Peter K. Lindenauer

Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007.

Objectives:To assess trends in number of hospitalizations, outcomes, and costs of severe sepsis in the United States. Design:Temporal trends study using the Nationwide Inpatient Sample. Patients:Adult patients with severe sepsis (defined as a diagnosis of sepsis and organ dysfunction) diagnosed between 2003 and 2007. Measurements and Main Results:We determined the weighted frequency of patients hospitalized with severe sepsis. We calculated age- and sex-adjusted population-based mortality rates for severe sepsis per 100,000 population and also used logistic regression to adjust in-hospital mortality rates for patient characteristics. We calculated inflation-adjusted costs using hospital-specific cost-to-charge ratios. We identified a rapid steady increase in the number of cases of severe sepsis, from 415,280 in 2003 to 711,736 in 2007 (a 71% increase). The total hospital costs for all patients with severe sepsis increased from

Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003-2009

15.4 billion in 2003 to

Association Between the Choice of IV Crystalloid and In-Hospital Mortality Among Critically Ill Adults With Sepsis*

24.3 billion in 2007 (57% increase). The proportion of patients with severe sepsis and only a single organ dysfunction decreased from 51% in 2003 to 45% in 2007 (p < .001), whereas the proportion of patients with three or four or more organ dysfunctions increased 1.19-fold and 1.51-fold, respectively (p < .001). During the same time period, we observed 2% decrease per year in hospital mortality for patients with severe sepsis (p < .001), as well as a slight decrease in the length of stay (9.9 days to 9.2 days; p < .001) and a significant decrease in the geometric mean cost per case of severe sepsis (

Patients’ Evaluations of Health Care Providers in the Era of Social Networking: An Analysis of Physician-Rating Websites

20,210 per case in 2003 and

Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease.

19,330 in 2007; p = .025). Conclusions:The increase in the number of hospitalizations for severe sepsis coupled with declining in-hospital mortality and declining geometric mean cost per case may reflect improvements in care or increases in discharges to skilled nursing facilities; however, these findings more likely represent changes in documentation and hospital coding practices that could bias efforts to conduct national surveillance.

Association of Corticosteroid Dose and Route of Administration With Risk of Treatment Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

CONTEXT Recent reports suggest that the mortality rate of patients hospitalized with pneumonia has steadily declined. While this may be the result of advances in clinical care or improvements in quality, it may also represent an artifact of changes in diagnostic coding. OBJECTIVE To compare estimates of trends in hospitalizations and inpatient mortality among patients with pneumonia using 2 approaches to case definition: one limited to patients with a principal diagnosis of pneumonia, and another that includes patients with a secondary diagnosis of pneumonia if the principal diagnosis is sepsis or respiratory failure. DESIGN, SETTING, AND PARTICIPANTS Trends study using data from the 2003-2009 releases of the Nationwide Inpatient Sample. MAIN OUTCOME MEASURES Change in the annual hospitalization rate and change in inpatient mortality over time. RESULTS From 2003 to 2009, the annual hospitalization rate for patients with a principal diagnosis of pneumonia declined 27.4%, from 5.5 to 4.0 per 1000, while the age- and sex-adjusted mortality decreased from 5.8% to 4.2% (absolute risk reduction [ARR], 1.6%; 95% CI, 1.4%-1.9%; relative risk reduction [RRR], 28.2%; 95% CI, 25.2%-31.2%). Over the same period, hospitalization rates of patients with a principal diagnosis of sepsis and a secondary diagnosis of pneumonia increased 177.6% from 0.4 to 1.1 per 1000, while inpatient mortality decreased from 25.1% to 22.2% (ARR, 3.0%; 95% CI, 1.6%-4.4%; RRR, 12%; 95% CI, 7.5%-16.1%); hospitalization rates for patients with a principal diagnosis of respiratory failure and a secondary diagnosis of pneumonia increased 9.3% from 0.44 to 0.48 per 1000 and mortality declined from 25.1% to 19.2% (ARR, 6.0%; 95% CI, 4.6%-7.3%; RRR, 23.7%; 95% CI, 19.7%-27.8%). However, when the 3 groups were combined, the hospitalization rate declined only 12.5%, from 6.3 to 5.6 per 1000, while the age- and sex-adjusted inpatient mortality rate increased from 8.3% to 8.8% (AR increase, 0.5%; 95% CI, 0.1%-0.9%; RR increase, 6.0%; 95% CI, 3.3%-8.8%). Over this same time frame, the age-, sex-, and comorbidity-adjusted mortality rate declined from 8.3% to 7.8% (ARR, 0.5%; 95% CI, 0.2%-0.9%; RRR, 6.3%; 95% CI, 3.8%-8.8%). CONCLUSIONS From 2003 to 2009, hospitalization and inpatient mortality rates for patients with a principal diagnosis of pneumonia decreased substantially, whereas hospitalizations with a principal diagnosis of sepsis or respiratory failure accompanied by a secondary diagnosis of pneumonia increased and mortality declined. However, when the 3 pneumonia diagnoses were combined, the decline in the hospitalization rate was attenuated and inpatient mortality was little changed, suggesting an association of these results with temporal trends in diagnostic coding.

The Influence of Procedure Volumes and Standardization of Care on Quality and Efficiency in Total Joint Replacement Surgery

Objective:Isotonic saline is the most commonly used crystalloid in the ICU, but recent evidence suggests that balanced fluids like Lactated Ringer’s solution may be preferable. We examined the association between choice of crystalloids and in-hospital mortality during the resuscitation of critically ill adults with sepsis. Design:A retrospective cohort study of patients admitted with sepsis, not undergoing any surgical procedures, and treated in an ICU by hospital day 2. We used propensity score matching to control for confounding and compared the following outcomes after resuscitation with balanced versus with no-balanced fluids: in-hospital mortality, acute renal failure with and without dialysis, and hospital and ICU lengths of stay. We also estimated the dose-response relationship between receipt of increasing proportions of balanced fluids and in-hospital mortality. Setting:Three hundred sixty U.S. hospitals that were members of the Premier Healthcare alliance between November 2005 and December 2010. Patients:A total of 53,448 patients with sepsis, treated with vasopressors and crystalloids in an ICU by hospital day 2 including 3,396 (6.4%) that received balanced fluids. Interventions:None. Measurements and Main Results:Patients treated with balanced fluids were younger and less likely to have heart or chronic renal failure, but they were more likely to receive mechanical ventilation, invasive monitoring, colloids, steroids, and larger crystalloid volumes (median 7 vs 5 L). Among 6,730 patients in a propensity-matched cohort, receipt of balanced fluids was associated with lower in-hospital mortality (19.6% vs 22.8%; relative risk, 0.86; 95% CI, 0.78, 0.94). Mortality was progressively lower among patients receiving larger proportions of balanced fluids. There were no significant differences in the prevalence of acute renal failure (with and without dialysis) or in-hospital and ICU lengths of stay. Conclusions:Among critically ill adults with sepsis, resuscitation with balanced fluids was associated with a lower risk of in-hospital mortality. If confirmed in randomized trials, this finding could have significant public health implications, as crystalloid resuscitation is nearly universal in sepsis.

Antibiotic therapy and treatment failure in patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease.

BACKGROUNDInternet-based social networking tools that allow users to share content have enabled a new form of public reporting of physician performance: the physician-rating website.OBJECTIVETo describe the structure and content of physician-rating websites and to assess the extent to which a patient might find them valuable.METHODSWe searched Google for websites that allowed patients to review physicians in the US. We included websites that met predetermined criteria, identified common elements of these websites, and recorded website characteristics. We then searched the websites for reviews of a random sample of 300 Boston physicians. Finally, we separately analyzed quantitative and narrative reviews.RESULTSWe identified 33 physician-rating websites, which contained 190 reviews for 81 physicians. Most reviews were positive (88%). Six percent were negative, and six percent were neutral. Generalists and subspecialists did not significantly differ in number or nature of reviews. We identified several narrative reviews that appeared to be written by the physicians themselves.CONCLUSIONPhysician-rating websites offer patients a novel way to provide feedback and obtain information about physician performance. Despite controversy surrounding these sites, their use by patients has been limited to date, and a majority of reviews appear to be positive.Internet-based social networking tools that allow users to share content have enabled a new form of public reporting of physician performance: the physician-rating website. To describe the structure and content of physician-rating websites and to assess the extent to which a patient might find them valuable. We searched Google for websites that allowed patients to review physicians in the US. We included websites that met predetermined criteria, identified common elements of these websites, and recorded website characteristics. We then searched the websites for reviews of a random sample of 300 Boston physicians. Finally, we separately analyzed quantitative and narrative reviews. We identified 33 physician-rating websites, which contained 190 reviews for 81 physicians. Most reviews were positive (88%). Six percent were negative, and six percent were neutral. Generalists and subspecialists did not significantly differ in number or nature of reviews. We identified several narrative reviews that appeared to be written by the physicians themselves. Physician-rating websites offer patients a novel way to provide feedback and obtain information about physician performance. Despite controversy surrounding these sites, their use by patients has been limited to date, and a majority of reviews appear to be positive.

Improving nurse-to-patient staffing ratios as a cost-effective safety intervention.

Context Evidence-based guidelines for the care of patients with chronic obstructive pulmonary disease (COPD) recommend explicit criteria for appropriate management of the disease. These guidelines identify tests and treatments of uncertain benefit as well as those that are potentially harmful. The degree of adherence to these guidelines is unknown. Contribution By surveying 360 hospitals, these investigators found that use of ideal care varied from 10% at some hospitals to greater than 60% at others. Cautions Administrative data were used instead of medical chart review to determine adherence to guidelines. Implications Despite well-accepted criteria for care of acute exacerbations of COPD, guideline adherence remains poor. The Editors Chronic obstructive pulmonary disease (COPD) affects approximately 16 million adults, accounts for more than

Hospitalists and the Practice of Inpatient Medicine: Results of a Survey of the National Association of Inpatient Physicians

18 billion in annual health care costs, and is the fourth leading cause of death in the United States (1, 2). In 2002, approximately 620000 persons were hospitalized for acute exacerbation of COPD, making this 1 of the 10 leading causes of hospitalization among U.S. adults (3). In 1987, the American Thoracic Society became the first organization to produce clinical practice guidelines for the management of COPD (4). The number of standards has grown steadily since then, and various national and international organizations now produce guidelines (5-11). The American College of Physicians and the American College of Chest Physicians have coproduced evidence-based guidelines recommending that patients with acute exacerbations of COPD undergo a diagnostic evaluation that includes chest radiography and arterial blood gas analysis, followed by treatment with supplemental oxygen; anticholinergic bronchodilators; short-acting 2-agonists; systemic corticosteroids; antibiotics; and, in some circumstances, noninvasive positive-pressure ventilation. These guidelines identify spirometry, mucolytic agents, sputum examinations, methylxanthine bronchodilators, and chest physiotherapy to be of uncertain or no benefit, with the latter 2 treatments being potentially harmful (5). While the attention of policymakers, regulatory agencies, and the federal government has focused on measuring and improving quality of care for patients with pneumonia (12-17), remarkably little is known about the management of patients with acute exacerbations of COPD. General information about the quality of care for patients with COPD is lacking, and it is unknown whether regional differences in treatment exist or whether there is a positive relationship between hospital volume and quality of care for patients with COPD (such relationships are well documented for some surgical procedures and medical conditions [18]). Similarly, it is unclear whether disparities that have been observed between sexes and among ethnic groups across a wide variety of conditions and treatment settings are found in the management of patients with acute exacerbations of COPD (19). Consequently, we evaluated the quality of care provided to patients hospitalized for acute exacerbations of COPD by measuring adherence to current guideline recommendations and examining the impact of hospital and patient characteristics on composite measures of performance. Methods Setting and Participants We conducted a retrospective cohort study using data from 360 hospitals that participate in Perspective (Premier Inc., Charlotte, North Carolina), a database developed for measuring quality and health care utilization. Participating hospitals represent all regions of the United States, are predominantly small to medium-sized nonteaching facilities, and serve mostly urban patient populations. In addition to the information available in the standard hospital discharge file, Perspective contains a date-stamped log of all billed items (including medications and laboratory, diagnostic, and therapeutic services) at the individual patient level. Patients were included in our analysis if they were 40 years of age and older, had a principal diagnosis of COPD or a principal diagnosis of respiratory failure paired with a secondary diagnosis of COPD, and were discharged between 1 January 2001 and 31 December 2001. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to assess diagnostic information. Patients were excluded if they had a secondary diagnosis of pneumonia. The All Patient RefinedDiagnosis-Related Group classification system, version 15.0 (3M Corp., Minneapolis, Minnesota), was used to exclude patients if they were assigned to a diagnosis-related group other than COPD or one consistent with a hospitalization for COPD, such as respiratory failure. The institutional review board at Baystate Medical Center approved the study, and the need for written informed consent was waived. Data Elements In addition to age, sex, and ethnicity, we recorded the presence of congestive heart failure, valvular heart disease, pulmonary circulation disorders, peripheral vascular disorders, hypertension, paralysis and other neurologic disorders, diabetes, hypothyroidism, renal failure, liver disease, chronic peptic ulcer disease, HIV and AIDS, lymphoma, metastatic cancer, solid tumor without metastasis, rheumatoid arthritis and collagen vascular diseases, coagulation deficiency, obesity, weight loss, fluid and electrolyte disorders, blood loss anemia, deficiency anemias, alcohol abuse, drug abuse, psychoses, and depression. On the basis of work by Elixhauser and colleagues (20), we assessed comorbid conditions using Healthcare Cost and Utilization Project Comorbidity Software, version 3.1 (Agency for Healthcare Research and Quality, Rockville, Maryland). We obtained data regarding in-hospital mortality; length of stay; and disease-specific, pulmonary-specific, and overall readmission rates at 14 and 30 days from the Perspective discharge file. In addition to information related to the admission, we noted each hospitals bed size, annual number of admissions for acute exacerbations of COPD, teaching status, geographic region, and whether the institution served an urban or rural population. Adherence to Guideline Recommendations Using guidelines produced collaboratively by the American College of Physicians and the American College of Chest Physicians (5), we developed a set of performance measures that could be used to evaluate quality of care. On the basis of recommendations contained in these guidelines, we categorized the following diagnostic evaluations and treatments as beneficial: chest radiography, arterial blood gas analysis, supplemental oxygen, inhaled anticholinergic bronchodilators, inhaled short-acting 2-agonists, systemic corticosteroids, antibiotics, and noninvasive positive-pressure ventilation. Antibiotic regimens were classified as providing broad- or narrow-spectrum coverage. Narrow-spectrum coverage was defined as treatment with first-generation penicillins, first-generation cephalosporins, macrolides, tetracyclines, sulfonamides, vancomycin, or clindamycin. Broad-spectrum coverage was defined as treatment with second- or later-generation cephalosporins, antistaphylococcal penicillins, aminopenicillins, antipseudomonal penicillins, fluoroquinolones, carbapenems, monobactams, aminoglycosides, aztreonam, or combination therapy that included 2 or more narrow-spectrum agents. In addition, we categorized the following management strategies as having uncertain or no benefit and possibly causing harm: sputum examinations, acute spirometry, mucolytic agents, chest physiotherapy, and methylxanthine bronchodilators. Acute spirometry was defined as spirometry performed before the day of discharge. Adherence to these measures was assessed by using a combination of pharmacy billing data and records of other diagnostic and therapeutic services rendered during the hospitalization. Statistical Analysis Summary statistics at both the patient and the hospital level were constructed by using frequencies and proportions for categorical data and by using means, standard deviations, medians, and interquartile ranges for continuous variables. By applying the Institute for Healthcare Improvements (21) concept of the bundle, a collection of processes needed to effectively care for patients with a particular condition, we classified patients as receiving recommended care if they received all of the following diagnostic tests and treatments: chest radiography, supplemental oxygen, bronchodilator therapy, systemic corticosteroid therapy, and antibiotic treatment. The authors of the American College of Physicians and American College of Chest Physicians guideline viewed arterial blood gas analysis as helpful; however, given insufficient evidence demonstrating a benefit, the guideline stopped short of giving this test a full recommendation. Consequently, arterial blood gas analysis was not included in the recommended care bundle. Patients were identified as receiving nonrecommended care if they received any of the following: sputum examination, acute spirometry, therapy with methylxanthine bronchodilator or mucolytic agents, or chest physiotherapy. Patients were considered to have received ideal care if they received all 5 recommended care elements and none of the nonrecommended ones. We examined the association of patient age (differentiating patients who were 40 to 64 years of age, 65 to 74 years of age, and 75 years of age), sex, and ethnicity with the provision of recommended and ideal care by using chi-square statistics. The MantelHaenszel chi-square test was used to adjust for hospital, and hospital-adjusted relative risks for receiving recommended and ideal care were computed. In addition, KruskalWallis analysis of variance was used to determine if hospital region, teaching status, and the annual number of patients admitted with COPD were associated with hospital rates of delivery of recommended and ideal care. All analyses wer