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

The effect of nonmedical factors on variations in the performance of colonoscopy among different health care settings

BACKGROUND

Previous published studies have shown significant variations in colonoscopy performance, even when medical factors are taken into account. This study aimed to examine the role of nonmedical factors (ie, embodied in health care system design) as possible contributors to variations in colonoscopy performance.

METHODS

Patient data from a multicenter observational study conducted between 2000 and 2002 in 21 centers in 11 western countries were used. Variability was captured through 2 performance outcomes (diagnostic yield and colonoscopy withdrawal time), jointly studied as dependent variables, using a multilevel 2-equation system.

RESULTS

Results showed that open-access systems and high-volume colonoscopy centers were independently associated with a higher likelihood of detecting significant lesions and longer withdrawal durations. Fee for service (FFS) payment was associated with shorter withdrawal durations, and so had an indirect negative impact on the diagnostic yield. Teaching centers exhibited lower detection rates and longer withdrawal times.

CONCLUSIONS

Our results suggest that gatekeeping colonoscopy is likely to miss patients with significant lesions and that developing specialized colonoscopy units is important to improve performance. Results also suggest that FFS may result in a lower quality of care in colonoscopy practice and highlight the fact that longer withdrawal times do not necessarily indicate higher quality in teaching centers.

Nurse staffing and post-surgical complications using the present on admission indicator

We evaluated the relationship between registered nurse (RN) staffing and six post-surgical complications: pneumonia, septicemia, urinary tract infections, thrombophlebitis, fluid overload, and decubitus ulcers, in a dataset that contained the present on admission (POA) indicator. We analyzed a longitudinal panel of 283 acute care hospitals in California from 1996 to 2001. Using an adaptation of the Quality Health Outcomes Model, we found no statistically significant relationships between RN staffing and the complications. In addition, the signs of the relationships were opposite to those expected. That is, as staffing increased, so did some of the complications. We discuss potential reasons for these anomalous results, including the possibility that increases in RN staffing may result in earlier detection of complications. Other explanations include issues with risk adjustment, the lack of nurse level variables in the model, and issues with the POA indicator itself.

Does participation in graduate medical education contribute to improved patient outcomes as outlined by Surgical Care Improvement Project guidelines?

BACKGROUND

Patient quality outcomes are a major focus of the health care industry. It is unknown what effect involvement in graduate medical education (GME) has on patient outcomes. The purpose of this study is to begin to examine whether GME involvement in postoperative care impacts patient quality outcomes.

METHODS

The retrospective cohort included all patients who underwent a nonemergent colectomy from January 1, 2007 to January 1, 2008 at a 2-hospital system. Data collected included patient demographics, patient quality outcomes, complications, and GME involvement. Patient quality outcomes were based on compliance with the Surgical Care Improvement Project (SCIP) guidelines.

RESULTS

A total of 159 nonemergent colectomies were analyzed. The GME group accounted for 116 (73%) patients. A significant difference was found in several SCIP process-based measures of quality when comparing the GME group with the non-GME group. Postoperative antibiotics were more likely to be stopped within 24 hours (p = 0.010), and preoperative heparin and postoperative deep vein thrombosis (DVT) prophylaxis were more likely to be administered (p < 0.001). Additionally, patients in the GME group showed improved quality outcomes as there were significantly fewer postoperative complications (p < 0.001) and a shorter duration of stay (p = 0.008). The use of gastrointestinal prophylaxis was more common in the non-GME group (p = 0.002). No significant differences were observed between the 2 groups in respect to age, sex, diabetes, preoperative antibiotics, antibiotics, 1 hour before surgery, postoperative antibiotics, and continuation of home beta blockade.

CONCLUSIONS

GME at teaching institutions has a positive impact on patient quality outcomes. At our institution, many of the SCIP measurable outcomes had improved compliance if an attending physician participated in the GME program.

Safety and effectiveness of bivalirudin in routine care of patients undergoing percutaneous coronary intervention

AIMS

To evaluate the effectiveness and safety of bivalirudin as used in routine care. Bivalirudin has been studied as an alternative to heparin plus glycoprotein IIb/IIIa inhibitor (GPI) during percutaneous coronary intervention (PCI). Trials have indicated that bivalirudin is non-inferior to heparin with respect to death and repeat revascularization and may decrease the risk of major bleeds. The use of bivalirudin in routine care has not been evaluated.

METHODS AND RESULTS

Using a representative database, we identified 127 185 individuals who underwent inpatient PCI between June 2003 and December 2006 and were administered either bivalirudin plus provisional GPI or the comparator, heparin plus GPI. We estimated relative risks of blood transfusion, repeated PCI, and in-hospital death. The adjusted hazard ratio (HR) for blood transfusion was 0.67 (0.61-0.73); instrumental variable analysis showed an HR of 0.72 (0.12-4.47). We observed a risk of in-hospital death of 0.80% in the bivalirudin group and 2.1% in the heparin group; the adjusted HR was 0.51 (0.44-0.60).

CONCLUSION

In our non-randomized study of routine care, we observed a reduction in blood transfusions and in short-term mortality for patients treated with bivalirudin compared with heparin plus GPI. The mortality benefit was more pronounced in our study than in randomized trials.

Is there a relationship between high-quality performance in major teaching hospitals and residents' knowledge of quality and patient safety?

PURPOSE

The relationship of the quality of teaching hospitals' clinical performance to resident education in quality and patient safety is unclear. The authors studied residents' knowledge of these areas in major teaching hospitals with higher- and lower-quality performance rankings. They assessed the presence of formal and informal quality curricula to determine whether programmatic differences exist.

METHOD

The authors used qualitative research methodology with purposeful sampling. They gathered data from individual structured interviews with residents and key educational and quality leaders in six medical schools and teaching hospitals, which represented a range of quality performance rankings, geographic regions, and public or private status.

RESULTS

No relationship emerged between a hospital's quality status, residents' curriculum, and the residents' understanding of quality. Residents' definitions of quality and safety and their knowledge of the practice-based learning and systems-based practice competencies were indistinguishable between hospitals. Residents in all programs had extensive patient safety knowledge acquired through an informal curriculum in the hospital setting. A formal curriculum existed in only two programs, both of them ambulatory settings.

CONCLUSIONS

Residents' learning about quality and patient safety is extensive, largely through a positive informal curriculum in the teaching hospital and, less frequently, via a formal curriculum. No relationship was found between the quality performance of the teaching hospital and the residents' curriculum or understanding of quality or safety. Residents seem to learn through an informal curriculum provided by hospital initiatives and resources, and thus these data suggest the importance of major teaching hospitals in quality education.

Testing the association between patient safety indicators and hospital structural characteristics in VA and nonfederal hospitals

This study tested the association between hospital structural characteristics-teaching status, bedsize, and nurse staffing-and potentially preventable adverse events. The authors calculated 14 Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) and a PSI composite, using discharge databases from VA and nonfederal hospitals. This study compared the likelihood of PSI events in hospitals, controlling for structural and other characteristics, including patients' case-mix. Additional controls were employed to account for differences in VA versus nonfederal patients and data. The study found some associations, most notably a positive (unfavorable) association between status as a major teaching hospital and six PSIs. However, for most PSIs, the authors found no association between the structural characteristics tested and likelihood of PSI events. The study's findings extend previous research showing a lack of consistent relationship between structural characteristics and patient safety. However, the results also suggest continued need for examination of the relationship between teaching status and potentially preventable adverse events.

Looking forward, looking back: assessing variations in hospital resource use and outcomes for elderly patients with heart failure

BACKGROUND

Recent studies have found substantial variation in hospital resource use by expired Medicare beneficiaries with chronic illnesses. By analyzing only expired patients, these studies cannot identify differences across hospitals in health outcomes like mortality. This study examines the association between mortality and resource use at the hospital level, when all Medicare beneficiaries hospitalized for heart failure are examined.

METHODS AND RESULTS

A total of 3999 individuals hospitalized with a principal diagnosis of heart failure at 6 California teaching hospitals between January 1, 2001, and June 30, 2005, were analyzed with multivariate risk-adjustment models for total hospital days, total hospital direct costs, and mortality within 180-days after initial admission ("Looking Forward"). A subset of 1639 individuals who died during the study period were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180-days before death ("Looking Back"). "Looking Forward" risk-adjusted hospital means ranged from 17.0% to 26.0% for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs. Spearman rank correlation coefficients were -0.68 between mortality and hospital days, and -0.93 between mortality and indexed total direct costs. "Looking Back" risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs. Variation in resource use site ranks between expired and all individuals were attributable to insignificant differences.

CONCLUSIONS

California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.

Did duty hour reform lead to better outcomes among the highest risk patients?

BACKGROUND

Earlier work demonstrated that ACGME duty hour reform did not adversely affect mortality, with slight improvement noted among specific subgroups.

OBJECTIVE

To determine whether resident duty hour reform differentially affected the mortality risk of high severity patients or patients who experienced post-operative complications (failure-to-rescue).

DESIGN

Observational study using interrupted time series analysis with data from July 1, 2000 - June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of mortality or failure-to-rescue (FTR) in more versus less teaching-intensive hospitals before and after duty hour reform.

PARTICIPANTS

All unique Medicare patients (n = 8,529,595) admitted to short-term acute care non-federal hospitals and all unique VA patients (n = 318,636 patients) with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, stroke or a DRG classification of general, orthopedic or vascular surgery.

MEASUREMENTS AND MAIN RESULTS

We measured mortality within 30 days of hospital admission and FTR, measured by death among patients who experienced a surgical complication. The odds of mortality and FTR generally changed at similar rates for higher and lower risk patients in more vs. less teaching intensive hospitals. For example, comparing the mortality risk for the 10% of Medicare patients with highest risk to the other 90% of patients in post-reform year 1 for combined medical an OR of 1.01 [95% CI 0.90, 1.13], for combined surgical an OR of 0.91 [95% CI 0.80, 1.04], and for FTR an OR of 0.94 [95% CI 0.80, 1.09]. Findings were similar in year 2 for both Medicare and VA. The two exceptions were a relative increase in mortality for the highest risk medical (OR 1.63 [95% CI 1.08, 2.46]) and a relative decrease in the high risk surgical patients within VA in post-reform year 1 (OR 0.52 [95% CI 0.29, 0.96]).

CONCLUSIONS

ACGME duty hour reform was not associated with any consistent improvements or worsening in mortality or failure-to-rescue rates for high risk medical or surgical patients.

Higher hospital volume is associated with lower mortality in acute nonvariceal upper-GI hemorrhage

BACKGROUND

Acute nonvariceal upper-GI hemorrhage (NVUGIH) is associated with significant morbidity and mortality.

OBJECTIVE

To examine the relationship between hospital volume and outcomes of NVUGIH.

DESIGN

A cross-sectional study.

SETTING

Participating hospitals from the Nationwide Inpatient Sample 2004.

PATIENTS

All discharged patients with a primary discharge diagnosis of NVUGIH based on the International Classification of Diseases, Clinical Modification, ninth edition codes.

INTERVENTIONS

Patients were divided into 3 groups based on discharge from hospitals with annual discharge volumes of 1 to 125 (low), 126 to 250 (medium), and >250 (high).

MAIN OUTCOME MEASUREMENTS

In-hospital mortality, length of stay, and hospitalization charges.

RESULTS

The study included a total of 135,366, 132,746, and 123,007 discharges with NVUGIH occurred from low-volume, medium-volume, and high-volume hospitals, respectively. On multivariate analysis, when adjusting for age, comorbidity, and the presence of complications, patients at high-volume hospitals had significantly lower in-hospital mortality (odds ratio [OR] 0.85 [95% CI, 0.74-0.98]) than patients at low-volume hospitals. Patients at high-volume hospitals were also more likely to undergo upper-GI endoscopy (OR 1.52 [95% CI, 1.36-1.69]) or early endoscopy within 1 day of hospitalization compared with low-volume hospitals (60.5% vs 53.8%, adjusted OR 1.28 [95% CI, 1.02-1.61]). Undergoing endoscopy within day 1 was associated with shorter hospital stays (-1.08 days [95% CI, -1.24 to -0.92 days]) and lower hospitalization charges (-$1958 [95% CI, -$3227 to -$688]).

LIMITATIONS

The study was based on an administrative data set.

CONCLUSIONS

Higher hospital volume is associated with lower mortality and with higher rates of endoscopy and endoscopic intervention in patients with NVUGIH.

Hospital teaching intensity, patient race, and surgical outcomes

OBJECTIVES

To determine if the lower mortality often observed in teaching-intensive hospitals is because of lower complication rates or lower death rates after complications (failure to rescue) and whether the benefits at these hospitals accrue equally to white and black patients, since black patients receive a disproportionate share of their care at teaching-intensive hospitals.

DESIGN

A retrospective study of patient outcomes and teaching intensity using logistic regression models, with and without adjusting for hospital fixed and random effects.

SETTING

Three thousand two hundred seventy acute care hospitals in the United States.

PATIENTS

Medicare claims on general, orthopedic, and vascular surgery admissions in the United States for 2000-2005 (N = 4,658,954 unique patients).

MAIN OUTCOME MEASURES

Thirty-day mortality, in-hospital complications, and failure to rescue (the probability of death following complications).

RESULTS

Combining all surgeries, compared with nonteaching hospitals, patients at very major teaching hospitals demonstrated a 15% lower odds of death (P < .001), no difference in complications, and a 15% lower odds of death after complications (failure to rescue) (P < .001). These relative benefits associated with higher resident-to-bed ratio were not experienced by black patients, for whom the odds of mortality and failure to rescue were similar at teaching and nonteaching hospitals, a pattern that is significantly different from that of white patients (P < .001).

CONCLUSIONS

Survival after surgery is higher at hospitals with higher teaching intensity. Improved survival is because of lower mortality after complications (better failure to rescue) and generally not because of fewer complications. However, this better survival and failure to rescue at teaching-intensive hospitals is seen for white patients, not for black patients.

Physician job satisfaction and quality of care among hospital employed physicians in Japan

BACKGROUND

Physician job satisfaction is reportedly associated with interpersonal quality of care, such as patient satisfaction, but its association with technical quality of care, as determined by whether patients are offered recommended services, is unknown.

OBJECTIVE

We explored whether the job satisfaction of hospital-employed physicians in Japan is associated with the technical quality of care, with an emphasis on process qualities as measured by quality indicators.

DESIGN

Cross-sectional study linking data from physician surveys with data abstracted from outpatient charts.

PARTICIPANTS

A total of 53 physicians working at 13 hospitals in Japan participated. Medical records covering 568 patients were reviewed.

MEASUREMENTS

Disease-specific indicators related to the care of patients with hypertension, type 2 diabetes, and asthma, as well as disease-independent measures of the process of care were abstracted. We analyzed the association between the quality of care score for individual physicians, which is defined as the percentage of quality indicators satisfied among the total for which their patients were eligible, and physician job satisfaction, which was measured by a validated scale.

RESULTS

No statistically significant association between physician job satisfaction and quality of care was observed. A 1-standard deviation (SD) increment in the physician job satisfaction scale was associated with an increase of only 0.3% for overall quality (P = 0.85), -3.0% for hypertension (P = 0.22), 2.5% for type 2 diabetes (P = 0.44), 8.0% for asthma (P = 0.21), and -0.4% for cross-cutting care (P = 0.76).

CONCLUSION

Contrary to the positive association reported between physician job satisfaction and high quality of interpersonal care, no association was seen between physician job satisfaction and the technical quality of care.

Higher hospital volume predicts endoscopy but not the in-hospital mortality rate in patients with acute variceal hemorrhage

BACKGROUND

Acute variceal hemorrhage (AVH) is an important complication of cirrhosis that carries a high mortality rate. Management of AVH requires early initiation of specialized care that may be more readily available at centers that deal with a high volume of AVH.

OBJECTIVE

Our purpose was to examine the relationship between the annual hospitalization volume and the in-hospital mortality rate for AVH.

DESIGN

Cross-sectional study from a national representative sample.

SETTING

A 20% sample of all nonfederal short-term hospitals from 37 states participating in the Nationwide Inpatient Sample 2004.

PATIENTS

A total of 28,817 discharges with AVH identified through appropriate International Classification of Diseases, 9th Revision, Clinical Modification codes for bleeding esophageal varices. Hospitals were divided into low-, medium-, and high-volume hospitals if they had 1 to 15, 16 to 35, and 36 or more annual discharges related to AVH.

MAIN OUTCOME MEASUREMENT

In-hospital mortality rate.

RESULTS

On multivariate analysis, there was no significant difference in the mortality rate either for medium- (odds ratio [OR] 0.84; 95% CI, 0.67-1.05) or high-volume hospitals (OR 1.06; 95% CI, 0.82-1.37). However, patients both at medium- (OR 1.27; 95% CI, 1.02-1.58) and high-volume hospitals (OR 1.40; 95% CI, 1.07-1.84) were more likely to undergo endoscopy for AVH. Endoscopic intervention for control of variceal hemorrhage was significantly more common in medium- (OR 1.20) and high- (OR 1.33) volume hospitals. Patients at medium- (OR 3.10; 95% CI, 2.09-4.60) and high-volume hospitals (OR 4.12; 95% CI, 2.52-6.75) were also more likely to undergo transjugular intrahepatic portosystemic shunt (TIPS).

CONCLUSION

Higher hospital volume is associated with greater rates of endoscopy, endoscopic intervention, and higher utilization of TIPS in the management of AVH.

A strategy for enhancing financial performance: a study of general acute care hospitals in South Korea

In this study, the determinants of hospital profitability were evaluated using a sample of 142 hospitals that had undergone hospital standardization inspections by the South Korea Hospital Association over the 4-year period from 1998 to 2001. The measures of profitability used as dependent variables in this study were pretax return on assets, after-tax return on assets, basic earning power, pretax operating margin, and after-tax operating margin. Among those determinants, it was found that ownership type, teaching status, inventory turnover, and the average charge per adjusted inpatient day positively and statistically significantly affected all 5 of these profitability measures. However, the labor expenses per adjusted inpatient day and administrative expenses per adjusted inpatient day negatively and statistically significantly affected all 5 profitability measures. The debt ratio negatively and statistically significantly affected all 5 profitability measures, with the exception of basic earning power. None of the market factors assessed were shown to significantly affect profitability. In conclusion, the results of this study suggest that the profitability of hospitals can be improved despite deteriorating external environmental conditions by facilitating the formation of sound financial structures with optimal capital supplies, optimizing the management of total assets with special emphasis placed on inventory management, and introducing efficient control of fixed costs including labor and administrative expenses.

Variations in Quality of Care for Men With Early-Stage Prostate Cancer

Purpose

The commencement of quality-improvement initiatives such as Pay for Performance and the Physician Consortium for Performance Improvement has underscored calls to evaluate the quality of cancer care on a patient level for nationally representative samples.

Methods

We sampled early-stage prostate cancer cases diagnosed in 2000 through 2001 from the American College of Surgeons National Cancer Data Base and explicitly reviewed medical records from 2,775 men (weighted total = 55,160 cases) treated with radical prostatectomy or external-beam radiation therapy. We determined compliance with 29 quality-of-care disease-specific structure and process indicators developed by RAND, stratified by race, geographic region, and hospital type.

Results

Overall compliance exceeded 70% for structural and pretherapy disease assessment indicators but was lower for documentation of pretreatment functioning (46.4% to 78.4%), surgical pathology (37.1% to 86.3%), radiation technique (62.6% to 88.3%), and follow-up (55%). Geographic variations were observed as higher compliance in the South Atlantic division than the New England division for having at least one board-certified urologist (odds ratio [OR], 9.2; 95% CI, 1.9 to 45.0), at least one board-certified radiation oncologist (OR, 3.3; 95% CI, 1.2 to 9.0), use of Gleason grading (OR, 4.1; 95% CI, 1.2 to 13.8), and administering total radiation dose ≥ 70 Gy (OR, 3.1; 95% CI, 1.6 to 6.1). Teaching/research hospitals and Comprehensive Cancer Centers had higher compliance than Community Cancer Centers, whereas racial differences were not observed for any indicator.

Conclusion

The significant and unwarranted variations observed for these quality indicators by census division and hospital type illustrate the inconsistencies in prostate cancer care and represent potential targets for quality improvement. The lack of racial disparities suggests equity in care once a patient initiates treatment.

Hospital characteristics and use of innovative surgical therapies among patients with kidney cancer

BACKGROUND

Despite their potential benefits to patients, the adoption of partial nephrectomy and laparoscopic kidney cancer surgery has been both gradual and concentrated in select hospitals.

OBJECTIVE

We assessed the degree to which adjusting for hospital structural characteristics modifies the association between hospital nephrectomy volume and patient receipt of partial nephrectomy and/or laparoscopic kidney cancer surgery.

RESEARCH DESIGN AND SUBJECTS

From the Nationwide Inpatient Sample, we identified an unweighted sample of 4943 patients who underwent kidney cancer surgery in 2003.

MAIN OUTCOME MEASURE

Our primary outcomes were patient receipt of (1) partial nephrectomy and/or (2) laparoscopic kidney cancer surgery.

RESULTS

Our weighted analytic cohort comprised 34,045 cases. Overall, 16% of patients received a partial nephrectomy, and 17% underwent laparoscopic surgery; at high-nephrectomy-volume hospitals the proportions increased to 22% and 26%, respectively. Hospital structural characteristics varied across nephrectomy-case volume strata. In unadjusted models, patients treated at hospitals in the highest-nephrectomy-volume tercile were more likely than those treated at low-volume facilities to receive a partial nephrectomy [Risk RatioPN (RRPN) 2.2; 95% confidence interval (CI), 1.6-2.8] or laparoscopic surgery (RRlap 2.9; 95% CI, 2.0-4.0). Adjusting for differences in hospital structure attenuated the association between hospital nephrectomy volume and use of partial nephrectomy or laparoscopy by 60% (adjusted RRPN 1.4; 95% CI, 0.9-2.2) and 12% (adjusted RRlap 2.5; 95% CI, 1.4-4.1), respectively.

CONCLUSIONS

Changes to the hospital environment may facilitate greater use of partial nephrectomy at hospitals that infrequently perform kidney cancer surgery. Efforts to increase the uptake of laparoscopy are probably best directed at surgeon-specific adoption barriers.

United States rural hospital quality in the Hospital Compare database-accounting for hospital characteristics

BACKGROUND

Rural hospitals in the United States have demonstrated lower adherence to evidence based guidelines than their urban counterparts in national public reporting initiatives. We compared the quality of rural hospitals participating in a public reporting initiative to that of their urban counterparts using Hospital Compare, a new national database containing process measures.

METHODS

Cross-sectional analyses of hospitals participating in Hospital Compare in 2005, evaluating percent adherence to guidelines for 10 processes of care for acute myocardial infarction (AMI), heart failure (HF), and community-acquired pneumonia (CAP) using multivariable linear regression analyses.

RESULTS

Participating rural hospitals demonstrated lower adherence to evidence based guidelines in MI and HF quality measures (p<0.05) and higher adherence to prescribing antibiotics in a timely manner in CAP (p<0.05). Differences increased with bed size (F test for linear trend, p<0.05). After adjustment, the trends demonstrating lower adherence persisted in 6 AMI and HF measures and higher adherence in 1 CAP measure in spite of a disproportionate number of drop-outs among lower performing urban hospitals.

CONCLUSIONS

Participating rural hospitals had lower performance than their urban counterparts. As the rural/urban quality gap varies by condition, bed size, and participation, we recommend comparing performance across a wide variety of condition-specific measures to enable targeted quality improvement.

Measuring and explaining mortality in Dutch hospitals; the hospital standardized mortality rate between 2003 and 2005

Background

Indicators of hospital quality, such as hospital standardized mortality ratios (HSMR), have been used increasingly to assess and improve hospital quality. Our aim has been to describe and explain variation in new HSMRs for the Netherlands.

Methods

HSMRs were estimated using data from the complete population of discharged patients during 2003 to 2005. We used binary logistic regression to indirectly standardize for differences in case-mix. Out of a total of 101 hospitals 89 hospitals remained in our explanatory analysis. In this analysis we explored the association between HSMRs and determinants that can and cannot be influenced by hospitals. For this analysis we used a two-level hierarchical linear regression model to explain variation in yearly HSMRs.

Results

The average HSMR decreased yearly with more than eight percent. The highest HSMR was about twice as high as the lowest HSMR in all years. More than 2/3 of the variation stemmed from between-hospital variation. Year (-), local number of general practitioners (-) and hospital type were significantly associated with the HSMR in all tested models.

Conclusion

HSMR scores vary substantially between hospitals, while rankings appear stable over time. We find no evidence that the HSMR cannot be used as an indicator to monitor and compare hospital quality. Because the standardization method is indirect, the comparisons are most relevant from a societal perspective but less so from an individual perspective. We find evidence of comparatively higher HSMRs in academic hospitals. This may result from (good quality) high-risk procedures, low quality of care or inadequate case-mix correction.

Do postoperative complications vary by hospital teaching status?

OBJECTIVE

The purpose of this paper is to assess postoperative patient safety outcomes across teaching and nonteaching hospitals and to examine the relation of hospital and patient factors to patient safety outcomes.

RESEARCH DESIGN AND METHODS

The Nationwide Inpatient Sample and American Hospital Association annual survey data were used for analyses. Patient safety indicators (PSIs) developed by the Agency for Healthcare Research and Quality (AHRQ) were used to identify 6 postoperative PSIs. The study sample consisted of 646 acute care hospitals, divided into nonteaching (n = 400), minor teaching (n = 207), and major teaching hospitals (n = 39). The unit of analysis was the patient. Associations between hospital teaching status and patient and hospital characteristics were determined using one-way analysis of variance and Pearson chi test. Multivariable analysis using generalized estimating equation regression models assessed the relationship between teaching status and PSIs.

RESULTS

Bivariate results showed higher observed PSI rates at major teaching hospitals. Results from multivariable analyses, after adjusting for hospital size, staffing variables, patient case mix, and other risk factors, showed that major teaching hospitals had significantly higher odds of postoperative pulmonary embolism or deep vein thrombosis and postoperative sepsis, lower odds of postoperative respiratory failure, and showed no difference for postoperative hip fracture, postoperative hematoma or hemorrhage, and postoperative physio-metabolic derangement.

CONCLUSIONS

The present analysis found an inconsistent relationship between teaching status and postoperative patient safety event rates. Teaching status of the hospital was associated with numerous hospital and patient characteristics which mediate the relationship between teaching status and PSIs.

Hospital nurse practice environments and outcomes for surgical oncology patients

OBJECTIVE

To examine the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery.

DATA SOURCES

Secondary analysis of cancer registry, inpatient claims, administrative and nurse survey data collected in Pennsylvania for 1998-1999.

STUDY DESIGN

Nurse staffing (patient to nurse ratio), educational preparation (proportion of nurses holding at least a bachelor's degree), and the practice environment (Practice Environment Scale of the Nursing Work Index) were calculated from a survey of nurses and aggregated to the hospital level. Logistic regression models predicted the odds of 30-day mortality, complications, and failure to rescue (death following a complication).

PRINCIPAL FINDINGS

Unadjusted death, complication, and failure to rescue rates were 3.4, 35.7, and 9.3 percent, respectively. Nurse staffing and educational preparation of registered nurses were significantly associated with patient outcomes. After adjusting for patient and hospital characteristics, patients in hospitals with poor nurse practice environments had significantly increased odds of death (odds ratio, 1.37; 95 percent confidence interval, 1.07-1.76) and of failure to rescue (odds ratio, 1.48; 95 percent confidence interval, 1.07-2.03). Receipt of care in National Cancer Institute-designated cancer centers significantly decreased the odds of death, which can be explained partly by better nurse practice environments.

CONCLUSIONS

This study is one of the first to examine the predictive validity of the National Quality Forum's endorsed measure of the nurse practice environment. Improvements in the quality of nurse practice environments could reduce adverse outcomes for hospitalized surgical oncology patients.

Factors predicting adherence to the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients

PURPOSE

The aim of this study was to determine factors that are associated with adherence to the Canadian nutrition support clinical practice guidelines (CPGs).

MATERIALS AND METHODS

We conducted a secondary analysis of data from a prospective observational cohort study of nutrition support practices in 58 intensive care units (ICUs) across Canada, grouped into 50 clusters. Adequacy of enteral nutrition (EN) (energy received from EN / energy prescribed by the dietitian x 100), was used as a marker of adherence to the guidelines. We applied hierarchical modeling techniques to examine the impact of various hospital, ICU, and patient factors on EN adequacy.

RESULTS

The overall average EN adequacy was 51.3% (SE, 1.8%). In a multiple regression analysis, after adjusting for varying days of observation, hospital type (academic 54.3% vs community 45.2%, P < .001), admission category of the patient (medical 60.2% vs surgical 39.2%, P < .001), and sex of the patient (male 46.5% vs female 52.8%, P < .001) were found to be significant predictors of EN adequacy and adherence to the Canadian nutrition support CPGs.

CONCLUSIONS

Specific hospital, ICU, and patient characteristics influence adherence to the Canadian nutrition support CPGs. Further research is required to illuminate the mechanisms by which female and surgical patients and community hospitals lead to lower guideline adherence.

A comparative study of quality outcomes in freestanding ambulatory surgery centers and hospital-based outpatient departments: 1997-2004

RESEARCH OBJECTIVE

To compare quality outcomes from surgical procedures performed at freestanding ambulatory surgery centers (ASCs) and hospital-based outpatient departments (HOPDs).

DATA SOURCES

Patient-level ambulatory surgery (1997-2004), hospital discharge (1997-2004), and vital statistics data (1997-2004) for the state of Florida were assembled and analyzed.

STUDY DESIGN

We used a pooled, cross-sectional design. Logistic regressions with time fixed-effects were estimated separately for the 12 most common ambulatory surgical procedures. Our quality outcomes were risk-adjusted 7-day and 30-day mortality and 7-day and 30-day unexpected hospitalizations. Risk-adjustment for patient demographic characteristics and severity of illness were calculated using the DCG/HCC methodology adjusting for primary diagnosis only and separately for all available diagnoses.

PRINCIPAL FINDINGS

Although neither ASCs nor HOPDs performed better overall, we found some difference by procedure that varied based on the risk-adjustment approach used.

CONCLUSIONS

There appear to be important variations in quality outcomes for certain procedures, which may be related to differences in organizational structure, processes, and strategies between ASCs and HOPDs. The study also confirms the importance of risk-adjustment for comorbidities when using administrative data, particularly for procedures that are sensitive to differences in severity.

Quality of Care in Hospitals with a High Percent of Medicaid Patients

BACKGROUND

Certain hospitals play a central role in ensuring Medicaid-insured patients' access to care. Their quality of care is critical to evaluate.

OBJECTIVE

To determine whether hospitals for which Medicaid patients represent a high percentage of total discharges provide a different quality of care than other hospitals.

RESEARCH DESIGN

Cross-sectional analysis.

SUBJECTS

Acute care hospitals participating in the first Hospital Compare public report (released November 2004) and the 2004 American Hospital Association hospital survey.

MEASURES

Hospitals serving 1 standard deviation above the national mean percentage of Medicaid patients were designated high Medicaid hospitals. Performance was assessed using percent compliance with 10 processes of care for 3 conditions: myocardial infarction, congestive heart failure, and community-acquired pneumonia.

RESULTS

Among the 2874 nonteaching hospitals, high Medicaid hospitals had lower adherence (P < 0.01) than other nonteaching hospitals on all 10 indicators. Of particular clinical importance, high Medicaid nonteaching hospitals less frequently prescribed beta-blockers (83% vs. 90%%, P < 0.0001) and aspirin at discharge in myocardial infarction (85% vs. 91%%, P < 0.0001), and administered antibiotics on time in CAP (68% vs. 75%, P < 0.0001). Among teaching institutions, there were few differences between high Medicaid and other hospitals.

CONCLUSIONS

Among hospitals publicly reporting on the Hospital Compare Web site, nonteaching hospitals treating a high percentage of Medicaid patients had lower adherence to quality indicators than other nonteaching hospitals on 10 indicators. Further research is needed to determine what factors contribute to differences in reported quality.

Do "most wired" hospitals deliver better care?

BACKGROUND

A study was conducted in 2006 to compare differences in objective quality of care measures among hospitals labeled "Most Wired"--a hospital or member-hospital of a health system listed among the Hospital and Health Network's Healthcare's Most Wired Hospitals for 2004--versus hospitals without that designation.

METHODS

Ten quality indicators representing cardiac and pulmonary measures were calculated for adult hospitals participating in the U.S. Department of Health and Human Services' Hospital Compare initiative. Performance of Most Wired hospitals and comparison hospitals was compared using t-tests. The association of the Most Wired designation to measures of care was assessed using multivariable linear regression and generalized estimating equations.

RESULTS

Compared with comparison hospitals, Most Wired hospitals tend to be larger, not-for profit and teaching hospitals. Most Wired hospitals outperformed comparison hospitals in all but one quality indicator (p < .05). After adjustment, Most Wired hospitals were independently associated with better quality scores for only 2 out of 10 quality indicators. The Most Wired hospitals did not significantly underperform for any indicator.

CONCLUSION

Most Wired hospitals outperformed other hospitals on most objective quality of care measures. However, some of the results were significantly attenuated by other factors associated with quality, suggesting that for specific indicators, "Most Wired" may be a marker of overall quality more than an independent factor. More research is needed on how overall implementation of health information technology directly affects quality of care measures.

Hospital competition, managed care, and mortality after hospitalization for medical conditions in California

OBJECTIVE

To assess the effect of hospital competition and health maintenance organization (HMO) penetration on mortality after hospitalization for six medical conditions in California.

DATA SOURCE

Linked hospital discharge and vital statistics data for short-term general hospitals in California in the period 1994-1999. The study sample included adult patients hospitalized for one of the following conditions: acute myocardial infarction (N=227,446), hip fracture (N=129,944), stroke (N=237,248), gastrointestinal hemorrhage (GIH, N=216,443), congestive heart failure (CHF, N=355,613), and diabetes (N=154,837).

STUDY DESIGN

The outcome variable was 30-day mortality. We estimated multivariate logistic regression models for each study condition with hospital competition, HMO penetration, hospital characteristics, and patient severity measures as explanatory variables.

PRINCIPAL FINDINGS

Higher hospital competition was associated with lower 30-day mortality for three to five of the six study conditions, depending on the choice of competition measure, and this finding was robust to a variety of sensitivity analyses. Higher HMO penetration was associated with lower mortality for GIH and CHF.

CONCLUSIONS

Hospitals that faced more competition and hospitals in market areas with higher HMO penetration provided higher quality of care for adult patients with medical conditions in California. Studies using linked hospital discharge and vital statistics data from other states should be conducted to determine whether these findings are generalizable.

Jordanian Nurses' Job Satisfaction and Intent to Stay: Comparing Teaching and Non-Teaching Hospitals

The aims of this study were to identify variables of Jordanian nurses' job satisfaction and intent to stay, compare the phenomena of interest in teaching and non-teaching hospitals, and correlate the two concepts of nurses' job satisfaction and intent to stay. A convenience sample of 433 nurses was obtained from three teaching hospitals and two non-teaching hospitals. Nurses were "neither satisfied nor dissatisfied" and were "neutral" in reporting their intent to stay at their current jobs. Nurses who were working in non-teaching hospitals reported higher job satisfaction and intent to stay rates than those working in teaching hospitals. Nurses' job satisfaction and intent to stay were at the borderlines, which require the immediate attention of nursing and hospital administrators. Nurses' job satisfaction and intent to stay, particularly in teaching hospitals, have to be promoted; thus, interventions have to be effectively initiated and maintained at the unit and organizational levels.

Nationwide data confirms absence of 'July phenomenon' in obstetrics: it's safe to deliver in July

OBJECTIVE(S)

To determine whether operator-dependent obstetric complications occur at higher rates in July at teaching hospitals using a large, nationwide sample of deliveries.

STUDY DESIGN

Data for this study were obtained from an administrative dataset, the Nationwide Inpatient Sample, for the years 1998 to 2002. Singleton deliveries and singleton livebirth admissions among Medicaid patients at teaching hospitals with OB/GYN residents working on the Labor and Delivery ward were identified. Outcomes for various complications for these patients in the month of July were compared to those occurring in the months from August to June.

RESULTS

The 26,546 women in our cohort who delivered in July were compared to the 272,584 women delivering during August to June. There were no statistically significant differences in the rates of cesarean delivery, urethral/bladder injury, third or fourth degree lacerations, wound complications, postpartum hemorrhage, transfusion, shoulder dystocia, chorioamnionitis or anesthesia-related complications. The 26,175 singleton livebirth admissions in July were compared to 266,158 such admissions in August to June. There were no statistically significant differences in the rates of brachial plexus injury (0.2 vs 0.2%, P=0.824) or birth asphyxia (0.1 vs 0.1%, P=0.643).

CONCLUSION(S)

This study shows no increased rate of operator-dependent complications of delivery at teaching hospitals nationwide in the month of July.

Association of emergency department care factors with admission and discharge decisions for pediatric patients

OBJECTIVE

We evaluated overutilization or underutilization of inpatient resources to measure the emergency department (ED) decision-making process and its association with the following care factors: annual pediatric volume, presence or absence of a pediatric emergency medicine specialist; and presence or absence of ED residents.

STUDY DESIGN

Block random selection, using the three care factors, of 16 hospitals with pediatric intensive care units. The Pediatric Risk of Admission (PRISA II) Score was used to measure illness severity. Decision-making was evaluated for admissions (Admission Index: observed minus predicted admissions) and returns (Return Index: observed minus predicted 72-hour returns). The Combined Index was a weighted average of the Admission and Return Indexes.

RESULTS

There were 11,664 patients enrolled. Residents but not volume or pediatric emergency medicine specialists were associated with the decision-making performance indexes in multivariable analysis (no residents versus residents: Admission Index: 2.5 of 1000 patients versus 34.8 of 1000, P = .082; Return Index: -3.0 of 1000 versus 33.6 of 1000, P = .039; Combined Index: 1.9 of 1000 versus 35.5 of 1000, P = .024.

CONCLUSIONS

There is significant variability in ED decision-making for children. Residents but not volume or presence of a pediatric emergency medicine specialist are associated with increased differences in admission decisions. The process by which these differences occur was not investigated.

Patient outcomes with teaching versus nonteaching healthcare: a systematic review

BACKGROUND

Extensive debate exists in the healthcare community over whether outcomes of medical care at teaching hospitals and other healthcare units are better or worse than those at the respective nonteaching ones. Thus, our goal was to systematically evaluate the evidence pertaining to this question.

METHODS AND FINDINGS

We reviewed all studies that compared teaching versus nonteaching healthcare structures for mortality or any other patient outcome, regardless of health condition. Studies were retrieved from PubMed, contact with experts, and literature cross-referencing. Data were extracted on setting, patients, data sources, author affiliations, definition of compared groups, types of diagnoses considered, adjusting covariates, and estimates of effect for mortality and for each other outcome. Overall, 132 eligible studies were identified, including 93 on mortality and 61 on other eligible outcomes (22 addressed both). Synthesis of the available adjusted estimates on mortality yielded a summary relative risk of 0.96 (95% confidence interval [CI], 0.93-1.00) for teaching versus nonteaching healthcare structures and 1.04 (95% CI, 0.99-1.10) for minor teaching versus nonteaching ones. There was considerable heterogeneity between studies (I(2) = 72% for the main analysis). Results were similar in studies using clinical and those using administrative databases. No differences were seen in the 14 studies fully adjusting for volume/experience, severity, and comorbidity (relative risk 1.01). Smaller studies did not differ in their results from larger studies. Differences were seen for some diagnoses (e.g., significantly better survival for breast cancer and cerebrovascular accidents in teaching hospitals and significantly better survival from cholecystectomy in nonteaching hospitals), but these were small in magnitude. Other outcomes were diverse, but typically teaching healthcare structures did not do better than nonteaching ones.

CONCLUSIONS

The available data are limited by their nonrandomized design, but overall they do not suggest that a healthcare facility's teaching status on its own markedly improves or worsens patient outcomes. Differences for specific diseases cannot be excluded, but are likely to be small.

The effect of cuts in medicare reimbursement on hospital mortality

OBJECTIVE

To determine if patients treated at hospitals under different levels of financial strain from the Balanced Budget Act (BBA) of 1997 had differential changes in 30-day mortality, and whether vulnerable patient populations such as the uninsured were disproportionately affected.

DATA SOURCE

Hospital discharge data from all general acute care hospitals in Pennsylvania from 1997 to 2001.

STUDY DESIGN

A multivariate regression analysis was performed retrospectively on 30-day mortality rates, using hospital discharge data, hospital financial data, and death certificate information from Pennsylvania.

DATA COLLECTION

We used 370,017 hospital episodes with one of four conditions identified by the Agency for Healthcare Research and Quality as inpatient quality indicators were extracted.

PRINCIPAL FINDINGS

The average magnitude of Medicare payment reduction on overall net revenues was estimated at 1.8 percent for hospitals with low BBA impact and 3.6 percent for hospitals with a high impact in 1998, worsening to 2 and 4.8 percent, respectively, by 2001. Operating margins decreased significantly over the time period for all hospitals (p<.05). While unadjusted mortality rates demonstrated a disproportionate rise in mortality for patients from high impact hospitals from 1997 to 2000, adjusted analyses show no consistent, significant difference in the rate of change in mortality between high-impact and low-impact hospitals (p=.04-.94). Similarly, uninsured patients did not experience greater increases in mortality in high-impact hospitals relative to low-impact hospitals.

CONCLUSIONS

An analysis of hospitalizations in the Commonwealth of Pennsylvania did not find an adverse impact of increased financial strain from the BBA on patient mortality either among all patients or among the uninsured.

Medical education in the public versus the private setting: a qualitative study of medical students' attitudes

Public hospitals serve as primary training sites for medical students. Public patients may therefore bear a disproportionate burden of medical student education. The purpose of this study was to critically examine the ethics of medical education in the public setting. Attitudes of first- and fourth-year students towards the role of public patients in medical education were elicited in focus groups. Inductive qualitative analysis was utilized to organize data into conceptual groups, which were then analyzed within an ethical framework. All patients have an equal obligation to participate in medical education. Students identified modifying factors that could affect a patient's obligation to educate future physicians. Available data highlight a concern that public teaching hospitals may provide a lower quality of care. If true, then the public teaching setting is creating an unfair burden upon that patient population who would then have a weakened obligation to participate in medical education.

Did Postoperative Mortality Increase After the Implementation of the Medicare Balanced Budget Act?

BACKGROUND

The Balanced Budget Act (BBA) of 1997 was a cost-saving measure designed to reduce Medicare reimbursements by $116.4 billion from 1998 to 2002. Resulting financial strain could adversely affect the quality of patient care in hospitals.

OBJECTIVE

We sought to determine whether 30-day mortality rates for surgical patients who developed complications changed at different rates in hospitals under different levels of financial strain from the BBA.

METHODS

Pennsylvania hospital discharge data, financial data, and death certificate data from 1997 to 2001 were obtained. A retrospective multivariate analysis examined whether 30-day mortality rates from 8 postoperative complications varied based on degree of hospital financial strain.

RESULTS

The average magnitude of Medicare payment reduction on overall hospital net revenues was estimated at 1.8% for hospitals with low BBA impact and 3.5% for hospitals with high impact in 1998, worsening to 2.0% and 4.8%, respectively, by 2001. Mortality rates changed at similar rates for high- and low-impact hospitals from 1997 to 1999, but from 1997 to 2000 mortality rates increased more among patients in high-impact compared with low-impact hospitals (P<0.05). From 2000 to 2001, mortality rates among impact groups converged. There were no statistically significant differences based on BBA impact in changes in nursing staff or length of stay.

CONCLUSIONS

The mortality of surgical patients who developed postoperative complications increased to a greater degree in the short term in hospitals affected more by BBA. Measuring the quality impact of reimbursement cuts is necessary to understand cost-quality tradeoffs that may accompany cost-saving reforms.

The Association Between Hospital Characteristics and Rates of Preventable Complications and Adverse Events

BACKGROUND/OBJECTIVES

This study examined the statistical relationship between hospital ownership and teaching status and hospital rates for potentially preventable adverse events measured using patient safety indicators recently developed by the Agency for Healthcare Research and Quality. RESEARCH DESIGN/MEASURES: A nationally representative sample of hospitals grouped into mutually exclusive combinations of control/ownership, teaching status, and rurality was defined using the Nationwide Inpatient Sample data set for the year 2000. Hospital rates for 5 categories of preventable adverse events were measured in 3 forms: unadjusted, risk-adjusted, and risk-adjusted ratios with smoothing. Multivariable regression analysis was used to measure the statistical significance of the relationship between hospital type and rates for potentially preventable adverse events, with adjustments for differences in hospital bed size and region.

RESULTS

This analysis found an inconsistent relationship between categories of hospital type and quality care measured by alternative indicators of potentially preventable conditions.

CONCLUSIONS

Hospital ownership and teaching status is not a consistent predictor of differences in rates of potentially preventable adverse events, and these characteristics explain little of the observed variation in the rates of these events across hospitals.

Uncomplicated acute renal failure and hospital resource utilization: a retrospective multicenter analysis

BACKGROUND

Although acute renal failure (ARF) complicating nonrenal organ dysfunction in the intensive care unit is associated with significant mortality and hospital costs, hospital resource utilization attributed to uncomplicated ARF is not well known. The goal of this study is to characterize the costs and lengths of stay (LOSs) incurred by hospitalized patients with uncomplicated ARF and their important determining factors.

METHODS

We obtained hospital case-mix data sets from 23 Massachusetts hospitals for a 2-year period (1999 to 2000) from the Massachusetts Division of Health Care Finance and Policy. A total of 2,252 records of patients hospitalized with uncomplicated ARF were identified. Patient records of other common medical diagnoses were studied for comparison.

RESULTS

Patients hospitalized with uncomplicated ARF incurred median direct hospital costs of 2,600 dollars, median hospital LOS of 5 days, and mortality of 8%. Dialysis was independently associated with significantly greater hospital costs and LOSs for patients with uncomplicated ARF (P < 0.05). Male sex and nonwhite race were associated with significantly lower hospital costs and LOSs, whereas type of hospital had opposing effects on these 2 resource utilization outcomes (P < 0.05). Unadjusted aggregate resource utilization associated with uncomplicated ARF exceeded that of many other common illnesses.

CONCLUSION

Demographic and hospital factors, as well as dialysis therapy, are significant determinants of hospital resource utilization for patients with uncomplicated ARF. Uncomplicated ARF appears to incur greater hospital costs and longer LOSs compared with other common medical conditions. Greater focus should be directed toward further understanding of the factors influencing resource utilization for ARF.

The roles of teaching hospitals, insurance status, and race/ethnicity in receipt of adjuvant therapy for regional-stage breast cancer in Florida

OBJECTIVES

We examined the roles of teaching hospitals, insurance status, and race/ ethnicity in women's receipt of adjuvant therapy for regional-stage breast cancer.

METHODS

Data were taken from the Florida Cancer Data System for cases diagnosed from July 1997 to December 2000. We evaluated the impact of health insurance status and hospital type on use of adjuvant therapy (after adjustment for age, race/ethnicity, and marital status). Interaction terms for hospital type, insurance status, and race/ethnicity were entered in each model.

RESULTS

Teaching facilities diagnosed 12.5% of the cases; however, they cared for a disproportionate percentage (21.3%) of uninsured and Medicaid-insured women. Among women who received adjuvant chemotherapy only, those diagnosed in teaching hospitals were more likely than those diagnosed in nonteaching hospitals to receive therapy regardless of insurance status or race/ethnicity. Among women who received chemotherapy with or without hormonal therapy, Hispanics were more likely than White non-Hispanic women to receive therapy, whereas women with private insurance or Medicare were less likely than uninsured and Medicaid-insured women to receive this type of therapy.

CONCLUSIONS

Teaching facilities play an important role in the diagnosis and treatment of regional-stage breast cancer among Hispanics, uninsured women, and women insured by Medicaid.

Did recent changes in Medicare reimbursement hit teaching hospitals harder?

PURPOSE

To inform the policy debate on Medicare reimbursement by examining the financial effects of the Balanced Budget Act of 1997 (BBA) and subsequent adjustments on major academic medical centers, minor teaching hospitals, and nonteaching hospitals.

METHOD

The authors simulated the impacts of BBA and subsequent BBA adjustments to predict the independent effects of changes in Medicare reimbursement on hospital revenues using 1997-2001 Medicare Cost Reports for all short-term acute-care hospitals in the United States. The authors also calculated actual (nonsimulated) operating and total margins among major teaching, minor teaching, and nonteaching hospitals to account for hospital response to the changes.

RESULTS

The BBA and subsequent refinements reduced Medicare revenues to a greater degree in major teaching hospitals, but the fact that such hospitals had a smaller proportion of Medicare patients meant that the BBA reduced overall revenues by similar percentages across major, minor, and nonteaching hospitals. Consistently lower margins may have made teaching hospitals more vulnerable to cuts in Medicare support.

CONCLUSIONS

Recent Medicare changes affected revenues at teaching and nonteaching hospitals more similarly than is commonly believed. However, the Medicare cuts under the BBA probably exacerbated preexisting financial strain on major teaching hospitals, and increased Medicare funding may not suffice to eliminate the strain. This report's findings are consistent with recent calls to support needed services of teaching hospitals through all-payer or general funds.

Effect of cuts in Medicare reimbursement on process and outcome of care for acute myocardial infarction patients

BACKGROUND

The Balanced Budget Act (BBA) of 1997 was designed to reduce Medicare reimbursements by $116.4 billion from 1998 to 2002. The objective of this study was to determine whether the process of care for acute myocardial infarction (AMI) worsened to a greater degree in hospitals under increased financial strain from the BBA and whether vulnerable populations such as the uninsured were disproportionately affected.

METHODS AND RESULTS

We examined how process-of-care measures and in-hospital mortality for AMI patients changed in accordance with the degree of BBA-induced financial stress using data on 236,506 patients from the National Registry of Myocardial Infarction (NRMI) and Medicare Cost Reports from 1996 to 2001. BBA-induced reductions in hospital net revenues were estimated at 1.5% (2.9 million dollars) for hospitals with low BBA impact and 3.2% (3.7 million dollars) for hospitals with a high impact in 1998, worsening to 2.2% (4.4 million dollars) and 4.7% (6.0 million dollars), respectively, by 2001. For both insured and uninsured patients in high- versus low-impact hospitals, there was no systematic worsening of time to thrombolytic therapy, balloon inflation, medication use on admission, medication use on discharge, or mortality. There was no systematic pattern of different treatment among the insured and uninsured. Operating margins decreased to a degree commensurate with the degree of revenue reduction in high- versus low-impact hospitals.

CONCLUSIONS

BBA created a moderate financial strain on hospitals. However, process-of-care measures for both insured and uninsured patients with AMI were not appreciably affected by these revenue reductions. It is important to note that these results apply only to AMI patients; we do not know the degree to which these findings generalize to other conditions.

Why do patients and families request transfers to tertiary care? a qualitative study

Interhospital transfers comprise a significant and increasing proportion of admissions to tertiary care centers. Patient dissatisfaction with the quality of hospital care may play an important role in these trends. The objective of this study was to describe why and how patients and surrogates request transfers to tertiary care. We interviewed 32 patients transferred to the Johns Hopkins Hospital, a US tertiary care center, or their surrogate decision-makers using a semi-structured, open-ended, iterative protocol. We used ethnographic decision modeling to develop an influence diagram of the decision. We contrasted subjects' perceptions of situations where patients did and did not request transfer to describe the threshold for requesting transfer. Subjects reported three major influences on the request to transfer to tertiary care: the quality of care at the community hospital compared to the tertiary center; the severity and potential consequences of the current illness; and their relationship with community hospitals, physicians, and tertiary care. Subjects' perceptions of the quality differential between community hospitals and tertiary centers focused on communication and medical errors rather than specialized care, hospital volume, or teaching status. Thresholds for when patients requested transfers were influenced by relationships with community hospitals and physicians and previous experience with tertiary care. This model provides a framework for understanding requests to transfer to tertiary care. Further investigation into the elements we have described might provide insights into improvements in the quality of care at community hospitals that might reduce the rates of requests for transfer. Our results also highlight the importance of including patient or surrogate perspectives in evaluations of the appropriateness of care.

Care in U.S. hospitals--the Hospital Quality Alliance program

BACKGROUND

The Hospital Quality Alliance (HQA) is the first initiative that routinely reports data on hospitals' performance nationally. Heretofore, such data have been unavailable.

METHODS

We used data collected by the Centers for Medicare and Medicaid Services on 10 indicators of the quality of care for acute myocardial infarction, congestive heart failure, and pneumonia. The main outcome measures were hospitals' performance with respect to each indicator and summary scores for each clinical condition. Predictors of a high level of performance were determined with the use of multivariable linear regression.

RESULTS

A total of 3558 hospitals reported data on at least one stable measure (defined as information obtained from discharge data from at least 25 patients) during the first half of 2004. Median performance scores (expressed as the percentage of patients who satisfied the criterion) were at least 90 percent for 5 of the 10 measures but lower for the other 5. Performance varied moderately among large hospital-referral regions, with the top-ranked regions scoring 12 percentage points (for acute myocardial infarction) to 23 percentage points (for pneumonia) higher than the bottom-ranked regions. A high quality of care for acute myocardial infarction predicted a high quality of care for congestive heart failure but was only marginally better than chance at predicting a high quality of care for pneumonia. Characteristics associated with small but significant increases in performance included being an academic hospital, being in the Northeast or Midwest, and being a not-for-profit hospital.

CONCLUSIONS

Analysis of data from the new HQA national reporting system shows that performance varies among hospitals and across indicators. Given this variation and small differences based on hospitals' characteristics, performance reporting will probably need to include numerous clinical conditions from a broad range of hospitals.

Quality of care in teaching hospitals: a literature review

PURPOSE

To compare the quality of care in teaching hospitals with that in nonteaching hospitals.

METHOD

By performing a literature review via PubMed, the author identified and surveyed 23 studies that compared the quality of care in teaching hospitals with that in nonteaching hospitals. The studies were published from 1989-2004 and in all but one case dealt exclusively with U.S. hospitals.

RESULTS

The teaching hospitals studied had better-quality measures than did nonteaching hospitals in the predominant number of studies reviewed. Process measures were significantly better in teaching hospitals in seven of the eight studies where such measures were observed, and equal in the other study. Risk-adjusted mortality was lower in teaching hospitals in nine of the 15 studies using that measure, not significantly different in five, and significantly lower in nonteaching hospitals in one study (in pediatric intensive care units, even though the teaching hospitals had a better process of care). In nonmortality outcomes, teaching hospitals were better in one study using that measure; there were no significant differences in five other such studies. Major teaching hospitals had more favorable outcomes end points than did minor teaching hospitals in eight studies in which they were compared. Including only those six studies using clinical data for process analysis or risk adjustment, teaching hospitals had a better process in all six and lower adjusted mortality in five of seven studies where that measure was used.

CONCLUSIONS

Overall, the favorable results in teaching hospitals extended over a range of locations, conditions, and populations, including routine as well as complex conditions. However, the quality measured in these studies was not at target levels across the spectrum of hospitals. There needs to be a continuous and determined effort for improvement in all institutions. It is to be hoped that teaching hospitals will take the lead not only in continuously improving their own quality, but also in developing and evaluating ever improving methods of quality assessment.

Effects of race, insurance status, and hospital volume on perforated appendicitis in children

OBJECTIVE

Previous research suggests that perforated appendicitis is more common in Medicaid patients, but the roles of minority race and hospital volume remain largely unstudied. We sought to investigate the association of perforated appendicitis in children with minority race, insurance status, and hospital volume.

METHODS

We conducted a retrospective, population-based cohort study of 33184 children who had an International Classification of Diseases, Ninth Revision diagnosis code for acute appendicitis in The Kids' Inpatient Database, a pediatric database from 22 states in 1997. A multivariate logistic regression model was developed to determine patient and hospital characteristics predictive of perforated appendicitis.

RESULTS

Of 33184 children with acute appendicitis, 10777 (32.5%) were perforated. In multivariate analysis, black (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.10-1.39) and Hispanic (OR: 1.19; 95% CI: 1.10-1.29) children were more likely to have perforated appendicitis than white children. Perforation was also more likely in Medicaid patients (OR: 1.30; 95% CI 1.22-1.39) compared with privately insured children. Annual hospital volume of cases of appendicitis was not significantly associated with perforation in multivariate analysis.

CONCLUSIONS

Perforated appendicitis disproportionately affected both children of minority race and children insured by Medicaid. No effect of hospital volume was observed. To reduce this racial disparity, efforts should focus on the causes of delayed diagnosis and the treatment of appendicitis in children of minority race.

Provider and practice characteristics associated with antibiotic use in children with presumed viral respiratory tract infections

OBJECTIVE

Although overuse of antibiotics in children has been well documented, relatively little information is known about provider and facility characteristics associated with this prescribing practice. This study was done to evaluate the differences in overuse of antibiotics among staff physicians and resident/interns (housestaff [HS]) who work in hospital-based outpatient clinics.

METHODS

This cross-sectional study involved patient encounters in outpatient departments that were included in the US National Hospital Ambulatory Medical Care Survey database from 1995 to 2000. Encounters with patients who were aged <18 years and had a primary diagnosis suggestive of viral respiratory tract infection were evaluated. Patients with comorbid conditions that might justify antibiotic use were excluded.

RESULTS

This study included 1952 patient encounters with a primary diagnosis suggestive of a viral infection and 33.2% of these patients receiving antibiotics. Overall, antibiotic use was significantly less among HS (19.5%) than staff physicians (36.4%; odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.33-0.59). This difference between HS (19.5%) and staff physicians (32.5%) persisted even within teaching hospitals (OR: 0.5; 95% CI: 0.4-0.7). Among staff physicians, antibiotic use was greater among those who work in nonteaching (39.6%) compared with teaching hospitals (32.5%; OR: 1.51; 95%: CI 1.15-1.98). Controlling for other patient and provider variables, antibiotic use occurred less among HS than among staff physicians in teaching hospitals (OR: 0.53; 95% CI: 0.38-0.75).

CONCLUSIONS

Antibiotic prescribing in the context of an outpatient visit for a diagnosis suggestive of a viral respiratory tract illness occurs more commonly among staff physicians than trainees and among staff physicians more commonly in nonteaching compared with teaching institutions.

Physicians' views of interventions to reduce medical errors: does evidence of effectiveness matter?

PURPOSE

Despite widespread public attention and numerous ongoing patient safety initiatives, physicians are skeptical of the most commonly prescribed interventions to reduce medical errors. This study examined the association between the published evidence of effectiveness of interventions to reduce medical errors and physicians' ratings of the effectiveness of those interventions. It further assessed whether academic affiliation was associated with physicians' ratings of effectiveness.

METHOD

The authors conducted a literature review seeking evidence of effectiveness of 13 interventions to reduce medical errors. A four-page questionnaire was sent to a random sample of 1,332 U.S. physicians in the spring of 2002. A total of 831 (62%) responded, providing ratings of the perceived effectiveness of these interventions to reduce medical errors.

RESULTS

We identified published evidence of effectiveness for six of the 13 interventions. Physicians rated 34% of these and 29% of the interventions without published evidence as "very effective" (p < .01). Physicians with an academic affiliation and those in practice for more years were slightly more likely to rate interventions with published evidence as "very effective."

CONCLUSIONS

Physicians' ratings of the effectiveness of interventions to reduce medical errors are only weakly associated with published evidence of effectiveness. More evidence, better dissemination strategies for existing evidence such as inclusion in medical school curriculum or recertification examinations, and a focus on removing barriers to interventions may be needed to engage physicians in moving patient safety interventions into medical practice.