Medication Discrepancies in Older Veterans Receiving Home Healthcare.

In a prospective cohort study of Veterans and community health nurses, we enrolled hospitalized older Veterans referred to home care for skilled nursing and/or physical or occupational therapy for posthospitalization care. We assessed preadmission activities of daily living and instrumental activities of daily living, health literacy, numeracy, and cognition. Postdischarge phone calls identified medication errors and medication reconciliation efforts by home healthcare clinicians. Veterans Administration-based community health nurses completed surveys about content and timing of postdischarge interactions with home healthcare clinicians. We determined the types and frequency of medication errors among older Veterans receiving home healthcare, patient-provider communication patterns in this setting, and patient characteristics affecting medication error rates. Most Veterans (24/30, 80%) had at least one discordant medication, and only one noted that errors were identified and resolved. Veterans were asked about medications in the home healthcare setting, but far fewer were questioned about medication-taking details, adherence, and as-needed or nonoral medications. Higher numeracy was associated with fewer errors. Veterans Administration community health nurses reported contact by home healthcare clinicians in 41% of cases (7/17). Given the high rate of medication errors discovered, future work should focus on implementing best practices for medication review in this setting, as well as documenting barriers/facilitators of patient-provider communication.

A transition care coordinator model reduces hospital readmissions and costs.

BACKGROUND: The optimal structure and intensity of interventions to reduce hospital readmission remains uncertain, due in part to lack of head-to-head comparison. To address this gap, we evaluated two forms of an evidence-based, multi-component transitional care intervention. METHODS: A quasi-experimental evaluation design compared outcomes of Transition Care Coordinator (TCC) Care to Usual Care, while controlling for sociodemographic characteristics, comorbidities, readmission risk, and administrative factors. The study was conducted between January 1, 2013 and April 30, 2015 as a quality improvement initiative. Eligible adults (N = 7038) hospitalized with pneumonia, congestive heart failure, or chronic obstructive pulmonary disease were identified for program evaluation via an electronic health record algorithm. Nurse TCCs provided either a full intervention (delivered in-hospital and by post-discharge phone call) or a partial intervention (phone call only). RESULTS: A total of 762 hospitalizations with TCC Care (460 full intervention and 302 partial intervention) and 6276 with Usual Care was examined. In multivariable models, hospitalizations with TCC Care had significantly lower odds of readmission at 30 days (OR = 0.512, 95% CI 0.392 to 0.668) and 90 days (OR = 0.591, 95% CI 0.483 to 0.723). Adjusted costs were significantly lower at 30 days (difference = $3969, 95% CI $5099 to $2691) and 90 days (difference = $5684, 95% CI $7602 to $3627). The effect was similar whether patients received the full or partial intervention. CONCLUSION: An evidence-based multi-component intervention delivered by nurse TCCs reduced 30- and 90-day readmissions and associated health care costs. Lower intensity interventions delivered by telephone after discharge may have similar effectiveness to in-hospital programs.

The Cost of ICU Delirium and Coma in the Intensive Care Unit Patient.

RATIONALE: Intensive care unit (ICU) delirium is highly prevalent and a potentially avoidable hospital complication. The current cost of ICU delirium is unknown. OBJECTIVES: To specify the association between the daily occurrence of delirium in the ICU with costs of ICU care accounting for time-varying illness severity and death. RESEARCH DESIGN: We performed a prospective cohort study within medical and surgical ICUs in a large academic medical center. SUBJECTS: We analyzed critically ill patients (N=479) with respiratory failure and/or shock. MEASURES: Covariates included baseline factors (age, insurance, cognitive impairment, comorbidities, Acute Physiology and Chronic Health Evaluation II Score) and time-varying factors (sequential organ failure assessment score, mechanical ventilation, and severe sepsis). The primary analysis used a novel 3-stage regression method: first, estimation of the cumulative cost of delirium over 30 ICU days and then costs separated into those attributable to increased resource utilization among survivors and those that were avoided on the account of delirium's association with early mortality in the ICU. RESULTS: The patient-level 30-day cumulative cost of ICU delirium attributable to increased resource utilization was $17,838 (95% confidence interval, $11,132-$23,497). A combination of professional, dialysis, and bed costs accounted for the largest percentage of the incremental costs associated with ICU delirium. The 30-day cumulative incremental costs of ICU delirium that were avoided due to delirium-associated early mortality was $4654 (95% confidence interval, $2056-7869). CONCLUSIONS: Delirium is associated with substantial costs after accounting for time-varying illness severity and could be 20% higher (∼$22,500) if not for its association with early ICU mortality.

Low Health Literacy Is Associated with Increased Transitional Care Needs in Hospitalized Patients.

OBJECTIVE: To examine the association of health literacy with the number and type of transitional care needs (TCN) among patients being discharged to home. DESIGN, SETTING, PARTICIPANTS: A cross-sectional analysis of patients admitted to an academic medical center. MEASUREMENTS: Nurses administered the Brief Health Literacy Screen and documented TCNs along 10 domains: caregiver support, transportation, healthcare utilization, high-risk medical comorbidities, medication management, medical devices, functional status, mental health comorbidities, communication, and financial resources. RESULTS: Among the 384 patients analyzed, 113 (29%) had inadequate health literacy. Patients with inadequate health literacy had needs in more TCN domains (mean = 5.29 vs 4.36; P < 0 .001). In unadjusted analysis, patients with inadequate health literacy were significantly more likely to have TCNs in 7 out of the 10 domains. In multivariate analyses, inadequate health literacy remained significantly associated with inadequate caregiver support (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.37-4.99) and transportation barriers (OR, 1.69; 95% CI, 1.04-2.76). CONCLUSIONS: Among hospitalized patients, inadequate health literacy is prevalent and independently associated with other needs that place patients at a higher risk of adverse outcomes, such as hospital readmission. Screening for inadequate health literacy and associated needs may enable hospitals to address these barriers and improve postdischarge outcomes.

Role of Health Insurance Status in Interfacility Transfers of Patients With ST-Elevation Myocardial Infarction.

Lack of health insurance is associated with interfacility transfer from emergency departments for several nonemergent conditions, but its association with transfers for ST-elevation myocardial infarction (STEMI), which requires timely definitive care for optimal outcomes, is unknown. Our objective was to determine whether insurance status is a predictor of interfacility transfer for emergency department visits with STEMI. We analyzed data from the 2006 to 2011 Nationwide Emergency Department Sample examining all emergency department visits for patients age 18 years and older with a diagnosis of STEMI and a disposition of interfacility transfer or hospitalization at the same institution. For emergency department visits with STEMI, our multivariate logistic regression model included emergency department disposition status (interfacility transfer vs hospitalization at the same institution) as the primary outcome, and insurance status (none vs any [including Medicare, Medicaid, and private insurance]) as the primary exposure. We found that among 1,377,827 emergency department STEMI visits, including 249,294 (18.1%) transfers, patients without health insurance (adjusted odds ratio 1.6, 95% CI 1.5 to 1.7) were more likely to be transferred than those with insurance. Lack of health insurance status was also an independent risk factor for transfer compared with each subcategory of health insurance, including Medicare, Medicaid, and private insurance. In conclusion, among patients presenting to United States emergency departments with STEMI, lack of insurance was an independent predictor of interfacility transfer. In conclusion, because interfacility transfer is associated with longer delays to definitive STEMI therapy than treatment at the same facility, lack of health insurance may lead to important health disparities among patients with STEMI.

Using the WHODAS 2.0 to Assess Functioning Among Veterans Seeking Compensation for Posttraumatic Stress Disorder.

OBJECTIVE: One of the major changes in DSM-5 was removal of the Global Assessment of Functioning (GAF). To determine whether the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a suitable replacement for the GAF, this study compared how well the WHODAS 2.0 and the GAF measured functional impairment and other phenomena related to posttraumatic stress disorder (PTSD) among veterans applying for financial compensation (service connection) for PTSD. METHODS: Clinicians evaluating veteran claimants administered the Clinician Administered PTSD Scale (CAPS) and the WHODAS 2.0 to 177 veterans during their evaluations. Veterans also completed the Inventory of Psychosocial Functioning (IPF), a self-report measure of functional impairment, and received a GAF rating from the examiner. Actual benefit determinations and ratings were obtained. RESULTS: Confirmatory factor analyses demonstrated that the WHODAS 2.0 and the IPF were stronger indicators of a latent variable reflecting functioning compared with the GAF. In receiver operating characteristic curve analyses, the WHODAS 2.0, IPF, and GAF all displayed similar ability to identify veterans with PTSD-related impairment assessed by the CAPS. Compared with the GAF, the WHODAS 2.0 and IPF were less strongly related to PTSD symptom severity and disability ratings by the U.S. Department of Veterans Affairs, but these variables are typically influenced by GAF scores. CONCLUSIONS: The WHODAS 2.0 and IPF are acceptable replacements for the GAF and can be used to assess functional impairment among veterans seeking compensation for PTSD.

Racial differences in veterans' satisfaction with examination of disability from posttraumatic stress disorder.

OBJECTIVE: The examination that determines if a veteran has service-connected posttraumatic stress disorder (PTSD) affects veterans' lives for years. This study examined factors potentially associated with veterans' perception of their examination's quality. METHODS: Veterans (N=384) being evaluated for an initial PTSD service-connection claim were randomly assigned to receive either a semistructured interview or the examiner's usual interview. Immediately after the interview, veterans completed confidential ratings of the examinations' quality and of their examiners' interpersonal qualities and competence. Extensive data characterizing the veterans, the 33 participating examiners, and the examinations themselves were collected. RESULTS: Forty-seven percent of Caucasian veterans and 34% of African-American veterans rated their examination quality as excellent. African Americans were less likely than Caucasians to assign a higher quality rating (odds ratio=.61, 95% confidence interval=.38-.99, p=.047). Compared with Caucasians, African Americans rated their examiners as having significantly worse interpersonal qualities but not lower competence. Ratings were not significantly related to the veterans' age, gender, marital status, eventual diagnosis of PTSD, Global Assessment of Functioning score, the examiner's perception of the prevalence of malingering, or the presence of a third party during the examination. CONCLUSIONS: Ratings of disability examinations were generally high, although ratings were less favorable among African-American veterans than among Caucasian veterans.

Impact of evidence-based standardized assessment on the disability clinical interview for diagnosis of service-connected PTSD: a cluster-randomized trial.

Posttraumatic stress disorder (PTSD) is one of the fastest growing compensated medical conditions. The present study compared usual disability examiner practices for PTSD with a standardized assessment that incorporates evidence-based assessments. The design was a multicenter, cluster randomized, parallel-group study involving 33 clinical examiners and 384 veterans at 6 Veterans Affairs medical centers. The standardized group incorporated the Clinician Administered PTSD Scale and the World Health Organization Disability Assessment Schedule-II into their assessment interview. The main outcome measures were completeness and accuracy of PTSD diagnosis and completeness of functional assessment. The standardized assessments were 85% complete for diagnosis compared to 30% for nonstandardized assessments (p < .001), and, for functional impairment, 76% versus 3% (p < .001). The findings demonstrate that the quality of PTSD disability examination would be improved by using evidence-based assessment.

Automated identification of postoperative complications within an electronic medical record using natural language processing.

CONTEXT: Currently most automated methods to identify patient safety occurrences rely on administrative data codes; however, free-text searches of electronic medical records could represent an additional surveillance approach. OBJECTIVE: To evaluate a natural language processing search-approach to identify postoperative surgical complications within a comprehensive electronic medical record. DESIGN, SETTING, AND PATIENTS: Cross-sectional study involving 2974 patients undergoing inpatient surgical procedures at 6 Veterans Health Administration (VHA) medical centers from 1999 to 2006. MAIN OUTCOME MEASURES: Postoperative occurrences of acute renal failure requiring dialysis, deep vein thrombosis, pulmonary embolism, sepsis, pneumonia, or myocardial infarction identified through medical record review as part of the VA Surgical Quality Improvement Program. We determined the sensitivity and specificity of the natural language processing approach to identify these complications and compared its performance with patient safety indicators that use discharge coding information. RESULTS: The proportion of postoperative events for each sample was 2% (39 of 1924) for acute renal failure requiring dialysis, 0.7% (18 of 2327) for pulmonary embolism, 1% (29 of 2327) for deep vein thrombosis, 7% (61 of 866) for sepsis, 16% (222 of 1405) for pneumonia, and 2% (35 of 1822) for myocardial infarction. Natural language processing correctly identified 82% (95% confidence interval [CI], 67%-91%) of acute renal failure cases compared with 38% (95% CI, 25%-54%) for patient safety indicators. Similar results were obtained for venous thromboembolism (59%, 95% CI, 44%-72% vs 46%, 95% CI, 32%-60%), pneumonia (64%, 95% CI, 58%-70% vs 5%, 95% CI, 3%-9%), sepsis (89%, 95% CI, 78%-94% vs 34%, 95% CI, 24%-47%), and postoperative myocardial infarction (91%, 95% CI, 78%-97%) vs 89%, 95% CI, 74%-96%). Both natural language processing and patient safety indicators were highly specific for these diagnoses. CONCLUSION: Among patients undergoing inpatient surgical procedures at VA medical centers, natural language processing analysis of electronic medical records to identify postoperative complications had higher sensitivity and lower specificity compared with patient safety indicators based on discharge coding.

Cost-effectiveness of routine radiographs after emergent open cavity operations.

BACKGROUND: Emergency surgery increases the risk of a retained surgical sponge (RSS) by 9-fold. In most cases, surgical counts are falsely reported as correct. We hypothesized that the institutional costs resulting from a RSS would make routine intraoperative radiography (IOR) more cost-effective than surgical counts in preventing RSS after emergent open cavity cases. METHODS: A cost-effectiveness analysis was performed to compare routine IOR with surgical counts after emergent open cavity operations. Parameter estimates were obtained from the literature, expert opinion via a standardized survey, and existing institutional data. RESULTS: Routine IOR was the preferred strategy ($705 vs $1155 per patient) under the assumptions of the base case. The surgical count strategy was dominated by the institutional costs incurred after a RSS. Routine IOR was preferential as long as the sensitivity of surgical counts was less than 98% and the legal fees were more than $44,000 per case of RSS. CONCLUSIONS: Routine IOR is a simple, cost-effective option to reduce the occurrence of this preventable medical error. Institutional costs and legal fees associated with RSS dominate the cost of the surgical count strategy, making routine IOR a more cost-effective strategy than surgical counts given the best available parameter estimates.

The effects of gender and age on health-related quality of life following kidney transplantation.

AIMS AND OBJECTIVES: To evaluate whether gender, age and their interaction affect health-related quality of life and overall health status following kidney transplantation. BACKGROUND: Some investigators have examined the main effects of gender and/or age on health-related quality of life following kidney transplantation, but the potential interaction effect of these measures on this outcome has not been reported. DESIGN: This was a cross-sectional, single-centre study, based in one US geographic area. METHODS: Self-report survey data were provided by adult kidney transplant recipients using the SF-36 Health Survey (SF-36) and a visual analogue scale of overall health. SF-36 physical and mental component summary and individual scales and overall health were measured prospectively at one time point post-transplant. All adult patients were eligible to participate and rolling enrolment was employed. Statistical effects were tested using analysis of covariance (controlling for time post-transplant). RESULTS: Subjects (n = 138) included 66 women and 72 men. There were no effects of gender, age group, or their interaction on MCS or overall health scores (all p >or= 0.12). Physical component summary scale data demonstrated: (i) a significant effect of gender (p = 0.025); (ii) a statistically marginal effect of age group (p = 0.068); and (iii) a statistically marginal gender by age group interaction effect (p = 0.066). Women reported poorer scores on the SF-36 physical functioning (p = 0.049), role physical (p = 0.014) and bodily pain scales (p = 0.028). There was an effect of age group on physical functioning (p = 0.005), with younger patients reporting higher scores. CONCLUSIONS: Women report lower scores on several physical measures and may experience a greater reduction with age in physical health-related quality of life than men. Physical functioning declines with age following kidney transplantation. RELEVANCE TO CLINICAL PRACTICE: Findings may help healthcare professionals to develop gender- and age-specific interventions to optimize health-related quality of life of kidney transplant patients.

The ethics of using quality improvement methods in health care.

Quality improvement (QI) activities can improve health care but must be conducted ethically. The Hastings Center convened leaders and scholars to address ethical requirements for QI and their relationship to regulations protecting human subjects of research. The group defined QI as systematic, data-guided activities designed to bring about immediate improvements in health care delivery in particular settings and concluded that QI is an intrinsic part of normal health care operations. Both clinicians and patients have an ethical responsibility to participate in QI, provided that it complies with specified ethical requirements. Most QI activities are not human subjects research and should not undergo review by an institutional review board; rather, appropriately calibrated supervision of QI activities should be part of professional supervision of clinical practice. The group formulated a framework that would use key characteristics of a project and its context to categorize it as QI, human subjects research, or both, with the potential of a customized institutional review board process for the overlap category. The group recommended a period of innovation and evaluation to refine the framework for ethical conduct of QI and to integrate that framework into clinical practice.

Assessment of adverse drug events among patients in a tertiary care medical center.

PURPOSE: Specific patient and clinical characteristics associated with an increased risk of sustaining an adverse event (AE) were identified. METHODS: AE reports for patients in a 658-bed tertiary care medical center between January 1, 2000, and June 30, 2002, were analyzed. The data collected from each report included medical record number, patient sex, patient age, clinical service, date of occurrence, diagnoses, type of error, suspected medication, and severity of the AE. A three-stage logistic regression model with high-risk indicators was used to evaluate key indicators of the most vulnerable patient populations. RESULTS: The number of control patients and those with AEs totaled 60,206. This population was then randomly split into two equal groups of patients: the training data set (n = 30,103) and the validation data set (n = 30,103). AEs occurred in a higher percentage of patients who were age <1 year, 1-15, 47-59, and > or =60 years than in other groups. A higher percentage of AEs were reported in men than women, but the groups were not significantly different when comparing those with an AE and those without an AE. Asian Indian patients demonstrated a high rate of AEs, but this may be a statistical artifact, reflecting their very small percentage in the study. Evaluation of admission sources revealed that doctors' offices, clinic referrals, and local hospital transfers accounted for higher rates of AEs than other sources. CONCLUSION: Certain age groups, diagnoses, admission sources, types of insurance, and the use of specific medications or medication classes were associated with increased AE rates at a tertiary care medical center.

eQuality: electronic quality assessment from narrative clinical reports.

OBJECTIVE: To evaluate an electronic quality (eQuality) assessment tool for dictated disability examination records. METHODS: We applied automated concept-based indexing techniques to automated quality screening of Department of Veterans Affairs spine disability examinations that had previously undergone gold standard quality review by human experts using established quality indicators. We developed automated quality screening rules and refined them iteratively on a training set of disability examination reports. We applied the resulting rules to a novel test set of spine disability examination reports. The initial data set was composed of all electronically available examination reports (N=125,576) finalized by the Veterans Health Administration between July and September 2001. RESULTS: Sensitivity was 91% for the training set and 87% for the test set (P-.02). Specificity was 74% for the training set and 71% for the test set (P=.44). Human performance ranged from 4% to 6% higher (P<.001) than the eQuality tool in sensitivity and 13% to 16% higher in specificity (P<.001). In addition, the eQuality tool was equivalent or higher in sensitivity for 5 of 9 individual quality indicators. CONCLUSION: The results demonstrate that a properly authored computer-based expert systems approach can perform quality measurement as well as human reviewers for many quality indicators. Although automation will likely always rely on expert guidance to be accurate and meaningful, eQuality is an important new method to assist clinicians in their efforts to practice safe and effective medicine.

Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan.

BACKGROUND: In the evaluation of the cervical spine (c-spine), helical CT scan has higher sensitivity and specificity than plain radiographs in the moderate- and high-risk trauma population, but is more costly. We hypothesize that institutional costs associated with missed injuries make helical CT scan the least costly approach. STUDY DESIGN: A cost-minimization study was performed using decision analysis examining helical CT scan versus radiographic evaluation of the c-spine. Parameter estimates were obtained from the literature for probability of c-spine injury, probability of paralysis after missed injury, plain film sensitivity and specificity, CT scan sensitivity and specificity, and settlement cost of missed injuries resulting in paralysis. Institutional costs of CT scan and plain radiography were used. Sensitivity analyses tested robustness of strategy preference, accounted for parameter variability, and determined threshold values for individual parameters on strategy preference. RESULTS: C-spine evaluation with helical CT scan has an expected cost of US 554 dollars per patient compared with US 2,142 dollars for plain films. CT scan is the least costly alternative if threshold values exceed US 58,180 dollars for institutional settlement costs, 0.9% for probability of c-spine fracture, and 1.7% for probability of paralysis. Plain films are least costly if CT scan costs surpass US 1,918 dollars or plain film sensitivity exceeds 90%. CONCLUSIONS: Helical CT scan is the preferred initial screening test for detection of cervical spine fractures among moderate- to high-risk patients seen in urban trauma centers, reducing the incidence of paralysis resulting from false-negative imaging studies and institutional costs, when settlement costs are taken into account.

Refining a health-related quality of life assessment strategy for solid organ transplant patients.

PURPOSE: The psychometric properties of generic health-related quality of life (HRQOL) assessment instruments were evaluated to identify a reliable, valid, and non-redundant battery to measure longitudinal outcomes in organ transplant patients. METHODS: Objective functional performance and subjective HRQOL were assessed in 371 solid organ (liver, heart, kidney, lung) transplant patients using the Karnofsky scale, the SF-36 Health Survey (SF-36), and Psychosocial Adjustment to Illness Scale (PAIS). The surveys' internal-consistency reliability, criterion-related validity, and redundancy were tested. RESULTS: The SF-36 mental (MCS) and physical components (PCS), and PAIS summary scales were internally consistent (all alpha > or = 0.83). Four out of seven PAIS scales (vocational, domestic, sexual, social) were collectively associated with the PCS (R = 0.65, P < 0.001), as was functional performance (r = 0.52, P < 0.001). Three PAIS scales (family, social, psychological distress) were associated with the MCS (R = 0.72, P < 0.001). Only the PAIS healthcare orientation (satisfaction) scale was not associated with the SF-36((R)). The relationship between functional performance and the PCS is stronger (r = 0.52, P < 0.001) than with the MCS (r = 0.25, P < 0.001) and the PAIS global score (r = 0.37, P < 0.001). CONCLUSIONS: The SF-36 and PAIS are internally consistent and exhibit divergent criterion-related validity but, with the exception of the PAIS healthcare orientation scale, are statistically redundant. The advantages of the SF-36 include wider use, more norms, and a lesser response burden. A transplant-specific patient satisfaction inventory was indicated and was developed.

Costs and net health effects of contraceptive methods.

BACKGROUND: Pregnancy and contraceptive methods both have important health effects that include risks and benefits. The net impact of contraception on women's health has not been reported previously. STUDY DESIGN: This is a cost-utility analysis using a Markov model evaluated by Monte Carlo simulation using the societal perspective for costs. The analysis compared 13 methods of contraception to nonuse of contraception with respect to healthcare costs and quality-adjusted life years (QALYs). Discounting was applied for future costs and health effects. The base-case analysis applies to women of average health and fertility, ranging from 15 to 50 years of age, who are sexually active in a mutually monogamous relationship; smoking rates observed in women of reproductive age were used. Sensitivity analysis extended the analysis to nonmonogamous status and smoking status. RESULTS: Compared with use of no contraception, contraceptive methods of all types result in substantial cost savings over 2 years, ranging from US$5907 per woman for tubal sterilization to US$9936 for vasectomy and health gains ranging from 0.088 QALYs for diaphragm to 0.147 QALYs for depot medroxyprogesterone acetate. Compared with nonuse, even with a time horizon as short as 1 year, use of any method other than sterilization results in financial savings and health gains. Most of the financial savings and health gains were due to contraceptive effects. In a population of patients, even modest increases in the use of the most effective methods result in financial savings and health gains. CONCLUSIONS: Every method of contraception dominates nonuse in most clinical settings. Increasing the use of more effective methods even modestly at the expense of less effective methods will improve health and reduce costs. Methods that require action by the user less frequently than daily are both less costly and more effective than methods requiring action on a daily basis.

Costs associated with delirium in mechanically ventilated patients.

OBJECTIVE: To determine the costs associated with delirium in mechanically ventilated medical intensive care unit patients. DESIGN: Prospective cohort study. SETTING: A tertiary care academic hospital. PATIENTS: Patients were 275 consecutive mechanically ventilated medical intensive care unit patients. INTERVENTIONS: We prospectively examined patients for delirium using the Confusion Assessment Method for the Intensive Care Unit. MEASUREMENTS AND MAIN RESULTS: Delirium was categorized as "ever vs. never" and by a cumulative delirium severity index. Costs were determined from individual ledger-level patient charges using cost-center-specific cost-to-charge ratios and were reported in year 2001 U.S. dollars. Fifty-one of 275 patients (18.5%) had persistent coma and died in the hospital and were excluded from further analysis. Of the remaining 224 patients, delirium developed in 183 (81.7%) and lasted a median of 2.1 (interquartile range, 1-3) days. Baseline demographics were similar between those with and without delirium. Intensive care unit costs (median, interquartile range) were significantly higher for those with at least one episode of delirium ($22,346, $15,083-$35,521) vs. those with no delirium ($13,332, $8,837-$21,471, p <.001). Total hospital costs were also higher in those who developed delirium ($41,836, $22,782-$68,134 vs. $27,106, $13,875-$37,419, p =.002). Higher severity and duration of delirium were associated with incrementally greater costs (all p <.001). After adjustment for age, comorbidity, severity of illness, degree of organ dysfunction, nosocomial infection, hospital mortality, and other potential confounders, delirium was associated with 39% higher intensive care unit (95% confidence interval, 12-72%) and 31% higher hospital (95% confidence interval, 1-70%) costs. CONCLUSIONS: Delirium is a common clinical event in mechanically ventilated medical intensive care unit patients and is associated with significantly higher intensive care unit and hospital costs. Future efforts to prevent or treat intensive care unit delirium have the potential to improve patient outcomes and reduce costs of care.

A model for improving the quality and timeliness of compensation and pension examinations in VA facilities.

In response to external and internal customer dissatisfaction and in anticipation of markedly higher volumes of examination requests, the Department of Veterans Affairs (VA) produced an eight-month facilitated quality-improvement project designed to improve the quality and timeliness of compensation examination processing. To determine whether participation in the project was associated with better outcomes and to identify team characteristics that were associated with high performance, we obtained centrally collected facility-level performance measures on quality and timeliness of the examinations. To determine factors associated with team success, we compared measures of leadership support reported by teams with high and low performance outcomes. Thirty teams representing 34 VA medical centers and 22 Veterans Benefits Administration's regional offices participated in the project. Monthly volumes were significantly higher for participating teams, and volumes increased significantly over time for both groups. At the beginning of the project, examination timeliness was substantially worse for participating teams (34.1 versus 29.9 days, p = .03); by the end, participants had better performance (28.5 versus 30.3 days, p = .00). Quality measures were maintained. By the end of the project, high performers reported improved leadership, frontline support, resource availability, alignment with strategic goals, and leadership mandate when compared to performance at the beginning of the project; low performers reported the opposite. These results suggest that the principles of clinical improvement can be applied successfully to teach teams how to achieve process improvements within a large healthcare organization. Visible, ongoing support by leadership and alignment of project objectives with strategic goals are associated with improved project outcomes.

Risk factors for recurrent asthma hospital visits and death among a population of indigent older adults with asthma.

BACKGROUND: Little is known about the morbidity and mortality among older adults with asthma requiring hospital care. OBJECTIVES: To determine whether an initial hospital visit for asthma was associated with an increase in use of inhaled corticosteroids (CCS) at discharge, and to identify risk factors for recurrent asthma hospital visits and death. METHODS: A retrospective cohort analysis identified 93,174 persons 65 years and older enrolled in the Tennessee Medicaid program for at least 1 year and free of asthma hospital visits during that year; 510 survived a single hospital visit for asthma in 1992 and comprised the study population. Main outcome measures included recurrent hospital visit for asthma and all-cause mortality during the year after an asthma hospital visit. RESULTS: Among the 510 study subjects, 10% were on inhaled CCS at admission compared with 11% at discharge. Twenty-three percent of the population had recurrent asthma hospital visits and 12% died during 1-year followup. Asthma severity was the strongest independent risk factor for both a recurrent hospital visit [relative risk for moderate to severe disease 1.92 (1.01 to 3.66), and for near-fatal disease 2.28 (1.01 to 5.13), respectively] and death [relative risk for moderate to severe disease 2.99 (1.07 to 8.32) and for near-fatal disease 4.44 (1.34 to 4.69), respectively]. CONCLUSIONS: In this population, older adults with an exacerbation of asthma requiring hospital care experienced significant morbidity and mortality. An acute hospital visit for an asthma exacerbation did not result in initiation of inhaled CCS therapy. Asthma severity predicted both recurrent hospital visits and all-cause mortality among older adults with asthma requiring hospital care.