Gregory W. Ruhnke

Trends in Mortality and Medical Spending in Patients Hospitalized for Community-Acquired Pneumonia: 1993 – 2005

Background:Community-acquired pneumonia (CAP) is the most common infectious cause of death in the United States. To understand the effect of efforts to improve quality and efficiency of care in CAP, we examined the trends in mortality and costs among hospitalized CAP patients. Methods:Using the National Inpatient Sample between 1993 and 2005, we studied 569,524 CAP admissions. The primary outcome was mortality at discharge. We used logistic regression to evaluate the mortality trend, adjusting for age, gender, and comorbidities. To account for the effect of early discharge practices, we also compared daily mortality rates and performed a Cox proportional hazards model. We used a generalized linear model to analyze trends in hospitalization costs, which were derived using cost-to-charge ratios. Results:Over time, length of stay declined, while more patients were discharged to other facilities. The frequency of many comorbidities increased. Age/gender-adjusted mortality decreased from 8.9% to 4.1% (P < 0.001). In multivariable analysis, the mortality risk declined through 2005 (odds ratio, 0.50; 95% confidence interval, 0.48–0.53), compared with the reference year 1993. The daily mortality rates demonstrated that most of the mortality reduction occurred early during hospitalization. After adjusting for early discharge practices, the risk of mortality still declined through 2005 (hazard ratio, 0.74; 95% confidence interval, 0.70–0.78). Median hospitalization costs exhibited a moderate reduction over time, mostly because of reduced length of stay. Conclusions:Mortality among patients hospitalized for CAP has declined. Lower in-hospital mortality at a reduced cost suggests that pneumonia is a case of improved productivity in health care.

Understanding patient-centred readmission factors: a multi-site, mixed-methods study

Importance Patient concerns at or before discharge inform many transitional care interventions; few studies examine patients’ perceptions of self-care and other factors related to readmission. Objectives To characterise patient-reported or caregiver-reported factors contributing to readmission. Design, setting and participants Cross-sectional, national study of general medicine patients readmitted within 30 days at 12 US hospitals. Interviews included multiple-choice survey and open-ended survey questions of patients or their caregivers. Measurements Multiple-choice survey quantified post-discharge difficulty in seven domains of self-care: medication use, contacting providers, transportation, basic needs (eg, food and shelter), diet, social support and substance abuse. Open-ended responses were coded into themes that added depth to the domains above or captured additional patient-centred concerns. Results We interviewed 1066 readmitted patients. 91% reported understanding their discharge plan; however, only 37% reported that providers asked about barriers to carrying out the plan. 52% reported experiencing difficulty in ≥1 self-care domains ranging in frequency from 22% (diet) to 7% (substance use); 26% experienced difficulty in two or more domains. Among 508 patients (48% overall) who reported no difficulties in these domains, two-thirds either could not attribute their readmission to any specific difficulty (34%) or attributed their readmission to progression or persistence of their disease despite following their discharge plan (31%). Only 20% attributed their readmission to early discharge (8%), poor-quality hospital care (6%) or issues such as inadequate discharge instructions or follow-up care (6%). Limitations The study population included only patients readmitted at academic medical centres and may not be representative of community-based care. Conclusion Patients readmitted within 30 days reported understanding their discharge plans, but frequent difficulties in self-care and low anticipatory guidance for resolving these issues after discharge.

Redesigning Care For Patients At Increased Hospitalization Risk: The Comprehensive Care Physician Model

Patients who have been hospitalized often experience care coordination problems that worsen outcomes and increase costs. One reason is that hospital care and ambulatory care are often provided by different physicians. However, interventions to improve care coordination for hospitalized patients have not consistently improved outcomes and generally have not reduced costs. We describe the rationale for the Comprehensive Care Physician model, in which physicians focus their practice on patients at increased risk of hospitalization so that they can provide both inpatient and outpatient care to their patients. We also describe the design and implementation of a study supported by the Center for Medicare and Medicaid Innovation to assess the models effects on costs and outcomes. Evidence concerning the effectiveness of the program is expected by 2016. If the program is found to be effective, the next steps will be to assess the durability of its benefits and the models potential for dissemination; evidence to the contrary will provide insights into how to alter the program to address sources of failure.

Association of Patient Preferences for Participation in Decision Making With Length of Stay and Costs Among Hospitalized Patients

IMPORTANCE Patient participation in medical decision making has been associated with improved patient satisfaction and health outcomes. However, there is little evidence concerning its effects on resource utilization. Patient participation in medical decision making has been hypothesized to decrease excess utilization but might be expected to increase utilization when other decision makers have incentives to reduce utilization, as under prospective payment systems for hospital care. OBJECTIVE To examine the relationship between patient preferences for participation in medical decision making and health care utilization among hospitalized patients. DESIGN AND SETTING Survey study in an academic research setting. PARTICIPANTS A survey that included questions about preferences to receive medical information and to participate in medical decision making was administered to all patients admitted to the University of Chicago Medical Center general internal medicine service between July 1, 2003, and August 31, 2011, and completed by 21,754 (69.6%) of admitted patients. MAIN OUTCOMES AND MEASURES The survey data were linked with administrative data, including length of stay and total hospitalization costs. We used generalized linear models to measure the association of patient preference for participation in decision making with length of stay and costs. RESULTS The mean length of stay was 5.34 days, and the mean hospitalization costs were

Trends in Pathogens Among Patients Hospitalized for Pneumonia From 1993 to 2011

14,576. While 96.3% of patients expressed a desire to receive information about their illnesses and treatment options, 71.1% of patients preferred to leave medical decision making to their physician. Preference to participate in decision making increased with educational level and with private health insurance. Compared with patients who had a strong desire to delegate decisions to their physician, patients who preferred to participate in decision making concerning their care had a 0.26-day (95% CI, 0.06-0.47 day) longer length of stay (P = .01) and

Mortality Reduction among Pneumonia Patients Still Substantial despite the Impact of Coding Changes

865 (95% CI,

Trust in Residents and Board Examinations: When Sharing Crosses the Boundary

155-

Applying Classification Trees to Hospital Administrative Data to Identify Patients with Lower Gastrointestinal Bleeding.

1575) higher total hospitalization costs (P = .02). CONCLUSIONS AND RELEVANCE Patient preference to participate in decision making concerning their care may be associated with increased resource utilization among hospitalized patients. Variation in patient preference to participate in medical decision making and its effects on costs and outcomes in the presence of varying physician incentives deserve further examination.

Palliative Care in Critical Care Settings: A Systematic Review of Communication-Based Competencies Essential for Patient and Family Satisfaction.

The Nationwide Inpatient Sample aggregated data from approximately 20% of US hospital admissions from 1993 to 2011. Prior literature found that pneumonia admissions decreased following the introduction of the pneumococcal vaccine in 2000.1 The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes provide information regarding pneumonia pathogens, but no studies, to our knowledge, have used these codes to analyze longitudinal trends in the pathogens documented during hospitalizations for pneumonia.

Discharge disposition as an independent predictor of readmission among patients hospitalised for community-acquired pneumonia

BACKGROUND Accounting for changes in coding practices may be important in analyzing trends based on administrative data. Several studies have demonstrated large reductions in mortality over time among pneumonia patients. However, a recent study suggested that this reduction may have been an artifact of case definition because more of the highest-risk patients were being coded under alternative principal diagnoses in recent years. METHODS Using the National Inpatient Sample from 1993 to 2005, we selected hospitalizations with a principal diagnosis of pneumonia or a secondary diagnosis of pneumonia and a principal diagnosis of sepsis or respiratory failure. We performed logistic regression, estimating the likelihood of in-hospital mortality in each year, adjusting for age, sex, and comorbidities. RESULTS Over time, there was a substantial increase in the frequency of sepsis and respiratory failure as a principal diagnosis. Length of stay decreased in all 3 principal diagnosis groups. By 2005, the adjusted odds ratio (OR) of death among principal diagnosis pneumonia and respiratory failure hospitalizations decreased to 0.50 (95% confidence interval [CI], 0.49-0.51) and 0.62 (95% CI, 0.58-0.66), respectively, compared with 1993. With all 3 groups combined, there was still a substantial, albeit attenuated, reduction in the risk of mortality (OR(2005) 0.70; 95% CI, 0.69-0.72). CONCLUSIONS Survival of patients with community-acquired pneumonia has improved greatly over time. However, interpretation of such findings based on administrative data must be made with caution and careful attention to case definition and coding trends.