A Post Hoc Exploratory Analysis: Induced Abortion Complications Mistaken for Miscarriage in the Emergency Room are a Risk Factor for Hospitalization.

Introduction: Previous research indicates that an increasing number of women who go to an emergency room for complications following an induced abortion are treated for a miscarriage, meaning their abortion is miscoded or concealed. Objective: To determine if the failure to identify a prior induced abortion during an ER visit is a risk factor for higher rates of subsequent hospitalization. Methods: Post hoc analysis of hospital admissions following an induced abortion and ER visit within 30 days: 4273 following surgical abortion and 408 following chemical abortion; abortion not miscoded versus miscoded or concealed at prior ER visit. Results: Chemical abortion patients whose abortions are misclassified as miscarriages during an ER visit subsequently experience on average 3.2 hospital admissions within 30 days. 86% of the patients ultimately have surgical removal of retained products of conception (RPOC). Chemical abortions are more likely than surgical abortions (OR 1.80, CL 1.38-2.35) to result in an RPOC admission, and chemical abortions concealed are more likely to result (OR 2.18, CL 1.65-2.88) in a subsequent RPOC admission than abortions without miscoding. Surgical abortions miscoded/concealed are similarly twice as likely to result in hospital admission than those without miscoding. Conclusion: Patient concealment and/or physician failure to identify a prior abortion during an ER visit is a significant risk factor for a subsequent hospital admission. Patients and ER personnel should be made aware of this risk.

Matter-Driven Change of Spacetime Topology.

Using Monte Carlo computer simulations, we study the impact of matter fields on the geometry of a typical quantum universe in the causal dynamical triangulations (cdt) model of lattice quantum gravity. The quantum universe has the size of a few Planck lengths and the spatial topology of a three-torus. The matter fields are multicomponent scalar fields taking values in a torus with circumference δ in each spatial direction, which acts as a new parameter in the cdt model. Changing δ, we observe a phase transition caused by the scalar field. This discovery may have important consequences for quantum universes with nontrivial topology, since the phase transition can change the topology to a simply connected one.

Characteristics of the new phase in CDT.

The approach of Causal Dynamical Triangulations (CDT), a candidate theory of nonperturbative quantum gravity in 4D, turns out to have a rich phase structure. We investigate the recently discovered bifurcation phase [Formula: see text] and relate some of its characteristics to the presence of singular vertices of very high order. The transition lines separating this phase from the "time-collapsed" B-phase and the de Sitter phase [Formula: see text] are of great interest when searching for physical scaling limits. The work presented here sheds light on the mechanisms behind these transitions. First, we study how the B-[Formula: see text] transition signal depends on the volume fixing implemented in the simulations, and find results compatible with the previously determined second-order character of the transition. The transition persists in a transfer matrix formulation, where the system's time extension is taken to be minimal. Second, we relate the new [Formula: see text]-[Formula: see text] transition to the appearance of singular vertices, which leads to a direct physical interpretation in terms of a breaking of the homogeneity and isotropy observed in the de Sitter phase when crossing from [Formula: see text] to the bifurcation phase [Formula: see text].

Diabetes complications and adverse health outcomes after coronary revascularization.

AIMS: To examine effects of diabetes complications on health outcomes following coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI), comparing outcomes for patients with diabetes complications to those without diabetes complications. METHODS: Retrospective analysis of discharge data for 61,566 patients with diabetes age 45 or older who had CABG or PCI in 2007 in United States community hospitals, using data from the Nationwide Inpatient Sample. Analysis included propensity score-adjusted logistic regression. RESULTS: Of all patients, 21.2% of the weighted sample had diabetes complications. Older patients, Blacks and Hispanics, and those with greater illness severity were more likely to have diabetes complications. Unadjusted rates of in-hospital mortality, postoperative stroke, and renal failure were higher for patients with diabetes complications (rate ratios 2.2, 1.8, and 9.8, respectively; all p<0.0001). In adjusted results, having diabetes complications was associated with higher odds of in-hospital mortality (odds ratio, OR 1.62, 95% confidence interval, CI 1.37-1.91) and renal failure (OR 3.03, CI 1.71-5.39). Compared to CABG, PCI was associated with extra risk of postoperative renal failure for those with diabetes complications. CONCLUSION: Among patients with diabetes having revascularization, those with diabetes complications have higher risks of in-hospital death and renal failure irrespective of having CABG or PCI.

Comparing alternative methods for composing community peer groups: a data warehouse application.

A method for assessing the health status of communities has been under development for a decade at the University of South Florida. Known as CATCH (Comprehensive Assessment for Tracking Community Health), the method utilizes health status indicators from multiple data sources. With federal grant support, a unique data warehouse has been created to automate CATCH assessments and to enhance online analytical processing for efficient data browsing, knowledge discovery, and model testing. A comparison of two peer grouping methods (population size versus predicted age-adjusted mortality) is reviewed to demonstrate the warehouse capabilities.

Rating the health status of U.S. communities.

Although the existence of small-area variation in health care utilization and quality had been acknowledged decades ago, and the public release of data about the performance of hospitals and physicians is no longer controversial, the wide range of variability in the health status of U.S. communities has received relatively little attention. The authors demonstrate (using Florida data) an empirically derived national system for rating the health status of communities, presented in a simplified consumer-type format, using a symbol-graded report card. This system is intended to keep the symbols of poor health status prominently in the minds and on the political agendas of community leaders.

A minimum data set and empirical model for population health status assessment.

BACKGROUND: The need to assess the health status of American communities in a comprehensive and systematic manner has been widely acknowledged. This study attempts to empirically derive a minimum core data set of indicators, in order to produce a uniform parsimonious model for population health status monitoring. METHODS: Five years of secondary data (1992-1996) for 113 indicators of community health for each of Florida's 67 counties were organized into 11 conceptual groups. Principal component analysis with orthogonal rotation was conducted separately on each group of indicators for each year. The component scores were converted to standard scores to further study the relationships among the conceptual groups measuring community health. A causal model was hypothesized and tested using ordinary least-squares path analysis. RESULTS: Nineteen principal components composed of 78 indicators were identified. The model demonstrated a large difference in the ability to explain variance in adult mortality (56%) compared with variance associated with adverse birth outcomes (13%). Both demographic and socioenvironmental factors have a direct effect on adult mortality. Socioeconomic factors, on the other hand, influence adult mortality indirectly through adequacy of primary care and other available resources. CONCLUSIONS: Minimum core data sets of indicators drawn from extant databases can be used to uniformly describe and explain variation in adult mortality. This research suggests caution in regard to the creation of integrated indices that combine mortality, morbidity, and other concepts such as quality of life into a single measure of community health. Further validation research employing a national sample of counties is recommended.

Physician practice volume and alternative surgical treatment for breast cancer in Florida.

OBJECTIVE: To determine whether surgeon procedure volume is related to the selection of a surgical option (mastectomy versus breast-conserving surgery) for breast cancer treatment . STUDY SETTING/STUDY DESIGN: Secondary data sources were used to study surgical procedures performed for female breast cancer in Florida during the years 1997-98 in a retrospective population-based analysis. DATA EXTRACTION: Surgical procedures for female breast cancer in Florida were identified during 1997 and 1998 (N = 28,380) by combining data from the Florida Acute Hospital and Short-term Psychiatric Inpatient Data Collection and the Ambulatory Outpatient Data Collection. A total of 1,320 physicians who provided breast surgical procedures in Florida during the two-year study period were identified. PRINCIPAL FINDINGS: After controlling for selected patient and physician characteristics, the lowest volume surgeons were nearly twice as likely to perform mastectomies rather th an breast-conserving surgery compared with the highest volume group. Patients with Medicaid as an insurer were also nearly twice as likely to receive mastectomies. Patient demographic factors such as age, while statistically significant, were shown to be far less predictive of procedure choice. Forty-two percent of the physicians performed fewer than two surgeries on average per year. CONCLUSIONS: Patients treated by lower volume physicians have a greater likelihood of receiving mastectomies than do those patients treated by higher volume physicians.

Awareness of and compliance with recommended screening procedures: a comparison of HMO and fee-for-service enrollees.

Managed care organizations, particularly HMOs, have emphasized disease prevention and early detection (screening) programs as a component of high-quality, cost-effective medical care. Studies in the 1980s found higher levels of utilization of screening by HMO enrollees compared with individuals enrolled in fee-for-service (FFS) plans, although this pattern is less clear in more recent reports. This paper reports on an analysis of a survey designed to determine awareness, compliance, and potential barriers to participating in common screening tests by adults living in Hillsborough County (greater Tampa), Florida. A random digit--dialing telephone survey of a stratified random sample of 500 adults over 18 years of age was conducted. Health plan enrollees were found to be younger, more likely to receive health insurance through an employer, and were more likely to have a regular source of health care. Few statistically significant differences, however, were detected in awareness of or compliance with recommended screening procedures between HMO and FFS enrollees in the study. Consistent with other recent research, these findings suggest that the changing nature of managed care, from traditional staff models toward IPA or network-hybrid models, has somewhat reduced HMOs' influence on prevention and screening services.

CATCH/IT: a data warehouse to support comprehensive assessment for tracking community health.

A systematic methodology, Comprehensive Assessment for Tracking Community Health (CATCH), for analyzing the health status of communities has been under development at the University of South Florida since the early 1990s. CATCH draws 226 health status indicators from multiple data sources and uses an innovative comparative framework and weighted evaluation criteria to produce a rank-ordered list of community health problems. CATCH has been applied successfully in many Florida counties; focusing attention on high priority health issues and measuring the impact of health expenditures on community health status outcomes. Previously performed manually, we are using information technology (IT) to automate the CATCH methodology with a full-scale data warehouse, user-friendly forms and reports, and extended analysis and data mining capabilities. The automated system, CATCH/IT, will reduce the time to prepare community health status reports from months to days. In this paper, we present the current status of the project, along with the principal research and development issues and future directions of the project.

The impact of legislatively imposed practice guidelines on cesarean section rates: the Florida experience.

Florida legislation implemented in the fall of 1992, unique in the nation, mandated that practice guidelines regarding cesarean section deliveries be disseminated to obstetric physicians. The law also required that peer review boards at hospitals be established to review cesarean deliveries and that the exact dates of implementation of the guidelines be reported to a state agency. To determine the impact of the legislation, we conducted a retrospective analysis of 366,246 total live births occurring in Florida hospitals during 1992 and 1993, before and after formal hospital certification of the implementation of the guidelines. Changes in primary and repeat cesarean rates were analyzed for 108 independent groups of births, controlling for the mother's age, race, payment source, and the timing of the implementation of the guidelines at hospitals. The guideline certification program did not accelerate the consistent but gradual downward trend in cesarean births which had already been evident in the three prior years. The data do suggest that the guideline program may have affected repeat cesareans more than primary cesareans, especially in the first quarter of 1993, immediately after the hospital certification period. Reductions in repeat cesareans involved both Medicaid and commercially insured births, whereas reductions in primary cesareans were found almost exclusively within commercially insured mothers, where the existing rates are highest. Although births with a prior cesarean represent only 12.5% of all births, significant decreases in repeat cesareans were found in groups representing 72.6% of this population. By comparison, significant decreases in primary cesareans were found in groups representing only 36.5% of the births without a prior cesarean. The date of guideline implementation reported by hospitals was not related to any systematic change in observed cesarean section rates. We concluded that the mere dissemination of practice guidelines by a state agency may not achieve either the magnitude or the specificity of the results desired without an explicit and thorough guideline implementation program. Blunt legislative mandates may be ineffective when multiple initiatives are already achieving desired outcomes.

A community health report card: comprehensive assessment for tracking community health (CATCH).

A systematic method for assessing the health status of communities has been under development at the University of South Florida since 1991. The system, known as CATCH, draws 226 indicators from multiple sources and uses an innovative comparative framework and weighted evaluation criteria to produce a rank-ordered community problem list. The CATCH results from II Floridian counties have focused attention on high priority health problems and provided a framework for measuring the impact of health expenditures on community health status outcomes. The method and plans to create an automated data warehouse to support its expansion and enrichment are described.

A national profile of the use of intensive care by Medicare patients with cancer.

BACKGROUND: The broad picture of intensive care unit (ICU) outcomes and expenditures cannot be discerned from previous studies that were conducted at single hospitals and focused on narrow subsets of patients. METHODS: This study provides a comprehensive national profile of ICU used by Medicare patients with cancer. The data source was the Medicare Provider Analysis and Review file for fiscal year 1990, representing 100% of all hospital admissions that occurred within 723 ICD-9-CM codes and organized into 11 code groups. Using screening criteria, admissions were categorized as surgical (both major and minor procedures) or nonsurgical (no procedures) and with and without involvement of the ICU. The categories were compared using the following outcome variables: total hospital charges, ICU charges, ancillary charges, average length of stay, and in-hospital mortality. RESULTS: This study population accounted for nearly 800,000 admissions, of which 143,458 (18.1%) involved the use of the ICU. Actual ICU charges represented 4.9% of the $9.3 billion in total hospital charges. Intensive care unit use is associated positively with service intensity, and 73% of all the admissions involving the ICU were for major procedures. Only 2% involved no procedures. Admissions involving use of the ICU generate higher charges and longer lengths of stay than non-ICU admissions, although the differences decrease with declining treatment intensity and resource use. In-hospital mortality rates, for those cases that used the ICU, were 9.8% for major procedures, 21.2% for minor procedures, and 37.6% for cases involving no procedures. CONCLUSIONS: Contrary to the conclusions drawn from previous research, these findings suggest that patients who receive less intense service and use fewer hospital resources are more likely to die in the hospital than those who receive more care, with or without a stay in the ICU during the hospitalization. A global view of ICU use does not support the conclusion that a disproportionate share of special care resources is expended on futile care of the terminally ill or excessive monitoring of low risk patients, although these problems undoubtedly exist. Analysis of comprehensive national data regarding the use of intensive care provides a perspective that challenges some of the conclusions based on more limited studies that were conducted in single hospitals and focused on nonsurvivors or subsets of patients narrowly defined in other ways.

Analyzing organizational practices in local health departments.

Few researchers have examined the problem of comparing the performances of local health departments. A contributing factor is the lack of a uniform method for describing the range of public health activities. The Centers for Disease Control and Prevention's Public Health Practice Program Office has identified 10 organizational practices that may be used to assure that the core functions of public health are being carried out at a local health department. The researchers determined the percentage of time devoted to each of the 10 practices by individual employees at a local public health unit in Tampa, FL. They identified the manpower expenditures and hours allocated to each of the 10 practices within the major program divisions of the unit. They found that the largest portion of manpower resources was allocated to implementing programs. A much smaller fraction of agency resources was devoted to analysis of the health needs of the community and to the development of plans and policies. Together, primary care and communicable disease programs accounted for fully three-quarters of the resources, environmental health for 11 percent, and administrative support services for 13 percent. With continuing refinement and modification, the methodology could provide a highly effective basis for describing and analyzing the activities and performances of local health departments.

Mass mammography screening: using an information system to track participation and identify target populations.

This article describes the 1991 American Cancer Society Greater Tampa Bay Breast Screening Program and an information system developed to track participants from the point of inquiry to mammography results. Information from three sources was linked to create a comprehensive data base, including participant demographics, mammography history, perceived risks of breast cancer, barriers to mammography, and mammography results. This comprehensive data base allowed investigators to describe the 11,134 participants and to assess the program's impact. The analysis suggested that women older than 65 years are underrepresented in this voluntary program. Black women were less likely to participate, as were women in lower income and education groups. To reduce mortality effectively, leaders of mass screening programs need to develop creative strategies for reaching these high-risk groups. Effective information systems can identify program weaknesses and track the impact of changes.

Response to the National Cancer Institute Alert. The effect of practice guidelines on two hospitals in the same medical community.

BACKGROUND: Despite the recent increase in medical practice guideline development and dissemination, physician compliance with the guidelines has often been low. Previous research has suggested that physicians at hospitals with low volumes of cases and weakened financial status were more likely to omit indicated diagnostic testing or appropriate treatment. The authors sought to determine whether differences in compliance to a widely disseminated set of guidelines would exist even among the most dominant hospital providers within the same medical community. METHODS: Two hospitals, together providing nearly half of the cancer surgery within a metropolitan area, were studied for their compliance to the May 1988 National Cancer Institute (NCI) Clinical Alert regarding adjuvant therapy after primary treatment for node negative breast cancer. A case series consecutive collection of 549 women treated at the study hospitals for 2 years before and two years after the Alert determined those patients who had received any form or combination of adjuvant therapy after primary surgical treatment (lumpectomy or modified radical mastectomy). RESULTS: Following modified radical mastectomy, for women age 50 and older, the university hospital (U) provided adjuvant therapy to a higher percentage of patients than the community hospital (C) both before (25.6% versus 4.7%, P < 0.005) and after (58.9% versus 23.2%, P < 0.001) the Alert. For women younger than 50 years of age, the two hospitals were equally likely to provide adjuvant therapy both before and after the Alert. Following lumpectomy, hospital U increased the percentage of women receiving adjuvant therapy following the Alert in women younger than 50 years of age (25-75.8%, P < 0.001) and in women age 50 and older (33.3-56.5%, P < 0.025). Hospital C provided no adjuvant therapy before or after the Alert. Preferences for breast conserving surgical treatment were significantly (P < 0.001) different with hospital U performing a higher percentage of lumpectomies than hospital C both before (50.9% versus 14.9%) and after (57.6% versus 16.8%) the Alert. CONCLUSIONS: Significant differences in compliance with practice guidelines may be found even among the most dominant hospital providers of cancer services within the same medical community. The role of the surgeon in referring patients to the oncologist greatly influences the ultimate provision of adjuvant therapy. Strategies for enhancing compliance should be considered integral to the process of guideline development.

Intensive care, survival, and expense of treating critically ill cancer patients.

OBJECTIVE: To determine the survival and factors affecting the survival of patients with solid tumors and hematologic cancers who were admitted to the intensive care unit, the time these patients spent at home (meaningful survival) before they died, and the cost per year of life gained and per year of life gained at home. DESIGN: Survival and cost-effectiveness analysis. SETTING: A tertiary-care cancer center at a university medical center. PATIENTS: Every patient admitted to the intensive care unit between July 1, 1988, and June 30, 1990, was entered into the study. This group comprised 83 patients with solid tumors and 64 patients with hematologic cancers. MAIN OUTCOME MEASURES: Factors affecting survival, such as age, sex, malignancy, length of stay in the intensive care unit, and necessity for mechanical ventilator assistance, as well as cost per year of life gained and cost per year of life gained at home. RESULTS: The only factor that significantly affected survival was the requirement for mechanically assisted ventilation for patients with hematologic cancers. More than three fourths of the patients in either group spent less than 3 months at home before dying. The cost per year of life gained for patients with solid tumors was $82,845 and for patients with hematologic cancers was $189,339. The cost per year of life gained at home was $95,142 for patients with solid tumors and $449,544 for patients with hematologic cancers. CONCLUSION: The majority of patients with solid tumors and hematologic cancers admitted to the intensive care unit die before discharge, or, if they survive the hospital admission, they spend a minimal amount of time at home before dying. This limited survival is achieved at considerable cost. Physicians who treat patients with neoplastic disease should discuss potential outcomes and the possibility of withdrawing life-supportive therapy if appropriate with the patient and family, so that a reasonable strategy can be agreed on before the initiation of therapy.

A feedback system for reducing excessive laboratory tests.

At the James A. Haley Veterans Hospital in Tampa, Fla, a program has been implemented to reduce the amount of potentially excessive laboratory testing. The major program components are a set of test frequency guidelines and a system of feedback to resident physicians that compares their test ordering patterns against the predetermined guidelines. The guidelines are analyte specific and differentiate between normal and abnormal test values reported during 1-day and 7-day time periods. The feedback process includes both systematic reporting of objective data and individual and group education and counseling sessions related to the appropriate use of laboratory tests. A reduction in the percentage of tests that fell outside the guidelines (outliers) was achieved following implementation of the program.