Patrick S. Romano

Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures

There have been no comprehensive studies that have compared the incidence of symptomatic VTE over a spectrum of different urgent or elective surgical procedures. In this study we determined the incidence of symptomatic venous thromboembolic events (VTE) within a 3 month period after 76 different surgical procedures. Using a large administrative data-base, we analyzed 1,653,275 cases that underwent one of 76 selected surgical procedures between January 1, 1992 and September 30, 1996. The principal outcomes were venous thrombosis or pulmonary embolism, during either the initial hospitalization or a re-hospitalization for VTE within 91 days of the date of surgery. Predictors of VTE were analyzed using logistic regression. Overall, VTE was diagnosed in 13,533 cases (0.8%, 95% CI = 0.7-0.9%) and of these, 5049 (37%, 95% CI = 36-38%) had pulmonary embolism. Predictors of VTE included: advancing age (OR=1.1 per 5 year increment in age, 95% CI =1.1-1.1), Latino ethnicity (OR = 0.9, 95% CI = 0.8-0.9), Asian/Pacific Islander ethnicity (OR = 0.5, 95% CI = 0.4-0.6), presence of a malignancy (OR = 1.7, 95% CI = 1.6-1.8) and prior VTE (OR = 6.2, 95% CI = 5.5-7.0). High-risk procedures that had an incidence of symptomatic VTE of approximately 2 to 3% included invasive neurosurgery, total hip arthroplasty, major vascular surgery and radical cystectomy. Fifty-six percent of all VTE events diagnosed within 91 days of surgery occurred after discharge. The findings of this study provide a basis for categorizing different surgical procedures as low, intermediate, high and very high risk for VTE. Because of the high incidence of VTE diagnosed after hospital discharge, further studies of extended thromboprophylaxis appear warranted.

Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes

Objective: To determine whether the peer-reviewed literature supports specific, minimum nurse–patient ratios for acute care hospitals and whether nurse staffing is associated with patient, nurse employee, or hospital outcomes. Background: Hospital care may be compromised by forces that have increased patient acuity, reduced the ratio of caregivers to patients, and lowered the level of training of these caregivers. Methods: We systematically reviewed studies of the effects of nurse staffing on patient, nurse employee, and hospital outcomes published between 1980 and 2003 to determine whether they could guide the setting of minimum licensed nurse–patient ratios in acute care hospitals. Results: Of 2897 titles and abstracts of interest, 490 articles were retrieved, and 43 met the inclusion criteria. Although all adjusted for case mix and skill mix, only one recent study addressed minimum nurse staffing ratios. Patient outcomes were limited to in-hospital, adverse events. Evidence suggests that richer nurse staffing is associated with lower failure-to-rescue rates, lower inpatient mortality rates, and shorter hospital stays. Conclusion: The literature offers no support for specific, minimum nurse–patient ratios for acute care hospitals, especially in the absence of adjustments for skill and patient mix, although total nursing hours and skill mix do appear to affect some important patient outcomes.

Bias in the Coding of Hospital Discharge Data and Its Implications for Quality Assessment

t From the Department of Family Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin. Presented in part at the Association for Health Services Research annual meeting, Chicago, IL, June 1992. This research was supported in part by the Agency for Health Care Policy and Research. Address correspondence to: Patrick S. Romano, MD, University of California Davis, Division of General Medicine, Primary Care Center, Room 3107, 2221 Stockton Boulevard, Sacramento, CA 95817. tions are underreported when patients die, for two possible reasons: coders identify all relevant diagnoses but the chronic codes are discarded when abstracts are truncated to

PREDICTORS OF REHOSPITALIZATION FOR SYMPTOMATIC VENOUS THROMBOEMBOLISM AFTER TOTAL HIP ARTHROPLASTY

Background Recent studies have shown that symptomatic venous thromboembolism after total hip arthroplasty most commonly develops after the patient is discharged from the hospital. Risk factors associated with these symptomatic thromboembolic events are not well defined. Methods Using administrative data from the California Medicare records for 1993 through 1996, we identified 297 patients 65 years of age or older who were rehospitalized for thromboembolism within three months after total hip arthroplasty. We compared demographic, surgical, and medical variables potentially associated with the development of thromboembolism in these patients and 592 unmatched controls. Results A total of 89.6 percent of patients with thromboembolism and 93.8 percent of control patients were treated with pneumatic compression, warfarin, enoxaparin, or unfractionated heparin, alone or in combination. In addition, 22.2 percent and 29.7 percent, respectively, received warfarin after discharge. A body-mass index (the weight in ...

Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial.

BACKGROUND Many patients with upper gastrointestinal (GI) bleeding have a benign outcome and could receive less intensive and costly care if accurately identified. We sought to determine whether early endoscopy performed shortly after admission in the emergency department could significantly reduce the health care use and costs of caring for patients with nonvariceal upper GI bleeding without adversely affecting the clinical outcome. METHODS All eligible patients with upper GI bleeding and stable vital signs were randomized after admission to undergo endoscopy in 1 to 2 days (control) or early endoscopy in the emergency department. Patients with low-risk findings on early endoscopy were discharged directly from the emergency department. Clinical outcomes and costs were prospectively assessed for 30 days. RESULTS We randomized 110 consecutive stable patients with nonvariceal upper GI bleeding during the 12-month study period. The baseline demographic features, endoscopic findings, and the clinical outcomes were no different between the two groups. However the findings of the early endoscopy allowed us to immediately discharge 26 of 56 (46%) patients randomized to that group. No patient discharged from the emergency department suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] vs. 2 days [interquartile range of 2 to 3 days], p = 0.0001) and the cost of care (

Can administrative data be used to compare postoperative complication rates across hospitals

2068 [interquartile range of

A comparison of administrative versus clinical data: coronary artery bypass surgery as an example

928 to

Major bleeding after hospitalization for deep-venous thrombosis.

3960] versus

Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era

3662 [interquartile range of

Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure the better effectiveness after transition-heart failure (BEAT-HF) randomized clinical trial

2473 to