Mortality trends during a program that publicly reported hospital performance

Short-term mortality after primary and revision total joint arthroplasty: a single-center analysis of 103,560 patients

INTRODUCTION

The demand for total joint arthroplasty (TJA) is increasing worldwide with excellent long-term results. In general, TJA provides several benefits to the patients but also causes possible complications. The aim of our study was to describe trends in mortality after TJA in a high-volume arthroplasty center, and to examine the potential risk factors.

METHODS

From 1996 to 2018, a total of 103,560 patients (73,130 primary cases, 30,430 revision cases) underwent a TJA procedure in our institution. Anthropometric parameters, Charlson Comorbidity Index (CCI), pre- and postoperative hemoglobin (Hb), blood loss during surgery, postoperative complication (such as infection, deep vein thrombosis, pulmonary embolism, etc.) and cause of death from all patients who deceased during hospitalization were collected. The short-term mortality rate was analyzed between the primary and the revision groups.

RESULTS

The short-term mortality rate within our investigated groups was low with 0.041% in primary THA, 0.299% in revision THA, 0.045% in primary TKA, 0.205% in revision TKA, 0.214% in TSA/RSA, 0.15 % in primary TAA and 0% after TEA. Significant differences were found for preoperative Hb-values in patients undergoing septic revision (10.7 g/dl) compared to patients undergoing aseptic revision (12.8 g/dl) or primary arthroplasty (13.6 g/dl) (p < 0.001). Furthermore, we found significant differences regarding CCI between the groups. The comparison between causes of death (COD) showed a significantly higher number for pulmonary embolisms in the aseptic groups, while septic shock was the leading COD in the septic group and myocardial infarction as COD was found significantly more often after primary TJA.

CONCLUSION

This is the largest single-center study presenting the short-term mortality rate following TJA. Consequently, TJA is a safe procedure with a low short-term mortality rate. However, depending on the type of surgery, certain risk factors cannot be eliminated. In order to further reduce the mortality, procedures as such should continue to be performed at specialized centers under standardized conditions.

Mechanisms and impact of public reporting on physicians and hospitals' performance: A systematic review (2000-2020)

BACKGROUND

Public performance reporting (PPR) of physician and hospital data aims to improve health outcomes by promoting quality improvement and informing consumer choice. However, previous studies have demonstrated inconsistent effects of PPR, potentially due to the various PPR characteristics examined. The aim of this study was to undertake a systematic review of the impact and mechanisms (selection and change), by which PPR exerts its influence.

METHODS

Studies published between 2000 and 2020 were retrieved from five databases and eight reviews. Data extraction, quality assessment and synthesis were conducted. Studies were categorised into: user and provider responses to PPR and impact of PPR on quality of care.

RESULTS

Forty-five studies were identified: 24 on user and provider responses to PPR, 14 on impact of PPR on quality of care, and seven on both. Most of the studies reported positive effects of PPR on the selection of providers by patients, purchasers and providers, quality improvement activities in primary care clinics and hospitals, clinical outcomes and patient experiences.

CONCLUSIONS

The findings provide moderate level of evidence to support the role of PPR in stimulating quality improvement activities, informing consumer choice and improving clinical outcomes. There was some evidence to demonstrate a relationship between PPR and patient experience. The effects of PPR varied across clinical areas which may be related to the type of indicators, level of data reported and the mode of dissemination. It is important to ensure that the design and implementation of PPR considered the perspectives of different users and the health system in which PPR operates in. There is a need to account for factors such as the structural characteristics and culture of the hospitals that could influence the uptake of PPR.

Validation of a prospective mortality prediction score for hip fracture patients

PURPOSE

Although mortality prediction tools are the subject of significant interest as components of comprehensive hip fracture protocols, few have been applied or validated to prospectively inform ongoing patient management. Five regional hospitals are currently generating real-time mortality risk scores for all adults at the time of admission using available laboratory and comorbidity data (Cowen et al. J Hosp Med 9(11):720-726, 2014). Although results for aggregated conditions have been published, the primary aim of this study is to determine how well prospectively calculated scores predict mortality for hip fracture patients specifically.

METHODS

Using a five-hospital database, 1376 patients who were prospectively scored on admission were identified from January 2013 to April 2017, cross-referencing ICD9/10 diagnosis and procedure codes for AO/OTA 31A1 through 31B3 fractures. Prospective mortality scores have been previously divided into 5 risk categories to facilitate ease of clinical use. Vital status was determined from hospital data, Social Security and Michigan Death Indices.

RESULTS

Prospective scores demonstrated good mortality prediction, with AUCs of 0.80, 0.73, 0.74 and 0.74 for in hospital, 30-, 60- and 90-day mortality, respectively. Patients in the top 2 mortality risk categories represented 30% (410/1376) of the cohort and accounted for 78% (25/32) of the inpatient and 59% (57/97) of the 30 day deaths.

CONCLUSIONS

Implementation of this real-time mortality risk tool is feasible and valid for the prediction of short- to medium-term mortality risk for hip fracture patients, and potentially offers valuable information to guide ongoing patient management decisions such as admitting service or level of care.

The Practice of Respect in the ICU

Although "respect" and "dignity" are intuitive concepts, little formal work has addressed their systematic application in the ICU setting. After convening a multidisciplinary group of relevant experts, we undertook a review of relevant literature and collaborative discussions focused on the practice of respect in the ICU. We report the output of this process, including a summary of current knowledge, a conceptual framework, and a research program for understanding and improving the practice of respect and dignity in the ICU. We separate our report into findings and proposals. Findings include the following: 1) dignity and respect are interrelated; 2) ICU patients and families are vulnerable to disrespect; 3) violations of respect and dignity appear to be common in the ICU and overlap substantially with dehumanization; 4) disrespect may be associated with both primary and secondary harms; and 5) systemic barriers complicate understanding and the reliable practice of respect in the ICU. Proposals include: 1) initiating and/or expanding a field of research on the practice of respect in the ICU; 2) treating "failures of respect" as analogous to patient safety events and using existing quality and safety mechanisms for improvement; and 3) identifying both benefits and potential unintended consequences of efforts to improve the practice of respect. Respect and dignity are important considerations in the ICU, even as substantial additional research remains to be done.

Mortality After Total Knee Arthroplasty: A Systematic Review of Incidence, Temporal Trends, and Risk Factors

BACKGROUND

The capacity for total knee arthroplasty to improve pain, quality of life, and functional outcomes is widely recognized. Postoperative mortality is rare but of paramount importance, and needs to be accurately quantified and conveyed to patients in order to support decision-making prior to surgery. The purpose of this study was to determine a contemporary estimate of the risk of mortality following total knee arthroplasty, including the identification of temporal trends, common causes, and modifiable and nonmodifiable risk factors.

METHODS

We performed a systematic review with searches of MEDLINE, AMED, CAB Abstracts, and Embase. Studies in any language published from 2006 to 2016 reporting 30 or 90-day mortality following total knee arthroplasty were included, supplemented by contact with authors. Meta-analysis and meta-regression were performed for quantitative data.

RESULTS

Thirty-seven studies with mortality data from 15 different countries following over 1.75 million total knee arthroplasties formed the basis of this review. The pooled Poisson-normal random-effects meta-analysis estimates of 30 and 90-day mortality were 0.20% (95% confidence interval [CI], 0.17% to 0.24%) and 0.39% (95% CI, 0.32% to 0.49%). Both estimates have fallen over the 10-year study period (p < 0.001). Meta-regression using the median year of surgery as a moderator showed that 30 and 90-day mortality following total knee arthroplasty fell to 0.10% (95% CI, 0.07% to 0.14%) and 0.19% (95% CI, 0.15% to 0.23%), respectively, in 2015. The leading cause of death was cardiovascular disease.

CONCLUSIONS

There is an ongoing worldwide temporal decline in mortality following total knee arthroplasty. Improved patient selection and perioperative care and a healthy-population effect may account for this observation. Efforts to further reduce mortality should be targeted primarily at reducing cardiovascular events following total knee arthroplasty.

LEVEL OF EVIDENCE

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

Hospitalization Trends in Adult Patients with COPD and Other Respiratory Diseases in Northeast China from 2005 to 2015

Chronic obstructive pulmonary disease (COPD), pneumonia, asthma, and lung cancer are four common respiratory diseases that impose a substantial economic burden on both patients and government in China. The objective of our study is to analyze the temporal trends of several clinical tracking metrics for hospitalization regarding these diseases. Hospital discharge data of 54 hospitals for the period 2005–2015 were derived from the Health and Family Planning Commission in Northeast China. The age-adjusted rate of discharge for the four respiratory diseases increased significantly (COPD, pneumonia, asthma: P trend <  .001; lung cancer: P trend =  .046). The mean LOS for the four diseases all showed a significant decline (P trend <  .001), whereas the mean charge per stay and aggregate charge followed an upward trend over time (P trend <  .001). There was a clear upward trend for the readmission rate for asthma patients (P trend =  .001), while the trend for COPD patients was unclear (P trend =  .224). Age-adjusted discharge rates, LOS, and charges for hospitalization regarding several common respiratory diseases in China showed different patterns of change over the past decade. Our results should aid government and administrators in making informed decisions about the management and treatment of respiratory diseases.

Impact of outlier status on critical care patient outcomes: Does boarding medical intensive care unit patients make a difference?

PURPOSE

To evaluate the impact of outlier status, or the practice of boarding ICU patients in distant critical care units, on clinical and utilization outcomes.

MATERIALS AND METHODS

Retrospective observational study of all consecutive admissions to the MICU service between April 1, 2014-January 3, 2016, at an urban university hospital.

RESULTS

Of 1931 patients, 117 were outliers (6.1%) for the entire duration of their ICU stay. In adjusted analyses, there was no association between outlier status and hospital (OR 1.21, 95% CI 0.72-2.05, p=0.47) or ICU mortality (OR 1.20, 95% CI 0.64-2.25, p=0.57). Outliers had shorter hospital and ICU lengths of stay (LOS) in addition to fewer ventilator days. Crossover patients who had variable outlier exposure also had no increase in hospital (OR 1.61; 95% CI 0.80-3.23; p=0.18) or ICU mortality (OR 1.05; 95% CI 0.43-2.54; p=0.92) after risk-adjustment.

CONCLUSIONS

Boarding of MICU patients in distant units during times of bed nonavailability does not negatively influence patient mortality or LOS. Increased hospital and ventilator utilization observed among non-outliers in the home unit may be attributable, at least in part, to differences in patient characteristics. Prospective investigation into the practice of ICU boarding will provide further confirmation of its safety.

Hospital Competition, Managed Care, and Mortality after Hospitalization for Medical Conditions: Evidence from Three States

This study assessed the effect of hospital competition and HMO penetration on mortality after hospitalization for six medical conditions in California, New York, and Wisconsin. We used linked hospital-discharge and vital-statistics data to study adults hospitalized for myocardial infarction, hip fracture, stroke, gastrointestinal hemorrhage, congestive heart failure, or diabetes. We estimated logistic regression models with death within 30 days of admission as the dependent variable and hospital competition, HMO penetration, and hospital and patient characteristics as explanatory variables. Higher hospital competition was associated with lower mortality in California and New York but not Wisconsin. Higher HMO penetration was associated with lower mortality in California but higher mortality in New York. These findings suggest that hospitals in highly competitive markets compete on quality even in the absence of mature managed-care markets. The findings also underscore the need to consider geographic effects in studies of market structure and hospital quality.

The impact of Public Reporting on clinical outcomes: a systematic review and meta-analysis

Background

To assess both qualitatively and quantitatively the impact of Public Reporting (PR) on clinical outcomes, we carried out a systematic review of published studies on this topic.

Methods

Pubmed, Web of Science and SCOPUS databases were searched to identify studies published from 1991 to 2014 that investigated the relationship between PR and clinical outcomes. Studies were considered eligible if they investigated the relationship between PR and clinical outcomes and comprehensively described the PR mechanism and the study design adopted. Among the clinical outcomes identified, meta-analysis was performed for overall mortality rate which quantitative data were exhaustively reported in a sufficient number of studies. Two reviewers conducted all data extraction independently and disagreements were resolved through discussion. The same reviewers evaluated also the quality of the studies using a GRADE approach.

Results

Twenty-seven studies were included. Mainly, the effect of PR on clinical outcomes was positive. Meta-analysis regarding overall mortality included, in a context of high heterogeneity, 10 studies with a total of 1,840,401 experimental events and 3,670,446 control events and resulted in a RR of 0.85 (95 % CI, 0.79-0.92).

Conclusions

The introduction of PR programs at different levels of the healthcare sector is a challenging but rewarding public health strategy. Existing research covering different clinical outcomes supports the idea that PR could, in fact, stimulate providers to improve healthcare quality.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1543-y) contains supplementary material, which is available to authorized users.

Has Public Reporting of Hospital Readmission Rates Affected Patient Outcomes?: Analysis of Medicare Claims Data

BACKGROUND

In 2009, the Centers for Medicare & Medicaid Services (CMS) began publicly reporting 30-day hospital readmission rates for patients discharged with acute myocardial infarction (MI), heart failure (HF), or pneumonia.

OBJECTIVES

This study assessed trends of 30-day readmission rates and post-discharge care since the implementation of CMS public reporting.

METHODS

We analyzed Medicare claims data from 2006 to 2012 for patients discharged after a hospitalization for MI, HF, or pneumonia. For each diagnosis, we estimated trends in 30-day all-cause readmissions and post-discharge care (emergency department visits and observation stays) by using hospitalization-level regression models. We modeled adjusted trends before and after the implementation of public reporting. To assess for a change in trend, we tested the difference between the slope before implementation and the slope after implementation.

RESULTS

We analyzed 37,829 hospitalizations for MI, 100,189 for HF, and 79,076 for pneumonia from >4,100 hospitals. When considering only recent trends (i.e., since 2009), we found improvements in adjusted readmission rates for MI (-2.3%), HF (-1.8%), and pneumonia (-2.0%), but when comparing the trend before public reporting with the trend after reporting, there was no difference for MI (p = 0.72), HF (p = 0.19), or pneumonia (p = 0.21). There were no changes in trends for 30-day post-discharge care for MI or pneumonia; however, the trend decreased for HF emergency department visits from 2.3% to -0.8% (p = 0.007) and for observation stays from 15.1% to 4.1% (p = 0.04).

CONCLUSIONS

The release of the CMS public reporting of hospital readmission rates was not associated with any measurable change in 30-day readmission trends for MI, HF, or pneumonia, but it was associated with less hospital-based acute care for HF.

Effect of public reporting on intensive care unit discharge destination and outcomes

RATIONALE

Public reporting of hospital performance is designed to improve healthcare outcomes by promoting quality improvement and informing consumer choice, but these programs may carry unintended consequences.

OBJECTIVE

To determine whether publicly reporting in-hospital mortality rates for intensive care unit (ICU) patients influenced discharge patterns or mortality.

METHODS

We performed a retrospective cohort study taking advantage of a natural experiment in which California, but not other states, publicly reported hospital-specific severity-adjusted ICU mortality rates between 2007 and 2012. We used multivariable logistic regression adjusted for patient, hospital, and regional characteristics to compare mortality rates and discharge patterns between California and states without public reporting for Medicare fee-for-service ICU admissions from 2005 through 2009 using a difference-in-differences approach.

MEASUREMENTS AND MAIN RESULTS

We assessed discharge patterns using post-acute care use and acute care hospital transfer rates and mortality using in-hospital and 30-day mortality rates. The study cohort included 936,063 patients admitted to 646 hospitals. Compared with control subjects, admission to a California ICU after the introduction of public reporting was associated with a reduced odds of post-acute care use in post-reform year 2 (ratio of odds ratios [ORs], 0.94; 95% confidence interval [CI], 0.91-0.96) and increased odds of transfer to another acute care hospital in both post-reform years (year 1: ratio of ORs, 1.08; 95% CI, 1.01-1.16; year 2: ratio of ORs, 1.43; 95% CI, 1.33-1.53). There were no significant differences in in-hospital or 30-day mortality.

CONCLUSIONS

Public reporting of ICU in-hospital mortality rates was associated with changes in discharge patterns but no change in risk-adjusted mortality.

Hospital discharges, readmissions, and ED visits for COPD or bronchiectasis among US adults: findings from the nationwide inpatient sample 2001-2012 and Nationwide Emergency Department Sample 2006-2011

BACKGROUND

Numbers and rates of hospitalizations and ED visits by patients with COPD are important metrics for surveillance purposes. The objective of this study was to examine trends in these rates from 2001 to 2012 among adults aged ≥ 18 years in the United States.

METHODS

Data from the Nationwide Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS) were examined for temporal trends in the numbers and rates of hospitalizations by patients with COPD or bronchiectasis, mean length of stay, in-hospital case-fatality rate, 30-day readmission rate, and numbers and rates of ED visits.

RESULTS

The national number of discharges with COPD or bronchiectasis as the principal diagnosis was about 88,000 higher in 2012 than in 2001, but the age-adjusted rate of discharges did not change significantly (range, 242.7-286.0 per 100,000 population, P trend = .554). In contrast, hospitalization rates for common cardiovascular disorders, pneumonia, and lung cancer decreased significantly by 27% to 68%, whereas the mean charge doubled and mean cost increased by 40%. From 2006 to 2011, the numbers of ED visits increased from 1,480,363 to 1,787,612. The age-adjusted rate increased nonsignificantly from 654 to 725 per 100,000 population (P trend = .072).

CONCLUSIONS

Despite many local and national efforts to reduce the burden of COPD, total hospitalizations and ED visits over the past decade have increased for COPD, and the age-adjusted rates of hospitalizations and ED visits for COPD or bronchiectasis have not changed significantly in the United States.

Hospital factors associated with discharge bias in ICU performance measurement

OBJECTIVE

Performance assessments based on in-hospital mortality for ICU patients can be affected by discharge practices such that differences in mortality may reflect variation in discharge patterns rather than quality of care. Time-specific mortality rates, such as 30-day mortality, are preferred but are harder to measure. The degree to which the difference between 30-day and in-hospital ICU mortality rates-or "discharge bias"-varies by hospital type is unknown. The aim of this study was to quantify variation in discharge bias across hospitals and determine the hospital characteristics associated with greater discharge bias.

DESIGN

Retrospective cohort study.

SETTING

Nonfederal Pennsylvania hospital discharges in 2008.

PATIENTS

Eligible patients were 18 years old or older and admitted to an ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We used logistic regression with hospital-level random effects to calculate hospital-specific risk-adjusted 30-day and in-hospital mortality rates. We then calculated discharge bias, defined as the difference between 30-day and in-hospital mortality rates, and used multivariable linear regression to compare discharge bias across hospital types. A total of 43,830 patients and 134 hospitals were included in the analysis. Mean (SD) risk-adjusted hospital-specific in-hospital and 30-day ICU mortality rates were 9.6% (1.3) and 12.7% (1.5), respectively. Hospital-specific discharge biases ranged from -1.3% to 6.6%. Discharge bias was smaller in large hospitals compared with small hospitals, making large hospitals appear comparatively worse from a benchmarking standpoint when using in-hospital mortality instead of 30-day mortality.

CONCLUSIONS

Discharge practices bias in-hospital ICU mortality measures in a way that disadvantages large hospitals. Accounting for discharge bias will prevent these hospitals from being unfairly disadvantaged in public reporting and pay-for-performance.

Does public reporting improve the quality of hospital care for acute myocardial infarction? Results from a regional outcome evaluation program in Italy

OBJECTIVE

To evaluate whether public reporting of performance data was associated with a change over time in quality indicators for acute myocardial infarction (AMI) in Italian hospitals.

DESIGN

Pre-post evaluation of AMI indicators in the Lazio region, before and after disclosure of the Regional Outcome Evaluation Program, and a comparative evaluation versus other Italian regions not participating in the program.

SETTING/DATA SOURCES

Nationwide Hospital Information System and vital status records.

PARTICIPANTS

24 800 patients treated for AMI in Lazio and 39 350 in the other regions.

INTERVENTION

Public reporting of the Regional Outcome Evaluation Program in the Lazio region.

MAIN OUTCOME MEASURE

Risk-adjusted indicators for AMI.

RESULTS

The proportion of ST-segment elevation myocardial infarction (STEMI) patients treated with percutaneous coronary interventions (PCI) within 48 h in Lazio changed from 31.3 to 48.7%, before and after public reporting, respectively (relative increase 56%; P < 0.001). In the other regions, the proportion increased from 51.5 to 58.4% (relative increase 13%; P < 0.001). Overall 30-day mortality and 30-day mortality for patients treated with PCI did not improve during the study period. The 30-day mortality for STEMI patients not treated with PCI in Lazio was significantly higher in 2009 (29.0%) versus 2006/07 (24.0%) (P = .002).

CONCLUSIONS

Public reporting may have contributed to increasing the proportion of STEMI patients treated with timely PCI. The mortality outcomes should be interpreted with caution. Changes in AMI diagnostic and coding systems should also be considered. Risk-adjusted quality indicators represent a fundamental instrument for monitoring and potentially enhancing quality of care.

Dissemination of performance information and continuous improvement: A narrative systematic review

PURPOSE

Developing a performance measure and reporting the results to support decision making at an individual level has yielded poor results in many health systems. The purpose of this paper is to highlight the factors associated with the dissemination of performance information that generate and support continuous improvement in health organizations.

DESIGN/METHODOLOGY/APPROACH

A systematic data collection strategy that includes empirical and theoretical research published from 1980 to 2010, both qualitative and quantitative, was performed on Web of Science, Current Contents, EMBASE and MEDLINE. A narrative synthesis method was used to iteratively detail explicative processes that underlie the intervention. A classification and synthesis framework was developed, drawing on knowledge transfer and exchange (KTE) literature. The sample consisted of 114 articles, including seven systematic or exhaustive reviews.

FINDINGS

Results showed that dissemination in itself is not enough to produce improvement initiatives. Successful dissemination depends on various factors, which influence the way collective actors react to performance information such as the clarity of objectives, the relationships between stakeholders, the system's governance and the available incentives.

RESEARCH LIMITATIONS/IMPLICATIONS

This review was limited to the process of knowledge dissemination in health systems and its utilization by users at the health organization level. Issues related to improvement initiatives deserve more attention.

PRACTICAL IMPLICATIONS

Knowledge dissemination goes beyond better communication and should be considered as carefully as the measurement of performance. Choices pertaining to intervention should be continuously prompted by the concern to support organizational action.

ORIGINALITY/VALUE

While considerable attention was paid to the public reporting of performance information, this review sheds some light on a more promising avenue for changes and improvements, notably in public health systems.

Optimal timing of transfer out of the intensive care unit

BACKGROUND

Little other than subjective judgment is available to help clinicians determine when a patient should be transferred out of the intensive care unit.

OBJECTIVE

To assess whether remaining in the intensive care unit longer than judged to be medically necessary is associated with increased 30-day mortality.

METHODS

This prospective, observational cohort study was performed in a 13-bed, closed-model, adult medical intensive care unit of a county-owned, university-affiliated hospital that often has difficulty transferring patients to general care areas because of a lack of available beds. Analysis included all 2401 survivors of intensive care from the study period. Delay in discharge from the intensive care unit was defined as time elapsed between the request for transfer and the actual transfer. Logistic regression was used to assess the association of discharge delay with 30-day mortality, adjusting for demographics, comorbid conditions, type and severity of acute illness, care limitations in the unit, and other potential confounding variables. Nonlinear relationships with continuous variables were modeled with restricted cubic splines.

RESULTS

Overall, 30-day mortality was 10.1%. Mean discharge delay was 9.6 (SD, 11.7) hours; 9.9% had a discharge delay exceeding 24 hours. The relationship of 30-day mortality to discharge delay was statistically significant and U-shaped, with the nadir at 20 hours.

CONCLUSIONS

These data indicate an optimal time window for patients to leave the intensive care unit, with increased mortality not only if they leave earlier but also if they leave later than this optimal timing.

Mortality predictions on admission as a context for organizing care activities

BACKGROUND

Favorable health outcomes are more likely to occur when the clinical team recognizes patients at risk and intervenes in consort. Prediction rules can identify high-risk subsets, but the availability of multiple rules for various conditions present implementation and assimilation challenges.

METHODS

A prediction rule for 30-day mortality at the beginning of the hospitalization was derived in a retrospective cohort of adult inpatients from a community hospital in the Midwestern United States from 2008 to 2009, using clinical laboratory values, past medical history, and diagnoses present on admission. It was validated using 2010 data from the same and from a different hospital. The calculated mortality risk was then used to predict unplanned transfers to intensive care units, resuscitation attempts for cardiopulmonary arrests, a condition not present on admission (complications), intensive care unit utilization, palliative care status, in-hospital death, rehospitalizations within 30 days, and 180-day mortality.

RESULTS

The predictions of 30-day mortality for the derivation and validation datasets had areas under the receiver operating characteristic curve of 0.88. The 30-day mortality risk was in turn a strong predictor for in-hospital death, palliative care status, 180-day mortality; a modest predictor for unplanned transfers and cardiopulmonary arrests; and a weaker predictor for the other events of interest.

CONCLUSIONS

The probability of 30-day mortality provides health systems with an array of prognostic information that may provide a common reference point for organizing the clinical activities of the many health professionals involved in the care of the patient.

A typology of structural approaches to HIV prevention: a commentary on Roberts and Matthews

Renewed enthusiasm for biomedical HIV prevention strategies has followed the recent publication of several high-profile HIV antiretroviral therapy-based HIV prevention trials. In a recent article, Roberts and Matthews (2012) accurately note some of the shortcomings of these individually targeted approaches to HIV prevention and advocate for increased emphasis on structural interventions that have more fundamental effects on the population distribution of HIV. However, they make some implicit assumptions about the extent to which structural interventions are user-independent and more sustainable than biomedical or behavioral interventions. In this article, I elaborate a simple typology of structural interventions along these two axes and suggest that they may be neither user-independent nor sustainable and therefore subject to the same sustainability concerns, costs, and potential unintended consequences as biomedical and behavioral interventions.

Reporting of quality indicators and improvement in hospital performance: the P.Re.Val.E. Regional Outcome Evaluation Program

OBJECTIVE

To evaluate whether reporting of hospital performance was associated with a change in quality indicators in Italian hospitals.

DATA SOURCES/STUDY SETTING

Nationwide Hospital Information System for 2006-2009.

STUDY DESIGN

We performed a pre-post evaluation in Lazio (before and after disclosure of the Regional Outcome Evaluation Program P.Re.Val.E.) and a comparative evaluation versus Italian regions without comparable programs. We analyzed risk-adjusted proportions of percutaneous coronary intervention (PCI), hip fractures operated on within 48 hours, and cesarean deliveries.

DATA COLLECTION/EXTRACTION METHODS

Using standardized ICD-9-CM coding algorithms, we selected 381,053 acute myocardial infarction patients, 250,712 hip fractures, and 1,736,970 women who had given birth.

PRINCIPAL FINDINGS

In Lazio PCI within 48 hours changed from 22.49 to 29.43 percent following reporting of the P.Re.Val.E results (relative increase, 31 percent; p < .001). In the other regions this proportion increased from 22.48 to 27.09 percent during the same time period (relative increase, 21 percent; p < .001). Hip fractures operated on within 48 hours increased from 11.73 to 15.78 percent (relative increase, 34 percent; p < .001) in Lazio, and not in other regions (29.36 to 28.57 percent). Cesarean deliveries did not decrease in Lazio (34.57-35.30 percent), and only slightly decreased in the other regions (30.49-28.11 percent).

CONCLUSIONS

Reporting of performance data may have a positive but limited impact on quality improvement. The evaluation of quality indicators remains paramount for public accountability.

Comparison of 30-day, 90-day and in-hospital postoperative mortality for eight different cancer types

BACKGROUND

Various definitions are used to calculate postoperative mortality. As variation hampers comparability between reports, a study was performed to evaluate the impact of using different definitions for several types of cancer surgery.

METHODS

Population-based data for the period 1997-2008 were retrieved from the Rotterdam Cancer Registry for resectional surgery of oesophageal, gastric, colonic, rectal, breast, lung, renal and bladder cancer. Postoperative deaths were tabulated as 30-day, in-hospital or 90-day mortality. Postdischarge deaths were defined as those occurring after discharge from hospital but within 30 days.

RESULTS

This study included 40,474 patients. Thirty-day mortality rates were highest after gastric (8·8 per cent) and colonic (6·0 per cent) surgery, and lowest after breast (0·2 per cent) and renal (2·0 per cent) procedures. For most tumour types, the difference between 30-day and in-hospital rates was less than 1 per cent. For bladder and oesophageal cancer, however, the in-hospital mortality rate was considerably higher at 5·1 per cent (+1·3 per cent) and 7·3 per cent (+2·8 per cent) respectively. For gastric, colonic and lung cancer, 1·0 per cent of patients died after discharge. For gastric, lung and bladder cancer, more than 3 per cent of patients died between discharge and 90 days.

CONCLUSION

The 30-day definition is recommended as an international standard because it includes the great majority of surgery-related deaths and is not subject to discharge procedures. The 90-day definition, however, captures mortality from multiple causes; although this may be of less interest to surgeons, the data may be valuable when providing information to patients before surgery.

Little evidence of correlation between growth in health care spending and reduced mortality

As rapid U.S. health care spending growth continues, the question of whether additional dollars purchase better health or unnecessary care remains in sharp focus for policy makers, large employers, and other stakeholders. To investigate this question, we measured changes in mortality and cost for seven common diagnoses at 122 U.S. hospitals from 2000 to 2004. After adjusting for inflation, we found little correlation between reduced mortality for certain conditions and increased spending on patients with those conditions. The message to be underscored once again for policy makers is that health care dollars provide inconsistent value, and future spending increases should be targeted to care that improves outcomes.

Outcomes for mitral valve surgery among Medicare fee-for-service beneficiaries, 1999 to 2008

BACKGROUND

Mitral valve surgery in older adults carries with it substantial morbidity and mortality risks, yet there are a paucity of national surveillance data. Therefore, we sought to determine trends in hospitalization rate, readmission, and mortality among Medicare fee-for-service (FFS) patients undergoing mitral valve surgery.

METHODS AND RESULTS

Inpatient Medicare standard analytic files were used to identify 100% of FFS patients aged ≥ 65 years who underwent mitral valve surgery between 1999 and 2008. We constructed a denominator file from Medicare administrative data to report hospitalization rates for mitral valve surgery (total and isolated) per 100 000 beneficiary-years. For isolated mitral valve surgery, 30-day readmission, 30-day mortality, and 1-year mortality outcomes were ascertained through corresponding inpatient and vital status files, and risk-standardized rates were calculated adjusting for age, sex, race, and comorbidities. During 1999 to 2008, the overall rate of mitral valve surgery per 100K beneficiary-years declined (56/100K to 51/100K), and the proportion of patients undergoing mitral valve repair (versus replacement) increased (24.7% to 46.9%, P<0.001). For isolated mitral valve surgery, there were significant declines in risk-adjusted 30-day mortality (8.1% to 4.2%, P<0.001 for trend) and 1-year mortality (15.3% to 9.2%, P=0.003 for trend) and a slight decline in risk-adjusted 30-day readmission (23.0% to 21.0%, P=0.035 for trend) over the study period. Mortality rates decreased in all age, sex, and race subgroups, and among patients undergoing mitral valve repair or replacement, but remained higher among patients aged ≥ 85 years, women, and nonwhites.

CONCLUSIONS

Between 1999 and 2008, outcomes after isolated mitral valve surgery significantly improved among Medicare FFS patients. Disparities among demographic subgroups indicate potential areas for quality improvement.

Comparison of hospital risk-standardized mortality rates calculated by using in-hospital and 30-day models: an observational study with implications for hospital profiling

BACKGROUND

In-hospital mortality measures, which are widely used to assess hospital quality, are not based on a standardized follow-up period and may systematically favor hospitals with shorter lengths of stay (LOSs).

OBJECTIVE

To assess the agreement between performance measures of U.S. hospitals by using risk-standardized in-hospital and 30-day mortality rates.

DESIGN

Observational study.

SETTING

Nonfederal acute care hospitals in the United States with at least 30 admissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia from 2004 to 2006.

PATIENTS

Medicare fee-for-service patients admitted for AMI, HF, or pneumonia from 2004 to 2006.

MEASUREMENTS

The primary outcomes were in-hospital and 30-day risk-standardized mortality rates (RSMRs).

RESULTS

Included patients comprised 718,508 admissions to 3135 hospitals for AMI, 1,315,845 admissions to 4209 hospitals for HF, and 1,415,237 admissions to 4498 hospitals for pneumonia. The hospital-level mean patient LOS varied across hospitals for each condition, ranging from 2.3 to 13.7 days for AMI, 3.5 to 11.9 days for HF, and 3.8 to 14.8 days for pneumonia. The mean RSMR differences (30-day RSMR minus in-hospital RSMR) were 5.3% (SD, 1.3) for AMI, 6.0% (SD, 1.3) for HF, and 5.7% (SD, 1.4) for pneumonia; distributions varied widely across hospitals. Performance classifications differed between the in-hospital and 30-day models for 257 hospitals (8.2%) for AMI, 456 (10.8%) for HF, and 662 (14.7%) for pneumonia. Hospital mean LOS was positively correlated with in-hospital RSMRs for all 3 conditions.

LIMITATION

Medicare claims data were used for risk adjustment.

CONCLUSION

In-hospital mortality measures provide a different assessment of hospital performance than 30-day mortality and are biased in favor of hospitals with shorter LOSs.

PRIMARY FUNDING SOURCE

The Centers for Medicare & Medicaid Services and National Heart, Lung, and Blood Institute.

Do inter-hospital comparisons of in-hospital, acute myocardial infarction case-fatality rates serve the purpose of fostering quality improvement? An evaluative study

BACKGROUND

In-hospital case-fatality rates in patients, admitted for acute myocardial infarction (AMI-CFRs), are internationally used as a quality indicator. Attempting to encourage the hospitals to assume responsibility, the Belgian Ministry of Health decided to stimulate initiatives of quality improvement by means of a limited set of indicators, among which AMI-CFR, to be routinely analyzed. In this study we aimed, by determining the existence of inter-hospital differences in AMI-CFR, (1) to evaluate to which extent Belgian discharge records allow the assessment of quality of care in the field of AMI, and (2) to identify starting points for quality improvement.

METHODS

Hospital discharge records from all the Belgian short-term general hospitals in the period 2002-2005. The study population (N = 46,287) included patients aged 18 years and older, hospitalized for AMI. No unique patient identifier being present, we tried to track transferred patients. We assessed data quality through a comparison of MCD with data from two registers for acute coronary events and through transfer and sensitivity analyses. We compared AMI-CFRs across hospitals, using multivariable logistic regression models. In the main model hospitals, Charlson's co-morbidity index, age, gender and shock constituted the covariates. We carried out two types of analyses: a first one wherein transferred-out cases were excluded, to avoid double counting of patients when computing rates, and a second one with exclusion of all transferred cases, to allow the study of patients admitted into, treated in and discharged from the same hospital.

RESULTS

We identified problems regarding both the CFR's numerator and denominator.Sensitivity analyses revealed differential coding and/or case management practices. In the model with exclusion of transfer-out cases, the main determinants of AMI-CFR were cardiogenic shock (OR(adj) 23.0; 95% CI [20.9;25.2]), and five-year age groups OR(adj) 1.23; 95% CI [1.11;1.36]). Sizable inter-hospital and inter-type of hospital differences {(OR(comunity vs tertiary hospitals)1.36; 95% CI [1.34;1.39]) and (OR(intermediary vs tertiary hospitals)1.36; 95% CI [1.34;1.39])}, and nonconformities to guidelines for treatment were observed.

CONCLUSIONS

Despite established data quality shortcomings, the magnitude of the observed differences and the nonconformities constitute leads to quality improvement. However, to measure progress, ways to improve and routinely monitor data quality should be developed.

Trends in the inpatient quality indicators: the Veterans Health Administration experience

BACKGROUND

The Agency for Healthcare Research and Quality Inpatient Quality Indicators (IQIs), which include in-hospital mortality and utilization rates, have received little attention in the Veterans Health Administration (VA), despite extensive private sector use for quality improvement.

OBJECTIVES

We examined the following: the feasibility of applying the IQIs to VA data; temporal trends in national VA IQI rates; temporal and regional IQI trends in geographic areas defined by Veterans Integrated Service Networks' (VISNs); and VA versus non-VA (Nationwide Inpatient Sample) temporal trends.

METHODS

We derived VA- and VISN-level IQI observed rates, risk-adjusted rates, and observed to expected ratios (O/Es), using VA inpatient data (2004-2007). We examined the trends in VA- and VISN-level rates using weighted linear regression, variation in VISN-level O/Es, and compared VA to non-VA trends.

RESULTS

VA in-hospital mortality rates from selected medical conditions (stroke, hip fracture, pneumonia) decreased significantly over time; procedure-related mortality rates were unchanged. Laparoscopic cholecystectomy rates increased significantly. A few VISNs were consistently high or low outliers for the medical-related mortality IQIs. Within any given year, utilization indicators, especially cardiac catheterization and cholecystectomy, showed the most inter-VISN variation. Compared with the non-VA, VA medical-related mortality rates for the above-mentioned conditions decreased more rapidly, whereas laparascopic cholecystectomy rates rose more steeply.

CONCLUSIONS

The IQIs are easily applied to VA administrative data. They can be useful to tracks rate trends over time, reveal variation between sites, and for trend comparisons with other healthcare systems. By identifying potential quality events related to mortality and utilization, they may complement existing VA quality improvement initiatives.

Declining length of hospital stay for pneumonia and postdischarge outcomes

OBJECTIVE

This study was designed to assess 8-year trends in the duration of hospitalization for community-acquired pneumonia and to evaluate the impact of declining length of stay on postdischarge short-term readmission and mortality.

METHODS

We conducted a prospective observational cohort study of 1886 patients with community-acquired pneumonia who were discharged from a single hospital between March 1, 2000, and June 30, 2007. The main outcomes measured were all-cause mortality and hospital readmission during the 30-day period after discharge. Regression models were used to identify risk factors associated with hospital length of stay and the adjusted associations between length of stay and mortality and readmission.

RESULTS

Factors associated with a longer hospital stay included the number of comorbid conditions, high risk classification on the Pneumonia Severity Index, bilateral or multilobe radiographic involvement, and treatment failure. Patients treated with an appropriate antibiotic were less likely to have an increased length of stay. The mean length of stay was significantly shorter during the 2006 to 2007 period (3.6 days) than during the 2000 to 2001 period (5.6 days, P<.001). Despite the reduction in length of stay, there were no significant differences in the likelihood of death or readmission at 30 days between the 2 time periods. Adjusted multivariate analysis showed that patients with hospital stays less than 3 days did not have significant increases in postdischarge outcomes.

CONCLUSION

The marked decreased in the length of stay for patients hospitalized with community-acquired pneumonia since 2000 has not been accompanied by an increase in short-term mortality or hospital readmission.

Using Automated Clinical Data for Risk Adjustment

BACKGROUND

Clinically plausible risk-adjustment methods are needed to implement pay-for-performance protocols. Because billing data lacks clinical precision, may be gamed, and chart abstraction is costly, we sought to develop predictive models for mortality that maximally used automated laboratory data and intentionally minimized the use of administrative data (Laboratory Models). We also evaluated the additional value of vital signs and altered mental status (Full Models).

METHODS

Six models predicting in-hospital mortality for ischemic and hemorrhagic stroke, pneumonia, myocardial infarction, heart failure, and septicemia were derived from 194,903 admissions in 2000-2003 across 71 hospitals that imported laboratory data. Demographics, admission-based labs, International Classification of Diseases (ICD)-9 variables, vital signs, and altered mental status were sequentially entered as covariates. Models were validated using abstractions (629,490 admissions) from 195 hospitals. Finally, we constructed hierarchical models to compare hospital performance using the Laboratory Models and the Full Models.

RESULTS

Model c-statistics ranged from 0.81 to 0.89. As constructed, laboratory findings contributed more to the prediction of death compared with any other risk factor characteristic groups across most models except for stroke, where altered mental status was more important. Laboratory variables were between 2 and 67 times more important in predicting mortality than ICD-9 variables. The hospital-level risk-standardized mortality rates derived from the Laboratory Models were highly correlated with the results derived from the Full Models (average rho = 0.92).

CONCLUSIONS

Mortality can be well predicted using models that maximize reliance on objective pathophysiologic variables whereas minimizing input from billing data. Such models should be less susceptible to the vagaries of billing information and inexpensive to implement.

Processes and outcomes for acute myocardial infarction patients

Purpose

The purpose of this paper is to determine whether process quality indicators for acute myocardial infarction (AMI) one associated with outcome indicators (hospital mortality and early readmission).

Design/methodology/approach

A retrospective cohort study was conducted among patients discharged from three Swiss university hospitals with a primary or secondary International Classification of Diseases, 10th revision (ICD‐10) AMI code in 1999. A total of 1,129 patients' records were abstructed. Demographic characteristics and risk factors at admission were recorded. The main ECG and laboratory findings were further abstracted as well as hospital and discharge management and treatment. The main outcome measure was process quality indicators derived from evidence‐based guidelines, and hospital mortality and early readmissions.

Findings

After exclusions, 577 patients with AMI were eligible for this study. The mean (SD) age was 68.2 (13.9). In the assessment of quality indicators patients with potential contra‐indications were excluded. Among cohorts of “ideal candidates” for specific interventions, aspirin was not prescribed within 24 hours after admission in 33 (6.2 percent) patients. Among those, 17 (51.5 percent) died (p<0.0001). The adjusted OR for no aspirin after admission was 3.61 (95 percent CI 1.11‐11.77) for hospital mortality. Further, 78 (19.5 percent) patients did not receive β‐blockers at discharge. Among them nine (11.5 percent) were readmitted (p=0.133). The adjusted OR for no β‐blockers at discharge was 2.15 (95 percent CI 0.86‐5.41) for readmissions. Among patients with AMI, not prescribing aspirin within 24 hours after admission was associated with hospital mortality. However, process indicators derived from evidence‐based guidelines were not related to early readmission in this study.

Originality/value

The paper stresses the importance of clinicians confronting their decisions with recommendations of evidence‐based guidelines for the management and treatment of AMI patients.

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

OBJECTIVE

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

DATA SOURCE

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

STUDY DESIGN

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

The impact of venous thromboembolism on risk of death or hemorrhage in older cancer patients

BACKGROUND

Among older cancer patients, there is uncertainty about the degree to which venous thromboembolism (VTE) and its treatment increase the risk of death or major hemorrhage.

OBJECTIVE

To determine the prevalence of VTE in a cohort of older cancer patients, as well as the degree to which VTE increased the risk of death or major hemorrhage.

METHODS

We conducted a retrospective cohort study of linked Surveillance, Epidemiology, and End Results cancer registry and Medicare administrative claims data. Patients with any of ten invasive cancers diagnosed during 1995 through 1999 were included; the independent variable was VTE diagnosed concomitantly with cancer diagnosis. Outcomes included major hemorrhage during the first year after cancer diagnosis and all-cause mortality;

RESULTS

Overall, about 1% of patients who were diagnosed with cancer also had a VTE diagnosed concomitantly. After adjusting for sociodemographic factors and cancer stage and grade, concomitant VTE was associated with a relative increase in the risk of death for 8 of the 10 cancer types; the increase in risk tended to range 20-40% across most cancer types. Approximately 16.8% (95% confidence interval [CI] 14.9-18.8%) of patients with a concomitant VTE and 7.9% (95% CI 7.7-8.0%) of patients without a VTE experienced a major hemorrhage during the year after cancer diagnosis (P value <.001). The excess risk of hemorrhage associated with VTE varied substantially across cancer types, ranging from no significant excess (kidney and uterine cancer) to 11.5% (lymphoma).

CONCLUSION

Concomitant VTE is not only a marker and potential mediator of increased risk of death among older cancer patients, but patients with a VTE have a marked increased risk of major hemorrhage.

Redirecting patients to improve stroke outcomes: implications of a volume-based approach in one urban market

BACKGROUND

The designation of primary stroke centers may result in patients being redirected from their usual source of care, although there is little evidence that these centers would result in better outcomes or lower costs. An alternative approach could direct patients to hospitals treating greater volumes of stroke patients.

OBJECTIVES

We sought to estimate the effect of hospital stroke volume on patient mortality and costs in a regional hospital market and to analyze the implications of hypothetical volume-based referral policies in that market, including the effects of patient-hospital distance.

METHODS

Using a retrospective cohort, we studied 12,150 Medicare patients admitted for acute stroke to 1 of 29 hospitals in Greater Cleveland during a 7-year period. The primary outcome was risk-adjusted 30-day mortality. Secondary outcomes included log hospital costs and discharge destination. The primary measure of volume was average annual number of stroke patients; patient distance to the nearest hospital was approximated using patient zip code and hospital address data.

RESULTS

Overall 30-day mortality was 14.9%. For each 100-patient increase in hospitals' annual stroke volume, risk-adjusted mortality declined 0.9 percentage points (odds ratio = 0.90; 95% confidence interval = 0.82-0.98; P < 0.02) with no significant difference in hospital costs. For each 1-mile increase in patient distance to nearest hospital, mortality increased 0.6 percentage points (odds ratio = 1.07; 95% confidence interval = 1.03-1.11; P < 0.01). Only 3 of 29 hospitals (10.3%) exceeded the highest plausible threshold (250 strokes/year), redirecting 81.4% of patients for a net reduction in mortality of 0.4%; lower thresholds would redirect fewer patients but have negligible effects on mortality.

CONCLUSIONS

Our findings fail to support redirecting acute stroke patients based on hospital stroke volume.

Present-at-admission diagnoses improved mortality risk adjustment among acute myocardial infarction patients

OBJECTIVE

Hospital mortality outcomes for acute myocardial infarction (AMI) patients are a focus of quality improvement programs conducted by government agencies. AMI mortality risk-adjustment models using administrative data typically adjust for baseline differences in mortality risk with a limited set of common and definite comorbidities. In this study, we present an AMI mortality risk-adjustment model that adjusts for comorbid disease and for AMI severity using information from secondary diagnoses reported as present at admission for California hospital patients.

STUDY DESIGN AND SETTING

AMI patients were selected from California hospital administrative data for 1996 through 1999 according to criteria used by the California Hospital Outcomes Project Report on Heart Attack Outcomes, a state-mandated public report that compares hospital mortality outcomes. We compared results for the new model to two mortality risk-adjustment models used to assess hospital AMI mortality outcomes by the state of California, and to two other models used in prior research.

RESULTS

The model using present-at-admission diagnoses obtained substantially better discrimination between predicted survival and inpatient death than the other models we considered.

CONCLUSION

AMI mortality risk-adjustment methods can be meaningfully improved using present-at-admission diagnoses to identify comorbid disease and conditions related closely to AMI.

Overcoming bias in estimating the volume-outcome relationship

OBJECTIVE

To examine the effect of hospital volume on 30-day mortality for patients with congestive heart failure (CHF) using administrative and clinical data in conventional regression and instrumental variables (IV) estimation models.

DATA SOURCES

The primary data consisted of longitudinal information on comorbid conditions, vital signs, clinical status, and laboratory test results for 21,555 Medicare-insured patients aged 65 years and older hospitalized for CHF in northeast Ohio in 1991-1997.

STUDY DESIGN

The patient was the primary unit of analysis. We fit a linear probability model to the data to assess the effects of hospital volume on patient mortality within 30 days of admission. Both administrative and clinical data elements were included for risk adjustment. Linear distances between patients and hospitals were used to construct the instrument, which was then used to assess the endogeneity of hospital volume.

PRINCIPAL FINDINGS

When only administrative data elements were included in the risk adjustment model, the estimated volume-outcome effect was statistically significant (p=.029) but small in magnitude. The estimate was markedly attenuated in magnitude and statistical significance when clinical data were added to the model as risk adjusters (p=.39). IV estimation shifted the estimate in a direction consistent with selective referral, but we were unable to reject the consistency of the linear probability estimates.

CONCLUSIONS

Use of only administrative data for volume-outcomes research may generate spurious findings. The IV analysis further suggests that conventional estimates of the volume-outcome relationship may be contaminated by selective referral effects. Taken together, our results suggest that efforts to concentrate hospital-based CHF care in high-volume hospitals may not reduce mortality among elderly patients.

Publishing outcome data: is it an effective approach?

RATIONALE, AIMS AND OBJECTIVES

The publication of health outcome data--rather than merely the measurement and collection--is being given increasing consideration. Publication reflects society's increasing emphasis on a general 'right to know', as well as being a means of informing consumer choice. In theory, publication may help to promote public trust, support patient choice, and stimulate action to improve the quality of care whilst controlling costs.

METHODS

Drawing on a literature review, this paper overviews the strategies employed in the UK and US to publish outcome data. The focus is on outcomes, and certain related process measures, that measure the performance of hospitals or surgeons.

RESULTS AND CONCLUSIONS

Presenting the limited evidence that exists, we review the potential beneficial and harmful effects of publishing hospital outcome data. We also consider the risks of making incorrect inferences based on these data and the potential for dysfunctional consequences. Recognizing that the public largely mistrusts currently published health outcome data, we offer some recommendations for the future direction of strategies for publication.

Do report cards influence hospital choice? The case of kidney transplantation

The national program to report hospital-level outcomes for transplantation has been in place since 1991, yet it has not been addressed in the existing literature on hospital report cards. We study the impact of reported outcomes on demand at kidney transplant centers. Using a negative binomial regression with hospital fixed effects, we estimate the number of patients choosing each center as a function of reported outcomes. Parameters are identified by the within-hospital variation in outcomes over five successive report cards. We find some evidence that report cards influence younger and college-educated patients, but, overall, report cards do not affect demand.

Improving the ICU: part 2

ICUs are a vital but troubled component of modern health-care systems. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance, to a systems-oriented approach that emphasizes the need to assess and improve the ICU systems and processes that hinder the ability of individuals to perform their jobs well. This second part of a two-part treatise establishes a practical framework for performance improvement and examines specific strategies to improve ICU performance, including the use of information systems.

Improving the ICU: part 1

ICUs are a vital component of modern health care. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance to a different paradigm that emphasizes the need to assess and improve ICU systems and processes. This is the first part of a two-part treatise. It discusses existing problems in ICU care, and the methods for defining and measuring ICU performance.

Does the Collaborative Model Improve Care for Chronic Heart Failure?

BACKGROUND

Organizationally based, disease-targeted collaborative quality improvement efforts are widely applied but have not been subject to rigorous evaluation. We evaluated the effects of the Institute of Healthcare Improvement's Breakthrough Series (IHI BTS) on quality of care for chronic heart failure (CHF).

RESEARCH DESIGN

We conducted a quasi-experiment in 4 organizations participating in the IHI BTS for CHF in 1999-2000 and 4 comparable control organizations. We reviewed a total of 489 medical records obtained from the sites and used a computerized data collection tool to measure performance on 23 predefined quality indicators. We then compared differences in indicator performance between the baseline and post-intervention periods for participating and non-participating organizations.

RESULTS

Participating and control patients did not differ significantly with regard to measured clinical factors at baseline. After adjusting for age, gender, number of chronic conditions, and clustering by site, participating sites showed greater improvement than control sites for 11 of the 21 indicators, including use of lipid-lowering and angiotensin converting enzyme inhibition therapy. When all indicators were combined into a single overall process score, participating sites improved more than controls (17% versus 1%, P < 0.0001). The improvement was greatest for measures of education and counseling (24% versus -1%, P < 0.0001).

CONCLUSIONS

Organizational participation in a common disease-targeted collaborative provider interaction improved a wide range of processes of care for CHF, including both medical therapeutics and education and counseling. Our data support the use of programs like the IHI BTS in improving the processes of care for patients with chronic diseases.

The evolving science of quality measurement for hospitals: implications for studies of competition and consolidation

The literature on hospital competition and quality is young; most empirical studies have focused on few conditions and outcomes. Measures of in-hospital mortality and complications are susceptible to bias from unmeasured severity and transfer/discharge practices. Only one research team has evaluated related process and outcome measures, and none has exploited chart-review or patient survey-based data. Prior studies have generated inconsistent findings, suggesting the need for additional research. We describe the strengths and limitations of various approaches to quality measurement, summarize how quality has been operationalized in studies of hospital competition, outline three mechanisms by which competition may affect hospital quality, and propose measures appropriate for testing each mechanism.

New estimates of influenza-related pneumonia and influenza hospitalizations among the elderly

OBJECTIVES

The aim of this study is to present a method to provide accurate estimates of influenza-associated pneumonia and influenza (P&I) hospitalizations and costs for use in tracking the continuing burden of influenza.

METHODS

We estimated influenza-associated P&I hospitalizations among the U.S. elderly population for six influenza seasons, 1990-91 through 1995-96, by applying a Poisson regression model to national influenza virus surveillance information and Medicare administrative data. This model is similar to that recently published by the U.S. National Centers for Disease Control and Prevention (CDC) to estimate influenza-related mortality.

RESULTS

During the six years of the study, 318,666 (9.8%) of P&I hospitalizations were estimated to be associated with influenza: range = 25,819 to 70,068 per year; average annual cost = $372.3 million. Influenza A(H3N2) was associated with 73.9% of influenza-related P&I hospitalizations; influenza B with 21.3% and influenza A(H1N1) with 4.8%.

CONCLUSIONS

Our estimates were consistent with the estimates of influenza-associated P&I mortality reported by CDC. Thus, we suggest that estimates of influenza-associated morbidity and costs based on virus surveillance and administrative data may be used for monitoring the impact of influenza and of intervention strategies.

The GDAHA hospital performance reports project: a successful community-based quality improvement initiative

During the past decade there has been increasing distribution of hospital performance information but few examples of how this information is affecting the quality of health care delivery. This article describes the methods of implementation and factors influencing a successful community-based quality improvement initiative in Dayton, Ohio, involving a collaborative of five competing hospitals in partnership with the business community and local and state hospital associations. The initiative contributed to a 36% reduction in acute myocardial infarction mortality over a 3-year period by changing reperfusion patterns in patients with ST segment elevated myocardial infarction. Identification of an opportunity gap, root cause analysis, and development of process measures used to facilitate health care provider change are summarized. The driving and restraining forces that have shaped this initiative from a report card to a quality improvement program are outlined and a list of five contributors to success are presented. These factors can serve as a basis for how other communities can benefit from this collaborative model.

The effect of publicly reporting hospital performance on market share and risk-adjusted mortality at high-mortality hospitals

BACKGROUND

It is unclear whether publicly reporting hospitals' risk-adjusted mortality affects market share and mortality at outlier hospitals.

OBJECTIVES

To examine hospitals' market share and risk-adjusted mortality from 1991 to 1997 at hospitals participating in Cleveland Health Quality Choice (CHQC).

RESEARCH DESIGN

Time series.

SUBJECTS

Changes in market share were examined for all patients hospitalized with acute myocardial infarction, heart failure, gastrointestinal hemorrhage, obstructive pulmonary disease, pneumonia, or stroke at all 30 nonfederal hospitals in Northeast Ohio. Patients insured by Medicare were used to examine changes in mortality.

MEASURES

Trends in market share (proportion of patients with the target conditions discharged from a given hospital) and risk-adjusted 30-day mortality.

RESULTS

CHQC identified several hospitals with consistently higher than expected mortality. The five hospitals with the highest mortality tended to lose market share (mean change -0.6%, 95% CI -1.9-0.6), but this was not significant. The only outlier hospital with a large decline in market share had declining volume for 2 years before being declared an outlier. Risk-adjusted mortality declined only slightly at hospitals classified by us as "below average" (-0.8%; 95% CI, 2.9-1.8%) or "worst" (-0.4%; 95% CI -2.3-1.7). However, risk-adjusted mortality at one hospital changed from consistently above expected to consistently below expected shortly after first being declared an outlier.

CONCLUSION

Despite CHQC's strengths, identifying hospitals with higher than expected mortality did not adversely affect their market share or, with one exception, lead to improved outcomes. This failure may have resulted from consumer disinterest or difficulty interpreting CHQC reports, unwillingness of businesses to create incentives targeted to hospitals' performance, and hospitals' inability to develop effective quality improvement programs.