2012 January 20

Urban hospital ‘clusters’ do shift high-risk procedures to key facilities, but more could be done.

Health Aff (Millwood) Start a Discussion »

Jan 202012

Urban hospital 'clusters' do shift high-risk procedures to key facilities, but more could be done.

Health Aff (Millwood). 2011 Sep;30(9):1743-50

Authors: Luke RD, Luke T, Muller N

Abstract
Since the 1990s, rapid consolidation in the hospital sector has resulted in the vast majority of hospitals joining systems that already had a considerable presence within their markets. We refer to these important local and regional systems as "clusters." To determine whether hospital clusters have taken measurable steps aimed at improving the quality of care-specifically, by concentrating low-volume, high-complexity services within selected "lead" facilities-this study examined within-cluster concentrations of high-risk cases for seven surgical procedures. We found that lead hospitals on average performed fairly high percentages of the procedures per cluster, ranging from 59 percent for esophagectomy to 87 percent for aortic valve replacement. The numbers indicate that hospitals might need to work with rival facilities outside their cluster to concentrate cases for the lowest-volume procedures, such as esophagectomies, whereas coordination among cluster members might be sufficient for higher-volume procedures. The results imply that policy makers should focus on clusters' potential for restructuring care and further coordinating services across hospitals in local areas.

PMID: 21900666 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Midregional Pro-A-Type Natriuretic Peptide for Diagnosis and Prognosis in Patients With Suspected Acute Myocardial Infarction.

Am J Cardiol Start a Discussion »

Jan 202012

Midregional Pro-A-Type Natriuretic Peptide for Diagnosis and Prognosis in Patients With Suspected Acute Myocardial Infarction.

Am J Cardiol. 2012 Jan 16;

Authors: Meune C, Twerenbold R, Drexler B, Balmelli C, Wolf C, Haaf P, Reichlin T, Irfan A, Reiter M, Zellweger C, Meissner J, Stelzig C, Freese M, Capodarve I, Mueller C

Abstract
We hypothesized that midregional pro-A-type natriuretic peptide (MR-proANP), the stable midregional epitope of proANP, might be useful in the early diagnosis and risk stratification of patients with suspected acute myocardial infarction (AMI). In this multicenter study we measured MR-proANP, cardiac troponin T (cTnT), and high-sensitive cTnT (hs-cTnT) at presentation in 675 consecutive patients presenting to the emergency department with suspected AMI. The final diagnosis was adjudicated by 2 independent cardiologists. Patients were followed 360 days for mortality and AMI. AMI was the final diagnosis in 119 patients (18%). Median MR-proANP levels at presentation were significantly higher in patients with AMI (189 pmol/L, interquartile range 97 to 341) versus patients with another final diagnosis (83 pmol/L, 49 to 144, p <0.001). However, neither the combination of MR-proANP with cTnT nor its combination with hs-cTnT significantly improved diagnostic accuracy as quantified by area under the receiver operating characteristic curve (0.91 vs 0.89 for cTnT alone, p = 0.086; 0.95 vs 0.96 for hs-cTnT, respectively, p = 0.02). Cumulative 360-day mortality/AMI rates were 2.4% in the first, 3.6% in the second, 9.5% in the third, and 18.8% in the fourth quartiles of MR-proANP (p <0.001). MR-proANP (area under the curve 0.76) predicted mortality/AMI independently of and more accurately than cTnT (area under the curve 0.62), hs-cTnT (area under the curve 0.71), and Thrombolysis In Myocardial Infarction risk score (area under the curve 0.72). Net reclassification improvements offered by the additional use of MR-proANP were 0.388 (p <0.001), 0.425 (p <0.001), and 0.217 (p = 0.007), respectively. In conclusion, MR-proANP improves risk prediction for 360-day mortality/AMI but does not seem to help in the early diagnosis of AMI.

PMID: 22257708 [PubMed - as supplied by publisher]

Link to Article at PubMed

Risk of suicide among operated and non-operated patients hospitalised for peptic ulcers.

J Epidemiol Community Health Start a Discussion »

Jan 202012

Risk of suicide among operated and non-operated patients hospitalised for peptic ulcers.

J Epidemiol Community Health. 2009 Dec;63(12):1016-21

Authors: Bahmanyar S, Sparén P, Rutz EM, Hultman CM

Abstract
BACKGROUND: Some small studies have reported high risk of suicide after surgical treatment for peptic ulcer. The aim of the present study was to explore the risk of suicide in hospitalised gastric ulcer and duodenal ulcer patients separately among operated and non-operated cohorts.
METHODS: Retrospective cohorts of 163,579 non-operated patients with gastric ulcer or duodenal ulcer and 28,112 patients with surgical treatment for ulcer, recorded in the Swedish Inpatient Register since 1965, were followed from the first hospitalisation, or operation for the surgery cohort, until death, any cancer, emigration, or 31 December 2003. Standardised mortality ratios (SMRs) were calculated, and Poisson regression produced adjusted relative risk estimates among operated and non-operated patients.
RESULTS: Non-operated patients hospitalised for peptic ulcer showed a 70% excess risk of suicide (SMR 1.7, 95% CI 1.6 to 1.9) and those who underwent operation had a 60% increased risk (SMR 1.6, 95% CI 1.4 to 1.8). The risk of suicide was very high during the first year after hospitalisation (SMR 4.0, 95% CI 3.4 to 4.7) and more marked among women, patients under 70 and patients hospitalised without complications of ulcer. Both gastric ulcer and duodenal ulcer patients had high risk of suicide completion.
CONCLUSION: Hospitalised patients with gastric ulcer or duodenal ulcer have an increased risk of suicide regardless of surgical treatment. These patients, especially women, are at very high risk during the first year after first hospitalisation/operation. The evaluation and management of suicidal thoughts in patients in medical settings should be further considered.

PMID: 19602471 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Effect of case-based training for medical residents on inpatient glycemia.

Diabetes Care Start a Discussion »

Jan 202012

Effect of case-based training for medical residents on inpatient glycemia.

Diabetes Care. 2011 Aug;34(8):1738-40

Authors: Tamler R, Green DE, Skamagas M, Breen TL, Looker HC, Babyatsky M, Leroith D

Abstract
OBJECTIVE: To determine whether an educational intervention for medical house staff improves blood glucose (BG) in hospitalized patients.
RESEARCH DESIGN AND METHODS: All 116 medicine residents at an academic medical center were assigned to online or classroom training on inpatient dysglycemia in fall 2008. Both groups were offered an online refresher course in spring 2009 addressing gaps in clinical practice identified on chart review. We assessed event BG, the first BG of any 3-h period, on two teaching wards.
RESULTS: A total of 108 residents (93.1%) completed the initial training. The primary outcome, median event BG, decreased from 152 mg/dL in August 2008 to 139 mg/dL in December 2008 (P < 0.0001). Prevalence of event BG >200 mg/dL decreased from 25.5 to 22.7% (P = 0.0207), at the expense of more event BGs <70 mg/dL (2.0-3.9%, P = 0.0124).
CONCLUSIONS: A curriculum for medicine residents on inpatient glycemia led to lower inpatient BG.

PMID: 21715520 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

A simple approach to fairer hospital benchmarking using patient experience data.

Int J Qual Health Care Start a Discussion »

Jan 202012

A simple approach to fairer hospital benchmarking using patient experience data.

Int J Qual Health Care. 2011 Oct;23(5):524-30

Authors: Holzer BM, Minder CE

Abstract
OBJECTIVE: To determine the factors contributing most to variability in patient experience in order to present approaches for fairer benchmarking of hospitals and for quality improvement.
DESIGN: Secondary analysis of data from a widely used survey on patient experience.
SETTING: Inpatients from all 24 acute hospitals in the Canton of Bern in Switzerland. Data collection followed the standardized and validated Picker Institute methodology for a period of 13 weeks in the fall/winter of 2005.
PARTICIPANTS: Inpatients age 18 years and older (n = 14 089), discharged within the sampling period.
MAIN OUTCOME MEASURES: 'Patient experience', measured by the total Picker Problem Score (PPS) and by six domain scores (care, communication, respect, cooperation, organization, discharge management).
RESULTS: In regression analysis, the patient factors self-reported health, age and education explained the highest proportion of variability in the PPS (4.8, 2.2 and 0.7%, respectively). Multiple linear adjustment for factors associated with patients removed between 29 and 33% of variability between hospital categories. The domain score means varied from under 5% for 'respect towards the patient' to 34% for 'discharge management'. Ranking of hospitals by domain scores differed from the ranking based on the total PPS.
CONCLUSIONS: Statistical adjustment for patient mix and additional stratification for some hospital factors make benchmarking using patient survey data fairer and more transparent. Use of our approach for presenting quality data may make interpretation easier for the different target groups and may enhance the relevance of such information for decision-making.

PMID: 21813509 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Risk stratification schemes, anticoagulation use and outcomes: the risk–treatment paradox in patients with newly diagnosed non-valvular atrial fibrillation.

Heart Start a Discussion »

Jan 202012

Risk stratification schemes, anticoagulation use and outcomes: the risk--treatment paradox in patients with newly diagnosed non-valvular atrial fibrillation.

Heart. 2011 Dec;97(24):2046-50

Authors: Sandhu RK, Bakal JA, Ezekowitz JA, McAlister FA

Abstract
OBJECTIVE: To examine whether warfarin use and outcomes differ across CHADS(2) and CHA(2)DS(2)-VASc risk strata for non-valvular atrial fibrillation (NVAF).
DESIGN: Population-based cohort study using linked administrative databases in Alberta, Canada.
SETTING: Inpatient and outpatient.
PATIENTS: 42,834 consecutive patients ? 20 years of age with newly diagnosed NVAF.
MAIN OUTCOME MEASURES: Cerebrovascular events and/or mortality in the first year after diagnosis.
RESULTS: Of 42,834 NVAF patients, 22.7% were low risk on the CHADS(2) risk score (0), 27.5% were intermediate risk (1), and 49.8% were high risk (? 2). The CHA(2)DS(2)-VASc risk score reclassified 16,722 patients such that 7.8% were defined low risk, 13.8% intermediate risk and 78.4% high risk. Of the elderly cohort (? 65 years) with definite NVAF visits (at least two encounters 30 days apart, n = 8780), 49% were taking warfarin within 90 days of diagnosis. Warfarin use did not differ across risk strata using either the CHADS(2) (p for trend = 0.85) or CHA(2)DS(2)-VASC (p = 0.35). In multivariable adjusted analyses, warfarin use was associated with substantially lower rates of death or cerebrovascular events for patients with CHADS(2) scores of 1 (OR 0.52, 95% CI 0.41 to 0.67) or ? 2 (OR 0.61, 95% CI 0.53 to 0.71), or CHA(2)DS(2)-VASc scores of ? 2 (OR 0.60, 95% CI 0.53 to 0.68).
CONCLUSIONS: In elderly patients with NVAF and elevated CHADS(2) or CHA(2)DS(2)-VASC scores, warfarin users exhibited lower rates of cerebrovascular events and mortality. However, warfarin use did not differ across risk strata, another example of the risk--treatment paradox in cardiovascular disease.

PMID: 22076011 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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