American Hospital Association Survey Research Articles

Association of partial nephrectomy and presence of robotic surgery for kidney cancer in the United States.

484 Background: While hospital and surgeon characteristics are associated with the type of nephrectomy performed for renal cell carcinoma (RCC), it is unknown whether hospital presence of robotic surgery increases the likelihood of patients receiving partial nephrectomy (PN). Therefore, we evaluate the relationship of PN and hospital presence of robotic surgery from a population-based cohort in the U.S. Methods: After merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association (AHA) survey from 2006 to 2008, we identified 21,999 patients who underwent either PN or radical nephrectomy (RN) for RCC. The primary outcome of this study was the type of nephrectomy performed. Multivariable logistic regression was used to identify hospital characteristics associated with receipt of PN, after adjusting for patient case mix. Results: Overall, we identified 4,832 (22.0%) and 16,347 (88.0%) patients who were surgically treated for RCC with PN and RN, respectively. On multivariable analysis, patients undergoing surgery were more likely to receive PN at academic (OR: 2.77;p<0.001), urban (OR: 3.66; p<0.001), and American College of Surgeon (ACOS) designated cancer centers (OR: 1.10; p<0.05) compared to non-academic, rural, and non-designated hospitals, respectively. After adjusting for patient and hospital characteristics, patients undergoing surgery at hospitals with presence of robotic surgery were also associated with higher adjusted odds ratios for receipt of PN compared to those treated at hospitals without the presence of this advanced treatment technology (OR: 1.28; p<0.001). Conclusions: While academic status and urban locations are established characteristics influencing the type of nephrectomy performed for RCC, ACOS cancer center designation and hospital presence of robotic surgery were also associated with higher use of PN. Our results are informative in identifying key hospital characteristics which may facilitate greater adoption of PN.

Abstract W P311: Demographic and Regional Characteristics Associated With Advanced Primary Stroke Center Designation

Background: Nationwide less than a third of eligible hospitals have achieved advanced certification in stroke, and there may be disparities affecting less affluent areas serving a higher proportion of minorities. We aimed to characterize demographic and regional factors associated with achievement of stroke center certification while controlling for hospital characteristics. Methods: We linked the 2011 American Hospital Association survey of hospital characteristics to the 2010 national census for population and household data by region. Emergency medical services stroke routing data was obtained from communication with state and county contact. Only hospitals with ≥ 25 beds and 24-hour emergency departments were evaluated. The Joint Commission, Healthcare Facilities Accreditation Program and DNV Healthcare websites were used to determine certification status of each hospital. We controlled for hospital bed size, teaching affiliation (AMA, ACGME), emergency department volume, rural designation, hospital type (governmental/for-profit/nonprofit), and trauma center designation in analysis. Results: Of the 3696 hospitals to complete the survey, the 3069 fulfilling study criteria included 908 PSC (31%) and 2161 non-PSC. In univariate analysis PSC hospitals were located in areas with greater population in immediate vicinity (29, 316 vs. 20,901, p<0.0001), greater proportion of minorities (73% white, 16% black, 15% Hispanic vs. 80%/12%/11%, p<0.0001), greater number of households per zip code (11,540 vs. 8050, p<0.0001) and a higher regional mean income ($52,112 vs. $46,262, p<0.0001) and higher home value ($234,000 vs. $170,000, p<0.0001). More PSC hospitals were located in regions with preferential EMS routing of stroke (52% vs. 40%). While controlling for hospital-based factors, the demographic and regional factors independently associated with hospital PSC designation were number of households per zip code (per 1000 households OR 1.1, 95%CI 1.0-1.2), increasing Hispanic population (every 10% increase OR 1.1, 1.0-1.2), and income per household (per $10,000 OR 1.2, 1.1-1.3). Conclusions: Hospitals achieving PSC designation are located in more affluent and densely populated areas with higher population of Hispanic residents.

Abstract T MP54: Hospital Characteristics Associated with Advanced Primary Stroke Center Designation

Background: Organized stroke systems of care, including accreditation of hospitals as primary stroke centers (PSC), are meant to improve patient care and compliance with national guidelines. Nationwide, less than a third of eligible hospitals have achieved advanced certification in stroke. We aimed to characterize hospital factors associated with achievement of stroke center certification. Methods: We utilized the 2011 American Hospital Association survey to obtain data on hospital characteristics. Only hospitals with ≥ 25 beds and 24-hour emergency departments were evaluated. The Joint Commission (TJC), Healthcare Facilities Accreditation Program and DNV Healthcare websites were used to determine certification status of each hospital as a primary stroke center. All comprehensive SC were considered as PSC. Factors found to be associated with achievement of certification (P<0.010) were evaluated by logistic regression to determine a final model of independent association. Results: Of the 3696 hospitals to complete the survey, 3069 fulfilled study criteria, including 908 PSC (31%) and 2161 non-PSC. PSC were larger (mean 354 vs. 136 beds), had busier EDs (56,000 vs. 24,000 visits/year), were more often affiliated with ACGME residency programs (43% vs. 14%), AMA medical schools (51% vs. 21%), TJC-accreditation (95% vs. 65%), inpatient neurological services (94% vs. 46%) and trauma centers (55% VS 38%); and were less likely to be governmental (Federal/State/County 10% vs. 26%) and designated sole community provider (1% vs 9%). Independent hospital characteristics associated with PSC certification were TJC accreditation (OR 3.5, 95%CI 2.4-5.0), sole community provider (OR 0.22, 0.10-0.47), hospital type (governmental vs. non 0.61, 0.44-0.84), increasing size (per quartile in number of beds OR 2.5, 2.1-3.1) and neurological services (OR 3.2, 2.4-4.6). Conclusions: PSC hospitals are larger non-governmental hospitals with availability of neurological services. Increasing the low numbers of governmental (i.e. County or State) hospital achievement of PSC may be a potential area of focus.

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

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. Retrospective cohort study of 35,446 children in 2003, 2006, and 2009 Kids' Inpatient Database (KID). Cross-sectional logistic regression of risk-adjusted inpatient mortality and hospital costs, adjusting for a variety of patient-, hospital-, and community-level confounders. 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. 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. 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.

Drug Shortage: A Transdisciplinary Team Approach to Injectable Vitamin K Shortage for Newborns

Purpose for the Program The 2011 American Hospital Association survey found 100% of responding hospitals (N = 800) experienced a drug shortage in the past 6 months. The proposed presentation will present a model of care developed in response to a critical shortage of injectable vitamin K to newborns at a tertiary regional hospital. The implemented management strategy, developed by a transdisciplinary team, considered issues of safety, ethics, communication, collaboration, education, and evaluated published, evidence‐based data on the use of alternative formulations of vitamin K. Proposed Change In an immediate response to a critical injectable vitamin K shortage at a children's hospital, a transdisciplinary team was formed and an action plan developed, which currently serves as a response model for drug shortage management. Inclusion of the voice of patients was a cornerstone to addressing their needs during this drug shortage crisis. Implementation, Outcomes, and Evaluation The response included availability assessment of alternative drug formulations; development of evidence‐based clinical guidelines; electronic point of care decision‐making tools for physicians; education materials for patients/families; education materials for healthcare providers on management plans; ethical considerations for rationing of supplies; and communication strategies for all administrators, healthcare providers, and patients. The success of the program was linked to working with a local pharmacy to compound oral vitamin K for administration to the infants who met the criteria for that route of administration. Injectable vitamin K was reserved for infants in the neonatal intensive care unit and high‐risk infants. Tools developed to support the model of drug shortage response include color coding system of drug supply for pharmacy and healthcare providers, process flow diagrams, published literature classification system, point of care decision templates, lists of ethical principles to consider, pharmacy policies guiding evaluation of alternative suppliers, and educational guides. As a result of the collaborative response to the injectable vitamin K shortage, 100% of the infants, whose parents consented to receive vitamin K, were given the correct oral dosage while in the hospital. Continued development and system‐wide dissemination of the drug shortage response model is underway. Implications for Nursing Practice By proactively addressing the drug shortage, safety, evidence‐based clinical practice, ethical decision making, efficiency, and cost have the potential to be affected. The response to drug shortages is best conducted with a proactive, rather than reactive, approach to have the necessary elements in place for an appropriate controlled response. The 2011 American Hospital Association survey found 100% of responding hospitals (N = 800) experienced a drug shortage in the past 6 months. The proposed presentation will present a model of care developed in response to a critical shortage of injectable vitamin K to newborns at a tertiary regional hospital. The implemented management strategy, developed by a transdisciplinary team, considered issues of safety, ethics, communication, collaboration, education, and evaluated published, evidence‐based data on the use of alternative formulations of vitamin K. In an immediate response to a critical injectable vitamin K shortage at a children's hospital, a transdisciplinary team was formed and an action plan developed, which currently serves as a response model for drug shortage management. Inclusion of the voice of patients was a cornerstone to addressing their needs during this drug shortage crisis. The response included availability assessment of alternative drug formulations; development of evidence‐based clinical guidelines; electronic point of care decision‐making tools for physicians; education materials for patients/families; education materials for healthcare providers on management plans; ethical considerations for rationing of supplies; and communication strategies for all administrators, healthcare providers, and patients. The success of the program was linked to working with a local pharmacy to compound oral vitamin K for administration to the infants who met the criteria for that route of administration. Injectable vitamin K was reserved for infants in the neonatal intensive care unit and high‐risk infants. Tools developed to support the model of drug shortage response include color coding system of drug supply for pharmacy and healthcare providers, process flow diagrams, published literature classification system, point of care decision templates, lists of ethical principles to consider, pharmacy policies guiding evaluation of alternative suppliers, and educational guides. As a result of the collaborative response to the injectable vitamin K shortage, 100% of the infants, whose parents consented to receive vitamin K, were given the correct oral dosage while in the hospital. Continued development and system‐wide dissemination of the drug shortage response model is underway. By proactively addressing the drug shortage, safety, evidence‐based clinical practice, ethical decision making, efficiency, and cost have the potential to be affected. The response to drug shortages is best conducted with a proactive, rather than reactive, approach to have the necessary elements in place for an appropriate controlled response.

A Profile of Hospitals With Leadership Development Programs

Community hospitals face increasing organizational and environmental complexities that challenge effective leadership. Hospitals are embracing leadership development programs in efforts to ensure leadership talent. While prior literature has described the intent and availability of these programs, the characteristics and performance of hospitals having such programs and their associated market characteristics have not been fully addressed. This article identifies significant differences in organizational, operational, performance, and market factors that are associated with hospitals offering a leadership development program, compared with those hospitals lacking such a program. The authors used American Hospital Association Survey data for 2008, the Area Resource File, and Centers for Medicare & Medicaid data to identify hospitals with and without leadership development programs and analyzed the differences for a number of organizational, operational, performance, and market variables. Findings indicate that hospitals having leadership development programs were large-bed-size facilities, had not-for-profit ownership, were system affiliated, were located in metropolitan statistical areas, and were teaching affiliated facilities. These hospitals also generated higher patient discharges, had higher occupancy, and had a longer average length of stay, compared with hospitals without such programs. In addition, these hospitals had higher net patient revenue per adjusted discharge and higher total profit margins relative to the comparison group.

Overcoming challenges to achieving meaningful use: insights from hospitals that successfully received Centers for Medicare and Medicaid Services payments in 2011

In an effort to understand better the federal electronic health record (EHR) incentive programme's challenges, this study compared hospitals that did and did not receive meaningful use (MU) payments in the programme's first year based on the challenges they anticipated a year before. This cross-sectional study used 2010 American Hospital Association survey data and 2011 Centers for Medicare and Medicaid Services data that identify hospitals receiving MU payments. Multivariate regression analysis assessed differences in 2010 anticipated challenges to MU for hospitals that were successful in earning 2011 MU payment compared to hospitals that intended to participate in the programme but were not yet successful. The study sample consisted of 2475 hospitals, 313 of which received MU payments in 2011. Controlling for standard hospital characteristics, hospitals that reported the computerized provider order entry (CPOE) MU criterion as a primary challenge were 18% less likely to receive a 2011 MU payment compared to hospitals that reported other criteria as primary challenges. CPOE was the main challenge among hospitals that failed to achieve MU in the first year of the programme. In order to maximize the incentive programme's effectiveness, policymakers, healthcare organizations, and EHR vendors may benefit from increased attention to hospitals' challenges with CPOE. As the EHR incentive programme matures, policymakers and other stakeholders should consider strategies that maintain the critical elements of MU while adequately supporting hospitals that desire to become MU but are impeded by specific technological, cultural, and organizational adoption and use challenges.

Electronic Medical Record Adoption in Hospitals That Care for Children

ObjectiveHospitals that care for children face unique barriers in electronic medical records (EMR) use that may affect their ability to meaningfully use EMR. The purpose of this study was to investigate hospitals that care for children, both freestanding and adult hospitals with children's services, to determine progress toward advanced stages of EMR use. MethodsThe American Hospital Association survey described hospitals across the United States. Healthcare Information and Management Systems Society 2006 and 2010 databases identified hospitals' EMR use. EMR stage was classified according to previous studies. Multivariable analysis was used to determine independent predictors of EMR use. ResultsThe analysis included 2794 hospitals. During the study time frame, a significant increase occurred for hospitals moving into any stage of EMR in adult hospitals with children's services (47% to 75%; P < .001), while improvements for freestanding children's hospitals were modest at best (46% to 59%; P = .3). Conversely, freestanding children's hospitals had the largest gain in advance stage 3 adoption (6% to 39%; P < .001) compared to adult hospitals with children's services (6% to 23%; P < .001). Freestanding children's hospitals were less likely to use pharmacy information systems but more likely to use computerized provider order entry. ConclusionsIn 2010, freestanding children's hospitals had the highest percentage use of advanced stage EMR (39%), but the lowest improvements in percentage of hospitals entering into any stage of adoption over the study period. This trend created a digital divide among freestanding children's hospitals that may improve with pediatric-specific electronic medication management products.

Variations in US Hospital Performance on Imaging-use Measures

The Hospital Outpatient Quality Reporting Program (HOQR) publicly reports measures of US hospitals' use of 4 imaging studies that may be problematic if overused: magnetic resonance imaging (MRI) for low back, follow-up imaging after screening mammography, and abdominal and thoracic computed tomography (CT) with and without contrast. To characterize performance on these measures, determine whether performance was consistent across measures, and identify hospital characteristics associated with highest-decile imaging use. Cross-sectional analysis. Correlation across measures was assessed using Spearman rank order tests. We linked 2008 HOQR data to the 2009 American Hospital Association Survey and used multivariable logistic regression to examine associations between hospital characteristics and the likelihood of highest-decile imaging use. Imaging use varied widely. Imaging use was weakly correlated (ρ<0.10) across most measures. Compared with hospitals with moderate imaging volume (25th to 75th percentile), hospitals with low volume (<25th percentile) were more likely to report highest-decile imaging use on all measures [adjusted odds ratios (95% confidence interval) range from 1.38 (1.05-1.80) for CT Abdomen to 4.22 (3.04-5.84) for MRI Back]. Rural hospitals were more likely to report highest-decile use on most measures [MRI: 1.42 (1.21-1.68), CT Abdomen: 1.46 (1.28-1.66), and CT Thorax: 1.32 (1.16-1.51)]. For-profit hospitals were more likely to report highest-decile use on mammography [1.47 (1.10-1.98)] and CT Thorax measures [1.71 (1.28-2.27)]. Wide variations in imaging use and extraordinarily high use at some hospitals may indicate that imaging overuse occurs at US hospitals. The effectiveness of the HOQR measures to decrease imaging overuse remains to be seen.

Hospitalization Costs for Radical Prostatectomy Attributable to Robotic Surgery

BackgroundWith health technology innovation responsible for higher health care costs, it is essential to have accurate estimates regarding the differential costs between robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP). ObjectiveTo describe the total hospitalization costs attributable to robotic and open surgery for radical prostatectomy (RP). Design, setting, and participantsUsing a population-based cohort by merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association (AHA) survey from 2006 to 2008, we identified 29 837 prostate cancer patients who underwent RP. InterventionsORP and RARP. Outcome measurements and statistical analysisThe primary outcome was total hospitalization costs adjusted to year 2008 US dollars. Generalized estimating equations were used to identify patient and hospital characteristics associated with total hospitalization costs and to estimate costs of ORP and RARP adjusted for case mix and hospital teaching status, location, and annual case volume. Results and limitationsOverall, 20 424 (68.5%) patients were surgically treated with RARP, and 9413 (31.5%) patients underwent ORP. Compared to ORP, patients undergoing RARP had shorter median length of stay (1 d vs 2 d; p<0.001) and were less likely to experience any postoperative complications (8.2% vs 11.3%; p<0.001). However, patients undergoing RARP had higher median hospitalization costs ($10409 vs $8862; p<0.001). After adjusting for patient and hospital features, RARP was associated with higher total hospitalization costs compared to ORP ($11932 vs $9390; p<0.001). Our results are limited by a study design using retrospective population-based data. ConclusionsDespite RARP having lower complications and shorter length of stay than ORP, total hospitalization costs are higher for patients treated with RARP compared with those treated with ORP.

Impact of Electronic Health Records on Nurses’ Productivity

As the use of electronic health records increases, it becomes necessary to address their global impact on nurses' productivity in hospitals. A retrospective cross-sectional study was conducted to explore the impact of electronic health records on nurses' productivity and to examine whether the impacts are moderated through case-mix index or adjusted patient-days. Two sources of data were linked and analyzed for years 2007 and 2008: the American Hospital Association survey and the Centers for Medicare & Medicaid Services data. Almost two-thirds of the respondent hospitals in both years (63.9% in 2007 and 68.4% in 2008) had a high electronic health record index (≥5). Hospitals with higher penetration of electronic health records had more RNs employed (coefficient=0.234, P=.002) compared with hospitals with low penetration of electronic health records, even when controlling for adjusted patient-day volumes. This difference decreased for hospitals with higher case-mix index values. The study findings fail to suggest any financial savings or superior productivity in nurses due to usage of electronic health records.

413 INPATIENT UROLOGIC CARE IN CRITICAL ACCESS HOSPITALS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness III1 Apr 2012413 INPATIENT UROLOGIC CARE IN CRITICAL ACCESS HOSPITALS Adam J. Gadzinski, Justin B. Dimick, Zaojun Ye, and David C. Miller Adam J. GadzinskiAdam J. Gadzinski Ann Arbor, MI More articles by this author , Justin B. DimickJustin B. Dimick Ann Arbor, MI More articles by this author , Zaojun YeZaojun Ye Ann Arbor, MI More articles by this author , and David C. MillerDavid C. Miller Ann Arbor, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.479AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Critical Access Hospitals (CAHs) comprise over 25% of acute care hospitals in the United States. As evidenced by their unique cost-based reimbursement, policymakers view CAHs as essential healthcare providers for rural communities and other underserved populations. In order to better understand their role in urologic care delivery, we examined utilization patterns for inpatient urological procedures at CAHs and non-CAH hospitals. METHODS We used data from the American Hospital Association (AHA) survey to identify all CAHs in the United States. After linking AHA data with the Nationwide Inpatient Sample (NIS), we used Clinical Classification Software to identify all patients who underwent at least one urological procedure during an inpatient stay at a CAH or non-CAH hospital. We classified each procedure as major (i.e., requiring an operating room) or minor, and assigned it to one of seven clinical categories (Figure). We then examined and compared the type and distribution of urological procedures performed at CAH versus non-CAH centers. RESULTS Among the 1,292 CAHs and 3,760 non-CAHs reporting data to the AHA, 35% and 36%, respectively, had at least one year of data in the NIS. From 2005 through 2009, these centers performed 1,013,762 urological procedures (49% major) during 702,116 admissions. CAHs performed only 1% of all procedures. Additionally, the proportion of CAHs performing any (65%) or major urological procedures (55%) was significantly lower than for non-CAH facilities (98% and 96%, respectively, both p-values<0.01). The distribution of both minor and major procedures also differed for CAH vs non-CAH centers (p<0.01). For major procedures, urologic cancer surgery is comparatively rare at CAHs (Figure). Instead, anti-incontinence surgeries represent the most common major inpatient urological procedures. CONCLUSIONS Two-thirds of CAHs perform inpatient urological procedures; however, only half provide access to major urologic surgery. The profile of major procedures is also different than for non-CAH facilities, with a greater emphasis on treatment of urinary incontinence and other benign urological conditions. These data inform ongoing efforts to enhance access and quality of urological care for rural communities and other underserved populations. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e169 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adam J. Gadzinski Ann Arbor, MI More articles by this author Justin B. Dimick Ann Arbor, MI More articles by this author Zaojun Ye Ann Arbor, MI More articles by this author David C. Miller Ann Arbor, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Drive Times to Hospitals With Perinatal Care in the United States

To evaluate access to inpatient obstetric care, we determined the proportions of women of reproductive age who resided within 30-minute and 60-minute driving times to the nearest hospital offering perinatal services. Perinatal centers, identified from the 2007 American Hospital Association survey, were designated as being level I (uncomplicated obstetric and nursery care), level II (limited complicated care), or level III (full complement of care). The study population consisted of all reproductive-aged (18-39 years) women included in the 2010 U.S. Census Bureau estimates. We used geographic information system mapping software to map 30-minute and 60-minute drive times from the census block group centroid to the nearest perinatal center. A total of 2,606 hospitals in the United States offered some level of perinatal care for the 49.8 million reproductive-aged women. Access to perinatal centers within a 30-minute drive varied by the level of care: 87.5% of the population to any center; 78.6% to level II or level III centers; and 60.8% to level III facilities. Access to the centers within a 60-minute drive also varied: 97.3% of the population to any center; 93.1% to level II or level III centers; and 80.1% to level III facilities. The mostly rural western half of the United States (except for the Pacific Coast) and Alaska had the greatest geographic maldistribution of perinatal services. Driving times to hospitals offering perinatal care vary considerably. Using geographic information system software can be valuable for regional obstetric workforce planning and policy-making in relation to accessing care.

Increasing hospital volume is not associated with improved survival in out of hospital cardiac arrest of cardiac etiology

BackgroundResuscitation centers may improve patient outcomes by achieving sufficient experience in post-resuscitation care. We analyzed the relationship between survival and hospital volume among patients suffering out-of-hospital cardiac arrest (OHCA). MethodsThis prospective cohort investigation collected data from the Cardiac Arrest Registry to Enhance Survival database from 10/1/05 to 12/31/09. Primary outcome was survival to discharge. Hospital characteristics were obtained via 2005 American Hospital Association Survey. A hospital's use of hypothermia was obtained via direct survey. To adjust for hospital- and patient-level variation, multilevel, hierarchical logistic regression was performed. Hospital volume was modeled as a categorical (OHCA/year≤10, 11–39, ≥40) variable. A stratified analysis evaluating those with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) was also performed. ResultsThe cohort included 4125 patients transported by EMS to 155 hospitals in 16 states. Overall survival to hospital discharge was 35% among those admitted to the hospital. Individual hospital rates of survival varied widely (0–100%). Unadjusted survival did not differ between the 3 hospital groups (36% for ≤10 OHCA/year, 35% for 11–39, and 36% for ≥40; p=0.75). After multilevel adjustment, differences in survival across the groups were not statistically significant. Compared to patients at hospitals with ≤10 OHCA/year, adjusted OR for survival was 1.04 (CI95 0.83–1.28) among 11–39 annual volume and 0.97 (CI95 0.73–1.30) among the ≥40 volume hospitals. Among patients presenting with VF/VT, no difference in survival was identified between the hospital groups. ConclusionSurvival varied substantially across hospitals. However, hospital OHCA volume was not associated with likelihood of survival. Additional efforts are required to determine what hospital characteristics might account for the variability observed in OHCA hospital outcomes.

Variability in Case-mix Adjusted In-hospital Cardiac Arrest Rates

It is unknown how in-hospital cardiac arrest (IHCA) rates vary across hospitals and predictors of variability. Measure variability in IHCA across hospitals and determine if hospital-level factors predict differences in case-mix adjusted event rates. Get with the Guidelines Resuscitation (GWTG-R) (n=433 hospitals) was used to identify IHCA events between 2003 and 2007. The American Hospital Association survey, Medicare, and US Census were used to obtain detailed information about GWTG-R hospitals. Adult patients with IHCA. Case-mix-adjusted predicted IHCA rates were calculated for each hospital and variability across hospitals was compared. A regression model was used to predict case-mix adjusted event rates using hospital measures of volume, nurse-to-bed ratio, percent intensive care unit beds, palliative care services, urban designation, volume of black patients, income, trauma designation, academic designation, cardiac surgery capability, and a patient risk score. We evaluated 103,117 adult IHCAs at 433 US hospitals. The case-mix adjusted IHCA event rate was highly variable across hospitals, median 1/1000 bed days (interquartile range: 0.7 to 1.3 events/1000 bed days). In a multivariable regression model, case-mix adjusted IHCA event rates were highest in urban hospitals [rate ratio (RR), 1.1; 95% confidence interval (CI), 1.0-1.3; P=0.03] and hospitals with higher proportions of black patients (RR, 1.2; 95% CI, 1.0-1.3; P=0.01) and lower in larger hospitals (RR, 0.54; 95% CI, 0.45-0.66; P<0.0001). Case-mix adjusted IHCA event rates varied considerably across hospitals. Several hospital factors associated with higher IHCA event rates were consistent with factors often linked with lower hospital quality of care.

Incidence of treated cardiac arrest in hospitalized patients in the United States*

The incidence and incidence over time of cardiac arrest in hospitalized patients is unknown. We sought to estimate the event rate and temporal trends of adult inhospital cardiac arrest treated with a resuscitation response. Three approaches were used to estimate the inhospital cardiac arrest event rate. First approach: calculate the inhospital cardiac arrest event rate at hospitals (n = 433) in the Get With The Guidelines-Resuscitation registry, years 2003-2007, and multiply this by U.S. annual bed days. Second approach: use the Get With The Guidelines-Resuscitation inhospital cardiac arrest event rate to develop a regression model (including hospital demographic, geographic, and organizational factors), and use the model coefficients to calculate predicted event rates for acute care hospitals (n = 5445) responding to the American Hospital Association survey. Third approach: classify acute care hospitals into groups based on academic, urban, and bed size characteristics, and determine the average event rate for Get With The Guidelines-Resuscitation hospitals in each group, and use weighted averages to calculate the national inhospital cardiac arrest rate. Annual event rates were calculated to estimate temporal trends. Get With The Guidelines-Resuscitation registry. Adult inhospital cardiac arrest with a resuscitation response. The mean adult treated inhospital cardiac arrest event rate at Get With The Guidelines-Resuscitation hospitals was 0.92/1000 bed days (interquartile range 0.58 to 1.2/1000). In hospitals (n = 150) contributing data for all years of the study period, the event rate increased from 2003 to 2007. With 2.09 million annual U.S. bed days, we estimated 192,000 inhospital cardiac arrests throughout the United States annually. Based on the regression model, extrapolating Get With The Guidelines-Resuscitation hospitals to hospitals participating in the American Hospital Association survey projected 211,000 annual inhospital cardiac arrests. Using weighted averages projected 209,000 annual U.S. inhospital cardiac arrests. There are approximately 200,000 treated cardiac arrests among U.S. hospitalized patients annually, and this rate may be increasing. This is important for understanding the burden of inhospital cardiac arrest and developing strategies to improve care for hospitalized patients.

13 Quality Improvement Strategies and the Link to Performance on Percutaneous Intervention for Acute Myocardial Infarction

In an effort to encourage quality improvement in emergency care, a number of organizations (eg, Institute of Medicine, Joint Commission, American College of Emergency Physicians) have recommended that hospitals adopt various improvement practices and technologies including patient flow improvement, emergency department (ED) dashboards, and 5-level triage systems. These quality improvement strategies have been shown to be beneficial in single-site evaluations, but to our knowledge, they have not been evaluated in multisite studies. Our study explores the relationship between use of these 3 quality improvement strategies and hospital performance on receipt of percutaneous intervention within 90 minutes for acute myocardial infarction patients. In 2009, we administered a survey on quality improvement activities to chief quality officers at 1,988 hospitals; 28.8% (n=572) responded. The survey asked respondents about the use of ED dashboards and whether patient flow strategies were used widely or hospital-wide. We obtained data from the 2009 American Hospital Association (AHA) Annual Survey on hospitals' ED triage systems. We paired these data with 2008 and 2009 Hospital Quality Alliance data on the percentage of acute myocardial infarction patients with a percutaneous coronary intervention time under 90 minutes. After excluding hospitals with less than 25 cases, data were available for 271 hospitals. T-tests were used to detect differences in percutaneous coronary intervention performance scores based on whether hospitals used patient flow strategies, an ED dashboard, and a 5-level triage system. Linear regression models were used to adjust for hospital characteristics (bed size, region, ownership, network affiliation, and teaching status) obtained from the AHA Survey. Forty-four percent of respondents reported using patient flow strategies widely or hospital-wide, 46% reported using an ED dashboard, and 55% reported using a 5-level triage system. In comparison to hospitals that did not use the practice or technology, percutaneous coronary intervention performance scores were significantly (p<.05) better at hospitals that used patient flow strategies (83.9% versus 80.4%), ED dashboards (83.7% versus 80.0%) and 5-level triage systems (83.7% versus 78.4%). Even after controlling for hospital characteristics, percutaneous coronary intervention performance scores were 3.5 (p<.03) percentage points higher (ie, better) for hospitals that used patient flow strategies and 6.2 (p<.01) percentage points higher for hospitals that used a 5-level triage system. percutaneous coronary intervention performance scores were 5.2 (p<.01) percentage points higher at hospitals with 2 quality improvement strategies in place and 7.6 (p<.01) percentage points higher at hospitals with 3 quality improvement strategies in place. Use of multiple quality improvement strategies was associated with significantly and sizably better percutaneous coronary intervention performance scores, and the biggest difference in percutaneous coronary intervention scores was between hospitals that do and do not use 5-level triage. Our findings suggest that hospitals should consider adopting these quality improvement strategies.

Choledocholithiasis Management in Rural America: Health Disparity or Health Opportunity?

Choledocholithiasis (CDL) management is dictated by local expertise, individual training, and availability of appropriate staff. This study evaluates the management of CDL between urban and rural communities. Patients undergoing inpatient management of CDL were identified from the 2007 Healthcare Cost and Utilization Project. Availability of endoscopic retrograde cholangiopancreatography (ERCP) was determined from the 2007 American Hospital Association survey. The proportion of common bile duct exploration (CBDE), ERCP, or percutaneous (PERC) interventions were compared across census regions and National Centers for Health Statistics (NCHS) urban-rural classes. The NCHS urban-ruralclassification scheme divides counties from most populous (NCHS 1) to rural (NCHS 6). Proportions were compared using the 95% confidence interval (95%CI) approach. We estimated 111,021 CDL hospitalizations in the U.S. in 2007. Of these, 67% had a coded intervention. Intervention frequencies were similar across census regions. Comparisons across NCHS classes revealed higher proportions of ERCP in urban areas (NCHS 1-4) while a higher proportion of CBDE was seen in rural areas (NCHS 5-6). ERCP availability was high in metropolitan areas (available in 35%-44% of hospitals NCHS 1-4) and low in rural areas (25% of NCHS 5 hospitals and 5% NCHS 6). PERC management was similar across NCHS classes. Rural hospitals and communities need surgeons trained in CBDE, where ERCP expertise may not be readily available. Feasible ways of expanding ERCP coverage to the nation's rural areas need to be explored. These observations may impact surgical training at least for those targeting careers in rural surgery.

Variation in Hospital Mortality Rates for Patients With Acute Myocardial Infarction

Hospitals vary by twofold in their hospital-specific 30-day risk-stratified mortality rates (RSMRs) for Medicare beneficiaries with acute myocardial infarction (AMI). However, we lack a comprehensive investigation of hospital characteristics associated with 30-day RSMRs and the degree to which the variation in 30-day RSMRs is accounted for by these characteristics, including the socioeconomic status (SES) profile of hospital patient populations. We conducted a cross-sectional national study of hospitals with ≥15 AMI discharges from July 1, 2005 to June 20, 2008. We estimated a multivariable weighted regression using Medicare claims data for hospital-specific 30-day RSMRs, American Hospital Association Survey of Hospitals for hospital characteristics, and the United States Census data reported by Neilsen Claritas, Inc., for zip-code level estimates of SES status. Analysis included 2,908 hospitals with 513,202 AMI discharges. Mean hospital 30-day RSMR was 16.5% (SD 1.7 percentage points). Our multivariable model explained 17.1% of the variation in hospital-specific 30-day RSMRs. Teaching status, number of hospital beds, AMI volume, cardiac facilities available, urban/rural location, geographic region, ownership type, and SES profile of patients were significantly (p < 0.05) associated with 30-day RSMRs. In conclusion, substantial variation in hospital outcomes for patients with AMI remains unexplained by measurements of hospital characteristics including SES patient profile.

The Relationship Between Hospital Size and ICU Type on Select Adverse Patient Outcomes

The authors examined the relationships among hospital size and unit type, the prevalence of pressure ulcers, and rates of ventilator-associated pneumonia and catheter-related bloodstream infections in 25 intensive care units (ICUs) in 8 hospitals. Data came from the American Hospital Association survey, and nursing and infection control databases. Multiple regression was the main statistical technique. Pressure ulcer prevalence and catheter-related bloodstream infection rates were higher in large hospitals; ventilator-associated pneumonia rates were higher in surgical ICUs. Future researchers should include factors often hidden within hospital and unit characteristics to expose possible relationships that may be incorporated into interventions to prevent adverse outcomes.