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Jacobs MA, Gao Y, Schmidt S, Shireman PK, Mader M, Duncan CA, Hausmann LRM, Stitzenberg KB, Kao LS, Vaughan Sarrazin M, Hall DE. Social Determinants of Health and Surgical Desirability of Outcome Ranking in Older Veterans. JAMA Surg 2024; 159:1158-1168. [PMID: 39083255 PMCID: PMC11292565 DOI: 10.1001/jamasurg.2024.2489] [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] [Received: 02/20/2024] [Accepted: 05/08/2024] [Indexed: 08/03/2024]
Abstract
Importance Evaluating how social determinants of health (SDOH) influence veteran outcomes is crucial, particularly for quality improvement. Objective To measure associations between SDOH, care fragmentation, and surgical outcomes using a Desirability of Outcome Ranking (DOOR). Design, Setting, And Participants This was a cohort study of US veterans using data from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP; 2013-2019) limited to patients aged 65 years or older with inpatient stays between 2 and 30 days, merged with multiple data sources, including Medicare. Race and ethnicity data were retrieved from VASQIP, Medicare and Medicaid beneficiary summary files, the Veterans Health Administration Corporate Data Warehouse, and the United States Veterans Eligibility Trends and Statistics file. Data were analyzed between September 2023 and February 2024. Exposure Living in a highly deprived neighborhood (Area Deprivation Index >85), race and ethnicity used as a social construct, rurality, and care fragmentation (percentage of non-VA care days). Main Outcomes and Measures DOOR is a composite, patient-centered ranking of 26 outcomes ranging from no complication (1, best) to 90-day mortality or near-death complications (6, worst). A series of proportional odds regressions was used to assess the impact of SDOH and care fragmentation adjusted for clinical risk factors, including presentation acuity (presenting with preoperative acute serious conditions and urgent or emergent surgical procedures). Results The cohort had 93 644 patients (mean [SD] age, 72.3 [6.2] years; 91 443 [97.6%] male; 74 624 [79.7%] White). Veterans who identified as Black (adjusted odds ratio [aOR], 1.06; 95% CI, 1.02-1.10; P = .048) vs White and veterans with higher care fragmentation (per 20% increase in VA care days relative to all care days: aOR, 1.01; 95% CI, 1.01-1.02; P < .001) were associated with worse (higher) DOOR scores until adjusting for presentation acuity. Living in rural geographic areas was associated with better DOOR scores than living in urban areas (aOR, 0.93; 95% CI, 0.91-0.96; P < .001), and rurality was associated with lower presentation acuity (preoperative acute serious conditions: aOR, 0.88; 95% CI, 0.81-0.95; P = .001). Presentation acuity was higher in veterans identifying as Black, living in deprived neighborhoods, and with increased care fragmentation. Conclusions and Relevance Veterans identifying as Black and veterans with greater proportions of non-VA care had worse surgical outcomes. VA programs should direct resources to reduce presentation acuity among Black veterans, incentivize veterans to receive care within the VA where possible, and better coordinate veterans' treatment and records between care sources.
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Affiliation(s)
- Michael A. Jacobs
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Yubo Gao
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Paula K. Shireman
- Department of Medical Physiology, College of Medicine, Texas A&M University, Bryan
- Department of Primary Care and Rural Medicine, College of Medicine, Texas A&M University, Bryan
| | | | - Carly A. Duncan
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | - Mary Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Jacobs MA, Schmidt S, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships Between Race/Ethnicity, Insurance Type, and Neighborhood Deprivation. Ann Surg 2024; 279:246-257. [PMID: 37450703 PMCID: PMC10787813 DOI: 10.1097/sla.0000000000005994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Develop an ordinal Desirability of Outcome Ranking (DOOR) for surgical outcomes to examine complex associations of Social Determinants of Health. BACKGROUND Studies focused on single or binary composite outcomes may not detect health disparities. METHODS Three health care system cohort study using NSQIP (2013-2019) linked with EHR and risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status and operative stress assessing associations of multilevel Social Determinants of Health of race/ethnicity, insurance type (Private 13,957; Medicare 15,198; Medicaid 2835; Uninsured 2963) and Area Deprivation Index (ADI) on DOOR and the binary Textbook Outcomes (TO). RESULTS Patients living in highly deprived neighborhoods (ADI>85) had higher odds of PASC [adjusted odds ratio (aOR)=1.13, CI=1.02-1.25, P <0.001] and urgent/emergent cases (aOR=1.23, CI=1.16-1.31, P <0.001). Increased odds of higher/less desirable DOOR scores were associated with patients identifying as Black versus White and on Medicare, Medicaid or Uninsured versus Private insurance. Patients with ADI>85 had lower odds of TO (aOR=0.91, CI=0.85-0.97, P =0.006) until adjusting for insurance. In contrast, patients with ADI>85 had increased odds of higher DOOR (aOR=1.07, CI=1.01-1.14, P <0.021) after adjusting for insurance but similar odds after adjusting for PASC and urgent/emergent cases. CONCLUSIONS DOOR revealed complex interactions between race/ethnicity, insurance type and neighborhood deprivation. ADI>85 was associated with higher odds of worse DOOR outcomes while TO failed to capture the effect of ADI. Our results suggest that presentation acuity is a critical determinant of worse outcomes in patients in highly deprived neighborhoods and without insurance. Including risk adjustment for living in deprived neighborhoods and urgent/emergent surgeries could improve the accuracy of quality metrics.
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Affiliation(s)
- Michael A. Jacobs
- Department of Surgery, University of Texas Health San
Antonio, San Antonio, Texas
| | - Susanne Schmidt
- Department of Population Health Sciences, University of
Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and
Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh
Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh,
Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel
Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The
University of Texas Health Science Center at Houston, Houston, Texas
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University
of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of
Texas Health San Antonio, San Antonio, Texas
| | - Laura S. Manuel
- UT Health Physicians Business Intelligence and Data
Analytics, University of Texas Health San Antonio, San Antonio, Texas
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of
Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Paula K. Shireman
- Department of Surgery, University of Texas Health San
Antonio, San Antonio, Texas
- Departments of Primary Care & Rural Medicine and
Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
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Lingard MCH, Willis J, Frampton CMA, Hooper GJ. Survey of New Zealand Arthroplasty Surgeons on Surgeon-Level Outcome Reporting. J Arthroplasty 2023; 38:2254-2258. [PMID: 37279844 DOI: 10.1016/j.arth.2023.05.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/20/2023] [Accepted: 05/24/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Surgeon-specific outcome monitoring has become increasingly prevalent over the last 3 decades. The New Zealand Orthopaedic Association monitors individual surgeon performance through 2 mechanisms: arthroplasty revision rates derived from the New Zealand Joint Registry and a practice visit program. Despite remaining confidential, surgeon-level outcome reporting remains contentious. The purpose of this survey was to evaluate the opinions of hip and knee arthroplasty surgeons in New Zealand on the perceived importance of outcome monitoring, current methods used to evaluate surgeon-specific outcomes, and potential improvements identified through literature review and discussion with other registries. METHODS The survey consisted of 9 questions on surgeon-specific outcome reporting, using a five-point Likert scale, and 5 demographic questions. It was distributed to all current hip and knee arthroplasty surgeons. There were 151 hip and knee arthroplasty surgeons who completed the survey, a response rate of 50%. RESULTS Respondents agreed that monitoring arthroplasty outcomes is important and that revision rates are an acceptable measure of performance. Reporting risk-adjusted revision rates and more recent timeframes were supported, as was including patient-reported outcomes when monitoring performance. Surgeons did not support public reporting of surgeon-level or hospital-level outcomes. CONCLUSION The findings of this survey support the use of revision rates to confidentially monitor surgeon-level arthroplasty outcomes and suggest that concurrent use of patient-reported outcome measures would be acceptable.
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Affiliation(s)
- Morgan C H Lingard
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | - Jinny Willis
- New Zealand Joint Registry, Christchurch, New Zealand
| | | | - Gary J Hooper
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, Christchurch, New Zealand
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Shwartz M, Rosen AK, Beilstein-Wedel E, Davila H, Harris AH, Gurewich D. Using the Kitagawa Decomposition to Measure Overall-and Individual Facility Contributions to-Within-facility and Between-facility Differences: Analyzing Racial and Ethnic Wait Time Disparities in the Veterans Health Administration. Med Care 2023; 61:392-399. [PMID: 37068035 PMCID: PMC10175195 DOI: 10.1097/mlr.0000000000001849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
BACKGROUND Identifying whether differences in health care disparities are due to within-facility or between-facility differences is key to disparity reductions. The Kitagawa decomposition divides the difference between 2 means into within-facility differences and between-facility differences that are measured on the same scale as the original disparity. It also enables the identification of facilities that contribute most to within-facility differences (based on facility-level disparities and the proportion of patient population served) and between-facility differences. OBJECTIVES Illustrate the value of a 2-stage Kitagawa decomposition to partition a disparity into within-facility and between-facility differences and to measure the contribution of individual facilities to each type of difference. SUBJECTS Veterans receiving a new outpatient consult for cardiology or orthopedic services during fiscal years 2019-2021. MEASURES Wait time for a new-patient consult. METHODS In stage 1, we predicted wait time for each Veteran from a multivariable model; in stage 2, we aggregated individual predictions to determine mean adjusted wait times for Hispanic, Black, and White Veterans and then decomposed differences in wait times between White Veterans and each of the other groups. RESULTS Noticeably longer wait times were experienced by Hispanic Veterans for cardiology (2.32 d, 6.8% longer) and Black Veterans for orthopedics (3.49 d, 10.3% longer) in both cases due entirely to within-facility differences. The results for Hispanic Veterans using orthopedics illustrate how positive within-facility differences (0.57 d) can be offset by negative between-facility differences (-0.34 d), resulting in a smaller overall disparity (0.23 d). Selecting 10 facilities for interventions in orthopedics based on the largest contributions to within-in facility differences instead of the largest disparities resulted in a higher percentage of Veterans impacted (31% and 12% of Black and White Veterans, respectively, versus 9% and 10% of Black and White Veterans, respectively) and explained 21% of the overall within-facility difference versus 11%. CONCLUSIONS The Kitagawa approach allows the identification of disparities that might otherwise be undetected. It also allows the targeting of interventions at those facilities where improvements will have the largest impact on the overall disparity.
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Affiliation(s)
| | - Amy K Rosen
- VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
| | | | - Heather Davila
- VA Iowa City Health Care System, Iowa City, IA
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Alex Hs Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA
- Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Palo Alto, CA
| | - Deborah Gurewich
- VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
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Moazzam Z, Lima HA, Endo Y, Alaimo L, Ejaz A, Dillhoff M, Cloyd J, Pawlik TM. The implications of fragmented practice in hepatopancreatic surgery. Surgery 2023; 173:1391-1397. [PMID: 36907781 DOI: 10.1016/j.surg.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/09/2023] [Accepted: 02/06/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Familiarity with the surgical work environment has been demonstrated to improve outcomes. We sought to investigate the impact of the rate of fragmented practice on textbook outcomes, a validated composite outcome representing an "optimal" postoperative course. METHODS Patients who underwent a hepatic or pancreatic surgical procedure between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The rate of fragmented practice was defined as the surgeon's volume over the study period relative to the number of facilities practiced at. The association between the rate of fragmented practice and textbook outcomes was assessed using multivariable logistic regression. RESULTS A total of 37,599 patients were included (pancreatic: n = 23,701, 63.0%; hepatic: n = 13,898, 37.0%). After controlling for relevant characteristics, patients who underwent surgery by surgeons in higher rate of fragmented practice categories had lower odds of achieving a textbook outcome (reference: low rate of fragmented practice; intermediate rate of fragmented practice: odds ratio = 0.88 [95% confidence interval 0.84-0.93]; high rate of fragmented practice: odds ratio = 0.58 [95% confidence interval 0.54-0.61]) (both P < .001). Of note, the adverse effect of a high rate of fragmented practice on the achievement of textbook outcomes remained substantial, regardless of the county-level social vulnerability index [high rate of fragmented practice; low social vulnerability index: odds ratio = 0.58 (95% confidence interval 0.52-0.66); intermediate social vulnerability index: odds ratio = 0.56 (95% confidence interval 0.52-0.61); high social vulnerability index: odds ratio = 0.60 (95% confidence interval 0.54-0.68)] (all P < .001). Patients in intermediate and high social vulnerability index counties had 19% and 37% greater odds of undergoing surgery by a high rate of fragmented practice surgeon (reference: low social vulnerability index; intermediate social vulnerability index: odds ratio = 1.19 [95% confidence interval 1.12-1.26]; high social vulnerability index: odds ratio = 1.37 [95% confidence interval 1.28-1.46]). CONCLUSION Owing to the impact of the rate of fragmented practice on postoperative outcomes, decreasing fragmentation of care may be an important target for quality initiatives and a means to alleviate social disparities in surgical care.
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Affiliation(s)
- Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/ZoraysM
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/HLimaSurg
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/YutakaEndoSurg
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/LauraAlaimo5
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/AEjaz85
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/mary_dillhoff
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/jcloydmd
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Moazzam Z, Lima HA, Alaimo L, Endo Y, Ejaz A, Beane J, Dillhoff M, Cloyd J, Pawlik TM. Hepatopancreatic Surgeons Versus Pancreatic Surgeons: Does Surgical Subspecialization Impact Patient Care and Outcomes? J Gastrointest Surg 2023; 27:750-759. [PMID: 36857013 DOI: 10.1007/s11605-023-05639-3] [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: 01/10/2023] [Accepted: 02/18/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Hepatopancreatic (HP) surgeon and hospital procedural volume may vary relative to liver or pancreas cases. We sought to investigate the impact of surgeon and hospital pancreatic subspecialization on patient outcomes. METHODS Patients who underwent pancreatic surgery between 2013-2017 were identified from the Medicare Standard Analytic Files. The surgery subspecialization index (SSI) was calculated to signify surgeon and hospital pancreatic subspecialization, and categorized as low, intermediate, and high SSI. The association of SSI with Textbook Outcome (TO) and its components, failure to rescue (FTR), discharge to home and index admission expenditures was assessed with mixed-effects multivariable logistic regression. RESULTS Among 19,625 patients, most pancreatic procedures were characterized by high SSI (Low SSI: 27.7%, Intermediate SSI: 34.7%, High SSI: 37.7%). Notably, higher SSI was associated with greater odds of achieving a TO [Intermediate SSI: OR 1.16 (95%CI 1.06-1.27); High SSI: OR 1.23 (95%CI 1.11-1.35)] as well as being discharged home, and lower odds of experiencing FTR. Furthermore, this association persisted in both low-volume [referent: Low SSI; Intermediate SSI: OR 1.14 (95%CI 1.01-1.28); High SSI: OR 1.15 (95%CI 1.02-1.31)] and high-volume hospitals [referent: Low SSI; Intermediate SSI: OR 1.16 (95%CI 1.01-1.32); High SSI: OR 1.26 (95%CI 1.09-1.45)]. CONCLUSIONS Greater pancreatic subspecialization was associated with improved postoperative outcomes following pancreatic resection. Amidst increasing efforts to improve quality of care, surgical subspecialization may play a role in determining patient outcomes regardless of total surgeon or hospital volume.
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Affiliation(s)
- Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Henrique Araujo Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Joal Beane
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Jacobs MA, Kim J, Tetley JC, Schmidt S, Brimhall BB, Mika V, Wang CP, Manuel LS, Damien P, Shireman PK. Cost of Failure to Achieve Textbook Outcomes: Association of Insurance Type with Outcomes and Cumulative Cost for Inpatient Surgery. J Am Coll Surg 2023; 236:352-364. [PMID: 36648264 DOI: 10.1097/xcs.0000000000000468] [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: 01/18/2023]
Abstract
BACKGROUND Surgical outcome/cost analyses typically focus on single outcomes and do not include encounters beyond the index hospitalization. STUDY DESIGN This cohort study used NSQIP (2013-2019) data with electronic health record and cost data risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status, and operative stress assessing cumulative costs of failure to achieve textbook outcomes defined as absence of 30-day Clavien-Dindo level III and IV complications, emergency department visits/observation stays (EDOS), and readmissions across insurance types (private, Medicare, Medicaid, uninsured). Return costs were defined as costs of all 30-day emergency department visits/observation stays and readmissions. RESULTS Cases were performed on patients (private 1,506; Medicare 1,218; Medicaid 1,420; uninsured 2,178) with a mean age 52.3 years (SD 14.7) and 47.5% male. Medicaid and uninsured patients had higher odds of presenting with preoperative acute serious conditions (adjusted odds ratios 1.89 and 1.81, respectively) and undergoing urgent/emergent surgeries (adjusted odds ratios 2.23 and 3.02, respectively) vs private. Medicaid and uninsured patients had lower odds of textbook outcomes (adjusted odds ratios 0.53 and 0.78, respectively) and higher odds of emergency department visits/observation stays and readmissions vs private. Not achieving textbook outcomes was associated with a greater than 95.1% increase in cumulative costs. Medicaid patients had a relative increase of 23.1% in cumulative costs vs private, which was 18.2% after adjusting for urgent/emergent cases. Return costs were 37.5% and 65.8% higher for Medicaid and uninsured patients, respectively, vs private. CONCUSIONS Higher costs for Medicaid patients were partially driven by increased presentation acuity (increased rates/odds of preoperative acute serious conditions and urgent/emergent surgeries) and higher rates of multiple emergency department visits/observation stays and readmission occurrences. Decreasing surgical costs/improving outcomes should focus on reducing urgent/emergent surgeries and improving postoperative care coordination, especially for Medicaid and uninsured populations.
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Affiliation(s)
- Michael A Jacobs
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
| | - Jeongsoo Kim
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
| | - Jasmine C Tetley
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
| | - Susanne Schmidt
- Department of Population Health Sciences (Schmidt, Wang), University of Texas Health San Antonio, San Antonio, TX
| | - Bradley B Brimhall
- Department of Pathology and Laboratory Medicine (Brimhall), University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX (Brimhall, Mika, Shireman)
| | - Virginia Mika
- University Health, San Antonio, TX (Brimhall, Mika, Shireman)
| | - Chen-Pin Wang
- Department of Population Health Sciences (Schmidt, Wang), University of Texas Health San Antonio, San Antonio, TX
| | - Laura S Manuel
- Business Intelligence and Data Analytics, University of Texas Health Physicians (Manuel), University of Texas Health San Antonio, San Antonio, TX
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, TX (Damien)
| | - Paula K Shireman
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX (Brimhall, Mika, Shireman)
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX (Shireman)
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Impact of shock aetiology and hospital characteristics on the clinical profile, management and prognosis of patients with non ACS-related cardiogenic shock. Hellenic J Cardiol 2023; 69:16-23. [PMID: 36334704 DOI: 10.1016/j.hjc.2022.11.001] [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: 07/02/2022] [Revised: 09/08/2022] [Accepted: 11/01/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND A significant proportion of cases of cardiogenic shock (CS) are due aetiologies other than acute coronary syndromes (non ACS-CS). We assessed differences regarding clinical profile, management, and prognosis according to the cause of CS among nonselected patients with CS from a large nationwide database. METHODS We performed an observational study including patients admitted from the hospitals of the Spanish National Health System (SNHS) with a principal or secondary diagnosis code of CS (2016-2019). Data were obtained from the Minimum Basic Data Set (MBDS). Hospitals were classified according to the availability of cardiology related resources, as well as the availability of Intensive Cardiac Care Unit (ICCU). RESULTS A total of 10,826 episodes of CS were included, of whom 5,495 (50.8%) were non-ACS related. Non ACS-CS patients were younger (71.5 vs. 72.4 years) and had a lower burden of arteriosclerosis-related comorbidities. Non ACS-CS cases underwent less often invasive procedures and presented lower in-hospital mortality (57.1% vs. 61%,p < 0.001). The most common main diagnosis among non ACS-CS was acute decompensation of chronic heart failure (ADCHF) (35.4%). A lower risk-adjusted in-hospital mortality rate was observed in high volume hospitals (52.6% vs. 56.7%; p < 0.001), as well as in centers with ICCU (OR: 0.71; CI 95%: 0.58-0.87; p < 0.001). CONCLUSIONS More than a half of cases of CS were due to non-ACS causes. Non ACS-CS cases are a very heterogeneous group, with different clinical profile and management. Management at high-volume hospitals and availability of ICCU were associated with lower risk adjusted mortality among non ACS-CS patients.
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Fernández-Ortiz A, Bas Villalobos MC, García-Márquez M, Bernal Sobrino JL, Fernández-Pérez C, del Prado González N, Viana Tejedor A, Núñez-Gil I, Macaya Miguel C, Elola Somoza FJ. Identificación y cuantificación del efecto fin de semana y festivos en la atención del síndrome coronario agudo en el Sistema Nacional de Salud. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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10
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Fernández-Ortiz A, Bas Villalobos MC, García-Márquez M, Bernal Sobrino JL, Fernández-Pérez C, Del Prado González N, Viana Tejedor A, Núñez-Gil I, Macaya Miguel C, Elola Somoza FJ. The effect of weekends and public holidays on the care of acute coronary syndrome in the Spanish National Health System. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:756-762. [PMID: 35067469 DOI: 10.1016/j.rec.2021.10.022] [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: 08/04/2021] [Accepted: 10/25/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION AND OBJECTIVES To analyze whether admission on weekends or public holidays (WHA) influences the management (performance of angioplasty, percutaneous coronary intervention [PCI]) and outcomes (in-hospital mortality) of patients hospitalized for acute coronary syndrome in the Spanish National Health System compared with admission on weekdays. METHODS Retrospective observational study of patients admitted for ST-segment elevation myocardial infarction (STEMI) or for non-ST-segment elevation acute coronary syndrome (NSTEACS) in hospitals of the Spanish National Health system from 2003 to 2018. RESULTS A total of 438 987 episodes of STEMI and 486 565 of NSTEACS were selected, of which 28.8% and 26.1% were WHA, respectively. Risk-adjusted models showed that WHA was a risk factor for in-hospital mortality in STEMI (OR, 1.05; 95%CI,1.03-1.08; P < .001) and in NSTEACS (OR, 1.08; 95%CI, 1.05-1.12; P < .001). The rate of PCI performance in STEMI was more than 2 percentage points higher in patients admitted on weekdays from 2003 to 2011 and was similar or even lower from 2012 to 2018, with no significant changes in NSTEACS. WHA was a statistically significant risk factor for both STEMI and NSTEACS. CONCLUSIONS WHA can increase the risk of in-hospital death by 5% (STEMI) and 8% (NSTEACS). The persistence of the risk of higher in-hospital mortality, after adjustment for the performance of PCI and other explanatory variables, probably indicates deficiencies in management during the weekend compared with weekdays.
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Affiliation(s)
- Antonio Fernández-Ortiz
- Instituto Cardiovascular, Hospital Clínico Universitario San Carlos, Madrid, Spain; Fundación Interhospitalaria de Investigación Cardiovascular, Madrid, Spain
| | - Marian Cristina Bas Villalobos
- Instituto Cardiovascular, Hospital Clínico Universitario San Carlos, Madrid, Spain; Fundación Interhospitalaria de Investigación Cardiovascular, Madrid, Spain
| | | | - José Luis Bernal Sobrino
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Control de Gestión, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Cristina Fernández-Pérez
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Medicina Preventiva y Salud Pública, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | | | - Ana Viana Tejedor
- Instituto Cardiovascular, Hospital Clínico Universitario San Carlos, Madrid, Spain; Fundación Interhospitalaria de Investigación Cardiovascular, Madrid, Spain
| | - Iván Núñez-Gil
- Instituto Cardiovascular, Hospital Clínico Universitario San Carlos, Madrid, Spain; Fundación Interhospitalaria de Investigación Cardiovascular, Madrid, Spain
| | - Carlos Macaya Miguel
- Instituto Cardiovascular, Hospital Clínico Universitario San Carlos, Madrid, Spain; Fundación Interhospitalaria de Investigación Cardiovascular, Madrid, Spain
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Kuhn J, van den Berg P, Mamede S, Zwaan L, Bindels P, van Gog T. Improving medical residents' self-assessment of their diagnostic accuracy: does feedback help? ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2022; 27:189-200. [PMID: 34739632 PMCID: PMC8938348 DOI: 10.1007/s10459-021-10080-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 10/10/2021] [Indexed: 06/13/2023]
Abstract
When physicians do not estimate their diagnostic accuracy correctly, i.e. show inaccurate diagnostic calibration, diagnostic errors or overtesting can occur. A previous study showed that physicians' diagnostic calibration for easy cases improved, after they received feedback on their previous diagnoses. We investigated whether diagnostic calibration would also improve from this feedback when cases were more difficult. Sixty-nine general-practice residents were randomly assigned to one of two conditions. In the feedback condition, they diagnosed a case, rated their confidence in their diagnosis, their invested mental effort, and case complexity, and then were shown the correct diagnosis (feedback). This was repeated for 12 cases. Participants in the control condition did the same without receiving feedback. We analysed calibration in terms of (1) absolute accuracy (absolute difference between diagnostic accuracy and confidence), and (2) bias (confidence minus diagnostic calibration). There was no difference between the conditions in the measurements of calibration (absolute accuracy, p = .204; bias, p = .176). Post-hoc analyses showed that on correctly diagnosed cases (on which participants are either accurate or underconfident), calibration in the feedback condition was less accurate than in the control condition, p = .013. This study shows that feedback on diagnostic performance did not improve physicians' calibration for more difficult cases. One explanation could be that participants were confronted with their mistakes and thereafter lowered their confidence ratings even if cases were diagnosed correctly. This shows how difficult it is to improve diagnostic calibration, which is important to prevent diagnostic errors or maltreatment.
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Affiliation(s)
- Josepha Kuhn
- Department of General Practice, Erasmus Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Institute of Medical Education Research Rotterdam, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | - Pieter van den Berg
- Department of General Practice, Erasmus Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Silvia Mamede
- Institute of Medical Education Research Rotterdam, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Patrick Bindels
- Department of General Practice, Erasmus Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Tamara van Gog
- Department of Education, Utrecht University, Utrecht, The Netherlands
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12
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Méndez-Bailón M, Sobrino JLB, Marco-Martínez J, Elola-Somoza J, Márquez MG, Fernández-Pérez C, Azana-Gómez J, García-Klepzig JL, Andrès E, Zapatero-Gaviria A, Barba-Martin R, Canora-Lebrato J, Lorenzo-Villalba N. Heart failure and in-hospital mortality in elderly patients after elective noncardiac surgery in Spain. Med Clin (Barc) 2022; 159:307-312. [DOI: 10.1016/j.medcli.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022]
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13
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Spolverato G, Paro A, Capelli G, Dalmacy D, Poultsides GA, Fields RC, Weber SM, Votanopoulos KI, He J, Maithel SK, Pucciarelli S, Pawlik TM. Surgical treatment of gastric adenocarcinoma: Are we achieving textbook oncologic outcomes for our patients? J Surg Oncol 2021; 125:621-630. [PMID: 34964983 DOI: 10.1002/jso.26778] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/28/2021] [Accepted: 11/30/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Composite measures are increasingly used to assess quality of care in surgical oncology. We sought to define the incidence of "textbook oncologic outcome" (TOO) following resection of gastric adenocarcinoma among a large, international cohort of patients. METHODS Gastric adenocarcinoma patients undergoing resection between 2000 and 2020 were identified from an international database. TOO was defined as margin-negative resection, examination of ≥16 lymph nodes, no prolonged length-of-stay (LOS), no 30-day mortality, and stage-appropriate receipt of chemotherapy. RESULTS Among a total of 910 patients, 321 patients (35.3%) achieved a postoperative TOO. While failure to evaluate ≥16 lymph nodes (n = 591, 65.0%) and receipt of chemotherapy (n = 651, 71.5%) had the greatest negative impact on the ability to obtain a TOO, no 30-day mortality (n = 880, 96.7%), margin-negative resection (n = 831, 91.3%), and no extended LOS (n = 706, 77.6%) were more commonly achieved. No postoperative complications (OR: 0.44; 95% CI: 0.31-0.63) and T1a/T1b-stage disease (OR: 2.87; 95% CI: 1.59-5.18) were independently associated with achieving a TOO (p < 0.05). The odds of achieving a TOO improved over time (p-trend < 0.05), which was largely attributable to improved odds of evaluating ≥16 lymph nodes (2010-2014 vs. 2000-2004: OR, 5.21; 95% CI: 3.22-8.45). CONCLUSIONS Only about one in three patients achieved a TOO following resection of gastric adenocarcinoma. Odds of TOO increased over time, largely due to improved lymph node evaluation.
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Affiliation(s)
- Gaya Spolverato
- Department of Surgical Oncological and Gastrointestinal Science, University of Padova, Padova, Italy
| | - Alessandro Paro
- Department of Surgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Giulia Capelli
- Department of Surgical Oncological and Gastrointestinal Science, University of Padova, Padova, Italy
| | - Djhenne Dalmacy
- Department of Surgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | | | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Sharon M Weber
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Salvatore Pucciarelli
- Department of Surgical Oncological and Gastrointestinal Science, University of Padova, Padova, Italy
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
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Lissenden B, Lewis RS, Giombi KC, Spain PC. Detecting bad actors in value-based payment models. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2021; 22:59-78. [PMID: 34220292 PMCID: PMC8237252 DOI: 10.1007/s10742-021-00253-9] [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: 10/12/2020] [Revised: 04/30/2021] [Accepted: 05/25/2021] [Indexed: 12/05/2022]
Abstract
The U.S. federal government is spending billions of dollars to test a multitude of new approaches to pay for healthcare. Unintended consequences are a major consideration in the testing of these value-based payment (VBP) models. Since participation is generally voluntary, any unintended consequences may be magnified as VBP models move beyond the early testing phase. In this paper, we propose a straightforward unsupervised outlier detection approach based on ranked percentage changes to identify participants (e.g., healthcare providers) whose behavior may represent an unintended consequence of a VBP model. The only data requirements are repeated measurements of at least one relevant variable over time. The approach is generalizable to all types of VBP models and participants and can be used to address undesired behavior early in the model and ultimately help avoid undesired behavior in scaled-up programs. We describe our approach, demonstrate how it can be applied with hypothetical data, and simulate how efficiently it detects participants who are truly bad actors. In our hypothetical case study, the approach correctly identifies a bad actor in the first period in 86% of simulations and by the second period in 96% of simulations. The trade-off is that 9% of honest participants are mistakenly identified as bad actors by the second period. We suggest several ways for researchers to mitigate the rate or consequences of these false positives. Researchers and policymakers can customize and use our approach to appropriately guard VBP models against undesired behavior, even if only by one participant.
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Affiliation(s)
- Brett Lissenden
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709 USA
| | - Rebecca S Lewis
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709 USA
| | - Kristen C Giombi
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709 USA
| | - Pamela C Spain
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709 USA
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Rodríguez-Padial L, Fernández-Pérez C, Bernal JL, Anguita M, Sambola A, Fernández-Ortiz A, Elola FJ. Diferencias en mortalidad intrahospitalaria tras IAMCEST frente a IAMSEST por sexo. Tendencia durante once años en el Sistema Nacional de Salud. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.04.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Heart Failure Is a Poor Prognosis Risk Factor in Patients Undergoing Cholecystectomy: Results from a Spanish Data-Based Analysis. J Clin Med 2021; 10:jcm10081731. [PMID: 33923710 PMCID: PMC8072897 DOI: 10.3390/jcm10081731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background: The incidence of cholecystectomy is increasing as the result of the aging worldwide. Our aim was to determine the influence of heart failure on in-hospital outcomes in patients undergoing cholecystectomy in the Spanish National Health System (SNHS). Methods: We conducted a retrospective study using the Spanish National Hospital Discharge Database. Patients older than 17 years undergoing cholecystectomy in the period 2007–2015 were included. Demographic and administrative variables related to patients’ diseases as well as procedures were collected. Results: 478,111 episodes of cholecystectomy were identified according to the data from SNHS hospitals in the period evaluated. From all the episodes, 3357 (0.7%) were excluded, as the result the sample was represented by 474,754 episodes. Mean age was 58.3 (+16.5) years, and 287,734 (60.5%) were women (p < 0.001). A primary or secondary diagnosis of HF was identified in 4244 (0.89%) (p < 0.001) and mean age was 76.5 (+9.6) years. A higher incidence of all main complications studied was observed in the HF group (p < 0.001), except stroke (p = 0.753). Unadjusted in-hospital mortality was 1.1%, 12.9% in the group with HF versus 1% in the non HF group (p < 0.001). Average length of hospital stay was 5.4 (+8.9) days, and was higher in patients with HF (16.2 + 17.7 vs. 5.3 + 8.8; p < 0.001). Risk-adjusted in-hospital mortality models’ discrimination was high in both cases, with AUROC values = 0.963 (0.960–0.965) in the APRG-DRG model and AUROC = 0.965 (0.962–0.968) in the CMS adapted model. Median odds ratio (MOR) was high (1.538 and 1.533, respectively), stating an important variability of risk-adjusted outcomes among hospitals. Conclusions: The presence of HF during admission increases in hospital mortality and lengthens the hospital stay in patients undergoing cholecystectomy. However, mortality and hospital stay have significantly decreased during the study period in both groups (HF and non HF patients).
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17
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Ruiz-Ortiz M, Anguita-Sánchez M, Bonilla-Palomas JL, Fernández-Pérez C, Bernal-Sobrino JL, Cequier-Fillat A, Bueno-Zamora H, Marín F, Elola-Somoza FJ. Incidence and outcomes of hospital treated acute myocarditis from 2003 to 2015 in Spain. Eur J Clin Invest 2021; 51:e13444. [PMID: 33152138 DOI: 10.1111/eci.13444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/16/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are no data on population-based epidemiological changes in acute myocarditis in Europe. Our aim was to evaluate temporal trends in incidence, clinical features and outcomes of hospital treated acute myocarditis (AM) in Spain from 2003 to 2015. METHODS We conducted a retrospective longitudinal study using information of all hospital discharges of the Spanish National Health System. All episodes with a discharge diagnosis of AM from 1 January 2003 to 31 December 2015 were included. The risk-standardized in-hospital mortality ratio (RSMR) was calculated using a multilevel risk-adjustment model developed by the Medicare and Medicaid Services. Temporal trends for in-hospital mortality were modelled using Poisson regression analysis. RESULTS A total of 11 147 episodes of AM were analysed, most of them idiopathic (94.7%). The rate of AM discharges increased along the period, from 13 to 30/million inhabitants/year (2003-2015), and this increase was statistically significant when weighted by age and sex (incidence rate ratio, IRR 1.06, 95% CI 1.04-1.08, P = .001). In-hospital crude mortality rate was 3.1%, diminishing significantly along 2003-2015 (IRR 0.95, 95% CI 0.92-0.99, P = .02). RSMR also significantly diminished along the period (IRR 0.95, 95% CI 0.92-0.99, P = .01). Renal failure (OR 7.03, 5.38-9.18, P = .001), liver disease (OR 4.61, 2.59-8.21, P = .001), pneumonia (OR 4.13, 2.75-6.20, P = .001) and heart failure (OR 1.91, 95% CI 1.47-2.47, P = .001) were the strongest independent factors associated with in-hospital mortality. CONCLUSIONS Acute myocarditis is an uncommon entity, although hospital discharges have increased in Spain along the study period. Most of AM were idiopathic. Adjusted mortality was low and seemed to decrease from 2003 to 2015, suggesting an improvement in AM management.
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Affiliation(s)
- Martín Ruiz-Ortiz
- Cardiology Department, Reina Sofía University Hospital, Córdoba, Spain
| | - Manuel Anguita-Sánchez
- Cardiology Department, Reina Sofía University Hospital, Córdoba, Spain.,Cardiology Department, Hospital Quirón Salud, Córdoba, Spain
| | | | - Cristina Fernández-Pérez
- Preventive Medicine Department, Hospital Clínico San Carlos, Madrid, Spain.,Foundation Institute for Healthcare Improvement, Madrid, Spain.,Institute for Health Research, Hospital Clínico San Carlos, Madrid, Spain
| | - José Luis Bernal-Sobrino
- Foundation Institute for Healthcare Improvement, Madrid, Spain.,Servicio de Control de Gestión, University Hospital 12 de Octubre, Madrid, Spain
| | | | | | - Francisco Marín
- Cardiology Deparment, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBERCV, Murcia, Spain
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Impact of Heart Failure on In-Hospital Outcomes after Surgical Femoral Neck Fracture Treatment. J Clin Med 2021; 10:jcm10050969. [PMID: 33801169 PMCID: PMC7957564 DOI: 10.3390/jcm10050969] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/20/2021] [Accepted: 02/22/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Femoral neck fracture (FNF) is a common condition with a rising incidence, partly due to aging of the population. It is recommended that FNF should be treated at the earliest opportunity, during daytime hours, including weekends. However, early surgery shortens the available time for preoperative medical examination. Cardiac evaluation is critical for good surgical outcomes as most of these patients are older and frail with other comorbid conditions, such as heart failure. The aim of this study was to determine the impact of heart failure on in-hospital outcomes after surgical femoral neck fracture treatment. METHODS We performed a retrospective study using the Spanish National Hospital Discharge Database, 2007-2015. We included patients older than 64 years treated for reduction and internal fixation of FNF. Demographic characteristics of patients, as well as administrative variables, related to patient's diseases and procedures performed during the episode were evaluated. RESULTS A total of 234,159 episodes with FNF reduction and internal fixation were identified from Spanish National Health System hospitals during the study period; 986 (0.42%) episodes were excluded, resulting in a final study population of 233,173 episodes. Mean age was 83.7 (±7) years and 179,949 (77.2%) were women (p < 0.001). In the sample, 13,417 (5.8%) episodes had a main or secondary diagnosis of heart failure (HF) (p < 0.001). HF patients had a mean age of 86.1 (±6.3) years, significantly older than the rest (p < 0.001). All the major complications studied showed a higher incidence in patients with HF (p < 0.001). Unadjusted in-hospital mortality was 4.1%, which was significantly higher in patients with HF (18.2%) compared to those without HF (3.3%) (p < 0.001). The average length of stay (LOS) was 11.9 (±9.1) and was also significantly higher in the group with HF (16.5 ± 13.1 vs. 11.6 ± 8.7; p < 0.001). CONCLUSIONS Patients with HF undergoing FNF surgery have longer length of stay and higher rates of both major complications and mortality than those without HF. Although their average length of stay has decreased in the last few years, their mortality rate has remained unchanged.
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Sanmartín-Fernández M, Raposeiras-Roubin S, Anguita-Sánchez M, Marín F, Garcia-Marquez M, Fernández-Pérez C, Bernal-Sobrino JL, Elola-Somoza FJ, Bueno H, Cequier Á. In-hospital outcomes of mechanical complications in acute myocardial infarction: Analysis from a nationwide Spanish database. Cardiol J 2020; 28:589-597. [PMID: 33346367 DOI: 10.5603/cj.a2020.0181] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Mechanical complications represent an important cause of mortality in myocardial infarction (MI) patients. This is a nationwide study performed to evaluate possible changes in epidemiology or prognosis of these complications with current available strategies. METHODS Information was obtained from the minimum basis data set of the Spanish National Health System, including all hospitalizations for acute myocardial infarction (AMI) from 2010 to 2015. Risk-standardized in-hospital mortality ratio was calculated using multilevel risk adjustment models. RESULTS A total of 241,760 AMI episodes were analyzed, MI mechanical complications were observed in 842 patients: cardiac tamponade in 587, ventricular septal rupture in 126, and mitral regurgitation due to papillary muscle or chordae tendineae rupture in 155 (there was more than one complication in 21 patients). In-hospital mortality was 59.5%. On multivariate adjustment, variables with significant impact on in-hospital mortality were: age (OR 1.06; 95% CI 1.04-1.07; p < 0.001), ST-segment elevation AMI (OR 2.91; 95% CI 1.88-4.5; p < 0.001), cardiogenic shock (OR 2.35; 95% CI 1.66-3.32; p < 0.001), cardio-respiratory failure (OR 3.48; 95% CI 2.37-5.09; p < 0.001), and chronic obstructive pulmonary disease (OR 1.85; 95% CI 1.07-3.20; p < 0.001). No significant trends in risk-adjusted in-hospital mortality were detected (IRR 0.997; p = 0.109). Cardiac intensive care unit availability and more experience with mechanical complications management were associated with lower adjusted mortality rates (56.7 ± 5.8 vs. 60.1 ± 4.5; and 57 ± 6.1 vs. 59.9 ± 5.6, respectively; p < 0.001). CONCLUSIONS Mechanical complications occur in 3.5 per thousand AMI, with no significant trends to better survival over the past few years. Advanced age, cardiogenic shock and cardio-respiratory failure are the most important risk factors for in-hospital mortality. Higher experience and specialized cardiac intensive care units are associated with better outcomes.
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Affiliation(s)
| | | | | | - Francisco Marín
- Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, IMIB-Arrixaca, CIBERCV, Murcia, Spain
| | | | - Cristina Fernández-Pérez
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain.,Servicio de Medicina Preventiva, Complejo Hospitalario Universitario De Santiago de Compostela, Spain
| | - Jose-Luis Bernal-Sobrino
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain.,Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Héctor Bueno
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ángel Cequier
- Hospital Universitario de Bellvitge, Universidad de Barcelona, IDIBELL, Hospitalet de Ll, Spain
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Li E, Nash D. Public Accountability and the Technologic Imperative: The Interplay Between Public Reporting and Cardiac Surgery Outcomes in the United States. Jt Comm J Qual Patient Saf 2020; 47:201-203. [PMID: 33303382 DOI: 10.1016/j.jcjq.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 11/19/2022]
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Diabetes mellitus, revascularization and outcomes in elderly patients with myocardial infarction-related cardiogenic shock. J Geriatr Cardiol 2020; 17:604-611. [PMID: 33224179 PMCID: PMC7657943 DOI: 10.11909/j.issn.1671-5411.2020.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background The prognostic role of diabetes mellitus (DM) in elderly patients with myocardial infarction-related cardiogenic shock (MI-CS) remains controversial. Little information exists about the impact of intensive cardiac care unit (ICCU) and revascularization on outcomes of elderly patients with MI-CS. We aimed to assess the prognostic impact of DM according to age in patients with MI-CS, and to analyze the impact ICCU management and revascularization on in-hospital mortality in MI-CS patients at older ages. Methods Discharge episodes with diagnosis of CS associated with MI were selected from the Spanish National Health System's Basic Data Set. Centers were classified according to their availability of ICCU. Main outcome measured was in-hospital mortality. Results A total of 23, 590 episodes of MI-CS were identified, of whom 12, 447 (52.8%) were in patients aged ≥ 75 years. The impact of DM on in-hospital mortality was different among age subgroups. While in younger patients, DM was associated to a higher mortality risk (0.52 vs. 0.47, OR = 1.12, 95% CI: 1.06-1.18, χ2 < 0.001), this association became non-significant in older patients (0.76 vs. 0.81, χ2 = 0.09). Adjusted mortality rate of MI-CS aged ≥ 75 years was lower in patients admitted to hospitals with ICCU (adjusted mortality rate: 74.2% vs. 77.7%, P < 0.001) and in patients undergoing revascularization (74.9% vs. 77.3%, P < 0.001). Conclusions Prognostic impact of DM in patients with MI-CS was different according to age, with a significantly lower impact at older ages. The availability of ICCU and revascularization were associated with better outcomes in these complex patients.
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Commentary: Safety in numbers. J Thorac Cardiovasc Surg 2020; 161:1043-1045. [PMID: 32863033 DOI: 10.1016/j.jtcvs.2020.07.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 07/17/2020] [Accepted: 07/17/2020] [Indexed: 11/20/2022]
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Sánchez-Salado JC, Burgos V, Ariza-Solé A, Sionis A, Canteli A, Bernal JL, Fernández C, Castrillo C, Ruiz-Lera M, López-de-Sá E, Lidón RM, Worner F, Martínez-Sellés M, Segovia J, Viana-Tejedor A, Lorente V, Alegre O, Llaó I, González-Costello J, Manito N, Cequier Á, Bueno H, Elola J. Tendencias en el tratamiento del shock cardiogénico e impacto pronóstico del tipo de centros tratantes. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.10.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVE To define and test "Textbook Outcome" (TO)-a composite measure for healthcare quality-among Medicare patients undergoing hepatopancreatic resections. Hospital variation in TO and Medicare payments were analyzed. BACKGROUND Composite measures of quality may be superior to individual measures for the analysis of hospital performance. METHODS The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. TO was defined as: no postoperative surgical complications, no prolonged length of hospital stay, no readmission ≤ 90 days after discharge, and no postoperative mortality ≤ 90 days after surgery. Medicare payments were compared among patients who achieved TO versus patients who did not. Multivariable logistic regression was used to investigate patient factors associated with TO. A nomogram to predict probability of TO was developed and validated. RESULTS TO was achieved in 44% (n = 5919) of 13,467 patients undergoing hepatopancreatic surgery. Adjusted TO rates at the hospital level varied from 11.1% to 69.6% for pancreatic procedures and from 16.6% to 78.7% for liver procedures. Prolonged length of hospital stay represented the major obstacle to achieve TO. Average Medicare payments were substantially higher among patients who did not have a TO. Factors associated with TO on multivariable analysis were age, sex, Charlson comorbidity score, previous hospital admissions, procedure type, and surgical approach (all P > 0.05). CONCLUSIONS Less than one-half of Medicare patients achieved a TO following hepatopancreatic procedures with a wide variation in the rates of TO among hospitals. There was a discrepancy in Medicare payments for patients who achieved a TO versus patients who did not. TO could be useful for the public reporting of patient level hospital performance and hospital variation.
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Rodríguez-Padial L, Fernández-Pérez C, Bernal JL, Anguita M, Sambola A, Fernández-Ortiz A, Elola FJ. Differences in in-hospital mortality after STEMI versus NSTEMI by sex. Eleven-year trend in the Spanish National Health Service. ACTA ACUST UNITED AC 2020; 74:510-517. [PMID: 32561143 DOI: 10.1016/j.rec.2020.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 04/23/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Conflicting results have been reported on the possible existence of sex differences in mortality after myocardial infarction (MI). There is also a scarcity of data on the impact of sex on outcomes after ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). The aim of this study was to analyze sex difference trends in sex-related differences in mortality for STEMI and NSTEMI. METHODS A retrospective analysis of 445 145 episodes of MI (2005-2015) was carried out using information from the Spanish National Health System. The incidence rates were expressed as events per 10 000 person-years. The denominators (age-specific groups) were obtained from the nationwide census. We calculated crude and adjusted (multilevel logistic regression) mortality. Poisson regression analysis was used to study temporal trends for in-hospital mortality. RESULTS A total of 69.8% episodes occurred in men. The mean age in men was 66.1±13.3 years, which was significantly younger than in women, 74.9±12.1 (P<.001). A total of 272 407 (61.2%) episodes were STEMI, and 172 738 (38.8%) were NSTEMI. Women accounted for 28.8% of STEMI and 33.9% of NSTEMI episodes (P <.001). The effect of female sex on risk-adjusted models for in-hospital mortality was the opposite in STEMI (OR for women, 1.18; 95%CI, 1.14-1.22; P <.001) and NSTEMI (OR for women, 0.85; 95%CI, 0.81-0.89; P <.001). MI hospitalization rates were higher in men than in women for all age groups [20 vs 7.7 per 10 000 individuals aged 35-94 years (P <.001)], with a trend to diminish in both sexes. CONCLUSIONS Women had a slight but significantly increased risk of in-hospital mortality after MI, but the effect of sex depended on MI type, with women exhibiting higher mortality for STEMI and lower mortality for NSTEMI.
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Affiliation(s)
| | - Cristina Fernández-Pérez
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Medicina Preventiva, Hospital Clínico Universitario San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - José L Bernal
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Control de Gestión, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Anguita
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Antonia Sambola
- Unidad de Cuidados Agudos Cardiológicos, Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Antonio Fernández-Ortiz
- Unidad de Cuidados Agudos Cardiológicos, Servicio de Cardiología, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Francisco J Elola
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
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Shahian D. Improving cardiac surgical quality: lessons from the Japanese experience. BMJ Qual Saf 2020; 29:531-535. [PMID: 32015051 DOI: 10.1136/bmjqs-2019-010125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2020] [Indexed: 12/28/2022]
Affiliation(s)
- David Shahian
- Division of Cardiac Surgery, Department of Surgery, and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ebadi A, Tighe PJ, Zhang L, Rashidi P. A quest for the structure of intra- and postoperative surgical team networks: does the small-world property evolve over time? SOCIAL NETWORK ANALYSIS AND MINING 2019. [DOI: 10.1007/s13278-019-0550-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Mortalidad hospitalaria y reingresos por insuficiencia cardiaca en España. Un estudio de los episodios índice y los reingresos por causas cardiacas a los 30 días y al año. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2019.01.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Trends in cardiogenic shock management and prognostic impact of type of treating center. ACTA ACUST UNITED AC 2019; 73:546-553. [PMID: 31780424 DOI: 10.1016/j.rec.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 10/10/2019] [Indexed: 11/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES Current guidelines recommend centralizing the care of patients with cardiogenic shock in high-volume centers. The aim of this study was to assess the association between hospital characteristics, including the availability of an intensive cardiac care unit, and outcomes in patients with ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS). METHODS Discharge episodes with a diagnosis of STEMI-related CS between 2003 and 2015 were selected from the Minimum Data Set of the Spanish National Health System. Centers were classified according to the availability of a cardiology department, catheterization laboratory, cardiac surgery department, and intensive cardiac care unit. The main outcome measured was in-hospital mortality. RESULTS A total of 19 963 episodes were identified. The mean age was 73.4±11.8 years. The proportion of patients with CS treated at hospitals with a catheterization laboratory and cardiac surgery department increased from 38.4% in 2005 to 52.9% in 2015 (P <.005). Crude- and risk-adjusted mortality rates decreased over time, from 82% to 67.1%, and from 82.7% to 66.8%, respectively (both P <.001). Coronary revascularization, either percutaneous or coronary artery bypass grafting, was independently associated with a lower mortality risk (OR, 0.29 and 0.25; both P <.001, respectively). Intensive cardiac care unit availability was associated with lower adjusted mortality rates (65.3%±7.9 vs 72±11.7; P <.001). CONCLUSIONS The proportion of patients with STEMI-related CS treated at highly specialized centers increased while mortality decreased during the study period. Better outcomes were associated with the increased performance of revascularization procedures and access to intensive cardiac care units over time.
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Reyes García R, Bernal Sobrino JL, Fernandez Pérez C, Morillas Ariño C, Azriel Mira S, Elola Somoza FJ, Breton Lesmes I, Botella Romero F. Trends on Diabetes Mellitus's healthcare management in Spain 2007-2015. Diabetes Res Clin Pract 2019; 156:107824. [PMID: 31446112 DOI: 10.1016/j.diabres.2019.107824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/01/2019] [Accepted: 08/20/2019] [Indexed: 11/16/2022]
Abstract
AIMS To analyze the trends on diabetes mellitus (DM) healthcare management in Spain. METHODS Retrospective observational study between January 1st 2007 and 31th December 2015 with DM as the principal diagnosis. The main clinical outcome measures were all-cause, in-hospital mortality and 30-day readmissions. We also analyze three Prevention Quality Indicators (PQI) for DM. RESULTS The number of hospitalization episodes decreased significantly as well as the frequentation rate and average length of stay (Incidence Rate Ratio [IRR] = 0.963, p < 0.001; 0.91, p < 0.001 and 0.986, p < 0.001, respectively). Crude in-hospital mortality and readmissions rates and risk-standardized in-hospital mortality rates (RSMR), however, remained stable (IRR = 0.988, p = 0.073; IRR = 1.003, p = 0.334 and IRR = 0.997, p = 0.116, respectively). A relevant variability in RSMR, both at hospital (Median Odds Ratio 1.49) and regional level, was found. High volume hospitals (≥105 DM discharges at year) showed better outcomes. High variability was also found in PQI indicators al regional level. CONCLUSION The present analysis shows an improvement in hospitalizations related to DM in Spain in the period 2007-2015. There was also a decrease in the frequentation rate and in the average length of stay. These findings are probably explained by quality improvements in the healthcare management of the DM at the ambulatory level. However, there were important differences in the management of diabetic inpatients both at the hospital and the regional level.
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Affiliation(s)
- Rebeca Reyes García
- Unidad de Endocrinología y Nutrición, Hospital Universitario Torrecárdenas, Almería, Spain; Sociedad Española de Endocrinología y Nutricion (SEEN), Spain.
| | - Jose Luis Bernal Sobrino
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Hospital 12 de Octubre, Madrid, Spain
| | - Cristina Fernandez Pérez
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Hospital 12 de Octubre, Madrid, Spain
| | - Carlos Morillas Ariño
- Sociedad Española de Endocrinología y Nutricion (SEEN), Spain; Sección de Endocrinología y Nutrición, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Sharona Azriel Mira
- Sociedad Española de Endocrinología y Nutricion (SEEN), Spain; Servicio de Endocrinología y Nutrición, Hospital Universitario Infanta Sofia, Madrid, Spain
| | | | - Irene Breton Lesmes
- Sociedad Española de Endocrinología y Nutricion (SEEN), Spain; Servicio de Endocrinologia y Nutrición, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Francisco Botella Romero
- Sociedad Española de Endocrinología y Nutricion (SEEN), Spain; Gerencia de Atención Integrada de Albacete, Albacete, Spain
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Kwan A, Daniels B, Bergkvist S, Das V, Pai M, Das J. Use of standardised patients for healthcare quality research in low- and middle-income countries. BMJ Glob Health 2019; 4:e001669. [PMID: 31565413 PMCID: PMC6747906 DOI: 10.1136/bmjgh-2019-001669] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/28/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
The use of standardised patients (SPs)-people recruited from the local community to present the same case to multiple providers in a blinded fashion-is increasingly used to measure the quality of care in low-income and middle-income countries. Encouraged by the growing interest in the SP method, and based on our experience of conducting SP studies, we present a conceptual framework for research designs and surveys that use this methodology. We accompany the conceptual framework with specific examples, drawn from our experience with SP studies in low-income and middle-income contexts, including China, India, Kenya and South Africa, to highlight the versatility of the method and illustrate the ongoing challenges. A toolkit and manual for implementing SP studies is included as a companion piece in the online supplement.
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Affiliation(s)
- Ada Kwan
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Benjamin Daniels
- McCourt School of Public Policy and School of Foreign Service, Georgetown University, Washington, District of Columbia, USA
| | - Sofi Bergkvist
- ACCESS Health International, New York City, New York, USA
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Madhukar Pai
- Department of Epidemiology & Biostatistics, and McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Jishnu Das
- McCourt School of Public Policy and School of Foreign Service, Georgetown University, Washington, District of Columbia, USA
- Center for Policy Research, Delhi, India
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Alkhouli M, Alqahtani F, Cook CC. Association between surgical volume and clinical outcomes following coronary artery bypass grafting in contemporary practice. J Card Surg 2019; 34:1049-1054. [PMID: 31389634 DOI: 10.1111/jocs.14205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Mohamad Alkhouli
- Division of Cardiology, Department of MedicineWest Virginia University Morgantown West Virginia
- Department of Cardiovascular DiseasesMayo Clinic College of Medicine and Science Rochester Minnesota
| | - Fahad Alqahtani
- Division of Cardiology, Department of MedicineWest Virginia University Morgantown West Virginia
| | - Chris C. Cook
- Department of Cardiovascular SurgeryWest Virginia University Morgantown West Virginia
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Merath K, Chen Q, Bagante F, Alexandrescu S, Marques HP, Aldrighetti L, Maithel SK, Pulitano C, Weiss MJ, Bauer TW, Shen F, Poultsides GA, Soubrane O, Martel G, Koerkamp BG, Guglielmi A, Itaru E, Cloyd JM, Pawlik TM. A Multi-institutional International Analysis of Textbook Outcomes Among Patients Undergoing Curative-Intent Resection of Intrahepatic Cholangiocarcinoma. JAMA Surg 2019; 154:e190571. [PMID: 31017645 DOI: 10.1001/jamasurg.2019.0571] [Citation(s) in RCA: 148] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Composite measures may be superior to individual measures for the analysis of hospital performance and quality of surgical care. Objective To determine the incidence of a so-called textbook outcome, a composite measure of the quality of surgical care, among patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma. Design, Setting, and Participants This cohort study involved an analysis of a multinational, multi-institutional cohort of patient from 15 major hepatobiliary centers in North America, Europe, Australia, and Asia who underwent curative-intent resection of intrahepatic cholangiocarcinoma between 1993 and 2015. Data analysis was conducted from April 2018 to May 2018. Main Outcomes and Measures Hospital variation in the composite end point of textbook outcome, defined as negative margins, no perioperative transfusion, no postoperative surgical complications, no prolonged length of stay, no 30-day readmissions, and no 30-day mortality. Secondary end points were factors associated with achieving textbook outcomes. Results Among 687 patients (of whom 370 [53.9%] were men; median patient age, 61 [range, 18-86] years) undergoing curative-intent resection of intrahepatic cholangiocarcinoma, a textbook outcome was achieved in 175 patients (25.5%). Being 60 years or younger (odds ratio [OR], 1.61 [95% CI, 1.04-2.49]; P = .03), absence of preoperative jaundice (OR, 4.40 [95% CI, 1.28-15.15]; P = .02), no neoadjuvant chemotherapy (OR, 2.57 [95% CI, 1.05-6.29]; P = .04), T1a/T1b-stage disease (OR, 1.58 [95% CI, 1.01-2.49]; P = .049), N0 status (OR, 3.89 [95% CI, 1.77-8.54]; P = .001), and no bile duct resection (OR, 2.46 [95% CI, 1.25-4.84]; P = .009) were independently associated with achieving a textbook outcome after resection. A prolonged length of stay had the greatest negative association with a textbook outcome. A nomogram to assess the probability of textbook outcome was developed and had good accuracy in both the training data set (area under the curve, 0.755) and validation data set (area under the curve, 0.763). Conclusions and Relevance In this study, while hepatic resection for intrahepatic cholangiocarcinoma was performed with less than 5% mortality in specialized centers, a textbook outcome was achieved in only approximately 26% of patients. A textbook outcome may be useful for the reporting of patient-level hospital performance and hospital variation, leading to quality improvement efforts after resection of intrahepatic cholangiocarcinoma.
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Affiliation(s)
| | - Qinyu Chen
- The Ohio State University Wexner Medical Center, Columbus
| | - Fabio Bagante
- The Ohio State University Wexner Medical Center, Columbus.,University of Verona, Verona, Italy
| | | | | | | | | | | | | | - Todd W Bauer
- University of Virginia, Charlottesville, Virginia
| | - Feng Shen
- Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | | | | | | | | | | | - Endo Itaru
- Yokohama City University, Yokohama, Japan
| | - Jordan M Cloyd
- The Ohio State University Wexner Medical Center, Columbus
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In-hospital Mortality and Readmissions for Heart Failure in Spain. A Study of Index Episodes and 30-Day and 1-year Cardiac Readmissions. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2019; 72:998-1004. [PMID: 30930253 DOI: 10.1016/j.rec.2019.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 01/29/2019] [Indexed: 11/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES Heart failure (HF) is a major health care problem in Spain. Epidemiological data from hospitalized patients are scarce and the association between hospital characteristics and patient outcomes is largely unknown. The aim of this study was to identify the factors associated with in-hospital mortality and readmissions and to analyze the relationship between hospital characteristics and outcomes. METHODS A retrospective analysis of discharges with HF as the principal diagnosis at hospitals of the Spanish National Health System in 2012 was performed using the Minimum Basic Data Set. We calculated risk-standardized mortality rates (RSMR) at the index episode and risk-standardized cardiac diseases readmissions rates (RSRR) and in-hospital mortality at 30 days and 1 year after discharge by using a multivariate mixed model. RESULTS We included 77 652 HF patients. Mean age was 79.2±9.9 years and 55.3% were women. In-hospital mortality during the index episode was 9.2%, rising to 14.5% throughout the year of follow-up. The 1-year cardiovascular readmissions rate was 32.6%. RSMR were lower among patients discharged from high-volume hospitals (> 340 HF discharges) (in-hospital RSMR, 10.3±5.6%; 8.6±2.2%); P <.001). High-volume hospitals had higher 1-year RSRR (32.3±3.7%; 33.7±4.5%; P=.006). The availability of a cardiology department at the hospital was associated with better outcomes (in-hospital RSMR, 9.9±3.8%; 9.2±2.4%; P <.001). CONCLUSIONS High-volume hospitals and the availability of a cardiology department were associated with lower in-hospital mortality.
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Wu B, Jung JK, Kim H, Polsky D. Entry regulation and the effect of public reporting: Evidence from Home Health Compare. HEALTH ECONOMICS 2019; 28:492-516. [PMID: 30689246 PMCID: PMC6405307 DOI: 10.1002/hec.3859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 12/18/2018] [Accepted: 12/31/2018] [Indexed: 06/09/2023]
Abstract
Economic theory suggests that competition and information are complementary tools for promoting health care quality. The existing empirical literature has documented this effect only in the context of competition among existing firms. Extending this literature, we examine competition driven by the entry of new firms into the home health care industry. In particular, we use the certificate of need (CON) law as a proxy for the entry of firms to avoid potential endogeneity of entry. We find that home health agencies in non-CON states improved quality under public reporting significantly more than agencies in CON states. Because home health care is a labor-intensive and capital-light industry, the state CON law is a major barrier for new firms to enter. Our findings suggest that policymakers may jointly consider information disclosure and entry regulation to achieve better quality in home health care.
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Affiliation(s)
- Bingxiao Wu
- Department of Economics, Rutgers University, 75 Hamilton St, NJ Hall, New Brunswick, NJ 08901, USA
| | - Jeah Kyoungrae Jung
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, 604 Ford Building, University Park, PA 16802, USA
| | - Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Daniel Polsky
- School of Medicine and the Wharton School University of Pennsylvania 3641 Locust Walk, Philadelphia, PA 19104
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Shojania KG. Are increases in emergency use and hospitalisation always a bad thing? Reflections on unintended consequences and apparent backfires. BMJ Qual Saf 2019; 28:687-692. [DOI: 10.1136/bmjqs-2019-009406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2019] [Indexed: 11/04/2022]
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Randhawa S, Viqar A, Strother J, Prabhu AV, Xia F, Heron D, Beriwal S. How Do Patients Rate Their Radiation Oncologists in the Modern Era: An Analysis of Vitals.com. Cureus 2018; 10:e3312. [PMID: 30473945 PMCID: PMC6248776 DOI: 10.7759/cureus.3312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction The popularity of online physician rating websites has risen substantially. These third-party sites have the potential to significantly influence patients’ perception of their healthcare providers. The purpose of this study was to evaluate online ratings of U.S. radiation oncologists (ROs) on Vitals.com, one of the most popular physician rating websites, and the variables that most significantly affect patients’ overall rating (OR) of their ROs. Methods The Centers for Medicare and Medicaid Physician Comparable Downloadable File was analyzed to obtain data on all self-identified ROs in the U.S. and Puerto Rico. Patient Review Satisfaction Scores (PRSS) that ranged from one (poor) to five (excellent) for the following variables were recorded: OR, accurate diagnosis, spending appropriate time with patients, ease of appointment, courteous staff, bedside manner, follow-up after visit, promptness, and wait time. Associations among these factors were assessed. Results Of 4,443 self-identifying Medicare-accepting ROs, 1,797 (40.4%) ROs who had at least one OR rating and at least one written comment were included in this study. The ROs’ mean OR was 4.34 ± 0.2 (median 4; 30% received a score of 5; 78% received a score greater than 4). OR was found to have a strong correlation with accuracy of diagnosis (r = 0.69), bedside manner (r = 0.71), and spends appropriate time with patients (r = 0.69). With the exception of the number of ratings (p = 0.07), physicians with over 10 years of experience showed statistically significant differences in how much better they scored in each of the variables compared to those with less than 10 years of experience (p < 0.01 for each characteristic). Significant differences in OR were also observed between ROs whose wait times exceeded 20 minutes compared to those with wait times less than 10 minutes (p < 0.01) for all internal and external metrics except for the number of ratings (p = 0.42) and number of reviews (p = 0.88) Conclusion Patients are providing high ratings for their ROs on Vitals.com and are more frequently recommending them to friends and family. Given the rise in popularity of third-party physician rating sites, it is important for ROs to understand the various factors that may influence their online ratings.
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Affiliation(s)
- Simrath Randhawa
- Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, USA
| | - Asim Viqar
- Medicine, Perelman School of Medicine, University of Pennsylvania, Pittsburgh, USA
| | - Julia Strother
- Medicine, Frank H. Netter Md School of Medicine at Quinnipiac University, North Haven, USA
| | - Arpan V Prabhu
- Radiation Oncology, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Fen Xia
- Radiation Oncology, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Dwight Heron
- Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Sushil Beriwal
- Radiation Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, USA
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Jewett PI, Zhu L, Huang B, Feuer EJ, Gangnon RE. Optimal Bayesian point estimates and credible intervals for ranking with application to county health indices. Stat Methods Med Res 2018; 28:2876-2891. [PMID: 30062909 DOI: 10.1177/0962280218790104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
It is fairly common to rank different geographic units, e.g. counties in the USA, based on health indices. In a typical application, point estimates of the health indices are obtained for each county, and the indices are then simply ranked as if they were known constants. Several authors have considered optimal rank estimators under squared error loss on the rank scale as a default method for general purpose ranking, e.g. situations where ranking units across the full spectrum of performance (low, medium, high) is important. While computationally convenient, squared error loss on the rank scale may not represent the true inferential goals of rank consumers. We construct alternative loss functions based on three components: (1) the inferential goal (rank position or pairwise comparisons), (2) the scale (original, log-transformed or rank) and (3) the (positional or pairwise) loss function (0/1, squared error or absolute error). We can obtain optimal ranks for loss functions based on rank positions and nearly optimal ranks for loss functions based on pairwise comparisons paired with highest posterior density (HPD) credible intervals. We compare inferences produced by the various ranking methods, both optimal and heuristic, using low birth weight data for counties in the Midwestern United States, from 2006 to 2012.
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Affiliation(s)
- Patricia I Jewett
- 1 Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Li Zhu
- 2 Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Bin Huang
- 3 Department of Biostatistics, University of Kentucky, Lexington, KY, USA
| | - Eric J Feuer
- 2 Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ronald E Gangnon
- 1 Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
- 4 Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
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Brakenhoff TB, Moons KG, Kluin J, Groenwold RH. Investigating Risk Adjustment Methods for Health Care Provider Profiling When Observations are Scarce or Events Rare. Health Serv Insights 2018; 11:1178632918785133. [PMID: 30083056 PMCID: PMC6069022 DOI: 10.1177/1178632918785133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/24/2018] [Indexed: 12/03/2022] Open
Abstract
Background: When profiling health care providers, adjustment for case-mix is essential. However, conventional risk adjustment methods may perform poorly, especially when provider volumes are small or events rare. Propensity score (PS) methods, commonly used in observational studies of binary treatments, have been shown to perform well when the amount of observations and/or events are low and can be extended to a multiple provider setting. The objective of this study was to evaluate the performance of different risk adjustment methods when profiling multiple health care providers that perform highly protocolized procedures, such as coronary artery bypass grafting. Methods: In a simulation study, provider effects estimated using PS adjustment, PS weighting, PS matching, and multivariable logistic regression were compared in terms of bias, coverage and mean squared error (MSE) when varying the event rate, sample size, provider volumes, and number of providers. An empirical example from the field of cardiac surgery was used to demonstrate the different methods. Results: Overall, PS adjustment, PS weighting, and logistic regression resulted in provider effects with low amounts of bias and good coverage. The PS matching and PS weighting with trimming led to biased effects and high MSE across several scenarios. Moreover, PS matching is not practical to implement when the number of providers surpasses three. Conclusions: None of the PS methods clearly outperformed logistic regression, except when sample sizes were relatively small. Propensity score matching performed worse than the other PS methods considered.
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Affiliation(s)
- Timo B Brakenhoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karel Gm Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jolanda Kluin
- Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - Rolf Hh Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Brakenhoff TB, Roes KCB, Moons KGM, Groenwold RHH. Outlier classification performance of risk adjustment methods when profiling multiple providers. BMC Med Res Methodol 2018; 18:54. [PMID: 29902975 PMCID: PMC6003201 DOI: 10.1186/s12874-018-0510-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 05/15/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND When profiling multiple health care providers, adjustment for case-mix is essential to accurately classify the quality of providers. Unfortunately, misclassification of provider performance is not uncommon and can have grave implications. Propensity score (PS) methods have been proposed as viable alternatives to conventional multivariable regression. The objective was to assess the outlier classification performance of risk adjustment methods when profiling multiple providers. METHODS In a simulation study based on empirical data, the classification performance of logistic regression (fixed and random effects), PS adjustment, and three PS weighting methods was evaluated when varying parameters such as the number of providers, the average incidence of the outcome, and the percentage of outliers. Traditional classification accuracy measures were considered, including sensitivity and specificity. RESULTS Fixed effects logistic regression consistently had the highest sensitivity and negative predictive value, yet a low specificity and positive predictive value. Of the random effects methods, PS adjustment and random effects logistic regression performed equally well or better than all the remaining PS methods for all classification accuracy measures across the studied scenarios. CONCLUSIONS Of the evaluated PS methods, only PS adjustment can be considered a viable alternative to random effects logistic regression when profiling multiple providers in different scenarios.
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Affiliation(s)
- Timo B. Brakenhoff
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA the Netherlands
| | - Kit C. B. Roes
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA the Netherlands
| | - Karel G. M. Moons
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA the Netherlands
| | - Rolf H. H. Groenwold
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA the Netherlands
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Fernández Rodríguez CM, Fernández Pérez C, Bernal JL, Vera I, Elola J, Júdez J, Carballo F. RECALAD. Patient care at National Health System Digestive Care Units - A pilot study, 2015. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 110:44-50. [PMID: 29284269 DOI: 10.17235/reed.2017.5316/2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To reach a situation diagnosis on the status of patient management at digestive care units (DCUs) in Spain. MATERIAL AND METHODS A cross-sectional descriptive study across DCUs in general acute care hospitals within the Spanish National Health System (data referred to 2015). The study variables were collected with a questionnaire including items on structure, services portfolio, activity, education, research, and good practice. Hospital discharge rates for digestive diseases were also assessed using the minimum basic data set (2005-2014). RESULTS Two hundred and nine hospitals invited, 55 responders (26.3%). Average discharges from hospital were 1,139 ± 653 per DCU/year, and 100 ± 66 per year per dedicated gastroenterologist. In 2014, admission rate to DCUs per 1,000 population and year was 280, with a mean stay of 7.4 days. The analysis of the MBDS for 2005-2014 reveals a progressive increase in the number of discharges (37% more in 2014 versus 2005), with a 28% decrease in hospital gross mortality rate (3.7% in 2014) and a slightly reduced (14%) mean stay (7.6 days in 2014). Considerable variability may be seen in structure, activity, and results indicators. Mortality and readmission rates, as well as mean stay, vary more than 100% amongst DCUs, and major dispersions also exist in frequentation and results amongst autonomous communities. CONCLUSIONS The RECALAD 2015 survey unveiled relevant aspects related to DCUs organization, structure, and management. The notable variability encountered likely reflects relevant differences in efficiency and productivity, and thus points out there is ample room for improvement.
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Affiliation(s)
| | | | | | - Isabel Vera
- Hospital Universitario Puerta de Hierro Majadahonda
| | - Javier Elola
- Director, Fundacion Instituto para la Mejora de la Asistencia Sanitaria, España
| | - Javier Júdez
- Gestion del conocimiento, Fundacion SEPD, España
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Abstract
IMPORTANCE Clinicians who order unnecessary radiographic imaging may cause financial harm to patients who have increasing levels of cost sharing. Clinician predictors of low-value imaging are largely unknown. OBJECTIVE To characterize clinician predictors of low-value imaging for acute uncomplicated back pain and headache, including clinicians who saw both conditions. DESIGN, SETTING, AND PARTICIPANTS Multivariate logistic regression modeling of imaging rates after acute uncomplicated back pain and headache visits as indicated by January 2010 to December 2014 commercial insurance claims and demographic data from a large US health insurer. Participants included 100 977 clinicians (primary care physicians, specialist physicians, and chiropractors). MAIN OUTCOMES AND MEASURES Imaging after acute uncomplicated back pain and headache visits was recorded. We identified whether the clinician's prior patient received imaging, whether the clinician was an owner of imaging equipment, and the varying impact by clinician specialty. We then used high rates of low-value back imaging as a predictor for low-value headache imaging. RESULTS Clinicians conducted 1 007 392 visits for 878 720 adults ages 18 to 64 years with acute uncomplicated back pain; 52 876 primary care physicians conducted visits for 492 805 adults ages 18 to 64 years with acute uncomplicated headache; 34 190 primary care clinicians conducted 405 721 visits for 344 991 adults ages 18 to 64 years with headache and had also conducted at least 4 visits from patients with back pain. If a primary care physician's prior patient received low-value back imaging, the patient had 1.81 higher odds of low-value imaging (95% CI, 1.77-1.85). This practice effect was larger for chiropractors (odds ratio [OR], 2.80; 95% CI, 2.74-2.86) and specialists (OR, 2.98; 95% CI, 2.88-3.07). For headache, a prior low-value head image predicted 2.00 higher odds of a subsequent head imaging order (95% CI, 1.95-2.06). Clinician ownership of imaging equipment was a consistent independent predictor of low-value imaging (OR, 1.65-7.76) across clinician type and imaging scenario. Primary care physicians with the highest rates of low-value back imaging also had 1.53 (95% CI, 1.45-1.61) higher odds of ordering low-value headache imaging. CONCLUSIONS AND RELEVANCE Clinician characteristics such as ordering low-value imaging on a prior patient, high rates of low-value imaging in another clinical scenario, and ownership of imaging equipment are strong predictors of low-value back and headache imaging. Findings should inform policies that target potentially unnecessary and financially burdensome care.
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Affiliation(s)
- Arthur S Hong
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Science, University of Texas Southwestern Medical Center, Dallas
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - Fang Zhang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - J Frank Wharam
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
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Zapatero-Gaviria A, Barba-Martín R, Canora Lebrato J, Fernández-Pérez C, Gómez-Huelgas R, Bernal-Sobrino J, Díez-Manglano J, Marco-Martínez J, Elola-Somoza F. RECALMIN II. Eight years of hospitalization in Internal Medicine Units (2007–2014). What has changed? Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2017.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Zapatero-Gaviria A, Barba-Martín R, Canora Lebrato J, Fernández-Pérez C, Gómez-Huelgas R, Bernal-Sobrino JL, Díez-Manglano J, Marco-Martínez J, Elola-Somoza FJ. RECALMIN II. Eight years of hospitalisation in Internal Medicine Units (2007-2014). What has changed? Rev Clin Esp 2017; 217:446-453. [PMID: 28851485 DOI: 10.1016/j.rce.2017.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 07/20/2017] [Accepted: 07/22/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To analyse the evolution of care provided by the internal medicine units (IMU) of the Spanish National Health System from 2007 to 2014. MATERIAL AND METHODS We analysed all discharges from the IMU of the Spanish National Health System in 2007 and 2014, using the Minimum Basic Data Set. We compared the risk factors by episode, mortality and readmissions between the two periods. We prepared specific fits for the risk for mortality and readmissions in heart failure, pneumonia and chronic obstructive pulmonary disease, as well as the Charlson index for all activity. RESULTS Discharges from the IMU between the two periods increased 14%. The average patient age increased by 2.8 years (71.2±17.1 vs. 74±16.2; p<.001), with a marked increase in comorbidity (Charlson index, 4±3.7 vs. 4.7±3.9; p<.001; 24% increase in risk factors per episode). The adjusted mortality rates decreased slight but significantly, with a slight increase in readmissions. CONCLUSIONS During the analysed period, there was an increase of almost 3 years in the mean age of patients treated in the IMU of the Spanish National Health System, with a marked increase in comorbidity. These results should lead to a more appropriate assignment of nurse workloads and an increased implementation of good practices in clinical management.
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Affiliation(s)
- A Zapatero-Gaviria
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Madrid, España.
| | - R Barba-Martín
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos Móstoles, Madrid, España
| | - J Canora Lebrato
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Madrid, España
| | - C Fernández-Pérez
- Servicio de Medicina Preventiva, Hospital Clínico Universitario San Carlos, Madrid, España
| | - R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Universitario Regional de Málaga, Málaga, España
| | - J L Bernal-Sobrino
- Unidad de Control de Gestión, Hospital Universitario 12 de Octubre, Madrid, España
| | - J Díez-Manglano
- Servicio de Medicina Interna, Hospital Universitario Miguel Servet, Zaragoza, España
| | - J Marco-Martínez
- Servicio de Medicina Interna, Hospital Clínico Universitario San Carlos, Madrid, España
| | - F J Elola-Somoza
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, España
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Early mortality following percutaneous coronary intervention and cardiac surgery: Correlations within providers and operators. Int J Cardiol 2017; 240:97-102. [DOI: 10.1016/j.ijcard.2017.04.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/31/2017] [Accepted: 04/30/2017] [Indexed: 11/23/2022]
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Abstract
BACKGROUND Surgical quality improvement depends on hospitals having accurate and timely information about comparative performance. Profiling accuracy is improved by risk adjustment and shrinkage adjustment to stabilize estimates. These adjustments are included in ACS NSQIP reports, where hospital odds ratios (OR) are estimated using hierarchical models built on contemporaneous data. However, the timeliness of feedback remains an issue. STUDY DESIGN We describe an alternative, nonhierarchical approach, which yields risk- and shrinkage-adjusted rates. In contrast to our "Traditional" NSQIP method, this approach uses preexisting equations, built on historical data, which permits hospitals to have near immediate access to profiling results. We compared our traditional method to this new "on-demand" approach with respect to outlier determinations, kappa statistics, and correlations between logged OR and standardized rates, for 12 models (4 surgical groups by 3 outcomes). RESULTS When both methods used the same contemporaneous data, there were similar numbers of hospital outliers and correlations between logged OR and standardized rates were high. However, larger differences were observed when the effect of contemporaneous versus historical data was added to differences in statistical methodology. CONCLUSIONS The on-demand, nonhierarchical approach provides results similar to the traditional hierarchical method and offers immediacy, an "over-time" perspective, application to a broader range of models and data subsets, and reporting of more easily understood rates. Although the nonhierarchical method results are now available "on-demand" in a web-based application, the hierarchical approach has advantages, which support its continued periodic publication as the gold standard for hospital profiling in the program.
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Rodriguez-Padial L, Elola FJ, Fernández-Pérez C, Bernal JL, Iñiguez A, Segura JV, Bertomeu V. Patterns of inpatient care for acute myocardial infarction and 30-day, 3-month and 1-year cardiac diseases readmission rates in Spain. Int J Cardiol 2017; 230:14-20. [DOI: 10.1016/j.ijcard.2016.12.121] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 11/26/2016] [Accepted: 12/17/2016] [Indexed: 11/30/2022]
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Hatfield LA, Baugh CM, Azzone V, Normand SLT. Regulator Loss Functions and Hierarchical Modeling for Safety Decision Making. Med Decis Making 2017; 37:512-522. [PMID: 28112994 DOI: 10.1177/0272989x16686767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Regulators must act to protect the public when evidence indicates safety problems with medical devices. This requires complex tradeoffs among risks and benefits, which conventional safety surveillance methods do not incorporate. OBJECTIVE To combine explicit regulator loss functions with statistical evidence on medical device safety signals to improve decision making. METHODS In the Hospital Cost and Utilization Project National Inpatient Sample, we select pediatric inpatient admissions and identify adverse medical device events (AMDEs). We fit hierarchical Bayesian models to the annual hospital-level AMDE rates, accounting for patient and hospital characteristics. These models produce expected AMDE rates (a safety target), against which we compare the observed rates in a test year to compute a safety signal. We specify a set of loss functions that quantify the costs and benefits of each action as a function of the safety signal. We integrate the loss functions over the posterior distribution of the safety signal to obtain the posterior (Bayes) risk; the preferred action has the smallest Bayes risk. Using simulation and an analysis of AMDE data, we compare our minimum-risk decisions to a conventional Z score approach for classifying safety signals. RESULTS The 2 rules produced different actions for nearly half of hospitals (45%). In the simulation, decisions that minimize Bayes risk outperform Z score-based decisions, even when the loss functions or hierarchical models are misspecified. LIMITATIONS Our method is sensitive to the choice of loss functions; eliciting quantitative inputs to the loss functions from regulators is challenging. CONCLUSIONS A decision-theoretic approach to acting on safety signals is potentially promising but requires careful specification of loss functions in consultation with subject matter experts.
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Affiliation(s)
- Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA (LAH, VA)
| | - Christine M Baugh
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, MA, USA (CMB)
| | - Vanessa Azzone
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA (LAH, VA)
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School and Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA (S-LTN)
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Klein LW, Harjai KJ, Resnic F, Weintraub WS, Vernon Anderson H, Yeh RW, Feldman DN, Gigliotti OS, Rosenfeld K, Duffy P. 2016 Revision of the SCAI position statement on public reporting. Catheter Cardiovasc Interv 2016; 89:269-279. [PMID: 27755653 DOI: 10.1002/ccd.26818] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/08/2016] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Fred Resnic
- Lahey Hospital and Medical Center, Burlington, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | | | - H Vernon Anderson
- University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas
| | - Robert W Yeh
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Dmitriy N Feldman
- New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | | | - Kenneth Rosenfeld
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Lipitz-Snyderman A, Sima CS, Atoria CL, Elkin EB, Anderson C, Blinder V, Tsai CJ, Panageas KS, Bach PB. Physician-Driven Variation in Nonrecommended Services Among Older Adults Diagnosed With Cancer. JAMA Intern Med 2016; 176:1541-1548. [PMID: 27533635 PMCID: PMC5363077 DOI: 10.1001/jamainternmed.2016.4426] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
IMPORTANCE Interventions to address overuse of health care services may help reduce costs and improve care. Understanding physician-level variation and behavior patterns can inform such interventions. OBJECTIVE To assess patterns of physician ordering of services that tend to be overused in the treatment of patients with cancer. We hypothesized that physicians exhibit consistent behavior. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of patients 66 years and older diagnosed with cancer between 2004 and 2011, using population-based Surveillance, Epidemiology, and End Results (SEER)-Medicare data to assess physician-level variation in 5 nonrecommended services. Services included imaging for staging and surveillance in low-risk disease, intensity-modulated radiation therapy (IMRT) after breast-conserving surgery, and extended fractionation schemes for palliation of bone metastases. MAIN OUTCOME AND MEASURES To assess variation in service use between physicians, we used a random effects model and a logistic regression model with a lag variable to assess whether a physician's use of a service for a prior patient predicts subsequent service use. RESULTS Cohorts ranged from 3464 to 89 006 patients. The total proportion of patients receiving each service varied from 14% for imaging in staging early breast cancer to 41% in early prostate cancer. From the random effects analysis, we found significant unexplained variation in service use between physicians (P < .001 for each service; ICC, 0.04-0.59). Controlling for case mix, whether a physician ordered a service for the prior patient was highly predictive of service use, with adjusted odds ratios (aORs) ranging from 1.12 (95% CI, 1.07-1.18) for surveillance imaging for patients with breast cancer (28% service use if prior patient had imaging vs 25% if not), to 24.91 (95% CI, 22.86-27.15) for IMRT for whole breast radiotherapy (69% vs 7%, respectively). CONCLUSIONS AND RELEVANCE Physicians' utilization of nonrecommended services that tend to be overused exhibit patterns that suggest consistent behavior more than personalized patient care decisions. Reducing overuse may require understanding cognitive drivers of repetitive inappropriate decisions.
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Affiliation(s)
- Allison Lipitz-Snyderman
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Camelia S Sima
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York3Genentech, California
| | - Coral L Atoria
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elena B Elkin
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher Anderson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York5Department of Urology, Columbia University, New York, New York
| | - Victoria Blinder
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York6Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter B Bach
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
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