Surgical Diagnosis-related Groups Research Articles

Variation in the Reporting of Elective Surgeries and Its Influence on Patient Safety Indicators.

US hospital safety is routinely measured via Patient Safety Indicators (PSIs). Receiving a score for most PSIs requires a minimum number of qualifying cases to meet specific criteria; for example, whether an admission was elective. Because admission type is determined by hospitals' internal policies, the study team suspected that hospitals may be exempted from elective-based PSI scores as a result of their internal admission classification policies. Multiple regression was combined with machine learning to analyze Medicare inpatient claims data reported by 3,484 hospitals during the 2015-2017 PSI measurement period. The researchers examined the average percentage of elective admissions across surgical diagnosis-related groups (DRGs) (average percent elective [APE]) in relation to hospital characteristics, surgical claims volumes, and numbers and types of surgical DRGs. This study asked whether hospitals with exceptionally low APE shared particular characteristics, reported claims for similar DRGs, or were disproportionately exempted from elective-based PSIs. Cross-validated multiple regression explained 73.9% of variation in APE among hospitals and identified surgical claims volume and 16 surgical DRGs as consistently important variables. However, the exceptionally low APE of 96 hospitals could not be explained by surgical claims volume, surgical DRGs among claims, or hospital characteristics. These outliers were disproportionately exempt from elective-based PSI scores. Some hospitals may have classified admissions in a way that exempted them from elective-based PSI scores. Transparency into admission classification policies is needed to ensure fair and reliable use of PSIs when ranking hospitals and adjusting payments. Alternatively, PSIs may need modifications to rely on externally validated criteria.

Comparing Hospital Length of Stay Risk-Adjustment Models in US Value-Based Physician Payments.

Under the Affordable Care Act, the US Centers for Medicare & Medicaid Services created the Physician Value-Based Payment Modifier Program and its successor, the Merit-Based Incentive Payment System, to tie physician payments to quality and cost. The addition of hospital length of stay (LOS) to these value-based physician payment models reflects its increasing importance as a metric of health care cost and efficiency and its association with adverse health outcomes. This study compared the Centers for Medicare & Medicaid Services-endorsed LOS risk-adjustment methodology with a novel methodology that accounts for pre-hospitalization clinical, socioeconomic status (SES), and admission-related factors as influential factors of hospital LOS. Using the 2014 New York, Florida, and New Jersey State Inpatient Database, we compared the observed-to-expected LOS of 2373102 adult admissions for 742 medical and surgical diagnosis-related groups (DRGs) by 3 models: ( a ) current risk-adjustment model (CRM), which adjusted for age, sex, number of chronic conditions, Elixhauser comorbidity score, and DRG severity weight, ( b ) CRM but modeling LOS using a generalized linear model (C-GLM), and (c) novel risk-adjustment model (NRM), which added to the C-GLM covariates for race/ethnicity, SES, discharge destination, weekend admission, and individual intercepts for DRGs instead of severity weights. The NRM disadvantaged physicians for fewer medical and surgical DRGs, compared with both the C-GLM and CRM models (medical DRGs: 0.49% vs 13.17% and 10.89%, respectively; surgical DRGs: 0.30% vs 13.17% and 10.98%, respectively). In subgroup analysis, the NRM reduced the proportion of physician-penalizing DRGs across all racial/ethnic and socioeconomic groups, with the highest reduction among Whites, followed by low SES patients, and the lowest reduction among Hispanic patients. After accounting for pre-hospitalization socioeconomic and clinical factors, the adjusted LOS using the NRM was lower than estimates from the current Centers for Medicare & Medicaid Services-endorsed model. The current model may disadvantage physicians serving communities with higher socioeconomic risks.

Abstract TMP101: Preoperative Atrial Fibrillation And Risk Of Stroke After Noncardiac Surgery

Objective: To assess rates of postoperative stroke after elective noncardiac surgery in patients with atrial fibrillation (AF). Methods: We conducted a retrospective cohort study using all-payer administrative claims data on all non-federal hospitalizations and emergency department visits in 11 states between 2016 and 2018. We included patients hospitalized for elective noncardiac surgery, as defined by a surgical diagnosis related group and major diagnostic category codes. The exposure variable was preoperative AF. The outcome variable was ischemic stroke within 30 days of surgery. We performed survival analyses using Kaplan-Meier cumulative rates and Cox proportional hazards models. We stratified AF patients by their CHA 2 DS 2 -VASc score and tested its discrimination using the c-statistic. Results: We identified 1,301,709 patients undergoing elective noncardiac surgery, of whom 94,363 (7.3%) had preoperative AF. Patients with AF were older (mean age, 73 versus 62 years) and had higher CHA 2 DS 2 -VASc scores (mean score, 3.2 vs 2.2). We identified 2,893 patients with postoperative stroke. The cumulative rate of postoperative stroke was 0.65% (95% CI, 0.60-0.70%) in patients with AF vs 0.19% (95% CI, 0.18-0.20%) in patients without AF. After adjustment for demographics and vascular risk factors, AF was associated with a higher risk of postoperative stroke (HR, 1.7; 95% CI, 1.5-1.8). Among AF patients, the CHA 2 DS 2 -VASc score was a good predictor of postoperative stroke (AUC, 0.81; 95% CI, 0.79-0.83). Rates of postoperative stroke among AF patients ranged from <0.1% in those with a CHA 2 DS 2 -VASc score of 0-2 to 14% in those with a score of 8 (Figure). Conclusions: Patients with AF faced a heightened risk of postoperative stroke and this risk varied in proportion to the CHA 2 DS 2 -VASc score.

Economic analysis of the costs associated with Hidradenitis suppurativa at a German University Hospital.

Background and objectivesHidradenitis suppurativa (HS) significantly affects the patient`s quality of life and leads to multiple medical consultations. Aim of this study was to assess the utilization of medical care of HS patients.Patients and methodsAll patients presenting in 2017 for an outpatient, day patient and / or inpatient treatment with leading claim type HS at the Department of Dermatology, University Hospital Würzburg, were included. Primary outcome was the economic burden of HS patients, measured by resource utilization in €.ResultsThe largest share of the direct medical costs for HS were the inpatient costs with a leading surgical diagnosis-related group (DRG). Antiseptics were the predominant topical prescription. While doxycycline was the most frequently prescribed systemic therapy, adalimumab was the main cost driver. The difference between in-patient (€ 110.25) and outpatient (€ 26.34) direct non-medical costs was statistically significant (p < 0.001). With regards to indirect medical costs, a statistically significantly higher loss of gross value added (inpatient mean € 1,827.00; outpatient mean € 203.00) and loss of production (inpatient mean € 1,026.00; outpatient mean € 228.00) could be noted (p < 0.001), respectively.ConclusionsThe present study on disease-specific costs of HS confirms that the hospital care of patients with this disease is cost-intensive. However, the primary goal of physicians is not and should not be to save costs regarding their patients`treatment, but rather the premise to utilize the existing resources as efficient as possible. Reducing the use of costly therapeutics and inpatient stays therefore requires more effective therapy options with an improved cost-benefit profile.

Opioid prescribing on discharge to skilled nursing facilities.

Skilled nursing facility (SNF) residents are at increased risk for opioid-related harms. We quantified the frequency of opioid prescribing among patients discharged from an acute care hospital to SNFs. This was a retrospective cohort study among adult (≥18 years) inpatients discharged from a quaternary-care academic referral hospital in Portland, OR to a SNF between January 1, 2017 and December 31, 2018. Our primary outcome was receipt of an opioid prescription on discharge to a SNF. Our exposures included patient demographics (eg, age, sex), comorbid illnesses, surgical diagnosis related group (DRG), receiving opioids on the first day of the index hospital admission, and inpatient hospital length of stay. Among 4374 patients discharged to a SNF, 3053 patients (70%) were prescribed an opioid on discharge. Among patients prescribed an opioid, 61% were over the age of 65 years, 50% were male, and 58% had a surgical Medicare severity diagnosis related group (MS-DRG). Approximately 70% of patients discharged to a SNF were prescribed an opioid on discharge, of which 68% were for oxycodone, and 52% were for ≥90 morphine milligram equivalents per day. Surgical DRG, diagnoses of cancer or chronic pain, last pain score, and receipt of an opioid on first day of the index hospital admission were independently associated with being prescribed an opioid on discharge to a SNF. Opioids were frequently prescribed at high doses to patients discharged to a SNF. Efforts to improve opioid prescribing safety during this transition may be warranted.

PMU65 EVALUATION OF HOME HEALTH FOR PATIENTS ELIGIBLE FOR THE POST-ACUTE CARE TRANSFER POLICY

The CMS Post-acute Care Transfer (PACT) policy distributes payment across healthcare settings for patients with a shorter than average hospital length of stay (LOS) and specific Diagnosis Related Groups (DRG) who require post-acute care such as home health (HH). In 2018, patients were PACT eligible if they were discharged for any of the 280 PACT policy defined DRGs with an LOS shorter than the geometric mean for the DRG. To investigate the potential benefits of this policy, we assessed differences in re-admissions and healthcare costs between PACT eligible patients discharged to HH and those discharged to home with no home healthcare. Patients enrolled in Medicare Advantage with a PACT eligible discharge in 2018 were evaluated for this retrospective, claims analysis of a large national health plan. Index was the date of discharge. Patients with a claim for HH services within 7 days post-index comprised the HH group. Patients discharged to home with no claim for HH in the 90-day post-index period were the comparison group. Cox proportional-hazards models with an instrumental variable (hospital-level probability of HH referral) and adjustment for case-mix were used to assess all-cause readmissions post-index. Post-index total healthcare costs were modeled using generalized estimating equations fit to a gamma distribution. There were 3,753 HH patients and 13,342 home only patients in the study cohort. HH patients were older [mean age 71.7 (+/- 7) vs 70.8 (+/-9)], more frequently female (58.5%), with mostly surgical DRGs (85.4%). For HH patients, the risk of 30-day readmission was reduced by 60%, 60-day by 45% and 90-day by 37%. Healthcare costs were 11% lower for the HH group. For PACT eligible patients, the provision of additional healthcare services in the home setting was associated with fewer hospital re-admissions and reduced total healthcare costs, including costs of home health.

Bending the cost curve: time series analysis of a value transformation programme at an academic medical centre

BackgroundReducing costs while increasing or maintaining quality is crucial to delivering high value care.ObjectiveTo assess the impact of a hospital value-based management programme on cost and quality.DesignTime series analysis of...

Glaucoma in inpatient care in Germany in 2015

Analysis of structural characteristics of inpatient treatment of glaucoma in clinical units run by affiliated physicians and those run by hospital physicians in Germany are described. The frequency and distribution of glaucoma diagnoses as the main and secondary diagnosis at different departments and glaucoma diagnoses, number of cases, surgeries and procedures and patient characteristics of the four glaucoma-specific diagnosis-related groups (DRG) are presented. Secondary data analysis using the G‑DRG browser from 2015/2016 provided by the German Institute for Remuneration Systems in Hospitals. In 30% of the 156,524 cases glaucoma was classified as the main diagnosis, in 24% as secondary diagnosis in ophthalmological departments and 46% as secondary diagnosis in other departments. Primary open angle glaucoma was reported most frequently (40%), whilst non-ophthalmological departments mainly coded as "other" or "unspecified types of glaucoma". Glaucoma was coded in 20DRGs as the main diagnosis and in all ophthalmic DRGs as secondary diagnosis. The number of cases and procedures differed among the four glaucoma-specific DRGs (C06Z, C07A, C07B, C64Z), the diagnostic spectrum, however, was similar. Patients were mainly women, older and with few comorbidities or complications. The C64Z was mainly characterized by cases with "suspected glaucoma" and only conservative procedures. Only 6% of the glaucoma patients were treated in clinical units run by affiliated physicians. In contrast to units run by hospital physicians surgical DRGs and operations prevailed but the diagnostic spectrum and patient characteristics were not different. With 20% of the main diagnoses, glaucoma was highly relevant for inpatient ophthalmological care. Glaucoma as a secondary diagnosis was also common in other medical specialties, though no diagnostic differentiation was made here. Patients with glaucoma are mainly treated in clinical units run by hospital physicians. Nevertheless, patients of affiliated physicians showed the same characteristics.

A Dashboard for Monitoring Opioid-Related Adverse Drug Events Following Surgery Using a National Administrative Database.

Opioid-related adverse drug events (ORADEs) include a range of complications, from respiratory arrest to ileus and urinary retention. ORADEs correlate to morbidity, mortality, and increased costs. The Centers for Medicare & Medicaid Services database, which represents approximately 35% of hospital discharges. The authors searched for previously published ICD-9 codes that defined ORADEs. A group of surgical diagnosis-related groups (DRGs) were selected. Recurring queries were programmed using these ICD codes and DRGs and used to update an online dashboard. The dashboard presents an estimate of the burden of ORADEs to frontline clinicians and hospital leadership and allows users to compare local data on ORADEs rates to other hospitals. Users are able to refine their search by surgery type or ORADE type. An interface was created, using national administrative claims data, to allow hospitals to access their ORADEs and benchmark local data against national trends.

Reductions in Average Lengths of Stays for Surgical Procedures Between the 2008 and 2014 United States National Inpatient Samples Were Not Associated With Greater Incidences of Use of Postacute Care Facilities

Diagnosis-related group (DRG) based reimbursement creates incentives for reduction in hospital length of stay (LOS). Such reductions might be accomplished by lesser incidences of discharges to home. However, we previously reported that, while controlling for DRG, each 1-day decrease in hospital median LOS was associated with lesser odds of transfer to a postacute care facility (P = .0008). The result, though, was limited to elective admissions, 15 common surgical DRGs, and the 2013 US National Readmission Database. We studied the same potential relationship between decreased LOS and postacute care using different methodology and over 2 different years. The observational study was performed using summary measures from the 2008 and 2014 US National Inpatient Sample, with 3 types of categories (strata): (1) Clinical Classifications Software's classes of procedures (CCS), (2) DRGs including a major operating room procedure during hospitalization, or (3) CCS limiting patients to those with US Medicare as the primary payer. Greater reductions in the mean LOS were associated with smaller percentages of patients with disposition to postacute care. Analyzed using 72 different CCSs, 174 DRGs, or 70 CCSs limited to Medicare patients, each pairwise reduction in the mean LOS by 1 day was associated with an estimated 2.6% ± 0.4%, 2.3% ± 0.3%, or 2.4% ± 0.3% (absolute) pairwise reduction in the mean incidence of use of postacute care, respectively. These 3 results obtained using bivariate weighted least squares linear regression were all P < .0001, as were the corresponding results obtained using unweighted linear regression or the Spearman rank correlation. In the United States, reductions in hospital LOS, averaged over many surgical procedures, are not accomplished through a greater incidence of use of postacute care.

Readmissions to Different Hospitals After Common Surgical Procedures and Consequences for Implementation of Perioperative Surgical Home Programs.

We consider whether there should be greater priority of information sharing about postacute surgical resources used: (1) at skilled nursing facilities or inpatient rehabilitation hospitals to which patients are transferred upon discharge (when applicable) versus (2) at different hospitals where readmissions occur. Obtaining and storing data electronically from these 2 sources for Perioperative Surgical Home initiatives are dissimilar; both can be challenging depending on the country and health system. Using the 2013 US Nationwide Readmissions Database, we studied discharges of surgical diagnosis-related group (DRG) with US national median length of stay (LOS) ≥ 3 days and ≥ 10 hospitals each with ≥ 100 discharges for the Medicare Severity DRG. Nationwide, 16.15% (95% confidence interval [CI], 15.14%-17.22%) of discharges were with a disposition of "not to home" (ie, transfer to a skilled nursing facility or an inpatient rehabilitation hospital). Within 30 days, 0.88% of discharges (0.82%-0.95%) were followed by readmission and to a different hospital than the original hospital where the surgery was performed. Among all discharges, disposition "not to home" versus "to home" was associated with greater odds that the patient would have readmission within 30 days and to a different hospital than where the surgery was performed (2.11, 95% CI, 1.96-2.27; P < .0001). In part, this was because disposition "not to home" was associated with greater odds of readmission to any hospital (1.90, 95% CI, 1.82-1.98; P < .0001). In addition, among the subset of discharges with readmission within 30 days, disposition "not to home" versus "to home" was associated with greater odds that the readmission was to a different hospital than where the surgery was performed (1.20, 95% CI, 1.11-1.31; P < .0001). There was no association between the hospitals' median LOS for the DRG and the odds that readmission was to a different hospital (P = .82). The odds ratio per each 1 day decrease in the hospital median LOS was 1.01 (95% CI, 0.91-1.12). Departments and hospitals wishing to demonstrate the value of their Perioperative Surgical Home initiatives, or to calculate risk assumption contracts, should ensure that their informatics priorities include obtaining accurate data on resource use at postacute care facilities such as skilled nursing facilities. Although approximately a quarter of readmissions are to different hospitals than where surgery was performed, provided that is recognized, obtaining those missing data is of less importance.

Elderly patients hospitalized in the ICU in France: a population-based study using secondary data from the national hospital discharge database.

In the global context of population ageing, understanding and monitoring intensive care use by the elderly is a strategic issue. National-level data are needed to overcome sampling biases that often limit epidemiologic studies of the critically ill elderly. The objective of this study was to describe intensive care use for hospitalized elderly patients using secondary data from the French national hospital discharge database. Structured assessment of the national database coverage and accuracy; cross-sectional analysis of hospitalizations including at least one admission in an intensive care unit (ICU) for patients aged ≥ 80 years from 1 January to 31 December 2009. In 2009, people aged ≥ 80 years accounted for 5.4% of the population but 15.3% of the 215 210 adult hospitalizations involving intensive care in France. In this elderly group, the mean age was 84.0 (± 3.56) years, and 51.6% were male. In-hospital mortality was 33.9%. The median time spent in the ICU was 3 [interquartile range (IQR), 2-8] days, the median time spent in hospital was 14 (IQR, 8-24) days and 9% of hospitalizations ended by the patient's death involved intensive care. A surgical procedure was included in 43% of hospitalizations. Medical and surgical diagnosis-related group hospitalizations were characterized by significant differences in volume, mortality, ICU days and costs. There was marked clinical heterogeneity in the population of elderly patients hospitalized in the ICU. These data provide baseline information and prompt further studies comparing intensive care utilization across age groups, between countries and over time.

Hospital Burden and Gastrointestinal Surgery in Inflammatory Bowel Disease Patients in Italy: A Retrospective Observational Study

Despite recent advances in medical therapies for inflammatory bowel disease [IBD], little is known about their impact on inpatient management. Our objectives were to explore hospitalisation and surgery trends for all IBD patients in Italy at three time points over 7 years. National hospital discharge records were retrospectively reviewed for all admissions with a Crohn's disease [CD, 555*] or ulcerative colitis [UC, 556*] diagnosis in 2005, 2008, and 2011. Quantitative variables [mean, standard deviation] and categorical variables [frequencies] were described; comparison among admission-years was made by analysis of variance and chi-square tests. A multivariate logistic regression analysis was performed to identify predictors of surgery risk regarding demographics, inpatient management, and clinical features; p-values ≤ 0.05 were considered statistically significant. Overall, 109657 hospitalisations occurred over the 3 years, with a decreasing trend observed in UC admissions. Mean age was higher in UC [50.1±19.7] than in CD [43.2±21.9]. The number of paediatric admissions rose from 3637 to 4372 between 2005 and 2011. An increasing proportion of CD [from 12.4% to 14.6%] and UC [from 5.8% to 8.0%] admissions reported a digestive system-related, surgical diagnosis-related group in the same period; overall, gastrointestinal surgical admissions increased from 3299 to 3964. In regression analysis, male gender, age, admission year, northern university hospital, disease localisation, and cancer as independent factors significantly affected the likelihood of surgery. Despite a reduction in total IBD hospitalisations, surgical and paediatric admissions rose over time. Further study is needed to clarify benefits associated with new drugs in terms of inpatient management.

Incidence of hospital-acquired pressure ulcers - a population-based cohort study.

Our study sought to estimate the association between race, gender, comorbidity and body mass index (BMI) on the incidence of hospital-acquired pressure ulcer (PU) from a population-based retrospective cohort comprising 242 745 unique patient hospital discharges in two fiscal years from July 2009 to June 2010 from 15 general and tertiary care hospitals. Cases were patients with a single inpatient encounter that led to an incident PU. Controls were patients without a PU at any encounter during the two fiscal years with the earliest admission retained for analysis. Logistic regression models quantified the association of potential risk factors for PU incidence. Spline functions captured the non-linear effects of age and comorbidity. Overall 2·68% of patients experienced an incident PU during their inpatient stay. Unadjusted analyses revealed statistically significant associations by age, gender, race, comorbidity, BMI, admitted for a surgical procedure, source of admission and fiscal year, but differences by gender and race did not persist in adjusted analyses. Interactions between age, comorbidity and BMI contributed significantly to the likelihood of PU incidence. Patients who were older, with multiple comorbidities and admitted for a surgical diagnosis-related groups (DRG) were at greater risk of experiencing a PU during their stay.

Hospital- and patient-related factors associated with differences in hospital antibiotic use: analysis of national surveillance results.

BackgroundSurveillance data of antibiotic use are increasingly being used for benchmarking purposes, but there is a lack of studies dealing with how hospital- and patient-related factors affect antibiotic utilization in hospitals. Our objective was to identify factors that may contribute to differences in antibiotic use.MethodsBased on pharmacy sales data (2006–2011), use of all antibiotics, all penicillins, and broad-spectrum antibiotics was analysed in 22 Health Enterprises (HEs). Antibiotic utilization was measured in World Health Organisation defined daily doses (DDDs) and hospital-adjusted (ha)DDDs, each related to the number of bed days (BDs) and the number of discharges. For each HE, all clinical specialties were included and the aggregated data at the HE level constituted the basis for the analyses. Fourteen variables potentially associated with the observed antibiotic use – extracted from validated national databases – were examined in 12 multiple linear regression models, with four different measurement units: DDD/100 BDs, DDD/100 discharges, haDDD/100 BDs and haDDD/100 discharges.ResultsSix variables were independently associated with antibiotic use, but with a variable pattern depending on the regression model. High levels of nurse staffing, high proportions of short (<2 days) and long (>10 days) hospital stays, infectious diseases being the main ICD-10 diagnostic codes, and surgical diagnosis-related groups were correlated with a high use of all antibiotics. University affiliated HEs had a lower level of antibiotic utilization than other institutions in eight of the 12 models, and carried a high explanatory strength. The use of broad-spectrum antibiotics correlated strongly with short and long hospital stays. There was a residual variance (30%–50% for all antibiotics; 60%–70% for broad-spectrum antibiotics) that our analysis did not explain.ConclusionsThe factors associated with hospital antibiotic use were mostly non-modifiable. By adjusting for these factors, it will be easier to evaluate and understand observed differences in antibiotic use between hospitals. Consequently, the inter-hospital differences can be more confidently acted upon. The residual variation is presumed to largely reflect prescriber-related factors.

Incidence and costs of bleeding-related complications in French hospitals following surgery for various diagnoses

BackgroundLimited information is available on the epidemiology and economics of bleeding during surgery in France.MethodThe objective of this study was to examine the incidence, costs and length of stay (LOS) of bleeding-related complications during various surgical procedures.A retrospective DRG (diagnosis-related group) analysis was conducted using the French National database PMSI (Programme Médicalisé des Systèmes d’Informations). Patients undergoing surgery during 2008 were identified according to their DRG classifications and those with at least one episode of secondary haemostasis and blood transfusion (according to French procedure codes) were designated as ‘with bleeding’ (WB). The analysis focussed on DRGs where ≥10% of patients presenting with bleeding and compared them to patients who did not require blood transfusions (i.e. without bleeding: WoB).Hospital LOS and costs (age and gender adjusted) were compared between WB and WoB patients within each DRG. Hospitalisation periods exceeding the LOS average (derived from the PMSI database) were compared using multivariate logistic regression adjusted for patient characteristics.ResultsAmongst all 88 different surgical DRGs recognised by the French database 24 (totalling 321,657 hospitalisations) yielded WB rates ≥10% (range 10.3–25.3%). The highest DRG rates were for transplantations, cardiac and major orthopaedic surgery, vascular and solid organ surgery.The average LOS for the WB population (adjusted for age, gender, number of procedures and secondary diagnoses) were 3.38 days (26.5%) longer than for the WoB population (p < 0.001). The average adjusted LOS costs for a WB patient were estimated at €12,087, and for a WoB patient €10,086 i.e. 19.9% higher than for WB patients (p < 0.001). The overall mean LOS was exceeded by 42.3% of WB patients compared to 37.0% of WoB patients (p < 0.001). Also, WB patients were more likely to exceed the average LOS than were WoB patients (Odds Ratio (OR) = 1.09, p < 0.001), after adjusting for patient characteristics.ConclusionsThe present study for France demonstrates a significant increase of hospital LOS and associated costs following post-surgical bleeding, supporting the need for blood conservation strategies.

Patient‐Centered Care for Older Adults with Multiple Chronic Conditions: These are the Polypathological Patients!

We read with interest the article of the American Geriatrics Society Expert Panel (AGSPE), describing patient-centered care for older adults with multiple chronic conditions (PMCs).1Within the population of PMCs, polypathological patients (PPs) stand out. This new notion has been introduced in the management of PMCs, arising from the needs of clinicians to approach the problems of PMC. PMCs are considered PPs when they have chronic diseases from two or more of eight predefined categories.2 These categories were established using criteria of established organ failure (independent of the primary disease), frequent chronic conditions with high mortality or the potential to become unstable, or frequent comorbidities when mental or functional impairment thresholds were definitively reached.2 The PPs constitute a homogenous population in terms of advanced age, complexity, high mortality, limited functionality, and vulnerability.2-4 These individuals probably reflect the same population that the AGSPE calls “older adults with multiple chronic conditions.” The homogeneity among these characteristics makes it clear that this new patient-centered notion of PP is solid and will make it possible to establish comprehensive intervention strategies designed for the main PP healthcare problems, as the expert panel suggests.1 This approach will become a cornerstone in the near future of most healthcare systems, because the effect of this population is not only qualitative, but quantitative as well. Hospital-based PP data from Andalusia (a region of southern Spain with 8,424,102 inhabitants) from 2000 to 2010 are detailed in Table 1 using the discharge information of the Minimum Basic Dataset from 33 Andalusian hospitals. Ten percent of the 6,286,704 discharges were PPs, with a continuous increase of this population over the study period.5 This increase was similar in medical and surgical Diagnosis-Related Groups (a system to classify hospital cases into one of originally 467 groups, to identify the “products” that a hospital provides), with a parallel increasing trend in discharges of older adults. Our data are concordant with those obtained in primary care settings 6 and reflect this emergent epidemiological–clinical paradigm to which clinicians, investigators, healthcare systems, and medical education institutions must attend. This is not an epidemic, but rather, at least in part, a social achievement as a result of previous generations' efforts, albeit an achievement that requires a deep adaptation of global healthcare systems. PP discharges, n (%) ≥3 categoriesaa ≥3,4, or 5 definitory categories of polypathological patients, this reflects the increasing complexity and disease's burden. , n (%) ≥4 categoriesaa ≥3,4, or 5 definitory categories of polypathological patients, this reflects the increasing complexity and disease's burden. , n (%) ≥5 categoriesaa ≥3,4, or 5 definitory categories of polypathological patients, this reflects the increasing complexity and disease's burden. , n (%) Conflict of Interest: The authors have no conflicts of interest to report. Author Contributions: All authors contributed substantially to the work. Sponsor's Role: No sponsor.

Venous Thromboembolism Prophylaxis in Surgical Patients: Identifying a Patient Group to Maximize Performance Improvement

Venous thromboembolism (VTE) in surgical patients is a cause of increased morbidity, mortality, and cost of care. Deep vein thrombosis (DVT) prophylaxis reduces the risk of DVT or pulmonary embolism (PE), but not to zero, which is concerning because DVT/PE is being considered a serious reportable event. A study was conducted in January-June 2009 to test the hypothesis that most surgical VTEs occur despite the patient's receiving appropriate prophylaxis. All patients with a surgical diagnosis-related group (DRG) who had a documented DVT/PE in 2008 were retrospectively reviewed. Each VTE episode was characterized as occurring during the index admission for surgery or being present on admission (POA). DVT prophylaxis compliance was measured in all patients who had a procedure at the institution, a 454-bed university teaching hospital, and those patients were classified in terms of compliance with our VTE protocols. Class 1 patients had VTE protocols followed; Class 2 patients had contraindications to VTE protocols documented; Class 3 patients should have received VTE prophylaxis but did not; and Class 4 patients had contraindications to VTE prophylaxis that were not documented. Some 156 (6.3%) of 2,474 surgical patients had a DVT/PE in 2008; for the 144 patients with complete records for review, 89 were candidates for VTE prophylaxis. Some 77 of the 89 patients had received appropriate VTE prophylaxis or had documented contraindications to prophylaxis. Eleven (12.4%) patients who should have received VTE prophylaxis did not. Compliance with VTE protocols continues to be less than 100%, and even when patients adhere to existing protocols VTE events continue to occur.

Effect of Hospitalists on Length of Stay in the Medicare Population: Variation According to Hospital and Patient Characteristics

To assess how shorter length of stay (LOS) associated with hospitalist care than with care by other physicians varied according to patient and hospital characteristics and to explore whether these differences in LOS changed over time in the Medicare population. Retrospective cohort study using data from a 5% national sample of Medicare beneficiaries. Hospital. To examine temporal trends, 1,981,654 Medicare admissions in 2001 to 2006 at 5,036 U.S. hospitals were used. To examine the influence of patient and hospital characteristics, 314,590 admissions in 2006 were used. Hospital LOS. In multivariable analyses controlling for patient and hospital characteristics, differences in LOS associated with hospitalist care increased from 0.02 fewer days in 2001/02 to 0.22 days in 2003/04 to 0.35 days in 2005/06. For 2006 admissions, differences in LOS were greater in older patients and patients with a higher diagnosis-related group (DRG) weight. The differences were three times as great for medical as for surgical DRGs, with greater differences in LOS at nonprofit than for-profit hospitals and at community than teaching hospitals. The shorter LOS associated with hospitalist care would appear to be greatest in older, complicated, nonsurgical patients cared for at community hospitals.

Regional and Institutional Variation in the Initiation of Early Do-Not-Resuscitate Orders

Do-not-resuscitate (DNR) orders are an important step in decision making about aggressiveness of care for patients in hospitals. The use of DNR orders is known to vary with patient characteristics, but few studies have investigated the role of hospital factors or of regional variation. We examined these influences on the use of early DNR orders (written <24 hours after admission). We conducted a retrospective cross-sectional study of patients 50 years and older admitted to acute-care hospitals in California in 2000 from the most prevalent medical and surgical diagnosis related groups. We performed multivariate logistic regression predicting use of DNR by hospital characteristics while accounting for patient characteristics, and estimated indirectly standardized rates of DNR use by county. In the selected diagnosis related groups, 819 686 persons were admitted to 386 hospitals. Early DNR orders varied from 2% (patients aged 50-59 years) to 17% (patients aged > or =80 years). In multivariate analyses, the odds of having early DNR orders written were significantly lower in for-profit (vs private nonprofit) hospitals, higher in the smallest (vs the largest) hospitals, and lower in academic (vs nonacademic) hospitals. Standardized rates of DNR order use varied 10-fold across counties. The highest rates were among patients from rural areas. However, variation in use did not correspond well to county population, hospital bed availability, or population density. Hospital characteristics appear to be associated with the use of DNR orders, even after accounting for differences in patient characteristics. This association reflects institutional culture, technological bent, and physician practice patterns. If these factors do not match patient preferences, then improvements in care are needed.