The association between hospital type and mortality and length of stay: a study of 16.9 million hospitalized Medicare beneficiaries

Should Doctors Open Online Consultation Services? An Empirical Investigation of Their Impact on Offline Appointments

Online healthcare portals have become prevalent worldwide in recent years. One common form of healthcare portal is the online consultation website, which provides a bridge between patients and doctors and reduces patients’ time and cost when seeking healthcare services. Another form is the healthcare service appointment website, which facilitates offline visits for patients. Though nominally separate, the behaviors of the users (including patients and doctors) on these two types of websites could be related to each other. In particular, how does opening online consultation services impact the offline appointments of doctors? Although this is an important question for healthcare portals, doctors, and policy makers, it has not been rigorously examined in the literature. We examine the overall impact of opening online consultation services on offline appointments and show that the number of offline appointments for doctors increases after opening online consultation services. Given that online consultation is a new but important way to connect patients and doctors, our findings provide useful implications for all the stakeholders—doctors, patients, hospitals, and policy makers—regarding how to integrate online and offline channels in the healthcare context.

Congestive heart failure-related hospital deaths across the urban-rural continuum in the United States

Congestive heart failure (CHF) is a growing public health problem that affects nearly 6.5 million individuals nationwide. Access to quality outpatient care and disease management programs has been shown to improve disease treatment and prognosis. Rural populations face unique challenges in the availability and accessibility of quality cardiovascular care. In 2018, we conducted a pooled cross-sectional analysis of the Nationwide Inpatient Sample (NIS) for 2009–2014 to examine recent trends in CHF-related hospital deaths in the United States, highlighting urban-rural differences within each census region. We performed a multivariable logistic regression analysis to compare the odds of CHF-related hospital death, by levels of rurality and within each census region. Most CHF-related hospital deaths occurred in the South and Midwest census regions and in large central metropolitan areas. Findings from census region stratified models revealed that non-core residents living within the West (OR 1.47, CI 1.26, 1.71), Midwest (OR 1.30, CI 1.17, 1.44), and South (OR = 1.21, 95% C.I. = 1.12–1.32) had a higher relative risk (but not higher absolute numbers) of experiencing death during a CHF-related hospitalization, compared to patients in large central metropolitan areas. Within each census region, there were also differences in odds of a CHF-related hospital death depending on patient sex, comorbidities, insurance type, median annual income, and year. As efforts to reduce rural health disparities in CHF morbidity continue, more work is needed to understand and test interventions to reduce the risk of death from CHF in noncore areas of the West, Midwest, and South.

Better Outcomes and Reduced Hospitalization Cost are Associated with Ultra-Early Treatment of Ruptured Intracranial Aneurysms: A US Nationwide Data Sample Study

BACKGROUND

The benefit of surgical treatment of ruptured aneurysms is well established.

OBJECTIVE

To determine whether ultra-early ruptured aneurysm treatment leads to not only improved outcomes but also reduced hospitalization cost.

METHODS

Using 2008-2011 Nationwide Inpatient Sample data, we analyzed demographic, clinical, and hospital factors for nontraumatic subarachnoid hemorrhage (SAH) patients who were "directly" admitted to the treating hospital where they underwent intervention (clipping/coiling). Patients treated on the day of admission (day 0) formed the ultra-early cohort; others formed the deferred treatment cohort. All Patient Refined Diagnosis-Related Groups were also included in regression analyses.

RESULTS

A total of 17 412 patients were directly admitted to a hospital following nontraumatic SAH where they underwent intervention (clipping/coiling). Mean patient age was 53.87 yr (median 53.00, standard deviation 14.247); 68.3% were women (n = 11 893). A total of 6338 (36.4%) patients underwent treatment on the day of admission (ultra-early). Patients who underwent treatment on day 0 had significantly more routine discharge dispositions than those treated >admission day 0 (P < .0001). In regression analysis, treatment on day 0 was protective against other than routine discharge disposition outcome (P < .0001; odds ratio 0.657; 95% confidence interval 0.614-0.838). Total cost incurred by hospitals was $4.36 billion. Mean cost of hospital charges in the ultra-early cohort was $239 126.05, which was significantly lower than that for the cohort treated >day 0 ($272 989.56, P < .001), Mann-Whitney U-test). Performance of an intervention on admission day 0 was protective against higher hospitalization cost (P < .0001; odds ratio 0.811; 95% confidence interval 0.732-0.899).

CONCLUSION

Ultra-early treatment of ruptured aneurysms is significantly associated with better discharge disposition and decreased hospitalization cost.

A cross-sectional survey on patient safety culture among healthcare providers in the Upper East region of Ghana

INTRODUCTION

Adverse events pose a serious threat to quality patient care. Promoting a culture of safety is essential for reducing adverse events. This study aims to assess healthcare providers' perceptions of patient safety culture in three selected hospitals in the Upper East region of Ghana.

METHODS

The English version of the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire was administered to 406 clinical staff. Statistical Package for Social Science (SPSS) software, version 23, was used to analyze the data. The results were presented using descriptive statistics, Pearson Correlation Analysis and One-way Analysis of Variance (ANOVA).

RESULTS

It was found that two out of twelve patient safety culture dimensions recorded high positive response rates (≥ 70%). These include teamwork within units (81.5%) and organizational learning (73.1%). Three patient safety culture dimensions (i.e. staffing, non-punitive response to error and frequency of events reported) recorded low positive response rates (≤ 50%). The overall perception of patient safety correlated significantly with all patient safety culture dimensions, except staffing. There was no statistically significant difference in the overall perception of patient safety among the three hospitals.

CONCLUSION

Generally, healthcare providers in this study perceived patient safety culture in their units as quite good. Some of the respondents perceived punitive response to errors. Going forward, healthcare policy-makers and managers should make patient safety culture a top priority. The managers should consider creating a 'blame-free' environment to promote adverse event reporting in the hospitals.

Increased Mortality Rates With Prolonged Corticosteroid Therapy When Compared With Antitumor Necrosis Factor-α-Directed Therapy for Inflammatory Bowel Disease

OBJECTIVES

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) that compromise quality of life and may increase mortality. This study compared the mortality risk with prolonged corticosteroid use vs. antitumor necrosis factor-α (anti-TNF) drugs in IBD.

METHODS

A retrospective cohort study was conducted among Medicaid and Medicare beneficiaries from 2001 to 2013 with IBD prescribed either >3,000 mg of prednisone or equivalent within a 12-month period or new initiation of anti-TNF therapy, each treated as time-updating exposures. The primary outcome was all-cause mortality. Secondary outcomes included common causes of death. Marginal structural models were used to determine odds ratios (ORs) and 95% confidence intervals (CIs) for anti-TNF use relative to corticosteroids.

RESULTS

Among patients with CD, 7,694 entered the cohort as prolonged corticosteroid users and 1,879 as new anti-TNF users. Among patients with UC, 3,224 and 459 entered the cohort as prolonged CS users and new anti-TNF users, respectively. The risk of death was statistically significantly lower in patients treated with anti-TNF therapy for CD (21.4 vs. 30.1 per 1,000 person-years, OR 0.78, 0.65-0.93) but not for UC (23.0 vs. 30.9 per 1,000 person-years, OR 0.87, 0.63-1.22). Among the CD cohort, anti-TNF therapy was also associated with lower rates of major adverse cardiovascular events (OR 0.68, 0.55-0.85) and hip fracture (OR 0.54, 0.34-0.83).

CONCLUSIONS

Compared with prolonged corticosteroid exposure, anti-TNF drug use was associated with reduced mortality in patients with CD that may be explained by lower rates of major adverse cardiovascular events and hip fracture.

Hospital-ownership status and cesareans in the United States: The effect of for-profit hospitals

BACKGROUND

Given the increasing proportion of United States hospitals that are for-profit, we examined whether women who give birth in for-profit hospitals are more likely to have cesareans than women who give birth in not-for-profit hospitals. We hypothesized that cesareans are more likely to occur in for-profit hospitals because of the organizational emphasis on short-term financial indicators, including payment of shareholder dividends.

METHODS

We used logistic regression and difference of means tests to analyze data from the Listening to Mothers III survey of women who gave birth in the United States in 2011 and 2012.

RESULTS

Controlling for patient-level characteristics, we found that the odds of a woman's having a cesarean were two times higher in for-profit hospitals than in not-for-profit hospitals. We also found for-profit hospitals were significantly more likely to be members of multihospital systems and to have fewer full-time registered nurses and staff members per hospital bed.

CONCLUSION

This research suggests that women who give birth in for-profit hospitals are more likely to have cesareans than women who give birth in not-for-profit hospitals. This information is important to women when deciding where to give birth. Knowing which hospital characteristics are associated with a greater likelihood of cesarean is helpful since hospital cesarean rates may be difficult to find. These findings are also informative for obstetric professionals, who can implement improvement initiatives to decrease cesarean rates and improve the overall quality of care for childbearing women in the United States.

In-hospital mortality after hip fracture by treatment setting

BACKGROUND

Where patients with hip fracture undergo treatment may influence their outcome. We compared the risk of in-hospital death after hip fracture by treatment setting in Canada.

METHODS

We examined all discharge abstracts from the Canadian Institute for Health Information with diagnosis codes for hip fracture involving patients 65 years and older who were admitted to hospital with a nonpathological first hip fracture between Jan. 1, 2004, and Dec. 31, 2012, in Canada (excluding Quebec). We compared the risk of in-hospital death, overall and after surgery, between teaching hospitals and community hospitals of various bed capacities, accounting for variation in length of stay.

RESULTS

Compared with the number of deaths per 1000 admissions at teaching hospitals, there were an additional 3 (95% confidence interval [CI] 1-6), 14 (95% CI 10-18) and 43 (95% CI 35-51) deaths per 1000 admissions at large, medium and small community hospitals, respectively. For the risk of in-hospital death overall, the adjusted odds ratios (ORs) were 1.05 (95% CI 0.99-1.11), 1.16 (95% CI 1.09-1.24) and 1.44 (95% CI 1.31-1.57) at large, medium and small community hospitals, respectively, compared with teaching hospitals. For the risk of postsurgical death in hospital, the adjusted ORs were 1.06 (95% CI 1.00-1.13), 1.13 (95% CI 1.04-1.23) and 1.18 (95% CI 0.87-1.60) at large, medium and small community hospitals, respectively.

INTERPRETATION

Compared with teaching hospitals, the risk of in-hospital death among patients with hip fracture was higher at medium and small community hospitals, and the risk of in-hospital death after surgery was higher at medium community hospitals. No differences were found between teaching and large community hospitals. Future research should examine the role of volume, demand and bed occupancy for observed differences.

Myths and Memes about Single-Payer Health Insurance in the United States: A Rebuttal to Conservative Claims

Recent years have seen the rapid growth of private think tanks within the neoconservative movement that conduct “policy research” biased to their own agenda. This article provides an evidence-based rebuttal to a 2002 report by one such think tank, the Dallas-based National Center for Policy Analysis (NCPA), which was intended to discredit 20 alleged myths about single-payer national health insurance as a policy option for the United States. Eleven “myths” are rebutted under eight categories: access, cost containment, quality, efficiency, single-payer as solution, control of drug prices, ability to compete abroad (the “business case”), and public support for a single-payer system. Six memes (self-replicating ideas that are promulgated without regard to their merits) are identified in the NCPA report. Myths and memes should have no place in the national debate now underway over the future of a failing health care system, and need to be recognized as such and countered by experience and unbiased evidence.

The impact of fellowship training on pathological outcomes following radical prostatectomy: a population based analysis

Background

Radical prostatectomy (RP) is a common treatment for prostate cancer (PCa). Morbidity, mortality and pathological outcomes may be superior in academic institutions. One explanation may be the involvement of oncology fellowship trained urologists within academic institutions. The literature examining pathological outcomes often lacks individual surgeon data. The objective of this study was to compare pathological outcomes following RP between fellowship trained and non-fellowship trained urologists.

Methods

Population-based, retrospective chart review of men diagnosed with PCa between 2003 and 2008, the majority treated with open approach RP (>99%). Pathological outcomes were compared between oncology fellowship trained academic (FTA), non-fellowship trained academic (NFTA) and non-academic (NA) urologists. Relationships with pathological outcomes were examined utilizing multivariable logistic regression.

Results

83.1% of eligible patients were included in our analysis resulting in 1075 patients. In multivariable analysis, surgeon group was an independent predictor of positive surgical margin (PSM) (p < 0.0001). NFTA and NA urologists were more likely to have PSM compared to FTA urologists (OR 2.50; 95% CI: 1.44 - 4.35 and OR 2.10; 95% CI: 1.53 - 2.88, respectively). However, the proportion of PSM between NFTA and NA urologists was not significant (p = 0.492). In addition, pathological stage (p = 0.0004), Gleason sum (p < 0.0001), and surgeon volume (p = 0.017) were associated with PSM. Limitations include retrospective design and lack of clinical and functional outcomes.

Conclusions

Uro-oncology fellowship trained surgeons had significantly lower rates of PSM than non-fellowship trained surgeons in this population based cohort. This study demonstrates the importance of surgeon-related variables on pathological outcomes and highlights the value of additional urologic oncology fellowship training.

Insurer market structure and variation in commercial health care spending

OBJECTIVE

To examine the relationship between insurance market structure and health care prices, utilization, and spending.

DATA SOURCES

Claims for 37.6 million privately insured employees and their dependents from the Truven Health Market Scan Database in 2009. Measures of insurer market structure derived from Health Leaders Inter study data.

METHODS

Regression models are used to estimate the association between insurance market concentration and health care spending, utilization, and price, adjusting for differences in patient characteristics and other market-level traits.

RESULTS

Insurance market concentration is inversely related to prices and spending, but positively related to utilization. Our results imply that, after adjusting for input price differences, a market with two equal size insurers is associated with 3.9 percent lower medical care spending per capita (p = .002) and 5.0 percent lower prices for health care services relative to one with three equal size insurers (p < .001).

CONCLUSION

Greater fragmentation in the insurance market might lead to higher prices and higher spending for care, suggesting some of the gains from insurer competition may be absorbed by higher prices for health care. Greater attention to prices and utilization in the provider market may need to accompany procompetitive insurance market strategies.

Factors and outcomes associated with early and delayed aneurysm treatment in subarachnoid hemorrhage patients in the United States

BACKGROUND

Recent studies from selected centers have shown that early surgical treatment of aneurysms in subarachnoid hemorrhage (SAH) patients can improve outcomes. These results have not been validated in clinical practice at large.

OBJECTIVE

To identify factors and outcomes associated with timing of ruptured intracranial aneurysm obliteration treatment in patients with SAH after hospitalization in the United States.

METHODS

We analyzed the data from the Nationwide Inpatient Sample (2005-2008) for all patients presenting with primary diagnosis of SAH, receiving aneurysm treatment (endovascular coil embolization or surgical clip placement). Early treatment was defined as aneurysm treatment performed within 48 hours and delayed treatment if treatment was performed after 48 hours of admission.

RESULTS

Of 32 048 patients with SAH who underwent aneurysm treatment, 24 085 (75.2%) underwent early treatment and 7963 (24.8%) underwent delayed treatment. Female sex (P = .002), endovascular embolization (P < .001), and weekday admission (P < .001) were independent predictors of early treatment. In the early treatment group, patients were more likely discharged with none to minimal disability (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.14-1.47) and less likely to be discharged with moderate to severe disability (OR 0.77, 95%CI 0.67-0.87) compared with those in the delayed treatment group. The in-hospital mortality was higher in the early treatment group compared with the delayed treatment group (OR 1.36 95%CI 1.12-1.66).

CONCLUSION

Patients with SAH who undergo aneurysm treatment within 48 hours of hospital admission are more likely to be discharged with none to minimal disability. Early treatment is more likely to occur in those undergoing endovascular treatment and in patients admitted on weekdays.

Factors influencing hospital high length of stay outliers

Background

The study of length of stay (LOS) outliers is important for the management and financing of hospitals. Our aim was to study variables associated with high LOS outliers and their evolution over time.

Methods

We used hospital administrative data from inpatient episodes in public acute care hospitals in the Portuguese National Health Service (NHS), with discharges between years 2000 and 2009, together with some hospital characteristics. The dependent variable, LOS outliers, was calculated for each diagnosis related group (DRG) using a trim point defined for each year by the geometric mean plus two standard deviations. Hospitals were classified on the basis of administrative, economic and teaching characteristics. We also studied the influence of comorbidities and readmissions. Logistic regression models, including a multivariable logistic regression, were used in the analysis. All the logistic regressions were fitted using generalized estimating equations (GEE).

Results

In near nine million inpatient episodes analysed we found a proportion of 3.9% high LOS outliers, accounting for 19.2% of total inpatient days. The number of hospital patient discharges increased between years 2000 and 2005 and slightly decreased after that. The proportion of outliers ranged between the lowest value of 3.6% (in years 2001 and 2002) and the highest value of 4.3% in 2009. Teaching hospitals with over 1,000 beds have significantly more outliers than other hospitals, even after adjustment to readmissions and several patient characteristics.

Conclusions

In the last years both average LOS and high LOS outliers are increasing in Portuguese NHS hospitals. As high LOS outliers represent an important proportion in the total inpatient days, this should be seen as an important alert for the management of hospitals and for national health policies. As expected, age, type of admission, and hospital type were significantly associated with high LOS outliers. The proportion of high outliers does not seem to be related to their financial coverage; they should be studied in order to highlight areas for further investigation. The increasing complexity of both hospitals and patients may be the single most important determinant of high LOS outliers and must therefore be taken into account by health managers when considering hospital costs.

A review of hospital characteristics associated with improved performance

PURPOSE

The objective of this review was to critically appraise the literature relating to associations between high-level structural and operational hospital characteristics and improved performance.

DATA SOURCES

The Cochrane Library, MEDLINE (Ovid), CINAHL, proQuest and PsychINFO were searched for articles published between January 1996 and May 2010. Reference lists of included articles were reviewed and key journals were hand searched for relevant articles.

STUDY SELECTION

and data extraction Studies were included if they were systematic reviews or meta-analyses, randomized controlled trials, controlled before and after studies or observational studies (cohort and cross-sectional) that were multicentre, comparative performance studies. Two reviewers independently extracted data, assigned grades of evidence according to the Australian National Health and Medical Research Council guidelines and critically appraised the included articles. Data synthesis Fifty-seven studies were reported within 12 systematic reviews and 47 observational articles. There was heterogeneity in use and definition of performance outcomes. Hospital characteristics investigated were environment (incentives, market characteristics), structure (network membership, ownership, teaching status, geographical setting, service size) and operational design (innovativeness, leadership, organizational culture, public reporting and patient safety practices, information technology systems and decision support, service activity and planning, workforce design, staff training and education). The strongest evidence for an association with overall performance was identified for computerized physician order entry systems. Some evidence supported the associations with workforce design, use of financial incentives, nursing leadership and hospital volume.

CONCLUSION

There is limited, mainly low-quality evidence, supporting the associations between hospital characteristics and healthcare performance. Further characteristic-specific systematic reviews are indicated.

Contemporary performance of U.S. teaching and nonteaching hospitals

PURPOSE

To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics.

METHOD

The authors classified acute care general hospitals filing a Medicare Institutional Cost Report according to teaching intensity: nonteaching, teaching, or Council of Teaching Hospitals member. They compared aggregate results across categories for Hospital Compare process compliance, mortality, and readmission rates (acute myocardial infarction [AMI], heart failure, pneumonia); Surgical Care Improvement Project (SCIP) performance; compliance with Leapfrog standards; patient experience; patient services and key technologies; safety (computerized physician order entry, intensive care unit staffing, National Quality Forum safe practices, hospital-acquired conditions); and cost/resource utilization (Medicare-adjusted expense per case; Leapfrog efficiency and resource use standards).

RESULTS

Availability of patient services and advanced technologies were associated with teaching intensity (P < .0001), as were most hospital safety metrics. Teaching intensity was favorably associated with SCIP performance, AMI and heart failure process scores, and mortality (P < .0001). It was unfavorably associated with higher AMI and pneumonia readmission rates (P < .0001) and lower scores for individual patient satisfaction measures. Costs per case were similar (P = .4194) across hospital categories after correction for federally allowed adjustments (case mix, wages, and low-income patient care).

CONCLUSIONS

Teaching hospitals offer advanced clinical capabilities, educate the next generation of providers, care for disadvantaged urban populations, and are leaders in health care research and innovation. However, many stakeholders may be unaware of an additional value-relatively higher quality and safety in many areas, with similar adjusted costs.

Total knee arthroplasty outcomes in top-ranked and non-top-ranked orthopedic hospitals: an analysis of Medicare administrative data

OBJECTIVE

To examine outcomes of Medicare enrollees who underwent primary total knee arthroplasty (TKA) in top-ranked orthopedic hospitals identified through the U.S. News & World Report hospital rankings and 2 comparison groups of hospitals.

PATIENTS AND METHODS

We used Medicare Part A data to identify patients who underwent primary TKA between January 1, 2006, and December 31, 2006, in 3 groups of hospitals: (1) top-ranked according to U.S. News & World Report rankings; (2) not top-ranked, but eligible for ranking; and (3) not eligible for ranking by U.S. News & World Report. We compared the demographics and comorbidity of patients treated in the 3 hospital groups. We examined rates of postoperative adverse outcomes--a composite consisting of hemorrhage, pulmonary embolism, deep vein thrombosis, wound infection, myocardial infarction, or mortality within 30 days of surgery. We also compared 30-day all-cause readmission rates and hospital length of stay (LOS) across groups.

RESULTS

Our cohort consisted of 48 top-ranked hospitals (performing 10,477 primary TKAs), 288 eligible non-top-ranked hospitals (28,938 TKAs), and 481 hospitals not eligible for ranking (25,297 TKAs). Unadjusted rates of the composite outcome were modestly higher for top-ranked hospitals (4.3%, 455 patients) as compared with non-top-ranked hospitals (4.1%, 1191 patients) and hospitals ineligible for ranking (3.3%, 843 patients) (P<.001), but these differences were no longer significant after accounting for differences in patient complexity. Likewise, there were no significant differences in readmission rates or LOS across groups.

CONCLUSION

Rates of postoperative complications and readmission and hospital LOS were similar for Medicare patients who underwent primary TKA in top-ranked and non-top-ranked hospitals.

Hospital ownership type and treatment choices

In the face of increasing health care costs, taxing not-for-profit hospitals may be seen as the right choice to increase government revenues if not-for-profit hospitals are not different from their for-profit counterparts. This study investigates how hospital ownership type affects treatment choices to show whether ownership type and teaching status are correlated with choosing a procedure as the treatment and how these choices relate to patient insurance type. Not-for-profit hospitals significantly differ from for-profits in terms of treatment choices of less profitable patients and all hospitals are more likely to accord the procedure when the patient is privately insured than uninsured though teaching government hospitals are the most likely to accord the procedures for all insurance types. Considering treatment choices, not-for-profit hospitals have different objectives than for-profit and government hospitals and in terms of profit-seeking behavior, not-for-profit hospitals seem to lie between for-profit and government hospitals.

Percutaneous coronary intervention outcomes in US hospitals with varying structural characteristics: analysis of the NCDR®

BACKGROUND

In the United States, there continues to be debate about whether certain types of hospitals deliver improved patient outcomes. We sought to assess the association between hospital organizational characteristics and in-hospital outcomes for percutaneous coronary intervention (PCI).

METHODS

Retrospective analysis of 2004 to 2007 data for 694 US hospitals participating in the CathPCI Registry(®). Our analysis focused on 1,113,554 patients who underwent PCI in 471 not-for-profit (NFP) hospitals, 131 major teaching hospitals, 79 for-profit (FP) hospitals, and 13 physician-owned specialty hospitals. Outcomes included in-hospital mortality, stroke, bleeding, vascular injury, and a composite representing one or more of the individual complications. We used the current CathPCI Registry mortality risk model to calculate risk-standardized mortality ratios (RSMRs) for each category of hospital and compared hospital groupings for all patients in aggregate and in subgroups stratified by patients' indications for PCI.

RESULTS

Patients treated in major teaching hospitals were younger, whereas FP hospitals performed a greater proportion of PCI for patients with ST-elevation myocardial infarction (P < .0001). Specialty hospitals treated patients with less acuity, including a lower proportion of patients with ST-elevation myocardial infarction. In unadjusted analyses, specialty hospitals had significantly lower rates of all adverse outcomes compared with NFP, teaching, and FP hospitals including in-hospital mortality (0.7%, 1.2%, 1.4%, and 1.4%, respectively; P < .001) and the composite end point (2.4%, 4.1%, 4.6%, and 4.3%, respectively; P < .001). In adjusted analyses, RSMR was significantly lower for specialty hospitals when compared with the other 3 groups for all patients in aggregate (RSMR 1.05%, 1.30%, 1.38%, 1.39%; P < .001); these differences remained clinically significant but were no longer statistically significant in subgroup analyses.

CONCLUSIONS

Specialty hospitals appear to have lower rates of most adverse outcomes for PCI. Specialty hospitals may have developed expertise in narrow procedural areas that could be adapted to the larger population of general hospitals.

Impact of insurance and hospital ownership on hospital length of stay among patients with ambulatory care-sensitive conditions

PURPOSE Some studies suggest proprietary (for-profit) hospitals are maximizing financial margins from patient care by limiting therapies or decreasing length of stay for uninsured patients. This study examines the role of insurance related to length of stay once the patient is in the hospital and risk for mortality, particularly in a for-profit environment. METHODS We undertook an analysis of hospitalizations in the National Hospital Discharge Survey (NHDS) of the 5-year period of 2003 to 2007 for patients aged 18 to 64 years (unweighted n = 849,866; weighted n = 90 million). The analysis included those who were hospitalized with both ambulatory care-sensitive conditions (ACSCs), hospitalizations considered to be preventable, and non-ACSCs. We analyzed the transformed mean length of stay between individuals who had Medicaid or all other insurance types while hospitalized and those who were hospitalized without insurance. This analysis was stratified by hospital ownership. We also examined the relationship between in-hospital mortality and insurance status. RESULTS After controlling for comorbidities; age, sex, and race/ethnicity; and hospitalizations with either an ACSC or non-ACSC diagnosis, patients without insurance tended to have a significantly shorter length of stay. Across all hospital types, the mean length of stay for ACSCs was significantly shorter for individuals without insurance (2.77 days) than for those with either private insurance (2.89 days, P = .04) or Medicaid (3.19, P <.01). Among hospitalizations for ACSCs, in-hospital mortality rate for individuals with either private insurance or Medicaid was not significantly different from the mortality rate for those without insurance. CONCLUSIONS Patients without insurance have shorter lengths of stay for both ACSCs and non-ACSCs. Future research should examine whether patients without insurance are being discharged prematurely.

Surgical margin status among men with organ-confined (pT2) prostate cancer: a population-based study

BACKGROUND

: Following prostate cancer surgery, positive surgical margin (PSM) status varies among institutions and there is evidence that high-volume surgeons and centres obtain better oncological results. However, larger studies recording PSM for radical prostatectomy (RP) are from large "centres of excellence" and not population-based. Cancer Care Ontario undertook an audit of pathology reports to determine the province-wide PSM rate for pathological stage T2 (pT2) disease prostate cancer and to assess the overall and regional-based PSM rates based on surgical volume to understand gaps in quality of care prior to undertaking quality improvement initiatives.

METHODS

: Data were extracted as part of the Pathology Project Audit data output (2005, 2006). Pathology reports were submitted to Cancer Care Ontario by Ontario hospitals electronically via the Pathology Information Management System. An experienced cancer pathology coder extracted the PSM data from eligible RP cancer specimen pathology reports. Only reports that provided a pathological stage were included in the analysis. Biopsy and transurethral resection of the prostate reports were excluded. A convenience sample of 1346 reports from 2006 and 728 from 2005 were analyzed. Regression analysis was performed to assess volume-margin associations.

RESULTS

: The median province-wide surgical PSM rate for pT2 disease was 33%, ranging 0-100% among 43 hospitals where RP volumes ranged 12-625. There was no significant correlation (p > 0.05) between volume and PSM by logistic regression with variable odds ratios (95% confidence interval [CI]) for PSM by quartile (1(st) = 1.66 [0.93-2.96]; 2(nd) = 0.97 [0.58-1.62]; 3(rd) = 1.44[0.91-2.29]) compared to the highest volume last quartile. Mean PSM rates between community and teaching hospitals were not significantly different.

CONCLUSIONS

: The province-wide PSM rate for pT2 disease prostate cancer undergoing RP is higher than those published from "centres of excellence." Results from larger volume centres were not statistically significantly better, which contradicts previously published data. Factors, such as individual surgeon, patient selection, pathological processing and interpretation, may explain the differences.

Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality

OBJECTIVE

To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitals

BACKGROUND

High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible. We examined low-volume hospitals and sought to identify characteristics of those with better outcomes.

METHODS

Using national data from Medicare and the American Hospital Association, we studied 4498 elderly patients who underwent an esophagectomy from 2004 to 2007. We divided hospitals into terciles based on esophagectomy volume and examined characteristics of patients and hospitals (size, nurse ratios, and presence of advanced medical, surgical, and radiological services). Our primary outcome was mortality. We identified 5 potentially beneficial systems characteristics in our data set and used multivariable logistic regression to determine whether these characteristics were associated with lower mortality rates at low-volume hospitals.

RESULTS

Of the 874 hospitals that performed esophagectomies, 83% (723) were low-volume hospitals whereas only 3% (25) were high-volume. Low-volume hospitals performed a median of 1 esophagectomy during the 4-year study period and cared for patients that were older, more likely to be minority, and more likely to have multiple comorbidities compared with high-volume centers. Low-volume hospitals that had at least 3 of 5 characteristics (high nurse ratios, lung transplantation services, complex medical oncology services, bariatric surgery services, and positron emission tomography scanners) had markedly lower mortality rates compared with low-volume hospitals with none of these characteristics (12.5% vs. 5.0%; P value = 0.042).

CONCLUSIONS

Low-volume hospitals with certain systems characteristics seem to achieve better esophagectomy outcomes. A more comprehensive study of the beneficial characteristics of low-volume hospitals is warranted because high-volume hospitals are difficult to access for many patients.

For-profit hospital status and rehospitalizations at different hospitals: an analysis of Medicare data

BACKGROUND

About one quarter of rehospitalized Medicare patients are admitted to hospitals different from their original hospital. The extent to which this practice is related to for-profit hospital status and affects payments and mortality is unknown.

OBJECTIVE

To describe and examine predictors of and payments for rehospitalization at a different hospital among Medicare patients rehospitalized within 30 days at for-profit and nonprofit or public hospitals.

DESIGN

Cohort study of patients discharged and rehospitalized from January 2005 to November 2006.

SETTING

Medicare fee-for-service hospitals throughout the United States.

PARTICIPANTS

A 5% random national sample of Medicare patients with acute care rehospitalizations within 30 days of discharge (n = 74,564).

MEASUREMENTS

30-day rehospitalizations at different hospitals and total payments or mortality over the subsequent 30 days. Multivariate logistic and quantile regression models included index hospital for-profit status, discharge counts, geographic region, rural-urban commuting area, and teaching status; patient sociodemographic characteristics, disability status, and comorbid conditions; and a measure of risk adjustment.

RESULTS

16 622 patients (22%) in the sample were rehospitalized at a different hospital. Factors associated with increased risk for rehospitalization at a different hospital included index hospitalization at a for-profit, major medical school-affiliated, or low-volume hospital and having a Medicare-defined disability. Compared with patients rehospitalized at the same hospital, patients rehospitalized at different hospitals had higher adjusted 30-day total payments (median additional cost, $1308 per patient; P < 0.001) but no statistically significant differences in 30-day mortality, regardless of index hospital for-profit status.

LIMITATION

The database lacked detailed clinical information about patients and did not include information about specific provider practice motivations or the role of patient choice in hospitalization venues.

CONCLUSION

Rehospitalizations at different hospitals are common among Medicare patients, are more likely among those initially hospitalized at a for-profit hospital, and are related to increased overall payments without improved mortality.

PRIMARY FUNDING SOURCE

University of Wisconsin Hartford Center of Excellence in Geriatrics, National Institutes of Health.

Performance of Dutch hospitals in the management of splenectomized patients

BACKGROUND

After splenectomy, patients are at increased risk of sepsis with considerable mortality. This risk can be reduced by taking preventive measures, such as prescribing immunizations and antibiotic prophylaxis. Studies from various countries show that a substantial percentage of patients are not managed adequately. The aim of the present study was to investigate the quality of care in the prevention of infections after splenectomy in Dutch hospitals. The research questions were two-fold: (1) Is there an association between hospital teaching status and guideline adherent preventive measures? (2) Which factors contribute to hospital performance?

METHODS

A total of 28 Dutch hospitals (30%) participated in the study. A retrospective review of medical records of 536 splenectomy patients was performed. Adherence to prevention guidelines was assessed for all patients, and analyzed according to teaching status and the presence or absence of a post-splenectomy protocol.

RESULTS

(1) University hospitals in the Netherlands offered higher quality of care than other teaching and nonteaching hospitals. There were only small differences between nonuniversity teaching and nonteaching hospitals. (2) The presence of a hospital post-splenectomy protocol did not improve vaccination rates. Other aspects of practice organization, such as surgical staff size and keeping a complication registry were only weakly related to performance.

CONCLUSIONS

In the Netherlands, university hospitals deliver state-of-the-art care in the prevention of infections in asplenic patients more often than nonuniversity teaching and nonteaching hospitals. The availability of a hospital protocol does not seem to contribute to guideline adherence.

Prevalence and predictors of adverse events in older surgical patients: impact of the present on admission indicator

PURPOSE OF THE STUDY

to examine the effects of the present on admission (POA) indicator on the prevalence of and factors associated with postsurgical adverse events in older patients.

DESIGN AND METHODS

this is a secondary data analysis of 82,898 surgical patients aged 65 years or older in 252 acute care hospitals in California in 2004. Four adverse events were counted using the Agency for Healthcare Research and Quality's Patient Safety Indicator (PSI) definitions with and without using the POA indicator. We also examined the effects of the POA indicator on the relationships between patient- and hospital-level factors and adverse events, using generalized linear mixed models.

RESULTS

the use of the POA indicator resulted in a marked reduction in the estimated rates of all 4 adverse event rates. Adjustment for POA conditions also influenced factors associated with adverse events. Compared with those with newly occurring adverse events only, admissions with only POA conditions were more likely to be admitted through the emergency department, be unplanned, and belong to patients with one or more preceding admissions or those with multiple admissions within the same year.

IMPLICATIONS

adverse event rates estimated from discharge abstracts using PSI methodology could be overstated when the POA indicator was not used. The POA indicator could influence predictors of adverse events. Studies on geriatric safety and outcomes using large administrative data sets should consider using the POA indicator. Further studies are needed on how to determine POA conditions.

Teaching hospital status and operative mortality in the United States: tipping point in the volume-outcome relationship following colon resections?

OBJECTIVE

To compare risk- and volume-adjusted outcomes of colon resections performed at teaching hospitals (THs) vs non-THs to assess whether benign disease may influence the volume-outcome effect.

DESIGN

Retrospective data analysis examining colon resections determined by International Classification of Diseases, Ninth Revision, Clinical Modification classification performed in the United States from 2001 through 2005 using the Nationwide Inpatient Sample (NIS) and the Area Resource File (2004). Patient covariates used in adjustment included age, sex, race, Charlson Index comorbidity score, and insurance status. Hospital covariates included TH status, presence of a colorectal surgery fellowship approved by the Accreditation Council for Graduate Medical Education, geographical region, institutional volume, and urban vs rural location. County-specific surgeon characteristics used in adjustment included average age of surgeons and proportion of colorectal board-certified surgeons within each county. Environmental or county covariates included median income and percentage of county residents living below the federal poverty level.

SETTING

A total of 1045 hospitals located in 38 states in the United States that were included in the NIS.

PATIENTS

All patients older than 18 years who had colon resection and were discharged from a hospital included in the NIS.

MAIN OUTCOME MEASURES

Operative mortality, length of stay (LOS), and total charges.

RESULTS

A total of 115 250 patients were identified, of whom 4371 died (3.8%). The mean LOS was 10 days. Fewer patients underwent surgical resection in THs than in non-THs (46 656 vs 68 589). Teaching hospitals were associated with increased odds of death (odds ratio, 1.14) (P = .03), increased LOS (P = .003), and a nonsignificant trend toward an increase in total charges (P = .36).

CONCLUSIONS

With the inclusion of benign disease, colon surgery displays a volume-outcome relationship in favor of non-THs. Inclusion of benign disease may represent a tipping point.

Regional differences in quality of care and outcomes for the treatment of acute coronary syndromes: an analysis from the get with the guidelines coronary artery disease program

BACKGROUND

Geographic differences in the delivery of guideline-driven care following acute myocardial infarction have been described. The effect of hospital participation in a national performance improvement program on regional variation in quality of care and in-hospital outcomes for acute coronary syndromes (ACS) is unknown.

METHODS

We evaluated the variation in conformity to the American Heart Association Get With The Guidelines-Coronary Artery Disease Program quality measures across 4 geographic regions (Northeast, Midwest, South, and East) in 161,236 patients admitted for ACS to 436 Get With The Guidelines hospitals. We evaluated 6 measures (aspirin within 24 hours, aspirin at discharge, ACEI or ARB therapy for left ventricular systolic dysfunction, beta-blocker at discharge, lipid-lowering medication for qualified patients, smoking cessation advice); a binary "all-or-none" process performance measure (primary outcome); an "opportunity-based" overall composite score (secondary outcome); in-hospital length of stay, and in-hospital mortality. Multivariable logistic regression was performed to test the associations between performance measures and short-term outcomes and geographic region.

RESULTS

Data were collected from January 2, 2000 to January 2, 2008. There was no significant regional variation in either the "all-or-none" (Northeast: 79.3%; Midwest: 83.2%; South: 78.9%; West: 81.6%) or "opportunity-based" (Northeast: 91.9%; Midwest: 93.6%; South: 91.5%; West: 92.6%) composite performance measures. Both performance measures exhibited significant improvement with participation time irrespective of region. In-hospital mortality was similar among regions. Adjusted hospital length of stay was significantly shorter in the Midwest.

CONCLUSION

Quality improvement program participation may help to facilitate high quality, consistent care for patients with ACS.

Relationship between discharge practices and intensive care unit in-hospital mortality performance: evidence of a discharge bias

CONTEXT

Current intensive care unit performance measures include in-hospital mortality after intensive care unit admission. This measure does not account for deaths occurring after transfer to another hospital or soon after discharge and therefore, may be biased.

OBJECTIVE

Determine how transfer rates to other acute care hospitals and early post-discharge mortality rates impact hospital performance assessments using an in-hospital mortality model.

DESIGN, SETTING, AND PARTICIPANTS

Data were retrospectively collected on 10,502 eligible intensive care unit patients across 35 California hospitals between 2001 and 2004.

MEASURES

We calculated the rates of acute care hospital transfers and early post-discharge mortality (30-day overall mortality-30-day in-hospital mortality) for each hospital. We assessed hospital performance with standardized mortality ratios (SMRs) using the Mortality Probability Model III. Using regression models, we explored the relationship between in-hospital SMRs and the rates of hospital transfers or early post-discharge mortality. We explored the same relationship using a 30-day SMR.

RESULTS

In multivariable models, for each 1% increase in patients transferred to another acute care hospital, there was an in-hospital SMR reduction of -0.021 (-0.040-0.001). Additionally, a 1% increase in early post-discharge mortality was associated with an in-hospital SMR reduction of -0.049 (-0.142-0.045). Assessing hospital performance based upon 30-day mortality end point resulted in SMRs closer to 1.0 for hospitals at high and low ends of in-hospital mortality performance.

CONCLUSIONS

Variations in transfer rates and potentially discharge timing appear to bias in-hospital SMR calculations. A 30-day mortality model is a potential alternative that may limit this bias.

Influence of NCI cancer center attendance on mortality in lung, breast, colorectal, and prostate cancer patients

Some evidence links cancer outcomes to place of service, but the influence of NCI (National Cancer Institute) cancer centers on outcomes has not been established. We compared mortality for NCI cancer center attendees versus nonattendees. This retrospective cohort study included individuals with incident cancers of the lung, breast, colon/rectum, or prostate from 1998 to 2002 (N = 211,084) from SEER (Surveillance, Epidemiology, and End Results)-Medicare linked data, with claims through 2003. We examined the relation of NCI cancer center attendance with 1- and 3-year all-cause and cancer-specific mortality using multilevel logistic regression models. NCI cancer center attendance was associated with a significant reduction in the odds of 1- and 3-year all-cause and cancer-specific mortality. The mortality risk reduction associated with NCI cancer center attendance was most apparent in late-stage cancers and was evident across all levels of comorbidities. Attendance at NCI cancer centers is associated with a significant survival benefit for the four major cancers among Medicare beneficiaries.

Training in the private sector: what works and how do we increase opportunities?

In Australia 61% of elective surgery takes place in private hospitals where current opportunities for surgical education and training (SET) are limited. The situation will shortly be compounded because of the large increase in local medical graduates, many of whom will aspire to be surgeons. How and where to train these extra surgeons to meet the expanding needs of the community must be addressed. Two models of private sector training are reviewed both of which involved combined training in both private and public sectors. Two second-year (SET 2) positions were created from one public hospital SET position by using the private sector for 3.5 days per week for 3 months of a 6-month rotation. The second model was applicable to post-fellowship training with a fairly even split between public and private sector responsibilities. In the first year, four registrars shared the two 6-month rotations for the SET 2 position. Trainees did the required minimum procedures (range 109-139) with primary operating targets of 20-25% (range 21-32%). The post-fellowship position in colorectal surgery was greatly enhanced by the private sector involvement with regard to operating experience as well as meeting part of the remuneration of the trainee. Successful models for training within the private sector in Australia can be found. To expand training in the private sector there will need to be a cultural shift in the perceptions of surgeons, patients, administrators, and trainees. Funding for posts may be available to those private hospitals that can meet the Royal Australasian College of Surgeons' accreditation standards for posts and hospitals.

Racial/ethnic differences in the relationship between the use of health care services and functional disability: the health and retirement study (1992-2004)

PURPOSE

The purpose of this study was to examine racial/ethnic differences in the relationship between functional disability and the use of health care services in a nationally representative sample of older adults by using the Andersen behavioral model of health services utilization.

DESIGN AND METHODS

The study used 12 years of longitudinal data from the Health and Retirement Study (1992-2004), a nationally representative sample of community-dwelling adults older than 50 in 1992 (N = 8,947). Nonlinear multilevel models used self-reported health care service utilization (physician visits and hospital admissions) to predict racial/ethnic differences in disability (activities of daily living and mobility limitations). The models also evaluated the roles of other predisposing (age and gender), health need (medical conditions and self-rated health), and enabling factors (health insurance, education, income, and wealth).

RESULTS

Blacks and Latinos utilizing physician visits and hospital admissions were associated with significantly more activity of daily living disability than Whites (p <.001). Blacks utilizing physician visits (p <.001) and hospital admissions (p <.05) and Latinos utilizing hospital admissions (p <.05) were associated with more mobility disability than Whites. Other predisposing, health need, and enabling factors did not account for these racial/ethnic differences.

IMPLICATIONS

Nationally, health care use for Blacks and Latinos was associated with more disabilities than for Whites after we accounted for predisposing, health need, and enabling factors. The findings suggest that improving health care quality for all Americans may supersede equal access to health care for reducing ethnic and racial disparities in functional health.

Hospital ownership and quality of care: what explains the different results in the literature?

This systematic review examines what factors explain the diversity of findings regarding hospital ownership and quality. We identified 31 observational studies written in English since 1990 that used multivariate analysis to examine quality of care at nonfederal general acute, short-stay US hospitals. We find that pooled estimates of ownership effects are sensitive to the subset of studies included and the extent of overlap among hospitals analyzed in the underlying studies. Ownership does appear to be systematically related to differences in quality among hospitals in several contexts. Whether studies find for-profit and government-controlled hospitals to have higher mortality rates or rates of adverse events than their nonprofit counterparts depends on data sources, time period, and region covered. Policymakers should be aware of the underlying reasons for conflicting evidence in this literature, and the strengths and weaknesses of meta-analytic synthesis. The 'true' effect of ownership appears to depend on institutional context, including differences across regions, markets, and over time.

Association between hospital and surgeon radical prostatectomy volume and patient outcomes: a systematic review

PURPOSE

We examined the association between hospital and surgeon volume, and patient outcomes after radical prostatectomy.

MATERIALS AND METHODS

Databases were searched from 1980 to November 2007 to identify controlled studies published in English. Information on study design, hospital and surgeon annual radical prostatectomy volume, hospital status and patient outcome rates were abstracted using a standardized protocol. Data were pooled with random effects models.

RESULTS

A total of 17 original investigations reported patient outcomes in categories of hospital and/or surgeon annual number of radical prostatectomies, and met inclusion criteria. Hospitals with volumes above the mean (43 radical prostatectomies per year) had lower surgery related mortality (rate of difference 0.62, 95% CI 0.47-0.81) and morbidity (rate difference -9.7%, 95% CI -15.8, -3.6). Teaching hospitals had an 18% (95% CI -26, -9) lower rate of surgery related complications. Surgeon volume was not significantly associated with surgery related mortality or positive surgical margins. However, the rate of late urinary complications was 2.4% lower (95% CI -5, -0.1) and the rate of long-term incontinence was 1.2% lower (95% CI -2.5, -0.1) for each 10 additional radical prostatectomies performed by the surgeon annually. Length of stay was lower, corresponding to surgeon volume.

CONCLUSIONS

Higher provider volumes are associated with better outcomes after radical prostatectomy. Greater understanding of factors leading to this volume-outcome relationship, and the potential benefits and harms of increased regionalization is needed.

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

Background

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

Methods

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

Results

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

Conclusion

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

Using patient safety indicators to estimate the impact of potential adverse events on outcomes

The authors estimated the impact of potentially preventable patient safety events, identified by Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs), on patient outcomes: mortality, length of stay (LOS), and cost. The PSIs were applied to all acute inpatient hospitalizations at Veterans Health Administration (VA) facilities in fiscal 2001. Two methods-regression analysis and multivariable case matching- were used independently to control for patient and facility characteristics while predicting the effect of the PSI on each outcome. The authors found statistically significant (p < .0001) excess mortality, LOS, and cost in all groups with PSIs. The magnitude of the excess varied considerably across the PSIs. These VA findings are similar to those from a previously published study of nonfederal hospitals, despite differences between VA and non-VA systems. This study contributes to the literature measuring outcomes of medical errors and provides evidence that AHRQ PSIs may be useful indicators for comparison across delivery systems.

Adjustments for unmeasured confounders in pharmacoepidemiologic database studies using external information

BACKGROUND

Nonexperimental studies of drug effects in large automated databases can provide timely assessment of real-life drug use, but are prone to confounding by variables that are not contained in these databases and thus cannot be controlled.

OBJECTIVES

To describe how information on additional confounders from validation studies can help address the problem of unmeasured confounding in the main study.

RESEARCH DESIGN

Review types of validation studies that allow adjustment for unmeasured confounding and illustrate these with an example.

SUBJECTS

Main study: New Jersey residents age 65 years or older hospitalized between 1995 and 1997, who filled prescriptions within Medicaid or a pharmaceutical assistance program. Validation study: representative sample of Medicare beneficiaries.

MEASURES

Association between nonsteroidal antiinflammatory drugs (NSAIDs) and mortality.

RESULTS

Validation studies are categorized as internal (ie, additional information is collected on participants of the main study) or external. Availability of information on disease outcome will affect choice of analytic strategies. Using an external validation study without data on disease outcome to adjust for unmeasured confounding, propensity score calibration (PSC) leads to a plausible estimate of the association between NSAIDs and mortality in the elderly, if the biases caused by measured and unmeasured confounders go in the same direction.

CONCLUSIONS

Estimates of drug effects can be adjusted for confounders that are not available in the main, but can be measured in a validation study. PSC uses validation data without information on disease outcome under a strong assumption. The collection and integration of validation data in pharmacoepidemiology should be encouraged.

Nurse staffing, mortality, and length of stay in for-profit and not-for-profit hospitals

The issue of differential quality in for-profit (FP) and not-for-profit (NFP) hospitals remains a critical health policy question. With research demonstrating a relationship between nurse staffing and quality, the question arises whether the relationship differs in these hospital types. Using Healthcare Cost and Utilization Project data from the period 1990-1995, we found that case mix-adjusted registered nurse (RN) staffing was significantly lower in FPs than in NFPs, and we found a superior distribution of outcomes (mortality and length of stay) obtained with a lower level of RN staffing. The differences in mortality and length of stay disappeared, however, after controlling for population and market characteristics.

Effect of interhospital transfer on resource utilization and outcomes at a tertiary care referral center

OBJECTIVE

Mortality and length of stay are two outcome variables commonly used as benchmarks in rating the performance of medical centers. Acceptance of transfer patients has been shown to affect both outcomes and the costs of health care. Our objective was to compare observed and predicted lengths of stay, observed and predicted mortality, and resource consumption between patients directly admitted and those transferred to the intensive care unit (ICU) of a large academic medical center.

DESIGN

Observational cohort study.

SETTING

Mixed medical/surgical ICU of a university hospital.

PATIENTS

A total of 4,569 consecutive patients admitted to a tertiary care ICU from April 1, 1997, to March 30, 2000.

INTERVENTIONS

None.

MEASUREMENTS

Acute Physiology and Chronic Health Evaluation (APACHE) III score, actual and predicted ICU and hospital lengths of stay, actual and predicted ICU and hospital mortality, and costs per admission.

MAIN RESULTS

Crude comparison of directly admitted and transfer patients revealed that transfer patients had significantly higher APACHE III scores (mean, 60.5 vs. 49.7, p < .001), ICU mortality (14% vs. 8%, p < .001), and hospital mortality (22% vs. 14%, p < .001). Transfer patients also had longer ICU lengths of stay (mean, 6.0 vs. 3.8 days, p < .001) and hospital lengths of stay (mean, 20 vs. 15.9 days, p < .001). Stratified by disease severity using the APACHE III model, there was no difference in either ICU or hospital mortality between the two populations. However, in the transfer group with the lowest predicted mortality of 0-20%, ICU and hospital lengths of stay were significantly higher. In crude cost analysis, transfer patients' costs were $9,600 higher per ICU admission compared with nontransfer patients (95% confidence interval, $6,000-$13,400). Risk stratification revealed that the higher per-patient cost was entirely confined to the transfer patients with the lowest predicted mortality.

CONCLUSIONS

Patients transferred to a tertiary care ICU are generally more severely ill and consume more resources. However, they have similar adjusted mortality outcomes when compared with directly admitted patients. The difference in resource consumption is mainly attributable to the group of patients in the lowest predicted risk bracket.

Advancing the science in the measurement of health care quality influenced by nurses

A robust set of quality measures is essential to provide consumers with a vehicleto evaluate nurses' contributions to the care of hospitalized patients, providers, and systems with a set of nursing processes and outcomes to guide quality improvement, and insurers with indicators to reward hospitals for high quality nursing services. The processes employed by the Nursing Care Performance Measures Steering Committee convened by the National Quality Forum (NQF) in 2004 resulted in the endorsement of 15 indicators of health care quality influenced by nurses and contributed to the identification of significant gaps in measurement and priority areas for future research. This critical review of the state of the science related to health care processes and outcomes that reflect nurses' contributions to the quality of care for hospitalized patients is intended to push the boundaries in the measurement of nursing performance. Specific recommendations for future research and measure development are presented.

Effect of critical care medicine fellows on patient outcome in the intensive care unit

BACKGROUND

The impact that physician trainees have on patient outcomes in academic adult medical/surgical intensive care units (ICUs) has not been adequately assessed.

METHOD

All admissions to adult ICUs within the Calgary Health Region over a three-year period when a critical care medicine fellow (CCMF) was on service were compared to when an attending physician was alone on service. Primary outcomes were ICU and in-hospital mortality and length of stay (LOS).

RESULTS

CCMFs and attending physicians admitted 3,341 patients, while attending physicians alone admitted 3,224 patients. There was no difference in ICU or in-hospital mortality between the two groups; regression analysis determined CCMFs did not affect patient LOS.

CONCLUSION

In teaching hospitals with adult mixed medical/surgical ICUs, CCMFs do not have an effect on patient outcome or LOS. Improved patient outcomes at academic institutions previously attributed to the presence of CCMFs may instead be due to institution and patient-related factors.

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

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

Not-for-profit versus for-profit health care providers--Part II: Comparing and contrasting their records

The debate over which health care providers are most capably meeting their responsibilities in serving the public's interest continues unabated, and the comparisons of not-for-profit (NFP) versus for-profit (FP) hospitals remain at the epicenter of the discussion. From the perspective of available factual information, which of the two sides to this debate is correct? This article is part II of a 2-part series on comparing and contrasting the performance records of NFP health care providers with their FP counterparts. Although it is demonstrated that both NFP and FP providers perform virtuous and selfless feats on behalf of America's public, it is also shown that both camps have been accused of being involved in potentially willful clinical and administrative missteps. Part I provided the background information (eg, legal differences, perspectives on social responsibility, and types of questionable and fraudulent behavior) required to adequately understand the scope of the comparison issue. Part II offers actual comparisons of the 2 organizational structures using several disparate factors such as specific organizational behaviors, approach to the health care priorities of cost and quality, and business-focused goals of profits, efficiency, and community benefit.

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

BACKGROUND/OBJECTIVES

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

RESULTS

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

CONCLUSIONS

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

Differences in Triage Thresholds for Patients Presenting with Possible Acute Coronary Syndromes

BACKGROUND

Many studies have shown differences in cardiac care by racial/ethnic groups without accounting for institutional factors at the location of care.

OBJECTIVE

Exploratory analysis of the effect of hospital funding status (public vs private) on emergency department (ED) triage decision making for patients with symptoms suggestive of acute coronary syndromes (ACSs) and on the likelihood of ED discharge for patients with confirmed ACS.

STUDY DESIGN AND SETTING

Secondary analysis of data from a randomized controlled trial of 10,659 ED patients with possible ACS in five urban academic public and five private hospitals. The main outcome measures were the sensitivity and specificity of hospital admission for the presence of ACS at public and private hospitals and the adjusted odds of a patient with ACS not being hospitalized at public versus private hospitals.

RESULTS

Of 10,659 ED patients, 1,856 had confirmed ACS. For patients with suspected ACS, triage decisions at private hospitals were considerably more sensitive (99 vs 96%; p<.001) but less specific (30 vs 48%; p<.001) than at public hospitals. The difference between hospital types persisted after adjustment for multiple patient-level and hospital-level characteristics.

CONCLUSION

Significant differences in triage for patients with suspected ACS exist between public and private hospital EDs, even after adjustment for multiple patient demographic, clinical, and institutional factors. Further studies are needed to clarify the causes of the differences.

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

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

Adjusting effect estimates for unmeasured confounding with validation data using propensity score calibration

Often, data on important confounders are not available in cohort studies. Sensitivity analyses based on the relation of single, but not multiple, unmeasured confounders with an exposure of interest in a separate validation study have been proposed. In this paper, the authors controlled for measured confounding in the main cohort using propensity scores (PS's) and addressed unmeasured confounding by estimating two additional PS's in a validation study. The "error-prone" PS exclusively used information available in the main cohort. The "gold standard" PS additionally included data on covariates available only in the validation study. Based on these two PS's in the validation study, regression calibration was applied to adjust regression coefficients. This propensity score calibration (PSC) adjusts for unmeasured confounding in cohort studies with validation data under certain, usually untestable, assumptions. The authors used PSC to assess the relation between nonsteroidal antiinflammatory drugs (NSAIDs) and 1-year mortality in a large cohort of elderly persons. "Traditional" adjustment resulted in a hazard ratio for NSAID users of 0.80 (95% confidence interval (CI): 0.77, 0.83) as compared with an unadjusted hazard ratio of 0.68 (95% CI: 0.66, 0.71). Application of PSC resulted in a more plausible hazard ratio of 1.06 (95% CI: 1.00, 1.12). Until the validity and limitations of PSC have been assessed in different settings, the method should be seen as a sensitivity analysis.