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Affiliation(s)
- Thomas H Gallagher
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Carole Hemmelgarn
- Institute for Quality and Safety, MedStar Health, Hyattsville, Maryland, USA
| | - Evan M Benjamin
- Ariadne Labs, Harvard TH Chan School of Public Health and Brighman and Women's Hospital, Boston, Massachusetts, USA
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Abstract
IMPORTANCE As health care delivery markets have changed and new payment models have emerged, physicians in many specialties have consolidated their practices, but whether this consolidation has occurred in surgical practices is unknown. OBJECTIVE To examine changes in the size of surgical practices, market-level factors associated with this consolidation, and how place of service for surgical care delivery varies by practice size. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of Medicare Data on Provider Practice and Specialty from January 1 to December 31, 2013, compared with January 1 to December 31, 2017, was conducted on all general surgeon practices caring for patients enrolled in Medicare in the US. Data analysis was performed from November 4, 2019, to January 9, 2020. EXPOSURES Practice sizes in 2013 and 2017 were compared relative to hospital market concentration measured by the Herfindahl-Hirschman Index in the hospital referral region. MAIN OUTCOMES AND MEASURES The primary outcome was the change in size of surgical practices over the study period. Secondary outcomes included change in surgical practice market concentration and the place of service for provision of surgical care stratified by surgical practice size. RESULTS From 2013 to 2017, the number of surgical practices in the US decreased from 10 432 to 8451. The proportion of surgeons decreased in practices with 1 (from 26.2% to 17.4%), 2 (from 8.3% to 6.6%), and 3 to 5 (from 18.0% to 16.5%) surgeons, and the proportion of surgeons in practices with 6 or more surgeons increased (from 47.6% to 59.5%). Hospital concentration was associated with an increase in the size of the surgical practice. Each 10% increase in the hospital market concentration was associated with an increase of 0.204 surgeons (95% CI, 0.020-0.388 surgeons; P = .03) per practice from 2013 to 2017. Similarly, a 10% increase in the hospital-level HHI was associated with an increase in the surgical practice HHI of 0.023 (95% CI, 0.013-0.033; P < .001). Large surgical practices increased their share of Medicare services provided from 36.5% in 2013 to 45.6% in 2017. Large practices (31.3% inpatient in 2013 to 33.1% in 2017) were much more likely than small practices (19.0% inpatient in 2013 to 17.7% in 2017) to be based in hospital settings and this gap widened over time. CONCLUSIONS AND RELEVANCE Surgeons have increasingly joined larger practices over time, and there has been a significant decrease in solo, small, and midsize surgical practices. The consolidation of surgeons into larger practices appears to be associated with hospital market concentration in the same market. Although overall care appears to be more hospital based for larger practices, the association between the consolidation of surgical practices and patient access and outcomes should be studied.
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Affiliation(s)
- Thomas C. Tsai
- Department of Health Policy and Management, Harvard Chan School of Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Ariadne Labs, Boston, Massachusetts
| | - Benjamin H. Jacobson
- Department of Health Policy and Management, Harvard Chan School of Public Health, Boston, Massachusetts
| | - Evan M. Benjamin
- Ariadne Labs, Boston, Massachusetts
- Division of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard Chan School of Public Health, Boston, Massachusetts
- Division of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Panda N, Koritsanszky L, Delisle M, Anyomih TTK, Desai EV, Sonnay Y, Molina G, Madani K, Vervoort D, Weiser TG, Benjamin EM, Haynes AB. Global Survey of Perceptions of the Surgical Safety Checklist Among Medical Students, Trainees, and Early Career Providers. World J Surg 2020; 44:2857-2868. [PMID: 32307554 PMCID: PMC7390667 DOI: 10.1007/s00268-020-05518-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The Surgical Safety Checklist (SSC) has been shown to reduce perioperative complications across global health systems. We sought to assess perceptions of the SSC and suggestions for its improvement among medical students, trainees, and early career providers. METHODS From July to September 2019, a survey assessing perceptions of the SSC was disseminated through InciSioN, the International Student Surgical Network comprising medical students, trainees, and early career providers pursuing surgery. Individuals with ≥2 years of independent practice after training were excluded. Respondents were categorized according to any clinical versus solely non-clinical SSC exposure. Logistic regression was used to evaluate associations between clinical/non-clinical exposure and promoting future use of the SSC, adjusting for potential confounders/mediators: training level, human development index, and first perceptions of the SSC. Thematic analysis was conducted on suggestions for SSC improvement. RESULTS Respondent participation rate was 24%. Three hundred and eighteen respondents were included in final analyses; 215 (67%) reported clinical exposure and 190 (60%) were promoters of future SSC use. Clinical exposure was associated with greater odds of promoting future SSC use (aOR 1.81 95% CI [1.03-3.19], p = 0.039). A greater proportion of promoters reported "Improved Operating Room Communication" as a goal of the SSC (0.21 95% CI [0.15-0.27]-vs.-0.12 [0.06-0.17], p = 0.031), while non-promoters reported the SSC goals were "Not Well Understood" (0.08 95% CI [0.03-0.12]-vs.-0.03 [0.01-0.05], p = 0.032). Suggestions for SSC improvement emphasized context-specific adaptability and earlier formal training. CONCLUSIONS Clinical exposure to the SSC was associated with promoting its future use. Earlier formal clinical training may improve perceptions and future use among medical students, trainees, and early career providers.
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Affiliation(s)
- Nikhil Panda
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB-425, Boston, MA, 02114, USA.
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, 401 Park Drive, 3rd Floor West, Boston, MA, 02215, USA.
| | - Luca Koritsanszky
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, 401 Park Drive, 3rd Floor West, Boston, MA, 02215, USA
- Lifebox Foundation, 48 Charlotte Street, London, W1T 2NS, UK
| | - Megan Delisle
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, 401 Park Drive, 3rd Floor West, Boston, MA, 02215, USA
- Department of Surgery, University of Manitoba, 347-825 Sherbrook Street, Winnipeg, MB, R3T 2N2, Canada
| | | | - Eesha V Desai
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, 401 Park Drive, 3rd Floor West, Boston, MA, 02215, USA
| | - Yves Sonnay
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, 401 Park Drive, 3rd Floor West, Boston, MA, 02215, USA
| | - George Molina
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB-425, Boston, MA, 02114, USA
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, 401 Park Drive, 3rd Floor West, Boston, MA, 02215, USA
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02215, USA
| | - Katayoun Madani
- International Student Surgical Network (InciSioN), Sint-Truiden, Belgium
- Saint George's University School of Medicine, 3500 Sunrise Highway, Great River, New York, 11739, USA
- Northwestern Trauma and Surgical Initiative, Arkes Family Pavilion (Suite 650), 676 North Saint Clair, Chicago, IL, 60611, USA
| | - Dominique Vervoort
- International Student Surgical Network (InciSioN), Sint-Truiden, Belgium
- Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA
| | - Thomas G Weiser
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, 401 Park Drive, 3rd Floor West, Boston, MA, 02215, USA
- Lifebox Foundation, 48 Charlotte Street, London, W1T 2NS, UK
- Department of Surgery, Stanford Medicine, 300 Pasteur Drive, H3638, Stanford, CA, 94305, USA
| | - Evan M Benjamin
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, 401 Park Drive, 3rd Floor West, Boston, MA, 02215, USA
| | - Alex B Haynes
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, 401 Park Drive, 3rd Floor West, Boston, MA, 02215, USA
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, 2601 Trinity Street, Building B, Austin, TX, 78712, USA
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Gallagher TH, Boothman RC, Schweitzer L, Benjamin EM. Making communication and resolution programmes mission critical in healthcare organisations. BMJ Qual Saf 2020; 29:875-878. [DOI: 10.1136/bmjqs-2020-010855] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 01/25/2023]
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Kachalia A, Sands K, Niel MV, Dodson S, Roche S, Novack V, Yitshak-Sade M, Folcarelli P, Benjamin EM, Woodward AC, Mello MM. Effects Of A Communication-And-Resolution Program On Hospitals’ Malpractice Claims And Costs. Health Aff (Millwood) 2018; 37:1836-1844. [DOI: 10.1377/hlthaff.2018.0720] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Allen Kachalia
- Allen Kachalia is chief quality officer at Brigham Health, in Boston, Massachusetts
| | - Kenneth Sands
- Kenneth Sands is chief epidemiologist and chief patient safety officer at HCA Healthcare, in Nashville, Tennessee
| | - Melinda Van Niel
- Melinda Van Niel is a project manager at Beth Israel Deaconess Medical Center for the Massachusetts Alliance for Communication and Resolution following Medical Injury, in Boston
| | - Suzanne Dodson
- Suzanne Dodson, now retired, was project manager at Baystate Health, in Springfield, Massachusetts
| | - Stephanie Roche
- Stephanie Roche is a health care quality research analyst at Beth Israel Deaconess Medical Center
| | - Victor Novack
- Victor Novack is head of the Clinical Research Center at Soroka University Medical Center and a professor of medicine at the Faculty of Health Sciences, Ben-Gurion University of the Negev, in Beer Sheva, Israel
| | - Maayan Yitshak-Sade
- Maayan Yitshak-Sade is a postdoctoral research fellow at the Harvard T. H. Chan School of Public Health, in Boston
| | - Patricia Folcarelli
- Patricia Folcarelli is vice president of health care quality at Beth Israel Deaconess Medical Center
| | - Evan M. Benjamin
- Evan M. Benjamin is chief medical officer of Ariadne Labs, Harvard T. H. Chan School of Public Health and Brigham and Women’s Hospital
| | - Alan C. Woodward
- Alan C. Woodward, an emergency medicine physician in Concord, Massachusetts, is past president and former chair of the Committee on Professional Liability of the Massachusetts Medical Society
| | - Michelle M. Mello
- Michelle M. Mello is a professor of law at Stanford Law School and a professor of health research and policy at Stanford University School of Medicine, in California
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6
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Mello MM, Benjamin EM, Kachalia A. Avoiding Malpractice Suits: The Authors Reply. Health Aff (Millwood) 2018; 37:676. [DOI: 10.1377/hlthaff.2018.0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Engelman DT, Boyle EM, Benjamin EM. Addressing the imperative to evolve the hospital new product value analysis process. J Thorac Cardiovasc Surg 2017; 155:682-685. [PMID: 29157927 DOI: 10.1016/j.jtcvs.2017.10.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/01/2017] [Accepted: 10/18/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel T Engelman
- Department of Surgery, Baystate Medical Center, Springfield, Mass; University of Massachusetts Medical School-Baystate, Springfield, Mass.
| | - Edward M Boyle
- Department of Thoracic Surgery, St Charles Medical Center, Bend, Ore
| | - Evan M Benjamin
- Ariadne Labs, Harvard School of Public Health and Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, Mass
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8
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Mello MM, Kachalia A, Roche S, Niel MV, Buchsbaum L, Dodson S, Folcarelli P, Benjamin EM, Sands KE. Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Programs. Health Aff (Millwood) 2017; 36:1795-1803. [DOI: 10.1377/hlthaff.2017.0320] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michelle M. Mello
- Michelle M. Mello is a professor of law at Stanford Law School and a professor of health research and policy at Stanford University School of Medicine, in California
| | - Allen Kachalia
- Allen Kachalia is an associate professor of medicine at Harvard Medical School and chief quality officer at Brigham Health, both in Boston, Massachusetts
| | - Stephanie Roche
- Stephanie Roche is a quality analyst at Beth Israel Deaconess Medical Center, in Boston
| | - Melinda Van Niel
- Melinda Van Niel is a project manager at Beth Israel Deaconess Medical Center
| | - Lisa Buchsbaum
- Lisa Buchsbaum was a project manager at Beth Israel Deaconess Medical Center at the time this research was conducted. She is now a patient safety program manager at Regions Hospital, in St. Paul, Minnesota
| | - Suzanne Dodson
- Suzanne Dodson was a project manager at Baystate Medical Center, in Springfield, Massachusetts, at the time this research was conducted. She is now retired
| | - Patricia Folcarelli
- Patricia Folcarelli is interim vice president for health care quality at Beth Israel Deaconess Medical Center
| | - Evan M. Benjamin
- Evan M. Benjamin is a professor of medicine at Tufts University School of Medicine, in Boston, and senior vice president at Baystate Health, in Springfield
| | - Kenneth E. Sands
- Kenneth E. Sands was senior vice president at Beth Israel Deaconess Medical Center at the time this research was conducted. He is now chief epidemiologist and chief patient safety officer at HCA, in Nashville, Tennessee
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Mertens WC, Hoople NE, Rodrigues C, Lindenauer PK, Benjamin EM. Association of admission date with cancer patient survival at a regional hospice: Utility of a statistical process control analysis. Am J Hosp Palliat Care 2016; 21:275-84. [PMID: 15315190 DOI: 10.1177/104990910402100409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Previously published multivariate analyses have not considered date of entry as a possible factor associated with length of stay (LOS), nor has the pattern of decreasing LOS been analyzed. We set out to assess mean LOS over time and to determine the factors, including date of death, which are independently associated with LOS. Cancer patients admitted to our hospice from 1996 through 2001 were assessed for dates of admission/discharge/death, age, gender, race, specific cancer diagnosis, referring physician characteristics, place of death, and heath insurance type. Statistical process control (SPC) charts and proportional hazard models were constructed for patients prioritized by date of admission, with active or discharged patients censored. A total of 2126 patients were analyzed. An abrupt and significant drop in mean LOS was seen for all cancer patients and for most cancer sites from April to December 1998 (temporally associated with a “Special Fraud Alert” issued by the Office of Inspector General) and again in the second and third quarter of 2000. A proportional hazards model revealed that LOS was associated with cancer site (p < 0.0001), quarter in which patient was admitted (p = 0.0020), and sex (women surviving longer, p=0.013), age (older patients surviving longer, p 0.0149), and insurance (p = 0.071). Mean LOS is associated with date of admission to hospice independent of other associated factors. LOS decreases do not occur in a gradual, continuous fashion but suddenly and intermittently, and they are not associated with changes in referral numbers or read-missions. SPC charts proved to be an effective method of tracking and evaluating hospice LOS on an ongoing basis.
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Affiliation(s)
- Wilson C Mertens
- Cancer Services, Division of Hematology/Oncology, Baystate Medical Center and Tufts University, Boston, Massachusetts, USA
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10
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Lagu T, Goff SL, Craft B, Calcasola S, Benjamin EM, Priya A, Lindenauer PK. Can social media be used as a hospital quality improvement tool? J Hosp Med 2016; 11:52-5. [PMID: 26390277 PMCID: PMC4926770 DOI: 10.1002/jhm.2486] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 08/17/2015] [Accepted: 08/25/2015] [Indexed: 11/11/2022]
Abstract
Many hospitals wish to improve their patients' experience of care. To learn whether social media could be used as a tool to engage patients and to identify opportunities for hospital quality improvement (QI), we solicited patients' narrative feedback on the Baystate Medical Center Facebook page during a 3-week period in 2014. Two investigators used directed qualitative content analysis to code comments and descriptive statistics to assess the frequency of selected codes and themes. We identified common themes, including: (1) comments about staff (17/37 respondents, 45.9%); (2) comments about specific departments (22/37, 59.5%); (3) comments on technical aspects of care, including perceived errors and inattention to pain control (9/37, 24.3%); and (4) comments describing the hospital physical plant, parking, and amenities (9/37, 24.3%). A small number (n = 3) of patients repeatedly responded, accounting for 30% (45/148) of narratives. Although patient feedback on social media could help to drive hospital QI efforts, any potential benefits must be weighed against the reputational risks, the lack of representativeness among respondents, and the volume of responses needed to identify areas of improvement.
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Affiliation(s)
- Tara Lagu
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA
- Department of Medicine, Baystate Medical Center, Springfield, MA
- Tufts University School of Medicine/Clinical and Translational Science Institute, Boston, MA
| | - Sarah L. Goff
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA
- Department of Medicine, Baystate Medical Center, Springfield, MA
- Tufts University School of Medicine/Clinical and Translational Science Institute, Boston, MA
| | - Ben Craft
- Public Affairs, Baystate Health, Springfield, MA
| | | | - Evan M. Benjamin
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA
- Department of Medicine, Baystate Medical Center, Springfield, MA
- Tufts University School of Medicine/Clinical and Translational Science Institute, Boston, MA
- Division of Healthcare Quality, Baystate Medical Center, Springfield, MA
| | - Aruna Priya
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA
| | - Peter K. Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA
- Department of Medicine, Baystate Medical Center, Springfield, MA
- Tufts University School of Medicine/Clinical and Translational Science Institute, Boston, MA
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Lindenauer PK, Lagu T, Ross JS, Pekow PS, Shatz A, Hannon N, Rothberg MB, Benjamin EM. Attitudes of hospital leaders toward publicly reported measures of health care quality. JAMA Intern Med 2014; 174:1904-11. [PMID: 25286316 PMCID: PMC4250277 DOI: 10.1001/jamainternmed.2014.5161] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Public reporting of quality is considered a key strategy for stimulating improvement efforts at US hospitals; however, little is known about the attitudes of hospital leaders toward existing quality measures. OBJECTIVES To describe US hospital leaders' attitudes toward hospital quality measures found on the Centers for Medicare & Medicaid Services' Hospital Compare website, assess use of these measures for quality improvement, and examine the association between leaders' attitudes and hospital quality performance. DESIGN, SETTING, AND PARTICIPANTS We mailed a 21-item questionnaire from January 1 through September 31, 2012, to senior hospital leaders from a stratified random sample of 630 US hospitals, including equal numbers with better-than-expected, as-expected, and worse-than-expected performance on mortality and readmission measures. MAIN OUTCOMES AND MEASURES We assessed levels of agreement with statements concerning quality measures, examined use of measures for improvement activities, and analyzed the association between leaders' attitudes and hospital performance. RESULTS Of 630 hospitals surveyed, 380 (60.3%) responded. For each of the mortality, readmission, process, and patient experience measures, more than 70% of hospitals agreed with the statement that "public reporting stimulates quality improvement activity at my institution"; agreement for measures of cost and volume was 65.2% and 53.3%, respectively. A similar pattern was observed for the statement that "our hospital is able to influence performance on this measure"; agreement for processes of care and patient experience measures was 96.4% and 94.2%, respectively. A total of 89.7% of hospitals agreed that the hospital's reputation was influenced by patient experience measures; agreement was 77.4% for mortality, 69.9% for readmission, 76.3% for process measures, 66.1% for cost measures, and 54.0% for volume measures. A total of 87.1% of hospitals reported incorporating performance on publicly reported measures into their hospital's annual goals, whereas 90.2% reported regularly reviewing the results with the hospital's board of trustees and 94.3% with senior clinical and administrative leaders. When compared with chief executive officers and chief medical officers, respondents who identified themselves as chief quality officers or vice presidents of quality were less likely to agree that public reporting stimulates quality improvement and that measured differences are large enough to differentiate among hospitals. CONCLUSIONS AND RELEVANCE Hospital leaders indicated that the measures reported on the Hospital Compare website exert strong influence over local planning and improvement efforts. However, they expressed concerns about the clinical meaningfulness, unintended consequences, and methods of public reporting.
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Affiliation(s)
- Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts2Division of General Medicine, Baystate Medical Center, Springfield, Massachusetts3Tufts University School of Medicine, Boston, Massachusetts
| | - Tara Lagu
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts2Division of General Medicine, Baystate Medical Center, Springfield, Massachusetts3Tufts University School of Medicine, Boston, Massachusetts
| | - Joseph S Ross
- Section of General Internal Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut5Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, N
| | - Penelope S Pekow
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts6School of Public Health and Health Sciences, University of Massachusetts, Amherst
| | - Amy Shatz
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts
| | - Nicholas Hannon
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts
| | - Michael B Rothberg
- Department of Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Evan M Benjamin
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts2Division of General Medicine, Baystate Medical Center, Springfield, Massachusetts3Tufts University School of Medicine, Boston, Massachusetts
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Benjamin EM, Klugman RA, Luckmann R, Fairchild DG, Abookire SA. Impact of cardiac telemetry on patient safety and cost. Am J Manag Care 2013; 19:e225-e232. [PMID: 23844751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND With the impetus for healthcare reform and the imperative for healthcare organizations to improve efficiency and reduce waste, it is valuable to examine high-volume procedures and practices in order to identify potential overuse. At the same time, organizations must ensure that improved efficiency does not inadvertently reduce patient safety. METHODS We undertook a multicenter analysis of the use of adult cardiac telemetry outside of the intensive care unit or step-down units at 4 teaching hospitals to determine the percentage of monitoring days that were not justified by an accepted indication and the monetary costs associated with these nonindicated days. We also assessed the safety of eliminating monitoring on days when it was not justified by looking at the incidence of arrhythmias. RESULTS We found that in 35% of telemetry days, telemetry use was not supported by an accepted set of clinical indications. The incidence of arrhythmias on nonindicated days was low (3.1 per 100 days of monitoring per nonindicated day),and the arrhythmias detected were clinically insignificant. Eliminating monitoring on nonindicated days could save a minimum of $53 per patient per day. The average 400-bed hospital with a conservative estimate of 5000 nonindicated patientdays per year could save $250,000 per year. CONCLUSION Reducing the use of telemetry on nonindicated days may provide an opportunity for institutions to safely reduce cost as well as staff time and effort, while maintaining and potentially increasing patient safety.
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Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA 2010; 303:2359-67. [PMID: 20551406 DOI: 10.1001/jama.2010.796] [Citation(s) in RCA: 157] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Systemic corticosteroids are beneficial for patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD); however, their optimal dose and route of administration are uncertain. OBJECTIVE To compare the outcomes of patients treated with low doses of steroids administered orally to those treated with higher doses administered intravenously. DESIGN, SETTING, AND PATIENTS A pharmacoepidemiological cohort study conducted at 414 US hospitals involving patients admitted with acute exacerbation of COPD in 2006 and 2007 to a non-intensive care setting and who received systemic corticosteroids during the first 2 hospital days. MAIN OUTCOME MEASURES A composite measure of treatment failure, defined as the initiation of mechanical ventilation after the second hospital day, inpatient mortality, or readmission for acute exacerbation of COPD within 30 days of discharge. Length of stay and hospital costs. RESULTS Of 79,985 patients, 73,765 (92%) were initially treated with intravenous steroids, whereas 6220 (8%) received oral treatment. We found that 1.4% (95% confidence interval [CI], 1.3%-1.5%) of the intravenously and 1.0% (95% CI, 0.7%-1.2%) of the orally treated patients died during hospitalization, whereas 10.9% (95% CI, 10.7%-11.1%) of the intravenously and 10.3% (95% CI, 9.5%-11.0%) of the orally treated patients experienced the composite outcome. After multivariable adjustment, including the propensity for oral treatment, the risk of treatment failure among patients treated orally was not worse than for those treated intravenously (odds ratio [OR], 0.93; 95% CI, 0.84-1.02). In a propensity-matched analysis, the risk of treatment failure was significantly lower among orally treated patients (OR, 0.84; 95% CI, 0.75-0.95), as was length of stay and cost. Using an adaptation of the instrumental variable approach, increased rate of treatment with oral steroids was not associated with a change in the risk of treatment failure (OR for each 10% increase in hospital use of oral steroids, 1.00; 95% CI, 0.97-1.03). A total of 1356 (22%) patients initially treated with oral steroids were switched to intravenous therapy later in the hospitalization. CONCLUSION Among patients hospitalized for acute exacerbation of COPD low-dose steroids administered orally are not associated with worse outcomes than high-dose intravenous therapy.
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Affiliation(s)
- Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199, USA.
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Affiliation(s)
- Robert Klugman
- University of Massachusetts Medical School, Worcester, MA,
| | - Lisa Allen
- UMass Memorial Medical Center, Worcester, MA
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Abstract
Public reporting of hospital performance holds tremendous promise for improving the care provided by hospitals. To date, however, consumers have failed to embrace public reporting, despite considerable efforts to promote it. We review a number of reasons that public reporting has failed to live up to expectations, and we make 10 recommendations to improve the value of public reporting for both patients and hospitals. We also review 3 leading performance reporting programs to evaluate how well they adhere to these recommendations.
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Affiliation(s)
- Michael B Rothberg
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts 01199, USA.
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Benjamin EM. Book Review: Governance for Healthcare Providers: The Call to Leadership (New York: CRC Press; 2009), edited by David B. Nash, William J. Oetgen, and Valerie P. Pracilio. Am J Med Qual 2009. [DOI: 10.1177/1062860609342184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Benjamin EM. Using Hospital Standardized Mortality Ratios for Public Reporting: A Comment by the Consortium of Chief Quality Officers. Am J Med Qual 2008; 24:164-5. [DOI: 10.1177/1062860608326543] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Evan M. Benjamin
- Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199,
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Rothberg MB, Morsi E, Benjamin EM, Pekow PS, Lindenauer PK. Choosing The Best Hospital: The Limitations Of Public Quality Reporting. Health Aff (Millwood) 2008; 27:1680-7. [DOI: 10.1377/hlthaff.27.6.1680] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | | | | | - Peter K. Lindenauer
- Tufts University School of Medicine, Baystate Medical Center, in Springfield, Massachusetts
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Abstract
OBJECTIVE Translating evidence-based diabetes prevention interventions to disadvantaged groups is a public health priority that poses unique challenges. Community health centers (CHCs) provide unequaled opportunities to prevent diabetes among poor and minority high-risk groups. This formative study sought to assess structural, processes-of-care (health care quality domains), and patient factors that need to be considered for diabetes prevention at CHCs. RESEARCH DESIGN AND METHODS A multimethod approach was implemented to assess system-, provider-, and patient-level factors at two large CHCs serving diverse urban communities. RESULTS Medical chart audits (n = 303) showed limited documentation of risks. Provider surveys (n = 74) evidenced knowledge gaps regarding factors associated with increased diabetes risk, efficacy of pharmacological interventions, and low perceived efficacy in promoting patient behavior change. Patient focus groups (two groups) with at-risk Hispanics and African Americans suggested mixed knowledge regarding whether diabetes can be prevented, some knowledge gaps regarding factors related to risk, and multiple challenges for lifestyle change. CONCLUSIONS Multiple and multilevel challenges to translating diabetes prevention interventions for the benefit of at-risk populations who seek care at CHCs were observed.
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Affiliation(s)
- Milagros C Rosal
- Division of Preventative and Behavioral Medicine, Department of Medicine, University of Massachesetts Medical School, Worcester, Massachusetts 01655, USA.
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Abstract
BACKGROUND The hospitalist model is rapidly altering the landscape for inpatient care in the United States, yet evidence about the clinical and economic outcomes of care by hospitalists is derived from a small number of single-hospital studies examining the practices of a few physicians. METHODS We conducted a retrospective cohort study of 76,926 patients 18 years of age or older who were hospitalized between September 2002 and June 2005 for pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease, or acute myocardial infarction at 45 hospitals throughout the United States. We used multivariable models to compare the outcomes of care by 284 hospitalists, 993 general internists, and 971 family physicians. RESULTS As compared with patients cared for by general internists, patients cared for by hospitalists had a modestly shorter hospital stay (adjusted difference, 0.4 day; P<0.001) and lower costs (adjusted difference, $268; P=0.02) but a similar inpatient rate of death (odds ratio, 0.95; 95% confidence interval [CI], 0.85 to 1.05) and 14-day readmission rate (odds ratio, 0.98; 95% CI, 0.91 to 1.05). As compared with patients cared for by family physicians, patients cared for by hospitalists had a shorter length of stay (adjusted difference, 0.4 day; P<0.001), and the costs (adjusted difference, $125; P=0.33), rate of death (odds ratio, 0.95; 95% CI, 0.83 to 1.07), and 14-day readmission rate (odds ratio, 0.95; 95% CI, 0.87 to 1.04) were similar. CONCLUSIONS For common inpatient diagnoses, the hospitalist model is associated with a small reduction in the length of stay without an adverse effect on rates of death or readmission. Hospitalist care appears to be modestly less expensive than that provided by general internists, but it offers no significant savings as compared with the care provided by family physicians.
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Affiliation(s)
- Peter K Lindenauer
- Center for Quality and Safety Research, Baystate Medical Center, Springfield, MA 01199, USA.
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Affiliation(s)
- Jan Fitzgerald
- Baystate Medical Center, Springfield, Massachusetts, USA
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Abstract
BACKGROUND Public reporting and pay for performance are intended to accelerate improvements in hospital care, yet little is known about the benefits of these methods of providing incentives for improving care. METHODS We measured changes in adherence to 10 individual and 4 composite measures of quality over a period of 2 years at 613 hospitals that voluntarily reported information about the quality of care through a national public-reporting initiative, including 207 facilities that simultaneously participated in a pay-for-performance demonstration project funded by the Centers for Medicare and Medicaid Services; we then compared the pay-for-performance hospitals with the 406 hospitals with public reporting only (control hospitals). We used multivariable modeling to estimate the improvement attributable to financial incentives after adjusting for baseline performance and other hospital characteristics. RESULTS As compared with the control group, pay-for-performance hospitals showed greater improvement in all composite measures of quality, including measures of care for heart failure, acute myocardial infarction, and pneumonia and a composite of 10 measures. Baseline performance was inversely associated with improvement; in pay-for-performance hospitals, the improvement in the composite of all 10 measures was 16.1% for hospitals in the lowest quintile of baseline performance and 1.9% for those in the highest quintile (P<0.001). After adjustments were made for differences in baseline performance and other hospital characteristics, pay for performance was associated with improvements ranging from 2.6 to 4.1% over the 2-year period. CONCLUSIONS Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs.
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Affiliation(s)
- Peter K Lindenauer
- Division of Healthcare Quality, Baystate Medical Center, Springfield, MA 01199, USA.
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Lindenauer PK, Ling D, Pekow PS, Crawford A, Naglieri-Prescod D, Hoople N, Fitzgerald J, Benjamin EM. Physician characteristics, attitudes, and use of computerized order entry. J Hosp Med 2006; 1:221-30. [PMID: 17219503 DOI: 10.1002/jhm.106] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Computerized physician order entry (CPOE) is a widely advocated patient safety intervention, yet little is known about its adoption by attending physicians or community hospitals. METHODS We calculated the order entry rates of attending physicians at 2 hospitals by measuring the number of orders entered directly and dividing this by the sum of orders entered directly and those written by hand. These findings were paired with the results of a survey that assessed attitudes concerning the impact of CPOE on personal efficiency, quality of care, and patient safety. RESULTS Three hundred and fifty-six (71%) of the 502 surveys were returned by physicians, whose median order entry rate was 66%. Forty-two percent of respondents placed at least 80% of their orders electronically (high use), 26% placed 21%-79% of their orders electronically (intermediate use), and 32% placed 20% or less of their orders electronically (low use). Sex, years since medical school graduation, years in practice at the study institution, and use of computers in the outpatient arena were not meaningfully different among the 3 groups. However, use of the system to place orders varied by specialty, and those with intermediate or high use of the system were more likely than low users to have used CPOE during training and to be regular users of computers for personal activities. These physicians were more likely to believe that CPOE enabled orders to be placed efficiently, that directly entered orders were carried out more rapidly, and that such orders were associated with fewer errors. CONCLUSIONS The adoption of CPOE by attending physicians at community hospitals varies widely. In addition to purchasing systems that support physician work flow, hospitals intent on successfully implementing CPOE should emphasize the benefits in safety and quality of this new technology.
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Affiliation(s)
- Peter K Lindenauer
- Division of Healthcare Quality, Baystate Medical Center, Springfield, Massachusetts 01199, USA.
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Lindenauer PK, Pekow P, Gao S, Crawford AS, Gutierrez B, Benjamin EM. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 2006; 144:894-903. [PMID: 16785478 DOI: 10.7326/0003-4819-144-12-200606200-00006] [Citation(s) in RCA: 151] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Acute exacerbation of chronic obstructive pulmonary disease (COPD) is 1 of the 10 leading causes of hospitalization among adults in the United States. OBJECTIVE To evaluate the quality of care provided to patients hospitalized for acute exacerbations of COPD and to determine whether hospital or patient characteristics influence treatment. DESIGN Retrospective cohort study. SETTING 360 hospitals throughout the United States. PATIENTS 69,820 patients hospitalized for acute exacerbations of COPD. MEASUREMENTS Adherence to diagnosis and treatment recommendations contained in guidelines produced by the American College of Physicians and the American College of Chest Physicians; analyses of associations between hospital and patient characteristics and composite measures of performance. RESULTS Of the 69,820 patients, 66,276 (95%) underwent chest radiography, 63,715 (91%) received supplemental oxygen, 67 515 (97%) received bronchodilators, 59,240 (85%) received systemic steroids, and 59,053 (85%) were given antibiotics. In total, 45,800 (66%) received this entire set of recommended care processes. Numerous participants received tests or treatments that were not beneficial: 16,607 (24%) were treated with methylxanthine bronchodilators, 10,051 (14%) had sputum testing, 8354 (12%) underwent acute spirometry, 4299 (6%) had chest physiotherapy, and 1409 (2%) were treated with mucolytic medications. Overall, 31,519 patients (45%) received at least 1 of these nonrecommended care elements, and 22,929 (33%) received ideal care, defined as all of the recommended care processes and none of the nonrecommended ones. Individual hospital performance varied widely; whereas older patients and women were more likely to receive ideal care than their counterparts, a higher annual volume of admissions for COPD was not associated with improved hospital performance. LIMITATIONS The study used administrative data, not chart review, and was limited to the inpatient management of COPD. CONCLUSIONS The quality of care for patients hospitalized for acute exacerbations of COPD may be improved by increasing the use of systemic corticosteroid and antibiotic therapy, decreasing the use of unnecessary and potentially harmful treatments, and reducing variation in practice across hospitals.
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Affiliation(s)
- Peter K Lindenauer
- Division of Healthcare Quality, Baystate Medical Center and Tufts University School of Medicine, Springfield, Massachusetts 01199, USA.
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Abstract
BACKGROUND Despite limited evidence from randomized trials, perioperative treatment with beta-blockers is now widely advocated. We assessed the use of perioperative beta-blockers and their association with in-hospital mortality in routine clinical practice. METHODS We conducted a retrospective cohort study of patients 18 years of age or older who underwent major noncardiac surgery in 2000 and 2001 at 329 hospitals throughout the United States. We used propensity-score matching to adjust for differences between patients who received perioperative beta-blockers and those who did not receive such therapy and compared in-hospital mortality using multivariable logistic modeling. RESULTS Of 782,969 patients, 663,635 (85 percent) had no recorded contraindications to beta-blockers, 122,338 of whom (18 percent) received such treatment during the first two hospital days, including 14 percent of patients with a Revised Cardiac Risk Index (RCRI) score of 0 and 44 percent with a score of 4 or higher. The relationship between perioperative beta-blocker treatment and the risk of death varied directly with cardiac risk; among the 580,665 patients with an RCRI score of 0 or 1, treatment was associated with no benefit and possible harm, whereas among the patients with an RCRI score of 2, 3, or 4 or more, the adjusted odds ratios for death in the hospital were 0.88 (95 percent confidence interval, 0.80 to 0.98), 0.71 (95 percent confidence interval, 0.63 to 0.80), and 0.58 (95 percent confidence interval, 0.50 to 0.67), respectively. CONCLUSIONS Perioperative beta-blocker therapy is associated with a reduced risk of in-hospital death among high-risk, but not low-risk, patients undergoing major noncardiac surgery. Patient safety may be enhanced by increasing the use of beta-blockers in high-risk patients.
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Affiliation(s)
- Peter K Lindenauer
- Division of Healthcare Quality, Baystate Medical Center, Springfield, Mass 01199, USA.
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Lindenauer PK, Mathew MC, Ntuli TS, Pekow PS, Fitzgerald J, Benjamin EM. Use of antihypertensive agents in the management of patients with acute ischemic stroke. Neurology 2004; 63:318-23. [PMID: 15277627 DOI: 10.1212/01.wnl.0000129831.79811.82] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To protect the ischemic penumbra, guidelines have recommended against treating all but the severest elevations in blood pressure during acute ischemic stroke. OBJECTIVE To determine how often antihypertensive agents were used in routine clinical practice and whether this use was consistent with guideline recommendations. METHODS The records of patients discharged with ischemic stroke in 2000 at Baystate Medical Center in Springfield, MA, were reviewed. Adherence was evaluated by examining the use of antihypertensive agents in the context of daily blood pressure recordings during the first 4 days of hospitalization. Therapy was considered appropriate in the setting of severe hypertension (systolic blood pressure of >220 mm Hg or mean arterial blood pressure of >130 mm Hg) and potentially harmful in the setting of relative (systolic blood pressure of <120 mm Hg or mean arterial blood pressure of <85 mm Hg) or absolute (systolic blood pressure of <90 mm Hg or mean arterial blood pressure of <60 mm Hg) hypotension. RESULTS One hundred (65%) of the 154 ischemic stroke patients were treated with antihypertensive agents. Forty-two percent of those who had received therapy prior to admission had their regimen intensified, and 36% of previously untreated patients had therapy initiated. Sixteen (11%) patients had hypertension severe enough to warrant treatment upon arrival, and 34 (22%) had at least one episode of severe hypertension during the first 4 hospital days. Sixty-five (65%) patients developed relative hypotension on a day when antihypertensive agents were administered, and five (5%) developed absolute hypotension. CONCLUSIONS Most patients with acute ischemic stroke are treated with antihypertensive agents despite the absence of severe hypertension. Although low blood pressure is common among treated patients, frank hypotension is unusual.
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Affiliation(s)
- P K Lindenauer
- Division of Healthcare Quality, Baystate Medical Center, 759 Chestnut St., P-5931, Springfield, MA 01199, USA.
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Abstract
CONTEXT Cardiovascular complications following major noncardiac surgery are an important source of perioperative morbidity and mortality. Although lipid-lowering medications are considered a key component in the primary and secondary prevention of cardiovascular disease, their potential benefit during the perioperative period is uncertain. OBJECTIVE To examine the association between treatment with lipid-lowering medications and in-hospital mortality following major noncardiac surgery. DESIGN, SETTING, AND PATIENTS A retrospective cohort study based on hospital discharge and pharmacy records of 780,591 patients aged 18 years or older who underwent major noncardiac surgery from January 1, 2000, to December 31, 2001, at any 1 of 329 hospitals throughout the United States. Only patients who survived through at least the second hospital day were included. Lipid-lowering therapy was defined as use during the first 2 hospital days. Propensity matching was used to adjust for numerous baseline differences. MAIN OUTCOME MEASURE In-hospital mortality. RESULTS Of the 780,591 patients, 77,082 patients (9.9%) received lipid-lowering therapy perioperatively and 23 100 (2.96%) died during the hospitalization. Treatment with lipid-lowering agents was associated with lower crude mortality (2.13% vs 3.05%, P<.001). In an analysis using matching by propensity score, 1595 patients (2.18%) treated with lipid-lowering medications died compared with 4158 patients (3.15%) who did not receive therapy or in whom treatment was initiated after the second day (P<.001). After adjusting for residual differences in the propensity matched groups using conditional logistic regression, risk of mortality remained lower among treated patients (adjusted odds ratio [OR], 0.62; 95% confidence interval [CI], 0.58-0.67). Based on this adjusted OR, the number needed to treat to prevent a postoperative death in the propensity matched cohort was 85 (95% CI, 77-98) and varied from 186 among patients at lowest risk to 30 among those with a revised cardiac risk index score of 4 or more. In a further analysis using the entire study cohort and adjusting for quintile of propensity, a significant effect of treatment persisted (adjusted OR, 0.71; 95% CI, 0.67-0.75). CONCLUSIONS Treatment with lipid-lowering agents may reduce risk of death following major noncardiac surgery. Clinical trials are required to confirm this observation.
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Affiliation(s)
- Peter K Lindenauer
- Division of Healthcare Quality, Baystate Medical Center, Springfield, Mass 01199, USA.
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Abstract
BACKGROUND Among selected patients undergoing major noncardiac surgery, beta-adrenergic blockade has been shown to reduce the risk for postoperative cardiac complications and mortality. We sought to determine how often postoperative MI might be considered preventable through appropriate use of these medications. METHODS We reviewed the medical records of patients who developed a postoperative MI between January 1, 1998, and October 31, 2001, at Baystate Medical Center, a 570-bed community-based teaching hospital in Springfield, Mass. We calculated a Revised Cardiac Risk Index score and used criteria from previous randomized trials to determine whether patients would have been candidates for perioperative beta-adrenergic blockade. Postoperative MI was considered potentially preventable if the patient appeared to have been an ideal candidate for beta-blocker therapy but did not receive it before the infarction. We compared the mortality of ideal candidates who did and did not receive beta-blockers before their infarction using multivariable logistic regression. RESULTS Seventy (97%) of the 72 patients who developed postoperative MI could have been identified as being at increased risk for cardiac complications, and 58 (81%) appeared to be ideal perioperative beta-blocker candidates. Thirty ideal candidates (52%) were treated with beta-blockers before the development of the infarction. Among ideal candidates, treatment with a beta-blocker before infarction was associated with an odds ratio of in-hospital mortality of 0.19 (95% confidence interval, 0.04-0.87). CONCLUSIONS A large percentage of the postoperative MIs at our institution might have been prevented if a beta-blocker had been administered to all ideal candidates around the time of surgery. Use of beta-blockers before infarction may reduces overall mortality, even among patients who go on to develop this complication.
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Affiliation(s)
- Peter K Lindenauer
- Division of Healthcare Quality, Baystate Medical Center, Springfield, Mass, USA.
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Fairchild DG, Benjamin EM, Gifford DR, Huot SJ. Physician leadership: enhancing the career development of academic physician administrators and leaders. Acad Med 2004; 79:214-8. [PMID: 14985193 DOI: 10.1097/00001888-200403000-00004] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
As the health care environment grows more complex, there is greater opportunity for physician administrative and management leadership. Although physicians in general, and academic physicians in particular, view management as outside their purview, the increased importance of physician administrative leadership represents an opportunity for academic physicians interested in working at the interface of clinical medicine, health care, finance, and management. These physicians are called academic physician administrators and leaders (APALs). APALs are clinician-administrators whose academic contributions include both scholarly work related to their administrative duties and administrative leadership of academically important programs. However, existing academic career development infrastructure, such as academic promotions, is oriented toward traditional clinician-educator and clinician-researcher faculty. The APAL career path differs from traditional academic pathways because APALs require unique skills, different mentors, and a more expansive definition of academic productivity. This article describes how academic medical institutions could enhance the career development of academic physicians in administrative and leadership positions.
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Affiliation(s)
- David G Fairchild
- Division of General Medicine at Tufts-New England Medical Center, Boston, Massachusetts 02111, USA.
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Affiliation(s)
- Wilson C. Mertens
- Baystate Regional Cancer Program, Baystate Medical Center, Springfield, MA, Tufts University School of Medicine, Boston, MA
| | - Donald J. Higby
- Baystate Regional Cancer Program, Baystate Medical Center, Springfield, MA, Tufts University School of Medicine, Boston, MA
| | - David Brown
- Baystate Regional Cancer Program, Baystate Medical Center, Springfield, MA, Tufts University School of Medicine, Boston, MA
| | - Regina Parisi
- Baystate Regional Cancer Program, Baystate Medical Center, Springfield, MA, Tufts University School of Medicine, Boston, MA
| | - Janice Fitzgerald
- Baystate Regional Cancer Program, Baystate Medical Center, Springfield, MA, Tufts University School of Medicine, Boston, MA
| | - Evan M. Benjamin
- Baystate Regional Cancer Program, Baystate Medical Center, Springfield, MA, Tufts University School of Medicine, Boston, MA
| | - Peter K. Lindenauer
- Baystate Regional Cancer Program, Baystate Medical Center, Springfield, MA, Tufts University School of Medicine, Boston, MA
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Mertens WC, Higby DJ, Brown D, Parisi R, Fitzgerald J, Benjamin EM, Lindenauer PK. Improving the care of patients with regard to chemotherapy-induced nausea and emesis: the effect of feedback to clinicians on adherence to antiemetic prescribing guidelines. J Clin Oncol 2003; 21:1373-8. [PMID: 12663729 DOI: 10.1200/jco.2003.08.118] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the effect of performance and outcomes feedback on adherence to clinical practice guidelines regarding chemotherapy-induced nausea and emesis (CINE). METHODS Institutional CINE clinical practice guidelines were developed based on American Society of Clinical Oncology guidelines. Consecutive administrations of moderately/highly emetogenic chemotherapy were assessed for errors. Baseline statistical process control (SPC) charts were created and mean errors per administration were calculated. Prospective SPC charts were used to measure the effect of guideline development and distribution, a visiting lecturer, and ongoing feedback regarding compliance with guidelines employing SPC charts. Patients were surveyed regarding the extent and severity of CINE for 5 days postadministration. These outcomes were then shared with physicians. RESULTS Baseline compliance was poor (mean, 0.87 omissions per chemotherapy administration), largely because of inadequate adherence to recommendations for delayed CINE management. Most patients experienced delayed nausea, particularly on day 3 postchemotherapy. Physician prescribing performance did not undergo sustained improvement despite guideline development or distribution, a lecture by a visiting expert, or sharing of adherence data with clinicians. Once patient outcomes were shared, physicians accepted the need for compliance and instituted nurse practitioner antiemetic prescribing, with almost complete compliance and concurrent measurable reduction in day 3 nausea. SPC charts documented improvements in both outcomes. CONCLUSIONS SPC charts effectively monitor ongoing compliance and patient symptoms and represent appropriate outcome measurement and change facilitation tools. However, physician participation in guideline development and evidence of poor compliance alone did not improve prescribing performance. Only evidence of patient CINE experience coupled with noncompliance improved results.
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Affiliation(s)
- Wilson C Mertens
- Baystate Regional Cancer Program, Division of Hematology Oncology, Baystate Medical Center, Springfield, MA 01107, USA.
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Lindenauer PK, Benjamin EM, Naglieri-Prescod D, Fitzgerald J, Pekow P. The role of the institutional review board in quality improvement: a survey of quality officers, institutional review board chairs, and journal editors. Am J Med 2002; 113:575-9. [PMID: 12459404 DOI: 10.1016/s0002-9343(02)01250-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE There has been growing concern about whether and when quality improvement activities require Institutional Review Board (IRB) review and informed consent. We sought to determine whether quality officers, IRB chairs, and journal editors share similar views about the role of IRB review and informed consent in quality improvement. METHODS A survey consisting of six quality improvement scenarios detailing the development, implementation, and evaluation of a clinical practice guideline for the management of patients with acute myocardial infarction was mailed to all medical directors of quality and IRB chairpersons at hospitals with at least 400 beds that are members of the Council of Teaching Hospitals of the Association of American Medical Colleges. The same survey was mailed to the editors of all U.S. medical journals that appear in Abridged Index Medicus. RESULTS Quality officers were less likely than IRB chairs to believe that IRB review was required for all but one of the scenarios. When a clinical practice guideline developed by a national specialty society was implemented locally and its effects evaluated by chart review and telephone calls to patients, 47% (44/94) of IRB chairs, 66% (25/38) of journal editors, but only 20% (20/100) of quality officers believed the activity should be subjected to IRB review. Among those who thought that IRB review was required, there were similar but less striking differences in the perceived need for informed consent. Agreement between quality officers and IRB chairs within the same institution was poor, ranging from 44% to 52% for three of the six scenarios. CONCLUSION In light of the pressing need to improve quality while protecting the rights of patients, efforts should be supported to clarify the role of the IRB in quality improvement activities.
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Affiliation(s)
- Peter K Lindenauer
- Division of Healthcare Quality, Baystate Medical Center, 759 Chestnut Street P-5928, Springfield, MA 01199, USA.
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Lindenauer PK, Chehabeddine R, Pekow P, Fitzgerald J, Benjamin EM. Quality of care for patients hospitalized with heart failure: assessing the impact of hospitalists. Arch Intern Med 2002; 162:1251-6. [PMID: 12038943 DOI: 10.1001/archinte.162.11.1251] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The quality of care provided to patients hospitalized for heart failure has been shown to vary by physician, hospital, and region. Hospitalists appear to reduce costs and length of stay, yet their impact on quality of care is less certain. OBJECTIVE To compare quality of care and resource utilization among patients with heart failure treated by hospitalists and nonhospitalist general internists. METHODS We reviewed the medical records of patients with a principal diagnosis of heart failure between April 1, 1999, and March 30, 2000, at a 550-bed community-based teaching hospital in Massachusetts. We evaluated quality of care by measuring adherence to a set of commonly used process measures and compared resource utilization using severity-adjusted length of stay and costs. RESULTS The analysis included 280 patients, accounting for 326 heart failure admissions: 20 hospitalists cared for 137 (42%) cases, while 65 nonhospitalists cared for 189 (58%). Of 137 hospitalist cases, 129 (94%) had new or prior left ventricular ejection fraction testing results documented during the hospitalization compared with 165 (87%) of 189 nonhospitalist cases (P =.04). In cohorts of ideal candidates, performance rates for hospitalist and nonhospitalist cases were similar for prescriptions of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for patients with ejection fractions lower than 40% (97% vs 96%; P>.99) and warfarin for patients with atrial fibrillation (60% vs 55%; P =.64). Rates of comprehensive discharge counseling was similar in the 2 groups. Multivariable modeling did not substantially alter these findings. After adjusting for differences in severity, patients treated by hospitalists had a shorter length of stay but similar overall costs when compared with those treated by nonhospitalists. CONCLUSION Compared with nonhospitalists, hospitalists were more likely to document assessment of left ventricular function and their patients had a shorter length of stay.
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Affiliation(s)
- Peter K Lindenauer
- Division of Healthcare Quality, Baystate Medical Center, 759 Chestnut St P-5928, Springfield, MA 01199, USA.
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Schmidt M, Lindenauer PK, Fitzgerald JL, Benjamin EM. Forecasting the impact of a clinical practice guideline for perioperative beta-blockers to reduce cardiovascular morbidity and mortality. Arch Intern Med 2002; 162:63-9. [PMID: 11784221 DOI: 10.1001/archinte.162.1.63] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Beta-blockers reduce morbidity and mortality when administered to high-risk patients undergoing major noncardiac surgery, yet little is known about how often they are being prescribed. Clinical practice guidelines are tools that can be used to speed the translation of research into practice and may be one method to improve the use of beta-blockers. Before implementing any guideline, it is important to forecast its potential clinical and financial impact. METHODS We conducted a retrospective cohort study, using administrative and medical record review data, of all adult patients undergoing major noncardiac surgery at Baystate Medical Center, Springfield, Mass, during a 1-month period in 1999. Patients with 2 or more cardiac risk factors or with documented coronary artery disease were classified as high risk and were considered eligible for treatment with a beta-blocker if they had no obvious contraindications to its use. We estimated the potential clinical benefit of treating eligible patients with a beta-blocker by extrapolating the treatment effect observed in a previously reported randomized clinical trial. RESULTS Of 158 patients undergoing major noncardiac surgery, 67 (42.4%) seemed to be ideal candidates for treatment with perioperative beta-blockers. Of these 67 patients, 25 (37%) received a beta-blocker at some time perioperatively. During the course of a year, we estimate that between 560 and 801 patients who do not receive beta-blockers might benefit from treatment with these medications. Full use of beta-blockers among eligible patients at our institution could result in 62 to 89 fewer deaths each year at an overall cost of $33 661 to $40 210. CONCLUSIONS There seems to be a large opportunity to improve the quality of care of patients undergoing major noncardiac surgery by increasing the use of beta-blockers in the perioperative period. A clinical practice guideline may be one method to achieve these goals at little cost.
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Affiliation(s)
- Michael Schmidt
- Department of Biostatistics and Epidemiology, University of Massachusetts at Amherst, Amherst, MA, USA
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Rolka DB, Narayan KM, Thompson TJ, Goldman D, Lindenmayer J, Alich K, Bacall D, Benjamin EM, Lamb B, Stuart DO, Engelgau MM. Performance of recommended screening tests for undiagnosed diabetes and dysglycemia. Diabetes Care 2001; 24:1899-903. [PMID: 11679454 DOI: 10.2337/diacare.24.11.1899] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the performance, in settings typical of opportunistic and community screening programs, of screening tests currently recommended by the American Diabetes Association (ADA) for detecting undiagnosed diabetes. RESEARCH DESIGN AND METHODS Volunteers aged > or =20 years without previously diagnosed diabetes (n = 1,471) completed a brief questionnaire and underwent recording of postprandial time and measurement of capillary blood glucose (CBG) with a portable sensor. Participants subsequently underwent a 75-g oral glucose tolerance test; fasting serum glucose (FSG) and 2-h postload serum glucose (2-h SG) concentrations were measured. The screening tests we studied included the ADA risk assessment questionnaire, the recommended CBG cut point of 140 mg/dl, and an alternative CBG cut point of 120 mg/dl. Each screening test was evaluated against several diagnostic criteria for diabetes (FSG > or =126 mg/dl, 2-h SG > or =200 mg/dl, or either) and dysglycemia (FSG > or =110 mg/dl, 2-h SG > or =140 mg/dl, or either). RESULTS Among all participants, 10.7% had undiagnosed diabetes (FSG > or =126 or 2-h SG > or =200 mg/dl), 52.1% had a positive result on the questionnaire, 9.5% had CBG > or =140 mg/dl, and 18.4% had CBG > or =120 mg/dl. The questionnaire was 72-78% sensitive and 50-51% specific for the three diabetes diagnostic criteria; CBG > or =140 mg/dl was 56-65% sensitive and 95-96% specific, and CBG > or =120 mg/dl was 75-84% sensitive and 86-90% specific. CBG > or =120 mg/dl was 44-62% sensitive and 89-90% specific for dysglycemia. CONCLUSIONS Low specificity may limit the usefulness of the ADA questionnaire. Lowering the cut point for a casual CBG test (e.g., to 120 mg/dl) may improve sensitivity and still provide adequate specificity.
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Affiliation(s)
- D B Rolka
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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Benjamin EM, Schneider MS, Hinchey KT. Implementing practice guidelines for diabetes care using problem-based learning. A prospective controlled trial using firm systems. Diabetes Care 1999; 22:1672-8. [PMID: 10526733 DOI: 10.2337/diacare.22.10.1672] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A controlled trial with 15-month follow-up was conducted in two outpatient clinics to study the effects of using the problem-based learning technique to implement a diabetes clinical practice guideline. RESEARCH DESIGN AND METHODS A total of 144 patients with type 2 diabetes aged 25-65 years in two internal medicine outpatient clinics were enrolled in the study. African-Americans and Hispanics made up > 75% of the patients. Doctors and staff in one of the clinics were trained in the use of a clinical practice guideline based on Staged Diabetes Management. A problem-based learning educational program was instituted to reach consensus on a stepped intensification scheme for glycemic control and to determine the standards of care used in the clinic. HbA1c was obtained at baseline and at 9 and 15 months after enrollment. RESULTS At 9 months, there was a mean -0.90% within-subject change in HbA1c in the intervention group, with no significant changes in the control group. The 15-month mean within-subject change in HbA1c of -0.62% in the intervention group was also significant. Among intervention patients, those with the poorest glycemic control at baseline realized the greatest benefit in improvement of HbA1c. The intervention group also exhibited significant changes in physician adherence with American Diabetes Association standards of care. CONCLUSIONS Clinical practice guidelines are an effective way of improving the processes and outcomes of care for patients with diabetes. Problem-based learning is a useful strategy to gain physician support for clinical practice guidelines. More intensive interventions are needed to maintain treatment gains.
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Affiliation(s)
- E M Benjamin
- Clinical Practices Evaluation and Management, Baystate Medical Center, Springfield, MA 01199, USA.
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Benjamin EM, Gershman M, Goldberg BW. Community-acquired invasive group A beta-hemolytic streptococcal infections in Zuni Indians. Arch Intern Med 1992; 152:1881-4. [PMID: 1520055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Outbreaks of invasive group A beta-hemolytic streptococcal (GABS) infections have recently been reported. We observed a high incidence of invasive GABS disease among Native Americans at a small rural community hospital between 1982 and 1991. METHODS A retrospective chart review was performed, and all cases of invasive GABS disease were studied for their clinical features. RESULTS Sixteen cases of invasive GABS infection were identified during the 10-year study period. The rate of invasive GABS infection was 13.3 cases per 100,000 population per year. Mortality was 25%. Nearly half of the patients presented with systemic signs of sepsis without any obvious source of infection. CONCLUSIONS Our experience documents a high rate of invasive GABS infections in a defined Native American population. To determine whether this population has a unique susceptibility to GABS disease requires further study.
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Affiliation(s)
- E M Benjamin
- Department of Medicine, Public Health Service Indian Hospital, Zuni, NM 87327
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