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Background Food insecurity (FI) has been associated with an increased atherosclerotic cardiovascular disease (ASCVD) risk; however, the pathways by which FI leads to worse cardiovascular health are unknown. We tested the hypothesis that FI is associated with ASCVD risk through nutritional/anthropometric (eg, worse diet quality and increased weight), psychological/mental health (eg, increased depressive symptoms and risk of substance abuse), and access to care pathways. Methods and Results We conducted a cross‐sectional study of adults (aged 40–79 years) using the 2007 to 2016 National Health and Nutrition Examination Survey. Our primary exposure was household FI, and our outcome was 10‐year ASCVD risk categorized as low (P P P =0.002) pathways. We did not find a significant direct effect of FI on ASCVD risk, and the nutrition, psychological, and access to care pathways accounted for 31.6%, 43.9%, and 15.8% of the association, respectively. Conclusions We found that the association between FI and ASCVD risk category was mediated through the nutrition/anthropometric, psychological/mental health, and access to care pathways. Interventions that address all 3 pathways may be needed to mitigate the negative impact of FI on cardiovascular disease.

Digital informed consent may better inform individuals about health research and increase participation. In the United States and elsewhere, minorities and rural populations are underrepresented in health research and may benefit from well-designed electronic informed consent (eIC). Seven focus groups were conducted with 50 Caucasian, African American, and rural patients in the United States. Participants were asked their preferences for a paper versus electronic informed consent document. Participants found the e-version easier to use, more interesting, and better for understanding. Minority participants emphasized limited access, computer literacy, and trust barriers to eIC. Rural participants were concerned about accessibility, connectivity, privacy, and confidentiality. People see value in electronic consenting. Researchers should consider barriers to eIC among underrepresented populations before recruitment.

Objective Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. Methods The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. Results Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. Conclusions VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.

Background While women are under-represented in research on cardiovascular disease (CVD), little is known about the attitudes of men and women with CVD regarding participation in clinical research studies/clinical trials. Methods Patients with CVD (and/or risk factors) and patients with other chronic conditions from Iowa were recruited from a commercial panel. An on-line survey assessed willingness to participate (WTP) and other attitudes towards aspects of clinical research studies. Results Based on 504 respondents, there were no differences in WTP in patients with CVD compared to patients with other chronic diseases. Across all respondents, men had 14% lower WTP (relative risk (RR) for men, 0.86, 95% CI, 0.72–1.02). Among patients with CVD, there was no significant difference in WTP between women (RR for women = 1) and men (RR for men, 0.96, 95% CI, 0.82–1.14). There were no significant differences based on sex or CVD status for attitudes on randomization, blinding, side effects, conflict of interest, experimental treatments or willingness to talk to one’s physician. Women had more favorable attitudes about participants being treated like “guinea pigs” (RR for men, 0.84, 95% CI, 0.73–0.98) and clinical trials being associated with terminally ill patients (RR for men, 0.93, 95% CI, 0.86–1.00). Conclusions The findings reported here suggest that the observed lower levels of participation by women are due to factors other than a lower WTP or to women having more negative attitudes towards aspects of study participation. Patients with CVD have similar attitudes and WTP as patients with other chronic conditions. Electronic supplementary material The online version of this article (10.1186/s13063-018-2667-7) contains supplementary material, which is available to authorized users.

Policies limiting exposure to cigarette smoke have been associated with reduced hospitalizations for heart attacks, but little is known about the impact of smoking bans on other health conditions and whether findings from individual communities generalize to other areas. We investigated the association between smoking bans targeting workplaces, restaurants, and bars passed throughout the United States during 1991-2008 and hospital admissions for smoking-related illnesses-acute myocardial infarction and chronic obstructive pulmonary disease-among Medicare beneficiaries age sixty-five or older. Risk-adjusted hospital admission rates for acute myocardial infarction fell 20-21 percent thirty-six months following implementation of new restaurant, bar, and workplace smoking bans. Admission rates for chronic obstructive pulmonary disease fell 11 percent where workplace smoking bans were in place and 15 percent where bar smoking bans were present. By contrast, very little effect was found for hospitalization for gastrointestinal hemorrhage and hip fracture-two conditions largely unrelated to smoking and examined as points of comparison. These findings provide further support for the public health benefits of laws that limit exposure to tobacco smoke.

Home telehealth programs often focus on a single disease, yet many patients who need monitoring have multiple conditions. This study evaluated secondary outcomes from a clinical trial evaluating the efficacy of home telehealth to improve outcomes of patients with co-morbid diabetes and hypertension.A single-center randomized controlled clinical trial compared two remote monitoring intensity levels (low and high) and usual care in patients with type 2 diabetes and hypertension being treated in primary care. Secondary outcomes assessed were knowledge (diabetes, hypertension, medications), self-efficacy, adherence (diabetes, medications), and patient perceptions of the intervention mode.Knowledge scores improved in the high-intensity intervention group participants, but upon further analysis, we found the intervention effect was not mediated by gain in knowledge. No significant differences were found across the groups in self-efficacy, adherence, or patient perceptions of the intervention mode.Home telehealth can enhance detection of key clinical symptoms that occur between regular physician visits. While our intervention improved glycemic and blood pressure control, the mechanism of the effect for this improvement was not clear.

Increased emphasis is being placed on the critical need to control hypertension (HTN) in patients with diabetes.The objective of this study was to evaluate the efficacy of a nurse-managed home telehealth intervention to improve outcomes in veterans with comorbid diabetes and HTN.A single-center, randomized, controlled clinical trial design comparing two remote monitoring intensity levels and usual care in patients with type 2 diabetes and HTN being treated in primary care was used.Primary outcomes were hemoglobin A1c and systolic blood pressure (SBP); secondary outcome was adherence.Intervention subjects experienced decreased A1c during the 6-month intervention period compared with the control group, but 6 months after the intervention was withdrawn, the intervention groups were comparable with the control group. For SBP, the high-intensity subjects had a significant decrease in SBP compared with the other groups at 6 months and this pattern was maintained at 12 months. Adherence improved over time for all groups, but there were no differences among the three groups.Subjects had relatively good baseline control for A1c and SBP; minorities and women were underrepresented.Home telehealth provides an innovative and pragmatic approach to enhance earlier detection of key clinical symptoms requiring intervention. Transmission of education and advice to the patient on an ongoing basis with close surveillance by nurses can improve clinical outcomes in patients with comorbid chronic illness.

Purpose To examine the effects of preexisting comorbid psychiatric conditions on mortality in a large cohort of patients admitted to a nonsurgical intensive care unit. Methods This retrospective cohort study involved 66 672 consecutive eligible nonsurgical patients admitted to intensive care units in 129 Veterans Health Administration hospitals during 2005 and 2006. Preexisting comorbid psychiatric conditions were identified by using diagnoses from outpatient encounters in the prior year for depression, anxiety, psychosis, bipolar disorders, and posttraumatic stress disorder. Generalized estimating equations were used to adjust the risks of inhospital and 30-day mortality for demographics, comorbid medical conditions, markers of severity, and abnormal findings on laboratory tests at admission. Results Comorbid psychiatric conditions were identified in 28% (n = 18 698) of patients. Patients with preexisting comorbid psychiatric conditions had lower (P < .001) unadjusted inhospital mortality (7.3% vs 8.7%) and 30-day mortality (10.0% vs 12.8%) than did patients without such conditions. After demographics, comorbid medical conditions, and severity were adjusted for, risk of in-hospital mortality among patients with comorbid psychiatric conditions was somewhat higher (odds ratio, 1.07, 95% confidence interval, 1.01–1.14; P = .02), although differences in 30-day mortality (odds ratio, 1.01, 95% confidence interval, 0.94–1.08; P = .70) were no longer significant. Conclusion Preexisting comorbid psychiatric conditions are common among intensive care patients, but after comorbid medical conditions and severity were adjusted for, preexisting comorbid psychiatric conditions were not associated with a higher risk of 30-day mortality in a large national cohort of veterans.

Objective: The objective of this study was to describe the epidemiology, clinical features, outcomes, and predictors of mortality in veterans with peripheral artery disease (PAD). Methods: We used national data from the Veterans Health Administration from fiscal years 2009 to 2011 to identify patients with a new diagnosis of PAD. Within this cohort, we describe characteristics of the patients, use of recommended medications, and clinical outcomes during a 3-year follow-up (fiscal year 2014). We used Cox proportional hazards regression to examine predictors of mortality and adverse limb outcomes (amputation and hospitalization for critical limb ischemia [CLI]) during follow-up. Results: A total of 175,865 patients with a new diagnosis of PAD were included. The mean age was 69.9 years; 97.8% were male, and 67.7% were white. Nearly 77% of patients had hypertension, 46.5% had diabetes, 23% had chronic obstructive pulmonary disease, and 12.9% had renal failure. A prescription for statins was filled by 60.8%, and 34.9% received high-intensity statins within 90 days of PAD diagnosis. At 1 year, 2.6% underwent revascularization, 1.3% developed CLI, and 1.1% underwent amputation. During a median follow-up of 3.8 years, a total of 28.6% patients died (6.7% at 1 year), and 3.7% developed a limb outcome (2.0% at 1 year). Predictors of mortality included advanced age, comorbidities, and CLI or amputation at presentation. In contrast, prescription with statins was associated with lower mortality. Similar findings were present with regard to predictors of adverse limb outcomes, except that older age was associated with a lower risk of amputation or CLI. Conclusions: We found that veterans with PAD have a high prevalence of comorbid conditions and have a significant risk of mortality and limb loss. A substantial proportion of veterans with PAD are not prescribed recommended medications, especially statin therapy. Our data highlight important opportunities for improving care of veterans with PAD. (J Vasc Surg 2018; 68:527–35.)

Background. We examined whether older adults who had continuity of care with a primary care physician (PCP) had lower mortality. Methods. Secondary analyses were conducted using baseline interview data (19931994) from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). The analytic sample included 5,457 self-respondents 70 years old or more who were not enrolled in managed care plans. AHEAD data were linked to Medicare claims for 19912005, providing up to 12 years of follow-up. Two time-dependent measures of continuity addressed whether there was more than an 8-month interval between any two visits to the same PCP during the prior 2-year period. The present exposure measure calculated this criterion on a daily basis and could switch on or off daily, whereas the cumulative exposure measure reflected the percentage of follow-up days, also on a daily basis allowing it to switch on or off daily, for which the criterion was met. Results. Two thousand nine hundred and fifty-four (54%) participants died during the follow-up period. Using the cumulative exposure measure, 27% never had continuity of care, whereas 31%, 20%, 14%, and 8%, respectively, had continuity for 1%33%, 34%67%, 68%99%, and 100% of their follow-up days. Adjusted for demographics, socioeconomic status, social support, health lifestyle, and morbidity, both measures of continuity were associated (p < .001) with lower mortality (adjusted hazard ratios of 0.84 for the present exposure measure and 0.31, 0.39, 0.46, and 0.62, respectively, for the 1%33%, 34%67%, 68%99%, and 100% categories of the cumulative exposure measure). Conclusion. Continuity of care with a PCP, as assessed by two distinct measures, was associated with substantial reductions in long-term mortality.

The authors prospectively explored the consequences of hip fracture with regard to discharge placement, functional status, and mortality using the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Data from baseline (1993) AHEAD interviews and biennial follow-up interviews were linked to Medicare claims data from 1993-2005. There were 495 postbaseline hip fractures among 5,511 respondents aged >or=69 years. Mean age at hip fracture was 85 years; 73% of fracture patients were white women, 45% had pertrochanteric fractures, and 55% underwent surgical pinning. Most patients (58%) were discharged to a nursing facility, with 14% being discharged to their homes. In-hospital, 6-month, and 1-year mortality were 2.7%, 19%, and 26%, respectively. Declines in functional-status-scale scores ranged from 29% on the fine motor skills scale to 56% on the mobility index. Mean scale score declines were 1.9 for activities of daily living, 1.7 for instrumental activities of daily living, and 2.2 for depressive symptoms; scores on mobility, large muscle, gross motor, and cognitive status scales worsened by 2.3, 1.6, 2.2, and 2.5 points, respectively. Hip fracture characteristics, socioeconomic status, and year of fracture were significantly associated with discharge placement. Sex, age, dementia, and frailty were significantly associated with mortality. This is one of the few studies to prospectively capture these declines in functional status after hip fracture.

OBJECTIVE: This study examines two dimensions of racial segregation across hospitals, using a disease for which substantial disparities have been documented. DATA SOURCES: Black (n=32,289) and white (n=244,042) patients 67 years and older admitted for acute myocardial infarction during 2004-2005 in 105 hospital markets were identified from Medicare data. Two measures of segregation were calculated: Dissimilarity (i.e., dissimilar distribution by race across hospitals), and Isolation (i.e., racial isolation within hospitals). For each measure, markets were categorized as having low, medium, or high segregation. STUDY DESIGN: The relationship of hospital segregation to residential segregation and other market characteristics was evaluated. Cox proportional hazards regression was used to evaluate disparities in the use of revascularization within 90 days by segregation level. RESULTS: Agreement of segregation category based on Dissimilarity and Isolation was poor (kappa=0.12), and the relationship of disparities in revascularization to segregation differed by measure. The hazard of revascularization for black relative to white patients was lowest (i.e., greatest disparity) in markets with low Dissimilarity, but it was unrelated to Isolation. CONCLUSIONS: Significant racial segregation across hospitals exists in many U.S. markets, although the magnitude and relationship to disparities depends on definition. Dissimilar distribution of race across hospitals may reflect divergent cultural preferences, social norms, and patient assessments of provider cultural competence, which ultimately impact utilization.

This study compared mortality in African American and white patients admitted to veterans affairs (VA) hospitals for chronic obstructive pulmonary disease (COPD) exacerbation and determined the potential impact of differences in intensive care unit (ICU) admission and mechanical ventilation. Administrative data from 2003-2006 identified African American (n = 7159) and white (n = 43820) patients admitted to VA hospitals with COPD exacerbation. Hierarchical logistic regression was used to compare risk-adjusted 30-day or inhospital mortality in African American and white patients. African Americans were more likely than whites to be admitted to ICUs (19.1% vs 17.2%, respectively; p.001) and to receive mechanical ventilation (4.8% vs 4.1%, p.001). African Americans had lower unadjusted mortality than white patients overall (7.1% vs 9.2%, p.001), and among patients admitted to ICUs (16.9% vs 20.3%, p.01) and non-ICU wards (4.8% vs 6.9%, p.001). Mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs 31.4%, p = .34). The risk-adjusted odds of death were lower for African Americans relative to white patients (OR, 0.71; p.001) and in analyses that further adjusted for ICU admission and ventilation use (OR, 0.69; p.001). Mortality was lower in African Americans than white veterans admitted for COPD exacerbation, even after adjusting for differences in ICU admission rates and ventilatory support. The lower risk-adjusted mortality in African Americans was not explained by more aggressive care.

Background: Black patients are more likely than white patients to prefer and receive more life-sustaining interventions in advanced stages of disease. However, little is known about potential racial differences in use of mechanical ventilation (MV), and the newer modality of noninvasive ventilation (NIV), in treatment of chronic obstructive pulmonary disease (COPD). Objective: To determine if rates of MV and NIV use differ among black and white patients admitted to Veterans Administration (VA) hospitals for COPD exacerbation. Research Design: Retrospective cohort analysis of VA database FY2003 to FY2005 including 153 hospitals nationwide. Subjects: All black (n = 5479) and white (n = 31,537) patients admitted with COPD exacerbation. Measures: Ventilation use during hospitalization as identified by ICD-9-CM codes for MV and NIV. Hierarchical logistic regression compared rates of MV or NIV use among black and white patients, adjusting for patient characteristics and accounting for hospital-level variation. Results: Unadjusted rates of MV were higher in black patients than in white patients (4.1% vs. 3.0%; P < 0.001), but similar for NIV (6.0% vs. 6.1%; P = 0.65). The adjusted odds of MV for black patients relative to white patients remained higher (OR = 1.27, 95% CI: 1.01-1.54; P < 0.01) while the adjusted odds of NIV remained similar (OR = 0.94, 95% CI: 0.82-1.08; P = 0.38). Conclusions: Black patients with COPD exacerbation in VA hospitals are more likely than white patients to receive MV, and this difference is not explained by available clinical or demographic variables. By contrast, black and white patients are equally likely to receive NIV. These findings suggest that unmeasured factors, such as patient preferences or disease severity, may be affecting the use of MV in this setting and therefore warrant further investigation.

Previous studies have found that home-based intervention programs reduce readmission rates for patients with heart failure. Only one previous trial has compared telephone and videophone to traditional care to deliver a home-based heart failure intervention program. The objective of this study was to evaluate the efficacy of a telehealth-facilitated postdischarge support program in reducing resource use in patients with heart failure. Patients at a Midwestern Department of Veterans Affairs Medical Center were randomized to telephone, videophone, or usual care for follow-up care after hospitalization for heart failure exacerbation. Outcome measures included readmission rates; time to first readmission; urgent care clinic visits; survival; and quality of life. The intervention resulted in a significantly longer time to readmission but had no effect on readmission rates or mortality. There were no differences in hospital days or urgent care clinic use. All subjects reported higher disease-specific quality of life scores at 1 year. There was evidence of the value of telephone follow-up, but there was no evidence to support the benefit of videophone care over telephone care. Rigorous evaluation is needed to determine which patients may benefit most from specific telehealth applications and which technologies are most cost-effective.

To compare outcomes after aortic valve replacement (AVR) according to valve type specifically in older patients since valve-related risks are age-dependent; two randomised trials comparing mechanical and bioprosthetic valves found better outcomes with mechanical valves, but the samples were small and the patients were considerably younger than most who undergo AVR.Cohort study.1199 US hospitals.Patients 65 years and older undergoing AVR during 1991-2003 (n = 307 054) identified through Medicare claims data.Relative hazard ratios associated with bioprosthetic valves of (1) death (n = 131,719); (2) readmission for haemorrhage (n = 31,186), stroke (n = 25,051) or embolism (n = 5870); (3) reoperation (n = 4216); and (4) death or reoperation (reoperation free survival) in Cox regression analyses adjusting for demographic and clinical factors and hospital-level effects.Overall, 36% of AVR patients received bioprosthetic valves. Bioprosthetic valve recipients were older (77 vs 75 years, p0.001) and generally had higher comorbidity. Bioprosthetic valve recipients had a slightly lower adjusted hazard ratios of death (HR = 0.97; 95% CI 0.95 to 0.98); readmission for haemorrhage, stroke or embolism (HR = 0.90, 95% CI 0.88 to 0.92); and death or reoperation (HR = 0.97, 95% CI 0.96 to 0.98), but a higher hazard ratio of reoperation (HR = 1.25, 95% CI 1.16 to 1.35). However, overall mortality and complication rates were more than 20 and 10 times higher, respectively, than the overall reoperation rate.In older patients undergoing AVR, bioprosthetic valve recipients had slightly lower risks of death and complications, but a higher risk of reoperation. Given the low reoperation rate, these data suggest that bioprosthetic valves may be preferred in older patients.

Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units.To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA).A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals.We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission.In-hospital mortality.: Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality.Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

Objective This study compared differences in nurse and patient communication profiles between two telehealth modes: telephone and videophone, and evaluated longitudinal changes in communication, nurse perceptions, and patient satisfaction. Methods Subjects were enrolled in a randomized controlled clinical trial evaluating a 90-day home-based intervention for heart failure. Telephone (n = 14) and videophone (n = 14) interactions were audio taped and analyzed using the Roter Interaction Analysis System. Results Nurses were more likely to use open-ended questions, back-channel responses, friendly jokes, and checks for understanding on the telephone compared to videophone. Compliments given and partnership were more common on the videophone. Patients were more likely to give lifestyle information and approval comments on the telephone, and used more closed-ended questions on the videophone. Nurses perceptions of the interactions were not different between the telephone and videophone, nor did their perceptions change significantly over the course of the intervention. There were no significant differences in patient satisfaction between the telephone and videophone. Conclusions The results of this study did not support use of a videophone over the telephone. Practice implications It is critical to match technologies to patient needs and use the least complex technology possible. When considering use a videophone, health care providers should critically examine the trade-offs between additional complexities with the added value of the visual interaction.

We identified 4-year (2 years before and 2 years after the index [baseline] interview) ED use patterns in older adults and the factors associated with them.A secondary analysis of baseline interview data from the nationally representative Survey on Assets and Health Dynamics Among the Oldest Old linked to Medicare claims data. Participants were 4310 self-respondents 70 years old or older. Current Procedural Terminology (CPT) codes 99281 and 99282 identified low-intensity use, and CPT codes 99283-99285 identified high-intensity use. Exploratory factor analysis and multivariable multinomial logistic regression were used.The majority (56.6%) of participants had no ED visits during the 4-year period. Just 5.7% had only low-intensity ED use patterns, whereas 28.9% used the ED only for high-intensity visits, and 8.7% had a mixture of low-intensity and high-intensity use. Participants with lower immediate word recall scores and those who did not live in major metropolitan areas were more likely to be low-intensity-only ED users. Older individuals, those who did not live in rural counties, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to be high-intensity-only ED users. Participants who were older, did not live in major cities, had lower education levels, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to have mixed ED use patterns.Nearly half of these older adults used the ED at least once over a 4-year period, with a mean annual ED use percentage of 18.4. Few, however, used the ED only for visits that may have been avoidable. This finding suggests that triaging Medicare patients would not decrease ED overcrowding, although continued surveillance is necessary to detect potential changes in ED use patterns among older adults.

Background This study compares surgical volumes and mortality rates in the Society of Thoracic Surgeons voluntary clinical National Cardiac Database (NCD) with those from an administrative claims database (Medicare Provider Analysis and Review [MedPAR]) to assess the suitability of the NCD for tracking national cardiac surgery outcomes. Methods Hospitals common to both databases were matched. In each database, patients aged 65 years and older who underwent coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement in United States hospitals from 1993 to 2001 were identified. Results Annual volumes for all procedures were consistently higher in the NCD. This may be attributed to Medicare managed care; a Medicare group not collected into MedPAR. In-hospital mortality rates trended lower over time and were comparable between the databases. Surgical volumes were generally higher and mortality rates lower for hospitals that submitted data to the NCD than for those that did not. Conclusions The close match between NCD and MedPAR in-hospital mortality rates combined with the larger volumes in the NCD suggest that under-reporting in the NCD is not a significant issue. Further investigations into the accuracy of both the NCD and MedPAR are necessary because both are being used for evaluation of provider quality.

Background: The emergence of specialty orthopaedic hospitals has generated widespread controversy, but little is known about the quality of care they deliver. Our objective was to compare the characteristics and outcomes of patients undergoing major joint replacement in specialty orthopaedic and general hospitals. Methods: We conducted a retrospective cohort study of 51,788 Medicare beneficiaries who underwent total hip replacement and 99,765 who underwent total knee replacement in thirty-eight specialty orthopaedic hospitals and 517 general hospitals between 1999 and 2003. We compared demographic data, rates of comorbid illness, and socioeconomic status of patients treated in specialty and general hospitals. Logistic regression was used to calculate the odds of an adverse outcome (death or selected surgical complications) after adjustment for patient characteristics and hospital procedural volume. Results: The demographic data and the ratio of primary to revision arthroplasties were similar, but patients who received care in specialty hospitals had less comorbidity and resided in more affluent zip codes than their counterparts in general hospitals in 2003. Specialty hospitals had significantly greater mean procedural volumes in 2003 than did general hospitals for both total hip replacement (thirty-three compared with twenty procedures; p = 0.05) and total knee replacement (seventy-five compared with forty procedures; p = 0.006). The unadjusted rate of adverse outcomes was lower in specialty hospitals than in general hospitals for total hip replacement (3.0% compared with 6.9%; p < 0.001) and total knee replacement (2.1% compared with 3.9%; p < 0.001). After adjusting for patient characteristics and procedural volume, the odds of adverse outcomes occurring were significantly lower for patients in specialty hospitals than for those in general hospitals for both primary joint replacement (odds ratio, 0.64; 95% confidence interval, 0.56 to 0.75; p < 0.001) and revision joint replacement (odds ratio, 0.49; 95% confidence interval, 0.36 to 0.66; p < 0.001). Conclusions: After adjustment for patient characteristics and hospital volume, the specialty orthopaedic hospitals had better patient outcomes, as measured by Medicare administrative data, than did the general hospitals. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

The objective of the study was to examine veterans' perceptions of problems and benefits of outsourcing inpatient care from Veterans Affairs (VA) hospitals to private sector hospitals. Primary data were collected from a cross-section of 42 veterans who were VA users and nonusers using focus groups. Focus group discussion examined reasons patients use VA care, differences between VA and civilian care, positive and negative impacts of outsourcing, and special needs of veterans. Analyses revealed five domains related both to use of VA services and perceptions of outsourcing: costs, access, quality of care, contract (i.e., a covenant between veterans and the U.S. government), veteran milieu, and special needs. Participants identified a variety of potential positive and negative impacts. In general, veterans perceived more advantages than disadvantages to outsourcing VA care but still expressed significant concerns related to outsourcing. These issues should be considered in the development of future policy toward outsourcing VA care to the private sector.

Whether prior use of Veterans Affairs services is a marker for increased mortality was evaluated by using Medicare data for men aged 67 years and older admitted for acute myocardial infarction, chronic heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke during 1996 to 2002. Patients using Veterans Affairs services during the 2 years preceding hospital admission were identified using Veterans Affairs encounter data, and 30-day mortality was compared in patients who did and did not use Veterans Affairs services, adjusting for patient risk factors. For most Veterans Affairs users, the odds of death were similar or slightly less than the odds of death for nonusers. For acute myocardial infarction, pneumonia, and stroke, the risk of death was slightly higher for Veterans Affairs users with low income. Results using propensity-matched samples were similar. The use of Veterans Affairs services is not a strong marker of unmeasured severity among patients in private sector hospitals.

BACKGROUND:: Health services use typically is examined using either self-reports or administrative data, but the concordance between the 2 is not well established. OBJECTIVE:: We evaluated the concordance of hospital and physician utilization data from self-reports and claims data, and identified factors associated with disagreement. METHODS:: We performed a secondary analysis on linked observational and administrative data. A national sample of 4310 respondents who were 70 years old or older at their baseline interviews was used. Self-reported and Medicare claims-based hospital episodes and physician visits for 12 months before baseline were examined. Kappa statistics were used to evaluate concordance, and multivariable multinomial logistic regression was used to identify factors associated with overreporting (self-reports > claims), underreporting (self-reports < claims), and concordant-reporting (self-reports ĝ̂1/4 claims). RESULTS:: The concordance of hospital episodes was high (° ≤ 0.767 for the 2 - 2 comparison of none vs. some and ° ≤ 0.671 for the 6 - 6 comparison of none, 1, ĝ€■, 4, or 5 or more), but concordance for physician visits was low (° ≤ 0.255 for the 2 - 2 comparison of none versus some and ° ≤ 0.351 for the 14 - 14 comparison of none, 1, ..., 12, and 13 or more). Multivariable multinomial logistic regression indicated that over-, under-, and concordant-reporting of hospital episodes was significantly associated with gender, alcohol consumption, arthritis, cancer, heart disease, psychologic problems, lower body functional limitations, self-rated health, and depressive symptoms. Over-, under-, and concordant-reporting of physician visits were significantly associated with age, gender, race, living alone, veteran status, private health insurance, arthritis, cancer, diabetes, hypertension, heart disease, lower body functional limitations, and poor memory. CONCLUSIONS:: Concordance between self-reported and claims-based hospital episodes was high, but concordance for physician visits was low. Factors significantly associated with bidirectional (over- and underreporting) and unidirectional (over- or underreporting) error patterns were detected. Therefore, caution is advised when drawing conclusions based on just one physician visit data source. Copyright © 2007 by Lippincott Williams and Wilkins.

To examine the receipt of colonoscopy through the Veterans Health Administration (VA) or through Medicare by older veterans who are dually enrolled.Retrospective cohort study.The VA Outpatient Care Files and Medicare Enrollment Files were used to identify 1,060,523 patients 65 years and older in 15 of the 22 Veterans Integrated Service Networks nationally, who had 2 or more VA primary care visits in 2009 and who were simultaneously enrolled in Medicare. VA and Medicare files were used to identify the receipt of an outpatient colonoscopy. Patients were categorized as receiving care in community-based outpatient clinics (CBOCs) (n=601,337; 57%) or VA medical centers (n=459,186; 43%) based on where most patient-centered encounters occurred. Analyses used multinomial logistic regression to identify patient characteristics related to the odds of receiving a colonoscopy at the VA or through Medicare.Patients had a mean age of 76.9 (SD=7.0) years; 98% were male, 89% were white, and 21% resided in a rural location. Overall, 100,060 (9.4%) patients underwent outpatient colonoscopy either through the VA (n=33,600; 35.5%) or Medicare providers (n=65,716; 65.5%). The adjusted odds of receiving a colonoscopy from Medicare providers were higher (P.001) for patients who were male, white, receiving primary care at CBOCs, and for residents of an urban location. The receipt of colonoscopy through the VA decreased dramatically by age; for example, the odds of colonoscopy by the VA in patients aged85 years and 80 to 84 years, relative to patients aged 65 to 69 years, were 0.26 and 0.13, respectively. In contrast, the receipt of colonoscopy through Medicare did not decline as markedly with age.In a national analysis of the receipt of an outpatient colonoscopy by older veterans, more veterans received their colonoscopies through CMS than through the VA. The use of colonoscopy within the VA was found to be more concordant with age-related practice guidelines.

Clinical pharmacists are utilized in Veterans Health Administration (VHA) facilities to assist with management of patients with chronic conditions including hypertension. The goal of this study was to examine blood pressure (BP) control after discontinuation of an intensive pharmacist-managed intervention. The study was conducted at a single Midwest VHA medical center and two affiliated community-based outpatient clinics. Patients with uncontrolled BP received an intensive pharmacist intervention for the first 6 months. Patients were then stratified based on whether their BP was controlled or not and were randomized to either continue the intervention for another 24 months (30 month total time period) or the intervention was discontinued following one-time receipt of educational materials. Mean systolic and diastolic BPs were reduced (P

Background While prior research has found an inverse relationship between hospital volume and mortality after coronary artery bypass graft surgery (CABG), the use of volume as a proxy for quality and a means for selecting hospitals is controversial. The objective of this study is to quantify the relationship between hospital volume alone and CABG mortality. Methods A retrospective cohort of 948,093 Medicare patients undergoing CABG in 870 US hospitals from 1996 to 2001 was categorized into quintiles, based on hospital CABG volume. Hospitals were also classified by volume criterion proposed by the Leapfrog Group. Logistic regression was used to adjust hospital mortality rates (in-hospital or within 30 days after CABG) for patient characteristics; discrimination of the volume categories was assessed by the c statistic. Results The range in risk-adjusted mortality for hospitals within the quintiles was substantial: 1% to 17% at very low, 2% to 12% at low, 2% to 10% at medium, 2% to 9% at high, and 3% to 11% at very high volume hospitals. Moreover, volume alone was a poor discriminator of mortality ( c statistic=0.52). Similar variation in adjusted mortality was seen within the Leapfrog low-volume (1% to 17%) and high-volume groups (2% to 11%), and the Leapfrog criterion was a poor discriminator of mortality ( c statistic=0.51). Of the 660 low-volume Leapfrog hospitals, 253 (38%) had risk-adjusted mortality rates that were similar to or lower than the overall risk-adjusted mortality of high-volume hospitals (5.2%). Conclusions Volume alone, as a discriminator of mortality, is only slightly better than a coin flip ( c statistic of 0.50).

Positive relationships between hospital volume and outcomes have been demonstrated for several surgeries and medical conditions. However, little is known about the volume-outcome relationship in patients admitted to medical ICUs.To determine the relationship between hospital volume and risk-adjusted in-hospital mortality for patients admitted to ICUs with respiratory, neurologic, and GI disorders.Retrospective cohort study.Twenty-nine hospitals in a single metropolitan area.Adult ICU admissions from 1991 through 1997.Using Cox proportional hazards models, we compared in-hospital mortality between tertiles of hospital volume (high, medium, and low) for respiratory (n = 16,949), neurologic (n = 13,805), and GI (n = 12,881) diseases after adjusting for age, gender, admission severity of illness, admitting diagnosis, and source. Severity of illness was measured using the APACHE (acute physiology and chronic health evaluation) III methodology.Among respiratory and neurologic ICU admissions, hazard ratios were similar (por = 0.05) in patients in low-, medium-, and high-volume hospitals. However, among GI diagnoses, risk of mortality was lower in high-volume hospitals, relative to low-volume hospitals (hazard ratio, 0.68; 95% confidence interval [CI], 0.54 to 0.85; p0.001), and was somewhat lower in medium-volume hospitals (hazard ratio, 0.83; 95% CI, 0.68 to 1.01; p = 0.06). Among subgroups based on severity of illness, high-volume hospitals had lower mortality, relative to low-volume hospitals, among sicker patients (APACHE III score57) in the respiratory cohort (hazard ratio, 0.77; 95% CI, 0.59 to 0.99) and the GI cohort (hazard ratio, 0.67; 95% CI, 0.53 to 0.85).Associations between ICU volume and risk-adjusted mortality were significant for patients with GI diagnoses and for sicker patients with respiratory diagnoses. However, associations were not significant for patients with neurologic diagnoses. The lack of a consistent volume-outcome relationship may reflect unmeasured patient complexity in higher-volume hospitals, relative standardization of care across ICUs, or lack of efficacy of some accepted ICU processes of care.

Background— Hospital volume has been linked to quality of care. The relation between hospital volume and recommended use of bioprosthetic valves in older patients undergoing aortic valve replacement (AVR) is unknown. Methods and Results— We identified 80 470 patients aged ≥65 years undergoing isolated AVR (with or without bypass surgery) in 1045 US hospitals during 1999–2001 from Medicare Part A files. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients undergoing bioprosthetic valve (35.21) or mechanical valve (35.22) AVR. The sample was categorized into deciles on the basis of the valve surgery volume of the hospital. Generalized estimating equations determined the relative risk of receiving a bioprosthetic valve in different volume deciles, with adjustment for age, gender, race, comorbidity, and other factors. Bioprosthetic valve use increased ( P P Conclusions— Hospital volume was a strong predictor of bioprosthetic valve use in older patients undergoing AVR. The lower use of bioprosthetic valves in low-volume hospitals is at odds with recent guidelines recommending bioprosthetic valves in patients aged ≥65 years. These findings further support the use of volume as a marker of hospital quality.

Background— Few studies have examined the association of race and outcomes after coronary artery bypass graft (CABG) surgery while controlling for both patient and hospital effects. Methods and Results— We retrospectively analyzed data on a cohort of 566 785 white and 24 354 black Medicare beneficiaries 65 years old and older undergoing CABG in 1091 US hospitals from 1997 to 2000. Mortality and repeat revascularization rates were examined after sequential adjustment for patient and hospital differences by use of generalized estimating equations. Unadjusted mortality was higher ( P P Conclusions— Racial disparities in CABG outcomes are sensitive to the effects of sex and duration of postsurgical follow-up. The increasing disparity in outcomes as follow-up increased is consistent with the hypothesis that black patients have less access to secondary prevention and rehabilitation services after surgery.

Evidence suggests that patients diagnosed with osteoporosis are often undertreated. One potential solution to undertreatment is to enhance patient involvement in their osteoporosis care (a.k.a. patient activation) by having the dual-energy X-ray absorptiometry (DXA) center directly provide patients with their test results and educational material. However, little is known about patient interest in such an intervention. Consecutive patients presenting to an academic medical center DXA scanning unit were given a questionnaire to assess their preferences for being informed of their test results and interest in receiving their results plus educational material by mail from the testing center. Two hundred and two (202) of 206 (98%) of patients agreed to complete the survey. Fifty-one percent of participants preferred receiving their results by mail directly from the DXA center, followed by phone call (28%) and office visit (11%). Overall, 90% of patients reported interest in receiving results and educational material by mail. Younger patients were more interested in receiving their results by mail when compared with older patients, but this difference did not reach statistical significance (odds ratio [OR] = 2.40: 95% confidence interval [CI]: 0.91–6.31, p = 0.14). Patients undergoing DXA scanning were interested in receiving their scan results and educational material directly from the testing center. This might represent an effective intervention for improving care of patients with osteoporosis.

OBJECTIVES. Compare risk-adjusted length of stay (LOS) in VA and other United States (non-VA) hospitals and determine if relative differences in LOS have changed in recent years. RESEARCH DESIGN. Retrospective cohort study. PATIENTS. Patients with ten common medical diagnoses admitted to all VA hospitals and to non-VA hospitals included in the National Hospital Discharge Survey (NHDS) during 1996 through 1999. DATA. Comparable data elements were obtained from VA administrative databases and the NHDS. LOS was adjusted for age, gender, marital status, and comorbidity. Comorbidity was assessed using a validated methodology that considers 30 conditions. RESULTS. Unadjusted mean LOS was longer in VA than non-VA patient for all 4 years, in aggregate (7.1 vs. 4.9 days, respectively; P < 0.001), and for each year individually. However, the difference in mean LOS in VA and non-VA patients declined from 2.9 days in 1996 to 1.6 days in 1999. LOS in VA patients remained longer (P < 0.001) in linear regression analyses, adjusting for demographics and comorbidity. However, the difference in LOS declined from 28.5% (95% CI, 28.1%-29.0%) in 1996 to 17.0% (95% CI, 16.6%-17.4%) in 1999. These results were similar in analyses of individual geographic regions. CONCLUSIONS. Risk-adjusted LOS was longer in VA hospitals than in other United States hospitals. However, differences in LOS narrowed between 1996 and 1999. These findings suggest that changes in the organization and delivery of VA health care in the mid-1990s may be closing the gap between the VA and other healthcare systems in hospital utilization.

Compare severity-adjusted in-hospital mortality in patients undergoing coronary artery bypass graft surgery (CABG) in VA and private sector hospitals in two geographic regions.Retrospective Cohort Study.Consecutive male patients undergoing CABG from October 1993 to December 1996 in: 43 VA hospitals with cardiac surgery programs (n = 19,266); 32 hospitals in New York (NY) State (n = 44,247); and 10 hospitals in Northeast (NE) Ohio (n = 9696).Demographic and clinical data were abstracted from medical records. Logistic regression analysis identified 10 independent patient-level predictors (P0.01) of in-hospital mortality: age, prior CABG, angioplasty before CABG, ejection fraction, diabetes, peripheral vascular disease, congestive heart failure (CHF), cerebrovascular disease, renal insufficiency, and chronic obstructive pulmonary disease (COPD).Unadjusted mortality was higher in VA patients than in NY or NE Ohio patients (3.5% vs. 2.0%, and 2.2%, respectively). Mortality decreased (P0.001) with increasing volume (3.6% in low [500 cases], 3.0% in moderate [500-1000 cases], and 2.0% in high [1000 cases] volume hospitals). Median volume was lower in VA than private sector hospitals (410 vs. 1520), and no VA hospitals were classified as high volume. Adjusting for patient-level predictors and volume, the odds of death was higher in VA patients, relative to private sector patients (OR, 1.34; 95% CI, 1.11-1.63; P0.001). In stratified analyses, the odds of death in VA patients was similar in low volume hospitals (OR, 0.86; P = 0.39), but higher in moderate volume hospitals (OR, 1.50; P = 0.01).VA hospitals had lower CABG volume than private sector hospitals in NY and NE Ohio, and higher in-hospital mortality. However, the difference in mortality was limited to moderate-volume hospitals. These findings suggest that hospital volume is an important modifier in comparisons of CABG mortality in VA and private sector hospitals. The higher mortality in VA hospitals may, in part, be caused by differences in surgical capacity and patient demand that lead to lower volume cardiac surgery programs.

OBJECTIVES: To determine independent relationships between age and the risk of in-hospital death. DESIGN: Retrospective cohort study. SETTING: Thirty-eight intensive care units (ICUs) in 28 hospitals in a large Midwest metropolitan region. PARTICIPANTS: One hundred fifty-six thousand, one hundred thirty-six consecutive admissions to medical, surgical, neurological, and mixed medical/surgical ICUs between March 1, 1991, and March 31, 1997. MEASUREMENTS: In-hospital death rates were compared at successive 5-year age intervals, adjusting for gender, diagnosis, admission source, comorbidity, and acute physiology scores. Acute physiology scores were determined using a validated methodology based on abnormalities in 17 physiological measures collected during the first 24 hours of ICU admission. RESULTS: The adjusted odds of death increased with each 5-year age increment. For example, relative to patients younger than 35, adjusted odds of death in patients aged 40 to 44, 50 to 54, 60 to 64, 70 to 74, 80 to 84, and 90 and older were 1.51, 1.73, 2.38, 2.98, 3.86, and 4.74, respectively. In stratified analyses, age-related increases in the odds of death were somewhat higher in surgical than medical patients or patients with lower severity of illness at admission. Although acute physiology scores had excellent discrimination in all age groups, discrimination decreased with age (e.g., c-statistics of 0.928 and 0.835 in patients younger than 45 and 85 and older, respectively). CONCLUSION: Our findings demonstrate incremental increases in the risk of hospital death associated with age that was independent of severity of illness and other prognostic factors. Although the current results may be less biased by differences in treatment goals than studies of general hospitalized patients, the lower discrimination of physiology scores in older patients suggests that unmeasured factors (e.g., functional status, patient preferences for care, differences in physician practices) may be of greater prognostic importance in older than in younger patients. From the *Research Service, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa; D ivision of General Internal Medicine, Department of Internal Medicine, University of Iowa College of Medicine and University of Iowa Hospital and Clinics, Iowa City, Iowa; and 1 Health Evaluation Systems Delivery Team, Department of Anesthesiology and Critical Care Medicine, University of Pittshurgh School of Medicine, Pittsburgh, Pennsylvania.

BACKGROUND. Relationships between day of the week of admission to hospitals and hospital outcomes have been poorly studied. Intensive care units (ICUs) appear to be uniquely suited to examine such a question given the unpredictability of ICU admissions and the clinical instability of their patient populations. METHODS. This retrospective cohort study included 156,136 patients admitted to 38 ICUs in 28 hospitals in a large Midwestern metropolitan area during 1991 to 1997. Demographic and clinical data were collected from patients' medical records and used in multivariable risk-adjustment models that examined the risk for in-hospital death and ICU length of stay. RESULTS. The adjusted odds of in-hospital death were 9% higher (OR 1.09; 95% CI, 1.04-1.15; P

OBJECTIVES Compare intensive care unit (ICU) mortality and length of stay (LOS) in a VA hospital and private sector hospitals and examine the impact of hospital utilization on mortality comparisons. RESEARCH DESIGN Retrospective cohort study. SUBJECTS Consecutive ICU admissions to a VA hospital (n = 1,142) and 27 private sector hospitals (n = 51,249) serving the same health care market in 1994 to 1995. MEASURES Mortality and ICU LOS were adjusted for severity of illness using a validated method that considers physiologic data from the first 24 hours of ICU admission. Mortality comparisons were made using two different multivariable techniques. RESULTS Unadjusted in-hospital mortality was higher in VA patients (14.5% vs. 12.0%; P = 0.01), as was hospital (28.3 vs. 11.3 days; P

Objectives: To compare colorectal cancer screening rates in veterans receiving primary care (PC) in Veterans Administration (VA) community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs). Methods: The VA Outpatient Care Files were used to identify 2 837 770 patients ≥50 years with ≥2 PC visits in 2010. Veterans undergoing screening/surveillance colonoscopy, sigmoidoscopy, fecal-occult-blood testing (FOBT), and double-contrast barium enema (DCBE) were identified from ICD-9-CM/CPT codes. Patients were categorized as VAMC (n = 1 403 273; 49.5%) or CBOC (1 434 497; 50.5%) based on where majority of PC encounters occurred and as high risk (n = 284 090) or average risk (n = 2 553 680) based on colorectal cancer risk factors and validated ICD-9-CM-based algorithms. Results: CBOC patients were older than VAMC (mean ages 69.3 vs 67.4 years; P < .001), more likely ( P < .001) to be male (96.5% vs 95.1%), and white (67.8% vs 64.2%), but less likely to be high-risk (9.4% vs 10.5%; P < .001). Rates of colonoscopy, sigmoidoscopy, and DCBE were all lower in CBOC ( P < .001). Among high-risk veterans, rates in CBOC and VAMC, respectively, were 27.4% versus 36.8% for colonoscopy, 1.3% versus 0.8% for sigmoidoscopy, and 0.8% versus 0.5% for DCBE. Among average-risk veterans, these rates were 1.3% versus 1.9%, 0.2% versus 0.1%, and 0.2% versus 0.1%, respectively. The differences remained after adjusting for age/comorbidity. The adjusted odds of colonoscopy for CBOC were 0.73 (95% confidence interval = 0.64-0.82) for average risk and 0.76 (95% confidence interval = 0.67-0.87) for high risk. In contrast, the use of FOBT was relatively similar in CBOCs and VAMCs among both high risk (11.1% vs 11.2%) and average risk (14.3% vs 14.1%). Screening rates were similar between those younger than 65 years and older than 65 years. Conclusions: Veterans receiving PC in CBOCs are less likely to receive screening colonoscopy, sigmoidoscopy, and DCBE than VAMC according to VA records. The lower use in CBOC was not offset by higher use of FOBT, including the degree to which CBOC patients may be more reliant to use non-VA services. The clinical appropriateness of these differences merits further examination.

The objective of this study was to compare hospital mortality in Veterans Affairs (VA) and private-sector patients. The study included 5016 patients admitted to 1 VA hospital. Admission severity of illness was measured using a commercial methodology that was developed in a nationwide database of 850,000 patients from 111 private-sector hospitals. The method uses data abstracted from patients' medical records to predict the risk of death in individual patients, based on the normative database. Analyses compared actual and predicted mortality rates in VA patients. VA patients had higher (P.05) severity of illness than private-sector patients. The observed mortality rate in VA patients was 4.0% and was similar (P = .09) to the predicted risk of death (4.4%; 95% confidence interval 4.0-4.9%). In subgroup analyses, actual and predicted mortality rates were similar in medical and surgical patients and in groups stratified according to severity of illness, except in the highest severity stratum, in which actual mortality was lower than predicted mortality (57% vs 73%; P.001). We found that in-hospital mortality in 1 VA hospital and a nationwide sample of private-sector hospitals were similar, after adjusting for severity of illness. Although not directly generalizable to other VA hospitals, our findings nonetheless suggest that the quality of VA and private-sector care may be similar with respect to one important and widely used measure.

Previous research measuring differences in the care between men and women with myocardial infarction has focused on differences in procedure use and mortality. However, little is known about differences in processes and outcomes that are reported by patients, such as interpersonal processes of care and health status. Our goal was to measure differences in patient-reported measures for men and women who recently were hospitalized with myocardial infarction.We surveyed by mail patients with myocardial infarction discharged to home from one of 27 Cleveland area hospitals 3 months following discharge; 502 (64%) of 783 patients responded. The mean age of subjects was 65 years and 40% were women.Process measures included the quality of communication during the hospitalization and at time of discharge and reports of health education discussions during hospitalization. Outcome measures included physical and mental health component scores of the Medical Outcomes Study 36-Item Short-Form Health Survey, change in work status, and days spent in bed because of ill health. We compared processes and outcomes in men and women using multivariate analyses that adjusted for age, other demographic characteristics, comorbid conditions, severity of the myocardial infarction, and premorbid global health status.In multivariate analyses, women were as likely as men to report at least one problem with communication during the hospitalization (odds ratio [OR] 0.86; 95% confidence interval [95% CI] 0.56 to 1. 33) or at time of discharge (OR 1.24; 95% CI, 0.82 to 1.89) and to report that they were given dietary advice before discharge (OR 0. 60; 95% CI, 0.36 to 1.01), were told what to do if they developed chest pain (OR 1.21; 95% CI, 0.66 to 2.23), or, if they smoked cigarettes, given advice about how to stop smoking (OR 0.64; 95% CI, 0.26 to 1.58). However, 3 months after discharge, women reported worse physical health (P.05) and mental health (P.05), were more likely to report spending time in bed because of ill health (OR 1. 80; 95% CI, 1.06, 3.05), and were more likely to report working less than before their myocardial infarction (OR 4.02; 95% CI, 1.58 to 10. 20).In terms of processes of care measured with patient reports, women with myocardial infarction reported their quality of care to be similar to that of men. However, 3 months following myocardial infarction, women reported worse health status and were less likely to return to work than men.

Background: The impact of upper endoscopy in patients with upper gastrointestinal hemorrhage treated in community practice is unknown. Thus we examined the effectiveness of endoscopy performed within 24 hours of admission (early endoscopy). Methods: Medical records of 909 consecutive hospitalized patients with upper gastrointestinal hemorrhage who underwent endoscopy at 13 hospitals in a large metropolitan area were reviewed. We evaluated unadjusted and severity-adjusted associations of early endoscopy with recurrent bleeding or surgery to control hemorrhage, length of hospital stay, and associations of endoscopic therapy in patients with bleeding ulcers or varices. Results: Early endoscopy was performed in 64% of patients and compared with delayed endoscopy and was associated with clinically significant reductions in adjusted risk of recurrent bleeding or surgery (odds ratio [OR] 0.70: 95% CI [0.44, 1.13]) and a 31% decrease in adjusted length of stay (95% CI: [24%, 37%]). In patients at high risk for recurrent bleeding, the use of early endoscopic therapy to control hemorrhage was associated with reductions in recurrent bleeding or surgery (OR 0.21: 95% CI [0.10, 0.47]) and length of stay (–31%: 95% CI [–44%, –14%). Conclusion: In this study of community-based practice, the routine use of endoscopy, and in selected cases endoscopic therapy, performed early in the clinical course of patients with upper gastrointestinal hemorrhage was associated with reductions in length of stay and, possibly, the risk of recurrent bleeding and surgery. (Gastrointest Endosc 1999;49:145-52.)

OBJECTIVES The study sought to describe the association between do-not-resuscitate (DNR) orders and length of hospital stay (LOS), and how the association varies according to in-hospital mortality, timing of the DNR order, and admission severity of illness. METHODS The authors conducted a retrospective cohort analysis involving standardized review of patients' medical records. The study was performed at 30 acute care hospitals in a large metropolitan area. The authors studied the data of 13,337 consecutive patients with a primary diagnosis of stroke discharged in 1991 through 1994. RESULTS Do-not-resuscitate orders were written for 22% (n = 2,898) of the sample. In all patients, mean LOS was longer in patients with DNR orders than in patients without orders (12.0 versus 9.5 days; P < 0.001). A series of Cox regression analyses were performed to adjust LOS for admission severity of illness and other covariates. In analyses of patients discharged alive (n = 12,011), LOS was similar in patients with DNR orders written on days 1 to 2 compared with patients without DNR orders. However, LOS was longer in patients with DNR orders written on days 3 to 7 (Hazard Ratio [HR], 1.59; 95% CI, 1.43-1.77) and on day 8 or later (HR, 2.72; 95% CI, 2.34-3.16). In analyses of patients who died (n = 1,326), LOS was shorter for patients with DNR orders written on days 1 and 2 (HR, 0.59; 95% CI, 0.49-0.71) than for patients without DNR orders but was longer among patients with DNR orders written on day 8 or later (HR, 2.58; 95% CI, 2.06-3.22). In analyses stratified by admission severity, the relative effect of a DNR order tended to be less in patients with higher severity. CONCLUSIONS The relationship between DNR orders and LOS is complex and varies according to in-hospital mortality, the timing of the DNR order, and admission severity of illness. These findings highlight the importance of explicitly accounting for such factors in studies evaluating the implications of DNR orders on the costs of hospital care.

The authors determined whether standardized hospital mortality rates varied for six common medical diagnoses.The retrospective cohort study included 89,851 patients aged 18 years and older discharged from 30 hospitals in a large metropolitan area in 1991 to 1993 with a principal diagnosis of acute myocardial infarction, congestive heart failure, pneumonia, stroke, obstructive lung disease, or gastrointestinal hemorrhage. For each hospital, standardized mortality ratios (observed/predicted mortality) were determined using validated risk-adjustment models that were based on clinical data elements abstracted from patients' hospital records. Hospitals also were categorized into quintiles on the basis of standardized mortality ratios. Correlations between standardized mortality ratios and agreement between quintile rankings were determined for each pair of diagnoses.Correlations between hospital-standardized mortality ratios for individual diagnoses were generally weak. For the 15 possible pairs of diagnoses, Pearson coefficients ranged from -0.10 to 0.43; only six were 0.30 or greater. Agreement between hospital quintile rankings was also generally low, with weighted kappa values ranging from -0.12 to 0.42. Three of 15 kappa values were less than 0 (ie, agreement lower than chance), and only four exceeded 0.20, the threshold for "fair" agreement. Although simulated analyses found that random variation and relatively low hospital volumes accounted for some of the difference in standardized mortality ratios for diagnoses, a large proportion of the difference remained unexplained.Standardized hospital mortality rates varied for six diagnoses that likely are managed by similar practitioners. Although variability may be decreased by restricting analyses to hospitals with large volumes, the findings indicate that for many hospitals, diagnosis-specific mortality rates may be an inconsistent measure of hospital quality, even when data are aggregated for multiple years.

Determine the relation of race and gender to outcome from bleeding peptic ulcer.Retrospective cohort study.All acute care hospitals in the United States.A 100% sample of hospitalized Medicare beneficiaries older than 64 years (n = 82,868) with a primary discharge diagnosis of peptic ulcer with hemorrhage.Surgical treatment was performed in 6.9% of patients, 30-day mortality was 8.5%, and average length of stay was 9.4 days. Surgery was somewhat more common in men than women (7.3% vs 6.5%, p.001), and in whites than African Americans (6.9% vs 6.3%, p.001), but neither race nor gender was associated with surgery in multivariable analysis adjusting for potentially confounding factors. Mortality rates were similar in African Americans and whites (8.5%), and somewhat higher in men than women (10.7% vs 9.3%, p.001). In multivariable analysis, there was no difference in mortality across gender and racial groups. Although unadjusted and adjusted lengths of stay were longer for African Americans and shorter for men, the differences were modest (i.e., 16% increase and 6% decrease in multivariable analysis, respectively, p.0001).In this national sample, there is no significant gender or racial difference in therapy and outcome for patients with hemorrhagic peptic ulcer. The findings raise the possibility that studies that have shown race and gender differences in management of coronary artery disease and cancer may not be generalizable to other common diagnoses.

Determine patient and hospital-level variation in proportions of low-severity admissions.Retrospective cohort study.Thirty hospitals in a large metropolitan region.A total of 43,209 consecutive eligible patients discharged in 1991 through 1993 with congestive heart failure (n = 25,213) or pneumonia (n = 17,995).Admission severity of illness was measured from validated multivariable models that estimated the risk of in-hospital death; models were based on clinical data abstracted from patients' medical records. Admissions were categorized as "low severity" if the predicted risk of death was less than 1%. Nearly 15% of patients (n = 6,382) were categorized as low-severity admissions. Compared with other patients, low-severity admissions were more likely (p.001) to be nonwhite and to have Medicaid or be uninsured. Low-severity admissions had shorter median length of stay (4 vs 7 days; p.001), but accounted for 10% of the total number of hospital days. For congestive heart failure, proportions of low-severity admissions across hospitals ranged from 10% to 25%; 12 hospitals had rates that were significantly different (p.01) than the overall rate of 17%. For pneumonia, proportions ranged from 3% to 22%; 12 hospitals had rates different from the overall rate of 12%. Variation across hospitals remained after adjusting for patient sociodemographic factors.Rates of low-severity admissions for congestive heart failure and pneumonia varied across hospitals and were higher among nonwhite and poorly insured patients. Although the current study does not identify causes of this variability, possible explanations include differences in access to ambulatory services, decisions to admit patients for clinical indications unrelated to the risk of hospital mortality, and variability in admission practices of individual physicians and hospitals. The development of protocols for ambulatory management of low-severity patients and improvement of access to outpatient care would most likely decrease the utilization of more costly hospital services.

OBJECTIVE: Although physical function is believed to be an important predictor of outcomes in older people, it has seldom been used to adjust for prognosis or case mix in evaluating mortality rates or resource use. The goal of this study was to determine whether patients' activity of daily living (ADL) function on admission provided information useful in adjusting for prognosis and case mix after accounting for routine physiologic measures and comorbid diagnoses. SETTING: The general medical service of a teaching hospital. PARTICIPANTS: Medical inpatients (n = 823) over age 70 (mean age 80.7, 68% women). MEASUREMENTS: Independence in ADL function on admission was assessed by interviewing each patient's primary nurse. We determined the APACHE II Acute Physiology Score (APS) and the Charlson comorbidity score from chart review. Outcome measures were hospital and 1-year mortality, nursing home use in the 90 days following discharge, and cost of hospitalization. Patients were divided into four quartiles according to the number of ADLs in which they were dependent. MAIN RESULTS: ADL category stratified patients into groups that were at markedly different risks of mortality and higher resource use. For example, hospital mortality varied from 0.9% in patients dependent in no ADL on admission, to 17.4% in patients dependent in all ADLs. One-year mortality ranged from 17.5% to 54.9%, nursing home use from 3% to 33%, and hospital costs varied by 53%. In multivariate analyses controlling for APS, Charlson scores, and demographic characteristics, compared with patients dependent in no ADL, patients dependent in all ADLs were at greater risk of hospital mortality (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.1-58.8), 1-year mortality (OR 4.4; 2.7-7.4), and 90-day nursing home use (OR 14.9; 6.0-37.0). The DRG-adjusted hospital cost was 50% higher for patients dependent in all ADLs. ADL function also improved the discrimination of hospital and 1-year mortality models that considered APS, or Charlson scores, or both. CONCLUSIONS: ADL function contains important information about prognosis and case mix beyond that provided by routine physiologic data and comorbidities in hospitalized elders. Prognostic and case-mix adjustment methods may be improved if they include measures of function, as well as routine physiologic measures and comorbidity.

OBJECTIVE: To identify age-related differences in the treatment of patients with acute myocardial infarction. DESIGN: Retrospective cohort study. SETTING: Two university-affiliated medical centers with integrated clinical programs. PATIENTS: 329 patients admitted with acute myocardial infarction in 1988–1990 for whom complete medical records were available. Study exclusions included patients transferred from other hospitals specifically to undergo angiography or other cardiac procedures, nursing home residents, patients with metastatic cancer or dementia, and patients in whom “do not resuscitate” orders were written during the first 2 hospital days. MEASUREMENTS: Medical records were reviewed to determine socio-demographic data, comorbidity, admission severity of illness, medications, the use of specific diagnostic and therapeutic modalities during and after hospitalization, treatment limitations, and patient outcomes. MAIN RESULTS: Chronological age of patients was related to the use of several diagnostic and therapeutic modalities. Using logistic regression to adjust for comorbidity, severity, infarct size and location, and other covariates, patients 75 years and older were 12 times less likely to receive thrombolytic therapy, 8 times less likely to undergo coronary angiography, and 7 times less likely to undergo coronary angioplasty than patients less than 65 years of age. However, age was not related to the use of other modalities, including echocardiography or gated blood pool scanning, pulmonary artery catheterization, and transvenous pacing. Finally, in a logistic regression model, the risk of in-hospital death was 4 times greater for patients 75 years and older than patients less than 65 years. CONCLUSIONS: Physicians' management of patients with acute myocardial infarction differed greatly according to patient age for some diagnostic and therapeutic modalities, but not for others. These findings indicate that generalizations about age-related practice variations should not be based on analysis of a single procedure. Moreover, judgments about the appropriateness of age-related differences in management require knowledge of the relative effectiveness of management strategies in older and younger patients.

Background It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates. Methods Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen's behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects. Results We identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58). Conclusions We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.

Background Episodes of Emergency Department (ED) service use among older adults previously have not been constructed, or evaluated as multi-dimensional phenomena. In this study, we constructed episodes of ED service use among a cohort of older adults over a 15-year observation period, measured the episodes by severity and intensity, and compared these measures in predicting subsequent hospitalization. Methods We conducted a secondary analysis of the prospective cohort study entitled the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). Baseline (1993) data on 5,511 self-respondents ≥70 years old were linked to their Medicare claims for 1991-2005. Claims then were organized into episodes of ED care according to Medicare guidelines. The severity of ED episodes was measured with a modified-NYU algorithm using ICD9-CM diagnoses, and the intensity of the episodes was measured using CPT codes. Measures were evaluated against subsequent hospitalization to estimate comparative predictive validity. Results Over 15 years, three-fourths (4,171) of the 5,511 AHEAD participants had at least 1 ED episode, with a mean of 4.5 episodes. Cross-classification indicated the modified-NYU severity measure and the CPT-based intensity measure captured different aspects of ED episodes (kappa = 0.18). While both measures were significant independent predictors of hospital admission from ED episodes, the CPT measure had substantially higher predictive validity than the modified-NYU measure (AORs 5.70 vs. 3.31; p < .001). Conclusions We demonstrated an innovative approach for how claims data can be used to construct episodes of ED care among a sample of older adults. We also determined that the modified-NYU measure of severity and the CPT measure of intensity tap different aspects of ED episodes, and that both measures were predictive of subsequent hospitalization.

Surgical complications contribute substantially to costs. Most important, surgical complications contribute to morbidity and mortality, and some may be preventable. This study estimates costs of specific surgical complications for patients undergoing general surgery in VA hospitals using merged data from the VA Surgical Quality Improvement Program and VA Decision Support System.Costs associated with 19 potentially preventable complications within 6 broader categories were estimated using generalized, linear mixed regression models to control for patient-level determinants of costs (eg, type of operation, demographics, comorbidity, severity) and hospital-level variation in costs. Costs included costs of the index hospitalization and subsequent 30-day readmissions.In 14,639 patients undergoing general surgical procedures from 10/2005 through 9/2006, 20% of patients developed postoperative surgical complications. The presence of any complication significantly increased unadjusted costs nearly 3-fold ($61,083 vs $22,000), with the largest cost differential attributed to respiratory complications. Patients who developed complications had several markers for greater preoperative severity, including increased age and a lesser presurgery functional health status. After controlling for differences in patient severity, costs for patients with any complication were 1.89 times greater compared to costs for patients with no complications (P.0001). Within major complication categories, adjusted costs were significantly greater for patients with respiratory, cardiac, central nervous system, urinary, wound, or other complications.Surgical complications contribute markedly to costs of inpatient operations. Investment in quality improvement that decreases the incidence of surgical complications could decrease costs.

We investigated whether prior hospitalization was a risk factor for heart attacks among older adults in the survey on Assets and Health Dynamics among the Oldest Old.Baseline (1993-1994) interview data were linked to 1993-2005 Medicare claims for 5,511 self-respondents aged 70 years and older and not enrolled in managed Medicare. Primary hospital International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 410.xx discharge codes identified postbaseline hospitalizations for acute myocardial infarctions (AMIs). Participants were censored at death or postbaseline managed Medicare enrollment. Traditional risk factors and other covariates were included. Recent postbaseline non-AMI hospitalizations (ie, prior hospitalizations) were indicated by a time-dependent marker, and sensitivity analyses identified their peak effect.The total number of person-years of surveillance was 44,740 with a mean of 8.1 (median = 9.1) per person. Overall, 483 participants (8.8%) suffered postbaseline heart attacks, with 423 participants (7.7%) having their first-ever AMI. As expected, significant traditional risk factors were sex (men); race (whites); marital status (never being married); education (noncollege); geography (living in the South); and reporting a baseline history of angina, arthritis, diabetes, and heart disease. Risk factors were similar for both any postbaseline and first-ever postbaseline AMI analyses. The time-dependent recent non-AMI hospitalization marker did not alter the effects of the traditional risk factors but increased AMI risk by 366% (adjusted hazards ratio = 4.66, p.0001). Discussion. Our results suggest that some small percentage (3%) of heart attacks among older adults might be prevented if effective short-term postdischarge planning and monitoring interventions were developed and implemented.