Technology-Enabled Outreach to Patients Taking High-Risk Medications Reduces a Quality Gap in Completion of Clinical Laboratory Testing.

Clinical laboratory quality improvement (QI) efforts can include population test utilization. The authors used a health care organization's Medical Data Warehouse (MDW) to characterize a gap in guideline-concordant laboratory testing recommended for safe use of antirheumatic agents, then tested the effectiveness of laboratory-led, technology-enabled outreach to patients at reducing this gap. Data linkages available through the Kaiser Permanente Colorado MDW and electronic health record were used to identify ambulatory adults taking antirheumatic agents who were due/overdue for alanine aminotransferase (ALT), aspartate aminotransferase (AST), complete blood count (CBC), or serum creatinine (SCr) testing. Outreach was implemented using an interactive voice response system to send patients text or phone call reminders. Interrupted time series analysis was used to estimate reminder effectiveness. Rates of guideline-concordant testing and testing timeliness in baseline vs. intervention periods were determined using generalized linear models for repeated measures. Results revealed a decrease in percentage of 3763 patients taking antirheumatic agents due/overdue for testing at any given time: baseline 24.3% vs. intervention 17.5% (P < 0.001). Among 3205 patients taking conventional antirheumatic agents, concordance for all ALT testing was baseline 52.8% vs. intervention 65.4% (P < 0.001) among patients chronically using these agents and baseline 20.6% vs. intervention 26.1% (P < 0.001) among patients newly starting these agents. The 95th percentiles for days to ALT testing were baseline 149 vs. intervention 117 among chronic users and baseline 134 vs. intervention 92 among new starts. AST, CBC, and SCr findings were similar. Technology-enabled outreach reminding patients to obtain laboratory testing improves health care system outcomes.

The impact of new hospital orthopaedic surgery programs on total joint arthroplasty utilization.

BACKGROUND: Utilization of arthroplasty is increasing, but there are little data exploring the causes of this increase. The objective of this study was to examine the relationship between new programs for arthroplasty of the lower extremity joints and the utilization of arthroplasty. METHODS: We identified twenty-four markets (hospital referral regions) that experienced the entry of new physician-owned specialty hospitals, using 1991 to 2005 Medicare data. We matched each market with a new specialty hospital to two different control markets (one market with a new arthroplasty program in a general hospital and one market without a new arthroplasty program), using a propensity score that accounted for market supply and demand for orthopaedic surgery and the regulatory environment. We compared the utilization of arthroplasty of the lower extremity joints (total hip arthroplasty and total knee arthroplasty) in each group of markets over a five-year window, extending from two years before to three years after the entry of new orthopaedic surgery programs. RESULTS: The twenty-four markets with new specialty orthopaedic hospitals had higher utilization of arthroplasty at baseline (10.9 arthroplasties per 1000 Medicare beneficiaries per year) and follow-up (12.7 per 1000 beneficiaries) compared with the twenty-four markets with new arthroplasty programs in general hospitals (9.7 and 11.4, respectively) and the twenty-four markets with no new programs (9.9 and 11.3), although the differences were not significant (p > 0.05). Growth in the utilization of arthroplasty was similar in markets with new specialty hospitals before (an increase of 0.63 procedure per 1000 beneficiaries per year) and after the entry of new specialty hospitals (an increase of 0.39) compared with markets with new surgery programs in general hospitals (an increase of 0.24 before and 0.43 after) and markets with no new programs (an increase of 0.38 before and 0.33 after the entry of new specialty hospitals) (p > 0.05 for all comparisons). CONCLUSIONS: The utilization of arthroplasty is increasing at similar rates in markets with and without new arthroplasty programs.

Relation between hospital orthopaedic specialisation and outcomes in patients aged 65 and older: retrospective analysis of US Medicare data.

OBJECTIVE: To explore the relation between hospital orthopaedic specialisation and postoperative outcomes after total hip or knee replacement surgery. DESIGN: Retrospective analysis of US Medicare data, 2001-5. SETTING: 3818 US hospitals carrying out total joint replacement. Population 1 273 081 Medicare beneficiaries age 65 and older who underwent primary or revision hip or knee replacement. MAIN OUTCOME MEASURES: Hospitals were stratified into fifths on the basis of their degree of orthopaedic specialisation (lowest fifth, least specialised; highest fifth, most specialised). The primary outcome was defined as a composite representing the occurrence of one or more of pulmonary embolism, deep vein thrombosis, haemorrhage, infection, myocardial infarction, or death within 90 days of the index surgery. RESULTS: As hospital orthopaedic specialisation increased from the lowest fifth to highest fifth, the proportion of people admitted who were women or black, or who had diabetes or heart failure progressively decreased (P<0.001), whereas procedural volume increased. Compared with the most specialised hospitals (highest fifth), after adjustment for patient characteristics and hospital volume, the odds of adverse outcomes increased progressively with decreased hospital specialisation: lowest fifth (odds ratio 1.59, 95% confidence interval 1.53 to 1.65), second fifth (1.32, 1.28 to 1.36), third fifth (1.24, 1.21 to 1.28), and fourth fifth (1.10, 1.07 to 1.13). CONCLUSIONS: Increased hospital orthopaedic specialisation is associated with improved patient outcomes after adjusting for both patient characteristics and hospital procedural volume. These results should be interpreted with caution because the possibility that other unmeasured confounders related to socioeconomic status or different factors are responsible for the improved patient outcomes rather than hospital specialisation can not be excluded. The findings suggest that hospital specialisation may capture different components of hospital quality than the components captured by hospital volume.

The impact of physician-owned specialty orthopaedic hospitals on surgical volume and case complexity in competing hospitals.

Published studies of physician-owned specialty hospitals have typically examined the impact of these hospitals on disparities, quality, and utilization at a national level. Our objective was to examine the impact of newly opened physician-owned specialty orthopaedic hospitals on individual competing general hospitals. We used Medicare Part A administrative data to identify all physician-owned specialty orthopaedic hospitals performing total hip arthroplasty (THA) and total knee arthroplasty (TKA) between 1991 and 2005. We identified newly opened specialty hospitals in three representative markets (Durham, NC, Kansas City, and Oklahoma City) and assessed their impact on surgical volume and patient case complexity for the five competing general hospitals located closest to each specialty hospital. The average general hospital maintained THA and TKA volume following the opening of the specialty hospitals. The average general hospital also did not experience an increase in patient case complexity. Thus, based on these three markets, we found no clear evidence that entry of physician-owned specialty orthopaedic hospitals resulted in declines in THA or TKA volume or increases in patient case complexity for the average competing general hospital.