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EACH YEAR, NEARLY 1 MILLION OLDER ADULTS ARE HOSpitalized in the United States for treatment of an acute illness. Although many hospitalizations are necessary and lead to improvement, iatrogenic complications are common. All too frequently, older patients develop infections, pressure ulcers, delirium, adverse effects from treatment, and falls resulting in injury, among other complications. According to a report by the Office of the Inspector General, 7.4% of Medicare beneficiaries who were hospitalized in 2008 experienced a preventable adverse event. To improve the quality and safety of hospital care, Congress has enacted several broad programs that mandate reporting of quality, safety, patient experience, and adverse events and that provide financial incentives to improve performance. An insidious and underappreciated complication associated with hospitalization of older adults for acute illness is the loss of independence that comes from the inability to perform self-care functions. As noted by Covinsky et al in this issue of JAMA, at least 30% of patients aged 70 years and older and hospitalized with a medical illness are discharged with a new disability that was not present before the onset of illness. Hospitalization-associated disability involves the new loss of ability, by discharge, to perform at least 1 of the basic activities of daily living (ADLs), such as bathing or showering, dressing, transferring out of a bed or chair, eating, and walking without assistance. The loss of independence has profound implications for these patients often, portending long-term care in a nursing home, repeat hospitalization, and even death. Despite the importance of hospitalization-associated disability, it is virtually ignored by health care professionals and policy makers. One reason for this lack of awareness is that healthrelated quality of life and sustainability of independence are not measured as outcomes of care. The Centers for Medicare & Medicaid Services (CMS) publishes hospital quality measures on its Hospital Compare Web site, but neither the current nor proposed hospital quality metrics measure healthrelated quality of life. Starting in October 2012, Medicare will reward hospitals that provide this sort of high-quality care for their patients and withhold a portion of payments to those hospitals that do not through the hospital ValueBased Purchasing (VBP) program. Inpatient, prospective payment hospitals will contribute 1% of their Medicare base operating diagnosis related group payments to a VBP pool of dollars. Hospitals will be eligible to receive a VBP payment amount based on a composite quality score. Initially, that score will comprise a hospital’s performance in process measures and the patient’s experience in the hospital. The amount of money at risk increases in succeeding years, and the list of measures will expand to include adverse events, efficiency, and mortality, but no measures of physical function or other aspects of health-related quality of life. Thus, the VBP program will not fully measure and reward value from the patient’s standpoint. Most hospitals will focus time and energy only on improving those measures that are publically reported and that determine reimbursement. Physical function and other dimensions of quality of life should be measured over the course of illness. Simple, valid, and reliable instruments that measure functional status should be incorporated into the care process for older patients and also should be used at regular intervals and at transitions of care. The value of measurement will increase as hospitals and physicians implement electronic health records, facilitating assessment of health-related quality of life aggregated across populations of older patients to better understand trajectories and causes of physical disability. Measurement alone is not sufficient to address the problem, but measurement would facilitate assessing interventions for effectiveness. What can and should be done to avert the onset of new disability associated with an acute illness requiring hospitalization? The answer to this question remains unclear and additional study is needed. Although patients at high risk of disability can be identified prospectively, which patients have reversible and/or preventable loss of function can

Importance Patient outcomes associated with the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms have not been evaluated at a national level. Objective To evaluate the association of the 2011 ACGME duty hour reforms with mortality and readmissions. Design, Setting, and Participants Observational study of Medicare patient admissions (6 384 273 admissions from 2 790 356 patients) to short-term, acute care, nonfederal hospitals (n = 3104) with principal medical diagnoses of acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure or a Diagnosis Related Group classification of general, orthopedic, or vascular surgery. Of the hospitals, 96 (3.1%) were very major teaching, 138 (4.4%) major teaching, 442 (14.2%) minor teaching, 443 (14.3%) very minor teaching, and 1985 (64.0%) nonteaching. Exposure Resident-to-bed ratio as a continuous measure of hospital teaching intensity. Main Outcomes and Measures Change in 30-day all-location mortality and 30-day all-cause readmission, comparing patients in more intensive relative to less intensive teaching hospitals before (July 1, 2009–June 30, 2011) and after (July 1, 2011–June 30, 2012) duty hour reforms, adjusting for patient comorbidities, time trends, and hospital site. Results In the 2 years before duty hour reforms, there were 4 325 854 admissions with 288 422 deaths and 602 380 readmissions. In the first year after the reforms, accounting for teaching hospital intensity, there were 2 058 419 admissions with 133 547 deaths and 272 938 readmissions. There were no significant postreform differences in mortality accounting for teaching hospital intensity for combined medical conditions (odds ratio [OR], 1.00; 95% CI, 0.96-1.03), combined surgical categories (OR, 0.99; 95% CI, 0.94-1.04), or any of the individual medical conditions or surgical categories. There were no significant postreform differences in readmissions for combined medical conditions (OR, 1.00; 95% CI, 0.97-1.02) or combined surgical categories (OR, 1.00; 95% CI, 0.98-1.03). For the medical condition of stroke, there were higher odds of readmissions in the postreform period (OR, 1.06; 95% CI, 1.001-1.13). However, this finding was not supported by sensitivity analyses and there were no significant postreform differences for readmissions for any other individual medical condition or surgical category. Conclusions and Relevance Among Medicare beneficiaries, there were no significant differences in the change in 30-day mortality rates or 30-day all-cause readmission rates for those hospitalized in more intensive relative to less intensive teaching hospitals in the year after implementation of the 2011 ACGME duty hour reforms compared with those hospitalized in the 2 years before implementation.

ContextLimitations in duty hours for physicians-in-training in the United States were established by the Accreditation Council for Graduate Medical Education (ACGME) and implemented on July 1, 2003. The association of these changes with mortality among hospitalized patients has not been well established.ObjectiveTo determine whether the change in duty hour regulations was associated with relative changes in mortality in hospitals of different teaching intensity within the US Veterans Affairs (VA) system.Design, Setting, and PatientsAn observational study of all unique patients (N = 318 636) admitted to acute-care VA hospitals (N = 131) using interrupted time series analysis with data from July 1, 2000, to June 30, 2005. All patients had principal diagnoses of acute myocardial infarction (AMI), congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery. Logistic regression was used to examine the change in mortality for patients in more vs less teaching-intensive hospitals before (academic years 2000-2003) and after (academic years 2003-2005) duty hour reform, adjusting for patient comorbidities, common time trends, and hospital site.Main Outcome MeasureAll-location mortality within 30 days of hospital admission.ResultsIn postreform year 1, no significant relative changes in mortality were observed for either medical or surgical patients. In postreform year 2, the odds of mortality decreased significantly in more teaching-intensive hospitals for medical patients only. Comparing a hospital having a resident-to-bed ratio of 1 with a hospital having a resident-to-bed ratio of 0, the odds of mortality were reduced for patients with AMI (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.33-0.71), for the 4 medical conditions together (OR, 0.74; 95% CI, 0.61-0.89), and for the 3 medical conditions excluding AMI (OR, 0.79; 95% CI, 0.63-0.98). Compared with hospitals in the 25th percentile of teaching intensity, there was an absolute improvement in mortality from prereform year 1 to postreform year 2 of 0.70 percentage points (11.1% relative decrease) and 0.88 percentage points (13.9% relative decrease) in hospitals in the 75th and 90th percentile of teaching intensity, respectively, for the combined medical conditions.ConclusionsThe ACGME duty hour reform was associated with significant relative improvement in mortality for patients with 4 common medical conditions in more teaching-intensive VA hospitals in postreform year 2. No associations were identified for surgical patients.

ContextThe Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour regulations for physicians-in-training throughout the United States on July 1, 2003. The association of duty hour reform with mortality among patients in teaching hospitals nationally has not been well established.ObjectiveTo determine whether the change in duty hour regulations was associated with relative changes in mortality among Medicare patients in hospitals of different teaching intensity.Design, Setting, and PatientsAn observational study of all unique Medicare patients (N = 8 529 595) admitted to short-term, acute-care, general US nonfederal hospitals (N = 3321) using interrupted time series analysis with data from July 1, 2000, to June 30, 2005. All Medicare patients had principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery. Logistic regression was used to examine the change in mortality for patients in more vs less teaching-intensive hospitals before (academic years 2000-2003) and after (academic years 2003-2005) duty hour reform, adjusting for patient comorbidities, common time trends, and hospital site.Main Outcome MeasureAll-location mortality within 30 days of hospital admission.ResultsIn medical and surgical patients, no significant relative increases or decreases in the odds of mortality for more vs less teaching-intensive hospitals were observed in either postreform year 1 (combined medical conditions group: odds ratio [OR], 1.03; 95% confidence interval [CI], 0.98-1.07; and combined surgical categories group: OR, 1.05; 95% CI, 0.98-1.12) or postreform year 2 (combined medical conditions group: OR, 1.03; 95% CI, 0.99-1.08; and combined surgical categories group: OR, 1.01; 95% CI, 0.95-1.08) compared with the prereform years. The only condition for which there was a relative increase in mortality in more teaching-intensive hospitals postreform was stroke, but this association preceded the onset of duty hour reform. Compared with nonteaching hospitals, the most teaching-intensive hospitals had an absolute change in mortality from prereform year 1 to postreform year 2 of 0.42 percentage points (4.4% relative increase) for patients in the combined medical conditions group and 0.05 percentage points (2.3% relative increase) for patients in the combined surgical categories group, neither of which were statistically significant.ConclusionThe ACGME duty hour reform was not associated with either significant worsening or improvement in mortality for Medicare patients in the first 2 years after implementation.

ContextThe increasing prevalence and associated sociodemographic disparities of morbid obesity are serious public health concerns. Bariatric surgical procedures provide greater and more durable weight reduction than behavioral and pharmacological interventions for morbid obesity.ObjectiveTo examine trends for elective bariatric surgical procedures, patient characteristics, and in-hospital complications from 1998 to 2003 in the United States.Design, Setting, and PatientsThe Nationwide Inpatient Sample was used to identify bariatric surgery admissions from 1998-2002 (with preliminary data for 12 states from 2003) using International Classification of Diseases, Ninth Revision, codes for foregut surgery with a confirmatory diagnosis of obesity or by diagnosis related group code for obesity surgery. Annual estimates and trends were determined for procedures, patient characteristics, and adjusted complication rates.Main Outcome MeasuresTrends in bariatric surgical procedures, patient characteristics, and complications.ResultsThe estimated number of bariatric surgical procedures increased from 13 365 in 1998 to 72 177 in 2002 (P

In this issue ofThe Journal, Stern et al 1 compare hospital charges and lengths of stay for patients admitted through the emergency department with charges and lengths of stay for patients admitted through other routes to any of five Massachusetts hospitals. Even with adjustments for diagnosis related group, severity of illness, age, and income, patients admitted through the emergency department incurred hospital charges 13% higher and hospital stays 27% longer than other patients.

The development of techniques for the measurement of hospital output is one of the primary issues facing health service researchers. Scales must be developed which can be used to categorize patients in such a way that homogeneity within patient groups and heterogeneity between patient groups, with respect to the nature of their illness, is maximized. Such a categorization scheme, which must allow for the assessment of the severity of illness can then be used for studies of hospital utilization and costs; development of equitable reimbursement mechanisms for hospitals; and for clinical trails designed to test the efficacy of different treatment modalities.

DATA about whether patients live or die following short-term—care hospitalization can serve at least two purposes: (1) to determine if hospital performance has improved or deteriorated over time and (2) to determine if performance differs across hospitals at one given time. Hospital mortality figures have been used in this manner primarily because such data are readily available, easy to understand, and potentially important to the public. However, if mortality data are to be used for these purposes, they must reflect actual differences in the quality of care, not other factors, such as patient sickness at admission. We have been studying hospital mortality and other outcomes as part of a clinically detailed national study to assess the impact of the diagnosis related group (DRG)-based prospective payment system (PPS) on the quality of care for hospitalized Medicare patients. In this report we document and justify some of the design decisions we made

To clarify the financial incentives for hospitals to prevent nosocomial infections, we analyzed 9423 nosocomial infections identified in 169526 admissions selected randomly from the adult admissions to a random sample of US hospitals. By classifying each admission into a baseline diagnosis related group (DRG) (after first excluding all diagnoses of nosocomial infection) and a final DRG (after including these diagnoses), we found that only 5% to 18% of nosocomial infections would have caused the admission to be reclassified to a higher-paying DRG, depending on the extent to which physicians recorded nosocomial infection diagnoses in patients' medical records. The extra payment from the reclassification, averaged over all nosocomial infections, would have been no more than $93 per infection (in 1985 reimbursement rates), constituting only 5% of the hospitals' costs for treating these infections. Thus, at least 95% of the cost savings obtained from preventing nosocomial infections represents financial gains to the hospital. ( JAMA 1987;257:1611-1614)

TODAY we face a crisis in clinical research that demands that attention be directed to a problem that physicians have not had to worry about in the past: the impact of reimbursement for patient care on the progress of medical science. Until this year, the costs for patients involved in clinical trials were paid in two ways: the research costs of data collection and analysis, experimental drugs, and such were paid by research grants; the patient-care costs were paid by the patient or the insurance carrier. The advent of the prospective payment system and diagnosis-related group (DRG) reimbursement dramatically alters this system and changes the incentives. Under the DRG system, the hospital receives a fee fixed by diagnosis, and administrators are likely to show little enthusiasm for anything that increases the cost of care. Extra laboratory tests or x-ray films beyond a bare minimum will not be encouraged. The pattern