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Background: Slow hospital discharges reduce efficiency and compromise care for patients awaiting a bed. Although efficient discharge is a widely held goal, the natural history of the discharge process has not been well studied., Objective: To describe the discharge process and identify factors associated with longer and later discharges., Design: Prospective cohort study., Setting: A general medicine ward without house-staff coverage, in a tertiary care hospital (The Johns Hopkins Hospital) in Baltimore, Maryland, from January 1, 2005 to April 30, 2005., Patients: Two hundred and nine consecutively discharged adult inpatients., Measurements: Discharge time (primary outcome) and discharge duration (secondary outcome)., Results: Median discharge time was 3:09 PM (25th% to 75th%: 1:08 to 5:00 PM). In adjusted analysis, discharge time was associated with ambulance used on discharge (1.5 hours), prescriptions filled prior to discharge (1.4 hours), subspecialty consult prior to discharge (1.2 hours), and procedure prior to discharge (1.1 hours). Median duration of the discharge process was 7 hours 34 minutes (25th% to 75th%: 4.0 to 22.0 hours). Discharge duration was associated with discharge to a location other than home (28.9 hours), and with need for consultation (14.8 hours) or a procedure (13.4 hours) prior to discharge (all P values <0.05)., Conclusions: Discharge time and duration have wide variability. Longer and later discharges were associated with procedures and consults. Successful efforts to decrease time of discharge will require broad institutional effort to improve delivery of interdepartmental services., ((c) 2009 Society of Hospital Medicine.)

Background and Purpose: Previous studies have shown that midlife systolic blood pressure (SBP) predicts late-life cognitive decline and incident dementia. This study explores whether this association is attributable to the pulsatile, ie, pulse pressure (PP), or the nonpulsatile component of blood pressure (BP)., Methods: Data are from the Honolulu-Asia Aging Study, a community-based study of Japanese American men. Midlife BP was measured in 1971 to 1974 and dementia assessment was conducted in late-life. The 2505 men who were dementia free in 1991 and had complete follow-up data were re-examined for incident dementia in 1994 to 1996 and 1997 to 1999. Their age ranged from 71 to 93 years. Survival analysis with age as the time scale was performed to estimate the risk (hazard ratio [HR] and 95% CI) for incident dementia associated with mid- and late-life tertiles of PP and mean arterial BP, as well as SBP and diastolic BP categories., Results: Over a mean of 5.1 years of follow-up, 189 cases (7.5%) of incident Alzheimer disease or vascular dementia were identified. After adjustment for cerebrovascular risk factors, dementia was significantly associated with SBP (HR 1.77; 95% CI, 1.10 to 2.84, for SBP > or =140 mm Hg compared with SBP <120 mm Hg), but not with PP tertiles. Limiting the analysis to those never treated with antihypertensives, high levels of all 4 BP components were significantly associated with dementia. In models with 2 BP components, only SBP remained significant in both the total sample and the never-treated subgroup (HR 2.29; 95% CI, 1.23 to 4.25, for SBP > or =140 mm Hg in total sample), whereas PP was not significantly associated with the risk for dementia., Conclusions: Midlife PP is not independently associated with dementia incidence. Midlife SBP is the strongest BP component predicting incident dementia.

Purpose of Review: Given the continuous relations of blood pressure to cardiovascular risk, any definition of high blood pressure is arbitrary, and based on thresholds at which there is clear evidence that treatment benefits outweigh potential risks. This review examines what constitutes optimal blood pressure., Recent Findings: A recent report raised the possibility of an age- and sex-dependent threshold for risk associated with systolic blood pressure, questioning the use of a single threshold (such as 140/90 mmHg) for defining hypertension. Several subsequent studies have questioned this notion and reemphasized that lower blood pressure levels are associated with less morbidity and mortality even within the nonhypertensive range. A recent meta-analysis confirmed that a blood pressure of 115/75 mmHg is associated with minimal vascular mortality and likely constitutes optimal blood pressure. Such blood pressure levels are infrequent in westernized societies. The target blood pressure goal for treated hypertensives is higher at 140/90 mmHg but is infrequently achieved. Select individuals at high absolute risk of cardiovascular disease events and/or with specific conditions (notably diabetes, renal insufficiency and prior vascular disease) may benefit from blood pressure lowering below this threshold., Summary: At a population level, a blood pressure of 115/75 mmHg seems optimal because it is associated with minimal vascular risk. Over half of all hypertensives do not have their blood pressure controlled underscoring the challenges facing health care providers. Efforts should be strengthened for the primary prevention of hypertension and the promotion of optimal blood pressure through lifestyle measures.