Comment on Silber et al.: Investing in postadmission survival—a “failure-to-rescue” U.S. population health

Hospital costs and inpatient mortality among children undergoing surgery for congenital heart disease

OBJECTIVE

To determine the association between hospital costs and risk-adjusted inpatient mortality among children undergoing surgery for congenital heart disease (CHD) in U.S. acute-care hospitals.

DATA SOURCES/STUDY SETTINGS

Retrospective cohort study of 35,446 children in 2003, 2006, and 2009 Kids' Inpatient Database (KID).

STUDY DESIGN

Cross-sectional logistic regression of risk-adjusted inpatient mortality and hospital costs, adjusting for a variety of patient-, hospital-, and community-level confounders.

DATA COLLECTION/EXTRACTION METHODS

We identified relevant discharges in the KID using the AHRQ Pediatric Quality Indicator for pediatric heart surgery mortality, and linked these records to hospital characteristics from American Hospital Association Surveys and community characteristics from the Census.

PRINCIPAL FINDINGS

Children undergoing CHD surgery in higher cost hospitals had lower risk-adjusted inpatient mortality (p=.002). An increase from the 25th percentile of treatment costs to the 75th percentile was associated with a 13.6 percent reduction in risk-adjusted mortality.

CONCLUSIONS

Greater hospital costs are associated with lower risk-adjusted inpatient mortality for children undergoing CHD surgery. The specific mechanisms by which greater costs improve mortality merit further exploration.

Reconceptualising failure to rescue in midwifery: a concept analysis

AIM

to reconceptualise the concept of failure to rescue, distinguishing it from its current scientific usage as a surveillance strategy to recognise physiologic decline.

BACKGROUND

failure to rescue has been consistently defined as a failure to save a patient׳s life after development of complications. The term, however, carries a richer connotation when viewed within a midwifery context. Midwives have historically believed themselves to be the vanguards of normal, physiologic processes, including birth. This philosophy mandates careful consideration of what it means to promote normal birth and the consequences of failure to rescue women from processes which challenge that outcome.

DATA SOURCES

the Medline, CINAHL, PsycINFO, PubMED, Web of Science and Google Scholar databases were searched from the period of 1992-2014 using the key terms of concept analysis, failure-to-rescue, childbirth, midwifery outcomes, obstetrical outcomes, suboptimal care, and patient outcomes. English language reports were used exclusively. The search yielded 45 articles which were reviewed in this paper.

REVIEW METHOD

a critical analysis of the published literature was undertaken as a means of determining the adequacy of the concept for midwifery practice and to detail how it relates to other concepts important in development of a conceptual framework promoting normal birth processes.

FINDINGS

failure to rescue within the context of the midwifery model of care requires robust attention to a midwifery managed setting and surveillance based on a caring presence, patient protection, and midwifery partnership with patient.

CONCLUSION

clarifying the definition of failure to rescue in childbirth and defining its attributes can help inform midwifery providers throughout the world of the ethical importance of considering failure to rescue in clinical practice. Relevance to midwifery care mandates use of failure to rescue as both a process and outcome measure.

Spending and mortality in US acute care hospitals

BACKGROUND

Despite evidence that greater US Medicare spending is not associated with better quality of care at a regional level, recent studies suggest that greater hospital spending is associated with lower risk-adjusted mortality. Studies have been limited to older data, specific US states and conditions, and the Medicare population.

OBJECTIVES

To analyze the association between hospital spending and risk-adjusted inpatient mortality for 6 major medical conditions in US acute care hospitals.

STUDY DESIGN

Retrospective cohort study of risk adjusted inpatient mortality, with hospital spending taken from the Dartmouth Atlas of Health Care. The study population included 2,635,510 patients admitted to 1201 US hospitals between 2003 and 2007.

METHODS

Patient-level logistic regression models were used to estimate the effect of hospital spending on inpatient mortality, controlling for mortality risk, comorbidities, community characteristics (eg, median household income in a patient's zip code), hospital volume and ownership, and admission year.

RESULTS

Patients treated at hospitals in the highest spending quintile (relative to the lowest) had lower risk-adjusted inpatient mortality for acute myocardial infarction (odds ratio [OR] 0.751, 95% confidence interval [CI] 0.656-0.859), congestive heart failure (OR 0.652, 95% CI 0.560-0.759), stroke (OR 0.852, 95% CI, 0.739-0.983), and hip fracture (OR 0.691, 95% CI 0.545-0.876). Greater spending was associated with lower mortality primarily in nonteaching hospitals, hospitals with fewer than the median number of beds, and nonprofit/public hospitals.

CONCLUSIONS

Greater hospital spending is associated with lower risk-adjusted inpatient mortality for major medical conditions in the United States.