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Siddique SM, Hettinger G, Dash A, Neuman M, Mitra N, Lewis JD. The Role of Hospital Characteristics in Clinical and Quality Outcomes for Gastrointestinal Bleeding in a National Cohort. Am J Gastroenterol 2024; 119:1616-1623. [PMID: 38477470 PMCID: PMC11316957 DOI: 10.14309/ajg.0000000000002755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/07/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes. METHODS This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality. RESULTS Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services. DISCUSSION Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.
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Affiliation(s)
- Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania
- Leonard Davis Institute for Health Economics, University of Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
| | - Gary Hettinger
- Leonard Davis Institute for Health Economics, University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Anwesh Dash
- Department of Medicine, University of Pennsylvania
| | - Mark Neuman
- Leonard Davis Institute for Health Economics, University of Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
- Department of Anesthesiology and Critical Care, University of Pennsylvania
| | - Nandita Mitra
- Leonard Davis Institute for Health Economics, University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - James D. Lewis
- Division of Gastroenterology, University of Pennsylvania
- Leonard Davis Institute for Health Economics, University of Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
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Bonsel JM, Kodali H, Poeran J, Bonsel GJ. Socioeconomic, Patient, and Hospital Determinants for the Utilization of Peripheral Nerve Blocks in Total Joint Arthroplasty. Anesth Analg 2024:00000539-990000000-00873. [PMID: 39042570 DOI: 10.1213/ane.0000000000007107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
BACKGROUND While peripheral nerve blocks (PNBs) are associated with various improved outcomes in patients undergoing total hip or knee arthroplasty (THA/TKA), disparities in PNB utilization have been reported. This study assessed the importance of socioeconomic, demographic, clinical, and hospital determinants in explaining PNB utilization using the population-attributable risk (PAR) framework. Subsequently, we examined the association between PNB use and 3 secondary outcomes: Centers for Medicare and Medicaid Services (CMS)-defined complications, 90-day all-cause readmissions, and length of stay >3 days. METHODS This retrospective cohort study included 52,926 THA and 94,795 TKA cases from the 5% 2012 to 2021 Medicare dataset. Mixed-effects logistic regression models measured the association between study variables and PNB utilization. Variables of interest were demographic (age, sex), clinical (outpatient setting, diagnosis, prior hospitalizations in the year before surgery, Deyo-Charlson index, obesity, (non)-opioid abuse, smoking), socioeconomic (neighborhood Social Deprivation Index, race and ethnicity) and hospital variables (beds, ownership, region, rurality, resident-to-bed ratio). The model was used for the calculation of variable-specific and variable category-specific PARs (presented in percentages), reflecting the proportion of variation in PNB use explained after eliminating variables (or groups of variables) of interest with all other factors held constant. Subsequently, regression models measured the association between PNB use and secondary outcomes. Associations are presented with odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS Socioeconomic and demographic variables accounted for only a small proportion of variation in PNB use (up to 3% and 7%, respectively). Clinical (THA: 46%; TKA: 34%) and hospital variables (THA: 31%; TKA: 22%) were the primary drivers of variation. In THA, variation by clinical variables was driven by increased PNB use in the inpatient setting (OR, 1.28 [95% CI, 1.07-1.53]) and decreased use in patients with ≥2 prior hospitalizations (OR, 0.72 [95% CI, 0.57-0.90]). Moreover, nonosteoarthritis diagnoses associated with reduced PNB utilization in THA (OR, 0.64 [95% CI, 0.58-0.72]) and TKA (OR, 0.35 [95% CI, 0.34-0.37]).In TKA, PNB use was subsequently associated with fewer complications (OR, 0.82 [95% CI, 0.75-0.90]) and less prolonged length of stay (OR, 0.90 [95% CI, 0.86-0.95]); no association was found for readmissions (OR, 0.98 [95% CI, 0.93-1.03]). In THA, associations did not reach statistical significance. CONCLUSIONS Among THA and TKA patients on Medicare, large variations exist in the utilization of PNBs by clinical and hospital variables, while demographic and socioeconomic variables played a limited role. Given the consistent benefits of PNBs, particularly in TKA patients, more standardized provision may be warranted to mitigate the observed variation.
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Affiliation(s)
- Joshua M Bonsel
- From the Department of Orthopedics and Sports Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hanish Kodali
- Department of Population Health and Policy, Icahn School of Medicine, Mount Sinai Hospital, New York, New York
| | - Jashvant Poeran
- Department of Population Health and Policy, Icahn School of Medicine, Mount Sinai Hospital, New York, New York
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Romatoski K, Davids JS, Sachs TE, Hagopian EJ. Defining the role and impact of specialty surgeons in ensuring high-quality, accessible abdominal surgery: a report from the 2024 GI Surgery Summit. J Gastrointest Surg 2024:S1091-255X(24)00542-0. [PMID: 39043323 DOI: 10.1016/j.gassur.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/19/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The 2024 GI Surgery Summit brought together Society for Surgery of the Alimentary Tract (SSAT), Society of Surgical Oncology (SSO), and Society of University Surgeons (SUS) members to assess the current state of gastrointestinal (GI) surgery. This report reviews the key discussions and recommendations after the dedicated plenary session that addressed challenges in providing high-quality, accessible GI surgery for all patients. METHODS The Summit took place from January 14 to 16. During the plenary session "Defining the role and impact of specialty surgeons in ensuring high-quality, accessible abdominal surgery," leaders, rising leaders, and members of SSAT, SSO, and SUS met and discussed challenges in providing high-quality, accessible GI surgery. RESULTS Actionable recommendations to address the challenges in providing high-quality, accessible GI surgical care were made, including engaging communities and patients, building alliances across hospitals and surgeons, and establishing standards of GI surgical care. CONCLUSION Surgeons, hospital systems, and surgical societies can improve healthcare access and outcomes for all GI surgical patients.
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Affiliation(s)
- Kelsey Romatoski
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Jennifer S Davids
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Ellen J Hagopian
- Department of Surgery, University of Toledo Medical Center, Toledo, OH, United States; Department of Medical Education and Surgery, University of Toledo College of Medicine & Life Sciences, Toledo, OH, United States.
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Sharbatji M, Anand Sachin P, Abhishek R, Ali S, Ur Rahman A. Outcomes of Upper Gastrointestinal Bleeding at United States Teaching and Non-teaching Hospitals: A National Inpatient Sample Analysis. Cureus 2024; 16:e61793. [PMID: 38975508 PMCID: PMC11227120 DOI: 10.7759/cureus.61793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND/AIMS Studies have varied results regarding the impact of the teaching and non-teaching status of hospitals on the outcomes for hospitalized patients with upper gastrointestinal bleeding (UGIB). To evaluate these outcomes, we conducted a retrospective cohort study using the 2014 National Inpatient Sample (NIS) database. METHODS We included all adult patients who were admitted with the principal diagnosis of UGIB. Patients admitted to rural and urban non-teaching hospitals were classified as non-teaching, whereas those admitted to urban teaching hospitals were classified as teaching. The main outcomes of interest were in-hospital mortality, percentage of patients requiring inpatient endoscopy, and endoscopic therapy, packed red blood cell (PRBC) transfusion, length of stay (LOS), and total hospitalization charges. RESULTS The study included 132,085 (97%) with nonvariceal UGIB (NVUGIB) and 4,200 (3%) with variceal UGIB (VUGIB). Of them, 62% were managed at teaching hospitals. Compared with admitted patients at non-teaching hospitals, patients with nonvariceal UGIB admitted at teaching hospitals had similar adjusted in-hospital mortality rates (adjusted odds ratio (OR): 0.97, 95% confidence interval (CI): 0.79-1.19), inpatient endoscopy rates (OR: 0.98, 95% CI: 0.91-1.1), and early endoscopy rates (within 24 hours) (OR: 0.98, 95% CI: 0.91-1.1) and lower PRBC transfusion rates (OR: 0.87, 95% CI: 0.79-0.97) but higher endoscopic therapy rates (OR: 1.3, 95% CI: 1.2-1.4), length of stay (mean increase of 0.43 days) (P<0.01), and total hospital charges (mean increase of $4,369) (P<0.01). Patients with variceal UGIB had similar adjusted in-hospital mortality rates (OR: 1.2, 95% CI: 0.61-2.3), inpatient endoscopy rates (OR: 0.97, 95% CI: 0.67-1.4), early endoscopy rates (within 24 hours) (OR: 0.97, 95% CI: 0.67-1.4), endoscopic therapy rates (OR: 2.5, 95% CI: 0.54- 11.2), and total hospital charges (P=0.45), and lower PRBC transfusion rates (OR: 0.63, 95% CI: 0.45-0.88) but higher length of stay (mean increase of 0.69 days) (P=0.02). CONCLUSIONS Patients with nonvariceal UGIB treated at US teaching hospitals and non-teaching hospitals have similar mortality, rates of in-hospital endoscopy, and early endoscopy, but teaching hospitals have higher rates of in-hospital therapeutic endoscopy, length of stay, and total hospital charges. There was no difference in any of the outcomes for variceal gastrointestinal (GI) bleeding treated at teaching hospitals compared with those treated at non-teaching hospitals, except for length of stay, which was higher among patients admitted to teaching hospitals compared to those admitted to non-teaching hospitals.
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Affiliation(s)
| | | | | | - Saeed Ali
- Internal Medicine, AdventHealth Orlando, Orlando, USA
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Ramadan OI, Rosenbaum PR, Reiter JG, Jain S, Hill AS, Hashemi S, Kelz RR, Fleisher LA, Silber JH. Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes. Ann Surg 2024; 279:631-639. [PMID: 38456279 PMCID: PMC10926994 DOI: 10.1097/sla.0000000000006132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls. SUMMARY BACKGROUND DATA It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients. METHODS Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality. RESULTS We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001]. CONCLUSIONS Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.
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Affiliation(s)
- Omar I. Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Paul R. Rosenbaum
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Siddharth Jain
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sean Hashemi
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Rachel R. Kelz
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Lee A. Fleisher
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jeffrey H. Silber
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA
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Ramanathan D, Bruckman D, Appachi S, Hopkins B. Association of Discharge Location Following Pediatric Tracheostomy with Social Determinants of Health: A National Analysis. Otolaryngol Head Neck Surg 2024; 170:522-534. [PMID: 37727943 DOI: 10.1002/ohn.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/10/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE To evaluate the breakdown of discharge locations among pediatric tracheostomy patients and determine the impact of demographic variables and social determinants of health. STUDY DESIGN Retrospective review of the 2016 and 2019 Healthcare Cost and Utilization Project Kids' Inpatient Database (HCUP KID). SETTING A total of 4000 United States community hospitals, defined as short-term, non-Federal, general, and specialty hospitals. METHODS ICD-10-PCS, ICD-10 CM codes, and HCUP data elements were selected for patients and variables of interest. Bivariate comparisons were performed using Rao-Scott Chi-square tests; significance levels in post hoc pairwise testing were adjusted using Bonferroni adjustment. Multinomial generalized logistic regression models were used to determine the average annual odds ratio (OR) of 3 dispositions at discharge relative to discharge home for self-care. RESULTS Patients aged 11-17, patients from large metropolitan areas, and patients of "Other" race have an increased odds of discharge to a short- or long-term care facility (all P < .001). Weekend admissions, nonelective admissions, patients in Northeast hospitals, and patients at urban nonteaching hospitals are also more likely to be discharged to a short- or long-term care facility (all P < .001). Mean and median total costs of admission were $424,387 and $243,479, respectively, with a median total charge of $854,499. CONCLUSION Among pediatric tracheostomy patients, demographic factors that affect discharge disposition include age, community type, and race, and significant hospital factors include day and type of admission, geographic region, and hospital type. Hospitalizations are associated with high overall costs and charges to the patient, which are increasing over time.
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Affiliation(s)
- Diya Ramanathan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - David Bruckman
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Swathi Appachi
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brandon Hopkins
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Yazdanpanah O, Mahadevan A, Sharma A, Benjamin DJ, Kalebasty AR. A comparative study of spinal cord compression management in metastatic prostate cancer: Teaching versus non-teaching hospitals in the United States. Cancer Med 2024; 13:e6845. [PMID: 38146897 PMCID: PMC10807570 DOI: 10.1002/cam4.6845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/04/2023] [Accepted: 12/10/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Spinal cord compression (SCC) in metastatic prostate cancer (MPC) is a critical complication and multiple factors influence the optimal therapeutic strategy. We investigated the differences in practice patterns between teaching hospitals (TH) and non-teaching hospitals (NTH) across the United States. METHOD Using the National Inpatient Sample Database (NIS), we performed a retrospective study on hospitalizations with MPC and SCC between 2016 and 2020 in US. We compared demographic factors, comorbidities, treatment modalities, duration of hospitalization, financial expenditures, and mortality between TH and NTH. We also examined the patients' characteristics and outcomes in TH and NTH based on their chosen therapeutic strategy. RESULTS We identified 11,380 admissions with metastatic prostate cancer and SCC; 9610 in TH and 1770 in NTH. The median cost of hospitalization was $21,922 in TH and $15,141 in NTH. Although the median age and Charlson comorbidity score did not differ between two groups, patients in TH were more likely to receive intervention (radiation or surgery) compared to NTH (Surgery: 28.2% in TH vs. 23.0% in NTH & Radiation: 12.1% in TH vs. 8.2% in NTH). Mortality was lower in TH than NTH (4.5% vs. 7.9%). In both TH and NTH, a higher proportion of patients with private insurance underwent surgery (TH: Surgery 25.1% vs. Radiation 18.8% & NTH: Surgery 27.0% vs. 6.9%). Black patients were more likely to receive radiation than surgery in TH (34.2% vs. 26.8%). CONCLUSION This study showed a greater percentage of patients underwent surgical intervention at TH compared to NTH. Additionally, the type of insurance and racial background were associated with distinctive treatment approaches.
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Affiliation(s)
- Omid Yazdanpanah
- Division of Hematology and Oncology, Internal Medicine DepartmentUniversity of California IrvineOrangeCaliforniaUSA
| | - Aditya Mahadevan
- Division of Hematology and Oncology, Internal Medicine DepartmentUniversity of California IrvineOrangeCaliforniaUSA
| | - Aditi Sharma
- Division of Hematology/OncologyWayne State University School of Medicine/Karmanos Cancer InstituteDetroitMichiganUSA
| | | | - Arash Rezazadeh Kalebasty
- Division of Hematology and Oncology, Internal Medicine DepartmentUniversity of California IrvineOrangeCaliforniaUSA
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Burke LG, Burke RC, Orav EJ, Bryan AF, Friend TH, Richardson DA, Jha AK, Tsai TC. Trends in performance of hospital outpatient procedures and associated 30-day costs among Medicare beneficiaries from 2011 to 2018. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2023; 11:100718. [PMID: 37913606 DOI: 10.1016/j.hjdsi.2023.100718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/20/2023] [Accepted: 09/11/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND United States healthcare has increasingly transitioned to outpatient care delivery. The degree to which Academic Medical Centers (AMCs) have been able to shift surgical procedures from inpatient to outpatient settings despite higher patient complexity is unknown. METHODS This observational study used a 20% sample of fee-for-service Medicare beneficiaries age 65 and older undergoing eight elective procedures from 2011 to 2018 to model trends in procedure site (hospital outpatient vs. inpatient) and 30-day standardized Medicare costs, overall and by hospital teaching status. RESULTS Of the 1,222,845 procedures, 15.9% occurred at AMCs. There was a 2.42% per-year adjusted increase (95% CI 2.39%-2.45%; p < .001) in proportion of outpatient hospital procedures, from 68.9% in 2011 to 85.4% in 2018. Adjusted 30-day standardized costs declined from $18,122 to $14,353, (-$560/year, 95% CI -$573 to -$547; p < .001). Patients at AMCs had more chronic conditions and higher predicted annual mortality. AMCs had a lower proportion of outpatient procedures in all years compared to non-AMCs, a difference that was statistically significant but small in magnitude. AMCs had higher costs compared to non-AMCs and a lesser decline over time (p < .001 for the interaction). AMCs and non-AMCs saw a similar decline in 30-day mortality. CONCLUSIONS There has been a substantial shift toward outpatient procedures among Medicare beneficiaries with a decrease in total 30-day Medicare spending as well as 30-day mortality. Despite a higher complexity population, AMCs shifted procedures to the outpatient hospital setting at a similar rate as non-AMCs. IMPLICATIONS The trend toward outpatient procedural care and lower spending has been observed broadly across AMCs and non-AMCs, suggesting that Medicare beneficiaries have benefited from more efficient delivery of procedural care across academic and community hospitals.
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Affiliation(s)
- Laura G Burke
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; The Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; The Department of Emergency Medicine, Harvard Medical School, Department of Surgery, Brigham and Women's Hospital, USA.
| | - Ryan C Burke
- The Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; The Department of Emergency Medicine, Harvard Medical School, Department of Surgery, Brigham and Women's Hospital, USA
| | - E John Orav
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Tynan H Friend
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Damien A Richardson
- Department of Orthopaedic Surgery, The University of Arizona, College of Medicine, Phoenix, AZ, USA
| | - Ashish K Jha
- Brown University School of Public Health, Providence, RI, USA
| | - Thomas C Tsai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; The Department of Emergency Medicine, Harvard Medical School, Department of Surgery, Brigham and Women's Hospital, USA
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Gopaldas JA, Padyana M, Rai PP. Practice Patterns in the Diagnosis and Management of Alcohol Withdrawal Syndrome in Indian Intensive Care Units. Indian J Crit Care Med 2023; 27:816-820. [PMID: 37936810 PMCID: PMC10626245 DOI: 10.5005/jp-journals-10071-24572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/01/2023] [Indexed: 11/09/2023] Open
Abstract
Alcohol use disorders (AUDs) are prevalent in intensive care units (ICUs). Alcohol abuse and/or dependence, leading to alcohol withdrawal syndrome (AWS), is as high as 10% or more. There seem to be wide variations in management strategies used to manage these patients, prompting an evaluation of the knowledge gap as well as finding the barriers. Noting lack of such literature in the Indian setting, a survey is undertaken to evaluate practice patterns surrounding the identification and management of alcohol dependence/abuse and AWS in the Indian critical care scenario. The main respondents of the survey are independent practitioners with anesthesia as their base specialty and overwhelmingly practice in multidisciplinary ICUs. They estimated AUD prevalence to be under 10%. The reason most expressed for lack of AUD documentation is fear of insurance rejection. Very few used risk assessment tool in evaluation of AUDs and AWS. Awareness of ICD 10/DSM-V components of AWS diagnosis was negligible. Chlordiazepoxide and lorazepam were used either in a fixed- or symptom-based therapy. Compared to available literature, haloperidol use is excessive, while barbiturates rarely. The wide variation is seen with the dose and frequency of thiamine in AWS without neurological complications. The impact on mortality and morbidity is poorly understood. In conclusion, the survey reported a lower prevalence compared to international literature. Insurance rejection is one of the main factors in limiting adequate history taking or documenting AUDs. Alcohol withdrawal syndrome risk assessment, monitoring, and management is variable and suboptimal. Variability in all aspects of AUDs is attributable to the knowledge gap. Further studies are needed to bridge the research gap. How to cite this article Gopaldas JA, Padyana M, Rai PP. Practice Patterns in the Diagnosis and Management of Alcohol Withdrawal Syndrome in Indian Intensive Care Units. Indian J Crit Care Med 2023;27(11):816-820.
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Affiliation(s)
| | - Mahesha Padyana
- Multidisciplinary Intensive Care Unit, Manipal Hospital, Jayanagar, Bengaluru, India
| | - Poonam P Rai
- Multidisciplinary Intensive Care Unit, Manipal Hospital, Jayanagar, Bengaluru, India
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Maldonado-Cañón K, Buitrago G, Molina G, Rincón Tello FM, Maldonado-Escalante J. Teaching hospitals and their influence on survival after valve replacement procedures: A retrospective cohort study using inverse probability of treatment weighting (IPTW). PLoS One 2023; 18:e0290734. [PMID: 37624801 PMCID: PMC10456128 DOI: 10.1371/journal.pone.0290734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND The effect of teaching hospital status on cardiovascular surgery has been of common interest in recent decades, yet its magnitude on heart valve replacement is still a matter of debate. Given the ethical and practical unfeasibility of randomly assigning a patient to such an exposure, we use the inverse probability of treatment weighting (IPTW) to assess this marginal effect on the survival of Colombian patients who underwent a first heart valve replacement between 2016 and 2019. METHODS A retrospective cohort study was conducted based on administrative records. The time-to-death event and cumulative incidences of death, readmission, and reoperation are presented as outcomes. An artificial sample is configured through IPTW, adjusting for sociodemographic variables, comorbidities, technique, and intervention weight. RESULTS Of a sample of 3,517 patients, 1,051 (29.9%) were operated on in a teaching hospital. The median age was 65.0 (18.1-91.5), 38.5% of patients were ≤60, and 6.9% were ≥80. The cumulative incidences of death at 30, 90 days, and one year were 5.9%, 8%, and 10.9%, respectively. Furthermore, 23.5% of the patients were readmitted within 90 days and 3.6% underwent reintervention within one year. The odds of 30-day mortality are lower for patients operated in a teaching hospital (OR 0.51; 95% CI 0.29-0.92); however, no effect on survival was identified in terms of time-to-event of death (HR 1.07; 95%CI 0.78-1.46). CONCLUSIONS After IPTW, the odds of 30-day mortality are lower for patients operated in a teaching hospital. There was no effect on survival, 90-day or one-year mortality, 90-day readmission, or one-year reintervention. Together, we offer an opening for investigating an exposure that has yet to be explored in Latin America with potential value to understand teaching hospitals as the essential nature of reality of an academic-clinical synergy.
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Affiliation(s)
- Kevin Maldonado-Cañón
- Facultad de Medicina, Instituto de Investigaciones Clínicas, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Giancarlo Buitrago
- Facultad de Medicina, Instituto de Investigaciones Clínicas, Universidad Nacional de Colombia, Bogotá, Colombia
- Hospital Universitario Nacional de Colombia, Bogotá, Colombia
| | - Germán Molina
- Department of Cardiovascular Surgery, Clínica Universitaria Colombia, Bogota, Colombia
| | - Francisco Mauricio Rincón Tello
- Department of Cardiovascular Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogota, Colombia
- Department of Cardiovascular Surgery, Clínica Los Nogales, Bogota, Colombia
| | - Javier Maldonado-Escalante
- Department of Cardiovascular Surgery, Clínica Universitaria Colombia, Bogota, Colombia
- Department of Cardiovascular Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogota, Colombia
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11
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Pope E, Sehgal N. Characterizing industry payments to US teaching hospitals and affiliated physicians: a cross-sectional analysis of the Open Payments datasets from 2016 to 2022. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad031. [PMID: 38756245 PMCID: PMC10986265 DOI: 10.1093/haschl/qxad031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/15/2023] [Accepted: 07/27/2023] [Indexed: 05/18/2024]
Abstract
Industry payments to US teaching hospitals are common; however, little is known about whether these financial relationships influence affiliated physicians to engage in similar financial relationships with industry. Using national hospital, physician, and industry payment data we investigated trends in industry payments made to US teaching hospitals and affiliated physicians to characterize the magnitude and nature of payments. In addition, we assessed if physicians may be influenced to accept higher value industry payments depending on the value of promotional payments accepted by the teaching hospital they affiliate with. We found that physicians with a US teaching hospital affiliation are associated with accepting higher value industry payments as the total value of industry payments of the teaching hospital increases. Our findings varied by specialty, with surgeons accepting the highest value payments. These results highlight the need for greater public disclosure and awareness of payments to better manage and mitigate industry-biased clinical decision making.
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Affiliation(s)
- Elle Pope
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA 02130, United States
| | - Neil Sehgal
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, United States
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Smith TE, Corbeil T, Wall MM, Tang F, Essock SM, Frimpong E, Goldman ML, Mascayano F, Radigan M, Wang R, Rodgers I, Dixon LB, Olfson M, Lewis-Fernández R. Community, Hospital, and Patient Factors Contributing to Ethnoracial Disparities in Follow-Up After Psychiatric Hospitalization. Psychiatr Serv 2023; 74:684-694. [PMID: 36651116 PMCID: PMC10329986 DOI: 10.1176/appi.ps.20220110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE This study used an ecosocial perspective to examine ethnoracial disparities in timely outpatient follow-up care after psychiatric hospitalization in a cohort of Medicaid recipients. METHODS This retrospective analysis used 2012-2013 New York State Medicaid claims data for 17,488 patients ages <65 years who were treated in hospital psychiatric units and discharged to the community. Claims data were linked to other administrative data sets capturing key social conditions and determinants of mental health for non-Latinx White (White hereafter), non-Latinx Black (Black), Latinx, non-Latinx Asian/Pacific Islander (Asian/Pacific Islander), non-Latinx American Indian or Native Alaskan (American Indian or Native Alaskan), and other ethnoracial groups. Regression models were used to estimate the variations in disparities in timely follow-up care that were attributable to community, organization (i.e., hospital), and individual patient characteristics. RESULTS Overall, 60.1% of patients attended an outpatient mental health visit within 30 days of discharge. Compared with the rate for White patients, the attendance rates were 9.5 percentage points lower for Black patients and 7.8 percentage points higher for Asian/Pacific Islander patients. No significant difference in attendance rates was found between Latinx and White patients. Community factors, specifically urban versus rural classification and county poverty status, accounted for the greatest variation in timely follow-up care in all comparisons. CONCLUSIONS Efforts to increase connection to outpatient mental health follow-up care after psychiatric hospitalization should incorporate cultural and structural competencies to address social conditions and determinants of mental health that underly ethnoracial disparities.
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Affiliation(s)
- Thomas E. Smith
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Tom Corbeil
- New York State Psychiatric Institute, New York, New York
| | - Melanie M. Wall
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Fei Tang
- Office of Performance Measurement and Evaluation, New York State Office of Mental Health, Albany, New York
| | - Susan M. Essock
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Eric Frimpong
- Office of Performance Measurement and Evaluation, New York State Office of Mental Health, Albany, New York
| | - Matthew L. Goldman
- Department of Psychiatry and Behavioral Sciences, University of California-San Francisco, San Francisco, California
| | | | - Marleen Radigan
- Office of Performance Measurement and Evaluation, New York State Office of Mental Health, Albany, New York
| | - Rui Wang
- Office of Performance Measurement and Evaluation, New York State Office of Mental Health, Albany, New York
| | - Ian Rodgers
- New York State Psychiatric Institute, New York, New York
| | - Lisa B. Dixon
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Mark Olfson
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Roberto Lewis-Fernández
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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Kocher B, Wachter RM. Why is it so hard for academic medical centers to succeed in value-based care? HEALTH AFFAIRS SCHOLAR 2023; 1:qxad002. [PMID: 38756833 PMCID: PMC10985910 DOI: 10.1093/haschl/qxad002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/03/2023] [Indexed: 05/18/2024]
Abstract
Academic medical centers (AMCs) excel in many ways, but struggle to succeed at delivering cost-effective care in value-based payment models. To the extent these payment models become more widespread, or mandatory, this could be a giant risk to the future success of AMCs. Many attributes of AMCs that have served them well in a fee-for-service payment system may hinder the transformation needed to succeed in value-based care. Much of the underperformance of AMCs may be explained by two core competencies that AMCs lack: the limited ability to redesign clinical workflows and inability to change their economic relationships with their own specialists and primary care providers. These limitations, in turn, flow from a combination of electronic medical record systems that lock-in existing practice patterns, compensation systems that reward volume over value, organizational structures that make it very hard to drive clinicians to change, workforces with too many specialists, and complex accounting systems. To preserve current margins in value-based care, AMCs need to reduce their cost structures and gain new skills in primary and preventive care. Alternative, AMCs may choose to eschew value-based care and raise their prices for fee-for-service to offset declines in patient volume.
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Affiliation(s)
- Bob Kocher
- Department of Health Policy, Stanford University, 3340 Hillview Avenue, Palo Alto, CA 94304, United States
| | - Robert M Wachter
- Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94117, United States
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Jain S, Rosenbaum PR, Reiter JG, Ramadan OI, Hill AS, Hashemi S, Brown RT, Kelz RR, Fleisher LA, Silber JH. Defining Multimorbidity in Older Patients Hospitalized with Medical Conditions. J Gen Intern Med 2023; 38:1449-1458. [PMID: 36385407 PMCID: PMC10160274 DOI: 10.1007/s11606-022-07897-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The term "multimorbidity" identifies high-risk, complex patients and is conventionally defined as ≥2 comorbidities. However, this labels almost all older patients as multimorbid, making this definition less useful for physicians, hospitals, and policymakers. OBJECTIVE Develop new medical condition-specific multimorbidity definitions for patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia patients. We developed three medical condition-specific multimorbidity definitions as the presence of single, double, or triple combinations of comorbidities - called Qualifying Comorbidity Sets (QCSs) - associated with at least doubling the risk of 30-day mortality for AMI and pneumonia, or one-and-a-half times for HF patients, compared to typical patients with these conditions. DESIGN Cohort-based matching study PARTICIPANTS: One hundred percent Medicare Fee-for-Service beneficiaries with inpatient admissions between 2016 and 2019 for AMI, HF, and pneumonia. MAIN MEASURES Thirty-day all-location mortality KEY RESULTS: We defined multimorbidity as the presence of ≥1 QCS. The new definitions labeled fewer patients as multimorbid with a much higher risk of death compared to the conventional definition (≥2 comorbidities). The proportions of patients labeled as multimorbid using the new definition versus the conventional definition were: for AMI 47% versus 87% (p value<0.0001), HF 53% versus 98% (p value<0.0001), and pneumonia 57% versus 91% (p value<0.0001). Thirty-day mortality was higher among patients with ≥1 QCS compared to ≥2 comorbidities: for AMI 15.0% versus 9.5% (p<0.0001), HF 9.9% versus 7.0% (p <0.0001), and pneumonia 18.4% versus 13.2% (p <0.0001). CONCLUSION The presence of ≥2 comorbidities identified almost all patients as multimorbid. In contrast, our new QCS-based definitions selected more specific combinations of comorbidities associated with substantial excess risk in older patients admitted for AMI, HF, and pneumonia. Thus, our new definitions offer a better approach to identifying multimorbid patients, allowing physicians, hospitals, and policymakers to more effectively use such information to consider focused interventions for these vulnerable patients.
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Affiliation(s)
- Siddharth Jain
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA.
| | - Paul R Rosenbaum
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Statistics, The Wharton School, The University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Omar I Ramadan
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander S Hill
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sean Hashemi
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca T Brown
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Division of Geriatric Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Geriatrics and Extended Care, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Rachel R Kelz
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Lee A Fleisher
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Perioperative Outcomes Research and Transformation, The University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- The Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia, PA, USA
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Ramadan OI, Rosenbaum PR, Reiter JG, Jain S, Hill AS, Hashemi S, Kelz RR, Fleisher LA, Silber JH. Redefining Multimorbidity in Older Surgical Patients. J Am Coll Surg 2023; 236:1011-1022. [PMID: 36919934 DOI: 10.1097/xcs.0000000000000659] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations. STUDY DESIGN We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general = 230,410 patients, orthopaedic = 778,131 patients, vascular = 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching. RESULTS Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general = 85.0% (conventional) vs 55.9% (new) (p < 0.0001); orthopaedic = 66.6% vs 40.2% (p < 0.0001); and vascular = 96.2% vs 52.7% (p < 0.0001). Thirty-day mortality was higher by the new definitions: general = 3.96% (conventional) vs 5.64% (new) (p < 0.0001); orthopaedic = 0.13% vs 1.68% (p < 0.0001); and vascular = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference = -0.94% [-1.36%, -0.52%], p < 0.0001; orthopaedic = -0.20% [-0.34%, -0.05%], p = 0.0087; and vascular = -0.12% [-0.69%, 0.45%], p = 0.6795). CONCLUSIONS Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.
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Affiliation(s)
- Omar I Ramadan
- From the Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Ramadan, Kelz)
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
| | - Paul R Rosenbaum
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, PA (Rosenbaum)
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA (Reiter, Jain, Hill, Silber)
| | - Siddharth Jain
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA (Reiter, Jain, Hill, Silber)
| | - Alexander S Hill
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA (Reiter, Jain, Hill, Silber)
| | - Sean Hashemi
- From the Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Ramadan, Kelz)
| | - Rachel R Kelz
- From the Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Ramadan, Kelz)
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
| | - Lee A Fleisher
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Fleisher)
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, PA (Fleisher)
| | - Jeffrey H Silber
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber)
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA (Reiter, Jain, Hill, Silber)
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Silber)
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA (Silber)
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Regional Disparities in the Use of Septal Reduction Therapy and Associated Outcomes in the United States (from a Real-World Database). Am J Cardiol 2023; 191:51-58. [PMID: 36640600 DOI: 10.1016/j.amjcard.2022.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/18/2022] [Accepted: 12/10/2022] [Indexed: 01/15/2023]
Abstract
The regional differences in the use of septal reduction therapies and the associated outcomes in patients with Hypertrophic obstructive cardiomyopathy (HOCM) are unknown. The primary objective of our study was to evaluate the regional disparities in the use of septal reduction therapies, including septal myectomy and alcohol septal ablation, in patients with HOCM. The secondary objective was to analyze the regional differences in the outcomes in these patients. Patients with HOCM had 87% higher risk-adjusted odds of getting septal myectomy (adjusted odds ratio 1.87, p = 0.03) and 37% lower risk-adjusted odds of getting alcohol septal ablation (adjusted odds ratio 0.63, p = 0.03) in the Midwest than in the Northeast. The in-hospital mortality rate was higher for patients who underwent septal myectomy in the South versus the Northeast on the unadjusted analysis. These differences persisted despite the adjustment for demographic and clinical characteristics. Additional adjustment for hospital volume partially explained these disparities, but the adjustment for both hospital volume and hospital teaching status completely explained these disparities. The risk-adjusted in-hospital mortality in patients who underwent alcohol septal ablation was similar in the South versus other regions. In conclusion, regional disparities may exist in the use of septal myectomy and alcohol septal ablation, and patients with HOCM should be referred to high-volume teaching hospitals for septal myectomy for better outcomes, which may also eliminate the extra burden of hospital mortality in the South.
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Burke LG, Burke RC, Orav EJ, Duggan CE, Figueroa JF, Jha AK. Association of Academic Medical Center Presence With Clinical Outcomes at Neighboring Community Hospitals Among Medicare Beneficiaries. JAMA Netw Open 2023; 6:e2254559. [PMID: 36723939 PMCID: PMC9892959 DOI: 10.1001/jamanetworkopen.2022.54559] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Studies suggest that academic medical centers (AMCs) have better outcomes than nonteaching hospitals. However, whether AMCs have spillover benefits for patients treated at neighboring community hospitals is unknown. OBJECTIVE To examine whether market-level AMC presence is associated with outcomes for patients treated at nonteaching hospitals within the same markets. DESIGN, SETTING, AND PARTICIPANTS This retrospective, population-based cohort study assessed traditional Medicare beneficiaries aged 65 years and older discharged from US acute care hospitals between 2015 and 2017 (100% sample). Data were analyzed from August 2021 to December 2022. EXPOSURES The primary exposure was market-level AMC presence. Health care markets (ie, hospital referral regions) were categorized by AMC presence (percentage of hospitalizations at AMCs) as follows: no presence (0%), low presence (>0% to 20%), moderate presence (>20% to 35%), and high presence (>35%). MAIN OUTCOMES AND MEASURES The primary outcomes were 30-day and 90-day mortality and healthy days at home (HDAH), a composite outcome reflecting mortality and time spent in facility-based health care settings. RESULTS There were 22 509 824 total hospitalizations, with 18 865 229 (83.8%) at non-AMCs. The median (IQR) age of patients was 78 (71-85) years, and 12 568 230 hospitalizations (55.8%) were among women. Of 306 hospital referral regions, 191 (62.4%) had no AMCs, 61 (19.9%) had 1 AMC, and 55 (17.6%) had 2 or more AMCs. Markets characteristics differed significantly by category of AMC presence, including mean population, median income, proportion of White residents, and physicians per population. Compared with markets with no AMC presence, receiving care at a non-AMC in a market with greater AMC presence was associated with lower 30-day mortality (9.5% vs 10.1%; absolute difference, -0.7%; 95% CI, -1.0% to -0.4%; P < .001) and 90-day mortality (16.1% vs 16.9%; absolute difference, -0.8%; 95% CI, -1.2% to -0.4%; P < .001) and more HDAH at 30 days (16.49 vs 16.12 HDAH; absolute difference, 0.38 HDAH; 95% CI, 0.11 to 0.64 HDAH; P = .005) and 90 days (61.08 vs 59.83 HDAH; absolute difference, 1.25 HDAH; 95% CI, 0.58 to 1.92 HDAH; P < .001), after adjustment. There was no association between market-level AMC presence and mortality for patients treated at AMCs themselves. CONCLUSIONS AND RELEVANCE AMCs may have spillover effects on outcomes for patients treated at non-AMCs, suggesting that they have a broader impact than is traditionally recognized. These associations are greatest in markets with the highest AMC presence and persist to 90 days.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ashish K. Jha
- Brown University School of Public Health, Providence, Rhode Island
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Cilla F, Sabione I, D’Amelio P. Risk Factors for Early Hospital Readmission in Geriatric Patients: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1674. [PMID: 36767038 PMCID: PMC9914102 DOI: 10.3390/ijerph20031674] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/09/2023] [Accepted: 01/16/2023] [Indexed: 06/18/2023]
Abstract
The number of older patients is constantly growing, and early hospital readmissions in this population represent a major problem from a health, social and economic point of view. Furthermore, the early readmission rate is often used as an indicator of the quality of care. We performed a systematic review of the literature to better understand the risk factors of early readmission (30 and 90 days) in the geriatric population and to update the existing evidence on this subject. The search was carried out on the MEDLINE, EMBASE and PsycINFO databases. Three independent reviewers assessed the potential inclusion of the studies, and then each study was independently assessed by two reviewers using Joanna Briggs Institute critical appraisal tools; any discrepancies were resolved by the third reviewer. Studies that included inpatients in surgical wards were excluded. Twenty-nine studies were included in the review. Risk factors of early readmission can be classified into socio-economic factors, factors relating to the patient's health characteristics, factors related to the use of the healthcare system and clinical factors. Among these risk factors, those linked to patient frailty play an important role, in particular malnutrition, reduced mobility, risk of falls, fatigue and functional dependence. The early identification of patients at higher risk of early readmission may allow for targeted interventions in view of discharge.
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Shahidi Sadeghi N, Maleki M, Abolghasem Gorji H, Vatankhah S, Mohaghegh B. The experiences of hospitals in changing the function of a non-teaching hospital to a teaching hospital: Short-Communication. CASPIAN JOURNAL OF INTERNAL MEDICINE 2023; 14:365-370. [PMID: 37223282 PMCID: PMC10201128 DOI: 10.22088/cjim.14.2.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 01/30/2022] [Accepted: 02/21/2022] [Indexed: 05/25/2023]
Abstract
Background In recent years, there have been many non-teaching hospitals that have become teaching hospitals. Although the decision to make this change is made at the policy level; But the unknown consequences can create many problems. The present study investigated the experiences of hospitals in changing the function of a non-teaching to a teaching hospital in Iran. Methods A Phenomenological qualitative study was conducted using semi-structured interviews with 40 hospital managers and policy makers who had the experience of changing the function of hospitals in Iran through a purposive sampling in 2021. Thematic analysis using inductive approach and MAXQDA 10 was used for data analysis. Results According to the results extracted 16 main categories and 91 subcategories. Considering the complexity and instability of command unity, understanding the change of organizational hierarchy, developing a mechanism to cover client's costs, considering increase management team' legal and social responsibility, coordinating policy demands with Providing resources, funding the teaching mission, organizing the multiple supervisory organizations, transparent communication between hospital and colleges, understanding the complexity of processes, considering change the performance appraisal system and pay for performance were the solutions for decrease problems of changing the function of non-teaching to teaching hospital. Conclusion Important matter about the improvement of university hospitals is evaluating the performance of hospitals to maintain their role as progressive actors in hospital network and also as the main actors of teaching future professional human resources. In fact, in the world, hospital becoming teaching is based on the performance of hospitals.
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Affiliation(s)
- Niusha Shahidi Sadeghi
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Maleki
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Abolghasem Gorji
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Soudabeh Vatankhah
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Bahram Mohaghegh
- Department of Public Health, School of Health, Qom University of Medical Sciences, Qom, Iran
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Naar L, Maurer LR, Dorken Gallastegi A, El Hechi MW, Rao SR, Coughlin C, Ebrahim S, Kadambi A, Mendoza AE, Saillant NN, Renne BCB, Velmahos GC, Kaafarani HMA, Lee J. Hospital Academic Status and the Volume-Outcome Association in Postoperative Patients Requiring Intensive Care: Results of a Nationwide Analysis of Intensive Care Units in the United States. J Intensive Care Med 2022; 37:1598-1605. [PMID: 35437045 DOI: 10.1177/08850666221094506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To determine whether the outcomes of postoperative patients admitted directly to an intensive care unit (ICU) differ based on the academic status of the institution and the total operative volume of the unit. Methods: This was a retrospective analysis using the eICU Collaborative Research Database v2.0, a national database from participating ICUs in the United States. All patients admitted directly to the ICU from the operating room were included. Transfer patients and patients readmitted to the ICU were excluded. Patients were stratified based on admission to an ICU in an academic medical center (AMC) versus non-AMC, and to ICUs with different operative volume experience, after stratification in quartiles (high, medium-high, medium-low, and low volume). Primary outcomes were ICU and hospital mortality. Secondary outcomes included the need for continuous renal replacement therapy (CRRT) during ICU stay, ICU length of stay (LOS), and 30-day ventilator free days. Results: Our analysis included 22,180 unique patients; the majority of which (15,085[68%]) were admitted to ICUs in non-AMCs. Cardiac and vascular procedures were the most common types of procedures performed. Patients admitted to AMCs were more likely to be younger and less likely to be Hispanic or Asian. Multivariable logistic regression indicated no meaningful association between academic status and ICU mortality, hospital mortality, initiation of CRRT, duration of ICU LOS, or 30-day ventilator-free-days. Contrarily, medium-high operative volume units had higher ICU mortality (OR = 1.45, 95%CI = 1.10-1.91, p-value = 0.040), higher hospital mortality (OR = 1.33, 95%CI = 1.07-1.66, p-value = 0.033), longer ICU LOS (Coefficient = 0.23, 95%CI = 0.07-0.39, p-value = 0.038), and fewer 30-day ventilator-free-days (Coefficient = -0.30, 95%CI = -0.48 - -0.13, p-value = 0.015) compared to their high operative volume counterparts. Conclusions: This study found that a volume-outcome association in the management of postoperative patients requiring ICU level of care immediately after a surgical procedure may exist. The academic status of the institution did not affect the outcomes of these patients.
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Affiliation(s)
- Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Majed W El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sowmya R Rao
- MGH Biostatistics Center, Harvard Medical School; Department of Global Health, 27118Boston University School of Public Health, Boston, MA, USA
| | - Catherine Coughlin
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Senan Ebrahim
- Hikma Health, San Jose, CA, USA
- 1811Harvard Medical School, Boston, MA, USA
| | - Adesh Kadambi
- Hikma Health, San Jose, CA, USA
- 7938University of Toronto, Toronto, ON, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - B Christian B Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jarone Lee
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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21
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Tomei KL, Selby LV, Kirk LM, Bello JA, Nolan NS, Varma SK, Turner PL, Elliott VS, Brotherton SE. Beyond Training the Next Generation of Physicians: The Unmeasured Value Added by Residents to Teaching Hospitals and Communities. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1592-1596. [PMID: 35731593 PMCID: PMC9592142 DOI: 10.1097/acm.0000000000004792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Following medical school, most newly graduated physicians enter residency training. This period of graduate medical education (GME) is critical to creating a physician workforce with the specialized skills needed to care for the population. Completing GME training is also a requirement for obtaining medical licensure in all 50 states. Yet, crucial federal and state funding for GME is capped, creating a bottleneck in training an adequate physician workforce to meet future patient care needs. Thus, additional GME funding is needed to train more physicians. When considering this additional GME funding, it is imperative to take into account not only the future physician workforce but also the value added by residents to teaching hospitals and communities during their training. Residents positively affect patient care and health care delivery, providing intrinsic and often unmeasured value to patients, the hospital, the local community, the research enterprise, and undergraduate medical education. This added value is often overlooked in decisions regarding GME funding allocation. In this article, the authors underscore the value provided by residents to their training institutions and communities, with a focus on current and recent events, including the global COVID-19 pandemic and teaching hospital closures.
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Affiliation(s)
- Krystal L. Tomei
- K.L. Tomei is associate professor of pediatric neurosurgery, Rainbow Babies & Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Luke V. Selby
- L.V. Selby is assistant professor of surgery, Department of Surgery, Division of Colorectal and Oncologic Surgery, University of Kansas Medical Center, Kansas City, Kansas; ORCID: https://orcid.org/0000-0002-0202-9646
| | - Lynne M. Kirk
- L.M. Kirk is chief of accreditation and recognition, Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Jacqueline A. Bello
- J.A. Bello is director of neuroradiology and professor of radiology and neurosurgery, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York
| | - Nathan S. Nolan
- N.S. Nolan is medical education fellow and infectious disease physician, Washington University Hospital, St. Louis, Missouri
| | - Surendra K. Varma
- S.K. Varma is executive associate dean for graduate medical education and resident affairs, university distinguished professor, and vice chair, Department of Pediatrics, Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas
| | - Patricia L. Turner
- P.L. Turner is executive director, American College of Surgeons, and clinical associate professor of surgery, University of Chicago Medicine, Chicago, Illinois
| | - Victoria Stagg Elliott
- V.S. Elliott is a technical writer, Medical Education Outcomes, American Medical Association, Chicago, Illinois; ORCID: https://orcid.org/0000-0003-1223-0084
| | - Sarah E. Brotherton
- S.E. Brotherton is director, Data Acquisition Services, American Medical Association, Chicago, Illinois
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22
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Sotillo CL, Franco I, Arriaga AF. Predictive Algorithms for a Crisis. Crit Care Med 2022; 50:1150-1153. [PMID: 35726979 PMCID: PMC9196921 DOI: 10.1097/ccm.0000000000005550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Claudia L Sotillo
- Department of Anesthesiology & Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Idalid Franco
- Harvard Radiation Oncology Program, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alexander F Arriaga
- Department of Anesthesiology & Perioperative Medicine, Tufts Medical Center, Boston, MA.,Harvard Radiation Oncology Program, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Center for Surgery and Public Health, Boston, MA.,Ariadne Labs, Boston, MA
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23
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Emergency departments: The gatekeepers of admissions in Pennsylvania's rural hospitals. Am J Emerg Med 2022; 57:138-148. [PMID: 35576794 DOI: 10.1016/j.ajem.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/25/2022] [Accepted: 05/03/2022] [Indexed: 01/02/2023] Open
Abstract
STUDY OBJECTIVE To analyze trends in admission rates and the proportion of admissions via the ED at rural hospitals in Pennsylvania and to identify factors that may impact admission rates. METHODS We use retrospective, longitudinal data on rural acute care hospitals in Pennsylvania for 2000-19 to investigate temporal patterns in admission rates and the proportion of admissions via the ED. Regression analysis is then used to identify factors that may impact admission rates. RESULTS In general admission rates, which averaged 14.5%, experienced a gradual decline (Change: -16.9%; from 15.7% to 13%) between 2000 and 2019. The proportion of hospital admissions via the ED, which averaged 64.9%, increased steadily (21%; from 57% to 69%). Critical access hospitals experienced a sharp decline in admissions via the ED (-49.1%) and admission rates (-55.3%). The fixed-effects regression model revealed several hospital- and ED-level characteristics were significantly associated with admission rate. CONCLUSIONS Emergency departments are the gatekeepers of admissions at rural acute care hospitals in Pennsylvania. Many hospitals in rural Pennsylvania, including CAHs, are admitting most of their patients through the ED, concomitant with a significant decline in admissions and admission rates. This highlights the need to strengthen primary care practices serving rural Pennsylvania as well as the need to improve rural emergency and trauma systems. In the short to medium term, policy makers should explore innovative ways to fund smaller hospitals, especially CAHs, to develop level IV trauma center capabilities.
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24
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Tam K, Williamson T, Ma IWY, Ambasta A. Association Between Health System Factors and Utilization of Routine Laboratory Tests in Clinical Teaching Units: a Cohort Analysis. J Gen Intern Med 2022; 37:1444-1449. [PMID: 34355347 PMCID: PMC9085997 DOI: 10.1007/s11606-021-07063-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/21/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Few studies have looked at health system factors associated with laboratory test use. OBJECTIVE To determine the association between health system factors and routine laboratory test use in medical inpatients. DESIGN We conducted a retrospective cohort study on adult patients admitted to clinical teaching units over a 3-year period (January 2015 to December 2017) at three tertiary care hospitals in Calgary, Alberta. PARTICIPANTS Patients were assigned to a Case Mix Group+ (CMG+) category based on their clinical characteristics, and patients in the top 10 CMG+ groups were included in the cohort. EXPOSURES The examined health system factors were (1) number of primary attending physicians seen by a patient, (2) number of attending medical teams seen by a patient, (3) structure of the medical team, and (4) day of the week. MAIN MEASURES The primary outcome was the total number of routine laboratory tests ordered on a patient during their admission. Statistical models were adjusted for age, sex, length of stay, Charlson comorbidity index, and CMG+ group. RESULTS The final cohort consisting of 36,667 patient-days in hospital (mean (SD) age 62.5 (18.4) years) represented 5071 unique hospitalizations and 4324 unique patients. Routine laboratory test use was increased when patients saw multiple attending physicians; with an adjusted incidence rate ratio (IRR) of 1.46 (95% CI, 1.37-1.55) for two attending physicians, and 2.50 (95% CI, 2.23-2.79) for three or more attending physicians compared to a single attending physician. The number of routine laboratory tests was slightly lower on weekends (IRR 0.98, 95% CI, 0.96-0.99) and on teams without a senior resident as part of their team structure (IRR 0.89, 95% CI 0.830.96). CONCLUSIONS The associations observed in this study suggest that breaks in continuity of care, including increased frequency in patient transfer of care, may impact the utilization of routine laboratory tests.
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Affiliation(s)
- Keith Tam
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Tyler Williamson
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada
| | - Irene W Y Ma
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada.,Ward of the 21st Century, University of Calgary, Alberta, Canada
| | - Anshula Ambasta
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada. .,Ward of the 21st Century, University of Calgary, Alberta, Canada.
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25
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Sadeghi NS, Maleki M, Gorji HA, Vatankhah S, Mohaghegh B. Differences and their contexts between teaching and nonteaching hospitals in Iran with other countries: A concurrent mixed-methods study. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2022; 11:32. [PMID: 35281395 PMCID: PMC8893075 DOI: 10.4103/jehp.jehp_1431_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 05/20/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND In terms of missions, hospitals are divided into teaching and nonteaching. In addition, differences in health-care systems in countries will lead to differences in hospitals' operation. Iran, as a specific health-care system, is different from other countries. Hence, the present study investigated differences between teaching and nonteaching hospitals and their differences in Iran and the world. MATERIALS AND METHODS A concurrent mixed-methods study was conducted in two stages. The first stage was a narrative review of studies (2000-2020). Using narrative inquiry and reflective analysis, the content was analyzed and the categories were extracted. The second stage was a qualitative study conducted using semi-structured interviews with forty Iranian hospital managers and policymakers through a purposive sampling in 2020. Content analysis was made using deductive approach, and MAXQDA 12 was used for data analysis. RESULTS According to the first stage, categories were extracted as follows: service quality, type of cases, patient satisfaction, efficiency, performance indicators, patient safety, personnel, use of drugs, access to services, technologies, justice in the type of services received, using guidelines, processes, and number of services. In the second stage, 8 main categories, 17 categories, and 45 subcategories were extracted. The extracted main categories were as follows: mission and target, management and behavioral organizations, supply chain and chain of results, human resources, costs and budget, policy demands, clients' satisfaction and patients' right, and integration of medical education. CONCLUSION Unlike other countries, in Iran, the combination of missions and the complete dependence of teaching hospitals on the government has caused differences. Reducing the treatment mission of teaching hospitals; differences in the budget and development of its indicators; lower tariffs for teaching hospitals; developing a cost-income management model and supply chain; preventing uncertainty other than medical students except medicine; considering the clients' right to choose hospital; and organizing research missions in hospitals were the solutions for decrease differences.
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Affiliation(s)
- Niusha Shahidi Sadeghi
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Maleki
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Abolghasem Gorji
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Soudabeh Vatankhah
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Bahram Mohaghegh
- Department of Public Health, School of Health, Qom University of Medical Sciences, Qom, Iran
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26
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Lee Y, Schaubel DE. Facility profiling under competing risks using multivariate prognostic scores: Application to kidneytransplant centers. Stat Methods Med Res 2021; 31:563-575. [PMID: 34879778 DOI: 10.1177/09622802211052873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The performance of health care facilities (e.g. hospitals, transplant centers, etc.) is often evaluated through time-to-event outcomes. In this paper, we consider the case where, for each subject, the failure event is due to one of several mutually exclusive causes (competing risks). Since the distribution of patient characteristics may differ greatly by the center, some form of covariate adjustment is generally necessary in order for center-specific outcomes to be accurately compared (to each other or to an overall average). We propose a weighting method for comparing facility-specific cumulative incidence functions to an overall average. The method directly standardizes each facility's non-parametric cumulative incidence function through a weight function constructed from a multivariate prognostic score. We formally define the center effects and derive large-sample properties of the proposed estimator. We evaluate the finite sample performance of the estimator through simulation. The proposed method is applied to the end-stage renal disease setting to evaluate the center-specific pre-transplant mortality and transplant cumulative incidence functions from the Scientific Registry of Transplant Recipients.
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Affiliation(s)
- Youjin Lee
- Department of Biostatistics, 6752Brown University, USA
| | - Douglas E Schaubel
- Center for Causal Inference, 14640University of Pennsylvania, USA.,Department of Biostatistics, Epidemiology & Informatics, 14640University of Pennsylvania, USA
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27
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Carr MJ, Badiee J, Benham DA, Diaz JA, Calvo RY, Sise CB, Martin MJ, Bansal V. Surgical management and outcomes of adhesive small bowel obstruction: teaching versus non-teaching hospitals. Eur J Trauma Emerg Surg 2021; 48:107-112. [PMID: 34775508 DOI: 10.1007/s00068-021-01812-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The relationship between surgical management of adhesive small bowel obstruction (ASBO) and hospital teaching status is not well known. We sought to elucidate the association between hospital teaching status and clinical metrics for ASBO. METHODS Using the 2007-2017 California Office of Statewide Health Planning and Development database, we identified adult ASBO patients hospitalized for surgical intervention. Hospital teaching status was categorized as major teaching (MajT), minor teaching (MinT), and non-teaching (NT). Cox proportional hazards modeling was used to evaluate risk of death and other adverse outcomes. RESULTS Of 25,047 admissions, 15.4% were at MajT, 32.0% at MinT, and 52.6% at NT; 2.9% died. Patients at MajT had longer overall hospital stays (HLOS) than those at MinT or NT (median days 9 vs. 8 vs. 8; p = 0.005), longer post-ASBO procedure HLOS (median days 7 vs. 6 vs. 6; p = 0.0001) and higher rates of small bowel resection (27.1% vs. 21.7% vs. 21.7%; p < 0.0001). Mean time to first surgery at MajT was 3.3 days compared with 2.6 days (p = 0.004) at MinT and NT. Compared with patients at NT, those at MajT were significantly less likely to die (HR 0.62, p < 0.0001), develop pneumonia (HR 0.57, p = 0.001), or experience adverse discharge disposition (HR 0.79, p < 0.0001). CONCLUSION Mortality and morbidity of ASBO surgery were reduced at MajT; however, time to surgery, HLOS, and rate of small bowel resection were greater. These findings may guide improvements in the management of ASBO patients.
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Affiliation(s)
- Matthew J Carr
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Jayraan Badiee
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Derek A Benham
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Joseph A Diaz
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Richard Y Calvo
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Carol B Sise
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Matthew J Martin
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
| | - Vishal Bansal
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
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28
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Alweis R, Donato A, Terry R, Goodermote C, Qadri F, Mayo R. Benefits of developing graduate medical education programs in community health systems. J Community Hosp Intern Med Perspect 2021; 11:569-575. [PMID: 34567443 PMCID: PMC8462840 DOI: 10.1080/20009666.2021.1961381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The creation of new CMS-funded Graduate Medical Education (GME) cap positions by the Consolidated Appropriations Act 2021 offers a unique opportunity for systems in community and rural settings to develop and expand their training programs. This article provides a review of the evidence behind the value proposition for system administrators to foster the growth of GME in community health systems. The infrastructure needed to accredit GME programs may reduce the cost of care for both the patients and the system through improved patient outcomes and facilitation of system efforts to recognize and mitigate social determinants of health. Residents, fellows and medical students expand the capacity of the current healthcare workforce of a system by providing coverage during healthcare emergencies and staffing services in difficult-to-recruit specialties. Those trainees are the nucleus of succession planning for the current medical staff, can facilitate the creation and expansion of service lines, and may elevate the profile of the system through scholarly work and equity and quality improvement activities. While creating GME programs in a community health system may, at first glance, be perceived as cost-prohibitive, there are robust advantages to a system for their creation.
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Affiliation(s)
- Richard Alweis
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Anthony Donato
- Department of Medicine, Tower Health, West Reading, Pennsylvania, United States
| | - Richard Terry
- Academic Affairs, Lake Erie College of Medicine at Elmira, Elmira, New York, United States
| | - Christina Goodermote
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Farrah Qadri
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
| | - Robert Mayo
- Department of Medical Education, Rochester Regional Health, Rochester, New York, United States
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29
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Sloan FA. Quality and Cost of Care by Hospital Teaching Status: What Are the Differences? Milbank Q 2021; 99:273-327. [PMID: 33751662 DOI: 10.1111/1468-0009.12502] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care. CONTEXT The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy. METHODS Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers. FINDINGS Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures. CONCLUSIONS Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.
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30
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Lasater KB, McHugh MD, Rosenbaum PR, Aiken LH, Smith HL, Reiter JG, Niknam BA, Hill AS, Hochman LL, Jain S, Silber JH. Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions. J Gen Intern Med 2021; 36:84-91. [PMID: 32869196 PMCID: PMC7458128 DOI: 10.1007/s11606-020-06151-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 08/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear. OBJECTIVE To determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources. DESIGN Matched cohort study of patients in 306 acute care hospitals. PATIENTS A total of 74,045 matched pairs of fee-for-service Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status. MAIN MEASURES Better (n = 76) and worse (n = 230) nursing resourced hospitals were defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs. KEY RESULTS Patients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%, p < 0.0001) and fewer readmissions (32.3% vs 33.6%, p < 0.0001) yet costs were not significantly different ($18,848 vs 18,671, p = 0.133). The greatest outcomes and cost advantage of better nursing resourced hospitals were in patients with sepsis who had lower mortality (25.3% vs 27.6%, p < 0.0001). Overall, patients with the highest risk of mortality on admission experienced the greatest reductions in mortality and readmission from better nursing at no difference in cost. CONCLUSIONS Medicare beneficiaries with common medical conditions admitted to hospitals with better nursing resources experienced more favorable outcomes at almost no difference in cost.
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Affiliation(s)
- Karen B Lasater
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul R Rosenbaum
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Herbert L Smith
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Population Studies Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bijan A Niknam
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexander S Hill
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lauren L Hochman
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Siddharth Jain
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey H Silber
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Departments of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
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Lasater KB, McHugh M, Rosenbaum PR, Aiken LH, Smith H, Reiter JG, Niknam BA, Hill AS, Hochman LL, Jain S, Silber JH. Valuing hospital investments in nursing: multistate matched-cohort study of surgical patients. BMJ Qual Saf 2020; 30:46-55. [PMID: 32220938 DOI: 10.1136/bmjqs-2019-010534] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND There are known clinical benefits associated with investments in nursing. Less is known about their value. AIMS To compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks. METHODS Retrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital's size category, teaching and technology status, and were closely matched on comorbidities and other risk factors. RESULTS Patients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (p<0.001), lower failure-to-rescue: 5.4% vs 6.2% (p<0.001), lower readmissions: 12.6% vs 13.5% (p<0.001), shorter lengths of stay: 4.70 days vs 4.76 days (p<0.001), more intensive care unit admissions: 17.2% vs 15.4% (p<0.001) and marginally higher nurse-adjusted costs (which account for the costs of better nursing resources): $20 096 vs $19 358 (p<0.001), as compared with patients in worse nursing resourced hospitals. The nurse-adjusted cost associated with a 1% improvement in mortality at better nursing hospitals was $2035. Patients with the highest mortality risk realised the greatest value from nursing resources. CONCLUSION Hospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.
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Affiliation(s)
- Karen B Lasater
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew McHugh
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul R Rosenbaum
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Linda H Aiken
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Herbert Smith
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Population Studies Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bijan A Niknam
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexander S Hill
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lauren L Hochman
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Siddharth Jain
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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