Claudia Campbell

A comparison of hospital adverse events identified by three widely used detection methods

OBJECTIVE Determine the degree of congruence between several measures of adverse events. DESIGN Cross-sectional study to assess frequency and type of adverse events identified using a variety of methods. SETTING Mayo Clinic Rochester hospitals. PARTICIPANTS All inpatients discharged in 2005 (n = 60 599). INTERVENTIONS Adverse events were identified through multiple methods: (i) Agency for Healthcare Research and Quality-defined patient safety indicators (PSIs) using ICD-9 diagnosis codes from administrative discharge abstracts, (ii) provider-reported events, and (iii) Institute for Healthcare Improvement Global Trigger Tool with physician confirmation. PSIs were adjusted to exclude patient conditions present at admission. MAIN OUTCOME MEASURE Agreement of identification between methods. RESULTS About 4% (2401) of hospital discharges had an adverse event identified by at least one method. Around 38% (922) of identified events were provider-reported events. Nearly 43% of provider-reported adverse events were skin integrity events, 23% medication events, 21% falls, 1.8% equipment events and 37% miscellaneous events. Patients with adverse events identified by one method were not usually identified using another method. Only 97 (6.2%) of hospitalizations with a PSI also had a provider-reported event and only 10.5% of provider-reported events had a PSI. CONCLUSIONS Different detection methods identified different adverse events. Findings are consistent with studies that recommend combining approaches to measure patient safety for internal quality improvement. Potential reported adverse event inconsistencies, low association with documented harm and reporting differences across organizations, however, raise concerns about using these patient safety measures for public reporting and organizational performance comparison.

Posttraumatic stress disorder in pregnancy: prevalence, risk factors, and treatment.

OBJECTIVE: To estimate the prevalence of posttraumatic stress disorder and its treatment in economically disadvantaged pregnant women. METHODS: The sample included 744 pregnant Medicaid-eligible women from Women, Infants and Children Supplemental Nutrition Program sites in 5 counties in rural Missouri and the city of St. Louis. Race (black and white) was proportional to clients seen at each site. Women were assessed by using standardized measures of posttraumatic stress disorder, 18 other psychiatric disorders, environmental stressors, and pregnancy characteristics. Logistic regression identified risk factors associated with posttraumatic stress disorder. RESULTS: Posttraumatic stress disorder prevalence was 7.7% (n = 57/744). Comorbid disorders were common. Women with posttraumatic stress disorder were 5 times more likely to have a major depressive episode (odds ratio 5.17; 95% confidence interval 2.61, 10.26) and more than 3 times as likely to have generalized anxiety disorder (odds ratio 3.25; 95% confidence interval 1.22, 8.62). Besides these comorbid disorders, risk factors for posttraumatic stress disorder included a history of maternal separation for 6 months and multiple traumatic events. Although most women with posttraumatic stress disorder reported moderate impairment in their daily lives, only 7 of the 57 women with this disorder reported speaking with any health professional about it in the last 12 months. CONCLUSIONS: The prevalence of posttraumatic stress disorder in pregnancy and low treatment rates suggest that screening for this disorder should be considered in clinical practice. LEVEL OF EVIDENCE: II-2

Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources

Context:Many attempts to identify hospital complications rely on secondary diagnoses from billing data. To be meaningful, diagnosis codes must distinguish between diagnoses after admission and those existing before admission. Objective:To assess the influence of diagnoses at admission on patient safety, comorbidity, severity measures, and case mix groupings for Medicare reimbursement. Design:Cross-sectional association of various diagnosis-based clinical and performance measures with and without diagnosis present on admission. Setting:Hospital discharges from Mayo Clinic Rochester hospitals in 2005 (N = 60,599). Patients:All hospital inpatients including surgical, medical, pediatric, maternity, psychiatric, and rehabilitation patients. About 33% of patients traveled more than 120 miles for care. Main Outcome Measures:Hospital patient safety indicators, comorbidity, severity, and case mix measures with and without diagnoses present at admission. Results:Over 90% of all diagnoses were present at admission whereas 27.1% of all inpatients had a secondary diagnosis coded in-hospital. About one-third of discharges with a safety indicator were flagged because of a diagnosis already present at admission, more likely among referral patients. In contrast, 87% of postoperative hemorrhage, 22% of postoperative hip fractures, and 54% of foreign bodies left in wounds were coded as in-hospital conditions. Severity changes during hospitalization were observed in less than 8% of discharges. Slightly over 3% of discharges were assigned to higher weight diagnosis-related groups based on an in-hospital complication. Conclusions:In general, many patient safety indicators do not reliably identify adverse hospital events, especially when applied to academic referral centers. Except as noted, conditions recorded after admission have minimal impact on comorbidity and severity measures or on Medicare reimbursement.

Persistent Tobacco Use During Pregnancy and the Likelihood of Psychiatric Disorders

OBJECTIVES We examined the association between psychiatric disorders and tobacco use during pregnancy. METHODS Data were derived from a population-based cohort of 744 pregnant African American and White low-income women living in urban and rural areas. The Diagnostic Interview Schedule was used to assess women for 20 different psychiatric disorders. RESULTS In comparison with nonusers, persistent tobacco users (women who had used tobacco after confirmation of their pregnancy) and nonpersistent users (women who had used tobacco but not after pregnancy confirmation) were 2.5 and 2 times as likely to have a psychiatric disorder. Twenty-five percent of persistent users had at least 1 of the following diagnoses: generalized anxiety disorder, bipolar I disorder, oppositional disorder, drug abuse or dependence, and attention deficit-hyperactivity disorder. CONCLUSIONS In this cohort study, 5 diagnoses were more prevalent among persistent tobacco users than among nonusers, suggesting that several psychiatric disorders contribute to difficulty discontinuing tobacco use during pregnancy. Smoking cessation efforts focusing on pregnant women may need to address co-occurring psychiatric disorders if they are to be successful.

Predicting persistently high primary care use.

PURPOSE We wanted to identify risk factors for persistently high use of primary care. METHODS We analyzed outpatient office visits to practitioners in family medicine, general internal medicine, general pediatrics, and obstetrics for 1997–1999 among patients in a small Midwestern city covered by a fee-for-service insurance plan with no co-payments for physician visits and no requirement for referral to specialty care. Logistic regression was used to predict which patients with 10 or more primary care visits in 1997 would repeat high use in 1998 based on demographic and diagnostic categories (adjusted clinical groups [ACGs]). A confirmatory data set (high primary care use in 1998 persistent into 1999) was used to evaluate the model. RESULTS Two percent of the 54,074 patients had 10 or more primary care visits in 1997, and of these, almost 19% had 10 or more visits in the next year. Among adults, 4 ambulatory diagnosis groups (ADGs) were simultaneously positive predictors of repeated high primary care visits: unstable chronic medical conditions, see and reassure conditions, minor time-limited psychosocial conditions, and minor signs and symptoms. Meanwhile, pregnancy was negatively associated. The area under the receiver operating characteristic (ROC) curve was 0.794 for adults in the developmental data set and 0.752 in the confirmatory data set, indicating a moderately accurate assessment. A satisfactory model was not developed for pediatric patients. CONCLUSIONS Many persistently high primary care users appear to be overserviced but underserved, with underlying problems not addressed by a medical approach. Some may benefit from psychosocial support, whereas others may be good candidates for disease management interventions.

Psychiatric Disorders and Treatment in Low-Income Pregnant Women

AIMS This study estimated the prevalence of twenty-two 12-month and lifetime psychiatric disorders in a sample of 744 low-income pregnant women and the frequency that women with psychiatric disorders received treatment. METHOD To identify psychiatric disorders, the Diagnostic Interview Schedule (DIS) was administered to Medicaid or Medicaid-eligible pregnant women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). The sample was stratified by the rural or urban location of the WIC sites in southeastern Missouri and the city of St. Louis. Eligible women were enrolled at each site until their numbers were proportional to the racial distribution of African American and Caucasian pregnant women served there. RESULTS The 12-month prevalence of one or more psychiatric disorders was 30.9%. Most common were affective disorders (13.6%), particularly major depressive disorder (8.2%) and bipolar I disorder (5.2%). Only 24.3% of those with a psychiatric disorder reported that they received treatment in the past year. Lifetime prevalence of at least one disorder was 45.6%, with affective disorders being the most frequent (23.5%). Caucasian women were more likely than African Americans to have at least one 12-month disorder, with the difference largely accounted for by nicotine dependence. Higher prevalence of lifetime disorders was also found in Caucasian women, particularly affective disorders and substance use disorders. There were no differences in the prevalence of 12-month or lifetime psychiatric disorders by the urban or rural residence of subjects. CONCLUSIONS With nearly one third of pregnant women meeting criteria for a 12-month psychiatric disorder and only one fourth receiving any type of mental health treatment, comprehensive psychiatric screening during pregnancy is needed along with appropriate treatment.

Associations Between Psychiatric Disorders and Menstrual Cycle Characteristics

An understanding of the relationship between psychiatric disorders and menstrual characteristics is important to the assessment and care of women. Menstrual cycle regularity and length have significant associations with specific current and lifetime psychiatric disorders. The purpose of this study was to investigate whether psychiatric disorders are associated with menstrual cycle length or regularity. The sample included 628 pregnant Medicaid-eligible women from Women, Infants, and Childrens Supplemental Nutrition Program sites in five counties in rural Missouri and the city of St. Louis. Women were assessed for current (12-month) and lifetime psychiatric disorders with the Diagnostic Interview Schedule IV. Menstrual length and regularity were assessed by self-report. Analyses consisted of logistic regression while controlling for race. Independent of the effects of race, (a) women who reported irregular cycles were less than half as likely to have a current anxiety disorder as those that reported regular cycles, and (b) women with shorter cycles (<or=28 days) have one and a half times to two times greater risk of current affective disorder, lifetime affective disorder, lifetime anxiety disorder, lifetime substance use or dependence disorder, and lifetime drug abuse or dependence. A significant interaction effect for race and cycle length indicated that cycle length predicted likelihood of having any lifetime psychiatric disorder for Caucasians only and there was no association between cycle length and lifetime psychiatric diagnosis for African American women.

Effect of illness severity and comorbidity on patient safety and adverse events.

The objective was to investigate the effect of admission health status on hospital adverse events and added costs. Secondary data were from merged administrative and clinical sources for Mayo Clinic Rochester, Minnesota hospital discharges in 2005 (N = 60 599). This was a retrospective cross-sectional study of the effect of demographics, diagnosis group, comorbidity, and admission illness severity on adverse events, incremental costs, and length of stay (LOS) using the Agency for Healthcare Research and Quality Patient Safety Indicators and provider-reported events with harm. Estimates are derived from generalized linear models. Admission severity increased the likelihood of all types of adverse events (7.2% per unit acute physiology score for any event); 7 specific comorbidities were associated with increased events and 2 with decreased events. High admission severity increased incremental costs and LOS. Selected comorbidities increased incremental LOS but had no significant effect on incremental costs. Adverse event reporting should incorporate comorbidity and admission severity. Reimbursement incentives to improve patient safety should consider adjustment for admission health status.

Effect of premium, copayments, and health status on the choice of health plans

Objective:Explore effects of comorbidity and prior health care utilization on choice of employee health plans with different levels of cost sharing. Data Sources/Study Setting:Mayo Clinic employees in Rochester, Minnesota (MCR) under age 65 in January 2004; N = 20,379. Study Design:Assessment of a natural experiment where self-funded medical care benefit options were changed to contain costs within a large medical group practice. Before the change, most employees were enrolled in a plan with first dollar coverage, while 18% had a plan with copays and deductibles. In 2004, 3 existing plans were replaced by 2 new options, one with lower premiums and higher out-of-pocket costs and the other with higher premiums, a lower coinsurance rate, and lower out-of-pocket maximums. Data Collection/Extraction Methods:Data on employees were merged across insurance claims, medical records, eligibility files, and employment files for 2003 and 2004. Principal Findings:As the number of chronic comorbidities among family members increased, the probability of choosing high-premium option also increased. Seventy-two percent of employees with at least 1 family member with comorbidity chose the high-cost option versus 54.7% of employees with no comorbidities. High-premium and low-premium plans seem to subdivide population into discrete risk categories, which may adversely affect the future stability of the insurance plan options. Conclusions:Various factors affect decision making of employees regarding the choice of plan with different levels of cost-sharing. In a natural experiment setting where all options were redesigned, the health status of employees and their dependents played a very significant role in plan choice.

Characteristics of physician relocation following Hurricane Katrina.

INTRODUCTION On August 29, 2005, Hurricane Katrina made landfall along the US Gulf Coast, resulting in the evacuation of >1.5 million people, including nearly 6000 physicians. This article examines the relocation patterns of physicians following the storm, determines the impact that the disaster had on their lives and practices, and identifies lessons learned. METHODS An Internet-based survey was conducted among licensed physicians reporting addresses within Federal Emergency Management Agency-designated disaster zones in Louisiana and Mississippi. Descriptive data analysis was used to describe respondent characteristics. Multivariate logistic regression was performed to identify the factors associated with physician nonreturn to original practice. For those remaining relocated out of state, bivariate analysis with chi or Fisher exact test was used to determine factors associated with plans to return to original practice. RESULTS A total of 312 eligible responses were collected. Among disaster zone respondents, 85.6% lived in Louisiana and 14.4% resided in Mississippi before the hurricane struck. By spring 2006, 75.6% (n = 236) of the respondents had returned to their original homes, whereas 24.4% (n = 76) remained displaced. Factors associated with nonreturn to original employment included family or general medicine practice (OR 0.42, 95% CI 0.17-1.04; P = .059) and severe or complete damage to the workplace (OR 0.24, 95% CI 0.13-0.42; P < .001). CONCLUSIONS A sizeable proportion of physicians remain displaced after Hurricane Katrina, along with a lasting decrease in the number of physicians serving in the areas affected by the disaster. Programs designed to address identified physician needs in the aftermath of the storm may give confidence to displaced physicians to return.