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BackgroundPatients undergoing complex pediatric cardiac surgery remain at considerable risk of mortality and morbidity, and variation in outcomes exists across hospitals. The Pediatric Cardiac Critical Care Consortium (PC4) was formed to improve the quality of care for these patients through transparent data sharing and collaborative learning between participants.ObjectivesThe purpose of this study was to determine whether outcomes improved over time within PC4.MethodsThe study analyzed 19,600 hospitalizations (18 hospitals) in the PC4 clinical registry that included cardiovascular surgery from August 2014 to June 2018. The primary exposure was 2 years of PC4 participation; this provided adequate time for hospitals to accrue data and engage in collaborative learning. Aggregate case mix-adjusted outcomes were compared between the first 2 years of participation (baseline) and all months post-exposure. We also evaluated outcomes from the same era in a cohort of similar, non-PC4 hospitals.ResultsDuring the baseline period, there was no evidence of improvement. We observed significant improvement in the post-exposure period versus baseline for post-operative intensive care unit mortality (2.1% vs. 2.7%; 22% relative reduction [RR]; p = 0.001), in-hospital mortality (2.5% vs. 3.3%; 24% RR; p = 0.001), major complications (10.1% vs. 11.5%; 12% RR; p

Background: We sought to determine whether dementia is associated with treatment intensity and mortality in patients hospitalized with COVID‐19. Methods: This study includes review of the medical records for patients >60 years of age (n = 5394) hospitalized with COVID‐19 from 132 community hospitals between March and June 2020. We examined the relationships between dementia and treatment intensity (including intensive care unit [ICU] admission and mechanical ventilation [MV] and care processes that may influence them, including advance care planning [ACP] billing and do‐not‐resuscitate [DNR] orders) and in‐hospital mortality adjusting for age, sex, race/ethnicity, comorbidity, month of hospitalization, and clustering within hospital. We further explored the effect of ACP conversations on the relationship between dementia and outcomes, both at the individual patient level (effect of having ACP) and at the hospital level (effect of being treated at a hospital with low: <10%, medium 10%–20%, or high >20% ACP rates). Results: Ten percent (n = 522) of the patients had documented dementia. Dementia patients were older (>80 years: 60% vs. 27%, p < 0.0001), had a lower burden of comorbidity (3+ comorbidities: 31% vs. 38%, p = 0.003), were more likely to have ACP (28% vs. 17%, p < 0.0001) and a DNR order (52% vs. 22%, p < 0.0001), had similar rates of ICU admission (26% vs. 28%, p = 0.258), were less likely to receive MV (11% vs. 16%, p = 0.001), and more likely to die (22% vs. 14%, p < 0.0001). Differential treatment intensity among patients with dementia was concentrated in hospitals with low, dementia‐biased ACP billing practices (risk‐adjusted ICU use: 21% vs. 30%, odds ratio [OR] = 0.6, p = 0.016; risk‐adjusted MV use: 6% vs. 16%, OR = 0.3, p < 0.001). Conclusions: Dementia was associated with lower treatment intensity and higher mortality in patients hospitalized with COVID‐19. Differential treatment intensity was concentrated in low ACP billing hospitals suggesting an interplay between provider bias and "preference‐sensitive" care for COVID‐19. [ABSTRACT FROM AUTHOR]

Background. With nearly 53 million ambulatory procedures performed annually, future efforts to achieve greater value in surgical care should include a focus on outpatient surgery. To inform such efforts, a better understanding of specialty-specific trends in outpatient surgery is required. Objectives. To assess the prevalence and distribution of outpatient surgery across specialties. Research design. Repeated cross-sectional. Measures. Using all-payer data from Florida (1998-2008), we identified physicians who performed one or more procedures. We assigned a specialty to each physician based on his procedure mix. After measuring the proportion of procedures performed on an outpatient basis, we assessed for specialty-specific changes over time in this proportion. Finally, we determined the frequency with which individual specialties used surgery centers for their outpatient care. Results. More than two thirds (67.8%) of all surgical procedures are carried out on an outpatient basis. The popularity of outpatient surgery has grown among many specialties over the past decade, including several (urology, gastroenterology, plastic surgery, and ophthalmology) that perform most of their cases in outpatient settings. Within surgical disciplines, overall trends in the use of outpatient surgery are strongly associated with the specialty’s affinity for freestanding ambulatory surgery centers (Pearson’s correlation coefficient = 0.76; P < .001). Conclusions. A majority of surgeons in many specialties now provide predominantly outpatient care. Incorporating these findings into the design of future payment and delivery system reforms will help ensure adequate surgeon exposure to the efficiency gains that evolve from them. [ABSTRACT FROM PUBLISHER]

Hospital executives pursue external recognition to improve market share and demonstrate institutional commitment to quality of care. The Magnet Recognition Program of the American Nurses Credentialing Center identifies hospitals that epitomize nursing excellence, but it is not clear that receiving Magnet recognition improves patient outcomes. Using Medicare data on patients hospitalized for coronary artery bypass graft surgery, colectomy, or lower extremity bypass in 1998-2010, we compared rates of risk-adjusted thirty-day mortality and failure to rescue (death after a postoperative complication) between Magnet and non-Magnet hospitals matched on hospital characteristics. Surgical patients treated in Magnet hospitals, compared to those treated in non-Magnet hospitals, were 7.7 percent less likely to die within thirty days and 8.6 percent less likely to die after a postoperative complication. Across the thirteen-year study period, patient outcomes were significantly better in Magnet hospitals than in non-Magnet hospitals. However, outcomes did not improve for hospitals after they received Magnet recognition, which suggests that the Magnet program recognizes existing excellence and does not lead to additional improvements in surgical outcomes. [ABSTRACT FROM AUTHOR]

We analyzed advance care planning (ACP) billing for adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. Prompting hospitalists to answer the validated "surprise question" (SQ; "Would you be surprised if the patient died in the next year?") for inpatient admissions served to prime hospitalists and triggered an icon next to the patient's name. Among 113,621 hospital-based encounters, only 6,146 (5.4%) involved a billed ACP conversation: 8.3% among SQ-prompted who answered "no" and 4.1% SQ-prompted who answered "yes" (for non-SQ prompted cases, the fraction was 3.5%; P < .0001). ACP conversations were associated with a comfort-focused care trajectory. Low ACP rates among even those with high hospitalist-predicted mortality risk underscore the need for quality improvement interventions to increase hospital-based ACP.

Objectives: Aiming to encourage care coordination and cost efficiency, the Center for Medicare and Medicaid Innovation (CMMI) launched the Bundled Payments for Care Improvement (BPCI) initiative in 2013. To help gauge the program's potential impact and generalizability, we describe early and current participants., Study Design: We examined the cross-sectional association between BPCI participation and providers' structural and cost characteristics., Methods: Using data from October 2013 and June 2014, we quantified changes in BPCI participation. We described structural differences between participating and nonparticipating hospitals using t tests and χ2 tests, and we used the Cochrane-Armitage test to assess whether participants were more likely be in higher 90-day episode cost quintiles than their peers at baseline (2009-2010)., Results: Overall (risk-bearing and non-risk-bearing) participation in BPCI increased from about 400 in October 2013 to more than 2000 in June 2014-attributable, in part, to Model 2, the most comprehensive of the 4 models offered by CMMI for provider participation. Model 2 hospitals increasingly resemble eligible but nonparticipating hospitals. For the most commonly chosen condition of hip replacement, Model 2 hospitals were not costlier than their peers. Hospitals used to make up 97% of Model 2 participants, but physician practices now comprise a substantial number of Model 2 participants. However, most BPCI participants have not yet begun to bear financial risk. Risk-bearing Model 2 hospitals are a smaller and less representative group, with higher baseline costs for hip replacement than their peers., Conclusions: Growing participation in BPCI suggests strong interest in bundled payments. The long-term impact of BPCI will depend on CMMI's ability to persuade interested but non-risk-bearing participants to bear risk.