Hsou Mei Hu

A validation study of a retrospective venous thromboembolism risk scoring method.

Objectives:Validate a retrospective venous thromboembolism (VTE) risk scoring method, which was developed at the University of Michigan Health System and based on the Caprini risk assessment model, and assess the confounding effects of VTE prophylaxis. Background:Assessing patients for risk of VTE is essential to initiating appropriate prophylaxis and reducing the mortality and morbidity associated with deep vein thrombosis and pulmonary embolism. Methods:VTE risk factors were identified for 8216 inpatients from the National Surgical Quality Improvement Program using the retrospective scoring method. Logistic regression was used to calculate odds ratios (OR) for VTE within 30 days after surgery for risk factors and risk level. A bivariate probit model estimated the effects of risk while controlling for adherence to prophylaxis guidelines. Results:Distribution of the study population by risk level was highest, 52.1%; high, 36.5%; moderate, 10.4%; and low, 0.9%. Incidence of VTE within 30 days was overall 1.4%; by risk level: highest, 1.94%; high, 0.97%; moderate, 0.70%; low, 0%. Controlling for length of hospitalization (>2 d) and fiscal year, pregnancy or postpartum (OR = 8.3; 1.0–68, P < 0.05), recent sepsis (4.0; 1.4–10.9, P < 0.01), malignancy (2.3; 1.5–3.3, P < 0.01), history of VTE (2.1; 1.1–4.1, P < 0.05), and central venous access (1.8; 1.1–3.0, P < 0.05) were significantly associated with VTE. Risk level was significantly associated with VTE (1.9; 1.3–2.6, P < 0.01). The bivariate probit demonstrated significant correlation between the probability of VTE and lack of adherence to prophylaxis guidelines (&rgr; = 0.299, P = 0.013). Conclusion:The retrospective risk scoring method is valid and supports use of individual patient assessment of risk for VTE within 30 days after surgery.

Stratifying the Risk of Venous Thromboembolism in Otolaryngology

Objective. The consequences of perioperative venous thromboembolism (VTE) are devastating; identifying patients at risk is an essential step in reducing morbidity and mortality. The utility of perioperative VTE risk assessment in otolaryngology is unknown. This study was designed to risk-stratify a diverse population of otolaryngology patients for VTE events. Study Design. Retrospective cohort study. Setting. Single-institution academic tertiary care medical center. Subjects and Methods. Adult patients presenting for otolaryngologic surgery requiring hospital admission from 2003 to 2010 who did not receive VTE chemoprophylaxis were included. The Caprini risk assessment was retrospectively scored via a validated method of electronic chart abstraction. Primary study variables were Caprini risk scores and the incidence of perioperative venous thromboembolic outcomes. Results. A total of 2016 patients were identified. The overall 30-day rate of VTE was 1.3%. The incidence of VTE in patients with a Caprini risk score of 6 or less was 0.5%. For patients with scores of 7 or 8, the incidence was 2.4%. Patients with a Caprini risk score greater than 8 had an 18.3% incidence of VTE and were significantly more likely to develop a VTE when compared to patients with a Caprini risk score less than 8 (P < .001). The mean risk score for patients with VTE (7.4) was significantly higher than the risk score for patients without VTE (4.8) (P < .001). Conclusion. The Caprini risk assessment model effectively risk-stratifies otolaryngology patients for 30-day VTE events and allows otolaryngologists to identify patient subgroups who have a higher risk of VTE in the absence of chemoprophylaxis.

Do the Ahrq Patient Safety Indicators Flag Conditions That Are Present at the Time of Hospital Admission

Objective:The Agency for Healthcare Research and Quality (AHRQ) developed 20 patient safety indicators (PSIs) to identify potentially preventable complications of acute inpatient care based on administrative data. The objective of this patient safety performance study was to assess the impact of cases flagged by each PSI for diagnoses that were actually present on admission on unadjusted PSI rates. Methods:The latest AHRQ PSI software, which allows users to produce 14 of the 20 PSIs for adult inpatients both without and with a “present on admission” (PoA) variable, was applied to administrative data for adult patients discharged from the University of Michigan Health System (UMHS) in 2006. The impact of the PoA values on unadjusted PSI rates was evaluated. Because of concerns about the accuracy of PoA values, results were compared with those of a prior analysis at UMHS that was similar but based on a review of medical records. Findings:Thirteen PSIs had at least 1 case in the numerator. Rates for all but 1 of the 13 were lower using the PoA values and the reduction was statistically significant for 5 PSIs: decubitus ulcer (P < 0.001), foreign body left in (P = 0.033), selected infections due to medical care (P < 0.001), postoperative physiologic and metabolic derangement (P = 0.039), and postoperative pulmonary embolism or deep vein thrombosis (P < 0.001). Results were consistent with those of the analysis of medical records. Conclusions:Unadjusted PSI rates at UMHS are substantially overstated, because the PSIs do not differentiate preexisting conditions from complications and therefore include false positive cases. Because of these findings and the lack of a broader study of the validity of the indicators, PSIs should not be used to profile hospital performance.

Chemoprophylaxis for Venous Thromboembolism in Otolaryngology

IMPORTANCE Venous thromboembolism (VTE) causes significant morbidity and mortality in surgical patients. Despite strong evidence that thromboprophylaxis reduces the incidence VTE, guidelines for prophylaxis in otolaryngology are not well established. Key to the development of VTE prophylaxis recommendations are effective VTE risk stratification and evaluation of the benefits and harms of prophylaxis. OBJECTIVE To evaluate the effectiveness and safety of VTE chemoprophylaxis among a population of otolaryngology patients stratified by risk. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 3498 adult patients admitted for otolaryngologic surgery at a single-institution academic tertiary care medical center between September 1, 2003, and June 30, 2010. INTERVENTIONS Patients were stratified into 2 groups based on whether they received VTE chemoprophylaxis. MAIN OUTCOMES AND MEASURES Incidence of VTE and bleeding-related complications within 30 days after surgery. RESULTS Of 1482 patients receiving VTE chemoprophylaxis, 18 (1.2%) developed a VTE compared with 27 of 2016 patients (1.3%) who did not receive prophylaxis (P = .75). Patients with Caprini VTE risk scores greater than 7 were less likely to have a VTE with perioperative chemoprophylaxis (5.3% vs 10.4%; P = .06). Of patients with VTE chemoprophylaxis, 3.5% developed a bleeding complication compared with 1.2% of patients without prophylaxis (P < .001). Bleeding complications were associated with concomitant use of antiplatelet medications and chemoprophylaxis. Among patients undergoing free tissue transfer, chemoprophylaxis significantly decreased the incidence of VTE (2.1% vs 7.7%; P = .002) and increased bleeding complications (11.9% vs 4.5%; P = .01). In all other patients, VTE chemoprophylaxis did not significantly influence the likelihood of VTE (1.0% vs 0.6%; P = .12) or bleeding (1.5% vs 0.9%; P = .15). CONCLUSIONS AND RELEVANCE Effectiveness and safety of VTE chemoprophylaxis differed between patient subgroups, defined by Caprini risk score and by procedure. Effectiveness was most evident in patients with high Caprini risk scores and microvascular free tissue reconstruction. Bleeding complications were associated with VTE chemoprophylaxis administered in close proximity to potent antiplatelet therapy. The Caprini risk assessment model appears to be an effective tool to stratify otolaryngology patients by risk for VTE. Patients undergoing free tissue reconstruction merit further study before developing recommendations for VTE prophylaxis because of their higher risk of both VTE and bleeding.

Detection of co-occurring mental illness among adult patients in the New Jersey substance abuse treatment system

OBJECTIVES We assessed the detection of mental illness in an adult population of substance abuse patients and the rate of referral for mental health treatment. METHODS We obtained combined administrative records from 1994 to 1997 provided by the New Jersey substance abuse and mental health systems and estimated detection and referral rates of patients with co-occurring disorders (n = 47,379). Mental illness was considered detected if a diagnosis was in the record and considered undetected if a diagnosis was not in the record but the patient was seen in both treatment systems within the same 12-month period. Predictors of detection and referral were identified. RESULTS The detection rate of co-occurring mental illness was 21.9% (n=10364); 57.9% (n=6001) of these individuals were referred for mental health treatment. Methadone maintenance clinics had the lowest detection rate but the highest referral rate. Male, Hispanic, and African American patients, as well as those who used heroin or were in the criminal justice system, had a higher risk of mental illness not being detected. Once detected, African American patients, heroin users, and patients in the criminal justice system were less likely to be referred for treatment. CONCLUSIONS There is a need to improve the detection of mental illness among substance abuse patients and to provide integrated treatment.

New persistent opioid use Among patients with cancer after curative-intent surgery

Purpose The current epidemic of prescription opioid misuse has increased scrutiny of postoperative opioid prescribing. Some 6% to 8% of opioid-naïve patients undergoing noncancer procedures develop new persistent opioid use; however, it is unknown if a similar risk applies to patients with cancer. We sought to define the risk of new persistent opioid use after curative-intent surgery, identify risk factors, and describe changes in daily opioid dose over time after surgery. Methods Using a national data set of insurance claims, we identified patients with cancer undergoing curative-intent surgery from 2010 to 2014. We included melanoma, breast, colorectal, lung, esophageal, and hepato-pancreato-biliary/gastric cancer. Primary outcomes were new persistent opioid use (opioid-naïve patients who continued filling opioid prescriptions 90 to 180 days after surgery) and daily opioid dose (evaluated monthly during the year after surgery). Logistic regression was used to identify risk factors for new persistent opioid use. Results A total of 68,463 eligible patients underwent curative-intent surgery and filled opioid prescriptions. Among opioid-naïve patients, the risk of new persistent opioid use was 10.4% (95% CI, 10.1% to 10.7%). One year after surgery, these patients continued filling prescriptions with daily doses similar to chronic opioid users ( P = .05), equivalent to six tablets per day of 5-mg hydrocodone. Those receiving adjuvant chemotherapy had modestly higher doses ( P = .002), but patients with no chemotherapy still had doses equivalent to five tablets per day of 5-mg hydrocodone. Across different procedures, the covariate-adjusted risk of new persistent opioid use in patients receiving adjuvant chemotherapy was 15% to 21%, compared with 7% to 11% for those with no chemotherapy. Conclusion New persistent opioid use is a common iatrogenic complication in patients with cancer undergoing curative-intent surgery. This problem requires changes to prescribing guidelines and patient counseling during the surveillance and survivorship phases of care.

Inadequate Venous Thromboembolism Risk Stratification Predicts Venous Thromboembolic Events in Surgical Intensive Care Unit Patients

BACKGROUND Surgical intensive care unit (SICU) patients are known to be at high risk for venous thromboembolism (VTE). The 2005 Caprini Risk Assessment Model (RAM) predicts VTE risk in surgical patients. However, a physicians ability to accurately complete this RAM and the effect that inaccurate RAM completion might have on VTE risk remain unknown. STUDY DESIGN Between 2009 and 2012, physicians completed a 2005 Caprini score for all SICU admissions at our institution. For comparison, we used a previously validated, computer-generated score. Regression-based techniques examined the effect of inadequate risk stratification on inpatient VTE risk, when controlling for other confounders. RESULTS Among 3,338 consecutive SICU admissions, 55.2% had computer-generated scores that were higher than the physician-reported score, and 20.6% of scores were equal. Computer-generated scores were higher than physician-reported scores for both median (6 vs 5) and interquartile range (5 to 8 vs 3 to 7). Inter-rater reliability between the 2 scores was poor (kappa = 0.238). Risk score underestimation by ≥2 points was significantly associated with inpatient VTE (7.67% vs 4.59%, p = 0.002). Regression analysis demonstrated that each additional days delay in chemoprophylaxis (odds ratio [OR] 1.05, 95% CI 1.01 to 1.08, p = 0.011) and under-risk stratification by ≥2 points (OR 2.46, 95% CI 1.53 to 3.96, p < 0.001) were independent predictors of inpatient VTE, as were higher admission APACHE score, personal history of VTE, recent pneumonia, and younger age. CONCLUSIONS Physicians under-risk stratify SICU patients when using the 2005 Caprini RAM. As hospitals incorporate electronic medical records into daily practice, computer-calculated Caprini scores may result in more accurate VTE risk stratification. Inadequate VTE risk assessment and delay to chemoprophylaxis carry independent and significant increased risk for VTE.

Postoperative Opioid Prescribing and the Pain Scores on Hospital Consumer Assessment of Healthcare Providers and Systems Survey

In 2012, the Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to capture key elements of patient satisfaction, including pain management. HCAHPS surveys are administered to patients 48 hours to 6 weeks after discharge, and scores are used to determine hospital payments.1 However, patients complete surveys during a time when many are filling postdischarge opioid prescriptions. This timing has raised concerns that HCAHPS measures could inadvertently incentivize clinicians to overprescribe opioids after discharge to ensure satisfactory ratings and reimbursement.2,3 Citing these concerns, CMS announced it will remove pain management from its determination of hospital payments beginning in 2018, even though little is known regarding the potential correlation between HCAHPS scores and postdischarge opioid prescribing.3 We sought to evaluate the association between HCAHPS pain measures and postoperative opioid prescribing in surgical patients, which accounts for nearly 40% of surgical prescriptions.

Link between patients' perceptions of their acute care hospital experience and institutions' injurious fall rates.

This exploratory study used 4 publicly available large data sets to determine whether significant correlations exist between patients’ perceptions of their acute care hospital experience and hospital-acquired injurious fall rates at their hospitals in the states of California, Florida, and New York in 2007. The results showed that the higher the inpatient satisfaction levels with the responsiveness of hospital staff and cleanliness and quietness of the hospital environment, the lower were the injurious fall rates.

Persistent Opioid Use Among Pediatric Patients After Surgery

Through a national sample of adolescents and young adults, we investigated the incidence of persistent opioid use after common pediatric surgeries. BACKGROUND: Despite efforts to reduce nonmedical opioid misuse, little is known about the development of persistent opioid use after surgery among adolescents and young adults. We hypothesized that there is an increased incidence of prolonged opioid refills among adolescents and young adults who received prescription opioids after surgery compared with nonsurgical patients. METHODS: We performed a retrospective cohort study by using commercial claims from the Truven Health Marketscan research databases from January 1, 2010, to December 31, 2014. We included opioid-naïve patients ages 13 to 21 years who underwent 1 of 13 operations. A random sample of 3% of nonsurgical patients who matched eligibility criteria was included as a comparison. Our primary outcome was persistent opioid use, which was defined as ≥1 opioid prescription refill between 90 and 180 days after the surgical procedure. RESULTS: Among eligible patients, 60.5% filled a postoperative opioid prescription (88 637 patients). Persistent opioid use was found in 4.8% of patients (2.7%–15.2% across procedures) compared with 0.1% of those in the nonsurgical group. Cholecystectomy (adjusted odds ratio 1.13; 95% confidence interval, 1.00–1.26) and colectomy (adjusted odds ratio 2.33; 95% confidence interval, 1.01–5.34) were associated with the highest risk of persistent opioid use. Independent risk factors included older age, female sex, previous substance use disorder, chronic pain, and preoperative opioid fill. CONCLUSIONS: Persistent opioid use after surgery is a concern among adolescents and young adults and may represent an important pathway to prescription opioid misuse. Identifying safe, evidence-based practices for pain management is a top priority, particularly among at-risk patients.