Teaching hospitals and quality of care: a review of the literature

Costs of hospital malnutrition

BACKGROUND & AIMS

Hospital malnutrition has been established as a critical, prevalent, and costly problem in many countries. Many cost studies are limited due to study population or cost data used. The aims of this study were to determine: the relationship between malnutrition and hospital costs; the influence of confounders on, and the drivers (medical or surgical patients or degree of malnutrition) of the relationship; and whether hospital reported cost data provide similar information to administrative data. To our knowledge, the last two goals have not been studied elsewhere.

METHODS

Univariate and multivariate analyses were performed on data from the Canadian Malnutrition Task Force prospective cohort study combined with administrative data from the Canadian Institute for Health Information. Subjective Global Assessment was used to assess the relationship between nutritional status and length of stay and hospital costs, controlling for health and demographic characteristics, for 956 patients admitted to medical and surgical wards in 18 hospitals across Canada.

RESULTS

After controlling for patient and hospital characteristics, moderately malnourished patients' (34% of surveyed patients) hospital stays were 18% (p = 0.014) longer on average than well-nourished patients. Medical stays increased by 23% (p = 0.014), and surgical stays by 32% (p = 0.015). Costs were, on average, between 31% and 34% (p-values < 0.05) higher than for well-nourished patients with similar characteristics. Severely malnourished patients (11% of surveyed patients) stayed 34% (p = 0.000) longer and had 38% (p = 0.003) higher total costs than well-nourished patients. They stayed 53% (p = 0.001) longer in medical beds and had 55% (p = 0.003) higher medical costs, on average. Trends were similar no matter the type of costing data used.

CONCLUSIONS

Over 40% of patients were found to be malnourished (1/3 moderately and 1/10 severely). Malnourished patients had longer hospital stays and as a result cost more than well-nourished patients.

A widening gap? Static and dynamic performance differences between specialist and general hospitals

This paper develops and tests a dynamic model of hospital focus. It does so by tracing the performance trajectories of specialist and general hospitals to identify whether a performance gap exists and whether it widens or shrinks over time. Our longitudinal analyses of all hospital organizations within the English National Health Service (NHS) reveal not only a notable performance gap between specialist and general hospitals in particular with regards to patient satisfaction that widens over time, but also the emergence of a gap especially with regards to hospital staff job satisfaction. These findings reflect the considerable potential of specialization as a means to enhance hospital effectiveness. However, they also alert health policy makers to the threat of a widening performance gap between specialist and general hospitals with potential negative repercussions at the patient and health system level.

Impact of Resident Involvement on Morbidity in Adult Patients Undergoing Fusion for Spinal Deformity

STUDY DESIGN

A retrospective study of prospectively collected data.

OBJECTIVE

The aim of this study was to determine whether patients undergoing spinal deformity surgery with resident involvement are at an increased risk of morbidity.

SUMMARY OF BACKGROUND DATA

Resident involvement has been investigated in other orthopedic procedures but has not been studied in adult spinal deformity surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current procedural terminology (CPT) codes were used to query the database for adults who underwent fusion for spinal deformity between 2005 and 2012. Patients were separated into propensity score matched groups of those with and without resident involvement. Univariate analysis and multivariate logistic regression were used to analyze the effect of resident involvement on the incidence of postoperative morbidity and other surgical outcomes.

RESULTS

Resident involvement was an independent predictor of overall morbidity [odds ratio (OR) 2.2, P < 0.0001], wound complication (OR 2.5, P = 0.0252), intra-/postoperative transfusion (OR 2.3, P < 0.0001), and length of stay > 5 days (OR 2.0, P < 0.0001). However, resident involvement was not an independent predictor for other complications, such as mortality.

CONCLUSION

Resident participation was associated with significantly longer operative times. As a result, higher rate of certain morbidity, but not mortality, was found, specifically for complications that have been previously associated with long operative duration.

LEVEL OF EVIDENCE

3.

Do university hospitals perform better than general hospitals? A comparative analysis among Italian regions

OBJECTIVE

The aim of this research was to investigate how university hospitals (UHs) perform compared with general hospitals (GHs) in the Italian healthcare system.

DESIGN AND SETTING

27 indicators of overall performance were selected and analysed for UHs and GHs in 10 Italian regions. The data refer to 2012 and 2013 and were selected from two performance evaluation systems based on hospital discharge administrative data: the Inter-Regional Performance Evaluation System developed by the Management and Health Laboratory of the Scuola Superiore Sant'Anna of Pisa and the Italian National Outcome Evaluation Programme developed by the National Agency for Healthcare Services. The study was conducted in 2 stages and by combining 2 statistical techniques. In stage 1, a non-parametric Mann-Whitney U test was carried out to compare the performance of UHs and GHs on the selected set of indicators. In stage 2, a robust equal variance test between the 2 groups of hospitals was carried out to investigate differences in the amount of variability between them.

RESULTS

The overall analysis gave heterogeneous results. In general, performance was not affected by being in the UH rather than the GH group. It is thus not possible to directly associate Italian UHs with better results in terms of appropriateness, efficiency, patient satisfaction and outcomes.

CONCLUSIONS

Policymakers and managers should further encourage hospital performance evaluations in order to stimulate wider competition aimed at assigning teaching status to those hospitals that are able to meet performance requirements. In addition, UH facilities could be integrated with other providers that are responsible for community, primary and outpatient services, thereby creating a joint accountability for more patient-centred and integrated care.

Trainee participation and perioperative complications in benign hysterectomy: the effect of route of surgery

BACKGROUND

Intraoperative trainee involvement in hysterectomy is common. However, the effect of intraoperative trainee involvement on perioperative complications depending on surgical approach is unknown.

OBJECTIVE

To estimate the effect of intraoperative trainee involvement on perioperative complication after vaginal, laparoscopic, and abdominal hysterectomy for benign disease.

METHODS

Patients undergoing laparoscopic, vaginal, or abdominal hysterectomy for benign disease from 2010 to 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with and without trainee involvement were compared with regard to perioperative complications. Complications that occurred from the start of surgery to 30-days postoperatively were included. Perioperative complications were defined via the use of the validated Clavien-Dindo scale with ≥grade 3 complications defined as major and ≤grade 2 complications defined as minor. Major complications included myocardial infarction, pneumonia, venous thromboembolism, deep or organ space surgical-site infection, stroke, fascial dehiscence, unplanned return to the operating room, renal failure, cardiopulmonary arrest, sepsis, intubation greater than 48 hours, and death. Minor complications included urinary tract infection, blood transfusion, and superficial wound infection. To estimate the effect of trainee involvement depending on route of surgery, a stratified analysis was performed. Bivariable analysis and adjusted multivariable logistic regression were used.

RESULTS

We identified 22,499 patients, of whom 42.1% had trainee participation. Surgical approaches were vaginal (22.7%), abdominal (47.1%), and laparoscopic (30.2%). The rate of major complication was 3.2%, and minor complication was 7.2%. In bivariable analysis, trainee involvement was associated with major complications in vaginal hysterectomy (3.3% vs 2.3%, P = .03), but not laparoscopic (3.0% vs 2.9%, P = .78) or abdominal hysterectomy (4.4% vs 3.6%, P = .07). Trainee involvement was also associated with minor complication in vaginal (7.3% vs 5.4%, P = .007), laparoscopic (5.9% vs 4.3%, P < .001), and abdominal hysterectomy (14.1% vs 9.2%, P < .001). In a multivariable analysis in which we adjusted for age, body mass index, medical comorbidity, American Society of Anesthesiologists score, and surgical complexity, the association between trainee involvement in vaginal hysterectomy and major complication persisted (adjusted odds ratio 1.45, 95% confidence interval 1.03-2.04); however, when operative time was added to the model, there was no longer an association between trainee involvement and major complication (adjusted odds ratio 1.26, 95% confidence interval 0.89-1.80).

CONCLUSION

Surgical approach influences the relationship between trainee involvement and perioperative complication. Operative time is a key mediator of the relationship between trainee involvement and complication, and may be a modifiable risk factor.

Association between Hospital Birth Volume and Maternal Morbidity among Low-Risk Pregnancies in Rural, Urban, and Teaching Hospitals in the United States

Objectives This study aims to examine the relationship between hospital birth volume and multiple maternal morbidities among low-risk pregnancies in rural hospitals, urban non-teaching hospitals, and urban teaching hospitals, using a representative sample of U.S. hospitals. Study Design Using the 2011 Nationwide Inpatient Sample from 607 hospitals, we identified 508,146 obstetric deliveries meeting low-risk criteria and compared outcomes across hospital volume categories. Outcomes include postpartum hemorrhage (PPH), chorioamnionitis, endometritis, blood transfusion, severe perineal laceration, and wound infection. Results Hospital birth volume was more consistently related to PPH than to other maternal outcomes. Lowest-volume rural (< 200 births) and non-teaching (< 650 births) hospitals had 80% higher odds (adjusted odds ratio [AOR] = 1.80; 95% CI = 1.56-2.08) and 39% higher odds (AOR = 1.39; 95% CI = 1.26-1.53) of PPH respectively, than those in corresponding high-volume hospitals. However, in urban teaching hospitals, delivering in a lower-volume hospital was associated with 14% lower odds of PPH (AOR = 0.86; 95% CI = 0.80-0.93). Deliveries in rural hospitals had 31% higher odds of PPH than urban teaching hospitals (AOR = 1.31; 95% CI = 1.13-1.53). Conclusions Low birth volume was a risk factor for PPH in both rural and urban non-teaching hospitals, but not in urban teaching hospitals, where higher volume was associated with greater odds of PPH.

The influence of race and hospital environment on the care of patients with cervical spine fractures

BACKGROUND

The influence of non-white race on outcomes following orthopedic injury has been described in the past. The impact of such factors on hospital processes and quality of care after spinal trauma is less well understood.

STUDY DESIGN

A cohort control study using the Massachusetts Statewide Inpatient Dataset (2003-2010) was used as the study design.

PURPOSE

This study aimed to determine whether (1) hospital processes and quality of care associated with the treatment of cervical spine fractures was significantly altered by non-white race and (2) whether findings were different among those treated at academic medical centers (AMCs).

SAMPLE

The study comprised 10,841 patients.

OUTCOMES

Surgical rate, postoperative morbidity, mortality, and length of stay (LOS) were the outcome measures.

METHODS

Baseline differences between cohorts were evaluated using chi-square or Wilcoxon rank sum tests. Logistic and negative binomial regression techniques were used to adjust for confounders, including whether a surgical intervention was performed. Subset analyses were performed to evaluate whether findings were different for individuals treated at AMCs.

RESULTS

The rate of surgical intervention was not significantly different between non-whites and whites (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.82-1.04). LOS (regression coefficient [RC] 0.18, 95% CI 0.13-0.23), mortality (OR 1.49, 95% CI 1.20-1.85), and complications (OR 1.17, 95% CI 1.02-1.33) were significantly increased among non-white patients. These findings were largely preserved among those treated at AMCs.

CONCLUSIONS

Our results reinforce the fact that efforts at universal access to care may be insufficient to reduce differences in care among minority patients following cervical trauma. Future mixed-methods research is necessary to more effectively evaluate the etiologies behind health-care disparities associated with race in different health-care environments.

LEVEL OF EVIDENCE

The level of evidence is Level III, prognostic study.

Risk Adjusting Survival Outcomes in Hospitals That Treat Patients With Cancer Without Information on Cancer Stage

IMPORTANCE

Instituting widespread measurement of outcomes for cancer hospitals using administrative data is difficult owing to lack of cancer-specific information such as disease stage.

OBJECTIVE

To evaluate the performance of hospitals that treat patients with cancer using Medicare data for outcome ascertainment and risk adjustment and to assess whether hospital rankings based on these measures are altered by the addition of cancer-specific information.

DESIGN, SETTING, AND PARTICIPANTS

Risk-adjusted cumulative mortality rates of patients with cancer were captured in Medicare claims data from 2005 through 2009 nationally and assessed at the hospital level. Similar analyses were conducted using Surveillance, Epidemiology, and End Results (SEER)-Medicare data for the subset of the United States covered by the SEER program to determine whether the inclusion of cancer-specific information (only available in cancer registries) in risk adjustment altered measured hospital performance. Data were from 729 279 fee-for-service Medicare beneficiaries treated for cancer in 2006 at hospitals treating 10 or more patients with each of the following cancers, according to Medicare claims: lung, prostate, breast, colon, and other. An additional sample of 18 677 similar patients were included from the SEER-Medicare administrative data.

MAIN OUTCOMES AND MEASURES

Risk-adjusted mortality overall and by cancer category, stratified by type of hospital; measures of correlation and agreement between hospital-level outcomes risk adjusted using Medicare data alone and Medicare data with SEER data.

RESULTS

There were large survival differences between different types of hospitals that treat Medicare patients with cancer. At 1 year, mortality for patients treated by hospitals exempt from the Medicare prospective payment system was 10% lower than at community hospitals (18% vs 28%) across all cancers, and the pattern persisted through 5 years of follow-up and within specific cancer categories. Performance ranking of hospitals was consistent with or without SEER-Medicare disease stage information (weighted κ ≥ 0.81).

CONCLUSIONS AND RELEVANCE

Potentially important outcome differences exist between different types of hospitals that treat patients with cancer after risk adjustment using information in Medicare administrative data. This type of risk adjustment may be adequate for evaluating hospital performance, since the additional adjustment for data available only in cancer registries does not seem to appreciably alter measures of performance.

Does Practice Type Determine the Complexity of Patients Encountered for Orthognathic Surgery?

PURPOSE

This study sought to determine whether the type of oral and maxillofacial surgery (OMS) practice dictated the complexity of patients encountered for orthognathic surgery and to determine whether there were meaningful differences in comorbidities between patient groups.

MATERIALS AND METHODS

This was a retrospective cohort study of orthognathic surgical patients operated on by surgeons at an academic medical center (AMC; OMS department at the University of Alabama-Birmingham) compared with a private practice (PP) group that also operated at the AMC auxiliary facility. Surgical procedures included in this study were Le Fort osteotomy, bilateral sagittal split osteotomy, genioplasty, and combinations of these procedures. An experienced surgeon scrutinized the medical records of the AMC and PP groups for age, gender, medical history, American Society of Anesthesiologists (ASA) classification, and indications for surgical procedures. These data were statistically compared for differences in patient complexity.

RESULTS

The average age of patients in the 2 groups was similar (AMC, 29 yr; PP, 27 yr). Many more females were treated in the PP setting (male-to-female ratio, 1.06:1 in the AMC group and 1:1.6 in the PP group). The AMC group had a larger percentage of patients with medical comorbidities, a larger proportion of patients with ASA class 2 or 3, and a larger proportion of patients who underwent procedures for reasons other than malocclusion or cosmetic purposes, and these proportions were statistically relevant. Average length of surgery and average length of stay were longer in the AMC group.

CONCLUSION

This retrospective cohort study suggests that OMS departments in AMCs tend to treat orthognathic surgical patients with increased comorbidities and systemic illnesses and operate on a larger percentage of patients with concomitant dentofacial issues versus more routine dentofacial skeletal and occlusion deformities.

Impact of Hospital Operating Margin on Central Line-Associated Bloodstream Infections Following Medicare's Hospital-Acquired Conditions Payment Policy

In October 2008, Medicare ceased additional payment for hospital-acquired conditions not present on admission. We evaluated the policy's differential impact in hospitals with high vs low operating margins. Medicare's payment policy may have had an impact on reducing central line-associated bloodstream infections in hospitals with low operating margins. Infect. Control Hosp. Epidemiol. 2015;37(1):100-103.

Inpatient Pediatric Tonsillectomy: Does Hospital Type Affect Cost and Outcomes of Care?

OBJECTIVE

To ascertain whether hospital type is associated with differences in total cost and outcomes for inpatient tonsillectomy.

STUDY DESIGN

Cross-sectional analysis of the 2006, 2009, and 2012 Kids' Inpatient Database (KID).

SUBJECTS AND METHODS

Children ≤18 years of age undergoing tonsillectomy with/without adenoidectomy were included. Risk-adjusted generalized linear models assessed for differences in hospital cost and length of stay (LOS) among children managed by (1) non-children's teaching hospitals (NCTHs), (2) children's teaching hospitals (CTHs), and (3) nonteaching hospitals (NTHs). Risk-adjusted logistic regression compared the odds of major perioperative complications (hemorrhage, respiratory failure, death). Models accounted for clustering of patients within hospitals, were weighted to provide national estimates, and controlled for comorbidities.

RESULTS

The 25,685 tonsillectomies recorded in the KID yielded a national estimate of 40,591 inpatient tonsillectomies performed in 2006, 2009, and 2012. The CTHs had significantly higher risk-adjusted total cost and LOS per tonsillectomy compared with NCTHs and NTHs ($9423.34/2.8 days, $6250.78/2.11 days, and $5905.10/2.08 days, respectively; P < .001). The CTHs had higher odds of complications compared with NCTHs (odds ratio [OR], 1.48; 95% CI, 1.15-1.91; P = .002) but not when compared with NTHs (OR, 1.19; 95% CI, 0.89-1.59; P = .23). The CTHs were significantly more likely to care for patients with comorbidities (P < .001).

CONCLUSION

Significant differences in costs, outcomes, and patient factors exist for inpatient tonsillectomy based on hospital type. Although reasons for these differences are not discernable using isolated claims data, findings provide a foundation to further evaluate patient, institutional, and system-level factors that may reduce cost of care and improve value for inpatient tonsillectomy.

Outcome, Use of Resources and Their Relationship in the Treatment of AMI, Stroke and Hip Fracture at European Hospitals

The aim of the present study was to compare the quality (survival), use of resources and their relationship in the treatment of three major conditions (acute myocardial infarction (AMI), stroke and hip fracture), in hospitals in five European countries (Finland, Hungary, Italy, Norway and Sweden). The comparison of quality and use of resources was based on hospital-level random effects models estimated from patient-level data. After examining quality and use of resources separately, we analysed whether a cost-quality trade-off existed between the hospitals. Our results showed notable differences between hospitals and countries in both survival and use of resources. Some evidence would support increasing the horizontal integration: higher degrees of concentration of regional AMI care were associated with lower use of resources. A positive relation between cost and quality in the care of AMI patients existed in Hungary and Finland. In the care of stroke and hip fracture, we found no evidence of a cost-quality trade-off. Thus, the cost-quality association was inconsistent and prevailed for certain treatments or patient groups, but not in all countries.

Anterior cervical discectomy and fusion: is surgical education safe?

BACKGROUND

Operative skills are key to neurosurgical resident training. They should be acquired in a structured manner and preferably starting early in residency. The aim of this study was to test the hypothesis that the outcome and complication rate of anterior cervical discectomy and fusion with or without instrumentation (ACDF(I)) is not inferior for supervised residents as compared to board-certified faculty neurosurgeons (BCFN).

METHODS

This was a retrospective single-center study of all consecutive patients undergoing ACDF(I)-surgery between January 2011 and August 2014. All procedures were dichotomized into two groups according to the surgeon's level of experience: teaching cases (postgraduate year (PGY)-2 to PGY-6 neurosurgical residents) and non-teaching cases operated by BCFN. The primary study endpoint was patients' clinical outcome 4 weeks after surgery, categorized into a binary responder and non-responder variable. Secondary endpoints were complications, need for re-do surgery, and clinical outcome until the last follow-up.

RESULTS

After exclusion of six cases because of incomplete data, a total of 287 ACDF(I) operations were enrolled into the study, of which 82 (29.2 %) were teaching cases and 199 (70.8 %) were non-teaching cases. Teaching cases required a longer operation time (131 min (95 % confidence interval (CI) 122-141 min) vs. 102 min (95-108 min; p < 0.0001) and were associated with a slightly higher estimated blood loss (84 ml (95 % CI 56-111 ml) vs. 57 ml (95 % CI 47-66 ml); p = 0.0017), while there was no difference in the rate of intraoperative complications (2.4 vs. 1.5 %; p = 0.631). Four weeks after surgery, 92.7 and 93 % of the patients had a positive response to surgery (p = 1.000), respectively. There was no difference in the postoperative complication rate (4.9 vs. 3.0 %; p = 0.307). Around 30 % of the study patients were followed up in outpatient clinics for more than once up until a mean period of 6.4 months (95 % CI 5.3-7.6 months). At the last follow-up, the clinical outcome was similar with a 90 % responder rate for both groups (p = 0.834). In total, five patients from the teaching group and eight patients from the non-teaching group required re-do surgery (p = 0.602).

CONCLUSIONS

Short- and mid-term outcomes and complication rates following microscopic ACDF(I) were comparable for patients operated on by supervised neurosurgical residents or by senior surgeons. Our data thus indicate that a structured neurosurgical education of operative skills does not lead to worse outcomes or increase the complication rates after ACDF(I). Confirmation of the results by a prospective study is desired.

Prevalence and Predictors of Gastrostomy Tube and Tracheostomy Placement in Anoxic/Hypoxic Ischemic Encephalopathic Survivors of In-Hospital Cardiopulmonary Resuscitation in the United States

Introduction

Current prevalence estimates of gastrostomy tube (GT) /tracheostomy placement in hospitalized patients with anoxic/hypoxic ischemic encephalopathic injury (AHIE) post cardiopulmonary resuscitation (CPR) are unknown. We sought, to estimate the prevalence of AHIE in hospitalized patients who had CPR and to identify patient/hospital level factors that predict the performance of GT/tracheostomy in those with AHIE.

Methods

We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2004–2010). All patients who developed AHIE following CPR were included. In this cohort the odds of having GT and tracheostomy was computed by multivariable logistic regression analysis. Patient and hospital level factors were the independent variables.

Results

During the study period, a total of 686,578 CPR events occurred in hospitalized patients. Of these, 94,336 (13.7%) patients developed AHIE. In this AHIE cohort, 6.8% received GT and 8.3% tracheostomy. When compared to the 40–49 yrs age group, those aged >70 yrs were associated with lower odds for GT (OR = 0.65, 95% CI:0.53–0.80, p<0.0001). Those aged <18 years & those >60 years were associated with lower odds for having tracheostomy when compared to the 40–49 years group (p<0.0001). Each one unit increase in co-morbid burden was associated with higher odds for having GT (OR = 1.23,p<0.0001) or tracheostomy (OR = 1.17, p<0.0001). Blacks, Hispanics, Asians/Pacific Islanders, and other races were associated with higher odds for having GT or tracheostomy when compared to whites (p<0.05). Hospitals located in northeastern regions were associated with higher odds for performing GT (OR = 1.48, p<0.0001) or tracheostomy (OR = 1.63, p<0.0001) when compared to those in Western regions. Teaching hospitals (TH) were associated with higher odds for performing tracheostomy when compared to non-TH (OR = 1.36, 1.20–1.54, p<0.0001).

Conclusions

AHIE injury occurs in a significant number of in-hospital arrests requiring CPR. Certain predictors of GT/ Tracheostomy placement are identified. Patients in teaching hospitals were more likely to receive tracheostomy than their counterparts.

Use of foreign-educated nurses and patient satisfaction in U.S. hospitals

PURPOSE

In the context of value-based purchasing, this study examines the association between the utilization of foreign-educated registered nurses (RNs) and patient satisfaction among U.S. acute care hospitals.

DATA SOURCES/STUDY SETTING

We utilized data from the Hospital Consumer Assessment of Healthcare Providers and Systems to measure patient satisfaction and data from the American Hospital Association regarding the utilization of foreign-educated RNs in 2012.

METHODOLOGY/APPROACH

In this study, a cross-sectional design with propensity score adjustment to examine the relationship between use of foreign-educated nurses and 10 patient satisfaction outcome measures. Control variables include hospital size, ownership, geographic location, teaching status, system membership, a high-technology index, and U.S. region based on census categories.

FINDINGS

The utilization of foreign-educated RNs was negatively and significantly related to six patient satisfaction measures. Specifically, hospitals with foreign-educated RNs scored, on average, lower on measures related to nurse communication (β = -0.649, p = .01), doctor's communication (β = -0.837, p ≤ .001), communication about administered drugs (β = -0.539, p = .81), and communication about what to do during their recovery at home (β = -0.571, p = .01). Moreover, hospitals utilizing foreign-educated RNs scored, on average, lower on overall satisfaction measures including rating the hospital as 9 or 10 overall (β = -1.20, p = .005), and patients would definitely recommend the hospital (β = -1.32, p = .006).

PRACTICE IMPLICATIONS

Utilization of foreign-educated RNs is negatively associated with measures of patient satisfaction pertaining to communication and overall perceptions of care. Hospitals that utilize foreign-educated RNs should consider strategies that enhance communication competency and aid improving perception of care among patients.

Hospital academic status and value of care for nonmetastatic colon cancer

PURPOSE

The relationship between oncologic hospital academic status and the value of care for stage II and III colon cancer is unknown.

METHODS

Retrospective SEER-Medicare analysis of patients age ≥ 66 years with stage II or III colon cancer and seen by medical oncology. Eligible patients were diagnosed 2000 to 2009 and followed through December 31, 2010. Hospitals reporting a major medical school affiliation in the NCI Hospital File were classified as academic medical centers. The association between hospital academic status and survival was assessed using Kaplan-Meier curves and Cox proportional hazards models. The association with mean cost of care was estimated using generalized linear models with log link and gamma family and with cost of care at various quantiles using quantile regression models.

RESULTS

Of 24,563 eligible patients, 5,707 (23%) received care from academic hospitals. There were no significant differences in unadjusted disease-specific median survival or adjusted risk of colon cancer death by hospital academic status (stage II hazard ratio = 1.12; 95% CI, 0.98 to 1.28; P = .103; stage III hazard ratio = 0.99; 95% CI, 0.90 to 1.08; P = .763). Excepting patients at the upper limits of the cost distribution, there was no significant difference in adjusted cost by hospital academic status.

CONCLUSION

We found no survival differences for elderly patients with stage II or III colon cancer, treated by a medical oncologist, between academic and nonacademic hospitals. Furthermore, cost of care was similar across virtually the full range of the cost distribution.

Cardiopulmonary resuscitation of pregnant women in the emergency department

AIM

Little is known about outcomes of cardiopulmonary resuscitation (CPR) in pregnancy. The purpose of this study was to determine the prognostic value of pregnancy in women receiving CPR in the emergency department (ED).

METHODS

We conducted a population-based, matched cohort study using the Nationwide Emergency Department Sample (NEDS) from 2006 to 2010. A cohort of pregnant women receiving CPR in the ED was compared to an age-matched cohort of non-pregnant women at a 1:10 ratio. Conditional logistic regression was used to calculate the odds ratio (OR) and corresponding 95% confidence intervals (95% CIs) for variables of interest and survival.

RESULTS

Among 8162 women requiring CPR in the ED, we identified 157 pregnant women. Pregnancy was associated with better overall survival of 36.9% compared to 25.9% in non-pregnant women, OR 1.89 (1.32-2.70), p < 0.01. Traumatic injury was identified as a significant predictor of outcome in pregnancy. In non-trauma patients, pregnant women had significantly better odds of surviving CPR than non-pregnant women, OR 2.10 (1.41-3.13), p < 0.01. In cases of trauma, no significant difference was observed between groups.

CONCLUSION

Although further studies are needed, CPR in pregnancy is associated with a better prognosis compared to non-pregnant women, with trauma status being a key factor predicting outcome in the pregnant patient.

Facility characteristics and quality of lung cancer care in an integrated health care system

INTRODUCTION

In a national, integrated health care system, we sought to identify facility-level attributes associated with better quality of lung cancer care.

METHODS

Adherence to 23 quality indicators across four domains (Diagnosis and Staging, Treatment, Supportive Care, End-of-Life Care) was assessed through abstraction of electronic records from 4804 lung cancer patients diagnosed in 2007 at 131 Veterans Health Administration facilities. Performance was reported as proportions of eligible patients fulfilling adherence criteria. With stratification of patients by stage, generalized estimating equations identified facility-level characteristics associated with performance by domain.

RESULTS

Overall performance was high for the older (mean age 67.7 years, SD 9.4 years), predominantly male (98%) veterans. However, no facility did well on every measure, and range of adherence across facilities was large; 9% of facilities were in the highest quartile for one or more domain of care, more than 30% for two, and 65% for three. No facility performed consistently well across all domains. Less than 1% performed in the lowest quartile for all. Few facility-level characteristics were associated with care quality. For End-of-Life Care, diagnosis and treatment within the same facility, availability of cancer psychiatry/psychology consultation services, and availability of both inpatient and outpatient palliative care consultation services were associated with better adherence.

CONCLUSIONS

Quality of Veterans Health Administration lung cancer care is generally high, though substantial variation exists across facilities. With the exception of the salutary impact of palliative care consultation services on end-of-life quality of care, observed facility-level characteristics did not consistently predict adherence to indicators, suggesting quality may be determined by complex local factors that are difficult to measure.

Meeting patients' health information needs in breast cancer center hospitals - a multilevel analysis

BACKGROUND

Breast cancer patients are confronted with a serious diagnosis that requires them to make important decisions throughout the journey of the disease. For these decisions to be made it is critical that the patients be well informed. Previous studies have been consistent in their findings that breast cancer patients have a high need for information on a wide range of topics. This paper investigates (1) how many patients feel they have unmet information needs after initial surgery, (2) whether the proportion of patients with unmet information needs varies between hospitals where they were treated and (3) whether differences between the hospitals account for some of these variation.

METHODS

Data from 5,024 newly-diagnosed breast cancer patients treated in 111 breast center hospitals in Germany were analyzed and combined with data on hospital characteristics. Multilevel linear regression models were calculated taking into account hospital characteristics and adjusting for patient case mix.

RESULTS

Younger patients, those receiving mastectomy, having statutory health insurance, not living with a partner and having a foreign native language report higher unmet information needs. The data demonstrate small between-hospital variation in unmet information needs. In hospitals that provide patient-specific information material and that offer health fairs as well as those that are non-teaching or have lower patient-volume, patients are less likely to report unmet information needs.

CONCLUSION

We found differences in proportions of patients with unmet information needs between hospitals and that hospitals' structure and process-related attributes of the hospitals were associated with these differences to some extent. Hospitals may contribute to reducing the patients' information needs by means that are not necessarily resource-intensive.

The impact of the hospital work environment on social support from physicians in breast cancer care

OBJECTIVE

Research on determinants of a good patient-physician interaction mainly disregards systemic factors, such as the work environment in healthcare. This study aims to identify stressors and resources within the work environment of hospital physicians that enable or hinder the physicians' provision of social support to patients.

METHODS

Four data sources on 35 German breast cancer center hospitals were matched: structured hospital quality reports and surveys of 348 physicians, 108 persons in hospital leadership, and 1844 patients. Associations between hospital structures, physicians' social resources as well as job demands and control and patients' perceived support from physicians have been studied in multilevel models.

RESULTS

Patients feel better supported by their physicians in hospitals with high social capital, a high percentage of permanently employed physicians, and less physically strained physicians.

CONCLUSION

The results highlight the importance of the work environment for a good patient-physician interaction. They can be used to develop interventions for redesigning the hospital work environment, which in turn may improve physician satisfaction, well-being, and performance and consequently the quality of care.

PRACTICE IMPLICATIONS

Health policy and hospital management could create conditions conducive to better patient-physician interaction by strengthening the social capital and by increasing job security for physicians.

Impact of Resident Involvement on Orthopaedic Surgery Outcomes: An Analysis of 30,628 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

Operative procedural training is a key component of orthopaedic surgery residency. The influence of intraoperative resident participation on the outcomes of surgery has not been studied extensively using large, population-based databases.

METHODS

We identified 30,628 patients who underwent orthopaedic procedures from the 2011 American College of Surgeons National Surgical Quality Improvement Program. Outcomes as measured by perioperative complications, readmission rates, and mortality within thirty days were compared for cases with and without intraoperative resident involvement.

RESULTS

Logistic regression with propensity score analysis revealed that intraoperative resident participation was associated with decreased rates of overall complications (odds ratio, 0.717 [95% confidence interval, 0.657 to 0.782]), medical complications (odds ratio, 0.723 [95% confidence interval, 0.661 to 0.790]), and mortality (odds ratio, 0.638 [95% confidence interval, 0.427 to 0.951]). Resident presence in the operating room was not predictive of wound complications (odds ratio, 0.831 [95% confidence interval, 0.656 to 1.053]), readmission (odds ratio, 0.962 [95% confidence interval, 0.830 to 1.116]), or reoperation (odds ratio, 0.938 [95% confidence interval, 0.758 to 1.161]). A second analysis by propensity score stratification into quintiles grouped by similar probability of intraoperative resident presence showed resident involvement to correlate with decreased rates of overall and medical complications in three quintiles, but increased rates of overall and medical complications in one quintile. All other outcomes were equivalent across quintiles.

CONCLUSIONS

Orthopaedic resident involvement during surgical procedures is associated with lower risk of perioperative complications and mortality in the National Surgical Quality Improvement Program database. The results support resident participation in the operative care of orthopaedic patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Concurrent and lagged effects of registered nurse turnover and staffing on unit-acquired pressure ulcers

OBJECTIVE

We examined the concurrent and lagged effects of registered nurse (RN) turnover on unit-acquired pressure ulcer rates and whether RN staffing mediated the effects.

DATA SOURCES/SETTING

Quarterly unit-level data were obtained from the National Database of Nursing Quality Indicators for 2008 to 2010. A total of 10,935 unit-quarter observations (2,294 units, 465 hospitals) were analyzed.

METHODS

This longitudinal study used multilevel regressions and tested time-lagged effects of study variables on outcomes.

FINDINGS

The lagged effect of RN turnover on unit-acquired pressure ulcers was significant, while there was no concurrent effect. For every 10 percentage-point increase in RN turnover in a quarter, the odds of a patient having a pressure ulcer increased by 4 percent in the next quarter. Higher RN turnover in a quarter was associated with lower RN staffing in the current and subsequent quarters. Higher RN staffing was associated with lower pressure ulcer rates, but it did not mediate the relationship between turnover and pressure ulcers.

CONCLUSIONS

We suggest that RN turnover is an important factor that affects pressure ulcer rates and RN staffing needed for high-quality patient care. Given the high RN turnover rates, hospital and nursing administrators should prepare for its negative effect on patient outcomes.

Variations in the hospital standardized mortality ratios in Korea

OBJECTIVES

The hospital standardized mortality ratio (HSMR) has been widely used because it allows for robust risk adjustment using administrative data and is important for improving the quality of patient care.

METHODS

All inpatients discharged from hospitals with more than 700 beds (66 hospitals) in 2008 were eligible for inclusion. Using the claims data, 29 most responsible diagnosis (MRDx), accounting for 80% of all inpatient deaths among these hospitals, were identified, and inpatients with those MRDx were selected. The final study population included 703 571 inpatients including 27 718 (3.9% of all inpatients) in-hospital deaths. Using logistic regression, risk-adjusted models for predicting in-hospital mortality were created for each MRDx. The HSMR of individual hospitals was calculated for each MRDx using the model coefficients. The models included age, gender, income level, urgency of admission, diagnosis codes, disease-specific risk factors, and comorbidities. The Elixhauser comorbidity index was used to adjust for comorbidities.

RESULTS

For 26 out of 29 MRDx, the c-statistics of these mortality prediction models were higher than 0.8 indicating excellent discriminative power. The HSMR greatly varied across hospitals and disease groups. The academic status of the hospital was the only factor significantly associated with the HSMR.

CONCLUSIONS

We found a large variation in HSMR among hospitals; therefore, efforts to reduce these variations including continuous monitoring and regular disclosure of the HSMR are required.

OBJECTIVES

The hospital standardized mortality ratio (HSMR) has been widely used because it allows for robust risk adjustment using administrative data and is important for improving the quality of patient care.

METHODS

All inpatients discharged from hospitals with more than 700 beds (66 hospitals) in 2008 were eligible for inclusion. Using the claims data, 29 most responsible diagnosis (MRDx), accounting for 80% of all inpatient deaths among these hospitals, were identified, and inpatients with those MRDx were selected. The final study population included 703 571 inpatients including 27 718 (3.9% of all inpatients) in-hospital deaths. Using logistic regression, risk-adjusted models for predicting in-hospital mortality were created for each MRDx. The HSMR of individual hospitals was calculated for each MRDx using the model coefficients. The models included age, gender, income level, urgency of admission, diagnosis codes, disease-specific risk factors, and comorbidities. The Elixhauser comorbidity index was used to adjust for comorbidities.

RESULTS

For 26 out of 29 MRDx, the c-statistics of these mortality prediction models were higher than 0.8 indicating excellent discriminative power. The HSMR greatly varied across hospitals and disease groups. The academic status of the hospital was the only factor significantly associated with the HSMR.

CONCLUSIONS

We found a large variation in HSMR among hospitals; therefore, efforts to reduce these variations including continuous monitoring and regular disclosure of the HSMR are required.

The Cost and Inpatient Burden of Treating Mandible Fractures

Objective

To discuss patient demographics, hospitalization characteristics, and costs associated with the treatment of mandible fractures.

Study Design

Cross-sectional study.

Setting

The 2009 Nationwide Inpatient Sample (NIS) database.

Subjects/Methods

Patient demographics, hospital characteristics, fracture locations, and common comorbidities for patients with isolated mandible fractures were analyzed, and variables associated with increased cost and length of hospitalization stay were ascertained.

Results

A total of 1481 patients were identified with isolated mandible fractures. The average age was 32, 85.4% were male, 39% were Caucasian, and 25% African American. Forty percent were from the lowest median household income quartile, and 77% were uninsured or government funded. The average length of stay (LOS) was 2.65 days, and average hospitalization cost was $35,804. A statistically significant increased LOS was associated with alcohol abuse, drug abuse, mental illness, diabetes mellitus type 2, cardiovascular disease, HIV, and age over 40. There was a statistically significant increased total cost associated with drug abuse, alcohol abuse, mental illness, cardiovascular disease, and age over 40.

Conclusion

The average cost for treatment of mandible fractures was $35,804 per person with increased expenditures for older patients and those with a history of mental illness, cardiovascular disease, or substance abuse. To improve outcomes and reduce hospital charges, outpatient resources and inpatient protocols should be implemented to address the factors we identified as contributing to higher costs and increased hospital stay.

Paying more wisely: effects of payment reforms on evidence-based clinical decision-making

This article reviews the recent research, policy and conceptual literature on the effects of payment policy reforms on evidence-based clinical decision-making by physicians at the point-of-care. Payment reforms include recalibration of existing fee structures in fee-for-service, pay-for-quality, episode-based bundled payment and global payments. The advantages and disadvantages of these reforms are considered in terms of their effects on the use of evidence in clinical decisions made by physicians and their patients related to the diagnosis, testing, treatment and management of disease. The article concludes with a recommended pathway forward for improving current payment incentives to better support evidence-based decision-making.

The effect of resident participation on short-term outcomes after orthopaedic surgery

BACKGROUND

The influence of resident involvement on short-term outcomes after orthopaedic surgery is mostly unknown.

QUESTIONS/PURPOSES

The purposes of our study were to examine the effects of resident involvement in surgical cases on short-term morbidity, mortality, operating time, hospital length of stay, and reoperation rate and to analyze these parameters by level of training.

METHODS

The 2005–2011 American College of Surgeons National Surgical Quality Improvement Program data set was queried using Current Procedural Terminology codes for 66,817 cases across six orthopaedic procedural domains: 28,686 primary total joint arthroplasties (TJAs), 2412 revision TJAs, 16,832 basic and 5916 advanced arthroscopies, 8221 lower extremity traumas, and 4750 spine arthrodeses (fusions). Bivariate and multivariate logistic regression and propensity scores were used to build models of risk adjustment. We compared the morbidity and mortality rates, length of operating time, hospital length of stay, and reoperation rate for cases with or without resident involvement. For cases with resident participation, we analyzed the same parameters by training level.

RESULTS

Resident participation was associated with higher morbidity in TJAs (odds ratio [OR], 1.6; range, 1.4–1.9), lower extremity trauma (OR, 1.3; range, 1.2–1.5), and fusion (OR, 1.4; range, 1.2–1.7) after adjustment. However, resident involvement was not associated with increased mortality. Operative time was greater (all p < 0.001) with resident involvement in all procedural domains. Longer hospital length of stay was associated with resident participation in lower extremity trauma (p < 0.001) and fusion cases (p = 0.003), but resident participation did not affect length of stay in other domains. Resident involvement was associated with greater 30-day reoperation rates for cases of lower extremity trauma (p = 0.041) and fusion (p < 0.001). Level of resident training did not consistently influence surgical outcomes.

CONCLUSIONS

Results of our study suggest resident involvement in surgical procedures is not associated with increased short-term major morbidity and mortality after select cases in orthopaedic surgery. Findings of longer operating times and differences in minor morbidity should lead to future initiatives to provide resident surgical skills training and improve perioperative efficiency in the academic setting.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

The effect of care setting in the delivery of high-value colon cancer care

BACKGROUND

The effect of care setting on value of colon cancer care is unknown.

METHODS

A Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort study of 6544 patients aged ≥ 66 years with stage IV colon cancer (based on the American Joint Committee on Cancer staging system) who were diagnosed between 1996 and 2005 was performed. All patients were followed through December 31, 2007. Using outpatient and carrier claims, patients were assigned to a treating hospital based on the hospital affiliation of the primary oncologist. Hospitals were classified academic or nonacademic using the SEER-Medicare National Cancer Institute Hospital File.

RESULTS

Of the 6544 patients, 1605 (25%) received care from providers affiliated with academic medical centers. The unadjusted median cancer-specific survival was 16.0 months at academic medical centers versus 13.9 months at nonacademic medical centers (P < .001). After adjustment, treatment at academic hospitals remained significantly associated with a reduced risk of death from cancer (hazard ratio, 0.87; 95% confidence interval [95% CI], 0.82-0.93 [P < .001]). Adjusted mean 12-month Medicare spending was $8571 higher at academic medical centers (95% CI, $2340-$14,802; P = .007). The adjusted median cost was $1559 higher at academic medical centers; this difference was not found to be statistically significant (95% CI, -$5239 to $2122; P = .41). A small percentage of patients who received very expensive care skewed the difference in mean cost; the only statistically significant difference in adjusted costs in quantile regressions was at the 99.9th percentile of costs (P < .001).

CONCLUSIONS

Among Medicare beneficiaries with stage IV colon cancer, treatment by a provider affiliated with an academic medical center was associated with a 2 month improvement in overall survival. Except for patients in the 99.9th percentile of the cost distribution, costs at academic medical centers were not found to be significantly different from those at nonacademic medical centers.

An observational study: associations between nurse-reported hospital characteristics and estimated 30-day survival probabilities

Background

There is a growing body of evidence for associations between the work environment and patient outcomes. A good work environment may maximise healthcare workers’ efforts to avoid failures and to facilitate quality care that is focused on patient safety. Several studies use nurse-reported quality measures, but it is uncertain whether these outcomes are correlated with clinical outcomes. The aim of this study was to determine the correlations between hospital-aggregated, nurse-assessed quality and safety, and estimated probabilities for 30-day survival in and out of hospital.

Methods

In a multicentre study involving almost all Norwegian hospitals with more than 85 beds (sample size=30, information about nurses’ perceptions of organisational characteristics were collected. Subscales from this survey were used to describe properties of the organisations: quality system, patient safety management, nurse–physician relationship, staffing adequacy, quality of nursing and patient safety. The average scores for these organisational characteristics were aggregated to hospital level, and merged with estimated probabilities for 30-day survival in and out of hospital (survival probabilities) from a national database. In this observational, ecological study, the relationships between the organisational characteristics (independent variables) and clinical outcomes (survival probabilities) were examined.

Results

Survival probabilities were correlated with nurse-assessed quality of nursing. Furthermore, the subjective perception of staffing adequacy was correlated with overall survival.

Conclusions

This study showed that perceived staffing adequacy and nurses’ assessments of quality of nursing were correlated with survival probabilities. It is suggested that the way nurses characterise the microsystems they belong to, also reflects the general performance of hospitals.

Perioperative characteristics and outcomes of patients undergoing anterior cervical fusion in July: analysis of the "July effect"

STUDY DESIGN

Retrospective national database analysis.

OBJECTIVE

A national population-based database was analyzed to characterize the "July effect" on the perioperative outcomes of anterior cervical fusions (ACFs).

SUMMARY OF BACKGROUND DATA

Perception biases exist regarding the outcomes of cervical spine surgery based upon the month of admission.

METHODS

The Nationwide Inpatient Sample database was queried from 2009-2011. Patients who underwent an ACF in teaching and nonteaching hospitals were identified and separated into cohorts. Patients who were admitted in July were then compared with non-July admissions in both cohorts. Demographics, Charlson Comorbidity Index, length of stay, costs, postoperative complications, and mortality were assessed.

RESULTS

A total of 52,499 ACF cases were identified in the Nationwide Inpatient Sample of which 26,831 (51.2%) were performed in teaching hospitals and 25,668 (48.8) in nonteaching institutions. July admissions represented 6.8% and 7.4% of cases in the teaching and nonteaching hospital cohorts, respectively. Among July admissions, the teaching cohort incurred a longer hospitalization than the nonteaching cohort (P < 0.05). In contrast, no significant differences in mortality or total hospital costs were demonstrated. In teaching institutions, the in-hospital complications associated with July patients included deep vein thrombosis and surgical site infection (P < 0.05), but this did not reach significance in nonteaching hospitals. Postoperative dysphagia and deep vein thromboses were also significantly more prevalent among July admissions in teaching hospitals compared with nonteaching institutions.

CONCLUSION

This national study demonstrated that the early resident academic year was associated with a greater length of stay among July patients in teaching hospitals. This study did not demonstrate an increase in mortality or total hospital costs among July patients in either hospital cohort. In teaching hospitals, ACF-treated patients in July were associated with a greater incidence of postoperative thromboses and surgical site infection. In addition, the incidence of dysphagia was significantly greater among July patients in teaching hospitals than nonteaching hospitals.

Complications after lumbar spine surgery between teaching and nonteaching hospitals

STUDY DESIGN

Retrospective national database analysis.

OBJECTIVE

A national population-based database was analyzed to characterize the perioperative complications of lumbar spine procedures performed at teaching and nonteaching hospitals.

SUMMARY OF BACKGROUND DATA

Perception biases exist regarding the complications of lumbar spine surgery based upon the hospital teaching environment.

METHODS

Data from the Nationwide Inpatient Sample was queried from 2002-2011. Patients undergoing an anterior lumbar interbody fusion, posterior lumbar interbody fusion, anterior/posterior lumbar fusion, or lumbar decompression to treat lumbar degenerative pathology were identified and separated into cohorts based upon the teaching status of the hospital. Patient demographics, Charlson Comorbidity Index, length of stay, complications, mortality, and costs were assessed.

RESULTS

A total of 658,616 lumbar procedures were identified from 2002-2011, of which 367,875 (55.9%) were performed at teaching hospitals. An older patient population comprised the teaching hospital cohort and demonstrated a greater comorbidity burden than the nonteaching group (Charlson Comorbidity Index 2.90 vs. 2.55; P < 0.001). In addition, the teaching hospital cohort was associated with a significantly greater number of multilevel fusion cases (P < 0.001) and incurred a greater mean length of stay (3.7 vs. 3.0 d; P < 0.001). Patients treated at teaching hospitals demonstrated a significantly greater incidence of postoperative pulmonary embolism, deep vein thrombosis, infection, and neurological complications than the nonteaching cohort (P < 0.001). Overall, there were no significant differences in the mean total hospital costs or mortality between the hospital cohorts. Regression analysis demonstrated that teaching status was not a significant predictor of mortality (OR, 1.02; confidence interval 0.8-1.2; P = 0.8).

CONCLUSION

Patients treated in teaching hospitals for lumbar spine surgery incurred a longer hospitalization and a greater incidence of postoperative complications including pulmonary embolism, deep vein thrombosis, infection, and neurological events. These findings may be explained by an increased complexity of procedures performed at teaching hospitals along with an older and a more comorbid patient population. Despite these differences, the teaching status was not a significant predictor of in-hospital mortality after a lumbar spine surgery.

LEVEL OF EVIDENCE

3.

Is the presence of medical trainees associated with increased mortality with weekend admission?

BACKGROUND

Several studies have demonstrated increased inhospital mortality following weekend admission. We hypothesized that the presence of resident trainees reduces the weekend mortality trends.

METHODS

We identified all patients with a non-elective hospital admission from 1/1/2003 through 12/31/2008. We abstracted vital status on discharge and calculated the Charlson comorbidity score for all inpatients. We compared odds of inpatient mortality following non-elective admission on a weekend day as compared to a weekday, while considering diagnosis, patient characteristics, comorbidity, hospital factors, and care at hospitals with resident trainees.

RESULTS

Data were available for 48,253,968 patient discharges during the six-year study period. The relative risk of mortality was 15% higher following weekend admission as compared to weekday admission. After adjusting for diagnosis, age, sex, race, income level, payer, comorbidity, and weekend admission the overall odds of mortality was higher for patients in hospitals with fewer nurses and staff physicians. Mortality following a weekend admission for patients admitted to a hospital with resident trainees was significantly higher (17%) than hospitals with no resident trainees (p < 0.001).

CONCLUSIONS

Low staffing levels of nurses and physicians significantly impact mortality on weekends following non-elective admission. Conversely, patients admitted to hospitals with more resident trainees had significantly higher mortality following a weekend admission.

Association of hospitalist presence and hospital-level outcome measures among Medicare patients

BACKGROUND

Hospitalists have been shown to lower patient costs through better resource utilization and decreased length of stay, but it is unclear whether hospitalists are associated with quality of care. We examined the association between the presence of hospitalists and 30-day predicted excess all-cause hospital mortality and readmissions among Medicare patients admitted to a hospital with any of 3 conditions: heart failure, acute myocardial infarction, and pneumonia.

METHODS

Using national hospital-level, case mix-adjusted, risk-standardized, 30-day all-cause excess mortality and readmission data from the Centers for Medicare and Medicaid Services, we used descriptive and bivariate statistics to illustrate trends across hospitals. Using multivariable ordinary least squares regression to control for hospital-level characteristics, we then estimated the association between the presence of hospitalists and predicted hospital mortality and readmission.

RESULTS

After multivariable adjustment, the presence of hospitalists was associated with lower probability of readmission for all 3 target conditions. No significant associations for any of the target conditions were found in all-cause mortality models.

CONCLUSIONS

Hospitalists are already integral to the delivery of inpatient care at most institutions. This study, however, showed an association at the national level of the presence of hospitalists with an important and timely quality measure: reduction of readmission rates. Future research is indicated to explore specific causation pathways for the impact of hospitalists on quality of care.

Engagement in research: an innovative three-stage review of the benefits for health-care performance

Background

There is a widely held assumption that research engagement improves health-care performance at various levels, but little direct empirical evidence.

Objectives

To conduct a theoretically and empirically grounded synthesis to map and explore plausible mechanisms through which research engagement might improve health services performance. A review of the effects on patients of their health-care practitioner's or institution's participation in clinical trials was published after submission of the proposal for this review. It identified only 13 relevant papers and, overall, suggested that the evidence that research engagement improves health-care performance was less strong than some thought. We aimed to meet the need for a wider review.

Methods

An hourglass review was developed, consisting of three stages: (1) a planning and mapping stage; (2) a focused review concentrating on the core question of whether or not research engagement improves health care; and (3) a wider (but less systematic) review of papers identified during the two earlier stages. Studies were included inthe focused review if the concept of ‘engagementinresearch’ was an input and some measure of ‘performance’ an output. The search strategy covered the period 1990 to March 2012. MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and other relevant databases were searched. A total of 10,239 papers were identified through the database searches, and 159 from other sources. A further relevance and quality check on 473 papers was undertaken, and identified 33 papers for inclusion in the review. A standard meta-analysis was not possible on the heterogeneous mix of papers in the focused review. Therefore an explanatory matrix was developed to help characterise the circumstances in which research engagement might improve health-care performance and the mechanisms that might be at work, identifying two main dimensions along which to categorise the studies:the degree of intentionalityandthe scope of the impact.

Results

Of the 33 papers in the focused review, 28 were positive (of which six were positive/mixed) in relation to the question of whether or not research engagement improves health-care performance. Five papers were negative (of which two were negative/mixed). Seven out of 28 positive papers reported some improvement in health outcomes. For the rest, the improved care took the form of improved processes of care. Nine positive papers were at a clinician level and 19 at an institutional level. The wider review demonstrated, for example, how collaborative and action research can encourage some progress along the pathway from research engagement towards improved health-care performance. There is also evidence that organisations in which the research function is fully integrated into the organisational structure out-perform other organisations that pay less formal heed to research and its outputs. The focused and wider reviews identified the diversity in the mechanisms through which research engagement might improve health care: there are many circumstances and mechanisms at work, more than one mechanism is often operative, and the evidence available for each one is limited.

Limitations

To address the complexities of this evidence synthesis of research we needed to spend significant time mapping the literature, and narrowed the research question to make it feasible. We excluded many potentially relevant papers (though we partially addressed this by conducting a wider additional synthesis). Studies assessing the impact made on clinician behaviour by small, locally conducted pieces of research could be difficult to interpret without full knowledge of the context.

Conclusions

Drawing on the focused and wider reviews, it is suggested that when clinicians and health-care organisations engage in research there is the likelihood of a positive impact on health-care performance. Organisations that have deliberately integrated the research function into organisational structures demonstrate how research engagement can, among other factors, contribute to improved health-care performance. Further explorations are required of research networks and schemes to promote the engagement of clinicians and managers in research. Detailed observational research focusing on research engagement within organisations would build up an understanding of mechanisms.

Study registration

PROSPERO: CRD42012001990.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Differences in the outcome of patients undergoing percutaneous coronary interventions at teaching versus non-teaching hospitals

BACKGROUND

Teaching hospitals have superior outcomes for major medical conditions including cardiovascular disease compared to non-teaching hospitals. This may not be applicable to invasive cardiac procedures given a potential increase in complications due to trainee participation.

METHODS

We assessed the impact of hospital teaching status on the outcome of 89,048 patients who underwent percutaneous coronary intervention (PCI). Teaching hospitals were defined as trainee involvement in greater than 50% of PCIs conducted at that hospital and corresponded to teaching status granted by national accreditation agencies. Unadjusted and risk adjusted analyses were used to determine differences in process of care, morbidity and mortality.

RESULTS

Of 89,048 patients studied, 30,870 received their PCI at teaching hospitals and 58,178 at non-teaching hospitals. Risk-adjusted analysis showed no significant difference in death, in-hospital myocardial infarction, contrast induced nephropathy or gastrointestinal bleeding between teaching and non-teaching hospitals. PCI at teaching hospitals was associated with a lower rate of emergency coronary artery bypass grafting (OR, 0.63; 95% CI, 0.49-0.83; P = .0009) and an increased rate of vascular complications (OR, 1.33; 95% CI, 1.21-1.46; P < .0001).

CONCLUSIONS

General outcomes of patients undergoing PCI are similar across hospital types. However, PCI at teaching hospitals is associated with increased risk of vascular complications and reduced risk of emergency coronary artery bypass grafting compared to non-teaching hospitals.

Impact of hospital teaching intensity on quality of care and patient outcomes

BACKGROUND

Proposed changes to financing of teaching hospitals and new quality-based performance incentives may differentially impact the financial health of teaching and safety-net institutions. Few data have examined the potential impact of these financial changes on teaching institutions.

OBJECTIVES

To determine the association of hospital teaching intensity with processes and outcomes of care for the most common inpatient diagnoses in the United States.

RESEARCH DESIGN

Cross-sectional analysis of the 2008 Hospital Quality Alliance and 2007 American Hospital Association databases, adjusted for hospital characteristics.

SUBJECTS

A total of 2418 hospitals distributed across the country with available data on teaching intensity (resident-to-bed ratio), quality-of-care process measures, and risk-adjusted readmission and mortality rates for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia.

MEASURES

Hospital-level quality-of-care process indicators and 30-day risk-adjusted readmission and mortality rates for AMI, CHF, and pneumonia.

RESULTS

Multivariable analysis demonstrates that all hospitals perform uniformly well on quality-of-care process measures for AMI, CHF, and pneumonia. However, when compared with nonteaching hospitals, increasing hospital teaching intensity is significantly associated with improved risk-adjusted mortality for AMI and CHF, but higher risk-adjusted readmission rates for all 3 conditions. Among high teaching intensity hospitals, those with larger Medicaid populations (safety-net institutions) had particularly high readmission rates for AMI and CHF.

CONCLUSIONS

In this nationally representative evaluation, we found significant variation in performance on risk-adjusted mortality and readmission rates, and differences in readmission rates based on safety-net status. Our findings suggest that high teaching intensity and safety-net institutions may be disproportionately affected by upcoming changes in hospital payment models.

Utilization patterns and outcomes associated with central venous catheter in septic shock: a population-based study

OBJECTIVES

In 2001, a randomized trial showed decreased mortality with early, goal-directed therapy in septic shock, a strategy later recommended by the Surviving Sepsis Campaign. Placement of a central venous catheter is necessary to administer goal-directed therapy. We sought to evaluate nationwide trends in: 1) central venous catheter utilization and 2) the association between early central venous catheter insertion and mortality in patients with septic shock.

DESIGN

We retrospectively analyzed the proportion of septic shock cases receiving an early (day of admission) central venous catheter and the odds of hospital mortality associated with receiving early central venous catheter from years 1998 to 2001 compared with 2002 to 2009.

SETTING

Non-federal acute care hospitalizations from the Nationwide Inpatient Sample, 1998-2009.

PATIENTS

A total of 203,481 (population estimate: 999,545) patients admitted through an emergency department with principal diagnosis of septicemia and secondary diagnosis of shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

From 1998 to 2009, population-adjusted rates of septic shock increased from 12.6 cases per 100,000 U.S. adults to 78 cases per 100,000. During this time, age-adjusted hospital mortality associated with septic shock declined from 40.4% to 31.4%. Early central venous catheter insertion increased from 5.7% (95% confidence interval 5.1% to 6.3%) to 19.2% (95% confidence interval 18.7% to 19.5%) cases with septic shock, with an increased rate of early central venous catheter placement identified after 2007. The rate of decline in age-adjusted hospital mortality was significantly greater for patients who received an early central venous catheter (-4.2% per year, 95% confidence interval -3.2, -4.2%) as compared with no central venous catheter (-2.9% per year, 95% confidence interval -2.3, -3.5%; p = 0.016). Hospital mortality associated with early central venous catheter insertion significantly decreased from a multivariable-adjusted odds ratio of 1.29 (95% confidence interval 1.14-1.45) prior to 2001 to an adjusted odds ratio of 0.87 (95% confidence interval 0.84-0.90) after 2001.

CONCLUSIONS

Placement of a central venous catheter early in septic shock has increased three-fold since 1998. The mortality associated with early central venous catheter insertion decreased after publication of evidence-based instructions for central venous catheter use.

Factors affecting adherence to evidence-based guidelines in the treatment of URI, sinusitis, and pharyngitis

INTRODUCTION

Sinus infections, sore throats, and upper respiratory tract infections (URI) are common reasons patients seek medical care. Well-established treatment guidelines exist for prescribing antibiotics in these clinical scenarios, but are not often followed.

OBJECTIVE

The objective of this study is to determine practice patterns related to prescribing antibiotics for sinusitis, URI, and pharyngitis. The main hypothesis is that attending physicians improve their adherence to antibiotic guidelines with a learner present.

METHODS

A retrospective cohort study was performed on patients treated for URI, sinusitis, and pharyngitis at an ambulatory faculty practice. The use of relevant ICD-9 codes from January 1, 2008 to January 30, 2012 resulted in 1,548 patient encounters which were reviewed for guideline adherence. Univariate analysis and multivariate logistic regression was performed for each outcome variable to determine if they influence antibiotic adherence. Variables studied were physician, presence of a learner, BMI, age, gender, day of the week, month, diabetes, immunosuppression, and COPD.

RESULTS

Multivariate analysis showed the statistically significant variables were age (p=0.038) for pharyngitis and provider (p=0.013) for URI. There were no significant findings for sinusitis. Guideline adherence was 24% in patients with pharyngitis, 42% in acute sinusitis, 79% in URI, and 57% overall.

CONCLUSION

Guideline adherence varies depending on the treating physician and decreases when treating younger patients with pharyngitis. The presence of a learner did not improve prescribing habits. The reason for these findings remain unclear, but considerations for improvement could include following antibiotic adherence as a quality measure, giving patients handouts educating them about the impact of overprescribing antibiotics, and further education amongst faculty and residents about adhering to nationally recognized guidelines.

Effects of morning report case presentation on length of stay and hospitalisation costs

CONTEXT

The primary goal of discussing patient cases during the morning report is to teach appropriate clinical decision making. In addition, the selection of the best diagnostic strategy and application of evidence-based patient care are important. Reducing hospital costs is fundamental to controlling inflation in health care costs, especially in university hospitals that are subject to budget constraints in developing countries. The goal of this study was to explore the effect of morning report case presentation on length of stay (LoS) and hospitalisation costs in a university teaching hospital.

METHODS

A total of 54 patients whose cases had been presented at morning report sessions in the department of internal medicine during a 3-month period (presented group) were selected and their medical records reviewed for data on final diagnosis, hospital LoS and detailed hospital costs. A control group of 104 patients, whose cases had not been presented, were selected on the basis that their final diagnoses matched with those of the presented group. In addition, the groups were matched for age, sex, occupation, comorbidities and insurance coverage. Final diagnoses were based on International Classification of Disease 10 (ICD-10) diagnostic code criteria.

RESULTS

The mean ± standard deviation (SD) hospital LoS was 8.32 ± 4.11 days in the presented group and 10.46 ± 4.92 days in the control group (p = 0.045). Mean ± SD hospitalisation costs per patient were significantly lower in the presented group (US$553.43 ± 92.16) than the control group (US$1621.93 ± 353.14) (p = 0.004). Although costs for paraclinical services were similar, there were very significant reductions in costs for medications used during hospitalisation and bed-days (p = 0.002).

CONCLUSIONS

Discussing clinical aspects of patient cases in morning report sessions facilitates the management process and has a significant effect on LoS and hospitalisation costs in patients admitted to hospital.

Patterns of obstetric infection rates in a large sample of US hospitals

OBJECTIVE

Maternal infection is a common complication of childbirth, yet little is known about the extent to which infection rates vary among hospitals. We estimated hospital-level risk-adjusted maternal infection rates (RAIR) in a large sample of US hospitals and explored associations between RAIR and select hospital features.

STUDY DESIGN

This retrospective cohort study included hospitals in the Perspective database with >100 deliveries over 2 years. Using a composite measure of infection, we estimated and compared RAIR across hospitals using hierarchical generalized linear models. We then estimated the amount of variation in RAIR attributable to hospital features.

RESULTS

Of the 1,001,189 deliveries at 355 hospitals, 4.1% were complicated by infection. Patients aged 15-19 years were 50% more likely to experience infection than those aged 25-29 years. Rupture of membranes >24 hours (odds ratio [OR], 3.0; 95% confidence interval [CI], 3.24-3.5), unengaged fetal head (OR, 3.11; 95% CI, 2.97-3.27), and blood loss anemia (OR, 2.42; 95% CI, 2.34-2.49) had the highest OR among comorbidities commonly found in patients with infection. RAIR ranged from 1.0-14.4% (median, 4.0%; interquartile range, 2.8-5.7%). Hospital features such as geographic region, teaching status, urban setting, and higher number of obstetric beds were associated with higher infection rates, accounting for 14.8% of the variation observed.

CONCLUSION

Obstetric RAIR vary among hospitals, suggesting an opportunity to improve obstetric quality of care. Hospital features such as region, number of obstetric beds, and teaching status account for only a small portion of the observed variation in infection rates.

Outcomes of cervical spine surgery in teaching and non-teaching hospitals

STUDY DESIGN

Retrospective national database analysis.

OBJECTIVE

A national population-based database was analyzed to characterize cervical spine procedures performed at teaching and nonteaching hospitals with regards to patient demographics, clinical outcomes/complications, resource use, and costs.

SUMMARY OF BACKGROUND DATA

There are mixed reports in the literature regarding the quality and costs of health care provided by teaching hospitals in the United States. However, outcomes of cervical spine surgery based upon teaching status remains largely unknown. METHODS.: Data from the Nationwide Inpatient Sample were obtained from 2002-2009. Patients undergoing elective anterior or posterior cervical fusion, or posterior cervical decompression (i.e., laminoforaminotomy, laminectomy, laminoplasty) for a diagnosis of cervical myelopathy and/or radiculopathy were identified and separated into 2 cohorts (teaching and nonteaching hospitals). Patient demographics, comorbidities, complications, length of hospitalization, costs, and mortality were compared for both groups. Regression analysis was performed to assess independent predictors of mortality.

RESULTS

A total of 212,385 cervical procedures were identified from 2002-2009 in the United States, with 54.6% performed at teaching hospitals. More multilevel fusions and posterior approaches were performed in teaching hospitals (P < 0.0005). Patients treated in teaching hospitals trended toward male sex, increased costs, and hospitalizations. Overall, procedure-related complications and inhospital mortality were increased in teaching hospitals. Regression analysis revealed that significant predictors of mortality were age 65 years or more (odds ratio = 3.0) and multiple comorbidities. Teaching status was not a significant predictor of mortality (P = 0.07).

CONCLUSION

Patients treated in teaching hospitals for cervical spine surgery demonstrated longer hospitalizations, increased costs, and mortality compared with patients treated in nonteaching hospitals. Incidences of postoperative complications were identified to be higher in teaching hospitals. Possible explanations for these findings are an increased complexity of procedures performed at teaching hospitals. Older age and presence of comorbidities were more significant predictors of inhospital mortality than teaching status. Future studies should identify long-term complications and costs beyond an inpatient setting to assess if differences extend beyond the perioperative period.

LEVEL OF EVIDENCE

4.