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PubMed2000

Acute myocardial infarction in the Brazilian State of São Paulo. In-hospital deaths from 1979 to 1996 and hospital fatality from 1984 to 1998 in the public health system.

OBJECTIVE: To determine the following parameters in the Brazilian State of São Paulo: 1) the percentage of deaths due to acute myocardial infarction (AMI) occurring in hospitals; 2) the percentage of deaths due to AMI occurring in public health system hospitals as compared with all in-hospital deaths due to AMI between 1979 and 1996; 3) the fatality due to AMI in public health system hospitals from 1984 to 1998. METHODS: Data were available on the Datasus Web site (the health information agency of the Brazilian Department of Health) that provided the following: a) number of deaths resulting from AMI in hospitals; b) number of deaths resulting from AMI in public health system hospitals; c) number of hospital admissions due to AMI in public health system hospitals. RESULTS: The percentage of in-hospital deaths due to AMI increased from 54.9 in 1979 to 68.6 in 1996. The percentage contribution of the public health system to total number of deaths due to AMI occurring in hospitals decreased from 22.9 in 1984 to 13.7 in 1996; fatality due to AMI occurring in public health system hospitals had an irregular evolution from 1984 to 1992 and showed a slight trend for increased frequency from 1993 to 1998. CONCLUSION: The percentage of in-hospital deaths due to AMI has been increasing. Deaths resulting from AMI in public health system hospitals have decreased when compared with the total number of deaths due to AMI in all hospitals. Fatality due to AMI in public health system hospitals did not decrease from 1992 to 1998.

Journal Article↗

PubMed2000

Acute myocardial infarction in the Brazilian State of Sao Paulo. In-hospital deaths from 1979 to 1996 and hospital fatality from 1984 to 1998 in the public health system

OBJECTIVE: To determine the following parameters in the Brazilian State of Sao Paulo: 1) the percentage of deaths due to acute myocardial infarction (AMI) occurring in hospitals; 2) the percentage of deaths due to AMI occurring in public health system hospitals as compared with all in-hospital deaths due to AMI between 1979 and 1996; 3) the fatality due to AMI in public health system hospitals from 1984 to 1998. METHODS: Data were available on the Datasus Web site (the health information agency of the Brazilian Department of Health) that provided the following: a) number of deaths resulting from AMI in hospitals; b) number of deaths resulting from AMI in public health system hospitals; c) number of hospital admissions due to AMI in public health system hospitals. RESULTS: The percentage of in-hospital deaths due to AMI increased from 54.9 in 1979 to 68.6 in 1996. The percentage contribution of the public health system to total number of deaths due to AMI occurring in hospitals decreased from 22.9 in 1984 to 13.7 in 1996; fatality due to AMI occurring in public health system hospitals had an irregular evolution from 1984 to 1992 and showed a slight trend for increased frequency from 1993 to 1998. CONCLUSION: The percentage of in-hospital deaths due to AMI has been increasing. Deaths resulting from AMI in public health system hospitals have decreased when compared with the total number of deaths due to AMI in all hospitals. Fatality due to AMI in public health system hospitals did not decrease from 1992 to 1998.

Journal Article↗

PubMedDate not supplied

Antimicrobial resistance patterns among urine isolates from patients in a geriatric hospital and from older patients in a general hospital in Jerusalem.

INTRODUCTION AND RATIONALE: Urinary tract infection is the most common cause of nosocomial infections in patients hospitalized in chronic care facilities. The changing spectrum of microorganisms involved in urinary tract infections and the emerging resistance require continuous monitoring to provide crucial information to guide empirical therapy and encourage prudent use of antibiotics. The aim of this survey was to assess the antimicrobial resistance profile of urine isolates from patients hospitalized in a geriatric hospital and from elderly patients hospitalized in an acute care hospital in order to guide empirical therapy of urinary tract infections. METHODS: The survey was performed in two hospitals in Jerusalem: a university-affiliated geriatric hospital- Herzog -and an acute secondary- and tertiary-care university hospital- Hadassah. We performed a retrospective analysis of antimicrobial resistance of all positive urine cultures obtained from patients in the geriatric division of Herzog Hospital and from patients aged 65 years and older hospitalized in the Internal Medicine departments in Hadassah Hospital during a 1-year period. RESULTS: The most common bacteria isolated from urine specimens in Herzog Hospital were, in order of frequency, Escherichia coli, Proteus mirabilis, and Pseudomonas aeruginosa. We demonstrated a high rate of antimicrobial resistance of those bacteria in both hospitals. The pattern we observed necessitates recommending ceftazidime as the most appropriate empirical therapy for urinary tract infection in Herzog Hospital. In Hadassah Hospital we recommend cefuroxime for those patients in good general condition and ceftazidime for those who present with clinical sepsis. Antimicrobial resistance patterns should be assessed periodically and recommendations modified accordingly. Infection control guidelines should be implemented in order to try to decrease the rate of antimicrobial resistance. Further research is requested to assess the efficacy of such interventions in long-term care facilities.

Journal Article↗

PubMed1994

Treatment of infants with indirect hyperbilirubinemia. Readmission to birth hospital vs nonbirth hospital.

BACKGROUND/OBJECTIVE: Indirect hyperbilirubinemia is a common cause for readmission to a hospital during the first week of life. Many newborn nurseries are ill equipped to readmit such newborns. The purpose of this study was to compare the care and treatment of infants with indirect hyperbilirubinemia who were readmitted to their birth hospital with those who were admitted to a hospital that differed from their birth hospital. DESIGN: Retrospective cohort study. SETTING: Children's and community hospitals. PATIENTS: We reviewed the records of 100 newborns who were readmitted during the first week of life (36 were readmitted to their birth hospital) with a primary admission diagnosis of indirect hyperbilirubinemia. RESULTS: Infants who were admitted to their birth hospital were less likely to have blood cultures (none of 36 vs 17 of 64, P = .0005), urine cultures (none of 36 vs eight of 64, P = .02), or more than one complete blood cell count (two of 36 vs 18 of 64, P = .001) performed compared with infants who were admitted to a nonbirth hospital. Antibiotic, intravenous therapy (P = .0005), and emergency department (P = .0001) use was more common among infants who were admitted to a nonbirth hospital. Infants who were admitted through the emergency department at a nonbirth hospital had phototherapy started later (mean +/- SD, 5.3 +/- 1.6 vs 2.2 +/- 1.7 hours; P = .0001) than did infants who were directly readmitted to the same nonbirth hospital. CONCLUSIONS: Readmitting infants with indirect hyperbilirubinemia to birth hospitals or ensuring that accurate, timely, and complete information is obtained from the birth centers by admitting hospital personnel before laboratory studies and treatment are performed will reduce diagnostic workups and should reduce hospital charges for these infants. Phototherapy should be initiated in the emergency department if stabilization is required before admission.

Continuity of Patient Care↗

PubMedDate not supplied

Japanese hospitals--culture and competition: a study of ten hospitals.

Japanese health care is characterized by a pluralistic system with a high degree of private producers. Central government regulates the prices and the financing system. All citizens are covered by a mandatory employment-based health insurance operating on a non-profit basis. The consumer has a free choice of physician and hospital. A comparison between Japan, Sweden and some other countries shows significant dissimilarities in the length of stay, number of treatments per hospital bed and year and the staffing of hospitals. About 80 per cent of the hospitals and 94 per cent of the clinics are privately owned. The typical private hospital owned by a physician has less than 100 beds. In this paper, data collected (1992/93) in an empirical study of Japanese hospitals and their leadership is presented. Also discussed are the hospitals' style of management, tools and strategies for competition and competences--personal and formal skills required of the leadership in the hospital. There follows a study of ten hospitals, among which hospital directors and chief physicians were interviewed. Interviews are also made with key persons in the Ministry of Health and Welfare and other organizations in the health care field. The result is also analysed from a cultural perspective--'what kind of impact does the Japanese culture have on the health care organization?' and/or 'what kind of sub-culture is developed in the Japanese hospitals'. Some comparisons are made with Sweden, USA, Canada and Germany. The different roles of the professions in the hospital are included in the study as well as the incentives for different kinds of strategies--specialization, growing in size, investments in new equipment, different kind of ownership and hospitals. Another issue discussed is the attempt to uncover whether there is an implicit distribution of specialties--silent agreements between hospitals, etc.

Economic Competition↗

PubMed1998

The effectiveness of hospital at home compared with in-patient hospital care: a systematic review.

BACKGROUND: Despite the widespread adoption of hospital at home services it is not known if these services represent an effective way to manage patients, compared with in-patient hospital care. METHOD: A systematic review was carried out of randomized controlled trials comparing hospital at home care with acute hospital in-patient care for patients age 18 years and over, excluding those with long-term care needs, obstetric patients, and those requiring mental health services. The following databases were searched: Medline, Embase, Social Science Citation Index, CINAHL, EconLit, PsychLit, SIGLE, Medical Care supplement on economic literature, and the EPOC (Cochrane Effective Practice and Organization of Care Review Group) register. Data were extracted for the following outcomes: mortality, clinical complications, re-admissions, costs, hospital days saved from the provision of hospital at home, discharge destination from hospital at home, functional status, psychological well-being, patient satisfaction and carer satisfaction. Data analysis and quality assessment were undertaken independently by two reviewers using a data checklist, following standard methods described by the EPOC group. RESULTS: Five trials were included in the review. No statistically significant differences were detected for patient health outcomes. Patients discharged early from hospital to hospital at home following elective surgery expressed greater satisfaction with care than those who remained in hospital. Carers, however, expressed less satisfaction with hospital at home compared with hospital care. Only one trial, which recruited patients requiring terminal care, formally tested for a difference in cost. No statistically significant difference was detected for overall net health costs. CONCLUSIONS: This review does not support the widespread adoption of hospital at home, nor the discontinuation of existing schemes for elderly medical patients, patients who have had elective surgery, or those with a terminal illness. There is insufficient evidence to determine the effect of hospital at home on patient outcomes, or cost to the health service.

Home Care Services, Hospital-Based↗

PubMed1996

Identifying poor-quality hospitals. Can hospital mortality rates detect quality problems for medical diagnoses?

OBJECTIVES: Many groups involved in health care are very interested in using external quality indices, such as risk-adjusted mortality rates, to examine hospital quality. The authors evaluated the feasibility of using mortality rates for medical diagnoses to identify poor-quality hospitals. METHODS: The Monte Carlo simulation model was used to examine whether mortality rates could distinguish 172 average-quality hospitals from 19 poor-quality hospitals (5% versus 25% of deaths being preventable, respectively), using the largest diagnosis-related groups (DRGs) for cardiac, gastrointestinal, cerebrovascular, and pulmonary diseases as well as an aggregate of all medical DRGs. Discharge counts and observed death rates for all 191 Michigan hospitals were obtained from the Michigan Inpatient Database. Positive predictive value (PPV), sensitivity, and area under the receiver operating characteristic curve were calculated for mortality outlier status as an indicator of poor-quality hospitals. Sensitivity analysis was performed under varying assumptions about the time period of evaluation, quality differences between hospitals, and unmeasured variability in hospital casemix. RESULTS: For individual DRG groups, mortality rates were a poor measure of quality, even using the optimistic assumption of perfect casemix adjustment. For acute myocardial infarction, high mortality rate outlier status (using 2 years of data and a 0.05 probability cutoff) had a PPV of only 24%, thus, more than three fourths of those labeled poor-quality hospitals (high mortality rate outliers) actually would have average quality. If we aggregate all medical DRGs and continue to assume very large quality differences and perfect casemix adjustment, the sensitivity for detecting poor-quality hospitals is 35% and PPV is 52%. Even for this extreme case, the PPV is very sensitive to introduction of small amounts of unmeasured casemix differences between hospitals. CONCLUSION: Although they may be useful for some surgical diagnoses, DRG-specific hospital mortality rates probably cannot accurately detect poor-quality outliers for medical diagnoses. Even collapsing to all medical DRGs, hospital mortality rates seem unlikely to be accurate predictors of poor quality, and punitive measures based on high mortality rates frequently would penalize good or average hospitals.

Cerebrovascular Disorders↗

PubMed1997

Pain in the oldest-old during hospitalization and up to one year later. HELP Investigators. Hospitalized Elderly Longitudinal Project.

OBJECTIVE: To evaluate the pain experience of very old hospitalized patients during and up to 1 year after hospitalization. To understand the relationship of level of pain to demographic, psychological, and illness-related variables. DESIGN: Prospective cohort study. SETTING: Four teaching hospitals. PARTICIPANTS: 1266 patients at least 80 years of age in the Hospitalized Elderly Longitudinal Project (HELP). MEASUREMENTS: Pain interviews during hospitalization and 2 and 6 months later. Ordinal logistic regression was used to study the association of variables with level of pain. RESULTS: Interviews about symptoms were available for 806 (64.6% of survivors) patients during hospitalization, 614 (57.9% of survivors) at 2-months, and 416 (48.0% of survivors) at 12 months; of these, 45.8, 49.8 and 53.6%, respectively, reported pain, and 12.9% of those with pain during hospitalization were dissatisfied with its control. Multivariable analysis revealed that study hospital, admission diagnosis, depressed mood, alertness, and level of activity 2 weeks before admission were associated with pain during hospitalization, and pain reported during hospitalization, study site, patient level of activity 2 weeks before hospital admission, and patient education were associated with pain 2 months later. CONCLUSIONS: Frequency of pain among very old hospitalized patients and at follow-up is similar to that reported for other hospitalized patients. Further studies of strategies to better control pain during and after hospitalization in very old patients are needed. These studies will have to adjust for other variables associated with pain in the oldest-old.

Activities of Daily Living↗

PubMed2003

Impact of conversion to critical access hospital status for Oklahoma's rural hospitals.

CONTEXT: The Medicare Rural Hospital Flexibility Grant Program established a new hospital category, the Critical Access Hospital, designed to provide financial stability to small rural hospitals that were losing money after changes in the Prospective Payment System implemented by Medicare. PURPOSE: This article describes the impact of conversion to Critical Access Hospital (CAH) status for 15 small rural hospitals in Oklahoma. Objectives of the study were to identify how conversion to CAH affected hospital utilization and finances for the first year after conversion. METHODS: A telephone survey was used to collect information from hospital administrators. Fifteen of 16 eligible hospitals participated in the study. FINDINGS: In general, services and patient census declined slightly with conversion to CAH. All 15 hospitals had reported losses prior to conversion, totaling $6,985,033. Ten hospitals reported losses after conversion. After converting to CAH status, the hospitals reported total losses of $3,094,547. The hospitals had a net change of $4,293,040. CONCLUSIONS: Most of the 15 study hospitals greatly improved their financial situation in the first year after conversion to CAH status, but in aggregate still operated at a loss.

Critical Care↗

PubMed2004

A multicasualty event: out-of-hospital and in-hospital organizational aspects.

UNLABELLED: In a wedding celebration of 700 participants, the third floor of the hall in which the celebration was taking place suddenly collapsed. While the walls remained intact, all three floors of the building collapsed, causing Israel's largest disaster. OBJECTIVES: To study the management of a multicasualty event (MCE), in the out-of-hospital and in-hospital phases, including rescue, emergency medical services (EMS) deployment and evacuation of casualties, emergency department (ED) deployment, recalling staff, medical care, imaging procedures, hospitalization, secondary referral, and interhospital transfer of patients. METHODS: Data on all the victims who arrived at the four EDs in Jerusalem were collected through medical files, telephone interviews, and hospital computerized information. RESULTS: The disaster resulted in 23 fatalities and 315 injured people; 43% were hospitalized. During the first hour, 42% were evacuated and after seven hours the scene was empty. Ninety-seven basic life support ambulances, 18 mobile intensive care units, 600 emergency medical technicians, 40 paramedics, and 15 physicians took part in the out-of-hospital stage. At the hospitals, about 1,300 staff members arrived immediately, either on demand or voluntarily, a number that seems too large for this disaster. Computed tomography (CT) demand was over its capability. CONCLUSIONS: During this MCE, the authors observed "rotating" bottleneck phenomena within out-of-hospital and in-hospital systems. For maximal efficiency, hospitals need to fully coordinate the influx and transfer of patients with out-of-hospital rescue services as well as with other hospitals. Each hospital has to immediately deploy its operational center, which will manage and monitor the hospital's resources and facilitate coordination with the relevant institutions.

Adolescent↗

PubMed2003

Keeping children out of hospitals: parents' and physicians' perspectives on how pediatric hospitalizations for ambulatory care-sensitive conditions can be avoided.

BACKGROUND: Avoidable hospitalization conditions (AHCs) are hospitalizations that potentially can be avoided with timely, appropriate outpatient care. The specific reasons for avoidability, and parents and physicians' perspectives on the proportion of actually avoidable pediatric AHCs, have not been examined adequately. OBJECTIVES: To identify how pediatric hospitalizations might be avoided, and to determine the proportion of avoidable AHCs according to parents and physicians of hospitalized children. METHODS: Cross-sectional survey of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of children who were admitted with AHCs to an urban hospital in a 14-month period. RESULTS: The 554 hospitalized children had a median age of 4 years; most were poor (median annual family income: 12,000 dollars), nonwhite (91%), and had public (73%) or no (16%) health insurance. The most frequent AHC diagnoses were asthma (43%), dehydration/gastroenteritis (16%), pneumonia (11%), seizure disorder (8%), and skin infections (8%). Only 25% of parents said that their child's admission was avoidable, compared with 29% of PCPs and 32% of IAPs. The proportion of AHC hospitalizations assessed as avoidable varied according to the source or combination of sources, from 13% for agreement among all 3 sources to 46% as identified by any 1 of the 3 sources. PCPs (71%) and IAPs (48%) significantly more often than parents (35%) cited parent/patient-related reasons for how hospitalizations could have been avoided, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (48%) significantly more often than PCPs (18%) and IAPs (37%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the child's condition, and better quality of care. Multivariate analyses revealed that an age >or=11 years, an asthma diagnosis, working poor family income, and having no health insurance were associated with approximately double to triple the odds of an avoidable hospitalization. CONCLUSIONS: The proportion of AHCs assessed as avoidable varies from 13% to 46%, depending on the source. Adolescents, children with asthma, children from working-poor families, and uninsured children are at greatest risk for avoidable hospitalizations. Many pediatric hospitalizations might be avoided if parents and children were better educated about the child's condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers. Direct assessment by parents and physicians of hospitalized children can be an informative way to examine the proportion of avoidable pediatric hospitalizations and how they can be prevented.

Adolescent↗

PubMed2005

Is hospital service associated with racial and ethnic disparities in experiences with hospital care?

PURPOSE: Little is known about the influence of processes of hospital care on racial and ethnic differences in experiences with hospital care. SUBJECTS AND METHODS: To determine whether patient experiences differed by race and ethnicity and whether these differences were associated with hospital care characteristics, we analyzed survey and hospital administrative data from 2664 adult patients after hospitalization at an urban teaching hospital during 1998-1999. We assessed the association of patient race and ethnicity with reporting problems in multiple dimensions of patient experience, using logistic regression to adjust for sex, age, self-reported health status, insurance status, income, route of hospital admission, and hospital service. We then stratified adjusted analyses by hospital service. RESULTS: After adjustment for demographic and hospital characteristics, black (odds ratio (OR): 1.8; 95% confidence interval [CI]: 1.3-2.6) and Latino (OR: 2.0; 95% CI: 1.3-3.0) patients reported more problems with respect for their preferences compared to whites. Blacks reported more problems with respect for their preferences (OR: 1.7; 95% CI: 1.0-3.0) among patients discharged from surgical services, and Latinos reported more problems with respect for their preferences (OR:3.6; CI: 1.6-8.2) among patients discharged from obstetrical services when compared to whites. Patient experiences did not significantly differ by race among patients discharged from medical services. CONCLUSIONS: We found significant racial and ethnic differences in patients' experiences with hospital care, particularly in respect for patient preferences. Our findings suggest physicians and hospital staff should strive to understand and address the expectations of black and Latino patients, particularly those who are hospitalized for surgical or obstetrical issues.

Adult↗

PubMed1996

Preliminary report of data collection in hospital quality assurance programs--a project of the Association of Hospitals of the Czech Republic.

OBJECTIVES: This was the first attempt of the association representing all acute care hospitals in the Czech Republic to collect mutual data which might be used for quality assurance (QA) purposes and which might lead to the development of national standards of care which could be used for hospital accreditation. Data collected included information which was available universally and which could be measured; in addition, information was intended to be similar in each hospital. In most cases, the data collection systems were based on financial information and data had to be identified which might be used for QA purposes, rather than being able to design a system specific for QA purposes. DESIGN: Since the hospital payment system was established in 1992, hospitals have had to develop data collection systems to measure clinical activity; this current study was based on this data collection, adapted to QA purposes. SETTING: The Executive Committee of the Hospital Association agreed to a pilot study of hospitals in 1993; data were collected from approximately 40 hospitals, beginning in 1994. STUDY PARTICIPANTS: Hospitals were chosen based on their ability to collect data and participate in the program, and it was determined that there should be variability in the hospitals, in size, location and activities, but that the data collected should be generic. INTERVENTIONS: Raw data included 33 different items, most of which were irrelevant to QA. Using a computer program, various combinations of data were reviewed and evaluated to ascertain the most appropriate for QA purposes. MAIN OUTCOME MEASURES: Data were chosen for study which included (a) data from the largest departments in the individual hospitals; (b) length of stay for patients hospitalized in these departments; (c) number of occupied beds/physician in the department and (d) mortality/1000 admissions to the department. RESULTS: The combination of (1) a long length of stay; (2) a high occupied bed/doctor ratio; and (3) a high mortality rate/1000 admissions might be indicators of poor quality. Additional factors to consider include: the type of department-emergency, cancer, geriatric, etc.; the nature of the medical activity-acute, referral, primary care, etc.; whether or not "social" beds are included and, generally, comparability among departments. However, as a pilot study, certain indicators can be determined which then can be used for future study to determine quality of care. The ability to cooperate and collect seemingly comparable data indicates reason for optimism in the future; more detailed and accurate studies can be carried out which will enable assessment of the quality of care given in comparable situations in hospitals throughout the Czech Republic.

Accreditation↗

PubMed2002

Patient and hospital characteristics associated with recommended processes of care for elderly patients hospitalized with pneumonia: results from the medicare quality indicator system pneumonia module.

BACKGROUND: Unexplained wide variability exists in the performance of key initial processes of care associated with improved survival of elderly patients (those > or =65 years) hospitalized with pneumonia. The objective of this study was to assess which patient and hospital characteristics are associated with performance of these key initial processes of care for hospitalized elderly patients with pneumonia. METHODS: A retrospective cohort analysis was performed using data from the Medicare Quality Indicator System Pneumonia Module for 14 069 patients 65 years or older hospitalized with pneumonia throughout the United States. Associations were calculated using multivariate logistic regression analysis between specific patient and hospital characteristics and 2 processes of care associated with improved 30-day survival: administration of antibiotics within 8 hours of hospital arrival and blood culture collection within 24 hours of arrival. RESULTS: Timely antibiotic administration was negatively associated with nonwhite race (African American: odds ratio [OR], 0.71; 95% confidence interval [CI], 0.60-0.85; and other racial minorities: OR, 0.79; 95% CI, 0.68-0.92), major hospital teaching status (OR, 0.79; 95% CI, 0.67-0.93), and larger hospital size (> or =250 beds vs. <100 beds: OR, 0.68; 95% CI, 0.59-0.80). Timely blood culture collection was positively associated with larger hospital size (OR, 1.61; 95% CI, 1.39-1.87). Performance of both processes of care were positively associated with registered nurse-bed ratios of 1.25 or higher (for antibiotic administration: OR, 1.23; 95% CI, 1.10-1.38; and for blood culture collection: OR, 1.43; 95% CI, 1.26-1.61) and fever (for antibiotic administration: OR, 1.35; 95% CI, 1.23-1.49; and for blood culture collection: OR, 3.07; 95% CI, 2.81-3.34) and were negatively associated with hospital location in the South (for antibiotic administration: OR, 0.77; 95% CI, 0.69-0.86; and for blood culture collection: OR, 0.85; 95% CI, 0.77-0.93). CONCLUSIONS: Minority race, fever, nurse-bed ratio, hospital size and teaching status, and southern location are among the major patient and hospital characteristics associated, either negatively or positively, with the timeliness of performance of initial antibiotic administration and blood culture collection for patients hospitalized with pneumonia. Because performance of these processes of care is associated with improved likelihood of survival, medical providers should seek to eliminate the variations in care associated with these patient and hospital characteristics. In addition, the impact of nurse staffing changes on performance of key time-sensitive processes of care should be weighed carefully.

Aged↗

PubMed2003

Hospital discharge to other healthcare facilities: impact on in-hospital mortality.

BACKGROUND: In-hospital mortality is frequently used as an outcomes measure for surgical procedures. Recently, hospitals have developed subacute care facilities to allow earlier discharge. Outcomes of patients discharged (transferred) to these units or to other similar facilities may not be captured in reports of in-hospital mortality. STUDY DESIGN: The California Office of Statewide Health Planning and Development (OSHPD) patient discharge abstract database was examined to determine the rates of discharge to other facilities (transfer) and the number of in-hospital deaths occurring during the index hospitalization and after transfer in patients undergoing cardiac surgery procedures. Data were collected for 1997, 1998, and 1999 for coronary artery bypass grafting (CABG-only, n = 82,897), CABG plus additional procedures (CABG-plus, n = 11,869), and valve repair or replacement (Valve-only, n = 14,872). In-hospital mortality and transfer rates (same-day discharge and readmission to another facility) were determined for all hospitals through the index hospitalization and subsequent transfers. RESULTS: Aggregated 3-year in-hospital mortality rates for the index hospitalization were 2.98% for CABG-only, 9.25% for CABG-plus, and 4.85% in Valve-only groups. Transfer rates were 12.41%, 23.16%, and 13.43%, respectively. The percentages of all in-hospital deaths occurring after transfer from the index hospital were 13.5% (385 of 2,857) in CABG-only, 13.3% (168 of 1,266) in CABG-plus, and 11.0% (89 of 811) in Valve-only patients. When corrected for these additional deaths, the actual in-hospital mortality rate was 3.45% for CABG-only, 10.67% for CABG-plus, and 5.45% for Valve-only procedures. CONCLUSIONS: Transfer to another healthcare facility rather than discharge home is a common practice after cardiac surgery. A substantial percentage of in-hospital deaths occurs after discharge from the primary institution.

Bias↗

PubMed1993

Chance, continuity, and change in hospital mortality rates. Coronary artery bypass graft patients in California hospitals, 1983 to 1989.

OBJECTIVE: To assess whether risk-adjusted mortality rates for hospitals reflect primarily chance variation. DESIGN: Observation over time. SETTING: All 115 California hospitals with five or more coronary artery bypass graft (CABG) patients in any year 1983 to 1989. PATIENTS: All CABG patients aged 18 years and older excluding those with other open heart procedures and percutaneous transluminal coronary angioplasty on the day of CABG surgery (n = 132,750). OUTCOME MEASURE: Inpatient mortality adjusted for age, gender, chronic comorbidities, timing of surgery, and presence of additional procedures. METHODS: Data were derived from routinely collected hospital discharge abstracts. Observed and expected semiannual mortality rates were examined for each hospital to identify consistent patterns over time. Using the quartile of patients with the highest predicted risk (average mortality, 10%), high- and low-outlier hospitals were identified from 2 consecutive years of pooled data and outcomes 2 years later were examined. Each hospital-year observation was also examined individually to identify outliers and to assess differences for observed and expected death rates, patient volume, and other characteristics. RESULTS: Some hospitals showed consistently lower-than-expected inpatient mortality. Some hospitals had periods of significantly higher-than-expected mortality followed by a correction. High-outlier hospitals that were selected based on 2 years of data had mortality rates 2 years later that averaged 31% above expected, while low-outlier hospitals had rates 2 years later that averaged 28% below expected. On a contemporaneous basis, high outliers had proportionately more transfers to other acute care hospitals and longer postoperative stays among survivors. CONCLUSIONS: Risk-adjusted outcomes for CABG patients derived from administrative data exhibit substantial patterns of consistency. Such patterns cannot be detected for low-risk patients but are evident for the top quartile of patients stratified by risk. Even with reporting lags and changes in hospital outcomes over time, a policy of channeling high-risk patients away from high-outlier hospitals and toward low-outlier hospitals could lower their overall risk-adjusted mortality rate by 45% [corrected].

Adult↗

PubMed1996

[Hospital admission of nursing home patients considered but not carried out: role of the nursing home physician and the involved parties and various differences with realized hospital admissions].

The objective of the study was to establish in which way nursing home patients, for whom is refrained from hospitalization, differ from hospitalized nursing home patients. The question was also raised of how the decision to refrain from hospitalization is taken: which point of view and method the nursing home physician has, on which arguments decisions are based and which parties are involved and in which way. The design of the study was retrospective and descriptive. Data obtained from semi-structured interviews held in 1987 with 24 nursing home physicians on 45 situations were compared with registration data on 387 hospitalizations of patients from 30 nursing homes. In the non-hospitalized patients malignancies were relatively more frequent than in the hospitalized patients (29% versus 7%). The mean age of hospitalized patients was 78 and of non-hospitalized patients 80 years. The physical condition of non-hospitalized patients was more frequently judged as poor and the life expectancy as more limited. Already at an early stage nursing home physicians appeared to have a point of view, with which they determined the decision making procedure: in favour of (40%), opposing (35%) and in doubt of hospitalization (25%). In 'non-hospitalizations' there was much more involvement in decision making of family members and nurses, and less involvement of patients and medical specialists than in decisions to hospitalization. Non-medical arguments opposing hospitalization had slightly the upper hand above medical arguments. The decisive arguments opposing hospitalization were in the case of psychogeriatric patients more often of medical origin than in the case of somatic patients. The 'quality of live' mentioned arguments were of limited importance. The nursing home physician needs good communicative qualities in such decision making processes. He has to be skilled to judge competency of patients and, if needed, to balance in the right way the information of relatives, nurses, colleagues and specialists.

Aged↗

PubMed2004

Effects of weekend admission and hospital teaching status on in-hospital mortality.

PURPOSE: The effect of reduced hospital staffing during weekends on in-hospital mortality is not known. We compared mortality rates between patients admitted on weekends and weekdays and whether weekend-weekday variation in rates differed between patients admitted to teaching and nonteaching hospitals in California. METHODS: The sample comprised patients admitted to hospitals from the emergency department with any of 50 common diagnoses (N = 641,860). Mortality between patients admitted on weekends and those admitted on weekdays (the "weekend effect") was compared. The magnitude of the weekend effect was also compared among patients admitted to major teaching, minor teaching, and nonteaching hospitals. RESULTS: The adjusted odds of death for patients admitted on weekends when compared with weekdays was 1.03 (95% confidence interval [CI]: 1.01 to 1.06; P = 0.0050). Three diagnoses (cancer of the ovary/uterus, duodenal ulcer, and cardiovascular symptoms) were associated with a statistically significant weekend effect. None of the 50 diagnoses demonstrated a statistically significant reduction in mortality for weekend admissions as compared with weekday admissions. Mortality was similar among patients admitted to major (odds ratio [OR] = 1.06; 95% CI: 0.94 to 1.19) and minor (OR = 1.03; 95% CI: 0.97 to 1.09) teaching hospitals, compared with nonteaching hospitals. However, the weekend effect was larger in major teaching hospitals compared with nonteaching hospitals (OR =1.13 vs. 1.03, P = 0.03) and minor teaching hospitals (OR = 1.05, P = 0.11). CONCLUSION: Patients admitted to hospitals on weekends experienced slightly higher risk-adjusted mortality than did patients admitted on weekdays. While overall mortality was similar for patients admitted to all hospital categories, the weekend effect was larger in major teaching hospitals and is cause for concern.

Aged↗