Siran M. Koroukian

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections

CONTEXT The Surgical Care Improvement Project (SCIP) aims to reduce surgical infectious complication rates through measurement and reporting of 6 infection-prevention process-of-care measures. However, an association between SCIP performance and clinical outcomes has not been demonstrated. OBJECTIVE To examine the relationship between SCIP infection-prevention process-of-care measures and postoperative infection rates. DESIGN, SETTING, PARTICIPANTS A retrospective cohort study, using Premier Incs Perspective Database for discharges between July 1, 2006 and March 31, 2008, of 405 720 patients (69% white and 11% black; 46% Medicare patients; and 68% elective surgical cases) from 398 hospitals in the United States for whom SCIP performance was recorded and submitted for public report on the Hospital Compare Web site. Three original infection-prevention measures (S-INF-Core) and all 6 infection-prevention measures (S-INF) were aggregated into 2 separate all-or-none composite scores. Hierarchical logistical models were used to assess process-of-care relationships at the patient level while accounting for hospital characteristics. MAIN OUTCOME MEASURE The ability of reported adherence to SCIP infection-prevention process-of-care measures (using the 2 composite scores of S-INF and S-INF-Core) to predict postoperative infections. RESULTS There were 3996 documented postoperative infections. The S-INF composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1000 discharges (adjusted odds ratio, 0.85; 95% confidence interval, 0.76-0.95). The S-INF-Core composite process-of-care measure predicted a decrease in postoperative infection rates from 11.5 to 5.3 per 1000 discharges (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-1.01), which was not a statistically significantly lower probability of infection. None of the individual SCIP measures were significantly associated with a lower probability of infection. CONCLUSIONS Among hospitals in the Premier Inc Perspective Database reporting SCIP performance, adherence measured through a global all-or-none composite infection-prevention score was associated with a lower probability of developing a postoperative infection. However, adherence reported on individual SCIP measures, which is the only form in which performance is publicly reported, was not associated with a significantly lower probability of infection.

Prevalence and Predictors of Interval Colorectal Cancers in Medicare Beneficiaries

After a colonoscopy that is negative for cancer, a subset of patients may be diagnosed with colorectal cancer, also termed interval cancer. The frequency and predictors have not been well studied in a population‐based US cohort.

Context and Healthcare Access: Looking Beyond the Individual

Background:Although health is influenced by an individuals characteristics and choices, accumulating evidence suggests that contextual attributes may influence a variety of health outcomes. Whether these factors also represent “upstream” factors affecting ones ability to enter the healthcare system is less clear, however. Objective:The objective of this study was to assess associations between contextual characteristics and an individuals report of having a usual source of health care. Research Design:Cross-sectional, survey-weighted data assessing demographics, insurance status, needs, and healthcare access were obtained through telephone survey in 1998 and were linked with county-level data from the 1998 Area Resource File and the 1990 US Census. Subjects:A state-representative sample of 16,261 adult residents, living in urban, suburban, and rural settings throughout Ohio comprised this study. Measures:Operational measures for social, economic, and health system characteristics were used in multilevel logistic regression models to test associations with an individuals report of a usual source of care. Results:The weighted proportion of individuals reporting no usual source of care was 18.0%. Although individuals’ current health, insurance status, income, demographics, educational attainment, and social support were closely associated with this outcome, significant associations remained for county-level characteristics representing the level of poverty and degree of urbanization. Conclusions:Persisting health status disparities increase the need for programs that promote equitable access to health care. Policy interventions may be more effective if they look beyond individual characteristics to incorporate strategies that address economic factors in areas where healthcare access is inequitable.

Geographic Variation among Medicare Beneficiaries in the Use of Colorectal Carcinoma Screening Procedures

OBJECTIVES:To study geographic variation in the use of recommended screening procedures for colorectal carcinoma.METHODS:All Medicare claims for fecal occult blood testing (FOBT), flexible sigmoidoscopy, colonoscopy, barium enema and two reference procedures, upper endoscopy, and upper gastrointestinal series in patients ≥65 yr were obtained from the 1997–1999 physician-supplier and outpatient files. State-level procedure rates and the change in rates from 1997 to 1999 were calculated.RESULTS:The median annual rates were as follows: FOBT, 14.54%; flexible sigmoidoscopy, 3.03%; colonoscopy, 6.22%; barium enema, 2.21%; upper gastrointestinal endoscopy, 4.88%; and upper gastrointestinal series, 2.78%. Whereas there was at least a 50% difference between the 25th and 75th percentiles for state rates of FOBT and sigmoidoscopy, the variation in other procedures was more modest. State-level rates of colonoscopy and upper gastrointestinal endoscopy were highly correlated (r = 0.79; p < 0.0001), as were the rates of barium enema and upper gastrointestinal series (r = 0.68; p < 0.0001). Universal increases in colonoscopy use (median +25.0%) and decreases in barium enema use (median –20.9%) from 1997 to 1999 were observed among individual states.CONCLUSIONS:There is variation at the state level in the use of some, but not all colorectal procedures, as well as fairly consistent temporal trends. The etiology of the differences is not clear, but the correlation in the rates of selected procedures suggests the presence of local practice patterns.

Relative risk of postpartum complications in the Ohio Medicaid population: vaginal versus cesarean delivery.

The objective of this study was to estimate the relative risk of postpartum complication by type of delivery among Ohio Medicaid beneficiaries. The study uses the linked Medicaid and Ohio birth certificate data for births occurring from July 1991 through April 1996 (N = 168,736). The results indicate that the incidence of major puerperal infection, thromboembolic events, anesthetic complications, and obstetrical surgical wound infection was higher among women undergoing a C-section as compared to those with vaginal delivery, even after limiting the analysis to elective cesarean deliveries and uncomplicated vaginal deliveries. On the other hand, women with C-sections were less likely to experience obstetrical trauma, and results on postpartum hemorrhage were inconclusive. Aside from obstetrical trauma, the relative risk of postpartum complications remains significantly higher among women undergoing C-section. These findings are of particular relevance in light of the substantial proportion of repeat C-sections performed on an elective basis.

The "Adequacy of Prenatal Care Utilization" (APNCU) index to study low birth weight: is the index biased?

A recent, nationwide study of 54 million births reported increasing trends toward more prenatal resource utilization from 1981 to 1995, when other indicators have shown worsening trends in birth outcomes. The Adequacy of Prenatal Care Utilization (APNCU) Index was used to measure resource utilization, but the Index appears to be biased because women grouped in the intensive category have the highest rates of low birth weight (LBW). The objective of this paper is to provide a systematic examination of the Index and to uncover biases that may preclude its use in analyzing the association between resource utilization and birth outcomes. This is a cross-sectional study including all singleton live births in 1993 through 1996 (n = 591,403) in Ohio. Birth certificate data are used to derive the Index, which categorizes women as follows: Adequate Plus (A+), Adequate, Intermediate, and Inadequate. The Index is based on the ratio of observed to expected (O/E) number of prenatal visits. The expected number of visits is based on the American College of Obstetricians and Gynecologists (ACOG) recommendations. The Index also considers the month of initiation of prenatal care. The outcome measures are low birth weight (LBW) and small-for-gestational age (SGA). The LBW rate is 11.8% in the (A+) category, compared to 9.4% in the Inadequate category, and 3.3% and 3.5% in each of the Intermediate and Adequate categories, respectively. Preterm births are disproportionately represented in the (A+) category: 61.2% of births prior to 37 weeks are (A+), whereas only 18.9% of term births are (A+). This apparent bias results from the fact that the ACOG schedule of prenatal visits allocates nearly one third of the total visits to the last 4-5 weeks of gestation. A shorter gestational age implies fewer number of expected visits, a smaller denominator in the O/E ratio, and O/E ratios exceeding 100% by large margins. In fact, the observed number of visits exceeds the expected number of visits by only one or two in 40.1% of all births grouped in the (A+) category. Consequently, the Index yields misleading results indicating that women grouped in the (A+) category (or O/E ratios > 110%) are most likely to deliver LBW infants. Contrary to the results obtained through the APNCU Index, our gestational age-specific analysis showed that increasing number of prenatal visits is associated with improved birth outcomes. We recommend that the use of the APNCU Index to study the association between prenatal resource utilization and LBW be discontinued.

Comorbidities, Functional Limitations, and Geriatric Syndromes in Relation to Treatment and Survival Patterns Among Elders With Colorectal Cancer

PURPOSE To examine patterns of colorectal cancer (CRC) treatment and survival in relation to comorbidities (COM), functional limitations (FL), and geriatric syndromes (GS). METHODS Our study population consisted of Ohio elders diagnosed with incident invasive CRC in the period August 1999 to November 2001 and admitted to home health care (HHC) in the 30 days before or after cancer diagnosis (n = 1009). We used data from the Ohio Cancer Incidence Surveillance System, vital records, and Medicare administrative data, including the HHC Outcome and Assessment Information Set (OASIS), which includes detailed clinical data for HHC patients. Counts of COM, FL, and GS at baseline were retrieved from the OASIS. Multivariable logistic and survival models were developed to examine the association between clinical attributes and outcomes, adjusting for demographic covariates and cancer stage. RESULTS Comorbidities were associated with increased likelihood of surgery-only, but not with surgery + chemotherapy. Both FL and GS were associated with lower likelihood to undergo surgery-only or surgery + chemotherapy. Two or more GS was associated with disease-specific mortality (adjusted hazard ratio [AHR]: 2.71; 95% confidence interval [CI]: 1.80-4.07) and overall mortality (AHR: 2.34; 95% CI: 1.74-3.15). Two or more FL was associated with overall mortality (AHR: 1.33; 95% CI: 1.10-1.62), but not with disease-specific mortality. COM was not associated with overall mortality, but was negatively associated with disease-specific mortality at borderline level of significance (AHR: 0.78; 95% CI: 0.61-1.00). CONCLUSION Our findings demonstrate the importance of accounting for FL and GS, in addition to COM, when studying cancer-related outcomes in elders.

Ability of Medicaid Claims Data to Identify Incident Cases of Breast Cancer in the Ohio Medicaid Population

BACKGROUND The use of Medicaid data to study cancer-related outcomes would be highly desirable. However, the accuracy of Medicaid claims data in the identification of incident cases of breast cancer is unknown. OBJECTIVES (1) To estimate the sensitivity of Medicaid claims data for case ascertainment of breast cancer, and (2) to determine the positive predictive value (PPV) of diagnostic and procedure codes retrieved from Medicaid claims, using the Ohio Cancer Incidence Surveillance System (OCISS) as the gold standard. METHODS The study used the linked OCISS and Medicaid enrollment files, 1997-1998 (n = 1,648). The claims search yielded 2,635 incident cases, of which 1,132 were also identified through the OCISS-Medicaid files. Sensitivity and PPV of Medicaid data were calculated in subgroups of the population. RESULTS The overall sensitivity was 68.7 percent, but varied greatly across the subgroups of the population. It was lower among women enrolled in Medicaid only for part of the study year than those enrolled in Medicaid for 12 months of the study year (56.7 percent and 78.0 percent respectively, p < 0.0001), and lower among those who are dual Medicare-Medicaid eligible compared to those not participating in the Medicare program (63.1 percent and 78.6 percent respectively, p < 0.0001). The overall PPV was 43.0 percent, increasing up to 86.6 percent in the presence of procedure codes indicating the presence of mastectomy and lumpectomy, in addition to that of breast cancer diagnosis. CONCLUSIONS The sensitivity of Medicaid claims for case ascertainment of breast cancer is somewhat low, but improves considerably when accounting for women enrolled in Medicaid for the entire duration of the study year. The PPV is poor due to a high rate of false positives. The higher PPV obtained in the presence of procedure codes, in addition to diagnosis codes, will help researchers to correctly identify incident cases of breast cancer using Medicaid claims data.

Rehospitalization in a National Population of Home Health Care Patients with Heart Failure

OBJECTIVE Patients with heart failure (HF) have high rates of rehospitalization. Home health care (HHC) patients with HF are not well studied in this regard. The objectives of this study were to determine patient, HHC agency, and geographic (i.e., area variation) factors related to 30-day rehospitalization in a national population of HHC patients with HF, and to describe the extent to which rehospitalizations were potentially avoidable. DATA SOURCES Chronic Condition Warehouse data from the Centers for Medicare & Medicaid Services. STUDY DESIGN Retrospective cohort design. DATA EXTRACTION The 2005 national population of HHC patients was matched with hospital and HHC claims, the Provider of Service file, and the Area Resource File. PRINCIPAL FINDINGS The 30-day rehospitalization rate was 26 percent with 42 percent of patients having cardiac-related diagnoses for the rehospitalization. Factors with the strongest association with rehospitalization were consistent between the multilevel model and Cox proportional hazard models: number of prior hospital stays, higher HHC visit intensity category, and dyspnea severity at HHC admission. Substantial numbers of rehospitalizations were judged to be potentially avoidable. CONCLUSIONS The persistently high rates of rehospitalization have been difficult to address. There are health care-specific actions and policy implications that are worth examining to improve rehospitalization rates.

Survival disparities by Medicaid status: an analysis of 8 cancers.

A study was undertaken to compare survival and 5‐year mortality by Medicaid status in adults diagnosed with 8 select cancers.