Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions.

Importance: Although patients with emergency general surgery (EGS) conditions frequently undergo interhospital transfers, the transfer patterns and associated factors are not well understood. Objective: To examine whether patients with EGS conditions are consistently directed to hospitals with more resources and better outcomes. Design, Setting, and Participants: This cohort study performed a network analysis of interhospital transfers among adults with EGS conditions from January 1 to December 31, 2016. The analysis used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in 8 states. A total of 728 hospitals involving 85 415 transfers of 80 307 patients were included. Patients were eligible for inclusion if they were 18 years or older and had an acute care hospital encounter with a diagnosis of an EGS condition as defined by the American Association for the Surgery of Trauma. Data were analyzed from January 1, 2020, to June 17, 2021. Exposures: Hospital-level measures of size (total bed capacity), resources (intensive care unit [ICU] bed capacity, teaching status, trauma center designation, and presence of trauma and/or surgical critical care fellowships), EGS volume (annual EGS encounters), and EGS outcomes (risk-adjusted failure to rescue and in-hospital mortality). Main Outcomes and Measures: The main outcome was hospital-level centrality ratio, defined as the normalized number of incoming transfers divided by the number of outgoing transfers. A higher centrality ratio indicated more incoming transfers per outgoing transfer. Multivariable regression analysis was used to test the hypothesis that a higher hospital centrality ratio would be associated with more resources, higher volume, and better outcomes. Results: Among 80 307 total patients, the median age was 63 years (interquartile range [IQR], 50-75 years); 52.1% of patients were male and 78.8% were White. The median number of outgoing and incoming transfers per hospital were 106 (IQR, 61-157) and 36 (IQR, 8-137), respectively. A higher log-transformed centrality ratio was associated with more resources, such as higher ICU capacity (eg, >25 beds vs 0-10 beds: ß = 1.67 [95% CI, 1.16-2.17]; P < .001), and higher EGS volume (eg, quartile 4 [highest] vs quartile 1 [lowest]: ß = 0.78 [95% CI, 0-1.57]; P = .01). However, a higher log-transformed centrality ratio was not associated with better outcomes, such as lower in-hospital mortality (eg, quartile 4 [highest] vs quartile 1 [lowest]: ß = 0.30 [95% CI, -0.09 to 0.68]; P = .83) and lower failure to rescue (eg, quartile 4 [highest] vs quartile 1 [lowest]: ß = -0.50 [95% CI, -1.13 to 0.12]; P = .27). Conclusions and Relevance: In this study, EGS transfers were directed to high-volume hospitals with more resources but were not necessarily directed to hospitals with better clinical outcomes. Optimizing transfer destination in the interhospital transfer network has the potential to improve EGS outcomes.

Factors associated with potentially avoidable interhospital transfers in emergency general surgery-A call for quality improvement efforts.

BACKGROUND: Emergency general surgery conditions are common, require urgent surgical evaluation, and are associated with high mortality and costs. Although appropriate interhospital transfers are critical to successful emergency general surgery care, the performance of emergency general surgery transfer systems remains unclear. We aimed to describe emergency general surgery transfer patterns and identify factors associated with potentially avoidable transfers. METHODS: We performed a retrospective cohort study of emergency general surgery episodes in 8 US states using the 2016 Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases and the American Hospital Association Annual Surveys. We identified Emergency Department-to-Inpatient and Inpatient-to-Inpatient interhospital emergency general surgery transfers. Potentially avoidable transfers were defined as discharge within 72 hours after transfer without undergoing any procedure or operation at the destination hospital. We examined transfer incidence and characteristics. We performed multilevel regression examining patient-level and hospital-level factors associated with potentially avoidable transfers. RESULTS: Of 514,410 adult emergency general surgery episodes, 26,281 (5.1%) involved interhospital transfers (Emergency Department-to-Inpatient: 65.0%, Inpatient-to-Inpatient: 35.1%). Over 1 in 4 transfers were potentially avoidable (7,188, 27.4%), with the majority occurring from the emergency department. Factors associated with increased odds of potentially avoidable transfers included self-pay (versus government insurance, odds ratio: 1.26, 95% confidence interval: 1.09-1.45, P = .002), level 1 trauma centers (versus non-trauma centers, odds ratio: 1.24, 95% confidence interval: 1.05-1.47, P = .01), and critical access hospitals (versus non-critical access, odds ratio: 1.30, 95% confidence interval: 1.15-1.47, P < .001). Hospital-level factors (size, trauma center, ownership, critical access, location) accounted for 36.1% of potentially avoidable transfers variability. CONCLUSION: Over 1 in 4 emergency general surgery transfers are potentially avoidable. Understanding factors associated with potentially avoidable transfers can guide research, quality improvement, and infrastructure development to optimize emergency general surgery care.

The centralization of bladder cancer care and its implications for patient travel distance.

OBJECTIVES: To evaluate the impact of centralized surgical and nonsurgical care (i.e., radiation and chemotherapy) on travel distances and survival outcomes for patients with advanced bladder cancer. Bladder cancer is a disease with high mortality for which treatment access is paramount and survival is superior in patients receiving surgery at high-volume centers. METHODS: Using SEER-Medicare, we identified patients 66 years or older diagnosed with bladder cancer between 2004-2013. We categorized patients as treated with either surgical (i.e., radical cystectomy) or nonsurgical (i.e., radiation or chemotherapy) care. We fit a linear probability model to generate the predicted proportion of patients treated at the top quintile of volume over time and assessed travel distance, 1-year all-cause mortality, and 1-year bladder cancer-specific mortality over time. RESULTS: A total of 6,756 and 10,383 patients underwent surgical and nonsurgical care, respectively. The percentage of patients treated at high-volume centers increased over the study period for both surgical care (53% to 62%) and nonsurgical care (47% to 55%), (both P< 0.001). Median travel distance increased (11.8 to 20.3 miles) for surgical care and (6.5 to 8.3 miles) for nonsurgical care, (both P < 0.001). The 1-year adjusted all-cause mortality and 1-year adjusted bladder-cancer specific mortality decreased significantly for both surgical and nonsurgical care (both P < 0.05). CONCLUSIONS: Over time, centralization of surgical and nonsurgical care for bladder cancer patients increased, which was associated with increasing patient travel distance and decreased all-cause and bladder-cancer specific mortality.

Radiation oncologists' attitudes and beliefs about intensity-modulated radiation therapy and stereotactic body radiation therapy for prostate cancer.

BACKGROUND: To better understand how radiation oncologists perceive intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) for prostate cancer and how these perceptions may influence treatment decisions. METHODS: We conducted semi-structured interviews of radiation oncologists between January-May, 2016. We used a purposeful sampling technique to select participants across a wide range of experience, regions, and practice types. Two trained qualitative researchers used an inductive, iterative approach to code transcripts and identify themes. We then used content analysis and thematic analysis of the coded transcripts to understand radiation oncologists' attitudes and beliefs about IMRT and SBRT. RESULTS: Thematic saturation was achieved after 20 interviews. Participants were affiliated with academic (n = 13; 65%), private (n = 5; 25%), and mixed (n = 2; 10%) practices and had a wide range of clinical experience (median 19 years; range 4-49 years). Analysis of interview transcripts revealed four general themes: 1) most radiation oncologists offered surgery, brachytherapy, IMRT, and active surveillance for low-risk patients; 2) there was no consensus on the comparative effectiveness of IMRT and SBRT; 3) key barriers to adopting SBRT included issues related to insurance, reimbursement, and practice inertia; and 4) despite these barriers, most participants envisioned SBRT use increasing over the next 5-10 years. CONCLUSIONS: In the absence of strong opinions about effectiveness, nonclinical factors influence the choice of radiation treatment. Despite a lack of consensus, most participants agreed SBRT may become a standard of care in the future.

The Development and Validation of Prostate Cancer-specific Physician-Hospital Networks.

OBJECTIVE: To develop prostate cancer-specific physician-hospital networks to define hospital-based units that more accurately group hospitals, providers, and the patients they serve. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare, we identified men diagnosed with localized prostate cancer between 2007 and 2011. We created physician-hospital networks by assigning each patient to a physician and each physician to a hospital based on treatment patterns. We assessed content validity by examining characteristics of hospitals anchoring the physician-hospital networks and of the patients associated with these hospitals. RESULTS: We identified 42,963 patients associated with 344 physician-hospital networks. Networks anchored by a teaching hospital (compared to a nonteaching hospital) had higher median numbers of prostate cancer patients (117 [interquartile range {71-189} vs 82 {50-126}]) and treating physicians (7 [4-11] vs 4 [3-6]) (both P <0.001). On average, patients traveled farther to networks anchored by a teaching hospital (49 miles [standard deviation] [207] vs 41 [183]; P <.001). Hospitals known as high-volume centers for robotic prostatectomies, proton-beam therapy, and active surveillance had network rates for these procedures well above the mean. Hospitals known as safety net providers served higher proportions of minorities. CONCLUSION: We empirically developed prostate-cancer specific physician-hospital networks that exhibit content validity and are relevant from a clinical and policy perspective. They have the potential to become targets for policy interventions focused on improving the delivery of prostate cancer care.

The Influence of Stereotactic Body Radiation Therapy Adoption on Prostate Cancer Treatment Patterns.

PURPOSE: To our knowledge it is unknown whether stereotactic body radiation therapy of prostate cancer is a substitute for other radiation treatments or surgery, or for expanding the pool of patients who undergo treatment instead of active surveillance. MATERIALS AND METHODS: Using SEER (Surveillance, Epidemiology, and End Results)-Medicare we identified men diagnosed with prostate cancer between 2007 and 2011. We developed physician-hospital networks by identifying the treating physician of each patient based on the primary treatment received and subsequently assigning each physician to a hospital. We examined the relative distribution of prostate cancer treatments stratified by whether stereotactic body radiation therapy was performed in a network by fitting logistic regression models with robust SEs to account for patient clustering in networks. RESULTS: We identified 344 physician-hospital networks, including 30 (8.7%) and 314 (91.3%) in which stereotactic body radiation therapy was and was not performed, respectively. Networks in which that therapy was and was not done did not differ with time in the performance of robotic and radical prostatectomy, and active surveillance (all p >0.05). The relationship with intensity modulated radiation therapy did not show any consistent temporal pattern. In networks in which it was performed less intensity modulated radiation therapy was initially done but there were similar rates in later years. Brachytherapy trends differed among networks in which stereotactic body radiation therapy was vs was not performed with a lower brachytherapy rate in networks in which stereotactic body radiation therapy was done (p=0.03). CONCLUSIONS: Surgery and active surveillance rates did not differ in networks in which stereotactic body radiation therapy was vs was not performed but when that therapy was done there was a lower brachytherapy rate. Stereotactic body radiation therapy may represent more of an alternative to brachytherapy than to active surveillance.

Association Between Intravenous Fluid Bolus and Biomarker Trajectory During Prehospital Care.

Background: Patients with acute illness who receive intravenous (IV) fluids prior to hospital arrival may have a lower in-hospital mortality. To better understand whether this is a direct treatment effect or epiphenomenon of downstream care, we tested the association between a prehospital fluid bolus and the change in inflammatory cytokines measured at prehospital and emergency department timepoints in a sample of non-trauma, non-cardiac arrest patients at risk for critical illness. Methods: In a prospective cohort study, we screened 4,013 non-trauma, non-cardiac arrest encounters transported by City of Pittsburgh Emergency Medical Services (EMS) to 2 hospitals from August 2013 to February 2014. In 345 patients, we measured prehospital biomarkers (IL-6, IL-10, and TNF) at 2 time points: the time of prehospital IV access placement by EMS and at ED arrival. We determined the relative change for marker X as: ([XED - XEMS]/XEMS). We determined the risk-adjusted association between prehospital IV fluid bolus and relative change for each marker using multivariable linear regression. Results: Among 345 patients, 88 (26%) received a prehospital IV fluid bolus and 257 (74%) did not. Compared to patients who did not receive prehospital fluids, median prehospital IL-6 was greater initially in subjects receiving a prehospital IV fluid bolus (22.3 [IQR 6.4-113] vs. 11.5 [IQR 5.5-47.6]). Prehospital IL-10 and TNF were similar in both groups (IL-10: 3.5 [IQR 2.2-25.6] vs. 3.0 [IQR 1.9-9.0]; TNF: 7.5 [IQR 6.4-10.4] vs. 6.9 [IQR 6.0-8.3]). After adjustment for demographics, illness severity, and prehospital transport time, we observed a relative decrease in IL-6 at hospital arrival in those receiving a prehospital fluid bolus (adjusted ß = -10.0, 95% CI: -19.4, -0.6, p = 0.04), but we did not detect a significant change in IL-10 (p = 0.34) or TNF (p = 0.53). Conclusions: Among non-trauma, non-cardiac arrest patients at risk for critical illness, a prehospital IV fluid bolus was associated with a relative decrease in IL-6, but not IL-10 or TNF.

Patterns of stereotactic body radiation therapy: The influence of lung cancer treatment on prostate cancer treatment.

INTRODUCTION: Technology availability and prior experience with novel cancer treatments may partially drive their use. We sought to examine this issue in the context of stereotactic body radiation therapy (SBRT) by studying how its use for an established indication (lung cancer) impacts its use for an emerging indication (prostate cancer). METHODS: Using SEER-Medicare from 2007 to 2011, we developed prostate cancer-specific physician-hospital networks. Our primary dependent variable was SBRT use for prostate cancer and our primary independent variable was SBRT use for lung cancer, both at the network level. To assess the influence of SBRT availability and experiential use, we generated predicted probabilities of SBRT use for prostate cancer stratified by a network's use of lung cancer SBRT, adjusting for network characteristics. To assess intensity of use, we examined the correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT within a network. RESULTS: We identified 316 networks that served 41,034 prostate cancer and 83,433 lung cancer patients. A network was significantly more likely to use SBRT for prostate cancer if that network used SBRT for lung cancer (e.g., in 2011, odds ratio [OR] 12.7; 95% confidence interval [CI] 3.9-41.8). The Pearson's correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT in a network was 0.34, which was not statistically significant (P = 0.12). CONCLUSIONS: SBRT availability and experiential use for lung cancer influences its use for prostate cancer, but intensity of use for one does not relate to intensity of use for the other.

Association of Practitioner Interfacility Triage Performance With Outcomes for Severely Injured Patients With Fee-for-Service Medicare Insurance.

Importance: Despite evidence that treatment of severely injured patients at trauma centers is associated with reduced mortality, nearly half of all such patients are treated at nontrauma centers (undertriaged). Little is known about whether interfacility undertriage occurs because of practitioner decision-making or institutional and regional factors. Objectives: To assess the associations between variation in triage practitioners at nontrauma centers and between practitioner-level variation and patient outcomes after injury. Design, Setting, and Participants: This retrospective cohort study used Medicare claims data from severely injured patients presenting to nontrauma centers and the practitioners who evaluated them in the emergency department from January 1, 2010, to October 15, 2015. Data analysis was performed from January 15, 2018, to March 21, 2019. Main Outcomes and Measures: Proportion of variation in undertriage associated with practitioners, practitioner rates of undertriage, practitioner characteristics associated with undertriage, and 30-day case-fatality rate. Results: A total of 124 008 severely injured patients (mean [SD] age, 81 [8.4] years; 67 253 [54.2%] female) and the 25 376 practitioners (5564 [21.9%] female) who evaluated the patients in the emergency department of nontrauma centers were included in the study. Undertriage occurred among 85 403 patients (68.9%), with 40.6% of total variation associated with practitioners, 37.8% with hospitals, and 6.7% with regions. Compared with physicians with National Provider Identification (NPI) enumeration before 2007, those with an NPI enumerated between 2007 and 2010 had an undertriage risk ratio (RR) of 0.98 (95% CI, 0.97-0.99), and those with an NPI enumerated after 2010 had an undertriage RR of 0.96 (95% CI, 0.94-0.99). Hospitals with neurosurgeons had an undertriage RR of 1.51 (95% CI, 1.45-1.57) compared with those that did not; hospitals with spine surgeons had an undertriage RR of 1.10 (95% CI, 1.06-1.13); hospitals with general surgeons had an undertriage RR of 1.13 (95% CI, 1.09-1.17). Compared with practitioners who undertriaged 25% or less of patients, a statistically significant increase was found in the odds of death for patients treated by practitioners with a triage rate of less than 25% to 50% (odds ratio [OR], 1.08; 95% CI, 1.05-1.20) and less than 50% to 75% undertriage (OR, 1.12; 95% CI, 1.09-1.26) but not undertriage at greater than 75% (OR, 1.03, 95% CI, 1.00-1.18). In sensitivity analyses to adjust for unmeasured confounding, the association between triage practices and the case fatality rate became monotonic; compared with patients treated by practitioners with an undertriage rate of 25% or less, the odds of case fatality were 1.13 (95% CI, 1.05-1.21; P = .001) among patients treated by practitioners with undertriage rates less than 25% to 50%, 1.22 (95% CI, 1.13-1.32; P < .001) for patients treated by practitioners with undertriage rates less than 50% to 75%, and 1.20 (95% CI, 1.10-1.30; P < .001) for patients treated by practitioners with undertriage rates greater than 75%. Conclusions and Relevance: The findings suggest that individual practitioner practices are an important source of variation in triage and represent a potential locus of intervention to reduce preventable deaths after injury.

Effects of Changes in ICU Bed Supply on ICU Utilization.

BACKGROUND: The availability of intensive care unit (ICU) beds may influence the demand for critical care. Although small studies support a model of supply-induced demand in the ICU, there is a paucity of system-wide data. OBJECTIVE: The objective of this study was to determine the relationship between ICU bed supply and ICU admission in United States hospitals. RESEARCH DESIGN: Retrospective cohort study using all-payer inpatient records from Florida, Massachusetts, New Jersey, New York, and Washington from 2010 to 2012, linked to hospital data from Medicare's Healthcare Cost Reporting Information System. SUBJECTS: Three patient groups with a low likelihood of benefiting from ICU admission-low severity patients with acute myocardial infarction and pulmonary embolism; and high severity patients with metastatic cancer at the end of life. MEASURES: We compared the risk-adjusted probability of ICU admission at hospitals that increased their ICU bed supply over time to matched hospitals that did not, using a difference-in-differences approach. RESULTS: For patients with acute myocardial infarction, ICU supply increases were associated with an increase in the probability of ICU admission that diminished over time. For patients with pulmonary embolism, there was a trend toward an association between change in ICU supply and ICU admission that did not meet statistical significance. For patients with metastatic cancer, admission to hospitals with an increasing ICU supply was not associated with changes in the probability of ICU admission. CONCLUSIONS: Increases in ICU bed supply were associated with inconsistent changes in the probability of ICU admission that varied across patient subgroups.

The early adoption of intensity-modulated radiotherapy and stereotactic body radiation treatment among older Medicare beneficiaries with prostate cancer.

BACKGROUND: Several new prostate cancer treatments have emerged since 2000, including 2 radiotherapies with similar efficacy at the time of their introduction: intensity-modulated radiotherapy (IMRT) and stereotactic body radiation therapy (SBRT). The objectives of this study were to compare their early adoption patterns and identify factors associated with their use. METHODS: By using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, patients who received radiation therapy during the 5 years after IMRT introduction (2001-2005) and the 5 years after SBRT introduction (2007-2011) were identified. The outcome of interest was the receipt of new radiation therapy (ie, IMRT or SBRT) compared with the existing standard radiation therapies at that time. The authors fit a series of multivariable, hierarchical logistic regression models accounting for patients nested within health service areas to examine the factors associated with the receipt of new radiation therapy. RESULTS: During 2001 to 2005, 5680 men (21%) received IMRT compared with standard radiation (n = 21,555). Men who received IMRT were older, had higher grade tumors, and lived in more populated areas (P < .05). During 2007 through 2011, 595 men (2%) received SBRT compared with standard radiation (n = 28,255). Men who received ng SBRT were more likely to be white, had lower grade tumors, lived in more populated areas, and were more likely to live in the Northeast (P < .05). Adjusting for cohort demographic and clinical factors, the early adoption rate for IMRT was substantially higher than that for SBRT (44% vs 4%; P < .01). CONCLUSIONS: There is a stark contrast in the adoption rates of IMRT and SBRT at the time of their introduction. Further investigation of the nonclinical factors associated with this difference is warranted. Cancer 2017;123:2945-54. © 2017 American Cancer Society.

Impact of Volume Change Over Time on Trauma Mortality in the United States.

OBJECTIVE: To evaluate the association of trauma center volume change over time with mortality. BACKGROUND: Regionalization of trauma systems assumes a volume-outcome relationship for severe injury. Whereas this has been shown for cross-sectional volume, it is unclear whether volume changes over time translate into predictable outcome changes. METHODS: Retrospective cohort study of severely injured (injury severity score >15) patients from the National Trauma Databank 2000 to 2012. A center-level standardized mortality ratio (SMR) was constructed (ratio of observed to expected deaths). Expected mortality was obtained from multilevel logistic regression model, adjusting for demographics, mechanism, vital signs, and injury severity. Center-level percent volume change was assessed across early (2000-2006) and late (2007-2012) periods. Longitudinal panel modeling evaluated association between annual SMR change and volume change over preceding years. RESULTS: There were 839,809 patients included from 287 centers. Each 1% increase in volume was associated with 73% increased odds of improving SMR over time [odds ratio (OR) 1.73; 95% confidence interval (CI) 1.03-2.91; P = 0.03]. Each 1% decrease in volume was associated with 2-fold increase in odds of worsening SMR over time (OR 2.14; 95% CI 1.07-4.26, P = 0.03). Significant improvement in the SMR emerged after 3 or more preceding years of increasing volume (SMR change -0.008; 95% CI -0.015, -0.002; P = 0.01). This benefit occurred only in centers that were level I or II verified. CONCLUSIONS: Increasing volume was associated with improving outcomes, whereas decreasing volume was associated with worsening outcomes. High-level trauma center infrastructure seems to facilitate the volume-outcome relationship. The trauma center designation process should consider volume changes in the overall system.

Effects of Organizational Characteristics on Outcomes and Resource Use in Patients With Cancer Admitted to Intensive Care Units.

PURPOSE: To investigate the impact of organizational characteristics and processes of care on hospital mortality and resource use in patients with cancer admitted to intensive care units (ICUs). PATIENTS AND METHODS: We performed a retrospective cohort study of 9,946 patients with cancer (solid, n = 8,956; hematologic, n = 990) admitted to 70 ICUs (51 located in general hospitals and 19 in cancer centers) during 2013. We retrieved patients' clinical and outcome data from an electronic ICU quality registry. We surveyed ICUs regarding structure, organization, staffing patterns, and processes of care. We used mixed multivariable logistic regression analysis to identify characteristics associated with hospital mortality and efficient resource use in the ICU. RESULTS: Median number of patients with cancer per center was 110 (interquartile range, 58 to 154), corresponding to 17.9% of all ICU admissions. ICU and hospital mortality rates were 15.9% and 25.4%, respectively. After adjusting for relevant patient characteristics, presence of clinical pharmacists in the ICU (odds ratio [OR], 0.67; 95% CI, 0.49 to 0.90), number of protocols (OR, 0.92; 95% CI, 0.87 to 0.98), and daily meetings between oncologists and intensivists for care planning (OR, 0.69; 95% CI, 0.52 to 0.91) were associated with lower mortality. Implementation of protocols (OR, 1.52; 95% CI, 1.11 to 2.07) and meetings between oncologists and intensivists (OR, 4.70; 95% CI, 1.15 to 19.22) were also independently associated with more efficient resource use. Neither admission to ICUs in cancer centers compared with general hospitals nor annual case volume had an impact on mortality or resource use. CONCLUSION: Organizational aspects, namely the implementation of protocols and presence of clinical pharmacists in the ICU, and close collaboration between oncologists and ICU teams are targets to improve mortality and resource use in critically ill patients with cancer.

Triage patterns for medicare patients presenting to nontrauma hospitals with moderate or severe injuries.

OBJECTIVE: To understand hospital-level variation in triage practices for patients with moderate-to-severe injuries presenting initially to nontrauma centers. BACKGROUND: Many patients with moderate-to-severe traumatic injuries receive care at nontrauma hospitals, despite evidence of a survival benefit from treatment at trauma centers. METHODS: We used claims from the Centers for Medicare and Medicaid Services to identify patients with moderate-to-severe injuries who presented initially to nontrauma centers. We determined whether or not they were transferred to a level I or II trauma center within 24 hours of presentation, and used multivariate regression to assess the influence of hospital-level factors on triage practices, after adjusting for differences in case mix. RESULTS: Transfer of patients with moderate-to-severe injuries to trauma centers occurred infrequently, with significant variation among hospitals (median 2%; interquartile range 1%-6%). Greater resource availability at nontrauma centers was associated with lower rates of successful triage, including the presence of neurosurgeons (relative reduction in transfer rate: 76%, P < 0.01), more than 20 intensive care unit beds (relative reduction 30%, P < 0.01) and a high resident-to-bed ratio (relative reduction 23%, P < 0.01). However, patients were more likely to survive if they presented to hospitals with higher triage rates (odds of death for patients cared for at hospitals with the highest tercile of triage rates, compared with lowest tercile: 0.92; 95% confidence interval: 0.85-0.99, P = 0.02). CONCLUSIONS: Injured Medicare beneficiaries presenting to nontrauma centers experience high rates of undertriage, determined in part by increasing availability of resources. Care at hospitals with low rates of successful triage is associated with worse outcomes.

Quality improvement in end-of-life critical care.

Patients, clinicians and policy makers are increasingly interested in measuring and improving the quality of health care at the end of life. The intensive care unit (ICU) is characterized by high mortality and frequent use of life-sustaining treatments, making critical care a natural target for these efforts. Indeed, multiple local and regional quality improvement efforts now specifically target the dying experience for ICU patients, patients at risk for ICU admission, and their families. These activities either target ICU caregivers through educational programs and quality incentives, or target patients and their families directly through palliative care and efforts to improve decisions around the end of life. Although these initiatives hold great promise, they also face inherent challenges-it is difficult to measure the quality of end-of-life care, we lack practical targets for affecting quality, and uncertain political climates can often preclude serious discussions about end-of-life care. Moreover, these programs may lead to unintended consequences, potentially negatively impacting the very care they seek to improve. Future innovations surrounding how we measure the quality of end-of-life care and paradigm shifts in the way we think about ICU quality may help us to fully realize the goal of improving the dying process for ICU patients.