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OBJECTIVE: To examine how estimates of the association between nurse staffing and patient length of stay (LOS) change with data aggregation over varying time periods and settings, and statistical controls for unobserved heterogeneity. DATA SOURCES/STUDY SETTING: Longitudinal secondary data from October 2002 to September 2006 for 215 intensive care units and 438 general acute care units at 143 facilities in the Veterans Affairs (VA) health care system. RESEARCH DESIGN: This retrospective observational study used unit‐level panel data to analyze the association between nurse staffing and LOS. This association was measured over both a month‐long and a year‐long period, with and without fixed effects. DATA COLLECTION: We used VA administrative data to obtain patient data on the severity of illness and LOS, as well as labor hours and wages for each unit by month. PRINCIPAL FINDINGS: Overall, shorter LOS was associated with higher nurse staffing hours and lower proportions of hours provided by licensed professional nurses (LPNs), unlicensed personnel, and contract staff. Estimates of the association between nurse staffing and LOS changed in magnitude when aggregating data over years instead of months, in different settings, and when controlling for unobserved heterogeneity. CONCLUSIONS: Estimating the association between nurse staffing and LOS is contingent on the time period of analysis and specific methodology. In future studies, researchers should be aware of these differences when exploring nurse staffing and patient outcomes.

BACKGROUND: In response to the opioid crisis, states and health systems are encouraging clinicians to use risk mitigation strategies aimed at assessing a patient’s risk for opioid misuse or abuse: opioid agreements, prescription drug monitoring programs (PDMPs), and urine drug tests (UDT). OBJECTIVE: The objective of this qualitative study was to understand how clinicians perceived and used risk mitigation strategies for opioid abuse/misuse and identify barriers to implementation. METHODS: We interviewed clinicians who prescribe opioid medications in the outpatient setting from 2016-2018 and analyzed the data using Constructivist Grounded Theory methodology. RESULTS: We interviewed 21 primary care clinicians and 12 specialists. Nearly all clinicians reported using the PDMP. Some clinicians (adopters) found the opioid agreement and UDTs to be valuable, but most (non-adopters) did not. Adopters found the agreements and UDTs helpful in treating patients equitably, setting limits, and having objective evidence of misuse; protocols and workflows facilitated the use of the strategies. Non-adopters perceived the strategies as awkward, disruptive to the clinician-patient relationship, and introducing a power differential; they also cited lack of time and resources as barriers to use. CONCLUSIONS: Our study demonstrates that clinicians in certain settings have found effective ways to implement and use the PDMP, opioid agreements, and UDT but that other clinicians are less comfortable with their use. Administrators and policymakers should ensure that the strategies are designed in a way that strengthens the clinician-patient relationship while maximizing safety for patients and that clinicians are adequately trained and supported when introducing the strategies.

Background Given the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care. Methods We identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2–4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication. Results In our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1–4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1–3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5–9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0–3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: − 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08–0.23%), 0.44% (95%CI: 0.30–0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03–0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13–0.26%). Conclusions Patients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.

BACKGROUND: Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis. OBJECTIVE: To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis. DESIGN: Retrospective cohort study using multivariable analysis of clinical data. PARTICIPANTS: A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection. SETTING: Four university hospitals in California between 2014 and 2016. MAIN OUTCOMES AND MEASURES: The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen. KEY RESULTS: Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29–0.38, p

BackgroundThe association of nursing staffing with patient outcomes has primarily been studied by comparing high to low staffed hospitals, raising concern other factors may account for observed differences. We examine the association of inpatient mortality with patients’ cumulative exposure to shifts with low registered nurse (RN) staffing, low nursing support staffing and high patient turnover.MethodsCumulative counts of exposure to shifts with low staffing and high patient turnover were used as time-varying covariates in survival analysis of data from a three-campus US academic medical centre for 2007–2012. Staffing below 75% of annual median unit staffing for each staff category and shift type was characterised as low. High patient turnover per day was defined as admissions, discharges and transfers 1 SD above unit annual daily averages.ResultsModels included cumulative counts of patient exposure to shifts with low RN staffing, low nursing support staffing, both concurrently and high patient turnover. The HR for exposure to shifts with low RN staffing only was 1.027 (95% CI 1.002 to 1.053, pConclusionLow RN and nursing support staffing were associated with increased mortality. The results should encourage hospital leadership to assure both adequate RN and nursing support staffing.

Background Hospital benchmarking is essential to quality improvement, but its usefulness depends on the ability of statistical models to adequately control for inter-hospital differences in patient mix. We explored whether the addition of injury-specific clinical variables to the current American College of Surgeons-Trauma Quality Improvement Program (TQIP) algorithm would improve model fit. Methods We analyzed a prospective registry containing all adult patients who presented to a regional consortium of 14 trauma centers between 2010 and 2011 with severe traumatic brain injury (TBI). We used hierarchical logistic regression and stepwise forward selection to develop two novel risk-adjustment models. We then tested our novel models against the current TQIP model and ranked hospitals by their risk-adjusted mortality rates under each model to determine how model selection affects quality benchmarking. Results Seven hundred thirty-four patients met inclusion criteria. Stepwise selection resulted in two distinct models: one that added three TBI-specific variables (pupil reactivity, cerebral edema, loss of basal cisterns) to the model specification currently used by TQIP and another that combined two TBI-specific variables (pupil reactivity, cerebral edema) with a three-variable subset of TQIP (age, Abbreviated Injury Scale score for the head region, Glasgow Coma Scale motor score). Both novel models outperformed TQIP. Although rankings remained largely unchanged across model configurations, several hospitals moved across quality terciles. Conclusion The inclusion of injury-specific variables improves risk adjustment for patients with severe TBI. Trauma Quality Improvement Program should consider replacing several of its general patient characteristics with injury-specific clinical predictors to increase efficiency, reduce the risk of overfitting, and improve the accuracy of hospital benchmarking. Level of evidence Prognostic and epidemiological, level II.

Background Understanding the long-term inpatient service cost and utilization of psychiatric patients may provide insight into service demand for these patients and guide the design of targeted mental health programs. This study assesses 3-year hospitalization patterns and quantifies service utilization intensity of psychiatric patients in Beijing, China. Methods We identified patients admitted for one of three major psychiatric disorders (schizophrenia, bipolar and depressive disorders) between January 1 and December 31, 2013 in Beijing, China. Inpatient admissions during the following 3 years were extracted and analyzed using sequence analysis. Clinical characteristics, psychiatric and non-psychiatric service use of included patients were analyzed. Results The study included 3443 patients (7657 hospitalizations). The patient hospitalization sequences were grouped into 4 clusters: short stay (N = 2741 (79.61% of patients), who had 126,911 or 26.82% of the hospital days within the sample), repeated long stay (N = 404 (11.73%), 76,915 (16.26%) days), long-term stay (N = 101 (2.93%), 59,909 (12.66%) days) and permanent stay (N = 197 (5.72%), 209,402 (44.26%) days). Length and frequency of hospitalization, as well as readmission rates were significantly different across the 4 clusters. Over the 3-year period, hospitalization days per year decreased for patients in the short stay and repeated long stay clusters. Patients with schizophrenia (1705 (49.52%)) had 78.4% of cumulative psychiatric stays, with 11.14% of them in the permanent stay cluster. Among patients with depression, 23.11% had non-psychiatric hospitalizations, and on average 46.65% of their total inpatient expenses were for non-psychiatric care, the highest among three diagnostic groups. Conclusion Hospitalization patterns varied significantly among psychiatric patients and across diagnostic categories. The high psychiatric care service use of the long-term and permanent stay patients underlines the need for evidence-based interventions to reduce cost and improve care quality.

Background/objectives To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA). Design A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equations to evaluate monthly cost trajectories experienced by patients in their last year of life, with patients nested within hospital referral region. Setting Care received at VA facilities or by Medicare-reimbursed providers nationwide. Participants A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare. Measurements We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12 months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life. Results All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care. Conclusion Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.

Background Given the risks of opioid therapy, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs have their own risks; patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined how primary care clinicians balance patient comorbidities and concurrent medications when prescribing opioids. Methods We used a retrospective cross-sectional study design and data from one health system. We identified office visits for low back pain from 2012-2017 and sampled the first visit per patient per year (N= 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent use of anticoagulants/antiplatelets) and opioids (depression, anxiety, substance use and bipolar disorders, chronic corticosteroid use, and concurrent benzodiazepines) and estimated four logistic regression models, with the first model including all patient visits and then stratifying for previous opioid use. Results Patients received an opioid prescription at 4% of visits. Among all patients, kidney disease (marginal effect [ME]: 3%; 95%CI: 1%-4%) or chronic/concurrent anticoagulant/antiplatelet prescriptions (ME: 2%, 95%CI: 1%-3%) were associated with a higher probability of receiving an opioid prescription. Concurrent benzodiazepines (ME: 7%, 95%CI: 5%-9%) and substance use diagnoses (ME: 1%, 95%CI: 0%-3%) were also associated with a higher probability of opioid prescription receipt. Among patients with long-term opioid use, contraindications for NSAIDs were not associated with a higher probability of opioid prescription receipt, while the probability of opioid receipt among those with concurrent benzodiazepines was substantially higher (ME: 10%, 95%CI: 14%-53%).Conclusions Among our entire sample, patients with kidney disease were 75% more likely to receive an opioid prescription for low back pain. Among patients with long-term opioid use, we did not find the same association. Patients with long-term use were likely started on opioids when opioid prescribing was more liberal; discussions regarding non-opioid options would be worthwhile for this population. Patients with concurrent benzodiazepines were 175% more likely to receive an opioid prescription; among patients with long-term opioid use, they were 250% more likely to receive opioids. These findings are troubling, as this combination is dangerous and can lead to overdose.

RESEARCH OBJECTIVE: Research suggests that about 80% of women veterans receiving care at the Department of Veterans Affairs (VA) have experienced at least one trauma in their lifetimes, including military sexual trauma or combat‐related trauma. Trauma‐sensitive communication reflects an understanding of the impact of trauma and the needs of trauma survivors during health care encounters. We explored whether provider gender sensitivity is associated with positive ratings of trauma‐sensitive communication among women veteran patients. STUDY DESIGN: We conducted cross‐sectional surveys of providers to measure provider gender sensitivity using 10 survey items adapted from the Gender Awareness Inventory‐VA. Example items included “Sometimes I wish VA primary care clinics had only male patients.” We averaged responses in 5‐point Likert scales to create a composite score, with a higher score indicating higher sensitivity. We used cross‐sectional surveys of patients to measure women veterans' perspectives of trauma‐sensitive communication: providers (1) asked about any serious problems or stresses in life (yes vs no), (2) made sure they were comfortable before any treatments or examinations (always vs otherwise), and (3) made them feel comfortable talking about emotional issues (very comfortable vs otherwise). We linked survey responses of providers to women veterans via VA primary care visit information in 2014. We used logistic regression to predict each measure of trauma‐sensitive communication, controlling for women veterans' age, race, and ethnicity, a service‐connected disability, military sexual trauma, physical and mental comorbidities, and primary care and mental health visits in 2014. All analyses were weighted for survey nonresponses. POPULATION STUDIED: A total of 94 primary care providers (PCPs) (33% response rate) and 1395 women veterans (45% response rate) from 12 VA medical centers (VAMCs) completed the surveys between 2014 and 2015. After linking women veterans to PCPs, they had visited for primary care or women's health at the same 12 VAMCs in 2014, and the analyses included 804 women veterans and 58 PCPs who responded to the surveys. PRINCIPAL FINDINGS: Overall, 80.3% of women veterans reported that their PCPs asked about any serious problems or stresses in life, 79.3% reported that PCPs always made sure they were comfortable before any treatments or examinations, and 55.6% felt very comfortable talking with PCPs about emotional issues. After adjusting for covariates, higher provider gender sensitivity score was associated with more women veterans reporting that (1) PCPs asked about any serious problems or stresses in life (AOR: 1.33, 95% CI: 1.08‐1.63), (2) PCPs always made sure they were comfortable before any treatments or examinations (AOR: 1.10, 95% CI: 0.91‐1.34), and (3) they felt very comfortable talking with PCPs about emotional issues (AOR: 1.11, 95% CI: 0.93‐1.30). CONCLUSIONS: Overall, women veterans' ratings of trauma‐sensitive communication were positive. Higher provider sensitivity was associated with greater trauma‐sensitive communication. IMPLICATIONS FOR POLICY OR PRACTICE: Strategies to improve provider readiness to care for women veterans and their gender sensitivity can improve trauma‐sensitive communication with women veterans. PRIMARY FUNDING SOURCE: Department of Veterans Affairs.

Objective Compare comorbidity identification in Medicare and Veterans Health Administration (VA) data for the purposes of risk adjustment. Data sources Analysis of Medicare and VA datasets for dually-enrolled Veterans receiving care in both settings, fiscal years 2010-2014. Study design A retrospective analysis of administrative data for a national sample of cancer decedents. Data extraction methods Comorbidities were evaluated using Elixhauser and Charlson coding algorithms. Principal findings Clinical comorbidities were more likely to be recorded in Medicare than in VA datasets. Of 42 comorbidities, 36 (86%) were recorded at a different frequency. For example, congestive heart failure was recorded for 22.0% of patients in Medicare data and for 11.3% of patients in VA data (P Conclusion There are large differences in comorbidity assessment across VA and Medicare administrative data for the same patient, posing challenges for risk adjustment.

Objective Given the changing political and social climate around opioids, we examined how clinicians in the outpatient setting made decisions about managing opioid prescriptions for new patients already on long-term opioid therapy. Methods We conducted in-depth interviews with 32 clinicians in Southern California who prescribed opioid medications in the outpatient setting for chronic pain. The study design, interview guides, and coding for this qualitative study were guided by constructivist grounded theory methodology. Results We identified three approaches to assuming a new patient’s opioid prescriptions. Staunch Opposers, mostly clinicians with specialized training in pain medicine, were averse to continuing opioid prescriptions for new patients and often screened outpatients seeking opioids. Cautious and Conflicted Prescribers were wary about prescribing opioids but were willing to refill prescriptions if they perceived the patient as trustworthy and the medication fell within their comfort zone. Clinicians in the first two groups felt resentful about other clinicians “dumping” patients on opioids on them. Rapport Builders, mostly primary care physicians, were the most willing to assume opioid prescriptions and were strategic in their approach to transitioning patients to safer doses. Conclusions Clinicians with the most training in pain management were the least willing to assume responsibility for opioid prescriptions for patients already on long-term opioid therapy. In contrast, primary care clinicians were the most willing to assume this responsibility. However, primary care clinicians face barriers to providing high-quality care for patients with complex pain conditions, such as short visit times and less specialized training.

Background Gender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- and individual-level characteristics associated with gender sensitivity of primary care providers (PCPs) and staff. Methods We surveyed PCPs and staff (nurses, medical assistants, and clerks) at 12 VA medical centers (VAMCs) (n = 256 of 649; response rate, 39%). Gender sensitivity was measured using a 10-item scale adapted from the Gender Awareness Inventory-VA. We used weighted multivariate regression with maximum likelihood estimation to identify individual- and practice-level characteristics associated with gender sensitivity of PCPs and staff. Results PCPs and staff had similar gender sensitivity but differed in most characteristics associated with that gender sensitivity. Among PCPs, women's health training and positive communication with others in the clinic were associated with greater gender sensitivity. For staff, prior work experience caring for women, working in Women's Health Patient-Aligned Care Teams, and rural location were associated with greater gender sensitivity, whereas more years of VA service was associated with lower gender sensitivity. Working at VA medical centers with a higher volume of women veteran patients was associated with greater gender sensitivity for both PCPs and staff. Conclusions Women's health training and experience in working with other women's health professionals are strongly correlated with greater gender sensitivity in the clinical workforce.

Background Comorbidities are common among patients with schizophrenia yet the prevalence of comorbidity combinations and their associations with inpatient service utilization and readmission have been scarcely explored. Methods Data were extracted from discharge summaries of patients whose primary diagnosis was schizophrenia spectrum disorders (ICD-10: F20-F29). We identified 30 most frequent comorbidities in patients’ secondary diagnoses and then used the association rule mining (ARM) method to derive comorbidity combinations associated with length of stay (LOS), daily expense and one-year readmission. Results The study included data from 8252 patients. The top five most common comorbidities were extrapyramidal syndrome (EPS, 44.58%), constipation (31.63%), common cold (21.80%), hyperlipidemia (20.99%) and tachycardia (19.13%). Most comorbidity combinations identified by ARM were significantly associated with longer LOS (≥70 days), few were associated with higher daily expenses, and fewer with readmission. The 3-way combination of common cold, hyperlipidemia and fatty liver had the strongest association with longer LOS (adjusted OR (aOR): 3.38, 95% CI: 2.12-5.38). The combination of EPS and mild cognitive disorder was associated with higher daily expense (≥700 RMB) (aOR: 1.67, 95% CI: 1.20-2.31). The combination of constipation, tachycardia and fatty liver were associated with higher 1-year readmission (aOR: 2.05, 95% CI: 1.03-4.09). Conclusion EPS, constipation, and tachycardia were among the most commonly reported comorbidities in schizophrenia patients in Beijing, China. Specific groups of comorbidities may contribute to higher inpatient psychiatric service utilization and readmission. The mechanism behind the associations and potential interventions to optimize service use warrant further investigation.

Author(s): Squitieri, Lee; Waxman, Daniel A; Mangione, Carol M; Saliba, Debra; Ko, Clifford Y; Needleman, Jack; Ganz, David A | Abstract: OBJECTIVES:To evaluate national present-on-admission (POA) reporting for hospital-acquired pressure ulcers (HAPUs) and examine the impact of quality measure exclusion criteria on HAPU rates. DATA SOURCES/STUDY SETTING:Medicare inpatient, outpatient, and nursing facility data as well as independent provider claims (2010-2011). STUDY DESIGN:Retrospective cross-sectional study. DATA COLLECTION/EXTRACTION METHODS:We evaluated acute inpatient hospital admissions among Medicare fee-for-service (FFS) beneficiaries in 2011. Admissions were categorized as follows: (1) no pressure ulcer diagnosis, (2) new pressure ulcer diagnosis, and (3) previously documented pressure ulcer diagnosis. HAPU rates were calculated by varying patient exclusion criteria. PRINCIPAL FINDINGS:Among admissions with a pressure ulcer diagnosis, we observed a large discrepancy in the proportion of admissions with a HAPU based on hospital-reported POA data (5.2 percent) and the proportion with a new pressure ulcer diagnosis based on patient history in billing claims (49.7 percent). Applying quality measure exclusion criteria resulted in removal of 91.2 percent of admissions with a pressure injury diagnosis from HAPU rate calculations. CONCLUSIONS:As payers and health care organizations expand the use of quality measures, it is important to consider how the measures are implemented, coding revisions to improve measure validity, and the impact of patient exclusion criteria on provider performance evaluation.

The issue of the adequacy of nurse staffing in hospitals and its impact on patient outcomes remains contentious. While there have been a large number of studies demonstrating an association of staffing levels and skills mix on a wide range of outcomes, including mortality, hospital-acquired infections and overall length of stay in patients in hospitals, the vast majority of these studies have been conducted comparing high-staffed hospitals to low-staffed hospitals.1–6 Concerns have been raised that other factors than staffing also differ between high-staffed and low-staffed hospitals that might contribute to the observed differences, and that staffing plays a smaller role than is suggested by these studies. Settling the issue through a study by randomly assigning different staffing levels to hospitals or units seems very unlikely to occur on logistic grounds. And given the existing body of work research ethics committees would probably not approve such a study. What has proven feasible is utilising day-to-day variations in staffing and census across units within hospitals to assess the impact of low staffing on patient outcomes. Prior to the study by Griffiths et al in this issue of BMJ Quality & Safety ,7 two published studies have used this methodology. Needleman et al 8 identified shifts by units with substantial shortfalls in professional nurse staffing from targets established by a large academic medical centre’s staff projection system, and examined the association of cumulative exposure to low-staffed shifts on patient mortality over a 5-year period for 40 units. They found a substantial increase in mortality associated each low-staffed shift to which a patient was exposed. They also found that the hazard of mortality was increased for shifts with substantially higher than average patient turnover, as turnover was not incorporated into the staffing system. Fagerstrom et al 9 used data from 36 units …

Purpose Development of scoring systems to predict the risk of aminoglycoside resistance and to guide therapy is described. Methods Infections due to aminoglycoside-resistant gram-negative rods (AR-GNRs) are increasingly common and associated with adverse outcomes; selection of effective initial antibiotic therapy is necessary to reduce adverse consequences and shorten length of stay. To determine risk factors for AR-GNR recovery from culture, cases of GNR infection among patients admitted to 2 institutions in a major academic hospital system during the period 2011–2016 were retrospectively analyzed. Gentamicin and tobramycin resistance (GTR-GNR) and amikacin resistance (AmR-GNR) patterns were analyzed separately. A total of 26,154 GNR isolates from 12,516 patients were analyzed, 6,699 of which were GTR, and 2,467 of which were AmR. Results In multivariate analysis, risk factors for GTR-GNR were presence of weight loss, admission from another medical or long-term care facility, a hemoglobin level of Conclusion A scoring system derived from the developed risk prediction models can be applied by providers to guide empirical antimicrobial therapy for treatment of GNR infections.

ObjectivesChina launched the National Healthcare Improvement Initiative (NHII) in 2015 to improve patient experiences in healthcare. This study aimed to generate evidence of hospital care quality from the patients’ perspective.DesignThis nationwide cross-sectional study interviewed participants from 31 provinces, municipalities and autonomous regions across China.SettingA total of 117 tertiary hospitals in mainland China.Participants48 422 responses from outpatients and 35 957 responses from inpatients were included in this study.Primary outcome measureThe scores of six predefined domains in the Chinese Patient Experience Questionnaire, five of which were designed to reflect specific dimensions of care, and one of which indicated the overall rating.ResultsMore than 80% of the respondents viewed their care experiences as positive. The NHII seems to have had a positive impact, as indicated by the steady, although unremarkable, increase in the patient experience scores over the 2016–2018 period. The Chinese patients generally reported a positive experience with the clinical aspects of care, but reported a less positive experience with the environmental, interpersonal and social services aspects of care. The institutional factors, including region and type of hospital, and personal factors, such as gender, age, education and occupation, were factors affecting the patient experience in China. Humanistic care was the aspect of care with the greatest association with the overall patient experience rating in both the outpatient and inpatient settings.ConclusionsThe national survey indicated an overall positive patient perspective of care in China. Older age, higher education level and formal employment status were found to be correlated with positive care experiences, as were higher levels of economic development of the region, a more generous insurance benefits package and a higher degree of coordinated care. The interpersonal-related initiatives had substantial roles in the improvement of the patient experience. In the regions where farmers and users of traditional Chinese medicine services constitute a greater proportion of the population, improvement of patient experiences for these groups deserves special policy attention.

Aims To identify and group hospitalization trajectory of alcohol use disorder (AUD) patients and its associations with service utilization, healthcare quality and hospital-level variations. Methods Inpatients with AUD as the primary diagnosis from 2012 to 2014 in Beijing, China, were identified. Their discharge medical records were extracted and analyzed using the sequence analysis and the cluster analysis. Results Eight-hundred thirty-one patients were included, and their hospitalization patterns were grouped into four clusters: short stay (n = 565 (67.99%)), mean psychiatric length of stay in 3 years: (32.25 ± 18.69), repeated short stay (n = 211 (25.39%), 137.76 ± 88.8 days), repeated long stay (n = 41 (4.93%), 405.44 ± 146.54 days), permanent stay (n = 14 (1.68%), 818.14 ± 225.22 days). The latter two clusters (6.61% patients) used 37.26% of the total psychiatric hospital days and 33.65% of the total psychiatric hospitalization expenses. All the patients in the permanent stay cluster and 41.77% of the patients in the short stay cluster were readmitted at least once within 3 years. Two-hundred thirty-four patients (28.16%) were admitted at least once for non-psychiatric reasons, primarily for diseases of circulatory and digestive systems. Cluster composition varied significantly among different hospitals. Conclusion Hospitalization pattern of patients with AUD varies greatly, and while most (>2/3) hospitalizations were short stay, those with repeated long stay and permanent stay used more than one third of the hospital days and expenses. Our findings suggest interventions targeting at certain patients may be more effective in reducing resource utilization.

Background Psychiatric readmissions negatively impact patients and their families while increasing healthcare costs. This study aimed at investigating factors associated with psychiatric readmissions within 30 days and 1 year of the index admissions and exploring the possibilities of monitoring and improving psychiatric care quality in China. Methods Data on index admission, subsequent admission(s), clinical and hospital-related factors were extracted in the inpatient medical record database covering 10 secondary and tertiary psychiatric hospitals in Beijing, China. Logistic regressions were used to examine the associations between 30-day and 1-year readmissions plus frequent readmissions (≥3 times/year), and clinical variables as well as hospital characteristics. Results The 30-day and 1-year psychiatric readmission rates were 16.69% (1289/7724) and 33.79% (2492/7374) respectively. 746/2492 patients (29.34%) were readmitted 3 times or more within a year (frequent readmissions). Factors significantly associated with the risk of both 30-day and 1-year readmission were residing in an urban area, having medical comorbidities, previous psychiatric admission(s), length of stay > 60 days in the index admission and being treated in tertiary hospitals (p Conclusion More than 30% of the psychiatric inpatients were readmitted within 1 year. Urban residents, those with medical comorbidities and previous psychiatric admission(s) or a longer length of stay were more likely to be readmitted, and men are more likely to be frequently readmitted. ECT treatment may reduce the likelihood of 30-day readmission and frequent admissions. Targeted interventions should be designed and piloted to effectively monitor and reduce psychiatric readmissions.

Objectives To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care. Design Cross-sectional patient discharge data, hospital characteristics and nurse and patient survey data were merged and analysed using generalised estimating equations (GEE) and logistic regression models. Setting Adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland. Participants Survey data were collected from 13 077 nurses in 243 hospitals, and 18 828 patients in 182 of the same hospitals in the six countries. Discharge data were obtained for 275 519 surgical patients in 188 of these hospitals. Main outcome measures Patient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction. Results Richer nurse skill mix (eg, every 10-point increase in the percentage of professional nurses among all nursing personnel) was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80

Objective The aim of this study is to examine the relationship between nursing time use and perceptions of missed care. Background Recent literature has highlighted the problem of missed nursing care, but little is known about how nurses' time use patterns are associated with reports of missed care. Methods In 15 nursing units at 2 hospitals, we assessed registered nurse (RN) perceptions of missed care, observed time use by RNs, and examined the relationship between time spent and degree of missed care at the nursing unit level. Results Patterns of time use were similar across hospitals, with 25% of time spent on documentation. For 6 different categories of nursing tasks, no association was detected between time use, including time spent on documentation, and the degree of missed care at the nursing unit level. Conclusions Nursing time use cannot fully explain variation in missed care across nursing units. Further work is needed to account for patterns of missed care.

Importance The Early Management Bundle for Severe Sepsis/Septic Shock (SEP-1) is a quality metric based on a care bundle for early sepsis management. Published evidence on the association of SEP-1 with mortality is mixed and largely excludes cases of hospital-onset sepsis. Objective To assess the association of the SEP-1 bundle with mortality and organ dysfunction in cohorts with hospital-onset or community-onset sepsis. Design, Setting, and Participants This retrospective cohort study used data from 4 University of California hospitals from October 1, 2014, to October 1, 2017. Adult inpatients with a diagnosis consistent with sepsis or disseminated infection and laboratory or vital signs meeting the Sepsis-3 (Third International Consensus Definitions for Sepsis and Septic Shock) criteria were divided into community-onset sepsis and hospital-onset sepsis cohorts based on whether time 0 of sepsis occurred after arrival in the emergency department or an inpatient area. Data were analyzed from April to October 2019. Additional analyses were performed from December 2019 to January 2020. Exposures Administration of SEP-1 and 4 individual bundle components (serum lactate level testing, blood culture, broad-spectrum intravenous antibiotic treatment, and intravenous fluid treatment). Main Outcomes and Measures The primary outcome was in-hospital mortality. The secondary outcome was days requiring vasopressor support, measured as vasopressor days. Results Among the 6404 patient encounters identified (3535 men [55.2%]; mean [SD] age, 64.0 [18.2] years), 2296 patients (35.9%) had hospital-onset sepsis. Among 4108 patients (64.1%) with community-onset sepsis, serum lactate level testing within 3 hours of time 0 was associated with reduced mortality (absolute difference, –7.61%; 95% CI, –14.70% to –0.54%). Blood culture (absolute difference, –1.10 days; 95% CI, –1.85 to –0.34 days) and broad-spectrum intravenous antibiotic treatment (absolute difference, –0.62 days; 95% CI, –1.02 to –0.22 days) were associated with fewer vasopressor days. Among patients with hospital-onset sepsis, broad-spectrum intravenous antibiotic treatment was the only bundle component significantly associated with any improved outcome (mortality difference, –5.20%; 95% CI, –9.84% to –0.56%). Care that was adherent to the complete SEP-1 bundle was associated with increased vasopressor days in patients with community-onset sepsis (absolute difference, 0.31 days; 95% CI, 0.11-0.51 days) but was not significantly associated with reduced mortality in either cohort (absolute difference, –0.07%; 95% CI, –3.02% to 2.88% in community-onset; absolute difference, –0.42%; 95% CI, –6.77% to 5.93% in hospital-onset). Conclusions and Relevance SEP-1–adherent care was not associated with improved outcomes of sepsis. Although multiple components of SEP-1 were associated with reduced mortality or decreased days of vasopressor therapy for patients who presented with sepsis in the emergency department, only broad-spectrum intravenous antibiotic treatment was associated with reduced mortality when time 0 occurred in an inpatient unit. Current sepsis quality metrics may need refinement.

BACKGROUND: High-cost patients are a frequent focus of improvement projects based on primary care and other settings. Efforts to characterize high-cost, high-need patients are needed to inform care planning, but such efforts often rely on a priori assumptions, masking underlying complexities of a heterogenous population. OBJECTIVE: To define recognizable subgroups of patients among high-cost adults based on clinical conditions, and describe their survival and future spending. DESIGN: Retrospective observational cohort study. PARTICIPANTS: Within a large integrated delivery system with 2.7 million adult members, we selected the top 1% of continuously enrolled adults with respect to total healthcare expenditures during 2010. MAIN MEASURES: We used latent class analysis to identify clusters of alike patients based on 53 hierarchical condition categories. Prognosis as measured by healthcare spending and survival was assessed through 2014 for the resulting classes of patients. RESULTS: Among 21,183 high-cost adults, seven clinically distinctive subgroups of patients emerged. Classes included end-stage renal disease (12% of high-cost population), cardiopulmonary conditions (17%), diabetes with multiple comorbidities (8%), acute illness superimposed on chronic conditions (11%), conditions requiring highly specialized care (14%), neurologic and catastrophic conditions (5%), and patients with few comorbidities (the largest class, 33%). Over 4 years of follow-up, 6566 (31%) patients died, and survival in the classes ranged from 43 to 88%. Spending regressed to the mean in all classes except the ESRD and diabetes with multiple comorbidities groups. CONCLUSIONS: Data-driven characterization of high-cost adults yielded clinically intuitive classes that were associated with survival and reflected markedly different healthcare needs. Relatively few high-cost patients remain persistently high cost over 4 years. Our results suggest that high-cost patients, while not a monolithic group, can be segmented into few subgroups. These subgroups may be the focus of future work to understand appropriateness of care and design interventions accordingly. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4626-0) contains supplementary material, which is available to authorized users.

Background Infections due to carbapenem-resistant Gram-negative rods (CR-GNR) are increasing in frequency and result in high morbidity and mortality. Appropriate initial antibiotic therapy is necessary to reduce adverse consequences and shorten length of stay. Methods To determine risk factors for recovery on culture of CR-GNR, cases were retrospectively analyzed at a major academic hospital system from 2011 to 2016. Ertapenem resistance (ER-GNR) and antipseudomonal (nonertapenem) carbapenem resistance (ACR-GNR) patterns were analyzed separately. A total of 30951 GNR isolates from 12370 patients were analyzed, 563 of which were ER and 1307 of which were ACR. Results In multivariate analysis, risk factors for ER-GNR were renal disease, admission from another health care facility, ventilation at any point before culture during the index hospitalization, receipt of any carbapenem in the prior 30 days, and receipt of any anti-methicillin-resistant Staphylococcus aureus (anti-MRSA) agent in the prior 30 days (c-statistic, 0.74). Risk factors for ACR-GNR were male sex, admission from another health care facility, ventilation at any point before culture during the index hospitalization, receipt of any carbapenem in the prior 30 days, and receipt of any anti-MRSA agent in the prior 30 days (c-statistic, 0.76). Conclusions A straightforward scoring system derived from these models can be applied by providers to guide empiric antimicrobial therapy; it outperformed use of a standard hospital antibiogram in predicting infections with ER-GNR and ACR-GNR.

BackgroundAlthough homelessness and opioid overdose are major public health issues in the U.S., evidence is limited as to whether homelessness is associated with an increased risk of opioid overdose.ObjectiveTo compare opioid-related outcomes between homeless versus housed individuals in low-income communities.Design, setting, and participantsCross-sectional analysis of individuals who had at least one ED visit or hospitalization in four states (Florida, Maryland, Massachusetts, and New York) in 2014.MeasurementsRisk of opioid overdose and opioid-related ED visits/hospital admissions were compared between homeless versus low-income housed individuals, adjusting for patient characteristics and hospital-specific fixed effects (effectively comparing homeless versus low-income housed individuals treated at the same hospital). We also examined whether risk of opioid-related outcomes varied by patients' sex and race/ethnicity.ResultsA total of 96,099 homeless and 2,869,230 low-income housed individuals were analyzed. Homeless individuals had significantly higher risk of opioid overdose (adjusted risk, 1.8% for homeless vs. 0.3% for low-income housed individuals; adjusted risk difference [aRD], +1.5%; 95%CI, +1.0% to +2.0%; p&nbsp

Key Points Question What is the cost associated with National Quality Forum–identified intensive medical services in the last month of life to beneficiaries and to the health care system? Findings In this cohort study of 48 937 patients with cancer enrolled in Medicare and the Veterans Health Administration, those receiving no intensive service had a health system cost of $7660, whereas for the 59% of patients receiving 1 or more intensive services in the last month of life, the cost was $23 612. Expected beneficiary costs in the last month of life were $133 for patients with no intensive service and $1257 for patients with at least 1 intensive service. Meaning Despite recommendations, more than half of patients with cancer receive intensive services at the end of life at a substantial cost to beneficiaries and the heath system., Importance Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services. Objective To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life. Design, Setting, and Participants This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48 937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019. Exposures American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days. Main Outcomes and Measures Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region. Results Of 48 937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23 612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15 952 (95% CI, $15 676-$16 206; P, To provide physicians with reference cost estimates, this cohort study quantifies beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life among patients with advanced cancer.

BACKGROUND A healthy work environment can improve patient outcomes and registered nurse (RN) turnover. Creating cultures of retention and fostering healthy work environments are 2 major challenges facing nurse leaders today. SPECIFIC AIMS Examine the effects of the healthy work environment (communication, collaboration, and leadership) on RN turnover from data collected from a research study. METHODS Descriptive, cross-sectional, correlational design. Pediatric critical care RNs from 10 pediatric intensive care units (PICU) completed the Practice Environment Scale of the Nursing Work Index Revised and a subscale of the Intensive Care Unit Nurse-Physician Communication Questionnaire. These staff nurses were asked whether they intend to leave their current job in the next 6 months. Statistical analysis included correlations, multiple linear regression, t tests (2-tailed), and 1-way analysis of variance. RESULTS A total of 415 RNs completed the survey. There was a statistically significant relationship between leadership and the intent to leave (P < .05). There was also an inverse relationship between years of experience and intent to leave. None of the communication variables between RNs and among RNs and MDs or collaboration were significantly associated with PICU nurses' intention to leave. CONCLUSION Effective leadership in the PICU is important to PICU RNs and significantly influences their decisions about staying in their current job.

OBJECTIVE Studies suggest that a business case for improving nurse staffing can be made to increase registered nurse (RN) skill mix without changing total licensed nursing hours. It is unclear whether a business case for increasing RN skill mix can be justified equally among patients of varying health needs. This study evaluated whether nursing hours per patient day (HPPD) and skill mix are associated with higher inpatient care costs within acute medical/surgical inpatient units using data from the Veterans Health Administration. METHODS Retrospective cross-sectional study, including 139,360 inpatient admissions to 292 acute medical/surgical units at 125 Veterans Health Administration medical centers between February and June 2003, was conducted. Dependent variables were inpatient costs per admission and costs per patient day. RESULTS The average costs per surgical and medical admission were $18,624 and $6,636, respectively. Costs per admission were positively associated with total nursing HPPD among medical admissions ($164.49 per additional HPPD, P

Cross-sectional studies of hospital-level administrative data have shown an association between lower levels of staffing of registered nurses (RNs) and increased patient mortality. However, such studies have been criticized because they have not shown a direct link between the level of staffing and individual patient experiences and have not included sufficient statistical controls.We used data from a large tertiary academic medical center involving 197,961 admissions and 176,696 nursing shifts of 8 hours each in 43 hospital units to examine the association between mortality and patient exposure to nursing shifts during which staffing by RNs was 8 hours or more below the staffing target. We also examined the association between mortality and high patient turnover owing to admissions, transfers, and discharges. We used Cox proportional-hazards models in the analyses with adjustment for characteristics of patients and hospital units.Staffing by RNs was within 8 hours of the target level for 84% of shifts, and patient turnover was within 1 SD of the day-shift mean for 93% of shifts. Overall mortality was 61% of the expected rate for similar patients on the basis of modified diagnosis-related groups. There was a significant association between increased mortality and increased exposure to unit shifts during which staffing by RNs was 8 hours or more below the target level (hazard ratio per shift 8 hours or more below target, 1.02; 95% confidence interval [CI], 1.01 to 1.03; P0.001). The association between increased mortality and high patient turnover was also significant (hazard ratio per high-turnover shift, 1.04; 95% CI, 1.02 to 1.06; P0.001).In this retrospective observational study, staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients' needs for nursing care. (Funded by the Agency for Healthcare Research and Quality.).

Anesthesia provider models were characterized based on responsibilities and technique privileges and the distribution of clinical resource and process variables using a survey of 1,135 hospitals offering obstetric care in eight representative states. The resulting models were then analyzed by resource availability. In the 40% of hospitals where certified registered nurse anesthetists (CRNAs) and anesthesiologists both practiced obstetric anesthesia, three models emerged based on consistency of privileges within the institution and permission to initiate procedures. Hospitals in which only anesthesiologists practice and those in which CRNAs practice was most restricted had more resources than other hospitals surveyed. Traditional characterizations of provider fail to capture differences in technique privileges. Clinical resource variables and the scope of technique privileges should be included in the study of anesthesia provider credentials on outcomes.

Long-term care hospitals are postacute care facilities for patients requiring extended hospital-level care. These facilities are reimbursed by Medicare under a prospective payment system with a short-stay outlier policy, which results in substantially lower payments for patients discharged before a diagnosis-related group-specific short-stay threshold. Using Medicare data, we examined the impact of the short-stay policy on lengths-of-stay and Medicare reimbursement among patients in long-term care hospitals who require prolonged mechanical ventilation. After accounting for case-mix and facility-level differences, we found that discharges for reasons other than death in the period 2005-10 were most likely to occur on the day of or immediately after the short-stay threshold; this held true regardless of facility ownership. In contrast, live discharges in 2002—the year before the prospective payment system started phasing out cost-based payment—were evenly distributed around the day that later became the short-stay threshold. Our findings confirm that the short-stay outlier payment policy created a strong financial incentive for long-term care hospitals to time patient discharges to maximize Medicare reimbursement. The results suggest that the new very-short-stay policy implemented in December 2012 could have a similar effect.

We construct national estimates of the cost of increasing hospital nurse staffing and associated reductions in days, deaths, and adverse outcomes. Raising the proportion of nursing hours provided by registered nurses (RNs) without increasing total nursing hours is associated with a net reduction in costs. Increasing nursing hours, with or without increasing the proportion of hours provided by RNs, reduces days, adverse outcomes, and patient deaths, but with a net increase in hospital costs of 1.5 percent or less at the staffing levels modeled. Whether or not staffing should be increased depends on the value patients and payers assign to avoided deaths and complications.

Purpose: To assess nurse overtime in acute care general hospitals and the factors that influence overtime among various hospitals and in the same hospitals from year to year. Methods: Staffing data from 1995 to 2000 from 193 acute general hospitals in New York State were used to examine hospital characteristics (size, location, RN unionization, hospital ownership, and teaching status) to determine whether they were associated with nurse overtime. Results: The average weekly overtime RNs worked was 4.5% of total hours, varying from almost none to 16.6%. At mean overtime levels, nurses were working less overtime than the mean for manufacturing workers, but, at the extreme, nurses were working more than 6 hours overtime per week. Significant differences were observed in the use of overtime by hospital ownership and by union status. Nurses in government hospitals worked less overtime than did those in nongovernment hospitals. Nurses in unionized hospitals worked slightly more overtime than did nurses in nonunionized hospitals. Conclusions: Hospitals varied dramatically in their overtime use. That some categories of hospitals (e.g., government-owned) used little overtime indicates that hospital management can find substitutes for overtime to meet fluctuating staffing needs. The finding that hospitals with similar characteristics varied greatly in their number of overtime hours also supported this conclusion.

Monitoring quality of care across institutions and over time and examining the correlates of quality are critical to pursuing effective policy to improve quality (Institute of Medicine Committee on Quality of Health Care in America 2001; Kohn et al. 2000). Medical record abstraction has been the “gold standard” for constructing quality measures but the costs associated with abstracting data from the patient's chart makes its use infeasible in monitoring quality and overall health system performance and examining the factors that influence quality. Researchers wishing to conduct analysis on large samples of hospitals have turned to less expensive and more readily available administrative data, primarily patient discharge abstracts, to construct measures of hospital quality (Agency for Healthcare Research and Quality 2000; Ball et al. 1998; Geraci 2000; Iezzoni, Daley, Heeren, Foley, Hughes et al. 1994; Iezzoni, Daley, Heeren, Foley, Fisher et al. 1994; Johantgen et al. 1998; Kuykendall et al. 1995; Silber and Rosenbaum 1997). Over 40 states now collect discharge abstracts on all hospitalized patients in acute care hospitals. These data vary in completeness, number of primary and secondary diagnoses and procedures reported, presence of other patient information, such as race/ethnicity and insurer, years available, and cost. The Centers for Medicare and Medicaid Services' (CMS) MedPAR system contains information on hospital discharges for all Medicare patients. These data are relatively inexpensive, consistently coded, available for virtually all acute care hospitals in the United States, and have been used in many studies (Lawthers et al. 2000; Romano et al. 1994; Romano et al. 1995; Weingart et al. 2000). There are, however, important differences between the state and national discharge data on Medicare patients. For example, the public-use MedPAR data do not include information on dates for procedures and have fewer coded secondary diagnoses and procedures than most state datasets. Nevertheless, the quality of patient care based on Medicare data is often regarded as a surrogate measure of the quality of care for all hospitalized patients. Although the data on Medicare patients contained within all-patient state datasets are generally consistent with information on Medicare patients in the CMS Medicare data (Medstat Group Research and Policy Division 2000), and there is some evidence that hospital admission patterns for all patients can be predicted from the admission patterns of Medicare patients (Radany and Luft 1993), it is an empirical question whether Medicare data can be used as a close substitute for all-patient data for hospital quality studies. Quality measures have been used in studies to assess quality in specific hospitals and in studies of hospital characteristics associated with quality care. We focus on the second type of study and assess whether all-patient and Medicare data provide the same results in regression-based studies of correlates of quality across a range of measures. We analyze data from a sample of all-patient discharge abstracts for hospitals in 11 states, and patients in a national sample drawn from MedPAR data, examining three samples of patients: the 11-state all-patient sample, the Medicare patients in the 11-state data (11-state Medicare sample), and national MedPAR sample. Our quality indicators were developed and tested in a larger study that examined the association of patient outcomes and nurse staffing in acute care hospitals (Needleman et al. 2002; Needleman et al. 2001). Our analytic strategy is first to compare rates of adverse outcomes and results from regression analysis of outcomes on nurse staffing in the 11-state all-patient sample to those from analysis of the 11-state Medicare sample. This comparison allows us to draw conclusions on how closely Medicare patients are a surrogate for all patients in the same sample of hospitals using consistently coded discharge data and identical measures of nurse staffing. Because researchers working with Medicare data will likely use data from the CMS national MedPAR files, and because less information is available on these abstracts than in most state discharge abstracts, we compare adverse outcome rates and regression results in the national MedPAR sample with those from our 11-state Medicare and 11-state all-patient samples to determine if the results from the MedPAR and state data are consistent. We find some differences in regression results between the MedPAR and two 11-state samples and conduct additional analyses to determine the source of these differences.

Hospitals, nurses, the media, Congress, and the private sector are increasingly concerned about shortages of registered nurses (RNs) and the impact on safety and quality of patient care. Findings from a growing number of studies provide evidence of a relationship between hospital nurse staffing and adverse outcomes experienced by medical and surgical patients. These findings have policy implications for strengthening the nursing profession, monitoring the quality of hospital care associated with nursing, and improving the relationship between hospitals and the nursing profession.

This study aims to describe the magnitude of hospital costs among patients undergoing elective colectomy, cholecystectomy, and pancreatectomy, determine whether these costs relate as expected to duration of care, patient case-mix severity and comorbidities, and whether risk-adjusted costs vary significantly by hospital. Correctly estimating the cost of production of surgical care may help decision makers design mechanisms to improve the efficiency of surgical care.Patient data from 202 hospitals in the ACS-NSQIP were linked to Medicare inpatient claims. Patient charges were mapped to cost center cost-to-charge ratios in the Medicare cost reports to estimate costs. The association of patient case-mix severity and comorbidities with cost was analyzed using mixed effects multivariate regression. Cost variation among hospitals was quantified by estimating risk-adjusted hospital cost ratios and 95% confidence intervals from the mixed effects multivariate regression.There were 21,923 patients from 202 hospitals who underwent an elective colectomy (n = 13,945), cholecystectomy (n = 5,569), or pancreatectomy (n = 2,409). Median cost was lowest for cholecystectomy ($15,651) and highest for pancreatectomy ($37,745). Room and board costs accounted for the largest proportion (49%) of costs and were correlated with length of stay, R = 0.89, p0.001. The patient case-mix severity and comorbidity variables most associated with cost were American Society of Anesthesiologists (ASA) class IV (estimate 1.72, 95% CI 1.57 to 1.87) and fully dependent functional status (estimate 1.63, 95% CI 1.53 to 1.74). After risk-adjustment, 66 hospitals had significantly lower costs than the average hospital and 57 hospitals had significantly higher costs.The hospital costs estimates appear to be consistent with clinical expectations of hospital resource use and differ significantly among 202 hospitals after risk-adjustment for preoperative patient characteristics and procedure type.

Conversion of hospitals, health insurers, and health plans from nonprofit to for-profit ownership has become a focus of national debate. The author examines why nonprofit ownership has been dominant in the US health system and assesses the strength of the argument that nonprofits provide community benefits that would be threatened by for-profit conversion. The author concludes that many of the specific community benefits offered by nonprofits, such as care for the poor, could be maintained or replaced by adequate funding of public programs and that quality and fairness in treatment can be better assured through clear standards of care and adequate monitoring systems. As health care becomes increasingly commercialized, the most difficult parts of nonprofits' historic mission to preserve are the community orientation, leadership role, and innovation that nonprofit hospitals and health plans have provided out of their commitment to a community beyond those to whom they sell services.

Background The Agency for Healthcare Research and Quality (AHRQ) patient safety indicator "death among surgical inpatients with serious treatable complications" (failure-to-rescue) uses rules to exclude complications presumed to be present-on-admission (POA). Like other administrative data-based quality measures, exclusion rules were developed with limited information on whether complications were POA. We examine whether the accuracy of failure-to-rescue exclusion rules can be improved with data with good POA indicators. Methods POA-coded data from 243,825 discharges from a large academic medical center were used to develop 3 failure-to-rescue exclusion rules. Data from 82,871 discharges from California hospitals screened for good POA coding practices was used as a validation sample. The AHRQ failure-to-rescue measure and 3 new measures based on alternative exclusion rules were compared on sensitivity, specificity, and C-statistics for prediction of POA status. Using data from the AHRQ HCUP National Inpatient Sample, the alternative specifications were tested for sensitivity to nurse staffing. Results The AHRQ exclusion rules had sensitivity of 18.5%, specificity 92.1%, and a C-statistic of 0.553. All POA-informed specifications of exclusion rules improved the C-statistic of the failure-to-rescue measure and its sensitivity, with modest losses of specificity. For all tested specifications, higher licensed hours and proportions of registered nurse were statistically significant and associated with lower risk of death. Conclusions Failure-to-rescue is a robust quality measure, sensitive to nursing across alternative exclusion rule specifications. Despite expanded POA coding, exclusion-based rules are needed to analyze datasets not coded for POA, legacy datasets, and datasets with poor POA coding. POA-informed construction of exclusions significantly improves rules identifying POA complications.

Over the past year, published research has drawn increased attention to issues of hospital nurse staffing and adverse patient outcomes. Among the published articles that have appeared are those by Aiken et al . [1], Kovner et al . [2], and Needleman et al . [3]. The article by Aiken et al . focused on post-surgical mortality, and received substantial attention because of its conclusion that, controlling for patient and hospital characteristics, the addition of one patient to a registered nurse's workload was associated with a 7% increase in mortality. Research examining the association between nurse staffing and mortality has reached mixed conclusions. Needleman et al . found an association between nurse staffing levels and ‘failure to rescue’, defined in that study as death among patients who had one of five complications (pneumonia, sepsis, shock or cardiac arrest, upper gastrointestinal bleeding, and deep vein thrombosis), in surgical patients and to a lesser extent in medical patients. While Needleman et al . measured nurse staffing in a different way to Aiken et al ., reanalysis of the study generates an estimate of the magnitude of the impact of nurse staffing on failure to rescue similar to that reported by Aiken and colleagues. Needleman et al . did not, however, find an association with overall in-hospital mortality and nurse staffing. At least four other studies have found an association between nurse staffing and hospital mortality [4–7], while others have not [8–10]. How should these conflicting findings be viewed? Firstly, it must be recognized that because many factors influence hospital mortality, it can be difficult to tease out the effect of an individual factor. Many of these studies have used administrative data, including the three studies cited that were …

Background: Treatment for most children with cancer includes the use of a central venous catheter (CVC). CVCs provide reliable venous access for delivery of chemotherapy and supportive care. This advantage is mitigated by an increased risk of bloodstream infections (BSIs). Despite the ubiquitous use of CVCs, few prospective studies have been conducted to address infection prevention strategies in pediatric oncology patients. Design: Prospective, crossover pilot study of a CVC team intervention versus standard care. Setting: Two inpatient oncology units in a metropolitan children’s hospital. Patients: A total of 41 patients/135 admissions for the experimental unit (EU) and 41/129 admissions for the control unit (CU). Methods: Patients received a CVC blood draw bundle procedure by a CVC registered nurse (RN) team member (experimental intervention: EU) for 6 months and by the assigned bedside RN (standard care: CU) for 6 months. Feasibility of implementing a CVC RN team; a significant difference in CVC-related BSIs between the team intervention versus standard care and risk factors associated in the development of CVC-related BSIs were determined. Results: There were 7 CVC-related BSIs/1238 catheter days in the EU group (5.7/1000 catheter days) versus 3 CVC-related BSIs/1419 catheter days in the CU group (2.1/1000 catheter days; P = .97). Selected risk factors were not significantly associated with the development of a CVC-related BSI. Conclusions: A CVC team in the care of pediatric oncology patients is feasible; however, a larger cohort will be required to adequately determine the effectiveness of the team reducing CVC-related BSIs.

Reducing or eliminating hospital acquired infections is a national quality of care priority. The majority of the 12 400 children diagnosed with cancer each year require long-term intravenous access to receive intensive and complex therapies. These children are at high risk for infection by nature of their disease and treatment, which often involves use of a central venous catheter (CVC). Throughout the nation, nurses assume frontline responsibility for safe, quality CVC care to minimize the risk of potentially life-threatening infections. Substantial financial and human costs are associated with CVC-related bloodstream infections, including prolonged hospital lengths of stay and increased care required to treat these infections. The purpose of this review of the literature is to summarize existing adult and pediatric data on CVC-related bloodstream infections and explore nursing models of CVC care that may improve pediatric oncology patient outcomes.

The primary objective of this study was to test the feasibility of creating a central venous catheter blood draw bundle checklist to ensure adherence to the evidence-based blood draw procedure. This study included establishing checklist reliability and validity and periodic observations in 2 inpatient pediatric oncology units. The findings provided support for the reliability and validity of this checklist based on content validity, test-retest reliability, interrater agreement, and internal consistency and reinforced the need for periodic observations to ensure consistency in proper central venous catheter blood draw procedures.

The size and mix of nurse staffing in U.S. hospitals has a direct impact on the outcome of patient health according to a study based on discharge data for more than 6 million patients and financial reports and hospital staffing surveys from 799 hospitals in 11 states. The data were analyzed to determine staffing levels of RNs, licensed practicing/vocational nurses, and aides and to measure the frequency of a wide range of complications that patients developed during their hospital stays. Of the hospital inpatient nursing personnel studied, the study found that registered nurse staffing makes the biggest impact on adverse patient outcomes. The researchers found that lower levels of nurse staffing were associated with higher rates of urinary tract infections, pneumonia, shock and cardiac arrest, upper gastrointestinal bleeding, “failure to rescue,” and length of hospital stay in both medical and major surgery patients treated in hospitals.

Background: Fall-related injuries (FRIs) result in morbidity and mortality for patients, as well as unnecessary expense to health care institutions. Objectives: (a) Estimate the incidence of falls and FRIs with a nursing home as the source of admission in Veterans Administration (VA) and non-VA facilities. (b) Estimate the cost of hospitalizations for each level of FRI severity. Research Design: Retrospective analysis of falls and FRI resulting in a hospitalization whose source of admission was a VA nursing home. Data: Falls and FRIs were obtained from Minimum Data Set (MDS) reports (January 2007-June 2009). Costs were obtained from the VA Decision Support System reports and Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) reports (2000-2006). Measures: Incidence of falls, fracture incidence, number of hospitalizations for FRIs, and costs associated with hospitalization for by level of FRI severity. Results: Fall incidence was 10.6% in VA and 13.1% in CMS facilities. Fracture incidence was 0.9% in VHA and 1.65% in CMS facilities. Over a 3-year period, there were 2,400 admissions to VHA hospitals for FRI, with 55.4% hip fractures and10.1% intracranial injuries, with an average cost of US$23,723 per admission. Over a 9-year period, there were 141,308 admissions from nursing homes to non-VA hospitals for FRIs, with 38.8% hip fractures, 35.7% other fractures, and 11.1% intracranial injuries, with an average cost of US$31,507 per admission. Conclusions: Prevention program emphasis should shift away from a focus on preventing falls as a measure of quality care to decreasing FRIs. These findings support implementation of injury prevention programs for the elderly that reduces risk for injury as the primary outcome.

The objective of this study was to examine the effect of hospital-level factors on mortality of very low birth weight infants using multilevel modeling.This is a secondary data analysis of California maternal-infant hospital discharge data from 1997 to 2002. The study population was limited to singleton, non-anomalous, very low birth weight infants, who delivered in hospitals providing neonatal intensive care services (level-2 and higher). Hierarchical generalized linear modeling, also known as multilevel modeling, was used to adjust for individual-level confounders.In a multilevel model, increasing hospital volume of very low birth weight deliveries was associated with lower odds of very low birth weight mortality. Characteristics of a particular hospital's obstetrical and neonatal services (the presence of residency and fellowship training programs and the availability of perinatal and neonatal services) had no independent effect.Using multilevel modeling, hospital volume of very low birth weight deliveries appears to be the primary driver of reduced mortality among very low birth weight infants.

Objective: To determine the adjusted effect of hospital level of care and volume on mortality of very low birth weight (VLBW) infants in the state of California, where deregionalization of perinatal care has occurred. Research Design: Secondary data analysis of California maternalinfant hospital discharge data from 1997 to 2002 was performed. Logistic regression was used to evaluate the odds of mortality among VLBW infants by hospital level of neonatal intensive care and volume of VLBW deliveries, in the context of differences in antenatal and delivery factors by hospital site of delivery. Results: Both maternal and fetal antenatal risk profiles and delivery characteristics vary by hospital site of delivery. After risk adjustment, lower-level, lower-volume units were associated with a higher odds of mortality. The highest odds of mortality occurred in level-1 units with 10 VLBW deliveries per year (odds ratio, 1.69; 95% confidence interval, 1.43‐1.99). In isolation, hospital volume, rather than level of care, had the greater effect. Conclusions: Although deregionalization of perinatal services may increase access to care for high-risk mothers and newborns, its impact on hospital volume may outweigh its potential benefit.