Variation In Hospital Performance Research Articles

Variation in Hospital Performance for General Surgery in Younger and Older Adults: A Retrospective Cohort Study.

To compare hospital surgical performance in older and younger patients. In-hospital mortality after surgical procedures varies widely between hospitals. Prior studies suggest that failure-to-rescue rates drive this variation for older adults, but the generalizability of these findings to younger patients remains unknown. We performed a retrospective cohort study of patients ≥18 years undergoing one of ten common and complex general surgery operations in 16 states using the Healthcare Cost and Utilization Projects State Inpatient Databases (2016-2018). Patients were split into two populations: Medicare ≥65 (older adult) and non-Medicare <65 (younger adult) patients. Hospitals were sorted into quintiles using risk-adjusted in-hospital mortality rates for each age population. Correlations between hospitals in each mortality quintile across age populations were calculated. Complication and failure-to-rescue rates were compared across the highest and lowest mortality quintiles in each age population. We identified 579,582 patients treated in 732 hospitals. The mortality rate was 3.6% among older adults and 0.7% among younger adults. Among older adults, high- relative to low-mortality hospitals had similar complication rates (32.0% vs. 29.8%; P=0.059) and significantly higher failure-to-rescue rates (16.0% vs. 4.0%; P<0.001). Among younger adults, high- relative to low-mortality hospitals had higher complication (15.4% vs. 12.1%; P<0.001) and failure-to-rescue rates (8.3% vs. 0.7%; P<0.001). The correlation between observed-to-expected mortality ratios in each age group was 0.385 (P<0.001). High surgical mortality rates in younger patients may be driven by both complication and failure-to-rescue rates. There is little overlap between low-mortality hospitals in the older and younger adult populations. Future work must delve into the root causes of this age-based difference in hospital-level surgical outcomes.

Variation in hospital performance measures from the Turkey Ministry of Health.

The Turkish healthcare system has seen broad population-based improvements in expanded health insurance coverage and access to healthcare services. Hospital performance in this national system is understudied. We aimed to identify trends in hospital performance over time following implementation of the Health Transformation Program and describe how regional outcomes correlate with regional vital statistics. We examine hospital performance data collected by the PHA from 2013 to 2015. We aim to identify the temporal variation in hospital performance for nearly 30 individual measures and to describe the relationship between hospital-level performance measures and regional vital statistics. We conducted a retrospective cohort study of 674 public hospitals in Turkey using baseline data from 2013 and follow-up data from 2014-15 collected by the Turkish Statistical Institution and the Public Hospital Agency. We report demographic and socioeconomic data across 12 geographic regions and analyze 29 hospital-level performance measures across four domains: (i) health services; (ii) administrative services; (iii) financial services and (iv) quality measures. We examine temporal variation, and study correlation between performance measures and regional vital statistics. We fit mixed-effects linear regression models to estimate linear trend over time accounting for within-hospital residual correlation. We prepared our manuscript in accordance with guidelines set by the STROBE statement for cohort studies. During the 3 years of study period, 21 of 29 measures improved and 8 measures worsened. All but three measures demonstrated significant differences across regions of the country. Several measures, including inpatient efficiency, patient satisfaction and audit score, are associated with regional infant mortality and life expectancy. Evidence of temporal improvement in hospital-level performance may suggest some positive changes within the Turkish national healthcare system. Correlation of some measures with regional level health outcomes suggests a quality measurement strategy to monitor performance changes in the future. Although hospital-level functions have improved performance, the results of our study may help achieve further improvement for the health of the country's citizens.

Rating Hospital Performance in China: Review of Publicly Available Measures and Development of a Ranking System.

BackgroundIn China, significant emphasis and investment in health care reform since 2009 has brought with it increasing scrutiny of its public hospitals. Calls for greater accountability in the quality of hospital care have led to increasing attention toward performance measurement and the development of hospital ratings. Despite such interest, there has yet to be a comprehensive analysis of what performance information is publicly available to understand the performance of hospitals in China.ObjectiveThis study aims to review the publicly available performance information about hospitals in China to assess options for ranking hospital performance.MethodsA review was undertaken to identify performance measures based on publicly available data. Following several rounds of expert consultation regarding the utility of these measures, we clustered the available options into three key areas: research and development, academic reputation, and quality and safety. Following the identification and clustering of the available performance measures, we set out to translate these into a practical performance ranking system to assess variation in hospital performance.ResultsA new hospital ranking system termed the China Hospital Development Index (CHDI) is thus presented. Furthermore, we used CHDI for ranking well-known tertiary hospitals in China.ConclusionsDespite notable limitations, our assessment of available measures and the development of a new ranking system break new ground in understanding hospital performance in China. In doing so, CHDI has the potential to contribute to wider discussions and debates about assessing hospital performance across global health care systems.

Hospital Quality Metrics for Radical Cystectomy: Disease Specific and Correlated to Mortality Outcomes.

Measuring quality is a high priority for health care systems globally. Despite the high perioperative morbidity, mortality, expenditures and performance variation of radical cystectomy there is a paucity of validated bladder cancer quality metrics. We aimed to create a hospital quality scoring system for radical cystectomy which is disease specific and associated with patient centered outcomes. We used the National Cancer Database to identify hospitals where radical cystectomy was performed from 2004 to 2014. Mixed effects models were constructed to assess variation in hospital performance across 7 quality indicators. Indirect standardization was used to case mix adjust hospital performance. We assessed associations between quality indicators as well as the novel BC-QS (Bladder Cancer Quality Score) composite hospital quality metric with 30-day, 90-day and overall mortality using logistic and Cox regression, respectively. At 1,200 facilities radical cystectomy was performed in a total of 48,341 patients from 2004 to 2014. Mixed effects models demonstrated significant between hospital variation across all quality indicators after case mix adjustment. The composite BC-QS metric was composed of the hospital positive margin rate, the lymph node dissection rate and the neoadjuvant chemotherapy rate. Better BC-QS performance was associated with lower 30-day and 90-day mortality (adjusted OR 0.78, 95% CI 0.64-0.96, and OR 0.84, 95% CI 0.72-0.97, respectively) and overall mortality (HR 0.86, 95% CI 0.81-0.92). Hospitals with a higher BC-QS had higher volume and more were affiliated with an academic institution than hospitals with a lower BC-QS (p <0.0001). The BC-QS captures variations in the hospital performance of radical cystectomy and it shows an association of higher quality with lower patient mortality. Our validation of this quality metric provides support for its potential use by policy makers and payers in efforts to measure hospital quality for high cost surgeries.

Deploying end-of-life utilization measures for oncology patients to assess hospital care quality and value.

106 Background: Addressing utilization near the end of life (EOL) for cancer patients is critical to enhance the value of cancer care. Cancer EOL utilization measures have been widely endorsed, including by the National Quality Forum (chemotherapy in the last 14 days; ICU in the last 30 days; not admitted to hospice; admitted to hospice for &lt; 3 days). However, efforts to use these measures to assess hospital quality and value have been constrained, in part because currently endorsed specifications do not provide a claims-based approach to cohort identification, and do not include a hospital attribution methodology. Methods: Using Medicare fee-for-service claims for adults ≥65 years, and through an iterative process informed by an expert panel, we developed extensible claims-based algorithms to a) identify patients who were deceased from cancer; b) attribute each patient to a responsible hospital; and c) derive hospital-level performance measures. We sought to ensure that these algorithms had strong face validity and were consistent with standard practices for claims-based analyses. Results: We identified 347,452 cancer decedents as those who had a cancer diagnosis associated with ≥2 hospital inpatient (IP), hospital outpatient (OP), or hospice claims, and died between 2011-2014. A decedent’s care was attributed to a hospital if there were ≥2 claims from that institution during the 6 months before death (N = 221,102). If this identified multiple hospitals, one was selected using the following sequence: total majority of all claims; most OP claims; most IP claims; last IP claim before death. Measure performance reflected national published data: 6% received chemotherapy in the last 14 days; 28% admitted to ICU in the last 30 days; and 34% not admitted to hospice. There was significant variation in hospital performance for all measures. Conclusions: Claims-based EOL measures do not define ‘ideal’ performance, but they do provide hospitals with broad utilization data that can help inform value-based cancer care delivery. These methods addressed gaps hindering the application of endorsed cancer EOL measures to hospitals. Companion quality measures to assess goal-concordant care are also needed.

Limitations of Using Pediatric Respiratory Illness Readmissions to Compare Hospital Performance.

Adult hospital readmission rates can reliably identify meaningful variation in hospital performance; however, pediatric condition-specific readmission rates are limited by low patient volumes. To determine if a National Quality Forum (NQF)-endorsed measure for pediatric lower respiratory illness (LRI) 30-day readmission rates can meaningfully identify high- and low-performing hospitals. Observational, retrospective cohort analysis. We applied the pediatric LRI measure and several variations to evaluate their ability to detect performance differences. Administrative claims from all hospital admissions in California (2012-2014). Children (age <18 years) with LRI (primary diagnosis: bronchiolitis, influenza, or pneumonia; or LRI as a secondary diagnosis with a primary diagnosis of respiratory failure, sepsis, bacteremia, or asthma). Thirty-day hospital readmission rates and costs. Hierarchical regression models adjusted for age, gender, and chronic conditions were used. Across all California hospitals admitting children (n = 239) using respiratory readmission rates, no outlier hospitals were identified with (1) the NQF-endorsed metric, (2) inclusion of primary asthma or secondary asthma exacerbation diagnoses, or (3) inclusion of 30-day emergency revisits. By including admissions for asthma, adding emergency revisits, and merging 3 years of data, we identified 9 outlier hospitals (2 high-performers, 7 low-performers). There was no association of hospital readmission rates with costs. Using a nationally-endorsed quality measure of inpatient pediatric care, we were unable to identify meaningful variation in hospital performance without broadening the metric definition and merging multiple years of data. Utilizers of pediatric-quality measures should consider modifying metrics to better evaluate the quality of pediatric care at low-volume hospitals. Supported by the Agency for Healthcare Research and Quality (K08 HS24592 to SVK and U18HS25297 to MDC and NSB) and the National Institute of Child Health and Human Development (K23HD065836 to NSB). The funding agency played no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the manuscript for publication.

PD41-03 VALIDATED HOSPITAL QUALITY METRICS FOR RADICAL CYSTECTOMY: DISEASE-SPECIFIC AND CORRELATED TO LONG-TERM OUTCOMES

You have accessJournal of UrologyBladder Cancer: Invasive V1 Apr 2018PD41-03 VALIDATED HOSPITAL QUALITY METRICS FOR RADICAL CYSTECTOMY: DISEASE-SPECIFIC AND CORRELATED TO LONG-TERM OUTCOMES Abhinav Khanna, Olli Saarela, Keith Lawson, Andrew Stephenson, Georges-Pascal Haber, Byron Lee, Antonio Finelli, and Robert Abouassaly Abhinav KhannaAbhinav Khanna More articles by this author , Olli SaarelaOlli Saarela More articles by this author , Keith LawsonKeith Lawson More articles by this author , Andrew StephensonAndrew Stephenson More articles by this author , Georges-Pascal HaberGeorges-Pascal Haber More articles by this author , Byron LeeByron Lee More articles by this author , Antonio FinelliAntonio Finelli More articles by this author , and Robert AbouassalyRobert Abouassaly More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1942AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Centers for Medicare and Medicaid (CMS), private insurers, and many independent rating agencies are all measuring and publicly reporting hospital quality. However, commonly used quality metrics are not disease-specific and are rarely correlated with meaningful long term outcomes. We aim to develop and validate hospital quality metrics for radical cystectomy that are both disease-specific and correlated with meaningful outcomes. METHODS The National Cancer Database was utilized to identify hospitals performing radical cystectomy for bladder cancer from 2004-2014. A list of candidate quality indicators was developed based on literature review, and included performance of lymphadenectomy, receipt of neoadjuvant chemotherapy, receipt of continent urinary diversion, duration of time from diagnosis to cystectomy, inpatient length of stay and 30-day hospital readmission. Random effects models were used to identify quality indicators (QI's) with statistically significant between-hospital variance. Case-mix adjustment was performed by comparing observed to expected performance using the indirect standardization method. Outlier hospitals were defined as those that performed better or worse than expected based on z-test statistics. Outlier status was correlated to overall mortality using logistic and Cox regression analyses, respectively. RESULTS From 2004-2014, 48,341 patients underwent radical cystectomy at 1200 hospitals. Random effects models demonstrated significant between-hospital variance for all QI's even after adjusting for sociodemographic and clinical patient characteristics. Case-mix adjusted analyses revealed 1.7-25.4% of hospitals were categorized as outliers across the various QI's. High-performing outlier status was associated with lower overall mortality for performance of lymphadenectomy (HR 0.89, 95% confidence interval 0.83-0.95), receipt of neoadjuvant chemotherapy (HR 0.78, 0.66-0.93), receipt of continent urinary diversion (HR 0.80, 0.73-0.89), time from diagnosis to cystectomy (HR 0.90, 0.83-0.98), and 30-day hospital readmission (HR 0.84, 0.74-0.95). CONCLUSIONS Among patients undergoing radical cystectomy, there was significant variation in hospital performance across all quality indicators. High-performing outlier hospitals were associated with lower overall mortality. Our validation of these quality metrics provides support for their potential use by both policymakers and payers in efforts to measure hospital quality for high-cost surgical procedures. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e810 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Abhinav Khanna More articles by this author Olli Saarela More articles by this author Keith Lawson More articles by this author Andrew Stephenson More articles by this author Georges-Pascal Haber More articles by this author Byron Lee More articles by this author Antonio Finelli More articles by this author Robert Abouassaly More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Managing in-hospital quality improvement: An importance-performance analysis to set priorities for ST-elevation myocardial infarction care.

A focus on specific priorities increases the success rate of quality improvement efforts for broad and complex-care processes. Importance-performance analysis presents a possible approach to set priorities around which to design and implement effective quality improvement initiatives. Persistent variation in hospital performance makes ST-elevation myocardial infarction care relevant to consider for importance-performance analysis. The purpose of this study was to identify quality improvement priorities in ST-elevation myocardial infarction care. Importance and performance levels of ST-elevation myocardial infarction key interventions were combined in an importance-performance analysis. Content validity indexes on 23 ST-elevation myocardial infarction key interventions of a multidisciplinary RAND Delphi Survey defined importance levels. Structured review of 300 patient records in 15 acute hospitals determined performance levels. The significance of between-hospital variation was determined by a Kruskal-Wallis test. A performance heat-map allowed for hospital-specific priority setting. Seven key interventions were each rated as an overall improvement priority. Priority key interventions related to risk assessment, timely reperfusion by percutaneous coronary intervention and secondary prevention. Between-hospital performance varied significantly for the majority of key interventions. The type and number of priorities varied strongly across hospitals. Guideline adherence in ST-elevation myocardial infarction care is low and improvement priorities vary between hospitals. Importance-performance analysis helps clinicians and management in demarcation of the nature, number and order of improvement priorities. By offering a tailored improvement focus, this methodology makes improvement efforts more specific and achievable.

Variation in 60-day Readmission for Surgical-site Infections (SSIs) and Reoperation Following Spinal Fusion Operations for Neuromuscular Scoliosis.

Readmission for surgical-site infection (SSIs) following spinal fusion for NMS impacts costs, patient risk, and family burden; however, it may be preventable. The purpose of this study was to examine variation in hospital performance based on risk-standardized 60-day readmission rates for SSI and reoperation across 39 US Children's Hospitals. Retrospective cohort study using the Pediatric Health Information Systems (PHIS) database involving children aged 10 to 18 years with ICD9 codes indicating spinal fusion, scoliosis, and neuromuscular disease discharged from 39 US children's hospitals between January 1, 2007 and September 1, 2012. Readmissions within 60 days for SSI were identified based on the presence of ICD9 codes for (1) infectious complication of device or procedure, or (2) sepsis or specific bacterial infection with an accompanying reoperation. Logistic regression models accounting for patient-level risk factors for SSI were used to estimate expected (patient-level risk across all hospitals) and predicted (weighted average of hospital-specific and all-hospital estimates) outcomes. Relative performance was determined using the hospital-specific predicted versus expected (pe) ratios. Average volume across hospitals ranged from 2 to 23 fusions/quarter and was not associated with readmissions. Of the 7560 children in the cohort, 534 (7%) were readmitted for reoperation and 451 (6%) were readmitted for SSI within 60 days of discharge. Reoperations were associated with an SSI in 70% of cases. Across hospitals, SSI and reoperation rates ranged from 1% to 11% and 1% to 12%, respectively. After adjusting for age, sex, insurance, presence of a gastric tube, ventriculoperitoneal shunt, tracheostomy, prior admissions, number of chronic conditions, procedure type (anterior/posterior), and level (>9 or <9 vertebrae), pe ratios indicating hospital performance varied by 2-fold for each outcome. After standardizing outcomes using patient-level factors and relative case mix, several hospitals in this cohort were more successful at preventing readmissions for SSIs and reoperations. Closer examination of the organization and implementation of strategies for SSI prevention at high-performing centers may offer valuable clues for improving care at lower performing institutions. Level III.

Developing a flow-based spatial algorithm to delineate hospital service areas

Hospital service areas (HSAs) capture most of local patient-to-hospital travel flows, and have been accepted as the most basic unit for analyzing local hospital utilization and hospitalization patterns. If a given HSA includes multiple hospitals providing care for its residents, it is complicated to assign responsibility for small-area variation in hospital performance or healthcare costs to specific hospitals without established HSA managers. The goal of this study is to produce HSAs with the fewest number of hospitals within an HSA unit. Only a very limited number of studies are related to the HSA delineation. This study reviews the existing approaches to delineate a broader range of service areas besides HSAs. A spatial algorithm named Travel-to-Hospital Algorithm (TTHA) was developed and implemented using the individual hospital discharge records from the Florida State Inpatient Database for 2011. The final output, named the TTHA-derived HSAs, included 14 more eligible divisions in Florida than the HSAs produced by the traditional approach (92 vs. 78), with the degree of self-containment comparable between the two sets of HSAs. The TTHA provides insight into the patterns of hospital visits and holds great value for the delineation of other types of service and catchment areas.

Variation in hospital performance for heart failure management in the National Heart Failure Audit for England and Wales

ObjectiveInvestigation of variations in provider performance and its determinants may help inform strategies for improving patient outcomes.MethodsWe used the National Heart Failure Audit comprising 68 772 patients with heart failure...

Site of delivery contribution to black-white severe maternal morbidity disparity

The black-white maternal mortality disparity is the largest disparity among all conventional population perinatal health measures, and the mortality gap between black and white women in New York City has nearly doubled in recent years. For every maternal death, 100 women experience severe maternal morbidity, a life-threatening diagnosis, or undergo a life-saving procedure during their delivery hospitalization. Like maternal mortality, severe maternal morbidity is more common among black than white women. A significant portion of maternal morbidity and mortality is preventable, making quality of care in hospitals a critical lever for improving outcomes. Hospital variation in risk-adjusted severe maternal morbidity rates exists. The extent to which variation in hospital performance on severe maternal morbidity rates contributes to black-white disparities in New York City hospitals has not been studied. We examined the extent to which black-white differences in severe maternal morbidity rates in New York City hospitals can be explained by differences in the hospitals in which black and white women deliver. We conducted a population-based study using linked 2011-2013 New York City discharge and birth certificate datasets (n=353,773 deliveries) to examine black-white differences in severe maternal morbidity rates in New York City hospitals. A mixed-effects logistic regression with a random hospital-specific intercept was used to generate risk-standardized severe maternal morbidity rates for each hospital (n= 40). We then assessed differences in the distributions of black and white deliveries among these hospitals. Severe maternal morbidity occurred in 8882 deliveries (2.5%) and was higher among black than white women (4.2% vs 1.5%, P< .001). After adjustment for patient characteristics and comorbidities, the risk remained elevated for black women (odds ratio, 2.02; 95% confidence interval, 1.89-2.17). Risk-standardized severe maternal morbidity rates among New York City hospitals ranged from 0.8 to 5.7 per 100 deliveries. White deliveries were more likely to be delivered in low-morbidity hospitals: 65% of white vs 23% of black deliveries occurred in hospitals in the lowest tertile for morbidity. We estimated that black-white differences in delivery location may contribute as much as 47.7% of the racial disparity in severe maternal morbidity rates in New York City. Black mothers are more likely to deliver at higher risk-standardized severe maternal morbidity hospitals than are white mothers, contributing to black-white disparities. More research is needed to understand the attributes of high-performing hospitals and to share best practices among hospitals.

Variation in hospital performance according to payment sources in the states of São Paulo and do Rio Grande do Sul, Brazil

In Brazil, the combined presence of public and private interests in financing and provision of healthcare services stands out clearly in hospital care. Financing arrangements adopted by hospitals (the public Brazilian Unified National Health System - SUS and/or health plans and/or out-of-pocket payment) can affect quality of care. Studies have analyzed the hospital standardized mortality ratio (HSMR) in relation to quality improvements. The objective was to analyze HSMR according to source of payment for the hospitalization and the hospital's financing arrangement. The study analyzed secondary data and causes that accounted for 80% of hospital deaths. HSMR was calculated for each hospital and payment source. Hospitals with worse-than-expected performance (HSMR > 1) were mostly large public hospitals. HSMR was higher in the SUS, including between admissions in the hospital. Despite the study's limitations, the findings point to inequalities in results of care. Efforts are needed to improve the quality of hospital services, regardless of the payment sources.

EVALUATING THE PERFORMANCE OF AMPUTEE SERVICES AT NEIGHBOURING HOSPITALS: A RISK ADJUSTED PERFORMANCE ANALYSIS

Background: Despite advances in vascular surgery techniques, ageing populations and increasing rates of vascular disease and diabetes have contributed to relatively steady amputation rates. Older amputees have limited life expectancies and often require expensive rehabilitation interventions on top of vascular procedures. Services warrant scrutiny with view to reducing clinical practice variations, improving hospital performance and securing the best patient outcomes. Objective: This study employed a novel methodology to assess 12-month hospital performance associated with provision of lower-limb amputee services at three neighbouring hospitals. Design and Setting: Routinely collected data on individuals having an initial lower-limb amputation from July 2001 to June 2008 at three hospital networks in Adelaide, South Australia were analysed. Observed and expected lengths of stay and patient outcomes were generated, from which relative performance across hospitals were compared. Results: Following amputation we observed a short time-to-death (0.8 years, IQR 0.21-2.12) and 12-month mortality rate of 25% (unadjusted). Risk-adjusted analyses indicated that one hospital with co-located vascular and rehabilitation services had greater performance with lower re-amputation rates and fewer deaths. However, length of stay at this hospital was longer than expected. Conclusion: The risk-adjusted performance analysis provided an approach which could inform further investigations around variation in hospital performance to inform best practice service delivery.

Hospital variation in rates of acid-reducing medication use after laparoscopic sleeve gastrectomy

BackgroundPostoperative gastroesophageal reflux is one of the most important long-term complications of sleeve gastrectomy, the most common bariatric procedure. ObjectiveTo assess variation in hospital performance with laparoscopic sleeve gastrectomy using rates of acid-reducing medication use at postoperative 1 year. SettingClinical registry of bariatric surgical patients at academic and community hospitals in Michigan. MethodsWe studied 2923 patients who underwent laparoscopic sleeve gastrectomy across 39 hospitals in the Michigan Bariatric Surgery Collaborative, 2007 to 2014. We compared risk- and reliability-adjusted rates of new-onset reflux—defined by new use of acid-reducing medication—across hospitals and in relation to surgical quality indicators (hospital procedure volume and 30-day complications). ResultsOverall, 20% of patients were newly taking acid-reducing medication at postoperative 1 year. Hospital rates of new medication use varied 3-fold, ranging from 10% (95% CI 7−15%) to 31% (95% CI 23−40%) of patients. Of the 2 hospitals with significantly lower rates of new medication use, 1 was high volume and 1 was medium volume. The 1 hospital with significantly higher rates was medium volume. Rates of acid-reducing medication use did not correlate with hospital volume or perioperative complications. ConclusionAcross Michigan hospitals, rates of new acid-reducing medication use at 1 year after laparoscopic sleeve gastrectomy varied widely and did not correlate with traditional quality indicators. Future research could explore differences in surgical technique to better understand the factors underlying variation in long-term outcomes after sleeve gastrectomy.

Risk-Adjusted Variation of Publicly Reported Emergency Department Timeliness Measures

The Centers for Medicare & Medicaid Services (CMS) recently published emergency department (ED) timeliness measures. These data show substantial variation in hospital performance and suggest the need for process improvement initiatives. However, the CMS measures are not risk adjusted and may provide misleading information about hospital performance and variation. We hypothesize that substantial hospital-level variation will persist after risk adjustment. This cross-sectional study included hospitals that participated in the Emergency Department Benchmarking Alliance and CMS ED measure reporting in 2012. Outcomes included the CMS measures corresponding to median annual boarding time, length of stay of admitted patients, length of stay of discharged patients, and waiting time of discharged patients. Covariates included hospital structural characteristics and case-mix information from the American Hospital Association Survey, CMS cost reports, and the Emergency Department Benchmarking Alliance. We used a γregression with a log link to model the skewed outcomes. We used indirect standardization to create risk-adjusted measures. We defined "substantial" variation as coefficient of variation greater than 0.15. The study cohort included 723 hospitals. Risk-adjusted performance on the CMS measures varied substantially across hospitals, with coefficient of variation greater than 0.15 for all measures. Ratios between the 10th and 90th percentiles of performance ranged from 1.5-fold for length of stay of discharged patients to 3-fold for waiting time of discharged patients. Policy-relevant variations in publicly reported CMS ED timeliness measures persist after risk adjustment for nonmodifiable hospital and case-mix characteristics. Future "positive deviance" studies should identify modifiable process measures associated with high performance.

Complication rates of ostomy surgery are high and vary significantly between hospitals.

Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement. The purpose of this work was to evaluate the variation in outcomes after ostomy creation surgery within Michigan to identify targets for quality improvement. This was a retrospective cohort study. The study took place within the 34-hospital Michigan Surgical Quality Collaborative. Patients included were those undergoing ostomy creation surgery between 2006 and 2011. We evaluated hospital morbidity and mortality rates after risk adjustment (age, comorbidities, emergency vs elective, and procedure type). A total of 4250 patients underwent ostomy creation surgery; 3866 procedures (91.0%) were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95% CI, 18.4-43.9) to 60.8% (95% CI, 48.9-72.6). There were 5 statistically significant high-outlier hospitals and 3 statistically significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals. This work was limited by its retrospective study design, by unmeasured variation in case severity, and by our inability to differentiate between colostomies and ileostomies because of the use of Current Procedural Terminology codes. Morbidity and mortality rates for modern ostomy surgery are high. Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals.

National Assessment of Margin Status as a Quality Indicator after Pancreatic Cancer Surgery

Surgical margin involvement is an important outcome after pancreatic cancer surgery; however, variation in pathologic review practices may limit its use as a quality indicator. Our objectives were to assess variation in hospital performance and the reliability of margin involvement after pancreatic cancer surgery. From the National Cancer Data Base, patients who underwent pancreatic resection for stage I to III adenocarcinoma were identified. Risk-adjusted surgical margin involvement was evaluated using hierarchical regression methods, and variation in hospital performance and reliability was determined. From 1,002 hospitals, 14,889 patients underwent pancreatic resection for adenocarcinoma, and 3,573 (24.0 %) had an involved surgical margin (R1 22.8 %; R2 1.2 %). The strongest predictors associated with margin involvement were T stage [T3: odds ratio (OR) 2.08, 95 % confidence interval (CI) 1.68-2.59; T4: OR 7.26, 95 % CI 5.50-9.60; vs. T1] and tumor size (2-3.9 cm: OR 1.66, 95 % CI 1.39-1.98, ≥ 4 cm: OR 2.28, 95 % CI 1.90-2.74; vs. <2 cm). Factors associated with a decreased likelihood of margin involvement were the use of neoadjuvant therapy and hospital type (academic and National Cancer Institute-designated comprehensive cancer centers vs. community). At the hospital level, the mean risk-adjusted surgical margin involvement rate was 25.9 % and ranged 10.1 to 50.5 %. Twenty-one (2.1 %) hospitals had lower-than-expected and 17 (1.7 %) had higher-than-expected margin involvement. A minimum acceptable reliability of 0.4 was met after 13 cases and was achieved by 249 hospitals that performed 79 % of pancreatic resections assessed. Despite differences in pathologic evaluation practices, hospitals can be feasibly and reliably provided comparative data on surgical margin status after resection for pancreatic cancer.

Hospital cost and quality performance in relation to market forces: an examination of U.S. community hospitals in the “post-managed care era”

Managed care substantially transformed the U.S. healthcare sector in the last two decades of the twentieth century, injecting price competition among hospitals for the first time in history. However, total HMO enrollment has declined since 2000. This study addresses whether managed care and hospital competition continued to show positive effects on hospital cost and quality performance in the "post-managed care era." Using data for 1,521 urban hospitals drawn from the Healthcare Cost and Utilization Project, we examined hospital cost per stay and mortality rate in relation to HMO penetration and hospital competition between 2001 and 2005, controlling for patient, hospital, and other market characteristics. Regression analyses were employed to examine both cross-sectional and longitudinal variation in hospital performance. We found that in markets with high HMO penetration, increase in hospital competition over time was associated with decrease in mortality but no change in cost. In markets without high HMO penetration, increase in hospital competition was associated with increase in cost but no change in mortality. Overall, hospitals in high HMO penetration markets consistently showed lower average costs, and hospitals in markets with high hospital competition consistently showed lower mortality rates. Hospitals in markets with high HMO penetration also showed lower mortality rates in 2005 with no such difference found in 2001. Our findings suggest that while managed care may have lost its strength in slowing hospital cost growth, differences in average hospital cost associated with different levels of HMO penetration across markets still persist. Furthermore, these health plans appear to put quality of care on a higher priority than before.

Evaluation of hospital glycemic control at US Academic Medical Centers

To evaluate contemporary hospital glycemic management in US academic medical centers. This retrospective cohort study was conducted on patients discharged from 37 academic medical centers between July 1 and September 30, 2004; 1,718 eligible adult patients met at least 1 of the inclusion criteria: 2 consecutive blood glucose readings >180 mg/dL within 24 hours, or insulin treatment at any time during hospitalization. We assessed 3 consecutive measurement days of glucose values, glycemic therapy, and additional clinical and laboratory characteristics. In this diverse cohort, 79% of patients had a prior diagnosis of diabetes, and 84.6% received insulin on the second measurement day. There was wide variation in hospital performance of recommended hospital diabetes care measures such as glycosylated hemoglobin (A1C) assessment (range, 3%-63%) and timely admission laboratory glucose measurement (range, 39%-97%). Median glucose was significantly lower for patients in the intensive care unit (ICU) compared to ward/intermediate care. ICU patients treated with intravenous insulin had significantly lower median glucose when compared to subcutaneous insulin. Only 25% of ICU patients on day 3 had estimated 6 AM glucose <or=110 mg/dL. Hyperglycemia was common, 50% of all patients had >or=1 glucose measurement >or=180 mg/dL on measurement days 2 and 3. Severe hypoglycemia (<50 mg/dL) occurred in 2.8% of all patient days. Despite frequent insulin use, glucose control was suboptimal. Academic medical centers have opportunities to improve care to meet current American Diabetes Association hospital diabetes care standards.