Charles Saunders

Hospital quality of care: does information technology matter? The relationship between information technology adoption and quality of care.

Background: Hospitals have been slow to adopt information technology (IT) largely because of a lack of generalizable evidence of the value associated with such adoption. Purpose: To explore the relationship between IT adoption and quality of care in acute-care hospitals. Methods: Primary data on hospital IT adoption were combined with secondary hospital discharge data. Regression analyses were used to examine the relationship between various measures of IT adoption and several quality indicators after controlling for confounders. Adoption of IT was measured using a previously validated method that considers clinical, administrative, and strategic IT capabilities of acute-care hospitals. Quality measures included the Inpatient Quality Indicators developed by the Agency for Healthcare Research and Quality. Results: Data from 98 hospitals were available for analyses. Hospitals adopted an average of 11.3 (45.2%) clinical IT applications, 15.7 (74.8%) administrative IT applications, and 5 (50%) strategic IT applications. In multivariate regression analyses, hospitals that adopted a greater number of IT applications were significantly more likely to have desirable quality outcomes on seven Inpatient Quality Indicator measures, including risk-adjusted mortality from percutaneous transluminal coronary angioplasty, gastrointestinal hemorrhage, and acute myocardial infarction. An increase in clinical IT applications was also inversely correlated with utilization of incidental appendectomy, and an increase in the adoption of strategic IT applications was inversely correlated with risk-adjusted mortality from craniotomy and laparoscopic cholecystectomy. Practice Implications: Hospital adoption of IT is associated with desirable quality outcomes across hospitals in Florida. These findings will assist hospital leaders interested in understanding better the effect of costly IT adoption on quality of care in their institutions.

Hospital adoption of information technologies and improved patient safety: a study of 98 hospitals in Florida.

Most of the studies linking the use of information technology (IT) to improved patient safety have been conducted in academic medical centers or have focused on a single institution or IT application. Our study explored the relationship between overall IT adoption and patient safety performance across hospitals in Florida. Primary data on hospital IT adoption were combined with secondary hospital discharge data. Regression analyses were used to examine the relationship between measures of IT adoption and the Patient Safety Indicators (PSIs) of the Agency for Healthcare Research and Quality. We found that eight PSIs were related to at least one measure of IT adoption. Compared with administrative IT adoption, clinical IT adoption was related to more patient safety outcome measures. Hospitals with the most sophisticated and mature IT infrastructures performed significantly better on the largest number of PSIs. Adoption of IT is associated with desirable performance on many important measures of hospital patient safety. Hospital leaders and other decision makers who are examining IT systems should consider the impact of IT on patient safety.

Adolescent Cigarette Smokers’ and Non-Cigarette Smokers’ Use of Alternative Tobacco Products

INTRODUCTION This study uses the most recent data from the nationally representative National Youth Tobacco Survey (NYTS) to examine the use of alternative tobacco products among U.S. cigarette smokers and non-cigarette smokers aged 14-17. Alternative tobacco product use is defined as use of one or more of the following products: smokeless tobacco, cigars, pipes, bidis, or kreteks. METHODS Using the results from the 2004, 2006, and 2009 NYTS, multivariate logistic regressions were used to investigate separately the extent of alternative tobacco product use in current cigarette smokers and in those who reported not smoking cigarettes controlling for demographic and other independent influences. RESULTS The results indicate that for adolescent smokers and nonsmokers, the use of one type of alternative tobacco product made it much more likely the individual would use one or more of the other alternative tobacco products. Non-cigarette smokers using these tobacco products appeared to exhibit symptoms of nicotine dependence comparable to those of cigarette smokers. CONCLUSIONS More information on adolescent use of alternative tobacco products is needed. Current cigarette use declined 3.4% annually over 2004-2009 for the NYTS 14- to 17-year-old population, but this cohorts use of alternative tobacco products was unchanged. The number of adolescents aged 14-17 who did not smoke cigarettes but used alternative tobacco products increased 5.9% per year over the same period. Current surveillance measures need to be expanded in order to gain a more comprehensive understanding of adolescent alternative tobacco use.

A comparative study of quality outcomes in freestanding ambulatory surgery centers and hospital-based outpatient departments: 1997-2004.

RESEARCH OBJECTIVE To compare quality outcomes from surgical procedures performed at freestanding ambulatory surgery centers (ASCs) and hospital-based outpatient departments (HOPDs). DATA SOURCES Patient-level ambulatory surgery (1997-2004), hospital discharge (1997-2004), and vital statistics data (1997-2004) for the state of Florida were assembled and analyzed. STUDY DESIGN We used a pooled, cross-sectional design. Logistic regressions with time fixed-effects were estimated separately for the 12 most common ambulatory surgical procedures. Our quality outcomes were risk-adjusted 7-day and 30-day mortality and 7-day and 30-day unexpected hospitalizations. Risk-adjustment for patient demographic characteristics and severity of illness were calculated using the DCG/HCC methodology adjusting for primary diagnosis only and separately for all available diagnoses. PRINCIPAL FINDINGS Although neither ASCs nor HOPDs performed better overall, we found some difference by procedure that varied based on the risk-adjustment approach used. CONCLUSIONS There appear to be important variations in quality outcomes for certain procedures, which may be related to differences in organizational structure, processes, and strategies between ASCs and HOPDs. The study also confirms the importance of risk-adjustment for comorbidities when using administrative data, particularly for procedures that are sensitive to differences in severity.

Quality of Care in Accredited and Nonaccredited Ambulatory Surgical Centers

BACKGROUND Little is known about quality outcomes in accredited and nonaccredited ambulatory surgical centers (ASCs). Quality outcomes in ASCs accredited by either the Accreditation Association for Ambulatory Health Care (AAAHC) or The Joint Commission were compared with those of nonaccredited ASCs in Florida. METHODS Patient-level ambulatory surgery and hospital discharge data from Florida for 2004 were merged and analyzed. Multivariate logistic regressions were estimated separately for the five most common ambulatory surgical procedures: colonoscopy, cataract removal, upper gastroendoscopy, arthroscopy, and prostate biopsy. Statistical models examined differences in risk-adjusted 7-day and 30-day unexpected hospitalizations between nationally accredited and nonaccredited ASCs. In addition to risk adjustment, each model controlled for facility volume of procedure and patient demographic characteristics including gender, race, age, and insurance type. RESULTS In multivariate analyses that controlled for facility volume and patient characteristics, patients at Joint Commission-accredited facilities were still significantly less likely to be hospitalized after colonoscopy. Specifically, compared with patients treated in nonaccredited ASCs regulated by the state agency, patients treated at those facilities were 10.9% less likely to be hospitalized within 7 days (adjusted odds ratio [OR] = 0.891; 95% confidence interval [C.I.], 0.799-0.993) and 9.4% less likely to be hospitalized within 30 days (adjusted OR = 0.906; 95% C.I., 0.850-0.966). No other differences in unexpected hospitalization rates were detected in the other procedures examined. DISCUSSION With the exception of one procedure, systematic differences in quality of care do not exist between ASCs that are accredited by AAAHC, those accredited by the Joint Commission, or those not accredited in Florida.

Quality of Care Differs by Patient Characteristics: Outcome Disparities After Ambulatory Surgical Procedures

The surgery literature is filled with reports on racial or gender disparities in quality. However, whether patient demographics are risk factors for complications or death from ambulatory surgical procedures is unknown. This study explores whether racial, age, and gender outcome disparities exist after ambulatory surgeries. Patients studied included adults (>18 years) receiving common ambulatory surgical procedures (N = 3 174 436) in either a freestanding ambulatory surgical center or a hospital-based outpatient department during 1997-2004 in Florida. Results demonstrate that African Americans were at a significantly increased risk for either mortality or unexpected hospitalization in 4 of the 5 procedures examined, even after controlling for confounders. For women, unexpected hospital admission or mortality was less likely to occur after almost all procedures examined. Thus, many of the racial and gender disparities in the inpatient surgical literature are also observed in the ambulatory setting. More research is needed to determine the source of these disparities. (Am J Med Qual 2007;22:395-401)

Is there a relationship between physician and facility volumes of ambulatory procedures and patient outcomes

This study explores associations between patient outcomes (7- and 30-day hospitalization and mortality) and healthcare provider (physician and facility) volumes of outpatient colonoscopy, cataract removal, and upper gastrointestinal endoscopy performed in outpatient surgical settings in Florida. Findings indicate that patients treated by high-volume physicians or facilities had lower adjusted odds ratios for hospitalizations and mortality. When physician and facility volume were assessed simultaneously, physician volume accounted for larger effects than facility volume in hospitalization models. When assessing both physician and facility volume together for mortality, facility volume was a stronger predictor of mortality outcomes at 30 days. Further examinations of associations of outpatient physician and facility volumes and patient outcomes are suggested.

Bypassing the Local Rural Hospital for Outpatient Procedures.

PURPOSE To assess the amount of local rural hospital outpatient department (HOPD) bypass for outpatient procedures. METHODS We analyzed data on colonoscopies and upper gastrointestinal endoscopies performed in the state of Florida over the period 1997-2004. FINDINGS Approximately, 53% of colonoscopy and 45% of upper gastrointestinal endoscopy patients bypassed their local rural hospital for treatment at either a free-standing ambulatory surgical center (ASC) or a nonlocal hospital outpatient department. Independent predictors of bypass included risk-adjusted severity of the patients medical condition, insurance status, and race. Patients treated in ASCs were predominately healthier, white and commercially insured. Nonlocal HOPDs tend to treat a sicker cohort of patients who were publicly insured or under managed care. CONCLUSIONS The results indicate that patients who bypass their local HOPD to an ASC differ from those bypassing to a nonlocal HOPD, and that patient factors influencing bypass for outpatient procedures differ from those influencing inpatient bypass. From a policy perspective, as procedures continue to migrate from the inpatient to the outpatient setting, bypassing the local rural hospital for treatment elsewhere could create conditions that negatively impact rural hospital operations.

Underrepresented minorities in academic medicine: is Florida better off?

Objectives The state of Florida has experienced challenges recruiting and retaining underrepresented minority faculty in academic medicine, as well as maintaining a population-like balance of minority physicians practicing in the state. We sought to quantify the percentage of practicing minority physicians as compared to the general population of Florida and focus specifically on black, Hispanic, and Asian/Pacific Islander physicians in academic medicine. We hypothesized that because of the diversity of the state, the number of underrepresented minority academic physicians in Florida would be higher than the national average. Methods Data were derived and analyzed from a biennial survey initiated in 2007 that all physicians renewing licenses in Florida are required to complete. Fifty percent of the licensing cohort completes the survey annually. We focused on physician practice demographics and academic employment. Results Blacks make up 15.4% of the state population, 6.4% of practicing physicians, but only 3.9% of academic physicians. Hispanics are 22.8% of the state population, 19.2% of practicing physicians, but only 12.5% of academic physicians. Asians are 2.5% of the state population, 14.4% of practicing physicians, and 12.6% of academic physicians. Whites are 58% of the state population, 52% of practicing physicians, and 65% of academic physicians. Conclusions There is disparity in clinical practice and academic medicine for blacks and Hispanics. Despite the diversity of the state, the disparity of blacks in academic medicine in Florida only marginally exceeds the national average. Asians and Hispanics make up the same percentage of academic physicians, but there are 10 times more Hispanics in the state. More research and programming are needed to further define and arrive at solutions to this problem.

Access to Cigarettes by Daily Smokers in Florida's Public Middle Schools and High Schools

INTRODUCTION Youth who smoke daily have diverse methods for obtaining cigarettes, which range from commercial sources to essentially black market transactions. This study examines access to cigarettes, attitudes toward tobacco, and the demographic characteristics of youth who are daily cigarette smokers. METHODS Biennial data from the Florida Youth Tobacco Survey, a representative sample of Florida public middle- and high-school students, were used. Daily smoking was categorized into ordinal categories of increasing intensity. Analysis was done with a logistic partial proportional odds model, which allowed the effects of the independent predictors to vary according to smoking intensity. RESULTS The multivariate analysis revealed that males and females have different methods of obtaining cigarettes. Moreover, certain modes of access to cigarettes were related to daily smoking intensity. Males who obtained cigarettes from their parents or stole them from a store were much more likely to have a higher intensity of daily smoking. Females who gave someone money to buy their cigarettes or bought them from a person were more likely to smoke more cigarettes per day. Males, but not females, also perceived that increasing the number of cigarettes smoked per day provides social benefits in the form of more friends. CONCLUSIONS Understanding how daily youth smokers obtain cigarettes is necessary if effective antitobacco policies are to be developed for these individuals. Daily youth smokers are at increased risk of becoming addicted to nicotine, making them more likely to transition to daily adult smoking.