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BACKGROUND: Lack of standardization in CT protocol choice contributes to radiation dose variation. PURPOSE: To create a framework to assess radiation doses within broad CT categories defined according to body region and clinical imaging indication and to cluster indications according to the dose required for sufficient image quality. MATERIALS AND METHODS: This was a retrospective study using Digital Imaging and Communications in Medicine metadata. CT examinations in adults from January 1, 2016 to December 31, 2019 from the University of California San Francisco International CT Dose Registry were grouped into 19 categories according to body region and required radiation dose levels. Five body regions had a single dose range (ie, extremities, neck, thoracolumbar spine, combined chest and abdomen, and combined thoracolumbar spine). Five additional regions were subdivided according to dose. Head, chest, cardiac, and abdomen each had low, routine, and high dose categories; combined head and neck had routine and high dose categories. For each category, the median and 75th percentile (ie, diagnostic reference level [DRL]) were determined for dose-length product, and the variation in dose within categories versus across categories was calculated and compared using an analysis of variance. Relative median and DRL (95% CI) doses comparing high dose versus low dose categories were calculated. RESULTS: Among 4.5 million examinations, the median and DRL doses varied approximately 10 times between categories compared with between indications within categories. For head, chest, abdomen, and cardiac (3 266 546 examinations [72%]), the relative median doses were higher in examinations assigned to the high dose categories than in examinations assigned to the low dose categories, suggesting the assignment of indications to the broad categories is valid (head, 3.4-fold higher [95% CI: 3.4, 3.5]; chest, 9.6 [95% CI: 9.3, 10.0]; abdomen, 2.4 [95% CI: 2.4, 2.5]; and cardiac, 18.1 [95% CI: 17.7, 18.6]). Results were similar for DRL doses (all P < .001). CONCLUSION: Broad categories based on image quality requirements are a suitable framework for simplifying radiation dose assessment, according to expected variation between and within categories. © RSNA, 2021 See also the editorial by Mahesh in this issue.

OBJECTIVE: To reweight the Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator [PSI] 90) from weights based solely on the frequency of component PSIs to those that incorporate excess harm reflecting patients' preferences for outcome‐related health states. DATA SOURCES: National administrative and claims data involving hospitalizations in nonfederal, nonrehabilitation, acute care hospitals. STUDY DESIGN: We estimated the average excess aggregate harm associated with the occurrence of each component PSI using a cohort sample for each indicator based on denominator‐eligible records. We used propensity scores to account for potential confounding in the risk models for each PSI and weighted observations to estimate the “average treatment effect in the treated” for those with the PSI event. We fit separate regression models for each harm outcome. Final PSI weights reflected both the disutilities and the frequencies of the harms. DATA COLLECTION/EXTRACTION METHODS: We estimated PSI frequencies from the 2012 Healthcare Cost and Utilization Project State Inpatient Databases with present on admission data and excess harms using 2012–2013 Centers for Medicare & Medicaid Services Medicare Fee‐for‐Service data. PRINCIPAL FINDINGS: Including harms in the weighting scheme changed individual component weights from the original frequency‐based weighting. In the reweighted composite, PSIs 11 (“Postoperative Respiratory Failure”), 13 (“Postoperative Sepsis”), and 12 (“Perioperative Pulmonary Embolism or Deep Vein Thrombosis”) contributed the greatest harm, with weights of 29.7%, 21.1%, and 20.4%, respectively. Regarding reliability, the overall average hospital signal‐to‐noise ratio for the reweighted PSI 90 was 0.7015. Regarding discrimination, among hospitals with greater than median volume, 34% had significantly better PSI 90 performance, and 41% had significantly worse performance than benchmark rates (based on percentiles). CONCLUSIONS: Reformulation of PSI 90 with harm‐based weights is feasible and results in satisfactory reliability and discrimination, with a more clinically meaningful distribution of component weights.

Background: For newborns requiring transfer to a higher level of care, stabilization before the arrival of the transport team is essential. Telemedicine consultations with a neonatologist may impro...

BACKGROUND: Weight telemonitoring may be an effective way to improve patients' ability to manage heart failure and prevent unnecessary utilization of health services. However, the effectiveness of such interventions is dependent upon patient adherence. OBJECTIVE: The purpose of this study was to determine how adherence to weight telemonitoring changes in response to 2 types of events: hospital readmissions and emergency department visits. METHODS: The Better Effectiveness After Transition–Heart Failure trial examined the effectiveness of a remote telemonitoring intervention compared with usual care for patients discharged to home after hospitalization for decompensated heart failure. Participants were followed for 180 days and were instructed to transmit weight readings daily. We used Poisson regression to determine the within-person effects of events on subsequent adherence. RESULTS: A total of 625 events took place during the study period. Most of these events were rehospitalizations (78.7%). After controlling for the number of previous events and discharge to a skilled nursing facility, the rate for adherence decreased by nearly 20% in the 2 weeks after a hospitalization compared with the 2 weeks before (adjusted rate ratio, 0.81; 95% confidence interval: 0.77–0.86; P < .001). CONCLUSIONS: Experiencing a rehospitalization had the effect of diminishing adherence to daily weighing. Providers using telemonitoring to monitor decompensation and manage medications should take advantage of the potential “teachable moment” during hospitalization to reinforce the importance of adherence.

Researchers use risk-adjustment models to account for severity of illness in comparing patient outcomes across hospitals. Researchers specify important features as main effects, but they ignore interaction effects or use stratification methods, to account for effect modification, despite its limitations resulting from the number of potential strata. The Agency for Healthcare Research and Quality Inpatient Quality Indicator (IQI) 11, Abdominal Aortic Aneurysm Repair Mortality, is stratified into four groups based on the type of repair and rupture. IQI 09, Pancreatic Resection Mortality Rate, is stratified into two groups based on the presence of pancreatic cancer. The variable performance of these models motivated design of better models. We used hierarchical group lasso regularisation (HGLR) to identify first-order interactions in patient discharge data used in the development of risk-standardised models. HGLR identified unsuspected but clinically meaningful interactions for IQI 11, which has a heterogeneous population, but not for IQI 09. Synergistic interactions, such as between hypertension and respiratory failure, suggest patients merit special attention in perioperative care. Antagonistic interactions, such as between shock at admission and chronic comorbidities, illustrate that naïve main effects models overpredict risk in key population subsets, leading to miscalibrated models that yield biased estimates of hospital performance. HGLR is a useful and necessary step to identify first-order interactions for the development of robust risk-adjustment models used by agencies and stakeholders to rank hospitals in the US.

Background Postoperative respiratory failure is the most common serious postoperative pulmonary complication, yet little is known about factors that can reduce its incidence. We sought to elucidate modifiable factors associated with respiratory failure that developed within the first 5 d after an elective operation. Materials and Methods Matched case-control study of adults who had an operation at five academic medical centers between October 1, 2012 and September 30, 2015. Cases were identified using administrative data and confirmed via chart review by critical care clinicians. Controls were matched 1:1 to cases based on hospital, age, and surgical procedure. Results Our total sample (n = 638) was 56.4% female, 71.3% white, and had a median age of 62 y (interquartile range 51, 70). Factors associated with early postoperative respiratory failure included male gender (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.12-2.63), American Society of Anesthesiologists class III or greater (OR 2.85, 95% CI 1.74-4.66), greater number of preexisting comorbidities (OR 1.14, 95% CI 1.004-1.30), increased operative duration (OR 1.14, 95% CI 1.06-1.22), increased intraoperative positive end-expiratory pressure (OR 1.23, 95% CI 1.13-1.35) and tidal volume (OR 1.13, 95% CI 1.004-1.27), and greater net fluid balance at 24 h (OR 1.17, 95% CI 1.07-1.28). Conclusions We found greater intraoperative ventilator volume and pressure and 24-h fluid balance to be potentially modifiable factors associated with developing early postoperative respiratory failure. Further studies are warranted to independently verify these risk factors, explore their role in development of early postoperative respiratory failure, and potentially evaluate targeted interventions.

Background Administrative data can be used to identify cases of postoperative respiratory failure (PRF). We aimed to determine if recent changes to the Agency for Healthcare Research and Quality Patient Safety Indicator 11 (PSI 11) and adoption of clinical documentation improvement programs have improved the validity of PSI 11. We also analyzed reasons why PSI 11 was falsely triggered. Study design Cross-sectional study of all eligible discharges using health record data from five academic medical centers between October 1, 2012 and September 30, 2015. Results Of 437 flagged records, 434 (99.3%) were accurately coded and 414 (94.7%) represented true clinical PRF. None of the false positive records involved respiratory failure present on admission. Most (78.3%) false positive records required airway protection but did not have respiratory failure. Conclusion The validity of PSI 11 has improved with recent changes to the code criterion and adoption of clinical documentation improvement programs.

OBJECTIVE: Differences in the quality of emergency department (ED) care are often attributed to nonclinical factors such as variations in the structure, systems, and processes of care. Few studies have examined these associations among children. We aimed to determine whether process measures of quality of care delivered to patients receiving care in children’s hospital EDs were associated with physician-level or hospital-level factors. METHODS: We included children (

OBJECTIVE The aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice. SUMMARY BACKGROUND DATA In 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied. METHODS We studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors. RESULTS Traditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P < 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9 min; 95% CI (8-10), P < 0.001], and costs [255USD; 95% CI (2-508), P = 0.049]. CONCLUSIONS Duty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care.

Objective The purpose of this study was to examine risk factor and temporal associations between acute care hospitalization and post-discharge home injury falls in a population-based analysis sample of community dwelling older adults. Methods We applied a unidirectional case-crossover design to a retrospective analysis sample derived from healthcare administrative data from all non-federal licensed hospitals in the State of California. The analysis sample was comprised of California residents age 65 years or older with a record of treatment for injury fall occurring at home from January 1, 2014 to December 31, 2014. A conditional Poisson regression with fixed person effects and a robust estimator of variance was used to calculate the incidence rate ratio of acute care admissions during the 90 day period immediately preceding an injury fall, with the period of 360–271 days prior to index fall as reference. Results The rate of acute care admissions was 121% greater (IRR: 2.21; 95% CI 2.15–2.27) during the 90 days immediately preceding the index injury fall than 181–360 days prior. Period effects on rates of admissions were significantly higher in the acute care treatment subsample (IRR 2.63; 95% CI 2.51–2.76) than the emergency department treatment subsample (IRR 2.00; 95% CI 1.94–2.07). Discharge to post-acute care facilities; discharge to home health and Elixhauser comorbidity index all significantly modified period effects on acute care admissions. Conclusions Older adults have an increased risk of falling at home after being discharged from an acute care hospitalization, with highest risk occurring during the 90-day post-discharge period. Special consideration should be given to assessing hospital-associated changes in fall risk among geriatric patients prior to discharge directly home. Discharge planning should include efforts to reduce home fall risk during the period of transition from hospital care.

Noninvasive telemonitoring and nurse telephone coaching (NTM-NTC) is a promising post-discharge strategy in heart failure (HF). Comorbid conditions and disease burden influence health outcomes in HF, but how comorbidity burden modulates the effectiveness of NTM-NTC is unknown. This study aims to identify HF patients who may benefit from post-discharge NTM-NTC based on their burden of comorbidity.In the Better Effectiveness After Transition - Heart Failure trial, patients hospitalized for acute decompensated HF were randomized to post-discharge NTM-NTC or usual care. In this secondary analysis of 1,313 patients with complete data, comorbidity burden was assessed by scoring complication/coexisting diagnoses from index admissions. Clinical outcomes included 30-day and 180-day readmissions, mortality, days alive, and combined days alive and out of the hospital.Patients had a mean of 5.7 comorbidities and were stratified into low (0-2), moderate (3-8), and high comorbidity (9+) subgroups. Increased comorbidity burden was associated with worse outcomes. NTM-NTC was not associated with readmission rates in any comorbidity subgroup. Among high comorbidity patients, NTM-NTC was associated with significantly lower mortality at 30 days (hazard ratio (HR): 0.25; 95% confidence interval (CI): 0.07-0.90) and 180 days (HR: 0.51; 95% CI: 0.27-0.98), as well as more days alive (160.1 vs 140.3, p=0.029) and days alive out of the hospital (152.0 vs 133.2; p=0.044) compared to usual care.Post-discharge NTM-NTC improved survival among HF patients with high comorbidity burden. Comorbidity burden may be useful for identifying patients likely to benefit from this management strategy.

To develop and evaluate the psychometric properties of a family caregiver-reported survey that assesses family-centeredness of care in the context of pediatric emergency department (ED) encounters.We created a caregiver-reported scale, incorporated content expert feedback, and iteratively revised it based on cognitive interviews with caregivers. We then field tested the scale in a survey with caregivers. We dichotomized items using top-box scoring and obtained a summary score per respondent. Using a sample of 191 caregivers recruited from 9 EDs, we analyzed internal consistency reliability, dimensionality via item response theory modeling, and convergent validity with the ED Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.Feedback from the 9 experts led us to remove 4 items. We conducted 16 cognitive interviews and revised the survey in 4 rounds. An 11-item survey was field tested. Mean (standard deviation) respondent 11-item summary score was 77.2 (26.6). We removed 2 items given inconsistent response patterns, poor variability, and poor internal consistency, which increased coefficient alpha from 0.85 to 0.88 for the final scale. A multidimensional model fit the data best, but factor scores correlated strongly with summary scores, suggesting the latter are sufficient for quality improvement and future research. Regarding convergent validity, adjusted partial correlation between our scale's 9-item summary score and the ED CAHPS summary score was 0.75 (95% confidence interval 0.67-0.81).Psychometric analyses demonstrated strong item performance, reliability, and convergent validity for the 9-item scale. This survey can be used to assess family-centered care in the ED for research and quality improvement purposes.

Few interventions are known to reduce the incidence of respiratory failure that occurs following elective surgery (postoperative respiratory failure; PRF). We previously reported risk factors associated with PRF that occurs within the first 5 days after elective surgery (early PRF; E-PRF); however, PRF that occurs six or more days after elective surgery (late PRF; L-PRF) likely represents a different entity. We hypothesized that L-PRF would be associated with worse outcomes and different risk factors than E-PRF.This was a retrospective matched case-control study of 59,073 consecutive adult patients admitted for elective non-cardiac and non-pulmonary surgical procedures at one of five University of California academic medical centers between October 2012 and September 2015. We identified patients with L-PRF, confirmed by surgeon and intensivist subject matter expert review, and matched them 1:1 to patients who did not develop PRF (No-PRF) based on hospital, age, and surgical procedure. We then analyzed risk factors and outcomes associated with L-PRF compared to E-PRF and No-PRF.Among 95 patients with L-PRF, 50.5% were female, 71.6% white, 27.4% Hispanic, and 53.7% Medicare recipients; the median age was 63 years (IQR 56, 70). Compared to 95 matched patients with No-PRF and 319 patients who developed E-PRF, L-PRF was associated with higher morbidity and mortality, longer hospital and intensive care unit length of stay, and increased costs. Compared to No-PRF, factors associated with L-PRF included: preexisiting neurologic disease (OR 4.36, 95% CI 1.81-10.46), anesthesia duration per hour (OR 1.22, 95% CI 1.04-1.44), and maximum intraoperative peak inspiratory pressure per cm HWe identified that pre-existing neurologic disease, longer duration of anesthesia, and greater maximum intraoperative peak inspiratory pressures were associated with respiratory failure that developed six or more days after elective surgery in adult patients (L-PRF). Interventions targeting these factors may be worthy of future evaluation.

PURPOSE: Half of the 21-item Minnesota Living with Heart Failure Questionnaire (MLHFQ) response categories are labeled (0 = No, 1 = Very little, 5 =Very much) and half are not (2, 3, and 4). We hypothesized that the unlabeled response options would not be more likely to be chosen at some place along the scale continuum than other response options and, therefore, not satisfy the monotonicity assumption of simple-summated scoring. METHODS: We performed exploratory and confirmatory factor analyses of the MLHFQ items in a sample of 1437 adults in the Better Effectiveness After Transition--Heart Failure study. We evaluated the unlabeled response options using item characteristic curves from item response theory graded response models for MLHFQ physical and emotional health scales. Then, we examined the impact of collapsing response options on correlations of scale scores with other variables. RESULTS: The sample was 46% female; 71% 65 or older; 11% Hispanic, 22% Black, 54% White, and 12% other. The unlabeled response options were rarely chosen. The standard approach to scoring and scores obtained by collapsing adjacent response categories yielded similar associations with other variables, indicating that the existing response options are problematic. CONCLUSIONS: The unlabeled MLHFQ response options do not meet the assumptions of simple-summated scoring. Further assessment of the performance of the unlabeled response options and evaluation of alternative scoring approaches is recommended. Adding labels for response options in future administrations of the MLHFQ should be considered.

Background Smoking is a risk factor for complications after lung resection. Our primary aim was to ascertain thoracic surgeons’ beliefs and practices on smoking cessation before lung resection. Methods An anonymous survey was emailed to 846 thoracic surgeons who participate in The Society of Thoracic Surgeons General Thoracic Surgery Database. Results The response rate was 23.6% (n = 200). Surgeons were divided when asked whether it is ethical to require that patients quit smoking (yes, n = 96 [48%]) and whether it is fair to have their outcomes affected by patients who do not quit (yes, n = 87 [43.5%]). Most do not require smoking cessation (n = 120 [60%]). Of those who require it, the most common required period of cessation is 2 weeks or more. Most believe that patient factors are the main barrier to quitting (n = 160 [80%]). Risk of disease progression (39% vs 17.5%, p = 0.02) and alienating patients (17.5% vs 8.8%, p = 0.04) were very important considerations of those who do not require smoking cessation versus those who do. Only 19 (9.5%) always refer to a smoking cessation program and prescribe nicotine replacement therapy and even fewer, 9 (4.5%), always refer to a program and prescribe medical therapy. Conclusions Thoracic surgeons are divided on their beliefs and practices regarding smoking cessation before lung resection. Most believe patient factors are the main barrier to quitting and have concerns about disease progression while awaiting cessation. Very few surgeons refer to a smoking cessation program and prescribe nicotine replacement therapy or medical therapy.

Objectives While hospital-hospital transfers of pediatric patients are often necessary, some pediatric transfers are potentially avoidable. Pediatric potentially avoidable transfers (PATs) represent a process with high costs and safety risks but few, if any, benefits. To better understand this issue, we described pediatric interfacility transfers with early discharges. Methods We conducted a descriptive study using electronic medical record data at a single-center over a 12-month period to examine characteristics of pediatric patients with a transfer admission source and early discharge. Among patients with early discharges, we performed descriptive statistics for PATs defined as patient transfers with a discharge home within 24 hours without receiving any specialized procedures or diagnoses. Results Of the 2,415 pediatric transfers, 31.4% were discharged home within 24 hours. Among transferred patients with early discharges, 356 patients (14.7% of total patient transfers) received no specialized procedures or diagnoses. Direct admissions were categorized as PATs 1.9-fold more frequently than transfers arriving to the emergency department. Among transferred direct admissions, PAT proportions to the neonatal intensive care unit (ICU), pediatric ICU, and non-ICU were 5.1%, 17.3%, and 27.3%, respectively. Respiratory infections, asthma, and ill-defined conditions (eg, fever, nausea with vomiting) were the most common PAT diagnoses. Conclusions Early discharges and PATs are relatively common among transferred pediatric patients. Further studies are needed to identify the etiologies and clinical impacts of PATs, with a focus on direct admissions given the high frequency of PATs among direct admissions to both the pediatric ICU and non-ICU.

The burden of rising health care costs is being shifted to consumers, and 30 percent of health care costs are attributed to wasteful spending on low- or no-value services. Value-based insurance design (VBID) is intended to encourage the use of high-value services or discourage the use of low-value services by aligning cost with quality. During the summer and fall of 2016, this mixed-methods study used focus groups and a quantitative analysis of survey data to explore consumer decision making in Northern California. When presented with three common VBID approaches, the focus groups favored value-based benefit design the most (41 percent), followed by reference pricing (28 percent) and narrow networks (21 percent). When presented with VBID scenarios, participants were skeptical of the value-based trade-offs and reported seeking information they wanted instead of relying on information that health plans provide. Engaging consumers to successfully reduce waste through VBID will require clarifying trade-offs to support consumers' processes for arriving at high-value decisions as well as reaching out to consumers through trusted sources and networks.

PURPOSE: Pediatric readiness scores may be a useful measure of a hospital’s preparedness to care for children. However, there is limited evidence linking these scores with patient outcomes or other metrics, including the need for interfacility transfer. This study aims to determine the association of pediatric readiness scores with the odds of interfacility transfer among a cohort of non-injured children (< 18 years old) presenting to emergency departments (ED) in small rural hospitals in the state of California. METHODS: Data from the National Pediatric Readiness Project assessment were linked with the California Office of Statewide Health Planning and Development’s ED and inpatient databases to conduct a cross-sectional study of pediatric interfacility transfers. Hospitals were manually matched between these data sets. Logistic regression was performed with random intercepts for hospital and adjustment for patient-level confounders. FINDINGS: A total of 54 hospitals and 135,388 encounters met the inclusion criteria. EDs with a high pediatric readiness score (>70) had lower adjusted odds of transfer (aOR: 0.55, 95% CI: 0.33-0.93) than EDs with a low pediatric readiness score (≤ 70). The pediatric readiness section with strongest association with transfer was the “Policies, Procedures, and Protocols” section; EDs in the highest quartile had lower odds of transfer than EDs in the lowest quartile (aOR: 0.54, 95% CI: 0.31-0.91). CONCLUSIONS: Pediatric patients presenting to EDs at small rural hospitals with high pediatric readiness scores may be less likely to be transferred. Additional studies are recommended to investigate other pediatric outcomes in relation to hospital ED pediatric readiness.

IntroductionExternal cause of injury matrices is used to classify mechanisms/causes of injuries for surveillance and research. Little is known about the performance of the Centers for Disease Control and Prevention’s new external cause of injury matrix for Clinical Modification of the 10th Revision of the International Classification of Diseases (ICD-10-CM), compared with the ICD-9-CM version.MethodsDually coded (ICD-9-CM and ICD-10-CM) administrative data were obtained from two major academic trauma centres. Injury-related cases were identified and categorised by mechanism/cause and manner/intent. Comparability ratios (CR) were used to estimate the net impact of changing from ICD-9-CM to ICD-10-CM on the number of cases classified to each mechanism/cause category. Chamberlain’s percent positive agreements (PPA) were calculated and McNemar’s test was used to assess the significance of observed classification differences.ResultsOf 4832 and 5211 dual-coded records from the two centres, 632 and 520 with injury-related principal diagnoses and external cause codes in both ICD-9-CM and ICD-10-CM were identified. CRs for the mechanisms/causes with at least 20 records ranged from 0.85 to 1.9 at one centre and from 0.97 to 1.07 at the other. Among these mechanisms/causes, PPAs ranged from 33% for ‘other transport’ to 94% for poisoning at one centre, and from 75% for ‘other transport’ to 100% for fires/burns at the other centre. Case assignment differed significantly for falls, motor vehicle traffic, other transport, and ‘struck by/against’ injuries at one centre, and for ‘other pedal cyclist’ at the other centre.ConclusionSwitching to ICD-10-CM and the new external cause of injury matrix may affect injury surveillance and research, especially for certain mechanisms/causes.

Background Improving the quality of cancer care and reducing preventable health system use are goals of increasing importance to health practitioners and policy makers. Emergency department (ED) visits are often cited as a source of preventable health system use, however, few studies have described the incidence of ED use by recently diagnosed cancer patients in population-based samples, and no study has addressed the full spectrum of cancer types. Objective To describe ED use by recently diagnosed cancer patients. Methods California Office of Statewide Health Planning and Development data and the California Cancer Registry were used to describe ED use in the year after a cancer diagnosis (2009-2010). The incidence of ED use was tabulated by cancer type. Logistic regression and recycled predictions were used to examine ED use adjusting for confounding factors. Results Most ED visits (68%) occurred within 180 days of diagnosis. The incidence of ED use for all cancer types examined was 17% within 30 days, 35% within 180 days and 44% within 365 days of diagnosis. ED use varied by cancer type (5%-39% within 30 days of diagnosis; 14% -62% within 180 days; and 22%-69% within 365 days). Patterns of ED use by cancer type remained similar after accounting for demographic and socioeconomic factors. Limitations Those common to administrative and registry datasets. Specifically, we were unable to account for ED visits in relation to cancer treatment dates and comorbid conditions. Conclusions Cancer patients use EDs at higher rates than previously reported, with considerable variability by cancer type. Future research should examine reasons for ED visits by cancer type and identify predictors of ED use, including treatment and comorbid conditions.

We aimed to develop and validate an instrument to detect hospital medication prescribing errors using repurposed clinical decision support system data. Despite significant efforts to eliminate medication prescribing errors, these events remain common in hospitals. Data from clinical decision support systems have not been used to identify prescribing errors as an instrument for physician-level performance. We evaluated medication order alerts generated by a knowledge-based electronic prescribing system occurring in one large academic medical center's acute care facilities for patient encounters between 2009 and 2012. We developed and validated an instrument to detect medication prescribing errors through a clinical expert panel consensus process to assess physician quality of care. Six medication prescribing alert categories were evaluated for inclusion, one of which - dose - was included in the algorithm to detect prescribing errors. The instrument was 93% sensitive (recall), 51% specific, 40% precise, 62% accurate, with an F1 score of 55%, positive predictive value of 96%, and a negative predictive value of 32%. Using repurposed electronic prescribing system data, dose alert overrides can be used to systematically detect medication prescribing errors occurring in an inpatient setting with high sensitivity.

Key Points Question Is adherence to weight telemonitoring associated with health care use and death for patients with heart failure? Findings This post hoc secondary analysis of a randomized clinical trial that included 538 participants found that an increase in weight telemonitoring adherence in a given week was associated with a significant decrease in the risk of subsequent hospitalization or death in the following week. Adherence was not associated with emergency department visits. Meaning Adherence to telemonitoring may be associated with risk of hospitalization and death for patients with heart failure., Importance Adherence to telemonitoring may be associated with heart failure exacerbation but is not included in telemonitoring algorithms. Objective To assess whether telemonitoring adherence is associated with a patient’s risk of hospitalization, emergency department visit, or death. Design, Setting, and Participants This post hoc secondary analysis of the Better Effectiveness After Transition–Heart Failure randomized clinical trial included patients from 6 academic medical centers in California who were eligible if they were hospitalized for decompensated heart failure and excluded if they were discharged to a skilled nursing facility, were expected to improve because of a medical procedure, or did not have the cognitive or physical ability to participate. The trial compared a telemonitoring intervention with usual care for patients with heart failure after hospital discharge from October 12, 2011, to September 30, 2013. Data analysis was performed from November 8, 2016, to May 10, 2019. Interventions The intervention group (n = 722) received heart failure education, telephone check-ins, and a wireless telemonitoring system that allowed the patient to transmit weight, blood pressure, heart rate, and selected symptoms. The control group (n = 715) received usual care. Patients were followed up for 180 days after discharge. Main Outcomes and Measures The main outcome was within-person risk of hospitalization, emergency department visit, or death by week during the study period. Poisson regression was used to determine the within-person association of adherence to daily weighing with the risk of experiencing these events in the following week. Results Among the 538 participants (mean [SD] age, 70.9 [14.1] years; 287 [53.8%] male; 269 [50.7%] white) in the present analysis, adherence was lowest during the first week after enrollment but steadily increased, peaking between days 26 and 60 at 69%, or 371 transmissions. Adherence to weight telemonitoring was associated with events in the following week; an increase in adherence by 1 day was associated with a 19% decrease in the rate of death in the following week (incidence rate ratio, 0.81; 95% CI, 0.73-0.90) and an 11% decrease in the rate of hospitalization (incidence rate ratio, 0.89; 95% CI, 0.86-0.91). Adherence in the previous week was not associated with reduced rates of emergency department visits (incidence rate ratio, 0.95; 95% CI, 0.90-1.02). Conclusions and Relevance In this study, lower adherence to weight telemonitoring in a given week was associated with an increased risk of subsequent hospitalization or death in the following week. It is unlikely that this is a result of the telemonitoring intervention; rather, adherence may be an important factor associated with a patient’s health status., This post hoc secondary analysis of a randomized clinical trial of patients with decompensated heart failure assesses whether telemonitoring adherence is associated with risk of hospitalization, emergency department visit, or death.

ObjectiveTo identify factors associated with the ABCDEF bundle (Assess, prevent, and manage pain, Both, spontaneous awakening and breathing trials, Choice of sedation/analgesia, Delirium assess, prevent and manage, Early mobility/exercise and Family engagement/empowerment) adherence, in critically ill patients during the first 96hours of mechanical ventilation.DesignObservational study using electronic health record data.Setting15 intensive care units located in seven community hospitals in a western United States health system.Patients977 adult patients who were on mechanical ventilation for greater than 24hours and admitted to an intensive care unit over six months.Measurements and main resultsMultiple regression analysis was used to examine factors contributing to bundle adherence while adjusting for severity of illness, days on mechanical ventilation, hospital site and time elapsed. ABCDEF bundle adherence was higher in patients on mechanical ventilation for less than 48hours (p=0.01), who received continuous sedation for less than 24hours (p&nbsp

PURPOSE: Reducing acute care use is an important strategy for improving value in cancer care. However, little information is available to describe and compare population-level hospital use across cancer types. Our aim was to estimate unplanned hospitalization rates and to describe the reasons for hospitalization in a population-based cohort recently diagnosed with cancer. MATERIALS AND METHODS: California Cancer Registry data linked with administrative inpatient data were used to examine unplanned hospitalization among individuals diagnosed with cancer between 2009 and 2012 (n = 412,850). Hospitalizations for maintenance chemotherapy, radiotherapy, or planned surgery were excluded. Multistate models were used to estimate age-adjusted unplanned hospitalization rates, accounting for survival. RESULTS: Approximately 67% of hospitalizations in the year after diagnosis were unplanned, 35% of newly diagnosed individuals experienced an unplanned hospitalization, and 67% of unplanned hospitalizations originated in the emergency department (ED). Nonmalignancy principal diagnoses most frequently associated with unplanned hospitalization included infection (15.8%) and complications of a medical device or care (6.5%). Unplanned hospitalization rates were highest for individuals with hepatobiliary or pancreatic cancer (2.08 unplanned hospitalizations per person-year at risk), lung cancer (1.58 unplanned hospitalizations), and brain or CNS cancer (1.47 unplanned hospitalizations), and were lowest among individuals with prostate cancer (0.18 unplanned hospitalizations) and melanoma (0.25 unplanned hospitalizations). CONCLUSION: The population burden of unplanned hospitalization among individuals newly diagnosed with cancer is substantial. Many unplanned hospitalizations originate in the ED and are associated with potentially preventable admission diagnoses. Efforts to reduce unplanned hospitalization might target subgroups at higher risk and focus on the ED as a source of admission.

This study aimed to evaluate a quality metric that identifies pediatric potentially avoidable transfers from diagnosis and procedure codes. Using physician medical record review as the gold standard, the following steps were used: (1) develop the initial metric definition, (2) estimate initial metric definition operating characteristics, (3) refine this definition to optimize the c-statistic, and (4) validate this optimized metric definition using a separate sample. The initial metric using Sample A patient transfers had a c-statistic of 0.63 (95% confidence interval = 0.53-0.73). Following 22 revisions, the optimized metric definition was a transfer discharged within 24 hours that did not receive any of a select list of 60 268 specialized diagnoses or procedures. The optimized metric on Sample B demonstrated a sensitivity of 80.6%, specificity of 85.7%, and c-statistic of 0.83 (95% confidence interval = 0.75-0.91). The quality metric developed and validated in this study demonstrated satisfactory operating characteristics, providing a feasible means to measure this important outcome.

Background Traditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these 2 methods might not overlap. Study Design This is a retrospective observational study of all hospitalizations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event (PSIs 03, 05 to 15) identified by surgery faculty and residents for review by departmental M&M conference or administrative data (according to AHRQ, version 6.0). Pediatric cases were excluded. We analyzed the degree to which these 2 processes captured PSI-defined events and reasons for exclusion by each process. Results Among 6,563 surgical hospitalizations, 647 hospitalizations (9.9%) had at least 1 complication identified by the M&M process or the PSIs (or both). Of these hospitalizations, 116 had at least 1 PSI-defined event (for a total of 149 PSI-defined events) captured by either M&M or the PSIs. Most complications (n = 82 [88.2%]) identified by M&M alone were excluded by PSI criteria (as intended), but 11 true PSI events (ie false negatives) were identified by M&M only. In contrast, pressure ulcers and central venous catheter-related bloodstream infections were detected exclusively by the PSIs and not reported via M&M. There was limited overlap, with 18 events (12.1%) captured by both processes. Conclusions Surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.

BACKGROUND Failure-to-rescue (FTR), originally developed to study quality of care in surgery, measures an institution's ability to prevent death after a patient becomes complicated. OBJECTIVES Develop an FTR metric modified to analyze acute myocardial infarction (AMI) outcomes. RESEARCH DESIGN Split-sample design: a random 20% of hospitals to develop FTR definitions, a second 20% to validate test characteristics, and an out-of-sample 60% to validate results. SUBJECTS Older Medicare beneficiaries admitted to short-term acute-care hospitals for AMI between 2009 and 2011. MEASURES Thirty-day mortality and FTR rates, and in-hospital complication rates. RESULTS The 60% out-of-sample validation included 234,277 patients across 1142 hospitals that admitted at least 50 patients over 2.5 years. In total, 72.1% of patients were defined as Medically Complicated (complex on admission or subsequently developed a complication or died without a recorded complication) of whom 19.3% died. Spearman r between hospital risk-adjusted 30-day mortality and FTR was 0.89 (P

Objective To determine the association between potentially avoidable transfers (PATs) and emergency department (ED) pediatric readiness scores and the score's associated components. Study design This cross-sectional study linked the 2012 National Pediatric Readiness Project assessment with individual encounter data from California's statewide ED and inpatient databases during the years 2011-2013. A probabilistic linkage, followed by deterministic heuristics, linked pre-transfer and post-transfer encounters. Applying previously published definitions, a transferred child was considered a PAT if they were discharged within one day from the ED or inpatient care and had no specialized procedures. Analyses were stratified by injured and non-injured children. We compared PATs with necessary transfers using mixed-effects logistic regression models with random intercepts for hospital and adjustment for patient and hospital covariates. Results After linkage, there were 6675 injured children (27% PATs) and 18 793 non-injured children (14% PATs) who presented to 283 hospitals. In unadjusted analyses, a ten-point increase in pediatric readiness was associated with lower odds of PATs in both injured (OR: 0.93, 95% CI: 0.90-0.96) and non-injured children (OR: 0.90, 95% CI: 0.88-0.93). In adjusted analyses, a similar association was detected in injured patients (aOR: 0.92, 95% CI: 0.86-0.98) and was not detected in non-injured patients (aOR: 0.94, 95% CI 0.88-1.00). Components associated with decreased PATs included having a nurse pediatric emergency care coordinator and a quality improvement plan. Conclusions Hospital ED pediatric readiness is associated with lower odds of a PAT. Certain pediatric readiness components are modifiable risk factors that EDs could target to reduce PATs.

BackgroundHospital-acquired pressure injuries (HAPIs) are publicly reported in the USA and used to adjust Medicare payment to acute inpatient facilities. Current methods used to identify HAPIs in administrative claims rely on hospital-reported present-on-admission (POA) data instead of prior patient health information.ObjectiveTo study the reliability of claims data for HAPIs and pressure injury (PI) stage by evaluating diagnostic coding agreement across interfacility transfers.MethodsUsing the 2012 100% Medicare Provider and Analysis Review file, we identified all fee-for-service acute inpatient discharge records with a PI diagnosis among Medicare patients 65 years and older. We then identified additional facility claims (eg, acute inpatient, long-stay inpatient or skilled nursing facility) belonging to the same patient who had either (1) admission within 1day of hospital discharge or (2) discharge within 1day of hospital admission. Multivariable logistic regression and stratified kappa statistics were used to measure coding agreement between transferring and receiving facilities in the presence or absence of a PI diagnosis at the time of patient transfer and PI stage category (early vs advanced).ResultsIn our comparison of claims data between transferring and receiving facilities, we observed poor agreement in the presence or absence of a PI diagnosis at the time of transfer (36.3%, kappa=0.03) and poor agreement in PI stage category (74.3%, kappa=0.17). Among transfers with a POA PI reported by the receiving hospital, only 34.0% had a PI documented at the prior transferring facility.ConclusionsThe observed discordance in PI documentation and staging between transferring and receiving facilities may indicate inaccuracy of HAPI identification in claims data. Future research should evaluate the accuracy of hospital-reported POA data and its impact on PI quality measurement.

ObjectiveStudies evaluating major amputation after initial minor amputation are few with rates of subsequent major amputation ranging from 14% to 35% with limited understanding of associated comorbidities and time to limb loss. The aim of this study is to determine the major amputation rates for patients who had already undergone an initial minor amputation and determine which factors are associated with the need for subsequent major amputation.MethodsUsing statewide data between 2005 and 2013, patients with peripheral artery disease (PAD), diabetes mellitus (DM), and combined PAD/DM who had a lower extremity ulcer and who had also undergone a minor amputation were identified. These patients were evaluated for the rate of subsequent major amputation and competing risk Cox proportional hazards modeling was used to study which factors were associated with the risk of subsequent limb loss.ResultsThe cohort consisted of 11,597 patients (DM, n= 4254; PAD, n= 2142; PAD/DM, n= 5201) with lower extremity ulcers who underwent an initial minor amputation. The rate of any subsequent amputation was highest in patients with PAD/DM (23% vs DM= 17%, PAD= 17%; P= not statistically significant). The rate of subsequent minor amputation was 16% in the PAD/DM versus 15.2% in PAD and 12.2% in patients with DM (P< .001). Patients with PAD/DM had the highest rate of subsequent major amputation (6.3% vs DM= 5.2%, PAD= 2.1%; P< .001). There was no statistically significant difference in the median time to major amputation among the three groups (PAD/DM, 13months; DM, 14months; PAD, 8.6months; P= NS). Patients who were revascularized before a repeat minor amputation had a decreased risk of a major amputation compared with those who were intervened on after a repeat minor amputation (hazard ratio, 0.002; 95% confidence interval, 0-0.22). Patients treated completely in the outpatient setting were also less likely to undergo subsequent major amputation (hazard ratio, 0.7; 95% confidence interval, 0.5-0.98) compared with those who required hospitalization or presented to the emergency room.ConclusionsPatients with ulcers and combined PAD and DM have a higher risk for secondary major and minor amputation than patients with either disease alone with half of the limb loss occurring at approximately 1year after the initial minor amputation. Additionally, early diagnosis and appropriate referral may result in decreased limb loss for these patients.

The 30-day all-cause readmission rate following coronary artery bypass graft (CABG) surgery is considered an important outcome measure for patients because higher rates can be an indicator of low quality and unnecessary health care costs. Our research uses rigorous methods to explore the impact of mandatory public reporting of all-cause readmission rates following CABG surgery in California. We used a hierarchical logistic regression model on 173, 823 CABG patient records. This model standardised outcomes across 10 U.S. states that were not previously comparable due to different CABG definitions and metrics. Additionally, in order to account for the differences in medical practice across different states, we applied a differencein-difference method to estimate the impact of public reporting. Finally, a recycled prediction method was used to estimate the number of averted readmissions following public reporting initiation in California.

Background The CardioMEMS HF system is a remote monitoring device that allows patients to transmit pulmonary artery pressure readings to providers, who are alerted when pressures increase above the patient's normal threshold. Objectives The purpose of this study was to gain a better understanding of patient adherence to the CardioMEMS system and to compare patients’ self-reported use of the system with actual adherence. Methods We conducted semi-structured interviews with patients who had a CardioMEMS device. Transcripts were analyzed using a combination of structural and process coding. Results Patients engaged with the CardioMEMS system in a reciprocal manner, continually learning from the feedback provided by the system. Self-concept influenced the way that patients adhere. Conclusions Patients experience many benefits of the CardioMEMS system; however, it is not clear that these perceived or real benefits affect how a person adheres. Rather, our findings suggest that a person's self-concept may be a better predictor of adherence to telemonitoring systems.

Background: Critical limb ischemia remains a difficult disease to treat, with limited level one data. The BEST-CLI trial (Best Endovascular vs Best Open Surgical Therapy in Patients with Critical Limb Ischemia) is attempting to answer whether initial treatment with open surgical bypass or endovascular therapy improves outcomes, although it remains in enrollment. This study aims to compare amputation-free survival and reintervention rates in patients treated with initial open surgical bypass or endovascular intervention for ischemic ulcers of the lower extremities. Methods and Results: Using California nonfederal hospital data linked to statewide death data, all patients with lower extremity ulcers and a diagnosis of peripheral artery disease who underwent a revascularization procedure from 2005 to 2013 were identified. Propensity scores were formulated from baseline patient characteristics. Inverse probability weighting was used with Kaplan–Meier analysis to determine amputation-free survival and time to reintervention for open versus endovascular treatment. Mixed-effects Cox proportional hazards modeling was used to adjust for patient ability to manage their disease and hospital revascularization volume. A total of 16 800 patients were identified. Open surgical bypass was the initial treatment in 5970 (36%) while 10 830 (64%) underwent endovascular interventions. Patients in the endovascular group were slightly younger compared with the open group (70 versus 71 years, ±12 years; P P values Conclusions: Patients with critical limb ischemia have multiple comorbidities, and initial surgical bypass is associated with poorer amputation-free survival compared with an endovascular-first approach, perhaps due to increased severity of wounds at the time of presentation.

ObjectiveTo determine whether outcomes achieved by new surgeons are attributable to inexperience or to differences in the context in which care is delivered and patient complexity.BackgroundAlthough prior studies suggest that new surgeon outcomes are worse than those of experienced surgeons, factors that underlie these phenomena are poorly understood.MethodsA nationwide observational tapered matching study of outcomes of Medicare patients treated by new and experienced surgeons in 1221 US hospitals (2009-2013). The primary outcome studied is 30-day mortality. Secondary outcomes were examined.ResultsIn total, 694,165 patients treated by 8503 experienced surgeons were matched to 68,036 patients treated by 2119 new surgeons working in the same hospitals. New surgeons' patients were older (25.8% aged ≥85 vs 16.3%,P