James M. Livingston

Impact of inhaled antiinflammatory therapy on hospitalization and emergency department visits for children with asthma

Objective. Although the efficacy of inhaled antiinflammatory therapy in improving symptoms and lung function in childhood asthma has been shown in clinical trials, the effectiveness of these medications in real-world practice settings in reducing acute health care use has not been well-evaluated. This study examined the effect of inhaled antiinflammatory therapy on hospitalizations and emergency department (ED) visits by children for asthma. Design. Defined population cohort study over 1 year. Setting. Three managed care organizations (MCOs) in Seattle, Boston, and Chicago participating in the Pediatric Asthma Care–Patient Outcome Research and Treatment II trial. Participants. All 11 195 children, between 3 to 15 years old, with a diagnosis of asthma who were enrolled in the 3 MCOs between July 1996 and June 1997. Outcome Measures. We identified children with 1 or more asthma diagnoses using automated encounter data. Medication dispensings were identified from automated pharmacy data. Multivariate logistic regression analysis was used to calculate effects of inhaled antiinflammatory therapy on the adjusted relative risk (RR) for hospitalization and ED visits for asthma. Results. Over 12 months, 217 (1.9%) of children had an asthma hospitalization, and 757 (6.8%) had an ED visit. After adjustment for age, gender, MCO, and reliever dispensing, compared with children who did not receive controllers, the adjusted RRs for an ED visit were: children with any (≥1) dispensing of cromolyn, 0.4 (95% confidence interval [CI]: 0.3, 0.5); any inhaled corticosteroid (ICS), 0.5 (95% CI: 0.4, 0.6); any cromolyn or ICS combined (any controller), 0.4 (95% CI: 0.3, 0.5). For hospitalization, the adjusted RR for cromolyn was 0.6 (95% CI: 0.4, 0.9), for ICS 0.4 (95% CI: 0.3, 0.7), and for any controller 0.4 (95% CI: 0.3, 0.6). A significant protective effect for both events was seen among children with 1 to 5 and with >5 antiinflammatory dispensings. When the analysis was stratified by frequency of reliever dispensing, there was a significant protective effect for controllers on ED visits for children with 1 to 5 and with >5 reliever dispensings and on the risk of hospitalization for children with >5 reliever dispensings. Conclusions. Inhaled antiinflammatory therapy is associated with a significant protective effect on the risk for hospitalization and ED visits in children with asthma. Cromolyn and ICSs were associated with similar effects on risks.asthma drug therapy, inhaled antiinflammatory agents, health maintenance organizations, hospitalization, emergency department.

Antidepressant medication use and risk of persistent pulmonary hypertension of the newborn

To determine the prevalence of persistent pulmonary hypertension of the newborn (PPHN) among infants whose mothers were exposed to antidepressants in the third trimester of pregnancy compared to the prevalence among infants whose mothers were not exposed to antidepressants in the third trimester.

Enhanced Identification of Postoperative Infections among Inpatients

Monitoring antimicrobial exposure and diagnosis codes for certain procedures identifies more postoperative infections than routine surveillance methods.

Efficient Identification of Postdischarge Surgical Site Infections: Use of Automated Pharmacy Dispensing Information, Administrative Data, and Medical Record Information

Although most surgical site infections (SSIs) occur after hospital discharge, there is no efficient way to identify them. The utility of automated claims and electronic medical record data for this purpose was assessed in a cohort of 4086 nonobstetric procedures following which 96 postdischarge SSIs occurred. Coded diagnoses, tests, and treatments were assessed by use of recursive partitioning, with 10-fold cross-validation, and logistic regression with bootstrap resampling. Specific codes and combinations of codes identified a subset of 2% of all procedures among which 74% of SSIs had occurred. Accepting a specificity of 92% improved the sensitivity from 74% to 92%. Use of only hospital discharge diagnosis codes plus pharmacy dispensing data had sensitivity of 77% and specificity of 94%. All of these performance characteristics were better than questionnaire responses from patients or surgeons. Thus, information routinely collected by health care systems can be the basis of an efficient, largely passive, surveillance system for postdischarge SSIs.

Outpatient use of cardiovascular drugs during pregnancy

To provide information on the prevalence of use of cardiovascular drugs, some of which may have fetotoxic or teratogenic effects, in the outpatient setting among pregnant women in the United States.

Use of Medicare Claims to Rank Hospitals by Surgical Site Infection Risk following Coronary Artery Bypass Graft Surgery

OBJECTIVE To evaluate whether longitudinal insurer claims data allow reliable identification of elevated hospital surgical site infection (SSI) rates. DESIGN We conducted a retrospective cohort study of Medicare beneficiaries who underwent coronary artery bypass grafting (CABG) in US hospitals performing at least 80 procedures in 2005. Hospitals were assigned to deciles by using case mix-adjusted probabilities of having an SSI-related inpatient or outpatient claim code within 60 days of surgery. We then reviewed medical records of randomly selected patients to assess whether chart-confirmed SSI risk was higher in hospitals in the worst deciles compared with the best deciles. PARTICIPANTS Fee-for-service Medicare beneficiaries who underwent CABG in these hospitals in 2005. RESULTS We evaluated 114,673 patients who underwent CABG in 671 hospitals. In the best decile, 7.8% (958/12,307) of patients had an SSI-related code, compared with 24.8% (2,747/11,068) in the worst decile ([Formula: see text]). Medical record review confirmed SSI in 40% (388/980) of those with SSI-related codes. In the best decile, the chart-confirmed annual SSI rate was 3.2%, compared with 9.4% in the worst decile, with an adjusted odds ratio of SSI of 2.7 (confidence interval, 2.2-3.3; [Formula: see text]) for CABG performed in a worst-decile hospital compared with a best-decile hospital. CONCLUSIONS Claims data can identify groups of hospitals with unusually high or low post-CABG SSI rates. Assessment of claims is more reproducible and efficient than current surveillance methods. This example of secondary use of routinely recorded electronic health information to assess quality of care can identify hospitals that may benefit from prevention programs.

Using Automated Health Plan Data to Assess Infection Risk from Coronary Artery Bypass Surgery

We determined if infection indicators were sufficiently consistent across health plans to allow comparison of hospitals’ risks of infection after coronary artery bypass surgery. Three managed care organizations accounted for 90% of managed care in eastern Massachusetts, from October 1996 through March 1999. We searched automated inpatient and outpatient claims and outpatient pharmacy dispensing files for indicator codes suggestive of postoperative surgical site infection. We reviewed full text medical records of patients with indicator codes to confirm infection status. We compared the hospital-specific proportions of cases with an indicator code, adjusting for health plan, age, sex, and chronic disease score. A total of 536 (27%) of 1,953 patients had infection indicators. Infection was confirmed in 79 (53%) of 149 reviewed records with adequate documentation. The proportion of patients with an indicator of infection varied significantly (p<0.001) between hospitals (19% to 36%) and health plans (22% to 33%). The difference between hospitals persisted after adjustment for health plan and patients’ age and sex. Similar relationships were observed when postoperative antibiotic information was ignored. Automated claims and pharmacy data from different health plans can be used together to allow inexpensive, routine monitoring of indicators of postoperative infection, with the goal of identifying institutions that can be further evaluated to determine if risks for infection can be reduced.

Assessment of asthma using automated and full-text medical records.

Automated medical records systems are used to study clinical outcomes and quality of care, but this requires accurate disease identification and assessment of severity. We sought to determine the reliability of identifying asthmatics through automated medical and pharmacy records, and the adequacy of such data for severity assessment. All adult health maintenance organization (HMO) members who received at least one asthma drug and an asthma diagnosis between April 1988 and September 1991 were identified. Records of a random sample were reviewed to validate the diagnosis and extract clinical information. Asthma drugs were dispensed to 15,491 individuals; 7583 (49%) also received an asthma diagnosis. Asthma drug use was three times greater for persons with diagnosed asthma compared to those with no diagnosis. Record review revealed that a coded asthma diagnosis had a positive predictive value of 86%. Nearly 4000 ambulatory encounters were reviewed, 10% of which were for asthma; the median number of encounters was two. Asthma symptoms were mentioned in 9% of all encounters; wheezing was most common. Peak flow and spirometry were measured in 4% and 1% of encounters, respectively. Records from recipients of asthma drugs who lacked an asthma diagnosis showed that 79% did not have asthma. Automated medical and pharmacy records from an HMO were relatively accurate when used to identify individuals with asthma. Similarly, most asthma drug recipients who lacked a coded diagnosis of asthma did not have asthma. However, conventional full-text records usually do not contain sufficient information to assess asthma severity, limiting the utility of such records for research and quality improvement.

Developing algorithms for healthcare insurers to systematically monitor surgical site infection rates

BackgroundClaims data provide rapid indicators of SSIs for coronary artery bypass surgery and have been shown to successfully rank hospitals by SSI rates. We now operationalize this method for use by payers without transfer of protected health information, or any insurer data, to external analytic centers.ResultsWe performed a descriptive study testing the operationalization of software for payers to routinely assess surgical infection rates among hospitals where enrollees receive cardiac procedures. We developed five SAS programs and a user manual for direct use by health plans and payers. The manual and programs were refined following provision to two national insurers who applied the programs to claims databases, following instructions on data preparation, data validation, analysis, and verification and interpretation of program output.A final set of programs and user manual successfully guided health plan programmer analysts to apply SSI algorithms to claims databases. Validation steps identified common problems such as incomplete preparation of data, missing data, insufficient sample size, and other issues that might result in program failure. Several user prompts enabled health plans to select time windows, strata such as insurance type, and the threshold number of procedures performed by a hospital before inclusion in regression models assessing relative SSI rates among hospitals. No health plan data was transferred to outside entities.Programs, on default settings, provided descriptive tables of SSI indicators stratified by hospital, insurer type, SSI indicator (inpatient, outpatient, antibiotic), and six-month period. Regression models provided rankings of hospital SSI indicator rates by quartiles, adjusted for comorbidities. Programs are publicly available without charge.ConclusionWe describe a free, user-friendly software package that enables payers to routinely assess and identify hospitals with potentially high SSI rates complicating cardiac procedures.