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Konety BR, Allareddy V, Herr H. Complications after radical cystectomy: Analysis of population-based data. Urology 2006; 68:58-64. [PMID: 16806414 DOI: 10.1016/j.urology.2006.01.051] [Citation(s) in RCA: 181] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Revised: 12/09/2005] [Accepted: 01/13/2006] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To determine the morbidity and mortality from radical cystectomy in a nationally representative population-derived sample. Complications after radical cystectomy have been reported from large single-institution series but population-based representative data are lacking. METHODS All patients undergoing radical cystectomy for bladder cancer were identified from the National Inpatient Sample data set of the Health Care Utilization Project (1998 to 2002). The prevalence of different complications coded according to the International Classification of Diseases, version 9, after cystectomy were determined. Independent hospital and patient-related factors associated with the occurrence of a complication were determined by logistic regression analysis. The prevalence of complication by type and frequency were compared with that in other large reported series. RESULTS The in-hospital mortality rate was 2.57%, and at least one complication other than death occurred in 28.4% of patients. These rates were comparable to those reported in published studies. Younger patients had a lower likelihood of complications. Younger patients and those undergoing cystectomy at large bed size, urban, teaching hospitals were less likely to have secondary complications after surgery, and younger patients, women, and those undergoing cystectomy at high-volume hospitals were less likely to have primary complications directly related to their surgery. CONCLUSIONS The overall morbidity and mortality rates after radical cystectomy in a population-based sample were comparable to those reported from individual centers. Larger centers in urban locations may have lower complication rates but only hospitals performing a high volume of cystectomies were associated with fewer primary surgery-related complications.
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Affiliation(s)
- Badrinath R Konety
- Department of Urology, University of California, San Francisco, School of Medicine, UCSF-Mt. Zion Medical Center, San Francisco, California 94143-1695, USA.
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252
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Berney B, Needleman J. Impact of nursing overtime on nurse-sensitive patient outcomes in New York hospitals, 1995-2000. Policy Polit Nurs Pract 2006; 7:87-100. [PMID: 16864629 DOI: 10.1177/1527154406291132] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
During the past several years, nurses and their advocates have expressed concern about heavy use of overtime in hospitals and claimed that it undermines the quality of nursing care. Using staffing and discharge data covering 1995 to 2000 from 161 acute general hospitals in New York State, this study uses multi variate regression to analyze the relationship between overtime and the rates of six nurse-sensitive patient outcomes and mortality. We find an association of overtime with lower rates of mortality in medical and surgical patients but do not consider these findings definitive. Because overtime use is episodic and unit specific, further study of these issues using data that examines the occurrence of adverse events by unit during periods of heavy nurse overtime is recommended.
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253
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Khan NA, Quan H, Bugar JM, Lemaire JB, Brant R, Ghali WA. Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med 2006; 21:177-80. [PMID: 16606377 PMCID: PMC1484655 DOI: 10.1111/j.1525-1497.2006.00319.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Postoperative complications are a significant source of morbidity and mortality. There are limited studies, however, assessing the impact of common postoperative complications on health care resource utilization. OBJECTIVE To assess the association of clinically important postoperative complications with total hospital costs and length of stay (LOS) in patients undergoing noncardiac surgery. METHODS We determined total hospital costs and LOS in all patients admitted to a single tertiary care center between July 1, 1996 and March 31, 1998 using a detailed administrative hospital discharge database. Total hospital costs and LOS were adjusted for preoperative and surgical characteristics. RESULTS Of 7,457 patients who underwent noncardiac surgery, 6.9% developed at least 1 of the postoperative complications. These complications increased hospital costs by 78% (95% confidence interval [CI]: 68% to 90%) and LOS by 114% (95% CI: 100% to 130%) after adjustment for patient preoperative and surgical characteristics. Postoperative pneumonia was the most common complication (3%) and was associated with a 55% increase in hospital costs (95% CI: 42% to 69%) and an 89% increase in LOS (95% CI: 70% to 109%). CONCLUSIONS Postoperative complications consume considerable health care resources. Initiatives targeting prevention of these events could significantly reduce overall costs of care and improve patient quality of care.
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Affiliation(s)
- Nadia A Khan
- Department of Medicine, University of British Columbia, BC, Canada.
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254
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Abstract
OBJECTIVE Iatrogenic pneumothorax (IP) is an inherent risk to patients who undergo procedures that involve the intentional puncturing of the lung. IP also could occur accidentally to patients who do not undergo such procedures; such accidental IP (AIP) is suggestive of lapses in safe care. This study assessed the risk for AIP in patients hospitalized with specific diagnoses who underwent specific procedures. RESEARCH DESIGN We analyzed 7.5 million discharge abstracts from 994 short-term acute care hospitals across 28 states in 2000 in the Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project Nationwide Inpatient Sample. AHRQ Patient Safety Indicators (PSIs) were used to identify AIP. AIP incidences and associated diagnoses and procedures were explored. RESULTS Patients who were admitted for pleurisy, cancer of the kidney and renal pelvis, or conduction disorders and complications of cardiac devices had the highest rates of developing AIP during hospitalization, with AIP rates at 2.24%, 1.14%, and 0.83% respectively. The procedure-specific rates for AIP varied from 2.68% for patients who underwent thoracentesis to 1.30% for those who underwent nephrectomy, to 0.06% for those who underwent gastrostomy. Thoracentesis appeared to be a high-risk procedure for patients who were admitted for secondary malignancies, pleurisy, or pneumonia, with AIP rates at 3.76%, 3.13%, and 2.28%, respectively. CONCLUSIONS Although AIP is most common after thoracentesis, it is a substantial threat to patients undergoing a wide range of procedures.
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Affiliation(s)
- Chunliu Zhan
- Agency for Healthcare Research and Quality, Rockville, Maryland 20850, USA.
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255
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Krumholz HM, Brindis RG, Brush JE, Cohen DJ, Epstein AJ, Furie K, Howard G, Peterson ED, Rathore SS, Smith SC, Spertus JA, Wang Y, Normand SLT. Standards for Statistical Models Used for Public Reporting of Health Outcomes. Circulation 2006; 113:456-62. [PMID: 16365198 DOI: 10.1161/circulationaha.105.170769] [Citation(s) in RCA: 255] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With the proliferation of efforts to report publicly the outcomes of healthcare providers and institutions, there is a growing need to define standards for the methods that are being employed. An interdisciplinary writing group identified 7 preferred attributes of statistical models used for publicly reported outcomes. These attributes include (1) clear and explicit definition of an appropriate patient sample, (2) clinical coherence of model variables, (3) sufficiently high-quality and timely data, (4) designation of an appropriate reference time before which covariates are derived and after which outcomes are measured, (5) use of an appropriate outcome and a standardized period of outcome assessment, (6) application of an analytical approach that takes into account the multilevel organization of data, and (7) disclosure of the methods used to compare outcomes, including disclosure of performance of risk-adjustment methodology in derivation and validation samples.
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Amin-Hanjani S, Butler WE, Ogilvy CS, Carter BS, Barker FG. Extracranial—intracranial bypass in the treatment of occlusive cerebrovascular disease and intracranial aneurysms in the United States between 1992 and 2001: a population-based study. J Neurosurg 2005; 103:794-804. [PMID: 16304982 DOI: 10.3171/jns.2005.103.5.0794] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The authors assessed the results of extracranial—intracranial (EC—IC) bypass surgery in the treatment of occlusive cerebrovascular disease and intracranial aneurysms in the US between 1992 and 2001 by using population-based methods.
Methods. This is a retrospective cohort study based on data from the Nationwide Inpatient Sample (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, Rockville, MD). Five hundred fifty-eight operations were performed at 158 hospitals by 115 identified surgeons. The indications for surgery were cerebral ischemia in 74% of the operations (2.4% mortality rate), unruptured aneurysms in 19% of the operations (7.7% mortality rate), and ruptured aneurysms in 7% of the operations (21% mortality rate). Overall, 4.6% of the patients died and 4.7% of the patients were discharged to long-term facilities, 16.4% to short-term facilities, and 74.2% to their homes. The annual number of admissions in the US increased from 190 per year (1992–1996) to 360 per year (1997–2001), whereas the mortality rates increased from 2.8% (1992–1996) to 5.7% (1997–2001).
The median annual number of procedures was three per hospital (range one–27 operations) or two per surgeon (range one–21 operations). For 29% of patients, their bypass procedure was the only one recorded at their particular hospital during that year; for these institutions the mean annual caseload was 0.4 admissions per year. For 42% of patients, their particular surgeon performed no other bypass procedure during that year. Older patient age (p < 0.001) and African-American race (p = 0.005) were risk factors for adverse outcome. In a multivariate analysis in which adjustments were made for age, sex, race, diagnosis, admission type, geographic region, medical comorbidity, and year of surgery, high-volume hospitals less frequently had an adverse discharge disposition (odds ratio 0.54, p = 0.03).
Conclusions. Most EC—IC bypasses performed in the US during the last decade were performed for occlusive cerebrovascular disease. Community mortality rates for aneurysm treatment including bypass procedures currently exceed published values from specialized centers and, during the period under study, the mortality rates increased with time for all diagnostic subgroups. This technically demanding procedure has become a very low-volume operation at most US centers.
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Affiliation(s)
- Sepideh Amin-Hanjani
- Neurosurgical Service, Massachusetts General Hospital, and Department of Surgery Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA
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257
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Romano PS, Yasmeen S, Schembri ME, Keyzer JM, Gilbert WM. Coding of Perineal Lacerations and Other Complications of Obstetric Care in Hospital Discharge Data. Obstet Gynecol 2005; 106:717-25. [PMID: 16199627 DOI: 10.1097/01.aog.0000179552.36108.6d] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the validity of obstetric complications, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Core Measure on perineal lacerations, in the California Patient Discharge Data Set. METHODS We randomly sampled 1,611 deliveries from 52 of the 267 hospitals that performed more than 678 eligible deliveries in California in 1992-1993. We compared hospital-reported complications against our recoding of the same records. RESULTS Third- and fourth-degree perineal lacerations were reported accurately, with estimated sensitivities exceeding 90% and positive predictive values exceeding 65% (weighted to account for the stratified sampling design) or 85% (unweighted). Based on in-depth review of discrepant cases, we estimate the actual positive predictive value at over 90%. Most coding discrepancies were between no injury and first degree, or between first and second degree. Most postpartum complications, including urinary tract and wound infections, endometritis, anesthesia complications, and postpartum hemorrhage were reported with less than 70% sensitivity, but at least 80% positive predictive value. Composite measures from HealthGrades and Solucient, which include these complication codes, also suffer from high false-negative rates. CONCLUSION Third- and fourth-degree perineal lacerations are accurately reported on hospital discharge abstracts, confirming the validity of related quality indicators sponsored by the Agency for Healthcare Research and Quality and JCAHO. Administrative data seem less useful for monitoring other in-hospital postpartum complications.
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Affiliation(s)
- Patrick S Romano
- Division of General Medicine, the Center for Health Services Research in Primary Care, and the Department of Obstetrics and Gynecology, University of California Davis School of Medicine, Sacramento, California 95817, USA.
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Elting LS, Pettaway C, Bekele BN, Grossman HB, Cooksley C, Avritscher EBC, Saldin K, Dinney CPN. Correlation between annual volume of cystectomy, professional staffing, and outcomes: a statewide, population-based study. Cancer 2005; 104:975-84. [PMID: 16044400 DOI: 10.1002/cncr.21273] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The association between high procedure volume and lower perioperative mortality is well established among cancer patients who undergo cystectomy. However, to the authors' knowledge, the association between volume and perioperative complications has not been studied to date and hospital characteristics contributing to the volume-outcome correlation are unknown. In the current study, the authors studied these associations, emphasizing hospital factors that contribute to the volume-outcome correlation. METHODS Multiple-variable models of inpatient mortality and complications were developed among all 1302 bladder carcinoma patients who underwent cystectomy between January 1, 1999 and December 31, 2001 in all Texas hospitals. General estimating equations were used to adjust for clustering within the 133 hospitals. Data were obtained from hospital claims, the 2000 U.S. Census, and databases from the Center for Medicare and Medicaid Services and the American Hospital Association. RESULTS Complications were reported to occur in 12% of patients, 2.2% of whom died. Mortality was higher in low-volume hospitals compared with high-volume hospitals (3.1% vs. 0.7%; P < 0.001); mortality in moderate-volume hospitals was reported to be intermediate (2.9%). After adjustment for advanced age and comorbid conditions, treatment in high-volume hospitals was associated with lower risks of mortality (odds ratio [OR] = 0.35; P = 0.02) and complications (OR = 0.53; P = 0.01). Hospitals with a high registered nurse-to-patient ratio also had a lower mortality risk (OR = 0.43; P = 0.04). CONCLUSIONS Mortality after cystectomy was found to be significantly lower in high-volume hospitals, regardless of patient age. Referral to a hospital performing greater than 10 cystectomies annually is indicated for all patients. However, patients with poor access to a high-volume hospital may derive similar benefit from treatment at a hospital with a high-registered nurse-to-patient ratio. This finding requires further confirmation.
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Affiliation(s)
- Linda S Elting
- Section of Health Services Research, Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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259
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Shufelt JL, Hannan EL, Gallagher BK. The postoperative hemorrhage and hematoma patient safety indicator and its risk factors. Am J Med Qual 2005; 20:210-8. [PMID: 16020678 DOI: 10.1177/1062860605276941] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study employed a retrospective cohort analysis using New York State's Statewide Planning and Research Cooperative System (SPARCS) to improve the Patient Safety Indicator (PSI) definition of postoperative hemorrhage/hematoma (POHH) and to identify patient risk factors associated with POHH. Study participants were nonobstetric, inpatient surgical admissions in SPARCS and readmissions within 30 days with a principal diagnosis of POHH. The main outcome measures were mortality rate, length of stay, and readmissions. The mortality rates of events identified by a secondary diagnosis only and by the PSI were not significantly different. The number of POHH events increased by 9.3% when readmissions were captured. The PSI definition of POHH may need modification to capture events with no secondary procedure. The PSI misses events identified on readmission, but the consequences of these events are not as severe as those currently captured. A variety of patient and hospital characteristics are predictive of a higher risk of POHH.
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Affiliation(s)
- Jennie L Shufelt
- State University of New York at Albany, Rensselaer, NY 12144, USA
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260
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Rosen AK, Rivard P, Zhao S, Loveland S, Tsilimingras D, Christiansen CL, Elixhauser A, Romano PS. Evaluating the Patient Safety Indicators. Med Care 2005; 43:873-84. [PMID: 16116352 DOI: 10.1097/01.mlr.0000173561.79742.fb] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Patient Safety Indicators (PSIs), an administrative data-based tool developed by the Agency for Healthcare Research and Quality, are increasingly being used to screen for potential in-hospital patient safety problems. Although the Veterans Health Administration (VA) is a national leader in patient safety, accurate information on the epidemiology of patient safety events in the VA is still unavailable. OBJECTIVES Our objectives were to: (1) apply the AHRQ PSI software to VA administrative data to identify potential instances of compromised patient safety; (2) determine occurrence rates of PSI events in the VA; and (3) examine the construct validity of the PSIs. METHODS We examined differences between observed and risk-adjusted PSI rates in the VA, compared VA and non-VA PSI rates, and investigated the construct validity of the PSIs by examining correlations of the PSIs with other outcomes of VA hospitalizations. RESULTS We identified 11,411 PSI events in the VA nationwide in FY'01. Observed PSI rates per 1000 discharges ranged from 0.007 for "transfusion reaction" to 155.5 for "failure to rescue." There were significant, although small, differences between VA and non-VA risk-adjusted PSI rates. Hospitalizations with PSI events had longer lengths of stay, higher mortality, and higher costs than those without PSI events. CONCLUSIONS Our results suggest that the PSIs may be useful as a patient safety screening tool in the VA. Our PSI rates were consistent with the national incidence of low rates; however, differences between VA and non-VA rates suggest that inadequate case-mix adjustment may be contributing to these findings.
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Affiliation(s)
- Amy K Rosen
- Center for Health Quality, Outcomes and Economic Research, Bedford VAMC (152), Bedford, Massachusetts 01730, USA.
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261
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Arnason T, Wells PS, van Walraven C, Forster AJ. Accuracy of coding for possible warfarin complications in hospital discharge abstracts. Thromb Res 2005; 118:253-62. [PMID: 16081144 DOI: 10.1016/j.thromres.2005.06.015] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Revised: 06/10/2005] [Accepted: 06/23/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Hospital discharge abstracts could be used to identify complications of warfarin if coding for bleeding and thromboembolic events are accurate. OBJECTIVES To measure the accuracy of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9CM) codes for bleeding and thromboembolic diagnoses. SETTING University affiliated, tertiary care hospital in Ottawa, Canada. PATIENTS A random sample of patients discharged between September 1999 and September 2000 with an ICD-9-CM code indicating a bleeding or thromboembolic diagnosis. METHODS Gold-standard coding was determined by a trained chart abstractor using explicit standard diagnostic criteria for bleeding, major bleeding, and acute thromboembolism. The abstractor was blinded to the original coding. We calculated the sensitivity, specificity, positive, and negative predictive values of the original ICD-9CM codes for bleeding or thromboembolism diagnoses. RESULTS We reviewed 616 medical records. 361 patients (59%) had a code indicating a bleeding diagnosis, 291 patients (47%) had a code indicating a thromboembolic diagnosis and 36 patients (6%) had a code indicating both. According to the gold standard criteria, 352 patients experienced bleeding, 333 experienced major bleeding, and 188 experienced an acute thromboembolism. For bleeding, the ICD-9CM codes had the following sensitivity, specificity, positive and negative predictive values [95% CI]: 93% [90-96], 88% [83-91], 91% [88-94], and 91% [87-94], respectively. For major bleeding, the ICD-9CM codes had the following sensitivity, specificity, positive and negative predictive values: 94% [91-96], 83% [78-87], 87% [83-90], and 92% [88-95], respectively. For thromboembolism, the ICD-9CM codes had the following sensitivity, specificity, positive and negative predictive values: 97% [94-99], 74% [70-79], 62% [57-68], and 98% [96-99], respectively. By selecting a sub-group of ICD-9CM codes for thromboembolism, the positive predictive value increased to 87%. CONCLUSION In our centre, the discharge abstract could be used to identify and exclude patients hospitalized with a major bleed or thromboembolism. If coding quality for bleeding is similar in other hospitals, these ICD-9-CM diagnostic codes could be used to study population-based warfarin-associated hemorrhagic complications using administrative databases.
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Affiliation(s)
- T Arnason
- Ottawa Health Research Institute-Clinical Epidemiology Program, Canada
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262
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Poulose BK, Ray WA, Arbogast PG, Needleman J, Buerhaus PI, Griffin MR, Abumrad NN, Beauchamp RD, Holzman MD. Resident work hour limits and patient safety. Ann Surg 2005; 241:847-56; discussion 856-60. [PMID: 15912034 PMCID: PMC1357165 DOI: 10.1097/01.sla.0000164075.18748.38] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study evaluates the effect of resident physician work hour limits on surgical patient safety. BACKGROUND Resident work hour limits have been enforced in New York State since 1998 and nationwide from 2003. A primary assumption of these limits is that these changes will improve patient safety. We examined effects of this policy in New York on standardized surgical Patient Safety Indicators (PSIs). METHODS An interrupted time series analysis was performed using 1995 to 2001 Nationwide Inpatient Sample data. The intervention studied was resident work hour limit enforcement in New York teaching hospitals. PSIs included rates of accidental puncture or laceration (APL), postoperative pulmonary embolus or deep venous thrombosis (PEDVT), foreign body left during procedure (FB), iatrogenic pneumothorax (PTX), and postoperative wound dehiscence (WD). PSI trends were compared pre- versus postintervention in New York teaching hospitals and in 2 control groups: New York nonteaching hospitals and California teaching hospitals. RESULTS A mean of 2.6 million New York discharges per year were analyzed with cumulative events of 33,756 (APL), 36,970 (PEDVT), 1,447 (FB), 10,727 (PTX), and 2,520 (WD). Increased rates over time (expressed per 1000 discharges each quarter) were observed in both APL (0.15, 95% confidence interval, 0.09-0.20, P<0.05) and PEDVT (0.43, 95% confidence interval, 0.03-0.83, P<0.05) after policy enforcement in New York teaching hospitals. No changes were observed in either control group for these events or New York teaching hospital rates of FB, PTX, or WD. CONCLUSIONS Resident work hour limits in New York teaching hospitals were not associated with improvements in surgical patient safety measures, with worsening trends observed in APL and PEDVT corresponding with enforcement.
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Affiliation(s)
- Benjamin K Poulose
- Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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263
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Curry WT, McDermott MW, Carter BS, Barker FG. Craniotomy for meningioma in the United States between 1988 and 2000: decreasing rate of mortality and the effect of provider caseload. J Neurosurg 2005; 102:977-86. [PMID: 16028755 DOI: 10.3171/jns.2005.102.6.0977] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The goal of this study was to determine the risk of adverse outcomes after contemporary surgical treatment of meningiomas in the US and trends in patient outcomes and patterns of care.
Methods. The authors performed a retrospective cohort study by using the Nationwide Inpatient Sample covering the period of 1988 to 2000. Multivariate regression models with disposition end points of death and hospital discharge were used to test patient, surgeon, and hospital characteristics, including volume of care, as outcome predictors.
Multivariate analyses revealed that larger-volume centers had lower mortality rates for patients who underwent craniotomy for meningioma (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.59–0.93, p = 0.01). Adverse discharge disposition was also less likely at high-volume hospitals (OR 0.71, 95% CI 0.62–0.80, p < 0.001). With respect to the surgeon caseload, there was a trend toward a lower rate of mortality after surgery when higher-caseload providers were involved, and a significantly less frequent adverse discharge disposition (OR 0.71, 95% CI 0.62–0.80, p <, 0.001).
The annual meningioma caseload in the US increased 83% between 1988 and 2000, from 3900 patients/year to 7200 patients/year. In-hospital mortality rates decreased 61%, from 4.5% in 1988 to 1.8% in 2000. Reductions in the mortality rates were largest at high-volume centers (a 72% reduction in the relative mortality rate at largest-volume-quintile centers, compared with a 6% increase in the relative mortality rate at lowest-volume-quintile centers). The number of US hospitals where craniotomies were performed for meningiomas increased slightly. Fewer centers hosted one meningioma resection annually, whereas the largest centers had disproportionate increases in their caseloads, indicating a modest centralization of meningioma surgery in the US during this interval.
Conclusions. The mortality and adverse hospital discharge disposition rates were lower when meningioma surgery was performed by high-volume providers. The annual US caseload increased, whereas the mortality rates decreased, especially at high-volume centers.
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Affiliation(s)
- William T Curry
- Brain Tumor Center, Neurosurgical Service, Massachusetts General Hospital, Boston 02114, USA
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264
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Dy SM, Garg P, Nyberg D, Dawson PB, Pronovost PJ, Morlock L, Rubin H, Wu AW. Critical pathway effectiveness: assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis. Health Serv Res 2005; 40:499-516. [PMID: 15762904 PMCID: PMC1361153 DOI: 10.1111/j.1475-6773.2005.00369.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To qualitatively describe patient, hospital care, and critical pathway characteristics that may be associated with pathway effectiveness in reducing length of stay. DATA SOURCES/STUDY SETTING Administrative data and review of pathway documentation and a sample of medical records for each of 26 surgical critical pathways in a tertiary care center's department of surgery, 1988-1998. STUDY DESIGN Retrospective qualitative study. DATA COLLECTION/ABSTRACTION METHODS: Using information from a literature review and consultation with experts, we developed a list of characteristics that might impact critical pathway effectiveness. We used hypothesis-driven qualitative comparative analysis to describe key primary and secondary characteristics that might differentiate effective from ineffective critical pathways. PRINCIPAL FINDINGS " All 7 of the 26 pathways associated with a reduced length of stay had at least one of the following characteristics: (1) no preexisting trend toward lower length of stay for the procedure (71 percent), and/or (2) it was the first pathway implemented in its surgical service (71 percent). In addition, pathways effective in reducing length of stay tended to be for procedures with lower patient severity of illness, as indicated by fewer intensive care days and lower mortality. Effective pathways tended to be used more frequently than ineffective pathways (77 versus 59 percent of medical records with pathway documents present), but high rates of documented pathway use were not necessary for pathway effectiveness. CONCLUSIONS Critical pathway programs may have limited effectiveness, and may be effective only in certain situations. Because pathway utilization was not a strong predictor of pathway effectiveness, the mechanism by which critical pathways may reduce length of stay is unclear.
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Affiliation(s)
- Sydney M Dy
- Maryland Community Hospice, Room 609, 624N. Broadway, Baltimore, MD 21205, USA
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265
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Mukherjee D, Wainess RM, Dimick JB, Cowan JA, Rajagopalan S, Chetcuti S, Grossman PM, Upchurch GR. Variation in Outcomes after Percutaneous Coronary Intervention in the United States and Predictors of Periprocedural Mortality. Cardiology 2005; 103:143-7. [PMID: 15722631 DOI: 10.1159/000084029] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2004] [Accepted: 08/24/2004] [Indexed: 11/19/2022]
Abstract
The objective of this study was to characterize variation in mortality rates across hospitals performing percutaneous coronary intervention (PCI) in the United States. For this purpose, data (n = 735,022) from the Nationwide Inpatient Sample from 1996 to 2001 were analyzed. The primary outcome for the analysis was postprocedural in-hospital mortality. Mortality rates were calculated by race, gender, geographic region, comorbid status and hospital volume. There were significant variations in mortality across gender groups, comorbid status, regions and by hospital volume status. Independent predictors of mortality in this large cohort were older age, female gender, lower income and lower hospital volume. The data suggests targets for quality improvement initiatives for patients undergoing PCI particularly in the elderly, females, lower income patients and low volume hospitals. Even in the contemporary era of adjunctive pharmacological therapies and ubiquitous use of stents, hospital volume remains a significant independent predictor of in-hospital mortality.
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Abstract
Public and corporate pressure to improve the quality of healthcare in the United States has never been greater. Rising costs, recent discouraging appraisals of patient safety, accelerating malpractice litigation, and an increasing burden of chronic disease have intensified the demand for a change in current policies. Central to these efforts are payers who are increasingly creating financial incentives for providers to deliver high-quality healthcare. It is hoped that these programs (sometimes referred to as "quality incentive payment systems") will stimulate the adoption of systems that will reduce variability and assure that high-quality care is being delivered. Whether these programs will achieve their objectives remains to be determined. There are many unanswered questions about their effectiveness.
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Affiliation(s)
- Peter A L Bonis
- Division of Gastroenterology, Tufts, University School of Medicine, Boston, MA 02481, USA.
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267
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Zhan C, Kelley E, Yang HP, Keyes M, Battles J, Borotkanics RJ, Stryer D. Assessing patient safety in the United States: challenges and opportunities. Med Care 2005; 43:I42-7. [PMID: 15746590 DOI: 10.1097/00005650-200503001-00007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In 1999, the US Congress mandated the Agency for Healthcare Research and Quality (AHRQ), Department of Health and Human Services (DHHS), to report annually to the nation about healthcare quality. One chapter in the National Healthcare Quality Report (NHQR) is focused on patient safety. OBJECTIVES The objectives of this study were to describe the challenges in reporting the national status on patient safety for the first NHQR and discuss emerging opportunities to improve the comprehensiveness and reliability of future reporting. RESEARCH DESIGN This study is a selective review of definitions, frameworks, data sources, measures, and emerging developments for assessing patient safety in the United States. RESULTS Available data and measures for patient safety assessment in the nation are inadequate, especially for comparing regions and subpopulations and for trend analysis. However, many opportunities are emerging from the recently increased investments in patient safety research and many ongoing safety improvement efforts in the private sector and at the federal, state, and local government levels. CONCLUSION There are many challenges in assessing national performance on patient safety today. Ongoing developments on multiple fronts will provide data and measures for more accurate and more comprehensive assessments of patient safety for future NHQRs.
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Affiliation(s)
- Chunliu Zhan
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, MD 20850, USA.
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268
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Dy SM, Garg P, Nyberg D, Dawson PB, Pronovost PJ, Morlock L, Rubin H, Wu AW. Critical Pathway Effectiveness: Assessing the Impact of Patient, Hospital Care, and Pathway Characteristics Using Qualitative Comparative Analysis. Health Serv Res 2005. [DOI: 10.1111/j.1475-6773.2005.0r370.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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269
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Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Morlock LL. Defining and measuring patient safety. Crit Care Clin 2005; 21:1-19, vii. [PMID: 15579349 DOI: 10.1016/j.ccc.2004.07.006] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Despite the growing demand for improved safety in health care, debate remains regarding the magnitude of the problem and the degree to which harm is preventable. To a great extent, this debate stems from variation in the definition and methods for measuring safety, its "shadow" error, and the degree of preventability. This article reviews the definition of safety and error, discusses approaches to measuring safety, and provides a framework for investigating incidents that unveils how the systems under which care is delivered may contribute to adverse incidents.
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Affiliation(s)
- Peter J Pronovost
- Department of Anesthesiology & Critical Care Medicine, Surgery and Health Policy & Management, The Johns Hopkins University School of Medicine, 901 South Bond Street, Suite 318, Baltimore, MD 21231, USA.
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270
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Johnson CE, Handberg E, Dobalian A, Gurol N, Pearson V. Improving perinatal and neonatal patient safety: The AHRQ patient safety indicators. J Perinat Neonatal Nurs 2005; 19:15-23. [PMID: 15796421 DOI: 10.1097/00005237-200501000-00007] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study reviews the development and implementation of the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs). The genesis of the use of administrative data as a tool to combat safety problems is presented, and how indicators were constructed using various administrative codes. Examples of how the PSIs are being used to identify potential safety problems within the general population are presented, with a special emphasis on how these are being used within the perinatal and neonatal arena to understand current issues within that subpopulation. Results from studies within the general population and targeted at perinatal and neonatal patients are presented. Finally, suggestions are discussed for clinicians to use the AHRQ PSIs as one of their early warning tools for potential safety-related problems.
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Affiliation(s)
- Christopher E Johnson
- Rehabilitation Outcomes Research Center of Excellence, North Florida/South Georgia Veteran's Health System, Gainesville, FL 32608, USA.
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271
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Abstract
A paucity of population-based data exist which describe the rapid growth of revision total knee arthroplasties, changes in patient characteristics, or the association of hospital volume with complication rates. We analyzed whether inpatient complications for 2986 revision knee arthroplasties done on patients admitted to 63 hospitals in northern Illinois from 1993-1999 were correlated with volume of revision total knee arthroplasties. Coded complication rates for hospitals with less than seven, seven to 14, or greater than 14 annual procedures were compared using logistic regression to control for clinical and demographic characteristics of patients, hospital teaching status, and the proportion of the hospitals' patients discharged to rehabilitation facilities. Revision total knee arthroplasties increased 59%, and the overall complication rate declined from 9.3% during 1993-1996 to 7.3% during 1997-1999 (p = .04). When compared with the lowest volume hospitals, medium-volume hospitals had higher complication rates, whereas the highest volume hospitals were not significantly different. The absence of volume-outcome effects may be related to the relatively high volume of primary knee arthroplasties done at almost all area hospitals, surgeon group coverage across multiple hospitals, and the small annual number of revision total knee arthroplasties done during these years.
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Affiliation(s)
- Joe Feinglass
- Division of General Internal Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
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272
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Romano PS, Mutter R. The evolving science of quality measurement for hospitals: implications for studies of competition and consolidation. ACTA ACUST UNITED AC 2004; 4:131-57. [PMID: 15211103 DOI: 10.1023/b:ihfe.0000032420.18496.a4] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The literature on hospital competition and quality is young; most empirical studies have focused on few conditions and outcomes. Measures of in-hospital mortality and complications are susceptible to bias from unmeasured severity and transfer/discharge practices. Only one research team has evaluated related process and outcome measures, and none has exploited chart-review or patient survey-based data. Prior studies have generated inconsistent findings, suggesting the need for additional research. We describe the strengths and limitations of various approaches to quality measurement, summarize how quality has been operationalized in studies of hospital competition, outline three mechanisms by which competition may affect hospital quality, and propose measures appropriate for testing each mechanism.
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Affiliation(s)
- Patrick S Romano
- Division of General Medicine and Center for Health Services Research in Primary Care, University of California, Davis School of Medicine, Sacramento, CA 95817, USA.
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273
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Weller WE, Gallagher BK, Cen L, Hannan EL. Readmissions for venous thromboembolism: expanding the definition of patient safety indicators. ACTA ACUST UNITED AC 2004; 30:497-504. [PMID: 15469127 DOI: 10.1016/s1549-3741(04)30058-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Agency for Healthcare Research and Quality (AHRQ) defines its venous thromboembolism (VTE) patient safety indicator (PSI) as surgical cases with a secondary diagnosis of pulmonary embolism or deep vein thrombosis. Short-term readmissions for VTE are excluded because most state administrative databases are unable to track readmissions. METHODS Patients meeting the AHRQ VTE PSI definition and those readmitted with a VTE principal diagnosis within 30 days of a prior surgical hospitalization were identified on the basis of inpatient discharge data. RESULTS A total of 4,906 surgical discharges in New York met the AHRQ VTE PSI definition in 2001. An additional 1,059 cases of VTE were found when surgical patients with a short-term readmission for VTE were identified. Patients readmitted with VTE were less likely to die but were more likely to have a pulmonary embolism and were more likely to be white and non-Hispanic compared to those who met the AHRQ VTE PSI definition. DISCUSSION Short-term readmissions for VTE represent potentially important cases to capture when monitoring adverse events. Prophylaxis, monitoring, and patient education may be required after hospital discharge to prevent or treat VTE as early as possible. Data systems that can track patients across multiple admissions to identify complications resulting in short-term readmissions are needed.
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Affiliation(s)
- Wendy E Weller
- Department of Health Policy, Management, and Behavior, University at Albany School of Public Health, Rensselaer, New York, USA.
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274
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Quan H, Parsons GA, Ghali WA. Validity of procedure codes in International Classification of Diseases, 9th revision, clinical modification administrative data. Med Care 2004; 42:801-9. [PMID: 15258482 DOI: 10.1097/01.mlr.0000132391.59713.0d] [Citation(s) in RCA: 310] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Administrative hospital discharge data are widely used to assess quality of care in patients undergoing certain procedures. However, little is known about the validity of administrative coding of procedure data. We conducted a detailed chart review to evaluate the accuracy and completeness of information on procedures in administrative data. METHODS We randomly selected 1200 hospital separations in the period April 1, 1996, to March 31, 1997, from administrative discharge data of 3 acute adult hospitals in Calgary, Alberta, Canada. Each separation record in administrative data contains up to 10 procedure coding fields. The corresponding medical charts were reviewed for recording presence or absence of procedures. We then determined sensitivity to quantify the accuracy of coding presence of procedures in administrative data when these are present in the chart data (criterion standard). RESULTS The agreement between the 2 databases varied greatly across 35 procedures studied. The sensitivity ranged from 0% to 94%. Of 6 major procedures studied, validity of coding was generally good, with 5 procedures having coding sensitivity of 69% and over and only 1 (lysis of peritoneal adhesion) with a low sensitivity of 41%. In contrast, many minor procedures had low sensitivities. Of 29 minor procedures studied, sensitivity was lower than 50% for 15 procedures, between 50% and 79% for 10, and 80% and over for 4. CONCLUSION Validity of information on procedures in administrative discharge data appears to be related to type of procedures. Major procedures that are usually performed in operating rooms are reasonably well-coded. Meanwhile, minor procedures that are routinely performed on wards or in radiology departments are generally undercoded.
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Affiliation(s)
- Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
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275
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Quan H, Parsons GA, Ghali WA. Assessing accuracy of diagnosis-type indicators for flagging complications in administrative data. J Clin Epidemiol 2004; 57:366-72. [PMID: 15135837 DOI: 10.1016/j.jclinepi.2003.01.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2003] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Canadian administrative hospital discharge data contain a diagnosis-type indicator for each coded diagnosis that allows researchers to distinguish complications from pre-existing diagnoses. Given that the validity of diagnosis-type indicators is unknown, we conducted a detailed chart review to evaluate the accuracy of diagnosis-type indicators for flagging complications. STUDY DESIGN AND SETTING We obtained administrative hospital discharge data for 1,200 randomly selected adult inpatient separations in Calgary, Alberta, occurring between April 1, 1996 and March 31, 1997. Each discharge record contains up to 16 diagnoses and 16 corresponding diagnosis-type indicators (value of "2"=complication). The corresponding medical charts were reviewed for evidence of diagnoses and complications. A complication was defined as a new diagnosis arising after the start of hospitalization. We determined the extent to which the diagnosis-type indicator in the administrative data agreed with the chart reviewer's assessment (criterion standard) of whether a diagnosis was a complication or not. RESULTS The agreement for complications between the two databases varied greatly across 12 conditions studied (kappa range: 0-0.72) and was often low (kappa <0.20 for six conditions). Sensitivity ranged from 0 to 57.1% (higher than 50% for only two conditions), indicating a tendency for complications to often be miscoded as baseline comorbidities. In contrast, specificity was generally high (range: 99.0-100%), suggesting that pre-existing conditions were usually appropriately coded as such in the administrative data. CONCLUSION The validity of diagnosis-type indicators in Canadian administrative discharge data appears to be poor for some types of complications. This is likely to be of greatest concern in studies that rely solely on diagnosis-type indicators to define complications as outcomes.
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Affiliation(s)
- Hude Quan
- Quality Improvement and Health Information, Calgary Health Region, 1403 29th Street NW, Calgary, Alberta, Canada T2N 2T9.
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276
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Murff HJ, Patel VL, Hripcsak G, Bates DW. Detecting adverse events for patient safety research: a review of current methodologies. J Biomed Inform 2004; 36:131-43. [PMID: 14552854 DOI: 10.1016/j.jbi.2003.08.003] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Promoting patient safety is a national priority. To evaluate interventions for reducing medical errors and adverse event, effective methods for detecting such events are required. This paper reviews the current methodologies for detection of adverse events and discusses their relative advantages and limitations. It also presents a cognitive framework for error monitoring and detection. While manual chart review has been considered the "gold-standard" for identifying adverse events in many patient safety studies, this methodology is expensive and imperfect. Investigators have developed or are currently evaluating, several electronic methods that can detect adverse events using coded data, free-text clinical narratives, or a combination of techniques. Advances in these systems will greatly facilitate our ability to monitor adverse events and promote patient safety research. But these systems will perform optimally only if we improve our understanding of the fundamental nature of errors and the ways in which the human mind can naturally, but erroneously, contribute to the problems that we observe.
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Affiliation(s)
- Harvey J Murff
- Department of Veterans Affairs, Tennessee Valley Healthcare System, GRECC, 1310 24th Avenue South, Nashville, TN 37212-2637, USA.
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277
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Vemuri C, Wainess RM, Dimick JB, Cowan JA, Henke PK, Stanley JC, Upchurch GR. Effect of increasing patient age on complication rates following intact abdominal aortic aneurysm repair in the united states1. J Surg Res 2004; 118:26-31. [PMID: 15093713 DOI: 10.1016/j.jss.2004.02.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2003] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Advanced age is generally acknowledged as a risk factor for adverse surgical outcomes, but little information exists to define the magnitude of this association from a population-based perspective. This study was undertaken to determine the relation of patient age to complications following abdominal aortic aneurysm (AAA) repair in a population-based experience. METHODS This study was based upon data from 6397 patients with a primary diagnosis of intact AAA and a procedure code for repair of AAA from the Nationwide Inpatient Sample (NIS) in 2000. The NIS is a 20% stratified random sample representative of all United States hospitals. Primary outcome variables were postoperative complications determined from secondary diagnostic codes. Adjustment for confounding variables was performed using multiple logistic regression. RESULTS At least one complication affected 29% of patients. Increasing age correlated with a higher risk of having one or more complications (51-60 years, 18.8%; 61-70 years, 27.3%; 71-80 years, 31.2%; >80 years, 34.3%; P < 0.01). Comparison of the oldest to the youngest age group revealed an increased incidence of pulmonary insufficiency (13.9% versus 6.4%), pneumonia (7.7% versus 3.0%), reintubation (9.5% versus 3.9%), acute renal failure (8.8% versus 2.5%), myocardial infarction (4.3% versus 1.6%), and mortality (7.9% versus 1.1%). The association of increasing age to complications and mortality persisted after adjusting for patient case-mix. CONCLUSIONS Older patient age is independently associated with an increased risk of major postoperative complications after AAA repair. The increasing age of the United States population will compound this healthcare problem. Quality improvement efforts must focus on minimizing complication rates in elderly patients undergoing common vascular surgical procedures including AAA repair.
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Affiliation(s)
- Chandu Vemuri
- Surgical Outcomes Research Team, Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
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278
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Mark BA, Harless DW, McCue M, Xu Y. A longitudinal examination of hospital registered nurse staffing and quality of care. Health Serv Res 2004; 39:279-300. [PMID: 15032955 PMCID: PMC1361008 DOI: 10.1111/j.1475-6773.2004.00228.x] [Citation(s) in RCA: 148] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate previous research findings of the relationship between nurse staffing and quality of care by examining the effects of change in registered nurse staffing on change in quality of care. DATA SOURCES/STUDY SETTING Secondary data from the American Hospital Association (AHA)(nurse staffing, hospital characteristics), InterStudy and Area Resource Files (ARF) (market characteristics), Centers for Medicare and Medicaid Services (CMS) (financial performance), and Healthcare Cost and Utilization Project (HCUP) (quality measures-in-hospital mortality ratio and the complication ratios for decubitus ulcers, pneumonia, and urinary tract infection, which were risk-adjusted using the Medstat disease staging algorithm). STUDY DESIGN Data from a longitudinal cohort of 422 hospitals were analyzed from 1990-1995 to examine the relationships between nurse staffing and quality of care. DATA COLLECTION/EXTRACTION METHODS A generalized method of moments estimator for dynamic panel data was used to analyze the data. Principal Findings. Increasing registered nurse staffing had a diminishing marginal effect on reducing mortality ratio, but had no consistent effect on any of the complications. Selected hospital characteristics, market characteristics, and financial performance had other independent effects on quality measures. CONCLUSIONS The findings provide limited support for the prevailing notion that improving registered nurse (RN) staffing unconditionally improves quality of care.
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Affiliation(s)
- Barbara A Mark
- School of Nursing, Carrington Hall CB#7460, University of North Carolina, Chapel Hill, Chapel Hill, NC 27599-7460, USA
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279
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Barker FG, Amin-Hanjani S, Butler WE, Hoh BL, Rabinov JD, Pryor JC, Ogilvy CS, Carter BS. Age-dependent differences in short-term outcome after surgical or endovascular treatment of unruptured intracranial aneurysms in the United States, 1996-2000. Neurosurgery 2004; 54:18-28; discussion 28-30. [PMID: 14683537 DOI: 10.1227/01.neu.0000097195.48840.c4] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2003] [Accepted: 08/12/2003] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Unruptured intracranial aneurysm patients are frequently eligible for both open surgery ("clipping") and endovascular repair ("coiling"). We compared short-term end points (mortality, discharge disposition, complications, length of stay, and charges) for clipping and coiling in a nationally representative discharge database. METHODS We conducted a retrospective cohort study using Nationwide Inpatient Sample data from 1996 to 2000. Multivariate logistic regression analyses adjusted for age, sex, race, payer status, geographic region, presenting signs and symptoms, admission type and source, procedure timing, hospital caseload, and possible clustering of outcomes within hospitals. The results were confirmed by performing propensity score analysis. RESULTS A total of 3498 patients had clipping, and 421 underwent coiling. Clipped patients were slightly younger (P < 0.001). Medical comorbidity was similar between the groups. More clipped patients had urgent or emergency admissions (P = 0.02). More coiling procedures were performed on hospital Day 1 (P = 0.007). When only death and discharge to long-term care were counted as adverse outcomes, there was no significant difference between clipping and coiling. On the basis of a four-level discharge status outcome scale (dead, long-term care, short-term rehabilitation, or discharge to home), coiled patients had a significantly better discharge disposition (odds ratio, 2.1; P < 0.001). With regard to patient age, most of the difference in discharge disposition was in patients older than 65 years of age. The degree of difference between treatments increased from 1996 to 2000. Neurological complications were coded twice as frequently in clipped patients as in coiled patients (P = 0.002). Length of stay was longer (5 d versus 2 d, P < 0.001) and charges were higher ($21,800 versus $13,200, P = 0.007) for clipped patients than for coiled patients. CONCLUSION There was no significant difference in mortality rates or discharge to long-term facilities after clipping or coiling of unruptured aneurysms. When discharge to short-term rehabilitation was counted as an adverse event, coiled patients had significantly better outcomes than clipped patients at the time of hospital discharge, but most of the coiling advantage was concentrated in patients older than 65 years of age. Even in older patients, long-term end points-including long-term functional status in patients discharged to rehabilitation and efficacy in preventing hemorrhage-will be critical in determining the best treatment option for patients with unruptured aneurysms.
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Affiliation(s)
- Fred G Barker
- Neurosurgical Service, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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280
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Feinglass J, Amir H, Taylor P, Lurie I, Manheim LM, Chang RW. How safe is primary knee replacement surgery? Perioperative complication rates in Northern Illinois, 1993-1999. ACTA ACUST UNITED AC 2004; 51:110-6. [PMID: 14872463 PMCID: PMC1991288 DOI: 10.1002/art.20072] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To describe inpatient complications for primary total knee replacement (TKR) in a period of rapidly growing orthopedic surgery capacity, declining length of stay, and more frequent discharge to rehabilitation facilities. METHODS Complication incidence according to published coding algorithms was estimated for 35,531 primary TKR admissions of northern Illinois residents to 65 Illinois hospitals. Complication odds were estimated as a function of patients' clinical and sociodemographic status, hospital volume, residency training, TKR length of stay, International Classification of Diseases, Ninth Revision (ICD-9) coding intensity, and discharges to skilled nursing or rehabilitation facilities. RESULTS Primary TKR admissions increased 36% between 1993 and 1999, length of stay declined 43%, average ICD-9 code use increased 31%, and rehabilitation discharges increased 68%. Major complication rates declined 44% (12.4% to 6.9%; P < 0.0001) over this period, reflecting a 50% reduction in the adjusted odds of complication between 1993 and 1999. There was no association of procedure volume and outcome. CONCLUSION It is likely that the reduction in complications reflects true safety improvements as well as reduced length of stay.
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Affiliation(s)
- Joe Feinglass
- Northwestern University Medical School and Northwestern University, Chicago, IL 60611, USA.
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281
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Naessens JM, Scott CG, Huschka TR, Schutt DC. Do Complication Screening Programs Detect Complications Present at Admission? ACTA ACUST UNITED AC 2004; 30:133-42. [PMID: 15032070 DOI: 10.1016/s1549-3741(04)30015-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A study was undertaken to verify the accuracy of computer algorithms on administrative data to identify hospital complications. The assessment was based on a medical records indicator that differentiated hospital-acquired conditions from preexisting comorbidities. METHODS The indicators for identifying potential hospital complications were applied to all secondary diagnoses to distinguish hospital-acquired from preexisting conditions for all 1997-1998 discharges. RESULTS Of the 95 defined complication types, cases were found with secondary diagnoses that met the criteria for 71 different complications. Sixty-nine of these complications had one or more cases with the trigger diagnosis coded as an acquired condition. Thirty-five complications had at least 30 cases with acquired conditions. Hospital complications add greatly to costs; for example, postoperative septicemia increased the hospital bill by more $25,000, added 13 hospital days to the stay, and increased hospital mortality by 16.6%. CONCLUSIONS Current complication algorithms identify many cases where the condition was actually present on hospital admission. This fact, coupled with the known variability in coding between institutions, makes comparisons between hospitals on many of the complications problematic. Collection of the present-on-admission flag significantly reduces the noise in monitoring complication rates.
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Affiliation(s)
- James M Naessens
- Divisions of Health Care Policy & Research and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA.
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282
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Zhan C, Miller MR. Administrative data based patient safety research: a critical review. Qual Saf Health Care 2004; 12 Suppl 2:ii58-63. [PMID: 14645897 PMCID: PMC1765777 DOI: 10.1136/qhc.12.suppl_2.ii58] [Citation(s) in RCA: 144] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Administrative data are readily available, inexpensive, computer readable, and cover large populations. Despite coding irregularities and limited clinical details, administrative data supplemented by tools such as the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) could serve as a screen for potential patient safety problems that merit further investigation, offer valuable insights into adverse impacts and risks of medical errors and, to some extent, provide benchmarks for tracking progress in patient safety efforts at local, state, or national levels.
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Affiliation(s)
- C Zhan
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD 20852, USA.
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283
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Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. Measuring hospital quality: can medicare data substitute for all-payer data? Health Serv Res 2004; 38:1487-508. [PMID: 14727784 PMCID: PMC1360960 DOI: 10.1111/j.1475-6773.2003.00189.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To assess whether adverse outcomes in Medicare patients can be used as a surrogate for measures from all patients in quality-of-care research using administrative datasets. DATA SOURCES Patient discharge abstracts from state data systems for 799 hospitals in 11 states. National MedPAR discharge data for Medicare patients from 3,357 hospitals. State hospital staffing surveys or financial reports. American Hospital Association Annual Survey. STUDY DESIGN We calculate rates for 10 adverse patient outcomes, examine the correlation between all-patient and Medicare rates, and conduct negative binomial regressions of counts of adverse outcomes on expected counts, hospital nurse staffing, and other variables to compare results using all-patient and Medicare patient data. DATA COLLECTION/EXTRACTION Coding rules were established for eight adverse outcomes applicable to medical and surgical patients plus two outcomes applicable only to surgical patients. The presence of these outcomes was coded for 3 samples: all patients in the 11-state sample, Medicare patients in the 11-state sample, and Medicare patients in the national Medicare MedPAR sample. Logistic regression models were used to construct estimates of expected counts of the outcomes for each hospital. Variables for teaching, metropolitan status, and bed size were obtained from the AHA Annual Survey. PRINCIPAL FINDINGS For medical patients, Medicare rates were consistently higher than all-patient rates, but the two were highly correlated. Results from regression analysis were consistent across the 11-state all-patient, 11-state Medicare, and national Medicare samples. For surgery patients, Medicare rates were generally higher than all-patient rates, but correlations of Medicare and all-patient rates were lower, and regression results less consistent. CONCLUSIONS Analyses of quality of care for medical patients using Medicare-only and all-patient data are likely to have similar findings. Measures applied to surgery patients must be used with more caution, as those tested only in Medicare patients may not provide results comparable to those from all-patient samples or across different samples of Medicare patients.
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Affiliation(s)
- Jack Needleman
- Department of Health Services, UCLA School of Public Health, 90095-1772, USA
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284
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Vahey DC, Swan BA, Lang NM, Mitchell PH. Measuring and improving health care quality: nursing's contribution to the state of science. Nurs Outlook 2004; 52:6-10. [PMID: 15014374 DOI: 10.1016/j.outlook.2003.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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285
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Abstract
BACKGROUND In 1998, the Committee on Health Care Quality in America was created and given the charge of devising a strategy to achieve substantial improvement in the quality of health care for all Americans. One strategy to move the quality agenda forward is the use of evidence by both providers of health care and consumers of health care. One feature of this agenda, evidence-based practice, refers to a hierarchy of evidence ranging from individual randomized, controlled trials to expert opinion. OBJECTIVES The purposes of this article are to describe the evidence base in nursing, discuss the quality and strength of nursing's evidence, illustrate the application of the Quality Health Outcomes Model, and present recommendations for practice, research, and policy to increase nursing's contribution to quality health care. RESULTS AND RECOMMENDATIONS Nurses everywhere must use innovative solutions to operationalize the "evidence" in evidence-based nursing. The Quality Health Outcomes Model (QHOM) provides a useful way of advancing research and evidence about the quality of health care in America. In concert with the conceptual framework for the National Health Care Quality Report, the QHOM provides a map for identifying evidence gaps and research questions arising from the model and conceptual framework, as well as evidence synthesis (integrating methodologic quality) driven by theoretical understanding.
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Affiliation(s)
- Beth Ann Swan
- Office of International Programs & PAHO/WHO Collaborating Center for Nursing and Midwifery Leadership, and the Family and Community Health Division, University of Pennsylvania School of Nursing, Philadelphia, USA.
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286
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Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA, Stanley JC, Upchurch GR. Variation in postoperative complication rates after high-risk surgery in the United States. Surgery 2003; 134:534-40; discussion 540-1. [PMID: 14605612 DOI: 10.1016/s0039-6060(03)00273-3] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Our goal was to characterize variation in complication rates across hospitals with differing volumes for select high-risk operations in the United States. METHODS Data from the Nationwide Inpatient Sample for 1996 and 1997 were analyzed for 3 high-risk operations: esophagectomy (n=1,226), pancreatectomy (n=4,789), and intact abdominal aortic aneurysm repair (n=11,863). Complications evaluated included aspiration, cardiac complications, infection, pneumonia, pulmonary failure, renal failure, septicemia, and others. The risk of complications was calculated by hospital volume deciles, as well as for high-volume hospitals (HVH) and low-volume hospitals (LVH) defined by median hospital volume. RESULTS Rates of any postoperative complication varied nearly 2-fold across hospital volume groups. The proportion of patients across hospital deciles having at least one complication ranged from 30% to 51% for esophageal resection, 6% to 12% for pancreatic resection, and 9% to 18% for abdominal aortic aneurysm repair. HVH had lower rates of one or more complications after pancreatic resection (OR, 0.71; 95% CI, 0.57 to 0.83; P=.002), esophageal resection (OR, 0.68; 95% CI, 0.52 to 0.90; P=.008), and intact abdominal aortic aneurysm (AAA) repair (OR, 0.67; 95% CI, 0.59 to 0.76; P<.001). Patients with one or more complications after pancreatic resection had a mortality of 18.8% versus only 5.2% for those without complications (P<.001). Esophageal resection mortality was 16.9% for patients with at least one complication and 2.5% for those without complications (P<.001) and AAA repair mortality was 10.4% for patients with at least one complication and 2.9% for those without complications (P<.001). CONCLUSIONS High-risk operations have a decreased rate of postoperative complications when performed at HVH. Variation in complication rates may contribute to the volume-outcome relationship and provide a focus for quality improvement at LVH.
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Affiliation(s)
- Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Taubman Center 2210, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0329, USA
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287
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Eliason JL, Wainess RM, Proctor MC, Dimick JB, Cowan JA, Upchurch GR, Stanley JC, Henke PK. A national and single institutional experience in the contemporary treatment of acute lower extremity ischemia. Ann Surg 2003; 238:382-9; discussion 389-90. [PMID: 14501504 PMCID: PMC1422711 DOI: 10.1097/01.sla.0000086663.49670.d1] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine the contemporary clinical relevance of acute lower extremity ischemia and the factors associated with amputation and in-hospital mortality. SUMMARY BACKGROUND DATA Acute lower extremity ischemia is considered limb- and life-threatening and usually requires therapy within 24 hours. The equivalency of thrombolytic therapy and surgery for the treatment of subacute limb ischemia up to 14 days duration is accepted fact. However, little information exists with regards to the long-term clinical course and therapeutic outcomes in these patients. METHODS Two databases formed the basis for this study. The first was the National Inpatient Sample (NIS) from 1992 to 2000 of all patients (N = 23,268) with a primary discharge diagnosis of acute embolism and thrombosis of the lower extremities. The second was a retrospective University of Michigan experience from 1995 to 2002 of matched ICD-9-CM coded patients (N = 105). Demographic factors, atherosclerotic risk factors, the need for amputation, and in-hospital mortality were assessed by univariate and multivariate logistic regression analysis. RESULTS In the NIS, the mean patient age was 71 years, and 54% were female. The average length of stay (LOS) was 9.4 days, and inflation-adjusted cost per admission was $25,916. The amputation rate was 12.7%, and mortality was 9%. Decreased amputation rates accompanied: female sex (0.90, 0.81-0.99), age less than 63 years (0.47, 0.41-0.54), angioplasty (0.46, 0.38-0.55), and embolectomy (0.39, 0.35-0.44). Decreased mortality accompanied: angioplasty (0.79, 0.64-0.96), heparin administration (0.50, 0.29-0.86), and age less than 63 years(0.27, 0.23-0.33). The University of Michigan patients' mean age was 62 years, and 57% were men. The LOS was 11 days, with a 14% amputation rate and a mortality of 12%. Prior vascular bypasses existed in 23% of patients, and heparin use was documented in 16%. Embolectomy was associated with decreased amputation rates (0.054, 0.01-0.27) and mortality (0.07, 0.01-0.57). CONCLUSIONS In patients with acute limb ischemia, the more widespread use of heparin anticoagulation and, in select patients, performance of embolectomy rather than pursuing thrombolysis may improve patient outcomes.
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Affiliation(s)
- Jonathan L Eliason
- Department of Surgery, Section of Vascular Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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288
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Kozlow JH, Berenholtz SM, Garrett E, Dorman T, Pronovost PJ. Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, 1999-2000. Crit Care Med 2003; 31:1930-7. [PMID: 12847385 DOI: 10.1097/01.ccm.0000069738.73602.5f] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The epidemiology of aspiration pneumonia and its impact on clinical and economic outcomes in surgical patients are poorly defined. We sought to identify preoperative patient characteristics and surgical procedures that are associated with an increased risk for aspiration pneumonia and to determine the clinical and economic impact in hospitalized surgical patients. DESIGN Observational study using a state discharge database. SETTING All hospitals in Maryland. PATIENTS We obtained discharge data for 318,880 adult surgical patients in 52 Maryland hospitals from January 1, 1999, through December 31, 2000. MEASUREMENTS AND MAIN RESULTS The primary outcome variable was a discharge diagnosis of aspiration pneumonia. Unadjusted and adjusted analyses were performed to identify patient characteristics and surgical procedures associated with an increased risk for aspiration pneumonia and to determine the impact on intensive care unit admission, in-hospital mortality, hospital length of stay, and total hospital charges. The overall prevalence of aspiration pneumonia was 0.8%. The prevalence varied among hospitals (range, 0% to 1.9%) and by surgical procedure (range, <0.1% to 19.1%). Patient characteristics independently associated with an increased risk included: male sex, nonwhite race, age of >60 yrs vs. 18-29 yrs, dementia, chronic obstructive pulmonary disease, renal disease, malignancy, moderate to severe liver disease, and emergency room admission. In patients undergoing procedures other than tracheostomy, aspiration pneumonia was independently associated with an increased risk for admission to the intensive care unit (odds ratio, 4.0; 95% confidence interval, 3.0-5.1), in-hospital mortality (odds ratio, 7.6; 95% confidence interval, 6.5-8.9), longer hospital length of stay (estimated mean increase of 9 days; 95% confidence interval, 8-10), and increased total hospital charges (estimated mean increase of 22,000 US dollars; 95% confidence interval, 19,000 US dollars-25,000 US dollars). CONCLUSIONS Aspiration pneumonia occurs in approximately 1% of surgical patients and is associated with significant morbidity, mortality, and costs of care. Given that the rate of aspiration pneumonia varies among hospitals, we can improve the quality and reduce the costs of care by implementing strategies to reduce the rate of aspiration pneumonia.
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Affiliation(s)
- Jeffrey H Kozlow
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University Schools of Medicine and Hygiene and Public Health, Baltimore, MD, USA
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289
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Barker FG, Amin-Hanjani S, Butler WE, Ogilvy CS, Carter BS. In-hospital Mortality and Morbidity after Surgical Treatment of Unruptured Intracranial Aneurysms in the United States, 1996–2000: The Effect of Hospital and Surgeon Volume. Neurosurgery 2003. [DOI: 10.1227/01.neu.0000057743.56678.5f] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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290
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Barker FG, Amin-Hanjani S, Butler WE, Ogilvy CS, Carter BS. In-hospital Mortality and Morbidity after Surgical Treatment of Unruptured Intracranial Aneurysms in the United States, 1996–2000: The Effect of Hospital and Surgeon Volume. Neurosurgery 2003. [DOI: 10.1093/neurosurgery/52.5.995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
OBJECTIVE
We sought to determine the risk of adverse outcome after contemporary surgical treatment of patients with unruptured intracranial aneurysms in the United States. Patient, surgeon, and hospital characteristics were tested as potential outcome predictors, with particular attention to the surgeon's and hospital's volume of care.
METHODS
We performed a retrospective cohort study with the Nationwide Inpatient Sample, 1996 to 2000. Multivariate logistic and ordinal regression analyses were performed with endpoints of mortality, discharge other than to home, length of stay, and total hospital charges.
RESULTS
We identified 3498 patients who were treated at 463 hospitals, and we identified 585 surgeons in the database. Of all patients, 2.1% died, 3.3% were discharged to skilled-nursing facilities, and 12.8% were discharged to other facilities. The analysis adjusted for age, sex, race, primary payer, four variables measuring acuity of treatment and medical comorbidity, and five variables indicating symptoms and signs. The statistics for median annual number of unruptured aneurysms treated were eight per hospital and three per surgeon. High-volume hospitals had fewer adverse outcomes than hospitals that handled comparatively fewer unruptured aneurysms: discharge other than to home occurred after 15.6% of operations at high-volume hospitals (20 or more cases/yr) compared with 23.8% at low-volume hospitals (fewer than 4 cases/yr) (P = 0.002). High surgeon volume had a similar effect (15.3 versus 20.6%, P = 0.004). Mortality was lower at high-volume hospitals (1.6 versus 2.2%) than at hospitals that handled comparatively fewer unruptured aneurysms, but not significantly so. Patients treated by high-volume surgeons had fewer postoperative neurological complications (P = 0.04). Length of stay was not related to hospital volume. Charges were slightly higher at high-volume hospitals, partly because arteriography was performed more frequently than at hospitals that handled comparatively fewer unruptured aneurysms.
CONCLUSION
For patients with unruptured aneurysms who were treated in the United States between 1996 and 2000, surgery performed at high-volume institutions or by high-volume surgeons was associated with significantly lower morbidity and modestly lower mortality.
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Affiliation(s)
- Fred G. Barker
- Neurosurgical Service, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Sepideh Amin-Hanjani
- Neurosurgical Service, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - William E. Butler
- Neurosurgical Service, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Christopher S. Ogilvy
- Neurosurgical Service, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Bob S. Carter
- Neurosurgical Service, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts
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291
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Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA. Complications and costs after high-risk surgery: where should we focus quality improvement initiatives? J Am Coll Surg 2003; 196:671-8. [PMID: 12742194 DOI: 10.1016/s1072-7515(03)00122-4] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Data on the relative clinical and economic impact of postoperative complications are needed in order to direct quality improvement efforts. STUDY DESIGN Patients undergoing two high-risk surgical procedures, hepatectomy (n = 569) and esophagectomy (n = 366), from 1994 to 1998 were included. Data were abstracted from the Maryland hospital discharge database. Relative resource use was determined using median regression, adjusting for patient comorbidities and other case-mix variables. RESULTS A total of 935 patients were studied. Overall in-hospital mortality was 6.1%; complication rate was 38.4%. Median cost for all patients was $14,527 (interquartile range $10,936-$21,412) and length of stay 9 days (interquartile range 7-13 days). Median hospital cost was increased for patients with complications ($16,868 versus $12,861; p < 0.001). In the multivariate analysis, several complications remained associated with increased cost. Acute renal failure ($25,219), septicemia ($18,852), and myocardial infarction ($9,573) were associated with the greatest increase in resource use. But because the incidence of each complication varies, the attributable fraction of total resource use was highest for acute renal failure (19%), septicemia (16%), and surgical complications (16%). CONCLUSIONS Complications are independently associated with increased resource use after high-risk surgery. Population-based studies may be valuable in determining the relative economic importance of postoperative complications. Quality improvement efforts for these complications should be prioritized based on both the incidence of the complication and its independent contribution to increased resource use.
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Affiliation(s)
- Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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292
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Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA. Surgical volume and quality of care for esophageal resection: do high-volume hospitals have fewer complications? Ann Thorac Surg 2003; 75:337-41. [PMID: 12607635 DOI: 10.1016/s0003-4975(02)04409-0] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Previous studies have shown that high-volume hospitals (HVHs) have lower mortality rates than low-volume hospitals (LVHs). However, little is known regarding the relationship of morbidity to hospital volume. The objective of the current study was to investigate the relative incidence of postoperative complications after esophageal resection at HVHs and LVHs. METHODS All patients discharged from a nonfederal, acute-care hospital in Maryland after esophageal resection from 1994 to 1998 were included (n = 366). Rates of 10 postoperative complications were compared at HVHs and LVHs. Risk-adjusted analyses were performed using multiple logistic regression. RESULTS High-volume hospitals had a mortality rate of 2.5% compared with 15.4% at LVHs (p < 0.001), with a case-mixed adjusted odds ratio (OR) of death equal to 5.7 (95% confidence interval [CI], 2.0 to 16; p < 0.001). Low-volume hospitals had a profound increase in the risk of several complications after adjusting for case-mix: renal failure (OR, 19; 95% CI, 1.9 to 178; p = 0.01), pulmonary failure (OR, 4.8; 95% CI, 1.6 to 14; p = 0.002), septicemia (OR, 4.0; 95% CI, 1.1 to 15; p = 0.04), reintubation (OR, 2.9; 95% CI, 1.4 to 6.1; p = 0.004), surgical complications (OR, 3.3; 95% CI, 1.6 to 6.9; p = 0.001), and aspiration (OR, 1.8; 95% CI, 1.0 to 3.3; p = 0.04). CONCLUSIONS Patients undergoing esophageal resection at LVHs were at a markedly increased risk of postoperative complications and death. Pulmonary complications are particularly prevalent at LVHs and contribute to the death of patients having surgery at those centers.
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Affiliation(s)
- Justin B Dimick
- Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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293
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Murff HJ, Forster AJ, Peterson JF, Fiskio JM, Heiman HL, Bates DW. Electronically screening discharge summaries for adverse medical events. J Am Med Inform Assoc 2003; 10:339-50. [PMID: 12668691 PMCID: PMC181984 DOI: 10.1197/jamia.m1201] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Detecting adverse events is pivotal for measuring and improving medical safety, yet current techniques discourage routine screening. The authors hypothesized that discharge summaries would include information on adverse events, and they developed and evaluated an electronic method for screening medical discharge summaries for adverse events. DESIGN A cohort study including 424 randomly selected admissions to the medical services of an academic medical center was conducted between January and July 2000. The authors developed a computerized screening tool that searched free-text discharge summaries for trigger words representing possible adverse events. MEASUREMENTS All discharge summaries with a trigger word present underwent chart review by two independent physician reviewers. The presence of adverse events was assessed using structured implicit judgment. A random sample of discharge summaries without trigger words also was reviewed. RESULTS Fifty-nine percent (251 of 424) of the discharge summaries contained trigger words. Based on discharge summary review, 44.8% (327 of 730) of the alerted trigger words indicated a possible adverse event. After medical record review, the tool detected 131 adverse events. The sensitivity and specificity of the screening tool were 69% and 48%, respectively. The positive predictive value of the tool was 52%. CONCLUSION Medical discharge summaries contain information regarding adverse events. Electronic screening of discharge summaries for adverse events using keyword searches is feasible but thus far has poor specificity. Nonetheless, computerized clinical narrative screening methods could potentially offer researchers and quality managers a means to routinely detect adverse events.
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Affiliation(s)
- Harvey J Murff
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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294
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Abstract
OBJECTIVE To examine the changes in licensed nursing staff in Pennsylvania hospitals from 1991 to 1997, and to assess the relationship of licensed nursing staff with patient adverse events in hospitals. DATA SOURCE A convenience sample of all Pennsylvania, acute-care, hospitals, 1991 to 1997. STUDY DESIGN The study first describes the percentage change of licensed nursing staff categories in Pennsylvania hospitals from 1991 to 1997. Second, random effects Poisson regressions are used to assess the association of the numbers and proportions of licensed nurses with yearly iatrogenic lung collapse, pressure sores, falls, pneumonia, posttreatment infections, and urinary tract infections. Controls are the yearly number of patients, hospital acuity, and other hospital characteristics. DATA COLLECTION Secondary data containing patient- and hospital-level measures from three sources were recoded to establish the incidence of adverse events, aggregated to the hospital level, and merged to form one data set. PRINCIPAL FUNDING: Licensed nurses' acuity-adjusted patient load increased from 1991 to 1997. Licensed nurse/total nursing staff declined from 1994 to 1997. Greater incidence of nearly all adverse events occurred in hospitals with fewer licensed nurses. Greater incidence of decubitus ulcers and pneumonia occurred in hospitals with a lower proportion of licensed nurses. CONCLUSIONS This study suggests that licensed nurses' patient load began increasing in the 1990s. Adequate licensed nurse staffing is important in minimizing the incidence of adverse events in hospitals. Ensuring adequate licensed nurse staffing should be an area of major concern to hospital management. Improved measures of nurse staffing and patient outcomes, and further studies are suggested.
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Affiliation(s)
- Lynn Unruh
- Department of Health Professionals, College of Health and Public Affairs, University of Central Florida, Orlando, 32816-2200, USA.
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295
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Hospital and ICU Organizational Structure and Quality of Care for Surgical Patients. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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296
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Cowan JA, Dimick JB, Thompson BG, Stanley JC, Upchurch GR. Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume. J Am Coll Surg 2002; 195:814-21. [PMID: 12495314 DOI: 10.1016/s1072-7515(02)01345-5] [Citation(s) in RCA: 161] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND High-volume hospitals have been shown to have superior outcomes after carotid endarterectomy (CEA), but the contribution of surgeon volume and specialty practice to CEA outcomes in a national sample is unknown. STUDY DESIGN Using the National Inpatient Sample for 1996 and 1997, 35,821 patients who underwent CEA (ICD-9-CM code 3812) and had data for unique surgeon identification were studied. Surgeons were categorized in terms of annual CEA volume as low-volume surgeons (< 10 procedures), medium-volume surgeons (10 to 29), and high-volume surgeons (> or = 30). Data from cardiac, general, neurologic, and vascular surgical practices were analyzed. In-hospital mortality, postoperative stroke, and prolonged length of stay (> 4 days) were the primary outcomes variables. Unadjusted and case-mix adjusted analyses were performed. RESULTS The overall in-hospital mortality was 0.61%. CEA was performed annually by high-volume surgeons in 52% of patients, by medium-volume surgeons in 30% of patients, and by low-volume surgeons in 18% of patients. Observed mortality by surgeon volume was 0.44% for high-volume surgeons, 0.63% for medium-volume surgeons, and 1.1% for low-volume surgeons (p < 0.001). The postoperative stroke rate was 1.14% for high-volume surgeons, 1.63% for medium-volume surgeons, and 2.03% for low-volume surgeons (p < 0.001). Surgeon specialty had no statistically significant effect on mortality or postoperative stroke. In the logistic regression model, increased risk of mortality was associated with emergent admission (odds ratio [OR] = 2.1; 95% confidence interval [CI] 1.6 to 2.8, p < 0.001), patient age > 65 years (OR = 2.0; 95% CI 1.3 to 3.1, p = 0.001), low-volume surgeon (OR = 1.9; 95% CI 1.4 to 2.5, p < 0.001), and COPD (OR = 1.8; 95% CI 1.3 to 2.5, p = 0.001). Low hospital CEA volume (< 100) was not a significant risk factor in the multivariate analysis. CONCLUSIONS More than 50% of the CEAs in the United States are performed by high-volume surgeons with superior outcomes. Health policy efforts should focus on reducing the number of low-volume surgeons, regardless of surgeon specialty or total hospital CEA volume.
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Affiliation(s)
- John A Cowan
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, MI, USA
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297
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298
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Romano PS, Chan BK, Schembri ME, Rainwater JA. Can administrative data be used to compare postoperative complication rates across hospitals? Med Care 2002; 40:856-67. [PMID: 12395020 DOI: 10.1097/00005650-200210000-00004] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several quality assessment systems use administrative data to identify postoperative complications, with uncertain validity. OBJECTIVES To determine how accurately postoperative complications are reported in administrative data, whether accuracy varies systematically across hospitals, and whether serious complications are more consistently reported. DESIGN Retrospective cohort. SUBJECTS Nine hundred ninety-one randomly sampled adults who underwent elective lumbar diskectomies at 30 nonfederal acute care hospitals in California in 1990 to 1991. Hospitals with especially low or high risk-adjusted complication rates, and patients who experienced complications, were over sampled. MEASURES Postoperative complications were specified by reviewing medical literature and consulting clinical experts; each complication was mapped to ICD-9-CM. Hospital-reported complications were compared with our independent recoding of the same records. RESULTS The weighted sensitivity, specificity, and positive and negative predictive values for reported complications were 35%, 98%, 82%, and 84%, respectively. The weighted sensitivity was 30% for serious, 40% for minor, and 10% for questionable complications. It varied from 21% among hospitals with fewer complications than expected to 45% among hospitals with more complications than expected. Only reoperation, bacteremia/sepsis, postoperative infection, and deep vein thrombosis were reported with at least 60% sensitivity. Half of the difference in risk-adjusted complication rates between low and high outlier hospitals was attributable to reporting variation. CONCLUSIONS ICD-9-CM complications were underreported among diskectomy patients, especially at hospitals with low risk-adjusted complication rates. The validity of using coded complications to compare provider performance is questionable, even with careful efforts to identify serious events, although these results must be confirmed using more recent data.
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Affiliation(s)
- Patrick S Romano
- Division of General Medicine, Department of Internal Medicine, and the Center for Health Services Research in Primary Care, University of California Davis School of Medicine, Sacramento 95817, USA.
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299
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Bonsanto MM, Hamer J, Tronnier V, Kunze S. A complication conference for internal quality control at the Neurosurgical Department of the University of Heidelberg. ACTA NEUROCHIRURGICA. SUPPLEMENT 2002; 78:139-45. [PMID: 11840709 DOI: 10.1007/978-3-7091-6237-8_26] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
The registration of adverse events is an important issue in the field of medicine. Even today adverse event screening and registration is not part of the routine in most medical areas. In 1994, the Department of Neurosurgery at the University of Heidelberg implemented a conference for screening and registering adverse events. The aim was to record all complications occurring for an internal quality control. High priority was given to improving the process of data screening and registering. The conference is held every 2 weeks and all medical staff and residents of the department are obligated to be present. Screening of the adverse events encompasses all operations performed during a bi-weekly period. Every single operation is revised for an adverse event during or following the hospital stay. Adverse events are registered on a standardized data sheet and later transferred to a database for use in further investigations. After 6 years, the conference has been fully accepted and become an integral part of the workflow of the department. During this period, 8160 operations were screened and 1335 adverse events registered. The next step will be to integrate the data-collection process into the daily ward rounds using a personal digital assistant (PDA). This process is less time consuming and may perhaps augment the number of registered cases.
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Affiliation(s)
- M M Bonsanto
- Department of Neurosurgery, University of Heidelberg, Germany
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300
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Potosky AL, Warren JL, Riedel ER, Klabunde CN, Earle CC, Begg CB. Measuring complications of cancer treatment using the SEER-Medicare data. Med Care 2002; 40:IV-62-8. [PMID: 12187170 DOI: 10.1097/00005650-200208001-00009] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The linkage of SEER registry data with Medicare claims allows the longitudinal tracking of health care and outcomes for patients after a cancer diagnosis. One category of outcomes amenable to research using Medicare claims is complications of cancer treatments: the unintentional, adverse side effects or sequelae of interventions used to treat or palliate cancer patients. RESEARCH DESIGN The authors review some of the methods and limitations of using Medicare claims to identify both acute and chronic complications of cancer treatments, and present an original analysis comparing survey-based and claims-based complications following radical prostatectomy for prostate cancer to illustrate some of the potential limitations inherent in using claims for this purpose. RESULTS Utility of the Medicare claims for identifying postdischarge complications varies by the patient type, the initial treatment used, and any subsequent treatment of complications. For patients undergoing surgical interventions, Medicare claims can be used to identify most acute inpatient complications. However, claims data cannot be used as effectively in the long-term to capture chronic complications, particularly when the complication does not consistently prompt an intervention. CONCLUSION Researchers who use the SEER-Medicare-linked database to assess long-term complications of cancer treatments should exercise caution when designing and interpreting studies. Ideally, for studies of most chronic complications of cancer care, validation studies similar to the one performed here would provide valuable additional evidence to assess the credibility of conclusions based on claims data.
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Affiliation(s)
- Arnold L Potosky
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland 20892-7344, USA.
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