US Acute Care Hospitals Research Articles

Health information technology adoption: effects on patient safety and quality of care

The adoption of healthcare information technology (HIT) has been advocated by various groups as critical for addressing the growing crisis in the US healthcare industry. This study aims to understand differences in patient outcomes between healthcare providers that do and that do not adopt HIT. This is accomplished by examining the relationships between the adoption of HIT in US acute care hospitals and two risk-adjusted patient outcomes: patient safety and quality. The new contribution of the study lies in the fact that it uses nationally representative data and it incorporates a large number of technologies.

Quality of care for elderly patients hospitalized for pneumonia in the United States, 2006 to 2010.

Nearly every US acute care hospital reports publicly on adherence to recommended processes of care for patients hospitalized with pneumonia. However, it remains uncertain how much performance of these process measures has improved over time or whether performance is associated with superior patient outcomes. To describe trends in processes of care, mortality, and readmission for elderly patients hospitalized for pneumonia and to assess the independent associations between processes and outcomes of care. Retrospective cohort study conducted from January 1, 2006, to December 31, 2010, at 4740 US acute care hospitals. The cohort included 1 818 979 cases of pneumonia in elderly (≥65 years), Medicare fee-for-service patients who were eligible for at least 1 of 7 pneumonia inpatient processes of care tracked by the Centers for Medicare & Medicaid Services (CMS). Annual performance rates for 7 pneumonia processes of care and an all-or-none composite of these measures; and 30-day, all-cause mortality and hospital readmission, adjusted for patient and hospital characteristics. Adjusted annual performance rates for all 7 CMS processes of care (expressed in percentage points per year) increased significantly from 2006 to 2010, ranging from 1.02 for antibiotic initiation within 6 hours to 5.30 for influenza vaccination (P < .001). All 7 measures were performed in more than 92% of eligible cases in 2010. The all-or-none composite demonstrated the largest adjusted relative increase over time (6.87 percentage points per year; P < .001) and was achieved in 87.4% of cases in 2010. Adjusted annual mortality decreased by 0.09 percentage points per year (P < .001), driven primarily by decreasing mortality in the subgroup not treated in the intensive care unit (ICU) (-0.18 percentage points per year; P < .001). Adjusted annual readmission rates decreased significantly by 0.25 percentage points per year (P < .001). All 7 processes of care were independently associated with reduced 30-day mortality, and 5 were associated with reduced 30-day readmission. Performance of processes of care for elderly patients hospitalized for pneumonia improved substantially from 2006 to 2010. Adjusted 30-day mortality declined slightly over time primarily owing to improved survival among non-ICU patients, and all individual processes of care were independently associated with reduced mortality.

Association between hospital conversions to for-profit status and clinical and economic outcomes.

An increasing number of hospitals have converted to for-profit status, prompting concerns that these hospitals will focus on payer mix and profits, avoiding disadvantaged patients and paying less attention to quality of care. To examine characteristics of US acute care hospitals associated with conversion to for-profit status and changes following conversion. Retrospective cohort study conducted among 237 converting hospitals and 631 matched control hospitals. Participants were 1,843,764 Medicare fee-for-service beneficiaries at converting hospitals and 4,828,138 at control hospitals. Conversion to for-profit status, 2003-2010. Financial performance measures, quality process measures, mortality rates, Medicare volume, and patient population for the 2 years prior and the 2 years after conversion, excluding the conversion year, assessed using difference-in-difference models. Hospitals that converted to for-profit status were more often small or medium in size, located in the south, in an urban or suburban location, and were less often teaching institutions. Converting hospitals improved their total margins (ratio of net income to net revenue plus other income) more than controls (2.2% vs 0.4% improvement; difference in differences, 1.8% [ 95% CI, 0.5% to 3.1%]; P = .007). Converting hospitals and controls both improved their process quality metrics (6.0% vs 5.6%; difference in differences, 0.4% [95% CI, -1.1% to 2.0%]; P = .59). Mortality rates did not change at converting hospitals relative to controls for Medicare patients overall (increase of 0.1% vs 0.2%; difference in differences, -0.2% [95% CI, -0.5% to 0.2%], P = .42) or for dual-eligible or disabled patients. There was no change in converting hospitals relative to controls in annual Medicare volume (-111 vs -74 patients; difference in differences, -37 [95% CI, -224 to 150]; P = .70), Disproportionate Share Hospital Index (1.7% vs 0.4%; difference in differences, 1.3% [95% CI, -0.9% to 3.4%], P = .26), the proportion of patients with Medicaid (-0.2% vs 0.4%; difference in differences, -0.6% [95% CI, -2.0% to 0.8%]; P = .38) or the proportion of patients who were black (-0.4% vs -0.1%; difference in differences, -0.3% [95% CI, -1.9% to 1.3%]; P = .72) or Hispanic (0.1% vs -0.1%; difference in differences, 0.2% [95% CI, -0.3% to 0.7%]; P = .50). Hospital conversion to for-profit status was associated with improvements in financial margins but not associated with differences in quality or mortality rates or with the proportion of poor or minority patients receiving care.

Prevalence of antimicrobial use in US acute care hospitals, May-September 2011.

Inappropriate antimicrobial drug use is associated with adverse events in hospitalized patients and contributes to the emergence and spread of resistant pathogens. Targeting effective interventions to improve antimicrobial use in the acute care setting requires understanding hospital prescribing practices. To determine the prevalence of and describe the rationale for antimicrobial use in participating hospitals. One-day prevalence surveys were conducted in acute care hospitals in 10 states between May and September 2011. Patients were randomly selected from each hospital's morning census on the survey date. Data collectors reviewed medical records retrospectively to gather data on antimicrobial drugs administered to patients on the survey date and the day prior to the survey date, including reasons for administration, infection sites treated, and whether treated infections began in community or health care settings. Antimicrobial use prevalence, defined as the number of patients receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed patients. Of 11,282 patients in 183 hospitals, 5635 (49.9%; 95% CI, 49.0%-50.9%) were administered at least 1 antimicrobial drug; 77.5% (95% CI, 76.6%-78.3%) of antimicrobial drugs were used to treat infections, most commonly involving the lower respiratory tract, urinary tract, or skin and soft tissues, whereas 12.2% (95% CI, 11.5%-12.8%) were given for surgical and 5.9% (95% CI, 5.5%-6.4%) for medical prophylaxis. Of 7641 drugs to treat infections, the most common were parenteral vancomycin (1103, 14.4%; 95% CI, 13.7%-15.2%), ceftriaxone (825, 10.8%; 95% CI, 10.1%-11.5%), piperacillin-tazobactam (788, 10.3%; 95% CI, 9.6%-11.0%), and levofloxacin (694, 9.1%; 95% CI, 8.5%-9.7%). Most drugs administered to treat infections were given for community-onset infections (69.0%; 95% CI, 68.0%-70.1%) and to patients outside critical care units (81.6%; 95% CI, 80.4%-82.7%). The 4 most common treatment antimicrobial drugs overall were also the most common drugs used for both community-onset and health care facility-onset infections and for infections in patients in critical care and noncritical care locations. In this cross-sectional evaluation of antimicrobial use in US hospitals, use of broad-spectrum antimicrobial drugs such as piperacillin-tazobactam and drugs such as vancomycin for resistant pathogens was common, including for treatment of community-onset infections and among patients outside critical care units. Further work is needed to understand the settings and indications for which reducing antimicrobial use can be most effectively and safely accomplished.

Use of medical consultants for hospitalized surgical patients: an observational cohort study.

Payments around episodes of inpatient surgery vary widely among hospitals. As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important. To describe the use of medical consultations for hospitalized surgical patients, factors associated with use, and practice variation across hospitals. Observational retrospective cohort study of fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) between January 1, 2007, and December 31, 2010, at US acute care hospitals. Number of inpatient medical consultations. More than half of patients undergoing colectomy (91,684) or THR (339,319) received at least 1 medical consultation while hospitalized (69% and 63%, respectively). Median consultant visits from a medicine physician were 9 (interquartile range [IQR], 4-19) for colectomy and 3 for THR (IQR, 2-5). The likelihood of having at least 1 medical consultation varied widely among hospitals (interquartile range [IQR], 50%-91% for colectomy and 36%-90% for THR). For colectomy, settings associated with greater use included nonteaching (adjusted risk ratio [ARR], 1.14 [95% CI, 1.04-1.26]) and for-profit (ARR, 1.10 [95% CI, 1.01-1.20]). Variation in use of medical consultations was greater for colectomy patients without complications (IQR, 47%-79%) compared with those with complications (IQR, 90%-95%). Results stratified by complications were similar for THR. The use of medical consultations varied widely across hospitals, particularly for surgical patients without complications. Understanding the value of medical consultations will be important as hospitals prepare for bundled payments and strive to enhance efficiency.

From hospice to hospital: short-term follow-up study of hospice patient outcomes in a US acute care hospital surveillance system

ObjectivesIn the USA, there is little systematic evidence about the real-world trajectories of patient medical care after hospice enrolment. The objective of this study was to analyse predictors of the...

On-site availability of Legionella testing in acute care hospitals, United States.

We surveyed 399 US acute care hospitals regarding availability of on-site Legionella testing; 300 (75.2%) did not offer Legionella testing on site. Availability varied according to hospital size and geographic location. On-site access to testing may improve detection of Legionnaires disease and inform patient management and prevention efforts.

Differences in nursing practice environment among US acute care unit types: A descriptive study

BackgroundThe hospital nursing practice environment has been found to be crucial for better nurse and patient outcomes. Yet little is known about the professional nursing practice environment at the unit level where nurses provide 24-hour bedside care to patients. ObjectivesTo examine differences in nursing practice environments among 11 unit types (critical care, step-down, medical, surgical, combined medical–surgical, obstetric, neonatal, pediatric, psychiatric, perioperative, and emergency) and by Magnet status overall, as well as four specific aspects of the practice environment. DesignCross-sectional study. Settings5322 nursing units in 519 US acute care hospitals. MethodsThe nursing practice environment was measured by the Practice Environment Scale of the Nursing Work Index. The Practice Environment Scale of the Nursing Work Index mean composite and four subscale scores were computed at the unit level. Two statistical approaches (one-way analysis of covariance and multivariate analysis of covariance analysis) were employed with a Tukey-Kramer post hoc test. ResultsIn general, the nursing practice environment was favorable in all unit types. There were significant differences in the nursing practice environment among the 11 unit types and by Magnet status. Pediatric units had the most favorable practice environment and medical–surgical units had the least favorable. A consistent finding across all unit types except neonatal units was that the staffing and resource adequacy subscale scored the lowest compared with all other Practice Environment Scale of the Nursing Work Index subscales (nursing foundations for quality of care, nurse manager ability, leadership, and support, and nurse–physician relations). Unit nursing practice environments were more favorable in Magnet than non-Magnet hospitals. ConclusionsFindings indicate that there are significant variations in unit nursing practice environments among 11 unit types and by hospital Magnet status. Both hospital-level and unit-specific strategies should be considered to achieve an excellent nursing practice environment in all hospital units.

Editorial Commentary: Healthcare-Associated Pneumonia: Where Do We Go Next?

Editorial Commentary: Healthcare-Associated Pneumonia: Where Do We Go Next?

Trends In Thromboprophylaxis Use In US Hospitals, 2006–2010

The use of thromboprophylaxis among at-risk groups of inpatients to prevent hospital-associated venous thromboembolism (HA-VTE) has long been considered suboptimal. Little is known, though, whether utilization of anticoagulants in inpatient settings has increased in recent years. The objective of this study was to assess trends in the administration of anticoagulants to inpatients in a sample of US hospitals from 2006 through 2010 and to further evaluate how trends in utilization vary by type of patient group.A comprehensive national database of all-payer billing records from more than 600 US acute care hospitals, the Truven Health MarketScan® Hospital Drugs Database, was accessed for the years 2006 through 2010. Uniquely, this national hospital database contains records on prescription medications administered in the inpatient setting. Data were analyzed for a subset of hospitals for which an indicator of potential record error was zero. Data for this analysis were contributed by 394 hospitals in 2006 and 333 hospitals in 2010. The analysis was restricted to inpatient admissions of longer than 1 day for adult (age ≥ 18 years) patients who were neither admitted from nor discharged to another acute care hospital (i.e., no hospital transfers). Records were excluded for admissions with a diagnosis that could require anticoagulation for treatment, i.e., deep vein thrombosis, pulmonary embolism, atrial fibrillation, stroke, or myocardial infarct. Total admissions included were 3,188,966 in 2006 and 2,554,806 in 2010.For the purposes of this study, records with one or more prescriptions for the following anticoagulants--enoxaparin, dalteparin, fondaparinux, or warfarin--were classified as presumed thromboprophylaxis since conditions for which anticoagulants are prescribed as treatment had been excluded. In addition, administration of unfractionated heparin of 1,000 U or more was considered prophylactic; low-dose heparin prescriptions (< 1000 U) were assumed to be used as a heparin flush. Anticoagulation prophylaxis rates were assessed for all inpatients and for 5 selected at-risk patient groups based on ICD-9-CM codes used for the same patient groups in Amin A, et al. (2011; 2012): hip/knee surgery, cancer, congestive heart failure (CHF), severe lung disease (including chronic obstructive pulmonary disease), and infectious disease. The associated numbers of admissions in 2010 and the percentages of all admissions for the five at-risk groups are: 52,517 (2.1%) knee/hip, 127,407 (5.0%) cancer, 33,212 (1.3%) severe lung disease, 28,514 (1.1%) CHF, and 27,541 (1.1%) infection.Provisional results indicate that the frequency of administration of thromboprophylaxis in a sample of US inpatient hospitalizations increased over time, from 34.0% in 2006 to 41.40% in 2010, a relative increase of 21.5% in a 4-year period. The use of anticoagulation was highest among major orthopedic surgical patients at each point, 85.97% in 2006 and 87.40% in 2010. The second highest use was observed in hospitalizations for patients with severe lung disease, increasing from 65.33% in 2006 to 69.63% in 2010. Use of anticoagulants for hospitalizations with CHF diagnoses increased from 60.61% in 2006 to 67.99% in 2010. Increases in use of anticoagulation were larger in both absolute and relative terms for two other groups of at-risk hospitalizations. For hospitalizations associated with infectious disease diagnoses, the frequency of use increased from 46.03% in 2006 to 57.71% in 2010, a relative increase of 25.4%. Finally, the largest relative increase in thromboprophylaxis use in at-risk patient groups was observed for hospitalizations associated with cancer diagnoses, among which use increased from 40.52% in 2006 to 52.53% in 2010, a relative increase of 29.6%.These data suggest that substantial increases have occurred in recent years in the frequency with which anticoagulants are prescribed to US inpatients for the prevention of HA-VTE. Additional analyses are being conducted to assess whether increased use of anticoagulants for thromboprophylaxis has been associated with outcomes such as changes in the frequency of in-hospital bleeding events that require treatment. Disclosures:Amin:Johnson & Johnson: Research Funding, Speakers Bureau; BMS/Pfizer: Research Funding, Speakers Bureau.

Economic burden of healthcare-associated infection in US acute care hospitals: societal perspective

Background:Assessing the costs of healthcare-associated infection (HAI) is challenging. Methodological issues abound. Previous estimates have been derived in diverse ways from varied perspectives in different settings with dissimilar data. Results can be confusing. Full societal costs, which are more inclusive than commonly reported direct hospital costs, have never been fully measured or reported.Objective:To update, combine, and expand previous cost estimates to determine the annual societal burden of illness (direct medical, non-medical, and indirect costs) arising from HAIs in US acute-care hospitals.Methods:The research approach encompassed literature and internet searches; reference identification, selection, and review; then data abstraction, compilation, and analyses to estimate full societal costs. Previously published systemic reviews, surveillance reports, and individual clinical studies, along with newly computed component costs, all contributed to final estimates.Results:HAIs in US acute-care hospitals lead to direct and indirect costs totaling $96–$147 billion annually. These results are subject to the same limitations as previous studies from which contributing data were derived.Conclusion:The enormous clinical and economic burden of infection places HAIs high on the list of devastating and costly illnesses, such as cancer, heart attack, stroke, and diabetes, thereby mandating further research and greater efforts to contain a pressing healthcare problem.

Early enteral nutrition in critical illness: a full economic analysis using US costs

PurposeAlthough published meta-analyses demonstrate patient survival may be improved if enteral nutrition (EN) is provided to critically ill patients within 24 hours of injury or admission to the intensive care unit (ICU), these publications did not investigate the impact of early EN on measures of health care resource consumption and total costs.Materials and methodsFrom the perspective of the US acute care hospital system, a cost-effectiveness analysis was undertaken based on a large-scale Monte Carlo simulation (N = 1,000,000 trials) of a 1,000-patient stochastic model, developed using clinical outcomes and measures of resource consumption reported by published meta-analyses combined with cost distributions obtained from the published literature. The mean cost differences between early EN and standard care, along with respective 95% confidence intervals, were obtained using the percentile method.Results and conclusionThe provision of early EN to critically ill patients is a dominant technology: Patient survival is significantly improved and total costs of care reduced meaningfully. Under conservative assumptions, the total costs of acute hospital care were reduced by US$14,462 per patient (95% confidence interval US$5,464 to US$23,669). These results were robust, with all sensitivity analyses demonstrating significant savings attributable to the use of early EN, including sensitivity analysis conducted using European cost data.

Development, validation, and results of a risk‐standardized measure of hospital 30‐day mortality for patients with exacerbation of chronic obstructive pulmonary disease

Despite its large clinical and economic significance, measuring and improving the outcomes of patients hospitalized for chronic obstructive pulmonary disease (COPD) is only beginning to emerge as a national priority for policy makers and payers. To facilitate the public reporting of hospital outcomes, we developed a risk-standardized measure of hospital 30-day mortality for patients admitted with exacerbation of COPD. Hierarchical logistic regression model. Medicare Part A and Part B claims in a random sample of half of all admissions for patients admitted to acute care hospitals in 2008 (development cohort) and remaining 2008 admissions (validation cohort). We also assessed model performance and predictive ability in 2007 and 2009 data. Hospital risk-standardized 30-day mortality rates. The model development sample consisted of 150,035 admissions at 4537 nonfederal acute care US hospitals, with a mean unadjusted hospital 30-day mortality rate of 8.6%. The mean risk-standardized mortality rate was 8.6% and ranged from 5.9% to 13.5%. The development and validation models had good discrimination (areas under the receiver operating characteristic curve 0.72 and 0.72, respectively) and predictive ability (predicted mortality at the 1st and 10th deciles 1.5%, 23.7%, and 1.6%, 23.8%, respectively) and showed no evidence of over-fitting. A 30-day mortality model based on administrative claims had similar discrimination to other public reporting models and can be used to compare risk-adjusted outcomes for patients with exacerbations of COPD and to track changes in outcomes over time. The high mortality and variation in rates across institutions suggest opportunities to improve quality of care.

Mortality for Publicly Reported Conditions and Overall Hospital Mortality Rates

Federal efforts about public reporting and quality improvement programs for hospitals have focused primarily on a small number of medical conditions. Whether performance on these conditions accurately predicts the quality of broader hospital care is unknown. To determine whether mortality rates for publicly reported medical conditions are correlated with hospitals' overall performance. Using national Medicare data, we compared hospital performance at 2322 US acute care hospitals on 30-day risk-adjusted mortality, aggregated across the 3 publicly reported conditions (acute myocardial infarction, congestive heart failure, and pneumonia), with performance on a composite risk-adjusted mortality rate across 9 other common medical conditions, a composite mortality rate across 10 surgical conditions, and both composites combined. We also examined the relationship between alternative surrogates of quality (hospital size and teaching status) and performance on these composite outcomes. Our sample included 6,670,859 hospitalizations for Medicare fee-for-service beneficiaries from 2008 through 2009. Hospitals in the top quartile of performance on publicly reported conditions had a 3.6% lower absolute risk-adjusted mortality rate on the combined medical-surgical composite than those in the bottom quartile (9.4% vs 13.0%; P < .001). These top performers on publicly reported conditions had 5 times greater odds of being in the top quartile on the overall combined composite risk-adjusted mortality rate (odds ratio [OR], 5.3; 95% CI, 4.3-6.5). Mortality rates for the index condition were predictive of medical (OR, 8.4; 95% CI, 6.8-10.3) and surgical (2.7; 2.2-3.3) performance when these groups were considered separately. In comparison, large size (OR, 1.9; 95% CI, 1.5-2.4) and teaching status (2.4; 1.8-3.2) showed weaker relationships with overall hospital mortality rates. Hospital performance on publicly reported conditions can potentially be used as a signal of overall hospital mortality rates.

Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a full economic analysis of a multicenter randomized controlled trial based on US costs

PurposeThe provision of early enteral (gut) nutrition to critically ill patients, started within 24 hours of injury or intensive care unit admission, is accepted to improve health outcomes. However, not all patients are able to receive early enteral nutrition. The purpose of the economic analysis presented here was to estimate the cost implications of providing early parenteral (intravenous) nutrition to critically ill patients with short-term relative contraindications to early enteral nutrition.Materials and methodsFrom the perspective of the US acute care hospital system, a cost-minimization analysis was undertaken based on large-scale Monte Carlo simulation (N = 1,000,000 trials) of a stochastic model developed using clinical outcomes and measures of resource consumption reported in a 1,363-patient multicenter clinical trial combined with cost distributions obtained from the published literature. The mean costs of acute care attributable to each study group (early parenteral nutrition versus pragmatic standard care) and the mean cost difference between groups, along with respective 95% confidence intervals, were obtained using the percentile method.Results and conclusionThe use of early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition may significantly and meaningfully reduce total costs of acute hospital care by US$3,150 per patient (95% confidence interval US$1,314 to US$4,990). These findings were robust, with all sensitivity analyses demonstrating significant savings attributable to the use of early parenteral nutrition, including sensitivity analysis conducted using European cost data.

Hospital laboratory reporting may be a barrier to detection of ‘microsize’ myocardial infarction in the US: an observational study

BackgroundInternational guidelines recommend that the decision threshold for troponin should be the 99th percentile of a normal population, or, if the laboratory assay is not sufficiently precise at this low level, the level at which the assay achieves a 10% or better coefficient of variation (CV). Our objectives were to examine US hospital laboratory troponin reports to determine whether either the 99th percentile or the 10% CV level were clearly indicated, and whether nonconcordance with these guidelines was a potential barrier to detecting clinically important microscopic or ‘microsize’ myocardial infarctions (MIs). To confirm past reports of the clinical importance of microsize MIs, we also contrasted in-hospital, 28-day and 1-year mortality among those with microsize and nonmicrosize MI.MethodsIn the REasons for Geographic And Racial Differences in Stroke national prospective cohort study (n=30,239), 1029 participants were hospitalized for acute coronary syndrome (ACS) between 2003–2009. For each case, we recorded all thresholds of abnormal troponin on the laboratory report and whether the 99th percentile or 10% CV value were clearly identified. All cases were expert adjudicated for presence of MI. Peak troponin values were used to classify MIs as microsize MI (< five times the lowest listed upper limit of normal) and nonmicrosize MI.ResultsParticipants were hospitalized at 649 acute care US hospitals, only 2% of whose lab reports clearly identified the 99th percentile or the 10% CV level; 52% of reports indicated an indeterminate range, a practice that is no longer recommended. There were 183 microsize MIs and 353 nonmicrosize MIs. In-hospital mortality tended to be lower in the microsize than in the nonmicrosize MI group (1.1 vs. 3.6%, p = 0.09), but 28-day and 1-year mortality were similar (2.5% vs. 2.7% [p = 0.93] and 5.2% vs. 4.3% [p = 0.64], respectively).ConclusionsCurrent practices in many US hospitals created barriers to the clinical recognition of microsize MI, which was common and clinically important in our study. Improved hospital troponin reporting is warranted.

Abstract 8: Get With The Guidelines-Stroke Program Participation and Clinical Outcomes for Medicare Beneficiaries

Background: Get With The Guidelines (GWTG)-Stroke is a national, hospital-based quality improvement program developed by the American Heart Association. While studies have shown a beneficial effect of hospital participation in GWTG-Stroke upon processes of care, whether there are associated improvements in clinical outcomes has not been previously investigated. Methods: From among all acute care US hospitals, we matched 366 hospitals that joined the GWTG-Stroke program between April 2004 and December 2007, with 366 hospitals that did not. Matching was based on ischemic stroke case volume, calendar year, baseline hospital post-stroke 1-year all-cause mortality rates, teaching status, and geographic region. Outcomes of all acute ischemic stroke (AIS) patients admitted to the study hospitals were abstracted from the CMS administrative claims database (65 years and older). Outcomes at matched hospitals were compared in the PRE-GWTG-Stroke period (-540 to -181 days before program launch), RUN-UP period (-180- to -1 day), EARLY period (0 to 180 days) and SUSTAINED period (181 to 540 days). Additional analysis was performed of the entire BEFORE (-540 to -1 days) and AFTER periods (0 to 540 days). The main analytical approach was stratified Cox proportional hazard modeling, with matched site ID at stratum. We adjusted for patient characteristics (age, gender, race, medical history) and hospital characteristics (rural vs. urban, # beds, annual IS discharges.) Results: The study analyzed 88,584 AIS admissions at the 366 GWTG-Stroke hospitals and 85,401 admissions at the 366 matched non-GWTG-Stroke hospitals. In adjusted analysis comparing BEFORE and AFTER periods, GWTG-Stroke hospitals achieved reduced 30 day mortality (30M - HR 0.911, p&lt;0.0001), reduced 1 year mortality (1YM - HR 0.902, p&lt;0.0001), reduced 30 day all-cause rehospitalization (HR 0.956, p=0.013), reduced 30 day stroke rehospitalization (HR 0.927, p=0.038), and reduced 1 year all-cause rehospitalization (HR 0.972, p=0.007). Conversely, matched, non-GWTG-Stroke hospitals showed only reduced 30M (HR 0.954, p=0.010) between the BEFORE and AFTER periods. Comparing the degree of change at GWTG-Stroke with non-GWTG Stroke hospitals, there were greater improvements in discharge to home (DCH), 30M, and 1YM at GWTG-Stroke hospitals in each of the intervention periods: EARLY: DCH, HR 1.090, p&lt;0.0001; 30M, HR 0.894, p=0.0006; 1YM, HR 0.889, p&lt;0.0001; SUSTAINED: DCH, HR 1.097, p&lt;0.0001; 30M, HR 0.934, p=0.004; 1YM, HR 0.918, p&lt;0.0001. Conclusions: Hospitals joining the GWTG-Stroke quality improvement program between 2004-2008 achieved significantly greater improvement in stroke patient outcomes than matched hospitals not joining the program, with lower all-cause mortality at 30 days and 1 year and higher rates of discharge directly to home.

Mortality Rates for Medicare Beneficiaries Admitted to Critical Access and Non–Critical Access Hospitals, 2002-2010

Critical access hospitals (CAHs) provide inpatient care to Americans living in rural communities. These hospitals are at high risk of falling behind with respect to quality improvement, owing to their limited resources and vulnerable patient populations. How they have fared on patient outcomes during the past decade is unknown. To evaluate trends in mortality for patients receiving care at CAHs and compare these trends with those for patients receiving care at non-CAHs. Retrospective observational study using data from Medicare fee-for-service patients admitted to US acute care hospitals with acute myocardial infarction (1,902,586 admissions), congestive heart failure (4,488,269 admissions), and pneumonia (3,891,074 admissions) between 2002 and 2010. Trends in risk-adjusted 30-day mortality rates for CAHs and other acute care US hospitals. Accounting for differences in patient, hospital, and community characteristics, CAHs had mortality rates comparable with those of non-CAHs in 2002 (composite mortality across all 3 conditions, 12.8% vs 13.0%; difference, -0.3% [95% CI, -0.7% to 0.2%]; P = .25). Between 2002 and 2010, mortality rates increased 0.1% per year in CAHs but decreased 0.2% per year in non-CAHs, for an annual difference in change of 0.3% (95% CI, 0.2% to 0.3%; P < .001). Thus, by 2010, CAHs had higher mortality rates compared with non-CAHs (13.3% vs 11.4%; difference, 1.8% [95% CI, 1.4% to 2.2%]; P < .001). The patterns were similar when each individual condition was examined separately. Comparing CAHs with other small, rural hospitals, similar patterns were found. Among Medicare beneficiaries with acute myocardial infarction, congestive heart failure, or pneumonia, 30-day mortality rates for those admitted to CAHs, compared with those admitted to other acute care hospitals, increased from 2002 to 2010. New efforts may be needed to help CAHs improve.

Economic Measurement of Medical Errors Using a Hospital Claims Database

ObjectiveThe primary objective of this study was to estimate the occurrence and costs of medical errors from the hospital perspective. MethodsMethods from a recent actuarial study of medical errors were used to identify medical injuries. A visit qualified as an injury visit if at least 1 of 97 injury groupings occurred at that visit, and the percentage of injuries caused by medical error was estimated. Visits with more than four injuries were removed from the population to avoid overestimation of cost. Population estimates were extrapolated from the Premier hospital database to all US acute care hospitals. ResultsThere were an estimated 161,655 medical errors in 2008 and 170,201 medical errors in 2009. Extrapolated to the entire US population, there were more than 4 million unique injury visits containing more than 1 million unique medical errors each year. This analysis estimated that the total annual cost of measurable medical errors in the United States was $985 million in 2008 and just over $1 billion in 2009. The median cost per error to hospitals was $892 for 2008 and rose to $939 in 2009. Nearly one third of all medical injuries were due to error in each year. ConclusionsMedical errors directly impact patient outcomes and hospitals’ profitability, especially since 2008 when Medicare stopped reimbursing hospitals for care related to certain preventable medical errors. Hospitals must rigorously analyze causes of medical errors and implement comprehensive preventative programs to reduce their occurrence as the financial burden of medical errors shifts to hospitals.

Utilization of epidermal growth factor receptor (EGFR) testing in the United States: a case study of T3 translational research

We examined hospital use of the epidermal growth factor receptor assay in patients with lung cancer in the United States. Our goal was to inform the development of a model to predict phase 3 translation of guideline-directed molecular diagnostic tests. This was a retrospective observational study. Using logistic regression, we analyzed the association between hospitals' institutional and regional characteristics and the likelihood that an epidermal growth factor receptor assay would be ordered. Significant institutional predictors included affiliation with an academic medical center (odds ratio, 1.48; 95% confidence interval, 1.20-1.83), participation in a National Cancer Institute clinical research cooperative group (odds ratio, 2.06, 1.66-2.55), and -availability of positron emission tomography scan (odds ratio, 1.44, 1.07-1.94) and cardiothoracic surgery (odds ratio, 1.90, 1.52-2.37) services. Significant regional predictors included metropolitan county (odds ratio, 2.08, 1.48-2.91), population with above-average education (odds ratio, 1.46, 1.09-1.96), and population with above-average income (odds ratio, 1.46, 1.04-2.05). Distance from a National Cancer Institute cancer center was a negative predictor (odds ratio, 0.996, 0.995-0.998), with a 34% decrease in likelihood for every 100 miles. In 2010, only 12% of US acute-care hospitals ordered the epidermal growth factor receptor assay, suggesting that most patients with lung cancer did not have access to this test. This case study illustrated the need for: (i) increased dissemination and implementation research, and (ii) interventions to improve adoption of guideline-directed molecular diagnostic tests by community hospitals.