Dallas-Fort Worth Hospital Council Research Articles

Patient age, gender, and early outcome after PVI atrial ablation: analysis of a large regional database

Abstract Background Demographics such as patient age and gender have been inconsistently found to be associated with outcome after ablation to achieve pulmonary vein isolation (PVI). A database created by the Dallas-Fort Worth Hospital Council (DFWHC) includes a collaboration of 90 member hospitals in North Texas reporting data on procedures, diagnoses, and discharges. All patients in this system can be followed longitudinally via unique identification number. The availability of this large, regional database offers opportunities to better characterize trends. Objective Characterize the association between age, gender, and 60-day outcome in patients receiving PVI over a 7-year time span. Methods Using the DFWHC database, all PVI procedures performed from January 2013 to December 2019 were identified. Follow up visits for this cohort of patients were then obtained, and outcomes recorded. Early mortalities (occurring less than 60 days from PVI), mean age and patient gender were determined for each of the groups and compared. Results A total of 11,880 unique PVI procedures were performed over this 7 year timeframe. Mean patient age was 64±10 years, with 66% male and 34% female. A total of 130 mortalities at any time after PVI occurred (1.1%), with 19 (0.16%) occurring within 60 days of the procedure. In multivariate analysis, the risk of 60-day mortality increased with year of procedure (OR 1.07, 95% CI 0.85 to 1.4) and female gender (OR 1.43, 95% CI 0.57 to 3.6), and decreased with age (OR 0.99, 95% CI 0.95 to 1.03); however no variable demonstrated statistically significant association with outcome. Conclusions Although trends towards increasing mortality over time and in female patients were seen, the total number of events remained low, and no statistically significant associations between age, gender, and early mortality were identified in this large regional database. Funding Acknowledgement Type of funding sources: None.

B-PO05-113 TIMING OF MORTALITY EVENTS AFTER PULMONARY VEIN ISOLATION: ANALYSIS OF A LARGE REGIONAL DATABASE

Ablation using pulmonary vein isolation (PVI) to treat atrial fibrillation is effective; however, there is limited information regarding mortality after discharge. Recent studies of the Nationwide Readmissions Database have found higher than expected mortality after ablation procedures. A database created by the Dallas-Fort Worth Hospital Council (DFWHC) includes a collaboration of 90 member hospitals in North Texas reporting data on procedures, diagnoses, and discharges. All patients in this system can be followed longitudinally via unique identification number. The availability of this database offers additional opportunities to better quantify mortality rates after PVI. Measure the incidence and timing of mortality after PVI in a large regional database. We queried the DFWHC database for all PVI ablations occurring over the timeframe from January 2013 to December 2019. We then queried the resulting population for all subsequent hospital visits and discharge outcomes. A total of 11,880 unique PVI procedures were performed over this 7 year time span, with 1242 occurring in 2013, increasing to 3177 in 2019 (a 156% increase over these 7 years). Out of this group, at total of 130 deaths occurred (1.1%), with 4 (.32%) in 2013, and 32 (0.92%) in 2019; however, the majority of these were late events (beyond 120 days from the procedure). Mortality at 30, 60, 90, and 120 days after PVI was 7 (0.059%), 19 (0.16%), 21 (0.18%), and 24 (0.20%), respectively. In line with trends in recently reported data, mortality after PVI may be increasing slightly; however, overall mortality after PVI in this large regional database remains low, and early mortality is lower than that found in the Nationwide Readmissions Database.

Triple Aim and the Hospital Readmission Reduction Program.

Objectives:Despite substantial attention on hospital readmission rates, the impact of the Hospital Readmission Reduction Program (HRRP) on a comprehensive set of Triple Aim goals has not been studied: improve hospital quality, reduce cost, and improve patient experience.Methods:We analyze inpatient claims data from 2006 to 2015 from the Dallas Fort Worth Hospital Council Foundation with a panel of 27,397 patients with chronic obstructive pulmonary disease and congestive heart failure. We deploy a quasi-natural experiment using a difference-in-difference specification to estimate the effect of HRRP effect on readmission rates, length of stay (LOS), and hospital satisfaction.Results:We find that the likelihood of 30-day readmissions declined by 2.6%, average LOS decreased by 7.9%, and overall hospital rating increased by 2.1% among hospitals that fell under the scope of the HRRP, compared to non-HRRP hospitals. Our results provide evidence of a spillover effect of the HRRP in terms of its impact not only on Medicare patients, but across all insurance types, and other performance measures such as cost and patient experience.Conclusion:Our findings indicate that HRRP hospitals do not trade-off reductions in readmission rates with lower quality across other patient health outcomes. Rather, we find evidence that the HRRP has affected all 3 dimensions of the Triple Aim with respect to patient and hospital outcomes.

Predictors for 30-Day Readmissions After Traumatic Brain Injury.

To examine predictors for 30-day readmission post-onset of traumatic brain injury (TBI) after initial trauma hospitalization. Retrospective cohort. In total, 5284 patients with an acute TBI admitted from January 1, 2006, through December 31, 2015. Demographic and clinical data after initial TBI onset were extracted from the local trauma registry and matched with the Dallas-Fort Worth Hospital Council registry. Multiple logistic regression analysis was used to determine factors significantly associated with 30-day readmission. Top diagnosis codes for 30-day readmission were also described. Patients were primarily male (64.6%), non-Hispanic White (47.6%), uninsured (35.4%), and aged 46.1 ± 23.3 years. In total, 448 patients (8.5%) had a 30-day readmission. Median cumulative charges for each readmitted subject was $34 313. Factors significantly associated with 30-day readmission were falling as the cause of injury, having increased Charlson Comorbidity Index and Injury Severity Score, and discharging to a skilled nursing facility or long-term acute care. Being uninsured was associated with decreased odds of a 30-day readmission. Top diagnosis codes among the readmission visits included cardiac codes (57.7%), fluid and acid-base disorders (54.8%), and hypertension (50.1%). These data highlight those at risk for 30-day readmission across a diverse population of TBI at a large medical center. Interventions such as health literacy education or patient navigation may help mitigate 30-day readmission for at-risk patients.

1505-P: Lower Extremity Amputation Trends among People with Diabetes in a Large Urban Environment

Non-traumatic lower extremity amputations (NLEAs) are a major complication for individuals with poorly controlled diabetes. We sought to identify trends for diabetic NLEAs in Dallas County between 2015 (4th quarter) to 2019 (3rdquarter) by using hospitalization data available from Dallas-Fort Worth Hospital Council Educational and Research Foundation and the CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Per BRFSS, the prevalence of diabetes in Dallas County is 11.7% with a mean (±SD) age of 53±19.1 years, and 56% male, 27% Hispanic, 35% black and 30% non-Hispanic white. The age-adjusted NLEA rates per 1,000 in this population of adults with diabetes increased 18.1% between 2015 and 2019 (incomplete years annualized), with men experiencing higher NLEA rates than women. There was a significant decrease in age-adjusted rates of all NLEAs in women from 2017 and 2018, reflecting prior reports at the national level. The age-adjusted rates for major NLEAs decreased in all age groups except ages 75+ between 2018 and 2019 with a concomitant increase in minor NLEAs; this had been preceded by a steady increase in rates of all NLEAs up to 2018. Of relevance is that starting in 2018 the proportion of major to minor NLEAs has been decreasing steadily. In conclusion, we note a fall in NLEA rates in the last year of observation with the added benefit of a relative fall in major compared to minor NLEAs in patients with diabetes. Disclosure K.K. Chatha: None. B. Walsh: None. J. La Fontaine: None. M.E. Bowen: None. L. Meneghini: Advisory Panel; Self; Novo Nordisk Inc., Sanofi US. Consultant; Self; Applied Therapeutics, Sanofi US.

Predicting admissions for adult asthma exacerbations in North Texas.

The purpose of this study was to provide a picture of asthma disparities and the contributions of social and environmental factors to asthma exacerbations in the north central region of Texas, where intense, rapid development is a feature of contemporary life. Cross-sectional analysis of data associated with 66 hospitals in the 8 counties containing and surrounding the Dallas/Fort Worth metropolitan area. Census blocks containing adult asthma patients admitted to emergency departments (ED) or inpatient units for asthma exacerbations in 2014. Data for secondary analysis were collected from the Dallas Fort Worth Hospital Council Foundation. Sex, family income, education, race, age of housing, speed, and traffic density on neighborhood roads affected asthma admissions. Proximity to urban drilling sites had only a small effect on admissions in this sample. Minorities were significantly more likely to obtain services in the ED than whites. Attributes associated with poor and underserved patients predicted asthma exacerbations in the target region. These are vulnerable patients who can ill afford further erosion of health care insurance or additional environmental insults.

Emergency Department Testing Patterns for Sexually Transmitted Diseases in North Texas.

Little is known about population-level sexually transmitted disease (STD) testing in emergency departments (EDs). We sought to explore STD testing patterns in EDs in a large, urban metroplex in North Texas, a high prevalence region. Emergency department claims data were extracted from the Dallas Fort Worth Hospital Council databank for patients attending 54 EDs in 4 counties (Dallas, Tarrant, Collin, and Denton) who were tested for an STD during an ED visit between July 2014 and June 2015. We analyzed patterns of testing for 3 types of STD tests: (1) combined gonorrhea and chlamydia DNA-based tests, (2) human immunodeficiency virus (HIV) antibody tests, and (3) syphilis serological tests. Emergency departments administered at least 1 STD test to 65,702 unique patients over 1 year; most were ethnoracial minorities (73%), female (72%), and had no known insurance (59%). Only 8% of patients received more than 1 of these tests at that same visit; of those, 90% were cotested for HIV. The most common diagnosis code associated with STD testing was "genital/urinary symptoms" (31%). The majority of tests took place at the ED of a single county-funded hospital (42%). Only 36% of all patients had visits that were deemed true emergencies. Most patients tested for syphilis, HIV, or chlamydia/gonorrhea in EDs received only 1 test type at that visit, and most visits were nonemergent in nature. Given shared risk factors for multiple STD and high coinfection rates, EDs serving high-risk populations could consider STD cotesting to help reduce transmission of undiagnosed, untreated infections.

Addressing Systemic Health Literacy Issues and Patient Safety through a Grassroots Collaborative

An innovative Health Literacy Collaborative between academia and the Dallas Fort Worth Hospital Council Foundation (DFWHCF) which encompasses 80-member organizations. The collaborative works to build a “Culture of Health Literacy” throughout north Texas and ultimately the entire state. The goal is to bridge the divide between the culture of healthcare and the culture of people’s lives in following medical and health related advice through community-based education and advocacy. The DFWHCF provides the infrastructure to the collaborative to incorporate/to address the CDC recommendations for health literacy intervention while utilizing the evidence-based power of systemic change to improve patient care, outcomes and costs.

Healthcare utilization following spinal cord injury: Objective findings from a regional hospital registry

Objective: The purpose was to describe the prevalence and characteristics of healthcare utilization among individuals with spinal cord injury (SCI) from a Level I trauma center.Design: Retrospective data analysis utilizing a local acute trauma registry for initial hospitalization and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year.Setting: Dallas, TX, USA.Participants: Six hundred and sixty four patients were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty five patients that expired during initial hospitalization and 18 patients with unspecified SCI (defined by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591.Outcome Measures: Data included demographic and clinical characteristics, charges, and healthcare utilization.Results: Mean age was 46.1 years (±18.9 years), the majority of patients were male (74%), and Caucasian (58%). Of the 591 patients, 345 (58%) had additional inpatient or emergency healthcare utilization accounting for 769 additional visits (median of 3 visits per person). Of the 769 encounters, 534 (69%) were inpatient and 235 (31%) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension, and tobacco use.Conclusion: Individuals with SCI experience high levels of healthcare utilization which are costly and may be preventable. Increasing our understanding of the prevalence and causes for healthcare utilization after acute SCI is important to target preventive strategies.

Frequency of Hospital Use Before and After Home-Delivery Meal by Meals On Wheels, of Tarrant County, Texas.

Patients recently discharged from the hospital are vulnerable and are at high risk for readmission. Home-delivered meals may be beneficial in improving their health and facilitating independent living in the community. The purpose of this study was to identify the association between home-delivered meals and use of hospital services. This study includes 120 clients recently discharged from an inpatient hospital stay or from an emergency department (ED) visit who received meal services from Meals On Wheels, Inc., of Tarrant County. Healthcare utilization data was extracted from the Dallas-Fort Worth Hospital Council Foundation, a regional all claims database used by over 90% of hospitals in Dallas-Fort Worth area. Signed tests and generalized linear models (GLM) were performed. A total of 16,959 meals were delivered from March 2013 through March 2014. Each client received an average of 6.19 meals per week. The average number of ED visits decreased from 5.03 before receipt of meals to 1.45 after receipt of meals, z = -5.23, p < .001. The average number of hospitalizations decreased from 1.33 to .83, z = -7.29, p < .001. The average length of stay per hospitalization decreased from 5.47 days to 2.34 days, z = -5.84, p < .001. Clients who received more meals were less likely to experience ED visits and hospitalizations after controlling for demographic characteristics and levels of physical functioning. The findings of this study indicate that home-delivered meals services may contribute to a reduction in hospital based care services among frail and vulnerable adults. Additional studies should consider the short and long-term effects of home-delivered meals services on healthcare utilization and the potential to decrease healthcare costs.

Abstract 13398: Impact of CREST on Carotid Artery Stenting and CEA Utilization in the Dallas/Fort Worth Area

Introduction: Carotid endarterectomy (CEA) is a safe and effective way to reduce the ischemic stroke risk in patients with both symptomatic and asymptomatic carotid stenosis. Following the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study in the early 1990s, the number of CEAs performed annually surged. An alternative to this procedure is carotid angioplasty and stenting, which was introduced in 1994. In May 2010, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) compared the overall effectiveness of carotid artery stenting (CAS) versus CEA. CREST is currently considered the definitive study demonstrating the therapeutic equivalence of CEA and CAS. The goal of our study is to compare the incidence of CEA before and after the CREST study in the Dallas-Fort Worth (DFW) area. We hypothesize that the number of CAS procedures has increased since the CREST study. This is the first report to determine the effect of CREST on CAS utilization. Methods: Consecutive cases of intervention for carotid artery stenosis were reviewed before and after CREST using data from the DFW Hospital Council from 7/1/07-7/1/13. The primary endpoint of the study was the number of CEA and CAS performed during Pre-CREST (7/1/07-6/30/10) and Post-CREST (7/1/10-7/1/13). Results: A total of 12021 interventions on patients with carotid stenosis were identified. Pre-CREST there were 4575 CEA and 1060 CAS performed. Post-CREST there were 5250 CEA and 1136 CAS performed. The adjusted p-value comparing the likelihood of undergoing CAS between the two study periods was 0.305. Conclusions: In contrast to previous carotid treatment trials the CREST study has not impacted the utilization CAS in the DFW area. Possible reasons for this include the higher rate of stroke with CAS compared with CEA in CREST, the CMS restrictions on re-imbursement for CAS compared with CEA, limitations in the physician workforce performing CAS, and non-malleable referral patterns that favor the status quo for these two procedures.

Do neighborhood demographics, crime rates, and alcohol outlet density predict incidence, severity, and outcome of hospitalization for traumatic injury? A cross-sectional study of Dallas County, Texas, 2010.

BackgroundUnintentional injury leads all other causes of death for those 1 to 45 years old. The expense of medical care for injured people is estimated to exceed $406 billion annually. Given this burden on the population, the Centers for Disease Control and Prevention consistently refers to injury prevention as a national priority. We postulated that exposure to crime and the density of alcohol outlets in one's neighborhood will be positively associated with the incidence of hospitalization for and mortality from traumatic injuries, independent of other neighborhood characteristics.MethodsWe conducted a cross-sectional study with ecological and individual analyses. Patient-level data for traumatic injury, injury severity, and hospital mortality due to traumatic injury in 2010 were gathered from the Dallas-Fort Worth Hospital Council Foundation. Each case of traumatic injury or death was geospatially linked with neighborhood of origin information from the 2010 U.S. Census within Dallas County, Texas. This information was subsequently linked with crime data gathered from 20 local police departments and the Texas Alcoholic Beverage Commission alcohol outlet dataset. The crime data are the Part One crimes reported to the Federal Bureau of Investigation.ResultsThe proportion of persons 65 years old or older was the strongest predictor of the incidence of hospitalization for traumatic injury (b = 12.64, 95% confidence interval (CI) 8.73 to 16.55). In turn, the incidence of traumatic injury most strongly predicted the severity of traumatic injury (b = 0.008, 95% CI 0.0003 – 0.0012). The tract-level unemployment rate was associated with a 5% increase in the odds of hospital mortality among hospitalized trauma patients.ConclusionsSeveral neighborhood characteristics were associated with the incidence, severity, and hospital mortality from traumatic injury. However, crime rates and alcohol outlet density carried no such association. Prevention efforts should focus on neighborhood characteristics such as population density, mean age of the residents, and unemployment rate, regardless of crime rates and alcohol outlet density.Electronic supplementary materialThe online version of this article (doi:10.1186/s40621-014-0023-2) contains supplementary material, which is available to authorized users.

Academic Partnerships to Increase Nursing Education Capacity: Centralized Faculty Resource and Clinical Placement Centers

The North Texas Consortium of Professional Nursing Programs and Practice Partners is a regional academic partnership of nursing education and practice organizational leaders working together to share innovative ideas and best practices and to improve efficiencies that impact nursing education. The region's 15 nursing schools produced 25% of the Texas graduates, or 1,782 graduates, in 2008-2009. Yet, 3,522 graduates are needed in 2013-2014 to meet the projected north Texas demand. Barriers to increasing enrollment and graduation numbers were the lack of sufficient faculty to meet demand and insufficient numbers of clinical placement sites. To increase the capacity for graduating the numbers of nurses needed, the region developed a three-pronged plan to overcome each of these barriers: expansion of partnership members and development of a regional computerized clinical placement center and faculty resource center. The academic partnership expanded its members to include the 15 schools of nursing, more than 50 hospitals, and the Dallas Fort Worth Hospital Council (DFWHC) Foundation for the purposes of governance of the two proposed computerized centers and strategic planning for increased capacity. The faculty resource center is a centralized, one-stop shop for those interested in teaching and those needing faculty. The Centralized Clinical Placement Center is expected to streamline the nursing student clinical placements process and monitor the numbers of students per site at a given time so as to ensure that placements are at capacity and that schools of nursing benefit fairly in placing students in specialty areas to meet course objectives.

Electronic Health Records

Electronic health records (EHRs) have been proposed as a sustainable solution for improving the quality of medical care. This study investigates how EHR use, as implemented and utilized, impacts patient safety and quality performance. Data in this paper include nonfederal acute care hospitals in the state of Texas, and the data sources include the American Hospital Association, the Dallas Fort Worth Hospital Council, and the American Hospital Directory. The authors use partial least squares modeling to assess the relationship between hospital EHR use, patient safety, and quality of care. Patient safety is measured using 11 indicators as identified by the Agency for Healthcare Research and Quality (AHRQ) and quality performance is measured by 11 mortality indicators as related to 2 constructs, that is, conditions and surgical procedures. Results identify positive significant relationships between EHR use, patient safety, and quality of care with respect to procedures. The authors conclude that there is sufficient evidence of the relationship between hospital EHR use and patient safety, and that sufficient evidence exists for the support of EHR use with hospital surgical procedures.

Local Perspectives on Bioterrorism

In Dallas, as in most metropolitan areas, the medical community is exceedingly complex. The health care community is fractionated into a bewildering array of providers including, among others, physician offices, clinics, urgent care centers, public health agencies, nursing agencies, and, of course, hospitals. In addition, the hospital community comprises a multitude of private and public facilities providing a range of services including basic medical/surgical care, acute/tertiary care, or special population (e.g., children, veterans) services. Such diversity and fractionation may act as a barrier in efforts to unify and organize the medical community's approach to WME events. Tenuous economics, competitive postures, and the absence of a single, controlling health care authority further dilute the medical community's sense of ownership and responsibility as it pertains to the management and mitigation of a WME event. An analysis of the Dallas medical community revealed that there are 25 acute care hospitals with approximately 6300 beds (1999 American Hospital Association Guide, hospital listings). Less than 15% of hospitals within the greater Dallas–Fort Worth area have incorporated WME-specific planning, training, and treatment policies into facility disaster plans (Dallas–Fort Worth Hospital Council hospital survey, 1999). City planners, public health officials, and health care administrators have not developed a comprehensive, communitywide medical response plan. Such a plan should incorporate the resources of all facilities within the medical community. The entire medical community must commit to organized, widespread preparative efforts. As a public service and health resource, hospitals should acknowledge their responsibility to minimize morbidity and mortality within the community in which they reside. Hospital administrators and decision makers must prepare their facilities for the pivotal role they will play in the stabilization and treatment of victims, who may number in the thousands. Individual hospital characteristics, such as bed capacity, complexity of medical services, work-force sophistication, and mutual aid/contractual agreements, may be utilized to define the roles and responsibilities of specific facilities within the context of a WME event. If preparative efforts are not widespread and comprehensive, a single institution working in isolation will not significantly reduce community morbidity and mortality in the event of a WME incident.

Coping with the Joint Commission: The New Quality Assurance Third Generation

3rd edition, 1988. Dallas-Fort Worth Hospital Council, 1431 Greenway Drive, Suite 300, Irving, Texas, 75038-2417.