Patient Refined Diagnosis Related Group Research Articles

Severity of illness and risk of mortality from all patient refined-diagnosis related groups: Two scales of different concepts or two sides of the same coin?

All patient refined-diagnosis related groups (APR-DRGs) includes severity of illness (SOI) and risk of mortality (ROM) subclasses. For predictions, both subscales are used together or interchangeably. We aimed to compare SOI and ROM by evaluating the reliability and agreement between both. We performed a retrospective observational study using mainland Portuguese public hospitalisations of adult patients from 2011 to 2016. Reliability (quadratic weighted kappa) and agreement (proportion of agreement) between SOI and ROM were analysed overall and by APR-DRG. While overall reliability and agreement between SOI and ROM were high (weighted kappa: 0.717, 95% CI 0.717-0.718; proportion of agreement: 69.0%, 95% CI 69.0-69.0) there was high heterogeneity across APR-DRGs, ranging from 0.016 to 0.846 on reliability and from 23.1% to 94.8% on agreement. Most of APR-DRGs (263 out of 284) showed a higher proportion of episodes with ROM level above the SOI level than the opposite. In conclusion, SOI and Risk of Mortality measures must be clearly distinguished and are 'two scales of different concepts' rather than 'two sides of the same coin'. However, this is more evident for some APR-DRGs than for others.

The economic cost of not coding disease-related malnutrition: A study in cancer inpatients

Disease-related malnutrition (DRM) coding rate is usually low in hospitalised patients. The objective of our study was to estimate the percentage of correct DRM coding in cancer inpatients and to calculate the economic losses caused by such lack of coding. This was an observational, prospective study that was conducted in patients hospitalised in the Medical Oncology Unit of our hospital. A nutritional assessment was performed through subjective global assessment (SGA). The all patient refined-diagnosis related group (APR-DRG) weights were obtained at the moment of discharge; moreover, recalculation was done after including the diagnosis of malnutrition in the medical record of those patients in whom it had not been initially coded. The associated cost reimbursement were calculated based on the weight before and after revising the diagnosis of DRM. A total of 266 patients were evaluated. From them, 220 (82.7%) suffered from DRM according to the SGA. In 137 (51.5%) of these patients, diagnosis was coded, as opposed to 83 (31.2%) cases (33 subjects with moderate and 50 with severe DRM) in whom it was not coded. The sum of the APR-DRG weights before revising the diagnosis of malnutrition was 343.4 points (mean: 1.29±0.89). Whereas, after revising the diagnosis, it increased up to 384.3 (1.44±0.96). The total cost reimbursement for the hospital before revising the diagnosis of malnutrition was 1,607,861.21€ and after revision it increased up to 1,799,199.69€, which means that 191,338.48€ were not reimbursed to the hospital due to the lack of coding of malnutrition. The cost reimbursement for each admission increased an average of 719.32€. The prevalence of DRM in cancer inpatients is high. Nevertheless, the diagnosis is not coded in one third of patients, which results in important economic losses for the hospitals.

The important role of immunization in alcoholic and non-alcoholic chronic liver disease: A population-based study.

To determine differences in frequencies of vaccine-preventable diseases between alcoholic liver disease (ALD) and non-alcoholic liver disease (NALD) patients. This population-based cohort study used USA national inpatient sample ICD-9 codes from January 2012 to September 2015. Frequencies of admissions for ALD and NALD in patients with pneumococcal pneumonia, influenza, herpes zoster virus, varicella zoster virus, hepatitis A, hepatitis B, human papilloma virus, meningococcal meningitis, diphtheria, pertussis and tetanus were measured. Frequencies and patients' characteristics were compared for ALD and NALD using χ2 test and multivariate logistic regression analysis. There was no difference in admissions for hepatitis A and pneumococcal pneumonia between the ALD and NALD groups. There were fewer admissions for hepatitis B (1.17% vs 1.80%, odds ratio [OR] 0.64, P < 0.01), herpes zoster (0.12% vs 0.17%, OR 0.69, P < 0.01), influenza (0.16% vs 0.26%, OR 0.59, P < 0.01) and all others (0.005% vs 0.015%, OR 0.36, P = 0.01) in the ALD group than the NALD group. The extreme all patient refined-diagnosis related groups mortality risk was 15.24% in ALD and 7.77% in NALD admissions (P < 0.0001). The most frequent vaccine-preventable disease in both groups was hepatitis B. Patients with NALD had higher odds of admissions for hepatitis B, herpes zoster virus, influenza and other vaccine-preventable disease than ALD patients. However, the ALD group had a higher risk of mortality when admitted to hospital with a vaccine-preventable disease than the NALD group.

Trends in Use of Advanced Imaging in Pediatric Emergency Departments, 2009-2018

There is increased awareness of radiation risks from computed tomography (CT) in pediatric patients. In emergency departments (EDs), evidence-based guidelines, improvements in imaging technology, and availability of nonradiating modalities have potentially reduced CT use. To evaluate changes over time and hospital variation in advanced imaging use. This cross-sectional study assessed 26 082 062 ED visits by children younger than 18 years from the Pediatric Health Information System administrative database from January 1, 2009, through December 31, 2018. Imaging. The primary outcome was the change in CT, ultrasonography, and magnetic resonance imaging (MRI) rates from January 1, 2009, to December 31, 2018. Imaging for specific diagnoses was examined using all patient-refined diagnosis related groups. Secondary outcomes were hospital admission and 3-day ED revisit rates and ED length of stay. There were a total of 26 082 062 visits by 9 868 406 children (mean [SD] age, 5.59 [5.15] years; 13 842 567 [53.1%] male; 9 273 181 [35.6%] non-Hispanic white) to 32 US pediatric EDs during the 10-year study period, with 1 or more advanced imaging studies used in 1 919 283 encounters (7.4%). The proportion of ED encounters with any advanced imaging increased from 6.4% (95% CI, 6.2%-6.2%) in 2009 to 8.7% (95% CI, 8.7%-8.8%) in 2018. The proportion of ED encounters with CT decreased from 3.9% (95% CI, 3.9%-3.9%) to 2.9% (95% CI, 2.9%-3.0%) (P < .001 for trend), with ultrasonography increased from 2.5% (95% CI, 2.5%-2.6%) to 5.8% (95% CI, 5.8%-5.9%) (P < .001 for trend), and with MRI increased from 0.3% (95% CI, 0.3%-0.4%) to 0.6% (95% CI, 0.6%-0.6%) (P < .001 for trend). The largest decreases in CT rates were for concussion (-23.0%), appendectomy (-14.9%), ventricular shunt procedures (-13.3%), and headaches (-12.4%). Factors associated with increased use of nonradiating imaging modalities included ultrasonography for abdominal pain (20.3%) and appendectomy (42.5%) and MRI for ventricular shunt procedures (17.9%) (P < .001 for trend). Across the study period, EDs varied widely in the use of ultrasonography for appendectomy (median, 57.5%; interquartile range [IQR], 40.4%-69.8%) and MRI (median, 15.8%; IQR, 8.3%-35.1%) and CT (median, 69.5%; IQR, 54.5%-76.4%) for ventricular shunt procedures. Overall, ED length of stay did not change, and hospitalization and 3-day ED revisit rates decreased during the study period. This study found that use of advanced imaging increased from 2009 to 2018. Although CT use decreased, this decrease was accompanied by a greater increase in the use of ultrasonography and MRI. There appears to be substantial variation in practice and a need to standardize imaging practices.

Importance of coding co-morbidities for APR-DRG assignment: Focus on cardiovascular and respiratory diseases.

The All Patient-Refined Diagnosis-Related Groups (APR-DRGs) system has adjusted the basic DRG structure by incorporating four severity of illness (SOI) levels, which are used for determining hospital payment. A comprehensive report of all relevant diagnoses, namely the patient's underlying co-morbidities, is a key factor for ensuring that SOI determination will be adequate. In this study, we aimed to characterise the individual impact of co-morbidities on APR-DRG classification and hospital funding in the context of respiratory and cardiovascular diseases. Using 6 years of coded clinical data from a nationwide Portuguese inpatient database and support vector machine (SVM) models, we simulated and explored the APR-DRG classification to understand its response to individual removal of Charlson and Elixhauser co-morbidities. We also estimated the amount of hospital payments that could have been lost when co-morbidities are under-reported. In our scenario, most Charlson and Elixhauser co-morbidities did considerably influence SOI determination but had little impact on base APR-DRG assignment. The degree of influence of each co-morbidity on SOI was, however, quite specific to the base APR-DRG. Under-coding of all studied co-morbidities led to losses in hospital payments. Furthermore, our results based on the SVM models were consistent with overall APR-DRG grouping logics. Comprehensive reporting of pre-existing or newly acquired co-morbidities should be encouraged in hospitals as they have an important influence on SOI assignment and thus on hospital funding. Furthermore, we recommend that future guidelines to be used by medical coders should include specific rules concerning coding of co-morbidities.

Use of Intravenous Immunoglobulin G in HIT: Impact on Thrombosis and Mortality in a Population-Based Study

Introduction: Heparin-induced thrombocytopenia (HIT) is a severe prothrombotic syndrome with a mortality rate of 10% (Lancet Haematol. 2018 May; 5(5):e220-e231). Case reports show that Intravenous Immunoglobulin G (IVIg) can rapidly and durably counteract HIT antibody-mediated platelet activation in the setting of severe persistent HIT (Chest. 2017 Sep;152(3):478-485 and others). While this data supports use of IVIg in severe HIT, it is well documented that “positive result bias” enhances the likelihood of publication of studies that demonstrate salutary effects of interventions. IVIg has a black box warning for thrombosis which lists a number of potential predisposing states for this complication including hypercoagulable conditions (such as HIT). Thus, one concern is that of new/worsening thrombosis in HIT patients treated with this drug, something that is not evaluable with the limited publications in this area. The Nationwide Inpatient Sample (NIS) is the largest publicly available patient discharge database in the US that includes ~7 million discharges per year representative of discharges from all hospital types in the country. The goal of this study was to evaluate thrombosis, bleeding and mortality outcomes associated with IVIg use in HIT using the NIS database.Methods: Hospital discharges with an ICD-9-CM code for HIT (289.84) in the NIS were used to compare outcomes in adult patients (≥18yrs) who did and did not receive IVIg treatment (ICD-9-CM code 99.14) from October 1, 2008 to December 31, 2014. Discharges with diagnoses suggestive of a history of thrombosis (ICD-9-CM codes V12.51, V12.52, V12.55), idiopathic thrombocytopenic purpura (287.31), or secondary thrombocytopenia (287.4) were excluded. Patient characteristics included age, sex, all patient refined diagnosis related groups (APR-DRG) severity index, and APR-DRG mortality index. Outcomes included arterial thrombosis, venous thrombosis, bleeding, mortality, and a composite of all outcomes. Variables were compared by IVIg treatment status using survey weighted Chi-squared tests for categorical variables and ANOVA for continuous variables. Survey weighted multiple logistic regression was used to model each binary outcome by IVIg treatment status while adjusting for age, gender, APR-DRG severity index and mortality index. A matched analysis was performed as a sensitivity analysis for the multiple logistic regression results. Controls were matched with IVIg cases by exact gender, APRDRG severity index, and mortality index. Five matching controls were selected for each case based on nearest age. Conditional logistic regression was used to analyze each outcome using the matched dataset.Results: HIT patients treated with IVIg and those without were no different in age and sex (Table 1). Consistent with the limited published experience of IVIg use in HIT, those who received IVIg had more severe disease with greater likelihood of dying as indicated by their APR-DRG severity and mortality indices (Table 1). Multiple logistic regression showed that the adjusted odds ratio (aOR) was lower for all outcomes except bleeding in the IVIg-treated group, although this did not reach statistical significance (Fig 1; aOR of 0.766, 0.922, 1.049, 0.685 and 0.703 for arterial thrombosis, venous thrombosis, bleeding, death and composite outcome, respectively). Similar results were obtained in conditional logistic regression of matched data (Fig 2).Conclusions: Use of IVIg was not associated with worse thrombotic outcomes or mortality in HIT. On the contrary, results suggest a possible protective effect on these outcomes, but results did not achieve statistical significance possibly due to small numbers of IVIg-treated patients. The aOR was higher (but not significantly so) for bleeding in IVIg-treated HIT patients, however, this finding is consistent with the possibility that IVIg was used more frequently in patients who had more severe disease (and had already hemorrhaged), as suggested by worse APR-DRG severity and mortality indices in IVIg-treated patients. A prospective randomized treatment study may be necessary to provide conclusive data on IVIg efficacy and risk in HIT. [Display omitted] DisclosuresDhakal:Amgen: Honoraria; Celgene: Consultancy, Honoraria; Takeda: Honoraria. Aster:BloodCenter of Wisconsin: Patents & Royalties. Padmanabhan:Janssen Pharmaceuticals: Consultancy; GE Healthcare: Other: Material support for Clinical Quality Improvement Initiative; Retham Technologies LLC: Equity Ownership, Other: Retham seeks to develop HITDx(TM), a new assay for HIT diagnosis; BloodCenter of Wisconsin: Patents & Royalties: Patent/royalties for HIT diagnostic testing; Veralox Therapeutics: Other: Advisory Board; TerumoBCT: Consultancy.

Abstract WMP33: Real-World Clinical Outcomes of Ruptured Intracranial Arterial Aneurysm Treatment

Introduction: Comparison of real world clinical outcomes between clipping and coiling for ruptured aneurysm is challenging, mainly due to confounding case severity and variation in physician expertise. We sought to compare outcomes and costs of coiling and clipping by utilizing a large national database. Methods: Ruptured intracranial aneurysm patients age 18 to 86 years were identified from the National Inpatient Sample (NIS) from 2007 to 2013. The clinical outcomes evaluated were in-hospital mortality, in-hospital stroke, discharge destination and other complications. Also, the total hospitalization cost was compared. Multivariate logistic regression and propensity-score matching were used. Confounding factors such as specific neurovascular comorbidities (e.g. hypertension, diabetes), Charleson comorbidity index (CCI), all patient refined diagnosis related group (APR-DRG) risk of mortality, APR-DRG severity index, and NIS-SAH severity score were also controlled for. Results: 14379 patients with ruptured intracranial arterial aneurysms were identified (5966 clipping, 8413 coiling). Univariate analysis showed that coiling patients had higher preprocedural risks by CCI (p &lt; 0.001) and APR-DRG mortality (p&lt;0.001). Multivariate analysis showed no difference in in-house mortality (OR 0.96, p = 0.60), but coiling showed lower in-house strokes (OR 0.67, p &lt; 0.001) and more discharge to a rehabilitation facility (OR 0.63, p&lt;0.001). Coiling patients had higher odds of a hematoma (OR 1.44, p = 0.09) and hydrocephalus requiring treatment (OR 1.55, p&lt;0.01), but lower odds of requiring a blood transfusion (OR 0.52, p&lt;0.01). Analysis over time showed that in-house mortality has decreased over time (p=0.01) in coiling patients, but mortality after clipping has not changed. Coiling was slightly more expensive, but the difference was not significant ($2267, p=0.13). Conclusions: After adjusting for severity, there was no significant difference in mortality between coiling and clipping in ruptured aneurysm treatment. However, coiling patients had a lower chance of an in-hospital stroke and a higher chance of being discharged home. A limitation of the study is the possibility of unmeasured confounders.

Patient autonomy–centered self-care checklist reduces hospital readmissions after ileostomy creation

Patients who undergo a colorectal operation that includes a new ileostomy incur high rates of readmission. Ostomates face a steep learning curve to master the skills and knowledge needed for success at home. We designed and implemented a patient-centered checklist promoting independence and validating self-care knowledge and care skills and evaluated its effect on readmissions after ileostomy creation. On a single inpatient unit, new ileostomy patients were taught and evaluated using a novel postoperative self-care checklist, while perioperative care for ostomates remained unchanged elsewhere in the institution. In a retrospective cohort including all consecutive ileostomy patients from 2years before (period 1) and 1year after (period 2) the checklist implementation, we identified univariable predictors of readmission within 30days of discharge and used a multivariable, difference-in-differences approach to compare trends in readmission between the intervention and control units. Of the 430 patients in the study period, there were 116 with readmissions (26%). Readmitted patients had significantly greater all patient refined diagnosis related group weights (3.6 vs 3.3, P=.006) and longer initial duration of stay (13.3 vs 11.3days, P=.006), and they were more likely to be emergency admissions (49% vs 38%, P=.04). The readmission rate on the intervention unit decreased from 28% in period 1 to 20% in period 2. The logistic regression-based difference-in-differences approach revealed that implementation of the checklist was an independent negative predictor of readmission (P=.04). Implementation of a patient-centered, self-care-oriented postoperative education checklist was associated with significantly reduced odds of readmission after ileostomy creation.

Younger and Sicker: Comparing Micronesians to Other Ethnicities in Hawaii.

We compared the age at admission and the severity of illness of hospitalized Micronesians with 3 other racial/ethnic groups in Hawaii. With Hawaii Health Information Corporation inpatient data, we determined the age at admission and the severity of illness for 162,152 adult, non-pregnancy-related hospital discharges in Hawaii from 2010 to 2012. We performed multivariable linear regression analyses within major disease categories by racial/ethnic group. We created disease categories with all patient refined-diagnosis related groups. Hospitalized Micronesians were significantly younger at admission than were comparison racial/ethnic groups across all patient refined-diagnosis related group categories. The severity of illness for Micronesians was significantly higher than was that of all comparison racial/ethnic groups for cardiac and infectious diseases, higher than was that of Whites and Japanese for cancer and endocrine hospitalizations, and higher than was that of Native Hawaiians for substance abuse hospitalizations. Micronesians were hospitalized significantly younger and often sicker than were comparison populations. Our results will be useful to researchers, state governments, and hospitals, providers, and health systems for this vulnerable group.

Rising United States Hospital Admissions for Acute Bacterial Skin and Skin Structure Infections: Recent Trends and Economic Impact.

BackgroundThe number of ambulatory patients seeking treatment for skin and skin structure infections (SSSI) are increasing. The objective of this study is to determine recent trends in hospital admissions and healthcare resource utilization and identify covariates associated with hospital costs and mortality for hospitalized adult patients with a primary SSSI diagnosis in the United States.MethodsWe performed a retrospective cross-sectional analysis (years 2005–2011) of data from the US Healthcare Cost and Utilization Project National Inpatient Sample. Recent trends, patient characteristics, and healthcare resource utilization for patients hospitalized with a primary SSSI diagnosis were evaluated. Descriptive and bivariate analyses were conducted to assess patient and hospital characteristics.ResultsA total of 1.8% of hospital admissions for the years 2005 through 2011 were for adult patients with a SSSI primary diagnosis. SSSI-related hospital admissions significantly changed during the study period (P < .001 for trend) ranging from 1.6% (in 2005) to 2.0% (in 2011). Mean hospital length of stay (LOS) decreased from 5.4 days in the year 2005 to 5.0 days in the year 2011 (overall change, P < .001) with no change in hospital costs. Patients with postoperative wound infections had the longest hospital stays (adjusted mean, 5.81 days; 95% confidence interval (CI), 5.80–5.83) and highest total costs (adjusted mean, $9388; 95% CI, $9366-$9410). Year of hospital admission was strongly associated with mortality; infection type, all patient refined diagnosis related group severity of illness level, and LOS were strongly associated with hospital costs.ConclusionsHospital admissions for adult patients in the United States with a SSSI primary diagnosis continue to increase. Decreasing hospital inpatient LOS and mortality rate may be due to improved early treatment. Future research should focus on identifying alternative treatment processes for patients with SSSI that could shift management from inpatient to outpatient treatment settings.

Variability of nursing care by APR-DRG and by severity of illness in a sample of nine Belgian hospitals.

BackgroundAs soon as Diagnosis related Groups (DRG) were introduced in many hospital financing systems, most nursing research revealed that DRG were not very homogeneous with regard to nursing care. However, few studies are based on All Patient refined Diagnosis related Groups (APR-DRGs) and few of them use recent data. Objectives of this study are: (1) to evaluate if nursing activity is homogeneous by APR-DRG and by severity of illness (SOI) (2) to evaluate the outlier’s rate associated with the nursing activity and (3) to compare nursing cost homogeneity per DRG and SOI.MethodsStudy done in 9 Belgian hospitals on a selection of APR-DRG with more than 30 patients (7 638 inpatient stays). The evaluation of the homogeneity is based on coefficients of variation (CV). The 75th percentile + 1.5 × inter-quartile range was used to select high outliers. 25th percentile −1.5 × inter-quartile range was used to select low outliers. Nursing costs per ward were distributed on inpatient stays of each ward following two techniques (the LOS vs. the number of nursing care minutes per stay).ResultsThe homogeneity of LOS by DRG and by SOI is relatively good (CV: 0.56). The homogeneity of the nursing activity by DRG is less good (CVs between 0.36 and 1.54) and is influenced by nursing activity outliers (high outliers’ rate: 5.19%, low outliers’ rate: 0.14%). The outlier’s rate varies according to the studied variable. The high outliers’ rate is higher for nursing activity than for LOS. The homogeneity of nursing costs is higher when costs are based on the LOS of patients than when based on minutes of nursing care (CVs between 0.26 and 1.46 for nursing costs based on LOS and between 0.49 and 2.04 for nursing costs based on minutes of nursing care).ConclusionsIt is essential that the calculation of nursing cost by stay and by DRG for hospital financing purposes was based on nursing activity data, that more reflect resources used in wards, and not on LOS data. The only way to obtain this information is the generalization of computerized nursing files.

Abstract 19554: Cardiologist Involvement in Heart Failure Hospitalizations is Associated with Reduced Rates of Readmissions and Increased Severity of Illness

Background: Congestive Heart Failure (CHF) is the most common cause for hospital readmission in patients over the age of 65 years. Whereas, efforts to reduce readmission rates have focused on transitions of care and short-term outpatient follow-up, limited data exist on the impact of specialist care during the index admission in reducing readmission rates. Methods: All CHF admissions between January 1, 2009 and December 31, 2011 were identified retrospectively by primary discharge codes. Patient demographics, length of stay (LOS), time to readmission, all patient refined diagnosis related groups (APRDRG), hospital attending at time of discharge, and total hospital costs were abstracted and analyzed based on the attending provider at discharge. Because traditional methods for standardization/transformation of data were insufficient to adjust for patient APRDRG, bootstrapping was employed. Results: Among 2311 patients (median age 75, 49.9% male), 1505 (65%) patients were treated by a Hospitalist attending, whereas, the remaining 808 (35%) patients were treated by a Cardiologist attending. 535 (23.2%) patients were readmitted within 30 days of discharge. Readmission rates were significantly lower when the attending was a cardiologist as compared to a hospitalist (16.0% [95% CL: 12.3%, 20.8%] vs. 27.1% [95% CL: 24.9%, 29.4%]; p&lt;0.001). The APRDRG geometric mean for patients with a cardiologist either as consultant or attending was 1.80 (95% CL: 1.74, 1.87) and 1.02 (95% CL: 0.98, 1.05) for those without (p&lt;0.001), indicating cardiologists were seeing higher severity cases. Median LOS was similar between attending cardiologists and hospitalists (4.8 days vs. 4.2 days; p=0.60). Adjusting for APRDRG, mean total costs for patients treated by a cardiologist were higher than those treated by a hospitalist ($9850 [95% CL: $9614, $10093] vs. $7741 [95% CL: $7560, $7926]; p&lt;0.001). Conclusions: Reduced rates of hospital readmissions despite an increased severity of illness among patients with a cardiologist as the attending compared to those with a hospitalist attending highlights the value of specialized care in heart failure treatment. Additionally, total costs for patients treated by cardiologists are likely over-stated due to interventional charges.

Effect of Reduced Vancomycin Susceptibility on Clinical and Economic Outcomes in Staphylococcus aureus Bacteremia

Reduced vancomycin susceptibility (RVS) may lead to poor clinical outcomes in Staphylococcus aureus bacteremia. The objective of this study was to evaluate the clinical and economic impact of RVS in patients with bacteremia due to S. aureus. A cohort study of patients who were hospitalized from December 2007 to May 2009 with S. aureus bacteremia was conducted within a university health system. Multivariable logistic regression and zero-truncated negative binomial regression models were developed to evaluate the association of RVS with 30-day in-hospital mortality, length of stay, and hospital charges. One hundred thirty-four (34.2%) of a total of 392 patients had bacteremia due to S. aureus with RVS as defined by a vancomycin Etest MIC of >1.0 μg/ml. Adjusted risk factors for 30-day in-hospital mortality included the all patient refined-diagnosis related group (APRDRG) risk-of-mortality score (odds ratio [OR], 7.11; 95% confidence interval [CI], 3.04 to 16.6), neutropenia (OR, 13.4; 95% CI, 2.46 to 73.1), white blood cell count (OR, 1.05; 95% CI, 1.01 to 1.09), immunosuppression (OR, 6.31; 95% CI, 1.74 to 22.9), and intensive care unit location (OR, 3.51; 95% CI, 1.65 to 7.49). In multivariable analyses, RVS was significantly associated with increased mortality in patients with S. aureus bacteremia as a result of methicillin-susceptible (OR, 3.90; 95% CI, 1.07 to 14.2) but not methicillin-resistant (OR, 0.53; 95% CI, 0.19 to 1.46) isolates. RVS was associated with greater 30-day in-hospital mortality in patients with bacteremia due to methicillin-susceptible S. aureus but not methicillin-resistant S. aureus. Further research is needed to identify optimal treatment strategies to reduce mortality associated with RVS in S. aureus bacteremia.

Dopamine and Dobutamine Use in Preterm or Low Birth Weight Neonates in the Premier 2008 Database

Background Dobutamine and dopamine are off-patent drugs prioritized by the National Institute of Child Health and Human Development and US Food and Drug Administration for further study under the Best Pharmaceuticals for Children Act. Both agents are used to manage cardiac insufficiency in preterm neonates and are subject to controversy among neonatologists. Among the controversies are outcome measures (blood pressure vs end organ perfusion) and long-term effects. Objectives We analyzed retrospective hospitalization data to (1) describe the use of dopamine and dobutamine in low birth weight (LBW) or preterm infants in a large sample and (2) explore the potential of using observational data to describe outcomes in LBW or preterm infants treated with dopamine or dobutamine. Methods Inpatient data were extracted from the Premier database to calculate the prevalence of use of dopamine and dobutamine among neonates in 2008. Prevalence of use was calculated by categorizing patients as ever or never having received dopamine or dobutamine. We compared mortality in the neonates by using Cox proportional hazards models to identify variables associated with survival and to control for their effects. Results Out of 877,201 pediatric hospitalizations in 2008, 65,216 were neonates and had data available about dopamine and dobutamine use. Of these, 7459 were preterm or LBW and included 1143 very LBW (VLBW) neonates. Dopamine alone was given to 194 VLBW neonates, dobutamine alone was given to 14, and both dopamine and dobutamine were given to 79 neonates. For the VLBW neonates, probability of treatment with dopamine or dobutamine varied almost 10-fold from 4.4% to 38.4% at 11 hospitals and did not differ by 3M APR-DRG (all patient refined diagnosis related group) severity of illness or 3M APR-DRG risk of mortality. Conclusions Our data suggest the prevalence of dopamine or dobutamine use was 4.9% in preterm or LBW neonates and 25.1% in VLBW neonates. Treatment with dopamine alone was more common than treatment with dobutamine alone. There was no difference in mortality between neonates treated with dopamine compared with treatment with dobutamine, but access to charts and clinical details are required to conduct a comparative effectiveness study.

The Use of Ambulatory Patient Groups for Regulation of Hospital Ambulatory Surgery Revenue in Maryland

The Maryland Health Services Cost Review Commission (HSCRC or the commission) is a government agency with the authority to establish rates for both inpatient and outpatient services for all general acute care hospitals in the state. By law and consistent with the state's unique Medicare waiver, all payers (including Medicare and Medicaid) must pay hospitals on the basis of these rates. The HSCRC has used diagnosis related groups to set case-mix-adjusted limits on the revenue per discharge for inpatient services (similar to Medicare inpatient prospective payment nationally) yet, the Maryland rate-setting system for outpatient services has not embodied incentives to control utilization of services. Beginning in the state's fiscal year 2008, the HSCRC is implementing regulation of ambulatory surgery services using ambulatory patient groups to provide better incentives to control utilization, and to facilitate comparisons of the case-mix-adjusted charges per ambulatory surgery case across hospitals. Maryland has been an innovator in the design and successful implementation of payment systems and other incentive mechanisms to constrain hospital cost, maintain payment equity, and ensure access to needed hospital care. The HSCRC's adoption of all patient refined diagnosis related groups and the hospital-specific relative value method for establishing diagnosis related group weights in 2005 was relevant to the Centers for Medicare and Medicaid Services' decision to move to Medicare severity diagnosis related groups beginning in federal fiscal year 2008, and to consider the use of hospital-specific relative value weights. The HSCRC's decision to use ambulatory patient groups for ambulatory surgery is an attempt to apply the most effective features of inpatient payment systems, prospective payment, including incentives to control service volumes. As such, it represents a radical departure from prevailing payment arrangements in that it seeks to remove the traditional distinction between inpatient and outpatient surgical services, a distinction that has blocked the development of effective and well-integrated outpatient payment systems for decades. This article describes the policy rationale for this system, the analysis that was performed, and the methods that will be used to control the revenue per case and compare the relative charges of the hospitals.

Prediction of mortality for congestive heart failure patients: results from different wards of an Italian teaching hospital.

Congestive heart failure (CHF) constitutes an important public health problem in Italy, evidenced by the high number of hospital admissions each year. Significant inter-hospital as well as interward differences in mortality rates for CHF patients that have been described may, in part, be explained by the differences in the severity of the illness of admitted patients. The goal of this study was to predict 30-day severity-adjusted mortality risk in patients with CHF admitted to wards of a teaching hospital in Siena, Italy, in 1997. A 30-day mortality was determined by linking hospital discharge files with the Tuscany Mortality Registry database. The 3M all patient refined diagnosis related group (APR-DRG) software was used as a risk assessment method. The relationships between death and the following variables were studied by univariate analyses: APR-severity risk, APR-mortality risk, age, sex, length of stay and, discharge ward. Multivariate analysis was also performed to verify the associations between death and those parameters found to be significant by univariate analysis. Unadjusted mortality proportions ranged from 4.3 to 44.0%. Logistic regression analysis demonstrated that APR-mortality risk, length of stay, and discharge ward were significantly and independently associated with 30-day mortality risk in patients with CHF. In summary, 30-day mortality risk varied significantly according to the ward of discharge in an Italian teaching hospital, even after adjustment for severity of illness.

Does considering severity of illness improve interpretation of patient satisfaction data?

With the emergence of new, relatively low-cost code-based severity indexes, this question arises: Do complex descriptions of patient population in terms of severity yield a clearer picture of patients' opinions about hospital care and service? Consumers and third-party payers of healthcare are using patient satisfaction data with increasing frequency to evaluate the quality of care that hospitals provide. Insurers also use satisfaction data, when they are available, for contracting and ensuring provider accountability. The study described here examines whether the all patient refined-diagnosis related groups (APR-DRG) severity-of-illness rating system, in particular, can explain the variability in inpatient satisfaction ratings independently of patient demographics and clinical events. Multiple logistic regression was used on a data set of 3,720 patient records from one tertiary care facility, and model terms were fitted on the basis of reason for admission, year, gender, length of stay, age, and severity. The findings were that age and reason for admission were consistent predictors of high satisfaction on 14 survey items. APR-DRG severity was not a significant factor. Length of stay made a small but significant contribution on three items related to clinical quality.