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Dawson LP, Andrew E, Nehme Z, Bloom J, Okyere D, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Risk-standardized mortality metric to monitor hospital performance for chest pain presentations. Eur Heart J Qual Care Clin Outcomes 2023; 9:583-591. [PMID: 36195327 DOI: 10.1093/ehjqcco/qcac062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/10/2022] [Accepted: 09/29/2022] [Indexed: 09/13/2023]
Abstract
AIMS Risk-standardized mortality rates (RSMR) have been used to monitor hospital performance in procedural and disease-based registries, but limitations include the potential to promote risk-averse clinician decisions and a lack of assessment of the whole patient journey. We aimed to determine whether it is feasible to use RSMR at the symptom-level to monitor hospital performance using routinely collected, linked, clinical and administrative data of chest pain presentations. METHODS AND RESULTS We included 192 978 consecutive adult patients (mean age 62 years; 51% female) with acute chest pain without ST-elevation brought via emergency medical services (EMS) to 53 emergency departments in Victoria, Australia (1/1/2015-30/6/2019). From 32 candidate variables, a risk-adjusted logistic regression model for 30-day mortality (C-statistic 0.899) was developed, with excellent calibration in the full cohort and with optimism-adjusted bootstrap internal validation. Annual 30-day RSMR was calculated by dividing each hospital's observed mortality by the expected mortality rate and multiplying it by the annual mean 30-day mortality rate. Hospital performance according to annual 30-day RSMR was lower for outer regional or remote locations and at hospitals without revascularisation capabilities. Hospital rates of angiography or transfer for patients diagnosed with non-ST elevation myocardial infarction (NSTEMI) correlated with annual 30-day RSMR, but no correlations were observed with other existing key performance indicators. CONCLUSION Annual hospital 30-day RSMR can be feasibly calculated at the symptom-level using routinely collected, linked clinical, and administrative data. This outcome-based metric appears to provide additional information for monitoring hospital performance in comparison with existing process of care key performance measures.
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Affiliation(s)
- Luke P Dawson
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3004, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
| | - Emily Andrew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
- Department of Paramedicine, Monash University, Melbourne, VIC 3199, Australia
| | - Jason Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3004, Australia
- Heart Failure Research Group, The Baker Institute, Melbourne, VIC 3004, Australia
| | - Daniel Okyere
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
| | - Shelley Cox
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
| | - David Anderson
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
- Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
- Department of Paramedicine, Monash University, Melbourne, VIC 3199, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
| | - Andrew J Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3004, Australia
- Department of Medicine, Monash University, Melbourne, VIC 3800, Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3004, Australia
- Heart Failure Research Group, The Baker Institute, Melbourne, VIC 3004, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
- Department of Paramedicine, Monash University, Melbourne, VIC 3199, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3004, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Heart Failure Research Group, The Baker Institute, Melbourne, VIC 3004, Australia
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Scharf T, Hügli C, Martin Y, Tal K, Biller-Andorno N, Dvořák C, Bulliard JL, Ducros C, Selby K, Auer R. Association between the colorectal cancer screening status of primary care physicians and their patients: Evidence from the Swiss Sentinella practice-based research network. Prev Med Rep 2023; 32:102140. [PMID: 36865393 PMCID: PMC9971517 DOI: 10.1016/j.pmedr.2023.102140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/14/2022] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
Swiss health insurance reimburses screening for colorectal cancer (CRC) with either colonoscopy or fecal occult blood test (FOBT). Studies have documented the association between a physician's personal preventive health practices and the practices they recommend to their patients. We explored the association between CRC testing status of primary care physicians (PCP) and the testing rate among their patients. From May 2017 to September 2017, we invited 129 PCP who belonged to the Swiss Sentinella Network to disclose their CRC test status and whether they had been tested with colonoscopy or FOBT/other methods. Each participating PCP collected demographic data and CRC testing status from 40 consecutive 50- to 75-year-old patients. We analyzed data from 69 (54%) PCP 50 years or older and 2623 patients. Most PCP were men (81%); 75% were tested for CRC (67% with colonoscopy and 9% with FOBT). Mean patient age was 63; 50% were women; 43% had been tested for CRC (38%, 1000/2623 with colonoscopy and 5%, 131/2623, with FOBT or other non-endoscopic test). In multivariate adjusted regression models that clustered patients by PCP, the proportion of patients tested for CRC was higher among PCP tested for CRC than among PCP not tested (47% vs 32%; OR 1.97; 95% CI 1.36 to 2.85). Since PCP CRC testing status is associated with their patients CRC testing rates, it informs future interventions that will alert PCPs to the influence of their health decisions and motivate them to further incorporate the values and preferences of their patients in their practice.
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Affiliation(s)
- Tamara Scharf
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
- Corresponding author.
| | - Claudia Hügli
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Yonas Martin
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kali Tal
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | | | | | - Jean-Luc Bulliard
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland
| | - Cyril Ducros
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland
| | - Kevin Selby
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland
| | - Reto Auer
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland
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3
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Ingram M, Short HL, Sathya C, Fevrier H, Raval MV. Hospital-level factors associated with nonoperative management in common pediatric surgical procedures. J Pediatr Surg 2020; 55:609-614. [PMID: 31708206 DOI: 10.1016/j.jpedsurg.2019.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 09/18/2019] [Accepted: 10/19/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Our purpose was to examine patient- and hospital-level factors associated with nonoperative management in common pediatric surgical diagnoses. METHODS Using the 2012 Kid's Inpatient Database (KID), we identified patients <20 years old diagnosed with cholecystitis (CHOL), bowel obstruction (BO), perforated appendicitis (PA), or spontaneous pneumothorax (SPTX). Logistic regression models were used to identify factors associated with nonoperative management. RESULTS Of 36,026 admissions for the diagnoses of interest, 7472 (20.7%) were managed nonoperatively. SPTX had the highest incidence of NONOP (55.9%; n = 394), while PA had the lowest incidence (9.2%; n = 1641). Utilization of operative management varied significantly between hospitals. Patients diagnosed with BO (OR 0.41; 95% CI 0.30-0.56) and SPTX (OR 0.28; 95% CI 0.14-0.56) had decreased odds of operative management when treated at an urban, teaching hospital compared to a rural hospital. Patients with PA had increased odds of operative management when treated at an urban, teaching hospital (OR 2.42; 95% CI 1.78-3.30). Hospital-level factors associated with decreased odds of nonoperative management included urban, nonteaching status (OR 0.54; 95% CI 0.31-0.91) and location in the South (OR 0.53; 95% CI 0.34-83) and West (OR 0.47; 95% CI 0.30-0.74). CONCLUSIONS Despite representing more than 20% of pediatric surgical care for several conditions, nonoperative management is an understudied aspect of care with significant variation that warrants further research. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Martha Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Chethan Sathya
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Helene Fevrier
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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Kuenzig ME, Stukel TA, Kaplan GG, Murthy SK, Nguyen GC, Talarico R, Benchimol EI. Variation in care of patients with elderly-onset inflammatory bowel disease in Ontario, Canada: A population-based cohort study. J Can Assoc Gastroenterol 2020; 4:e16-e30. [PMID: 33855268 PMCID: PMC8023856 DOI: 10.1093/jcag/gwz048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/21/2019] [Indexed: 11/18/2022] Open
Abstract
Background Variation in health care, when not based on patient preference, may result in
poorer care. We determined whether variation in health services utilization,
gastroenterologist care and outcomes existed among patients with
elderly-onset inflammatory bowel disease (IBD). Methods Patients with IBD (diagnosed ≥65 years) were identified from
population-based health administrative data from Ontario, Canada (1999 to
2014). We assessed variation across multispecialty physician networks in
gastroenterologist care and outcomes using multilevel logistic regression.
Median odds ratios (MOR) described variation. We evaluated the association
between gastroenterologist supply, specialist care and outcomes. Results In 4806 patients, there was significant variation in having ever seen a
gastroenterologist (MOR 3.35, P < 0.0001), having a
gastroenterologist as the primary IBD care provider (MOR 4.16,
P < 0.0001), 5-year colectomy risk in ulcerative
colitis (MOR 1.38, P = 0.01), immunomodulator use (MOR
1.47, P = 0.001), and corticosteroid use (MOR 1.26,
P = 0.006). No variation in emergency department
visits, hospitalizations or intestinal resection (Crohn’s) was noted.
Patients in networks with fewer gastroenterologists were less likely to see
a gastroenterologist (odds ratio [OR] 0.29, 95% confidence interval [CI]
0.15 to 0.56), have a gastroenterologist as their primary care provider (OR
0.27, 95% CI 0.12 to 0.59), be hospitalized within 5 years (OR 0.82, 95% CI
0.69 to 0.98), and be prescribed biologics within 1 year (OR 0.50, 95% CI
0.28 to 0.89). Conclusions Utilization of gastroenterology care in patients with elderly-onset IBD
varies greatly. Patients treated by gastroenterologists and in networks with
more gastroenterologists have better outcomes. There is a need to ensure all
individuals with IBD have equal access to and utilization of specialist care
to ensure the best possible outcomes.
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Affiliation(s)
- M Ellen Kuenzig
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada.,CHEO Research Institute, Ottawa, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Therese A Stukel
- ICES, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gilaad G Kaplan
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanjay K Murthy
- The Ottawa Hospital IBD Centre, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey C Nguyen
- ICES, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Eric I Benchimol
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada.,CHEO Research Institute, Ottawa, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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5
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Löppenberg B, Sood A, Dalela D, Karabon P, Sammon JD, Vetterlein MW, Noldus J, Peabody JO, Trinh QD, Menon M, Abdollah F. Variation in Locoregional Prostate Cancer Care and Treatment Trends at Commission on Cancer Designated Facilities: A National Cancer Data Base Analysis 2004 to 2013. Clin Genitourin Cancer 2017; 15:e955-68. [PMID: 28558991 DOI: 10.1016/j.clgc.2017.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 04/05/2017] [Accepted: 04/14/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Contemporary treatment trends for prostate cancer show increased rates of active surveillance. However, nationwide applicability of these reports is limited. Additionally, the effect of Commission on Cancer facility type on prostate cancer treatment patterns is unknown. PATIENTS AND METHODS We used the National Cancer Data Base to identify men diagnosed with prostate cancer, between 2004 and 2013. Our cohort was stratified on the basis of the National Comprehensive Cancer Network prostate cancer risk classes. Cochran-Armitage tests were used to evaluate temporal trends. Random effects hierarchical logit models were used to assess treatment variation at Commission on Cancer facility and institution level. RESULTS In 825,707 men, utilization of radiation therapy declined and utilization of radical prostatectomy increased for all prostate cancer risk groups between 2004 and 2013 (P < .0001). Observation for low-risk prostate cancer increased from 16.3% in 2004 to 2005 to 32.0% in 2012 to 2013 (P < .0001). Significant treatment variation was observed on the basis of Commission on Cancer facility type. Across all risk groups, the lowest rates of radical prostatectomy and highest rates of external beam radiation therapy were observed in community cancer programs. The highest rates of observation for low-risk disease were observed in academic centers. Treatment variation according to institution ranged from 14% (95% confidence interval, 0.12-0.15) for androgen deprivation therapy up to 59% (95% confidence interval, 0.45-0.73) for cryotherapy. CONCLUSION The increased utilization of observation in low-risk prostate cancer is an encouraging finding, which appears to be mainly derived by a decrease in radiotherapy utilization in this risk group. Regardless of tumor characteristics, significant variations in treatment modality exist among different facility types and institutions.
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Abstract
BACKGROUND There is significant variation surrounding the indications, surgical approaches, and outcomes for children undergoing antireflux procedures (ARPs) resulting in geographic variation of care. Our purpose was to quantify this geographic variation in the utilization of ARPs in children. METHODS A cross-sectional analysis of the 2009 Kid's Inpatient Database was performed to identify patients with gastroesophageal reflux disease or associated diagnoses. Regional surgical utilization rates were determined, and a mixed effects model was used to identify factors associated with the use of ARPs. RESULTS Of the 148,959 patients with a diagnosis of interest, 4848 (3.3%) underwent an ARP with 2376 (49%) undergoing a laparoscopic procedure. The Northeast (2.0%) and Midwest (2.2%) had the lowest overall utilization of surgery, compared with the South (3.3%) and West (3.4%). After adjustment for age, case-mix, and surgical approach, variation persisted with the West and the South demonstrating almost two times the odds of undergoing an ARP compared with the Northeast. Surgical utilization rates are independent of state-level volume with some of the highest case volume states having surgical utilization rates below the national rate. In the West, the use of laparoscopy correlated with overall utilization of surgery, whereas surgical approach was not correlated with ARP use in the South. CONCLUSIONS Significant regional variation in ARP utilization exists that cannot be explained entirely by differences in patient age, race/ethnicity, case-mix, and surgical approach. In order to decrease variation in care, further research is warranted to establish consensus guidelines regarding indications for the use ARPs for children.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Wanzhe Zhu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Lance A Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
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Nattabi B, Matthews V, Bailie J, Rumbold A, Scrimgeour D, Schierhout G, Ward J, Guy R, Kaldor J, Thompson SC, Bailie R. Wide variation in sexually transmitted infection testing and counselling at Aboriginal primary health care centres in Australia: analysis of longitudinal continuous quality improvement data. BMC Infect Dis 2017; 17:148. [PMID: 28201979 PMCID: PMC5312578 DOI: 10.1186/s12879-017-2241-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 02/02/2017] [Indexed: 11/25/2022] Open
Abstract
Background Chlamydia, gonorrhoea and syphilis are readily treatable sexually transmitted infections (STIs) which continue to occur at high rates in Australia, particularly among Aboriginal Australians. This study aimed to: explore the extent of variation in delivery of recommended STI screening investigations and counselling within Aboriginal primary health care (PHC) centres; identify the factors associated with variation in screening practices; and determine if provision of STI testing and counselling increased with participation in continuous quality improvement (CQI). Methods Preventive health audits (n = 16,086) were conducted at 137 Aboriginal PHC centres participating in the Audit and Best Practice for Chronic Disease Program, 2005–2014. STI testing and counselling data were analysed to determine levels of variation in chlamydia, syphilis and gonorrhoea testing and sexual health discussions. Multilevel logistic regression was used to determine factors associated with higher levels of STI-related service delivery and to quantify variation attributable to health centre and client characteristics. Results Significant variation in STI testing and counselling exists among Aboriginal PHC centres with health centre factors accounting for 43% of variation between health centres and jurisdictions. Health centre factors independently associated with higher levels of STI testing and counselling included provision of an adult health check (odds ratio (OR) 3.40; 95% Confidence Interval (CI) 3.07-3.77) and having conducted 1–2 cycles of CQI (OR 1.34; 95% CI 1.16-1.55). Client factors associated with higher levels of STI testing and counselling were being female (OR 1.45; 95% CI 1.33-1.57), Aboriginal (OR 1.46; 95% CI 1.15-1.84) and aged 20–24 years (OR 3.84; 95% CI 3.07-4.80). For females, having a Pap smear test was also associated with STI testing and counselling (OR 4.39; 95% CI 3.84-5.03). There was no clear association between CQI experience beyond two CQI cycles and higher levels of documented delivery of STI testing and counselling services. Conclusions A number of Aboriginal PHC centres are achieving high rates of STI testing and counselling, while a significant number are not. STI-related service delivery could be substantially improved through focussed efforts to support health centres with relatively lower documented evidence of adherence to best practice guidelines.
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Affiliation(s)
- Barbara Nattabi
- Western Australian Centre for Rural Health, University of Western Australia, 167 Fitzgerald Street, Geraldton, WA, 6530, Australia.
| | | | - Jodie Bailie
- University Centre for Rural Health, University of Sydney, Lismore, NSW, Australia
| | - Alice Rumbold
- The Robinson Research Institute, The University of Adelaide, Adelaide, Australia
| | - David Scrimgeour
- Spinifex Health Service Tjuntjuntjara, Kalgoorlie, WA, Australia
| | - Gill Schierhout
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - James Ward
- South Australian Health and Medical Research Institute, Adelaide, South Australia
| | - Rebecca Guy
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - John Kaldor
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Sandra C Thompson
- Western Australian Centre for Rural Health, University of Western Australia, 167 Fitzgerald Street, Geraldton, WA, 6530, Australia
| | - Ross Bailie
- University Centre for Rural Health, University of Sydney, Lismore, NSW, Australia
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Winchester DE, Agarwal N, Burke L, Bradley S, Schember T, Schmalfuss C. Physician-level variation in the diagnosis of myocardial infarction and the use of angiography among Veterans with elevated troponin. Mil Med Res 2016; 3:22. [PMID: 27458522 PMCID: PMC4959051 DOI: 10.1186/s40779-016-0090-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/04/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Cardiac troponin assays have improved the ability to detect myocardial damage. However, ascertaining whether troponin elevation is due to myocardial infarction (MI) or secondary to another process can be challenging. Our aim is to evaluate provider-level variation in the diagnosis of MI and the use of invasive coronary angiography (ICA) among patients with undifferentiated elevations in cardiac troponin. METHODS We analyzed data from all patients with elevated troponin levels in a single Veterans Affairs (VA) Medical Center between 2006 and 2007. One of several cardiologists prospectively evaluated each patient's presentation and course of care. We compared the frequency of MI diagnosis and ICA use between physicians using univariate odds ratios (OR). RESULTS Among 761 patients, 34.0 % were diagnosed with MI and 25.9 % underwent ICA. The unadjusted rates of MI (23.9 to 56.7 %, P = 0.02) and ICA (17.3 to 73.3 %, P < 0.001) differed between physicians. Comparing the patient cohorts for each physician, baseline characteristics were similar except for chest pain. In multivariate regression, factors associated with the use of cardiac ICA included an abnormal electrocardiograph (ECG) (OR = 1.89, P = 0.014), level of troponin (OR = 1.71, P = 0.004), chest pain (OR = 8.60, P < 0.001), and care by non-VA physicians (OR = 4.45, P = 0.006). One physician had a lower ICA use (OR = 0.56, P = 0.017). In multivariate regression of MI, no physician-level variation was observed. CONCLUSION Among patients with elevated troponin, the likelihood of being diagnosed with MI and undergoing ICA is dependent on their clinical presentation. After adjustment, physician-level variation in care was observed for the use of ICA, but not for the diagnosis of MI.
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Affiliation(s)
- David E Winchester
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL USA ; Malcom Randall Veterans Affairs Medical Center, Gainesville, FL USA
| | - Nayan Agarwal
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL USA
| | - Lucas Burke
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL USA
| | - Steven Bradley
- Division of Cardiology, Department of Medicine, VA Eastern Colorado Health Care System, Denver, CO USA ; Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, CO USA
| | - Tatiana Schember
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL USA
| | - Carsten Schmalfuss
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL USA ; Malcom Randall Veterans Affairs Medical Center, Gainesville, FL USA
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Abstract
BACKGROUND Biologic therapy has been shown to be effective in achieving and maintaining remission in the treatment of inflammatory bowel disease (IBD). However, their impact on healthcare resource utilization is not well understood. This study explored the impact of biologic use on IBD-related hospital admissions and emergency room visits and healthcare expenditures. METHODS This study used a retrospective cohort design to analyze data from the MarketScan Commercial and Medicare databases (Truven Health Analytics Inc.) for the years 2006-2010. Patients were identified using ICD-9 diagnosis codes for IBD and age 18 or older at time of initial diagnosis. Linear models were used to predict the probability of an IBD-related hospitalization or ER visit and healthcare expenditures with binary variables indicating use of biologics in the current year and in the previous 2 years, as well as patient- and area-level control variables. RESULTS Patients using biologics in the current year were 14.1-17.6% more likely to be hospitalized for IBD. However, biologic use in the previous year was associated with a 3.8-5.6% reduction in hospitalizations, and biologic use 2 years prior was associated with a 1-2.8% reduction in hospitalizations in the current year. Similar results are found for ER visits. All indicators for biologic use were associated with increased expenditures. CONCLUSIONS There was a negative association between lagged use of biologics and the proportion of patients with IBD-related hospitalizations and ER visits. This finding may suggest that increased use of biologics over time is associated with a decrease in IBD-related healthcare utilization.
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Affiliation(s)
- Guy David
- University of Pennsylvania , Philadelphia, PA , USA
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