Inpatient Quality Indicators Research Articles

Factors associated with length of stay in hospitalized psychiatric patients: a monocentric retrospective study in Lebanon

IntroductionThe length of stay (LOS) in psychiatric hospitals is regularly used as an indicator of inpatient care efficiency and quality indicator. Psychiatric hospitalizations have been linked to a variety of clinical and patient-related factors. The objectives of this study were to assess the duration of stay in psychiatric hospital in Lebanon and to evaluate the LOS associated factors.MethodsA five years retrospective study was conducted at the Psychiatric hospital of the Cross between January 2018 and December 2022. Data on hospital admissions was obtained from medical files and the LOS was defined as the time in days elapsed between the admission and discharge date as noted in the medical file.ResultsThe mean duration of the global length of the stay was 28.35 ± 26.57 days, with a range between 2 and 300 and a median of 21.00 days. Being diagnosed with schizophrenia (Beta = 10.25), having a public insurance (Beta = 4.09) and having an intermediate social status (Beta = 3.45) were significantly associated with higher length of stay. Being a female (Beta = − 5.15), married (Beta = − 3.94) and older age (Beta = − 0.17) were significantly associated with lower length of stay.ConclusionThe importance of social factors should be highlighted, as they are necessary components of patients’ wellbeing and may facilitate the decision of discharge. Being single, male gender and a diagnosis of schizophrenia were associated with a longer stay at the psychiatric hospital. Further studies are needed to explore the clinical implication of the factors related to LOS in order to identify patients with a higher probability for prolonged hospitalization, to plan necessary interventions for these specific situations.

Detection of Adverse Events With the Austrian Inpatient Quality Indicators.

Indicators based on routine data are considered a readily available and cost-effective method for assessing health care quality and safety. The Austrian Inpatient Quality Indicators (A-IQI) have been introduced in all Austrian public hospitals as a mandatory quality measurement. The purpose of this study was to assess the value of conspicuous A-IQI in predicting the presence of adverse events (AEs). We conducted an exploratory study comparing all indicator-positive patient cases contributing to 18 conspicuous A-IQI indicators to randomly selected indicator-negative control cases regarding the prevalence and severity of AEs. Structured medical record review using the Institute for Healthcare Improvement Global Trigger Tool was used as the gold standard. In 421 chart reviews, we identified 158 AEs. 70.9% (n = 112) of the AEs were found in cases with a positive indicator. The relative risk of an AE occurring was 3.47 (95% confidence interval: 2.30, 5.24) in indicator-positive cases compared to indicator-negatives. The proportion of severe events (National Coordination Council for Medication Error Reporting and Prevention Index categories H and I) was 54.5% (n = 61) in indicator-positive cases and only 15.3% (n = 7) in indicator-negative cases. Overall sensitivity of the A-IQI was 68.2%, specificity 69.4%, positive predictive value 36.0%, and negative predictive value 89.6%. Our study shows that significantly more AEs and more severe AEs were found in cases with positive A-IQI than in indicator-negative control cases. However, studies with larger numbers of cases and with larger numbers of conspicuous indicators are needed for the validation of the entire A-IQI indicator set.

Defining quality indicators, pharmaceutical care bundles and outcomes of clinical pharmacy service delivery using a Delphi consensus approach.

Clinical pharmacy quality indicators are often non-uniform and measure individual activities not linked to outcomes. To define a consensus agreed pharmaceutical care bundle and patient outcome measures across an entire state health service. A four-round modified-Delphi approach with state Directors of Pharmacy was performed (n = 25). They were asked to rate on a 5-point Likert scale the relevance and measurability of 32 inpatient clinical pharmacy quality indicators and outcome measures. They also ranked clinical pharmacy activities in order from perceived most to least beneficial. Based upon these results, pharmaceutical care bundles consisting of multiple clinical pharmacy activities were formed, and relevance and measurability assessed. Response rate ranged from 40 to 60%. Twenty-six individual clinical pharmacy quality indicators reached consensus. The top ranked clinical pharmacy quality indicator was 'proportion of patients where a pharmacist documents an accurate list of medicines during admission'. There were nine pharmaceutical care bundles formed consisting between 3 and 7 activities. Only one pharmaceutical care bundle reached consensus: medication history, adverse drug reaction/allergy documentation, admission and discharge medication reconciliation, medication review, provision of medicines education and provision of a medication list on discharge. Sixteen outcome measures reached consensus. The top ranked were hospital acquired complications, readmission due to medication misadventure and unplanned readmission within 10 days. Consensus has been reached on one pharmaceutical care bundle and sixteen outcomes to monitor clinical pharmacy service delivery. The next step is to measure the extent of pharmaceutical care bundle delivery and the link to patient outcomes.

Improving hospital quality risk-adjustment models using interactions identified by hierarchical group lasso regularisation

BackgroundRisk-adjustment (RA) models are used to account for severity of illness in comparing patient outcomes across hospitals. Researchers specify covariates as main effects, but they often ignore interactions or use stratification to account for effect modification, despite limitations due to rare events and sparse data. Three Agency for Healthcare Research and Quality (AHRQ) hospital-level Quality Indicators currently use stratified models, but their variable performance and limited interpretability motivated the design of better models.MethodsWe analysed patient discharge de-identified data from 14 State Inpatient Databases, AHRQ Healthcare Cost and Utilization Project, California Department of Health Care Access and Information, and New York State Department of Health. We used hierarchical group lasso regularisation (HGLR) to identify first-order interactions in several AHRQ inpatient quality indicators (IQI) - IQI 09 (Pancreatic Resection Mortality Rate), IQI 11 (Abdominal Aortic Aneurysm Repair Mortality Rate), and Patient Safety Indicator 14 (Postoperative Wound Dehiscence Rate). These models were compared with stratum-specific and composite main effects models with covariates selected by least absolute shrinkage and selection operator (LASSO).ResultsHGLR identified clinically meaningful interactions for all models. Synergistic IQI 11 interactions, such as between hypertension and respiratory failure, suggest patients who merit special attention in perioperative care. Antagonistic IQI 11 interactions, such as between shock and chronic comorbidities, illustrate that naïve main effects models overestimate risk in key subpopulations. Interactions for PSI 14 suggest key subpopulations for whom the risk of wound dehiscence is similar between open and laparoscopic approaches, whereas laparoscopic approach is safer for other groups. Model performance was similar or superior for composite models with HGLR-selected features, compared to those with LASSO-selected features.ConclusionsIn this application to high-profile, high-stakes risk-adjustment models, HGLR selected interactions that maintained or improved model performance in populations with heterogeneous risk, while identifying clinically important interactions. The HGLR package is scalable to handle a large number of covariates and their interactions and is customisable to use multiple CPU cores to reduce analysis time. The HGLR method will allow scholars to avoid creating stratified models on sparse data, improve model calibration, and reduce bias. Future work involves testing using other combinations of risk factors, such as vital signs and laboratory values. Our study focuses on a real-world problem of considerable importance to hospitals and policy-makers who must use RA models for statutorily mandated public reporting and payment programmes.

A computable biomedical knowledge object for calculating in-hospital mortality for patients admitted with acute myocardial infarction.

Quality indicators play an essential role in a learning health system. They help healthcare providers to monitor the quality and safety of care delivered and to identify areas for improvement. Clinical quality indicators, therefore, need to be based on real world data. Generating reliable and actionable data routinely is challenging. Healthcare data are often stored in different formats and use different terminologies and coding systems, making it difficult to generate and compare indicator reports from different sources. The Observational Health Sciences and Informatics community maintains the Observational Medical Outcomes Partnership Common Data Model (OMOP). This is an open data standard providing a computable and interoperable format for real world data. We implemented a Computable Biomedical Knowledge Object (CBK) in the Piano Platform based on OMOP. The CBK calculates an inpatient quality indicator and was illustrated using synthetic electronic health record (EHR) data in the open OMOP standard. The CBK reported the in-hospital mortality of patients admitted for acute myocardial infarction (AMI) for the synthetic EHR dataset and includes interactive visualizations and the results of calculations. Value sets composed of OMOP concept codes for AMI and comorbidities used in the indicator calculation were also created. Computable biomedical knowledge (CBK) objects that operate on OMOP data can be reused across datasets that conform to OMOP. With OMOP being a widely used interoperability standard, quality indicators embedded in CBKs can accelerate the generation of evidence for targeted quality and safety management, improving care to benefit larger populations.

Status of Quality and Compliance to Inpatient Quality Indicators and Patient Safety Indicators in a Selected Private Corporate Hospital at Dhaka City Bangladesh

Background: The stutus of quality and compliance to inpatient quality indicators (IQIs) and patient safety indicators (PSIs) in corporate hospitals at dhaka city Bangladesh are not known as they are not adequately studied. Objective: The present descriptive cross-sectional study was therefor undertaken to know the status of quality and compliance to selected IQIs and PSIs in a selected private (corporate) hospital at Dhaka City Bangladesh. The period of study and hospital data collection period were May to August 2019 and January to March 2019 respectively. Methods: Selected IQIs and PSIs developed by Agency for Healthcare Research and Quality (AHRQ), USA and hospital facilities utilization parameters were investigated. Data were collected using questionnaires and checklists for the period of January to March 2019 from the purposively selected private (corporate) hospital. Sociodemographic information of randomly selected junior doctors and nurses were taken. Randomly selected senior clinicians, nurses and executives were interviewed regarding knowledge about selective IQIs, PSIs, JCIS, ISO relevant to quality healthcare. Data were analysed by SPSS programme version 20. Results: The hospital has all relevant admistrative and clinical departments, bed patterns and has efficient admission and discharge processes for inpatients. Bed utilization was 87.5% of total 159 available beds. Patients visited OPD: 2434 per day, admitted: 28 per day and discharged with successful outcome: 27 per day. Average length of stay (ALS), hospital acquired infection (HAI) and hospital deaths were 3.6 days, 1.76% (18/1000 cases), and 124 (01 per day) respectively during data collection period. Tests done in Laboratory Medicine were 267637 with Clinical Biochemistry tests highest (51.21%) and investigations in Radiology-Imaging departments were 74997 with X-rays being highest (40.22%). Of the five selected IQIs, total CABG cases done were 191 with 04 hospital deaths i.e. 2.1% (21 per 1000 cases) and total AMI cases done were 140 with 12 hospital deaths i.e. 8.5% (85 per 1000 cases). No casualties were reported for caesarean deliveries or primary/normal deliveries. None of the five selected PSIs were traced over the data collection period. Conclusion: These findings suggested that the selected hospital’s services were demanding and it was concerned about quality healthcare services. However, comparative studies with other private corporate hospotals at Dhaka City including larger number of respodents are warrented. Bangladesh Medical Res Counc Bull 2023; 49(2): 98-112

On the Relationships among Nurse Staffing, Inpatient Care Quality, and Hospital Competition under the Global Budget Payment Scheme of Taiwan’s National Health Insurance System: Mixed Frequency VAR Analyses

Background: Time series analyses on the relationship between nurse staffing and inpatient care quality are rare due to inconsistent frequencies of data between common observations of nurse-staffing (e.g., monthly) and inpatient care quality indicators (e.g., quarterly). Methods: In order to deal with the issue of mixed frequency data, this research adopted the MF-VAR model to explore causal relationships among nurse staffing, inpatient care quality, and hospital competition under the global budget payment scheme of Taiwan’s healthcare system. Results: Our results identified bi-directional causation between nurse staffing and patient outcomes and one-way Granger causality running between nurse staffing and reimbursement payments for inpatient care services. Impulse-response analyses found positive (negative) effects of the patient-to-nurse ratio on adverse patient outcomes (reimbursement payments) in all types of hospitals and detrimental effects of adverse patient outcomes on the patient-to-nurse ratio in medical centers and regional hospitals across a 12-month period. Conclusions: These findings suggest that nurse staffing is an essential determinant of both patient outcomes and reimbursement payments. Strategic policies such as direct subsidy and hospital accreditation for appropriate nurse staffing levels should be implemented for medical centers and regional hospitals to mitigate the harmful effects of adverse patient outcomes on nurse staffing.

Quality aspects relating to giving birth in Switzerland: An analysis of quality indicators in inpatient obstetrics from 2013 to 2017.

Quality transparency supports the reduction of information asymmetries in the health care system and enables the targeted regulation of health care. This study examines quality variation in inpatient obstetric care using the official Federal Office of Public Health Inpatient Quality Indicators (CH-IQI; vaginal births with 3rd- and 4th-degree perineal tears, vaginal births with episiotomy, and Caesarean section for low-risk births). It includes 101 maternity hospitals and 425,810 births between 2013 and 2017. For births with perineal laceration of 3rd and 4th degree, Switzerland performs 0.9% poorer in comparison to Germany (D-IQI) and Austria (A-IQI). For births with episiotomy, Switzerland is 1.1% above Germany. The Caesarean section rate for low-risk births was 26.8% in Switzerland in 2017 (Germany: 25.9%). When comparing Swiss clinics, private clinic locations in particular stand out. One possible reason for this may be the density of care, patient demands or the system of affiliated physicians at these clinics.

Practice testing of generic quality indicators for responsible antibiotic use in nine hospitals in the Dutch–Belgian border area

Inpatient quality indicators (IQIs) were previously developed to assess responsible antibiotic use. Practice testing of these QIs in the hospital setting. This study was performed within a Dutch-Belgian border network of hospitals implementing the Infection Risk Scan (IRIS) point prevalence survey (PPS) as part of the i-4-1-Health project. Twenty out of 51 DRIVE-AB IQIs, including 13 structure and seven process IQIs, were tested. Data on structure IQIs were obtained through a web-based questionnaire sent to the hospital medical microbiologists. PPS data from October to December 2018 were used to calculate performance scores for the process QIs. Nine hospitals participated. Regarding structure IQIs: the lowest performance scores were observed for recommendations for microbiological investigations in the guidelines and the use of an approval system for restricted antibiotics. In addition, most hospitals reported that some antibiotics were out of stock due to shortages. Regarding process IQIs: 697 systemic antibiotic prescriptions were used to calculate performance scores. The lowest score was observed for documentation of an antibiotic plan in the medical file (58.8%). Performance scores for IQIs on guideline compliance varied between 74.1% and 82.3% for different aspects of the antibiotic regimen (duration, choice, route, timing). This multicentre practice testing of IQIs identified improvement targets for stewardship efforts for both structure and process aspects of antibiotic care (approval system for restricted antibiotics, documentation of antibiotic plan). These results can guide the design of future PPS studies and a more extensive evaluation of the clinimetric properties of the IQIs.

Combined impact of Medicare’s hospital pay for performance programs on quality and safety outcomes is mixed

BackgroundThree major hospital pay for performance (P4P) programs were introduced by the Affordable Care Act and intended to improve the quality, safety and efficiency of care provided to Medicare beneficiaries. The financial risk to hospitals associated with Medicare’s P4P programs is substantial. Evidence on the positive impact of these programs, however, has been mixed, and no study has assessed their combined impact. In this study, we examined the combined impact of Medicare’s P4P programs on clinical areas and populations targeted by the programs, as well as those outside their focus.MethodsWe used 2007–2016 Healthcare Cost and Utilization Project State Inpatient Databases for 14 states to identify hospital-level inpatient quality indicators (IQIs) and patient safety indicators (PSIs), by quarter and payer (Medicare vs. non-Medicare). IQIs and PSIs are standardized, evidence-based measures that can be used to track hospital quality of care and patient safety over time using hospital administrative data. The study period of 2007–2016 was selected to capture multiple years before and after introduction of program metrics. Interrupted time series was used to analyze the impact of the P4P programs on study outcomes targeted and not targeted by the programs. In sensitivity analyses, we examined the impact of these programs on care for non-Medicare patients.ResultsMedicare P4P programs were not associated with consistent improvements in targeted or non-targeted quality and safety measures. Moreover, mortality rates across targeted and untargeted conditions were generally getting worse after the introduction of Medicare’s P4P programs. Trends in PSIs were extremely mixed, with five outcomes trending in an expected (improving) direction, five trending in an unexpected (deteriorating) direction, and three with insignificant changes over time. Sensitivity analyses did not substantially alter these results.ConclusionsConsistent with previous studies for individual programs, we detect minimal, if any, effect of Medicare’s hospital P4P programs on quality and safety. Given the growing evidence of limited impact, the administrative cost of monitoring and enforcing penalties, and potential increase in mortality, CMS should consider redesigning their P4P programs before continuing to expand them.

Relationships between multiple patient safety outcomes and healthcare and hospital-related risk factors in colorectal resection cases: cross-sectional evidence from a nationwide sample of 232 German hospitals

ObjectivesStudies analysing colorectal resections usually focus on a specific outcome (eg, mortality) and/or specific risk factors at the individual (eg, comorbidities) or hospital (eg, volume) level. Comprehensive evidence across different...

266 Inpatient Quality Indicators Risk-Adjustment Using Interactions Selected by Machine Learning Methods

OBJECTIVES/GOALS: Predictive models for health outcomes often have poor calibration potentially due to interactions that are ignored by standard methods. Using AHRQ models for Inpatient Quality Indicator (IQI) 11 Abdominal Aortic Aneurysm Repair and IQI 09 Pancreatic Resection mortality, we hypothesize that identifying interactions may improve model calibration. METHODS/STUDY POPULATION: We used adult discharge data from 16 states obtained from AHRQ Healthcare Cost and Utilization Project (State Inpatient Database), California Department of Health Care Access and Information, and New York State Department of Health. We used AHRQ’s v2021-1 Clinical Classifications Software Refined (CCSR) with present on admission flags to create features for risk-adjustment. We compared the performance of Least absolute shrinkage and selection operator (LASSO) model and first-order interaction models estimated using Hierarchical Group Lasso Regression (HGLR), after splitting the data into training and test sets. C-statistics, area under the precision-recall curve and Hosmer-Lemeshow calibration plots are reported. Finally, logistic regression models with selected CCSRs were evaluated on the test set. RESULTS/ANTICIPATED RESULTS: IQI 11 has four strata: open and endovascular repair of ruptured aneurysms (39% and 21% mortality, respectively); open and endovascular repair of unruptured aneurysms (6% and 0.8% mortality, respectively). IQI 09 has two strata: with and without pancreatic cancer (2% and 2.5% mortality, respectively). Comparing the HGLR model (with interaction effects) with Lasso models (without interactions), we noticed meaningful improvements in discrimination and calibration. However, for IQI 09, the extremely low mortality rate did not result in good HGLR or LASSO models. Interactions involving CCSRs could be identified using the novel HGLR method, which improved model performance given a heterogeneous population in IQI 11 with a mix of high and low event rates, unlike the more homogeneous patient population in IQI 09. DISCUSSION/SIGNIFICANCE: Standard implementations of regression models fail to address critical issues that arise in healthcare data – (a) quadratic explosion of potential interactions that cannot be manually identified, and (b) categorical variables with multiple levels or values (e.g., age categories). We propose innovative use of HGLR to robustly address these issues.

Quality Variation in Switzerland: Analysis of Mammary Resections for Breast Cancer using the Quality Indicator of Breast Preservation

The aim of the study was to investigate whether there are regional differences in the treatment results of elective mammary resections for breast cancer in Switzerland and, if so, whether a possible cause could be found in the hospital planning by the cantons. Using the Inpatient Quality Indicators (CH-IQI), the quality of outcomes was analysed at the level of the Swiss cantons and compared with the cantonal requirements for carrying out this treatment. Cantonal differences became apparent both in the quality of results based on the quality indicator of breast preservation and in the level of detail of the requirements for structural and process quality. The quality of treatment in Switzerland can hardly be compared in a transparent manner; interpreting the available quality information is demanding and hardly possible for patients. In order to reduce the quality differences shown, hospital planning should be intercantonal, as is the case in highly specialised medicine.

In defense of Direct Care: Limiting access to military hospitals could worsen quality and safety.

Ongoing health care reforms within the US Military Health System (MHS) are expected to shift >1.9 million MHS beneficiaries from military treatment facilities (MTFs) into local civilian hospitals over the next 1-2 years. The objective of this study was to examine how such health care reforms are likely to affect the quality of MHS care. Adult MHS beneficiaries, aged 18-64 years, treated in MTFs (under a program known as Direct Care) were compared against (1) MHS beneficiaries treated in locally available civilian hospitals (under a program known as Purchased Care) and (2) similarly-aged adult civilian patients across the United States. MHS beneficiaries in Direct and Purchased Care were identified from fiscal-year 2016-2018 MHS inpatient claims. National inpatients were identified in the 2017 Nationwide Readmissions Database. Retrospective cohort. Differences in quality were compared using two sets of quality metrics endorsed by the US Agency for Healthcare Research and Quality (AHRQ): Inpatient Quality Indicators, 19 quality metrics that look at differences in in-hospital mortality, and Patient Safety Indicators, 18 quality metrics that look at differences in in-hospital morbidity and adverse events. Among MHS beneficiaries (Direct and Purchased Care), we further simulated what changes in quality indicators might look like under various proposed scenarios of reduced access to Direct Care. A total of 502,252 MHS admissions from 37 MTFs and surrounding civilian hospitals were included (326,076 Direct Care, 179,176 Purchased Care). Nationwide, 9.34million adult admissions from 2453 hospitals were included. On average, MHS beneficiaries treated in MTFs experienced better inpatient quality and improved patient safety compared with MHS beneficiaries treated in locally available civilian hospitals (e.g., summary observed-to-expected ratio for medical mortality: 0.98 vs. 1.03, p < 0.001) and adult patients across the United States (0.98 vs. 1.02, p < 0.001). Simulations of proposed changes resulted in consistently worse outcomes for MHS patients, whether reducing MTF access by 10%, 20%, or 50% nationwide; limiting MTF access to active-duty beneficiaries; or closing MTFs with the worst performance on patient safety (p < 0.001 for overall quality indicators for each). Reducing access to MTFs could result in significant harm to MHS patients. The results underscore the importance of health-policy planning based on evidence-based evaluation and the need to consider the consequential downstream effects caused by changes in access to care.

The Impact of Electronic Health Records and Meaningful Use on Inpatient Quality.

It is unclear if national investments of the HITECH Act have resulted in significant improvements in care processes and outcomes by making "Meaningful Use (MU)" of Electronic Health Record (EHR) systems. The objective of this study is to determine the impact of EHRs and MU on inpatient quality. We used inpatient hospitalization data, American Hospital Association annual survey, and the Centers for Medicare and Medicaid Services attestation records to study the impact of EHRs on inpatient quality composite scores. Agency for Healthcare Research and Quality Inpatient Quality Indicator (IQI) software version 5.0 was used to compute the hospital-level risk-adjusted standardized rates for IQI indicators and composite scores. After adjusting for confounding factors, EHRs that attested to MU had a positive impact on IQI 90 and IQI 91 composite scores with an 8% decrease in composites for mortality for selected procedures and 18% decrease in composites for mortality for selected conditions. Meaningful Use attestation may be an important driver related to inpatient quality. Health care leaders may need to focus on quality improvement initiatives and advanced analytics to better leverage their EHRs to improve IQI 90 composite score for mortality for selected procedures, because we observed a lesser impact on IQI 90 compared with IQI 91.

Audit of empirical antibiotic therapy for sepsis and the impact of early multidisciplinary consultation on patient outcomes.

ObjectivesTo perform an audit of empirical antibiotic therapy (EAT) of sepsis at the emergency department and to analyse the impact of an antimicrobial stewardship (AMS) programme on process and patient outcomes. Patients and MethodsA prospective, single-centre cohort study including patients with sequential organ failure assessment (SOFA) score ≥2 from whom blood cultures were taken was conducted between February 2019 and April 2020. EAT was assessed using eight applicable inpatient quality indicators (IQIs) for responsible antibiotic use. Patient outcomes were hospital length-of-stay (LOS), ICU admission, ICU LOS, and in-hospital mortality. ResultsThe audit included 900 sepsis episodes in 803 patients. Full guideline adherence regarding choice and dosing was 45.9%; adherence regarding choice alone was 68.1%. EAT was active against all likely pathogens in 665/787 (84.5%) episodes. In the guideline non-adherent group, choice of EAT was inappropriate in 122/251 (48.6%) episodes. Changes within 3 days occurred in 335/900 (37.2%) episodes. Treating physicians changed administration route more often, whereas microbiological/infectious disease (ID)/AMS consultant advice resulted in de-escalation and discontinuation (P = 0.000). Guideline-adherent choice was associated with significantly shorter LOS (6 (4-11) vs. 8 (5-15) days). Full adherence was associated with significantly lower mortality (23 (6.4%) vs. 48 (11.3%)) and shorter LOS (6 (4-10) vs. 8 (5-14) days). ConclusionFive global quality indicators of EAT were measurable in routine clinical practice. Full adherence to guidelines was only moderate. Adherence to guidelines was associated with better patient outcomes.

Impact of Inpatient Attending Specialty and Gastroenterology Consultation on Quality of Care of Patients Hospitalized with Decompensated Cirrhosis

BackgroundData suggest hospitalists are less adherent to quality indicators for decompensated cirrhosis, and gastroenterology consultation may improve adherence. We sought to evaluate the impact of inpatient attending specialty and gastroenterology consultation on quality of care for decompensated cirrhosis. MethodsThis was a retrospective cohort study of patients with decompensated cirrhosis admitted to gastroenterology or hospitalist service at the University of Michigan between 2016-2020. The primary outcome was adherence to nationally recommended inpatient quality indicators for ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and gastrointestinal bleeding. Performance was calculated per patient admission as the proportion of quality indicators met vs quality indicators for which the patient was eligible. Quality indicator scores were compared between services using t-tests. We also evaluated the effect of gastroenterology consultation on quality indicator scores for patients admitted to hospitalist service. Clinical outcomes were compared using multivariable models adjusted for patient characteristics. ResultsTwo hundred eighty-eight admissions were included (155 to gastroenterology service; 133 to hospitalist service). Quality indicator score for all admissions was 69.9% (standard deviation [SD] ± 24.2%). Quality indicator scores were similar between gastroenterology (69.9%, SD ± 23.6%) and hospitalist (69.8%, SD ± 25.1%) services (P = .913). There was no difference in quality indicator subscores for each complication between services. Hospitalists placed a gastroenterology consultation in 53.4% of admissions, and it was associated with higher albumin administration for patients with spontaneous bacterial peritonitis (57.1% vs 25%, P = .044). Patients admitted to gastroenterology service had higher readmissions within 30 days (adjusted odds ratio = 1.95) and shorter length of hospitalization (adjusted rate ratio = 0.85). ConclusionsHospitalists provided comparable quality of care to gastroenterologists for inpatients with decompensated cirrhosis.

Impact of Global Budget Payments on Cardiovascular Care in Maryland: An Interrupted Time Series Analysis.

Background Global budget payments (GBP) are considered effective in containing health care expenditures; however, information on their impact on quality of cardiovascular care is limited. We aimed to evaluate the effects of GBP on utilization, outcomes, and costs for 3 major cardiovascular conditions. Methods We analyzed claims data of hospital admissions in Maryland from fiscal year 2013 to 2018. Using segmented regression, we evaluated temporal trends in hospitalizations, length of stay, percutaneous coronary intervention and coronary artery bypass grafting volumes, case mix-adjusted 30-day readmission rates, risk-standardized mortality rates, and hospitalization charges in patients with principal diagnosis of heart failure, acute ischemic stroke, and acute myocardial infarction (AMI) in relation to GBP implementation. Trends in global cardiovascular procedure charges/volumes were also studied. Results Hospitalization rates for congestive heart failure and AMI remained unaffected by GBP, while the gradient of ischemic stroke admissions decreased (Ptrend <0.0001). Length of stay slightly increased for patients with congestive heart failure (Ptrend=0.03). Inpatient coronary artery bypass grafting surgeries decreased (Ptrend <0.0001). We observed a significant decrease in casemix-adjusted 30-day readmission rate in the AMI cohort beyond the prepolicy trend (Ptrend=0.0069). There were no significant changes in mortality for any of the 3 conditions. Hospitalization charges increased for ischemic stroke (Ptrend <0.0001), remained constant for congestive heart failure (Ptrend=0.1), and decreased for AMI (Ptrend=0.0005). We observed a significant increase in electrocardiography rate charges (Ptrend <0.0001), coincidentally with a reduction in volumes (Ptrend=0.0003). Conclusions Introducing GBP in Maryland had no perceivable adverse effects on inpatient outcomes and quality indicators for 3 major cardiovascular conditions. Savings were observed in the AMI cohort, possibly due to reduced unnecessary readmissions, efficiency improvements, or shifts to outpatient care. Reduced cardiovascular procedure volumes were counterbalanced by a proportional rise in charges. State-level adoption of GBP with pay-for-performance incentives may be effective for cost containment without adversely impacting quality of cardiovascular care.

A clinical study on quality use of antimicrobials and self-medication, medication adherence of antimicrobials in community and hospital settings

Background: Antimicrobial resistance is a global health concern. Globally, between 20 to 50% of antimicrobial consumption is inappropriate, causing significant impact on the quality of care, cost of therapy and incidence of adverse drug reactions and posing a huge risk of antimicrobial resistance. Aim and objectives: Research study aims to assess extent of quality use of antimicrobials among inpatients & outpatients by using inpatient quality indicators, outpatient quality indicators, assessing of self-medication of antimicrobials in community and general public, medication adherence to antimicrobial therapy in outpatients. Methods and materials: Prospective, interventional study. Inpatient and Outpatient quality indicator were used to assess Quality use of antimicrobials. Document review of Prescriptions, Review of patient records, Overview of drug consumption in hospitals and distribution, Semi-structured interviews, Focus group discussions used for data collection. Results: Inpatients: Empirical systemic antibiotic therapy prescribed according to the local guideline has improved from 58.39% to 7.95% as a result of intervention (Imposing of physicians and clinical pharmacist to strictly adhere to local guidelines which are prepared and made available). Practice of ordering at least 2 sets of blood cultures before starting systemic antibiotic therapy also improved from 33.18% to 48.96%, which profoundly impacted the appropriate antimicrobial selection. Empirical antibiotics should be changed to pathogen-directed therapy after culture results become available was also improved from 41.38% to 54.89% after intervention of using of antibiotic usage policy. Outpatients: Antibiotic prescribing in viral infections or (most) self-limiting bacterial infections was made to limit from 43.27% to 38.21% by intervention of prescription auditing, medication review by clinical pharmacist. Prescribed antibiotics should be chosen from an essential list/formulary also improved from 67.12% to 79.14% due to the intervention of designing and dissemination of Essential antimicrobial list and Hospital formulary for individual health care facilities. Conclusion: Research study concludes that, in inpatients, outpatient's majority of antimicrobials are being used Non adherently to quality use indicators so there is a huge need of Promotion of rational use of antimicrobials by raising awareness on antimicrobial resistance and join hands of all health care professionals for combating antibiotic resistance with local solutions to tackle global challenge.

Trend of Death in Pediatric Ventriculo-Peritoneal Shunts in the United States

Background: Ventriculoperitoneal shunts (VPS) have been used to treat hydrocephalus for many years. This procedure has saved many lives, but it does not come without its complications. Considering the invasiveness of the procedure, we sought to investigate the mortality rate of VPS in children in the USA. Methods: This retrospective cohort study used the Nationwide Inpatient Sample database to examine patients from the ages of 0 - 17 years who underwent the procedures involving the insertion, replacement, or removal of VPS from 1997 to 2012. Z-test was used to analyze the statistical significance. Results: During the study period, we recorded a total number of 165,484 cases of VPS with 54.5% occurring in males. The mean age was 5.25 years old, and the average mortality rate was 1.03%. The annual number of patients receiving VPS at all institutions during the study period decreased significantly from 13,075 in 1997 to 8,499 in 2012 (P = 0.001). The rate of patients receiving VPS per 100,000 discharges at all institutions during the study period also decreased significantly from 18.4 in 1997 to 11.5 in 2012 (P = 0.0001). The number of in-hospital deaths significantly decreased from 150 in 1997 to 50 in 2012 (P = 0.001), and the main decrease in the mortality happened after 2009 (P = 0.001). Conclusions: Utilization of pediatric VPS decreased in the USA between 1997 and 2012, and the number of in-hospital deaths significantly decreased as well. This may be related to better healthcare services in recent years, especially with more emphasis on the inpatient quality indicators (IQIs). Future research should determine the cause of the significant decrease and use the information to continue bringing the mortality rate down. J Neurol Res. 2020;10(3):69-72 doi: https://doi.org/10.14740/jnr573