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Fecher-Jones I, Grimmett C, Ainsworth B, Wensley F, Rossiter L, Grocott MP, Levett DZ. Systematic review and narrative description of the outcomes of group preoperative education before elective major surgery. BJA OPEN 2024; 10:100286. [PMID: 38832071 PMCID: PMC11145434 DOI: 10.1016/j.bjao.2024.100286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/14/2024] [Indexed: 06/05/2024]
Abstract
Background Group preoperative education is becoming standard care for patients preparing for surgery, alongside optimisation of exercise, diet, and wellbeing. Although patient education is essential, the effectiveness of group education programmes or 'surgery schools' as a means of delivery is unclear. This review examines whether attending group preoperative education improves patient outcomes. Methods We systematically reviewed studies of group perioperative education before major elective surgery. Observational or intervention studies with a baseline group or control arm were included. All outcomes reported were collected and, where possible, effect estimates were summarised using random effects meta-analysis. Results Twenty-seven studies reported on 48 different outcomes after group education. Overall, there was a 0.7 (95% confidence interval 0.27-1.13) day reduction in mean length of stay. The odds ratio for postoperative complications after abdominal surgery was 0.56 (95% confidence interval 0.36-0.85; nine studies). Patient-centred outcomes were grouped into themes. Most studies reported a benefit from group education, but only postoperative physical impairment, pain, knowledge, activation, preoperative anxiety, and some elements of quality of life were statistically significant. Conclusion This review presents a summary of published evidence available for group preoperative education. While these data lend support for such programmes, there is a need for adequately powered prospective studies to evaluate the effectiveness of preoperative education on clinical outcomes and to evaluate whether behaviour change is sustained. Furthermore, the content, timing and mode of delivery, and evaluation measures of preoperative education require standardisation. Systematic review protocol PROSPERO (166297).
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Affiliation(s)
- Imogen Fecher-Jones
- Department of Perioperative Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Chloe Grimmett
- Centre for Psychosocial Research in Cancer: CentRIC+, School of Health Sciences, Southampton, UK
| | - Ben Ainsworth
- School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Frances Wensley
- Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Laura Rossiter
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Michael P.W. Grocott
- Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Denny Z.H. Levett
- Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Merola R, Vargas M. Economic Indicators, Quantity and Quality of Health Care Resources Affecting Post-surgical Mortality. J Epidemiol Glob Health 2024:10.1007/s44197-024-00249-x. [PMID: 38801492 DOI: 10.1007/s44197-024-00249-x] [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: 04/03/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE to identify correlations between quality and quantity of health care resources, national economic indicators, and postoperative in-hospital mortality as reported in the EUSOS study. METHODS Different variables were identified from a series of publicly available database. Postoperative in-hospital mortality was identified as reported by EUSOS study. Spearman non-parametric and Coefficients of non-linear regression were calculated. RESULTS Quality of health care resources was strongly and negatively correlated to postoperative in-hospital mortality. Quantity of health care resources were negatively and moderately correlated to postoperative in-hospital mortality. National economic indicators were moderately and negatively correlated to postoperative in-hospital mortality. General mortality, as reported by WHO, was positively but very moderately correlated with postoperative in-hospital mortality. CONCLUSIONS Postoperative in-hospital mortality is strongly determined by quality of health care instead of quantity of health resources and health expenditures. We suggest that improving the quality of health care system might reduce postoperative in-hospital mortality.
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Affiliation(s)
- Raffaele Merola
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy.
| | - Maria Vargas
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
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Nimptsch U, Mansky T, Busse R. Impact of early death recording on international comparison of acute myocardial infarction mortality - administrative hospital data study using the example of Germany and the United States. BMC Health Serv Res 2024; 24:593. [PMID: 38715041 PMCID: PMC11075306 DOI: 10.1186/s12913-024-11044-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND In-hospital mortality from acute myocardial infarction (AMI) is widely used in international comparisons as an indicator of health system performance. Because of the high risk of early death after AMI, international comparisons may be biased by differences in the recording of early death cases in hospital inpatient data. This study examined whether differences in the recording of early deaths affect international comparisons of AMI in-hospital mortality by using the example of Germany and the United States, and explored approaches to address this issue. METHODS The German Diagnosis-Related Groups Statistics (DRG Statistics), the U.S. National Inpatient Sample (NIS) and the U.S. Nationwide Emergency Department Sample (NEDS) were analysed from 2014 to 2019. Cases with treatment for AMI were identified in German and U.S. inpatient data. AMI deaths occurring in the emergency department (ED) without inpatient admission were extracted from NEDS data. 30-day in-hospital mortality figures were calculated according to the OECD indicator definition (unlinked data) and modified by including ED deaths, or excluding all same-day cases. RESULTS German age-and-sex standardized 30-day in-hospital mortality was substantially higher compared to the U.S. (in 2019, 7.3% vs. 4.6%). The ratio of German vs. U.S. mortality was 1.6. After inclusion of ED deaths in U.S. data this ratio declined to 1.4. Exclusion of same-day cases in German and U.S. data led to a similar ratio. CONCLUSIONS While short-duration treatments due to early death are generally recorded in German inpatient data, in U.S. inpatient data those cases are partially missing. Excluding cases with short-duration treatment from the calculation of mortality indicators could be a feasible approach to account for differences in the recording of early deaths, that might be existent in other countries as well.
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Affiliation(s)
- Ulrike Nimptsch
- Department of Health Care Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany.
| | | | - Reinhard Busse
- Department of Health Care Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany
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Saravi B, Zink A, Ülkümen S, Couillard-Despres S, Lang G, Hassel F. Artificial intelligence-based analysis of associations between learning curve and clinical outcomes in endoscopic and microsurgical lumbar decompression surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-08084-7. [PMID: 38156994 DOI: 10.1007/s00586-023-08084-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 11/22/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE A common spine surgery procedure involves decompression of the lumbar spine. The impact of the surgeon's learning curve on relevant clinical outcomes is currently not well examined in the literature. A variety of machine learning algorithms have been investigated in this study to determine how a surgeon's learning curve and other clinical parameters will influence prolonged lengths of stay (LOS), extended operating times (OT), and complications, as well as whether these clinical parameters can be reliably predicted. METHODS A retrospective monocentric cohort study of patients with lumbar spinal stenosis treated with microsurgical (MSD) and full-endoscopic (FED) decompression was conducted. The study included 206 patients with lumbar spinal stenosis who underwent FED (63; 30.6%) and MSD (118; 57.3%). Prolonged LOS and OT were defined as those exceeding the 75th percentile of the cohort. Furthermore, complications were assessed as a dependent variable. Using unsupervised learning, clusters were identified in the data, which helped distinguish between the early learning curve (ELC) and the late learning curve (LLC). From 15 algorithms, the top five algorithms that best fit the data were selected for each prediction task. We calculated the accuracy of prediction (Acc) and the area under the curve (AUC). The most significant predictors were determined using a feature importance analysis. RESULTS For the FED group, the median number of surgeries with case surgery type at the time of surgery was 72 in the ELC group and 274 in the LLC group. FED patients did not significantly differ in outcome variables (LOS, OT, complication rate) between the ELC and LLC group. The random forest model demonstrated the highest mean accuracy and AUC across all folds for each classification task. For OT, it achieved an accuracy of 76.08% and an AUC of 0.89. For LOS, the model reached an accuracy of 83.83% and an AUC of 0.91. Lastly, in predicting complications, the random forest model attained the highest accuracy of 89.90% and an AUC of 0.94. Feature importance analysis indicated that LOS, OT, and complications were more significantly affected by patient characteristics than the surgical technique (FED versus MSD) or the surgeon's learning curve. CONCLUSIONS A median of 72 cases of FED surgeries led to comparable clinical outcomes in the early learning curve phase compared to experienced surgeons. These outcomes seem to be more significantly affected by patient characteristics than the learning curve or the surgical technique. Several study variables, including the learning curve, can be used to predict whether lumbar decompression surgery will result in an increased LOS, OT, or complications. To introduce the provided prediction tools into clinics, the algorithms need to be implemented into open-source software and externally validated through large-scale randomized controlled trials.
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Affiliation(s)
- Babak Saravi
- Department of Orthopedics and Trauma Surgery, Medical Centre - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany.
- Department of Spine Surgery, Loretto Hospital, Freiburg, Germany.
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, 5020, Salzburg, Austria.
| | - Alisia Zink
- Department of Spine Surgery, Loretto Hospital, Freiburg, Germany
| | - Sara Ülkümen
- Department of Spine Surgery, Loretto Hospital, Freiburg, Germany
| | - Sebastien Couillard-Despres
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, 5020, Salzburg, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Gernot Lang
- Department of Orthopedics and Trauma Surgery, Medical Centre - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
- Department of Spine Surgery, Loretto Hospital, Freiburg, Germany
| | - Frank Hassel
- Department of Spine Surgery, Loretto Hospital, Freiburg, Germany
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Stanley CC, Zulu M, Msuku H, Phiri VS, Kazembe LN, Chinkhumba J, Mvalo T, Mathanga DP. Competing risks modeling of length of hospital stay enhances risk-stratification of patient care: application to under-five children hospitalized in Malawi. FRONTIERS IN EPIDEMIOLOGY 2023; 3:1274776. [PMID: 38455913 PMCID: PMC10911049 DOI: 10.3389/fepid.2023.1274776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/26/2023] [Indexed: 03/09/2024]
Abstract
Introduction Length of hospital stay (LOS), defined as the time from inpatient admission to discharge, death, referral, or abscondment, is one of the key indicators of quality in patient care. Reduced LOS lowers health care expenditure and minimizes the chance of in-hospital acquired infections. Conventional methods for estimating LOS such as the Kaplan-Meier survival curve and the Cox proportional hazards regression for time to discharge cannot account for competing risks such as death, referral, and abscondment. This study applied competing risk methods to investigate factors important for risk-stratifying patients based on LOS in order to enhance patient care. Methods This study analyzed data from ongoing safety surveillance of the malaria vaccine implementation program in Malawi's four district hospitals of Balaka, Machinga, Mchinji, and Ntchisi. Children aged 1-59 months who were hospitalized (spending at least one night in hospital) with a medical illness were consecutively enrolled between 1 November 2019 and 31 July 2021. Sub-distribution-hazard (SDH) ratios for the cumulative incidence of discharge were estimated using the Fine-Gray competing risk model. Results Among the 15,463 children hospitalized, 8,607 (55.7%) were male and 6,856 (44.3%) were female. The median age was 22 months [interquartile range (IQR): 12-33 months]. The cumulative incidence of discharge was 40% lower among HIV-positive children compared to HIV-negative (sub-distribution-hazard ratio [SDHR]: 0.60; [95% CI: 0.46-0.76]; P < 0.001); lower among children with severe and cerebral malaria [SDHR: 0.94; (95% CI: 0.86-0.97); P = 0.04], sepsis or septicemia [SDHR: 0.90; (95% CI: 0.82-0.98); P = 0.027], severe anemia related to malaria [SDHR: 0.54; (95% CI: 0.48-0.61); P < 0.001], and meningitis [SDHR: 0.18; (95% CI: 0.09-0.37); P < 0.001] when compared to non-severe malaria; and also 39% lower among malnourished children compared to those that were well-nourished [SDHR: 0.61; (95% CI: 0.55-0.68); P < 0.001]. Conclusions This study applied the Fine-Gray competing risk approach to more accurately model LOS as the time to discharge when there were significant rates of in-hospital mortality, referrals, and abscondment. Patient care can be enhanced by risk-stratifying by LOS based on children's age, HIV status, diagnosis, and nutritional status.
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Affiliation(s)
- Christopher C. Stanley
- MAC-Communicable Diseases Action Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Madalitso Zulu
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Harrison Msuku
- MAC-Communicable Diseases Action Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Vincent S. Phiri
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Lawrence N. Kazembe
- Department of Computing, Mathematical and Statistical Sciences, University of Namibia, Windhoek, Namibia
| | - Jobiba Chinkhumba
- MAC-Communicable Diseases Action Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Don P. Mathanga
- MAC-Communicable Diseases Action Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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Maier CF, Schölch C, Zhu L, Nzomo MM, L’hoest H, Marschall U, Reißfelder C, Schölch S. Weekday-dependent long-term outcomes in gastrointestinal cancer surgery: a German population-based retrospective cohort study. Int J Surg 2023; 109:3126-3136. [PMID: 37418560 PMCID: PMC10583906 DOI: 10.1097/js9.0000000000000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/26/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND For most solid cancers, surgery represents the mainstay of curative treatment. Several studies investigating the effects of the weekday of surgery (WOS) on patient outcomes have yielded conflicting results. Barmer, the second-largest health insurance company in Germany, serves roughly 10% of the German population. The authors have used the Barmer database to evaluate how the weekday on which the surgery is performed influences long-term oncologic outcomes. METHODS For this retrospective cohort study, the Barmer database was used to investigate the effect of the WOS (Monday-Friday) on outcomes following oncological resections of the colorectum ( n =49 003), liver ( n =1302), stomach ( n =5027), esophagus ( n =1126), and pancreas ( n =6097). In total, 62 555 cases from 2008 to 2018 were included in the analysis. The endpoints were overall survival (OS), postoperative complications, and the necessity for therapeutic interventions or reoperations. The authors further examined whether the annual caseload or certification as a cancer center influenced the weekday effect. RESULTS The authors observed a significantly impaired OS for patients receiving gastric or colorectal resections on a Monday. Colorectal surgery performed on Mondays was associated with more postoperative complications and a higher probability of reoperations. The annual caseload or a certification as a colorectal cancer center had no bearing on the observed weekday effect. There is evidence that hospitals schedule older patients with more comorbidities earlier in the week, possibly explaining these findings. CONCLUSION This is the first study investigating the influence of the WOS on long-term survival in Germany. Our findings indicate that, in the German healthcare system, patients undergoing colorectal cancer surgery on Mondays have more postoperative complications and, therefore, require significantly more reoperations, ultimately lowering the OS. This surprising finding appears to reflect an attempt to schedule patients with higher postoperative risk earlier in the week as well as semi-elective patients admitted on weekends scheduled for surgery on the next Monday.
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Affiliation(s)
- Christopher F. Maier
- JCCU Translational Surgical Oncology (A430), German Cancer Research Center (DKFZ), Heidelberg
- DKFZ-Hector Cancer Institute, University Medical Center Mannheim
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim
| | - Caroline Schölch
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim
| | - Lei Zhu
- JCCU Translational Surgical Oncology (A430), German Cancer Research Center (DKFZ), Heidelberg
- DKFZ-Hector Cancer Institute, University Medical Center Mannheim
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim
| | | | | | | | - Christoph Reißfelder
- DKFZ-Hector Cancer Institute, University Medical Center Mannheim
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim
| | - Sebastian Schölch
- JCCU Translational Surgical Oncology (A430), German Cancer Research Center (DKFZ), Heidelberg
- DKFZ-Hector Cancer Institute, University Medical Center Mannheim
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim
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Viticchi G, Falsetti L, Riva A, Paolucci S, Malatini S, Guerrieri E, Bartolini M, Silvestrini M. Ipsilateral and contralateral carotid stenosis contribute to the outcome of reperfusion treatment for ischemic stroke. Front Neurol 2023; 14:1237721. [PMID: 37638193 PMCID: PMC10448052 DOI: 10.3389/fneur.2023.1237721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/20/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Ipsilateral and contralateral carotid stenosis (ICS, CCS) influence acute ischemic stroke (AIS) severity and prognosis. Few data are available about their impact on reperfusion therapies efficacy. Aim of this study was to evaluate the impact of ICS and CCS on the effect of intravenous thrombolysis (IT), mechanical thrombectomy (MT) or both and of antiplatelet therapy (AT). Methods We enrolled all the consecutive patients admitted for AIS to our stroke unit and submitted to IT, MT, IT+MT, or AT. We established the presence of a significant ICS or CCS (≥70%) by ultrasound examination or brain angio-CT, or MRI. Clinical and instrumental information were collected; delta National Institutes of Health Stroke Scale (NIHSS) from pre-treatment to patients' discharge was employed as the main outcome measure. Results In total, 460 subjects were enrolled, 86 with ICS and 38 with CCS. We observed a significant linear trend of delta (NIHSS) between carotid stenosis categories for patients undergoing IT (p = 0.011), MT (p = 0.046), and MT+IT (p = 0.040), but no significant trend among subjects receiving no reperfusion treatments was observed (p = 0.174). Discussion According to our findings, ICS and CCS negatively influence AIS patients' outcome treated by interventional therapies. ICS might exert an unfavorable effect both by cerebral hypoperfusion and by continuous microembolization toward ischemic area, while CCS is probable involved in reducing the collateral circles effectiveness. The importance of early carotid stenosis detection and treatment should then be reevaluated not only to manage the prevention approaches but also to obtain insights about post-stroke treatment strategies efficacy.
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Affiliation(s)
| | - Lorenzo Falsetti
- Internal and Subintensive Medicine, Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | - Alice Riva
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Silvia Paolucci
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Simone Malatini
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Emanuele Guerrieri
- Emergency Medicine Residency Program, Marche Polytechnic University, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
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Saravi B, Zink A, Ülkümen S, Couillard-Despres S, Hassel F, Lang G. Performance of Artificial Intelligence-Based Algorithms to Predict Prolonged Length of Stay after Lumbar Decompression Surgery. J Clin Med 2022; 11:jcm11144050. [PMID: 35887814 PMCID: PMC9318293 DOI: 10.3390/jcm11144050] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Decompression of the lumbar spine is one of the most common procedures performed in spine surgery. Hospital length of stay (LOS) is a clinically relevant metric used to assess surgical success, patient outcomes, and socioeconomic impact. This study aimed to investigate a variety of machine learning and deep learning algorithms to reliably predict whether a patient undergoing decompression of lumbar spinal stenosis will experience a prolonged LOS. Methods: Patients undergoing treatment for lumbar spinal stenosis with microsurgical and full-endoscopic decompression were selected within this retrospective monocentric cohort study. Prolonged LOS was defined as an LOS greater than or equal to the 75th percentile of the cohort (normal versus prolonged stay; binary classification task). Unsupervised learning with K-means clustering was used to find clusters in the data. Hospital stay classes were predicted with logistic regression, RandomForest classifier, stochastic gradient descent (SGD) classifier, K-nearest neighbors, Decision Tree classifier, Gaussian Naive Bayes (GaussianNB), support vector machines (SVM), a custom-made convolutional neural network (CNN), multilayer perceptron artificial neural network (MLP), and radial basis function neural network (RBNN) in Python. Prediction accuracy and area under the curve (AUC) were calculated. Feature importance analysis was utilized to find the most important predictors. Further, we developed a decision tree based on the Chi-square automatic interaction detection (CHAID) algorithm to investigate cut-offs of predictors for clinical decision-making. Results: 236 patients and 14 feature variables were included. K-means clustering separated data into two clusters distinguishing the data into two patient risk characteristic groups. The algorithms reached AUCs between 67.5% and 87.3% for the classification of LOS classes. Feature importance analysis of deep learning algorithms indicated that operation time was the most important feature in predicting LOS. A decision tree based on CHAID could predict 84.7% of the cases. Conclusions: Machine learning and deep learning algorithms can predict whether patients will experience an increased LOS following lumbar decompression surgery. Therefore, medical resources can be more appropriately allocated to patients who are at risk of prolonged LOS.
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Affiliation(s)
- Babak Saravi
- Department of Orthopedics and Trauma Surgery, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79108 Freiburg, Germany;
- Department of Spine Surgery, Loretto Hospital, 79108 Freiburg, Germany; (A.Z.); (S.Ü.); (F.H.)
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, 5020 Salzburg, Austria;
- Correspondence:
| | - Alisia Zink
- Department of Spine Surgery, Loretto Hospital, 79108 Freiburg, Germany; (A.Z.); (S.Ü.); (F.H.)
| | - Sara Ülkümen
- Department of Spine Surgery, Loretto Hospital, 79108 Freiburg, Germany; (A.Z.); (S.Ü.); (F.H.)
| | - Sebastien Couillard-Despres
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, 5020 Salzburg, Austria;
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria
| | - Frank Hassel
- Department of Spine Surgery, Loretto Hospital, 79108 Freiburg, Germany; (A.Z.); (S.Ü.); (F.H.)
| | - Gernot Lang
- Department of Orthopedics and Trauma Surgery, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79108 Freiburg, Germany;
- Department of Spine Surgery, Loretto Hospital, 79108 Freiburg, Germany; (A.Z.); (S.Ü.); (F.H.)
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Westley-Wise V, Lago L, Mullan J, Facci F, Zingel R, Eagar K. Patterns of morbidity and multimorbidity associated with early and late readmissions in an Australian regional health service. Chronic Illn 2022; 18:86-104. [PMID: 32036681 DOI: 10.1177/1742395319899459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To describe morbidity and multimorbidity patterns among adults readmitted to an Australian regional health service, in terms of occurrence of the same and different morbidities at index admission and readmission. METHODS This cohort study used hospital admissions data for patients admitted between 1 July 2014 and 30 June 2016 to estimate proportions of unplanned readmissions ('early' within 30 days and 'late' within 1-6 months) with the same and different morbidities as the index admission. Readmission rates were estimated by selected sociodemographic, admission and diagnostic characteristics. RESULTS The majority of early and late readmissions were in different diagnostic groups and for different primary morbidities to the index admission. Only 38.8% of readmissions were in the same major diagnostic group as the index admission and 18.4% in the same Adjacent Diagnosis-Related Group. Twenty one percent of admitted patients were readmitted within six months, with this increasing to 35.3% among multimorbid patients. CONCLUSION With increasing prevalence of multimorbidity, particularly among those at increased risk of readmission, it is essential to step away from a single disease focus in the design of both hospital avoidance and chronic disease management programmes. Holistic interventions and strategies that address multiple chronic conditions are required.
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Affiliation(s)
- Victoria Westley-Wise
- Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia.,Centre for Health Research Illawarra Shoalhaven Population, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Luise Lago
- Centre for Health Research Illawarra Shoalhaven Population, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Judy Mullan
- Centre for Health Research Illawarra Shoalhaven Population, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Franca Facci
- Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Rebekah Zingel
- Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Kathy Eagar
- Centre for Health Research Illawarra Shoalhaven Population, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
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Soong JTY, Ng SHX, Tan KXQ, Kaubryte J, Hopper A. Variation in coded frailty syndromes in secondary care administrative data: an international retrospective exploratory study. BMJ Open 2022; 12:e052735. [PMID: 35105628 PMCID: PMC8808387 DOI: 10.1136/bmjopen-2021-052735] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Challenges with manual methodologies to identify frailty, have led to enthusiasm for utilising large-scale administrative data, particularly standardised diagnostic codes. However, concerns have been raised regarding coding reliability and variability. We aimed to quantify variation in coding frailty syndromes within standardised diagnostic code fields of an international dataset. SETTING Pooled data from 37 hospitals in 10 countries from 2010 to 2014. PARTICIPANTS Patients ≥75 years with admission of >24 hours (N=1 404 671 patient episodes). PRIMARY AND SECONDARY OUTCOME MEASURES Frailty syndrome groups were coded in all standardised diagnostic fields by creation of a binary flag if the relevant diagnosis was present in the 12 months leading to index admission. Volume and percentages of coded frailty syndrome groups by age, gender, year and country were tabulated, and trend analysis provided in line charts. Descriptive statistics including mean, range, and coefficient of variation (CV) were calculated. Relationship to in-hospital mortality, hospital readmission and length of stay were visualised as bar charts. RESULTS The top four contributors were UK, US, Norway and Australia, which accounted for 75.4% of the volume of admissions. There were 553 595 (39.4%) patient episodes with at least one frailty syndrome group coded. The two most frequently coded frailty syndrome groups were 'Falls and Fractures' (N=3 36 087; 23.9%) and 'Delirium and Dementia' (N=221 072; 15.7%), with the lowest CV. Trend analysis revealed some coding instability over the frailty syndrome groups from 2010 to 2014. The four countries with the lowest CV for coded frailty syndrome groups were Belgium, Australia, USA and UK. There was up to twofold, fourfold and twofold variation difference for outcomes of length of stay, 30-day readmission and inpatient mortality, respectively, across the countries. CONCLUSIONS Variation in coding frequency for frailty syndromes in standardised diagnostic fields are quantified and described. Recommendations are made to account for this variation when producing risk prediction models.
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Affiliation(s)
- John T Y Soong
- Department of Medicine, National University Hospital, Singapore
- Yong Loo Lin Medical School, National University of Singapore, Singapore
| | - Sheryl Hui-Xian Ng
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Kyle Xin Quan Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | | | - Adrian Hopper
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
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11
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VAN SCHIE P, VAN BODEGOM-VOS L, VAN STEENBERGEN LN, NELISSEN RGHH, MARANG-VAN DE MHEEN PJ. A more comprehensive evaluation of quality of care after total hip and knee arthroplasty: combining 4 indicators in an ordered composite outcome. Acta Orthop 2022; 93:138-145. [PMID: 34984484 PMCID: PMC8815379 DOI: 10.2340/17453674.2021.861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - Most arthroplasty registers give hospital-specific feedback on revision rates after total hip and knee arthroplasties (THA/TKA). However, due to the low number of events per hospital, multiple years of data are required to reliably detect worsening performance, and any single indicator provides only part of the quality of care delivered. Therefore, we developed an ordered composite outcome including revision, readmission, complications, and long length-of-stay (LOS) for a more comprehensive view on quality of care and assessed the ability to reliably differentiate between hospitals in their performance (rankability) with fewer years of data. Methods - All THA and TKA performed between 2017 and 2019 in 20 Dutch hospitals were included. All combinations of the 4 indicators were ranked from best to worst to create the ordinal composite outcome for THA and TKA separately. Between-hospital variation for the composite outcome was compared with individual indicators standardized for case-mix differences, and we calculated the statistical rankability using fixed and random effects models. Results - 22,908 THA and 20,423 TKA were included. Between-hospital variation for the THA and TKA composite outcomes was larger when compared with revision, readmission, and complications, and similar to long LOS. Rankabilities for the composite outcomes were above 80% even with 1 year of data, meaning that largely true hospital differences were detected rather than random variation. Interpretation - The ordinal composite outcome gives a more comprehensive overview of quality of delivered care and can reliably differentiate between hospitals in their performance using 1 year of data, thereby allowing earlier introduction of quality improvement initiatives.
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Affiliation(s)
- Peter VAN SCHIE
- Department of Orthopedics, Leiden University Medical Centre, Leiden,Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden
| | - Leti VAN BODEGOM-VOS
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden
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12
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Yang GM, Zhou S, Xu Z, Goh SS, Zhu X, Chong DQ, Tan DS, Kanesvaran R, Yee AC, Neo PS, Cheung YB. Comparing the effect of a consult model versus an integrated palliative care and medical oncology co-rounding model on health care utilization in an acute hospital - an open-label stepped-wedge cluster-randomized trial. Palliat Med 2021; 35:1578-1589. [PMID: 34524044 DOI: 10.1177/02692163211022957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The benefit of specialist palliative care for cancer inpatients is established, but the best method to deliver specialist palliative care is unknown. AIM To compare a consult model versus a co-rounding model; both provide the same content of specialist palliative care to individual patients but differ in the level of integration between palliative care and oncology clinicians. DESIGN An open-label, cluster-randomized trial with stepped-wedge design. The primary outcome was hospital length of stay; secondary outcomes were 30-day readmissions and access to specialist palliative care. ClinicalTrials.gov number NCT03330509. SETTING/PARTICIPANTS Cancer patients admitted to the oncology inpatient service of an acute hospital in Singapore. RESULTS A total of 5681 admissions from December 2017 to July 2019 were included, of which 5295 involved stage 3-4 cancer and 1221 received specialist palliative care review. Admissions in the co-rounding model had a shorter hospital length of stay than those in the consult model by 0.70 days (95%CI -0.04 to 1.45, p = 0.065) for all admissions. In the sub-group of stage 3-4 cancer patients, the length of stay was 0.85 days shorter (95%CI 0.05-1.65, p = 0.038). In the sub-group of admissions that received specialist palliative care review, the length of stay was 2.62 days shorter (95%CI 0.63-4.61, p = 0.010). Hospital readmission within 30 days (OR1.03, 95%CI 0.79-1.35, p = 0.822) and access to specialist palliative care (OR1.19, 95%CI 0.90-1.58, p = 0.215) were similar between the consult and co-rounding models. CONCLUSIONS The co-rounding model was associated with a shorter hospital length of stay. Readmissions within 30 days and access to specialist palliative care were similar.
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Affiliation(s)
- Grace M Yang
- National Cancer Centre Singapore, Singapore.,Duke-NUS Medical School, Singapore.,Sengkang General Hospital, Singapore
| | - Siqin Zhou
- National Cancer Centre Singapore, Singapore
| | - Zhizhen Xu
- National Cancer Centre Singapore, Singapore
| | | | - Xia Zhu
- National Cancer Centre Singapore, Singapore
| | | | | | | | | | | | - Yin-Bun Cheung
- Duke-NUS Medical School, Singapore.,Tampere University, Finland
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13
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Wellings EP, Wagner ER, Wilke BK, Asante D, Sangaralingham LR, Rose PS, Moran SL, Houdek MT. What are the predictors of emergency department utilization and readmission following extremity bone sarcoma resection? J Surg Oncol 2020; 122:1356-1363. [PMID: 32794224 DOI: 10.1002/jso.26173] [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: 05/09/2020] [Revised: 07/18/2020] [Accepted: 08/05/2020] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Treatment for bone sarcomas are large undertakings. Emergency department (ED) visits and unplanned hospital readmissions are a potential target for cost containment. The purpose of this study was to evaluate the risk factors for ED visits and unplanned readmissions following extremity bone sarcoma surgery. METHODS Data from Optum Labs Data Warehouse, a national administrative claims database, was analyzed to identify patients with extremity bone sarcomas from 2006 to 2017. Multivariable logistic regression was used to identify factors associated with ED visits and readmissions. RESULTS Of 1390 (743 males, 647 female) adult patients, 137 (12%) visited the ED and 245 (18%) were readmitted within 30 days of discharge. The most common indication for ED visits (n = 63, 45.9%) and readmission (n = 119, 48.5%) were complications of surgery. Length of stay >10 days was associated with ED utilization (OR, 1.83; P = .01) and readmission (OR, 4.47; P < .001). CONCLUSION One in ten patients will use the ED, and one in five patients will be readmitted to the hospital within 30 days of discharge following extremity bone sarcoma surgery. Length of stay was associated with ED visits and readmission. These patients could be targeted with alternative management strategies in the outpatient setting with early clinical follow-up to minimize readmission.
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Affiliation(s)
| | - Eric R Wagner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Orthopedic Surgery, Emory University, Atlanta, Georgia
| | - Benjamin K Wilke
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Dennis Asante
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.,OptumLabs, Cambridge, Massachusetts
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.,OptumLabs, Cambridge, Massachusetts
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Steven L Moran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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14
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Tolvi M, Mattila K, Haukka J, Aaltonen LM, Lehtonen L. Analysis of weekend effect on mortality by medical specialty in Helsinki University Hospital over a 14-year period. Health Policy 2020; 124:1209-1216. [PMID: 32778343 DOI: 10.1016/j.healthpol.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 07/16/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The weekend effect, the phenomenon of patients admitted at the weekend having a higher mortality risk, has been widely investigated and documented in both elective and emergency patients. Research on the issue is scarce in Europe, with the exception of the United Kingdom. We examined the situation in Helsinki University Hospital over a 14-year period from a specialty-specific approach. MATERIALS AND METHODS We collected the data for all patient visits for 2000-2013, selecting patients with in-hospital care in the university hospital and extracting patients that died during their hospital stay or within 30 days of discharge. These patients were categorized according to urgency of care and specialty. RESULTS A total of 1,542,230 in-patients (853,268 emergency patients) met the study criteria, with 47,122 deaths in-hospital or within 30 days of discharge. Of 12 specialties, we found a statistically significant weekend effect for in-hospital mortality in 7 specialties (emergency admissions) and 4 specialties (elective admissions); for 30-day post-discharge mortality in 1 specialty (emergency admissions) and 2 specialties (elective admissions). Surgery, internal medicine, neurology, and gynecology and obstetrics were most sensitive to the weekend effect. CONCLUSIONS The study confirms a weekend effect for both elective and emergency admissions in most specialties. Reducing the number of weekend elective procedures may be necessary. More disease-specific research is needed to find the diagnoses most susceptible.
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Affiliation(s)
- Morag Tolvi
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029 HUS, Helsinki, Finland.
| | - Kimmo Mattila
- Group Administration, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Jari Haukka
- Clinicum, Department of Public Health, University of Helsinki, P.O. Box 20, 00014, Helsinki University, Helsinki and Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland.
| | - Leena-Maija Aaltonen
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029 HUS, Helsinki, Finland.
| | - Lasse Lehtonen
- Diagnostic Center, Helsinki University Hospital and University of Helsinki, P.O. Box 720, 00029 HUS, Helsinki, Finland.
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15
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Reply: Medical Thoracoscopy for Pleural Infection: Are We There Yet? Ann Am Thorac Soc 2020; 17:1174-1175. [PMID: 32667224 PMCID: PMC7462328 DOI: 10.1513/annalsats.202007-780le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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16
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Brunner-La Rocca HP, Peden CJ, Soong J, Holman PA, Bogdanovskaya M, Barclay L. Reasons for readmission after hospital discharge in patients with chronic diseases-Information from an international dataset. PLoS One 2020; 15:e0233457. [PMID: 32603361 PMCID: PMC7326238 DOI: 10.1371/journal.pone.0233457] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/05/2020] [Indexed: 11/18/2022] Open
Abstract
Background Chronic diseases are increasingly prevalent in Western countries. Once hospitalised, the chance for another hospitalisation increases sharply with large impact on well-being of patients and costs. The pattern of readmissions is very complex, but poorly understood for multiple chronic diseases. Methods This cohort study of administrative discharge data between 2009–2014 from 21 tertiary hospitals (eight USA, five UK, four Australia, four continental Europe) investigated rates and reasons of readmissions to the same hospital within 30 days after unplanned admission with one of the following chronic conditions; heart failure; atrial fibrillation; myocardial infarction; hypertension; stroke; chronic obstructive pulmonary disease (COPD); bacterial pneumonia; diabetes mellitus; chronic renal disease; anaemia; arthritis and other cardiovascular disease. Proportions of readmissions with similar versus different diseases were analysed. Results Of 4,901,584 admissions, 866,502 (17.7%) were due to the 12 chronic conditions. In-hospital, 43,573 (5.0%) patients died, leaving 822,929 for readmission analysis. Of those, 87,452 (10.6%) had an emergency 30-day readmission, rates ranged from 2.8% for arthritis to 18.4% for COPD. One third were readmitted with the same condition, ranging from 53% for anaemia to 11% for arthritis. Reasons for readmission were due to another chronic condition in 10% to 35% of the cases, leaving 30% to 70% due to reasons other than the original 12 conditions (most commonly, treatment related complications and infections). The chance of being readmitted with the same cause was lower in the USA, for female patients, with increasing age, more co-morbidities, during study period and with longer initial length of stay. Conclusion Readmission in chronic conditions is very common and often caused by diseases other than the index hospitalisation. Interventions to reduce readmissions should therefore focus not only on the primary condition but on a holistic consideration of all the patient’s comorbidities.
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Affiliation(s)
| | - Carol J. Peden
- Center for Health System Innovation, Keck Medicine of USC, Los Angeles, California, United States of America
| | - John Soong
- NIHR CLAHRC for Northwest London Team, Imperial College London, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Per Arne Holman
- Department of Patients safety and Research, Lovisenberg Diaconal Hospital, Oslo, Norway
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17
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Multi-level models for heart failure patients' 30-day mortality and readmission rates: the relation between patient and hospital factors in administrative data. BMC Health Serv Res 2019; 19:1012. [PMID: 31888610 PMCID: PMC6936032 DOI: 10.1186/s12913-019-4818-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/09/2019] [Indexed: 01/16/2023] Open
Abstract
Background This study aims at gathering evidence about the relation between 30-day mortality and 30-day unplanned readmission and patient and hospital factors. By definition, we refer to 30-day mortality and 30-day unplanned readmission as the number of deaths and non-programmed hospitalizations for any cause within 30 days after the incident heart failure (HF). In particular, the focus is on the role played by hospital-level factors. Methods A multi-level logistic model that combines patient- and hospital-level covariates has been developed to better disentangle the role played by the two groups of covariates. Later on, hospital outliers in term of better-than-expected/worst-than-expected performers have been identified by comparing expected cases vs. observed cases. Hospitals performance in terms of 30-day mortality and 30-day unplanned readmission rates have been visualized through the creation of funnel plots. Covariates have been selected coherently to past literature. Data comes from the hospital discharge forms for Heart Failure patients in the Lombardy Region (Northern Italy). Considering incident cases for HF in the timespan 2010–2012, 78,907 records for adult patients from 117 hospitals have been collected after quality checks. Results Our results show that 30-day mortality and 30-day unplanned readmissions are explained by hospital-level covariates, paving the way for the design and implementation of evidence-based improvement strategies. While the percentage of surgical DRG (OR = 1.001; CI (1.000–1.002)) and the hospital type of structure (Research hospitals vs. non-research public hospitals (OR = 0.62; CI (0.48–0.80)) and Non-research private hospitals vs. non-research hospitals OR = 0.75; CI (0.63–0.90)) are significant for mortality, the mean length of stay (OR = 0.96; CI (0.95–0.98)) is significant for unplanned readmission, showing that mortality and readmission rates might be improved through different strategies. Conclusion Our results confirm that hospital-level covariates do affect quality of care, and that 30-day mortality and 30-day unplanned readmission are affected by different managerial choices. This confirms that hospitals should be accountable for their “added value” to quality of care.
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18
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Immediate Breast Reconstruction in The Netherlands and the United States: A Proof-of-Concept to Internationally Compare Quality of Care Using Cancer Registry Data. Plast Reconstr Surg 2019; 144:565e-574e. [PMID: 31568284 DOI: 10.1097/prs.0000000000006011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Studies based on large-volume databases have made significant contributions to research on breast cancer surgery. To date, no comparison between large-volume databases has been made internationally. This is the first proof-of-concept study exploring the feasibility of combining two existing operational databases of The Netherlands and the United States, focusing on breast cancer care and immediate breast reconstruction specifically.313/291 METHODS:: The National Breast Cancer Organization The Netherlands Breast Cancer Audit (NBCA) (2011 to 2015) and the U.S. Surveillance, Epidemiology, and End Results (SEER) database (2010 to 2013) were compared on structure and content. Data variables were grouped into general, treatment-specific, cancer-specific, and follow-up variables and were matched. As proof-of-concept, mastectomy and immediate breast reconstruction rates in patients diagnosed with invasive breast cancer or ductal carcinoma in situ were analyzed. RESULTS The NBCA included 115 variables and SEER included 112. The NBCA included significantly more treatment-specific variables (n = 46 versus 6), whereas the SEER database included more cancer-specific variables (n = 74 versus 26). In patients diagnosed with breast cancer or ductal carcinoma in situ, immediate breast reconstruction was performed in 19.3 percent and 24.0 percent of the breast cancer cohort and 44.0 percent and 35.3 percent of the ductal carcinoma in situ cohort in the NBCA and SEER, respectively. Immediate breast reconstruction rates increased significantly over time in both data sets. CONCLUSIONS This study provides a first overview of available registry data on breast cancer care in The Netherlands and the United States, and revealed limited data on treatment in the United States. Comparison of treatment patterns of immediate breast reconstruction showed interesting differences. The authors advocate the urgency for an international database with alignment of (treatment) variables to improve quality of breast cancer care for patients across the globe.
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Hong MKY, Skandarajah AR, Joy MP, Hayes IP. Elective colectomy after acute diverticulitis: an international comparison. Colorectal Dis 2019; 21:1067-1072. [PMID: 30980588 DOI: 10.1111/codi.14648] [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: 02/09/2019] [Accepted: 04/02/2019] [Indexed: 01/15/2023]
Abstract
AIM Routine elective colectomy after acute diverticulitis is not recommended, yet significant numbers are still being performed. Amidst global concern over the rising costs of surgery and the value of healthcare, acute diverticulitis is a disease that is amenable to optimization of strategies for operative intervention. We aim to compare rates of elective colectomy after acute diverticulitis in the USA, England and Australia. METHOD Index unplanned admissions for acute diverticulitis were found from an international administrative dataset between 2008 and 2012 for hospitals in the USA, England and Australia. Recurrent unplanned admissions for acute diverticulitis and any subsequent elective admissions for colectomy were found between 2008 and 2014 to allow a minimum 2-year follow-up period. The primary outcome measured was elective colectomy rate. Secondary outcomes included rates of emergency operative intervention and recurrence. Multivariable analysis was performed to control for patient and disease factors. RESULTS There were 7842 index unplanned admissions for acute diverticulitis over 4 years in selected hospitals from the USA, England and Australia. The elective colectomy rates were 13%, 5.4% and 3.4% for the USA, England and Australia, respectively. The propensity for elective colectomy was higher in the USA (OR 4.2, P < 0.001) and England (OR 1.8, P < 0.001) than in Australia. The recurrence rate in all patients with acute diverticulitis was 10% across the countries. CONCLUSION There is a higher propensity for elective colectomy after acute diverticulitis in the USA than in England and Australia. This highlights the possibilities for a less aggressive surgical approach to reduce resource utilization, but prospective analysis of information on quality of life is required to support this.
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Affiliation(s)
- M K-Y Hong
- Department of Surgery (Western Health), The University of Melbourne, Melbourne, Victoria, Australia
| | - A R Skandarajah
- Department of Surgery (Royal Melbourne Hospital), The University of Melbourne, Melbourne, Victoria, Australia
| | - M P Joy
- School of Health Sciences, University of Surrey, Surrey, UK
| | - I P Hayes
- Department of Surgery (Royal Melbourne Hospital), The University of Melbourne, Melbourne, Victoria, Australia
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Abstract
OBJECTIVES Evaluating whether future studies to develop prediction models for early readmissions based on health insurance claims data available at the time of a hospitalisation are worthwhile. DESIGN Retrospective cohort study of hospital admissions with discharge dates between 1 January 2014 and 31 December 2016. SETTING All-cause acute care hospital admissions in the general population of Switzerland, enrolled in the Helsana Group, a large provider of Swiss mandatory health insurance. PARTICIPANTS The mean age of 138 222 hospitalised adults included in the study was 60.5 years. Patients were included only with their first index hospitalisation. Patients who deceased during the follow-up period were excluded, as well as patients admitted from and/or discharged to nursing homes or rehabilitation clinics. MEASURES The primary outcome was 30-day readmission rate. Area under the receiver operating characteristic curve (AUC) was used to measure the discrimination of the developed logistic regression prediction model. Candidate variables were theory based and derived from a systematic literature search. RESULTS We observed a 30-day readmission rate of 7.5%. Fifty-five candidate variables were identified. The final model included pharmacy-based cost group (PCG) cancer, PCG cardiac disease, PCG pain, emergency index admission, number of emergency visits, costs specialists, costs hospital outpatient, costs laboratory, costs therapeutic devices, costs physiotherapy, number of outpatient visits, sex, age group and geographical region as predictors. The prediction model achieved an AUC of 0.60 (95% CI 0.60 to 0.61). CONCLUSIONS Based on the results of our study, it is not promising to invest resources in large-scale studies for the development of prediction tools for hospital readmissions based on health insurance claims data available at admission. The data proved appropriate to investigate the occurrence of hospitalisations and subsequent readmissions, but we did not find evidence for the potential of a clinically helpful prediction tool based on patient-sided variables alone.
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Affiliation(s)
- Beat Brüngger
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
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Soong JTY, Kaubryte J, Liew D, Peden CJ, Bottle A, Bell D, Cooper C, Hopper A. Dr Foster global frailty score: an international retrospective observational study developing and validating a risk prediction model for hospitalised older persons from administrative data sets. BMJ Open 2019; 9:e026759. [PMID: 31230009 PMCID: PMC6596946 DOI: 10.1136/bmjopen-2018-026759] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES This study aimed to examine the prevalence of frailty coding within the Dr Foster Global Comparators (GC) international database. We then aimed to develop and validate a risk prediction model, based on frailty syndromes, for key outcomes using the GC data set. DESIGN A retrospective cohort analysis of data from patients over 75 years of age from the GC international administrative data. A risk prediction model was developed from the initial analysis based on seven frailty syndrome groups and their relationship to outcome metrics. A weighting was then created for each syndrome group and summated to create the Dr Foster Global Frailty Score. Performance of the score for predictive capacity was compared with an established prognostic comorbidity model (Elixhauser) and tested on another administrative database Hospital Episode Statistics (2011-2015), for external validation. SETTING 34 hospitals from nine countries across Europe, Australia, the UK and USA. RESULTS Of 6.7 million patient records in the GC database, 1.4 million (20%) were from patients aged 75 years or more. There was marked variation in coding of frailty syndromes between countries and hospitals. Frailty syndromes were coded in 2% to 24% of patient spells. Falls and fractures was the most common syndrome coded (24%). The Dr Foster Global Frailty Score was significantly associated with in-hospital mortality, 30-day non-elective readmission and long length of hospital stay. The score had significant predictive capacity beyond that of other known predictors of poor outcome in older persons, such as comorbidity and chronological age. The score's predictive capacity was higher in the elective group compared with non-elective, and may reflect improved performance in lower acuity states. CONCLUSIONS Frailty syndromes can be coded in international secondary care administrative data sets. The Dr Foster Global Frailty Score significantly predicts key outcomes. This methodology may be feasibly utilised for case-mix adjustment for older persons internationally.
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Affiliation(s)
- John T Y Soong
- Medicine, National University Hospital, Singapore, Singapore
- Medicine, Imperial College London Department of Primary Care and Public Health, London, UK
| | | | - Danny Liew
- Epidemiology and Preventive Medicine at The Alfred Centre, Monash University, Melbourne, Victoria, Australia
| | - Carol Jane Peden
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Alex Bottle
- Primary Care and Social Medicine, Imperial College, London, UK
| | - Derek Bell
- The National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, London, UK
- Imperial College London Department of Primary Care and Public Health, London, UK
| | - Carolyn Cooper
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Adrian Hopper
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
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Lipkind HS, Zuckerwise LC, Turner EB, Collins JJ, Campbell KH, Reddy UM, Illuzi JL, Merriam AA. Severe maternal morbidity during delivery hospitalisation in a large international administrative database, 2008-2013: a retrospective cohort. BJOG 2019; 126:1223-1230. [PMID: 31100201 DOI: 10.1111/1471-0528.15818] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study utilized the Dr. Foster Global Comparators database to identify pregnancy complications and associated risk factors that led to severe maternal morbidity during delivery hospitalisations in large university hospitals based in the USA, Australia, and England. DESIGN Retrospective cohort. SETTING Births in the USA, England and Australia from 2008 to 2013. SAMPLE Data from delivery hospitalisations between 2008 and 2013 were examined using the Dr. Foster Global Comparators database. METHODS We identified delivery hospitalisations with life-threatening diagnoses or use of life-saving procedures, using algorithms for severe maternal morbidity from the Center for Disease Control. Frequency of severe maternal morbidity was calculated for each country. MAIN OUTCOME MEASURES Multivariable analysis was used to examine the association between morbidity and socio-demographic and clinical characteristics within each country. Chi-square tests assessed differences in covariates between countries. RESULTS From 2008 to 2013, there were 516 781 deliveries from a total of 18 hospitals: 24.5% from the USA, 57.0% from England and 18.4% from Australia. Overall severe maternal morbidity rate was 8.2 per 1000 deliveries: 15.6 in the USA, 5.0 in England, and 8.2 in Australia. The most common codes identifying severe morbidity included transfusion, disseminated intravascular coagulation, acute renal failure, cardiac events/procedures, ventilation, hysterectomy, and eclampsia. Advanced maternal age, hypertension, diabetes, and substance abuse were associated with severe maternal morbidity in all three countries. CONCLUSION Rates of severe maternal morbidity differed by country. Identification of geographical, socio-demographic, and clinical differences can help target modifications of practice and potentially reduce severe maternal morbidity. TWEETABLE ABSTRACT Rates of severe maternal morbidity vary, but risk factors associated with adverse outcomes are similar in developed countries.
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Affiliation(s)
- H S Lipkind
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - L C Zuckerwise
- Division of Maternal-Fetal Medicine, Vanderbilt University, Nashville, TN, USA
| | - E B Turner
- Dr Foster - Global Comparators Ltd, London, UK
| | - J J Collins
- Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK
| | - K H Campbell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - U M Reddy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - J L Illuzi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - A A Merriam
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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Lindgren A, Turner EB, Sillekens T, Meretoja A, Lee JM, Hemmen TM, Koivisto T, Alberts M, Lemmens R, Jääskeläinen JE, Vergouwen MDI, Rinkel GJE. Outcome After Clipping and Coiling for Aneurysmal Subarachnoid Hemorrhage in Clinical Practice in Europe, USA, and Australia. Neurosurgery 2019; 84:1019-1027. [PMID: 29846713 PMCID: PMC8764701 DOI: 10.1093/neuros/nyy223] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 05/02/2018] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Within randomized clinical trials (RCTs), coiling of the ruptured aneurysm to prevent rebleeding results in better outcomes than clipping in patients with aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To study the association of coiling and clipping with outcome after aSAH in daily clinical practice. METHODS In this controlled, nonrandomized study, we compared outcomes after endovascular coiling and neurosurgical clipping of ruptured intracranial aneurysms in an administrative dataset of 7658 aSAH patients (22 tertiary care hospitals from Europe, USA, Australia; 2007-2013). Because the results contradicted those of the randomized trials, findings were further explored in a large clinical dataset from 2 European centers (2006-2016) of 1501 patients. RESULTS In the administrative dataset, the crude 14-d case-fatality rate was 6.4% (95% confidence interval [CI] 5.6%-7.2%) after clipping and 8.2% (95% CI 7.4%-9.1%) after coiling. After adjustment for age, sex, and comorbidity/severity, the odds ratio (OR) for 14-d case-fatality after coiling compared to clipping was 1.32 (95% CI 1.10-1.58). In the clinical dataset crude 14-d case fatality rate was 5.7% (95% CI 4.2%-7.8%) for clipping and 9.0% (95% CI 7.3%-11.2%) for coiling. In multivariable logistic regression analysis, the OR for 14-d case-fatality after coiling compared to clipping was 1.7 (95% CI 1.1-2.7), for 90-d case-fatality 1.28 (95% CI 0.91-1.82) and for 90-d poor functional outcome 0.78 (95% CI 0.6-1.01). CONCLUSION In clinical practice, coiling after aSAH is associated with higher 14-d case-fatality than clipping and nonsuperior outcomes at 90 d. Both options need to be considered in aSAH patients. Further studies should address the reasons for the discrepancy between current data and those from the RCTs.
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Affiliation(s)
- Antti Lindgren
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | | | - Tomas Sillekens
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Jin-Moo Lee
- Department of Neurology, and the Hope Center for Neurological disorders, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas M Hemmen
- Department of Neurosciences, University of California, San Diego, California
| | - Timo Koivisto
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Mark Alberts
- Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Robin Lemmens
- KU Leuven – University of Leuven, Department of Neurosciences, Experimental Neurology, Leuven Institute for Neuroscience and Disease (LIND), Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
- University Hospitals Leuven, Department of Neurology, Leuven, Belgium
| | - Juha E Jääskeläinen
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Westley-Wise V, Lago L, Mullan J, Facci F, Zingel R, Eagar K. Trends in unplanned readmissions over 15 years: a regional Australian perspective. AUST HEALTH REV 2019; 44:241-247. [PMID: 30827332 DOI: 10.1071/ah18072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 11/19/2018] [Indexed: 11/23/2022]
Abstract
Objective The aim of this study was to assess 15-year trends in unplanned readmissions in an Australian regional health service. Methods Drawing on data held in the Illawarra Health Information Platform (IHIP), this longitudinal retrospective study of adults admitted to hospital between 2001-02 and 2015-16 assessed rates of unplanned all-cause readmissions within 30 days ('early') and 1-6 months ('late') following discharge. Rates were compared over time and between patient groups. Results Age-adjusted early readmission rates declined over the 15 years by an average of 1.3% per annum, whereas late readmission rates increased by an average of 0.6% per annum. Together, there was an overall decline in readmission rates. The entire decline in early readmission rates and a reversal of the increasing trend in late readmission rates occurred since 2010-11. Similar trends occurred across age groups, but were most pronounced among those aged ≥75 years. Conclusions The decline in readmissions since 2010-11 suggests that the region has achieved improvements in discharge planning and in continuity between hospitals and community-based care. These improvements have occurred across broad patient groups. The longitudinal and linked data held in the IHIP provides a unique opportunity to examine patterns of service utilisation at a regional level. What is known about the topic? Published reports of longitudinal trends in readmissions are typically limited by short study periods and narrow criteria used to define study populations and readmissions. Australian longitudinal data suggest rates of early readmission have remained relatively unchanged in recent years, despite the focus on readmission rates as a metric to assess the quality and continuity of care. What does this paper add? This unique longitudinal study reports on long-term readmission trends over 15 years to hospitals within a single geographic area, with trends reported for both early (30-day) and late (1- to 6-month) readmissions by age group and major diagnostic categories. The findings reflect more complex patterns than are typically reported in cross-sectional and more limited longitudinal studies. What are the implications for practitioners? The results suggest improvements at a regional level that may be associated with care during the initial hospitalisation and discharge (reflected particularly in early readmissions) and in the community (reflected particularly in late readmissions). Future investigations will explore specific patient groups and the effects of specific initiatives, services and models of care to better predict those at risk of readmission and to inform translation locally and further afield. The relationship between readmissions and the use of ambulatory services (primary care, emergency department and out-patient) also warrants further investigation.
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Affiliation(s)
- Victoria Westley-Wise
- Illawarra Shoalhaven Local Health District, Level 1, 67-71 King Street, Warrawong, NSW 2502, Australia. ; ; and Centre for Health Services Research Illawarra Shoalhaven Population, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia. , ; and Corresponding author.
| | - Luise Lago
- Centre for Health Services Research Illawarra Shoalhaven Population, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia. ,
| | - Judy Mullan
- Centre for Health Services Research Illawarra Shoalhaven Population, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia. ,
| | - Franca Facci
- Illawarra Shoalhaven Local Health District, Level 1, 67-71 King Street, Warrawong, NSW 2502, Australia. ;
| | - Rebekah Zingel
- Illawarra Shoalhaven Local Health District, Level 1, 67-71 King Street, Warrawong, NSW 2502, Australia. ;
| | - Kathy Eagar
- Australian Health Services Research Institute, University of Wollongong, Building 234, Innovation Campus, Wollongong, NSW 2522, Australia.
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Arpey NC, Sloan MJ, Hahn AE, Polgreen PM, Erickson BA. Unscheduled Clinical Encounters in the Postoperative Period After Adult and Pediatric Urologic Surgery. Urology 2018; 124:113-119. [PMID: 30385259 DOI: 10.1016/j.urology.2018.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/02/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To qualify and quantify unscheduled clinical encounters (UCEs) in postoperative urologic patients and to identify patient and procedural risk factors for UCEs. MATERIALS AND METHODS All UCEs, including phone calls, emails, patient portal messages, clinic visits, ER visits, and hospital readmissions, were analyzed, including the reason for the interaction (eg, pain, infection, etc) were assessed retrospectively for consecutive surgical patients over a 3-month period. Demographic and perioperative data for each patient and surgery was recorded and risk factors for UCE were determined using uni- and multivariate analyses. RESULTS Approximately 40% of adult and pediatric patients experienced a UCE, the most common being phone calls (adult-68.2%, pediatric-90.0%) for new medical concerns (adult-67.7%, pediatric-58.1%). Risk factors for UCE in the adult population included lower BMI, living closer to the surgical hospital, discharge with catheter/wound packing, higher discharge pain, and open (vs endoscopic) surgery. In the pediatric population, surgery on the urethra/ureter and discharge with catheters predicted for UCE. UCEs led to changes in clinical management (17%, 21%), unplanned clinic visits (12%, 20%), and hospital readmissions (6%, 3%) for both adult and pediatric patients, respectively. CONCLUSION Nearly 40% of both adult and pediatric patients experienced an unplanned need for the healthcare system in the postoperative period. The effect that UCEs have on overall costs and patient satisfaction, as well as ways to decrease UCEs, require further study.
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Affiliation(s)
| | - Matthew J Sloan
- Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Amy E Hahn
- Carver College of Medicine, University of Iowa, Iowa City, IA
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Faragher IG, Hong MKY, Stupart D, Watters DA, Yeung J. Complete state-wide outcomes in elective colon cancer surgery. ANZ J Surg 2018; 88:1174-1177. [PMID: 30321908 DOI: 10.1111/ans.14872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/14/2018] [Accepted: 08/23/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Maintaining high standards in colon cancer surgery requires the measurement of quality indicators and the re-allocation of resources to address deficiencies. We used state-wide administrative data to determine the inpatient mortality for patients undergoing elective colon cancer surgery and to compare individual hospital rates. METHODS The Dr Foster Quality Investigator Tool was used to explore the Victorian Admitted Episodes Dataset for elective admissions for colon cancer surgery between 2012 and 2016. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured. Risk-adjusted rates were used to compare public and private hospitals. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. RESULTS There were 6120 colectomies performed for colon cancer in Victoria over 3 years. The crude inpatient mortality rate was 1.3%. It was significantly higher in public than private hospitals, even after risk adjustment. Variation in crude mortality was demonstrated among 14 selected hospitals. The lowest volume hospitals had significantly higher inpatient mortality rates. Right hemicolectomy was the commonest procedure performed. CONCLUSION Using an efficient method of complete state-wide data capture, we have demonstrated that the inpatient mortality rate after elective colon cancer surgery in Victoria is low. However, complexity remains around the interpretation of inter-hospital variation, defining outliers, and comparing outcomes between public and private hospitals. Resolving these complexities and defining additional quality indicators remain a priority in the use of administrative data to audit the quality of colon cancer care.
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Affiliation(s)
- Ian G Faragher
- Colorectal Surgery Unit, Western Health, Melbourne, Victoria, Australia.,Academic Department of Surgery, Western Health, Melbourne, Victoria, Australia
| | - Michael K-Y Hong
- Colorectal Surgery Unit, Western Health, Melbourne, Victoria, Australia
| | - Douglas Stupart
- Department of Surgery, Geelong Hospital, Deakin University, Geelong, Victoria, Australia
| | - David A Watters
- Department of Surgery, Geelong Hospital, Deakin University, Geelong, Victoria, Australia
| | - Justin Yeung
- Colorectal Surgery Unit, Western Health, Melbourne, Victoria, Australia.,Academic Department of Surgery, Western Health, Melbourne, Victoria, Australia
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Roshanghalb A, Mazzali C, Lettieri E, Paganoni AM. Chapter 10 Performance Measurement in Health Care: The Case of Best/Worst Performers Through Administrative Data. PERFORMANCE MEASUREMENT AND MANAGEMENT CONTROL: THE RELEVANCE OF PERFORMANCE MEASUREMENT AND MANAGEMENT CONTROL RESEARCH 2018. [DOI: 10.1108/s1479-351220180000033010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Re-evaluating the Weekend Effect on SAH: A Nationwide Analysis of the Association Between Mortality and Weekend Admission. Neurocrit Care 2018; 30:293-300. [DOI: 10.1007/s12028-018-0609-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Lindgren A, Burt S, Bragan Turner E, Meretoja A, Lee JM, Hemmen TM, Alberts M, Lemmens R, Vergouwen MDI, Rinkel GJE. Hospital case-volume is associated with case-fatality after aneurysmal subarachnoid hemorrhage. Int J Stroke 2018; 14:282-289. [DOI: 10.1177/1747493018790073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Inverse association between hospital case-volume and case-fatality has been observed for various nonsurgical interventions and surgical procedures. Aims To study the impact of hospital case-volume on outcome after aneurysmal subarachnoid hemorrhage (aSAH). Methods We included aSAH patients who underwent aneurysm coiling or clipping from tertiary care medical centers across three continents using the Dr Foster Stroke GOAL database 2007–2014. Hospitals were categorized by annual case-volume (low volume: <41/year; intermediate: 41–70/year; high: >70/year). Primary outcome was 14-day in-hospital case-fatality. We calculated proportions, and used multiple logistic regression to adjust for age, sex, differences in comorbidity or disease severity, aneurysm treatment modality, and hospital. Results We included 8525 patients (2363 treated in low volume hospitals, 3563 treated in intermediate volume hospitals, and 2599 in high-volume hospitals). Crude 14-day case-fatality for hospitals with low case-volume was 10.4% (95% confidence interval (CI) 9.2–11.7%), for intermediate volume 7.0% (95% CI 6.2–7.9%; adjusted odds ratio (OR) 0.63 (95%CI 0.47–0.85)) and for high volume 5.4% (95% CI 4.6–6.3%; adjusted OR 0.50 (95% CI 0.33–0.74)). In patients with clipped aneurysms, adjusted OR for 14-day case-fatality was 0.46 (95% CI 0.30–0.71) for hospitals with intermediate case-volume and 0.42 (95% CI 0.25–0.72) with high case-volume. In patients with coiled aneurysms, adjusted OR was 0.77 (95% CI 0.55–1.07) for hospitals with intermediate case-volume and 0.56 (95% CI 0.36–0.87) with high case-volume. Conclusions Even within a subset of large, tertiary care centers, intermediate and high hospital case-volume is associated with lower case-fatality after aSAH regardless of treatment modality, supporting centralization to higher volume centers.
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Affiliation(s)
- Antti Lindgren
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | | | | | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Jin-Moo Lee
- Department of Neurology, and the Hope Center for Neurological disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Thomas M Hemmen
- Department of Neurosciences, University of California, San Diego, CA, USA
| | - Mark Alberts
- Department of Neurology, Hartford Hospital, Hartford, CT, USA
| | - Robin Lemmens
- KU Leuven – University of Leuven, Department of Neurosciences, Experimental Neurology, Leuven Institute for Neuroscience and Disease (LIND), Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Mervyn DI Vergouwen
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gabriel JE Rinkel
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Clinical and Health System Determinants of Venous Thromboembolism Event Rates After Hip Arthroplasty: An International Comparison. Med Care 2018; 56:862-869. [PMID: 30001253 DOI: 10.1097/mlr.0000000000000959] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Routinely collected hospital data provide increasing opportunities to assess the performance of health care systems. Several factors may, however, influence performance measures and their interpretation between countries. OBJECTIVE We compared the occurrence of in-hospital venous thromboembolism (VTE) in patients undergoing hip replacement across 5 countries and explored factors that could explain differences across these countries. METHODS We performed cross-sectional studies independently in 5 countries: Canada; France; New Zealand; the state of California; and Switzerland. We first calculated the proportion of hospital inpatients with at least one deep vein thrombosis (DVT) or pulmonary embolism by using numerator codes from the corresponding Patient Safety Indicator. We then compared estimates from each country against a reference value (benchmark) that displayed the baseline risk of VTE in such patients. Finally, we explored length of stay, number of secondary diagnoses coded, and systematic use of ultrasound to detect DVT as potential factors that could explain between-country differences. RESULTS The rates of VTE were 0.16% in Canada, 1.41% in France, 0.84% in New Zealand, 0.66% in California, and 0.37% in Switzerland, while the benchmark was 0.58% (95% confidence interval, 0.35-0.81). Factors that could partially explain differences in VTE rates between countries were hospital length of stay, number of secondary diagnoses coded, and proportion of patients who received lower limb ultrasound to screen for DVT systematically before hospital discharge. An exploration of the French data showed that the systematic use of ultrasound may be associated with over detection of DVT but not pulmonary embolism. CONCLUSIONS In-hospital VTE rates after arthroplasty vary widely across countries, and a combination of clinical, data-related, and health system factors explain some of the variations in VTE rates across countries.
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Zheng W, Wu YCJ, Chen L. Business intelligence for patient-centeredness: A systematic review. TELEMATICS AND INFORMATICS 2018. [DOI: 10.1016/j.tele.2017.06.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Hofstede SN, Ceyisakar IE, Lingsma HF, Kringos DS, Marang-van de Mheen PJ. Ranking hospitals: do we gain reliability by using composite rather than individual indicators? BMJ Qual Saf 2018; 28:94-102. [DOI: 10.1136/bmjqs-2017-007669] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/26/2018] [Accepted: 04/28/2018] [Indexed: 11/03/2022]
Abstract
BackgroundDespite widespread use of quality indicators, it remains unclear to what extent they can reliably distinguish hospitals on true differences in performance. Rankability measures what part of variation in performance reflects ‘true’ hospital differences in outcomes versus random noise.ObjectiveThis study sought to assess whether combining data into composites or including data from multiple years improves the reliability of ranking quality indicators for hospital care.MethodsUsing the Dutch National Medical Registration (2007–2012) for stroke, colorectal carcinoma, heart failure, acute myocardial infarction and total hiparthroplasty (THA)/ total knee arthroplasty (TKA) in osteoarthritis (OA), we calculated the rankability for in-hospital mortality, 30-day acute readmission and prolonged length of stay (LOS) for single years and 3-year periods and for a dichotomous and ordinal composite measure in which mortality, readmission and prolonged LOS were combined. Rankability, defined as (between-hospital variation/between-hospital+within hospital variation)×100% is classified as low (<50%), moderate (50%–75%) and high (>75%).ResultsAdmissions from 555 053 patients treated in 95 hospitals were included. The rankability for mortality was generally low or moderate, varying from less than 1% for patients with OA undergoing THA/TKA in 2011 to 71% for stroke in 2010. Rankability for acute readmission was low, except for acute myocardial infarction in 2009 (51%) and 2012 (62%). Rankability for prolonged LOS was at least moderate. Combining multiple years improved rankability but still remained low in eight cases for both mortality and acute readmission. Combining the individual indicators into the dichotomous composite, all diagnoses had at least moderate rankability (range: 51%–96%). For the ordinal composite, only heart failure had low rankability (46% in 2008) (range: 46%–95%).ConclusionCombining multiple years or into multiple indicators results in more reliable ranking of hospitals, particularly compared with mortality and acute readmission in single years, thereby improving the ability to detect true hospital differences. The composite measures provide more information and more reliable rankings than combining multiple years of individual indicators.
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Lingsma HF, Bottle A, Middleton S, Kievit J, Steyerberg EW, Marang-van de Mheen PJ. Evaluation of hospital outcomes: the relation between length-of-stay, readmission, and mortality in a large international administrative database. BMC Health Serv Res 2018; 18:116. [PMID: 29444713 PMCID: PMC5813333 DOI: 10.1186/s12913-018-2916-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/06/2018] [Indexed: 11/21/2022] Open
Abstract
Background Hospital mortality, readmission and length of stay (LOS) are commonly used measures for quality of care. We aimed to disentangle the correlations between these interrelated measures and propose a new way of combining them to evaluate the quality of hospital care. Methods We analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged between 2007 and 2012. We correlated standardized and risk-adjusted hospital outcomes on mortality, readmission and long LOS. We constructed a composite measure with 5 levels, based on literature review and expert advice, from survival without readmission and normal LOS (best) to mortality (worst outcome). This composite measure was analyzed using ordinal regression, to obtain a standardized outcome measure to compare hospitals. Results Overall, we observed a 3.1% mortality rate, 7.8% readmission rate (in survivors) and 20.8% long LOS rate among 4,327,105 admissions. Mortality and LOS were correlated at the patient and the hospital level. A patient in the upper quartile LOS had higher odds of mortality (odds ratio = 1.45, 95% confidence interval 1.43–1.47) than those in the lowest quartile. Hospitals with a high standardized mortality had higher proportions of long LOS (r = 0.79, p < 0.01). Readmission rates did not correlate with either mortality or long LOS rates. The interquartile range of the standardized ordinal composite outcome was 74–117. The composite outcome had similar or better reliability in ranking hospitals than individual outcomes. Conclusions Correlations between different outcome measures are complex and differ between hospital- and patient-level. The proposed composite measure combines three outcomes in an ordinal fashion for a more comprehensive and reliable view of hospital performance than its component indicators.
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Affiliation(s)
- Hester F Lingsma
- Department of Public Health, Erasmus Medical Centre, PO box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Alex Bottle
- Imperial College, Faculty of Medicine, School of Public Health, South Kensington Campus, London, SW7 2AZ, UK
| | | | - Job Kievit
- Department of Medical Decision Making, Leiden University Medical Centre, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus Medical Centre, PO box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Perla J Marang-van de Mheen
- Department of Medical Decision Making, Leiden University Medical Centre, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
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International Variation in Emergency Operation Rates for Acute Diverticulitis: Insights into Healthcare Value. World J Surg 2018; 41:2121-2127. [PMID: 28265735 DOI: 10.1007/s00268-017-3965-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND International comparison of outcomes of surgical diseases has become a global focus because of widespread concern over surgical quality, rising costs and the value of healthcare. Acute diverticulitis is a common disease potentially amenable to optimization of strategies for operative intervention. The aim was to compare the emergency operative intervention rates for acute diverticulitis in USA, England and Australia. METHODS Unplanned admissions for acute diverticulitis were found from an international administrative dataset between 2008 and 2014 for hospitals in USA, England and Australia. The primary outcome measured was emergency operative intervention rate. Secondary outcomes included inpatient mortality and percutaneous drainage rate. Multivariable analysis was performed after development of a weighted comorbidity scoring system. RESULTS There were 15,150 unplanned admissions for acute diverticulitis. The emergency operative intervention rates were 16, 13 and 10% for USA, England and Australia. The percutaneous drainage rate was highest in USA at 10%, while the mortality rate was highest in England at 2.8%. The propensity for emergency operative intervention was higher in USA (OR 1.45, p < 0.001) and England (OR 1.49, p < 0.001) than in Australia. The risk of 7-day mortality was higher in England than in Australia (OR 2.79, p < 0.001). Percutaneous drainage was associated with reduced 7-day mortality risk. CONCLUSION Australia has a lower propensity for emergency operative intervention, while England has a greater risk of mortality for acute diverticulitis. International variations raise the issue of healthcare value in terms of differing resource use and outcomes.
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Hofstede SN, van Bodegom-Vos L, Kringos DS, Steyerberg E, Marang-van de Mheen PJ. Mortality, readmission and length of stay have different relationships using hospital-level versus patient-level data: an example of the ecological fallacy affecting hospital performance indicators. BMJ Qual Saf 2017; 27:474-483. [PMID: 28986516 DOI: 10.1136/bmjqs-2017-006776] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 08/22/2017] [Accepted: 08/24/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ecological fallacy refers to an erroneous inference about individuals on the basis of findings for the group to which those individuals belong. Suppose analysis of a large database shows that hospitals with a high proportion of long length of stay (LOS) patients also have higher than average in-hospital mortality. This may prompt efforts to reduce mortality among patients with long LOS. But patients with long LOS may not be the ones at higher risk of death. It may be that hospitals with higher mortality (regardless of LOS) also have more long LOS patients-either because of quality problems on both counts or because of unaccounted differences in case mix. To provide more insight how the ecological fallacy influences the evaluation of hospital performance indicators, we assessed whether hospital-level associations between in-hospital mortality, readmission and long LOS reflect patient-level associations. METHODS Patient admissions from the Dutch National Medical Registration (2007-2012) for specific diseases (stroke, colorectal carcinoma, heart failure, acute myocardial infarction and hip/knee replacements in patients with osteoarthritis) were analysed, as well as all admissions. Logistic regression analysis was used to assess patient-level associations. Pearson correlation coefficients were used to quantify hospital-level associations. RESULTS Overall, we observed 2.2% in-hospital mortality, 8.1% readmissions and a mean LOS of 5.9 days among 8 478 884 admissions in 95 hospitals. Of the 10 disease-specific associations tested, 2 were reversed at hospital-level, 3 were consistent and 5 were only significant at either hospital-level or patient-level. A reversed association was found for stroke: patients with long LOS had 58% lower in-hospital mortality (OR 0.42 (95% CI 0.40 to 0.44)), whereas the hospital-level association was reversed (r=0.30, p<0.01). Similar negative patient-level associations were found for each hospital, but LOS varied across hospitals, thereby resulting in a positive hospital-level association. A similar effect was found for long LOS and readmission in patients with heart failure. CONCLUSIONS Hospital-level associations did not reflect the same patient-level associations in 7 of 10 associations, and were even reversed in 2 associations. Ecological fallacy thus potentially influences interpretation of hospital performance when patient-level associations are not taken into account.
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Affiliation(s)
- Stefanie N Hofstede
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Dionne S Kringos
- Department of Public Health, AMC, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Ewout Steyerberg
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leids Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
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Lobo MF, Azzone V, Azevedo LF, Melica B, Freitas A, Bacelar-Nicolau L, Rocha-Gonçalves FN, Nisa C, Teixeira-Pinto A, Pereira-Miguel J, Resnic FS, Costa-Pereira A, Normand SL. A comparison of in-hospital acute myocardial infarction management between Portugal and the United States: 2000-2010. Int J Qual Health Care 2017; 29:669-678. [PMID: 28992151 DOI: 10.1093/intqhc/mzx092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 07/04/2017] [Indexed: 12/26/2022] Open
Abstract
Objective To compare healthcare in acute myocardial infarction (AMI) treatment between contrasting health systems using comparable representative data from Europe and USA. Design Repeated cross-sectional retrospective cohort study. Setting Acute care hospitals in Portugal and USA during 2000-2010. Participants Adults discharged with AMI. Interventions Coronary revascularizations procedures (percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery). Main Outcome Measures In-hospital mortality and length of stay. Results We identified 1 566 601 AMI hospitalizations. Relative to the USA, more hospitalizations in Portugal presented with elevated ST-segment, and fewer had documented comorbidities. Age-sex-adjusted AMI hospitalization rates decreased in USA but increased in Portugal. Crude procedure rates were generally lower in Portugal (PCI: 44% vs. 47%; CABG: 2% vs. 9%, 2010) but only CABG rates differed significantly after standardization. PCI use increased annually in both countries but CABG decreased only in the USA (USA: 0.95 [0.94, 0.95], Portugal: 1.04 [1.02, 1.07], odds ratios). Both countries observed annual decreases in risk-adjusted mortality (USA: 0.97 [0.965, 0.969]; Portugal: 0.99 [0.979, 0.991], hazard ratios). While between-hospital variability in procedure use was larger in USA, the risk of dying in a high relative to a low mortality hospital (hospitals in percentiles 95 and 5) was 2.65 in Portugal when in USA was only 1.03. Conclusions Although in-hospital mortality due to an AMI improved in both countries, patient management in USA seems more effective and alarming disparities in quality of care across hospitals are more likely to exist in Portugal.
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Affiliation(s)
- Mariana F Lobo
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal
| | - Vanessa Azzone
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA
| | - Luís Filipe Azevedo
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal.,Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal
| | - Bruno Melica
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal.,Serviço de Cardiologia, Unidade de Diagnóstico e Intervenção Cardiovascular, Centro Hospitalar de Vila Nova de Gaia e Espinho, R. Conceição Fernandes 1079, Vila Nova de Gaia Portugal
| | - Alberto Freitas
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal.,Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal
| | - Leonor Bacelar-Nicolau
- Institute of Preventive Medicine and Public Health and ISAMB - Institute of Environmental Health, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisbon, Portugal
| | - Francisco N Rocha-Gonçalves
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal.,Portuguese Institute of Oncology Porto, R. Dr. António Bernardino de Almeida 62, 4200-162 Porto, Portugal
| | - Cláudia Nisa
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal
| | - Armando Teixeira-Pinto
- School of Public Health, Faculty of Medicine, Edward Ford Building (A27), The University of Sidney, NSW 2006, Australia
| | - José Pereira-Miguel
- Institute of Preventive Medicine and Public Health and ISAMB - Institute of Environmental Health, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisbon, Portugal
| | - Frederic S Resnic
- Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, MA 01805, USA.,Tufts University School of Medicine, Boston, MA 02111, USA
| | - Altamiro Costa-Pereira
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal.,Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, s/n 4200-450 Porto, Portugal
| | - Sharon-Lise Normand
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA.,Department of Biostatistics, Havard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
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Investigating Adverse Event Free Admissions in Medicare Inpatients as a Patient Safety Indicator. Ann Surg 2017; 265:910-915. [PMID: 27192350 DOI: 10.1097/sla.0000000000001792] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To investigate adverse event free admissions as a potential, patient-centered indicator aligned directly with the goal of patient safety-freedom from harm. BACKGROUND Preventable adverse event rates in healthcare could be further reduced. These are generally measured separately, one adverse event at a time. However, this does not reveal whether different patients are affected or the same patients are experiencing multiple events. METHODS We examined Medicare inpatient hospital administrative datasets for 2009 to 2011, processed using standard criteria. Events were (i) death within 30 days, (ii) unplanned readmissions within 30 days, (iii) long length of stay, (iv) healthcare acquired infections, and (v) established patient safety indicators not present on admission. We defined adverse event free admissions as those without record of any of these events. National rates were calculated by diagnosis group. Risk-adjusted hospital-specific rates of adverse event free admissions were calculated using colorectal procedures as an example. RESULTS There were 23,991,193 admissions after exclusions. Approximately, 64% went through the acute inpatient Medicare system without record of anything untoward. Multiple events were recorded in 22·7% admissions; 15% of these experienced more than 2 adverse events. Risk-adjusted hospital-specific rates of adverse event free admissions for colorectal procedures showed 131 out of 3786 hospitals below the 99·8% lower control limit of the national upper quartile. CONCLUSIONS Overall, only 60% of admissions were recorded as adverse event free. Multiple adverse events were common. Even if events are under recorded, this measure could provide an easily understandable and useful baseline for clinicians and managers.
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Marang-van de Mheen PJ, Bragan Turner E, Liew S, Mutalima N, Tran T, Rasmussen S, Nelissen RGHH, Gordon A. Variation in Prosthetic Joint Infection and treatment strategies during 4.5 years of follow-up after primary joint arthroplasty using administrative data of 41397 patients across Australian, European and United States hospitals. BMC Musculoskelet Disord 2017; 18:207. [PMID: 28532409 PMCID: PMC5441102 DOI: 10.1186/s12891-017-1569-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 05/11/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To identify best practices and quality improvement initiatives, we aimed to assess whether the incidence of Periprosthetic Joint Infection (PJI) and treatment strategies differed across patients treated in Australian, European and United States (US) hospitals. METHODS Routinely collected administrative data for 41397 patients undergoing a primary total hip or knee arthroplasty between July 2007-December 2010 across 22 hospitals were included. Patients were followed for 2 years looking for PJI occurrence, defined as early (within 4 weeks) and late PJI, and surgical treatment during 2.5 years after PJI diagnosis. Logistic and Poisson regression models were used to test for differences in PJI occurrence and treatment strategies across the three geographical regions, adjusted for age, sex, joint and Elixhauser comorbidity groups. RESULTS PJI occurrence varied from 1.4% in European to 1.7% in Australian patients, which were significantly higher than US patients after adjustment for patient characteristics (OR 1.24 [1.01-1.52] and 1.40 [1.03-1.91] respectively). Early PJIs varied between 0.3% in European to 0.6% in Australian patients, but adjusted rates were similar. Revision following PJI was significantly lower in Australian than in US patients (OR 0.46 [0.25-0.86]) as were the total number of revisions (RR 0.51 [0.36-0.71]) and number of surgical procedures (RR 0.60 [0.44-0.81]) used to treat PJI. CONCLUSION The overall PJI rate was significantly higher in Australian patients, but fewer procedures were needed to treat these PJIs. Future research should reveal whether this reflects PJIs caught earlier or less severe when diagnosed, and whether this is associated with the longer length of stay after primary arthroplasty in Australian hospitals.
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Affiliation(s)
- Perla J. Marang-van de Mheen
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | | | - Susan Liew
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Australia
| | - Nora Mutalima
- Department of Orthopaedic Surgery, Monash Health, Dandenong, Australia
- Department of Surgery, Monash University, Dandenong, Australia
| | - Ton Tran
- Department of Orthopaedic Surgery, Monash Health, Dandenong, Australia
| | - Sten Rasmussen
- Orthopaedic Surgery Research Unit, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Rob G. H. H. Nelissen
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew Gordon
- Department of Orthopaedic Surgery, Sheffield Teaching Hospitals NHS trust, Sheffield, UK
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Chiu HC, Lin YC, Hsieh HM, Chen HP, Wang HL, Wang JY. The impact of complications on prolonged length of hospital stay after resection in colorectal cancer: A retrospective study of Taiwanese patients. J Int Med Res 2017; 45:691-705. [PMID: 28173723 PMCID: PMC5536677 DOI: 10.1177/0300060516684087] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objectives To assess the impact of minor, major and individual complications on prolonged length of hospital stay in patients with colorectal cancer (CRC) after surgery using multivariate models. Methods This was a retrospective review of data from patients who underwent surgery for stage I-III CRC at two medical centres in southern Taiwan between 2005-2010. Information was derived from four databases. Multivariate logistic regression methods were used to assess the impact of complications on prolonged length of stay (PLOS) and prolonged postoperative length of stay (PPOLOS). Results Of 1658 study patients, 251 (15.1%) experienced minor or major postsurgical complications during hospitalizations. Minor and major complications were significantly associated with PLOS (minor, odds ratio [OR] 3.59; major, OR 8.82) and with PPOLOS (minor, OR 5.55; major, OR 10.00). Intestinal obstruction, anastomosis leakage, abdominal abscess and bleeding produced the greatest impact. Conclusions Minor and major complications were stronger predictors of prolonged hospital stay than preoperative demographic and disease parameters. Compared with the PLOS model, the PPOLOS model better predicted risk of prolonged hospital stay. Optimal surgical and medical care have major roles in surgical CRC patients.
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Affiliation(s)
- Herng-Chia Chiu
- 1 Research Education and Epidemiology Centre, Changhua Christian Hospital, Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan.,2 Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Yi-Chieh Lin
- 3 Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hui-Min Hsieh
- 4 Department of Colorectal Surgery, E-DA Hospital, Kaohsiung, Taiwan
| | - Hsin-Pao Chen
- 5 Department of Medical Affairs, E-DA Hospital, Kaohsiung, Taiwan
| | - Hui-Li Wang
- 5 Department of Medical Affairs, E-DA Hospital, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- 6 Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,7 Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,8 Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Abstract
BACKGROUND Diverticulitis is a common and morbid disease with incompletely understood risk factors and pathophysiology. Geographic and, recently, seasonal trends in diverticulitis have been described in the United States. OBJECTIVE The purpose of this study was to investigate and compare seasonal trends in urgent hospital admission for diverticulitis in geographically distinct populations in the northern and southern hemispheres. DESIGN Inpatient, urgent admissions for diverticulitis were identified within the Dr Foster Intelligence Global Comparators Dataset, a global benchmarking collaborative. SETTINGS Admissions to participating hospitals in the United Kingdom, Australia, and the United States were identified between 2008 and 2013. PATIENTS A total of 18,672 urgent admissions for diverticulitis were identified among 5.5-million admissions. MAIN OUTCOME MEASURES Four separate hypothesis testing methods were used to identify seasonal trends in diverticulitis admissions among international patient populations. RESULTS Seasonal trends were present in all 3 countries. A summer peak was observed in both hemispheres using multiple statistical testing methods. Logistic regression analyses identified summer months as significantly associated with diverticulitis admission in all 3 countries. LIMITATIONS This study is limited by restriction to inpatient admissions, reliance on administrative data, and participation of select hospitals within the database. CONCLUSIONS These data suggest a shared seasonal risk factor among geographically distinct populations for diverticulitis.
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Ghith N, Wagner P, Frølich A, Merlo J. Short Term Survival after Admission for Heart Failure in Sweden: Applying Multilevel Analyses of Discriminatory Accuracy to Evaluate Institutional Performance. PLoS One 2016; 11:e0148187. [PMID: 26840122 PMCID: PMC4739586 DOI: 10.1371/journal.pone.0148187] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/14/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hospital performance is frequently evaluated by analyzing differences between hospital averages in some quality indicators. The results are often expressed as quality charts of hospital variance (e.g., league tables, funnel plots). However, those analyses seldom consider patients heterogeneity around averages, which is of fundamental relevance for a correct evaluation. Therefore, we apply an innovative methodology based on measures of components of variance and discriminatory accuracy to analyze 30-day mortality after hospital discharge with a diagnosis of Heart Failure (HF) in Sweden. METHODS We analyzed 36,943 patients aged 45-80 treated in 565 wards at 71 hospitals during 2007-2009. We applied single and multilevel logistic regression analyses to calculate the odds ratios and the area under the receiver-operating characteristic (AUC). We evaluated general hospital and ward effects by quantifying the intra-class correlation coefficient (ICC) and the increment in the AUC obtained by adding random effects in a multilevel regression analysis (MLRA). Finally, the Odds Ratios (ORs) for specific ward and hospital characteristics were interpreted jointly with the proportional change in variance (PCV) and the proportion of ORs in the opposite direction (POOR). FINDINGS Overall, the average 30-day mortality was 9%. Using only patient information on age and previous hospitalizations for different diseases we obtained an AUC = 0.727. This value was almost unchanged when adding sex, country of birth as well as hospitals and wards levels. Average mortality was higher in small wards and municipal hospitals but the POOR values were 15% and 16% respectively. CONCLUSIONS Swedish wards and hospitals in general performed homogeneously well, resulting in a low 30-day mortality rate after HF. In our study, knowledge on a patient's previous hospitalizations was the best predictor of 30-day mortality, and this information did not improve by knowing the sex and country of birth of the patient or where the patient was treated.
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Affiliation(s)
- Nermin Ghith
- Unit for Social Epidemiology, Faculty of Medicine, Lund University, Malmö, Sweden
- Research Unit of Chronic Conditions, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Philippe Wagner
- Unit for Social Epidemiology, Faculty of Medicine, Lund University, Malmö, Sweden
- Centre for Clinical Research, Västmanland, Uppsala University, Västerås, Sweden
| | - Anne Frølich
- Research Unit of Chronic Conditions, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Juan Merlo
- Unit for Social Epidemiology, Faculty of Medicine, Lund University, Malmö, Sweden
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Rost NS, Bottle A, Lee JM, Randall M, Middleton S, Shaw L, Thijs V, Rinkel GJE, Hemmen TM. Stroke Severity Is a Crucial Predictor of Outcome: An International Prospective Validation Study. J Am Heart Assoc 2016; 5:JAHA.115.002433. [PMID: 26796252 PMCID: PMC4859362 DOI: 10.1161/jaha.115.002433] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Stroke is among the leading causes of morbidity and mortality worldwide. Without reliable prediction models and outcome measurements, comparison of care systems is impossible. We analyzed prospectively collected data from 4 countries to explore the importance of stroke severity in outcome prediction. Methods and Results For 2 months, all acute ischemic stroke patients from the hospitals participating in the Global Comparators Stroke GOAL (Global Outcomes Accelerated Learning) collaboration received a National Institutes of Health Stroke Scale (NIHSS) score on admission and a modified Rankin Scale score at 30 and 90 days. These data were added to the administrative data set, and risk prediction models including age, sex, comorbidity index, and NIHSS were derived for in‐hospital death within 7 days, all in‐hospital death, and death and good outcome at 30 and 90 days. The relative importance of each variable was assessed using the proportion of explained variation. Of 1034 admissions for acute ischemic stroke, 614 had a full set of NIHSS and both modified Rankin Scale values recorded; of these, 507 patients could be linked to administrative data. The marginal proportion of explained variation was 0.7% to 4.0% for comorbidity index, and 11.3 to 25.0 for NIHSS score. The percentage explained by the model varied by outcome (16.6–29.1%) and was highest for good outcome at 30 and 90 days. There was high agreement between 30‐ and 90‐day modified Rankin Scale scores (weighted κ=0.82). Conclusions In this prospective pilot study, the baseline NIHSS score was essential for prediction of acute ischemic stroke outcomes, followed by age; whereas traditional comorbidity index contributed little to the overall model. Future studies of stroke outcomes between different care systems will benefit from including a baseline NIHSS score.
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Affiliation(s)
- Natalia S Rost
- Stroke Division, Neurology Department, Massachusetts General Hospital, Boston, MA (N.S.R.)
| | - Alex Bottle
- Dr. Foster Unit at Imperial College London, London, UK (A.B.)
| | - Jin-Moo Lee
- Stroke Center, Department of Neurology and the Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO (J.M.L.)
| | - Marc Randall
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK (M.R.)
| | | | - Louise Shaw
- Royal United Hospital Bath NHS Trust, Bath, UK (L.S.)
| | - Vincent Thijs
- University Hospitals Leuven, Department of Neurology, Leuven, Belgium (V.T.) Austin Health and Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia (V.T.)
| | - Gabriel J E Rinkel
- Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands (G.E.R.)
| | - Thomas M Hemmen
- University of California - San Diego Health System, San Diego, CA (T.M.H.)
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Ruiz M, Bottle A, Long S, Aylin P. Multi-Morbidity in Hospitalised Older Patients: Who Are the Complex Elderly? PLoS One 2015; 10:e0145372. [PMID: 26716440 PMCID: PMC4696783 DOI: 10.1371/journal.pone.0145372] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/01/2015] [Indexed: 12/21/2022] Open
Abstract
Background No formal definition for the “complex elderly” exists; moreover, these older patients with high levels of multi-morbidity are not readily identified as such at point of hospitalisation, thus missing a valuable opportunity to manage the older patient appropriately within the hospital setting. Objectives To empirically identify the complex elderly patient based on degree of multi-morbidity. Design Retrospective observational study using administrative data. Setting English hospitals during the financial year 2012–13. Subjects All admitted patients aged 65 years and over. Methods By using exploratory analysis (correspondence analysis) we identify multi-morbidity groups based on 20 target conditions whose hospital prevalence was ≥ 1%. Results We examined a total of 2788900 hospital admissions. Multi-morbidity was highly prevalent, 62.8% had 2 or more of the targeted conditions while 4.7% had six or more. Multi-morbidity increased with age from 56% (65-69yr age-groups) up to 67% (80-84yr age-group). The average multi-morbidity was 3.2±1.2 (SD). Correspondence analysis revealed 3 distinct groups of older patients. Group 1 (multi-morbidity ≤2), associated with cancer and/or metastasis; Group 2 (multi-morbidity of 3, 4 or 5), associated with chronic pulmonary disease, lung disease, rheumatism and osteoporosis; finally Group 3 with the highest level of multi-morbidity (≥6) and associated with heart failure, cerebrovascular accident, diabetes, hypertension and myocardial infarction. Conclusions By using widely available hospital administrative data, we propose patients in Groups 2 and 3 to be identified as the complex elderly. Identification of multi-morbidity patterns can help to predict the needs of the older patient and improve resource provision.
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Affiliation(s)
- Milagros Ruiz
- Dr Foster Unit at Imperial, Dept. Primary Care and Public Health, School of Public Health, Imperial College London, Reynolds Building, St. Dunstan's Road, London, W6 6RP, United Kingdom
- * E-mail:
| | - Alex Bottle
- Dr Foster Unit at Imperial, Dept. Primary Care and Public Health, School of Public Health, Imperial College London, Reynolds Building, St. Dunstan's Road, London, W6 6RP, United Kingdom
| | - Susannah Long
- Department of Medicine for the Elderly, Cambridge Wing, St Mary's Campus, Imperial College London, Praed Street, London, W2 1NY, United Kingdom
| | - Paul Aylin
- Dr Foster Unit at Imperial, Dept. Primary Care and Public Health, School of Public Health, Imperial College London, Reynolds Building, St. Dunstan's Road, London, W6 6RP, United Kingdom
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Pandit MJ, Alsop R. Using international data to set benchmarks for morbidity outcomes after hysterectomy. Int J Gynaecol Obstet 2015; 133:84-8. [PMID: 26797201 DOI: 10.1016/j.ijgo.2015.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 08/01/2015] [Accepted: 12/02/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To set an international benchmark for monitoring morbidity after hysterectomy. METHODS In a retrospective, observational study, data were assessed from women who underwent abdominal, vaginal, or laparoscopic hysterectomy in three countries (Australia, England, and the USA) between 2008 and 2012. The main outcome measures were length of stay (LOS), readmission, hemorrhage, and intraoperative conversion. RESULTS Overall, 32 181 procedures were included. The intraoperative conversion rate from vaginal and laparoscopic to abdominal hysterectomy was 1.5%. The LOS was significantly higher after abdominal surgery (3 days) than after vaginal (2 days; P<0.001) or laparoscopic (1 day; P<0.001) surgery. LOS was also higher after conversion (3 days) than after vaginal and laparoscopic hysterectomy (P<0.001 for both). Conversion cases had the highest rate of hemorrhage (7.5% vs 2.4% for abdominal, 1.8% vaginal, and 1.2% laparoscopic) and readmission (5.0% vs 4.2% for abdominal, 3.1% vaginal, and 2.8% laparoscopic). The odds of readmission were higher after abdominal than after laparoscopic hysterectomy (odds ratio 1.41, 95% confidence interval 1.19-1.67; P<0.001). CONCLUSION The morbidity associated with different surgical approaches to hysterectomy, including after intraoperative conversion, should be used as a benchmark. There is a need to measure and publish morbidity data after hysterectomy.
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Affiliation(s)
- Meghana J Pandit
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
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Ruiz M, Bottle A, Aylin PP. The Global Comparators project: international comparison of 30-day in-hospital mortality by day of the week. BMJ Qual Saf 2015; 24:492-504. [PMID: 26150550 PMCID: PMC4515980 DOI: 10.1136/bmjqs-2014-003467] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 05/02/2015] [Indexed: 12/28/2022]
Abstract
Objective To examine the association of mortality by day of the week for emergency and elective patients. Design Retrospective observational study using the international dataset from the Global Comparators (GC) project consisting of hospital administrative data. Setting 28 hospitals from England, Australia, USA and the Netherlands during 2009–2012. Participants Emergency and surgical-elective patients. Main outcome measures In-hospital deaths within 30 days of emergency admission or of elective surgery. Results We examined 2 982 570 hospital records; adjusted odds of 30-day death were higher for weekend emergency admissions to 11 hospitals in England (OR 1.08, 95% CI 1.04 to 1.13 on Sunday), 5 hospitals in USA (OR 1.13, 95% CI 1.04 to 1.24 on Sunday) and 6 hospitals in the Netherlands (OR 1.20, 95% CI 1.09 to 1.33 on Saturday). Emergency admissions to the six Australian hospitals showed no daily variation in adjusted 30-day mortality, but showed a weekend effect at 7 days post emergency admission (OR 1.12, 95% CI 1.04 to 1.22 on Saturday). All weekend elective patients showed higher adjusted odds of 30-day postoperative death; we observed a ‘Friday effect’ for elective patients in the six Dutch hospitals. Conclusions We show that mortality outcomes for our sample vary within each country and per day of the week in agreement with previous studies of the ‘weekend effect’. Due to limitations of administrative datasets, we cannot determine the reasons for these findings; however, the international nature of our database suggests that this is a systematic phenomenon affecting healthcare providers across borders. Further investigation is needed to understand the factors that give rise to the weekend effect. The participating hospitals represent varied models of service delivery, and there is a potential to learn from best practice in different healthcare systems.
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Affiliation(s)
- Milagros Ruiz
- Dr Foster Unit, PCPH Imperial College London, London, UK
| | - Alex Bottle
- Dr Foster Unit, PCPH Imperial College London, London, UK
| | - Paul P Aylin
- Dr Foster Unit, PCPH Imperial College London, London, UK
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Lilford RJ, Chen YF. The ubiquitous weekend effect: moving past proving it exists to clarifying what causes it. BMJ Qual Saf 2015; 24:480-2. [DOI: 10.1136/bmjqs-2015-004360] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2015] [Indexed: 11/03/2022]
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Defining world-class care in academic medicine: enablers and challenges. Adv Health Care Manag 2015. [PMID: 25985506 DOI: 10.1108/s1474-823120140000017002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
Abstract
PURPOSE Interest has grown among U.S. academic medical centers in developing international benchmarks for excellence in process and outcomes. Drivers behind this trend, as well as barriers to the development of useful benchmarks, are explored in this invited commentary. DESIGN/METHODOLOGY/APPROACH The commentary is based on the authors' conversations with members of the U.S. Cooperative for International Patient Programs as well as the University Healthsystem Consortium (UHC). FINDINGS Six key themes are summarized in this commentary, including four key drivers and two barriers. ORIGINALITY/VALUE The practice-based perspectives this commentary summarizes provide a useful starting point for researchers and practitioners interested in establishing international comparison with the United States.
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Hong MKY, Tomlin AM, Hayes IP, Skandarajah AR. Operative intervention rates for acute diverticulitis: a multicentre state-wide study. ANZ J Surg 2015; 85:734-8. [PMID: 25902717 DOI: 10.1111/ans.13126] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute colonic diverticulitis is placing an increasing strain on our health care resources. Measurement of the problem is difficult at a regional level, yet essential to improve and optimize treatment of this condition. Therefore, we aimed to use Australian state-level administrative data to determine the current practice and outcomes in major metropolitan hospitals. METHODS Coding algorithms designed to increase the yield and accuracy of administrative data were used to find emergency admissions from the Victorian Admitted Episodes Dataset. Eight tertiary referral centres with specialist colorectal services from 2009 to 2013 were studied. Key metrics including the operative intervention rate were measured. RESULTS There were 2829 emergency admissions for acute diverticulitis across 4 years in eight hospitals, with 724 being complicated. The emergency operative intervention rate was 10.4%, with a third of admissions for complicated diverticulitis having an operation. Hartmann's procedure was the most commonly performed emergency operation, accounting for 72% of resections. Patient characteristics were consistent across the hospitals, including a median length of stay of 3 and 6 days for uncomplicated and complicated diverticulitis, respectively. CONCLUSION Hartmann's procedure is currently the most common emergency operation for acute complicated diverticulitis in Victorian metropolitan hospitals. Our practice and outcomes can be measured meaningfully using administrative data.
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Affiliation(s)
- Michael K-Y Hong
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew M Tomlin
- Melbourne EpiCentre, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ian P Hayes
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anita R Skandarajah
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Reduced perioperative death following laparoscopic colorectal resection: results of an international observational study. Surg Endosc 2015; 29:3628-39. [PMID: 25761553 DOI: 10.1007/s00464-015-4119-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic approaches to colorectal surgery are known to accelerate recovery but the effect on postoperative mortality is uncertain. The purpose of this study was to determine whether differences exist in postoperative mortality between patients undergoing laparoscopic and open colorectal surgery in a group of international healthcare institutions. METHODS Administrative data from 30 worldwide institutions were searched for patients who underwent elective colorectal surgical resection between January 2007 and December 2011. The primary outcome measure was 30-day-in-hospital mortality rate. Secondary outcome measures were 30-day readmission rate, length of stay, and 30-day reoperation rate. RESULTS There were 30,369 (20,641 colonic and 9728 rectal) resections recorded over the 5 years. Eight thousand eighty-six were laparoscopic (26.6%) and 22,283 (73.4%) were open. Following propensity-score matching of the laparoscopic and open cohorts, mortality was 0.5% following laparoscopic colectomy and 1.2% after conventional surgery (P < 0.001). After adjusting for differences in preoperative risk factors including gender, age, comorbidity, type of surgery and diagnosis, by matching on propensity score, laparoscopic surgery was a strong determinant of reduced 30-day mortality (odds ratio 0.44; 95% confidence interval 0.31-0.62; P < 0.001), reduced hospital stay (odds ratio 0.42, 95% confidence interval 0.39-0.45; P < 0.001), reduced readmission (odds ratio 0.78, 95% confidence interval 0.71-0.86; P < 0.001) and reduced re-operation (odds ratio 0.75, 95% confidence interval 0.65-0.76; P < 0.001). CONCLUSIONS Minimally invasive colorectal surgery is associated with reduced in-hospital mortality when compared with conventional techniques. This finding is consistent across international healthcare institutions and supports efforts to disseminate laparoscopic skills.
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Munasinghe A, Chang D, Mamidanna R, Middleton S, Joy M, Penninckx F, Darzi A, Livingston E, Faiz O. Reconciliation of international administrative coding systems for comparison of colorectal surgery outcome. Colorectal Dis 2014; 16:555-61. [PMID: 24661398 DOI: 10.1111/codi.12624] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 02/15/2014] [Indexed: 02/08/2023]
Abstract
AIM Significant variation in colorectal surgery outcomes exists between different countries. Better understanding of the sources of variable outcomes using administrative data requires alignment of differing clinical coding systems. We aimed to map similar diagnoses and procedures across administrative coding systems used in different countries. METHOD Administrative data were collected in a central database as part of the Global Comparators (GC) Project. In order to unify these data, a systematic translation of diagnostic and procedural codes was undertaken. Codes for colorectal diagnoses, resections, operative complications and reoperative interventions were mapped across the respective national healthcare administrative coding systems. Discharge data from January 2006 to June 2011 for patients who had undergone colorectal surgical resections were analysed to generate risk-adjusted models for mortality, length of stay, readmissions and reoperations. RESULTS In all, 52 544 case records were collated from 31 institutions in five countries. Mapping of all the coding systems was achieved so that diagnosis and procedures from the participant countries could be compared. Using the aligned coding systems to develop risk-adjusted models, the 30-day mortality rate for colorectal surgery was 3.95% (95% CI 0.86-7.54), the 30-day readmission rate was 11.05% (5.67-17.61), the 28-day reoperation rate was 6.13% (3.68-9.66) and the mean length of stay was 14 (7.65-46.76) days. CONCLUSION The linkage of international hospital administrative data that we developed enabled comparison of documented surgical outcomes between countries. This methodology may facilitate international benchmarking.
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Affiliation(s)
- A Munasinghe
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
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