Multihospital System Research Articles

Safety of early antiplatelet administration in patients with acute ischemic stroke treated with alteplase (SEAPT-24)

ObjectivesAlteplase, a tissue-type plasminogen activator, is recommended for ischemic stroke patients presenting within 4.5 h. Due to bleeding risks, current guidelines advise delaying antiplatelet therapy for 24 h after alteplase. However, specific scenarios may require antiplatelet therapy to be given within the 24 h window. This study aimed to examine the safety of early antiplatelet therapy administration within the first 24 h after alteplase. Materials and methodsThis study is a retrospective, observational study of adult patients with acute ischemic stroke who received alteplase across a multi-hospital system. Patients were grouped based on early antiplatelet therapy (within 24 h window) or as recommended per guidelines. The occurrence of bleeding events, including symptomatic intracranial hemorrhage and/or gastrointestinal bleeding, in-hospital mortality, unfavorable outcomes (modified Rankin score 3–6), and hospital length of stay, were compared between groups. ResultsPatients were predominantly African American (72%) and female (53%) with a median age of 62 years. Median baseline NIHSS scores were higher in the early group (5 vs. 7; p = 0.04), and patients in the early group were more likely to undergo endovascular therapy (26% vs. 8%, p < 0.0001). In patients treated with alteplase only and who did not undergo endovascular therapy, there was no difference in symptomatic intracranial hemorrhage (1.4% vs. 0%, p = 0.1), gastrointestinal bleeding, in-hospital mortality, unfavorable outcomes, or length of stay. ConclusionsIn our retrospective analysis, early administration of antiplatelet therapy (< 24 h post-alteplase) did not increase the risk of symptomatic intracranial hemorrhage, gastrointestinal bleeding, or unfavorable outcomes in patients who received alteplase alone for management of acute ischemic stroke. Prospective studies are needed to validate these findings.

An electronic medical record-based intervention to improve hepatitis A vaccination rates in the emergency department during a regional outbreak

BackgroundIn response to the severe hepatitis A outbreak that occurred in Michigan between August 2016 and September 2019, our multihospital health system implemented an electronic medical record (EMR)-based vaccination intervention...

Correlation between lymph node size on pathology and metastatic disease in right-sided colon cancer: A retrospective review

BackgroundIdentification of positive lymph nodes in colon cancer can significantly impact treatment. Few studies have examined the role of lymph node size in staging and prognosis. This study evaluated the relationship between lymph node size and lymph node metastases in right-sided colon cancer. MethodsRetrospective chart review was performed for patients undergoing colectomy for right-sided colon cancer from 2015 to 2020 across a single multi-hospital health system. Patients under age 18 or who did not have invasive adenocarcinoma upon pathological examination were excluded. Primary endpoints assessed lymph node size and lymph node metastases. 572 patients were stratified by lymph node size; lymph nodes ≥5 mm (n = 308) were characterized as enlarged. ResultsAll surgical specimens examined had adequate number of lymph nodes for staging. 33.9% of all specimens examined contained lymph node metastases. Patients with enlarged lymph nodes were significantly more likely to have lymph node metastases than those with normal-sized lymph nodes (p < 0.001). Enlarged lymph nodes were associated with advanced nodal staging. ConclusionsPatients with enlarged nodes were significantly more likely to have lymph node metastases than those with normal-sized lymph nodes. Further research to analyze these enlarged lymph nodes on radiologic imaging is warranted to determine the role of radiographic assessment of lymph node size during pre-operative staging.

DIFFERENCES IN PROLONGED MECHANICAL VENTILATION ACROSS RACIAL IDENTITY

DIFFERENCES IN PROLONGED MECHANICAL VENTILATION ACROSS RACIAL IDENTITY

S1606 A Retrospective Study of Doxycycline-Based Quadruple Therapy versus Tetracycline-Based Quadruple Therapy for the First Line Treatment of Helicobacter pylori

Introduction: The global prevalence of antimicrobial resistance has resulted in challenges with H. pylori eradication. Gastric acid suppression and antibiotic therapy are used to eradicate H. pylori. Cost and shortages inhibit use of tetracycline for first line treatment of H. pylori. Doxycycline represents a possible cost-effective alternative for treating H. pylori. We performed an analysis of first line doxycycline-based quadruple therapy in comparison to tetracycline-based quadruple therapy in the eradication of H. pylori. Methods: A retrospective chart review was conducted using the Advocate Aurora Health database, a multi-hospital community-based system consisting of sixteen hospitals and over 500 sites of care. All patients age 18 and older with documented H. pylori infection treated with either a first line doxycycline-based regimen (DOX) or tetracycline-based regimen (TCN) from January 2012 to April 2022 were included. In total, 3,384 patients were identified. Patients who received prior first-line treatment with other regimens were excluded. All cases were reviewed for confirmation of infection (either by biopsy, breath test or stool antigen testing), the treatment regimen used, and confirmation of H. Pylori eradication (either by biopsy, breath test, or stool antigen). Patients without confirmation of eradication or with pending eradication test results were excluded. Patient demographics were summarized and eradication rates determined. Results: Of the 3,384 reviewed cases, 628 cases met inclusion and exclusion criteria. Of these, 305 patients were treated with DOX and 323 patients were treated with TCN. Based on these numbers, a posteriori non-inferiority calculation with an assumed 85% eradication rate for the TCN and 80% for DOX and 90% power suggested 100 patents were needed per group (HyLown Consulting LLC, Statistical Calculators). The average age for DOX was 57 years and 193/305 (60%) were female. The average age for TCN was 58.5 years and 210/323 (69%) were female. Eradication rates were 87.6% for DOX and 88.2% for TCN (Table). Conclusion: Doxycycline-based quadruple therapy regimen is effective and appears to be non-inferior to tetracycline-based quadruple therapy regimens for first line treatment of H. pylori. Table 1. - The number of patients with tetracycline or doxycycline antibiotic regimens and the eradication rate Doxycycline Regimen # of Patients % of Patients Successful Eradication 283 87.6% Failed Eradication 40 12.4% Total 323 Tetracycline Regimen # of Patients % of Patients Successful Eradication 269 88.2% Failed Eradication 36 11.8% Total 305

Predicting Patient Demographics From Chest Radiographs With Deep Learning.

Deep learning models are increasingly informing medical decision making, for instance, in the detection of acute intracranial hemorrhage and pulmonary embolism. However, many models are trained on medical image databases that poorly represent the diversity of the patients they serve. In turn, many artificial intelligence models may not perform as well on assisting providers with important medical decisions for underrepresented populations. Assessment of the ability of deep learning models to classify the self-reported gender, age, self-reported ethnicity, and insurance status of an individual patient from a given chest radiograph. Models were trained and tested with 55,174 radiographs in the MIMIC Chest X-ray (MIMIC-CXR) database. External validation data came from two separate databases, one from CheXpert and another from a multihospital urban health care system after institutional review board approval. Macro-averaged area under the curve (AUC) values were used to evaluate performance of models. Code used for this study is open-source and available at https://github.com/ai-bias/cxr-bias, and pixelstopatients.com/models/demographics. Accuracy of models to predict gender was nearly perfect, with 0.999 (95% confidence interval: 0.99-0.99) AUC on held-out test data and 0.994 (0.99-0.99) and 0.997 (0.99-0.99) on external validation data. There was high accuracy to predict age and ethnicity, ranging from 0.854 (0.80-0.91) to 0.911 (0.88-0.94) AUC, and moderate accuracy to predict insurance status, with AUC ranging from 0.705 (0.60-0.81) on held-out test data to 0.675 (0.54-0.79) on external validation data. Deep learning models can predict the age, self-reported gender, self-reported ethnicity, and insurance status of a patient from a chest radiograph. Visualization techniques are useful to ensure deep learning models function as intended and to demonstrate anatomical regions of interest. These models can be used to ensure that training data are diverse, thereby ensuring artificial intelligence models that work on diverse populations.

Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System

We hypothesized that a pain management prescribing tool embedded in the electronic health record system of a multihospital health care system would decrease prescription opioids for postoperative pain by hand, orthopedic, plastic, and spine surgeons. A prescribing tool for postoperative pain was designed for hand, orthopedic, plastic, and spine surgeons and implemented into electronic discharge order sets in a 10-hospital health care system. Stakeholders were educated on tool use in person and/or by email on 2 occasions. A dashboard was created to monitor opioid pill quantities and morphine milligram equivalents (MMEs) prescribed. Overall compliance with the suggested opioid amounts was assessed for 20 months after tool implementation. A subgroup of 6 hand surgeons, one of whom was instrumental in designing the tool, were evaluated for MMEs prescribed, opioid refills, patient emergency room visits, and patient readmissions within 30 days after discharge. Comparisons in this subgroup were made from 12 months before to 15 months after tool implementation. The mean system-wide compliance with the suggested opioid pill quantities and MMEs prescribed in all 4 specialties improved by less than 5%. In the subgroup of hand surgeons, 5 of whom championed tool use, prescribed MMEs decreased by 10% during each of the 4 quarters before launching the tool and contracted an additional 26% in the first quarter after tool implementation. Opioid refills held steady at 5%, and there were no emergency room visits or readmissions within 30 days after discharge in this patient subgroup. The prescribing tool had a negligible impact on system-wide compliance with suggested prescription opioid pill quantities and MMEs. In a small group of surgeons who championed the use of the tool, there was a significant and sustained decline in MMEs prescribed without adversely impacting patient refills, emergency room visits, or readmissions. An electronic prescribing tool to assist surgeons in lowering opioid prescription pill quantities and MMEs may have a negligible impact on prescribing behavior in a multihospital health care system.

Reducing Catheter-Associated Urinary Tract Infections Across a Hospital System Through Urine Culture Stewardship

ObjectiveTo evaluate the effectiveness and safety of an evidence-based urine culture stewardship program in reducing hospital catheter-associated urinary tract infections (CAUTIs) and the rate of CAUTIs across a 3-hospital system. Patients and MethodsThis is a prospective, 2-year quality improvement program conducted from October 1, 2018, to September 30, 2020. An evidence-based urine culture stewardship program was designed, which consisted of the following: criteria for allowing or restricting urine cultures from catheterized patients, a best practice advisory integrated into the ordering system of an electronic medical record, and a systematic provider education and feedback program to ensure compliance. The system-wide rates of CAUTIs (total CAUTIs/catheter days×1000), changes in intercepts, trends, mortality, length of stay, rates of device utilization, and rates of hospital-onset sepsis were compared for 3 years before and 2 years after the launch of the program. ResultsCatheter-associated urinary tract infections progressively decreased after the initiation of the program (B=−0.21, P=.001). When the trends before and after the initiation of the program were compared, there were no statistically significant increases in the ratio of actual to predicted hospital length of stay, intensive care unit length of stay, system-wide mortality, and intensive care unit mortality. Although the rates of hospital-acquired sepsis remained consistent after the implementation of the stewardship program through the first quarter of 2020, the rates showed an increase in the second and third quarters of 2020. However, hospital-onset sepsis events associated with the diagnosis of a urinary tract infection did not increase after the intervention. ConclusionUrine culture stewardship is a safe and effective way to reduce CAUTIs among patients in a large multihospital health care system. Patient safety indicators appeared unchanged after the implementation of the program, and ongoing follow-up will improve confidence in the long-term sustainability of this strategy.

Pay-for-performance schemes and hospital HIT adoption

Pay-for-performance (P4P) schemes are implemented to incentivize or penalize hospitals for their safe caregiving. Given that health information technology (HIT) results in better healthcare outcomes, P4P schemes are expected to promote hospital HIT adoption. However, P4P schemes could also discourage hospitals from adopting HIT because they may take away resources initially allocated for HIT adoption. This paper is one of the first to empirically investigate the double-edged role of P4P schemes in HIT adoption. We leverage a natural experiment in the US healthcare system, which introduced P4P schemes in 2013. Our empirical analysis reveals an unintended side effect of P4P schemes that could potentially impede HIT adoption. We also find that P4P schemes have a negative spillover effect on nonparticipating hospitals in the same multihospital system (MHS) as participating hospitals, particularly for small nonparticipating hospitals. Our findings provide important implications for health policy design and MHS management.

Drainage of anorectal abscesses in the operating room is associated with a decreased risk of abscess recurrence and fistula formation

BackgroundTimely incision and drainage (I&D) is first line management for anorectal abscesses. We aimed to define current practices in anorectal abscess management and identify factors associated with abscess recurrence and fistula formation. MethodsIndex episodes of anorectal abscesses treated with I&D in 2014–2018 at a multi-hospital healthcare system were included. Association with one-year abscess recurrence or fistula formation was evaluated using Cox proportional hazard regression. Fistulae were captured only among patients without fistulae at the index operation. ResultsA total of 458 patients met study criteria. One-year rate of abscess recurrence or fistula formation was 20.3%. When compared to bedside procedures, drainage in the operating room was associated with a reduced risk of either recurrence or fistula formation (aHR 0.20 [95%CI 0.114–0.367]). ConclusionsImproved exposure and patient comfort in the operating room may allow more complete drainage contributing to decreased rates of abscess recurrence or fistula formation.

Building a Business Case for Hiring Wound, Ostomy, and Continence Nurses.

To describe how one organization built a business case for a wound, ostomy, and continence (WOC) nurse team expansion. The organization is part of a multihospital system; it is an 862-bed, urban, academic medical center with a gastrointestinal surgery program. The director of nursing and the WOC nurse staff worked collaboratively to build a staffing proposal. Finding a lack of published staffing guidelines for WOC nurses, researchers assessed workload and volume growth, benchmarked internal and external staffing, and conducted a market comparison. The proposal demonstrated impact on care outcomes related to a reduction in WOC nurses. Based on the case presented, the Off Budget Investment Team committee was satisfied that additional WOC nurse resources would bring both quality and financial value to the organization by reducing hospital-acquired pressure injury (HAPI) incidence and increasing ostomy consults. Approval of additional full-time equivalents was contingent upon a commitment to reduce year-over-year HAPI incidence and to assess the additional costs of treating a HAPI, specific to this organization. Wound ostomy continence nurses bring value to clinical outcomes that impact patient experience, direct and indirect expenses, rankings, reputation, liability, and pay for performance.

Successful Hepatitis C Birth Cohort Screening and Linkage to Care in a US Community Health System.

Context:Birth cohort (“baby boomer”) screening represents a well-validated strategy for the identification of asymptomatic hepatitis C–infected patients. However, successful linkage of newly diagnosed patients to antiviral therapy has been more difficult to accomplish.Objective:To analyze the results of a systemwide birth cohort screening program in a US community health care system.Design:We analyzed the data from an ongoing hepatitis C virus (HCV) screening and treatment program that was established at NorthShore University Health System in 2015. Hepatitis C virus screening by primary care providers was prompted through automated Best Practice and Health Maintenance alerts. Patient visits and screening orders were tracked using a customized HCV dashboard. Virologic, demographic, and treatment data were assessed and compared with those of a cohort of patients with previously established HCV infection.Results:Since program inception, 61 8161 (64.3%) of the entire NorthShore baby boomer population of 96 001 patients have completed HCV antibody testing, and 160 patients (0.26%) were antibody positive. Of 152 antibody-positive patients who underwent HCV RNA testing, 53 (34.2%) were viremic. A total of 39 of 53 patients (73.6%) underwent antiviral therapy and achieved a sustained virologic response. Compared with patients identified through screening, a comparison cohort of patients with previously established HCV had more advanced fibrosis and significantly lower dropout rates. The COVID-19 pandemic was associated with a decrease in the number of outpatient visits of screening-eligible patients and with a reduction in HCV screening rates.Conclusion:Our data demonstrate the electronic medical records–assisted systemwide implementation of HCV birth cohort screening and successful linkage to antiviral therapy in a community-based US multihospital system.

Multi-center matched cohort study of convalescent plasma for hospitalized patients with COVID-19.

BackgroundAlthough frequently used in the early pandemic, data on the effectiveness of COVID-19 convalescent plasma (CCP) remain mixed. We investigated the effectiveness and safety of CCP in hospitalized COVID-19 patients in real-world practices during the first two waves of the pandemic in a multi-hospital healthcare system in Texas.Methods and findingsAmong 11,322 hospitalized patients with confirmed COVID-19 infection from July 1, 2020 to April 15, 2021, we included patients who received CCP and matched them with those who did not receive CCP within ±2 days of the transfusion date across sites within strata of sex, age groups, days and use of dexamethasone from hospital admission to the match date, and oxygen requirements 4–12 hours prior to the match date. Cox proportional hazards model estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for effectiveness outcomes in a propensity score 1:1 matched cohort. Pre-defined safety outcomes were described. We included 1,245 patients each in the CCP treated and untreated groups. Oxygen support was required by 93% of patients at the baseline. The pre-defined primary effectiveness outcome of 28-day in-hospital all-cause mortality (HR = 0.85; 95%CI: 0.66,1.10) were similar between treatment groups. Sensitivity and stratified analyses found similar null results. CCP-treated patients were less likely to be discharged alive (HR = 0.82; 95%CI: 0.74, 0.91), and more likely to receive mechanical ventilation (HR = 1.48; 95%CI: 1.12, 1.96). Safety outcomes were rare and similar between treatment groups.ConclusionThe findings in this large, matched cohort of patients hospitalized with COVID-19 and mostly requiring oxygen support at the time of treatment, do not support a clinical benefit in 28-day in-hospital all-cause mortality for CCP. Future studies should assess the potential benefits with specifically high-titer units in perhaps certain subgroups of patients (e.g. those with early disease or immunocompromised).

Staff pooling in healthcare systems – results from a mixed-methods study

ABSTRACT This study examines how staff pooling can be used to create a higher service level at a predetermined total capacity in the healthcare sector. We develop new empirical knowledge through a systematic empirical study, using a mixed-methods approach, with a preliminary interview study followed by a principal quantitative survey study, with data from a multihospital system. The purpose was to explore practical barriers for a staff pooling strategy in healthcare systems. Three barriers were identified:recruitment difficulties, community view, and specialisation. Significant differences in perceived height among these barriers were found. The results from this study have important managerial implications for healthcare systems when implementing a staff pooling approach. This study contributes to the existing literature since, to the best of our knowledge, no previous research has been done where barriers to staff pools are systematically identified using a holistic approach that includes all healthcare professions in a multihospital system.

Development of a universal thoracic enhanced recover after surgery protocol for implementation across a diverse multi-hospital health system.

BackgroundImplementation of enhanced recovery after surgery (ERAS) pathways for patients undergoing anatomic lung resection have been reported at individual institutions. We hypothesized that an ERAS pathway can be successfully implemented across a large healthcare system including different types of hospital settings (academic, academic-affiliated, community).MethodsAn expert panel with representation from each hospital within a healthcare system was convened to establish a thoracic ERAS pathway for patients undergoing anatomic lung resection and to develop tools and analytics to ensure consistent application. The protocol was translated into an order set and pathway within the electronic health record (EHR). Iterative implementation was performed with recording of the processes involved. Barriers and facilitators to implementation were recorded.ResultsDevelopment and implementation of the protocol took 13 months from conception to rollout. Considerable change management was needed for consensus and incorporation into practice. Facilitators of change included peer accountability, incorporating ERAS care elements into the EHR, and conducting case reviews with timely feedback on protocol deviations. Barriers included institutional cultural differences, agreement in defining mindful deviation from the ERAS protocol, lack of access to specific coded data, and resource scarcity caused by the COVID-19 pandemic. Support from the hospital system’s executive leadership and institutional commitment to quality improvement helped overcome barriers and maintain momentum.ConclusionsDevelopment and implementation of a health-system wide thoracic ERAS protocol for anatomic lung resections across a six-hospital health system requires a multidisciplinary team approach. Barriers can be overcome though multidisciplinary team engagement and executive leadership support.

Score that Snore: Proactive Nursing Identification of Obstructive Sleep Apnea in Surgical Patients

<h3>Introduction</h3> Surgical patients with undiagnosed Obstructive Sleep Apnea (OSA) are at an increased risk for post-operative complications of respiratory distress and over sedation. Early identification of undiagnosed OSA can mitigate future risks of post-operative adverse events. <h3>Identification of the problem</h3> In2020, 22% of RRT events occurring within 24 hours of transfer from PACU to inpatient units were related to over sedation and respiratory issues. Retrospective assessment of these patients indicate 50% would have a STOP BANG score of ≥ 3 (moderate to severe OSA risk) while 88% of these patients had no prior OSA diagnosis. Current practice excludes preoperative screening for OSA risks among surgical patients. <h3>EBP Question/Purpose</h3> <b>PICOquestion -</b> In adult surgical patients does a preoperative STOP BANG assessment to identify undiagnosed OSA compared to no assessment reduce post-operative rapid response (RRT) events of respiratory distress and over sedation? <b>Databases utilized</b> - PubMed, CINHAL <h3>Methods/Evidence</h3> Preoperative nurses assess patient risk for OSA using the STOP BANG questionnaire. Moderate to high-risk patients (STOP BANG score ≥ 3) are identified. Nurses notify providers prior to surgery. Post-operatively, PACU nurses implement interventions such as oxygenation, patient positioning, multimodal pain relief, and, if needed, extended monitoring in these moderate to high risk OSA patients. <h3>Significance of Findings/Outcomes</h3> Resultsare pending. Anticipate reduction in RRT events of respiratory distress and over sedation in postoperative patients transferred within 24 hours from PACU to inpatient units. Introduces new perioperative practice of proactive identification of pre-surgical patients with moderate to severe OSA risk which allows for intra-and post-operative interventions that prevent adverse events. Standardizes best practices in perioperative services across multi-hospital healthcare system. <h3>Implications for perianesthesia nurses and future research</h3> Proactive early identification of high risk undiagnosed OSA patients by preoperative nurses can ensure coordinated medical and nursing interventions at all stages of the perioperative process.

Resident assistant training level is not associated with patient spinal fusion outcomes

ObjectiveA hallmark of surgical training is resident involvement in operative procedures. While resident-assisted surgeries have been deemed generally safe, few studies have rigorously isolated the impact of resident post-graduate year (PGY) level on post-operative outcomes in a neurosurgical patient population. The objective of this study is to evaluate the relationship between resident training level and outcomes following single-level, posterior-only lumbar fusion, after matching on key patient demographic/clinical characteristics and attending surgeon. Patients and methodsThis coarsened-exact matching (CEM) study analyzed 2338 consecutive adult patients who underwent single-level lumbar fusion with a resident assistant surgeon at a multi-hospital university health system from 2013 to 2019. Primary outcomes were 30-day and 90-day readmissions, Emergency Department (ED) visits, reoperations, surgical complications, and mortality. First, univariate logistic regression examined the relationship between PGY level and outcomes. Then, CEM was used to control for key patient characteristics – such as race and comorbid status – and supervising attending surgeon, between the most junior (PGY-2)-assisted cases and the most senior (PGY-7)-assisted cases, thereby isolating the relationship between training level and outcomes. ResultsAmong all patients, resident training level was not associated with risk of adverse post-surgical outcomes. Similarly, between exact-matched cohorts of PGY-2- and PGY-7-assisted cases, no significant differences in adverse events or discharge disposition were observed. Patients with the most senior resident assistant surgeons demonstrated longer length of stay (mean 100.5 vs. 93.8 h, p = 0.022) and longer duration of surgery (mean 173.5 vs. 159.8 min, p = 0.036). ConclusionTraining level of the resident assistant surgeon did not impact adverse outcomes provided to patients in the setting of single-level, posterior-only lumbar fusion. These findings suggest that attending surgeons appropriately manage cases with resident surgeons at different levels of training.

Alteplase for the treatment of midline catheter occlusions: a retrospective, single-cohort descriptive study.

Despite the increasing popularity of midline catheters, data on the use of alteplase for restoring midline catheter patency is scarce. This study aimed to evaluate off-label use of alteplase for midline catheter occlusions. Adults who received alteplase into a midline catheter between January 2015 and May 2018 within a multi-hospital health system were included in this study. The primary outcome was restoration of infusion or withdrawal function from at least one lumen of a treated midline catheter. Following alteplase administration, withdrawal function was restored in 47% (25/53) of occlusion events, infusion function was restored in 65% (11/17) of complete occlusion events, and infusion or withdrawal function was restored in 58% (31/53) of occlusion events. Only 34% (17/50) of catheters were replaced because of malfunction. Local bleeding was documented in 9% (n=5) of occlusion events after alteplase administration. Most midline catheter occlusions treated with alteplase demonstrated restoration of infusion or withdrawal function.

Effect of a Perinatal Clinical Decision Support System on the Incidence and Management of Uterine Tachysystole

A multihospital community health care system installed and implemented a new perinatal clinical decision support software program in October 2020. This system included artificial intelligence to assess uterine contractions and to display an alert if uterine tachysystole (UT; more than five contractions in a 10-minute period averaged over 30 minutes) was detected. Only one study was identified in the literature that demonstrated that the rate of UT decreased after implementation of this perinatal system.

Risk of Closure Among Independent and Multihospital-Affiliated Rural Hospitals

The increase in rural hospital closures has strained access to inpatient care in rural communities. It is important to understand the association between hospital system affiliation and access to care in these communities to inform policy on this issue. To examine the association between affiliation and rural hospital closure. This cohort study used survival models with a time-dependent variable for affiliation vs independent status to assess risk of closure among a national cohort of US rural hospitals from January 2007 through December 2019. Data analysis was conducted from March to October 2021. Hospital affiliations were identified from the American Hospital Association Annual Survey and Irving Levin Associates and closures from the University of North Carolina Sheps Center (Chapel Hill). Additional covariates came from the Healthcare Cost and Utilization Project State Inpatient Databases and other national sources. Affiliation with another hospital or multihospital health system. Closure was the main outcome. The models included hospital, market, and utilization characteristics and were stratified by financial distress in 2007. Among 2237 rural hospitals operating in 2007, 140 (6.3%) had closed by 2019. The proportion of rural hospitals that were independent decreased from 68.9% in 2007 to 47.0% in 2019; the proportion that were affiliated increased from 31.1% to 46.7%. Among financially distressed hospitals in 2007, affiliation was associated with lower risk of closure compared with being independent (adjusted hazard ratio [aHR], 0.49; 95% CI, 0.26-0.92). Conversely, among hospitals that were financially stable in 2007, affiliation was associated with higher risk of closure compared with being independent (aHR, 2.36; 95% CI, 1.20-4.62). For-profit ownership was also strongly associated with closure for hospitals that were financially stable in 2007 (aHR, 4.08; 95% CI, 1.86-8.97). The results of this cohort study suggest that affiliations may be associated with lower risk of closure for some rural hospitals in financial distress. However, among initially financially stable hospitals, an increased risk of closure for hospitals associated with affiliation and proprietary ownership raises concerns about the association of affiliation with closures in some circumstances. Policy interventions to stabilize inpatient care in rural areas should account for these findings.