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Loughlin E, Gabr A, Galvin R, McCormack J, Brych O, O'Donnell MJ, Collins R, Thornton J, Harbison J, O'Connor M. The impact of hospital presentation time on stroke outcomes: A nationally representative Irish cohort study. PLoS One 2024; 19:e0304536. [PMID: 38995918 PMCID: PMC11244793 DOI: 10.1371/journal.pone.0304536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 05/14/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVES There is conflicting evidence regarding the outcomes of acute stroke patients who present to hospital within normal working hours ('in-hours') compared with the 'out-of-hours' period. This study aimed to assess the effect of time of stroke presentation on outcomes within the Irish context, to inform national stroke service delivery. MATERIALS AND METHODS A secondary analysis of data from the Irish National Audit of Stroke (INAS) from Jan 2016 to Dec 2019 was carried out. Patient and process outcomes were assessed for patients presenting 'in-hours' (8:00-17:00 Monday-Friday) compared with 'out-of-hours' (all other times). RESULTS Data on arrival time were available for 13,996 patients (male 56.2%; mean age 72.5 years), of which 55.7% presented 'out-of-hours'. In hospital mortality was significantly lower among those admitted 'in-hours' (11.3%, n = 534) compared with 'out-of-hours' (12.8%, n = 749); (adjusted Odds Ratio (OR) 0.82; 95% Confidence Interval CI [95% CI] 0.72-0.89). Poor functional outcome at discharge (Modified Rankin Scale ≥ 3) was also significantly lower in those presenting 'in-hours' (adjusted OR 0.79; 95% CI 0.68-0.91). In patients receiving thrombolysis, mean door to needle time was shorter for 'in-hours' presentation at 55.8 mins (n = 562; SD 35.43 mins), compared with 'out-of-hours' presentation at 80.5 mins (n = 736; SD 38.55 mins, p < .001). CONCLUSION More than half of stroke patients in Ireland present 'out-of-hours' and these presentations are associated with a higher mortality and a lower odds of functional independence at discharge. It is imperative that stroke pathways consider the 24 hour period to ensure the delivery of effective stroke care, and modification of 'out-of-hours' stroke care is required to improve overall outcomes.
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Affiliation(s)
- Elaine Loughlin
- Department of Ageing and Therapeutics, and Ageing Research Centre, University of Limerick Hospitals Group, Limerick, Ireland
| | - Ahmed Gabr
- Department of Ageing and Therapeutics, and Ageing Research Centre, University of Limerick Hospitals Group, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Ageing Research Centre, University of Limerick, Limerick, Ireland
| | | | - Olga Brych
- National Office of Clinical Audit, Ireland
| | | | - Rónán Collins
- Clinical Lead, National Stroke Programme, Royal College of Physicians of Ireland and Health Service Executive, Ireland
| | - John Thornton
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Joseph Harbison
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, and Ageing Research Centre, University of Limerick Hospitals Group, Limerick, Ireland
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Kim SB, Lee BM, Park JW, Kwak MY, Jang WM. Weekend effect on 30-day mortality for ischemic and hemorrhagic stroke analyzed using severity index and staffing level. PLoS One 2023; 18:e0283491. [PMID: 37347776 PMCID: PMC10287008 DOI: 10.1371/journal.pone.0283491] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/11/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND AND PURPOSE Previous studies on the weekend effect-a phenomenon where stroke outcomes differ depending on whether the stroke occurred on a weekend-mostly targeted ischemic stroke and showed inconsistent results. Thus, we investigated the weekend effect on 30-day mortality in patients with ischemic or hemorrhagic stroke considering the confounding effect of stroke severity and staffing level. METHODS We retrospectively analyzed data of patients hospitalized for ischemic or hemorrhagic stroke between January 1, 2015, and December 31, 2018, which were extracted from the claims database of the National Health Insurance System and the Medical Resource Report by the Health Insurance Review & Assessment Service. The primary outcome measure was 30-day all-cause mortality. RESULTS In total, 278,632 patients were included, among whom 84,240 and 194,392 had a hemorrhagic and ischemic stroke, respectively, with 25.8% and 25.1% of patients, respectively, being hospitalized during the weekend. Patients admitted on weekends had significantly higher 30-day mortality rates (hemorrhagic stroke 16.84%>15.55%, p<0.0001; ischemic stroke 5.06%>4.92%, p<0.0001). However, in the multi-level logistic regression analysis adjusted for case-mix, pre-hospital, and hospital level factors, the weekend effect remained consistent in patients with hemorrhagic stroke (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.00-1.10), while the association was no longer evident in patients with ischemic stroke (OR 1.01, 95% CI 0.96-1.06). CONCLUSIONS Weekend admission for hemorrhagic stroke was significantly associated with a higher mortality rate after adjusting for confounding factors. Further studies are required to understand factors contributing to mortality during weekend admission.
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Affiliation(s)
- Seung Bin Kim
- Interdepartment of Critical Care Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Bo Mi Lee
- HIRA Research Institute, Health Insurance Review & Assessment Service, Wonju, Republic of Korea
| | - Joo Won Park
- Center for Public Healthcare, National Medical Center, Seoul, Republic of Korea
| | - Mi Young Kwak
- Center for Public Healthcare, National Medical Center, Seoul, Republic of Korea
| | - Won Mo Jang
- Department of Public Health and Community Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Republic of Korea
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Nakamoto CH, Wilcock AD, Schwamm LH, Majersik JJ, Zachrison KS, Mehrotra A. Trends in characteristics of neurologists who provide stroke consultations in the USA, 2008-2021. Stroke Vasc Neurol 2023; 8:86-88. [PMID: 35902139 PMCID: PMC9985800 DOI: 10.1136/svn-2022-001662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/09/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Patients with acute ischaemic strokes (AIS), on average, fare better with timely neurologist consultation, and a growing proportion of them receive one. However, little is known about trends in the characteristics of neurologists who treat AIS. METHODS We identified AIS and transient ischaemic attack (TIA) episodes with neurologist consults in fee-for-service Medicare from January 2008 to September 2021. For each episode, we determined whether the neurologist was a vascular neurologist, was a high-volume provider, whether the patient was transferred between hospitals and the distance between the patient's home and physician's practice. RESULTS From 2008 to 2021, the share of AIS/TIA episodes (n=5 073 294) with neurologist consults increased (52.9% to 61.7%). Among episodes with consults, the fraction conducted by a vascular neurologist (5.2% to 13.7%) or by a high-volume neurologist (13.2% to 14.9%) also increased. The fraction with the patient's home and neurologist greater than 100 miles apart (4.8% to 9.6%) or in different states (5.1% to 8.1%) increased, as did the fraction with transfers (4.2% to 8.5%). DISCUSSION Over the study period, the proportion of AIS/TIA episodes with consultations from neurologists with either vascular neurology certifications or high volumes increased substantially.
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Affiliation(s)
- Carter H Nakamoto
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew D Wilcock
- Department of Family Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA .,Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Wen YP, Liu SS, Sheu JT, Wang HH, Becker ER, Lu JFR. The cost-saving effect of continuity of care (COC): an analysis of institutional COC on diabetic treatment costs using panel 2SLS regressions. BMC Health Serv Res 2021; 21:1113. [PMID: 34663318 PMCID: PMC8522076 DOI: 10.1186/s12913-021-07052-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The high costs of chronic conditions call for new treatment approaches that reduce costs while ensuring desirable health outcomes. There has been a growing transformation of care delivery models from conventional referral systems to integrated care models. This study seeks to evaluate the cost-saving impact of integrated care delivery model under pay-for-performance (P4P) scheme with continuity of care at institution level (ICOC). METHODS We analyzed the Taiwan National Health Insurance claim data of 21,725 diabetic patients who visited clinics and/or hospitals at least four times a year for 8 years. Using average local provider P4P participation rate (for each accreditation level) as an instrumental variable in two-stage least squares (2SLS) regressions, we have estimated consistent estimates of the ICOC elasticities for all-cause inpatient and outpatient costs. RESULTS Our results show that ICOC significantly reduced inpatient costs but increased outpatient costs with the elasticity for treatment costs of -11.6 and 1.03, respectively. The decrease in inpatient costs offset the increase in outpatient costs and the resulting total cost saving showed significant association with ICOC. The saving effect of ICOC is especially robust among patients who used clinics as their principal source of care. CONCLUSIONS Institutional continuity of care has a substantial impact on the treatment costs of diabetes patients. In the context where inpatient care costs are significantly higher than that of the outpatient care, ICOC would lead to a meaningful cost-saving effect. For new diabetes patients, care by clinics demonstrated the strongest saving effect.
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Affiliation(s)
- Yu-Ping Wen
- Department of Health Care Management, College of Management, Chang Gung University, Taoyuan, Taiwan, R. O. C
| | - Sandra S Liu
- Professor Emerita in Public Health, Purdue University, West Lafayette, Indiana, USA
| | - Ji-Tian Sheu
- Department of Health Care Management, College of Management, Chang Gung University, Taoyuan, Taiwan, R. O. C
- Department of Nursing, Linkou Branch, Chang Gung Memorial Hospital, Taoyuan, Taiwan, R. O. C
| | - Hong-Huei Wang
- Department of Health Care Management, College of Management, Chang Gung University, Taoyuan, Taiwan, R. O. C
| | - Edmund R Becker
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jui-Fen Rachel Lu
- Department of Health Care Management, College of Management, Chang Gung University, Taoyuan, Taiwan, R. O. C..
- Graduate Institute of Management, College of Management, Chang Gung University, Taoyuan, Taiwan, R. O. C..
- Department of Radiation Oncology, Linkou Branch, Chang Gung Memorial Hospital, Taoyuan, Taiwan, R. O. C..
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Lee JH, Ko RE, Park TK, Cho YH, Suh GY, Yang JH. Association between a Multidisciplinary Team Approach and Clinical Outcomes in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation in the Emergency Department. Korean Circ J 2021; 51:908-918. [PMID: 34595885 PMCID: PMC8558569 DOI: 10.4070/kcj.2021.0167] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/19/2021] [Accepted: 08/18/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite recent improvements in advanced life support, the overall survival rate after cardiac arrest remains low. We aimed to examine the association of a multidisciplinary team approach with clinical outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) in the emergency department (ED). METHODS This retrospective, single-center, observational study included 125 patients who underwent ECPR in the ED between May 2004-December 2018. In January 2014, our institution implemented a multidisciplinary extracorporeal membrane oxygenation (ECMO) team. Eligible patients were classified into pre-ECMO-team (n=65) and post-ECMO-team (n=60) groups. The primary outcome was in-hospital mortality. RESULTS In-hospital mortality (72.3% vs. 58.3%, p=0.102) and poor neurological outcomes (78.5% vs. 68.3%, p=0.283) did not differ significantly between the pre- and post-ECMO-team groups. However, among the 60 patients who experienced in-hospital cardiac arrest, in-hospital mortality (75.8% vs. 40.7%, p=0.006) and poor neurological outcomes (78.8% vs. 48.1%, p=0.015) significantly decreased after the multidisciplinary team formation. Multivariable logistic regression analysis showed that the multidisciplinary team approach (adjusted odds ratio, 0.20; 95% confidence interval, 0.07-0.61; p=0.005) was an independent prognostic factor for in-hospital mortality in in-hospital cardiac arrest patients. CONCLUSIONS A multidisciplinary team approach was associated with improved clinical outcomes in in-hospital cardiac arrest patients undergoing ECPR in the ED. These findings may help in improving the selection criteria for ECPR in the ED. Further studies to overcome the study limitations may help improving the outcomes of out-of-hospital cardiac arrest patients.
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Affiliation(s)
- Ji Han Lee
- Department of Emergency Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Ryoung Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Nishimura K, Ogasawara K, Kitazono T, Iihara K. Impact of Physician Volume and Specialty on In-Hospital Mortality of Ischemic and Hemorrhagic Stroke. Circ J 2021; 85:1876-1884. [PMID: 34393151 DOI: 10.1253/circj.cj-20-1214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The degree of association between mortality and case volume/physician volume is well known for many surgical procedures and medical conditions. However, the link between physician volume and death rate in patients hospitalized for stroke remains unclear. This study analyzed the correlation between in-hospital stroke mortality and physician volume per hospital, considering board certification status. METHODS AND RESULTS For this retrospective registry-based cohort study, data were obtained from the Japanese nationwide registry on patients hospitalized for ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) between 2010 and 2016. The number of stroke care physicians and relevant board-certified physicians was also obtained. Odd ratios (ORs) of 30-day in-hospital mortality were estimated after adjusting for institutional and patient differences using generalized mixed logistic regression. From 295,150 (ischemic stroke), 98,657 (ICH), and 36,174 (SAH) patients, 30-day in-hospital mortality rates were 4.4%, 16.0%, and 26.6%, respectively. There was a correlation between case volume and physician volume. A higher number of stroke care physicians was associated with a reduction in 30-day mortality after adjusting for stroke case volume and comorbidities for all stroke types (all P for trend<0.05). CONCLUSIONS An increased number of stroke care physicians was associated with reduced in-hospital mortality for all types of stroke. The volume threshold of board-certified physicians depends on the specialty and stroke type.
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Affiliation(s)
- Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | | | - Takanari Kitazono
- Department of Medicine and Clinical Science, Kyushu University Graduate School of Medical Sciences
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Kim T, Jwa C. Impact of Off-Hour Hospital Presentation on Mortality in Different Subtypes of Acute Stroke in Korea : National Emergency Department Information System Data. J Korean Neurosurg Soc 2020; 64:51-59. [PMID: 33267532 PMCID: PMC7819795 DOI: 10.3340/jkns.2020.0127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/25/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Several studies have reported inconsistent findings among countries on whether off-hour hospital presentation is associated with worse outcome in patients with acute stroke. However, its association is yet not clear and has not been thoroughly studied in Korea. We assessed nationwide administrative data to verify off-hour effect in different subtypes of acute stroke in Korea.
Methods We respectively analyzed the nationwide administrative data of National Emergency Department Information System in Korea; 7144 of ischemic stroke (IS), 2424 of intracerebral hemorrhage (ICH), and 1482 of subarachnoid hemorrhage (SAH), respectively. “Off-hour hospital presentation” was defined as weekends, holidays, and any times except 8:00 AM to 6:00 PM on weekdays. The primary outcome measure was in-hospital mortality in different subtypes of acute stroke. We adjusted for covariates to influence the primary outcome using binary logistic regression model and Cox's proportional hazard model.
Results In subjects with IS, off-hour hospital presentation was associated with unfavorable outcome (24.6% off hours vs. 20.9% working hours, p<0.001) and in-hospital mortality (5.3% off hours vs. 3.9% working hours, p=0.004), even after adjustment for compounding variables (hazard ratio [HR], 1.244; 95% confidence interval [CI], 1.106–1.400; HR, 1.402; 95% CI, 1.124–1.747, respectively). Off-hours had significantly more elderly ≥65 years (35.4% off hours vs. 32.1% working hours, p=0.029) and significantly more frequent intensive care unit admission (32.5% off hours vs. 29.9% working hours, p=0.017) than working hours. However, off-hour hospital presentation was not related to poor short-term outcome in subjects with ICH and SAH.
Conclusion This study indicates that off-hour hospital presentation may lead to poor short-term morbidity and mortality in patients with IS, but not in patients with ICH and SAH in Korea. Excessive death seems to be ascribed to old age or the higher severity of medical conditions apart from that of stroke during off hours.
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Affiliation(s)
- Taikwan Kim
- Department of Neurosurgery, Incheon Hospital 21, Incheon, Korea
| | - Cheolsu Jwa
- Department of Neurosurgery, National Medical Center, Seoul, Korea
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Huang HK, Chang WC, Hsu JY, Wang JH, Liu PS, Lin SM, Loh CH. Holiday Season and Weekend Effects on Stroke Mortality: A Nationwide Cohort Study Controlling for Stroke Severity. J Am Heart Assoc 2020; 8:e011888. [PMID: 30973048 PMCID: PMC6507216 DOI: 10.1161/jaha.118.011888] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background The effect of holiday season admission for stroke on mortality has not been investigated. Thus, we aimed to evaluate whether "holiday season" and "weekend" effects exist on mortality risk for stroke admission. Methods and Results A nationwide cohort study was conducted using Taiwan's National Health Insurance Research Database. We identified all patients admitted for stroke between 2011 and 2015 in Taiwan, and categorized them according to the admission date: holiday season (at least 4 days off) (n=3908), weekend (n=13 774), and weekday (n=49 045). We analyzed in-hospital, 7-day, and 30-day mortality using multivariable logistic regression, adjusting for stroke severity and other confounders. Compared with weekday admissions, holiday season admission for stroke was significantly associated with a 20%, 33%, and 21% increase in in-hospital, 7-day, and 30-day mortality, respectively. Compared with weekend admissions, holiday season admissions were associated with a 24%, 30%, and 22% increased risk of in-hospital, 7-day, and 30-day mortality, respectively. However, mortality did not differ significantly between weekend and weekday admissions. Subanalyses after stratification for age, sex, and stroke type also revealed similar trends. Conclusions We report for the first time a "holiday season effect" on stroke mortality. Patients admitted during holiday seasons had higher mortality risks than those admitted on weekends and weekdays. This holiday season effect persisted even after adjusting for stroke severity and other important confounders. These findings highlight the need for healthcare delivery systems with a consistent quality of round-the-clock care for patients admitted for stroke.
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Affiliation(s)
- Huei-Kai Huang
- 1 Department of Family Medicine Buddhist Tzu Chi General Hospital Hualien Taiwan
| | - Wei-Chuan Chang
- 2 Department of Medical Research Buddhist Tzu Chi General Hospital Hualien Taiwan
| | - Jin-Yi Hsu
- 3 Department of Neurology Buddhist Tzu Chi General Hospital Hualien Taiwan
| | - Jen-Hung Wang
- 2 Department of Medical Research Buddhist Tzu Chi General Hospital Hualien Taiwan
| | - Pin-Sung Liu
- 5 Center for Aging and Health Buddhist Tzu Chi General Hospital Hualien Taiwan
| | - Shu-Man Lin
- 4 Department of Physical Medicine and Rehabilitation Buddhist Tzu Chi General Hospital Hualien Taiwan
| | - Ching-Hui Loh
- 5 Center for Aging and Health Buddhist Tzu Chi General Hospital Hualien Taiwan
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Melnychuk M, Morris S, Black G, Ramsay AIG, Eng J, Rudd A, Baim-Lance A, Brown MM, Fulop NJ, Simister R. Variation in quality of acute stroke care by day and time of admission: prospective cohort study of weekday and weekend centralised hyperacute stroke unit care and non-centralised services. BMJ Open 2019; 9:e025366. [PMID: 31699710 PMCID: PMC6858222 DOI: 10.1136/bmjopen-2018-025366] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units compared with the rest of England. DESIGN Prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. SETTING Acute stroke services in London hyperacute stroke units and the rest of England. PARTICIPANTS 68 239 patients with a primary diagnosis of stroke admitted between January and December 2014. INTERVENTIONS Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. MAIN OUTCOME MEASURES 16 indicators of quality of acute stroke care, mortality at 3 days after admission to the hospital, disability at the end of the inpatient spell, length of stay. RESULTS There was no variation in quality of care by day and time of admission to the hospital across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor was there variation in 3-day mortality or disability at hospital discharge (all p values>0.05). Other quality of care measures significantly varied by day and time of admission across the week in London (all p values<0.01). In the rest of England there was variation in all measures by day and time of admission across the week (all p values<0.01), except for mortality at 3 days (p value>0.05). CONCLUSIONS The London hyperacute stroke unit model achieved performance standards for 'front door' stroke care across the week. The same benefits were not achieved by other models of care in the rest of England. There was no weekend effect for mortality in London or the rest of the England. Other aspects of care were not constant across the week in London hyperacute stroke units, indicating some performance standards were perceived to be more important than others.
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Affiliation(s)
- Mariya Melnychuk
- Department of Applied Health Research, University College London, London, UK
- Faculty of Law and Social Sciences, Universidad Rey Juan Carlos, Madrid, Spain
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Georgia Black
- Department of Applied Health Research, University College London, London, UK
| | - Angus I G Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Jeannie Eng
- Cancer Division, University College London Hospitals NHS Foundation Trust, London
| | - Anthony Rudd
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK
| | - Abigail Baim-Lance
- Institute for Implementation Science in Population Health, City University of New York, New York, USA
| | - Martin M Brown
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Robert Simister
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
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10
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Paley L, Williamson E, Bray BD, Hoffman A, James MA, Rudd AG. Associations Between 30-Day Mortality, Specialist Nursing, and Daily Physician Ward Rounds in a National Stroke Registry. Stroke 2019; 49:2155-2162. [PMID: 30354982 PMCID: PMC6116797 DOI: 10.1161/strokeaha.118.021518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Well-organized stroke care is associated with better patient outcomes, but the most important organizational factors are unknown. Methods— Data were extracted from the Sentinel Stroke National Audit Programme of adults with acute stroke treated in stroke hospitals in England and Wales between April 2013 and March 2015. Multilevel models with random intercepts for hospitals were used to estimate the association of each variable with 30-day mortality to estimate the impact of admission to differently organized hospitals. Results— Of the 143 578 patients with acute stroke admitted to 154 hospitals, 14.4% died within 30 days of admission. In adjusted analyses, admission to hospitals with higher ratios of nurses trained in swallow screening was associated with reduced odds of death (P=0.004), and admission to hospitals with daily physician ward rounds was associated with 10% lower odds of mortality compared with less-frequent ward rounds (95% CI, 0.82–0.98; P=0.013). Number of stroke admissions and overall ratio of registered nurses on duty at weekends were not found to be independently associated with mortality after adjustment for other factors. Conclusions— If these associations are causal, an extra 1332 deaths annually in England and Wales could be saved by hospitals providing care associated with a ratio of nurses trained in swallow screening of at least 3 per 10 beds and daily stroke physician ward rounds.
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Affiliation(s)
- Lizz Paley
- From the Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, United Kingdom (L.P., A.H.)
| | - Elizabeth Williamson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (E.W.)
| | - Benjamin D Bray
- School of Population Health and Environmental Sciences, King's College London, United Kingdom (B.D.B., A.G.R.)
| | - Alex Hoffman
- From the Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, United Kingdom (L.P., A.H.)
| | - Martin A James
- Royal Devon and Exeter NHS Foundation Trust, United Kingdom (M.A.J.)
| | - Anthony G Rudd
- School of Population Health and Environmental Sciences, King's College London, United Kingdom (B.D.B., A.G.R.)
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Optimal Hospital and Surgeon Volume Thresholds to Improve 30-Day Readmission Rates, Costs, and Length of Stay for Total Hip Replacement. J Arthroplasty 2019; 34:1901-1908.e1. [PMID: 31133428 DOI: 10.1016/j.arth.2019.04.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/16/2019] [Accepted: 04/23/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Little is known about whether there are optimal hospital and surgeon volume thresholds to reduce readmission, costs, and length of stay (LOS) for total hip replacement (THR). Nationwide population-based data were applied to identify the optimal hospital and surgeon volume thresholds and to discover the effects of these volume thresholds on 30-day unplanned readmission, costs and LOS for THR. METHODS A total of 6367 patients identified through Taiwan's National Health Insurance Research Database received THR in 2012. Restricted cubic splines were used to identify the optimal hospital and surgeon volume needed to decrease the risk of 30-day unplanned readmission. Multilevel regression modeling and propensity score weighting were used to examine the impact of hospital and surgeon volume thresholds on 30-day unplanned readmission, costs, and LOS, after adjusting for patient, surgeon, and hospital characteristics. RESULTS The volume thresholds for hospitals and surgeons were 65 cases and 15 cases a year, respectively. The overall mean LOS was 7.3 ± 4.3 days. Patients who received THR from surgeons who did not reach the volume threshold had higher 30-day unplanned readmission rates, costs, and LOS than those who received THR from surgeons who reached the volume threshold. CONCLUSION This is the first study to identify the surgeon volume threshold that can reduce 30-day unplanned readmission rates, costs, and LOS for THR. However, the results from Taiwan may not be applicable to other parts of the world. Identifying the threshold could help patients, providers, and policymakers to make decisions regarding optimal delivery of THR.
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Angerer S, Buttinger K, Stummer H. The weekend effect revisited: evidence from the Upper Austrian stroke registry. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:729-737. [PMID: 30756194 DOI: 10.1007/s10198-019-01035-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/31/2019] [Indexed: 06/09/2023]
Abstract
Empirical evidence on the so-called 'weekend-effect' on stroke mortality is mixed with some studies reporting significantly higher mortality for weekend admissions and others finding no difference. The aim of this paper is to enhance the evidence on the weekend-effect on stroke mortality using a rich stroke registry data set from Upper Austria and to discuss underlying reasons for the heterogeneity in results. Using logistic regressions and ordinary least squares regressions with hospital and year-fixed effects, the outcomes of weekend versus weekday admissions are compared for patients admitted to 16 hospitals in Upper Austria with transient ischemic attack (TIA), cerebral infarction or hemorrhage between 2007 and 2015. The primary outcomes include in-hospital mortality, 30-day and 90-day all-cause mortality as well as the length of hospital stay. In addition, we analyze differences in process-quality indicators between weekdays and weekends. Our results show that on weekends there are on average 25% fewer admissions than on weekdays with significantly higher in-hospital mortality. Adjusting for case-mix, the association between weekend admissions and mortality becomes null suggesting that the higher mortality on weekends is explained by heterogeneities in admissions rather than health-care quality.
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Affiliation(s)
- Silvia Angerer
- UMIT, University for Health Sciences, Medical Informatics and Technology, Institute for Management and Economics in Healthcare, Eduard-Wallnöfer-Zentrum 1, 6060 Hall in Tirol, Austria
| | - Klaus Buttinger
- UMIT, University for Health Sciences, Medical Informatics and Technology, Institute for Management and Economics in Healthcare, Eduard-Wallnöfer-Zentrum 1, 6060 Hall in Tirol, Austria
- Salzkammergut Klinikum, Miller-von-Aichholz-Straße 49, 4810, Gmunden, Austria
| | - Harald Stummer
- UMIT, University for Health Sciences, Medical Informatics and Technology, Institute for Management and Economics in Healthcare, Eduard-Wallnöfer-Zentrum 1, 6060 Hall in Tirol, Austria.
- University Seeburg Castle, Institut für Gesundheitsmanagement und Innovation, Seeburgstraße 8, 5201, Seekirchen am Wallersee, Austria.
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Do Hospital and Physician Volume Thresholds for the Volume-Outcome Relationship in Heart Failure Exist? Med Care 2019; 57:54-62. [PMID: 30439795 DOI: 10.1097/mlr.0000000000001022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although volume-outcome relationships have been explored for various procedures and interventions, limited information is available concerning the effect of hospital and physician volume on heart failure mortality. Most importantly, little is known about whether there are optimal hospital and physician volume thresholds to reduce heart failure mortality. OBJECTIVES We used nationwide population-based data to identify the optimal hospital and physician volume thresholds to achieve optimum mortality and to examine the relative and combined effects of the volume thresholds on heart failure mortality. METHODS We analyzed all 20,178 heart failure patients admitted in 2012 through Taiwan's National Health Insurance Research Database. Restricted cubic splines and multilevel logistic regression were used to identify whether there are optimal hospital and physician volume thresholds and to assess the relative and combined relationships of the volume thresholds to 30-day mortality, adjusted for patient, physician, and hospital characteristics. RESULTS Hospital and physician volume thresholds of 40 cases and 15 cases a year, respectively, were identified, under which there was an increased risk of 30-day mortality. Patients treated by physicians with previous annual volumes <15 cases had higher 30-day mortality compared with those with previous annual volumes ≥15 cases, and the relationship was stronger in hospitals with previous annual volumes <40 cases. CONCLUSIONS This is the first study to identify both the hospital and physician volume thresholds that lead to decreases in heart failure mortality. Identifying the hospital and physician volume thresholds could be applied to quality improvement and physician training.
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Yu TH, Chou YY, Tung YC. Should we pay attention to surgeon or hospital volume in total knee arthroplasty? Evidence from a nationwide population-based study. PLoS One 2019; 14:e0216667. [PMID: 31075135 PMCID: PMC6510420 DOI: 10.1371/journal.pone.0216667] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/25/2019] [Indexed: 11/18/2022] Open
Abstract
Background Although prior research into the relationship between volume and outcome indicates that this relationship is not linear and that an optimal volume should be specified, consensus is lacking regarding the ideal value of this optimal volume. The purposes of this study were to use a visual method to identify surgeon- and hospital-volume thresholds and to examine the relationships of surgeon and hospital volume thresholds to 30-day readmission. Methods A retrospective nationwide population-based study design was adopted. Patients who received total knee replacement surgery between 2007 and 2008 in any hospital in Taiwan were included. After adjusting for patient, physician, and hospital characteristics, a restricted cubic spline regression model was used to identify optimal surgeon- and hospital-volume thresholds. Further, a patient-level mixed effect model was conducted to test the respective relationships between these thresholds and 30-day readmission. Results A total of 30,828 patients who had received their surgeries from 1,468 surgeons in 437 hospitals were included in this study. Thresholds of 50 cases a year for surgeons and 75 cases a year for hospitals were identified using a restricted cubic spline regression model. However, only the surgeon volume threshold was associated with 30-day readmission using a patient-level mixed effect model after adjusting for patient-, surgeon- and hospital-level covariates. Conclusions According to the results of the restricted cubic spline models, the optimal volume thresholds for surgeons and hospitals are 50 cases and 75 cases a year, respectively. However, only the surgeon volume threshold is associated with 30-day readmission.
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Affiliation(s)
- Tsung-Hsien Yu
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Ying-Yi Chou
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Yu-Chi Tung
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
- * E-mail:
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Cho KH, Nam CM, Lee SG, Kim TH, Lee SH, Park EC. Measuring of quality of care in patients with stroke and acute myocardial infarction: An application of algebra effectiveness model. Medicine (Baltimore) 2019; 98:e15353. [PMID: 31096434 PMCID: PMC6531128 DOI: 10.1097/md.0000000000015353] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Ischemic stroke, hemorrhagic stroke, and acute myocardial infarction (AMI) are diseases with golden hour. This study aimed to identify and compare factors that affect in-hospital mortality in patients with stroke and AMI who admitted via the emergency department.This study used the Korean National Health Insurance claims data from 2002 to 2013. The study sample included 7693 patients who had an ischemic stroke, 2828 patients who had a hemorrhagic stroke, and 4916 patients with AMI who were admitted via the emergency departments of a superior general hospital and general hospital, did not transfer to another hospital or come from another hospital, and were aged ≥20 years. This study was analyzed by using Cox's proportional hazards frailty model.Five hundred (6.5%) of 7693 patients with ischemic stroke, 569 (20.1%) of 2828 patients with hemorrhagic stroke, and 399 (8.1%) of 4916 patients with AMI were dead. The clinical factors were associated with in-hospital mortality such as age, CCI, hypertension, and diabetes of patient characteristics. In treatment characteristics, performing PCI and weekday admission was associated with in-hospital mortality (aHR, 0.43; 95% CI, 0.27-0.67; aHR, 1.42; 95% CI, 1.14-1.77, respectively). In hospital characteristics, the volume, the proportion of transferred patient to other hospital and ratio of beds per one nurse was associated with in-hospital mortality.Clinical factors of patient characteristics, intervention such as performing PCI and reducing ICP of treatment characteristics, and the volume, transferred rate, and the number of nurse of hospital characteristics were associated with in-hospital mortality.
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Affiliation(s)
- Kyoung Hee Cho
- Department of Public Health, Graduate School
- Institute of Health Services Research, College of Medicine
- Health Insurance Policy Research Insititue, National Health Insurance Service, Wonju
| | - Chung Mo Nam
- Institute of Health Services Research, College of Medicine
- Department of Biostatistics, College of Medicine
| | - Sang Gyu Lee
- Institute of Health Services Research, College of Medicine
- Graduate School of Public Health, Yonsei University, Seoul
| | - Tae Hyun Kim
- Institute of Health Services Research, College of Medicine
- Graduate School of Public Health, Yonsei University, Seoul
| | - Seon-Heui Lee
- Department of Nursing Science, College of Nursing, Gachon University, Incheon
| | - Eun-Cheol Park
- Institute of Health Services Research, College of Medicine
- Department of Preventive Medicine, College of Medicine, Yonsei University, Seoul, Korea
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Abstract
RATIONALE Physicians are increasingly being held accountable for patient outcomes, yet their specific contribution to the outcomes remains uncertain. OBJECTIVES To determine variation in outcomes of mechanically ventilated patients among intensivists, as well as associations between intensivist experience and patient outcomes. METHODS We performed a retrospective cohort study of mechanically ventilated Medicare fee-for-service patients in acute care hospitals in Pennsylvania using administrative, clinical, and physician data from Centers for Medicare and Medicaid Services and the American Medical Association from 2008 and 2009. We identified intensivists by training background, board certification, and claims for services provided to patients admitted to an intensive care unit. We assigned patients to intensivists for outcome attribution based on submitted claims for critical care and in-patient services. We estimated the physician-specific adjusted odds ratios (ORs) for 30-day mortality using a hierarchical model with a random effect for physician, adjusted for patient and hospital characteristics. We tested for independent association of physician experience with patient outcomes using mixed-effects regression for the primary outcome of 30-day mortality. We defined physician experience in two ways: years since training completion ("duration") and annual number of mechanically ventilated patients ("volume"). RESULTS We assigned 345 physicians to 11,268 patients. The 30-day mortality was 43% and median hospital length of stay was 11 days (interquartile range = 6-18). The physician adjusted OR varied from 0.72 to 1.64 (median = 0.99; interquartile range = 0.92-1.09). A total of 48% of physicians was outliers, with an adjusted OR significantly different from 1. However, among intensivists, physician experience was not associated with 30-day mortality (duration OR = 1.00 per additional year; 95% confidence interval = 1.00-1.01; volume OR = 1.00 per additional patient; 95% confidence interval = 1.00-1.00). CONCLUSIONS Intensivists independently contribute to outcomes of Medicare patients who undergo mechanical ventilation, as evidenced by the variation in risk-adjusted mortality across intensivists. However, physician experience does not underlie this relationship between intensivists, suggesting the need to identify modifiable physician factors to improve outcomes.
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Singh K, Wilson MSJ, Coats M. Does time of surgery influence the rate of false-negative appendectomies? A retrospective observational study of 274 patients. Patient Saf Surg 2018; 12:33. [PMID: 30564285 PMCID: PMC6293631 DOI: 10.1186/s13037-018-0180-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/05/2018] [Indexed: 01/20/2023] Open
Abstract
Background Multiple disciplines have described an “after-hours effect” relating to worsened mortality and morbidity outside regular working hours. This retrospective observational study aimed to evaluate whether diagnostic accuracy of a common surgical condition worsened after regular hours. Methods Electronic operative records for all non-infant patients (age > 4 years) operated on at a single centre for presumed acute appendicitis were retrospectively reviewed over a 56-month period (06/17/2012–02/01/2017). The primary outcome measure of unknown diagnosis was compared between those performed in regular hours (08:00–17:00) or off hours (17:01–07:59). Pre-clinical biochemistry and pre-morbid status were recorded to determine case heterogeneity between the two groups, along with secondary outcomes of length of stay and complication rate. Results Out of 289 procedures, 274 cases were deemed eligible for inclusion. Of the 133 performed in regular hours, 79% were appendicitis, compared to 74% of the 141 procedures performed off hours. The percentage of patients with an unknown diagnosis was 6% in regular hours compared to 15% off hours (RR 2.48; 95% CI 1.14–5.39). This was accompanied by increased numbers of registrars (residents in training) leading procedures off hours (37% compared to 24% in regular hours). Pre-morbid status, biochemistry, length of stay and post-operative complication rate showed no significant difference. Conclusions This retrospective study suggests that the rate of unknown diagnoses for acute appendicitis increases overnight, potentially reflecting increased numbers of unnecessary procedures being performed off hours due to poorer diagnostic accuracy. Reduced levels of staffing, availability of diagnostic modalities and changes to workforce training may explain this, but further prospective work is required. Potential solutions may include protocolizing the management of common acute surgical conditions and making more use of non-resident on call senior colleagues.
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Affiliation(s)
- Kirit Singh
- 1Department of General Surgery, Ninewells Hospital, NHS Tayside, Dundee, UK.,2Cardiff University, Cardiff, UK
| | - Michael S J Wilson
- 1Department of General Surgery, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Maria Coats
- 1Department of General Surgery, Ninewells Hospital, NHS Tayside, Dundee, UK
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Liao CH, Lu N, Tang CH, Chang HC, Huang KC. Assessing the relationship between healthcare market competition and medical care quality under Taiwan's National Health Insurance programme. Eur J Public Health 2018; 28:1005-1011. [PMID: 29873710 DOI: 10.1093/eurpub/cky099] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is still significant uncertainty as to whether market competition raises or lowers clinical quality in publicly funded healthcare systems. We attempted to assess the effects of market competition on inpatient care quality of stroke patients in a retrospective study of the universal single-payer health insurance system in Taiwan. METHODS In this 11-year population-based study, we conducted a pooled time-series cross-sectional analysis with a fixed-effects model and the Hausman test approach by utilizing two nationwide datasets: the National Health Insurance Research Database and the National Hospital and Services Survey in Taiwan. Patients who were admitted to a hospital for ischemic or hemorrhagic stroke were enrolled. After excluding patients with a previous history of stroke and those with different types of stroke, 247 379 ischemic and 79 741 hemorrhagic stroke patients were included in our analysis. Four outcome indicators were applied: the in-hospital mortality rate, 30-day post-operative complication rate, 14-day re-admission rate and 30-day re-admission rate. RESULTS Market competition exerted a negative or negligible effect on the medical care quality of stroke patients. Compared to hospitals located in a highly competitive market, in-hospital mortality rates for hemorrhagic stroke patients were significantly lower in moderately (β = -0.05, P < 0.01) and less competitive markets (β = -0.05, P < 0.01). Conversely, the impact of market competition on the quality of care of ischemic stroke patients was insignificant. CONCLUSIONS Simply fostering market competition might not achieve the objective of improving the quality of health care. Other health policy actions need to be contemplated.
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Affiliation(s)
- Chih-Hsien Liao
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
- The Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ning Lu
- Department of Health Administration, College of Health and Human Services, Governors State University, University Park, IL, USA
| | - Chao-Hsiun Tang
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Hui-Chih Chang
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Kuo-Cherh Huang
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
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Comparison of outcome in stroke patients admitted during working hours vs. off-hours; a single-center cohort study. J Neurol 2018; 266:782-789. [DOI: 10.1007/s00415-018-9079-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022]
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Poznanska A, Wojtyniak B, Chwojnicki K, Lewtak K, Rubikowska B, Seroka W. Cerebrovascular diseases in Poland-inconsistent seasonal patterns of hospitalisation and mortality. Eur J Public Health 2018; 28:376-381. [PMID: 29020302 DOI: 10.1093/eurpub/ckx133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background A seasonal variation in the incidence of cerebrovascular diseases still remains inconsistently evidenced. Herein, we analyse the monthly patterns of two health phenomena: hospital admissions and deaths due to these diseases. Methods We identified 69 511 cases of hospital admissions and 14 956 deaths due to cerebrovascular diseases (ICD10: I60-I69 and G45) among the inhabitants of five Polish voivodeship capitals in 2004-13. The method of time series analysis (exponential smoothing with linear trend and monthly additive seasonality) was applied to calculate the monthly specific seasonal indices. The monthly variation in an in-hospital fatality and nonhospital deaths were also analysed. Results A summer season reduction in number of cases was observed for hospital admissions and deaths. Interestingly, the winter season effect is much more complex, mainly due to the contribution of December, when a high mortality is accompanied by a substantial decrease in the hospitalisation level. This unique discrepancy was observed for all the studied cities. Moreover, this month is characterised by a notably high in-hospital fatality. However, neither the number of non-hospital deaths nor the average length of hospital stay or the kind of hospitalised diseases evidenced that cerebrovascular problems were more serious in December than in any other month. Conclusion The obtained results confirmed a seasonal variation in cerebrovascular diseases among the inhabitants of Polish cities. Habitual and administrative limitations in hospital activities observed every December do not seem indifferent from the patient health's perspective since they may lead to a low hospitalisation level and a high in-hospital fatality.
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Affiliation(s)
- Anna Poznanska
- Centre for Monitoring and Analyses of Population Health Status, National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
| | - Bogdan Wojtyniak
- Centre for Monitoring and Analyses of Population Health Status, National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
| | - Kamil Chwojnicki
- Department of Neurology, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Lewtak
- Department of Health Promotion and Postgraduate Education, National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
| | - Barbara Rubikowska
- Centre for Monitoring and Analyses of Population Health Status, National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
| | - Wojciech Seroka
- Centre for Monitoring and Analyses of Population Health Status, National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
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Lee CB, Chang YH, Wen PC, Li CY. Association of Failed Root Canal Treatment with Dentist and Institutional Volumes: A Population-based Cohort Study in Taiwan. J Endod 2017; 43:1628-1634. [PMID: 28756959 DOI: 10.1016/j.joen.2017.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/02/2017] [Accepted: 06/03/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Chiachi Bonnie Lee
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung, Taiwan
| | - Ya-Hui Chang
- Department and Graduate Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Pei-Chun Wen
- Department and Graduate Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Chung-Yi Li
- Department and Graduate Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan City, Taiwan.
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Tung YC, Chang GM, Chang HY, Yu TH. Relationship between Early Physician Follow-Up and 30-Day Readmission after Acute Myocardial Infarction and Heart Failure. PLoS One 2017; 12:e0170061. [PMID: 28129332 PMCID: PMC5271349 DOI: 10.1371/journal.pone.0170061] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 12/28/2016] [Indexed: 12/25/2022] Open
Abstract
Background Thirty-day readmission rates after acute myocardial infarction (AMI) and heart failure are important patient outcome metrics. Early post-discharge physician follow-up has been promoted as a method of reducing 30-day readmission rates. However, the relationships between early post-discharge follow-up and 30-day readmission for AMI and heart failure are inconclusive. We used nationwide population-based data to examine associations between 7-day physician follow-up and 30-day readmission, and further associations of 7-day same physician (during the index hospitalization and at follow-up) and cardiologist follow-up with 30-day readmission for non-ST-segment-elevation myocardial infarction (NSTEMI) or heart failure. Methods We analyzed all patients 18 years or older with NSTEMI and heart failure and discharged from hospitals in 2010 in Taiwan through Taiwan’s National Health Insurance Research Database. Cox proportional hazard models with robust sandwich variance estimates and propensity score weighting were performed after adjustment for patient and hospital characteristics to test associations between 7-day physician follow-up and 30-day readmission. Results The study population for NSTEMI and heart failure included 5,008 and 13,577 patients, respectively. Early physician follow-up was associated with a lower hazard ratio of readmission compared with no early physician follow-up for patients with NSTEMI (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.39–0.57), and for patients with heart failure (HR, 0.54; 95% CI, 0.48–0.60). Same physician follow-up was associated with a reduced hazard ratio of readmission compared with different physician follow-up for patients with NSTEMI (HR, 0.56; 95% CI, 0.48–0.65), and for patients with heart failure (HR, 0.69; 95% CI, 0.62–0.76). Conclusions For each condition, patients who have an outpatient visit with a physician within 7 days of discharge have a lower risk of 30-day readmission. Moreover, patients who have an outpatient visit with the same physician within 7 days of discharge have a much lower risk of 30-day readmission.
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Affiliation(s)
- Yu-Chi Tung
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Guann-Ming Chang
- Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Tsung-Hsien Yu
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- * E-mail:
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Choi EY, Kim SH, Ock M, Lee HJ, Son WS, Jo MW, Lee SI. Evaluation of the Validity of Risk-Adjustment Model of Acute Stroke Mortality for Comparing Hospital Performance. HEALTH POLICY AND MANAGEMENT 2016. [DOI: 10.4332/kjhpa.2016.26.4.359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Vedantam A, Hansen D, Briceño V, Moreno A, Ryan SL, Jea A. Interhospital transfer of pediatric neurosurgical patients. J Neurosurg Pediatr 2016; 18:638-643. [PMID: 27447345 DOI: 10.3171/2016.5.peds16155] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The purpose of this study was to describe patterns of transfer, resource utilization, and clinical outcomes associated with the interhospital transfer of pediatric neurosurgical patients. METHODS All consecutive, prospectively collected requests for interhospital patient transfer to the pediatric neurosurgical service at Texas Children's Hospital were retrospectively analyzed from October 2013 to September 2014. Demographic patient information, resource utilization, and outcomes were recorded and compared across predefined strata (low [< 5%], moderate [5%-30%], and high [> 30%]) of predicted probability of mortality using the Pediatric Risk of Mortality score. RESULTS Requests for pediatric neurosurgical care comprised 400 (3.7%) of a total of 10,833 calls. Of 400 transfer admissions, 96.5%, 2.8%, and 0.8% were in the low, moderate, and high mortality risk groups, respectively. The median age was 54 months, and 45% were female. The median transit time was 125 minutes. The majority of transfers were after-hours (69.8%); nearly a third occurred during the weekend (32.3%). The median intensive care unit stay for 103 patients was 3 days (range 1-269 days). Median length of hospital stay was 2 days (range 1-269 days). Ninety patients (22.5%) were discharged from the emergency room after transfer. Seventy-seven patients (19.3%) required neurosurgical intervention after transfer, with the majority requiring a cranial procedure (66.2%); 87.3% of patients were discharged home. CONCLUSIONS This study highlights patient characteristics, resource utilization, and outcomes among pediatric neurosurgical patients. Opportunities for quality improvement were identified in diagnosing and managing isolated skull fractures and neck pain after trauma.
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Affiliation(s)
- Aditya Vedantam
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Daniel Hansen
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Valentina Briceño
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Amee Moreno
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sheila L Ryan
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Andrew Jea
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Huang HL, Kung CY, Pan CC, Kung PT, Wang SM, Chou WY, Tsai WC. Comparing the mortality risks of nursing professionals with diabetes and general patients with diabetes: a nationwide matched cohort study. BMC Public Health 2016; 16:1054. [PMID: 27716138 PMCID: PMC5053173 DOI: 10.1186/s12889-016-3734-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/30/2016] [Indexed: 11/10/2022] Open
Abstract
Background Nursing professionals have received comprehensive medical education and training. However, whether these medical professionals exhibit positive patient care attitudes and behaviors and thus reduce mortality risks when they themselves are diagnosed with chronic diseases is worth exploring. This study compared the mortality risks of female nurses and general patients with diabetes and elucidated factors that caused this difference. Methods A total of 510,058 female patients newly diagnosed with diabetes between 1998 and 2006 as recorded in the National Health Insurance Research Database were the participants in this study. Nurses with diabetes and general population with diabetes were matched with propensity score method in a 1:10 ratio. The participants were tracked from the date of diagnosis to 2009. The Cox proportional hazards model was utilized to compare the mortality risks in the two groups. Results Nurses were newly diagnosed with diabetes at a younger age compared with the general public (42.01 ± 12.03 y vs. 59.29 ± 13.11 y). Nevertheless, the matching results showed that nurses had lower mortality risks (HR: 0.53, 95 % CI: 0.38–0.74) and nurses with diabetes in the < 35 and 35–44 age groups exhibited significantly lower mortality risks compared with general patients (HR: 0.23 and 0.36). A further analysis indicated that the factors that influenced the mortality risks of nurses with diabetes included age, catastrophic illnesses, and the severity of diabetes complications. Conclusion Nurses with diabetes exhibited lower mortality risks possibly because they had received comprehensive medical education and training, may had more knowledge regarding chronic disease control and change their lifestyles. The results can serve as a reference for developing heath education, and for preventing occupational hazards in nurses.
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Affiliation(s)
- Hsiu-Ling Huang
- Department of Aged Welfare and Social Work, Toko University, Taiwan, Republic Of China.,Department of Public Health and Department of Health Services Administration, China Medical University, Taiwan, Republic Of China
| | - Chuan-Yu Kung
- Department of Nursing, Hengchun Tourism Hospital, Ministry of Health and Welfare, Taiwan, Republic Of China
| | - Cheng-Chin Pan
- Department of Urology, Hengchun Tourism Hospital, Ministry of Health and Welfare, Taiwan, Republic Of China
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, Taichung, Taiwan, Republic Of China
| | - Shun-Mu Wang
- Department of Aged Welfare and Social Work, Toko University, Taiwan, Republic Of China
| | - Wen-Yu Chou
- Department of Health Services Administration, China Medical University, 91, Hsueh-Shih Road, Taichung, Taiwan, 40402, Republic Of China
| | - Wen-Chen Tsai
- Department of Health Services Administration, China Medical University, 91, Hsueh-Shih Road, Taichung, Taiwan, 40402, Republic Of China.
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Starr JB, Becker KJ, Tirschwell DL. Weekend Discharge and Stroke Quality of Care: Get With The Guidelines-Stroke Data from a Comprehensive Stroke Center. J Stroke Cerebrovasc Dis 2016; 25:2962-2967. [PMID: 27599907 DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/26/2016] [Accepted: 08/07/2016] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Get With The Guidelines-Stroke collects data on hospital compliance with evidence-based stroke quality of care indicators. Prior work has investigated a link between weekend hospital admission and increased mortality after stroke. There is, however, a paucity of work investigating a similar association between weekend hospital discharge and quality of care. We aimed to determine if weekend discharge affects care to enlighten opportunities for quality improvement. MATERIALS AND METHODS Through a retrospective analysis of records from a Comprehensive Stroke Center from July 2010 to June 2015, we identified patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Our quality of care indicators were dysphagia screening, rehabilitation assessment, smoking cessation counseling, stroke education, and weight reduction counseling. We created regression models to find adjusted differences in quality of care measure compliance for patients discharged on the weekend. RESULTS Our analysis included 2737 patients, of which 431 were discharged on the weekend. After adjustment, weekend discharge was significantly associated with reduced stroke education (odds ratio .67, confidence interval .51-0.88, P = .004) and reduced weight reduction counseling (odds ratio .65, confidence interval .45-0.93, P = .018). CONCLUSIONS Hospital discharge on the weekend was associated with an adjusted one-third decrease in odds of stroke education and weight reduction counseling. There is an opportunity for quality improvement in educating stroke patients before hospital discharge on the weekend.
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Affiliation(s)
- Jordan B Starr
- Department of Anesthesiology and Pain Medicine, University of Washington Seattle, Washington.
| | - Kyra J Becker
- Department of Neurology, University of Washington, Seattle, Washington
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Hsieh CY, Lin HJ, Chen CH, Li CY, Chiu MJ, Sung SF. "Weekend effect" on stroke mortality revisited: Application of a claims-based stroke severity index in a population-based cohort study. Medicine (Baltimore) 2016; 95:e4046. [PMID: 27336904 PMCID: PMC4998342 DOI: 10.1097/md.0000000000004046] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Previous studies have yielded inconsistent results on whether weekend admission is associated with increased mortality after stroke, partly because of differences in case mix. Claims-based studies generally lack sufficient information on disease severity and, thus, suffer from inadequate case-mix adjustment. In this study, we examined the effect of weekend admission on 30-day mortality in patients with ischemic stroke by using a claims-based stroke severity index.This was an observational study using a representative sample of the National Health Insurance claims data linked to the National Death Registry. We identified patients hospitalized for ischemic stroke, and examined the effect of weekend admission on 30-day mortality with vs without adjustment for stroke severity by using multilevel logistic regression analysis adjusting for patient-, physician-, and hospital-related factors. We analyzed 46,007 ischemic stroke admissions, in which weekend admissions accounted for 23.0%. Patients admitted on weekends had significantly higher 30-day mortality (4.9% vs 4.0%, P < 0.001) and stroke severity index (7.8 vs 7.4, P < 0.001) than those admitted on weekdays. In multivariate analysis without adjustment for stroke severity, weekend admission was associated with increased 30-day mortality (odds ratio (OR), 1.20; 95% confidence interval [CI], 1.08-1.34). This association became null after adjustment for stroke severity (OR, 1.07; 95% CI, 0.95-1.20).The "weekend effect" on stroke mortality might be attributed to higher stroke severity in weekend patients. While claims data are useful for examining stroke outcomes, adequate adjustment for stroke severity is warranted.
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Affiliation(s)
| | | | - Chih-Hung Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan
- Department of Public Health, China Medical University, Taichung
| | - Meng-Jun Chiu
- Department of Public Health, College of Medicine, Tainan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi City
- Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
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Adil MM, Vidal G, Beslow LA. Weekend Effect in Children With Stroke in the Nationwide Inpatient Sample. Stroke 2016; 47:1436-43. [DOI: 10.1161/strokeaha.116.013453] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 03/18/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Malik M. Adil
- From the Department of Neurology, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA (M.M.A., G.V.); and Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, CT (L.A.B.)
| | - Gabriel Vidal
- From the Department of Neurology, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA (M.M.A., G.V.); and Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, CT (L.A.B.)
| | - Lauren A. Beslow
- From the Department of Neurology, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA (M.M.A., G.V.); and Departments of Pediatrics and Neurology, Yale University School of Medicine, New Haven, CT (L.A.B.)
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Tung YC, Chang GM. The Relationships Among Regionalization, Processes, and Outcomes for Stroke Care: A Nationwide Population-based Study. Medicine (Baltimore) 2016; 95:e3327. [PMID: 27082581 PMCID: PMC4839825 DOI: 10.1097/md.0000000000003327] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Regionalization for stroke care, including stroke center designation, is being implemented in the United States, Canada, or other countries. Limited information is available, however, concerning the relationships among regionalization, processes, and outcomes for stroke care. We examined the association of regionalization with processes and outcomes, and the mediating effect of processes of care on the association between regionalization and mortality for acute stroke in Taiwan. We analyzed all 229,568 admissions with acute ischemic stroke from January 2004 to September 2012 through Taiwan's National Health Insurance Research Database. Regionalized care for acute stroke has been implemented since July 2009 in Taiwan. Rates of thrombolytic therapy within 3 hours after onset of ischemic stroke, average numbers of processes of care, and 30-day mortality rates at monthly intervals for baseline (66 months) and 39 months after the implementation of regionalization. After accounting for secular trends and other confounders, changes in rates of thrombolytic therapy (level change 0.269% per month, P = 0.017 and trend change 0.010% per month, P = 0.048), average numbers of processes of care (trend change 0.001 per month, P = 0.030), and 30-day mortality rates (level change -0.442% per month, P = 0.007 and trend change -0.021% per month, P = 0.015) were attributable to regionalization. The processes of care were mediators of the association between regionalization and 30-day mortality after stroke. Regionalization for stroke care may improve timeliness and processes of stroke care, including access to timely thrombolytic therapy from emergency medical services to hospital care, which may in turn enhance stroke outcomes.
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Affiliation(s)
- Yu-Chi Tung
- From the Institute of Health Policy and Management, National Taiwan University (Y-CT), Taipei; and Department of Family Medicine, Cardinal Tien Hospital; and School of Medicine, Fu Jen Catholic University (G-MC), New Taipei City, Taiwan
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Tung YC, Hsu YH, Chang GM. The Effect of Anesthetic Type on Outcomes of Hip Fracture Surgery: A Nationwide Population-Based Study. Medicine (Baltimore) 2016; 95:e3296. [PMID: 27057897 PMCID: PMC4998813 DOI: 10.1097/md.0000000000003296] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hip fractures are a global public health problem. During surgery following hip fractures, both general and regional anesthesia are used, but which type of anesthesia offers a better outcome remains controversial. There has been little research evaluating different anesthetic types on mortality and readmission rates for hip fracture surgery using nationwide population-based data.We used nationwide population-based data to examine the effect of anesthetic type on mortality and readmission rates for hip fracture surgery.Retrospective observational study.General acute care hospitals throughout Taiwan.A total of 17,189 patients hospitalized for hip fracture surgery in 2011.Generalized estimating equation models with propensity score weighting were performed after adjustment for patient, surgeon, and hospital characteristics to examine the associations of anesthesia type with 30-day all-cause mortality, 30-day all-cause readmission, and 30-day specific-cause readmission (including surgical site infection, sepsis, acute respiratory failure, acute stroke, acute myocardial infarction, acute renal failure, deep vein thrombosis, pneumonia, and urinary tract infection).Of 17,189 patients, 11,153 (64.9%) received regional anesthesia and 6036 (35.1%) received general anesthesia. Overall, the 30-day mortality rate was 1.7%, and the 30-day readmission rate was 12.3%. Regional anesthesia was not associated with decreased 30-day all-cause mortality (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.67-1.18, P = 0.409), but associated with decreased 30-day all-cause readmission and surgical site infection readmission relative to general anesthesia (OR 0.83, 95% CI 0.75-0.93, P = 0.001 and OR 0.69, 95% CI 0.49-0.97, P = 0.031).Regional anesthesia is not associated with 30-day mortality, but is associated with lower 30-day all-cause and surgical site infection readmission compared with general anesthesia for hip fracture surgery.
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Affiliation(s)
- Yu-Chi Tung
- From the Institute of Health Policy and Management (Y-CT), Institute of Health Policy and Management, National Taiwan University, Taipei (Y-HH), Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan (Y-HH), Department of Family Medicine, Cardinal Tien Hospital, New Taipei City (G-MC), and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G-MC)
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Desai V, Gonda D, Ryan SL, Briceño V, Lam SK, Luerssen TG, Syed SH, Jea A. The effect of weekend and after-hours surgery on morbidity and mortality rates in pediatric neurosurgery patients. J Neurosurg Pediatr 2015; 16:726-31. [PMID: 26406160 DOI: 10.3171/2015.6.peds15184] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Several studies have indicated that the 30-day morbidity and mortality risks are higher among pediatric and adult patients who are admitted on the weekends. This "weekend effect" has been observed among patients admitted with and for a variety of diagnoses and procedures, including myocardial infarction, pulmonary embolism, ruptured abdominal aortic aneurysm, stroke, peptic ulcer disease, and pediatric surgery. In this study, morbidity and mortality outcomes for emergency pediatric neurosurgical procedures carried out on the weekend or after hours are compared with emergency surgical procedures performed during regular weekday business hours. METHODS A retrospective analysis of operative data was conducted. Between December 1, 2011, and August 20, 2014, a total of 710 urgent or emergency neurosurgical procedures were performed at Texas Children's Hospital in children younger than than 18 years of age. These procedures were then stratified into 3 groups: weekday regular hours, weekday after hours, and weekend hours. By cross-referencing these events with a prospectively collected morbidity and mortality database, the impact of the day and time on complication incidence was examined. Outcome metrics were compared using logistic regression models. RESULTS The weekday regular hours and after-hours (weekday after hours and weekends) surgery groups consisted of 341 and 239 patients and 434 and 276 procedures, respectively. There were no significant differences in the types of cases performed (p = 0.629) or baseline preoperative health status as determined by American Society of Anesthesiologists classifications (p = 0.220) between the 2 cohorts. After multivariate adjustment and regression, children undergoing emergency neurosurgical procedures during weekday after hours or weekends were more likely to experience complications (p = 0.0227). CONCLUSIONS Weekday after-hours and weekend emergency pediatric neurosurgical procedures are associated with significantly increased 30-day morbidity and mortality risk compared with procedures performed during weekday regular hours.
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Affiliation(s)
- Virendra Desai
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - David Gonda
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sheila L Ryan
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Valentina Briceño
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Thomas G Luerssen
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sohail H Syed
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Andrew Jea
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Cho KH, Park EC, Nam CM, Choi Y, Shin J, Lee SG. Effect of Weekend Admission on In-Hospital Mortality in Patients with Ischemic Stroke: An Analysis of Korean Nationwide Claims Data from 2002 to 2013. J Stroke Cerebrovasc Dis 2015; 25:419-27. [PMID: 26654666 DOI: 10.1016/j.jstrokecerebrovasdis.2015.10.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/06/2015] [Accepted: 10/17/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Studies conducted on patients with stroke in countries other than Korea demonstrated a phenomenon known as the weekend effect on 7-day, 30-day, and in-hospital mortalities. We studied patients with stroke using nationwide cohort data to determine if there was a weekend effect on mortality in a Korean population. METHODS Nationwide cohort data, collected from 2002 to 2013, were searched for all hospitalizations via the emergency department due to ischemic stroke. Cox's proportional hazards frailty model was employed, and we adjusted for all patient and hospital characteristics. RESULTS There were 8957 patients with ischemic stroke admitted via the emergency department: 2632 weekend admissions and 6325 weekday admissions. Of these, 478 (5.3%) patients were dead. After adjusting for patient and hospital characteristics, the frailty model analysis revealed significantly higher in-hospital mortality in patients admitted on weekends than in those admitted on weekdays (hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.01-1.47). We obtained consistent results for the 30-day mortality findings (HR, 1.27; 95% CI, 1.04-1.55). However, no significant differences were observed in the 7-day mortality (HR, 1.13; 95% CI, .88-1.45). CONCLUSIONS Weekend admission for ischemic stroke was significantly associated with higher in-hospital and 30-day mortality after adjusting for individual characteristics and hospital factors.
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Affiliation(s)
- Kyoung Hee Cho
- Department of Public Health, Graduate School, Yonsei University, Republic of Korea; Institute of Health Services Research, College of Medicine, Yonsei University, Republic of Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, College of Medicine, Yonsei University, Republic of Korea; Department of Preventive Medicine, College of Medicine, Yonsei University, Republic of Korea
| | - Chung Mo Nam
- Institute of Health Services Research, College of Medicine, Yonsei University, Republic of Korea; Department of Biostatistics, College of Medicine, Yonsei University, Republic of Korea
| | - Young Choi
- Department of Public Health, Graduate School, Yonsei University, Republic of Korea; Institute of Health Services Research, College of Medicine, Yonsei University, Republic of Korea
| | - Jaeyong Shin
- Institute of Health Services Research, College of Medicine, Yonsei University, Republic of Korea; Department of Preventive Medicine, College of Medicine, Yonsei University, Republic of Korea
| | - Sang Gyu Lee
- Institute of Health Services Research, College of Medicine, Yonsei University, Republic of Korea; Graduate School of Public Health, Yonsei University, Republic of Korea.
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Variation in Risk-Standardized Mortality of Stroke among Hospitals in Japan. PLoS One 2015; 10:e0139216. [PMID: 26444695 PMCID: PMC4596625 DOI: 10.1371/journal.pone.0139216] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/10/2015] [Indexed: 11/19/2022] Open
Abstract
Despite recent advances in care, stroke remains a life-threatening disease. Little is known about current hospital mortality with stroke and how it varies by hospital in a national clinical setting in Japan. Using the Diagnosis Procedure Combination database (a national inpatient database in Japan), we identified patients aged ≥ 20 years who were admitted to the hospital with a primary diagnosis of stroke within 3 days of stroke onset from April 2012 to March 2013. We constructed a multivariable logistic regression model to predict in-hospital death for each patient with patient-level factors, including age, sex, type of stroke, Japan Coma Scale, and modified Rankin Scale. We defined risk-standardized mortality ratio as the ratio of the actual number of in-hospital deaths to the expected number of such deaths for each hospital. A hospital-level multivariable linear regression was modeled to analyze the association between risk-standardized mortality ratio and hospital-level factors. We performed a patient-level Cox regression analysis to examine the association of in-hospital death with both patient-level and hospital-level factors. Of 176,753 eligible patients from 894 hospitals, overall in-hospital mortality was 10.8%. The risk-standardized mortality ratio for stroke varied widely among the hospitals; the proportions of hospitals with risk-standardized mortality ratio categories of ≤ 0.50, 0.51-1.00, 1.01-1.50, 1.51-2.00, and >2.00 were 3.9%, 47.9%, 41.4%, 5.2%, and 1.5%, respectively. Academic status, presence of a stroke care unit, higher hospital volume and availability of endovascular therapy had a significantly lower risk-standardized mortality ratio; distance from the patient's residence to the hospital was not associated with the risk-standardized mortality ratio. Our results suggest that stroke-ready hospitals play an important role in improving stroke mortality in Japan.
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Lee DS, Chung CR, Jeon K, Park CM, Suh GY, Song YB, Hahn JY, Choi SH, Choi JH, Gwon HC, Yang JH. Survival After Extracorporeal Cardiopulmonary Resuscitation on Weekends in Comparison With Weekdays. Ann Thorac Surg 2015; 101:133-40. [PMID: 26431921 DOI: 10.1016/j.athoracsur.2015.06.077] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/06/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) requires urgent decision-making and high-quality skills, which may not be uniformly available throughout the week. Few data exist on the outcomes of patients with cardiac arrest who receive in-hospital ECPR on the weekday versus weekend. Therefore, we investigated whether the outcome differed when patients with in-hospital cardiac arrest received ECPR during the weekend compared with a weekday. METHODS Two hundred patients underwent extracorporeal membrane oxygenation after in-hospital cardiac arrest between January 2004 and December 2013. Patients treated between 0800 on Monday to 1759 on Friday were considered to receive weekday care and patients treated between 1800 on Friday through 0759 on Monday were considered to receive weekend care. RESULTS A total of 135 cases of ECPR for in-hospital cardiac arrest occurred during the weekday (64 during daytime hours and 71 during nighttime hours), and 65 cases occurred during the weekend (39 during daytime/evening hours and 26 during nighttime hours). Rates of survival to discharge were higher with weekday care than with weekend care (35.8% versus 21.5%, p = 0.041). Cannulation failure was more frequent in the weekend group (1.5% versus 7.7%, p = 0.038). Complication rates were higher on the weekend than on the weekday, including cannulation site bleeding (3.0% versus 10.8%, p = 0.041), limb ischemia (5.9% versus 15.6%, p = 0.026), and procedure-related infections (0.7% versus 9.2%, p = 0.005). CONCLUSIONS ECPR on the weekend was associated with a lower survival rate and lower resuscitation quality, including higher cannulation failure and higher complication rate.
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Affiliation(s)
- Dae-Sang Lee
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Inoue T, Fushimi K. Weekend versus Weekday Admission and In-Hospital Mortality from Ischemic Stroke in Japan. J Stroke Cerebrovasc Dis 2015; 24:2787-92. [PMID: 26365617 DOI: 10.1016/j.jstrokecerebrovasdis.2015.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/29/2015] [Accepted: 08/09/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The initial treatment of acute ischemic stroke critically affects patient outcome. Patient outcome may also be associated with the day of hospital admission due to differences in the number of the hospital staff between weekdays and weekends. We aimed to assess the effect of weekend admission on in-hospital mortality among patients with ischemic stroke in Japan. METHODS We analyzed patients with ischemic stroke from a large nationwide administrative dataset. The patients were grouped according to the treatment ward to which they were initially admitted: a general medical ward (GMW) or an intensive or stroke care unit (S-ICU). The primary outcome, in-hospital mortality, was compared between the patients admitted on a weekday versus weekend according to the initial treatment ward. A generalized estimated equation was applied for multivariate analysis. RESULTS In total, 47,885 patients were included in the study. Of these patients, 32.0% were admitted to an S-ICU and 27.8% were admitted to a GMW on a weekend. The estimated in-hospital mortality rate was significantly higher among the patients admitted to a GMW on a weekend compared with those admitted on a weekday (7.9% versus 7.0%), but this difference was not significant after adjusting for the patients' background characteristics. The estimated in-hospital mortality rates of the patients admitted to an S-ICU were similar between weekend and weekday admissions (10.0% versus 9.9%). CONCLUSIONS No significant effect of weekend admission in-hospital mortality was observed in our study population regardless of the initial treatment ward.
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Affiliation(s)
- Takahiro Inoue
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Japan.
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Yu TH, Tung YC, Chung KP. Does Categorization Method Matter in Exploring Volume-Outcome Relation? A Multiple Categorization Methods Comparison in Coronary Artery Bypass Graft Surgery Surgical Site Infection. Surg Infect (Larchmt) 2015; 16:466-72. [PMID: 26069929 DOI: 10.1089/sur.2014.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Volume-infection relation studies have been published for high-risk surgical procedures, although the conclusions remain controversial. Inconsistent results may be caused by inconsistent categorization methods, the definitions of service volume, and different statistical approaches. The purpose of this study was to examine whether a relation exists between provider volume and coronary artery bypass graft (CABG) surgical site infection (SSI) using different categorization methods. METHODS A population-based cross-sectional multi-level study was conducted. A total of 10,405 patients who received CABG surgery between 2006 and 2008 in Taiwan were recruited. The outcome of interest was surgical site infection for CABG surgery. The associations among several patient, surgeon, and hospital characteristics was examined. The definition of surgeons' and hospitals' service volume was the cumulative CABG service volumes in the previous year for each CABG operation and categorized by three types of approaches: Continuous, quartile, and k-means clustering. RESULTS The results of multi-level mixed effects modeling showed that hospital volume had no association with SSI. Although the relation between surgeon volume and surgical site infection was negative, it was inconsistent among the different categorization methods. CONCLUSIONS Categorization of service volume is an important issue in volume-infection study. The findings of the current study suggest that different categorization methods might influence the relation between volume and SSI. The selection of an optimal cutoff point should be taken into account for future research.
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Affiliation(s)
- Tsung-Hsien Yu
- Institute of Health Policy and Management, National Taiwan University , Taipei, Taiwan
| | - Yu-Chi Tung
- Institute of Health Policy and Management, National Taiwan University , Taipei, Taiwan
| | - Kuo-Piao Chung
- Institute of Health Policy and Management, National Taiwan University , Taipei, Taiwan
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Tung YC, Jeng JS, Chang GM, Chung KP. Processes and outcomes of ischemic stroke care: the influence of hospital level of care. Int J Qual Health Care 2015; 27:260-6. [DOI: 10.1093/intqhc/mzv038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2015] [Indexed: 11/14/2022] Open
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Tung YC, Chang GM, Cheng SH. Long-Term Effect of Fee-For-Service–Based Reimbursement Cuts on Processes and Outcomes of Care for Stroke. Circ Cardiovasc Qual Outcomes 2015; 8:30-7. [DOI: 10.1161/circoutcomes.114.001086] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yu-Chi Tung
- From the Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan (Y.-C.T., S.-H.C.); Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan (G.-M.C.); and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G.-M.C.)
| | - Guann-Ming Chang
- From the Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan (Y.-C.T., S.-H.C.); Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan (G.-M.C.); and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G.-M.C.)
| | - Shou-Hsia Cheng
- From the Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan (Y.-C.T., S.-H.C.); Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan (G.-M.C.); and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G.-M.C.)
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Factors influencing surgical delay after hip fracture in hospitals of Emilia Romagna Region, Italy: a multilevel analysis. Hip Int 2014; 23:15-21. [PMID: 23397198 DOI: 10.5301/hip.2013.10717] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2012] [Indexed: 02/04/2023]
Abstract
Hip fracture is becoming a major public health concern, with associated mortality and morbidity particularly in the elderly. This study aims to investigate factors (i.e. patient factors and hospital variables) associated with increased risk for delaying surgery after hip fractures, and to assess whether and to what extent timing was associated with mortality risk. All patients aged 65 and over, resident in Emilia Romagna Region (Italy) and admitted to hospital for hip fracture (2009 - 2010) were selected. Data on surgical delay were adjusted using multilevel logistic regression model. A Cox proportional hazard model was fitted to a propensity score matched sample to assess mortality between delayed and early treated patients. Of the 10, 995 patients included (mean age: 83.3 years), 44.9% underwent surgery within 2 days. Significant risk factors for delayed surgery were: gender (OR: 1.16), comorbidity (OR: 1.29), anticoagulant (OR: 7.64) ,antiplatelet medication (OR: 2.43) , type of procedure (OR: 1.37) and day of admission (OR: Thu-Fri: 6.05; Sat-Sun: 1.17). Type of hospital and annual volume of hip fracture surgeries were not sufficient to explain hospital variability. A significant difference in mortality rate between early and delayed surgery emerged six months post surgery.
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Kristiansen NS, Mainz J, Nørgård BM, Bartels PD, Andersen G, Johnsen SP. Off-hours admission and acute stroke care quality: a nationwide study of performance measures and case-fatality. Stroke 2014; 45:3663-9. [PMID: 25378421 DOI: 10.1161/strokeaha.114.005535] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Studies have reported higher risks of death and other adverse outcomes in acute stroke patients admitted off-hours; however, little is known about the underlying mechanisms. According to time of admission, our aim was to examine compliance with performance measures for acute stroke care processes, including the effect of a systematic quality improvement program, and to examine 30 days case-fatality. METHODS A population-based historical cohort study, including patients admitted to Danish hospitals with a first ever acute stroke (January 1, 2003, to December 31, 2011; N=64 975). Off-hours were weekends and evening and nighttime shifts on weekdays. Compliance with performance measures was compared using general linear modeling, and odds ratios for 30 days case-fatality were obtained using multivariable logistic regression. RESULTS Patients admitted off-hours had a lower chance of compliance with 8 out of 10 performance measures; however, these differences diminished over time. Unadjusted odds ratio for 30 days case-fatality, for patients admitted off-hours compared with patients admitted on-hours, was 1.15 (95% confidence interval, 1.09-1.21). Adjusting for patient characteristics (in particular, stroke severity) decreased the odds ratio to 1.03 (95% confidence interval, 0.97-1.10). Additional adjustment for hospital characteristics and compliance with performance measures had no effect on the odds ratio. CONCLUSION Patients admitted off-hours received a poorer quality of care. However, the admission time-related differences in care were substantially reduced over time, and the differences in 30 days case-fatality appeared primarily to be explained by differences in stroke severity.
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Affiliation(s)
- Nina Sahlertz Kristiansen
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark.
| | - Jan Mainz
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark
| | - Bente Mertz Nørgård
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark
| | - Paul D Bartels
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark
| | - Grethe Andersen
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark
| | - Søren Paaske Johnsen
- From the Centre for Quality, Region of Southern Denmark, Middelfart, Denmark (N.S.K.); Institute of Public Health (N.S.K.), and Research Unit of Clinical Epidemiology, Institute of Clinical Research (B.M.N.), University of Southern Denmark, Odense, Denmark; Aalborg Psychiatric University Hospital, and Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark (J.M.); Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark (B.M.N.); The Danish Clinical Registries, Aarhus, Denmark (P.D.B.); Department of Clinical Medicine, Faculty of Medicine, University of Aalborg, Aalborg, Denmark (P.D.B.); and Department of Neurology (G.A.) and Department of Clinical Epidemiology (S.P.J.), Aarhus University Hospital, Aarhus, Denmark
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Kamitani S, Nishimura K, Nakamura F, Kada A, Nakagawara J, Toyoda K, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Matsuda S, Miyamoto Y, Iwata M, Suzuki A, Ishikawa KB, Kataoka H, Morita K, Kobayashi Y, Iihara K. Consciousness level and off-hour admission affect discharge outcome of acute stroke patients: a J-ASPECT study. J Am Heart Assoc 2014; 3:e001059. [PMID: 25336463 PMCID: PMC4323811 DOI: 10.1161/jaha.114.001059] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background Poor outcomes have been reported for stroke patients admitted outside of regular working hours. However, few studies have adjusted for case severity. In this nationwide assessment, we examined relationships between hospital admission time and disabilities at discharge while considering case severity. Methods and Results We analyzed 35 685 acute stroke patients admitted to 262 hospitals between April 2010 and May 2011 for ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH). The proportion of disabilities/death at discharge as measured by the modified Rankin Scale (mRS) was quantified. We constructed 2 hierarchical logistic regression models to estimate the effect of admission time, one adjusted for age, sex, comorbidities, and number of beds; and the second adjusted for the effect of consciousness levels and the above variables at admission. The percentage of severe disabilities/death at discharge increased for patients admitted outside of regular hours (22.8%, 27.2%, and 28.2% for working‐hour, off‐hour, and nighttime; P<0.001). These tendencies were significant in the bivariate and multivariable models without adjusting for consciousness level. However, the effects of off‐hour or nighttime admissions were negated when adjusted for consciousness levels at admission (adjusted OR, 1.00 and 0.99; 95% CI, 1.00 to 1.13 and 0.89 to 1.10; P=0.067 and 0.851 for off‐hour and nighttime, respectively, versus working‐hour). The same trend was observed when each stroke subtype was stratified. Conclusions The well‐known off‐hour effect might be attributed to the severely ill patient population. Thus, sustained stroke care that is sufficient to treat severely ill patients during off‐hours is important.
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Affiliation(s)
- Satoru Kamitani
- Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo (S.K., F.N., Y.K.)
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Japan (K.N., Y.M.)
| | - Fumiaki Nakamura
- Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo (S.K., F.N., Y.K.)
| | - Akiko Kada
- Clinical Research Center, Nagoya Medical Center, Nagoya, Japan (A.K.)
| | - Jyoji Nakagawara
- Department of Integrative Stroke Imaging Center, National Cerebral and Cardiovascular Center, Suita, Japan (J.N.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine and Neurology, National Cerebral and Cardiovascular Center, Suita, Japan (K.T.)
| | - Kuniaki Ogasawara
- Department of neurosurgery, Iwate Medical University, Morioka, Japan (K.O.)
| | - Junichi Ono
- Chiba Cardiovascular Center, Chiba, Japan (J.O.)
| | | | - Toru Aruga
- Showa University Hospital, Shinagawa-ku, Japan (T.A.)
| | - Shigeru Miyachi
- Department of Neurosurgery, Nagoya University, Nagoya, Japan (S.M.)
| | | | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, School of Medicine, Universityof Occupational and Environmental Health, Kitakyushu, Japan (S.M.)
| | - Yoshihiro Miyamoto
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Japan (K.N., Y.M.)
| | - Michiaki Iwata
- Department of Intellectual Asset Management, National Cerebral and Cardiovascular Center, Suita, Japan (M.I.)
| | - Akifumi Suzuki
- Research Institute for Brain and Blood Vessels, Akita, Japan (A.S.)
| | - Koichi B Ishikawa
- Center for Cancer Controland Information Services, National Cancer Center, Chuo-ku, Japan (K.B.I.)
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan (H.K., K.M.)
| | - Kenichi Morita
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan (H.K., K.M.)
| | - Yasuki Kobayashi
- Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo (S.K., F.N., Y.K.)
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan (K.I.)
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Yu TH, Hou YC, Chung KP. Do low-income coronary artery bypass surgery patients have equal opportunity to access excellent quality of care and enjoy good outcome in Taiwan? Int J Equity Health 2014; 13:64. [PMID: 25052723 PMCID: PMC4159514 DOI: 10.1186/s12939-014-0064-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 07/06/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Equity is an important issue in the healthcare research field. Many studies have focused on the relationship between patient characteristics and outcomes of care. These studies, however, have seldom examined whether patients' characteristics affected their access to quality healthcare, which further affected the care outcome. The purposes of this study were to determine whether low-income coronary artery bypass surgery (CABG) patients receive healthcare services with poorer quality, and if such differences in treatment result in different outcomes. METHODS A retrospective multilevel study design was conducted using claims data from Taiwan's universal health insurance scheme for 2005-2008. Patients who underwent their CABG surgery between 2006 and 2008 were included in this study. CABG patients who were under 18 years of age or had unknown gender or insured classifications were excluded. Hospital and surgeon's performance indicators in the previous one year were used to evaluate the level of quality via k-means clustering algorithm. Baron and Kenny's procedures for mediation effect were conducted to explore the relationship among patient's income, quality of CABG care, and inpatient mortality. RESULTS A total of 10,320 patients were included in the study. The results showed that 5.65% of the low-income patients received excellent quality of care, which was lower than that of patients not in the low-income group (5.65% vs.11.48%). The mortality rate of low-income patients (12.10%) was also higher than patients not in the low-income group (5.25%). Also, the mortality of patients who received excellent care was half as low as patients receiving non-excellent care (2.63% vs. 5.68%). Finally, after the procedure of mediation effect testing, the results showed that the relationship between patient income level and CABG mortality was partially mediated by patterns of quality of care. CONCLUSIONS The results of the current study implied that worse outcome in low-income CABG patients might be associated with poorer quality of received services. Health authorities should pay attention to this issue, and propose appropriate solutions.
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Affiliation(s)
| | | | - Kuo-Piao Chung
- Institute of Healthcare Policy and Management, National Taiwan University, Taipei, Taiwan.
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Off-hour effect on 3-month functional outcome after acute ischemic stroke: a prospective multicenter registry. PLoS One 2014; 9:e105799. [PMID: 25165816 PMCID: PMC4148337 DOI: 10.1371/journal.pone.0105799] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 07/24/2014] [Indexed: 01/04/2023] Open
Abstract
Background and Purpose The time of hospital arrival may have an effect on prognosis of various vascular diseases. We examined whether off-hour admission would affect the 3-month functional outcome in acute ischemic stroke patients admitted to tertiary hospitals. Methods We analyzed the ‘off-hour effect’ in consecutive patients with acute ischemic stroke using multi-center prospective stroke registry. Work-hour admission was defined as when the patient arrived at the emergency department between 8 AM and 6 PM from Monday to Friday and between 8 AM and 1 PM on Saturday. Off-hour admission was defined as the rest of the work-hours and statutory holidays. Multivariable logistic regression was used to analyze the association between off-hour admission and 3-month unfavorable functional outcome defined as modified Rankin Scale (mRS) 3–6. Multivariable model included age, sex, risk factors, prehospital delay time, intravenous thrombolysis, stroke subtypes and severity as covariates. Results A total of 7075 patients with acute ischemic stroke were included in this analysis: mean age, 67.5 (±13.0) years; male, 58.6%. In multivariable analysis, off-hour admission was not associated with unfavorable functional outcome (OR, 0.89; 95% CI, 0.72–1.09) and mortality (OR, 1.09; 95% CI, 0.77–1.54) at 3 months. Moreover, off-hour admission did not affect a statistically significant shift of 3-month mRS distributions (OR, 0.90; 95% CI, 0.78–1.05). Conclusions ‘Off-hour’ admission is not associated with an unfavorable 3-month functional outcome in acute ischemic stroke patients admitted to tertiary hospitals in Korea. This finding indicates that the off-hour effects could be overcome with well-organized stroke management strategies.
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Chen CH, Tang SC, Tsai LK, Hsieh MJ, Yeh SJ, Huang KY, Jeng JS. Stroke code improves intravenous thrombolysis administration in acute ischemic stroke. PLoS One 2014; 9:e104862. [PMID: 25111200 PMCID: PMC4128738 DOI: 10.1371/journal.pone.0104862] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/12/2014] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Timely intravenous (IV) thrombolysis for acute ischemic stroke is associated with better clinical outcomes. Acute stroke care implemented with “Stroke Code” (SC) may increase IV tissue plasminogen activator (tPA) administration. The present study aimed to investigate the impact of SC on thrombolysis. Methods The study period was divided into the “pre-SC era” (January 2006 to July 2010) and “SC era” (August 2010 to July 2013). Demographics, critical times (stroke symptom onset, presentation to the emergency department, neuroimaging, thrombolysis), stroke severity, and clinical outcomes were recorded and compared between the two eras. Results During the study period, 5957 patients with acute ischemic stroke were admitted; of these, 1301 (21.8%) arrived at the emergency department within 3 h of stroke onset and 307 (5.2%) received IV-tPA. The number and frequency of IV-tPA treatments for patients with an onset-to-door time of <3 h increased from the pre-SC era (n = 91, 13.9%) to the SC era (n = 216, 33.3%) (P<0.001). SC also improved the efficiency of IV-tPA administration; the median door-to-needle time decreased (88 to 51 min, P<0.001) and the percentage of door-to-needle times ≤60 min increased (14.3% to 71.3%, P<0.001). The SC era group tended to have more patients with good outcome (modified Rankin Scale ≤2) at discharge (49.5 vs. 39.6%, P = 0.11), with no difference in symptomatic hemorrhage events or in-hospital mortality. Conclusion The SC protocol increases the percentage of acute ischemic stroke patients receiving IV-tPA and decreases door-to-needle time.
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Affiliation(s)
- Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Division of Neurology, Department of Internal Medicine, Far-Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Yu Huang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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Patient outcomes following subarachnoid hemorrhage between the medical center and regional hospital: whether all patients should be transferred to medical centers. BIOMED RESEARCH INTERNATIONAL 2014; 2014:927803. [PMID: 25126581 PMCID: PMC4122094 DOI: 10.1155/2014/927803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 05/27/2014] [Accepted: 06/06/2014] [Indexed: 02/01/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a critical illness that may result in patient mortality or morbidity. In this study, we investigated the outcomes of patients treated in medical center and nonmedical center hospitals and the relationship between such outcomes and hospital and surgeon volume. Patient data were abstracted from the National Health Insurance Research Database of Taiwan in the Longitudinal Health Insurance Database 2000, which contains all claims data of 1 million beneficiaries randomly selected in 2000. The International Classification of Diseases, Ninth Revision, subarachnoid hemorrhage (430) was used for the inclusion criteria. We identified 355 patients between 11 and 87 years of age who had subarachnoid hemorrhage. Among them, 32.4% (115/355) were men. The median Charlson comorbidity index (CCI) score was 1.3 (SD ± 0.6). Unadjusted logistic regression analysis demonstrated that low mortality was associated with high hospital volume (OR = 3.21; 95% CI: 1.18–8.77). In this study, we found no statistical significances of mortality, LOS, and total charges between medical centers and nonmedical center hospitals. Patient mortality was associated with hospital volume. Nonmedical center hospitals could achieve resource use and outcomes similar to those of medical centers with sufficient volume.
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Goldstein SD, Papandria DJ, Aboagye J, Salazar JH, Van Arendonk K, Al-Omar K, Ortega G, Sacco Casamassima MG, Abdullah F. The "weekend effect" in pediatric surgery - increased mortality for children undergoing urgent surgery during the weekend. J Pediatr Surg 2014; 49:1087-91. [PMID: 24952794 DOI: 10.1016/j.jpedsurg.2014.01.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 01/05/2014] [Accepted: 01/11/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND For a number of pediatric and adult conditions, morbidity and mortality are increased when patients present to the hospital on a weekend compared to weekdays. The objective of this study was to compare pediatric surgical outcomes following weekend versus weekday procedures. METHODS Using the Nationwide Inpatient Sample and the Kids' Inpatient Database, we identified 439,457 pediatric (<18 years old) admissions from 1988 to 2010 that required a selected index surgical procedure (abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation, or placement/revision of ventricular shunt) on the same day of admission. Outcome metrics were compared using logistic regression models that adjusted for patient and hospital characteristics as well as procedure performed. RESULTS Patient characteristics of those admitted on the weekend (n=112,064) and weekday (n=327,393) were similar, though patients admitted on the weekend were more likely to be coded as emergent (61% versus 53%). After multivariate adjustment and regression, patients undergoing a weekend procedure were more likely to die (OR 1.63, 95% CI 1.21-2.20), receive a blood transfusion despite similar rates of intraoperative hemorrhage (OR 1.15, 95% CI 1.01-1.26), and suffer from procedural complications (OR 1.40, 95% CI 1.14-1.74). CONCLUSION Pediatric patients undergoing common urgent surgical procedures during a weekend admission have a higher adjusted risk of death, blood transfusion, and procedural complications. While the exact etiology of these findings is not clear, the timing of surgical procedures should be considered in the context of systems-based deficiencies that may be detrimental to pediatric surgical care.
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Affiliation(s)
- Seth D Goldstein
- Center for Pediatric Surgical Clinical Trials & Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine.
| | - Dominic J Papandria
- Center for Pediatric Surgical Clinical Trials & Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine
| | - Jonathan Aboagye
- Center for Pediatric Surgical Clinical Trials & Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine
| | - Jose H Salazar
- Center for Pediatric Surgical Clinical Trials & Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine
| | - Kyle Van Arendonk
- Center for Pediatric Surgical Clinical Trials & Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine
| | - Khaled Al-Omar
- Center for Pediatric Surgical Clinical Trials & Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine
| | - Gezzer Ortega
- Center for Pediatric Surgical Clinical Trials & Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine
| | - Maria Grazia Sacco Casamassima
- Center for Pediatric Surgical Clinical Trials & Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine
| | - Fizan Abdullah
- Center for Pediatric Surgical Clinical Trials & Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine
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The Relationships Among Physician and Hospital Volume, Processes, and Outcomes of Care for Acute Myocardial Infarction. Med Care 2014; 52:519-27. [DOI: 10.1097/mlr.0000000000000132] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yu TH, Hou YC, Lin KC, Chung KP. Is it possible to identify cases of coronary artery bypass graft postoperative surgical site infection accurately from claims data? BMC Med Inform Decis Mak 2014; 14:42. [PMID: 24884488 PMCID: PMC4050397 DOI: 10.1186/1472-6947-14-42] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 05/20/2014] [Indexed: 11/15/2022] Open
Abstract
Background Claims data has usually been used in recent studies to identify cases of healthcare-associated infection. However, several studies have indicated that the ICD-9-CM codes might be inappropriate for identifying such cases from claims data; therefore, several researchers developed alternative identification models to correctly identify more cases from claims data. The purpose of this study was to investigate three common approaches to develop alternative models for the identification of cases of coronary artery bypass graft (CABG) surgical site infection, and to compare the performance between these models and the ICD-9-CM model. Methods The 2005–2008 National Health Insurance claims data and healthcare-associated infection surveillance data from two medical centers were used in this study for model development and model verification. In addition to the use of ICD-9-CM codes, this study also used classification algorithms, a multivariable regression model, and a decision tree model in the development of alternative identification models. In the classification algorithms, we defined three levels (strict, moderate, and loose) of the criteria in terms of their strictness. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to evaluate the performance of each model. Results The ICD-9-CM-based model showed good specificity and negative predictive value, but sensitivity and positive predictive value were poor. Performances of the other models were varied, except for negative predictive value. Among the models, the performance of the decision tree model was excellent, especially in terms of positive predictive value. Conclusion The accuracy of identification of cases of CABG surgical site infection is an important issue in claims data. Use of the decision tree model to identify such cases can improve the accuracy of patient-level outcome research. This model should be considered when performing future research using claims data.
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Affiliation(s)
| | | | | | - Kuo-Piao Chung
- Institute of Healthcare Policy and Management, National Taiwan University, Taipei, Taiwan.
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Yu TH, Chung KP. Is the implementation of quality improvement methods in hospitals subject to the neighbourhood effect? Int J Qual Health Care 2014; 26:231-9. [PMID: 24699197 DOI: 10.1093/intqhc/mzu029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Quality improvement (QI) methods have been fashionable in hospitals for decades. Previous studies have discussed the relationships between the implementation of QI methods and various external and internal factors, but there has been no examination to date of whether the neighbourhood effect influences such implementation. The aim of this study was to use a multilevel model to investigate whether and how the neighbourhood effect influences the implementation of QI methods in the hospital setting in Taiwan. DESIGN This is a retrospective questionnaire-based survey. SETTING All medical centres, regional hospitals and district teaching hospitals in Taiwan. PARTICIPANTS Directors or persons in charge of implementing QI methods in hospitals. INTERVENTIONS None. MAIN OUTCOME MEASURES The breadth and depth of QI method implementation. RESULTS Seventy-two of the 139 hospitals contacted returned the questionnaire, yielding a 52% response rate. The breadth and depth of QI method implementation increased over the 10-year study period, particularly between 2004 and 2006. The breadth and depth of the QI methods implemented in the participating hospitals were significantly associated with the average breadth and depth of those implemented by their competitors in the same medical area during the previous period. In addition, time was positively associated with the breadth and depth of QI method implementation. CONCLUSIONS In summary, the findings of this study show that hospitals' QI implementation status is influenced by that of their neighbours. Hence, the neighbourhood effect is an important factor in understanding hospital behaviour.
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Affiliation(s)
- Tsung-Hsien Yu
- Institute of Healthcare Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Kuo-Piao Chung
- Institute of Healthcare Policy and Management, National Taiwan University, Taipei, Taiwan
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Sorita A, Ahmed A, Starr SR, Thompson KM, Reed DA, Dabrh AMA, Prokop L, Kent DM, Shah ND, Murad MH, Ting HH. Off-hour presentation and outcomes in patients with acute ischemic stroke: a systematic review and meta-analysis. Eur J Intern Med 2014; 25:394-400. [PMID: 24721584 DOI: 10.1016/j.ejim.2014.03.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/07/2014] [Accepted: 03/15/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Studies have suggested that patients with acute ischemic stroke who present to the hospital during off-hours (weekends and nights) may or may not have worse clinical outcomes compared to patients who present during regular hours. METHODS We searched Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus through August 2013, and included any study that evaluated the association between time of patient presentation to a healthcare facility and mortality or modified Rankin Scale in acute ischemic stroke. Quality of studies was assessed with the Newcastle-Ottawa Scale. A random-effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I(2). A priori subgroup analyses were used to explain observed heterogeneity. RESULTS A total of 21 cohort studies (23 cohorts) with fair quality enrolling 1,421,914 patients were included. Off-hour presentation for patients with acute ischemic stroke was associated with significantly higher short-term mortality (OR, 1.11, 95% CI 1.06-1.17). Presenting at accredited stroke centers (OR 1.04, 95% CI 0.98-1.11) and countries in North America (OR 1.05, 95% CI 1.01-1.09) were associated with smaller increase in mortality during off-hours. The results were not significantly different between adjusted (OR, 1.11, 95% CI 1.05-1.16) and unadjusted (OR, 1.13, 95% CI 0.95-1.35) outcomes. The proportion of patients with modified Rankin Scale at discharge ≥ 2-3 was higher in patients presenting during off-hours (OR, 1.14, 95% CI 1.06-1.22). DISCUSSION The evidence suggests that patients with acute ischemic stroke presenting during off-hours have higher short-term mortality and greater disability at discharge.
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Affiliation(s)
- Atsushi Sorita
- Division of Preventive Medicine, Mayo Clinic, Rochester, MN, United States
| | - Adil Ahmed
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, United States
| | - Stephanie R Starr
- Division of Community Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kristine M Thompson
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Darcy A Reed
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Larry Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, United States
| | - David M Kent
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States
| | - Nilay D Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, United States
| | | | - Henry H Ting
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States.
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