Trends in Adverse Event Rates in Hospitalized Patients, 2010-2019.

Importance: Patient safety is a US national priority, yet lacks a comprehensive assessment of progress over the past decade. Objective: To determine the change in the rate of adverse events in hospitalized patients. Design, Setting, and Participants: This serial cross-sectional study used data from the Medicare Patient Safety Monitoring System from 2010 to 2019 to assess in-hospital adverse events in patients. The study included 244 542 adult patients hospitalized in 3156 US acute care hospitals across 4 condition groups from 2010 through 2019: acute myocardial infarction (17%), heart failure (17%), pneumonia (21%), and major surgical procedures (22%); and patients hospitalized from 2012 through 2019 for all other conditions (22%). Exposures: Adults aged 18 years or older hospitalized during each included calendar year. Main Outcomes and Measures: Information on adverse events (abstracted from medical records) included 21 measures across 4 adverse event domains: adverse drug events, hospital-acquired infections, adverse events after a procedure, and general adverse events (hospital-acquired pressure ulcers and falls). The outcomes were the total change over time for the observed and risk-adjusted adverse event rates in the subpopulations. Results: The study sample included 190 286 hospital discharges combined in the 4 condition-based groups of acute myocardial infarction, heart failure, pneumonia, and major surgical procedures (mean age, 68.0 [SD, 15.9] years; 52.6% were female) and 54 256 hospital discharges for the group including all other conditions (mean age, 57.7 [SD, 20.7] years; 59.8% were female) from 3156 acute care hospitals across the US. From 2010 to 2019, the total change was from 218 to 139 adverse events per 1000 discharges for acute myocardial infarction, from 168 to 116 adverse events per 1000 discharges for heart failure, from 195 to 119 adverse events per 1000 discharges for pneumonia, and from 204 to 130 adverse events per 1000 discharges for major surgical procedures. From 2012 to 2019, the rate of adverse events for all other conditions remained unchanged at 70 adverse events per 1000 discharges. After adjustment for patient and hospital characteristics, the annual change represented by relative risk in all adverse events per 1000 discharges was 0.94 (95% CI, 0.93-0.94) for acute myocardial infarction, 0.95 (95% CI, 0.94-0.96) for heart failure, 0.94 (95% CI, 0.93-0.95) for pneumonia, 0.93 (95% CI, 0.92-0.94) for major surgical procedures, and 0.97 (95% CI, 0.96-0.99) for all other conditions. The risk-adjusted adverse event rates declined significantly in all patient groups for adverse drug events, hospital-acquired infections, and general adverse events. For patients in the major surgical procedures group, the risk-adjusted rates of events after a procedure declined significantly. Conclusions and Relevance: In the US between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions. Further research is needed to understand the extent to which these trends represent a change in patient safety.

Association Between Medicare Expenditures and Adverse Events for Patients With Acute Myocardial Infarction, Heart Failure, or Pneumonia in the United States.

Importance: Studies have shown that adverse events are associated with increasing inpatient care expenditures, but contemporary data on the association between expenditures and adverse events beyond inpatient care are limited. Objective: To evaluate whether hospital-specific adverse event rates are associated with hospital-specific risk-standardized 30-day episode-of-care Medicare expenditures for fee-for-service patients discharged with acute myocardial infarction (AMI), heart failure (HF), or pneumonia. Design, Setting, and Participants: This cross-sectional study used the 2011 to 2016 hospital-specific risk-standardized 30-day episode-of-care expenditure data from the Centers for Medicare & Medicaid Services and medical record-abstracted in-hospital adverse event data from the Medicare Patient Safety Monitoring System. The setting was acute care hospitals treating at least 25 Medicare fee-for-service patients for AMI, HF, or pneumonia in the United States. Participants were Medicare fee-for-service patients 65 years or older hospitalized for AMI, HF, or pneumonia included in the Medicare Patient Safety Monitoring System in 2011 to 2016. The dates of analysis were July 16, 2017, to May 21, 2018. Main Outcomes and Measures: Hospitals' risk-standardized 30-day episode-of-care expenditures and the rate of occurrence of adverse events for which patients were at risk. Results: The final study sample from 2194 unique hospitals included 44 807 patients (26.1% AMI, 35.6% HF, and 38.3% pneumonia) with a mean (SD) age of 79.4 (8.6) years, and 52.0% were women. The patients represented 84 766 exposures for AMI, 96 917 exposures for HF, and 109 641 exposures for pneumonia. Patient characteristics varied by condition but not by expenditure category. The mean (SD) risk-standardized expenditures were $22 985 ($1579) for AMI, $16 020 ($1416) for HF, and $16 355 ($1995) for pneumonia per hospitalization. The mean risk-standardized rates of occurrence of adverse events for which patients were at risk were 3.5% (95% CI, 3.4%-3.6%) for AMI, 2.5% (95% CI, 2.5%-2.5%) for HF, and 3.0% (95% CI, 2.9%-3.0%) for pneumonia. An increase by 1 percentage point in the rate of occurrence of adverse events was associated with an increase in risk-standardized expenditures of $103 (95% CI, $57-$150) for AMI, $100 (95% CI, $29-$172) for HF, and $152 (95% CI, $73-$232) for pneumonia per discharge. Conclusions and Relevance: Hospitals with high adverse event rates were more likely to have high 30-day episode-of-care Medicare expenditures for patients discharged with AMI, HF, or pneumonia.

Estimated Cost Savings: Everyone With Diabetes Counts (EDC) Program.

Everyone with Diabetes Counts (EDC) is a national disparities reduction program funded by the Centers for Medicare & Medicaid Services to improve outcomes in the underserved minority, diverse, and rural populations. This analysis evaluates West Virginia's pilot program of diabetes self-management education (DSME), one component of EDC. We frequency-matched 422 DSME completers to 1688 others by demographics and enrollment from Medicare fee-for service claims. We estimated savings associated with reduced hospitalizations in multivariable negative binomial models. DSME completers had 29% fewer hospitalizations (adjusted P < .0069). We estimated savings of $35 900 per 100 DSME completers in West Virginia.

Association Between Hospital Performance on Patient Safety and 30-Day Mortality and Unplanned Readmission for Medicare Fee-for-Service Patients With Acute Myocardial Infarction.

BACKGROUND: Little is known regarding the relationship between hospital performance on adverse event rates and hospital performance on 30-day mortality and unplanned readmission rates for Medicare fee-for-service patients hospitalized for acute myocardial infarction (AMI). METHODS AND RESULTS: Using 2009-2013 medical record-abstracted patient safety data from the Agency for Healthcare Research and Quality's Medicare Patient Safety Monitoring System and hospital mortality and readmission data from the Centers for Medicare & Medicaid Services, we fitted a mixed-effects model, adjusting for hospital characteristics, to evaluate whether hospital performance on patient safety, as measured by the hospital-specific risk-standardized occurrence rate of 21 common adverse event measures for which patients were at risk, is associated with hospital-specific 30-day all-cause risk-standardized mortality and unplanned readmission rates for Medicare patients with AMI. The unit of analysis was at the hospital level. The final sample included 793 acute care hospitals that treated 30 or more Medicare patients hospitalized for AMI and had 40 or more adverse events for which patients were at risk. The occurrence rate of adverse events for which patients were at risk was 3.8%. A 1% point change in the risk-standardized occurrence rate of adverse events was associated with average changes in the same direction of 4.86% points (95% CI, 0.79-8.94) and 3.44% points (95% CI, 0.19-6.68) for the risk-standardized mortality and unplanned readmission rates, respectively. CONCLUSIONS: For Medicare fee-for-service patients discharged with AMI, hospitals with poorer patient safety performance were also more likely to have poorer performance on 30-day all-cause mortality and on unplanned readmissions.

National trends in patient safety for four common conditions, 2005-2011.

BACKGROUND: Changes in adverse-event rates among Medicare patients with common medical conditions and conditions requiring surgery remain largely unknown. METHODS: We used Medicare Patient Safety Monitoring System data abstracted from medical records on 21 adverse events in patients hospitalized in the United States between 2005 and 2011 for acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. We estimated trends in the rate of occurrence of adverse events for which patients were at risk, the proportion of patients with one or more adverse events, and the number of adverse events per 1000 hospitalizations. RESULTS: The study included 61,523 patients hospitalized for acute myocardial infarction (19%), congestive heart failure (25%), pneumonia (30%), and conditions requiring surgery (27%). From 2005 through 2011, among patients with acute myocardial infarction, the rate of occurrence of adverse events declined from 5.0% to 3.7% (difference, 1.3 percentage points; 95% confidence interval [CI], 0.7 to 1.9), the proportion of patients with one or more adverse events declined from 26.0% to 19.4% (difference, 6.6 percentage points; 95% CI, 3.3 to 10.2), and the number of adverse events per 1000 hospitalizations declined from 401.9 to 262.2 (difference, 139.7; 95% CI, 90.6 to 189.0). Among patients with congestive heart failure, the rate of occurrence of adverse events declined from 3.7% to 2.7% (difference, 1.0 percentage points; 95% CI, 0.5 to 1.4), the proportion of patients with one or more adverse events declined from 17.5% to 14.2% (difference, 3.3 percentage points; 95% CI, 1.0 to 5.5), and the number of adverse events per 1000 hospitalizations declined from 235.2 to 166.9 (difference, 68.3; 95% CI, 39.9 to 96.7). Patients with pneumonia and those with conditions requiring surgery had no significant declines in adverse-event rates. CONCLUSIONS: From 2005 through 2011, adverse-event rates declined substantially among patients hospitalized for acute myocardial infarction or congestive heart failure but not among those hospitalized for pneumonia or conditions requiring surgery. (Funded by the Agency for Healthcare Research and Quality and others.).

Recommended use of aspirin and other antiplatelet medications among adults--National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, United States, 2005-2008.

Cardiovascular disease (CVD) is the most highly prevalent disease in the United States and remains the leading cause of death among adults aged ≥18 years despite advancements in treatment and prevention in recent decades. Each year, approximately 800,000 persons die from CVD, which includes coronary heart disease (CHD); the majority of those persons who die from CVD had underlying atherosclerosis. Approximately 7.9 million U.S. adults have a history of heart attack, approximately 7 million U.S. adults have a history of stroke, and, approximately 16 million U.S. adults have received a diagnosis of CHD. CVD and CHD cause a substantial economic burden in the United States. In 2010, the estimated annual cost (direct and indirect) of CVD in the United States was approximately $450 billion, including $109 billion for CHD and $54 billion for stroke alone.

Emergency department volume and racial and ethnic differences in waiting times in the United States.

BACKGROUND: Racial and ethnic differences in emergency department (ED) waiting times have been observed previously. OBJECTIVES: We explored how adjusting for ED attributes, particularly visit volume, affected racial/ethnic differences in waiting time. RESEARCH DESIGN: We constructed linear models using generalized estimating equations with 2007-2008 National Hospital Ambulatory Medical Care Survey data. SUBJECTS: We analyzed data from 54,819 visits to 431 US EDs. MEASURES: Our dependent variable was waiting time, measured from arrival to time seen by physician, and was log transformed because it was skewed. Primary independent variables were individual race/ethnicity (Hispanic and non-Hispanic white, black, other) and ED race/ethnicity composition (covariates for percentages of Hispanics, blacks, and others). Covariates included patient age, triage assessment, arrival by ambulance, payment source, volume, region, and teaching hospital. RESULTS: Geometric mean waiting times were 27.3, 37.7, and 32.7 minutes for visits by white, black, and Hispanic patients. Patients waited significantly longer at EDs serving higher percentages of black patients; per 25 point increase in percent black patients served, waiting times increased by 23% (unadjusted) and 13% (adjusted). Within EDs, black patients waited 9% (unadjusted) and 4% (adjusted) longer than whites. The ED attribute most strongly associated with waiting times was visit volume. Waiting times were about half as long at low-volume compared with high-volume EDs (P<0.001). For Hispanic patients, differences were smaller and less robust to model choice. CONCLUSIONS: Non-Hispanic black patients wait longer for ED care than whites primarily because of where they receive that care. ED volume may explain some across-ED differences.

Racial differences in functioning among elderly nursing home residents, 2004.

Reducing racial disparities in health care is an important national policy goal. Previous research on racial disparities has focused on nursing home placement rates. Recent research suggests that black nursing home residents may be more likely than residents of other races to reside in facilities that have serious deficiencies, such as low staffing ratios and greater financial vulnerability. In 2004, 11% of the 1.3 million nursing home residents aged 65 and over in the United States were black. National descriptions of black nursing home residents are limited. Using data from the most recent National Nursing Home Survey, this report highlights differences observed between elderly black nursing home residents and residents of other races in functioning and resident-centered care. The specific measures highlighted are functional status, incontinence, and management of incontinence.

Racial and ethnic differences in delivery of tobacco-cessation services.

BACKGROUND: Reducing racial and ethnic disparities in health care is an important national goal. Racial and ethnic differences in the delivery of tobacco-cessation services were examined in the course of visits to primary care physicians. METHODS: In 2007, data about tobacco screening were analyzed from 29,470 visits by adult patients to 2153 physicians in the 2001-2005 National Ambulatory Medical Care Survey, a cross-sectional survey. Counseling was examined for visits by patients with known current tobacco use. Logistic regression models included age, gender, visit diagnoses, expected payment source, and past-year visits to the provider. RESULTS: The respective percentages of visits with tobacco screening and counseling were 79.2% and 28.8% for non-Hispanic white patients, 79.3% and 29.2% for non-Hispanic black patients, 80.2% and 30.6% for non-Hispanic Asian patients, and 68.2% and 21.4% for Hispanic patients. In multivariable models, the adjusted difference between Hispanics and non-Hispanic whites in the percentage of visits with screening was -7.9 (95% CI=-15.5, -0.3) and of visits with counseling was -7.6 (95% CI=-15.2, 0.0). CONCLUSIONS: Tobacco screening and counseling were less common at visits made by Hispanics compared to non-Hispanic whites. Traditional barriers to care among Hispanic patients, such as lack of insurance and more new-patient visits, did not explain the observed differences.

Underestimation of cardiovascular disease mortality among Maine American Indians: the role of procedural and data errors.

We collaborated with Maine American Indian tribes to evaluate racial coding on death certificates and the effects of coding errors on estimation of cardiovascular disease (CVD) mortality. Lists of tribal decedents were matched to death certificates; 38.5% were misclassified (17.8% coding errors; 20.7% data entry errors). After errors were corrected, CVD mortality trends were similar between American Indians and all Maine residents. Racial misclassification occurred during a period when budget cuts had prompted procedural changes.

A public health response to a cluster of suicidal behaviors: clinical psychiatry, prevention, and community health.

OBJECTIVE: To develop and implement a community public health response to a suicidal behavior cluster, including collection of risk factor data in order to prevent further behaviors. METHODS: A three-phase response, including school-wide educational debriefings, individual screening for referrals, and on-site crisis management, was implemented. Incidence of suicidal behaviors and their association with hypothesized risk factors were measured. RESULTS: Thirty-three percent of students were screened. Depression and poor social functioning were associated with an increased risk of suicidal ideation. Poor social functioning and school adjustment were associated with an increased risk of suicide attempts. CONCLUSIONS: Development and implementation of a timely public health response, including elucidation of critical risk factors, might prevent further suicidal behaviors.