Dwain L. Harper

Reliability of birth certificate data: a multi-hospital comparison to medical records information.

Objective: To examine the reliability of birth certificate data and determine if reliability differs between teaching and nonteaching hospitals. Methods: We compared information from birth certificates and medical records in 33,616 women admitted for labor and delivery in 1993–95 to 20 hospitals in Northeast Ohio. Analyses determined the agreement for 36 common data elements, and the sensitivity, specificity, and positive and negative predictive values of birth certificate data, using medical record data as a “gold standard.” Results: Sensitivity and positive predictive value varied widely (9–100% and 2–100%, respectively), as did agreement, which was “almost perfect” for measures of prior obstetrical history, delivery type, and infant Apgar score (κ = 0.854–0.969) and “substantial” for several other variables (e.g., tobacco use (κ = 0.766), gestational age (κ = 0.726), prenatal care (κ = 0.671)). However, agreement was only “slight” to “moderate” for most maternal risk factors and comorbidities (κ = 0.085–0.545) and for several complications of pregnancy and/or labor and delivery (κ = 0.285–0.734). Overall agreement was similar in teaching (mean κ = 0.51) and nonteaching (κ = 0.52) hospitals. Although agreement in teaching and nonteaching hospitals varied for some variables, no systematic differences were seen across types of variables. Conclusions: Our findings indicate that the reliability of birth certificate data vary for specific elements. Researchers and health policymakers need to be cognizant of the potential limitations of specific data elements.

Racial Variation in the Use of Do-Not-Resuscitate Orders

OBJECTIVE: To compare the use of do-not-resuscitate (DNR) orders in African-American and white patients using a large, multisite, community-based sample.MEASUREMENTS: Our sample included 90,821 consecutive admissions to 30 hospitals in a large metropolitan region with six nonsurgical conditions from 1993 through 1995. Demographic and clinical data were abstracted from medical records. Admission severity of illness was measured using multivariate risk-adjustment models with excellent discrimination (receiver-operating characteristic curve areas, 0.82–0.88). Multiple logistic regression analysis was used to determine the independent association between race and use of DNR orders, adjusting for age, admission severity, and other covariates.MAIN RESULTS: In all patients, the rate of DNR orders was lower in African Americans than whites (9% vs 18%; p<.001). Rates of orders were also lower (p<.001) among African Americans in analyses stratified by age, gender, diagnosis, severity of illness, and in-hospital death. After adjusting for severity and other important covariates, the odds of a DNR order remained lower (p<.001) for African-Americans relative to whites for all diagnoses, ranging from 0.38 for obstructive airway disease to 0.71 for gastrointestinal hemorrhage. Results were similar in analyses limited to orders written by the first, second, or seventh hospital day. Finally, among patients with DNR orders, African Americans were less likely to have orders written on the first hospital day and more likely to have orders written on subsequent days.CONCLUSIONS: The use of DNR orders was substantially lower in African Americans than in whites, even after adjusting for severity of illness and other covariates. Identification of factors underlying such differences will improve our understanding of the degree to which expectations for care differ in African American and white patients.

Cleveland Health Quality Choice: A Model for Collaborative Community-Based Outcomes Assessment

BACKGROUND Cleveland Health Quality Choice Coalition was established in 1989 as a voluntary, collaborative effort between hospitals, physicians, and purchasers in the Cleveland metropolitan area to assess the quality and efficiency of care in 31 hospitals. The objective of the project is to produce high-fidelity comparative hospital outcomes data that support market-based health care reform strategies. METHODS The project reports on a broad spectrum of hospital outcomes, including patient satisfaction, in-hospital mortality, length of stay, hospital-acquired complications, and cesarean section rates for adult medical, surgical, obstetrical, and intensive care patients. Intensive care outcomes and patient satisfaction are assessed using previously validated measurement systems. Outcomes for medical, surgical, and obstetrical patients are examined using a standardized data collection and severity adjustment methodology developed by Cleveland physicians and an independent consultant. RESULTS The project released its initial report to purchasers in April 1993, with subsequent reports scheduled for release every six months. Several policies, procedures, and programs have been instituted to ensure data quality and participant buy-in. These include initial testing and rigorous validation of all outcomes measurement systems before release of data, a commitment to continuously refine risk-adjustment methodologies, independent auditing of data reliability, and a series of user-training workshops for project participants and local news media. CONCLUSION The early success of Cleveland Health Quality Choice Coalition demonstrates that it is possible for purchasers and providers to cooperatively assess the quality of health care on a regional basis and to institute a market-based strategy for health care reform. Further evaluation is needed to determine how performance data being reported are used by purchasers in selecting health care and by hospitals for quality improvement.

The Effectiveness of Early Endoscopy for Upper Gastrointestinal Hemorrhage: A Community-based Analysis

OBJECTIVES The effectiveness of upper endoscopy in unselected patients with upper gastrointestinal hemorrhage has not been well studied. This study was undertaken to identify factors associated with the performance of early endoscopy (ie, within 1 day of hospitalization) and, after adjusting for these factors, to determine associations between early endoscopy and in-hospital mortality, length of stay, and performance of surgery. METHODS Subjects in this observational cohort study were 3,801 consecutive admissions with upper gastrointestinal hemorrhage to 30 hospitals in a large metropolitan region. Demographic and clinical data were abstracted from hospital records. A multivariable model based on factors that potentially could relate to the decision to perform endoscopy was developed to determine the propensity (0 to 100%) for early endoscopy in each patient. RESULTS Early endoscopy was performed in 2,240 patients (59%), and although it was not associated with mortality after adjusting for severity of illness among all patients, it was associated with a higher risk of death for patients in the lowest propensity group. Early endoscopy was associated with a lower likelihood of upper gastrointestinal surgery in all patients and in the two highest propensity groups and with a shorter length of stay in the entire cohort and in all subgroups. CONCLUSIONS In the absence of specific contraindications, early endoscopy should be considered because of associated reductions in length of stay and surgical intervention. Further studies are needed to identify subgroups in whom the procedure may be associated with adverse effects on survival.

Differences in patient-reported processes and outcomes between men and women with myocardial infarction

OBJECTIVE: Previous research meassuring differences in the care between men and women with myocardial infarction has focused on differences in procedure use and mortality. However, little is known about differences in processes and outcomes that are reported by patients, such as interpersonal processes of care and health status. Our goal was to measure differences in patient-reported measures for men and women who recently were hospitalized with myocardial infarction.PARTICIPANTS AND SETTING: We surveyed by mail patients with myocardial infarction discharged to home from one of 27 Cleveland area hospitals 3 months following discharge; 502 (64%) of 783 patients responded. The mean age of subjects was 65 years and 40% were women.MEASUREMENTS: Process measures included the quality of communication during the hospitalization and at time of discharge and reports of health education discussions during hospitalization. Outcome measures included physical and mental health component scores of the Medical Outcomes Study 36-Item Short-Form Health Survey, change in work status, and days spent in bed because of ill health. We compared processes and outcomes in men and women using multivariate analyses that adjusted for age, other demographic characteristics, comorbid conditions, severity of the myocardial infarction, and premorbid global health status.MAIN RESULTS: In multivariate analyses, women were as likely as men to report at least one problem with communication during the hospitalization (odds ratio [OR] 0.86; 95% confidence interval [95% CI] 0.56 to 1.33) or at time of discharge (OR 1.24; 95% CI, 0.82 to 1.89) and to report that they were given dietary advice before discharge (OR 0.60; 95% CI, 0.36 to 1.01), were told what to do if they developed chest pain (OR 1.21; 95% CI, 0.66 to 2.23), or, if they smoked cigarettes, given advice about how to stop smoking (OR 0.64; 95% CI, 0.26 to 1.58). However, 3 months after discharge, women reported worse physical health (P <.05) and mental health (P<.05), were more likely to report spending time in bed because of ill health (OR 1.80; 95% CI, 1.06, 3.05), and were more likely to report working less than before their myocardial infarction (OR 4.02; 95% CI, 1.58 to 10.20).CONCLUSIONS: In terms of processes of care measured with patient reports, women with myocardial infarction reported their quality of care to be similar to that of men. However, 3 months following myocardial infarction, women reported worse health status and were less likely to return to work than men.

Mortality and length of stay in a Veterans affairs hospital and private sector hospitals serving a common market

OBJECTIVE: To compare severity-adjusted in-hospital mortality and length of stay (LOS) in a Veterans Administration (VA) hospital and private sector hospitals serving the same health care market.DESIGN: Retrospective cohort study.SETTING: A large VA hospital and 27 private sector hospitals in the same metropolitan area.PATIENTS: Consecutive VA (N=1,960) and private sector (N=157,147) admissions in 1994 to 1995 with 9 high-volume diagnoses.MEASUREMENTS: Severity of illness was measured using validated multivariable models that were based on data abstracted from medical records. Outcomes were adjusted for severity and compared in VA and private sector patients using multiple logistic or linear regression analysis.MAIN RESULTS: Unadjusted mortality was similar in VA and private sector patients (5.0% vs 5.6%, respectively; P=.26), although mean LOS was longer in VA patients (12.7 vs 7.0 days; P<.001). Adjusting for severity, the odds of death in VA patients was similar (odds ratio [OR] 1.07; 95% confidence interval [95% CI], 0.74 to 1.54; P=.73). However, a larger proportion of deaths in VA patients occurred later during hospitalization (P<.001), and the odds of death in VA patients were actually lower (P<.05) in analyses limited to deaths during the first 7 (OR, 0.56) or 14 (OR, 0.63) days. Adjusted LOS was longer (P<.001) in VA patients for all 9 diagnoses.CONCLUSIONS: If the current findings generalizable to other markets, hospital mortality, a widely used performance measure, may be similar or lower in VA and private sector hospitals serving the same markets. The longer LOS of VA patients may reflect differences in practice patterns and may be an important source of bias in comparisons of VA and private sector hospitals.

Racial differences in the utilization of oral anticoagulant therapy in heart failure : A study of elderly hospitalized patients

To assess racial differences in the use of oral anticoagulant therapy for patients with heart failure, we conducted a cohort study of 30 hospitals in northeast Ohio. For 12,911 Medicare enrollees consecutively admitted in 1992 through 1994 with heart failure, crude and adjusted odds of being on oral anticoagulation were determined. The crude and adjusted odds of being African Americans on oral anticoagulant therapy relative to whites were 0.57 (95% confidence interval 0.47–0.69) and 0.55 (95% confidence interval 0.45–0.67), respectively. African-Americans with heart failure were much less likely than whites to receive oral anticoagulant therapy, even after adjusting for other variables associated with anticoagulant use.

Endoscopic practice for upper gastrointestinal hemorrhage: differences between major teaching and community-based hospitals☆☆☆★★★

BACKGROUND Differences in endoscopic practice in major teaching and community hospitals are not known. METHODS A total of 1031 consecutive patients discharged from 13 hospitals (4 major teaching, 9 others) in 1994 with upper gastrointestinal hemorrhage were studied. Data obtained from chart abstraction included endoscopic findings and therapy and selected outcomes. Multivariable analyses adjusted for admission severity of illness and endoscopic findings. RESULTS Rates of endoscopy were similar between patients admitted to major teaching and other hospitals, although procedures to control hemorrhage were used more often in major teaching hospitals (35% vs. 19%, p < 0.001). Use of endoscopic therapy was higher in major teaching hospitals for lesions in which therapy is recommended, as well as other lesions. Recurrent bleeding was also more common in major teaching hospitals (14.3% vs. 7.8%, p = 0.001), and the difference persisted in multivariable analysis (odds ratio 1.69: 95% CI [1.09 to 2.64], p = 0.02). Unadjusted and adjusted length of stay were somewhat shorter in major teaching hospitals. CONCLUSIONS There was large variation in the use of endoscopic therapy, with higher rates observed in major teaching hospitals for lesions in which therapy is recommended, as well as other stigmata. Further studies are needed to better define the reasons for the practice variation and to assess the impact on other outcomes such as readmission and costs.

Racial differences in mortality among elderly patients admitted for heart failure

Several studies have examined predictors of mortality among elderly patients hospitalized with heart failure. In some, elderly African American patients hospitalized for heart failure were reported to have lower risk-adjusted in-hospital mortality compared with Whites. Whether this difference is sustained in the long term and what factors account for this difference remain poorly understood. The objective of this study was to compare risk-adjusted short-term and long-term mortality of a cohort of elderly African American and White patients hospitalized for heart failure to all 30 hospitals in northeast Ohio. The database used for this analysis includes information on demographics and detailed clinical information abstracted from patients’ hospital records. Crude and adjusted 30-day and 18-month survival were compared using Kaplan-Meier method and logistic regression models for multivariate analysis. African American patients had significantly lower 30-day mortality compared with Whites. However, this difference diminished over time and when adjusted for important explanatory covariates, including “do not resuscitate” orders.