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1.  Reducing potentially preventable complications at the multi hospital level 
BMC Research Notes  2011;4:271.
This study describes the continuation of a program to constrain health care costs by limiting inpatient hospital programs among the hospitals of Syracuse, New York. Through a community demonstration project, it identified components of individual hospital programs for reduction of complications and their impact on the frequency and rates of these outcomes.
This study involved the implementation of interventions by three hospitals using the Potentially Preventable Complications System developed by 3M™ Health Information Systems. The program is noteworthy because it included competing hospitals in the same community working together to reduce adverse patient outcomes and related costs.
The study data identified statistically significant reductions in the frequency of high and low volume complications during the three year period at two of the hospitals. At both of these hospitals, aggregate complication rates also declined. At these hospitals, the differences between actual complication rates and severity adjusted complication rates were also reduced.
At the third hospital, specific and aggregate complication rates remained the same or increased slightly. Differences between these rates and those of severity adjusted comparison population also remained the same or increased.
Results of the study suggested that, in one community health care system, the progress of reducing complications involved different experiences. At two hospitals with relatively higher rates at the beginning of the study, management by administrative and clinical staff outside quality assurance produced significant reductions in complication rates, while at a hospital with lower rates, management by quality assurance staff had little effect on reducing the rate of PPCs.
PMCID: PMC3160398  PMID: 21801385
2.  Inpatient hospital complications and lengths of stay: a short report 
BMC Research Notes  2011;4:135.
Increasingly, efforts are being made to link health care outcomes with more efficient use of resources. The current difficult economic times and health care reform efforts provide incentives for specific efforts in this area.
This study defined relationships between inpatient complications for urinary tract infection and pneumonia and hospital lengths of stay in three general hospitals in the metropolitan area of Syracuse, New York. It employed the Potentially Preventable Complications (PPC) software developed by 3M™ Health Information Services to identify lengths of stay for patients with and without urinary tract infection and pneumonia. The patient populations included individuals assigned to the same All Patients Refined Diagnosis Related Groups and severity of illness. The comparisons involved two nine month periods in 2008 and 2009.
The study demonstrated that patients who experienced the complications had substantially longer inpatient hospital stays than those who did not. Patients with a PPC of urinary tract infection stayed a mean of 8.9 - 11.9 days or 161 - 216 percent longer than those who did not for the two time periods. This increased stay produced 2,020 - 2,427 additional patient days.
The study demonstrated that patients who experienced the complications had substantially longer inpatient hospital stays than those who did not. Patients with a PPC of pneumonia stayed a mean of 13.0 - 16.3 days or 232 - 281 percent longer than those who did not for the two time periods. This increased stay produced 2,626 - 3,456 additional patient days. Similar differences were generated for median lengths of stay.
The differences in hospital stays for patients in the same APR DRGs and severity of illness with and without urinary tract infection and pneumonia in the Syracuse hospitals were substantial. The additional utilization for these complications was valued at between $2,000,000 - $3,000,000 for a three month period. These differences in the use of hospital resources have important implications for reduction of health care costs among providers and payors of care.
PMCID: PMC3098808  PMID: 21545741
3.  Market Reform in New Jersey and the Effect on Mortality from Acute Myocardial Infarction 
Health Services Research  2003;38(2):515-533.
To determine whether mortality rates for patients with acute myocardial infarction (AMI) changed in New Jersey after implementation of the Health Care Reform Act, which reduced subsidies for hospital care for the uninsured and changed hospital payment to price competition from a rate-setting system based on hospital cost.
Data Sources/Study Setting
Patient discharge data from hospitals in New Jersey and New York from 1990 through 1996 and the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS).
Study Design
A comparison between states over time of unadjusted and risk-adjusted mortality and cardiac procedure rates.
Data Collection
Discharge data were obtained for 286,640 patients with the primary diagnosis of AMI admitted to hospitals in New Jersey or New York from 1990 through 1996. Records of 364,273 NIS patients were used to corroborate time trends.
Principal Findings
There were no significant differences in AMI mortality among insured patients in New Jersey relative to New York or the NIS. However, there was a relative increase in mortality of 41 to 57 percent among uninsured New Jersey patients post-reform, and their rates of expensive cardiac procedures decreased concomitantly.
The introduction of hospital price competition and reductions in subsidies for hospital care of the uninsured were associated with an increased mortality rate among uninsured New Jersey AMI patients. A relative decrease in the use of cardiac procedures in New Jersey may partly explain this finding. Additional studies should be done to identify whether other market reforms have been associated with changes in the quality of care.
PMCID: PMC1360901  PMID: 12785559
Quality of health care; health care reform, economics; financing; economics/hospital
4.  Quantitative tools for addressing hospital readmissions 
BMC Research Notes  2012;5:620.
Increased interest in health care cost containment is focusing attention on reduction of hospital readmissions. Major payors have already developed financial penalties for providers that generate excess readmissions. This subject has benefitted from the development of resources such as the Potentially Preventable Readmissions software. This process has encouraged hospitals to renew efforts to improve these outcomes. The aim of this study was to describe quantitative tools such as definitions, risk estimation, and tracking of patients for reducing hospital readmissions.
This study employed the Potentially Preventable Readmissions software to develop quantitative tools for addressing hospital readmissions. These tools included two definitions of readmissions that support identification and management of patients. They also included analytical approaches for estimation of the risk of readmission for individual patients by age, discharge status of the initial admission, and severity of illness. They also included patient specific spreadsheets for tracking of target populations and for evaluation of the impact of interventions.
The study demonstrated that quantitative tools including the development of definitions of readmissions, estimation of the risk of readmission, and patient specific spreadsheets could contribute to the improvement of patient outcomes in hospitals.
PMCID: PMC3517364  PMID: 23121730
Hospitalization; Quality assurance; Hospital readmissions
5.  Racial Variation in the Quality of Surgical Care for Prostate Cancer 
The Journal of urology  2012;188(4):1279-1285.
Difference in the quality of care may contribute to the less optimal prostate cancer treatment outcomes among Blacks compared with Whites. Our objective was to determine whether a racial quality of care gap exists in surgical care for prostate cancer, as evidenced by racial variation in the utilization of high-volume surgeons and facilities, and in certain outcome measures of care quality.
Materials and Methods
We performed cross-sectional and cohort analyses of administrative data from the Healthcare Cost and Utilization Project's all-payer State Inpatient Databases, encompassing all non-Federal hospitals in Florida, Maryland and New York State (1996-2007). Included were men 18 or older with a diagnosis of prostate cancer who underwent radical prostatectomy. We compared use of surgeons and/or hospitals in the top quartile of annual volume for this procedure, inpatient blood transfusion, complications, mortality and length of stay (LOS) between Black and White patients.
Among 105,972 cases, 81,112 (76.5%) were White, 14,006 (13.2%) were Black, 6,999 (6.6%) were Hispanic and 3,855 (3.6%) were All Other. In mixed effects multivariate models, Blacks had markedly lower use of high-volume hospitals (Odds Ratio [OR] = 0.73, 95% Confidence interval [0.70, 0.76]), and surgeons (0.67 [0.64, 0.70]) compared to Whites. Blacks also had a higher odds of receiving a blood transfusion (1.08 [1.01, 1.14]), of longer LOS (1.07 [1.06, 1.07]) and of inpatient mortality (1.73 [1.02, 2.92]).
Using an all-payer dataset, we identified concerning potential quality of care gaps between Blacks and Whites undergoing radical prostatectomy for prostate cancer.
PMCID: PMC3770766  PMID: 22902011
Health disparities; quality of care; prostate cancer; surgery
6.  Effect of Hospital Setting and Volume on Clinical Outcomes in Women with Gestational and Type 2 Diabetes Mellitus 
Journal of Women's Health  2009;18(10):1567-1576.
Efforts to improve health care outcomes in the United States have led some organizations to recommend specific hospital settings or case volumes for complex medical diagnoses and procedures. But there are few studies of the effect of setting and volume on maternal outcomes, particularly in complicated conditions, such as diabetes. Our objective was to estimate the effect of hospital setting and volume on childbirth morbidity and length of stay in pregnancies complicated by type 2 and gestational diabetes.
We analyzed Maryland hospital discharge data during 1999–2004. The dependent variables were primary cesarean delivery, episiotomy, a composite variable for severe maternal morbidity, and hospital length of stay. The independent variables were hospital setting (community, non-teaching hospitals, community, teaching hospitals, and academic medical centers) and tertiles of annual hospital diabetes delivery volume. Multivariable regression analysis was used to assess the relation of hospital setting with each outcome, adjusting for hospital volume and maternal case mix.
5,507 deliveries with type 2 (15%) and gestational (85%) diabetes were analyzed. Primary cesarean delivery rates among women with any diabetes did not vary across settings. After adjustment for volume and patient case mix, the likelihood of severe maternal morbidity was higher among deliveries at academic centers compared to community, non-teaching hospitals (odds ratio [OR], 2.1; 95% confidence interval: 1.0, 4.2). Academic centers had a protective effect (OR, 0.3; 95% CI: 0.2, 0.7) and community teaching hospitals had a borderline protective effect (OR, 0.8; 95% CI: 0.7, 1.0) on episiotomy, compared to community, non-teaching hospitals. Length of stay was greater at academic centers and community, teaching hospitals compared to community, non-teaching hospitals (5.4 days, 3.5 days vs. 2.8 days, respectively). We did not identify an independent association between hospital diabetes volume and clinical outcomes after adjustment for case mix.
Among women with type 2 and gestational diabetes, hospital setting is associated with a higher likelihood of severe maternal morbidity and length of stay, independent of volume. Patient case mix accounts for some of the variation across settings. The volume-outcome relationship found with other complex medical conditions or procedures was not found among diabetic pregnancies. Further investigations are needed to explain variations in outcomes across hospital settings and volumes.
PMCID: PMC2864466  PMID: 19764843
7.  Minimum Nurse Staffing Legislation and the Financial Performance of California Hospitals 
Health Services Research  2011;47(3 Pt 1):1030-1050.
To estimate the effect of minimum nurse staffing ratios on California acute care hospitals’ financial performance.
Data Sources/Study Setting
Secondary data from Medicare cost reports, the American Hospital Association’s (AHA) Annual Survey, and the California Office of Statewide Health Planning and Development (OSHPD) are combined from 2000 to 2006 for 203 hospitals in California and 407 hospitals in 12 comparison states.
Study Design
The study employs a difference-in-difference analytical approach. Hospitals are grouped into quartiles based on pre-regulation nurse staffing levels in adult medical-surgical and pediatric units (quartile 1 = lowest staffing). Differences in operating margin, operating expenses per day, and inpatient operating expenses per discharge for California hospitals within a staffing quartile during the period of regulation are compared to differences at hospitals in comparison states during the same period.
Data Collection/Extraction Methods
Hospital data from Medicare cost reports are merged with nurse staffing measures obtained from AHA and from OSPHD.
Principal Findings
Relative to hospitals in comparison states, operating margins declined significantly for California hospitals in quartiles 2 and 3. Operating expenses increased significantly in quartiles 1, 2 and 3.
Implementation of minimum nurse staffing legislation in California put substantial financial pressure on some hospitals.
PMCID: PMC3337946  PMID: 22150627
Nurse staffing ratios; hospitals; financial performance; California; AB394
8.  Variation in inpatient therapy and diagnostic evaluation of children with Henoch Schönlein purpura 
The Journal of pediatrics  2009;155(6):812-818.e1.
To describe variation regarding inpatient therapy and evaluation of children with Henoch Schönlein purpura (HSP) admitted to children’s hospitals across the United States.
Study design
We conducted a retrospective cohort study of children discharged with a diagnosis of HSP between 2000 and 2007 using inpatient administrative data from 36 children’s hospitals. We examined variation among hospitals in the use of medications, diagnostic tests, and intensive care services using multivariate mixed effects logistic regression models.
During the initial HSP hospitalization (N=1,988), corticosteroids were the most common medication (56% of cases), followed by opioids (36%), NSAIDs (35%), and anti-hypertensives (11%). After adjustment for patient characteristics, hospitals varied significantly in their use of corticosteroids, opioids, and NSAIDs; the use of diagnostic abdominal imaging, endoscopy, laboratory testing, and renal biopsy; and the utilization of intensive care services. By contrast, hospitals did not differ significantly regarding administration of anti-hypertensives or performance of skin biopsy.
The significant variation identified may contribute to varying HSP clinical outcomes between hospitals, warrants further investigation, and represents a potentially important opportunity to improve quality of care.
PMCID: PMC2784130  PMID: 19643437
opioids; corticosteroids; anti-hypertensives; non-steroidal anti-inflammatory drugs; adolescents; epidemiology
9.  An increase in the burden of neonatal admissions to a rural district hospital in Kenya over 19 years 
BMC Public Health  2010;10:591.
Most of the global neonatal deaths occur in developing nations, mostly in rural homes. Many of the newborns who receive formal medical care are treated in rural district hospitals and other peripheral health centres. However there are no published studies demonstrating trends in neonatal admissions and outcome in rural health care facilities in resource poor regions. Such information is critical in planning public health interventions. In this study we therefore aimed at describing the pattern of neonatal admissions to a Kenyan rural district hospital and their outcome over a 19 year period, examining clinical indicators of inpatient neonatal mortality and also trends in utilization of a rural hospital for deliveries.
Prospectively collected data on neonates is compared to non-neonatal paediatric (≤ 5 years old) admissions and deliveries' in the maternity unit at Kilifi District Hospital from January 1st 1990 up to December 31st 2008, to document the pattern of neonatal admissions, deliveries and changes in inpatient deaths. Trends were examined using time series models with likelihood ratios utilised to identify indicators of inpatient neonatal death.
The proportion of neonatal admissions of the total paediatric ≤ 5 years admissions significantly increased from 11% in 1990 to 20% by 2008 (trend 0.83 (95% confidence interval 0.45 -1.21). Most of the increase in burden was from neonates born in hospital and very young neonates aged < 7days. Hospital deliveries also increased significantly. Clinical diagnoses of neonatal sepsis, prematurity, neonatal jaundice, neonatal encephalopathy, tetanus and neonatal meningitis accounted for over 75% of the inpatient neonatal admissions. Inpatient case fatality for all ≤ 5 years declined significantly over the 19 years. However, neonatal deaths comprised 33% of all inpatient death among children aged ≤ 5 years in 1990, this increased to 55% by 2008. Tetanus 256/390 (67%), prematurity 554/1,280(43%) and neonatal encephalopathy 253/778(33%) had the highest case fatality. A combination of six indicators: irregular respiration, oxygen saturation of <90%, pallor, neck stiffness, weight < 1.5 kg, and abnormally elevated blood glucose > 7 mmol/l predicted inpatient neonatal death with a sensitivity of 81% and a specificity of 68%.
There is clear evidence of increasing burden in neonatal admissions at a rural district hospital in contrast to reducing numbers of non-neonatal paediatrics' admissions aged ≤ 5years. Though the inpatient case fatality for all admissions aged ≤ 5 years declined significantly, neonates now comprise close to 60% of all inpatient deaths. Simple indicators may identify neonates at risk of death.
PMCID: PMC2965720  PMID: 20925939
10.  The Course and Correlates of High Hospital Utilization in Sickle Cell Disease: Evidence from a large, urban Medicaid Managed Care Organization 
American journal of hematology  2009;84(10):666-670.
Although most patients with sickle cell disease (SCD) are hospitalized infrequently and manage painful crises at home, a small subpopulation is frequently admitted to emergency departments and inpatient units. This small group accounts for the majority of health care expenses for patients with sickle cell disease. Using inpatient claims data from a large, urban Medicaid MCO for five consecutive years, this study sought to describe the course of high inpatient utilization (averaging four or more admissions per year enrolled for at least one year) in members with a diagnosis of sickle cell disease and a history of hospitalizations for vaso-occlusive crisis. High utilizers were compared with other members with SCD on demographics, medical and psychiatric comorbidity, and use of other health care resources. Members who were high utilizers had more diagnostic mentions of sickle cell complications than low utilizers. However, the pattern of high inpatient utilization was likely to moderate over successive years, and return to the pattern after moderation was uncommon. Despite this, a small subpopulation engaged in exceptional levels of inpatient utilization over multiple years.
PMCID: PMC2783233  PMID: 19743465
sickle cell disease; health care utilization; comorbidity
11.  Utility of Syndromic Surveillance Using Novel Clinical Data Sources 
To document the current evidence base for the use of electronic health record (EHR) data for syndromic surveillance using emergency department, urgent care clinic, hospital inpatient, and ambulatory clinical care data.
Historically, syndromic surveillance has primarily involved the use of near real-time data sent from hospital emergency department (EDs) and urgent care (UC) clinics to public health agencies. The use of data from inpatient and ambulatory settings is now gaining interest and support throughout the United States, largely as a result of the Stage 2 and 3 Meaningful Use regulations [1]. Questions regarding the feasibility and utility of applying a syndromic approach to these data sources are hampering the development of systems to collect, analyze, and share this potentially valuable information. Solidifying the evidence base and communicating the results to the public health surveillance community may help to initiate and build support for using these data to advance surveillance functions.
We conducted a literature search in the published and grey literature that scanned for relevant articles in the Google Scholar, Pub Med, and EBSCO Information Services databases. Search terms included: “inpatient/ambulatory electronic health record”; “ambulatory/inpatient/hospital/outpatient/chronic disease syndromic surveillance”; and “EHR syndromic surveillance”. Information gleaned from each article included data use, data elements extracted, and data quality indicators. In addition, several stakeholders who provided input on the September 2012 ISDS Recommendations [2] also provided articles that were incorporated into the literature review.
ISDS also invited speakers from existing inpatient and ambulatory syndromic surveillance systems to give webinar presentations on how they are using data from these novel sources.
The number of public health agencies (PHAs) routinely receiving ambulatory and inpatient syndromic surveillance data is substantially smaller than the number receiving ED and UC data. Some health departments, private medical organizations (including HMOs), and researchers are conducting syndromic surveillance and related research with health data captured in these clinical settings [2].
In inpatient settings, many of the necessary infrastructure and analytic tools are already in place. Syndromic surveillance with inpatient data has been used for a range of innovative uses, from monitoring trends in myocardial infarction in association with risk factors for cardiovascular disease [3] to tracking changes in incident-related hospitalizations following the 2011 Joplin, Missouri tornado [3].
In contrast, ambulatory systems face a need for new infrastructure, as well as pose a data volume challenge. The existing systems vary in how they address data volume and what types of encounters they capture. Ambulatory data has been used for a variety of uses, from monitoring gastrointestinal infectious disease [3], to monitoring behavioral health trends in a population, while protecting personal identities [4].
The existing syndromic surveillance systems and substantial research in the area indicate an interest in the public health community in using hospital inpatient and ambulatory clinical care data in new and innovative ways. However, before inpatient and ambulatory syndromic surveillance systems can be effectively utilized on a large scale, the gaps in knowledge and the barriers to system development must be addressed. Though the potential use cases are well documented, the generalizability to other settings requires additional research, workforce development, and investment.
PMCID: PMC3692877
Syndromic surveillance; EHR; Meaningful Use
12.  A study protocol of a randomised controlled trial incorporating a health economic analysis to investigate if additional allied health services for rehabilitation reduce length of stay without compromising patient outcomes 
Reducing patient length of stay is a high priority for health service providers. Preliminary information suggests additional Saturday rehabilitation services could reduce the time a patient stays in hospital by three days. This large trial will examine if providing additional physiotherapy and occupational therapy services on a Saturday reduces health care costs, and improves the health of hospital inpatients receiving rehabilitation compared to the usual Monday to Friday service. We will also investigate the cost effectiveness and patient outcomes of such a service.
A randomised controlled trial will evaluate the effect of providing additional physiotherapy and occupational therapy for rehabilitation. Seven hundred and twelve patients receiving inpatient rehabilitation at two metropolitan sites will be randomly allocated to the intervention group or control group. The control group will receive usual care physiotherapy and occupational therapy from Monday to Friday while the intervention group will receive the same amount of rehabilitation as the control group Monday to Friday plus a full physiotherapy and occupational therapy service on Saturday. The primary outcomes will be patient length of stay, quality of life (EuroQol questionnaire), the Functional Independence Measure (FIM), and health utilization and cost data. Secondary outcomes will assess clinical outcomes relevant to the goals of therapy: the 10 metre walk test, the timed up and go test, the Personal Care Participation Assessment and Resource Tool (PC PART), and the modified motor assessment scale. Blinded assessors will assess outcomes at admission and discharge, and follow up data on quality of life, function and health care costs will be collected at 6 and 12 months after discharge. Between group differences will be analysed with analysis of covariance using baseline measures as the covariate. A health economic analysis will be carried out alongside the randomised controlled trial.
This paper outlines the study protocol for the first fully powered randomised controlled trial incorporating a health economic analysis to establish if additional Saturday allied health services for rehabilitation inpatients reduces length of stay without compromising discharge outcomes. If successful, this trial will have substantial health benefits for the patients and for organizations delivering rehabilitation services.
Clinical trial registration number
Australian and New Zealand Clinical Trials Registry ACTRN12609000973213
PMCID: PMC2998505  PMID: 21073703
13.  The Effects of HMO Penetration on Preventable Hospitalizations 
Health Services Research  2004;39(2):345-361.
To examine the effects of health maintenance organization (HMO) penetration on preventable hospitalizations.
Data Source
Hospital inpatient discharge abstracts for 932 urban counties in 22 states from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), hospital data from American Hospital Association (AHA) annual survey, and population characteristics and health care capacity data from Health Resources and Services Administration (HRSA) Area Resource File (ARF) for 1998.
Preventable hospitalizations due to 14 ambulatory care sensitive conditions were identified using the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators. Multiple regressions were used to determine the association between preventable hospitalizations and HMO penetration while controlling for demographic and socioeconomic characteristics and health care capacity of the counties.
Principal Findings
A 10 percent increase in HMO penetration was associated with a 3.8 percent decrease in preventable hospitalizations (95 percent confidence interval, 2.0 percent–5.6 percent). Advanced age, female gender, poor health, poverty, more hospital beds, and fewer primary care physicians per capita were significantly associated with more preventable hospitalizations.
Our study suggests that HMO penetration has significant effects in reducing preventable hospitalizations due to some ambulatory care sensitive conditions.
PMCID: PMC1361011  PMID: 15032958
HMOs; preventable hospitalizations; quality of care
14.  Racial Comparison of Outcomes and Costs for Inpatient Neutropenic Patients: A Multicenter Evaluation 
Journal of Oncology Practice  2006;2(2):53-56.
Racial disparities have been reported in the care and outcome of cancer patients. We evaluated whether race would influence the cost and outcomes of inpatient neutropenic cancer patients in a multicenter study from a large health care system in the southern United States.
Data was collected on all cancer inpatients with a diagnosis code for neutropenia in a 16-hospital system between October 1, 2002, and September 30, 2003. Demographics, treatment outcomes, and costs were compared between white and minority patients. A P value less than .05 was considered statistically significant.
Two hundred seventy-nine cancer patients (0.29% of all admits) had a diagnosis of neutropenia. Demographics were similar between white and minority patients. However, minorities were more likely to be younger than whites (P = .002). With regards to outcomes, length of stay (LOS), LOS in the intensive care unit, and discharge status were not statistically different. Total hospital, medication, laboratory, radiation, surgery, and respiratory costs were also similar (P > .05), although minorities were less likely to receive myeloid colony-stimulating factors (P = .032) and more likely to have higher nursing care costs (P = .048).
In light of the escalating reports of racial disparities in cancer care, these minimal differences are encouraging.
PMCID: PMC2794609  PMID: 20871717
15.  Is follow up by specialists routinely needed after elective surgery? A controlled trial 
STUDY OBJECTIVE: To assess the benefit of planned specialist follow up appointments after elective inpatient surgery. DESIGN: This was a controlled trial, using repeated alternate allocation of time periods to the two study groups. Group 1: Planned outpatient follow up 6-12 weeks after surgery. Group 2: No planned follow up: additional written information for patients and general practitioners. SETTING: A district general hospital in the north west of England. PARTICIPANTS: 264 patients listed for one of: transurethral resection of the prostate, varicose vein surgery, cholecystectomy (open or laparoscopic), inguinal herniorraphy (open or laparoscopic). MAIN OUTCOME MEASURES: Health status, complications, return to normal activity, patient satisfaction, use and costs of primary and secondary care in the 12 weeks after surgery. MAIN RESULTS: Data were available for 212 (80%) of eligible patients. Thirty eight per cent of patients in the "no planned follow up" group were in fact seen in outpatients after their discharge. Intention to treat analysis showed that there were no significant differences between the groups for health status, complications, or time to return to normal activity. Patients in the "no planned follow up" group had significantly fewer hospital visits and costs (mean difference in visits 0.51, 95% confidence intervals 0.39 to 0.69; mean difference in hospital costs 12.75 Pounds, 9.75 Pounds to 15.50 Pounds). There were fewer primary care staff contacts and costs in the "no planned follow up" group, although this difference was not significant (mean difference = 0.61 visits, -0.13 to 1.33 visits; primary care costs difference 8.37 Pounds, -1.31 Pounds to 18.73 Pounds). Patients in the "no planned follow up group" had significantly reduced patient travel costs (mean difference 4.84 Pounds, 3.44 Pounds to 6.22 Pounds). Eighty nine (42%) patients would prefer to be followed up by both their hospital doctor and GP; 53 (25%) patients would prefer to be followed up by the hospital doctor only. There were no significant differences between the two groups in their preferences for follow up. The majority of GPs agreed with the statement that a policy of no follow up at hospital outpatients for each of the six surgical procedures would increase their workload. CONCLUSIONS: Planned outpatient appointments after uncomplicated surgery seem to be neither necessary nor cost effective. A policy of "no planned follow up" results in no increase in primary care costs, and savings in hospital and patient costs. However, many patients expected and wanted to be seen again by their surgeon and GPs were concerned that a "no follow up" policy would result in an increase in workload.
PMCID: PMC1756834  PMID: 10396473
16.  Impact of a pharmacist-prepared interim residential care medication administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and post-intervention study (MedGap Study) 
BMJ Open  2012;2(3):e000918.
To test the impact of a hospital pharmacist-prepared interim residential care medication administration chart (IRCMAC) on medication administration errors and use of locum medical services after discharge from hospital to residential care.
Prospective pre-intervention and post-intervention study.
One major acute care hospital and one subacute aged-care hospital; 128 residential care facilities (RCF) in Victoria, Australia.
428 patients (median age 84 years, IQR 79–88) discharged to a RCF from an inpatient ward over two 12-week periods.
Seven-day IRCMAC auto-populated with patient and medication data from the hospitals' pharmacy dispensing software, completed and signed by a hospital pharmacist and sent with the patient to the RCF.
Primary and secondary outcome measures
Primary end points were the proportion of patients with one or more missed or significantly delayed (>50% of prescribed dose interval) medication doses, and the proportion of patients whose RCF medication chart was written by a locum doctor, in the 24 h after discharge. Secondary end points included RCF staff and general practitioners' opinions about the IRCMAC.
The number of patients who experienced one or more missed or delayed doses fell from 37/202 (18.3%) to 6/226 (2.7%) (difference in percentages 15.6%, 95% CI 9.5% to 21.9%, p<0.001). The number of patients whose RCF medication chart was written by a locum doctor fell from 66/202 (32.7%) to 25/226 (11.1%) (difference in percentages 21.6%, 95% CI 13.5% to 29.7%, p<0.001). For 189/226 (83.6%) discharges, RCF staff reported that the IRCMAC improved continuity of care; 31/35 (88.6%) general practitioners said that the IRCMAC reduced the urgency for them to attend the RCF and 35/35 (100%) said that IRCMACs should be provided for all patients discharged to a RCF.
A hospital pharmacist-prepared IRCMAC significantly reduced medication errors and use of locum medical services after discharge from hospital to residential care.
Article summary
Article focus
Medication administration errors are common when patients are discharged from hospital to a residential care facility (RCF). In Australia, a contributing factor is the need for the patient's primary care doctor to attend the RCF at short notice to write a medication administration chart; when the doctor cannot attend, doses may be missed or delayed and a locum doctor may be called to write a medication chart.
The objective of this study was to test the impact of a hospital pharmacist-prepared residential care medication administration chart (IRCMAC) on medication administration errors and use of locum medical services after discharge from hospital.
Key messages
Provision of a hospital pharmacist-prepared IRCMAC resulted in significant reductions in missed or delayed medication doses and use of locum medical services after discharge from hospital.
RCF staff reported that the IRCMAC improved continuity of care, and primary care doctors reported that it reduced pressure on them to attend RCFs at short notice.
Strengths and limitations of this study
This is the first study to evaluate the impact of a hospital-provided IRCMAC on medication errors or use of locum medical services. Strengths were that the two study groups were well matched in terms of demographics, ward type, number of medications and number of RCFs.
The main limitations were the use of a pre-intervention and post-intervention study design and data collection via RCF staff telephone interview. However, quantitative data on medication errors and use of locum services were validated by strongly positive feedback from RCF staff and doctors and widespread uptake and ongoing use of the IRCMAC.
PMCID: PMC3367148  PMID: 22637373
17.  Variation in the use of observation status evaluation in Massachusetts acute care hospitals, 2003–2006 
Observation evaluation is an alternate pathway to inpatient admission following Emergency Department (ED) assessment.
We aimed to describe the variation in observation use and charges between acute care hospitals in Massachusetts from 2003 to 2006.
Retrospective pilot analysis of hospital administrative data. Patients discharged from a Massachusetts hospital between 2003 and 2006 after an observation visit or inpatient hospitalization for six emergency medical conditions, grouped by the Clinical Classification System (CCS), were included. Patients discharged with a primary obstetric condition were excluded. The primary outcome measure, “Observation Proportion” (pOBS), was the use of observation evaluation relative to inpatient evaluation (pOBS = n Observation/(n Observation + n Inpatient). We calculated pOBS, descriptive statistics of use and charges by the hospital for each condition.
From 2003 to 2006 the number of observation visits in Massachusetts increased 3.9% [95% confidence interval (CI) 3.8% to 4.0%] from 128,825 to 133,859, while inpatient hospitalization increased 1.29% (95% CI 1.26% to 1.31%) from 832,415 to 843,617. Nonspecific chest pain (CCS 102) was the most frequently observed condition with 85,843 (16.3% of total) observation evaluations. Observation visits for nonspecific chest pain increased 43.5% from 2003 to 2006. Relative observation utilization (pOBS) for nonspecific chest pain ranged from 25% to 95% across hospitals. Wide variation in hospital use of observation and charges was seen for all six emergency medical conditions.
There was wide variation in use of observation across six common emergency conditions in Massachusetts in this pilot analysis. This variation may have a substantial impact on hospital resource utilization. Further investigation into the patient, provider and hospital-level characteristics that explain the variation in observation use could help improve hospital efficiency.
PMCID: PMC3047847  PMID: 21373306
Emergency service; Hospital; Small-area analysis; Hospital charges; Chest pain
18.  Variation in Hospital Length of Stay: Do Physicians Adapt Their Length of Stay Decisions to What Is Usual in the Hospital Where They Work? 
Health Services Research  2006;41(2):374-394.
To test the hypothesis that physicians who work in different hospitals adapt their length of stay decisions to what is usual in the hospital under consideration.
Data Sources
Secondary data were used, originating from the Statewide Planning and Research Cooperative System (SPARCS). SPARCS is a major management tool for assisting hospitals, agencies, and health care organizations with decision making in relation to financial planning and monitoring of inpatient and ambulatory surgery services and costs in New York state.
Study Design
Data on length of stay for surgical interventions and medical conditions (a total of seven diagnosis-related groups [DRGs]) were studied, to find out whether there is more variation between than within hospitals. Data (1999, 2000, and 2001) from all hospitals in New York state were used. The study examined physicians practicing in one hospital and physicians practicing in more than one hospital, to determine whether average length of stay differs according to the hospital of practice. Multilevel models were used to determine variation between and within hospitals. A t-test was used to test whether length of stay for patients of each multihospital physician differed from the average length of stay in each of the two hospitals.
Principal Findings
There is significantly (p<.05) more variation between than within hospitals in most of the study populations. Physicians working in two hospitals had patient lengths of stay comparable with the usual practice in the hospital where the procedure was performed. The proportion of physicians working in one hospital did not have a consistent effect for all DRGs on the variation within hospitals.
Physicians adapt to their colleagues or to the managerial demands of the particular hospital in which they work. The hospital and broader work environment should be taken into account when developing effective interventions to reduce variation in medical practice.
PMCID: PMC1702523  PMID: 16584454
Length of stay; variation; hospitals; multihospital physicians
19.  Schizophrenia and potentially preventable hospitalizations in the United States: a retrospective cross-sectional study 
BMC Psychiatry  2013;13:37.
Persons with schizophrenia may face barriers to high quality primary care due to communication difficulties, cognitive impairment, lack of social support, and fragmentation of healthcare delivery services. As a result, this group may be at high risk for ambulatory care sensitive (ACS) hospitalizations, defined as hospitalizations potentially preventable by timely primary care. The goal of this study was to determine if schizophrenia is associated with overall, acute, and chronic ACS hospitalizations in the United States (US).
We conducted a retrospective cross-sectional study. Hospitalization data for the US were obtained from the Nationwide Inpatient Sample for years 2003–2008. We examined 15,275,337 medical and surgical discharges for adults aged 18–64, 182,423 of which had a secondary diagnosis of schizophrenia. ACS hospitalizations were measured using the Agency for Healthcare Research and Quality’s Prevention Quality Indicators (PQIs). We developed logistic regression models to obtain nationally-weighted odds ratios (OR) for ACS hospitalizations, comparing those with and without a secondary diagnosis of schizophrenia after adjusting for patient, hospitalization, and hospital characteristics.
Schizophrenia was associated with increased odds of hospitalization for acute ACS conditions (OR = 1.34; 95% CI: 1.31, 1.38), as well as for chronic ACS conditions characterized by short-term exacerbations. Schizophrenia was associated with decreased odds of hospitalization for diabetes mellitus long-term complications and diabetes-related lower extremity amputation, conditions characterized by long-term deterioration.
Additional research is needed to determine which individual and health systems factors contribute to the increased odds of hospitalization for acute PQIs in schizophrenia.
PMCID: PMC3599909  PMID: 23351438
Schizophrenia; Ambulatory care-sensitive condition; Preventable hospitalization; Primary care; United States
20.  Multiple approaches to assessing the effects of delays for hip fracture patients in the United States and Canada. 
Health Services Research  2000;34(7):1499-1518.
OBJECTIVE: To examine the determinants of postsurgery length of stay (LOS) and inpatient mortality in the United States (California and Massachusetts) and Canada (Manitoba and Quebec). DATA SOURCES/STUDY SETTING: Patient discharge abstracts from the Agency for Health Care Policy and Research Nationwide Inpatient Sample and from provincial health ministries. STUDY DESIGN: Descriptive statistics by state or province, pooled competing risks hazards models (which control for censoring of LOS and inpatient mortality data), and instrumental variables (which control for confounding in observational data) were used to analyze the effect of wait time for hip fracture surgery on postsurgery outcomes. DATA EXTRACTIONS: Data were extracted for patients admitted to an acute care hospital with a primary diagnosis of hip fracture who received hip fracture surgery, were admitted from home or the emergency room, were age 45 or older, stayed in the hospital 365 days or less, and were not trauma patients. PRINCIPAL FINDINGS: The descriptive data indicate that wait times for surgery are longer in the two Canadian provinces than in the two U.S. states. Canadians also have longer postsurgery LOS and higher inpatient mortality. Yet the competing risks hazards model indicates that the effect of wait time on postsurgery LOS is small in magnitude. Instrumental variables analysis reveals that wait time for surgery is not a significant predictor of postsurgery length of stay. The hazards model reveals significant differences in mortality across regions. However, both the regressions and the instrumental variables indicate that these differences are not attributable to wait time for surgery. CONCLUSIONS: Statistical models that account for censoring and confounding yield conclusions that differ from those implied by descriptive statistics in administrative data. Longer wait time for hip fracture surgery does not explain the difference in postsurgery outcomes across countries.
PMCID: PMC1975661  PMID: 10737450
21.  Specialty and Full-Service Hospitals: A Comparative Cost Analysis 
Health Services Research  2008;43(5 Pt 2):1869-1887.
To compare the costs of physician-owned cardiac, orthopedic, and surgical single specialty hospitals with those of full-service hospital competitors.
Data Sources
The primary data sources are the Medicare Cost Reports for 1998–2004 and hospital inpatient discharge data for three of the states where single specialty hospitals are most prevalent, Texas, California, and Arizona. The latter were obtained from the Texas Department of State Health Services, the California Office of Statewide Health Planning and Development, and the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. Additional data comes from the American Hospital Association Annual Survey Database.
Study Design
We identified all physician-owned cardiac, orthopedic, and surgical specialty hospitals in these three states as well as all full-service acute care hospitals serving the same market areas, defined using Dartmouth Hospital Referral Regions. We estimated a hospital cost function using stochastic frontier regression analysis, and generated hospital specific inefficiency measures. Application of t-tests of significance compared the inefficiency measures of specialty hospitals with those of full-service hospitals to make general comparisons between these classes of hospitals.
Principal Findings
Results do not provide evidence that specialty hospitals are more efficient than the full-service hospitals with whom they compete. In particular, orthopedic and surgical specialty hospitals appear to have significantly higher levels of cost inefficiency. Cardiac hospitals, however, do not appear to be different from competitors in this respect.
Policymakers should not embrace the assumption that physician-owned specialty hospitals produce patient care more efficiently than their full-service hospital competitors.
PMCID: PMC2654166  PMID: 18662170
Hospitals; specialty; cost; inefficiency; competition
22.  Accuracy of Hospital Report Cards Based on Administrative Data 
Health Services Research  2006;41(4 Pt 1):1413-1437.
Many of the publicly available health quality report cards are based on administrative data. ICD-9-CM codes in administrative data are not date stamped to distinguish between medical conditions present at the time of hospital admission and complications, which occur after hospital admission. Treating complications as preexisting conditions gives poor-performing hospitals “credit” for their complications and may cause some hospitals that are delivering low-quality care to be misclassified as average- or high-performing hospitals.
To determine whether hospital quality assessment based on administrative data is impacted by the inclusion of condition present at admission (CPAA) modifiers in administrative data as a date stamp indicator.
Design, Setting, and Patients
Retrospective cohort study based on 648,866 inpatient admissions between 1998 and 2000 for coronary artery bypass graft (CABG) surgery, coronary angioplasty (PTCA), carotid endarterectomy (CEA), abdominal aortic aneurysm (AAA) repair, total hip replacement (THR), acute MI (AMI), and stroke using the California State Inpatient Database which includes CPAA modifiers. Hierarchical logistic regression was used to create separate condition-specific risk adjustment models. For each study population, one model was constructed using only secondary diagnoses present at admission based on the CPAA modifier: “date stamp” model. The second model was constructed using all secondary diagnoses, ignoring the information present in the CPAA modifier: the “no date stamp model.” Hospital quality was assessed separately using the “date stamp” and the “no date stamp” risk-adjustment models.
Forty percent of the CABG hospitals, 33 percent of the PTCA hospitals, 40 percent of the THR hospitals, and 33 percent of the AMI hospitals identified as low-performance hospitals by the “date stamp” models were not classified as low-performance hospitals by the “no date stamp” models. Fifty percent of the CABG hospitals, 33 percent of the PTCA hospitals, 50 percent of the CEA hospitals, and 36 percent of the AMI hospitals identified as low-performance hospitals by the “no date stamp” models were not identified as low-performance hospitals by the “date stamp” models. The inclusion of the CPAA modifier had a minor impact on hospital quality assessment for AAA repair, stroke, and CEA.
This study supports the hypothesis that the use of routine administrative data without date stamp information to construct hospital quality report cards may result in the mis-identification of hospital quality outliers. However, the CPAA modifier will need to be further validated before date stamped administrative data can be used as the basis for health quality report cards.
PMCID: PMC1797077  PMID: 16899015
Administrative data; quality of care; measurement; and reporting systems
23.  HMO Coverage Reduces Variations In The Use Of Health Care Among Patients Under Age Sixty-Five 
Health affairs (Project Hope)  2010;29(11):2068-2074.
Variation in the use of hospital and physician services among Medicare beneficiaries is well documented. However, less is known about the younger, commercially insured population. Using data from the Community Tracking Study to investigate this issue, we found significant variation in the use of both inpatient and outpatient services across twelve metropolitan areas. HMO insurance reduces, but does not eliminate, the extent of this variation. Our results suggest that health plan spending to better organize delivery systems and manage care may be efficient, and regulations that arbitrarily cap plans’ spending on administration, such as minimum medical loss ratios, could undermine efforts to achieve better value in health care.
PMCID: PMC3195432  PMID: 21041750
24.  Clostridium difficile Infections among Hospitalized Children, United States, 1997–2006 
Emerging Infectious Diseases  2010;16(4):604-609.
Physicians need a better understanding of outcomes of these infections.
We evaluated the annual rate (cases/10,000 hospitalizations) of pediatric hospitalizations with Clostridium difficile infection (CDI; International Classification of Diseases, 9th revision, clinical modification code 008.45) in the United States. We performed a time-series analysis of data from the Kids’ Inpatient Database within the Health Care Cost and Utilization Project during 1997–2006 and a cross-sectional analysis within the National Hospital Discharge Survey during 2006. The rate of pediatric CDI-related hospitalizations increased from 7.24 to 12.80 from 1997 through 2006; the lowest rate was for children <1 year of age. Although incidence was lowest for newborns (0.5), incidence for children <1 year of age who were not newborns (32.01) was similar to that for children 5–9 years of age (35.27), which in turn was second only to incidence for children 1–4 years of age (44.87). Pediatric CDI-related hospitalizations are increasing. A better understanding of the epidemiology and outcomes of CDI is urgently needed.
PMCID: PMC3363321  PMID: 20350373
Clostridium difficile; bacteria; pediatric; hospital; children; epidemiology; United States; research
25.  Fluid overload is associated with increases in length of stay and hospital costs: pooled analysis of data from more than 600 US hospitals 
Fluid overload, including transfusion-associated circulatory overload (TACO), is a serious complication of fresh frozen plasma (FFP) transfusion. The incidence of fluid overload is underreported and its economic impact is unknown. An evaluation of fluid overload cases in US hospitals was performed to assess the impact of fluid overload on length and cost of hospital stay.
Study design and methods
Retrospective analysis was performed using a clinical and economic database covering >600 US hospitals. Data were collected for all inpatients discharged during 2010 who received ≥1 unit FFP during hospitalization. Incidence of fluid overload was determined through International Classification of Diagnosis (ICD-9) codes. Multivariate regression analysis was performed for primary outcome measures: hospital length of stay (LOS) and total hospital costs.
Data were analyzed for 129,839 FFP-transfused patients, of whom 4,138 (3.2%) experienced fluid overload (including TACO). Multivariate analysis, adjusting for baseline characteristics, found that increased LOS and hospital costs were independently associated with fluid overload. Patients diagnosed with fluid overload had longer mean LOS (12.9 days versus 10.0 days; P < 0.001) and higher mean hospital cost per visit ($46,644 versus $32,582; P < 0.001) compared with patients without fluid overload.
For a population of US inpatients who received FFP during hospitalization, fluid overload was associated with a 29% increase in LOS and a $14,062 increase in hospital costs per visit. These findings suggest that the incidence of fluid overload in the general population is greater than historically reported. A substantial economic burden may be associated with fluid overload in the US.
PMCID: PMC3699028  PMID: 23836999
fresh frozen plasma; fluid overload; hospital costs; hypervolemia; length of stay; transfusion-associated circulatory overload

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