Improvement In In-hospital Mortality Research Articles

Abstract 19358: Comparative Outcomes of Catheter-Directed Thrombolysis plus Anticoagulation versus Anti-Coagulation Alone in the Treatment of Lower Extremity Proximal Deep Vein Thrombosis

Background: The role of catheter-directed thrombolysis (CDT) in treatment of acute proximal deep vein thrombosis (DVT) is controversial and national rates of in-hospital mortality and acute complications in these patients are unknown. Methods: We used the Nationwide Inpatient Sample (NIS) database from 2005 to 2009 to identify all patients admitted with a principal diagnosis of proximal or caval DVT. In these patients, we evaluated the trends in the utilization rates of CDT and in-hospital outcomes. We compared in-hospital outcomes between the matched groups treated with CDT plus anticoagulation (Group A - 10,730 patients) versus anticoagulation alone (Group B - 10,730). We used propensity scores and Elixhauser comorbidity risk index to match the two treatment groups. Results: Among a total of 368,974 patients admitted with lower extremity proximal or caval DVT, 3.7% (13,542) underwent CDT. The national CDT utilization rates gradually increased from 2.3% in 2005 to 5.1% in 2009. The groups that were less likely to be treated with thrombolysis included females (3.5% versus 3.9%; p <0.0001), patients greater than 65 years of age (3% versus 6.6%; p < 0.0001), and African Americans (2.9% versus 3.7%; p<0.0001). The outcomes analysis of the matched groups showed that in-hospital mortality was similar in the CDT group than in the anti-coagulation alone group (1.2% versus 0.9%; p= 0.287). In the CDT group, a decline in mortality was noted from 2.0% in 2005 to 0.6% in 2006. The rates of blood transfusion, pulmonary embolism, intracranial bleeding, and vena caval filter placement were significantly higher in the CDT group. The CDT group also had significantly increased length of stay (7±2.3 versus 4.9±1.9 days; P < 0.00001) and hospital charges ($85416 ± 67940 versus $26841 ± 43872; p<0.0001) than the anticoagulation alone group. Conclusions: In this observational study we found that in-hospital morbidity with catheter-directed thrombolysis remains higher than anticoagulation alone, however recently a significant improvement in in-hospital mortality has been noted.

Effect of Statins on the Clinical Outcomes of Patients with Sepsis

Despite numerous attempts at novel intervention and tests to aid in earlier diagnosis and improved treatment, there has been an increased incidence of overall mortality related to sepsis, despite improvements in in-hospital mortality. Statins have emerged as potential immunomodulatory and antioxidant agents that might impact on sepsis outcomes. Definitive evidence to support the routine use of statins in patients with sepsis has not yet been elicited. We retrospectively analysed data from patients who presented with sepsis, severe sepsis or septic shock, stratifiying them according to statin use into two groups (statin and no statin). Sequential Organ Failure Assessment was used to evaluate severity of illness. The primary outcome was hospital mortality. Secondary outcomes included intensive care unit (ICU) mortality, hospital and ICU length of stay, and mechanical ventilation and vasopressor therapy duration. Five hundred and sixty-eight patients were included. Patients with prior statin use (statin group) were older; more obese and had higher prevalence of smoking, diabetes and ischaemic heart disease. There was no difference in Sequential Organ Failure Assessment scores and mortality did not vary between the two groups (19.6 vs. 16.9%). Furthermore, secondary outcomes including ICU mortality, hospital and ICU length of stay, mechanical ventilation and vasopressor duration did not differ Multivariate analysis revealed age and Sequential Organ Failure Assessment score were independent predictors of survival, while history of statin use was not (p = 0.403). This current retrospective study did not find any benefit of statin use on primary and secondary outcomes of the patients admitted to an academic hospital with sepsis.

Pay for Performance, Quality of Care, and Outcomes in Acute Myocardial Infarction

Pay for performance has been promoted as a tool for improving quality of care. In 2003, the Centers for Medicare & Medicaid Services (CMS) launched the largest pay-for-performance pilot project to date in the United States, including indicators for acute myocardial infarction. To determine if pay for performance was associated with either improved processes of care and outcomes or unintended consequences for acute myocardial infarction at hospitals participating in the CMS pilot project. An observational, patient-level analysis of 105,383 patients with acute non-ST-segment elevation myocardial infarction enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines (CRUSADE) national quality-improvement initiative. Patients were treated between July 1, 2003, and June 30, 2006, at 54 hospitals in the CMS program and 446 control hospitals. The differences in the use of ACC/AHA class I guideline recommended therapies and in-hospital mortality between pay for performance and control hospitals. Among treatments subject to financial incentives, there was a slightly higher rate of improvement for 2 of 6 targeted therapies at pay-for-performance vs control hospitals (odds ratio [OR] comparing adherence scores from 2003 through 2006 at half-year intervals for aspirin at discharge, 1.31; 95% confidence interval [CI], 1.18-1.46 vs OR, 1.17; 95% CI, 1.12-1.21; P = .04) and for smoking cessation counseling (OR, 1.50; 95% CI, 1.29-1.73 vs OR, 1.28; 95% CI, 1.22-1.35; P = .05). There was no significant difference in a composite measure of the 6 CMS rewarded therapies between the 2 hospital groups (change in odds per half-year period of receiving CMS therapies: OR, 1.23; 95% CI, 1.15-1.30 vs OR, 1.17; 95% CI, 1.14-1.20; P = .16). For composite measures of acute myocardial infarction treatments not subject to incentives, rates of improvement were not significantly different (OR, 1.09; 95% CI, 1.05-1.14 vs OR, 1.08; 95% CI, 1.06-1.09; P = .49). Overall, there was no evidence that improvements in in-hospital mortality were incrementally greater at pay-for-performance sites (change in odds of in-hospital death per half-year period, 0.91; 95% CI, 0.84-0.99 vs 0.97; 95% CI, 0.94-0.99; P = .21). Among hospitals participating in a voluntary quality-improvement initiative, the pay-for-performance program was not associated with a significant incremental improvement in quality of care or outcomes for acute myocardial infarction. Conversely, we did not find evidence that pay for performance had an adverse association with improvement in processes of care that were not subject to financial incentives. Additional studies of pay for performance are needed to determine its optimal role in quality-improvement initiatives.