Rural-Urban Disparities in Colorectal Cancer Screening, Diagnosis, Treatment, and Survivorship Care: A Systematic Review and Meta-Analysis.

BACKGROUND: Rural residents have a higher prevalence of colorectal cancer (CRC) mortality compared to urban individuals. Policies have been aimed at improving access to CRC screening to reduce these outcomes. However, little attention has been paid to other determinants of CRC-related outcomes, such as stage at diagnosis, treatment, or survivorship care. The main objective of this analysis was to evaluate literature describing differences in CRC screening, stage at diagnosis, treatment, and survivorship care between rural and urban individuals. MATERIALS AND METHODS: We conducted a systematic review of electronic databases using a combination of MeSH and free-text search terms related to CRC screening, stage at diagnosis, treatment, survivorship care, and rurality. We identified 921 studies, of which 39 were included. We assessed methodological quality using the ROBINS-E tool and summarized findings descriptively. A meta-analysis was performed of studies evaluating CRC screening using a random-effects model. RESULTS: Seventeen studies reported disparities between urban and rural populations in CRC screening, 12 on treatment disparities, and 8 on staging disparities. We found that rural individuals were significantly less likely to report any type of screening at any time period (pooled odds ratio = 0.81, 95% CI, 0.76-0.86). Results were inconclusive for disparities in staging at diagnosis and treatment. One study reported a lower likelihood of use of CRC survivorship care for rural individuals compared to urban individuals. CONCLUSION: There remains an urgent need to evaluate and address CRC disparities in rural areas. Investigators should focus future work on assessing the quality of staging at diagnosis, treatment, and survivorship care in rural areas.

Going the Extra Mile? How Provider Network Design Increases Consumer Travel Distance, Particularly for Rural Consumers.

CONTEXT: The practical accessibility to medical care facilitated by health insurance plans depends not just on the number of providers within their networks but also on distances consumers must travel to reach the providers. Long travel distances inconvenience almost all consumers and may substantially reduce choice and access to providers for some. METHODS: The authors assess mean and median travel distances to cardiac surgeons and pediatricians for participants in (1) plans offered through Covered California, (2) comparable commercial plans, and (3) unrestricted open-network plans. The authors repeat the analysis for higher-quality providers. FINDINGS: The authors find that in all areas, but especially in rural areas, Covered California plan subscribers must travel longer than subscribers in the comparable commercial plan; subscribers to either plan must travel substantially longer than consumers in open networks. Analysis of access to higher-quality providers show somewhat larger travel distances. Differences between ACA and commercial plans are generally substantively small. CONCLUSIONS: While network design adds travel distance for all consumers, this may be particularly challenging for transportation-disadvantaged populations. As distance is relevant to both health outcomes and the cost of obtaining care, this analysis provides the basis for more appropriate measures of network adequacy than those currently in use.

Participatory decision-making for cancer care in a high-risk sample of low income Mexican-American breast cancer survivors: The role of acculturation.

BACKGROUND: Despite declining cancer incidence and mortality rates, Latina patients continue to have lower 5-year survival rates compared to their non-Hispanic white counterparts. Much of this difference has been attributed to lack of healthcare access and poorer quality of care. Research, however, has not considered the unique healthcare experiences of Latina patients. METHODS: Latina women with prior diagnoses of stage 0-III breast cancer were asked to complete a cross-sectional survey assessing several socio-demographic factors along with their experiences as cancer patients. Using a series of linear regression models in a sample of 68 Mexican-American breast cancer survivors, we examined the extent to which patients' ratings of provider interpersonal quality of care were associated with patients' overall healthcare quality, and how these associations varied by acculturation status. RESULTS: Findings for Latina women indicated that both participatory decision-making (PDM) (ß = 0.62, p < .0001) and trust (ß = 0.53, p = .02) were significantly associated with patients' ratings of healthcare quality. The interaction between acculturation and PDM further suggested that participating in the decision-making process mattered more for less acculturated than for more acculturated patients (ß = -0.51, p ≤ .01). CONCLUSIONS: The variation across low and high acculturated Latinas in their decision-making process introduces a unique challenge to health care providers. Further understanding the relationship between provider-patient experiences and ratings of overall healthcare quality is critical for ultimately improving health outcomes.

A Consumer-Centric Approach To Network Adequacy: Access To Four Specialties In California's Marketplace.

We assessed the effect of provider networks on access to four medical specialties for Affordable Care Act Marketplace enrollees in California. Our approach incorporated a crucial consumer-focused attribute, travel distance, and identified the restrictions on provider access resulting from network design. Our analysis indicated that Marketplace plan networks are narrower than their commercial plan counterparts and feature just over half as many providers. However, there is much diversity in network breadth, depending on consumers' choice of plans and geographic region. Furthermore, network designs often create important access issues for consumers because of what we call "artificial local provider deserts"-geographic areas within networks devoid of providers by design. Consumers in large metropolitan areas are generally guaranteed a significant degree of access and choice, but network design exacerbates limited access for rural areas in which few providers are available to any consumer.

Screening emergency department patients for opioid drug use: A qualitative systematic review.

INTRODUCTION: The opioid drug epidemic is a major public health concern and an economic burden in the United States. The purpose of this systematic review is to assess the reliability and validity of screening instruments used in emergency medicine settings to detect opioid use in patients and to assess psychometric data for each screening instrument. METHODS: PubMed/MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov were searched for articles published up to May 2018. The extracted articles were independently screened for eligibility by two reviewers. We extracted 1555 articles for initial screening and 95 articles were assessed for full-text eligibility. Six articles were extracted from the full-text assessment. RESULTS: Six instruments were identified from the final article list: Screener and Opioid Assessment for Patients with Pain - Revised; Drug Abuse Screening Test; Opioid Risk Tool; Current Opioid Misuse Measure; an Emergency Medicine Providers Clinician Assessment Questionnaire; and an Emergency Provider Impression Data Collection Form. Screening instrument characteristics, and reliability and validity data were extracted from the six studies. A meta-analysis was not conducted due to heterogeneity between the studies. CONCLUSIONS: There is a lack of validity and reliability evidence in all six articles; and sensitivity, specificity and predictive values varied between the different instruments. These instruments cannot be validated for use in emergency medicine settings. There is no clear evidence to state which screening instruments are appropriate for use in detecting opioid use disorders in emergency medicine patients. There is a need for brief, reliable, valid and feasible opioid use screening instruments in the emergency medicine setting.

Patients' perceptions of interactions with hospital staff are associated with hospital readmissions: a national survey of 4535 hospitals.

BACKGROUND: Reducing 30-day hospital readmissions has become a focus of the current national payment policies. Medicare requires that hospitals collect and report patients' experience with their care as a condition of payment. However, the extent to which patients' experience with hospital care is related to hospital readmission is unknown. METHODS: We established multivariate regression models in which 30-day risk-adjusted readmission rates were the dependent variables and patients' perceptions of the responsiveness of the hospital staff and communication (as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores) were the independent variables of interest. We selected six different clinical conditions for analyses, including acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure, hip/knee surgery, pneumonia, and stroke. Data included all acute care hospitals reporting in Hospital Compare in 2014. RESULTS: The number of hospitals with reported readmissions ranged from 2234 hospitals for AMI to 3758 hospitals for pneumonia. The average 30-day readmission rates ranged from 5.19% for knee/hip surgery to 22.7% for COPD. Patient experience of hospital-staff responsiveness as "top-box" ranged from 64% to 67% across the six clinical conditions, communication with nurses ranged from 77% to 79% and communication with doctors ranged from 80% to 81% (higher numbers are better). Our finding suggests that hospitals with better staff responsiveness were significantly more likely to have lower 30-day readmissions for all conditions. The effect size depended on the baseline readmission rates, with the largest effect on hospitals in the upper 75th quartile. A ten-percentage-point increase in staff responsiveness led to a 0.03-0.18 percentage point decrease in readmission rates. We found that neither communication with physicians nor communication with nurses was significantly associated with hospital readmissions. CONCLUSIONS: Our findings suggest that elements of care related to staff responsiveness during patients' stay may influence rehospitalization rates. Changes in staff responsiveness may offer an additional tool for hospitals to employ ongoing efforts to achieve reductions in readmissions, an important objective both financially and for patient health outcomes.

Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial.

BACKGROUND: Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested. OBJECTIVE: Test the impact of PCTeams on end-of-life outcomes. RESEARCH DESIGN: Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect. SUBJECTS: In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents). MEASURES: Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions. RESULTS: Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations. CONCLUSIONS: The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.

Improving palliative care through teamwork (IMPACTT) in nursing homes: Study design and baseline findings.

BACKGROUND: The 2014 Institute of Medicine report recommended that healthcare providers caring for individuals with advanced illness have basic palliative care competencies in communication, inter-professional collaboration, and symptom management. Nursing homes, where one in three American decedents live and die, have fallen short of these competency goals. We implemented an intervention study to examine the efficacy of nursing home-based integrated palliative care teams in improving the quality of care processes and outcomes for residents at the end of life. METHODS/DESIGN: This paper describes the design, rationale, and challenges of a two-arm randomized controlled trial of nursing home-based palliative care teams in 31 facilities. The impact of the intervention on residents' outcomes is measured with four risk-adjusted quality indicators: place of death (nursing home or hospital), number of hospitalizations, and self-reported pain and depression in the last 90-days of life. The effect of the intervention is also evaluated with regard to staff satisfaction and impact on care processes (e.g. palliative care competency, communication, coordination). Both secondary (e.g. the Minimum Data Set) and primary (e.g. staff surveys) data are employed to examine the effect of the intervention. DISCUSSION: Several challenges in conducting a complex, nursing home-based intervention have been identified. While sustainability of the intervention without research funding is not clear, we surmise that without changes to the payment model that put palliative care services in this care setting on par with the more "skilled" care, it will not be reasonable to expect any widespread efforts to implement facility-based palliative care services.

Personalizing Nursing Home Compare and the Discharge from Hospitals to Nursing Homes.

OBJECTIVE: To test whether use of a personalized report card, Nursing Home Compare Plus (NHCPlus), embedded in a reengineered discharge process, can lead to better outcomes than the usual discharge process from hospitals to nursing homes. DATA SOURCES/SETTING: Primary data collected in the Departments of Medicine and Surgery at a University Medical Center between March 2014 and August 2015. STUDY DESIGN: A randomized controlled trial in which patients in the intervention group were given NHCPlus. Participants included 225 patients or their family members/surrogates. DATA COLLECTION: Key strokes of NHCPlus users were recorded to obtain information about usage. Users were surveyed about usability and satisfaction with NHCPlus. All participants were surveyed at discharge from the hospital. Survey data were merged with medical records. PRINCIPAL FINDINGS: About 85 percent of users indicated satisfaction with NHCPlus. Compared to controls, intervention patients were more satisfied with the choice process (by 40 percent of the standard deviation p < .01), more likely to go to higher ranked five-star nursing homes (OR = 1.8, p < .05), traveled to further nursing homes (IRR = 1.27, p < .10), and had shorter hospital stays (IRR = 0.84, p < .05). CONCLUSIONS: Personalizing report cards and reengineering the discharge process may improve quality and may lower costs compared to the usual discharge process.

Cost Variation Within Spinal Fusion Payment Groups.

STUDY DESIGN: Retrospective, large administrative database. OBJECTIVE: To investigate cost variation within current spinal fusion diagnosis-related groups (DRGs). SUMMARY OF BACKGROUND DATA: Medicare reimbursement to hospitals for spinal fusion surgery is provided as a fixed payment for each admission based on DRG. This assumes that patients can be grouped into homogenous units of resource use such that a single payment will cover the costs of hospitalization for most patients within a given DRG. However, major differences in costs exist for different methods of spinal fusion surgery. A previous study in total joint arthroplasty (TJA) showed that variation within DRGs can lead to differences between hospital costs and Medicare reimbursement, resulting in predictable financial losses to hospitals and hindering access to care for some patients. No study to our knowledge has investigated cost variation within current spinal fusion DRGs. METHODS: Direct hospital costs were obtained from the 2011 Nationwide Inpatient Sample (NIS) for patients in spinal fusion DRGs 453-460 and TJA DRGs 466-470. Our primary outcome was the coefficient of variation (CV), defined as the ratio of the standard deviation (SD) to the mean (CV = SD/mean × 100), for all costs within a given DRG. CVs were compared to an established TJA benchmark for within-DRG cost variation. RESULTS: CVs for costs within spinal fusion DRGs ranged from 44.16 to 52.6 and were significantly higher than the CV of 38.2 found in the TJA benchmark group (P < 0.0001). CONCLUSION: As in TJA, the cost variation observed within spinal fusion DRGs in this study may be leading to differences between costs and reimbursement that places undue financial burden on some hospitals and potentially compromises access to care for some patients. Future studies should seek to identify drivers of cost variation to determine whether changes can be made to further homogenize current payment groups and ensure equal access for all patients. LEVEL OF EVIDENCE: 3.

Consensus in controversy: The modified Delphi method applied to Gynecologic Oncology practice.

OBJECTIVES: To determine the degree of consensus regarding the probabilities of outcomes associated with IP/IV and IV chemotherapy. METHODS: A survey was administered to an expert panel using the Delphi method. Ten ovarian cancer experts were asked to estimate outcomes for patients receiving IP/IV or IV chemotherapy. The clinical estimates were: 1) probability of completing six cycles of chemotherapy, 2) probability of surviving five years, 3) median survival, and 4) probability of ER/hospital visits during treatment. Estimates for two patients, one with a low comorbidity index (patient 1) and the other with a moderate index (patient 2), were included. The survey was administered in three rounds, and panelists could revise their subsequent responses based on review of the anonymous opinions of their peers. RESULTS: The ranges were smaller for IV compared with IP/IV therapy. Ranges decreased with each round. Consensus converged around outcomes related to IP/IV chemotherapy for: 1) completion of 6 cycles of therapy (type 1 patient, 62%, type 2 patient, 43%); 2) percentage of patients surviving 5 years (type 1 patient, 66%, type 2 patient, 47%); and 3) median survival (type 1 patient, 83 months, type 2 patient, 58 months). The group required three rounds to achieve consensus on the probabilities of ER/hospital visits (type 1 patient, 24%, type 2 patient, 35%). CONCLUSIONS: Initial estimates of survival and adverse events associated with IP/IV chemotherapy differ among experts. The Delphi process works to build consensus and may be a pragmatic tool to inform patients of their expected outcomes.

Developing palliative care practice guidelines and standards for nursing home-based palliative care teams: a Delphi study.

CONTEXT: Lack of nursing home (NH)-specific palliative care practice guidelines has been identified as a barrier to improving palliative and end-of-life (EOL) quality of care. OBJECTIVES: The objectives of this study were to (1) assess which of the guidelines developed by the National Consensus Project, and the corresponding preferred care practices endorsed by the National Quality Forum, are important and feasible to implement in NHs; and (2) identify the operational standards for palliative care teams in NHs. METHODS: Two-round mail Delphi study. Based on the existing literature, a set of 7 domains with associated 22 palliative practice guidelines was drafted. We invited 48 NH leaders, including clinicians, to review the importance (10-point Likert scale) and the feasibility (5-point Likert scale) of these guidelines. Participants were also asked about palliative care team composition rounding frequency. RESULTS: The response rate to both rounds was 85%. With regard to importance, the mean rating for all guidelines was 8 or higher (ie, highly important), but there was variability in agreement with regard to 5 of the guidelines. The same 5 guidelines were also considered more difficult to implement (eg, costly, unrealistic). Overall, 17 palliative care guidelines were identified for use by NH palliative care teams. Five disciplines (social work, certified nurse assistant, nurse, physician, and nurse practitioner or physician assistant) were identified as comprising a core team and 3 were proposed as extended or ad hoc members. CONCLUSION: The palliative care guidelines and team standards identified in this study may be helpful in providing practical direction to NH administrators and staff looking to improve palliative care practice for their residents.

Hospital readmission after noncardiac surgery: the role of major complications.

IMPORTANCE: Hospital readmissions are believed to be an indicator of suboptimal care and are the focus of efforts by the Centers for Medicare and Medicaid Services to reduce health care cost and improve quality. Strategies to reduce surgical readmissions may be most effective if applied prospectively to patients who are at increased risk for readmission. Hospitals do not currently have the means to identify surgical patients who are at high risk for unplanned rehospitalizations. OBJECTIVE: To examine whether the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) predicted risk of major complications can be used to identify surgical patients at risk for rehospitalization. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 142,232 admissions in the ACS NSQIP registry for major noncardiac surgery. MAIN OUTCOMES AND MEASURES: The association between unplanned 30-day readmission and the ACS NSQIP predicted risk of major complications, controlling for severity of disease and surgical complexity. RESULTS: Of the 143,232 patients undergoing noncardiac surgery, 6.8% had unplanned 30-day readmissions. The rate of unplanned 30-day readmissions was 78.3% for patients with any postdischarge complication, compared with 12.3% for patients with only in-hospital complications and 4.8% for patients without any complications. Patients at very high risk for major complications (predicted risk of ACS NSQIP complication >10%) had 10-fold higher odds of readmission compared with patients at very low risk for complications (adjusted odds ratio = 10.35; 95% CI, 9.16-11.70), whereas patients at high (adjusted odds ratio = 6.57; 95% CI, 5.89-7.34) and moderate (adjusted odds ratio = 3.96; 95% CI, 3.57-4.39) risk of complications had 7- and 4-fold higher odds of readmission, respectively. CONCLUSIONS AND RELEVANCE: Unplanned readmissions in surgical patients are common in patients experiencing postoperative complications and can be predicted using the ACS NSQIP risk of major complications. Prospective identification of high-risk patients, using the NSQIP complication risk index, may allow hospitals to reduce unplanned rehospitalizations.

Impact of obesity on mortality and complications in trauma patients.

OBJECTIVE: To examine the association between obesity and outcomes in injured patients. BACKGROUND: The United States is facing an obesity epidemic affecting 1 in 3 adult Americans. Very little is known about the role of obesity in acute illness. Optimal care of obese trauma patients can only be achieved once we gain a better understanding of the impact of severe obesity on trauma outcomes. METHODS: We conducted a retrospective cohort study of 147,680 patients admitted to 28 level I and level II Pennsylvania trauma centers between 2000 and 2009. Logistic regression was used to examine the association between obesity and in-hospital mortality and major complications, adjusting for injury severity, age, gender, mechanism of injury, systolic blood pressure, and the motor component of the Glasgow Coma Scale, comorbidities, and year of admission. Patients were grouped into predefined weight categories: underweight (<1st percentile), reference (1st-74th percentile), grade 1 obesity (75th-90th percentile), grade 2 obesity (91th-95th percentile), grade 3 obesity (96th-99th percentile), and grade 4 obesity (>99th percentile). Body mass index was not calculated because height data was not available. RESULTS: After adjusting for injury severity and other risk factors, male patients with severe obesity-grade 3 obesity [adjusted odds ratio (AOR) 1.28; 95% confidence interval (CI): 1.00, 1.64; P = 0.052] or grade 4 obesity (AOR 2.30; 95% CI: 1.48, 3.58; P < 0.001)-were more likely to die than nonobese patients. Severe obesity was associated with an approximately twofold higher risk of major complications: male patients with grade 3 obesity (AOR 1.71; 95% CI: 1.48, 1.97; P < 0. 001) or grade 4 obesity (AOR 2.14; 95% CI: 1.83, 2.51; P < 0.001). Similar results were obtained for female patients. Male and female patients with severe obesity had a 2.5- to 4-fold higher risk of developing acute renal failure. Severely obese females had 2.5- to 4.5-fold higher risk of developing wound complications, and a 4-to 8-fold higher risk of developing decubiti. CONCLUSIONS: Severely obese trauma patients were at least 30% more likely to die and approximately twice as likely to have a major complication compared with nonobese patients.

Effectiveness of nonpublic report cards for reducing trauma mortality.

IMPORTANCE: An Institute of Medicine report on patient safety that cited medical errors as the 8th leading cause of death fueled demand to use quality measurement as a catalyst for improving health care quality. OBJECTIVE: To determine whether providing hospitals with benchmarking information on their risk-adjusted trauma mortality outcomes will decrease mortality in trauma patients. DESIGN, SETTING, AND PARTICIPANTS: Hospitals were provided confidential reports of their trauma risk-adjusted mortality rates using data from the National Trauma Data Bank. Regression discontinuity modeling was used to examine the impact of nonpublic reporting on in-hospital mortality in a cohort of 326206 trauma patients admitted to 44 hospitals, controlling for injury severity, patient case mix, hospital effects, and preexisting time trends. MAIN OUTCOMES AND MEASURES: In-hospital mortality rates. RESULTS Performance benchmarking was not significantly associated with lower in-hospital mortality (adjusted odds ratio [AOR], 0.89; 95% CI, 0.68-1.16; P=.39). Similar results were obtained in secondary analyses after stratifying patients by mechanism of trauma: blunt trauma (AOR, 0.91; 95% CI, 0.69-1.20; P=.51) and penetrating trauma (AOR, 0.75; 95% CI, 0.44-1.28; P=.29). We also did not find a significant association between nonpublic reporting and in-hospital mortality in either low-risk (AOR, 0.84; 95% CI, 0.57-1.25; P=.40) or high-risk (AOR, 0.88; 95% CI, 0.67-1.17; P=.38) patients. CONCLUSIONS AND RELEVANCE Nonpublic reporting of hospital risk-adjusted mortality rates does not lead to improved trauma mortality outcomes. The findings of this study may prove useful to the American College of Surgeons as it moves ahead to further develop and expand its national trauma benchmarking program.

Association between surgical resident involvement and blood use in noncardiac surgery.

BACKGROUND: Although there is significant variability in the rate of blood transfusion in surgical patients, the role of surgical skill as a determinant of blood use is unknown. STUDY DESIGN AND METHODS: We examined the association between surgery resident participation and intraoperative blood transfusion, and 30-day mortality and complications, among 381,036 patients undergoing noncardiac surgery, adjusting for patient factors and procedure complexity. RESULTS: Compared to attending surgeons working without a resident, cases in which the attendings worked with either Postgraduate Year (PGY) 3 to 4 resident or a PGY5 to 8 resident had a 56% (adjusted odds ratio [AOR], 1.56; 95% confidence interval [CI, 1.48-1.64) or a 78% (AOR, 1.78; 95% CI, 1.70-1.87) higher odds of receiving a blood transfusion, respectively. Involvement of surgical interns or junior residents (PGY1-2), whose role in the operative procedure is assumed to be limited, was associated with a 27% higher odds of receiving a blood transfusion (AOR, 1.27; 95% CI, 1.18-1.37). Overall, resident involvement was not associated with increased risk of 30-day mortality (AOR, 0.97; 95% CI, 0.91-1.04), but was associated with a slightly increased risk of complications (AOR, 1.13; 95% CI, 1.10-1.16). CONCLUSION: Senior surgery resident participation in noncardiac surgery is associated with between a 56% to 78% higher risk of receiving a blood transfusion intraoperatively compared to attending surgeons working without a resident. Assuming that senior surgical trainees are performing critical parts of the operative procedure and are less skilled than attending surgeons, the findings from this exploratory study suggest that intraoperative blood transfusion may serve as an indirect measure of surgical technical quality.

Ranking trauma center quality: can past performance predict future performance?

OBJECTIVE: To explore whether trauma center quality metrics based on historical data can reliably predict future trauma center performance. BACKGROUND: The goal of the American College of Surgeons Trauma Quality Improvement Program is to create a new paradigm in which high-quality trauma centers can serve as learning laboratories to identify best practices. This approach assumes that trauma quality reporting can reliably identify high-quality centers using historical data. METHODS: We performed a retrospective observational study on 122,408 patients in 22 level I and level II trauma centers in Pennsylvania. We tested the ability of the Trauma Mortality Prediction Model to predict future hospital performance based on historical data. RESULTS: Patients admitted to the lowest performance hospital quintile had a 2-fold higher odds of mortality than patients admitted to the best performance hospital quintile using either 2-year-old data [adjusted odds ratio (AOR): 2.11; 95% confidence interval (CI): 1.36-3.27; P < 0.001] or 3-year-old data (AOR: 2.12; 95% CI: 1.34-3.21; P < 0.001). There was a trend toward increased mortality using 5-year-old data (AOR: 1.70; 95% CI: 0.98-2.95; P = 0.059). The correlation between hospital observed-to-expected mortality ratios in 2009 and 2007 demonstrated moderate agreement (intraclass correlation coefficient = 0.56; 95% CI: 0.22-0.77). The intraclass correlation coefficients for observed-to-expected mortality ratios obtained using 2009 data and 3-, 4-, or 5-year-old data were not significantly different from zero. CONCLUSIONS: Trauma center quality based on historical data is associated with subsequent patient outcomes. Patients currently admitted to trauma centers that are classified as low-quality centers using 2- to 5-year-old data are more likely to die than patients admitted to high-quality centers. However, although the future performance of individual trauma centers can be predicted using performance metrics based on 2-year-old data, the performance of individual centers cannot be predicted using data that are 3 years or older.

Site of death among nursing home residents in the United States: changing patterns, 2003-2007.

CONTEXT: The proportion of US deaths occurring in nursing homes (NHs) has been increasing in the past 2 decades and is expected to reach 40% by 2020. Despite being recognized as an important setting in the provision of end-of-life (EOL) care, little is known about the quality of care provided to dying NH residents. There has been some, but largely anecdotal evidence suggesting that many US NHs transfer dying residents to hospitals, in part to avoid incurring the cost of providing intensive on-site care, and in part because they lack resources to appropriately serve the dying residents. We assessed longitudinal trends and geographic variations in place of death among NH residents, and examined the association between residents' characteristics, treatment preferences, and the probability of dying in hospitals. METHODS: We used the Minimum Data Set (NH assessment records), Medicare denominator (eligibility) file, and Medicare inpatient and hospice claims to identify decedent NH residents. In CY2003-2007, there were 2,992,261 Medicare-eligible NH decedents from 16,872 US Medicare- and/or Medicaid-certified NHs. Our outcome of interest was death in NH or in a hospital. The analytical strategy included descriptive analyses and multiple logistic regression models, with facility fixed effects, to examine risk-adjusted temporal trends in place of death. FINDINGS: Slightly more than 20% of decedent NH residents died in hospitals each year. Controlling for individual-level risk factors and for facility fixed effects, the likelihood of residents dying in hospitals has increased significantly each year between 2003 through 2007. CONCLUSIONS: This study fills a significant gap in the current literature on EOL care in US nursing homes by identifying frequent facility-to-hospital transfers and an increasing trend of in-hospital deaths. These findings suggest a need to rethink how best to provide care to EOL nursing home residents.

Mental illness, access to hospitals with invasive cardiac services, and receipt of cardiac procedures by Medicare acute myocardial infarction patients.

OBJECTIVE: Older persons with coronary heart disease have reduced access to appropriate medical and surgical services if they are also mentally ill. This study determined whether difference exists in access to hospitals that provide on-site invasive cardiac procedures among a national cohort of Medicare acute myocardial infarction (AMI) patients with and without comorbid mental illness, and its implications for subsequent procedure use. METHODS: Retrospective analyses of Medicare claims for initial AMI admissions between January and September 2007. Hospital service availability was obtained from annual survey data. Logistic regression estimated the associations of mental illness with admission to hospitals with any invasive cardiac services (diagnostic catheterization, coronary angioplasty, or bypass surgery) and post-admission care patterns and outcomes. RESULTS: Eighty-two percent of mentally ill AMI patients (n = 28,888) versus 87 percent of other AMI patients (n = 73,895) were initially admitted to hospitals with invasive cardiac facilities [adjusted odds ratio (OR) = 0.81, p < .001]. Admission to such hospitals was associated with overall higher rate of procedure use within 90 days of admission and improved 30-days readmission and mortality rates. However, irrespective of on-site service availability of the admitting hospital, mentally ill patients were one half as likely to receive invasive procedures (adjusted OR approximately 0.5, p < .001). CONCLUSIONS: Among Medicare patients with AMI, those with comorbid mental illness were less likely to be admitted to hospitals with on-site invasive cardiac services. Mental illness was associated with reduced cardiac procedure use within each type of admitting hospitals (with on-site invasive cardiac services or not).