High-intensity Care Research Articles

Do hospitals provide lower quality of care to black patients for pneumonia?

Recent studies reported lower quality of care for black vs. white patients with community-acquired pneumonia and suggested that disparities persist at the individual hospital level. We examined racial differences in emergency department and intensive care unit care processes to determine whether differences persist after adjusting for case-mix and variation in care across hospitals. Prospective, observational cohort study. Twenty-eight U.S. hospitals. Patients with community-acquired pneumonia: 1738 white and 352 black patients. None. We compared care quality based on antibiotic receipt within 4 hrs and adherence to American Thoracic Society antibiotic guidelines, and intensity based on intensive care unit admission and mechanical ventilation use. Using random effects and generalized estimating equations models, we adjusted for case-mix and clustering of racial groups within hospitals and estimated odds ratios for differences in care within and across hospitals. Black patients were less likely to receive antibiotics within 4 hrs (odds ratio, 0.55; 95% confidence interval, 0.43-0.70; p < .001) and less likely to receive guideline-adherent antibiotics (odds ratio, 0.72; 95% confidence interval, 0.57-0.91; p = .006). These differences were attenuated after adjusting for casemix (odds ratio, 0.59; 95% confidence interval; 0.46-0.76 and 0.84; 95% confidence interval, 0.66 -1.09). Within hospitals, black and white patients received similar care quality (odds ratio, 1; 95% confidence interval, 0.97-1.04 and 1; 95% confidence interval, 0.97-1.03). However, hospitals that served a greater proportion of black patients were less likely to provide timely antibiotics (odds ratio, 0.84; 95% confidence interval, 0.78-0.90). Black patients were more likely to receive mechanical ventilation (odds ratio, 1.57; 95% confidence interval, 1.02-2.42; p = .042). Again, within hospitals, black and white subjects were equally likely to receive mechanical ventilation (odds ratio, 1; 95% confidence interval, .94-1.06) and hospitals that served a greater proportion of black patients were more likely to institute mechanical ventilation (odds ratio, 1.13; 95% confidence interval, 1.02-1.25). Black patients appear to receive lower quality and higher intensity of care in crude analyses. However, these differences were explained by different case-mix and variation in care across hospitals. Within the same hospital, no racial differences in care were observed.

Special Section on the GAF: Continuity of Care and Clinical Outcomes in a National Health System

Continuity of care is widely viewed as a key quality indicator for outpatient mental health care. However, few studies have been conducted of the relationship between continuity of care and client outcomes. This study examined the relationship between measures of three aspects of continuity of care (regularity of care, continuity of treatment across organizational boundaries, and intensity of treatment) and the Global Assessment of Functioning (GAF), a single-item mental health status measure, in a national health care system. Three analytic samples were derived from a nationwide Department of Veterans Affairs administrative data set: patients with at least one inpatient GAF rating and a later outpatient GAF rating (N=8,334) and two groups who had at least two outpatient GAF ratings, one group that was beginning a new episode of treatment (N=49,946) and a second group in ongoing treatment (N=123,371). Hierarchical linear modeling was used to control for potential site-level autocorrelation and to adjust for differences in diagnostic status, sociodemographic characteristics, baseline GAF score, and the length of time between GAF ratings. Several positive and significant relationships were found for discharged inpatients and new outpatients. However, only a few of these relationships could be confidently said to be clinically meaningful. Specifically, among discharged inpatients, for every additional month in which an outpatient visit occurred over a six-month period, there was a .69 increase in the GAF change score for a total increase of 4.1 points. Among new outpatients the equivalent values were smaller, at .3 and 1.8. In contrast with the findings for discharged inpatients and new outpatients, high intensity of care was negatively associated with GAF change scores for continuing outpatients. In contrast with several earlier studies, this study showed positive and statistically significant associations between several continuity-of-care measures and client outcomes. These relationships were observed only in transitional treatment situations, that is, after hospital discharge and at the beginning an episode of outpatient care, situations in which continuity of care may be especially important. However, although positive and statistically significant, the magnitude of these effects may not have been clinically meaningful.

Determinants of post-intensive care mortality in high-level treated critically ill patients.

To assess the predictive ability of preillness and illness variables, impact of care, and discharge variables on the post-intensive care mortality. 5,805 patients treated with high intensity of care in 89 ICUs in 12 European countries (EURICUS-I study) surviving ICU stay. Case-mix was split in training sample (logistic regression model for post-ICU mortality: discrimination assessed by area under ROC curve) and in testing sample. Time to death was studied by Cox regression model validated with bootstrap sampling on the unsplit case-mix. There were 5,805 high-intensity patients discharged to ward and 423 who died in hospital. Significant odds ratios were observed for source of admission, medical/surgical unscheduled admission, each year age, each SAPSII point, each consecutive day in high-intensity treatment, and each NEMS point on the last ICU day. Time to death in ward was significantly shortened by different source of admission; age over 78 years, medical/unscheduled surgical admission; SAPSII score without age, comorbidity and type of admission over 16 points; more than 2 days in high-intensity treatment; all days spent in high treatment; respiratory, cardiovascular, and renal support at discharge; and last ICU day NEMS higher than 27 points Worse outcome is associated with the physiological reserve before admission in the ICU, type of illness, intensity of care required, and the clinical stability and/or the grade of nursing dependence at discharge.

Effectiveness of Child Case Management Services for Offspring of Drug-Dependent Women

Female drug users and their children have many medical and psychosocial problems, yet they often fail to follow through with prescribed treatments. The present study describes a specialized, case management program for children, birth through age 2, exposed to drugs in utero. Evaluation of program efficacy was examined by comparing 2-year outcomes for women who received different intensities of these child case management services. Mothers who received higher intensity care were more likely to be abstinent from illicit drugs and to have retained custody of their child(ren) at 2-year follow-up than those with lower intensity services. Study findings support clinical and economic efficacy of this model of care.

Patient characteristics related to intensity of weight reduction care in a university medical clinic.

To identify patient characteristics related to intensity of weight reduction care provided in a primary care practice. Cross-sectional study linking data from a patient survey and data from medical records. Internal medicine housestaff clinic in an urban university hospital. 321 outpatients who represented a systematic sample of all outpatients who had visited the clinic over one year. The patient population was largely black (86%) and female (65%). Most patients (54%) were overweight [body-mass index (BMI) > 85th percentile for the United States by gender]. Intensity of care was defined by a composite scale: points were awarded for actions documented in the medical chart or recalled by the patient. Factors independently associated with a higher intensity of care among the 161 overweight patients were: BMI [odds ratio (OR) = 1.13 per kg/m2; 95% confidence interval (95% CI) = 1.04, 122; p = 0.002], the patient's self-perception of being overweight (OR = 5.37; 95% CI = 1.99, 14.46; p = 0.001), and age of 64 years or younger (OR = 2.48; 95% CI = 1.12, 5.48; p = 0.02). Race, gender, and presence of hypertension or hypercholesterolemia were not associated with greater intensity of care. Patients with hypertension and hypercholesterolemia may be receiving suboptimal weight reduction care. Heightened awareness of being overweight may enhance the provision of weight reduction care. Prospective studies are required to confirm these findings.