Agency For Healthcare Research & Quality Research Articles

Using Administrative Data for Mortality Risk Adjustment in Pediatric Congenital Cardiac Surgery*

To evaluate the performance of risk-adjustment models from the University HealthSystem Consortium and the Agency for Healthcare Research Quality on an administrative dataset for children undergoing congenital cardiac surgery. Retrospective cross-sectional cohort analysis. Multi-institutional database of administrative data provided by the University HealthSystem Consortium. Children whose discharge diagnosis had an associated cardiac surgical procedure. None. The performance of two risk-adjustment modeling schemata was measured in terms of discrimination and calibration, and receiver operating characteristic curves were compared. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. A total of 19,436 patients were included in the analysis with 816 deaths and an unadjusted overall mortality rate of 4.2%. The University HealthSystem Consortium models applied to the entire population resulted in an area under the curve = 0.73, and by comparison, the Agency for Healthcare Research Quality risk-adjustment model revealed area under the curve = 0.86. The risk-adjustment model of the University HealthSystem Consortium subgroup of Circulatory System Major Diagnostic Category 5 showed better performance with area under the curve = 0.81. Calibration using the Hosmer-Lemeshow test failed to show good agreement between the predicted and actual outcomes across the University HealthSystem Consortium mortality risk groups with an overall standardized mortality ratio of 1.2 (95% CI, 1.1-1.3; p < 0.0001) and poor predictive ability for the highest risk group, with a nearly 1.5-fold overprediction of death. The Agency for Healthcare Research Quality model shared similar calibration results with an overall standardized mortality ratio of 1.6 (95% CI, 1.5-1.7; p < 0.0001) and a nearly two-fold underprediction of death in the highest risk group. Administrative data can be used to create risk-adjustment models in the congenital cardiac surgery population. Risk-adjustment models generated from administrative data may represent an attractive addition to clinically derived models in pediatric congenital cardiac surgery patients and should be considered for use either alone or in combination with clinical data in future analyses where mortality is a measure of performance and quality.

The effectiveness of non-invasive complementary therapies in reducing postoperative nausea and vomiting following abdominal laparoscopic surgery in women: a systematic review.

Background Postoperative nausea and vomiting (PONV) are common adverse events following surgery and anaesthesia. The reported incidence is particularly high in patients undergoing laparoscopic surgery, ranging from 40-77%. PONV can be very distressing for patients and can result in unplanned readmission in ambulatory surgery. Antiemetics are only partially effective for both prophylaxis and treatment, can have adverse effects and in the case of the newer medications are expensive. The effectiveness of a number of complementary therapies in reducing the incidence of PONV continues to be investigated, given their relative ease of application, relatively low cost, lack of significant side effects, and patient interest and acceptability. Objectives The objective of this review was to determine from the available evidence the most effective non-invasive complementary therapies for reducing the incidence and/or severity of postoperative nausea and vomiting in women undergoing abdominal laparoscopies. Search strategy A literature search was undertaken using: relevant health care databases (eg. AMED, CINAHL, MEDLINE/PubMed, Current Contents, Science Direct); databases of reports, theses, and conference papers (eg Dissertation Abstracts, Conference Papers Index, National Research Register [UK]); and major sources of evidence-based practice information (e.g. Cochrane Library, Agency for Healthcare Research Quality, and clinical trials databases or registers) between the years 1980 and 2007. In addition reference lists of relevant journal articles and selected web sites were checked. Selection criteria Randomised controlled trials and quasi-experimental studies investigating the effects of non-invasive complementary interventions on postoperative nausea and/or vomiting, and the need for rescue medication following abdominal laparoscopic surgery in women were considered for inclusion in the review. Trials with only a ‘no-treatment’ control group were not included. Data collection and analysis Assessment of the eligibility of studies for inclusion in the review and the methodological quality of eligible studies, and data extraction from included studies were undertaken independently by two reviewers. Odds ratios and relative risks for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals. Where pooling of data was inappropriate, studies were considered separately and a narrative summary reported. Main results Twenty-one studies involving a total of 2286 participants were included in the review. Thirteen studies investigated the effect of four interventions on PONV following gynaecological laparoscopy: ginger, acupressure, guided imagery and music. Eight studies examined the effect of two interventions on PONV following laparoscopic cholecystectomy: stimulation of acupoints by various means and oral carbohydrate rich beverage. Six trials with a total of 554 participants investigated the effectiveness of varying dosages of ginger powder (Zingiber officinale) following gynaecological laparoscopy. There is some limited evidence to support providing ginger in doses between 1g and 1.5g to prevent or reduce the level of nausea postoperatively and to reduce the need for rescue medication whereas there is currently no evidence to support either a lower or higher dosage, i.e. 1.5g. Ginger in this dosage range (1-1.5g) has not been demonstrated to be effective in preventing vomiting. Four trials, with a total of 399 participants, investigated the effectiveness of acupressure as prophylactic treatment for PONV in patients undergoing laparoscopic gynaecological procedures; two using the P6 acupoint on the lower arm and two using the Korean K-K9 acupoint on the hand. There is evidence that stimulation of the K-K9 acupoint is effective, however the evidence for stimulating the P6 acupoint in this group of patients is equivocal. Six trials involving 719 participants investigated the effectiveness of stimulation of acupoints in patients undergoing laparoscopic cholecystectomy. There is some evidence to suggest that acupressure or acustimulation at P6 may be somewhat more effective in reducing nausea and vomiting following this surgical procedure TRUNCATED AT 600 WORDS.

Systematic Review of Lumbar Provocation Discography in Asymptomatic Subjects with a Meta-analysis of False-positive Rates

Lumbar provocation discography is a controversial diagnostic test. Currently, there is a concern that the test has an unacceptably high false-positive rate. Systematic review and meta-analysis. To perform a systematic review of lumbar discography studies in asymptomatic subjects and discs with a meta-analysis of the specificity and false-positive rate of lumbar discography. A systematic review of the literature was conducted via a PUBMED search. Studies were included/excluded according to modern discography practices. Study quality was scored using the Agency for Healthcare Research and Quality (AHRQ) instrument for diagnostic accuracy. Specific data was extracted from studies and tabulated per published criteria and standards to determine the false-positive rates. A meta-analysis of specificity was performed. Strength of evidence was rated according to the AHRQ U.S. Preventive Services Task Force (USPSTF) criteria. Eleven studies were identified. Combining all extractable data, a false-positive rate of 9.3% per patient and 6.0% per disc is obtained. Data pooled from asymptomatic subjects without low back pain or confounding factors, shows a false-positive rate of 3.0% per patient and 2.1% per disc. In data pooled from chronic pain patients, asymptomatic of low back pain, the false-positive rate is 5.6% per patient and 3.85% per disc. Chronic pain does not appear to be a confounding factor in a chronic low back pain patient's ability to distinguish between positive (pathologic) and negative (non-pathologic) discs. Among additional asymptomatic patient subgroups analyzed, the false-positive rate per patient and per disc is as follows: iliac crest pain 12.5% and 7.1%; chronic neck pain 0%; somatization disorder 50% and 22.2%, and, post-discectomy 15% and 9.1%, respectively. In patients with chronic backache, no false-positive rate can be calculated. Low-pressure positive criteria (< or = 15 psi a.o.) can obtain a low false-positive rate. Based on meta-analysis of the data, using the ISIS standard, discography has a specificity of 0.94 (95% CI 0.88 - 0.98) and a false-positive rate of 0.06. Strength of evidence is level II-2 based on the Agency for Healthcare Research Quality (USPSTF) for the diagnostic accuracy of discography. Contrary to recently published studies, discography has a low false-positive rate for the diagnosis of discogenic pain.

The contribution of complications to high resource utilization during congenital heart surgery admissions.

The Institutes of Medicine estimates that patient safety events cost the United States between $17 billion and $29 billion annually. Costs associated with patient safety events or complications among congenital heart surgery admissions are understudied. To determine the independent contribution of complications on increased resource utilization during congenital heart surgery admissions. Data were obtained from the Healthcare Cost and Utilization Project Kids' Inpatient Database year 2000. Cases of congenital heart surgery <18 years of age were identified. High resource use admissions were defined as admissions above the 90th percentile for total hospital charges. Complications were identified by a method published by the Agency for Healthcare Research Quality using ICD-9-CM codes. Multivariate analyses using generalized estimating equations adjusted for previously identified factors associated with high resource use to estimate the independent effect of a complication on high resource use. These factors include: Risk Adjustment for Congenital Heart Surgery risk categories, age, prematurity, major noncardiac structural anomalies, Medicaid, weekend admission, and state. The added explanatory power attributed to a complication diagnosis variable was measured by an increase in the area under the receiver operator characteristic curve (ROC). Among 10,602 congenital heart surgery admissions identified, the median total charges were $51,125. The threshold for high resource use was total charges >or=$192,272. High resource admissions accounted for >40% of the total charges for all admissions. Complications were identified in 3360 (32%) of congenital heart surgery admissions. Univariate analysis demonstrated that admissions with at least 1 complication diagnosis were more likely to be a high resource use admission (18% vs. 6%, OR 3.0, P < 0.001). Multivariate analyses revealed that admissions with a complication diagnosis were much more likely to exceed the threshold for high resource utilization (OR 3.2, P < 0.001). The addition of the complication variable to the multivariate model increased the area under the ROC curve from 0.837 to 0.863. Congenital heart surgery admissions with a complication diagnosis are 3 times more likely to exceed $192 272 in total charges despite adjusting for known risk factors for high resource use. Complication reduction may result in both an economic and clinical benefit.

The nursing shortage and the role of technology

The nursing shortage and the role of technology