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Lu H, Hatfield LA, Al-Azazi S, Bakx P, Banerjee A, Burrack N, Chen YC, Fu C, Gordon M, Heine R, Huang N, Ko DT, Lix LM, Novack V, Pasea L, Qiu F, Stukel TA, Uyl-de Groot CA, Weinreb G, Landon BE, Cram P. Sex-Based Disparities in Acute Myocardial Infarction Treatment Patterns and Outcomes in Older Adults Hospitalized Across 6 High-Income Countries: An Analysis From the International Health Systems Research Collaborative. Circ Cardiovasc Qual Outcomes 2024; 17:e010144. [PMID: 38328914 DOI: 10.1161/circoutcomes.123.010144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 10/27/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Sex differences in acute myocardial infarction treatment and outcomes are well documented, but it is unclear whether differences are consistent across countries. The objective of this study was to investigate the epidemiology, use of interventional procedures, and outcomes for older females and males hospitalized with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) in 6 diverse countries. METHODS We conducted a serial cross-sectional cohort study of 1 508 205 adults aged ≥66 years hospitalized with STEMI and NSTEMI between 2011 and 2018 in the United States, Canada, England, the Netherlands, Taiwan, and Israel using administrative data. We compared females and males within each country with respect to age-standardized hospitalization rates, rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery within 90 days of hospitalization, and 30-day age- and comorbidity-adjusted mortality. RESULTS Hospitalization rates for STEMI and NSTEMI decreased between 2011 and 2018 in all countries, although the hospitalization rate ratio (rate in males/rate in females) increased in virtually all countries (eg, US STEMI ratio, 1.58:1 in 2011 and 1.73:1 in 2018; Israel NSTEMI ratio, 1.71:1 in 2011 and 2.11:1 in 2018). Rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery were lower for females than males for STEMI in all countries and years (eg, US cardiac catheterization in 2018, 88.6% for females versus 91.5% for males; Israel percutaneous coronary intervention in 2018, 76.7% for females versus 84.8% for males) with similar findings for NSTEMI. Adjusted mortality for STEMI in 2018 was higher for females than males in 5 countries (the United States, Canada, the Netherlands, Israel, and Taiwan) but lower for females than males in 5 countries for NSTEMI. CONCLUSIONS We observed a larger decline in acute myocardial infarction hospitalizations for females than males between 2011 and 2018. Females were less likely to receive cardiac interventions and had higher mortality after STEMI. Sex disparities seem to transcend borders, raising questions about the underlying causes and remedies.
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Affiliation(s)
- Hannah Lu
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX (H.L., P.C.)
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, MA (L.A.H., C.F., G.W., B.E.L.)
- Division of General Medicine, Beth Israel Deaconess Medical Center (L.A.H., B.E.L.)
| | - Saeed Al-Azazi
- George & Fay Yee Centre for Healthcare Innovation (S.A.-A., L.M.L.), University of Manitoba, Winnipeg, Canada
| | - Pieter Bakx
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands (P.B., R.H., C.A.U.G.)
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, United Kingdom (A.B., L.P.)
- Consultant in Cardiology, University College London Hospitals, United Kingdom (A.B.)
| | - Nitzan Burrack
- Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel (N.B., M.G., V.N.)
| | - Yu-Chin Chen
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan (Y.-C.C., N.H.)
| | - Christina Fu
- Department of Health Care Policy, Harvard Medical School, Boston, MA (L.A.H., C.F., G.W., B.E.L.)
| | - Michal Gordon
- Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel (N.B., M.G., V.N.)
| | - Renaud Heine
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands (P.B., R.H., C.A.U.G.)
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan (Y.-C.C., N.H.)
| | - Dennis T Ko
- ICES, Toronto, ON (D.T.K., F.Q., T.A.S., P.C.)
- Schulich Heart Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (D.T.K.)
- Faculty of Medicine (D.T.K., P.C.), University of Toronto, ON, Canada
| | - Lisa M Lix
- George & Fay Yee Centre for Healthcare Innovation (S.A.-A., L.M.L.), University of Manitoba, Winnipeg, Canada
- Department of Community Health Sciences (L.M.L.), University of Manitoba, Winnipeg, Canada
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel (N.B., M.G., V.N.)
| | - Laura Pasea
- Institute of Health Informatics, University College London, United Kingdom (A.B., L.P.)
| | - Feng Qiu
- ICES, Toronto, ON (D.T.K., F.Q., T.A.S., P.C.)
| | - Therese A Stukel
- ICES, Toronto, ON (D.T.K., F.Q., T.A.S., P.C.)
- Institute for Health Management Policy and Evaluation (T.A.S.), University of Toronto, ON, Canada
| | - Carin A Uyl-de Groot
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands (P.B., R.H., C.A.U.G.)
| | - Gabe Weinreb
- Department of Health Care Policy, Harvard Medical School, Boston, MA (L.A.H., C.F., G.W., B.E.L.)
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, MA (L.A.H., C.F., G.W., B.E.L.)
- Division of General Medicine, Beth Israel Deaconess Medical Center (L.A.H., B.E.L.)
| | - Peter Cram
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX (H.L., P.C.)
- ICES, Toronto, ON (D.T.K., F.Q., T.A.S., P.C.)
- Faculty of Medicine (D.T.K., P.C.), University of Toronto, ON, Canada
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Juhnke C, Bethge S, Mühlbacher AC. A Review on Methods of Risk Adjustment and their Use in Integrated Healthcare Systems. Int J Integr Care 2016; 16:4. [PMID: 28316544 PMCID: PMC5354219 DOI: 10.5334/ijic.2500] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 06/28/2016] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Effective risk adjustment is an aspect that is more and more given weight on the background of competitive health insurance systems and vital healthcare systems. The objective of this review was to obtain an overview of existing models of risk adjustment as well as on crucial weights in risk adjustment. Moreover, the predictive performance of selected methods in international healthcare systems should be analysed. THEORY AND METHODS A comprehensive, systematic literature review on methods of risk adjustment was conducted in terms of an encompassing, interdisciplinary examination of the related disciplines. RESULTS In general, several distinctions can be made: in terms of risk horizons, in terms of risk factors or in terms of the combination of indicators included. Within these, another differentiation by three levels seems reasonable: methods based on mortality risks, methods based on morbidity risks as well as those based on information on (self-reported) health status. CONCLUSIONS AND DISCUSSION After the final examination of different methods of risk adjustment it was shown that the methodology used to adjust risks varies. The models differ greatly in terms of their included morbidity indicators. The findings of this review can be used in the evaluation of integrated healthcare delivery systems and can be integrated into quality- and patient-oriented reimbursement of care providers in the design of healthcare contracts.
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Affiliation(s)
- Christin Juhnke
- IGM Institute Health Economics and Healthcare Management, Hochschule Neubrandenburg, Neubrandenburg, Germany
| | - Susanne Bethge
- IGM Institute Health Economics and Healthcare Management, Hochschule Neubrandenburg, Neubrandenburg, Germany
- Institute of Epidemiology, Social Medicine and Health System Research, Hannover Medical School, Hannover, Germany
| | - Axel C. Mühlbacher
- IGM Institute Health Economics and Healthcare Management, Hochschule Neubrandenburg, Neubrandenburg, Germany
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Katzan IL, Spertus J, Bettger JP, Bravata DM, Reeves MJ, Smith EE, Bushnell C, Higashida RT, Hinchey JA, Holloway RG, Howard G, King RB, Krumholz HM, Lutz BJ, Yeh RW. Risk adjustment of ischemic stroke outcomes for comparing hospital performance: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:918-44. [PMID: 24457296 DOI: 10.1161/01.str.0000441948.35804.77] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Stroke is the fourth-leading cause of death and a leading cause of long-term major disability in the United States. Measuring outcomes after stroke has important policy implications. The primary goals of this consensus statement are to (1) review statistical considerations when evaluating models that define hospital performance in providing stroke care; (2) discuss the benefits, limitations, and potential unintended consequences of using various outcome measures when evaluating the quality of ischemic stroke care at the hospital level; (3) summarize the evidence on the role of specific clinical and administrative variables, including patient preferences, in risk-adjusted models of ischemic stroke outcomes; (4) provide recommendations on the minimum list of variables that should be included in risk adjustment of ischemic stroke outcomes for comparisons of quality at the hospital level; and (5) provide recommendations for further research. METHODS AND RESULTS This statement gives an overview of statistical considerations for the evaluation of hospital-level outcomes after stroke and provides a systematic review of the literature for the following outcome measures for ischemic stroke at 30 days: functional outcomes, mortality, and readmissions. Data on outcomes after stroke have primarily involved studies conducted at an individual patient level rather than a hospital level. On the basis of the available information, the following factors should be included in all hospital-level risk-adjustment models: age, sex, stroke severity, comorbid conditions, and vascular risk factors. Because stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor of hospital-level performance for 30-day mortality, inclusion of a stroke severity measure in risk-adjustment models for 30-day outcome measures is recommended. Risk-adjustment models that do not include stroke severity or other recommended variables must provide comparable classification of hospital performance as models that include these variables. Stroke severity and other variables that are included in risk-adjustment models should be standardized across sites, so that their reliability and accuracy are equivalent. There is a pressing need for research in multiple areas to better identify methods and metrics to evaluate outcomes of stroke care. CONCLUSIONS There are a number of important methodological challenges in undertaking risk-adjusted outcome comparisons to assess the quality of stroke care in different hospitals. It is important for stakeholders to recognize these challenges and for there to be a concerted approach to improving the methods for quality assessment and improvement.
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Krzych LJ, Lees B, Nugara F, Banya W, Bochenek A, Cook J, Taggart D, Flather MD. Assessment of data quality in an international multi-centre randomised trial of coronary artery surgery. Trials 2011; 12:212. [PMID: 21943128 PMCID: PMC3205027 DOI: 10.1186/1745-6215-12-212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 09/26/2011] [Indexed: 11/16/2022] Open
Abstract
Background ART is a multi-centre randomised trial of cardiac surgery which provided a unique opportunity to evaluate the data from a large number of centres from a variety of countries. We attempted to assess data quality, including recruitment rates, timeliness and completeness of the data obtained from the centres in different socio-economic strata. Methods The analysis was based on the 2-page CRF completed at the 6 week follow-up. CRF pages were categorised into "clean" (no edit query) and "dirty" (any incomplete, inconsistent or illegible data). The timelines were assessed on the basis of the time interval from the visit and receipt of complete CRF. Data quality was defined as the number of data queries (in percent) and time delay (in days) between visit and receipt of correct data. Analyses were stratified according to the World Bank definitions into: "Developing" countries (Poland, Brazil and India) and "Developed" (Italy, UK, Austria and Australia). Results There were 18 centres in the "Developed" and 10 centres in the "Developing" countries. The rate of enrolment did not differ significantly by economic level ("Developing":4.1 persons/month, "Developed":3.7 persons/month). The time interval for the receipt of data was longer for "Developing" countries (median:37 days) compared to "Developed" ones (median:11 days) (p < 0.001). The median number of data queries was 23% in "Developed" countries compared to 19% in "Developing" ones (p = ns). Conclusions In this study we showed that data quality was comparable between centres from "Developed" and "Developing" countries. Data was received in a less timely fashion from Developing countries and appropriate systems should be instigated to minimize any delays. Close attention should be paid to the training of centres and to the central management of data quality. Trial registration ISRCTN46552265
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Affiliation(s)
- Lukasz J Krzych
- Clinical Trials and Evaluation Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
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Lee DS, Verocai F, Husain M, Al Khdair D, Wang X, Freeman M, Iwanochko RM. Cardiovascular outcomes are predicted by exercise-stress myocardial perfusion imaging: Impact on death, myocardial infarction, and coronary revascularization procedures. Am Heart J 2011; 161:900-7. [PMID: 21570520 DOI: 10.1016/j.ahj.2011.01.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 01/31/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of this study was to determine the impact of myocardial perfusion imaging (MPI) on the outcomes of death, myocardial infarction (MI), and late coronary revascularization procedures. METHODS In patients undergoing exercise-stress MPI (January 1, 2003-March 31, 2007), we determined the impact of summed stress score (SSS) and percent left ventricular (LV) ischemia on (a) death or MI and (b) composite of death, MI, or late coronary revascularization occurring more than 90 days post-MPI. RESULTS During 35,007 person-years of follow-up among 9,605 patients (mean ± SD age 54.4 ± 13.2 years, 60.3% men), there were 290 deaths, 175 MIs, and 525 coronary revascularization procedures. Of those who attained ≥10 metabolic equivalents (METS) workload, major stress perfusion defects (SSS ≥7) were present in 4.2% overall and in 3.7% without ST-segment shifts, whereas large ischemic defects (≥10% LV ischemia) were present in 1% overall and 0.7% without ST-segment shifts. For those with 1% to 4%, 5% to 9%, and ≥10% LV ischemia, adjusted hazard ratios were 1.40 (95% CI 1.13-1.73, P = .002), 2.07 (95% CI 1.56-2.74, P < .001), and 3.03 (95% CI 2.21-4.16, P < .001) for the outcome of late revascularization, MI, or death versus no ischemia. Summed stress scores ≥7 were associated with increased risk of death or MI, with an adjusted hazard ratio of 1.57 (95% CI 1.16-2.13, P = .004) compared with those with no stress perfusion defects. CONCLUSION Although workload ≥10 METS conferred lower frequency of major ischemia (≥10%), %LV ischemia predicted the occurrence of cardiovascular events and death (eg, MI, late coronary revascularization, or death). Presence of a large stress perfusion defect (SSS ≥7) predicted increased risk of MI or death.
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Shahian DM, Edwards F, Grover FL, Jacobs JP, Wright CD, Prager RL, Rich JB, Mack MJ, Mathisen DJ. The Society of Thoracic Surgeons National Adult Cardiac Database: A continuing commitment to excellence. J Thorac Cardiovasc Surg 2010; 140:955-9. [DOI: 10.1016/j.jtcvs.2010.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 09/10/2010] [Accepted: 09/20/2010] [Indexed: 10/18/2022]
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Quantifying data quality for clinical trials using electronic data capture. PLoS One 2008; 3:e3049. [PMID: 18725958 PMCID: PMC2516178 DOI: 10.1371/journal.pone.0003049] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2008] [Accepted: 08/04/2008] [Indexed: 11/20/2022] Open
Abstract
Background Historically, only partial assessments of data quality have been performed in clinical trials, for which the most common method of measuring database error rates has been to compare the case report form (CRF) to database entries and count discrepancies. Importantly, errors arising from medical record abstraction and transcription are rarely evaluated as part of such quality assessments. Electronic Data Capture (EDC) technology has had a further impact, as paper CRFs typically leveraged for quality measurement are not used in EDC processes. Methods and Principal Findings The National Institute on Drug Abuse Treatment Clinical Trials Network has developed, implemented, and evaluated methodology for holistically assessing data quality on EDC trials. We characterize the average source-to-database error rate (14.3 errors per 10,000 fields) for the first year of use of the new evaluation method. This error rate was significantly lower than the average of published error rates for source-to-database audits, and was similar to CRF-to-database error rates reported in the published literature. We attribute this largely to an absence of medical record abstraction on the trials we examined, and to an outpatient setting characterized by less acute patient conditions. Conclusions Historically, medical record abstraction is the most significant source of error by an order of magnitude, and should be measured and managed during the course of clinical trials. Source-to-database error rates are highly dependent on the amount of structured data collection in the clinical setting and on the complexity of the medical record, dependencies that should be considered when developing data quality benchmarks.
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Video-Assisted Thoracic Surgery Lobectomy: Centers of Excellence or Excellence of Centers? Thorac Surg Clin 2008; 18:263-8. [DOI: 10.1016/j.thorsurg.2008.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Ribera A, Marsal JR, Ferreira-González I, Cascant P, Pons JM, Mitjavila F, Salas T, Permanyer-Miralda G. Predicción de la mortalidad hospitalaria en la cirugía de derivación aortocoronaria mediante datos administrativos: comparación con un estudio observacional prospectivo. Rev Esp Cardiol 2008. [DOI: 10.1157/13124995] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Park HK, Yoon SJ, Ahn HS, Ahn LS, Seo HJ, Lee SI, Lee KS. Comparison of risk-adjustment models using administrative or clinical data for outcome prediction in patients after myocardial infarction or coronary bypass surgery in Korea. Int J Clin Pract 2007; 61:1086-90. [PMID: 17537190 DOI: 10.1111/j.1742-1241.2007.01345.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The objectives of this study were to compare the performance indicators of risk-adjustment models based on administrative and clinical data in Korea, and to assess whether administrative data alone is useful for comparing quality of care. METHODS Outcome was defined as death within 30 days of discharge. For administrative data, the risk factors were; age, sex, and 11 past histories and two past major procedures, which were retrospectively chased in National Health Insurance database using patient Identification Number. For clinical data, the severity score of the three risk-adjustment measures [MedisGroups, Disease Staging (DS) and Computerized Severity Index (CSI)] was used as the independent predictors of 30-day mortality. Risk-adjustment models were developed by logistic regression analysis for 13,885 Acute Myocardial Infarction (AMI) and 2115 Coronary Artery Bypass Graft (CABG) patients based on administrative data and for 208 AMI patients and 478 CABG patients using clinical data. Performances of models were examined using c-statistic and Hosmer-Lemeshow statistic. RESULTS The results obtained showed the superiority of the clinical model. For AMI, the c-statistic of the administrative model was 0.696, and those of the CSI, DS and MedisGroups models were 0.772, 0.861 and 0.988 respectively. For CABG, the c-statistic of the administrative model was 0.568, and those of the CSI, DS and MedisGroups models were 0.665, 0.731 and 0.816 respectively. CONCLUSION Our results indicate that risk-adjustment model only using administrative data are probably not useful for assessing quality of care in Korea.
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Affiliation(s)
- H-K Park
- Department of Health Policy and Management, College of Medicine, Cheju National University, Cheju University Street Jeju-city, Jeju Province, Korea
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Shahian DM, Silverstein T, Lovett AF, Wolf RE, Normand SLT. Comparison of Clinical and Administrative Data Sources for Hospital Coronary Artery Bypass Graft Surgery Report Cards. Circulation 2007; 115:1518-27. [PMID: 17353447 DOI: 10.1161/circulationaha.106.633008] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Regardless of statistical methodology, public performance report cards must use the highest-quality validated data, preferably from a prospectively maintained clinical database. Using logistic regression and hierarchical models, we compared hospital cardiac surgery profiling results based on clinical data with those derived from contemporaneous administrative data.
Methods and Results—
Fiscal year 2003 isolated coronary artery bypass grafting surgery results based on an audited and validated Massachusetts clinical registry were compared with those derived from a contemporaneous state administrative database, the latter using the inclusion/exclusion criteria and risk model of the Agency for Healthcare Research and Quality. There was a 27.4% disparity in isolated coronary artery bypass grafting surgery volume (4440 clinical, 5657 administrative), a 0.83% difference in observed in-hospital mortality (2.05% versus 2.88%), corresponding differences in risk-adjusted mortality calculated by various statistical methodologies, and 1 hospital classified as an outlier only with the administrative data–based approach. The discrepancies in volumes and risk-adjusted mortality were most notable for higher-volume programs that presumably perform a higher proportion of combined procedures that were misclassified as isolated coronary artery bypass grafting surgery in the administrative cohort. Subsequent analyses of a patient cohort common to both databases revealed the smoothing effect of hierarchical models, a 9% relative difference in mortality (2.21% versus 2.03%) resulting from nonstandardized mortality end points, and 1 hospital classified as an outlier using logistic regression but not using hierarchical regression.
Conclusions—
Cardiac surgery report cards using administrative data are problematic compared with those derived from audited and validated clinical data, primarily because of case misclassification and nonstandardized end points.
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Halfon P, Eggli Y, Matter M, Kallay C, van Melle G, Burnand B. Risk-adjusted rates for potentially avoidable reoperations were computed from routine hospital data. J Clin Epidemiol 2007; 60:56-67. [PMID: 17161755 DOI: 10.1016/j.jclinepi.2006.03.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2004] [Revised: 03/16/2006] [Accepted: 03/20/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Reoperations may reflect a suboptimal initial surgical treatment. The study aimed to develop a screening algorithm for those potentially avoidable, using only routinely collected hospital data and a prediction model to adjust rates for case-mix. STUDY DESIGN AND SETTING Data of a 3-year random sample of 7,370 therapeutic operations on inpatients, among which 833 were followed-up by a reoperation during the same stay. A review of medical records identified clearly avoidable and other potentially avoidable reoperations to develop and test the screening algorithm. A logistic prediction model of potentially avoidable reoperations was developed on one randomly chosen half of the data (about 9,000 interventions) and tested on the other half (cross-validation). RESULTS Two hundred thirty-seven interventions (3%) were followed by a potentially avoidable reoperation, among which 144 were clearly avoidable. The screening algorithm had a sensitivity of 75% and a specificity of 72%. Predictors of potentially avoidable reoperations were surgery categories, diagnosis related conditions, and experiencing prior surgery. The risk score, based on these variables, showed at once a satisfactory discriminative performance (C-statistic=0.76) and goodness-of-fit measure on the validation set. CONCLUSION The adjusted rate of potentially avoidable reoperations should be included in internal reporting of hospital quality indicators, but further validated in various settings.
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Affiliation(s)
- Patricia Halfon
- Institut Universitaire de Médecine Sociale et Préventive, University of Lausanne, 17 Rue du Bugnon, 1005 Lausanne, Switzerland.
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Guru V, Fremes SE, Naylor CD, Austin PC, Shrive FM, Ghali WA, Tu JV. Public versus private institutional performance reporting: what is mandatory for quality improvement? Am Heart J 2006; 152:573-8. [PMID: 16923433 DOI: 10.1016/j.ahj.2005.10.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Accepted: 10/20/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND In the past 11 years, Ontario has generated institution-level performance report cards on outcomes of coronary artery bypass graft (CABG) surgery. The objective of this study was to evaluate the differences in patient characteristics and outcomes observed during the transition from no reporting to confidential, and ultimately public performance report cards for CABG surgery in a public health system. METHODS We used clinical and administrative data to assess crude, expected, and risk-adjusted 30-day mortality rates after isolated CABG surgery in Ontario for 67693 patients from September 1, 1991, to March 31, 2002. Confidence intervals on relative mortality reductions were determined by bootstrapping. We compared 30-day mortality trends to a control outcome (risk-adjusted 30-day all-cause readmission). We analyzed inhospital mortality trends for Ontario compared with the rest of Canada for the period from 1992 to 1998. RESULTS The risk-adjusted 30-day mortality rate decreased 29% (95% CI 21-39) from the era of no reporting (1991-1993) to confidential reporting (1994-1998). There was no further decrease with public reporting (1999-2001). The control outcome of 30-day readmission did not decrease across reporting eras. Inhospital mortality fell significantly faster in Ontario during the period of confidential reporting than in other parts of Canada. CONCLUSION Ontario CABG mortality outcomes improved sharply after provider results were confidentially disclosed at an institutional level. No such changes were seen for nondisclosed outcomes or regions outside Ontario. Further public reporting of outcomes had no discernible impact on performance. These results are consistent with the hypothesis that confidential disclosure of outcomes was sufficient to accelerate quality improvement in a public system with little competition for patients between hospitals.
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Affiliation(s)
- Veena Guru
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Roos LL, Gupta S, Soodeen RA, Jebamani L. Data quality in an information-rich environment: Canada as an example. Can J Aging 2006; 24 Suppl 1:153-70. [PMID: 16080132 DOI: 10.1353/cja.2005.0055] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
This review evaluates the quality of available administrative data in the Canadian provinces, emphasizing the information needed to create integrated systems. We explicitly compare approaches to quality measurement, indicating where record linkage can and cannot substitute for more expensive record re-abstraction. Forty-nine original studies evaluating Canadian administrative data (registries, hospital abstracts, physician claims, and prescription drugs) are summarized in a structured manner. Registries, hospital abstracts, and physician files appear to be generally of satisfactory quality, though much work remains to be done. Data quality did not vary systematically among provinces. Primary data collection to check place of residence and longitudinal follow-up in provincial registries is needed. Promising initial checks of pharmaceutical data should be expanded. Because record linkage studies were ''conservative'' in reporting reliability, the reduction of time-consuming record re-abstraction appears feasible in many cases. Finally, expanding the scope of administrative data to study health, as well as health care, seems possible for some chronic conditions. The research potential of the information-rich environments being created highlights the importance of data quality.
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Affiliation(s)
- Leslie L Roos
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba, 4th Floor Brodie Centre, Room 408, 727 McDermot Avenue, Winnipeg, MB, R3E 3P5, Canada.
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Parker JP, Li Z, Damberg CL, Danielsen B, Carlisle DM. Administrative Versus Clinical Data for Coronary Artery Bypass Graft Surgery Report Cards. Med Care 2006; 44:687-95. [PMID: 16799364 DOI: 10.1097/01.mlr.0000215815.70506.b6] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to compare the performance of a risk model for isolated coronary artery bypass graft (CABG) surgery based on administrative data with that of a clinical risk model in predicting mortality and identifying hospital performance outliers. METHODS Clinical data records from the California CABG Mortality Reporting Program for 38,230 isolated CABG patients undergoing surgery in 2000-2001 were linked to records in the California patient discharge data (PDD) abstract. Risk factors based on administrative data that mirrored clinical risk factors were developed using the condition present at admission indicator in the PDD to separate preoperative acute conditions from complications of surgery. Using logistic regression, risk model performance across data sources was compared along with hospital risk-adjusted mortality ranks and quality ratings. RESULTS The administrative data showed lower prevalence of risk factors when compared with the clinical data. The clinical risk model had somewhat better discrimination (C = 0.824) than the administrative model (C = 0.799). The clinical model yielded 17 outliers and the administrative model 16 with agreement on 12 hospitals' status. Performance of the administrative risk model was minimally affected by removal of information from prior admissions and removal of risk factors not confirmed in the clinical record. CONCLUSIONS Unique properties of the California administrative data, including the ability to distinguish acute preoperative risk factors from complications of surgery, permitted construction of an administrative risk model that predicts mortality on par with most published clinical models. Despite this, the administrative model identified slightly different hospital outliers, which may indicate somewhat biased assessments of hospital patient risk.
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Affiliation(s)
- Joseph P Parker
- Healthcare Outcomes Center, California Office of Statewide Health Planning and Development, 818 K Street, Sacramento, CA 95814, USA.
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Morton JM, Galanko JA, Soper NJ, Low DE, Hunter J, Traverso LW. NIS vs SAGES: a comparison of national and voluntary databases. Surg Endosc 2006; 20:1124-8. [PMID: 16703443 DOI: 10.1007/s00464-004-8829-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2004] [Accepted: 08/25/2005] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgical outcomes are increasingly examined in an effort to improve quality and reduce medical error. The Nationwide Inpatient Sample (NIS) is a retrospective, claims-derived and population-based database and the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Outcomes Project is a prospective, voluntary and specialty surgeon database. We hypothesized that these two sources of outcome data would differ in regard to a single, commonly performed procedure. METHODS Both the NIS, a national sample of all nonfederal hospital discharges, and the gastroesophageal reflux disease log of the SAGES Outcomes Project were queried for all fundoplications performed between 1999 and 2001 using either ICD-9 procedure code 44.66 or CPT codes 43280 or 43324. Patients with an emergency admission, age <17 years, and/or diagnoses for either esophageal cancer or achalasia were excluded. Both demographic and outcome variables were compared by either t-test or chi-square analysis, with a p value of <0.05 as significant. RESULTS Both data sets were comparable for age and gender; however, the SAGES group had a higher rate of teaching hospital affiliation (71 vs 48%, p < 0.001). SAGES fundoplications had a consistently higher rate of comorbidities, including Barrett's esophagus (2.3 vs 1.1%, p = 0.005). The NIS fundoplications had a clear trend toward more associated procedures, including cholecystectomy (7.2 vs 2%, p < 0.001). Complication rates for the NIS data set were higher, including pulmonary complications (1.7 vs 0.5%, p = 0.03). No statistically significant differences existed between the two data sets for either length of stay or mortality. CONCLUSIONS The two databases indicate that fundoplication is an operation with low morbidity and mortality. The SAGES Outcomes Project demonstrated that participating surgeons had a higher affiliation with teaching hospitals, higher reporting of comorbidity, and lower associated procedures than the NIS. Despite having more comorbidity and technical difficulty, patients from the SAGES Outcomes Project had equivalent or lower complication rates.
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Affiliation(s)
- J M Morton
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305-5655, USA.
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18
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Nguyen NT, Morton JM, Wolfe BM, Schirmer B, Ali M, Traverso LW. The SAGES Bariatric Surgery Outcome Initiative. Surg Endosc 2005; 19:1429-38. [PMID: 16206007 DOI: 10.1007/s00464-005-0301-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Accepted: 06/06/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND The recent initiative for identifying centers of excellence in bariatric surgery calls for documentation of surgical outcomes. The SAGES Outcomes Initiative is a national database introduced in 1999 as a method for surgeons to accumulate and compare their data with summary national data. A bariatric-specific dataset was established later in 2001. The aim of this study was to compare the outcomes of bariatric surgery from the Society of American Gastrointestinal Endoscopic Surgeons' (SAGES) bariatric database with data derived from a national administrative database of academic centers. METHODS Between 2001 and 2004, 24 surgeons with 1,954 patients participated in the SAGES Bariatric Outcome Initiative, and 97 institutions with 42,847 patients participated in the University HealthSystem Consortium (UHC) database. Only 7 of the 24 surgeons participating in the SAGES Bariatric Outcome Initiative submitted more than 50 cases. The main outcome measures included demographics, comorbidities, type of bariatric procedure, operative time, length of hospital stay, short- and long-term complications, mortality, and weight loss. RESULTS Both datasets were comparable for gender. Roux-en-Y gastric bypass had been performed for 88% of the patients in the SAGES database and 96% of the patients in the UHC database. Associated comorbidities were similar between the two groups except for a higher rate of hyperlipidemia for the patients in the SAGES database. The SAGES database contains more bariatric-specific information such as body mass index, operative time, blood loss, bariatric-specific complications, long-term complications, and weight loss data than the UHC database. According to the available data, no statistically significant differences exist between the two datasets in terms of perioperative complications and mortality. CONCLUSIONS The SAGES Bariatric Outcome Initiative provides valuable bariatric-specific data not currently available in an administrative database that may be useful for benchmarking purposes. However, this database is currently underutilized.
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Affiliation(s)
- N T Nguyen
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA 92868, USA.
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Lorenz KA, Asch SM, Yano EM, Wang M, Rubenstein LV. Comparing strategies for United States veterans' mortality ascertainment. Popul Health Metr 2005; 3:2. [PMID: 15730553 PMCID: PMC554976 DOI: 10.1186/1478-7954-3-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2004] [Accepted: 02/24/2005] [Indexed: 11/10/2022] Open
Abstract
Background We aimed to determine optimal strategies for complete mortality ascertainment comparing death certificates and United States (US) Veterans Administration (VA) records. Methods We constructed a cohort of California veterans who died in fiscal year (FY) 2000 and used VA services the year before death. We determined decedent status using California death certificates linked to VA utilization data and the VA Beneficiary Identification and Records Locator System (BIRLS) death file. We compared the characteristics of decedents who would not have been identified by either single source (e.g., VA BIRLS alone or California death certificates alone) with the rest of the cohort. Results A total of 8,813 veteran decedents were identified from both VA decedent files and death certificates. Of all decedents, 5,698 / 8,813 (65%) veterans were identified in both source files, but 2,426 / 8,813 (28%) decedents were not identified in VA BIRLS, and 689 / 8,813 (8%) were not identified in death certificates. Compared to the rest of the cohort, decedents whose mortality status was ascertained through either single source differed by race / ethnicity, marital status, and California residence. Clinically, veterans identified from either single source had less comorbidity and were less likely to have been users of VA inpatient or long term care, but equally or more likely to have been users of VA outpatient services. Conclusion As single sources, VA decedent files and death certificates each provided an incomplete record, and death ascertainment was improved by using both source files. Potential bias may vary depending on analytic interest.
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Affiliation(s)
- Karl A Lorenz
- VA Greater Los Angeles Healthcare System, Los Angeles CA, USA
- Geffen School of Medicine at UCLA, Los Angeles CA, USA
- RAND, Santa Monica CA, USA
| | - Steven M Asch
- VA Greater Los Angeles Healthcare System, Los Angeles CA, USA
- Geffen School of Medicine at UCLA, Los Angeles CA, USA
- RAND, Santa Monica CA, USA
| | - Elizabeth M Yano
- VA Greater Los Angeles Healthcare System, Los Angeles CA, USA
- Department of Health Services, UCLA School of Public Health, Los Angeles CA, USA
| | - Mingming Wang
- VA Greater Los Angeles Healthcare System, Los Angeles CA, USA
| | - Lisa V Rubenstein
- VA Greater Los Angeles Healthcare System, Los Angeles CA, USA
- Geffen School of Medicine at UCLA, Los Angeles CA, USA
- RAND, Santa Monica CA, USA
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Lok CE, Austin PC, Wang H, Tu JV. Impact of renal insufficiency on short- and long-term outcomes after cardiac surgery. Am Heart J 2004; 148:430-8. [PMID: 15389229 DOI: 10.1016/j.ahj.2003.12.042] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Renal insufficiency is highly prevalent in North America and has been established as a nontraditional risk factor for cardiovascular disease. Cardiovascular disease remains the primary cause of mortality in the general population and is often treated with coronary artery bypass surgery (CABG). This population-based study aimed to determine the risk of nondialysis dependent renal insufficiency (RI) on the long-term outcomes of patients who undergo CABG. METHODS Prospectively collected data from 26,506 patients were abstracted from the Cardiac Care Network database from 9 revascularization hospitals in Ontario, Canada. Multivariate regression analysis examined associations between preoperative RI and inhospital, 30-day, and 1-year mortality according to 3 levels of serum creatinine: <120 micromol/L (normal), 120 to 180 micromol/L (mild RI), and >180 micromil/L (moderate-severe RI) and 5 levels of creatinine clearance (Cockcroft-Gault): >100 mL/min (normal), 80 to 99 mL/min (mild impairment), 60 to 79 mL/min (mild-moderate impairment), 40 to 59 mL/min (moderate impairment), and <40 mL/min (severe impairment). RESULTS The overall inhospital, 30-day, and 1-year mortality rates were 1.90%, 2.0%, and 4.5%, respectively. Patients with RI had greater overall comorbidity. After adjustment for confounding factors, RI was associated with the greater risk of both 30-day (odds ratio 3.7, 95% CI 2.3-5.8, P <.0001) and 1-year mortality (odds ratio 4.6, 95% CI 3.3-6.4, P <.0001). CONCLUSION Preoperative renal impairment should be recognized as a significant risk factor for mortality after CABG. A trend of increasing risk with severity of renal impairment was demonstrated for both 30-day and 1-year mortality in this large, population-based study.
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Affiliation(s)
- Charmaine E Lok
- Institute for Clinical Evaluative Sciences and the University of Toronto, Toronto, Ontario, Canada.
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Needham DM, Bronskill SE, Sibbald WJ, Pronovost PJ, Laupacis A. Mechanical ventilation in Ontario, 1992-2000: incidence, survival, and hospital bed utilization of noncardiac surgery adult patients. Crit Care Med 2004; 32:1504-9. [PMID: 15241095 DOI: 10.1097/01.ccm.0000129972.31533.37] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Mechanical ventilation is a common therapy used in caring for critically ill patients, but its epidemiology is poorly understood. We describe population-based, temporal trends in the incidence, survival, and hospital bed utilization of mechanically ventilated, noncardiac surgery adult patients. DESIGN Retrospective, observational cohort study using linked administrative databases. SETTING Province of Ontario, Canada. PATIENTS Subjects were 150,755 unique patients who received mechanical ventilation between 1992 and 2000. INTERVENTIONS None. MEASUREMENTS Annual measures of mechanical ventilation incidence, 30-day patient mortality rate, and number of mechanical ventilation days and inpatient days for mechanically ventilated patients as a proportion of total adult inpatient bed days. MAIN RESULTS From 1992 to 2000, the crude and age- and gender-adjusted incidence of mechanical ventilation increased 9% (p <.001) and 2% (p <.027), respectively, to 217 per 100,000 adults. Crude mortality rate 30 days after initiation of mechanical ventilation increased from 27% to 32% (p <.001). Significant predictors of 30-day mortality rate (adjusted hazard ratio, 95% confidence interval) were calendar year (1.03, 1.02-1.03), age >80 yrs (2.3, 2.2-2.3), Charlson score 3+ (2.0, 2.0-2.1), and specific diagnosis. From 1992 to 2000, the number of mechanical ventilation days and inpatient days for mechanically ventilated patients, as a proportion of total adult inpatient bed days, increased 69% and 30% (both p <.001), respectively, to 1.8% and 6.2%. CONCLUSIONS There was a small, but important, increase in mechanical ventilation incidence and a substantial increase in the proportion of inpatient bed days used by mechanically ventilated patients in Ontario during the 1990s. These trends are important in planning for expansion of health care resources to meet the needs of the aging population. The increase, over time, in risk-adjusted mortality rate of mechanically ventilated patients is concerning and requires further investigation.
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Affiliation(s)
- Dale M Needham
- Department of Critical Care Medicine and Medicine, University of Toronto, Toronto, Canada
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Noronha JCD, Martins M, Travassos C, Campos MR, Maia P, Panezzuti R. Aplicação da mortalidade hospitalar após a realização de cirurgia de revascularização do miocárdio para monitoramento do cuidado hospitalar. CAD SAUDE PUBLICA 2004; 20 Suppl 2:S322-30. [PMID: 15608944 DOI: 10.1590/s0102-311x2004000800025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Este estudo classificou os hospitais vinculados ao Sistema Único de Saúde (SUS) do Brasil com base no desempenho para a realização de cirurgia de revascularização do miocárdio, entre 1996 e 1998, com o uso da taxa de mortalidade hospitalar ajustada pelo risco de morrer. Foram estudados 76 hospitais (58,00% do total) que realizaram mais de 150 cirurgias no período, correspondentes a 38.962 cirurgias (92,10% do total), que foram classificados como desviantes altos ou baixos, de acordo com a razão entre o número observado e o esperado de óbitos para cada hospital. A taxa global de mortalidade hospitalar foi de 7,20%. Para o grupo de pacientes operados nos hospitais desviantes baixos, foi de 3,48%, e, de 13,96% para os desviantes altos. A metodologia tem utilidade para discriminar os hospitais brasileiros com relação à mortalidade pós cirurgia de revascularização do miocárdio e pode ser um instrumento útil para identificação daqueles que possam apresentar problemas de qualidade.
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Abstract
BACKGROUND Outcomes must be measured as a first step toward improving performance. We sought to measure the national and provincial outcomes from carotid endarterectomy (CE) and explain provincial differences. METHODS We analyzed a large Canada-wide administrative hospital discharge database of all patients, except those in Quebec, receiving CE in 1994-1997 and used logistic regression for risk adjustment to measure adverse outcomes nationally and by province. Our main outcome measures were in-hospital stroke and/or death. RESULTS A total of 14,268 patients underwent CE in the years 1994-1997. The overall death rate was 1.3% and the combined stroke and/or death rate was 4.1%. There was a trend towards improvement over the four years. The provinces of Saskatchewan and Newfoundland had significantly higher adverse event rates for the risk-adjusted combined outcome measure. CONCLUSIONS The outcome of CE in Canada is good and showed improvement over four years. However, significant differences in provincial outcomes were found. This suggests that regionalization across provincial boundaries may be needed to promote higher surgeon and hospital case volumes and thus improve outcomes.
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Affiliation(s)
- Thomas E Feasby
- Department of Clinical Neurosciences, University of Calgary and the Calgary Health Region, Calgary, Alberta, Canada
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