Soeren Mattke

Evaluating the Role of Patient Sample Definitions for Quality Indicators Sensitive to Nurse Staffing Patterns

BackgroundAdministrative data are an attractive data source for the construction of quality indicators to assess and monitor quality of nursing care in hospitals. Current approaches to constructing measures from discharge abstracts apply substantial restrictions to exclude patients at high risk or with preexisting conditions. This study evaluates whether broader sample definitions combined with risk adjustment would allow for larger samples and increase analytic power. MethodsEight indicators were constructed from discharge abstracts of major surgical and medical patients from 799 hospitals in 11 states using existing definitions: pneumonia, urinary tract infection, decubitus ulcers, central nervous system complications, shock, sepsis, pulmonary failure, and upper gastrointestinal bleeding. We tested the effect of broadening the samples in 4 ways: comparing indicator rates in the broader and restrictive samples; assessing correlations of hospital ranks in the broader and restrictive samples; performing clinical reviews of cases in the added samples; and using different samples in regressions of indicators on nurse staffing variables, adjusting for patient risk. ResultsIndicator rates in the broader samples tended to be higher but did not change hospital rankings significantly. Clinical review suggested that many sample restrictions could be dropped. Using indicators based on broader definitions, coefficients on staffing variables increased in magnitude ConclusionLess restrictive sample definitions were shown to be feasible and increased the sensitivity of the indicators and thus the power of the analysis. Particularly in surgical patients, the samples could be broadened, although more conservative definitions appeared appropriate for medical patients.

Nurse Staffing and Quality of Care in Hospitals in the United States

The size and mix of nurse staffing in U.S. hospitals has a direct impact on the outcome of patient health according to a study based on discharge data for more than 6 million patients and financial reports and hospital staffing surveys from 799 hospitals in 11 states. The data were analyzed to determine staffing levels of RNs, licensed practicing/vocational nurses, and aides and to measure the frequency of a wide range of complications that patients developed during their hospital stays. Of the hospital inpatient nursing personnel studied, the study found that registered nurse staffing makes the biggest impact on adverse patient outcomes. The researchers found that lower levels of nurse staffing were associated with higher rates of urinary tract infections, pneumonia, shock and cardiac arrest, upper gastrointestinal bleeding, “failure to rescue,” and length of hospital stay in both medical and major surgery patients treated in hospitals.

Anesthesia Service Use and the Uptake of Screening Colonoscopies.

Background: The Center for Medicare & Medicaid Services recently defined “screening colonoscopy” to include separately furnished anesthesia services. Objective: To examine the relationship between anesthesia service use and the uptake of screening colonoscopies. Study Design: We correlated metropolitan statistical area (MSA) level anesthesia service use rates, derived from the 2008, 2010, and 2012 Medicare and MarketScan claims data, with the presence of individual level guideline concordant screening colonoscopy using the Behavioral Risk Factor Surveillance System data for the same years. Measures: Proportion of colonoscopies with anesthesia service was calculated at the MSA level. A guideline concordant screening colonoscopy was defined as a colonoscopy received within the past 10 years. Results: The average MSA level anesthesia service use rate in colonoscopy significantly increased from 25.34% in 2008 to 44.25% in 2012; but only a moderate increase in the rate of guideline concordant colonoscopies was observed, from 57.36% in 2008 to 65.32% in 2012. After adjusting for patient characteristics, we found a nonsignificant negative association between anesthesia service use rate and colonoscopy screening rate, with an odds ratio of 0.90 for receiving a guideline concordant colonoscopy for each percentage point increase in anesthesia service use rate (P=0.27). The relationship between anesthesia service use and the overall colorectal cancer screening rate followed the same pattern and was also not statistically significant. Conclusions: No significant association between anesthesia service use and colonoscopy screening or colorectal cancer screening rates was found, suggesting that more evidence is needed to support the Center for Medicare & Medicaid Services rule change.

Personalizing Antipsychotic Treatment of Schizophrenia: Monitoring Plasma Levels for Improved Treatment Decisions

D espite the availability of efficacious antipsychotic drugs, the pharmacological management of schizophrenia remains a challenge, and it largely follows a trial-anderror paradigm. With notoriously high rates of poor antipsychotic drug adherence and limited means to detect it, prescribers are often uncertain whether a lack of treatment response is due to poor adherence or true lack of effect, which in turn may simply be a reflection of insufficient plasma concentration of the drug. Moreover, when encountering a patient with intolerable side effects, prescribers do not know whether to switch to another drug or merely reduce the dose. This uncertainty results in unnecessarily high rates of unwarranted treatment changes and antipsychotic polypharmacy, loss of adherence and disease control, and ultimately poor patient and societal outcomes. In this Perspective, we argue that point-of-care information on antipsychotic plasma levels —the amount of drug circulating in the patient’s blood— will result in better patient care, which should lead to better health and better value for the health care system. While tests for antipsychotic plasma levels have long been available through specialized labs, they are not routinely used, in part because of delays in obtaining results. Access to information on antipsychotic plasma levels at the point of care would facilitate better use of currently available drugs and reduce the uncertainty associated with the management of complicated presentations by providing prescribers with a tool to “personalize” treatment to patients’ characteristics, including responsiveness to specific medications, metabolism, and adherence behavior.