Impact of hospital-acquired Clostridium difficile.

BACKGROUND AND AIM: To investigate the impact of hospital-acquired Clostridium difficile infection (CDI) on hospital costs and patient length of stay. METHODS: Data from the 2007-2008 New York State Department of Health's Statewide Planning and Research Cooperative System (SPARCS) database was analyzed using regression analysis and descriptive statistics. RESULTS: After analysis of 4 853 800 patient discharges, the incidence rate of hospital-acquired CDI was 0.8 cases per 1000 discharges. The estimated marginal cost associated with each hospital infection was approximately $29 000. The estimated annual cost of CDI in New York State was approximately $55 million with nearly 23 000 additional hospital days. CONCLUSIONS: The development of hospital-acquired CDI is associated with a significant increase in hospital costs and patient length of stay. Extrapolation of these estimates to all US hospitals suggests this condition represents a major burden to the US healthcare system. Our findings may help hospitals understand the impact of these infections, as well as potential implications if deemed preventable by Centers for Medicare & Medicaid Services and/or private payers. Additionally, this information may benefit hospitals or health care systems transitioning to alternative payment models, such as episode-based payments or accountable care. Healthcare providers and hospitals would benefit from better understanding the impact and frequency of these infections in order to best target preventive strategies.

The financial impact of hospital-acquired conditions.

CONTEXT: This article investigates the financial impact of the Centers for Medicare & Medicaid Services' hospital-acquired conditions (HACs). METHODS: Data from 2007-2008 was analyzed using New York State Department of Health's Statewide Planning and Research Cooperative System (SPARCS), using regression analysis and descriptive statistics for each condition. RESULTS: Of 4,853,800 patient discharges, the development of decubitus ulcers was the most prevalent condition, associated with an annual cost of nearly $680 million and 376,546 hospital days. Mediastinitis after Coronary Artery Bypass Graft (CABG) had the highest marginal impact for both length of stay (LOS) and total costs, but this condition had a relatively low frequency. Extrapolation of the results suggests that HACs represent a major burden to US hospitals. CONCLUSIONS: HACs have a significant financial impact on the US health care system. Hospitals would benefit from better understanding the impact and frequency of these conditions in order to best target preventative strategies.

Development and validation of a patient self-assessment score for diabetes risk.

BACKGROUND: National guidelines disagree on who should be screened for undiagnosed diabetes. No existing diabetes risk score is highly generalizable or widely followed. OBJECTIVE: To develop a new diabetes screening score and compare it with other available screening instruments (Centers for Disease Control and Prevention, American Diabetes Association, and U.S. Preventive Services Task Force guidelines; 2 American Diabetes Association risk questionnaires; and the Rotterdam model). DESIGN: Cross-sectional data. SETTING: NHANES (National Health and Nutrition Examination Survey) 1999 to 2004 for model development and 2005 to 2006, plus a combined cohort of 2 community studies, ARIC (Atherosclerosis Risk in Communities) Study and CHS (Cardiovascular Health Study), for validation. PARTICIPANTS: U.S. adults aged 20 years or older. MEASUREMENTS: A risk-scoring algorithm for undiagnosed diabetes, defined as fasting plasma glucose level of 7.0 mmol/L (126 mg/dL) or greater without known diabetes, was developed in the development data set. Logistic regression was used to determine which participant characteristics were independently associated with undiagnosed diabetes. The new algorithm and other methods were evaluated by standard diagnostic and feasibility measures. RESULTS: Age, sex, family history of diabetes, history of hypertension, obesity, and physical activity were associated with undiagnosed diabetes. In NHANES (ARIC/CHS), the cut-point of 5 or more points selected 35% (40%) of persons for diabetes screening and yielded a sensitivity of 79% (72%), specificity of 67% (62%), positive predictive value of 10% (10%), and positive likelihood ratio of 2.39 (1.89). In contrast, the comparison scores yielded a sensitivity of 44% to 100%, specificity of 10% to 73%, positive predictive value of 5% to 8%, and positive likelihood ratio of 1.11 to 1.98. LIMITATION: Data during pregnancy were not available. CONCLUSION: This easy-to-implement diabetes screening score seems to demonstrate improvements over existing methods. Studies are needed to evaluate it in diverse populations in real-world settings. PRIMARY FUNDING SOURCE: Clinical and Translational Science Center at Weill Cornell Medical College.

Economic impact of hyponatremia in hospitalized patients: a retrospective cohort study.

BACKGROUND: Hyponatremia is the most common electrolyte abnormality seen in general hospital patients, with an incidence of 1% to 6% in the United States. OBJECTIVE: We aimed to evaluate the impact of varying levels of hyponatremia at admission on length of stay (LOS) and cost of care in adult hospitalized patients. METHODS: A retrospective cohort study was conducted using an existing clinical database from a large academic-setting hospital. All adult admissions from January 2004 through May 2005 with serum sodium level at admission of < or = 134 mEq/L were separated into 2 cohorts: patients with moderate-to-severe hyponatremia (serum sodium level at admission of < or = 129 mEq/L, n = 547) and patients with mild-to-moderate hyponatremia (serum sodium level of 130-134 mEq/L, n = 1500). ICD-9 diagnosis codes for these 2047 admissions with hyponatremia were used to identify a cohort of 7573 admissions with the same principal admitting diagnoses and a serum sodium level of 135 to 145 mEq/L. Differences in hospital LOS, intensive care unit (ICU) admission rate, and median total costs per admission between cohorts were examined using multiple linear regression, logistic, and quantile regression models. RESULTS: Admissions with hyponatremia had significantly longer hospital LOS than those admitted without hyponatremia (median LOS: moderate-to-severe hyponatremia, 8 days; mild-to-moderate hyponatremia, 8 days; normal, 6 days; P < 0.001). Patients with more severe hyponatremia were also more likely to be admitted to the ICU during the hospital stay (moderate-to-severe hyponatremia, 32%; mild-to-moderate hyponatremia, 26%; normal, 22%; P < 0.001). These trends were also reflected in the total costs per admission, with median costs of $16,606 for moderate-to-severe hyponatremia cases, $14,266 for mild-to-moderate hyponatremia cases, and $13,066 for normal admissions (P < 0.001). CONCLUSIONS: Hyponatremia at admission was associated with increased LOS and cost of care for hospitalized patients. Interventions or pharmacotherapies for the prompt treatment of hyponatremia could potentially reduce morbidity and LOS, thereby reducing the utilization of health care resources.

Physicians' attitudes towards copy and pasting in electronic note writing.

BACKGROUND: The ability to copy and paste text within computerized physician documentation facilitates electronic note writing, but may affect the quality of physician notes and patient care. Little is known about physicians' collective experience with the copy and paste function (CPF). OBJECTIVES: To determine physicians' CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use. DESIGN: Cross-sectional survey. PARTICIPANTS: Resident and faculty physicians within two affiliated academic medical centers currently using a computerized documentation system. MEASUREMENTS: Responses on a self-administered survey. RESULTS: A total of 315 (70%) of 451 eligible physicians responded to the survey. Of the 253 (80%) physicians who wrote inpatient notes electronically, 226 (90%) used CPF, and 177 (70%) used it almost always or most of the time when writing daily progress notes. While noting that inconsistencies (71%) and outdated information (71%) were more common in notes containing copy and pasted text, few physicians felt that CPF had a negative impact on patient documentation (19%) or led to mistakes in patient care (24%). The majority of physicians (80%) wanted to continue to use CPF. CONCLUSIONS: Although recognizing deficits in notes written using CPF, the majority of physicians used CPF to write notes and did not perceive an overall negative impact on physician documentation or patient care. Further studies of the effects of electronic note writing on the quality and safety of patient care are required.

Value of serum antisperm antibodies in diagnosing obstructive azoospermia.

PURPOSE: The requisite presence of active spermatogenesis for antisperm antibody production may be useful in identifying obstructive azoospermia. The diagnostic performance of serum antisperm antibody was evaluated as a test for obstructive azoospermia. MATERIALS AND METHODS: A total of 484 men with male infertility who had undergone antisperm antibody testing were evaluated. Demographic data, patient history, and followup were recorded. Obstruction was confirmed by surgical exploration. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated to quantify diagnostic performance. ROC curves were calculated and compared. RESULTS: Of 484 men 272 possessed documented obstruction of the vas or epididymis and 212 had documented infertility without azoospermia. The obstructed group had significantly increased antisperm antibody levels compared to the nonobstructed group. IgG, IgA, and IgM were analyzed as diagnostic tests for obstruction. The AUC for IgG, IgA and IgM ROC curves was 0.92, 0.85 and 0.67, respectively. The AUC for serum IgG against sperm tails was 0.92, 0.87 against sperm heads and 0.79 against sperm midpieces. IgG demonstrated the highest sensitivity (85%) with a specificity of 97% (chi-square test p <0.01). IgA possessed the highest specificity (99%), positive predictive value (99%) and positive likelihood ratio (70.0). CONCLUSIONS: The presence of serum antisperm antibody was highly accurate in predicting obstructive azoospermia, particularly after vasectomy. It can obviate the need for testis biopsy, the current but more invasive and costly gold standard of detection. This allows the surgeon to proceed directly to surgical reconstruction or sperm retrieval after a simple blood test.

Physicians' attitudes towards copy and pasting in electronic note writing.

The ability to copy and paste text within computerized physician documentation facilitates electronic note writing but may affect the quality of physician notes and patient care. Little is known about physicians' collective experience with the copy and paste function (CPF). We surveyed resident and faculty physicians within two affiliated academic medical centers in order to describe physicians' CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use.

Electronic result viewing and quality of care in small group practices.

BACKGROUND: There is a paucity of data on the effectiveness of commercially available electronic systems for improving health care in office practices, where the majority of health care is delivered. In particular, the effect of electronic laboratory result viewing on quality of care, including preventive care, chronic disease management, and patient satisfaction, is unclear. OBJECTIVE: To determine whether electronic laboratory result viewing is associated with higher ambulatory care quality. METHODS: We conducted a cross-sectional study of primary care physicians (PCPs) in the Taconic IPA in New York, all of whom have the opportunity to use a free-standing electronic portal for laboratory result viewing. We analyzed 15 quality measures, reflecting preventive care, chronic disease management, and patient satisfaction, which were collected in 2005. Using generalized estimating equations, we determined associations between portal usage and quality, adjusting for adoption of electronic health records and 10 other physician characteristics, including case mix. MAIN RESULTS: One-third of physicians (54/168, 32%) used the portal at least once over a 6-month period. Use of the portal was associated with higher quality overall (adjusted odds ratio [OR] 1.25; 95% confidence interval [CI] 1.003, 1.57). In stratified analyses, portal usage was associated with higher quality on those performance measures expected to be impacted by result viewing (adjusted OR 1.34; 95% CI 1.00, 1.81; p = 0.05), but not associated with quality for measures not expected to be impacted by result viewing (adjusted OR 1.03; 95% CI 0.72, 1.48; p = 0.85). CONCLUSION: Electronic laboratory result viewing was independently associated with higher ambulatory care quality. Longitudinal studies are needed to confirm this association.

Sexually active HIV-positive patients frequently report never using condoms in audio computer-assisted self-interviews conducted at routine clinical visits.

HIV prevention has become a new priority for HIV clinicians, as their patients live longer and more sexually active lives. Prevention interventions can be effective in clinical settings, but first patients must be screened and inconsistent condom use must be disclosed. Audio computer-assisted self-interviews (ACASI) are an effective way to elicit this sensitive information. We assessed condom use by ACASI among 198 English- or Spanish-speaking HIV patients at 2 community hospital-based HIV clinics in Queens and the Bronx, New York. Among 120 patients reporting sex with a regular partner in the past 4 weeks, 41 (34%) reported not using a condom every time and 22 (18%) reported never using a condom. Among 81 reporting sex with a casual partner in the past 4 weeks, 21 (26%) reported not using a condom every time and 12 (15%) reported never using a condom. Overall, 24 of 129 sexually active patients (19%) reported never using a condom. In a multivariable model controlling for age, race/ethnicity, gender, and HIV exposure category, depression symptoms (Center for Epidemiological Studies Depression Scale [CES-D] score >/= 16; p = 0.03) and self-reported antiretroviral medication non-adherence (

Insurance status, but not race, predicts perforation in adult patients with acute appendicitis.

BACKGROUND: Delay in treatment is a strong risk factor for perforation during acute appendicitis. In addition, lower socioeconomic status has been linked to impaired access to surgical care. We sought to examine the relationships among race, insurance status, and perforation in a recent, adult population with acute appendicitis. STUDY DESIGN: Data on adult patients with acute appendicitis were abstracted from the New York State Statewide Planning and Cooperative Systems Database for the years 2003 and 2004. A multiple logistic regression model, which adjusted for patient, community, and hospital factors, was used to examine the independent effects of both race and insurance status on likelihood of perforation. RESULTS: A total of 29,637 patients had acute appendicitis; 7,969 (26.9%) of these were perforated. Although Caucasian patients were more likely to perforate compared with minority patients, by univariate analysis, adjustment for age alone eliminated this disparity. In addition, by multivariable analysis, no difference existed in odds of perforation for Caucasian patients compared with African-American (odds ratio [OR]=1.03, 95% CI [0.93, 1.15], p=0.52), Hispanic (OR=0.99, 95% CI [0.90, 1.08], p=0.82), or Asian patients (OR=0.85, 95% CI [0.73, 1.00], p=0.05). But compared with privately insured patients, uninsured patients (OR 1.18, 95% CI [1.07 to 1.30], p=0.0005), Medicaid patients (OR=1.22, 95% CI [1.12 to 1.33], p < 0.0001), and Medicare patients (OR=1.14, 95% CI [1.03, 1.25], p=0.01) were significantly more likely to have perforation. CONCLUSIONS: Race does not appear to be an important variable in predicting perforation in adult patients with acute appendicitis, but the likelihood of perforation varies significantly according to insurance status. Future research is necessary to both understand and have an impact on this socioeconomic disparity.

Glucose testing and insufficient follow-up of abnormal results: a cohort study.

BACKGROUND: More than 6 million Americans have undiagnosed diabetes. Several national organizations endorse screening for diabetes by physicians, but actual practice is poorly understood. Our objectives were to measure the rate, the predictors and the results of glucose testing in primary care, including rates of follow-up for abnormal values. METHODS: We conducted a retrospective cohort study of 301 randomly selected patients with no known diabetes who received care at a large academic general internal medicine practice in New York City. Using medical records, we collected patients' baseline characteristics in 1999 and followed patients through the end of 2002 for all glucose tests ordered. We used multivariate logistic regression to measure associations between diabetes risk factors and the odds of glucose testing. RESULTS: Three-fourths of patients (78%) had at least 1 glucose test ordered. Patient age (> or = 45 vs. < 45 years), non-white ethnicity, family history of diabetes and having more primary care visits were each independently associated with having at least 1 glucose test ordered (p < 0.05), whereas hypertension and hyperlipidemia were not. Fewer than half of abnormal glucose values were followed up by the patients' physicians. CONCLUSION: Although screening for diabetes appears to be common and informed by diabetes risk factors, abnormal values are frequently not followed up. Interventions are needed to trigger identification and further evaluation of abnormal glucose tests.

The role of leadership in instilling a culture of safety: lessons from the literature.

The publication of To Err Is Human has highlighted concern for patient safety. Attention to date has focused primarily on micro issues such as minimizing medication errors and adverse drug reactions, improving select aspects of care, and reducing diagnostic and treatment errors. However, attention is also required to a macro issue--an organization's culture and the level of leadership required to create a culture. This article discusses the concepts of culture and leadership and summarizes two paradigms that are useful in understanding the precursors of medical errors and developing interventions to prevent them: normal accident theory and high-reliability organization theory. It also delineates approaches to instilling a safety culture. Normal accident theory asserts that errors result from system failures. An important element of this perspective is the need for a system that collects, analyzes, and disseminates information from incidents and near misses as well as regular proactive checks on the system's vital signs. Four subcultures are necessary to support such an environment: a reporting culture, a just culture, a flexible culture, and a learning culture. High-reliability organization theory posits that accidents occur because individuals who operate and manage complex systems are themselves not sufficiently complex to sense and anticipate the problems generated by the system. Lessons learned from high-reliability organizations indicate that a safety culture is supported by migrated distributed decision making, management by exception or negotiation, and fostering a sense of the "big picture." Lessons from other industries are also shared in this article.

Influence of surgical subspecialty training on in-hospital mortality for gastrectomy and colectomy patients.

OBJECTIVE: This study examined the relationship of surgeon subspecialty training and interests to in-hospital mortality while controlling for both hospital and surgeon volume. SUMMARY BACKGROUND DATA: The relationship between volume of surgical procedures and in-hospital mortality has been studied and shows an inverse relationship. METHODS: A large Statewide Planning and Research Cooperative System was used to identify all 55,016 inpatients who underwent gastrectomy (n = 6434) or colectomy (n = 48,582) between January 1, 1998 and December 31, 2001. Surgical subspecialty training and interest was defined as surgeons who were members of the Society of Surgical Oncology (training/interest; n = 68) or the Society of Colorectal Surgery (training; n = 61) during the study period. The association of in-hospital mortality and subspecialty training/interest was examined using a logistic regression model, adjusting for demographics, comorbidities, insurance status, and hospital and surgeon volume. RESULTS: Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (adjusted odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (adjusted OR = 0.70; 95% CI = 0.46, 1.08; P = 0.10). CONCLUSIONS: For gastrectomies and colectomies, risk-adjusted mortality is substantially lower when performed by subspecialty interested and trained surgeons, even after accounting for hospital and surgeon volume and patient characteristics. These findings may have implications for surgical training programs and for regionalization of complex surgical procedures.

Accuracy of screening for inhalational anthrax after a bioterrorist attack.

BACKGROUND: Bioterrorism using anthrax claimed five lives in the United States in 2001 and remains a potential public health threat. In the aftermath of a large-scale anthrax attack, mass screening to identify early inhalational anthrax may improve both the management of individual cases and the efficiency of health resource utilization. PURPOSE: To develop the evidence base for outpatient anthrax screening protocols by quantifying differences in clinical presentation between inhalational anthrax and common viral respiratory tract infections. DESIGN: Review, compilation, and data extraction from English-language case reports of inhalational anthrax and epidemiologic studies of influenza and other viral respiratory infections. DATA SOURCES: 13 reports of 28 cases of inhalational anthrax from 1920 to 2001 and 5 studies reporting on the clinical features of 2762 cases of influenza and 1932 cases of noninfluenza viral respiratory disease. DATA SYNTHESIS: Characterization of presenting clinical symptoms in anthrax and viral disease and calculation of likelihood ratios for the presence of selected clinical features. RESULTS: Fever and cough do not reliably discriminate between inhalational anthrax and viral respiratory tract infection. Features suggestive of anthrax include the presence of nonheadache neurologic symptoms (positive likelihood ratio cannot be calculated), dyspnea (positive likelihood ratio, 5.3 [95% CI, 3.7 to 7.4]), nausea or vomiting (positive likelihood ratio, 5.1 [CI, 3.0 to 8.5]), and finding of any abnormality on lung auscultation (positive likelihood ratio, 8.1 [CI, 5.3 to 12.5]). In contrast, rhinorrhea (positive likelihood ratio, 0.2 [CI, 0.1 to 0.4]) and sore throat (positive likelihood ratio, 0.2 [CI, 0.1 to 0.5]) are more suggestive of viral respiratory tract infection. CONCLUSION: Inhalational anthrax has characteristic clinical features that are distinct from those seen in common viral respiratory tract infections. Screening protocols based on these features may improve rapid identification of patients with presumptive inhalational anthrax in the setting of a large-scale anthrax attack.

Modeling the public health response to bioterrorism: using discrete event simulation to design antibiotic distribution centers.

BACKGROUND: Post-exposure prophylaxis is a critical component of the public health response to bioterrorism. Computer simulation modeling may assist in designing antibiotic distribution centers for this task. METHODS: The authors used discrete event simulation modeling to determine staffing levels for entry screening, triage, medical evaluation, and drug dispensing stations in a hypothetical antibiotic distribution center operating in low, medium, and high disease prevalence bioterrorism response scenarios. Patient arrival rates and processing times were based on prior mass prophylaxis campaigns. Multiple sensitivity analyses examined the relationship between average staff utilization rate (UR) (i.e., percentage of time occupied in patient contact) and capacity of the model to handle surge arrivals. RESULTS: Distribution center operation required from 93 staff for the low-prevalence scenario to 111 staff for the high-prevalence scenario to process approximately 1000 people per hour within the baseline model assumptions. Excess capacity to process surge arrivals approximated (1-UR) for triage staffing. CONCLUSIONS: Discrete event simulation modeling is a useful tool in developing the public health infrastructure for bioterrorism response. Live exercises to validate the assumptions and outcomes presented here may improve preparedness to respond to bioterrorism.