Trends in Initial Anticoagulation Among US Patients Hospitalized With Acute Pulmonary Embolism 2011-2020.

STUDY OBJECTIVE: Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE. METHODS: We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment. RESULTS: Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81). CONCLUSIONS: Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care.

The Relationship Between Governing Board Composition and Medicare Shared Savings Program Accountable Care Organizations Outcomes: an Observational Study.

BACKGROUND: Early studies of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) suggested that physician leadership was an important driver of ACO success, but it is unknown whether the demographic and professional composition of current MSSP ACO governing boards is associated with ACOs' publicly reported outcomes. OBJECTIVE: To investigate whether governing boards with higher physician participation and greater female involvement have better outcomes. DESIGN: Cross-sectional observational study. PARTICIPANTS: All 2017 MSSP ACOs identified by the Center for Medicare and Medicaid Services ACO Public Use Files (PUF). MAIN MEASURES: We collected governing board composition from ACO websites in 2019. Outcome metrics included risk-standardized readmission and unplanned admissions rates. We used descriptive statistics and linear regression models to examine the association between board composition and outcomes. KEY RESULTS: Of the 339 ACOs that still existed in 2019 and had available data, 77% had physician-majority boards and 11.5% had no women on their boards. Eighty-nine percent reported a Medicare beneficiary on their board, of which about one-third had a woman representative. The average number of members on MSSP ACO boards was 12, with a mean of 67% physicians and 24% women. Board composition varied minimally by ACO characteristics, such as geographic region, number of beneficiaries, or type of participants. Higher levels of physician participation in ACO governing boards were associated with lower all-cause unplanned admission rates for patients with heart failure (p = - 0.26, p < 0.001) and for patients with multiple chronic conditions (p = - 0.28, p = 0.001). The number of women on the board was not associated with any outcome differences. CONCLUSIONS: MSSP ACO governing boards were predominately male and physician-led. Physician involvement may be important for achieving quality goals, while lack of female involvement showcases an opportunity to diversify boards.

Association between Initiation of Pulmonary Rehabilitation and Rehospitalizations in Patients Hospitalized with Chronic Obstructive Pulmonary Disease.

Rationale: Although clinical trials have found that pulmonary rehabilitation (PR) can reduce the risk of readmissions after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, less is known about PR's impact in routine clinical practice. Objectives: To evaluate the association between initiation of PR within 90 days of discharge and rehospitalization(s). Methods: We analyzed a retrospective cohort of Medicare beneficiaries (66 years of age or older) hospitalized for COPD in 2014 who survived at least 30 days after discharge. Measurements and Main Results: We used propensity score matching and estimated the risk of recurrent all-cause rehospitalizations at 1 year using a multistate model to account for the competing risk of death. Of 197,376 total patients hospitalized in 4,446 hospitals, 2,721 patients (1.5%) initiated PR within 90 days of discharge. Overall, 1,534 (56.4%) patients who initiated PR and 125,720 (64.6%) who did not were rehospitalized one or more times within 1 year of discharge. In the propensity-score-matched analysis, PR initiation was associated with a lower risk of readmission in the year after PR initiation (hazard ratio, 0.83; 95% confidence interval, 0.77-0.90). The mean cumulative number of rehospitalizations at 1 year was 0.95 for those who initiated PR within 90 days and 1.15 for those who did not (P < 0.001). Conclusions: After hospitalization for COPD, Medicare beneficiaries who initiated PR within 90 days of discharge experienced fewer rehospitalizations over 1 year. These results support findings from randomized controlled clinical trials and highlight the need to identify effective strategies to increase PR participation.

A scoring system derived from electronic health records to identify patients at high risk for noninvasive ventilation failure.

OBJECTIVE: To develop and validate a clinical risk prediction score for noninvasive ventilation (NIV) failure defined as intubation after a trial of NIV in non-surgical patients. DESIGN: Retrospective cohort study of a multihospital electronic health record database. PATIENTS: Non-surgical adult patients receiving NIV as the first method of ventilation within two days of hospitalization. MEASUREMENT: Primary outcome was intubation after a trial of NIV. We used a non-random split of the cohort based on year of admission for model development and validation. We included subjects admitted in years 2010-2014 to develop a risk prediction model and built a parsimonious risk scoring model using multivariable logistic regression. We validated the model in the cohort of subjects hospitalized in 2015 and 2016. MAIN RESULTS: Of all the 47,749 patients started on NIV, 11.7% were intubated. Compared with NIV success, those who were intubated had worse mortality (25.2% vs. 8.9%). Strongest independent predictors for intubation were organ failure, principal diagnosis group (substance abuse/psychosis, neurological conditions, pneumonia, and sepsis), use of invasive ventilation in the prior year, low body mass index, and tachypnea. The c-statistic was 0.81, 0.80 and 0.81 respectively, in the derivation, validation and full cohorts. We constructed three risk categories of the scoring system built on the full cohort; the median and interquartile range of risk of intubation was: 2.3% [1.9%-2.8%] for low risk group; 9.3% [6.3%-13.5%] for intermediate risk category; and 35.7% [31.0%-45.8%] for high risk category. CONCLUSIONS: In patients started on NIV, we found that in addition to factors known to be associated with intubation, neurological, substance abuse, or psychiatric diagnoses were highly predictive for intubation. The prognostic score that we have developed may provide quantitative guidance for decision-making in patients who are started on NIV.

Organizational characteristics associated with high performance on quality measures in pediatric primary care: A positive deviance study.

BACKGROUND: Pediatric health care quality in the United States varies, but the reasons for variation are not fully understood. Differences in pediatric practices' organizational characteristics, such as organizational structures, strategies employed to improve quality, and other contextual factors, may contribute to the variation observed. PURPOSE: To assess the relationship between organizational characteristics and performance on clinical quality (CQ) and patient experience (PE) measures in primary care pediatric practices in Massachusetts. METHODOLOGY: A 60-item questionnaire that assessed the presence of selected organizational characteristics was sent to 172 pediatric practice managers in Massachusetts between December 2017 and February 2018. The associations between select organizational characteristics and publicly available CQ and PE scores were analyzed using analysis of variance; open-ended survey questions were analyzed using qualitative content analysis. RESULTS: Eighty-six practices (50.0%) responded; 80 (46.5%) were included in the primary analysis. Having a quality champion ( p = .03), offering co-located specialty services (e.g., behavioral health; p = .04), being a privately owned practice ( p = .04), believing that patients and families feel respected ( p = .03), and having a lower percentage of patients (10%-25%) covered by public health insurance ( p = .04) were associated with higher CQ scores. Higher PE scores were associated with private practice ownership ( p = .0006). Qualitative analysis suggested organizational culture and external factors, such as health care finance, may affect quality. CONCLUSIONS: Both modifiable organizational practices and factors external to a practice may affect quality of care. Addressing differences in practice performance may not be reducible to implementation of changes in single organizational characteristics. PRACTICE IMPLICATIONS: Pediatric practices seeking to improve quality of care may wish to adopt the strategies that were associated with higher performance on quality measures, but additional studies are needed to better understand the mechanisms behind these associations and how they relate to each other.

Risk Factors for Severe Opioid-Related Adverse Events in a National Cohort of Medical Hospitalizations.

BACKGROUND: Opioids are a leading cause of adverse drug events in the hospital. Guidelines recommend that physicians assess the risks of opioids and discuss them with patients when considering opioid use. There are no studies examining patient- and prescribing-related risk factors for opioid-related adverse drug events (ORADEs) in hospitalized medical patients. OBJECTIVE: To identify independent risk factors for severe ORADEs in hospitalized medical patients. DESIGN: Retrospective cohort study. PATIENTS: Medical patients hospitalized at US, non-federal, and acute care facilities, with at least one pharmacy charge for an opioid during hospitalization. We excluded patients with metastatic malignancy, hospice, or palliative care billing codes. MAIN MEASURES: We used Cox proportional hazards modeling to identify risk factors for severe ORADEs, defined by a pharmacy charge for naloxone. Candidate risk factors were chosen a priori, based on clinical grounds and prior literature. KEY RESULTS: Among 731,208 hospitalizations (median age 60, 56.5% female), a severe ORADE occurred in 2727 (0.4%). Independent risk factors included patient characteristics (advanced age, female gender), comorbidities (congestive heart failure, opioid abuse/dependence, non-opioid drug abuse/dependence, psychosis, depression, obstructive sleep apnea), organ failures on admission (respiratory failure, shock/hypotension, renal failure, hepatic failure, acidosis, and neurologic failure), medication co-administrations (antipsychotics and short-acting benzodiazepines), and characteristics of the opioid prescriptions themselves (total dose for the day, parenteral route of administration, and receipt of multiple types of opioids in a day). Although a risk prediction model derived from these factors performed well on stratified k-fold cross-validation (average c-statistics 0.68-0.71), the low incidence of the outcome limited the positive predictive value of the risk score. CONCLUSIONS: In this national cohort of medical patients, we identified several risk factors for ORADEs that can be used to inform physician decision-making, conversations with patients about risk, and development and targeting of harm reduction strategies for at-risk populations.

Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries.

Importance: Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge. Objective: To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival. Design, Setting, and Patients: This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015. Exposures: Initiation of pulmonary rehabilitation within 90 days of hospital discharge. Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality. Results: Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD], -6.7% [95% CI, -7.9% to -5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P < .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD, -4.6% [95% CI, -5.9% to -3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P < .001) to 61 to 90 days after discharge (ARD, -11.1% [95% CI, -13.2% to -8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P < .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01). Conclusions and Relevance: Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.

Spatial analysis of factors influencing choice of paediatric practice for mothers from low-income and minority populations.

AIM: Publicly reported quality data theoretically enable parents to choose higher-performing paediatric practices. However, little is known about how parents decide where to seek paediatric care. We explored the relationship between geographic factors, care quality and choice of practice to see if the decision-making process could be described in terms of a 'gravity model' of spatial data. METHODS: In the context of a randomised controlled trial, we used a geographic information system to calculate flow volume between practice locations and participants' homes, to locate subjects within a census tract, to determine distances between points and to perform exploratory mapping. Generalised linear modelling was then used to determine whether the data fit a gravity model, which is a spatial model that evaluates factors impacting travel from one set of locations to another. RESULTS: A total of 662 women and 52 paediatric practices were included in the analysis. Proximity of a practice to home was the most important factor in choosing a practice (Z = -15.01, P < 0.001). Practice size was important to a lesser extent, with larger practices more likely to be chosen (Z = 8.96, P < 0.001). A practice's performance on quality measures was associated with choice only for women who had received an intervention to increase use of quality data (Z = 2.51, P < 0.05). CONCLUSIONS: The gravity model and the concept of flow can help explain the choice of paediatric practice in a predominantly low-income, racially ethnic minority (non-White) urban population. This has important ramifications for the potential impact of publicly reported quality data.

Use of Inpatient Palliative Care Services in Patients With Advanced Cancer Receiving Critical Care Therapies.

Background: Invasive mechanical ventilation (IMV), dialysis for acute kidney failure, and other critical care therapies (CCTs) are associated with a high risk for complications in patients with metastatic cancer. Inpatient palliative care (IPC) can assist in assessing patients' preferences for life-prolonging treatment at the end of life. This study investigated the use pattern of IPC, outcomes (in-hospital mortality, length of stay [LOS], discharge destination, and cost of care), and predictors of IPC use in patients with metastatic cancer who received CCTs. We hypothesized that IPC services are underused in this cohort. Methods: In this retrospective cohort study, we used the 2010 California State Inpatient Databases to identify adults with metastatic cancer who received CCTs that are common and reliably coded (IMV, tracheostomy, percutaneous endoscopic gastrostomy tube, dialysis for acute kidney failure, and total parenteral nutrition). We determined IPC use in all patients, in those who received IMV, and across 4 cancer subtypes (lung, breast, colorectal, and genitourinary). Outcomes were assessed based on IPC use. Multivariable analyses were used to investigate factors associated with IPC use. Results: We identified 5,862 hospitalizations, 19.8% of which used IPC services. IPC use varied across cancer subtypes (lung, 28.3%; breast, 22.4%; colorectal, 12.8%; genitourinary, 16.1%; P<.01). Patients who received and did not receive IPC services had high in-hospital mortality rates (63.9% and 29.8%, respectively), and costs of care and LOS were lower in survivors who received IPC compared with those who did not. Predictors of IPC use were lung cancer (vs colorectal or genitourinary cancer), higher comorbidity score, do-not-resuscitate status on admission or within 24 hours of admission, infections (vs cancer-related diagnoses), and higher hospital bed count. Conclusions: Use of IPC was low in the cohort who received CCTs with poor outcomes, although data on outpatient palliative care services is lacking. Predictors of IPC use may be used to identify patients who may benefit from these services.

Hospital Volume and Outcomes of Noninvasive Ventilation in Patients Hospitalized With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

OBJECTIVE: To determine the relationship between hospital noninvasive ventilation caseload and outcomes among patients with an acute chronic obstructive pulmonary disease exacerbation. DESIGN: Cross-sectional study of 13,893 patients with chronic obstructive pulmonary disease treated with noninvasive ventilation. SETTING: A total of 243 U.S. hospitals participating in the Premier Inpatient Database. PATIENTS: A total of 13,893 patients admitted between July 2009 and June 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Annual hospital volume of noninvasive ventilation was analyzed as a continuous variable, as well as after grouping it in four categories. The median hospital annual volume of noninvasive ventilation use was 627 and varied from 234 admissions in quartile 1 to 1,529 admissions in quartile 4. Noninvasive ventilation failure occurred in 15.2%, and in-hospital mortality was 6.5%. After adjusting for patient characteristics, relative to low-volume hospitals, high-volume hospitals did not have lower noninvasive ventilation failure (odds ratio quartile 4 vs quartile 1, 1.05; 95% CI, 0.65-1.68) or in-hospital mortality (odds ratio quartile 4 vs quartile 1, 0.88; 95% CI, 0.69-1.12). In a hierarchical multivariable analysis with adjustment for patient characteristics where volume was assessed as a continuous variable, hospital volume was not related to outcomes, including noninvasive ventilation failure (p = 0.87), in-hospital mortality (p = 0.88), 30-day readmission for chronic obstructive pulmonary disease (p = 0.83), or hospital length of stay (p = 0.12). CONCLUSIONS: The results of this large retrospective cohort study suggest that hospitals with higher noninvasive ventilation volume do not achieve better outcomes of patients with chronic obstructive pulmonary disease exacerbation treated with noninvasive ventilation; even hospitals with low noninvasive ventilation volume are able to successfully implement this intervention.

Association Between Initial Route of Fluoroquinolone Administration and Outcomes in Patients Hospitalized for Community-acquired Pneumonia.

BACKGROUND: Fluoroquinolones have equivalent oral and intravenous bioavailability, but hospitalized patients with community-acquired pneumonia (CAP) generally are treated intravenously. Our objectives were to compare outcomes of hospitalized CAP patients initially receiving intravenous vs oral respiratory fluoroquinolones. METHODS: This was a retrospective cohort study utilizing data from 340 hospitals involving CAP patients admitted to a non-intensive care unit (ICU) setting from 2007 to 2010, who received intravenous or oral levofloxacin or moxifloxacin. The primary outcome was in-hospital mortality. Secondary outcomes included clinical deterioration (transfer to ICU, initiation of vasopressors, or invasive mechanical ventilation [IMV] initiated after the second hospital day), antibiotic escalation, length of stay (LOS), and cost. RESULTS: Of 36 405 patients who met inclusion criteria, 34 200 (94%) initially received intravenous treatment and 2205 (6%) received oral treatment. Patients who received oral fluoroquinolones had lower unadjusted mortality (1.4% vs 2.5%; P = .002), and shorter mean LOS (5.0 vs 5.3; P < .001). Multivariable models using stabilized inverse propensity treatment weighting revealed lower rates of antibiotic escalation for oral vs intravenous therapy (odds ratio [OR], 0.84; 95% confidence interval [CI], .74-.96) but no differences in hospital mortality (OR, 0.82; 95% CI, .58-1.15), LOS (difference in days 0.03; 95% CI, -.09-.15), cost (difference in $-7.7; 95% CI, -197.4-182.0), late ICU admission (OR, 1.04; 95% CI, .80-1.36), late IMV (OR, 1.17; 95% CI, .87-1.56), or late vasopressor use (OR, 0.94; 95% CI, .68-1.30). CONCLUSIONS: Among hospitalized patients who received fluoroquinolones for CAP, there was no association between initial route of administration and outcomes. More patients may be treated orally without worsening outcomes.

Association of guideline-based antimicrobial therapy and outcomes in healthcare-associated pneumonia.

OBJECTIVES: Guidelines for treatment of healthcare-associated pneumonia (HCAP) recommend empirical therapy with broad-spectrum antimicrobials. Our objective was to examine the association between guideline-based therapy (GBT) and outcomes for patients with HCAP. PATIENTS AND METHODS: We conducted a pharmacoepidemiological cohort study at 346 US hospitals. We included adults hospitalized between July 2007 and June 2010 for HCAP, defined as patients admitted from a nursing home, with end-stage renal disease or immunosuppression, or discharged from a hospital in the previous 90 days. Outcome measures included in-hospital mortality, length of stay and costs. RESULTS: Of 85 097 patients at 346 hospitals, 31 949 (37.5%) received GBT (one agent against MRSA and at least one against Pseudomonas). Compared with patients who received non-GBT, those who received GBT had a heavier burden of chronic disease and more severe pneumonia. GBT was associated with higher mortality (17.1% versus 7.7%, P < 0.001). Adjustment for demographics, comorbidities, propensity for treatment with GBT and initial severity of disease decreased, but did not eliminate, the association (OR 1.39, 95% CI 1.32-1.47). Using an adaptation of an instrumental variable analysis, GBT was not associated with higher mortality (OR 0.93, 95% CI 0.75-1.16). Adjusted length of stay and costs were also higher with GBT. CONCLUSIONS: Among patients who met HCAP criteria, GBT was not associated with lower adjusted mortality, length of stay or costs in any analyses. Better criteria are needed to identify patients at risk for MDR infections who might benefit from broad-spectrum antimicrobial coverage.

Variation in diagnostic coding of patients with pneumonia and its association with hospital risk-standardized mortality rates: a cross-sectional analysis.

BACKGROUND: Most U.S. hospitals publicly report 30-day risk-standardized mortality rates for pneumonia. Rates exclude severe cases, which may be assigned a secondary diagnosis of pneumonia and a principal diagnosis of sepsis or respiratory failure. By assigning sepsis and respiratory failure codes more liberally, hospitals might improve their reported performance. OBJECTIVE: To examine the effect of the definition of pneumonia on hospital mortality rates. DESIGN: Cross-sectional study. SETTING: 329 U.S. hospitals. PATIENTS: Adults hospitalized for pneumonia (as a principal diagnosis or secondary diagnosis paired with a principal diagnosis of sepsis or respiratory failure) between 2007 and 2010. MEASUREMENTS: Proportion of patients with pneumonia coded with a principal diagnosis of sepsis or respiratory failure and risk-standardized mortality rates excluding versus including a principal diagnosis of sepsis or respiratory failure. RESULTS: When the definition of pneumonia was limited to patients with a principal diagnosis of pneumonia, the risk-standardized mortality rate was significantly better than the mean in 4.3% of hospitals and significantly worse in 6.4%. When the definition was broadened to include patients with a principal diagnosis of sepsis or respiratory failure, this rate was better than the mean in 11.9% of hospitals and worse in 22.8% and the outlier status of 28.3% of hospitals changed. Among hospitals in the highest quintile of proportion of patients coded with a principal diagnosis of sepsis or respiratory failure, outlier status under the broader definition improved in 7.6% and worsened in 40.9%. Among those in the lowest quintile, 20.0% improved and none worsened. LIMITATION: Only inpatient mortality was studied. CONCLUSION: Variation in use of the principal diagnosis of sepsis or respiratory failure may bias efforts to compare hospital performance regarding pneumonia outcomes. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

A qualitative analysis of hospital leaders' opinions about publicly reported measures of health care quality.

BACKGROUND: Hospital leaders play an important role in the success of quality improvement (QI) initiatives, yet little is known about how leaders engaged in QI currently view quality performance measures. In a follow-up to a quantitative study conducted in 2012, a study employing qualitative content analysis was conducted to (1) describe leaders' opinions about the quality measures reported on the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website, (2) to generate hypotheses about barriers/facilitators to improving hospitals' performance, and (3) to elicit recommendations about how to improve publicly reported quality measures. METHODS: The opinions of leaders from a stratified sample of 630 hospitals across the United States regarding quality measures were assessed with an open-ended prompt that was part of a 21-item questionnaire about quality measures publicly reported by CMS. Their responses were qualitatively analyzed in an iterative process, resulting in the identification of the presence and frequency of major themes and subthemes. RESULTS: Participants from 131 (21%) of the 630 hospitals surveyed replied to the open-ended prompt; 15% were from hospitals with higher-than-average performance scores, and 52% were from hospitals with lower-than-average scores. Major themes included (1) concerns regarding quality measurement (measure validity, importance, and fairness) and/or public reporting; 76%); (2) positive views of quality measurement (stimulate improvement, focus efforts; 13%); and (3) recommendations for improving quality measurement. CONCLUSIONS: Among hospital leaders responding to an open-ended survey prompt, some supported the concept of measuring quality, but the majority criticized the validity and utility of current quality measures. Although quality measures are frequently being reevaluated and new measures developed, the ability of such measures to stimulate improvement may be limited without greater buy-in from hospital leaders.

Experience with Designing and Implementing a Bundled Payment Program for Total Hip Replacement.

BACKGROUND: Bundled payments, also known as episode-based payments, are intended to contain health care costs and promote quality. In 2011 a bundled payment pilot program for total hip replacement was implemented by an integrated health care delivery system in conjunction with a commercial health plan subsidiary. In July 2015 the Centers for Medicare & Medicaid Services (CMS) proposed the Comprehensive Care for Joint Replacement Model to test bundled payment for hip and knee replacement. METHODS: Stakeholders were identified and a structure for program development and implementation was created. An Oversight Committee provided governance over a Clinical Model Subgroup and a Financial Model Subgroup. RESULTS: The pilot program included (1) a clinical model of care encompassing the period from the preoperative evaluation through the third postoperative visit, (2) a pricing model, (3) a program to share savings, and (4) a patient engagement and expectation strategy. Compared to 32 historical controls-patients treated before bundle implementation-45 post-bundle-implementation patients with total hip replacement had a similar length of hospital stay (3.0 versus 3.4 days, p=.24), higher rates of discharge to home or home with services than to a rehabilitation facility (87% versus 63%), similar adjusted median total payments ($22,272 versus $22,567, p=.43), and lower median posthospital payments ($704 versus $1,121, p=.002), and were more likely to receive guideline-consistent care (99% versus 95%, p=.05). DISCUSSION: The bundled payment pilot program was associated with similar total costs, decreased posthospital costs, fewer discharges to rehabilitation facilities, and improved quality. Successful implementation of the program hinged on buy-in from stakeholders and close collaboration between stakeholders and the clinical and financial teams.

Variation in resource utilization for the management of uncomplicated community-acquired pneumonia across community and children's hospitals.

OBJECTIVE: To describe patterns of diagnostic testing and antibiotic management of uncomplicated pneumonia in general community hospitals and children's hospitals within hospitals and to determine the association between diagnostic testing and length of hospital stay. STUDY DESIGN: We conducted a retrospective cohort study of children 1-17 years of age hospitalized with the diagnosis of pneumonia from 2007 to 2010 to hospitals contributing data to Perspective Database Warehouse, assessing patterns of diagnostic testing and antibiotic management. We constructed logistic regression models of log-transformed length of stay (LOS) and grouped treatment models to ascertain whether performance of blood cultures and viral respiratory testing were associated with LOS. RESULTS: A total of 17 299 pneumonia cases occurred at 125 hospitals, with considerable variability in pneumonia management. Only 40 (0.2%) received ampicillin/penicillin G alone or in combination with other antibiotics, and 1318 (7.4%) received macrolide monotherapy as initial antibiotic management. Performance of blood culture and testing for respiratory viruses was associated with a statistically significant longer LOS, but these differences did not persist in grouped treatment models. CONCLUSIONS: We observed greater rates of diagnostic testing in this cohort of structurally diverse hospitals than previously reported at freestanding children's hospitals, with extremely low rates of narrow-spectrum antibiotic use. Tailored antibiotic stewardship initiatives at these hospitals are needed to achieve adherence to national guideline recommendations.

Malaria-related knowledge and prevention practices in four neighbourhoods in and around Mumbai, India: a cross-sectional study.

BACKGROUND: India accounts for the highest number of malaria cases outside of Africa. Eighty per cent of India's population lives in malaria-risk areas, with cases increasing in urban areas. Mumbai, India, one of the most populous cities in the world, has experienced such an increase. To be successful, many malaria control efforts require community participation, which in turn depends on individuals' knowledge and awareness of the disease. This study assessed the knowledge and prevention practices regarding malaria in residents of four different areas of Mumbai, India, around the time of a malaria outbreak and the start of a widespread awareness campaign. METHODS: A cross-sectional comparative study assessed malaria-related knowledge and prevention practices in four geographically and socio-demographically distinct areas of Mumbai, India. A structured interviewer-administered questionnaire was administered to a stratified random sample of 119 households between 16 December 2010 and 30 January 2011. Participant socio-demographic characteristics, malaria knowledge, malaria prevention practices, and household environmental factors were examined overall and compared across the four areas of Mumbai. RESULTS: Overall, respondents had excellent knowledge of the mosquito as the means of transmission of malaria, mosquito biting times and breeding sites, and fever as a symptom of malaria. However, many respondents also held misconceptions about malaria transmission and symptoms. Respondents generally knew that bed nets are an effective prevention strategy, but only 30% used them, and only 4% used insecticide-treated bed nets. Knowledge and prevention practices varied across the four areas of Mumbai. CONCLUSIONS: Although most residents know that bed nets are effective in preventing malaria, usage of bed nets is very low, and almost no residents use insecticide-treated bed nets. As the four areas of Mumbai differed in knowledge, prevention practices, and primary sources of information, malaria control campaigns should be tailored according to the knowledge gaps, practices, environments, resources, and preferences in different areas of the city, using the interpersonal and media channels most likely to reach the target audiences. Malaria control efforts involving bed nets should emphasize use of insecticide-treated bed nets.

Access to subspecialty care for patients with mobility impairment: a survey.

BACKGROUND: Adults who use wheelchairs have difficulty accessing physicians and receive less preventive care than their able-bodied counterparts. OBJECTIVE: To learn about the accessibility of medical and surgical subspecialist practices for patients with mobility impairment. DESIGN: A telephone survey was used to try to make an appointment for a fictional patient who was obese and hemiparetic, used a wheelchair, and could not self-transfer from chair to examination table. SETTING: 256 endocrinology, gynecology, orthopedic surgery, rheumatology, urology, ophthalmology, otolaryngology, and psychiatry practices in 4 U.S. cities. PATIENTS: None. MEASUREMENTS: Accessibility of the practice, reasons for lack of accessibility, and planned method of transfer of the patient to an examination table. RESULTS: Of 256 practices, 56 (22%) reported that they could not accommodate the patient, 9 (4%) reported that the building was inaccessible, 47 (18%) reported inability to transfer a patient from a wheelchair to an examination table, and 22 (9%) reported use of height-adjustable tables or a lift for transfer. Gynecology was the subspecialty with the highest rate of inaccessible practices (44%). LIMITATION: Small numbers of practices in 8 subspecialties in 4 cities and use of a fictional patient with obesity and hemiparesis limit generalizability. CONCLUSION: Many subspecialists could not accommodate a patient with mobility impairment because they could not transfer the patient to an examination table. Better awareness among providers about the requirements of the Americans with Disabilities Act and the standards of care for patients in wheelchairs is needed. PRIMARY FUNDING SOURCE: None.

Hospital performance measures and 30-day readmission rates.

BACKGROUND: Lowering hospital readmission rates has become a primary target for the Centers for Medicare & Medicaid Services, but studies of the relationship between adherence to the recommended hospital care processes and readmission rates have provided inconsistent and inconclusive results. OBJECTIVE: To examine the association between hospital performance on Medicare's Hospital Compare process quality measures and 30-day readmission rates for patients with acute myocardial infarction (AMI), heart failure and pneumonia, and for those undergoing major surgery. DESIGN, SETTING AND PARTICIPANTS: We assessed hospital performance on process measures using the 2007 Hospital Inpatient Quality Reporting Program. The process measures for each condition were aggregated in two separate measures: Overall Measure (OM) and Appropriate Care Measure (ACM) scores. Readmission rates were calculated using Medicare claims. MAIN OUTCOME MEASURE: Risk-standardized 30-day all-cause readmission rate was calculated as the ratio of predicted to expected rate standardized by the overall mean readmission rate. We calculated predicted readmission rate using hierarchical generalized linear models and adjusting for patient-level factors. RESULTS: Among patients aged ≥ 66 years, the median OM score ranged from 79.4 % for abdominal surgery to 95.7 % for AMI, and the median ACM scores ranged from 45.8 % for abdominal surgery to 87.9 % for AMI. We observed a statistically significant, but weak, correlation between performance scores and readmission rates for pneumonia (correlation coefficient R = 0.07), AMI (R = 0.10), and orthopedic surgery (R = 0.06). The difference in the mean readmission rate between hospitals in the 1st and 4th quartiles of process measure performance was statistically significant only for AMI (0.25 percentage points) and pneumonia (0.31 percentage points). Performance on process measures explained less than 1 % of hospital-level variation in readmission rates. CONCLUSIONS: Hospitals with greater adherence to recommended care processes did not achieve meaningfully better 30-day hospital readmission rates compared to those with lower levels of performance.