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Azhar A, Defor E, Bandyopadhyay D, Kamal L, Tanriover B, Gupta G. "Long-term effects of center volume on transplant outcomes in adult kidney transplant recipients". PLoS One 2024; 19:e0301425. [PMID: 38843258 PMCID: PMC11156332 DOI: 10.1371/journal.pone.0301425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 03/17/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND The influence of center volume on kidney transplant outcomes is a topic of ongoing debate. In this study, we employed competing risk analyses to accurately estimate the marginal probability of graft failure in the presence of competing events, such as mortality from other causes with long-term outcomes. The incorporation of immunosuppression protocols and extended follow-up offers additional insights. Our emphasis on long-term follow-up aligns with biological considerations where competing risks play a significant role. METHODS We examined data from 219,878 adult kidney-only transplantations across 256 U.S. transplant centers (January 2001-December 2015) sourced from the Organ Procurement and Transplantation Network registry. Centers were classified into quartiles by annual volume: low (Q1 = 28), medium (Q2 = 75), medium-high (Q3 = 121), and high (Q4 = 195). Our study investigated the relationship between center volume and 5-year outcomes, focusing on graft failure and mortality. Sub-population analyses included deceased donors, living donors, diabetic recipients, those with kidney donor profile index >85%, and re-transplants from deceased donors. RESULTS Adjusted cause-specific hazard ratios (aCHR) for Five-Year Graft Failure and Patient Death were examined by center volume, with low-volume centers as the reference standard (aCHR: 1.0). In deceased donors, medium-high and high-volume centers showed significantly lower cause-specific hazard ratios for graft failure (medium-high aCHR = 0.892, p<0.001; high aCHR = 0.953, p = 0.149) and patient death (medium-high aCHR = 0.828, p<0.001; high aCHR = 0.898, p = 0.003). Among living donors, no significant differences were found for graft failure, while a trend towards lower cause-specific hazard ratios for patient death was observed in medium-high (aCHR = 0.895, p = 0.107) and high-volume centers (aCHR = 0.88, p = 0.061). CONCLUSION Higher center volume is associated with significantly lower cause-specific hazard ratios for graft failure and patient death in deceased donors, while a trend towards reduced cause-specific hazard ratios for patient death is observed in living donors.
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Affiliation(s)
- Ambreen Azhar
- Division of Nephrology, Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Edem Defor
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA
| | | | - Layla Kamal
- Division of Nephrology, Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Bekir Tanriover
- Division of Nephrology, Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ
| | - Gaurav Gupta
- Division of Nephrology, Department of Medicine, Virginia Commonwealth University, Richmond, VA
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Warn MJ, Torabi SJ, Bitner BF, Chan D, Nguyen TV, Kuan EC. Clinical Productivity and Patient Complexity of Academic Rhinologists: An Analysis of Medicare Metrics. Laryngoscope 2024. [PMID: 38597779 DOI: 10.1002/lary.31437] [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: 02/02/2024] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/11/2024]
Abstract
INTRODUCTION Current data regarding reimbursement trends in Medicare services and the complexity of patients treated as physicians' progress in their academic career are conflicting. In otolaryngology, there are no data examining these metrics. METHODS Medicare services, reimbursement, and patient complexity risk scores (based on hierarchical condition category coding) of US rhinology fellowship-trained faculty were stratified and compared by rank and years in practice. RESULTS A cohort of 209 rhinologists were included. Full professors were reimbursed more per service than assistant professors ($791.53 [$491.69-1052.46] vs. $590.34 [$429.91-853.07] p = 0.045) and had lower risk scores (1.37 [1.26-1.52] vs. 1.49 [1.29-1.68], p = 0.013). Full professors had similar risk scores to associate professors (1.47 [1.25-1.64], p = 0.14). Full professors ($791.53 [$491.69-1,052.46], p < 0.001), associate professors ($706.85 [$473.48-941.15], p < 0.001), and assistant professors ($590.34 [$429.91-853.07], p < 0.001) were all reimbursed more per service than non-ranked faculty ($326.08 [$223.37-482.36]). As a cohort, significant declines in risk scores occurred within the 10th-14th year of practice (p = 0.032) and after the 20th year (p = 0.038). Years in practice were inversely correlated with risk score (R = -0.358, p < 0.001). CONCLUSION Full professors were reimbursed more per service and treated less comorbid Medicare patients than junior academic colleagues. Patient comorbidity was correlated negatively with years in practice, with significant drops in mid and late career. Rhinologists employed at academic institutions had greater total reimbursement and reimbursement per service than non-ranked faculty. LEVEL OF EVIDENCE N/A Laryngoscope, 2024.
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Affiliation(s)
- Michael J Warn
- School of Medicine, University of California, Riverside, California, U.S.A
| | - Sina J Torabi
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A
| | - Benjamin F Bitner
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A
| | - Daniella Chan
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A
| | - Theodore V Nguyen
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A
| | - Edward C Kuan
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A
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Rodin R, Stukel TA, Chung H, Bell CM, Detsky AS, Isenberg S, Quinn KL. Attending physicians' annual service volume and use of virtual end-of-life care: A population-based cohort study in Ontario, Canada. PLoS One 2024; 19:e0299826. [PMID: 38457383 PMCID: PMC10923452 DOI: 10.1371/journal.pone.0299826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/15/2024] [Indexed: 03/10/2024] Open
Abstract
IMPORTANCE Physicians and their practice behaviors influence access to healthcare and may represent potentially modifiable targets for practice-changing interventions. Use of virtual care at the end-of-life significantly increased during the COVID-19 pandemic, but its association with physician practice behaviors, (e.g., annual service volume) is unknown. OBJECTIVE Measure the association of physicians' annual service volume with their use of virtual end-of-life care (EOLC) and the magnitude of physician-attributable variation in its use, before and during the pandemic. DESIGN, SETTING AND PARTICIPANTS Population-based cohort study using administrative data of all physicians in Ontario, Canada who cared for adults in the last 90 days of life between 01/25/2018-12/31/2021. Multivariable modified Poisson regression models measured the association between attending physicians' use of virtual EOLC and their annual service volume. We calculated the variance partition coefficients for each regression and stratified by time period before and during the pandemic. EXPOSURE Annual service volume of a person's attending physician in the preceding year. MAIN OUTCOMES AND MEASURES Delivery of ≥1 virtual EOLC visit by a person's attending physician and the proportion of variation in its use attributable to physicians. RESULTS Among the 35,825 unique attending physicians caring for 315,494 adults, use of virtual EOLC was associated with receiving care from a high compared to low service volume attending physician; the magnitude of this association diminished during the pandemic (adjusted RR 1.25 [95% CI 1.14, 1.37] pre-pandemic;1.10 (95% CI 1.08, 1.12) during the pandemic). Physicians accounted for 36% of the variation in virtual EOLC use pre-pandemic and 12% of this variation during the pandemic. CONCLUSIONS AND RELEVANCE Physicians' annual service volume was associated with use of virtual EOLC and physicians accounted for a substantial proportion of the variation in its use. Physicians may be appropriate and potentially modifiable targets for interventions to modulate use of EOLC delivery.
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Affiliation(s)
- Rebecca Rodin
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Thérèse A. Stukel
- ICES, Toronto and Ottawa, ON, Canada
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | | | - Chaim M. Bell
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Allan S. Detsky
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Sarina Isenberg
- Division of Palliative Care, Dept of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Kieran L. Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto and Ottawa, ON, Canada
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Nishi M, Seki T, Shikuma A, Kawamata H, Horiguchi G, Matoba S. Association between patient volume to cardiologist, process of care, and clinical outcomes in heart failure. ESC Heart Fail 2023. [PMID: 37075756 PMCID: PMC10375098 DOI: 10.1002/ehf2.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/07/2023] [Accepted: 04/04/2023] [Indexed: 04/21/2023] Open
Abstract
AIMS The impact of hospital volume on clinical performance has been investigated by many researchers to date and thought that it is associated with quality of care and outcome for patients with heart failure (HF). This study sought to determine whether annual admissions of HF per cardiologist are associated with process of care, mortality, and readmission. METHODS AND RESULTS Among the nationwide registry 'Japanese registry of all cardiac and vascular diseases - diagnostics procedure combination' data collected from 2012 to 2019, a total of 1 127 113 adult patients with HF and 1046 hospitals were included in the study. Primary outcome was in-hospital mortality, and secondary outcome was 30 day in-hospital mortality and readmission at 30 days and 6 months. Hospital and patient characteristics and process of care measures were also assessed. Mixed-effect logistic regression and Cox proportional-hazards model was used for multivariable analysis, and adjusted odds ratio and hazard ratio were evaluated. Process of care measures had inverse trends for annual admissions of HF per cardiologist (P < 0.01 for all measures: prescription rate of beta-blocker, angiotensin converting enzyme inhibitor or angiotensin II receptor blocker, mineralocorticoid receptor antagonist, and anticoagulant for atrial fibrillation). Adjusted odds ratio for in-hospital mortality was 1.04 (95% confidence interval (CI): 1.04-1.08, P = 0.04) and 30 day in-hospital mortality was 1.05 (95% CI: 1.01-1.09, P = 0.01) for interval of 50 annual admissions of HF per cardiologist. Adjusted hazard ratio for 30 day readmission was 1.05 (95% CI: 1.02-1.08, P < 0.01) and 6 month readmission was 1.07 (95% CI: 1.03-1.11, P < 0.01). Plots of the adjusted odds indicated 300 as the threshold of annual admissions of HF per cardiologist for substantial increase of in-hospital mortality risk. CONCLUSIONS Our findings demonstrated that annual admissions of HF per cardiologist are associated with worse process of care, mortality, and readmission with the threshold for mortality risk increased, emphasizing the optimal proportion of patients admitted with HF to cardiologist for better clinical performance.
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Affiliation(s)
- Masahiro Nishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akira Shikuma
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hirofumi Kawamata
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Go Horiguchi
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Udell JA, Brickman AR, Chu A, Ferreira-Legere LE, Sheth MS, Ko DT, Austin PC, Abdel-Qadir H, Ivers NM, Bhatia RS, Farkouh ME, Stukel TA, Tu JV. Primary Care Clinical Volumes, Cholesterol Testing, and Cardiovascular Outcomes. Can J Cardiol 2023; 39:340-349. [PMID: 36574928 DOI: 10.1016/j.cjca.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 12/07/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND It is unknown whether the annual number of primary care physician (PCP) unique outpatient assessments, which we refer to as clinical volume, translates into better cardiovascular preventive care. We examined the relationship between PCP outpatient clinical volumes and cholesterol testing and major adverse cardiovascular event rates among guideline-recommended eligible patients. METHODS This was a retrospective cohort study conducted as part of the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort, a population-based cohort of almost all adult residents of Ontario, Canada, followed from 2008 to 2012. For each clinical volume quintile, we compared cholesterol testing and major adverse cardiovascular events, defined as time to first event of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. RESULTS The 10,037 PCPs evaluated had an annualized median volume of 2303 clinical encounters (IQR 1292-3680). Among 4,740,380 patients, 84% underwent guideline-concordant cholesterol testing at least once over 5 years, ranging from 73% with the lowest clinical volume quintile physicians to 86% with the highest. After multivariable adjustment, there was a 10.5% relative increase in the probability of cholesterol testing for every doubling of clinical volumes (95% CI 9.7-11.4; P < 0.001). Patients treated by the lowest volume quintile physicians had the highest rate of major adverse cardiovascular outcomes (compared with the highest volume quintile physicians: adjusted HR 1.15, 95% CI 1.10-1.21; P < 0.001). CONCLUSIONS Patients of physicians with the lowest clinical volumes received less frequent cholesterol testing and had the highest rate of incident cardiovascular events. Further research investigating the drivers of this relationship is warranted.
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Affiliation(s)
- Jacob A Udell
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Arielle R Brickman
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | | | | | - Maya S Sheth
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Noah M Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Family Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Thérèse A Stukel
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jack V Tu
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Burke LG, Burke RC, Orav EJ, Duggan CE, Figueroa JF, Jha AK. Association of Academic Medical Center Presence With Clinical Outcomes at Neighboring Community Hospitals Among Medicare Beneficiaries. JAMA Netw Open 2023; 6:e2254559. [PMID: 36723939 PMCID: PMC9892959 DOI: 10.1001/jamanetworkopen.2022.54559] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Studies suggest that academic medical centers (AMCs) have better outcomes than nonteaching hospitals. However, whether AMCs have spillover benefits for patients treated at neighboring community hospitals is unknown. OBJECTIVE To examine whether market-level AMC presence is associated with outcomes for patients treated at nonteaching hospitals within the same markets. DESIGN, SETTING, AND PARTICIPANTS This retrospective, population-based cohort study assessed traditional Medicare beneficiaries aged 65 years and older discharged from US acute care hospitals between 2015 and 2017 (100% sample). Data were analyzed from August 2021 to December 2022. EXPOSURES The primary exposure was market-level AMC presence. Health care markets (ie, hospital referral regions) were categorized by AMC presence (percentage of hospitalizations at AMCs) as follows: no presence (0%), low presence (>0% to 20%), moderate presence (>20% to 35%), and high presence (>35%). MAIN OUTCOMES AND MEASURES The primary outcomes were 30-day and 90-day mortality and healthy days at home (HDAH), a composite outcome reflecting mortality and time spent in facility-based health care settings. RESULTS There were 22 509 824 total hospitalizations, with 18 865 229 (83.8%) at non-AMCs. The median (IQR) age of patients was 78 (71-85) years, and 12 568 230 hospitalizations (55.8%) were among women. Of 306 hospital referral regions, 191 (62.4%) had no AMCs, 61 (19.9%) had 1 AMC, and 55 (17.6%) had 2 or more AMCs. Markets characteristics differed significantly by category of AMC presence, including mean population, median income, proportion of White residents, and physicians per population. Compared with markets with no AMC presence, receiving care at a non-AMC in a market with greater AMC presence was associated with lower 30-day mortality (9.5% vs 10.1%; absolute difference, -0.7%; 95% CI, -1.0% to -0.4%; P < .001) and 90-day mortality (16.1% vs 16.9%; absolute difference, -0.8%; 95% CI, -1.2% to -0.4%; P < .001) and more HDAH at 30 days (16.49 vs 16.12 HDAH; absolute difference, 0.38 HDAH; 95% CI, 0.11 to 0.64 HDAH; P = .005) and 90 days (61.08 vs 59.83 HDAH; absolute difference, 1.25 HDAH; 95% CI, 0.58 to 1.92 HDAH; P < .001), after adjustment. There was no association between market-level AMC presence and mortality for patients treated at AMCs themselves. CONCLUSIONS AND RELEVANCE AMCs may have spillover effects on outcomes for patients treated at non-AMCs, suggesting that they have a broader impact than is traditionally recognized. These associations are greatest in markets with the highest AMC presence and persist to 90 days.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ashish K. Jha
- Brown University School of Public Health, Providence, Rhode Island
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Finn CB, Tong JK, Alexander HE, Wirtalla C, Wachtel H, Guerra CE, Mehta SJ, Wender R, Kelz RR. How Referring Providers Choose Specialists for Their Patients: a Systematic Review. J Gen Intern Med 2022; 37:3444-3452. [PMID: 35441300 PMCID: PMC9550909 DOI: 10.1007/s11606-022-07574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Physician referrals are a critical step in directing patients to high-quality specialists. Despite efforts to encourage referrals to high-volume hospitals, many patients receive treatment at low-volume centers with worse outcomes. We aimed to determine the most important factors considered by referring providers when selecting specialists for their patients through a systematic review of medical and surgical literature. METHODS PubMed and Embase were searched from January 2000 to July 2021 using terms related to referrals, specialty, surgery, primary care, and decision-making. We included survey and interview studies reporting the factors considered by healthcare providers as they refer patients to specialists in the USA. Studies were screened by two independent reviewers. Quality was assessed using the CASP Checklist. A qualitative thematic analysis was performed to synthesize common decision factors across studies. RESULTS We screened 1,972 abstracts and identified 7 studies for inclusion, reporting on 1,575 providers. Thematic analysis showed that referring providers consider factors related to the specialist's clinical expertise (skill, training, outcomes, and assessments), interactions between the patient and specialist (prior experience, rapport, location, scheduling, preference, and insurance), and interactions between the referring physician and specialist (personal relationships, communication, reputation, reciprocity, and practice or system affiliation). Notably, studies did not describe how providers assess clinical or technical skills. CONCLUSIONS Referring providers rely on subjective factors and assessments to evaluate quality when selecting a specialist. There may be a role for guidelines and objective measures of quality to inform the choice of specialist by referring providers.
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Affiliation(s)
- Caitlin B Finn
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jason K Tong
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah E Alexander
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Wirtalla
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen E Guerra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Wender
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Dunlay SM, Killian JM, Roger VL, Schulte PJ, Blecker SB, Savitz ST, Redfield MM. Guideline-Directed Medical Therapy in Newly Diagnosed Heart Failure With Reduced Ejection Fraction in the Community. J Card Fail 2022; 28:1500-1508. [PMID: 35902033 PMCID: PMC9588715 DOI: 10.1016/j.cardfail.2022.07.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/03/2022] [Accepted: 07/13/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Guideline-directed medical therapy (GDMT) dramatically improves outcomes in heart failure with reduced ejection fraction (HFrEF). Our goal was to examine GDMT use in community patients with newly diagnosed HFrEF. METHODS AND RESULTS We performed a population-based, retrospective cohort study of all Olmsted County, Minnesota, residents with newly diagnosed HFrEF (EF ≤ 40%) 2007-2017. We excluded patients with contraindications to medication initiation. We examined the use of beta-blockers, HF beta-blockers (metoprolol succinate, carvedilol, bisoprolol), angiotensin converting enzyme inhibitors (ACEis), angiotensin receptor blockers (ARBs), angiotensin receptor neprilysin inhibitors (ARNIS), and mineralocorticoid receptor antagonists (MRAs) in the first year after HFrEF diagnosis. We used Cox models to evaluate the association of being seen in an HF clinic with the initiation of GDMT. From 2007 to 2017, 1160 patients were diagnosed with HFrEF (mean age 69.7 years, 65.6% men). Most eligible patients received beta-blockers (92.6%) and ACEis/ARBs/ARNIs (87.0%) in the first year. However, only 63.8% of patients were treated with an HF beta-blocker, and few received MRAs (17.6%). In models accounting for the role of an HF clinic in initiation of these medications, being seen in an HF clinic was independently associated with initiation of new GDMT across all medication classes, with a hazard ratio (95% CI) of 1.54 (1.15-2.06) for any beta-blocker, 2.49 (1.95-3.20) for HF beta-blockers, 1.97 (1.46-2.65) for ACEis/ARBs/ARNIs, and 2.14 (1.49-3.08) for MRAs. CONCLUSIONS In this population-based study, most patients with newly diagnosed HFrEF received beta-blockers and ACEis/ARBs/ARNIs. GDMT use was higher in patients seen in an HF clinic, suggesting the potential benefit of referral to an HF clinic for patients with newly diagnosed HFrEF.
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Affiliation(s)
- Shannon M Dunlay
- Department of Cardiovascular Medicine, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota.
| | - Jill M Killian
- Department of Quantitative Health Sciences, Rochester, Minnesota
| | - Veronique L Roger
- National Heart Lung Blood Institute in the National Institutes of Health, Bethesda, Maryland
| | | | - Saul B Blecker
- Department of Population Health and Medicine, New York University Langone, New York, New York
| | - Samuel T Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
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Bainvoll L, Mandelbaum RS, Violette CJ, Matsuzaki S, Ho JR, Wright JD, Paulson RJ, Matsuo K. Association between hospital treatment volume and major complications in ovarian hyperstimulation syndrome. Eur J Obstet Gynecol Reprod Biol 2022; 272:240-246. [PMID: 35405452 DOI: 10.1016/j.ejogrb.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/24/2022] [Accepted: 04/03/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE An inverse relationship between hospital volume and adverse patient outcomes has been established for many conditions, but has not yet been examined in ovarian hyperstimulation syndrome (OHSS). Given the rarity of severe OHSS, but potential for high morbidity, this study aimed to elucidate the effect of hospital volume on inpatient OHSS-related complications. METHODS This is a retrospective observational study querying the National Inpatient Sample, 1/2001-12/2011. Study population was 11,878 patients with OHSS treated at 735 hospitals. Annualized hospital OHSS treatment volume was grouped as: low-volume (1 case/year), mid-volume (>1 but < 3.5 cases/year), and high-volume (≥3.5 cases/year). Main outcome measure was major complication rates stratified by hospital treatment volume, assessed by multinomial regression and binary logistic regression models. RESULTS A total of 2,415 (20.3%) patients were treated at low-volume centers, 5,023 (42.3%) at mid-volume centers, and 4,440 (37.4%) at high-volume centers. Patients treated at high-volume centers were more likely to be older and less comorbid with higher incomes and lower body mass index (P < 0.05). High-volume hospitals were more likely to be urban-teaching centers with large bed capacity (P < 0.001). Overall, 1,624 (13.7%) patients experienced a major complication during hospitalization. Patients treated at high-volume hospitals had lower rates of major complications (high: 11.0%, mid: 15.2%, low: 15.6%, P < 0.001). On multivariable analysis, treatment at high-volume hospitals was independently associated with a nearly 20% lower rate of major complications (odds ratio 0.82, 95% confidence interval 0.70-0.97, P = 0.021). CONCLUSION Our study suggests that higher hospital treatment volume for OHSS may be associated with improved outcomes.
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Affiliation(s)
- Liat Bainvoll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Caroline J Violette
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Jacqueline R Ho
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Richard J Paulson
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
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Differences in Hospitalization Outcomes of Kidney Disease between Patients Who Received Care by Nephrologists and Non-Nephrologist Physicians: A Propensity-Score-Matched Study. J Clin Med 2021; 10:jcm10225269. [PMID: 34830549 PMCID: PMC8623768 DOI: 10.3390/jcm10225269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/29/2021] [Accepted: 11/08/2021] [Indexed: 11/29/2022] Open
Abstract
The influence of physician specialty on the outcomes of kidney diseases (KDs) remains underexplored. We aimed to compare the complications and mortality of patients with admissions for KD who received care by nephrologists and non-nephrologist (NN) physicians. We used health insurance research data in Taiwan to conduct a propensity-score matched study that included 17,055 patients with admissions for KD who received care by nephrologists and 17,055 patients with admissions for KD who received care by NN physicians. Multivariable logistic regressions were conducted to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for 30-day mortality and major complications associated with physician specialty. Compared with NN physicians, care by nephrologists was associated with a reduced risk of 30-day mortality (OR 0.29, 95% CI 0.25–0.35), pneumonia (OR 0.82, 95% CI 0.76–0.89), acute myocardial infarction (OR 0.68, 95% CI 0.54–0.87), and intensive care unit stay (OR 0.78, 95% CI 0.73–0.84). The association between nephrologist care and reduced admission adverse events was significant in every age category, for both sexes and various subgroups. Patients with admissions for KD who received care by nephrologists had fewer adverse events than those who received care by NN physicians. We suggest that regular nephrologist consultations or referrals may improve medical care and clinical outcomes in this vulnerable population.
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11
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Oh TK, Song IA. Hospital Case Volume, Health Care Providers, and Mortality in Patients Undergoing Coronary Artery Bypass Grafting: a Nationwide Cohort Study in South Korea. Korean Circ J 2021; 51:518-529. [PMID: 33764013 PMCID: PMC8176067 DOI: 10.4070/kcj.2020.0443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/14/2020] [Accepted: 01/20/2021] [Indexed: 11/11/2022] Open
Abstract
Our South Korean population-based cohort study showed that a higher annual hospital case volume was associated with a lower 90-day mortality after isolated coronary artery bypass grafting (CABG). Additionally, a higher overall specialty physician volume was independently associated with a lower 90-day mortality. We reported cut-off values of ≥65 and ≥18 for the annual case volume of CABG and the total number of overall specialty doctors per 100 hospital beds, respectively, for achieving better outcomes after CABG. Background and Objectives Surgical quality is evaluated by measuring the annual hospital case volume; a higher case volume is associated with better survival after various surgeries. We aimed to investigate if the annual hospital case volume and the health care providers were associated with a 90-day mortality after coronary artery bypass grafting (CABG). Methods For this population-based cohort study, we used data from a National Health Insurance Service database in South Korea. We included all adult patients diagnosed with ischemic heart disease who underwent isolated CABG between January 2012 and December 2017. Data on the annual surgical volume for CABG in each hospital where the patients received CABG and the total number of health care providers (including physicians [trainees and specialists] from all department of the hospitals, nurses, and pharmacists) were collected. Results The final analysis included 15,790 adult patients; of these, 1,039 (6.6%) died within 90 days. The annual CABG volume was divided into 4 groups (Q1: ≤33, Q2: 34–86, Q3: 87–223, and Q4: ≥224). Multivariable Cox regression analysis revealed that the 90-day mortality rates in the Q4, Q3, Q2 groups were 75%, 32%, and 31% lower than that in the Q1 group, respectively. Additionally, an increase in the ratio of the total number of specialist physicians to 100 hospital beds was associated with a 4% decrease in the 90-day mortality after CABG. Conclusion Both, a higher annual hospital case volume and overall specialist physician volume were associated with better 90-day mortality rates after isolated CABG.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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Johnson L, Shapiro M, Stricker RB, Vendrow J, Haddock J, Needell D. Antibiotic Treatment Response in Chronic Lyme Disease: Why Do Some Patients Improve While Others Do Not? Healthcare (Basel) 2020; 8:healthcare8040383. [PMID: 33022914 PMCID: PMC7712932 DOI: 10.3390/healthcare8040383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/10/2023] Open
Abstract
There is considerable uncertainty regarding treatment of Lyme disease patients who do not respond fully to initial short-term antibiotic therapy. Choosing the best treatment approach and duration remains challenging because treatment response among these patients varies: some patients improve with treatment while others do not. A previous study examined treatment response variation in a sample of over 3500 patients enrolled in the MyLymeData patient registry developed by LymeDisease.org (San Ramon, CA, USA). That study used a validated Global Rating of Change (GROC) scale to identify three treatment response subgroups among Lyme disease patients who remained ill: nonresponders, low responders, and high responders. The present study first characterizes the health status, symptom severity, and percentage of treatment response across these three patient subgroups together with a fourth subgroup, patients who identify as well. We then employed machine learning techniques across these subgroups to determine features most closely associated with improved patient outcomes, and we used traditional statistical techniques to examine how these features relate to treatment response of the four groups. High treatment response was most closely associated with (1) the use of antibiotics or a combination of antibiotics and alternative treatments, (2) longer duration of treatment, and (3) oversight by a clinician whose practice focused on the treatment of tick-borne diseases.
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Affiliation(s)
| | - Mira Shapiro
- Analytic Designers LLC, Bethesda, MD 20817, USA;
| | - Raphael B. Stricker
- Union Square Medical Associates, San Francisco, CA 94108, USA
- Correspondence: ; Tel.: +1-415-399-1035; Fax: +1-415-399-1057
| | - Joshua Vendrow
- Department of Mathematics, University of California, Los Angeles, CA 90095, USA; (J.V.); (J.H.); (D.N.)
| | - Jamie Haddock
- Department of Mathematics, University of California, Los Angeles, CA 90095, USA; (J.V.); (J.H.); (D.N.)
| | - Deanna Needell
- Department of Mathematics, University of California, Los Angeles, CA 90095, USA; (J.V.); (J.H.); (D.N.)
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Kanaoka K, Okayama S, Nakai M, Sumita Y, Onoue K, Soeda T, Nishimura K, Kawakami R, Okura H, Miyamoto Y, Yasuda S, Tsutsui H, Komuro I, Ogawa H, Saito Y. Number of Cardiologists per Cardiovascular Beds and In-Hospital Mortality for Acute Heart Failure: A Nationwide Study in Japan. J Am Heart Assoc 2019; 8:e012282. [PMID: 31495302 PMCID: PMC6818015 DOI: 10.1161/jaha.119.012282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Little evidence is available about the number of cardiologists required for appropriate treatment of heart failure (HF). Our objective was to determine the association between the number of cardiologists per cardiology beds for treating patients with acute HF and in‐hospital mortality. Methods and Results This was a cross‐sectional study, and we used the Japanese Registry of All Cardiac and Vascular Diseases Diagnosis Procedure Combination discharge database. The data of patients with HF on emergency admission from April 1, 2012, to March 31, 2014, were extracted. The patients were categorized into 4 groups by the quartiles of the numbers of cardiologists per 50 cardiovascular beds (first group: median, 4.4 [interquartile range, 3.5–5.0]; second group: median, 6.7 [interquartile range, 6.5–7.5]; third group: median, 9.7 [interquartile range, 8.8–10.1]; and fourth group: median, 16.7 [interquartile range, 14.0–23.8]). Using multilevel mixed‐effect logistics regression, we determined adjusted odds ratios for in‐hospital mortality. We identified 154 290 patients with HF on emergency admissions. There were 29 626, 36 587, 46 451, and 41 626 patients in the first, second, third, and fourth groups, respectively. HF severity, on the basis of New York Heart Association classification, was similar in the 3 groups. Adjusted odds ratios (95% CIs) for in‐hospital mortality were 0.92 (0.82–1.04; P=0.20), 0.82 (0.72–0.92; P<0.001), and 0.70 (0.61–0.80; P<0.001) for the second, third, and fourth groups, respectively. The proportion of medication used, including angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, β blockers, and mineralocorticoid receptor antagonists, was positively correlated to the number of cardiologists. Conclusions Patients hospitalized for HF in hospitals with larger numbers of cardiologists per cardiovascular beds had lower 30‐day mortality.
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Affiliation(s)
- Koshiro Kanaoka
- Department of Cardiovascular Medicine Nara Medical University Nara Japan
| | - Satoshi Okayama
- Department of Cardiovascular Medicine Nara Medical University Nara Japan
| | | | - Yoko Sumita
- National Cerebral and Cardiovascular Center Suita Japan
| | - Kenji Onoue
- Department of Cardiovascular Medicine Nara Medical University Nara Japan
| | - Tsunenari Soeda
- Department of Cardiovascular Medicine Nara Medical University Nara Japan
| | | | - Rika Kawakami
- Department of Cardiovascular Medicine Nara Medical University Nara Japan
| | - Hiroyuki Okura
- Department of Cardiovascular Medicine Nara Medical University Nara Japan
| | | | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine Kyushu University Graduate School of Medical Sciences Fukuoka Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine The University of Tokyo Graduate School of Medicine Tokyo Japan
| | - Hisao Ogawa
- National Cerebral and Cardiovascular Center Suita Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine Nara Medical University Nara Japan
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Do Hospital and Physician Volume Thresholds for the Volume-Outcome Relationship in Heart Failure Exist? Med Care 2019; 57:54-62. [PMID: 30439795 DOI: 10.1097/mlr.0000000000001022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although volume-outcome relationships have been explored for various procedures and interventions, limited information is available concerning the effect of hospital and physician volume on heart failure mortality. Most importantly, little is known about whether there are optimal hospital and physician volume thresholds to reduce heart failure mortality. OBJECTIVES We used nationwide population-based data to identify the optimal hospital and physician volume thresholds to achieve optimum mortality and to examine the relative and combined effects of the volume thresholds on heart failure mortality. METHODS We analyzed all 20,178 heart failure patients admitted in 2012 through Taiwan's National Health Insurance Research Database. Restricted cubic splines and multilevel logistic regression were used to identify whether there are optimal hospital and physician volume thresholds and to assess the relative and combined relationships of the volume thresholds to 30-day mortality, adjusted for patient, physician, and hospital characteristics. RESULTS Hospital and physician volume thresholds of 40 cases and 15 cases a year, respectively, were identified, under which there was an increased risk of 30-day mortality. Patients treated by physicians with previous annual volumes <15 cases had higher 30-day mortality compared with those with previous annual volumes ≥15 cases, and the relationship was stronger in hospitals with previous annual volumes <40 cases. CONCLUSIONS This is the first study to identify both the hospital and physician volume thresholds that lead to decreases in heart failure mortality. Identifying the hospital and physician volume thresholds could be applied to quality improvement and physician training.
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15
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Yu TH, Chou YY, Tung YC. Should we pay attention to surgeon or hospital volume in total knee arthroplasty? Evidence from a nationwide population-based study. PLoS One 2019; 14:e0216667. [PMID: 31075135 PMCID: PMC6510420 DOI: 10.1371/journal.pone.0216667] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/25/2019] [Indexed: 11/18/2022] Open
Abstract
Background Although prior research into the relationship between volume and outcome indicates that this relationship is not linear and that an optimal volume should be specified, consensus is lacking regarding the ideal value of this optimal volume. The purposes of this study were to use a visual method to identify surgeon- and hospital-volume thresholds and to examine the relationships of surgeon and hospital volume thresholds to 30-day readmission. Methods A retrospective nationwide population-based study design was adopted. Patients who received total knee replacement surgery between 2007 and 2008 in any hospital in Taiwan were included. After adjusting for patient, physician, and hospital characteristics, a restricted cubic spline regression model was used to identify optimal surgeon- and hospital-volume thresholds. Further, a patient-level mixed effect model was conducted to test the respective relationships between these thresholds and 30-day readmission. Results A total of 30,828 patients who had received their surgeries from 1,468 surgeons in 437 hospitals were included in this study. Thresholds of 50 cases a year for surgeons and 75 cases a year for hospitals were identified using a restricted cubic spline regression model. However, only the surgeon volume threshold was associated with 30-day readmission using a patient-level mixed effect model after adjusting for patient-, surgeon- and hospital-level covariates. Conclusions According to the results of the restricted cubic spline models, the optimal volume thresholds for surgeons and hospitals are 50 cases and 75 cases a year, respectively. However, only the surgeon volume threshold is associated with 30-day readmission.
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Affiliation(s)
- Tsung-Hsien Yu
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Ying-Yi Chou
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Yu-Chi Tung
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
- * E-mail:
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Abstract
RATIONALE Physicians are increasingly being held accountable for patient outcomes, yet their specific contribution to the outcomes remains uncertain. OBJECTIVES To determine variation in outcomes of mechanically ventilated patients among intensivists, as well as associations between intensivist experience and patient outcomes. METHODS We performed a retrospective cohort study of mechanically ventilated Medicare fee-for-service patients in acute care hospitals in Pennsylvania using administrative, clinical, and physician data from Centers for Medicare and Medicaid Services and the American Medical Association from 2008 and 2009. We identified intensivists by training background, board certification, and claims for services provided to patients admitted to an intensive care unit. We assigned patients to intensivists for outcome attribution based on submitted claims for critical care and in-patient services. We estimated the physician-specific adjusted odds ratios (ORs) for 30-day mortality using a hierarchical model with a random effect for physician, adjusted for patient and hospital characteristics. We tested for independent association of physician experience with patient outcomes using mixed-effects regression for the primary outcome of 30-day mortality. We defined physician experience in two ways: years since training completion ("duration") and annual number of mechanically ventilated patients ("volume"). RESULTS We assigned 345 physicians to 11,268 patients. The 30-day mortality was 43% and median hospital length of stay was 11 days (interquartile range = 6-18). The physician adjusted OR varied from 0.72 to 1.64 (median = 0.99; interquartile range = 0.92-1.09). A total of 48% of physicians was outliers, with an adjusted OR significantly different from 1. However, among intensivists, physician experience was not associated with 30-day mortality (duration OR = 1.00 per additional year; 95% confidence interval = 1.00-1.01; volume OR = 1.00 per additional patient; 95% confidence interval = 1.00-1.00). CONCLUSIONS Intensivists independently contribute to outcomes of Medicare patients who undergo mechanical ventilation, as evidenced by the variation in risk-adjusted mortality across intensivists. However, physician experience does not underlie this relationship between intensivists, suggesting the need to identify modifiable physician factors to improve outcomes.
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Manes E, Tchetchik A, Tobol Y, Durst R, Chodick G. An Empirical Investigation of "Physician Congestion" in U.S. University Hospitals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16050761. [PMID: 30832384 PMCID: PMC6427243 DOI: 10.3390/ijerph16050761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/22/2019] [Accepted: 02/26/2019] [Indexed: 01/01/2023]
Abstract
We add a new angle to the debate on whether greater healthcare spending is associated with better outcomes, by focusing on the link between the size of the physician workforce at the ward level and healthcare results. Drawing on standard organization theories, we proposed that due to organizational limitations, the relationship between physician workforce size and medical performance is hump-shaped. Using a sample of 150 U.S. university departments across three specialties that record measures of clinical scores, as well as a rich set of covariates, we found that the relationship was indeed hump-shaped. At the two extremes, departments with an insufficient (excessive) number of physicians may gain a substantial increase in healthcare quality by the addition (dismissal) of a single physician. The marginal elasticity of healthcare quality with respect to the number of physicians, although positive and significant, was much smaller than the marginal contribution of other factors. Moreover, research quality conducted at the ward level was shown to be an important moderator. Our results suggest that studying the relationship between the number of physicians per bed and the quality of healthcare at an aggregate level may lead to bias. Framing the problem at the ward-level may facilitate a better allocation of physicians.
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Affiliation(s)
- Eran Manes
- The Department of Public Policy and Administration, Ben-Gurion University of the Negev, POB 653, Beer-Sheva 84105, Israel.
- Faculty of Management, Lev College of Technology, Havaad Haleumi 21 St., Givat Mordechai, Jerusalem 9116001, Israel.
| | - Anat Tchetchik
- The Department of Geography and Environment, Bar-Ilan University, Ramat-Gan 5290002, Israel.
| | - Yosef Tobol
- Faculty of Management, Lev College of Technology, Havaad Haleumi 21 St., Givat Mordechai, Jerusalem 9116001, Israel.
- IZA-Institute of Labor Economics Schaumburg-Lippe-Straße 5-9, 53113 Bonn, Germany.
| | - Ronen Durst
- Cardiology Division, Hadassah Hebrew University Medical Center, Ein Kerem, Jerusalem 91120, Israel.
| | - Gabriel Chodick
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, P.O. Box 39040, Tel Aviv 6997801, Israel.
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Wilkinson C, Thomas H, McMeekin P, Price C. PROCESS AND SYSTEMS: A cohort study to evaluate the impact of service centralisation for emergency admissions with acute heart failure. Future Healthc J 2019; 6:41-46. [PMID: 31098585 PMCID: PMC6520079 DOI: 10.7861/futurehosp.6-1-41] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The aim of our study was to describe the impact of emergency care centralisation on unscheduled admissions with a primary discharge diagnosis of acute heart failure (HF). We carried out a retrospective cohort study of HF admissions 1 year before and 1 year after centralisation of three accident and emergency departments into one within a single large NHS trust. Outcomes included mortality, length of stay, readmissions, specialist inpatient input and follow-up, and prescription rates of stabilising medication. Baseline characteristics were similar for 211 patients before and for 307 following reconfiguration. Median length of stay decreased from 8 to 6 days (p=0.020) without an increase in readmissions (4.7% versus 4.2%, p=0.813). The proportion with specialist follow-up increased (60% to 72%, p=0.036). There was a trend towards decreased mortality (32.2% versus 27.7% at 90 days; p=0.266). Contact with the cardiology team was associated with decreased mortality. In conclusion, centralisation of specialist emergency care was associated with greater service efficiency and a trend towards reduced mortality.
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Affiliation(s)
- Chris Wilkinson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
- Northern Deanery, Northumbria NHS Foundation Trust, UK
| | | | - Peter McMeekin
- School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
| | - Chris Price
- Northumbria NHS Foundation Trust, UK
- NIHR Newcastle Biomedical Research Centre and Institute of Neuroscience, Newcastle University, Newcastle upon Tyne
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Abstract
Risk-adjusted mortality has been proposed as a quality of care indicator to gauge cardiovascular intensive care Unit (CICU) performance. Mortality is easily measured, readily understandable, and a meaningful outcome for the patient, provider, administrative agencies, and other key stakeholders. Disease-specific risk-adjusted mortality is commonly used in cardiovascular medicine as an indicator of care quality, for external accreditation, and to determine payer reimbursement. However, the evidence base for overall risk-adjusted mortality in the CICU is limited, with most available data coming from the general critical care literature. In addition, existing risk-adjusted mortality models vary considerably in terms of approach and composition, and there is no nationally recognized standard. Thus, the objective of this study was to review the use of risk-adjusted mortality as a measure of overall unit performance and quality of care in the CICU. We found a considerable variability in the risk-adjustment methodology for cardiovascular disease. Although predictive models for disease-specific risk-adjusted mortality in cardiovascular disease have been developed, there are limited published data on overall risk-adjusted mortality for the CICU. Without standardization of risk-adjustment methodology, researchers are often required to use existing risk-adjustment models developed in noncardiac patient populations. Further studies are needed to establish whether risk-adjusted overall CICU mortality is a valid performance measure and whether it reflects care quality.
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Improving Outcomes for Critically Ill Cardiovascular Patients Through Increased Physical Therapy Staffing. Arch Phys Med Rehabil 2018; 100:270-277.e1. [PMID: 30172645 DOI: 10.1016/j.apmr.2018.07.437] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/16/2018] [Accepted: 07/23/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To examine the effect of increasing physical therapy (PT) staff in a cardiovascular intensive care unit (CVICU) on temporal measures of PT interventions and on outcomes important to patients and hospitals. DESIGN Retrospective pre/post subgroup analysis from a quality improvement initiative. SETTING Academic medical center. PARTICIPANTS Cardiovascular patients in either a baseline (N=52) or quality improvement period (N=62) with a CVICU length of stay (LOS) ≥7 days and use of any one of the following: mechanical ventilation, continuous renal replacement therapy, or mechanical circulatory support. INTERVENTIONS The 6-month quality improvement initiative increased CVICU-dedicated PT staff from 2 to 4. MAIN OUTCOME MEASURES Changes in physical therapy delivery were examined using the frequency and daily duration of PT intervention. Post-CVICU LOS was the primary outcome. CVICU LOS, mobility change, and discharge level of care were secondary outcomes. A secondary analysis of hospital survivors was also conducted. RESULTS Compared to those in the baseline period, cardiovascular patients in the quality improvement period participated in PT for an additional 9.6 minutes (95% confidence interval [CI]: 1.9, 17.2) per day for all patients and 15.1 minutes (95% CI: 7.6, 22.6) for survivors. Post-CVICU LOS decreased 2.2 (95% CI: -6.0, 1.0) days for all patients and 2.6 days (95% CI: -5.3, 0.0) for survivors. CVICU LOS decreased 3.6 days (95% CI: -6.4, -0.8) for all patients and 3.1 days (95% CI: -6.4, -0.9) for survivors. Differences in mobility change and discharge level of care were not significant. CONCLUSIONS Additional CVICU-dedicated PT staff was associated with increased PT treatment and reductions in CVICU and post-CVICU LOS. The effects of each were greatest for hospital survivors.
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Lee JE, Park EC, Jang SY, Lee SA, Choy YS, Kim TH. Effects of Physician Volume on Readmission and Mortality in Elderly Patients with Heart Failure: Nationwide Cohort Study. Yonsei Med J 2018; 59:243-251. [PMID: 29436192 PMCID: PMC5823826 DOI: 10.3349/ymj.2018.59.2.243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 12/13/2017] [Accepted: 12/19/2017] [Indexed: 12/05/2022] Open
Abstract
PURPOSE Readmission and mortality rates of patients with heart failure are good indicators of care quality. To determine whether hospital resources are associated with care quality for cardiac patients, we analyzed the effect of number of physicians and the combined effects of number of physicians and beds on 30-day readmission and 1-year mortality. MATERIALS AND METHODS We used national cohort sample data of the National Health Insurance Service (NHIS) claims in 2002-2013. Subjects comprised 2345 inpatients (age: >65 years) admitted to acute-care hospitals for heart failure. A multivariate Cox regression was used. RESULTS Of the 2345 patients hospitalized with heart failure, 812 inpatients (34.6%) were readmitted within 30 days and 190 (8.1%) had died within a year. Heart-failure patients treated at hospitals with low physician volumes had higher readmission and mortality rates than high physician volumes [30-day readmission: hazard ratio (HR)=1.291, 95% confidence interval (CI)=1.020-1.633; 1-year mortality: HR=2.168, 95% CI=1.415-3.321]. Patients admitted to hospitals with low or middle bed and physician volume had higher 30-day readmission and 1-year mortality rates than those admitted to hospitals with high volume (30-day readmission: HR=2.812, 95% CI=1.561-5.066 for middle-volume beds & low-volume physicians, 1-year mortality: HR=8.638, 95% CI=2.072-36.02 for middle-volume beds & low-volume physicians). CONCLUSION Physician volume is related to lower readmission and mortality for heart failure. Of interest, 30-day readmission and 1-year mortality were significantly associated with the combined effects of physician and institution bed volume.
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Affiliation(s)
- Joo Eun Lee
- Department of Public Health, Yonsei University College of Medicine, Seoul, Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Cheol Park
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Suk Yong Jang
- Department of Preventive Medicine, Eulji University College of Medicine, Daejeon, Korea
| | - Sang Ah Lee
- Department of Public Health, Yonsei University College of Medicine, Seoul, Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Soo Choy
- Department of Public Health, Yonsei University College of Medicine, Seoul, Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hyun Kim
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
- Department of Hospital Administration, Graduate School of Public Health, Yonsei University, Seoul, Korea.
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22
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Avaldi VM, Lenzi J, Urbinati S, Molinazzi D, Descovich C, Campagna A, Taglioni M, Fioritti A, Fantini MP. Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: results from an observational study based on administrative data. BMJ Open 2017; 7:e018243. [PMID: 29101146 PMCID: PMC5695401 DOI: 10.1136/bmjopen-2017-018243] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/08/2017] [Accepted: 09/29/2017] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF). DESIGN Retrospective observational study based on administrative data. SETTING Local Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants. PARTICIPANTS All patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015. PRIMARY AND SECONDARY OUTCOME MEASURES Multivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge. RESULTS The study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/angiotensin receptor blockers (ACEIs/ARBs), β-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or β-blockers (-53% and -28%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (-28%). CONCLUSIONS Compared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF.
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Affiliation(s)
- Vera Maria Avaldi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Emilia-Romagna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Emilia-Romagna, Italy
| | - Stefano Urbinati
- Department of Cardiology, Bellaria Hospital, Bologna, Emilia-Romagna, Italy
| | - Dario Molinazzi
- Department of Management Control and Administrative Data, Bologna Local Healthcare Authority, Bologna, Emilia-Romagna, Italy
| | - Carlo Descovich
- Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Emilia-Romagna, Italy
| | - Anselmo Campagna
- Regional Agency for Health and Social Care of Emilia-Romagna, Bologna, Emilia-Romagna, Italy
| | - Martina Taglioni
- Department of Clinical Governance and Quality, St Orsola-Malpighi Hospital, Bologna, Emilia-Romagna, Italy
| | - Angelo Fioritti
- Medical Directorate, Bologna Local Healthcare Authority, Bologna, Emilia-Romagna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Emilia-Romagna, Italy
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23
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Salamanca Bautista P, Aramburu Bodas Ó, Formiga F. [Heart failure: Does it matter which speciality treats it?]. Rev Esp Geriatr Gerontol 2017; 52:177-178. [PMID: 28559096 DOI: 10.1016/j.regg.2017.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 01/17/2017] [Indexed: 06/07/2023]
Affiliation(s)
| | | | - Francesc Formiga
- Servicio de Medicina Interna, IDIBELL, Hospital Universitario Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
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24
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Tsugawa Y, Newhouse JP, Zaslavsky AM, Blumenthal DM, Jena AB. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ 2017; 357:j1797. [PMID: 28512089 PMCID: PMC5431772 DOI: 10.1136/bmj.j1797] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Objectives To investigate whether outcomes of patients who were admitted to hospital differ between those treated by younger and older physicians.Design Observational study.Setting US acute care hospitals.Participants 20% random sample of Medicare fee-for-service beneficiaries aged ≥65 admitted to hospital with a medical condition in 2011-14 and treated by hospitalist physicians to whom they were assigned based on scheduled work shifts. To assess the generalizability of findings, analyses also included patients treated by general internists including both hospitalists and non-hospitalists.Main outcome measures 30 day mortality and readmissions and costs of care. Results 736 537 admissions managed by 18 854 hospitalist physicians (median age 41) were included. Patients' characteristics were similar across physician ages. After adjustment for characteristics of patients and physicians and hospital fixed effects (effectively comparing physicians within the same hospital), patients' adjusted 30 day mortality rates were 10.8% for physicians aged <40 (95% confidence interval 10.7% to 10.9%), 11.1% for physicians aged 40-49 (11.0% to 11.3%), 11.3% for physicians aged 50-59 (11.1% to 11.5%), and 12.1% for physicians aged ≥60 (11.6% to 12.5%). Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. Similar patterns were observed among general internists and in several sensitivity analyses.Conclusions Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients.
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Affiliation(s)
- Yusuke Tsugawa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Joseph P Newhouse
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Harvard Kennedy School, Cambridge, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | | | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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25
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Álvarez-García J, Salamanca-Bautista P, Ferrero-Gregori A, Montero-Pérez-Barquero M, Puig T, Aramburu-Bodas Ó, Vázquez R, Formiga F, Delgado J, Arias-Jiménez JL, Vives-Borrás M, Cerqueiro González JM, Manzano L, Cinca J. Impacto pronóstico de la especialidad en el paciente ambulatorio con insuficiencia cardiaca: un análisis emparejado de los registros REDINSCOR y RICA. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.09.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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27
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Álvarez-García J, Salamanca-Bautista P, Ferrero-Gregori A, Montero-Pérez-Barquero M, Puig T, Aramburu-Bodas Ó, Vázquez R, Formiga F, Delgado J, Arias-Jiménez JL, Vives-Borrás M, Cerqueiro González JM, Manzano L, Cinca J. Prognostic Impact of Physician Specialty on the Prognosis of Outpatients With Heart Failure: Propensity Matched Analysis of the REDINSCOR and RICA Registries. ACTA ACUST UNITED AC 2017; 70:347-354. [PMID: 28189543 DOI: 10.1016/j.rec.2016.12.026] [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: 04/12/2016] [Accepted: 09/19/2016] [Indexed: 12/16/2022]
Abstract
INTRODUCTION AND OBJECTIVES The specialty treating patients with heart failure (HF) has a prognostic impact in the hospital setting but this issue remains under debate in the ambulatory environment. We aimed to compare the clinical profile and outcomes of outpatients with HF treated by cardiologists or internists. METHODS We analyzed the clinical, electrocardiogram, laboratory, and echocardiographic data of 2 prospective multicenter Spanish cohorts of outpatients with HF treated by cardiologists (REDINSCOR, n=2150) or by internists (RICA, n=1396). Propensity score matching analysis was used to test the influence of physician specialty on outcome. RESULTS Cardiologist-treated patients were often men, were younger, and had ischemic etiology and reduced left ventricular ejection fraction (LVEF). Patients followed up by internists were predominantly women, were older, and a higher percentage had preserved LVEF and associated comorbidities. The 9-month mortality was lower in the REDINSCOR cohort (11.6% vs 16.9%; P<.001), but the 9-month HF-readmission rates were similar (15.7% vs 16.9%; P=.349). The propensity matching analysis selected 558 pairs of comparable patients and continued to show significantly lower 9-month mortality in the cardiology cohort (12.0% vs 18.8%; RR, 0.64; 95% confidence interval [95%CI], 0.48-0.85; P=.002), with no relevant differences in the 9-month HF-readmission rate (18.1% vs 17.2%; RR, 0.95; 95%CI, 0.74-1.22; P=.695). CONCLUSIONS Age, sex, LVEF and comorbidities were major determinants of specialty-related referral in HF outpatients. An in-depth propensity matched analysis showed significantly lower 9-month mortality in the cardiologist cohort.
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Affiliation(s)
- Jesús Álvarez-García
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain.
| | | | - Andreu Ferrero-Gregori
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Teresa Puig
- Servicio de Epidemiología y Salud Pública, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Óscar Aramburu-Bodas
- Servicio de Medicina Interna, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Rafael Vázquez
- Servicio de Cardiología, Hospital Puerta del Mar, Cádiz, Spain
| | - Francesc Formiga
- Servicio de Medicina Interna, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Juan Delgado
- Servicio de Cardiología, Hospital 12 de Octubre, Madrid, Spain
| | | | - Miquel Vives-Borrás
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Luis Manzano
- Servicio de Medicina Interna, Hospital Ramón y Cajal, Madrid, Spain
| | - Juan Cinca
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
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28
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Pathik B, De Pasquale CG, McGavigan AD, Sinhal A, Vaile J, Tideman PA, Jones D, Bridgman C, Selvanayagam JB, Heddle W, Chew DP. Subspecialisation in cardiology care and outcome: should clinical services be redesigned, again? Intern Med J 2016; 46:158-66. [PMID: 26387874 DOI: 10.1111/imj.12909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/01/2015] [Accepted: 09/06/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Inpatient management of cardiac patients by cardiologists results in reduced mortality and hospitalisation. With increasing subspecialisation of the field because of growing management complexity and use of technological innovations, the impact of sub-specialisation on patient outcomes is unclear. AIM To investigate whether management by subspecialty cardiologists impacts the outcomes of patients with subspecialty-specific diseases. METHODS All patients admitted to a tertiary centre over nine years with a diagnosis of heart failure, acute coronary syndrome (ACS) or primary arrhythmia were reviewed. The outcomes of these patients managed by cardiologists subspecialised in their admission diagnosis (heart failure specialists, interventionalists and electrophysiologists) were compared with those treated by general cardiologists. RESULTS Heart failure was diagnosed in 1704 patients, ACS in 7763 and arrhythmia in 4398. There was no difference in length of stay (LOS) (P = 0.26), mortality (P = 0.57) or cardiovascular readmissions (P = 0.50) in heart failure patients treated by general cardiologists compared with subspecialists. In ACS patients, subspecialty management was associated with reduced LOS, cardiovascular readmissions and mortality (all P < 0.05). This reduction in mortality was seen mainly in lower risk patients (P < 0.05). There was a reduction in LOS and cardiovascular readmissions in arrhythmia patients receiving subspecialty management (both P < 0.05) but no difference in mortality (P = 0.14). ACS patients managed by interventionalists were more likely to undergo coronary intervention (P < 0.05). Electrophysiologists more frequently referred patients for catheter ablation and pacemaker implantation than general cardiologists (P < 0.05). CONCLUSIONS The benefits of subspecialty care seem attributable to the appropriate selection of patients who would benefit from technological innovations in care. These results suggest that the development of healthcare systems which align cardiovascular disease with the subspecialist may be more effective.
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Affiliation(s)
- B Pathik
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - C G De Pasquale
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - A D McGavigan
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - A Sinhal
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - J Vaile
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - P A Tideman
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - D Jones
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - C Bridgman
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - J B Selvanayagam
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - W Heddle
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - D P Chew
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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29
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Frankenstein L, Fröhlich H, Cleland JGF. Multidisciplinary Approach for Patients Hospitalized With Heart Failure. ACTA ACUST UNITED AC 2016; 68:885-91. [PMID: 26409892 DOI: 10.1016/j.rec.2015.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/04/2015] [Indexed: 12/24/2022]
Abstract
Acute heart failure describes the rapid deterioration, over minutes, days or hours, of symptoms and signs of heart failure. Its management is an interdisciplinary challenge that requires the cooperation of various specialists. While emergency providers, (interventional) cardiologists, heart surgeons, and intensive care specialists collaborate in the initial stabilization of acute heart failure patients, the involvement of nurses, discharge managers, and general practitioners in the heart failure team may facilitate the transition from inpatient care to the outpatient setting and improve acute heart failure readmission rates. This review highlights the importance of a multidisciplinary approach to acute heart failure with particular focus on the chain-of-care delivered by the various services within the healthcare system.
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Affiliation(s)
- Lutz Frankenstein
- Department of Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Hanna Fröhlich
- Department of Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany
| | - John G F Cleland
- National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom
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Scrutinio D, Passantino A, Guida P, Ammirati E, Oliva F, Braga SS, La Rovere MT, Lagioia R, Frigerio M. Prognostic impact of comorbidities in hospitalized patients with acute exacerbation of chronic heart failure. Eur J Intern Med 2016; 34:63-67. [PMID: 27263064 DOI: 10.1016/j.ejim.2016.05.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 05/13/2016] [Accepted: 05/17/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND To assess the impact of comorbidities on long-term all-cause mortality in patients hospitalized with exacerbated signs/symptoms of previously chronic stable HF (AE-CHF). METHODS 1119 patients admitted for AE-CHF and with NT-proBNP levels >900pg/mL were enrolled. Univariable and multivariable Cox analyses were performed to assess the association of age, gender, hypertension, diabetes, obesity, atrial fibrillation, coronary heart disease (CHD), chronic obstructive pulmonary disease, previous cerebrovascular accidents, chronic liver disease (CLD), thyroid disease, renal impairment (RI), and anemia with 3-year all-cause mortality. RESULTS During the follow-up, 441 patients died and 126 underwent heart transplantation (HT) or ventricular assist device (VAD) implantation. 45.8% of the fatal events and 52.4% of HT/VAD implantations occurred within 180days after admission. Increasing age (p=.012), obesity (p=.037), atrial fibrillation (p=.030), CHD (p=.015), CLD (p=.001), RI (p<.001), and anemia (p<.001) were independently associated with 3-year all-cause mortality. Most of the prognostic impact of CHD, took place within the first 180days after admission. Male gender was associated with mortality beyond 180days. Compared with normal weight, obesity was associated with better overall survival. Obese patients, however, had significantly lower NT-proBNP concentrations and less frequently presented with hypotension, hyponatremia, and severe left ventricular systolic dysfunction, despite a similar prevalence of severe dyspnea at admission. CONCLUSIONS Several comorbidities are associated with long-term risk of death in hospitalized patients with worsening HF, although the nature of this association does appear to be complex. Our data may help to raise awareness about the clinical relevance of comorbid conditions.
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Affiliation(s)
- Domenico Scrutinio
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy.
| | - Andrea Passantino
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy
| | - Pietro Guida
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy
| | - Enrico Ammirati
- Cardiothoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan, Italy; San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Fabrizio Oliva
- Cardiothoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Simona Sarzi Braga
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Tradate, Varese, Italy
| | - Maria Teresa La Rovere
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Montescano, Pavia, Italy
| | - Rocco Lagioia
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy
| | - Maria Frigerio
- Cardiothoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan, Italy
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Pintalhao M, Castro‐Chaves P, Vasques‐Novoa F, Gonçalves F, Mendonça L, Fontes‐Carvalho R, Lourenço P, Almeida P, Leite‐Moreira A, Bettencourt P. Relaxin serum levels in acute heart failure are associated with pulmonary hypertension and right heart overload. Eur J Heart Fail 2016; 19:218-225. [DOI: 10.1002/ejhf.611] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 05/24/2016] [Accepted: 06/10/2016] [Indexed: 01/05/2023] Open
Affiliation(s)
- Mariana Pintalhao
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Internal Medicine DepartmentSão João Hospital Centre Porto Portugal
- Cardiovascular Research Centre Portugal
| | - Paulo Castro‐Chaves
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Internal Medicine DepartmentSão João Hospital Centre Porto Portugal
- Cardiovascular Research Centre Portugal
| | - Francisco Vasques‐Novoa
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Internal Medicine DepartmentSão João Hospital Centre Porto Portugal
- Cardiovascular Research Centre Portugal
| | - Francisco Gonçalves
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
| | - Luís Mendonça
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Cardiovascular Research Centre Portugal
| | - Ricardo Fontes‐Carvalho
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Cardiovascular Research Centre Portugal
- Cardiology DepartmentGaia Hospital Centre Gaia Portugal
| | - Patrícia Lourenço
- Internal Medicine DepartmentSão João Hospital Centre Porto Portugal
- Cardiovascular Research Centre Portugal
| | - Pedro Almeida
- Cardiology DepartmentSão João Hospital Centre Porto Portugal
| | - Adelino Leite‐Moreira
- Department of Physiology and Cardiothoracic SurgeryFaculty of Medicine, University of Porto Portugal
- Cardiovascular Research Centre Portugal
- Cardiothoracic Surgery DepartmentSão João Hospital Centre Porto Portugal
| | - Paulo Bettencourt
- Internal Medicine DepartmentSão João Hospital Centre Porto Portugal
- Cardiovascular Research Centre Portugal
- Department of Medicine, Faculty of MedicineUniversity of Porto Portugal
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Wu Y, Zhong W, Cui N, Johnson CM, Xing H, Zhang S, Jiang C. Characterization of Rett Syndrome-like phenotypes in Mecp2-knockout rats. J Neurodev Disord 2016; 8:23. [PMID: 27313794 PMCID: PMC4910223 DOI: 10.1186/s11689-016-9156-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/02/2016] [Indexed: 12/04/2022] Open
Abstract
Background Rett Syndrome (RTT) is a neurodevelopmental disease caused by the disruption of the MECP2 gene. Several mouse models of RTT have been developed with Mecp2 disruptions. Although the mouse models are widely used in RTT research, results obtained need to be validated in other species. Therefore, we performed these studies to characterize phenotypes of a novel Mecp2−/Y rat model and compared them with the Mecp2tm1.1Bird mouse model of RTT. Methods RTT-like phenotypes were systematically studied and compared between Mecp2−/Y rats and Mecp2−/Y mice. In-cage conditions of the rats were monitored. Grip strength and spontaneous locomotion were used to evaluate the motor function. Three-chamber test was performed to show autism-type behaviors. Breathing activity was recorded with the plethysmograph. Individual neurons in the locus coeruleus (LC) were studied in the whole-cell current clamp. The lifespan of the rats was determined with their survival time. Results Mecp2−/Y rats displayed growth retardation, malocclusion, and lack of movements, while hindlimb clasping was not seen. They had weaker forelimb grip strength and a lower rate of locomotion than the WT littermates. Defects in social interaction with other rats were obvious. Breathing frequency variation and apnea in the null rats were significantly higher than in the WT. LC neurons in the null rats showed excessive firing activity. A half of the null rats died in 2 months. Most of the RTT-like symptoms were comparable to those seen in Mecp2−/Y mice, while some appeared more or less severe. The findings that most RTT-like symptoms exist in the rat model with moderate variations and differences from the mouse models support the usefulness of both Mecp2−/Y rodent models. Conclusions The novel Mecp2−/Y rat model recapitulated numerous RTT-like symptoms as Mecp2−/Y mouse models did, which makes it a valuable alternative model in the RTT studies when the body size matters.
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Affiliation(s)
- Yang Wu
- Department of Biology, Georgia State University, 50 Decatur Street, Atlanta, GA 30302 USA
| | - Weiwei Zhong
- Department of Biology, Georgia State University, 50 Decatur Street, Atlanta, GA 30302 USA
| | - Ningren Cui
- Department of Biology, Georgia State University, 50 Decatur Street, Atlanta, GA 30302 USA
| | - Christopher M Johnson
- Department of Biology, Georgia State University, 50 Decatur Street, Atlanta, GA 30302 USA
| | - Hao Xing
- Department of Biology, Georgia State University, 50 Decatur Street, Atlanta, GA 30302 USA
| | - Shuang Zhang
- Department of Biology, Georgia State University, 50 Decatur Street, Atlanta, GA 30302 USA
| | - Chun Jiang
- Department of Biology, Georgia State University, 50 Decatur Street, Atlanta, GA 30302 USA
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Rose-Felker K, Kelleman MS, Campbell RM, Oster ME, Sachdeva R. Appropriate Use and Clinical Impact of Echocardiographic “Evaluation of Murmur” in Pediatric Patients. CONGENIT HEART DIS 2016; 11:721-726. [DOI: 10.1111/chd.12379] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Kirsten Rose-Felker
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Michael S. Kelleman
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Robert M. Campbell
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Matthew E. Oster
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
| | - Ritu Sachdeva
- Department of Pediatrics; Emory University School of Medicine; Atlanta Ga USA
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta; Atlanta Ga USA
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Iyngkaran P, Beneby GS. Toward phase 4 trials in heart failure: A social and corporate responsibility of the medical profession. World J Methodol 2015; 5:179-184. [PMID: 26713277 PMCID: PMC4686414 DOI: 10.5662/wjm.v5.i4.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 09/07/2015] [Accepted: 10/27/2015] [Indexed: 02/06/2023] Open
Abstract
Congestive heart failure (CHF) is a chronic condition, requiring polypharmacy, allied health supports and regular monitoring. All these factors are needed to ensure compliance and to deliver the positive outcomes demonstrated from randomized controlled trials. Unfortunately many centers around the world are unable to match trial level support. The outcomes for many communities are thus unclear. Research design factors in post-marketing surveillance to address this issue. Phase 4 studies is the name given to trials designed to obtain such community level data and thus address issues of external validity. CHF phase 4 studies are relatively underutilized. We feel the onus for this research lies with the health profession. In this commentary we provide arguments as to why phase 4 studies should be viewed as a social and corporate responsibility of health professional that care for clients with CHF.
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Affiliation(s)
- Sean van Diepen
- Divisions of Critical Care and Cardiology, University of Alberta, Edmonton, Alberta, Canada (S.D.) Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada (S.D.)
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van Diepen S, Bakal JA, Lin M, Kaul P, McAlister FA, Ezekowitz JA. Variation in critical care unit admission rates and outcomes for patients with acute coronary syndromes or heart failure among high- and low-volume cardiac hospitals. J Am Heart Assoc 2015; 4:e001708. [PMID: 25725089 PMCID: PMC4392446 DOI: 10.1161/jaha.114.001708] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Little is known about cross‐hospital differences in critical care units admission rates
and related resource utilization and outcomes among patients hospitalized with acute coronary
syndromes (ACS) or heart failure (HF). Methods and Results Using a population‐based sample of 16 078 patients admitted to a critical care unit with a
primary diagnosis of ACS (n=14 610) or HF (n=1467) between April 1, 2003 and March 31,
2013 in Alberta, Canada, we stratified hospitals into high (>250), medium (200 to 250), or
low (<200) volume based on their annual volume of all ACS and HF hospitalization. The
percentage of hospitalized patients admitted to critical care units varied across low, medium, and
high‐volume hospitals for both ACS and HF as follows: 77.9%, 81.3%, and
76.3% (P<0.001), and 18.0%, 16.3%, and 13.0%
(P<0.001), respectively. Compared to low‐volume units, critical care
patients with ACS and HF admitted to high‐volume hospitals had shorter mean critical care
stays (56.6 versus 95.6 hours, P<0.001), more critical care procedures (1.9
versus 1.2 per patient, <0.001), and higher resource‐intensive weighting (2.8 versus
1.5, P<0.001). No differences in in‐hospital mortality (5.5%
versus 6.2%, adjusted odds ratio 0.93; 95% CI, 0.61 to 1.41) were observed between
high‐ and low‐volume hospitals; however, 30‐day cardiovascular readmissions
(4.6% versus 6.8%, odds ratio 0.77; 95% CI, 0.60 to 0.99) and cardiovascular
emergency‐room visits (6.6% versus 9.5%, odds ratio 0.80; 95% CI, 0.69
to 0.94) were lower in high‐volume compared to low‐volume hospitals. Outcomes
stratified by ACS or HF admission diagnosis were similar. Conclusions Cardiac patients hospitalized in low‐volume hospitals were more frequently admitted to
critical care units and had longer hospitals stays despite lower resource‐intensive
weighting. These findings may provide opportunities to standardize critical care utilization for ACS
and HF patients across high‐ and low‐volume hospitals.
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Affiliation(s)
- Sean van Diepen
- Divisions of Critical Care and Cardiology, University of Alberta, Edmonton, Alberta, Canada (S.D.) Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada (S.D., J.A.B., M.L., P.K., F.A.M.A., J.A.E.)
| | - Jeffrey A Bakal
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada (S.D., J.A.B., M.L., P.K., F.A.M.A., J.A.E.)
| | - Meng Lin
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada (S.D., J.A.B., M.L., P.K., F.A.M.A., J.A.E.)
| | - Padma Kaul
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada (S.D., J.A.B., M.L., P.K., F.A.M.A., J.A.E.) Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (P.K., J.A.E.)
| | - Finlay A McAlister
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada (S.D., J.A.B., M.L., P.K., F.A.M.A., J.A.E.) Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Canada (F.A.M.A.)
| | - Justin A Ezekowitz
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada (S.D., J.A.B., M.L., P.K., F.A.M.A., J.A.E.) Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (P.K., J.A.E.)
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Sasaki N, Kunisawa S, Otsubo T, Ikai H, Fushimi K, Yasumura Y, Kimura T, Imanaka Y. The relationship between the number of cardiologists and clinical practice patterns in acute heart failure: a cross-sectional observational study. BMJ Open 2014; 4:e005988. [PMID: 25550294 PMCID: PMC4281546 DOI: 10.1136/bmjopen-2014-005988] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Despite the increasing burden of acute heart failure (AHF) on healthcare systems, the association between centralised cardiovascular specialist care and the quality of AHF care remains unknown. We examine the relationship between the number of cardiologists per hospital and hospital practice variations. DESIGN, SETTING AND PARTICIPANTS In a retrospective observational study, we analysed 38,668 patients with AHF admitted to 546 Japanese acute care hospitals between 2010 and 2011 using the Diagnosis Procedure Combination administrative claims database. Sample hospitals were categorised into four groups according to the number of cardiologists per facility (none, 1-4, 5-9 and ≥10). To confirm the capability of administrative data to identify patients with AHF, the ≥10 cardiologists group was compared with two recent clinical registries in Japan. MAIN OUTCOME MEASURES Using multivariable logistic regression models, patient risk-adjusted in-hospital mortality rates and age-sex-adjusted ORs of various AHF therapies were calculated and compared among four hospital groups. RESULTS The ≥10 cardiologists group of hospitals from the administrative database had similar major underlying disease incidence and therapeutic practices to those of the clinical registry hospitals. Age-adjusted and sex-adjusted ORs of various AHF therapies in the four hospital groups revealed wide practice variations associated with the number of cardiologists. Adjusted in-hospital mortality demonstrated a negative association with the number of cardiologists. In addition, the different hospital-level distribution patterns of specific therapeutic practices illustrated the diffusion process of therapies across facilities. CONCLUSIONS Wide practice variations in AHF care were associated with the number of cardiologists per facility, indicating a possible relationship between the quality of AHF care and manpower resources. The provision of recommended therapies increased together with the number of cardiologists.
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Affiliation(s)
- Noriko Sasaki
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tetsuya Otsubo
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroshi Ikai
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshio Yasumura
- Division of Cardiology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Affiliation(s)
- Karen E. Joynt
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA; and United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Washington, DC
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