Health care costs associated with hospital acquired complications in patients with chronic kidney disease.

BACKGROUND: Patients with CKD are at increased risk of potentially preventable hospital acquired complications (HACs). Understanding the economic consequences of preventable HACs, may define the scope and investment of initiatives aimed at prevention. METHODS: Adult patients hospitalized from April, 2003 to March, 2008 in Alberta, Canada comprised the study cohort. Healthcare costs were determined and categorized into 'index hospitalization' including hospital cost and in-hospital physician claims, and 'post discharge' including ambulatory care cost, physician claims, and readmission costs from discharge to 90 days. Multivariable regression was used to estimate the incremental healthcare costs associated with potentially preventable HACs. RESULTS: In fully adjusted models, the median incremental index hospitalization cost was CAN-$6169 (95% CI; 6003-6336) in CKD patients with ≥1 potentially preventable HACs, compared with those without. Post-discharge incremental costs were 1471(95% CI; 844-2099) in those patients with CKD who developed potentially preventable HACs within 90 days after discharge compared with patients without potentially preventable HACs. Additionally, the incremental costs associated with ≥1 potentially preventable HACs within 90 days from admission in patients with CKD were $7522 (95% CI; 7219-7824). A graded relation of the incremental costs was noted with the increasing number of complications. In patients without CKD but with ≥1 preventable HACs incremental costs within 90 days from hospital admission was $6688 (95% CI: 6612-6723). CONCLUSIONS: Potentially preventable HACs are associated with substantial increases in healthcare costs in people with CKD. Investment in implementing targeted strategies to reduce HACs may have a significant benefit for patient and health system outcomes.

Exploring in-hospital adverse drug events using ICD-10 codes.

OBJECTIVE: Adverse drug events (ADEs) during hospital admissions are a widespread problem associated with adverse patient outcomes. The 'external cause' codes in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) provide opportunities for identifying the incidence of ADEs acquired during hospital stays that may assist in targeting interventions to decrease their occurrence. The aim of the present study was to use routine administrative data to identify ADEs acquired during hospital admissions in a suburban healthcare network in Melbourne, Australia. METHODS: Thirty-nine secondary diagnosis fields of hospital discharge data for a 1-year period were reviewed for 'diagnoses not present on admission' and assigned to the Classification of Hospital Acquired Diagnoses (CHADx) subclasses. Discharges with one or more ADE subclass were extracted for retrospective analysis. RESULTS: From 57205 hospital discharges, 7891 discharges (13.8%) had at least one CHADx, and 402 discharges (0.7%) had an ADE recorded. The highest proportion of ADEs was due to administration of analgesics (27%) and systemic antibiotics (23%). Other major contributors were anticoagulation (13%), anaesthesia (9%) and medications with cardiovascular side-effects (9%). CONCLUSION: Hospital data coded in ICD-10 can be used to identify ADEs that occur during hospital stays and also clinical conditions, therapeutic drug classes and treating units where these occur. Using the CHADx algorithm on administrative datasets provides a consistent and economical method for such ADE monitoring.

Oxygen isotope exchange with quartz during pyrolysis of silver sulfate and silver nitrate.

RATIONALE: Triple oxygen isotopes of sulfate and nitrate are useful metrics for the chemistry of their formation. Existing measurement methods, however, do not account for oxygen atom exchange with quartz during the thermal decomposition of sulfate. We present evidence for oxygen atom exchange, a simple modification to prevent exchange, and a correction for previous measurements. METHODS: Silver sulfates and silver nitrates with excess (17)O were thermally decomposed in quartz and gold (for sulfate) and quartz and silver (for nitrate) sample containers to O(2) and byproducts in a modified Temperature Conversion/Elemental Analyzer (TC/EA). Helium carries O(2) through purification for isotope-ratio analysis of the three isotopes of oxygen in a Finnigan MAT253 isotope ratio mass spectrometer. RESULTS: The Δ(17)O results show clear oxygen atom exchange from non-zero (17)O-excess reference materials to zero (17)O-excess quartz cup sample containers. Quartz sample containers lower the Δ(17)O values of designer sulfate reference materials and USGS35 nitrate by 15% relative to gold or silver sample containers for quantities of 2-10 µmol O(2). CONCLUSIONS: Previous Δ(17)O measurements of sulfate that rely on pyrolysis in a quartz cup have been affected by oxygen exchange. These previous results can be corrected using a simple linear equation (Δ(17)O(gold) = Δ(17)O(quartz) * 1.14 + 0.06). Future pyrolysis of silver sulfate should be conducted in gold capsules or corrected to data obtained from gold capsules to avoid obtaining oxygen isotope exchange-affected data.

Discovery and measurement of an isotopically distinct source of sulfate in Earth's atmosphere.

Sulfate (SO(4)) and its precursors are significant components of the atmosphere, with both natural and anthropogenic sources. Recently, our triple-isotope ((16)O, (17)O, (18)O) measurements of atmospheric sulfate have provided specific insights into the oxidation pathways leading to sulfate, with important implications for models of the sulfur cycle and global climate change. Using similar isotopic measurements of aerosol sulfate in a polluted marine boundary layer (MBL) and primary sulfate (p-SO(4)) sampled directly from a ship stack, we quantify the amount of p-SO(4) found in the atmosphere from ships. We find that ships contribute between 10% and 44% of the non-sea-salt sulfate found in fine [diameter (D) < 1.5 microm) particulate matter in coastal Southern California. These fractions are surprising, given that p-SO(4) constitutes approximately 2-7% of total sulfur emissions from combustion sources [Seinfed JH, Pandis SN (2006) Atmospheric Chemistry and Physics (Wiley-Interscience, New York)]. Our findings also suggest that the interaction of SO(2) from ship emissions with coarse hydrated sea salt particles may lead to the rapid removal of SO(2) in the MBL. When combined with the longer residence time of p-SO(4) emissions in the MBL, these findings suggest that the importance of p-SO(4) emissions in marine environments may be underappreciated in global chemical models. Given the expected increase of international shipping in the years to come, these findings have clear implications for public health, air quality, international maritime law, and atmospheric chemistry.

Comparing the coding of complications in Queensland and Victorian admitted patient data.

OBJECTIVE: To examine differences between Queensland and Victorian coding of hospital-acquired conditions and suggest ways to improve the usefulness of these data in the monitoring of patient safety events. DESIGN: Secondary analysis of admitted patient episode data collected in Queensland and Victoria. METHODS: Comparison of depth of coding, and patterns in the coding of ten commonly coded complications of five elective procedures. RESULTS: Comparison of the mean complication codes assigned per episode revealed Victoria assigns more valid codes than Queensland for all procedures, with the difference between the states being significantly different in all cases. The proportion of the codes flagged as complications was consistently lower for Queensland when comparing 10 common complications for each of the five selected elective procedures. The estimated complication rates for the five procedures showed Victoria to have an apparently higher complication rate than Queensland for 35 of the 50 complications examined. CONCLUSION: Our findings demonstrate that the coding of complications is more comprehensive in Victoria than in Queensland. It is known that inconsistencies exist between states in routine hospital data quality. Comparative use of patient safety indicators should be viewed with caution until standards are improved across Australia. More exploration of data quality issues is needed to identify areas for improvement.

Access with evidence development: an approach to introducing promising new technologies into healthcare.

The rapid development of new health technologies for which there is limited, but promising, evidence has resulted in a daunting challenge - to provide care that meets population health needs and optimizes patient outcomes, demonstrates an efficient use of healthcare resources, and upholds basic principles of equity, access, and choice. In this paper, we introduce 'Access with Evidence Development' as a possible mechanism for addressing this challenge and discuss its application to the "Zamboni procedure" for Multiple Sclerosis.

Prospective payment to encourage system wide quality improvement.

BACKGROUND: Casemix-based inpatient prospective payment systems allocate payments for acute care based on what is done within an episode of care without regard for the outcome. To date, they have provided little incentive to improve quality. The Centers for Medicare & Medicaid Services have recently excluded 8 avoidable complications from their payment system. OBJECTIVE: This study models an inpatient prospective payment system that comprehensively excludes not-present-on-admission and other complication diagnoses from the entire funding process, effectively adding a diagnosis-related group (DRG)-specific average complication payment across all discharges. RESEARCH DESIGN: Complication-averaged cost weights were estimated using the same patient level cost dataset used for estimating the relative resource weights for Victorian public hospitals in 2006-07. All codes with a "C" prefix (secondary diagnoses that are coded as having arisen after admission) and codes that define a condition that prima facie represent a specific complication of care were excluded from the code string. The episodes were then regrouped to DRGs and new complication-averaged cost weights were developed. RESULTS: When complication codes were excluded across 1.2 million discharges, 1.37% became ungroupable, 14.86% included at least one complication diagnosis code, and 1.56% grouped to another DRG. Modeled funding for individual metropolitan hospitals in Victoria, Australia, was redistributed by -2.5% to 1.8%. CONCLUSIONS: The cost weights reflect the average cost of preventable and unpreventable complications and have the potential to drive improvements in clinical care. This study is in contrast to previous studies estimating the funding impact of preventing all complications.

Development of a validation algorithm for 'present on admission' flagging.

BACKGROUND: The use of routine hospital data for understanding patterns of adverse outcomes has been limited in the past by the fact that pre-existing and post-admission conditions have been indistinguishable. The use of a 'Present on Admission' (or POA) indicator to distinguish pre-existing or co-morbid conditions from those arising during the episode of care has been advocated in the US for many years as a tool to support quality assurance activities and improve the accuracy of risk adjustment methodologies. The USA, Australia and Canada now all assign a flag to indicate the timing of onset of diagnoses. For quality improvement purposes, it is the 'not-POA' diagnoses (that is, those acquired in hospital) that are of interest. METHODS: Our objective was to develop an algorithm for assessing the validity of assignment of 'not-POA' flags. We undertook expert review of the International Classification of Diseases, 10th Revision, Australian Modification (ICD-10-AM) to identify conditions that could not be plausibly hospital-acquired. The resulting computer algorithm was tested against all diagnoses flagged as complications in the Victorian (Australia) Admitted Episodes Dataset, 2005/06. Measures reported include rates of appropriate assignment of the new Australian 'Condition Onset' flag by ICD chapter, and patterns of invalid flagging. RESULTS: Of 18,418 diagnosis codes reviewed, 93.4% (n = 17,195) reflected agreement on status for flagging by at least 2 of 3 reviewers (including 64.4% unanimous agreement; Fleiss' Kappa: 0.61). In tests of the new algorithm, 96.14% of all hospital-acquired diagnosis codes flagged were found to be valid in the Victorian records analysed. A lower proportion of individual codes was judged to be acceptably flagged (76.2%), but this reflected a high proportion of codes used <5 times in the data set (789/1035 invalid codes). CONCLUSION: An indicator variable about the timing of occurrence of diagnoses can greatly expand the use of routinely coded data for hospital quality improvement programmes. The data-cleaning instrument developed and tested here can help guide coding practice in those health systems considering this change in hospital coding. The algorithm embodies principles for development of coding standards and coder education that would result in improved data validity for routine use of non-POA information.

Reconciling hospital-acquired complications and CHADx+ in Victorian coded hospital data.

BACKGROUND: The Council of Australian Governments has focused the attention of health service managers and state health departments on a list of hospital-acquired complications (HACs) proposed as the basis of funding adjustments for poor quality of hospital inpatient care. These were devised for the Australian Commission on Safety and Quality in Health Care as a subset of their earlier classification of hospital-acquired complications (CHADx) and designed to be used by health services to monitor safety performance for their admitted patients. OBJECTIVE: To improve uptake of both classification systems by clarifying their purposes and by reconciling the ICD-10-AM code sets used in HACs and the Victorian revisions to the CHADx system (CHADx+). METHOD: Frequency analysis of individual clinical codes with condition onset flag (COF 1) included in both classification systems using the Victorian Admitted Episodes Dataset for 2014/2015 ( n = 2,623,275 separations). Narrative description of the resulting differences in definition of "adverse events" embodied in the two systems. RESULTS: As expected, a high proportion of ICD-10-AM codes used in the HACs also appear in CHADx+, and given the wider scope of CHADx+, it uses a higher proportion of all COF 1 diagnoses than HACs (82% vs. 10%). This leads to differing estimates of rates of adverse events: 2.12% of cases for HACs and 11.13% for CHADx+. Most CHADx classes (70%) are not covered by the HAC system; discrepancies result from the exclusion from HACs of several major CHADx+ groups and from a narrower definition of detailed HAC classes compared with CHADx+. Case exclusion criteria in HACs (primarily mental health admissions) resulted in a very small proportion of discrepancies (0.13%) between systems. DISCUSSION: Issues of purpose and focus of these two Australian systems, HACs for clinical governance and CHADx+ for local quality improvement, explain many of the differences between them, and their approach to preventability, and risk stratification. CONCLUSION: A clearer delineation between these two systems using routinely coded hospital data will assist funders, clinicians, quality improvement professionals and health information managers to understand discrepancies in case identification between them and support their different information needs.

Emergency and urgent care systems in Australia, Denmark, England, France, Germany and the Netherlands - Analyzing organization, payment and reforms.

INTRODUCTION: Increasing numbers of hospital emergency department (ED) visits pose a challenge to health systems in many countries. This paper aims to examine emergency and urgent care systems, in six countries and to identify reform trends in response to current challenges. METHODS: Based on a literature review, six countries - Australia, Denmark, England, France, Germany and the Netherlands - were selected for analysis. Information was collected using a standardized questionnaire that was completed by national experts. These experts reviewed relevant policy documents and provided information on (1) the organization and planning of emergency and urgent care, (2) payment systems for EDs and urgent primary care providers, and (3) reform initiatives. RESULTS: In the six countries four main reform approaches could be identified: (a) extending the availability of urgent primary care, (b) concentrating and centralizing the provision of urgent primary care, (c) improving coordination between urgent primary care and emergency care, and (d) concentrating emergency care provision at fewer institutions. The design of payment systems for urgent primary care and for emergency care is often aligned to support these reforms. CONCLUSION: Better guidance of patients and a reconfiguration of emergency and urgent care are the most important measures taken to address the current challenges. Nationwide planning of all emergency care providers, closely coordinated reforms and informing patients can support future reforms.

Dabigatran (Pradaxa) Is Safe for Extended Venous Thromboembolism Prophylaxis After Surgery for Pancreatic Cancer.

BACKGROUND: The American College of Chest Physicians and American Hepato-Pancreato-Biliary Association recommend using low-molecular-weight heparin for 28 days postoperatively for venous thromboembolism prophylaxis after cancer surgery. Dabigatran is a once daily oral anticoagulant that is FDA approved for venous thromboembolism prophylaxis after orthopedic surgery, uses fixed dosing, and has an antidote. METHODS: Patients undergoing surgery for malignant pancreatic tumors (neuroendocrine excluded) from January 2017 to January 2018 were converted to dabigatran 220 mg daily on discharge until postoperative day 28; patients with medical or insurance contraindications were converted to enoxaparin or another direct oral anticoagulant. The primary endpoint was bleeding complications through 90 days. RESULTS: A total of 134 patients were considered for this study (median age 67 ± 10; 58.9% male). Eighty-seven (82.9%) patients received dabigatran and 18 (17.1%) received another form of anticoagulation. There were 19 (4.2%) patients not prescribed dabigatran due to medical or inpatient contraindications. Four patients experienced bleeding complications after discharge while on dabigatran. Two (2%) were major bleeds (Clavien-Dindo IV and V), and 2 (2%) were minor (Clavien-Dindo I). Patient compliance was excellent, with 93% of prescribed patients fully completing their prophylaxis. There were 2 patients that developed symptomatic deep vein thrombosis. CONCLUSION: The use of a direct oral anticoagulant as extended venous thromboembolism prophylaxis after major gastrointestinal surgery has not been studied to date. These results show dabigatran to be a safe alternative to low-molecular-weight heparin for extended venous thromboembolism prophylaxis with regard to bleeding complications.

Describing Iranian hospital activity using Australian Refined DRGs: a case study of the Iranian Social Security Organisation.

OBJECTIVE: To describe Iran's hospital activity with Australian Refined Diagnosis Related Groups (AR-DRGs). METHOD: A total of 445,324 separations was grouped into discreet DRG classes using AR-DRGs. L(3)H(3); IQR and 10th-95th percentile were used to exclude outlier cases. Reduction in variance (R(2)) and coefficient of variation (CV) were applied to measure model fit and within group homogeneity. RESULTS: Total hospital acute inpatients were grouped into 579 DRG groups in which 'surgical' cases represented 63% of the total separations and 40% of total DRGs. Approximately 12.5% of the total separations fell into DRGs O60C (vaginal delivery) and 28% of the total separations classified into major diagnostic category (MDC) 14 (pregnancy and childbirth). Although reduction in variance (R(2)) for untrimmed data was low (R(2)=0.17) for LOS, trimming by L(3)H(3), IQR, and 10th-95th percentile methods improved the value of R(2) to 0.53, 0.48, and 0.51, respectively. Low value of R(2) for AR-DRGs within several MDCs were identified, and found to reflect high variability in one or two DRGs. High within-DRG variation was identified for 23% of DRGs using untrimmed data. CONCLUSION: Low quality and incomplete data undermines the accuracy of casemix information. This may require improvement in coding quality or further classification refinement in Iran. Further study is also required to compare AR-DRG performance with other versions of DRGs and to determine whether the low value of R(2) for several MDCs is due to the weakness of the AR-DRG algorithm or to Iranian specific factors.

Unwanted pregnancy, mental health and abortion: untangling the evidence.

Abortion policy is still contentious in many parts of the world, and periodically it emerges to dominate health policy debates. This paper examines one such debate in Australia centering on research findings by a New Zealand research group, Fergusson, Horwood & Ridder, published in early 2006. The debate highlighted the difficulty for researchers when their work is released in a heightened political context. We argue that the authors made a logical error in constructing their analysis and interpreting their data, and are therefore not justified in making policy claims for their work. The paper received significant public attention, and may have influenced the public policy position of a major professional body. Deeply held views on all sides of the abortion debate are unlikely to be reconciled, but if policy is to be informed by research, findings must be based on sound science.

An evaluation of the validity of inferences made from 3 diabetes assessment instruments: a Rasch analysis.

BACKGROUND: Many patients who have diabetes lack adequate knowledge, positive attitudes, and sufficient resources to achieve optimal outcomes in the management of their disease. A key to assessing the impact of pharmacists' interactions with diabetes patients is the resultant impact on patient knowledge, attitudes, and satisfaction. As such, it is important that quality instruments be used to obtain accurate and dependable measures of these outcomes. OBJECTIVE: To evaluate the validity of inferences made from 3 separate diabetes instruments used in the assessment of patient knowledge, attitudes, and satisfaction. METHODS: This pilot study enrolled 30 patients with diabetes mellitus to evaluate the following 3 instruments: (1) Check Your Hemoglobin A1CIQ, (2) the revised Diabetes Questionnaire, and (3) a satisfaction questionnaire. The instruments were used to assess patient knowledge of diabetes and diabetes-related complications, attitudes toward having diabetes mellitus, and satisfaction with the services provided in a pharmacist-run diabetes clinic, respectively. Rasch analysis was used to determine if the instruments were able to measure the concepts they are intended to measure when used in this sample. RESULTS: After evaluating the 3 instruments, it was determined that Instrument 1 displayed construct underrepresentation and some mistargeting. Moreover, Instrument 2 demonstrated reasonably good rating scale function but exhibited construct underrepresentation and ceiling effects. Finally, Instrument 3 did not meet the necessary requirements for proper rating scale function and displayed ceiling effects and mistargeting. CONCLUSIONS: This pilot evaluation suggested that none of the instruments were useful in this population, which reinforces the need for researchers to use item response theories to examine the psychometric properties of instruments used in reporting various patient outcome measures. Pharmacists and other health care professionals should be alerted to potential problems with the validity of inferences made from underperforming instruments, so as to prevent inaccurate conclusions.

The incidence and cost of cardiac surgery adverse events in Australian (Victorian) hospitals 2003-2004.

The aim of this study was to estimate the incidence of adverse events in acute surgical admissions for cardiac disease in admitted episodes in the year 2003-2004 and to estimate the cost of these complications to the Victorian health system. Cardiac surgery adverse events are among the most frequent and significant contributors to the morbidity, mortality and cost associated with hospitalisation. Patient-level costing data set for major Victorian public hospitals in 2003-2004 was analysed for adverse events using C-prefixed markers, denoting complications that arose during the course of hospital treatment for cardiac surgery diagnosis related groups (DRGs). The cost of adverse events was estimated by linear regression modelling, adjusted for age and co-morbidity. A total of 16,766 multi-day cardiac disease cases were identified, of whom 6,181 (36.85%) had at least one adverse event. Patients with adverse events stayed approximately 7 days longer and had four times the case fatality rate than those without. After adjustment for age and co-morbidity, the presence of an adverse event adds AUS$5,751. The sum of the total cost of adverse events for each DRG was AUS$42.855 million, representing 21.6% of total expenditure on cardiac surgery and adding 27.5% in broad terms to the cardiac surgery budget.

Adverse Outcomes Associated with Preventable Complications in Hospitalized Patients with CKD.

BACKGROUND: and objectives Patients with CKD are at risk of hospital-acquired complications (HACs). We sought to determine the association of preventable HACs with mortality, length of stay (LOS), and readmission. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: All adults hospitalized from April of 2003 to March of 2008 in Alberta were characterized by kidney function and occurrence of preventable HACs. CKD was defined by eGFR<60 ml/min per 1.73 m2 and/or albumin-to-creatinine ratio >3-30 mg/mmol for >3 months in the time frame from 365 to 90 days before admission. Regression models examined the association of HACs with outcomes. RESULTS: Of 536,549 hospitalizations, 8.5% (n=45,733) had CKD and 9.8% of patients with CKD had one or more potentially preventable HAC. In patients with potentially preventable HACs, proportions of death within index hospitalization and from discharge to 90 days were 17.7% and 6.8%, respectively. In patients with CKD, comparing with those hospitalizations without potentially preventable HACs, the adjusted odds ratio (OR) of mortality during index hospitalization and from hospital discharge to 90 days in patients with one or more preventable HAC was 4.67 (95% confidence interval [95% CI], 4.17 to 5.22) and 1.08 (95% CI, 0.94 to 1.25), respectively. Median incremental LOS in patients with one or more preventable HAC was 9.86 days (95% CI, 9.25 to 10.48). The OR for readmission with preventable HAC was 1.24 (95% CI, 1.15 to 1.34). In a cohort with and without CKD, the adjusted ORs of mortality during index hospitalization in patients with CKD and no preventable HACs, patients without CKD and with preventable HACs, and patients with CKD and preventable HACs were 2.22 (95% CI, 1.69 to 2.94), 5.26 (95% CI, 4.98 to 5.55), and 9.56 (95% CI, 7.23 to 12.56), respectively (referenced to patients without CKD or preventable HACs). CONCLUSIONS: Preventable HACs are associated with higher mortality, incremental LOS, and greater risk of readmission, especially in people with CKD. Targeted strategies to reduce complications should be a high priority.

Measurement of adverse events using "incidence flagged" diagnosis codes.

OBJECTIVE: To compare two methods for identifying adverse events using routinely recorded hospital abstract data in all public and private hospitals in Victoria, Australia. METHODS: Secondary analysis of data on all admissions in the period 1 July 2000-30 June 2001 (n = 1,645,992) to estimate the rates of adverse events using International Classification of Diseases 10th Revision Australian Modification codes alone and in combination with an "incidence" data flag indicating complicating diagnoses which arise after hospitalization; rates of incidence and pre-existing adverse events, and rates for same-day and multi-day admissions. RESULTS: In total, 8% of all admissions were recorded with an adverse event. Use of ICD codes alone identified only 59% of the events identified using the combined method, giving a prevalence rate of only 5%. Incident cases, that is, those occurring in the index admission, represented 68% of identified adverse events. The adverse events incidence rate for multi-day admissions was significantly higher at 12%, compared with the same day rate of 0.4%. CONCLUSION: An "incidence flag" is essential to identify those adverse events for which a hospital has unambiguous responsibility. Using such a flag, secondary analysis of administrative data can provide hospital quality assurance programmes with a comprehensive view of all adverse events (not just "sentinel" events) at a reasonable cost and with more timely results than more intensive methods can achieve. Although the method is likely to underestimate the true rate of adverse events (in particular, by not capturing adverse events which only manifest after discharge), in this study of Australian hospitals, rates of adverse events were found to be similar to those derived from studies using manual review of patient records.

Analysis of cost outliers within APR-DRGs in a Belgian general hospital: two complementary approaches.

CONTEXT AND OBJECTIVES: The objective of this study was to find factors that could explain high and low resource use outliers, by associating an explanatory analysis with a statistical analysis. METHOD: High resource use outliers were selected according to the following rule: 75th percentile + 1.5* inter-quartile range. Low resource use outliers were selected according to: 25th percentile - 1.5* inter-quartile range. The statistical approach was based on a multivariate analysis using logistic regression. A decision tree approach using predictors from this analysis (intensive care unit (ICU) stay, high severity of illness and social factors associated with longer length of stay) was also tested as a more intuitive tool for use by hospitals in focussing review efforts on "not explained" cost outliers. RESULTS: High resource use outliers accounted for 6.31% of the hospital stays versus 1.07% for low resource use outliers. The probability of a patient being a high resource use outlier was higher with an increase in the length of stay (odds ratios (OR) = 1.08), when the patient was treated in an intensive care unit (OR = 3.02), with a major or extreme severity of illness (OR=1.46), and with the presence of social factors (OR = 1.44). The probability of being a low outlier is lower for older patients (OR = 0.98). The probability of being a low outlier is also lower without readmission within the year (OR = 0.55). The more intuitive decision tree method identified 92.26% of the cases identified through residuals of the regression model. One quarter of the high cost outliers were flagged for additional review ("not justified" on the basis of the model), with nearly three-quarters "justified" by clinical and social factors. CONCLUSION: The analysis of cost outliers can meet different aims (financing of justifiable outliers, improvement of the care process for the outliers not justifiable on medical or social grounds). The two methods are complementary, by proposing a statistical and a didactic approach to achieve the goal of high quality care using fewer resources.

Prospective casemix-based funding, analysis and financial impact of cost outliers in all-patient refined diagnosis related groups in three Belgian general hospitals.

This study examined the impact of cost outliers in term of hospital resources consumption, the financial impact of the outliers under the Belgium casemix-based system, and the validity of two "proxies" for costs: length of stay and charges. The cost of all hospital stays at three Belgian general hospitals were calculated for the year 2001. High resource use outliers were selected according to the following rule: 75th percentile +1.5 xinter-quartile range. The frequency of cost outliers varied from 7% to 8% across hospitals. Explanatory factors were: major or extreme severity of illness, longer length of stay, and intensive care unit stay. Cost outliers account for 22-30% of hospital costs. One-third of length-of-stay outliers are not cost outliers, and nearly one-quarter of charges outliers are not cost outliers. The current funding system in Belgium does not penalize hospitals having a high percentage of outliers. The billing generated by these patients largely compensates for costs generated. Length of stay and charges are not a good approximation to select cost outliers.

Adverse events in Victorian admissions for elective surgery.

OBJECTIVES: To investigate a method to identify and understand patterns of adverse events by utilising secondary data analysis; to identify the types of complications associated with elective surgery; to identify any specific "adverse event-prone" elective procedures; and to consider the implications of these patterns for hospital patient safety programs. SETTING: Public hospitals in Victoria. DESIGN: Secondary analysis of data on acute hospital admissions for elective surgery in the period 1 July 2000 to 30 June 2001, for non-obstetric patients older than 15 years (n = 177 533). MAIN OUTCOME MEASURES: Estimated rates of adverse events for the most commonly performed elective surgery procedures; frequency of the most commonly recorded adverse event types. RESULTS: Of all admissions, 15.5% had at least one complication of care. The most frequent first-recorded single complication code, in 9.6% of cases with a complication, was "Haemorrhage and haematoma complicating a procedure". The most common adverse event categories were cardiac and circulatory complications (23%), symptomatic complications (18%), and surgical and drug-related complications (17%). The procedure blocks most frequently associated with an adverse event were coronary artery bypass surgery (67%), colectomy (52%), hip and knee arthroplasty (42% and 36%, respectively), and hysterectomy (20%). The types of complications associated with the four most adverse event-prone procedures were cardiac arrhythmias, surgical adverse events (haemorrhage or laceration), intestinal obstruction, anaemia, and symptomatic complications. CONCLUSION: Routinely collected data are valuable in obtaining information on complication types associated with elective surgery. International Classification of Diseases codes and surgical procedure "blocks" allow very sophisticated investigation of types of complications and differences in complication rates for different surgical approaches. The usefulness of such data relies on good documentation in the medical record, thorough coding and periodic data audit. The limitations of the method described here include the lack of follow-up after discharge, variable coding standards between institutions and over time (potentially distorting information on rates), lack of information on the causative factors for some adverse events, and a limited capacity to support investigation of particular cases. Hospitals should consider monitoring complication rates for individual elective procedures or blocks of similar procedures, and comparing adverse event rates over time and with peer hospitals as an integral part of their patient safety programs.