Using Both Clinical Registry and Administrative Claims Data to Measure Risk-adjusted Surgical Outcomes.

OBJECTIVE: To examine the validity of hybrid quality measures that use both clinical registry and administrative claims data, capitalizing on the strengths of each data source. BACKGROUND: Previous studies demonstrate substantial disagreement between clinical registry and administrative claims data on the occurrence of postoperative complications. Clinical data have greater validity than claims data for quality measurement but can be burdensome for hospitals to collect. METHODS: American College of Surgeons National Surgical Quality Improvement Program records were linked to Medicare inpatient claims (2005-2008). National Quality Forum-endorsed risk-adjusted measures of 30-day postoperative complications or death assessed hospital quality for patients undergoing colectomy, lower extremity bypass, or all surgical procedures. Measures use hierarchical multivariable logistic regression to identify statistical outliers. Measures were applied using clinical data, claims data, or a hybrid of both data sources. Kappa statistics assessed agreement on determinations of hospital quality. RESULTS: A total of 111,984 patients participated from 206 hospitals. Agreement on hospital quality between clinical and claims data was poor. Hybrid models using claims data to risk-adjust complications identified by clinical data had moderate agreement with all clinical data models, whereas hybrid models using clinical data to risk-adjust complications identified by claims data had routinely poor agreement with all clinical data models. CONCLUSIONS: Assessments of hospital quality differ substantially when using clinical registry versus administrative claims data. A hybrid approach using claims data for risk adjustment and clinical data for complications may be a valid alternative with lower data collection burden. For quality measures focused on postoperative complications to be meaningful, such policies should require, at a minimum, collection of clinical outcomes data.

Variation in Hospital Use of Postacute Care After Surgery and the Association With Care Quality.

BACKGROUND: Little is known about hospital use of postacute care after surgery and whether it is related to measures of surgical quality. RESEARCH DESIGN: We used data merged between a national surgery registry, Medicare inpatient claims, the Area Resource File, and the American Hospital Association Annual Survey (2005-2008). Using bivariate and multivariate analyses, we calculated hospital-level, risk-adjusted rates of postacute care use for both inpatient facilities (IF) and home health care (HHC), and examined the association of these rates with hospital quality measures, including mortality, complications, readmissions, and length of stay. RESULTS: Of 112,620 patients treated at 217 hospitals, 18.6% were discharged to an IF, and 19.9% were discharged with HHC. Even after adjusting for differences in patient and hospital characteristics, hospitals varied widely in their use of both IF (mean, 20.3%; range, 2.7%-39.7%) and HHC (mean, 22.3%; range, 3.1%-57.8%). A hospital's risk-adjusted postoperative mortality rate or complication rate was not significantly associated with its use of postacute care, but higher 30-day readmission rates were associated with higher use of IF (24.1% vs. 21.2%, P=0.03). Hospitals with longer average length of stay used IF less frequently (19.4% vs. 24.4%, P<0.01). CONCLUSIONS: Hospitals vary widely in their use of postacute care. Although hospital use of postacute care was not associated with risk-adjusted complication or mortality rates, hospitals with high readmission rates and shorter lengths of stay used inpatient postacute care more frequently. To reduce variations in care, better criteria are needed to identify which patients benefit most from these services.

Comparison between clinical registry and medicare claims data on the classification of hospital quality of surgical care.

OBJECTIVE: To compare the classification of hospital statistical outlier status as better or worse performance than expected for postoperative complications using Medicare claims versus clinical registry data. BACKGROUND: Controversy remains as to the most favorable data source for measuring postoperative complications for pay-for-performance and public reporting polices. METHODS: Patient-level records (2005-2008) were linked between the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Medicare inpatient claims. Hospital statistical outlier status for better or worse performance than expected was assessed using each data source for superficial surgical site infection (SSI), deep/organ-space SSI, any SSI, urinary tract infection, pneumonia, sepsis, deep venous thrombosis, pulmonary embolism, venous thromboembolism, and myocardial infarction by developing hierarchical multivariable logistic regression models. Kappa statistics and correlation coefficients assessed agreement between the data sources. RESULTS: A total of 192 hospitals with 110,987 surgical patients were included. Agreement on hospital rank for complication rates between Medicare claims and ACS-NSQIP was poor-to-moderate (weighted κ: 0.18-0.48). Of hospitals identified as statistical outliers for better or worse performance by Medicare claims, 26% were also identified as outliers by ACS-NSQIP. Of outliers identified by ACS-NSQIP, 16% were also identified as outliers by Medicare claims. Agreement between the data sources on hospital outlier status classification was uniformly poor (weighted κ: -0.02-0.34). CONCLUSIONS: Despite using the same statistical methodology with each data source, classification of hospital outlier status as better or worse performance than expected for postoperative complications differed substantially between ACS-NSQIP and Medicare claims.

Measuring risk-adjusted value using Medicare and ACS-NSQIP: is high-quality, low-cost surgical care achievable everywhere?

OBJECTIVE: To evaluate the relationship between risk-adjusted cost and quality for colectomy procedures and to identify characteristics of "high value" hospitals (high quality, low cost). BACKGROUND: Policymakers are currently focused on rewarding high-value health care. Hospitals will increasingly be held accountable for both quality and cost. METHODS: Records (2005-2008) for all patients undergoing colectomy procedures in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Cost was derived from hospital payments by Medicare. Quality was derived from the occurrence of 30-day postoperative major complications and/or death as recorded in ACS-NSQIP. Risk-adjusted cost and quality metrics were developed using hierarchical multivariable modeling, consistent with a National Quality Forum-endorsed colectomy measure. RESULTS: The study population included 14,745 colectomy patients in 169 hospitals. Average hospitalization cost was $21,350 (SD $20,773, median $16,092, interquartile range $14,341-$24,598). Thirty-four percent of patients had a postoperative complication and/or death. Higher hospital quality was significantly correlated with lower cost (correlation coefficient 0.38, P < 0.001). Among hospitals classified as high quality, 52% were found to be low cost (representing highest value hospitals) whereas 14% were high cost (P = 0.001). Forty-one percent of low-quality hospitals were high cost. Highest "value" hospitals represented a mix of teaching/nonteaching affiliation, small/large bed sizes, and regional locations. CONCLUSIONS: Using national ACS-NSQIP and Medicare data, this study reports an association between higher quality and lower cost surgical care. These results suggest that high-value surgical care is being delivered in a wide spectrum of hospitals and hospital types.

Association between physician age and patterns of end-of-life care among older Americans.

BACKGROUND: End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age. METHODS: We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL. RESULTS: Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001). CONCLUSIONS: We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education.

Association between occurrence of a postoperative complication and readmission: implications for quality improvement and cost savings.

OBJECTIVE: To estimate the effect of preventing postoperative complications on readmission rates and costs. BACKGROUND: Policymakers are targeting readmission for quality improvement and cost savings. Little is known regarding mutable factors associated with postoperative readmissions. METHODS: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Risk factors, procedure, and 30-day postoperative complications were determined from ACS-NSQIP. The 30-day postoperative readmission and costs were determined from Medicare. Occurrence of a postoperative complication included surgical site infections and cardiac, pulmonary, neurologic, and renal complications. Multivariate regression models predicted the effect of reducing complication rates on risk-adjusted readmission rates and costs by procedure. RESULTS: The 30-day postoperative readmission rate was 12.8%. Complication rates for readmitted and nonreadmitted patients were 53% and 16% (P < 0.001). Patients with a postoperative complication had higher predicted probability of readmission and cost of readmission than patients without a complication. For the 20 procedures accounting for the greatest number of readmissions, reducing ACS-NSQIP complication rates by a relative 5% could result in prevention of 2092 readmissions per year and a savings to Medicare of $31.0 million per year. Preventing all ACS-NSQIP complications for these procedures could result in prevention of 41,846 readmissions per year and a savings of $620.3 million per year. CONCLUSIONS: This study provides substantial evidence that efforts to reduce postoperative readmissions should begin by focusing on postoperative complications that can be reliably and validly measured. Such an approach will not eliminate all postoperative readmissions but will likely have a major effect on readmission rates.

Changes over time in POLST use and content by race and ethnicity among California nursing home residents.

BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) are commonly used for nursing home (NH) residents. Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust. Because national efforts focus on addressing the underpinnings of racial and ethnic differences in treatment (i.e., access to care and trust), we describe POLST use and content by race and ethnicity. METHODS: California requires NHs to document POLST completion and content in the Minimum Data Set. We describe POLST completion and content for all California NH residents from 2011 to 2016 (N = 1,120,376). Adjusting for resident characteristics, we compared changes in completion rate and differences by race and ethnicity in POLST content-orders for cardiopulmonary resuscitation (CPR), do not resuscitate (DNR), CPR with full treatment, DNR with selective treatment or comfort orders, and if unsigned. RESULTS: POLST completion increased across all racial and ethnic groups from 2011 to 2016; by 2016, NH residents had a POLST two-thirds or more of the time. In 2011, Black residents had a POLST with a CPR order 30.4% of the time, Hispanic residents 25.6%, and White residents 19.7%. By 2016, this grew to 42.5%, 38.2%, and 28.1%, respectively, with Black and Hispanic residents demonstrating larger increases than White residents (p < 0.001). Increases over time in POLST with CPR and full treatment were greater for Black and Hispanic residents compared to White residents. The increase in POLST with DNR and DNR with Selective treatment and Comfort orders was greater for White compared to Black patients (p < 0.001). Unsigned POLST with CPR and DNR orders decreased across all racial and ethnic groups. CONCLUSIONS: Racial and ethnic differences in POLST intensity of care orders increased between 2011 and 2016 suggesting that efforts to mitigate factors underlying differences were ineffective. Studies of newer POLST data are imperative.

A comparison of clinical registry versus administrative claims data for reporting of 30-day surgical complications.

OBJECTIVES: To compare the recording of 30-day postoperative complications between a national clinical registry and Medicare inpatient claims data and to determine whether the addition of outpatient claims data improves concordance with the clinical registry. BACKGROUND: Policymakers are increasingly discussing use of postoperative complication rates for value-based purchasing. There is debate regarding the optimal data source for such measures. METHODS: Patient records (2005-2008) from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient and outpatient claims data sets. We assessed the ability of (1) Medicare inpatient claims and (2) Medicare inpatient and outpatient claims to detect a core set of ACS-NSQIP 30-day postoperative complications: superficial surgical site infection (SSI), deep/organ-space SSI, any SSI (superficial and/or deep/organ-space), urinary tract infection, pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism, venous thromboembolism (DVT and/or pulmonary embolism), and myocardial infarction. Agreement of patient-level complications by ACS-NSQIP versus Medicare was assessed by κ statistics. RESULTS: A total of 117,752 patients from more than 200 hospitals were studied. The sensitivity of inpatient claims data for detecting ACS-NSQIP complications ranged from 0.27 to 0.78; the percentage of false-positives ranged from 48% to 84%. Addition of outpatient claims data improved sensitivity slightly but also greatly increased the percentage of false-positives. Agreement was routinely poor between clinical and claims data for patient-level complications. CONCLUSIONS: This analysis demonstrates important differences between ACS-NSQIP and Medicare claims data sets for measuring surgical complications. Poor accuracy potentially makes claims data suboptimal for evaluating surgical complications. These findings have meaningful implications for performance measures currently being considered.

Risk of surgery following recent myocardial infarction.

OBJECTIVE: We aimed to assess the impact of recent myocardial infarction (MI) on outcomes after subsequent surgery in the contemporary clinical setting. BACKGROUND: Prior work shows that a history of a recent MI is a risk factor for complications following noncardiac surgery. However, this data does not reflect current advances in clinical management. METHODS: Using the California Patient Discharge Database, we retrospectively analyzed patients undergoing hip surgery, cholecystectomy, colectomy, elective abdominal aortic aneurysm repair, and lower extremity amputation from 1999 to 2004 (n = 563,842). Postoperative 30-day MI rate, 30-day mortality, and 1-year mortality were compared for patients with and without a recent MI using univariate analyses and multivariate logistic regression. Relative risks (RR) with 95% confidence intervals were estimated using bootstrapping with 1000 repetitions. RESULTS: Postoperative MI rate for the recent MI cohort decreased substantially as the length of time from MI to operation increased (0-30 days = 32.8%, 31-60 days = 18.7%, 61-90 days = 8.4%, and 91-180 days = 5.9%), as did 30-day mortality (0-30 days = 14.2%, 31-60 days = 11.5%, 61-90 days = 10.5%, and 91-180 days = 9.9%). MI within 30 days of an operation was associated with a higher risk of postoperative MI (RR range = 9.98-44.29 for the 5 procedures), 30-day mortality (RR range, 1.83-3.84), and 1-year mortality (RR range, 1.56-3.14). CONCLUSIONS: A recent MI remains a significant risk factor for postoperative MI and mortality following surgery. Strategies such as delaying elective operations for at least 8 weeks and medical optimization should be considered.

Association of claims-based quality of care measures with outcomes among community-dwelling vulnerable elders.

BACKGROUND: Few studies examine the link between measured process of care and outcome. OBJECTIVE: To evaluate the relationship of claims-based assessment of process of care to subsequent function and survival. RESEARCH DESIGN: Retrospective cohort study using claims from 1999 to assess performance on 41 quality indicators (QIs) from the Assessing Care of Vulnerable Elders (ACOVE) measurement set on functional decline and death in 2000. SETTING: Community-dwelling individuals. SUBJECTS: All persons ≥75 years enrolled in Medicare and Medicaid in 19 California counties in 1998 and 1999 who received In Home Supportive Services. MEASURES: Quality of care index, activities of daily living, and instrumental activities of daily living (IADL) need indices, mortality. RESULTS: Total 21,310 persons were eligible for a mean of 7.1 QIs; and received 46% of recommended care. The ADL index increased from 8.1 to 11.6 between baseline and follow-up. The IADL index increased from 13.6 to 14.1. Fifteen percent of the cohort died in 2000. After accounting for number of QIs triggered, baseline function and other covariates, better quality was associated with better function at follow-up. Ten percent better quality was associated at follow-up with 0.21 lower ADL need score [95% confidence interval (CI), 0.25-0.17], 0.022 lower IADL need score (95% CI, 0.032-0.013), and lower odds of death (0.91; 95% CI, 0.89 to 0.93). CONCLUSIONS: Routinely collected data implementing ACOVE measures for community vulnerable elders generate quality scores that are directly related to patient functional and survival outcomes. These findings suggest that population-based assessment of care is feasible for vulnerable older persons.

Disparities in the utilization of high-volume hospitals for total hip replacement.

OBJECTIVE: Higher hospital surgical volumes have been associated with lower complication rates following total-hip replacement. The objective of this study was to identify the characteristics of patients who undergo total-hip replacement at high-volume hospitals and their differences from those who receive care at low-volume hospitals. METHODS: Discharge data from patients undergoing total hip replacement in California from 1995 to 2005 were analyzed. Hospitals were classified into 3 tiers of low, intermediate, or high surgical volume. The relationships between race/ethnicity and income to utilization of low-volume and high-volume hospitals were examined by creating logistic regression models that include patient covariates such as age, gender, and comorbidity. RESULTS: This study analyzed 138399 cases of primary total-hip replacements during the study period. Patients of Hispanic ethnicity, or black or Asian race had higher relative risk ratios for being treated at a low-volume center compared to white patients. CONCLUSIONS: There are disparities in the characteristics of patients receiving care at hospitals performing a high volume or low volume of total-hip replacements. Hispanic ethnicity, and black and Asian race were statistically significant predictors of utilization of a low-volume hospital.

Complication rates following operative treatment of calcaneus fractures.

BACKGROUND: The purpose of this study is to report the short-term complication rates and mid-term subtalar fusion rates following operative management of calcaneal fractures. METHODS: This is a retrospective study of Californians undergoing operative treatment of a calaneus fracture from 1995 to 2005. The main outcomes reported are readmission for a short-term complication within 90 days of surgery and reoperation for subtalar fusion during the observation period. RESULTS: We identified 4481 patients who underwent open reduction and internal fixation of their fracture as inpatients within 30 days of the index admission. The short-term rate of complications included a 90-day rate of readmission of 1.03% for wound infection, 0.25% for thromboembolic disease, and 0.22% for mortality. The mid-term rate of subtalar fusion was 3.49% at 5 years post-operatively. CONCLUSIONS: This study reports the short-term complication rates and mid-term subtalar fusion rates following operative management of calcaneal fractures using population-based data.

Incidence and factors predicting pulmonary embolism and deep venous thrombosis following surgical treatment of ankle fractures.

BACKGROUND: The purpose of this study was to identify the incidence and risk factors associated with pulmonary embolism and deep venous thrombosis following open reduction and internal fixation of ankle fractures. METHODS: This was a retrospective study of patients in California undergoing operative treatment of an ankle fracture from 1995 to 2005. The main outcome measure was readmission for pulmonary embolism or deep venous thrombosis within 90 days of surgery. RESULTS: A total of 57,183 patients from the California discharge database were identified. The readmission rate for pulmonary embolism was low at 0.34%. The risk was increased in patients aged 50-75, those with open fractures, and those with higher Charlson comorbidity score. The overall rate of readmission for deep venous thrombosis was also low at 0.05%. CONCLUSIONS: The overall rate of thromboembolic disease was low in this large patient sample. Increased age and comorbidity were associated with an increased risk.

Caring for octogenarian and nonagenarian patients with colorectal cancer: what should our standards and expectations be?

PURPOSE: Octogenarians and nonagenarians constitute a rapidly growing segment of patients undergoing colorectal cancer resection. We describe their outcomes in a large population cohort and aim to establish expectations and improvements for their care. METHODS: All patients undergoing surgical resection for colorectal cancer in California (1994-2005) were identified in the California Cancer Registry, which was linked with the California Office of Statewide Health Planning and Development Patient Discharge Database and the 2000 United States Census. Multivariate logistic regression was used to determine significant outcome predictors. RESULTS: Octogenarians and nonagenarians comprised 26% of all patients undergoing colon cancer resection and 16% of all patients undergoing rectal cancer resection from 1994 to 2005. This cohort had more comorbidities but less distant disease than patients <65 years old (P < .001). Twelve percent of patients with rectal cancer and 17% of patients with colon cancer who were 80 years or older had emergent surgery vs 5% and 12%, respectively, for patients <65 years old (P < .001). Patients 80 years or older had nearly twice the readmission incidence rate (417 readmissions per thousand patient-years) of patients <65 years old. Twenty-seven percent of 90-day readmissions were for surgical complications, 52% of which required a subsequent procedure. Patients 80 years or older had high in-hospital mortality (6%) and one-year mortality (29%). Medical complications, increasing comorbidities, and cancer stage were predictive of in-hospital and 1-year mortality. CONCLUSIONS: : Octogenarians and nonagenarians represent a large segment of patients with colorectal cancer undergoing surgical resection with high rates of morbidity, mortality, and readmission. Medical optimization and excellent continuity of care may contribute to improved outcomes following surgery for these complex patients.

Factors that predict short-term complication rates after total hip arthroplasty.

BACKGROUND: There remains uncertainty regarding the relative importance of patient factors such as comorbidity and provider factors such as hospital volume in predicting complication rates after total hip arthroplasty (THA). PURPOSE: We therefore identified patient and provider factors predicting complications after THA. METHODS: We reviewed discharge data from 138,399 patients undergoing primary THA in California from 1995 to 2005. The rate of complications during the first 90 days postoperatively (mortality, infection, dislocation, revision, perioperative fracture, neurologic injury, and thromboembolic disease) was regressed against a variety of independent variables, including patient factors (age, gender, race/ethnicity, income, Charlson comorbidity score) and provider variables (hospital volume, teaching status, rural location). RESULTS: Compared with patients treated at high-volume hospitals (above the 20th percentile), patients treated at low-volume hospitals (below the 60th percentile) had a higher aggregate risk of having short-term complications (odds ratio, 2.00). A variety of patient factors also had associations with an increased risk of complications: increased Charlson comorbidity score, diabetes, rheumatoid arthritis, advanced age, male gender, and black race. Hispanic and Asian patients had lower risks of complications. CONCLUSIONS: Patient and provider characteristics affected the risk of a short-term complication after THA. These results may be useful for educating patients and anticipating perioperative risks of THA in different patient populations. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Incidence of pulmonary embolism following surgical treatment of metatarsal fractures.

BACKGROUND: The purpose of this study was to identify the rates of readmission to the hospital for pulmonary embolism following open reduction and internal fixation of metatarsal fractures using observational, population-based data from all inpatient admissions in California over an 11-year period. MATERIALS AND METHODS: We identified patients undergoing open reduction and internal fixation of a metatarsal fracture in the years 1995 to 2005 as inpatients using California's discharge database. The outcomes analyzed included readmission within 90 days of surgery for pulmonary embolism. Logistic regression models were used to estimate the impact of patient factors such as age, race/ethnicity and gender in predicting the rates of thromboembolic disease. RESULTS: A total of 1,477 metatarsal ORIF procedures were performed as inpatients during the study period. We identified four patients (0.27%) readmitted with pulmonary embolism within 90 days of their initial ORIF procedure. There were three (0.20%) cases of mortality, none of which occurred in the four patients readmitted with pulmonary embolism. Given the low incidence, we did not identify age, gender, or race/ethnicity as statistically significant predictors of a higher risk of thromboembolic disease. CONCLUSION: The rate of readmission for pulmonary embolism was low. This suggests that the routine use of thromboprophylaxis may not be necessary for isolated metatarsal fractures to prevent pulmonary embolism.

Measuring the quality of care provided to dually enrolled Medicare and Medicaid beneficiaries living in nursing homes.

OBJECTIVES: To adapt the Assessing Care of Vulnerable Elders project nursing home (NH) specific quality indicators (QIs), for use with routinely collected data, and to evaluate which clinical conditions and types of care were inadequately measured using these data sources. DESIGN: Retrospective cohort study. SETTING: Nursing homes. PARTICIPANTS: NH residents 66 years of age and older dually enrolled in Medicare and Medicaid in 19 California counties between 1999 and 2000. MEASUREMENTS: Identification of care inaccessible to measurement by Medicare and Medicaid claims linked to the Minimum Data Set (MDS). Assessment of care provided for measurable QIs by condition (eg, heart failure) and by intervention type (eg, medication use). RESULTS: Only 50 of 283 QIs were captured using linked claims data. The 21,657 patients triggered 152,376 QIs (7.0 QIs/person). The overall QI pass rate (receipt of recommended care) for eligible participants was 76%. In this sample, QIs with the highest pass rates measured avoidance of adverse medications and appropriate medication use. Fewer than half of the QIs were passed for ischemic heart disease, stroke, and osteoporosis. The MDS permitted assessment of 8 QIs that focus on geriatric care. No measured QIs assessed history taking or nursing care. CONCLUSIONS: The use of claims data linked to MDS to measure the quality of care process measures is feasible for NH populations, but would be more valuable if additional data elements focused on geriatric and residential care. QIs that could be applied to patients in this study suggested areas of care needing improvement.

Drug toxicity, HIV progression, or comorbidity of aging: does tipranavir use increase the risk of intracranial hemorrhage?

The US Food and Drug Administration has issued a warning that tipranavir may be associated with increased risk of intracranial hemorrhage. We studied 2 large cohorts to estimate the background rate of intracranial hemorrhage and compared it with rates reported among persons who had been exposed to tipranavir.

Do racial/ethnic disparities exist in the utilization of high-volume surgeons for women with ovarian cancer?

OBJECTIVE: Determine if racial/ethnic disparities exist for access to high-volume surgeons (HVS) for patients with ovarian cancer. METHODS: Retrospective study of ovarian cancer surgeries identified by the California Cancer Registry (CCR) linked to hospital discharge data (1991-2002). Surgeon volume was defined as HVS (>10 ovarian cancer surgeries/year), middle volume (MVS; 2-9/year), and low volume (LVS;