1
|
Han JS, Wenger T, Demetriou AN, Dallas J, Ding L, Zada G, Mack WJ, Attenello FJ. Procedural volume is linearly associated with mortality, major complications, and readmissions in patients undergoing malignant brain tumor resection. J Neurooncol 2024:10.1007/s11060-024-04800-5. [PMID: 39266885 DOI: 10.1007/s11060-024-04800-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 08/09/2024] [Indexed: 09/14/2024]
Abstract
PURPOSE Improved outcomes have been noted in patients undergoing malignant brain tumor resection at high-volume centers. Studies have arbitrarily chosen high-volume dichotomous cutoffs and have not evaluated volume-outcome associations at specific institutional procedural volumes. We sought to establish the continuous association of volume with patient outcomes and identify cutoffs significantly associated with mortality, major complications, and readmissions. We hypothesized that a linear volume-outcome relationship can estimate likelihood of adverse outcomes when comparing any two volumes. METHODS The patient cohort was identified with ICD-10 coding in the Nationwide Readmissions Database(NRD). The association of volume and mortality, major complications, and 30-/90-day readmissions were evaluated in multivariate analyses. Volume was used as a continuous variable with two/three-piece splines, with various knot positions to reflect the best model performance, based on the Quasi Information Criterion(QIC). RESULTS From 2016 to 2018, 34,486 patients with malignant brain tumors underwent resection. When volume was analyzed as a continuous variable, mortality risk decreased at a steady rate of OR 0.988 per each additional procedure increase for hospitals with 1-65 cases/year(95% CI 0.982-0.993, p < 0.0001). Risk of major complications decreased from 1 to 41 cases/year(OR 0.983, 95% CI 0.979-0.988, p < 0.0001), 30-day readmissions from 1 to 24 cases/year(OR 0.987, 95% CI 0.979-0.995, p = 0.001) and 90-day readmissions from 1 to 23 cases/year(OR 0.989, 95% CI 0.983-0.995, p = 0.0003) and 24-349 cases/year(OR 0.9994, 95% CI 0.999-1, p = 0.01). CONCLUSION In multivariate analyses, institutional procedural volume remains linearly associated with mortality, major complications, and 30-/90-day readmission up to specific cutoffs. The resulting linear association can be used to calculate relative likelihood of adverse outcomes between any two volumes.
Collapse
Affiliation(s)
- Jane S Han
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300, Los Angeles, CA, 90033, USA.
| | - Talia Wenger
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300, Los Angeles, CA, 90033, USA
| | - Alexandra N Demetriou
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300, Los Angeles, CA, 90033, USA
| | - Jonathan Dallas
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300, Los Angeles, CA, 90033, USA
| | - Li Ding
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300, Los Angeles, CA, 90033, USA
| | - William J Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300, Los Angeles, CA, 90033, USA
| | - Frank J Attenello
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300, Los Angeles, CA, 90033, USA
| |
Collapse
|
2
|
Teixeira RMP, Oliveira JC, de Andrade MAB, Pinheiro FGDMS, Vieira RDCA, Santana-Santos E. Are patient volume and care level in teaching hospitals variables affecting clinical outcomes in adult intensive care units? EINSTEIN-SAO PAULO 2023; 21:eAO0406. [PMID: 37820201 PMCID: PMC10519666 DOI: 10.31744/einstein_journal/2023ao0406] [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: 12/06/2022] [Accepted: 02/07/2023] [Indexed: 10/13/2023] Open
Abstract
Teixeira et al. showed that patients admitted to the intensive care unit of a teaching hospital in a non-metropolitan region needed more support, had worse prognostic indices, and had a higher nursing workload in the first 24 hours of admission. In addition, worse outcomes, including mortality, need for dialysis, pressure injury, infection, prolonged mechanical ventilation, and prolonged hospital stay, were observed in the teaching hospital. Worse outcomes were more prevalent in the teaching hospital. Understanding the importance of teaching hospitals to implement well-established care protocols is critical. OBJECTIVE To compare the clinical outcomes of patients admitted to the intensive care unit of teaching (HI) and nonteaching (without an academic affiliation; H2) hospitals. METHODS In this prospective cohort study, adult patients hospitalized between August 2018 and July 2019, with a minimum length of stay of 24 hours in the intensive care unit, were included. Patients with no essential information in their medical records to evaluate the study outcomes were excluded. Resuslts: Overall, 219 patients participated in this study. The clinical and demographic characteristics of patients in H1 and H2 were similar. The most prevalent clinical outcomes were death, need for dialysis, pressure injury, length of hospital stay, mechanical ventilation >48 hours, and infection, all of which were more prevalent in the teaching hospital. CONCLUSION Worse outcomes were more prevalent in the teaching hospital. There was no difference between the institutions concerning the survival rate of patients as a function of length of hospital stay; however, a difference was observed in intensive care unit admissions.
Collapse
Affiliation(s)
| | - Jussiely Cunha Oliveira
- Universidade Federal de SergipeSão CristovãoSEBrazil Universidade Federal de Sergipe, São Cristovão, SE, Brazil.
| | | | | | | | - Eduesley Santana-Santos
- Universidade Federal de SergipeSão CristovãoSEBrazil Universidade Federal de Sergipe, São Cristovão, SE, Brazil.
| |
Collapse
|
3
|
Sasaki K, Koeda Y, Yoshizawa R, Ishikawa Y, Ishida M, Itoh T, Morino Y, Saitoh H, Onodera H, Nozaki T, Maegawa Y, Nishiyama O, Ozawa M, Osaki T, Nakamura A. Comparing In-Hospital Outcomes for Acute Myocardial Infarction Patients in High-Volume Hospitals Performing Primary Percutaneous Coronary Intervention vs. Regional General Hospitals. Circ J 2023; 87:1347-1355. [PMID: 37558468 DOI: 10.1253/circj.cj-23-0188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
BACKGROUND It has been reported that patients with acute myocardial infarction (AMI) transferred to low-volume primary percutaneous coronary intervention (PCI) hospitals (<115/year) in low population density areas experience higher in-hospital mortality rates. This study compared in-hospital outcomes of patients admitted to high-volume primary PCI hospitals (≥115/year) with those for other regional general hospitals. METHODS AND RESULTS Retrospective analysis was conducted on data obtained from 2,453 patients with AMI admitted to hospitals in Iwate Prefecture (2014-2018). Multivariate analysis revealed that the in-hospital mortality rate of AMI among patients in regional general hospitals was significantly higher than among patients in high-volume hospitals. However, no significant difference in mortality rate was observed among patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI. Although no significant difference was found in the in-hospital mortality rate of patients with Killip class I STEMI, significantly lower in-hospital mortality rates were observed in patients admitted in high-volume hospitals for Killip classes II, III, and IV. CONCLUSIONS Although in-hospital outcomes for patients with STEMI undergoing primary PCI were similar, patients with heart failure or cardiogenic shock exhibited better in-hospital outcomes in high-volume primary PCI hospitals than those in regional general hospitals.
Collapse
Affiliation(s)
- Koto Sasaki
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Yorihiko Koeda
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Reisuke Yoshizawa
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Yuh Ishikawa
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Masaru Ishida
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Tomonori Itoh
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | | | | | - Tetsuji Nozaki
- Department of Cardiology, Iwate Prefectural Isawa Hospital
| | - Yuko Maegawa
- Department of Cardiology, Iwate Prefectural Miyako Hospital
| | | | - Mahito Ozawa
- Department of Cardiology, Japanese Red Cross Morioka Hospital
| | - Takuya Osaki
- Department of Cardiology, Iwate Prefectural Kuji Hospital
| | | |
Collapse
|
4
|
Zhang M, Xie W, Xiao Y, Guo W, Wang Y, Zhang W, Duan S, Gao Q, Zhang S, Zhang Y, Guo X, Yin A, Peng J, Wan J, Zhai Z. Current status of diagnosis and treatment of pulmonary hypertension in Chinese tertiary hospitals: A nationwide survey. Pulm Circ 2023; 13:e12241. [PMID: 37215375 PMCID: PMC10196214 DOI: 10.1002/pul2.12241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/24/2023] Open
Abstract
We intended to evaluate the diagnosis and treatment status of pulmonary hypertension (PH) in China and provide the basis for the design of the Chinese PH centers system. A questionnaire survey was conducted by sampling from Chinese Class A tertiary hospitals that have carried out the clinical work of PH, including the composition of PH clinical team, the current application of examinations related to PH diagnosis, the availability of PAH-specific medicine and the implementation of PH-related intervention and surgery. A total of 44 valid questionnaires from 20 provinces were collected in this survey. In the vast majority of centers (83.33%, n = 35), pulmonary artery catheterization was routinely performed under X-ray guidance. In 19.05% (n = 8) of centers, pressure measurements were determined at the right time (the end of normal expiration). Only 73.81% (n = 31) centers have carried out acute vasoreactivity testing. Prostacyclin analogues and prostaglandin receptor agonists were just prescribed in 45.45% (n = 20) of the centers. 19 centers (43.18%) were capable of performing balloon pulmonary angioplasty (BPA) and pulmonary endarterectomy (PEA), while 25% (n = 11) were able to perform BPA, PEA, and lung transplantation. There was no significant difference in the diagnosis and treatment of PH between economic regions. The majority of Chinese tertiary hospitals were well equipped with the corresponding personnel, examinations and medicines related to PH, but the standardization and specialization of the management of PH need to be strengthened.
Collapse
Affiliation(s)
- Meng Zhang
- Department of Pulmonary and Critical Care MedicineBeijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel DiseasesBeijingChina
| | - Wanmu Xie
- Department of Pulmonary and Critical Care MedicineCenter of Respiratory Medicine, China‑Japan Friendship HospitalBeijingChina
| | - Yao Xiao
- Department of Pulmonary and Critical Care MedicineBeijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel DiseasesBeijingChina
| | - Wei Guo
- Department of Pulmonary and Critical Care MedicineBeijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel DiseasesBeijingChina
| | - Yan Wang
- Department of Pulmonary and Critical Care MedicineBeijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel DiseasesBeijingChina
| | - Wenmei Zhang
- Department of Pulmonary and Critical Care MedicineBeijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel DiseasesBeijingChina
| | - Shengchen Duan
- Department of Pulmonary and Critical Care MedicineBeijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel DiseasesBeijingChina
| | - Qian Gao
- Department of Pulmonary and Critical Care MedicineCenter of Respiratory Medicine, China‑Japan Friendship HospitalBeijingChina
| | - Shuai Zhang
- Department of Pulmonary and Critical Care MedicineCenter of Respiratory Medicine, China‑Japan Friendship HospitalBeijingChina
| | - Yunxia Zhang
- Department of Pulmonary and Critical Care MedicineCenter of Respiratory Medicine, China‑Japan Friendship HospitalBeijingChina
| | - Xueran Guo
- Department of Pulmonary and Critical Care MedicineBeijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel DiseasesBeijingChina
- The Sixth Clinical Medical College, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Ao Yin
- Department of Pulmonary and Critical Care MedicineBeijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel DiseasesBeijingChina
- The Sixth Clinical Medical College, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Jiafei Peng
- Department of Pulmonary and Critical Care MedicineBeijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel DiseasesBeijingChina
- The Sixth Clinical Medical College, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Jun Wan
- Department of Pulmonary and Critical Care MedicineBeijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel DiseasesBeijingChina
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care MedicineCenter of Respiratory Medicine, China‑Japan Friendship HospitalBeijingChina
| | | |
Collapse
|
5
|
Bloom JE, Nehme Z, Andrew E, Dawson LP, Fernando H, Noaman S, Stephenson M, Anderson D, Pellegrino V, Cox S, Lefkovits J, Chan W, Kaye DM, Smith K, Stub D. HOSPITAL CHARACTERISTICS ARE ASSOCIATED WITH CLINICAL OUTCOMES IN PATIENTS WITH CARDIOGENIC SHOCK. Shock 2022; 58:204-210. [PMID: 36018300 DOI: 10.1097/shk.0000000000001974] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Background: Regionalized systems of care for the management of cardiogenic shock (CS) are increasingly being utilized. This study aims to assess whether receiving hospital characteristics such as the availability of 24-hour coronary angiography, on-site cardiac surgery, and annual treated CS volume influence outcomes in patients transferred by emergency medical services (EMS) to hospital with CS. Methods: This population-based cohort study included consecutive adult patients with CS who were transferred to hospital by EMS between January 1, 2015 and June 30, 2019 in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. The primary outcome assessed was 30-day mortality stratified by the availability of 24-hour coronary angiography (cardiac center) at the receiving hospital. Results: A total of 3,217 patients were transferred to hospital with CS. The population had an average age of 67.9 +/- 16.1 years, and 1,289 (40.1%) were female. EMS transfer to a cardiac center was associated with significantly reduced rates of 30-day mortality (adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.64-0.95), compared with noncardiac centers. Compared with the lowest annual CS volume quartile (<18 cases per year), hospitals in the highest volume quartile (>55 cases per year) had reduced risk of 30-day mortality (aOR, 0.71; 95% CI, 0.56-0.91). A stepwise reduction in the adjusted probability of 30-day mortality was observed in patients transferred by EMS to trauma level 1 centers (34.6%), compared with cardiothoracic surgical centers (39.0%), noncardiac surgical metropolitan (44.9%), and rural (51.3%) cardiac centers, all P < 0.05. Conclusion: Receiving hospital characteristics are associated with survival outcomes in patients with CS. These finding have important implications for establishing regionalized systems of care for patients with CS who are transferred to hospital by EMS.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Vincent Pellegrino
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Shelley Cox
- Ambulance Victoria, Blackburn, Victoria, Australia
| | | | | | | | | | | |
Collapse
|
6
|
Association between psoriasis and short-term outcomes of acute myocardial infarction: A matched-pair cohort study using a nationwide inpatient database in Japan. JAAD Int 2022; 8:21-30. [PMID: 35620322 PMCID: PMC9127561 DOI: 10.1016/j.jdin.2022.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/23/2022] Open
Abstract
Background Objective Methods Results Limitations Conclusion
Collapse
|
7
|
Chen Y, Ma XD, Kang XH, Gao SF, Peng JM, Li S, Liu DW, Zhou X, Weng L, Du B. Association of annual hospital septic shock case volume and hospital mortality. Crit Care 2022; 26:161. [PMID: 35659338 PMCID: PMC9166431 DOI: 10.1186/s13054-022-04035-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/26/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The burden of sepsis remains high in China. The relationship between case volume and hospital mortality among patients with septic shock, the most severe complication of sepsis, is unknown in China. METHODS In this retrospective cohort study, we analyzed surveillance data from a national quality improvement program in intensive care units (ICUs) in China in 2020. Association between septic shock case volume and hospital mortality was analyzed using multivariate linear regression and restricted cubic splines. RESULTS We enrolled a total of 134,046 septic shock cases in ICUs from 1902 hospitals in China during 2020. In this septic shock cohort, the median septic shock volume per hospital was 33 cases (interquartile range 14-76 cases), 41.4% were female, and more than half of the patients were over 61 years old, with average hospital mortality of 21.2%. An increase in case volume was associated with improved survival among septic shock cases. In the linear regression model, the highest quartile of septic shock volume was associated with lower hospital mortality compared with the lowest quartile (β - 0.86; 95% CI - 0.98, - 0.74; p < 0.001). Similar differences were found in hospitals of respective geographic locations and hospital levels. With case volume modeled as a continuous variable in a restricted cubic spline, a lower volume threshold of 40 cases before which a substantial reduction of the hospital mortality rate was observed. CONCLUSIONS The findings suggest that hospitals with higher septic shock case volume have lower hospital mortality in China. Further research is needed to explain the mechanism of this volume-outcome relationship.
Collapse
Affiliation(s)
- Yan Chen
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xu-Dong Ma
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Xiao-Hui Kang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Si-Fa Gao
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Jin-Min Peng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shan Li
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Department of Information Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xiang Zhou
- Department of Critical Care Medicine, Department of Information Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| |
Collapse
|
8
|
Bloom JE, Andrew E, Dawson LP, Nehme Z, Stephenson M, Anderson D, Fernando H, Noaman S, Cox S, Milne C, Chan W, Kaye DM, Smith K, Stub D. Incidence and Outcomes of Nontraumatic Shock in Adults Using Emergency Medical Services in Victoria, Australia. JAMA Netw Open 2022; 5:e2145179. [PMID: 35080603 PMCID: PMC8792885 DOI: 10.1001/jamanetworkopen.2021.45179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Nontraumatic shock is a challenging clinical condition, presenting urgent and unique demands in the prehospital setting. There is a paucity of data assessing its incidence, etiology, and clinical outcomes. OBJECTIVE To assess the incidence, etiology, and clinical outcomes of patients treated by emergency medical services (EMS) with nontraumatic shock using a large population-based sample. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study included consecutive adult patients with shock not related to trauma who received care by EMS between January 1, 2015, and June 30, 2019, in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. During the study period there were 2 485 311 cases attended by EMS, of which 16 827 met the study's inclusion criteria for shock. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day mortality. Secondary outcomes included length of hospital stay, emergency department discharge disposition, rates of coronary angiography and revascularization procedures, and the use of mechanical circulatory support. RESULTS A total of 12 695 patients were successfully linked, with a mean (SD) age of 65.7 (19.1) years; 6411 (50.5%) were men. The overall population-wide incidence of EMS-treated prehospital shock was 76 (95% CI, 75-77) per 100 000 person-years. An increased incidence was observed in men (79 [77-81] per 100 000 person-years), older patients (eg, aged 70-79 years: 177 [171-183] per 100 000 person-years), regional locations (outer regional or remote: 100 [94-107] per 100 000 person-years), and in areas with increased socioeconomic disadvantage (lowest socioeconomic status quintile: 92 [89-95] per 100 000 person-years). Patients with hospital outcome data were stratified into shock etiologies; 3615 (28.5%) had cardiogenic shock: 3998 (31.5%), septic shock; 1457 (11.5%), hypovolemic shock; and 3625 (28.6%), other causes of shock. Nearly one-third of patients (4158 [32.8%]) were deceased at 30 days. In multivariable analyses, increased age (all etiologies: hazard ratio [HR], 1.04; 95% CI, 1.03-1.04), female sex (cardiogenic shock: HR, 1.26; 95% CI, 1.12-1.42), increased initial heart rate (all etiologies: 1.01; 95% CI, 1.00-1.01), prehospital intubation (all etiologies: HR, 3.93; 95% CI, 3.48-4.44), and preexisting comorbidities (eg, chronic kidney disease, all etiologies: HR, 1.25; 95% CI, 1.10-1.42) were independently associated with 30-day mortality, while higher socioeconomic status (all etiologies: HR, 0.96; 95% CI, 0.94-0.98) and increased initial systolic blood pressure (all etiologies: HR, 0.99; 95% CI, 0.99-0.99) were associated with lower risk. CONCLUSIONS AND RELEVANCE This population-level cohort study found that EMS-treated nontraumatic shock was a common condition, with a high risk of morbidity and mortality regardless of etiology. It disproportionately affected men, older patients, patients in regional areas, and those with social disadvantage. Further studies are required to assess how current systems of care can be optimized to improve outcomes.
Collapse
Affiliation(s)
- Jason E. Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Department of Cardiology, Western Health, St Albans, Victoria, Australia
- Ambulance Victoria, Blackburn, Victoria, Australia
| | - Emily Andrew
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Luke P. Dawson
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Michael Stephenson
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - David Anderson
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Ambulance Victoria, Blackburn, Victoria, Australia
| | - Himawan Fernando
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, Western Health, St Albans, Victoria, Australia
| | - Shelley Cox
- Ambulance Victoria, Blackburn, Victoria, Australia
| | | | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, Western Health, St Albans, Victoria, Australia
| | - David M. Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, Western Health, St Albans, Victoria, Australia
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
9
|
Hallet J, Jerath A, Sutradhar R. Looking Over the Drape-Anesthesiologists' Volume and Surgical Outcomes-Reply. JAMA Surg 2021; 157:79. [PMID: 34586359 DOI: 10.1001/jamasurg.2021.3756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Measurement, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Angela Jerath
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Measurement, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Measurement, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Jiang HJ, Fingar KR, Liang L, Henke RM, Gibson TP. Quality of Care Before and After Mergers and Acquisitions of Rural Hospitals. JAMA Netw Open 2021; 4:e2124662. [PMID: 34542619 PMCID: PMC8453322 DOI: 10.1001/jamanetworkopen.2021.24662] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE Rural hospitals are increasingly merging with other hospitals. The associations of hospital mergers with quality of care need further investigation. OBJECTIVES To examine changes in quality of care for patients at rural hospitals that merged compared with those that remained independent. DESIGN, SETTING, AND PARTICIPANTS In this case-control study, mergers at community nonrehabilitation hospitals in Federal Office of Rural Health Policy-eligible zip codes during 2009 to 2016 in 32 states were identified from Irving Levin Associates and the American Hospital Association Annual Survey. Outcomes for inpatient stays for select conditions and elective procedures were derived from the Healthcare Cost and Utilization Project State Inpatient Databases. Difference-in-differences linear probability models were used to assess premerger to postmerger changes in outcomes for patients discharged from merged vs comparison hospitals that remained independent. Data were analyzed from February to December 2020. EXPOSURES Hospital mergers. MAIN OUTCOMES AND MEASURES The main outcome was in-hospital mortality among patients admitted for acute myocardial infarction (AMI), heart failure, stroke, gastrointestinal hemorrhage, hip fracture, or pneumonia, as well as complications during stays for elective surgeries. RESULTS A total of 172 merged hospitals and 266 comparison hospitals were analyzed. After matching, baseline patient characteristics were similar for 303 747 medical stays and 175 970 surgical stays at merged hospitals and 461 092 medical stays and 278 070 surgical stays at comparison hospitals. In-hospital mortality among AMI stays decreased from premerger to postmerger at merged hospitals (9.4% to 5.0%) and comparison hospitals (7.9% to 6.3%). Adjusting for patient, hospital, and community characteristics, the decrease in in-hospital mortality among AMI stays 1 year postmerger was 1.755 (95% CI, -2.825 to -0.685) percentage points greater at merged hospitals than at comparison hospitals (P < .001). This finding held up to 4 years postmerger (DID, -2.039 [95% CI, -3.388 to -0.691] percentage points; P = .003). Greater premerger to postmerger decreases in mortality at merged vs comparison hospitals were also observed at 5 years postmerger among stays for heart failure (DID, -0.756 [95% CI, -1.448 to -0.064] percentage points; P = .03), stroke (DID, -1.667 [95% CI, -3.050 to -0.283] percentage points; P = .02), and pneumonia (DID, -0.862 [95% CI, -1.681 to -0.042] percentage points; P = .04). CONCLUSIONS AND RELEVANCE These findings suggest that rural hospital mergers were associated with better mortality outcomes for AMI and several other conditions. This finding is important to enhancing rural health care and reducing urban-rural disparities in quality of care.
Collapse
Affiliation(s)
- H. Joanna Jiang
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | - Lan Liang
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | | |
Collapse
|
11
|
Hallet J, Davis L, Mahar A, Mavros M, Beyfuss K, Liu Y, Law CHL, Earle C, Coburn N. Benefits of High-Volume Medical Oncology Care for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis. J Natl Compr Canc Netw 2021; 18:297-303. [PMID: 32135510 DOI: 10.6004/jnccn.2019.7361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/13/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although pancreatic adenocarcinoma (PA) surgery performed by high-volume (HV) providers yields better outcomes, volume-outcome relationships are unknown for medical oncologists. This study examined variation in practice and outcomes in noncurative management of PA based on medical oncology provider volume. METHODS This population-based cohort study linked administrative healthcare datasets and included nonresected PA from 2005 through 2016. The volume of PA consultations per medical oncology provider per year was divided into quintiles, with HV providers (≥16 patients/year) constituting the fifth quintile and low-volume (LV) providers the first to fourth quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). The Brown-Forsythe-Levene (BFL) test for equality of variances was performed to assess outcome variability between provider-volume quintiles. Multivariate regression models were used to examine the association between management by HV provider and outcomes. RESULTS A total of 7,062 patients with noncurable PA consulted with medical oncology providers. Variability was seen in receipt of chemotherapy and median survival based on provider volume (BFL, P<.001 for both), with superior 1-year OS for HV providers (30.1%; 95% CI, 27.7%-32.4%) compared with LV providers (19.7%; 95% CI, 18.5%-20.6%) (P<.001). After adjustment for age at diagnosis, sex, comorbidity burden, rural residence, income, and diagnosis period, HV provider care was independently associated with higher odds of receiving chemotherapy (odds ratio, 1.19; 95% CI, 1.05-1.34) and with superior OS (hazard ratio, 0.79; 95% CI, 0.74-0.84). CONCLUSIONS Significant variation was seen in noncurative management and outcomes of PA based on provider volume, with management by an HV provider being independently associated with superior OS and higher odds of receiving chemotherapy. This information is important to inform disease care pathways and care organization. Cancer care systems could consider increasing the number of HV providers to reduce variation and improve outcomes.
Collapse
Affiliation(s)
- Julie Hallet
- Odette Cancer Centre, Sunnybrook Health Sciences Centre.,University of Toronto.,Sunnybrook Research Institute.,Institute of Clinical Evaluative Sciences, Toronto, Ontario; and
| | | | - Alyson Mahar
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - Ying Liu
- Institute of Clinical Evaluative Sciences, Toronto, Ontario; and
| | - Calvin H L Law
- Odette Cancer Centre, Sunnybrook Health Sciences Centre.,University of Toronto.,Sunnybrook Research Institute
| | - Craig Earle
- Odette Cancer Centre, Sunnybrook Health Sciences Centre.,Sunnybrook Research Institute.,Institute of Clinical Evaluative Sciences, Toronto, Ontario; and
| | - Natalie Coburn
- Odette Cancer Centre, Sunnybrook Health Sciences Centre.,University of Toronto.,Sunnybrook Research Institute.,Institute of Clinical Evaluative Sciences, Toronto, Ontario; and
| |
Collapse
|
12
|
Hallet J, Jerath A, Turgeon AF, McIsaac DI, Eskander A, Zuckerman J, Zuk V, Sohail S, Darling GE, Dharma C, Coburn NG, Sutradhar R. Association Between Anesthesiologist Volume and Short-term Outcomes in Complex Gastrointestinal Cancer Surgery. JAMA Surg 2021; 156:479-487. [PMID: 33729435 DOI: 10.1001/jamasurg.2021.0135] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Intraoperative anesthesiology care is crucial to high-quality surgical care. The clinical expertise and experience of anesthesiologists may decrease the risk of adverse outcomes. Objective To examine the association between anesthesiologist volume and short-term postoperative outcomes for complex gastrointestinal (GI) cancer surgery. Design, Setting, and Participants This population-based cohort study used administrative health care data sets from various data sources in Ontario, Canada. Adult patients who underwent esophagectomy, pancreatectomy, or hepatectomy for GI cancer from January 1, 2007, to December 31, 2018, were eligible. Patients with an invalid identification number, a duplicate surgery record, and missing primary anesthesiologist information were excluded. Exposures Primary anesthesiologist volume was defined as the annual number of procedures of interest (esophagectomy, pancreatectomy, and hepatectomy) supported by that anesthesiologist in the 2 years before the index surgery. Volume was dichotomized into low-volume and high-volume categories, with 75th percentile or 6 or more procedures per year selected as the cutoff point. Main Outcome and Measures The primary outcome was a composite of 90-day major morbidity (with a Clavien-Dindo classification grade 3-5) and readmission. Secondary outcomes were individual components of the primary outcome. The association between exposure and outcomes was examined using multivariable logistic regression models, accounting for potential confounders. Results Of the 8096 patients included, 5369 were men (66.3%) and the median (interquartile range [IQR]) age was 65 (57-72) years. Operations were supported by 842 anesthesiologists and performed by 186 surgeons, and the median (IQR) anesthesiologist volume was 3 (1.5-6) procedures per year. A total of 2166 patients (26.7%) received care from high-volume anesthesiologists. Primary outcome occurred in 36.3% of patients in the high-volume group and 45.7% of patients in the low-volume group. After adjustment, care by high-volume anesthesiologists was independently associated with lower odds of the primary outcome (adjusted odds ratio [aOR], 0.85; 95% CI, 0.76-0.94), major morbidity (aOR, 0.83; 95% CI, 0.75-0.91), unplanned intensive care unit admission (aOR, 0.84; 95% CI, 0.76-0.94), but not readmission (aOR, 0.87; 95% CI, 0.73-1.05) or mortality (aOR, 1.05; 95% CI, 0.84-1.31). E-values analysis indicated that an unmeasured variable would unlikely substantively change the observed risk estimates. Conclusions and Relevance This study found that, among adults who underwent complex gastrointestinal cancer surgery, those who received care from high-volume anesthesiologists had a lower risk of adverse postoperative outcomes compared with those who received care from low-volume anesthesiologists. These findings support organizing perioperative care to increase anesthesiologist volume to optimize patient outcomes.
Collapse
Affiliation(s)
- Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Measurement, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Angela Jerath
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Measurement, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada.,CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Antoine Eskander
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Measurement, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jesse Zuckerman
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Measurement, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Victoria Zuk
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Safa Sohail
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Gail E Darling
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Measurement, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Measurement, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
13
|
Shen YC, Krumholz H, Hsia RY. Association of Cardiac Care Regionalization With Access, Treatment, and Mortality Among Patients With ST-Segment Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2021; 14:e007195. [PMID: 33641339 DOI: 10.1161/circoutcomes.120.007195] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Regionalization of ST-segment elevation myocardial infarction (STEMI) systems of care has been championed over the past decade. Although timely access to percutaneous coronary intervention (PCI) has been shown to improve outcomes, no studies have determined how regionalization has affected the care and outcomes of patients. We sought to determine if STEMI regionalization is associated with changes in access, treatment, and outcomes. METHODS Using a difference-in-differences approach, we analyzed a statewide, administrative database of 139 494 patients with STEMI in California from 2006 to 2015 using regionalization data based on a survey of all local Emergency Medical Services agencies in the state. RESULTS For patients with STEMI, the base rate of admission to a hospital with PCI capability was 72.7%, and regionalization was associated with an increase of 5.34 percentage points (95% CI, 1.58-9.10), representing a 7.1% increase. Regionalization was also associated with a statistically significant increase of 3.54 (95% CI, 0.61-6.48) percentage points in the probability of same-day PCI, representing an increase of 7.1% from the 49.7% base rate and a 4.6% relative increase (2.97 percentage points [95% CI, 0.1-5.85]) in the probability of receiving PCI at any time during the hospitalization. There was a 1.84 percentage point decrease (95% CI, -3.31 to -0.37) in the probability of receiving fibrinolytics. For 7-day mortality, regionalization was associated with a 0.53 (95% CI, -1 to -0.06) percentage point greater reduction (representing 5.8% off the base rate of 9.1%) and a 1.75 percentage point decrease in the likelihood of all-cause 30-day readmission (95% CI, -3.39 to -0.11; representing 6.4% off the base rate of 27.4%). No differences were found in longer-term mortality. CONCLUSIONS Among patients with STEMI in California from 2006 to 2015, STEMI regionalization was associated with increased access to a PCI-capable hospital, greater use of PCI, lower 7-day mortality, and lower 30-day readmissions.
Collapse
Affiliation(s)
- Yu-Chu Shen
- Graduate School of Defense Management, Naval Postgraduate School (Y.-C.S.).,National Bureau of Economic Research (Y.-C.S.)
| | - Harlan Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine (H.K.).,Department of Health Policy and Management, Yale School of Public Health (H.K.).,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital (H.K.)
| | - Renee Y Hsia
- Department of Emergency Medicine (R.Y.H.), University of California at San Francisco.,Philip R. Lee Institute for Health Policy Studies (R.Y.H.), University of California at San Francisco
| |
Collapse
|
14
|
Kobayashi T, Young MN, Giri J. Volume, outcomes, and 'Centers of Excellence' for pulmonary embolism care. Vasc Med 2021; 26:47-49. [PMID: 33448907 DOI: 10.1177/1358863x20980523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, PA, USA
| | - Michael N Young
- Division of Cardiovascular Medicine, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, PA, USA
| |
Collapse
|
15
|
Yan XN, Jin JL, Zhang M, Hong LF, Guo YL, Wu NQ, Zhu CG, Dong Q, Li JJ. Differential leukocyte counts and cardiovascular mortality in very old patients with acute myocardial infarction: a Chinese cohort study. BMC Cardiovasc Disord 2020; 20:465. [PMID: 33115409 PMCID: PMC7594328 DOI: 10.1186/s12872-020-01743-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 10/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background Total leukocyte and differential Leukocyte counts are prognostic indictors in patients with coronary artery disease (CAD). However, there is no data available regarding their prognostic utility in very old patients with acute myocardial infarction (AMI). The aim of this study is to investigate the potential role of different leukocyte parameters in predicting the mortality among very old patients with AMI. Methods A total of 523 patients aged over 80 years with AMI were consecutively enrolled into this study. Leukocyte and its subtypes were obtained at admission in each patient. The primary study endpoint was cardiovascular mortality. Patients were followed up for an average of 2.2 years and 153 patients died. The associations of leukocyte parameters with mortality were assessed using Cox regression analyses. The concordance index was calculated to test the model efficiency. Results In multivariable regression analysis, neutrophils-plus-monocytes-to-lymphocytes ratio (NMLR) and neutrophils-to-lymphocytes ratio (NLR) were two most significant predictors of mortality among all the leukocyte parameters (HR = 3.21, 95% CI 1.75–5.35; HR = 2.79, 95% CI 1.59–4.88, respectively, all p < 0.001, adjusted for age, male gender, body mass index, family history of CAD, smoking, hypertension, diabetes mellitus, high-density lipoprotein cholesterol (HDL-C), non-HDL-C, high sensitivity C-reactive protein, creatinine, left ventricular ejection fraction, troponin I, use of statin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and percutaneous coronary intervention). Furthermore, adding NMLR and NLR into the Cox model increased the C-statistic by 0.038 and 0.037 respectively, which were more significant than that of other leukocyte parameters. Besides, addition of NMLR and NLR to the Canada Acute Coronary Syndrome Risk Score model also increased the C-statistic by 0.079 and 0.077 respectively. Conclusion Our data firstly indicated that most leukocyte subtypes were independent markers for the mortality in very old patients with AMI, while NMLR and NLR appeared to be more effective.
Collapse
Affiliation(s)
- Xiao-Ni Yan
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, BeiLiShi Road 167, Beijing, 100037, China.,Division of Cardiology, The Fifth Hospital of Wuhan & Cardiovascular Insititute of Jianghan University, Wuhan, 430050, China
| | - Jing-Lu Jin
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, BeiLiShi Road 167, Beijing, 100037, China
| | - Meng Zhang
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, BeiLiShi Road 167, Beijing, 100037, China
| | - Li-Feng Hong
- Division of Cardiology, The Fifth Hospital of Wuhan & Cardiovascular Insititute of Jianghan University, Wuhan, 430050, China
| | - Yuan-Lin Guo
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, BeiLiShi Road 167, Beijing, 100037, China
| | - Na-Qiong Wu
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, BeiLiShi Road 167, Beijing, 100037, China
| | - Cheng-Gang Zhu
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, BeiLiShi Road 167, Beijing, 100037, China
| | - Qian Dong
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, BeiLiShi Road 167, Beijing, 100037, China
| | - Jian-Jun Li
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, BeiLiShi Road 167, Beijing, 100037, China.
| |
Collapse
|
16
|
Wu YM, Liu CC, Yeh CC, Sung LC, Lin CS, Cherng YG, Chen TL, Liao CC. Hospitalization outcome of heart diseases between patients who received medical care by cardiologists and non-cardiologist physicians: A propensity-score matched study. PLoS One 2020; 15:e0235207. [PMID: 32629459 PMCID: PMC7338078 DOI: 10.1371/journal.pone.0235207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 05/28/2020] [Indexed: 11/28/2022] Open
Abstract
Background and aims The effects of physician specialty on the outcome of heart disease remains incompletely understood because of inconsistent findings from some previous studies. Our purpose is to compare the admission outcomes of heart disease in patients receiving care by cardiologists and noncardiologist (NC) physicians. Methods Using reimbursement claims data of Taiwan’s National Health Insurance from 2008–2013, we conducted a matched study of 6264 patients aged ≥20 years who received a cardiologist’s care during admission for heart disease. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, and type of heart disease, 6264 controls who received an NC physician’s care were selected. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for complications and mortality during admission for heart disease associated with a cardiologist’s care. Results Patients who received a cardiologist’s care had a lower risk of pneumonia (OR = 0.61; 95% CI, 0.53–0.70), septicemia (OR = 0.49; 95% CI, 0.39–0.61), urinary tract infection (OR = 0.76; 95% CI, 0.66–0.88), and in-hospital mortality (OR = 0.37; 95% CI, 0.29–0.47) than did patients who received an NC physician’s care. The association between a cardiologist’s care and reduced adverse events following admission was significant in both sexes and in patients aged ≥40 years. Conclusion We raised the possibility that cardiologist care was associated with reduced infectious complications and mortality among patients who were admitted due to heart disease.
Collapse
Affiliation(s)
- Yu-Ming Wu
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Chung Liu
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Chieh Yeh
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
- Department of Surgery, University of Illinois, Chicago, IL, United States of America
| | - Li-Chin Sung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Chao-Shun Lin
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yih-Giun Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ta-Liang Chen
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chien-Chang Liao
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
- * E-mail: ,
| |
Collapse
|
17
|
Maeda T, Arima H. Rural Health Disparities in Japan - Urgent Need for Big Data Utilization and Health Service Research. Circ J 2020; 84:1057-1058. [PMID: 32507803 DOI: 10.1253/circj.cj-20-0497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Toshiki Maeda
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University
| |
Collapse
|
18
|
Tie HT, Shi R, Zhou Q, Wang K, Zheng XQ, Wu QC. Annual case volume on mortality after coronary artery bypass grafting: a dose-response meta-analysis. Interact Cardiovasc Thorac Surg 2020; 29:568-575. [PMID: 31230080 DOI: 10.1093/icvts/ivz151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 05/19/2019] [Accepted: 05/21/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This study evaluated the effect of both hospital and surgeon annual case volumes on patient mortality following coronary artery bypass grafting (CABG). METHODS PubMed and Embase databases were searched for clinical studies on CABG. The outcome was mortality, including operative mortality, in-hospital mortality and 30-day mortality. RESULTS Twenty-five studies involving 3 492 101 participants and 143 951 deaths were included for hospital volume, and 4 studies involving 108 356 participants and 2811 deaths were included for surgeon volume. The pooled estimate revealed that both hospital and surgeon annual case volumes were inversely associated with mortality in patients after CABG [odds ratio (OR) for hospital: 0.62, 95% confidence interval (CI) 0.56-0.69; P < 0.001; OR for surgeon: 0.51, 95% CI 0.31- 0.83; P < 0.001] with high heterogeneity (hospital: I2 = 90.6%, Pheterogeneity < 0.001; surgeon: I2 = 86.8%, Pheterogeneity < 0.001). The relationship remained consistent and robust in most subgroup and sensitivity analyses. Our meta-regression analysis of time suggested that the strength of the negative associations between volume and mortality for both hospitals and surgeons remained unattenuated over time even though the CABG mortality gradually decreased over time. The dose-response analysis suggested a non-linear relationship between both hospital and surgeon annual case volumes and mortality (both Pnon-linearity = 0.001). CONCLUSIONS Both higher hospital and surgeon annual case volumes are associated with lower mortality in patients undergoing CABG, and the negative associations remain unattenuated over time. CLINICAL REGISTRATION NUMBER The study was registered at PROSPERO as CRD42017067912.
Collapse
Affiliation(s)
- Hong-Tao Tie
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Shi
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Quan Zhou
- Department of Science and Education, The First People's Hospital of Changde City, Hunan, China
| | - Kang Wang
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Qing Zheng
- Department of Chemical Biology, School of Pharmaceutical Science, Peking University Health Science Center, Beijing, China
| | - Qing-Chen Wu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
19
|
Hallet J, Davis LE, Mahar AL, Liu Y, Zuk V, Gupta V, Earle CC, Coburn NG. Variation in receipt of therapy and survival with provider volume for medical oncology in non-curative esophago-gastric cancer: a population-based analysis. Gastric Cancer 2020; 23:300-309. [PMID: 31628561 DOI: 10.1007/s10120-019-01012-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND While surgical care by high-volume providers for esophago-gastric cancer (EGC) yields better outcomes, volume-outcome relationships are unknown for systemic therapy. We examined receipt of therapy and outcomes in the non-curative management of EGC based on medical oncology provider volume. METHODS We conducted a population based retrospective cohort study of non-curative EGC over 2005-2017 by linking administrative healthcare datasets. The volume of new EGC consultations per medical oncology provider per year was calculated and divided into quintiles. High-volume (HV) medical oncologists were defined as the 4-5th quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). Multivariate logistic and Cox-proportional hazards regressions examined the association between management by HV medical oncologist, receipt of systemic therapy, and OS. RESULTS 7011 EGC patients with non-curative management consulted with medical oncology. 1-year OS was superior for HV medical oncologists (> 11 patients/year), with 28.4% (95% CI 26.7-30.2%) compared to 25.1% (95% CI 23.8-26.3%) for low volume (p < 0.001). After adjusting for age, sex, comorbidity burden, rurality, income quintile, and diagnosis year, HV medical oncologist was independently associated with higher odds of receiving chemotherapy (OR 1.13, 95% CI 1.01-1.26), and independently associated with superior OS (HR 0.89, 95% CI 0.84-0.93). CONCLUSIONS Medical oncology provider volume was associated with variation in non-curative management and outcomes of EGC. Care by an HV medical oncologist was independently associated with higher odds of receiving chemotherapy and superior OS, after adjusting for case mix. This information is important to inform disease care pathways and care organization; an increase in the number of HV medical oncologists may reduce variation and improve outcomes.
Collapse
Affiliation(s)
- Julie Hallet
- Division of Surgical Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, 2075 Bayview avenue, T2-063, Toronto, ON, M4N 3M5, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Sunnybrook Research Institute, Toronto, ON, Canada. .,ICES, Toronto, ON, Canada.
| | | | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | | | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Vaibhav Gupta
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Craig C Earle
- ICES, Toronto, ON, Canada.,Division of Medical Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Natalie G Coburn
- Division of Surgical Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, 2075 Bayview avenue, T2-063, Toronto, ON, M4N 3M5, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| |
Collapse
|
20
|
Mizuno A, Niwa K, Ochiai R, Shiraishi I, Sumita Y, Daida H, Fukuda T, Miyamoto Y, Nishimura K, Ogawa H, Yasuda S. Impact of facilities accredited by both adult and pediatric cardiology societies on the outcome of patients with adult congenital heart disease. J Cardiol 2020; 75:105-109. [DOI: 10.1016/j.jjcc.2019.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/16/2019] [Accepted: 06/03/2019] [Indexed: 11/26/2022]
|
21
|
Ni Z, Lin X, Wang Y, Jiang T, Tao H. Hospital volume and outcomes for inpatients with acute myocardial infarction in Shanxi, China: A cross-sectional study. Int J Health Plann Manage 2019; 34:1195-1204. [PMID: 30977578 DOI: 10.1002/hpm.2787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 11/10/2022] Open
Abstract
In this cross-sectional study, we assessed the relationship between hospital volume and clinical outcomes for inpatients with acute myocardial infarction (AMI) in tertiary A hospitals in Shanxi, China (N = 12 931). In-hospital mortality, length of stay (LOS), and total cost were measured. The crude in-hospital mortality rate was 1.69%. Adjusted in-hospital mortality was significantly lower for medium-volume hospitals (odds ratio (OR) = 0.605, 95% confidence interval (CI) = 0.411-0.900) compared with low-volume hospitals. LOS in medium- and high-volume hospitals were 0.915 (95% CI = 0.880-0.951) and 1.069 (95% CI = 1.041-1.098) days longer than in low-volume hospitals, respectively. The cost of inpatients attending low- and high-volume hospitals (OR = 1.180, 95% CI = 1.140-1.221) was higher than that of medium-volume hospitals (OR = 0.897, 95% CI = 0.868-0.926). These results inform health care policy in countries with strained medical resources.
Collapse
Affiliation(s)
- Ziling Ni
- Department of Health Administration, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Xiaojun Lin
- Department of Health Administration, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Ying Wang
- Zhongnan Hospital of Wuhan University, Wuhan, P.R. China
| | - Tianyu Jiang
- Department of Health Administration, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Hongbing Tao
- Department of Health Administration, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| |
Collapse
|
22
|
Do Hospital and Physician Volume Thresholds for the Volume-Outcome Relationship in Heart Failure Exist? Med Care 2019; 57:54-62. [PMID: 30439795 DOI: 10.1097/mlr.0000000000001022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although volume-outcome relationships have been explored for various procedures and interventions, limited information is available concerning the effect of hospital and physician volume on heart failure mortality. Most importantly, little is known about whether there are optimal hospital and physician volume thresholds to reduce heart failure mortality. OBJECTIVES We used nationwide population-based data to identify the optimal hospital and physician volume thresholds to achieve optimum mortality and to examine the relative and combined effects of the volume thresholds on heart failure mortality. METHODS We analyzed all 20,178 heart failure patients admitted in 2012 through Taiwan's National Health Insurance Research Database. Restricted cubic splines and multilevel logistic regression were used to identify whether there are optimal hospital and physician volume thresholds and to assess the relative and combined relationships of the volume thresholds to 30-day mortality, adjusted for patient, physician, and hospital characteristics. RESULTS Hospital and physician volume thresholds of 40 cases and 15 cases a year, respectively, were identified, under which there was an increased risk of 30-day mortality. Patients treated by physicians with previous annual volumes <15 cases had higher 30-day mortality compared with those with previous annual volumes ≥15 cases, and the relationship was stronger in hospitals with previous annual volumes <40 cases. CONCLUSIONS This is the first study to identify both the hospital and physician volume thresholds that lead to decreases in heart failure mortality. Identifying the hospital and physician volume thresholds could be applied to quality improvement and physician training.
Collapse
|
23
|
Abstract
RATIONALE Physicians are increasingly being held accountable for patient outcomes, yet their specific contribution to the outcomes remains uncertain. OBJECTIVES To determine variation in outcomes of mechanically ventilated patients among intensivists, as well as associations between intensivist experience and patient outcomes. METHODS We performed a retrospective cohort study of mechanically ventilated Medicare fee-for-service patients in acute care hospitals in Pennsylvania using administrative, clinical, and physician data from Centers for Medicare and Medicaid Services and the American Medical Association from 2008 and 2009. We identified intensivists by training background, board certification, and claims for services provided to patients admitted to an intensive care unit. We assigned patients to intensivists for outcome attribution based on submitted claims for critical care and in-patient services. We estimated the physician-specific adjusted odds ratios (ORs) for 30-day mortality using a hierarchical model with a random effect for physician, adjusted for patient and hospital characteristics. We tested for independent association of physician experience with patient outcomes using mixed-effects regression for the primary outcome of 30-day mortality. We defined physician experience in two ways: years since training completion ("duration") and annual number of mechanically ventilated patients ("volume"). RESULTS We assigned 345 physicians to 11,268 patients. The 30-day mortality was 43% and median hospital length of stay was 11 days (interquartile range = 6-18). The physician adjusted OR varied from 0.72 to 1.64 (median = 0.99; interquartile range = 0.92-1.09). A total of 48% of physicians was outliers, with an adjusted OR significantly different from 1. However, among intensivists, physician experience was not associated with 30-day mortality (duration OR = 1.00 per additional year; 95% confidence interval = 1.00-1.01; volume OR = 1.00 per additional patient; 95% confidence interval = 1.00-1.00). CONCLUSIONS Intensivists independently contribute to outcomes of Medicare patients who undergo mechanical ventilation, as evidenced by the variation in risk-adjusted mortality across intensivists. However, physician experience does not underlie this relationship between intensivists, suggesting the need to identify modifiable physician factors to improve outcomes.
Collapse
|
24
|
Do Hospitals Performing Frequent Neuraxial Anesthesia for Hip and Knee Replacements Have Better Outcomes? Anesthesiology 2019; 129:428-439. [PMID: 29878899 DOI: 10.1097/aln.0000000000002299] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neuraxial anesthesia is increasingly recommended for hip/knee replacements as some studies show improved outcomes on the individual level. With hospital-level studies lacking, we assessed the relationship between hospital-level neuraxial anesthesia utilization and outcomes. METHODS National data on 808,237 total knee and 371,607 hip replacements were included (Premier Healthcare 2006 to 2014; 550 hospitals). Multivariable associations were measured between hospital-level neuraxial anesthesia volume (subgrouped into quartiles) and outcomes (respiratory/cardiac complications, blood transfusion/intensive care unit need, opioid utilization, and length/cost of hospitalization). Odds ratios (or percent change) and 95% CI are reported. Volume-outcome relationships were additionally assessed by plotting hospital-level neuraxial anesthesia volume against predicted hospital-specific outcomes; trend tests were applied with trendlines' R statistics reported. RESULTS Annual hospital-specific neuraxial anesthesia volume varied greatly: interquartile range, 3 to 78 for hips and 6 to 163 for knees. Increasing frequency of neuraxial anesthesia was not associated with reliable improvements in any of the study's clinical outcomes. However, significant reductions of up to -14.1% (95% CI, -20.9% to -6.6%) and -15.6% (95% CI, -22.8% to -7.7%) were seen for hospitalization cost in knee and hip replacements, respectively, both in the third quartile of neuraxial volume. This coincided with significant volume effects for hospitalization cost; test for trend P < 0.001 for both procedures, R 0.13 and 0.41 for hip and knee replacements, respectively. CONCLUSIONS Increased hospital-level use of neuraxial anesthesia is associated with lower hospitalization cost for lower joint replacements. However, additional studies are needed to elucidate all drivers of differences found before considering hospital-level neuraxial anesthesia use as a potential marker of quality.
Collapse
|
25
|
Ko DT, Dattani ND, Austin PC, Schull MJ, Ross JS, Wijeysundera HC, Tu JV, Eberg M, Koh M, Krumholz HM. Emergency Department Volume and Outcomes for Patients After Chest Pain Assessment. Circ Cardiovasc Qual Outcomes 2018; 11:e004683. [DOI: 10.1161/circoutcomes.118.004683] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Dennis T. Ko
- Sunnybrook Health Sciences Centre, University of Toronto, Canada (D.T.K., M.J.S., H.C.W., J.V.T.)
- Institute for Clinical Evaluative Sciences, Toronto, Canada (D.T.K, P.C.A., M.J.S., H.C.W., J.V.T., M.E., M.K.)
| | - Neil D. Dattani
- Department of Family and Community Medicine, University of Toronto, Canada (N.D.D.)
| | - Peter C. Austin
- Institute for Clinical Evaluative Sciences, Toronto, Canada (D.T.K, P.C.A., M.J.S., H.C.W., J.V.T., M.E., M.K.)
| | - Michael J. Schull
- Sunnybrook Health Sciences Centre, University of Toronto, Canada (D.T.K., M.J.S., H.C.W., J.V.T.)
- Institute for Clinical Evaluative Sciences, Toronto, Canada (D.T.K, P.C.A., M.J.S., H.C.W., J.V.T., M.E., M.K.)
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S.R., H.M.K.)
| | - Harindra C. Wijeysundera
- Sunnybrook Health Sciences Centre, University of Toronto, Canada (D.T.K., M.J.S., H.C.W., J.V.T.)
- Institute for Clinical Evaluative Sciences, Toronto, Canada (D.T.K, P.C.A., M.J.S., H.C.W., J.V.T., M.E., M.K.)
| | - Jack V. Tu
- Sunnybrook Health Sciences Centre, University of Toronto, Canada (D.T.K., M.J.S., H.C.W., J.V.T.)
- Institute for Clinical Evaluative Sciences, Toronto, Canada (D.T.K, P.C.A., M.J.S., H.C.W., J.V.T., M.E., M.K.)
| | - Maria Eberg
- Institute for Clinical Evaluative Sciences, Toronto, Canada (D.T.K, P.C.A., M.J.S., H.C.W., J.V.T., M.E., M.K.)
| | - Maria Koh
- Institute for Clinical Evaluative Sciences, Toronto, Canada (D.T.K, P.C.A., M.J.S., H.C.W., J.V.T., M.E., M.K.)
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S.R., H.M.K.)
| |
Collapse
|
26
|
Incidence and trends of cardiac complications in major abdominal surgery. Surgery 2018; 164:539-545. [PMID: 29929759 PMCID: PMC7652382 DOI: 10.1016/j.surg.2018.04.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/11/2018] [Accepted: 04/25/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Cardiovascular complications are the leading cause of death after noncardiac surgery. Major abdominal operations represent the largest category of procedures considered to have an increased risk of cardiovascular complications. The current aim was to examine trends in the incidence of mortality, perioperative myocardial infarction, and cardiac arrest to determine the presence of potential volume-outcome relationships. METHODS We performed a retrospective analysis of the Nationwide Inpatient Sample for patients undergoing elective, open abdominal esophagectomy, gastrectomy, pancreatectomy, nephrectomy, hepatectomy, splenectomy, and colectomy (major abdominal surgery) during 2008-2014. Univariate and multivariate analyses were performed to determine the impact of operative volume on rates of myocardial infarction, cardiac arrest, and mortality. RESULTS Of the 962,754 elective admissions for major abdominal surgery, 1.4% experienced in-hospital mortality, 0.7% myocardial infarction, and 0.35% cardiac arrest. Myocardial infarction and cardiac arrest were associated with a 24-fold increase in risk of perioperative mortality. Compared with institutions that have a very low volume of operations, those hospitals with larger volumes of operations had a decreased risk of cardiac arrest and incident mortality after cardiovascular complications, but the odds of myocardial infarction were greatest at higher operative-volume hospitals. The annual all-cause mortality and myocardial infarction rates decreased over time, but the incidence of cardiac arrest increased. CONCLUSION Myocardial infarction or cardiac arrest after major abdominal surgery increased the odds of mortality with superior rescue after cardiovascular complications at higher volume institutions. Across all US hospitals performing major abdominal surgery, the rate of cardiac arrest increased without a concomitant increase in myocardial infarction or mortality. Novel targets for risk modification of myocardial infarction and cardiac arrest as well as investigation of processes that facilitate rescue after these complications at higher operative-volume hospitals are needed to delineate quality improvement opportunities.
Collapse
|
27
|
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.
Collapse
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.
| |
Collapse
|
28
|
Couper K, Kimani PK, Gale CP, Quinn T, Squire IB, Marshall A, Black JJM, Cooke MW, Ewings B, Long J, Perkins GD. Variation in outcome of hospitalised patients with out-of-hospital cardiac arrest from acute coronary syndrome: a cohort study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background
Each year, approximately 30,000 people have an out-of-hospital cardiac arrest (OHCA) that is treated by UK ambulance services. Across all cases of OHCA, survival to hospital discharge is less than 10%. Acute coronary syndrome (ACS) is a common cause of OHCA.
Objectives
To explore factors that influence survival in patients who initially survive an OHCA attributable to ACS.
Data source
Data collected by the Myocardial Ischaemia National Audit Project (MINAP) between 2003 and 2015.
Participants
Adult patients who had a first OHCA attributable to ACS and who were successfully resuscitated and admitted to hospital.
Main outcome measures
Hospital mortality, neurological outcome at hospital discharge, and time to all-cause mortality.
Methods
We undertook a cohort study using data from the MINAP registry. MINAP is a national audit that collects data on patients admitted to English, Welsh and Northern Irish hospitals with myocardial ischaemia. From the data set, we identified patients who had an OHCA. We used imputation to address data missingness across the data set. We analysed data using multilevel logistic regression to identify modifiable and non-modifiable factors that affect outcome.
Results
Between 2003 and 2015, 1,127,140 patient cases were included in the MINAP data set. Of these, 17,604 OHCA cases met the study inclusion criteria. Overall hospital survival was 71.3%. Across hospitals with at least 60 cases, hospital survival ranged from 34% to 89% (median 71.4%, interquartile range 60.7–76.9%). Modelling, which adjusted for patient and treatment characteristics, could account for only 36.1% of this variability. For the primary outcome, the key modifiable factors associated with reduced mortality were reperfusion treatment [primary percutaneous coronary intervention (pPCI) or thrombolysis] and admission under a cardiologist. Admission to a high-volume cardiac arrest hospital did not influence survival. Sensitivity analyses showed that reperfusion was associated with reduced mortality among patients with a ST elevation myocardial infarction (STEMI), but there was no evidence of a reduction in mortality in patients who did not present with a STEMI.
Limitations
This was an observational study, such that unmeasured confounders may have influenced study findings. Differences in case identification processes at hospitals may contribute to an ascertainment bias.
Conclusions
In OHCA patients who have had a cardiac arrest attributable to ACS, there is evidence of variability in survival between hospitals, which cannot be fully explained by variables captured in the MINAP data set. Our findings provide some support for the current practice of transferring resuscitated patients with a STEMI to a hospital that can deliver pPCI. In contrast, it may be reasonable to transfer patients without a STEMI to the nearest appropriate hospital.
Future work
There is a need for clinical trials to examine the clinical effectiveness and cost-effectiveness of invasive reperfusion strategies in resuscitated OHCA patients of cardiac cause who have not had a STEMI.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Keith Couper
- Warwick Medical School, University of Warwick, Coventry, UK
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Peter K Kimani
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- York Teaching Hospital NHS Foundation Trust, York, UK
| | - Tom Quinn
- Faculty of Health, Social Care and Education, Kingston University, London and St George’s, University of London, London, UK
| | - Iain B Squire
- University of Leicester and Leicester NIHR Cardiovascular Research Unit, Glenfield Hospital, Leicester, UK
| | | | - John JM Black
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK
| | | | | | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heart of England NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
29
|
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranckx P, Widimský P. [2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.]. Eur Heart J 2018; 39:119-177. [PMID: 29457615 DOI: 10.1093/eurheartj/ehx393] [Citation(s) in RCA: 6184] [Impact Index Per Article: 1030.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Borja Ibanez
- Department of Cardiology, IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Abstract
OBJECTIVES To determine whether ICUs caring for higher volumes of acute respiratory distress syndrome patients would be associated with lower ICU mortality. DESIGN A 9-year multicenter retrospective cohort study of prospectively collected data. SETTING French medical ICUs. PATIENTS From 2004 to 2012, acute respiratory distress syndrome cases were identified from a coding system through a regional database (Collège des Utilisateurs de Données en Réanimation). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Volume was calculated as the cumulative annual mean number of acute respiratory distress syndrome cases. Severity (Simplified Acute Physiology Score 2) and ICU mortality between categories (low, medium, and high) of acute respiratory distress syndrome cases volume were analyzed. Multivariable analysis using mixed effects models was performed to adjust for severity of illness and confounding factors. Over the study period, 8,383 acute respiratory distress syndrome patients among 31 ICUs met the study inclusion criteria. Overall, Simplified Acute Physiology Score 2 (median [interquartile]) was 58 (43-74), whereas ICU mortality was 53.7%. Severity as assessed by Simplified Acute Physiology Score 2 (median [interquartile]) was significantly higher in high-volume ICUs (> 65 acute respiratory distress syndrome per year) as compared to low (≤ 29 acute respiratory distress syndrome per year) and medium-volume ICUs (> 29-65 acute respiratory distress syndrome per year): 61 (46-77) versus 55 (41-72) and 55.0 (40-72), respectively (p < 0.01). ICU mortality was similar across the acute respiratory distress syndrome volume categories (53.6%, 54.1%, and 53.3% in low-, medium-, and high-volume categories ICUs, respectively). After adjustment for confounders, acute respiratory distress syndrome case volume was independently associated with ICU mortality (odds ratio for log-transformed volume: 0.77 [95% CI, 0.62-0.96]; p = 0.02). CONCLUSIONS ICUs caring for higher volumes of acute respiratory distress syndrome cases were associated with lower ICU mortality.
Collapse
|
31
|
|
32
|
Joint Replacement Volume Positively Correlates With Improved Hospital Performance on Centers for Medicare and Medicaid Services Quality Metrics. J Arthroplasty 2017; 32:1409-1413. [PMID: 28089185 DOI: 10.1016/j.arth.2016.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 12/01/2016] [Accepted: 12/10/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Center for Medicare and Medicaid Services (CMS) is transitioning Medicare from a fee-for-service program into a value-based pay-for-performance program. In order to accomplish this goal, CMS initiated 3 programs that attempt to define quality and seek to reward high-performing hospitals and penalize poor-performing hospitals. These programs include (1) penalties for hospital-acquired conditions (HACs), (2) penalties for excess readmissions for certain conditions, and (3) performance on value-based purchasing (VBP). The objective of this study was to determine whether high-volume total joint hospitals perform better in these programs than their lower-volume counterparts. METHODS We analyzed data from the New York Statewide Planning and Research Cooperative System database on total New York State hospital discharges from 2013 to 2015 for total knee and total hip arthroplasty. This was compared to data from Hospital Compare on HAC's, excess readmissions, and VBP. From these databases, we identified 123 hospitals in New York, which participated in all 3 Medicare pay-for-performance programs and performed total joint replacements. RESULTS Over the 3-year period spanning 2013-2015, hospitals in New York State performed an average of 1136.59 total joint replacement surgeries and achieved a mean readmission penalty of 0.005909. The correlation coefficient between surgery volume and combined performance score was 0.277. Of these correlations, surgery volume and VBP performance, and surgery volume and combined performance showed statistical significance (P < .01). CONCLUSION Our study demonstrates that there is a positive association between joint replacement volumes and overall hospital quality, as well as joint replacement volumes and VBP performance, specifically. These findings are consistent with previously reported associations between patient outcomes and procedure volumes. However, a relationship between joint replacement volume and HAC scores or readmission penalties could not be demonstrated.
Collapse
|
33
|
Hospital characteristics and favourable neurological outcome among patients with out-of-hospital cardiac arrest in Osaka, Japan. Resuscitation 2016; 110:146-153. [PMID: 27893969 DOI: 10.1016/j.resuscitation.2016.11.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/27/2016] [Accepted: 11/13/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess the association between favourable neurological outcome and hospital characteristics such as hospital volume and number of critical care centres (CCMCs) after out-of-hospital cardiac arrest (OHCA). METHODS This retrospective, population-based observational study conducted in Osaka Prefecture, Japan included adult patients with OHCA, aged ≥18 years who were transported to acute care hospitals between January 2005 and December 2012. We divided acute care hospitals into CCMCs or non-CCMCs, the latter of which were divided into the following three groups according to the annual average number of transported OHCA cases: low-volume (≤10 cases), middle-volume (11-39 cases), and high-volume (≥40 cases) groups. Random effects logistic regression models, with hospital treated as a random effect, were used to assess factors potentially associated with a favourable neurological outcome. RESULTS A total of 44,474 patients were eligible. The proportions of favourable neurological outcome from OHCA were 0.9% (31/3559) in the low-volume group, 1.2% (106/9171) in the middle-volume group, 1.6% (222/14,007) in the high-volume group, and 4.3% (766/17,737) in the CCMC group (P<0.001). In the multivariable analysis, transport to CCMCs was significantly associated with favourable neurological outcome, compared with transport to non-CCMCs (adjusted odds ratio 1.63; 95% confidence interval, 1.60-1.66). Among the non-CCMC group, there was no significant relationship between hospital volume and favourable neurological outcome. CONCLUSIONS In this population, transport of OHCA patients to CCMCs led to significantly higher one-month survival rates with favourable neurological outcome from OHCA, whereas no significant association was noted among the hospitals with different volumes.
Collapse
|
34
|
Pulmonary Hypertension Care Center Network: Improving Care and Outcomes in Pulmonary Hypertension. Chest 2016; 151:749-754. [PMID: 27818333 DOI: 10.1016/j.chest.2016.10.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pulmonary hypertension (PH) is a chronic, progressive, life-threatening disease that requires expert multidisciplinary care. To facilitate this level of care, the Pulmonary Hypertension Association established across the United States a network of pulmonary hypertension care centers (PHCCs) with special expertise in PH, particularly pulmonary arterial hypertension, to raise the overall quality of care and outcomes for patients with this life-threatening disease. Since the inception of PHCCs in September 2014, to date 35 centers have been accredited in the United States. This model of care brings together physicians and specialists from other disciplines to provide care, facilitate basic and clinical research, and educate the next generation of providers. PHCCs also offer additional opportunities for improvements in PH care. The patient registry offered through the PHCCs is an organized system by which data are collected to evaluate the outcomes of patients with PH. This registry helps in detecting variations in outcomes across centers, thus identifying opportunities for improvement. Multiple tactics were undertaken to implement the strategic plan, training, and tools throughout the PHCC network. In addition, strategies to foster collaboration between care center staff and individuals with PH and their families are the cornerstone of the PHCCs. The Pulmonary Vascular Network of the American College of Chest Physicians believes this to be a positive step that will improve the quality of care delivered in the United States to patients with PH.
Collapse
|
35
|
Meara E, Landrum MB, Ayanian JZ, McNeil BJ, Guadagnoli E. The Effect of Managed Care Market Share on Appropriate Use of Coronary Angiography among Traditional Medicare Beneficiaries. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2016; 41:144-58. [PMID: 15449430 DOI: 10.5034/inquiryjrnl_41.2.144] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Evidence suggests that when managed care market share increases in a geographic area, expenditures in Medicare's fee-for-service sector decrease. But it is unclear how expenditure reductions relate to the quality of medical care for traditional Medicare beneficiaries. We estimated how managed care market share varied with the proportion of fee-for-service Medicare beneficiaries who were admitted for acute myocardial infarction (AMI) and underwent angiography. We classified patients as appropriate, discretionary, and inappropriate, according to guidelines of the American College of Cardiology and the American Heart Association (ACC-AHA). Within all ACC-AHA classes, coronary angiography fell slightly as managed care market share increased.
Collapse
Affiliation(s)
- Ellen Meara
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115-5899, USA.
| | | | | | | | | |
Collapse
|
36
|
Affiliation(s)
- Erik K Mayer
- Department of Biosurgery and Surgical Technology, Imperial College London, St Mary's Hospital, London, UK
| | | | | | | |
Collapse
|
37
|
Impact of Operator Experience and Volume on Outcomes After Left Main Coronary Artery Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2016; 9:2086-2093. [DOI: 10.1016/j.jcin.2016.08.011] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/19/2016] [Accepted: 08/11/2016] [Indexed: 12/28/2022]
|
38
|
Impact of Infectious Diseases Consultation on Clinical Outcomes of Patients with Staphylococcus aureus Bacteremia in a Community Health System. Antimicrob Agents Chemother 2016; 60:5682-7. [PMID: 27401580 DOI: 10.1128/aac.00439-16] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/07/2016] [Indexed: 12/19/2022] Open
Abstract
Staphylococcus aureus bacteremia (SAB) causes high rates of morbidity and death. Several studies in academic health settings have demonstrated that consultations from infectious diseases specialists improve the quality of care and clinical outcomes for SAB. Few data that describe the impact in resource-limited settings such as community hospitals are available. This retrospective cohort study evaluated the adherence to quality-of-care indicators and the clinical outcomes for SAB in a five-hospital community health system (range of 95 to 272 available beds per hospital), for patients with versus without infectious diseases consultation (IDC). IDC was provided if requested by the attending physician. The primary outcome was the incidence of treatment failure, defined as 30-day in-hospital death or 90-day SAB recurrence. Other outcomes included adherence to quality-of-care indicators. A total of 473 adult patients with SAB were included, with 369 (78%) receiving IDC. We identified substantial differences in baseline characteristics between the IDC group and the no-IDC group, including greater incidences of complicated bacteremia and intravenous drug users in the IDC group, with similar rates of severe illness (measured by Pitt bacteremia scores). Adherence to quality-of-care indicators was greater for patients with IDC (P < 0.001). After adjustment for other predicting variables, IDC was associated with a lower rate of treatment failure (adjusted odds ratio, 0.42 [95% confidence interval, 0.20 to 0.86]; P = 0.018). IDC provided better quality of care and better clinical outcomes for patients with SAB who were treated at small, resource-limited, community hospitals.
Collapse
|
39
|
|
40
|
Harrison RW, Simon D, Miller AL, de Lemos JA, Peterson ED, Wang TY. Association of hospital myocardial infarction volume with adherence to American College of Cardiology/American Heart Association performance measures: Insights from the National Cardiovascular Data Registry. Am Heart J 2016; 178:95-101. [PMID: 27502856 DOI: 10.1016/j.ahj.2016.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 04/09/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adherence to guideline-based therapy improves patient outcomes after acute myocardial infarction (AMI) and hospital AMI volume is associated with reperfusion care, but the extent hospital AMI volume is associated with overall guideline adherence is unclear. METHODS AND RESULTS We studied 486 hospitals treating 249,877 AMI patients in ACTION Registry-GWTG from January 1, 2007, to March 31, 2011. Hospital adherence to each American College of Cardiology/American Heart Association performance measure was compared between tertiles defined by hospital AMI volume: low (≤108 cases/y), middle (≥109 and ≤227 cases/y), and high (≥228 cases/y). Multivariable logistic regression, adjusting for patient and hospital characteristics, was used to examine the association between annual AMI volume and adherence to each measure. Similar modeling was used to evaluate the relationship between AMI volume and in-hospital mortality. Compared with high-volume hospitals, lower-volume hospitals were less likely to be academically affiliated, or to have cardiac surgery capabilities, electronic health records, or dedicated tobacco treatment services. Higher-volume hospitals had greater adherence to each performance measure, except aspirin use at arrival and reperfusion therapy. The greatest difference was in the rates of referral to cardiac rehabilitation (59%, 76%, and 83% in low-, middle-, and high-volume hospitals, respectively). After multivariable adjustment, higher AMI volume (up to 400 AMI patients/y) remained associated with higher-performance measure adherence. There was no association between AMI volume and in-hospital mortality after adjusting for patient and hospital characteristics. CONCLUSIONS Higher hospital AMI volume was correlated with better adherence to process of care measures, but not in-hospital mortality.
Collapse
|
41
|
Makarov DV, Hu EYC, Walter D, Braithwaite RS, Sherman S, Gold HT, Zhou XA, Gross CP, Zeliadt SB. Appropriateness of Prostate Cancer Imaging among Veterans in a Delivery System without Incentives for Overutilization. Health Serv Res 2016; 51:1021-51. [PMID: 26423687 PMCID: PMC4874832 DOI: 10.1111/1475-6773.12395] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine the frequency of appropriate and inappropriate prostate cancer imaging in an integrated health care system. DATA SOURCES/STUDY SETTING Veterans Health Administration Central Cancer Registry linked to VA electronic medical records and Medicare claims (2004-2008). STUDY DESIGN We performed a retrospective cohort study of VA patients diagnosed with prostate cancer (N = 45,084). Imaging (CT, MRI, bone scan, PET) use was assessed among patients with low-risk disease, for whom guidelines recommend against advanced imaging, and among high-risk patients for whom guidelines recommend it. PRINCIPAL FINDINGS We found high rates of inappropriate imaging among men with low-risk prostate cancer (41 percent) and suboptimal rates of appropriate imaging among men with high-risk disease (70 percent). Veterans utilizing Medicare-reimbursed care had higher rates of inappropriate imaging [OR: 1.09 (1.03-1.16)] but not higher rates of appropriate imaging. Veterans treated in middle [OR: 0.51 (0.47-0.56)] and higher [OR: 0.50 (0.46-0.55)] volume medical centers were less likely to undergo inappropriate imaging without compromising appropriate imaging. CONCLUSIONS Our results highlight the overutilization of imaging, even in an integrated health care system without financial incentives encouraging provision of health care services. Paradoxically, imaging remains underutilized among high-risk patients who could potentially benefit from it most.
Collapse
Affiliation(s)
- Danil V. Makarov
- VA New York Harbor Healthcare SystemNew York UniversityNew YorkNY
- Department of UrologyNew York UniversityNew YorkNY
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
- Robert F. Wagner Graduate School of Public ServiceNew York UniversityNew YorkNY
| | - Elaine Y. C. Hu
- VA Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Dawn Walter
- VA New York Harbor Healthcare SystemNew York UniversityNew YorkNY
- Department of UrologyNew York UniversityNew YorkNY
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | - R. Scott Braithwaite
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | - Scott Sherman
- VA New York Harbor Healthcare SystemNew York UniversityNew YorkNY
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | - Heather T. Gold
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | | | - Cary P. Gross
- Robert Wood Johnson Clinical Scholars Program and Department of Internal MedicineYale University School of MedicineNew HavenCT
| | - Steven B. Zeliadt
- VA Puget Sound Healthcare System and University of WashingtonSeattleWA
| |
Collapse
|
42
|
Rashid M, Sperrin M, Ludman PF, O'Neill D, Nicholas O, de Belder MA, Mamas MA. Impact of operator volume for percutaneous coronary intervention on clinical outcomes: what do the numbers say?: Table 1. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:16-22. [DOI: 10.1093/ehjqcco/qcv030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Indexed: 12/25/2022]
|
43
|
Yasuda S, Nakao K, Nishimura K, Miyamoto Y, Sumita Y, Shishido T, Anzai T, Tsutsui H, Ito H, Komuro I, Saito Y, Ogawa H. The Current Status of Cardiovascular Medicine in Japan – Analysis of a Large Number of Health Records From a Nationwide Claim-Based Database, JROAD-DPC –. Circ J 2016; 80:2327-2335. [DOI: 10.1253/circj.cj-16-0196] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Issei Komuro
- Graduate School of Medicine and Faculty of Medicine, The University of Tokyo
| | | | | | | |
Collapse
|
44
|
Han KT, Kim SJ, Kim W, Jang SI, Yoo KB, Lee SY, Park EC. Associations of volume and other hospital characteristics on mortality within 30 days of acute myocardial infarction in South Korea. BMJ Open 2015; 5:e009186. [PMID: 26546143 PMCID: PMC4636601 DOI: 10.1136/bmjopen-2015-009186] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE The mortality for acute myocardial infarction (AMI) has declined worldwide. However, improvements in care for AMI in South Korea have lagged slightly behind those in other countries. Therefore, it is important to investigate how factors such as hospital volume, structural characteristics of hospital and hospital staffing level affect 30-day mortality due to AMI in South Korea. SETTING We used health insurance claim data from 114 hospitals to analyse 30-day mortality for AMI. PARTICIPANTS These data consisted of 19,638 hospitalisations during 2010-2013. INTERVENTIONS No interventions were made. OUTCOME MEASURE Multilevel models were analysed to examine the association between the 30-day mortality and inpatient and hospital level variables. RESULTS In the 30 days after hospitalisation, 10.5% of patients with AMI died. Hospitalisation cases at hospitals with a higher AMI volume had generally inverse associations with 30-day mortality (1st quartile=ref; 2nd quartile=OR 0.811, 95% CI 0.658 to 0.998, 3rd quartile=OR 0.648, 95% CI 0.500 to 0.840, 4th quartile=OR 0.807, 95% CI 0.573 to 1.138). In addition, hospitals with a greater proportion of specialists were associated with better outcomes (above median=OR 0.789, 95% CI 0.663 to 0.940). CONCLUSIONS Health policymakers need to include volume and staffing when defining the framework for treatment of AMI in South Korean hospitals. Otherwise, they must consider increasing the proportion of specialists or regulating the hiring of emergency medicine specialists. In conclusion, they must make an effort to reduce 30-day mortality following AMI based on such considerations.
Collapse
Affiliation(s)
- Kyu-Tae Han
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sun Jung Kim
- Department of Health Administration and Management, Soonchunhyang University, Asan, Republic of Korea
| | - Woorim Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-In Jang
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ki-Bong Yoo
- Department of Hospital Management, Eulji University, Seongnam, Republic of Korea
| | - Seo Yoon Lee
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
45
|
López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
46
|
López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
47
|
Gozalo P, Leland NE, Christian TJ, Mor V, Teno JM. Volume Matters: Returning Home After Hip Fracture. J Am Geriatr Soc 2015; 63:2043-51. [PMID: 26424223 DOI: 10.1111/jgs.13677] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To examine the effect of the relationship between volume (number of hip fracture admissions during the 12 months before participant's fracture) and other facility characteristics on outcomes. DESIGN Prospective observational study. SETTING U.S. skilled nursing facilities (SNFs) admitting individuals discharged from the hospital after treatment for hip fracture between 2000 and 2007 (N = 15,439). PARTICIPANTS Community-dwelling fee-for-service Medi-care beneficiaries aged 75 and older admitted to U.S. hospitals for their first hip fracture and discharged to a SNF for postacute care from 2000 to 2007 (N = 512,967). MEASUREMENTS Successful discharge from SNF to community, defined as returning to the community within 30 days of hospital discharge to the SNF and remaining in the community without being institutionalized for at least 30 days, was examined using Medicare administrative data, propensity score matching, and instrumental variables. RESULTS The overall rate of successful discharge to the community was 31%. Of the 15,439 facilities, the facility interquartile range varied from 0% (25th percentile) to 42% (75th percentile). An important determinant of variation in discharge rate was SNF volume of hip fracture admissions. Unadjusted successful discharge from SNF to community was 43.7% in high-volume facilities (>24 admissions/year), versus 18.8% in low-volume facilities (1-6 admissions/year). This facility volume effect persisted after adjusting for participant and facility characteristics associated with outcomes (e.g., adjusted odds ratio = 2.06, 95% confidence interval = 1.91-2.21 for volume of 25 vs 3 admissions per year). CONCLUSION In community-dwelling persons with their first hip fracture, successful return to the community varies substantially according to SNF provider volume and staffing characteristics.
Collapse
Affiliation(s)
- Pedro Gozalo
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Natalie E Leland
- Division of Occupational Science and Occupational Therapy, Herman Ostrow School of Dentistry and Davis School of Gerontology, University of Southern California, Los Angeles, California
| | | | - Vincent Mor
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island.,Health Services Research, Providence Veteran's Administration Medical Center, Providence, Rhode Island
| | - Joan M Teno
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| |
Collapse
|
48
|
López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper. ACTA ACUST UNITED AC 2015; 68:976-995.e10. [PMID: 26315766 DOI: 10.1016/j.rec.2015.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023]
Abstract
Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.
Collapse
Affiliation(s)
- José López-Sendón
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain.
| | - José Ramón González-Juanatey
- Sociedad Española de Cardiología, Madrid, Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Fausto Pinto
- European Society of Cardiology; Department of Cardiology, University Hospital Santa Maria, Lisbon, Portugal
| | - José Cuenca Castillo
- Sociedad Española de Cirugía Torácica-Cardiovascular; Servicio de Cirugía Cardiaca, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Lina Badimón
- Centro de Investigación Cardiovascular (CSIC-ICCC), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Regina Dalmau
- Unidad de Rehabilitación Cardiaca, Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Esteban González Torrecilla
- Unidad de Electrofisiología y Arritmias, Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - José Ramón López-Mínguez
- Unidad de Cardiología intervencionista, Servicio de Cardiología, Hospital Infanta Crsitina, Badajoz, Spain
| | - Alicia M Maceira
- Unidad de Imagen Cardiaca, Servicio de Cardiología, ERESA Medical Center, Valencia, Spain
| | - Domingo Pascual-Figal
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | | | - Alessandro Sionis
- Unidad de Cuidados Intensivos Cardiológicos, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Luis Zamorano
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | |
Collapse
|
49
|
Teno J, Meltzer DO, Mitchell SL, Fulton AT, Gozalo P, Mor V. Type of attending physician influenced feeding tube insertions for hospitalized elderly people with severe dementia. Health Aff (Millwood) 2015; 33:675-82. [PMID: 24711330 DOI: 10.1377/hlthaff.2013.1248] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Striking variation has been documented in the rates of feeding tube insertion for hospitalized patients with advanced dementia. This occurs despite the harms of the procedure, which may outweigh its benefits, and the procedure's inconsistency with care focused on the patient's comfort. Among nursing home residents with advanced dementia who were hospitalized in 2001-10 with an infection or dehydration, we found that rates of insertion of a percutaneous endoscopic gastrostomy feeding tube varied by type of attending physician. Insertion rates were markedly lower when all of a patient's attending physicians were hospitalists (1.6 percent) or nonhospitalist generalists (2.2 percent), compared to all subspecialists (11.0 percent) or a mixture of physicians by type, which typically included a subspecialist (15.6 percent). The portion of patients seen by a mixture of attending physicians increased from 28.9 percent in 2001 to 38.3 percent in 2010. Efforts to improve decision making in the care of patients with advanced dementia should include interventions to improve communication among physicians and the education of subspecialists about the merits of using feeding tubes with this population.
Collapse
|
50
|
Mesman R, Westert GP, Berden BJ, Faber MJ. Why do high-volume hospitals achieve better outcomes? A systematic review about intermediate factors in volume–outcome relationships. Health Policy 2015; 119:1055-67. [DOI: 10.1016/j.healthpol.2015.04.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 02/01/2015] [Accepted: 04/08/2015] [Indexed: 11/30/2022]
|