Characteristics Associated With High-Performing Pediatric Heart Transplant Centers in the United States From 2006 to 2015

IMPORTANCE

Differences among pediatric transplant centers in long-term survival of pediatric recipients of heart transplants can be mostly explained by differences in 90-day mortality.

OBJECTIVE

To understand characteristics associated with high-performing pediatric HT centers by comparing key outcomes among centers stratified by 90-day risk-adjusted mortality.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included recipients of HT aged younger than 18 years in the US. Analyses included 44 US centers during 2006 to 2015 using the Organ Procurement and Transplant Network database. A risk model for 90-day mortality was developed using data from all recipients to estimate expected 90-day mortality and 90-day standardized mortality ratio (SMR; calculated as observed mortality divided by expected mortality) for each center. Centers were stratified into tertiles by SMR and compared for key outcomes. Data were analyzed from January to March 2020.

EXPOSURES

High-, medium-, and low-performing centers (SMR tertile).

MAIN OUTCOMES AND MEASURES

Posttransplant 90-day mortality across recipient risk spectrum and incidence of and mortality following early posttransplant complications.

RESULTS

Of 3211 children analyzed, 1016 (31.6%) were infants younger than 1 year and 1459 (45.4%) were girls. The median (interquartile range) age was 4 (0-12) years. Centers were stratified by SMR tertile, and SMR was 0 to 0.71 among 15 high-performing centers, 0.79 to 1.12 among 14 medium-performing centers, and 1.19 to 3.33 among 15 low-performing centers. High-performing centers had 90-day mortality of 0.8% (95% CI, 0.3%-1.8%) in children with low risk and expected mortality of 2.0%, 2.3% (95% CI, 0.6%-5.7%) in children with intermediate risk and expected mortality of 6.5%, and 16.7% (95% CI, 7.9%-29.3%) in children with high risk and expected mortality of 30.8%. Incidence of acute rejection during transplant hospitalization was 10.3% at high-performing centers, 10.3% at medium-performing centers, and 9.7% at low-performing centers (P for trend = .68), and incidence of post-HT kidney failure requiring dialysis was 4.1% at high-performing centers, 5.2% at medium-performing centers, and 8.5% at low-performing centers (P for trend = .001). Ninety-day mortality was significantly lower at high-performing centers among children treated for rejection (high-performing: 2.0%; medium-performing: 6.9%; low-performing: 11.7%; P for trend = .006) and among recipients receiving dialysis for post-HT kidney failure (high-performing: 17.5%; medium-performing: 39.4%; low-performing: 47.6%; P for trend < .001).

CONCLUSIONS AND RELEVANCE

This cohort study found that high-performing pediatric HT centers had lower 90-day mortality across the recipient risk spectrum and lower mortality among recipients who develop rejection or post-HT kidney failure during transplant hospitalization. These findings suggest presence of superior processes and systems of care at high-performing pediatric HT centers.

Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project

INTRODUCTION

There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist hernia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems.

METHODS

The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group-Hernia Accreditation and Certification of Centers and Surgeons-Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries.

RESULTS

The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accredited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for education and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group suggests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center.

CONCLUSION

Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems.

Fred Hutchinson Report Plots The Nexus of Cost and Quality

A report from the Hutchinson Institute for Cancer Outcomes Research is remarkable. Committing to transparency as a catalyst for improvement, 27 hospital systems and cancer centers across Washington State bare all in the first public report to integrate clinic level quality and cost data in oncology.

[Current issues in pancreatic surgery]

AIM

To present own experience of pancreatic surgery and to analyze literature data for this issue.

MATERIAL AND METHODS

We have analyzed work of abdominal surgery department over the last 5 years. Moreover, MEDLINE and RSCI databases regarding surgical treatment of pancreatic diseases were assessed.

RESULTS

There were 456 pancreatectomies. Postoperative complications arose in 176 (38.6%) patients, 11 patients died (2.4%). According to world data, mortality after pancreatectomy reaches 10%. Only creation of specialized centers is proven way to improve the outcomes.

CONCLUSION

Current medical assistance for pancreatic disease may be only achieved in specialized centers with large number of various pancreatic procedures. The organization of such centers is required throughout the country and certain accreditation criteria should be developed for this purpose. Targeted routing of patients to specialized pancreatology centers will be able to reduce incidence of diagnostic, tactical and technical errors.

Short-term Outcomes of Total Knee Arthroplasty Performed at an Orthopedic Specialty Hospital

This study compared perioperative outcomes for total knee arthroplasty (TKA) at an orthopedic specialty hospital and a tertiary referral center. The authors identified all primary TKA procedures performed in 2014 at the 2 facilities. Each patient at the orthopedic specialty hospital was manually matched to a patient at the tertiary referral center according to demographic and clinical variables. Matching was blinded to outcomes. Outcomes were 90-day readmission, mortality rate, reoperation, length of stay, and use of inpatient rehabilitation. Each group had 215 TKA patients. The 2 groups of patients were similar in age (66.8 years, P=.98), body mass index (30.4 kg/m², P=.99), age-adjusted Charlson Comorbidity Index (3.4, P=1.00), and sex (46.0% male, P=1.00). Mean length of stay was 1.47±0.62 days at the orthopedic specialty hospital vs 1.87±0.75 days (P<.01) at the tertiary referral center. There were 3 readmissions at the orthopedic specialty hospital and 6 readmissions at the tertiary referral center (P=.31). There were 6 reoperations at the orthopedic specialty hospital and 5 at the tertiary referral center (P=.76). In addition, 8 patients at the orthopedic specialty hospital used inpatient rehabilitation vs 15 patients at the tertiary referral center (P=.08). One patient who was treated at the orthopedic specialty hospital required transfer to a tertiary referral center. This study found that perioperative outcomes were similar for matched patients who underwent primary TKA at an orthopedic specialty hospital and a tertiary referral center. Patients treated at the orthopedic specialty hospital spent 0.4 fewer days in the hospital compared with matched patients who were treated at the tertiary referral center. This equals 2 fewer hospital nights for every 5 TKA patients. [Orthopedics. 2018; 41(1):e84-e91.].

Centralization of Services: Standard Setting and Outcomes

Objective

To test specific standards set in the newly established cleft lip and palate service in three regions of the U.K. The standards relate to record collection and outcomes.

Design

Retrospective analysis.

Patients

Records of 31 children, 5 years of age, who were born in 1997 with complete unilateral clefts of lip and palate and were treated by surgeons in three regions.

Main outcome measures

Record collection standards were measured by collecting dental study models. Outcomes were measured with the 5-Year-Old Index.

Results

Of the 31 subjects, 52% had excellent and good outcomes. The 31 cases represented 62% of the total records collected.

Conclusions

The three regions examined fell short of the standards set, but the outcomes were improved compared with previous national outcomes. The failings in record collection need to be rectified. This study provides baseline data for further development of cleft services within three regions.

An Assessment of the Safety of an Orthopedic Specialty Hospital: A 5-Year Experience

One of the goals of orthopedic specialty hospitals is to provide safe and efficient care to medically optimized patients. The authors' orthopedic specialty hospital is a physician-owned, 24-bed facility that accommodates a multispecialty orthopedic practice in the areas of spine, hip and knee arthroplasty, shoulder and elbow, sports, foot and ankle, and hand surgery. The purpose of this study was to examine the first 5 years of an institutional experience with an orthopedic specialty hospital and to determine if any procedures were at increased risk of postoperative transfer. When higher-level emergency treatment was required, patients were appropriately and expeditiously transferred and treated at an acute care facility. Length of stay compared favorably with that in traditional acute care hospitals. The specialty hospital may be an appropriate model for delivery of care to medically screened patients in the United States. [Orthopedics. 2017; 40(4):223-229.].

Associations Between Hospital Characteristics, Measure Reporting, and the Centers for Medicare & Medicaid Services Overall Hospital Quality Star Ratings

This study uses CMS Overall Hospital Quality Star Rating data to estimate associations between hospital characteristics, number and types of measures reported, and the CMS Hospital Quality Star Ratings.

Benchmarking specialty hospitals, a scoping review on theory and practice

BACKGROUND

Although benchmarking may improve hospital processes, research on this subject is limited. The aim of this study was to provide an overview of publications on benchmarking in specialty hospitals and a description of study characteristics.

METHODS

We searched PubMed and EMBASE for articles published in English in the last 10 years. Eligible articles described a project stating benchmarking as its objective and involving a specialty hospital or specific patient category; or those dealing with the methodology or evaluation of benchmarking.

RESULTS

Of 1,817 articles identified in total, 24 were included in the study. Articles were categorized into: pathway benchmarking, institutional benchmarking, articles on benchmark methodology or -evaluation and benchmarking using a patient registry. There was a large degree of variability:(1) study designs were mostly descriptive and retrospective; (2) not all studies generated and showed data in sufficient detail; and (3) there was variety in whether a benchmarking model was just described or if quality improvement as a consequence of the benchmark was reported upon. Most of the studies that described a benchmark model described the use of benchmarking partners from the same industry category, sometimes from all over the world.

CONCLUSIONS

Benchmarking seems to be more developed in eye hospitals, emergency departments and oncology specialty hospitals. Some studies showed promising improvement effects. However, the majority of the articles lacked a structured design, and did not report on benchmark outcomes. In order to evaluate the effectiveness of benchmarking to improve quality in specialty hospitals, robust and structured designs are needed including a follow up to check whether the benchmark study has led to improvements.

A comparison of the surgical mortality due to colorectal perforation at different hospitals with data from 10,090 cases in the Japanese National Clinical Database

Colorectal perforation has a high rate of mortality. We compared the incidence and fatality rates of colorectal perforation among different hospitals in Japan using data from the nationwide surgical database.Patients were registered in the National Clinical Database (NCD) between January 1st, 2011 and December 31st, 2013. Patients with colorectal perforation were identified from surgery records by examining if acute diffuse peritonitis (ADP) and diseases associated with a high probability of colorectal perforation were noted. The primary outcome measures included the 30-day postsurgery mortality and surgical mortality of colorectal perforation. We analyzed differences in the observed-to-expected mortality (O/E) ratio between the two groups of hospitals, that is, specialized and non-specialized, using the logistic regression analysis forward selection method.There were 10,090 cases of disease-induced colorectal perforation during the study period. The annual average postoperative fatality rate was 11.36%. There were 3884 patients in the specialized hospital group and 6206 in the non-specialized hospital group. The O/E ratio (0.9106) was significantly lower in the specialized hospital group than in the non-specialized hospital group (1.0704). The experience level of hospitals in treating cases of colorectal perforation negatively correlated with the O/E ratio.We conducted the first study investigating differences among hospitals with respect to their fatality rate of colorectal perforation on the basis of data from a nationwide database. Our data suggest that patients with colorectal perforation should choose to be treated at a specialized hospital or a hospital that treats five or more cases of colorectal perforation per year. The results of this study indicate that specialized hospitals may provide higher quality medical care, which in turn proves that government policy on healthcare is effective at improving the medical system in Japan.

[Ebola virus disease and accredited specialist health institutions]

Ebola virus disease (EVD) went in the space of a few months from being a forgotten tropical disease to a global "health emergency". The scope of this Ebola virus epidemic (Zaire strain), which has broken out in West Africa, its spread and the high number of deaths reported among frontline health workers are unprecedented. This article describes how a specialist hospital deals with imported cases of EVD.

[THE EVALUATION OF EFFECTIVENESS OF FUNCTIONING OF TUBERCULOSIS HOSPITALS AND CALCULATION OF NECESSARY NUMBER OF BEDS AT THE REGIONAL LEVEL]

The adequate planning of capacity of hospital medical care accounting regional characteristics of prevalence of tuberculosis infection and functioning of anti-tuberculosis institutions are one of activities increasing effectiveness of resources using. So far, in the Russian Federation no techniques was developed permitting to determine need of tuberculosis service of region in number of beds based on epidemiological indicators of tuberculosis. To bring nearer as much as possible to reliable level of such a need in the Irkutskaia oblast the technique was developed on the basis of listing of indications for hospitalization of tuberculosis patients. This technique permits to substantiate the need of the subject of the Russian Federation in necessary number of beds in consideration of regional characteristics of prevalence of tuberculosis. This approach supports development of organization, planning and increasing of effectiveness of anti-tuberculosis activities in modern conditions.

Evaluation of headache service quality indicators: pilot implementation in two specialist-care centres

BACKGROUND

Evaluating quality of health care is increasingly recognized as an important contributor to the advancement of health-care delivery. We recently developed a set of quality indicators for headache care, intended to be applicable across countries, cultures and settings so that deficiencies in headache care worldwide might be recognized and rectified. These indicators themselves require evaluation and proof of fitness for purpose. This pilot study begins this process.

METHODS

We tested the quality indicators in the tertiary headache centres of the University of Duisburg-Essen in Essen, Germany, and the Hospital da Luz in Lisbon, Portugal. Using seven previously-developed enquiry instruments, we interrogated health-care providers (HCPs), including doctors, nurses, psychologists and physiotherapists, as well as consecutive patients and their medical records.

RESULTS

The questionnaires were easily understood by both HCPs and patients and were not unduly time-consuming. The results from the two headache centres were comparable despite their differences in structure, staffing and language. These findings met the purpose of the study. Diagnoses were made according to ICHD criteria and critically evaluated during follow-up. However, diagnostic diaries and instruments assessing burden and response to treatment were not always in place or routinely utilised. Triage systems adjusted waiting times to urgency of need. Treatment plans included pathways to other specialities. Patients felt welcomed, reassured and educated, and were mostly satisfied. Discussion points arose over inclusion of psychological therapies in treatment plans; over recording of outcomes; over indicators of efficiency and equitability (protocols to limit wastage of resources, systems to measure input costs and means of ensuring equal access to the services); and over protocols for reporting serious adverse events.

CONCLUSION

This pilot study to assess feasibility of the methods and acceptability of the instruments of headache service quality evaluation was successful. The project is ready to be taken into its next stages.

[Clinical competence certification for advanced heart failure: an emerging need also in Italy?]

Advanced heart failure (HF) is a deadly condition. Fortunately, an increasing array of effective (but often expensive) therapies has become available. The management of patients with advanced HF is complex and requires a high level of expertise. The American Board of Internal Medicine was the first regulatory board to recognize the need for a subspecialty in Advanced HF and Transplant Cardiology. More recently, the HF Association of the European Society of Cardiology has proposed a curriculum for HF specialists that includes the optional module of advanced HF therapy. However, the successful completion of such a curriculum does not result in a European Certification in Heart Failure, because no European Board of Medicine does exist. While in some European countries the secondary specialty of HF has been implemented, no country has a subspecialty in advanced HF. The ANMCO HF Area has proposed a survey to 25 Italian centers with accredited programs for heart transplant or ventricular assist device implant as destination therapy with the aim to assess the actual need of a certification of clinical competence in advanced HF and a certification of institutional competence for the centers with the highest expertise in advanced HF management. The survey indicated that there is a perceived need. A first step towards education of advanced HF specialists could be the implementation of CME courses by Scientific Societies. As regards certification of institutional competence for the centers with the highest expertise in advanced HF management, the government appears to be the only entity that can grant it.

Increased Rate of Catheter-Related Bloodstream Infection Associated With Use of a Needleless Mechanical Valve Device at a Long-Term Acute Care Hospital

Objective.

To determine whether introduction of a needleless mechanical valve device (NMVD) at a long-term acute care hospital was associated with an increased frequency of catheter-related bloodstream infection (BSI).

Design.

For patients with a central venous catheter in place, the catheter-related BSI rate during the 24-month period before introduction of the NMVD, a period in which a needleless split-septum device (NSSD) was being used (hereafter, the NSSD period), was compared with the catheter-related BSI rate during the 24-month period after introduction of the NMVD (hereafter, the NMVD period). The microbiological characteristics of catheter-related BSIs during each period were also compared. Comparisons and calculations of relative risks (RRs) with 95% confidence intervals (CIs) were performed using χ2 analysis.

Results.

Eighty-six catheter-related BSIs (3.86 infections per 1,000 catheter-days) occurred during the study period. The rate of catheter-related BSI during the NMVD period was significantly higher than that during the NSSD period (5.95 vs 1.79 infections per 1,000 catheter-days; RR, 3.32 [95% CI, 2.88–3.83]; P < .001). A significantly greater percentage of catheter-related BSIs during the NMVD period were caused by gram-negative organisms, compared with the percentage recorded during the NSSD period (39.5% vs 8%; P = .007). Among catheter-related BSIs due to gram-positive organisms, the percentage caused by enterococci was significantly greater during the NMVD period, compared with the NSSD period (54.8% vs 13.6%; P = .004). The catheter-related BSI rate remained high during the NMVD period despite several educational sessions regarding proper use of the NMVD.

Conclusions.

An increased catheter-related BSI rate was temporally associated with use of a NMVD at the study hospital, despite several educational sessions regarding proper NMVD use. The current design of the NMVD may be unsafe for use in certain patient populations.

Governmental designation of spine specialty hospitals, their characteristics, performance and designation effects: a longitudinal study in Korea

OBJECTIVES

This study compares the characteristics and performance of spine specialty hospitals versus other types of hospitals for inpatients with spinal diseases in South Korea. We also assessed the effect of the government's specialty hospital designation on hospital operating efficiency.

SETTING

We used data of 823 hospitals including 17 spine specialty hospitals in Korea.

PARTICIPANTS

All spine disease-related inpatient claims nationwide (N=645 449) during 2010-2012.

INTERVENTIONS

No interventions were made.

OUTCOME MEASURES

Using a multilevel generalised estimating equation and multilevel modelling, this study compared inpatient charges, length of stay (LOS), readmission within 30 days of discharge and in-hospital death within 30 days of admission in spine specialty versus other types of hospitals.

RESULTS

Spine specialty hospitals had higher inpatient charges per day (27.4%) and a shorter LOS (23.5%), but per case charges were similar after adjusting for patient-level and hospital-level confounders. After government designation, spine specialty hospitals had 8.8% lower per case charges, which was derived by reduced per day charge (7.6%) and shorter LOS (1.0%). Rates of readmission also were lower in spine specialty hospitals (OR=0.796). Patient-level and hospital-level factors both played important roles in determining outcome measures.

CONCLUSIONS

Spine specialty hospitals had higher per day inpatient charges but a much shorter LOS than other types of hospitals due to their specialty volume and experience. In addition, their readmission rate was lower. Spine specialty hospitals also endeavoured to be more efficient after governmental 'specialty' designation.

[The quality management in clinical diagnostic laboratory in conditions of the Federal Center of traumatology, orthopedics and endoprosthesis replacement of Minzdrav of Russia (Cheboksary)]

The article presents experience of clinical diagnostic laboratory of the Federal Center of traumatology, orthopedics and endoprosthesis replacement of Minzdrav of Russia (Cheboksary) in the area of quality management of medical laboratory services on the basis of evaluation of efficacy and effectiveness of processes. The factors effecting quality of functioning of clinical diagnostic laboratory are indicated. The criteria and indicators of efficacy of work of employees of clinical diagnostic laboratory are presented.

Implementation of patient safety and patient-centeredness strategies in Iranian hospitals

OBJECTIVE

To examine the extent of implementation for patient safety (PS) and patient-centeredness (PC) strategies and their association with hospital characteristics (type, ownership, teaching status, annual evaluation grade) in Iran.

METHODS

A cross-sectional study through an adapted version of the MARQuIS questionnaire, eliciting information from hospital and nursing managers in 84 Iranian hospitals on the implementation of PS and PC strategies in 2009-2010.

RESULTS

The majority of hospitals reported to have implemented 84% of the PS and 72% of the PC strategies. In general, implementation of PS strategies was unrelated to the type of hospital, with the exception of health promotion reports, which were more common in the Social Security Organization (SSO), and MRSA testing, which was reported more often in nonprofit hospitals. MRSA testing was also more common among teaching hospitals compared to non-teaching hospitals. The higher grade hospitals reported PS strategies significantly more frequently than lower grade hospitals. Overall, there was no significant difference in the reported implementation of PC strategies across general and specialized hospitals; except for the provision of information in different languages and recording of patient's diet which were reported significantly more often by general than specialized hospitals. Moreover, patient hotel services were more common in private compared to public hospitals.

CONCLUSIONS

Despite substantial reporting of PS and PC strategies, there is still room for strengthening standard setting on safety, patient services and patient-centered information strategies in Iranian hospitals. To assure effective implementation of PS and PC strategies, enforcing standards, creating a PS and PC culture, increasing organizational responsiveness, and partnering with patients and their families need more attention.

Bayreuth Productivity Analysis-a method for ascertaining and improving the holistic service productivity of acute care hospitals

The healthcare sector is lacking a method with which hospitals can measure the extent to which they achieve their goals in terms of aggregate productivity from both patients' and employees' perspectives. The Bayreuth Productivity Analysis (BPA) provides a solution to this problem because it uses two standardized questionnaires-one for patients and one for employees-to ascertain productivity at hospitals. These questionnaires were developed in several steps according to the principles of classical test theory, and they consist of six dimensions (information, organization, climate, methods, infrastructure and equipment) of five items each. One item describes a factual situation relevant to productivity and services so that it makes a contribution to the overall productivity of a hospital. After individualized evaluation of these items, the dimensions are subjectively weighted in the two questionnaires. The productivity index thus ascertained can be considered "holistic" when all patients and employees in a hospital make a differentiated assessment and weigh off each of the dimensions. In conclusion, the BPA constitutes a simple yet practicable method to ascertain and improve the holistic service productivity of hospitals.

[The universal audiological screening of newborn infants: achievements and challenges]

The objective of the present study was to estimate the effectiveness of universal audiological screening of newborn infants in Russia based on the results of this procedure obtained in 2011-2012 by the analysis of the activities of surdological centres in 15 regions of the country. It was shown, that the main indicators of the effectiveness of the screening are the technical equipment of maternity houses, newborn coverage at the first stage of screening, and its continuity. The study revealed 3.14% of the infants who failed to be involved in the first stage of screening. Hearing impairment was diagnosed in two of each 1,000 newborn infants at the second stage of screening, the frequency of severe forms of hearing impairment was estimated as three cases per 10,000 infants. The disadvantages of the current system of identification of newborn infants suffering congenital loss of hearing are discussed. The importance of the improvement of data collection methods is emphasized.

Joint commission primary stroke centers utilize more rt-PA in the nationwide inpatient sample

Background

The Joint Commission began certifying primary stroke centers (PSCs) in December 2003 and provides a standardized definition of stroke center care. It is unknown if PSCs outperform noncertified hospitals. We hypothesized that PSCs would use more recombinant tissue plasminogen activator (rt‐PA) for ischemic stroke than would non‐PSCs.

Methods and Results

Data were obtained from the Nationwide Inpatient Sample from 2004 to 2009. The analysis was limited to states that publicly reported hospital identity. All patients ≥18 years with a primary diagnosis of acute ischemic stroke were included. Subjects were excluded if the treating hospital was not identified, if it was not possible to determine the temporal relationship between certification and admission, and/or if admitted as a transfer. Rt‐PA was defined by ICD9 procedure code 99.10. All eligibility criteria were met by 323 228 discharges from 26 states. There were 63 145 (19.5%) at certified PSCs. Intravenous rt‐PA was administered to 3.1% overall: 2.2% at non‐PSCs and 6.7% at PSCs. Between 2004 and 2009, rt‐PA administration increased from 1.4% to 3.3% at non‐PSCs and from 6.0% to 7.6% at PSCs. In a multivariable model incorporating year, age, sex, race, insurance, income, comorbidities, DRG‐based disease severity, and hospital characteristics, evaluation at a PSC was significantly associated with rt‐PA utilization (OR, 1.87; 95% CI, 1.61 to 2.16).

Conclusions

Subjects evaluated at PSCs were more likely to receive rt‐PA than those evaluated at non‐PSCs. This association was significant after adjustment for patient and hospital‐level variables. Systems of care are necessary to ensure stroke patients have rapid access to PSCs throughout the United States.

[A new system of specialized gastroenterological care to patients with inflammatory bowel diseases in St. Petersburg]

AIM

To substantiate the effectiveness of the set-up center in the early detection of patients with inflammatory bowel diseases (IBD) and in its organization and implementation of current therapeutic programs.

MATERIALS AND METHODS

The therapeutic activity of the specialized medical care system set up in St. Petersburg for patients with IBD (ulcerative colitis (UC) and Crohn's disease (CD)), which is based on a multifunctional inflammatory bowel disease center at City Clinical Hospital Thirty-One, was analyzed.

RESULTS

The effective work of the center could reduce time for verification of the diagnosis of UC from 6.4 +/- 1.4 to 3.6 +/- 0.8 months and CD from 28.6 +/- 6.7 to 15.3 +/- 4.2 months, respectively; decline the annual number of patients with moderate and severe UC from 73.4 to 53.6 and CD from 66.7 to 47%, and also set up a centralized system for all required types of current therapeutic and diagnostic care for these patients.

CONCLUSION

The establishment of the St. Petersburg Center for the diagnosis and treatment of inflammatory bowel diseases could develop and realize in practice a new closed-loop urban system for the early detection and notification of IBD patients, the organization and rendering of individual effective therapeutic-and-prophylactic care.

The Joint Commission reports high interest in new certification program for Comprehensive Stroke Centers

Hospitals with the advanced resources and personnel capable of providing state-of-the-art care for the most complex types of stroke can now seek certification from The Joint Commission (TJC) as a Comprehensive Stroke Center. The move follows recommendations by the Brain Attack Coalition, an expert panel that established criteria for Comprehensive Stroke Centers. The concept is designed to strengthen a network of stroke care in the country similar to the system in place for trauma care. The certification process includes a two-day, on-site evaluation by TJC reviewers. Experts anticipate that about 200 medical centers will become certified as Comprehensive Stroke Centers. Comprehensive Stroke Centers should serve as referral centers for the more than 900 Primary Stroke Centers as well as other hospitals that are not equipped to care for complex stroke patients.

Evaluation of common operator errors in panoramic radiography in Trinidad and Tobago: a comparison of formally vs informally trained operators

AIM

To evaluate and compare the frequency of common operator errors seen on panoramic radiographs in dental private practices and in the dental hospital (taken by informally and formally trained operators, respectively) in Trinidad and Tobago.

METHOD

One thousand panoramic radiographs of patients over the age of 10 years were included in this study. These comprised 500 from the dental hospital and 500 from dental private practices. The radiographs were reviewed using standardized criteria to identify the most common operator errors.

RESULTS

There were only 21 (4.2%) error free radiographs in the dental private practice sample and 29 (5.80%) in the dental hospital sample. Frequencies of specific errors were significantly higher in the dental private practice sample in each category except for "Chin tipped too low" (Chi-square p < 0.05)

CONCLUSION

This study supports the need for the introduction of statutory guidelines with respect to the use of ionizing radiation in dentistry in Trinidad and Tobago and in particular, the implementation of formally assessed dedicated dental radiography training for all operators of dental X-ray equipment.

[Certification of vascular centers. Influence on quality and healthcare structures]

Diagnosis and therapy of vascular diseases are increasingly being performed following a multimodal, interdisciplinary and less invasive approach. The introduction of specialized, organ-related centers is a logical consequence in view of a better treatment quality and a more effective use of resources. The German societies of radiology, vascular surgery and angiology jointly developed a process of certification, which has been successfully applied to more than 100 units in Germany. In this article the terms and results of the process are described and possible effects on the quality and structures of the healthcare system are discussed.

Measuring patients satisfaction: a cross sectional study to improve quality of care at a tertiary care hospital

OBJECTIVE

To measure the satisfaction of patients attending the OPD in SKIMS tertiary hospital of Soura, India.

METHODS

Pre-structured questionnaire was framed and data collected from consenting patients attending the OPD of SKIMS hospital. The data were analyzed using SPSS version 12.

SETTINGS

OPD section of SKIMS hospital, Soura, India.

RESULTS

Four hundred (400) OPD patients were included in the study to know their perceptions towards the said hospital, reason for choosing the hospital, perception towards registration process, basic amenities and perception towards doctors and other staff. The major reason for choosing the health facility was skilled doctors. Majority of patients were satisfied with the facilities available as well as with the behaviour of doctors and other health staff.

CONCLUSION

The health care delivered at this institute can be improved more and more once the organization, measures the delivery of quality of care on and ongoing basis and continually making small changes to improve the individual processes.

Infection rates following hip and knee joint arthroplasty: large referral centre versus a small elective-only hospital

PURPOSE

The aim of this study was to investigate deep infection rates following hip and knee arthroplasty at a large referral hospital and to compare these rates with a smaller hospital where only elective surgery was performed. Both hospitals were administered by the same public institution.

METHODS

A search of the medical records was performed for all deep infections following elective primary hip and knee arthroplasty; revision procedures were excluded as were total hip replacement and hemiarthroplasty following trauma. To be considered, a deep infection cases must have had bacterial growth confirmed on deep tissue surgical specimens or on aspiration of the joint within 1 year of the index procedure.

RESULTS

There were 14 infections confirmed following 1,160 arthroplasties at the larger hospital and 1 infection for the elective-only hospital following 466 arthroplasties. Statistical analysis showed there was a 7.06 greater chance of having an infection at the larger campus compared with the smaller campus CI (1.3, 130.7). Although there was a trend towards a greater number of infections at the larger hospital, the result was not statistically significant (P = 0.06). We acknowledge there were some differences between the two study populations.

CONCLUSION

We found a trend towards, but not a statistically significant difference, between infection rates at the elective-only hospital compared to the larger institution. Given the low overall rate of infection, studies with improved statistical power are needed to determine whether there is a difference in infection rates at smaller elective-only hospitals versus larger hospitals providing elective and non-elective services. The reasons for the difference are likely to be multifactorial. We hypothesise that infection rates are increased in the larger hospital where there is more procedures, both clean and contaminated being performed in the operating theatres, as well as a greater number of inpatient beds and where the hospital admits non-elective cases via its emergency department.

LEVEL OF EVIDENCE

Level-two cohort study.

Academic ranking score: a publication-based reproducible metric of thought leadership in urology

BACKGROUND

Hospital rankings have become integral to the marketing strategies of many health care systems. Methodology used in compiling these lists appears highly flawed.

OBJECTIVE

To improve on current hospital ranking systems and to develop a more meaningful measure of a urology department's contribution to the field, we developed an academic ranking score (ARS) based on publicly available data.

DESIGN, SETTING, AND PARTICIPANTS

An active faculty list was assembled for each department. A list of all publications from each department from 2005 to 2010 was then compiled. Only publications with faculty members as first or last author were considered. The ARS was then derived by identifying the number of publications within an institution, normalized by the impact factor of the peer-reviewed journal in which the publication appeared.

MEASUREMENTS

The 2010 U.S. News & World Report (USNWR) urology list was reranked based on ARS and compared with the USNWR rank list. ARS was also calculated for several leading European urologic centers.

RESULTS AND LIMITATIONS

A total of 6437 urologic publications were indexed to calculate the ARS. Two of the top three programs in the USNWR rankings dropped out of the top 10. The top 10 academically ranked programs increased or decreased an average of >5 positions (range: 0-17). No correlation was seen between programs ranked in the top 10 by USNWR and our objective ARS method (Spearman ρ: -0.1; p=0.75). Because ARS only includes first- or last-author publications for faculty with clinical duties, ARS likely excludes basic science contributions and contributions from nonclinical faculty.

CONCLUSIONS

Ranking of urology departments through quantification of each program's recent academic contribution, as captured by the ARS, differs substantially from rankings developed by USNWR. Integration of such objective measures into an overall urology program ranking system would replace current subjective opinions marred by historical biases with up-to-date merit-based assessments.

[Monitoring evaluation system for high-specialty hospitals]

Hospital evaluation is a fundamental process to identify medical units' objective compliance, to analyze efficiency of resource use and allocation, institutional values and mission alignment, patient safety and quality standards, contributions to research and medical education, and the degree of coordination among medical units and the health system as a whole. We propose an evaluation system for highly specialized regional hospitals through the monitoring of performance indicators. The following are established as base thematic elements in the construction of indicators: safe facilities and equipment, financial situation, human resources management, policy management, organizational climate, clinical activity, quality and patient safety, continuity of care, patients' and providers' rights and obligations, teaching, research, social responsibility, coordination mechanisms. Monitoring refers to the planned and systematic evaluation of valid and reliable indicators, aimed at identifying problems and opportunity areas. Moreover, evaluation is a powerful tool to strengthen decision-making and accountability in medical units.

[Comprehensive model of care for highly specialized hospitals]

In August 2007 the committee was installed to guide and direct medical management to the satisfaction and needs of medical equipment as special ingredient in the pursuit of quality health services that should be granted to the population.

Benefit of specialized clinics for the treatment of patients with heart failure

BACKGROUND

Current guidelines recommend special attention for heart failure (HF) patients in dedicated outpatient units.

AIMS AND METHODS

In this observational cohort study we sought to determine whether an equivalent benefit is achieved in all HF patients treated in specialized heart failure clinics. Patients were stratified to patients recently referred and those who already receiving long-term care (>1 year). Data were collected at baseline and after 12 months.

RESULTS

474 patients were prospectively observed. 130 subjects were recently referred and 344 subjects had received long-term care. During follow-up of recently referred patients, enhancement of neurohumoral pharmacotherapy was achieved in 67% (p<0.001), which was paralleled by a reduction in NT-proBNP (baseline 1779 pg/ml [range 458;4685]; after 12 months 668 pg/ml [range 167;1690]; p<0.001) and improvement in quality of life score, measured by the Minnesota Living with Heart Failure Questionnaire by 8 points [range 0;23]; (at baseline 34 points [range 16;59], and after 12 months 15 points [range 5;42]; p=0.04). In contrast, these parameters were unchanged in long-term care patients. Hospitalization for HF and other cardiovascular causes was higher in patients recently referred, and all-cause mortality was comparable in both groups.

CONCLUSIONS

This comprehensive analysis of chronic HF patients treated in a specialized HF outpatient clinic confirmed the potential to optimize pharmacotherapy paralleled by improvements in quality of life and NT-proBNP levels in patients referred within the first 12 months. Prolonged management of HF patients after this optimization of maintenance therapy yields little additional benefit.

[The "outcome benchmarking in rheumatologic acute care" project of the Association of Rheumatologic Acute Care Clinics (VRA e.V.) in Germany]

By initiating and taking part in the pilot project obra (outcome benchmarking in rheumatologic acute care), which was supported by the German Ministry of Health, the rheumatologic hospitals committed themselves to the continuous improvement of quality through a collective benchmarking and learning process. In addition to verifiable and concrete improvements in quality, the major achievements of the obra pilot project include a cultural change in the participating hospitals as well as the continuation of outcome benchmarking and its expansion to an increasing number of hospitals.

Documentation of nonroutine communications of critical or significant radiology results: a multiyear experience at a tertiary hospital

PURPOSE

The aim of this study was to determine the frequency of radiology reports that contain nonroutine communications of results and categorize the urgency of such communications.

METHODS

A rule-based text-query algorithm was applied to a database of 2.3 million radiology reports, which has an accuracy of 98% for classifying reports containing documentation of communications. The frequency of such communications by year, modality, and study type was then determined. Finally, 200 random reports selected by the algorithm were analyzed, and reports containing critical results were categorized according to ascending levels of urgency.

RESULTS

Critical or noncritical results to health care providers were present in 5.09% of radiology reports (116,184 of 2,282,923). For common modalities, documentation of communications were most frequent in CT (14.34% [57,537 of 402,060]), followed by ultrasound (9.55% [17,814 of 186,626]), MRI (5.50% [13,697 of 248,833]), and chest radiography (1.57% [19,840 of 1,262,925]). From 1997 to 2005, there was an increase in reports containing such communications (3.04% in 1997, 6.82% in 2005). More reports contained nonroutine communications in single-view chest radiography (1.29% [5,533 of 428,377]) than frontal/lateral chest radiography (0.80% [1,815 of 226,837]), diagnostic mammography (9.42% [3,662 of 38,877]) than screening mammography (0.47% [289 of 61,114]), and head CT (26.21% [20,963 of 79,985]) than abdominal CT (15.05% [19,871 of 132,034]) or chest CT (5.33% [3,017 of 56,613]). All of these results were statistically significant (P < .00001). Of 200 random radiology reports indicating nonroutine communications, 155 (78%) had critical and 45 (22%) had noncritical results. Regarding level of urgency, 94 of 155 reports (60.6%) with critical results were categorized as high urgency, 31 (20.0%) as low urgency, 26 (16.8%) as medium urgency, and 4 (2.6%) as discrepant.

CONCLUSIONS

From 1997 to 2005, there was a significant increase in documentation of nonroutine communications, which may be due to increasing compliance with ACR guidelines. Most reports with nonroutine communications contain critical findings.

Association between stroke center hospitalization for acute ischemic stroke and mortality

CONTEXT

Although stroke centers are widely accepted and supported, little is known about their effect on patient outcomes.

OBJECTIVE

To examine the association between admission to stroke centers for acute ischemic stroke and mortality.

DESIGN, SETTING, AND PARTICIPANTS

Observational study using data from the New York Statewide Planning and Research Cooperative System. We compared mortality for patients admitted with acute ischemic stroke (n = 30,947) between 2005 and 2006 at designated stroke centers and nondesignated hospitals using differential distance to hospitals as an instrumental variable to adjust for potential prehospital selection bias. Patients were followed up for mortality for 1 year after the index hospitalization through 2007. To assess whether our findings were specific to stroke, we also compared mortality for patients admitted with gastrointestinal hemorrhage (n = 39,409) or acute myocardial infarction (n = 40,024) at designated stroke centers and nondesignated hospitals.

MAIN OUTCOME MEASURE

Thirty-day all-cause mortality.

RESULTS

Among 30,947 patients with acute ischemic stroke, 15,297 (49.4%) were admitted to designated stroke centers. Using the instrumental variable analysis, admission to designated stroke centers was associated with lower 30-day all-cause mortality (10.1% vs 12.5%; adjusted mortality difference, -2.5%; 95% confidence interval [CI], -3.6% to -1.4%; P < .001) and greater use of thrombolytic therapy (4.8% vs 1.7%; adjusted difference, 2.2%; 95% CI, 1.6% to 2.8%; P < .001). Differences in mortality also were observed at 1-day, 7-day, and 1-year follow-up. The outcome differences were specific for stroke, as stroke centers and nondesignated hospitals had similar 30-day all-cause mortality rates among those with gastrointestinal hemorrhage (5.0% vs 5.8%; adjusted mortality difference, +0.3%; 95% CI, -0.5% to 1.0%; P = .50) or acute myocardial infarction (10.5% vs 12.7%; adjusted mortality difference, +0.1%; 95% CI, -0.9% to 1.1%; P = .83).

CONCLUSION

Among patients with acute ischemic stroke, admission to a designated stroke center was associated with modestly lower mortality and more frequent use of thrombolytic therapy.

Drive-time proximity to Joint Commission Primary Stroke Centers among North Carolina residents who died of stroke

OBJECTIVE

In developing a statewide system of stroke care, understanding the relative availability of acute stroke care at designated centers for stroke care is essential. In this article, we compare the change in availability of acute stroke care in North Carolina at Joint Commission Primary Stroke Centers (JCPSCs) between 2006 and 2008 by examining the drive-time proximity of the residential address to the nearest JCPSC among people who died of stroke.

METHODS

We assigned geographic coordinates to residential addresses of North Carolinians who died of stroke and to addresses of North Carolina JCPSCs. We calculated the distance within a 40-minute drive from each JCPSC and determined whether the residential addresses of patients who died of stroke were in the areas demarcated by the drive time. In a secondary analysis, we included non-ICPSCs that participate in recognized quality-improvement programs for stroke care.

RESULTS

In 2006, 37% of geocodable residences of patients who died of stroke (3,834 of 10,469) were within a 40-minute drive from a JCPSC. By the end of 2008, this percentage increased to 56% (3,482 of 6,204). Inclusion of other hospitals that participate in recognized quality-improvement programs for acute stroke care increased the 40-minute drive-time coverage to 82% (5,095 of 6,204).

LIMITATIONS

As an index of the geographic distribution of the stroke burden, we used deaths due to stroke, rather incident strokes. We included several assumptions in our drive-time calculation.

CONCLUSIONS

For many regions of North Carolina in which the stroke burden is high, timely care at JCPSCs for acute stroke is unavailable. To develop a statewide system for acute stroke care in North Carolina, criteria beyond JCPSC certification should be considered for designating hospitals as centers for stroke care.

[Approaches to optimization of the organizational and economic management of a sanatorium-and-spa facility]

The main goals of reorganization of sanatorium-and-spa facilities and their activities under current economic conditions should be standardization of services provided to the patients, improvement of their quality, efficacious exploitation of the available resources, and motivation of the personnel.

Administration and union partnership: one Magnet hospital's story

For each hospital that has achieved Magnet designation as an organization of excellence, a unique story exists about its experience. Our story of excellence is founded in a long partnership between administration and union leadership spanning 2 decades. We recognize that excellence is not a steady state, rather a continued commitment to improved patient, staff, and organizational outcomes. This article provides a glimpse into one hospital's story-administration and union partnership in achieving and sustaining the American Nurses Credentialing Center's Magnet designation.

Bumps on the road to Magnet designation: achieving organizational excellence

The chief nursing officer is in a unique position to guide his or her organization to excellence by creating a compelling vision; maintaining objectivity regarding the nursing department's accomplishments; holding senior nurse leaders accountable as Magnet champions; demonstrating strategic thinking, business planning development, operational connection, and awareness of clinical aspects of care; and establishing levels of ownership and decision making within the nursing department's operational framework. The clear definition of terms including responsibility, authority, delegation, accountability, and empowerment are necessary and, coupled with specific actions, skills, and measures of success, guide individual and group processes to achieve organizational excellence and ultimately Magnet designation.