Virginia Hospital Research Articles

POSITIVE FLOW CROSSMATCHES ASSOCIATED WITH POORER OUTCOME FOLLOWING HEART TRANSPLANTATION

1Surgery, Medical College of Virginia Hospitals, Richmond/VA/UNITED STATES OF AMERICA, 2Surgery, Medical College of Virginia Hospitals, Richmond/UNITED STATES OF AMERICA

Abdominal pain in the ED: a 35 year retrospective

Objective Research published in 1972 and 1993 has detailed the demographics, diagnoses, and diagnostic test utilization of adult patients presenting with nontraumatic abdominal pain to the emergency department (ED) at the University of Virginia Hospital. This is an update of those studies, designed to examine the present state of diagnosis and management of abdominal pain, as well as to look at trends during the 35-year span of the investigations. Methods One thousand consecutive adult patients presenting in the year 2007 with abdominal pain as their chief complaint were included in the analysis. Demographic data, discharge diagnosis, disposition, ED length of stay, charges, and diagnostic test utilization information were gathered and analyzed using electronic databases. Results These patients represented 6.5% of the total ED census. Sixty-five percent were female, 24.7% hospitalized, and 21% diagnosed with undifferentiated abdominal pain. Relative to 1993, there were more patients receiving specific diagnoses, (79% versus 75%) and a higher rate of hospitalization (24.7% versus 18.3%). Use of diagnostic testing has markedly increased in frequency, most notably computed tomography and ultrasound, which have risen 6-fold. One of these imaging modalities is now used in 42% of patient encounters. Visit times were longer and patient charges higher. There were 2 cases of missed surgical disease in 2007 compared with 1 in 1993 and 8 in 1972. Conclusion Over the past 35 years, ED management of atraumatic abdominal pain has become time, money, and resource intense. Widespread use of sophisticated imaging has had a small impact on diagnostic specificity but has not produced lower admission rates or fewer cases of missed surgical illness.

Admissions of African Americans to state psychiatric hospitals

This investigation examines the admissions of African-Americans to state psychiatric hospitals in Virginia. It compares admissions of African-Americans primarily with European-Americans and other racial and ethnic minorities. Data spanning the 20-year period from 1970 to 1990 from nine state psychiatric hospitals were analysed to determine the relationship of race to number of admissions, to primary diagnosis at admission and to length of stay. Compared to European-Americans, African-Americans were significantly more likely to be admitted to state psychiatric hospitals, had longer lengths of stay and were likely to be given more severe diagnoses. Key policy implications are provided.

Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period

Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified. To describe the clinical characteristics and outcomes in a large single-center experience with patients referred for ampullary lesions. A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database. Tertiary referral center. One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007. Endoscopic management of ampullary lesions. The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients. One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy. Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in 1 (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting success were a smaller adenoma size and the absence of dilated ducts. Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting success.

Rates of Stenotrophomonas maltophilia colonization and infection in relation to antibiotic cycling protocols

This study evaluated whether antibiotic cycling programmes using broad-spectrum agents including carbapenems were associated with increased rates of colonization or infection by Stenotrophomonas maltophilia. Retrospective analyses of colonization or infection by S. maltophilia from 1992 to 2002 were conducted using University of Virginia Hospital clinical microbiology records of patients with any culture positive for S. maltophilia and hospital epidemiology records of nosocomial S. maltophilia infections. Incidence rates were calculated and compared for cycling and non-cycling periods. No significant differences were found in incidence rates of S. maltophilia isolates between cycling and non-cycling periods, but there was a significant secular increase in the hospital-wide rate of infections caused by S. maltophilia (P=0.01728). Antibiotic cycling protocols were not associated with a significantly increased rate of colonization of S. maltophilia as determined by the frequency of patients having at least one positive routine clinical culture in this hospital.

Assessing the Differences and Similarities Between Hospital Chains and Independents Regarding Revenues, Profits, and Community Contributions

Hospital systems or chains continue to grow their market share relative to independent hospitals. This trend generates concerns among health care industry observers as historical performance suggests chains charge more for health care services than the independents while providing reduced contributions to their community. This study empirically assesses key performance measures of 67 acute-care hospitals in Virginia by testing if there are differences between chains and independents regarding total patient revenues, revenues per admission, profitability and community support, including charity care, bad debt, taxes paid and Medicaid participation. Implications to industry policy-makers as well as to hospital executives and marketing managers are then presented.

Management Roles for Speech-Language Pathologists in Health Care

Management Roles for Speech-Language Pathologists in Health Care

Successful Treatment of Fulminant Clostridium difficile Infection with Fecal Bacteriotherapy

Letters15 April 2008Successful Treatment of Fulminant Clostridium difficile Infection with Fecal BacteriotherapyDavid M. You, MD, M. Alaric Franzos, MD, and Robert P. Holman, MDDavid M. You, MDFrom National Naval Medical Center, Bethesda, MD 20889, and Virginia Hospital Center, Arlington, VA 22205.Search for more papers by this author, M. Alaric Franzos, MDFrom National Naval Medical Center, Bethesda, MD 20889, and Virginia Hospital Center, Arlington, VA 22205.Search for more papers by this author, and Robert P. Holman, MDFrom National Naval Medical Center, Bethesda, MD 20889, and Virginia Hospital Center, Arlington, VA 22205.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-148-8-200804150-00024 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: A subset of patients with Clostridium difficile–associated diarrhea will develop fulminant, life-threatening C. difficile infection that is refractory to medical therapy. Surgical options for fulminant disease are associated with high mortality rates. We describe a patient with fulminant C. difficile infection successfully treated with donor stool by retention enema.Objective: To describe a successful case of using fecal bacteriotherapy to treat life-threatening, fulminant C. difficile enterocolitis.Case Report: A 69-year-old man was admitted to the hospital after undergoing radical prostatectomy. The patient was given perioperative, intravenous cefazolin. On postoperative day 2, the patient developed an ileus and oliguric renal ...

Four Hundred Fifty Consecutive Laparoscopic Roux-en-Y Gastric Bypasses with No Mortality and Declining Leak Rates and Lengths of Stay in a Bariatric Training Program

We reviewed our obesity surgery database for 2 experienced bariatric surgeons since their last patient death in October 2003 through July 2007. Data on all patients undergoing planned laparoscopic Roux-en-Y gastric bypass (L-GBP) by the two attending bariatric surgeons at the Medical College of Virginia Hospitals were reviewed. The operations were performed by fellows in minimally invasive surgery, assisted by the 2 attending physicians in more than 90% of patients. Surgical technique included a handsewn imbrication of a gastrojejejunostomy and jejunojejunostomy, each performed with a linear stapler. Routine sampling of a juxtaanastamotic drain for amylase levels was substituted for routine upper gastrointestinal contrast studies during the study period. All patients, except those who had earlier extensive upper abdominal surgery in that time period, were offered a laparoscopic approach (5.7% were converted to open procedures). The mean (+/- SD) age was 42.4+/-11 years; body mass index was 49.5+/-9 kg/m(2). Women represented 80.5% of patients. The leak rate declined from 9.7% in 2004 to 2.0% in 2006 (p < 0.05, chi-square test); there have been no leaks in any patient since July 2006, including the 40 patients in 2007. Hospital length of stay declined from 4.7+/-5.7 days in 2004 to 2.9+/-3.3 days in 2006 (p < 0.05, Wilcoxon rank test). At 1-year followup, 270 patients had lost 66.1%+/-17% of initial excess weight, which was similar to that in our open gastric bypasses. Comorbid conditions improved or resolved in 67.6% of patients with diabetes, 56.1% of those with hypertension, 75% of those with sleep apnea, 87.8% of those with urinary stress incontinence, 95.9% of those with gastroesophageal reflux disease, and in 100% of those with stasis ulcers. Overall complication rates of wound infection (1.5%), incisional hernia (1.7%), internal hernia (0.2%), and intestinal obstruction (1.7%) were low. Results for laparoscopic Roux-en-Y gastric bypass improve with experience and can be taught in an academic training program, with low morbidity and mortality. Routine postoperative upper gastrointestinal contrast studies are unnecessary and may lengthen hospital stay.

Data Envelopment Analysis Comparison of Hospital Efficiency and Quality

Using a sample of Virginia hospitals, performance measures of quality were examined as they related to technical efficiency. Efficiency scores for the study hospitals were computed using Data Envelopment Analysis (DEA). The study found that the technically efficient hospitals were performing well as far as quality measures were concerned. Some of the technically inefficient hospitals were also performing well with respect to quality. DEA can be used to benchmark both dimensions of hospital performance: technical efficiency and quality. The results have policy implications in view of growing concern that hospitals may be improving their efficiency at the expense of quality.

Racial Segregation and Differential Outcomes in Hospital Care

This exploratory study of patients in Pennsylvania (PA) and Virginia (VA) hospitals in 1998-1999 measures the segregation of care for Black patients receiving inpatient care for specific medical and surgical conditions. It also examined inpatient mortality risk for Black patients and the impact of treatment in heavily segregated hospitals on mortality for Blacks and non-Blacks. Segregation of hospital care was found across both states but was more pronounced in PA. Blacks did not experience higher mortality rates than non-Blacks either before or after controls for clinical risk factors in either state and for certain admission types had lower mortality. Both Black and non-Black surgical, heart failure, and lung disease patients treated in VA hospitals with more Black patients had poorer outcomes. Future research should examine how access, patient choice, hospital organization, processes of care, and factors related to nursing care might influence hospital outcomes for patients from different racial backgrounds.

Mobile cardiac catheterization laboratories increase use of cardiac care in women and African Americans

Women and minorities traditionally have shown less use of diagnostic cardiac catheterization. We sought to determine whether mobile cardiac catheterization laboratories may increase the use of catheterization among women and minorities by bringing the technology to remote communities. We collected data on consecutive patients undergoing cardiac catheterization at mobile laboratories located at 15 community hospitals in North Carolina and Virginia from 1994 to 2005. These data were compared with those from similar consecutive outpatients at the Duke University Medical Center (Durham, NC) cardiac catheterization laboratory over the same period. Logistic regression modeling techniques were used to determine which patient factors were associated with the decision to use a particular facility. Women comprised 48% of the patients undergoing cardiac catheterization via mobile laboratory versus 42% of those patients receiving outpatient catheterization at the medical center laboratory (P < .001). All racial minorities combined (African American, Hispanic, Native American, Asian, and other) made up 27% of the mobile laboratory population undergoing catheterization versus 21% of the medical center outpatients who underwent the procedure (P < .001). Most minorities were African American. The most important predictor of patients receiving catheterization via a mobile laboratory rather than at the medical center catheterization laboratory was distance to the nearest mobile facility. Within a home-to-mobile laboratory range of approximately 35 miles, the odds of being treated at a mobile laboratory increased greatly the closer the patient lived to the facility. The strongest predictor of mobile laboratory use was the patient's proximity to the mobile facility. When compared with a traditional tertiary referral outpatient hospital setting, a greater percentage of women and African Americans received cardiac catheterization at mobile laboratories. The availability of mobile laboratories may increase the use of cardiac procedures among women and African Americans.

Is Fever Protective in Surgical Patients with Bloodstream Infection?

Sepsis from bloodstream infection (BSI) is an important cause of morbidity and mortality among surgical patients. Our hypothesis was that fever and leukocytosis during BSI would be associated with gram-negative pathogens and worse outcomes among hospitalized surgical patients. A prospectively collected dataset of all infections diagnosed on the adult general and trauma surgery services between December 1996 and December 2005 at the University of Virginia Hospital was reviewed. Fever was considered a temperature of > or = 38.5 degrees C, and leukocytosis was defined as a white blood cell count > or = 15,000/microL within 24 hours of treatment for infection. Logistic regression was used to identify predictors of fever and mortality. Over 9 years, 823 BSIs were analyzed. One hundred forty-eight BSIs resulted in death (18.0%), and 541 (65.7%) patients were febrile at diagnosis; mortality for these two groups were 12.9% and 27.7%, respectively (p < 0.0001). Febrile patients had a trend toward fewer gram-negative infections (27.0% versus 31.9%, p = 0.13), 403 had a leukocytosis at diagnosis and 420 did not; mortality for the two groups was 19.1% and 16.9%, respectively (p = NS). Higher maximum temperature was protective against mortality in the logistic regression analysis (odds ratio = 0.60 per C degrees, p < 0.0001). Among surgical patients with sepsis, fever during BSI was not associated with a gram-negative cause and correlated with survival, although increasing WBC had little effect. Mortality after BSI appears associated more with an initially blunted physiologic response than with a robust, proinflammatory response. In addition, a threshold for blood culture other than temperature > or = 38.5 degrees C should be considered.

A comparative analysis of the community contributions and profits of Virginia's hospitals

In return for receiving favorable treatment from the government, U.S. general hospitals are expected to provide contributions to their community consisting of charity care, bad debt, and taxes paid. Recently, the Government Accountability Office proposed that an analysis that compares what for-profit and nonprofit hospitals contribute be conducted. For 72 Virginia hospitals, it is determined whether (a) for-profit hospitals' community contributions exceed their profits and (b) nonprofit hospitals' community contributions exceed the for-profits' contributions in addition to the nonprofits' forgone taxes. Based on audited fiscal year 2004 financial statements, six null hypotheses were tested for significant differences between the two independent variables, namely, hospital charter and size, and the three dependent variables, including (a) operating income, (b) the ratio of community contributions to net patient revenues, and (c) the ratio of community contributions to operating income. No significant differences were found to exist between (a) hospital charter and operating income, (b) hospital charter and the percentage of community contributions to net patient revenues, and (c) hospital charter and the percentage of community contributions to operating income. The community contributions of nonprofits exceeded their taxes forgone by a wide margin, but they fell short of exceeding the for-profits' community contributions plus the taxes forgone by a very slight margin. Hospital management, in conjunction with health care policy planners, needs to develop mutually acceptable standards regarding the required level of hospitals' community contributions. It is proposed that the most equitable standard is "quartile comparisons" for a given hospital's financial performance and its level of community contributions. Furthermore, to reduce charity care, it is imperative that high-cost hospital treatment of primary health care for indigent patients be shifted to lower cost delivery systems.

Postpartum depression, urge urinary incontinence, and overactive bladder syndrome: is there an association?

The purpose of this prospective, cross-sectional study was to determine if there was an association between postpartum depression and symptoms of overactive bladder in postpartum women. At their 6 week postpartum visit, participants completed questionnaires regarding lifestyle, personal health, urinary incontinence, and depression symptoms, including the Urge-Urinary Distress Inventory (URGE-UDI), the Urge-Incontinence Impact Questionnaire (URGE-IIQ), and the Edinburgh Postnatal Depression Scale (EPDS). Past medical history, including obstetric variables, family history, and medications were extracted from the medical record. One hundred patients completed the questionnaires at the University of Michigan Hospital and 46 patients at the University of Virginia Hospital (mean age 29.2+/-6.1 years; 18-47 years) at their postpartum visit (mean time 45.2+/-9.4 days postpartum; 11-79 days). Sixteen percent of the women had depression (EPDS score of >12) or were borderline (EPDS score of 9-12) for postpartum depression. There was no difference in age and race in women with and without depression. Type of delivery, vaginal vs cesarean section did not significantly impact their URGE-UDI or URGE-IIQ score. There was a significant correlation between the URGE-IIQ score and depression (0.24, p=0.003), but not the URGE-UDI score. In this cross-sectional study, we found an association between postpartum depression and symptoms of urge incontinence. Because birth is a predictable event, further studies evaluating the causal relationships and physiologic changes linking depression and incontinence can be studied using this model.

Reports of Death with Use of Propofol (Diprivan) for Nonprocedural (Long-term) Sedation and Literature Review

Reports of Death with Use of Propofol (Diprivan) for Nonprocedural (Long-term) Sedation and Literature Review

Improving Self-Reporting of Adverse Drug Events in a West Virginia Hospital

Adverse drug events significantly increase length of stay and costs of hospitalization but are underreported in health care institutions. We hypothesized that hospitals could improve the accuracy of adverse drug event self-reporting by comparing adverse drug events recorded in an occurrence reporting tool with those detected by surveillance of "rescue" drugs administered to treat adverse drug events. We conducted a prospective cohort study of all adult inpatient discharges from a 200-bed rural acute care hospital in West Virginia during a 6-month period. We performed 3572 chart audits, of which 1011 included rescue drug administration. Our outcome measure was the proportion of adverse drug events in the rescue drug surveillance that were found in the occurrence reporting tool. We found that less than 4% of all adverse drug events involving use of rescue drugs were reported. We concluded that underreporting of preventable adverse drug events in this hospital is comparable to published rates and that surveillance of adverse drug events to detect underreporting is feasible.

Surgical Site Infection in the Elderly Following Orthopaedic Surgery

Risk factor and outcomes data pertaining to surgical site infection in the elderly following orthopaedic operations are lacking. The aim of this study was to identify risk factors for surgical site infections and to quantify the impact of these infections on health outcomes in elderly patients following orthopaedic surgery. A risk factor and outcomes study was performed at Duke University Medical Center, a tertiary care center, and seven community hospitals in North Carolina and Virginia between 1991 and 2002. The study included elderly patients in whom a surgical site infection had developed following orthopaedic surgery and elderly patients in whom a surgical site infection had not developed following orthopaedic surgery (controls). Outcome measures included mortality during the one-year postoperative period and the total length of the hospital stay (including readmissions during the ninety-day postoperative period). One hundred and sixty-nine patients with a surgical site infection were identified, and 171 controls were selected. The mean age of the patients was 74.7 years. The most frequent procedures were hip arthroplasty (n = 74, 22%) and open reduction of fractures (n = 55, 16%). The most common pathogen was Staphylococcus aureus (n = 95, 56%). A risk factor for surgical site infection, identified in the multivariate analysis, was admission from a health-care facility (odds ratio = 4.35; 95% confidence interval = 1.64, 11.11). Multivariate analysis also indicated that surgical site infection was a strong predictor of mortality (odds ratio = 3.80; 95% confidence interval = 1.49, 9.70) and an increased length of stay in the hospital (multiplicative effect = 2.49; 95% confidence interval = 2.10, 2.94; 9.31 mean attributable days per infection, 95% confidence interval = 6.88, 12.13). Measures for prevention of surgical site infection in elderly patients should target individuals who reside in health-care facilities prior to surgery. Future studies should be done to examine the effectiveness of such interventions in preventing infection and improving outcomes in elderly patients who undergo orthopaedic surgery.

Racial Variation in End‐of‐Life Intensive Care Use: A Race or Hospital Effect?

To determine if racial and ethnic variations exist in intensive care (ICU) use during terminal hospitalizations, and, if variations do exist, to determine whether they can be explained by systematic differences in hospital utilization by race/ethnicity. 1999 hospital discharge data from all nonfederal hospitals in Florida, Massachusetts, New Jersey, New York, and Virginia. We identified all terminal admissions (N = 192,705) among adults. We calculated crude rates of ICU use among non-Hispanic whites, blacks, Hispanics, and those with "other" race/ethnicity. We performed multivariable logistic regression on ICU use, with and without adjustment for clustering of patients within hospitals, to calculate adjusted differences in ICU use and by race/ethnicity. We explored both a random-effects (RE) and fixed-effect (FE) specification to adjust for hospital-level clustering. The data were collected by each state. ICU use during the terminal hospitalization was highest among nonwhites, varying from 64.4 percent among Hispanics to 57.5 percent among whites. Compared to white women, the risk-adjusted odds of ICU use was higher for white men and for nonwhites of both sexes (odds ratios [ORs] and 95 percent confidence intervals: white men = 1.16 (1.14-1.19), black men = 1.35 (1.17-1.56), Hispanic men = 1.52 (1.27-1.82), black women = 1.31 (1.25-1.37), Hispanic women =1.53 (1.43-1.63)). Additional adjustment for within-hospital clustering of patients using the RE model did not change the estimate for white men, but markedly attenuated observed differences for blacks (OR for men =1.12 (0.96-1.31), women = 1.10 (1.03-1.17)) and Hispanics (OR for men =1.19 (1.00-1.42), women = 1.18 (1.09-1.27)). Results from the FE model were similar to the RE model (OR for black men = 1.10 (0.95-1.28), black women = 1.07 (1.02-1.13) Hispanic men = 1.17 (0.96-1.42), and Hispanic women = 1.14 (1.06-1.24)) The majority of observed differences in terminal ICU use among blacks and Hispanics were attributable to their use of hospitals with higher ICU use rather than to racial differences in ICU use within the same hospital.

Pituitary apoplexy: do histological features influence the clinical presentation and outcome?

A retrospective analysis of a contemporary series of patients with pituitary apoplexy was performed to ascertain whether the histopathological features influence the clinical presentation or the outcome. A retrospective analysis was performed in 59 patients treated for pituitary apoplexy at the University of Virginia Health System, Charlottesville, Virginia, or Groote Schuur Hospital, University of Cape Town, South Africa. The patients were divided into two groups according to the histological features of their disease: one group with infarction alone, comprising 22 patients; and the other with hemorrhagic infarction and/or frank hemorrhage, comprising 37 patients. The presenting symptoms, clinical features, endocrinological status, and outcome were compared between the two groups. The patients who presented with histological features of pituitary tumor infarction alone had less severe clinical features on presentation, a longer course prior to presentation, and a better outcome than those presenting with hemorrhagic infarction or frank hemorrhage. The endocrine replacement requirements were similar in both groups.