Maryland Hospital Research Articles

Inpatient safety outcomes following the 2011 residency work‐hour reform

The impact of the 2011 residency work-hour reforms on patient safety is not known. To evaluate the association between implementation of the 2011 reforms and patient safety outcomes at a large academic medical center. Observational study using difference-in-differences estimation strategy to evaluate whether safety outcomes improved among patients discharged from resident and hospitalist (nonresident) services before (2008-2011) and after (2011-2012) residency work-hour changes. All adult patients discharged from general medicine services from July 2008 through June 2012. Outcomes evaluated included length of stay, 30-day readmission, intensive care unit (ICU) admission, inpatient mortality, and presence of Maryland Hospital Acquired Conditions. Independent variables included time period (pre- vs postreform), resident versus hospitalist service, patient age at admission, race, gender, and case mix index. Patients discharged from the resident services in the postreform period had higher likelihood of an ICU stay (5.7% vs 4.5%, difference 1.4%; 95% confidence interval [CI]: 0.5% to 2.2%), and lower likelihood of 30-day readmission (17.2% vs 20.1%, difference 2.8%; 95 % CI: 1.3 to 4.3%) than patients discharged from the resident services in the prereform period. Comparing pre- and postreform periods on the resident and hospitalist services, there were no significant differences in patient safety outcomes. In the first year after implementation of the 2011 work-hour reforms relative to prior years, we found no change in patient safety outcomes in patients treated by residents compared with patients treated by hospitalists. Further study of the long-term impact of residency work-hour reforms is indicated to ensure improvement in patient safety.

Developing Dual Role Nursing Staff–Clinical Instructor

Supported by visionary leadership, a unique strategic-academic partnership model was established with grant support between the University of Maryland School of Nursing, Baltimore, and 13 Maryland hospitals to prepare hospital-based staff nurses as clinical instructors. Participating hospitals gained masters' degree-prepared nurses able to lead the achievement of clinical and organizational goals. The schools of nursing gained additional access to clinical education resources to enable increased undergraduate enrollment.

Trends and outcomes of total and partial nephrectomy in children: A statewide analysis

ObjectiveTo report trends in surgical approach and associations with outcomes in children undergoing extirpative renal surgery in the state of Maryland over a 12-year period. MethodsThe Maryland Health Services Cost Review Commission (HSCRC) database was queried to identify children undergoing total or partial nephrectomy between 2000 and 2011. Demographic, clinical, hospital, and charge data were compared between children undergoing open and minimally invasive renal surgery. Multivariable logistic regression analysis was performed to identify independent predictors of prolonged length of hospital stay and 30-day readmission. Multivariable linear regression was performed to identify independent predictors of increased hospital charges. ResultsOf the 346 children undergoing extirpative renal surgery, 289 (83.5%) underwent total nephrectomy and 48 (13.9%) underwent minimally invasive surgery. Utilization of minimally invasive surgery for congenital urinary anomalies has steadily increased from 15% to 35% over the past decade. Children undergoing minimally invasive total nephrectomy were healthier, had shorter hospital stay, and were more likely to have surgery at a high-volume institution. No such differences were noted in patients undergoing open and minimally invasive partial nephrectomy. On multivariable regression analyses, high patient complexity was the main predictor of increased length of stay (OR 16.02, 95% CI 7.06–36.31), 30-day readmission (OR 3.04, 95% CI 1.38–6.70), and total hospital charge (p < 0.001). ConclusionIn Maryland hospitals, most extirpative renal surgeries in children are total nephrectomies performed using an open technique by high-volume surgeons. Although the overall proportion of minimally invasive surgeries has not increased over time, the utilization of MIS in congenital anomaly cases has. Patient complexity and not operative approach dictates postoperative morbidity and hospital charges.

Not-for-profit hospitals’ provision of community benefit during the 2008 recession: An analysis of hospitals in Maryland

During the 2008 recession, many U.S. hospitals had to lay off staff and cut services to reduce costs, yet little is known about how these cuts affected hospitals’ provision of community benefits. While the need for charitable programs and services grew during this economically difficult time, financial pressures may have forced hospitals to cut back on their community benefit spending. Using data for not-for-profit hospitals in the state of Maryland for the years 2006 to 2010, this study explored whether, and if so how, hospitals changed their provision of community benefit during the 2008 recession. The findings showed that, on average, Maryland hospitals increased their charitable activities during the recent recession. Between 2006 and 2010, total spending on community benefits grew from an average of 5.6% to 7.7% of operating expenses with the most substantial growth in hospitals’ provision of charity care and mission-driven health services. Panel regression analysis showed that this increase in charitable activity was associated with increases in community need. Hospitals’ financial performance, on the other hand, was unrelated to their community benefit spending. These findings indicate that even in times of constrained budgets, Maryland hospitals provided substantial amounts of community benefit in response to the needs of the communities they serve. Hospital-based community benefit programs thus have the potential to play an important role in on-going community-wide efforts aimed at reducing the burden of illness and improving population health.

Validation Of a Brief Arsenic Trioxide (ATO)-Based Consolidation Chemotherapy In The Upfront Management Of Acute Promyelocytic Leukemia (APL): Less Anthracycline Exposure and Faster Completion Of Consolidation Therapy With Equivalent Survival

BackgroundAlthough anthracyclines have significant proven activity in APL, their use is associated with significant cardiac toxicity and risk of secondary malignancy. Therefore there has been an increased interest in minimizing anthracycline exposure without compromising outcomes. All-trans retinoic acid (ATRA)-ATO combination has been shown to be an active and less toxic regimen in APL, but the experience with this regimen is largely limited to patients (pts) without high-risk (HR) disease (White cell count [WBC]<10,000/µL) (Lo-Coco et al. NEJM 369: 111-121). Moreover, this regimen requires ≥8 months of therapy. We have previously reported that a single cycle of ATO- based consolidation chemotherapy is effective in the primary management of APL while significantly minimizing anthracycline exposure (Gore et al. JCO, 2010; 28:1047-1053). We sought to evaluate the “real-life” performance of this approach in patients treated following completion of protocol accrual. MethodsWe identified and screened all APL pts who received ATO-based consolidation at Johns Hopkins University (JHU), Baltimore, Maryland and Northside hospital (NSH), Atlanta, Georgia. We excluded pts who were enrolled on the original trial and pts who were diagnosed after August 1st 2012 to allow for adequate follow-up. Induction therapy used ATRA 45mg/m2/day (d) x 60d and daunorubicin 60mg/m2 on d 4, 6, and 8. Consolidation consisted of one course of therapy that included continuous infusion cytarabine 667 mg/m2/d, intravenous daunorubicin 60 mg/m2/d on d1-3, and ATO 0.15 mg/kg given for 5d per week for 30 doses beginning d8. Pts received 2 years of risk-adapted maintenance therapy: all patients received ATRA alone for 15d every 3 months, with the addition of mercaptopurine daily and oral methotrexate weekly for HR pts (WBC >10,000/µL). Descriptive statistics were used to summarize data and Kaplan-Meier methodology was used to calculate survivals. Event free survival (EFS) was defined as time from diagnosis till relapse or death, leukemia-free survival (LFS) was defined as time from remission to relapse (censoring for death in remission), and overall survival (OS) was defined as time from diagnosis to death. ResultsWe identified 63 pts (30 JHU, 33 NSH) who were treated according to the study protocol but not enrolled on the original trial. 14 pts (8 JHU, 6 NSH) were diagnosed after August first, 2012 and therefore were excluded. Forty-nine pts (22 JHU and 27 NSH) were included in the analysis. The median age was 55 years (range, 21-73). Twenty-seven were males and 22 were females, and 14 had HR disease while 35 had low-risk disease. The median follow-up of survivors was 2.4 years (95% confidence interval [95%CI], 1– 8.8). Two patients died during induction (one with HR and one with low risk disease); all other pts achieved complete remission (CR). Two pts died during maintenance therapy while in CR (both low-risk disease, one died due to graft failure in a cardiac transplant recipient, and the other due to recurrent metastatic breast cancer). One patient relapsed during the follow-up period, but is currently in CR after autologous transplant. The EFS was 86.1% (95%CI, 74 – 100%), the LFS 97.6% (95%CI, 92-100%), and OS was 88.5% (95%CI, 76-100%). Among the 14 HR patients, the estimated OS and EFS were both 93 % (95%CI, 86-100%). ConclusionThese data confirm the outcomes of the original clinical trial. While ATRA-ATO combination is an attractive non-chemotherapy approach for APL pts, its efficacy in HR pts is not yet documented and it requires prolonged intensive therapy (≥8 months). ATO-based chemotherapy consolidation is typically completed within 3-4 months and is effective in HR pts. This approach may be preferable in selected patients with HR APL or if a shorter period of intensive therapy is preferred. Disclosures:No relevant conflicts of interest to declare.

The Implementation and Evaluation of an Evidence-based Statewide Prehospital Pain Management Protocol Developed using the National Prehospital Evidence-based Guideline Model Process for Emergency Medical Services

Background. In 2008, the National Highway Traffic Safety Administration funded the development of a model process for the development and implementation of evidence-based guidelines (EBGs) for emergency medical services (EMS). We report on the implementation and evaluation of an evidence-based prehospital pain management protocol developed using this model process. Methods. An evidence-based protocol for prehospital management of pain resulting from injuries and burns was reviewed by the Protocol Review Committee (PRC) of the Maryland Institute for Emergency Medical Services Systems (MIEMSS). The PRC recommended revisions to the Maryland protocol that reflected recommendations in the EBG: weight-based dosing and repeat dosing of morphine. A training curriculum was developed and implemented using Maryland's online Learning Management System and successfully accessed by 3,941 paramedics and 15,969 BLS providers. Field providers submitted electronic patient care reports to the MIEMSS statewide prehospital database. Inclusion criteria were injured or burned patients transported by Maryland ambulances to Maryland hospitals whose electronic patient care records included data for level of EMS provider training during a 12-month preimplementation period and a 12-month postimplementation period from September 2010 through March 2012. We compared the percentage of patients receiving pain scale assessments and morphine, as well as the dose of morphine administered and the use of naloxone as a rescue medication for opiate use, before and after the protocol change. Results. No differences were seen in the percentage of patients who had a pain score documented or the percent of patients receiving morphine before and after the protocol change, but there was a significant increase in the total dose and dose in mg/kg administered per patient. During the postintervention phase, patients received an 18% higher total morphine dose and a 14.9% greater mg/kg dose. Conclusions. We demonstrated that the implementation of a revised statewide prehospital pain management protocol based on an EBG developed using the National Prehospital Evidence-based Guideline Model Process was associated with an increase in dosing of narcotic pain medication consistent with that recommended by the EBG. No differences were seen in the percentage of patients receiving opiate analgesia or in the documentation of pain scores.

Impact of Hospital Volume and Specialization on the Cost of Orbital Trauma Care

To examine the impact of hospital volume and specialization on the cost of orbital trauma care. Comparative case series and database study. Four hundred ninety-nine patients who underwent orbital reconstruction at either a high-volume regional eye trauma center, its academic parent institution, or all other hospitals in Maryland between 2004 and 2009. We used a publicly available database of hospital discharge data to identify the study population's clinical and cost characteristics. Multivariate models were developed to determine the impact of care setting on hospital costs while controlling for patient demographic and clinical variables. Mean hospital costs accrued during hospital admission for orbital reconstruction in 3 separate care settings. Almost half (n = 248) of all patients received surgical care at the regional eye trauma center and had significantly lower adjusted mean hospital costs ($6194; 95% confidence interval [CI], $5709-$6719) compared with its parent institution ($8642; 95% CI, $7850-$9514) and all other hospitals ($12,692; 95% CI, $11,467-$14,047). A subpopulation analysis selecting patients with low comorbidity scores also was performed. The eye trauma center continued to have lower adjusted costs ($4277; 95% CI, $4112-$4449) relative to its parent institution ($6595; 95% CI, $5838-$7451) and other hospitals ($7150; 95% CI, $5969-$8565). Higher volume and specialization seen at a regional eye trauma center are associated with lower costs in the surgical management of orbital trauma.

Financial Impact of Surgical Site Infections on Hospitals

Surgical site infections (SSIs) may increase health care costs, but few studies have conducted an analysis from the perspective of hospital administrators. To determine the change in hospital profit due to SSIs. Retrospective study of data from January 1, 2007, to December 31, 2010. The study was performed at 4 of The Johns Hopkins Health System acute care hospitals in Maryland: Johns Hopkins Bayview (560 beds); Howard County General Hospital (238 beds); The Johns Hopkins Hospital (946 beds); and Suburban Hospital (229 beds). Eligible patients for the study included those patients admitted to the 4 hospitals between January 1, 2007, and December 31, 2010, with complete data and the correct International Classification of Diseases, Ninth Revision code, as determined by the infection preventionist. Infection preventionists performed complete medical record review using National Healthcare Safety Network definitions to identify SSIs. Patients were stratified using the All Patient Refined Diagnosis Related Groups to estimate the change in hospital profit due to SSIs. Surgical site infections. The outcomes of the study were the difference in daily total charges, length of stay (LOS), 30-day readmission rate, and profit for patients with an SSI when compared with patients without an SSI. The hypothesis, formulated prior to data collection, that patients with an SSI have higher daily total costs, a longer LOS, and higher 30-day readmission rates than patients without an SSI, was tested using a nonpaired Mann-Whitney U test, an analysis of covariance, and a Pearson χ2 test. Hospital charges were used as a proxy for hospital cost. RESULTS The daily total charges, mean LOS, and 30-day readmission rate for patients with an SSI compared with patients without an SSI were $7493 vs $7924 (P = .99); 10.56 days vs 5.64 days (P < .001); and 51.94 vs 8.19 readmissions per 100 procedures (P < .001). The change in profit due SSIs was $2 268 589. The data suggest that hospitals have a financial incentive to reduce SSIs, but hospitals should expect to see an increase in both cost and revenue when SSIs are reduced.

RBC Transfusion Practices Among Critically Ill Patients

Increasing evidence, including publication of the Transfusion Requirements in Critical Care trial in 1999, supports a lower hemoglobin threshold for RBC transfusion in ICU patients. However, little is known regarding the influence of this evidence on clinical practice over time in a large population-based cohort. Retrospective population-based cohort study. Thirty-five Maryland hospitals. Seventy-three thousand three hundred eighty-five nonsurgical adults with an ICU stay greater than 1 day between 1994 and 2007. None. The unadjusted odds of patients receiving an RBC transfusion increased from 7.9% during the pre-Transfusion Requirements in Critical Care baseline period (1994-1998) to 14.7% during the post-Transfusion Requirements in Critical Care period (1999-2007). A logistic regression model, including 40 relevant patient and hospital characteristics, compared the annual trend in the adjusted odds of RBC transfusion during the pre- versus post-Transfusion Requirements in Critical Care periods. During the pre-Transfusion Requirements in Critical Care period, the trend in the adjusted odds of RBC transfusion did not differ between hospitals averaging>200 annual ICU discharges and hospitals averaging≤200 annual ICU discharges (odds ratio, 1.07 [95% CI, 1.01-1.13] annually and 1.03 [95% CI, 0.99-1.07] annually, respectively; p=0.401). However, during the post-Transfusion Requirements in Critical Care period, the adjusted odds of RBC transfusion decreased over time in higher ICU volume hospitals (odds ratio, 0.96 [95% CI, 0.93-0.98] annually) but continued to increase in lower ICU volume hospitals (odds ratio, 1.10 [95% CI, 1.08-1.13] annually), p<0.001. In this population-based cohort of ICU patients, the unadjusted odds of RBC transfusion increased in both higher and lower ICU volume hospitals both before and after Transfusion Requirements in Critical Care publication. After adjusting for relevant characteristics, the odds continued to increase in lower ICU volume hospitals in the post-Transfusion Requirements in Critical Care period, but it decreased in higher ICU volume hospitals. This suggests that evidence supporting restrictive RBC transfusion thresholds may not be uniformly translated into practice in different hospital settings.

Variable Impact of State Legislative Advocacy on Registry Participation and Regional Systems of Care Implementation

Regionalization, systems of care design, and quality improvement (QI) registry participation all promote the widespread dissemination of guideline-based evidence into actual practice. As a result, policy statements from the American Heart Association/American Stroke Association (AHA/ASA) advocate for the creation of regional systems of care for various time-critical diagnoses, including ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest resuscitation, and acute stroke.1–3 Creation of these regional networks requires multidisciplinary collaboration to implement 5 mutually reinforcing core elements4 that build each system: (1) Designation of certain hospitals with special treatment capabilities as Receiving Centers for STEMI, resuscitation, or stroke; (2) emergency medical services (EMS) destination protocols that allow for direct transport of certain patients identified by explicit triage criteria to a designated Receiving Center, thus allowing for bypass of closer hospitals if they lack the needed specialty service; (3) organized interhospital transfer and transport protocols to a Receiving Center for appropriate patients who initially self-present or are mistriaged to a Referral Hospital; (4) communication or telemedicine options to provide real-time expert consultation as needed from a Receiving Center to its associated Referral Hospitals or EMS providers; and (5) participation in a regional and/or national QI registry to track relevant process-of-care metrics and meaningful risk-adjusted clinical outcomes. Within each of the 50 states, unique challenges exist for stakeholders attempting to implement the 5 aforementioned core elements of regional or statewide systems of care. In particular, substantial variation exists with regard to the starting point for these initiatives. For example, some states already have sufficient regulatory authority within their EMS agency or state department of health (DOH) to regionalize care of time-critical diagnoses, whereas other states require new legislation to create coordinated systems. In October 2011, the Advocacy Coordinating Committee of the AHA convened a multispecialty task force to assess the …

A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation

A requirement for improved methods of hemorrhage control and resuscitation along with the translation of endovascular specialty skills has resulted in reappraisal of resuscitative endovascular balloon occlusion of the aorta (REBOA) for end-stage shock. The objective of this report was to describe implementation of REBOA in civilian trauma centers. Descriptive case series of REBOA (December 2012 to March 2013) used in scenarios of end-stage hemorrhagic shock at the University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland, and Herman Memorial Hospital, The Texas Trauma Institute, Houston, Texas. REBOA was performed by trauma and acute care surgeons for blunt (n = 4) and penetrating (n = 2) mechanisms. Three cases were REBOA in the descending thoracic aorta (Zone I) and three in the infrarenal aorta (Zone III). Mean (SD) systolic blood pressure at the time of REBOA was 59 (27) mm Hg, and mean (SD) base deficit was 13 (5). Arterial access was accomplished using both direct cutdown (n = 3) and percutaneous (n = 3) access to the common femoral artery. REBOA resulted in a mean (SD) increase in blood pressure of 55 (20) mm Hg, and the mean (SD) aortic occlusion time was 18 (34) minutes. There were no REBOA-related complications, and there was no hemorrhage-related mortality. REBOA is a feasible and effective means of proactive aortic control for patients in end-stage shock from blunt and penetrating mechanisms. With available technology, this method of resuscitation can be performed by trauma and acute care surgeons who have benefited from instruction on a limited endovascular skill set. Future work should be aimed at devices that allow easy, fluoroscopy-free access and studies to define patients most likely to benefit from this procedure. Therapeutic study, level V.

Commentary on the spread of new payment models

The state of Maryland implemented innovative budgeting of outpatient and inpatient services in eight rural hospitals under the Total Patient Revenue (TPR) system in July, 2010.This paper uses data on Maryland discharges from the 2009–2011 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). Individual inpatient discharges from eight treatment hospitals and three rural control hospitals (n=374,353) are analyzed. To get robust estimates and control for trends in the state, we also compare treatment hospitals to all hospitals in Maryland that report readmissions (n=1,997,164). Linear probability models using the difference-in-differences approach with hospital fixed effects are estimated to determine the effect of the innovative payment mechanisms on hospital readmissions, controlling for patient demographics and characteristics.Difference-in-differences estimates show that after implementation of TPR in the treatment hospitals, there were no statistically significant changes in the predicted probability of readmissions.Early evidence from the TPR program shows that readmissions were not affected in the 18 months after implementation.As the health care system innovates, it is important to evaluate the success of these innovations. One of the goals of TPR was to lower readmission rates, however these rates did not show consistent downward trends after implementation. Our results suggest that payment innovations that provide financial incentives to ensure patients receive care in the most appropriate setting while maintaining quality of care may not have immediate effects on commonly used measures of hospital performance, particularly for rural hospitals that may lack coordinated care delivery infrastructure.

Infection Prevention Considerations Related to New Delhi Metallo-β-Lactamase Enterobacteriaceae A Case Report

A 60-year-old American man who was hospitalized in India for 4 weeks after an intracranial bleed was transferred by air ambulance to a 249-bed community hospital in Maryland in January 2011. His clinical course is described elsewhere. Here, we describe the infection prevention considerations surrounding his care in the hospital. A sputum sample obtained from the patient grew a New Delhi metallo-β-lactamase-producing (NDM) Klebsiella pneumoniae (NDM-KP) strain and panresistant Acinetobacter species, among other pathogens. Two weeks later, a perirectal swab sample grew an NDM-1 Salmonella Senftenberg (NDM-SS) isolate, described elsewhere. Gut decolonization was attempted with rifaximin 300 mg every 12 hours for 12 days. The patient was discharged home 4.5 months later. He was readmitted to the hospital within 1 week and died shortly thereafter.In recognition of his epidemiological risk factors, empiric contact isolation was instituted by the infectious disease physician who was consulted when the patient experienced a fever 24 hours after hospital admission. Once the NDM-KP strain was identified, a 1:1 nursing protocol was instituted for the patient; respiratory therapists, however, continued to care for other Patients. The patient's nurses were empowered to enforce strict contact isolation. Visitors were restricted to the patient's immediate family members. The hospital implemented an intensive education and communication program for the professional staff, nurses, respiratory therapists, ancillary personnel, and the patient's family.

Relationship of influenza vaccine match and use rate to medically attended acute respiratory illnesses in older residents of Maryland. November 13, 2012

The effectiveness of seasonal influenza vaccine may be influenced by mismatches to circulating influenza viruses. The relationship of these vaccine mismatches to the occurrence of medically attended acute respiratory illnesses (MAARI)-related emergency department (ED) visits and hospitalizations for all Maryland residents aged 50 years or older was examined for seven years (2001–2008). Also, relationships of individual circulating influenza types or subtypes to these MAARI-encounters were investigated.Anonymous, retrospective discharge data from all Maryland hospitals were utilized to determine daily numbers of MAARI-related ED visits and hospitalizations. Rate ratios (RR) of these MAARI-related encounters were then determined between intense influenza outbreak periods and non-influenza season time periods for each year using a Poisson regression model. Center for Disease Control end of season data reports were used to estimate each season's ‘match’ of each trivalent influenza vaccine component to subsequent circulating influenza viruses in the United States. The overall vaccine match proportion for the three vaccine viruses was then multiplied by reported vaccination rates of Maryland residents aged 50 years or older to determine an ‘estimated influenza vaccine impact factor’ (EIVIF) for each year. Correlation coefficients (CC) were then calculated comparing RR of MAARI-encounters to the corresponding EIVIF data. Finally, yearly RR of MAARI-encounters were compared to corresponding rates of individual circulating influenza types or subtypes circulating in the Maryland area.Consistent trends were observed whereby increased EIVIF proportions were correlated with decreased RR of MAARI-related ED visits and hospitalizations. This correlation reached statistical significance when comparing EIVIF to RR of MAARI-related ED visits (CC=−0.77, P=0.04). Also, the proportion of A/H3N2 viruses circulating each season was significantly positively correlated to that season's RR of MAARI-related ED visits (CC=0.89) and hospitalizations (CC=0.92); both P<0.01.Our data suggest increased protective effects of influenza immunization on reducing MAARI-related ED visits and hospitalizations in older individuals when the vaccine is well matched to the circulating strains. A/H3N2 viruses were clearly associated with more frequent MAARI-related ED visits and hospitalizations than A/H1N1 and B viruses.

Hospital-Acquired DVT/PE As “Never Events”: A Misguided Strategy for Performance Improvement in VTE Prevention.

AbstractAbstract 3180 Introduction:Venous thromboembolism (VTE) is recognized as a common cause of preventable patient harm. To reduce the incidence of preventable VTE in hospitalized patients, VTE has been designated as a “Never Event”, a complication for which reimbursement is withheld. To identify VTE “Never Events” that occur during the hospital stay, payors are using the International Classification of Disease revision 9 (ICD-9) diagnosis codes for VTE. The estimated positive predictive value of ICD-9 diagnosis codes for objectively confirmed acute hospital-acquired VTE varies widely (17% to 100%). The purpose of the current study was to review consecutive cases of hospital-acquired VTE identified during fiscal year 2011 by the Maryland Hospital Acquired Conditions (MHAC) algorithm for VTE “Never Events.” We hypothesized that a significant number of VTE identified using this strategy would not fulfill the definition of preventable episodes of VTE. Methods:We conducted a retrospective review of an administrative database of consecutive patients admitted to the Johns Hopkins Hospital during fiscal year 2011 who suffered events coded as hospital-acquired VTE. The ICD-9 codes used by the MHAC initiative to define VTE are: 451.11, 451.19, 451.2, 451.81, 451.83, 451.9, 453.40, 453.41, 453.42, 453.82, 453.84, 453.85, 453.86, 453.87, 453.89, 453.9, and 997.2. Demographic and clinical data including VTE risk category and ordered VTE prophylaxis were retrieved from our electronic patient record system. Our definition for a hospital-acquired VTE required objective radiologic confirmation of lower extremity deep venous thrombosis (DVT) or pulmonary embolism (PE) in the absence of a central venous catheter (CVC). Thrombotic events were consider CVC-DVT if they occurred in the same vascular distribution. VTE were considered present on admission if objectively-confirmed within the first 24 hours of admission. Results:Between July 1, 2010 and June 30, 2011, one hundred sixty three patients were coded and accepted as developing preventable VTE by the MHAC initiative. Ninety one patients were admitted to a surgical service, 58 patients were medically ill, and 14 were neurology patients. The mean age was 61.2 (SD: 17.5) years, mean BMI was 28.0 (SD: 7.6) kg/m2, median length of hospitalization was 14 days and median time to diagnosis was 5 days. One hundred four patients (63.8%) were categorized as being at high or very high risk for VTE while 59 patients (36.2%) were determined to be at moderate risk for VTE.Eighty seven patients (53.4%) had DVT, 47 (28.8%) had PE, 9 (5.5%) had superficial thrombophlebitis, and 19 (11.7%) had arterial thromboembolism. One patient, who died on post-operative day 1 without an objective finding of VTE, was coded as developing VTE. Fifty eight patients (35.6%) had CVC-associated events and 7 patients (4.3%) had VTE that were present on admission. Overall, 85 of 163 (52%) thrombotic events designated as VTE “Never Events” were in fact either not preventable (CVC-VTE) or not hospital-acquired VTE. Discussion:Our retrospective study of consecutive patients designated as having developed hospital-acquired VTE found that a substantial percentage of VTE “Never Events” are invalid or unlikely to be preventable with currently available best practices VTE prophylaxis. These findings highlight the inaccuracy of ICD-9 code based strategies to identify potentially preventable hospital-acquired conditions. Furthermore, the data emphasize that process measures rather than outcomes should be used to determine performance on quality indicators such as VTE prevention. We believe that a method with greater sensitivity and specificity to identify true VTE is needed, which may be aided by ICD-10-CM. While we agree with the concept of disincentivizing suboptimal care, a more practical approach may be to evaluate process measures, such as prescribing and administering guideline-based, best-practice VTE prophylaxis for patients who develop VTE. Disclosures:Streiff:sanofi-aventis: Consultancy, Honoraria; BristolMyersSquibb: Research Funding; Eisai: Consultancy; Janssen Healthcare: Consultancy; Daiichi-Sankyo: Consultancy.

Racial variation in vitamin D cord blood concentration in white and black male neonates.

The aim of this study is to evaluate racial variation in umbilical cord blood concentration of vitamin D and to explore its correlation with markers of the insulin-like growth factor axis (IGFs) and sex steroid hormones in white and black male neonates. In 2004-2005, venous umbilical cord blood samples were collected from 75 black and 38 white male neonates, along with maternal and birth characteristics from two hospitals in Maryland, United States. 25-Hydroxyvitamin D [25(OH)D] and 1,25-dihydroxyvitamin D [1,25(OH)(2)D] were measured by radioimmunoassay and testosterone, estradiol, and sex hormone-binding globulin (SHBG) by immunoassay and IGF-1, IGF-2, and IGF-binding protein-3 by ELISA. Crude and multivariable-adjusted geometric mean concentrations were computed. Mean 25(OH)D levels were lower in black than in white neonates (11.44; 95% CI 10.10-12.95ng/mL vs. 18.24; 95% CI 15.32-21.72ng/mL; p<0.0001). Black neonates were at higher risk of suboptimal vitamin D levels [25(OH)D<20ng/mL] than whites (84 vs. 63%). 25(OH)D concentrations varied by season in whites but not in blacks and were significantly inversely correlated with mother's parity (number of live births) in blacks but not in whites. Mean concentration of 1,25(OH)(2)D did not differ by race. 25(OH)D and 1,25(OH)(2)D did not correlate with IGFs, sex steroid hormones, and SHBG. Suboptimal vitamin D levels were prevalent especially in blacks and influenced by mother's parity and by season. The observed vitamin D differences between black and white neonates warrant further evaluation of the etiology of the disparity in chronic diseases in adulthood.

Methadone treatment centers and crime

The paper by Boyd et al. explores the association between the location of methadone treatment centers (MTCs) and crime in Baltimore, MD, USA 1. Comparing spatial patterns of total crime counts during the period 1999–2001 in 100 m concentric buffers around MTCs, convenience stores, residential locations and general hospitals, the authors argue that MTCs do not act as a focus of crime compared with convenience stores. Online publication of the article attracted the attention of the Baltimore media and the research was immediately deployed to push back against recent community protests over the clustering of MTCs in a disadvantaged area of the city 2. There are, however, a number of methodological flaws in the research that are not acknowledged in the article and render its conclusions questionable. For reasons of space, I highlight just a few of the problems below. Thirteen MTCs in Baltimore were grouped together without taking into account the huge variation in neither the daily number of patients treated in each facility nor the socio-demographic characteristics of the areas surrounding them. The number of patients treated was not compared with the number of customers visiting convenience stores, to the number of people using the hospitals nor to the number of people (permanent residents or ambient population) in residential areas. The 1999–2001 study period was determined by the availability of crime data. However, the telephone survey of the MTCs was conducted much more recently. It is unclear precisely where the recalled information for the MTCs originated, whether it referred to the 1999–2001 period or whether it was verified independently. The location of convenience stores was identified using www.switchboard.com a decade after the 1999–2001 crime data referring to those locations. It is unclear whether the criteria for inclusion on www.switchboard.com introduced potential bias. There is no description of a validation exercise that shows these stores were, in fact, operational in 1999–2001 or that these sites were even used as convenience stores at that date. As Boyd et al. acknowledge, alcohol sales outlets are also known to be foci of crime, yet we are not told whether any of these, or other potential crime-attracting activities such as open-air drug markets, operated in any of the study areas. There may have been biases in the reporting of crimes. Time-sensitive crime control or law enforcement measures may have been operational in and around any of the study sites. For example, eight of the MTCs were located on, or near, hospital campuses. Medical facilities in Baltimore tend to be heavily policed, particularly around the Johns Hopkins and University of Maryland hospitals. Crimes were not disaggregated by type, even though it is well-known that drug addicts most commonly commit acquisitive crimes to fund their addiction 3. It is unclear, then, precisely how the researchers envisaged the causal relationship between MTCs and ‘total crime’. They are extremely critical of the crude popular misconception about the relationship between criminality and addiction, yet they are willing to use a version of it as their research hypothesis. The connections between space, place and crime are highly complex and were inadequately captured in this model. Studies have shown that drug users do commit less crime when they are in treatment. However, the Baltimore AIDS Linked to the Intravenous Experience (ALIVE) prospective cohort study has demonstrated that it takes 9 years of treatment to achieve long-term cessation in about 40% of injecting drug users 4. For 60% of injectors, then, treatment either takes longer than 9 years to work or it fails altogether, perpetuating, for many, a cycle of substance abuse, treatment and crime. Boyd et al. seem to assume that arbitrarily chosen concentric buffers of 100 m—equaling a radius of fewer than three blocks—captures the spatial impact of MTCs and other urban phenomena. They therefore avoid the point about why local communities protest the location of MTCs; it is not just the successful patients that matter to them, it is the failures. Treatment providers (a group to which Boyd belongs) do not routinely share aggregate anonymized information about their programs, such as long-term treatment outcomes or where successfully and unsuccessfully treated patients decide to live. Until they do, and with the collusion of methodologically-flawed studies such as this, communities who protest about the clustering of MTCs are under-informed through no fault of their own and are exposed to convenient accusations of NIMBYism. None.

Access to surgical care of endometrial cancer at high volume hospitals in Maryland

Access to surgical care of endometrial cancer at high volume hospitals in Maryland

Racial Variation in the Quality of Surgical Care for Prostate Cancer

Difference in the quality of care may contribute to the less optimal prostate cancer treatment outcomes among black men compared with white men. We determined whether a racial quality of care gap exists in surgical care for prostate cancer, as evidenced by racial variation in the use of high volume surgeons and facilities, and in the quality of certain outcome measures of care. We performed cross-sectional and cohort analyses of administrative data from the Healthcare Cost and Utilization Project all-payer State Inpatient Databases, encompassing all nonfederal hospitals in Florida, Maryland and New York State from 1996 to 2007. Included in analysis were men 18 years old or older with a diagnosis of prostate cancer who underwent radical prostatectomy. We compared the use of surgeons and/or hospitals in the top quartile of annual volume for this procedure, inpatient blood transfusion, complications, mortality and length of stay between black and white patients. Of 105,972 patients 81,112 (76.5%) were white, 14,006 (13.2%) were black, 6,999 (6.6%) were Hispanic and 3,855 (3.6%) were all other. In mixed effects multivariate models, black men had markedly lower use of high volume hospitals (OR 0.73, 95% CI 0.70-0.76) and surgeons (OR 0.67, 95% CI 0.64-0.70) compared to white men. Black men also had higher odds of blood transfusion (OR 1.08, 95% CI 1.01-1.14), longer length of stay (OR 1.07, 95% CI 1.06-1.07) and inpatient mortality (OR 1.73, 95% CI 1.02-2.92). Using an all-payer data set, we identified concerning potential quality of care gaps between black and white men undergoing radical prostatectomy for prostate cancer.

All in a Day’s Work: Establishing Rapport, Making Decisions, Reducing Disparities

All in a Day’s Work: Establishing Rapport, Making Decisions, Reducing Disparities