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Abreu P, Correia M, Azevedo E, Sousa-Pinto B, Magalhães R. Rapid systematic review of readmissions costs after stroke. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:22. [PMID: 38475856 DOI: 10.1186/s12962-024-00518-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 01/22/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Stroke readmissions are considered a marker of health quality and may pose a burden to healthcare systems. However, information on the costs of post-stroke readmissions has not been systematically reviewed. OBJECTIVES To systematically review information about the costs of hospital readmissions of patients whose primary diagnosis in the index admission was a stroke. METHODS A rapid systematic review was performed on studies reporting post-stroke readmission costs in EMBASE, MEDLINE, and Web of Science up to June 2021. Relevant data were extracted and presented by readmission and stroke type. The original study's currency values were converted to 2021 US dollars based on the purchasing power parity for gross domestic product. The reporting quality of each of the included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS Forty-four studies were identified. Considerable variability in readmission costs was observed among countries, readmissions, stroke types, and durations of the follow-up period. The UK and the USA were the countries reporting the highest readmission costs. In the first year of follow-up, stroke readmission costs accounted for 2.1-23.4%, of direct costs and 3.3-21% of total costs. Among the included studies, only one identified predictors of readmission costs. CONCLUSION Our review showed great variability in readmission costs, mainly due to differences in study design, countries and health services, follow-up duration, and reported readmission data. The results of this study can be used to inform policymakers and healthcare providers about the burden of stroke readmissions. Future studies should not solely focus on improving data standardization but should also prioritize the identification of stroke readmission cost predictors.
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Affiliation(s)
- Pedro Abreu
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.
| | - Manuel Correia
- Department of Neurology, Hospital Santo António- Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Bernardo Sousa-Pinto
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Rui Magalhães
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
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Crooks E, Rampley T, Weeks DL, Billings C, Stengem D, Rangel T. Perceived Barriers to Patient Mobilization Among Therapy and Nursing Acute Care Staff: A Multi-Site Survey Study. Arch Phys Med Rehabil 2024; 105:243-250. [PMID: 37429536 DOI: 10.1016/j.apmr.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/24/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE To identify differences in perceived barriers to patient mobilization in acute care among therapy and nursing clinicians, and among hospitals of different sizes and types. DESIGN Cross-sectional survey study. SETTING Eight hospitals of various sizes and types (teaching vs non-teaching; urban vs rural), from 2 different states in the Western region of the United States. PARTICIPANTS A nonprobability sample of 568 acute care clinicians (N=586) involved in direct patient care were surveyed. Clinicians indicated a clinical role within the branch of therapy (physical therapy or occupational therapy) or nursing (registered nurse or nurse assistant). MAIN OUTCOME MEASURES The Patient Mobilization Attitudes and Beliefs Survey (PMABS) was used to assess perceived barriers to early patient mobilization among therapy and nursing staff. A PMABS total score and 3 subscale scores (knowledge, attitudes, or behaviors associated with barriers to mobilization) were calculated, with higher scores indicative of greater mobilization barriers. RESULTS Mean PMABS total scores were significantly lower (better) for therapy providers (24.63±6.67) than nursing providers (38.12±10.95), P<.001. Additionally, therapy providers had significantly lower scores than nursing providers on all 3 subscales (all P<.001). Item-specific analyses revealed significant differences in responses between therapy and nursing staff on 22 of 25 items, with nursing staff indicating greater perceptions of barriers than therapy staff on 20 of the 22 items. The top 5 items with the largest response differences between therapy and nursing clinicians included adequate time to mobilize patients, understanding appropriate referral to therapy staff, knowledge on when it is safe to mobilize patients, confidence in the ability to mobilize patients, and receiving training on methods of safe mobilization. While hospital type did not affect perceived barriers to early mobilization, PMABS scores were significantly higher for large and small hospitals when compared to medium-sized hospitals. CONCLUSION Perceived barriers to patient mobilization exist among therapy and nursing acute care clinicians, with greater barriers noted among nursing staff for knowledge, attitudes, and behaviors associated with patient mobility practices. Findings suggest future work is warranted, with opportunities for therapy providers to collaborate with nursing providers to address barriers to implementing patient mobility.
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Affiliation(s)
- Elena Crooks
- Department of Physical Therapy, Eastern Washington University, Spokane, WA.
| | | | - Douglas L Weeks
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | - Crystal Billings
- Nursing Excellence, Providence Swedish, South Puget Sound Region, WA
| | - Danell Stengem
- Nursing Quality & Clinical Education Departments, Providence St. Patrick Hospital, Missoula, MT
| | - Teresa Rangel
- Professional Development Department, Providence Health and Services, Spokane, WA
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Sakowitz S, Bakhtiyar SS, Vadlakonda A, Ali K, Sanaiha Y, Benharash P. Failure to rescue among octogenarians undergoing cardiac surgery in the United States. Surgery 2023; 174:893-900. [PMID: 37544816 DOI: 10.1016/j.surg.2023.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/30/2023] [Accepted: 06/18/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND A rapidly growing population, octogenarians are considered at high-risk for mortality and complications after cardiac surgery. Given the recent addition of failure to rescue as a Society of Thoracic Surgeons quality metric, a better understanding of patient and operative factors predictive of failure to rescue in this cohort is warranted. METHODS The 2010-2020 Nationwide Readmissions Database was used to identify all patients ≥80 years undergoing first-time, elective coronary artery bypass grafting or concomitant valve operations. Patients experiencing failure to rescue, defined as mortality after a major or minor complication, were classified as Failure to Rescue (others: Non-Failure to Rescue). Multivariable regression models were developed to ascertain significant perioperative factors associated with failure to rescue. RESULTS Of ∼562,794 octogenarian patients, 76,473 (13.6%) developed complications. Of these, 7,055 (9.2%) experienced failure to rescue. The incidence of failure to rescue decreased across the study time course (9.7% in 2010 to 7.6% in 2019, P = .001). After risk adjustment, age (adjusted odds ratio, 1.05/year; 95% confidence interval, 1.03-1.07), female sex (adjusted odds ratio, 1.40; 95% confidence interval, 1.27-1.53), congestive heart failure (adjusted odds ratio, 1.54; 95% confidence interval, 1.38-1.71), late-stage kidney disease (adjusted odds ratio, 2.38; 95% confidence interval, 1.79-3.17), liver disease (adjusted odds ratio, 9.59; 95% confidence interval, 8.17-11.26), and cerebrovascular disease (adjusted odds ratio, 2.42; 95% confidence interval, 2.12-2.76) were associated with failure to rescue. Relative to isolated coronary artery bypass grafting, combined coronary artery bypass grafting-valve (adjusted odds ratio, 1.67; 95% confidence interval, 1.43-1.95) and multi-valve procedures (adjusted odds ratio, 2.23; 95% confidence interval, 1.75-2.85) were linked with greater odds of failure to rescue. There was no association between failure to rescue and hospital volume. CONCLUSION Despite improvements in perioperative management, failure to rescue occurs in ∼9% of octogenarians undergoing elective cardiac operations. Although incidence has declined over the past decade, the continued prevalence of failure to rescue underscores the need for novel risk assessments and targeted interventions.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA.
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Roey T, Hung DY, Rundall TG, Fournier PL, Zhong A, Shortell SM. Lean Performance Indicators and Facilitators of Outcomes in U.S. Public Hospitals. J Healthc Manag 2023; 68:325-341. [PMID: 37678825 DOI: 10.1097/jhm-d-22-00107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
GOAL This study investigated the association between Lean and performance outcomes in U.S. public hospitals. Public hospitals face substantial pressure to deliver high-quality care with limited resources. Lean-based management systems can provide these hospitals with alternative approaches to improve efficiency and effectiveness. Prior research shows that Lean can have positive impacts in hospitals ranging in ownership type, but more study is needed, specifically in publicly owned hospitals. METHODS We performed multivariable regressions using data from the 2017 National Survey of Lean/Transformational Performance Improvement. The data were linked to publicly available hospital performance data from the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. We examined 11 outcomes measuring financial performance, quality of care, and patient experience and their associations with Lean adoption. We also explored potential drivers of positive outcomes by examining Lean implementation in each hospital, measured as the number of units using Lean tools and practices; leader commitment to Lean principles; Lean training and education among physicians, nurses, and managers; and use of a daily management system among C-suite leaders and managers. PRINCIPAL FINDINGS Lean adoption and implementation were associated with improved performance in U.S. public hospitals. Compared with hospitals that did not adopt Lean, those that did had significantly lower adjusted inpatient expenses per discharge and higher-than-average national scores on the appropriate use of medical imaging and timeliness of care. The study results also showed marginally significant improvements in patient experience and hospital earnings before interest, taxes, depreciation, and amortization margins. Focusing on these select outcomes, we found that drivers of such improvements involved the extent of Lean implementation, as reflected by leadership commitment, daily management, and training/education while controlling for the number of years using Lean. PRACTICAL APPLICATIONS Lean is a method of continuous improvement centered around a culture of providing high-value care for patients. Our findings provide insight into the potential benefits of Lean in U.S. public hospitals. Notably, they suggest that leader buy-in is key to success. When executives and managers support Lean initiatives and provide proper training for the workforce, improved financial and operational performance can result. This commitment, starting with upper management, may also play a broader role in the effort to reform healthcare while having a positive impact on patient care in U.S. public hospitals.
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Affiliation(s)
| | | | | | | | | | - Stephen M Shortell
- Center for Lean Engagement & Research, Division of Health Policy and Management, University of California, Berkeley, California
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Bennett CL, Clay CE, Siddiqi KA, Olatosi BA, Parsonnet J, Camargo JCA. Characteristics of California Emergency Departments in Centers for Disease Control and Prevention-Designated HIV Priority Counties. J Emerg Med 2023; 64:93-102. [PMID: 36650074 PMCID: PMC10208592 DOI: 10.1016/j.jemermed.2022.10.020] [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] [Received: 06/15/2022] [Revised: 09/21/2022] [Accepted: 10/21/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Refocused national HIV testing initiatives include a geographic focus. OBJECTIVE Using a geographic focus, we sought to identify which emergency departments (EDs) might be the most efficient targets for future HIV testing efforts, using California as an example. METHODS Retrospective analysis of California EDs, emergency physicians, and patients served, along with county-level estimates of HIV prevalence and proportion of the population living in poverty. Emphasis was placed on characterizing EDs affiliated with teaching hospitals and those located in Centers for Disease Control (CDC) and Prevention HIV priority counties. RESULTS Of the 320 EDs studied, 178 were in priority counties, 29 were affiliated with teaching hospitals, and 24 had both characteristics. Of the 12,869,889 ED visits included, 61.8% occurred in priority counties, 14.7% in EDs affiliated with teaching hospitals, and 12.0% in EDs with both characteristics. The subset of EDs in priority counties with teaching hospital affiliations (compared with priority and nonpriority county ED groups without a teaching hospital affiliation) had higher overall median visit volumes and higher proportions of visits by at-risk and CDC-targeted populations (e.g., individuals who were homeless, those who identified as Black or African American race, and those who identified as Hispanic or Latino ethnicity, all p < 0.01). CONCLUSIONS EDs in priority counties affiliated with teaching hospitals are major sources of health care in California. These EDs more often serve populations disproportionately impacted by HIV. These departments are efficient targets to direct testing efforts. Increasing testing in these EDs could reduce the burden of undiagnosed HIV in California.
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Affiliation(s)
- Christopher L Bennett
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California; Department of Epidemiology, Stanford University School of Medicine, Stanford, California
| | - Carson E Clay
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Khairul A Siddiqi
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida
| | - Bankole A Olatosi
- Department of Health Services Policy and Management, University of South Carolina, Columbia, South Carolina
| | - Julie Parsonnet
- Department of Epidemiology, Stanford University School of Medicine, Stanford, California; Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jr Carlos A Camargo
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Naar L, Maurer LR, Dorken Gallastegi A, El Hechi MW, Rao SR, Coughlin C, Ebrahim S, Kadambi A, Mendoza AE, Saillant NN, Renne BCB, Velmahos GC, Kaafarani HMA, Lee J. Hospital Academic Status and the Volume-Outcome Association in Postoperative Patients Requiring Intensive Care: Results of a Nationwide Analysis of Intensive Care Units in the United States. J Intensive Care Med 2022; 37:1598-1605. [PMID: 35437045 DOI: 10.1177/08850666221094506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To determine whether the outcomes of postoperative patients admitted directly to an intensive care unit (ICU) differ based on the academic status of the institution and the total operative volume of the unit. Methods: This was a retrospective analysis using the eICU Collaborative Research Database v2.0, a national database from participating ICUs in the United States. All patients admitted directly to the ICU from the operating room were included. Transfer patients and patients readmitted to the ICU were excluded. Patients were stratified based on admission to an ICU in an academic medical center (AMC) versus non-AMC, and to ICUs with different operative volume experience, after stratification in quartiles (high, medium-high, medium-low, and low volume). Primary outcomes were ICU and hospital mortality. Secondary outcomes included the need for continuous renal replacement therapy (CRRT) during ICU stay, ICU length of stay (LOS), and 30-day ventilator free days. Results: Our analysis included 22,180 unique patients; the majority of which (15,085[68%]) were admitted to ICUs in non-AMCs. Cardiac and vascular procedures were the most common types of procedures performed. Patients admitted to AMCs were more likely to be younger and less likely to be Hispanic or Asian. Multivariable logistic regression indicated no meaningful association between academic status and ICU mortality, hospital mortality, initiation of CRRT, duration of ICU LOS, or 30-day ventilator-free-days. Contrarily, medium-high operative volume units had higher ICU mortality (OR = 1.45, 95%CI = 1.10-1.91, p-value = 0.040), higher hospital mortality (OR = 1.33, 95%CI = 1.07-1.66, p-value = 0.033), longer ICU LOS (Coefficient = 0.23, 95%CI = 0.07-0.39, p-value = 0.038), and fewer 30-day ventilator-free-days (Coefficient = -0.30, 95%CI = -0.48 - -0.13, p-value = 0.015) compared to their high operative volume counterparts. Conclusions: This study found that a volume-outcome association in the management of postoperative patients requiring ICU level of care immediately after a surgical procedure may exist. The academic status of the institution did not affect the outcomes of these patients.
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Affiliation(s)
- Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Majed W El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sowmya R Rao
- MGH Biostatistics Center, Harvard Medical School; Department of Global Health, 27118Boston University School of Public Health, Boston, MA, USA
| | - Catherine Coughlin
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Senan Ebrahim
- Hikma Health, San Jose, CA, USA
- 1811Harvard Medical School, Boston, MA, USA
| | - Adesh Kadambi
- Hikma Health, San Jose, CA, USA
- 7938University of Toronto, Toronto, ON, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - B Christian B Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jarone Lee
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Turcotte J, Spirt A, Keblish D, Holt E. Total Ankle Arthroplasty Can Be Safely and Effectively Performed in the Community Hospital Setting: A Case Series of 65 Patients. J Foot Ankle Surg 2022; 61:827-830. [PMID: 34974983 DOI: 10.1053/j.jfas.2021.11.026] [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: 04/08/2020] [Revised: 07/20/2020] [Accepted: 11/29/2021] [Indexed: 02/03/2023]
Abstract
The use of total ankle arthroplasty has expanded over the past decade, primarily due to improvements in implant design and survivorship that have significantly reduced the high failure rates observed in first-generation implants. A retrospective review of 65 consecutive patients undergoing primary total ankle arthroplasty with a single senior orthopedic surgeon in a community hospital from January 2014 to December 2019 was performed. All procedures were performed for end stage osteoarthritis, with the most common secondary diagnoses being Achilles contracture (23%), retained hardware (17%) and calcaneovalgus deformity (11%). Preoperatively, patients averaged 10.45 ̊ ± 10.00 ̊ of non-weightbearing dorsiflexion and 30.00 ̊ ± 8.79 ̊ of plantarflexion. Postoperatively, patients averaged 13.33 ̊ ± 7.62 ̊ dorsiflexion, and 25.48 ̊ ± 7.87 ̊ of plantarflexion. A total of 8 (12.3%) patients required reoperation, and average time to reoperation was 1.55 ± 1.58 years. Implant failure, defined as reoperation requiring prosthesis removal, occurred in 2 (3.1%) patients, with an average time to failure of 342 days (105 days in failure due to periprosthetic joint infection and 582 days in failure due to subsidence). Patients undergoing total ankle arthroplasty at our institution had a 12.3% reoperation rate, and a 96.9% implant survival rate over an average follow-up period of 2.42 years, results that compare favorably with previously reported outcomes. Based on these findings, we suggest that this procedure, which is often offered only in academic tertiary care facilities, can be safely and effectively performed by experienced surgeons in the community hospital setting.
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Affiliation(s)
- Justin Turcotte
- Director, Orthopedic and Surgery Research, Anne Arundel Medical Center Orthopedics, Annapolis, MD.
| | - Adrienne Spirt
- Attending Foot and Ankle Surgeon, Anne Arundel Medical Center Orthopedics, Annapolis, MD
| | - David Keblish
- Attending Foot and Ankle Surgeon, Anne Arundel Medical Center Orthopedics, Annapolis, MD
| | - Edward Holt
- Attending Foot and Ankle Surgeon, Anne Arundel Medical Center Orthopedics, Annapolis, MD
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Comparison of a Teaching and Nonteaching Service at a Children's Hospital in the Community. Acad Pediatr 2022; 22:440-446. [PMID: 34252607 DOI: 10.1016/j.acap.2021.07.004] [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: 03/11/2021] [Revised: 06/29/2021] [Accepted: 07/03/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The impact of trainees on inpatient patient care is incompletely understood. This study sought to discern the impact of trainees on patient outcomes and costs at a children's hospital in the community. We hypothesized that there would be no differences in patient outcomes and costs on an inpatient teaching service compared to a nonteaching service. As a secondary goal, we analyzed trainee evaluations. METHODS The authors conducted a cohort study of patients hospitalized from October 1, 2016 to September 30, 2017 on an acute care unit in a children's hospital in the community. Using t test or Fisher exact test, the authors compared patient outcomes between teaching and nonteaching services including, length of stay, discharge times, readmission rates, rapid response team (RRT) calls, pediatric intensive care unit (PICU) transfers, hospital transfers, and costs. RESULTS During the study period, there were 1066 patients admitted and discharged from the teaching service and 1038 from the nonteaching service. There were no statistically significant differences in patient demographics or patient complexity. Similarly, there were no differences in length of stay, discharge times, readmission rates, RRT calls, PICU transfers, hospital transfers or patient costs between services. Trainee evaluations of the inpatient experience were overwhelmingly positive. CONCLUSIONS In a children's hospital in the community, there were no significant differences in patient outcomes and costs on a teaching service compared to a nonteaching service. Furthermore, trainee evaluations suggested a favorable learning experience, illustrating the feasibility of incorporating trainees into inpatient care in a nontraditional learner setting.
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Aby E, Olson APJ, Lim N. Serum ammonia use: unnecessary, frequent and costly. Frontline Gastroenterol 2021; 13:275-279. [PMID: 35722602 PMCID: PMC9186040 DOI: 10.1136/flgastro-2021-101837] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/03/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND/OBJECTIVE While ammonia plays a role in the complex pathophysiology of hepatic encephalopathy (HE), serum ammonia is unreliable for both diagnosis of, and correlation with, neurological symptoms in patients with cirrhosis. We aimed to quantify ordering, cost and appropriate use of serum ammonia in a major Midwestern healthcare system. DESIGN/METHOD Serum ammonia ordering in adult patients presenting to a large Midwestern health system was evaluated from 1 January 2015 to 31 December 2019. RESULTS Serum ammonia ordering was prevalent, with 20 338 tests ordered over 5 years. There were no differences in the number of inappropriate serum ammonia tests per 100 000 admissions for chronic liver disease over time (Pearson's correlation coefficient=-0.24, p=0.70). As a proportion of total ammonia tests ordered, inappropriate tests increased over time (Pearson's correlation coefficient=0.91, p=0.03). Inappropriate ordering was more common at community hospitals compared with the academic medical centre (99.3% vs 87.6%, p<0.001). CONCLUSION Despite evidence that serum ammonia levels are unreliable for the diagnosis of HE and are not associated with severity of HE in individuals with cirrhosis, ordering remains prevalent, contributing to waste and potential harm.
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Affiliation(s)
- Elizabeth Aby
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew P J Olson
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA,Department of Pediatrics, Division of Pediatric Hospital Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
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Do hospital type or caseload make a difference in chemotherapy treatment patterns for early breast cancer? Results from 104 German institutions, 2008-2017. Breast 2021; 58:63-71. [PMID: 33933924 PMCID: PMC8102997 DOI: 10.1016/j.breast.2021.04.006] [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: 12/29/2020] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Over the past decade, chemotherapy has been used more selectively in early breast cancer (EBC) due to better risk stratification. Neoadjuvant chemotherapy (NACT) has evolved to the primary treatment option. The type and size of hospitals is known to have a substantial influence on the kinds of treatment they provide, and therefore on patient outcomes (e.g. rates for pathological complete response, pCR), but it is not yet known how this has affected delivery of chemotherapy for EBC in Germany. METHODS This study analyzed chemotherapy use and pCR rates after NACT for EBC patients treated at 104 German institutions 2008-2017. Institutions were separated into associated hospital type (university hospital; teaching hospital; community hospital) and annual caseload (≤100; 101-250; >250 cases/year). RESULTS Overall, 124,084 patients were included, of whom 11.6% were treated at university hospitals, 63.1% at teaching hospitals, and 25.3% at community hospitals. In total, 46,274 (37.3%) received chemotherapy, of whom 44,765 had information available about systemic treatment and surgery. From 2008 to 2017, chemotherapy use declined from 48.3% to 36.4% for university hospitals, from 40.7% to 30.3% for teaching hospitals, and from 42.4% to 33.7% for community hospitals. Furthermore, the proportion of NACT increased the most in university hospitals (from 32.0% to 68.1%); whereas, the rate of pCR (defined as ypT0 ypN0) increased irrespective of institutional type. Analyses regarding annual caseload did not show any differences. CONCLUSIONS The results from this large, nationwide cohort reflect a more selective use of chemotherapy in Germany, irrespective of institutional type or case load.
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11
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Tsilimigras DI, Pawlik TM, Moris D. Textbook outcomes in hepatobiliary and pancreatic surgery. World J Gastroenterol 2021; 27:1524-1530. [PMID: 33958840 PMCID: PMC8058657 DOI: 10.3748/wjg.v27.i15.1524] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/12/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
The concept of textbook outcome (TO) has recently gained popularity in surgical research and has been used to evaluate the quality or success of different surgical procedures, including hepatopancreatobiliary (HPB) operations. TO consists of individual outcome parameters that each reflect different domains of care including structure, process, and individual outcomes; in turn, the composite TO metric represents the optimal course after a surgical episode. TO can be used to assess patient-level outcomes, hospital performance, center designation and quality metrics. In addition to being an outcome measurement, TO may also be linked to healthcare costs. Future efforts should be directed towards establishing a universal definition of TO in HPB surgery so that surgeons and hospitals can assess and compare outcomes, identify shortcomings and improve real world patient outcomes.
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Affiliation(s)
| | | | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Duke University, Durham, NC 27710, United States
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12
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Dobre R, Niculescu DA, Cirstoiu C, Popescu G, Poiana C. Mortality rates and risk factors after low-trauma hip fracture in the largest university center in Romania. Arch Osteoporos 2021; 16:64. [PMID: 33834297 DOI: 10.1007/s11657-021-00934-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/31/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED We calculated in-hospital, 30-day, and 1-year mortality rates and analyzed potential mortality risk factors in 2742 patients with low-trauma hip fractures. We found a high mortality rate at 30 days and 1 year after hip fracture. The high mortality can be explained by a very high number of conservatively treated fractures. PURPOSE Data on mortality after low-trauma hip fracture in Romania is scarce and comes from a single-hospital study. Our aim was to calculate mortality rates and risk factors in all patients admitted for low-trauma hip fracture in the largest university medical center of Romania. METHODS We retrospectively analyzed the charts of all patients (>40 years old) admitted for hip fracture in a 12-month period in hospitals with an Orthopedic Department in Bucharest, Romania, and surrounding Ilfov County and calculated the crude in-hospital, 30-day, and 1-year mortality rates after low-trauma hip fractures. A number of potential clinical risk factors for mortality were evaluated. RESULTS We analyzed 2742 low-trauma hip fractures. The in-hospital, 30-day, and 1-year all-cause mortality rates were 4.26% (n=117), 9.59% (n=263), and 29.72% (n=815) respectively. Four hundred and fifty (16.41%) fractures were managed conservatively with a 1-year mortality HR of 3.05 (p<0.001) compared to surgically treated fractures. The 1-year mortality rate in conservatively treated fractures was 56.44% compared to 24.47% in surgically treated fractures. Age, male sex, length of stay in hospital, day of surgery, post-surgical complications, and late surgery were significantly associated (p<0.001) with mortality after hip fracture. The lowest 1-year mortality rate was in surgically treated patients with a length of stay in hospital between 6 and 10 days. CONCLUSION We found a high mortality rate at 30 days and 1 year after low-trauma hip fracture. The high mortality rates can be attributable, in part, to the high number of conservatively treated fractures.
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Affiliation(s)
- Ramona Dobre
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania. .,Department of Endocrinology, National Institute of Endocrinology CI Parhon, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania.
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania.,Department of Endocrinology, National Institute of Endocrinology CI Parhon, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Catalin Cirstoiu
- Department of Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, 169 Splaiul Independenței, 050098, Bucharest, Romania.,Bucharest Emergency University Hospital, 169 Splaiul Independenței, 050098, Bucharest, Romania
| | - Gheorghe Popescu
- Department of Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, 8 Calea Floreasca, 014461, Bucharest, Romania.,Bucharest Clinical Emergency Hospital, 8 Calea Floreasca, 014461, Bucharest, Romania
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania.,Department of Endocrinology, National Institute of Endocrinology CI Parhon, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
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Sloan FA. Quality and Cost of Care by Hospital Teaching Status: What Are the Differences? Milbank Q 2021; 99:273-327. [PMID: 33751662 DOI: 10.1111/1468-0009.12502] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care. CONTEXT The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy. METHODS Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers. FINDINGS Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures. CONCLUSIONS Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.
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Walker RJ, Segon A, Good J, Nagavally S, Gupta N, Levine D, Neuner J, Egede LE. Differences in length of stay by teaching team status in an academic medical center in the Midwestern United States. Hosp Pract (1995) 2021; 49:119-126. [PMID: 33499682 DOI: 10.1080/21548331.2021.1882238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 01/25/2021] [Indexed: 06/12/2023]
Abstract
Background: Given the high cost of inpatient stays, hospital systems are investigating ways to decrease lengths of stay while ensuring high-quality care. The goal of this study was to determine if patients in teaching teams (hospitalist teams with residents and interns) had a higher length of stay after adjusting for relevant confounders compared to hospitalist-only teams (staffed only by attending physicians).Methods: Using a retrospective design, we investigated differences in length of stay for 17,577 inpatient encounters over a 2-year period. Length of stay was calculated based on the time between hospital admission and hospital discharge with no removal of outliers. Encounters were assigned to teams based on the discharge provider. Teams were grouped based on whether they were teaching teams or nonteaching teams. Since the length of stay was not normally distributed, it was modeled first using generalized linear models with gamma distribution and log link, and secondly by quantile regression. Models were adjusted for age, gender, race, medicine vs. non-medicine unit, MS-DRGs, and comorbidities.Results: Using gamma models to account for the skewed nature of the data, the length of stay for encounters assigned to teaching teams was 0.56 days longer (β = 0.10 95% CI 0.06 0.14) than for nonteaching teams after adjustment. Using quantile regression, teaching teams had encounters on average 0.63 days longer (95% CI 0.44 0.81) than nonteaching teams at the 75th percentile and 1.19 days longer (95% CI 0.77 1.61) compared to nonteaching teams at the 90th percentile after adjustment.Conclusions: After adjusting for demographics and clinical factors, teaching teams on average had lengths of stay that were over half day longer than nonteaching teams. In addition, for the longest encounters, differences between teaching and nonteaching teams were over 1-day difference. Given these results, process improvement opportunities exist within teaching teams regarding length of stay, particularly for longer encounters.
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Affiliation(s)
- Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ankur Segon
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer Good
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sneha Nagavally
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Navdeep Gupta
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Doug Levine
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joan Neuner
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
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Shortell SM, Blodgett JC, Rundall TG, Henke RM, Reponen E. Lean Management and Hospital Performance: Adoption vs. Implementation. Jt Comm J Qual Patient Saf 2021; 47:296-305. [PMID: 33648858 DOI: 10.1016/j.jcjq.2021.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Lean management system is being adopted and implemented by an increasing number of US hospitals. Yet few studies have considered the impact of Lean on hospitalwide performance. METHODS A multivariate analysis was performed of the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals and 2018 publicly available data from the Agency for Healthcare Research and Quality and the Center for Medicare & Medicaid Services on 10 quality/appropriateness of care, cost, and patient experience measures. RESULTS Hospital adoption of Lean was associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores (b = 3.35, p < 0.0001) on a scale of 100-300 but none of the other 9 performance measures. The degree of Lean implementation measured by the number of units throughout the hospital using Lean was associated with lower adjusted inpatient expense per admission (b = -38.67; p < 0.001), lower 30-day unplanned readmission rate (b = -0.01, p < 0.007), a score above the national average on appropriate use of imaging-a measure of low-value care (odds ratio = 1.04, p < 0.042), and higher HCAHPS patient experience scores (b = 0.12, p < 0.012). The degree of Lean implementation was not associated with any of the other 6 performance measures. CONCLUSION Lean is an organizationwide sociotechnical performance improvement system. As such, the actual degree of implementation throughout the organization as opposed to mere adoption is, based on the present findings, more likely to be associated with positive hospital performance on at least some measures.
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Hoxha I, Zhubi E, Grezda K, Kryeziu B, Bunjaku J, Sadiku F, Agahi R, Lungu DA, Bonciani M, Little G. Caesarean sections in teaching hospitals: systematic review and meta-analysis of hospitals in 22 countries. BMJ Open 2021; 11:e042076. [PMID: 33509847 PMCID: PMC7845681 DOI: 10.1136/bmjopen-2020-042076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/26/2020] [Accepted: 01/08/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE The aim of this study is to determine the odds of caesarean section in all births in teaching hospitals as compared with non-teaching hospitals. SETTING Over 3600 teaching and non-teaching hospitals in 22 countries. We searched CINAHL, The Cochrane Library, PubMed, sciELO, Scopus and Web of Science from the beginning of records until May 2020. PARTICIPANTS Women at birth. Over 18.5 million births. INTERVENTION Caesarean section. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measures are the adjusted OR of caesarean section in a variety of teaching hospital comparisons. The secondary outcome is the crude OR of caesarean section in a variety of teaching hospital comparisons. RESULTS In adjusted analyses, we found that university hospitals have lower odds than non-teaching hospitals (OR=0.66, 95% CI 0.56 to 0.78) and other teaching hospitals (OR=0.46, 95% CI 0.24 to 0.89), and no significant difference with unspecified teaching status hospitals (OR=0.92, 95% CI 0.80 to 1.05, τ2=0.009). Other teaching hospitals had higher odds than non-teaching hospitals (OR=1.23, 95% CI 1.12 to 1.35). Comparison between unspecified teaching hospitals and non-teaching hospitals (OR=0.91, 95% CI 0.50 to 1.65, τ2=1.007) and unspecified hospitals (OR=0.95, 95% CI 0.76 to 1.20), τ2<0.001) showed no significant difference. While the main analysis in larger sized groups of analysed studies reveals no effect between hospitals, subgroup analyses show that teaching hospitals carry out fewer caesarean sections in several countries, for several study populations and population characteristics. CONCLUSIONS With smaller sample of participants and studies, in clearly defined hospitals categories under comparison, we see that university hospitals have lower odds for caesarean. With larger sample size and number of studies, as well as less clearly defined categories of hospitals, we see no significant difference in the likelihood of caesarean sections between teaching and non-teaching hospitals. Nevertheless, even in groups with no significant effect, teaching hospitals have a lower or higher likelihood of caesarean sections in several analysed subgroups. Therefore, we recommend a more precise examination of forces sustaining these trends. PROSPERO REGISTRATION NUMBER CRD42020158437.
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Affiliation(s)
- Ilir Hoxha
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Research Unit, Heimerer College, Prishtina, Kosovo
- LifestylediagnostiX, Prishtina, Kosovo
| | | | | | | | | | | | - Riaz Agahi
- Research Unit, Heimerer College, Prishtina, Kosovo
| | - Daniel Adrian Lungu
- Health and Management Laboratory (MeS Lab), Institute of Management and Department EMbeDS, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Manila Bonciani
- Health and Management Laboratory (MeS Lab), Institute of Management and Department EMbeDS, Scuola Superiore Sant'Anna, Pisa, Italy
| | - George Little
- Department of Pediatrics and of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Rosko M, Al-Amin M, Tavakoli M. Efficiency and profitability in US not-for-profit hospitals. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2020; 20:359-379. [PMID: 32816192 PMCID: PMC7439627 DOI: 10.1007/s10754-020-09284-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/07/2020] [Indexed: 06/11/2023]
Abstract
This article examines the relationship between hospital profitability and efficiency. A cross-section of 1317 U.S. metropolitan, acute care, not-for-profit hospitals for the year 2015 was employed. We use a frontier method, stochastic frontier analysis, to estimate hospital efficiency. Total margin and operating margin were used as profit variables in OLS regressions that were corrected for heteroskedacity. In addition to estimated efficiency, control variables for internal and external correlates of profitability were included in the regression models. We found that more efficient hospitals were also more profitable. The results show a positive relationship between profitability and size, concentration of output, occupancy rate and membership in a multi-hospital system. An inverse relationship was found between profits and academic medical centers, average length of stay, location in a Medicaid expansion state, Medicaid and Medicare share of admissions, and unemployment rate. The results of a Hausman test indicates that efficiency is exogenous in the profit equations. The findings suggest that not-for-profit hospitals will be responsive to incentives for increasing efficiency and use market power to increase surplus to pursue their objectives.
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Affiliation(s)
- Michael Rosko
- Graduate Program in Health Care Management, School of Business Administration, Widener University, One University Place, Chester, PA, 19013, USA.
| | - Mona Al-Amin
- Department of Healthcare Administration, Sawyer Business School, Suffolk University, 120 Tremont Street, Room 5603, Boston, MA, 02108, USA
| | - Manouchehr Tavakoli
- School of Management, University of St. Andrews, St. Andrews, KY16 9RJ, Scotland, UK
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Farley BJ, Shear BM, Lu V, Walworth K, Gray K, Kirsch M, Clements JM. Rural, urban, and teaching hospital differences in hip fracture mortality. J Orthop 2020; 21:453-458. [PMID: 32982100 DOI: 10.1016/j.jor.2020.08.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/29/2020] [Accepted: 08/31/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Hip fractures remain one of the most prevalent and deadly conditions afflicting those 65 years and older. For other health conditions (e.g. myocardial infarction), hospital location is associated with poorer health outcomes. To our knowledge, no study has investigated the relationship between hip fracture morality rate in the United States between urban and rural hospital settings. Methods A retrospective cohort study was conducted to examine differences in in-hospital mortality between groups treated in rural, urban-teaching, and urban-non-teaching hospitals, as well as public and private hospitals. Mortality rates were also compared for variances between surgical treatment, sex, insurance, patient location, race, and income. Discharge data was collected for 256,240 inpatient stays from the 2012 National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Results Odds of mortality were 14.6% greater in rural hospital hip fracture patients compared to Urban/Non-Teaching centers (p < 0.05). Conclusions Results from this study lend support to necessitate further research investigating prospective barriers to care of those in rural settings. This may point to limitations in resources and trained medical and surgical specialists in rural hospitals and need for continued research to mitigate such findings.
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Affiliation(s)
- Brendan J Farley
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Brian M Shear
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Vivian Lu
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Kyla Walworth
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Kevin Gray
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Matt Kirsch
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - John M Clements
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
- Michigan State University, College of Human Medicine, Division of Public Health, Flint, MI, USA
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Diaz-Dilernia F, Garcia-Mansilla A, Llano L, Buljubasich M, Oñativia JI, Slullitel PAI, Zanotti G, Comba F, Piccaluga F, Buttaro MA. Who Restores Hip Biomechanics More Effectively after a Femoral Neck Fracture? Comparison of Total Hip Arthroplasties Performed by Either Hip Surgeons or Orthopaedic Residents. Arthroplast Today 2020; 6:736-741. [PMID: 32923560 PMCID: PMC7475170 DOI: 10.1016/j.artd.2020.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 07/02/2020] [Accepted: 07/15/2020] [Indexed: 12/21/2022] Open
Abstract
Background This study aims to analyze the ability to restore hip biomechanics in patients who undergo total hip arthroplasty for displaced femoral neck fractures operated by either hip surgeons (HSs) or orthopaedic residents (ORs). Methods We retrospectively compared 95 patients treated by HSs (group A) with 110 patients treated by ORs (group B). Leg-length discrepancy, femoral offset (FO), center of rotation (COR), acetabular inclination, and acetabular anteversion were evaluated on postoperative radiographs using the healthy contralateral hip as control. Results The median leg-length discrepancy was 2 mm for both groups (P = .74). The leg length was increased in 54% of the HS group and 57% of the OR group (P = .13). The median FO difference of groups A and B were 7 mm and 5.5 mm, respectively (P = .14). FO was increased in 80% of the HS group and 69% of the OR group (P = .19). Median discrepancies of the horizontal and vertical CORs were not statistically relevant, with P-values of .69 and .14, respectively. The horizontal COR was slightly medialized in 58% of the HS group and 53% of the OR group (P = .003). The vertical COR was slightly proximal in 66% of the HS group and 76% of the OR group (P = .28). The median acetabular inclination angles of groups A and B were 41° and 40°, respectively (P = .62). The median anteversion angle was 19° for both groups (P = .89). Conclusions The horizontal COR was the only measurement with statistical significance. To conclude, ORs under supervision are as reliable as HSs to properly restore hip biomechanics in patients who undergo total hip arthroplasty for displaced femoral neck fractures.
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Affiliation(s)
- Fernando Diaz-Dilernia
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Agustin Garcia-Mansilla
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Lionel Llano
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin Buljubasich
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Jose Ignacio Oñativia
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Pablo Ariel Isidoro Slullitel
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Gerardo Zanotti
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Comba
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Piccaluga
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin Alejandro Buttaro
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Polsky D, Wu B. Provider networks and health plan premium variation. Health Serv Res 2020; 56:16-24. [PMID: 32790200 DOI: 10.1111/1475-6773.13447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine how plan premiums are associated with physician network breadth, hospital network breadth, and hospital network quality on the Affordable Care Act's Health Insurance Marketplaces in all 50 states and the DC in 2016. DATA SOURCES Data on plan premiums and characteristics came from 2016 Robert Wood Johnson Foundation Health Insurance Exchange (HIX) Compare. Provider network information was obtained from Vericred. Hospital characteristics were obtained from CMS Hospital Compare and the American Hospital Association (AHA) survey. STUDY DESIGN We analyzed how plan premiums were associated with variations in physician network breadth, hospital network breadth, and hospital network quality using ordinary least square regressions with state-rating area fixed effects and carrier fixed effects. PRINCIPAL FINDINGS Plan premiums were positively associated with physician network breadth and hospital network breadth. We find the following statistically significant results: a one standard deviation increase in physician network breadth was linked to a premium increase of 2.8 percent or $101 per year; a one standard deviation increase in hospital network breadth was linked to a premium increase of 2.4 percent or $86 per year. There was no significant association between premiums and hospital network quality, as measured by hospital star ratings and the inclusion of teaching hospitals or the top-20 hospitals nationwide. CONCLUSIONS Physician network breadth and hospital network breadth contributed positively to plan premiums. The roles of the two types of provider network breadth are quantitatively similar. Premiums appear to be insensitive to hospital network quality.
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Affiliation(s)
- Daniel Polsky
- Department of Health Policy and Management, Bloomberg School of Public Health, Carey School of Business, Johns Hopkins University, Baltimore, Maryland
| | - Bingxiao Wu
- Department of Economics, Rutgers, The State University of New Jersey, New Brunswick, New Jersey
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21
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Adoption of Lean management and hospital performance: Results from a national survey. Health Care Manage Rev 2020; 46:E10-E19. [DOI: 10.1097/hmr.0000000000000287] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ren Y, Sethi RKV, Stankovic KM. National Trends in Surgical Resection of Vestibular Schwannomas. Otolaryngol Head Neck Surg 2020; 163:1244-1249. [PMID: 32571146 DOI: 10.1177/0194599820932148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To characterize the national trend for surgical resection of vestibular schwannoma (VS) and to assess changes in demographics, length of stay (LOS), discharge patterns, and hospital charges. STUDY DESIGN Population-based inpatient registry analysis. SETTING National Inpatient Sample and SEER database (Surveillance, Epidemiology, and End Results). PATIENTS AND METHODS Retrospective review of the US National Inpatient Sample and the SEER database from 2001 to 2014 of all patients who underwent resection of VS. RESULTS A total of 24,380 VS resections were performed. While the annual incidence of VS remained stable at 1.38 per 100,000, surgical volume declined by 36.1%, from 2807 in 2001 to 1795 in 2014 (R2 = 0.58). Total hospital charges more than doubled, from $52,475 in 2001 to $115,164 in 2014 ($4478 per year, R2 = 0.96). While most procedures were performed at large-sized hospitals, this decreased from 89% in 2002 to 75.8% in 2014. Average LOS remained stable at 5.2 days during the study period. The number of discharges to a nursing facility increased from 113 (5.5%) in 2002 to 245 (13.6%) in 2014 (P = .0002). CONCLUSION VS resection has evolved in the United States. While the incidence remained stable, surgical volume decreased by 36%, and hospital charges more than doubled. More cases are being performed at smaller hospitals. Although LOS did not vary significantly, there is an increase in nonroutine discharges. These data may guide future research in resource utilization in neurotology.
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Affiliation(s)
- Yin Ren
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine, University of California-San Diego, San Diego, California, USA
| | - Rosh K V Sethi
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Konstantina M Stankovic
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
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Mehta R, Paredes AZ, Tsilimigras DI, Moro A, Sahara K, Farooq A, Dillhoff M, Cloyd JM, Tsung A, Ejaz A, Pawlik TM. Influence of hospital teaching status on the chance to achieve a textbook outcome after hepatopancreatic surgery for cancer among Medicare beneficiaries. Surgery 2020; 168:92-100. [PMID: 32303348 DOI: 10.1016/j.surg.2020.02.024] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/13/2020] [Accepted: 02/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Assessing composite measures of quality such as textbook outcome may be superior to focusing on individual parameters when evaluating hospital performance. The aim of the current study was to assess the impact of teaching hospital status on the occurrence of a textbook outcome after hepatopancreatic surgery. METHODS The Medicare Inpatient Standard Analytic Files were used to identify patients undergoing hepatopancreatic surgery from 2013 to 2015 for a malignant indication. Stratified and multivariable regression analyses were performed to determine the relationship between teaching hospital status, hospital surgical volume and textbook outcome. RESULTS Among 8,035 Medicare patients (hepatectomy; 41.8%, pancreatectomy; 58.2%), 6,196 (77.1%) patients underwent surgery at a major teaching hospital, whereas 1,839 (22.9%) patients underwent surgery at a minor teaching hospital. Patients undergoing surgery for pancreatic cancer at a major teaching hospital had a greater likelihood of achieving a textbook outcome compared with patients treated at a minor teaching hospital (minor teaching hospital: 456, 40% versus major teaching hospital: 1,606, 45.4%; P = .002). The likelihood of textbook outcome was also greater among patients undergoing hepatopancreatic surgery at high-volume centers (pancreas, low volume: 875, 40.5% versus high volume: 1,187, 47.1% P < .001; liver, low volume: 608, 41.8% versus high volume: 886, 46.6%; P = .005). When examining only major teaching hospitals, patients undergoing a pancreatectomy at a high-volume center had 29% greater odds of achieving a textbook outcome (odds ratio 1.29, 95% confidence interval 1.12-1.49). In contrast, among patients undergoing pancreatic resection at high-volume centers, the odds of achieving a textbook outcome was comparable among major versus minor teaching hospital (odds ratio 1.17, 95% confidence interval 0.89-1.53). CONCLUSION The odds of achieving a textbook outcome after pancreatic and hepatic surgery was greater at major versus minor teaching hospitals; however, this effect was largely mediated by hepatopancreatic procedural volume. Patients and payers should focus on regionalization of pancreatic and liver resection to high-volume centers in an effort to optimize the chances of achieving a textbook outcome.
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Affiliation(s)
- Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH.
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Lasater KB, McHugh M, Rosenbaum PR, Aiken LH, Smith H, Reiter JG, Niknam BA, Hill AS, Hochman LL, Jain S, Silber JH. Valuing hospital investments in nursing: multistate matched-cohort study of surgical patients. BMJ Qual Saf 2020; 30:46-55. [PMID: 32220938 DOI: 10.1136/bmjqs-2019-010534] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND There are known clinical benefits associated with investments in nursing. Less is known about their value. AIMS To compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks. METHODS Retrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital's size category, teaching and technology status, and were closely matched on comorbidities and other risk factors. RESULTS Patients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (p<0.001), lower failure-to-rescue: 5.4% vs 6.2% (p<0.001), lower readmissions: 12.6% vs 13.5% (p<0.001), shorter lengths of stay: 4.70 days vs 4.76 days (p<0.001), more intensive care unit admissions: 17.2% vs 15.4% (p<0.001) and marginally higher nurse-adjusted costs (which account for the costs of better nursing resources): $20 096 vs $19 358 (p<0.001), as compared with patients in worse nursing resourced hospitals. The nurse-adjusted cost associated with a 1% improvement in mortality at better nursing hospitals was $2035. Patients with the highest mortality risk realised the greatest value from nursing resources. CONCLUSION Hospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.
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Affiliation(s)
- Karen B Lasater
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew McHugh
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul R Rosenbaum
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Linda H Aiken
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Herbert Smith
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Population Studies Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bijan A Niknam
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexander S Hill
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lauren L Hochman
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Siddharth Jain
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Amato ACM, Dos Santos RV, Saucedo DZ, Amato SJDTA. Machine learning in prediction of individual patient readmissions for elective carotid endarterectomy, aortofemoral bypass/aortic aneurysm repair, and femoral-distal arterial bypass. SAGE Open Med 2020; 8:2050312120909057. [PMID: 32128209 PMCID: PMC7036506 DOI: 10.1177/2050312120909057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 01/21/2020] [Indexed: 11/26/2022] Open
Abstract
Objective: Early hospital readmissions have been rising and are increasingly used for
public reporting and pay-for-performance. The readmission problem is
fundamentally different in surgical patients compared with medical patients.
There is an opportunity to intervene preoperatively to decrease the risk of
readmission postoperatively. Methods: A predictive model of 90-day hospital readmission for patients undergoing
elective carotid endarterectomy, aortofemoral bypass/aortic aneurysm repair,
and femoral-distal arterial bypass was developed using data from the
Healthcare Cost and Utilization Project State Inpatient Database for Florida
State. The model training followed a nested resampling method with
subsampling to increase execution speed and reduce overfitting. The
following predictors were used: age, gender, race, median household income,
primary expected payer, patient location, admission type, Elixhauser–van
Walraven Comorbidity Index, Charlson comorbidity score, main surgical
procedure, length of stay, disposition of the patient at discharge, period
of the year, hospital volume, and surgeon volume. Results: Our sample comprised data on 246,405 patients, of whom 30.3% were readmitted
within 90 days. Readmitted patients were more likely to be admitted via
emergency (47.2% vs 30%), included a higher percentage with a Charlson score
greater than 3 (35.8% vs 18.7%), had a higher mean van Walraven score (8.32
vs 5.34), and had a higher mean length of hospital stay (6.59 vs 3.51).
Endarterectomy was the most common procedure, accounting for 19.9% of all
procedures. When predicting 90-day readmission, Shrinkage Discriminant
Analysis was the best performing model (area under the curve = 0.68).
Important variables for the best predictive model included length of stay in
the hospital, comorbidity scores, endarterectomy procedure, and elective
admission type. The survival analysis for the time to readmission after the
surgical procedures demonstrated that the hazard ratios were higher for
subjects who presented Charlson comorbidity score above three (2.29 (2.26,
2.33)), patients transferred to a short-term hospital (2.4 (2.23, 2.59)),
home healthcare (1.64 (1.61, 1.68)), other type of facility (2.59 (2.54,
2.63)) or discharged against medical advice (2.06 (1.88, 2.26)), and those
with greater length of stay (1.89 (1.86, 1.91)). Conclusion: The model stratifies readmission risk on the basis of vascular procedure
type, which suggests that attempts to decrease vascular readmission should
focus on emergency procedures. Given the current focus on readmissions and
increasing pressure to prevent unplanned readmissions, this score stratifies
patients by readmission risk, providing an additional resource to identify
and prevent unnecessary readmissions.
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Affiliation(s)
- Alexandre Campos Moraes Amato
- Universidade Santo Amaro (UNISA), São Paulo, Brazil.,Department of Vascular Surgery, Amato-Instituto de Medicina Avançada, São Paulo, Brazil
| | - Ricardo Virgínio Dos Santos
- Universidade Santo Amaro (UNISA), São Paulo, Brazil.,Department of Vascular Surgery, Amato-Instituto de Medicina Avançada, São Paulo, Brazil
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Comparing Outcomes and Costs of Medical Patients Treated at Major Teaching and Non-teaching Hospitals: A National Matched Analysis. J Gen Intern Med 2020; 35:743-752. [PMID: 31720965 PMCID: PMC7080946 DOI: 10.1007/s11606-019-05449-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 09/15/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Teaching hospitals typically pioneer investment in new technology and cultivate workforce characteristics generally associated with better quality, but the value of this extra investment is unclear. OBJECTIVE Compare outcomes and costs between major teaching and non-teaching hospitals by closely matching on patient characteristics. DESIGN Medicare patients at 339 major teaching hospitals (resident-to-bed (RTB) ratios ≥ 0.25); matched patient controls from 2439 non-teaching hospitals (RTB ratios < 0.05). PARTICIPANTS Forty-three thousand nine hundred ninety pairs of patients (one from a major teaching hospital and one from a non-teaching hospital) admitted for acute myocardial infarction (AMI), 84,985 pairs admitted for heart failure (HF), and 74,947 pairs admitted for pneumonia (PNA). EXPOSURE Treatment at major teaching hospitals versus non-teaching hospitals. MAIN MEASURES Thirty-day all-cause mortality, readmissions, ICU utilization, costs, payments, and value expressed as extra cost for a 1% improvement in survival. KEY RESULTS Thirty-day mortality was lower in teaching than non-teaching hospitals (10.7% versus 12.0%, difference = - 1.3%, P < 0.0001). The paired cost difference (teaching - non-teaching) was $273 (P < 0.0001), yielding $211 per 1% mortality improvement. For the quintile of pairs with highest risk on admission, mortality differences were larger (24.6% versus 27.6%, difference = - 3.0%, P < 0.0001), and paired cost difference = $1289 (P < 0.0001), yielding $427 per 1% mortality improvement at 30 days. Readmissions and ICU utilization were lower in teaching hospitals (both P < 0.0001), but length of stay was longer (5.5 versus 5.1 days, P < 0.0001). Finally, individual results for AMI, HF, and PNA showed similar findings as in the combined results. CONCLUSIONS AND RELEVANCE Among Medicare patients admitted for common medical conditions, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used.
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Dowzicky P, Wirtalla C, Fieber J, Berger I, Raper S, Kelz RR. Hospital Teaching Status Impacts Surgical Discharge Efficiency. JOURNAL OF SURGICAL EDUCATION 2019; 76:1329-1336. [PMID: 30987921 DOI: 10.1016/j.jsurg.2019.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/21/2019] [Accepted: 03/27/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE There is a paucity of data regarding the efficiency of care provided by teaching hospitals. Yet, instruction on transitions in care and an understanding of systems-based practice are key components of modern graduate medical education. We aimed to determine the relationship between hospital teaching status and the discharge efficiency from a surgical service. SETTING Patients who were cared for at teaching and nonteaching hospitals captured in the Healthcare Cost and Utilization Project National Inpatient Sample from 2012. PARTICIPANTS A total of 272,090 patients who underwent one of 44 predefined general surgery procedure types. DESIGN Patients were stratified based on treating hospital teaching status (TH vs. NTH). Procedure-specific early discharge (PSED) was defined for each operation type as a discharge that occurred within the lowest 25th percentile for overall length of stay. PSED was used as the discharge efficiency metric. To adjust for cofounders and hospital level clustering, multivariable mixed-effects logistic regression was used to examine the association between teaching status and PSED. Subgroup analysis was performed by operation type. Models were constructed with and without adjustment for inpatient complications. RESULTS There were 140,878 (51.8%) patients who received care at a TH. TH status was significantly associated with lower PSED (TH: 10.7% vs. NTH: 11.4%; p < 0.001) and longer length of stay (TH: 5.5 days vs. NTH: 4.5 days; p < 0.001). In the adjusted model of the overall cohort, patients treated at a TH were 8% less likely to receive a PSED compared to those treated at NTH (odds ratio 0.92, 95% confidence interval (0.88, 0.97); p < 0.002). Differences in the rates and odds of PSED were noted across the subgroups. CONCLUSIONS Teaching hospital status is associated with a reduced likelihood of PSED. The effect of TH on PSED varied by procedure subgroup. Examining the recovery pathways and discharge practices at NTH may allow for the identification of more efficient methods of care that can be applied to the broader healthcare system.
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Affiliation(s)
- Phillip Dowzicky
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Chris Wirtalla
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Fieber
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Berger
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Steve Raper
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Khullar D, Frakt AB, Burke LG. Advancing the Academic Medical Center Value Debate: Are Teaching Hospitals Worth It? JAMA 2019; 322:205-206. [PMID: 31206128 DOI: 10.1001/jama.2019.8306] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Dhruv Khullar
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Austin B Frakt
- Partnered Evidence-Based Policy Resource Center, Veterans Health Administration, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Laura G Burke
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Second Place Award: Residents or hip surgeons for the treatment of displaced femoral neck fractures? A 10-year survivorship rate analysis. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Burke LG, Khullar D, Zheng J, Frakt AB, Orav EJ, Jha AK. Comparison of Costs of Care for Medicare Patients Hospitalized in Teaching and Nonteaching Hospitals. JAMA Netw Open 2019; 2:e195229. [PMID: 31173121 PMCID: PMC6563581 DOI: 10.1001/jamanetworkopen.2019.5229] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/20/2019] [Indexed: 01/09/2023] Open
Abstract
Importance Little empirical work has been performed on whether teaching hospitals are more expensive when considering total costs of care for an acute care episode. Objective To compare total standardized costs at 30 days by hospital teaching status for common conditions. Design, Setting, and Participants This cross-sectional study assessed the costs of hospitalizations among US Medicare beneficiaries 65 years and older at major, minor, and nonteaching hospitals from January 1, 2014, to November 30, 2015, for 15 medical conditions and 6 surgical procedures. Data analysis was performed from February 26, 2019, to April 16, 2019. Exposures Hospital teaching status (major, minor, and nonteaching hospitals). Main Outcomes and Measures The primary outcome was 30-day total standardized costs to Medicare for hospitalizations for all 21 conditions in aggregate as well as stratified by medical and surgical condition categories. Secondary outcomes included 30-day spending for individual components of care (index hospitalization, physician services, readmission, and outpatient and post-acute care services) as well as total standardized costs at 90 days. Results The sample consisted of 1 249 006 hospitalizations at 3064 hospitals (232 [7.6%] major teaching, 837 [27.3%] minor teaching, and 1995 [65.1%] nonteaching hospitals). Treatment at a major teaching hospital was associated with lower total 30-day adjusted standardized costs ($18 605 vs $18 793 at minor teaching hospitals and $18 873 at nonteaching hospitals; difference between major and nonteaching hospitals: -$268; 95% CI, -$456 to -$80; P = .005). Treatment at a major teaching hospital was associated with higher spending for the index hospitalization ($8529 vs $8370 at minor teaching hospitals and $8180 at nonteaching hospitals; difference between major and nonteaching hospitals: $349; 95% CI, $308-$390; P < .001) but lower physician costs ($677 vs $725 at minor teaching hospitals and $728 at nonteaching hospitals; difference: -$50; 95% CI, -$60 to -$41; P < .001). Furthermore, post-acute care costs at 30 days were lowest at major teaching hospitals ($6015 vs $6239 for minor teaching hospitals and $6260 for nonteaching hospitals; difference: -$245; 95% CI, -$375 to -$115; P < .001). Thirty-day total costs were lower at major teaching hospitals compared with nonteaching hospitals for 12 of the 21 individual conditions examined. There was no difference in costs by teaching status at 90 days ($24 982 at major teaching hospitals vs $24 959 at minor teaching hospitals vs $25 044 at nonteaching hospitals; difference: -$61; 95% CI, -$310 to $188; P = .63). Conclusions and Relevance Medicare patients treated at major teaching hospitals had lower Medicare spending at 30 days and similar costs at 90 days compared with Medicare patients at nonteaching hospitals. These findings appear to raise doubts that care at teaching hospitals is necessarily more expensive than care at nonteaching hospitals.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts
| | - Dhruv Khullar
- Department of Medicine, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts
| | - Austin B. Frakt
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Health Law, Policy and Management, Boston University, Boston, Massachusetts
| | - E. John Orav
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts
| | - Ashish K. Jha
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts
- Harvard Global Health Institute, Cambridge, Massachusetts
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
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Kotwal S, Abougergi MS, Wright S. Differences in healthcare outcomes between teaching and non teaching hospitals for patients with delirium: a retrospective cohort study. Int J Qual Health Care 2019; 31:378-384. [PMID: 30165567 DOI: 10.1093/intqhc/mzy182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 05/22/2018] [Accepted: 08/03/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The physician workforce at teaching hospitals differs compared to non-teaching hospitals, and data suggest that patient outcomes may also be dissimilar. Delirium is a common, costly disorder among hospitalized patients and approaches to care are not standardized. OBJECTIVE This study set out to explore differences in healthcare outcomes between teaching and non-teaching hospitals for patients admitted with delirium. DESIGN Retrospective cohort analysis. SETTING AND PARTICIPANTS We used the 2014 Nationwide Inpatient Sample database. Adult patients (≥18 years of age) hospitalized in acute-care hospitals in the USA with delirium (defined with ICD-9 code) were studied. MAIN OUTCOME MEASURES The primary outcome was in-hospital all-cause mortality. Secondary outcomes were discharge status and several measures of healthcare resource utilization: length of stay, total hospitalization costs and multiple procedures performed. RESULTS In 2014, out of 57 460 adult patients admitted to hospitals with delirium, 58.4% were hospitalized at teaching hospitals and the remainder 41.6% at non-teaching hospitals. The in-hospital mortality of delirium patients in teaching hospitals was 1.33% (95% CI 1.08%-1.63%), and 1.26% (95% CI 0.97%-1.63%) in non-teaching hospitals. The mean total hospital costs were $7642 (95% CI 7384-7900) in teaching hospitals, and $6650 (95% CI 6460-6840) in non-teaching hospitals. After adjustment for confounders, total hospitalization costs were statistically significantly different between the hospitals types-with non-teaching providing less expensive care. CONCLUSIONS Patients with delirium admitted to non-teaching hospitals had comparable clinical and process outcomes achieved at lower costs. Further research can be conducted to explore the contextual issues and reasons for these differences in healthcare costs.
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Affiliation(s)
- Susrutha Kotwal
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marwan S Abougergi
- Catalyst Medical Consulting, LLC 722 Elmbrook Drive Simpsonville, SC, USA.,Division of Gastroenterology, Department of Medicine, University of South Carolina, Columbia, SC, USA
| | - Scott Wright
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
BACKGROUND Discharge to a nonhome destination (ie, skilled nursing facility, subacute rehabilitation, or long-term care facility) after surgery is associated with increased mortality and higher costs and is less desirable to patients than discharge to home. OBJECTIVE We sought to identify modifiable hospital-level factors that may reduce rates of nonhome discharge after colorectal resection. DESIGN This was a retrospective cohort study of patients undergoing colorectal resection in the Michigan Surgical Quality Collaborative (July 2012 to June 2015). Patient- and hospital-level characteristics were tested for association with nonhome discharge patterns. SETTINGS Patients were identified using prospectively collected data from the Michigan Surgical Quality Collaborative, a statewide collaborative encompassing 63 community, academic, and tertiary hospitals. PATIENTS Patients undergoing colon and rectal resections were included. MAIN OUTCOME MEASURE The main outcome measure was hospital use patterns of nonhome discharge. RESULTS Of the 9603 patients identified, 1104 (11.5%) were discharged to a nonhome destination. After adjustments for patient factors associated with nonhome discharge, we identified variability in hospital use patterns for nonhome discharge. Designation as a low utilizer hospital was associated with affiliation with a medical school (p = 0.020) and high outpatient volume (p = 0.028). After adjustments for all hospital factors, only academic affiliation maintained a statistically significant relationship (OR = 4.94; p = 0.045). LIMITATIONS This study had a retrospective cohort design with short-term follow-up of sampled cases. Additionally, by performing our analysis on the hospital level, there is a decreased sample size. CONCLUSIONS This population-based study shows that there is significant variation in hospital practices for nonhome discharge. Specifically, hospitals affiliated with a medical school are less likely to discharge patients to a facility, even after adjustment for patient and procedural risk factors. This study raises the concern that there may be overuse of subacute facility discharge in certain hospitals, and additional study is warranted. See Video Abstract at http://links.lww.com/DCR/A837.
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Burke L, Khullar D, Orav EJ, Zheng J, Frakt A, Jha AK. Do Academic Medical Centers Disproportionately Benefit The Sickest Patients? Health Aff (Millwood) 2019; 37:864-872. [PMID: 29863940 DOI: 10.1377/hlthaff.2017.1250] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Academic medical centers are widely considered to have higher costs than nonteaching hospitals, which has led some policy makers to suggest that the centers should be reserved for patients with the most complex conditions. While prior studies have shown lower mortality at the centers, it is unclear how this varies by patient severity. We examined more than 11.8 million hospitalizations in the period 2012-14 for Medicare beneficiaries ages sixty-five and older and found that, after adjustment for patient and hospital characteristics, high-severity patients had 7 percent lower odds, medium-severity patients had 13 percent lower odds, and low-severity patients had 17 percent lower odds of thirty-day mortality when treated at an academic medical center for common medical conditions, compared to similar patients treated at a nonteaching hospital. For surgical procedures, high-severity patients had 17 percent lower odds of mortality, medium-severity patients had 10 percent lower odds, and there was no difference for low-severity patients. The availability of technology explained some, but not all, of these differences. Taken together, these findings suggest that efforts to limit care at academic medical centers have the potential to lead to worse outcomes, as mortality rates for even low-severity patients seem to be lower at the centers.
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Affiliation(s)
- Laura Burke
- Laura Burke is an assistant professor of emergency medicine at Beth Israel Deaconess Medical Center/Harvard Medical School, in Boston, Massachusetts
| | - Dhruv Khullar
- Dhruv Khullar is a physician at NewYork-Presbyterian Hospital and a researcher in the Department of Healthcare Policy and Research, Weill Cornell Medical Center, in New York City
| | - E John Orav
- E. John Orav is an associate professor of biostatistics at the Harvard T. H. Chan School of Public Health, in Cambridge, Massachusetts
| | - Jie Zheng
- Jie Zheng is a senior statistician at the Harvard T. H. Chan School of Public Health
| | - Austin Frakt
- Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the Veterans Affairs (VA) Boston Healthcare System; an associate professor in the Boston University School of Public Health; and an adjunct associate professor at the Harvard T. H. Chan School of Public Health
| | - Ashish K Jha
- Ashish K. Jha ( ) is the K. T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health and director of the Harvard Global Health Institute
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Hospital Characteristics Associated With Postdischarge Hospital Readmission, Observation, and Emergency Department Utilization. Med Care 2019; 56:281-289. [PMID: 29462075 DOI: 10.1097/mlr.0000000000000882] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Whether types of hospitals with high readmission rates also have high overall postdischarge acute care utilization (including emergency department and observation care) is unknown. DESIGN Cross-sectional analysis. SUBJECTS Nonfederal United States acute care hospitals. MEASURES Using methodology established by the Centers for Medicare & Medicaid Services, we calculated each hospital's "excess days in acute care" for fee-for-service (FFS) Medicare beneficiaries aged over 65 years discharged after hospitalization for acute myocardial infarction, heart failure (HF), or pneumonia, representing the mean difference between predicted and expected total days of acute care utilization in the 30 days following hospital discharge, per 100 discharges. We assessed the multivariable association of 8 hospital characteristics with excess days in acute care and the proportion of hospitals with each characteristic that were statistical outliers (95% credible interval estimate does not include 0). RESULTS We included 2184 hospitals for acute myocardial infarction [228 (10.4%) better than expected, 549 (25.1%) worse than expected], 3720 hospitals for HF [484 (13.0%) better and 840 (22.6%) worse], and 4195 hospitals for pneumonia [673 (16.0%) better, 1005 (24.0%) worse]. Results for all conditions were similar. Worse than expected outliers for pneumonia included: 18.8% of safety net hospitals versus 26.1% of nonsafety net hospitals; 16.7% of public hospitals versus 33.1% of for-profit hospitals; 19.5% of nonteaching hospitals versus 52.2% of major teaching hospitals; 7.9% of rural hospitals versus 42.1% of large urban hospitals; 5.9% of hospitals with 24-<50 beds versus 58% of hospitals with >500 beds; and 29.0% of hospitals with nurse-to-bed ratios >1.0-1.5 versus 21.7% of hospitals with ratios >2.0. CONCLUSIONS Including emergency department and observation stays in measures of postdischarge utilization produces similar results as measuring only readmissions in that major teaching, urban and for-profit hospitals still perform disproportionately poorly versus nonteaching or public hospitals. However, it enables identification of more outliers and a more granular assessment of the association of hospital factors and outcomes.
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Kidwai SM, Yang A, Gray ML, McKee S, Iloreta AM, Shrivastava R, Govindaraj S. Hospital Charge Variability across New York State: Sociodemographic Factors in Pituitary Surgery. J Neurol Surg B Skull Base 2019; 80:612-619. [PMID: 31750048 DOI: 10.1055/s-0038-1676839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022] Open
Abstract
Introduction Significant charge disparities exist across New York State (NYS). Race and income are associated with increased charges. To determine risk factor, we correlate hospital charges for pituitary surgery with socioeconomic factors. Additionally, we identify patients at risk for increased hospital charges and provide insight into cost-effective practices. Methods Retrospective cohort study of the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health was conducted. The SPARCS database was reviewed. Patients who underwent transsphenoidal pituitary surgery from 1995 to 2015 were identified. Income and urban status were referenced from U.S. census data. Linear regression was performed to analyze the effect of sociodemographic factors, comorbidities, and complications on hospital charges while controlling for length of stay. Results A total of 9,373 patients were identified. Black (10.8%, p < 0.001) and Asian (14.5%, p < 0.001) had higher hospital charges. Patients from nonurban cities (13.4%, p < 0.001), Medicaid (13.8%, p < 0.001), and those from the 0 to 25th (9.1%, p < 0.001) and 25 to 50th (11.7%, p < 0.001) income quartile had lower hospital charges. Patients with postoperative cerebrospinal fluid leak (24.0%, p < 0.001), diabetes insipidus (22.1%, p < 0.001), smoking history (11.8%, p < 0.001), hypertension (7.4%, p < 0.001), and hypothyroidism (6.9%, p < 0.001) had higher hospital charges. Conclusion Patients incurring higher chargers were more likely to have a smoking history, hypertension, hypothyroidism, and comorbidities. The determinants of this analysis may provide insight into barriers to patient access and cost improvement strategies. In addition, this emphasizes the need for future studies to create a risk stratification model, similar to those in other fields.
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Affiliation(s)
- Sarah M Kidwai
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Anthony Yang
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Mingyang L Gray
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Sean McKee
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Alfred Marc Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Raj Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Satish Govindaraj
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
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Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System? Clin Orthop Relat Res 2019; 477:177-190. [PMID: 30179946 PMCID: PMC6345301 DOI: 10.1097/corr.0000000000000460] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hospital-related factors associated with mortality and morbidity after hip fracture surgery are not completely understood. The Veterans Health Administration (VHA) is the largest single-payer, networked healthcare system in the country serving a relatively homogenous patient population with facilities that vary in size and resource availability. These characteristics provide some degree of financial and patient-level controls to explore the association, if any, between surgical volume and facility resource availability and hospital performance regarding postoperative complications after hip fracture surgery. QUESTIONS/PURPOSES (1) Do VHA facilities with the highest complexity level designation (Level 1a) have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-complexity level facilities? (2) Do VHA facilities with higher hip fracture surgical volume have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-volume facilities? METHODS We explored the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database from October 2001 to September 2012 for records of hip fracture surgery performed. Data reliability of the VASQIP database has been previously validated. We excluded nine of the 98 VHA facilities for contributing fewer than 30 records. The remaining 89 VHA facilities provided 23,029 records. The VHA designates a complexity level to each facility based on multiple criteria. We labeled facilities with a complexity Level 1a (38 facilities)-the highest achievable VHA designated complexity level-as high complexity; we labeled all other complexity level designations as low complexity (51 facilities). Facility volume was divided into tertiles: high (> 277 hip fracture procedures during the sampling frame), medium (204 to 277 procedures), and low (< 204 procedures). The patient population treated by low-complexity facilities was older, had a higher prevalence of severe chronic obstructive pulmonary disease (26% versus 22%, p < 0.001), and had a higher percentage of patients having surgery within 2 days of hospital admission (83% versus 76%, p < 0.001). High-complexity facilities treated more patients with recent congestive heart failure exacerbation (4% versus 3%, p < 0.001). We defined major postoperative complications as having at least one of the following: death within 30 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, new q-wave myocardial infarction, deep vein thrombosis and/or pulmonary embolism, ventilator dependence for at least 48 hours after surgery, reintubation for respiratory or cardiac failure, acute renal failure requiring renal replacement therapy, progressive renal insufficiency with a rise in serum creatinine of at least 2 mg/dL from preoperative value, pneumonia, or surgical site infection. We used the observed-to-expected ratio (O/E ratio)-a risk-adjusted metric to classify facility performance-for major postoperative complications to assess the performance of VHA facilities. Outlier facilities with 95% confidence intervals (95% CI) for O/E ratio completely less than 1.0 were labeled "exceed expectation;" those that were completely greater than 1.0 were labeled "below expectation." We compared differences in the distribution of outlier facilities between high and low-complexity facilities, and between high-, medium-, and low-volume facilities using Fisher's exact test. RESULTS We observed no association between facility complexity level and the distribution of outlier facilities (high-complexity: 5% exceeded expectation, 5% below expectation; low-complexity: 8% exceeded expectation, 2% below expectation; p = 0.742). Compared with high-complexity facilities, the adjusted odds ratio for major postoperative complications for low-complexity facilities was 0.85 (95% CI, 0.67-1.09; p = 0.108).We observed no association between facility volume and the distribution of outlier facilities: 3% exceeded expectation and 3% below expectation for high-volume; 10% exceeded expectation and 3% below expectation for medium-volume; and 7% exceeded expectation and 3% below expectation for low-volume; p = 0.890). The adjusted odds ratios for major postoperative complications were 0.87 (95% CI, 0.73-1.05) for low- versus high-volume facilities and 0.89 (95% CI, 0.79-1.02] for medium- versus high-volume facilities (p = 0.155). CONCLUSIONS These results do not support restricting facilities from treating hip fracture patients based on historical surgical volume or facility resource availability. Identification of consistent performance outliers may help health care organizations with multiple facilities determine allocation of services and identify characteristics and processes that determine outlier status in the interest of continued quality improvement. LEVEL OF EVIDENCE Level III, therapeutic study.
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Canal C, Kaserer A, Ciritsis B, Simmen HP, Neuhaus V, Pape HC. Is There an Influence of Surgeon's Experience on the Clinical Course in Patients With a Proximal Femoral Fracture? JOURNAL OF SURGICAL EDUCATION 2018; 75:1566-1574. [PMID: 29699929 DOI: 10.1016/j.jsurg.2018.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/06/2017] [Accepted: 04/03/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Teaching of surgical procedures is of paramount importance. However, it can affect patients outcome. The aim of this study was to evaluate if teaching of hip fracture surgery is an independent predictor for negative in-hospital outcome. DESIGN AND SETTING Retrospectively, we analyzed all hip fracture patients between 2008 and 2013 recorded in a national quality measurement database (AQC). Inclusion criteria were proximal femoral fracture (ICD-10 diagnostic codes S72.00-S72.11), surgical care of those fracture and a documented teaching status of the intervention. Variables were sought in bivariate and multivariate analyses. Teaching status was entered in multiple regression analysis models for in-hospital death, complications and length of stay while controlling for confounders. PARTICIPANTS In the 6-year study period, a total of 4397 patients at a mean age of 80 years met the inclusion criteria. Totally, 48% (n = 2107) of the procedures were conducted as teaching interventions. The rest of our examined cases (n = 2290) were conducted as nonteaching procedures. RESULTS There was no association between teaching and mortality, but complications (odds ratio = 1.3; 95% CI: 1.04-1.5; p = 0.018) and prolonged hospitalization (standardized beta = 0.045, p = 0.002) were more likely to occur in the teaching group while controlling for confounders. CONCLUSIONS There appears to be no effect of the educational status on the in-hospital death in patients with a proximal femoral fracture. However, teaching was an independent predictor of complications and longer length of stay. Although the differences were significant, the clinical outcome was comparable in both groups, thus justifying the benefits of resident teaching.
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Affiliation(s)
- Claudio Canal
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Bernhard Ciritsis
- Department of Surgery, Regional Hospital Bellinzona, Bellinzona, Switzerland
| | - Hans-Peter Simmen
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Valentin Neuhaus
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Hans-Christoph Pape
- Division of Trauma Surgery, Department of Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Åhman R, Siverhall PF, Snygg J, Fredrikson M, Enlund G, Björnström K, Chew MS. Determinants of mortality after hip fracture surgery in Sweden: a registry-based retrospective cohort study. Sci Rep 2018; 8:15695. [PMID: 30356058 PMCID: PMC6200788 DOI: 10.1038/s41598-018-33940-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/06/2018] [Indexed: 11/27/2022] Open
Abstract
Surgery for hip fractures is associated with high mortality and morbidity. The causes of poor outcome are not fully understood and may be related to other factors than the surgery itself. The relative contributions of patient, surgical, anaesthetic and structural factors have seldom been studied together. This study, a retrospective registry-based cohort study of 14 932 patients undergoing hip fracture surgery in Sweden from 1st of January 2014 to 31st of December 2016, aimed to identify important predictors of mortality post-surgery. The independent predictive power of our included variables was examined using Cox proportional hazards modeling with all-cause mortality at longest follow-up as the outcome. Twelve independent variables were considered as interrelated ‘exposures’ and their individual adjusted effect within a single model were evaluated. Kaplan-Meier curves were also generated. Crude mortality rates were 8.2% at 30 days (95% CI 7.7–8.6%) and 23.6% at 365 days (95% CI 22.9–24.2%). Of the 12 factors entered into the Cox regression analysis, age (aHR1.06, p < 0.001), male gender (aHR 1.45, p < 0.001), ASA-PS-class (ASA 1&2 reference; ASA 3 aHR 2.12; ASA 4 aHR 4.79; ASA 5 aHR 12.57 respectively, p < 0.001) and PACU-LOS (aHR 1.01, p < 0.001) were significantly associated with mortality at longest follow-up (up to 3 years). University hospital status was protective (aHR 0.83, p < 0.001) in the same model. Age, gender and ASA-PS-class were strong predictors of mortality after surgery for hip fractures in Sweden. University hospital status and length of stay in the postoperative care unit were also identified as modifiable risk factors after multivariable adjustment and require confirmation in future studies.
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Affiliation(s)
- Rasmus Åhman
- Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Linköping University, Linköping, S-58185, Sweden.
| | - Pontus Forsberg Siverhall
- Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Linköping University, Linköping, S-58185, Sweden
| | - Johan Snygg
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health, Linköping University, S-58185, Linköping, Sweden
| | - Gunnar Enlund
- Department of Anaesthesia and Intensive Care, Uppsala University Hospital, 78185, Uppsala, Sweden
| | - Karin Björnström
- Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Linköping University, Linköping, S-58185, Sweden
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Linköping University, Linköping, S-58185, Sweden
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Nejim B, Beaulieu RJ, Alshaikh H, Hamouda M, Canner J, Malas MB. A Unique All-Payer Rate-Setting System Controls the Cost but Not the Racial Disparity in Lower Extremity Revascularization Procedures. Ann Vasc Surg 2018; 52:116-125. [PMID: 29783031 DOI: 10.1016/j.avsg.2018.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/11/2017] [Accepted: 03/10/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with peripheral arterial disease often have high comorbidity burden that may complicate post-interventional course and drive increased health-care expenditures. Racial disparity had been observed in lower extremity revascularization (LER) patterns and outcomes. In 2014, Maryland adopted an all-payer rate-setting system to limit the rising hospitalization costs. This resulted in an aggregate payment system in which hospital compensation takes place as an overall per capita expenditure for hospital services. We sought to examine racial differences and other patient-level factors that might lead to discrepancies in LER hospital costs in the State of Maryland. METHODS We used International Classification of Diseases, Ninth Revision codes to identify patients who underwent infrainguinal open bypass (open) and endovascular repair (endo) in the Maryland Health Services Cost Review Commission database (2009-2015). Multivariable generalized linear model regression analysis was conducted to report cost differences adjusting for patient-specific demographics, comorbidities, and insurance status. Logistic regression analysis was used to assess quality metrics: intensive care unit (ICU) admission, 30-day readmission, protracted length of stay (pLOS) (endo: pLOS >9, open: pLOS > 10 days) and in-hospital mortality. RESULTS Among patients undergoing open, costs were higher for nonwhite patients (African-American [AA]: $6,092 [4,682-7,501], other: $3,324 [437-6,212]; both P ≤ 0.024), diabetics ($2,058 [837-3,279]; P < 0.001), and patients with Medicaid had an increased cost over Medicare patients by $4,325 (1,441-7,209). Critical limb ischemia (CLI) was associated with $5,254 (4,014-6,495) risk-adjusted cost increment. In addition, AA patients demonstrated higher risk-adjusted odds of ICU admission (adjusted odds ratio [aOR] [95% confidence interval {CI}]:1.65 [1.46-1.86]; P < 0.001) and pLOS (aOR [95% CI]: 1.56 [1.37-1.79]; P < 0.001) than their white counterparts. For patients undergoing endo, costs were higher for nonwhite patients (AA: $2,642 [1,574-3,711], other: $4,124 [2,091-6,157]; both P < 0.001). Patients with CLI and heart failure had increased costs after endo. AA patients were more likely to be readmitted or stayed longer after endo (1.16 [1.03-1.29], 1.34 [1.21-1.49]; both P < 0.010, respectively). The overall cost trend was rapidly increasing before all-payer rate policy implementation but it dramatically plateaued after 2014. CONCLUSIONS This study showed that the all-payer rate-setting system has curbed the LER rising costs, but these costs remained disproportionally higher for disadvantaged populations such as AA and Medicaid communities. This underpins the existing racial disparity in LER. AA patients had higher LER costs, most likely driven by extended hospitalization and ICU admission. Efforts could be directed to evaluate the contributing socioeconomic factors, invest in primary prevention of comorbid conditions that had shown to be associated with prohibitive costs, and identify mechanisms to overcome the existing racial disparity in LER within the promising cost-saving payment system at the State of Maryland.
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Affiliation(s)
- Besma Nejim
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Robert J Beaulieu
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Husain Alshaikh
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Mohammed Hamouda
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Joseph Canner
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Mahmoud B Malas
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD.
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Chen Q, Bagante F, Merath K, Idrees J, Beal EW, Cloyd J, Dillhoff M, Schmidt C, Diaz A, White S, Pawlik TM. Hospital Teaching Status and Medicare Expenditures for Hepato-Pancreato-Biliary Surgery. World J Surg 2018; 42:2969-2979. [DOI: 10.1007/s00268-018-4566-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Wilson LE, Pollack CE, Greiner MA, Dinan MA. Association between physician characteristics and the use of 21-gene recurrence score genomic testing among Medicare beneficiaries with early-stage breast cancer, 2008-2011. Breast Cancer Res Treat 2018. [PMID: 29536319 DOI: 10.1007/s10549-018-4746-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE We sought to determine whether physician-level characteristics were associated with 21-gene recurrence score (RS) genomic testing to evaluate recurrence risk and benefit of adjuvant chemotherapy in patients with estrogen receptor-positive, node-negative breast cancer. METHODS Retrospective cohort study of a nationally representative sample of Medicare beneficiaries using Surveillance, Epidemiology, and End Results program-Medicare data linked with the American Medical Association physician master file. The main outcome was receipt of genomic testing within 1 year of diagnosis as a function of physician-level factors. RESULTS A total of 24,463 patients met the study criteria; they received care from 3172 surgeons and 2475 medical oncologists. Of 4124 tests ordered, 70% were ordered by a medical oncologist and 16% by a surgeon. In multivariable regression models, multiple variables were associated with receipt of testing, including having a medical oncologist (odds ratio [OR] 2.77; 95% CI 2.00-3.82), a surgeon specializing in surgical oncology (OR 1.20; 95% CI 1.09-1.31), and a female medical oncologist (OR 1.10; 95% CI 1.02-1.20). Having a medical oncologist with 5 or more years in practice was associated with lower odds of testing (OR 0.83; 95% CI 0.76-0.92). Surgical procedures performed at academic centers were associated with higher odds of testing (OR 1.11; 95% CI 1.02-1.20). CONCLUSIONS Although most RS testing was ordered by medical oncologists, physicians in other specialties ordered roughly one-third of the tests. Physician characteristics, including gender and time in practice, were associated with receiving testing, creating opportunities for targeting interventions to help patients receive optimal care.
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Affiliation(s)
- Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Erwin Square Suite 720A, Box 104023, Durham, NC, 27705, USA.
| | - Craig Evan Pollack
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Erwin Square Suite 720A, Box 104023, Durham, NC, 27705, USA
| | - Michaela A Dinan
- Department of Population Health Sciences, Duke University School of Medicine, Erwin Square Suite 720A, Box 104023, Durham, NC, 27705, USA
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Wei Y, Yu H, Geng J, Wu B, Guo Z, He L, Chen Y. Hospital efficiency and utilization of high-technology medical equipment: A panel data analysis. HEALTH POLICY AND TECHNOLOGY 2018. [DOI: 10.1016/j.hlpt.2018.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Gupta T, Patel K, Kolte D, Khera S, Villablanca PA, Aronow WS, Frishman WH, Cooper HA, Bortnick AE, Fonarow GC, Panza JA, Weisz G, Menegus MA, Garcia MJ, Bhatt DL. Relationship of Hospital Teaching Status with In-Hospital Outcomes for ST-Segment Elevation Myocardial Infarction. Am J Med 2018; 131:260-268.e1. [PMID: 29037939 DOI: 10.1016/j.amjmed.2017.09.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 09/10/2017] [Accepted: 09/11/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prior analyses have largely shown a survival advantage with admission to a teaching hospital for acute myocardial infarction. However, most prior studies report data on patients hospitalized over a decade ago. It is important to re-examine the association of hospital teaching status with outcomes of acute myocardial infarction in the current era. METHODS We queried the 2010 to 2014 National Inpatient Sample databases to identify all patients aged ≥18 years hospitalized with the principal diagnosis of ST-segment elevation myocardial infarction (STEMI). Multivariable logistic regression models were constructed to compare rates of reperfusion and in-hospital outcomes between patients admitted to teaching vs nonteaching hospitals. RESULTS Of 546,252 patients with STEMI, 273,990 (50.1%) were admitted to teaching hospitals. Compared with patients admitted to nonteaching hospitals, those at teaching hospitals were more likely to receive reperfusion therapy during the hospitalization (86.7% vs 81.5%; adjusted odds ratio [OR] 1.41; 95% confidence interval [CI], 1.39-1.44; P < .001) and had lower risk-adjusted in-hospital mortality (4.9% vs 6.9%; adjusted OR 0.84; 95% CI, 0.82-0.86; P < .001). After further adjustment for differences in use of in-hospital reperfusion therapy, the association of teaching hospital status with lower risk-adjusted in-hospital mortality was significantly attenuated but remained statistically significant (adjusted OR 0.97; 95% CI, 0.94-0.99; P = .02). CONCLUSIONS Patients admitted to teaching hospitals are more likely to receive reperfusion and have lower risk-adjusted in-hospital mortality after STEMI compared with those admitted to nonteaching hospitals. Our results suggest that hospital performance for STEMI continues to be better at teaching hospitals in the contemporary era.
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Affiliation(s)
- Tanush Gupta
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Kavisha Patel
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Dhaval Kolte
- Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI
| | - Sahil Khera
- Division of Cardiology, Massachusetts General Hospital, Boston
| | - Pedro A Villablanca
- Division of Cardiology, New York University Langone Medical Center, New York
| | - Wilbert S Aronow
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla
| | - William H Frishman
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla
| | - Howard A Cooper
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla
| | - Anna E Bortnick
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles
| | - Julio A Panza
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla
| | - Giora Weisz
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Mark A Menegus
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Mario J Garcia
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA.
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Bekelis K, Missios S, Coy S, MacKenzie TA. Association of Hospital Teaching Status with Neurosurgical Outcomes: An Instrumental Variable Analysis. World Neurosurg 2017; 110:e689-e698. [PMID: 29174238 DOI: 10.1016/j.wneu.2017.11.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/12/2017] [Accepted: 11/15/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The interpretation of the results of prior studies on the association of hospital teaching status with surgical outcomes is limited by selection bias. We investigated whether undergoing surgical operations in teaching hospitals is associated with improved outcomes. METHODS We performed a cohort study of all patients undergoing spine and cranial operations who were registered in the New York Statewide Planning and Research Cooperative System database from 2009 to 2013. We examined the association of teaching status (defined as academic affiliation for the primary analysis) with inpatient case fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and to simulate the effect of a randomized trial. RESULTS During the study period, 186,483 patients underwent surgical operations that met the inclusion criteria. Instrumental variable analysis demonstrated that hospitalization in teaching hospitals was associated with higher rates of case fatality (adjusted difference, 25%; 95% confidence interval [CI], 4%-46%), discharge to a facility (adjusted difference, 5.7%; 95% CI, 4.5%-7.0%), and longer LOS (adjusted difference, 31.4%; 95% CI, 16.0%-46.1%) in comparison with nonteaching hospitals. The same associations were present in propensity score adjusted mixed effects models. These persisted in prespecified subgroups stratified on particular operations and for different definitions of teaching hospitals. CONCLUSIONS Using a comprehensive all-payer cohort of surgical patients in New York State, we identified an association of treatment in teaching hospitals with increased case fatality, rate of discharge to rehabilitation, and longer LOS. Further research into the factors contributing to superior outcomes in nonteaching institutions is warranted.
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Affiliation(s)
- Kimon Bekelis
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA; Population Health Research Institute of New York at CHS, Melville, New York, USA; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
| | - Symeon Missios
- Center for Neuro and Spine, Akron General - Cleveland Clinic, Akron, Ohio, USA
| | - Shannon Coy
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Todd A MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Abstract
OBJECTIVE To compare the cost and outcomes of patients treated at orthopaedic teaching hospitals (OTHs) with those treated at nonteaching hospitals (NTHs). DESIGN Retrospective study. SETTING The Statewide Planning and Research Cooperative Systems (SPARCS) database, which includes all admissions to New York State hospitals from 2000-2011. PATIENTS/PARTICIPANTS A total of 165,679 patients with isolated closed hip fracture 65 years of age and older met inclusion criteria. Of them, 57,279 were treated at OTH and 108,400 were treated at NTH. INTERVENTION Admission for the management of a hip fracture. MAIN OUTCOME MEASURE Cost, length of stay (LOS), and inpatient mortality. RESULTS Univariate analysis shows that mean total hospital costs were higher at OTH ($16,576 ± $17,514) versus NTH ($13,358 ± $11,366) (P < 0.001); LOS was equivalent at OTH (8.0 ± 9.0 days) versus NTH (8.0 ± 7.6 days) (P = 0.904); and mortality was lower in OTH (3.4%) versus NTH (4.0%) (P < 0.001). In the multivariate total cost analysis, in addition to demographic differences, we identified total hospital beds and total ICU beds as significant confounding variables. Interestingly, when controlling for these patient and hospital factors, OTH designation was not a significant predictor of cost. In addition, multivariate analysis found that OTH status decreased LOS by 0.743 days (95% confidence interval: 0.632-0.854, P < 0.001) and mortality by 21% (odds ratio 0.794, 95% confidence interval: 0.733-0.859, P < 0.001), confirming the univariate trends. CONCLUSIONS While OTH may seem to have higher hospital costs for operative hip fractures on cursory analysis, controlling for patient and hospital factors including hospital bed number negates this effect such that OTH has no additional cost compared with NTH. In addition, OTH status is associated with shorter LOS and lower in-hospital mortality. With the results of this study, health care systems and patients should feel confident that the quality of care at teaching hospitals is no less and potentially better than that at NTH with no added cost. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Hospital Quality Factors Influencing the Mobility of Patients for Radical Prostate Cancer Radiation Therapy: A National Population-Based Study. Int J Radiat Oncol Biol Phys 2017; 99:1261-1270. [PMID: 28964586 PMCID: PMC5693556 DOI: 10.1016/j.ijrobp.2017.08.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/29/2017] [Accepted: 08/12/2017] [Indexed: 11/30/2022]
Abstract
Purpose To investigate whether patients requiring radiation treatment are prepared to travel to alternative more distant centers in response to hospital choice policies, and the factors that influence this mobility. Methods and Materials We present the results of a national cohort study using administrative hospital data for all 44,363 men who were diagnosed with prostate cancer and underwent radical radiation therapy in the English National Health Service between 2010 and 2014. Using geographic information systems, we investigated the extent to which men choose to travel beyond (“bypass”) their nearest radiation therapy center, and we used conditional logistic regression to estimate the effect of hospital and patient characteristics on this mobility. Results In all, 20.7% of men (n=9161) bypassed their nearest radiation therapy center. Travel time had a very strong impact on where patients moved to for their treatment, but its effect was smaller for men who were younger, more affluent, and from rural areas (P for interaction always <.001). Men were prepared to travel further to hospitals that offered hypofractionated prostate radiation therapy as their standard schedule (odds ratio 3.19, P<.001), to large-scale radiation therapy units (odds ratio 1.56, P<.001), and to hospitals that were early adopters of intensity modulated radiation therapy (odds ratio 1.37, P<.001). Conclusions Men with prostate cancer are prepared to bypass their nearest radiation therapy centers. They are more likely to travel to larger established centers and those that offer innovative technology and more convenient radiation therapy schedules. Indicators that accurately reflect the quality of radiation therapy delivered are needed to guide patients' choices for radiation therapy treatment. In their absence, patient mobility may negatively affect the efficiency and capacity of a regional or national radiation therapy service and offer perverse incentives for technology adoption.
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Financial, Resource Utilization and Mortality Impacts of Teaching Hospital Status on Pediatric Patients Admitted for Sepsis. Pediatr Infect Dis J 2017; 36:712-719. [PMID: 28033241 DOI: 10.1097/inf.0000000000001526] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND With the changing healthcare landscape in the United States, teaching hospitals face increasing pressure to provide medical education as well as cost-effective care. Our study investigated the financial, resource utilization and mortality impact of teaching hospital status on pediatric patients admitted with sepsis. METHODS We conducted a retrospective, weighted statistical analysis of hospitalized children with the diagnosis of sepsis. The Agency for Healthcare Research and Quality 2009 Kids' Inpatient Database provided the data for analysis. Diagnosis of sepsis and severity of illness levels were based on All Patient Refined Diagnosis-Related Groups of 720: Septicemia and Disseminated Infections. Teaching hospital status was based on presence of training programs. Statistical analysis was conducted using STATA 12.1 (Stata Corporation, College Station, TX). RESULTS Weighted analysis revealed 17,461 patients with sepsis-9982 in teaching and 7479 in nonteaching hospitals. When comparing all patients, length of stay (8.2 vs. 4.8, P < 0.001), number of procedures received (2.03 vs. 0.87, P < 0.001), mortality (4.7% vs. 1.6%, P < 0.001), costs per day ($2326 vs. $1736, P < 0.001) and total costs ($20,428 vs. $7960, P < 0.001) were higher in teaching hospitals. Even when stratified by severity classes, length of stay, number of procedures received and total costs were higher in teaching hospitals with no difference in mortality. CONCLUSIONS Our study suggested that teaching hospitals provide pediatric inpatient care for sepsis at greater costs and resource utilization without a clear improvement in overall mortality rates in comparison with nonteaching hospitals.
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Ibrahim AM, Ghaferi AA, Thumma JR, Dimick JB. Hospital Quality and Medicare Expenditures for Bariatric Surgery in the United States. Ann Surg 2017; 266:105-110. [PMID: 27607102 PMCID: PMC6132221 DOI: 10.1097/sla.0000000000001980] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To examine the relationship between hospital outcomes and expenditures in patients undergoing bariatric surgery in the United States. BACKGROUND As one of the most common surgical procedures in the United States, bariatric surgery is a major focus of policy reforms aimed at reducing surgical costs. These policy mechanisms have made it imperative to understand the potential cost savings of quality-improvement initiatives. METHODS We performed a retrospective review of 38,374 Medicare beneficiaries undergoing bariatric surgery between 2011 and 2013. We ranked hospitals into quintiles by their risk and reliability-adjusted postoperative serious complications. We then examined the relationship between upper and lower outcome quintiles with risk-adjusted total episode payments. Additionally, we stratified patients by their risk (low, medium, high) of developing a complication to understand how this impacted payment. RESULTS We found a strong correlation between hospital complication rates and episode payments. For example, hospitals in the lowest quintile of complication rates had average total episode payments that were $1321 per patient less than hospitals in the highest quintile ($11,112 vs $12,433; P < 0.005). Cost savings was more prominent amongst high-risk patients where the difference of total episode payments per patient between lowest and highest quintile hospitals was $2160 ($12,960 vs $15,120; P < 0.005). In addition to total episode payment savings, hospitals with the lowest complication rates also had decreased costs for index hospitalization, readmissions, physician services, and postdischarge ancillary care compared with hospitals with the highest complication rates. CONCLUSIONS Medicare payments for bariatric surgery are significantly lower at hospitals with low complication rates. These findings suggest that efforts to improve bariatric surgical quality may ultimately help reduce costs. Additionally, these cost savings may be most prominent amongst the patients at the highest risk for complications.
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Affiliation(s)
- Andrew M Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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David JM, Ho AS, Luu M, Yoshida EJ, Kim S, Mita AC, Scher KS, Shiao SL, Tighiouart M, Zumsteg ZS. Treatment at high-volume facilities and academic centers is independently associated with improved survival in patients with locally advanced head and neck cancer. Cancer 2017. [DOI: 10.1002/cncr.30843] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- John M. David
- Department of Radiation Oncology; Cedars-Sinai Medical Center; Los Angeles California
- Samuel Oschin Comprehensive Cancer Institute; Cedars-Sinai Medical Center; Los Angeles California
| | - Allen S. Ho
- Samuel Oschin Comprehensive Cancer Institute; Cedars-Sinai Medical Center; Los Angeles California
- Department of Surgery; Cedars-Sinai Medical Center; Los Angeles California
| | - Michael Luu
- Biostatistics and Bioinformatics Research Center; Cedars-Sinai Medical Center; Los Angeles California
| | - Emi J. Yoshida
- Department of Radiation Oncology; Cedars-Sinai Medical Center; Los Angeles California
- Samuel Oschin Comprehensive Cancer Institute; Cedars-Sinai Medical Center; Los Angeles California
| | - Sungjin Kim
- Samuel Oschin Comprehensive Cancer Institute; Cedars-Sinai Medical Center; Los Angeles California
- Biostatistics and Bioinformatics Research Center; Cedars-Sinai Medical Center; Los Angeles California
| | - Alain C. Mita
- Samuel Oschin Comprehensive Cancer Institute; Cedars-Sinai Medical Center; Los Angeles California
| | - Kevin S. Scher
- Samuel Oschin Comprehensive Cancer Institute; Cedars-Sinai Medical Center; Los Angeles California
| | - Stephen L. Shiao
- Department of Radiation Oncology; Cedars-Sinai Medical Center; Los Angeles California
- Samuel Oschin Comprehensive Cancer Institute; Cedars-Sinai Medical Center; Los Angeles California
| | - Mourad Tighiouart
- Samuel Oschin Comprehensive Cancer Institute; Cedars-Sinai Medical Center; Los Angeles California
- Biostatistics and Bioinformatics Research Center; Cedars-Sinai Medical Center; Los Angeles California
| | - Zachary S. Zumsteg
- Department of Radiation Oncology; Cedars-Sinai Medical Center; Los Angeles California
- Samuel Oschin Comprehensive Cancer Institute; Cedars-Sinai Medical Center; Los Angeles California
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