Differences In Patient Case Mix Research Articles

Do outcomes for patients with hospital-acquired Acute Kidney Injury (H-AKI) vary across specialties in England?

BackgroundAcute Kidney Injury (AKI) is a common and serious clinical syndrome. There is increasing recognition of heterogeneity in observed AKI across different clinical settings. In this analysis we have utilised a large national dataset to outline, for the first time, differences in burden of hospital acquired AKI (H-AKI) and mortality risk across different treatment specialities in the English National Health Service (NHS).MethodsA retrospective observational study was conducted using a large national dataset of patients who triggered a biochemical AKI alert in England during 2019. This dataset was enriched through linkage with NHS hospitals administrative and mortality data. Episodes of H-AKI were identified and attributed to the speciality of the supervising consultant during the hospitalisation episode in which the H-AKI alert was generated. Associations between speciality and death in hospital or within 30 days of discharge (30-day mortality) was modelled using logistic regression, adjusting for patient age, sex, ethnicity, socioeconomic status, AKI severity, season and method of admission.ResultsIn total, 93,196 episodes of H-AKI were studied. The largest number of patients with H-AKI were observed under general medicine (21.9%), care of the elderly (18.9%) and general surgery (11.2%). Despite adjusting for differences in patient case-mix, 30-day mortality risk was consistently lower for patients in surgical specialities compared to general medicine, including general surgery (OR 0.65, 95% CI 0.61 to 0.7) and trauma and orthopaedics (OR 0.52, 95% CI 0.48 to 0.56). Mortality risk was highest in critical care (OR 1.78, 95% CI 1.56 to 2.03) and oncology (OR 1.74, CI 1.54 to 1.96).ConclusionsSignificant differences were identified in the burden of H-AKI and associated mortality risk for patients across different specialities in the English NHS. This work can help inform future service delivery and quality improvement activity for patients with AKI across the NHS.

Prediction Algorithms: Is Peer Review Enough?

Prediction Algorithms: Is Peer Review Enough?

A nationwide evaluation of antibiotics consumption in Swedish intensive care units

Background Around 70% of all ICU patients are treated with antibiotics whereas up to 30% are suggested as unnecessary. Measuring antibiotic consumption is a prerequisite to improving its use and the purpose of the present investigation was to explore the use of antibiotics in Swedish ICUs. Material and methods Daily Defined Doses (DDDs) of antimicrobials delivered to Swedish ICUs, 2016–2018, were retrieved from Swedish pharmacies. From the Swedish Intensive Care Registry, we extracted data on a number of patient admissions, occupied bed days and Simplified Acute Physiology Score (SAPS)3. Results There was a similar annual rate of total DDDs per admission of 3.7, 3.5, 3.8 and total DDDs per 100 occupied bed days of 111, 111, and 115 but with an approximately 6-fold difference of DDDs per occupied bed days (61–366) between the ICUs. The most frequently used antibiotics were isoxazolyl penicillins (J01CF), penicillins with betalactamase-inhibitors, mainly piperacillin/tazobactam (J01CR), 3rd and 4th generation cephalosporins (J01DD + DE) and carbapenems (J01DH). Together these four classes accounted for a median of 52% of all antibiotic use. The use of carbapenems had a moderate positive correlation with the mean SAPS3 score (r = 0.6, p = .01). The use of other broad-spectrum antibiotics showed no such correlation. Conclusion Overall antibiotic use remained similar in Swedish ICUs during the years 2016–2018. Broad-spectrum antibiotics accounted for 50% of all DDDs but with a large inter-ICU variation which only partly can be explained by differences in patient case mix and microbial resistance. Presumably, it also reflects varying local prescribing practices.

Qualitative Evaluation of an automated nationwide benchmarking antimicrobial utilization dashboard for the VHA

Background: Antimicrobial stewardship programs (ASPs) are advised to audit antimicrobial consumption as a metric to feedback to clinicians. However, many ASPs lack the tools necessary for appropriate risk adjustment and standardized data collection, which are critical for peer-program benchmarking. We evaluated the impact of the dashboard deployment that displays these metrics and its acceptance among ASP members and antimicrobial prescribers. Materials/methods: We conducted semistructured interviews of ASP stewards and antimicrobial prescribers before and after implementation of a web-based ASP information dashboard (Fig. 1) implemented in the VA Midwest Health Care Network (VISN23). The dashboard provides risk-adjusted benchmarking, longitudinal trends, and analysis of antimicrobial usage patterns at each facility. Risk-adjusted benchmarking was based on an observed-to-expected comparison of antimicrobial days of therapy at each facility, after adjusting for differences in patient case mix and facility-level variables. Respondents were asked to evaluate several aspects of the dashboard, including its ease of use, applicability to ongoing ASP activities, perceived validity and reliability, and advantages compared to other ASP monitoring systems. All interviews were digitally recorded and transcribed verbatim. The analysis was conducted using MaxQDA 2020.4 and the Consolidated Framework for Implementation Research (CFIR) constructs. Results: We completed 4 preimplementation interviews and 11 postimplementation interviews with ASP champions and antimicrobial prescribers from 6 medical centers. We derived 4 key themes from the data that map onto CFIR constructs. These themes were interconnected so that implementation of the dashboard (ie, adapting and adopting) was influenced by respondents’ perception of a facility’s size, patient population, and priority placed on stewardship (ie, structural and cultural context), the availability of dedicated stewardship staff and training needed to implement the dashboard (ie, resources needed), and how the dashboard compared to established stewardship activities (ie, relative advantage). ASP champions and antimicrobial prescribers indicated that dashboard metrics were useful for identifying antimicrobial usage and for comparing metrics among similar facilities. Respondents also specified barriers to acceptance of the risk-adjusted metric, such as disagreement regarding how antimicrobials were grouped by the current NHSN protocol, uncertainty of factors involved in risk adjustments, and difficulty developing a clear interpretation of hospital rankings. Conclusions: Given the limited resources for antimicrobial stewardship personnel, automated, risk-adjusted, antimicrobial-use dashboards provided by ASPs are an attractive method to both facilitate compliance and improve efficiency. To increase the uptake of surveillance systems in antimicrobial stewardship, our study highlights the need for clear descriptions of methods and metrics.Funding: NoneDisclosures: None

Variation Across Hospitals in In-Hospital Cardiac Arrest Incidence Among Medicare Beneficiaries

Although survival for in-hospital cardiac arrest (IHCA) has improved substantially over the last 2 decades, survival rates have plateaued in recent years. A better understanding of hospital differences in IHCA incidence may provide important insights regarding best practices for prevention of IHCA. To determine the incidence of IHCA among Medicare beneficiaries, and evaluate hospital variation in incidence of IHCA. This observational cohort study analyzes 2014 to 2017 data from 170 hospitals participating in the Get With The Guidelines-Resuscitation registry, linked to Medicare files. Participants were adults aged 65 years and older. Statistical analysis was performed from January to December 2021. Case-mix index, teaching status, and nurse-staffing. Hospital incidence of IHCA among Medicare beneficiaries was estimated as the number of IHCA patients divided by the total number of hospital admissions. Multivariable hierarchical regression models were used to calculate hospital incidence rates adjusted for differences in patient case-mix and evaluate the association of hospital variables with IHCA incidence. Among a total of 4.5 million admissions at 170 hospitals, 38 630 patients experienced an IHCA during 2014 to 2017. Among the 38 630 patients with IHCAs, 7571 (19.6%) were non-Hispanic Black, 26 715 (69.2%) were non-Hispanic White, and 16 732 (43.3%) were female; the mean (SD) age at admission was 76.3 (7.8) years. The median risk-adjusted IHCA incidence was 8.5 per 1000 admissions (95% CI, 8.2-9.0 per 1000 admissions). After adjusting for differences in case-mix index, IHCA incidence varied markedly across hospitals ranging from 2.4 per 1000 admissions to 25.5 per 1000 admissions (IQR, 6.6-11.4; median odds ratio, 1.51 [95% CI, 1.44-1.58]). Among hospital variables, a higher case-mix index, higher nurse staffing, and teaching status were associated with a lower hospital incidence of IHCA. This cohort study found that the incidence of IHCA varies markedly across hospitals, and hospitals with higher nurse staffing and teaching status had lower IHCA incidence rates. Future studies are needed to better understand processes of care at hospitals with exceptionally low IHCA incidence to identify best practices for cardiac arrest prevention.

Associations between resources and practices of ILD centers and outcomes in patients with idiopathic pulmonary fibrosis: data from the IPF-PRO Registry

BackgroundPerformance benchmarks for the management of idiopathic pulmonary fibrosis (IPF) have not been established. We used data from the IPF-PRO Registry, an observational registry of patients with IPF managed at sites across the US, to examine associations between the characteristics of the enrolling sites and patient outcomes.MethodsAn online survey was used to collect information on the resources, operations, and self-assessment practices of IPF-PRO Registry sites that enrolled ≥ 10 patients. Site variability in 1-year event rates of clinically relevant outcomes, including death, death or lung transplant, and hospitalization, was assessed. Models were adjusted for differences in patient case mix by adjusting for known predictors of each outcome. We assessed whether site-level heterogeneity existed for each patient-level outcome, and if so, we investigated potential drivers of the heterogeneity.ResultsAll 27 sites that enrolled ≥ 10 patients returned the questionnaire. Most sites were actively following > 100 patients with IPF (70.4%), had a lung transplant program (66.7%), and had a dedicated ILD nurse leader (77.8%). Substantial heterogeneity was observed in the event rates of clinically relevant outcomes across the sites. After controlling for patient case mix, there were no outcomes for which the site variance component was significantly different from 0, but the p-value for hospitalization was 0.052. Starting/completing an ILD-related quality improvement project in the previous 2 years was associated with a lower risk of hospitalization (HR 0.60 [95% CI 0.44, 0.82]; p = 0.001).ConclusionsAnalyses of data from patients with IPF managed at sites across the US found no site-specific characteristics or practices that were significantly associated with clinically relevant outcomes after adjusting for patient case mix.Trial registration ClinicalTrials.gov, NCT01915511. Registered 5 August 2013, https://clinicaltrials.gov/ct2/show/NCT01915511

Center differences in diabetes treatment outcomes among children with type 1 diabetes: A nationwide study of 3866 Danish children.

Mean differences in HbA1c across centers are well established, but less well understood. The aim was to assess whether differences in patient case-mix can explain the variation in mean HbA1c between pediatric diabetes centers in Denmark. The association between HbA1c , frequency of blood glucose monitoring (BGM), treatment modality, and center visits was investigated. This longitudinal nationwide study included 3866 Danish children with type 1 diabetes from 2013 to 2017 (n= 12,708 child-year observations) from 16 different pediatric diabetes centers. Mean HbA1c , proportion of children reaching HbA1c treatment target (HbA1c ≤ 58 mmol/mol [7.5%]) were compared across centers using linear regression models. This was done with and without adjustment for socioeconomic characteristics (patient case-mix). The mean difference in HbA1c during follow-up was 11.6 mmol/mol (95% CI 7.9, 15.3) (1.1% [95% CI 0.7, 1.4]) when comparing the centers with the lowest versus highest mean HbA1c . The difference was attenuated and remained significant after adjustment for the patient case-mix (difference: 10.5 mmol/mol [95% CI 6.8, 14.2] (1.0% [95% CI 0.6, 1.3])). Overall, 6.8% of the differences in mean HbA1c across centers were explained by differences in the patient case-mix. Across centers, more frequent BGM was associated with lower HbA1c . The proportion of insulin pump users and number of visits was not associated with HbA1c . In a setting of universal health care, large differences in HbA1c across centers were found, and could not be explained by patient background, number of visits or use of technology. Only BGM was associated with center HbA1c .

Abstract 9152: Incidence of Cardiac Arrest Among Medicare Beneficiaries

Introduction: Although survival for in-hospital cardiac arrest (IHCA) has improved substantially over the last two decades, survival rates have plateaued in recent years. Our understanding of incidence of IHCA remains limited. We measured incidence of IHCA among Medicare beneficiaries and evaluated hospital variation in incidence of IHCA. Methods: We used an observational cohort study using data from 2014-2017 Get with the Guidelines-Resuscitation (GWTG-R) data linked with Medicare inpatient data summarized by hospital. Hospital incidence of IHCA among Medicare beneficiaries was calculated as the total number of patients 65 years and older with an IHCA divided by the total number of Medicare admissions. Multivariable hierarchical regression models were used to adjust hospital incidence rates for differences in case-mix across study hospitals and evaluate its the association with hospital variables. Results: Among a total of 4.5 million admissions at 170 hospitals, 38,630 patients experienced an IHCA. The median risk-adjusted IHCA incidence was 8.3 per-1000 admissions. Even after adjusting for differences in case-mix index, IHCA incidence varied markedly across hospitals (Figure 1) ranging from 2.1 per-1000 admissions to 24.7 per-1000 admissions (interquartile range: 6.5-11.4; median odds ratio: 1.52; 95% credible interval 1.45-1.59). Among hospital variables, a higher case-mix index, higher nurse staffing and teaching status were associated with a lower hospital incidence of IHCA. Conclusions: Incidence of IHCA varies markedly across hospitals, even after adjustment for differences in patient case-mix. Hospital variables including case-mix severity, nurse staffing and teaching status were significantly associated with incidence rates. Future studies are needed to better understand processes of care at hospitals with exceptionally low IHCA incidence to identify best practices for cardiac arrest prevention.

Variation in Use of High-Cost Technologies for Palliative Radiation Therapy by Radiation Oncologists.

Understanding the sources of variation in the use of high-cost technologies is important for developing effective strategies to control costs of care. Palliative radiation therapy (RT) is a discretionary treatment and its use may vary based on patient and clinician factors. Using data from the SEER-Medicare linked database, we identified patients diagnosed with metastatic lung, prostate, breast, and colorectal cancers in 2010 through 2015 who received RT, and the radiation oncologists who treated them. The costs of radiation services for each patient over a 90-day episode were calculated, and radiation oncologists were assigned to cost quintiles. The use of advanced technologies (eg, intensity-modulated radiation, stereotactic RT) and the number of RT treatments (eg, any site, bone only) were identified. Multivariable random-effects models were constructed to estimate the proportion of variation in the use of advanced technologies and extended fractionation (>10 fractions) that could be explained by patient fixed effects versus physician random effects. We identified 37,361 patients with metastatic lung cancer, 3,684 with metastatic breast cancer, 5,323 with metastatic prostate cancer, and 8,726 with metastatic colorectal cancer, with 34%, 27%, 22%, and 9% receiving RT within the first year, respectively. The use of advanced technologies and extended fractionation was associated with higher costs of care. Compared with the patient case-mix, physician variation accounted for a larger proportion of the variation in the use of advanced technologies for palliative RT and the use of extended fractionation. Differences in radiation oncologists' practice and choices, rather than differences in patient case-mix, accounted for a greater proportion of the variation in the use of advanced technologies and high-cost radiation services.

Hospital-level Effects Contribute to Variations in Prostate Cancer Quality of Care

A paucity of real-world data exists highlighting whether variations in prostate cancer quality of care occur at a hospital level, independent of differences in case mix. To overcome this knowledge gap, we benchmarked hospital-level quality (n = 1245 hospitals) across a broad multidisciplinary panel of previously reported disease-specific, expert-defined quality indicators (QIs), adjusting for differences in patient case mix by indirect standardization. A composite measure of prostate cancer quality—the prostate cancer quality score (PC-QS)—was derived, and associations between PC-QS and hospital volume, academic status, and location as well as patient all-cause mortality were determined. After adjusting for the case mix, of the total of 1245 hospitals evaluated, 2–37% were identified as those performing significantly below the national average for a given QI. Hospitals with a higher PC-QS displayed larger patient volumes, were more commonly academic affiliated, and had lower overall mortality. Collectively, our data-driven benchmarking analysis reveals that widespread hospital-level variations exist in prostate cancer quality of care after adjusting for differences in case mix, with the PC-QS serving as a novel, validated, quality benchmarking tool. Patient summaryOur statistical benchmarking method shows that the quality of prostate cancer care varies between hospitals, after accounting for differences in patient characteristics. The prostate cancer quality score is a novel, validated, quality benchmarking tool.

After-hours emergency department care: Does time or day of arrival affect survival?

To determine whether after-hours presentation to EDs is associated with differences in 7-day and 30-day mortality. The influence of patient case-mix and workforce staffing differences are also explored. We conducted a retrospective observational study of 3.7 million ED episodes across 30 public hospitals in Queensland, Australia during May 2013-September 2015 using routinely collected hospital data linked to hospital staffing data and the death registry. Episodes were categorised as within/after-hours using time of presentation. Staffing was derived from payroll records and explored by defining 11 staffing ratios. Weekend presentation was slightly more associated (7-day mortality odds ratio 1.05, 95% confidence interval [CI] 1.01-1.10) or no more associated (30-day mortality odds ratio 1.01, 95% CI 0.98-1.03) with death than weekday presentation. When weeknights are included in the 'after-hours' period, odds ratios are smaller, so that after-hours presentation is no more associated (7-day mortality odds ratio 1.03, 95% CI 0.99-1.08) or less associated (30-day mortality odds ratio 0.95, 95% CI 0.93-0.97) with death. No significant after-hours patient case-mix differences were observed between weekday and weekend presentations for 7-day mortality. In other combinations of outcome and after-hours definition, some differences (especially measures relating to severity of presenting condition) were found. Staffing ratios were not strongly associated with any within/after-hours differences in ED mortality. After-hours presentation on the weekend to an ED is associated with higher 7-day mortality even after controlling for case-mix.

International variation in dialysis discontinuation in patients with advanced kidney disease.

Decisions about dialysis for advanced kidney disease are often strongly shaped by sociocultural and system-level factors rather than the priorities and values of individual patients. We examined international variation in the uptake of conservative approaches to the care of patients with advanced kidney disease, in particular discontinuation of dialysis. We employed an observational cohort study design using data collected from patients maintained on long-term hemodialysis between 1996 and 2015 in facilities across 12 developed countries participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS). The main outcome was discontinuation of dialysis therapy. We analyzed the association between several patient characteristics and time to dialysis discontinuation by country and phase of study entry. A total of 259 343 DOPPS patients contributed data to the study, of whom 48 519 (18.7%) died during the study period. Of the decedents, 5808 (12.0%) discontinued dialysis before death. Rates of discontinuation were higher within the first few months after initiation of dialysis, among older adults, among those with a greater number of comorbidities and among those living in an institution. After adjustment for age, sex, dialysis duration, diabetes and dialysis era, rates of discontinuation were highest in Canada, the United States and Australia/New Zealand (33.8, 31.4 and 21.5 per 1000/yr, respectively) and lowest in Japan and Italy (< 0.1 per 1000/yr). Crude discontinuation rates were highest in dialysis facilities that were more likely to offer comprehensive conservative renal care to older adults. We found persistent international variation in average rates of dialysis discontinuation not explained by differences in patient case-mix. These differences may reflect physician-, facility- and society-level differences in clinical practice. There may be opportunities for international cross-collaboration to improve support for patients with end-stage renal disease who prefer a more conservative approach.

Comparing national point prevalence surveys of healthcare-associated infection and antimicrobial prescribing: a methodological approach to adjust for differences in case-mix.

National point prevalence surveys (PPS) of healthcare-associated infection (HAI) and antimicrobial prescribing in hospitals were conducted in 2011 and 2016 in Scotland. When comparing results of PPS, it is important to adjust for any differences in patient case-mix that may confound the comparison. To describe the methodology used to compare prevalence for the two surveys and illustrate the importance of taking case-mix (patient and hospital stay characteristics) into account. Multivariate models (clustered logistic regression) that adjusted for differences in patient case-mix were used to describe the difference in prevalence of six outcomes (HAI, antimicrobial prescribing and four devices: central vascular catheter, peripheral vascular catheter, urinary catheterisation and intubation) between the 2011 and 2016 PPS. Univariate models that did not adjust for these differences were also developed for comparison to show the importance of adjusting for confounders. Without adjustment for case-mix, HAI and intubation prevalence estimates were not significantly different in 2016 compared with 2011 although with adjustment, the prevalence of both was significantly lower (P=0.03 and P=0.02, respectively). These associations were only identified after adjustment for confounding by case-mix. While prevalence surveys do not provide intelligence on temporal trends as an incidence-based surveillance system would, if limitations and caveats are acknowledged, it is possible to compare two prevalence surveys to describe changing epidemiology. Adjusting for differences in case-mix is essential for robust comparisons. This methodology may be useful for other countries that are conducting large, repeated prevalence surveys.

Inter-hospital variation in use of obstetrical blood transfusion: a population-based cohort study.

To identify the extent of hospital-to-hospital variation in use of obstetrical blood transfusion. Population-based cohort study linking provincial perinatal and blood transfusion registries. British Columbia, Canada, 2004-2015. All pregnant women delivering at or beyond 20weeks' gestation at any British Columbia hospital. Mixed-effects regression models were used to estimate hospital-specific transfusion rates after sequentially accounting for (1) the role of random variation, (2) maternal medical and obstetrical characteristics (i.e. patient case mix) and (3) institutional and delivery factors (such as use of instrumental or caesarean delivery). Hospital-specific use of obstetrical red blood cell transfusion. Among 44 hospitals, crude institutional transfusion rates across the study period ranged from 3.7 to 23.6 per 1000, with an average of 8.3 per 1000. After adjusting for maternal characteristics, institution and delivery risk factors, a nearly three-fold difference in rates between the 10th and 90th percentile remained (5.4-14.5 per 1000). Twelve sites had rates significantly higher or lower than the provincial average. Women residing in remote areas were 2.5-fold (95% CI 1.8-3.5] more likely to receive a blood transfusion than were women residing in metropolitan areas. Meaningful variation between hospitals in use of blood transfusion during pregnancy was not explained by differences in patient case-mix or institutional factors, suggesting that over- or under-utilisation of this resource may be occurring in obstetrical care. Use of blood transfusion in pregnant women varied broadly between hospitals in British Columbia, Canada.

Variations in the use of caesarean section: a Comparison between France and Australia

Abstract Background There has been a rise in obstetric intervention during labour and birth including rates of caesarean section around the world. The rates of caesarean section are lower in France (20%) than Australia (34%). Both countries have universal health care systems. Australia has a well-established program of obstetric benchmarking and national data collection for comparing maternal and perinatal outcomes taking into account maternity units and maternal characteristics. Although the optimal caesarean section rate is not known, variation in caesarean section rates raise questions about what is driving variation in practice and whether the right care is being delivered. The World Health Organisation has recently released non-clinical recommendations aiming to reduce unnecessary caesarean sections, including that births are classified by Robson classification for easier comparison. Methods We aim to compare rates of mode of birth in 2 tertiary hospitals- one in France and one in Australia using Robson classification. This project will investigate differences in patient casemix, and obstetric management that may lead to differences in outcome. In addition, we will try to explore differences in the health systems including clinical activity, induction rates, staffing (number, type (medical, nursing, midwifery)), and models of care. Outcomes Caesarean section is one of the most common operations performed in hospitals. Important variations of surgical rates raise question regarding whether access to this procedure is optimized. Determining current practice and outcomes of women in two different settings will provide important data to inform hospital practice and further research. In addition, this research may inform national guidelines about indications for caesarean section.

Home Care Nursing After Elective Vascular Surgery: An Opportunity to Reduce Emergency Department Visits and Hospital Readmission

Background Events occurring outside the hospital setting are underevaluated in surgical quality improvement initiatives and research. Objective To quantify regional variation in home care nursing following vascular surgery and explore its impact on emergency department (ED) visits and hospital readmission. Methods Patients who underwent elective vascular surgery and were discharged directly home were identified from population-based administrative databases for the province of Ontario, Canada, 2006–2015. The index surgeries included carotid endarterectomy, open and endovascular aortic aneurysm repair and bypass for lower extremity peripheral arterial disease. Home care nursing within 30 days of discharge was captured and compared across regions. Using multilevel logistic regression, we characterised the association between home care nursing and the risk of an ED visit or hospital readmission within 30 days of discharge. Results The cohort included 23 617 patients, of whom 9002 (38%) received home care nursing within 30 days of discharge home. Receipt of nursing care after discharge home varied widely across Ontario’s 14 administrative health regions (range 16%–84%), even after accounting for differences in patient case mix. A lower likelihood of an ED visit or hospital readmission within 30 days of discharge was observed among patients who received home care nursing following three of four index surgeries: carotid endarterectomy OR 0.74, 95% CI 0.61 to 0.91; endovascular aortic aneurysm repair OR 0.85, 95% CI 0.72 to 0.99; open aortic aneurysm repair OR 1.06, 95% CI 0.91 to 1.23; bypass for lower extremity peripheral arterial disease OR 0.81, 95% CI 0.72 to 0.92. Conclusion Home care nursing may contribute to reducing ED visits and hospital readmission and is variably prescribed after vascular surgery.

Home care nursing after elective vascular surgery: an opportunity to reduce emergency department visits and hospital readmission

BackgroundEvents occurring outside the hospital setting are underevaluated in surgical quality improvement initiatives and research.ObjectiveTo quantify regional variation in home care nursing following vascular surgery and explore its impact on...

Assessment of Between-Hospital Variation in Readmission and Mortality After Cancer Surgical Procedures

Although current federal quality improvement programs do not include cancer surgery, the Centers for Medicare & Medicaid Services and other payers are considering extending readmission reduction initiatives to include these and other common high-cost episodes. To quantify between-hospital variation in quality-related outcomes and identify hospital characteristics associated with high and low performance. This retrospective cohort study obtained data through linkage of the California Cancer Registry to hospital discharge claims databases maintained by the California Office of Statewide Health Planning and Development. All 351 acute care hospitals in California at which 1 or more adults underwent curative intent surgery between January 1, 2007, and December 31, 2011, with analyses finalized July 15, 2018, were included. A total of 138 799 adults undergoing surgery for colorectal, breast, lung, prostate, bladder, thyroid, kidney, endometrial, pancreatic, liver, or esophageal cancer within 6 months of diagnosis, with an American Joint Committee on Cancer stage of I to III at diagnosis, were included. Measures included adjusted odds ratios and variance components from hierarchical mixed-effects logistic regression analyses of in-hospital mortality, 90-day readmission, and 90-day mortality, as well as hospital-specific risk-adjusted rates and risk-adjusted standardized rate ratios for hospitals with a mean annual surgical volume of 10 or more. Across 138 799 patients at the 351 included hospitals, 8.9% were aged 18 to 44 years and 45.9% were aged 65 years or older, 57.4% were women, and 18.2% were nonwhite. Among these, 1240 patients (0.9%) died during the index admission. Among 137 559 patients discharged alive, 19 670 (14.3%) were readmitted and 1754 (1.3%) died within 90 days. After adjusting for patient case-mix differences, evidence of statistically significant variation in risk across hospitals was identified, as characterized by the variance of the random effects in the mixed model, for all 3 metrics (P < .001). In addition, substantial variation was observed in hospital performance profiles: across 260 hospitals with a mean annual surgical volume of 10 or more, 59 (22.7%) had lower-than-expected rates for all 3 metrics, 105 (40.4%) had higher-than-expected rates for 2 of the 3, and 19 (7.3%) had higher-than-expected rates for all 3 metrics. Accounting for patient case-mix differences, there appears to be substantial between-hospital variation in in-hospital mortality, 90-day readmission, and 90-day mortality after cancer surgical procedures. Recognizing the multifaceted nature of hospital performance through consideration of mortality and readmission simultaneously may help to prioritize strategies for improving surgical outcomes.

Hospital variation in utilization and success of trial of labor after a prior cesarean

Trial of labor after cesarean delivery is an effective and safe option for women without contraindications. The objective of the study was to examine hospital variation in utilization and success of trial of labor after cesarean delivery and identify associated institutional characteristics and patient outcomes. Using linked maternal and newborn hospital discharge records and birth certificate data in 2010-2012 from the state of California, we identified 146,185 term singleton mothers with 1 prior cesarean delivery and no congenital anomalies or clear contraindications for trial of labor at 249 hospitals. Risk-standardized utilization and success rates of trial of labor after cesarean delivery were estimated for each hospital after accounting for differences in patient case mix. Risk for severe maternal and newborn morbidities, as well as maternal and newborn length of stay, were compared between hospitals with high utilization and high success rates of trial of labor after cesarean delivery and other hospitals. Bivariate analysis was also conducted to examine the association of various institutional characteristics with hospitals' utilization and success rates of trial of labor after cesarean delivery. In the overall sample, 12.5% of women delivered vaginally. After adjusting for patient clinical risk factors, utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals, with a median of 35.2% (10th to 90th percentile range: 10.2-67.1%) and 40.5% (10th to 90th percentile range: 8.5-81.1%), respectively. Risk-standardized utilization and success rates of trial of labor after cesarean delivery demonstrated an inverted U-shaped relationship such that low or excessively high use of trial of labor after cesarean delivery was associated with lower success rate. Compared with other births, those delivered at hospitals with above-the-median utilization and success rates of trial of labor after cesarean delivery had a higher risk for uterine rupture (adjusted risk ratio, 2.74, P < .001), severe newborn respiratory complications (adjusted risk ratio, 1.46, P < .001), and severe newborn neurological complications/trauma (adjusted risk ratio, 2.48, P < .001), but they had a lower risk for severe newborn infection (adjusted risk ratio, 0.80, P= .003) and overall severe unexpected newborn complications (adjusted risk ratio, 0.86, P < .001) as well as shorter length of stays (adjusted mean ratio, 0.948 for mothers and 0.924 for newborns, P < .001 for both). Teaching status, system affiliation, larger volume, higher neonatal care capacity, anesthesia availability, higher proportion of midwife-attended births, and lower proportion of Medicaid or uninsured patients were positively associated with both utilization and success of trial of labor after cesarean delivery. However, rural location and higher local malpractice insurance premium were negatively associated with the utilization of trial of labor after cesarean delivery, whereas for-profit ownership was associated with lower success rate. Utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals. Strategies to promote vaginal birth should be tailored to hospital needs and characteristics (eg, increase availability of trial of labor after cesarean delivery at hospitals with low utilization rates while being more selective at hospitals with high utilization rates, and targeted support for lower capacity hospitals).

372 Derivation of a Clinical Decision Instrument to Identify Adults in a Community Setting With Mild Traumatic Intracranial Hemorrhage at Low Risk for Requiring Critical Care Intervention

Adults presenting to the ED with mild traumatic intracranial hemorrhage (tICH) are commonly admitted to the intensive care unit (ICU), although critical care interventions are often unnecessary. In prior research, we found that a clinical decision instrument (CDI) derived at an academic Level I trauma center to identify adults at low risk for critical care interventions performed poorly in a community setting, likely because of substantial differences in patient case-mix. We sought to derive a more generalizable CDI among patients of a large community-based integrated health care delivery system. This retrospective cohort study included non-anticoagulated adults (≥18 years of age) with mild tICH, defined as GCS score ≥13, across 21 community EDs from 01/2012 to 12/2013. No study facility carried a Level I trauma center designation, and only one carried a Level II designation. The primary outcome of at least one critical care intervention within 48 hours of ED arrival included intubation, neurosurgical intervention, vasopressor or inotrope use, invasive monitoring, or cardiopulmonary resuscitation. Using logistic regression with single independent variables, we identified potential predictors of the outcome, developed a 6-variable predictive logistic regression model, and created a simplified CDI to identify low-risk patients based on predicted probabilities from the model. We examined the prevalence of patients designated low-risk by both CDIs and compared performance metrics. We calculated sensitivity and specificity with Clopper-Pearson, positive and negative predictive values with standard logit, and c-statistics with Wald confidence interval (CI) estimates. Our cohort included 929 patients with mean age of 73.3 (SD 17.0) years; 50% were female, and 82% were injured by a ground-level fall. Of these, 110 (11.8%) received at least one critical care intervention, 100 of whom received a neurosurgical operation, mannitol or hypertonic saline. Patients identified as low risk had none of the following: time from trauma to ED >7 days, ED admitting GCS <15, lowest ED systolic blood pressure >140 mmHg, CT evidence of skull fracture, mass effect, or midline shift >5 mm. The new CDI designated nearly three times as many patients as low-risk than the academic-based CDI with similar sensitivity and significantly higher specificity (see Table). We derived a CDI to identify patients with mild tICH at low risk for requiring ICU-level care in this community setting. The community-based instrument was equally sensitive as its academic counterpart, but outperformed it with a greater specificity and positive predictive value. This lower rate of false positives may increase its ultimate clinical utility. Continued model development may further improve specificity, and a prospective validation study will be needed prior to clinical implementation.