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Background Comparing heart failure ( HF ) outcomes across hospitals requires adequate risk adjustment. We aimed to develop and validate a model that can be used to compare quality of HF care across hospitals. Methods and Results We included patients with HF aged ≥18 years admitted to one of 433 hospitals that participated in the Premier Inc Data Warehouse. This model (Premier) contained patient demographics, comorbidities, and acute conditions present on admission, derived from administrative and billing records. In a separate data set derived from electronic health records, we validated the Premier model by comparing hospital risk‐standardized mortality rates calculated with the Premier model to those calculated with a validated clinical model containing laboratory data (LAPS [Laboratory‐Based Acute Physiology Score]). Among the 200 832 admissions in the Premier Inc Data Warehouse, inpatient mortality was 4.0%. The model showed acceptable discrimination in the warehouse data (C statistic 0.75; 95% confidence interval, 0.74–0.76). In the validation data set, both the Premier model and the LAPS models showed acceptable discrimination (C statistic: Premier: 0.76 [95% confidence interval, 0.74–0.77]; LAPS: 0.78 [95% confidence interval, 0.76–0.80]). Risk‐standardized mortality rates for both models ranged from 2% to 7%. A linear regression equation describing the association between Premier‐ and LAPS ‐specific mortality rates revealed a regression line with a slope of 0.71 ( SE : 0.07). The correlation coefficient of the standardized mortality rates from the 2 models was 0.82. Conclusions Compared with a validated model derived from clinical data, an HF mortality model derived from administrative data showed highly correlated risk‐standardized mortality rate estimates, suggesting it could be used to identify high‐ and low‐performing hospitals for HF care.

Background: Invasive mechanical ventilation (IMV), dialysis for acute kidney failure, and other critical care therapies (CCTs) are associated with a high risk for complications in patients with metastatic cancer. Inpatient palliative care (IPC) can assist in assessing patients' preferences for life-prolonging treatment at the end of life. This study investigated the use pattern of IPC, outcomes (in-hospital mortality, length of stay [LOS], discharge destination, and cost of care), and predictors of IPC use in patients with metastatic cancer who received CCTs. We hypothesized that IPC services are underused in this cohort. Methods: In this retrospective cohort study, we used the 2010 California State Inpatient Databases to identify adults with metastatic cancer who received CCTs that are common and reliably coded (IMV, tracheostomy, percutaneous endoscopic gastrostomy tube, dialysis for acute kidney failure, and total parenteral nutrition). We determined IPC use in all patients, in those who received IMV, and across 4 cancer subtypes (lung, breast, colorectal, and genitourinary). Outcomes were assessed based on IPC use. Multivariable analyses were used to investigate factors associated with IPC use. Results: We identified 5,862 hospitalizations, 19.8% of which used IPC services. IPC use varied across cancer subtypes (lung, 28.3%; breast, 22.4%; colorectal, 12.8%; genitourinary, 16.1%; P

Article-at-a-Glance Background Bundled payments, also known as episode-based payments, are intended to contain health care costs and promote quality. In 2011 a bundled payment pilot program for total hip replacement was implemented by an integrated health care delivery system in conjunction with a commercial health plan subsidiary. In July 2015 the Centers for Medicare & Medicaid Services (CMS) proposed the Comprehensive Care for Joint Replacement Model to test bundled payment for hip and knee replacement. Methods Stakeholders were identified and a structure for program development and implementation was created. An Oversight Committee provided governance over a Clinical Model Subgroup and a Financial Model Subgroup. Results The pilot program included (1) a clinical model of care encompassing the period from the preoperative evaluation through the third postoperative visit, (2) a pricing model, (3) a program to share savings, and (4) a patient engagement and expectation strategy. Compared to 32 historical controls—patients treated before bundle implementation—45 post-bundle-implementation patients with total hip replacement had a similar length of hospital stay (3.0 versus 3.4 days, p = .24), higher rates of discharge to home or home with services than to a rehabilitation facility (87% versus 63%), similar adjusted median total payments ($22,272 versus $22,567, p = .43), and lower median posthospital payments ($704 versus $1,121, p = .002), and were more likely to receive guideline-consistent care (99% versus 95%, p = .05). Discussion The bundled payment pilot program was associated with similar total costs, decreased posthospital costs, fewer discharges to rehabilitation facilities, and improved quality. Successful implementation of the program hinged on buy-in from stakeholders and close collaboration between stakeholders and the clinical and financial teams.

Objectives Maternal periodontal disease is associated with adverse perinatal outcomes. Anxiety and depression adversely impact oral health in nonpregnant women; however, this association has not been evaluated during pregnancy, a time characterized by higher rates of anxiety and depression. Therefore, we examined the association between these factors and oral disease and oral healthcare utilization among 402 pregnant respondents to the 2010 Behavioral Risk Factor Surveillance System. Methods Self-reported lifetime diagnoses of anxiety, depression, and current depression were assessed. Oral health outcomes included self-reported tooth loss and dental visits in the past year. Results One-fifth (21.2 percent) of respondents reported a tooth loss and 32.5 percent reported nonuse of oral health services. The prevalence of lifetime diagnosed anxiety and depression was 13.6 percent and 11.3 percent, respectively, whereas 10.6 percent reported current depression. After adjusting for risk factors, pregnant women with diagnosed anxiety had increased odds of one or more tooth loss [odds ratio (OR) = 3.30; 95 percent confidence interval (CI): 1.01-10.77] compared with those without the disorder. Similarly, after adjusting for socioeconomic factors, women with anxiety had increased odds of nonuse of oral health services (OR = 2.67; 95 percent CI: 1.03-6.90); however, this was no longer significant after adjusting for health behaviors and body mass index. We observed no significant association with depression. Conclusions In this population-based sample, we found a two- to threefold increased odds of tooth loss and nonuse of oral health services among pregnant women with a lifetime diagnosis of anxiety. To our knowledge, this is the first study to examine these associations among pregnant women.

Excess weight is an epidemic problem in the United States, with 69.2% of the adult population overweight or obese (Ogden, Carroll, Kit, & Flegal, 2014). Prepregnancy obesity has been associated with increased risk of adverse pregnancy and birth outcomes including gestational hypertension, preeclampsia, and macrosomia, and, for the infant, increased risk of obesity later in life (Papachatzi, Dimitriou, Dimitropoulos, & Vantarakis, 2013; Patro et al., 2013; Sarwer, Allison, Gibbons, Markowitz, & Nelson, 2006). Gestational weight gain (GWG) guidelines are based on prepregnancy Body Mass Index (BMI), with overweight and obese women encouraged to gain less weight during pregnancy compared to normal and underweight women (Institute of Medicine and National Research Council, 2009). Hispanic mothers are more likely to begin their pregnancies overweight or obese compared to non-Hispanic White women (Kieffer et al., 2006). While obesity predicts depression and elevated depressive symptoms in nonpregnant women (Luppino et al., 2010), studies in the perinatal period are sparse. However, prenatal depression is common: occurring in up to 18% of women in the United States (Gavin et al., 2005), and up to 33% of Hispanic women in the United States (Chasan-Taber et al., 2010). Given current societal pressure in the United States to be thin, overweight women and those who gain excess weight may experience high levels of body dissatisfaction, which has been linked to depression (Clark, Skouteris, Wertheim, Paxton, & Milgrom, 2009). Our objective was to assess the association between prepregnancy BMI, GWG, and elevated depressive symptoms during pregnancy in a Hispanic cohort. We hypothesized that women who were overweight, obese, or gained more than the recommended amount of weight during pregnancy would experience elevated depressive symptoms during pregnancy.

BACKGROUND The American Thoracic Society and Infectious Diseases Society of America guidelines for management of healthcare-associated pneumonia (HCAP), first published in 2005, have been controversial regarding the selection of empiric broad-spectrum antibiotics, whether the criteria for HCAP predicts the likelihood of infection with multidrug resistant organisms, and whether HCAP patients have improved outcomes when treated with empiric broad-spectrum antibiotics. METHODS A retrospective cohort study at 488 US hospitals from July 2007 to November 2011. Patients who met criteria for HCAP were included. Guideline-concordant antibiotics were assessed based on guideline recommendations. We assessed changes in hospital rates of concordant antibiotic use over time and their correlation with outcomes. RESULTS Among 149,963 patients with HCAP, 19.6% received fully guideline-concordant antibiotics, 21.7% received partially concordant antibiotics, and 58.9% received discordant antibiotics. Guideline concordance increased over time. Rates of fully or partially concordant antibiotics varied across hospitals (median 36.4%; interquartile range 25.8%-49.1%). Among patients who received discordant antibiotics, 81.5% were treated according to community-acquired pneumonia (CAP) guidelines. On average, the rate of guideline concordance increased by 2.2% per 6-month interval, while hospital level rates of mortality, excess length of stay, and progression to respiratory failure did not change. CONCLUSIONS In this large, nationally representative cohort, only 1 in 5 patients with risk factors for HCAP received treatment that was fully in accordance with guidelines, and many received CAP therapy instead. At the hospital level, increases in the use of concordant antibiotics were not associated with declines in mortality, excess length of stay, or progression to respiratory failure.

Randomized trials suggest that assessment of serum procalcitonin (PCT) levels can be used to safely limit antibiotic use among patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD).To determine the impact of PCT testing on antibiotic treatment of patients hospitalized for exacerbations of COPD in routine practice.We conducted a series of cross-sectional and longitudinal multivariable analyses using data from 2009 to 2011 and 2013 to 2014 from a sample of 505 U.S. hospitals.Of 203,177 patients hospitalized for COPD exacerbation in 2013 to 2014, nearly 9 out of 10 were treated with antibiotics. Hospital PCT testing rates ranged from 0 to 83%. In cross-sectional analysis, there was a weak negative association between the rate of PCT testing and risk-adjusted rates of antibiotic initiation (Spearman correlation, -0.12; P = 0.005); each 10-point increase in the percentage of patients undergoing PCT testing was associated with a 0.7% decline in risk-adjusted antibiotic use (P = 0.001). There was no association between hospital rates of PCT testing and duration of antibiotic treatment. In a longitudinal analysis, comparing treatment patterns in 2009 to 2011 and 2013 to 2014, we did not observe a significant difference in the change in antibiotic treatment rates or duration of therapy between hospitals that had adopted PCT testing compared with those that had not.As currently implemented, PCT testing appears to have had little impact on decisions to initiate antibiotic therapy or on duration of treatment for COPD exacerbations. Implementation research is necessary to translate the promising outcomes from PCT testing observed in randomized trials into clinical practice.

Noninvasive ventilation (NIV) is a cornerstone of treatment for patients with severe exacerbations of chronic obstructive pulmonary disease (COPD), where it has been shown to reduce the need for intubation, hospital length of stay, and mortality. Despite high-quality evidence and strong recommendations in clinical guidelines, use of NIV varies widely across hospitals.To identify approaches used by hospitals that have been successful in implementing NIV to treat patients with severe exacerbations of COPD.Adopting a positive deviance approach, in-depth interviews were conducted with key stakeholders from a sample of high-performing hospitals selected from a large and representative network of 386 U.S. hospitals. High performers were defined as hospitals in which a high proportion of patients with COPD requiring mechanical ventilation were treated with NIV, and that also achieved low risk-adjusted mortality for all patients with COPD. Interviews were audio-recorded and transcribed verbatim. Themes and subthemes were identified through iterative readings of the transcripts and discussion until the team agreed that all important themes and subthemes had been identified. All transcripts were coded by three or four researchers. Differences in coding were discussed to negotiate consensus, resulting in a single agreed-on set of coded transcripts.Interviews were conducted with 32 participants from seven hospitals. Hospitals were diverse regarding size, teaching status, and geographic location. Participants included respiratory therapists (n = 15), physicians (n = 10), and nurses (n = 7). The qualitative analyses revealed three interrelated domains that characterized effective NIV use: processes, structural elements, and contextual factors. Several themes comprised each domain. Key processes included timely identification of appropriate patients, early initiation of NIV, frequent reassessment of patients, and attention to patient comfort. Necessary structural elements included adequate equipment, sufficient numbers of qualified respiratory therapists, and flexibility in staffing. Important contextual factors included provider buy-in, respiratory therapist autonomy, interdisciplinary teamwork, and staff education. Hospital leaders, policies, and protocols were identified as playing a supporting role in promoting essential elements.We identified factors, such as respiratory therapist autonomy, that facilitated essential processes (e.g., timely initiation) of NIV use at high-performing hospitals. These findings may be useful to hospitals seeking to optimize their use of NIV among patients with COPD.

This study aimed to evaluate the association between prepregnancy body mass index (BMI), gestational weight gain (GWG), and cesarean delivery in Hispanics.We examined these associations among 1,215 participants in Proyecto Buena Salud, a prospective cohort of Hispanic women studied from 2006 to 2011. Prepregnancy BMI, GWG, and the mode of delivery were abstracted from medical records.A quarter of the participants entered pregnancy with obesity, 23% delivered via cesarean, and 52% exceeded the Institute of Medicine guidelines for GWG. After adjusting for age, women with obesity had 2.03 times the odds of cesarean delivery compared with women with normal BMI (95% confidence interval [CI]: 1.46-2.82); findings remained significant after adjusting for GWG. Women with excessive total GWG had 1.49 times the odds of cesarean delivery (95% CI: 1.06-2.10) compared with women who gained within guidelines. An excessive rate of third trimester GWG (standard deviation [SD] change in GWG per week) increased the odds of cesarean delivery (odds ratio = 1.66; 95% CI: 1.05-2.62), while an excessive rate of first and third trimester GWG was not associated with increased odds.Obesity prior to pregnancy was associated with increased odds of cesarean delivery among Hispanics. Excessive GWG across pregnancy and an excessive rate of third trimester GWG were also associated with increased odds.

Pediatric practices’ scores on healthcare quality measures are increasingly available to the public. However, patients from low-income and racial/ethnic minority populations rarely use these data. We sought to understand potential barriers to using quality data by assessing what factors mattered to women when choosing a pediatric practice. As part of a randomized trial to overcome barriers to using quality data, we recruited women from a prenatal clinic serving an underserved population. Women reported how much 12 factors mattered when they chose a pediatric practice (5-point Likert scale), what other factors mattered to them, and which factors mattered the most. We assessed whether factor importance varied with selected participant characteristics and qualitatively analyzed the “other” factors named. Participants’ (n = 367) median age was 23 years, and they were largely Hispanic (60.4%), white (21.2%), or black (16.9%). Insurance acceptance “mattered a lot” to the highest percentage of women (93.2%), while online information about what other parents think of a practice “mattered a lot” to the fewest (7.4%). Major themes from our qualitative analysis of “other” factors that mattered included physicians’ interpersonal skills and pediatrician-specific traits. Factors related to access “mattered the most” to the majority of women. Pediatrician characteristics and factors related to access to care may be more important to low-income and racial/ethnic minority women than more commonly reported quality metrics. Aligning both the content and delivery of publicly reported quality data with women’s interests may increase use of pediatric quality data. Clinicaltrials.gov NCT01784575

Objectives Symptomatic ureterolithiasis (renal colic) is a common Emergency Department (ED) complaint. Variation in practice surrounding the diagnosis and management of suspected renal colic could have substantial implications for both quality and cost of care as well as patient radiation burden. Previous literature has suggested that CT scanning has increased with no improvements in outcome, owing at least partially to the spontaneous passage of kidney stones in the majority of patients. Concerns about the rising medical radiation burden in the US necessitate scrutiny of current practices and viable alternatives. Our objective was to use data from a diverse sample of US EDs to examine rates of and variation in the use of CT scanning, admission, and inpatient procedures for patients with renal colic and analyze the influence of patient and hospital factors on the diagnostic testing and treatment patterns for patients with suspected renal colic. Methods We conducted a retrospective cohort study of adult patients who received a diagnosis of renal colic via a visit to an ED at 444 US hospitals participating in the Premier Healthcare Alliance database from 2009–2011. We modeled use of CT, admission, and inpatient urologic intervention as functions of both patient characteristics and hospital characteristics. Results Over the 2-year period, 307,612 patient visits met inclusion criteria. Among these patients, 254,211 (82.6%) had an abdominal CT scan, with 91.5% being non-contrast (“renal protocol”) CT scans. Nineteen percent of visits (58,266) resulted in admission or transfer, and 9.8% of visits (30,239) resulted in a urologic procedure as part of the index visit. On multivariable analysis male patients, Hispanic patients, uninsured patients, and privately insured patients were more likely to have a CT scan performed. Older patients and those covered by Medicare were more likely to be admitted, and once admitted, white patients and privately insured patients were more likely to have a urologic intervention. Only hospital region was associated with variation in CT rates, and this variation was minimal. Region and size of the hospital were associated with admission rates, and hospitals with more practicing urologists had higher intervention rates. Conclusions In this dataset, the majority of patients did not require admission or immediate intervention. Despite this, the large majority received CT scans, in a cohort representing 15–20% of all US ED visits. The CT rate was minimally variable at the hospital level, but the admission rates varied 2-fold, suggesting that hospital-level factors affect patient management. The high rate of CT usage coupled with the low rate of immediate intervention suggests that further research is warranted to identify patients who are at low risk for an immediate intervention, and could potentially be managed with ultrasound alone, expectant management, or delayed CT.

Background.Healthcare-associated pneumonia (HCAP) is an entity distinct from community-acquired pneumonia (CAP). HCAP has a higher case-fatality rate, due either to HCAP organisms or to the health status of HCAP patients. The contribution of HCAP criteria to case-fatality rate is unknown.Methods.We conducted a retrospective review of adult patients admitted with a diagnosis of pneumonia from July 2007 through November 2011 to 491 US hospitals. HCAP was defined as having at least 1 of the following: prior hospitalization within 90 days, hemodialysis, admission from a skilled nursing facility, or immune suppression. We compared characteristics of patients with CAP and patients with HCAP and explored the contribution of HCAP criteria to case-fatality rate in a hierarchical generalized linear model.Results.Of 436,483 patients hospitalized with pneumonia, 149,963 (34.4%) had HCAP. Compared to CAP patients, HCAP patients were older, had more comorbidities, and were more likely to require intensive care unit (ICU) care. In-hospital case-fatality rate was higher among patients with HCAP, compared to those with CAP (11.1% vs 5.1%, P < .001). After adjustment for demographics, comorbidities, presence of other infections, early ICU admission, chronic and acute medications, early tests and therapies, and length of stay, HCAP remained associated with increased case-fatality rate (odds ratio [OR], 1.35 [95% confidence interval (CI), 1.32-1.39]); odds of death increased for each additional HCAP criterion (OR [95% CI]: 1 criterion, 1.27 [1.23-1.31], 2 criteria, 1.55 [1.49-1.62], and 3 or more criteria, 1.88 [1.72-2.06]).Conclusions.After adjustment for differences in patient characteristics, HCAP was associated with greater case-fatality rate than CAP. This difference may be due to HCAP organisms or to HCAP criteria themselves.

INTRODUCTION Although pneumonia is a common reason for pediatric hospitalization among children with complex chronic conditions (CCC), treatment and outcomes have not been well-described. We characterized the presentation, management and outcomes of pneumonia in children with and without CCC and described how antibiotic management and outcomes vary among subgroups of children with CCC. METHODS We conducted a cohort study of children

Hispanic women are at increased risk of gestational diabetes mellitus (GDM) as compared to non-Hispanic white women. While smoking has been associated with increased risk of type 2 diabetes, studies of smoking and GDM are sparse and conflicting. Therefore, we evaluated the relationship between cigarette smoking and GDM in Hispanic women.We conducted a pooled analysis of two Hispanic datasets based in Massachusetts: the UMass Medical Health Care dataset and the Proyecto Buena Salud dataset. A total of 3029 Hispanic prenatal care patients with singleton gestations were included. Cigarette smoking prior to and during pregnancy was collected via self-report. Diagnosis of GDM was abstracted from medical records and confirmed by study obstetricians.One-fifth of participants (20.4%) reported smoking prior to pregnancy, and 11.0% reported smoking in pregnancy. A total of 143 women (4.7%) were diagnosed with GDM. We did not observe an association between pre-pregnancy cigarette smoking and odds of GDM (multivariable OR=0.77, 95% CI 0.47, 1.25). In contrast, smoking during pregnancy was associated with a 54% reduction in odds of GDM (OR=0.46, 95% CI 0.22, 0.95). However, this association was no longer statistically significant after adjustment for age, parity, and study site (OR=0.47, 95% CI 0.23, 1.00).In this population of Hispanic pregnant women, we did not observe statistically significant associations between pre-pregnancy smoking and odds of GDM. A reduction in odds of GDM among those who smoked during pregnancy was no longer apparent after adjustment for important diabetes risk factors.

Introduction Certified nurse-midwives (CNMs) and certified midwives (CMs) attend 11% of US vaginal births, and CNM/CM databases include a rich source of information on the birth outcomes of women not generally available through obstetric electronic health records (oEHRs). Although CNM databases are in wide use, studies on their validity are sparse. We examined the validity of a practice-specific CNM birth database compared with an oEHR in a large tertiary-care facility. Methods The study population consisted of all 3133 births in a large CNM practice that were entered into a practice-specific electronic birth database from 2001 to 2008. We assessed agreement with the oEHR overall and according to individual maternal demographic characteristics; obstetric, medical, and social risk factors; labor and birth information; and newborn characteristics. We also evaluated whether there were differences in agreement according to early versus later study periods and by years of CNM clinical experience. Results Overall agreement between the CNM birth database and the oEHR was 92.4%. Agreement between the CNM birth database and the oEHR was greater than 90% for maternal age, race/ethnicity, route and type of birth, major genital tract trauma, newborn weight, and primary clinician attending the birth. Lower agreement rates for smoking, total weight gain in pregnancy, beginning of pregnancy body mass index, and anesthesia for birth were due, in part, to missing information in the oEHR. Agreement did not vary significantly by early versus late study periods or by years of CNM clinical experience. Discussion Findings indicate that a CNM/CM birth database is a valid data source for quality monitoring and outcomes research and may contain more complete information for some variables than the oEHR.

Guidelines for management of community-acquired pneumonia recommend empiric therapy with a macrolide and beta-lactam when infection with Mycoplasma pneumoniae is a significant consideration. Evidence to support this recommendation is limited. We sought to determine the effectiveness of ceftriaxone alone compared with ceftriaxone combined with a macrolide with respect to length of stay and total hospital costs.We conducted a retrospective cohort study of children 1-17 years with pneumonia, using Poisson regression and propensity score analyses to assess associations between antibiotic and length of stay. Multivariable linear regression and propensity score analyses were used to assess log-treatment costs, adjusting for patient and hospital characteristics and initial tests and therapies.A total of 4701 children received combination therapy and 8892 received ceftriaxone alone. Among children 1-4 years of age, adjusted models revealed no significant difference in length of stay, with significantly higher costs in the combination therapy group [cost ratio: 1.08 (95% confidence interval: 1.05-1.11)]. Among children 5-17 years of age, children receiving combination therapy had a shorter length of stay [relative risk: 0.95 (95% confidence interval: 0.92-0.98)], with no significant difference in costs [cost ratio: 1.01 (95% confidence interval: 0.98-1.04)].Combination therapy did not appear to benefit preschool children but was associated with higher costs. Among school-aged children, combination therapy was associated with a shorter length of stay without a significant impact on cost. Development of sensitive point-of-care diagnostic tests to identify children with M. pneumoniae infection may allow for more focused prescription of macrolides and enable comparative effectiveness studies of targeted provision of combination therapy.

AB Introduction: Elevated C-reactive protein (CRP) is associated with adverse pregnancy outcomes. In nonpregnant populations, physical activity has been inversely associated with CRP, but this association has not been evaluated during pregnancy. The purpose of this study was to evaluate the association between objectively measured physical activity, sedentary behavior, and CRP by pregnancy trimester. Methods: We evaluated this association among 294 pregnant participants in the National Health and Nutrition Examination Survey (2003-2004 and 2005-2006). Physical activity (min[middle dot]d-1) was assessed via accelerometer using established cut points. CRP (mg[middle dot]L-1) was measured using a high sensitivity assay. Multivariable linear regression was used to determine the relationship between physical activity, sedentary behavior, and CRP by trimester of pregnancy. Results: Among women in the second trimester, after adjusting for age, body mass index, smoking status, and history of adverse pregnancy outcomes, light-intensity physical activity was associated with lower CRP ([beta] = -0.002, P = 0.05). In unadjusted models, sedentary time and proportion of wear time spent sedentary were positively associated with CRP ([beta] = 0.048, P = 0.02 and [beta] = 2.36, P = 0.03, respectively); however, the relationship was no longer statistically significant in multivariable models ([beta] = 0.33, P = 0.2 and [beta] = 1.96, P = 0.08, respectively). Neither physical activity nor sedentary behavior was associated with CRP among women in the first or third trimester. Conclusions: Objectively measured light-intensity physical activity had a protective effect on CRP among women in the second trimester of pregnancy. Findings highlight the need for longitudinal studies of pregnancy physical activity and CRP with careful control for clinical characteristics of the current pregnanc

IMPORTANCE: Guidelines recommend that patients with acute myocardial infarction (AMI) undergo echocardiography for assessment of cardiac structure and ejection fraction, but little is known about the association between echocardiography as used in routine clinical management of AMI and patient outcomes. OBJECTIVE: To examine the association between risk-standardized hospital rates of transthoracic echocardiography and outcomes. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study of data from 397 US hospitals that contributed to the Premier Healthcare Informatics inpatient database from January 1, 2014, to December 31, 2014, used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify 98 999 hospital admissions for patients with AMI. Data were analyzed between October 2017 and January 2019. EXPOSURES: Rates of transthoracic echocardiography. MAIN OUTCOMES AND MEASURES: Inpatient mortality, length of stay, total inpatient costs, and 3-month readmission rate. RESULTS: Among the 397 hospitals with more than 25 admissions for AMI in 2014, a total of 98 999 hospital admissions for AMI were identified for analysis (38.2% women; mean [SD] age, 66.5 [13.6] years), of which 69 652 (70.4%) had at least 1 transthoracic echocardiogram performed. The median (IQR) hospital risk-standardized rate of echocardiography was 72.5% (62.6%-79.1%). In models that adjusted for hospital and patient characteristics, no difference was found in inpatient mortality (odds ratio [OR], 1.02; 95% CI, 0.88-1.19) or 3-month readmission (OR, 1.01; 95% CI, 0.93-1.10) between the highest and lowest quartiles of echocardiography use (median risk-standardized echocardiography use rates of 83% vs 54%, respectively). However, hospitals with the highest rates of echocardiography had modestly longer mean lengths of stay (0.23 days; 95% CI, 0.04-0.41; P = .01) and higher mean costs ($3164; 95% CI, $1843-$4485; P

The aim of this study is to prospectively examine the association between maternal depressive symptoms in early pregnancy and risk of abnormal glucose tolerance (AGT) and impaired glucose tolerance (IGT) in mid-pregnancy. We evaluated this association among 934 participants in Proyecto Buena Salud, a prospective cohort study of Hispanic (predominantly Puerto Rican) women in Western Massachusetts. Depressive symptoms were assessed in early pregnancy using the 10-item Edinburgh Postnatal Depression Scale. Scores ≥13 indicated at least probable minor depression and scores ≥15 indicated probable major depression. AGT and IGT were diagnosed using American Diabetes Association criteria. In early pregnancy, 247 (26.5 %) participants experienced at least minor depression and 163 (17.4 %) experienced major depression. A total of 123 (13.2 %) were classified with AGT and 56 (6.0 %) were classified with IGT. In fully-adjusted models, the odds ratio for AGT associated with minor depression was 1.20 (95 % CI 0.77-1.89) and for major depression was 1.34 (95 % CI 0.81-2.23). The odds ratio for IGT associated with minor depression was 1.22 (95 % CI 0.62-2.40) and for major depression was 1.53 (95 % CI 0.73-3.22). We did not observe an association with continuous screening glucose measures. Findings in this prospective cohort of Hispanic women did not indicate a statistically significant association between minor or major depression in early pregnancy and AGT or screening glucose values in mid-pregnancy. Due to the small number of cases of IGT, our ability to evaluate the association between depression and IGT risk was constrained.

Objective Hispanic women have high rates of excessive and inadequate gestational weight gain (GWG) according to Institute of Medicine (IOM) guidelines. Observational studies suggest that physical activity may be associated with GWG but have been conflicting and were largely conducted in non-Hispanic white populations. Methods The association between physical activity and compliance with GWG guidelines, total GWG, and rate of GWG among 1,276 Hispanic participants in Proyecto Buena Salud, a cohort study in Western Massachusetts was prospectively evaluated. The Pregnancy Physical Activity Questionnaire was used to assess pre, early, mid, and late pregnancy physical activity according to both intensity (i.e., sedentary, moderate, and vigorous) and type (i.e., housework/caregiving, occupational, and sports/exercise). Results A total of 26.9% of women gained within IOM guidelines, 21.2% had inadequate GWG, and 51.9% experienced excessive GWG. Overall, we did not observe statistically significant associations between type or intensity of physical activity during pre, early, mid, and late pregnancy and inadequate or excessive GWG, total GWG, or rate of GWG. Conclusions In this prospective cohort study of Hispanic women, after controlling for important risk factors, pregnancy physical activity did not appear to be associated with GWG.

Objectives: To examine the association between Beers criteria sedative medications and delirium in a large cohort of hospitalized elderly adults with common medical conditions. Design: Retrospective cohort and nested case�control studies. Setting: 374 U.S. hospitals. Participants: All individuals aged 65 and older admitted to the hospital between September 2003 and June 2005 with one of six principal diagnoses (acute myocardial infarction, chronic obstructive pulmonary disease, community-acquired pneumonia, congestive heart failure, ischemic stroke, urinary tract infection). Measurements: Primary outcome was presumed hospital-acquired delirium, defined as initiation of an antipsychotic medication or restraints on hospital Day 3 or later. Logistic and proportional hazards regression were used to model the associations between sedative exposure and delirium. Results: The dataset contained 225,028 participants (median age 82; 58% female). Four percent fit the definition of hospital-acquired delirium (median onset Day 5). In all, 38,883 (17%) participants received one or more sedative medications. In the cohort study, diphenhydramine (adjusted odds ratio (AOR) = 1.22, 95% confidence interval (CI) = 1.09�1.36) and short-acting benzodiazepines (AOR = 1.18, 95% CI = 1.03�1.34) were associated with greater risk of subsequent delirium. In the nested case�control study, diphenhydramine, short- and long-acting benzodiazepines and promethazine were associated with delirium. Amitriptyline and muscle relaxants were not associated with delirium in either study. Confounding by indication could not be excluded for drugs that are sometimes used improperly to treat delirium. Conclusion: An association was found between several Beers criteria sedative medications and delirium in hospitalized medical patients. Given the prevalence of these medications and the morbidity associated with delirium, further investigation into the appropriateness of such prescribing is warranted.

The objective of this study was to evaluate trends in hospitalization, cost, and short-term outcomes in acute respiratory failure (ARF) between 2001 and 2009 in the United States.Using the Nationwide Inpatient Sample we identified cases of ARF based on International Classification for Diseases, Ninth Revision, Clinical Modification codes. We calculated weighted frequencies of ARF hospitalizations by year and estimated population-adjusted incidence and mortality rates. We used logistic regression to examine hospital mortality rates over time while adjusting for changes in demographic characteristics and comorbidities of patients.The number of hospitalizations with a diagnosis of ARF rose from 1,007,549 in 2001 to 1,917,910 in 2009, with an associated increase in total hospital costs from $30.1 billion to $54.3 billion. During the same period we observed a decrease in hospital mortality from 27.6% in 2001 to 20.6% in 2009, a slight decline in average length of stay from 7.8 days to 7.1 days, and no significant change in the mean cost per case ($15,900). Rates of mechanical ventilation (noninvasive [NIV] or invasive mechanical ventilation [IMV]) remained stable over the 9-year period, and the use of NIV increased from 4% in 2001 to 10% in 2009.Over the period of 2001 to 2009, there was a steady increase in the number of hospitalizations with a discharge diagnosis of ARF, with a decrease in inpatient mortality. There was a significant shift during this time toward the use of NIV, with a decrease in the rates of IMVuse.

To examine the relationship of early initiation of noninvasive ventilation (NIV) with postoperative outcomes in patients with obstructive sleep apnea (OSA) undergoing bariatric surgery.We included 5,266 patients with OSA undergoing bariatric surgeries at 161 hospitals in the United States. We defined early postoperative NIV as NIV used on the day of or the day after surgery; this could include prophylactic NIV or NIV used for early signs of respiratory deterioration. We developed a hierarchical model to identify factors associated with early use of NIV. Then, in a propensity matched cohort, we assessed the association between NIV use and outcomes.Overall, 996 patients (18.9%) were treated with early postoperative NIV. Predictors of NIV initiation were: male sex (odds ratio: 1.34, 95% confidence interval 1.14-1.59), older age, chronic obstructive pulmonary disease (COPD; odds ratio 1.39, confidence interval: 1.17-1.64), gastric bypass surgery, short-acting narcotics intravenous on the day of surgery and admission to a hospital with high rate of OSA diagnosis. In a propensity matched analysis, we found no significant association between early initiation of NIV and receipt of invasive mechanical ventilation (IMV) (early NIV 4.5% vs. no NIV 3.8% p = 0.46), cardiovascular complications or mortality. Results were consistent in several sensitivity analyses.In this large observational study of patients with OSA undergoing bariatric surgery, early postoperative NIV use was not associated with better outcomes including less intubation and mortality. Properly designed controlled trials will be necessary to provide more definitive answers to this important clinical question.

Background Latina women are at increased risk for antenatal depressive disorders, which are common during pregnancy and are associated with elevated risk for poor maternal health and birth outcomes. Physical activity is a potential mechanism to reduce the likelihood of depressive symptoms. The purpose of the study was to assess whether total and domain-specific physical activity in early pregnancy reduced risk for elevated antenatal depressive symptoms in mid-late pregnancy in a population of Latina women at high-risk for depression. Methods Data from 820 Latina participants in the prospective cohort study Proyecto Buena Salud was examined using multivariable logistic regression. Total, moderate/vigorous, and domain-specific physical activity (household/caregiving, occupational, sports/exercise, transportation) were assessed using the Pregnancy Physical Activity Questionnaire. The Edinburgh Postnatal Depression Scale was used to assess depressive symptoms and identify women with elevated symptoms indicative of at least probable minor depression and probable major depression. Results A total of 25.9% of participants experienced at least probable minor depression and 19.1% probable major depression in mid-late pregnancy. After adjusting for important risk factors, no significant associations were observed between total physical activity (4th Quartile vs.1st Quartile OR = 1.02, 95% CI = 0.61, 1.71; p-trend = 0.62) or meeting exercise guidelines in pregnancy (OR = 0.96, 95% CI = 0.65, 1.41) and at least probable minor depression; similarly, associations were not observed between these measures and probable major depression. There was a suggestion of increased risk of probable major depression with high levels of household/caregiving activity (4th Quartile vs 1st Quartile OR = 1.51, 95% CI = 0.93, 2.46), but this was attenuated and remained not statistically significant after adjustment. When we repeated the analysis among women who did not have elevated depressive symptoms in early pregnancy (n = 596), findings were unchanged, though a nonsignificant protective effect was observed for sport/exercise activity and probable major depression in fully adjusted analysis (OR = 0.63, 95% CI = 0.30, 1.33). Conclusion Among Latina women at high-risk for antenatal depression, early pregnancy physical activity was not associated with elevated depressive symptoms in mid-to-late pregnancy.

Objectives To describe the effect of dementia on hospital outcomes of individuals requiring invasive mechanical ventilation (IMV). Design Retrospective cohort study. Setting 2011 Nationwide Inpatient Sample. Participants Hospitalized individuals with and without dementia undergoing IMV. Measurements The adjusted predicted probability of undergoing IMV was examined in individuals with and without dementia. Then the dataset was limited to individuals who received IMV, and a multivariable logistic regression model was created in which dementia was the primary predictor and mortality was the outcome. Results Of the 13,816,586 hospitalizations of older adults in the United States in 2011, 2,204,506 (16%) with a dementia diagnosis code were identified. Individuals with dementia had statistically significantly lower predicted probability of undergoing IMV (5.7%, 95% confidence interval (CI) = 5.6–5.8% than those without (6.5%, 95% CI = 6.4–6.6%). When the dataset was limited to individuals undergoing IMV, those with dementia were older (mean age 80 vs 76, P < .001) and had a higher combined Gagne comorbidity score (4.4 vs 4.1, P < .001) than those without. In a multivariable model, dementia was associated with greater likelihood of survival to hospital discharge (odds ratio (OR) = 0.79, P < .001). Individuals with dementia also had shorter mean length of stay (12.5 ± 0.2 vs 13.1 ± 0.2, P = .01) and lower cost per hospitalization for survivors ($37,213 vs $44,557, P < .001). Conclusion Older critically ill adults with dementia undergoing IMV had better in-hospital outcomes than those without dementia. Because a lower adjusted percentage of individuals with dementia underwent IMV, it is likely that patient selection drove outcome differences. These findings suggest that individuals, families, and clinicians are carefully considering prognosis, quality of life, and appropriate use of intensive care unit resources when deciding whether to use IMV in individuals with dementia.

OBJECTIVE Understanding which factors are associated with the use of critical care therapies (CCTs) can help with clinical decision-making and goals of care discussion. The goal of this study was to describe the predictors of CCT use (eg, mechanical ventilation, tracheostomy, percutaneous endoscopic gastrostomy tube, total parenteral nutrition, acute use of dialysis) in hospitalized patients with metastatic cancer. METHODS We used the 2010 California State Inpatient Databases sponsored by the Agency for Healthcare Research and Quality to identify all hospitalizations with a diagnosis of metastatic cancer (patients aged ≥18 years). We examined the predictors of any CCT use (and invasive mechanical ventilation [IMV] use), stratified by do-not-resuscitate (DNR) status, using multivariable logistic regression models. RESULTS We identified 99,085 hospitalizations involving patients with metastatic cancer; 9.4% received any CCTs and 4.7% received IMV. Predictors of CCT use in the no-DNR group included principal diagnosis of infections (vs cancer-related), greater burden of comorbidities, and presence of weight loss. Predictors of CCT use in the DNR group were similar, but also included non-white races. Liver disease was also a predictor of IMV use in the no-DNR group. Patients with metastatic lung cancer (vs breast and genitourinary) with no DNR were more likely to receive CCT (and IMV). CONCLUSIONS Higher burden of comorbidities, weight loss, liver disease, lung cancer subtype, and diagnosis of infections were associated with higher odds of receiving CCTs or IMV. These findings may help clinicians determine in whom to prioritize discussions around goals of care, especially in the group without a DNR status.

BACKGROUND Children may be hospitalized at general hospitals or freestanding children's hospitals. Knowledge about how inpatient care differs at these hospitals is important to inform national research and quality efforts. OBJECTIVE To describe the volume and characteristics of pediatric hospitalizations at acute care general and freestanding children's hospitals in the United States. DESIGN, PATIENTS, AND SETTING Cross-sectional study of hospitalizations in the United States among children

BACKGROUND: Consumers rarely use publicly reported health care quality data. Despite known barriers to use, few studies have explored the effectiveness of strategies to overcome barriers in vulnerable populations. METHODS: This randomized controlled trial tested the impact of a patient navigator intervention to increase consumer use of publicly reported quality data. Patients attending an urban prenatal clinic serving a vulnerable population enrolled between May 2013 and January 2015. The intervention consisted of 2 in-person sessions in which women learned about quality performance and viewed scores for local practices on the Massachusetts Health Quality Partners Web site. Women in both the intervention and control arms received a pamphlet about health care quality. Primary study outcomes were mean clinical quality and patient experience scores of the practices women selected (range 1–4 stars). RESULTS: Nearly all (726/746; 97.3%) women completed the study, 59.7% were Hispanic, and 65.1% had a high school education or less. In both unadjusted and adjusted models, women in the intervention group chose practices with modestly higher mean clinical quality (3.2 vs 3.0 stars; P = .001) and patient experience (3.0 vs 2.9 stars; P = .05) scores. When asked to rate what factors mattered the most in their decision, few cited quality scores. CONCLUSIONS: An intervention to reduce barriers to using publicly reported health care quality data had a modest effect on patient choice. These findings suggest that factors other than performance on common publicly reported quality metrics have a stronger influence on which pediatric practices women choose.

BACKGROUND: Although peripherally inserted central catheters (PICCs) are often used in adults hospitalized with pneumonia, patterns related to PICC use in this context are unknown. METHODS: Premier's inpatient database was used to identify patients hospitalized with pneumonia between July 1, 2007 and November 30, 2011. PICC placement was identified via billing codes. Generalized estimating equations were used to identify factors associated with PICC placement. Hospital risk-standardized rates of PICC insertion were estimated using hierarchical generalized linear models. RESULTS: There were 545,250 patients (median age: 71 years; range: 57–82 years) included. A total of 41,849 (7.7%) patients received a PICC during hospitalization (median receipt: hospital day 4). PICC recipients were younger (median age: 69 years), had higher levels of comorbidity (Gagne score median: 4 vs 2) and were more often diagnosed with healthcare-associated pneumonia (43.1% vs 29.9%) than those who did not receive PICCs. The 3 patient variables most associated with PICC receipt included weight loss (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.97-2.10), sepsis on admission (OR: 1.80, 95%CI: 1.75-1.85), and intensive care unit status on hospital day 1 or 2 (OR: 1.70, 95%CI: 1.64-1.75). Compared to internal medicine, admission by geriatricians and critical care physicians was associated with PICC placement (OR: 1.81, 95% CI: 1.62-2.03 and OR: 1.14, 95% CI: 1.05-1.24, respectively). Risk-standardized rates of PICC utilization varied from 0.3% to 41.7%. Nearly 70% of the variability in PICC use could not be explained by available data. CONCLUSIONS: In adults hospitalized with pneumonia, PICC use appears directed towards those with severe illness and varies substantially between hospitals. Journal of Hospital Medicine 2016;11:568–575. © 2016 Society of Hospital Medicine.

BACKGROUND Fluoroquinolones have equivalent oral and intravenous bioavailability, but hospitalized patients with community-acquired pneumonia (CAP) generally are treated intravenously. Our objectives were to compare outcomes of hospitalized CAP patients initially receiving intravenous vs oral respiratory fluoroquinolones. METHODS This was a retrospective cohort study utilizing data from 340 hospitals involving CAP patients admitted to a non-intensive care unit (ICU) setting from 2007 to 2010, who received intravenous or oral levofloxacin or moxifloxacin. The primary outcome was in-hospital mortality. Secondary outcomes included clinical deterioration (transfer to ICU, initiation of vasopressors, or invasive mechanical ventilation [IMV] initiated after the second hospital day), antibiotic escalation, length of stay (LOS), and cost. RESULTS Of 36 405 patients who met inclusion criteria, 34 200 (94%) initially received intravenous treatment and 2205 (6%) received oral treatment. Patients who received oral fluoroquinolones had lower unadjusted mortality (1.4% vs 2.5%; P = .002), and shorter mean LOS (5.0 vs 5.3; P < .001). Multivariable models using stabilized inverse propensity treatment weighting revealed lower rates of antibiotic escalation for oral vs intravenous therapy (odds ratio [OR], 0.84; 95% confidence interval [CI], .74-.96) but no differences in hospital mortality (OR, 0.82; 95% CI, .58-1.15), LOS (difference in days 0.03; 95% CI, -.09-.15), cost (difference in $-7.7; 95% CI, -197.4-182.0), late ICU admission (OR, 1.04; 95% CI, .80-1.36), late IMV (OR, 1.17; 95% CI, .87-1.56), or late vasopressor use (OR, 0.94; 95% CI, .68-1.30). CONCLUSIONS Among hospitalized patients who received fluoroquinolones for CAP, there was no association between initial route of administration and outcomes. More patients may be treated orally without worsening outcomes.

Lowering hospital readmission rates has become a primary target for the Centers for MedicareMedicaid Services, but studies of the relationship between adherence to the recommended hospital care processes and readmission rates have provided inconsistent and inconclusive results.To examine the association between hospital performance on Medicare's Hospital Compare process quality measures and 30-day readmission rates for patients with acute myocardial infarction (AMI), heart failure and pneumonia, and for those undergoing major surgery.We assessed hospital performance on process measures using the 2007 Hospital Inpatient Quality Reporting Program. The process measures for each condition were aggregated in two separate measures: Overall Measure (OM) and Appropriate Care Measure (ACM) scores. Readmission rates were calculated using Medicare claims.Risk-standardized 30-day all-cause readmission rate was calculated as the ratio of predicted to expected rate standardized by the overall mean readmission rate. We calculated predicted readmission rate using hierarchical generalized linear models and adjusting for patient-level factors.Among patients aged ≥ 66 years, the median OM score ranged from 79.4 % for abdominal surgery to 95.7 % for AMI, and the median ACM scores ranged from 45.8 % for abdominal surgery to 87.9 % for AMI. We observed a statistically significant, but weak, correlation between performance scores and readmission rates for pneumonia (correlation coefficient R = 0.07), AMI (R = 0.10), and orthopedic surgery (R = 0.06). The difference in the mean readmission rate between hospitals in the 1st and 4th quartiles of process measure performance was statistically significant only for AMI (0.25 percentage points) and pneumonia (0.31 percentage points). Performance on process measures explained less than 1 % of hospital-level variation in readmission rates.Hospitals with greater adherence to recommended care processes did not achieve meaningfully better 30-day hospital readmission rates compared to those with lower levels of performance.

Background β-Blocker therapy has been shown to improve survival among patients with ischaemic heart disease (IHD) and congestive heart failure (CHF) and is underused among patients with chronic obstructive pulmonary disease (COPD). Evidence regarding the optimal use of β-blocker therapy during an acute exacerbation of COPD is particularly weak. Methods We conducted a retrospective cohort study of patients aged ≥40 years with IHD, CHF or hypertension who were hospitalised for an acute exacerbation of COPD from 1 January 2006 to 1 December 2007 at 404 acute care hospitals throughout the USA. We examined the association between β-blocker therapy and in-hospital mortality, initiation of mechanical ventilation after day 2 of hospitalisation, 30-day all-cause readmission and length of stay. Results Of 35 082 patients who met the inclusion criteria, 29% were treated with β blockers in the first two hospital days, including 22% with β1-selective and 7% with non-selective β blockers. In a propensity-matched analysis, there was no association between β-blocker therapy and in-hospital mortality (OR 0.88, 95% CI 0.71 to 1.09), 30-day readmission (OR 0.96, 95% CI 0.89 to 1.03) or late mechanical ventilation (OR 0.98, 95% CI 0.77 to 1.24). However, when compared with β1 selective β blockers, receipt of non-selective β blockers was associated with an increased risk of 30-day readmission (OR 1.25, 95% CI 1.08 to 1.44). Conclusions Among patients with IHD, CHF or hypertension, continuing β1-selective β blockers during hospitalisation for COPD appears to be safe. Until additional evidence becomes available, β1-selective β blockers may be superior to treatment with a non-selective β blocker.

Purpose The aim of this study was to examine treatments of septic shock in a sample of US hospitals and to assess whether patient and hospital characteristics are associated with use of sepsis therapies. Materials and Methods We studied 192 hospitals that treated 50 or more adults with septic shock between 2004 and 2006. We examined hospital-level variation in commonly used therapies including mechanical ventilation, activated protein C (APC), hydrocortisone, central venous pressure (CVP) monitoring, albumin/colloid, and pulmonary artery catheters. We calculated interquartile range to assess the hospital-level variation in treatment. We developed hierarchical mixed-effects logistic regression models to examine the association between patient and hospital characteristics and selected treatments. Results A total of 22 702 patients met the inclusion criteria. When compared with patients younger than 45 years, patients 75 years or older were as likely to receive mechanical ventilation but less likely to receive APC (odds ratio [OR], 0.35 [95% confidence interval, 0.27-0.45]), hydrocortisone (OR, 0.65 [0.56-0.75]), or CVP monitoring (OR, 0.73 [0.63-0.84]). Compared with whites, black patients were more likely to be mechanically ventilated (OR, 1.15 [1.05-1.25]) but less likely to receive hydrocortisone (OR, 0.86 [0.78-0.95]) or APC (0.70 [0.58-0.86]). Conclusion Treatment of septic shock varies across hospitals. In contrast to mechanical ventilation, treatments with weaker supporting evidence showed greater variation, especially among black and older patients.

Background: The ability to measure and track changes in risk-adjusted obstetric complication rates using administrative data underpins efforts to improve obstetric quality of care, but the validity of this approach has not been adequately evaluated. We sought to assess the validity of using composites of ICD-9-CM codes to identify selected categories obstetric complications and risk factors associated with complications. Methods: Patients with ICD-9-CM codes for obstetric trauma/laceration, infection, haemorrhage, episiotomy or obesity discharged between January 2009 and March 2010 were identified in the study hospital's administrative data. One hundred medical records with ICD-9-CM codes of interest were randomly selected for review from each of the five categories. An additional 60 medical records without the ICD-9-CM codes of interest served as controls for each category. Sensitivity and specificity for the selected categories was estimated using inverse proportional weighting to adjust for sampling based on presence of one of the ICD-9-CM codes of interest. Results: Weighted sensitivities ranged from 0.15 [95% CI 0.11, 0.20] for obesity to 1.00 for overall infection while specificities ranged from 0.994 [95% CI 0.987, 0.998] for obesity to 0.999 [95% CI 0.996, 1.000] for episiotomy. Obese patients were not reliably identified and it was not possible ascertain whether some diagnoses were present on admission. Conclusions: For selected categories of obstetric complication diagnoses, use of composite sets of ICD-9-CM codes may be a valid method to identify patients within these complication categories.

BACKGROUND: Both unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are approved for venous thromboembolism (VTE) prophylaxis. Which agent is superior remains controversial. OBJECTIVE: To compare the effectiveness, complications, and costs of UFH and LMWH as VTE prophylaxis for hospitalized medical patients. DESIGN: Retrospective cohort. SETTING: Three hundred thirty-three acute care facilities in 2004–2005. PATIENTS: Adults with 4 common medical diagnoses considered to carry moderate-to-high risk of VTE. Excluded were patients on warfarin or with hospital stays of ≤2 days. VTE prophylaxis was assessed from billing data. INTERVENTION: None. MEASUREMENTS: VTE, major bleeding or heparin-induced thrombocytopenia, mortality, and cost. RESULTS: Of 32,104 patients who received prophylaxis, 55% received LMWH and the remainder received UFH. The hospital where the patient obtained care was the strongest predictor of receiving LMWH. VTE was observed in 163 (0.51%) patients; complications, followed by stopping therapy, were rare (

Background Limited data are available on the use of noninvasive ventilation in patients with asthma exacerbations. The objective of this study was to characterize hospital patterns of noninvasive ventilation use in patients with asthma and to evaluate the association with the use of invasive mechanical ventilation and case fatality rate. Methods This cross-sectional study used an electronic medical record dataset, which includes comprehensive pharmacy and laboratory results from 58 hospitals. Data on 13,558 patients admitted from 2009 to 2012 were analyzed. Initial noninvasive ventilation (NIV) or invasive mechanical ventilation (IMV) was defined as the first ventilation method during hospitalization. Hospital-level risk-standardized rates of NIV among all admissions with asthma were calculated by using a hierarchical regression model. Hospitals were grouped into quartiles of NIV to compare the outcomes. Results Overall, 90.3% of patients with asthma were not ventilated, 4.0% were ventilated with NIV, and 5.7% were ventilated with IMV. Twenty-two (38%) hospitals did not use NIV for any included admissions. Hospital-level adjusted NIV rates varied considerably (range, 0.4-33.1; median, 5.2%). Hospitals in the highest quartile of NIV did not have lower IMV use (5.4% vs 5.7%), but they did have a small but significantly shorter length of stay. Higher NIV rates were not associated with lower risk-adjusted case fatality rates. Conclusions Large variation exists in hospital use of NIV for patients with an acute exacerbation of asthma. Higher hospital rates of NIV use does not seem to be associated with lower IMV rates. These results indicate a need to understand contextual and organizational factors contributing to this variability.

Recent work suggests that infertility treatment is associated with adverse child health outcomes. In exploring various methods of assembling a cohort of children conceived by infertility treatment, the authors conducted a validation study of the assisted reproductive technology and infertility drug use check boxes on the Massachusetts birth certificate. Using 2001 and 2002 data, the authors conducted telephone interviews with 399 women whose child's birth certificate had at least one of the boxes checked along with 185 women who were over age 42 years or who delivered twins or higher order multiples to compare the check box information with maternal report. Among the 579 women with available information, the birth certificate was fully concordant with respect to infertility treatment status for 271 (47%) women, partially concordant for 248 (43%) women, and discordant for 60 (10%) women. Agreement between the birth certificate and maternal report was good for singletons (weighted kappa = 0.66) but was found to be very poor among twins and higher order multiples (weighted kappa = 0.05). The authors concluded that birth certificates are an efficient means of locating children conceived with the help of infertility treatment but that they are not appropriate for identifying type of treatment.

Purpose. To examine factors associated with smoking cessation at pregnancy onset in Hispanic women. Design. Cross-sectional analysis of baseline data from the prospective Latina Gestational Diabetes Mellitus Study. Setting. Public obstetrical practices of a medical center in Massachusetts, 2000–2004. Subjects. A total of 351 Hispanic (predominantly Puerto Rican) prenatal care patients who smoked in the year prior to pregnancy. Measures. At enrollment, interviewers collected self-reported cigarette smoking prior to and during pregnancy and sociodemographic, health, and acculturation factors. Analysis. Logistic regression and backward elimination procedures were used to determine factors independently associated with quitting. Results. Forty-five percent of women reported quitting smoking at pregnancy onset. In multivariate analyses, women born outside the United States, women with a family history of diabetes, and non–Puerto Rican Hispanics were 32% to 54% more likely to quit smoking. Women with high stress, women with marijuana use, and parous women were 23% to 49% less likely to quit. Women who smoked 20+ cigarettes/d in prepregnancy were less likely to quit smoking (relative risk = .44; 95% confidence interval .27, .65) compared with light smokers. Age, income, body mass index, language preference, prepregnancy exercise, and alcohol consumption were not associated with quitting. Conclusions. Non-U.S. birthplace, family history of diabetes, and non–Puerto Rican ethnicity were associated with quitting smoking at pregnancy onset in Hispanic women. Prepregnancy marijuana use and smoking, parity, and stress were associated with continued smoking.

Background How case volume and quality of care relate to each other and to results of complex cancer surgery is not well-understood. Study Design Observational cohort of 14,170 patients 18 years or older who underwent pneumonectomy, esophagectomy, pancreatectomy, or pelvic surgery for cancer between October 1, 2003 and September 1, 2005 at a US hospital participating in a large benchmarking database. Case volumes were estimated within our dataset. Quality was measured by determining whether ideal patients did not receive appropriate perioperative medications (such as antibiotics to prevent surgical site infections), both as individual "missed"measures and as overall number missed. We used hierarchical models to estimate effects of volume and quality on 30-day readmission, in-hospital mortality, length of stay, and costs. Results After adjustment, we noted no consistent associations between higher hospital or surgeon volume and mortality, readmission, length of stay, or costs. Adherence to individual measures was not consistently associated with improvement in readmission, mortality, or other outcomes. For example, continuing antimicrobials past 24 hours was associated with longer length of stay (21.5% higher, 95% CI, 19.5–23.6%) and higher costs (17% higher, 95% CI, 16–19%). In contrast, overall adherence, although not associated with differences in mortality or readmission, was consistently associated with longer length of stay (7.4% longer with 1 missed measure and 16.4% longer with ≥2) and higher costs (5% higher with 1 missed measure, and 11% higher with ≥2). Conclusions Although hospital and surgeon volume were not associated with outcomes, lower overall adherence to quality measures is associated with higher costs, but not improved outcomes. This finding might provide a rationale for improving care systems by maximizing care consistency, even if outcomes are not affected.

Background: The relationship between surgeon and hospital procedure volumes and clinical outcomes in total joint arthroplasty has long fueled a debate over regionalization of care. At the same time, numerous policy initiatives are focusing on improving quality by incentivizing surgeons to adhere to evidence-based processes of care. The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardization of care on short-term postoperative outcomes and resource utilization in lower-extremity total joint arthroplasty. Methods: An analysis of 182,146 consecutive patients who underwent primary total joint arthroplasty was performed with use of data entered into the Perspective database by 3421 physicians from 312 hospitals over a two-year period. Adherence to evidence-based processes of care was defined by administration of appropriate perioperative antibiotic prophylaxis, beta-blockade, and venous thromboembolism prophylaxis. Patient outcomes included mortality, length of hospital stay, discharge disposition, surgical complications, readmissions, and reoperations within the first thirty days after discharge. Hierarchical models were used to estimate the effects of hospital and surgeon procedure volume and process standardization on individual and combined surgical outcomes and length of stay. Results: After adjustment in multivariate models, higher surgeon volume was associated with lower risk of complications, lower rates of readmission and reoperation, shorter length of hospital stay, and higher likelihood of being discharged home. Higher hospital volume was associated with lower risk of mortality, lower risk of readmission, and higher likelihood of being discharged home. The impact of process standardization was substantial; maximizing adherence to evidence-based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of hospital or surgeon procedure volume. Conclusions: Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty, process standardization is also strongly associated with improved quality and efficiency of care. The exact relationship between individual processes of care and patient outcomes has not been established; however, our findings suggest that process standardization could help providers optimize quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Studies conducted among nonpregnant populations have observed an association between sedentary behavior and glucose intolerance. Few studies have investigated this association during pregnancy, particularly among Latina women, a population with higher rates of sedentary behavior and abnormal glucose tolerance (AGT) as compared with non-Latina white women. Objective: The purpose of this study was to estimate the association between sedentary behavior and AGT. Research Design and Methods: We used data from the Latina gestational diabetes mellitus study, a prospective cohort of 1231 Latina prenatal care patients in western Massachusetts. Sedentary behavior was assessed by bilingual interviewers using a modified version of the Kaiser Physical Activity Survey in prepregnancy, early pregnancy, and midpregnancy and defined as hours spent TV watching, frequency of sitting at work, and participation in sports or exercise activity as well as a derived composite of total sedentary activity. AGT was measured at 24-28 wk of gestation and abstracted from medical records after delivery. Multivariate logistic regression was used to calculate odds ratios and 95% confidence intervals. Results: A total of 12% (n = 119) of participants were classified as having AGT. After adjusting for AGT risk factors, sedentary behaviors in prepregnancy or in early pregnancy were not associated with AGT. However, in midpregnancy, low levels of participation in sports or exercise (odds ratio = 2.01, 95% CI = 1.01-4.02) and increasing total sedentary activity (Ptrend = 0.003) were associated with increased risk for AGT. Conclusions: Findings suggest an association between sedentary activity in midpregnancy and risk of AGT in this understudied population.

BACKGROUND: Meta-analyses of randomized trials have found that antibiotics are effective in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), but there is insufficient evidence to guide antibiotic selection. Current guidelines offer conflicting recommendations. OBJECTIVE: To compare the effectiveness of macrolides and quinolones for AECOPD DESIGN: Retrospective cohort study using logistic regression, propensity score–matching, and grouped treatment models. SETTING: A total of 375 acute care hospitals throughout the United States. PATIENTS: Age ≥40 years and hospitalized for AECOPD. INTERVENTION: Macrolide or quinolone antibiotic begun in the first 2 hospital days. MEASUREMENTS: Treatment failure (defined as the initiation of mechanical ventilation after hospital day 2, inpatient mortality, or readmission for AECOPD within 30 days), length of stay, and hospital costs. RESULTS: Of the 19,608 patients who met the inclusion criteria, 6139 (31%) were treated initially with a macrolide and 13,469 (69%) with a quinolone. Compared to patients treated initially with a quinolone, those who received macrolides had a lower risk of treatment failure (6.8% vs. 8.1%; P < 0.01), a finding that was attenuated after multivariable adjustment (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.78–1.01), and disappeared in a grouped-treatment analysis (OR, 1.01; 95% CI, 0.75–1.35). There were no differences in adjusted length of stay (ratio, 0.98; 95% CI, 0.97–1.00) or adjusted cost (ratio, 1.00; 95% CI, 0.99–1.02). After propensity score–matching, antibiotic-associated diarrhea was more common with quinolones (1.2% vs. 0.6%; P < 0.001). CONCLUSIONS: Macrolide and quinolone antibiotics are associated with similar rates of treatment failure in AECOPD; however, macrolides are less frequently associated with diarrhea. Journal of Hospital Medicine 2010;5:267–267. © 2010 Society of Hospital Medicine.

OBJECTIVES: Although osteoporosis treatment can dramatically reduce fracture risk, rates of treatment after hip fracture remain low. In-hospital initiation of recommended medications has improved outcomes in heart disease; hospitalization for hip fracture may represent a similar opportunity for improvement. The objective of this study was to examine rates of in-hospital treatment with a combination of calcium and vitamin D (Cal+D) and antiresorptive or bone-forming medications in patients hospitalized for hip fractures DESIGN: Observational cohort. SETTING: Three hundred eighteen hospitals in the United States. PARTICIPANTS: Fifty-one thousand three hundred forty-six patients aged 65 and older hospitalized for osteoporotic hip fracture. MEASUREMENTS: In-hospital administration of Cal+D and antiresorptive or bone-forming medications. RESULTS: Three thousand four hundred five patients (6.6%) received Cal+D anytime after a procedure to correct femoral fracture; 3,763 patients (7.3%) received antiresorptive or bone-forming medications. Only 1,023 patients (2.0%) were prescribed ideal therapy, receiving Cal+D and an antiresorptive or bone-forming medication. Treatment rates remained low across virtually all patient-, provider-, and hospital-level characteristics. The strongest predictor of treatment with Cal+D was the receipt of an antiresorptive or bone-forming medication (adjusted odds ratio=5.50, 95% confidence interval=4.84–6.25), but only 27.2% of patients who received these medications also received Cal+D. CONCLUSION: Rates of in-hospital initiation of osteoporosis treatment for patients with hip fracture are low and may represent an opportunity to improve care.

Background Medical research outsourcing provides a financial benefit to those conducting research and financial incentives to the developing countries hosting the research. Little is known about how frequently outsourcing occurs or the type of research that is outsourced. Methods To document changes in medical research outsourcing over a 10-year period, we conducted a cross-sectional comparison of 3 medical journals: Lancet, The New England Journal of Medicine, and JAMA: The Journal of the American Medical Association in the last 6 months of 1995 and 2005. The main outcome measure was the 10-year change in proportion of studies including patients from low-income countries. Findings We reviewed 598 articles. During the 10-year period, the proportion of first authors from low-income countries increased from 3% to 6% ( P = 0.21), whereas studies with participants from low-income countries increased from 8% to 22% ( P = < 0.001). In 2005, compared with studies conducted exclusively in high-income countries, those including participants from low-income countries were more likely to be randomized trials (55% vs 35%, P = 0.004), to study medications (65% vs 34%, P < 0.001), to be funded by pharmaceutical companies (33% vs 21%, P = 0.05), and to involve pediatric populations (29% vs 8%, P < 0.001). Interpretation Outsourcing of medical research seems to be increasing. Additional studies are required to know if subjects from low-income countries are being adequately protected.

OBJECTIVE Cystic fibrosis–related diabetes (CFRD) without fasting hyperglycemia (CFRD FH−) is not associated with microvascular or macrovascular complications, leading to controversy about the need for treatment. The Cystic Fibrosis Related Diabetes Therapy (CFRDT) Trial sought to determine whether diabetes therapy improves BMI in these patients. RESEARCH DESIGN AND METHODS A three-arm multicenter randomized trial compared 1 year of therapy with premeal insulin aspart, repaglinide, or oral placebo in subjects with cystic fibrosis who had abnormal glucose tolerance. RESULTS One hundred adult patients were enrolled. Eighty-one completed the study, including 61 with CFRD FH− and 20 with severly impaired glucose tolerance (IGT). During the year before therapy, BMI declined in all groups. Among the group with CFRD FH−, insulin-treated patients lost 0.30 ± 0.21 BMI units the year before therapy. After 1 year of insulin therapy, this pattern reversed, and they gained 0.39 ± 21 BMI units (P = 0.02). No significant change in the rate of BMI decline was seen in placebo-treated patients (P = 0.45). Repaglinide-treated patients had an initial significant BMI gain (0.53 ± 0.19 BMI units, P = 0.01), but this effect was not sustained. After 6 months of therapy they lost weight so that by 12 months there was no difference in the rate of BMI change during the study year compared with the year before (P = 0.33). Among patients with IGT, neither insulin nor repaglinide affected the rate of BMI decline. No significant differences were seen in the rate of lung function decline or the number of hospitalizations in any group. CONCLUSIONS Insulin therapy safely reversed chronic weight loss in patients with CFRD FH−.

Introduction The purpose of this study is to compare blood glucose levels measured by a point of care (POC) device to laboratory measurement using the same sample venous blood from patients with suspected diabetic ketoacidosis (DKA). Methods A descriptive correlational design was used for this IRB-approved quality assurance project. The study site was the 50-bed BMC emergency department (ED) which has an annual census of over 100, 000 patient visits. The convenience sample consisted of 54 blood samples from suspected DKA patients with orders for hourly blood draws for glucose measurement. Spearman correlations of the glucose POC values, reference lab values, and differences between the two, were evaluated. A chi-square test was used to evaluate the association between the acidosis status and FDA acceptability of POC values. Results Patient age range was 10-86 years; 63% were females; 46% had a final diagnosis of DKA. POC values underestimated glucose levels 93% of the time. There was a high correlation between the lab value and the magnitude of the difference, (lab minus POC value) indicating that the higher the true glucose value, the greater the difference between the lab and the POC value. A chi-square test showed no overall association between acidosis and FDA-acceptability. Discussion The POC values underestimated lab reported glucose levels in 50 of 54 cases even with the use of same venous sample sent to the lab, which make it highly unreliable for use in monitoring suspected DKA patients.