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Objectives This study aimed to determine whether patients in teaching hospitals are at higher risk of suffering from an adverse event during the summer trainee changeover period. Methods We performed a retrospective analysis of data from the Medicare Patient Safety Monitoring System, a medical-record abstraction-based database in the United States. Hospital admissions from 2010 to 2017 for acute myocardial infarction, heart failure, pneumonia, or a major surgical procedure were studied. Admissions were divided into nonsurgical (acute myocardial infarction, heart failure, or pneumonia) and surgical. Adverse event rates in July/August were compared with the rest of the year. Hospitals were stratified into major teaching, minor teaching, or nonteaching. Results were adjusted for patient demographics, comorbidities, and hospital characteristics. Outcomes were the adjusted odds of having at least 1 adverse event in July/August versus the rest of the year. Results We included 185,652 hospital admissions. The adjusted odds ratios (ORs) of suffering from at least one adverse event in a major teaching hospital in July/August was 0.83 (95% confidence interval [CI], 0.69-0.98) for nonsurgical patients and 1.09 (95% CI, 0.84-1.40) for surgical patients. In minor teaching hospitals, the adjusted ORs were 0.96 (95% CI, 0.88-1.04) for nonsurgical patients and 0.99 (95% CI, 0.87-1.12) for surgical patients. In nonteaching hospitals, the adjusted ORs were 0.98 (95% CI, 0.91-1.06) for nonsurgical patients and 1.10 (95% CI, 0.96-1.24) for surgical patients. Conclusions Patients admitted to teaching hospitals in July/August are not at increased risk of adverse events. These findings should reassure patients and medical educators that patients are not excessively endangered by admission to the hospital during these months.

It is known that hospitalized patients who experience adverse events are at greater risk of readmission; however, it is unknown whether patients admitted to hospitals with higher risk-standardized readmission rates had a higher risk of in-hospital adverse events.To evaluate whether patients with pneumonia admitted to hospitals with higher risk-standardized readmission rates had a higher risk of adverse events.This cross-sectional study linked patient-level adverse events data from the Medicare Patient Safety Monitoring System (MPSMS), a randomly selected medical record abstracted database, to the hospital-level pneumonia-specific all-cause readmissions data from the Centers for MedicareMedicaid Services. Patients with pneumonia discharged from July 1, 2010, through December 31, 2019, in the MPSMS data were included. Hospital performance on readmissions was determined by the risk-standardized 30-day all-cause readmission rate. Mixed-effects models were used to examine the association between adverse events and hospital performance on readmissions, adjusted for patient and hospital characteristics. Analysis was completed from October 2019 through July 2020 for data from 2010 to 2017 and from March through April 2022 for data from 2018 to 2019.Patients hospitalized for pneumonia.Adverse events were measured by the rate of occurrence of hospital-acquired events and the number of events per 1000 discharges.The sample included 46 047 patients with pneumonia, with a median (IQR) age of 71 (58-82) years, with 23 943 (52.0%) women, 5305 (11.5%) Black individuals, 37 763 (82.0%) White individuals, and 2979 (6.5%) individuals identifying as another race, across 2590 hospitals. The median hospital-specific risk-standardized readmission rate was 17.0% (95% CI, 16.3%-17.7%), the occurrence rate of adverse events was 2.6% (95% CI, 2.54%-2.65%), and the number of adverse events per 1000 discharges was 157.3 (95% CI, 152.3-162.5). An increase by 1 IQR in the readmission rate was associated with a relative 13% higher patient risk of adverse events (adjusted odds ratio, 1.13; 95% CI, 1.08-1.17) and 5.0 (95% CI, 2.8-7.2) more adverse events per 1000 discharges at the patient and hospital levels, respectively.Patients with pneumonia admitted to hospitals with high all-cause readmission rates were more likely to develop adverse events during the index hospitalization. This finding strengthens the evidence that readmission rates reflect the quality of hospital care for pneumonia.

This cross-sectional study evaluates whether hospital-specific adverse event rates are associated with hospital-specific risk-standardized 30-day episode-of-care Medicare expenditures for fee-for-service patients discharged with acute myocardial infarction, heart failure, or pneumonia., Key Points Question What is the association between 30-day episode-of-care expenditures and in-hospital adverse events? Findings This cross-sectional study of 44 807 patients, which linked the 2011 to 2016 hospital-specific risk-standardized 30-day episode-of-care expenditure data from the Centers for Medicare & Medicaid Services and medical record–abstracted in-hospital adverse event data from the Medicare Patient Safety Monitoring System, found that hospitals with high adverse event rates were more likely to have high 30-day episode-of-care Medicare expenditures for patients discharged with acute myocardial infarction, heart failure, or pneumonia. Meaning This study suggests that hospitals with higher adverse event rates are more likely to have higher costs for acute myocardial infarction, heart failure, or pneumonia., Importance Studies have shown that adverse events are associated with increasing inpatient care expenditures, but contemporary data on the association between expenditures and adverse events beyond inpatient care are limited. Objective To evaluate whether hospital-specific adverse event rates are associated with hospital-specific risk-standardized 30-day episode-of-care Medicare expenditures for fee-for-service patients discharged with acute myocardial infarction (AMI), heart failure (HF), or pneumonia. Design, Setting, and Participants This cross-sectional study used the 2011 to 2016 hospital-specific risk-standardized 30-day episode-of-care expenditure data from the Centers for Medicare & Medicaid Services and medical record–abstracted in-hospital adverse event data from the Medicare Patient Safety Monitoring System. The setting was acute care hospitals treating at least 25 Medicare fee-for-service patients for AMI, HF, or pneumonia in the United States. Participants were Medicare fee-for-service patients 65 years or older hospitalized for AMI, HF, or pneumonia included in the Medicare Patient Safety Monitoring System in 2011 to 2016. The dates of analysis were July 16, 2017, to May 21, 2018. Main Outcomes and Measures Hospitals’ risk-standardized 30-day episode-of-care expenditures and the rate of occurrence of adverse events for which patients were at risk. Results The final study sample from 2194 unique hospitals included 44 807 patients (26.1% AMI, 35.6% HF, and 38.3% pneumonia) with a mean (SD) age of 79.4 (8.6) years, and 52.0% were women. The patients represented 84 766 exposures for AMI, 96 917 exposures for HF, and 109 641 exposures for pneumonia. Patient characteristics varied by condition but not by expenditure category. The mean (SD) risk-standardized expenditures were $22 985 ($1579) for AMI, $16 020 ($1416) for HF, and $16 355 ($1995) for pneumonia per hospitalization. The mean risk-standardized rates of occurrence of adverse events for which patients were at risk were 3.5% (95% CI, 3.4%-3.6%) for AMI, 2.5% (95% CI, 2.5%-2.5%) for HF, and 3.0% (95% CI, 2.9%-3.0%) for pneumonia. An increase by 1 percentage point in the rate of occurrence of adverse events was associated with an increase in risk-standardized expenditures of $103 (95% CI, $57-$150) for AMI, $100 (95% CI, $29-$172) for HF, and $152 (95% CI, $73-$232) for pneumonia per discharge. Conclusions and Relevance Hospitals with high adverse event rates were more likely to have high 30-day episode-of-care Medicare expenditures for patients discharged with AMI, HF, or pneumonia.

Background Availability of nursing home care has declined and national efforts have been initiated to improve the quality of nursing home care in the U.S. Yet, data are limited on whether there are geographic variations in declines of availability and quality of nursing home care, and whether variations persist over time. We sought to assess geographic variation in availability and quality of nursing home care. Methods Retrospective study using Medicaid/Medicare-certified nursing home data from the Centers for Medicare & Medicaid Services, 1996–2016. Outcomes were 1) availability of all nursing home care (1996–2016), measured by the number of Medicaid/Medicare-certified beds for a given county per 100,000 population aged ≥65 years, regardless of nursing home star rating; 2) availability of 5-star nursing home care, measured by the number of Medicaid/Medicare-certified beds provided by 5-star nursing homes; and 3) utilization of nursing home beds, defined as the rate of occupied Medicaid/Medicare-certified beds among the total Medicaid/Medicare-certified beds. Results From 1999 to 2016, availability of all nursing home care declined from 4882 (standard deviation: 931) to 3480 (912) beds, per 100,000 population aged ≥65 years. Persistent geographic variation in availability of nursing home care was observed; the correlation coefficient of county-specific availabilities from 1996 to 2016 was 0.78 (95% CI 0.77–0.79). From 2011 to 2016, availability of 5-star nursing home beds increased from 658 (303) to 895 (661) per 100,000 population aged ≥65 years. The correlation coefficient for county-specific availabilities from 2011 to 2016 was 0.54 (95% CI 0.51–0.56). Availability and quality of nursing home care were not highly correlated. In 2016, the correlation coefficient for county-specific availabilities between all nursing home and 5-star nursing home beds was 0.33 (95% CI 0.30–0.36). From 1996 to 2016, the utilization of certified beds declined from 78.5 to 72.2%. This decline was consistent across all census divisions, but most pronounced in the Mountain division and less in the South-Atlantic division. Conclusion We observed persistent geographic variations in availability and quality of nursing home care. Availability of all nursing home care declined but availability of 5-star nursing home care increased. Availability and quality of nursing home care were not highly correlated. Electronic supplementary material The online version of this article (10.1186/s12877-019-1117-z) contains supplementary material, which is available to authorized users.

Objectives To evaluate national trends and geographic variation in the availability of home health care from 2002 to 2015 and identify county-specific characteristics associated with home health care. Design Observational study. Setting All counties in the United States. Participants All Medicare-certified home health agencies included in the Centers for Medicare & Medicaid Services Home Health Compare system. Measurements County-specific availability of home health care, defined as the number of available home health agencies that provided services to a given county per 100,000 population aged ≥18 years. Results The study included 15,184 Medicare-certified home health agencies that served 97% of U.S. ZIP codes. Between 2002–2003 and 2014–2015, the county-specific number of available home health agencies per 100,000 population aged ≥18 years increased from 14.7 to 21.8 and the median (inter-quartile range) population that was serviced by at least one home health agency increased from 403,605 (890,329) to 455,488 (1,039,328). Considerable geographic variation in the availability of home health care was observed. The West, North East, and South Atlantic regions had lower home health care availability than the Central regions, and this pattern persisted over the study period. Counties with higher median income, a larger senior population, higher rates of households without a car and low access to stores, more obesity, greater inactivity, and higher proportions of non-Hispanic white, non-Hispanic black, and Hispanic populations were more likely to have higher availability of home health care. Conclusion The availability of home health care increased nationwide during the study period, but there was much geographic variation.

Background.Little is known about racial and ethnic disparities in the occurrence of healthcare-associated infections (HAIs) in hospitalized patients.Objective.To determine whether racial/ethnic disparities exist in the rate of occurrence of HAIs captured in the Medicare Patient Safety Monitoring System (MPSMS).Methods.Chart-abstracted MPSMS data from randomly selected all-payer hospital discharges of adult patients (18 years old or above) between January 1, 2009, and December 31, 2011, for 3 common medical conditions: acute cardiovascular disease (composed of acute myocardial infarction and heart failure), pneumonia, and major surgery for 6 HAI measures (hospital-acquired antibiotic-associated Clostridium difficile, central line-associated bloodstream infections, postoperative pneumonia, catheter-associated urinary tract infections, hospital-acquired methicillin-resistant Staphylococcus aureus, and ventilator-associated pneumonia).Results.The study sample included 79,019 patients who had valid racial/ethnic information divided into 6 racial/ethnic groups—white non-Hispanic (n = 62,533), black non-Hispanic (n = 9,693), Hispanic (n = 4,681), Asian (n = 1,225), Native Hawaiian/Pacific Islander (n = 94), and other (n = 793)—who were at risk for at least 1 HAI. The occurrence rate for HAIs was 1.1% for non-Hispanic white patients, 1.3% for non-Hispanic black patients, 1.5% for Hispanic patients, 1.8% for Asian patients, 1.7% for Native Hawaiian/Pacific Islander patients, and 0.70% for other patients. Compared with white patients, the age/gender/comorbidity-adjusted odds ratios of occurrence of HAIs were 1.1 (95% confidence interval [CI], 0.99-1.23), 1.3 (95% CI, 1.15-1.53), 1.4 (95% CI, 1.07-1.75), and 0.7 (95% CI, 0.40-1.12) for black, Hispanic, Asian, and a combined group of Native Hawaiian/Pacific Islander and other patients, respectively.Conclusions.Among patients hospitalized with acute cardiovascular disease, pneumonia, and major surgery, Asian and Hispanic patients had significantly higher rates of HAIs than white non-Hispanic patients.

Background Little is known regarding the relationship between hospital performance on adverse event rates and hospital performance on 30‐day mortality and unplanned readmission rates for Medicare fee‐for‐service patients hospitalized for acute myocardial infarction ( AMI ). Methods and Results Using 2009–2013 medical record‐abstracted patient safety data from the Agency for Healthcare Research and Quality's Medicare Patient Safety Monitoring System and hospital mortality and readmission data from the Centers for Medicare & Medicaid Services, we fitted a mixed‐effects model, adjusting for hospital characteristics, to evaluate whether hospital performance on patient safety, as measured by the hospital‐specific risk‐standardized occurrence rate of 21 common adverse event measures for which patients were at risk, is associated with hospital‐specific 30‐day all‐cause risk‐standardized mortality and unplanned readmission rates for Medicare patients with AMI . The unit of analysis was at the hospital level. The final sample included 793 acute care hospitals that treated 30 or more Medicare patients hospitalized for AMI and had 40 or more adverse events for which patients were at risk. The occurrence rate of adverse events for which patients were at risk was 3.8%. A 1% point change in the risk‐standardized occurrence rate of adverse events was associated with average changes in the same direction of 4.86% points (95% CI , 0.79–8.94) and 3.44% points (95% CI , 0.19–6.68) for the risk‐standardized mortality and unplanned readmission rates, respectively. Conclusions For Medicare fee‐for‐service patients discharged with AMI , hospitals with poorer patient safety performance were also more likely to have poorer performance on 30‐day all‐cause mortality and on unplanned readmissions.

BACKGROUND The optimum international normalized ratio (INR) monitoring frequency for hospitalized patients receiving warfarin is unknown. OBJECTIVE Assess relationship between daily versus less frequent INR monitoring and overanticoagulation and warfarin-related adverse events. DESIGN Retrospective cohort study using Medicare Patient Safety Monitoring System data. SETTING Randomly selected acute care hospitals across the United States. PATIENTS Patients hospitalized from 2009 to 2013 for pneumonia, acute cardiac disease, or surgery who received warfarin. INTERVENTIONS None. MEASUREMENTS (1) Association between frequency of INR monitoring and an INR ≥6.0 or warfarin-related adverse event. (2) Association between the rate of change of the INR and a subsequent INR ≥5.0 and ≥6.0. RESULTS Among 8529 patients who received warfarin for ≥3 days, for 1549 (18.2%) the INR was not measured on 2 or more days. These patients had higher propensity-adjusted odds ratios (ORs) of having a warfarin-associated adverse event (OR: 1.48, 95% confidence interval [CI]: 1.02-2.17) for cardiac patients and surgical patients (OR: 1.73, 95% CI: 1.20-2.48), with no significant association for pneumonia patients. Cardiac and pneumonia patients with 1 day or more without an INR measurement had higher propensity-adjusted ORs of having an INR ≥6.0 (OR: 1.61, 95% CI: 1.07-2.41 and OR: 1.92, 95% CI: 1.36-2.71, respectively). A 1-day increase in the INR of ≥0.9 occurred in 621 patients (12.5%) and predicted a subsequent INR of ≥6.0 (positive likelihood ratio of 4.2). CONCLUSION Daily INR measurement and recognition of a rapidly rising INR might decrease the frequency of warfarin-associated adverse events in hospitalized patients. Journal of Hospital Medicine 2016;11:276–282. © 2015 Society of Hospital Medicine

Objective To describe and evaluate the impact of quality improvement (QI) support provided to skilled nursing facilities (SNFs) by a Quality Improvement Organization (QIO). Design Retrospective, mixed-method, process evaluation of a QI project intended to decrease preventable hospital readmissions from SNFs. Setting Five SNFs in Connecticut. Participants SNF Administrators, Directors of Nursing, Assistant Directors of Nursing, Admissions Coordinators, Registered Nurses, Certified Nursing Assistants, Receptionists, QIO Quality Improvement Consultant. Intervention QIO staff provided training and technical assistance to SNF administrative and clinical staff to establish or enhance QI infrastructure and implement an established set of QI tools [Interventions to Reduce Acute Care Transfers (INTERACT) tools]. Measurements Baseline SNF demographic, staffing, and hospital readmission data; baseline and follow-up SNF QI structure (QI Committee), processes (general and use of INTERACT tools), and outcome (30-day all-cause hospital readmission rates); details of QIO-provided training and technical assistance; QIO-perceived barriers to quality improvement; SNF leadership-perceived barriers, accomplishments, and suggestions for improvement of QIO support. Results Success occurred in establishing QI Committees and targeting preventable hospital readmissions, as well as implementing INTERACT tools in all SNFs; however, hospital readmission rates decreased in only 2 facilities. QIO staff and SNF leaders noted the ongoing challenge of engaging already busy SNF staff and leadership in QI activities. SNF leaders reported that they appreciated the training and technical assistance that their institutions received, although most noted that additional support was needed to bring about improvement in readmission rates. Conclusion This process evaluation documented mixed clinical results but successfully identified opportunities to improve recruitment of and provision of technical support to participating SNFs. Recommendations are offered for others who wish to conduct similar projects.

Objective.To define the relationships between age, sex and hospital-acquired infection (HAI) rates in a national cohort of hospitalized patients.Methods.Analysis of chart-abstracted Medicare Patient Safety Monitoring System data from randomly selected medical records of patients hospitalized between January 1, 2009, and December 31, 2011, for acute cardiovascular disease, pneumonia, or major surgery associated with 1 of 6 HAIs. Patients were stratified into 6 groups. We then analyzed the association of age, sex, and 2 outcomes; the rate of occurrence of HAI for patients who were at risk and the rate of patients having at least 1 HAI.Results.Among 85,461 patients, all groups except younger female surgical patients had higher catheter-associated urinary tract infection (CAUTI) rates than male patients. After adjustment for comorbidities, there was no overall evidence of higher HAI rates among elderly patients. In patients with acute cardiovascular disease, women had higher rates of HAIs. Among patients with pneumonia, there was no significant difference in the rate of HAIs among most age and sex groups. Among surgical patients, all age and sex groups had a significantly higher adjusted rate of developing at least 1 HAI except females 65 years of age or older. Similar results were seen for the outcome of the occurrence rate of HAIs.Conclusions.There was not an overall increased risk of HAIs among older patients hospitalized for acute cardiovascular disease, pneumonia, and major surgery after adjustment for comorbidities. The relationship between sex and the rate of HAIs varied depending upon the underlying acute reason for hospitalization.