Acute Care Hospitals In Maryland Research Articles

Assessment of Costs and Care Quality Associated With Major Surgical Procedures After Implementation of Maryland’s Capitated Budget Model

In 2014, Maryland implemented the all-payer model, a distinct hospital funding policy that applied caps on annual hospital expenditures and mandated reductions in avoidable complications. Expansion of this model to other states is currently being considered; therefore, it is important to evaluate whether Maryland's all-payer model is achieving the desired goals among surgical patients, who are an at-risk population for most potentially preventable complications. To examine the association between the implementation of Maryland's all-payer model and the incidence of avoidable complications and resource use among adult surgical patients. This comparative effectiveness study used hospital discharge records from the Healthcare Cost and Utilization Project state inpatient databases to conduct a difference-in-differences analysis comparing the incidence of avoidable complications and the intensity of health resource use before and after implementation of the all-payer model in Maryland. The analytical sample included 2 983 411 adult patients who received coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), spinal fusion, hip or knee arthroplasty, hysterectomy, or cesarean delivery between January 1, 2008, and December 31, 2016, at acute care hospitals in Maryland (intervention state) and New York, New Jersey, and Rhode Island (control states). Data analysis was conducted from July 2019 to July 2021. All-payer model. Complications (infectious, cardiovascular, respiratory, kidney, coagulation, and wound) and health resource use (ie, hospital charges). Of 2 983 411 total patients in the analytical sample, 525 262 patients were from Maryland and 2 458 149 were from control states. Across Maryland and the control states, there were statistically significant but not clinically relevant differences in the preintervention period with regard to patient age (mean [SD], 49.7 [19.0] years vs 48.9 [19.3] years, respectively; P < .001), sex (22.7% male vs 21.4% male; P < .001), and race (0.3% vs 0.4% American Indian, 2.8% vs 4.5% Asian or Pacific Islander, 25.9% vs 12.7% Black, 4.7% vs 11.9% Hispanic, and 63.5% vs 63.4% White; P < .001). After implementation of the all-payer model in Maryland, significantly lower rates of avoidable complications were found among patients who underwent CABG (-11.3%; 95% CI, -13.8% to -8.7%; P < .001), CEA (-1.6%; 95% CI, -2.9% to -0.3%; P = .02), hip arthroplasty (-0.8%; 95% CI, -1.0% to -0.5%; P < .001), knee arthroplasty (-0.4%; 95% CI, -0.7% to -0.1%; P = .01), and cesarean delivery (-1.0%; 95% CI, -1.3% to -0.7%; P < .001). In addition, there were significantly lower increases in index hospital costs in Maryland among patients who underwent CABG (-$6236; 95% CI, -$7320 to -$5151; P < .001), CEA (-$730; 95% CI, -$1367 to -$94; P = .03), spinal fusion (-$3253; 95% CI, -$3879 to -$2627; P < .001), hip arthroplasty (-$328; 95% CI, -$634 to -$21; P = .04), knee arthroplasty (-$415; 95% CI, -$643 to -$187; P < .001), cesarean delivery (-$300; 95% CI, -$380 to -$220; P < .001), and hysterectomy (-$745; 95% CI, -$974 to -$517; P < .001). Significant changes in patient mix consistent with a younger population (eg, a shift toward private/commercial insurance for orthopedic procedures, such as spinal fusion [4.3%; 95% CI, 3.4%-5.2%; P < .001] and knee arthroplasty [1.6%; 95% CI, 1.0%-2.3%; P < .001]) and a lower comorbidity burden across surgical procedures (eg, CABG: -0.7% [95% CI, -0.1% to -0.5%; P < .001]; hip arthroplasty: -3.0% [95% CI, -3.6% to -2.3%; P < .001]) were also observed. In this study, patients who underwent common surgical procedures had significantly fewer avoidable complications and lower hospital costs, as measured against the rate of increase throughout the study, after implementation of the all-payer model in Maryland. These findings may be associated with changes in the patient mix.

Racial and ethnic disparities in hospital observation in Maryland.

Hospital observation is a key disposition option from the emergency department (ED) and encompasses up to one third of patients requiring post-ED care. Observation has been associated with higher incidence of catastrophic financial costs and has downstream effects on post-discharge clinical services. Yet little is known about the non-clinical determinants of observation assignment. We sought to evaluate the impact of patient-level demographic factors on observation designation among Maryland patients. We conducted a retrospective analysis of all ED encounters in Maryland between July 2012 and January 2017 for four priority diagnoses (heart failure, chronic obstructive pulmonary disease [COPD], pneumonia, and acute chest pain) using multilevel logistic models allowing for heterogeneity of the effects across hospitals. The primary exposure was self-reported race and ethnicity. The primary outcome was the initial status assignment from the ED: hospital observation versus inpatient admission. Across 46 Maryland hospitals, 259,788 patient encounters resulted in a disposition of inpatient admission (65%) or observation designation (35%). Black (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 1.16-1.23) and Hispanic (aOR: 1.11; 95% CI: 1.01-1.21) patients were significantly more likely to be placed in observation than white, non-Hispanic patients. These differences were consistent across the majority of acute-care hospitals in Maryland (27/46). Black and Hispanic patients in Maryland are more likely to be treated under the observation designation than white, non-Hispanic patients independent of clinical presentation. Race agnostic, time-based status assignments may be key in eliminating these disparities.

Is Geographic Socioeconomic Disadvantage Associated with the Rate of THA in Medicare-aged Patients?

Disparities in THA use may lead to inequitable care. Prior research has focused on disparities based on individual-level and isolated socioeconomic and demographic variables. To our knowledge, the role of composite, community-level geographic socioeconomic disadvantage has not been studied in the United States. As disparities persist, exploring the potential underlying drivers of these inequities may help in developing more targeted recommendations on how to achieve equitable THA use. (1) Is geographic socioeconomic disadvantage associated with decreased THA rates in Medicare-aged patients? (2) Do these associations persist after adjusting for differences in gender, race, ethnicity, and proximity to hospitals performing THA? In a study with a cross-sectional design, using population-based data from five-digit ZIP codes in Maryland, USA, from July 1, 2012 to March 31, 2019, we included all inpatient and outpatient primary THAs performed in individuals 65 years of age or older at acute-care hospitals in Maryland, as reported in the Health Services Cost Review Commission database. This database was selected because it provided the five-digit ZIP code data necessary to answer our study question. We excluded THAs performed for nonelective indications. We examined the annual rate of THA in our study population for each Maryland ZIP code, adjusted for differences across areas in distributions of gender, race, ethnicity, and distance to the nearest hospital performing THAs. Four hundred fourteen ZIP codes were included, with an overall mean ± SD THA rate of 371 ± 243 per 100,000 persons 65 years or older, a rate similar to that previously reported in individuals aged 65 to 84 in the United States. Statistical significance was assessed at α = 0.05. THA rates were higher in more affluent areas, with the following mean rates per 100,000 persons 65 years or older: 422 ± 259 in the least socioeconomically disadvantaged quartile, 339 ± 223 in the second-least disadvantaged, 277 ± 179 in the second-most disadvantaged, and 214 ± 179 in the most-disadvantaged quartile (p < 0.001). After adjustment for distributions in gender, race, ethnicity, and hospital proximity, we found that geographic socioeconomic disadvantage was still associated with THA rate. Compared with the least-disadvantaged quartile, the second-least disadvantaged quartile had 63 fewer THAs per 100,000 people (95% confidence interval 12 to 114), the second-most disadvantaged quartile had 136 fewer THAs (95% CI 62 to 211), and the most-disadvantaged quartile had 183 fewer THAs (95% CI 41 to 325). Geographic socioeconomic disadvantage may be the underlying driver of disparities in THA use. Although our study does not determine the "correct" rate of THA, our findings support increasing access to elective orthopaedic surgery in disadvantaged geographic communities, compared with prior research and efforts that have studied and intervened on the basis of isolated factors such as race and gender. Increasing access to orthopaedic surgeons in disadvantaged neighborhoods, educating physicians about when surgical referral is appropriate, and educating patients from these geographic communities about the risks and benefits of THA may improve equitable orthopaedic care across neighborhoods. Future studies should explore disparities in rates of appropriate THA and the role of density of orthopaedic surgeons in an area. Level III, therapeutic study.

Health care worker perceptions toward computerized clinical decision support tools for Clostridium difficile infection reduction: A qualitative study at 2 hospitals

Clostridium difficile infection (CDI) is associated with significant morbidity and mortality. Computerized clinical decision support (CCDS) tools can aid process improvement in infection prevention and antibiotic stewardship, but implementation and health care workers (HCWs) uptake of these tools is often variable. The objective of this study was to describe HCWs' perceptions of barriers and facilitators related to uptake of CCDS tools as part of a CDI reduction bundle. We conducted a qualitative study among HCWs at 2 acute care hospitals in Maryland. Semi-structured interviews and structured surveys were completed by HCWs to evaluate their perception to CCDS tools at 2 different stages: predevelopment and preimplementation. Emergent themes and patterns in the data were identified and condensed. Gaps in CDI-related knowledge and in communication between HCWs were identified throughout the evaluation. HCWs agreed on the potential of the tools to improve CDI diagnosis, prevention, and control. An important barrier for uptake was the perceived loss of autonomy and clinical judgment, whereas standardization and error reduction were perceived advantages. These observations shaped the development and implementation of the CDI reduction bundle. Qualitative findings can provide valuable contextual information during the development stages of CCDS tools in infection prevention and antibiotic stewardship.

Do Hospitals Support Second Victims? Collective Insights From Patient Safety Leaders in Maryland

Second victims-defined as health care providers who are emotionally traumatized after a patient adverse event-may not receive needed emotional support. Although most health care organizations have an employee assistance program (EAP), second victims may be reluctant to access this service because of worries about confidentiality. A study was conducted to describe the extent to which organizational support for second victims is perceived as desirable by patient safety officers in acute care hospitals in Maryland and to identify existing support programs. Semistructured interviews (using existing and newly developed questions) were conducted with 43 patient safety representatives from 38 of the 46 acute care hospitals in Maryland (83% response rate). All but one of the responding hospitals offered EAP services to their employees, but there were gaps in the services provided related to timeliness, EAP staff's ability to relate to clinical providers, and physical accessibility. There were no valid measures in place to assess the effectiveness of EAP services. Participants identified a need for peer support, both for the second victim and potentially for individuals who provide that support. Six (16%) of the 38 hospitals had second victim support programs, which varied in structure, accessibility, and outcomes, while an additional 5 hospitals (13%) were developing such a program. Patient safety officers thought their organizations should reevaluate the support currently provided by their EAPs, and consider additional peer support mechanisms. Future research is needed to evaluate the effectiveness of these programs.

The 2013 Dip: Factors Influencing Falling Emergency Department Visits and Inpatient Admissions in District of Columbia and Maryland

BackgroundEarlier reports have documented growth of United States emergency department (ED) visits since the early 1990s. ObjectiveIn this report, we describe recent trends in ED utilization and inpatient admissions in Maryland and District of Columbia hospitals from 2011 to 2013. MethodsWe analyzed monthly ED visit and inpatient admission volumes from 53 acute care hospitals in Maryland and the District of Columbia from 2011 to 2013. Fixed-effect regression was used to assess the relationship between community-level demographics, hospital insurance mix, urgent care/retail clinic density, and hospitals participating in Maryland's Total Patient Revenue (TPR) pilot—a global payment program—and changes in ED visit and hospital admission volume from 2012 to 2013. ResultsAcross 53 Maryland and District of Columbia hospitals, ED visits grew 2.8% between 2011 and 2012. From 2012 to 2013, ED visits declined by 3.5%. Admissions declined by 3.3% from 2011 to 2012, then declined again 3.6% from 2012 to 2013. Community demographic or hospital insurance-mix variable and density of urgent care centers were not associated with lower ED visits. Inpatient admissions fell significantly more in hospitals participating in Maryland's TPR global payment pilot program. ConclusionsIn 2013, ED visits in fell in Maryland and District of Columbia hospitals, and inpatient admission volumes fell from 2011 to 2013. This is a reversal of decades-long trends in higher health care utilization. These trends were not explained by demographics, insurance, or ED alternatives, however, falling admission rates were more pronounced in Maryland hospitals participating in global payment programs.

Financial Impact of Surgical Site Infections on Hospitals

Surgical site infections (SSIs) may increase health care costs, but few studies have conducted an analysis from the perspective of hospital administrators. To determine the change in hospital profit due to SSIs. Retrospective study of data from January 1, 2007, to December 31, 2010. The study was performed at 4 of The Johns Hopkins Health System acute care hospitals in Maryland: Johns Hopkins Bayview (560 beds); Howard County General Hospital (238 beds); The Johns Hopkins Hospital (946 beds); and Suburban Hospital (229 beds). Eligible patients for the study included those patients admitted to the 4 hospitals between January 1, 2007, and December 31, 2010, with complete data and the correct International Classification of Diseases, Ninth Revision code, as determined by the infection preventionist. Infection preventionists performed complete medical record review using National Healthcare Safety Network definitions to identify SSIs. Patients were stratified using the All Patient Refined Diagnosis Related Groups to estimate the change in hospital profit due to SSIs. Surgical site infections. The outcomes of the study were the difference in daily total charges, length of stay (LOS), 30-day readmission rate, and profit for patients with an SSI when compared with patients without an SSI. The hypothesis, formulated prior to data collection, that patients with an SSI have higher daily total costs, a longer LOS, and higher 30-day readmission rates than patients without an SSI, was tested using a nonpaired Mann-Whitney U test, an analysis of covariance, and a Pearson χ2 test. Hospital charges were used as a proxy for hospital cost. RESULTS The daily total charges, mean LOS, and 30-day readmission rate for patients with an SSI compared with patients without an SSI were $7493 vs $7924 (P = .99); 10.56 days vs 5.64 days (P < .001); and 51.94 vs 8.19 readmissions per 100 procedures (P < .001). The change in profit due SSIs was $2 268 589. The data suggest that hospitals have a financial incentive to reduce SSIs, but hospitals should expect to see an increase in both cost and revenue when SSIs are reduced.

Abstract 2533: Statewide System Approach has Positive Impact on Stroke Care

Background and Issues: Approximately 83% of acute-care hospitals in Maryland are designated as primary stroke centers. The Maryland Stroke Center Consortium (MSCC) is a network of representatives from all hospitals in the state of Maryland that have been designated as stroke centers. In collaboration with the Maryland Institute of Emergency Medicine Services Systems (MIEMSS)--the body that provides state oversight, the American Heart Association (AHA), and the Maryland Stroke Alliance (MSA), the MSCC works to improve stroke care outcomes statewide. Since 2007, the MSCC has met bi-monthly to network, review data, mentor, educate, and share best practices. Registry participation and data collection are standardized across the state. Purpose: To determine if a statewide consortium can have a positive impact on the quality of care for patients with stroke via the nursing-focused measures of Dysphagia Screening and Patient Education. Methods: All primary stroke centers in Maryland participate in AHA’s Get with the Guidelines (GWTG) Stroke Program. Data were collected using the internet-based Patient Management Tool TM (Outcome, Inc.). A 4-year retrospective review was performed of the Stroke Core Measures and Dysphagia Screening data in the Maryland Stroke Registry. Results: Although over time, improvement was seen in all Stroke Core Measures at both state and national levels, in 2010, Maryland stroke centers demonstrated a higher level of compliance in seven measures compared to all centers participating in the GWTG stroke registry. Moreover, statistically significant higher levels of compliance were found for Dysphagia Screening (82.1% versus 78.3%, p = &lt;0.01) and Patient Education (85.4% versus 81.1%, p = &lt;0.01). Conclusions: Participation in a statewide consortium, paired with oversight at the state level, results in a positive impact on the quality of stroke care and patient outcomes. The critical thinking, open communication, and sharing of information that occur at the consortium level translate into improved care consistent with evidence-based best practices at individual facilities.

Racial disparities in surgical care for uterine cancer

Objective To evaluate the association of race and surgical approach for women who underwent surgical treatment for uterine cancer. Methods The design was a retrospective cohort study of discharge data from nonfederal acute care hospitals in Maryland from 2000 to 2009. Women aged 18 and older who underwent hysterectomy for uterine cancer were included in the study population. The main outcome measure was receipt of lymphadenectomy. Secondary outcomes included receipt of minimally-invasive surgical approach, in-hospital mortality and individual surgeon and individual hospital annual uterine cancer case volume. The independent variable was race. We used logistic regression to calculate odds ratios and confidence intervals for each outcome of interest. Caucasians were the reference group. Results Among 5470 women who underwent hysterectomy, 2727 (49.9%) underwent lymphadenectomy and 512 (9.4%) underwent surgery through a minimally-invasive approach. After adjusting for age, payer status and APR-DRG mortality risk score, African-Americans were more likely to be operated on by high-volume surgeons (adjusted OR = 1.27, 95% CI: 1.09–1.49) yet were less likely to undergo minimally-invasive surgery (adjusted OR = 0.60, 95% CI: 0.45–0.80). For the outcome of lymphadenectomy, there was no significant difference between Caucasians and African-Americans (OR = 1.13, 95% CI: 0.98–1.30). There was no association between race and in-hospital mortality or between race and the odds of undergoing surgery at a high-volume hospital. Conclusion In this retrospective analysis of uterine cancer patients, race is associated with likelihood of undergoing surgery through a minimally-invasive approach. Further analysis using prospectively collected data with more detail regarding peri-operative parameters is needed to further clarify possible reasons for this disparity.

Critical Assessment of Statewide Hospital Pharmaceutical Surge Capabilities for Chemical, Biological, Radiological, Nuclear, and Explosive Incidents

In recent years, government and hospital disaster planners have recognized the increasing importance of pharmaceutical preparedness for chemical, biological, radiological, nuclear, and explosive (CBRNE) events, as well as other public health emergencies. The development of pharmaceutical surge capacity for immediate use before support from the (US) Strategic National Stockpile (SNS) becomes available is integral to strengthening the preparedness of local healthcare networks. The Pharmaceutical Response Project served as an independent, multidisciplinary collaboration to assess statewide hospital pharmaceutical response capabilities. Surveys of hospital pharmacy directors were conducted to determine pharmaceutical response preparedness to CBRNE threats. All 45 acute care hospitals in Maryland were surveyed, and responses were collected from 80% (36/45). Ninety-two percent (33/36) of hospitals had assessed pharmaceutical inventory with respect to biological agents, 92% (33/36) for chemical agents, and 67% (24/36) for radiological agents. However, only 64% (23/36) of hospitals reported an additional dedicated reserve supply for biological events, 67% (24/36) for chemical events, and 50% (18/36) for radiological events. More than 60% of the hospitals expected to receive assistance from the SNS within < or = 48 hours. From a pharmaceutical perspective, hospitals generally remain under-prepared for CBRNE threats and many expect SNS support before it realistically would be available. Collectively, limited antibiotics and other supplies are available to offer prophylaxis or treatment, suggesting that hospitals may have insufficient pharmaceutical surge supplies for a large-scale event. Although most state hospitals are improving pharmaceutical surge capabilities, further efforts are needed.

Association Between Venous Thromboembolism and Perioperative Allogeneic Transfusion

Perioperative allogeneic blood product transfusion would be associated with venous thromboembolic complications in surgical patients. Observational study using a state discharge database. Nonfederal acute care hospitals in Maryland performing colorectal cancer resections between January 1, 1994, and December 31, 2000. We obtained data on 14 014 adult patients having a primary diagnosis code for colorectal cancer and a primary procedure code for colorectal resection. The primary outcome variable was a discharge diagnosis of venous thromboembolism (VTE). Venous thromboembolism occurred in 1% of patients and was associated with an adjusted 3.8-fold increase in mortality (odds ratio, 3.8; 95% confidence interval, 2.1-6.8), a 61% increase in mean hospital length of stay, and a 72% increase in mean total hospital charges. Risk factors for VTE after adjustment included transfusion, female sex, age 80 years or older, moderate to severe liver disease vs no liver disease, admission through the emergency department, and low annual surgeon case volume. Transfusion was associated with an increase in the odds of developing VTE in women (odds ratio, 1.8; 95% confidence interval, 1.2-2.6) but not in men (odds ratio, 0.9; 95% confidence interval, 0.5-1.9). In the absence of transfusion, female compared with male sex was not associated with an increased risk of VTE (odds ratio, 1.2; 95% confidence interval, 0.8-1.7). In this large observational study of patients undergoing colorectal cancer resection, perioperative allogeneic blood transfusion was associated with an increased risk of VTE in women but not in men. Given the substantial morbidity and mortality associated with VTE and the implication that this finding has for postoperative management in women, this association must be confirmed in independent studies.

Outcome and Cost of Craniotomy Performed to Treat Tumors in Regional Academic Referral Centers

Abstract OBJECTIVE Improved clinical and economic outcomes for high-risk surgical procedures have been previously cited in support of regionalization. The goal of this study was to examine the effects of regionalization by analyzing the cost and outcome of craniotomy for tumors and to compare the findings in academic medical centers versus community-based hospitals. METHODS Outcomes and charges were analyzed for all adult patients undergoing craniotomy for tumor in 33 nonfederal acute care hospitals in Maryland using the Maryland Health Service Cost Review Commission database for the years 1990 to 1996. A total of 4723 patients who underwent craniotomy for tumor were selected on the basis of Diagnostic Related Group 1 (craniotomy except for trauma, age 18 or older) and International Classification of Diseases–9th Revision diagnosis code for benign tumor, primary malignant neoplasm, or secondary malignant neoplasm (codes 191, 192, 194, 200, 225, 227, 228, 237, and 239). Hospitals were categorized as high-volume hospitals (&amp;gt;50 craniotomies/yr) or low-volume hospitals (≤50 craniotomies/yr). In-hospital mortality, length of stay, and charges were evaluated. RESULTS The mortality rate was 2.5% at high-volume centers and 4.9% at low-volume hospitals with an adjusted relative risk of 1.4 (P &amp;lt; 0.05), assuming equivalence of disease severity. Adjusted average length of stay in high-volume centers was 6.8, as compared with 8.8 days in low-volume hospitals (P &amp;lt; 0.001). Adjusted average total charges were $15,867 at high-volume centers and $14,045 at low-volume centers (P &amp;lt; 0.001). If all patients in the state had been treated at centers with survival rates equal to those achieved by the high-volume centers, then 46 patients would not have died of operation; that is, 48.6% fewer patients would have died, at an additional adjusted cost of $76,395 dollars per patient saved. CONCLUSION High-volume regional medical centers are capable of providing services with improved mortality rates and fewer hospital days, although with adjusted costs slightly higher than those at low-volume hospitals.

Outcome and Cost of Craniotomy Performed to Treat Tumors in Regional Academic Referral Centers

Improved clinical and economic outcomes for high-risk surgical procedures have been previously cited in support of regionalization. The goal of this study was to examine the effects of regionalization by analyzing the cost and outcome of craniotomy for tumors and to compare the findings in academic medical centers versus community-based hospitals. Outcomes and charges were analyzed for all adult patients undergoing craniotomy for tumor in 33 nonfederal acute care hospitals in Maryland using the Maryland Health Service Cost Review Commission database for the years 1990 to 1996. A total of 4723 patients who underwent craniotomy for tumor were selected on the basis of Diagnostic Related Group 1 (craniotomy except for trauma, age 18 or older) and International Classification of Diseases-9th Revision diagnosis code for benign tumor, primary malignant neoplasm, or secondary malignant neoplasm (codes 191, 192, 194, 200, 225, 227, 228, 237, and 239). Hospitals were categorized as high-volume hospitals (>50 craniotomies/yr) or low-volume hospitals (<or=50 craniotomies/yr). In-hospital mortality, length of stay, and charges were evaluated. The mortality rate was 2.5% at high-volume centers and 4.9% at low-volume hospitals with an adjusted relative risk of 1.4 (P < 0.05), assuming equivalence of disease severity. Adjusted average length of stay in high-volume centers was 6.8, as compared with 8.8 days in low-volume hospitals (P < 0.001). Adjusted average total charges were $15,867 at high-volume centers and $14,045 at low-volume centers (P < 0.001). If all patients in the state had been treated at centers with survival rates equal to those achieved by the high-volume centers, then 46 patients would not have died of operation; that is, 48.6% fewer patients would have died, at an additional adjusted cost of $76,395 dollars per patient saved. High-volume regional medical centers are capable of providing services with improved mortality rates and fewer hospital days, although with adjusted costs slightly higher than those at low-volume hospitals.

Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection.

To determine whether having daily rounds by an intensive care unit (ICU) physician is associated with clinical and economic outcomes after esophageal resection. ICU information was obtained from a prospective survey and linked to retrospective patient data from the Maryland Health Services Cost Review Commission. The main outcome variables were in-hospital mortality rate, length of stay, hospital cost, and complications after esophageal resection. Nonfederal acute care hospitals in Maryland that performed esophageal resection (n = 35 hospitals) during the study period, 1994-1998. Adult patients who underwent esophageal resection in Maryland (n = 366 patients) from 1994 to 1998. Presence vs. absence of daily rounds by an ICU physician. After adjusting for patient case-mix and other hospital characteristics, lack of daily rounds by an ICU physician was independently associated with a 73% increase in hospital length of stay (7 days; 95% confidence interval [CI], 1-15; p =.012) and a 61% increase in total hospital cost ($8,839; 95% CI, $ 1,674-$19,192; p =.013), but there was no association with in-hospital mortality rate. In addition, the following postoperative complications were independently associated with lack of daily rounds by an ICU physician: pulmonary insufficiency (odds ratio [OR], 4.0; CI, 1.4-11.0), renal failure (OR, 6.3; CI, 1.4-28.7), aspiration (OR, 1.7; CI, 1.0-2.8), and reintubation (OR, 2.8; CI, 1.5-5.2). Having daily rounds by an ICU physician is associated with shorter lengths of stay, lower hospital cost, and decreased frequency of postoperative complications after esophageal resection. Healthcare providers and policymakers should use this information to help improve quality of care and reduce costs for patients undergoing high-risk surgical procedures.

Organizational Characteristics of Intensive Care Units Related to Outcomes of Abdominal Aortic Surgery

ContextMorbidity and mortality rates in intensive care units (ICUs) vary widely among institutions, but whether ICU structure and care processes affect these outcomes is unknown.ObjectiveTo determine whether organizational characteristics of ICUs are related to clinical and economic outcomes for abdominal aortic surgery patients who typically receive care in an ICU.DesignObservational study, with patient data collected retrospectively and ICU data collected prospectively.SettingAll Maryland hospitals that performed abdominal aortic surgery from 1994 to 1996.Patients and ParticipantsWe analyzed hospital discharge data for patients in nonfederal acute care hospitals in Maryland who had a principal procedure code for abdominal aortic surgery from January 1994 through December 1996 (n = 2987). We obtained information about ICU organizational characteristics by surveying ICU medical directors at the 46 Maryland hospitals that performed abdominal aortic surgery. Thirty-nine (85%) of the ICU directors completed this survey.Main Outcome MeasuresIn-hospital mortality and hospital and ICU length of stay.ResultsFor patients undergoing abdominal aortic surgery, in-hospital mortality varied among hospitals from 0% to 66%. In multivariate analysis adjusted for patient demographics, comorbid disease, severity of illness, hospital and surgeon volume, and hospital characteristics, not having daily rounds by an ICU physician was associated with a 3-fold increase in in-hospital mortality (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.9). Furthermore, not having daily rounds by an ICU physician was associated with an increased risk of cardiac arrest (OR, 2.9; 95% CI, 1.2-7.0), acute renal failure (OR, 2.2; 95% CI, 1.3-3.9), septicemia (OR, 1.8; 95% CI, 1.2-2.6), platelet transfusion (OR, 6.4; 95% CI, 3.2-12.4), and reintubation (OR, 2.0; 95% CI, 1.0-4.1). Not having daily rounds by an ICU physician, having an ICU nurse-patient ratio of less than 1:2, not having monthly review of morbidity and mortality, and extubating patients in the operating room were associated with increased resource use.ConclusionsOrganizational characteristics of ICUs are related to differences among hospitals in outcomes of abdominal aortic surgery. Clinicians and hospital leaders should consider the potential impact of ICU organizational characteristics on outcomes of patients having high-risk operations.

Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery.

Morbidity and mortality rates in intensive care units (ICUs) vary widely among institutions, but whether ICU structure and care processes affect these outcomes is unknown. To determine whether organizational characteristics of ICUs are related to clinical and economic outcomes for abdominal aortic surgery patients who typically receive care in an ICU. Observational study, with patient data collected retrospectively and ICU data collected prospectively. All Maryland hospitals that performed abdominal aortic surgery from 1994 to 1996. We analyzed hospital discharge data for patients in non-federal acute care hospitals in Maryland who had a principal procedure code for abdominal aortic surgery from January 1994 through December 1996 (n = 2987). We obtained information about ICU organizational characteristics by surveying ICU medical directors at the 46 Maryland hospitals that performed abdominal aortic surgery. Thirty-nine (85%) of the ICU directors completed this survey. In-hospital mortality and hospital and ICU length of stay. For patients undergoing abdominal aortic surgery, in-hospital mortality varied among hospitals from 0% to 66%. In multivariate analysis adjusted for patient demographics, comorbid disease, severity of illness, hospital and surgeon volume, and hospital characteristics, not having daily rounds by an ICU physician was associated with a 3-fold increase in in-hospital mortality (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.9). Furthermore, not having daily rounds by an ICU physician was associated with an increased risk of cardiac arrest (OR, 2.9; 95% CI, 1.2-7.0), acute renal failure (OR, 2.2; 95% CI, 1.3-3.9), septicemia (OR, 1.8; 95% CI, 1.2-2.6), platelet transfusion (OR, 6.4; 95% CI, 3.2-12.4), and reintubation (OR, 2.0; 95% CI, 1.0-4.1). Not having daily rounds by an ICU physician, having an ICU nurse-patient ratio of less than 1:2, not having monthly review of morbidity and mortality, and extubating patients in the operating room were associated with increased resource use. Organizational characteristics of ICUs are related to differences among hospitals in outcomes of abdominal aortic surgery. Clinicians and hospital leaders should consider the potential impact of ICU organizational characteristics on outcomes of patients having high-risk operations.

Importance of hospital volume in the overall management of pancreatic cancer.

To determine whether hospital volume is associated with clinical and economic outcomes for patients with pancreatic cancer who underwent pancreatic resection, palliative bypass, or endoscopic or percutaneous stent procedures in Maryland between 1990 and 1995. Previous studies have demonstrated that outcomes for patients undergoing a Whipple procedure improve with higher surgical volume, but only 20% to 35% of patients with pancreatic cancer qualify for curative resection. Most patients undergo palliative procedures instead with a surgical bypass or biliary stent. Analysis of hospital discharge data from all nonfederal acute care hospitals in Maryland identified all patients with pancreatic cancer who underwent a pancreatic resection, palliative bypass, or stent procedure between 1990 and 1995. Hospitals (n = 48) were categorized as high-, medium-, and low-volume providers according to their average annual volume of these procedures. Multivariate regression was used to examine the association between hospital volume and in-hospital mortality rate, length of stay, and hospital charges, after adjusting for differences in case mix and surgeon volume. Increased hospital volume is associated with markedly decreased in-hospital mortality rates and a decreased or similar length of stay for all three types of procedures and with decreased or similar hospital charges for resections and stents. After adjustment for case mix differences, the relative risk (RR) of in-hospital death after pancreatic resection was 19.3 and 8 at the low- and medium-volume hospitals, respectively, versus the high-volume hospital; after bypasses, the RR of death was 2.7 and 1.9, respectively; and after stents, the RR was 4.3 and 4.8, respectively. Patients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.

Relapsing Invasive Group B Streptococcal Infection in Adults

To study recurrent group B streptococcal infection in adults. Patients with more than one reported group B streptococcal infection were identified through active surveillance for this infection. Sterile-site group B streptococcal isolates were evaluated for serotype and molecular subtyping using restriction endonuclease analysis of chromosomal DNA (REAC). All acute-care hospitals in Maryland. Nonpregnant residents of Maryland 18 years of age or older. 22 adults had at least two group B streptococcal episodes that were separated by 2 to 95 weeks (mean, 24 weeks). Of 395 patients with invasive group B streptococcal infection who survived the first episode and were followed for at least 1 year, 17 (4.3% [95% CI, 2.6% to 6.9%]) had more than one episode. Several patients were found to have endocarditis or osteomyelitis during the second episode. Group B streptococcal isolates from both episodes were obtained from 18 of 22 patients. Of the 18 isolate pairs, 13 (72% [CI, 46% to 90%]) had identical REAC patterns; the probability that at least 13 matches would be found by chance alone was less than 0.000001. Among patients with recurrent infection caused by the same strain, the interval between episodes was shorter (mean, 14 weeks) than that among patients with recurrent infection caused by another strain (mean, 43 weeks; P = 0.05). Recurrent group B streptococcal infection is common among adults and in most cases appears to be caused by relapse. The optimal management of adults with a first episode of group B streptococcal infection needs to be further defined to minimize the likelihood of recurrent disease.

Surgical Rates and Operative Mortality for Open and Laparoscopic Cholecystectomy in Maryland

Since 1989, laparoscopic cholecystectomy has been widely adopted as a treatment for gallstone disease. We analyzed the association between the introduction of this procedure and three variables: the rate at which cholecystectomy was performed in Maryland, the characteristics of patients undergoing cholecystectomy in routine clinical practice, and operative mortality. We used 1985-1992 hospital-discharge data from all 54 acute care hospitals in Maryland, to identify open and laparoscopic cholecystectomies, characteristics of patients undergoing these procedures, and deaths occurring during hospitalizations in which these procedures were performed. The annual rate of cholecystectomy, adjusted for age, rose from 1.69 per 1000 state residents in 1987-1989 to 2.17 per 1000 residents in 1992, an increase of 28 percent (P < 0.001). As compared with patients undergoing open cholecystectomy, patients undergoing laparoscopic cholecystectomy tended to be younger, less likely to have acute cholecystitis or a common-duct stone, and more likely to be white and have private health insurance or belong to a health maintenance organization (P < 0.001). Although the operative mortality associated with laparoscopic cholecystectomy was less than that with open cholecystectomy (adjusted odds ratio, 0.22; 95 percent confidence interval, 0.13 to 0.37) and the overall mortality rate for all cholecystectomies declined from 0.84 percent in 1989 to 0.56 percent in 1992, there was no significant change in the total number of cholecystectomy-related operative deaths because of the increase in the cholecystectomy rate. In Maryland, although the adoption of laparoscopic cholecystectomy has been accompanied by a 33 percent decrease in overall operative mortality per procedure, the total number of cholecystectomy-related deaths has not fallen because of a 28 percent increase in the total rate of cholecystectomy.

Trends in hospitalized discharge rates for head injury in Maryland, 1979-86.

Hospital discharge data from all acute care hospitals in Maryland were used to examine trends in hospitalized head injury incidence and outcome by severity. From 1979 to 1986, discharge rates increased by 3.4/100,000 per year; the largest percent increase was for more severe injuries. Discharge rates increased the most for adults ages 15-24 and ages 75+ but declined for children ages 0-4. Coinciding with the increase in head injury discharges was a decrease in the hospital case-fatality rate across all severity groups.