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OBJECTIVE:To quantify the contribution of acute versus postacute care factors to survival and functional outcomes after hip fracture. DESIGN, SETTING, AND PARTICIPANTS:Retrospective cohort study using Medicare data; subjects included previously ambulatory nursing home residents hospitalized for hip fracture between 2005 and 2009. METHODS:We used logistic regression to measure the associations of hospital and nursing home factors with functional and survival outcomes at 30 and 180 days among patients discharged to a nursing facility; we quantified the contribution of hospital versus nursing home factors to outcomes by the ω statistic. RESULTS:Among 45,996 hospitalized patients, 1814 (3.9%) died during hospitalization. A total of 42,781 (93%) were discharged alive to a nursing home. Of these, 12,126 (28%) died within 180 days and 20,479 (48%) died or were newly unable to walk within 180 days. Hospital characteristics were not consistently associated with outcomes. Multiple nursing home characteristics predicted 30- and 180-day outcomes, including bed count, chain membership, and performance on selected quality measures. Nursing home factors explained 3 times more variation in the odds of 30-day mortality than did hospital factors [ω, hospital vs. nursing home0.32; 95% confidence interval (CI), 0.11, 0.96], 7 times more variation in the odds of 180-day mortality (ω0.15; 95% CI, 0.04, 0.61), and 8 times more variation in the odds of 180-day death or new dependence in locomotion (ω0.12; 95% CI, 0.05, 0.31). CONCLUSIONS:Nursing home factors explain a larger proportion of the variation in clinical outcomes following hip fracture than do hospital factors.

ObjectiveDetermine impact of using delivery criteria to initiate antibiotics among very low birth weight (VLBW) and extremely low birth weight (ELBW) infants.Study designSingle site cohort study from 01/01/2009 to 01/31/2020. After 04/2017, infants delivered by Cesarean section, without labor or membrane rupture were categorized as low-risk for early-onset infection and managed without empiric antibiotics. We determined effect of this guideline by pre-post, and interrupted time-series analyses.ResultsAfter 04/2017, antibiotic initiation ≤3 days decreased among low-risk VLBW (62% vs. 13%, p < 0.001) and low-risk ELBW (88% vs. 21%, p < 0.001) infants. In time series analysis, guideline was associated with decreased initiation among low-risk ELBW infants. In contrast, low-risk VLBW infants demonstrated decreased antibiotic initiation throughout study period. Incidence of confirmed infection, death, or transfer ≤7 days age was unchanged.ConclusionDelivery criteria may be used to optimize early antibiotic initiation among preterm infants without short-term increase in adverse outcomes.

Background Severe maternal morbidity (SMM) is a significant complication associated with preterm delivery. However, most studies have focused solely on SMM during the delivery hospitalization, without differentiating by preterm birth subtype or examining postpartum SMM and readmissions. Objective To examine the association between preterm birth subtypes and SMM during delivery hospitalization, up to 1-year postpartum, and postpartum readmissions within 365 days. Study design We conducted a retrospective cohort study using linked birth and fetal death certificates and maternal hospital discharge data from Michigan, Oregon, and South Carolina (2008–2020). Modified Poisson regression models were used to estimate adjusted relative risks (aRR) and 95% confidence intervals (CI) for SMM during delivery hospitalization, postpartum SMM, and readmissions, stratified by preterm birth subtype. Models were adjusted for birth year, state, insurance type, education, maternal age, race/ethnicity, and adequacy of prenatal care. Results Among 2,570,808 deliveries, 156,763 (6.1%) were spontaneous preterm births and 70,877 (2.8%) were medically indicated preterm births. For medically indicated preterm births, the aRR for SMM during delivery hospitalization were 18.0 (95% CI 16.7–19.4) at ≤ 31 weeks, 14.5 (95% CI 13.2–15.8) at 32–33 weeks, and 6.7 (95% CI 6.3–7.1) at 34–36 weeks. For spontaneous preterm births, the corresponding aRRs were 7.5 (95% CI 7.0–8.0), 6.4 (95% CI 5.9-7.0), and 3.1 (95% CI 2.9–3.3), respectively. During the postpartum period, elevated risks of SMM persisted for both subtypes. For medically indicated preterm births, aRRs for postpartum SMM ranged from 3.4 (95% CI 3.0-3.9) at ≤ 31 weeks to 2.1 (95% CI 2.0-2.3) at 34–36 weeks. For spontaneous preterm births, aRRs for postpartum SMM ranged from 2.0 (95% CI 1.8–2.2) at ≤ 31 weeks to 1.6 (95% CI 1.5–1.7) at 34–36 weeks. Postpartum readmission risk was also elevated for both subtypes. Conclusion Preterm delivery, particularly when medically indicated, is strongly associated with increased risk of SMM during delivery hospitalization, throughout the postpartum period, and with postpartum readmissions. These findings suggest that individuals experiencing preterm birth, especially medically indicated preterm deliveries, may benefit from targeted postpartum monitoring and follow-up, including earlier clinical contacts and closer surveillance for complications beyond the standard 6-week postpartum visit.