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Olika lagstiftningar och ramverk har implementerats för att uppmuntra företag att anpassa sig till de förändringar som behövs för en hållbar framtid. Ett sådant ramverk är ESG, som står för Environmental, Social and Governance. ESG benämns som ett ramverk som skulle kunna vara intressant för investerare som vill ha mer hållbara investeringar. Däremot har resultaten varit varierande, vilket kan leda till risker med ESG-ramverk för hållbarhetsrapportering. Syftet med studien är att ta reda på vilka risker som skulle kunna förekomma vid investeringsbeslut kopplat till faktorer inom ESG-rapportering under året 2024 så att det kan göras mer välgrundade bedömningar i investeringar inom hållbarhet. Studien genomförs i flera steg. Först analyseras vad regelhållare ställer för krav för att ta reda på vilka skyldigheter bolagen har att rapportera. Sedan analyseras årsredovisningar/hållbarhetsrapporter från de 15 största fastighetsföretagen i Sverige. Signaleringsteori och teorin om planerat beteende (TPB) används vid analysen av årsredovisningarna/hållbarhetsrapporterna för att hitta potentiella beteendemönster bakom signaler som förmedlas genom bolagens rapportering. Analysen av årsredovisningar/hållbarhetsrapporter ligger också till grund för utformandet av intervjufrågor som kan vara relevanta för att besvara syftet. Dessa frågor används sedan vid semistrukturerade intervjuer med de bolag som låter sig intervjuas och svaren från bolagen analyseras för att hitta potentiella risker med ESG och hållbarhetsrapportering. Det visar sig att det inte finns någon styrningskontroll för hållbarhetsrapportering från myndigheter i Sverige. Detta utgör en risk att många bolag skulle kunna komma undan med en ganska otillräcklig rapportering. Studien visar även att användande av ESG-betyg som en form av signalering kan riskera att korrelera mer eller mindre bra med verkligheten. Att olika ESG-ratingbolag gör olika bedömningar skulle dessutom kunna resultera i att fastighetsbolagen väljer, Different legislations and frameworks have been implemented to encourage companies to adjust to the changes needed for a sustainable future. One such framework is ESG, which stands for Environmental, Social and Governance. ESG is mentioned as a framework that could be interesting for investors who want more sustainable investments. However, the results have been variable, which can lead to risks with ESG frameworks for sustainability reporting. The purpose of this study is to find out which risks could occur in investment decisions linked to factors within ESG reporting in the year 2024 so that more well-founded assessments can be made in investments within sustainability. The study is carried out in several stages. First, the requirements set by the regulatory authorities are analyzed to find out which requirements the companies must report. Annual reports/sustainability reports from the 15 largest real estate companies in Sweden are then analyzed. Signaling theory and Theory of Planned Behavior (TPB) are used in the analysis of the annual reports/sustainability reports to find potential behavioral patterns behind signals conveyed through the companies’ reporting. The analysis of annual reports/sustainability reports is also the basis for the design of interview questions that may be relevant to answer the purpose of the study. These questions are then used in semi-structured interviews with the companies that allow themselves to be interviewed and the answers from the companies are analyzed to find potential risks with ESG and sustainability reporting. It turns out that there is no governance control for sustainability reporting from authorities in Sweden. This poses a risk that many companies could get away with rather inadequate reporting. The study also shows that the use of ESG ratings as a form of signaling may risk correlating more or less well with reality. The fact that different ESG rating companies make different assessments could also result in the real

20 p., ill., De manier waarop de forfaitaire betalingen voor de medische huizen worden berekend, zou meer rekening moeten houden met de kenmerken van hun patiënten en praktijkvoering. Daarom vroeg het RIZIV aan het Federaal Kenniscentrum voor de Gezondheidszorg (KCE) om een nieuwe berekeningsmethode te ontwikkelen. Al snel bleek echter dat sommige gegevens over werklast en kenmerken van de patiënt (bv. lage gezondheidsvaardigheden, diagnostische informatie) niet beschikbaar zijn of niet uniform geregistreerd worden. Het KCE beveelt daarom aan dat het RIZIV eerst een pilootstudie organiseert bij een steekproef van vrijwillig deelnemende medische huizen, om de haalbaarheid van een uniforme registratie en extractie van gegevens na te gaan. Om te bepalen welke gegevens moeten worden geregistreerd, zou een technische werkgroep binnen het RIZIV moeten worden opgericht. Op basis van deze gegevens kan het KCE dan in een volgende studie een nieuwe berekeningsmethode voorstellen., SYNTHESE 2 -- 1. INLEIDING 4 -- 1.1. ACHTERGROND 4 -- 1.2. HOE GINGEN WE TE WERK? 4 -- 2. DE MEDISCHE HUIZEN IN BELGIË 5 -- 2.1. EVOLUTIE VAN HET AANTAL MEDISCHE HUIZEN 5 -- 2.2. ROL VAN DE COMMISSIE FORFAIT EN DE FEDERATIES 6 -- 3. HOE WORDEN DE BELGISCHE MEDISCHE HUIZEN VERGOED? .6 -- 3.1. WAT BETALEN DE PATIËNTEN AAN EEN MEDISCH HUIS? 6 -- 3.2. HOE WORDEN DE MEDISCHE HUIZEN DOOR DE OVERHEID VERGOED? 6 -- 3.3. ONTEVREDENHEID OVER HET HUIDIGE STATISTISCHE MODEL 7 -- 3.3.1. Verschil tussen medische huizen en betaling per prestatie praktijken te groot 7 -- 3.3.2. Complexiteit van het huidige statistische model: black box voor sommigen, niet voldoende geavanceerd voor anderen. 8 -- 3.3.3. Het huidige model leidt tot onstabiele forfaitaire bedragen 8 -- 4. IS EEN NIEUW MODEL VOOR DE BELGISCHE MEDISCHE HUIZEN HAALBAAR? .8 -- 4.1. DEFINITIE VAN EEN NIEUW MODEL 8 -- 4.2. HOE DE WERKLAST VAN ZORGVERLENERS METEN? 9 -- 4.3. DEFINITIE VAN MOGELIJKE RISICOPARAMETERS 9 -- 4.3.1. Een mix van gezondheidstoestand, psychosociale en socio-economische factoren 9 -- 4.3.2. Diagnostische informatie om de gezondheidstoestand van patiënten te bepalen 10 -- 4.4. UITDAGINGEN BIJ DE REGISTRATIE VAN DE WERKLAST EN DE DIAGNOSES 11 -- 4.5. PILOOTSTUDIE MET VRIJWILLIG DEELNEMENDE MEDISCHE HUIZEN 11 -- AANBEVELINGEN 13 -- REFERENTIES 15

138 p., ill., LIST OF FIGURES 5 -- LIST OF TABLES 6 -- LIST OF ABBREVIATIONS 7 -- SCIENTIFIC REPORT 12 -- 1 INTRODUCTION 12 -- 1.1 BACKGROUND 12 -- 1.2 OBJECTIVE, RESEARCH QUESTIONS AND SCOPE OF THE REPORT 13 -- 2 ORGANISATION OF GENERAL PRACTITIONER CARE IN BELGIUM 14 -- 2.1 GP WORKFORCE 14 -- 2.2 PRACTICE TYPES 15 -- 2.3 PATIENT ACCESS 16 -- 3 ORGANISATION OF COMMUNITY HEALTH CENTRES IN BELGIUM 17 -- 3.1 ROLE OF FEDERATIONS AND THE COMMISSION FORFAIT 17 -- 3.2 EVOLUTION OF THE NUMBER OF COMMUNITY HEALTH CENTRES 19 -- 3.3 ACTIVITY REPORTS 21 -- 4 RISK-ADJUSTED CAPITATION PAYMENTS FOR COMMUNITY HEALTH CENTRES IN BELGIUM 30 -- 4.1 RISK-ADJUSTED CAPITATION PAYMENTS FOR PROVIDERS 30 -- 4.2 RISK ADJUSTERS BASED ON INSURANCE STATUS BEFORE 2013 31 -- 4.3 LONG LIST OF RISK ADJUSTERS TO REFLECT HEALTH(CARE) NEEDS SINCE 2013 31 -- 4.3.1 Risk-adjustment model for sickness funds 32 -- 4.3.2 Risk-adjustment model for community health centres since 2013 32 -- 4.3.3 Diagnostic information as risk adjuster 35 -- 5 RISK-ADJUSTED CAPITATION MODELS IN PRIMARY CARE IN SELECTED COUNTRIES 37 -- 5.1 METHODS 37 -- 5.2 DENMARK 38 -- 5.2.1 Brief overview of primary care organisation 38 -- 5.2.2 Income sources of the regions 39 -- 5.2.3 Remuneration system of GPs 39 -- 5.2.4 Composition of the capitation remuneration model 40 -- 5.3 SWEDEN 45 -- 5.3.1 Brief overview of primary care organisation 45 -- 5.3.2 Income sources of regions 46 -- 5.3.3 Remuneration system of GPs 46 -- 5.3.4 Composition of the capitation remuneration model 47 -- 5.3.5 Adjusted Clinical Groups (ACG) 48 -- 5.4 ENGLAND 51 -- 5.4.1 Brief overview of primary care organisation 51 -- 5.4.2 Fair shares: NHS resource allocations 52 -- 5.4.3 Remuneration system of GPs 53 -- 5.4.4 Composition of the capitation remuneration model 54 -- 5.5 THE NETHERLANDS 59 -- 5.5.1 Brief overview of primary care organisation 59 -- 5.5.2 Remuneration system 60 -- 5.5.3 Composition of the capitation remuneration model 61 -- 5.6 FRANCE 63 -- 5.6.1 Brief overvie

We propose a model for risk adjustment, in the context of IFRS 17, for surrender risk. Surrender rates are assumed to follow a stochastic process, underpinned by data. The distribution of the present value of future individual cash flows is calculated. Using well-known techniques from the theory of convex ordering of stochastic variables, we present closed formula approximations of risk measures, such as quantiles, for the total portfolio. These formulas are easy to program and enable an insurance company to calculate its risk adjustment without time-consuming simulations.

Introduction: The aim of this study was to develop a risk adjustment strategy, including effect modifiers, for benchmarking emergency medical service (EMS) performance for out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand. Method: Using 2017–2019 data from the Australasian Resuscitation Outcomes Consortium (Aus-ROC) OHCA Epistry, we included adults who received an EMS attempted resuscitation for a presumed medical OHCA. Logistic regression was applied to develop risk adjustment models for event survival (return of spontaneous circulation at hospital handover) and survival to hospital discharge/30 days. We examined potential effect modifiers, and assessed model discrimination and validity. Results: Both OHCA survival outcome models included EMS agency and the Utstein variables (age, sex, location of arrest, witnessed arrest, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation prior to EMS arrival, and EMS response time). The model for event survival had good discrimination according to the concordance statistic (0.77) and explained 28% of the variation in survival. The corresponding figures for survival to hospital discharge/30 days were 0.87 and 49%. The addition of effect modifiers did little to improve the performance of either model. Conclusion: The development of risk adjustment models with good discrimination is an important step in benchmarking EMS performance for OHCA. The Utstein variables are important in risk-adjustment, but only explain a small proportion of the variation in survival. Further research is required to understand what factors contribute to the variation in survival between EMS.

90 p., ill., LIST OF FIGURES 3 -- LIST OF TABLES 4 -- SCIENTIFIC REPORT 9 -- 1 INTRODUCTION 9 -- 1.1 OVERVIEW OF THE ANTENATAL CARE ORGANISATION IN BELGIUM 9 -- 1.2 SCOPE OF THE STUDY 13 -- 2 METHODS 14 -- 2.1 A MULTIMODAL APPROACH .14 -- 2.2 FORMULATION OF RECOMMENDATIONS 15 -- 3 INTERPROFESSIONAL COLLABORATION DURING ANTENATAL FOLLOW-UP 15 -- 3.1 BARRIERS AND FACILITATORS TO INTERPROFESSIONAL COLLABORATION: AN EXPLORATIVE REVIEW 15 -- 3.1.4 Discussion 21 -- 3.1.5 Conclusion 22 -- 3.2 CURRENT PRACTICE IN COLLABORATION BETWEEN MIDWIVES AND GYNAECOLOGISTS DURING ANTENATAL FOLLOW-UP .23 -- 3.2.4 Discussion and conclusion 43 -- 4 ANTENATAL RISK SELECTION TOOLS .44 -- 4.1 INTRODUCTION .44 -- 4.2 METHODS 44 -- 4.2.1 Literature search 44 -- 4.2.2 Data extraction 45 -- 4.3 RESULTS 45 -- 4.3.1 Risk selection tools in the literature 45 -- 4.4 DISCUSSION 50 -- 5 DELPHI CONSULTATION ON CRITERIA SUPPORTING THE DECISION TO REFER PREGNANT WOMEN FROM A PRIMARY CARE PROVIDER TO A SPECIALIST DURING ANTENAL FOLLOW-UP 51 -- 5.1 INTRODUCTION .51 -- 5.2 METHODS 51 -- 5.2.1 Panel selection 51 -- 5.2.2 Pre-selection of items .52 -- 5.2.3 Structure of the Delphi consultation 52 -- 5.2.4 Round one 53 -- 5.2.5 First online meeting .54 -- 5.2.6 Round two 54 -- 5.2.7 Second online meeting .56 -- 5.2.8 Round three 57 -- 5.2.9 Round four 57 -- 5.2.10 Third online meeting 58 -- 5.2.11 Round Five 58 -- 5.2.12 Delphi round for technical problems 60 -- 5.3 RESULTS 60 -- 5.3.1 Referral actions and preambles 60 -- 5.3.2 Criteria 61 -- 5.4 DISCUSSION 74 -- REFERENCE LIST .79

46 p., ill., SOMMAIRE I -- INTRODUCTION 2 -- MODE D’EMPLOI 3 -- ACTIONS DE RÉFÉRENCEMENT 5 -- INFORMATIONS GÉNÉRALES ET MODE DE VIE 6 -- ANTÉCÉDENTS MÉDICAUX PERSONNELS 8 -- ANTÉCÉDENTS CHIRURGICAUX MAJEURS 12 -- ANTÉCÉDENTS GYNÉCOLOGIQUES 14 -- FACTEURS PSYCHOSOCIAUX 17 -- ANTÉCÉDENTS OBSTÉTRICAUX 19 -- GROSSESSE ACTUELLE 23 -- TABLEAUX 28 -- RÉPERTOIRE DES MEMBRES DU RÉSEAU PROFESSIONNEL 32 -- RECOMMANDATIONS DU RAPPORT KCE N°363 34

46 p., ill., INHOUDSTAFEL 1 -- INLEIDING 2 -- DOORVERWIJSACTIES 5 -- ALGEMENE INFORMATIE EN LEVENSSTIJL 6 -- PERSOONLIJKE MEDISCHE VOORGESCHIEDENIS 8 -- CHIRURGISCHE VOORGESCHIEDENIS 12 -- GYNAECOLOGISCHE VOORGESCHIEDENIS 14 -- PSYCHOSOCIALE FACTOREN 17 -- VERLOSKUNDIGE VOORGESCHIEDENIS 19 -- HUIDIGE ZWANGERSCHAP 22 -- TABELLEN 27 -- LEDENLIJST VAN HET PROFESSIONELE NETWERK 31 -- AANBEVELINGEN VAN HET KCE RAPPORT N°363 41

30 p., ill., Zwangere vrouwen kunnen, als hun zwangerschap zonder complicaties verloopt, ervoor kiezen om uitsluitend door een gynaecoloog opgevolgd te worden of door een eerstelijns zorgverlener (vroedvrouw of huisarts) én een gynaecoloog. In dit laatste geval is het van belang om regels vast te leggen om te bepalen in welke situaties de tussenkomst van een gynaecoloog noodzakelijk is om de veiligheid van moeder en kind te garanderen. Het Federaal Kenniscentrum voor de Gezondheidszorg (KCE) heeft in overleg met de betrokken beroepsbeoefenaars een document opgesteld ter ondersteuning van de ontwikkeling van dergelijke ‘doorverwijzingsregels’ voor 188 klinische of psychosociale situaties die als potentieel risicovol worden beschouwd. Een voorwaarde voor het gebruik van dergelijke regels is echter dat de gynaecologen en vroedvrouwen sterke samenwerkingsverbanden kunnen aangaan. De onderzoekers van het KCE hebben zich daarom ook gebogen over de voorwaarden voor evenwichtige partnerschappen tussen deze twee beroepen., VOORWOORD 1 -- SYNTHESE 2 -- 1. INLEIDING 4 -- 1.1. CONTEXT 4 -- 1.2. OVERZICHT VAN DE ORGANISATIE VAN PRENATALE ZORG IN BELGIË 4 -- 1.3. OVERZICHT VAN HET WETTELIJK KADER VOOR ZWANGERSCHAPSOPVOLGING 6 -- 1.4. ONDERZOEKSVRAGEN 7 -- 1.5. METHODEN 8 -- 2. INTERPROFESSIONELE SAMENWERKING BIJ PRENATALE OPVOLGING 9 -- 2.1. DE BASIS VAN DE INTERPROFESSIONELE VERHOUDINGEN ZOALS BESCHREVEN IN DE LITERATUUR 9 -- 2.2. ONDERZOEK NAAR DE SAMENWERKING TUSSEN GYNAECOLOGEN EN VROEDVROUWEN IN BELGIË 11 -- 2.3. MOGELIJKE PISTES IN HET VERBETEREN VAN DE INTERPROFESSIONELE SAMENWERKING BIJ DE PRENATALE OPVOLGING 13 -- 2.3.1. Communicatie en delen van informatie 13 -- 2.3.2. Delen van ervaringen 13 -- 2.3.3. Partnerschap 13 -- 2.3.4. Duidelijk gedefinieerde rollen en verantwoordelijkheden 13 -- 2.3.5. Organisatie van de prenatale opvolging 14 -- 2.3.6. Financiële aspecten 14 -- 2.3.7. Opleiding 14 -- 2.3.8. Regulering van het beroep van vroedvrouw 14 -- 3. NAAR EEN BELGISCH DOORVERWIJSINSTRUMENT 14 -- 3.1. RISICOFACTOREN GEÏDENTIFICEERD IN DE LITERATUUR 15 -- 3.2. UITWERKING VAN EEN BELGISCH DOORVERWIJSINSTRUMENT 15 -- 3.2.1. Waarom een Delphi-studie? 16 -- 3.2.2. Doelstellingen en resultaten van het Delphi-panel 16 -- 4. CONCLUSIE 19 -- 4.1. NAAR EEN DOORVERWIJZING OP MAAT, AANGEPAST AAN DE LOKALE REALITEIT? 19 -- 4.2. ENKELE CONCRETE VOORWAARDEN 19 -- AANBEVELINGEN 21

78 p., ill., APPENDIX REPORT 1 -- TABLE OF CONTENTS 1 -- LIST OF TABLES 2 -- 1 SURVEY AMONG GYNAECOLOGISTS AND MIDWIVES TO DESCRIBE THE ANTENATAL CURRENT PRACTICE IN BELGIUM 3 -- 1.1 FRENCH VERSION 3 -- 1.2 DUTCH VERSION 16 -- 2 SEARCH STRATEGY 29 -- 2.1 RISK SELECTION TOOLS 29 -- 2.1.1 Cinahl 29 -- 2.1.2 Medline 30 -- 2.1.3 Cochrane 30 -- 2.1.4 Embase 31 -- 2.2 BARRIERS AND FACILITATORS IN COLLABORATION BETWEEN MIDWIVES AND DOCTORS 32 -- 2.2.1 Cochrane 32 -- 2.2.2 Cinahl 33 -- 2.2.3 Embase 35 -- 2.2.4 Medline 36 -- 3 EXAMPLES OF RISK ASSESSMENT TOOLS TO ESTABLISH THE PLANNED PLACE OF BIRTH 38 -- 4 COMPARISON OF RISK SELECTION TOOLS RETRIEVED IN THE LITERATURE 39 -- 5 COMPARISON OF CRITERIA INCLUDED IN EXISTING REFERRAL INSTRUMENTS 44 -- 6 FULL LIST OF CRITERIA USED TO BUILD THE REFERRAL TOOL KIT 67 -- REFERENCE LIST 72 -- Table 1 – Criteria for general information and lifestyle 44 -- Table 2 – criteria for personal medical history 45 -- Table 3 – Criteria for gynaecologic history 51 -- Table 4 – Criteria for obstetric history 54 -- Table 5 – Criteria for psychosocial factors 59 -- Table 6 – Criteria for previous surgery 60 -- Table 8 – Criteria for current pregnancy 61

30 p., ill., Quand leur grossesse se déroule sans complications, les femmes enceintes peuvent choisir d’être suivies uniquement par un gynécologue, ou par un professionnel de santé de première ligne (sage-femme ou médecin généraliste) et un gynécologue. Dans ce dernier cas, il est important de fixer des règles pour identifier les situations où l'intervention du gynécologue est nécessaire pour garantir la sécurité de la mère et de l’enfant. Le Centre fédéral d’Expertise des Soins de Santé (KCE) a élaboré, en concertation avec les professionnels concernés, un document pour soutenir l'élaboration de telles « règles de référencement » pour 188 situations cliniques ou psychosociales considérées comme potentiellement à risque. Toutefois, une condition préalable à l’utilisation de telles règles est que gynécologues et sages-femmes puissent établir des liens solides de collaboration. Les chercheurs du KCE ont donc également réfléchi aux conditions nécessaires pour des partenariats équilibrés entre ces deux professions., PRÉFACE 1 -- SYNTHÈSE 2 -- 1. INTRODUCTION 4 -- 1.1. CONTEXTE 4 -- 1.2. APERÇU DE L’ORGANISATION DES SOINS PRÉNATALS EN BELGIQUE 4 -- 1.3. APERÇU DU CADRE LÉGAL DU SUIVI DE LA GROSSESSE 6 -- 1.4. QUESTIONS DE RECHERCHE 7 -- 1.5. MÉTHODES 8 -- 2. LA COLLABORATION INTERPROFESSIONNELLE LORS DU SUIVI PRÉNATAL 9 -- 2.1. LES FONDEMENTS DES RELATIONS INTERPROFESSIONNELLES DÉCRITS DANS LA LITTÉRATURE 9 -- 2.2. ENQUÊTE SUR LA COLLABORATION ENTRE GYNÉCOLOGUES ET SAGES-FEMMES EN BELGIQUE 11 -- 2.3. PISTES D’AMÉLIORATION DES COLLABORATIONS INTERPROFESSIONNELLES DANS LE SUIVI PRÉNATAL 13 -- 2.3.1. Communication et partage d'informations 13 -- 2.3.2. Partage d’expérience 13 -- 2.3.3. Partenariat 13 -- 2.3.4. Définition claire des rôles et responsabilités de chacun 13 -- 2.3.5. Organisation du suivi prénatal 14 -- 2.3.6. Aspects financiers 14 -- 2.3.7. Formation 14 -- 2.3.8. Régulation de la profession de sage-femme 14 -- 3. VERS UN OUTIL DE RÉFÉRENCEMENT BELGE 15 -- 3.1. LES FACTEURS DE RISQUE IDENTIFIÉS DANS LA LITTÉRATURE 15 -- 3.2. ÉLABORATION D’UN OUTIL DE RÉFÉRENCEMENT BELGE 15 -- 3.2.1. Pourquoi la méthode Delphi ? 16 -- 3.2.2. Objectifs et résultats du panel Delphi 16 -- 4. CONCLUSION 19 -- 4.1. VERS UN RÉFÉRENCEMENT SUR MESURE, ADAPTÉ AUX RÉALITÉS LOCALES ? 19 -- 4.2. QUELQUES PRÉALABLES CONCRETS 19 -- RECOMMANDATIONS 21

BackgroundPatients with ST-elevation myocardial infarction (STEMI) complicated by an out-of-hospital-cardiac-arrest (OHCA) may vary widely in their probability of dying. Large variation in mortality may have implications for current national efforts to benchmark operator and hospital mortality rates for coronary angiography. We aimed to build a risk-adjustment model of in-hospital mortality among OHCA survivors with concurrent STEMI.MethodsWithin the Cardiac Arrest Registry to Enhance Survival (CARES), we included adults with OHCA and STEMI who underwent emergent angiography within 2 hours of hospital arrival between January 2013 and December 2019. Using multivariable logistic regression to adjust for patient and cardiac arrest factors, we developed a risk-adjustment model for in-hospital mortality and examined variation in patients' predicted mortality.ResultsOf 2,999 patients (mean age 61.2 ± 12.0, 23.1% female, 64.6% white), 996 (33.2%) died during their hospitalization. The final risk-adjustment model included higher age (OR per 10-year increase, 1.50 [95% CI: 1.39-1.63]), unwitnessed OHCA (OR, 2.51 [1.99-3.16]), initial non-shockable rhythm [OR, 5.66 [4.52-7.13]), lack of sustained pulse for > 20 minutes (OR, 2.52 [1.88-3.36]), and longer resuscitation time (increased with each 10-minute interval) (c-statistic = 0.804 with excellent calibration). There was large variability in predicted mortality: median, 25.2%, inter-quartile-range: 14.0% to 47.8%, 10th-90th percentile: 8.2 % to 74.1%.ConclusionsIn a large national registry, we identified 5 key predictors for mortality in patients with STEMI and OHCA and found wide variability in mortality risk. Our findings suggest that current national benchmarking efforts for coronary angiography, which simply adjusts for the presence of OHCA, may not adequately capture patient case-mix severity.

BackgroundOutcome and utilization quality measures are adjusted for patient case-mix including demographic characteristics and comorbid conditions to allow for comparisons between hospitals and health plans. However, controversy exists around whether and how to adjust for social risk factors.ObjectiveTo assess an approach to incorporating social risk variables into a pediatric measure of utilization from the Pediatric Quality Measures Program (PQMP).MethodsWe used data from California Medicaid claims (2015-16) and Massachusetts All Payer Claims Database (2014-2015) to calculate health plan performance using measure specifications from the Pediatric Asthma Emergency Department Use measure. Health plan performance categories were assessed using mixed effect negative binomial models with and without adjustment for social risk factors, with both models adjusting for age, gender and chronic condition category. Mixed effects linear models were then used to compare patient social risk for health plans that changed performance categories to patient social risk for health plans that did not.ResultsOf 133 health plans, serving 404,649 pediatric patients with asthma, 7% to 13% changed performance categories after social risk adjustment. Health plans that moved to higher performance categories cared for lower socioeconomic status (SES) patients whereas those that moved to lower performance categories cared for higher SES patients.ConclusionsAdjustment for social risk factors changed performance rankings on the PQMP Pediatric Asthma Emergency Department Use measure for a substantial number of health plans. Some health plans caring for higher risk patients performed more poorly when social risk factors were not included in risk adjustment models. In light of this, social risk factors are incorporated into the National Quality Forum-endorsed measure; whether to incorporate social risk factors into pediatric quality measures will differ depending on the use case.

BackgroundThe Centers for Medicare and Medicaid Services (CMS) hierarchical condition category (HCC) coding is a risk adjustment model that allows for the estimation of risk-and cost-associated with health care provision. Current models may not include key factors that fully delineate the risk associated with spine surgery.ObjectiveTo augment CMS HCC risk adjustment methodology with socioeconomic data to improve its predictive capabilities for spine surgery.MethodsThe National Inpatient Sample was queried for spinal fusion, and the data was merged with county-level coverage and socioeconomic status variables obtained from the Brookings Institute. We predicted outcomes (death, nonroutine discharge, length of stay [LOS], total charges, and perioperative complication) with pairs of hierarchical, mixed effects logistic regression models-one using CMS HCC score alone and another augmenting CMS HCC scores with demographic and socioeconomic status variables. Models were compared using receiver operating characteristic curves. Variable importance was assessed in conjunction with Wald testing for model optimization.ResultsWe analyzed 653 815 patients. Expanded models outperformed models using CMS HCC score alone for mortality, nonroutine discharge, LOS, total charges, and complications. For expanded models, variable importance analyses demonstrated that CMS HCC score was of chief importance for models of mortality, LOS, total charges, and complications. For the model of nonroutine discharge, age was the most important variable. For the model of total charges, unemployment rate was nearly as important as CMS HCC score.ConclusionThe addition of key demographic and socioeconomic characteristics substantially improves the CMS HCC risk-adjustment models when modeling spinal fusion outcomes. This finding may have important implications for payers, hospitals, and policymakers.

BackgroundRisk factors common to nursing home (NH) residents are potentially not fully captured by the Hospital Readmissions Reduction Program (HRRP). The unique challenges faced by hospitals that disproportionately serve NH residents who are at greater risk of readmissions have not been studied.MethodsUsing 100% Medicare Provider Analysis and Review File and the Minimum Data Set from 2010-2013, we constructed a measure of hospital share of NH-originating hospitalizations (NOHs). We defined hospital share of NOHs as the proportion of inpatient stays by patients aged 65 or older who were directly admitted from NHs. To evaluate the impact of the share of NOHs on readmission penalties, we categorized hospitals into quartiles according to their share of NOHs and estimated the differences in the adjusted penalties across hospital quartiles after accounting for hospital characteristics, market characteristics and state fixed effects. We repeated the analyses for the penalties incurred in each year between 2015 and 2019.ResultsHospitals varied substantially in the share of NOHs (median [interquartile range], 11.3% [8.2%-15.1%]), with limited variation over time. In 2015, hospitals in the highest quartile of NOH received on average 0.58% Medicare payment reduction compared to 0.44% reduction among those in the lowest quartile (32.9% higher penalties, p < 0.001). The increase in penalties continued to grow in 2017 and 2018 when the HRRP expanded to include additional target conditions (47.3% and 66.7%, respectively, p < 0.001 for both). Although the effect diminished in 2019 following the additional adjustment for hospital's dual-eligible share, hospitals in the highest quartile of NOH still incurred 43.0% (p < 0.001) higher penalties than those in the lowest quartile.ConclusionsHospitals varied considerably in their share of NOHs. Hospitals having a higher share of NOHs were disproportionately penalized for excess readmissions, even under the revised policy that ad

BACKGROUND: A recently developed obstetrical comorbidity scoring system enables the comparison of severe maternal morbidity rates independent of health status at the time of birth hospitalization. However, the scoring system has not been evaluated in racial-ethnic and socioeconomic groups or used to assess disparities in severe maternal morbidity. OBJECTIVE: This study aimed to evaluate the performance of an obstetrical comorbidity scoring system when applied across racial-ethnic and socioeconomic groups and to determine the effect of comorbidity score risk adjustment on disparities in severe maternal morbidity. STUDY DESIGN: We analyzed a population-based cohort of live births that occurred in California during 2011 through 2017 with linked birth certificates and birth hospitalization discharge data (n=3,308,554). We updated a previously developed comorbidity scoring system to include the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modifications diagnosis codes and applied the scoring system to subpopulations (groups) defined by race-ethnicity, nativity, payment method, and educational attainment. We then calculated the risk-adjusted rates of severe maternal morbidity (including and excluding blood transfusion-only cases) for each group and estimated the disparities for these outcomes before and after adjustment for the comorbidity score using logistic regression. RESULTS: The obstetric comorbidity scores performed consistently across groups (C-statistics ranged from 0.68 to 0.76; calibration curves demonstrated overall excellent prediction of absolute risk). All non-White groups had significantly elevated rates of severe maternal morbidity before and after risk adjustment for comorbidities when compared with the White group (1.3% before, 1.3% after) (American Indian-Alaska Native: 2.1% before, 1.8% after; Asian: 1.5% before, 1.7% after; Black: 2.5% before, 2.0% after; Latinx: 1.6% before, 1.7% after; Pacific Islander: 2.2% before

BackgroundCurrent smokers undergoing lobectomy are at greater risk of complications than are former smokers. The Society of Thoracic Surgeons (STS) composite score for rating program performance for lobectomy adjusts for smoking status, a modifiable risk factor. This study examined variability in the proportion of current smokers undergoing lobectomy among STS database participants. Additionally, the study determined whether each participant's rating changed if smoking was excluded from the risk adjustment model.MethodsThis is a retrospective analysis of the STS cohort used to develop the composite score for rating program performance for lobectomy. The study summarized the variability among STS database participants for performing lobectomy on current smokers and compared star ratings developed from models with and without smoking status.ResultsThere were 24,912 patients with smoking status data: 23% current smokers, 62% former smokers, and 15% never smokers. There was significant variability among participants in the proportion of current smokers undergoing lobectomy (3% to 48.6%; P < .001). Major morbidity or mortality (composite) was greater in current smokers (12.1%) than in former smokers (8.6%) and never smokers (4.2%) (P < .001). Using the current risk adjustment model, participant star ratings were as follows: 1 star, n = 6 (3.2%); 2 stars, n = 170 (91.4%); and 3 stars, n = 10 (5.4%). When smoking status was excluded from the model, 1 participant shifted from a 2-star to a 3-star program.ConclusionsThere is substantial variability among STS database participants with regard to the proportion of current smokers undergoing lobectomy. However, exclusion of smoking status from the model did not significantly affect participant star rating.

ObjectiveThis study aimed to describe two cases of acute respiratory distress syndrome (ARDS) secondary to novel coronavirus disease 2019 (COVID-19) in pregnant women requiring extracorporeal membrane oxygenation (ECMO), and resulting in premature delivery.Study designThe clinical course of two women hospitalized with ARDS due to COVID-19 care in our intensive care (ICU) is summarized; both participants provided consent to be included in this case series.ResultsBoth women recovered with no clinical sequelae. Neonatal outcomes were within the realm of expected for prematurity with the exception of coagulopathy. There was no vertical transmission to the neonates.ConclusionThis case series highlights that ECMO is a feasible treatment in the pregnant woman with severe COVID-19 and that delivery can be performed safely on ECMO with no additional risk to the fetus. While ECMO carries its natural risks, it should be considered a viable option during pregnancy and the postpartum period.Key points· COVID-19 may present with a more severe course in pregnancy.. · ECMO may be used in pregnant woman with severe COVID-19.. · Delivery can be performed on ECMO without added fetal risk..

In programs monitoring surgical quality, risk-adjusted control charts have been used widely to detect changes in surgical performance. Ignoring the survival time may lead to information loss and thus attenuate the monitoring efficiency. However, previous methods based on survival time information only focus on detecting the change in average risk. The stability of surgical performance measured by scale parameters could be of interest in monitoring. In this study, we extend the risk-adjusted monitoring approach to include survival outcomes, in which both the location and scale parameters are monitored simultaneously. Based on the weighted score test for the Cox model, we propose to use an exponentially weighted moving average chart to monitor changes in average surgical risk and the existence of its variance, which could be of interest in practical surgical monitoring programs. Simulation results indicate that the proposed method detects changes in the variance of surgical performance and small shifts in surgical risk more efficiently than existing cumulative sum methods. In addition, the proposed method shows good efficiency for various magnitudes of shift. The proposed chart was applied to a data set from the Surgical Outcome Monitoring and Improvement Program in Hong Kong, identifying an improvement in a hospital's outcomes. © 2021 Elsevier Ltd

Background Cardiac sympathetic denervation (CSD) has been used as a bailout strategy for refractory ventricular tachycardia (VT). Risk of VT recurrence in patients with scar-related monomorphic VT referred for CSD and the extent to which CSD can modify this risk is unknown. We aimed to quantify arrhythmia recurrence risk and impact of CSD in this population. Methods and Results Adjusted competing risk time to event models were developed to adjust for risk of VT recurrence and sustained VT/implantable cardioverter-defibrillator shocks after VT ablation based on patient comorbidities at the time of VT ablation. Adjusted VT and implantable cardioverter-defibrillator shock recurrence rates were estimated for the subgroup who subsequently required CSD after ablation. The expected adjusted recurrence rates were then compared with the observed rates after CSD. Data from 381 patients with scar-mediated monomorphic VT who underwent VT ablation were analyzed, excluding patients with polymorphic VT. Sixty eight patients underwent CSD for recurrent VT. CSD reduced the expected adjusted VT recurrence rate by 36% (expected rate of 5.61 versus observed rate of 3.58 per 100 person-months, P=0.01) and the sustained VT/implantable cardioverter-defibrillator shock rates by 34% (expected rate of 4.34 versus observed 2.85 per 100 person-months, P=0.03). The median number of sustained VT/implantable cardioverter-defibrillator shocks in the year before versus the year after CSD was reduced by 90% (10 versus 1, P<0.0001). Conclusions Patients referred for CSD for refractory scar-mediated monomorphic VT are at a higher risk of VT recurrence after ablation as compared with those not requiring CSD, mostly because of their cardiac comorbidities. CSD significantly reduced both the expected risk of recurrences and VT burden.

Background Prenatal diagnosis of congenital heart disease has been associated with early-term delivery and cesarean delivery (CD). We implemented a multi-institutional standardized clinical assessment and management plan (SCAMP) through the University of California Fetal-Maternal Consortium. Our objective was to decrease early-term (37-39 weeks) delivery and CD in pregnancies complicated by fetal congenital heart disease using a SCAMP methodology to improve practice in a high-risk and clinically complex setting. Methods and Results University of California Fetal-Maternal Consortium site-specific management decisions were queried following SCAMP implementation. This contemporary intervention group was compared with a University of California Fetal-Maternal Consortium historical cohort. Primary outcomes were early-term delivery and CD. A total of 496 maternal-fetal dyads with prenatally diagnosed congenital heart disease were identified, 185 and 311 in the historical and intervention cohorts, respectively. Recommendation for later delivery resulted in a later gestational age at delivery (38.9 versus 38.1 weeks, P=0.01). After adjusting for maternal age and site, historical controls were more likely to have a CD (odds ratio [OR],1.8; 95% CI, 2.1-2.8; P=0.004) and more likely (OR, 2.1; 95% CI, 1.4-3.3) to have an early-term delivery than the intervention group. Vaginal delivery was recommended in 77% of the cohort, resulting in 61% vaginal deliveries versus 50% in the control cohort (P=0.03). Among pregnancies with major cardiac lesions (n=373), vaginal birth increased from 51% to 64% (P=0.008) and deliveries ≥39 weeks increased from 33% to 48% (P=0.004). Conclusions Implementation of a SCAMP decreased the rate of early-term deliveries and CD for prenatal congenital heart disease. Development of clinical pathways may help standardize care, decrease maternal risk secondary to CD, improve neonatal outcomes, and reduce healthcare costs.

Acquired cardiovascular conditions are a leading cause of maternal morbidity and mortality. A growing number of pregnant women have acquired and heritable cardiovascular conditions and cardiovascular risk factors. As the average age of childbearing women increases, the prevalence of acute coronary syndromes, cardiomyopathy, and other cardiovascular complications in pregnancy are also expected to increase. This document, the third of a 5-part series, aims to provide practical guidance on the management of such conditions encompassing pre-conception through acute management and considerations for delivery.

BackgroundHealth status outcomes are increasingly being promoted as measures of health care quality, given their importance to patients. In heart failure (HF), an American College of Cardiology/American Heart Association Task Force proposed using the proportion of patients with preserved health status as a quality measure but not as a performance measure because risk adjustment methods were not available.MethodsWe built risk adjustment models for alive with preserved health status and for preserved health status alone in a prospective registry of outpatients with HF with reduced ejection fraction across 146 US centers between December 2015 and October 2017. Preserved health status was defined as not having a ≥5-point decrease in the Kansas City Cardiomyopathy Questionnaire Overall Summary score at 1 year. Using only patient-level characteristics, hierarchical multivariable logistic regression models were developed for 1-year outcomes and validated using data from 1 to 2 years. We examined model calibration, discrimination, and variability in sites' unadjusted and adjusted rates.ResultsAmong 3932 participants (median age [interquartile range] 68 years [59-75], 29.7% female, 75.4% White), 2703 (68.7%) were alive with preserved health status, 902 (22.9%) were alive without preserved health status, and 327 (8.3%) had died by 1 year. The final risk adjustment model for alive with preserved health status included baseline Kansas City Cardiomyopathy Questionnaire Overall Summary, age, race, employment status, annual income, body mass index, depression, atrial fibrillation, renal function, number of hospitalizations in the past 1 year, and duration of HF (optimism-corrected C statistic=0.62 with excellent calibration). Similar results were observed when deaths were ignored. The risk standardized proportion of patients alive with preserved health status across the 146 sites ranged from 62% at the 10th percentile to 75% at the 90th percentile. Variability across sites was mod

Background: The ArgenSCORE I was developed in 1999 on a population with 8% mortality. The ArgenSCORE II emerged afterrecalibrating the original model in 2007 on a validation population with 4% mortality. Using the CONAREC XVI registry, weevaluated the hypothesis that the ArgenSCORE II could better predict the risk of in-hospital mortality in centers with lowmortality, whereas the ArgenSCORE I could better predict mortality in centers with high mortality. Methods: A total of 2548 patients from 44 centers of the prospective and multicenter cardiac surgery CONAREC XVI registry,were analyzed. Mean observed mortality (OM) and mean expected mortality (EM) were estimated applying both versions ofthe ArgenSCORE.The OM/EM ratio was calculated in each center for both models and the Z test was used to evaluate significant differences. Results: In-hospital mortality was 7.69% for the entire registry. In 75% of the centers (33/44) mortality was >6%. In centerswith mortality <6%, the OM/EM ratio was close to 1 after applying the ArgenSCORE II, without significant differences. Incenters with mortality >6%, the ArgenSCORE II significantly underestimated the risk. On the contrary, when the Argen-SCORE I was applied in these centers, the OM/EM ratio was close to 1, without significant differences. Conclusions: The recalibrated ArgenSCORE II is recommended in centers with mortality <6%, while in those with mortality>6% the original ArgenSCORE I has better performance., Introducción: El ArgenSCORE tiene una versión original (I) desarrollada en 1999 sobre una población con mortalidad del 8%y una versión II (recalibración del modelo en 2007) sobre una población con una mortalidad del 4%. Evaluamos en el registroCONAREC XVI la hipótesis de que el ArgenSCORE II podría estimar mejor el riesgo de mortalidad intrahospitalaria en loscentros con baja mortalidad; en cambio, el ArgenSCORE I estimaría mejor la mortalidad en los centros con alta mortalidad. Material y métodos: Se analizaron 2548 pacientes de 44 centros del registro prospectivo y multicéntrico en cirugía cardíaca,CONAREC XVI. En cada centro se evaluó la mortalidad media observada (MO) y se calculó la mortalidad estimada media(ME) aplicando ambas versiones del ArgenSCORE.Se calculó la relación MO/ME de cada centro para los dos modelos y se evaluó si había diferencias significativas mediante eltest Z. Resultados: La mortalidad intrahospitalaria del registro fue del 7,69%. El 75% de los centros (33/44) presentaban una mortalidadmayor del 6%. En centros con mortalidad menor del 6%, al aplicar el ArgenSCORE II, la relación MO/ME mostróvalores cercanos a 1 y sin diferencias significativas. En centros con mortalidad mayor del 6%, el ArgenSCORE II subestimasignificativamente el riesgo. En cambio, cuando se aplica en estos centros el ArgenSCORE I, la relación MO/ME es cercanaa 1 (sin diferencias significativas). Conclusiones: En centros con mortalidad menor del 6%, es recomendable utilizar el ArgenSCORE II-recalibrado; en centroscon mortalidad mayor del 6%, tiene mejor desempeño el ArgenSCORE I-original.

Background Case mix adjustment is a pre-requisite for valid measurement of healthcare performance and socioeconomic status (SES) is important to account for. Lack of information on individual-level SES has led to investigations into using a proxy for SES based on patient area of residence. The objective of this study was to use neighbourhood SES for case mix adjustment of performance indicators in total hip replacement (THR) in Sweden, and to compare with use of individual SES. Methods Data from patient administrative systems and the Swedish Hip Arthroplasty Register were extracted for all patients undergoing THR in four Swedish regions. For each subject, individual data and neighbourhood data on country of birth, educational level, and income were provided by Statistics Sweden. Three variables were selected for analysis of performance; EQ-5D, hip pain and length of stay (LoS). In addition to socioeconomic information, several important clinical characteristics were used as case mix factors. Regression analysis was used to study each variable’s impact on the three outcome variables and model fit was evaluated using mean squared error. Results A total of 27,121 patients operated between 2010 and 2016 were included in the study. Both educational level and income were higher when based on neighbourhood information than individual information, while proportion born in Sweden was similar. Higher SES was generally found to be associated with better outcomes and lower LoS, albeit with certain differences between the different measures of SES. The predictive ability of the models was increased when adding information on SES to the clinical characteristics. The increase in predictive ability was higher for individual SES compared to neighbourhood SES. When analysing performance for the two providers with most diverging case mix in terms of SES, the inclusion of SES altered the relative performance using individual as well as neighbourhood SES. Conclusions Incorporating SES i

ObjectiveTo evaluate the National Health Safety Network (NHSN) hospital-onset Clostridioides difficile infection (HO-CDI) standardized infection ratio (SIR) risk adjustment for general acute-care hospitals with large numbers of intensive care unit (ICU), oncology unit, and hematopoietic cell transplant (HCT) patients.DesignRetrospective cohort study.SettingEight tertiary-care referral general hospitals in California.MethodsWe used FY 2016 data and the published 2015 rebaseline NHSN HO-CDI SIR. We compared facility-wide inpatient HO-CDI events and SIRs, with and without ICU data, oncology and/or HCT unit data, and ICU bed adjustment.ResultsFor these hospitals, the median unmodified HO-CDI SIR was 1.24 (interquartile range [IQR], 1.15-1.34); 7 hospitals qualified for the highest ICU bed adjustment; 1 hospital received the second highest ICU bed adjustment; and all had oncology-HCT units with no additional adjustment per the NHSN. Removal of ICU data and the ICU bed adjustment decreased HO-CDI events (median, -25%; IQR, -20% to -29%) but increased the SIR at all hospitals (median, 104%; IQR, 90%-105%). Removal of oncology-HCT unit data decreased HO-CDI events (median, -15%; IQR, -14% to -21%) and decreased the SIR at all hospitals (median, -8%; IQR, -4% to -11%).ConclusionsFor tertiary-care referral hospitals with specialized ICUs and a large number of ICU beds, the ICU bed adjustor functions as a global adjustment in the SIR calculation, accounting for the increased complexity of patients in ICUs and non-ICUs at these facilities. However, the SIR decrease with removal of oncology and HCT unit data, even with the ICU bed adjustment, suggests that an additional adjustment should be considered for oncology and HCT units within general hospitals, perhaps similar to what is done for ICU beds in the current SIR.

Introduction: Syncope is common among emergency department (ED) patients with acute pulmonary embolism (PE) and indicates a higher acuity and worse prognosis than in patients without syncope. Whether presyncope carries the same prognostic implications has not been established. We compared incidence of intensive care unit (ICU) admission in three groups of ED PE patients: those with presyncope; syncope; and neither.Methods: This retrospective cohort study included all adults with acute, objectively confirmed PE in 21 community EDs from January 2013–April 2015. We combined electronic health record extraction with manual chart abstraction. We used chi-square test for univariate comparisons and performed multivariate analysis to evaluate associations between presyncope or syncope and ICU admission from the ED, reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI).Results: Among 2996 PE patients, 82 (2.7%) had presyncope and 109 (3.6%) had syncope. ICU admission was similar between groups (presyncope 18.3% vs syncope 25.7%) and different than their non-syncope counterparts (either 22.5% vs neither 4.7%; p<0.0001). On multivariate analysis, both presyncope and syncope were independently associated with ICU admission, controlling for demographics, higher-risk PE Severity Index (PESI) class, ventilatory support, proximal clot location, and submassive and massive PE classification: presyncope, aOR 2.79 (95% CI, 1.40, 5.56); syncope, aOR 4.44 (95% CI 2.52, 7.80). These associations were only minimally affected when excluding massive PE from the model. There was no significant interaction between either syncope or presyncope and PESI, submassive or massive classification in predicting ICU admission.Conclusion: Presyncope appears to carry similar strength of association with ICU admission as syncope in ED patients with acute PE. If this is confirmed, clinicians evaluating patients with acute PE may benefit from including presyncope in their calculus of ri

Background:About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings. Materials and methods:This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score's capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized. Results:Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility. Conclusions:The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective. PROSPERO registration number:CRD42017064600.

Thesis (Ph.D.)--University of Rochester. School of Medicine & Dentistry. Dept. of Health Services Research and Policy, 2018., Objectives: The reduction of readmission continues to be an important target for policymakers and clinical leaders to improve quality and lower cost. Hospitals that serve the most medically complex and vulnerable patients tend to have higher readmission rates and are bearing the highest amount of penalties under the Hospital Readmissions Reduction Program (HRRP). Prior research has suggested that the risks of readmissions are particularly high among patients originating from nursing homes (NHs). Little is known about whether hospitals that serve a higher proportion of frail older adults admitted from NHs will have higher readmission rates and whether quality of care in NHs from which these patients originate will influence hospital readmission performance. The first objective of this study is to understand hospital-level variations in the share of NH-originating hospitalization (NOH, defined as the proportion of hospital admissions originating from NHs). The second objective of the study is to examine the impact of these admissions and the quality of care in NHs on the overall rates of hospital readmissions at the hospital level. Methods: This study utilized the 100% Medicare Provider Analysis and Review file and Data Set, January 2010–December 2013, to identify NOHs. Hospital share of NOHs was calculated as the percentage of Medicare fee-for-service hospital admissions directly from NHs accrued over July 2010–June 2013. Generalized Linear Model was used to identify hospital and market characteristics associated with the share of NOHs. To evaluate the impact on hospital readmission performance under the current HRRP structure, the Centers for Medicare and Medicaid Services (CMS) 30-day all-cause hospital-wide readmission measure and the five HRRP target condition-specific readmission measures downloaded from Hospital Compare were employed as the outcome variables. Multiple regressions controlling for hospital characteristics, market characteristics and state fixed e

BackgroundDespite increasing neonatal antibiotic stewardship efforts, understanding of interhospital variation in neonatal antibiotic use is limited.MethodsA retrospective cohort study was conducted among primarily academically affiliated hospitals participating in the Vizient Clinical Database/Resource Manager. Neonatal discharges were identified by admission age <1 month, excluding nonviable neonates and normal newborns. Hospitals with ≥100 neonatal discharges and complete data for January-December 2016 were included. Antibiotic use was measured in days of therapy per 1000 patient-days (DOT/1000 pd). A composite measure of neonatal care complexity (NCC; low, medium, high) was based on the volume of very low-birth-weight neonates and neonates undergoing surgical procedures, cardiac surgery, or extracorporeal membranous oxygenation.ResultsThe 118 included hospitals represented 184 716 neonatal discharges; 22 hospitals with low NCC, 56 with medium NCC, and 40 with high NCC. Mean antibiotic DOT/1000 pd was 363 (standard deviation [SD], 94) in high NCC hospitals, 243 (SD, 88) in medium NCC hospitals, and 184 (SD, 122) in low NCC hospitals. Increasing NCC was associated with higher antibiotic use, with an incidence rate ratio (IRR) of 1.95 (95% confidence interval [CI], 1.55 to 2.47) for high vs low NCC and IRR 1.31 (95% CI, 1.05 to 1.64) for medium vs low NCC. Increasing case mix index was associated with higher antibiotic use (IRR 1.86 per unit increase; 95% CI, 1.50 to 2.31).ConclusionsAggregate antibiotic use among hospitalized neonates varies based on care complexity. Substantial variation despite stratification by complexity suggests incomplete risk adjustment and/or avoidable variation in care.

The Swiss healthcare financing system is on the verge of one of its largest reforms. The Swiss parliament is currently debating how to reallocate about 20 % of total health expenditures. Swiss cantons make substantial tax-funded contributions to health expenditures by paying 55 % of hospital inpatient costs. As health insurers are fully responsible for all outpatient costs, the present system may provide unintended incentives to treat patients in inpatient settings. This paper presents and evaluates three alternative reform proposals for the reallocation of the cantonal contribution. Two proposals are currently under consideration in the Swiss parliament, suggesting either partial cost-sharing (20 %) of all healthcare costs or inclusion of cantonal contributions into the risk-equalization fund. A third option is developed in this paper, which proposes using the cantonal funds to pay a share of insurer's expenses above a high-cost threshold. The high-cost risk-sharing alternative is clearly superior: it mitigates the incentive to discriminate against sicker individuals, improves incentives for cost control, and reduces risk of loss for insurers. The paper adds results from Switzerland to an international literature on the properties of adding high-cost risk sharing to a risk equalization model., + ID der Publikation: unilu_68252 + Sprache: Englisch + Letzte Aktualisierung: 2023-06-09 14:29:51

The COVID-19 pandemic has led to an exponential increase in SARS-CoV-2 infections and associated deaths, and represents a significant challenge to healthcare professionals and facilities. Individual countries have taken several prevention and containment actions to control the spread of infection, including measures to guarantee safety of both healthcare professionals and patients who are at increased risk of infection from COVID-19. Faecal microbiota transplantation (FMT) has a well-established role in the treatment of Clostridioides difficile infection. In the time of the pandemic, FMT centres and stool banks are required to adopt a workflow that continues to ensure reliable patient access to FMT while maintaining safety and quality of procedures. In this position paper, based on the best available evidence, worldwide FMT experts provide guidance on issues relating to the impact of COVID-19 on FMT, including patient selection, donor recruitment and selection, stool manufacturing, FMT procedures, patient follow-up and research activities.

Clinical trial designs targeting patient subgroups with certain genetic characteristics may enhance the efficiency of developing drugs for cardiovascular disease (CVD). To evaluate the extent to which genetic knowledge translates to the CVD pipeline, we analyzed how genomic biomarkers are utilized in trials. Phase II and III trial protocols for investigational new drugs for CVD and risk factors were evaluated for prospective and exploratory genomic biomarker use; drug targets were evaluated for the presence of evidence that genetic variations can impact CVD risk or drug response. We identified 134 programs (73 unique drug targets) and 147 clinical trials. Less than 1% (n = 1/147) trials used a genomic biomarker prospectively for in-trial enrichment despite 32% (n = 23/73) of the drug targets having evidence of genetic variations. Additionally, 46% (n = 68/147) of the trials specified exploratory biomarker use. The results highlight an opportunity for more targeted CVD drug development by leveraging genomic biomarker knowledge.

[EN] Objectives: This article has two main purposes. Firstly, to model the integrated healthcare expenditure for the entire population of a health district in Spain, according to multimorbidity, using Clinical Risk Groups (CRG). Secondly, to show how the predictive model is applied to the allocation of health budgets. Methods: The database used contains the information of 156,811 inhabitants in a Valencian Community health district in 2013. The variables were: age, sex, CRG's main health statuses, severity level, and healthcare expenditure. The two-part models were used for predicting healthcare expenditure. From the coefficients of the selected model, the relative weights of each group were calculated to set a case-mix in each health district. Results: Models based on multimorbidity-related variables better explained integrated healthcare expenditure. In the first part of the two-part models, a logit model was used, while the positive costs were modelled with a log-linear OLS regression. An adjusted R-2 of 46-49% between actual and predicted values was obtained. With the weights obtained by CRG, the differences found with the case-mix of each health district proved most useful for budgetary purposes. Conclusions: The expenditure models allowed improved budget allocations between health districts by taking into account morbidity, as opposed to budgeting based solely on population size.

This article analyzes selection incentives for insurers in the Dutch basic health insurance market, which operates with community-rated premiums and sophisticated risk adjustment. Selection incentives result from the interplay of three market characteristics: possible actions by insurers, consumer response to these actions, and predictable variation in profitability of insurance contracts. After a qualitative analysis of the first two characteristics our primar

ObjectiveRegionalization directs patients to high-volume hospitals for specialized care. We investigated regionalization trends and outcomes in pediatric cardiac surgery.Data sources/study settingStatewide inpatient data from eleven states between 2000 and 2012.Study designMortality, length of stay (LOS), and cost were assessed using multivariable hierarchical regression with state and year fixed effects. Primary predictor was hospital case-volume, categorized into low-, medium-, and high-volume tertiles.Data collection/extraction methodsWe used Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) to select pediatric cardiac surgery discharges.Principal findingsIn total, 2841 (8.5 percent), 8348 (25.1 percent), and 22 099 (66.4 percent) patients underwent heart surgeries in low-, medium-, and high-volume hospitals. Mortality decreased over time, but remained higher in low- and medium-volume hospitals. High-volume hospitals had lower odds of mortality and cost than low-volume hospitals (odds ratio [OR] 0.59, P < 0.01, and relative risk [RR] 0.91, P < 0.01, respectively). LOS was longer for high- and medium-volume hospitals, compared to low-volume hospitals (high-volume: RR 1.18, P < 0.01; medium-volume: RR 1.05, P < 0.01).ConclusionsRegionalization reduced mortality and cost, indicating fewer complications, but paradoxically increased LOS. Further research is needed to explore the full impact on health care utilization.

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Background: Mortality is the most considered outcome for assessing the quality of hospital care. However, hospital mortality depends on diverse patient characteristics; thus, complete risk stratification is crucial to correctly estimate a patient's prognosis. Electronic health records include standard medical data; however, standard nursing data, such as nursing diagnoses (which were considered essential for a complete picture of the patient condition) are seldom included. Objective: To explore the independent predictive power of nursing diagnoses on patient hospital mortality and to investigate whether the inclusion of this variable in addition to medical diagnostic data can enhance the performance of risk adjustment tools. Methods: Prospective observational study in one Italian university hospital. Data were collected for six months from a clinical nursing information system and the hospital discharge register. The number of nursing diagnoses identified by nurses within 24 h after admission was used to express the nursing dependency index (NDI). Eight logistic regression models were tested to predict patient mortality, by adding to a first basic model considering patient's age, sex, and modality of hospital admission, the level of comorbidity (CCI), and the nursing and medical condition as expressed by the NDI and the All Patient Refined-Diagnosis Related Group weight (APR-DRGw), respectively. Results: Overall, 2301 patients were included. The addition of the NDI to the model increased the explained variance by 20%. The explained variance increased by 56% when the APR-DRGw, CCI, and NDI were included. Thus, the latter model was nearly highly accurate (c = 0.89, 95% confidence interval: 0.87–0.92). Conclusion: Nursing diagnoses have an independent power in predicting hospital mortality. The explained variance in the predictive models improved when nursing data were included in addition to medical data. These findings strengthen the need to include standardized nurs

BackgroundPatients with severe chronic obstructive pulmonary disease (COPD) are at a higher risk for postoperative respiratory complications. Despite the benefits of a minimally invasive approach, laparoscopic pneumoperitoneum can substantially reduce functional residual capacity and raise alveolar dead space, potentially increasing the risk of respiratory failure which may be poorly tolerated by COPD patients. This raises controversy as to whether open techniques should be preferentially employed in this population.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2014 was used to examine the clinical data from patients with COPD who electively underwent laparoscopic and open colectomy. Patients defined as having COPD demonstrated either functional disability, chronic use of bronchodilators, prior COPD-related hospitalization, or reduced forced expiratory reserve volumes on lung testing (FEV1 <75%). Demographic data and preoperative characteristics were compared. Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes.ResultsOf the 4397 patients with COPD, 53.8% underwent laparoscopic colectomy (LC) while 46.2% underwent open colectomy (OC). The LC and OC groups were similar with respect to demographic data and preoperative comorbidities. Equivalent frequencies of exertional dyspnea (LC 35.4 vs OC 37.7%, P = 0.11) were noted. After multivariate risk adjustment, OC demonstrated an increased rate of overall respiratory complications including pneumonia, reintubation, and prolonged ventilator dependency when compared to LC (OR 1.60, 95% CI 1.30-1.98, P < 0.01). OC was associated with longer length of stay (10 ± 8 vs. 6.7 ± 7 days, P < 0.01) and higher readmission (OR 1.36, 95% CI 1.09-1.68, P < 0.01) compared to LC.ConclusionDespite the potential risks of laparoscopic

BACKGROUND: Young patients presenting with symptomatic Brugada syndrome have very high risks for ventricular arrhythmias and should be carefully considered for implantable cardioverter-defibrillator (ICD) placement. However, this therapy is associated with high rates of inappropriate shocks and device-related complications. OBJECTIVES: This study investigated clinical features, management, and long-term follow-up of young patients with Brugada syndrome and ICD. METHODS: Patients diagnosed with Brugada syndrome, who underwent implantation of an ICD at an age of ≤20 years, were studied. RESULTS: The study included 35 consecutive patients. The mean age at ICD placement was 13.9 ± 6.2 years. Ninety-two percent were symptomatic; 29% presented with aborted sudden cardiac death and 63% with syncope. During a mean follow-up period of 88 months, sustained ventricular arrhythmias were treated by the ICD in 9 patients (26%), including shocks in 8 patients (23%) and antitachycardia pacing in 1 patient (3%). Three patients (9%) died in an electrical storm. Seven patients (20%) experienced inappropriate shocks, and 5 patients (14%) had device-related complications. Aborted sudden cardiac death and spontaneous type I electrocardiogram were identified as independent predictors of appropriate shock occurrence. CONCLUSIONS: ICD therapy is an effective strategy in young patients with symptomatic Brugada syndrome, treating potentially lethal arrhythmias in >25% of patients during follow-up. Appropriate shocks were significantly associated with previously aborted sudden cardiac death and spontaneous type I electrocardiograms. However, ICDs are frequently associated with complications and inappropriate shocks, both of which remain high regardless of careful device implantation and programming.

ObjectivesTo explore effects of disease prevalence adjustment on ambulatory care-sensitive hospitalization (ACSH) rates used for quality comparisons.Data sources/study settingCounty-level hospital administrative data on adults discharged from German hospitals in 2011 and prevalence estimates based on administrative ambulatory diagnosis data were used.Study designA retrospective cross-sectional study using in- and outpatient secondary data was performed.Data collectionHospitalization data for hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, and asthma were obtained from the German Diagnosis Related Groups (DRG) database. Prevalence estimates were obtained from the German Central Research Institute of Ambulatory Health Care.Principal findingsCrude hospitalization rates varied substantially across counties (coefficients of variation [CV] 28-37 percent across conditions); this variation was reduced by prevalence adjustment (CV 21-28 percent). Prevalence explained 40-50 percent of the observed variation (r = 0.65-0.70) in ACSH rates for all conditions except asthma (r = 0.07). Between 30 percent and 38 percent of areas moved into or outside condition-specific control limits with prevalence adjustment.ConclusionsUnadjusted ACSH rates should be used with caution for high-stakes public reporting as differences in prevalence may have a marked impact. Prevalence adjustment should be considered in models analyzing ACSH.

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74-2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30-2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.

Medicare Advantage (MA) has grown rapidly since the Affordable Care Act; nearly one-third of Medicare beneficiaries now choose MA. An assessment of the comparative value of the 2 options is confounded by an apparent selection bias favoring MA, as reflected in mortality differences. Previous assessments have been hampered by lack of access to claims diagnosis data for the MA population. An indirect comparison of mortality as an outcome variable was conducted by modeling mortality on a traditional fee-for-service (FFS) Medicare data set, applying the model to an MA data set, and then evaluating the ratio of actual-to-predicted mortality in the MA data set. The mortality model adjusted for clinical conditions and demographic factors. Model development considered the effect of potentially greater coding intensity in the MA population. Further analysis calculated ratios for subpopulations. Predicted, risk-adjusted mortality was lower in the MA population than in FFS Medicare. However, the ratio of actual-to-predicted mortality (0.80) suggested that the individuals in the MA data set were less likely to die than would be predicted had those individuals been enrolled in FFS Medicare. Differences between actual and predicted mortality were particularly pronounced in low income (dual eligibility), nonwhite race, high morbidity, and Health Maintenance Organization (HMO) subgroups. After controlling for baseline clinical risk as represented by claims diagnosis data, mortality differences favoring MA over FFS Medicare persisted, particularly in vulnerable subgroups and HMO plans. These findings suggest that differences in morbidity do not fully explain differences in mortality between the 2 programs.

BackgroundLittle is known about hospital use of postacute care after surgery and whether it is related to measures of surgical quality.Research designWe used data merged between a national surgery registry, Medicare inpatient claims, the Area Resource File, and the American Hospital Association Annual Survey (2005-2008). Using bivariate and multivariate analyses, we calculated hospital-level, risk-adjusted rates of postacute care use for both inpatient facilities (IF) and home health care (HHC), and examined the association of these rates with hospital quality measures, including mortality, complications, readmissions, and length of stay.ResultsOf 112,620 patients treated at 217 hospitals, 18.6% were discharged to an IF, and 19.9% were discharged with HHC. Even after adjusting for differences in patient and hospital characteristics, hospitals varied widely in their use of both IF (mean, 20.3%; range, 2.7%-39.7%) and HHC (mean, 22.3%; range, 3.1%-57.8%). A hospital's risk-adjusted postoperative mortality rate or complication rate was not significantly associated with its use of postacute care, but higher 30-day readmission rates were associated with higher use of IF (24.1% vs. 21.2%, P=0.03). Hospitals with longer average length of stay used IF less frequently (19.4% vs. 24.4%, P<0.01).ConclusionsHospitals vary widely in their use of postacute care. Although hospital use of postacute care was not associated with risk-adjusted complication or mortality rates, hospitals with high readmission rates and shorter lengths of stay used inpatient postacute care more frequently. To reduce variations in care, better criteria are needed to identify which patients benefit most from these services.

ObjectiveTo characterize the health risk of enrollees in California's state-based insurance marketplace (Covered California) by metal tier, region, month of enrollment, and plan.Data source/study setting2014 Open-enrollment data from Covered California linked with 2012 hospitalization and emergency department (ED) visit records from statewide all-payer administrative databases.Data collection/extraction methodsChronic Illness and Disability Payment System (CDPS) health risk scores derived from an individual's age and sex from the enrollment file and the diagnoses captured in the hospitalization and ED records. CDPS scores were standardized by setting the average to 1.00.Principal findingsAmong the 1,286,089 enrollees, 120,573 (9.4 percent) had at least one ED visit and/or a hospitalization in 2012. Higher risk enrollees chose plans with greater actuarial value. The standardized CDPS health risk score was 11 percent higher in the first month of enrollment (1.08; 99 percent CI: 1.07-1.09) than the last month (0.97; 99 percent CI: 0.97-0.97). Four of the 12 plans enrolled 91 percent of individuals; their average health risk scores were each within 3 percent of the marketplace's statewide average.ConclusionsProviding health plans with a means to assess the health risk of their year 1 enrollees allowed them to anticipate whether they would receive or contribute payments to a risk-adjustment pool. After receiving these findings as a part of their negotiations with Covered California, health plans covering the majority of enrollees decreased their initially proposed 2015 rates, saving consumers tens of millions of dollars in potential premiums.

BackgroundLittle is known about racial/ethnic differences in the experience of care coordination. To the extent that they exist, such differences may exacerbate health disparities given the higher prevalence of some chronic conditions among minorities.ObjectiveTo investigate the extent to which racial/ethnic disparities exist in the receipt of coordinated care by Medicare beneficiaries.SubjectsA total of 260,974 beneficiaries who responded to the 2013 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.MethodsWe fit a series of linear, case-mix adjusted models predicting Medicare CAHPS measures of care coordination from race/ethnicity.ResultsHispanic, black, and Asian/Pacific Islander (API) beneficiaries reported that their personal doctor had medical records and other relevant information about their care significantly less often than did non-Hispanic white beneficiaries (-2 points for Hispanics, -1 point for blacks, and -4 points for APIs on a 100-point scale). These 3 groups also reported significantly greater difficulty getting timely follow-up on test results than non-Hispanic white beneficiaries (-9 points for Hispanics, -1 point for blacks, -5 points for APIs). Hispanic and black beneficiaries reported that help was provided in managing their care significantly less often than did non-Hispanic white beneficiaries (-2 points for Hispanics, -3 points for blacks). API beneficiaries reported that their personal doctor discussed their medications and had up-to-date information on care from specialists significantly less often than did non-Hispanic white beneficiaries (-2 and -4 points, respectively).DiscussionThese results suggest a need for efforts to address racial/ethnic disparities in care coordination to help ensure high-quality care for all patients. Public reporting of plan-level performance data by race/ethnicity may also be helpful to Medicare beneficiaries and their advocates.