Evaluating the Performance of Driver's License Agencies Using a Standardized Donor Ratio.

Department of Motor Vehicles (DMV) facilities are assessed based on the proportion of patrons who consent to donate. To evaluate the individual characteristics that may influence donation consent, we analyzed the most recent transactions of 9,767,839 patrons of 203 Ohio DMVs between January 1, 2014 and November 17, 2018. Patron age, gender, donor designation, and DMV location were linked via patron zip codes with census tract data on race, ethnicity, income, and education. The Standardized Donor Designation Ratio (SDDR) (the observed number of donors at each DMV divided by the expected number of donors based on patron demographic characteristics) was calculated. Altogether 5,769,561 DMV patrons (59.1%) were designated as donors. Donor designation was independently associated with younger age, female gender, nonblack race, Hispanic ethnicity, and higher income. Across 203 DMVs, the percent donors ranged from 33% to 73%, and SDDRs ranged from 0.7 to 1.61. The correlation between the 2 measures demonstrated that 47% of the variation in SDDR was explained by percent donors. In conclusion, across DMVs there is substantial variation in organ donor designation rates. SDDRs that adjust for DMV patron characteristics may distinctly and more accurately describe individual DMV facility success in promoting organ donation.

The Targeted Management (TEAM) Intervention for Reducing Stroke Risk in African American Men: Rationale and Study Design of a Prospective Randomized Controlled Trial.

BACKGROUND: African American (AA) male survivors of strokes or transient ischemic attacks (TIA) have the highest risk of recurrent stroke when compared to other racial-ethnic men. However, there is a paucity of evidence-based strategies, including organizational, educational, or behavioral interventions, that targets secondary stroke risk reduction in AA men. METHODS: Targeted Management for Reducing Stroke Risk (TEAM) is an ongoing, 6-month prospective, randomized controlled trial that will determine whether a curriculum-guided self-management approach, using peer dyads (men who had a stroke or TIA and their care partners) will improve post-stroke care in AA men. RESULTS: The study sample will consist of 160 AA men who have experienced a stroke or TIA within 5 years, randomized to TEAM or Wait-list control group. The primary outcome changes in systolic blood pressure (BP) and high-density lipoprotein (HDL), while secondary outcomes include diastolic BP, total cholesterol, low-density lipoprotein, triglycerides, and glycemic control for diabetics. We hypothesize that AA men in TEAM will have significantly lower systolic BP and higher HDL when compared to AA men in the Wait-list control group at 6-month. CONCLUSION: Persistent disparities for stroke burden in AA men highlight the need for novel interventions to promote secondary stroke-risk reduction. Building on promising pilot data, TEAM uses a group format, with a nurse and patient co-led intervention focused on AA men and family needs, practice in problem-solving, and attention to emotional and role management. In addition, the TEAM approach may help reduce stroke risk factors and health disparities in AA men. CLINICALTRIALSGOV IDENTIFIER: NCT04402125.

Trends in postdischarge mortality and readmissions: has length of stay declined too far?

BACKGROUND: Length of hospital stay continues to decline, but the effect on postdischarge outcomes is unclear. METHODS: We determined trends in risk-adjusted mortality rates and readmission rates for 83,445 Medicare patients discharged alive after hospitalization for myocardial infarction, heart failure, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, pneumonia, or stroke. Patients were stratified into deciles of observed/expected length of stay to determine whether patients whose length of stay was much shorter than expected had higher risk-adjusted mortality and readmission rates. Analyses were stratified by whether a do-not-resuscitate (DNR) order was written within 2 days of admission (early) or later. RESULTS: From 1991 through 1997, risk-adjusted postdischarge mortality generally remained stable for patients without a DNR order. Postdischarge mortality increased by 21% to 72% for patients with early DNR orders and increased for 2 of 6 diagnoses for patients with late DNR orders. Markedly shorter than expected length of stay was associated with higher than expected risk-adjusted mortality for patients with early DNR orders but not for others (no DNR and late DNR). Risk-adjusted readmission rates remained stable from 1991 through 1997, except for a 15% (95% confidence interval, 3%-30%) increase for patients with congestive heart failure. Short observed/expected length of stay was not associated with higher readmission rates. CONCLUSIONS: The dramatic decline in length of stay from 1991 through 1997 was not associated with worse postdischarge outcomes for patients without DNR orders. However, postdischarge mortality increased among patients with early DNR orders, and some of this trend may be due to patients being discharged more rapidly than previously.

Mortality trends for 23,505 Medicare patients hospitalized with heart failure in Northeast Ohio, 1991 to 1997.

BACKGROUND: Clinical trials have identified major therapeutic advances for heart failure (HF), but the degree to which survival has improved among the general population of patients with HF is not known. This study analyzed mortality trends from 1991 to 1997 for 23,505 Medicare patients hospitalized with a first admission for HF at 29 Northeast Ohio hospitals. METHODS: We linked databases from the Cleveland Health Quality Choice (CHQC) program and Medicare to allow identification of first admissions for HF and death date. We adjusted for changes in admission illness severity using chart data from CHQC (eg, vital signs, do-not-resuscitate status, comorbid conditions, and laboratory results). Logistic regression was used to analyze trends in risk-adjusted mortality. RESULTS: At baseline (1991), crude inhospital, 30-day and 1-year mortality rates were 6.4%, 8.6% and 36.5%, respectively. Between 1991 and 1997, mean length of stay declined steeply from 9.2 days to 6.6 days (P <.001 for trend). Risk-adjusted inhospital mortality also declined markedly (absolute-decline -3.7%, 95% CI -4.3 to -3.0), a 52.8% relative decrease. However, the decline in 30-day mortality was only -1.4% (95% CI -2.5 to -0.1, P <.05), a 15.3% relative decrease. The 1-year mortality declined -5.3% (95% CI -3.2 to -7.4, P <.001), a 14.6% relative decrease. CONCLUSIONS: Long-term mortality for patients hospitalized with HF improved from 1991 to 1997, although mortality remains very high. The 30-day mortality declined far less than inhospital mortality, indicating that mortality shortly after discharge increased. This raises concerns that the marked reduction in length of stay is causing adverse consequences.

Use and perceived value of health information exchange: one public healthcare system's experience.

OBJECTIVES: To describe health information exchange (HIE) use and providers' perceptions of value in a public healthcare system using a commercial electronic health record (EHR). STUDY DESIGN: Observational study of HIE implementation and cross-sectional provider survey. METHODS: We identified characteristics (age, gender, race/ethnicity, insurance type, comorbid conditions) and the care setting (primary care; emergency department [ED] or inpatient care; or specialty care) for patients with and without HIE. Associations between patient characteristics and HIE were examined using a multivariate logistic regression. Provider perceptions were assessed via confidential survey. RESULTS: During its first 14 months, 11,960 HIEs occurred among 9399 patients. Rates of HIE use were 13/1000 visits overall (20/1000 in primary care, 36/1000 in the ED/inpatient setting, and 5/1000 in specialty settings [P <.001]). Patients with HIE were older, more often female, African American, had more chronic conditions, and more often had Medicaid or Medicare insurance (P <.001). HIE was used least among commercially insured (odds ratio, 0.78, 95% confidence interval,0.73-0.83, compared with uninsured). Among the 18% (74/412) of survey respondents, 93% "disagreed/strongly disagreed" that obtaining consent was difficult and 97% reported no patient refusals. Respondents "agreed/strongly agreed" that HIE fostered more efficient care (93%), saved time (85%), decreased laboratory (84%) and imaging (74%) use, and 15% stated that HIE prevented an unnecessary admission. CONCLUSION: Early HIE use varied by care setting, patient characteristics, and insurance. Providers perceived HIE acceptable to patients, and helpful in avoiding redundant testing and unnecessary hospitalizations. Lower HIE use among commercially insured patients reinforces concerns that financial incentives may inhibit adoption.

Care fragmentation and emergency department use among complex patients with diabetes.

OBJECTIVE: To evaluate the association between patterns of fragmented care and emergency department (ED) use among adult patients with diabetes and chronic kidney disease. STUDY DESIGN: Observational study in an open healthcare system. METHODS: The study sample included patients with diabetes and chronic kidney disease (mean estimated glomerular filtration rate, 20-60 mL/min) and with an established primary care provider. Dispersion of care was defined by a fragmentation of care index (range, 0-1), with zero reflecting all care in 1 outpatient clinic and 1 reflecting each visit at a different clinic site. We used a negative binomial model to estimate the influence of fragmentation on ED use after adjusting for patient demographic characteristics, insurance, diabetes control, and number of comorbidities; results are reported as incidence rate ratios and associated 95% confidence intervals (CIs). The main outcome measure was the number of ED visits from 2002 to 2003. RESULTS: Of 3873 patients with diabetes having an established primary care provider, 623 (16.1%) had chronic kidney disease and comprised the final study sample. On average, patients made 19.0 (95% CI, 18.5-20.4) outpatient visits and 1.2 (95% CI, 1.1-1.4) ED visits over the 2-year period. The median fragmentation of care index was 0.48; 14.3% of subjects had a fragmentation of care index of zero. In the adjusted model, a 0.1-U increase in the fragmentation of care index was associated with a 15% increase in the number of ED visits (incidence rate ratio, 1.15; 95% CI, 1.09-1.21). CONCLUSIONS: The posited benefits of specialist referrals among patients with complex diabetes may be partially negated by care fragmentation. Better models for care coordination and stronger evidence of the marginal benefits of referrals are needed.

Changes in the use of do-not-resuscitate orders after implementation of the Patient Self-Determination Act.

OBJECTIVE: To determine changes in the use of do-not-resuscitate (DNR) orders and mortality rates following a DNR order after the Patient Self-determination Act (PSDA) was implemented in December 1991. DESIGN: Time-series. SETTING: Twenty-nine hospitals in Northeast Ohio. PATIENTS/PARTICIPANTS: Medicare patients (N = 91,539) hospitalized with myocardial infarction, heart failure, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, pneumonia, or stroke. MEASUREMENTS AND MAIN RESULTS: The use of "early" (first 2 hospital days) and "late" DNR orders was determined from chart abstractions. Deaths within 30 days after a DNR order were identified from Medicare Provider Analysis and Review files. Risk-adjusted rates of early DNR orders increased by 34% to 66% between 1991 and 1992 for 4 of the 6 conditions and then remained flat or declined slightly between 1992 and 1997. Use of late DNR orders declined by 29% to 53% for 4 of the 6 conditions between 1991 and 1997. Risk-adjusted mortality during the 30 days after a DNR order was written did not change between 1991 and 1997 for 5 conditions, but risk-adjusted mortality increased by 21% and 25% for stroke patients with early DNR and late DNR orders, respectively. CONCLUSIONS: Overall use of DNR orders changed relatively little after passage of the PSDA, because the increase in the use of early DNR orders between 1991 and 1992 was counteracted by decreasing use of late DNR orders. Risk-adjusted mortality rates after a DNR order generally remained stable, suggesting that there were no dramatic changes in quality of care or aggressiveness of care for patients with DNR orders. However, the increasing mortality for stroke patients warrants further examination.

Mortality trends during a program that publicly reported hospital performance.

BACKGROUND: It is unclear whether publicly reporting hospitals' risk-adjusted mortality leads to improvements in outcomes. OBJECTIVES: To examine mortality trends during a period (1991-1997) when the Cleveland Health Quality Choice program was operational. RESEARCH DESIGN: Time series. SUBJECTS: Medicare patients hospitalized with acute myocardial infarction (AMI; n = 10,439), congestive heart failure (CHF; n = 23,505), gastrointestinal hemorrhage (GIH; n = 11,088), chronic obstructive pulmonary disease (COPD; n = 8495), pneumonia (n = 23,719), or stroke (n = 14,293). MEASURES: Risk-adjusted in-hospital mortality, early postdischarge mortality (between discharge and 30 days after admission), and 30-day mortality. RESULTS: Risk-adjusted in-hospital mortality declined significantly for all conditions except stroke and GIH, with absolute declines ranging from -2.1% for COPD to -4.8% for pneumonia. However, the mortality rate in the early postdischarge period rose significantly for all conditions except COPD, with increases ranging from 1.4% for GIH to 3.8% for stroke. As a consequence, the 30-day mortality declined significantly only for CHF (absolute decline 1.4%, 95% CI, -2.5 to -0.1%) and COPD (absolute decline 1.6%, 95% CI, -2.8-0.0%). For stroke, risk-adjusted 30-day mortality actually increased by 4.3% (95% CI, 1.8-7.1%). CONCLUSION: During Cleveland's experiment with hospital report cards, deaths shifted from in hospital to the period immediately after discharge with little or no net reduction in 30-day mortality for most conditions. Hospital profiling remains an unproven strategy for improving outcomes of care for medical conditions. Using in-hospital mortality rates to monitor trends in outcomes for hospitalized patients may lead to spurious conclusions.

The effect of publicly reporting hospital performance on market share and risk-adjusted mortality at high-mortality hospitals.

BACKGROUND: It is unclear whether publicly reporting hospitals' risk-adjusted mortality affects market share and mortality at outlier hospitals. OBJECTIVES: To examine hospitals' market share and risk-adjusted mortality from 1991 to 1997 at hospitals participating in Cleveland Health Quality Choice (CHQC). RESEARCH DESIGN: Time series. SUBJECTS: Changes in market share were examined for all patients hospitalized with acute myocardial infarction, heart failure, gastrointestinal hemorrhage, obstructive pulmonary disease, pneumonia, or stroke at all 30 nonfederal hospitals in Northeast Ohio. Patients insured by Medicare were used to examine changes in mortality. MEASURES: Trends in market share (proportion of patients with the target conditions discharged from a given hospital) and risk-adjusted 30-day mortality. RESULTS: CHQC identified several hospitals with consistently higher than expected mortality. The five hospitals with the highest mortality tended to lose market share (mean change -0.6%, 95% CI -1.9-0.6), but this was not significant. The only outlier hospital with a large decline in market share had declining volume for 2 years before being declared an outlier. Risk-adjusted mortality declined only slightly at hospitals classified by us as "below average" (-0.8%; 95% CI, 2.9-1.8%) or "worst" (-0.4%; 95% CI -2.3-1.7). However, risk-adjusted mortality at one hospital changed from consistently above expected to consistently below expected shortly after first being declared an outlier. CONCLUSION: Despite CHQC's strengths, identifying hospitals with higher than expected mortality did not adversely affect their market share or, with one exception, lead to improved outcomes. This failure may have resulted from consumer disinterest or difficulty interpreting CHQC reports, unwillingness of businesses to create incentives targeted to hospitals' performance, and hospitals' inability to develop effective quality improvement programs.