Mark A. Moskowitz

Searching for an improved clinical comorbidity index for use with ICD-9-CM administrative data

We studied approaches to comorbidity risk adjustment by comparing two ICD-9-CM adaptations (Deyo, Dartmouth-Manitoba) of the Charlson comorbidity index applied to Massachusetts coronary artery bypass surgery data. We also developed a new comorbidity index by assigning study-specific weights to the original Charlson comorbidity variables. The 2 ICD-9-CM coding adaptations assigned identical Charlson comorbidity scores to 90% of cases, and specific comorbidities were largely found in the same cases (kappa values of 0.72-1.0 for 15 of 16 comorbidities). Meanwhile, the study-specific comorbidity index identified a 10% subset of patients with 15% mortality, whereas the 5% highest-risk patients according to the Charlson index had only 8% mortality (p = 0.01). A model using the new index to predict mortality had better validated performance than a model based on the original Charlson index (c = 0.74 vs. 0.70). Thus, in our population, the ICD-9-CM adaptation used to create the Charlson score mattered little, but using study-specific weights with the Charlson variables substantially improved the power of these data to predict mortality.

Mammography use, breast cancer stage at diagnosis, and survival among older women

BACKGROUND: Women age 65 years and older account for most newly diagnosed breast cancers and deaths from breast cancer. Yet, older women are least likely to undergo mammography, perhaps because mammographys value is less well demonstrated in older women.

Attitudes Toward Colorectal Cancer Screening Tests

OBJECTIVE: To examine patient and physician preferences in regard to 5 colorectal cancer screening alternatives endorsed by a 1997 expert panel, determine the impact of patient and physician values regarding certain test features on screening preference, and assess physicians’ perceptions of patients’ values.DESIGN: Cross-sectional survey.SETTING: A general internal medicine practice at an academic medical center in 1998.PARTICIPANTS: Patients (N=217; 76% response rate) and physicians (N=39; 87% response rate) at the study setting.MEASUREMENTS AND MAIN RESULTS: Patients preferred fecal occult blood testing (43%) or colonoscopy (40%). In patients for whom accuracy was the most important test feature, colonoscopy (62%) was the preferred screening method. Patients for whom invasive test features were more important preferred fecal occult blood testing (76%; P<.001). Patients and physicians were similar in their values regarding the various test features. However, there was a significant difference between physicians’ perceptions of which test features were important to patients compared with the patients’ actual responses (P<.001). The largest discrepancy was for accuracy (patient actual 54% vs physician opinion 15%) and discomfort (patient actual 15% vs physician opinion 64%).CONCLUSIONS: Patients have distinct preferences for colorectal cancer screening tests that are associated with the importance placed on certain test features. Physicians incorrectly perceive those factors that are important to patients. Physicians should incorporate patient values in regard to certain test features when discussing colorectal cancer screening with their patients and when eliciting their screening preferences.

Outcomes for older men and women with congestive heart failure.

OBJECTIVES: To describe and compare outcomes for men and women discharged alive following a hospitalization for congestive heart failure (CHF).

Deriving a Risk-Adjustment Model for Pressure Ulcer Development Using the Minimum Data Set

OBJECTIVE: To use the Minimum Data Set (MDS) to derive a risk‐adjustment model for pressure ulcer development that may be used in assessing the quality of nursing home care.

Variability in Mammography Use Among Older Women

OBJECTIVE: To determine rates of and explore factors associated with mammography use among older women.

Discharge decision-making in a medical intensive care unit: identifying patients at high risk of unexpected death or unit readmission

In an attempt to identify clinical variables associated with unexpected death or unit readmission following discharge from a medical intensive care unit (MICU), 300 consecutive patients admitted to a MICU were prospectively identified and followed through their hospital stay. Of the 229 patients at risk, 37 (16 percent) experienced one or more unexpected unit readmissions (n = 30) or death (n = 7). In comparison to the patients without such complications (n = 192), these 37 patients differed with respect to age, diagnosis, and severity of illness on admission. In addition, these patients were sicker on initial unit discharge as manifested by higher heart and respiratory rates and lower hematocrit values. On multivariate analysis, age, acute physiology score on admission, and a diagnosis of upper gastrointestinal bleeding were independent predictors of unexpected outcome. It is concluded that patients at high risk for unit readmission or unexpected death are distinguished from other MICU survivors on several clinical parameters. Whether such information can be useful in individual discharge decisions is uncertain and requires further investigation.

Intensive care unit use and mortality in the elderly.

AbstractOBJECTIVE: To examine utilization and outcomes of intensive care unit (ICU) use for the elderly in the United States. DESIGN: We used 1992 data from the Health Care Financing Administration to examine ICU utilization and mortality by age and admission reason for hospitalizations of elderly Medicare beneficiaries. MAIN RESULTS: Use of the ICU was least likely for the oldest elderly overall (85+ years, 21.1% of admissions involved ICU; 75–84 years, 27.9%; 65–74 years, 29.7%), but more likely during surgical admissions. Eighty-three percent of the Medicare patients who received intensive care survived at least 90 days. Of the oldest elderly, 74% survived. Even among the 10% most expensive ICU hospitalizations, 77% of all patients and 62% of those 85 years and older survived at least 90 days. CONCLUSIONS: The likelihood of ICU use among these elderly decreased with age, especially among those 85 years or older. Diagnostic mix importantly influenced ICU use by age. The great majority of the elderly, including those 85 years and older and those receiving the most expensive ICU care, survived at least 90 days.

Gender differences in the treatment of cerebrovascular disease

OBJECTIVE: Previous studies have shown that women receive fewer invasive procedures for the treatment of coronary artery disease than men, but gender differences in cerebrovascular disease have not been well studied. Our objective was to explore differences in the treatment of stroke between men and women.

Hospital cost of complications associated with coronary artery bypass graft surgery

We identified 6,791 coronary artery bypass grafting (CABG) cases using the Massachusetts hospital discharge data to quantify the contribution of complications to the cost of a hospitalization for CABG. After adjusting for in-hospital mortality and baseline clinical severity as other contributors to cost, the additional costs associated with complications were substantial.