Hospital Variation Research Articles

Characterizing geographic variation in postoperative venous thromboembolism

ObjectiveVenous thromboembolism (VTE) after major surgery remains an important contributor to morbidity and mortality. Despite significant quality improvement efforts in prevention and prophylaxis strategies, the degree of hospital and regional variation in the United States remains unknown. MethodsMedicare beneficiaries undergoing 13 different major surgeries at U.S. hospitals between 2016 and 2018 were included in this retrospective cohort study. We calculated the rates of 90-day VTE. We adjusted for a variety of patient and hospital covariates and used a multilevel logistic regression model to calculate the rates of VTE and coefficients of variation across hospitals and hospital referral regions (HRRs). ResultsA total of 4,115,837 patients from 4116 hospitals were included, of whom 116,450 (2.8%) experienced VTE within 90 days. The 90-day VTE rates varied substantially by procedure, from 2.5% for abdominal aortic aneurysm repair to 8.4% for pancreatectomy. Across the hospitals, there was a 6.6-fold variation in index hospitalization VTE and a 5.3-fold variation in the rate of postdischarge VTE. Across the HRRs, there was a 2.6-fold variation in 90-day VTE, with a 12.1-fold variation in the coefficient of variation. A subset of HRRs was identified with both higher VTE rates and higher variance across hospitals. ConclusionsSubstantial variation exists in the rate of postoperative VTE across U.S. hospitals. Characterizing HRRs with high overall rates of VTE and those with significant variation across the hospitals will allow for targeted quality improvement efforts.

Hospital variation in revision rates after primary knee arthroplasty was not explained by patient selection: baseline data from 1452 patients in the Danish prospective multicenter cohort study, SPARK

PurposeRevision rates following primary knee arthroplasty vary by country, region and hospital. The SPARK study was initiated to compare primary surgery across three Danish regions with consistently different revision rates. The present study investigated whether the variations were associated with differences in the primary patient selection.MethodsA prospective observational cohort study included patients scheduled Sep 2016 Dec 2017 for primary knee arthroplasty (total, medial/lateral unicompartmental or patellofemoral) at three high-volume hospitals, representing regions with 2-year cumulative revision rates of 1, 2 and 5%, respectively. Hospitals were compared with respects to patient demographics, preoperative patient-reported outcome measures, motivations for surgery, implant selection, radiological osteoarthritis and the regional incidence of primary surgery. Statistical tests (parametric and non-parametric) comprised all three hospitals.ResultsBaseline data was provided by 1452 patients (89% of included patients, 56% of available patients). Patients in Copenhagen (Herlev-Gentofte Hospital, high-revision) were older (68.6 ± 9 years) than those in low-revision hospitals (Aarhus 66.6 ± 10 y. and Aalborg (Farsø) 67.3 ± 9 y., p = 0.002). In Aalborg, patients who had higher Body Mass Index (mean 30.2 kg/m2 versus 28.2 (Aarhus) and 28.7 kg/m2 (Copenhagen), p < 0.001), were more likely to be male (56% versus 45 and 43%, respectively, p = 0.002), and exhibited fewer anxiety and depression symptoms (EQ-5D-5L) (24% versus 34 and 38%, p = 0.01). The preoperative Oxford Knee Score (23.3 ± 7), UCLA Activity Scale (4.7 ± 2), range of motion (Copenhagen Knee ROM Scale) and patient motivations were comparable across hospitals but varied with implant type. Radiological classification ≥ 2 was observed in 94% (Kellgren-Lawrence) and 67% (Ahlbäck) and was more frequent in Aarhus (low-revision) (p ≤ 0.02), where unicompartmental implants were utilized most (49% versus 14 (Aalborg) and 23% (Copenhagen), p < 0.001). In the Capital Region (Copenhagen), the incidence of surgery was 15–28% higher (p < 0.001).ConclusionPatient-reported outcome measures prior to primary knee arthroplasty were comparable across hospitals with differing revision rates. While radiographic classifications and surgical incidence indicated higher thresholds for primary surgery in one low-revision hospital, most variations in patient and implant selection were contrary to well-known revision risk factors, suggesting that patient selection differences alone were unlikely to be responsible for the observed variation in revision rates across Danish hospitals.Level of evidence II, Prospective cohort study.

Practice variation and outcomes of minimally invasive minor liver resections in patients with colorectal liver metastases: a population-based study

IntroductionIn 2017, the Southampton guideline stated that minimally invasive liver resections (MILR) should considered standard practice for minor liver resections. This study aimed to assess recent implementation rates of minor MILR, factors associated with performing MILR, hospital variation, and outcomes in patients with colorectal liver metastases (CRLM).MethodsThis population-based study included all patients who underwent minor liver resection for CRLM in the Netherlands between 2014 and 2021. Factors associated with MILR and nationwide hospital variation were assessed using multilevel multivariable logistic regression. Propensity-score matching (PSM) was applied to compare outcomes between minor MILR and minor open liver resections. Overall survival (OS) was assessed with Kaplan–Meier analysis on patients operated until 2018.ResultsOf 4,488 patients included, 1,695 (37.8%) underwent MILR. PSM resulted in 1,338 patients in each group. Implementation of MILR increased to 51.2% in 2021. Factors associated with not performing MILR included treatment with preoperative chemotherapy (aOR 0.61 CI:0.50–0.75, p < 0.001), treatment in a tertiary referral hospital (aOR 0.57 CI:0.50–0.67, p < 0.001), and larger diameter and number of CRLM. Significant hospital variation was observed in use of MILR (7.5% to 93.0%). After case-mix correction, six hospitals performed fewer, and six hospitals performed more MILRs than expected. In the PSM cohort, MILR was associated with a decrease in blood loss (aOR 0.99 CI:0.99–0.99, p < 0.01), cardiac complications (aOR 0.29, CI:0.10–0.70, p = 0.009), IC admissions (aOR 0.66, CI:0.50–0.89, p = 0.005), and shorter hospital stay (aOR CI:0.94–0.99, p < 0.01). Five-year OS rates for MILR and OLR were 53.7% versus 48.6%, p = 0.21.ConclusionAlthough uptake of MILR is increasing in the Netherlands, significant hospital variation remains. MILR benefits short-term outcomes, while overall survival is comparable to open liver surgery.Graphical abstract

Hospital variations in caesarean delivery rates: An analysis of national data in China, 2016-2020

The impact of China's use of caesarean delivery on global public health has been a long-term concern. The number of private hospitals is increasing in China and likely driving up caesarean delivery rates, yet specifics remain unknown. We aimed to investigate variations in caesarean delivery rates across and within hospital types in China. We retrieved data on hospital characteristics and national hospital-level annually aggregated data on the number of deliveries and caesarean deliveries from 2016-2020, covering 7085 hospitals in 31 provinces of mainland China, from the National Clinical Improvement System. We categorized hospitals as public-non-referral (n = 4103), public-referral (n = 1805) and private (n = 1177). Among the private hospitals, 89.1% (n = 1049) were non-referral regarding obstetrical services for uncomplicated pregnancies. Among 38 517 196 deliveries, 16 744 405 were caesarean, giving an overall rate of 43.5% with a minor range of 42.9%-43.9% over time. Median rates differed across hospital types, from 47.0% (interquartile range (IQR) = 39.8%-55.9%) in public-referral, 45.8% (36.2%-55.8%) in private, and 40.3% (30.6%-50.6%) in public-non-referral hospitals. The stratified analyses corroborated the results, except for the northeastern region, where the median rates did not differ across the public-non-referral (58.9%), public-referral (59.3%), and private (58.8%) hospitals, while all ranked higher than the other regions, regardless of hospital type and urbanization levels. The rates within hospital types differed as well, especially in the rural areas of the western region of China, where the difference of rates between the 5th and 95th percentiles was 55.6% (IQR = 4.9%-60.5%) in public-non-referral, 51.5% (IQR = 19.6%-71.1%) in public-referral, and 64.6% (IQR = 14.8%-79.4%) in private hospitals. Variation across hospital types in China was pronounced, with the highest rates either in public-referral or private hospitals, except in the northeastern region, where no variation was observed among the high rates of caesarean deliveries. Variation within each hospital type was pronounced, especially in rural areas of the western region.

Hospital admission decisions for older Veterans with community-onset pneumonia: An analysis of 118 U.S. Veterans Affairs Medical Centers.

Age is important for prognosis in community-onset pneumonia, but how it influences admission decisions in the emergency department (ED) is not well characterized. Using clinical data from the electronic health record in a national cohort, we examined pneumonia hospitalization patterns, variation, and relationships with mortality among older versus younger Veterans. In a retrospective cohort of patients ≥ 18 years presenting to EDs with a diagnosis of pneumonia at 118 VA Medical Centers January 1, 2006, to December 31, 2016, we compared observed, predicted, and residual hospitalization risk for Veterans < 70, 70-79, and ≥ 80 years of age using generalized estimating equations and machine learning models with 71 patient factors. We examined facility variation in residual hospitalization across facilities and explored whether facility differences in hospitalization risk correlated with differences in 30-day mortality. Among 297,498 encounters, 165,003 (55%) were for Veterans < 70 years, 61,076 (21%) 70-80, and 71,419 (24%) ≥ 80. Hospitalization rates were 52%, 67%, and 76%, respectively. After other patient factors were adjusting for, age 70-79 had an odds ratio (OR) of 1.39 (95% confidence interval [CI] 1.34-1.44) and ≥ 80 had an OR of 2.1 (95% CI 2.0-2.2) compared to age < 70. There was substantial variation in hospitalization across facilities among Veterans < 70 (<35% hospitalization at the lowest decile of facilities vs. > 66% at the highest decile) that was similar but with higher risk for patients 70-79 years (54% vs. 82%) and ≥ 80 years (59% vs. 85%) and remained after accounting for patient factors, with no consistently positive or negative associations with facility-level 30-day mortality. Older Veterans with community-onset pneumonia experience high risk of hospitalization, with widespread facility variation that has no clear relationship to short-term mortality.

Concurrent SARS-COV-19 and acute appendicitis: Management and outcomes across United States children's hospitals.

Nonoperative management of acute appendicitis is a safe and effective alternative to appendectomy, though rates of treatment failure and disease recurrence are significant. The purpose of this study was to determine whether COVID-19-positive children with acute appendicitis were more likely to undergo nonoperative management when compared to COVID-19-negative peers and to compare clinical outcomes and healthcare use for these groups. A retrospective cohort study of children <18 years with acute appendicitis across 45 US Children's Hospitals during the first 12 months of the COVID-19 pandemic was performed. Operative management was defined as appendectomy or percutaneous drain placement, whereas nonoperative management was defined as admission with antibiotics alone. Multivariable hierarchical logistic regression using an exact matched cohort was used to determine the association between COVID-19 positivity and nonoperative management. The secondary outcomes included intensive care unit admission, mechanical ventilation, length of stay, nonoperative management failure rates, and hospital variation in nonoperative management. Of 17,481 children in the cohort, 581 (3.3%) were positive for COVID-19. The odds of nonoperative management was significantly higher in the COVID-19-positive group (adjusted odds ratio [95% confidence interval]: 13.4 [10.7-16.8], P < .001). Patients positive for COVID-19 had increased odds of intensive care unit admission (adjusted odds ratio [95% confidence interval]: 3.78 [2.01-7.12], P < .001) and longer length of stay (median 2 days vs 1 day, P < .001). Hospital rates of nonoperative management ranged from 0% to 100% for COVID-19-positive patients and 0% to 42% for COVID-19-negative patients. Children with concurrent acute appendicitis and COVID-19 positivity are significantly more likely to undergo nonoperative management. Both groups experience infrequent nonoperative management failure rates and rare intensive care unit admissions. Marked hospital variability in nonoperative management practices was demonstrated.

Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O’CAFÉ trial)

BackgroundManagement of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk.MethodsWe describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California.DiscussionWe hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter.Trial registrationClinicalTrials.gov NCT05009225. Registered on 17 August 2021.

Evaluation of Cesarean Rates for Term, Singleton, Live Vertex Deliveries in China in 2020 Among Women With No Prior Cesarean Delivery

Substantial regional variation in cesarean delivery rates has been reported in China, but there is a lack of reports on hospital-level variation in these rates among low-risk deliveries. To evaluate hospital variation in cesarean rates in China for term, singleton, live vertex deliveries among women with no prior cesarean delivery and to estimate contributions of individual and hospital factors. This nationwide cross-sectional study used data from maternal patient discharge records collected by the Hospital Quality Monitoring System in China from January 1 to December 31, 2020. Pregnant female individuals aged 15 to 49 years (referred to hereafter as women) with at least 1 live birth were included, and low-risk deliveries were defined as term, singleton, live, vertex deliveries with no prior cesarean delivery. Birth by cesarean delivery. The main outcome was cesarean delivery rate by hospital. Hierarchical logistic regression analysis was used to calculate the adjusted cesarean rate and to estimate the percentage of hospital variation in low-risk deliveries explained by individual and hospital factors. Among the 7 635 149 deliveries identified from 4359 hospitals in 31 provinces of mainland China, 6 599 468 (86.4%) were considered low risk. Of overall and low-risk deliveries, 3 400 162 and 2 638 097 were cesarean deliveries, corresponding to mean rates of 44.5% and 40.0%, respectively. The mean (SD) maternal age for overall and low-risk deliveries was 29.1 (4.0) and 28.8 (4.8) years, respectively, and mothers were more likely to be of Han ethnicity (89.5%). Cesarean rates varied widely among hospitals, with absolute differences between the 5th and 95th percentiles of 53.5% (19.4%-72.9%) for overall deliveries and 56.8% (14.3%-71.1%) for low-risk deliveries. Large absolute differences remained after adjusting for maternal characteristics, with rates of 47.4% (19.1%-66.5%) for overall deliveries and 52.6% (15.0%-67.6%) for low-risk deliveries. Among low-risk deliveries, hospital factors (eg, hospital province location) explained 31.3% of the hospital variation in cesarean rate and individual factors explained an additional 2.0%. The findings of this cross-sectional study suggest that cesarean rates varied markedly among hospitals in China in 2020, which may be attributable to hospital rather than individual factors. Future work is needed to design hospital-level initiatives to optimize cesarean use, particularly among low-risk deliveries.

Ethnic variation in asthma healthcare utilisation and exacerbation: systematic review and meta-analysis.

Patients from ethnic minority groups (EMGs) frequently report poorer asthma outcomes; however, a broad synthesis summarising ethnic disparities is yet to be undertaken. What is the magnitude of ethnic disparities in asthma healthcare utilisation, exacerbations and mortality? MEDLINE, Embase and Web of Science databases were searched for studies reporting ethnic variation in asthma healthcare outcomes (primary care attendance, exacerbation, emergency department (ED) visits, hospitalisation, hospital readmission, ventilation/intubation and mortality) between White patients and those from EMGs. Estimates were displayed using forest plots and random-effects models were used to calculate pooled estimates. We conducted subgroup analyses to explore heterogeneity, including by specific ethnicity (Black, Hispanic, Asian and other). 65 studies, comprising 699 882 patients, were included. Most studies (92.3%) were conducted in the United States of America (USA). Patients from EMGs had evidence suggestive of lower levels of primary care attendance (OR 0.72, 95% CI 0.48-1.09), but substantially higher ED visits (OR 1.74, 95% CI 1.53-1.98), hospitalisations (OR 1.63, 95% CI 1.48-1.79) and ventilation/intubation (OR 2.67, 95% CI 1.65-4.31) when compared to White patients. In addition, we found evidence suggestive of increased hospital readmissions (OR 1.19, 95% CI 0.90-1.57) and exacerbation rates (OR 1.10, 95% CI 0.94-1.28) among EMGs. No eligible studies explored disparities in mortality. ED visits were much higher among Black and Hispanic patients, while Asian and other ethnicities had similar rates to White patients. EMGs had higher secondary care utilisation and exacerbations. Despite the global importance of this issue, the majority of studies were performed in the USA. Further research into the causes of these disparities, including whether these vary by specific ethnicity, is required to aid the design of effective interventions.

Variation in hospital use of cardiac resynchronization therapy-defibrillator among eligible patients and association with clinical outcomes

Despite strong guideline recommendations for cardiac resynchronization therapy-defibrillator (CRT-D) in select patients, this therapy is underutilized with substantial variation among hospitals, and the association of this variation with outcomes is unknown. The purpose of this study was to assess whether facility variation in CRT-D utilization is associated with differences in hospital-level outcomes. We linked Medicare claims data with the National Cardiovascular Data Registry's ICD Registry from 2010 to 2015. We calculated the intraclass correlation coefficient to quantify the degree of variation in patient-level CRT use that can be explained by interfacility variation on a hospital level. To quantify the degree of hospital variation in patient-level outcomes (all-cause mortality, readmissions, and cardiac readmissions) that can be attributed to variations in CRT-D use, we utilized multilevel modeling. The study included 30,134 patients across 1377 hospitals. The median rate of CRT-D implantation in those meeting guideline indications was 89%, but there was a wide variation across hospitals. After adjustment, most of the variation (74%) in hospital rates of CRT-D utilization was attributable to the hospital in which the patient was treated. Differences in hospital CRT-D utilization was associated with 8.76%, 5.26%, and 4.71% of differences in hospital mortality, readmissions, and cardiac readmission rates, respectively (P < .001 for all outcomes). There is a wide variation in the use of CRT-D across hospitals that was not explained by case mix. Hospital-level variation in CRT-D utilization was associated with clinically significant differences in outcomes. A measure of CRT-D utilization in eligible patients may serve as a useful metric for quality improvement efforts.

Updated Trends in Inferior Vena Cava Filter Use by Indication in the United States After Food and Drug Administration Safety Warnings: A Decade Analysis From 2010 to 2019

Background: Overall inferior vena cava filter (IVCF) utilization has decreased in the United States since the 2010 US Food and Drug Administration (FDA) safety communication. The FDA renewed this safety warning in 2014 with additional mandates on reporting IVCF-related adverse events. We evaluated the impact of the FDA recommendations on IVCF placements for different indications from 2010 to 2019 and further assessed utilization trends by region and hospital teaching status. Methods: Inferior vena cava filter placements between 2010 and 2019 were identified in the Nationwide Inpatient Sample database using the associated International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision codes. Inferior vena cava filter placements were categorized by indication for venous thromboembolism (VTE) “treatment” in patients with VTE diagnosis and contraindication to anticoagulation and “prophylaxis” in patients without VTE. Generalized linear regression was used to analyze utilization trends. Results: A total of 823 717 IVCFs were placed over the study period, of which 644 663 (78.3%) were for VTE treatment and 179 054 (21.7%) were for prophylaxis indications. The median age for both categories of patients was 68 years. The total number of IVCFs placed for all indications decreased from 129 616 in 2010 to 58 465 in 2019, with an aggregate decline rate of −8.4%. The decline rate was higher between 2014 and 2019 than between 2010 and 2014 (−11.6% vs −7.2%). From 2010 to 2019, IVCF placement for VTE treatment and prophylaxis trended downward at rates of −7.9% and −10.2%, respectively. Urban nonteaching hospitals saw the highest decline for both VTE treatment (−17.2%) and prophylactic indications (−18.0%). Hospitals located in the Northeast region had the highest decline rates for VTE treatment (−10.3%) and prophylactic indications (−12.5%). Conclusion: The higher decline rate in IVCF placements between 2014 and 2019 compared with 2010 and 2014 suggests an additional impact of the renewed 2014 FDA safety indications on national IVCF utilization. Variations in IVCF use for VTE treatment and prophylactic indications existed across hospital teaching types, locations, and regions. Clinical Impact Inferior vena cava filters (IVCF) are associated with medical complications. The 2010 and 2014 FDA safety warnings appeared to have synergistically contributed to a significant decline in IVCF utilization rates from 2010 – 2019 in the US. IVC filter placements in patients without venous thromboembolism (VTE) declined at a higher rate than VTE. However, IVCF utilization varied across hospitals and geographical locations, likely due to the absence of universally accepted clinical guidelines on IVCF indications and use. Harmonization of IVCF placement guidelines is needed to standardize clinical practice, thereby reducing the observed regional and hospital variations and potential IVC filter overutilization.

Abstract P471: Predictors of Referral to Community-Based Rehabilitation Following Stroke

Background: While several studies have examined care transitions following stroke, few have assessed use of rehabilitation. We explored factors predictive of referral to community-based rehabilitation following stroke. Setting: 40 NC acute care hospitals that participated in the COMprehensive Post-Acute Stroke Services study from 2016-2019. Participants: Adults discharged home following stroke or TIA (N=11,195) Methods: Guided by an a priori conceptual framework, 41 predictors of referral to community-based rehabilitation were grouped into 3 patient-level domains: demographics, stroke severity, and medical history (e.g., prior stroke); 2 hospital-level domains: structural characteristics (e.g., bed size) and stroke-specific characteristics (e.g., stroke center status); and 1 community-level domain (county-level therapist supply). We estimated predictors of referral using a logistic mixed model with a hospital-specific random effect. We used a hierarchical backward selection approach, first performing domain-specific model selection, then entering retained variables into a complete model. Results: The cohort was 49% female, 72% white, with a mean age of 66.8 (SD=14.0) years and overall low stroke severity [mean [SD] NIHSS 2.4 [3.8]). Thirty-six percent of patients were referred to rehabilitation. Referral varied across hospitals, ranging from 3-78%, with a median of 35%. In the final model, older age, female sex, non-white race, higher stroke severity, longer length of stay, previous stroke, current smoking, and heart failure were associated with higher odds of referral as was hospital-employed vs. external-contracted OT services (Table). Discussion: Approximately one-third of stroke survivors discharged home were referred to community-based rehabilitation. Women and non-white patients had higher odds of referral. Hospital and community factors were largely not independent predictors of referral. Unmeasured process measures may play a role in unexplained hospital variation.

Hospital Strain and Variation in Sepsis ICU Admission Practices and Associated Outcomes.

Retrospective cohort study using a validated hospital capacity strain index as a within-hospital instrumental variable governing ICU versus ward admission, stratified by hospital. Twenty-seven U.S. hospitals from 2013 to 2018. High-acuity emergency department patients with sepsis who do not require life support therapies. None. The mean predicted probability of ICU admission across strain deciles ranged from 4.9% (lowest ICU-utilizing hospital for sepsis without life support) to 61.2% (highest ICU-utilizing hospital for sepsis without life support). The difference in the predicted probabilities of ICU admission between the lowest and highest strain deciles ranged from 9.0% (least strain-sensitive hospital) to 45.2% (most strain-sensitive hospital). In pooled analyses, emergency department patients with sepsis (n = 90,150) experienced a 1.3-day longer median hospital length of stay (LOS) if admitted initially to the ICU compared with the ward, but across the 27 study hospitals (n = 517-6,564), this effect varied from 9.0 days shorter (95% CI, -10.8 to -7.2; p < 0.001) to 19.0 days longer (95% CI, 16.7-21.3; p < 0.001). Corresponding ranges for inhospital mortality with ICU compared with ward admission revealed odds ratios (ORs) from 0.16 (95% CI, 0.03-0.99; p = 0.04) to 4.62 (95% CI, 1.16-18.22; p = 0.02) among patients with sepsis (pooled OR = 1.48). There is significant among-hospital variation in ICU admission rates for patients with sepsis not requiring life support therapies, how sensitive those ICU admission decisions are to hospital capacity strain, and the association of ICU admission with hospital LOS and hospital mortality. Hospital-level heterogeneity should be considered alongside patient-level heterogeneity in critical and acute care study design and interpretation.

Hospital variation in feeding jejunostomy policy for minimally invasive esophagectomy; population-based results from the Dutch Upper gastrointestinal Cancer Audit (DUCA)

Hospital variation in feeding jejunostomy policy for minimally invasive esophagectomy; population-based results from the Dutch Upper gastrointestinal Cancer Audit (DUCA)

Abstract WP196: Seasonal Variation In Stroke Ischemic Hospitalization: Results From The A Large Health System In Six Western States Of The United States.

Background: Evidence of seasonal variations in the incidence of stroke is inconsistent with some studies reporting no association and some a significant rise in different months of the year. In addition, less is known about how seasonality impacts the incidence of stroke subtype. Methods: This was a cross-sectional, observational study of data from a multi-state health system’s stroke registry (n=40 hospitals) in Alaska, California, Montana, Oregon, Texas, and Washington state. We included all cases with acute ischemic stroke admitted from September 29, 2016, to November 30, 2021. Admission data were categorized according to four meteorological seasons: winter, spring, summer, and fall. Acute ischemic stroke was categorized into two sub-types as large vessel occlusion (LVO) or non-LVO. We calculated the aggregate number of individuals admitted with stroke by season. Using, linear regression models with generalized estimating equations (GEE), we assessed the relationship between meteorological season and daily hospitalization rate. We used R version 4.0.4 (2021-02-15) for both the descriptive and inferential analyses and the R gee pack package (version 1.2-1) to perform GEEs. Results: During the study period, we identified 18,886 patients with acute ischemic stroke (median age: 73; 49.5% women). Acute ischemic stroke was more commonly observed during winter compared with other seasons with some variations between the selected regions. Based on a generalized estimating equations model, stroke hospitalization increased during winter, with an additional 3.3 cases per day (95%, CI [2.4, 4.1]). Winter is also associated with a higher incidence of large vessel occlusion. Conclusion: The incidence of ischemic stroke, including cases of large vessel occlusion, increased during the winter months. The results are important for human resource allocation for better management of cases with ischemic strokes.

Hierarchical causal variance decomposition for institution and provider comparisons in healthcare

Disease-specific quality indicators are used to compare institutions and health care providers in terms of processes or outcomes relevant to treatment of a particular condition. In the context of surgical cancer treatments, the performance variations can be due to hospital and/or surgeon level differences, creating a hierarchical clustering. We consider how the observed variation in care received at patient level can be decomposed into that causally explained by the hospital performance, surgeon performance within hospital, patient case-mix, and unexplained (residual) variation. For this purpose, we derive a four-way variance decomposition, with particular attention to the causal interpretation of the components. For estimation, we use inputs from a mixed-effect model with nested random hospital/surgeon-specific effects, and a multinomial logistic model for the hospital/surgeon-specific patient populations. We investigate the performance of our methods in a simulation study and demonstrate them through analysis of administrative data on kidney cancer care in Ontario.

Interhospital Variability in Utilization of Cardioversion for Atrial Fibrillation in the Emergency Department

The role for direct current cardioversion (DCCV) in the management of atrial fibrillation (AF) in the emergency department (ED) is unclear. Factors associated with DCCV in current practice are not well described, nor is the variation across patients and institutions. All ED encounters with a primary diagnosis of AF were identified from the Nationwide Emergency Department Sample from 2006 to 2017. The independent association of patient and hospital factors with use of DCCV was assessed using multivariable hierarchical logistic regression. The relative contributions of patient, hospital, and unmeasured hospital factors were assessed using reference effect measures methods. Among 1,280,914 visits to 3,264 EDs with primary diagnosis of AF, 31,422 patients (2.4%) underwent DCCV in the ED. History of stroke (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.09 to 0.22, p <0.001) and dementia (OR 0.14, 95% CI 0.10 to 0.19, p <0.001) was associated with lowest odds of DCCV. Comparing patients more likely to receive DCCV (ninety-fifth percentile) with patients with median risk, the influence of unmeasured hospital factors (OR 14.13, 95% CI 12.55 to 16.09) exceeded the contributions of patient (OR 5.66, 95% CI 5.28 to 6.15) and measured hospital factors (OR 3.89, 95% CI 2.87 to 5.60). In conclusion, DCCV use in the ED varied widely across institutions. Disproportionately large unmeasured hospital variation suggests that presenting hospital is the most determinative factor in the use of DCCV for ED management of AF. Clarification is needed on best practices for management of AF in the ED, including the use of DCCV.

A Comparison of Negative Pressure and Conventional Therapy in Spine Infections: A Single-Center Retrospective Study

Purpose: To investigate the effectiveness and safety of negative-pressure wound therapy (NPWT) in treating primary spinal infections. Methods: Patients who underwent surgical treatment for primary spinal infection between January 2018 and June 2021 were retrospectively evaluated. They were divided into two groups based on the type of surgery: one that underwent negative-pressure wound therapy (NPWT) and another that underwent conventional surgery (CVSG-Posterior debridement, bone grafting, fusion, and internal fixation in one stage). The two groups were compared in terms of the total operation time, total blood loss, total postoperative drainage, postoperative pain score, time for the postoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to return to normal, postoperative complications, treatment time, and recurrence rate. Results: A total of 43 cases of spinal infection were evaluated, with 19 in the NPWT group and 24 in the CVSG group. The NPWT group had a superior postoperative drainage volume, antibiotic use time, erythrocyte sedimentation rate and CRP recovery times, VAS score at 3 months after the operation, and cure rate at 3 months after operation compared with the CVSG group. There were no significant variations in the total hospital stay and intraoperative blood loss between the two groups. Conclusions: This study supports the use of negative pressure in the treatment of a primary spinal infection and indicates that it has a notably better short-term clinical effect than conventional surgery. Additionally, its mid-term cure rate and recurrence rate are more desirable than those of conventional treatments.

Variation in electroencephalography and neuroimaging for children receiving extracorporeal membrane oxygenation

BackgroundSeizures, strokes, and intracranial hemorrhage are common and feared complications in children receiving extracorporeal membrane oxygenation (ECMO) support. Researchers and clinicians have proposed and deployed methods for monitoring and detecting neurologic injury, but best practices are unknown. We sought to characterize clinicians’ approach to electroencephalography (EEG) and brain imaging modalities in children supported by ECMO.MethodsWe performed a retrospective observational cohort study among US Children’s Hospitals participating in the Pediatric Health Information System (PHIS) from 2016 to 2021. We identified hospitalizations containing ECMO support. We stratified these admissions by pediatric, neonatal, cardiac surgery, and non-cardiac surgery. We characterized the frequency of EEG, cranial ultrasound, brain computed tomography (CT), magnetic resonance imaging (MRI), and transcranial Doppler during ECMO hospitalizations. We reported key diagnoses (stroke and seizures) and the prescription of antiseizure medication. To assess hospital variation, we created multilevel logistic regression models.ResultsWe identified 8746 ECMO hospitalizations. Nearly all children under 1 year of age (5389/5582) received a cranial ultrasound. Sixty-two percent of the cohort received an EEG, and use increased from 2016 to 2021 (52–72% of hospitalizations). There was marked variation between hospitals in rates of EEG use. Rates of antiseizure medication use (37% of hospitalizations) and seizure diagnoses (20% of hospitalizations) were similar across hospitals, including high and low EEG utilization hospitals. Overall, 37% of the cohort received a CT and 36% received an MRI (46% of neonatal patients). Stroke diagnoses (16% of hospitalizations) were similar between high- and low-MRI utilization hospitals (15% vs 17%, respectively). Transcranial Doppler (TCD) was performed in just 8% of hospitalizations, and 77% of the patients who received a TCD were cared for at one of five centers.ConclusionsIn this cohort of children at high risk of neurologic injury, there was significant variation in the approach to EEG and neuroimaging in children on ECMO. Despite the variation in monitoring and imaging, diagnoses of seizures and strokes were similar across hospitals. Future work needs to identify a management strategy that appropriately screens and monitors this high-risk population without overuse of resource-intensive modalities.

Multilevel Analysis of Racial and Ethnic Disparities in COVID-19 Hospitalization among Children with Allergies.

Rationale: Previous studies have identified risk factors for coronavirus disease (COVID-19) hospitalization in children. However, these studies have been limited in their ability to disentangle the contribution of racial disparities, allergic comorbidities, and environmental exposures to the development of severe COVID-19 in at-risk children with allergies. Objectives: To examine racial and ethnic disparities in COVID-19 hospitalization and their links to potentially underlying allergic comorbidities and individual and place-based factors in children with allergies. Methods: This is an electronic health record-based retrospective study of children in 2020. The outcome was COVID-19 hospitalization categorized as no hospital care for patients with asymptomatic/mild illness, short stay for patients admitted and discharged within 24 hours, and prolonged stay for patients requiring additional time to discharge (more than 24 h). Mixed-effects and mediation models were used to determine relationships among independent variables, mediators, and COVID-19 hospitalization. Results: Among the 5,258 children with COVID-19 positive test or diagnosis, 10% required a short stay, and 3.7% required a prolonged stay. Black and Hispanic children had higher odds of longer stays than non-Hispanic White children (both P < 0.001). Children with obesity and eosinophilic esophagitis diagnoses had higher odds of short and prolonged stay (all P < 0.05). Area-level deprivation was associated with short stay (adjusted odds ratio [AOR], 15.49; 95% confidence interval [CI], 5.16-45.47 for every 0.1-unit increase) and prolonged stay (AOR, 11.82; 95% CI, 2.25-62.01 for every 0.1-unit increase). Associations between race/ethnicity and COVID-19 hospitalization were primarily mediated by insurance and area-level deprivation, altogether accounting for 99% of the variation in COVID-19 hospitalization. Conclusions: There were racial and ethnic differences in children with allergies and individual and place-based factors related to COVID-19 hospitalization. Differences were primarily mediated by insurance and area-level deprivation, altogether accounting for 99% of the variation in COVID-19 hospitalization. A better understanding of COVID-related morbidity in children and the link to place-based factors is key to developing prevention strategies capable of equitably improving outcomes.