Hospital-level Confounders Research Articles

Ultrasound-guided or landmark techniques for central venous catheter placement in critically ill children.

To assess whether ultrasound guidance improves central venous catheter placement outcomes compared to the landmark technique in critically ill children. A prospective multicentre observational study was carried out in 26 paediatric intensive care units over 6months. Children 0-18years old who received a temporary central venous catheter, inserted using either ultrasound or landmark techniques, were eligible. The primary outcome was the first-attempt success rate. Secondary outcomes included overall placement success, number of puncture attempts, number of procedures requiring multiple punctures (>3 punctures), number of procedures requiring punctures at more than one vein site and immediate mechanical complications. To account for potential confounding factors, we used propensity scores. Our primary analysis was based on 1:1 propensity score matching. The association between cannulation technique and outcomes in the matched cohort was estimated using generalized estimating equations and mixed-effects models to account for patient-level and hospital-level confounders. Five hundred central venous catheter-placement procedures involving 354 patients were included. Ultrasound was used for 323 procedures, and the landmark technique was used for 177. Two hundred and sixty-six procedures were matched (133 in the ultrasound group and 133 in the landmark group). Ultrasound was associated with an increase in the first-attempt success rate [46.6 vs. 30%, odds ratio 2.09 (1.26-3.46); p<0.001], a reduced number of puncture attempts [2 (1-3) vs. 2 (1-4), B coefficient -0.51 (95% confidence interval -1.01 to -0.03), p=0.035], and fewer overall mechanical complications [12 vs. 22.5%, odds ratio 0.47 (95% confidence interval 0.24-0.91), p=0.025] in the matched cohort. The number of puncture attempts was the main factor associated with overall complications. Compared with the landmark technique, ultrasound guidance was associated with an increased first-attempt success rate, a reduced number of puncture attempts, and fewer complications during central venous catheter placement in critically ill children.

Orthognathic Surgical Outcomes in Patients With and Without Craniofacial Anomalies

The objective of this study is to examine hospitalization outcomes after orthognathic surgery.This study tests the hypothesis that patients with craniofacial anomalies have higher billed hospital charges, longer lengths of stay, and increased odds of development of infectious complications when compared with patients without craniofacial anomalies. The Nationwide Inpatient Sample for the years 2012 and 2013 was used. All patients who underwent an orthognathic surgical procedure were selected. The primary independent variable of interest was presence of a congenital cleft and/or craniofacial anomaly.The outcome variables were the occurrence of complications, billed hospital charges, and length of stay. Multivariable logistic and linear regression models were used to examine the effect of the presence of craniofacial anomalies on outcomes. During the study period, a total of 16,515 patients underwent an orthognathic surgical procedure in the United States. Of these patients, 2,760 had a cleft and/or craniofacial anomaly. An infectious complication occurred in 7.4% of those with a craniofacial anomaly (compared with 0.6% of those without a craniofacial anomaly). The mean billed hospital charges in those with a craniofacial anomaly was $139,317 (compared with $56,189 in those without a craniofacial anomaly). The mean length of stay in the hospital in patients with a craniofacial anomaly was 8.8days (compared with 1.8days in those without a craniofacial anomaly). These differences in outcomes between patients with and patients without craniofacial anomalies were significant after we adjusted for patient- and hospital-level confounders. Patients with a craniofacial anomaly are at higher risk of development of infectious complications, have higher hospital charges, and stay in the hospital for a longer duration after orthognathic surgery when compared with those without a craniofacial anomaly.

188 Lower Pediatric Patient Volume is Associated With Higher Mortality in US Emergency Departments

Children account for over 25% of emergency department (ED) visits in the United States. Almost ninety percent of pediatric ED visits occur in general community EDs, many of which have low pediatric volumes and sporadic exposure to critically ill children. The goal of this study was to assess the association between ED pediatric volume and mortality with the hypothesis that EDs with lower annual pediatric volumes will have higher mortality for similar life-threatening conditions. We performed a secondary analysis of the 2012 Nationwide Emergency Department Sample (NEDS) dataset, the largest all-payer ED database in the United States. We included all patients ages 0-17 years. Using ICD-9 codes, the dataset was restricted to all patients with respiratory failure or cardiac arrest to identify critically ill children at high risk for mortality. Annual pediatric ED volume was divided into quartiles: low (<6373), medium (6374-12117), medium-high (12118-25376), and high (>25376). Descriptive statistics were performed and hierarchical multivariable logistic regression used to estimate associations between pediatric ED volume and mortality, adjusting for patient-level (comorbidity count, age, insurance, household income, sex) and hospital-level factors (urban-rural classification, teaching status, trauma designation, inpatient capacity, children’s hospital designation) that may offer competing explanations for this association. Of the 6.4 million pediatric patient visits in the 2012 NEDS dataset, 2,629 had a primary ICD-9 diagnosis of respiratory failure or cardiac arrest and were included in the cohort. The mean age was 4.1 years (SD 5.4), 40% were female, and the mean comorbidity count was 1.6 (SD 1.77), with 83% having at least one comorbidity. Thirty-nine percent of the cohort died in the ED. The majority of patients had Medicaid insurance (60%), 26% were privately insured, 10% were self-pay, and 49% lived in an urban area. Eleven percent were seen at children’s hospitals, 42% at trauma centers, and 56% at teaching hospitals. Almost 19% of patients were treated at a low-volume (1st quartile) ED, 24% at a low-medium volume ED, 27% at a medium-high volume ED, and 31% at a high-volume ED. High-volume EDs were associated with decreased mortality (OR 0.40 95% CI 0.17-0.94) when compared to low-volume EDs. There was a trend toward incrementally lower odds of mortality in low-medium, medium-high, and high-volume EDs when compared to low-volume EDs, but only high-volume ED mortality reached significance. Using predicted probabilities to convert odds ratios to risk difference, children who present in cardiac arrest or with respiratory failure are 17% less likely to die in a high-volume ED than a low-volume ED, adjusting for patient- and hospital-level covariates available in the NEDS dataset. In a population-based pediatric ED sample of respiratory failure or cardiac arrest, higher volume EDs were significantly associated with decreased mortality after adjusting for patient- and hospital-level confounders.

Hospital-level balloon tamponade use is associated with increased mortality for all patients presenting with acute variceal haemorrhage.

Balloon tamponade (BT) can bridge patients to salvage therapy for uncontrollable acute variceal haemorrhage (AVH). However, data are limited regarding the reasons for, rate of and outcomes associated with Balloon tamponade use. First, we performed an single-centre cohort study of all patients (N=139) with oesophageal acute variceal haemorrhage from 01/2009 to 10/2015. Associations between Balloon tamponade use and adherence to four quality metrics (endoscopy within 12hours, band-ligation, pre-endoscopy antibiotics and octreotide) were evaluated. Second, we analysed the National Inpatient Sample (2005-2011) to determine the association between in-hospital mortality for patients and their hospital's Balloon tamponade-utilization to acute variceal haemorrhage volume ratio. In the national cohort, 5.5% of 140521 acute variceal haemorrhage admissions required Balloon tamponade utilization. Adjusting for patient- and hospital-level confounders, the rate of Balloon tamponade use per acute variceal haemorrhage managed at any given hospital was associated with increased mortality for all-comers with acute variceal haemorrhage. Compared to the lowest tertile, acute variceal haemorrhage admissions in the highest Balloon tamponade utilizers were associated with increased mortality of (OR1.17 95%CI (1.01-1.37). In the single-centre cohort, 14 (10.1%) patients required Balloon tamponade. Balloon tamponade utilization was significantly associated with alcohol abuse (50.4% vs 21.4%, P=.04), hepatocellular carcinoma (35.7% vs 8.8%, P=.01), higher median model for end-stage liver disease (MELD) score (26.3vs15.5, P=.002) and active bleeding during endoscopy (64.3% vs 27.5%, P=.01). Failure to provide all quality metrics was associated with a higher model for end-stage liver disease-adjusted risk of Balloon tamponade use: OR 16.7 95% CI(4.17-100.0, P<.0001). Balloon tamponade use is associated with severity of bleeding but may also implicate deficits in processes of care. Even for patients who did not need Balloon tamponade, presentation to hospitals with high Balloon tamponade utilization increases their odds of dying from acute variceal haemorrhage.

Abstract W MP98: Ethnic Differences in Stroke Quality of Care Between Mexican Americans and Non-Hispanic Whites: The BASIC Project

Background: Mexican Americans (MAs) have worse outcomes after stroke than non-Hispanic Whites (NHWs). We investigated ethnic differences in the quality of inpatient stroke care between MAs and NHWs to determine if quality differences may contribute to the observed outcome disparity. Methods: Cases of ischemic stroke were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project (February 2009- June 2012). Quality of inpatient stroke care was assessed with seven quality metrics based on the 2008 Joint Commission Primary Stroke Center definitions. Two summary measure of overall quality were also created (binary defect-free care and a continuous composite score: proportion of achieved eligible measures). Multilevel generalized linear regression models were used to assess ethnic differences in quality of care, both unadjusted and then adjusting for hospital-level effects, demographics and confounders. Results: A total of 757 individuals were included (480 MAs and 277 NHWs). MAs were less likely than NHWs to receive tPA (RR: 0.71, 95% confidence interval (CI) 0.53, 0.96, p=0.026), and MAs with atrial fibrillation were less likely to receive anticoagulant medications at discharge (RR 0.71, 95% CI 0.55, 0.91, p=0.008). There were no ethnic differences in the other individual quality measures, or in the two overall summary measures. Adjustment for hospital clustering, demographics, and other confounders (summary measures only) resulted in little to no change in the association between ethnicity and quality (Table). Conclusions: There were no ethnic differences in the overall quality of stroke care between MAs and NHWs, though ethnic differences were seen in indicators for tPA and anticoagulant at discharge for atrial fibrillation. Since less than 20% of the population were eligible for these two measures, factors other than quality are likely to be primarily responsible for ethnic differences in stroke outcome.

Governmental designation of spine specialty hospitals, their characteristics, performance and designation effects: a longitudinal study in Korea

ObjectivesThis study compares the characteristics and performance of spine specialty hospitals versus other types of hospitals for inpatients with spinal diseases in South Korea. We also assessed the effect of...

An analysis of the inpatient charge and length of stay for patients with joint diseases in Korea: Specialty versus small general hospitals

In 2011, the Korean government designated hospitals with certain structural characteristics as specialty hospitals. This study compared the inpatient charges and length of stay of patients with joint diseases treated at these specialty hospitals with those of patients treated at small general hospitals. In addition, the study investigated whether the designation of certain hospitals as specialty hospitals had an effect on inpatient charges and length of stay. Multi-level models were used to perform regression analyses on inpatient claims data (N=268,809) for 2010–2012 because of the hierarchical structure of the data. The inpatient charge at specialty hospitals was 19% greater than that at small general hospitals, but the length of stay was 21% shorter. After adjusting for patient and hospital level confounders, specialty hospitals had a higher inpatient charge (34.6%) and a reduced length of stay (31.7%). However, the effect of specialty hospital designation on inpatient charge (2.7% higher) and length of stay (2.3% longer) was relatively smaller. Among the patient characteristics, female gender, age, and severity of illness were positively associated with inpatient charge and length of stay. In terms of location, hospitals in metropolitan area had higher inpatient charges (5.5%), but much shorter length of stay (−14%). Several structural factors, such as occupancy rate, bed size, number of outpatients and nurses were positively associated with both inpatient charges and length of stay. However, number of specialists was positively associated with inpatient charges, but negatively associated with length of stay. In sum, this study found that specialty hospitals treating joint diseases tend to incur higher charges but produce shorter length of stay, compared to their counterparts. Specialty hospitals’ overcharging behaviors, although shorter length of stay, suggest that policy makers could introduce bundled payments for the joint procedures. To promote a successful specialty hospital system, a broader discussion and investigation that includes quality measures as well as real cost of care should be initiated.

698: Effect of elective induction of labor at 37-40 weeks compared with expectant management on perinatal mortality in California

compared with expectant management on perinatal mortality in California Blair Darney, Yvonne Cheng, Jonathan Snowden, Lorie Jacob, James Nicholson, Anjali Kaimal, Sascha Dublin, Darios Gethun, Aaron Caughey Oregon Health & Science University, Obstetrics & Gynecology, Portland, OR, Oregon Health & Science University, Center for Health Systems Effectiveness, Portland, OR, University of California, San Francisco, School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, CA, Group Health Research Institute, Center for Health Studies, Seattle, WA, University of Pennsylvania Health System, Department of Family Medicine and Community Health, Philadelphia, PA, Massachusetts General Hospital, Department of Obstetrics and Gynecology, Boston, MA, Kaiser Permanente Southern California, Department of Research and Evaluation, Pasadena, CA OBJECTIVE: Often, studies of elective induction of labor use spontaneous labor as a comparison group. However, in a randomized trial, induction of labor is compared to expectant management, and thus, increasing gestational age and delivery at a later date. We sought to examine the association between elective induction of labor and expectant management on perinatal death. STUDY DESIGN: We conducted a retrospective cohort study of all singleton, vertex pregnancies at 37-42 weeks in the State of California in 2006. For each gestational age of an elective induction, defined by the Joint Commission criteria, we created a comparison group of women who were undelivered at that gestational age, and who experienced labor at some future gestational age. We excluded chronic conditions, antepartum diagnoses, and fetal anomalies from the expectant comparison group. We compared the outcomes of perinatal death (fetal, neo and post-neonatal deaths) within each group using two group tests of proportions and multivariable logistic regression controlling for common individual and hospital-level confounders. RESULTS: There were 827 perinatal deaths in the cohort (.23%). We found reduced odds of perinatal death among women electively induced at 38, 39, and 40 weeks compared with women expectantly managed at each week (Table). In multivariable analyses, the relationship held at 39 and 40 weeks, but was no longer significant at 38 weeks, possibly due to low numbers of deaths. CONCLUSION: Our findings suggest that elective induction of labor at term, when compared with expectant management, is associated with a reductioninperinatalmortality.Furtherresearchshouldexaminearange of perinatal and maternal outcomes and elective induction of labor at term deserves study in a multicenter, prospective, randomized trial. 699 Hospital rates of cesarean deliveries are negatively associated with severe perineal lacerations in California Blair Darney, Jonathan Snowden, Erika Cottrelll, Jeanne-Marie Guise, Yvonne Cheng, Aaron Caughey Oregon Health & Science University, Obstetrics & Gynecology, Portland, OR, University of California, San Francisco, School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, CA OBJECTIVE: Hospital rates of 3rd and 4th degree lacerations are a quality metric for obstetric care. However, high cesarean rates are also a concern. We explored whether hospital-level rates of cesarean deliveries are associated with rates of 3rd/4th degree lacerations. STUDY DESIGN: We used linked birth registry/hospital discharge data including all deliveries in California in 2006. We excluded all hospitals with 50 deliveries per year. We included 527, 617 deliveries in 268 hospitals. We calculated the proportion of all deliveries at each hospital that were by cesarean and the proportion which resulted in 3rd/ 4th degree lacerations. We used scatterplots, fitted regression lines, and calculated covariances to examine the relationship of cesarean deliveries and 3rd/4th degree lacerations. RESULTS: The proportion of deliveries at hospitals by cesarean is negatively correlated with the proportion of 3rd/4th degree lacerations (covariance -.22) and significantly associated in a multivariable regression model ( -.04, p .0001). The effect is slightly stronger among multiparas than among nulliparas. CONCLUSION: Our findings suggest that hospital-level rates of cesarean deliveries and lacerations are inversely correlated. A focus on reducing lacerations to improve quality measures may increase cesarean rates, which are also of concern.

Effect of Emergency Department Crowding on Outcomes of Admitted Patients

Emergency department (ED) crowding is a prevalent health delivery problem and may adversely affect the outcomes of patients requiring admission. We assess the association of ED crowding with subsequent outcomes in a general population of hospitalized patients. We performed a retrospective cohort analysis of patients admitted in 2007 through the EDs of nonfederal, acute care hospitals in California. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay and costs. ED crowding was established by the proxy measure of ambulance diversion hours on the day of admission. To control for hospital-level confounders of ambulance diversion, we defined periods of high ED crowding as those days within the top quartile of diversion hours for a specific facility. Hierarchic regression models controlled for demographics, time variables, patient comorbidities, primary diagnosis, and hospital fixed effects. We used bootstrap sampling to estimate excess outcomes attributable to ED crowding. We studied 995,379 ED visits resulting in admission to 187 hospitals. Patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (95% confidence interval [CI] 2% to 8%), 0.8% longer hospital length of stay (95% CI 0.5% to 1%), and 1% increased costs per admission (95% CI 0.7% to 2%). Excess outcomes attributable to periods of high ED crowding included 300 inpatient deaths (95% CI 200 to 500 inpatient deaths), 6,200 hospital days (95% CI 2,800 to 8,900 hospital days), and $17 million (95% CI $11 to $23 million) in costs. Periods of high ED crowding were associated with increased inpatient mortality and modest increases in length of stay and costs for admitted patients.

Variations in surgical outcomes associated with hospital compliance with safety practices

The Leapfrog Group aims to improve patient safety by promoting hospital compliance with National Quality Forum (NQF) safe practices. It is unknown, however, whether implementation of these safety practices improve outcomes after high-risk operations. We conducted a cross-sectional analysis of 658 nationwide hospitals that responded to the 2005 Leapfrog Group Hospital Quality & Safety survey. A total of 79,462 patients were identified from Medicare claims data who underwent a pancreatectomy, hepatectomy, esophagectomy, open aortic aneurysm repair, colectomy, or gastrectomy procedure from 2004 through 2006. Random effects logistic regression models were used to estimate the association between hospital compliance with NQF safe practices and risk-adjusted odds of complications, rate of failure to rescue, and mortality after adjusting for patient- and hospital-level confounders. Of the 658 hospitals that responded to surveys, 41% had fully implemented NQF safe practices and 59% reported partial compliance with these standards. Compared with hospitals with partial NQF compliance, we found evidence that hospitals with full compliance had an increased likelihood of diagnosing a complication after any of the 6 high-risk operations (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.03-1.25), but had a decreased likelihood of failure to rescue (OR, 0.82; 95% CI, 0.71-0.96), and a decreased odds of mortality (OR, 0.80; 95% CI, 0.71-0.91). Despite having a greater rate of postoperative complications, hospitals fully complying with safe practices were associated with less failure to rescue and decreased mortality after high-risk operations. These results highlight the importance of having hospital systems in place to promote safety and manage postoperative complications.

The management of pelvic trauma in the emergency department

There is paucity of data regarding the characteristics and outcomes of patients admitted for ST Elevation Myocardial Infarction (STEMI) complicated by cardiogenic shock (CS) with concomitant Coronavirus Disease 2019 (COVID-19) infection.Using the National Inpatient Sample (NIS) Database for the year 2020, we conducted a retrospective cohort study to investigate the outcomes of patients who sustained STEMI-associated cardiogenic shock (STEMI-CS) with concomitant COVID-19 infection looking at its impact on in-hospital mortality and secondarily at the in-hospital procedure and intervention utilization rates as well as hospital length of stay.We identified a total of 22,775 patients with STEMI-CS, of which 1.71 % (n = 390/22,775) had COVID-19 infection. Using a stepwise survey multivariable logistic regression model that adjusted for patient and hospital level confounders, concomitant COVID-19 infection among STEMI-CS patients was found to be an independent predictor of overall in-hospital mortality compared to those without COVID-19 (adjusted OR 2.10; 95 % confidence interval [CI], 1.30–3.40). STEMI-CS patients with concomitant COVID-19 infection had similar in-hospital utilization rates for percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), extracorporeal membrane oxygenation (ECMO), percutaneous and durable left ventricular device, intra-arterial aortic balloon pump (IABP), renal replacement therapy (RRT), mechanical ventilation, as well as similar hospital lengths of stay.Concomitant COVID-19 infection was associated with higher in-hospital mortality rates among patients with cardiogenic shock related to STEMI but had similar in-hospital procedure and intervention utilization rates as well as hospital length of stay.

Diet Therapy of Diabetes Mellitus

In 2011, the Korean government designated hospitals with certain structural characteristics as specialty hospitals. This study compared the inpatient charges and length of stay of patients with joint diseases treated at these specialty hospitals with those of patients treated at small general hospitals. In addition, the study investigated whether the designation of certain hospitals as specialty hospitals had an effect on inpatient charges and length of stay. Multi-level models were used to perform regression analyses on inpatient claims data (N = 268,809) for 2010–2012 because of the hierarchical structure of the data. The inpatient charge at specialty hospitals was 19% greater than that at small general hospitals, but the length of stay was 21% shorter. After adjusting for patient and hospital level confounders, specialty hospitals had a higher inpatient charge (34.6%) and a reduced length of stay (31.7%). However, the effect of specialty hospital designation on inpatient charge (2.7% higher) and length of stay (2.3% longer) was relatively smaller. Among the patient characteristics, female gender, age, and severity of illness were positively associated with inpatient charge and length of stay. In terms of location, hospitals in metropolitan area had higher inpatient charges (5.5%), but much shorter length of stay (−14%). Several structural factors, such as occupancy rate, bed size, number of outpatients and nurses were positively associated with both inpatient charges and length of stay. However, number of specialists was positively associated with inpatient charges, but negatively associated with length of stay. In sum, this study found that specialty hospitals treating joint diseases tend to incur higher charges but produce shorter length of stay, compared to their counterparts. Specialty hospitals’ overcharging behaviors, although shorter length of stay, suggest that policy makers could introduce bundled payments for the joint procedures. To promote a successful specialty hospital system, a broader discussion and investigation that includes quality measures as well as real cost of care should be initiated.