36). There was no significant difference in total in-hospital LOS.ConclusionsIndirectly admitted MICU/HDU patients had generally poorer outcomes. As the magnitude of effect may vary across settings, context-specific studies may be useful for improving outcomes.

The aim of this study is to investigate the effects of inhaled furosemide on the sensation of dyspnea produced during exercise in patients with stable chronic obstructive pulmonary disease (COPD). In a double-blind, randomized, crossover study we compared the effect of inhaled furosemide on dyspneic sensation during exercise testing with that of placebo. Spirometry and incremental and constant-load exercise testing were performed after inhalation of placebo or furosemide on 2 separate days in 19 patients with moderate or severe COPD. Subjects were asked to rate their sensation of respiratory discomfort using a 100-mm visual analog scale. There was significant improvement in mean FEV1 and FVC after inhalation of furosemide (p = 0.038 and 0.005, respectively) but not after placebo. At standardized exercise time during constant-load exercise testing but not during incremental exercise, the mean dyspneic visual analog scale score was lower after inhalation of furosemide compared with placebo (33.7 +/- 25.2 vs. 42.4 +/- 24.0 mm, respectively, p = 0.014). We conclude that inhalation of furosemide alleviates the sensation of dyspnea induced by constant-load exercise testing in patients with COPD and that there is significant bronchodilation after inhalation of furosemide compared with placebo in these patients.

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Introduction: This study determines the extent of, and factors associated with, delayed discharges for stroke patients from inpatient rehabilitation. Materials and Methods: A retrospective cohort study utilising medical notes review was conducted at an inpatient rehabilitation centre in Singapore. Acute stroke patients (n = 487) admitted between March 2005 and December 2006 were studied. The primary measure was delayed discharge defi ned as an extension in inpatient stay beyond the planned duration. Factors associated with delays in discharge were categorised as individual, caregiver, medical and organisational. Results: There were a total of 172 delayed discharges (35.6%). The mean [standard deviation (SD)] length of stay was 40.5 days (SD, 19.5 days) and 25.8 days (SD, 11.4 days) for patients with delayed and prompt discharges, respectively. Mean extension of stay was 9.7 days (SD, 13.8 days). Caregiver-related reasons were cited for 79.7% of the delays whereas organisational factors (awaiting nursing home placement, investigations or specialist appointments) accounted for 17.4%. Four factors were found to be independently associated with delayed discharge: discharge to the care of foreign domestic helper, nursing home placement, lower admission Functional Independence Measure (FIM) motor score and discharge planning process. Conclusions: Our study suggests that caregiver and organisational factors were main contributors of delayed discharge. Targeted caregiver training and the provision of post-discharge support may improve the confidence of caregivers of patients with greater motor disability. The use of structured discharge planning programmes may improve the efficiency of the rehabilitation service. To reduce delays, problems with the supply of formal and informal post-discharge care must also be addressed. Key words: Caregiver, Discharge planning, Length of stay, Nursing home