A Novel Approach to Evaluating Cardiac Surgery Providers: An Alternative to the RAMR.

OBJECTIVE: We propose an alternative to the Risk Adjusted Mortality Rate (RAMR), about which we identify four serious concerns. We apply our method to cardiac surgery. DESIGN: We present a methodology that uses the upper and lower tail probabilities (UTP/LTP) of the binomial distribution to screen for poor/high performing providers. STUDY SETTING: The New York State Department of Health (NYS DOH) publicly releases data on all cardiac surgery patients in the state. We download cardiac surgery data from the NYS DOH website for the years 2011 through 2013. The state's objective is to identify poorly performing hospitals and surgeons and thereby reduce deaths. NYS employs the RAMR. RESULTS: The UTP/LTP approach agrees with the RAMR in its classification of all 132 surgeons and all 40 hospitals. However, performance is a continuous construct and strict categorization can lead to failure to identify marginal providers. CONCLUSIONS: Our methodology addresses all four concerns regarding the RAMR. The UTP/LTP approach avoids inappropriate hypothesis testing and is consistent with standard statistical theory and practice in its approach to case volume. It does not require confidence intervals and it applies to all providers regardless of case volume.

Using Data Analytics to Improve Hospital Quality Performance.

EXECUTIVE SUMMARY: The objective of this study was to build a unified quality performance model for hospitals using publicly available data. We obtained data from the New York State Department of Health's Statewide Planning and Research Cooperative System database for our model, which had three outcome measures that we wished to make smaller (deaths, readmissions, average length of stay). Because this was a performance model rather than an economic efficiency model, we excluded costs, which are affected significantly by local economic conditions. We included four site characteristics. With our data envelopment analysis model structure, we used logistic regression to analyze the output. We extracted data for 2,233,214 discharges in 2014 from 183 hospitals in the state. We found that 20.8% of the facilities were on the quality performance frontier-20.6% of the not-for-profit facilities and 21.4% of the other facilities. Hospitals with more discharges performed better with respect to mortality, readmission, and average length of stay. We found no difference in performance between not-for-profit hospitals and others. We concluded that 79.2% of hospitals could improve their quality of care. As an upper bound, if all hospitals increased each quality factor performance to 100%, there would have been 11,722 (24.8%) fewer deaths, 17,840 (15.8%) fewer readmissions, and the statewide average length of stay would have been 0.71 days (13.5%) less.

Using Data Analytics to Improve Nursing Home Quality.

BACKGROUND: There exists an array of quality performance measures for nursing homes. They can confuse consumers, administrators, and government regulators. Our methodology provides a unified multidimensional evaluation. OBJECTIVE: To present a methodology to perform a multidimensional assessment of each nursing home within any specified group of nursing homes to aid policy makers, administrators, and consumers with a clear, easy-to-interpret evaluation of a nursing home quality performance. METHODS: We use data envelopment analysis (DEA) to integrate several quality measures into a comprehensive benchmarking model. We present statewide results comparing DEA performance scores with the Five-Star rating using data from New York State (NYS) Department of Health. RESULTS: In total, 212 of the 526 nursing homes performed as well as possible. Public nursing homes are most likely to lie on the frontier and have the highest average performance scores. The relationship between the DEA-based performance scores and the NYS Five-Star quality ratings is very weak. CONCLUSION: DEA is a comprehensive methodology for measuring nursing home quality. The DEA factor performance scores provide detailed information for individual nursing homes, enabling administrators to benchmark their facility's quality performance and to focus quality improvement efforts more effectively.

Patient outcomes associated with subcutaneous C1INH prophylaxis for hereditary angioedema: a retrospective analysis.

BACKGROUND: Real-world data on subcutaneous C1INH (C1INH[SC]) usage and patient-level impacts on hereditary angioedema (HAE)-related outcomes and quality of life (QoL) are both lacking and challenging to generate using conventional study methodologies. Using a hybrid study design involving patient interviews supplemented by retrospective medical chart data review, we conducted a real-world assessment of the impact of C1INH(SC) prophylaxis on HAE attack patterns, QoL, and on-demand medication use. METHODS: The study was conducted at seven US sites and included 36 adults with HAE who had been treated with C1INH(SC) long-term prophylaxis following ≥ 12 months of on-demand management only. Patients underwent 30-min interviews, facilitated and analyzed by a trained qualitative research specialist. Medical records were reviewed for 12 months before (pre-index) and after (post-index) initiation of C1INH(SC). Using interview data with descriptive terms converted to numerical values, we compared pre- versus post-index attack frequency, severity, and rescue medication usage. RESULTS: Mean (SD) annualized attack frequency per patient decreased 82.0%, from 38.8 (38.8) attacks/year pre-index to 7.0 (15.3) attacks/year (P < 0.001); the median number of attacks decreased by 97.0% (30 pre-index to 1 post-index). For 20 patients, the annualized attack rate after starting C1INH(SC) prophylaxis was ≤ 1 attack/year; 12 of these patients reported 0 attacks. Mean (SD) attack severity (scale: 0 = none/mild to 4 = very severe) decreased from 2.3 (0.7) pre-index to 0.9 (0.9) post-index (P < 0.001). Mean/median rescue medication use decreased by 77.2%/96.3%. Improved QoL was narratively described for many domains. CONCLUSIONS: These real-world findings indicate that long-term prophylaxis with C1INH(SC) markedly improves important factors that contribute to the goal of achieving total disease control and normalization of patients' lives, including fewer and less severe attacks, less rescue medication usage, and improved QoL.

Measuring Hospital Performance Using Mortality Rates: An Alternative to the RAMR.

BACKGROUND: The risk-adjusted mortality rate (RAMR) is used widely by healthcare agencies to evaluate hospital performance. The RAMR is insensitive to case volume and requires a confidence interval for proper interpretation, which results in a hypothesis testing framework. Unfamiliarity with hypothesis testing can lead to erroneous interpretations by the public and other stakeholders. We argue that screening, rather than hypothesis testing, is more defensible. We propose an alternative to the RAMR that is based on sound statistical methodology, easier to understand and can be used in large-scale screening with no additional data requirements. METHODS: We use an upper-tail probability to screen for hospitals performing poorly and a lower-tail probability to screen for hospitals performing well. Confidence intervals and hypothesis tests are not needed to compute or interpret our measures. Moreover, unlike the RAMR, our measures are sensitive to the number of cases treated. RESULTS: To demonstrate our proposed methodology, we obtained data from the New York State Department of Health for 10 Inpatient Quality Indicators (IQIs) for the years 2009-2013. We find strong agreement between the upper tail probability (UTP) and the RAMR, supporting our contention that the UTP is a viable alternative to the RAMR. CONCLUSION: We show that our method is simpler to implement than the RAMR and, with no need for a confidence interval, it is easier to interpret. Moreover, it will be available for all hospitals and all diseases/conditions regardless of patient volume.

Examining the effect of a patient navigation intervention on outpatient cardiac rehabilitation awareness and enrollment.

PURPOSE: Awareness of and enrollment in outpatient cardiac rehabilitation (OCR) following a cardiac event or procedure remain suboptimal. Thus, it is important to identify new approaches to improve these outcomes. The objectives of this study were to identify (1) the contributions of a patient navigation (PN) intervention and other patient characteristics on OCR awareness; and (2) the contributions of OCR awareness and other patient characteristics on OCR enrollment among eligible cardiac patients up to 12 weeks posthospitalization. METHODS: In this randomized controlled study, 181 eligible and consenting patients were assigned to either PN (n = 90) or usual care (UC; n = 91) prior to hospital discharge. Awareness of OCR was assessed by telephone interview at 12 weeks posthospitalization, and OCR enrollment was confirmed by staff at collaborating OCR programs. Of the 181 study participants, 3 died within 1 month of hospital discharge and 147 completed the 12-week telephone interview. RESULTS: Participants in the PN intervention arm were nearly 6 times more likely to have at least some awareness of OCR than UC participants (OR = 5.99; P = .001). Moreover, participants who reported at least some OCR awareness were more than 9 times more likely to enroll in OCR (OR = 9.27, P = .034) and participants who were married were less likely to enroll (P = .031). CONCLUSIONS: Lay health advisors have potential to improve awareness of outpatient rehabilitation services among cardiac patients, which, in turn, can yield greater enrollment rates in a program.

An efficiency-based multicriteria strategic planning model for ambulatory surgery centers.

Ambulatory surgery centers (ASCs) provide a low-cost alternative to traditional inpatient care. In addition, with health care reform imminent, it is likely that many currently uninsured people will soon acquire health care coverage, significantly increasing the demand for health services. ASCs are among the providers that can expect to see a substantial amount of this new pent-up demand and, therefore, ASCs are likely to continue their current growth into the foreseeable future. Those ASCs that plan accordingly by optimizing procedure mix and volume will benefit most from the increased demand. We propose a two-stage efficiency-based multicriteria decision model to guide an ASC in identifying its optimal procedure mix. The first stage uses Data Envelopment Analysis (DEA) to calculate the efficiency of each procedure based on the resources required to perform the procedure, the revenue it generates, and its risk of complications. The second stage uses the DEA factor efficiency scores in a bottleneck program to optimize the mix of procedures while satisfying the ASC's resource and operational constraints. The criteria are to (1) maximize reimbursement while (2) minimizing the total number of complications. We demonstrate the approach using a data set based in part on data from an actual ASC.

The importance of basic science and clinical research as a selection criterion for general surgery residency programs.

OBJECTIVE: The selection criteria for surgical residents applying for residency differ among programs nationwide. Factors influencing this selection process have not been well defined, and research in particular has not been evaluated fully. This study aimed to evaluate the relative importance of basic science and clinical research in the selection criteria used by program directors (PDs). DESIGN: A web-based survey consisting of 11 questions was sent to PDs using the list server of the Association of Program Directors in Surgery. Respondents were asked to rank selection factors using a 1-to-5 scoring system, with 5 as most important. Their responses were recorded and tabulated. SETTING: University-based teaching hospital. PARTICIPANTS: The survey went to 251 accredited general surgery residency programs in the United States. RESULTS: Overall, 134 (53.3%) of the surveys were returned, representing 61 university-based programs, 57 community-based programs with university affiliation, and 16 community-based programs without university affiliation. In total, 120 PDs (89.5%) considered basic or clinical research almost always or all the time when evaluating applicants to their general surgery program. Another 73 PDs (54.5%) gave basic science and clinical research equal importance. Another 40 PDs (29.9%) rarely or never credited research unless it had been published as an abstract or paper. In ranking research, 11 (8.2%) respondents gave it the 5 score. Most respondents (n = 93; 69.4%) gave it the 3 score. An applicant's interview and interest in surgery were the factors considered most important by 93 (69.4%) and 78 (58.2%), respectively, of the PDs. CONCLUSIONS: Basic science and clinical research constituted an important but secondary criterion for resident selection by PDs into general surgery residency programs. PDs perceived the primary factors for residency selection to be the interview, demonstrated interest in surgery, AOA membership, letters of recommendation, and USMLE Step I scores.

Alleviating blood shortages in a resource-constrained environment.

BACKGROUND: The nation devotes considerable resources to the collection, processing, and distribution of blood products. Nonetheless, shortages of virtually every blood component persist. Economic theory suggests that the national blood supply can be increased either by increasing the level of resources used in the collection and production of blood components or by utilizing existing resources more efficiently. STUDY DESIGN AND METHODS: This study uses data envelopment analysis to analyze the efficiency of 70 blood centers to determine the extent to which operational efficiency can be improved, the increase in the nation's blood supply that would result, and management strategies that would lead to such improvements. Data were collected from the AABB 2002-2003 Directory of Community Blood Centers. RESULTS: The study found that roughly half of the 70 blood centers studied are efficient. The remaining blood centers collectively can both increase outputs and decrease some inputs. If the inefficient blood centers were to eliminate half of their inefficiency, then systemwide output of platelets would be increased by 17 percent, cryoprecipitate by 12 percent, plasma by 10 percent, and red blood cells by 7 percent. Inefficient blood centers have little opportunity to reduce full-time employees or reduce expenditures; however, they can decrease their use of part-time employees by 10 percent and volunteers by 9 percent. CONCLUSION: The results indicate that efficiency improvements would help to alleviate the nation's persistent blood shortages. These findings can be used by blood center managers to identify management interventions that can improve operational efficiency, resulting in greater output with existing levels of resources.