Failure-to-Rescue

OBJECTIVES

Use of failure-to-rescue (FTR) as an indicator of hospital quality has increased over the past decade, but recent authors have used different sets of complications and deaths to define this measure. This study examines the reliability and validity of different FTR measures currently in use.

RESEARCH DESIGN

We studied 3 definitions: (1) "original" FTR (using all deaths); (2) FTR-N, a "nursing sensitive" definition that uses only specific complications and deaths; and (3) FTR-A [another restricted definition of FTR used by Agency for Healthcare Research and Quality (AHRQ) for analyzing Healthcare Cost and Utilization Project (HCUP) data]. Each FTR measure was applied to 403,679 general surgical patients across 1567 hospitals reported in 1999-2000 Medicare MEDPAR data.

RESULTS

Although FTR used all deaths, FTR-N and FTR-A definitions omitted 49% and 42% of deaths, respectively. Reliability was better for FTR than FTR-A or FTR-N (rho = 0.32 vs. 0.18 vs. 0.18, respectively).

VALIDITY

Hospitals ranked by adjusted mortality were highly correlated with FTR (Kendall's tau = 0.83) and less correlated with FTR-A (tau = 0.43) and FTR-N (tau = 0.41). Adjusting for patient characteristics, all FTR measures showed strong associations with bed-to-nurse ratio, nursing mix, teaching status, and hospital size; however, hospital "high technology" was not as well associated with FTR-N.

CONCLUSIONS

For general surgery, more limited definitions used by FTR-N and FTR-A omit over 40% of deaths, display less reliability, and may have more questionable validity than the original FTR measure. We encourage analysts to use the original FTR definition that uses all deaths when analyzing hospital quality of care.

Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform

CONTEXT

Limitations in duty hours for physicians-in-training in the United States were established by the Accreditation Council for Graduate Medical Education (ACGME) and implemented on July 1, 2003. The association of these changes with mortality among hospitalized patients has not been well established.

OBJECTIVE

To determine whether the change in duty hour regulations was associated with relative changes in mortality in hospitals of different teaching intensity within the US Veterans Affairs (VA) system.

DESIGN, SETTING, AND PATIENTS

An observational study of all unique patients (N = 318 636) admitted to acute-care VA hospitals (N = 131) using interrupted time series analysis with data from July 1, 2000, to June 30, 2005. All patients had principal diagnoses of acute myocardial infarction (AMI), congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery. Logistic regression was used to examine the change in mortality for patients in more vs less teaching-intensive hospitals before (academic years 2000-2003) and after (academic years 2003-2005) duty hour reform, adjusting for patient comorbidities, common time trends, and hospital site.

MAIN OUTCOME MEASURE

All-location mortality within 30 days of hospital admission.

RESULTS

In postreform year 1, no significant relative changes in mortality were observed for either medical or surgical patients. In postreform year 2, the odds of mortality decreased significantly in more teaching-intensive hospitals for medical patients only. Comparing a hospital having a resident-to-bed ratio of 1 with a hospital having a resident-to-bed ratio of 0, the odds of mortality were reduced for patients with AMI (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.33-0.71), for the 4 medical conditions together (OR, 0.74; 95% CI, 0.61-0.89), and for the 3 medical conditions excluding AMI (OR, 0.79; 95% CI, 0.63-0.98). Compared with hospitals in the 25th percentile of teaching intensity, there was an absolute improvement in mortality from prereform year 1 to postreform year 2 of 0.70 percentage points (11.1% relative decrease) and 0.88 percentage points (13.9% relative decrease) in hospitals in the 75th and 90th percentile of teaching intensity, respectively, for the combined medical conditions.

CONCLUSIONS

The ACGME duty hour reform was associated with significant relative improvement in mortality for patients with 4 common medical conditions in more teaching-intensive VA hospitals in postreform year 2. No associations were identified for surgical patients.

Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform

CONTEXT

The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour regulations for physicians-in-training throughout the United States on July 1, 2003. The association of duty hour reform with mortality among patients in teaching hospitals nationally has not been well established.

OBJECTIVE

To determine whether the change in duty hour regulations was associated with relative changes in mortality among Medicare patients in hospitals of different teaching intensity.

DESIGN, SETTING, AND PATIENTS

An observational study of all unique Medicare patients (N = 8 529 595) admitted to short-term, acute-care, general US nonfederal hospitals (N = 3321) using interrupted time series analysis with data from July 1, 2000, to June 30, 2005. All Medicare patients had principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery. Logistic regression was used to examine the change in mortality for patients in more vs less teaching-intensive hospitals before (academic years 2000-2003) and after (academic years 2003-2005) duty hour reform, adjusting for patient comorbidities, common time trends, and hospital site.

MAIN OUTCOME MEASURE

All-location mortality within 30 days of hospital admission.

RESULTS

In medical and surgical patients, no significant relative increases or decreases in the odds of mortality for more vs less teaching-intensive hospitals were observed in either postreform year 1 (combined medical conditions group: odds ratio [OR], 1.03; 95% confidence interval [CI], 0.98-1.07; and combined surgical categories group: OR, 1.05; 95% CI, 0.98-1.12) or postreform year 2 (combined medical conditions group: OR, 1.03; 95% CI, 0.99-1.08; and combined surgical categories group: OR, 1.01; 95% CI, 0.95-1.08) compared with the prereform years. The only condition for which there was a relative increase in mortality in more teaching-intensive hospitals postreform was stroke, but this association preceded the onset of duty hour reform. Compared with nonteaching hospitals, the most teaching-intensive hospitals had an absolute change in mortality from prereform year 1 to postreform year 2 of 0.42 percentage points (4.4% relative increase) for patients in the combined medical conditions group and 0.05 percentage points (2.3% relative increase) for patients in the combined surgical categories group, neither of which were statistically significant.

CONCLUSION

The ACGME duty hour reform was not associated with either significant worsening or improvement in mortality for Medicare patients in the first 2 years after implementation.

Is thirty-day hospital mortality really lower for black veterans compared with white veterans?

OBJECTIVE

To examine the source of observed lower risk-adjusted mortality for blacks than whites within the Veterans Affairs (VA) system by accounting for hospital site where treated, potential under-reporting of black deaths, discretion on hospital admission, quality improvement efforts, and interactions by age group.

DATA SOURCES

Data are from the VA Patient Treatment File on 406,550 hospitalizations of veterans admitted with a principal diagnosis of acute myocardial infarction, stroke, hip fracture, gastrointestinal bleeding, congestive heart failure, or pneumonia between 1996 and 2002. Information on deaths was obtained from the VA Beneficiary Identification Record Locator System and the National Death Index.

STUDY DESIGN

This was a retrospective observational study of hospitalizations throughout the VA system nationally. The primary outcome studied was all-location mortality within 30 days of hospital admission. The key study variable was whether a patient was black or white.

PRINCIPAL FINDINGS

For each of the six study conditions, unadjusted 30-day mortality rates were significantly lower for blacks than for whites (p<.01). These results did not vary after adjusting for hospital site where treated, more complete ascertainment of deaths, and in comparing results for conditions for which hospital admission is discretionary versus non-discretionary. There were also no significant changes in the degree of difference by race in mortality by race following quality improvement efforts within VA. Risk-adjusted mortality was consistently lower for blacks than for whites only within the population of veterans over age 65.

CONCLUSIONS

Black veterans have significantly lower 30-day mortality than white veterans for six common, high severity conditions, but this is generally limited to veterans over age 65. This differential by age suggests that it is unlikely that lower 30-day mortality rates among blacks within VA are driven by treatment differences by race.

Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study

PURPOSE

To assess internal medicine and general surgery residents' attitudes about the effects of the Accreditation Council for Graduate Medical Education duty hours regulations on medical errors, quality of patient care, and residency experiences.

METHOD

In 2005, the authors surveyed 200 residents who trained both before and after duty hours reform at six residency programs (three internal medicine, three general surgery) at five academic medical centers in the United States. Residents' attitudes about the effects of the duty hours regulations on the quality of patient care, residency education, and quality of life were measured using a survey instrument containing 19 Likert scale questions on a scale of 1 to 5. Survey responses were compared using the Student's t-test.

RESULTS

The response rate was 80% (159 residents). Residents reported that whereas fatigue-related errors decreased slightly, errors related to reduced continuity of care significantly increased. Additionally, duty hours regulations somewhat decreased opportunities for formal education, bedside learning, and procedures, but there was no consensus that graduates would be less well trained after duty hours reform. Residents, particularly surgical trainees, reported improvements in quality of life and reduced burnout.

CONCLUSIONS

Residents in medicine and surgery had similar opinions about the effects of duty hours reform, including improved quality of life. However, resident opinions suggest that reduced fatigue-related errors have been offset by errors related to decreased continuity of care and that the quality of the educational experience may have declined. Quantifying the degree to which regulating duty hours affected errors related to discontinuity of care should be a focus of future research.

The effect of cuts in medicare reimbursement on hospital mortality

OBJECTIVE

To determine if patients treated at hospitals under different levels of financial strain from the Balanced Budget Act (BBA) of 1997 had differential changes in 30-day mortality, and whether vulnerable patient populations such as the uninsured were disproportionately affected.

DATA SOURCE

Hospital discharge data from all general acute care hospitals in Pennsylvania from 1997 to 2001.

STUDY DESIGN

A multivariate regression analysis was performed retrospectively on 30-day mortality rates, using hospital discharge data, hospital financial data, and death certificate information from Pennsylvania.

DATA COLLECTION

We used 370,017 hospital episodes with one of four conditions identified by the Agency for Healthcare Research and Quality as inpatient quality indicators were extracted.

PRINCIPAL FINDINGS

The average magnitude of Medicare payment reduction on overall net revenues was estimated at 1.8 percent for hospitals with low BBA impact and 3.6 percent for hospitals with a high impact in 1998, worsening to 2 and 4.8 percent, respectively, by 2001. Operating margins decreased significantly over the time period for all hospitals (p<.05). While unadjusted mortality rates demonstrated a disproportionate rise in mortality for patients from high impact hospitals from 1997 to 2000, adjusted analyses show no consistent, significant difference in the rate of change in mortality between high-impact and low-impact hospitals (p=.04-.94). Similarly, uninsured patients did not experience greater increases in mortality in high-impact hospitals relative to low-impact hospitals.

CONCLUSIONS

An analysis of hospitalizations in the Commonwealth of Pennsylvania did not find an adverse impact of increased financial strain from the BBA on patient mortality either among all patients or among the uninsured.

Did Postoperative Mortality Increase After the Implementation of the Medicare Balanced Budget Act?

BACKGROUND

The Balanced Budget Act (BBA) of 1997 was a cost-saving measure designed to reduce Medicare reimbursements by $116.4 billion from 1998 to 2002. Resulting financial strain could adversely affect the quality of patient care in hospitals.

OBJECTIVE

We sought to determine whether 30-day mortality rates for surgical patients who developed complications changed at different rates in hospitals under different levels of financial strain from the BBA.

METHODS

Pennsylvania hospital discharge data, financial data, and death certificate data from 1997 to 2001 were obtained. A retrospective multivariate analysis examined whether 30-day mortality rates from 8 postoperative complications varied based on degree of hospital financial strain.

RESULTS

The average magnitude of Medicare payment reduction on overall hospital net revenues was estimated at 1.8% for hospitals with low BBA impact and 3.5% for hospitals with high impact in 1998, worsening to 2.0% and 4.8%, respectively, by 2001. Mortality rates changed at similar rates for high- and low-impact hospitals from 1997 to 1999, but from 1997 to 2000 mortality rates increased more among patients in high-impact compared with low-impact hospitals (P<0.05). From 2000 to 2001, mortality rates among impact groups converged. There were no statistically significant differences based on BBA impact in changes in nursing staff or length of stay.

CONCLUSIONS

The mortality of surgical patients who developed postoperative complications increased to a greater degree in the short term in hospitals affected more by BBA. Measuring the quality impact of reimbursement cuts is necessary to understand cost-quality tradeoffs that may accompany cost-saving reforms.

A Randomized Controlled Trial of Financial Incentives for Smoking Cessation

BACKGROUND

Although 435,000 Americans die each year of tobacco-related illness, only approximately 3% of smokers quit each year. Financial incentives have been shown to be effective in modifying behavior within highly structured settings, such as drug treatment programs, but this has not been shown in treating chronic disease in less structured settings. The objective of this study was to determine whether modest financial incentives increase the rate of smoking cessation program enrollment, completion, and quit rates in a outpatient clinical setting.

METHODS

179 smokers at the Philadelphia Veterans Affairs Medical Center who reported smoking at least 10 cigarettes per day were randomized into incentive and non-incentive groups. Both groups were offered a free five-class smoking cessation program at the Philadelphia Veterans Affairs Medical Center. The incentive group was also offered $20 for each class attended and $100 if they quit smoking 30 days post program completion. Self-reported smoking cessation was confirmed with urine cotinine tests.

RESULTS

The incentive group had higher rates of program enrollment (43.3% versus 20.2%; P<0.001) and completion (25.8% versus 12.2%; P=0.02). Quit rates at 75 days were 16.3% in the incentive group versus 4.6% in the control group (P=0.01). At 6 months, quit rates in the incentive group were not significantly higher (6.5%) than in the control group (4.6%; P>0.20).

CONCLUSION

Modest financial incentives are associated with significantly higher rates of smoking cessation program enrollment and completion and short-term quit rates. Future studies should consider including an incentive for longer-term cessation.

Did recent changes in Medicare reimbursement hit teaching hospitals harder?

PURPOSE

To inform the policy debate on Medicare reimbursement by examining the financial effects of the Balanced Budget Act of 1997 (BBA) and subsequent adjustments on major academic medical centers, minor teaching hospitals, and nonteaching hospitals.

METHOD

The authors simulated the impacts of BBA and subsequent BBA adjustments to predict the independent effects of changes in Medicare reimbursement on hospital revenues using 1997-2001 Medicare Cost Reports for all short-term acute-care hospitals in the United States. The authors also calculated actual (nonsimulated) operating and total margins among major teaching, minor teaching, and nonteaching hospitals to account for hospital response to the changes.

RESULTS

The BBA and subsequent refinements reduced Medicare revenues to a greater degree in major teaching hospitals, but the fact that such hospitals had a smaller proportion of Medicare patients meant that the BBA reduced overall revenues by similar percentages across major, minor, and nonteaching hospitals. Consistently lower margins may have made teaching hospitals more vulnerable to cuts in Medicare support.

CONCLUSIONS

Recent Medicare changes affected revenues at teaching and nonteaching hospitals more similarly than is commonly believed. However, the Medicare cuts under the BBA probably exacerbated preexisting financial strain on major teaching hospitals, and increased Medicare funding may not suffice to eliminate the strain. This report's findings are consistent with recent calls to support needed services of teaching hospitals through all-payer or general funds.

Effect of cuts in Medicare reimbursement on process and outcome of care for acute myocardial infarction patients

BACKGROUND

The Balanced Budget Act (BBA) of 1997 was designed to reduce Medicare reimbursements by $116.4 billion from 1998 to 2002. The objective of this study was to determine whether the process of care for acute myocardial infarction (AMI) worsened to a greater degree in hospitals under increased financial strain from the BBA and whether vulnerable populations such as the uninsured were disproportionately affected.

METHODS AND RESULTS

We examined how process-of-care measures and in-hospital mortality for AMI patients changed in accordance with the degree of BBA-induced financial stress using data on 236,506 patients from the National Registry of Myocardial Infarction (NRMI) and Medicare Cost Reports from 1996 to 2001. BBA-induced reductions in hospital net revenues were estimated at 1.5% (2.9 million dollars) for hospitals with low BBA impact and 3.2% (3.7 million dollars) for hospitals with a high impact in 1998, worsening to 2.2% (4.4 million dollars) and 4.7% (6.0 million dollars), respectively, by 2001. For both insured and uninsured patients in high- versus low-impact hospitals, there was no systematic worsening of time to thrombolytic therapy, balloon inflation, medication use on admission, medication use on discharge, or mortality. There was no systematic pattern of different treatment among the insured and uninsured. Operating margins decreased to a degree commensurate with the degree of revenue reduction in high- versus low-impact hospitals.

CONCLUSIONS

BBA created a moderate financial strain on hospitals. However, process-of-care measures for both insured and uninsured patients with AMI were not appreciably affected by these revenue reductions. It is important to note that these results apply only to AMI patients; we do not know the degree to which these findings generalize to other conditions.

Accounting for apparent "reverse" racial disparities in Department of Veterans Affairs (VA)-based medical care: influence of out-of-VA care

Conclusions regarding racial differences in care following a newly elevated prostate-specific antigen (PSA) test at the Department of Veterans Affairs (VA) may differ depending on whether follow-up care outside the VA is considered. Consecutive Philadelphia, Pa, VA patients with newly elevated PSA tests (n = 183) were interviewed 1 year after baseline. Among exclusive VA users, Blacks had higher rates of urology referrals and prostate biopsies compared with Whites. However, these racial differences were attenuated when care obtained outside the VA also was considered.

Consumer protection and the HMO backlash: are HMOs to blame for drive-through deliveries?

This study used patient discharge data from New Jersey to examine differences in length of stay for normal, uncomplicated deliveries between patients in health maintenance organizations (HMOs) and those not in HMOs. The percentage of one-day stays increased from less than 4% for all payers in 1990 to 48.1% for HMO patients, and 31.5% for non-HMO patients in 1994. Controlling for other factors, the odds of an HMO patient staying one day were nearly twice as great as a non-HMO patient by 1994; for all patients, regardless of payer, the odds of a one-day stay in 1994 were more than 18 times the odds of a one-day stay in 1990. The strong secular trend suggests that legislation and regulations should be targeted at particular policies rather than insurers.