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Silber JH, Romano PS, Itani KMF, Rosen AK, Small D, Lipner RS, Bosk CL, Wang Y, Halenar MJ, Korovaichuk S, Even-Shoshan O, Volpp KG. Assessing the effects of the 2003 resident duty hours reform on internal medicine board scores. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:644-51. [PMID: 24556772 PMCID: PMC4139168 DOI: 10.1097/acm.0000000000000193] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
PURPOSE To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents. METHOD The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform. RESULTS The mean ABIM board score for the unexposed PGY-1 2000 cohort (n = 5,475) was 491, SD = 85. Adjusting for demographics, program, and USMLE Step 2 exam score, the mean differences (95% CI) in ABIM board scores between the PGY-1 2001, 2002, 2003, 2004 and 2005 cohorts minus the PGY-1 2000 cohort were -5.43 (-7.63, -3.23), -3.44 (-5.65, -1.24), 2.58 (0.36, 4.79), 11.10 (8.88, 13.33) and 11.28 (8.98, 13.58) points respectively. None of these differences exceeded one-fifth of an SD in ABIM board scores. CONCLUSIONS The duty hours reforms of 2003 did not meaningfully affect medical knowledge as measured by scores on the ABIM board examinations.
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Affiliation(s)
- Jeffrey H Silber
- Dr. Silber is professor, Departments of Pediatrics and Anesthesiology & Critical Care, Perelman School of Medicine; professor, Department of Health Care Management, The Wharton School; director, Center for Outcomes Research, The Children's Hospital of Philadelphia; and senior fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Romano is professor of medicine and pediatrics and director, Primary Care Outcomes Research Faculty Development Program, Division of General Medicine and Center for Healthcare Policy and Research, University of California Davis School of Medicine, Sacramento, California. Dr. Itani is professor, Department of Surgery, Boston University School of Medicine, and chief of surgery, VA Boston Health Care System and Boston University, Boston, Massachusetts. Dr. Rosen is professor, Department of Health Policy and Management, Boston University School of Public Health, affiliated with the Center for Organization, Leadership and Management Research, VA Boston Healthcare System, Boston, Massachusetts. Dr. Small is associate professor, Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Lipner is senior vice president of evaluation, research and development, American Board of Internal Medicine, Philadelphia, Pennsylvania. Dr. Bosk is professor, Departments of Sociology and Medical Ethics & Health Policy, and senior fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania. Ms. Wang is a statistical programmer, Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. Mr. Halenar is a research assistant, Center for Health Equity Research and Promotion, Veteran's Administration Hospital, Philadelphia, Pennsylvania. Ms. Korovaichuk is a research assistant, Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. Ms
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Silber JH, Rosenbaum PR, Ross RN, Ludwig JM, Wang W, Niknam BA, Mukherjee N, Saynisch PA, Even-Shoshan O, Kelz RR, Fleisher LA. Template matching for auditing hospital cost and quality. Health Serv Res 2014; 49:1446-74. [PMID: 24588413 DOI: 10.1111/1475-6773.12156] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Develop an improved method for auditing hospital cost and quality. DATA SOURCES/SETTING Medicare claims in general, gynecologic and urologic surgery, and orthopedics from Illinois, Texas, and New York between 2004 and 2006. STUDY DESIGN A template of 300 representative patients was constructed and then used to match 300 patients at hospitals that had a minimum of 500 patients over a 3-year study period. DATA COLLECTION/EXTRACTION METHODS From each of 217 hospitals we chose 300 patients most resembling the template using multivariate matching. PRINCIPAL FINDINGS The matching algorithm found close matches on procedures and patient characteristics, far more balanced than measured covariates would be in a randomized clinical trial. These matched samples displayed little to no differences across hospitals in common patient characteristics yet found large and statistically significant hospital variation in mortality, complications, failure-to-rescue, readmissions, length of stay, ICU days, cost, and surgical procedure length. Similar patients at different hospitals had substantially different outcomes. CONCLUSION The template-matched sample can produce fair, directly standardized audits that evaluate hospitals on patients with similar characteristics, thereby making benchmarking more believable. Through examining matched samples of individual patients, administrators can better detect poor performance at their hospitals and better understand why these problems are occurring.
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Affiliation(s)
- Jeffrey H Silber
- The Department of Pediatrics, The University of Pennsylvania School of Medicine, Philadelphia, PA; Department of Anesthesiology and Critical Care, The University of Pennsylvania School of Medicine, Philadelphia, PA; Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia, PA; The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA
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Arkin N, Lee PH, McDonald K, Hernandez-Boussard T. The Association of Nurse-to-Patient Ratio with Mortality and Preventable Complications Following Aortic Valve Replacement. J Card Surg 2014; 29:141-8. [DOI: 10.1111/jocs.12284] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Nicole Arkin
- Stanford University School of Medicine; Stanford California
| | - Peter H.U. Lee
- Department of Cardiothoracic Surgery; Stanford University School of Medicine; Stanford California
| | - Kathryn McDonald
- Primary Center for Outcomes Research; Stanford University; Stanford California
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Moriarty JP, Schiebel NE, Johnson MG, Jensen JB, Caples SM, Morlan BW, Huddleston JM, Huebner M, Naessens JM. Evaluating implementation of a rapid response team: considering alternative outcome measures. Int J Qual Health Care 2014; 26:49-57. [PMID: 24402406 DOI: 10.1093/intqhc/mzt091] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Determine the prolonged effect of rapid response team (RRT) implementation on failure to rescue (FTR). DESIGN Longitudinal study of institutional performance with control charts and Bayesian change point (BCP) analysis. SETTING Two academic hospitals in Midwest, USA. PARTICIPANTS All inpatients discharged between 1 September 2005 and 31 December 2010. INTERVENTION Implementation of an RRT serving the Mayo Clinic Rochester system was phased in for all inpatient services beginning in September 2006 and was completed in February 2008. MAIN OUTCOME MEASURE Modified version of the AHRQ FTR measure, which identifies hospital mortalities among medical and surgical patients with specified in-hospital complications. RESULTS A decrease in FTR, as well as an increase in the unplanned ICU transfer rate, occurred in the second-year post-RRT implementation coinciding with an increase in RRT calls per month. No significant decreases were observed pre- and post-implementation for cardiopulmonary resuscitation events or overall mortality. A significant decrease in mortality among non-ICU discharges was identified by control charts, although this finding was not detected by BCP or pre- vs. post-analyses. CONCLUSIONS Reduction in the FTR rate was associated with a substantial increase in the number of RRT calls. Effects of RRT may not be seen until RRT calls reach a sufficient threshold. FTR rate may be better at capturing the effect of RRT implementation than the rate of cardiac arrests. These results support prior reports that short-term studies may underestimate the impact of RRT systems, and support the need for ongoing monitoring and assessment of outcomes to facilitate best resource utilization.
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Affiliation(s)
- James P Moriarty
- Health Care Policy and Research, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Morbidity and mortality after pancreaticoduodenectomy in patients with borderline resectable type C clinical classification. J Gastrointest Surg 2014; 18:146-55; discussion 155-6. [PMID: 24129825 DOI: 10.1007/s11605-013-2371-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 09/20/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND We previously described the clinical classification of patients with resectable pancreatic tumor anatomy but marginal performance status (PS) or reversible comorbidities as "borderline resectable type C" (BR-C). This study was designed to analyze the incidence and risk factors for post-pancreaticoduodenectomy (PD) morbidity/mortality in a multi-institutional cohort of BR-C patients. METHODS Elective PDs were evaluated from the 2005-10 ACS-NSQIP database. BR-C was defined as age ≥ 80, poor PS, weight loss > 10 %, pulmonary disease, recent myocardial infarction/angina, stroke history, and/or preoperative sepsis. Variables associated with 30-day postoperative major complications (PMC) and mortality were analyzed. RESULTS A total of 3,033/8,266 (36.7 %) patients were BR-C. BR-C patients were more likely to suffer PMC (31.3 vs. 26.2 %) and mortality (4.1 vs. 2.3 %). BR-C patients with PMC suffered 50 % higher mortality versus non-BR-C patients with PMC (11.5 vs. 7.7 %) (all p < 0.001). For BR-C patients, multivariate analysis identified the following risk factors for PMC or mortality: albumin < 3.5 g/dL, dyspnea, preoperative sepsis, age ≥ 80, poor PS, anesthesia score ≥ 4, and intraoperative transfusion ≥ 4 units. CONCLUSIONS Nationwide, one third of patients undergoing PD are medically borderline. These BR-C patients are at higher risk for and less able to be rescued from PMC. Surgeons should identify and optimize comorbidities and utilize prehabilitation to address functional deficits before elective PD.
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Failure-to-Rescue Rate as a Measure of Quality of Care in a Cardiac Surgery Recovery Unit: A Five-Year Study. Ann Thorac Surg 2014; 97:147-52. [DOI: 10.1016/j.athoracsur.2013.07.097] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 07/24/2013] [Accepted: 07/29/2013] [Indexed: 11/19/2022]
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Brooks Carthon JM, Jarrín O, Sloane D, Kutney-Lee A. Variations in postoperative complications according to race, ethnicity, and sex in older adults. J Am Geriatr Soc 2013; 61:1499-507. [PMID: 24006851 PMCID: PMC3773274 DOI: 10.1111/jgs.12419] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To explore differences in the incidence of postoperative complications between three racial and ethnic groups (white, black, Hispanic) before and after taking into account potentially confounding patient and hospital characteristics. DESIGN Cross-sectional study using 2006 to 2007 administrative discharge data from hospitals in four states (CA, PA, NJ, FL) linked to American Hospital Association Annual Survey data and data from the U.S. Census. Risk-adjusted logistic regression models were used in the analyses. SETTING Six hundred U.S. adult nonfederal acute care hospitals. PARTICIPANTS Individuals aged 65 and older undergoing general, orthopedic, or vascular surgery (N = 587,314; 86% white, 6% black, 8% Hispanic). MEASUREMENTS Thirteen frequent postoperative complications. RESULTS When considered without controls, black patients had significantly greater odds than white patients of developing 12 of the 13 complications, by factors (ORs) ranging from 1.09 to 2.69. Hispanic patients had significantly greater odds than white patients in nine of the 13 complications (ORs = 1.11-1.82) and significantly lower odds than white patients on two of the other four (ORs both = 0.84). The fully adjusted models that accounted for hospital and especially patient characteristics substantially diminished the number of complications for which black and Hispanic patients had significantly greater odds than white patients. Many of the significant differences between black, Hispanic, and white patients that persisted after controls were different for men and women. CONCLUSION Older black and Hispanic individuals have greater odds than white individuals of developing a vast majority of postoperative complications. Procedure type and health status largely explained differences in postoperative complication risk, which are frequently conditional on sex.
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Affiliation(s)
- J Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania
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Pineau Stam LM, Spence Laschinger HK, Regan S, Wong CA. The influence of personal and workplace resources on new graduate nurses' job satisfaction. J Nurs Manag 2013; 23:190-9. [DOI: 10.1111/jonm.12113] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Lisa M. Pineau Stam
- Field of Leadership in Health Services Delivery; The University of Western Ontario; London ON Canada
| | | | - Sandra Regan
- Arthur Labatt Family School of Nursing; The University of Western Ontario; London Ontario
| | - Carol A. Wong
- MOHLTC Nursing Early Career Research Award Recipient; Arthur Labatt Family School of Nursing; The University of Western Ontario; London Ontario Canada
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Sukumar S, Roghmann F, Trinh VQ, Sammon JD, Gervais MK, Tan HJ, Ravi P, Kim SP, Hu JC, Karakiewicz PI, Noldus J, Sun M, Menon M, Trinh QD. National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA. BMJ Open 2013; 3:bmjopen-2013-002843. [PMID: 23804313 PMCID: PMC3696870 DOI: 10.1136/bmjopen-2013-002843] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES While multiple studies have demonstrated variations in the quality of cancer care in the USA, payers are increasingly assessing structure-level and process-level measures to promote quality improvement. Hospital-acquired adverse events are one such measure and we examine their national trends after major cancer surgery. DESIGN Retrospective, cross-sectional analysis of a weighted-national estimate from the Nationwide Inpatient Sample (NIS) undergoing major oncological procedures (colectomy, cystectomy, oesophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy and prostatectomy). The Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) were utilised to identify trends in hospital-acquired adverse events. SETTING Secondary and tertiary care, US hospitals in NIS PARTICIPANTS: A weighted-national estimate of 2 508 917 patients (>18 years, 1999-2009) from NIS. PRIMARY OUTCOME MEASURES Hospital-acquired adverse events. RESULTS 324 852 patients experienced ≥1-PSI event (12.9%). Patients with ≥1-PSI experienced higher rates of in-hospital mortality (OR 19.38, 95% CI 18.44 to 20.37), prolonged length of stay (OR 4.43, 95% CI 4.31 to 4.54) and excessive hospital-charges (OR 5.21, 95% CI 5.10 to 5.32). Patients treated at lower volume hospitals experienced both higher PSI events and failure-to-rescue rates. While a steady increase in the frequency of PSI events after major cancer surgery has occurred over the last 10 years (estimated annual % change (EAPC): 3.5%, p<0.001), a concomitant decrease in failure-to-rescue rates (EAPC -3.01%) and overall mortality (EAPC -2.30%) was noted (all p<0.001). CONCLUSIONS Over the past decade, there has been a substantial increase in the national frequency of potentially avoidable adverse events after major cancer surgery, with a detrimental effect on numerous outcome-level measures. However, there was a concomitant reduction in failure-to-rescue rates and overall mortality rates. Policy changes to improve the increasing burden of specific adverse events, such as postoperative sepsis, pressure ulcers and respiratory failure, are required.
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Affiliation(s)
- Shyam Sukumar
- Center for Outcomes Research and Analytics, Henry Ford Health System, Detroit, Michigan, USA
| | - Florian Roghmann
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada
- Department of Urology, Ruhr University Bochum, Marienhospital, Herne, Germany
| | - Vincent Q Trinh
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada
| | - Jesse D Sammon
- Center for Outcomes Research and Analytics, Henry Ford Health System, Detroit, Michigan, USA
| | - Mai-Kim Gervais
- Division of General Surgery, University of Montreal Health Center, Montreal, Canada
| | - Hung-Jui Tan
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Praful Ravi
- Center for Outcomes Research and Analytics, Henry Ford Health System, Detroit, Michigan, USA
| | - Simon P Kim
- Department of Urology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jim C Hu
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada
| | - Joachim Noldus
- Department of Urology, Ruhr University Bochum, Marienhospital, Herne, Germany
| | - Maxine Sun
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada
| | - Mani Menon
- Center for Outcomes Research and Analytics, Henry Ford Health System, Detroit, Michigan, USA
| | - Quoc-Dien Trinh
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada
- Department of Surgery, Division of Urology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
BACKGROUND Although there is evidence that hospitals recognized for nursing excellence--Magnet hospitals--are successful in attracting and retaining nurses, it is uncertain whether Magnet recognition is associated with better patient outcomes than non-Magnets, and if so why. OBJECTIVES To determine whether Magnet hospitals have lower risk-adjusted mortality and failure-to-rescue compared with non-Magnet hospitals, and to determine the most likely explanations. METHOD AND STUDY DESIGN: Analysis of linked patient, nurse, and hospital data on 56 Magnet and 508 non-Magnet hospitals. Logistic regression models were used to estimate differences in the odds of mortality and failure-to-rescue for surgical patients treated in Magnet versus non-Magnet hospitals, and to determine the extent to which differences in outcomes can be explained by nursing after accounting for patient and hospital differences. RESULTS Magnet hospitals had significantly better work environments and higher proportions of nurses with bachelor's degrees and specialty certification. These nursing factors explained much of the Magnet hospital effect on patient outcomes. However, patients treated in Magnet hospitals had 14% lower odds of mortality (odds ratio 0.86; 95% confidence interval, 0.76-0.98; P=0.02) and 12% lower odds of failure-to-rescue (odds ratio 0.88; 95% confidence interval, 0.77-1.01; P=0.07) while controlling for nursing factors as well as hospital and patient differences. CONCLUSIONS The lower mortality we find in Magnet hospitals is largely attributable to measured nursing characteristics but there is a mortality advantage above and beyond what we could measure. Magnet recognition identifies existing quality and stimulates further positive organizational behavior that improves patient outcomes.
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Henneman D, van Leersum NJ, ten Berge M, Snijders HS, Fiocco M, Wiggers T, Tollenaar RAEM, Wouters MWJM. Failure-to-Rescue After Colorectal Cancer Surgery and the Association with Three Structural Hospital Factors. Ann Surg Oncol 2013; 20:3370-6. [DOI: 10.1245/s10434-013-3037-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Indexed: 12/28/2022]
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Subirana M, Long A, Greenhalgh J, Firth J. A realist logic model of the links between nurse staffing and the outcomes of nursing. J Res Nurs 2013. [DOI: 10.1177/1744987113481782] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: There has been a long-standing debate over the definition and nature of the quality of healthcare and factors that influence and enhance quality. Within nursing, the challenge is to identify the outcomes that are measurable and amenable to change as a result of nursing care. Arising originally from concerns over potential nurse staffing shortages and nurse retention within the United States, an extensive literature has developed in the acute sector, exploring nurse staffing and its consequences. All of these studies raise the generic question of what potential causal mechanisms might link nurse staffing levels and skill mix to issues of patient safety and outcome. Objectives: To generate a tentative logic model to understand existing findings and to elucidate possible ways in which nurse staffing and skill mix may affect patient and nurse outcomes. Methods: This study was grounded within the principles of realist evaluation, realist review and logic modelling. The existing literature was reviewed to bring to light the underlying rationale suggested by the authors of this study on how nursing care might affect patient outcomes. A step-by-step process was followed to demonstrate the generation of a tentative logic model of how nurse staffing might influence patient, and nursing, outcomes. Results: The final logic model depicts staffing adequacy as having a complex link with patient outcomes. This is mediated at a general level through factors in the process of care (for example, nurse surveillance, clinical judgement, level of education, level of nurse training and length of nursing experience) and tasks left undone. These operate in conjunction with working with other nurses who are clinically competent, having good nurse–physician relationships and communication, supportive nurse manager/supervisor and good teamwork. Conclusions: This study extends the understanding of the mechanisms through which nurse staffing levels may result in adverse patient outcomes in the acute sector. Key intervening variables are the application of nurse intuition, operation of clinical judgement and missed nursing care/tasks left undone. The tentative logic model can be used to draw up areas and hypotheses to guide the direction of future research and to aid interpretation of existing research.
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Affiliation(s)
- Mireia Subirana
- Director of Nursing, Consorci Hospitalari de Vic, Faculty of Health Sciences and Welfare, University of Vic, Spain
- Consultant Nurse Rheumatology/Clinical Governance Lead, Pennine MSK Partnership Ltd, Integrated Care Centre, UK; Visiting Senior Research Fellow, University of Leeds, UK
| | - Andrew Long
- Professor, Health Systems Research, School of Healthcare, University of Leeds, UK
- Consultant Nurse Rheumatology/Clinical Governance Lead, Pennine MSK Partnership Ltd, Integrated Care Centre, UK; Visiting Senior Research Fellow, University of Leeds, UK
| | - Joanne Greenhalgh
- Social Research Methodologist, School of Sociology & Social Policy, University of Leeds, UK
- Consultant Nurse Rheumatology/Clinical Governance Lead, Pennine MSK Partnership Ltd, Integrated Care Centre, UK; Visiting Senior Research Fellow, University of Leeds, UK
| | - Jill Firth
- Consultant Nurse Rheumatology/Clinical Governance Lead, Pennine MSK Partnership Ltd, Integrated Care Centre, UK; Visiting Senior Research Fellow, University of Leeds, UK
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Jacobs ML, O'Brien SM, Jacobs JP, Mavroudis C, Lacour-Gayet F, Pasquali SK, Welke K, Pizarro C, Tsai F, Clarke DR. An empirically based tool for analyzing morbidity associated with operations for congenital heart disease. J Thorac Cardiovasc Surg 2013; 145:1046-1057.e1. [PMID: 22835225 PMCID: PMC3824389 DOI: 10.1016/j.jtcvs.2012.06.029] [Citation(s) in RCA: 179] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 04/26/2012] [Accepted: 06/12/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Congenital heart surgery outcomes analysis requires reliable methods of estimating the risk of adverse outcomes. Contemporary methods focus primarily on mortality or rely on expert opinion to estimate morbidity associated with different procedures. We created an objective, empirically based index that reflects statistically estimated risk of morbidity by procedure. METHODS Morbidity risk was estimated using data from 62,851 operations in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2002-2008). Model-based estimates with 95% Bayesian credible intervals were calculated for each procedure's average risk of major complications and average postoperative length of stay. These 2 measures were combined into a composite morbidity score. A total of 140 procedures were assigned scores ranging from 0.1 to 5.0 and sorted into 5 relatively homogeneous categories. RESULTS Model-estimated risk of major complications ranged from 1.0% for simple procedures to 38.2% for truncus arteriosus with interrupted aortic arch repair. Procedure-specific estimates of average postoperative length of stay ranged from 2.9 days for simple procedures to 42.6 days for a combined atrial switch and Rastelli operation. Spearman rank correlation between raw rates of major complication and average postoperative length of stay was 0.82 in procedures with n greater than 200. Rate of major complications ranged from 3.2% in category 1 to 30.0% in category 5. Aggregate average postoperative length of stay ranged from 6.3 days in category 1 to 34.0 days in category 5. CONCLUSIONS Complication rates and postoperative length of stay provide related but not redundant information about morbidity. The Morbidity Scores and Categories provide an objective assessment of risk associated with operations for congenital heart disease, which should facilitate comparison of outcomes across cohorts with differing case mixes.
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Affiliation(s)
- Marshall L Jacobs
- Department of Pediatric and Congenital Heart Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Sean M O'Brien
- Department of Biostatistics, Duke University School of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Jeffrey P Jacobs
- The Congenital Heart Institute of Florida, All Children's Hospital and Children's Hospital of Tampa, Cardiac Surgical Associates of Florida, University of South Florida College of Medicine, St Petersburg and Tampa, Fla
| | | | - Francois Lacour-Gayet
- Pediatric Cardiac Surgery Department, Montefiore Children's Hospital, Montefiore Medical Center, New York, NY
| | - Sara K Pasquali
- Department of Pediatrics, Duke University School of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Karl Welke
- Cardiothoracic Surgery, Seattle Children's Hospital, Seattle, Wash
| | | | - Felix Tsai
- Cardiac Surgery, Children's Hospital of the King's Daughters, Norfolk, Va
| | - David R Clarke
- Department of Cardiothoracic Surgery, The Children's Hospital, Aurora, Colo
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Navathe AS, Silber JH, Small DS, Rosen AK, Romano PS, Even-Shoshan O, Wang Y, Zhu J, Halenar MJ, Volpp KG. Teaching hospital financial status and patient outcomes following ACGME duty hour reform. Health Serv Res 2013; 48:476-98. [PMID: 22862427 PMCID: PMC3626351 DOI: 10.1111/j.1475-6773.2012.01453.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine whether hospital financial health was associated with differential changes in outcomes after implementation of 2003 ACGME duty hour regulations. DATA SOURCES/STUDY SETTING Observational study of 3,614,174 Medicare patients admitted to 869 teaching hospitals from July 1, 2000 to June 30, 2005. STUDY DESIGN Interrupted time series analysis using logistic regression to adjust for patient comorbidities, secular trends, and hospital site. Outcomes included 30-day mortality, AHRQ Patient Safety Indicators (PSIs), failure-to-rescue (FTR) rates, and prolonged length of stay (PLOS). PRINCIPAL FINDINGS All eight analyses measuring the impact of duty hour reform on mortality by hospital financial health quartile, in postreform year 1 ("Post 1") or year 2 ("Post 2") versus the prereform period, were insignificant: Post 1 OR range 1.00-1.02 and Post 2 OR range 0.99-1.02. For PSIs, all six tests showed clinically insignificant effect sizes. The FTR rate analysis demonstrated nonsignificance in both postreform years (OR 1.00 for both). The PLOS outcomes varied significantly only for the combined surgical sample in Post 2, but this effect was very small, OR 1.03 (95% CI 1.02, 1.04). CONCLUSIONS The impact of 2003 ACGME duty hour reform on patient outcomes did not differ by hospital financial health. This finding is somewhat reassuring, given additional financial pressure on teaching hospitals from 2011 duty hour regulations.
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Affiliation(s)
- Amol S Navathe
- Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA 19104, USA.
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Simpson JC, Moonesinghe SR. Introduction to the postanaesthetic care unit. Perioper Med (Lond) 2013; 2:5. [PMID: 24472674 PMCID: PMC3964324 DOI: 10.1186/2047-0525-2-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 02/28/2013] [Indexed: 12/26/2022] Open
Abstract
High-risk, noncardiac surgery represents only 12.5% of surgical procedures, but 83.3% of deaths. The postanaesthetic care unit (PACU) addresses the need for an improved level of care for these patients by providing postoperative high-dependency or intensive care (Level 2 or 3). The PACU aims to improve the structure of care provision for high-risk surgical patients. By maintaining 24-hour cover at the same staffing level, the risk of poorer ‘out-of- hours’ care is reduced. In a PACU, whose remit is solely postoperative care, evidence-based protocols can be established to standardize the care given. The aim is to provide 24 hours of postoperative optimized care, thus targeting the period when these patients are most vulnerable, to reduce the risk of complications developing and identify complications promptly, should they occur. The PACU is set up to facilitate certain processes to aid optimized care in the postoperative period. These include invasive and noninvasive ventilation, goal-directed haemodynamic management, invasive monitoring and optimal pain management. Identification of high-risk patients who might benefit from PACU care is not always straightforward. However, tools are available to aid the clinician, supplementing clinical assessment and basic investigations. These include clinical prediction rules and cardiopulmonary exercise testing. Both the setting up and the running of a PACU clearly have cost implications. However, the reduction in postoperative morbidity, and thus patients’ length of stay, should, overall, reduce costs. The benefits of a PACU should therefore be seen in terms of improved surgical outcomes, reducing postoperative morbidity and mortality, and cost savings.
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Affiliation(s)
- Joanna C Simpson
- UCL Centre for Anaesthesia, University College Hospital, London, NW1 2BU, UK.
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167
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Borgi J, Rubinfeld I, Ritz J, Jordan J, Velanovich V. The Differential Effects of Intermediate Complications with Postoperative Mortality. Am Surg 2013. [DOI: 10.1177/000313481307900324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Most attempts at understanding perioperative mortality have been based on assessing individual patient risk factors, types of operations, and hospital characteristics. The hypothesis of this study is that there is a relationship between postoperative mortality and postoperative complications; therefore, understanding this relationship may provide a basis for prevention and rescue. Using the 2007 SemiAnnual National Surgical Quality Improvement Program Report, we obtained data for each reporting hospital's rates of observed mortality, overall observed morbidity, observed cardiac, respiratory, renal complications, venothromboemoblic events (VTEs), surgical site infections (SSIs), and urinary tract infections (UTIs). Simple and multiple linear regression analyses were done comparing absolute rate of observed mortality with absolute rate of observed morbidity and each morbidity group. One hundred ninety-seven hospitals were included in the study. There were statistically significant associations between observed mortality rates and observed morbidity rates, cardiac complications, respiratory complications, and VTE rates. Renal complications, SSIs, and UTIs showed no statistically significant association with observed morbidity. This study demonstrates that rates of observed morbidity, especially cardiac, respiratory, and VTE complications, are associated with observed mortality. These findings suggest that care providers should focus efforts at prevention and rescue of cardiac, respiratory, and VTE complications.
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Affiliation(s)
- Jamil Borgi
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Ilan Rubinfeld
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Jennifer Ritz
- Office of Clinical Quality and Safety, Henry Ford Hospital, Detroit, Michigan
| | - Jack Jordan
- Office of Clinical Quality and Safety, Henry Ford Hospital, Detroit, Michigan
| | - Vic Velanovich
- University of South Florida, Tampa General Hospital, Tampa, Florida
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168
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Kutney-Lee A, Sloane DM, Aiken LH. An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality. Health Aff (Millwood) 2013; 32:579-86. [PMID: 23459738 PMCID: PMC3711087 DOI: 10.1377/hlthaff.2012.0504] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
An Institute of Medicine report has called for registered nurses to achieve higher levels of education, but health care policy makers and others have limited evidence to support a substantial increase in the number of nurses with baccalaureate degrees. Using Pennsylvania nurse survey and patient discharge data from 1999 and 2006, we found that a ten-point increase in the percentage of nurses holding a baccalaureate degree in nursing within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients--and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients. We estimate that if all 134 hospitals in our study had increased the percentage of their nurses with baccalaureates by ten points during our study's time period, some 500 deaths among general, orthopedic, and vascular surgery patients might have been prevented. The findings provide support for efforts to increase the production and employment of baccalaureate nurses.
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Affiliation(s)
- Ann Kutney-Lee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA.
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169
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Abstract
The rapid response team has been proposed as an effective strategy for reducing failure-to-rescue rates among adult inpatients; however, there is little research evidence to support the recommendation. This exploratory study used survey and administrative data to describe rapid response team characteristics and penetration among hospitals in a large metropolitan area while tracking corresponding failure-to-rescue rates among surgical inpatients over 5 years. The findings are promising and invite further investigation.
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170
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Griffiths P, Jones S, Bottle A. Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? Observational study. Int J Nurs Stud 2013. [DOI: 10.1016/j.ijnurstu.2012.10.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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171
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McHugh MD, Stimpfel AW. Nurse reported quality of care: a measure of hospital quality. Res Nurs Health 2012; 35:566-75. [PMID: 22911102 PMCID: PMC3596809 DOI: 10.1002/nur.21503] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2012] [Indexed: 11/10/2022]
Abstract
As the primary providers of round-the-clock bedside care, nurses are well positioned to report on hospital quality of care. Researchers have not examined how nurses' reports of quality correspond with standard process or outcomes measures of quality. We assess the validity of evaluating hospital quality by aggregating hospital nurses' responses to a single item that asks them to report on quality of care. We found that a 10% increment in the proportion of nurses reporting excellent quality of care was associated with lower odds of mortality and failure to rescue; greater patient satisfaction; and higher composite process of care scores for acute myocardial infarction, pneumonia, and surgical patients. Nurse reported quality of care is a useful indicator of hospital performance.
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Affiliation(s)
- Matthew D McHugh
- Center for Health Outcomes and Policy Research, University of Pennsylvania, 418 Curie Blvd., Philadelphia, PA 19104, USA
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172
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Wiltse Nicely KL, Sloane DM, Aiken LH. Lower mortality for abdominal aortic aneurysm repair in high-volume hospitals is contingent upon nurse staffing. Health Serv Res 2012; 48:972-91. [PMID: 23088426 DOI: 10.1111/1475-6773.12004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To determine whether and to what extent the lower mortality rates for patients undergoing abdominal aortic aneurysm (AAA) repair in high-volume hospitals is explained by better nursing. DATA SOURCES State hospital discharge data, Multi-State Nursing Care and Patient Safety Survey, and hospital characteristics from the AHA Annual Survey. STUDY DESIGN Cross-sectional analysis of linked patient outcomes for individuals undergoing AAA repair in four states. DATA COLLECTION Secondary data sources. PRINCIPAL FINDINGS Favorable nursing practice environments and higher hospital volumes of AAA repair are associated with lower mortality and fewer failures-to-rescue in main-effects models. Furthermore, nurse staffing interacts with volume such that there is no mortality advantage observed in high-volume hospitals with poor nurse staffing. When hospitals have good nurse staffing, patients in low-volume hospitals are 3.4 times as likely to die and 2.6 times as likely to die from complications as patients in high-volume hospitals (p < .001). CONCLUSIONS Nursing is part of the explanation for lower mortality after AAA repair in high-volume hospitals. Importantly, lower mortality is not found in high-volume hospitals if nurse staffing is poor.
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Affiliation(s)
- Kelly L Wiltse Nicely
- Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA 19104-4217, USA.
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173
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Aiken LH, Cimiotti JP, Sloane DM, Smith HL, Flynn L, Neff DF. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. J Nurs Adm 2012; 42:S10-6. [PMID: 22976889 PMCID: PMC6764437 DOI: 10.1097/01.nna.0000420390.87789.67] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
CONTEXT Better hospital nurse staffing, more educated nurses, and improved nurse work environments have been shown to be associated with lower hospital mortality. Little is known about whether and under what conditions each type of investment works better to improve outcomes. OBJECTIVE To determine the conditions under which the impact of hospital nurse staffing, nurse education, and work environment are associated with patient outcomes. DESIGN, SETTING, AND PARTICIPANTS Outcomes of 665 hospitals in 4 large states were studied through linked data from hospital discharge abstracts for 1,262,120 general, orthopedic, and vascular surgery patients, a random sample of 39,038 hospital staff nurses, and American Hospital Association data. MAIN OUTCOME MEASURES A 30-day inpatient mortality and failure-to-rescue. RESULTS The effect of decreasing workloads by 1 patient/nurse on deaths and failure-to-rescue is virtually nil in hospitals with poor work environments, but decreases the odds on both deaths and failures in hospitals with average environments by 4%, and in hospitals with the best environments by 9% and 10%, respectively. The effect of 10% more Bachelors of Science in Nursing Degree nurses decreases the odds on both outcomes in all hospitals, regardless of their work environment, by roughly 4%. CONCLUSIONS Although the positive effect of increasing percentages of Bachelors of Science in Nursing Degree nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environments.
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Affiliation(s)
- Linda H Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104-4217, USA.
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174
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Szymczak JE, Bosk CL. Training for efficiency: work, time, and systems-based practice in medical residency. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2012; 53:344-58. [PMID: 22863601 PMCID: PMC3886114 DOI: 10.1177/0022146512451130] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Medical residency is a period of intense socialization with a heavy workload. Previous sociological studies have identified efficiency as a practical skill necessary for success. However, many contextual features of the training environment have undergone dramatic change since these studies were conducted. What are the consequences of these changes for the socialization of residents to time management and the development of a professional identity? Based on observations of and interviews with internal medicine residents at three training programs, we find that efficiency is both a social norm and strategy that residents employ to manage a workload for which the demand for work exceeds the supply of time available to accomplish it. We found that residents struggle to be efficient in the face of seemingly intractable "systems" problems. Residents work around these problems, and in doing so develop a tolerance for organizational vulnerabilities.
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Affiliation(s)
- Julia E Szymczak
- University of Pennsylvania, Department of Sociology, Philadelphia, PA 19104, USA.
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175
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Ghaferi AA, Dimick JB. Variation in Mortality After High-Risk Cancer Surgery. Surg Oncol Clin N Am 2012; 21:389-95, vii. [DOI: 10.1016/j.soc.2012.03.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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176
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Cimiotti JP, Barton SJ, Chavanu Gorman KE, Sloane DM, Aiken LH. Nurse reports on resource adequacy in hospitals that care for acutely ill children. J Healthc Qual 2012; 36:25-32. [PMID: 22713115 DOI: 10.1111/j.1945-1474.2012.00212.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite the estimated 1.8 million children admitted to hospitals annually, little is known about the quality of care and the adequacy of resources in hospitals that care for acutely ill infants and children. Using survey data from 3,819 pediatric nurses working in 498 hospitals, we found that nursing resources vary significantly across different types of hospitals that care for children. Nurses working in a children's hospital within a hospital, and on a pediatric unit in a general hospital were more likely than nurses in freestanding children's hospitals to report inadequate nursing resources. We also found that inadequate nursing resources were associated with surveillance left undone and missed changes in patients' condition. These findings have implications for the quality and safety of pediatric care.
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177
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Carthon JMB, Kutney-Lee A, Jarrín O, Sloane D, Aiken LH. Nurse staffing and postsurgical outcomes in black adults. J Am Geriatr Soc 2012; 60:1078-84. [PMID: 22690984 PMCID: PMC3376011 DOI: 10.1111/j.1532-5415.2012.03990.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To determine the association between nurse staffing and postsurgical outcomes for older black adults, including 30-day mortality and failure to rescue. DESIGN A cross-sectional study of University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey data, linked to 2006-2007 administrative patient discharge data from four states (CA, PA, NJ, FL), American Hospital Association Annual Survey data, and a U.S. Census-derived measure of socioeconomic status (SES). Risk-adjusted logistic regression models with correction for clustering were used for the analysis. SETTING Five hundred ninety-nine adult nonfederal acute care hospitals in California, Pennsylvania, New Jersey, and Florida PARTICIPANTS Five hundred forty-eight thousand three hundred ninety-seven individuals ages 65 and older undergoing general, orthopedic, or vascular surgery (94% white, 6% black). MEASUREMENTS Thirty-day mortality and failure to rescue (death after a complication). RESULTS In models adjusting for sex and age, 30-day mortality was significantly higher for black than white participants (odds ratio (OR) = 1.42, 95% confidence interval (CI) = 1.32-1.52). In fully adjusted models that accounted for SES, surgery type, and comorbidities, as well as hospital characteristics, including nurse staffing, the odds of 30-day mortality were not significantly different for black and white participants. In the fully adjusted models, one additional patient in the average nurse's workload was associated with higher odds of 30-day mortality for all patients (OR = 1.03, 95% CI = 1.01-1.05). A significant interaction was found between race and nurse staffing for 30-day mortality, such that blacks experienced higher odds of death with each additional patient per nurse (OR = 1.10, 95% CI = 1.03-1.18) compared to whites (OR = 1.03, 95% CI = 1.01-1.06). Similar patterns were detected in failure-to-rescue models. CONCLUSION Older surgical patients experience poorer postsurgical outcomes, including mortality and failure to rescue, when cared for by nurses with higher workloads. The effect of nurse staffing inadequacies is more significant in older black individuals.
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Affiliation(s)
- J Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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178
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Yasunaga H, Hashimoto H, Horiguchi H, Miyata H, Matsuda S. Variation in cancer surgical outcomes associated with physician and nurse staffing: a retrospective observational study using the Japanese Diagnosis Procedure Combination Database. BMC Health Serv Res 2012; 12:129. [PMID: 22640411 PMCID: PMC3405470 DOI: 10.1186/1472-6963-12-129] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 05/28/2012] [Indexed: 02/06/2023] Open
Abstract
Background Little is known about the effects of professional staffing on cancer surgical outcomes. The present study aimed to investigate the association between cancer surgical outcomes and physician/nurse staffing in relation to hospital volume. Methods We analyzed 131,394 patients undergoing lung lobectomy, esophagectomy, gastrectomy, colorectal surgery, hepatectomy or pancreatectomy for cancer between July and December, 2007–2008, using the Japanese Diagnosis Procedure Combination database linked to the Survey of Medical Institutions data. Physician-to-bed ratio (PBR) and nurse-to-bed ratio (NBR) were determined for each hospital. Hospital volume was categorized into low, medium and high for each of six cancer surgeries. Failure to rescue (FTR) was defined as a proportion of inhospital deaths among those with postoperative complications. Multi-level logistic regression analysis was performed to examine the association between physician/nurse staffing and FTR, adjusting for patient characteristics and hospital volume. Results Overall inhospital mortality was 1.8%, postoperative complication rate was 15.2%, and FTR rate was 11.9%. After adjustment for hospital volume, FTR rate in the group with high PBR (≥19.7 physicians per 100 beds) and high NBR (≥77.0 nurses per 100 beds) was significantly lower than that in the group with low PBR (<19.7) and low NBR (<77.0) (9.2% vs. 14.5%; odds ratio, 0.76; 95% confidence interval, 0.68–0.86; p < 0.001). Conclusions Well-staffed hospitals confer a benefit for cancer surgical patients regarding reduced FTR, irrespective of hospital volume. These results suggest that consolidation of surgical centers linked with migration of medical professionals may improve the quality of cancer surgical management.
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Affiliation(s)
- Hideo Yasunaga
- Department of Health Management and Policy, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Tokyo, Japan.
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179
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Park SH, Blegen MA, Spetz J, Chapman SA, De Groot H. Patient turnover and the relationship between nurse staffing and patient outcomes. Res Nurs Health 2012; 35:277-88. [DOI: 10.1002/nur.21474] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2012] [Indexed: 11/11/2022]
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180
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Morbidity of the arterial switch operation. Ann Thorac Surg 2012; 93:1977-83. [PMID: 22365263 DOI: 10.1016/j.athoracsur.2011.11.061] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 11/23/2011] [Accepted: 11/29/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND The arterial switch operation (ASO) has become a safe, reproducible surgical procedure with low mortality in experienced centers. We examined morbidity, which remains significant, particularly for complex ASO. METHODS From 2003 to 2011, 101 consecutive patients underwent ASO, arbitrarily classified as "simple" (n=52) or "complex" (n=49). Morbidity was measured in selected complications and postoperative hospitalization. Three outcomes were analyzed: ventilation time, postextubation hospital length of stay, and a composite morbidity index, defined as ventilation time+postextubation hospital length of stay+occurrence of selected major complications. Complexity was measured with the comprehensive Aristotle score. RESULTS The operative mortality was zero. Twenty-five major complications occurred in 23 patients: 6 of 25 (12%) in simple ASO and 19 of 49 (39%) in complex ASO (p=0.002). The most frequent complication was unplanned reoperation (15 vs 6, p=0.03). No patients required permanent pacing. The complex group had a significantly higher morbidity index and longer ventilation time and postextubation hospital length of stay. In multivariate analysis, factors independently predicting higher morbidity were the comprehensive Aristotle score, arch repair, bypass time, and malaligned commissures. Myocardial infarction caused one sudden late death at 3 months. Late coronary failure was 2%. Overall survival was 99% at a mean follow-up of 49±27 months. CONCLUSIONS In this consecutive series without operative mortality, morbidity was significantly higher in complex ASO. The only anatomic incremental risk factors for morbidity were aortic arch repair and malaligned commissures, but not primary diagnosis, weight less than 2.5 kg, or coronary patterns.
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181
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Abstract
Mistakes can be life-threatening and result in malpractice claims. There are few studies that discuss malpractice claims and nursing. The purpose was to identify possible relationships between the actions, behaviors, or characteristics of RNs and the injury suffered by a patient involved in a compensable event. Claims were analyzed retrospectively. Using the Fischer exact test, nurse inaction yielded a higher patient outcome severity score. No single nurse behavior or characteristic was significantly related to the patient outcome severity score. Findings support the belief that system problems may be a contributing factor.
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182
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Abstract
INTRODUCTION Although the relationship between surgical volume and mortality is well established, the mechanisms underlying these associations remain uncertain. We sought to determine whether increased mortality at low-volume centers was due to higher complication rates or less success in rescuing patients from complications. METHODS Using 2005 to 2007 Medicare data, we identified patients undergoing 3 high-risk cancer operations: gastrectomy, pancreatectomy, and esophagectomy. We first ranked hospitals according to their procedural volume for these operations and divided them into 5 equal groups (quintiles) based on procedure volume cutoffs that most closely resulted in an equal distribution of patients through the quintiles. We then compared the incidence of major complications and "failure to rescue" (ie, case fatality among patients with complications) across hospital quintiles. We performed this analysis for all operations combined and for each operation individually. RESULTS With all 3 operations combined, failure to rescue had a much stronger relationship to hospital volume than postoperative complications. Very low-volume (lowest quintile) hospitals had only slightly higher complications rates (42.7% vs. 38.9%; odds ratio 1.17, 95% confidence interval, 1.02-1.33), but markedly higher failure-to-rescue rates (30.3% vs. 13.1%; odds ratio 2.89, 95% confidence interval, 2.40-3.48) compared with very high-volume hospitals (highest quintile). These relationships also held true for individual operations. For example, patients undergoing pancreatectomy at very low-volume hospitals were 1.7 times more likely to have a major complication than those at very high-volume hospitals (38.3% vs. 27.7%, P<0.05), but 3.2 times more likely to die once those complications had occurred (26.0% vs. 9.9%, P<0.05). CONCLUSIONS Differences in mortality between high and low-volume hospitals are not associated with large differences in complication rates. Instead, these differences seem to be associated with the ability of a hospital to effectively rescue patients from complications. Strategies focusing on the timely recognition and management of complications once they occur may be essential to improving outcomes at low-volume hospitals.
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183
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Aiken LH, Cimiotti JP, Sloane DM, Smith HL, Flynn L, Neff DF. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care 2011; 49:1047-53. [PMID: 21945978 PMCID: PMC3217062 DOI: 10.1097/mlr.0b013e3182330b6e] [Citation(s) in RCA: 549] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
CONTEXT Better hospital nurse staffing, more educated nurses, and improved nurse work environments have been shown to be associated with lower hospital mortality. Little is known about whether and under what conditions each type of investment works better to improve outcomes. OBJECTIVE To determine the conditions under which the impact of hospital nurse staffing, nurse education, and work environment are associated with patient outcomes. DESIGN, SETTING, AND PARTICIPANTS Outcomes of 665 hospitals in 4 large states were studied through linked data from hospital discharge abstracts for 1,262,120 general, orthopedic, and vascular surgery patients, a random sample of 39,038 hospital staff nurses, and American Hospital Association data. MAIN OUTCOME MEASURES A 30-day inpatient mortality and failure-to-rescue. RESULTS The effect of decreasing workloads by 1 patient/nurse on deaths and failure-to-rescue is virtually nil in hospitals with poor work environments, but decreases the odds on both deaths and failures in hospitals with average environments by 4%, and in hospitals with the best environments by 9% and 10%, respectively. The effect of 10% more Bachelors of Science in Nursing Degree nurses decreases the odds on both outcomes in all hospitals, regardless of their work environment, by roughly 4%. CONCLUSIONS Although the positive effect of increasing percentages of Bachelors of Science in Nursing Degree nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environments.
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Affiliation(s)
- Linda H. Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104, (p) 215.898.9759/(f) 215.573.2062
| | - Jeannie P. Cimiotti
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104, (p) 215.898.4989/(f) 215.573.2062
| | - Douglas M. Sloane
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104, (p) 215.898.5673/(f) 215.573.2062
| | - Herbert L. Smith
- Department of Sociology and Population Research Center, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104, (p) 215.746.0555/(f) 215.573.2062
| | - Linda Flynn
- College of Nursing, Rutgers, The State University of New Jersey, Ackerson Hall, Room 305, 180 University Avenue, Newark, NJ 07102, (p) 973.353.5060/(f) 973.353.1277
| | - Donna F. Neff
- College of Nursing, University of Florida, PO Box 100187, Gainesville, FL 32610-0187, (p) 352.273.2273/(f) 352.273.6505
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184
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Tsang C, Palmer W, Bottle A, Majeed A, Aylin P. A Review of Patient Safety Measures Based on Routinely Collected Hospital Data. Am J Med Qual 2011; 27:154-69. [DOI: 10.1177/1062860611414697] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Carmen Tsang
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- Imperial Centre for Patient Safety and Service Quality, London, UK
| | - William Palmer
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- National Audit Office, London, UK
| | - Alex Bottle
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- Imperial Centre for Patient Safety and Service Quality, London, UK
| | | | - Paul Aylin
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- Imperial Centre for Patient Safety and Service Quality, London, UK
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185
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Abstract
Failure to rescue (FTR) has been described as the end result of a series of events relating to the environment of care and nursing quality. Only recently has FTR as a process measure been applied to perinatal care settings. Nurses' continuous presence at the bedside puts them in a privileged position to recognize signs of clinical deterioration and to take action. Many factors contribute to nurses' ability to save lives when infants develop complications. Although such factors are often system-related, nurses may be held responsible if they do not act according to an acceptable standard of care. In the neonatal intensive care unit, FTR has not been applied or adopted as a measure of nursing quality. This article describes how FTR is relevant in the neonatal intensive care unit and outlines nursing and system actions that can be taken to rescue some of the hospital's most vulnerable patients.
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186
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Kendall-Gallagher D, Aiken LH, Sloane DM, Cimiotti JP. Nurse specialty certification, inpatient mortality, and failure to rescue. J Nurs Scholarsh 2011; 43:188-94. [PMID: 21605323 DOI: 10.1111/j.1547-5069.2011.01391.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine if hospital proportion of staff nurses with specialty certification is associated with risk-adjusted inpatient 30-day mortality and failure to rescue (deaths in surgical inpatients following a major complication). DESIGN Secondary analysis of risk-adjusted adult general, orthopedic, and vascular surgical inpatients discharged during 2005-2006 (n= 1,283,241) from 652 nonfederal hospitals controlling for state, hospital, patient, and nursing characteristics by linking outcomes, administrative, and nurse survey data (n= 28,598). METHOD Nurse data, categorized by education and certification status, were aggregated to the hospital level. Logistic regression models were used to estimate effects of specialty certification and other nursing characteristics on mortality and failure to rescue. FINDINGS Hospital proportion of baccalaureate and certified baccalaureate staff nurses were associated with mortality and failure to rescue; no effect of specialization was seen in the absence of baccalaureate education. A 10% increase in hospital proportion of baccalaureate and certified baccalaureate staff nurses, respectively, decreased the odds of adjusted inpatient 30-day mortality by 6% and 2%; results for failure to rescue were identical. CONCLUSIONS Nurse specialty certification is associated with better patient outcomes; effect on mortality and failure to rescue in general surgery patients is contingent upon baccalaureate education. CLINICAL RELEVANCE Investment in a baccalaureate-educated workforce and specialty certification has the potential to improve the quality of care.
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187
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O'Brien-Pallas L, Murphy GT, Shamian J, Li X, Hayes LJ. Impact and determinants of nurse turnover: a pan-Canadian study. J Nurs Manag 2011; 18:1073-86. [PMID: 21073578 DOI: 10.1111/j.1365-2834.2010.01167.x] [Citation(s) in RCA: 168] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM As part of a large study of nursing turnover in Canadian hospitals, the present study focuses on the impact and key determinants of nurse turnover and implications for management strategies in nursing units. BACKGROUND Nursing turnover is an issue of ever-increasing priority as work-related stress and job dissatisfaction are influencing nurses' intention to leave their positions. METHODS Data sources included the nurse survey, unit managers, medical records and human resources databases. A broad sample of hospitals was represented with nine different types of nursing units included. RESULTS Nurses turnover is a major problem in Canadian hospitals with a mean turnover rate of 19.9%. Higher levels of role ambiguity and role conflict were associated with higher turnover rates. Increased role conflict and higher turnover rates were associated with deteriorated mental health. Higher turnover rates were associated with lower job satisfaction. Higher turnover rate and higher level of role ambiguity were associated with an increased likelihood of medical error. CONCLUSION Managing turnover within nursing units is critical to high-quality patient care. A supportive practice setting in which role responsibilities are understood by all members of the caregiver team would promote nurse retention. IMPLICATIONS FOR NURSING MANAGEMENT Stable nurse staffing and adequate managerial support are essential to promote job satisfaction and high-quality patient care.
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Affiliation(s)
- Linda O'Brien-Pallas
- Nursing Human Resources, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Greater amounts of nursing surveillance is thought to decrease failure to rescue but studies to date have used nurse staffing levels as a proxy for nursing surveillance. The purpose of this nursing effectiveness study was to examine the unique treatment effect of nursing surveillance on failure to rescue. Data were abstracted from 9 electronic clinical data repositories including the nursing documentation system that used the Nursing Interventions Classification (NIC) to record nursing care. Nursing surveillance was quantified as “high use” when the subjects received it an average of 12 times per day or more. Propensity scores were used to match subjects who had received high-dose nursing surveillance with subjects who received low-dose nursing surveillance (average of less than 12 times a day). The results indicate that when nursing surveillance is performed an average of 12 times a day or greater, there is a significant ( p = .0058) decrease in the odds of experiencing failure to rescue (odds ratio [OR] = 0.52) compared to when surveillance was delivered an average of less than 12 times a day. Additional unique variables included in this study are robust levels of nurse staffing based on hourly data, medical treatments, pharmaceutical treatments, and nursing treatments. The use of propensity scores helped determine the unique contribution of nursing surveillance on failure to rescue in this observational study.
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189
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Abstract
CONTEXT It is widely believed that a significant amount, perhaps as much as 20 to 30 percent, of health care spending in the United States is wasted, despite market forces such as managed care organizations and large, self-insured firms with a financial incentive to eliminate waste of this magnitude. METHODS This article uses Medicare claims data to study the association between inpatient spending and the thirty-day mortality of Medicare patients admitted to hospitals between 2001 and 2005 for surgery (general, orthopedic, vascular) and medical conditions (acute myocardial infarction [AMI], congestive heart failure [CHF], stroke, and gastrointestinal bleeding). FINDINGS Estimates from the analysis indicated that except for AMI patients, a 10 percent increase in inpatient spending was associated with a decrease of between 3.1 and 11.3 percent in thirty-day mortality, depending on the type of patient. CONCLUSIONS Although some spending may be inefficient, the results suggest that the amount of waste is less than conventionally believed, at least for inpatient care.
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191
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Silber JH, Rosenbaum PR, Brachet TJ, Ross RN, Bressler LJ, Even-Shoshan O, Lorch SA, Volpp KG. The Hospital Compare mortality model and the volume-outcome relationship. Health Serv Res 2010; 45:1148-67. [PMID: 20579125 PMCID: PMC2965498 DOI: 10.1111/j.1475-6773.2010.01130.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE We ask whether Medicare's Hospital Compare random effects model correctly assesses acute myocardial infarction (AMI) hospital mortality rates when there is a volume-outcome relationship. DATA SOURCES/STUDY SETTING Medicare claims on 208,157 AMI patients admitted in 3,629 acute care hospitals throughout the United States. STUDY DESIGN We compared average-adjusted mortality using logistic regression with average adjusted mortality based on the Hospital Compare random effects model. We then fit random effects models with the same patient variables as in Medicare's Hospital Compare mortality model but also included terms for hospital Medicare AMI volume and another model that additionally included other hospital characteristics. PRINCIPAL FINDINGS Hospital Compare's average adjusted mortality significantly underestimates average observed death rates in small volume hospitals. Placing hospital volume in the Hospital Compare model significantly improved predictions. CONCLUSIONS The Hospital Compare random effects model underestimates the typically poorer performance of low-volume hospitals. Placing hospital volume in the Hospital Compare model, and possibly other important hospital characteristics, appears indicated when using a random effects model to predict outcomes. Care must be taken to insure the proper method of reporting such models, especially if hospital characteristics are included in the random effects model.
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Affiliation(s)
- Jeffrey H Silber
- Center for Outcomes Research, 3535 Market Street, Suite 1029, Philadelphia, PA 19104, USA.
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Silber JH, Kaestner R, Even-Shoshan O, Wang Y, Bressler LJ. Aggressive treatment style and surgical outcomes. Health Serv Res 2010; 45:1872-92. [PMID: 20880043 DOI: 10.1111/j.1475-6773.2010.01180.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Aggressive treatment style, as defined by the Dartmouth Atlas of Health Care, has been implicated as an important factor contributing to excessively high medical expenditures. We aimed to determine the association between aggressive treatment style and surgical outcomes. DATA SOURCES/STUDY SETTING Medicare admissions to 3,065 hospitals for general, orthopedic, and vascular surgery between 2000 and 2005 (N = 4,558,215 unique patients). STUDY DESIGN A retrospective cohort analysis. RESULTS For elderly surgical patients, aggressive treatment style was not associated with significantly increased complications, but it was associated with significantly reduced odds of mortality and failure-to-rescue. The odds ratio for complications in hospitals at the 75th percentile of aggressive treatment style compared with those at the 25th percentile (a U.S.$10,000 difference) was 1.01 (1.00-1.02), p<.066; whereas the odds of mortality was 0.94 (0.93-0.95), p<.0001; and for failure-to-rescue it was 0.93 (0.92-0.94), p<.0001. Analyses that used alternative measures of aggressiveness--hospital days and ICU days--yielded similar results, as did analyses using only low-variation procedures. CONCLUSIONS Attempting to reduce aggressive care that is not cost effective is a laudable goal, but policy makers should be aware that there may be improved outcomes associated with patients undergoing surgery in hospitals with a more aggressive treatment style.
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Affiliation(s)
- Jeffrey H Silber
- Center for Outcomes Research, The Children's Hospital of Philadelphia, 3535 Market Street, Suite 1029, Philadelphia, PA 19104, USA.
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194
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Friese CR, Silber JH, Aiken LH. National Cancer Institute Cancer Center designation and 30-day mortality for hospitalized, immunocompromised cancer patients. Cancer Invest 2010; 28:751-7. [PMID: 20504224 DOI: 10.3109/07357901003735667] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To examine 30-day mortality and National Cancer Institute (NCI) designation for cancer patients who are immunocompromised and hospitalized. METHOD Secondary analysis of 1998 and 1999 hospital claims, cancer registry, and vital statistics (n = 10,370) linked to survey and administrative data from 160 Pennsylvania hospitals. Logistic regression models estimated the effects of NCI designation on the likelihood of 30-day mortality. RESULTS NCI-designated centers were associated with a 33% reduction in the likelihood of death, after adjusting for patient, hospital, and nursing characteristics. CONCLUSIONS Immunocompromised cancer patients have lower mortality in NCI-designated hospitals. Identification and adoption of care processes from these institutions may improve mortality.
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Ghaferi AA, Osborne NH, Birkmeyer JD, Dimick JB. Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg 2010; 211:325-30. [PMID: 20800188 DOI: 10.1016/j.jamcollsurg.2010.04.025] [Citation(s) in RCA: 226] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 04/23/2010] [Accepted: 04/26/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Failure to rescue (ie, mortality after a major complication) has recently been demonstrated as a mechanism underlying differences between high and low mortality hospitals. In this study, we sought to better understand the hospital characteristics that may explain failure to rescue. STUDY DESIGN Using data from the 2000 to 2006 Nationwide Inpatient Sample and the American Hospital Association annual survey, we evaluated the effect of 5 hospital level characteristics on failure to rescue (FTR) rates. Using multivariate logistic regression models, we determined the relative contribution of each of these factors to the FTR rates at the lowest and highest mortality hospitals. RESULTS Failure to rescue varied 6-fold across hospitals (6.4% in very low mortality hospitals vs 40.0% in very high mortality hospitals, p < 0.001). Several hospital characteristics were significantly associated with lower FTR: teaching status (odds ratio [OR] 0.66, 95% CI 0.53 to 0.82), hospital size greater than 200 beds (OR 0.65, 95% CI 0.48 to 0.87), average daily census greater than 50% capacity (OR 0.56, 95%CI 0.32 to 0.98), increased nurse-to-patient ratios (OR 0.94, 95% CI 0.89 to 0.99), and high hospital technology (OR 0.65, 95% CI 0.52 to 0.81). Including all hospital characteristics into a multivariate model results in a 36% reduction in the odds of FTR between very high and very low mortality hospitals (OR 6.6, 95% CI 3.7 to 11.9). CONCLUSIONS Several hospital characteristics are associated with FTR from major complications. However, a large portion of what makes some hospitals better than others at rescuing patients remains unexplained. Future research should focus on hospital cultures and attitudes that may contribute to the timely recognition and effective management of major complications.
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Affiliation(s)
- Amir A Ghaferi
- Michigan Surgical Collaborative for Outcomes Research and Evaluation (M-SCORE), Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
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Harless DW, Mark BA. Nurse staffing and quality of care with direct measurement of inpatient staffing. Med Care 2010; 48:659-63. [PMID: 20548254 DOI: 10.1097/mlr.0b013e3181dbe200] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Studies of the impact of registered nurse (RN) staffing on hospital quality of care for hospital inpatients often rely on data sources that do not distinguish inpatient from outpatient staffing, thus requiring imputation of staffing level. As a result, estimates of the impact of staffing on quality may be biased. OBJECTIVE To estimate the impact of changes in RN staffing on changes in quality of care with direct measurement of staffing levels. RESEARCH DESIGN Longitudinal regression analysis of California general acute care hospitals where inpatient staffing is measured directly. SUBJECTS Estimation sample reflects outcomes for 11,945,276 adult inpatients at 283 hospitals from 1996 to 2001. MEASURES Patient outcomes are in-hospital mortality ratio and surgical failure-to-rescue ratio after nurse-sensitive complications with risk adjustment through calculation of the expected number of adverse outcomes using the Medstat disease staging algorithm. Staffing levels were measured as the number of full-time equivalent nurses per 1000 inpatient days. RESULTS Estimates suggest that changes in RN staffing were associated with reductions in mortality and failure to rescue. At 2.97 RN full-time equivalents per 1000 inpatient days, a 1-unit increase in staffing was associated with a 0.043 decrease in the mortality ratio (P < 0.05), and the estimated effect was smaller at hospitals with higher staffing levels. Estimates for failure to rescue ratio were statistically significant only at higher staffing levels. CONCLUSIONS Results are compared with those from similar studies, including studies using imputation of inpatient staffing, and are found to be consistent with attenuation bias induced by imputation.
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Affiliation(s)
- David W Harless
- Department of Economics, Virginia Commonwealth University, Richmond, VA 23284, USA.
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Abstract
Vigilance has been central to nursing practice since Florence Nightingale. Often, the nurse’s work of surveillance goes unnoticed and the public never recognizes the value of the nurse’s work. The 1999 Institute of Medicine report on hospital deaths due to preventable errors has lifted the veil shrouding professional vigilance. But how to measure vigilance remained elusive, until the concept, failure to rescue (FTR), was proposed. FTR has taken a prominent role in health care since its adoption as a patient safety indicator by the Agency for Healthcare Research and Quality (AHRQ) and as a measure for nursing performance in acute care by the National Quality Forum (NQF). However, its applicability to school nursing has been unexplored. This article provides an initial review of the literature and an analysis of anecdotal stories and media accounts that illustrate professional vigilance in school nursing practice.
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198
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Friese CR, Earle CC, Silber JH, Aiken LH. Hospital characteristics, clinical severity, and outcomes for surgical oncology patients. Surgery 2010; 147:602-9. [PMID: 20403513 DOI: 10.1016/j.surg.2009.03.014] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Accepted: 03/02/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients and payers wish to identify hospitals with good surgical oncology outcomes. Our objective was to determine whether differences in outcomes explained by hospital structural characteristics are mitigated by differences in patient severity. METHODS Using hospital administrative and cancer registry records in Pennsylvania, we identified 24,618 adults hospitalized for cancer-related operations. Colorectal, prostate, endometrial, ovarian, head and neck, lung, esophageal, and pancreatic cancers were studied. Outcome measures were 30-day mortality and failure to rescue (FTR) (30-day mortality preceded by a complication). After severity of illness adjustment, we estimated logistic regression models to predict the likelihood of both outcomes. In addition to American Hospital Association survey data, we externally verified hospitals with National Cancer Institute (NCI) cancer center or Commission on Cancer (COC) cancer program status. RESULTS Patients in hospitals with NCI cancer centers were significantly younger and less acutely ill on admission (P < .001). Patients in high volume hospitals were younger, had lower admission acuity, yet had more advanced cancer (P < .001). Unadjusted 30-day mortality rates were lower in NCI-designated hospitals (3.76% vs 2.17%;P = .01). Risk-adjusted FTR rates were significantly lower in NCI-designated hospitals (4.86% vs 3.51%;P = .03). NCI center designation was a significant predictor of 30-day mortality when considering patient and hospital characteristics (OR, 0.68; 95% CI, 0.47-0.97;P = .04). We did not find significant outcomes effects based on COC cancer program approval. CONCLUSION Patient severity of illness varies significantly across hospitals, which may explain the outcome differences observed. Severity adjustment is crucial to understanding outcome differences. Outcomes were better than predicted for NCI-designated hospitals.
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Affiliation(s)
- Christopher R Friese
- Division of Nursing Business and Health Systems, School of Nursing, University of Michigan, Ann Arbor, MI 48109-5482, USA.
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Identifying Cardiorespiratory Insufficiency Outside the ICU. Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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