Hospital-level factors associated with use of pediatric radiation dose-reduction protocols for head CT: results from a national survey.

OBJECTIVES: To examine hospital-level factors associated with the use of a dedicated pediatric dose-reduction protocol and protective shielding for head CT in a national sample of hospitals. METHODS: A mixed-mode (online and paper) survey was administered to a stratified random sample of US community hospitals (N = 751). Respondents provided information on pediatric head CT scanning practices, including use of a dose-reduction protocol. Modified Poisson regression analyses describe the relative risk (RR) of not reporting the use of a pediatric dose-reduction protocol or protective shielding; multivariable analyses adjust for census region, trauma level, children's hospital status, and bed size. RESULTS: Of hospitals that were contacted, 38 were ineligible (no CT scanner, hospital closed, do not scan infants), 1 refused, and 253 responded (35.5% response rate). Across all hospitals, 92.6% reported using a pediatric dose-reduction protocol. Modified Poisson regression showed that small hospitals (0-50 beds) were 20% less likely to report using a protocol than large hospitals (>150 beds) (RR: 0.80, 95% confidence interval [CI]: 0.65-0.99; adjusted for covariates). Teaching hospitals were more likely to report using a protocol (RR: 1.10, 95% CI: 1.02-1.19; adjusted for covariates). After adjusting for covariates, children's hospitals were significantly less likely to report using protective shielding than nonchildren's hospitals (RR: 0.64, 95% CI: 0.56-0.73), though this may be due to more advanced scanner type. CONCLUSION: Results from this study provide guidance for tailored educational campaigns and quality improvement interventions to increase the adoption of pediatric dose-reduction efforts.

Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality.

OBJECTIVE: To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitals BACKGROUND: High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible. We examined low-volume hospitals and sought to identify characteristics of those with better outcomes. METHODS: Using national data from Medicare and the American Hospital Association, we studied 4498 elderly patients who underwent an esophagectomy from 2004 to 2007. We divided hospitals into terciles based on esophagectomy volume and examined characteristics of patients and hospitals (size, nurse ratios, and presence of advanced medical, surgical, and radiological services). Our primary outcome was mortality. We identified 5 potentially beneficial systems characteristics in our data set and used multivariable logistic regression to determine whether these characteristics were associated with lower mortality rates at low-volume hospitals. RESULTS: Of the 874 hospitals that performed esophagectomies, 83% (723) were low-volume hospitals whereas only 3% (25) were high-volume. Low-volume hospitals performed a median of 1 esophagectomy during the 4-year study period and cared for patients that were older, more likely to be minority, and more likely to have multiple comorbidities compared with high-volume centers. Low-volume hospitals that had at least 3 of 5 characteristics (high nurse ratios, lung transplantation services, complex medical oncology services, bariatric surgery services, and positron emission tomography scanners) had markedly lower mortality rates compared with low-volume hospitals with none of these characteristics (12.5% vs. 5.0%; P value = 0.042). CONCLUSIONS: Low-volume hospitals with certain systems characteristics seem to achieve better esophagectomy outcomes. A more comprehensive study of the beneficial characteristics of low-volume hospitals is warranted because high-volume hospitals are difficult to access for many patients.

Risk-based selective referral for cancer surgery: a potential strategy to improve perioperative outcomes.

BACKGROUND: Studies have demonstrated volume-outcome relationships for numerous operations, providing an impetus for regionalization; however, volume-based regionalization may not be feasible or necessary. Our objective was to determine if low-risk patients undergoing surgery at Community Hospitals have perioperative mortality rates comparable with Specialized Centers. METHODS: From the National Cancer Data Base, 940,718 patients from approximately 1430 hospitals were identified who underwent resection for 1 of 15 cancers (2003-2005). Patients were stratified by preoperative risk according to age and comorbidities. Separately for each cancer, regression modeling stratified by high- and low-risk groups was used to compare 60-day mortality at Specialized Centers (National Cancer Institute-designated and/or highest-volume quintile institutions), Other Academic Institutions (lower-volume, non-National Cancer Institute), and Community Hospitals. RESULTS: Low-risk patients had statistically similar perioperative mortality rates at Specialized Centers and Community Hospitals for 13 of 15 operations. High-risk patients had significantly lower perioperative mortality rates at Specialized Centers compared with Community Hospitals for 9 of 15 cancers. Regardless of risk group, perioperative mortality rates were significantly lower for pancreatectomy and esophagectomy at Specialized Centers. Risk-based referral compared with volume-based regionalization of most patients would require fewer patients to change to Specialized Centers. CONCLUSIONS: Perioperative mortality for low-risk patients was comparable at Specialized Centers and Community Hospitals for all cancers except esophageal and pancreatic, thus questioning volume-based regionalization of all patients. Rather, only high-risk patients may need to change hospitals. Mortality rates could be reduced if factors at Specialized Centers resulting in better outcomes for high-risk patients can be identified and transferred to other hospitals.

Volume thresholds and hospital characteristics in the United States.

Procedure volume has been used as a proxy for quality and recommended as a basis for hospital referrals. We studied the volume, mortality, and associated hospital and staffing characteristics of ten complex procedures in U.S. hospitals using the 2000 HCUP Nationwide Inpatient Sample. Although the majority of patients had their procedures performed in high-volume hospitals, for seven procedures, more than three-fourths of hospitals would be considered low-volume. Unadjusted mortality rates were significantly higher at low-volume hospitals for five procedures. Low-volume hospitals also tended to have lower mean numbers of residents and RNs. However, for two procedures, low-volume hospitals had RN and resident staffing equal to or higher than those of high-volume hospitals, and the unadjusted mortality rates were no different.