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Soares A, Schilling LM, Richardson J, Kommadi B, Subbian V, Dehnbostel J, Shahin K, Robinson KA, Afzal M, Lehmann HP, Kunnamo I, Alper BS. Making Science Computable Using Evidence-Based Medicine on Fast Healthcare Interoperability Resources: Standards Development Project. J Med Internet Res 2024; 26:e54265. [PMID: 38916936 PMCID: PMC11234056 DOI: 10.2196/54265] [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: 11/03/2023] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Evidence-based medicine (EBM) has the potential to improve health outcomes, but EBM has not been widely integrated into the systems used for research or clinical decision-making. There has not been a scalable and reusable computer-readable standard for distributing research results and synthesized evidence among creators, implementers, and the ultimate users of that evidence. Evidence that is more rapidly updated, synthesized, disseminated, and implemented would improve both the delivery of EBM and evidence-based health care policy. OBJECTIVE This study aimed to introduce the EBM on Fast Healthcare Interoperability Resources (FHIR) project (EBMonFHIR), which is extending the methods and infrastructure of Health Level Seven (HL7) FHIR to provide an interoperability standard for the electronic exchange of health-related scientific knowledge. METHODS As an ongoing process, the project creates and refines FHIR resources to represent evidence from clinical studies and syntheses of those studies and develops tools to assist with the creation and visualization of FHIR resources. RESULTS The EBMonFHIR project created FHIR resources (ie, ArtifactAssessment, Citation, Evidence, EvidenceReport, and EvidenceVariable) for representing evidence. The COVID-19 Knowledge Accelerator (COKA) project, now Health Evidence Knowledge Accelerator (HEvKA), took this work further and created FHIR resources that express EvidenceReport, Citation, and ArtifactAssessment concepts. The group is (1) continually refining FHIR resources to support the representation of EBM; (2) developing controlled terminology related to EBM (ie, study design, statistic type, statistical model, and risk of bias); and (3) developing tools to facilitate the visualization and data entry of EBM information into FHIR resources, including human-readable interfaces and JSON viewers. CONCLUSIONS EBMonFHIR resources in conjunction with other FHIR resources can support relaying EBM components in a manner that is interoperable and consumable by downstream tools and health information technology systems to support the users of evidence.
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Affiliation(s)
- Andrey Soares
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lisa M Schilling
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Joshua Richardson
- Center for Informatics, Research Triangle Institute International, Berkeley, CA, United States
| | - Bhagvan Kommadi
- Quantica Computacao, Hyderabad, India
- Scientific Knowledge Accelerator Foundation, Franklin, NC, United States
| | - Vignesh Subbian
- Scientific Knowledge Accelerator Foundation, Franklin, NC, United States
- College of Public Health, Department of Epidemiology and Biostatistics, University of Arizona, Tucson, AZ, United States
| | - Joanne Dehnbostel
- Scientific Knowledge Accelerator Foundation, Franklin, NC, United States
- Computable Publishing LLC, Franklin, NC, United States
| | - Khalid Shahin
- Scientific Knowledge Accelerator Foundation, Franklin, NC, United States
- Computable Publishing LLC, Franklin, NC, United States
| | - Karen A Robinson
- Scientific Knowledge Accelerator Foundation, Franklin, NC, United States
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Muhammad Afzal
- Scientific Knowledge Accelerator Foundation, Franklin, NC, United States
- Department of Computing and Data Science, Birmingham City University, England, United Kingdom
| | - Harold P Lehmann
- Scientific Knowledge Accelerator Foundation, Franklin, NC, United States
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Ilkka Kunnamo
- Scientific Knowledge Accelerator Foundation, Franklin, NC, United States
- Duodecim Publishing Company Ltd, Helsinki, Finland
| | - Brian S Alper
- Scientific Knowledge Accelerator Foundation, Franklin, NC, United States
- Computable Publishing LLC, Franklin, NC, United States
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Lin L. Global, regional and national time trends in incidence of adverse effects of medical treatment, 1990-2019: an age-period-cohort analysis from the Global Burden of Disease 2019 study. BMJ Qual Saf 2024:bmjqs-2023-016971. [PMID: 38862263 DOI: 10.1136/bmjqs-2023-016971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 05/01/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Current adverse effects of medical treatment (AEMT) incidence estimates rely on limited record reviews and underreporting surveillance systems. This study evaluated global and national longitudinal patterns in AEMT incidence from 1990 to 2019 using the Global Burden of Disease (GBD) framework. METHODS AEMT was defined as harm resulting from a procedure, treatment or other contact with the healthcare system. The overall crude incidence rate, age-standardised incidence rate and their changes over time were analysed to evaluate temporal trends. Data were stratified by sociodemographic index (SDI) quintiles, age groups and sex to address heterogeneity across and within nations. An age-period-cohort model framework was used to differentiate the contributions of age, period and cohort effects on AEMT incidence changes. The model estimated overall and age-specific annual percentage changes in incidence rates. FINDINGS Although the global population increased 44.6% from 1990 to 2019, AEMT incidents rose faster by 59.3%. The net drift in the global incidence rate was 0.631% per year. The proportion of all cases accounted for by older adults and the incidence rate among older adults increased globally. The high SDI region had much higher and increasing incidence rates versus declining rates in lower SDI regions. The age effects showed that in the high SDI region, the incidence rate is higher among older adults. Globally, the period effect showed a rising incidence of risk after 2002. Lower SDI regions exhibited a significant increase in incidence risk after 2012. Globally, the cohort effect showed a continually increasing incidence risk across sequential birth cohorts from 1900 to 1950. CONCLUSION As the global population ageing intensifies alongside the increasing quantity of healthcare services provided, measures need to be taken to address the continuously rising burden of AEMT among the older population.
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Affiliation(s)
- Liangquan Lin
- School of Marxism, School of Humanities and Social Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Revilla-Pacheco F, Calderón-Juárez M, Lerma A, Herrada-Pineda T, Lerma C. Efficacy of an intervention program to prevent patient safety indicators in aneurysmal subarachnoid haemorrhage. Br J Neurosurg 2024; 38:579-584. [PMID: 34096815 DOI: 10.1080/02688697.2021.1931810] [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: 12/24/2020] [Revised: 04/24/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Patient safety indicators (PSI) are a set of potentially preventable events related to patient safety and opportunities for improvement. Eight pertinent PSI have been identified in patients with aneurysmal subarachnoid haemorrhage (ASAH), such as decubitus ulcer, and central line-related bacteraemia. Our aim was to evaluate the efficacy of a health care quality protocol to prevent the appearance of PSI in ASAH patients. METHODS Adult patients treated for ASAH were included in a retrospective control group of 35 patients and a prospective experimental group of 35 patients when the prevention program was implemented. We evaluated the occurrence of PSI, and its relation to age, sex, Hunt and Hess scale grade, type of aneurysm treatment, length of hospital stay, and Glasgow Outcome Scale scores. RESULTS Both groups had similar characteristics except for a longer hospital stay in the control group. The overall PSI prevalence decreased significantly in the experimental group compared to the control group. The experimental group had a decreased risk for having at least one PSI: OR = 0.21 (0.08-0.57, CI 95%). The absolute risk reduction is 37.1% (58.9%-15.4%), the preventable fraction for the population is 28.3% (10.6%-40.0%), and the number needed to treat is 2.69. CONCLUSIONS The health care quality protocol is effective to prevent ISP in ASAH patients. Implementing this prevention program has no effect on the neurological state of the patient at the hospital discharge. Still, it is successful in decreasing the PSI prevalence and the days of hospital stay.
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Affiliation(s)
| | - Martín Calderón-Juárez
- Department of Education, ABC Medical Center, Mexico City, Mexico
- Plan de Estudios Combinados en Medicina, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Abel Lerma
- Institute of Health Sciences, Universidad Autónoma del Estado de Hidalgo, San Juan Tilcuautla, Mexico
| | | | - Claudia Lerma
- Department of Electromechanical Instrumentation, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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Allaudeen N, Schalch E, Neff M, Poppler K, Vashi AA. Patient Safety Indicators at an Academic Veterans Affairs Hospital: Addressing Dual Goals of Clinical Care and Validity. Jt Comm J Qual Patient Saf 2024:S1553-7250(24)00132-6. [PMID: 38821745 DOI: 10.1016/j.jcjq.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Hospital-acquired complications add to patient morbidity and mortality, costs, length of stay, and negative patient experience. Patient Safety Indicators (PSIs) are a validated and widely used metric to evaluate hospital administrative data on preventing these events. Although many studies have addressed PSI validity, few have aimed to reduce PSI through clinical care. The authors aimed to reduce PSI events by addressing both validity and clinical care. METHODS Frontline clinicians used a deep dive template to provide input on all PSI cases, which were then reviewed by a PSI task force to identify performance gaps. After analyzing the frequency of gaps and cost-vs.-impact of potential solutions, five interventions were implemented to address the three most common, highly weighted PSIs: pressure ulcers, postoperative venous thromboembolism (VTE), and postoperative sepsis. Clinical care interventions included increasing patient mobility by creating a specialized mobility technician position, skin care audits to prevent pressure ulcers, and increasing use of pharmacologic VTE prophylaxis. Administrative interventions addressed improving clinician-coding concordance for sepsis and increasing documentation of comorbidities. RESULTS After interventions, the number of PSI events for composite PSI, VTE, and sepsis decreased by 41.3% (p = 0.039), 85.2% (p = 0.0091), and 51.5% (p = 0.063), respectively, relative to the preintervention period. Pressure ulcers increased by 33.3% (p = 0.0091). CONCLUSION Hospital complications cause substantial burden to hospitals, patients, and caregivers. Addressing administrative and clinical factors with targeted interventions led to reduction in composite PSI. Further efforts are needed locally to reduce the pressure ulcer PSI.
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Serpa JA, Gemeinhardt G, Arias CA, Morgan RO, Russell H, Miao H, Ganduglia Cazaban CM. Teaching and Safety-Net Hospital Penalization in the Hospital-Acquired Condition Reduction Program. JAMA Netw Open 2024; 7:e2356196. [PMID: 38363569 PMCID: PMC10873765 DOI: 10.1001/jamanetworkopen.2023.56196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/21/2023] [Indexed: 02/17/2024] Open
Abstract
Importance The Hospital-Acquired Condition Reduction Program (HACRP) evaluates acute care hospitals on the occurrence of patient safety events and health care-associated infections. Since its implementation, several studies have raised concerns about the overpenalization of teaching and safety-net hospitals, and although several changes in the program's methodology have been applied in the last few years, whether these changes reversed the overpenalization of teaching and safety-net hospitals is unknown. Objective To determine hospital characteristics associated with HACRP penalization and penalization reversal. Design, Setting, and Participants This retrospective cross-sectional study assessed data from 3117 acute care hospitals participating in the HACRP. The HACRP penalization and hospital characteristics were obtained from Hospital Compare (2020 and 2021), the Inpatient Prospective Payment System impact file (2020), and the American Hospital Association annual survey (2018). Exposures Hospital characteristics, including safety-net status and teaching intensity (no teaching and very minor, minor, major, and very major teaching levels). Main Outcomes and Measures The primary outcome was HACRP penalization (ie, hospitals that fell within the worst quartile of the program's performance). Multivariable models initially included all covariates, and then backward stepwise variable selection was used. Results Of 3117 hospitals that participated in HACRP in 2020, 779 (25.0%) were safety-net hospitals and 1090 (35.0%) were teaching institutions. In total, 771 hospitals (24.7%) were penalized. The HACRP penalization was associated with safety-net status (odds ratio [OR], 1.41 [95% CI, 1.16-1.71]) and very major teaching intensity (OR, 1.94 [95% CI, 1.15-3.28]). In addition, non-federal government hospitals were more likely to be penalized than for-profit hospitals (OR, 1.62 [95% CI, 1.23-2.14]), as were level I trauma centers (OR, 2.05 [95% CI, 1.43-2.96]) and hospitals located in the New England region (OR, 1.65 [95% CI, 1.12-2.43]). Safety-net hospitals with major teaching levels were twice as likely to be penalized as non-safety-net nonteaching hospitals (OR, 2.15 [95% CI, 1.14-4.03]). Furthermore, safety-net hospitals penalized in 2020 were less likely (OR, 0.64 [95% CI, 0.43-0.96]) to revert their HACRP penalization status in 2021. Conclusions and Relevance Findings from this cross-sectional study indicated that teaching and safety-net hospital status continued to be associated with overpenalization in the HACRP despite recent changes in its methodology. Most of these hospitals were also less likely to revert their penalization status. A reevaluation of the program methodology is needed to avoid depleting resources of hospitals caring for underserved populations.
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Affiliation(s)
- Jose A. Serpa
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Gretchen Gemeinhardt
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston
| | - Cesar A. Arias
- Center for Infectious Diseases, Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston Methodist Research Institute, Houston, Texas
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Robert O. Morgan
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston
| | - Heidi Russell
- Department of Management, Policy and Community Health, University of Texas School of Public Health, Houston
| | - Hongyu Miao
- Department of Statistics, and College of Nursing, Florida State University, Tallahassee
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Havranek MM, Rüter F, Bilger S, Dahlem Y, Oliveira L, Ehbrecht D, Moos RM, Westerhoff C, Beck T, Le Pogam MA. Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital complications: a medical record review across nine Swiss hospitals. Int J Qual Health Care 2023; 35:0. [PMID: 37949115 PMCID: PMC10656600 DOI: 10.1093/intqhc/mzad092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/25/2023] [Accepted: 10/22/2023] [Indexed: 11/12/2023] Open
Abstract
The validity of the Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) has been established in the USA and Canada. However, these indicators are also used for hospital benchmarking and cross-country comparisons in other nations with different health-care settings and coding systems as well as missing present on admission (POA) flags in the administrative data. This study sought to comprehensively assess and compare the validity of 16 PSIs in Switzerland, where they have not been previously applied. We performed a medical record review using administrative and electronic medical record data from nine Swiss hospitals. Seven independent reviewers evaluated 1245 cases at various hospitals using retrospective data from the years 2014-18. True positives, false positives, positive predictive values (PPVs), and reasons for misclassification were compared across all investigated PSIs, and the documentation quality of the PSIs was examined. PSIs 6 (iatrogenic pneumothorax), 10 (postoperative acute kidney injury), 11 (postoperative respiratory failure), 13 (postoperative sepsis), 14 (wound dehiscence), 17 (birth trauma), and 18 and 19 (obstetric trauma with or without instrument) showed high PPVs (range: 90-99%) and were not strongly influenced by missing POA information. In contrast, PSIs 3 (pressure ulcer), 5 (retained surgical item), 7 (central venous catheter-related bloodstream infection), 8 (fall with hip fracture), and 15 (accidental puncture/laceration) showed low PPVs (range: 18-49%). In the case of PSIs 3, 8, and 12 (perioperative embolism/thrombosis), the low PPVs were largely due to the lack of POA information. Additionally, it was found that the documentation of PSI 3 in discharge letters could be improved. We found large differences in validity across the 16 PSIs in Switzerland. These results can guide policymakers in Switzerland and comparable health-care systems in selecting and prioritizing suitable PSIs for quality initiatives. Furthermore, the national introduction of a POA flag would allow for the inclusion of additional PSIs in quality monitoring.
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Affiliation(s)
- Michael M Havranek
- Competence Center for Health Data Science, Faculty of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, Lucerne 6002, Switzerland
| | - Florian Rüter
- University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Selina Bilger
- University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Yuliya Dahlem
- University Hospital Zurich, Rämistrasse 100, Zurich 8006, Switzerland
| | - Leonel Oliveira
- University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Daniela Ehbrecht
- Zug Cantonal Hospital, Landhausstrasse 11, Zug 6340, Switzerland
| | - Rudolf M Moos
- Cantonal Hospital Winterthur, Brauerstrasse 15, Winterthur 8400, Switzerland
| | - Christian Westerhoff
- Hirslanden Private Hospital Group, Boulevard Lilienthal 2, Zurich 8152, Switzerland
| | - Thomas Beck
- University Hospital Berne (Inselspital), Freiburgstrasse, Berne 3010, Switzerland
| | - Marie-Annick Le Pogam
- Department of Epidemiology and Health Systems, Unisanté (University Center for Primary Care and Public Health), University of Lausanne, Route de la Corniche 10, Lausanne 1010, Switzerland
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Lee K, Hwang J, Lee CM. The Usefulness of Present-on-Admission Data as an Indicator of Healthcare Quality Evaluation Using the Korean National Hospital Discharge in-Depth Injury Survey Data from 2006 to 2019. Risk Manag Healthc Policy 2023; 16:2309-2320. [PMID: 37953808 PMCID: PMC10637211 DOI: 10.2147/rmhp.s423555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/19/2023] [Indexed: 11/14/2023] Open
Abstract
Purpose Comorbidities of a principal diagnosis have varying impacts on disease and require different management depending on the onset timing. This study investigated the usefulness of present-on-admission (POA), specifically focusing on decubitus ulcers, delirium, and hypokalemia, as an indicator of healthcare quality. Patients and Methods We analyzed patient discharge data for 14 years from 2006 to 2019 using Korean National Hospital Discharge In-Depth Injury Survey (KNHDIS). Results Out of 3,231,731 discharged patients, 19,871 had secondary diagnosis codes for decubitus ulcers (n=10,390, 52.3%), delirium (n=6103, 30.7%), or hypokalemia (n=3378, 17.0%). Analysis of patients with secondary diagnoses of decubitus ulcers, delirium, or hypokalemia revealed notable differences in demographics, including gender distribution, mean age, admission route, insurance type, surgical intervention rates, mortality rates, and length of stay (LOS). Among patients with one of the top 20 principal diagnoses, those with secondary diagnoses of decubitus ulcers, delirium, or hypokalemia exhibited higher odds of surgery, increased mortality risks, and longer LOS compared to those without these secondary diagnoses. Conclusion All three of these diseases commonly occur postoperatively or during treatment and thus should be designated as potentially preventable complications that require special attention, and should also be considered as quality-of-care indicators.
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Affiliation(s)
- Kyunghee Lee
- Department of Healthcare Management, Eulji University of Korea, Seongnam, Republic of Korea
| | - Jieun Hwang
- College of Health and Welfare, Department of Health Administration, Dankook University, Cheonan, Republic of Korea
| | - Chang Min Lee
- Department of Gastroenterology, Changwon Hanmaeum Hospital, Changwon, Republic of Korea
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Obaid LM, Ali I, Al Baker A, Al Shiekh Abdallah WO, Plando RL, Khawaldeh ME, Panaligan RKJ. Sustaining a culture of safety and optimising patient outcomes while implementing zero harm programme: a 2-year project of the nursing services - SBAHC. BMJ Open Qual 2023; 12:e002063. [PMID: 37821109 DOI: 10.1136/bmjoq-2022-002063] [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: 07/24/2022] [Accepted: 09/21/2023] [Indexed: 10/13/2023] Open
Abstract
This quality improvement report details how Sultan Bin Abdulaziz Humanitarian City (The City), the largest rehabilitation facility within Middle East with a capacity of 511 beds and more than 20 nursing in-patient units improved the quality and patient safety culture in nursing services after successfully adopting and implementing the zero harm programme.In healthcare settings, the idea of zero harm including zero incidents, zero injuries and injury-free are commonly used to highlight the importance of patient safety. Patient injuries and deaths resulting from hospital-acquired illnesses such as medication administration errors, falls, central line-associated bloodstream infections, hospital-acquired pressure injuries and catheter-associated urinary tract infection are largely preventable and grossly unacceptable occurrences. Achieving zero incidents of such critical measures can significantly impact treatment plan and enhance patient experience.The projects' purpose was to build a new culture of safety by implementing innovative strategy designed to protect patients from preventable harm while maintaining an extraordinary high standard of quality patient care. Additionally, the programme was established with the aim of instilling a sense of commitment to every nurse working in this organisation to anticipate potential harms and to be vigilant to prevent it before it reaches the patient.This document also describes a set of initiatives aimed at mitigating preventable incidents and ultimately achieving zero harm on our organisation. The result showed a significant increase by 95% between the percentage of nursing units that had 365 days of zero harm in 2020 and 2021. This improvement indicates that the concept of zero harm had been successfully inculcated among nursing units and had motivated nursing staff to uphold a higher culture of patient safety. Furthermore, by incorporating the Just Culture model into the electronic reporting system, the reporting rate of occurrences in the zero-harm programme was supported and sustained.
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Affiliation(s)
- Lina Mohammed Obaid
- Nursing Department, Sultan Bin Abdulaziz Humanitarian City (SBAHC), Riyadh, Saudi Arabia
| | - Ibrahim Ali
- Quality Management Departement, Sultan Bin Abdulaziz Humanitarian City (SBAHC), Riyadh, Saudi Arabia
| | - Ahmad Al Baker
- Nursing Department, Sultan Bin Abdulaziz Humanitarian City (SBAHC), Riyadh, Saudi Arabia
| | | | - Rhez Legaspi Plando
- Nursing Department, Sultan Bin Abdulaziz Humanitarian City (SBAHC), Riyadh, Saudi Arabia
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Milliren CE, Denhoff ER, Hahn PD, Ozonoff A. Incidence of Hospital-Acquired Conditions During Pediatric Clinical Research Inpatient Hospitalizations: A Matched Cohort Study. J Patient Saf 2023; 19:469-477. [PMID: 37678187 DOI: 10.1097/pts.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES In this matched cohort study using data from pediatric hospitals, we compared the incidence of hospital-acquired conditions (HACs) during clinical research hospitalizations to nonresearch hospitalizations. METHODS Using Pediatric Health Information System data for inpatient discharges January 2017-June 2022, we matched research hospitalizations (identified by International Classification of Diseases, Tenth Revision, diagnosis code) to nonresearch hospitalizations within hospital on age (±3 y), sex, discharge year (±2), and All Patients Refined Diagnosis Related Groups classification, severity of illness (±1), and risk of mortality (±1). We calculated the incidence (per 1000 discharges) and incidence rate (per 10,000 patient days) of HAC identified by International Classification of Diseases, Tenth Revision, codes and compare research versus nonresearch using logistic and Poisson regression, accounting for matching using generalized estimating equations and adjusting for sociodemographic factors and hospital utilization. RESULTS We matched 7000 research hospitalizations to 26,447 nonresearch from 28 hospitals. Median age was 6.0 years (interquartile range, 10.6 y). Median length of stay was 4.0 days (interquartile range, 11.0 days) with longer stays among research hospitalizations ( P < 0.001). Incidence of HAC among research hospitalizations was 13.1 versus 7.2 per 1000 for nonresearch ( P < 0.001) and incidence rate 6.7 versus 4.5 per 10,000 patient days. Adjusting for sociodemographic and clinical factors, research stays had 1.65 times the odds of any HAC (95% confidence interval, 1.27-2.16; P < 0.001) and 1.38 times the incidence rate (95% confidence interval, 1.09-1.75; P = 0.009). CONCLUSIONS Our findings indicate that pediatric research hospitalizations are more likely to experience HACs compared with nonresearch hospitalizations. These findings have important safety implications for pediatric inpatient clinical research that warrant further study.
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Affiliation(s)
- Carly E Milliren
- From the Institutional Centers for Clinical and Translational Research
| | - Erica R Denhoff
- From the Institutional Centers for Clinical and Translational Research
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10
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Locey KJ, Webb TA, Weinstein RA, Hota B, Stein BD. Random variation drives a critical bias in the comparison of healthcare-associated infections. Infect Control Hosp Epidemiol 2023; 44:1396-1402. [PMID: 36896667 DOI: 10.1017/ice.2022.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To evaluate random effects of volume (patient days or device days) on healthcare-associated infections (HAIs) and the standardized infection ratio (SIR) used to compare hospitals. DESIGN A longitudinal comparison between publicly reported quarterly data (2014-2020) and volume-based random sampling using 4 HAI types: central-line-associated bloodstream infections, catheter-associated urinary tract infections, Clostridioides difficile infections, methicillin-resistant Staphylococcus aureus infections. METHODS Using 4,268 hospitals with reported SIRs, we examined relationships of SIRs to volume and compared distributions of SIRs and numbers of reported HAIs to the outcomes of simulated random sampling. We included random expectations into SIR calculations to produce a standardized infection score (SIS). RESULTS Among hospitals with volumes less than the median, 20%-33% had SIRs of 0, compared to 0.3%-5% for hospitals with volumes higher than the median. Distributions of SIRs were 86%-92% similar to those based on random sampling. Random expectations explained 54%-84% of variation in numbers of HAIs. The use of SIRs led hundreds of hospitals with more infections than either expected at random or predicted by risk-adjusted models to rank better than other hospitals. The SIS mitigated this effect and allowed hospitals of disparate volumes to achieve better scores while decreasing the number of hospitals tied for the best score. CONCLUSIONS SIRs and numbers of HAIs are strongly influenced by random effects of volume. Mitigating these effects drastically alters rankings for HAI types and may further alter penalty assignments in programs that aim to reduce HAIs and improve quality of care.
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Affiliation(s)
- Kenneth J Locey
- Center for Quality, Safety and Value Analytics, Rush University Medical Center, Chicago, Illinois
| | - Thomas A Webb
- Center for Quality, Safety and Value Analytics, Rush University Medical Center, Chicago, Illinois
| | - Robert A Weinstein
- Division of Infectious Diseases, Rush Medical College, Chicago, Illinois
| | - Bala Hota
- Tendo Systems, Inc, Hinsdale, Illinois
| | - Brian D Stein
- Center for Quality, Safety and Value Analytics, Rush University Medical Center, Chicago, Illinois
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Xiao M, Kristensen SR, Marti J, Mossialos E. The impact of patient safety incidents during hip and knee replacements on patients' health related quality of life: a before and after study using longitudinal data linked to patient-reported outcome measures. Int J Surg 2023; 109:1085-1093. [PMID: 37026831 PMCID: PMC10389309 DOI: 10.1097/js9.0000000000000275] [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: 08/22/2022] [Accepted: 01/30/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND The burden of patient safety incidents (PSIs) is often characterized by their impact on mortality, morbidity, and treatment costs. Few studies have attempted to estimate the impact of PSIs on patients' health-related quality of life (HRQoL) and the studies that have made such estimates primarily focus on a narrow set of incidents. The aim of this paper is to estimate the impact of PSIs on HRQoL of patients undergoing elective hip and knee surgery in England. PATIENTS AND METHODS A unique linked longitudinal data set consisting of patient-reported outcome measures for patients with hip and knee replacements linked to Hospital Episode Statistics (HES) collected between 2013/14 and 2016/17 was examined. Patients with any of nine US Agency for Healthcare Research and Quality (AHRQ) PSI indicators were identified. HRQoL was measured using the general EuroQol five dimensions questionnaire (EQ-5D) before and after surgery. Exploiting the longitudinal structure of the data, exact matching was combined with difference in differences to estimate the impact of experiencing a PSI on HRQoL and its individual dimensions, comparing HRQoL improvements after surgery in similar patients with and without a PSI in a retrospective cohort study. This design compares the change in HRQoL before and after surgery in patients who experience a PSI to those who do not. RESULTS The sample comprised 190 697 and 204 649 observations for patients undergoing hip replacement and knee replacement respectively. For six out of nine PSIs, patients who experienced a PSI reported improvements in HRQoL that were 14-23% lower than those who did not experience a PSI during surgery. Those who experienced a PSI were also more likely to report worse health states after surgery than those without a PSI on all five dimensions of HRQoL. CONCLUSION PSIs are associated with a substantial negative impact on patients' HRQoL.
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Affiliation(s)
- Mimi Xiao
- School of Public Health, Development Research Center of Medical Science and Society, Chongqing Medical University, Chongqing, P.R. China
| | - Søren Rud Kristensen
- DaCHE - Danish Centre for Health Economics Department of Public Health, University of Southern Denmark, Odense, Denmark
- Patient Safety Translational Research Centre, Centre for Health Policy, Institute of Global Health Innovation, Imperial College London
| | - Joachim Marti
- Patient Safety Translational Research Centre, Centre for Health Policy, Institute of Global Health Innovation, Imperial College London
- Health Economics and Policy Unit, Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland
| | - Elias Mossialos
- Patient Safety Translational Research Centre, Centre for Health Policy, Institute of Global Health Innovation, Imperial College London
- Department of Health Policy, London School of Economics and Political Science, London, UK
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12
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Manrique S, Ruiz-Botella M, Rodríguez A, Gordo F, Guardiola JJ, Bodí M, Gómez J. Secondary use of data extracted from a clinical information system to assess the adherence of tidal volume and its impact on outcomes. Med Intensiva 2022; 46:619-629. [PMID: 36344013 DOI: 10.1016/j.medine.2022.03.003] [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: 11/04/2021] [Accepted: 03/09/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To extract data from clinical information systems to automatically calculate high-resolution quality indicators to assess adherence to recommendations for low tidal volume. DESIGN We devised two indicators: the percentage of time under mechanical ventilation with excessive tidal volume (>8mL/kg predicted body weight) and the percentage of patients who received appropriate tidal volume (≤8mL/kg PBW) at least 80% of the time under mechanical ventilation. We developed an algorithm to automatically calculate these indicators from clinical information system data and analyzed associations between them and patients' characteristics and outcomes. SETTINGS This study has been carried out in our 30-bed polyvalent intensive care unit between January 1, 2014 and November 30, 2019. PATIENTS All patients admitted to intensive care unit ventilated >72h were included. INTERVENTION Use data collected automatically from the clinical information systems to assess adherence to tidal volume recommendations and its outcomes. MAIN VARIABLES OF INTEREST Mechanical ventilation days, ICU length of stay and mortality. RESULTS Of all admitted patients, 340 met the inclusion criteria. Median percentage of time under mechanical ventilation with excessive tidal volume was 70% (23%-93%); only 22.3% of patients received appropriate tidal volume at least 80% of the time. Receiving appropriate tidal volume was associated with shorter duration of mechanical ventilation and intensive care unit stay. Patients receiving appropriate tidal volume were mostly male, younger, taller, and less severely ill. Adjusted intensive care unit mortality did not differ according to percentage of time with excessive tidal volume or to receiving appropriate tidal volume at least 80% of the time. CONCLUSIONS Automatic calculation of process-of-care indicators from clinical information systems high-resolution data can provide an accurate and continuous measure of adherence to recommendations. Adherence to tidal volume recommendations was associated with shorter duration of mechanical ventilation and intensive care unit stay.
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Affiliation(s)
- S Manrique
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain.
| | - M Ruiz-Botella
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - A Rodríguez
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Spain
| | - F Gordo
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Grupo de Investigación en Patología Crítica, Grado de Medicina, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | | | - M Bodí
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Spain
| | - J Gómez
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain
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Blike GT, Perreard IM, McGovern KM, McGrath SP. A Pragmatic Method for Measuring Inpatient Complications and Complication-Specific Mortality. J Patient Saf 2022; 18:659-666. [PMID: 35149621 DOI: 10.1097/pts.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The primary objective of this study was to develop hospital-level metrics of major complications associated with mortality that allows for the identification of opportunities for improvement. The secondary objective is to improve upon current metrics for failure to rescue (i.e., death from serious but treatable complications.). METHODS Agency for Healthcare Research and Quality metrics served as the basis for identifying specific complications related to major organ system morbidity associated with death. Complication-specific occurrence rates, observed mortality, and risk-adjusted mortality indices were calculated for the study institution and 182 peer organizations using component International Classification of Disease, Tenth Revision codes. Data were included for adults over a 4-year period, with exclusion of hospice patients and complications present on admission. Temporal visualizations of each metric were used to compare past and recent performance at the study hospital and in comparison to peers. RESULTS The complication-specific method showed statistically significant differences in the study hospital occurrence rates and associated mortality rates compared with peer institutions. The monthly control-chart presentation of these metrics provides assessment of hospital-level interventions to prevent complications and/or reduce failure to rescue deaths. CONCLUSIONS The method described supplements existing metrics of serious complications that occur during the course of acute hospitalization allowing for enhanced visualization of opportunities to improve care delivery systems. This method leverages existing measure components to minimize reporting burden. Monthly time-series data allow interventions to prevent and/or rescue patients to be rapidly assessed for impact.
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Affiliation(s)
- George T Blike
- From the Center for Surgical Innovation, Dartmouth-Hitchcock Health System, Department of Anesthesiology
| | | | - Krystal M McGovern
- Surveillance Analytics Core, Value Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Buza JA, Carreon LY, Steele PA, Nazar RG, Glassman SD, Gum JL. Patient safety indicators from a spine surgery perspective: the importance of a specialty specific clinician working with the documentation team and the impact to your hospital. Spine J 2022; 22:1595-1600. [PMID: 35671942 DOI: 10.1016/j.spinee.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/11/2022] [Accepted: 05/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The Hospital Acquired Conditions (HAC) Reduction Program supports the Centers for Medicare and Medicaid Services (CMS) effort to prevent harm to patients by providing a financial incentive to reduce HACs. HAC scores are impacted by Patient Safety Indicators (PSIs), potentially preventable hospital-related events associated with harmful patient outcomes. PSIs are identified using International Classification of Diseases (ICD) coding; however, ICD coding does not always reflect the patient's true medical course. PURPOSE To evaluate the efficacy of and costs savings associated with a clinical documentation review process in tandem with clinician collaboration in identifying incorrectly generated PSIs. STUDY DESIGN Retrospective chart review. PATIENT SAMPLE All patients undergoing spine surgery at a single multi-surgeon tertiary spine center. OUTCOME MEASURES Occurrence of PSI. METHODS Over two 11-month periods, all PSIs attributable to spine surgery were determined. The number and type of spine related PSIs were compared before (Control) and after the implementation of a specialty specific clinical review (Intervention) to identify incorrectly generated PSIs. The financial impact of this intervention was calculated in the form of an annual cost savings to our hospital system. RESULTS During the Control phase, 61 PSIs were reported in 3368 spine cases, representing a total of 3.6 PSIs/month. During Intervention phase, 26 PSIs in 4,482 spine cases, resulting in a statistically significant decrease of 1.5 PSIs per month. The percentage of PSIs across all surgical cases attributable to spine surgery had a statistically significant decrease during the Intervention period compared to the Control period (16% vs. 10%, p=.034), resulting in the avoidance of a 1% CMS cost reduction, an annual cost saving of approximately $3-4 million dollars per year. CONCLUSIONS The implementation of a clinical documentation review process with clinician collaboration to ensure ICD-10 coding accurately reflects the patient's medical course leads to more accurate PSI reporting, with the potential for substantial cost-savings for hospitals from CMS reimbursement.
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Affiliation(s)
- John A Buza
- Norton Leatherman Spine Center, 210 E. Gray St Suite 900, Louisville, KY, 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 E. Gray St Suite 900, Louisville, KY, 40202, USA.
| | - Portia A Steele
- Norton Leatherman Spine Center, 210 E. Gray St Suite 900, Louisville, KY, 40202, USA
| | - Ryan G Nazar
- Care Management, Norton Healthcare, 234 East Gray St, Suite 364, Louisville, KY, USA
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 E. Gray St Suite 900, Louisville, KY, 40202, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 E. Gray St Suite 900, Louisville, KY, 40202, USA
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Zabinski Z, Black BS. The deterrent effect of tort law: Evidence from medical malpractice reform. JOURNAL OF HEALTH ECONOMICS 2022; 84:102638. [PMID: 35691073 DOI: 10.1016/j.jhealeco.2022.102638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/26/2022] [Accepted: 05/15/2022] [Indexed: 06/15/2023]
Abstract
We examine whether caps on noneconomic damages in medical malpractice cases affect in-hospital patient safety. We use Patient Safety Indicators - measures of adverse events - as proxies for safety. In difference-in-differences ("DiD") analyses of five states that adopt caps during 2003-2005, we find that multiple measures of non-fatal patient safety events worsen after cap adoption relative to control states. DiD inference can be unreliable with a small number of treated units. We therefore develop a randomization inference-based test for inference with few treated units but multiple correlated outcomes and confirm the robustness of our results with this nonparametric approach. We also provide evidence that the decline in patient safety is unlikely to be driven by patient selection.
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Affiliation(s)
| | - Bernard S Black
- Northwestern University, Pritzker School of Law and Kellogg School of Management
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16
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Value in acute care surgery, part 2: Defining and measuring quality outcomes. J Trauma Acute Care Surg 2022; 93:e30-e39. [PMID: 35393377 DOI: 10.1097/ta.0000000000003638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The prior article in this series delved into measuring cost in acute care surgery, and this subsequent work explains in detail how quality is measured. Specifically, objective quality is based on outcome measures, both from administrative and clinical registry databases from a multitude of sources. Risk stratification is key in comparing similar populations across diseases and procedures. Importantly, a move toward focusing on subjective outcomes like patient-reported outcomes measures and financial well-being are vital to evolving surgical quality measures for the 21st century.
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Secondary use of data extracted from a clinical information system to assess the adherence of tidal volume and its impact on outcomes. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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18
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Horn CB, O'Malley JF, Carey EP, Culhane JT. Hospital-Acquired Condition Rate of Admitting Facility Does Not Predict Mortality in Traumatically Injured Patients. Cureus 2022; 14:e23908. [PMID: 35547464 PMCID: PMC9088883 DOI: 10.7759/cureus.23908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Hospital-acquired conditions (HACs) are increasingly scrutinized as markers of hospital quality and are subject to increasing regulatory and financial pressure. Despite this, there is little evidence that HACs are associated with poor outcomes in traumatically injured patients, or that lower HAC rates are a marker of a better quality of care. Our study compares mortality rates in hospitals with high versus low rates of HAC. Our hypothesis is that high HAC trauma centers have higher mortality. Methods: The latest editions of the National Trauma Data Bank (NTDB) containing facility identification keys (2011 to 2015) were combined. The HACs targeted by the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP) were identified. Hospital-acquired conditions per 1000 patient-days were calculated for individual trauma centers, and these facilities were stratified into quartiles by HAC rate. Propensity score matching was used to match patients admitted to hospitals in the highest versus the lowest quartiles. Results: Complete data was available for 3,510,818 patients; 58,296 (1.67%) developed HACs recorded in the NTDB. Good performing centers had a mean of 0.84 HACs per 1000 patient-days compared to 7.82 at poor-performing centers. After propensity matching, patients treated at good performing centers had higher mortality of 1.22% versus 1.02% at poor-performing centers (p<0.001). The facility characteristics most over-represented in the poor performing quartile were: University (45.19% vs 10.59%, p<0.001), American College of Surgeons (ACS) Level I Status (31.85% vs 2.24%, p<0.001), and bed size > 600 (28.15% vs 5.5%, p<0.001). Conclusion: Injured patients treated at poor-performing centers (high HAC) have reduced mortality relative to good performing centers (low HAC). Large academic centers were overwhelmingly represented in the poor-performing quartile. Hospital-acquired conditions may be markers of a non-modifiable underlying patient and facility characteristics rather than markers of poor hospital quality.
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Stefanou A, Gardner C, Rubinfeld I. A retrospective study of the effects of minimally invasive colorectal surgery on Patient Safety Indicators across a five-hospital system. Surg Endosc 2022; 36:7684-7699. [PMID: 35237902 DOI: 10.1007/s00464-022-09100-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Agency for Healthcare Research and Quality uses Patient Safety Indicators (PSI) to gauge quality of care and patient safety in hospitals. PSI 90 is a weighted combination of several PSIs that primarily comprises perioperative events. This score can affect reimbursement through Medicare and hospital quality ratings. Minimally invasive surgery (MIS) has been shown to decrease adverse events and outcomes. We sought to evaluate individual PSI and PSI 90 outcomes of minimally invasive versus open colorectal surgeries using a large medical database from 5 hospitals. METHODS A health system administrative database including all inpatients from 5 acute care hospitals was queried based on ICD 10 PC codes for colon and rectal surgery procedures performed between January 2, 2018 and December 31, 2019. Surgeries were labeled as MIS (laparoscopic) or open colorectal resection surgery. Patient demographics, health information, and case characteristics were analyzed with respect to surgical approach and PSI events. Statistical relationships between surgical approach and PSI were investigated using univariate methods and multivariate logarithmic regression analysis. PSIs of interest were PSI 8, PSI 9 PSI 11, PSI 12, and PSI 13. RESULTS There were 1382 operations identified, with 861 (62%) being open and 521 (38%) being minimally invasive. Logistic modeling showed no significant difference between the 2 groups for PSI 3, 6, or 8 through 15. CONCLUSION Understanding PSI 90 and its components is important to enhance perioperative patient care and optimize reimbursement rates. We showed that MIS, despite providing known clinical benefits, may not affect scores in the PSI 90. Surgical approach may have little effect on PSIs, and other patient and system components that are more important to these outcome measures should be pursued.
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20
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Spiera Z, Ilonzo N, Kaplan H, Leitman IM. Loss of independence as a metric for racial disparities in lower extremity amputation for diabetes: A National Surgery Quality Improvement Program (NSQIP) analysis. J Diabetes Complications 2022; 36:108105. [PMID: 34916145 DOI: 10.1016/j.jdiacomp.2021.108105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION This study assessed the association between race/ethnicity and amputation with mortality and loss of independence (LOI) for diabetic gangrene. METHODS We analyzed the American College of Surgeons National Surgery Quality Improvement Program database from 2016 to 2019. Chi-squared tests were performed to evaluate differences in baseline characteristics and complications. Multivariable logistic regression was performed to model LOI and 30-day mortality. RESULTS 5250 patients with diabetes underwent lower extremity amputation as treatment for gangrene. Hispanic patients were more likely to undergo below the knee amputation (BKA) (P = 0.006). Guillotine amputation (GA) was associated with age > 65 (P < 0.0001), independent functional status prior to admission (P < 0.0001), and mortality (OR 1.989, 95%CI 1.29-3.065), but was not associated with LOI. Mortality was less frequent in Black patients (OR 0.432, 95%CI 0.207-0.902), but loss of independence (LOI) was more frequent in Black patients (OR 1.373, 95%CI 1.017-1.853). Hispanic patients were less likely to experience LOI (OR 0.575, 95%CI 0.477-0.693). CONCLUSIONS LOI and mortality provide contrasting perspectives on outcomes following lower extremity amputation. Further assessment of risk factors may illuminate healthcare disparities.
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Affiliation(s)
- Zachary Spiera
- Icahn School of Medicine at Mount Sinai, Department of Surgery, New York, NY, USA
| | - Nicole Ilonzo
- Icahn School of Medicine at Mount Sinai, Department of Surgery, New York, NY, USA
| | - Harrison Kaplan
- Icahn School of Medicine at Mount Sinai, Department of Surgery, New York, NY, USA
| | - I Michael Leitman
- Icahn School of Medicine at Mount Sinai, Department of Surgery, New York, NY, USA.
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Arntson E, Dimick JB, Nuliyalu U, Errickson J, Engler TA, Ryan AM. Changes in Hospital-acquired Conditions and Mortality Associated With the Hospital-acquired Condition Reduction Program. Ann Surg 2021; 274:e301-e307. [PMID: 34506324 DOI: 10.1097/sla.0000000000003641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE To improve patient safety, the Centers for Medicare and Medicaid Services announced the Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The program reduces Medicare payments by 1% for hospitals in the lowest performance quartile related to hospital-acquired conditions. Performance measures are focused on perioperative care. OBJECTIVE To evaluate changes in HACs and 30-day mortality after the announcement of the HACRP. DESIGN Interrupted time-series design using Medicare Provider and Analysis Review (MEDPAR) claims data. We estimated models with linear splines to test for changes in HACs and 30-day mortality before the Affordable Care Act (ACA), after the ACA, and after the HACRP. SETTING Fee-for-service Medicare 2009-2015. PARTICIPANTS Medicare beneficiaries undergoing surgery and discharged from an acute care hospital between January 2009 and August 2015 (N = 8,857,877). MAIN OUTCOME AND MEASURE Changes in HACs and 30-day mortality after the announcement of the HACRP. RESULTS Patients experienced HACs at a rate of 13.39 per 1000 discharges [95% confidence interval (CI), 13.10 to 13.68] in the pre-ACA period. This declined after the ACA was passed and declined further after the HACRP announcement [adjusted difference in annual slope, -1.34 (95% CI, -1.64 to -1.04)]. Adjusted 30-day mortality was 3.69 (95% CI, 3.64 to 3.74) in the pre-ACA period among patients receiving surgery. Thirty-day mortality continued to decline after the ACA [adjusted annual slope -0.04 (95% CI, -0.05 to -0.02)] but was flat after the HACRP [adjusted annual slope -0.01 (95% CI, -0.04 to 0.02)]. CONCLUSIONS AND RELEVANCE Although hospital-acquired conditions targeted under the HACRP declined at a greater rate after the program was announced, 30-day mortality was unchanged.
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Affiliation(s)
- Emily Arntson
- University of Michigan Medical School, Ann Arbor, Michigan
- University of Michigan School of Public Health, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
| | - Justin B Dimick
- University of Michigan Medical School, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Ushapoorna Nuliyalu
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
| | - Josh Errickson
- University of Michigan Consulting for Statistics, Computing and Analytics Research, Ann Arbor, Michigan
| | - Tedi A Engler
- University of Michigan School of Public Health, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
| | - Andrew M Ryan
- University of Michigan School of Public Health, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- Center for Evaluating Health Reform, Ann Arbor, Michigan
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Chalmers K, Gopinath V, Brownlee S, Saini V, Elshaug AG. Adverse Events and Hospital-Acquired Conditions Associated With Potential Low-Value Care in Medicare Beneficiaries. JAMA HEALTH FORUM 2021; 2:e211719. [PMID: 35977201 PMCID: PMC8796970 DOI: 10.1001/jamahealthforum.2021.1719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/29/2021] [Indexed: 12/19/2022] Open
Abstract
Question What is the prevalence and cost of hospital-acquired conditions (HACs) and patient safety events (PSIs) associated with procedures that may be low value? Findings In this retrospective claims analysis of a cohort of Medicare fee-for-service beneficiaries, there were 231 HACs and 1764 PSIs in 197 755 claims for 7 inpatient procedures from 2016 to 2018. Meaning Patients with flagged, potential low-value procedures were harmed while in hospital, resulting in an extended length of stay and additional costs. Importance There has been insufficient research on the patient harms and costs associated with potential low-value procedures in the US Medicare population. Objective To report the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. Design, Setting, and Participants This is a retrospective cohort study using Medicare fee-for-service claims between January 2016 to December 2018. Participants were aged 65 years or older. Procedures were selected if they had previously published indicators of low-value care, including knee arthroscopy, spinal fusion, vertebroplasty, percutaneous coronary intervention (PCI), carotid endarterectomy, renal stenting, and hysterectomy for benign conditions. Analysis was conducted from July to December, 2020. Main Outcomes and Measures For inpatient procedures, the number and rate of admissions with a hospital-acquired condition (HAC) or patient safety indicator event (PSIs), as well as the unadjusted and adjusted difference in mean LOS and Medicare costs between admissions with and without a HAC/PSI. For outpatient procedures, we report the number of claims where the beneficiary had an unplanned hospital admission within seven days and the number of these admissions with a HAC/PSI. Results There were 573 351 patients included in the study, with 617 264 procedures; the mean (SD) age was 74.2 (6.7) years, with 320 637 women (55.9%), and mostly White patients (520 735; 90.8%). Among the 197 755 claims for the inpatient procedures, 231 had an HAC and 1764 had a PSI. Spinal fusion was associated with the most HACs (123 admissions) and PSIs (1015 admissions). Overall, HACs during a PCI admission were associated with the highest adjusted additional mean LOS (17.5 days; 95% CI, 10.3-23.6), with also the highest adjusted additional mean cost ($22 000; 95% CI, $9100-$32 600). There were 419 509 included outpatient procedures, and 7514 (1.8%) had an unplanned admission within 7 days. A total of 17 HACs and PSIs occurred in these admissions. Conclusions and Relevance In this cross-sectional cohort study of Medicare fee-for-service claims, patients receiving potential low-value care were exposed to risk of unnecessary harm associated with higher cost and LOS.
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Affiliation(s)
- Kelsey Chalmers
- Lown Institute, Needham, Massachusetts
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Australia, NSW
| | | | | | | | - Adam G. Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Australia, NSW
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Australia, VIC
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Leeds IL, Kachalia A, Haut ER. Rescuing Failure to Rescue-Patient Safety Indicator 04 on the Brink of Obsolescence. JAMA Surg 2021; 156:115-116. [PMID: 33026428 DOI: 10.1001/jamasurg.2020.2971] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ira L Leeds
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allen Kachalia
- Division of General Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Sheetz KH, Dimick JB, Englesbe MJ, Ryan AM. Hospital-Acquired Condition Reduction Program Is Not Associated With Additional Patient Safety Improvement. Health Aff (Millwood) 2020; 38:1858-1865. [PMID: 31682507 DOI: 10.1377/hlthaff.2018.05504] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 2013 the Centers for Medicare and Medicaid Services announced that it would begin levying penalties against hospitals with the highest rates of hospital-acquired conditions through the Hospital-Acquired Condition Reduction Program. Whether the program has been successful in improving patient safety has not been independently evaluated. We used clinical registry data on rates of hospital-acquired conditions in 2010-18 from a large surgical collaborative in Michigan to estimate the impact of the policy. While rates of all such conditions declined from 133.4 per 1,000 discharges in the pre-program period to 122.2 in the post-program period, greater improvements were observed for nontargeted measures. We conclude that the program did not improve patient safety in Michigan beyond existing trends. These findings raise questions about whether the program will lead to improvements in patient safety as intended.
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Affiliation(s)
- Kyle H Sheetz
- Kyle H. Sheetz is a general surgery resident in the Department of Surgery, University of Michigan Medical School, in Ann Arbor
| | - Justin B Dimick
- Justin B. Dimick is the Frederick A. Coller Professor of Surgery and chair of the Department of Surgery, University of Michigan Medical School
| | - Michael J Englesbe
- Michael J. Englesbe is the Cyrenus G. Darling Sr. M.D. and Cyrenus G. Darling Jr. M.D. Professor of Surgery, Department of Surgery, University of Michigan Medical School
| | - Andrew M Ryan
- Andrew M. Ryan ( amryan@umich. edu ) is the UnitedHealthcare Professor of Health Care Management, Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
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Unintended Consequences of Health Care Reform: Impact of Changes in Payor Mix on Patient Safety Indicators. Ann Surg 2020; 272:612-619. [PMID: 32932318 DOI: 10.1097/sla.0000000000004203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time. SUMMARY BACKGROUND DATA Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare and Medicaid Services-endorsed Patient Safety Indicators (PSI-90). METHODS Three hundred fifty-eight hospitals were identified using State Inpatient Databases (2012-2015) from 3 expansions (KY, MD, NJ) and 2 nonexpansion (FL, NC) states. PSI-90 scores were calculated using Agency for Healthcare Research and Quality modules. Hospital Medicaid and uninsured patients were categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90. RESULTS PSI-90 decreased (safety improved) over time across all hospitals (-5.2%), with comparable reductions in expansion versus nonexpansion states (-5.9% vs -4.7%, respectively; P = 0.441) and across high SNB hospitals within expansion versus nonexpansion states (-3.9% vs -5.2%, P = 0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by 5%, they incurred significantly more safety events in expansion relative to nonexpansion states (+1.87% vs -14.0%, P = 0.013). CONCLUSIONS Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, Centers for Medicare and Medicaid Services measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.
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Moghadamyeghaneh Z, Masi A, Silver M, Misawa R, Renz JF, Gruessner AC, Gruessner RG. Hospital-Acquired Conditions after Liver Transplantation. Am Surg 2020. [DOI: 10.1177/000313482008600112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Hospital-acquired conditions (HACs) are used to define hospital performance measures. Patient comorbidity may influence HAC development. The National Inpatient Sample database was used to investigate HACs for the patients who underwent liver transplantation. Multivariate analysis was used to identify HAC risk factors. We found a total of 13,816 patients who underwent liver transplantation during 2002–2014. Of these, 330 (2.4%) had a report of HACs. Most frequent HACs were vascular catheter–associated infection [220 (1.6%)], falls and trauma [66 (0.5%), catheter-associated UTI [24 (0.2%)], and pressure ulcer stage III/IV [22 (0.2%)]. Factors correlating with HACs included extreme loss function (AOR: 52.13, P < 0.01) and major loss function (AOR: 8.11, P = 0.04), hepatopulmonary syndrome (AOR: 3.39, P = 0.02), portal hypertension (AOR: 1.49, P = 0.02), and hospitalization length of stay before transplant (AOR: 1.01, P < 0.01). The rate of HACs for liver transplantation is three times higher than the reported overall rate of HACs for GI procedures. Multiple patient factors are associated with HACs, and HACs may not be a reliable measure to evaluate hospital performance. Vascular catheter–associated infection is the most common HAC after liver transplantation.
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Affiliation(s)
- Zhobin Moghadamyeghaneh
- Department of Surgery, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Antonio Masi
- Department of Surgery, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Michael Silver
- Department of Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Ryosuke Misawa
- Department of Surgery, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - John F. Renz
- Department of Surgery, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Angelika C. Gruessner
- Department of Statics, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Rainerw G. Gruessner
- Department of Surgery, State University of New York, Downstate Medical Center, Brooklyn, New York
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Hosseini Marznaki Z, Pouy S, Salisu WJ, Emami Zeydi A. Medication errors among Iranian emergency nurses: A systematic review. Epidemiol Health 2020; 42:e2020030. [PMID: 32512668 PMCID: PMC7644927 DOI: 10.4178/epih.e2020030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/13/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Medication errors (MEs) made by nurses are the most common errors in emergency departments (EDs). Identifying the factors responsible for MEs is crucial in designing optimal strategies for reducing such occurrences. The present study aimed to review the literature describing the prevalence and factors affecting MEs among emergency ward nurses in Iran. METHODS We searched electronic databases, including the Scientific Information Database, PubMed, Cochrane Library, Web of Science, Scopus, and Google Scholar, for scientific studies conducted among emergency ward nurses in Iran. The studies were restricted to full-text, peer-reviewed studies published from inception to December 2019, in the Persian and English languages, that evaluated MEs among emergency ward nurses in Iran. RESULTS Eight studies met the inclusion criteria. Most of the nurses (58.9%) had committed MEs only once. The overall mean rate of MEs was 46.2%, and errors made during drug administration accounted for 41.7% of MEs. The most common type of administration error was drug omission (17.8%), followed by administering drugs at the wrong time (17.5%) and at an incorrect dosage (10.6%). The lack of an adequate nursing workforce during shifts and improper nurse-patient ratios were the most critical factors affecting the occurrence of MEs by nurses. CONCLUSIONS Despite the increased attention on patient safety in Iran, MEs by nurses remain a significant concern in EDs. Therefore, nurse managers and policy-makers must take adequate measures to reduce the incidence of MEs and their potential negative consequences.
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Affiliation(s)
- Zohreh Hosseini Marznaki
- Department of Nursing, Amol Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran
| | - Somaye Pouy
- Student Research Committee, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
| | | | - Amir Emami Zeydi
- Department of Medical-Surgical Nursing, Nasibeh School of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran
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Adverse Effects of the Medicare PSI-90 Hospital Penalty System on Revenue-Neutral Hospital-Acquired Conditions. J Patient Saf 2020; 16:e97-e102. [DOI: 10.1097/pts.0000000000000517] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Patient Safety Indicators are an insufficient performance metric to track and grade outcomes of open aortic repair. J Vasc Surg 2020; 73:240-249.e5. [PMID: 32442611 DOI: 10.1016/j.jvs.2020.04.517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/24/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE National rankings of hospitals rely on outcomes-based evaluation to assess the performance of surgical programs, particularly those performing high-risk elective surgical procedures such as open aortic repair. Various classification systems exist for tracking outcomes, but increasingly the International Classification of Diseases, Tenth Revision-based Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) are used as a publicly reported comparison measure of hospital quality performance. We sought to critically evaluate the accuracy of the existing vehicles to assess open aortic repair outcomes in an established program. METHODS This is a case-control study of patients who underwent open abdominal aortic aneurysm repair at the Johns Hopkins Medical Institutions from 2004 to 2018. Patients' characteristics and outcomes were collected as part of a prospectively maintained retrospective database. For each case, hemorrhagic, cardiac, respiratory, renal, wound, and thromboembolic complications were identified with the unique definitions used for open abdominal aortic aneurysm repair by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, the Society for Vascular Surgery Vascular Quality Initiative (VQI) database, and the Agency for Healthcare Research and Quality PSI initiative. RESULTS Of the 154 patients included in the study, 79 (51.0%) were identified as having a complication as defined by the VQI, 46 (29.7%) according to the NSQIP, and 15 (9.7%) according to the PSI system (P < .001). Patients most likely to incur a complication in the PSI system were those with a pararenal or more extensive aneurysm, with baseline congestive heart failure, requiring a supramesenteric clamp (all P < .01), or with an aneurysm >6.5 cm in diameter (P = .02). The NSQIP and VQI systems both identified more postoperative hemorrhagic, respiratory, renal, and wound complications than the PSI system did (P < .05). The VQI system identified the most renal complications (52; P < .001); factors unique to incurring a complication in the VQI include use of a suprarenal clamp and performance of an aortorenal bypass procedure as part of the repair (P < .01). Particularly weak correlation was noted between the PSI system and the VQI with respect to renal outcomes (ρ = 0.163). CONCLUSIONS The PSI system identified fewer important complications than either of the clinically focused databases, with the VQI capturing the most postoperative events, mostly because of its stringent definition of renal injury. We conclude that the PSI system should not form the basis of grading hospital performance in comparing clinically relevant complications of open aortic surgery programs.
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Furrow BR. The Confused and Bewildered Hospital: Adverse Event Discovery, Pay-for-Performance, and Big Data Tools as Halfway Technologies. AMERICAN JOURNAL OF LAW & MEDICINE 2020; 46:219-235. [PMID: 32659191 DOI: 10.1177/0098858820933496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Barry R Furrow
- Professor Law, Kline School of Law at Drexel University; Direct
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Weingart SN, Nelson J, Koethe B, Yaghi O, Dunning S, Feldman A, Kent D, Lipitz-Snyderman A. Association between cancer-specific adverse event triggers and mortality: A validation study. Cancer Med 2020; 9:4447-4459. [PMID: 32285614 PMCID: PMC7300390 DOI: 10.1002/cam4.3033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 01/01/2023] Open
Abstract
Background As there are few validated measures of patient safety in clinical oncology, creating an efficient measurement instrument would create significant value. Accordingly, we sought to assess the validity of a novel patient safety measure by examining the association of oncology‐specific triggers and mortality using administrative claims data. Methods We examined a retrospective cohort of 322 887 adult cancer patients enrolled in commercial or Medicare Advantage products for one year after an initial diagnosis of breast, colorectal, lung, or prostate cancer in 2008‐2014. We used diagnosis and procedure codes to calculate the prevalence of 16 cancer‐specific "triggers"–events that signify a potential adverse event. We compared one‐year mortality rates among patients with and without triggers by cancer type and metastatic status using logistic regression models. Results Trigger events affected 19% of patients and were most common among patients with metastatic colorectal (41%) and lung (50%) cancers. There was increased one‐year mortality among patients with triggers compared to patients without triggers across all cancer types in unadjusted and multivariate analyses. The increased mortality rate among patients with trigger events was particularly striking for nonmetastatic prostate cancer (1.3% vs 7.5%, adjusted odds ratio 1.96 [95% CI 1.49‐2.57]) and nonmetastatic colorectal cancer (4.1% vs 11.7%, 1.44 [1.19‐1.75]). Conclusions The association between adverse event triggers and poor survival among a cohort of cancer patients supports the validity of a cancer‐specific, administrative claims‐based trigger tool.
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Affiliation(s)
- Saul N Weingart
- Tufts Medical Center, Boston, MA, USA.,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.,OptumLabs, Cambridge, MA, USA
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts University School of Medicine, Boston, MA, USA
| | - Benjamin Koethe
- Predictive Analytics and Comparative Effectiveness Center, Tufts University School of Medicine, Boston, MA, USA
| | | | | | | | - David Kent
- Tufts Medical Center, Boston, MA, USA.,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.,Predictive Analytics and Comparative Effectiveness Center, Tufts University School of Medicine, Boston, MA, USA
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Ivankovic D, Poldrugovac M, Garel P, Klazinga NS, Kringos DS. Why, what and how do European healthcare managers use performance data? Results of a survey and workshop among members of the European Hospital and Healthcare Federation. PLoS One 2020; 15:e0231345. [PMID: 32267883 PMCID: PMC7141666 DOI: 10.1371/journal.pone.0231345] [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: 01/14/2020] [Accepted: 03/21/2020] [Indexed: 11/19/2022] Open
Abstract
Objective of this study was to better understand the use of performance data for evidence-based decision-making by managers in hospitals and other healthcare organisations in Europe in 2019. In order to explore why, what and how performance data is collected, reported and used, we conducted a cross-sectional study based on a self-reported online questionnaire and a follow-up interactive workshop. Our study population were participants of a pan-European professional Exchange Programme and their hosts (n = 125), mostly mid-level hospital managers. We found that a substantial amount of performance data is collected and reported, but could be utilised better for decision-making purposes. Motivation to collect and report performance data is equally internal and external, for improvement as well as for accountability purposes. Benchmarking between organisations is recognised as being important but is still underused. A plethora of different data sources are used, but more should be done on conceptualising, collecting, reporting and using patient-reported data. Managers working for privately owned organisations reported greater use of performance data than those working for public ones. Strategic levels of management use performance data more for justifying their decisions, while managers on operational and clinical levels use it more for day-to-day decision-making. Our study showed that, despite the substantial and increasing use of performance data for evidence-based management, there is room and need to further explore and expand its role in strategic decision-making and supporting a shift in healthcare from organisational accountability towards the model of learning organisations.
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Affiliation(s)
- Damir Ivankovic
- Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- * E-mail:
| | - Mircha Poldrugovac
- Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pascal Garel
- The European Hospital and Healthcare Federation, Brussels, Belgium
| | - Niek S. Klazinga
- Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dionne S. Kringos
- Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Shojania KG, Marang-van de Mheen PJ. Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research. BMJ Qual Saf 2020; 29:265-270. [DOI: 10.1136/bmjqs-2019-009731] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 12/16/2022]
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Sheetz KH, Ryan A. Accuracy of quality measurement for the Hospital Acquired Conditions Reduction Program. BMJ Qual Saf 2019; 29:605-607. [PMID: 31862774 DOI: 10.1136/bmjqs-2019-009747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 11/27/2019] [Accepted: 12/03/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew Ryan
- School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA
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Vlasak AL, Shin DH, Kubilis PS, Roper SN, Karachi A, Hoh BL, Rahman M. Comparing Standard Performance and Outcome Measures in Hospitalized Pituitary Tumor Patients with Secretory versus Nonsecretory Tumors. World Neurosurg 2019; 135:e510-e519. [PMID: 31863896 DOI: 10.1016/j.wneu.2019.12.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patient safety indicators (PSIs) and hospital-acquired conditions (HACs) are reported quality measures. We compared their prevalence in patients with secretory and nonsecretory pituitary adenoma using the National (Nationwide) Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. METHODS The NIS was queried for hospitalizations 2002-2014 involving pituitary adenomas. Prevalence of PSI, HAC, and 9 pituitary-related complications was determined using International Classification of Diseases, Ninth Revision codes. Patient risk factors were evaluated through multivariate analysis. RESULTS A total of 20,743 patients with nonsecretory tumor and 3385 patients with secretory tumor were identified. Among patients with nonsecretory tumor, 3.79% experienced any PSI or HAC. Of patients with secretory tumor, 2.54% had any PSI or HAC. Before adjusting for covariation, secretory patients were less likely to have any PSI or HAC (odds ratio [OR], 0.652; P = 0.0002), experience any pituitary-related complication (OR, 0.804; P < 0.0001), have a poor outcome (hazard ratio [HR], 0.435; P < 0.0001), and die during hospitalization (HR, 0.293; P = 0.0015). Secretory patients had significantly shorter mean hospital length of stay (secretory/nonsecretory percent difference, -11.95%; P < 0.0001). However, inverse propensity score-weighted ORs comparing the groups' outcomes showed that there was no significant difference in the prevalence of any PSIs and HACs (OR, 0.963; P = 0.8570), pituitary-related complications (OR, 0.894; P = 0.1321), poor outcomes (HR, 0.990; P = 0.9287), in-hospital death (HR, 0.663; P = 0.2967), and length of stay (percent difference, -2.31%; P = 0.2967) between groups. CONCLUSIONS Lack of significant difference in outcome measures after controlling for covariation is consistent with our finding that patients with nonsecretory tumor have more comorbidities on presentation for treatment. PSIs and HACs have limited ability to measure complications specific to pituitary tumors.
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Affiliation(s)
- Alexander L Vlasak
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - David H Shin
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
| | - Paul S Kubilis
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Steven N Roper
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Aida Karachi
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Brian L Hoh
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Maryam Rahman
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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Preoperative risk stratification of patient mortality following elective craniotomy; a comparative analysis of prediction algorithms. J Clin Neurosci 2019; 67:24-31. [DOI: 10.1016/j.jocn.2019.06.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 05/10/2019] [Accepted: 06/21/2019] [Indexed: 11/17/2022]
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Drösler SE, Kostanjsek NFI. [Quality of care analyses using ICD 11 : Detailed capture of treatment events]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 61:821-827. [PMID: 29808284 DOI: 10.1007/s00103-018-2749-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The identification of treatment errors, the so-called "undesirable" or "critical incidents", is crucial for improving and developing the quality of care. The new International Statistical Classification of Diseases and Related Health Problems-ICD-11-supports a structured data collection in the context of the quality of care and patient safety. Documentation conceptually relies on the multiple coding of the three dimensions of a critical incident: harm, cause, and mode. In this way, it is possible to capture the event in great detail, including the reasons for it and the effects it has. An evaluation of this concept in a field trial using 45 clinical case studies showed good concordance in coding across the documented participants.As the ICD-11 permits the detailed capture of near misses and their context, it could be used for structured documentation in incident reporting systems (databanks for the anonymous reporting of treatment errors). In this way, the error reports can be gathered in a more systematic way, so that they can be used for better quality improvement.In quality assessment, it is important to consider the time of diagnosis. Thus, the feature present on admission (POA) is a diagnosis qualifier that is of substantial importance for quality assessment and is widely used internationally. Up to now, it has not been permanently available in Germany. ICD-11 includes the relevant code.
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Affiliation(s)
- Saskia E Drösler
- Kompetenzzentrum Routinedaten im Gesundheitswesen, Hochschule Niederrhein, Reinarzstr. 49, 47805, Krefeld, Deutschland.
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Bates DW, Singh H. Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety. Health Aff (Millwood) 2019; 37:1736-1743. [PMID: 30395508 DOI: 10.1377/hlthaff.2018.0738] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The Institute of Medicine's To Err Is Human, published in 1999, represented a watershed moment for the US health care system. The report dramatically raised the profile of patient safety and stimulated dedicated research funding to this essential aspect of patient care. Highly effective interventions have since been developed and adopted for hospital-acquired infections and medication safety, although the impact of these interventions varies because of their inconsistent implementation and practice. Progress in addressing other hospital-acquired adverse events has been variable. In the past two decades additional areas of safety risk have been identified and targeted for intervention, such as outpatient care, diagnostic errors, and the use of health information technology. In sum, the frequency of preventable harm remains high, and new scientific and policy approaches to address both prior and emerging risk areas are imperative. With the increasing availability of electronic data, investments must now be made in developing and testing methods to routinely and continuously measure the frequency and types of patient harm and even predict risk of harm for specific patients. This progress could lead us from a Bronze Age of rudimentary tool development to a Golden Era of vast improvement in patient safety.
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Affiliation(s)
- David W Bates
- David W. Bates ( ) is chief of the Division of General Internal medicine at Brigham and Women's Hospital, in Boston, Massachusetts
| | - Hardeep Singh
- Hardeep Singh is chief of the Health Policy, Quality, and Informatics Program, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and a professor of medicine at the Baylor College of Medicine, both in Houston, Texas
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Smith PK, Amster A. An Organization-Specific and Modifiable Inpatient Safety Composite Measure. Jt Comm J Qual Patient Saf 2019; 45:304-314. [PMID: 30642774 DOI: 10.1016/j.jcjq.2018.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 11/21/2018] [Accepted: 11/21/2018] [Indexed: 11/16/2022]
Abstract
In early 2013, seeking to apply the principles of value-based purchasing to all Kaiser Permanente hospitals as part of an existing organizationwide value-based performance incentive plan, Kaiser Permanente developed an inpatient safety composite measure that tracks hospital-level performance improvement related to 10 key inpatient safety events. The elements of the composite are weighted equally, and the tool draws on scoring methodologies used by the National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services Hospital Inpatient Value-Based Purchasing Program. Two years after implementation of the composite measure, hospitals experienced improvement across 9 of the 10 adverse events assessed, though only one improvement achieved statistical significance. The measure successfully distinguishes four levels of improvement and is broadly applicable to hospitals and hospital systems.
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Triep K, Beck T, Donzé J, Endrich O. Diagnostic value and reliability of the present-on-admission indicator in different diagnosis groups: pilot study at a Swiss tertiary care center. BMC Health Serv Res 2019; 19:23. [PMID: 30626388 PMCID: PMC6327414 DOI: 10.1186/s12913-018-3858-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/26/2018] [Indexed: 11/12/2022] Open
Abstract
Background With few exceptions the International Statistical Classification of Diseases (ICD) codes for diagnoses and official coding guidelines do not distinguish pre-existing conditions from complications or comorbidities which occur during hospitalization. However, information on diagnosis timing is relevant with regard to the case’s severity, resource consumption and quality of care. In this study we analyzed the diagnostic value and reliability of the present-on-admission (POA) indicator using routinely collected health data. Methods We included all inpatient cases of the department of medicine during 2016 with a diagnosis of deep vein thrombosis, decubitus ulcer or delirium. Swiss coding guidelines of 2016 and the definitions of the Swiss medical statistics of hospitals were analyzed to evaluate the potential to encode information on diagnosis timing. The diagnoses were revised by applying the information present-on-admission by a coding specialist and by a medical expert, serving as Gold Standard. The diagnostic value and reliability were evaluated. Results The inter-rater reliability for POA of all diagnoses was 0.7133 (Cohen’s kappa), but differed between diagnosis groups (0.558–0.7164). The rate of POA positive of the total applied by the coding specialist versus the expert was similar, but differed between diagnoses. In group “thrombosis” SEN was 0.95, SPE 0.75, PPV 0.97 and NPV 0.60, in group “decubitus ulcer” SEN 0.89, SPE 0.82, PPV 0.89 and NPV 0.82, in group “delirium” SEN 0.91, SPE 0.65, PPV 0.71 and NPV 0.88 For all diagnoses SEN 0.92, SPE 0.73, PPV 0.87, NPV 0.82, summing up the cases of all diagnosis groups. Conclusions Coding the POA indicator identified diagnoses which were pre-existent with insufficient reliability on individual patient’s level. The overall fair to sufficient diagnostic quality is appropriate for screening and benchmarking performance on population level. As the medical statistics of hospitals carries no variable on pre-existing conditions, the novel approach to apply the POA indicator to diagnoses gives more information on quality of hospital care and complexity of cases. By preparing documentation for POA reporting diagnostic quality must be increased before implementation for risk-assessment or reimbursement on the individual patient’s level. Electronic supplementary material The online version of this article (10.1186/s12913-018-3858-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karen Triep
- Medical Directorate, Inselspital, University Hospital of Bern, Bern, Switzerland. .,Direktion Medizin Insel Gruppe, Operatives Medizincontrolling Kodierung, University Hospital, Bern, CH-3010, Switzerland.
| | - Thomas Beck
- Department of General Internal Medicine, University Hospital of Bern, Bern, Switzerland
| | - Jacques Donzé
- Department of General Internal Medicine, University Hospital of Bern, Bern, Switzerland
| | - Olga Endrich
- Medical Directorate, Inselspital, University Hospital of Bern, Bern, Switzerland
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Sunshine JE, Meo N, Kassebaum NJ, Collison ML, Mokdad AH, Naghavi M. Association of Adverse Effects of Medical Treatment With Mortality in the United States: A Secondary Analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study. JAMA Netw Open 2019; 2:e187041. [PMID: 30657530 PMCID: PMC6484545 DOI: 10.1001/jamanetworkopen.2018.7041] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE More than 20 years have passed since the first publication of estimates of the extent of medical harm occurring in hospitals in the United States. Since then, considerable resources have been allocated to improve patient safety, yet policymakers lack a clear gauge of the progress made. OBJECTIVES To quantify the cause-specific mortality associated with adverse effects of medical treatment (AEMT) in the United States from 1990 to 2016 by age group, sex, and state of residence and to describe trends in types of harm and associations with other diseases and injuries. DESIGN, SETTING, AND PARTICIPANTS Cohort study using 1990-2016 data on mortality due to AEMT from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2016 study, which assessed death certificates of US decedents. EXPOSURES Death with International Classification of Diseases (ICD)-coded registration. MAIN OUTCOMES AND MEASURES Mortality associated with AEMT. Secondary analyses were performed on all ICD codes in the death certificate's causal chain to describe associations between AEMT and other diseases and injuries. RESULTS From 1990 to 2016, there were an estimated 123 603 deaths (95% uncertainty interval [UI], 100 856-163 814 deaths) with AEMT as the underlying cause. Despite an overall increase in the number of deaths due to AEMT over time, the national age-standardized mortality rate due to AEMT decreased by 21.4% (95% UI, 1.3%-32.2%) from 1.46 (95% UI, 1.09-1.76) deaths per 100 000 population in 1990 to 1.15 (95% UI, 1.00-1.60) deaths per 100 000 population in 2016. Men and women had similar rates of AEMT mortality, and those 70 years or older had mortality rates nearly 20-fold greater compared with those aged 15 to 49 years (mortality rate in 2016 for both sexes, 7.93 [95% UI, 7.23-11.45] per 100 000 population for those aged ≥70 years vs 0.38 [95% UI, 0.34-0.43] per 100 000 population for those aged 15-49 years). Per 100 000 population, California had the lowest age-standardized AEMT mortality rate at 0.84 deaths (95% UI, 0.57-1.47 deaths), whereas Mississippi had the highest mortality rate at 1.67 deaths (95% UI, 1.19-2.03 deaths). Surgical and perioperative events were the most common subtype of AEMT, accounting for 63.6% of all deaths for which an AEMT was identified as the underlying cause. CONCLUSIONS AND RELEVANCE This study's findings suggest a modest reduction in the mortality rate associated with AEMT in the United States from 1990 to 2016 while also observing increased mortality associated with advancing age and noted geographic variability. The annual GBD releases may allow for tracking of the burden of AEMT in the United States.
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Affiliation(s)
- Jacob E. Sunshine
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Nicholas Meo
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Nicholas J. Kassebaum
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
- Pediatric Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle
| | - Michael L. Collison
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Ali H. Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
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Patient Co-Morbidity and Functional Status Influence the Occurrence of Hospital Acquired Conditions More Strongly than Hospital Factors. J Gastrointest Surg 2019; 23:163-172. [PMID: 30225796 DOI: 10.1007/s11605-018-3957-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/28/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Never events (NE) and hospital-acquired conditions (HAC) are used by Medicare/Medicaid Services to define hospital performance measures that dictate payments/penalties. Pre-op patient comorbidity may significantly influence HAC development. METHODS We studied 8,118,615 patients from the NIS database (2002-2012) who underwent upper/lower gastrointestinal and/or hepatopancreatobiliary procedures. Multivariate analysis, using logistic regression, was used to identify HAC and NE risk factors. RESULTS A total of 63,762 (0.8%) HAC events and 1645 (0.02%) NE were reported. A total of 99.9% of NE were retained foreign body. Most frequent HAC were: pressure ulcer stage III/IV (36.7%), poor glycemic control (26.9%), vascular catheter-associated infection (20.3%), and catheter-associated urinary tract infection (13.7%). Factors correlating with HAC included: open surgical approach (AOR: 1.25, P < 0.01), high-risk patients with significant comorbidity [severe loss function pre-op (AOR: 6.65, P < 0.01), diabetes with complications (AOR: 2.40, P < 0.01), paraplegia (AOR: 3.14, P < 0.01), metastatic cancer (AOR: 1.30, P < 0.01), age > 70 (AOR: 1.09, P < 0.01)], hospital factors [small vs. large (AOR: 1.07, P < 0.01), non-teaching vs teaching (AOR: 1.10, P < 0.01), private profit vs. non-profit/governmental (AOR: 1.20, P < 0.01)], severe preoperative mortality risk (AOR: 3.48, P < 0.01), and non-elective admission (AOR: 1.38, P < 0.01). HAC were associated with increased: hospitalization length (21 vs 7 days, P < 0.01), hospital charges ($164,803 vs $54,858, P < 0.01), and mortality (8 vs 3%, AOR: 1.14, P < 0.01). CONCLUSION HAC incidence was highest among patients with severe comorbid conditions. While small, non-teaching, and for-profit hospitals had increased HAC, the strongest HAC risks were non-modifiable patient factors (preoperative loss function, diabetes, paraplegia, advanced age, etc.). This data questions the validity of using HAC as hospital performance measures, since hospitals caring for these complex patients would be unduly penalized. CMS should consider patient comorbidity as a crucial factor influencing HAC development.
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Spaulding A, Paul R, Colibaseanu D. Comparing the Hospital-Acquired Condition Reduction Program and the Accreditation of Cancer Program: A Cross-sectional Study. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018770294. [PMID: 29806532 PMCID: PMC5974575 DOI: 10.1177/0046958018770294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Under the Hospital-Acquired Condition Reduction Program (HACRP), introduced by the Affordable Care Act, the Centers for Medicare and Medicaid must reduce reimbursement by 1% for hospitals that rank among the lowest performing quartile in regard to hospital-acquired conditions (HACs). This study seeks to determine whether Accredited Cancer Program (ACP) hospitals (as defined by the American College of Surgeons) score differently on the HACRP metrics than nonaccredited cancer program hospitals. This study uses data from the 2014 American Hospital Association Annual Survey database, the 2014 Area Health Resource File, the 2014 Medicare Final Rule Standardizing File, and the FY2017 HACRP database (Medicare Hospital Compare Database). The association between ACPs, HACs, and market characteristics is assessed through multinomial logistic regression analysis. Odds ratios and 95% confidence intervals are reported. Accredited cancer hospitals have a greater risk of scoring in the Worse outcome category of HAC scores, vs Middle or Better outcomes, compared with nonaccredited cancer hospitals. Despite this, they do not have greater odds of incurring a payment reduction under the HACRP measurement system. While ACP hospitals can likely improve scores, questions concerning the consistency of the message between ACP hospital quality and HACRP quality need further evaluation to determine potential gaps or issues in the structure or measurement. ACP hospitals should seek to improve scores on domain 2 measures. Although ACP hospitals do likely see more complex patients, additional efforts to reduce surgical site infections and related HACs should be evaluated and incorporated into required quality improvement efforts. From a policy perspective, policy makers should carefully evaluate the measures utilized in the HACPR.
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Qiao Y, Spivey CA, Wang J, Shih YCT, Wan JY, Kuhle J, Dagogo-Jack S, Cushman WC, Chisholm-Burns M. Predictive Value Positive of MTM Eligibility Criteria under MMA and ACA in Identifying Individuals with Medication Utilization Issues. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2018; 9:393-401. [PMID: 30906425 PMCID: PMC6426324 DOI: 10.1111/jphs.12266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare the predictive value positives (PVP) of medication therapy management eligibility criteria under the Medicare Modernization Act (MMA) and Affordable Care Act (ACA) in identifying individuals with medication utilization issues (MUI). METHODS This is a retrospective analysis of Medicare database (2012-2013). MUI were determined based on medication utilization measures related to Medicare Part D Star Ratings. PVP or proportions of individuals with MUI were compared between individuals eligible for MTM under MMA and ACA. Need-based and demand-based logistic regression was used to adjust for patient characteristics. MTM eligibility thresholds in 2009 and 2013 and proposed 2015 MTM eligibility thresholds under MMA were examined. Main/sensitivity/disease-specific analyses were conducted to cover the range of eligibility thresholds and combinations. KEY FINDINGS MMA has higher PVP in identifying patients with MUI than ACA. Proportions of individuals with MUI were higher based on MMA than ACA (e.g., 74.96% for 2009 MMA, 73.51% for 2013 MMA, and 62.46% for proposed 2015 MMA vs. 52.17% for ACA in main analysis; P<0.05). Adjusted findings were similar. For example, based on the demand-based model in the main analysis, the odds ratios were 2.474 (95% CI: 2.454-2.494) for 2013 MMA in comparison to ACA. These numbers indicate that the MMA MTM eligibility criteria for 2013 had 147.4% higher PVP in identifying patients with MUI than ACA. Similar patterns were found in most sensitivity and disease-specific analyses. CONCLUSIONS MMA has higher PVP than ACA in identifying patients with MUI. This study may inform the government on future MTM policy.
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Affiliation(s)
- Yanru Qiao
- Health Outcomes and Policy Research, Department of Clinical Pharmacy & Translational Science, University of Tennessee College of Pharmacy, 881 Madison Avenue, Room 212, Memphis, TN 38163, , ,
| | - Christina A Spivey
- Department of Clinical Pharmacy & Translational Science, University of Tennessee College of Pharmacy, 881 Madison Avenue, Room 258, , ,
| | - Junling Wang
- Health Outcomes and Policy Research, Department of Clinical Pharmacy & Translational Science, University of Tennessee College of Pharmacy, 881 Madison Avenue, Room 221, Memphis, TN 38163, , ,
| | - Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center & Chief, Section of Cancer Economics and Policy, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1444, Houston, TX 77030, , ,
| | - Jim Y Wan
- Department of Preventive Medicine, University of Tennessee Health Science Center, 66 N. Pauline, Suite 633, Memphis, TN 38163, , ,
| | - Julie Kuhle
- Pharmacy Quality Alliance, 5911 Kingstowne Village Parkway, Suite 130, Alexandria, Virginia 22315, , ,
| | - Samuel Dagogo-Jack
- Division of Endocrinology, Diabetes & Metabolism & Director, Clinical Research Center, University of Tennessee Health Science Center, 920 Madison Avenue, Suite 300A, Memphis, TN 38163, , ,
| | - William C Cushman
- Department of Preventive Medicine and Medicine, University of Tennessee College of Medicine & Chief, Preventive Medicine Section, Veterans Affairs Medical Center, 1030 Jefferson Avenue, Room 5159, Memphis, TN 38104, , ,
| | - Marie Chisholm-Burns
- University of Tennessee College of Pharmacy, 881 Madison Avenue, Room 264, Memphis, TN 38163, , ,
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Austin JM, Kirley EM, Rosen MA, Winters BD. A comparison of two structured taxonomic strategies in capturing adverse events in U.S. hospitals. Health Serv Res 2018; 54:613-622. [PMID: 30474108 DOI: 10.1111/1475-6773.13090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To compare the Agency for Healthcare Research and Quality's Quality and Safety Review System (QSRS) and the proposed triadic structure for the 11th version of the International Classification of Disease (ICD-11) in their ability to capture adverse events in U.S. hospitals. DATA SOURCES/STUDY SETTING One thousand patient admissions between 2014 and 2016 from three general, acute care hospitals located in Maryland and Washington D.C. STUDY DESIGN The admissions chosen for the study were a random sample from all three hospitals. DATA COLLECTION/EXTRACTION METHODS All 1000 admissions were abstracted through QSRS by one set of Certified Coding Specialists and a different set of coders assigned the draft ICD-11 codes. Previously assigned ICD-10-CM codes for 230 of the admissions were also used. PRINCIPAL FINDINGS We found less than 20 percent agreement between QSRS and ICD-11 in identifying the same adverse event. The likelihood of a mismatch between QSRS and ICD-11 was almost twice that of a match. The findings were similar to the agreement found between QSRS and ICD-10-CM in identifying the same adverse event. When coders were provided with a list of potential adverse events, the sensitivity and negative predictive value of ICD-11 improved. CONCLUSIONS While ICD-11 may offer an efficient way of identifying adverse events, our analysis found that in its draft form, it has a limited ability to capture the same types of events as QSRS. Coders may require additional training on identifying adverse events in the chart if ICD-11 is going to prove its maximum benefit.
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Affiliation(s)
- John M Austin
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.,Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erin M Kirley
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Michael A Rosen
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.,Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bradford D Winters
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Schmocker RK, Cherney Stafford LM, Winslow ER. Satisfaction with surgeon care as measured by the Surgery-CAHPS survey is not related to NSQIP outcomes. Surgery 2018; 165:510-515. [PMID: 30322662 DOI: 10.1016/j.surg.2018.08.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 08/10/2018] [Accepted: 08/21/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patient satisfaction is a patient-centered outcome of particular interest. Previous work has suggested that global measures of satisfaction may not adequately evaluate surgical care, therefore the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey was developed. It remains unclear how traditional outcome measures, such as morbidity, impact patient satisfaction. Our aim was to determine whether National Surgical Quality Improvement Program-defined complications impacted satisfaction with the surgeon as measured by a surgery-specific survey, the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey. METHODS All patients undergoing a general surgical operation from June 2013-November 2013 were sent the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey after discharge. Retrospective chart review was conducted using the National Surgical Quality Improvement Program variable definitions, and major complications were defined. Data were analyzed as a function of response to the overall surgeon-rating item, and those surgeons rated as the "best possible" or "topbox" were compared with those rated lower. Univariate and logistic regression were used to determine variable importance. RESULTS A total of 529 patients responded, and 71.5% (378/529) rated the surgeon as topbox. The overall National Surgical Quality Improvement Program complication rate was 14.2% (75/529), with 26.7% of those (20/75) being major complications. On univariate analysis, patients who rated their surgeon more highly were somewhat older (59 vs 54 years: P < .001), more often underwent elective surgery (81% vs 57%: P < .001), and had an increased rate of operation for malignancy (31% vs 17%). Neither the complication rate (total or major) nor the number of complications were associated with satisfaction scores. CONCLUSIONS When examined on a patient level with surgery-specific measures and outcomes, the presence of complications after an operation does not appear to be associated with overall patient satisfaction with surgeon care. This finding suggests that satisfaction may be an outcome distinct from traditional measures.
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Affiliation(s)
- Ryan K Schmocker
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Emily R Winslow
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison.
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Blay E, Huang R, Chung JW, Yang AD, DeLancey JO, Merkow RP, Barnard C, Bilimoria KY. Evaluating the Impact of the Venous Thromboembolism Outcome Measure on the PSI 90 Composite Quality Metric. Jt Comm J Qual Patient Saf 2018; 45:148-155. [PMID: 30292465 DOI: 10.1016/j.jcjq.2018.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/18/2018] [Accepted: 08/27/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Patient Safety Indicator (PSI) 90 is a composite measure widely used in federal pay-for-performance and public reporting programs. A component metric of PSI 90, venous thromboembolism (VTE) rate, has been shown to be subject to surveillance bias and not a valid measure for hospital quality comparisons. A study was conducted to examine how hospital PSI 90 scores would change if the VTE measure were removed from calculation of this composite measure. METHODS Using 2014 Medicare inpatient claims data, PSI 90 scores were calculated with and without the VTE measure for 3,203 hospitals. Hospital characteristics obtained from the American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services Payment Update Impact File were merged with PSI 90 scores. RESULTS Removing the VTE outcome measure from the calculation of PSI 90 version 5 improved PSI 90 scores for 17.1% of hospitals but lowered scores for 20.8% of hospitals, while 62.1% had no change in scores. Hospitals were more likely to improve on PSI 90 when the VTE measure was removed if they were larger (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.00-2.58), were major teaching hospitals (OR = 1.76; 95% CI = 1.10-2.79), had greater technological resources (OR = 2.03; 95% CI = 1.40-2.94), or cared for sicker patients (OR = 1.12; 95% CI = 1.01-1.25). CONCLUSION Inclusion of the surveillance bias-prone VTE outcome measure in the PSI 90 composite disproportionately penalizes larger, academic hospitals and those that care for sicker patients. Removal of the VTE outcome measure from PSI 90 should be strongly considered.
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Yang Q, Zhang C, Hines K, Calder LA. Improved hospital safety performance and reduced medicolegal risk: an ecological study using 2 Canadian databases. CMAJ Open 2018; 6:E561-E566. [PMID: 30459173 PMCID: PMC6276943 DOI: 10.9778/cmajo.20180077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Few empirical studies have validated the relation between medicolegal risk and hospital patient safety performance. We sought to determine whether there was a relation between in-hospital patient safety events and medicolegal cases involving Canadian physicians. METHODS In this ecological study, we used Poisson regression to compare data from the Canadian Institute for Health Information's Discharge Abstract Database and the database of the Canadian Medical Protective Association (CMPA) of medicolegal cases over 10 years (2005/06 to 2014/15). We identified incidents and cases based on 15 Agency for Healthcare Research and Quality patient safety indicators within the Canadian Institute for Health Information and CMPA data sets. We performed subgroup analyses for obstetrical and surgical cases. RESULTS We found a statistically significant positive association between volume changes in patient safety indicator events (n = 339 741) and medicolegal cases (n = 15 180) (parameter estimate 1.15, 95% confidence interval [CI] 0.4 to 1.9). This association suggests that, on average, a 10% decrease in events would correspond to a decrease of 11% in medicolegal cases. The degree of positive association varied by practice type, with obstetrics (97 982 patient safety indicator events, 865 cases) showing a 25% decrease in medicolegal cases for every 10% decrease in events (parameter estimate 2.9, 95% CI 0.5 to 5.3) and surgery (168 886 patient safety indicator events, 4568 cases) showing a decrease of 9% for every 10% decrease in events (parameter estimate 0.9, 95% CI 0.2 to 1.7). INTERPRETATION The statistically significant positive association between patient safety indicator events and medicolegal cases quantifies a relation between patient safety and physician medicolegal risk in Canadian hospitals. This suggests new, practical uses for both medicolegal and patient safety indicator data in system-level quality-improvement efforts.
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Affiliation(s)
- Qian Yang
- Canadian Medical Protective Association (Yang, Zhang, Hines, Calder); Ottawa Hospital Research Institute (Calder); Department of Emergency Medicine (Calder), University of Ottawa, Ottawa, Ont
| | - Cathy Zhang
- Canadian Medical Protective Association (Yang, Zhang, Hines, Calder); Ottawa Hospital Research Institute (Calder); Department of Emergency Medicine (Calder), University of Ottawa, Ottawa, Ont
| | - Kristen Hines
- Canadian Medical Protective Association (Yang, Zhang, Hines, Calder); Ottawa Hospital Research Institute (Calder); Department of Emergency Medicine (Calder), University of Ottawa, Ottawa, Ont
| | - Lisa A Calder
- Canadian Medical Protective Association (Yang, Zhang, Hines, Calder); Ottawa Hospital Research Institute (Calder); Department of Emergency Medicine (Calder), University of Ottawa, Ottawa, Ont.
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Shmelev A, Sill AM, Kowdley GC, Sanchez JA, Cunningham SC. Detecting accidental punctures and lacerations during cholecystectomy in large datasets: Two methods of analysis. Hepatobiliary Pancreat Dis Int 2018; 17:430-436. [PMID: 30228025 DOI: 10.1016/j.hbpd.2018.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/22/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND After the Institute of Medicine (IOM) report To Err Is Human highlighted the impact of medical errors, the Agency for Healthcare Research and Quality (AHRQ) developed Patient-Safety Indicators (PSI) to improve quality by identifying potential inpatient safety problems. PSI-15 was created to study accidental punctures and lacerations (APL), but PSI-15 may underestimate APLs in populations of patients. This study compares PSI-15 with a more inclusive approach using a novel composite of secondary diagnostic and procedural codes. METHODS We used Nationwide Inpatient Sample (NIS) data (2000-2012) from AHRQ's Healthcare Cost and Utilization Project (H-CUP). We analyzed PSI-15-positive and -negative cholecystectomies. Cross tabulations identified codes that were significantly more frequent among PSI-15-positive cases; these secondary diagnostic and procedural codes were selected as candidate members of a composite marker (CM) of APL. We chose cholecystectomy patients for study because this is one of the most common general operations, and the large size of NIS allows for meaningful analysis of infrequent occurrences such as APL rates. RESULTS CM identified 1.13 times more APLs than did PSI-15. Patients with CM-detected APLs were significantly older and had worse mortality, comorbidities, lengths of stay, and charges than those detected with PSI-15. Further comparison of these two approaches revealed that time-series analysis for both APL markers revealed parallel trends, with inflections in 2007, and lowest APL rates in July. CONCLUSIONS Although CM may yield more false positives, it appears more inclusive, identifying more clinically significant APLs, than PSI-15. Both measures presented similar trends over time, arguing against inflation in PSI-15 reporting. While arguably less specific, CM may increase sensitivity for detecting APL events during cholecystectomies. These results may inform the interpretation of other large population studies of APLs following abdominal operations.
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Affiliation(s)
- Artem Shmelev
- Department of Surgery, Saint Agnes Hospital and Cancer Center, 900 Caton Avenue, MB 207, Baltimore, MD 21229, USA.
| | - Anne M Sill
- Department of Surgery, Saint Agnes Hospital and Cancer Center, 900 Caton Avenue, MB 207, Baltimore, MD 21229, USA
| | - Gopal C Kowdley
- Department of Surgery, Saint Agnes Hospital and Cancer Center, 900 Caton Avenue, MB 207, Baltimore, MD 21229, USA
| | - Juan A Sanchez
- Department of Surgery, Saint Agnes Hospital and Cancer Center, 900 Caton Avenue, MB 207, Baltimore, MD 21229, USA
| | - Steven C Cunningham
- Department of Surgery, Saint Agnes Hospital and Cancer Center, 900 Caton Avenue, MB 207, Baltimore, MD 21229, USA
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50
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Chan JK, Gardner AB, Mann AK, Kapp DS. Hospital-acquired conditions after surgery for gynecologic cancer — An analysis of 82,304 patients. Gynecol Oncol 2018; 150:515-520. [DOI: 10.1016/j.ygyno.2018.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/06/2018] [Accepted: 07/09/2018] [Indexed: 12/21/2022]
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