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Sanaiha Y, Verma A, Downey P, Hadaya J, Marzban M, Benharash P. Center-Level Variation in Hospitalization Costs of Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2024; 117:527-533. [PMID: 36940900 DOI: 10.1016/j.athoracsur.2023.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 02/16/2023] [Accepted: 03/13/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Using a nationally representative database, the present study evaluated the degree of center-level variation in the cost of transcatheter aortic valve replacement (TAVR). METHODS All adults undergoing elective, isolated TAVR were identified in the 2016 to 2018 Nationwide Readmissions Database. Multilevel mixed-effects models were used to identify patient and hospital characteristics associated with hospitalization costs. The random intercept for each hospital was generated and considered to be the baseline cost attributable to care at each center. Hospitals in the highest decile of baseline costs were classified as high-cost hospitals. The association of high-cost hospital status with in-hospital mortality and perioperative complications was subsequently assessed. RESULTS An estimated 119,492 patients, with a mean age of 80 years and a 45.9% prevalence of female sex, met the study criteria. Analysis of random intercepts indicated that 54.3% of variability in costs was attributable to interhospital differences rather than patient factors. Perioperative respiratory failure, neurologic complications, and acute kidney injury were associated with increased episodic expenditure but did not explain the observed center-level variation. The baseline cost associated with each hospital ranged from -$26,000 to $162,000. Notably, high-cost hospital status was not linked to annual TAVR caseload or to odds of mortality (P = .83), acute kidney injury (P = .18), respiratory failure (P = .32), or neurologic complications (P = .55). CONCLUSIONS The present analysis identified significant variation in the cost of TAVR, which was largely attributable to center-level rather than patient factors. Hospital TAVR volume and occurrence of complications were not drivers of the observed variation.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California
| | - Peter Downey
- Department of Cardiovascular and Thoracic Surgery, University of Kansas Health System, Kansas City, Kansas
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California
| | - Mehrab Marzban
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California.
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Aranda‐Michel E, Bianco V, Sultan I, Gleason TG, Navid F, Kilic A. Predictors of increased costs following index adult cardiac operations: Insights from a statewide publicly reported registry. J Card Surg 2019; 34:708-713. [DOI: 10.1111/jocs.14117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Edgar Aranda‐Michel
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
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Nejim BJ, Wang S, Arhuidese I, Obeid T, Alshaikh HN, Dakour Aridi H, Locham S, Malas MB. Regional variation in the cost of infrainguinal lower extremity bypass surgery in the United States. J Vasc Surg 2017; 67:1170-1180.e4. [PMID: 29074114 DOI: 10.1016/j.jvs.2017.08.055] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lower extremity bypass (LEB) remains the gold standard revascularization procedure in patients with peripheral arterial disease. The cost of LEB substantially varies based on patient's characteristics and comorbidities. The aim of this study was to assess regional variation in infrainguinal LEB cost and to identify the specific health care expenditures per service that are associated with the highest cost in each region. METHODS We identified adult patients who underwent infrainguinal LEB in the Premier database between June 2009 and March 2015. Generalized linear regression models were used to report differences between regions in total in-hospital cost and service-specific cost adjusting for patient's demographics, clinical characteristics, and hospital factors. RESULTS A total of 50,131 patients were identified. The median in-hospital cost was $13,259 (interquartile range, $9308-$19,590). The cost of LEB was significantly higher in West and Northeast regions with a median cost of nearly $16,000. The high cost in the Northeast region was driven by the fixed (indirect) cost, whereas the driver of the high cost in the West region was the variable (direct) cost. The adjusted total in-hospital cost was significantly higher in all regions compared with the South (mean difference, West, $3752 [95% confidence interval (CI), 3477-4027]; Northeast, $2959 [95% CI, 2703-3216]; Midwest, 1586 [95% CI, 1364-1808]). CONCLUSIONS In this study, we show the marked regional variability in LEB costs. This disparity was independent from patient clinical condition and hospital factors. Cost inequality across the US represents a financial burden on both the patient and the health system.
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Affiliation(s)
- Besma J Nejim
- Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md
| | - Sophie Wang
- Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md
| | - Isibor Arhuidese
- Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md; Division of Vascular Surgery, University of South Florida, Tampa, Fla
| | - Tammam Obeid
- Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md; Division of Vascular Surgery, University of Texas Medical Branch, Galveston, Tex
| | - Husain Nader Alshaikh
- Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md
| | - Hanaa Dakour Aridi
- Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md
| | - Satinderjit Locham
- Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
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Kilic A, Shah AS, Conte JV, Mandal K, Baumgartner WA, Cameron DE, Whitman GJ. Understanding variability in hospital-specific costs of coronary artery bypass grafting represents an opportunity for standardizing care and improving resource use. J Thorac Cardiovasc Surg 2014; 147:109-15. [DOI: 10.1016/j.jtcvs.2013.08.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/28/2013] [Accepted: 08/09/2013] [Indexed: 10/26/2022]
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Swaminathan M, Phillips-Bute BG, Patel UD, Shaw AD, Stafford-Smith M, Douglas PS, Archer LE, Smith PK, Mathew JP. Increasing healthcare resource utilization after coronary artery bypass graft surgery in the United States. Circ Cardiovasc Qual Outcomes 2009; 2:305-12. [PMID: 20031855 DOI: 10.1161/circoutcomes.108.831016] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite declining lengths of stay, postdischarge healthcare resource utilization may be increasing because of shifts to nonacute care settings. Although changes in hospital stay after coronary artery bypass graft (CABG) surgery have been described, patterns of discharge remain unclear. Our objective was to determine patterns of discharge disposition after CABG surgery in the United States. METHODS AND RESULTS We examined discharge disposition after CABG procedures from 1988 to 2005 using the Nationwide Inpatient Sample. Discharges with a "nonroutine" disposition defined patients discharged with continued healthcare needs. Multivariable regression models were constructed to assess trends and factors associated with nonroutine discharge. Median length of stay among 8,398,554 discharges decreased from 11 to 8 days between 1988 and 2005 (P<0.0001). There was a simultaneous increase in nonroutine discharges from 12% in 1988 to 45% in 2005 (P<0.0001), primarily comprising home healthcare and long-term facility use. Multivariable regression models showed age, female gender, comorbidities, concurrent valve surgery, and lower-volume hospitals more likely to be associated with nonroutine discharge. CONCLUSIONS We found a significant increase in nonroutine discharges after CABG surgery across the United States from 1988 to 2005. The significant shortening of length of stay during CABG may be counterbalanced by the increased requirement for additional postoperative healthcare services. Nonacute care institutions are playing an increasingly significant role in providing CABG patients with postdischarge healthcare and should be considered in investigations of postoperative healthcare resource utilization. The impact of these changes on long-term outcomes and net resource utilization remain unknown.
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Affiliation(s)
- Madhav Swaminathan
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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The Effect of Preoperative and Hospital Characteristics on Costs for Coronary Artery Bypass Graft. Ann Surg 2009; 249:335-41. [DOI: 10.1097/sla.0b013e318195e475] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ott E, Mazer CD, Tudor IC, Shore-Lesserson L, Snyder-Ramos SA, Finegan BA, Möhnle P, Hantler CB, Böttiger BW, Latimer RD, Browner WS, Levin J, Mangano DT. Coronary artery bypass graft surgery—care globalization: The impact of national care on fatal and nonfatal outcome. J Thorac Cardiovasc Surg 2007; 133:1242-51. [PMID: 17467436 DOI: 10.1016/j.jtcvs.2006.12.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Revised: 11/08/2006] [Accepted: 12/06/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In an international, prospective, observational study, we contrasted adverse vascular outcomes among four countries and then assessed practice pattern differences that may have contributed to these outcomes. METHODS A total of 5065 patients undergoing coronary artery bypass graft surgery were analyzed at 70 international medical centers, and from this pool, 3180 patients from the 4 highest enrolling countries were selected. Fatal and nonfatal postoperative ischemic complications related to the heart, brain, kidney, and gastrointestinal tract were assessed by blinded investigators. RESULTS In-hospital mortality was 1.5% (9/619) in the United Kingdom, 2.0% (9/444) in Canada, 2.7% (34/1283) in the United States, and 3.8% (32/834) in Germany (P = .03). The rates of the composite outcome (morbidity and mortality) were 12% in the United Kingdom, 16% in Canada, 18% in the United States, and 24% in Germany (P < .001). After adjustment for difference in case-mix (using the European System for Cardiac Operative Risk Evaluation) and practice, country was not an independent predictor for mortality. However, there was an independent effect of country on composite outcome. The practices that were associated with adverse outcomes were the intraoperative use of aprotinin, intraoperative transfusion of fresh-frozen plasma or platelets, lack of use of early postoperative aspirin, and use of postoperative heparin. CONCLUSIONS Significant between-country differences in perioperative outcome exist and appear to be related to hematologic practices, including administration of antifibrinolytics, fresh-frozen plasma, platelets, heparin, and aspirin. Understanding the mechanisms for these observations and selection of practices associated with improved outcomes may result in significant patient benefit.
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Affiliation(s)
- Elisabeth Ott
- Multicenter Study of Perioperative Ischemia Research Group, San Bruno, Calif, USA.
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Weintraub WS. Cost-Effectiveness Issues. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Cowper PA, DeLong ER, Hannan EL, Muhlbaier LH, Lytle BL, Jones RH, Holman WL, Pokorny JJ, Stafford JA, Mark DB, Peterson ED. Trends in postoperative length of stay after bypass surgery. Am Heart J 2006; 152:1194-200. [PMID: 17161075 DOI: 10.1016/j.ahj.2006.07.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Accepted: 07/11/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although single-site studies have reported reductions in coronary artery bypass graft (CABG) surgery length of stay (LOS) over the last 15 years, less information is available regarding overall temporal trends and interhospital variability. This study examined trends in postoperative LOS, associated rates of transfer at discharge and variation among hospitals in LOS at CABG hospitals in New York State. METHODS Trends in postoperative LOS and transfers at discharge for 105,842 CABG patients treated in 30 hospitals in New York between 1992 and 1998 were first described graphically. Mixed models were then used to assess temporal trends and interhospital variability in LOS, accounting for differences in patient risk and within-hospital correlation in outcomes. Clinical and LOS data were obtained from the Cardiac Surgery Reporting System. Additional information was extracted from the New York Statewide Planning and Research Cooperative System. RESULTS Postoperative LOS decreased 30% between 1992 and 1998 after adjusting for patient risk. A concurrent increase in the probability of nonacute patient transfers occurred over time, with the most pronounced increase in patients with stays exceeding 5 days. Underlying the downward trend in LOS was substantial interhospital variability that peaked in 1994 and remained significant in 1998. Stays were longer at hospitals located in New York City. CONCLUSIONS The downward shift in LOS observed in the 1990s was achieved in part by an increase in nonacute care transfers, reflecting a shift in care setting. After decreasing trends in postoperative stays tapered off, significant variability among hospitals remained.
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Garland A, Shaman Z, Baron J, Connors AF. Physician-attributable differences in intensive care unit costs: a single-center study. Am J Respir Crit Care Med 2006; 174:1206-10. [PMID: 16973977 DOI: 10.1164/rccm.200511-1810oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Variation in practice and outcomes, not explained by patient or illness characteristics, is common in health care, including in intensive care units (ICUs). OBJECTIVE To quantify within-ICU, between-physician variation in resource use in a single medical ICU. METHODS This was a prospective, noninterventional study in a medical ICU where nine intensivists provide care in 14-d rotations. Consecutive sample consisted of 1,184 initial patient admissions whose care was provided by a single intensivist. Multivariate models were constructed for average daily discretionary costs, ICU length of stay, and hospital mortality, adjusting for patient and illness characteristics, and workload. MEASUREMENTS AND MAIN RESULTS The identity of the intensivist was a significant predictor for average daily discretionary costs (p < 0.0001), but not ICU length of stay (p = 0.33) or hospital mortality (p = 0.83). The intensivists had more influence on costs than all other variables except the severity and type of acute illness. Average daily discretionary costs varied by 43% across the different intensivists, equating to a mean difference of 1,003 dollars per admission between the highest and lowest terciles of intensivists. CONCLUSIONS There are large differences among intensivists in the amount of resources they use to manage critically ill patients. Higher resource use was not associated with lower length of stay or mortality.
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Affiliation(s)
- Allan Garland
- Division of Pulmonary and Critical Care Medicine, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
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Mishra V, Andresen S, Brinch L, Kvaløy S, Ernst P, Lønset MK, Tangen JM, Wikelund J, Flatum C, Baggerød E, Helle B, Vaaler S, Hagen TP. Cost of autologous peripheral blood stem cell transplantation: the Norwegian experience from a multicenter cost study. Bone Marrow Transplant 2005; 35:1149-53. [PMID: 15880133 DOI: 10.1038/sj.bmt.1704988] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
High-dose therapy with autologous blood progenitor cell support is now routinely used for patients with certain malignant lymphomas and multiple myeloma. We performed a prospective cost analysis of the mobilization, harvesting and cryopreservation phases and the high-dose therapy with stem cell reinfusion and hospitalization phases. In total, 40 consecutive patients were studied at four different university hospitals between 1999 and 2001. Data on direct costs were obtained on a daily basis. Data on indirect costs were allocated to the specific patient based on estimates of relevant department costs (ie the service department's costs), and by means of predefined allocation keys. All cost data were calculated at 2001 prices. The mean total costs for the two phases were US$ 32,160 (range US$ 19,092-50,550). The mean total length of hospital stay for two phases was 31 days (range 27-37). A large part of the actual cost in the harvest phase was attributed to stem cell mobilization, including growth factors, harvesting and cryopreservation. In the high-dose chemotherapy phase, the most significant part of the costs was nursing staff. Average total costs were considerably higher than actual DRG-based reimbursement from the government, indicating that the treatment of these patients was heavily subsidized by the basic hospital grants.
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Affiliation(s)
- V Mishra
- Health Professional Support Department, Rikshospitalet University Hospital, Oslo, Norway.
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Mishra V, Lindberg H, Seem E, Klokkerud I, Fredriksen B, Skraastad O, Ostlie A, Andresen S, Vaaler S. A comparison of hospital costs with reimbursement received for patients undergoing the Norwood procedure for hypoplasia of the left heart. Cardiol Young 2005; 15:493-7. [PMID: 16164788 DOI: 10.1017/s1047951105001368] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2005] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To determine whether the present system of reimbursement, based on diagnosis-related groups and regular financial budgeting, covers the costs incurred during hospitalisation of 7 children undergoing the three stages of the Norwood sequence for surgical treatment of hypoplastic left heart syndrome. METHODS Between January and September 2003, 7 patients underwent initial surgical palliation with the Norwood procedure at the Rikshospitalet University Hospital. A prospective methodology was developed by our group to measure the costs associated with each individual patient. The patients were closely observed, and the relevant data was collected during their stay in hospital. The stay was divided into four different periods of requirements of resources, defined as heavy intensive care, light intensive care, intermediate care, and ordinary care. At each stage, we recorded the number of staff involved and the duration of surgery and other major procedures, as well as the cost of pharmaceuticals and other consumables. Based on these data, we calculated the cost for each patient. These costs were compared with the corresponding revenue received by the hospital for each of the patients. RESULTS We found the total mean cost for the three stages of the Norwood sequence was 138,934 American dollars, while the corresponding revenue received by the hospital was 43,735 American dollars. During this period, one patient died during the first stage of the Norwood sequence. CONCLUSIONS Our study shows that steps involved in the Norwood sequence are low-volume but high-cost procedures. The reimbursement received by our hospital for the procedures was less than one-third of the recorded costs.
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Affiliation(s)
- Vinod Mishra
- Hospital Management/Health Professional Support Department, Rikshospitalet University Hospital, Oslo, Norway.
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Eisenstein EL, Bethea CF, Muhlbaier LH, Davidian M, Peterson ED, Stafford JA, Mark DB. Surgeons' economic profiles: can we get the "right" answers? J Med Syst 2005; 29:111-24. [PMID: 15931798 DOI: 10.1007/s10916-005-3000-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Hospitals and payers use economic profiling to evaluate physician and surgeon performance. However, there is significant variation in the data sources and analytic methods that are used. We used information from a hospital's cardiac surgery and cost accounting information systems to create surgeon economic profiles. Three scenarios were examined: (1) surgeon modeled as fixed effect with no patient-mix adjustment; (2) surgeon modeled as fixed effect with patient-mix adjustment; (3) and surgeon modeled as random effect with patient-mix adjustment. We included 574 patients undergoing coronary artery bypass surgery at Baptist Medical Center, Oklahoma City, OK between July 1, 1995 and April 30, 1996. We found that profiles reporting unadjusted average surgeon costs may incorrectly identify high- and low-cost outliers. Adjusting for patient-mix differences and treating surgeons as random effects was the preferred approach. These results demonstrate the need for hospitals to reexamine their economic profiling methods.
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Affiliation(s)
- Eric L Eisenstein
- Outcomes Research and Assessment Group, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, 27715-7969, USA.
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Sales AE, Pineros SL, Magid DJ, Every NR, Sharp ND, Rumsfeld JS. The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals. BMC Health Serv Res 2005; 5:2. [PMID: 15649313 PMCID: PMC545996 DOI: 10.1186/1472-6963-5-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2004] [Accepted: 01/13/2005] [Indexed: 11/22/2022] Open
Abstract
Background Few studies report on the effect of organizational factors facilitating transfer between primary and tertiary care hospitals either within an integrated health care system or outside it. In this paper, we report on the relationship between degree of clinical integration of cardiology services and transfer rates of acute coronary syndrome (ACS) patients from primary to tertiary hospitals within and outside the Veterans Health Administration (VHA) system. Methods Prospective cohort study. Transfer rates were obtained for all patients with ACS diagnoses admitted to 12 primary VHA hospitals between 1998 and 1999. Binary variables measuring clinical integration were constructed for each primary VHA hospital reflecting: presence of on-site VHA cardiologist; referral coordinator at the associated tertiary VHA hospital; and/or referral coordinator at the primary VHA hospital. We assessed the association between the integration variables and overall transfer from primary to tertiary hospitals, using random effects logistic regression, controlling for clustering at two levels and adjusting for patient characteristics. Results Three of twelve hospitals had a VHA cardiologist on site, six had a referral coordinator at the tertiary VHA hospital, and four had a referral coordinator at the primary hospital. Presence of a VHA staff cardiologist on site and a referral coordinator at the tertiary VHA hospital decreased the likelihood of any transfer (OR 0.45, 95% CI 0.27–0.77, and 0.46, p = 0.002, CI 0.27–0.78). Conversely, having a referral coordinator at the primary VHA hospital increased the likelihood of transfer (OR 6.28, CI 2.92–13.48). Conclusions Elements of clinical integration are associated with transfer, an important process in the care of ACS patients. In promoting optimal patient care, clinical integration factors should be considered in addition to patient characteristics.
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Affiliation(s)
- Anne E Sales
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Sandra L Pineros
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle WA, USA
| | - David J Magid
- Colorado Permanente Clinical Research Unit, Denver, CO, USA
| | - Nathan R Every
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle WA, USA
- Cardiology Service, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nancy D Sharp
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
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Polverejan E, Gardiner JC, Bradley CJ, Holmes-Rovner M, Rovner D. Estimating mean hospital cost as a function of length of stay and patient characteristics. HEALTH ECONOMICS 2003; 12:935-947. [PMID: 14601156 DOI: 10.1002/hec.774] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Statistical models have been used to assess the influence of clinical and demographic factors on hospital charge and length of stay (LOS). Hospital costs constitute a significant proportion of overall expenditure in health care. With escalating costs, knowing the correlates of LOS and in-hospital cost is important for decisions on allocating resources. However, hospital charge and LOS are correlated. We describe two regression models that permit estimation of mean charges as a function of patient hospital stay and adjust for the influence of patient characteristics and treatment procedures on LOS and charge. In the first model, the mean charge over a specified duration is a weighted average of the expected cumulative charge, with weighting determined by the distribution of LOS. The second model for LOS and charge explicitly accounts for their correlation and yields estimates of the average charge per average LOS. The methods are applied to assess mean charges and mean charge per day by cardiac procedure in a cohort of patients hospitalized for acute myocardial infarction, while adjusting for the impact of patient demographic and clinical factors on LOS and charge. For relatively short hospital stays, and when only total hospital charges are available, these models provide a flexible approach to estimating summary measures on resource use while controlling for the effects of covariates on LOS and charge.
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Affiliation(s)
- Elena Polverejan
- Department of Epidemiology, Michigan State University, East Lansing, MI 48823, USA
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Arday DR, Fleming BB, Keller DK, Pendergrass PW, Vaughn RJ, Turpin JM, Nicewander DA. Variation in diabetes care among states: do patient characteristics matter? Diabetes Care 2002; 25:2230-7. [PMID: 12453966 DOI: 10.2337/diacare.25.12.2230] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine state variability in diabetes care for Medicare beneficiaries and the impact of certain beneficiary characteristics on those variations. RESEARCH DESIGN AND METHODS Medicare beneficiaries with diabetes, aged 18-75 years, were identified from 1997 to 1999 claims data. Claims data were used to construct rates for three quality of care measures (HbA(1c) tests, eye examinations, and lipid profiles). Person-level variables (e.g., age, sex, race, and socioeconomic status) were used to adjust state rates using logistic regression. RESULTS A third of 2 million beneficiaries with diabetes aged 18-75 years did not have annual HbA(1c) tests, biennial eye examinations, or biennial lipid profiles. There was wide variability in the measures among states (e.g., receipt of HbA(1c) tests ranged from 52 to 83%). Adjustment using person-level variables reduced the variance in HbA(1c) tests, eye examinations, and lipid profiles by 30, 23, and 27%, respectively, but considerable variability remained. The impact of the adjustment variables was also inconsistent across measures. CONCLUSIONS Opportunities remain for improvement in diabetes care. Large variations in care among states were reduced significantly by adjustment for characteristics of state residents. However, much variability remained unexplained. Variability of measures within states and variable impact of the adjustment variables argues against systems effects operating with uniformity on the three measures. These findings suggest that a single approach to quality improvement is unlikely to be effective. Further understanding variability will be important to improving quality.
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Affiliation(s)
- David R Arday
- Army Medical Surveillance Activity, Washington, DC, USA
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Carson JL, Scholz PM, Chen AY, Peterson ED, Gold J, Schneider SH. Diabetes mellitus increases short-term mortality and morbidity in patients undergoing coronary artery bypass graft surgery. J Am Coll Cardiol 2002; 40:418-23. [PMID: 12142105 DOI: 10.1016/s0735-1097(02)01969-1] [Citation(s) in RCA: 288] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this study was to determine the impact of diabetes mellitus (DM) on short-term mortality and morbidity in patients undergoing coronary artery bypass surgery (CABG). BACKGROUND Diabetes mellitus is present in approximately 20% to 30% of patients undergoing CABG, and the impact of diabetes on short-term outcome is unclear. METHODS We performed a retrospective cohort study in 434 hospitals from North America. The study population included 146,786 patients undergoing CABG during 1997: 41,663 patients with DM and 105,123 without DM. The primary outcome was 30-day mortality. Secondary outcomes were in-hospital morbidity, infections and composite outcomes of mortality or morbidity and mortality or infection. RESULTS The 30-day mortality was 3.7% in patients with DM and 2.7% in those without DM; the unadjusted odds ratio was 1.40 (95% confidence interval [CI], 1.31 to 1.49). After adjusting for other baseline risk factors, the overall adjusted odds ratio for diabetics was 1.23 (95% CI, 1.15 to 1.32). Patients treated with oral hypoglycemic medications had adjusted odds ratio 1.13; 95% CI, 1.04 to 1.23, whereas those on insulin had an adjusted odds ratio 1.39; 95% CI, 1.27 to 1.52. Morbidity, infections and the composite outcomes occurred more commonly in diabetic patients and were associated with an adjusted risk about 35% higher in diabetics than nondiabetics, particularly among insulin-treated diabetics (adjusted risk between 1.5 to 1.61). CONCLUSIONS Diabetes mellitus is an important risk factor for mortality and morbidity among those undergoing CABG. Research is needed to determine if good control of glucose levels during the perioperative time period improves outcome.
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Affiliation(s)
- Jeffrey L Carson
- Division of General Internal Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08093, USA.
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Peterson ED, Coombs LP, Ferguson TB, Shroyer AL, DeLong ER, Grover FL, Edwards FH. Hospital variability in length of stay after coronary artery bypass surgery: results from the Society of Thoracic Surgeon's National Cardiac Database. Ann Thorac Surg 2002; 74:464-73. [PMID: 12173830 DOI: 10.1016/s0003-4975(02)03694-9] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is growing interest in comparing resource, as well as patient outcome metrics among coronary artery bypass graft surgery (CABG) providers, yet few tools exist for adjusting these provider comparisons for patient case-mix. In this study, we aimed to define the magnitude of hospital variability in postoperative length of stay (PLOS) in contemporary practice and to determine the degree to which this variability was accounted for by differences in patient case-mix. We also sought to determine the relationship between hospitals' risk-adjusted PLOS and mortality outcomes. METHODS We analyzed 496,797 isolated CABG procedures performed between January 1997 to January 2001 at 587 US hospitals participating in the Society of Thoracic Surgeon's National Cardiac Database. Logistic and linear regression were used to identify independent preoperative factors affecting a patient's likelihood for early discharge (PLOS < or = 5 day), prolonged stay (> 14 days), and overall PLOS. Hierarchical models were used to determine the degree to which hospital factors influenced PLOS beyond patient factors. RESULTS Overall, 53% of CABG patients were discharged within 5 days of CABG, whereas 5% required prolonged (> 14 days) stays. More than 25 preoperative patient factors were independently associated with a patients' likelihood for early discharge and prolonged stay (model C index 0.70 and 0.75, respectively). After adjusting for patient factors, however, there remained wide unexplained variability among hospitals in PLOS and limited correlation between these PLOS metrics and hospitals' risk-adjusted mortality results (Spearman correlation coefficient -0.15 and 0.35). CONCLUSIONS Our study provides a method for institutions to receive meaningful risk-adjusted bypass PLOS information. Given the marked variability among hospitals in CABG PLOS, institutions should consider benchmarking metrics of efficiency, as well as patient outcomes.
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Affiliation(s)
- Eric D Peterson
- The Outcomes Research and Assessment Group, The Duke Clinical Research Institute, Durham, North Carolina, USA.
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Kaul P, Saunders LD, Roos LL, Kephart G, Ghali WA, Walld R, Warren J. Trends in utilization of coronary artery bypass surgery and associated outcomes: Alberta, Manitoba, and Nova Scotia. Am J Med Qual 2002; 17:103-12. [PMID: 12073866 DOI: 10.1177/106286060201700305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The primary objective of this study was to examine trends in rates and outcomes of coronary artery bypass graft (CABG) surgery across the 3 Canadian provinces of Alberta, Manitoba, and Nova Scotia, during fiscal years 1991-1995. Annual age-standardized CABG surgery rates were calculated by sex for each province. Province-specific average length of stay (ALOS) and postsurgical complication rates were calculated using ICD-9 codes. Rates of CABG were higher among men compared with women in all 3 provinces. Whereas ALOS, complications rates, and mortality rates decreased in all provinces over the study period, there was considerable variation in province-specific rates.
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Affiliation(s)
- Padma Kaul
- Duke Clinical Research Institute, Duke University, 2400 Pratt Street, Room 0311, Durham, NC 27705, USA.
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Cowper PA, DeLong ER, Peterson ED, Hannan EL, Ray KT, Racz M, Mark DB. Variability in cost of coronary bypass surgery in New York State: potential for cost savings. Am Heart J 2002; 143:130-9. [PMID: 11773923 DOI: 10.1067/mhj.2002.119617] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Previous analyses of variability in bypass resource use have not focused on hospital-level variation or adequately explored the influence of patient risk. We combined a clinical database with claims data to fully characterize patient level and hospital level variability in bypass surgery cost and length of stay in New York State and explored the extent to which lower cost is associated with worse quality of care. METHODS By use of 1992 clinical and claims data, we identified by multivariable regression which patient characteristics influence bypass cost and length of stay. Hospital was then incorporated as a random variable in mixed linear models to determine its impact on resource use. The relationship between risk-adjusted in-hospital mortality and cost was then explored. RESULTS In the 21 hospitals for which cost data were available, mean leveled cost (exclusive of professional fees and noncomparable costs) was $15,713, with a mean length of stay of 14 days (n = 12,087). One fifth of the variation in resource use was explained by baseline patient risk. After adjustment for patient risk, hospital explained an additional 42% of variation in cost and an additional 8% of variation in length of stay. Among hospitals, risk-adjusted cost varied almost 3-fold and risk-adjusted length of stay varied 50%. There was no association between cost and in-hospital mortality. CONCLUSIONS As of 1992, there was considerable interhospital variability in bypass surgery cost after patient baseline risk was accounted for. This suggests that reductions in bypass cost could be achieved by normalizing clinical practice.
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Affiliation(s)
- Patricia A Cowper
- Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC 27715, USA.
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Shahian DM, Heatley GJ, Westcott GA. Relationship of hospital size, case volume, and cost for coronary artery bypass surgery: analysis of 12,774 patients operated on in Massachusetts during fiscal years 1995 and 1996. J Thorac Cardiovasc Surg 2001; 122:53-64. [PMID: 11436037 DOI: 10.1067/mtc.2001.113750] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study investigates the relationship between the cost of coronary artery bypass graft surgery and both hospital size and case volume. METHODS Retrospective administrative and cost data were obtained for all 12,774 patients who underwent isolated coronary bypass surgery at 12 Massachusetts hospitals during 1995 and 1996. Hospitals were stratified by number of operating beds into 3 groups (group I, <250 beds; group II, 250-450 beds; group III, >450 beds). Total (diagnosis-related groups 106 + 107) annual coronary bypass cases per hospital varied from 271 to 913 (mean 532). Univariate and multivariable analyses were used to study the relationship between the direct and total cost and a number of patient (age, sex, acuity class, payer) and hospital (bed capacity, annual case volume per diagnosis-related group, cardiothoracic residency) predictor variables. For each hospital, we also studied the relationship between changes in coronary bypass case volume and the corresponding changes in average cost from 1995 to 1996. RESULTS Scatterplots revealed a broad range of mean direct cost of coronary bypass surgery among hospitals with comparable case volumes. When annual cases were analyzed as continuous variables, there was no linear relationship of case volume with direct or total cost of coronary bypass (r = -0.05 to +0.08) for any diagnosis-related group or year. When hospital bed capacity and case volume were grouped into strata and studied by analysis of variance, there was no evidence of an inverse relationship between these variables and cost. In multivariable analysis, patient acuity class and diagnosis-related group were the most important predictors of cost. Beds and case volume met inclusion criteria for most models but added little to the "explanation" of variability R(2), often less than 1%. Finally, substantial interhospital differences were noted in the magnitude and direction (direct vs inverse) of their 1995 to 1996 change in volume versus change in cost. CONCLUSIONS Within the range of hospital size and case volume represented in this study, there is no evidence that either variable is related to the cost of performing coronary bypass surgery. Massachusetts hospitals appear to function on different segments of different average cost curves. It is not possible to predict the relative cost of coronary bypass grafting at a given hospital based primarily on volume.
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Affiliation(s)
- D M Shahian
- Department of Thoracic and Cardiovascular Surgery, Lahey Clinic Medical Center, Burlington, MA 01805, USA.
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Eisenstein EL, Bethea CF. The use of patient mix-adjusted control charts to compare in-hospital costs of care. Health Care Manag Sci 1999; 2:193-8. [PMID: 10994484 DOI: 10.1023/a:1019008400263] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We introduce a technique for patient mix-adjusting x charts and compared differences between unadjusted and patient mix-adjusted results. Our data came from coronary artery bypass graft (CABG) surgery patients at Baptist Medical Center, Oklahoma City, Oklahoma. We first developed an unadjusted x control chart to compare monthly changes in CABG surgery costs and then used a published model to patient mix-adjust our x control chart information. Before adjustment, the average log costs for three of ten months were outside the 90% control limit lines, and there was a trend toward increasing costs. After adjustment, two months had average costs outside the 90% lower control limit lines, and the trend toward increasing costs had been explained by differences in patient acuity.
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Rosen AB, Humphries JO, Muhlbaier LH, Kiefe CI, Kresowik T, Peterson ED. Effect of clinical factors on length of stay after coronary artery bypass surgery: results of the cooperative cardiovascular project. Am Heart J 1999; 138:69-77. [PMID: 10385767 DOI: 10.1016/s0002-8703(99)70249-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Rising health care costs have prompted careful review of comparative hospital resource use. Length of stay after bypass surgery has received particular attention. However, many providers assert that these variations are caused by differences in the clinical mix of patients treated. Our goals were to identify the major clinical predictors of postoperative length of stay (PLOS) after coronary artery bypass graft surgery (CABG), document variations in PLOS among 28 hospitals, and assess the degree to which patient characteristics account for hospital variations in PLOS. METHODS Detailed clinical data on 3605 Medicare patients undergoing CABG in 28 Alabama and Iowa hospitals were analyzed by stepwise linear regression to identify significant clinical predictors of PLOS. Analysis of variance was used to compare hospitals' PLOS while controlling for significant patient risk factors. RESULTS The mean age was 72.1 years, 34.7% were female, and the in-hospital mortality rate was 5.6%. The median and mean PLOS were 8 and 11.1 days, respectively. Significant predictors of longer PLOS included increasing age, female sex, history of chronic obstructive pulmonary disease, cerebrovascular disease, or mitral valve disease, elevated admission blood urea nitrogen, and preoperative placement of an intraaortic balloon pump. Hospitals varied significantly (P =.0001) in their unadjusted PLOS. These hospital-level variations persisted despite adjustment for both preoperative patient characteristics (P =.0001) and postoperative complications and death (P =.0001). CONCLUSIONS This study found significant between-hospital variations in PLOS that were not explained by patient factors. This finding suggests the potential for increased efficiency in the care of patients undergoing CABG at many institutions. Further research is needed to determine the practice patterns contributing to variations in length of stay after bypass surgery.
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Affiliation(s)
- A B Rosen
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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Freund D, Lave J, Clancy C, Hawker G, Hasselblad V, Keller R, Schneiter E, Wright J. Patient Outcomes Research Teams: contribution to outcomes and effectiveness research. Annu Rev Public Health 1999; 20:337-59. [PMID: 10352862 DOI: 10.1146/annurev.publhealth.20.1.337] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This paper describes the key methodological and substantive findings of Patient Outcomes Research Teams, the first outcomes and effectiveness research centers funded by the Agency for Health Care Policy and Research. Patient Outcomes Research Teams contributed to our increased understanding of how to perform meta analysis on nontrial data, use administrative data to characterize patterns of care, develop general and disease-specific outcome measures, and disseminate important outcome information to patients and physicians to reduce practice variation. Patient Outcomes Research Teams also influenced the development of outcomes measurement in the private sector.
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Affiliation(s)
- D Freund
- Bowen Research Center, Indiana University, Indianapolis 46202, USA.
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Murphy M, Noetscher C, Lagoe R. A multihospital effort to reduce inpatient lengths of stay for pneumonia. J Nurs Care Qual 1999; 13:11-23. [PMID: 10343477 DOI: 10.1097/00001786-199906000-00004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Three large hospitals in the metropolitan area of Syracuse, New York, implemented a cooperative project to reduce hospital stays and resource utilization without adversely affecting patient outcomes for community acquired pneumonia. The project occurred under the leadership of nurse case managers and nurse managers. It was supported by active physician involvement. The project was implemented over a three-year period. It resulted in reductions of hospital stays through the standardization of patient care for pneumonia throughout the community.
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Affiliation(s)
- M Murphy
- St. Joseph's Hospital Health Center, Syracuse, NY, USA
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Every NR, Frederick PD, Robinson M, Sugarman J, Bowlby L, Barron HV. A comparison of the national registry of myocardial infarction 2 with the cooperative cardiovascular project. J Am Coll Cardiol 1999; 33:1886-94. [PMID: 10362189 DOI: 10.1016/s0735-1097(99)00113-8] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study was performed to evaluate whether or not the simpler case identification and data abstraction processes used in National Registry of Myocardial Infarction two (NRMI 2) are comparable with the more rigorous processes utilized in the Cooperative Cardiovascular Project (CCP). BACKGROUND The increased demand for quality of care and outcomes data in hospitalized patients has resulted in a proliferation of databases of varying quality. For patients admitted with myocardial infarction, there are two national databases that attempt to capture critical process and outcome data using different case identification and abstraction processes. METHODS We compared case ascertainment and data elements collected in Medicare-eligible patients included in the industry-sponsored NRMI 2 with Medicare enrollees included in the Health Care Financing Administration-sponsored CCP who were admitted during identical enrollment periods. Internal and external validity of NRMI 2 was defined using the CCP as the "gold standard." RESULTS Demographic and procedure use data obtained independently in each database were nearly identical. There was a tendency for NRMI 2 to identify past medical histories such as prior infarct (29% vs. 31%, p < 0.001) or heart failure (21% vs. 25%, p < 0.001) less frequently than the CCP. Hospital mortality was calculated to be higher in NRMI 2 (19.7% vs. 18.1%, p < 0.001) due mostly to the inclusion of noninsured patients 65 years and older in NRMI 2. CONCLUSIONS We conclude that the simpler case ascertainment and data collection strategies employed by NRMI 2 result in process and outcome measures that are comparable to the more rigorous methods utilized by the CCP. Outcomes that are more difficult to measure from retrospective chart review such as stroke and recurrent myocardial infarction must be interpreted cautiously.
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Affiliation(s)
- N R Every
- Northwest Health Services Research and Development Program, Puget Sound VA Healthcare System, University of Washington, Seattle, USA.
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Heller RF, O'Connell RL, Lim LL, Atallah A, Lanas F, Joshi P, Tatsanavivat P. Variation in stated management of acute myocardial infarction in five countries. Int J Cardiol 1999; 68:63-7. [PMID: 10077402 DOI: 10.1016/s0167-5273(98)00343-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We examined the variation in stated practice in the management of acute myocardial infarction (AMI) among doctors in Australia, Brazil, Chile, India and Thailand. Hospitals were identified as primary, secondary or tertiary by investigators from around their own region. All doctors within each hospital who would be expected to treat patients with AMI were asked to indicate which investigations and treatments they would offer to a patient with an AMI who develops angina on Day 3 after admission. The numbers of hospitals ranged from 5 to 26 per country, and doctor response rates varied from 70 to 100%. Within-country variation was large, and statistically significant variations were seen between countries in the use of most interventions. The large variation both between and within a range of countries across the economic spectrum suggests a widespread need for agreement about what constitutes appropriate management after AMI.
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Affiliation(s)
- R F Heller
- Centre for Clinical Epidemiology and Biostatistics, The University of Newcastle, Faculty of Medicine and Health Sciences, NSW, Australia.
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Carpenter CE, Cornman JM, Bender AD, Nash DB. Issues of cost and quality: barriers to an informed debate. J Eval Clin Pract 1998; 4:131-9. [PMID: 9839639 DOI: 10.1111/j.1365-2753.1998.tb00079.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Debates over health reform in the United States are hampered by a poorly informed public and misunderstandings about the concepts of quality, cost containment and their relationship to each other. This paper explores the nature and persistence of barriers to an informed public discussion of reform proposals. Those barriers are: (1) multiple definitions of quality, cost and cost containment, (2) the impact of the media on those definitions, (3) a false assumption that cost containment automatically results in diminished quality, and (4) the perceived impact of managed care and for-profit health firms on that assumption. We suggest a framework for building the understanding and knowledge base necessary to a reform of the nation's health care system.
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