Are diagnosis specific outcome indicators based on administrative data useful in assessing quality of hospital care?

BACKGROUND

Hospital performance reports based on administrative data should distinguish differences in quality of care between hospitals from case mix related variation and random error effects. A study was undertaken to determine which of 12 diagnosis-outcome indicators measured across all hospitals in one state had significant risk adjusted systematic (or special cause) variation (SV) suggesting differences in quality of care. For those that did, we determined whether SV persists within hospital peer groups, whether indicator results correlate at the individual hospital level, and how many adverse outcomes would be avoided if all hospitals achieved indicator values equal to the best performing 20% of hospitals.

METHODS

All patients admitted during a 12 month period to 180 acute care hospitals in Queensland, Australia with heart failure (n = 5745), acute myocardial infarction (AMI) (n = 3427), or stroke (n = 2955) were entered into the study. Outcomes comprised in-hospital deaths, long hospital stays, and 30 day readmissions. Regression models produced standardised, risk adjusted diagnosis specific outcome event ratios for each hospital. Systematic and random variation in ratio distributions for each indicator were then apportioned using hierarchical statistical models.

RESULTS

Only five of 12 (42%) diagnosis-outcome indicators showed significant SV across all hospitals (long stays and same diagnosis readmissions for heart failure; in-hospital deaths and same diagnosis readmissions for AMI; and in-hospital deaths for stroke). Significant SV was only seen for two indicators within hospital peer groups (same diagnosis readmissions for heart failure in tertiary hospitals and inhospital mortality for AMI in community hospitals). Only two pairs of indicators showed significant correlation. If all hospitals emulated the best performers, at least 20% of AMI and stroke deaths, heart failure long stays, and heart failure and AMI readmissions could be avoided.

CONCLUSIONS

Diagnosis-outcome indicators based on administrative data require validation as markers of significant risk adjusted SV. Validated indicators allow quantification of realisable outcome benefits if all hospitals achieved best performer levels. The overall level of quality of care within single institutions cannot be inferred from the results of one or a few indicators.

A key mechanism of pathogenesis in sheep infected with the nematode Teladorsagia circumcincta

Infection of sheep with the abomasal nematode Teladorsagia circumcincta can cause a relative protein deficiency and reduce growth rate in growing lambs. A key event appears to be the destruction of junctions between epithelial cells. If the infection is heavy or prolonged, this leads to increased mucus production, hyperplasia, decreased acid production, gastrinemia, inappetance and pepsinogenemia. The severity of the infection depends upon the extent of concurrent infection, the nutritional status of the host and genetically controlled variation in the ability to mount protective immune responses.

Excretory/secretory products of Haemonchus contortus inhibit aminopyrine accumulation by rabbit gastric glands in vitro

Abomasal parasites inhibit gastric acid secretion and reduce the number of acid secreting parietal cells either through physical contact with gastric tissue, the release of inhibitory excretory/secretory (ES) products or by initiating the host inflammatory response. To examine the role of parasite ES products, adult Haemonchus contortus were incubated in a medium based on Hank's balanced salt solution and three incubates were tested for the presence of inhibitors of acid secretion by dispersed rabbit gastric glands in vitro, using the intracellular accumulation of 14C-aminopyrine (AP) as an indirect measure of acid secretion. Acceptably sensitive rabbit preparations (80%) for testing ES products showed increased 14C-AP accumulation with either 10(-5) or 10(-4)M histamine. Sheep glands proved unsuitable as a test system as only two of six preparations responded weakly to histamine. Inhibitory activity was demonstrated in all the three parasite incubates, although responses varied quantitatively between tests, even with the same batch of incubate. In single tests, 16% ES products significantly reduced the 14C-AP ratio (P<0.05) of 10(-4)M histamine-stimulated glands (15 of 19 tests with Batch 1 and two of six with Batch 3). Even at 1 and 5%, ES products (Batch 2) were inhibitory for 10(-5)M histamine-stimulated glands: at 1% the mean reduction was 26.0% (range 7.8-54.8%, n=10), four of which were statistically significant and at 5% was 17.6% (range -15.3-53.8%, n=17), four of which were statistically significant. ES products were overall inhibitory (-12%, P<0.05), when tested on glands exposed to increasing histamine concentrations from 10(-6)M to 10(-3)M (which increased the 14C-AP ratio (P<0.001)). Responses by individual gland preparations differed (P<0.001). The active component(s) of the parasite ES products were less than 5000 molecular weight. Ammonium chloride, tested over the range of concentrations of ammonia present in worm incubates (0.2-1 mM, final concentrations in the gland incubations of 0.005-0.1 mM), had variable, but overall inhibitory effects on 10(-5)M histamine-stimulated glands (n=3). When tested with a range of histamine concentrations, 0.01 mM NH4Cl overall reduced the response by 8.6% (P<0.05)(n=4). The similarity of responses of rabbit glands to parasite ES products and to NH4Cl suggests that ammonia may be the small molecular weight ES product of adult H. contortus, which inhibited acid secretion in vitro.

Measurement of B --> K*gamma branching fractions and charge asymmetries

The branching fractions of the exclusive decays B0-->K(*0)gamma and B+-->K(*+)gamma are measured from a sample of (22.74+/-0.36)x10(6) BB decays collected with the BABAR detector at the PEP-II asymmetric e(+)e(-) collider. We find B (B0-->K(*0)gamma) = [4.23+/-0.40(stat)+/-0.22(syst)]x10(-5), B(B+-->K(*+)gamma) = [3.83+/-0.62(stat)+/-0.22(syst)]x10(-5) and constrain the CP-violating charge asymmetry to be -0.170<A(CP)(B-->K(*)gamma)<0.082 at 90% C.L.

Health services research: what is it and what does it offer?

Over the last 20 years, clinical medicine has witnessed rapid expansion in its underlying evidence base, greater demand for accountability in clinicians' use of limited resources and increasing societal expectation for health care that confers proven benefit at reasonable cost to all eligible recipients. Health services research, also referred to as the clinical evaluative sciences, has grown in response to the need for objective empirical analysis of the modern health system's ability to deliver effective, efficient, equitable and safe care and to further the health and well-being of whole populations. In this article we provide an overview of the aims, methods and outputs of this burgeoning new discipline.

Search for the decay B0-->gammagamma

We present a limit on the branching fraction for the decay B0-->gammagamma using data collected at the Upsilon(4S) resonance with the BABAR detector at the PEP-II asymmetric energy e+e- collider. Based on the observation of one event in the signal region, out of a sample of 21.3x10(6) e+e--->Upsilon(4S)-->BB decays, we establish an upper limit on the branching fraction of B(B0-->gammagamma)<1.7x10(-6) at the 90% confidence level. This result substantially improves upon existing limits.

Measurement of the B--> J/psiK*(892) decay amplitudes

We present a measurement of the decay amplitudes in B-->J/psiK*(892) channels using 20.7 fb(-1) of data collected at the Upsilon(4S) resonance with the BABAR detector at PEP-II. We measure a P-wave fraction R(perpendicular) = (16.0 +/- 3.2 +/- 1.4)% and a longitudinal polarization fraction (59.7 +/- 2.8 +/- 2.4)%. The measurement of a relative phase that is neither 0 nor pi, phi = 2.50 +/- 0.20 +/-0.08 radians, favors a departure from the factorization hypothesis. Although the decay B-->/psiK(pi) proceeds mainly via K*(892), there is also evidence for K2*(1430) and K(pi) S-wave contributions.

Measurements of the branching fractions of exclusive charmless B meson decays with eta(') or omega mesons

We present the results of searches for B decays to charmless two-body final states containing eta(') or omega mesons, based on 20.7 fb(-1) of data collected with the BABAR detector. We find the branching fractions Beta(B(+)-->eta(')K(+)) = (70+/-8+/-5) x 10(-6), Beta(B(0)-->eta(')K(0)) = (42(+13)(-11) +/- 4) x 10(-6), and Beta(B(+)-->omega pi(+)) = (6.6(+2.1)(-1.8) +/- 0.7) x 10(-6), where the first error quoted is statistical and the second is systematic. We give measurements of four additional modes for which the 90% confidence level upper limits are Beta(B(+)-->eta(')pi(+)) < 12 x 10(-6), Beta(B(+)-->omega K(+)) < 4 x 10(-6), Beta(B(0)-->omega K(0)) < 13 x 10(-6), and Beta(B(0)-->omega pi(0)) < 3 x 10(-6).

Measurement of the B(0) and B(+) meson lifetimes with fully reconstructed hadronic final states

The B(0) and B(+) meson lifetimes have been measured in e(+)e(-) annihilation data collected in 1999 and 2000 with the BABAR detector at center-of-mass energies near the Upsilon(4S) resonance. Events are selected in which one B meson is fully reconstructed in a hadronic final state while the second B meson is reconstructed inclusively. A combined fit to the B(0) and the B(+) decay time difference distributions yields tau(B(0)) = 1.546+/-0.032(stat)+/-0.022(syst) ps, tau(B(+)) = 1.673+/-0.032(stat)+/-0.023(syst) ps, and tau(B(+))/tau(B(0)) = 1.082+/-0.026(stat)+/-0.012(syst).

Measurement of J/psi production in continuum e(+)e(-) annihilations near square root of s = 10.6 GeV

The production of J/psi mesons in continuum e(+)e(-) annihilations has been studied with the BABAR detector at energies near the Upsilon(4S) resonance. The mesons are distinguished from J/psi production in B decays through their center-of-mass momentum and energy. We measure the cross section e(+)e(-)-->J/psi X to be 2.52+/-0.21+/-0.21 pb. We set a 90% C.L. upper limit on the branching fraction for direct Upsilon(4S)-->J/psi X decays at 4.7 x 10(-4).

Measurement of the decays B--> phiK and B--> phiK*

We have observed the decays B--> phiK and phiK(*) in a sample of over 45 million B mesons collected with the BABAR detector at the PEP-II collider. The measured branching fractions are B(B+--> phiK+) = (7.7(+1.6)(-1.4)+/-0.8)x10(-6), B(B0--> phiK0) = (8.1(+3.1)(-2.5)+/-0.8)x10(-6), B(B+--> phiK(*+)) = (9.7(+4.2)(-3.4)+/-1.7)x10(-6), and B(B0--> phiK(*0)) = (8.7(+2.5)(-2.1)+/-1.1)x10(-6). We also report the upper limit B(B+--> phipi(+))<1.4x10(-6) ( 90% C.L.).

Measurement of branching fractions and search for CP-violating charge asymmetries in charmless two-body B decays into pions and kaons

We present measurements, based on a sample of approximately 23x10(6) BB pairs, of the branching fractions and a search for CP-violating charge asymmetries in charmless hadronic decays of B mesons into two-body final states of kaons and pions. We find the branching fractions B(B0-->pi(+)pi(-)) = (4.1+/-1.0+/-0.7)x10(-6), B(B0-->K+pi(-)) = (16.7+/-1.6+/-1.3)x10(-6), B(B+-->K+pi(0)) = (10.8(+2.1)(-1.9)+/-1.0)x10(-6), B(B+-->K0pi(+)) = (18.2(+3.3)(-3.0)+/-2.0)x10(-6), B(B0-->K0pi(0)) = (8.2(+3.1)(-2.7)+/-1.2)x10(-6). We also report 90% confidence level upper limits for B meson decays to the pi(+)pi(0), K+K-, and K0K+ final states. In addition, charge asymmetries have been found to be consistent with zero, where the statistical precision is in the range of +/-0.10 to +/-0.18, depending on the decay mode.