Chunliu Zhan

Nurse Staffing and Postsurgical Adverse Events: An Analysis of Administrative Data from a Sample of U.S. Hospitals, 1990–1996

OBJECTIVE To examine the impact of nurse staffing on selected adverse events hypothesized to be sensitive to nursing care between 1990 and 1996, after controlling for hospital characteristics. DATA SOURCES/STUDY SETTING The yearly cross-sectional samples of hospital discharges for states participating in the National Inpatient Sample (NIS) from 1990-1996 were combined to form the analytic sample. Six states were included for 1990-1992, four states were added for the period 1993-1994, and three additional states were added in 1995-1996. STUDY DESIGN The study design was cross-sectional descriptive. DATA COLLECTION/EXTRACTION METHODS Data for patients aged 18 years and older who were discharged between 1990 and 1996 were used to create hospital-level adverse event indicators. Hospital-level adverse event data were defined by quality indicators developed by the Health Care Utilization Project (HCUP). These data were matched to American Hospital Association (AHA) data on community hospital characteristics, including registered nurse (RN) and licensed practical/vocational nurse (LPN) staffing hours, to examine the relationship between nurse staffing and four postsurgical adverse events: venous thrombosis/pulmonary embolism, pulmonary compromise after surgery, urinary tract infection, and pneumonia. Multivariate modeling using Poisson regression techniques was used. PRINCIPAL FINDINGS An inverse relationship was found between RN hours per adjusted inpatient day and pneumonia (p < .05) for routine and emergency patient admissions. CONCLUSIONS The inverse relationship between pneumonia and nurse staffing are consistent with previous findings in the literature. The results provide additional evidence for health policy makers to consider when making decisions about required staffing levels to minimize adverse events.

Incidence and short-term outcomes of primary and revision hip replacement in the United States.

BACKGROUND The purpose of this study was to use 2003 nationwide United States data to determine the incidences of primary total hip replacement, partial hip replacement, and revision hip replacement and to assess the short-term patient outcomes and factors associated with the outcomes. METHODS We screened more than eight million hospital discharge abstracts from the 2003 Healthcare Cost and Utilization Project Nationwide Inpatient Sample and approximately nine million discharge abstracts from five state inpatient databases. Patients who had undergone total, partial, or revision hip replacement were identified with use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes. In-hospital mortality, perioperative complications, readmissions, and the association between these outcomes and certain patient and hospital variables were analyzed. RESULTS Approximately 200,000 total hip replacements, 100,000 partial hip replacements, and 36,000 revision hip replacements were performed in the United States in 2003. Approximately 60% of the patients were sixty-five years of age or older and at least 75% had one or more comorbid diseases. The in-hospital mortality rates associated with these three procedures were 0.33%, 3.04%, and 0.84%, respectively. The perioperative complication rates associated with the three procedures were 0.68%, 1.36%, and 1.08%, respectively, for deep vein thrombosis or pulmonary embolism; 0.28%, 1.88%, and 1.27% for decubitus ulcer; and 0.05%, 0.06%, and 0.25% for postoperative infection. The rates of readmission, for any cause, within thirty days were 4.91%, 12.15%, and 8.48%, respectively, and the rates of readmissions, within thirty days, that resulted in a surgical procedure on the affected hip were 0.79%, 0.91%, and 1.53%. The rates of readmission, for any cause, within ninety days were 8.94%, 21.14%, and 15.72%, and the rates of readmissions, within ninety days, that resulted in a surgical procedure on the affected hip were 2.15%, 1.61%, and 3.99%. Advanced age and comorbid diseases were associated with worse outcomes, while private insurance coverage and planned admissions were associated with better outcomes. No consistent association between outcomes and hospital characteristics, such as hip procedure volume, was identified. CONCLUSIONS Total hip replacement, partial hip replacement, and revision hip replacement are associated with different rates of postoperative complications and readmissions. Advanced age, comorbidities, and nonelective admissions are associated with inferior outcomes.

Suboptimal Prescribing in Elderly Outpatients: Potentially Harmful Drug-Drug and Drug-Disease Combinations

Objectives: To assess the prevalence and correlates of potentially harmful drug‐drug combinations and drug‐disease combinations prescribed for elderly patients at outpatient settings.

Relationship Between Performance Measurement and Accreditation: Implications for Quality of Care and Patient Safety

This study examined the association between the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation scores and the Agency for Healthcare Research and Quality’s Inpatient Quality Indicators and Patient Safety Indicators (IQIs/PSIs). JCAHO accreditation data from 1997 to 1999 were matched with institutional IQI/PSI performance from 24 states in the Healthcare Cost and Utilization Project. Most institutions scored high on JCAHO measures despite IQI/PSI performance variation with no significant relationship between them. Principal component analysis found 1 factor each of the IQIs/PSIs that explained the majority of variance on the IQIs/PSIs. Worse performance on the PSI factor was associated with worse performance on JCAHO scores (P = .02). No significant relationships existed between JCAHO categorical accreditation decisions and IQI/PSI performance. Few relationships exist between JCAHO scores and IQI/PSI performance. There is a need to continuously reevaluate all measurement tools to ensure they are providing the public with reliable, consistent information about health care quality and safety.

The Validity of ICD-9-CM Codes in Identifying Postoperative Deep Vein Thrombosis and Pulmonary Embolism

BACKGROUND Deep vein thrombosis and pulmonary embolism (DVT/PE) are common complications after surgery and are associated with substantial excess mortality and length of stay. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes recorded in hospital claims have been used to identify and study DVT/PE, but the validity of this method is not well studied. METHODS Identification of postoperative DVT/PE events were compared using ICD-9-CM codes and medical record abstraction in random samples of hospital discharges of Medicare beneficiaries in 2002-2004. RESULTS Among 20,868 eligible surgical hospitalizations, 232 DVT cases and 95 PE cases were identified by ICD-9-CM codes; 108 DVT cases and 31 PE cases by medical record abstraction; 72 DVT cases and 23 PE cases by both methods. The resulting estimates of PPV of ICD9-CM coding were 31% (72/232 cases) for DVT, 24% (23/95) for PE, and 29% (90/308) for DVT/PE combined. The resulting sensitivity estimates were 67% (72/108 cases) for DVT, 74% (23/31) for PE, and 68% (90/133) for DVT/PE combined. DISCUSSION ICD-9-CM codes in Medicare claims are sensitive but have limited predictive validity in identifying postoperative DVT/PE. Improvements in the validity are needed before the indicator can be used for safety performance assessment.

Identification of hospital-acquired catheter-associated urinary tract infections from Medicare claims: sensitivity and positive predictive value.

Background and Objective:Hospital-acquired catheter-associated urinary tract infection (CAUTI) is one of the first 6 conditions Medicare is targeting to reduce payment associated with hospital-acquired conditions under Congressional mandate. This study was to determine the positive predictive value (PPV) and sensitivity in identifying patients in Medicare claims who had urinary catheterization and who had hospital-acquired CAUTIs. Research Design:CAUTIs identified by ICD-9-CM codes in Medicare claims were compared with those revealed by medical record abstraction in random samples of Medicare discharges in 2005 to 2006. Hospital discharge abstracts (2005) from the states of New York and California were used to estimate the potential impact of a present-on-admission (POA) indicator on PPV. Results:ICD-9-CM procedure codes for urinary catheterization appeared in only 1.4% of Medicare claims for patients who had urinary catheters. As a proxy, claims with major surgery had a PPV of 75% and sensitivity of 48%, and claims with any surgical procedure had a PPV of 53% and sensitivity of 79% in identifying urinary catheterization. The PPV and sensitivity for identifying hospital-acquired CAUTIs varied, with the PPV at 30% and sensitivity at 65% in claims with major surgery. About 80% of the secondary diagnosis codes indicating UTIs were flagged as POA, suggesting that the addition of POA indicators in Medicare claims would increase PPV up to 86% and sensitivity up to 79% in identifying hospital-acquired CAUTIs. Conclusions:The validity in identifying urinary catheter use and CAUTIs from Medicare claims is limited, but will be increased substantially upon addition of a POA indicator.

Economic assessment of the community-acquired pneumonia intervention trial employing levofloxacin.

OBJECTIVE The purpose of this study was to assess use of a critical pathway designed to manage community-acquired pneumonia more efficiently than its management with conventional therapy. METHODS Economic outcomes were assessed in conjunction with a cluster-design, randomized, controlled trial. Nineteen participating Canadian hospitals were randomized to implement the critical pathway (n = 9) or conventional therapy (n = 10). The critical pathway included a clinical prediction rule to guide the admission decision, treatment with levofloxacin, and practice guidelines. Patient data on medical resource use, lost productivity, and quality of life were collected prospectively for > or =6 weeks after treatment. Costs were calculated from the government, health care system, and societal perspectives, with imputation of missing outpatient costs and the costs of lost productivity when necessary. Bootstrapping was used to identify 95% CIs for the total cost per patient. RESULTS The analysis included all eligible patients in the critical pathway (n = 716) and conventional therapy (n = 1027) arms. There were fewer hospital admissions in the critical pathway arm than in the conventional therapy arm, both overall (46.5% vs 62.2%; P = 0.01) and in low-risk patients (33.2% vs 46.8%; P < 0.001). Compared with conventional therapy, hospitals in the critical pathway arm had 1.6 fewer bed days per patient managed (P = 0.05) and used fewer inpatient medical resources. The 2 study arms had similar outpatient, readmission, and lost-productivity costs, and similar quality-of-life outcomes. The critical pathway produced cost savings from all 3 perspectives that ranged from

How Useful Are Voluntary Medication Error Reports? The Case of Warfarin-Related Medication Errors

457 to

Modifying Drg-pps to Include Only Diagnoses Present on Admission: Financial Implications and Challenges

994 per patient. CONCLUSIONS The critical pathway employing levofloxacin resulted in cost savings compared with conventional therapy and did not compromise health outcomes.

Accidental iatrogenic pneumothorax in hospitalized patients.

BACKGROUND A study was conducted to explore the value and limitations of voluntary medical error reports and to learn about common errors in warfarin use. METHODS Voluntary reports of 8,837 inpatient errors and 820 outpatient errors in warfarin use submitted by 445 hospitals and 192 outpatient facilities participating in MEDMARX, a voluntary medication error reporting system, from 2002 to 2004, were gathered. RESULTS Overall, errors occurred most often during transcription/documentation (35%) and administration (30%) in hospitals, and during prescribing (31%) and dispensing (39%) in outpatient settings. Dosing errors were the most common type. In hospitals, more than 50% of reported errors were initiated by nurses, and 50% were intercepted by nurses, whereas in outpatient settings, about 50% of reported errors occurred in pharmacies and 50% were intercepted by pharmacists. About 17% of inpatient and 13% of outpatient warfarin errors resulted in changes in patient care, and 42% of inpatient and 62% of outpatient errors resulted in procedural changes. Cascade analysis and textual descriptions further located specific, correctible safety lapses. DISCUSSION Voluntary medical error reporting systems can, to some extent, provide meaningful and actionable information to guide patient safety improvement, but their usefulness is limited because of a lack of details, incomplete reporting, underreporting, and various reporting biases.