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Mentias A, Peterson ED, Keshvani N, Kumbhani DJ, Yancy C, Morris A, Allen L, Girotra S, Fonarow GC, Starling R, Alvarez P, Desai M, Cram P, Pandey A. Achieving Equity in Hospital Performance Assessments Using Composite Race-Specific Measures of Risk-Standardized Readmission and Mortality Rates for Heart Failure. Circulation 2023; 147:1121-1133. [PMID: 37036906 PMCID: PMC10765408 DOI: 10.1161/circulationaha.122.061995] [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: 08/06/2022] [Accepted: 01/23/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND The contemporary measures of hospital performance for heart failure hospitalization and 30-day risk-standardized readmission rate (RSRR) and risk-standardized mortality rate (RSMR) are estimated using the same risk adjustment model and overall event rate for all patients. Thus, these measures are mainly driven by the care quality and outcomes for the majority racial and ethnic group, and may not adequately represent the hospital performance for patients of Black and other races. METHODS Fee-for-service Medicare beneficiaries from January 2014 to December 2019 hospitalized with heart failure were identified. Hospital-level 30-day RSRR and RSMR were estimated using the traditional race-agnostic models and the race-specific approach. The composite race-specific performance metric was calculated as the average of the RSRR/RMSR measures derived separately for each race and ethnicity group. Correlation and concordance in hospital performance for all patients and patients of Black and other races were assessed using the composite race-specific and race-agnostic metrics. RESULTS The study included 1 903 232 patients (75.7% White [n=1 439 958]; 14.5% Black [n=276 684]; and 9.8% other races [n=186 590]) with heart failure from 1860 hospitals. There was a modest correlation between hospital-level 30-day performance metrics for patients of White versus Black race (Pearson correlation coefficient: RSRR=0.42; RSMR=0.26). Compared with the race-agnostic RSRR and RSMR, composite race-specific metrics for all patients demonstrated stronger correlation with RSRR (correlation coefficient: 0.60 versus 0.74) and RSMR (correlation coefficient: 0.44 versus 0.51) for Black patients. Concordance in hospital performance for all patients and patients of Black race was also higher with race-specific (versus race-agnostic) metrics (RSRR=64% versus 53% concordantly high-performing; 61% versus 51% concordantly low-performing). Race-specific RSRR and RSMR metrics (versus race-agnostic) led to reclassification in performance ranking of 35.8% and 39.2% of hospitals, respectively, with better 30-day and 1-year outcomes for patients of all race groups at hospitals reclassified as high-performing. CONCLUSIONS Among patients hospitalized with heart failure, race-specific 30-day RSMR and RSRR are more equitable in representing hospital performance for patients of Black and other races.
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Affiliation(s)
- Amgad Mentias
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Eric D. Peterson
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Dharam J. Kumbhani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Clyde Yancy
- Division of Cardiology, Northwestern University School of Medicine, Chicago, IL
| | - Alanna Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Larry Allen
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Denver, CO
| | - Saket Girotra
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Gregg C. Fonarow
- Ahmanson Cardiomyopathy Center, UCLA School of Medicine, Los Angeles, CA
| | - Randall Starling
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Paulino Alvarez
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Milind Desai
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Peter Cram
- Department of Internal Medicine, UT Medical Branch, Galveston, TX
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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Luedike P, Papathanasiou M, Schmack B, Kamler M, Perings C, Ruhparwar A, Rassaf T. Structural components for the development of a heart failure network. ESC Heart Fail 2022; 10:1545-1554. [PMID: 36484360 DOI: 10.1002/ehf2.14266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022] Open
Abstract
Diagnosis and treatment of heart failure (HF) is challenging, and development of specialized HF networks is mandatory to warrant broad access to guideline directed therapies for patients. Numerous national cardiovascular societies recommend a three-level association of health care providers. This comprises tertiary academic centres, specialized HF clinics and specialized general cardiologists to cover the large spectrum of HF severity and entities. Although this idea of a multi-level care is widely accepted, optimal approach to build and implement a HF network service needs further definition. The core principle is that of network healthcare facilities that also consider regional peculiarities and that implements academic standards, quality indicators (QIs), interdisciplinarity and reimbursement strategies. These determinants of trans-sectoral healthcare need to be embedded in a network that provides sustainability and that incorporates QIs to objectify the efficacy of specific measures. The basis of a HF-network should be a certification system of the respective national HF association to warrant guideline standards and to prevent development of regional hierarchies or dependencies between members. This nationwide framework needs to be complemented by a federal system of regional networks, which also takes local demands into account. These regional units should incorporate digital communication and interaction pathways, structured educational programmes, certified telehealth concepts and follow-up algorithms to meet the requirements of sustainability and efficacy. We here summarize different components of HF networks and introduce the structure and development philosophy of the RUHR-HF-network that constitutes the first certified HF-clinics-network in the Ruhr area-the largest metropolitan area in Germany.
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Affiliation(s)
- Peter Luedike
- West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine University Hospital Essen Essen Germany
| | - Maria Papathanasiou
- West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine University Hospital Essen Essen Germany
| | - Bastian Schmack
- West German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery University Hospital Essen Essen Germany
| | - Markus Kamler
- West German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery University Hospital Essen Essen Germany
| | - Christian Perings
- Katholisches Klinikum Lünen‐Werne, Medizinische Klinik I, Kardiologie, Pneumologie und Intensivmedizin St. Marien‐Hospital Lünen Germany
| | - Arjang Ruhparwar
- West German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery University Hospital Essen Essen Germany
| | - Tienush Rassaf
- West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine University Hospital Essen Essen Germany
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Aktaa S, Batra G, Wallentin L, Baigent C, Erlinge D, James S, Ludman P, Maggioni AP, Price S, Weston C, Casadei B, Gale CP. European Society of Cardiology methodology for the development of quality indicators for the quantification of cardiovascular care and outcomes. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:4-13. [PMID: 32845314 PMCID: PMC8727982 DOI: 10.1093/ehjqcco/qcaa069] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/06/2020] [Accepted: 08/19/2020] [Indexed: 01/29/2023]
Abstract
AIMS It is increasingly recognized that tools are required for assessing and benchmarking quality of care in order to improve it. The European Society of Cardiology (ESC) is developing a suite of quality indicators (QIs) to evaluate cardiovascular care and support the delivery of evidence-based care. This paper describes the methodology used for their development. METHODS AND RESULTS We propose a four-step process for the development of the ESC QIs. For a specific clinical area with a gap in care delivery, the QI development process includes: (i) the identification of key domains of care by constructing a conceptual framework of care; (ii) the construction of candidate QIs by conducting a systematic review of the literature; (iii) the selection of a final set of QIs by obtaining expert opinions using the modified Delphi method; and (iv) the undertaking of a feasibility assessment by evaluating different ways of defining the QI specifications for the proposed data collection source. For each of the four steps, key methodological areas need to be addressed to inform the implementation process and avoid misinterpretation of the measurement results. CONCLUSION Detailing the methodology for the ESC QIs construction enables healthcare providers to develop valid and feasible metrics to measure and improve the quality of cardiovascular care. As such, high-quality evidence may be translated into clinical practice and the 'evidence-practice' gap closed.
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Affiliation(s)
| | - Gorav Batra
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala 751 85, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala 751 85, Sweden
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund SE-221 85, Sweden
| | - Stefan James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala 751 85, Sweden
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Aldo P Maggioni
- National Association of Hospital Cardiologists Research Center (ANMCO), Florence 50121, Italy
| | - Susanna Price
- Department of Adult Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, Royal Brompton Hospital, National Heart & Lung Institute, Imperial College, London SW3 6NP, UK
| | - Clive Weston
- Department of Cardiology, Hywel Dda University Health Board, Wales SA6 6NL, UK
| | - Barbara Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds LS2 9JT, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
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Burgon T, Casebeer L, Aasen H, Valdenor C, Tamondong-Lachica D, de Belen E, Paculdo D, Peabody J. Measuring and Improving Evidence-Based Patient Care Using a Web-Based Gamified Approach in Primary Care (QualityIQ): Randomized Controlled Trial. J Med Internet Res 2021; 23:e31042. [PMID: 34941547 PMCID: PMC8738991 DOI: 10.2196/31042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/21/2021] [Accepted: 10/29/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Unwarranted variability in clinical practice is a challenging problem in practice today, leading to poor outcomes for patients and low-value care for providers, payers, and patients. OBJECTIVE In this study, we introduced a novel tool, QualityIQ, and determined the extent to which it helps primary care physicians to align care decisions with the latest best practices included in the Merit-Based Incentive Payment System (MIPS). METHODS We developed the fully automated QualityIQ patient simulation platform with real-time evidence-based feedback and gamified peer benchmarking. Each case included workup, diagnosis, and management questions with explicit evidence-based scoring criteria. We recruited practicing primary care physicians across the United States into the study via the web and conducted a cross-sectional study of clinical decisions among a national sample of primary care physicians, randomized to continuing medical education (CME) and non-CME study arms. Physicians "cared" for 8 weekly cases that covered typical primary care scenarios. We measured participation rates, changes in quality scores (including MIPS scores), self-reported practice change, and physician satisfaction with the tool. The primary outcomes for this study were evidence-based care scores within each case, adherence to MIPS measures, and variation in clinical decision-making among the primary care providers caring for the same patient. RESULTS We found strong, scalable engagement with the tool, with 75% of participants (61 non-CME and 59 CME) completing at least 6 of 8 total cases. We saw significant improvement in evidence-based clinical decisions across multiple conditions, such as diabetes (+8.3%, P<.001) and osteoarthritis (+7.6%, P=.003) and with MIPS-related quality measures, such as diabetes eye examinations (+22%, P<.001), depression screening (+11%, P<.001), and asthma medications (+33%, P<.001). Although the CME availability did not increase enrollment in the study, participants who were offered CME credits were more likely to complete at least 6 of the 8 cases. CONCLUSIONS Although CME availability did not prove to be important, the short, clinically detailed case simulations with real-time feedback and gamified peer benchmarking did lead to significant improvements in evidence-based care decisions among all practicing physicians. TRIAL REGISTRATION ClinicalTrials.gov NCT03800901; https://clinicaltrials.gov/ct2/show/NCT03800901.
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Affiliation(s)
| | | | | | | | | | | | | | - John Peabody
- QURE Healthcare, San Francisco, CA, United States.,School of Medicine, University of California, San Francisco, San Francisco, CA, United States
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Piña IL, Allen LA, Desai NR. Policy and Payment Challenges in the Postpandemic Treatment of Heart Failure: Value-Based Care and Telehealth. J Card Fail 2021; 28:835-844. [PMID: 34520854 PMCID: PMC8434774 DOI: 10.1016/j.cardfail.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/13/2022]
Abstract
Increasing patient and therapeutic complexity have created both challenges and opportunities for heart failure care. Within this background, the coronavirus disease-2019 pandemic has disrupted care as usual, accelerating the need for transition from volume-based to value-based care, and demanding a rapid expansion of telehealth and remote care for heart failure. Patients, clinicians, health systems, and payors have by necessity become more invested in these issues. Herein we review recent changes in health care policy related to the movement from volume to value-based payment and from in-person to remote care delivery.
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Affiliation(s)
- Ileana L Piña
- Central Michigan University, Mount Pleasant, Michigan.
| | - Larry A Allen
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Nihar R Desai
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2693] [Impact Index Per Article: 897.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Farooque U, Lohano AK, Kumar A, Karimi S, Yasmin F, Bollampally VC, Ranpariya MR. Validity of National Institutes of Health Stroke Scale for Severity of Stroke to Predict Mortality Among Patients Presenting With Symptoms of Stroke. Cureus 2020; 12:e10255. [PMID: 33042693 PMCID: PMC7536102 DOI: 10.7759/cureus.10255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction Cerebrovascular accident (CVA), also termed as stroke, is the third leading cause of mortality and the most common cause of disability globally. The National Institutes of Health Stroke Scale (NIHSS) is a valid assessment tool utilized to determine the severity of the stroke and can be used to prioritize patients to design treatment plans, rehabilitation, and better clinical outcomes. The primary objective of this study was to determine the validity of the NIHSS to predict mortality among patients presenting with symptoms of a stroke. Material and methods This was a descriptive case-series conducted over a period of six months between September 2019 and February 2020 at a tertiary care hospital in Nawabshah, Pakistan. The sample population included 141 patients admitted within 24 hours of the onset of symptoms of a stroke. A neurological examination of the patients was performed. On admission, stroke severity was evaluated with the NIHSS. After an initial clinical evaluation, patients underwent a non-enhanced computed tomography (CT) scan of the brain. The score of NIHSS and mortality at 72 hours were recorded on the pre-defined proforma by the investigators. All statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 23.0 (Armonk, NY: IBM Corp). Results The mean age of the participants was 52.37±8.61 years. 68.1% of patients were hypertensive, 29.1% were diabetic, and 36.9% of patients were found with hyperlipidemia. The mortality rate was 41.1%. The mean NIHSS score was 16.68±6.72 points. The findings of this study demonstrated that the score of 14.9% cases was good (0-6 points), the score of 29.1% cases was moderate (7-15 points), and the score of 56% cases was poor (≥16 points). There was a significant association of NIHSS score with mortality (p<0.001). Conclusions Baseline NIHSS score has a profound association with mortality after acute stroke. It can help clinicians decide whether to provide thrombolytic treatment, rehabilitation or a combination of both in these patients and decrease the mortality rate. However, more studies are needed to potentiate these conclusions.
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Affiliation(s)
- Umar Farooque
- Neurology, Dow University of Health Sciences, Karachi, PAK
| | - Ashok Kumar Lohano
- Medicine, Peoples University of Medical and Health Sciences for Women, Nawabshah, PAK
| | - Ashok Kumar
- Internal Medicine, Peoples University of Medical and Health Sciences for Women, Nawabshah, PAK
| | - Sundas Karimi
- General Surgery, Combined Military Hospital, Karachi, PAK
| | - Farah Yasmin
- Cardiology, Dow University of Health Sciences, Karachi, PAK
| | | | - Margil R Ranpariya
- Internal Medicine, Surat Municipal Institute of Medical Education and Research, Surat, IND
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Castellanos EH, Orlando A, Ma X, Parikh RB, O'Connell G, Meropol NJ, Hamrick J, Adamson BJS. Evaluating the Impact of Oncology Care Model Reporting Requirements on Biomarker Testing and Treatment. JCO Oncol Pract 2020; 16:e1216-e1221. [PMID: 32496874 PMCID: PMC7564129 DOI: 10.1200/jop.19.00747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Oncology Care Model (OCM) is Medicare's first alternative payment model program for patients with cancer. As of October 2017, participating practices were required to report biomarker testing of patients with advanced non-small-cell lung cancer (aNSCLC). Our objective was to evaluate the effect of this OCM reporting requirement on quality of care. METHODS We selected patients with aNSCLC receiving care in practices in a nationwide de-identified electronic health record-derived database. We used an adjusted difference-in-differences (DID) logistic regression model to compare changes in biomarker testing rates (EGFR, ROS1, and ALK) and receipt of biomarker-guided therapy between patients in OCM versus non-OCM practices, before and after OCM implementation. RESULTS The analysis included 14,048 patients from 45 OCM practices (n = 8,151) and 105 non-OCM practices (n = 5,897). The overall unadjusted rates for biomarker testing and receipt of biomarker-guided therapy increased over the study period (2011-2018) in both OCM (55.5% v 71.6%; 89.8% v 94.6%, respectively) and non-OCM (55.2% v 69.7%; 90.1% v 95.2%, respectively) practices. In the adjusted DID model, the rates of biomarker testing (odds ratio [OR], 1.09 [95% CI, 0.88 to 1.34]; P = .45) and receipt of biomarker-guided therapy (OR, 0.87 [95% CI, 0.52 to 1.45]; P = .58) were similar between OCM and non-OCM practices. CONCLUSION OCM biomarker documentation and reporting requirements did not appear to increase the proportions of patients with aNSCLC who underwent testing or who received biomarker-guided therapy in OCM versus non-OCM practices.
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Khera R. Do or Do Not, There Is No Try. Circ Cardiovasc Qual Outcomes 2020; 13:e006693. [DOI: 10.1161/circoutcomes.120.006693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
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Affiliation(s)
- Vinay Kini
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
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12
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Lin D, Liu S, Ruhm CJ. Opioid Deaths and Local Healthcare Intensity: A Longitudinal Analysis of the U.S. Population, 2003-2014. Am J Prev Med 2020; 58:50-58. [PMID: 31862102 DOI: 10.1016/j.amepre.2019.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION This study examines the association between local healthcare intensity and drug death rates. METHODS County-level drug death rates were computed for 2003-2014 using vital statistics data adjusted for incomplete reporting of drug involvement. A county-level healthcare intensity index was constructed using Dartmouth Atlas of Health Care data. Linear regression and dose-response models were estimated for all residents and for population subgroups to analyze the relationship between healthcare intensity and drug death rates, as well as for 7 indicators of healthcare quality. Data collection and analysis were conducted in 2018 and 2019. RESULTS Linear estimates indicated a positive correlation between healthcare intensity and opioid-involved drug death rates. Dose-response models revealed that the association was especially pronounced for the 2 highest healthcare intensity quintiles. Moving from the lowest to the highest healthcare intensity quintile was associated with a 2.14 (95% CI=1.56, 2.72) per 100,000 rise in opioid-involved drug death rates and a 25.1% (95% CI=18.3%, 31.9%) increase from the base rate of 8.54 per 100,000. Corresponding associations were larger in absolute terms for individuals who were male, white, aged 20-44 years, and not college educated than for their counterparts, but similar in percentages, except for 2 minority racial groups and seniors. Non-opioid drug death rates were unrelated to healthcare intensity. High healthcare intensity was associated with worse healthcare quality for 6 of 7 indicators. CONCLUSIONS In the U.S., between 2003 and 2014, high medical care intensity was associated with elevated opioid death rates and lower healthcare quality.
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Affiliation(s)
- Dajun Lin
- American Institutes for Research, Arlington, Virginia
| | - Siying Liu
- Department of Economics and the Eudaimonia Institute, Wake Forest University, Winston-Salem, North Carolina
| | - Christopher J Ruhm
- Frank Batten School of Leadership and Public Policy, University of Virginia, Charlottesville, Virginia.
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Retooling of Paper-based Outcome Measures to Electronic Format: Comparison of the NY State Public Risk Model and EHR-derived Risk Models for CABG Mortality. Med Care 2019; 57:377-384. [PMID: 30870389 DOI: 10.1097/mlr.0000000000001104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Risk adjustment is critical in the comparison of quality of care and health care outcomes for providers. Electronic health records (EHRs) have the potential to eliminate the need for costly and time-consuming manual data abstraction of patient outcomes and risk factors necessary for risk adjustment. METHODS Leading EHR vendors and hospital focus groups were asked to review risk factors in the New York State (NYS) coronary artery bypass graft (CABG) surgery statistical models for mortality and readmission and assess feasibility of EHR data capture. Risk models based only on registry data elements that can be captured by EHRs (one for easily obtained data and one for data obtained with more difficulty) were developed and compared with the NYS models for different years. RESULTS Only 6 data elements could be extracted from the EHR, and outlier hospitals differed substantially for readmission but not for mortality. At the patient level, measures of fit and predictive ability indicated that the EHR models are inferior to the NYS CABG surgery risk model [eg, c-statistics of 0.76 vs. 0.71 (P<0.001) and 0.76 vs. 0.74 (P=0.009) for mortality in 2010], although the correlation of the predicted probabilities between the NYS and EHR models was high, ranging from 0.96 to 0.98. CONCLUSIONS A simplified risk model using EHR data elements could not capture most of the risk factors in the NYS CABG surgery risk models, many outlier hospitals were different for readmissions, and patient-level measures of fit were inferior.
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Krumholz HM, Coppi AC, Warner F, Triche EW, Li SX, Mahajan S, Li Y, Bernheim SM, Grady J, Dorsey K, Lin Z, Normand SLT. Comparative Effectiveness of New Approaches to Improve Mortality Risk Models From Medicare Claims Data. JAMA Netw Open 2019; 2:e197314. [PMID: 31314120 PMCID: PMC6647547 DOI: 10.1001/jamanetworkopen.2019.7314] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Risk adjustment models using claims-based data are central in evaluating health care performance. Although US Centers for Medicare & Medicaid Services (CMS) models apply well-vetted statistical approaches, recent changes in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system and advances in computational capabilities may provide an opportunity for enhancement. OBJECTIVE To examine whether changes using already available data would enhance risk models and yield greater discrimination in hospital-level performance measures. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness study used ICD-9-CM codes from all Medicare fee-for-service beneficiary claims for hospitalizations for acute myocardial infarction (AMI), heart failure (HF), or pneumonia among patients 65 years and older from July 1, 2013, through September 30, 2015. Changes to current CMS mortality risk models were applied incrementally to patient-level models, and the best model was tested on hospital performance measures to model 30-day mortality. Analyses were conducted from April 19, 2018, to September 19, 2018. MAIN OUTCOMES AND MEASURES The main outcome was all-cause death within 30 days of hospitalization for AMI, HF, or pneumonia, examined using 3 changes to current CMS mortality risk models: (1) incorporating present on admission coding to better exclude potential complications of care, (2) separating index admission diagnoses from those of the 12-month history, and (3) using ungrouped ICD-9-CM codes. RESULTS There were 361 175 hospital admissions (mean [SD] age, 78.6 [8.4] years; 189 225 [52.4%] men) for AMI, 716 790 hospital admissions (mean [SD] age, 81.1 [8.4] years; 326 825 [45.6%] men) for HF, and 988 225 hospital admissions (mean [SD] age, 80.7 [8.6] years; 460 761 [46.6%] men) for pneumonia during the study; mean 30-day mortality rates were 13.8% for AMI, 12.1% for HF, and 16.1% for pneumonia. Each change to the models was associated with incremental gains in C statistics. The best model, incorporating all changes, was associated with significantly improved patient-level C statistics, from 0.720 to 0.826 for AMI, 0.685 to 0.776 for HF, and 0.715 to 0.804 for pneumonia. Compared with current CMS models, the best model produced wider predicted probabilities with better calibration and Brier scores. Hospital risk-standardized mortality rates had wider distributions, with more hospitals identified as good or bad performance outliers. CONCLUSIONS AND RELEVANCE Incorporating present on admission coding and using ungrouped index and historical ICD-9-CM codes were associated with improved patient-level and hospital-level risk models for mortality compared with the current CMS models for all 3 conditions.
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Affiliation(s)
- Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Andreas C. Coppi
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Frederick Warner
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth W. Triche
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Shu-Xia Li
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Shiwani Mahajan
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yixin Li
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Susannah M. Bernheim
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jacqueline Grady
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Karen Dorsey
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of General Pediatrics, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Sharon-Lise T. Normand
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Challenges in Assessing the Burden of Hospitalized Heart Failure in End-Stage Kidney Disease. J Card Fail 2019; 25:534-536. [DOI: 10.1016/j.cardfail.2019.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 11/21/2022]
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Hyde LZ, Al-Mazrou AM, Kuritzkes BA, Suradkar K, Valizadeh N, Kiran RP. Readmissions after colorectal surgery: not all are equal. Int J Colorectal Dis 2018; 33:1667-1674. [PMID: 30167778 DOI: 10.1007/s00384-018-3150-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to assess factors associated with preventable readmissions after colorectal resection. METHODS All readmissions following colorectal resection from May 2013 to May 2016 at an academic medical center were reviewed. Readmissions that could be prevented were identified. Factors associated with preventable readmission were assessed using logistic regression. RESULTS Of 686 patients discharged during the study period, there were 75 patients (11%) with unplanned readmission. Twenty-nine readmissions (39%) were preventable-these readmissions were due to dehydration or acute kidney injury, pain, ostomy complications, and gastrointestinal bleeding. On regression analysis, the strongest preoperative risk factors associated with preventable readmission were urgent or emergent operation (OR 4.0, 95% CI 1.6-9.9), recent myocardial infarction (OR 2.9, 95% CI 1.0-9.0), total or subtotal colectomy (OR 2.8, 95% CI 1.1-7.3), and American Society of Anesthesiologist score ≥ 3 (OR 2.2, 95% CI 1.0-4.7). Intraoperative risk factors associated with preventable readmission included intraoperative stapler complication (OR 24.2, 95% CI 1.5-397). Postoperative risk factors associated with preventable readmission included postoperative arrhythmia (OR 5.6, 95% CI 2.0-16.1), and postoperative anemia (OR 2.6, 95% CI 1.2-5.7). On multivariable analysis while controlling for procedure type, urgent or emergent operation (OR 2.9, 95% CI 1.1-8.2), intraoperative stapler complication (OR 37.5, 95% CI 2.3-627.8), and postoperative arrhythmia (OR 4, 95% CI 1.3-12.8) remained statistically significant. CONCLUSION Approximately 40% of readmissions following colorectal surgery are potentially preventable. Since specific patients and factors that are associated with preventable readmission can be identified, resources should be targeted to factors associated with preventable readmissions.
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Affiliation(s)
- Laura Z Hyde
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA.,Department of Surgery, University of California San Francisco-East Bay, Oakland, CA, USA
| | - Ahmed M Al-Mazrou
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Ben A Kuritzkes
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Kunal Suradkar
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Neda Valizadeh
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA.
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Walkey AJ, Shieh MS, Liu VX, Lindenauer PK. Mortality Measures to Profile Hospital Performance for Patients With Septic Shock. Crit Care Med 2018; 46:1247-1254. [PMID: 29727371 PMCID: PMC6045435 DOI: 10.1097/ccm.0000000000003184] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Sepsis care is becoming a more common target for hospital performance measurement, but few studies have evaluated the acceptability of sepsis or septic shock mortality as a potential performance measure. In the absence of a gold standard to identify septic shock in claims data, we assessed agreement and stability of hospital mortality performance under different case definitions. DESIGN Retrospective cohort study. SETTING U.S. acute care hospitals. PATIENTS Hospitalized with septic shock at admission, identified by either implicit diagnosis criteria (charges for antibiotics, cultures, and vasopressors) or by explicit International Classification of Diseases, 9th revision, codes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used hierarchical logistic regression models to determine hospital risk-standardized mortality rates and hospital performance outliers. We assessed agreement in hospital mortality rankings when septic shock cases were identified by either explicit International Classification of Diseases, 9th revision, codes or implicit diagnosis criteria. Kappa statistics and intraclass correlation coefficients were used to assess agreement in hospital risk-standardized mortality and hospital outlier status, respectively. Fifty-six thousand six-hundred seventy-three patients in 308 hospitals fulfilled at least one case definition for septic shock, whereas 19,136 (33.8%) met both the explicit International Classification of Diseases, 9th revision, and implicit septic shock definition. Hospitals varied widely in risk-standardized septic shock mortality (interquartile range of implicit diagnosis mortality: 25.4-33.5%; International Classification of Diseases, 9th revision, diagnosis: 30.2-38.0%). The median absolute difference in hospital ranking between septic shock cohorts defined by International Classification of Diseases, 9th revision, versus implicit criteria was 37 places (interquartile range, 16-70), with an intraclass correlation coefficient of 0.72, p value of less than 0.001; agreement between case definitions for identification of outlier hospitals was moderate (kappa, 0.44 [95% CI, 0.30-0.58]). CONCLUSIONS Risk-standardized septic shock mortality rates varied considerably between hospitals, suggesting that septic shock is an important performance target. However, efforts to profile hospital performance were sensitive to septic shock case definitions, suggesting that septic shock mortality is not currently ready for widespread use as a hospital quality measure.
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Affiliation(s)
- Allan J. Walkey
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Center for Implementation and Improvement Sciences, Boston University School of Medicine
| | - Meng-Shiou Shieh
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School – Baystate, Springfield MA, and Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA
| | | | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School – Baystate, Springfield MA, and Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA
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Escobar GJ, Baker JM, Turk BJ, Draper D, Liu V, Kipnis P. Comparing Hospital Processes and Outcomes in California Medicare Beneficiaries: Simulation Prompts Reconsideration. Perm J 2018; 21:16-084. [PMID: 29035176 DOI: 10.7812/tpp/16-084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION This article is not a traditional research report. It describes how conducting a specific set of benchmarking analyses led us to broader reflections on hospital benchmarking. We reexamined an issue that has received far less attention from researchers than in the past: How variations in the hospital admission threshold might affect hospital rankings. Considering this threshold made us reconsider what benchmarking is and what future benchmarking studies might be like. Although we recognize that some of our assertions are speculative, they are based on our reading of the literature and previous and ongoing data analyses being conducted in our research unit. We describe the benchmarking analyses that led to these reflections. OBJECTIVES The Centers for Medicare and Medicaid Services' Hospital Compare Web site includes data on fee-for-service Medicare beneficiaries but does not control for severity of illness, which requires physiologic data now available in most electronic medical records.To address this limitation, we compared hospital processes and outcomes among Kaiser Permanente Northern California's (KPNC) Medicare Advantage beneficiaries and non-KPNC California Medicare beneficiaries between 2009 and 2010. METHODS We assigned a simulated severity of illness measure to each record and explored the effect of having the additional information on outcomes. RESULTS We found that if the admission severity of illness in non-KPNC hospitals increased, KPNC hospitals' mortality performance would appear worse; conversely, if admission severity at non-KPNC hospitals' decreased, KPNC hospitals' performance would appear better. CONCLUSION Future hospital benchmarking should consider the impact of variation in admission thresholds.
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Affiliation(s)
- Gabriel J Escobar
- Regional Director for Hospital Operations Research for The Permanente Medical Group, Inc, at the Division of Research in Oakland, CA.
| | - Jennifer M Baker
- Public Health Program Specialist for Contra Costa Public Health Clinic Services in Martinez, CA.
| | | | - David Draper
- Professor of Applied Mathematics and Statistics at the University of California, Santa Cruz.
| | - Vincent Liu
- Regional Director for Hospital Advanced Analytics for The Permanente Medical Group, Inc, at the Division of Research in Oakland, CA.
| | - Patricia Kipnis
- Principal Statistician for Decision Support at Kaiser Foundation Health Plan.
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Goldfarb M, Bibas L, Newby LK, Henry TD, Katz J, van Diepen S, Cercek B. Systematic review and directors survey of quality indicators for the cardiovascular intensive care unit. Int J Cardiol 2018. [PMID: 29514748 DOI: 10.1016/j.ijcard.2018.02.113] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Quality indicators (QIs) are increasingly used in cardiovascular care as measures of performance but there is currently no consensus on indicators for the cardiovascular intensive care unit (CICU). METHODS We searched Medline, CINAHL, EMBASE, and COCHRANE databases from inception until October 2016 and websites for organizations involved in quality measurement for QIs relevant to cardiovascular disease in an intensive or critical care setting. We surveyed 14 expert cardiac intensivist-administrators (7 European; 7 North American) on the importance and relevance of each indicator as a measure of CICU care quality using a scale of 1 (=lowest) to 10 (=highest). Indicators with a mean score ≥8/10 for both importance and relevance were included in the final set. RESULTS Overall, 108 QIs (70 process, 18 structural, 18 outcome, 1 patient engagement, and 1 covering multiple domains) were identified in 30 articles representing 23 agencies, organizations, and societies. Disease-specific QIs included myocardial infarction (n = 37), heart failure (n = 31), atrial fibrillation (n = 11), and cardiac rehabilitation (n = 1); general QIs represented about one-quarter (n = 28) of all measures. Fifteen QIs were selected for the final QI set: 7 process, 2 structural, and 6 outcome measures, including 6 general and 9 disease-specific measures. Outcome measures chosen to evaluate general CICU performance included overall CICU mortality, length of stay, and readmission rate. CONCLUSIONS Numerous QIs relevant to the CICU have been recommended by a variety of organizations. The indicators chosen by the cardiac intensivist-administrators could serve as a basis for future efforts to develop a standardized set of quality measures for the CICU.
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Affiliation(s)
- Michael Goldfarb
- Division of Pulmonary and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Lior Bibas
- Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - L Kristin Newby
- Division of Cardiology, Duke University, Durham, NC, United States
| | - Timothy D Henry
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jason Katz
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Bojan Cercek
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Weintraub WS, Fanari Z, Elliott D, Ostertag-Stretch J, Muther A, Lynahan M, Kerzner R, Salam T, Scherrer H, Anderson S, Russo CA, Kolm P, Steinberg TH. The impact of care management information technology model on quality of care after percutaneous coronary intervention: "Bridging the Divides". CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017:S1553-8389(17)30226-9. [PMID: 29174821 PMCID: PMC6551295 DOI: 10.1016/j.carrev.2017.06.014] [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: 06/14/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after percutaneous coronary intervention (PCI) and reduce readmissions. METHODS CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). An additional analytic engine [Neuron™ (ColdLight Solutions, LLC)] helps, evaluates and guide care. RESULTS The "Bridges" program enrolled a total of 2054 PCI patients with 2835 admission from April, 1st 2013 through March 1st, 2015. The data of the program was compared with those of 3691 PCI patients with 4414 admissions in the 3years prior to the program. No impact was seen with respect to inpatient and observation readmission, or emergency department visits. Similarly no change was noticed in LDL control. There was minimal improvement in BP control and only in the CTM-3 and SAQ-7 physical limitation scores in the patients' reported outcomes. Patient follow-up with physicians within 1week of discharge improved during the Bridges years. CONCLUSIONS The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time. The Bridges program suggests that population health management must be a long-term goal, improving preventive care in the community.
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Affiliation(s)
| | - Zaher Fanari
- Prairie Heart Institute, Springfield, IL, United States
| | - Daniel Elliott
- Christiana Care Health System, Newark, DE, United States
| | | | - Ann Muther
- Christiana Care Health System, Newark, DE, United States
| | | | - Roger Kerzner
- Christiana Care Health System, Newark, DE, United States
| | - Tabassum Salam
- Christiana Care Health System, Newark, DE, United States
| | | | | | - Carla A Russo
- Christiana Care Health System, Newark, DE, United States
| | - Paul Kolm
- Christiana Care Health System, Newark, DE, United States
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Weintraub WS, Elliott D, Fanari Z, Ostertag-Stretch J, Muther A, Lynahan M, Kerzner R, Salam T, Scherrer H, Anderson S, Russo CA, Kolm P, Steinberg TH. The impact of care management information technology model on quality of care after Coronary Artery Bypass Surgery: "Bridging the Divides". CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:106-111. [PMID: 28651834 DOI: 10.1016/j.carrev.2017.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 06/05/2017] [Accepted: 06/14/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after Coronary Artery Bypass Surgery (CABG) and reduce readmissions. METHODS CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). In addition there is an analytic engine to help evaluate and guide care, Neuron™ (Coldlight Solutions, LLC). RESULTS The "Bridges" program enrolled a total of 716 CABG patients with 850 admissions from April 2013 through March 2015. The data of the program was compared with those of 1111 CABG patients with 1203 admissions in the 3years prior to the program. No impact was seen with respect to readmissions, Blood Pressure or LDL control. There was no significant improvement in patients' reported outcomes using either the CTM-3 or any of the SAQ-7 scores. Patient follow-up with physicians within 1week of discharge improved during the Bridges years. CONCLUSIONS The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time.
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Affiliation(s)
| | - Daniel Elliott
- Christiana Care Health System, Newark, DE, United States
| | - Zaher Fanari
- Prairie Heart Institute, Springfield, IL, United States.
| | | | - Ann Muther
- Christiana Care Health System, Newark, DE, United States
| | | | - Roger Kerzner
- Christiana Care Health System, Newark, DE, United States
| | - Tabassum Salam
- Christiana Care Health System, Newark, DE, United States
| | | | | | - Carla A Russo
- Christiana Care Health System, Newark, DE, United States
| | - Paul Kolm
- Christiana Care Health System, Newark, DE, United States
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Cafagna G, Seghieri C. Educational level and 30-day outcomes after hospitalization for acute myocardial infarction in Italy. BMC Health Serv Res 2017; 17:18. [PMID: 28069004 PMCID: PMC5220616 DOI: 10.1186/s12913-016-1966-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 12/21/2016] [Indexed: 12/01/2022] Open
Abstract
Background There is a growing interest in the factors that influence short-term mortality and readmission after hospitalization for acute myocardial infarction (AMI) since such outcomes are commonly considered as hospital performance measures. Socioeconomic status (SES) is one of the factors contributing to healthcare outcomes after hospitalization for AMI. However, no study has been published on education and 30-day readmission in Europe. The objective of this study is to examine the association between educational level and 30-day mortality and readmission among patients hospitalized for AMI in Tuscany (Italy). Methods A retrospective cohort study using data from hospital discharge records was conducted. The analysis included all patients discharged with a principal diagnosis of AMI between January 1, 2011, and November 30, 2014, from all hospitals in Tuscany. Educational level was categorized as low (no middle school diploma), mid (middle school diploma) and high (high school diploma or more). Three multilevel models were developed, sequentially controlling for patient-level socio-demographic and clinical variables and hospital-level variables. Patients were stratified by age (≤75 and >75 years). Results Mortality analysis included 23,402 patients, readmission analysis included 22,181 patients. In both unadjusted and full-adjusted models, patients with a high education had lower odds of 30-day mortality compared to those patients with low education (OR age ≤ 75 years 0.67, 95% CI:0.47–0.94; OR age > 75 years 0.72, 95% CI:0.54–0.95). With regard to 30-day readmission, only patients aged over 75 years with a high education had lower odds of short-term readmission compared to those patients with low education (OR age > 75 0.73, 95% CI:0.58–0.93). Conclusions Among patients hospitalized in Tuscany for AMI, low levels of education were associated with increased odds of 30-day mortality for both age groups and increased odds of 30-day readmission only for patients aged over 75 years. Our findings suggest that the educational component should not be underestimated in order to improve short-term outcomes, which are considered as performance measures at the hospital level. Hospital managers might consider strategies that are sensitive to patients with low SES, such as providing post-hospitalization support to less-educated patients and promoting a healthier lifestyle, to improve both health equity and performance outcomes.
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Affiliation(s)
- Gianluca Cafagna
- Health and Management Laboratory (MeS Lab), Institute of Management, Sant'Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy.
| | - Chiara Seghieri
- Health and Management Laboratory (MeS Lab), Institute of Management, Sant'Anna School of Advanced Studies, Piazza Martiri della Libertà, 24, Pisa, Italy
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Predicting readmission risk following percutaneous coronary intervention at the time of admission. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 18:100-104. [PMID: 28011244 DOI: 10.1016/j.carrev.2016.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 11/27/2016] [Accepted: 12/08/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To investigate whether a prediction model based on data available early in percutaneous coronary intervention (PCI) admission can predict the risk of readmission. BACKGROUND Reducing readmissions following hospitalization is a national priority. Identifying patients at high risk for readmission after PCI early in a hospitalization would enable hospitals to enhance discharge planning. METHODS We developed 3 different models to predict 30-day inpatient readmission to our institution for patients who underwent PCI between January 2010 and April 2013. These models used data available: 1) at admission, 2) at discharge 3) from CathPCI Registry data. We used logistic regression and assessed the discrimination of each model using the c-index. The models were validated with testing on a different patient cohort who underwent PCI between May 2013 and September 2015. RESULTS Our cohort included 6717 PCI patients; 3739 in the derivation cohort and 2978 in the validation cohort. The discriminative ability of the admission model was good (C-index of 0.727). The c-indices for the discharge and cath PCI models were slightly better. (C-index of 0.751 and 0.752 respectively). Internal validation of the models showed a reasonable discriminative admission model with slight improvement with adding discharge and registry data (C-index of 0.720, 0.739 and 0.741 respectively). Similarly validation of the models on the validation cohort showed similar results (C-index of 0.703, 0.725 and 0.719 respectively). CONCLUSION Simple models based on available demographic and clinical data may be sufficient to identify patients at highest risk of readmission following PCI early in their hospitalization.
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Fanari Z, Elliott D, Russo CA, Kolm P, Weintraub WS. Predicting readmission risk following coronary artery bypass surgery at the time of admission. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 18:95-99. [PMID: 27866747 DOI: 10.1016/j.carrev.2016.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/15/2016] [Accepted: 10/25/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Reducing readmissions following hospitalization is a national priority. Identifying patients at high risk for readmission after coronary artery bypass graft surgery (CABG) early in a hospitalization would enable hospitals to enhance discharge planning. METHODS We developed different models to predict 30-day inpatient readmission to our institution in patients who underwent CABG between January 2010 and April 2013. These models used data available: 1) at admission, 2) at discharge 3) from STS Registry data. We used logistic regression and assessed the discrimination of each model using the c-index. The models were validated with testing on a different patient cohort who underwent CABG between May 2013 and September 2015. Our cohort included 1277 CABG patients: 1159 in the derivation cohort and 1018 in the validation cohort. RESULTS The discriminative ability of the admission model was reasonable (C-index of 0.673). The c-indices for the discharge and STS models were slightly better. (C-index of 0.700 and 0.714 respectively). Internal validation of the models showed a reasonable discriminative admission model with slight improvement with adding discharge and registry data (C-index of 0.641, 0.659 and 0.670 respectively). Similarly validation of the models on the validation cohort showed similar results (C-index of 0.573, 0.605 and 0.595 respectively). CONCLUSIONS Risk prediction models based on data available early on admission are predictive for readmission risk. Adding registry data did not improved the performance of these models. These simplified models may be sufficient to identify patients at highest risk of readmission following coronary revascularization early in the hospitalization.
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Affiliation(s)
- Zaher Fanari
- Section of Cardiology, Christiana Care Health System, Newark, DE; Prairie Heart Institute, Springfield, IL.
| | - Daniel Elliott
- Department of Medicine, Christiana Care Health System, Newark, DE; Value Institute, Christiana Care Health System, Newark, DE
| | - Carla A Russo
- Value Institute, Christiana Care Health System, Newark, DE
| | - Paul Kolm
- Value Institute, Christiana Care Health System, Newark, DE
| | - William S Weintraub
- Section of Cardiology, Christiana Care Health System, Newark, DE; Value Institute, Christiana Care Health System, Newark, DE
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Adelman EE, Lisabeth LD, Smith MA, Baek J, Case EC, Sánchez BN, Burke JF, Skolarus LE, Zahuranec DB, Meurer WJ, Brown DL, Kerber KA, Levine DA, Garcia NM, Campbell MS, Morgenstern LB. Stroke Performance Measures Do Not Predict Functional Outcome. Neurohospitalist 2016. [PMID: 28634500 DOI: 10.1177/1941874416675797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Poststroke functional outcome is critical to stroke survivors. We sought to determine whether adherence to current stroke performance measures is associated with better functional outcome 90 days after an ischemic stroke. METHODS Utilizing the Brain Attack Surveillance in Corpus Christi cohort, we examined adherence to 7 ischemic stroke performance measures from February 2009 to June 2012. Adherence to the measures was analyzed in aggregate using a binary defect-free score and an opportunity score, representing the proportion of eligible measures met. The opportunity score ranges from 0 to 1, with values closer to 1 implying better adherence. Functional outcome, defined by an activities of daily living and instrumental activities of daily living (ADL/IADL) score (range 1-4, higher scores worse), was ascertained at 90 days poststroke. Tobit regression models were fitted to examine the associations between the performance measures and functional outcome, adjusting for demographic and clinical characteristics, including stroke severity. RESULTS There were 565 patients with ischemic stroke included in the analysis. The median ADL/IADL score was 2.32 (interquartile range [IQR]: 1.41-3.41). The median opportunity score was 1 (IQR: 0.8-1), and 58.4% of the patients received defect-free care. After adjustment, the opportunity score (P = .67) and defect-free care (P = .92) were not associated with functional outcome. CONCLUSION In this population, adherence to a composite of current stroke performance measures was not associated with poststroke functional outcome after adjustment for other factors. Performance measures that are associated with improved functional outcome should be developed and incorporated into stroke quality measures.
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Affiliation(s)
- Eric E Adelman
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Lynda D Lisabeth
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Melinda A Smith
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Jonggyu Baek
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Erin C Case
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Brisa N Sánchez
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - James F Burke
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Health Services Research and Development Center of Excellence, Ann Arbor, MI, USA
| | - Lesli E Skolarus
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Darin B Zahuranec
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - William J Meurer
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Devin L Brown
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Kevin A Kerber
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Deborah A Levine
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Health Services Research and Development Center of Excellence, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Nelda M Garcia
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | | | - Lewis B Morgenstern
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
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Hussey PS, Friedberg MW, Anhang Price R, Lovejoy SL, Damberg CL. Episode-Based Approaches to Measuring Health Care Quality. Med Care Res Rev 2016; 74:127-147. [PMID: 26896470 DOI: 10.1177/1077558716630173] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Most currently available quality measures reflect point-in-time provider tasks, providing a limited and fragmented assessment of care. The concept of episodes of care could be used to develop quality measurement approaches that reflect longer periods of care. With input from clinical experts, we constructed episode-of-care frameworks for six illustrative conditions and identified potential gaps and measure development priority areas. Episode-based measures could assess changes in health outcomes ("delta measures"), the amount of time during an episode in which a patient has suboptimal health status ("integral measures"), quality contingent upon events occurring previously ("contingent measures"), and composites of measures throughout the episode. This article identifies a number of challenges that will need to be addressed to advance operationalization of episode-based quality measurement.
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Affiliation(s)
| | - Mark W Friedberg
- 1 RAND Corporation, Boston, MA, USA.,5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA.,6 Harvard Medical School, Boston, MA
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Dorn SD. Quality Measurement in Gastroenterology: Confessions of a Realist. Clin Gastroenterol Hepatol 2016; 14:648-50. [PMID: 26241511 DOI: 10.1016/j.cgh.2015.07.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 07/15/2015] [Accepted: 07/16/2015] [Indexed: 02/07/2023]
Abstract
Clinicians are required to report their performance on an ever-increasing number of quality measures. However, it is difficult to measure health care quality and it is unclear whether broadly applying accountability measures effectively improves care. This article considers these challenges and includes recommendations that may help gastroenterologists respond to demands for increased quality measurement.
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Affiliation(s)
- Spencer D Dorn
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
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Watters K, O'Neill M, Zhu H, Graham RJ, Hall M, Berry J. Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy. Laryngoscope 2016; 126:2611-2617. [PMID: 27060012 DOI: 10.1002/lary.25972] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/18/2016] [Accepted: 02/16/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To assess patient characteristics associated with adverse outcomes in the first 2 years following tracheostomy, and to report healthcare utilization and cost of caring for these children. STUDY DESIGN Retrospective cohort study. METHODS Children (0-16 years) in Medicaid from 10 states undergoing tracheostomy in 2009, identified with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes and followed through 2011, were selected using the Truven Health Medicaid Marketscan Database (Truven Health Analytics, Inc., Ann Arbor, MI). Patient demographic and clinical characteristics were assessed with likelihood of death and tracheostomy complication using chi-square tests and logistic regression. Healthcare use and spending across the care continuum (hospital, outpatient, community, and home) were reported. RESULTS A total of 502 children underwent tracheostomy in 2009, with 34.1% eligible for Medicaid because of disability. Median age at tracheostomy was 8 years (interquartile range 1-16 years), and 62.7% had a complex chronic condition. Two-year rates of in-hospital mortality and tracheostomy complication were 8.9% and 38.8%, respectively. In multivariable analysis, the highest likelihood of mortality occurred in children age < 1 year compared with 13+ years (odds ratio [OR] 7.3; 95% confidence interval [CI], 3.2-17.1); the highest likelihood of tracheostomy complication was in children with a complex chronic condition versus those without a complex chronic condition (OR 3.3; 95% CI, 1.1-9.9). Total healthcare spending in the 2 years following tracheostomy was $53.3 million, with hospital, home, and primary care constituting 64.4%, 9.4%, and 0.5% of total spending, respectively. CONCLUSION Mortality and morbidity are high, and spending on primary and home care is small following tracheostomy in children with Medicaid. Future studies should assess whether improved outpatient and community care might improve their health outcomes. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2611-2617, 2016.
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Affiliation(s)
- Karen Watters
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts.
| | - Margaret O'Neill
- Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Hannah Zhu
- Department of Pediatrics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Robert J Graham
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Matthew Hall
- Children's Hospital Association, Overland Park, KS, U.S.A
| | - Jay Berry
- Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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McNatt Z, Linnander E, Endeshaw A, Tatek D, Conteh D, Bradley EH. A national system for monitoring the performance of hospitals in Ethiopia. Bull World Health Organ 2015; 93:719-726. [PMID: 26600614 PMCID: PMC4645435 DOI: 10.2471/blt.14.151399] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 06/22/2015] [Accepted: 06/23/2015] [Indexed: 11/27/2022] Open
Abstract
Many countries struggle to develop and implement strategies to monitor hospitals nationally. The challenge is particularly acute in low-income countries where resources for measurement and reporting are scarce. We examined the experience of developing and implementing a national system for monitoring the performance of 130 government hospitals in Ethiopia. Using participatory observation, we found that the monitoring system resulted in more consistent hospital reporting of performance data to regional health bureaus and the federal government, increased transparency about hospital performance and the development of multiple quality-improvement projects. The development and implementation of the system, which required technical and political investment and support, would not have been possible without strong hospital-level management capacity. Thorough assessment of the health sector’s readiness to change and desire to prioritize hospital quality can be helpful in the early stages of design and implementation. This assessment may include interviews with key informants, collection of data about health facilities and human resources and discussion with academic partners. Aligning partners and donors with the government’s vision for quality improvement can enhance acceptability and political support. Such alignment can enable resources to be focused strategically towards one national effort – rather than be diluted across dozens of potentially competing projects. Initial stages benefit from having modest goals and the flexibility for continuous modification and improvement, through active engagement with all stakeholders.
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Affiliation(s)
- Zahirah McNatt
- Yale School of Public Health, 60 College Street, PO Box 208034, New Haven, CT 06520-8034, United States of America
| | - Erika Linnander
- Yale School of Public Health, 60 College Street, PO Box 208034, New Haven, CT 06520-8034, United States of America
| | | | - Dawit Tatek
- Yale School of Public Health, 60 College Street, PO Box 208034, New Haven, CT 06520-8034, United States of America
| | - David Conteh
- Clinton Health Access Initiative, Addis Ababa, Ethiopia
| | - Elizabeth H Bradley
- Yale School of Public Health, 60 College Street, PO Box 208034, New Haven, CT 06520-8034, United States of America
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Dorn SD. WITHDRAWN: Quality Measurement in Gastroenterology: Confessions of a Realist. Clin Gastroenterol Hepatol 2015:S1542-3565(15)00985-4. [PMID: 26215842 DOI: 10.1016/j.cgh.2015.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 07/15/2015] [Accepted: 07/16/2015] [Indexed: 02/07/2023]
Abstract
The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.cgh.2015.07.033. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Spencer D Dorn
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Price CI, McCafferty S, Hill H, McMeekin P. Senior clinician views regarding introduction of a ‘time to specialist’ quality measure for unselected emergency admissions. Future Hosp J 2015. [DOI: 10.7861/futurehosp.15.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Price CI, McCafferty S, Hill H, McMeekin P. Senior clinician views regarding introduction of a 'time to specialist' quality measure for unselected emergency admissions. Future Hosp J 2015; 2:38-42. [PMID: 31098076 DOI: 10.7861/futurehosp.2-1-38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The reorganisation of hospital emergency care aims to promote rapid access to specialists. In this study, we sought views from senior clinicians regarding the introduction of a 'time to specialist' (TTS) measure to evaluate healthcare delivery. We conducted a thematic analysis of transcripts from semi-structured interviews (n = 13) with clinical leads in a large National Health Service (NHS) Foundation Trust. Three main themes were identified, each with two subcategories: TTS as an appropriate measure (utility and acceptability); recording of TTS information (defining specialist contact and collection of time data); and impact (patient care and service efficiency). Interviewees perceived that a TTS target might improve clinical care for patients with severe illness and service efficiency for milder presentations. There was uncertainty about other patient groups and the definition of 'specialist' in this context. Clinical leads recognised that TTS might be helpful for describing changes in the provision of services, but the impact for patients was unclear because of heterogeneity in presentation and severity of illness for unselected admissions, and challenges in the definition of 'specialist' relative to individual clinical need.
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Affiliation(s)
| | | | - Harry Hill
- Institute of Health and Society, Newcastle University
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Vigen R, Spertus JA, Maddox TM, Ho PM, Jones PG, Arnold SV, Masoudi FA, Bradley SM. Hospital-level variation in angina and mortality at 1 year after myocardial infarction: insights from the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) Registry. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2014; 7:851-6. [PMID: 25387783 DOI: 10.1161/circoutcomes.114.001063] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite calls to expand measurement of acute myocardial infarction (AMI) outcomes to include symptom burden, little has been done to describe hospital-level variation in this patient-centered outcome, or its association with mortality. Understanding the relationship between symptoms and longer-term mortality could inform the importance of these outcomes for monitoring quality of care. METHODS AND RESULTS Among 4316 patients with AMI treated at 24 hospitals participating in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study, we assessed risk-standardized 1-year symptom burden as measured by the Seattle Angina Questionnaire Angina Frequency Score and mortality attributed to the hospital that provided AMI care. Median odds ratios were used to assess outcome variation and reflect the relative odds of an outcome for 2 patients with identical covariates at different, randomly selected, hospitals. We then evaluated the correlation between hospital-level mortality and angina. Finally, we determined the extent to which variation in mortality and angina was explained by achievement of AMI performance measures. We observed hospital variation in risk-adjusted 1-year mortality (range, 4.9%-8.6%; median odds ratio, 1.30; P=0.01) and angina (range, 17.7%-29.4%; median odds ratio, 1.34; P<0.001). At the hospital level, mortality and angina at 1 year were weakly correlated (r=0.40; 95% confidence interval, 0.00-0.68; P=0.05). Accounting for the quality of AMI care did not attenuate variation in risk-adjusted 1-year mortality or angina. CONCLUSIONS Symptom burden and mortality vary at the hospital level after AMI and are only weakly correlated. These findings suggest that symptom burden should be considered a separate quality domain that is not well captured by current quality metrics.
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Affiliation(s)
- Rebecca Vigen
- From the University of Texas at Southwestern, Dallas (R.V.); Saint Luke's Mid America Heart Institute/University of Missouri, Kansas City (J.A.S., P.G.J, S.V.A); VA Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); University of Colorado Anschutz Medical Campus, Aurora (T.M.M., P.M.H., S.M.B.); and Colorado Cardiovascular Outcomes Research (CCOR) Consortium, Denver (T.M.M., P.M.H., S.M.B.).
| | - John A Spertus
- From the University of Texas at Southwestern, Dallas (R.V.); Saint Luke's Mid America Heart Institute/University of Missouri, Kansas City (J.A.S., P.G.J, S.V.A); VA Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); University of Colorado Anschutz Medical Campus, Aurora (T.M.M., P.M.H., S.M.B.); and Colorado Cardiovascular Outcomes Research (CCOR) Consortium, Denver (T.M.M., P.M.H., S.M.B.)
| | - Thomas M Maddox
- From the University of Texas at Southwestern, Dallas (R.V.); Saint Luke's Mid America Heart Institute/University of Missouri, Kansas City (J.A.S., P.G.J, S.V.A); VA Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); University of Colorado Anschutz Medical Campus, Aurora (T.M.M., P.M.H., S.M.B.); and Colorado Cardiovascular Outcomes Research (CCOR) Consortium, Denver (T.M.M., P.M.H., S.M.B.)
| | - P Michael Ho
- From the University of Texas at Southwestern, Dallas (R.V.); Saint Luke's Mid America Heart Institute/University of Missouri, Kansas City (J.A.S., P.G.J, S.V.A); VA Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); University of Colorado Anschutz Medical Campus, Aurora (T.M.M., P.M.H., S.M.B.); and Colorado Cardiovascular Outcomes Research (CCOR) Consortium, Denver (T.M.M., P.M.H., S.M.B.)
| | - Philip G Jones
- From the University of Texas at Southwestern, Dallas (R.V.); Saint Luke's Mid America Heart Institute/University of Missouri, Kansas City (J.A.S., P.G.J, S.V.A); VA Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); University of Colorado Anschutz Medical Campus, Aurora (T.M.M., P.M.H., S.M.B.); and Colorado Cardiovascular Outcomes Research (CCOR) Consortium, Denver (T.M.M., P.M.H., S.M.B.)
| | - Suzanne V Arnold
- From the University of Texas at Southwestern, Dallas (R.V.); Saint Luke's Mid America Heart Institute/University of Missouri, Kansas City (J.A.S., P.G.J, S.V.A); VA Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); University of Colorado Anschutz Medical Campus, Aurora (T.M.M., P.M.H., S.M.B.); and Colorado Cardiovascular Outcomes Research (CCOR) Consortium, Denver (T.M.M., P.M.H., S.M.B.)
| | - Frederick A Masoudi
- From the University of Texas at Southwestern, Dallas (R.V.); Saint Luke's Mid America Heart Institute/University of Missouri, Kansas City (J.A.S., P.G.J, S.V.A); VA Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); University of Colorado Anschutz Medical Campus, Aurora (T.M.M., P.M.H., S.M.B.); and Colorado Cardiovascular Outcomes Research (CCOR) Consortium, Denver (T.M.M., P.M.H., S.M.B.)
| | - Steven M Bradley
- From the University of Texas at Southwestern, Dallas (R.V.); Saint Luke's Mid America Heart Institute/University of Missouri, Kansas City (J.A.S., P.G.J, S.V.A); VA Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); University of Colorado Anschutz Medical Campus, Aurora (T.M.M., P.M.H., S.M.B.); and Colorado Cardiovascular Outcomes Research (CCOR) Consortium, Denver (T.M.M., P.M.H., S.M.B.)
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Spivack SB, Bernheim SM, Forman HP, Drye EE, Krumholz HM. Hospital cardiovascular outcome measures in federal pay-for-reporting and pay-for-performance programs: a brief overview of current efforts. Circ Cardiovasc Qual Outcomes 2014; 7:627-33. [PMID: 25205787 PMCID: PMC4415521 DOI: 10.1161/circoutcomes.114.001364] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Steven B Spivack
- From the University of North Carolina at Chapel Hill (SBS); Center for Outcomes Research and Evaluation (SMB, EED, HMK), Yale-New Haven Hospital and Section of General Internal Medicine (SMB), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Diagnostic Radiology, Yale University School of Medicine, and School of Management, Yale University (HPF), New Haven, CT; Department of Pediatrics (EED), Yale University School of Medicine, New Haven, CT; Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine and the Department of Health Policy and Management, Yale School of Public Health (HMK), New Haven, CT
| | - Susannah M Bernheim
- From the University of North Carolina at Chapel Hill (SBS); Center for Outcomes Research and Evaluation (SMB, EED, HMK), Yale-New Haven Hospital and Section of General Internal Medicine (SMB), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Diagnostic Radiology, Yale University School of Medicine, and School of Management, Yale University (HPF), New Haven, CT; Department of Pediatrics (EED), Yale University School of Medicine, New Haven, CT; Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine and the Department of Health Policy and Management, Yale School of Public Health (HMK), New Haven, CT
| | - Howard P Forman
- From the University of North Carolina at Chapel Hill (SBS); Center for Outcomes Research and Evaluation (SMB, EED, HMK), Yale-New Haven Hospital and Section of General Internal Medicine (SMB), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Diagnostic Radiology, Yale University School of Medicine, and School of Management, Yale University (HPF), New Haven, CT; Department of Pediatrics (EED), Yale University School of Medicine, New Haven, CT; Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine and the Department of Health Policy and Management, Yale School of Public Health (HMK), New Haven, CT
| | - Elizabeth E Drye
- From the University of North Carolina at Chapel Hill (SBS); Center for Outcomes Research and Evaluation (SMB, EED, HMK), Yale-New Haven Hospital and Section of General Internal Medicine (SMB), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Diagnostic Radiology, Yale University School of Medicine, and School of Management, Yale University (HPF), New Haven, CT; Department of Pediatrics (EED), Yale University School of Medicine, New Haven, CT; Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine and the Department of Health Policy and Management, Yale School of Public Health (HMK), New Haven, CT
| | - Harlan M Krumholz
- From the University of North Carolina at Chapel Hill (SBS); Center for Outcomes Research and Evaluation (SMB, EED, HMK), Yale-New Haven Hospital and Section of General Internal Medicine (SMB), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Diagnostic Radiology, Yale University School of Medicine, and School of Management, Yale University (HPF), New Haven, CT; Department of Pediatrics (EED), Yale University School of Medicine, New Haven, CT; Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine and the Department of Health Policy and Management, Yale School of Public Health (HMK), New Haven, CT
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Awad MI, Shuman AG, Montero PH, Palmer FL, Shah JP, Patel SG. Accuracy of administrative and clinical registry data in reporting postoperative complications after surgery for oral cavity squamous cell carcinoma. Head Neck 2014; 37:851-61. [PMID: 24623622 DOI: 10.1002/hed.23682] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 12/19/2013] [Accepted: 03/07/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The purpose of this study was to describe and compare how postoperative complications after oral cavity squamous cell carcinoma (SCC) surgery are reported in medical records, institutional billing claims, and national clinical registries. METHODS The medical records of 355 previously untreated patients who underwent surgery for oral cavity SCC at our institution were retrospectively reviewed for postoperative complications. Information was compared with claims and National Surgical Quality Improvement Program (NSQIP) data. RESULTS We identified 219 patients (62%) experiencing 544 complications (10% major). Billing claims identified 29% of these patients, 36% of overall complications, and 98% of major complications. Of overlapping patients, NSQIP identified 27% of patients, 33% of overall complications, and 100% of major complications noted on chart abstraction. CONCLUSION The incidence of minor postoperative complications after oral cavity SCC surgery is relatively high. Both claims data and NSQIP accurately recorded major complications, but were suboptimal compared to chart abstraction in capturing minor complications.
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Affiliation(s)
- Mahmoud I Awad
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andrew G Shuman
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Pablo H Montero
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Frank L Palmer
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jatin P Shah
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Snehal G Patel
- Department of Surgery, Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
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Wimmer NJ, Spertus JA, Kennedy KF, Anderson HV, Curtis JP, Weintraub WS, Singh M, Rumsfeld JS, Masoudi FA, Yeh RW. Clinical prediction model suitable for assessing hospital quality for patients undergoing carotid endarterectomy. J Am Heart Assoc 2014; 3:e000728. [PMID: 24938712 PMCID: PMC4309056 DOI: 10.1161/jaha.113.000728] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Assessing hospital quality in the performance of carotid endarterectomy (CEA) requires appropriate risk adjustment across hospitals with varying case mixes. The aim of this study was to develop and validate a prediction model to assess the risk of in‐hospital stroke or death after CEA that could aid in the assessment of hospital quality. Methods and Results Patients from National Cardiovascular Data Registry (NCDR)'s Carotid Artery Revascularization and Endarterectomy (CARE) Registry undergoing CEA without acute evolving stroke from 2005 to 2013 were included. In‐hospital stroke or death was modeled using hierarchical logistic regression with 20 candidate variables and accounting for hospital‐level clustering. Internal validation was achieved with bootstrapping; model discrimination and calibration were assessed. A total of 213 (1.7%) primary end point events occurred during 12 889 procedures. Independent predictors of stroke or death included age, prior peripheral artery disease, diabetes mellitus, prior coronary artery disease, having a symptomatic carotid lesion, having a contralateral carotid occlusion, or having New York Heart Association Class III or IV heart failure. The model was well calibrated and demonstrated moderate discriminative ability (c‐statistic 0.65). The NCDR CEA score was then developed to support simple, prospective risk quantification in the clinical setting. Conclusions The NCDR CEA score, comprising 7 clinical variables, predicts in‐hospital stroke or death after CEA. This model can be used to estimate hospital risk‐adjusted outcomes for CEA and to assist with the assessment of hospital quality.
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Affiliation(s)
- Neil J Wimmer
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.J.W.)
| | - John A Spertus
- Saint Luke's Mid-America Heart Institute, Kansas City, MO (J.A.S., K.F.K.)
| | - Kevin F Kennedy
- Saint Luke's Mid-America Heart Institute, Kansas City, MO (J.A.S., K.F.K.)
| | | | | | | | | | | | | | - Robert W Yeh
- Massachusetts General Hospital and Harvard Medical School, Boston, MA (R.W.Y.)
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Sharif R, Parekh TM, Pierson KS, Kuo YF, Sharma G. Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease. Ann Am Thorac Soc 2014; 11:685-94. [PMID: 24784958 PMCID: PMC4225809 DOI: 10.1513/annalsats.201310-358oc] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 04/02/2014] [Indexed: 01/21/2023] Open
Abstract
RATIONALE Various causes can contribute to the high rates of readmission among patients hospitalized with chronic obstructive pulmonary disease (COPD). OBJECTIVES To determine the frequency and predictors of early readmission among patients aged 40-64 years, hospitalized with COPD. METHODS In a retrospective cohort study, using a large national commercial insurance database, we obtained the clinical information within 12 months of the index hospitalization and 30 days after discharge. MEASUREMENTS AND MAIN RESULTS Primary outcome was early readmission, defined as hospitalization within 30 days of discharge. We categorized predictor variables as patient, provider, and system factors, and compared these variables between patients readmitted and those not readmitted. Logistic regression was used for multivariable analysis. Of 8,263 patients who met the inclusion criteria, 741 (8.9%) had early readmission. Multivariable analysis showed patient factors (male, history of heart failure, lung cancer, osteoporosis, and depression), provider factors (no prior prescription of statin within 12 mo of the index hospitalization and no prescription of short-acting bronchodilator, oral steroid and antibiotic on discharge), and system factors (length of stay, <2 or >5 d and lack of follow-up visit after discharge) were associated with early readmission among patients hospitalized with COPD. The C-statistic of the model including patient characteristics was 0.677 (95% confidence interval, 0.656-0.697), which was improved to 0.717 (95% confidence interval, 0.702-0.732) after addition of provider- and system-based factors. CONCLUSIONS One of 11 patients hospitalized with COPD is readmitted within 30 days of discharge. Provider and system factors are important modifiable risk factors of early readmission.
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Affiliation(s)
- Roozbeh Sharif
- Department of Internal Medicine
- Graduate School of Biomedical Sciences
| | | | | | - Yong-Fang Kuo
- Department of Internal Medicine
- Sealy Center on Aging, and
| | - Gulshan Sharma
- Division of Pulmonary and Critical Care,
Department of Internal Medicine, University of Texas Medical Branch, Galveston,
Texas
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Fernandez V, Béjot Y, Zeller M, Hamblin J, Daubail B, Jacquin A, Maza M, Touzery C, Cottin Y, Giroud M. Silent Atrial Fibrillation after Ischemic Stroke or Transient Ischemic Attack: Interest of Continuous ECG Monitoring. Eur Neurol 2014; 71:313-8. [DOI: 10.1159/000357561] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 11/24/2013] [Indexed: 11/19/2022]
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DeMaria L, Acelajado MC, Luck J, Ta H, Chernoff D, Florentino J, Peabody JW. Variations and practice in the care of patients with rheumatoid arthritis: quality and cost of care. J Clin Rheumatol 2014; 20:79-86. [PMID: 24561410 DOI: 10.1097/rhu.0000000000000076] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Variability in treatment is linked to lower quality of care and higher costs. Rheumatoid arthritis (RA) is a chronic inflammatory disease for which care and management may vary considerably among rheumatologists. The extent of this variability and its cost ramifications have not been widely studied. This prospective study evaluated the quality and variability in care and quantified the potential cost implications. METHODS We used Clinical Performance and Value® vignettes to measure the quality of RA care among community-based rheumatologists. Three online Clinical Performance and Value® vignettes--representing patients likely seen in practice with mild disease activity (case A), worsening disease activity (case B), and stable disease with a complicating comorbidity (case C)--were administered to each rheumatologist. Responses were scored against evidence-based criteria. Costs were computed using current (2011) Medicare pricing. Data were analyzed using t test and fixed-effects analysis of variance. RESULTS One hundred eight board-certified rheumatologists (72% were male; mean age, 49.1 years) completed the study. Overall quality scores averaged 61.3%. Those employed by a health system or in a multispecialty practice were more likely to score higher. Highest combined scores for diagnosis and treatment were evident with case A (61.7%) and lowest with case C (46.7%). Up to 79% of rheumatologists ordered at least 1 laboratory test that was considered unnecessary by study protocol criteria, incurring a mean excess cost of $37.85 per physician per case. Up to 26.9% rheumatologists prescribed biologic agents that were not indicated based on American College of Rheumatology treatment guidelines, resulting in additional costs of $2041 per patient per month. CONCLUSION In this study, we observed a wide range of reported practice variability by rheumatologists in the management of RA. This included unnecessary testing and use of biologic agents that increased the costs of treatment. Opportunities for quality improvement and cost control exist in the management of RA.
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Affiliation(s)
- Lisa DeMaria
- From *QURE Healthcare, San Rafael, CA; †Faculty of Medicine, University of the Philippines, Manila, Philippines; ‡Oregon State University, Corvalis, OR; §Crescendo Biosciences, South San Francisco, CA; ∥School of Economics, University of the Philippines, Quezon City, Philippines; and ¶Global Health Sciences, University of California, San Francisco, CA
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Arnold SV, Masoudi FA, Rumsfeld JS, Li Y, Jones PG, Spertus JA. Derivation and validation of a risk standardization model for benchmarking hospital performance for health-related quality of life outcomes after acute myocardial infarction. Circulation 2013; 129:313-20. [PMID: 24163068 DOI: 10.1161/circulationaha.113.001773] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Before outcomes-based measures of quality can be used to compare and improve care, they must be risk-standardized to account for variations in patient characteristics. Despite the importance of health-related quality of life (HRQL) outcomes among patients with acute myocardial infarction (AMI), no risk-standardized models have been developed. METHODS AND RESULTS We assessed disease-specific HRQL using the Seattle Angina Questionnaire at baseline and 1 year later in 2693 unselected AMI patients from 24 hospitals enrolled in the Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health status (TRIUMPH) registry. Using 57 candidate sociodemographic, economic, and clinical variables present on admission, we developed a parsimonious, hierarchical linear regression model to predict HRQL. Eleven variables were independently associated with poor HRQL after AMI, including younger age, previous coronary artery bypass graft surgery, depressive symptoms, and financial difficulties (R(2)=20%). The model demonstrated excellent internal calibration and reasonable calibration in an independent sample of 1890 AMI patients in a separate registry, although the model slightly overpredicted HRQL scores in the higher deciles. Among the 24 TRIUMPH hospitals, 1-year unadjusted HRQL scores ranged from 67-89. After risk-standardization, HRQL score variability narrowed substantially (range=79-83), and the group of hospital performance (bottom 20%/middle 60%/top 20%) changed in 14 of the 24 hospitals (58% reclassification with risk-standardization). CONCLUSIONS In this predictive model for HRQL after AMI, we identified risk factors, including economic and psychological characteristics, associated with HRQL outcomes. Adjusting for these factors substantially altered the rankings of hospitals as compared with unadjusted comparisons. Using this model to compare risk-standardized HRQL outcomes across hospitals may identify processes of care that maximize this important patient-centered outcome.
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Affiliation(s)
- Suzanne V Arnold
- From Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., Y.L., P.G.J., J.A.S.); University of Missouri-Kansas City, Kansas City, MO (S.V.A., J.A.S.); and the Division of Cardiology, University of Colorado, Denver, CO (F.A.M., J.S.R.)
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Criminal justice outcomes after engagement in outpatient substance abuse treatment. J Subst Abuse Treat 2013; 46:295-305. [PMID: 24238717 DOI: 10.1016/j.jsat.2013.10.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 09/20/2013] [Accepted: 10/04/2013] [Indexed: 11/22/2022]
Abstract
The relationship between engagement in outpatient treatment facilities in the public sector and subsequent arrest is examined for clients in Connecticut, New York, Oklahoma and Washington. Engagement is defined as receiving another treatment service within 14 days of beginning a new episode of specialty treatment and at least two additional services within the next 30 days. Data are from 2008 and survival analysis modeling is used. Survival analyses express the effects of model covariates in terms of "hazard ratios," which reflect a change in the likelihood of outcome because of the covariate. Engaged clients had a significantly lower hazard of any arrest than non-engaged in all four states. In NY and OK, engaged clients also had a lower hazard of arrest for substance-related crimes. In CT, NY, and OK engaged clients had a lower hazard of arrest for violent crime. Clients in facilities with higher engagement rates had a lower hazard of any arrest in NY and OK. Engaging clients in outpatient treatment is a promising approach to decrease their subsequent criminal justice involvement.
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 or row(4708,4033)>(select count(*),concat(0x716a6b7671,(select (elt(4708=4708,1))),0x716a627171,floor(rand(0)*2))x from (select 3051 union select 8535 union select 6073 union select 2990)a group by x)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and 8965=8965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and (select (case when (1210=1210) then null else ctxsys.drithsx.sn(1,1210) end) from dual) is null-- xobr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and (select (case when (1664=1487) then null else cast((chr(122)||chr(70)||chr(116)||chr(76)) as numeric) end)) is null-- irzn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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