Validity of selected AHRQ patient safety indicators based on VA National Surgical Quality Improvement Program data

Impact of the Centers for Medicare and Medicaid Services Hospital-Acquired Conditions Policy on Billing Rates for 2 Targeted Healthcare-Associated Infections

BACKGROUND

The 2008 Centers for Medicare & Medicaid Services hospital-acquired conditions policy limited additional payment for conditions deemed reasonably preventable.

OBJECTIVE

To examine whether this policy was associated with decreases in billing rates for 2 targeted conditions, vascular catheter-associated infections (VCAI) and catheter-associated urinary tract infections (CAUTI).

STUDY POPULATION

Adult Medicare patients admitted to 569 acute care hospitals in California, Massachusetts, or New York and subject to the policy. DESIGN We used an interrupted times series design to assess whether the hospital-acquired conditions policy was associated with changes in billing rates for VCAI and CAUTI.

RESULTS

Before the policy, billing rates for VCAI and CAUTI were increasing (prepolicy odds ratio per quarter for VCAI, 1.17 [95% CI, 1.11-1.23]; for CAUTI, 1.19 [1.16-1.23]). The policy was associated with an immediate drop in billing rates for VCAI and CAUTI (odds ratio for change at policy implementation for VCAI, 0.75 [95% CI, 0.69-0.81]; for CAUTI, 0.87 [0.79-0.96]). In the postpolicy period, we observed a decreasing trend in the billing rate for VCAI and a leveling-off in the billing rate for CAUTI (postpolicy odds ratio per quarter for VCAI, 0.98 [95% CI, 0.97-0.99]; for CAUTI, 0.99 [0.97-1.00]).

CONCLUSIONS

The Centers for Medicare & Medicaid Services hospital-acquired conditions policy appears to have been associated with immediate reductions in billing rates for VCAI and CAUTI, followed by a slight decreasing trend or leveling-off in rates. These billing rates, however, may not correlate with changes in clinically meaningful patient outcomes and may reflect changes in coding practices.

A multidisciplinary three-phase approach to improve the clinical utility of patient safety indicators

PURPOSE

The AHRQ Patient Safety Indicators (PSIs) are used for calculation of risk-adjusted postoperative rates for adverse events. The payers and quality consortiums are increasingly requiring public reporting of hospital performance on these metrics. We discuss processes designed to improve the accuracy and clinical utility of PSI reporting in practice.

METHODS

The study was conducted at a 793-bed tertiary care academic medical center where PSI processes have been aggressively implemented to track patient safety events at discharge. A three-phased approach to improving administrative data quality was implemented. The initiative consisted of clinical review of all PSIs, documentation improvement, and provider outreach including active querying for patient safety events.

RESULTS

This multidisciplinary effort to develop a streamlined process for PSI calculation reduced the reporting of miscoded PSIs and increased the clinical utility of PSI monitoring. Over 4 quarters, 4 of 41 (10%) PSI-11 and 9 of 138 (7%) PSI-15 errors were identified on review of clinical documentation and appropriate adjustments were made.

CONCLUSION

A multidisciplinary, phased approach leveraging existing billing infrastructure for robust metric coding, ongoing clinical review, and frontline provider outreach is a novel and effective way to reduce the reporting of false-positive outcomes and improve the clinical utility of PSIs.

Racial disparities in failure-to-rescue among children undergoing congenital heart surgery

OBJECTIVE

To determine if racial/ethnic disparities exist among children undergoing congenital heart surgery, using failure-to-rescue (FTR) as a measure of hospital-based quality.

STUDY DESIGN

This is a retrospective, repeated cross-sectional analysis using admissions from the 2003, 2006, and 2009 Kids' Inpatient Database. All pediatric admissions (≤ 18 years) with a Risk Adjustment for Congenital Heart Surgery procedure were included. Logistic regression models examining complications, FTR, and overall mortality were constructed.

RESULTS

Hispanic ethnicity (OR 1.13, 95% CI 1.01-1.26) was associated with increased odds of experiencing a complication when compared with white race. However, black race (OR 1.66, 95% CI 1.33-2.07) and other race/ethnicity (OR 1.40, 95% CI 1.10-1.79) were risk factors for FTR. Although Hispanic ethnicity was associated with increased odds of experiencing a complication, it was not associated with FTR. In hospital fixed-effects models, black race and other race/ethnicity remained as "within hospital" risk factors for FTR.

CONCLUSIONS

Black children and children of other race/ethnicity had higher rates of mortality after experiencing a complication. This suggests that racial disparities may exist in hospital-based cardiac care or response to care.

Using multiple sources of data for surveillance of postoperative venous thromboembolism among surgical patients treated in Department of Veterans Affairs hospitals, 2005-2010

BACKGROUND

There are limitations to using administrative data to identify postoperative venous thromboembolism (VTE). We used a novel approach to quantify postoperative VTE events among Department of Veterans Affairs (VA) surgical patients during 2005-2010.

METHODS

We used VA administrative data to exclude patients with VTE during 12 months prior to surgery. We identified probable postoperative VTE events within 30 and 90 days post-surgery in three settings: 1) pre-discharge inpatient, using a VTE diagnosis code and a pharmacy record for anticoagulation; 2) post-discharge inpatient, using a VTE diagnosis code followed by a pharmacy record for anticoagulation within 7 days; and 3) outpatient, using a VTE diagnosis code and either anticoagulation or a therapeutic procedure code with natural language processing (NLP) to confirm acute VTE in clinical notes.

RESULTS

Among 468,515 surgeries without prior VTE, probable VTEs were documented within 30 and 90 days in 3,931 (0.8%) and 5,904 (1.3%), respectively. Of probable VTEs within 30 or 90 days post-surgery, 47.8% and 62.9%, respectively, were diagnosed post-discharge. Among post-discharge VTE diagnoses, 86% resulted in a VA hospital readmission. Fewer than 25% of outpatient records with both VTE diagnoses and anticoagulation prescriptions were confirmed by NLP as acute VTE events.

CONCLUSION

More than half of postoperative VTE events were diagnosed post-discharge; analyses of surgical discharge records are inadequate to identify postoperative VTE. The NLP results demonstrate that the combination of VTE diagnoses and anticoagulation prescriptions in outpatient administrative records cannot be used to validly identify postoperative VTE events.

Association between hospital imaging use and venous thromboembolism events rates based on clinical data

OBJECTIVE

The objective was to assess the presence and extent of venous thromboembolic (VTE) surveillance bias using high-quality clinical data.

BACKGROUND

Hospital VTE rates are publicly reported and used in pay-for-performance programs. Prior work suggested surveillance bias: hospitals that look more for VTE with imaging studies find more VTE, thereby incorrectly seem to have worse performance. However, these results have been questioned as the risk adjustment and VTE measurement relied on administrative data.

METHODS

Data (2009-2010) from 208 hospitals were available for analysis. Hospitals were divided into quartiles according to VTE imaging use rates (Medicare claims). Observed and risk-adjusted postoperative VTE event rates (regression models using American College of Surgeons National Surgical Quality Improvement Project data) were examined across VTE imaging use rate quartiles. Multivariable linear regression models were developed to assess the impact of hospital characteristics (American Hospital Association) and hospital imaging use rates on VTE event rates.

RESULTS

The mean risk-adjusted VTE event rates at 30 days after surgery increased across VTE imaging use rate quartiles: 1.13% in the lowest quartile to 1.92% in the highest quartile (P < 0.001). This statistically significant trend remained when examining only the inpatient period. Hospital VTE imaging use rate was the dominant driver of hospital VTE event rates (P < 0.001), as no other hospital characteristics had significant associations.

CONCLUSIONS

Even when examined with clinically ascertained outcomes and detailed risk adjustment, VTE rates reflect hospital imaging use and perhaps signify vigilant, high-quality care. The VTE outcome measure may not be an accurate quality indicator and should likely not be used in public reporting or pay-for-performance programs.

Evaluation of quality indicators for Dutch community pharmacies using a comprehensive assessment framework

BACKGROUND

In 2008, the Dutch Health Care Transparency Programme (Zichtbare Zorg) was set up to develop and apply quality indicators (QIs) for health care. These QIs serve a range of purposes and can be categorized into those for internal use--for meeting quality standards and to continuously measure improvement (formative)--and external use--to enable patients and health insurance companies to distinguish between health care providers (summative). In order to assess the validity of QIs, a comprehensive Indicator Assessment Framework (IAF) was developed. This framework specifies the following criteria for validation: content validity, absence of selection bias, absence of measurement bias, and statistical reliability. Because of the intended summative use, the IAF was used for structural assessment of the QIs set for Dutch community pharmacists.

OBJECTIVE

To assess the validity of the current set of 52 QIs for community pharmacies using the IAF.

METHODS

An expert panel applied the IAF criteria to the set of QIs collected in 1,807 Dutch community pharmacies on their performance in 2011. The QIs were judged as meeting, partly meeting, or not meeting the requirements regarding these criteria. The judgments were evaluated for QI type (structure, process, or outcome) and for predefined domains.

RESULTS

Thirteen QIs (25%) were judged as meeting the requirements for all criteria. Among them were 12 structure indicators and 1 process indicator. For process indicators, the criterion for measurement bias poorly met the requirements, and content validity was unsatisfactory for outcome indicators. The 13 overall valid QIs covered 6 out of 10 predefined domains: continuity of care, clinical risk management, compounding, dispensing of medication, management, and quality management.

CONCLUSIONS

When subjecting the QI set for community pharmacies to the requirements of the IAF, only a quarter of the QIs met all requirements. To increase the number of valid process and outcome indicators, meaningful aspects for the outcome of pharmaceutical care have to be defined, and uniform measurement of relevant processes has to be implemented.

Accuracy of using automated methods for detecting adverse events from electronic health record data: a research protocol

Background

Adverse events are associated with significant morbidity, mortality and cost in hospitalized patients. Measuring adverse events is necessary for quality improvement, but current detection methods are inaccurate, untimely and expensive. The advent of electronic health records and the development of automated methods for encoding and classifying electronic narrative data, such as natural language processing, offer an opportunity to identify potentially better methods. The objective of this study is to determine the accuracy of using automated methods for detecting three highly prevalent adverse events: a) hospital-acquired pneumonia, b) catheter-associated bloodstream infections, and c) in-hospital falls.

Methods/design

This validation study will be conducted at two large Canadian academic health centres: the McGill University Health Centre (MUHC) and The Ottawa Hospital (TOH). The study population consists of all medical, surgical and intensive care unit patients admitted to these centres between 2008 and 2014. An automated detection algorithm will be developed and validated for each of the three adverse events using electronic data extracted from multiple clinical databases. A random sample of MUHC patients will be used to develop the automated detection algorithms (cohort 1, development set). The accuracy of these algorithms will be assessed using chart review as the reference standard. Then, receiver operating characteristic curves will be used to identify optimal cut points for each of the data sources. Multivariate logistic regression and the areas under curve (AUC) will be used to identify the optimal combination of data sources that maximize the accuracy of adverse event detection. The most accurate algorithms will then be validated on a second random sample of MUHC patients (cohort 1, validation set), and accuracy will be measured using chart review as the reference standard. The most accurate algorithms validated at the MUHC will then be applied to TOH data (cohort 2), and their accuracy will be assessed using a reference standard assessment of the medical chart.

Discussion

There is a need for more accurate, timely and efficient measures of adverse events in acute care hospitals. This is a critical requirement for evaluating the effectiveness of preventive interventions and for tracking progress in patient safety through time.

Anesthesia complications as a childbirth patient safety indicator

BACKGROUND

The Agency for Healthcare Research and Quality (AHRQ) has established multiple sets of indicators for quality monitoring and improvement. One such set is the patient safety indicators (PSIs), which focuses on potentially preventable hospital complications after surgeries, procedures, and childbirth. Our objective in this study was to determine the prevalence of childbirth-related anesthesia complications by method of delivery and to evaluate the variation in complication rates across hospitals using the AHRQ PSI methodology and a modification specific to childbirth with the goal of determining the relevance of tracking anesthesia complications as a potential PSI for childbirth.

METHODS

The technical specifications of the experimental Anesthesia Complication Quality Indicator, one of the PSI defined by AHRQ, were modified to create a childbirth-specific indicator that included all childbirth admissions (vaginal and cesarean deliveries) and complications from general and neuraxial anesthesia/analgesia. Using California hospital discharge data, we calculated hospital-specific rates, adjusting for age, race/ethnicity, and pregnancy complications.

RESULTS

A total of 508,842 deliveries occurred in 254 hospitals in California in 2009. Hospitals with <200 annual deliveries (N = 12) were excluded from analyses. Among 242 hospitals, the rate of anesthesia complications was 0.13% for the standard AHRQ study population (adult surgical admissions, which included cesarean deliveries). The childbirth-specific rate of anesthesia complications was 0.31%. When stratified by method of delivery, complication rates were 0.49% for cesarean delivery and 0.22% for vaginal delivery (P < 0.0001). The unadjusted mean (SD) was 0.34% (0.34%), with range (0%-2.46%). The rates of 13 hospitals (including their 95% confidence limits) remained in the upper quartile as outliers, with adjusted rates from 0.52% to 2.13%.

CONCLUSIONS

Rates of childbirth-related anesthesia complications may provide an opportunity to identify hospitals with extreme rates that may provide insights into systematic ways to improve patient safety.

Measuring surgical quality: a national clinical registry versus administrative claims data

BACKGROUND

This study compared postoperative complications of patients who underwent pancreaticoduodenectomy (PD) recorded in the National Surgical Quality Improvement Program (NSQIP) to patients who underwent PD recorded in the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS).

METHODS

Data included 8,822 PD cases recorded in NSQIP and 9,827 PD cases recorded in NIS performed between 2005 and 2010. Eighteen postoperative adverse outcomes were identified in NSQIP and then matched to corresponding International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes in NIS. Using logistic regression, the relationship between database and postoperative complications was determined while accounting for patient factors.

RESULTS

Patients undergoing PD in the NIS were more likely to have several adverse outcomes, including urinary tract infection (odds ratio (OR) = 1.42, p < 0.001), pneumonia (OR = 1.51, p < 0.001), renal insufficiency (OR = 2.39, p < 0.001), renal failure (OR = 1.67, p = 0.005), graft/prosthetic failure (OR = 9.35, p < 0.001), and longer length of stay (1.1 days, p < 0.001). They were less likely to have cardiac arrest (OR = 0.45, p = 0.002), postoperative sepsis (OR = 0.38, p < 0.001), deep vein thrombosis (OR = 0.18, p < 0.001), and cerebrovascular accident (OR = 0.04, p = 0.003).

CONCLUSIONS

There is considerable discordance between NSQIP and NIS in the assessment of postoperative complications following PD, which underscores the value of recognizing the capabilities and limitations of each data source.

Patient safety in the era of the 80-hour workweek

OBJECTIVE

In 2003, duty-hour regulations (DHR) were initially implemented for residents in the United States to improve patient safety and protect resident's well-being. The effect of DHR on patient safety remains unclear. The study objective was to evaluate the effect of DHR on patient safety.

DESIGN

Using an interrupted time series analysis, we analyzed selected patient safety indicators (PSIs) for 376 million discharges in teaching (T) vs nonteaching (NT) hospitals before and after implementation of DHR in 2003 that restricted resident work hours to 80 hours per week. The PSIs evaluated were postoperative pulmonary embolus or deep venous thrombosis (PEDVT), iatrogenic pneumothorax (PTx), accidental puncture or laceration, postoperative wound dehiscence (WD), postoperative hemorrhage or hematoma, and postoperative physiologic or metabolic derangement. Propensity scores were used to adjust for differences in patient comorbidities between T and NT hospitals and between discharge quarters. The primary outcomes were differences in the PSI rates before and after DHR implementation. The PSI differences between T and NT institutions were the secondary outcome.

SETTING

T and NT hospitals in the United States.

PARTICIPANTS

Participants were 376 million patient discharges from 1998 to 2007 in the Nationwide Inpatient Sample.

RESULTS

Declining rates of PTx in both T and NT hospitals preintervention slowed only in T hospitals postintervention (p = 0.04). Increasing PEDVT rates in both T and NT hospitals increased further only in NT hospitals (p = 0.01). There were no differences in the PSI rates over time for hemorrhage or hematoma, physiologic or metabolic derangement, accidental puncture or laceration, or WD. T hospitals had higher rates than NT hospitals both preintervention and postintervention for all the PSIs except WD.

CONCLUSIONS

Trends in rates for 2 of the 6 PSIs changed significantly after DHR implementation, with PTx rates worsening in T hospitals and PEDVT rates worsening in NT hospitals. Lack of consistent patterns of change suggests no measurable effect of the policy change on these PSIs.

Influence of data quality on computed Dutch hospital quality indicators: a case study in colorectal cancer surgery

BACKGROUND

Our study aims to assess the influence of data quality on computed Dutch hospital quality indicators, and whether colorectal cancer surgery indicators can be computed reliably based on routinely recorded data from an electronic medical record (EMR).

METHODS

Cross-sectional study in a department of gastrointestinal oncology in a university hospital, in which a set of 10 indicators is computed (1) based on data abstracted manually for the national quality register Dutch Surgical Colorectal Audit (DSCA) as reference standard and (2) based on routinely collected data from an EMR. All 75 patients for whom data has been submitted to the DSCA for the reporting year 2011 and all 79 patients who underwent a resection of a primary colorectal carcinoma in 2011 according to structured data in the EMR were included. Comparison of results, investigating the causes for any differences based on data quality analysis. Main outcome measures are the computability of quality indicators, absolute percentages of indicator results, data quality in terms of availability in a structured format, completeness and correctness.

RESULTS

All indicators were fully computable based on the DSCA dataset, but only three based on EMR data, two of which were percentages. For both percentages, the difference in proportions computed based on the two datasets was significant.All required data items were available in a structured format in the DSCA dataset. Their average completeness was 86%, while the average completeness of these items in the EMR was 50%. Their average correctness was 87%.

CONCLUSIONS

Our study showed that data quality can significantly influence indicator results, and that our EMR data was not suitable to reliably compute quality indicators. EMRs should be designed in a way so that the data required for audits can be entered directly in a structured and coded format.

Facilitating post-surgical complication detection through sublanguage analysis

Identification of postsurgical complications is the first step towards improving patient safety and health care quality as well as reducing heath care cost. Existing NLP-based approaches for retrieving postsurgical complications are based on search strategies. Here, we conduct a sublanguage analysis study using free text reports available for a cohort of patients with postsurgical complications identified manually to compare the keywords identified by subject matter experts with words/phrases automatically identified by sublanguage analysis. The results suggest that search-based approaches may miss some cases and the sublanguage analysis results can be used as a base to develop an information extraction system or support search-based NLP approaches by augmenting search queries.

The influence of complications on the costs of complex cancer surgery

BACKGROUND

It is widely known that outcomes after cancer surgery vary widely, depending on interactions between patient, tumor, neoadjuvant therapy, and provider factors. Within this complex milieu, the influence of complications on the cost of surgical oncology care remains unknown. The authors examined rates of Patient Safety Indicator (PSI) occurrence for 6 cancer operations and their association with costs of care.

METHODS

The Agency for Healthcare Research and Quality (AHRQ) PSI definitions were used to identify patient safety-related complications in Medicare claims data. Hospital and inpatient physician claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Risk-adjusted regression analyses were used to measure the association between each PSI and hospitalization costs.

RESULTS

Overall PSI rates ranged from a low of 0.01% for postoperative hip fracture to a high of 2.58% for respiratory failure. Death among inpatients with serious treatable complications, postoperative respiratory failure, postoperative thromboembolism, and accidental puncture/laceration were >1% for all 6 cancer operations. Several PSIs-including decubitus ulcer, death among surgical inpatients with serious treatable complications, and postoperative thromboembolism-raised hospitalization costs by ≥20% for most cancer surgery types. Postoperative respiratory failure resulted in a cost increase >50% for all cancer resections.

CONCLUSIONS

The consistently higher costs associated with cancer surgery PSIs indicate that substantial health care savings could be achieved by targeting these indicators for quality improvement.

Impact of including readmissions for qualifying events in the patient safety indicators

The Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) do not capture complications arising after discharge. This study sought to quantify the bias related to omission of readmissions for PSI-qualifying conditions. Using 2000-2009 California Office of Statewide Health Planning and Development Patient Discharge Data, the study team examined the change in PSI rates when including readmissions in the numerator, hospitals performing in the extreme deciles, and longitudinal performance. Including 7-day readmissions resulted in a 0.3% to 8.9% increase in average hospital PSI rates. Hospital PSI rates with and without PSI-qualifying 30-day readmissions were highly correlated for point estimates and within-hospital longitudinal change. Most hospitals remained in the same relative performance decile. Longer length of stay, public payer, and discharge to skilled nursing facilities were associated with a higher risk of readmission for a PSI-qualifying event. Failure to include readmissions in calculating PSIs is unlikely to lead to erroneous conclusions.

Detecting adverse events in surgery: comparing events detected by the Veterans Health Administration Surgical Quality Improvement Program and the Patient Safety Indicators

BACKGROUND

The Patient Safety Indicators (PSIs) use administrative data to screen for select adverse events (AEs). In this study, VA Surgical Quality Improvement Program (VASQIP) chart review data were used as the gold standard to measure the criterion validity of 5 surgical PSIs. Independent chart review was also used to determine reasons for PSI errors.

METHODS

The sensitivity, specificity, and positive predictive value of PSI software version 4.1a were calculated among Veterans Health Administration hospitalizations (2003-2007) reviewed by VASQIP (n = 268,771). Nurses re-reviewed a sample of hospitalizations for which PSI and VASQIP AE detection disagreed.

RESULTS

Sensitivities ranged from 31% to 68%, specificities from 99.1% to 99.8%, and positive predictive values from 31% to 72%. Reviewers found that coding errors accounted for some PSI-VASQIP disagreement; some disagreement was also the result of differences in AE definitions.

CONCLUSIONS

These results suggest that the PSIs have moderate criterion validity; however, some surgical PSIs detect different AEs than VASQIP. Future research should explore using both methods to evaluate surgical quality.

Validity of AHRQ patient safety indicators derived from ICD-10 hospital discharge abstract data (chart review study)

OBJECTIVE

To assess if the Agency for Healthcare Research and Quality  patient safety indictors (PSIs) could be used for case findings in the International Classification of Disease 10th revision (ICD-10) hospital discharge abstract data.

DESIGN

We identified and randomly selected 490 patients with a foreign body left during a procedure (PSI 5-foreign body), selected infections (IV site) due to medical care (PSI 7-infection), postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT; PSI 12-PE/DVT), postoperative sepsis (PSI 13-sepsis)and accidental puncture or laceration (PSI 15-laceration) among patients discharged from three adult acute care hospitals in Calgary, Canada in 2007 and 2008. Their charts were reviewed for determining the presence of PSIs and used as the reference standard, positive predictive value (PPV) statistics were calculated to determine the proportion of positives in the administrative data representing 'true positives'.

RESULTS

The PPV for PSI 5-foreign body was 62.5% (95% CI 35.4% to 84.8%), PSI 7-infection was 79.1% (67.4% to 88.1%), PSI 12-PE/DVT was 89.5% (66.9% to 98.7%), PSI 13-sepsis was 12.5% (1.6% to 38.4%) and PSI 15-laceration was 86.4% (75.0% to 94.0%) after excluding those who presented to the hospital with the condition.

CONCLUSIONS

Several PSIs had high PPV in the ICD administrative data and are thus powerful tools for true positive case finding. The tools could be used to identify potential cases from the large volume of admissions for verification through chart reviews. In contrast, their sensitivity has not been well characterised and users of PSIs should be cautious if using them for 'quality of care reporting' presenting the rate of PSIs because under-coded data would generate falsely low PSI rates.

Biliary and vascular anomalies in living liver donors: the role and accuracy of pre-operative radiological mapping

BACKGROUND

The aim of the present study was to determine the utility of computed tomography (CT) and magnetic resonance imaging (MRI) anatomic mapping in the detection of biliary and vascular anomalies prior to a living liver donor (LLD) operation.

METHODS

A retrospective study of all LLD patient charts, operative and radiology reports from 1 January 2002 to 1 January 2012 was conducted. Primary post-operative outcomes assessed included mortality, re-operation, readmission and need for endoscopic or percutaneous intervention. Sensitivity and specificity of MR and CT pre-operative screening was calculated against the gold standard of intra-operative findings.

RESULTS

A total of 34 donors had an average age of 38 years (range: 22-58) with a body mass index (BMI) of 25.6 kg/m(2) (range: 19.8-32.5) and a length of stay (LOS) of 10.1 days (range: 5-41). There were no donor mortalities. Sensitivity and specificity of CT was 70.0% and 91.3%, and of MRI screening 23.1% and 100.0%, respectively. Patients with inaccurate pre-operative CT or MRI did not have an increased risk of complications.

CONCLUSIONS

Even although it was specific, pre-operative MR screening missed up to 77.0% of biliary anomalies. An impeccable surgical technique remains the key in preventing biliary complications of a living donor hepatectomy where pre-operative MRI screening is false.

The Relationship Between Safety Culture and Patient Outcomes

Patient safety continues to be a serious health concern in acute-care hospitals. Safety culture has been a frequent target for patient safety improvement over the past decade, based on recommendations from the Institute of Medicine and its use in industry. However, the relationship between safety culture and patient safety in acute-care hospitals has yet to be systematically examined. Thus, a meta-analysis was devised to examine the relationship between patient safety outcomes and safety culture in that setting. Due to the limited empirical research reports available, five small pilot meta-analyses were conducted, examining the relationship between safety culture and each of the following: pressure ulcers, falls, medication errors, nurse-sensitive outcomes, and post-operative outcomes. No significant relationships of any size were identified. An assessment of the relevant literature is presented, offering potential explanations for this surprising finding and an agenda for future research.

Venous thromboembolism after joint replacement in older male veterans with comorbidity

OBJECTIVES

To identify older adults with comorbidities or poor functional status at high risk of postoperative venous thromboembolism (VTE).

DESIGN

Retrospective cohort study.

SETTING

Veterans Affairs Medical Center (VAMC).

PARTICIPANTS

Older adults who underwent total hip and knee replacement (THR and TKR) from 2002 to 2009.

MEASUREMENTS

Using multivariate logistic regression, the independent effect of cardiopulmonary comorbidities and diabetes on VTE was analyzed. Functional status expressed in a summary physical component score (PCS) was also analyzed in a subset of individuals in whom information on it was available.

RESULTS

There were 23,326 THR and TKR surgeries performed at the VAMC during the study period. Individuals with chronic obstructive pulmonary disease (COPD) had a 25% greater risk of VTE (odds ratio (OR) = 1.25, 95% confidence interval (CI) = 1.06-1.48), whereas those with coronary artery disease, congestive heart failure, and cerebrovascular disease did not have a greater risk of VTE. Individuals with diabetes mellitus had a lower risk of VTE (OR = 0.77, 95% CI = 0.64-0.92). Individuals with low PCS, which were available for 3,169 patients, had a 62% greater risk, although the effect did not reach statistical significance (lowest vs highest quartile OR = 1.62, 95% CI = 0.93-2.80).

CONCLUSION

Individuals with COPD had slightly greater risk of VTE, whereas low functional status had a larger effect that did not reach statistical significance. The constraints of administrative data analysis and sample size available for PCS limit conclusions about the role of these comorbidities and functional status.

Accidental puncture or laceration in colorectal surgery: a quality indicator or a complexity measure?

BACKGROUND

Accidental puncture or laceration during a surgical procedure is a patient safety indicator that is publicly reported and will factor into the Centers for Medicare and Medicaid's pay-for-performance plan. Accidental puncture or laceration includes serosal tear, enterotomy, and injury to the ureter, bladder, spleen, or blood vessels.

OBJECTIVE

This study aimed to identify risk factors and assess surgical outcomes related to accidental puncture or laceration.

DESIGN

This is a retrospective study.

SETTINGS

This study was conducted in a single-hospital department of colorectal surgery.

PATIENTS

Inpatients undergoing colorectal surgery in which an accidental puncture or laceration did or did not occur were selected.

MAIN OUTCOME MEASURES

The primary outcomes measured were surgical complications, length of stay, and readmission.

RESULTS

Of 2897 operations, 269 had accidental puncture or laceration (9.2%) including serosal tear (47%), enterotomy (38%), and extraintestinal injuries (15%). Accidental puncture or laceration cases had more diagnoses of enterocutaneous fistula (11% vs 2%, p < 0.001), reoperative cases (91% vs 61%, p < 0.001), open surgery (96% vs 77%, p < 0.001), longer operative times (186 vs 146 minutes, p = 0.001), and increased length of stay (10 vs 7 days, p = 0.002). Patients with serosal tears had entirely similar outcomes to those without an injury, whereas patients with enterotomies had increased operative times and length of stay, and patients with extraintestinal injuries had higher rates of reoperation and sepsis (p < 0.05 for all).

LIMITATIONS

This study was limited by the loss of sensitivity due to grouping extraintestinal injuries.

CONCLUSIONS

Accidental puncture or laceration is more likely to occur in complex colorectal operations. The clinical consequences range from none to significant depending on the specific type of injury. To make accidental puncture or laceration a more meaningful quality indicator, we advocate that groups who use the measure eliminate the injuries that have no bearing on surgical outcome and that risk adjustment for operative complexity is performed.

Hospital IT Sophistication Profiles and Patient Safety Outcomes

Information technology (IT) sophistication of acute care hospitals in Texas was measured to explore the relationships between IT infrastructure and patient outcomes using Donabedian’s framework. The sample was acute care hospitals (n=175) with an IT profile using HIMSS, demographic and operations data. Three dimensions of hospital IT sophistication were measured and related to patient care outcomes using the AHRQ Patient Safety Indicators (PSI). Significant relationships (p < 0.05) using linear regression were found between hospital IT sophistication and three PSI measures. A review of similar studies during the same time period in Iowa, Georgia, and Florida compares findings from two instruments used to profile hospital IT infrastructure. This study adds to and confirms findings of positive relationships between IT sophistication of hospitals and patient care outcomes using the AHRQ safety indicators. Discussion of the conceptual model and the IT sophistication construct provides a theoretical framework for this line of research.

Defining, measuring, and improving surgical quality: beyond teamwork and checklists to systems redesign and transformation

BACKGROUND

Surgical complications are multifactorial but often are attributable to deficiencies in the quality of care. This review examines how quality is defined in surgery, the modalities employed to measure quality, and the approaches to improving the quality of surgical care. Beyond developing a hospital environment supportive of organizational learning, the next generation of surgical performance improvement will include broader, more innovative approaches. These ideas will create partnerships among patients, clinicians, industry, the arts, hospital leaders, and other sectors to look for ways to reinvent the system rather than simply to make a better hospital.

METHODS

Review of pertinent English-language literature on surgical quality, definitions of quality, quality measures, performance improvement, and organizational learning in health care.

RESULTS

Medical care should be safe, effective, patient-centered, timely, efficient, and equitable, as defined by the Institute of Medicine core values for health care quality. There is substantive lack of agreement as to how to measure the quality of care. Although the goal of each measurement system is to give patients the ability to compare hospitals nationally, most of the methodologies measure widely different aspects of hospital care, resulting in conflicting illustrations of institutional performance and confounded decision making for patients and for purchasers of healthcare services and insurance.

CONCLUSIONS

The best pathway for surgical quality and performance improvement includes the application of systems engineering and innovation to determine ways to do better what we do currently, and to improve the present system while developing ideas for better delivery of high-quality care in the future.

Variation in academic medical centers' coding practices for postoperative respiratory complications: implications for the AHRQ postoperative respiratory failure Patient Safety Indicator

BACKGROUND

The Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) 11 uses International Classification of Disease, 9th Clinical Modification diagnosis code 518.81 ("Acute respiratory failure")-but not the closely related alternative, 518.5 ("Pulmonary insufficiency after trauma and surgery")-to detect cases of postoperative respiratory failure. We sought to determine whether hospitals vary in the use of 518.81 versus 518.5 and whether such variation correlates with coder beliefs.

STUDY DESIGN

We conducted a cross-sectional analysis of administrative data from July 2009 through June 2010 for UHC (formerly University HealthSystem Consortium)-affiliated centers to assess the use of diagnosis codes 518.81 and 518.5 in PSI 11-eligible cases. We also surveyed coders at these centers to evaluate whether variation in the use of 518.81 versus 518.5 might be linked to coder beliefs. We asked survey respondents which diagnosis they would use for 2 ambiguous cases of postoperative pulmonary complications and how much they agreed with 6 statements about the coding process.

RESULTS

UHC-affiliated centers demonstrated wide variation in the use of 518.81 and 518.5, ranging from 0 to 26 cases and 0 to 56 cases/1000 PSI 11-eligible hospitalizations, respectively. Of 56 survey respondents, 64% chose 518.81 and 30% chose 518.5 for a clinical scenario involving postoperative respiratory failure, but these responses were not associated with actual coding of 518.81 or 518.5 at the center level. Sixty-two percent of respondents agreed that they are constrained by the words that physicians use. Their self-reported likelihood of querying physicians to clarify the diagnosis was significantly associated with coding of 518.5 at the center level.

CONCLUSIONS

The extent to which diagnosis code 518.81 is used relative to 518.5 varies considerably across centers, based on local coding practice, the specific wording of physician documentation, and coder-physician communication. To standardize the coding of postoperative respiratory failure, the 518.81 and 518.5 codes have recently been revised to make the available options clearer and mutually exclusive, which may improve the capacity of PSI 11 to discriminate true differences in quality of care.

Rural relevant quality measures for critical access hospitals

PURPOSE

To identify current and future relevant quality measures for Critical Access Hospitals (CAHs).

METHODS

Three criteria (patient volume, internal usefulness for quality improvement, and external usefulness for public reporting and payment reform) were used to analyze quality measures for their relevance for CAHs. A 6-member panel with expertise in rural hospital quality measurement and improvement provided input regarding the final measure selection.

FINDINGS

The relevant quality measures for CAHs include measures that are ready for reporting now and measures that need specifications to be finalized and/or a data reporting mechanism to be established. They include inpatient measures for specific medical conditions, global measures that address appropriate care across multiple medical conditions, and Emergency Department measures.

CONCLUSIONS

All CAHs should publicly report on relevant quality measures. Acceptance of a single consolidated set of quality measures with common specifications for CAHs by all entities involved in regulation, accreditation, and payment; a phased process to implement the relevant measures; and the provision of technical assistance would help CAHs meet the challenge of reporting.

Hospital and surgeon variation in complications and repeat surgery following incident lumbar fusion for common degenerative diagnoses

OBJECTIVE

To identify factors that account for variation in complication rates across hospitals and surgeons performing lumbar spinal fusion surgery.

DATA SOURCES

Discharge registry including all nonfederal hospitals in Washington State from 2004 to 2007.

STUDY DESIGN

We identified adults (n = 6,091) undergoing an initial inpatient lumbar fusion for degenerative conditions. We identified whether each patient had a subsequent complication within 90 days. Logistic regression models with hospital and surgeon random effects were used to examine complications, controlling for patient characteristics and comorbidity.

PRINCIPAL FINDINGS

Complications within 90 days of a fusion occurred in 4.8 percent of patients, and 2.2 percent had a reoperation. Hospital effects accounted for 8.8 percent of the total variability, and surgeon effects account for 14.4 percent. Surgeon factors account for 54.5 percent of the variation in hospital reoperation rates, and 47.2 percent of the variation in hospital complication rates. The discretionary use of operative features, such as the inclusion of bone morphogenetic proteins, accounted for 30 and 50 percent of the variation in surgeons' reoperation and complication rates, respectively.

CONCLUSIONS

To improve the safety of lumbar spinal fusion surgery, quality improvement efforts that focus on surgeons' discretionary use of operative techniques may be more effective than those that target hospitals.

Variation in the adoption of patient safety practices among New Zealand district health boards

OBJECTIVE

To investigate the adoption and impact of quality improvement measures in New Zealand hospitals.

METHOD

Structured interviews with quality and safety managers of District Health Boards (DHBs). Correlation of use of measures with adjusted 30-day mortality data.

RESULTS

Eighteen of New Zealand's 21 DHBs participated in the survey. Structural or policy measures to improve patient safety, such as credentialing and event reporting procedures, had been introduced into all DHBs, whereas changes to general clinical processes such as medicine reconciliation, falls prevention interventions and disease-specific management guidelines were less consistently used. There was no meaningful correlation between risk-adjusted mortality rates for three common medical conditions and related quality measures.

CONCLUSION

Widespread variation exists among New Zealand DHBs in their adoption of quality and safety practices, especially in relation to clinical processes of care.

Inpatient safety trends in laparoscopic and open nephrectomy for renal tumours

Study Type--Cohort study Level of Evidence 2b. What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy for renal cancer provides equivalent long-term cancer control with shorter hospital stays, less postoperative pain, and faster resumption of normal activities, but it has diffused slowly into clinical practice, perhaps as a result of perceptions about safety. Patient safety outcomes for laparoscopic and open radical nephrectomy using validated measures remain incompletely characterized. This is the first study to investigate peri-operative outcomes of radical nephrectomy using validated patient safety measures. We found a 32% decreased probability of adverse patient safety events occurring in laparoscopic compared with open radical nephrectomy. The safety benefits of laparoscopy were attained only after 10% of cases were completed laparoscopically--a proportion some have proposed as the 'tipping point' for the adoption of surgical innovations. This observation could have implications for patient safety in the setting of diffusion of new surgical techniques.

OBJECTIVE

• To compare peri-operative adverse patient safety events occurring in laparoscopic radical nephrectomy (LRN) with those occurring in open radical nephrectomy (ORN).

METHODS

• We used the US Nationwide Inpatient Sample to identify patients undergoing kidney surgery for renal tumours from 1998 to 2008. • We used patient safety indicators (PSIs), which are validated measures of preventable adverse outcomes, and multivariate regression to analyse associations of surgery type with patient safety.

RESULTS

• Open radical nephrectomy accounted for 235,098 (89%) cases while 28,609 (11%) cases were LRN. • Compared with ORN, LRN patients were more likely to be male (P= 0.048), have lower Charlson comorbidity scores (P < 0.001), and to undergo surgery at urban (P < 0.001) and teaching (P < 0.001) hospitals. • PSIs occurred in 18,714 (8%) of ORN and 1434 (5%) of LRN cases (P < 0.001). • On multivariate analysis, LRN was associated with a 32% decreased probability of any PSI (adjusted odds ratio 0.68, 95% confidence interval: 0.6 to 0.77, P < 0.001). Stratification by year showed that this difference was initially manifested in 2003, when the proportion of LRN cases first exceeded 10%.

CONCLUSIONS

•  We found that LRN was associated with substantially superior peri-operative patient safety outcomes compared with ORN, but only after the national prevalence of LRN exceeded 10%. • Further study is needed to explain these patterns and promote the safe diffusion of novel surgical therapies into broad practice.

Determinants of adverse events in vascular surgery

BACKGROUND

Patient safety is a national priority. Patient Safety Indicators (PSIs) monitor potential adverse events during hospital stays. Surgical specialty PSI benchmarks do not exist, and are needed to account for differences in the range of procedures performed, reasons for the procedure, and differences in patient characteristics. A comprehensive profile of adverse events in vascular surgery was created.

STUDY DESIGN

The Nationwide Inpatient Sample was queried for 8 vascular procedures using ICD-9-CM codes from 2005 to 2009. Factors associated with PSI development were evaluated in univariate and multivariate analyses.

RESULTS

A total of 1,412,703 patients underwent a vascular procedure and a PSI developed in 5.2%. PSIs were more frequent in female, nonwhite patients with public payers (p < 0.01). Patients at mid and low-volume hospitals had greater odds of developing a PSI (odds ratio [OR] = 1.17; 95% CI, 1.10-1.23 and OR = 1.69; 95% CI, 1.53-1.87). Amputations had highest PSI risk-adjusted rate and carotid endarterectomy and endovascular abdominal aortic aneurysm repair had lower risk-adjusted rate (p < 0.0001). PSI risk-adjusted rate increased linearly by severity of patient indication: claudicants (OR = 0.40; 95% CI, 0.35-0.46), rest pain patients (OR = 0.78; 95% CI, 0.69-0.90), ulcer (OR = 1.20; 95% CI, 1.07-1.34), and gangrene patients (OR = 1.85; 95% CI, 1.66-2.06).

CONCLUSIONS

Patient safety events in vascular surgery were high and varied by procedure, with amputations and open abdominal aortic aneurysm repair having considerably more potential adverse events. PSIs were associated with black race, public payer, and procedure indication. It is important to note the overall higher rates of PSIs occurring in vascular patients and to adjust benchmarks for this surgical specialty appropriately.

Impact of alternative coding schemes on incidence rates of key complications after total hip arthroplasty: a risk-adjusted analysis of a national data set

BACKGROUND

Administrative data are commonly used to examine orthopedic outcomes including total hip arthroplasty (THA), but little is known about how minor analytic decisions impact results. Our objective was to examine how the rates of 3 adverse outcomes (deep vein thrombosis [DVT], pulmonary embolism [PE], and hemorrhage) varied with subtle adjustments to our analytic method.

METHODS

We used Medicare Part A data to identify all beneficiaries who underwent primary or revision THA during 2007 to 2008. We used 2 published algorithms (Katz/Cram and Patient Safety Indicators [PSIs]) to identify cases of DVT, PE, and hemorrhage occurring at 3 different points in time; index admission; 30-day readmission; and index admission plus readmission. We used the kappa statistic to compare the agreement between methods. We examined variation in complication rates across hospitals using regression models that adjusted for differences in patient demographics and comorbidity.

RESULTS

Among 202 773 primary and 40 973 revision THA patients, the agreement between the Katz/Cram and PSI methods was excellent for DVT and PE at all time points (kappa 0.95-1.0) but poor for hemorrhage (kappa 0.07-0.29). The incidence of DVT during the index admission among the primary THA cohort was 0.40% using the Katz/Cram method and 0.37% using the PSI method. The incidence of hemorrhage during the index admission among the primary THA cohort was 1.29% using the Katz/Cram method and 0.05% using the PSI method. We found significant variation in hospital rates of all 3 complications (DVT, PE, and hemorrhage). For example, the mean rate of hemorrhage at index admission or readmission for revision THA was 5.7% (standard deviation: 12.8%); we found 137 hospitals with hemorrhage rates of 25% or higher among their revision THA patients.

DISCUSSION

We found important differences in the rates of THA complications depending upon the coding algorithms and time frame employed. Our results suggest that administrative data can be used to evaluate THA complications but that methodology should be carefully considered.

Should policy-makers and managers trust PSI? An empirical validation study of five patient safety indicators in a national health service

BACKGROUND

Patient Safety Indicators (PSI) are being modestly used in Spain, somewhat due to concerns on their empirical properties. This paper provides evidence by answering three questions: a) Are PSI differences across hospitals systematic -rather than random?; b) Do PSI measure differences among hospital-providers -as opposed to differences among patients?; and, c) Are measurements able to detect hospitals with a higher than "expected" number of cases?

METHODS

An empirical validation study on administrative data was carried out. All 2005 and 2006 publicly-funded hospital discharges were used to retrieve eligible cases of five PSI: Death in low-mortality DRGs (MLM); decubitus ulcer (DU); postoperative pulmonary embolism or deep-vein thrombosis (PE-DVT); catheter-related infections (CRI), and postoperative sepsis (PS). Empirical Bayes statistic (EB) was used to estimate whether the variation was systematic; logistic-multilevel modelling determined what proportion of the variation was explained by the hospital; and, shrunken residuals, as provided by multilevel modelling, were plotted to flag hospitals performing worse than expected.

RESULTS

Variation across hospitals was observed to be systematic in all indicators, with EB values ranging from 0.19 (CI95%:0.12 to 0.28) in PE-DVT to 0.34 (CI95%:0.25 to 0.45) in DU. A significant proportion of the variance was explained by the hospital, once patient case-mix was adjusted: from a 6% in MLM (CI95%:3% to 11%) to a 24% (CI95%:20% to 30%) in CRI. All PSI were able to flag hospitals with rates over the expected, although this capacity decreased when the largest hospitals were analysed.

CONCLUSION

Five PSI showed reasonable empirical properties to screen healthcare performance in Spanish hospitals, particularly in the largest ones.

Is patient safety improving? National trends in patient safety indicators: 1998-2007

CONTEXT

Emphasis has been placed on quality and patient safety in medicine; however, little is known about whether quality over time has actually improved in areas such as patient safety indicators (PSIs).

OBJECTIVE

To determine whether national trends for hospital PSIs have improved from 1998 to 2007.

DESIGN, SETTING, AND PARTICIPANTS

Using PSI criteria from the Agency for Healthcare Research and Quality, PSIs were identified in the Nationwide Inpatient Sample (NIS) for all eligible inpatient admissions between 1998 and 2007. Joinpoint regression was used to estimate annual percentage changes (APCs) for PSIs.

MAIN OUTCOME MEASURE

Annual percent change for PSIs.

RESULTS

From 1998 to 2007, 7.6 million PSI events occurred for over 69 million hospitalizations. A total of 14 PSIs showed statistically significant trends. Seven PSIs had increasing APC: postoperative pulmonary embolism or deep vein thrombosis (8.94), postoperative physiological or metabolic derangement (7.67), postoperative sepsis (7.17), selected infections due to medical care (4.05), decubitus ulcer (3.05), accidental puncture or laceration (2.64), and postoperative respiratory failure (1.46). Seven PSIs showed decreasing APCs: birth trauma injury to neonate (-17.79), failure to rescue (-6.05), postoperative hip fracture (-5.86), obstetric trauma-vaginal without instrument (-5.69), obstetric trauma-vaginal with instrument (-4.11), iatrogenic pneumothorax (-2.5), and postoperative wound dehiscence (-1.8).

CONCLUSION

This is the first study to establish national trends of PSIs during the past decade indicating areas for potential quality improvement prioritization. While many factors influence these trends, the results indicate opportunities for either emulation or elimination of current patient safety trends.

Evaluation of a pilot surgical adverse event detection system for Italian hospitals

OBJECTIVE

To devise an adverse event (AE) detection system and assess its validity and utility.

DESIGN

Observational, retrospective study.

SETTING

Six public hospitals in Northern Italy including a Teaching Hospital.

PARTICIPANTS

Eligible cases were all patients with at least one admission to a surgical ward, over a 3-month period.

INTERVENTIONS

Computerized screening of administrative data and review of flagged charts by an independent panel.

MAIN OUTCOME MEASURES

Number of records needed to identify an AE using this detection system.

RESULTS

Out of the 3310 eligible cases, 436 (13%) were extracted by computerized screening. In addition, out of the 2874 unflagged cases, 77 randomly extracted records (3%) were added to the sample, to measure unidentified cases. Nursing staff judged 108 of 504 (21%) charts positive for one or more criteria; surgeons confirmed the occurrence of AEs in 80 of 108 (74%) of these. Compared with random chart review, the number of cases needed to detect an AE, with the computerized screening suggested by this study, was reduced by two-thirds, although sensitivity was low (41%).

CONCLUSIONS

This approach has the potential to allow the timely identification of AEs, enabling to quickly devise interventions. This detection system could be of true benefit for hospitals that intend assessing their AEs.

Measuring the cost of hospital adverse patient safety events

This paper estimates the excess cost of hospital inpatient care due to adverse safety events in the U.S. Department of Veterans Affairs (VA) hospitals during fiscal year 2007. We measured adverse events according to the Patient Safety Indicator (PSI) algorithms of the Agency for Healthcare Research and Quality. Patient level cost regression analyses were performed using generalized linear modeling techniques. Accounting for the heavily skewed distribution of costs among patients having adverse safety events, results suggested that the excess cost of nine different PSIs for VA patients are much higher than previously estimated. We tested sensitivity of results to whether costs were measured by VA's Decision Support System (DSS) that uses local costs of specific inputs, or by the average costing system developed by VA's Health Economics Resource Center. DSS costing appeared to better characterize the high cost patients.

[Systematic literature review on patient safety in medical departments]

Patient safety is an issue of interest. All scenarios of health care have a risk of adverse events (AE) and determination of its incidence has been reported in virtually all medical specialties.

OBJECTIVE

To determine the incidence reported in the medical literature of adverse events in medical departments.

DESIGN AND METHODS

An exhaustive search of biomedical databases using different strategies, search in high impact journals and a manual search of related articles.

RESULTS

We reviewed 17,437 entries. After reading the abstracts and articles, and applying previously defined inclusion and exclusion criteria, we selected 10 articles that reported the incidence of adverse events in medical departments. Most studies corresponded to a historical cohort, had used an AE screening to identify high risk patients, and had used a structured review to check clinical records. None of them had as their ultimate objective to report on the impact of adverse events or characterize them. The incidence reported in medical departments ranged from 3.6% to 21.7%. The definitions of adverse events and forms of detection were similar; however the few differences put the comparability at risk.

CONCLUSION

No studies were aimed at quantifying or characterising the adverse events in health care. None of them defined what constitutes a medical department, although the results reported are within the published values for health systems. Further research is needed in this area.

Relationship between patient safety and hospital surgical volume

OBJECTIVE

To examine the relationship between hospital volume and in-hospital adverse events.

DATA SOURCES

Patient safety indicator (PSI) was used to identify hospital-acquired adverse events in the Nationwide Inpatient Sample database in abdominal aortic aneurysm, coronary artery bypass graft, and Roux-en-Y gastric bypass from 2005 to 2008.

STUDY DESIGN

In this observational study, volume thresholds were defined by mean year-specific terciles. PSI risk-adjusted rates were analyzed by volume tercile for each procedure.

PRINCIPAL FINDINGS

Overall, hospital volume was inversely related to preventable adverse events. High-volume hospitals had significantly lower risk-adjusted PSI rates compared to lower volume hospitals (p < .05).

CONCLUSION

These data support the relationship between hospital volume and quality health care delivery in select surgical cases. This study highlights differences between hospital volume and risk-adjusted PSI rates for three common surgical procedures and highlights areas of focus for future studies to identify pathways to reduce hospital-acquired events.

Increases in mortality, length of stay, and cost associated with hospital-acquired infections in trauma patients

OBJECTIVE

To explore the clinical impact and economic burden of hospital-acquired infections (HAIs) in trauma patients using a nationally representative database.

DESIGN

Retrospective study.

SETTING

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample.

PATIENTS

Trauma patients.

MAIN OUTCOME MEASURES

We examined the association between HAIs (sepsis, pneumonia, Staphylococcus infections, and Clostridium difficile- associated disease) and in-hospital mortality, length of stay, and inpatient costs using logistic regression and generalized linear models.

RESULTS

After controlling for patient demographics, mechanism of injury, injury type, injury severity, and comorbidities, we found that mortality, cost, and length of stay were significantly higher in patients with HAIs compared with patients without HAIs. Patients with sepsis had a nearly 6-fold higher odds of death compared with patients without an HAI (odds ratio, 5.78; 95% confidence interval, 5.03-6.64; P < .001). Patients with other HAIs had a 1.5- to 1.9-fold higher odds of mortality compared with controls (P < .005). Patients with HAIs had costs that were approximately 2- to 2.5-fold higher compared with patients without HAIs (P < .001). The median length of stay was approximately 2-fold higher in patients with HAIs compared with patients without HAIs (P < .001).

CONCLUSIONS

Trauma patients with HAIs are at increased risk for mortality, have longer lengths of stay, and incur higher inpatient costs. In light of the preventability of many HAIs and the magnitude of the clinical and economic burden associated with HAIs, policies aiming to decrease the incidence of HAIs may have a potentially large impact on outcomes in injured patients.